A TREATISE 
ON THE 
SCIENCE AND PRACTICE 
OF 
M E D ICI N E 
OR THE 
PATHOLOGY AND THERAPEUTICS 
OF 
I.NTi: I INAL DISEASES 
\ / RT 
ALONZO B. PALMER. M.D., LL.D. 
4,| / ' 1 
•ROFESSOR OP PATHOLOGY AND PRACTICE Op MEDICINE, AND OF CLINICAL MEDICINE IN THE UNIVERSITY 
OF MICHIGAN, PHYSICIAN TO THE STATE UNIVERSITY HOSPITAL; FORMERLY PROFESSOR OF 
MATERIA MEDICA AND PRACTICE OF MEDICINE IN THE BERKSHIRE MEDICAL COLLEGE, 
MASSACHUSETTS, AND PROFESSOR OP PATHOLOGY AND PRACTICE OP MEDICINE 
AT BOWDOIN COLLEGE, MAINE ; HONORARY MEMBER OP THE NEW 
YORK STATE MEDICAL SOCIETY, EX-VICE-PRESIDENT OP 
THE AMERICAN MEDICAL ASSOCIATION, ETC. 
NEW YORK 
G. P. PUTNAM’S SONS 
27 an d 29 West 2o» Street 
1883 Copyright 
1882 
By U. P. Putnaji's Sons TO 
THOSE WHO HAVE LISTENED TO THE ORAL INSTRUCTION GIVEN DURING 
THE LAST THIRTY YEARS BY THE AUTHOR, 
THIS WORK IS RESPECTFULLY 
DEDICATED. PREFACE. 
In' adding a new work on the Science and Practice of Medicine to 
the number already claiming the attention of the American profes- 
sion, it seems proper that some reasons should be given for having 
undertaken its production, and some justification should be offered 
for its existence. 
The preparation of such a work has been long in contemplation, 
suggested by the requests of students, and their evident want of a 
text-book to follow the lectures on this subject in the Medical Schools 
with which the writer has been connected. The task has finally 
been executed, in compliance with conditional promises made to stu 
dents, and to numerous practitioners who had formerly attended these 
schools, and who have expressed a desire to have the substance of the 
teaching they had received, in a more precise and permanent form, 
for reference and study. 
There are other reasons, however, than the partiality and wishes 
of former and present students, or the wants of prospective ones, 
which may be adduced to favor the claims of this work to a place, 
whatever place that may be, in our literature. 
That the few domestic treatises on the Practice of Medicine are not 
sufficient to fully supply the wants of the reading American profes- 
sion is evident from the large number of foreign works which are 
reproduced and purchased among us. 
Judicious members of our profession, and especially those who 
have observed medical practice abroad, and who have given attention 
to the peculiarities of diseases, and the treatment required for them 
as they occur in different localities, and in persons of different races 
and habits, are very seriously raising the question whether therapeu- 
tical directions given by foreign authors are the best, if they are even 
safe guides in the treatment of the ordinary diseases in this country. 
In the International Medical Congress, recently held in London, the 
statement was made, and accepted without dissent, that each nation- 
ality had its own peculiarities of disease, requiring peculiarities of PREFACE. 
treatment; and climatic influences, as different as they are upon ihe 
two continents, must, at least in many cases, vary the remedial meas- 
ures indicated. 
Moreover, not only do race and climate produce differences in dis- 
eases, requiring modifications of treatment, but the habits and the 
particular surroundings of the people produce still greater effects. 
The habitations, the clothing, the exposure, the food, the drinks, the 
labor, the pleasures and the dissipations, and all the social and do- 
mestic arrangements, differ widely in Europe and in this country. 
But these are not all, or the chief reasons, why the conclusions 
and practical directions of the authors of foreign works cannot be 
accepted as proper guides to be fully followed in the treatment of the 
ordinary medical diseases of our general population. 
The authors of these foreign works have derived their experience, 
upon which conclusions are based, from a consultation practice in 
large cities, and from attendance upon patients in large city hospi- 
tals. In consultation practice, certainly as a rule, the consultant sees 
acute diseases either in their severer forms or in their later stages, and 
most frequently he is called to the severer cases at a stage when the 
time for most efficient treatment has passed, and when the remedies 
indicated at the beginning of the affections, with a view to their 
arrest, are no longer applicable. 
In a large metropolitan hospital the conditions of the patients 
differ still more from those met with in the ordinary practice in this 
country. The foreign hospital patients, especially those affected with 
acute diseases, are almost exclusively from the destitute and the 
starved, or from the intemperate and the degraded classes. They live, 
for the most part, in narrow, filthy lanes, in crowded tenements, in 
cellars, or in garrets ; they have not only insufficient food, but gener- 
ally they indulge in poisonous drinks, and are very often suffering from 
specific diseases produced by vice. Furthermore, especially in acute 
cases, they are brought into the hospital and to the notice of the phy- 
sician after the earlier stages of the diseases have passed. As a proof 
of this fact, it may be mentioned that in the standard foreign works 
giving the average daily temperatures of acute pneumonia, as derived 
from the observation of numbers, the record generally commences 
with the fourth or fifth day of the disease, because many have not 
been seen at an earlier period. These facts explain the prevailing 
skepticism among these authors as to the efficacy of remedies, and 
their failure to appreciate their effects when early given. 
It requires no argument to show that the cases they deal with 
differ vastly from those occurring in an ordinary American village or 
country situation, where well-housed, well-fed, non-alcoholized people PREFACE. 
are seen in the beginning of their diseases. The treatment adapted to 
the respective cases must be quite different, and the natural course of 
the disease must vary ; and yet the statistics of the effects of different 
modes of treatment, as by blood-letting, antimony, alcohol, quinine, 
the bath, expectancy, etc., are based upon these hospital cases ; and 
these and the cases seen in consultation, largely, if not exclusively, 
control the views of those who write the foreign books. 
The present work has been prepared from the standpoint of an 
American physician, whose practice for years was in a village and 
farming community, who has become familiar with diseases in their 
beginning as well as in their advanced stages, both in a country and 
a city practice—more in the West, but also in the East; in the army 
during the late war, as well as in civil life—from the standpoint of 
one who for years has been engaged in public clinical and hospital, 
as well as in private practice ; who has long acted as a consultant as 
well as an attending physician, and whose observations have extended 
to the large city hospitals of our own country; and who, years ago, as 
well as since this work has been in preparation, has made brief but 
careful observations in most of the medical centres of Europe. 
So varied an experience and so extended a field of observation, and 
an acquaintance with professional men of different special pursuits 
and different opinions on a variety of questions, it may be presumed, 
has tended to prevent narrowness of views and prejudiced judgments ; 
and whatever may be thought of the opinions contained in the work 
on important practical subjects, they have not been hastily formed, 
nor without opportunities of investigation. The differences between 
the diseases of our own and the countries of Europe, of the rural dis- 
tricts and the crowded cities, and of those met with in private and in 
hospital practice, have been recognized; and the importance and 
greater efficiency of early treatment, and the differences in the indica- 
tions presented and the remedies required in the early and later stages 
of most affections, have been pointed out. 
The time for a strictly scientific classification of diseases has not 
arrived, - and in the arrangement of subjects convenience has been 
followed rather than any attempt made at such a classification. As the 
most natural order, however, certain physiological and pathological 
facts and principles have been first presented, elementary morbid 
changes are next described, and an account of particular general dis- 
eases follows. Local diseases are then treated of, beginning with those 
of the digestive organs; the accounts of the diseases of other systems 
of organs follow, closing with the complex affections of the nervous 
system. An account of human parasites is added, and a description 
of the internal diseases they produce closes the work. PREFACE. 
Imperfections of various kinds unquestionably there are, which 
will be readily observed. One busily engaged in professional duties 
must have been on the alert to have kept pace with the progress which 
pathology and therapeutics have made within the past few years, and 
some new facts and principles of importance fairly established may 
have been overlooked; but many theories that have received attention 
but are not proven, and alleged facts of apparent importance but not 
authenticated, have been purposely omitted. 
A work aiming to give a general view of the present state of sci- 
entific and practical medicine cannot be entirely original. The writer 
of such work must draw materials from numerous sources, and it is 
often difficult to determine to whom the credit of originality should 
be given. In the haste of preparation acknowledgments may not 
always have been made where they were justly due. Much of the 
matter was collected for use in the lecture-room, and this has some- 
times been made available in this work without referring again to its 
sources. It has, however, been the purpose to give proper credit for 
all materials made use of which cannot be regarded as the common 
property of the profession. The recent general works on medicine of 
Drs. Flint, Bartholow, Bristowe, and M. Jaccoud, have been fre- 
quently consulted, as well as a large number of monographs upon 
particular subjects, such as are contained in Reynolds’ System of Med- 
icine and Ziemssen’s Cyclopaedia, as well as those which have been 
published separately or have appeared as articles in medical journals. 
To all these acknowledgments are due. 
Not having myself been devoted to original Avork in morbid anat- 
omy, the description of anatomical and histological changes partakes 
of the character of a compilation from the more recent and reliable 
sources; while the therapeutical views are more of a personal charac- 
ter, although the opinions and authority of others have not been ig- 
nored. When stated without reference to authorities, they are such 
as study, observation, and experience have enabled me to express as 
personal convictions. 
While pathology is recognized as the foundation of scientific medi- 
cine, and symptomatology and diagnosis as essential guides in the care 
and management of the sick, the practical cure of patients must be 
regarded as the crowning object of all medical study, and this has 
constantly been kept in view. Both the student and practitioner feel 
the want of full and specific accounts of the treatment of diseases in 
their earlier as well as in their later stages, in their milder as well as 
in their graver forms, and an attempt has been made to supply that 
want. 
In many different diseases similar pathological and therapeutical PREFACE. 
principles are concerned, and the same remedies are required, though 
with modifications in their applications. All must be presented in 
connection with each affection, and repetitions will therefore be 
found which may appear redundant. But fulness and explicitness 
in the account of each disease, particularly of its treatment, are too 
important to the student and young practitioner to be sacrificed to 
mere brevity or literary taste. 
In the treatment of the various subjects, reasons for the conclu- 
sions arrived at have usually been given, and principles have been 
hold in view and expressed, as well as details specified; and an effort 
has been made to produce a work that should be more than a synopsis 
which would foster superficiality, but less than an extended treatise 
which might exhaust the patience of the reader and obscure the more 
important matters. The aim has been to present what was essential 
to a proper understanding of each subject, without entering into his- 
torical devils, or dwelling upon doubtful facts, or upon theories not 
established. In short, a practical work has been attempted for stu- 
dents and physicians, which should avoid the extremes of superficial 
brevity and elaborate profuseness. How far these and other aims have 
been accomplished the readers will judge. 
In conclusion I may be permitted to add, that my grateful acknowl- 
edgments cannot justly be withheld from one whose interest in all 
that concerns me is deepest, who has encouraged and sustained me by 
her sympathy throughout the preparation of this work, and whose 
unstinted and efficient labor in superintending the copying of the 
manuscript for the press, and in the revision of the proof-sheets has 
rendered possible the accomplishment of this task in the time that has 
been given it. TABLE OF CONTENTS OF FIRST VOLUME. 
GENERAL PATHOLOGY AND THERAPEUTICS. 
PAGE 
Definitions and General Observations on the Nature of Disease 1 
Physiological and Pathological Observations, and a Discussion of the Ele- 
ments of Disease .V 11 
Pathology of Inflammation 50 
Non-inflammatory Changes 88 
Therapeutics of Inflammation 89 
Pyrexia—the Febrile State .. 100 
Infectious Poisons 123 
Classification of Fevers 128 
Minor Diseases. 130 
PARTICULAR GENERAL DISEASES. 
Symptomatic Fevers 157 
Idiopathic Fevers 159 
Therapeutics of Fevers • 161 
Specific Fevers 180 
Malarial Fevers—Ague 180 
Remitting Malarial Fevers 208 
Pernicious Malarial Fevers 220 
Typhoid Fever 229 
Typhus Fever 296 
Relapsing Fever 301 
Plague 306 
Diphtheria 308 
Influenza 330 
Hooping-Cough 337 
Mumps . % 341 
Dengue 344 
Miliary Fever 349 
Cerebro-Spinal Fever 358 
Small-Pox 373 
Cow-Pox 387 
Chicken-Pox 393 
Measles 395 
Rotheln 400 CONTENTS. 
PAGE 
Scarlatina 402 
Epidemic Cholera 411 
Yellow Fever .... 443 
Erysipelas 455 
Pyaemia and Septicaemia 463 
Scurvy 471 
Purpura 475 
Haemophilia 478 
Leucocythaemia 480 
Hodgkin’s Disease 484 
Pernicious Anaemia 485 
Simple Anaemia 486 
Chlorosis 489 
Addison’s Disease 489 
Diabetes Mellitus 492 
Diabetes Insipidus 507 
Dropsy 508 
Gout 511 
Rheumatism 521 
Rheumatoid Arthritis 541 
Myalgia—Muscular Rheumatism 544 
LOCAL DISEASES. 
Local Diseases 547 
Diseases of the Alimentary Canal and Digestive System 549 
Stomatitis 550 
Mercurial Stomatitis .. 552 
Noma 556 
Glossitis 558 
Cynanche 560 
Chronic Pharyngitis .. 563 
Phlegmonous Inflammation of Throat 569 
Post-Pharyngeal Abscess 569 
Tonsilitis 571 
Diseases of Oesophagus—CEsophagitis 575 
Stricture of CEsophagus 576 
Diseases of Abdominal Digestive Organs 583 
Diseases of Stomach 587 
Ilyperaemia 588 
Gastritis—Acute 589 
Chronic 597 
Gastric Ulcer \ 605 
Tumors of the Stomach 614 
Cancer of the Stomach 615 
Hemorrhage of the Stomach 622 
Gastric Obstruction and Dilatation 629 
Functional Diseases of the Stomach. ; 631 
Dyspepsia 632 
Gastralgia and Gastro6nteralgia 662 PAGB 
Diseases of Intestines 667 
Diseases of Duodenum 668 
Diseases chiefly of Small Intestines 669 
Enteritis 669 
Muco-Enteritis—Acute 670 
Chronic 684 
Choleroid Fluxion 687 
Cholera Infantum 688 
Phlegmonous Enteritis 691 
Inflammation of the Caecum and Neighboring Parts 698 
Periproctitis 708 
Proctitis 710 
Specific Dysentery 712 
Hemorrhoids 733 
Intestinal Hemorrhage 734 
Acute Peritonitis 735 
Chronic Peritonitis 746 
Ascites 750 
Cancer of Peritoneum 756 
Tumors of the Intestines 757 
Intestinal Obstruction 759 
Functional Diseases of the Intestines 769 
Colic 769 
Lead Colic 774 
Constipation 781 
Diarrhoea .... 789 
Diseases of the Pancreas 796 
Diseases of the Spleen 797 
Diseases of the Liver 807 
Functions of the Liver 811 
Functional Affections of Liver 813 
Jaundice 818 
Hepatic Congestion 827 
Organic Disease of Liver 839 
Hepatitis—Catarrhal 842 
Phlegmonous 847 
Non-Suppurative Hepatitis 856 
Hepatic Sclerosis ... .: 857 
Hypertrophic Cirrhosis 867 
Acute Yellow Atrophy...' 869 
Fatty Liver 872 
Waxy or Lardaceous Liver 874 
Hydatids of the Liver 877 
Cancer of the Liver 881 
Biliary Calculi 883 
Cholsemia 890 
Stenosis of Bile Ducts 894 
Hepatic Phlebitis 895 
CONTENTS. Pathology 
and 
Practice of Medicine. 
GENERAL PATHOLOGY AND THERAPEUTICS. 
DEFINITIONS AND GENERAL OBSERVATIONS 
ON THE NATURE OF DISEASE. 
Medicine, in its broadest signification, embraces all the subjects 
haying reference to health and disease. 
It includes Anatomy, Physiology, Chemistry, Materia Medica, 
Pathology, Hygiene, and Therapeutics. 
The present treatise will be especially devoted to that portion of 
Pathology, Hygiene, and Therapeutics belonging to human diseases, 
exclusive of surgical affections and those peculiar to women and 
children. 
Pathology is defined as the science of disease. It embraces a 
knowledge of the nature, causes, phenomena, and results of morbid 
conditions. 
Hygiene, in its widest sense, includes a particular knowledge of 
the causes of diseases, of the means of avoiding them, and of the rules 
for the preservation of health and a natural life. In this wider sense 
it includes and Prophylactics. is the study of 
the causes of disease, and Prophylactics, of those special measures 
necessary to prevent the occurrence of particularly threatened affec- 
tions ; while Hygiene, in its more restricted sense, teaches the modes 
of living applicable to the healthy condition, and for the purpose of 
its preservation. 
Therapeutics is that part of medicine which treats of the applica- 2 
PATHOLOGY AND PRACTICE OF MEDICINE. 
tion of remedies to the removal or melioration of diseases, and the 
relief of suffering from morbid states. 
The following seheme presents in compact form the general 
science and art of medicine : 
Pertaining to Health are 
Anatomy. 
Physiology. 
Hygiene. 
Pathology. 
Diagnosis. 
Prognosis. 
Pertaining to Disease are 
Dietetics. 
Pharmaceutics. 
Surgery or Manipulations. 
Therapeutics. 
Between Health and Disease are 
Aetiology. 
Prophylactics. 
Pathology, which comes first in the logical order of the subjects 
pertaining to disease, is divided into general and special—General 
Pathology treating of those facts and principles relating to the pro- 
duction, the nature, and the character of diseases in general; while 
Special Pathology describes the causes, phenomena, and results of 
particular affections. 
There are many facts and principles bearing upon the subject of 
the nature of disease, aside from the special phenomena of morbid 
action, some of which it will be important here to consider. 
The world of which we take cognizance as a subject of science 
consists of Matter and Force. 
By Matter is understood that which has material substance and 
form, which occupies space, and is subject to mechanical and chem- 
ical laws ; and by Force that which acts upon or within matter, 
holding its parts in certain relations to each other, or inducing 
motion or change. 
Matter is found in two conditions—dead and living. Dead matter 
is that which is subject to mechanical and chemical forces and laws 
only ; while living matter is subject to additional forces and laws, 
which are called Vital. 
Whether the vital forces and laws are essentially, and in their 
nature, different and distinct from the mechanical, or physical, and 
chemical forces, or whether they are only modifications or correlations 
of one general force, it will be unnecessary here to inquire : but it is 
certain that the vital force is different in its phenomena, in its mani- 
festations and laws, from the mechanical and chemical forces, and 
requires a distinct recognition and consideration. 
A distinctive feature of most living matter, or that which has been 
living, is its peculiar structure and organic form. The more charac- DEFINITIONS AND OBSERVATIONS OF DISEASE. 
3 
teristic living bodies, at least, are organisms—different parts having 
different structures and actions—the bodies having organs for the per- 
formance of particular functions. 
Simple non-living bodies are homogeneous. In a metal or a defi- 
nitely composed stone, one part is like every other part, having the 
same structure, relations, and susceptibilities; while in living organic 
bodies, the structure, the relations, and the susceptibilities of differ- 
ent parts differ, often widely. 
Thus in man, whose conditions, especially in relation to his abnor- 
malities and sufferings, it is the object of this work to consider, there 
is a large number of particular parts and organs of various struct- 
ures and forms, each performing a more or less distinctive office in 
the general economy of the body. There are, for example, bones, 
which give firmness and protection ; muscles, which are the instru- 
ments of motion; a stomach, which digests, and all these parts are 
bound together, in intimate relations, into a single complex organism. 
Simple Protoplasm, the physical basis of life, the lowest form of 
living matter, has been thought by some to be homogeneous; but this 
is denied by others—a reticulated structure, it is alleged, having been 
seen in amoeba, and in other of the simplest forms of living sub- 
stance ; and certainly in all the living bodies best known, particular 
forms and structures are present. 
In the substance of all living organisms, from the amoeba to man, 
the common properties of matter, mechanical, or physical, and chem- 
ical exist, and that substance is subject to its own appropriate mechan- 
ical and physical laws ; but in addition, the life-principle is present, 
modifying the physical and chemical conditions and actions ; and 
this is of so distinctive and important a character as to demand the 
most careful study. 
The essential nature of this life-principle we may never be able 
fully to understand, but a knowledge of its leading properties and 
effects lies at the foundation of medical science. 
As expressing our present knowledge respecting it, Life may be 
defined a certain relation or combination of matter and force, in which 
occur peculiar phenomena : , 
1. Motion from inherent power. 
2. Nutrition—capability of appropriat- 
ing nourishing materials. 
3. Eeproduction—the power of con- 
tinuing the species. 
Those essential to all forms of life are 
Those necessary for the higher forms 
are 
4. Differentiation of structure. 
5. Organization. 
6. Development. 4 
PATHOLOGY AND PRACTICE OF MEDICINE. 
Those phenomena belonging to the 
highest forms of life are 
7. Sensibility. 
8. Intelligence. 
9. Will, or free determination. 
The science of life in general, as manifested in all forms of living 
beings, is called Biology; and its study in the lower forms, and at its 
beginnings in higher organisms, often throws important light upon 
its conditions in developed human beings ; and therefore the general 
doctrines of biology are important to be understood. There are, how- 
ever, peculiarities in the human system which do not belong to other 
organisms, and the study of medicine is particularly the study of man. 
To obtain a knowledge of life as presenting itself in him is the special 
object of the student of medicine. 
Medicine may be considered as both a science and an art. A 
science ascertains and expresses in an orderly manner facts and prin- 
ciples ; an art applies them. A science is something to be known 
systematically ; an art is something to be done skillfully ; and medi- 
cine, as a subject to be mastered, considered in reference to its sources 
and its attainment, is the personal knowledge and experience of many, 
methodically arranged and recorded or expressed, so as to become 
attainable by others. 
The Science of Medicine is the arranged and organized knowl- 
edge of all the circumstances relating to the health of man, in what- 
ever climate or of whatever race ; and the Art of Medicine is the appli- 
cation of the science to the prevention of abnormal and unfavorable 
conditions in man in respect to health, and to their removal or relief 
by any means which may influence the various bodily functions or 
mental operations. 
Although a work on the Principles and Practice of Medicine is 
supposed to be occupied with an account of morbid conditions, their 
causes and their remedies, and though a knowledge of the system in 
its natural and proper conditions is supposed to be in possession of the 
reader, yet as this normal condition is so central a fact in medical 
science,—is the necessary standard of comparison by which the mor- 
bid conditions are made manifest,—some account of that standard, 
and frequent references to it, will be necessary in an elementary work 
of this character. 
That part of the general science of medicine which treats of the 
normal activities of the system, its proper molecular and grosser 
motions, its growth and development, and of its functions, such as 
secretion, respiration, perception, etc., is called Physiology, and the 
natural condition is called the Physiological State. 
Pathology treats of the morbid conditions and actions of the sys- DEFINITIONS AND OBSERVATIONS OF DISEASE. 
5 
tem; of the origin, nature, causes, course, and consequences of such 
actions; and the system, under any such injurious conditions and 
actions, is said to be in a Pathological State. 
Life actions, of whatever kind, require certain conditions to be 
present, without which they cannot occur. There must be Heat, for 
without it all would be locked in the rigidity of death. There must 
be Air, as its oxygen is the universal pabulum of living beings. There 
must be Food to furnish materials, or growth and the repair of waste 
could not be carried on. There must be Water to facilitate motion, 
or the wheels of life would stop. Electricity and Light also furnish 
important conditions of certain vital activities. 
Under the idea of life’s being a principle needing something to 
excite it into action, these agents—heat, air, food, water, electricity, 
and light—have been called the vital stimuli; but the phrase, “ con- 
ditions of life,” involving no theory, and stating simply what is 
known to be true, is the preferable expression. 
When these conditions of life are all present in proper proportions, 
and all unfavorable materials and influences affecting the individual 
or his ancestors are excluded, the normal functions are performed, 
the system is developed and sustained after its type, and comfort, 
enjoyment, efficiency, and health result. 
Perfect health, then, is the natural enjoyable condition of a 
normal organism in proper action. 
In considering the relations of health and disease, we obtain 
more clear conceptions of their nature by contrasting an ideal state 
of perfect health with that of positive and unequivocal disease ; but 
such an ideal state is not always present where we recognize the con- 
dition of health. As the term is commonly used, it is relative, and 
does not imply a fixed and definite state, or the performance in a 
perfect manner of all the functions of the body; and disease must 
therefore be equally indefinite, not separated from health by a well- 
defined boundary. All disease is abnormality, but all abnormality is 
not disease. The albino, deprived of the usual coloring matter of 
the system, and the individual who has lost a limb, are abnormal, 
but not necessarily diseased. The term disease usually implies 
morbid action, producing suffering or danger; while its opposite, 
health, implies freedom from such positive and decided morbid action, 
but not necessarily the most perfect state. Still the ideal distinctions 
are philosophical, and give more definite impressions of the nature of 
those conditions with which the practitioner has ordinarily to deal. 
A defective organization in structure, power, or hereditary or 
acquired tendencies, defective (deficient or excessive) “life con- 
ditions,” or the presence of directly injurious materials or agencies, 6 
PATHOLOGY AND PRACTICE OF MEDICINE. 
result in modified abnormal actions and states; and when these are 
such as to cause discomfort, inefficiency, or danger, disease exists. 
In consequence of these relations of health and disease—of the physi- 
ological and pathological states—pathology has been called the physi- 
ology of disease, and has very properly been defined “the science of 
life under abnormal or morbid conditions.” 
Many definitions have been given of disease, more or less express- 
ive of its nature ; but from the foregoing statements it will be seen 
to be, Perverted life-processes and their results—such changes in 
structure or function (or both) of the system or any of its parts as 
produce discomfort, inefficiency, or danger. 
With a distinct conception of what constitutes health, the simple 
expression, “ a deviation from the healthy state,” expresses correctly 
the idea of disease. So also with more fulness, as expressed by an- 
other : “ Disease is any condition of the system or its parts, attended 
with impairment or derangement of structure or function, or both, 
tending to render life uneasy, burdensome, or useless, or to shorten its 
duration.” As defined by still another : “Disease is some deviation 
from a state of health ; a deviation consisting for the most part in an 
alteration in the functions, properties, or structures of some tissue or 
organ, owing to which its office in the economy is no longer performed 
in accordance with the normal standard.” 
It will be observed that in all these definitions, and those that are 
quoted are from writers who represent the best general sentiments of 
the profession, disease is represented as a state of the system, and not 
a thing of itself ; as a condition, and not an entity ; as phenomenal, 
and not ontological. 
In the early stage of knowledge and among unenlightened people 
disease has been regarded as something having a distinct existence 
and an identity of its own, as something which possessed the body, as 
a spirit or a demon, or some other peculiar principle, to be driven out 
or destroyed by enchantments, by loud noises, by offensive odors, or by 
specific medicines ; and these ideas, in vague and variously modified 
forms, linger as “relics of barbarism ” in the popular, and even in 
some professional minds. 
It is true, the causes of disease maybe distinct entities—are often, 
as in infectious diseases, materies morbi—substances however minute 
or intangible, yet material substances, which enter the body and in- 
duce the changes constituting disease. But such primary causes are 
distinct from the effects they induce, and diseases are the modified 
actions and conditions produced by morbid causes, and cannot prop- 
erly be conceived of as separate from the body in which they occur. 
A disease, then, always implies a cause of some kind (very frequently DEFINITIONS AND OBSERVATIONS OF DISEASE. 
7 
other than a material substance), and certain changed phenomena 
produced by that cause. This is illustrated by such diseases as 
scabies, small-pox, and scarlatina, where, as is so demonstrable in 
scabies, a particular living material lodges in the body, and produces 
as results the specific phenomena. These phenomena constitute the 
disease, which does not include, though it implies, the cause. 
Some writers have made the term disease embrace the cause as well 
as the effect of that cause. Thus Bristowe defines disease as a “ com- 
plex of deleterious agency acting on the body, and of the phenomena 
(actual or potential) due to the operation of that agency.” It is true 
that some morbid actions of the system, and results within it, often 
induce other morbid actions and results—an effect thus becoming a 
cause—and such cause is a part of the phenomena constituting the 
disease. But causes and effects are logically separable, and a primary 
cause of disease is so distinct from its effects, from the disease itself, 
as to render its incorporation into the definition inadmissible. 
Indeed, the distinction between diseases and their extraneous 
causes is indicated by the fact, which should never be lost sight of, 
that diseased actions are effected by the same mechanism and the 
same forces that produce healthy actions, of which they are but 
modifications. Nothing can be truer or more clearly expressed than 
the statement of this same writer, that the “ processes of disease, 
however widely they may seem to diverge from those of health, are 
merely modifications of them, and their types must be sought in the 
normal physiological processes by which the body is developed, grows, 
maintains itself, and finally dies.” 
There are various elements in particular diseases; some of the 
elements receive distinct recognition and names, and are the causes 
of other morbid elements ; but a specific term, such as cancer, rheu- 
matism, pneumonia, scarlatina, etc., indicates a series of phenomena 
exclusive of the cause setting them in action. The derangements of 
the human body may be compared to those of a piece of artificial 
mechanism, such as an engine or a watch ; the difference being that 
the living human mechanism is much more complicated in its con- 
struction and its different operations, and is subject to various other 
laws than those of simple mechanics. When a watch is perfectly con- 
structed, when the proper force is supplied and no impediment inter- 
feres, its work is properly performed. When that work is not thus 
accomplished, there is a cause in the imperfect state of the mechan- 
ism, in the failure of the force impelling it, or in the presence of some 
obstructing or deranging agency extraneous to itself. The “ condi- 
tions ” of its proper state and activity are imperfect or wanting, or 
some other influence of an injurious character is operating upon it. 8 
PATHOLOGY AND PRACTICE OF MEDICINE. 
When derangement of its actions thus occurs, it is the duty of the 
mechanic who attempts to set it right, first to know the proper struct- 
ure and mechanism of the watch, the principles of mechanics that 
apply to it, and the conditions necessary for its proper movements; 
next to examine its present state, to inquire into its surroundings and 
the agencies that may have affected it, to see whether its wheels are 
in proper order or position, whether its spring has the proper elasticity 
and power, or whether any foreign substance is adhering to its pivots 
or wheels, or has fallen into any part of its machinery. When this is 
done and the difficulty is discovered, lie should proceed according to 
the principles of mechanical science and art, and the dictates of com- 
mon sense, in a rational, but in no theoretical, dogmatic, or specific 
way, using such instruments, regardless of theories, as with least 
injury to the watch will remove the obstruction or remedy the defect. 
It would be absurd to suppose that there was any one universal prin- 
ciple upon which the watch repairer could properly proceed to accom- 
plish his work—certainly no exclusive principle of similia similibus 
would be applicable. In the same manner the physician who under- 
takes to remove or diminish the derangement of the human body 
must first understand the normal structure and functions of this much 
more complex organism and the evidences of its proper state. He 
must know not only the physical structure and the mechanical prin- 
ciples concerned in it, but the chemical ingredients of which it is 
composed, and the chemical reactions and changes so constantly going 
on within it, and the chemical laws that govern such actions. Not 
only this, but he must have such knowledge as is possible of the much 
more obscure and complex life-principle and actions which give it its 
most striking characteristics, for all these elements and laws—mechan- 
ical, chemical, and vital—are present and in operation in the body, 
and each element may be deranged, requiring a remedy of its kind. 
With this knowledge prerequisite, he must proceed to examine, as 
far as he is able, each part, comparing it with the normal standard, to 
discover what is wrong physically, chemically, or vitally. He must 
inquire, in many cases at least, into the past history and present sur- 
roundings of his patient, into all the influences to which he has been 
subjected, in search of causes. He must know what is the natural 
history, the usual course of the particular wrong condition he discov- 
ers, whether it is slight, brief, or self-limited, or severe, protracted, or 
indefinite in duration. He must also know the power and dangers of 
all the agencies, wdtether mechanical, chemical, or vital, which may 
influence the morbid conditions and actions present. In short, he 
must become master of the facts in the case, and proceed on rational, 
but not on any fanciful theoretic principles, to place the system in the DEFINITIONS AND OBSERVATIONS OF DISEASE. 
9 
most favorable condition for tlie performance of its functions, and 
then apply such agencies as science and experience have shown to 
have the power of removing causes safely, modifying wrong actions 
beneficially, sustaining strength when needed, and soothing suffering 
and distress. These are among the fundamental ideas respecting 
Scientific and Rational Medicine ; and when the true nature of disease 
is understood, and the true principles of the science and art are appre- 
ciated, the intelligent and honest student will be saved from the delu- 
sions and the practice of any of the radically false systems which may 
be presented. These are germinal truths, which, once well planted in 
the soil of a sincere and intelligent mind, will take root and grow, 
and, expanding into a more extended series of truths, will exclude 
errors and absurdities; for it is true in the world of scientific truth, 
as in that of business or of faith, to him that hath shall be given, and 
he shall have more abundantly ; while from him that hath not shall 
be taken even that he hath. 
In the management of cases it should ever be borne in mind that a 
sick person is to be treated, and not merely a disease is to be combated. 
Disregarding the effects of the remedies aside from their influence on 
the diseased action, and overlooking the power of endurance of their 
effects by the system, while the disease, as something to be opposed 
and overcome is attacked, might result in the subduing of the disease 
and the patient too. The susceptible female or the feeble child must 
be managed with great delicacy ; and indeed all patients should be 
managed, though without undue timidity, yet with great care. While 
care should be taken to avoid injury, conserve power, and give the 
forces of the system an opportunity to do what they are able to do 
safely and well ; while, as is so often said, “ we must aid nature and 
give her a chance ; ” and although morbid processes sometimes remove 
morbid causes, and in such cases should not be opposed, yet morbid 
processes hate often to be interfered with, especially when their causes 
cannot be reached, and in many cases require to be directly modified 
or suppressed. For example, the increased heat may tend to remove 
the cause of a fever—may be an effort of the system to resist the shock 
of the morbid impression—yet the high temperature itself is a positive 
evil, and, when rising beyond a certain point, is of such great and im- 
minent danger as to call most imperatively for its abatement. So, in 
other cases, symptoms having the effect to remove the causes, as in 
vomiting and diarrhoea in cases of irritating materials in the aliment- 
ary canal, may yet go to such an extent as to do great mischief, and 
require suppression. 
If Nature was altogether wise and sufficient in all her efforts at 
remedying evils, there would be no need of the aid of art, and phy- 10 
PATHOLOGY AND PRACTICE OF MEDICINE. 
sicians would be useless ; but slie is not always thus wise and efficient; 
and in all cases whether to allow nature, upon which we always 
depend for ultimately establishing healthy action, to take its unaided 
and full course, or whether to interfere with positive agencies con- 
trolling activities and results, the intelligence and judgment of the 
physician must determine. 
From all these definitions and statements respecting the nature of 
disease (and they have been made so fully because of the great impor- 
tance of having accurate conceptions of these elementary facts and 
principles), it will be clearly seen that diseases are entirely phenom- 
enal, are conditions and actions physical, chemical, or vita], existing 
in and performed by the natural organs and forces of the system, but 
changed from their normal and healthy state by unfavorable condi- 
tions or agencies. It will be further seen that in properly exercising 
his functions as a healer of men, the physician must have scientific 
knowledge as a foundation, must know the nature and condition of 
both the healthy and morbid states of the system with which he has 
to deal, and must proceed on scientific and common-sense principles, 
without exclusive dogmas based on fanciful theories, availing himself 
of the light of all reliable experience in selecting such remedies as 
will tend to correct what is wrong and will do as little injury as 
possible, either immediate or remote, to the patient confided to his 
care and judgment. 
The whole range of the sciences, the observation of nature, the 
contemplation of analogies, the studying of various authors, learning 
from the experience of others as wrell as from that of his own, the 
recognition of differences of constitution, of the influence of locality 
and season—in short, all knowledge and all observation, so far as the 
capabilities of the mind will go, should be made available in coming 
to correct conclusions and in exercising the highest skill. 
These general observations cannot be better concluded than by 
quoting the advice of Lord Bacon (so applicable to students and 
practitioners of medicine), as translated and paraphrased by Sir 
Thomas Watson in his classical Lectures on the Practice of Medicine : 
“ Be not like the empiric ant, who collects from every side indis- 
criminately for present wants; nor speculative like the spider, who, 
seeking no materials abroad, spins his web of sophistry from the 
recesses of his being ; but imitate rather the praiseworthy bee, who, 
gathering crude honey from various flowers, stores it up within, and, 
by his own operation, matures and perfects it for future use.” PHYSIOLOGICAL OBSEB VA TIONS. 
11 
PHYSIOLOGICAL AND PATHOLOGICAL OBSERVATIONS. 
Before proceeding to consider those primary changes constituting 
the elements of disease, a more particular reference to some facts in 
physiology, the basis of pathology, will facilitate an understanding of 
our subject. 
Life, as we have already seen, comprises the formation and main- 
tenance of the tissues and organs, and the exhibitions of their various 
functions. 
The term Nutrition is applied to all those particular processes by 
which the body, from its earliest beginnings until the completion of 
the circle of its existence, is nourished, developed, and maintained. 
It consists in the continuous supply of new materials, in the elabora- 
tion of them, in their separation from the blood and their appropria- 
tion by the tissues ; and it also comprises the carrying away from the 
tissues and eliminating from the system the products of waste. 
Function is the performance of the special role of a part—the 
execution of the purpose it serves in the economy, as distinct from 
the growth, development, and maintenance of its structure. The 
function of a muscle is its action in producing motion; that of the 
heart and vessels in circulating the blood ; that of a gland in elabo- 
rating and separating a material subserving some useful end ; that of 
the brain in producing thought and purpose, etc. 
The performance of the function of an organ, of whatever hind, 
though not an act of the nutritive process in the organ, is entirely 
dependent upon nutrition : and the character of the function is 
dependent upon the character of the nutrition. 
Unless the blood, so important an agent of nutrition, finds its 
way to the organ, unless nutrient materials are furnished and appro- 
priated, whether that function be motion, secretion, or intellection, 
it inevitably ceases ; and when nutrition is imperfectly performed 
the function is impaired. The nervous system exerts an important 
influence over nutrition in all the higher animals, and its irregu- 
lar action often results in deranged nutrition and imperfect function. 
When nutrition and function are normal, there is health ; when 
materially perverted, there is disease : and as the perversion of func- 
tion depends chiefly, if not entirely, upon that of nutrition, disease 
for the most part, and certainly so far as structural changes are con- 
cerned, is perverted nutrition. 
There are several conditions necessary to healthy nutrition. As 
enumerated by Paget, there must be : 1. A proper and not far dis- 
tant supply of blood. 2. A proper composition and state of the 12 
PATHOLOGY AND PRACTICE OF MEDICINE. 
blood. 3. A proper nervous influence. 4. A proper condition of 
the part to be nourished. 
In closely studying these conditions, it is found that the last is of 
primary importance. Nutrition is chiefly dependent upon, and per- 
formed in and by, the solid tissues ; and although the supply of blood 
is absolutely essential, its condition and supply depend chiefly upon 
the action of the solids, and the blood is secondary in the process. 
The solid tissues which are being nourished, select, abstract, appro- 
priate, and elaborate the materials which are supplied to them by the 
blood, and upon their vital endowments the existence and character of 
the process immediately depend. From this view, the origin and 
characters of the tissues are seen to be subjects requiring careful 
study. 
Since the times of Remak and others, who have studied the 
minute and most ultimate structures by means of the microscope 
and other improved methods of modern science, a viscid, colorless, 
albuminous, and apparently homogeneous matter, insoluble in water 
and coagulating when deprived of life, has been regarded as the first 
origin of every living thing. This material has received the name of 
protoplasm or bioplasm, or, as occurring in the animal body, animal 
sarcode. This substance is contractile, has the power of motion 
Avithin itself; appropriates nourishing materials ; is germinal—capa- 
ble of multiplication and developmental changes ; and in a quiescent 
state assumes rounded or oval forms of small microscopic size, which 
have usually a degree of organization, and are called cells. This 
bioplasm, as its name indicates, is regarded as the material of life ; 
and the cell composed of it is spoken of as the “unit of life.” When 
the cell is fully formed, it is described as consisting of an outer cover- 
ing or investing membrane, inclosing more soft or semi-fluid con- 
tents, in Avhich is usually embedded one or more small points of more 
solid material, called nuclei, and sometimes in each of these still 
other points, called nucleoli. 
The outer covering, or cell wall, is called by Beale “ formed 
matter; ” is less active or vital than the contents—especially than 
the nuclei, which latter appear to possess the highest vitality. But 
neither the outer Avail nor the nuclei are iioav considered essential to 
the cell as a life element, the rounded particle of molecular proto- 
plasm being regarded as sufficient to constitute this “unit of life.” 
The nucleated cell, hoAvever, is regarded as the typical life form, 
though simple protoplasm is the essential basis material of which it 
is constituted. These cells have different degrees of vitality, accord- 
ing to their age and other circumstances, and assume different shapes 
as they exist in tissues; and many are differentiated or developed into PHYSIOLOGICAL OBSERVATIONS. 
13 
the material of the various organs of the body. But in the tissue of 
the organs more or less of these cells remain in some of their cell- 
forms, constituting the most vital and active part of the tissues. 
Every organized part is either cellular or composed of forms derived 
from cells ; and it is a cardinal principle, insisted upon so vehemently 
by Virchow and others, that cells originate from pre-existing cells, 
or at least from living germinal matter; and it is generally admitted 
that under no circumstances, so far as has been proved, do they 
originate cle novo, or from matter of another form and not living. 
These bioplastic molecules in the form of cells being the ultimate, 
if not exclusive, morphological elements capable of exhibiting mani- 
festations of life, in a complex organism the phenomena of life are 
the result of the continued activity of innumerable molecular masses 
or cells. Many of these cells possess peculiar functions, but the 
separate cells are united, some by contact and others by influence, 
and their combined action results in various functions. All of the 
ultimate processes of life, healthy and morbid, have been considered 
as consisting of molecular motion, more distinctly manifested in the 
nucleated cell. This cell, especially in its early and embryonic ’state, 
is endowed with remarkable power. Under favorable circumstances 
of warmth, moisture, air, materials for food, etc., it throws out pro- 
cesses and otherwise alters its form; it absorbs solid particles and 
thus increases its protoplasm ; it moves from place to place ; it dis- 
charges effete matter from itself, and thus grows and is maintained; 
and it multiplies by methods of simple division, by gemmation or 
budding, and by endogenous development. As already stated, these 
cells are capable of differentiation, of changes of form and arrange- 
ment, of the production of fibres and other tissues, and ultimately 
organs and organisms, according to the impulses derived from their 
origin, or the type-force of the parent cells, tissues, or organisms. 
Each cell, then, has a life of its own, and, in an important sense, a 
separate and individual existence. It has its period of development, 
activity, and death. Though varied in its action by different influ- 
ences by which it is surrounded, it has an independent action origi- 
nating in itself. According to the doctrine of pangenesis each living 
molecule may reproduce itself; and each cell, as we have seen, has 
the power of reproduction, and, in accordance with a general law, it 
tends to reproduce after its kind. This is illustrated in the vegetable 
world by a minute portion of a leaf of the common begonia, which, 
when placed under favorable conditions, develops into an entire 
plant; and the common operation of skin-grafting illustrates the 
separate vitality and multiplication of animal cells. The production, 
development, and maintenance of a human body, through all its stages, 14 
PATHOLOGY AND PRACTICE OF MEDICINE. 
is a series of generations, growth, and decay—generation and decay of 
molecules and cells, and growth, maintenance, and ultimate death of 
the body itself. 
In the process of the sexual generation of man and other animals, 
the egg-cell of the maternal, and the sperm-cell of the paternal, parent, 
each having its own characteristics, meet and blend together ; and the 
resultant vitalized cell partakes of the impulses and characteristics of 
both. 
The peculiar life of this resultant cell is the product of the 
paternal activities transmitted through the sperm-cell, together with 
maternal activities transmitted through the egg. These primary 
cells become many, and the early embryo is composed of cells in a 
very active state of vitality. In the vertebrata these fertilized embry- 
onic cells are arranged first into two, then into three, and ultimately, 
according to Kemak, into four layers. The upper stratum of the 
primary layer is described as a serous, and the lower as a mucous, 
layer. The third or intermediate layer is produced by the division of 
the lower or mucous layer ; and this third at a later period divides 
again. From these different embryonic cellular layers are produced 
different tissues and parts of the body. 
From the upper serous layer proceed those cells which compose 
the outer skin (the epidermis) and its appendages—hair, nails, etc.,— 
and remarkable as it is, this layer also produces the cells which con- 
stitute the central nervous system, the brain and spinal marrow. 
From the lower or mucous germ-layer are developed the cells 
which form the epithelium of the mucous or internal lining mem- 
brane of the alimentary canal, and that of the ducts of the glandular 
and other organs communicating with it, the lining of the ducts of 
the liver, lungs, salivary glands, etc., including all the tissues that 
take up the food and perform the work of digestion. From the mid- 
dle germinal layer, situated between the serous and the mucous, and 
which ultimately subdivides, arise all the other tissues of the body— 
the vascular system, ductless glands, flesh, blood, bones, and liga- 
ments, and the widely distributed connective tissue which is found in 
every organ and part of the system. The middle embryonic layer 
which produces all these tissues is called by Kemak the “ motor- 
generative ” layer; and he found that in its subdivision the upper 
part of the cleavage formed the true skin, the muscles, and the bones, 
while the lower part produced the alimentary fibrous lam el las, or 
serous membranes forming the outer covering of the alimentary canal, 
and also the heart, the blood-vessels, and other like parts having 
serous envelopes. 
These details may seem not to belong to our subject; but pathology PHYSIOLOGICAL OBSER VAIIONS. 
15 
is based upon physiological details, and a knowledge of the diverse 
origins of different tissues and organs may afford suggestions or 
explanations respecting the spread of diseases to various parts, or the 
sympathetic connections which may be found to exist. The simple 
tissues are variously grouped into organs; and the different kinds of 
tissue are arranged by Virchow into epithelial, connective, and higher 
grades, as those of the parenchyma of organs. The functions of 
organs having similar tissue origins are very various, but they may 
have other relations depending upon such origins not yet traced. 
The connective tissue derived from the middle embryonic layer 
pervades all parts of the body, forming an extensive net-work, receiv- 
ing and protecting the higher tissues, the elements of the organs. 
This connective tissue is largely composed of cells, often very small, 
commonly nucleated and walled, sometimes rounded and isolated, at 
others stellated with the processes joining other cells. Epithelial cells 
are in close contact, while connective-tissue cells are often separated 
by intervening substances, either lifeless deposits (calcareous, pigment- 
ary, etc.) or higher living material, the peculiar tissues of special 
organs. There are several varieties of these connective-tissue cells, 
all being somewhat specially liable to pathological changes, and there- 
fore of much interest in the study of disease. 
As ordinarily found in fasciae and tendons, the cells are compara- 
tively scanty, are mingled with white and yellow elastic fibrous, bands 
and with the mummified bodies of dead cells. In cartilages these 
cells are rounded or oval, an elastic homogeneous material intervening. 
The lacunae and canaliculi of bones mark the position of cells 
and their radiating processes, the proper earthy bone deposit being 
between. The central nervous organs and the lymphatic glands have 
what are called “retiform” connective-tissue cells, minute and 
s 
stellate, the rays delicate, apparently homogeneous, inclosing exceed- 
ingly small spaces filled in the respective organs with proper brain 
and gland substances. 
The mucous variety of connective-tissue cells is abundant in the 
foetus, especially in the umbilical cord ; but in adults it is found.only 
in the vitreous humor of the eye, the spaces containing fluid and 
mucine. In dark tissues, such as the choroid coat and the spinal 
pia mater, connective-tissue cells contain pigment, and in various 
places they contain oil, constituting in these different cases pigment 
tissue and fat tissue. The functions of the various cells so abundant 
in the body, and particularly those of the cells of the connective 
tissue, have received great attention, particularly from Virchow and 
others of his school, who contend that upon the protoplastic particles 
and their stellate processes—upon these cells found in this net-work 16 
PATHOLOGY AND PRACTICE OF MEDICINE. 
sustaining every element and organ of the body—the life actions, the 
growth and maintenance of the organism, immediately depend. 
Each individual cell being a “ unit of life,” Virchow thinks, has 
a minute “ cell district ” over which it presides ; and late observa- 
tions seem to indicate that a nerve filament penetrates to the mi- 
nutest part. 
The mode of tlxe composition of the various structures, from cells, 
differs in different cases. 
Tubular tissues, nerves, nerve-cells, muscular fibres, capillary 
vessels, and all organs are produced by the juxtaposition and coales- 
cence of protoplasm specialized into cells. 
The composite organs, such as brain, glands, muscles, etc., are 
made up by association of the more elementary tissues developed from 
cells, with more or less of the cell forms still remaining, especially 
in the net-work of connective tissue distributed through them. The 
non-vital elements—chemical compounds, distributed in the inter- 
stices of the living elements—are prepared and deposited under the in- 
fluence of living matter and the vital force, and are influenced in their 
changes and continuance in the parts by the living matter near them. 
The doctrine now held, and which it has been the object of the 
foregoing statements to express, may he summarized by saying : 
That the living matter which carries on the life functions is in the 
form of cells, generally nucleated, and chiefly in those which are so 
universally distributed in the net-work of the connective tissue ; but 
life functions are also performed by the free corpuscles in the cir- 
culating fluids, blood and lymph, which have the characters of cells, 
and have a similar vitality to that of other cells. 
Accordingly, in a complex organism, the phenomena of life are 
the results of the continued activity of innumerable molecules, or of 
living protoplasmic particles, usually in the form of cells; different 
cells possessing peculiar functions, but all more or less intimately 
united in sympathy and influence; and being all supplied by the 
same blood, and under the control of the one nervous system, act in 
harmony, and result in the various functions of the body. 
It follows from this, that in the cells is the seat of nutrition, that 
their normal actions result in healthy nutrition, and their abnormal 
actions in morbid nutrition ; and disease being perverted life actions, 
and for the most part perverted nutrition, the immediate seat of 
disease is in the cells, and is thought to be chiefly in the cells of the 
connective tissue. In the cells of the tissues all morbid structural 
changes occur, as well as all healthy nutritive processes ; but morbid 
changes in the cells of the blood also result in various perversions 
of function in different organs. PHYSIOLOGICAL OBSERVATIONS. 
17 
We thus come at the very citadel of disease, and from this point 
can better understand its nature, and may survey with more precision 
its outposts and approaches. It is at this point that the ultimate 
physiological actions take place, and pathological actions are but 
modifications of the physiological. 
Though in the solids of the body healthy nutrition and its mor- 
bid changes constituting disease have their more particular seat, yet, 
as just stated, the fluids are essentially concerned in many of these 
processes; and in the blood and lymph we have cells composed of 
solid or semi-solid matter, with a full endowment of life properties, 
differing from cells in the solid tissues chiefly in their greater isola- 
tion from each other and their mobility, floating, as they do, in a 
circulating fluid. 
For a full account of the structure, chemistry, and physiology of 
the blood, the reader is referred to the works on medical chemistry 
and on physiology ; but some of the facts respecting this “ fluid flesh,” 
and “ the life of all flesh,” as it has been called, are so important in 
physiological and pathological processes, that they require a notice in 
this connection. 
A nutritive fluid circulates through the tissues of all organized 
beings, and is essential to the carrying on of vital actions. In plants 
it is the sap ; and in the higher organized animals it is blood and 
lymph. Both these fluids carry nutrient materials ; and the blood, in 
addition, is the medium of distribution to all parts of the system cf 
oxygen—the element so immediately essential to all life. 
The blood has still another function. It receives into itself the 
results of the destructive metamorphosis of worn-out tissues, and car- 
ries them to the excreting organs for elimination. The lymphatic 
vessels sometimes carry other than nutrient materials—absorption of 
medicines and diseased products taking place through their coats and 
being conveyed through them to distant parts ; but the full functions 
of the lymph and lymph vessels are less understood than those of the 
blood. 
Some who take a very physical and chemical view of all life proc- 
esses regard the development of all life force as the result of the ox- 
idation and destruction of the tissues manifesting such force, as the 
simple result of force set free by the combination of oxygen with 
carbon and hydrogen, similarly to the movement of the steam-engine 
by the combustion of fuel ; but whether this be the true view or not 
—and it is a matter certainly admitting of question—there is more or 
less wear and destruction constantly going on in active parts, and the 
effete material, the result of such destruction, requires constant re- 
moval, which the blood is a medium in effecting. Tissues are chang- 18 
PATHOLOGY AND PRACTICE OF MEDICINE1 
ing at all times, but more rapidly in violent action, while repair goes 
on perpetually, and its results, if not its activity, are more manifest 
when the body is in a state of comparative repose. 
Wherever repair or growth takes place, the material of the produc- 
tive action must be supplied, and food, of course, is essential. It is 
estimated that an ordinarily active man receives into his system some 
3,000 pounds of matter, solid and liquid, in the course of a year, and 
in simple maintenance loses as much ; while in the growth and health 
of youth the supply is greater than the loss, and in the decay of age 
and disease the loss is greater than the supply. 
The blood as circulating in the healthy system is an albuminous 
fluid, charged with salts, holding fibrine in solution, and containing 
colored and colorless corpuscles. Its specific gravity averages about 
1.055, but varies from 1.050 to 1.059. In angemia from hemorrhage or 
other causes, its specific gravity is much less; and in plethora, or 
after much sudden loss of its watery parts by profuse liquid dis- 
charges, as in cholera, its specific gravity is greater. Its temperature 
is about 100° R—is'higher in the right side of the heart than in the 
left, and is higher in the hepatic veins than in any other part of the 
body. Its reaction is constantly alkaline during life, but is some- 
times acid after death, by the conversion of its sugar into lactic acid. 
Its quantity has been variously estimated ; but the heart, the arteries, 
and the veins of an adult man have not a capacity for more than about 
ten pounds, though an additional quantity may be in the system, con- 
tained in the minute capillaries and the tissues. The Avhole fluid 
portion of the blood, consisting of water, with salts, albumen, and 
fibrine in solution, is called the liquor sanguinis, or plasma. When the 
fibrine is coagulated and removed from the plasma, the remainder is 
called serum. The floating corpuscles in this liquor sanguinis are the 
more vitalized portions of the blood, and are of two kinds, white 
and red—the red flattened discs, the more numerous in the proportion 
of 370 or 400 to one of the white, average of an inch in the 
largest diameter and much less in thickness, are generally said to be 
without nuclei, though some recent observers think they have seen 
them in some of the discs. The white corpuscles, or leucocytes, 
are globular in form, slightly granular upon the surface, average 
xoVo of an inch in diameter, and are very similar in appearance to the 
corpuscles found in lymph and chyle, and to pus corpuscles. The 
leucocytes have nuclei, and some have regarded them as the more 
complete cells, and the lymph and chyle corpuscles as nuclei. These 
white-blood cells, or leucocytes, perform a very prominent part in 
certain processes of disease, as we shall hereafter have occasion to 
describe, passing with readiness through the coats of the vessels and PHYSIOLOGICAL OBSERVATIONS, 
19 
mingling with the elements of the tissues; and it seems at least possi- 
ble that in health they are capable of somewhat similar actions, and 
take some part in the supply of normal tissues. 
Besides these well-known morphological constituents of the blood, 
the higher powers of the microscope show also minute molecules or 
granules floating in it, and, during digestion especially, small fatty 
particles. 
There is an immense difference between the blood which enters and 
that which issues from the lungs. In the lungs it receives oxygen and 
loses its carbonic acid—is converted from venous into arterial blood; 
and the arterial blood is the supporter of life. Death follows the 
complete arrest of the circulation of arterial blood, and also the circu- 
lation of venous blood in the arteries, though carried by these vessels 
to the tissues. Arrest of circulation arrests nutrition, and the arrest 
of nutrition is death. The cessation of circulation is but a step from 
death, and that step is taken without delay. 
The arrest of circulation may be due to the suspension of the action 
of the nervous system, leading to suspension of the heart’s contrac- 
tions, or to the arrest of the movement of respiration, as a constant 
nervous influence is necessary to keep these parts in action ; or the 
morbid conditions suspending their actions may be in the heart and 
vessels, or in the lungs and respiratory passages themselves. The 
blood itself may be in so morbid a condition, or so deficient in quantity 
as to fail to sustain nutrition, when death is the result from that 
cause. A morbid condition of any of these parts, short of producing 
death, may cause such deficient or perverted action of the respiratory 
or circulatory system, or of the blood, as to lead to abnormal nutrition 
and the consequent phenomena of disease. 
When removed from the vessels the blood coagulates, or forms a 
clot, by the fibrine previously held in solution becoming solid, taking 
the form of small thread-like fibres, arranged in different directions, 
and forming a net-work or felting, in the meshes or interstices of 
which the blood corpuscles are held, leaving more or less of the serum 
to separate from the mass. The causes of this coagulation are obscure, 
and none of the theories proposed to account for it are satisfactory. 
In certain diseased states the blood coagulates in the system, and may 
result in most serious consequences. It usually coagulates when pass- 
ing out of the vessels into cavities or tissues, and sometimes clots form 
in the heart or vessels, and passing with the current of the blood to 
smaller branches, obstruct them, arresting circulation, nutrition, and 
function in the parts supplied by such vessels. . 
The conditions favoring such coagulation in the heart or vessels 
are : stagnation of the blood in them ; disease of their walls ; contact 20 
PATHOLOGY AND PRACTICE OF MEDICINE. 
with other diseased structures ; morbid products, as pus and sanies, 
mingling with the blood; obstructive disease of the heart; and great 
elevation of the temperature of the body. Besides these, a diminished 
vital influence of the vessels and tissues, from diminished or perverted 
nervous supply, may tend to the same result. 
The blood receives substances into itself from the air, from the 
food through the alimentary canal, and from the metamorphosis of 
tissues ; the materials from the latter source to be carried out by the 
excreting organs. Various medicinal and poisonous agents find their 
way into the blood through the stomach, lungs, skin, or any mem- 
brane, or by being injected into the vessels or the tissues. In what- 
ever way introduced into the fluid, they may affect its composition, 
thus indirectly affecting the solids ; or these materials may be carried 
by the blood directly to solid tissues, impressing the nerves or modify- 
ing the action of cells, producing a great variety of unnatural impres- 
sions and morbid results. The zymotic diseases are produced by poi- 
sons, supposed to be germinal, taken into the blood, and probably into 
the lymph, affecting changes in the fluids and cells by some process 
resembling the action of ferments. 
The operations of poisons taken in from without or generated 
within the system, harbored and carried by the blood, are among the 
most specific and frequent causes of the well-defined forms of disease. 
The view so clearly expressed by Sir James Paget, in his Surgical 
Pathology, that each single part of the body, in respect to the nutrient 
matter it receives and appropriates, stands to the whole body in the 
relation of an excretory substance, possesses a truth of some im- 
portance ; as, if a part cease to receive the material prepared in the 
system for it, the blood may retain that material, and it may affect 
other parts abnormally, in a similar manner as when an excretion 
proper is retained. As an example, the phosphate of lime normally 
deposited from the blood in the bones is the same substance, with 
the same relations to the system, as that which is secreted from the 
kidneys and passes out with the urine. If retained in the blood and 
not deposited in the bones, where it should be, it might be deposited 
injuriously elsewhere, or it might do other mischief to the organism. 
So the failure of nutrition in any part may leave materials in the 
blood which may modify in different ways the actions and con- 
ditions of other parts of the body. Thus, through the blood and the 
nutrition, the different parts of the body are connected together, so 
that the state of one part has an influence on others. 
The blood being so largely an agent of nutrition, its proper state, 
as we have seen, is necessary to healthy nutrition. In order that it 
may be in a proper state, there must be proper blood-making and PATHOLOGICAL BLOOD CHANGES. 
21 
proper blood-purifying processes. In order to the making of proper 
blood, there must be proper food, and that food must be properly 
digested, absorbed,, and elaborated. This proper digestion and elabo- 
ration requires the proper action of several organs—the stomach, 
liver, pancreas, etc.; and the proper purification of the blood requires 
the action of still other organs—the lungs, the kidneys, the skin, etc.; 
and in order that these organs may rightly perform their functions, 
they must in turn be properly nourished with healthy blood. This 
illustrates the mutual dependence of the different parts through the 
blood and the functions. 
A more full account of the particular affections of the blood will 
be given in connection with descriptions of the diseases in which they 
occur ; but a brief enumeration of the more common pathological 
changes to which it is liable, may be proper in connection with the 
subject of the immediate influence of the blood in producing path- 
ological phenomena. 
Following the arrangement of Dr. Flint, in his work on the 
Principles and Practice of Medicine, Diseases of the Blood may be 
considered under the following heads : 
1. Changes in quality or quantity of its natural and essential con- 
stituents. 
2. Accumulations in excess, of excrementitious substances. 
3. The presence of foreign or abnormal substances developed in 
the body. 
4. Foreign injurious substances introduced from without. 
5. Other, but undetermined, blood changes. 
Under the first head are the following changes, which will simply 
be named and defined : a. Plethora or Polyaemia—which consists in 
an abnormal quantity of the blood, and particularly of the red discs. 
b. Anaemia—the opposite condition to the last—consists in a defi- 
ciency of blood, and particularly of the red corpuscles, c. Spanaemia 
—which is an impoverishment of the blood—a lowered state in the 
richness and vitality of its ingredients, d. Necrsemia—death of the 
blood or of some of its vital ingredients, e. Leucocythemia or leu- 
caemia—an abnormal increase of the white corpuscles, and commonly 
a marked diminution of the red. f. Uyperinosis—morbid increase of 
the fibrine. g. Ilypinosis—a diminution of the fibrine. h. Throm- 
bosis and Embolism—an increased coagulability of the blood, induc- 
ing the formation of clots in the vessels, i. ITypcralbuminosis— 
excess of albumen, j. Hvpalbuminosis—the opposite state or defi- 
ciency of albumen, h. Ilydraemia—excess of water in the blood. 1. 
Anhydrasmia—diminution of the water, m. Lipaemia—excess of fat, 
fatty embolism, n. Anlipaemia—deficiency of fat. o. Mellinaemia 22 
BLOOD CHANGES—NER VO US INFLUENCE. 
or Glychsemia—excess of sugar, p. Excess or diminution of tlie 
salts of the blood. 
Under the second head are found : a. Uraemia—an excess of urea. 
b. Uricaemia or Lithaemia—an excess of uric acid. c. Cholaemia—an 
excess of bile in the blood, d. Cholesteraemia—an excess of choles- 
terine. e. Excess of carbonic acid. /. Excess of perspiration mat- 
ter. g. Fecal exuviae absorbed into the blood from intestines. 
Under the third head are : a. Pyaemia—pus in the blood, b. Sep- 
ticaemia—septic or decomposing putrefying matter in the blood, c. 
Ichorrhaemia—ichorous matter or impure pus in the blood—all these 
three latter conditions being similar, and not easily distinguishable 
from each other, d. Oxalaemia—oxalate of lime in the blood, e. 
Ammoniaemia—ammonia in the blood. /. Melanaemia—black pig- 
mentary substance in the blood. g. Acetonaemia—acetone in 
the blood, h. Zymotic viruses—poisons developed in the system 
and existing in the blood in various infectious and contagious 
diseases. 
Under the fourth head are : a. Zymotic poisons, generated exter- 
nal to the human body, or within another, and taken into the blood 
from without, including viruses, contagiums, miasms, malaria, crowd- 
poisons, and venoms—the secretions of animals in their normal state. 
b. Various poisons, mineral and vegetable. 
Under the last head, or that of undetermined blood affections, are 
doubtless many conditions, such as changes in the form, size, vitality 
and activity of the red discs and white corpuscles, disposing the one 
kind to adhere together, and the other to migrate freely from the 
vessels, and both to act abnormally in various ways. 
But not only are the cells of the solid tissues, and the fluids, the 
blood and lymph, immediately concerned in nutrition, healthy and 
morbid, but the nervous system, as already repeatedly indicated, is 
also an essential agent. In all the higher animals the brain and 
nerves exert a direct influence over the cells of the tissues, which we 
have seen are the more immediate seat of the different changes of 
health and disease; but the brain and nerves control the action of the 
heart, and through the vaso-nervous system, the arteries, capillaries, 
and veins—all the vessels that supply the blood. The nervous system 
also controls the action of the lungs, the kidneys, and all the other 
organs that purify this fluid ; and the functions of the stomach, the 
liver, and other organs which are concerned in forming it. 
The nervous system and its various actions must be taken into the 
account when attempts are made to explain the manner in which disease 
is produced. Indeed, in diseased action, this system is often the first 
to suffer the impression of the morbid cause, and in the progress of INDEPENDENT MUSCULAR ACTIONS. 
23 
diseases it is through it that many of the most dangerous phenomena 
are induced. 
Not only the organic nerves specially controlling circulation, calor- 
ification, secretion, etc.—both the exciting and inhibitory—but the 
parts of the brain the seat of sensation, thought, emotion and will, 
and the nerves concerned in sensation and voluntary action, exert an 
influence directly or indirectly upon those changes constituting dis- 
ease. The method of this influence may not be understood, but the 
fact of its existence and great power cannot be questioned. The most 
recent investigations indicate that nervous filaments are distributed to 
the minutest parts, and reach certainly by their influence each minute 
cell. The nerve influence upon the tissues has lately had additional 
light thrown upon it by the experimental observations of Dr. Brown- 
Sequard. He has noted the power possessed by the central nervous 
system, under the influence of certain irritations, of arresting the 
nutrition in different tissues and organs. The maximum arrest of the 
interchange between the tissues and the blood is produced by an 
excitement, as a puncture, near the point of the calamus scriptorius, 
but it is also caused by stimulation of other parts of the cerebro-spinal 
centre, and even by irritation of the sensory nerves. 
The medulla oblongata and spinal cord exert so much influence 
upon nutrition that it can be arrested by merely flexing the head sud- 
denly upon the thorax. Two effects have been observed—the blood 
in the veins, previously dark, becomes almost immediately bright red ; 
and the temperature of the animal falls. 
Various tests were applied, rendering it certain that these effects 
and others upon the calibre of the vessels were produced by irritation 
of the medulla and spinal cord, showing the influence of the nerve 
centres upon the organic processes. 
Vaso-motor action, or the influence of the nerves and other agen- 
cies over the action of blood-vessels, over their dilatation and con- 
traction, is of great importance, and has of late occupied much of the 
attention of physiologists and pathologists. That the nerves, par- 
ticularly those designated as vaso-motor, have great influence upon 
the vessels there can be no doubt; but there are other agencies, as 
well, acting more directly upon the vessels and other contractile tissues. 
It has very recently been found by Dr. W. II. Gaskell, that the 
nerveless apex of a frog’s heart, separated from the rest, will perform 
its rhythmical contractions under the stimulus of electricity, and also 
under that of an increased pressure of the frog’s own blood, and of an 
artificial blood solution, independent of the action of nerves. 
It has been very lately ascertained that a dilute alkaline solution 
will excite contractions in an isolated and quiescent nerveless apex, 24 
EXTENSION OF MORBID ACTION 
and if the action of the alkali be continued, the muscle goes into a 
condition of tonic spasm, stopping in systole. On the contrary, an 
acid solution (lactic and acetic acids were used) produced relaxation 
of the heart, and it stopped in diastole. The actions of alkalies and 
acids were antagonistic, one oxercoming the other, but neither of 
them was permanent in its effects, as an artificial blood solution 
would restore rhythmical action. 
It was further ascertained that certain poisons, as antiarin (that 
of the upas-tree) and digitalin, act as do alkalies, causing increased 
tone irrespective of contractions ; whereas muscarin and pilocarpin 
act like the acids, causing loss of tone. Atropine acts in the same 
manner as the alkalies. Not only the heart, but the muscles of the 
smaller arteries are affected in the same way by the alkalies and acids 
and the other agents, when nervous influence was apparently excluded. 
These experiments have shown that, aside from the influence 
exerted through the nerves, local conditions—the nature of the fluid 
surrounding the muscular fibres—affect their condition. Tonicity is 
augmented by the increased alkalinity of the fluid,'and diminished by 
its lessened alkalinity. The alkalinity of muscular fluids is modified 
by various conditions—by ingesta, by exercise, etc. The practical 
bearing and importance of these facts will be readily seen. Not only 
physiology and pathology, but therapeutics, may be greatly influenced 
by them. The nerves being sent from common centres in all direc- 
tions, each part of the body is joined through their distribution to 
every other part, uniting all in sympathy, and producing a unity of 
organism and action out of a diversity of tissues and organs. 
Morbid Actions strictly local in their beginning, as from a 
mechanical or chemical injury, extend to other parts and in various 
ways. They may extend : 1. By continuity and contiguity, by spread- 
ing on in the same structure by the contact of similar cells and tis- 
sues ; and also by nearness of parts, though dissimilar, by some influ- 
ence through the blood, nerves, or tissues found to be exerted by 
diseased structures over others in their neighborhood. 
2. Diseased actions spread, as has already been intimated, by the 
blood and lymph carrying morbid materials from the diseased to 
other parts, and also by that relation of different parts through 
the blood and the nutritive process by which one part bears to 
others the relation of an excretory substance. 
3. Disease in one part may extend to another by similarity of the 
structure and functions of the two. Similar parts engaged in the 
same work, supplied by similar vessels, and having the same relations 
to particular nutrient materials in the blood and lymph, are more 
liable to be affected in a similar manner. DEPENDENCE OF FUNCTION—SYMPATHY. 
25 
4. Diseases extend by sympathy conveyed through the nervous 
system by reflex action, and probably by direct nervous communica- 
tion, to parts distant and diverse from each other. 
The manner in which disease of one organ may affect others 
through dependence of function has already been stated, and may be 
illustrated by examples. Disease of the stomach, by preventing the 
proper digestion of food, will produce weakness and derangement of 
the whole body ; and disease of the kidneys, by interfering with the 
elimination of urea and causing its retention in the blood, will 
poison the whole system, causing a variety of morbid effects. But by 
sympathy proper, effects are produced in a different way. 
Sympathy, as the term is here used, is such a relation of different 
parts through the blood and the nerves, that the conditions of the 
one, change the conditions of others without dependence of function. 
The sympathy established through the blood and lymph has been 
sufficiently stated. That through the nervous system is more fre- 
quently and more strikingly manifested, arc! is a matter of much 
practical importance. 
For more full details of reflex and general nervous action, the 
reader is referred, as in the case of the blood, to the works on 
physiology. It may, however, here be stated, that in the spinal cord 
particularly, but also in the brain and ganglionic nerves, there are 
reflex centres, to which impressions are carried by one set of nerves, 
and from which they are reflected back by another, producing some- 
times sensation, sometimes motion, and sometimes modifications of 
nutrition and secretion, and resulting in various changes, physiologi- 
cal and pathological, in parts distant from the point where the 
first impression is made. 
Keflex action of all kinds—motor, sensory, or nutritive—whether 
conveyed through the cerebro-spinal nerves or the ganglionic, is inde- 
pendent of will, and reflex muscular motion as well as organic effects 
may be induced in unconscious states. By tickling the foot of a 
sleeping child, an impression is conveyed to the spinal cord through 
an afferent nerve, and conveyed back through an efferent motor fila- 
ment, and the foot is drawn away without the consciousness or act of 
will of the child. 
This illustrates the principle of reflex action, and shows one 
method by which impressions upon one part affect others distant and 
diverse. But, as already stated, impressions may doubtless be conveyed 
directly through nerves from one part to another without being 
reflected from a centre. But whatever the method, the fact is evident 
that conditions of one part affect those of another through those nerv- 
ous connections which aid in constituting the body a single entity. 26 
SYMPATHY. 
Sympathy between two parts is said to be direct when the con- 
dition of one part induces a similar condition in another. It is 
indirect sympathy or antagonism when a particular condition of one 
part causes an opposite one in another. When an irritation or 
inflammation in one part, as of the uterus, causes a similar irritation 
or inflammation in another, as of the peritoneum, the sympathy is 
direct. On the other hand, when an irritation or inflammation, as 
from a blister, on one part, diminishes that condition in another, 
there is indirect sympathy or antagonism. 
Sympathy, whether affecting sensory, motor, secretory, nutritive, or 
morphological changes, may be either physiological, pathological, or 
therapeutical. Some are entirely physiological, as where food taken 
into the mouth causes secretion of saliva; while others are pathologi- 
cal, as where an irritation of the uterus, as by the introduction of a 
tent, causes peritoneal inflammation ; and others still are therapeuti- 
cal, as when a blister over the epigastrium relieves, as it often does, 
an inflammation of the stomach. Sympathy is not equally active 
between all parts of the body. There are special sympathies between 
seme parts more than are manifested between different portions of the 
system in general. Thus there are more intimate sympathies between 
some dual organs, as where one eye suffers from traumatic injury— 
the presence of a foreign body—the other is exceedingly liable to be 
affected. There are also some special sympathies between parts on, 
the same side, as when a tooth is diseased and painful, the whole of 
the same side of the face suffers with it. 
There are special sympathies between particular organs not depend- 
ent upon duality or locality. The uterus and the breasts, the stom- 
ach and the heart, the stomach and the liver, the stomach and the 
brain, especially sympathize with each other ; and in children, partic- 
ularly, there seems a marked sympathy between the irritated gums, in 
teething, and the intestines. There are also special sympathies be- 
tween muscles habitually acting together ; so much so that paralyzed 
muscles, entirely deprived of the control of the will, may nevertheless 
act in sympathy with other muscles with which they are specially in 
concert. In the act of yawning the arms are automatically elevated, 
and in that of sneezing the low7er extremities are spasmodically con- 
tracted. During the act of yawning a paralyzed arm, motionless at 
other times from any impulse of the will, will sometimes be raised in 
sympathy with the general yawning movement, and a paralyzed leg 
will similarly be drawn up in sneezing. Sympathy has largely to do 
with automatic movements generally, as it has with vicarious actions, 
and with the metastasis of some diseases. It is indeed a principle con- 
stantly in action throughout the organism, accounting for many things SYMPA TIIY—MENTA L 1NFL UENCES. 
27 
that 'would otherwise be unaccountable. The stomach and pelvic or- 
gans of the female are two great centres of sympathetic actions. Many 
derangements of the stomach, though scarcely producing unpleasant 
sensations of that organ, are accompanied with pains in the head, the 
chest, and other parts of the body ; and morbid conditions of the 
uterus or ovaries, though unaccompanied by sensations in those parts 
sufficient to particularly attract attention, are productive of pains in 
the side, the back, under the breasts, in the head, and elsewhere, often 
of a severe character ; and other symptoms, and perversion of functions 
of organs, such as nausea, vomiting, spasm, emotional excitements, 
and changes of circulation, secretions, and nutrition, in various distant 
parts, are exceedingly common phenomena, and not to be overlooked 
in distinguishing and treating diseases. 
Mental influences operate by sympathy in producing bodily effects. 
Impressions upon any part of the sensational and intellectual, but 
especially upon the emotional parts of the brain, are conveyed to other 
parts of the organ with more or less force, and reflected in a great 
variety of actions, healthy or morbid, according to the character of 
the original impression and the state of the brain. Indeed, as for- 
cibly and recently shown by Dr. Browm-Sequard, the physiology and 
pathology of the brain, the location of its particular functions, and the 
variety of the effects produced by similar lesions, are not to be under- 
stood without taking into the account this principle of sympathy. 
Many facts shown by the observations of Charcot and others, and 
occurring in every-day experience, illustrate the truth and importance 
of this principle. Passions, thoughts, and acts of the will influence, 
sometimes markedly, organic functions, and become causes or reme- 
dies of morbid states. The influence of attention and confidence in 
modifying bodily actions of various kinds, is well known to the 
observant physician, and may be made available for therapeutical 
purposes. 
An important fact in relation to this subject is, that in disease and 
weakness, in fatigue, and in certain conditions of half-sleep, when the 
will has less control, the sympathies of every kind are usually more 
active. The system then yielding more to sympathetic impressions, 
they exercise far greater control. The tickling of the nose in half- 
sleep produces much more reflex action than in the full waking state. 
This greater sympathetic impressibility occurs in some diseases and 
with some persons more than with others. In females and others 
called “nervous,” and in many of the functional derangements of the 
nervous system, in a combination of dyspepsia, anaemia, and uterine 
derangements, morbid sympathies are often very strikingly mani- 
fested. 28 
INHIBITORY NERVES—SOCIAL SYMPATHY. 
In disease the inhibitory or restraining nerves are often paralyzed 
or weakened, leading to certain increased, unrestrained, and irregular 
actions, readily mistaken for stimulation or the manifestation of real 
increase of power. The division or paralysis of the splanchnic nerve 
causes increased peristaltic motion of the intestines, and the same 
division or paralysis of the inhibitory nerve of the heart increases the 
frequency of its beat; but in neither of these cases lias the real power 
of the organ been increased, only a restraining, governing influence 
has been removed; and like the removal of the pendulum from a 
clock, or the balance-wheel from a watch, the same, or even a less 
force would cause a more rapid motion of the machinery. Increased 
but exhausting activities in different directions often result from posi- 
tive weakness, and increased sympathetic actions are generally evi- 
dences of exhaustion or debility. 
The importance of these facts in understanding the action of 
various agents, medicinal or toxic, must be apparent. Overlooking 
them has given rise to serious errors in regard to the effects of 
alcohol, opium, and various other narcotic substances. 
But not only does sympathy exist between different parts of an 
organism, but between different individual organisms also. It would 
lead too far from the present purpose to discuss this subject in all its 
aspects, but it has relations to Medicine, and requires a brief notice. 
Sympathy between different persons is a fact of common observation. 
The condition, particularly mental, of one person, affects that 
of others brought in communication and intimate relations. It 
embraces the principle of imitation, so marked a quality in many, 
and is much more strongly manifested in some persons than in others. 
One with a strong personal force, and with feelings readily responsive 
to the interests of others, often exerts a powerfully controlling 
influence over those within his sphere. In conditions of high excite- 
ment, especially where large numbers are concerned, these sympa- 
thetic influences are much more manifested ; and like the imitative 
movements of gregarious animals following a leader, numbers rush in 
one direction or another, both in conclusions and actions, from feeling 
and impulse, rather than from reason and logical conviction. Illus- 
trations in experience and history might be given indefinitely. In 
most great movements, political, social, or religious, sympathy is a 
more powerful agent than logic. 
In some peculiar conditions of partial sleep, induced by monot- 
onous movements, by expectant attention and the excitement of 
novelty and mystery, the control of one person over another becomes 
in some cases almost unlimited. Particular mental and bodily func- 
tions may be specially excited, while others are in abeyance, and 1JSTFL FENCE OF VESSELS—ORDER OF STUD YINO DISEASE. 
29 
various strange phenomena, mental and physical, may follow. All 
that is not deception and chicanery in mesmerism, witchcraft, and 
other occult mysteries, can be accounted for, when more is known of 
life and the functions of the nervous system, on natural principles; 
and much is now explicable by the exaltation and peculiar excitement 
of certain faculties chiefly through sympathy. 
This principle of sympathy, though sometimes producing results 
that have disgraced humanity, as during the French Revolution, 
under the sympathetic influence of Robespierre and his associates, 
has great uses in the discipline of armies under strong and sympa- 
thetic generals ; and in the great political, moral, and religious move- 
ments which revolutionize communities and nations. In a smaller 
but very beneficial way it enables the physician and the nurse, pos- 
sessed of the proper qualities, to control by personal force many of 
the conditions of feeble, dependent, and confiding patients. The 
personal influence of the prescriber, and the attention and expecta- 
tion of the patient must not be lost sight of in determining the value 
of more material therapeutic agents; and mental influences are too 
important to be disregarded in the management of the sick. 
We have now taken a view of the ultimate bioplasm, the active 
tissue cells, the blood and lymph, and the nervous system, as more 
intimately concerned in the processes of life, normal and morbid. 
The vessels supplying the pabulum of the tissues, especially the capil- 
laries, are quite intimately connected with these processes, and are 
early changed in their conditions and actions where disease occurs. 
Different special organs of the body, consisting of an aggregation 
of more elementary parts performing peculiar functions, are neces- 
sary to the continuance of life and its processes, and their normal con- 
dition is necessary to the continuance of health. They are often early 
involved in diseases, and through their impaired functions or sym- 
pathetic influences many of the most distressing and dangerous phe- 
nomena of disease are produced. 
The derangements of these organs and their influence in producing 
morbid phenomena, as well as the more remote and particular causes 
modifying the healthy processes and setting the morbid ones in 
action, will be more particularly described as we come to the consider- 
ation of particular diseases. 
The order best adapted to our purpose in studying disease is : 1st. 
To inquire into its essential nature. 2d. To examine its more funda- 
mental elements analytically. 3d. To study the combination of these 
elements in series of phenomena constituting particular diseases, syn- 
thetically. 4th. To study the evidences of disease and its partic- 
ular forms, as presenting themselves in cases—first, theoretically, by 30 
ELEMENTARY CONSTITUENTS OF DISEASE—DEFINITIONS. 
descriptions, then by clinical observation and by post-mortem exami- 
nations—observing the grosser structural changes discoverable by the 
unaided senses, and then the minuter and more fundamental by 
means of the microscope and chemical reagents. 
In the preceding pages we have been inquiring into the nature of 
diseased actions, and examining those constituents of the body and 
their changes most immediately concerned in them. 
In examining the elementary constituents of disease we find : 1st. 
That certain changes of action occur—changes in the nutritive proc- 
esses, and in other functions than those of nutrition. 2d. Changes 
of products—the production of modified and new materials. 3d. 
Changes of structure—tissue and morphological changes—changes 
in the composition and arrangement of particles, and in the consist- 
ence, size, form, number of organs, etc. When changes of action 
alone occur, or without perceptible change of composition and struct- 
ure, the disease is said to be f unctional. Whether change of action 
takes place without some change of structure is questionable; but when 
no such change is perceptible by any of our means of investigation, 
the disease is called a functional affection. 
The changes of products, as of secretions, or the new morbid mat- 
ters produced, may be observed either by the unaided senses, by the 
microscope, or by chemical reagents. When reagents are used, the 
study comes under the head of Pathological Chemistry. Changes of 
structure in organs and parts are embraced in that part of pathology 
called Morbid Anatomy. 
Those minuter changes of tissues perceived by the aid of the 
microscope come under a division of morbid anatomy called Morbid 
Histology. 
The structural or functional changes alone or combined, the phe- 
nomena of disease occurring in the living body, perceptible to the 
physician or felt and described by the patient, and which may serve 
the purpose of determining the existence and character of such disease, 
are called Symptoms. They are the part of the phenomena of the 
disease apparent, given, or capable of being used for the discovery 
of the rest. The study of these phenomena is called Semiology or 
Symptomatology. Symptoms may be general, manifested in the 
system at large, or local, appearing in particular parts. Those di- 
rectly observed by the physician are called objective ; those felt and 
described by the patient, subjective. The value of subjective symptoms 
will depend much upon the intelligence, the clearness of statement, 
and reliability of the patient. 
The application of a knowledge of symptoms, and of the history PROGNOSIS-CA USES OF DISEASE. 
31 
and all the circumstances of the patient, to distinguish the existence 
of diseases and their special characters and varieties, is called Diag- 
nosis. The science here becomes an art; and the first, and often 
most difficult part of the physician’s duty in undertaking a case, is to 
make an accurate diagnosis. It often requires much knowledge, 
skill, and judgment—knowledge of the conditions normal to the 
patient, of the pathological changes that may occur, of the typical 
forms of special diseases and the varieties they may present, and of 
the true signification of the phenomena observed : and skill, in obtain- 
ing the history and observing the symptoms, and what are called 
physical signs ; and often skill is required in the use of the micro- 
scope, stethoscope, and other clinical instruments, and in the use of 
chemical reagents : and judgment, a judicial discrimination in weigh- 
ing evidence, excluding errors, and arriving at proper conclusions is 
always demanded. 
The foretelling of the course and termination of a disease, or of 
its results, is called Prognosis. This is based upon a knowledge of 
the history of diseased action of a similar character to that of the 
case under consideration, of the effects of remedies in such cases, and 
upon an estimate of the strength of the system, or power of endurance 
of the patient. It is the principal popular test of a physician’s knowl- 
edge and judgment. In doubtful cases, both for his own reputation 
and the interest of the patient, he must give his prognosis with care 
and reserve. An unfavorable opinion as to life should be expressed 
with great delicacy, if to the patient; but as a rule the opinion of a 
fatal result should be communicated to a relative of the patient or 
some judicious friend. As favorable an opinion as the case will 
justify should always bo given, as the patient is entitled to the benefit 
of all the hope he may properly entertain. The practice, sometimes 
indulged in by unprincipled charlatans, of representing a disease 
worse than it is, with reference to a larger fee, or for the purpose of 
obtaining the credit of a great cure, is such a betrayal of the con- 
fidence, and such a sacrifice of the interests of the patient, as to 
render one guilty of it unworthy of the character of a physician, and 
deserving of the most intense execration. 
Every disease, like every other event, has a cause—something 
producing it and necessary to its occurrence ; and the study of the 
causes of disease is called etiology. This is a subject of the 
greatest importance, especially in reference to prevention, or prophy- 
laxis. 
Many distinctions of the causes of disease have been made ; more, 
perhaps, than are logically required, but an enumeration of them may 
be suggestive of the character and variety of such causes. The follow- 32 
CAUSES OF DISEASE. 
mg may be mentioned, contrasting those most distinguishable from 
each other. 
They are predisposing and exciting; principal and accessory; 
proximate and remote; positive and negative ; specific and non- 
specific ; intrinsic and extrinsic ; vital, mechanical, chemical, and 
toxic. 
A predisposing cause is some condition or influence rendering the 
system more liable to a disease, while an exciting cause more imme- 
diately induces the result. A principal cause is the one most efficient, 
while an accessory one but aids its principal. A proximate cause is 
the one nearest the effect, and the term was formerly used to express 
what is now understood as the pathological condition inducing the 
symptoms. A remote cause is one acting at a greater distance in time 
or space—one not so immediately concerned in producing the result. 
The term, negative cause, indicates the privation of some material or 
condition necessary to health ; wdiile a positive cause is the presence 
of some injurious substance or agent. A specific cause is some pecul- 
iar material or influence producing a definite or specific form of 
disease, as the particular poison causing small-pox or ague ; while 
a non-specific cause is one producing some morbid action, but not 
necessarily of a definite or specific character, such as improper food, 
exposure to cold, excessive fatigue, etc. An extrinsic cause is one 
operating from without the system, or part; an intrinsic one oper- 
ating from within. A vital cause is one which influences the life- 
forces and actions, but which is not mechanical or chemical, such as 
impressions upon the mind, or effects on the nervous system inde- 
pendent of material substances. Some material substances, such as 
morphine and prussic acid, make an impression upon the activities of 
the system Avithout, so far as ascertained, producing mechanical or 
chemical changes. They are therefore said to act on the life endow- 
ment, and are spoken of as vital causes of the changes they induce. 
A mechanical cause is an injury by violence to structure; a 
chemical, an injury by chemical action either of the tissues or the 
fluids; and a toxic cause is some poison, mineral, vegetable, or ani- 
mal, living or dead matter, producing injurious changes, usually of a 
serious character, independent of bulk, and some say of mechanical 
or even chemical properties. Chemical poisons arc recognized, but 
such articles as morphia, strychnia, and prussic acid, which do not 
produce their effects by any marked chemical or mechanical actions, 
are regarded more particularly as poisons. 
The special causes of disease coming under these various heads 
are very numerous. There are mental and physical causes—emo- 
tions, impressions; various parasites, microzymes, zymoses, conta- ELEMENTS OF DISEASE. 
33 
gions; climate, heredity, bad habits, sexual abuses, improper food 
and drinks, narcotics, heat, cold, moisture, filth, “epidemic con- 
stitutions of the air,” age, sex, previous diseases, occupations, 
privations, etc. These will be more particularly mentioned in con- 
nection with the diseases they predispose to or excite. For a more 
detailed account of these causes the reader is referred to some of the 
many works on Hygiene or Preventive Medicine which are issuing 
from the press. 
Elements of Disease.—While the special causes of disease are 
so numerous, the particular results—the different varieties of element- 
ary morbid actions and products—are still more so; and as these 
elements may exist in any amount, and may have every degree of 
severity with an indefinite number of combinations, no two cases 
are in all respects exactly alike ; yet the elementary products and 
processes admit of enumeration and distinctive description ; and 
in individual cases series of phenomena occur having such resem- 
blances as to admit of groupings for the convenience of study, and 
for the purpose of an imperfect classification and naming. 
There are, as elementary products of morbid action, aqueous or 
liquid matters, as in dropsy ; gaseous materials more rarely—pneu- 
matoses ; coagulable lymph ; morbid cells from the cells of the tissues ; 
leucocytes, cytoid corpuscles or pyoid cells; pus, mucus, effused 
blood ; and albuminous, pigmentary, and fatty molecules. In the 
specific diseases are produced peculiar exudates and products, such as 
the lymph of the exanthems, the material of gonorrhoea and syphilis, 
of typhus and typhoid fever, the peculiar material of cancer, 
tubercle, and other morbid growths. Some of these materials are 
produced as living, multiplying germs or gemmules. There are 
more complex and organized substances produced by morbid proc- 
esses, such as granulations and cicatrices. These may not be morbid 
in results, as they often produce repair of tissues, but the process of 
their production is not that of normal growth ; and the production 
of a false membrane may be highly injurious in all its stages and 
consequences. There is often proliferation of connective tissue, and 
various morbid growths ; and concretions of inorganic matter occa- 
sionally occur. Parasites may not only find their way into the body, 
but may multiply there, becoming the causes or product of abnormal 
conditions. The solid products of diseased actions have been divided 
into three classes: euplastic substances, such as cicatrices and false 
membrane; cacoplastic, as fibro-cartilage and gray tubercle ; and 
aplastic, as atheroma, cheesy degenerations and concretions, or inor- 
ganic deposits. These and other particular materials and structural 
changes are the special subjects of works on Pathological Anatomy, 34 
CLASSIFICA T10N. 
Pathological Histology, and Pathological Chemistry. They will, 
however, be more fully described in connection with the diseases 
in which they occur. 
Besides these elementary products, there are various elementary 
complex processes. Some of these are local, affecting particular parts, 
others are general, occurring in the system at large. Of the local 
conditions there are local irritation, hypersemia, anaemia of particular 
parts, hemorrhage, hypersesthesia, hypertrophy, dilatation, contrac- 
tion, enlargement, atony, atrophy, degeneration, ulceration or necro- 
biosis, gangrene or necrosis, and the process of inflammation, which 
though chiefly local, yet involves the general system, and may be 
considered as between the local and general morbid processes. 
Of the general complex elementary morbid processes there are gen- 
eral irritation, shock, fever or pyrexia (the febrile state), cachexia, 
depression, exhaustion, debility, and all the general functional 
derangements. These different elementary processes, states, and 
products, variously combined, result in certain series of phenom- 
ena, constituting the different diseases nosologically arranged and 
named. 
Classification.—There are two possible kinds of classifications 
of diseases, Avhich may be designated, the one as scientific or theoreti- 
cal, and the other as empirical or practical. In the first, diseases 
would be considered as departures from the healthy state or physio- 
logical condition, and in the second, as approaching certain types of 
symptomatic phenomena. 
Classification and naming, by all the methods yet adopted, are very 
defective; and more perfect and consistent methods must be left for 
the future and the more advanced state of the science. Classification 
and naming, as in other sciences, should be based upon the most 
essential conditions, and these are the pathological states; but some of 
them are so imperfectly understood, and the diseases have so long 
been known by names derived from certain of their symptoms or fan- 
cied conditions, or by names imposed arbitrarily, that changes are 
difficult and perfection as yet impossible. At present, custom and 
convenience, rather than scientific accuracy, must govern in the nam- 
ing of disease. 
Various groups of diseases have certain characteristics belonging 
to them in common, to which terms designating them are applied. 
An epidemic disease is one prevailing over considerable regions and 
affecting many persons. 
An endemic disease is one prevailing in, and belonging to, a par- 
ticular locality. 
A sporadic disease is one which is neither epidemic nor endemic, ZYMOTIC DISEASES—INFECTION—CONTAGION. 
35 
but occurs in isolated and occasional instances, and is usually not de- 
pendent upon any wide-spread or prevailing cause. 
Zymotic diseases are those which are supposed to he produced by 
some peculiar poison, operating after the manner of a ferment. They 
are diseases affecting more or less the whole system, though commonly 
with some special local manifestations, and they are apt to prevail 
epidemically or endemically. 
An infectious disease is one produced by some injurious agent, 
which infects or enters the system, producing somewhat specific mor- 
bid phenomena, such as cholera, yellow fever, etc. It is substantially 
the same as a zymotic disease, though not implying by its name the 
fermentation theory. 
A contagious disease is one that is infectious, as it is produced by 
an infecting agent or poison, but this poison or eontagium is always 
generated in the body of a person having the disease, and is commu- 
nicated to another, producing the same affection, and such disease is 
usually produced in no other way. 
The poison in an infectious disease may originate or be produced 
otherwise and elsewhere than in the body of a person affected with the 
disease, and may be multiplied exterior to the body. All contagious 
diseases are infectious, but all infectious diseases are not contagious. 
“ Infection ” is a broader term, including contagion, while “conta- 
gion” is more limited, embracing but a part of the infections, that 
part where the poison is produced in the bodies of the sick. Contact 
or even proximity of persons is by no means necessary to the commu- 
nication of a contagion, as the poison may be carried often to great 
distances by fomites, substances to which the poison is attached, and 
otherwise ; but the poison must by some means come in contact with 
or must enter the body, in order to the production of its effects. The 
means of communication may be by sensible application, by inocula- 
tion, by inhalation through the air, or by ingestion with food or 
drinks. It is sometimes said that mental or nervous conditions spread 
by contagion, but this is a figurative expression borrowed from the 
true type described, and must mean that the communication is by 
sympathy. There is confusion in the statements of some writers and 
in many minds on this subject of infection and contagion, and the two 
are often confounded. 
The distinction ought not to be difficult, but can be made more 
clear by unequivocal examples. 
Ague or malarial fever is an infectious disease, according to the 
proper signification of the term, as it is believed by all to be produced 
by a poison or infectious matter which enters the system and pro- 
duces the specific phenomena. Small-pox is also an infectious 36 
KINDS OF DISEASES. 
disease, as it too is produced by a poison which enters the system and 
infects it. The ague or malarial poison is not generated in the body 
of a sick person, and is not communicated from one person to another; 
while the small-pox poison is generated in the body of one suffering 
from the disease, and is communicated to others, either by inocula- 
tion, through the air, by means of fomites, or otherwise. 
The only possible question as to the correctness of this illustration 
is as to whether malarial fever should be called an infectious disease. 
If by an infectious disease is meant one which produces a poison com- 
municable to others, then malarial fever is not infectious ; but if by 
the term is meant a disease produced by a poison which enters the 
body and infects it, producing peculiar and specific phenomena, a use 
of the term sanctioned by the best writers, then it is an infectious 
disease. In this work the terms infection and infectious are used to 
mean poisons which enter the system and infect it, producing specific 
forms of disease, and include such a poison as malaria, and such a 
disease as malarious fever. The distinction of the things can but be 
made, whatever may be thought of the use of the words. 
Yellow fever is called an infectious disease, but it is doubtful 
whether the poison is even multiplied in the bodies of the sick, and it 
is almost certain that it is not produced there exclusively or chiefly. 
If the poison is generated in the persons sick with the disease, and is 
communicated from them to others, it is contagious; if not, it is not 
contagious ; but it is constantly spoken of as an infectious disease, and 
according to the meaning here given to the term, it is so. The 
sooner these terms are thus used and understood, the sooner will con- 
fusion and misunderstanding on this subject disappear. 
A Continued disease, as a continued fever, is one whose symptoms 
do not disappear or remain in abeyance, but continue manifested 
until the disease has finished its course or ceases. 
An Intermitting disease is one whose symptoms do disappear and 
again return, often at regular intervals. The term Remitting is 
applied when the symptoms very markedly abate at intervals, but do 
not entirely disappear while the disease continues its course. 
A Relapsing disease is one which returns after more or less com- 
plete recovery. 
The term Congenital is applied to diseases present at and from 
birth. 
An Hereditary disease is one transmitted from parents. 
An Acquired disease is one contracted after birth, and not inherited. 
A Malignant disease is one of unusual severity and danger, or one 
which is persistent and usually incurable. Severe cases of cholera, 
yellow fever, and the different forms of cancer, are examples. KINDS OF DISEASES. 
37 
A Specific disease is usual!} dependen t upon a peculiar poison, and 
naturally runs a somewhat definite and specific course. 
A Diathetic disease is one which depends upon, or is accompanied 
by, some particular general morbid condition or tendency of the system, 
some special diathesis, as the strumous, arthritic, etc. 
A Primary disease is the one first attacking the patient, where 
different diseases or different stages occur. 
A Secondary disease is one following another, and is pathologically 
connected with it, or dependent upon it. 
An Intercurrent affection is one that occurs while another is 
present, but without being connected with it as cause and effect. 
A Symptomatic disease is a distinct, recognized pathological con- 
dition, which is a symptom of some other morbid state. 
An Idiopathic disease is one which in its own phenomena consti- 
tutes the disease under which the patient labors. It is opposed to a 
symptomatic disease. 
A Sthenic disease manifests in its phenomena much force of action 
—activity above the normal. 
An Asthenic disease is the opposite of the last, is a disease of 
debility, or one manifesting little force. 
The term Constitutional, as applied to a disease, indicates an affec- 
tion of the system at large, and is often used synonymously with the 
term general. It is, however, also used to indicate a more serious, or 
at least a more permanent, change than would be conveyed by the 
word general. The wTords constitution and constitutional, as applied 
to the system, indicate a permanent state. Thus one with a good con- 
stitution has a vigorous life-force, and the different vital organs and 
functions are well formed and properly balanced. One with a feeble 
or bad constitution has a feeble life-force, or a defect or want of 
proper balance of the organs and functions. These conditions may be 
hereditary or congenital. 
A broken constitution indicates a system which may have been 
originally good, but which has been permanently impaired by disease 
or accident, or by improper habits, or other bad life conditions. As 
an illustration of what is meant by a constitutional disease, the case 
of cancer or of syphilis may be mentioned. A cancerous growth, 
especially an epithelioma, may at first be local, but as it progresses it 
affects the wThole system permanently, and becomes in the fullest sense 
of the word, constitutional. So with chancre. It is at first a local 
affection produced by a poison locally applied, but at length the whole 
system becomes affected, often permanently, and the syphilis is consti- 
tutional. 
There are various conditions which modify the character of dis- 38 
MODIFYING INFLUENCES. 
eases, such as climate, locality, age, sex, habits, occupations, race, 
nationality, and personal peculiarities. 
It has been thought that particular diseases were produced at an 
early period in the existence of the race from peculiar causes, and that 
their primitive characters have continued unchanged until the present 
time. Some diseases have doubtless retained a somewhat stereotyped 
character, but neither history nor analogy sustains the view of the fixed 
character of all diseases. The earth and all upon it have undergone 
great revolutions, as geology has shown, and doubtless each epoch 
since there are traces of man, has had its peculiar maladies, and in his- 
toric periods, even comparatively recent, changes in diseases have been 
observed. As pathological conditions are dependent upon physiologi- 
cal, and upon influences constantly variable, those pathological states 
must vary with the physiological, and with the influences causing them. 
The nervous system, cultivated in all directions and strained and hur- 
ried by an intenser life, has assumed almost new relations to the rest 
of the organism, and has disordered states unknown in the medical 
literature of the past. The use of tobacco and other agents that 
impress the nervous system, is producing peculiar morbid states. 
Groups of nervous affections cluster around the present intensified 
self-consciousness, constituting a large and growing proportion of 
the troubles of the present advanced life. 
It seems to be true, as many hold, that there is a slowly deepening 
intolerance of alcohol, as well as an inability to bear depletion and 
other depressing agents, all tending to show that both physiological 
and pathological conditions are undergoing constant modifications ; 
and new diseases may be expected in the future, as they have appeared 
in the past. By better hygienic conditions and wise preventive meas- 
ures, it is to be hoped that many of the present diseases will pass 
away. 
The modifications of diseases, and the production of different dis- 
tinct morbid states by nationality, habits, associations, and localities, 
are too important to be lost sight of. For illustration, M. Charcot, 
when in London, desiring to illustrate the effect of certain agents 
upon a particular class of nervous and hysterical patients, was unable 
to find such patients, though inquiry was made in all the hospitals and 
of private practitioners, while such cases are readily gathered by scores 
in Paris. The climate, the locality, the customs, the hereditary influ- 
ences, and all the surroundings of different European nations, produce 
peculiarities different from each other, and especially from those of our 
own country; and, even with us, the differences of north and south, 
of east and west, of city and country, and of particular localities 
and occupations, produce differences in diseases and the treatment IRRITABILITY AND IRRITATION. 
39 
required and borne, which a close observer will perceive, and a 
judicious practitioner will not ignore. While general principles are 
the same, even with men and. animals, particular conditions differ 
among nations, classes, and individuals of our race ; and certainly the 
treatment adapted to the hospital patients in the great cities of Europe 
may not be best adapted to private patients in the rural districts of 
America. 
The works of foreign writers should not be followed implicitly by 
American physicians, nor should those produced by writers whose 
practice has been in large cities, in crowded hospitals, and as consult- 
ants, seeing diseases chiefly in their advanced stages, be strictly fol- 
lowed by the country practitioner who sees diseases under such differ- 
ent circumstances. 
We come now to a more detailed description of those elementary 
morbid processes by which morbid materials are produced, and which, 
in connection with morbid products in varied combinations, consti- 
tute the different diseases. 
IRRITABILITY AND IRRITATION. 
Impressibility or excitability, the quality of receiving impressions 
ancl responding to them in actions, is a quality belonging to all organ- 
ized living matter. 
The term irritability is sometimes used as signifying this normal 
life-quality. It is here, however, used to indicate a degree of excit- 
ability something above the normal. There are widely different 
degrees of excitability, and the line of demarkation between the nor- 
mal and the abnormal degree is not distinctly drawn. There are con- 
ditions of irritability, however, so much above the normal susceptibili- 
ties as to produce inconvenience and suffering, and therefore amount- 
ing to positive disease. Thus in practice, irritability of the stomach, 
the brain, the eyes, etc., is found to exist as a pathological condition 
requiring treatment. 
Irritability, then, is morbid excitability, or a condition in which 
the ordinary agents impressing the system or part produce abnormal 
and injurious effects. 
The excitability which is a necessary property of living matter has 
not only its degrees but its limits. It is subject to certain laws which 
may not be fully understood, but which it is the object of scientific 
research to reveal. Illustrations of some of the laws of excitability 
have been given by Dr. Burdon-Sanderson in his reported experiments 
upon the frog’s heart. A portion of the ventricle separated from its 40 
IRRITABILITY AND IRRITATION. 
connections lias the power of responding to an impression, and retains 
that power for hours if placed under favorable conditions of a Avarm 
and moist atmosphere. When the ganglion which is a nerve-centre 
in the heart, giving it a degree of independent action, is intact in the 
portion of the ventricle experimented upon, a stimulant, as a prick 
Avith a needle, causes contractions which go on rhythmically for a 
length of time; but when the ganglion is removed, the muscular fibres 
contract under a stimulus, but rather sloAvly and progressively, the 
a'ction commencing at the point touched, and the contraction is not 
repeated. It occurs but once from the same impression, and what is 
curious, it will not respond to another stimulating impression until it 
has completed the act commenced as the result of the first, and for 
some little time after. This necessity for rest might be regarded as 
the consequence of its exhaustion ; but its refusal to act from another 
stimulating impression, Avliile it is performing the contraction from 
the effect of the first, is called by Dr. S. its obduracy. Both terms 
indicate the limitation of the excitability of those fibres, and a certain 
laAV by which the action is governed. There seems a tendency to 
respond to but one stimulus at a time, and to the occurrence of a 
positive rest after one action. In this period of repose or suspended 
action, excitability accumulates or is recovered, and a response is 
then repeated. The existence of a laAV in the most elementary tissues, 
and in the simple acts, is indicative of a similar laAV or tendency in 
complex organisms and processes. 
In accordance Avith this general law, or this tendency to respond to 
only one impression, one stimulant or irritant at the same time, a 
medicinal impression, when stronger than that of the cause of a dis- 
ease, forced upon the organism, may, and sometimes does, supplant 
and arrest the action of the morbid cause. In other words, the medic- 
inal impression may counteract and overcome the diseased action. 
This laAV or tendency goes far toward explaining the antagonism be- 
tAveen certain articles, as between opium and belladonna, and also 
the antagonistic influence of certain remedies OAer particular diseases. 
The antipyretic effects of quinine, salicine, aconite, digitalis, and 
other articles, may find their explanation under this laAV. 
Whether or not the human system or its parts as readily respond 
to more than one impression at the same time, it is certain there is a 
tendency to respond to some impressions but once. This is shoAvn in 
the case of small-pox and other contagiums ; and it is a matter of 
common observation that excitability becomes exhausted by respon- 
sive actions, and is restored by rest. Indeed, excitability accumulates 
by suspended action, so as often to become greater than normal, 
resulting in more or less violent reaction. The temporary diminution IRRITATION. 
41 
of action produced by the cold bath, is physiologically followed by 
increased circulation and a glow of warmth, and by increased activity 
of various functions ; and the feebleness of action from the shock of 
an injury, if that be not too profound, is followed by a feverish 
excitement. 
Irritation is superexcitation with change of action, but without 
material change of structure. Increase of blood in the irritated part 
usually occurs as the only marked change perceptible, aside from 
changes of function. Irritation may be produced by a variety of 
causes. In a condition of morbid irritability the ordinary “ vital 
stimuli ” may excite it. Thus an irritable stomach will be excessively 
excited by ingesta, which in health would be physiological. So of the 
eye in regard to light, etc. An excess of the vital stimuli, or hetero- 
geneous or abnormal stimulants, applied in a healthy condition, will 
cause irritation. Thus an excess of food, an excess of light, or an 
excess of heat, applied to however healthy a stomach, eye, or surface 
—or an irritant, mechanical, chemical, or vital, will produce the 
effect. Reflex impressions of various kinds also produce irritation. 
The causes of irritation, then, may be morbid irritability, excesses 
of normal stimulants, the action of abnormal stimulants or irritants 
applied to the parts, or reflex impressions, physical or mental, from 
conditions of distant portions of the body. 
Irritation, when intense or long continued, often results in other 
morbid changes, and then the processes take other names. In simple 
irritation the condition resembles increased physiological activity, 
shading off from it. As in such increased physiological action, so in 
irritation, the circulation is usually more active, the temperature is 
moderately elevated, molecular changes are increased, and in some 
cases cell-development is more rapid, while waste is also accelerated, 
and functional activity may, temporarily at least, be greater in 
amount, though it is generally abnormal in character. Like all other 
disease, it is modified physiological action, hut the modification is 
less than in most other morbid states. 
The deer’s horn when growing, the uterus and mammary glands 
in pregnancy, the brain in active thought, the stomach during diges- 
tion, have conditions not easily distinguishable from the milder 
degrees of irritation : and this illustrates the intimate relations of 
health and disease. While irritation is so nearly connected with 
health on the one hand, it has the most intimate connections with 
more positive and serious disease on the other. An increase or con- 
tinuance of the same causes which produce irritation may lead on to 
hyperplasia, to morbid growths, to degenerations, to great perversion 
of functions, and particularly to the complex process of inflammation. 42 
H YPERyEMIA. 
The secondary effect of irritation is depression, or diminution of 
action ; and its remote effects on other parts are various in accordance 
with the laws of sympathy and dependence of function. A simple 
irritation of one part may cause an inflammation in another, if that 
other part be more susceptible to the inflammatory process. 
The frequent occurrence of irritation in other morbid states, and 
its intimate relation with them, and particularly with inflammation, 
which it precedes and of which it forms a part, will require further 
reference to it as we proceed. The beginning of many morbid proc- 
esses consists of irritation, and its treatment is a very important part 
of therapeutics. Irritability, as a morbid state, may be either local, 
manifested in a particular organ or part, or general, affecting the 
system at large. Irritation may be either local or general also, but it 
is more frequently found and spoken of as local ; and to its local 
conditions the preceding remarks more particularly apply. 
Hypersemia is an excessive quantity of blood in a part, and is 
an accompaniment of other morbid conditions, rather than a distinct 
disease of itself. It may be either active or passive. In active hyper- 
semia the current of • the blood is more rapid, and the circulation 
increased, while in the passive form the motion is diminished, and 
the circulation sluggish or even in points suspended. Active hyper- 
aemia is chiefly arterial, while passive is more venous; yet in either 
all the vessels, including the capillaries, usually contain an excess of 
blood. 
Hypersemia may depend upon various causes, remote and proxi- 
mate. The immediate condition rendering it possible for more blood 
than normal to be in a part, is enlargement of the calibre of the 
vessels. Their distention may be produced by a larger quantity of 
blood being forced into them by increased action of the heart, and 
of the arteries leading to the part ; by a greater attraction of the 
tissues for the blood; by obstruction of the return circulation through 
the veins ; or by relaxation of the walls of the vessels, in consequence 
of their weakness or through modified action of the vaso-motor 
nerves. Irritation of nerves usually produces relaxation of vessels, 
though this relaxation may be preceded by contraction ; and the 
division or paralysis of vaso-motor filaments also often results in such 
relaxation. Various causes, physical and mental, exciting and de- 
pressing influences, reflex impressions, etc., operating through the 
nervous system, modify the circulation, increasing or diminishing 
the quantity of blood in a part. The quantity of blood in the surface, 
particularly of the face, varies frequently and rapidly, especially in 
sensitive persons, by various emotions and impressions, as is witnessed 
in blushing and blanching; and doubtless changes of a similar char- HYPEREMIA—EEMORRUA GE. 
43 
acter, from a variety of causes, occur in internal organs as well. 
Some of these are physiological, serving a useful purpose in modify- 
ing functional activity normally ; others are pathological, changing 
functions morbidly. 
Collateral or compensatory hyperaemia is where more blood is in 
one part in consequence of less being in another. When a given 
quantity of blood flows to an organ through the main vessel leading 
to it, an interruption of the flow through particular branches, from 
whatever cause, will produce an increased flow through other branches 
which are unobstructed, supplied by the same common trunk, The 
same principle applies to different organs of the body, as well as to 
different parts of the same organ. Thus when there is an inter- 
ruption of the flow of blood to the lower part of the body, more 
will go to the upper part, and when there is less blood in superficial 
parts, there will be more internally. 
Organs in the active performance of their functions usually have 
a larger quantity of blood ; and it would seem most reasonable to 
suppose that this was effected by increased nervous stimulation of the 
vessels, and by their more active state. It is not easy to understand 
at first view how increased action of vessels, Avhich must consist 
mostly in contraction, increases the quantity of blood in them, when, 
as is well known, a passive and relaxed condition produces that 
result. But a greater range of the rhythmical motion would have the 
effect of increasing the amount and circulation of the blood in the 
vessels ; and this increased amount of expansion and contraction 
seems the most plausible explanation of the phenomena. AVhile the 
vessels contract with more force, they are expanded more widely at 
each rhythmical act, and the result is increased blood and increased 
circulation in the part. Conditions of the blood itself, a disposition 
of the corpuscles to adhere together and to attach themselves to the 
Avails of the vessels, may cause an accumulation, particularly of the 
corpuscles ; and an increased attraction of the tissues for the blood 
may draw into the part and retain there an excess of fluid. 
The phrase “ determination of blood ” is often used to signify 
active hyperaemia; while the term congestion, when used without 
qualification, and especially when applied to external diseases, gen- 
erally signifies passive hyperaemia; but the phrase active congestion 
is also used, signifying active hyperaemia. 
Like irritation, hyperaemia is intimately associated with other 
pathological processes—particularly Avith inflammation—often pre- 
ceding and ahvays accompanying it. 
Hemorrhage is a flow of blood out of its vessels, whether arte- 
ries, veins, or capillaries, or whether from the surface, into cavities or 44 
DIAPEDESIS—DROPS Y—ANuEMIA—DEGENERA TION. 
into tissues. When such flow takes place, at least in any considerable 
quantity, there is rupture of vessels ; and the essential condition pro- 
ducing it is a want of proportion between the blood pressure within 
the vessels and the resisting power of their walls. Interruption of 
the flow of blood through an artery will cause increased pressure in 
collateral branches, sometimes sufficient to cause hemorrhage; and 
indeed most of the causes producing hyperaemia may be so intense 
as to result in hemorrhage. Besides the increased blood-pressure, any 
degeneration or diseased process weakening or destroying the coats of 
the vessels, even without increased blood-pressure, may produce the 
same result. Infiltration of blood from small vessels, whether by 
their rupture or by the corpuscles passing through their pores into 
the interstices of tissues, is called hemorrhagic infarction ; and a flow 
into tissues from larger vessels, causing solution of continuity and 
the presence of blood in an adventitious cavity, is called apoplexy of 
the part.. 
The passage of blood through the pores of vessels, without their 
rupture, is called Diapedesis, a phenomenon which modern observation 
proves to occasionally occur. 
Dropsy is an effusion of serous or aqueous fluid into a cavity or 
into tissues. It takes different names as it is in different parts, and 
is a symptom of different pathological conditions, to be hereafter 
described. 
Local Anaemia not unfrequently occurs, and may be caused by 
a tonic spasm of vessels ; but is more frequently, in its severer forms, 
the result of obstruction of arteries leading to the part. The arteries 
may be obstructed by pressure from without, by morbid growths or 
deposits in their walls, or by clots of blood within them. The results 
will depend upon the extent of the obstruction, and when complete, 
death of the part will follow. In the less perfect obstructions, 
lowered vitality and impaired nutrition and functions are the condi- 
tions induced. 
Degeneration consists in the substitution of matter lower in 
vitality and organization in place of the natural tissue, and is the 
result of diminished nutritive energy. A familiar example is in fatty 
degeneration of a muscle, where globules of fat take the place of the 
contractile fibres ; and in proportion to its extent it destroys the 
character and power of the muscle. The substituted material is 
lower chemically, as well as physiologically, than the original tissue, 
and is the result as well as the cause of the loss of power. 
There are various forms of degeneration besides fatty, as amyloid 
or lardaceous, pigmentary, earthy or calcareous, cheesy, colloid, 
mucoid, and atheromatous. When a general tendency to degenera- ATROPHY—GANGRENE—ULCERATION—EMBOLISM. 
45 
tion exists, it is usually an evidence of such failure of power as fore- 
bodes the most serious ultimate results, and is'commonly progressive 
and persistent. 
Atrophy is the diminution or wasting of a part, usually with 
corresponding loss of functional power. In the process of nutrition, 
as stated when on that subject, production and waste, growth and 
decay, generation and death, are constantly going on in the cells and 
the tissues. When the waste is greater than the production, atrophy 
results. The more remote causes are various, such as obstructed 
circulation, previous disease, injuries, etc. ; but the immediate con- 
dition is either diminished production or increased loss, or both of 
these together, of the elements of the tissues ; and like degeneration, 
it is an evidence of the loss of proper power in the parts concerned. 
Gangrene or Necrosis is death in mass of some limited part 
of the body, and is the result of a complete arrest of nutrition in that 
part. It may be produced by various causes, such as a more com- 
plete obstruction of circulation, severe injury, or violent inflamma- 
tion. 
Ulceration or Necrobiosis is a process of molecular death, or 
death by small particles, without production in the part, resulting in 
tissue destruction and breach of surface. It is produced by causes 
similar to those of gangrene, but operating in a more limited manner. 
A similar process, when occurring in bone tissue, is called Caries. 
These latter conditions, though occurring in medical cases, are 
more common in surgical, and are treated of more fully in works on 
that subject. 
The terms Thrombosis and Embolism indicate coagulation of 
blood within the heart or blood-vessels. When a coagulum forms 
during life, and remains at the point of its formation, it is called a 
thrombus. When it becomes detached and floats on in the current of 
blood, generally lodging at length in smaller vessels, it is called an 
embolus. When a coagulum adheres to the walls of a vessel which 
it does not fully obstruct, it is said to bo parietal; when the obstruc- 
tion is more complete, it is said to be occluding. Such coagulation 
may occur from changes in the walls of the vessels, or from retarda- 
tion or arrest of the circulation of the blood, and it is favored by an 
increased quantity of fibrine and an increased tendency to its coagula- 
tion. Heart clots often form in the last stages of inflammation, when 
hyperinosis exists, and when the circulation becomes retarded from 
failure of the heart-power. When these occur slowly and some time 
before death, the red corpuscles are carried away in the current, and 
the fibrine remains, presenting the whitish or yellowish color and the 
greater firmness belonging to pure fibrine. Thrombi arising from 46 
HYPERTROPHY. 
retardation of the circulation are called marantic; those arising 
from wounds are called traumatic; and there are those from dilata- 
tion of vessels, as in aneurism, and from compression. Frequently a 
clot is formed from the combined influence of retardation of circula- 
tion and dilatation of vessels. The veins of the lower extremities in 
adults, and of the cerebral sinuses in children, are the most frequent 
seats of these thrombi. 
A thrombus may remain for a long time with but little change, or 
it may organize or soften—organize by vessels extending into the 
attached fibrinous mass from the vasa vasorum, and by cells from the 
surface of the vessels, as in the case of the organization of false mem- 
brane elsewhere. The softening is effected by a breaking down in the 
central part into a grayish-red pulp, consisting of granular material 
with leucocytes, red blood corpuscles, and blood pigment, which was 
formerly mistaken for simple pus. 
Some of these softened thrombi contain infectious matter, bacteria 
and decomposing substances, which, entering the circulation, induce 
the phenomena of septicaemia. Fragments of the thrombi are often 
detached, producing emboli, and both the thrombi and emboli are 
capable of producing severe mechanical effects and septic changes 
causing serious consequences. Infarctions in the lungs, liver, kidneys, 
spleen, brain, retina, and other parts, may result. The manner in 
which emboli produce infarctions has been differently explained by 
different pathologists. Colmheim’s view is that the capillaries of the 
obstructed district are filled with blood which has regurgitated through 
the veins, while Litten’s experiments tend to show that the extra- 
vasated blood is from the adjoining small arteries and capillaries, 
where the pressure is sufficient to send the blood into them, but not 
sufficient to send it into the veins. 
Hypertrophy is the opposite of atrophy, and consists in abnor- 
mal increase of normal, or at least nearly normal, tissue. Here the 
circulation is active, the production exceeds the waste, and it is an 
evidence of an abnormally active state of the nutritive process in the 
part, or possibly of an abnormal diminution of the process of waste, 
or a diminished removal of tissues which have served their ends. The 
increased size of the heart, when called upon for more labor to over- 
come some obstruction to the circulation, is a familiar example of 
hypertrophy proper. Here the power is increased with the size, and 
is compensative and useful. An enlarged spleen from malaria, or an 
enlarged uterus from certain irritations or displacements, arc examples 
of what are generally called hypertrophies. But here the results of the 
increased nutrition are not entirely normal tissue, the functional 
power is perverted, and the whole process is injurious. The term HYPER JEM.ESTHESIA—ATONY—DEPRESSION. 
47 
Hyperplasia in these latter cases is preferable to hypertrophy. Hyper- 
plasia indicates abnormal increase of tissue, usually morbid. Hyper- 
trophy should be restricted to mean the abnormal production of tissue, 
itself normal. 
Hypersemsesthesia is a term used by Dr. Hartshorne, indica- 
tive of a state of a part marked by the following conditions : 1. 
Enlarged vessels—increase in their calibre and in the thickness of 
their Avails—and consequent protracted hyperaemia. 2. Increased 
sensibility and morbid susceptibility to various impressions (irritabil- 
ity). 3. Deficient or irregular functional power. 4. Proneness to 
attacks of acute or fully developed inflammation. 5. Often, though 
not always, hyperplasia. This condition approaches and often shades 
off into chronic inflammation, and by many is not distinguished from 
that state. All the ordinary conditions of fully developed inflamma- 
tion are however not present, and the distinction seems one proper to 
be made. 
Atony is a condition, sometimes local, of a particular part, and 
consists of a want of tone or firmness in contractile tissues. It is an 
evidence of Aveakness in the tissues, and is produced by causes similar 
to those which produce atrophy and degeneration. The nervous 
supply has perhaps more to do with this condition than with the 
others named. 
Dilatations and Contractions occur, but are scarcely element- 
ary conditions, and are secondary to other changes, and may be 
passed by without further consideration in this connection. 
We have now described briefly the chief elementary local processes 
which occur as constituents of various diseases. Inflammation is 
usually considered as a local affection, but it so constantly involves 
the general system to a greater or less extent, and is so frequently 
dependent upon causes operating Avithin or upon the body at large, 
that it may be considered both local and general, and Avill be discussed 
by itself, after some less important general conditions have been 
noticed. 
It has already been intimated that irritability and irritation may 
be general as Avell as local; hut the remarks applicable to the one 
will, in a general way, apply to the other, and respecting it little 
further need be said. General irritation bears a similar relation to 
fever that local irritation does to inflammation. It often precedes 
fever and is merged into its phenomena, and Avill be referred to in 
connection with that important morbid process. 
Depression is an element of disease, and the term is usually 
applied to a condition of diminished action of the general system sud- 
denly occurring, as from failure of nervous influence in shock, or in 48 
DEBILITY— SHOCK— COLL A PSE—S YNCOPB. 
exhaustion from overaction, or from the direct effect of sedative 
agents. A diminished supply of blood to a part will cause local de- 
pression, as a loss of blood from the body and the other general 
causes will produce general depression. 
Debility resembles depression, but is a more permanent diminu- 
tion of action, arising from more permanent and slower acting causes, 
as from starvation or continued disease. It is an important condition, 
often requiring attention in treatment, but its importance and fre- 
quency as a cause and accompaniment of disease have been exag- 
gerated. There are increased and modified, as well as diminished, 
actions in disease equally worthy of attention. 
Shock is a depressing impression, usually violent in its cause and 
sudden in its occurrence. The depression produced by a mechanical 
injury, by a violent mental emotion, as of fear or sudden and great 
loss, or by the rapid onset and severe character of a local disease, is 
called by this name. It may be mitigated or prevented by agents 
diminishing sensibility or irritability, such as the narcotics or anaes- 
thetics. 
When a shock is not so violent as to completely overcome vital 
action, it is usually followed by reaction, by increased excitement, by 
irritation and fever. Shock and the response of the system in morbid 
action are of frequent occurrence, and are the cause of various diseased 
conditions, often requiring attention in treatment. 
Collapse is a condition of extreme depression, often a result of 
shock, or is a state scarcely separable from it. The term, however, 
indicates a condition of more extreme or more permanent depression 
than that usually understood by shock. The symptoms are coldness 
and pallor, but sometimes, as in cholera, blueness of surface, par- 
ticularly of the face and the extremities ; perspiration, often profuse, 
is generally present; frequent, shallow, and sometimes labored or gasp- 
ing respiration ; feebleness of the heart’s action, and often impercep- 
tible pulse at the wrist; extreme muscular debility, though occasion- 
ally brief, forcible, but irregular muscular action; noises in the ears 
and indistinct vision ; and often, though not always, confusion of 
thought. The temperature of the whole body sometimes falls several 
degrees below the normal, and it is usually soon followed by death. 
The causes are similar to those of shock and depression, operating 
in a more extreme degree. The sudden abatement of a protracted 
and exhausting fever, or other forms of excitement, may be accom- 
panied by collapse; but in other cases it is the result of profuse 
discharges, of the actions of poisons, or other extreme morbid con- 
ditions. 
Syncope is a sudden failure of the heart’s action, and differs from EMACIATION—OBESITY-CONGESTION. 
49 
collapse mainly in this suddenness and in the completeness and more 
transitory character of such failure. Sometimes when complete con- 
sciousness is lost, and often when the patient is passing into this 
state, rigidity, or occasionally more decided spasms occur. 
A more gradual failure of the heart’s action, but not necessarily 
accompanied with coldness or collapse, is called Asthenia. 
Emaciation is a general diminution or wasting of the flesh, and 
particularly of the adipose tissue of the body, and is produced by 
various diseases interfering with nutrition, or producing exhausting 
discharges, and by deficiency of food. 
Obesity is a general and excessive accumulation of fat in the sys- 
tem, and may amount to a positive disease. It differs from fatty 
degeneration by the fat not taking the place of the normal tissues by 
substitution for them, but by being deposited in the interstices and 
connective tissue of parts. The favorite seat of its accumulation is in 
the external areolar tissue and in the omentum. It may be caused by 
excessive alimentation, and particularly by too free indulgence in car- 
bonaceous foods; but it sometimes occurs in persons not addicted to 
any form of alimentary excess. 
Fatty Infiltration sometimes occurs as a local condition, fat 
being deposited in particular organs, as in the liver or heart, and found 
in the interstices of the proper tissues, but not taking their place. The 
pressure of the accumulated fat may interfere with the nutrition of 
the proper tissues, causing waste, and is likely to interfere also with 
the performance of function. Fat is lower in chemical composi- 
tion and organization than proper organ tissues, and its accumulation 
may be a result of arrested or incomplete assimilation of nutrient 
material. 
Hypersemia, as a strictly local condition, has already been noticed. 
Congestion was mentioned as a term nearly synonymous; but this 
latter term is often used in a more general sense, or as indicating a 
more extensive and severe affection than that usually indicated by the 
term liyperaemia. 
Congestion is an accumulation of blood in the capillaries, the 
arteries, the veins, or the heart; and the term may be applied to accu- 
mulations of fluids in the lymphatic vessels. Such an accumulation 
may result in dilatation of vessels, in hemorrhage, in dropsical effu- 
sions, and other exudates ; and when occurring in the heart, it may 
distend its cavities and arrest its actions. Congestion of the brain, 
or lungs, or other organs, may, when severe, arrest their functions, 
producing speedy death. From the suddenness with which serious 
results sometimes follow, the word has terrors to many minds, though 
it is generally a less serious form of disease than inflammation, pro- 50 
DIA THESIS— CACHEXIA—D TSCRASIA. 
ducing far less anatomical and permanent changes, and is usually 
more readily removed. 
The word Diathesis is used to indicate not so much a diseased 
condition as a tendency to some disease, and is commonly constitu- 
tional and permanent. We have the strumous, the tubercular, the 
arthritic, and neurotic diathesis, and others: that is, a tendency to the 
development of scrofula, consumption, rheumatism and gout, or nerv- 
ous diseases, etc., respectively. 
A Cachexia is a depraved condition of the system, the result of 
some constitutional disease, of some poison or other unfavorable con- 
dition a considerable time in operation, and which produces more or 
less permanent results. It is sometimes a diathesis developed, as the 
cancerous or strumous cachexia is the result of a fully formed cancer- 
ous or scrofulous disease. There are various cachexias from slowly 
acting but long-continued poisons, such as lead, arsenic, mercury, 
opium, alcohol, and tobacco. The lead and opium cachexias are not 
unfrequently observed, and the alcoholic and tobacco cachexias are 
exceedingly common. A kind of cachexia is not unfrequent as the 
result of the free use of tea and cotfee ; that from tea being manifested 
oftener in women who take insufficient food and depend upon the 
exciting effect of fhe beverage “ to keep them up.” A sallow or parch- 
ment countenance, with various distressing dyspeptic and nervous 
symptoms, marks this state when extreme. Milder nervous affections 
from the same cause are very common. We find besides those enu- 
merated, malarial, bilious, neurotic, arthritic, anaemic, scorbutic, 
suprarenal, and other cachexias, produced by the various states indi- 
cated by these terms. Dyscrasia is a term used as nearly synony- 
mous with cachexia—the first literally meaning a bad mixture (of 
the vital fluids), and the latter a bad habit (of body). They both 
indicate a depraved state of the system. The peculiarities of these 
various changes will be further noticed when treating of the different 
diseases with which they are connected. 
INFLAMMATION. 
Inflammation is one of the most frequent, and is the most impor- 
tant of the elementary morbid processes. It constitutes a leading part 
in a majority of cases both in medical and surgical practice. In very 
many diseases it is the original and essential condition, and in others, 
not inflammatory in their origin or essential characters, this process 
often appears in their course, presenting an element which more than 
any other determines the result. 1NFLAMMA TION—DEFINITIONS. 
51 
The study of its conditions and character, its phenomena, and the 
means of modifying and controlling it, involves the consideration of 
questions of the deepest interest in pathology and therapeutics. 
In a work upon the practice of either medicine or surgery, the 
subject cannot receive too careful attention ; and while the objects 
and limits of this work will not allow of a full discussion of the vari- 
ous views which have been entertained respecting it, even in recent 
times, the main facts, according to our best present lights, will require 
explicit statement. 
The word inflammation literally means “ to set on fire,” or “to 
kindle or burn as with a flame,” and is expressive of the heat and red- 
ness usually accompanying it. As these phenomena, from which the 
name of this complex process is derived, are not its most essential 
conditions, other names suggestive of more important facts have been 
proposed in its place. Thus one pathologist, regarding the arrest of 
movement of the blood in the part as the most essential condition, 
proposed the term Stasis as the proper designation. Another, re- 
garding the pouring out of material from the vessels into the tissues 
or into cavities as the essential fact, proposed the term Exudation; 
while another, regarding the abnormal multiplication of tissue cells as 
most characteristic, proposed the term Cell-proliferation. But neither 
of the conditions indicated by these terms can be regarded as the 
essentia] fact of this process, consisting as it does of many parts ; and 
indeed neither of them is absolutely essential to the existence of a 
process which is an aggregate of variable phenomena. 
Although an arrest of circulation usually occurs in the most cen- 
tral point of an inflamed part, yet inflammation may be present with- 
out a complete stasis of blood ; and stasis may occur without inflam- 
mation. So with exudation and so with proliferation. Both of these 
processes are usually present in inflammation; but inflammation may 
occur without marked exudation or proliferation, and exudations and 
proliferations are not'ajll inflammatory. Exudation occurs in dropsy 
and other infiltrations, and proliferation in all morbid growths. 
Neither of these nor any other single term will designate a process 
so complex and variable. The word inflammation, though not expres- 
sive in itself of the full process, has the sanction of use as an arbitrary, 
if not as an explanatory term, and may with propriety be retained. 
Various definitions of inflammation have been given, but most of 
them fall far short of indicating all the conditions belonging to the 
process. The classical expression of heat, redness, pain, and swelling 
of a part, is very imperfect as a definition. These conditions are 
certainly usually present; but neither is essential to inflammation, 
and each may be produced by other states ; and when all are together, 52 
IN FLA MM A TION- DEFINITIONS. 
giving the local signs of the process, they are not its most essential 
conditions. They can only be regarded as its common results or 
accompaniments. 
According to an excellent recent authority, “ inflammation may 
he defined to be the succession of changes which take place in a living 
tissue as the result of some kind of injury, provided that injury be 
insufficient immediately to destroy its vitality.” 
Although an injury, mechanical or chemical, gives rise to those 
forms of inflammation, the minute processes of which have been 
most carefully observed, there are many internal inflammations where 
it is not possible to discover any local injury, and when such injury, 
if it exists, must be presumed ; and the definition fails to suggest 
even a single characteristic of the process. Besides, an injury might 
be inflicted producing changes different from inflammation. 
Dr. Bristowe, in his excellent article on the pathology of inflam- 
mation, says : “ Inflammation consists primarily and essentially in an 
unnatural irritability and tendency to undue proliferation of the 
protoplasmic elements of a part—these giving rise, not as in simple 
hyperplasia to a mere increase in the number of the normal elements, 
but to cells which tend to resemble leucocytes, or embryonic cells, 
and which never go beyond the formation of simple granulation 
tissue. The connective-tissue corpuscles are those in which inflam- 
matory proliferation chiefly takes place ; but all protoplasmic masses 
. . . readily participate in the process. . . But in connection 
with these extra-vascular changes, vascular phenomena speedily ensue, 
and at once take an active share in the processes which are going on. 
Among the incidents which occur in the course of inflammation, or 
follow upon it, are exudations, suppuration, ulceration, gangrene, and 
granulation repair.” 
This statement, clear and explicit so far as it goes, fails to give 
any intimation of several processes as essential as those specified. 
As inflammation produces structural changes, it involves the 
nutritive process, and has been called “a change of nutrition.” 
There are, however, other changes of nutrition, not inflammatory, 
and this does not distinguish inflammation from them. It is, how- 
ever, a change of nutrition ; and, as in all structural or organic dis- 
eases, its changes are produced at the same place and by the same 
instrument as are the processes of healthy nutrition. The same 
cells, the same vessels, the same blood, and the same nerves are con- 
cerned in both the normal and abnormal actions, the one being a 
modification of the other. 
In the following definitive statement, a general idea of all the lead- 
ing facts of the inflammatory process is attempted to be given ; but INFLAMMA TION—DEFINITIONS. 
53 
this must be followed by explanations and fuller statements of de- 
tails in order to convey a proper knowledge of its many features. 
Inflammation is an abnormal process in, or alteration of a part, in 
which there is a change in the conditions and relations of the elements 
of the tissues, reducing the molecules and cells to a more embryonic 
state, when rapid metamorphoses are apt to occur. There are changes 
in the structure of the walls, in the vitality and relations, the calibre 
and the actions of the arteries, the veins and the capillaries, by which 
they become dilated, and also in the lymphatic vessels. There is an 
increase in the quantity, a change in the state, the relations, and the 
motions ef the blood and of the lymph in the part, with a tendency 
to stasis of the fluids. There is a tendency to an increased produc- 
tion and an accumulation of leucocytes, an increased disposition in 
them to adhere to the walls of the vessels, and an increase in their 
amoeboid motions. The red discs also accumulate in the vessels and 
adhere to their walls, and particularly they crowd into the capillaries, 
further distending them. There is an increase and also a change in 
the character of the albuminous and fibrinous elements of the blood, 
and a tendency to an effusion of the liquor sanguinis containing these 
elements, and of the lymph, into the tissues ; and to the migration of 
leucocytes, and to a much less extent the red corpuscles, through the 
coats of the softened and distended vessels, and not unfrequently 
through ruptures in their walls. There are perversions of nerve 
actions, either as causes or consequences of the molecular, cellular, 
vascular, and lisemic changes. There is a tendency to proliferation of 
tissue cells, and often to an increased but abnormal nutrition of the 
parts, chiefly in consequence of the increased pabulum furnished them. 
There is a tendency to the formation of new products (coagulable 
lymph, false membrane, pus, and in some situations mucus), and in 
severe grades of inflammation especially, there is a tendency to the 
destruction of proper tissues (softening and absorption, ulceration 
and gangrene). There is perversion or suspension of the function of 
the organs involved, and the process is ordinarily attended by heat, 
redness, swelling and pain, and by febrile disturbance of the general 
system. 
This inflammatory process is doubtless set up in a part by some 
mechanical, chemical, or vital injury or irritating impression upon it; 
but it is more readily induced in some peculiar general conditions of 
the system than in others; and a general impression as of cold, sup- 
pressed secretions, etc., may result first in a general irritation and 
fever, and afterward in a local inflammation. The object or effect 
of the inflammatory processes may be to remove the cause or the 
results of the injury, but the amount of action is not by any means 54 
INFLAMMATION—CHANGE OF NUTRITION. 
always simply proportional to that end. When the injury is mechan- 
ical or chemical, the process, when kept within proper limits, is gen- 
erally useful, resulting in repair. It is of essential service in surgical 
cases in healing wounds and ulcers by throwing out lymph, by caus- 
ing granulation and the production of scar-textures : and even the 
process of suppuration may serve a useful purpose in appropriating 
injured tissue, and removing foreign bodies, as a splinter, from the 
flesh ; and though inflammation in its more violent degrees often 
does great mischief, destroying the work of the surgeon and requiring 
the most careful efforts for its abatement, yet in its milder forms it 
is an essential aid to his efforts, and must be looked upon as his agent 
and helper. 
The physician habitually looks upon inflammation in a far differ- 
ent light. The good which it does, if any, in removing causes, is' not 
apparent, and it usually, when attacking internal organs, presents 
itself to him as an unmitigated evil in all its phenomena and results, 
requiring, as far as possible, the most speedy and complete suppres- 
sion. Inflammation occurring idiopathically in the brain, the lungs, 
the heart, or other parts, where no wound is to be healed or previous 
lesion repaired, can do no good, but only harm, to the organs. Inflam- 
mation when terminating in a manner which would be most favor- 
able for a gaping wound—in the formation of adventitious tissue 
which in the wound would close it up, and by its subsequent contrac- 
tion restore the part most nearly to its normal condition—would in 
the openings or on the valves of the heart produce the most disastrous 
stenosis or insufficiency, obstructing permanently, and often fatally, 
the function. Similarly with the membranes of the brain or of other 
parts. While the surgeon, therefore, has often but to watch the proc- 
ess, and mitigate it only when excessive—has sometimes, indeed, to 
excite it to accomplish his objects—the physician feels called upon to 
arrest it, if in his power ; and this fact may account for the discrep- 
ancies sometimes observed in the manner of treating the subject in 
the respective text-books and class-rooms. 
It is convenient to stirdy inflammation as a change of nutrition— 
to trace the modification of the healthy nutritive process as occurring 
in this form of morbid action. The conditions of healthy nutrition, 
as already stated, are a proper condition of the part to be nourished ; 
a proper supply of blood, and, we may add, lymph ; a proper state of 
the blood and lymph ; and a proper nervous influence. 
There* are concerned, both in healthy and diseased nutrition, the 
tissues, the blood-vessels and lymphatic vessels, the blood and lymph, 
and the nerves. There are peculiar processes in inflammation going INF LA MM A TION—PA 'PROLOG T. 
55 
on without and within the vessels, in the protoplasm and cells of the 
tissues, in the nervous actions as affecting the tissues, in the fluids 
within the vessels, in the nerves as affecting the vascular action, and 
in the vessels themselves, all of which require to be noticed in detail. 
The exact character of many of these processes, as induced by the 
application of irritants to the transparent tissues of the lower animals, 
has been carefully and repeatedly observed under the microscope ; and 
though different observers do not agree on all the minor points, the 
character of many of the changes has been satisfactorily established. 
From the experimental researches of Professors Cohnheim, Strieker, 
Burdon-Sanderson, Klein, and others, made and reported within the 
last few years, more minute and exact knowledge than existed before 
has been obtained ; and a summary will here be attempted, giving the 
more important facts as at present understood. The practical bearing 
pf these details may not at first be conspicuous, but the more minute 
the knowledge of them becomes, the better shall we understand the 
means capable of modifying them, and the manner in which these 
means effect that object; and, as a consequence, the more scientific 
and rational, and the more safe and efficient will the practice become. 
The primary morbid impression producing the inflammation may 
be made either upon the protoplasmic cells of the tissues outside of the 
vessels, or on the nerves supplying the tissues and vessels, or on the 
vessels themselves; and morbid conditions of the blood and lymph, or 
morbid materials within them, may irritate any of these parts, and 
thus, by changing their actions, give rise to the inflammatory process. 
If a costal or articular cartilage, or the cornea, or other non-vascu- 
lar structure be irritated mechanically or chemically, the inflam- 
matory process is set up independent of vessels. When a small 
portion of a cartilage is cut out, the injured surface in a few days 
becomes covered with a soft, grayish pulp, consisting of embryonic 
cells, together with some newly formed blood-vessels. If a cross sec- 
tion be made so as to expose the surface of the cartilage, including the 
wounded part and the pulp covering it, there will be found in the car- 
tilage, sufficiently far from the injury, a healthy state of the cartilage 
cells and hyaline substance in which they are embedded, or which 
in layers is interposed between them. On approaching the injured 
point, however, there will be seen enlargement of the cells and their 
nuclei, and enlargement, also, of the cavities or spaces in the hyaline 
substance in which the cells are contained. Coming nearer the injured 
part, fissiparous multiplication of the enlarged cells and nuclei will 
be observed, and several cells, the result of such division, will be found 
packed together in cavities or spaces in the hyaline substance formerly 
occupied by a single cell. Each of these young cells, like the parent 56 
INFL A MM AIION—.PA TIIOL OGT. 
cells, will be found invested in a thin, cartilaginous capsule, constitut- 
ing it a true cartilage cell. Still nearer the injury the proliferation is 
increased, the cells becoming much more numerous but smaller, losing 
their cartilaginous or formed capsules, and assuming all the charac- 
ters of simple embryonic cells, the part thus being reduced to the 
embryonic condition. The spaces in which these cells are contained 
enlarge at the expense of the hyaline matter, and often the cells, by 
crowding together, are found to coalesce. Then at the surface of the 
wound will be found an irregularly scolloped border, to which is 
attached and from which has grown the gray film of embryonic cell- 
tissue before mentioned as on the injured surface. Each of these 
scollops represents a portion of a primitive cartilaginous capsule, 
whose cavity has blended with those around it, and the gray embryonic 
mass is the result of the proliferation of the cell-contents of these'and 
other cartilage capsules. 
The effect of an injury in these parts then is, first, growth anct 
proliferation of the protoplasmic or living cell-parts of the cartilage. 
The new cells soon lose their character of true cartilage cells, and 
take on the character of embryonic cells. Secondly, there is progres- 
sive deliquescence and removal of the hyaline constituents of the 
cartilage, under this cell growth and multiplication, resulting in its 
entire disappearance when the proliferation has attained its most 
advanced stage. The less vitalized hyaline material is doubtless used 
as pabulum—is appropriated to the nourishment and growth of the 
cells. It may here be mentioned that more than twenty years ago, 
Dr. Redfern, of Aberdeen, Scotland, observed as the result of these 
inflammatory changes in cartilage cells, a transformation of them 
into well-formed pus cells. 
In this process observed in cartilages, is a type of what may occur 
in the cells and parts of other tissues under inflammatory irritation, 
in a degree at least, independent of vessels, blood, or nerves. It illus- 
trates also the inherent excitability of the ultimate tissues. Experi- 
ments upon the mesentery of adult animals show slight modifications 
of the inflammatory process as it is observed in cartilages, but essen- 
tially the same phenomena. The mesenteric membrane consists of a 
delicate net-work, the trabeculae or threads of which are often exceed- 
ingly fine ; the whole membrane is without blood-vessels in its sub- 
stance, and consists solely of connective tissue and a thin covering of 
tessellated epithelium. By exciting inflammation with some irritat- 
ing material, such as a solution of nitrate of silver applied to the 
membrane, changes very like those in the cartilage may be seen. 
After some hours a turbid fluid is found in the peritoneal cavity, the 
turbidity being due to the presence of cellular elements in different IN FLA MM A TION—PA THOLOO Y. 
57 
degrees of development, which, instead of adhering to the membrane, 
as was the case with the embryonic cells on the wounded surface of 
the cartilage, have become detached and are floating in a serous fluid. 
On examining a drop of this fluid under the microscope, ordinary 
pus cells, besides larger cells, containing two or more oval, well- 
defined nuclei, more embryonic cells, etc., will be found : and the 
epithelial cells at the surface of the membranous net-work have be- 
come larger and more rounded, have lost their cell-walls, have often 
undergone proliferation, becoming pyoid, and some of them, though 
still adherent, mature pus cells. These cells adhere irregularly to 
their points of origin, and are invested and often retained in their 
original positions by coagulated fibrine, which has exuded from the 
inflamed surface. If no further irritation occurs, in a few days the 
floating cells become opaque, undergo fatty changes, and disappear, 
while those adhering to the net-work structure of the peritoneal mem- 
brane, not having advanced to the condition of pus, flatten and 
resume the ordinary character of serous epithelium. This last fact 
illustrates the similarity of inflammatory hyperplasia and normal cell 
production and growth. 
Inflammation in the cornea of a frog shows a more complex proc- 
ess. This corneal tissue consists chiefly of a net-work, formed by the 
union of rays of star-shaped cells, the meshes or intervening spaces 
between the rays of the cells being filled with an indifferent substance, 
like the hyaline matter of the cartilage, and with some other material 
corresponding to the white fibrous bands of ordinary connective tissue. 
When inflammation is excited by touching a point near the centre of 
this membrane with nitrate of silver, changes soon take place, spread, 
and involve the whole cornea, rendering it milky and opaque. At 
the injured spot and its immediate vicinity the stellate cells first 
become unnaturally well defined, being a little more granular or turbid 
than normal. They then swell, their processes or rays become thin- 
ner, are retracted, and mostly disappear, and the growing cells assume 
a nodulated form. They now separate from each other, and become 
isolated in the corneal matrix, like the cartilage cells in the hyaline 
substance. They now become more opaque, proliferation commences 
by divisions and subdivisions of nuclei, each new cell having a cover- 
ing of protoplasm, until each original cell becomes the parent cell of 
a group of embryonic corpuscles. There is here the same liquefac- 
tion and disappearance of the intervening matrix, and ultimate coa- 
lescence of neighboring groups, and the same appearance of embryonic 
cell element, more or less advanced toward the surface and discharged 
from it, as in the other cases described. 
But here in the cornea something more occurs. While the changes 58 
INFLAMMA TION—PA TIIOLOG Y. 
are progressing from the centre where the injury was inflicted, other 
changes commence and proceed from the circumference toward the 
centre. These changes consist in the gradual escape of leucocytes 
from the now dilated marginal vessels, and the passage of these leuco- 
cytes by their amoeboid motions into the interstitial spaces of the 
cornea. These spaces they crowd, rendering the cornea more opaque. 
They, too, multiply, mingling their new corpuscles with the prolifer- 
ating corneal cells, and they are so like them as not to be distinguished, 
from them. Cohnlieim and his adherents regarded all these morbid 
cell developments as due to the migration of the white corpuscles of 
the blood, and in some forms of inflammation and in some tissues, 
the morbid corpuscles are chiefly, it may be in rare instances entirely, 
derived from this source ; but in other instances, as in the cartilages 
at a distance from the blood-vessels, the corpuscles are entirely from 
the cells of the part; and without doubt in most instances both the 
migrated leucocytes and the cells of the tissues unite, as seen in the 
cornea, in the production of similar embryonic elements. Observa- 
tions on this point have now been so often and so reliably made and 
recorded, that there can be no further grounds for doubt on the 
subject. 
From the analogies of physiological and pathological processes 
the remark may be ventured, that the normal production of cells in 
healthy nutrition has the same double origin that leucocytes and 
lymph cells have ; or that corpuscles migrate, though to a less extent, 
physiologically, and aid the cells of the tissues in effecting growth 
and repair. 
Processes essentially identical with those described occur in 
inflammation of all the tissues—in “ vascular” tissues, in connective 
tissue, in bony substance, in muscles and in nerves, in the proper 
tissue cells and structures of special organs, as the lungs, liver, brain, 
etc.; though the cells in these latter organs that have received a high 
degree of development, and have come to a state of full maturity, may 
not take on changes so readily as some of the cells mentioned. The 
connective-tissue cells, the epithelial cells, the cells of glands, and the 
endothelium of serous membranes—all those that undergo more read- 
ily and more rapidly nutritive changes—take on more readily inflam- 
matory metamorphoses, and young elements more readily than old ; 
still, recent observations prove that the proper cells of the brain and 
liver may be the primary seat of various morbid changes. 
Not only outside of the vessels, but within them, in their coats 
and their contents, important changes take place in the process of 
inflammation. Some pathologists, indeed, regard the vascular changes 
as first in occurrence and importance; and undoubtedly, in a IN FLA MM A TION—PA TIIOLOGT. 
59 
majority of cases, changes in the vessels, in their vital endowments 
and actions, their relations to the blood and the tissues, occur early, 
and exert a profound influence upon the process. 
Among the most obvious external evidences of inflammation are 
the redness of the part and the throbbing of the arteries leading to it. 
The redness is produced by enlargement of the calibre of the vessels, 
and the increased quantity of blood in them. The active processes 
going on outside of the vessels would create a demand for an increased 
supply of pabulum, and of the blood which furnishes it; and this 
increased demand can be supplied only by the vessels, which soon 
dilate and bring to the part a greater quantity of blood. 
If any living, transparent, vascular tissue, as the web of the frog’s 
foot or the bat’s wing, be sufficiently irritated, it may be seen that 
the small arteries of the irritated part gradually dilate, and before 
long may attain twice their normal calibre—that at length (perhaps 
in some hours) the capillaries and veins follow suit, and all the 
vessels become expanded. While these changes in the size of the 
vessels are going on, changes are occurring in the blood stream within 
them. While the arteries alone are affected, the rate of flow is in- 
creased, and there is a state of active hyperaemia—a condition which 
has already been described. As the veins and capillaries become 
dilated also, the flow of blood is retarded ; it usually goes on, becom- 
ing slower and slower, the blood oscillating in some of the capillaries ; 
the white corpuscles accumulate and adhere to the walls of the vessels ; 
at length the motion in the vessels at the part most advanced in the 
inflammation ceases, and the blood is in a state of stasis. It now 
loses much of its serum by osmosis through the vascular coats, or at 
any rate the serum is largely displaced by the crowding in of the 
corpuscles, white and red, which often become wedged together in an 
apparently amorphous mass. 
The vessels immediately around this inflamed part have become 
dilated, and the blood is circulating through them in increased 
quantity and with increased velocity ; and, as a rule, much more blood 
flows to and through a part, taking into account the whole organ 
affected, than normally. This was long ago proved by Mr. Lawrence, 
who by ligating both arms of a man, one of whose hands was in- 
flamed, and opening freely a vein at the bend of each arm, found 
more than twice as much blood to flow in a given time from the vein 
returning the blood from the inflamed member as from the well 
one. The same difference would not occur in all cases, much depend- 
ing upon the stage of inflammation, its more active or passive 
character, etc. ; but usually more than the normal quantity of blood 
flows to and through an inflamed organ. In non-vascular parts, the 60 
INF LA MM A TION—PA TIIOLOG F, 
vessels in the neighborhood, from which such parts receive their 
nourishment by osmosis, undergo similar changes of dilatation, and 
in them an increased flow of blood occurs. Thus an inflammation 
in the non-vascular part may be fully developed without a stasis of 
blood at any point. The arteries, the veins, and the capillaries, all, 
but in different degrees, have the power of active contraction and 
active dilatation, at least of dilating while tonicity is still preserved ; 
and the increased flow of blood is probably an active process, not only 
in the heart and larger arteries, but in the veins and capillaries as 
well; and when the action of the smaller vessels, by impairment of 
vitality, ceases, the blood flow may be retarded or arrested, though 
the heart sends it forth with equal force. The adherence of the 
blood corpuscles to the walls of the vessels tends to block them up and 
aids in arresting the flow. This disposition of the blood corpuscles 
is due to a changed relation between the coats of the vessels and the 
tissues without, on the one side, and the blood itself on the other. 
Normally there is an attraction by the tissues for the elements of the 
blood, and a selection of those they need. In inflammation that at- 
traction seems to be increased and to be less discriminative. There 
are new elements in the blood when inflammation and fever are 
present—at least new proportions of elements—more solid materials, 
and the greater attractive power of the tissues seems to draw all the 
elements, not excepting entirely the red corpuscles, through the coats 
of the vessels. Whatever be the explanation, in the condition of 
stasis and crowding of blood corpuscles, the migration of the leu- 
cocytes, generally in free quantities, takes place. Their passage is 
effected mostly through the veins. They are plainly seen to adhere 
to and penetrate their walls, disappearing from within and appearing 
on the outside like swelling buds, and at length passing through, they 
remain attached to the outside of the vein for a short time by a 
slender thread. This then yields, and the leucocyte travels off among 
the elements of the softened tissues, mingling with young proliferat- 
ing cells, as in the case of the cornea. It is at least probable, though 
it is a point difficult to demonstrate, that there is an attractive force 
on the part of the tissues, as well as a propulsive force on the part of 
the leucocytes causing their migration. Some of the red corpuscles 
follow the white in their passage through the walls of the vessels ; 
but when any large quantity of these are found outside of the vessels, 
it is doubtless by rupture of their coats. 
Associated with the passage of the corpuscles, as already intimated, 
there is a free exudation of the liquor sanguinis, having in it more 
solid material than normal, constituting the well-known common 
inflammatory exudate. This is composed largely of serum, but it INFLAMMA TION—FA TIIOLOG T. 
61 
differs from the effusion which takes place as the result of simple 
mechanical congestion and pressure. It usually contains a larger pro- 
portion of albumen and fibrine, and these ingredients are increased in 
proportion to the severity, and are varied by the character of the 
inflammation. The quality of this exudate is otherwise modified by 
the tissues through which it passes, and by the cavities or surfaces 
where it is found, as well as by the kind and grade of the inflamma- 
tion. The swelling which accompanies inflammation is due largely 
to these exudates, though the increased quantity of blood in the ves- 
sels of the part, and the proliferation of the cells of the tissue, aid this 
result. As the exudate contains more or less spontaneously coagu- 
lable material (fibrine) the swelling will be harder or softer ; and when 
the texture of the inflamed part is loose, a more abundant serous effu- 
sion is apt to occur, producing infiltration or oedema of the tissues 
beyond the limits of the actual inflammation. 
In inflammation of mucous membranes the tissue is not only infil- 
trated, but a free discharge usually takes place from the surface ; and 
into serous cavities, when their lining membrane is inflamed, a still 
more free discharge is likely to occur. 
In the severer grades of inflammation on serous surfaces a large 
quantity of fibrine is usually in the exudate, which speedily coagulates, 
and this, together with a large number of cell-elements, which is a 
leading characteristic of inflammatory exudates, constitutes the false 
meiribrane which will be described farther on. The greater number of 
these cell-structures or elements are probably from the leucocytes of 
the blood, but the cells of the tissues, multiplied, form a part of these 
elements. 
From the compact structure of the liver and kidneys large effusions 
cannot take place into their substance, and the effusion which occurs 
is so mingled with the tissue as scarcely to be distinguished from it. 
In the kidneys the effusion readily takes place into the uriniferous 
tubes, and appears in the urine, being detectable there as albumen and 
casts. 
In the lungs, where the texture is more loose and the vessels are less 
firmly supported, free exudation occurs, often into the connective tis- 
sue, but more especially upon the free surface of the air vesicles and 
the tubes. 
How far the retardation of the blood-flow and the exudation of the 
liquor sanguinis and leucocytes depend upon the blood itself, and how 
far they are dependent upon the state of the vessels and tissues with- 
out, it is not possible at present to determine. Some recent experi- 
ments seem to indicate that more depends upon the condition of the 
vessels, and less upon that of the blood, than was formerly supposed. 62 
INFLAMMA TION—PA THOLOG Y. 
Neither is the exact amount of influence exerted by the nervous sys- 
tem, central and vaso-motor, over the process, determined. 
Cohnheim asserts that simple congestion of the arteries, however 
great, never results in increased transudation, but that inflammation 
is always accompanied by such transudation ; that the swelling of arte- 
rial congestion is limited to the enlargement caused by the expansion 
of the vessels and the increase of the amount of blood in the part, and 
is not enhanced by any effusion.(?) 
In venous or passive hyperasmia effusion takes place, and the 
swelling is increased beyond that produced by the increase of blood, 
but heat is regularly wanting. The exudate here has no more of the 
cellular element than is contained in every normal transudate; but, 
when the congestion is intense, blood corpuscles may be present. In 
inflammation the white corpuscles abound in the exudate, and it is 
very much more concentrated. 
That the nerves exert a decided influence over nutrition, healthy 
and morbid, there can be no doubt; but to what extent these processes 
may, or do, originate and go on independent of the nerves, is another 
point not decided. 
That tissues possess a degree of impressibility and power of action 
independent of nervous influence, is shown by the experiments upon 
fragments of the frog’s heart already referred to; and some recent 
experiments by Cohnheim have shown that inflammation may be 
induced in a frog’s tongue when its connection with the rest of the 
system was only by the artery and veins. But vaso-motof nerves 
probably followed the vessels to the part, and for all that is shown, a 
ganglion, or comparatively independent nerve-element, may have been 
in the frog’s tongue itself, as is in the heart of that batrachian. 
That the central nervous element in man has far more control over 
all his functions than that element has in the frog, is well known; 
and there can be no doubt that in the human organism the nervous 
system exercises a very large degree of influence. 
The division or paralysis of certain organic nerves leading to a 
part, is not unfrequently followed by inflammation and other organic 
changes of that part, and morbid impressions upon nerves may initiate 
the inflammatory process. Many impressions modifying the actions 
of vessels and tissues are made upon the nerves, and may be conveyed 
to the parts either by direct or reflex communication ; still, morbid 
impressions made directly upon the tissues, as we have seen in the case 
of the cartilages and the cornea, or impressions upon the walls of 
vessels, or morbid conditions of those walls, have much to do with 
their functions in increasing, diminishing, and otherwise modifying 
the circulation of the blood. INF LAMM A TION—PA TIIOLOG T. 
63 
Although inflammation may be produced and sustained by irritat- 
ing impressions or injuries inflicted upon the elements of the tissues, 
as proven by experiments upon the non-vascular parts just referred 
to, yet the action of the vessels, and the exudates poured out of the 
blood play an important part in the changes of the inflamed tissues. 
In fact, all these elements act and react upon each other in the pro- 
duction of the inflammatory phenomena, and while we may usefully 
consider the comparative influence of each as bearing upon the differ- 
ent special objects most important to be aimed at in treatment, yet we 
must look upon the process in its aggregate of special phenomena, and 
give attention to its apparent features as found in actual cases. 
The blood is undoubtedly changed in inflammation and in the 
fever accompanying it, in its physical, chemical, and vital properties, 
and in its relations to the vessels and tissues—sometimes as a cause of 
other phenomena, and sometimes as a consequence of them. The 
amount of fibrine is markedly increased, the white corpuscles are in 
much larger numbers, and the red discs, though accumulating in the 
inflamed part, are gradually, sometimes rapidly, diminished in the 
general system, their debris coloring the urine ; and the result of 
this in protracted cases is anaemia and debility. Dr. Lionel Beale 
regards changes of the blood as the most important element in inflam- 
mations and fevers, two conditions which he regards as strikingly 
analogous—almost identical so far as this state of the blood is con- 
cerned. He says that the extractive matter soluble in boiling water 
is much increased, probably from insufficient oxidation ; various sub- 
stances remaining unoxidized, or but partially oxidized, pass out of the 
system slowly in a suboxidized state. He thinks an excess of soluble 
materials in the blood penetrates the tissues, passing through the 
small vessels more freely than serum, and that these materials are 
appropriated by the tissues to their detriment; that instead of thus 
being retained, they should have passed off as carbonic acid, urea, etc. 
He further states that the bioplasts are increased in size, and that there 
is increased growth of germinal matter in all inflammations and 
fevers, showing their analogies. He shows from experiments that 
there is twice the quantity of matter soluble in boiling water in the blood 
of cattle affected with the cattle fever that there is in healthy ox blood, 
and that the blood contains more solid matter in these cases than 
normal blood as shown by evaporation. He thinks this matter forms 
a pabulum which is very readily appropriated by degraded forms of 
bioplasm in the diseased tissues, leading to morbid products. He 
doubts what is believed by others, that any morbid state is produced 
by too much oxidation, or peroxidation, and affirms his belief that 
insufficient oxidation is general in diseases of all kinds. Whether 64 
INF LAMM A TOR Y EX UDA TES. 
these views he correct to the extent declared may well be questioned, 
but the high authority of Dr. Beale renders them worthy of attention ; 
and that very many diseases are accompanied and aggravated by 
diminished oxidation there can be no doubt. That changes in the 
blood occur and contribute, often largely, to the morbid phenomena, 
both in inflammation and fever—conditions so nearly allied that fever 
always accompanies inflammation, sometimes precedes it—cannot be 
questioned. 
The blood of a person laboring under an inflammation, when stand- 
ing in a vessel after being drawn, is buffed ; as, either by its slower 
coagulation, or by the more rapid sinking of the corpuscles from 
adhering together, the coagulated fibrine at the top of the vessel has 
not closed within its meshes sufficient corpuscles to give it the usual 
red color of the clot; and it is cupped, has a concave or cup-shaped 
surface from shrinking at the top, as it coagulates, more than below, 
where the corpuscles have gravitated, preventing so much contraction 
and keeping up its bulk. 
Besides these more apparent, and perhaps more constant, changes 
in the blood, there are doubtless various vital changes—changes in its 
activities and relations to the tissues, in its function as an oxygen 
carrier, etc.—less demonstrable, but not less important; and further, it 
is the receptacle of various substances foreign to itself, as previously 
pointed out, which act as excitants to inflammatory and other morbid 
processes. These foreign substances, taken in from without, and often 
multiplied within the system, or those materials generated there, are 
the common causes of specific inflammations, as well as the whole 
class of zymotic fevers. 
We have seen how the tissues are changed in their histological 
elements. In their grosser appearances swelling commonly occurs, 
and, as already intimated, is partly from the increased quantity of 
blood, partly from proliferation of tissue cells, but more commonly 
from the exudation which occurs ; while the proper normal tissues, 
especially in severe cases, change in the direction of decay. 
The nerves of an inflamed part are irritated by the process, are 
often pressed upon by the exudates, and sometimes disintegrated by 
the destructive changes. As consequences there are sensations of 
burning, of pain, frequent throbbing, and of tenderness ; and there 
are various sympathetic irritations in more or less distant parts. 
The inflammatory exudates, or the matters appearing in sensible 
amounts as the products or results of the inflammatory processes, are 
serum, blood, mucus, pus, and lymph, or common inflammatory 
exudate. • 
Serum is exuded through the coats of the vessels, favored by the INFLA MM A TION—P US. 
65 
internal pressure, by the distention, attenuation and softening of their 
walls, and by the looseness of the texture of the parts, or the freedom 
of the surface involved in the inflammation. The character of the 
surfaces or tissues, and the kind and degree of inflammation also 
modify its effusion. More or less serum is mingled with all the other 
exudates. 
Blood is not unfrequently found, as a result of inflammation, either 
in the tissues or upon surfaces, mingled with other inflammatory prod- 
ucts. As already stated, to a limited extent and in small numbers, 
red blood corpuscles may pass through the coats of vessels without 
destruction of continuity; but when they are in any considerable 
amount, rupture of vessels has, generally at least, taken place. In 
dysentery and pneumonia blood is commonly present in the exudates, 
and often inflamed tissues are stained with blood poured out into their 
structure. 
In ulcerative processes blood is frequently effused from the open- 
ing of vessels, and sometimes in large quantities. 
Mucus is commonly freely produced in inflammation of mucous 
membranes. D. I. Hamilton, M. B. F. R. C. S. Ed., L. R. 0. P. Ed., 
Demonstrator of Pathology, University of Edinburgh, and Patholo- 
gist to the Royal Infirmary, in his careful study of acute bronchitis, 
says there is an abnormal production of the fluid matter of the 
mucus, and of small spherical cells, or mucous corpuscles, a peculiar 
kind of secretion from the mucous follicles, mingled commonly with 
leucocytes from the blood, and with detached or aborted epithelial 
cells from the membrane. This latter is the chief source of the 
mucous corpuscles in acute bronchitis. 
The young cells manifesting life are either from leucocytes, or are 
produced within the epithelial cells by endogenous multiplications. 
Between the appearance of mucous corpuscles and pus, there is no 
clear line of demarkation, and frequently well-formed mucous globules 
and pus corpuscles are mingled together. The difference between the 
two is often one of degree of development. The severer the inflam- 
mation, the greater the tendency to the production of pus. 
Pus is another product of inflammation, and is never produced 
without that process. Its formation and accumulation is called 
Suppuration. What is called “laudable pus” is a homogeneous- 
looking creamy matter, of bland consistence and mawkish odor ; but 
when examined with a microscope it is found to consist of globular 
bodies floating in a serous, alkaline fluid, called the Liquor , Puris. 
This fluid resembles the liquor sanguinis; but in addition to the 
ingredients of the latter fluid, the liquor puris often contains a 
peculiar albuminoid substance called pyine, and may also contain a 66 
INF LA MMATION—P US. 
moderate quantity of other substances, as a little blood, and occa- 
sionally vibriones, without destroying its character as laudable or 
“ orthodox pus.” 
The pus corpuscles, as seen in the tissues, are scarcely distinguish- 
able from leucocytes. As seen after removal from the body, with proper 
magnifying and defining power, they are spherical, spheroidal, or more 
irregularly-shaped semi-transparent bodies, from the to 
of an inch in diameter, containing a variable number of granules, 
especially upon the surface, and usually one or more distinct nuclei. 
The addition of dilute acetic acid clears away some of the granules, 
causes the cells to swell, they become more transparent and spherical, 
and the nuclei are rendered more visible. There are variations as to the 
size of the corpuscles, the amount of granular matter, and as to the 
number and size of the nuclei. Young pus corpuscles, white blood 
corpuscles, lymph corpuscles, and many other young cells from pro- 
liferating tissues, are often un distinguish able; all consist of masses 
of contractile protoplasm, and are often called by the common name 
of leucocytes or pyoid cells. They all possess the power of spon- 
taneous movement, of appropriating nourishment, and of growing, 
are capable of multiplication, and thus present all the necessary 
properties of living matter, and while living they undergo continuous 
alterations in form and location, wandering among the tissues. There 
is but slight microscopical difference between even typical pus cor- 
puscles and the corpuscles developed previous to the full suppurative 
stage of an inflammation, by the proliferation of connective-tissue 
cells and other stationary protoplasmic bodies ; and as little dif- 
ference between them and the emigrant leucocytes ; and beyond ques- 
tion the pus cells originate both in altered tissue cells and in the 
white corpuscles of the blood. “ Indeed, at every suppurating surface 
the gradual transition of the one into the other may be readily 
observed. ”—(Bristowe.) 
It is, however, doubtful whether full-formed and completely mature 
pus cells are then capable of multiplication, and it is certain that 
their more active vitality ceases very soon after their maturity ; and 
although they retain for a much longer time sufficient life-force to 
prevent decomposition, they are incapable of further development ; 
they never, like other cells, form fibres or tissues, and they change 
slowly, and only in the direction of degeneration and decay. 
The term “ dead blastema,” applied to pus as a short definition, 
or as descriptive of its nature, since the advent of more exact knowl- 
edge and the abandonment of the old doctrine of blastema, or of a 
formless fluid out of which forms are produced, must of course dis- 
appear from the vocabulary of those who do not linger too far behind INFLAMMATION— P US. 
67 
the advancement of pathological knowledge. It was never consistent 
even with the theory of blastema, and the only apology for its use 
was in the fact that when fully formed and entirely mature, pus cor- 
puscles were incapable of further developmental changes, and like other 
mature organisms must either remain stationary, and that but for a 
time, or sooner undergo the process of death and decay. On no 
rational theory or supposition could an organic particle or body like 
the pus corpuscle, with a cell-wall and its contents, especially its 
nuclei, be the result of the death of a homogeneous substance, though 
capable, when living, of producing forms, as the fancied blastema 
was supposed to be. Organisms, however simple, are produced by a 
process of life, not of death. The forms supposed to be produced from 
the “ blastema,” were no longer the “ blastema ” itself, and “dead 
blastema ” must at least be as devoid of organic forms as living. But 
the clear observation of facts displaces errors, and no further refuta- 
tion of this is required. In the light of the microscopical observa- 
tions of the inflammatory process in transparent tissues and on sup- 
purating surfaces, already noticed, it is not difficult to trace some of 
the steps which lead to the development of pus (not to the death of a 
fancied homogeneous substance which was thought capable of pro- 
ducing forms), and it would seem that further controversy in regard 
to its origin must cease. 
We have already seen that when inflammatory proliferation is going 
on in a tissue, the indifferent or less vitalized stroma between the 
groups of active cells is softened, eroded, and disappears, and neighbor- 
ing groups of cells come together and constitute a continuous mass of 
embryonic or young cell tissue. These cells, thus in contact for a 
time, cohere together, either in the manner of epithelial cells, or by 
some scanty adhesive material. It needs only the separation of these 
cells by the loss of this cohesive property, which may be effected by 
the pouring in of serous fluid constituting the liquor puris, and a 
trifling further maturation of the cells, to constitute perfect pus. It 
is thus essentially that suppuration, in part at least, takes place at 
the surface of an ulcer, and also in this manner abscesses form ; but 
in addition to these changes in the tissue cells, the white corpuscles 
of the blood, increased and made more active by the inflammatory 
excitement, gather to the part, penetrate the vessels and other changed 
tissues, and mingle with the embryonic tissue cells, partake of their 
character, and join with them in their after course. 
In the formation of an abscess, softening occurs at the point of the 
most advanced changes in a proliferating region, and the cells which 
would otherwise have formed a solid exudate, and perhaps have been 
formed in time into a solid, adventitious, but living tissue, change, 68 
INFLAMMA TION—P US. 
by separation and slight modification, into pns corjrascles ; and the 
swelling, which before was more or less hard and firm, becomes soft 
and fluctuating. 
By the extension of this process; by the conversion of the tissue 
cells into embryonic and pus cells ; by the erosion and transformation 
of the less vitalized material; by the appropriation of its matter and 
of the matter of the albuminous exudates from the blood to the growth 
and multiplication of the cells ; and by the swarming in and multipli- 
cation of the leucocytes, an abscess obtains its dimensions, spreads in 
the direction of the least resistance, usually toward the surface of the 
body, and sometimes forms with astonishing rapidity. The pus cor- 
puscles within the cavity, if not obtaining an outlet sooner or later, 
sometimes quite soon, especially in low conditions of the system, 
undergo degenerative changes, lose their vitality, and perish. Their 
protoplasm is replaced by fatty particles, and they swell and break up, 
or they contract and become opaque and angular, or calcareous depos- 
its place within them, forming a mortar-like mass or a cheesy 
detritus; and as softening goes on absorption follows, and a more or 
less perfect cure of the abscess ensues. A natural or artificial opening 
of the abscess and discharge of its contents often greatly hastens the 
cure. 
Pus, when “ laudable,” forming in an abscess or elsewhere in a 
person of vigorous constitution and free from septic tendencies, and 
when the injury is not so severe as to lower general or local vitality 
too much, does not readily yield to chemical forces, but long resists 
decomposition. 
But pus of recent formation does not always present the character 
of laudable pus, as described. It sometimes is thin and watery, and is 
called ichorous pus ; it sometimes contains a more or less free mixture 
of changing blood, and is said to be sanious ; and sometimes it con- 
tains particles of dead and decomposing tissue, or dead and decompos- 
ing exudates, and is fetid pus, and is often then very irritating and 
poisonous, especially when in connection with large surfaces; and 
when absorbed into the circulation the most disastrous results follow, 
and it is called septic pus. The presence of bacteria favors these as 
well as other decomposing changes, and aggravates all the symptoms, 
general and local. In practice with open wounds, these bacteria 
require exclusion and destruction by cleanliness and various antiseptic 
means. 
In certain conditions of the system the pus cells, almost or quite 
at their formation, are imperfect, shriveled, and irregular; and 
sometimes, instead of being fully developed, many are left in the form 
of granule cells, or mere molecular debris. In severe crushing inju- INFLAMMA TI0N—DE8TR UCTIVE CHANGES. 
69 
ries, gunshot wounds, etc., even in previously healthy persons, some 
parts may be deprived of vitality, and others so severely injured as to 
become necrosed, while other adjoining parts are only so much injured 
as to excite inflammation. In these cases the pus will be mingled 
with dead and decaying tissue in various proportions, and when 
“ laudable ” pus appears the signs are more favorable. Here the for- 
mation of pus often appropriates injured material which might other- 
wise putrefy and become a source of septic infection. 
Though the formation of pus is always an inflammatory process, 
and therefore abnormal and in a sense morbid, yet the production of 
“laudable ” pus is often spoken of as “ healthy ” suppuration, to dis- 
tinguish it from those more injurious forms just mentioned. 
In connection with the production of pus and the formation of 
abscesses, the destructive effects of inflammation have already been 
adverted to. These destructive processes are shown in the softening 
and disintegration which take place in the less vitalized stroma, or 
hyaline substance of cartilage, in the white fibrous element in connec- 
tive tissue, and in the earthy matrix of bone and other parts, while 
the cell multiplication is in progress. 
Destructive or degenerative processes often occur in inflamed or- 
gans, in elements not the immediate seat of the proliferative changes, 
in consequence of the pressure of exudates, or the deranged and en- 
feebled nutrition from contiguous sympathy, or from the heat of 
fever and the general derangement which an inflammatory condi- 
tion induces. Destructive changes occur in a more marked form in 
the processes of ulceration or necrobiosis, and in that of gangrene or 
necrosis, as the results of inflammation. As already stated, an injury 
may be so severe in a part as to deprive it of life, while an adjoining 
part may be excited to inflammation. But gangrene maybe the effect 
of an inflammation. This may result from the obstruction of arteries 
supplying the part, by clots forming within them, or by thickening of 
their walls, or by pressure upon them by exudates, thus arresting 
nutrition; and the extreme heat and other morbid actions of an 
intense or an adynamic inflammation, independent of these obstruc- 
tions, may overcome vitality and produce the same destructive results. 
In inflammatory gangrene the parts are generally moist and swollen; 
as in the preceding process, they are infiltrated with exudates. 
In ulceration or necrobiosis the destruction, instead of being in 
mass, is molecular or in small fragments, and is progressive while the 
process continues. It resembles the destruction of elements in sup- 
puration, as already described, but differs from it in involving more 
indiscriminately the tissues, and in the open character of the sore. In 
ulceration there is excavation of the surface, the destroyed material 70 
INFLAMMA TION—L YMPH. 
being thrown off in the form of pus and of small devitalized particles 
of tissue ; and sometimes a portion of the softened and liquefied 
material is absorbed away. When the destructive process has ceased, 
and granulation and repair are going on, the sore is called an ulcer 
until the healing is complete. 
Common inflammatory exudate or coagulable lymph is a charac- 
teristic product of inflammation. It consists of the liquor sanguinis, 
which, however, contains more than the usual amount of fibrine, 
readily coagulating or fibrillating on being removed from the vessels. 
It also contains corpuscles derived from the blood, and particularly 
from the proliferating tissue cells. It contains the same corpuscular 
elements already described, but with the addition of fibrine and other 
albuminous matters exuded from the blood. 
This lymph exudation or deposit may be in tissues or upon surfaces, 
and is most characteristic or typical on serous membranes, though 
excellent specimens are often found between the lips of wounds. As 
recently exuded upon a surface, it is a straw-colored, gelatinous- 
looking substance, of greater or less tenacity, according to the pro- 
portions of fibrine, corpuscles, and serum it may contain, and is in 
layers of various thickness, from a thin film to several lines in depth. 
This material, whether deposited within tissues or upon surfaces, 
may undergo different changes. The fibrinous materials may be 
dissolved in the fluid exudated, and the corpuscles may be released 
and develop into pus, or the whole may liquefy and be absorbed away. 
In other cases the fibrinous felting may retain its consistence, the cor- 
puscles elongate, shoot out processes, and form into fibres, and these 
elements uniting may form a tissue of some thickness, or the corpus- 
cles may be flattened out into epithelial cells. 
When this fibrinous and corpuscular material is in any consider- 
able quantity deposited upon a surface, it is called a false or adven- 
titious membrane. It may remain for some time comparatively 
unaltered, it may break down and be removed, or it may receive 
blood-vessels in loops from the parts upon which it is deposited and 
become organized into a living tissue ; in time, lymphatics and nerves 
may be found in it, and it may become a part of the body itself. In 
the formation of this organized new tissue the fibrine seems to serve as 
a scaffolding for the corpuscular elements, which are more vitalized, 
and by their change form the more permanent tissue. The fibrine, hav- 
ing served its purpose, appears to be removed. D. T. Hamilton, before 
referred to, is of the opinion that neither the fibrine nor the white 
corpuscles, nor any of the elements of the blood, enter into the struct- 
ure of false membrane when fully organized, but that all the living INFLAMMATION—GRANULATIONS. 
71 
elements are from the proliferated tissue cells. This adventitious 
structure takes the character more or less of the tissue in connection 
with which it is formed, but it still tends to remain a fibrous struct- 
ure. Its organization and vitality is not of as high an order as 
natural tissue, and it more readily undergoes destructive changes. It 
is highly vascular at first, but much less so in time; and by losing 
many of its vessels and becoming of a more compact texture, it con- 
tracts for many weeks after its organization, and this contraction, by 
compressing organs which it surrounds, or distorting parts with which 
it is in contact, may produce the most serious mischief and interfere 
with various functions. In some cases, after advancement in organi- 
zation, it is gradually absorbed and disappears, while in other cases it 
becomes not only a real, but a fixed and permanent part of the body. 
When a false membrane becomes organized between two surfaces, it 
causes adhesions, sometimes binding them together with great firm- 
ness and persistency, while in other cases such adhesions become less 
firm and give way. A false membrane is subject to inflammation and 
morbid growths, even more so than the natural textures. In wounds 
and loss of tissue it becomes a means of repair, but on the valves of 
the heart and in various situations it may be a cause of disease and 
death. 
A modification of the production of adventitious structure occurs 
in the process of granulation. Granulations are described as rounded 
masses of cells produced by cell proliferation (and as is thought by 
some, by immigration of leucocytes also), upon a wounded or denuded 
surface. The cells at first are embryonic in character, and many of 
those at the surface are shed as pus, while others become fixed, retain 
their vitality, change into tissue cells and fibres, and build up a new 
or adventitious tissue upon the foundation of the old or normal one. 
When these granulations shoot up rapidly and become exuberant, and 
especially if extending above the normal level, they are called “proud 
flesh.” Sometimes granulations appear upon irritated and inflamed 
surfaces, as upon the conjunctival surfaces of the eyelids, or upon 
the mucous membrane of the throat, as a morbid process where repair 
is not effected or required. 
According to Hamilton,* granulations are loops of capillary vessels 
pushed from wounded or denuded surfaces by blood pressure, carrying 
with them attached tissue material. Leucocytes are thrown out 
when inflammatory irritation is present producing pus, and some of 
the tissue cells are converted into pus cells; but in his opinion the 
leucocytes take no part here or elsewhere in organization. The capil- 
* Edinburgh Journal. 72 
INFLA MM A TION—CICA TRICES. 
lary loops, Hamilton insists, are pushed out on mere mechanical 
principles, from not being supported by a cutaneous covering, and 
when exuberant should be kept down by pressure. It is evident, 
however, that in these granulations, cell proliferation takes place, as 
in healing by granulation new texture is formed. 
The structure formed by this and all the methods of inflammatory 
organization is called “cicatricial tissue,” and that produced by 
granulations is of the same character and follows the same laws as 
the organized false membrane already described. At first, like false 
membrane, it is abundantly supplied with blood-vessels, and to a con- 
siderable extent with lymphatics ; but later the vessels are diminished, 
and the plasmatic cells become few, and the scar texture consists 
chiefly of dense interstitial fibrous substance. It becomes bony when 
in connection with bone, contains fat when replacing fatty tissue ; but 
it results only in some of the lower forms of animals in the reproduc- 
tion of the highest forms of tissues, and only in them are lost parts 
fully restored. Hair and glands do not generally appear in new- 
formed skin. 
In exceptional cases external inflammatory proliferation becomes 
chronic, going on slowly but persistently for a long time. The new 
tissue, instead of contracting and hardening, remains bulky and soft, 
and presents a keloid-looking, projecting, cellular, and vascular mass, 
tending to degeneration and the taking on of other morbid processes. 
Somewhat similar internal processes also occur, leading to various 
degenerations. 
Cicatricial tissue may heal wounds, repair losses of tissue, stiffen 
joints, produce strictures, form adhesions, and result in degenerations 
—it may improve or restore functions, or impair or destroy them— 
may do good or evil according to its situation, extent, and course. 
The kind and quality of the exudates of inflammation are determined 
by the seat, the degree, and the special character of the inflamma- 
tion, and by the state of the general system and the blood. 
An ordinary inflammation of a mucous membrane produces 
mucus, and if severe, pus, and more rarely fibrous or plastic exudates. 
That of a serous surface, if mild, produces almost pure serum ; but 
if more severe, plastic matter, especially if there be high general 
vitality; while in other cases of severity, especially when there is a 
somewhat lower state of the system, pus is produced. The milder 
the inflammation, the nearer the exudate will be to the natural prod- 
uct of the part. 
Plastic exudates are more, likely to be produced in vigorous con- 
ditions of the system, and are promoted by tonics, iron, acids, bitters, 
and good food. INFLAMMA TION—MORTIFICA TION. 
73 
Aplastic products are more apt to occur in low conditions of the 
system, and are promoted by mercury, antimony, alkalies and salines, 
and a low or innutritious diet. 
Different kinds of inflammation tend to the production of different 
exudates. Thus, in erysipelas, plastic exudates are not produced, and 
in rheumatism, suppuration is almost unknown. 
In order to the complete organization of a false membrane, the 
inflammation in the part must subside and the action approach the 
healthy standard. While the inflammation continues so that exu- 
dates are poured out, and especially if pus is produced, organization 
will not take place. 
In the inflammation of mucous membranes covered by pavement 
epithelium, pus may be produced in free quantities without ulcera- 
tion ; but in mucous surfaces lined with cylindrical epithelium, a 
free suppuration does not take place without ulceration. 
From the description of inflammation given, it will be seen that 
the most noticeable changes in this process are : 
1. Distention of vessels, producing hyperaemia and redness of the 
part. 
2. Changes in the current of the blood. 
3. The embryonic state of the cells of the tissues, in which they 
change their form and are increased in their activities, are 
multiplied and often enlarged. 
4. The exudation of serum, the liquor sanguinis, and blood cor- 
puscles, and the production of pus and coagulable lymph. 
5. The hyperplasia of tissue, or the production of adventitious 
tissue. 
6. Swelling, from the increase of blood, from the exudates, and 
from cell multiplication. 
7. Heat, produced by the freer quantity of blood brought to the 
part, the arrest of its motion, and the more active chemical 
and vital changes, constructive and destructive, which take 
place. When the inflammation is at the surface, the change 
of temperature is greater, as the ordinary temperature of the 
skin is lower than that of internal parts or of the blood at the 
heart, and the free flow to the part, and the greater molecular 
action brings the temperature up to almost that of the blood in 
deep parts; but Colmheim agrees with the statement of John 
Hunter, that the temperature of an inflamed part never exceeds 
that of the blood at the centre of circulation. 
8. Pain, produced by involvement and pressure upon the nerves ; and 
it is more or less severe according to the nervous endowment 74 
INFLAMMATION— CA USES-STMPTOMS. 
and natural susceptibility of the part, and the greater or less 
firmness and unyielding character of the tissue. 
9. Defective nutrition of the natural parts, and the softening, ab- 
sorption, degeneration, ulceration, and gangrene which occur. 
The Causes of inflammation are various. There is always some 
injury to the part, but the agents producing the injury are various, 
and some of them obscure. Excessive irritation, whether mechanical, 
chemical, or vital, which interferes with the conditions of healthy 
nutrition, whether first impressing the tissues, the nerves, or the fluids, 
may result in the changes which have been described. A serious dis- 
turbance of the blood supply, a change in the quality of the blood 
by zymotic or other poisons introduced into it, morbid impressions 
upon the nerves supplying the tissues and vessels, whether directly or 
by reflex action, may produce the effect. In certain impressible con- 
ditions of the system, or of particular parts, causes that would have 
little effect in other states may produce inflammation. 
“Takingcold,”exposure to cold, and often moisture, when applied 
to particular parts of the body, are considered among the most fre- 
quent causes of internal inflammation. Such exposure produces its 
effect by an impression upon the cutaneous surface, making an irritat- 
ing impression on the nerve filaments, which is conveyed to other 
parts by reflex or sympathetic action, by checking perspiration and the 
retention of effete matters, and by the driving of the blood to internal 
organs, diminishing its circulation in the external plane. 
In many cases the cause of an inflammation is conjectural, and the 
mode of action of attributed causes is a matter of speculation and 
theory rather than of demonstrable fact. 
The Symptoms of Inflammation, those portions of the 
phenomena which are perceptible to the senses, giving evidence of 
the pathological state, are divided into local and general symptoms. 
The local evidences which are objective, are redness, heat, and swelling; 
and those which are subjective are pain and tenderness, the latter— 
pain on pressure or motion—often leading to the detection, where 
other local evidences are wanting. 
An inflammatory swelling may be hard, produced by more solid 
exudate, or soft, arising from the hypersemia, and especially from the 
more fluid effusions. It may be pitting, when the serous exudate 
effused in the areolar or connective tissue is removed from a point of 
pressure, and slowly returns when the pressure is removed. It may 
be elastic, when a soft exudate is present, but prevented from passing 
freely through the tissue by the presence of more solid and tenacious 
material. The swelling is said to be hoggy when pus or some other 
fluid is effused in a tissue weakened and more than normally porous ; INFLAMMATION-SYMPTOMS. 
75 
and the swelling is fluctuating when pus or fluid material is collected 
in a cavity, is free to move from one point to another, readily yielding 
to sudden pressure, and giving an impulse at a point distant from 
the tap or pressure. 
The skillful touch, by which different conditions are distinguished, 
has been called the tactus eruditus, and needs to be cultivated. 
The changed or suspended functions of organs inflamed are among 
the most important evidences of a diseased state, and stand between 
the local and general symptoms. 
The general symptoms of inflammation are particularly important 
to the physician, as in internal diseases those of a local character 
may be beyond his reach. When inflammation is present to any con- 
siderable extent, and especially after continuing for some little time, 
the blood is, as already stated, buffed and cupped, when speedily 
drawn and after standing in a proper vessel until coagulation has 
occurred. The fibrine is increased often to three or four times its 
normal amount, and the number of white corpuscles is usually very 
sensibly augmented. 
From the increased destructive metamorphosis of tissues, and the 
absorption of its results by the blood-vessels and lymphatics, and by 
the comparative diminution of excretions which commonly occur, 
and at a later period from absorption of the inflammatory exudates, 
there is an accumulation of effete matters in the blood ; but they are 
more noticeable in the general disturbance induced, and by their 
appearance in the excretions, than by their detection in the blood. 
The most marked constitutional effect of an inflammation is the 
Fever which it induces, and which so generally accompanies it. 
Febrile symptoms soon follow an inflammation, produced by what- 
ever cause, even by a strictly local and mechanical injury; and in 
what are called idiopathic inflammations—inflammations not depend- 
ent upon any obvious local cause—the symptoms in the part attacked 
are sometimes preceded by a general febrile disturbance, showing that 
the general system is concerned in the production of the local phe- 
nomena. The multiplication of leucocytes and the increase of fibrine 
must be, to some extent at least, systemic processes, and they may 
occur before the local evidences of inflammation are marked. These 
febrile symptoms are doubtless induced in part, and are kept up, by 
the impurities and changes in the blood already mentioned. They are 
in part, however, caused by the local suffering, communicated by sym- 
pathy to the system at large : and it may not be unreasonable to 
suppose that, by the evident intelligence which is manifested in 
nature, the feverish excitement is an effort of the system to resist and 
repair the injury inflicted. 76 
INFLAMMA TION—SYMPTOMS. 
It is alleged that the blood flowing from an inflamed part in the 
veins is of a higher temperature than that flowing to it in the arteries, 
and if this he so, this heated blood circulating through the body must 
aid in the general increase of temperature. 
It is now well known that increased heat much above the normal 
of the body, of itself interferes with nutrition, tends to degeneration, 
and affects very unfavorably the general functions of the system ; and 
a part of the general disturbance is therefore due to the elevation of 
temperature produced by the heated blood from the inflamed part. 
Diminished perspiration, when it occurs, by diminishing the loss 
of heat, must result in an increase of temperature. Another cause of 
systemic suffering is the changed action of the organ, the seat of the 
local disease, produced through dependence of function. Thus, when 
the lungs are extensively inflamed, the respiratory process is imper- 
fectly performed, and blood, imperfectly oxidized, carried to the brain 
and other organs, impairs their functions; and it is similar when 
other important organs are inflamed. 
The effect of morbid impressions on the nervous element conveyed 
to those portions of the brain wdiicli preside over circulation, secre- 
tions, calorification, and other organic functions, must not be over- 
looked in accounting for fevers in general, including the fever of 
inflammation. This subject will again be referred to in the descrip- 
tion of the febrile state. 
The ordinary phenomena of symptomatic inflammatory fever are, a 
general feeling of indisposition, and rigors, or a sense of coldness early 
in the attack, marking the period of onset. The chills are sometimes 
severe and continued for a few hours, while at other times they are 
short and slight, and generally toward the latter stage of the chilliness 
especially, are alternated with sensations of heat. At length the 
sensation of heat is the predominant feeling, and the temperature 
rises several degrees, the amount of increase depending upon the 
severity of the inflammation and the susceptibility of the system, and 
upon the amount of loss of heat from the surface. The chilliness 
may be repeated, especially if the inflammation be extending, but its 
recurrence is uncertain and irregular when it takes place. With the 
increase of temperature the pulse is increased in frequency, and 
usually in force, though it may be diminished in force when the 
disease is so extensive as to produce decided shock. With the increase 
in the frequency of the pulse the respiration is generally increased; 
and there are general pains, chiefly in the head and back, and these 
are sometimes quite as severe as those in the part inflamed. There is 
thirst, diminished appetite, and commonly a coated tongue, and in 
most cases a general diminution of the secretions. There is change INFLAMMA TION—S TMPTOM8. 
77 
of innervation, of nutrition, of secretions and excretions, and more or 
less of all the functions of the body. There is particularly to be 
noticed destructive metamorphosis of the tissues, resulting in wasting 
and debility ; and as the excretions are not correspondingly increased, 
this increased waste results in the rapid accumulation of effete matters 
in the system ; and this accumulation is contributed to by the pro- 
duction and absorption of inflammatory products from the seat of the 
disease. 
Inflammatory fever may be of a Sthenic type, manifesting much 
activity and force, or Asthenic or Adynamic, manifesting less force. 
It may be of a Nervous type, the sensibility and mobility, the func- 
tions of the mind—all the functions of external relation being; much 
disturbed. It may be Ataxic, irregular in its course and phenomena; 
and when pus or septic matter from the diseased part finds entrance 
in free quantity into the blood, a peculiar form of fever of great 
severity and danger occurs, called Pyaemic, Septic, or Toxaemic fever. 
A form of inflammatory fever, occurring in wounds and after opera- 
tions, is called a surgical fever ; and as pyaemic and septic fevers are 
more common in surgical than in medical practice, these fevers are 
more fully described in works on surgical pathology and practice. 
The more distinctive phenomena of toxaemic fevers are : repeated 
chills, a high temperature—often hyperpyrexia—frequently free per- 
spiration but still great heat, and a dry and parched tongue, decided 
delirium, a rapid but feeble pulse, and special irritation of the intes- 
tines, commonly accompanied with diarrhoea. This form of fever is 
exceedingly dangerous, and is more frequently met with when large 
numbers of surgical cases are crowded together, and where cleanliness, 
ventilation, and other hygienic measures are not properly observed. 
In chronic inflammations, especially where suppuration and wast- 
ing occur, a special form of symptomatic fever, called hectic, is pro- 
duced. Its more marked features are diurnal periodicity, chilliness 
of variable severity and continuance occurring in the fore part of the 
day, followed by a higher temperature, irregularly distributed on the 
surface, usually with a circumscribed flush of the cheek; and in the 
night free, uncomfortable sweats occur, followed by a reduction of 
the temperature during the morning and until another 
exacerbation returns. 
Generally an inflammatory fever abates as the inflammation sub- 
sides, but it is sometimes kept up, possibly by habit, but more likely 
by impurities of the blood ; but it disappears when both the inflamma- 
tion and impurities are removed. The fever also often abates when 
free suppuration or other effusions occur; the skin then becomes 
moist, and sometimes a chilliness is experienced. When an inflam- 78 
INFLAMMA TION— VARIETIES. 
mation results in gangrene to any considerable extent, the tempera- 
ture, at least of the face and extremities, falls, and a state of collapse 
commonly ensues. 
Varieties of Inflammation.—We have been considering in- 
flammation in its general or common features, but it has several 
varieties which will require pointing out. These varieties depend 
upon the degrees, types, and kinds of inflammation. 
An Acute inflammation is one which is intense in degree, and 
recent and brief as to duration, and is usually produced by some 
cause inflicting a severe injury, and the changes are likely to be 
destructive. 
A Chronic inflammation is one which is protracted in continuance 
and moderate in degree. It may be of large extent, but is more 
gentle and slow in its processes. The injury in these cases is usually 
not so severe, and the changes effected are more textural and often 
constructive. These productions, as the false membrane produced in 
cirrhosis of the liver, may, by contracting and obstructing the vessels, 
lead to atrophy, by interfering with circulation and nutrition. A 
protracted case may consist of a Series of acute attacks, but the 
inflammation would not be called chronic merely from its long con- 
tinuance. The idea of comparative moderateness is included in the 
term chronic. 
A Subacute case is one between the acute and chronic forms. 
The terms severe and mild scarcely need an explanation. They 
have reference to degrees rather than extent or continuance. 
A Sthenic inflammation, like a sthenic fever, is one manifesting 
much force of action, vigorous circulation, and much heat, often with 
productive changes. 
An Asthenic or Adynamic inflammation is one where little force is 
manifested, and where the destructive processes are likely to pre- 
dominate. 
A Congestive or Passive inflammation is one in which a slow cir- 
culation, with distention of the veins and capillaries, is present, and 
where slow and moderate changes, either constructive or destructive, 
occur. 
A Latent inflammation is one that is internal and hidden, or where 
the marked ordinary symptoms are concealed. 
A Patent inflammation, on the contrary, is one that is open and 
apparent, where the ordinary signs are well marked. 
An Erythematous inflammation is one that is superficial—upon a 
surface. 
A Phlegmonous, one affecting deeper tissues and tending to the 
production of a phlegmon or abscess. INFLA MM A TION— VABIE TIES. 
79 
A Parenchymatous inflammation is one involving the solid sub- 
stance or parenchyma of an organ, in contradistinction from one con- 
fined to its surface or covering membrane. 
Again, inflammations are divided, according to the causes produc- 
ing them, into Traumatic, produced by a mechanical or chemical 
injury, and Idiopathic, occurring apparently spontaneously or from 
some cause less apparent. 
Inflammations are also divided into Common Inflammations, or the 
ordinary forms common to all persons, and with phenomena common 
to all the forms, and capable of attacking any tissues, excited by the 
ordinary causes, as mechanical or chemical injuries, or exposure to 
cold, etc. 
The contrasting varieties are the Specific inflammations, those 
depending often upon specific or infectious causes, and having phe- 
nomena and courses peculiar to themselves. The contagia of small- 
pox and all the exanthems produce inflammations of a specific kind, 
affecting the skin and mucous surfaces in a peculiar way, and running 
a more or less definite course. Other cutaneous inflammations, not 
infectious, have specific characters ; and the Syphilitic, Gonorrhoeal, 
Erysipelatous, Diphtheritic, Rheumatic, and Gouty inflammations are 
peculiar and specific. 
Strumous and tuberculous inflammations are varieties depending 
upon constitutional peculiarities of the patient, and differ from com- 
mon inflammation in their phenomena and results. They will require 
a more particular description in connection with an account of the 
scrofulous or strumous and tubercular states. 
Dr. Francis Delafield makes seven varieties, dependent upon the 
particular tissues involved and the special manner of their involve- 
ment. 
1. Cellular inflammation, involving chiefly the fixed connective- 
tissue cells, increasing them in size and number, while the blood- 
vessels and basement substance are scarcely changed. 
2. Inflammation with production of exudates—serum, fibrine, and 
pus—involving principally the blood-vessels, through which are trans- 
uded these materials. 
3. Necrotic inflammation, involving both vessels and tissues, caus- 
ing death of parts, with or without putrefaction. 
4. Inflammation with formation of abscesses, described as a com- 
plex process, involving both vessels and tissues, producing destruction 
of tissues and the formation of pus from tissue ceils and leucocytes. 
5. Reparative inflammation—changes resulting in the formation of 
new or adventitious tissue, repairing injuries, or, as we have seen, 
causing mischief when there was no mechanical injury to repair. 80 
INFLAMMA TION—STR UMO US-TUBERCULO US. 
6. Hyperplastic inflammation—inflammatory growth of new con- 
nective tissue, both of cells and basement substance, not necessarily 
preceded by the production of pus or fibrine, or of cells alone. This 
seems scarcely distinguishable from the fifth. 
7. Tubercular inflammation, a form resulting in the production of 
tubercle, composed of reticulated basement substance, of flat nucleated 
cells and giant cells. 
An inflammation maybe arrested, either spontaneously or by treat- 
ment, in any stage of its progress, not necessarily going through with 
all its phenomena. When it suddenly abates and disappears from one 
part, and at the same time appears in another, there is said to be a 
metastasis of the disease. 
When it recedes to the normal state from its earlier stages, or before 
suppuration, much effusion, or material structural changes occur, it is 
said to terminate by Resolution. The moderate exudations that have 
been poured out are absorbed and eliminated, and the part returns to 
its original state. The more the exudate, and the more solid in 
character, the longer is the time required for its removal; and when 
destructive changes have occurred in the tissues, time will be required 
for their repair. Large quantities of serous effusion in the cavities, 
as in the pleura or peritoneum, are sometimes removed with great 
rapidity when the inflammatory process has ceased. Much more time 
is required to dispose of fibrous, corpuscular, and purulent exudates, 
as they require disintegration and solution before absorption ; but in 
time and under favorable conditions quite free quantities of both may 
be removed. 
Inflammation is spoken of as terminating in Resolution, in Effu- 
sion, in Adhesions (by false membrane), in Suppuration, Ulceration, 
and in Gangrene. 
From all the preceding statements it will be seen that though 
the different forms of inflammation have some things in common, it 
is a very complex and variable process, and is not an identical con- 
dition ; that it varies in its causes, its particular processes, and its 
results, and that the same management will not be applicable in all 
cases. 
Varieties of inflammation called Strumous and Tuberculous 
have peculiarities of such distinctive characters as to require a more 
particular consideration in connection with the conditions of the gen- 
eral system which give them that name. 
The Scrofulous and Tubercular Diatheses have engaged the atten- 
tion of physicians during a long period of medical history, and the 
question is not yet settled as to their identity or distinctive characters. 
When diseases are considered as they should be, and now so gener- INF LAMM A TION—STR UMO US. 
81 
ally are, not as entities, but as series of modified actions, it is not 
easy, nor is it essential, to determine what constitutes identity; and 
this difficulty depends chiefly upon the differences of meaning given 
to the same terms. Identity of cases of disease, in the sense of exact 
likeness, never occurs; but identity only occurs in the sense of such 
similarity in course and phenomena as to make it proper to class 
them together for the convenience of description and study. Between 
the cases commonly called scrofulous, and those called tuberculous, 
there are many points of similarity, and there are others of difference ; 
while there are other cases still, that combine the similarities and 
differences together, both in origin and cause, in phenomena and 
results. 
Rickets, by some, is regarded as a variety of scrofula, and it has 
indeed resemblances to scrofula, but it has differences so marked as 
to entitle it to be classed as distinct, and it will be excluded from the 
present consideration. 
Cases are frequently met with, especially in children and youth, 
of a constitutional defect, where there is feebleness, irregularity of 
organization, and where the operation of the life-force is of a peculiar 
character. This condition is often hereditary, or at least congenital; 
but it is not unfrequently acquired by unfavorable life-conditions. In 
this state there is a tendency to a variety of morbid actions, especially 
to slow inflammatory processes during childhood ; and after puberty, in 
early adult life, to pulmonary phthisis and a comparatively early 
death. Such cases are in the aggregate generally called scrofulous or 
strumous. If specific consumption occurs, or if there is a peculiar 
deposit or formation in the lungs, the serous membranes, or other parts, 
of an albuminous material of low vitality which is incapable of vascu- 
lar organization, a material containing irregular-shaped and some 
very large cells (giant cells), and which sooner or later loses its 
vitality entirely and softens and decays, the name of tubercle is applied 
to the deposit or formation, and the individual suffering from such a 
state is said to be tuberculous, or to be affected with tuberculosis. 
In most conditions of permanent lowered vitality, from whatever 
cause, this low-lived, bioplastic, tuberculous material is more likely 
to occur than in persons of vigorous life-force; and those who are 
called strumous are more liable to tubercle than those that are well- 
formed, healthy, and free from that condition. But these persons 
who may thus be more or less inclined to tubercle, if reaching the 
period of adolescence, vary much during childhood in the particular 
conditions presented. 
Some have the nervous system highly developed, the mind and 
body active, are often remarkably precocious in intellect and charac- 82 
1NFLA MM A TION—STR UMO US. 
ter, with slender figures, the fatty tissue rather deficient, the shin thin 
and delicate, complexion clear, veins distinct; they blush readily; the 
eyes are bright, pupils wide, eyelashes long, hair silken, face oval, 
are good looking and interesting; the ends of the long bones not large, 
and the shafts thin and firm, with limbs straight; and they cut teeth, 
run alone, and talk early. They have large, but not excessively large, 
brains, narrow chests, the scapulas stand out like budding wings, 
which the prophetic and sentimental say will be angel’s pinions soon, 
to carry them away. They talk philosophy and sentiment in the 
nursery, almost in the cradle ; they are considered “too smart to live,” 
and are excellent subjects for Sunday-school story-books. The lead- 
ing pathological tendencies are to fatty degeneration of the liver and 
kidneys, and particularly to miliary tubercular deposits or formations 
and their consequences in serous membranes, and sometimes to tubercle 
in the lungs in larger masses and of the yellow variety. These de- 
posits cause, or at least are associated with, a peculiar form of inflam- 
mation, producing what are called tubercular meningitis, tubercular 
peritonitis, tubercular pleuritis, or pulmonary consumption, or tuber- 
culosis, according to the seat and course of the local disease. 
Should these children escape the dangers and survive the period 
of childhood, there is the strongest tendency to early phthisis ; and if 
they escape consumption, the early promises of their precocious in- 
tellects and characters are not usually realized. 
Other cases present very different phenomena. The temperament 
is phlegmatic, the mind and body are sluggish, the figure is heavy, the 
skin thick and opaque, the complexion dull and pasty looking; the 
upper lip and alse of the nose are thick, the lip is sometimes fissured, 
and the nostrils are expanded. The lymphatic glands are enlarged 
and perceptible to the touch, often constantly and markedly so ; the 
abdomen is full and protuberant; the ends of the long bones are rather 
large, and the shafts thick. The size of the body varies—it may be 
stunted or almost gigantic, but flabby and feeble—tall and loose rather 
than broad and firm, and the cartilages are enlarged. The bones may 
have a deficiency of mineral matter and be comparatively soft, but not 
as distinctly so as in rickets. Dentition is tardy, the teeth are imper- 
fect in form, and apt to decay early. The head may be misshapen, 
from softness of the bones and the gravity of the brain ; the brain 
may be either too large or too small—when large it is deficient in 
quality and is liable to be affected by effusions from vascular debility. 
The leading pathological tendencies here are to inflammation of 
the mucous membrane of a peculiar and persistent kind ; to strumous 
ophthalmia; to inflammation of the tarsi; to catarrhal inflammation 
of the mucous membrane of the nose, pharynx, bronchi, stomach, and IN FLA MM A TION—STR UMO US. 
83 
intestines ; to obstinate diseases of the skin, depositive, suppurative, 
or effusive; to catarrh of the ears—otorrhoea; to caries of the bones ; 
to chronic inflammation of the joints, and particularly to enlarge- 
ment and induration of these parts, and on the slightest occasion to 
inflammation and suppuration of the lymphatic glands. 
Besides these more typical forms of diathetic conditions, cases are 
met with where various manifestations of the elements described as 
belonging to these different classes are combined in the same in- 
dividual. A bright intellect and delicate skin may occur in connec- 
tion with enlarged glands and diseased joints, etc. 
Now all these cases of both classes or varieties are, by some authors 
of high authority, called strumous or scrofulous; while others, as 
does Sir William Jenner, call the first class of cases tuberculous, and 
the second scrofulous, regarding them as pathologically distinct. Dr. 
Jenner says they are distinct, because the general condition of each is 
perfectly different; because the pathological tendencies are different; 
because we seldom see the subjects of one also subjects of the 
other; (?) because tuberculosis, being unquestionably hereditary, we 
do not find the children of phthisical parents specially prone to scrofu- 
losis ; and because the course, prognosis, and treatment of each of the 
diatheses are different. 
But notwithstanding these arguments, which must be regarded as 
having much force, there are similarities between the two classes of 
cases. An inflammation which may be easily excited in either takes 
on a peculiar and obstinate form. A slight injury of the hip-joint in 
any of these cases'is liable to produce coxalgia; an inflammation of 
the lungs is likely to terminate in phthisis, etc. ; and it, is only 
a question of words, of the meaning of terms, whether they shall be 
regarded as varieties of one disease or tendency, or as distinct affec- 
tions. 
Two varieties of pathological action in the same system are not 
likely to go on with as much activity as one alone ; and when there 
exists, as sometimes is the fact, tuberculosis of the lungs and inflam- 
mation and suppuration of external glands, the latter condition 
appears to retard the progress of the former : but this proves neither 
identity nor distinctness of the character of the two processes. It, 
however, suggests the propriety of counter-irritation by setons or 
issues in diseases of the kind. 
The words scrofula and struma are used by many in a very loose 
and general sense, as indicating almost any general chronic or lowered 
condition of vitality, even when arising directly from some unfavor- 
able local, even temporary, hygienic conditions; and though this is 
a wrong use of the terms, it is not without its apology, as any long-con- 84 
INFLA MM A TTOK—STR UMO US. 
tinned lowered condition is apt to lead to diseases of a strumous or 
tubercular character. 
Both the scrofulous and the tubercular tendencies are transmis- 
sible, as are all constitutional and long-continued conditions. But 
this subject of heredity will be referred to in another connection, 
when it will be considered more in detail, and the practical conclu- 
sions to be drawn from the facts will be pointed out. 
At present we are more particularly concerned in understanding 
that modification of the inflammatory process which occurs in persons 
called strumous and tuberculous, or who have actual strumous and 
tuberculous diseases going on in the body. 
As already stated, in these conditions, and particularly that variety 
which is more properly called the strumous or scrofulous state, there 
is an abnormal susceptibility of certain tissues to injury, and a pecul- 
iarity in the products and the course of the inflammation which the 
injury induces. This susceptibility, though general, is commonly 
most marked in the lymphatic glands and in the mucous membranes, 
although the skin, bones, and joints are frequently the seats of these 
peculiar inflammations. In some cases one, and in others another 
part, has the greater morbid susceptibility. 
When inflammation in any of these cases occurs, it tends to be ex- 
ceedingly protracted, though it may commence in an acute form. 
It is frequently, however, chronic from the beginning, in some cases 
coming on almost imperceptibly ; and when abated or subdued it is 
very readily reinduced. Ordinary inflammation in a healthy person 
has its products readily absorbed if terminating in resolution ; or if 
not, it goes on to suppuration, or to the formation of vascular fibro- 
nucleated tissue. In scrofulous and tuberculous inflammations the 
absorption of the inflammatory products is very much less readily 
effected ; they generally infiltrate the tissues and accumulate in them, 
interfere with circulation, produce irritation in the part, and lead to 
retrogressive changes of various kinds ; and often the morbid exudates, 
mingling with changed tissues, result in what is called caseous degen- 
eration. In the more strictly tuberculous cases, the exudates tend to 
the formation of more unequivocal tubercle. In these deposits or 
products there is little or no tendency to the development of new 
blood-vessels—none in the complete cheesy or tuberculous matter— 
and hence no organization of new growth. Infiltration, however, may 
take place into the glands and other tissues, mingling with the results 
of hyperplasia in those glands, forming glandular tumors with vessels 
in their structure. The inflammation may here proceed, and the 
glands at length suppurate, producing, however, unhealthy pus—the 
whole process commonly being slow. But there are some exceptions INFLA MM A TION—RES UL TS. 
85 
to the slowness of the processes. Sometimes in these glands, as about 
the neck, the infiltration and swelling are very rapid ; and sometimes, 
especially in children apparently strumous, the swelling as speedily 
disappears. But these are exceptional, though in many cases the 
amount of swelling in the strumous glands fluctuates remarkably 
within a few hours. These peculiarities of inflammation in scrofulous 
and tuberculous cases are due to the peculiar condition of lowered 
and perverted vitality ; and these conditions modify not only the 
general course, but the histology of the process and its products. 
These products are more cellular than in ordinary inflammation ; 
there is not so much fibrinous material; the proliferating processes in 
the tissues are less, and the bioplasms produced are of a lower grade 
of vitality and organizing power. Recent observations have shown, 
as already intimated, that many of the cells are much larger than 
those ordinarily produced as the result of inflammation. In tubercle 
particularly—which certainly must be considered as having close 
relations to the products of scrofulous inflammation, some of high 
authority regarding the materials as essentially identical—the exist- 
ence of these large cell-forms is almost constant. 
These histological peculiarities of the products of scrofulous and 
tuberculous inflammations, and the peculiar vital state of the tissues 
of scrofulous and strumous subjects, lead to poculiar infiltrations, 
and in the parenchyma of organs, as in glands and viscera, cause ob- 
struction of vessels so as to interfere with nutrition, and lead to the 
metamorphoses resulting in scrofulous and tubercular degenerations, 
and to the ulceration and necrotic processes in the various diseases 
coming under the heads of scrofulosis and tuberculosis, of joint dis- 
eases, phthisis, etc. 
The management of strumous and tuberculous patients and dis- 
eases will be considered in connection with the subject of phthisis. 
It has been already shown that inflammation produces more or 
less destruction of minute particles of the inflamed part, in its ordi- 
nary course, and not unfrequently more appreciable local death by the 
processes of ulceration and gangrene. 
Unfortunately, it also often produces somatic or systemic death. 
All that live must die, and wdien death comes in the course of nature, 
from the normal exhaustion of the vital force, or as the fruit ripens 
and falls to the earth, the physician can only observe the process : 
and to give advice as to the proper life conditions is all that he can 
do. Any attempt to interfere with drugs or any unnatural excitants 
or depressants will but hasten the event, and convert an euthanasia 
into a premature or violent death. The opinion that “ wine is the 
milk of old age,” the opinion that so unnatural an article as alcohol 86 
INFLAMMA TION—RESULTS. 
can serve as a condition of normal life in old age as milk does in 
infancy, is as far from the truth as anything else that is false ; and a 
belief in it has done much harm. Those who have regarded this 
article as useful in the exhaustion of age have inferred its usefulness 
to sustain healthy vigor at all ages ; and the acting upon that belief 
has resulted in the cultivation of tastes and the establishment of 
habits which have been transmitted through generations, involving 
nations and races, and has produced false beliefs and wrong practices, 
with the disastrous results of which the world is too familiar. 
Alcohol, like other drugs, may modify beneficially morbid actions, 
but, like them, it is incapable of increasing or sustaining healthy ones. 
The opinion is now becoming general in all enlightened medical 
circles, that alcohol in all its admixtures should be regarded, from a 
scientific point of view, as a medicine or a poison, according to the 
manner of its use, and should be classed with other drugs. 
Dr. D. 0. O’Connor, of Cork, in a presidential address to the 
British Medical Association, says : “ Happily the timely declaration 
of two hundred and sixty of the most eminent physicians of London 
—which might be printed in letters of gold—has placed this question 
on its true basis; stating that while unable to abandon the use of 
alcohol in some diseases, no medical practitioner should prescribe it 
without a sense of grave responsibility, and with as much care as any 
powerful drag.” 
But death from inflammation is premature, and when threatened 
requires the skill of the physician to avert it if possible. . Inflamma- 
tion may cause death in a variety of ways—from arresting the func- 
tions of various organs involved in the primary disease, by the severity 
of the fever induced, or by the shock to the system from the extent or 
severity of the inflammatory process—or death may occur from ex- 
haustion from its long continuance or its excessive exudations. But, 
as long ago shown by Bichat, the immediate support of life is a 
tripod, the branches of which are the brain, the heart, and the lungs. 
Other organs and their functions are essential to any considerable 
continuance of life ; but the functions of the stomach, the kidneys, cr 
the liver might be suspended for some time without death occurring. 
If, however, the brain, the heart, or the lungs should cease to act for a 
very short time, nutrition would cease, which is death. Whatever 
the remoter causes, the immediate approach of death is by one or the 
other of these organs. As a rule, certainly, one or the other of these 
tends first to cease its action. 
Death beginning at the brain is called coma; that at the heart, 
when sudden, is called syncope, and when more slow, asthenia; and 
that at the lungs, asphyxia, or, more properly, apneea. INFLAMMA TION—RES UL TS. 
87 
Death from the brain may be by local disease of that organ, by press- 
ure upon it, by arrest of the circulation to or from it, by blood poison- 
ing as in uraemia, or by excessive heat as in sunstroke or hyperpyrexia. 
The heart may cease either from paralysis or spasm produced 
by defective or irregular innervation, or by organic diseases of its 
structure. Chloroform or veratrum viride, when causing death by 
the heart, paralyzes it; digitalis causes tonic spasm—both equally 
arresting circulation. The heart also sometimes ceases from shock, 
from the excessive heat of fever, and from the formation of coagula 
within it. Asthenia is a common mode of death, the heart gradually 
failing from protracted shock or exhausting or disorganizing disease. 
The lungs may cease their functions from exclusion of air, as in 
croup or other obstructive diseases in the air-passages ; from effusions 
of fluid or the entrance of air into the cavity of the pleura ; from fill- 
ing up of the lung substance by inflammatory or dropsical effusions ; 
by wasting of the lung substance ; or by failure of innervation of the 
apparatus of the respiratory movement. In these and other modes the 
functions of these respective organs may be arrested, and frequently 
the same or various causes act upon more than one of them at a time. 
To prevent inflammation, wherever situated, from causing death, its 
course, if possible, must be arrested, or its severity abated ; but besides 
the means to that end, the different functions tending to cease must 
be kept in operation as long as possible by whatever measures may con- 
tribute to that end. Thus if the brain is ceasing to act from pressure 
or the poison of urea, the pressure should be removed, or the urea 
eliminated from the blood. If the heart should be ceasing its action 
from shock or inanition, the shock should be abated, nutriment should 
be supplied, and cardiac stimulants should be administered. Here 
drugs may be of service, and those which sound physiological and 
therapeutical principles point out, and which discrimination, observa- 
tion, and experience sanction, should be resorted to. These measures 
may include the use of alcohol, opium, ammonia, camphor, and other 
agents. That opium, alcohol, ether, and other neurotic agents often 
diminish shock, and thus indirectly sustain the heart’s aetion, there 
can be no doubt. That they directly excite it to increased action is 
much more doubtful. That alcohol does so is believed by many; but 
its efficacy in that respect has been much overrated, and further and 
more scientific and discriminative observations are needed to establish 
its true power. In health the sphygmograph does not show it to 
increase the heart’s force, and when it increases it in disease, it must 
be presumed to do so indirectly, by relieving shock or modifying some 
diseased process. Similarly the lungs must receive attention when 
their functions are tending first to cease. To “ obviate the tendency 88 
NON-1NFLAMMATORT CHANGES. 
to death,” which is among the objects of medicine in all cases, becomes 
the special duty of the physician when that event is immediately 
threatening ; and he must then consider the method of its approach, 
in order to do what is possible to stay it. 
NON INFLAMMATORY CHANGES. 
There are various other processes and products, the result of 
changes of nutrition, not necessarily inflammatory, which would natu- 
rally be considered in this connection in a full and systematic work on 
pathology. Those conditions belonging to medical cases will be de- 
scribed in connection with the diseases of which they constitute a part. 
The subject of tumors is generally considered as surgical. Tu- 
mors are modified tissue growths, varying in the amount and character 
of their vital endowment, and having different histories and results. 
They have been variously classified, according to their structures and 
courses, the tissues from which they spring, and which they resemble. 
The following classification, copied from “ Green’s Pathology, -' will 
give an idea of their formation and something of their characteristics : 
I. Type of the fully developed Connective Tissues. 
Type of Fibrous Tissue Fibroma. 
“ Adipose “ Lipoma. 
“ Cartilage Enchondroma. 
“ Bone Osteoma. 
“ Mucous Tissue Myxoma. 
“ Lymphatic Tissue... .Lymphoma, 
inducing the disease, Leucaemia. 
II. Type of Higher Tissues. 
Type of Muscle Myoma. 
‘ ‘ N erve Neu rom a. 
“ Blood-vessels Angioma. 
“ Papillae of Skin or Mucous Membrane. .Papilloma. 
“ * Secreting Glands Adenoma. 
III. Type of Embryonic Connective Tissue. 
The Sarcoma. 
' Small spindle-celled Sarcoma. 
Large “ “ 
Osteoid “ “ 
.Melanotic “ “ 
Spindle-celled Sarcoma 
Gliomata. 
Alveolar Sarcoma. 
Round-celled Sarcoma 
Myeloid Sarcoma. N ON-INFL A MM A TOR Y CHANGES. 
89 
IV. The Carcinomata. 
Scirrhus. 
Encephaloid. 
Colloid. 
Epitheliomata—Adenoid Cancer. 
Y. Cystic Tumors. 
Those tumors which appear in internal organs and present promi- 
nent symptoms, coming under the care of the physician, such as can- 
cer of the stomach, will be described in their proper connections. 
Syphilis, with its local and constitutional effects, is also regarded 
as belonging to surgery ; it, however, frequently complicates medical 
cases, and its gummata and other changes often occur in internal 
organs. It is a subject requiring attention from both the physician 
and surgeon, but, as it is usually elaborately dealt with in works on 
surgery, it will be omitted here. 
Cysts. 
THERAPEUTICS OF INFLAMMATION. 
Before proceeding to the consideration of particular diseases, it is 
judged proper to make some suggestions respecting therapeutical 
principles and measures, and to discuss, with some particularity and 
detail, the principles of the treatment of inflammation. 
The ultimate object of all medical science and medical study is the 
prevention, the alleviation, and cure of diseases, or the care and treat- 
ment of persons threatened with or affected by disease. While it is 
impossible for the most skeptical to doubt the efficacy of hygienic and 
prophylactic measures, curative therapeutics has failed to secure uni- 
versal confidence. There are very great differences of opinion as to 
the curative power of medicines, ranging from the greatest confidence 
in many specifics, to a disbelief in the efficacy of nearly all forms of 
internal medication. The truth here, as in so many other cases, is to 
be found in a mean. The skepticism which a few years ago so much 
prevailed, especially on the Continent of Europe, lias yielded, in some 
instances, to a confidence in positive and heroic measures, /which has 
perhaps gone to the other extreme. But whether through past skepti- 
cism or the intrinsic difficulties of the subject, therapeutics has not 
kept pace with other branches of medicine. The science of medicine 
in the progress of general science, and by the present and prospective 
means of investigation, promises in the early future to arrive at a 
degree of perfection which will bo most gratifying to the lovers of 
truth; but there are difficulties in the way of the art of healing 
which must delay longer the full fruition of the hopes of those most 
solicitous for the speedy and certain cure of diseases. 
To arrive at the truth respecting many of the normal and abnormal 90 
THERAPEUTICS OF INFLAMMATION. 
actions of the system, however minute the structures and obscure the 
processes involved (with the aid of the microscope and chemical 
reagents, and all the other modern means of scientific observation), only 
close observation and patient care are requisite to realize many positive 
and immediately satisfactory results. Other qualities are required for 
coming at just conclusions respecting the curative power of therapeu- 
tical agents amid the more complicated problems, and the more numer- 
ous sources of error involved in these investigations. More patience, 
a larger number of facts, more knowledge of logical processes, greater 
ability to sift and weigh evidence, to detect fallacies and exclude errors, 
are required here than in simple physiological and pathological inqui- 
ries.. There must be observation, experience, and comparison on a 
large scale, and for no limited time, to entitle one to an independent 
opinion upon questions so difficult as those of determining how much 
is due to the influence of medicine, and how much to the natural 
powers of the system and the natural tendencies of diseases toward 
recovery or death in the multifarious cases which occur. A judicial 
faculty of the highest order is needed here, to come to just opinions 
upon general questions of therapeutics ; and in the practical manage- 
ment of individual cases, other faculties still are required : quick and 
discriminative observation, the power of drawing ready inferences, 
the command of resources, their energetic yet judicious application, 
unwearied attention to minute details, and loving devotion to the 
work, are all essential in the most successful practitioner of medicine. 
Buckle says: “The philosophic pathologist is as different from a 
physician as a jurist is from an advocate, or an agricultural chemist 
from a farmer. The two sets of faculties may be united, as they 
occasionally are, but they are not always so.” To many persons the 
bench is more attractive than the bar, though not to those of the 
highest skill; and so are experiments in the laboratory more attrac- 
tive than the labor in the field, though perhaps not to those of the 
greatest physical energy. But it is the advocate that wins cases, and 
sometimes protects accused innocence and secures justice; and it is 
the farmer whose labor feeds the hungry and sustains the nation. 
The laboratory and the chemist would be useless if the farmer did 
not apply the knowledge and cultivate the fields. 
Similarly, the knowledge of the pathologist would be practically 
useless, if the physician did not transform the science into art, and 
apply the knowledge of pathological conditions and the actions of 
therapeutical agents to the relief of sufferings and the prevention 
and cure of disease. While careful to lay as good a foundation as 
possible in correct general principles, and in the exact pathological 
knowledge of the present day, it will be the chief aim of the present THERAPEUTICS OF INFLAMMATION. 
91 
work to teach the student, and express to the practitioner, what is 
reliably known as to the best methods of distinguishing and treating 
the diseases which engage the daily attention and anxious care of the 
laborious physician. 
While giving due heed to the views of others, derived from the 
numerous sources of different countries and localities, of country and 
city, of private and hospital practice, the individual views of the 
writer will be freely, though it is hoped cautiously expressed, based 
upon a careful weighing of evidence and a long experience in the 
common as well as in the more rare cases of disease. 
In the uncertainty still existing in the “ final and supreme stage 
—the stage of therapeutics ”—and the changes of opinion based upon 
new discoveries and larger observations which so rapidly occur, it 
requires some boldness to commit one’s self on various subjects whose 
aspects are so likely soon to change ; but such committal is inevita- 
ble in the production of a work of any value, and if views that will 
be expressed are proved to be erroneous, they will only share the fate 
of very many others, even from the highest sources in the past. Views 
will be expressed with much confidence and positiveness, based upon 
observation and experience deemed sufficient to establish their cor- 
rectness, though they may be quite different from those generally held 
by the profession, and different from those acquiesced in by the 
writer but a few years since. Better methods may be found in the 
future; but most of the means that will be recommended, he ven- 
tures to assert, cannot be found to be useless. But whatever be the 
fate of any views expressed, they will be the result of what appears tq 
him fair deductions from admitted facts and principles, or will be 
conclusions from sufficient evidence drawn from his own experience, 
or that of others, to commend them to his judgment as true. An 
effort will be made to avoid following any loose statement from mere 
routine authority and custom, as many errors have been handed 
down from one authority to another, without examining the grounds 
of evidence, either logical or from carefully observed and authorita- 
tively recorded experience, and without confirmation from personal 
observation. 
Although therapeutics is not yet in a satisfactory condition, many 
questions of importance remaining unsettled, and many prevalent 
ideas being, it is believed, quite erroneous, yet great advancement has 
been made in successful modes of treatment, and still greater, it is 
hoped, will be made in the early future. Therapeutical measures 
have much more power over the course of many diseases, when 
promptly applied in their early stages, than the writings of those 
who have seen acute cases chiefly in consultation and in hospital 92 
THERAPEUTICS OF INFLAMMATION. 
practice, and consequently in the stages more or less advanced, would 
lead us to suppose. The observing and well-informed private practi- 
tioner, especially if practicing in the country among a well-to-do popu- 
lation, who sees cases near their onset, has much m ore confidence in 
medicines than those who derive their conclusions from practice in 
large cities and among the inmates of large hospitals. 
Among this class of writers, which includes our standard authors, 
it is quite the fashion to deny the power of therapeutic agents to 
arrest or materially modify the course or character of most diseases, 
and to limit their efficacy to the diminution of pain and some other 
unpleasant symptoms ; and it is customary to regard the physician as 
doing all that can properly be attempted in most instances when he 
watches the case, places the patient under favorable hygienic con- 
ditions, endeavors to abate distressing symptoms, to sustain the 
strength by food and what are called “stimulants,” and thus seeks to 
enable the system to endure the disease, which, it is supposed, will 
take its course. 
With many the course recommended is that of expectancy, modi- 
fied, but it is feared far from being improved, by the addition of so- 
called “support” and “stimulation.” It is unfortunately true that 
we at present know no means of arresting the course of some diseases, 
such as small-pox, measles, and other similar affections ; and in these 
cases the duty of the physician is like that of a sailor in a storm—to 
manage his ship as best he may while the storm, which he is power- 
less to influence, lasts; but all diseases are not of this character. 
Simple non-specific inflammations do not run a definite and inevitable 
course; and some specific diseases, depending upon peculiar poisons, 
as the malarial or ague class, are among the affections most under the 
control of remedies. Some diseases that usually run a definite course, 
sometimes spontaneously abort, and we never should cease to hope 
that means may be discovered to safely arrest their progress. The old 
remedy for rheumatism was said to be “ flannel and six weeks in bed,” 
and that was too often not sufficient. Since the time of Fuller and 
Carrod this has not been the remedy ; and particularly since the very 
recent era of salicylic acid, rheumatic fever has, in a majority of cases, 
become a matter of flannel and salicylic acid and a few days, even in 
some cases of a few hours. 
The list of such curable diseases is increasing—it already embraces 
some of the internal inflammations and fevers, and, it is ardently 
hoped, may yet embrace them all. 
Among the qualities necessary to the best physician is faith. In 
morals it removes mountains ; in science it excites to investigation ; 
in art to effort and progress ; in the practice of medicine, when not THERAPEUTICS OF INFLAMMATION. 
93 
excessive, ifc leads to success. The difficulties in the way of thera- 
peutics, which are still great, will never be overcome by that paralysis 
which a universal skepticism is so sure to produce. But faith, how- 
ever useful or necessary, must be tempered by a knowledge of the 
uncertainties and the sources of fallacy which exist. There are 
fallacies of theory to be detected by experience, and fallacies of limited 
and imperfect experience to be corrected by scientific facts and 
analogical reasoning. There are fallacies of substituting a theoretical 
word for a fact; fallacies of general principles and the systems 
founded upon them ; fallacies of therapeutical principles; fallacies 
in the indefinite use of terms or in their being used differently by 
different persons ; and, above all, at least as most common, fallacies in 
investigating the relations of cause and effect. One event succeeding 
another does not always stand in relation to the preceding event as 
an effect—the relation of cause and effect may be absent—and this 
may be the case even when the first event has been brought about for 
the purpose of producing a result the same as that which has occurred. 
A medicine may be given to abate a fever, the fever in due time may 
subside, but from some other cause than that of the medicine. Fevers 
subside, and sometimes suddenly, when no medicine has been given, 
or even when medicines have been given that would tend to increase 
fever—the fever abating in spite of the medicine, though some medi- 
cines undoubtedly abate and arrest some febrile states. There are 
various compound fallacies arising from incorrect statements, from 
regarding as facts opinions which are unsupported, and at the same 
time from deriving illogical conclusions from unsound premises. 
One may make the most positive and the most conscientious state- 
ment that he was cured of a particular disease by a particular remedy. 
Such a statement is often accepted as a fact. But instead of its being 
a single fact, it is an expression of three opinions, either of which 
may be untrue. In the first place, the patient may never have had 
the disease as stated ; in the next place, he may not have been cured, 
the disease, whatever it was, may still be existing ; and in the third 
place, supposing the disease to have been present and removed, the 
remedy in question may have had nothing to do in its removal. It 
may have been a mistake and a fallacy from beginning to end. The 
certified cancer cures are illustrations, and all the false systems and 
useless nostrums are sustained by just such alleged facts. All these 
and other sources of fallacy must be considered and guarded against. 
They are sufficient to make the art in many respects conjectural 
rather than positive, to compel us to proceed upon probabilities 
rather than certainties; but we may remember that in other things as 
well as in medicine “probabilities are the guide of life.” 94 
THERAPEUTICS OF INFLAMMATION. 
With regard to the law, which has been eulogized as the “ perfec- 
tion of human wisdom,” even its “ delays ” are not as conspicuous as 
its uncertainties. And in politics, finance, and commerce, in all the 
affairs of secular life, not to mention philosophy, metaphysics, and 
theology, conjecture and uncertainty abound, and often something 
less than probability is the only guide to follow. 
In medicine, well observed cases sufficiently numerous will bring 
us to as much certainty as can be arrived at in any other profession 
or the affairs of our uncertain life. Deductions from scientific facts, 
corroborated by sufficient and well observed experience, will justify 
positive expressions of opinions at least, and such opinions, though 
they may not be regarded as conclusive, must be accepted at their 
estimated value. This, and nothing more, is asked for the opinions 
which may here be expressed. As already intimated, the duty of the 
physician is not limited to the treatment of diseases already occurring, 
but to their prevention as well ; and his practical work is comprised 
under three heads of Hygienic, Prophylactic, and Remedial Treat- 
ment. 
Hygiene is the science of Health—the knowledge of those con- 
ditions on which the preservation of health depends. It embraces 
the laws of health relating to the Individual, the Family, and 
the Public; to the relation of the Sexes, to the relation of Parents 
and Offspring; and the laws of health pertaining to the mind as 
well as to the body. It embraces a knowledge of the conditions of 
health and the causes of disease, and teaches how to secure the one 
and avoid the other. But the limits of this work will not allow of a 
full and systematic discussion of this subject. Sufficient, however, 
will be said, when treating'of particular diseases, to keep in mind the 
importance of the subject, and to give an idea of some of the means 
necessary for the accomplishment of its great objects. 
Prophylaxis signifies the more special preventive treatment of par- 
ticular diseases. 
In some respects it may be regarded as a part of hygiene, and ill 
others as remedial treatment. 
In many cases there is a tendency, inherited or acquired, to par- 
ticular forms of disease. The means to be used to prevent the devel- 
opment of such tendency would come under this head. 
The special measures to prevent the occurrence of parasitic infec- 
tions and endemic diseases, and the means to prevent the complications 
and sequelae attending or following particular primary affections, are 
also prophylactic. These matters will be considered in connection 
with the particular diseases. THERAPEUTICS OF INFLAMMATION. 
95 
The Remedial Treatment of cases of disease engrosses most of the 
time and constitute, the chief labor of a large majority of physicians. 
In undertaking a case the objects are : 
1. To ascertain the existing morbid condition—to make a Noso- 
logical Diagnosis. 
2. To ascertain the pre-existing morbid conditions, latent or appa- 
rent, and the causes which have produced the present state—to 
make, as some have designated it, an Etiological Diagnosis. 
3. It is well next to consider the probable course and termination 
of the disease—to form, though it is not always necessary to 
express, a Prognosis. 
4. Next to formulate in the mind an indication—to consider defi- 
nitely the particular object or special change of the morbid 
condition to be accomplished by treatment. This may be 
called the Therapeutical Diagnosis. 
5. And lastly, to determine, select, and apply the remedies be- 
lieved to be indicated, to consider their mode of operation, 
and undertake the general direction of all the conditions bear- 
ing upon the case. 
Under this head will be comprised not only the medicines to be 
prescribed, avoided, or discontinued, but all the surroundings—the diet 
and regimen, the hygienic management as well. The attainment of 
the first and second objects will require the inspection of the patient, 
the observation and interpretation of all the apparent characteristics 
of the person and the disease ; the listening to the patient’s statement 
of his complaint, and generally the eliciting of further facts by appro- 
priate questions; the ascertaining of the temperature; the physical 
exploration often of the various viscera ; and the microscopical and 
chemical investigation of the secretions and'morbid products. 
The third object will require a knowledge of the history of similar 
diseases, a judgment as to the tendencies and powers of endurance of 
the system, and the influence which treatment may exert on the case. 
To accomplish understandingly, rationally, and properly the third 
and fourth objects, a knowledge is required of the particular patho- 
logical condition, the morbid changes—physical, chemical, and vital— 
which are going on, the manner in which these changes are being ac- 
complished, the causes which are keeping them in operation, the con- 
ditions of all the organs and functions of the body, as well as the part 
particularly affected, so as to form a judgment of what treatment 
can be borne, as well as that which is indicated by the special disease. 
It is important also to know the action and power of the different 
medicines, physiological and therapeutical, not only upon the particu- 
lar diseased processes for which they may be prescribed, but upon all 96 
THERAPEUTICS OF INFLAMMATION. 
the organs and functions of the body, immediate and remote, primary 
and secondary; or, as some make the distinction, o,f the “ drug effect” 
and the therapeutical action, and then to form a judgment and give 
explicit directions as to the quantity, time, and manner of using them. 
The idiosyncrasies of the patient, if he has any, must be taken into 
the account, and his confidence, if possible, must be secured. In 
many cases no less knowledge and skill will be required in directing, 
respecting the hygienic or dietetic conditions, the food and regimen, 
than about the medicines, and, in some cases especially, these mat- 
ters must not be left to the caprices of patients, ignorant nurses, or 
friends, however solicitous. 
It may not be possible to have all this knowledge indicated; in- 
deed, in the present state of the science and art, many things must be 
left to conjecture and uncertainty ; but this full knowledge should be 
the aim of every physician, and should be approached as nearly as 
possible. 
Pathology, in its practical uses, is the Science of Indications; and 
in the fulfillment of these indications we are not entirely without 
reliable guides. There is an absolute constancy in the laws which 
regulate life; and there is “ a strict subordination of phenomena to 
certain conditions, which [however] have to be determined.”—{Ray- 
naud.) There are differences of susceptibility to the action of agen- 
cies, pathological and therapeutical, and differences in the forces of 
the system in their tendency to restore normal actions ; and these 
cannot always be foretold. Hence the uncertainties of therapeutics, 
even when pathological states are determined. 
The indications, the remedies, and the management will vary not 
only in different diseases, but in the variable conditions of each case, 
and, from the statement made, it can but be seen that, in the practice 
of the profession, there is opportunity and need for the exercise of the 
highest judgment, the most exquisite tact, and the greatest skill. 
The therapeutic agents, embracing the articles of the Materia Med- 
ica, are arranged variously for the convenience of study, and according 
to one or more of their leading properties. They may act by destroying 
the cause of a disease, by modifying the condition and function of 
some system, or organ, or part; or they may act more directly upon 
the complex phenomena in some specific manner which we do not 
understand. Some of these so-called specifics act upon some physi- 
ological factor, or some special modified action, rather than upon 
the aggregate phenomena. It is now well known that certain medi- 
cines or poisons antidote or counteract the effects of others, either hy 
exerting an opposite influence upon the same organ or function, or by 
playing off one function against another. The antagonism of atiopia THERAPEUTICS OF INFLAMMATION. 
97 
and morphia is an example. This suggests a similar force of drugs 
in reference to morbid actions produced by other causes, and consti- 
tuting particular diseases. These facts and considerations, especially 
the antagonism of diseases and remedies, the result of modern dis- 
covery, should suppress unreasonable skepticism and give courage and 
hope. 
With reference to the therapeutical indications they fulfill, medi- 
cines have been classed under the heads of— 
1. Anodynes—agents which relieve pain. Often the same articles 
are soporifics or anaesthetics—articles which induce sleep or destroy 
sensibility. 
2. Protectives—articles which shield, usually mechanically, from 
irritating influences. 
3. Balancive agents—means which influence the proportions or 
balancing of activities—sensitive, motor, circulatory, nutritive, or 
secretory—embracing revulsives or counter-irritants, local depress- 
ants, special stimulants, etc. 
4. Economics—agents which diminish waste and save the tissues 
and powers of the system. 
5. Eliminatives—agents which carry out of the system, or eliminate 
through the emunctories or excreting organs,effete or injurious matters. 
6. Antidotes—articles which neutralize, destroy, or prevent the 
effects of poisons. 
7. Alteratives—in its broadest sense embracing a very large num- 
ber of articles—agents which change actions beneficially, by whatever 
means or in whatever way ; in a more restricted sense, agents which 
change actions without producing sensible evacuations. 
8. Recuperatives—agents which increase or sustain power, or 
restore to the system something it needs—embracing tonics, stimu- 
lants, nutrient and chemical elements which restore to the system 
vigor and strength. 
9. Sedatives—agents which diminish action, general or local. 
Under these general headings may be made many more sub- 
divisions, as, for example, under the head of Eliminatives would come 
Cathartics, Diuretics, Diaphoretics, Cholagogues, etc. The details are 
the subjects of works on Materia Medica and Therapeutics. The 
terms which have here been given as designating the general classes 
of agents will be those chiefly used in the therapeutical directions 
which are to folloAV. 
The Pulse, as a means of determining the existence and character 
of an inflammation and its accompanying fever, and as furnishing 
therapeutical indications, is worthy of careful attention, and some 
statements respecting it may here be made. 98 
PULSE IN INFLAMMATION. 
Since the fever thermometer has come into such general use, a.id 
the sphygmograph has promised to reveal with more precision the 
force and character of the cardiac and arterial contractions, less atten- 
tion has been given to conditions of the pulse discovered by the fingers 
of the physician; and the tactus eruditus in pulse-feeling, once so 
much cultivated, has been neglected. Though the fever thermometer 
is now in almost every physician’s pocket, and its daily use is of great 
advantage in diagnosis and in furnishing therapeutical indications, a 
sphygmograph is possessed by few, the method of its use is not gener- 
ally understood, and it is very seldom brought into requisition in the 
sick room ; and the inconveniences of its use will prevent its being a 
common instrument in the hands of the general practitioner in the 
daily rounds of his common work. 
In the practice of blood-letting, so common fifty years ago, the fact 
of the presence of inflammation was sufficient, in the estimation of 
many, to call for this remedy in one form or another; but the pulse 
was consulted to determine the mode, whether general or local, and 
the extent to which it was to be carried. With the comparative aban- 
donment of this method of depletion, the importance of so closely 
watching the pulse may have diminished; but its conditions still fur- 
nish important indications of morbid processes, and of the means of 
correcting them, and particularly of the vital activity and the power 
of endurance of the patient. The conditions of the pulse and the 
common manner of observing them should be studied. 
In observing the pulse three points should be kept in view—the 
moving, propelling force of the heart, the motion of the blood, and 
the state of the artery. The physiology of the circulation is supposed 
to be understood by the reader, but a few points may be referred to as 
a basis of its pathology. 
These conditions have their normal standards, but they are varied 
physiologically, and are still more varied in disease. 
The pulse varies in frequency of beat by age. The pulse of the 
new-born infant is from about 120 to 140 beats per minute ; at one year 
of age, 110 to 120 ; two years, 100 to 110 ; three years, 95 to 105 ; 
four years, 90 to 100; at puberty, 80 to 90 ; manhood, 70 to 75 ; 
vigorous old age, 00 to 70 ; decrepitude, from 70 to 80. The pulse 
in women is from 6 to 12 beats faster than in men, and in warm cli- 
mates it is more rapid than in* cold. Temperature has a marked 
effect upon the frequency of the pulse. If a fluid of different temper- 
atures be thrown through a separated heart still possessed of vital 
excitability, the frequency of the pulsation rises and falls in proportion 
to the temperature, unless the temperature be excessive, when the 
irritability is completely destroyed. In disease, the fever heat increases PULSE IN INFLAMMATION. 
99 
the frequency of the pulse ; but various other circumstances influ- 
ence its motions. Generally in the adult when the temperature 
of the body is 37° Centigrade or 98.5° Fahrenheit, the pulse is 78.6 ; 
when 38° Centigrade or 100° Fahrenheit, it is 88.0; when 39° Centi- 
grade or 102.3° Fahrenheit, it is 97; when 40° Centigrade or 104° 
Fahrenheit, it is 105 ; when 41° Centigrade or 106° Fahrenheit, it is 
110 ; when 42° Centigrade or 108° Fahrenheit, it is 122. An increase 
of 2° Fahrenheit, on an average, increases the pulse eight beats. The 
condition of the nervous system, physical or mental excitement, the 
position of the body, lying, sitting, or standing, the degree of weakness 
or strength, as well as age and sex, vary its frequency. Between lying 
down and standing the pulse varies from five to twelve beats in health, 
and the erect position often increases it much more in disease. 
In examining the pulse we observe not only its time, but its 
force, equality, size, hardness, and various other qualities. We 
judge of the state of the heart, the volume of the blood, and the con- 
dition of the artery. 
The terms strong, weak, sharp, jarring, rapid, quick, slow, 
unequal, intermitting, and fluttering, indicate the character of the 
impulsion of the heart. The words full, large, and small, have refer- 
ence to the volume of the blood flowing through the artery. The 
terms hard, soft, contracted, open, and chorded, have reference chiefly 
to the state of the artery. The terms thready, gassy, firm, and tense, 
have reference to the force of the heart, the volume of blood, and 
the state of the artery together. 
The experienced observer distinguishes by the finger whether the 
artery fills slowly or gradually—whether the pulse is thus quick or 
tardy in each individual movement; he notices how high the pulse 
wave is—the largeness or smallness of the pulse ; how widely the 
artery is distended—its fullness or its vacancy ; in what degree of ten- 
sion is the artery—its hardness or its softness ; and whether the artery 
fills evenly or irregularly, producing a vibratory and sharp, or smooth 
and rounded pulse. 
The active fever pulse of a previously healthy adult is more or 
less large, full, hard, and quick, as well as rapid ; and it gains these 
properties chiefly by the influence of a quicker and stronger contrac- 
tion of the heart. In pneumonia and other acute inflammatory fevers 
this characteristic pulse is often observed. But in an advanced 
stage of such diseases, and sometimes in the early stages, there may 
be a small, empty, and soft pulse, one that is thready, scarcely per- 
ceptible, and at length absent at the wrist. The changes in the 
heart beats ; changes in the resistance at the extremities of the ves- 
sels due to variations in the calibres of the small arteries, caused by 100 
PULSE IN INFLAMMATION. 
the contraction of their muscular coats, in the arteries of particular 
points or of the system at large ; and changes in peripheral resistance 
to the flow of blood through the capillaries, due to alterations in the 
adhesiveness of the walls, or the relations—the attractions—of the 
blood and tissues, such as occurs in inflammation ; and changes in 
the quantity of blood in circulation, will all vary the characters of 
the pulse. Most of these conditions are under the influence of the 
nervous system—the exciting and inhibitory nerves—and through the 
action of this system chiefly an organ has more blood carried to it 
when at work than when at rest, and in inflammation than when in 
health. The vital endowments of the tissues, however, exert an influ- 
ence, and all these conspire to vary the circulation and the pulse. 
When the blood pressure is high, from obstruction to its free flow 
in the small arteries and capillaries, there is more resistance to the 
contraction of the ventricle, and the heart’s work is increased. The 
contractile energy of the heart becomes greater, and the blood is 
thrown into the arteries with more force, giving hardness and tense- 
ness to the pulse. The increase of blood pressure, however, does not 
increase the frequency of the beat. On the contrary, it has been 
stated that “ the rate of the beat is in inverse ratio to the arterial 
pressure.” This, however, is not always the case, and when the vagus 
is disturbed in its function, and probably in other disturbances of the 
nervous system, the results are varied, and no positive rule without 
exceptions can be established. 
These statements are intended to show some of the means by 
which the pulse is varied, and to give an understanding of some of 
the indications of differences in its beats. 
A rapid pulse may indicate a feverish increase of temperature, or 
a low grade of blood pressure—a deficiency of that fluid—or it may 
indicate a morbid irritability of the heart or of the nervous system. 
It does not of itself indicate an increased quantity of blood or the 
sthenic action of the heart, and is not an indication, even according 
to the depleting system, of lowering treatment. 
When the pulse is comparatively slow, but full, firm, and hard, 
the blood pressure is great, either from obstruction at the vascular 
periphery, or from a large quantity of blood in the system, or from 
a sthenic excitement of the heart. In such cases cardiac sedatives 
may be useful, and depleting measures can be borne. 
There are, however, complicated circumstances, givingto the pulse 
a great variety of characteristics, more even than those that have 
been named. 
There may be presented a full, slow, vigorous stroke of the artery ; 
a full, tense, and frequent pulse ; a hard, incompressible, quick PULSE IN INFLAMMATION. 
101 
pulse, feeling like a tightly drawn cord; a soft, open, compressible 
pulse ; a small, rapid, and weak pulse ; and a creeping, soft pulse. 
After a copious loss of blood the pulse often becomes vibratory, 
rapid, and thrilling, causing the sensitive and appreciative finger to 
tingle, almost as from a galvanic current. This indicates supporting 
measures. 
The indications which many of the different kinds of pulse afford 
will be mentioned in connection with the diseases in which they are 
observed. 
In examining the pulse some practical rules should be observed. 
In an acute disease the patient should lie in a recumbent position, 
and when comparisons are to be made, he should lie in the same 
position at each examination. 
The mind of the patient should be calm, and free from emotional 
agitation or excitement, and the body should be at rest. 
In feeling the pulse three or four fingers should be applied to the 
radial artery in front of the wrist. After observing the frequency, 
the fingers should be pressed on the proximal part of the artery felt, 
and by the finger at the more distant part it is ascertained whether 
the flow of blood is interrupted, and by the first fingers it is ascer- 
tained how much force is required to interrupt the flow. 
There should be no pressure on the course of the artery above by 
the dress or other means. The size, the hardness, the quality in all 
the respects named should be observed with a light pressure, but 
sufficient to obtain a distinct impression of the qualities to be noticed. 
Both wrists should be examined, and when any unusual distribu- 
tion of the radial arteries is present, other arteries, as the carotid, or 
the temporal, should be explored. , 
Often the hand, the ear, or a stethoscope should be applied to the 
chest to observe the force of the heart’s beat against the ribs, as well 
as the force of the blood sent to the arteries. 
The pulse in a severe and acute case should be examined more 
than once at each visit, and its frequency counted by the watch. 
The healthy adult male pulse may be described as regular, equal, 
compressible, moderately full, and swelling slowly and evenly under 
the finger. In the healthy female and in children, it is not only 
more frequent, but quicker in each beat and smaller than in the 
adult male. 
In old age the coats of the artery are apt to become firm, and 
sometimes calcareous, giviug a hardness not dependent upon in- 
creased force. 
There are many peculiarities and idiosyncrasies—some persons in 
health having a very slow, and others a very rapid pulse. 102 
PULSE IN INFLAMMATION. 
The natural pulse must be inquired after when unusual conditions 
or those not in harmony with other symptoms are observed. 
Various irregularities of the pulse are observed in diseases of the 
heart, both organic and functional; and a dicrotic pulse—one which 
gives a sense of two impulses at each heart contraction—a double 
wave—is a condition not unfrequent in low forms of fever, with much 
heart Aveakness and irritability, or irregularity in its innervation. 
When such a pulse continues many hours it is an unfavorable indica- 
tion. When it is followed by an epistaxis, and after that disappears, 
its indications are not so unfavorable. In some hemorrhagic ere- 
thisms it persists to the last, resisting measures to 'subdue it. 
The dicrotic pulse Avhen soft, and when due to the heart’s 
stopping in the midst of its contraction to take a rest, may indicate 
only weakness, and require supporting measures. 
When the dicrotic pulse is hard, it indicates a perversion of inner- 
vation which may require other means, and it will be either more or 
less dangerous according to the various circumstances. 
A supplementary wave or impulse of the pulse at the wrist has 
been noticed as resulting from a reaction of the arteries concerned in 
the palmar arch. It is, however, described by but few authors on 
the pulse. This recurrent palmar pulse should be distinguished from 
the small, hesitating, feeble pulse of true adynamia. The palmar 
recurrent pulse is present in some pulmonary affections, as in the 
latter stages of severe pneumonia, when the left heart is comparatively 
empty and the right heart and veins are surcharged with blood. In 
this condition we sometimes get a distinct recurrent pulse wave, by 
means of the palmar anastomosis, Avhile in true adynamia this 
retrograde pulse wave is absent or nearly imperceptible. 
A jerking pulse is one which is abrupt, with a projection of the 
artery which quickly recedes. It is characteristically observed in 
insufficiency of the aortic valves. 
While the pulse is only one of the means of making a diagnosis 
and forming indications, it is a means of importance, and should 
receive a proper degree of attention. 
These examples are illustrative of the importance of this subject, 
and will furnish suggestions for its proper study. 
The spliygmographic study of the pulse is of interest, and fur- 
nishes important indications. It is not entered upon here. GENERAL PRINCIPLES OF TREATMENT OF INFLAMMATION. 
103 
GENERAL PRINCIPLES OF THE TREATMENT OF 
INFLAMMATION. 
It will save time in describing the treatment of particular inflam- 
matory diseases, and give perhaps a clearer understanding of the most 
important subjects in therapeutics, to consider the principles of treat- 
ment of inflammation in general; and in doing so it will serve our 
purpose best to state the leading elements of this process so far as they 
may be influenced by treatment, and designate the remedies that may 
modify beneficially the particular element. 
In the description of the inflammatory process it will have been 
noticed that different elementary actions were present and progressing 
at the same time, and that some were conflicting in their character. 
While active hyperaemia is going on in one part, stasis is occurring in 
another ; and while hyperplasia is occurring in some tissues, destruc- 
tive metamorphosis is going on in others; and while exudation of 
inflammatory products is being poured out, an absorption of the nor- 
mal tissue is taking place. In the different stages of an inflammation 
the prevailing characters of the processes differ greatly, as they also 
do in different kinds and degrees of the disease. 
The different kinds, varieties, degrees, and stages of inflammation, 
the greater or less predominance of its different elements, and its 
modifications as it occurs in different persons and in different con- 
ditions of the system, will require modifications of treatment. To 
inquire how inflammation is to be treated, expecting a short and inclu- 
sive answer, would be almost as absurd as to expect such answer to the 
question how a sick man was to be treated. 
In this general discussion of the subject the analytical method will 
be pursued, and principles rather than detailed procedure will be 
stated, while a more synthetical and detailed method will be adopted 
when describing the treatment experience has proved most useful in 
particular inflammations. 
It is here assumed that in treating inflammation the object is to 
arrest its several processes, or at least to bring the whole process to as 
speedy an end as possible. There may, however, be cases wdiere it 
would be desirable to promote certain of the inflammatory processes, 
as that of suppuration where the severity of the inflammation and 
the amount and character of the exudation showed that the formation 
of pus would be the most ready method of terminating the whole 
process; or where a sluggish state supervened after the disease had 
reached a certain stage, the morbid condition remaining stationary, 
and when an increase of action involving inflammatory changes would 104 
ELEMENTS OF INFLAMMATION AND THEIR REMEDIES. 
lead to a more speedy cure. Here irritants may be demanded, as in 
indolent ulcers and in some diseases of the skin. In diphtheritic 
inflammation, if the suppurative process can be induced, the false 
membrane is more likely to be thrown off, and the absorption of poi- 
sonous matter prevented. These are rather exceptional cases, though 
they are not unfrequent. Generally each particular process requires 
to be checked or suppressed, and the suppression of one tends to affect 
favorably the aggregate. 
THE ELEMENTS OF INFLAMMATION AND THE REM- 
EDIES FOR EACH.—LOCAL STATES AND THEIR 
REMEDIES. 
1. Active Hyperaemia.—The remedies which may diminish 
this condition are : Cold steadily applied ; water, independent of its 
temperature, applied for a length of time, diminishes the calibre of 
the vessels and the circulation in them ; position—elevating the part, 
obtaining the aid of gravitation; evacuants—removing the blood by 
venesection, leeches, etc., or any of its constituents from the body, 
as by cathartics, etc. ; cardiac and arterial sedatives—diminishing 
the force with which the blood is sent forth to the part—the “vis 
a tergo; ” derivatives—by which the blood is drawn more to other 
parts, and thus the amount diminished in that which is inflamed. 
By evacuants, and, so far as the hyperaemic parts are concerned, 
by derivatives, the blood is taken from the smaller vessels of 
the tissues to supply the deficiency in the larger vessels, thus, as 
has been said, “bleeding the patient*into his own vessels.” Seda- 
tives to the nervous system, especially to the vaso-motor nerves may 
diminish the action of the vessels. Poultices act chiefly by the 
water they contain, and by means of which the water is constantly 
applied.. These means, as will be readily seen, will tend to diminish 
this condition, and thus diminish one of the elements of the inflam- 
matory process. 
2. Passive Hyperaemia is another condition. The remedies 
tending to relieve this are partly the same as those for the more active 
form, viz. : Evacuants, position, cold, and water. Heat, also, espe- 
cially when combined with water, is decided in its effect, and pro- 
duces a similar result on some forms of more active hyperaemia as well ; 
also astringents, stimulants, pressure, and friction. The astringents 
and stimulants applicable in the passive forms of inflammation, 
besides diminishing the size of the vessels, produce an alterative effect, 
changing the character of the action, tending to result in the normal ELEMENTS OF INFLAMMATION AND THEIR REMEDIES. 
105 
state. This action is similar to that of mild caustics, and is illustrated 
in chronic conjunctivitis, pharyngitis, cystitis, etc. 
3. For irritation of the nerves, the application of water, of cold, 
and of heat—sometimes one and sometimes the other of the last two 
will be best. Narcotics, nerve sedatives, and counter-irritation, sin- 
apisms, blisters, etc., are the more special remedies for this state. 
The narcotics may be applied locally or used generally, and their 
great power to control, chiefly through the nervous element, to 
abate and often arrest inflammation in the early stage, while at the 
same time they relieve pain and suffering, indicates the influence 
the nervous system has in causing and modifying inflammatory proc- 
esses, and the power of therapeutic agents in removing them. 
4. The increase of leucocytes in the part, and the increase in their 
amoeboid movements, resulting in exudations and suppurations, are 
checked by quinine. This appears not only from the direct experi- 
ments made upon animals, whose tissues have been observed under 
the microscope, but it is abundantly confirmed by experience in the 
treatment of various inflammations with strong suppurative tenden- 
cies. The importance of this agent for this purpose, and for counter- 
acting the general phenomena of inflammation, is coming to be recog- 
nized. Salicine and salicylic acid perhaps have similar effects, though 
the facts as to their efficacy in common inflammations have not been 
so fully established. The control of the latter over acute rheumatic 
inflammation and fever has been sufficiently proven. 
5. For effusions of whatever kinds, serous, etc., when excessive 
or injurious: Evacuants, derivatives, pressure, and position are 
applicable as in hyperaemia. Quinine in effusion of leucocytes, 
spanaemics for excess of fibrine and for fibrinous exudates, as in 
endocarditis, pericarditis, etc., where organized false membrane is so 
dangerous ; and sorbefacients, as the iodides, etc., where exudates have 
accrued and require removal. Counter-irritation, iodine locally, etc. 
6. For destructive changes, increased metamorphosis and absorp- 
tion of tissues, all the means which tend to arrest other changes lead- 
ing to these are applicable ; but when these become, or tend to become, 
the predominant condition, every means should be used to improve 
nutrition—good food, tonics, and stimulants. 
The General Conditions of the System, Fever, etc.—Their Remedies. 
7. For excitement of the heart and arteries, and high fever, always 
important elements in the inflammatory process, and often exces- 
sive, requiring abatement, bleeding, though less useful and necessary 
than formerly supposed, is still applicable and very useful in some 106 
ELEMENTS OF INFLAMMATION AND THEIR REMEDIES. 
cases when the excitement is high and the patient plethoric, and 
where hypersemia oppresses important organs, interfering with their 
functions. It is folly to condemn this practice under such circum- 
stances, and the dangers from loss of a reasonable quantity of blood 
have been by some greatly exaggerated. Besides bleeding, for fulfil- 
ling similar indications, we have cathartics, diaphoretics, and seda- 
tives. As antipyretics we have opium, veratrum viride, aconite, gel- 
seminum, jaborandi, antimony, salines, the bath, quinine, salicine, and 
salicylic acid. 
8. For the general increase of fibrine we have the salines, alkalies, 
antimony, mercury, and diluents. 
9. For the morbid increase of albumen, which occurs in some 
chronic, particularly in tuberculous cases, we have cod-liver oil, 
cream, and alkalies. 
10. For general increase of the white corpuscles in the blood, qui- 
nine, and perhaps salicine and salicylic acid are the remedies. 
The general anti-inflammatory and antipyretic, or antiphlogistic 
effects of quinine, is a subject lately attracting the attention of the 
profession, and is one of paramount importance. If the claims put 
forth for it are sustained—if the general experience of observing prac- 
titioners shall sustain the sentiments now held by some—an advance- 
ment is being made in practical medicine and surgery greater than 
any other which has occurred in recent times. In order that this 
article shall have its full and most striking effects in arresting inflam- 
mation it should be used early in the disease, and as much as twenty 
grains or more must be in the system at one time. It is appropriated 
and operates better after the bowels have been evacuated by a suitable 
cathartic, and its action is generally promoted by being combined 
with an opiate, the salts of morphia perhaps best, in decided but not 
heroic doses ; and sometimes it may be combined with other agents, 
according to the type and location of the disease. That it is capable 
of arresting promptly many severe inflammations when early given, 
and abating markedly those more advanced, diminishing the suppu- 
rative process, and at the same time not depressing permanently the 
vital powers, when not continued too long, are opinions held so 
strongly, based upon observations so numerous, that something more 
than the neglect or refusal of the profession to faithfully try the prac- 
tice will be required to convince the writer of their unsoundness. 
The particular methods of using this invaluable article, and some- 
thing more of its mode of operation, will be described in connection 
with special inflammatory diseases. 
11. For the increase of effete matters in the system and their re- 
tention—conditions occurring to a greater or less extent in inflamma- ELEMENTS OF INFLAMMATION AND TIIEIR REMEDIES. 
107 
tory diseases—eliminatives, as the patient may be able to bear them, 
are generally indicated. In the order of their general importance are 
cathartics—the saline generally best—very often preceded by a mild 
mercurial; diuretics, also the saline variety ; diaphoretics, jaborandi, 
the most powerful; and cholagogues, not denying the power of mer- 
cury in this respect. 
12. For the general depression from shock and sympathetic suf- 
fering, anaesthetics, stimulants, and narcotics will be required, and in 
the more protracted cases tonics—supporting food—such only as can 
be borne and digested, more than that increasing the irritation and 
depression. As stimulants and narcotics,—stimulants acting indi- 
rectly by relieving shock and suffering, if not directly upon the heart 
and brain,—we have alcohol, opium, camphor, ammonia, and various 
organic excitants ; and in the more protracted cases, as tonics, the 
bitter vegetable principles, iron, etc. 
13. For septic blood poisoning and its results there are the anti- 
septics and eliminatives, the sulphites, salicylic acid, quinine, etc. 
14. For the removal of its effused products, after the inflammation 
may have subsided, there are sorbefacicnts, attenuants, eliminatives, 
stimulants, tonics, frictions, pressure, proper diet, and blisters. The 
preparations of iodine and mercury are often very important, judi- 
ciously used. 
15. For the extreme heat sometimes occurring—hyperpyrexia— 
the cool or cold bath, cold affusions or packing (a very important 
agent), quinine, digitalis, salicylic acid, and some other agents 
included in what is called the antipyretic method are required. 
1G. For the debility following the active disease, nourishing diet 
carefully regulated, tonics and stimulants are applicable. 
17. In all cases the stomach should receive care, as upon it chiefly 
depends the power to take and appropriate food, so necessary in pro- 
tracted cases, and also the ability to take, appropriate, and endure 
the medicines needed. The means required for correcting its morbid 
states and preserving its better conditions may be various, according 
to the nature of each case. The liver and bowels, the kidneys and 
the functions of all the important organs should be looked to, and as 
far as possible preserved. 
These are the principles and the agents applicable in the manage- 
ment of inflammation, and the physician who still practices his pro- 
fession, and does not believe in their power to accomplish any of the 
results pointed out as desirable, must be a less useful member of the 
profession than one who has a reasonable confidence in them and skill 
in their application. 
The circumstances calling for particular selections from these dif-  ELEMENTS OF INFLAMMATION AND THEIR REMEDIES. 
108 
ferent agents, and the manner of their application, will be described 
in considering the different inflammatory affections. 
In view of the acknowledged power of many of these agencies, 
and particularly in view of a long and varied experience, it is impos- 
sible to agree with the statement of a recent, and, on the whole, an 
able writer on the Practice of Medicine, that, “ unfortunately, a 
direct cure, at all events a direct cure by means of drugs, in the great 
majority of cases, is totally impossible.” * But here, as is so often 
the ease, there is obscurity in the use of terms. If by a “direct 
cure by means of drugs,” is meant the direct excitement of perfectly 
healthy actions by them, the statement cannot be controverted, and 
it applies to every case. But this is evidently not his meaning, as he 
mentions some cases, instancing ague, gout, and syphilis, where he 
says direct cures are effected by quinine, colchicum, and mercury, 
respectively. But by no means, he says, “can wTe cure the infectious 
fevers, internal inflammations, carcinoma, degenerative changes, or 
many of the functional and other disturbances to which the organism 
is liable.” The italics are not his, but are added to call attention to 
the statement that internal inflammations are totally incapable of 
cure. If by this is meant that their processes cannot be arrested, or 
so modified that health results sooner, or as it would not without the 
use of remedies, the assertion I regard as intensely and injuriously 
erroneous. It is undoubtedly true that some internal inflammations 
are not arrested by any means that have been applied in the hands of 
the most skillful, and it might be inferred that none of them are ever 
arrested in the hands of the author quoted ; but that they are in other 
hands, ought to be beyond dispute; and it seems an unjust dispar- 
agement of the profession, as it is the denial of a truth, to assert 
otherwise. 
In some cases internal inflammations are not cured by any means; 
neither are some cases of syphilis cured by mercury, or gout by col- 
chicum, or even malarial fever by quinine or arsenic. A larger por- 
tion of internal inflammations may defy treatment, especially when 
that treatment is commenced late in the course, than of gout or syphilis, 
by what he calls specific remedies ; but this is exceedingly doubtful, 
if the inflammation is early attacked and vigorously and skillfully 
treated by the means we now have at our command. 
Medicines, it is true, cannot do everything desired ; but they can 
do many things desirable, when properly used; and this disparage- 
ment of them has been carried to an extreme. Nothing can be more 
judicious than the chief general indications, pointed out by this 
* Bristowe, Theory and Pract. of Med., 2d ed., p. 120. ELEMENTS OF INFLAMMATION AND THEIR REMEDIES. 
109 
author, viz.: “ 1st. To promote the patient’s general comfort. 2d. To 
support the patient’s strength by appropriate nourishment. 3d. To 
maintain or restore the healthy tone of his nutritive functions. 
4th. To promote the free action of his emunctories. 5th. To relieve 
the secondary phenomena or symptoms of his disease. And 6th. To 
obviate the tendency to death.” But by what means are all these 
objects to be accomplished, if medicines are so powerless in cases of a 
severe inflammatory disease ; and why not attempt to relieve the pri- 
mary as well as the secondary phenomena of the disease ? 
The extreme views of the late Dr. Todd, of London, and Dr. 
Bennett, of Edinburgh, are passing away, as the personal influence of 
these distinguished men is fading. Their intense and indiscriminate 
opposition to what is called “depleting measures,” was the result of 
a reaction from excessive depletion; and, particularly in the case of 
Dr. Todd, his advocacy of the large use of alcohol in acute diseases 
was due in part to wrong notions of the physiological and therapeu- 
tical actions of that article.' These distinguished men have very few 
or no disciples who follow them in all their views at the present 
time, and it has become unnecessary to present and criticise them in 
full. It is better to have them forgotten ; but some relics of them 
remain, as in the passages from the author quoted. Extremes always 
tend to follow each other, and the time may not be distant when it 
will be necessary to warn the profession against the extreme use of the 
lancet and other depletory measures. Though the lancet has its occa- 
sional uses now as ever, yet we have other and far better means for 
controlling fever and inflammation, and it is but rarely required. 
The changes that have occurred in its use have been attributed by 
some to a general change in the type of disease. That changes occur 
from time to time in the character of diseases, depending upon changes 
of habits and various other causes, as already pointed out, there can 
be no doubt; but that a great, wide-spread, and general change has 
occurred at the era of the change of practice from the strict depletory 
method, there is not sufficient evidence to prove. There have been 
more changes in opinions than in diseases, and in doctors than in their 
patients. Fluctuations in opinions on particular subjects are always 
occurring ; but when the disturbed pendulum settles back to its proper 
equilibrium, advancement toward truth is usually found to have been 
made. 
But inflammations, and the fever and other general derangements 
accompanying them, present different types at different times and in 
different places and in different individuals, requiring modifications of 
treatment. 
The same general principles, however, with proper adaptations, 110 
FEVER—PYREXIA—THE FEBRILE STATE. 
apply to all cases of inflammations; and whatever special methods 
may be pursued with a view to controlling particular phenomena, 
there are some general indications for the management of cases which 
admit of formulation. 
1. It is always proper to seek for the cause, and if present and 
found, to remove it if possible and safe. 
2. Thus, and by every means, prevent further irritation of the 
inflamed part. 
3. Procure rest, and particularly, as far as possible, of the part 
affected. 
4. Observe the constitutional peculiarities and particular condi- 
tions of patients, and the kinds, types, degrees, ail'd stages of the local 
disease, and adapt the remedies to the particular status. 
5. Preserve, as far as possible, the function of the inflamed part, 
especially when that function is one important to life. 
6. Consider whether it is safe and proper to use means with direct 
reference to arresting the inflammatory processes, and if so judged, 
use great care in their selection and application. 
FEVER—PYREXIA—THE FEBRILE STATE. 
The word Fever, in its original signification, indicates heat, or to 
seethe as with heat, while the word Pyrexia similarly indicates fire; 
and these terms, as applied to the body, indicate a condition of 
elevated temperature or preternatural heat. 
The normal temperature of the human body, measured by the 
thermometer in one of its deeper cavities, though observers are not 
precisely agreed, averages about 98.8° F. for the twenty-four hours, 
but some slight fluctuations from 97.25° to 99.50° occur during that 
period. 
According to the careful observations of Jiirgensen, the minimum 
temperature occurs from 1.30 a.m. to 7.30 a.m. ; the maximum, from 
4 p.m. to 9 p.m., the temperature between 7.30 a.m. and 4 p.m. rising 
with some fluctuation; that between 9 p.m. and 1.30 a.m. gradually 
falling. The variation between the highest and lowest points is 
from 1° to 2°, rarely exceeding 1.5°. Material elevation above, or 
depression below, these points indicates a morbid state. The activity 
of respiration and circulation nearly corresponds with this rise and 
decline in the temperature. A slight elevation usually follows the 
taking of food, especially a full meal; and muscular exercise has also 
some effect, though more in bringing the circulation actively to the 
surface, and increasing the external more than the internal heat. FEVER—PYREXIA—THE FEBRILE STATE. 
111 
The active performance of functions in particular organs increases 
the temperature in those organs, hut there is usually a corresponding 
diminution in other parts at the same time. 
The ordinary changes of temperature of the medium in which the 
body is placed, the variations of summer and winter, have very little 
effect upon its heat, a remarkable uniformity being maintained. 
Though rapid changes, such as a cold bath, or exposure to a current 
of cold air, temporarily reduce the heat, and exposure to greater 
heat than that of the body temporarily elevates it, yet an elevation 
follows the depression and a depression the elevation, so that the 
twenty-four hours’ mean is preserved. Even if from a morbid cause, 
but one which does not excite fever, the temperature of a part of the 
body is elevated, as by paralysis and distention of vessels and a freer 
blood flow, as sometimes occurs, there is a corresponding lowering in 
other parts. This preservation of temperature under varying influ- 
ences seems one of the most essential conditions of the healthy organ- 
ism, and must depend upon some very fundamental, but as yet not 
understood law. 
Though the temperature of the body observes such strict laws in 
health, the uniformity is readily disturbed by morbid causes, and in 
a very large proportion of diseases, both acute and chronic, morbid 
variations—generally elevations—occur ; and the pyrexial state is 
perhaps the most frequent of morbid conditions. 
The word fever is used in one sense to indicate this pyrexial state, 
or preternatural elevation of temperature, from the operation of 
causes within the system, under whatever circumstances and for how- 
ever short a time ; but the word is used in another sense as indicating 
certain series of morbid phenomena, or particular diseases. In this 
sense a fever is not merely a state, but a process, produced by some 
affecting—often infecting—cause operating upon or within the system. 
In both these senses, but more particularly in the latter, we are to 
consider it. 
The subject of the production of animal heat belongs to the physi- 
ologist, and until he has given a full and satisfactory account of the 
causes and conditions of the normal temperature, the pathologist 
cannot be expected to give a perfect account of the causes and condi- 
tions of its variations in disease. Some principles and facts in regard 
to this matter are sufficiently established; but, unfortunately, many 
points of detail, both physiological and pathological, are still in 
obscurity. 
It must be admitted that the general laws of the production of 
heat in the animal body are the same as those which govern its pro- 
duction in other bodies. The forces in nature all act in connection 112 
FEVER—PYREXIA—TUB FEBRILE STATE. 
with some form of matter, and the same force acts similarly in what- 
ever form of matter it exists. Heat is a force in correlation with 
other forces, and can no more be created out of nothing than can 
matter. Matter changes its forms in the transmutations of nature, 
and so does force; and though before the advancement of science, 
and to grosser comprehensions, annihilations and creations seemed to 
occur both in matter and force, yet all such appearances were decep- 
tive, and it is now well known that there are only changes of form 
in either. The vital power, itself a mode of force, is as incapable of 
effecting a new creation, either of matter or of force, as is light or 
heat, and it can only change the forms of the one or the other. 
Heat is regarded as molecular motion, and its laws have been 
studied with considerable success. It is well known to be produced 
by arrested massive motion, and its exact equivalent of such motion 
is accurately ascertained. A body of a certain weight falling a certain 
distance by the force of gravitation, when arrested produces a certain 
amount of heat. The motion which is seen, when arrested, is con- 
verted into molecular .motion, which may be felt and measured. 
Heat may be produced by chemical changes—by union of elements 
and the formation of new products—and electricity is also readily 
converted into it. It is also well known that heat diffuses itself, and 
that variously heated bodies seek an equilibrium of temperature. 
Heat passes from one body to another by conduction and radiation ; 
and its manifestations are lost—it becomes latent—by various proc- 
esses, of which evaporation is the one most important in relation to 
this subject. 
Heat is produced in the body chiefly by chemical action, and the 
material which is acted upon is derived ultimately, as is all matter in 
the body, from the food. This chemical action consists mostly in the 
process of oxidation of substances containing carbon, hydrogen, and 
nitrogen, and the production of new compounds, as carbonic acid, 
water, and urea, etc. 
Unquestionably, however, ae friction of muscular action, and of 
the circulation of fluids; the check in the rapidity of the flow, as 
these fluids meet with greater resistance in passing into the minuter 
vessels; the more complete arrest of the motion of the fluids, as they 
unite with the solids ; and the union and condensation of particles in 
the production of solid tissues (all of which processes are, perhaps, 
identical with the arrest of motion), contribute to the production of 
heat. Electrical phenomena are constantly occurring in the body, 
and, as electricity is readily interchangeable with heat, this may also 
contribute to its production. The comparative amount of heat fur- 
nished from these different sources it is impossible accurately to esti- FEVER—PYREXIA—THE FEBRILE STATE. 
113 
mate ; and while the chemical actions—the union of elements in the 
production of new compounds—may justly be regarded as furnishing 
the greater amount, the complete ignoring, as is often done, of all 
other sources, seems by no means justifiable. 
The loss of heat occurs by radiation from the surface, and by con- 
duction through substances in contact with the body—solid, liquid, or 
aeriform. The heat is largely reduced by the evaporation of perspi- 
ration, insensible or sensible ; by warming the cool air taken into the 
lungs at each inspiration, and by evaporation of fluid from the pul- 
monary surface. Something is lost by the warming of cool ingesta, 
which take the place of warm excreted materials ; and possibly loss 
may occur by electrical action, and also through the influence of the 
recently recognized “radiant matter,” or, indeed, by other means of 
which we as yet have no conception. It is estimated that eighty per 
cent, of the heat of the body is lost by the skin, and twenty per cent, 
by the lungs. Of this loss by the lungs twenty-six per cent, is by 
warming the air taken into them, and seventy-four per cent, in evap- 
orating the water which passes off from them.# 
In health the production and the loss of heat so nearly balance 
each other that the proper mean temperature is preserved. 
In fever the production is greater than the loss; and when the 
loss is greater than the production, an opposite condition follows. If 
the loss is so much greater than the production that the tempera- 
ture of the blood falls as low as 95° to 93°, there is great danger; 
and when coming below 92°, except in rare cases of poisoning by 
alcohol, where recovery has taken place after the temperature had 
reached 90°, death occurs. 
Fever may result from increased heat-production, or from dimin- 
ished heat-loss; and so an injurious or fatal reduction of temperature 
may be caused by a failure of the heat-producing function, or by 
the loss of heat from exposure to cold. 
The increase of temperature in fever may vary from the slightest 
amount above the normal to 110° or 112° Fahr.; and cases have been 
reported where, under peculiar conditions of the nervous system, it 
has gone much higher even, without fatal effects. If the temperature 
does not exceed 101°, it would be said the fever was slight; from 101° 
to 103° it would be regarded as moderate ; from 103° to 105°, decided 
or high ; if above 105°, especially if reaching 106° and over, the 
term hyperpyrexia is now applied to the condition, and it is justly 
regarded as dangerous, and demanding decided interference; and if 
it exceeds 107° or 108°, and so remains for any considerable time, 
death, as a rule, results. 
Febrile, like normal heat, usually undergoes diurnal changes. In 114 
FEVER—PYREXIA—THE FEBRILE STATE. 
some continued fevers, as typhoid, the fever line will be almost par- 
allel with the line of health for the twenty-four hours, but from 
three to five degrees higher. In other cases the temperature fluctu- 
ates greatly, and often irregularly, depending on the increase or dimi- 
nution of local morbid conditions; and in other cases still, very 
decided and more or less regular variations occur, as in remitting 
and intermitting fevers. 
Although elevation of temperature, more or less constant, is a 
necessary condition of fever, and is sometimes regarded as the only 
essential one, yet in “ a fever,” considered as a process or distinct 
disease, the heat is only one of several conditions, and is not the first, 
nor perhaps the last one present. 
In such fever there is an onset, an accession or increase, a period 
of continuance, and a declension and disappearance; and each stage 
has its peculiar features. 
At the onset, usually, after a feeling of general indisposition, 
there is a rigor or shivering, a subjective feeling of coldness, and 
generally some real reduction of temperature of the surface of the 
extremities, while there is already elevation of the temperature of the 
blood, as shown by the thermometer in the cavities, or even applied 
to the trunk ; and not unfrequently sensations of chilling are felt 
while the temperature even of the extremities is increased. At the 
time of the chill there is usually paleness or blueness of the extremi- 
ties and the face, and a shrunken condition, showing that there is 
but little circulation in the extreme vessels of these parts. As the 
quantity of blood in the system is not materially changed, more must 
be in the larger vessels or in the interior organs; and less blood com- 
ing to the surface, and the surface being colder, there is less loss of 
heat by radiation and conduction from the extreme heat-losing plane ; 
the secretion of the skin is diminished by the smaller blood-flow to 
it, and evaporation is less from the lowered temperature; the heat 
loss is also less from perspiration and evaporation. 
The respiration is usually hurried in frequency during this stage 
of rigor, but from the comparative congestion of the lungs it is often 
superficial, and as it is not likely that the blood passes as freely 
through the lungs, from the probably contracted or spasmodic state of 
the capillaries, not as much moisture is evaporated from the pul- 
monary surface ; so that if these suppositions are correct, not as much 
heat is lost in this stage by the lungs. But however this may be, 
the loss is certainly less from the cutaneous surface than when the 
hot stage is fully developed ; and as the production of heat in the 
internal parts of the body goes on, doubtless with increased rapidity, 
the accumulation of heat is rapid and soon manifests itself over the FEVER—PYREXIA—THE FEBRILE STATE. 
115 
entire surface. In the intermediate stage between the cold and the 
hot, there are often alternating sensations of heat and cold. 
The hot stage now becomes fully developed; the sensations of 
chilliness are replaced entirely by those of heat; the pulse, which 
before, though rapid, was contracted and smaller, now becomes full 
and strong, as well as fast; the vessels of the surface are distended 
with blood, the face is flushed, and the full condition of the febrile 
state is manifested. This state of increased temperature continues, 
with more or less diurnal and other fluctuations, for various periods, 
in different forms of fever, until the stage of decline. This may be 
sudden, by crisis, or more gradual, by lysis, and this decline is often 
accompanied by freer discharges from the skin, the kidneys, and the 
bowels. The stage of recuperation and repair follows, and the normal 
condition is restored. 
During this occurrence of deranged and increased temperature, 
other phenomena have occurred, quite as important as those men- 
tioned. Even before any noticeable change of temperature, general 
morbid sensations have probably been experienced ; j>ains may have 
occurred in the head and other parts of the body, and there has been 
more or less change in different functions ; a proper examination 
would detect an increase in the urea and uric acid secreted. Whether 
these conditions precede the increased temperature or not, they 
accompany it, and a general derangement of the whole organism 
exists. There is pain in the head, often accompanied or supplanted 
by delirium, a coated tongue, increase and change of its epithelium, 
thirst, loss of appetite, often restlessness, and always muscular weak- 
ness. Sometimes convulsions and coma occur, with profound de- 
rangements of different functions, and not unfrequently death. In 
short, in the process of a fever, changes take place in the calorifica- 
tion, in nervous action, in the blood, in the circulation, in respira- 
tion, digestion, secretion, and in general nutrition. 
The repair which follows in favorable cases is not a part of the 
fever process, and may be omitted in a discussion of the pathology of 
the diseased condition. 
Dr. Senator, of Berlin, found by experiments upon dogs, that 
injection of pus in their blood was sure to induce the phenomena of 
fever ; but, as the first effect, before the rise of temperature, an 
increase of urea took place. As urea, when but little or no food is 
taken, as was the case with these animals, is derived from destruction 
of nitrogenous tissues, the inference, from its early increase, is that 
the destructive metamorphosis of these tissues is the primary morbid 
condition in fever. During this initial stage the quantity of carbonic 116 
FEVER—PYREXIA—THE FEBRILE STATE. 
acid and aqueous vapor produced was not increased, but often dimin- 
ished. In the later stages, when the heat appeared, the excreted car- 
bonic acid and water were much increased—this “insensible loss,” 
together with the increased loss by urea, continuing during the whole 
course of the disease. From the very first impression of the morbid 
cause, the quantity of urine passed was augmented. 
Although this was the general fact, there were great fluctuations 
in the rapidity of these losses, and also in the functions of different 
organs. Indeed, according to these observations, the carbonic acid 
emitted was not always and necessarily in excess during the elevated 
temperature. 
These increased chemical actions, indicated by the increased pro- 
duction of their results, must necessarily cause an increase of heat; 
and the increased heat causes more rapid disintegrating changes. 
Heat increases destructive action, and destructive action increases 
heat. In proof of the increased destructive metamorphosis by increase 
of heat, it was found that the amount of carbonic acid was increased 
by the communication of heat from without. While the kidneys 
remained in a comparatively healthy condition, as was the case with 
these dogs, the quantity of urine Avas increased, doubtless produced 
by the diuretic action of the urea, which was in increased quantity in 
the blood. The rapidity of the circulation might tend to the same 
result. 
During the rigor, less "water passed off from the skin ; but during 
the hot stage, and particularly to Avar d its close, more Avater was lost 
by insensible perspiration, the more rapid evaporation from the higher 
temperature of the skin preventing the secretion from the SAveat 
glands from becoming sensible. As the heat declined, and sometimes 
before such declension, “all the Avater channels Avere Avide open.” 
Increased temperature caused both increased evaporation and increased 
discharge of carbonic acid, as already stated ; but in the case of the 
dogs there was said to be no proofs that these increased discharges 
were produced by the cause of the fever. When the fever was inter- 
mitting, the loss of the system Avas more than twice as much on the 
fever days as on the well ones, food being taken on neither. The 
greater loss of weight on the fe\rer days Avas said to be due chiefly to 
the greater loss of water on those days. 
In careful observations made on human fever patients, similar 
results Avere found to occur. The loss of weight of the fever patient 
was from one half to three times that of a Avell man placed in the 
same circumstances in bed, and taking the same amount, or rather 
restricted to the same amount, of food and drink. The condition of 
nutrition antecedent to the attack of fever varied the amount of loss. FEVER—PYREXIA—THE FEBRILE STATE. 
117 
If well fed and well nourished before, the loss was greater. The loss 
of nitrogen by the kidneys can be measured in the urine ; hut the loss 
of this material from the bowels, the skin, and by means of exudates, 
cannot be ascertained. 
In these observations different forms of disease were under investi- 
gation, having nothing in common but the febrile state. 
The conclusions of Prof. Burdon-Sanderson (from whose report to 
the Privy Council of England, published in The Practitioner of 1876, 
these observations by Prof. Senator have been gleaned) are that in the 
early stage of fever the patient secretes three times as much urea as 
the same man on the same diet would do in health ; but that later in 
the fever there is not so much difference. 
A healthy man’s urea is mostly from his food ; in fever it is from 
the tissues. This loss of tissues, as indicated in the increase of urea, 
Dr. Sanderson regards as the most essential condition in fever. It 
commences earlier and continues later than the heat, its maximum 
being after the fall of temperature. Ho concludes, therefore, that it 
is not the increase of temperature, not the pyrexia, which causes the 
increase of urea. With regard to the greater increase of the discharge 
of urea after the fall of the temperature, he seems not to have taken 
into the account the important fact that the urea accumulates in the 
system during the fever, and may be eliminated by the kidneys after 
its abatement and the revival of their function, though urea may have 
ceased to be produced in any extra quantities from the tissues. Tak- 
ing this into consideration, his last conclusion, if based upon the con- 
tinuance of the free discharge of urea after the fever heat abates, 
seems not to be sustained. 
Inquiring into the particular sources of the nitrogenous loss in 
fever, it is to be noticed that the nitrogen elements exist in the sys- 
tem, First, In what is called store albumen in the fluid or plasma of 
the blood and lymph, and in the juices of the tissues; and, Second, 
In the substance of the tissues, in their protoplasm, including the 
protoplasm of the blood corpuscles. 
In health there are more soda salts than potash salts in the urine 
—fifty-nine of the former to forty-one of the latter. In the fever 
state this is reversed. There is a positive increase and a very large 
relative increase of the potash salts, with a positive and relative dimi- 
nution of the soda salts. The increase of the potash is three or four 
times above the normal, while, at the time of convalescence, the soda 
increases and the potash greatly diminishes. The urea thus is evi- 
dently produced from substances containing potash. The store albu- 
men, that is, the liquor sanguinis, abounds in soda, but the blood cor- 
puscles and muscles contain potash. The inference is that urea is 118 
FEVER—PYREXIA—THE FEBRILE STATE. 
derived chiefly from the tissues—largely from the muscles and the 
blood corpuscles ; and this inference is strengthened by the facts that 
the muscles rapidly waste, and the coloring matter of the blood cor- 
puscles appears freely in the urine, indicating their disintegration. 
The angemia which the fever produces confirms the conclusion. 
Common salt seems to be retained in the system during the state 
of fever, as it is freely discharged after its abatement. The destruc- 
tion of the colored corpuscles, interfering with their function as oxy- 
gen carriers, deranges the whole system. Probably that function is 
impaired in corpuscles not entirely destroyed. But this is another 
unknown quantity in the problem of fever which pathologists are 
endeavoring to solve. Prof. Leyden has more fully investigated the 
amount of carbonic acid expired in fever and in health, and comes to 
the conclusion that in the febrile state about fifty per cent, more is 
given off from the lungs than in health, where all other conditions 
are the same. 
From the report of his observations, Dr. Sanderson concludes 
that both men and animals discharge more nitrogen when laboring 
under fever than in health, with the same amount of “nitrogen 
income ; ” in man aboiit three-fourths more than normal. The 
excess of carbonic acid lost in a fevered man is not to be accounted 
for by mere excess of respiration, but the experiments do not show 
that the same excessive loss by carbonic acid occurs in the case of 
fevered dogs. 
Although a patient suffering from fever loses much by the dis- 
charge of nitrogenous, carbonaceous, and aqueous material, and there- 
fore has more heat produced from these sources than one taking the 
same amount of food who is in health, still the same individual on an 
ordinary full mixed diet discharges about the same quantity of all 
these materials; and on the supposition that heat in the body is 
entirely produced from these particular chemical sources, and that 
these excreta accurately measure the heat produced, it follows that a 
well man has as much heat generated in his system as the fever 
patient. As his temperature is not as high, it is assumed that he 
loses more heat than the patient with fever. It is true that in the 
fever patient the excreta are produced chiefly from the consumption 
of tissues, while with the well man they are chiefly produced from 
the food he takes ; but the source of the materials would have no 
influence on the amount of heat produced by their consumption. 
But experiments show, as we should infer, that the heated body of a 
fever patient radiates more heat, his lungs warm more air and exhale 
more vapor, and therefore part with more heat in doing so ; and the 
skin, though apparently dry, really in most cases evaporates more FEVER—PYREXIA—THE FEBRILE STATE. 
119 
water from its surface, and therefore the body loses more heat from this 
source. It is contrary to all analogy and all reason that the same 
body five or six degrees higher in temperature in its external plane, 
will pass from its surface less heat, will communicate less warmth to 
surrounding objects, than when its temperature is lower. It would be 
quite absurd to suppose that a radiating steam-pipe heated to 212° 
would throw off less heat, or lose less from evaporating a given amount 
of water, than one at a temperature of 207°. Indeed, Dr. Leyden 
concludes, as the result of his long continued and carefully conducted 
experiments, that “ the discharge of heat is increased in fever, whether 
the temperature is constant or whether it falls or rises, consequently 
it is certain the product of heat is increased.” The only exception to 
the fact of the loss being greater, is during the cold stage, when 
the temperature of the surface is low. If the fever patient does not 
lose less heat, but more, it is certain, as Leyden says, that he pro- 
duces more to keep up the fever temperature ; and if no more com- 
bustion occurs in his system than in that of a well man, a portion of 
the heat must be produced in some.other way than byvthis chemical 
combustion. 
This establishes the fact that heat is produced in other ways than 
by the mere combustion of carbon, nitrogen, and hydrogen ; and that 
the quantity of excreta from these substances—the amount of urea 
and carbonic acid discharged—is not the exact measure of the heat 
produced in the system. 
All theories based on the assumption that this particular form of 
chemical action is the only source of animal heat, normal or morbid, 
must be worse than useless, leading to absurdity or false conclusions. 
Says Hermann, Physiology, 2d ed., p. 246, “We cannot forget that 
oxidation is not the only process associated with the liberation of 
energy, but that it is only one of the processes, though by far the 
most frequent, which prove the general law, that in every chemical 
process, in which stronger affinities are saturated than were saturated 
before its occurrence, potential energy becomes kinetic.” It is well 
known that other forms of energy are transformed into heat by proc- 
esses other than chemical, and that other kinds of chemical action 
than oxidation, as stated, transform latent energy into apparent. 
The transforming of latent into sensible heat is the most common of 
all these transformations. As an example, the conversion of sugar 
into alcohol in the process of fermentation is not an oxidizing proc- 
ess, but yet heat is developed. The conversion of motion into heat 
by friction, already referred to, is familiar. Hermann further says, 
that in the body in a state of rest all forms of energy are converted 
into heat; and instances particularly the loss in motion of the blood 120 
FEVER—PYREXIA—THE FEBRILE STATE. 
by friction against the walls of the blood-vessels, and especially the 
capillaries, as an evidence of such conversion. He also says the elec- 
tricity developed in the nervous and muscular systems appears in part 
to be converted into heat, and almost every change in the body is 
accompanied with change of temperature. In view of such facts, it 
seems very strange that so many of both systematic and speculative 
writers speak of body heat as alone the product of the combustion of 
certain elements. 
Dr. Lionel Beale, in treating of inflammatory fever, expresses the 
opinion, in the article already referred to, that the fever heat does 
not depend upon increased oxidation at all; but he does not indicate 
upon what it does depend. On this point he simply says, “ Fever is 
caused partly by diminished heat loss, and partly by increased heat 
production.” He lays great stress upon changes of the blood as the 
starting-point of fever and the cause of its continuance ; he makes 
much of its containing “extractive matter soluble in boiling water,” 
in free and abnormal quantities, and says it is produced “ probably 
from deficient oxidation,” stating that various substances remain in 
the system unoxidized, and pass out slowly and but partially oxidized. 
This morbid matter while in the blood, he says, penetrates the 
tissues too freely, and there is an increased growth of germinal matter, 
which is readily appropriated by the morbid tissues. He does not 
state particularly whether, or how, this produces heat ; though he 
might have plausibly suggested that it was by its condensation or its 
chemical union with other materials of the body. He does not 
account for the excess of urea and uric acid in the urine. Dr. San- 
derson does not allude to there being any excess of uric acid, and Dr. 
Beale leaves other important matters unexplained. 
It seems at least possible that the destructive metamorphosis and 
oxidation, complete or partial, of the tissues, prevents oxidation and 
removal of the other albuminous and carbonaceous matters which 
should have speedy exit from the system. It may be true, if it is not 
demonstrable, that in fever the protoplasm of the tissues, modified by 
the presence of zymotic matters, or from other causes, has an increased 
affinity for oxygen and readily undergoes destructive oxidation, while 
the “extractive” and other matters fail to be properly oxidized and 
eliminated ; the oxidation of the tissues contributing, with other 
causes, to the production of the abnormal heat. 
But, as very justly said by Dr. Sanderson, a full and satisfactory 
explanation of fever is not yet possible ; we are not vet possessed of 
sufficient physiological data. Many speculative opinions have been 
presented, and some of them may prove useful in aiding investigation. 
One view is that fever originates in disorder of the nervous centres— FEVER-PYREXIA—THE FEBRILE STATE. 
121 
that, by means of the influence of the nervous system on the sys- 
temic functions, the liberation of heat at the surface of the body is 
restrained, so that by retention the temperature rises; and finally, that 
the increased temperature so produced acts on the living substance of 
the body so as to disorder its nutrition. We have seen that though, 
during the chill, which frequently but by no means always ushers in 
an attack of fever, the escape of heat may be temporarily diminished, 
yet that retention cannot be permanent, and in all probability, in 
many cases, never occurs at all. It is, at all events, totally incapable 
of affording an explanation of the phenomena. 
Another view is that fever originates in the living tissues—that it 
is, from first to last, a disorder of the vital protoplasm, and that all 
systemic disorders are secondary. 
In most theories it is now assumed that a fever-producing material 
is in some way introduced or developed in the blood, the lymph, or 
tissue juice ; its disturbing influence, whether upon brain and nerves, 
or upon the elements of the tissues, being anterior to all. 
That such is the fact in many fevers, probably in all that are of a 
specific character, can scarcely be doubted. Feverish excitement, 
however, is often produced by the most strictly local impressions 
where there is no probability, and scarcely a possibility, of there being 
anything primarily wrong Avith the blood. Even mental impressions 
may excite a febrile movement, and here the primary morbid impres- 
sion must be on the nervous system. 
Virchow, whose opinions will have weight with many, says: “ Fever 
consists essentially of elevation of temperature, which must arise from 
an increased consumption of tissue, and appears to have its immediate 
cause in alterations of the nervous system.” 
That all the heat of fever is produced by the consumption of tissues, 
we ha\Te seen reasons for denying; but that the nervous system has 
much to do in originating and controlling the processes Avhich result 
in feverish heat, seems certain. 
This brings us to consider the causes of fe\rer, or those impres- 
sions, conditions, or materials capable of so affecting the nerves, the 
blood, or the protoplasm of the tissues as to result in the complex 
phenomena of this process. 
Physiological researches have established the fact that there exists 
in the nerve-centres, cerebral and ganglionic, groups of cells which 
are exciting or accelerating, and others which are inhibitory or re- 
straining, Avhose office it is, in part, to govern those forces in the 
heart and vessels which circulate the blood. These exciting and 
inhibitory cells are widely distributed. They are found in the brain, 122 
FEVER—PYREXIA—THE FEBRILE STATE. 
in the heart itself, and in ganglia along the course of the vessels. 
This control, originating, as all nervous power does, in the cells, is 
exerted through nerves which go to the heart and accompany the 
vessels to their minutest ramifications. Some of these excite the 
heart and vessels to contraction, some restrain their movements, and 
there are those which by their action have the effect to cause dilata- 
tion of the vessels. (Hermann.) 
The nerves accompanying the vessels and exciting them to contrac- 
tion are called vaso-motor, or vaso-constrictor nerves—those opposed to 
them in action are called vaso-dilator nerves. The vaso-motor seem 
always in action, keeping up the tone of the active vessels, while the 
vaso-dilators are thought to be only occasionally active, and to pro- 
duce their effect, when excited, by preventing the activity originating 
in the vaso-constrictors. 
In particular regions local nerve-centres are connected with cer- 
tain vascular areas—the whole mechanism, however, being under a 
general controlling influence of the centre cells, chiefly located in the 
medulla oblongata. There are also secretory nerves, terminating in 
glands and uniting with the vaso-motor nerves in influencing their 
functions; and, more to the present purpose, there are trophic nerve- 
fibres which terminate in particular areas of the molecules, cells, and 
tissues of the body, parenchymatous and connective, regulating the 
more intimate actions—the chemical and physical changes resulting 
in the various processes of nutrition. 
That in the nerve-centres and nerves there is an influence or 
“energy,” controlling, probably in part directly, and in part through 
cardiac and vascular activity—undoubtedly to some extent through 
trophic changes—the production and the loss of heat, and conse- 
quently regulating the temperature, there can be no question ; and if 
the regulation of the temperature, so remarkable, and so curiously 
adjusted in health, depends upon the nervous system, the inference 
is a fair one that in a similar degree its derangements will depend 
upon faulty conditions of this system, and morbid impressions upon it. 
We find from observation, which is bett:r than theoretical inferences, 
that the shock even of a physical impression, or of almost any injury, 
whether inflicted upon tissues by mechanical or chemical means; that 
almost any morbid material in the blood or lymph, or changed condi- 
tions of these fluids, make impressions, some of which could only be 
upon sensitive nerve elements, and could only be communicated 
through the wide-spread influence of the nervous system, so as to 
excite feverish changes. Some of these causes seem to act more 
directly in inducing the fever ; others, more indirectly, through other 
tissues, or by derangements of particular functions. Thus we find FEVER POISONS. 
123 
surgical injuries or operations—sometimes so slight an operation as 
the introduction of a catheter; the presence upon wounded surfaces 
of irritating substances ; the suppression of secretions from the skin, 
liver, or other glands; the retention of effete matters in the blood; 
the presence of irritating matters in the alimentary canal, or the irri- 
tation of a coming tooth, will produce the pyrexial state. Every form 
and degree of inflammation, sometimes even the mental shock of a 
great calamity, and particularly the absorption of morbid material 
from inflamed parts, will induce this condition. 
As already intimated, the specific fevers, which comprise a large 
and vastly the most important and formidable part of fevers with 
which the physician has to deal, depend upon specific poisons. These 
are probably protoplasmic, living substances, capable of multiplica- 
tion, introduced from without or developed in the body, which effect 
chemical and vital changes in the fluids and solids, impressing, either 
directly or by these changes, the nervous system, and deranging its 
actions; these impressions are followed by the febrile phenom- 
ena already sketched, and by a variety of modifications to bo de- 
scribed in the special kinds of fever which will require our careful 
attention. 
It may be too much to affirm that this infectious or zymotic origin 
of all the specific fevers is demonstrated, especially that their depend- 
ence on living organisms has been fully proven; but the facts that 
have been established respecting the existence of microscopic germs, 
their wide diffusion, their persistent vitality, their eagerness for 
elements and their ready appropriation of them, their ability to dis- 
turb the chemical relations and composition of organic bodies; their 
influence, so unquestionably shown, in producing fermentation, putre- 
faction, and other changes in various forms of matter ; their evident 
capability of exciting inflammatory, suppurative, and septic processes 
in wounded animals and men ; the success that has followed the 
greater care as to cleanliness and the use of various antiseptic meas- 
ures ; the certainties with which all are familiar respecting the propa- 
gation of small-pox and the vaccine disease ; in short, the vast accu- 
mulation of evidence pointing in the same direction, has brought the 
great mass of the most enlightened members of the profession to an 
unreserved belief in the theory of the zymotic, if not the baeterian 
causation of all the specific fevers. 
The present knowledge on this overwhelmingly important subject 
is by no means so complete as to preclude the hope of future discov- 
eries even more important than those that have yet been made. In 
this direction lies the greatest hope of the future of medical science 
and art. When Science has discovered the origin, the full character, 124 
INFECTIOUS POISONS. 
and the mode of action of these agencies, and the materials and influ- 
ences which Avill destroy or counteract them without injury to the 
organism, and when Art has devised effectual means of applying 
these, then will medical science and art have met together in a har- 
mony of equality, and have accomplished for humanity its greatest 
achievement. 
Considering the very large and increasing number of diseases 
believed, with so much reason, to be produced by morbid poisons, 
and the great influence the nervous system has upon the phenom- 
ena resulting, in the advanced state of knowledge hoped for, anti- 
dotes and neurotics—the one radically curative, and the other 
modifying and relieving—will become the great medicines of the 
future. 
In view of the present state and drift of science, the phenomenal 
character of diseases, the existence of specific causes, and the present 
and hoped-for discoveries of antidotal remedies, how absurd and 
ridiculous become the dreams of exclusive systems, particularly of 
the pretended universal therapeutical principle of similia similibus 
curantur. Such unfounded speculations, originating in the darkness 
of the past, and kept up by visionary or unscrupulous men of the 
present, unknown to science, must recede more and more into the 
obscurity of past follies as science advances. 
On the Theory of Infectious Diseases, in a paper read at the meeting 
of the International Congress of Medical Science for 1879, held in 
Amsterdam, and.which seemed to reflect the views of those present, 
comprising many cf the most prominent men in the profession in the 
different countries of Europe, it seemed to be assumed by the author, 
as well as by the president of the congress in the opening address, 
that the infectious diseases generally are produced by microzymes or 
living parasitic organisms; and the following conclusions were ar- 
rived at, which may be regarded as one of the most authoritative 
expressions of the present enlightened professional sentiment on the 
subject : 
1. It may be regarded as certain that the action of the mi- 
crococcus of fermentation, which plays such a prominent part in 
the production of certain infective diseases, of which charbon 
may be taken as a type, is the same in all the diseases of the same 
order. 
2. AVe are, therefore, justified in looking iipon infective diseases 
as being closely allied to the parasitic diseases. 
3. The parasitic micrococci, which cause infectious diseases, be- 
have in the organism like ferments. They cause much disturbance, INFECTIOUS POISONS. 
125 
both by the formation of new bodies that poison the organism,, and 
by robbing the latter of necessary materials. 
4. To every specific infectious disease, there corresponds necessa- 
rily a specific cause. 
5. There is reason to believe that all the microcosms of infection 
belong to one and the same family, viz., to septic ferments. Surgi- 
cal septicaemia, different varieties of typhoidal fevers, etc., are septic 
or septicoid affections. 
6. As the micrococci of infection are septic ferments, they are 
capable of living and multiplying when out of the human body. 
7. In certain infectious diseases, e. g. malaria, the infected in- 
dividual invariably receives the germs of infection from his sur- 
roundings, never from other individuals who have already been 
infected. 
8. In other infectious diseases, e. g. enteric fever, the patients are 
themselves foci of germs which, after having been transmitted to the 
outer world, infect the food (ingesta), the infected individuals becom- 
ing thus, indirectly, foci of contagion. 
9. Other infectious diseases, e. g. exanthematic typhus fever, 
where the germs not only infect the ingesta but the surroundings—■ 
the air—the infected persons thus becoming active foci of direct con- 
tagion. 
10. In diseases such as the vaccine disease, the virus is attached 
to solid matter; but we do not know whether these particles are 
micrococci, similar to the organisms of the other diseases, or not. It 
has not been-possible, as yet, to breed this virus outside of the living 
organism ; nor does the effect which certain poisons have upon them, 
at all correspond to the qualities attributed to living beings. Per- 
haps further experiments and observations will tend to prove that all 
contagious diseases are of the same nature, in which case they would 
all become parasitic diseases. In the International Medical Congress 
of 1881, held in London, similar general views were quite as posi- 
tively expressed, and the recent experiments of Pasteur in regard to 
the disease of the domestic fowls called the “ Chicken Cholera,” and 
in regard to charbon or splenic fever in cattle and sheep, have still 
further confirmed the views expressed two years before at Amsterdam. 
That these particular diseases are produced by parasitic germs the 
experiments of this distinguished discoverer and experimenter seem 
to have placed beyond doubt. 
These are not quoted as the exact truth, but as opinions of one 
who has given much attention to the subject, and as representing 126 
INFECTIO US POISONS—OTHER IMPRESSIONS. 
prevalent views. In the case of the vaccine disease there must be 
living germinal matter; but there is no evidence that there are dis- 
tinct organisms or parasites; and it may turn out that some of the 
other poisons, supposed to be parasitic, are, like the vaccine virus, 
germinal matter, but not distinct beings—not micrococci. As to par- 
ticulars on this whole subject, much is still conjectural; and as 
to antidotes, but little is yet known. Quinine and various other 
substances seem to act as antidotes to malaria; but whether they 
destroy the germs, or only prevent the system from responding to 
their poisonous effects, in the phenomena of fever, is not positively 
known. 
But in what way do germs, or any other poisons, or morbid 
impressions, act in producing the phenomena of fever ? 
However desirable an answer to this broad question may be, it 
cannot at present be fully given. 
Some have supposed tliat the microzymes consumed by their 
growth and multiplication sufficient quantities of the tissues, or the 
materials destined for their nutrition, to cause the heat, thirst, etc., 
and that the pains, the delirium, and other perversions of function, 
are produced by deficient nutrition, the result of the consumption of 
nutrient materials by these organisms. Others, as already stated, sup- 
pose the mischief results both from loss of needed ingredients, and the 
production of poisonous substances, which irritate tissues and nerves, 
these poisonous substances being the result of zymotic actions, of chem- 
ical and physical changes, induced by the infectious agents. It is pos- 
sible these organisms are capable, of themselves, by their presence 
in connection with nerves and tissues, of producing irritation and 
these various results. 
As to other morbid impressions, we know they are followed by 
feverish excitement and derangements, as we know other ultimate facts. 
It has been suggested that the shock of an injurious impression pro- 
duces an effort on the part of the system to resist the intruding 
injury, and a feverish excitement is the result. That there is a law in 
the system which leads to the resistance of injuries and to efforts at 
repair, we have frequent proofs. How much this law is concerned in 
the production of fever, it is difficult to say. Response to irritations— 
reaction to shock—is a fundamental law, and is the best explanation 
we can give for the various phenomena observed. But whatever may 
be the object or tendency of a fever as to the removal of an injurious 
cause, the effort itself may be of a character to produce danger, and to 
require interference and control. We cannot say why sugar gives the LAW OF TEMPERATURE. 
127 
sensation of sweetness, or quinine of bitterness. We cannot explain 
the ultimate causes of the normal regulation of temperature, and hence 
we ought not to be expected to say how a particular agent or impres- 
sion deranges that temperature, and we must be content with know- 
ing that certain agents do produce fever, and that certain other means 
will prevent or mitigate the process. In the absence of a satisfactory 
knowledge of the latter means, we must have the courage of patience 
and the energy of carefulness in the empirical use of such measures as 
science has suggested and experience has proved to do good. 
In health the body is able to preserve its temperature nearly the 
same, however rapidly the cold bath or an exposure may abstract heat, 
or however quickly a high external temperature may add to it. In 
fever, however, this is not the case, at least to the same extent. 
In typhoid and other fevers the temperature can be brought down and 
kept down nearly to the normal by the systematic use of the cold bath 
or cold affusion ; and various antipyretic medicines, notably quinine 
and salicylic acid, are capable of reducing feverish heat, though they 
may have little or no effect in reducing temperature in the normal 
state. In fever the law of sustained temperature is not abolished, but 
only weakened, as there is a tendency, and in some cases a very strong 
one, to maintain the high grade belonging to the disease. In health 
there may be, as suggested by Dr. Sanderson, a tendency to excess of 
heat, which is restrained by that protecting influence called “the law 
of temperature.” So in fever the influence may still exist and need 
to be strengthened, as it is by the administration of large doses of 
quinine, or the extraction of heat from the surface by the cold 
bath. 
But this is a speculative suggestion, not having the weight of an 
induction; and in view of the notion that the increased heat is the 
result of an effort to resist and remove an injury, the utility or pro- 
priety of thus abating the heat is a question to be determined by expe- 
rience, and will be considered when we come to the treatment of par- 
ticular forms of fever. The special causation and phenomena of the 
different forms of fever, and various other questions, will then be more 
particularly discussed. 
The general subject of fever which has occupied our attention, 
the statements of conditions belonging in common to all varieties, 
will both save time in the descriptions and give us a better under- 
standing of the different forms of the disease we have to study. 
The febrile state appears under a variety of particular forms, pro- 
duced by different causes, and presenting different aggregates of 
phenomena, that admit of classification and naming. 128 
PATHOLOGY AND PRACTICE OF MEDICINE. 
The following table gives a classified view of the different fevers 
we have to deal with : 
CLASSIFICATION OF FEVERS. 
r Simple, 
•! Accidental, 
[ Febricula. 
-Non-Specific. 
Intermit- 
tent. 
t Quotidian. 
; 'Tertian. 
( Quartan. 
Gastric. 
Intestical. 
Bilious. 
Periodical orj 
Malarial. 
Remittent.\ 
Perni- 
cious. 
Congestive. 
Collapsing. 
Typhoid, Typhus, 
Relapsing, Yellow, 
Whooping-Cough, 
Mumps, 
Cholera, Plague, 
Dysentery, Diphtheria, 
Influenza, 
Dengue, Cerebro-Spinal. 
.Miliary Fever. 
(Irri tative. 
Inflammatory. 
I Hectic. 
{ Pyaemic, 
| and 
I Septicsemic. 
[.Catarrhal. 
1. SYMPTO- 
MATIC. 
2. IDIO- 
PATHIC. 
—Specific. 
Continued. 
Small Pox, Cow Pox, 
Chicken Pox, 
Measles, 
German Measles, 
Scarlatina, 
Epidemic Roseola. 
Eruptive. 
All fevers, as we have seen, appear to depend proximately upon, 
some changed state or action of the protoplasmic tissues, under the 
influence of a changed condition of particular nerve-centres and 
nerves ; and these conditions may be produced by many causes, physi- 
cal, chemical, toxic, or mental—the more severe and regular, or, as 
they are called in the classifications, specific fevers, being caused by 
changes in the blood and tissues, for the most part, at least, induced 
by zymotic poisons—by germinal protoplasmic matter, in most in- 
stances probably in the form of distinct parasitic organisms or micro- 
zymes. Each fever has its own peculiarities in causes, phenomena, 
and course ; but the previous states of the system have an influence 
upon the severity and type of all the forms. CLASSIFICATION OF FEVERS. 
129 
They are more severe in the depressed, the exhausted, the obese, 
and plethoric, and especially in the alcoholic intemperate. There are 
also special prevailing types in particular seasons and places, materi- 
ally modifying the prognosis and treatment ; and the changing of 
types, the mingling of forms, and their conversion or substitution 
may occur. 
A fever commencing in a mild form may, as it progresses, take on 
one more severe, thus suffering a change of type. Two fever causes, 
each with more or less of their peculiar phenomena, may be operat- 
ing upon the system at the same time, thus producing a mingling of 
forms, as in typho-malarial fever; and an attack commencing in one 
form may lose its character and another take its place, a conversion or 
substitution of kinds thus being produced. 
The. terms used in the classification explain their applications, but 
a more explicit statement of the technical signification of some of them 
may lead to a more precise comprehension of the distinctions. 
By a symptomatic fever is meant one which is a symptom or a 
result of some other distinguishable pathological condition. Thus the 
fever which follows and is dependent upon an inflammation, is sympn 
tomatic of that pathological state. 
An idiopathic fever, on the other hand, is one which is itself the 
disease, depending of course upon a cause, but a cause that produces 
only or chiefly the phenomena which are considered as belonging to 
the fever. 
A specific fever is one produced by a peculiar poison, or an exclu- 
sive or specific cause, and the fever runs, or strongly tends to run, a 
definite course. 
A non-specific fever is one which does not depend upon a specific 
poison, and has not the same tendency to run a particular course. 
Such a fever is caused by more common disturbing influences, such as 
exposure to cold, checking secretions, dietetic excesses, various physi- 
cal and dynamical impressions not of a specific character, and not 
necessarily producing other special effects than the phenomena of 
fever. The signification of other terms will be given as we come to 
describe the diseases they indicate. 
There are various Minor Diseases, most of which are accompanied 
with feverishness, which may be considered here before entering upon 
the description of more definite diseases, having a place in nosology,, 
having distinct, well-marked characters, and to which are applied, 
more specific names. 130 
MINOR DISEASES, OR SLIGHT AILMENTS. 
MINOR DISEASES, OR SLIGHT AILMENTS. 
There are various slight deviations from the normal standard of 
health but little treated of in works on the practice of medicine, but 
which, from their great frequency, from their being often neglected, 
and from their liability to terminate in more serious diseases, require 
some separate consideration. 
There are very few persons in our communities -who do not suffer 
at times from slight derangement of the actions of the system, pro- 
ducing more or less uncomfortable sensations, inefficiency, or more 
positive suffering and incapacity ; and yet they have no well-defined 
diseases, no perceptible changes in the tissues of organs, or conditions 
likely to directly result in such changes. In many such instances 
the derangement probably depends upon the rate at which normal 
functions are performed, or upon a want of that balance of activities 
which constitutes the most perfect health. 
These semi-morbid conditions are sometimes produced by a wrong 
state of the blood and lymph, by some moderate excess of the effete 
materials which are so constantly passing through the fluids on their 
way to elimination bv the excreting glands, or by some improper 
matter introduced into it in the ingesta, or produced in the system by 
imperfect digestion and elaboration, or by imperfect secretions. In 
other instances the solids are at fault—some changes of innervation 
from fatigue and exhaustion, or from deficient or improperly propor- 
tioned activity, or from impressions from without; and even mental 
states may derange the various physical activities. 
Through modified innervation the blood may flow too slowly or 
too quickly through the vessels ; the capillaries may be too much 
distended or too empty in particular parts, disturbing the action 
of the adjacent nerve-fibres, and thus causing uncomfortable sensa- 
tions. 
Errors in food or drink, as to quality, quantity, and time of taking ; 
an atmosphere too cold or too hot, too moist or too dry ; a want of 
sleep, and a great variety of other imperfect hygienic conditions may 
be causes of derangement of action, which the system in time will 
overcome, but which, meanwhile, produce the phenomena of slight 
ailments. Many persons pay little heed to these derangements, as 
they are found to be temporary in their continuance ; but others have 
not the same recuperative powers ; their sufferings are more pro- 
tracted and severe from these slight causes, and they seek the aid of 
the physician, who should be prepared to advise them both as to pre- 
vention and cure. MINOR DISEASES, OR SLIGHT AILMENTS. 
131 
The student who has received his practical knowledge of disease 
entirely from observations in large hospitals, and in the dead-houses 
so liberally supplied from them, where he has studied structural 
changes produced by severe disease, will often, when coming into 
practice, be at a loss to know what to say or do when he is consulted 
by a patient who presents no evidence of any structural change, who 
has no train of symptoms characteristic of any of the diseases arranged 
in the classified nosologies, and who complains of morbid sensations 
and functions, the causes of which the stethoscope, and even the 
microscope and chemical reagents fail to detect. Possessed with the 
anatomical and chemical ideas of pathology, lie may conclude that 
nothing is the matter where he can see nothing, and may destroy the 
confidence of patients by expressing hasty opinions of the absence of 
disease where it nevertheless exists. A patient with a slight ailment 
that will of itself soon pass away, when he calls upon a physician is 
entitled to all the aid his art can afford ; and though active medica- 
tion may not be required, careful attention to the case is demanded, 
and advice may be of great service in relieving apprehension and mit- 
igating suffering. There are very few cases where benefit to some 
extent cannot be derived from treatment. In the management of 
such cases tact is required, but it should not be allowed to degenerate 
into disingenuousness. 
Great principles of pathology and therapeutics may be learned 
from slight as well as from severe diseases. As in zoology, studying 
the simplest forms is the surest method of obtaining a knowledge of 
the most complex ; so studying the slightest deviations from the 
healthy processes will lead to a knowledge of the more grave changes ; 
and we may often best learn from the effects of remedies on slighter 
ailments their tendencies in the graver diseases. 
The means that will shorten a slight fever, congestion, or inflam- 
mation, will tend to relieve one of a severer character; and the 
remedy that will arrest a slight fever or inflammation, when pushed 
with more vigor, will often do the same thing with a much severer 
attack, especially if applied in its earlier stages. 
Many of the slight ailments to which patients are subject are not 
definable. They are spoken of as “indispositions.” The patient is 
said to be “out of sorts,” to be affected with “ biliousness,” or to 
have “ derangement of the stomach,” “headaches,” “feverishness,” 
“pains in the bones,” “rheumatics,” “neuralgia,” “colds,” etc. 
Most common among the symptoms are loss of appetite, feelings of 
dullness, general or Avandering pains, dizziness, unpleasant taste in 
the mouth, furred tongue, foul breath, headache, debility, etc. These 
symptoms will be recognized as belonging to much more grave affec- 132 
THE TONGUE IN HEALTH AND DISEASE. 
tions—to more definite diseases ; but they exist where the more defi- 
nite diseases are absent. 
While some of these cases are of short duration, others are more 
protracted; and some people seldom feel well, though it would be 
difficult to say they had any definite form of disease. 
Many milder affections are properly attributed to functional dis- 
eases of the stomach, the bowels, or the liver ; some to disease of the 
kidneys; and, with females, many to derangements of the pelvic 
organs. Those general derangements, traceable to any one of these 
sources, are treated of in other connections. Indeed, most of the 
cases of slight ailments are better discussed in connection with the 
diseases of particular organs in which their phenomena are most 
exhibited. The main object in giving them a separate discussion is 
to call more particular attention to them, and to afford an opportu- 
nity for offering some general suggestions, which otherwise might not 
find a convenient place. 
THE TONGUE II* HEALTH At*D It* SLIGHT AILMEttTS. 
The tongue, in severe disease, is always examined, and its appear- 
ance and indications are described in connection with particular affec- 
tions. Its appearance in health and in slight ailments is of interest. 
This appearance differs in different persons in health, and in the 
same conditions of disease. Generally the epithelium, on the dorsum 
of the tongue, forms a layer of considerable thickness, covering the 
minute vessels so that the red color of the blood is not seen as 
distinctly as on most other mucous membranes. In most cases in 
health the color of the dorsum is a pale red ; but in some diseases, 
it is nearly denuded of its elongated epithelium, its capillaries are dis- 
tended, and it is a bright red. The red color of the blood shines 
through the smooth, flattened epithelium, giving it a raw, “beefy ” 
appearance, often with a distinctly glistening surface. An increased 
redness above the ordinary normal occurs in some conditions of slight 
derangement; but an increase in the epithelial covering, and a con- 
sequent obscuring of the red color, is more frequent. 
In health there are to be seen, at different points over the dorsal 
surface, little bright red elevations. These are small papillae, with 
a constricted neck, enlarged at the extremity like a mushroom ; and 
they are, therefore, called the fungiform papillae. The epithelium 
covering these papillae is very thin, and the blood shows through from 
the plexus of vessels in these projections. A net-work of terminal 
nerves, mostly those of the special sense of taste, is found at these 
points. CONDITIONS OF TONGUE. 
133 
More numerous, and spread more evenly over the tongue, are the 
Filiform Papillce. These are covered by thick epithelium, and do 
not present the red appearance ; and as sapid substances would not as 
readily penetrate this covering, the sense of taste in the tongue is sup- 
posed to be chiefly situated in the fungiform, and not in the filiform 
papillae. The soft red mucous membrane at the sides and back of the 
tongue, and on the palate and fauces, is also a seat of this sense. 
When the epithelial layer over the tongue is thin, it will be more 
red, though this depends upon the quantity of blood in the capillaries ; 
but when it is thick, a white or brownish appearance is presented. If 
there is a large accumulation of epithelium, soft and moist, upon its 
surface, an opaque dirty-white appearance is presented. 
In the central part of the dorsum the epithelium covering the 
numerous filiform papillae like sheaths is very long, resembling hairs 
in structure. Among these hair-like projections are often lodged par- 
ticles of food, starch, and oil globules, etc. These epithelial filaments 
are composed of cells, new ones being formed at the surface of the 
filiform papillae, while the older ones are at the extremity of the fila- 
ments. When these cells are rapidly produced and are firm and adhe- 
rent, they constitute the basis of the “fur,” or coat of the tongue. 
Sometimes they are piled up in large quantities and the coating is very 
thick. On microscopical examination immense numbers of spherical 
and oval particles are found among these cells, which are growing 
germs of organisms of different species, presenting different characters 
as they become developed. Some are fungi adherent to the cells, 
others are elongated, and evolve bacteria of various forms. These 
germ particles are probably produced by parents of different species, 
and from their rapid production and immense numbers they some- 
times constitute a considerable portion of the coat. Not only among 
the cells, but upon the surface of the filaments, they are detached in 
groups, from time to time, and are swallowed in large numbers. The 
longer the fur remains upon the tongue, the older the cells, the more 
of these organisms appear. In many cases whole forests of these fungi 
appear covering the dorsum, and are more abundant in some mor- 
bid conditions than others. They are present, more or less, even on 
healthy tongues both of men and animals ; but are much more numer- 
ous when the coat is more abundant. Germs of fungi are almost 
universally distributed, and when any matter is about to decay it is 
attacked by them ; but their influence in producing the decay is not 
always accurately determined. Some of them, probably, have but 
little effect, while various facts show that others produce very decided 
effects, exciting and hastening the process of decay. Myriads are 
often swallowed without apparent injury; but under other circum- 134 
STATE OF TONGUE. 
stances, or from different kinds of germs and developed bacteria pass- 
ing into the blood and tissues, specific diseases and great mischief 
may be induced. 
Particular appearances of the tongue, from the earliest records 
of medicine, have been considered as indicating the conditions of 
other parts of the system, particularly other parts of the digestive 
apparatus. There is doubtless a special sympathy between all parts 
of the alimentary canal. They have a somewhat similar structure, 
are supplied with similar nerves, and those nerves are connected 
together and harmonized by intercommunicating cords. A morbid 
state of one part of the canal, however limited, affects more or less 
the other parts, however distant. Impressions from slight changes of 
food or drinks, from exposure of the surface of the body to cold and 
dampness, wetting of the feet, or even mental emotions, change the 
secretion of the stomach, very often causing, in a marked degree, its 
diminution, and at the same time changing also the action of other 
parts of the mucous surface, and of the glands—salivary, hepatic, 
and pancreatic—which pour their secretions into the digestive tract. 
The mouth is apt to become dry from these impressions, and the 
production of the epithelium on the tongue is increased, or at any 
rate it is not thrown off as fast as produced, and accumulates. The 
tongue thus becomes coated, and with many persons quite heavily, 
from slight derangements. In all fevers, even in slight feverishness, 
the tongue is more or less coated, but more in some persons than in 
others from a similar cause, so that although a coated tongue indi- 
cates derangement, the amount of coating is not always an accurate 
measure of the extent or severity of the derangement. Still, much 
can be judged from the state of the tongue, but it must be taken in 
connection with other symptoms. 
When, from the imperfect action of any secreting surfaces or 
glands, secretions are diminished, matters are retained in the blood 
that should be eliminated, and the whole system is deranged from the 
wrong states of that all-pervading and all-essential fluid. 
Disturbances of this kind are exceedingly common. W hen the 
first morbid impression is but temporary, the secreting glands, after 
a comparative rest, resume their action, and, stimulated by the 
increased quantity of material brought to them by the blood to be 
eliminated, their action for a time is often increased beyond the 
normal, but with the effect of restoring the blood and the tissues to 
the state of their ordinary purity, when all abnormal actions subside 
and health is restored. 
In some cases nature is competent to do all that is required in a 
speedy and successful manner. She sometimes, however, fails in her CONDITIONS OF TONGUE. 
135 
efforts, and in most cases of this kind can be beneficially aided by art. 
In these conditions of feverishness with diminished secretions, with a 
dry mouth, throat, and skin, with diminished gastric secretion, and 
consequent loss of appetite, with constipated bowels, and perhaps 
diminished urine, the indications for treatment seem very obvious. 
The first is, to remove the primary irritating cause, if still present 
and in action—for example, to remove irritating matters from the 
alimentary canal, when such are still there ; and the next is, to excite 
the secretions ivhich have been diminished or suppressed. 
An emetic or a cathartic may answer a double purpose—removing 
irritating matters from the stomach or bowels, and exciting, in a 
decided manner, important secretions. A warm water, or hot air, or 
steam bath, by exciting perspiration, will often procure much relief. 
A few doses of chlorate, or nitrate, or bicarbonate of potash, or the 
liquor acetate of ammonia, by acting on the skin and kidneys, will also 
be useful. These means, or others of a similar character, one or more, 
according to the particular indications, can scarcely fail to procure 
relief and hasten restoration to the natural state. The influence of 
limited local irritations of the mucous membrane of the alimentary 
canal, communicated by sympathy, affecting secretions, corrupting 
the blood, and thus deranging the whole system, is frequently observed 
by the physician, and the young practitioner should bear this in mind 
and observe the tongue as a means of detecting these conditions. Not 
only its coated condition, by changes in the production of the epi- 
thelium and the accumulation of fungi, but its dryness or moisture, 
should be a subject of observation. Undue dryness is one of the most 
frequent changes of the tongue. Indeed, in the physiological con- 
dition, the amount of moisture of the mouth varies in different per- 
sons, and in the same person, at different times of day and night. 
Secretion of fluid takes place from the mucous surface as well as from 
the salivary glands, contributing to the moisture ; and the secretions 
generally, excepting that of the skin, are less in the night and during 
sleep than in the daytime and during waking hours. Sleeping with 
the mouth open, thus increasing evaporation when there is the least 
secretion, often causes unpleasant dryness of the tongue when no other 
cause exists. If other causes combine, the dryness may be very great. 
The moisture or dryness of the air breathed has an influence; but, 
independent of these conditions, the secretion from its surface and 
from the salivary glands is diminished, and the tongue often loses its 
normal moisture. Among the causes producing this dryness are those 
already mentioned as affecting the secretions. 
For palliating the dryness, water is taken, but its effect will be very 
temporary unless the secretion of moisture is restored. Glycerine 136 
STATE OF TONGUE. 
added to the water, in the proportion of one part to five or six, will be 
less temporary in its action in relieving the dryness; but the main 
object in treatment should be to restore the secretion. 
For this purpose removing the cause of the disturbance is most 
important; but some special means may be used to increase the buc- 
cal, lingual, and salivary secretions. The presence of any mechanical 
irritant in the mouth, as a pebble, or chewing a twig, a piece of lemon 
or orange peel, etc., will increase the salivary secretion by reflex 
action. 
There are various sialogogues, such as horse-radish, mezereum, 
ginger, sweet flag, etc., which taken into the mouth more actively 
promote the secretion of saliva. Some salts, as the chlorate of potash, 
nitrate of potash, bicarbonate of potash or soda, the latter especially, 
compressed into lozenges or pellets, and allowed to dissolve slowly in 
the mouth, increase the flow of the moisture. Linseed tea, flavored 
with lemon-juice and sweetened with glycerine, sipped occasionally, 
will relieve the dryness. 
Very small doses of mercury will act more permanently in increas- 
ing this and many other secretions, besides tending by their eliminative 
action to remove other pathological conditions likely to be present ; 
and in cases of any considerable continuance it should be prescribed. 
Judiciously used it is innocent, and in many cases of slight as well 
as of more severe disease it is the most efficient of remedies. A grain 
or less of calomel, or one, two, three, or more grains of blue pill or 
hydrarg. cum creta, repeated a few times at intervals of one, two, or 
three days, generally followed by a laxative, will give remarkably 
satisfactory results. The iodide of potassium in small and repeated 
doses will also quite certainly induce this secretion. It is in some 
cases preferable to any of the other articles. 
The tongue in some rather mild ailments has a white, moist, thick 
fur upon it, consisting of proliferated epithelium, mucus, bacteria, 
fund, and the debris of food. In rheumatic fever this condition is 
common ; but here it will require only the treatment adapted to this 
disease. A mild mercurial and saline cathartic may, however, well 
precede the more specific treatment for the rheumatism. 
In ancemic states the tongue is usually flabby and pale, and retains 
the impression of the teeth. Where, however, the gastric membrane 
is inflamed in this anaemic condition, the tongue will be more dry, 
and sometimes red. 
In slight chronic rheumatism, and in some temporary derange- 
ments of the stomach, the tongue has a thick, moist, extended, and 
what has been termed a blankety fur. 
The tongue of inveterate smokers is always dirty (Dr. Beale); and CONDITIONS OF TONGUE. 
137 
some persons in tolerable health always have a foul tongue. In 
smokers it is usually accompanied with a horribly offensive breath ; 
and wherever it is coated the breath is apt to be bad. 
Some persons, whatever their ailments, never have a coated 
tongue. In these it is naturally somewhat fissured, and often pre- 
sents a red appearance. 
In contrast with the blankety tongue is a bright red tongue, seen 
in some fevers, especially in scarlatina. In acute gastritis the edges 
of the tongue are almost always red, though the centre may be cov- 
ered with a fur. The redness, however, often spreads over the Avhole 
surface. This appearance seldom occurs in slight ailments. In 
cases of chronic gastritis, the tongue is often patchy or mapped in 
appearance, some spots clean and smoother, and others furred. This 
appearance is indicative of disease of considerable standing and of 
some severity, though the patient may be on his feet. 
A raw, beefy appearance of the tongue is often observed toward the 
close of exhausting diseases, sometimes with irregular patches of fur 
or aphthous spots upon it, and, in some cases of pyaemia, the tongue 
is red, or dark, dry, contracted, and hard. 
The dry brown tongue is often observed in low typhus and 
typhoidal fevers; but for a fuller description of its appearance, and 
for the sordes gathering on the teeth, reference is made to the articles 
on those diseases. 
Chronic cracks and fissures of the tongue, sometimes path ologically 
occur in persons of weak digestion and with morbid conditions of the 
stomach. It is often rather pale, though sometimes redder ; is quite 
moist, and at times becomes covered with a white fur, which may be 
distributed in patches. The cracks are more or less deep, the islands 
of different sizes and shapes, and the fissures, sometimes extending 
through the mucous coat, may bleed and become very sensitive and 
painful. A milder form of this same condition is not very uncom- 
mon. The stomach is sensitive, and can bear only bland food and 
medicines; the bowels often sluggish, with other evidences of dys- 
peptic symptoms. The general treatment is the same as that for 
dyspepsia (see article on that subject), and, locally, a lotion of car- 
bolic acid (one part to one hundred of water) with other astringent, 
antiseptic, or soothing applications, according to the particular con- 
ditions, may be required. 
In some more chronic and obstinate cases less dependent upon 
disease of the stomach, where there are cracks and fissures, but with 
some portion of the surface too smooth and shiny, free from any pro- 
jecting epithelium, the principal remedy, according to Dr. Lionel 
Beale, is iodide of potassium. By this remedy, he asserts, it is usually 138 
TASTES IN MOUTH. 
relieved, and, in not a few cases, cured. The remedy he directs must 
be taken in doses of two grains, two or three times a day, gradually 
increased to five or six grains, dissolved in as much as half a pint 
of water, continued for two, three, or more weeks ; then suspended 
for a short time, and resumed again. Some cases, the same author 
says, improve more rapidly on iodide of mercury, or from the thirty- 
second to the sixteenth of a grain of perchloride of mercury, with 
five grains of iodide of potassium and a little syrup of ginger, and 
perhaps with twenty minims of Battley’s liquor cinchonae in four 
ounces of water, twice or thrice a day for two or three weeks at 
a time. Some of these cases may be syphilitic in their origin, when 
these medicines will be particularly indicated ; but Dr. Beale contends 
that they are efficient in cases where syphilis has no share in their 
production. 
Somewhat similar fissured and chronically changed conditions 
may extend to the throat, and even to the larynx and trachea, or to 
the posterior nares, affecting the voice and respiration. The mucous 
membrane is glazed, red, and dry, and has lost that peculiar sensitive- 
ness which, in the natural condition, causes a reflex attempt at swal- 
lowing whenever the part is touched. This benumbed sensibility 
lasts only while the disease of the surface continues, and when the 
morbid condition just beneath the epithelium is removed, the nerve 
fibrils distributed there in great numbers resume their normal activity. 
The general treatment of these conditions is to be conducted on the 
same principles as where the tongue alone is the seat of the disease ; 
and besides, various local remedies are to be used, such as the appli- 
cation of glycerine and tannin, solutions of nitrate of silver, of chlo- 
rate of potash, of alum, etc., by a soft sponge, a cameFs-hair brush, 
or in the deeper parts by spray. In using the spray the solution 
should be filtered to prevent clogging up the tube of the spray pro- 
ducer ; or, what will answer the same purpose, the tube which dips 
into the solution may have tied over its end a piece of close-textured 
muslin. But the diseases of the mouth and throat are more particu- 
larly considered elsewhere. 
Metallic and other tastes in the mouth are expressions of general 
rather than of local derangement, and require a mention among the 
slighter ailments. Very peculiar tastes, in the absence of any sapid 
substances, are sometimes complained of and described as metallic, 
salt, acid, sweet, bitter, and sometimes as fecal. These are some- 
times clearly dependent on derangements of the stomach, and may 
have the character of rancid butter, butyric acid, valerian, etc. By 
correcting the conditions of the stomach and bowels, and by exciting 
the secreting organs, these unpleasant conditions may generally be PEliVERTED TASTES—LOSS OF APPETITE. 
139 
relieved. Small doses of mercurials with laxatives, alternated with 
diuretics and diaphoretics, aided by exercise and the warm bath, are 
indicated. 
Offensive Breath, when not dependent on decaying teeth or ulcer- 
ative or gangrenous conditions, is for the most part produced by sim- 
ilar causes, and requires similar treatment. 
Removing constipation, improving digestion and nutrition, will 
require attention, and various eliminatives—cholagogues, cathartics, 
diuretics, and diaphoretics—are called for. 
Mercury, says Dr. Beale, is of the greatest service if used with 
judgment and due care. It acts especially on the liver, and also causes 
increased action of all the glands connected with the alimentary, and 
probably the absorbent system. He adds : “I think our fathers gave 
it too frequently, and in unnecessarily large doses, but now I think 
we err in an opposite direction.” 
But various other eliminative medicines will be found useful, and 
some local remedies will palliate the symptoms. Charcoal powder, 
mixtures of camphor, weak solutions of carbolic acid, Condy’s fluid, 
tincture of myrrh, etc., are among these agents. 
The exceedingly foul breath, so often produced by free smoking, 
admits of only one remedy—abandonment of the pernicious habit. 
Other odors may, if strong enough, partially cover it, but it arises 
from destruction and putrefaction of organic matter, mostly of the 
blood, mingled with the odors of the tobacco, and they pass off, not so 
much from the mouth as from the lungs, and it can scarcely be 
reached and palliated by any remedies. The inveterate smoker must 
submit to be a nuisance to those around him, if not to himself, as one 
of the penalties of his indulgence. The same may be said of the 
drunkard’s breath when it gets beyond the alcoholic into the putre- 
factive smell. But these can scarcely be classed among the slight 
ailments. 
Impairment and Loss of Appetite are symptoms of various diseases 
of greater or less severity, but sometimes they occur as the chief and 
almost only recognized morbid condition. W hen diminution of appe- 
tite occurs as a symptom of various diseases, it is usually an evidence 
of diminished digestive power, and is often conservative and useful in 
its results. When it depends on inflammation or a congestive state of 
the stomach, it is better that food, except in very small quantities, for 
a time at least, be abstained from. When the result of a surfeit, the 
fasting it induces allowrs the stomach a rest which it much needs, and 
is likely to result in recuperation. Some who boast of an unfailing 
appetite would be the better for its occasional loss. 
In many cases, then, the attention of the physician should be 140 
MO It BID APPETITE. 
directed, not so much to the loss of appetite as to the morbid condi- 
tion inducing it. This, to some extent, should be the case always; 
but sometimes direct means to increase the desire for food should be 
used. 
In cases when the stomach is fairly healthy, but when, from weak- 
ness, great fatigue, too much brain work, anxiety, fear, joy, or other 
strong mental emotions, the appetite is lost and food is neglected, the 
weakness is increased by abstinence, and the appetite may often, with 
propriety, be stimulated. The articles most used for exciting an 
appetite are the vegetable bitters and aromatics, infusions or tinctures 
of Colombo, cascarilla, gentian, orange peel, quassia, ginger, etc. 
Small doses of quinine, strychnia, or salicine, the mineral acids, the 
use of spices, capsicum, mustard, pepper, allspice, and the like, are 
useful. In some cases a complete change of diet, and even of scenes 
and associations, will be required. 
Beer and wine in small quantity, especially in those accustomed to 
their use, are said to increase often the desire for food. Alcoholics 
may occasionally have that effect with others. 
The principal thing, however, is to search for and remove the 
cause, whatever that may be. 
The loss of appetite depending upon more established dyspeptic 
conditions and upon hysterical states, is considered in other places. 
An Excessive or Voracious Appetite is sometimes met w.ith. The 
person eats enormously, but is never satisfied. As stated in another 
connection, this is sometimes the result of bad management of chil- 
dren, or of gluttonous indulgence in adults. 
This Bulimia, as it is called, may be produced by morbid irritation 
of the stomach, and not unfrequently by the presence of worms. A 
craving appetite is sometimes felt when there is some obstruction to 
the absorption and appropriation of food, or when the food is trans- 
formed into unnatural products and carried out of the system without 
affording the proper nourishment. It is then an expression of inani- 
tion, or a want of food in the blood and tissues. Thus, in obstruc- 
tion of the lacteals or thoracic duct, and in diabetes, hunger is felt 
which can with difficulty be appeased, as the food is not satisfactorily 
appropriated. It is the food properly digested, absorbed, and appro- 
priated, and not always the amount taken into the stomach, that 
appeases hunger. 
In these cases the remedies should be directed to the causes when 
they are remediable. 
Over-indulgence of the appetite, even when the food is digested 
and appropriated, is far from increasing force. Some who take a too 
exclusively physical and chemical view of the animal system, regard EXCESSIVE APPETITE. 
141 
it as they do a steam-engine—where the more fuel is consumed and 
applied the more force is evolved. “This,” says Dr. Beale, “is a 
principle which, if correct as regards machinery, is certainly untrue 
when applied to living organisms, and devoid of all foundation as 
regards man.” In accordance with this purely mechanical philosophy 
—which I can but agree with Dr. Beale in believing erroneous—every 
transformation of material in the body produces an equivalent amount 
of force, and, if not heat, it must produce some other force, muscular, 
mental, etc. If this were true, a man could do work in proportion to 
the food he digests, and the amount of alcohol or other materials that 
may disappear and be transformed in his system. This, by observation 
and experience, is found not to be the case. Alcohol, though it dis- 
appears to a limited extent in the system, certainly does not increase 
heat, and unless indirectly, by relieving shock, it does not seem to 
increase force; and in cases where it appears to increase activities, a 
quarter of a grain of morphine or a couple of grains of quinine, which 
certainly cannot act mechanically or chemically from transformation, 
is quite as likely to do the same thing. In fact, when more food is 
taken than the system needs, however perfectly it may be oxidized and 
transformed, oppression and weakness, rather than increased strength, 
is the result. The excreting organs have a severer task and an 
increase of labor to perform to get rid of the superfluous material, but 
all other activities are diminished. The animal body is not a mere 
mechanical machine subject to gross chemical and physical laws 
alone, but it is a living organism with capabilities of responding to 
impressions and of exerting force without a necessary corresponding 
amount of combustion or transformation of either food or tissue. 
There is a physical basis of life, there are physical and chemical 
elements and principles present and in operation, and a physical 
structure which must be kept in repair, but there is a life element, 
which if not essentially different in its nature, is yet so peculiar in 
its action as not to be in all respects subordinated to, and in details 
dependent upon, physical and chemical conditions. In none of our 
present crude theories respecting living beings can the distinctive 
character of the life susceptibilities and life actions be ignored. The 
recent experiments of Dr. Brown-Sequard and others, as well as im- 
memorial observation, tend to disprove the more mechanical and 
chemical theories of life. 
According to observations among the English “ Railway Navi- 
gators, ” as they are called, selected from the strongest and most vig- 
orous men, whose high wages enable them to pamper and indulge 
their appetites, and who often consume enormous quantities of 
animal food, they, as a rule, become damaged and broken down be- 142 
NA U8SA. 
fore the age of forty, indeed, are seldom seen as old as that, often 
passing into states of disease which destroy life early. “ Like the 
popular philosopher, he adopts the absurd theory that the more he 
cats the more work will he be able to do, and unfortunately acts 
upon it, squandering his money in beef and beer that strain his 
organs of digestion, assimilation, and secretion, and ruin his health.” 
(Beale.) 
On the other hand, men of the working classes, who live moder- 
ately, are often very strong and vigorous, and able to do good wTork 
at the age of sixty-five or seventy, and even later; men who, like 
Shakespeare’s Old Adam, had led active but virtuous and temperate 
lives, and with him could say, 
“ For in my youth I never did apply 
Hot and rebellious liquors in my blood, 
Therefore my age is as a lusty winter, 
Frosty, but kindly.” 
In the treatment of cases of inordinate appetite from irritation of 
the stomach, as from worms, etc., the cause must be removed, and 
soothing measures applied. Small doses of hydrocyanic acid, fifteen 
or twenty grain doses of carbonate of soda in solution half an hour 
before meals ; or the liquor potassse, or bismuth, or henbane, or opium 
in small, cautious doses, etc., will allay irritability of the gastric 
nerves. In cases of habitual excess of appetite and eating, the diet 
must be regulated by rules, and the appetite will in time accommodate 
itself to what is best. 
Nausea is a condition usually preceding and accompanying 
vomiting, and is allied to anorexia. There is, however, a distinction 
between nausea and vomiting, and between nausea and simple loss of 
appetite. The causes of nausea are various. Besides those which 
acting in greater force produce vomiting, there are those which some- 
times keep up a protracted sense of nausea without emesis ever 
occurring. Some persons in high altitudes, as in visiting the moun- 
tainous regions of Switzerland, have an almost continued sense of 
nausea, which may bo relieved for short periods by the taking of 
food. In these cases it appears to be produced by the diminution of 
the accustomed atmospheric pressure. 
Various medicinal substances, the* motion at sea, or with some 
the motion in a carriage or railway car, or riding backward, or cer- 
tain articles of food, or disgusting substances or even disgusting 
thoughts, etc., are well known causes of this sensation. Some can- 
not endure the smell of tobacco smoke without that feeling. But NA USE A—TUI11ST. 
143 
nausea may be produced by irritation of the mucous membrane of the 
stomach from disease there ; or by morbid conditions elsewhere affect- 
ing the stomach by sympathy or reflex action. Congestion of the 
portal circulation, regurgitation of bile into the stomach, various 
slight morbid states as well as more grave diseases, may cause this 
sensation. 
The Treatment cannot be specific and empirical in this, any more 
than with other morbid symptoms depending upon a variety of causes 
and occurring in various conditions. The causative indication must 
be fulfilled wherever it can be discovered and reached. This may 
require a variety of measures. The regulation of the secretions, the 
administration of a cathartic, sometimes even the operation of an 
emetic, will be useful. A blue pill, followed by a laxative, will often, 
as in many other similar derangements, be most satisfactory in its 
effects. 
In some cases spices, spirits of ammonia, or effervescing mixtures, 
carbonic acid waters, aromatics, or bitters, will relieve the sensation. 
Counter-irritation or revulsives—a mustard plaster over the stomach, 
or a cloth wet with warm water and covered by oiled silk, a pedilu- 
vium, or a general warm bath, will often do good. Abstaining from 
food for a meal or two, or changing the diet entirely, may succeed. 
The administration of small doses of ipecacuanha will sometimes 
relieve promptly the sense of nausea. The homoeopathists claim this 
as an illustration and proof of their alleged law of similia similibus, 
and it is suggestive of a principle of counteraction wdiich has a cer- 
tain range of applicability ; but these small doses of ipecac fail quite 
as often as they succeed in arresting nausea, and are by no means spe- 
cifics against this symptom. Opium, camphor, and other anodyne or 
narcotic substances, will often succeed when other means have failed. 
Among these, hydrocyanic acid, in careful doses, is quite conspicuous. 
Thirst, when physiological, is the natural expression of a defi- 
ciency of fluid in the system, but as a pathological symptom, it is the 
result of various morbid states. There is usually thirst in all fevers, 
and it is apt to be specially marked in inflammation of the stomach 
and throat. In profuse watery discharges, as in cholera and diabetes, 
and in free sweating, it is apt to be intense ; but it may occur as the 
most marked phenomenon of a case, and can properly be placed among 
the minor ailments. 
Some people habitually drink too much water. This is the case 
not unfrequently with children, not so much from any morbid thirst 
as from a bad habit. Some, on the other hand, drink too little, and 
are greatly benefited—their secretions increased and their systems 
washed out—by a course of free water-drinking. 144 
THIRST—DRINK. 
Thirst and indulgence in too free drinking, diluting too much 
the gastric juice and the blood, and imposing too great a task upon 
the secreting organs, sometimes results from some local irritation 
of the mouth and throat and deficient secretion of the mucous mem- 
brane. The habit of constantly ejecting the saliva arising from 
the disgusting practice of chewing tobacco, or from other causes, may 
lead to inconvenient thirst, which, however, should be gratified, in 
order to supply the loss of fluid ; and it is fortunate if it be so with 
simple water. In the management of all the cases that require for 
this symptom any treatment, the cause must be looked for and 
removed. When from local dryness of the mouth and throat, the 
secretions of the part should be increased by the means already 
pointed out. When, from active exercise in traveling or labor, there 
is an inconvenient or painful thirst, without the means at hand for 
gratifying it, or where its gratification would lead to the ingestion of 
too much fluid, the taking of a pebble into the mouth and moving it 
about, or the chewing of a bit of orange peel, or even a twig, will 
often give relief. 
For the gratification of a normal thirst, pure water is the natural 
and best article. The various additions to it, made to gratify the 
taste or for producing other effects, seldom improve its efficacy in 
allaying thirst, and generally render it less wholesome and safe. The 
practice of taking other drinks than simple water, especially thoso 
having strong sapid qualities, impairs the natural appetite, and often 
destroys the relish for pure water. This is an unfortunate event, aa 
it often leads to indulgence in drinks dangerous and destructive. 
Carbonic acid water is often resorted to for the quenching of thirst, 
but, in most cases, it is less efficient than simple water, especially if 
flavored syrups be added to the effervescing fluid. 
The temperature of the drinking water is a matter of consequence. 
With Americans it is quite the custom to take ice-water, and it is 
regarded by some as an injurious practice. It is certainly agreeable in 
the heated season, and, when indulged in with proper moderation, is 
not, as a rule, injurious. A less quantity is required to allay thirst 
than of water of a higher temperature, and its use, in moderation, is to 
be encouraged. Drinks, decidedly warm, especially in connection with 
meals, agree with some persons of weak digestion better than those of 
a low temperature. Tea, coffee, and chocolate are those commonly 
used, but all of these articles have qualities rendering them other than 
simple diluents or thirst-allaying drinks. They impress the nervous 
system unnaturally, and often injuriously. In cold weather cold 
water seems not to agree with some, and in such cases hot water 
and a little milk and sugar, or some simple vegetable infusion desti- INDIGESTIONS. 
145 
tute of anything but a little flavoring or nutritious properties, may be 
taken with advantage. 
One confining himself exclusively to simple water as a drink, not 
however excluding milk as both food and drink, will relish water 
much more than those who even occasionally indulge in more sapid 
articles ; and there can be no doubt that the simple water-drinker is in 
the most natural, most physiological, and safest condition. His enjoy- 
ment of drink is not less, and his prospects of health and life are 
better. 
We have very ancient, and many will believe excellent, authority 
for saying that “ Wine is a mocker, strong drink is raging, and who- 
soever is deceived thereby is not wise.” (Solomon.) 
Many of the moderate and temporary Indigestions might be classed 
among the slight ailments, and be considered here; but the whole 
subject is treated together in another connection. 
Various headaches, too, might be classed among the slighter ail- 
ments, but may be better treated of in connection with other and 
more grave affections of the nervous system. So with the slighter 
and more transient neuralgic and rheumatic difficulties. They may 
better be treated of with the graver cases of the same disease. 
There are very great differences in different persons as to the 
amount of nervous impressibility, and the suffering from that cause, 
independent of actual disease. Painful susceptibility to slight mor- 
bid impressions, though entailing much discomfort, and even decided 
suffering, may be more favorable to the health and longevity of 
the individual than that insusceptibility and sluggishness of nerve 
action which will allow morbid processes to go on unrecognized by 
the sensibilities, until real structural changes have taken place and 
serious diseases are established. In the one case of highly active nerve 
organs, illness is prevented or is self-cured before it progresses to 
serious results. In the other, a morbid process may be unperceived, 
and consequently neglected, until remedies are ineffectual. The 
importance of attending to diseases of almost every kind in their 
early stages cannot be exaggerated. Remedies, then, often need to 
be much less active and complicated, and are almost always much 
more efficient than when deferred to a later period. 
Drowsiness on the one hand, and Wakefulness and Restlessness on 
the other, are not unfrequently complained of as the principal symp- 
toms noticeable. They are sometimes apparently dependent upon 
imperfect action of the digestive organs, upon associated impurities 
of the blood, and sometimes upon primary derangement of the nerve- 
centres. Drowsiness may often be traced to over-feeding, or to the 146 
DEO W8INE88— WAKEFULNESS—NEE VO USNESS. 
use of beer and wine. When this is the case, correction of the habits 
is called for. Frequently it arises from imperfect action of the liver 
and slight jaundice. In many cases eliminatives are needed—chola- 
gogues, cathartics, and diuretics. The often-abused blue pill, followed 
by saline laxatives, the doses repeated a few times at intervals of two 
or three days, will frequently remove the difficult}'. A shower bath 
soon after rising in the morning will often arouse the patient. 
When the difficulty is at the nerve-centres, its special character 
must be inquired into and treated accordingly. It may arise either 
from congestion or anaemia of the brain. 
Wakefulness and restlessness may arise from a variety of causes. 
Not unfrequently the excitement of business or of mental labor, often 
carried to the point of fatigue and exhaustion, produces the effect. 
At other times it may be traced to the use of free quantities of tea or 
coffee. When it arises from over-excitement and mental fatigue, with- 
drawal from business for a time, rest in the country, or diversion of 
some kind will be required. Moderate but not great muscular exer- 
cise in the open air may be prescribed, and the diet properly regulated. 
The bath, of various temperatures adapted to the case, will often 
soothe and aid other means. Any organs improperly performing 
their functions should be regulated, and all injurious habits corrected. 
Narcotics or soporifics to directly induce sleep should be resorted to 
with much caution, and should generally be avoided, lest a habit of 
dependence upon them be contracted. Of these articles, opium and 
alcohol are most dangerous, and bromide of potassium and valerian 
perhaps least so. An occasional resort to some of these articles may 
be justifiable; but the long-continued use, especially of the two 
articles first named, is disastrous. 
Nervousness is a term frequently used, but often without a very 
definite signification. It, however, indicates a morbid nervous im- 
pressibility, and some degree of irregular nervous action. The par- 
ticular phenomena produced by this state are various, and so also 
are the causes of it. The mind, especially the emotions and the 
temper, is disturbed, and sometimes even the intellect suffers. Some- 
times these conditions may be traced to perversions in the functions 
of the various organs, abdominal and pelvic, but in other instances the 
phenomena appear to depend upon a highly sensitive or excitable 
state of certain parts of the central nervous system, upon a wrong 
functional action of some portions of the brain. With some, such 
conditions are constitutional and hereditary, but they are induced 
and aggravated by the excitement and influences of our civilization. 
Some cases are produced, while others lead to and are aggravated, by 
indulgence in various stimulants and narcotics. Tobacco, strong tea NER VO US NESS. 
147 
and coffee, and alcoholic beverages, though often producing tempo- 
rary relief to present symptoms, are injurious in their ultimate and 
often in their immediate effects, increasing the difficulties which they 
sometimes, though not always, temporarily abate. 
'Too much mental cultivation and excitement in certain directions, 
with too little muscular exercise and development, tend to these 
results. 
Dr. Beard, of New York, suggests that our present American 
nervousness is due to the abandonment of the use of pork ! But the 
cause must be sought in something more profound, more radical, 
and more rational than this. 
Overwork of the brain is doubtless injurious, as is every excess; 
but other persons than brain-wrorkers are sometimes exceedingly nerv- 
ous, and too little mental exertion is as likely to be followed by nerv- 
ousness as too much. Dr. Beale, of London, expresses the opinion 
that, as a fact within his observation, more disease is produced by too 
little brain-work than by too much. 
This nervousness often occurs in connection with functional, and 
sometimes with organic, diseases of the heart. Not unfrequently 
examination will show oxalate of lime in the urine, or evidence of 
other derangement of the system. In other cases no other derange- 
ments than the nervousness can be discovered. 
It is difficult to say how such nervousness should be treated. 
Those cases connected with other morbid conditions and produced by 
them, must, of course, be treated for those conditions. 
The constitutional and idiopathic cases scarcely admit of medi- 
cation. Proper hygienic and moral management may diminish the 
manifestations of the phenomena; but most will depend upon the 
self-control of the patients themselves. Yielding to impressions and 
following wayward impulses, or noticing and dwelling upon peculiar 
sensations, will increase them, and they should, as far as possible, be 
ignored and resisted. The petting and indulgence of young persons 
often cultivates this nervousness. Travel, change of climate and 
scenery, the breaking up of old associations and the forming of new 
ones, and especially returning to more simple and less artificial modes 
of living, getting as near as possible to nature, and, while having 
motives and occupation, avoiding too much excitement and worry, 
will do Avhat can be done for overcoming these constitutional nervous 
states. When recognized morbid conditions of the nerve-centres are 
present, treatment adapted to these states will be required. The bro- 
mides will often produce palliative, and sometimes more radically 
curative effects. Various nerve tonics, such as nux vomica, oxide of 
zinc, quinine, arsenic, iron, etc., may, in some cases, improve the 148 
RHEUMATIC PAINS. 
general condition and be useful. Debility and anaemia tend to increase 
nervousness, and, when present, tonics are often required. 
What are called Rheumatic Pains are not unfrequently com- 
plained of by various persons. These pains affect various tissues in 
different parts of the body. They seldom cause any general feeling of 
illness, at least of a very decided character ; they are sometimes twinge- 
ing and transient, exaggerated by certain movements, but are some- 
times fixed for considerable periods in particular parts, especially 
about joints, in various fibrous and muscular structures, as in the back, 
about the neck, etc. Pains occurring sometimes in children or youths 
are called Growing Pains. In most American women they are called 
Neuralgic, but in men, especially those advanced in life, they are 
called Rheumatic. Their position in nosology is by no means well 
defined, and a knowledge of their pathology is not established. In 
different instances their pathology probably differs. A neuralgic ele- 
ment is often present, but they differ from purely neuralgic pains by 
not following the course of nerves, by being aggravated more by move- 
ment, and by being situated in fasciae, ligaments, tendons, and muscles. 
There is usually, or at least often, deficient elimination of effete mat- 
ters from the system, a deficiency of urea in the urine, while urates 
are more abundant, and not unfrequently oxalate of lime is found in 
that secretion. These rheumatic pains are exceedingly common 
among the beer-drinking people of England, the dampness of the cli- 
mate having something to do with its production, but beer also, as it 
is asserted that the sufferers who give up their beer almost invariably 
improve. 
Lumbago, a muscular or musculo-fibrous rheumatic pain and sore- 
ness in the back, is one of the worst forms of this unpleasant affection, 
sometimes confining the patient to his bed or couch for days or even 
weeks. The pain in different cases appears most severe near the inser- 
tions of muscles. The organic or non-striated muscular tissues, as well 
as the voluntary, may be the seat of these pains. The reason why the 
pain in the muscles is severest and most frequent near their insertions, 
in their tendonous parts, may perhaps be that the blood, circulating 
more slowly at those points, gives more opportunity for the passage of 
irritating matter from it to the tissues. More or less exudations 
doubtless take place, and in the firmer structures press more upon the 
ramifications of the delicate nerves everywhere distributed, thus caus- 
ing the greater pain. The long continuance of these pains in particu- 
lar parts causes thickening of the tissue from exudations or prolifera- 
tions, and parts may thus become more seriously and permanently 
impaired. In some cases joints become immovable, and the difficulty RHEUMATIC PAINS. 
149 
can be no longer included in tlie sphere of slight ailments. In the 
early stages, however, the pathological change is so slight that we are 
unable to say positively what it is. Probably, however, some irritat- 
ing material from the blood is exuded into the tissues and invades the 
sensitive nerves. The disuse of muscles which the pain and soreness 
causes sometimes results in wasting and contraction, with their attend- 
ant slight deformities. Some cases thus approach to the much more 
grave affection which has received the name of Rheumatoid Arthritis, 
and which is considered elsewdiere. 
Before commencing treatment many of these cases require careful 
investigation. The history of the case, the habits of the patient, the 
influences to which he has been subjected, and all the present con- 
ditions of the system, especially the quantity and state of the urine, 
should be ascertained. On the theory, which is most rational, that 
impurities of the blood are concerned in the production of the phe- 
nomena, eliminatives are called for ; and they are found by experi- 
ence to be most useful. The intestines and the glands pouring their 
secretions into them, the skin, the kidneys, and the lungs are the 
principal blood-purifying organs. Their eliminative functions should 
therefore be increased. A dry atmosphere favors elimination from 
the skin and the lungs, and this is well known to be favorable to 
these rheumatic patients. 
Exciting the skin to increased action by the wTarm-water bath or 
the Turkish bath, is often of great use in these cases, and should not 
be neglected as an element of the treatment. The body must be pro- 
tected from exposure and chill after their use, and flannels with 
other proper clothing are important. The bowels should be kept free, 
and in fact, should be frequently acted upon by saline eliminative laxa- 
tives or cathartics. Por this purpose we have no better article than 
the Rochelle salts. Besides its eliminative action upon the bowels 
and kidneys, its alkaline effect upon the blood is produced by the de- 
composition of its organic acid, leaving its base free in that fluid. 
Various diuretics are useful, particularly the saline and alkaline, 
though some of the vegetable may often be added with advantage. 
Alkalies, to a certain extent, are doubtless useful, but given too 
largely, or continued too long, they may injure the stomach, inter- 
fere with digestion, cause phosphates to appear in the urine, produce 
great debility, and thus do more harm than good. When prescribed 
and followed by relief, patients may go on with them for a long 
period without further advice until much mischief is done. The 
alkaline salts with organic acids are less likely to interfere with diges- 
tion, but these may be carried too far. 150 
BITES OF INSECTS. 
In many cases guaiacum may be added with much advantage to 
other treatment. It is an agreeable stimulant to the stomach, acts 
upon the skin and other excreting organs, and is supposed to have 
some specific action upon the rheumatic state. 
Salicine, salicylic acid, salicylate of soda having a very marked 
and specific effect in acute rheumatism, are worthy of a trial in these 
milder chronic forms. Quinine will sometimes be found useful, 
especially where there is a neuralgic element, and a debilitated con- 
dition. In some of these neuralgic cases the bromide of potassium 
will give relief. 
The alterative and eliminative effect of iodide of potassium in 
many of these cases is very marked and beneficial. 
In recommending it in these cases Dr. Beale remarks : “ Both the 
iodide of potassium and the bichloride of mercury (from one thirty- 
second to one-sixteenth of a grain for a dose) are extremely valuable 
remedies in very many affections, which are not in any way due to 
syphilis.” 
Occasionally free sweating at night occurs spontaneously in these 
cases, and is kept up for a considerable time, with very great relief to 
the symptoms—a method of nature’s cure. 
The diet should be nutritious, but much animal food should not 
be taken, and simple water, freely used, should constitute the princi- 
pal drink. There is now a general agreement that all alcoholics, 
especially beer and acid wines, should be scrupulously avoided. 
The subject of rheumatism is treated of elsewhere ; but these cases 
are of doubtful pathology, and are certainly quite different from gen- 
uine or acute rheumatic inflammation. Many of the cases differ from 
what is properly called muscular rheumatism, though others approach 
and are merged into that disease. The morbid material in the blood, 
in all these cases, is probably different from that of acute articular 
rheumatism. 
Bites of Insects.—The irritation and circumscribed inflam- 
mations produced by the bites of insects may properly be classed 
among the slight ailments, and are worthy of a brief notice. The 
bite or sting of the mosquito and flea are typical, and that of the flea 
particularly has been studied with care. As light is often thrown 
upon more grave and extensive diseases by a knowledge of the more 
slight and limited, a better knowledge of erysipelas and other inflam- 
mations may be obtained by a study of flea-bites. 
The introduction of the lancet of this little insect through the cuti- 
cle, and into the living matter of the true skin, wounding the formed 
matter of cells and penetrating minute vessels, and, withal, deposit- 
ing a minute quantity of acrid matter in the tissues, excites an inflam- BITES OF INSECTS. 
151 
mation somewhat specific in character, and generally abruptly lim- 
ited in extent. The question arises as to how this is effected, and 
what are the particular changes which occur in the production of the 
result ? Every cell in the living tissues has an external surface of 
formed material, or a cell-wall without, and a more highly vitalized 
bioplasm within. In the natural condition, in the nutrition of the liv- 
ing cell, the nutrient matter passes slowly through the firmer cell-wTall 
to the bioplasm, and changes are gradually produced. When a cell- 
wall is penetrated by the lancet of the flea, exposing the bioplasm of 
the cell, nutrient material is speedily taken in and appropriated, and 
a rapid but morbid cell growth takes place. These cells then become 
embryonic, undergo rapid change, and frequently become pus corpus- 
cles, many of which may thus be quickly produced. Where irri- 
tation and excitement exist, an increased quantity of pabulum is 
exuded from the blood-vessels and lymphatics, it accumulates, and 
speedy nutritive, but pathological, changes take place. The supera- 
bundant pabulum, appropriated by the bioplasm, is thus prevented 
from undergoing putrefactive changes, and inducing death of sur- 
rounding parts. 
When in an inflammatory process the vitality is too low to cause 
these growths and multiplication of cells and the production of pus, 
mortification is the result. But in all ordinary forms of inflamma- 
tion of a decided character, the bioplasm of cells increases, gives off 
diverticula, which become detached, form separate portions of living 
matter, that in turn grow and give off more processes, until from a 
few particles of irritated bioplasm, liberally supplied wfith pabulum, 
numerous embryonic cells, many becoming pus cells, result. 
Though leucocytes are exuded from vessels and present themselves 
as pus corpuscles, I can but think that, in the ordinary process of 
suppuration, the chief production of pus is from the multiplication 
and transformation of the cells of the tissues involved. In these 
small injuries effected by the flea the process is limited, and suppura- 
tion, at least to any considerable extent, is not established. But what 
really takes place here upon the surface, and subject to observation, 
is of much interest and is worthy of attention. 
The wound cf the small vessels allows a minute quantity of blood 
to pass out into the tissue, causing a deep red point, which does not 
disappear on pressure, called a petechia. Around this, however, is a 
less intensely red area, which is the result of accumulation of blood 
in distended capillaries, and w'hich does disappear on pressure. 
This red blush does not gradually shade off into the natural color of 
the surrounding skin, but terminates abruptly in a circular patch 
from one-eighth of an inch to something more in diameter. All 152 
BITES OF INSECTS. 
blood-vessels, the smallest included, are surrounded and supplied by 
minute branches of nerves, which exert an influence upon them, 
causing contraction or dilatation according to the character of the 
influence exerted ; and doubtless the dilatation of these small vessels is 
due to the action upon them of nerves which have been irritated by 
the wound inflicted by the lancet of the flea, and by the poisonous 
material introduced in the operation. Some of the small nerve-fibres 
are cut off by the proboscis, others are paralyzed by the poison, their 
influence in contracting the small vessels is diminished or destroyed 
in the limited area of the extent of these minute branches, and the 
dilatation and redness continue for some hours. Pressing the blood 
out until the part has the pale color of the surrounding skin, it 
returns again, until the morbid impression upon the nerves has 
exhausted itself, and their functions have been restored. The vessels 
then contract to their usual size, the effused blood and exudates are 
absorbed, and the healthy condition is restored. 
In severe and more extensive inflammations from more potent 
causes, other local results follow, which have already been sufficiently 
described. 
In many instances the results of the local injury are widely ex- 
tended. Even the inflammation of a flea-bite, in some conditions of 
the system, may spread, and the general organism may respond in 
morbid actions. In the severer inflammations, as in erysipelas, a 
poison often becomes introduced into the blood, so that the whole 
mass of nutrient fluid is changed, and through it every organ and 
tissue of the body may suffer. The sting of a bee or w7asp produces 
much more effect than the bite of a flea, but of a similar character, 
and other causes of inflammation, operating on a larger scale, pro- 
duce more serious results. Specific poisons, producing definite forms 
of disease, are communicated in different ways, and produce their 
peculiar effects. The flea-bite, and the little area of inflammation 
showing itself at the surface, illustrate the subject of inflammation 
occurring elsewhere, and on a larger scale. An injury is inflicted, 
the tissues and nerves are morbidly impressed, the vital activities are 
changed, and various diseased conditions result. The same injury 
will produce very different degrees of morbid action, depending upon 
the susceptibility of the system, the power of resistance, the effect of 
previous impressions, etc. 
The Treatment of the bites and stings of insects is a matter of 
some moment. As the poisons they inject are thought to be of an 
acid character, the use of alkaline applications is indicated. Solu- 
tions of ammonia are used, and often procure quite marked relief of 
the itching, the pain, and inflammation. The application of spirits HEMORRHAGE. 
153 
of camphor, or tincture of arnica, etc., is also useful. Anything 
more than this local treatment is seldom required, as the inflamma- 
tion generally soon subsides. 
Moderate Capillary Hemorrhages, particularly from the nose, not 
unfrequently occur, especially in young persons, and may be classed 
among the slighter ailments. The nasal mucous membrane is very 
delicate, and numerous capillaries and small arteries and yeins are 
near its surface. More extended transverse ruptures and longitudinal 
openings or slits in these small vessels occur, and the blood pours 
forth. This is sometimes the result of violence, sometimes of plethora 
and an active determination of blood to the part (when the hemor- 
rhage is often relieving), and sometimes it is due to a feeble and 
relaxed condition of the tissues of the vessels. 
The Treatment, when so severe as to require interference, is divided 
into that which is applicable to arrest the flow, and that given during 
the intervals, to prevent its recurrence. The most speedy and gener- 
ally effective method of arresting the flow is to seize the nose between 
the thumb and finger, embracing the extent of the cartilage and as 
near the nasal bones as possible, and press sufficiently to bring the 
internal surfaces together throughout the whole cartilaginous portion 
of the nostrils, and firmly and constantly hold them thus for a few 
minutes, or longer, as may be required. This very seldom indeed fails 
to arrest the bleeding. Should it continue, the blood passing out at 
the posterior nares, other means may be resorted to. The patient 
should maintain an erect position, sitting or standing, cold water, 
solutions of alum, or other astringents, may be snuffed up or thrown 
into the nostrils, cold water may be suddenly applied to different parts 
of the body to cause shock, the expedient of holding the hands above 
the head may be tried, and, as a last resort, the nostrils may be 
plugged anteriorly, and, if this is not effectual, posteriorly also, by 
proper surgical means. 
To prevent the recurrence of the hemorrhage the general condition 
of the system must be considered. If it depends upon plethora, con- 
stipation, determination of blood to the head, or local disease of the 
Schneiderian surface, these conditions must be remedied. If it depends 
upon a feeble and relaxed condition of the tissues and a thin state of 
the blood, tonics, preparations of iron, etc., will be required. The 
habit—if a habit of bleeding occurs—should be broken up as soon as 
possible by not allowing the flow to continue when the bleeding takes 
place ; and the consequences of the loss of blood must be remedied by 
iron and a good diet. 
There are various forms of limited and transient inflammations 154 
TAKING COLD. 
which might be treated of among the slight ailments, but many of 
them are surgical, and all are to be managed in accordance with the 
principles which have already been pointed out. 
The only remaining condition to which attention will be called 
under this general head is that of “Taking Cold ” and Coryza. An 
ordinary cold is the most common and best known of all slight ail- 
ments. Moderate irritation and congestion, often slight inflamma- 
tory and mild feverish conditions are present, and the phenomena, 
though less in degree, are similar to those of the severer inflammations 
and fevers. These phenomena are too familiar to require minute 
description. After some exposure to cold and damp, or the sudden 
checking of perspiration (though sometimes without any appreciable 
cause of the kind), some chilliness is often felt, with a sense of heavi- 
ness, and frequently some general pains ; but in other cases the first 
that is observed is an irritation of the Schneiderian membrane, inducing 
sneezing; or the throat is irritated and a cough is induced. The tem- 
perature increases one or two degrees, the pulse is moderately excited, 
the conjunctivae are injected, and a general sense of indisposition is 
felt. The Schneiderian and other portions of the mucous membrane, 
at first dry but injected, secrete in some hours, more or less, a thin 
watery fluid, often irritating in its properties, causing redness of the 
skin of the nostrils and upper lip. This thin serous secretion is soon 
replaced by a more thick or mucous material, and later still, depend- 
ing upon the severity and character of the inflammation which in the 
severer cases is now established, the case becomes acute catarrh, and 
various fibrinous, corpuscular, or purulent matters are poured forth 
from the nostrils and other air-passages in greater or less abundance. 
The feverishness commonly abates as the secretion is established, the 
temperature is scarcely above the normal, and the skin, which at first 
was perhaps dry, becomes moist, and sometimes there is a free sweat; 
the urine which earlier may have been scanty, becomes more free and 
deposits a sediment; the local irritation of the mucous surfaces sub- 
sides, the symptoms all abate, and the usual state of health is restored. 
An ordinary cold continues from a few days to a week, or to two or 
even three weeks, and the symptoms will vary according to the part 
of the mucous membrane most affected. If mostly in the nose and 
frontal sinuses, “the cold is in the head;” there will probably be 
headache, irritation of the eyes, discharge from the nostrils, etc. 
If more in the throat, fauces, larynx, and trachea, there will be more 
cough, hoarseness, expectoration, etc. When extending to the bron- 
chial tubes, the case becomes one of bronchitis, and is more properly 
described elsewhere. 
Although a cold usually terminates favorably in a short time, this TAKING COLD. 
155 
is by no means always the case. It may result in a chronic catarrhal 
condition, or, extending to the bronchi and lung tissue, the most serious 
consequences may follow. 
Not only does a “cold” resemble other inflammations and fevers 
of more severe forms, but the latter are often produced by the same 
causes as the former, and, in many instances, time will be required to 
determine whether one is attacked with a ‘ ‘ cold ” or some more seri- 
ous inflammatory or febrile disease. Indeed, the line of separation 
between the state first described and an accidental or non-specific 
catarrhal fever or acute coryza, described further on, is by no means 
clearly drawn. Even a specific influenza, produced by some peculiar 
zymotic cause, in its milder forms is scarcely distinguishable from a 
“common cold.” Moreover, the phenomena of fever and inflam- 
mation greatly resemble one another in many respects, as we have 
already seen ; and although many phenomenal differences are distin- 
guishable in different morbid affections, the similarity of all morbid 
states, and indeed their resemblances to physiological conditions, are 
more clearly recognized than formerly, and will be still more so by the 
profession at large in the future. 
The pathological state of the affected mucous membrane in a cold 
requires a few more descriptive words. 
The first condition noticed is that of hyperaemia. This is soon 
followed and accompanied by exudations of a serous fluid from the 
blood, containing more or less minute particles of bioplasm, by an 
increased mucous secretion, and by the rapid and abortive production 
of epithelial cells, which constitute mucous corpuscles; these having, 
when recent, vital properties, seem to be undergoing changes in their 
outline when examined by a strong magnifying power, and have 
amoeboid movements of a distinctly living character. These vital 
movements and changes are noticed not only in recent mucous cor- 
puscles, but in colorless blood corpuscles and in pus corpuscles ; and, 
according to Dr. Beale, in no form of bioplasm can these minute 
living movements and changes be better studied than in these cor- 
puscles, all of which may be produced in the discharges from the 
mucous membrane in a severe cold. The mucous membrane, swollen 
by the hyperaemia, by serous infiltration, and by the multiplication 
and deposits of other elements within it, is also more or less denuded 
of its epithelium, and presents conditions similar to those which are 
more fully described in the article on bronchitis. 
Treatment of Colds.—With many persons a common cold may 
safely and properly be left to itself without special treatment. With 
other persons treatment is important, and in most cases benefit may 
be obtained, the affection may be mitigated and its course cut short 156 
TREATMENT OF COLDS. 
by the judicious application of remedies. Another reason for treat- 
ment is found in the fact that, in the early stage of an attack, it is 
sometimes impossible to say whether the symptoms presented are 
those of a common cold or the beginning of a more serious inflamma- 
tion or fever. 
The principles of treatment are similar to those which have been 
described as applicable to other conditions where excretions have been 
checked, the blood has become impure, and irregularity in the inner- 
vation and circulation have occurred. The most important indication 
is to bring the blood back to the surface from which it has been sup- 
pressed, to excite the perspiration which has been checked, and thus 
to eliminate effete matters which have been retained. A hot pedilu- 
vium, a warm bath of water, air, or steam, a warm bed and warm 
diluent drinks, will almost certainly procure relief, and not unfre- 
quently will abort the cold. Diuretics as well as diaphoretics are 
indicated, and cathartics are not unfrequently more efficient than 
either in removing from the system the effete matter which soon accu- 
mulates, and thus relieving the symptoms. 
It should be borne in mind that the nerves, especially the vaso- 
motor, have very much to do in producing the irregularities of 
circulation and secretion, which constitute the phenomena of these 
affections. Impressions upon the nervous system are often most 
speedy and efficient in procuring relief. The particular remedies 
fulfilling these indications are various. 
A Dover’s poAvder or dose of morphine, given in connection with 
the bath, warm drinks, etc., will often cut short an attack. Better 
still will be a full dose—six to ten grains—of quinine, often best with 
an opiate, repeated a few times, so as to bring the system under its 
full influence. Probably the salicylate of soda will produce a similar 
effect. 
Tincture of aconite, in moderate but repeated doses, will often 
operate efficiently, inducing perspiration and abating feverishness. 
The chlorate of potash has become one of the most popular remedies 
for a cold. It is generally innocent when not given in excessive doses, 
and is often efficient. According to Dr. Ringer, iodide of potassium, 
in a ten-grain dose at bedtime, at the onset, will often cut short an 
acute cold in the head. Various applications directly to the mem- 
brane. have been advised. The inhalation of the fumes of iodine, of 
spirits of camphor, of pulverized bayberry bark, etc., are sometimes 
attended with some degree of relief. 
Various compound mixtures for colds may be found in the books, 
operating upon some of the principles indicated. A pill, recom- 
mended by Dr. Lincoln, of New York, composed of half a grain of SYMPTOMATIC FEVERS. 
157 
sulp. quinine, half a grain of camphor, and one-fourth of a grain 
of ext. of belladonna, taken once in two hours, for a few times, is 
thought, from its combination of ingredients, to have a peculiar 
power in arresting a cold. It often checks the irritation and secretion 
from the affected membrane, without producing any considerable 
unpleasant effects, and is worthy of trial in the cases where treatment 
is called for. As many of the indications presented in simple colds, 
and the particular medicines fulfilling them, will come under review 
in treating of acute coryza, simple fevers, bronchitis, etc., the articles 
upon these subjects are referred to. 
In concluding the account of some of the milder ailments for 
which the physician’s advice is sought, it seems proper to repeat, that 
by giving attention to slight deviations from normal conditions, and 
cutting them short as soon as possible, the more grave affections may 
often be prevented ; and that active treatment in the earliest stages of 
severe diseases will often be efficient in mitigating or arresting them, 
when if action be delayed to a later period all remedies might fail. 
Even in those diseases produced by specific poisons, and which are 
thought to necessarily run a specific course, it is possible that early 
treatment may prevent the full effect of those poisons, and we should 
not relinquish the hope that means may yet be discovered for arresting 
their progress. All credit is due to those who are seeking to discover 
the causes of disease and methods for prevention ; but those also are 
entitled to credit who, while diseases continue to occur, seek for 
means, timely applied, to cut them short. The time, it may be 
hoped, has passed, if it were ever present, when it is considered the 
highest function of the physician to study the natural history of the 
diseases with which he meets, to verify previous predictions in the 
dead-house, or, as it has been termed, “ indulge in meditations upon 
death.” 
SYMPTOMATIC FEVERS. 
Symptomatic Irritative Fever.—When a local or more 
general irritation exists, a super-excitation with change of function, 
but without material change of structure, recognizable as a morbid 
state, but not amounting to an inflammation, the feverish condition 
which is likely to accompany it is called a Symptomatic Irritative 
Fever. Such a fever often shades otf into a simple idiopathic fever, 
the line of demarkation between the two conditions not being dis- 
tinctly drawn. But when the irritating cause produces no local or 
general effect distinguishable from the phenomena of fever, it is said 
to be idiopathic ; and when a morbid state of irritation is distinguish- 158 
TREATMENT. 
able from the febrile symptoms, the fever is said to be symptomatic. 
The phenomena of such a fever are such as belong to fevers in general, 
which have already been described ; and its severity and continuance 
will depend upon the amount and permanency of the irritation and 
the susceptibility of the patient. Usually, although the temperature 
may be decidedly elevated, the fever is comparatively mild, and it 
readily passes away with the removal of the irritation. Among the 
most frequent causes of such fever are the irritation of the gastro- 
intestinal membrane from improper quality or quantity of food, and 
the reflex irritation of teething. This irritative fever shades off also 
into inflammatory fever, as irritation so frequently results in inflam- 
mation. The general symptoms in any of these cases will be varied, 
not only by the amount of irritation and susceptibility of the patient, 
but by the particular organs irritated, and the mingling of the local 
symptoms of such irritation with the general febrile phenomena. 
It is unnecessary in this connection to describe the varieties of spe- 
cial cases that may occur. 
Treatment.—The principles of treatment in these cases are simple, 
and will readily suggest themselves. The irritation and its causes will 
require the first and principal attention. Such irritation must be re- 
moved ; and the means applicable will be pointed out by the particular 
irritation and its cause, which requires to be carefully inquired into. 
Aside from this, the fever symptoms will require, if anything is needed 
for the purpose, management similar to that which will be described 
under the head of non-specific simple fever. It is proper, however, to 
say here, that when the cause of irritation is removed, while the fever 
still continues, or in cases where the cause cannot be reached, sooth- 
ing, anodyne, and neurotic remedies are often promptly and decidedly 
useful. By diminishing irritability, or impressibility, they diminish 
irritation and its results—the feverish phenomena. A properly 
selected opiate is most likely to procure relief. When preceded or 
followed by a laxative, and combined with a diaphoretic, not only the 
irritation, but the effete accumulations in the system, resulting from 
the fever, will be likely to be removed. In all cases, a regulated, 
bland, and moderate, or, for a day or so, a suspended diet; and rest, 
as a rule in bed, will be proper. 
Inflammatory fever has already been referred to in the account 
of the genera] inflammatory process, and its further consideration 
will be postponed until special inflammatory diseases are described. 
Pyaetnic and septicaemia fevers are generally surgical. Some of 
their phenomena have been referred to, and they will receive further 
attention when treating of those medical diseases, or affections of in- 
ternal organs in which they are likely to occur. IDIOPATHIC FEVERS. 
159 
The subjects of pyaemia, septicaemia, embolism, and other forms 
of blood-poisoning and their results, and the relations of bacteria to 
these processes, are matters of great interest and importance, and are 
undergoing investigations. 
The treatment of these conditions when developed is unsatis- 
factory, and preventive measures become doubly important. As 
morbid germs are now regarded as the fruitful source of these con- 
ditions, and as they multiply and abound in filth and decomposing 
matter, the great preventive remedy is cleanliness, in the largest sense 
of the term. Hospitalism is a term given to the conditions produced 
by the crowding together of large numbers of sick and wounded 
persons, and especially of puerperal women. When many wounded 
are brought together, a “traumatic atmosphere’’ is produced—that 
is, one abounding in organic matter, and in which germs—bacteria— 
are supposed to be abundantly present. 
Scrupulous cleanliness, free ventilation, a large air space for each, 
and antiseptics are demanded. The antiseptic dressings of Lister— 
the performance of operations under a spray of carbolic acid, etc.— 
are not only attracting a wide-spread attention, but at present an 
almost equally wide-spread approval by the profession. Very recently, 
however, the utility, and even propriety, of the spray has been ques- 
tioned, and there is little doubt that injurious effects have sometimes 
resulted from its use. Other means of destroying or excluding 
external morbid germs may be found more efficient and less objec- 
tionable than this, but the germ theory of Septicism seems at present 
too well established to be set aside. 
The treatment usually pursued in these fevers, when established, 
consists in the administration of sulphites, quinine, salicylic acid, 
tincture of iron, carbolic acid, opiates, and good nourishment. 
Alcohol is often given, but its value, even after so long an experience, 
is not yet fully ascertained. 
Catarrhal Fever, a somewhat peculiar form of irritative or inflam- 
matory fever, will be treated of in connection with inflammation of 
the mucous membrane of the air-passages, coryza, etc. 
IDIOPATHIC FEVERS. 
All those morbid processes constituting the distinct idiopathic 
fevers' belong particularly to medicine—to the physician as distin- 
guished from the surgeon or the accoucheur and gynsecologist. 
From their wide-spread prevalence and the large number affected, 
from their attacking by preference those in early and middle life, 160 
SIMPLE FEVERS. 
from their occurring in persons constitutionally vigorous and healthy, 
as well as in the feeble and diseased, from their being such common 
outlets of the most valuable human life, and from the many impor- 
tant and interesting questions connected with their causes, their 
phenomena, their prevention, and their treatment, they require, in a 
work on the Practice of Medicine, and by every medical student and 
practitioner, the most careful and thorough consideration. 
ACCIDENTAL OR SIMPLE FEVERS. 
The Non-specific Fevers, though they are never epidemic, and are 
less severe and persistent affections, are still quite frequent, especially 
in children and females, and in all impressible persons, and require a 
share of attention. 
They present the phenomena common to all fevers, are ushered in 
by feelings of general indisposition, languor, and commonly with head- 
ache and other pains, and the usual rigors. The chill, when present, 
is variable in amount and continuance ; the essential increased tem- 
perature occurs, often coming up rapidly to a decided fever point, 
from 104° to 106°. At other times the heat is less, but is still from 
1° to 3° above the normal; and the common restlessness, febrile sen- 
sations, deficient or perverted secretions, increased destructive meta- 
morphosis of tissues, and accumulation of effete matters, with subse- 
quent increased elimination by the kidneys, bowels, and skin, are all 
present. The kidneys, particularly, eliminate a free quantity of urea, 
uric acid, and urates, the salts often being deposited on the cooling 
of the urine, constituting what is called the lateritious sediment. 
They are derived from the rapid waste of the nitrogenous elements of 
the tissues. 
The accession of these fevers is generally abrupt, and, though 
more or less fluctuating in their course, with the usual variation of 
morning and evening temperature, the type is continuous, or but 
moderately remitting, until the final subsidence, which generally 
occurs in a few days, and sometimes in a few hours. The subsidence 
or defervescence, if by crisis, is usually accompanied by a freer perspi- 
ration ; and the very rapid loss of heat from the surface, caused by 
the more ready evaporation at this still high temperature, soon brings 
it down to the normal standard, and sometimes even below it. When 
a free discharge occurs from the bowels and kidneys, not only the 
fever but its effects are generally speedily removed. 
When these fevers are of short continuance, they are called ephem- 
eral ; when, mild, as well as brief, they are called febricula. From TREATMENT OF FEVERS. 
161 
their dependence upon accidental causes, such as exposure, moisture, 
and extremes of temperature, excesses, improper ingesta, suppression 
of secretions, shocks to the nervous system, etc., I have applied the 
term accidental fevers. From their approaching in character, and 
merging into symptomatic fevers from well-marked irritations, they 
are frequently designated as ‘ ‘ irritative ” fevers. 
The term accidental, however, seems more appropriate, as indicat- 
ing the non-specific character of the causes, and as embracing the 
whole class. 
These simple fevers are to be distinguished from those that are 
specific by their sporadic occurrence, their being traced to these acci- 
dental causes, by their less persistence, and by the absence of the 
peculiarities belonging to each form of the specific fevers. They are 
to be diagnosticated from the symptomatic fevers by the absence of 
local or clearly distinguishable pathological conditions, aside from the 
phenomena of the fever, to which the pyrexial condition can be attrib- 
uted. Local irritations, congestions, or inflammations may super- 
vene in the course of a fever of this kind, thus changing the type ; 
but the fever, if idiopathic, did not originate in, and, while continu- 
ing so, does not depend upon, the local pathological state. 
The prognosis is favorable, not only as to ultimate, but, under 
proper treatment, as to speedy and complete recovery ; yet in delicate 
and feeble persons a fatal result may follow. The fever is sometimes 
of a very active type, and, in children particularly, convulsions and 
coma, and rarely death, may supervene. 
TREATMENT. 
In all fevers there are certain general indications of treatment, 
which it will be well here to mention. 
1. To remove the cause or prevent its effects; to neutralize or 
remove any poison or injurious material from the system, if any such 
be present. 
2. To promote the elimination of effete matters, which the fever, 
by the more rapid destruction of tissues, produces in more than the 
normal quantity. 
3. To reduce the temperature when excessive, to moderate the 
heart’s action when violent, and thus diminish destructive and lower- 
ing changes and conserve the heart’s power. 
4. To maintain nutrition «f the tissues and sustain the action of 
the heart and other organs when they flag, taking care, while admin- 
istering food and stimulants for that purpose, to select such food and 162 
NON-MEDICINAL MANAGEMENT. 
administer it in such quantities only as the system can appropriate, 
and to select such stimulants as will increase action without producing 
irritation or congestion, or too much increase the work of the already 
overtasked glandular organs to eliminate them. 
5. To relieve distressing symptoms and procure quiet and rest. 
6. To prevent or relieve local complications. 
7. To obviate the tendency to death. 
At present we are limited in our knowledge of means for fulfilling 
the first indication—that of destroying the poisons which are the 
causes of so large a portion of fevers ; and frequently the other morbid 
impressions which cause fevers are not in operation, or are not to be 
reached, when treatment is called for. This causative indication, 
however, should always be kept in mind, and a principal aim of the 
profession should be to learn how to fulfill it. In some cases this indi- 
cation can be fulfilled ; quinine seems to antidote the malarial poison ; 
and when pent-up pus, irritating substances in the alimentary canal, 
obstruction of the bowels, common (not specific) poisons introduced 
into the system, arrested secretions, etc., are the causes of fever, their 
removal may often be effected. But an account of the means of ful- 
filling these different indications, and the methods of applying them, 
will constitute the practical part of what is to be said respecting the 
various fevers to be discussed. The very important part of the man- 
agement of fevers, or, more correctly speaking, of patients suffering 
from fevers, aside from the administration of medicines, is to be con- 
ducted in the same general way in all forms of fever and in most cases 
of acute and severe diseases, and may appropriately be considered here. 
NON-MEDICINAL MANAGEMENT OF FEVERS. 
In the first place, the physician, when he can exercise a choice, 
should select a proper room for his fever patient. It should be of 
good size, with a high ceiling, kept at a proper temperature, governed 
somewhat by the sensations of the patient, but usually between 55° 
and 65° F. The mode of heating is by no means unimportant, and 
that is best which secures the most frequent change of air and the 
most steady and manageable temperature. Proper ventilation is of 
primary importance, and where artificial heating is required it should 
be so conducted as to promote that object. The best methods of heat- 
ing are by open fireplaces or grates, and by indirect radiation or the 
introduction into the room of warmed air, which is allowed again to 
flow out, thus effecting a frequent change ; and this may be combined 
with direct radiation. 
When the heating is entirely from the warmed air, the tempera- TREATMENT OF FEVERS. 
163 
ture is apt to be kept at too high a point; and beating solely from 
steam and hot water radiators in the room produces no change of air. 
On the whole, a combination of direct and indirect radiation is best 
for the sick-room. The incoming current should be through or 
near the floor, and not too near the bed ; and the outflowing current 
should be both at the base and near the ceiling. Some of the ma- 
terials exhaled from the lungs and the surface of the body, all of 
which it is desirable to have removed as soon as they accumulate, rise 
toward the ceiling, and others sink toward the floor; while others 
still, on the principle of the diffusion of gases, are nearly equally dis- 
tributed in all parts of the air of the room. A speedy and constant 
change of all the air in the apartment is desirable, as it all contains 
material which when taken into the lungs again and again, may do 
serious harm both to the patient and the attendants. Most of these 
materials, when discharged into the open, pure, and moving air, are 
soon oxidized and destroyed. 
To prevent more perfectly their retention, there should be as little 
furniture as possible, especially of textile fabrics, in which these sub- 
stances may find a lodgment. There should be no carpets and no rugs, 
or only such as can be readily and frequently changed and exposed to 
the open air. The room should be rather light, though in certain 
complications of inflammation of the brain or eyes, it may require 
darkening; and its color should be cheerful. An air or water bed, 
or a hair mattress, should be selected. A feather bed is objectionable, 
as by its surrounding the body and its non-conducting quality too 
much heat is retained in the parts next the bed, and, moreover, the 
feather bed retains more of the emanations from the patient. A 
mattress is most common, and if properly constructed, light and 
elastic, and especially if placed upon a wire mattress, and changed 
daily (this can be done by having two, the one not in use being ex- 
posed to the sunlight and open air), every necessary condition in this 
respect will be fulfilled. A water-proof material—rubber or oilcloth 
—should be placed over the mattress and under the sheet ; and the 
linen of the bed and the patient should be daily changed. It may 
not be necessary that every article should thus frequently be sent to 
the laundry, but the change should be made, and the articles, when 
not in use, should be exposed to the open air, and, if possible, to the 
sun. Scrupulous cleanliness in every respect must bo observed— 
cleanliness of the room, the person, the bed, and the air. To that end 
great care must be taken of the excretions, especially in the infectious 
fevers ; as, in typhoid particularly, it is believed the infecting germs 
abound in the alvine discharges. They should be received into a 
vessel containing some disinfecting agent, such as a solution of 164 
NON-MEDIC1NAL MANAGEMENT. 
chloride of zinc, carbolic acid, permanganate of potash, etc., or, if 
these are not available, into a vessel containing dry earth, and should 
immediately be covered with it; and in all cases, especially if these 
disinfecting measures are not used, the vessel containing these dis- 
charges must be immediately covered and at once removed from the 
room ; and the contents should be buried in a trench of as dry earth 
as possible, and at a distance from wells or any water supply. It is 
absolutely essential that infectious fever discharges should not be 
thrown into the vaults of the ordinary country or village privy, 
and scarcely less important that when not thoroughly disinfected, 
they should not be thrown into the water-closet, however well trapped, 
to be sent abroad on their possible mission of death. The physician 
who will allow the discharges of a typhoid-fever patient, for instance, 
to be thrown not disinfected into the vault of a common privy to 
which other persons resort, must, in the present state of enlightened 
professional opinion, be regarded as culpable. If such privy is near 
a well, supplying potable water, with a moist and porous intervening 
soil, he must be doubly so. Caution on this subject, with reference to 
the spread of the disease, cannot be too exjfiieitly expressed, nor its 
neglect too forcibly denounced. Indeed, the whole abominable system 
of privy vaults, with their fecal accumulations pent up, fermenting 
and decomposing, often percolating through the earth into wells, and 
constantly sending emanations into the air, should be abolished alto- 
gether as filthy, indecent, and a dangerous nuisance. Various substi- 
tutes have been proposed. That known as the “ dry earth system ” 
is the most practicable for a country and village population, where a 
good system of sewerage is impossible. It has indeed marked advan- 
tages over the sewer, when carefully and properly carried out. 
Bathing and sponging the surface of the patient for purposes of 
cleanliness and comfort will be required in all cases, and, as a rule, 
should be frequently practiced, though with proper discrimination. 
The therapeutic uses of the bath will be noticed in describing the 
treatment of particular fevers. 
Many persons must not be allowed in the sick-room, nor a succes- 
sion of visitors. Wherever the custom prevails of neighbors and 
friends expressing their interest and sympathy, or gratifying their 
curiosity, by crowding into a fever-stricken patient's sick-room, the 
physician’s authority must be interposed, and not only in the interest 
of the patient, but of the friends, the practice should be broken up— 
at least the visits in the individual case must be prohibited. Loud 
talking and mysterious whispering, of which the patient is conscious, 
must be alike avoided. The whispering often excites suspicion, and 
sometimes alarm. The rustling of dresses often annoys a patient, TREATMENT OF FEVERS. 
165 
and every source of annoyance should be carefully avoided. There 
should be only so much attendance as is useful to the patient, and 
all fussy intermeddling, from however kind motives, should be pro- 
hibited. 
The importance of a proper nurse can scarcely be overestimated. 
It is a matter of congratulation that the science and art of nursing is 
receiving so much attention, and that so many intelligent and benev- 
olent persons are willing to devote themselves to this work. It is to 
be hoped that the reign of the Gamps is passing away. 
A good nurse is intelligent, instructed in the duties of the art ; 
obedient to the directions of the physician, wTho is the responsible 
autocrat in the case; honest in reporting what has actually occurred, 
even her own mistakes or negligence ; strong, to do what is necessary 
in helping the movements of the patient ; kind and sympathetic, but 
cheerful, not gloomy or effusive ; vigilant, observing, and, if possible, 
anticipating every want, yet not fussy and obtrusive; she is gentle 
and quiet, but steady and firm. When all these virtues are combined 
in an individual, as they sometimes are, the services of such a person 
are invaluable, and, where the ability exists on the part of the patient, 
should receive a liberal acknowledgment. When they are bestowed 
upon the poor, a reward will come from other sources. In ordinary, 
and particularly in country practice, professional nurses cannot often 
be obtained ; then the best attendant possible should be selected, and 
should be carefully, and often repeatedly, instructed in the details of 
necessary services. 
The matter of food and feeding is of very great importance, and 
often of difficulty, requiring much judgment and skill. The famous 
epitaph of Dr. Graves, “He fed fevers,” has done much good, but it 
may also have done harm, as it has been abused. The extremes of 
stuffing and starving should alike be avoided. While in protracted 
cases the importance of keeping up the nutrition can scarcely be 
exaggerated, in short attacks and in the early stages, and generally 
for the first day or two, very little and sometimes no food will be 
required. The gastric secretion and the powers of digestion and 
appropriation are more or less limited in all cases of severe fever ; and 
it never should be forgotten that more food taken into the stomach 
than can be digested and absorbed will prove a source of irritation and 
harm ; and more absorbed into the blood than can be used by the 
system, imposes an additional task upon the laboring organs to dispose 
of the redundancy. The physician must judge in each individual 
case as to what is required and can be borne, and specific directions 
must be explicitly given. In hospital practice, particular bills of 
dietaries are prearranged, and the trained nurses may be briefly told 166 
NON-MEDICINAL MANAGEMENT. 
to use a certain formula. In private practice, all the details of prep- 
aration and admipistration must be seen to, and must not be left to 
the judgment or the whims of an ignorant or inexperienced attendant. 
Even professional nurses often have crude and erroneous notions, and 
the matter is too important to be left to any chance or uncertainty. 
Milk, on the whole, is the most important staple. Milk with fari- 
naceous substances, the latter very thoroughly and delicately cooked 
and mingled with the milk, often diluted, constituting a mixture of 
milk and farinaceous substances—a nice gruel—is the food best 
adapted to most cases. But milk, especially when taken clear, and 
sometimes in any form, disagrees with some persons, and cannot be 
relied on. When diluted with lime-water it can sometimes be borne, 
when not otherwise. Beef-tea is often used, and useful when properly 
prepared—a matter of the utmost importance when it is depended 
upon ; but it acts, perhaps, more as a stimulant than a food, as it 
contains but a moderate quantity of solid and substantial nutrient 
matters. There is far more nutrient material in the same quantity of 
milk, or milk and farinaceous gruel, than even in the best prepared 
beef-tea; and this should be borne in mind where nutrient substances 
in considerable quantity are demanded. In some cases solid food can 
be digested and will be best. The tenderest muscle of beef or mutton, 
bruised and scraped into a disintegrated mass, a small portion in a 
rounded ball put upon a hot gridiron for a very short time to give a flavor 
of being cooked, but leaving the greater part quite raw—this, properly 
seasoned, will often be taken, even with some relish, when liquid foods 
are less acceptable; and this raw flesh is capable of affording much 
more nutrition than slops. The addition of hydrochloric acid or pep- 
sin to animal food, either before or after its introduction into the 
stomach, often aids markedly the digestive process, leaving the stom- 
ach with little more to do than to absorb the digested substances. 
The art of cooking for the sick, and indeed for the well, requires the 
attention of the physician. 
It is important, always, that the evacuations should be inquired 
after, and that a full account of them should be given. It is not 
sufficient to be informed by the nurse that a very sick patient has 
“passed water.” Even where small quantities of urine have been 
passed, frequently the bladder may be largely distended, or, from its 
long detention, the urine may be undergoing decomposition and pro- 
ducing severe irritation and ammoniacal absorption. The hand should 
be passed over the region of the lower abdomen at each visit, to ascertain 
whether such distention is present; and, in all cases of doubt, a well- 
cleansed catheter should be used. Great mischief, even fatal conse- 
quences, not very unfrequently arise from this neglect. TREATMENT OF FEVERS. 
167 
The danger of bed-sores, in protracted cases, should be borne in 
mind and guarded against. They are to be prevented by the utmost 
cleanliness and smoothness of the bed and linen, particularly avoiding 
the discharge or spilling of urine in the bed, and its consequent decom- 
position and production of ammonia there. Change of position, from 
lying on the back to the sides, and even to the anterior aspect of the 
body, is often important; thus, and by other means, taking the press- 
ure from the threatened part. The tendency is to be further obvi- 
ated by keeping up the nutrition, by frequently bathing the exposed 
parts, and by abating the great heat of fever which disposes to 
destructive changes. 
Patients often require moving, and may, with decided advantage, 
be transferred from one couch to another while changes of linen take 
place. A frame of the size of the mattress, to which an impervious 
cloth may be attached, would enable the patient to be taken up by two 
persons and carried across the room, or into an adjoining apartment, 
without disturbance or exertion ; or, in the absence of such arrange- 
ment, two light poles, the length of the person, may be rolled up in 
the under sheet from each margin until coming near the body, when a 
person on each side, firmly grasping the sheet and poles near the ends, 
can carry the patient about with a similar freedom from disturbance 
and fatigue. A very weak person should not be allowed to assume 
the erect position, as fainting, or even permanent failure of the heart’s 
action, may result. 
The physician should give all directions clearly, often repeatedly, 
and not unfrequently in writing. An attendant, in the agitation of 
anxiety or embarrassment, often fails to comprehend the directions, or 
forgets them almost as soon as given, and great explicitness, therefore, 
is often required ; and the physician should take pains to see at each 
visit that his directions have been understood and complied with. 
This is to be ascertained, not by asking in a general way whether the 
directions have been followed ; but by asking particularly what has 
been done—when, and how much, food and medicine have been 
given, etc. 
The physician should cultivate a proper manner in the sick-room ; 
and, what is vastly more important, as leading to that proper man- 
ner, he should have proper sentiments and feelings with regard to the 
high character of his profession, and his responsible and interesting 
relations to his patients. He should be, and then he will naturally 
appear to be, interested in his patient’s welfare, and he must be kind 
and sympathetic. While allowing all proper liberty, he should be firm 
in essentials ; and by his intelligence, his interest, and his authority, 
by a proper combination of frankness and reticence, by caution and 168 
TREATMENT OF FEVERISH STATE. 
truthfulness, he should secure the respect and confidence of those 
under his care. 
It is not given to all to reach the highest perfection in any depart- 
ment of human activity and usefulness, and we must be content with 
what is attainable. But there is an excellence in the profession of med- 
icine of a higher order than that which depends upon scientific knowl- 
edge or the possession of the technical art, one which is shown in the 
practical duties of the calling, giving them the charm of a superior 
beauty and the merit of greater efficiency. It manifests itself not 
merely by the skillful use of material agents, but by a general force 
and manner, which give evidence of sympathy and mental energy, 
that inspires a confidence and exercises a control which becomes a 
benefit. It is difficult to speak intelligibly of this ; nor is it neces- 
sary. This peculiar quality does not come by teaching; it has a 
higher origin. It may be better appreciated by suggesting it to the 
attention, and it may be more nearly reached by the possession of its 
ideal; it is not improved by discussion, and is not inspired by exhorta- 
tion ; but, according to the degree in which it is present, it places 
its possessor upon a higher level. 
We have been delayed, but it is hoped not unprofitably, by these 
general directions for the hygienic management of fever patients, in 
our account of the treatment of these accidental fevers, which em- 
braces the treatment of the simple febrile condition. 
In the management of a case of these milder forms of fever the 
causal indication must be observed. Often the causes are temporary, 
and the effects spontaneously cease. In such cases it is not easy to 
determine the precise value of therapeutical agents, and here ineffi- 
cient, or even worse than useless, measures obtain their reputation for 
success. In some cases, if the patient remains indoors and quiet, if he 
takes to his bed and abstains from food, perhaps absolutely, if pre- 
viously fully or over nourished, or if otherwise he takes but little, and 
that of a bland character, taking water freely as his thirst demands, 
all is done that may be required. A judicious physician here, as in 
all cases, should be early called, hut this ought not necessarily to im- 
ply the administration of drugs. If some temporary cause can be 
satisfactorily traced, and a clear diagnosis and a favorable probable 
prognosis can be formed, “ good advice and little medicine ” will suf- 
fice. But it is often difficult in the beginning of a feverish attack to 
determine its cause, and what will be its outcome. There are various 
courses of more positive treatment which will do no harm, which the 
essential conditions of fever suggest, and which may be of decided 
advantage in procuring a more speedy, a more certain, and a more 
complete recovery. In these cases, however mild, and arising from TREATMENT OF FEVERS. 
169 
whatever causes, but resulting in the essential feverish action, retro- 
grade metamorphosis is increased, effete matters are in greater abun- 
dance in the system, some of the secretions are diminished, they are 
seldom or never increased in proportion to the increase of effete mat- 
ter requiring elimination, and in all such cases a moderate increase 
of action induced in the bowels, the skin, and the kidneys, by cathar- 
tics, diaphoretics, or diuretics, one or more, can scarcely fail to do 
good. • It will be quite safe, and generally useful, in cases where no 
organic disease is present, and where the cause of the symptoms and 
their continuance are only conjectural, to order the patient to bed, 
to give him warm diluent drinks, and some simple diaphoretic mix- 
ture, such as the acetate of ammonia, with the addition of a moderate 
quantity of the syrup or the wine of ipecacuanha, to give a warm bath 
or at least a pediluvium, and to repeat the diaphoretic doses until 
sweating is induced. If after this the fever has not disappeared, a 
gentle saline cathartic, such as a dose of citrate of magnesia or 
Bochelle salts, or quite as well, perhaps better, as acting more upon 
the secretion of the liver, a dose of sulphate of soda. If the fever 
still continues, a persistence in an eliminative course, adding saline 
diuretics, such as acetate of potash, or other salts of potash or soda, 
will be useful. A light but appropriate diet, milk and farinaceous 
gruels, etc., will be required after the first twenty-four hours ; and if 
the fever be free from any specific character, and the cause is no 
longer in operation, in a few days convalescence will almost certainly 
be established. 
If the fever arises from repletion—too abundant alimentation, pleth- 
ora, or the injudicious use of tonics—not only an eliminative but a 
depleting course may be required. Abstinence, or a lower diet and for 
a longer time, may be necessary, more decided purgation may be 
required, the use of cardiac and arterial sedatives, if the excitement of 
the heart and arteries is high, such as aconite, veratrum viride, salines, 
etc., may be needful; and if plethora be decided, and serious conges- 
tions or inflammations, or cerebral hemorrhages are threatened before 
the quantity of blood can be reduced by purgatives, by a low diet and 
the salines, a bleeding is indicated and cannot fail to be useful. The 
dictum entirely proscribing the use of the lancet because in former times 
it was used excessively, is as unphilosophical and unreasonable as it is 
injurious. Though it may be and is but seldom required, there are 
conditions which clearly indicate its use, when it would be wrong to 
withhold it. 
If the fever has arisen from “ taking cold,” from a sudden lowering 
of the temperature by the exposure of the whole or a part of the body 
when there was a free quantity of blood in the heat-losing outer plane, 170 
TREATMENT OF FEVERS. 
and the reaction has occurred too late to meet the emergency, and if 
there is checked perspiration and effete matters have been retained, 
decided diaphoretics will be required. Besides eliminating from the 
skin the effete matters retained by suppression of its secretion, they 
cause a rapid loss of heat by evaporation from the surface. At the 
same time many of them diminish heat production by their sedative 
action, and thus by a double action reduce the temperature while 
removing the cause of the fever. Some agents reduce fever more by 
causing loss of heat, others by diminishing its production, while others 
operate in nearly equal degrees bv both methods. 
The loss of blood usually diminishes heat production, and yet the 
temperature, where there is still rapid Avaste, is sometimes very high in 
anaemic states; so that bleeding is by no means always, or even per- 
haps ever, indicated for increase of temperature alone; but if great 
increase of heat is accompanied with high cardiac excitement, and 
with a plethoric condition, and if severe congestion exists, a bleeding 
♦will relieve all these conditions, and may avert a hemorrhage, a serous 
effusion, or an inflammation that would otherwise occur and be seri- 
ous. Indeed, when these latter conditions present themseHes, when 
the plethora, congestions, effusions, hemorrhages, or inflammations are 
present or imminent, the bleeding may be indicated, though the tem- 
perature is not high and the circulation is oppressed and sluggish. 
The pulse may become fuller and the circulation freer after bleeding, 
and the feeling of strength and the general sensations be wonderfully 
improved. The quantity of blood to be taken will depend upon the 
size of the patient, the extent of the plethora, and the severity of the 
congests state, and also upon the effect produced. On this subject 
of watching the effect on the pulse, the respiration, the appearance 
and sensations of the patient, many of the writers of half a century and 
more ago were very full and explicit. But since bleeding has become so 
nearly a “lost art ” among the practitioners and writers of the present 
day, scarcely any directions of this kind are found in later Avorks. 
The acids, mineral and organic, are supposed to diminish feverish 
heat, and, to a limited extent, they probably have that effect. Dr. 
Fothergill recommends the folloAving for fulfilling the indication of 
abating heat : 
B Hydrochloric Acid, dilute ttixy 
Syrup of Orange 3j 
Water 
M. 
To be taken at a draught every three or four hours. Lemonade 
and other vegetable acid drinks are often very grateful to a feverish 
patient, and may be advised. TREATMENT OF FEVERS. 
171 
Fever from suppressed secretions, of whatever kind, should be 
treated by eliminatives, and, when severe, by decided apyretics 
also. 
If there be suppression of intestinal secretion and constipation, 
cathartics are very clearly indicated, and, as a rule, the salines are 
most eliminative of those that are mild in their operation, and they 
are not likely to produce irritation. If the secretion of the liver be 
deficient, and the organ congested, as indicated by a feeling of weight 
in its region, a bitter taste in the mouth, sleepiness and dull headache, 
a yellow conjunctiva, etc., cholagogues and cathartics, or cholagogue- 
cathartics are indicated, and are often strikingly useful. 
1 This brings up the question as to what are cholagogues, and the 
articles to be selected in fever due to suppressed biliary secretion, and 
other deranged liver functions. It should be premised that the rela- 
tion of the liver and alimentary canal, the mucous membrane of the 
stomach and intestines and their secretions, are so intimate that it is 
often impossible to determine in a given case whether the primary 
and principal disturbance is in the liver or in the alimentary mem- 
brane ; and the good effects of a medicine attributed to its action as 
a cholagogue, may be due to its action on the stomach and bowels. 
The question of cholagogues will be more fully considered in connec- 
tion with diseases, functional and organic, of the liver. Here it is 
proposed more particularly to mention those remedies which procure 
most relief in cases of accidental fever apparently dependent on 
deranged and diminished secretion of the liver, accompanied, as this 
condition is, with disturbed function of the prima via. 
Of these remedies I have no hesitation, in the present state of our 
knowledge, in giving the first place to the preparations of mercury. 
This remedy is to be accompanied, or better, generally, to be followed 
in a few hours by a cathartic, as one of the salines. For this purpose 
the “gray powder,” as it is commonly called in England—hydrarg. 
cum creta—is a favorite, and is often combined with rhubarb. I 
prefer the blue mass, either in powder or pill, in doses of from two to 
six or more grains, often giving at the same time ten to thirty grains 
of bicarbonate of soda, and sometimes repeating this dose in two or 
four hours. But generally a single dose, followed in from two to six 
hours by the saline cathartic—citrate of magnesia,or Rochelle salts, in 
form of Seidlitz powder, or alone, will be all that is required. Lately, 
since the experiments of Dr. Rutherford, of Edinburgh, tending to 
show the superiority of sulphate of soda as a cholagogue, I have often 
used that salt in place of the others. It has the disadvantage of 
being more unpleasant to the taste than the other articles named, but 
the advantage of being cheaper. I have been pleased with its effects, 172 
TREATMENT OF FEVERS. 
not only in the feverish conditions under consideration, but in more 
chronic cases of deranged liver and stomach requiring eholagogue and 
eliminative remedies. The mercurial given in the moderate doses 
mentioned, and followed by the saline laxative or cathartic, almost 
never produces any of the unpleasant effects of the larger or more 
continued doses of the metal ; and its beneficial effects seem to me 
unmistakable. There are many cases where I should feel that I had 
not done my duty to the patient should a mercurial not be directed. 
There are various other articles recommended as fulfilling the same 
indication, of acting upon the liver as cholagogues, particularly the 
vegetable—active princibles brought to the attention of the profession 
by the so-called eclectic practitioners, from whom we should accept, as 
from every source, anything valuable. The article of this class most 
generally used is the podophyllin ; but in free doses this irritates too 
much the intestinal membrane; though in small doses thoroughly 
triturated with sugar of milk its effects are more mild and apparently 
beneficial. Euonymin and irisin are alleged to act decidedly in in- 
creasing the secretion of bile, the euonymin Avithout irritating the in- 
testinal membrane, Avliile the irisin produces some effect of that kind. 
Most of the cathartics, as aloes, colocynth, jalap,and phosphate of soda, 
as Avell as ipecacuanha, sanguinarin, benzoate, and salicylate of soda, 
are reported by Dr. Rutherford to act decidedly as exciters of the 
secretion of the liver in the dog, and presumably in man, and clinical 
observations confirm some of these conclusions. 
These and still other new articles may be used as cholagogues, and 
further experience will doubtless sIioav more clearly their comparative 
value ; and some of them may prove to be better than those in more 
common use in the past. But it does not yet appear that any of 
them are as efficient in modifying favorably various gastric, intestinal, 
and liver derangements, connected with different feverish conditions, 
as the mercurials. 
Other eliminatives than cathartics and cholagogues will be useful, 
especially Avhen the secretion of the kidneys is not sufficiently active 
to carry aAvay the nitrogenous debris. The folloAving, recommended 
by Dr. Fothergill, is doubtless efficient in increasing the secretions 
both of the kidneys and skin : 
R Iodide of Potassium grs. vi 
Liquor of the Acetate of Ammonia ... 
M. 
To be taken, properly diluted, once in four or six hours, or in 
smaller doses more frequently repeated. The liquor acet. ammonia TREATMENT OF FEVERS. 
173 
alone in doses of from three to eight drachms, once in two to four or five 
hours, will operate both as a diaphoretic and diuretic, and its effects as 
an eliminative and antipyretic would often be increased beneficially by 
the addition of ipecacuanha in doses sufficient to produce slight nausea. 
An excellent cooling and eliminative drink may be prepared as fol- 
lows : 
B Bitartrafce of Potash 3j 
Bicarbonate of Soda 3j 
M. 
One half added to half a tumbler of water, and taken at one 
draught in a state of moderate effervescence, once in from one to three 
or four hours. The materials for this drink are to be found in most 
households, and it has the additional advantage of not being disagree- 
able, often even grateful, to the taste. 
The diaphoretic effect of any of these agents will be increased by 
the warm bath ; or, as a substitute, by six or eight soda-water bottles, 
and as many woolen stockings, filling the bottles with hot water, 
drawing a wet stocking over each, and surrounding the patient with 
them in bed. Free perspiration, with the relief it is quite sure to 
bring, can usually be obtained in this way in twenty or thirty 
minutes. 
In a fever produced by a direct impression on the nervous system, 
with decided irritability of that system, anodynes and narcotics are 
particularly indicated. From ten to twenty grains of Dover’s powder, 
or from one sixth to one quarter of a grain of a salt of morphia, with 
a grain, more or less, of ipecac., or a dose of chloral hydrate, or some 
other soothing neurotic may be sufficient to allay the symptoms. 
Other means may be combined or may follow, as the conditions indi- 
cate. Kecently, the Jamaica Dogwood (Piscidia erythrina) has been 
recommended as an anodyne and diaphoretic, and as a substitute for 
opium, especially where the latter article disagrees, or is followed by 
unpleasant secondary effects. The fluid extract is the form in which 
it is commonly used ; and in doses of from half a drachm to a drachm, 
repeated as may be required, its effects are often very agreeable, with- 
out that secondary nausea and depression sometimes following an 
opiate. It is, however, a powerful narcotic in large doses, and must 
be used with proper caution. 
But accidental fevers, especially when induced by taking cold, are 
apt to be followed by inflammations and congestions, rendering the 
case much more serious than where the feverish symptoms alone ap- 
pear. According to Dr. L. Beale the bioplasts increase in size, and 
there is an increased growth of germinal matter in all inflammations 174 
TREATMENT OF FEVERS. 
and fevers, showing their strong analogies. As fever accompanies 
inflammation, so inflammations tend to occur in fevers ; and in severe 
accidental fevers local complications are to be anticipated : and more 
decided measures than a selection from those already more particu- 
larly described may be required. 
In the foregoing remarks, an effort has been made to point out a 
variety of remedies, some of which may be required to mitigate the 
conditions and more speedily terminate the milder fevers so frequently 
met with, especially in children, which we have been considering. 
In the treatment of cases in children some modifications will he 
required, and great care in adapting doses, particularly of the narcotic 
agents, to their age and susceptibility; hut the same principles are 
applicable as in the treatment of adults, and I have not consid- 
ered it necessary to describe their cases particularly. Their pecul- 
iarities, and the particular modifications of treatment adapted to 
them, will be found in the special works on children and their 
diseases. 
A leading object of this work is to state physiological and path- 
ological facts, to inculcate correct therapeutical principles, and to 
instruct the student and aid the practitioner in the management of 
cases of illness, severe or otherwise, that he will be called upon to 
treat. The physician in general practice is frequently called to under- 
take cases in the early stage of attacks, ■when it may be impossible to 
determine the course the disease is inclined to take; and, as in most 
diseases controllable by treatment, such treatment is far more likely 
to be efficient when commenced early, there is a demand for prompt 
action before the full nature of the case is determined. In the 
beginning of some affections it may be best to apply the simplest 
tentative measures, and wrait for the disease to declare itself more 
fully before active measures are instituted. In other cases there are 
well-defined indications present which will justify decided treatment 
in reference to them, though the distinctive character of the disease 
in its full development may not be known. 
The physician, for example, may be called to a patient, who, 
after exposure to cold and wet, or some other exciting cause, has had 
a chill, and is now in the hot stage of a severe fever. His tempera- 
ture may be up to 104°, 105°, or even 105.5°, though often less, and 
possibly higher. There are general pains not specially concentrated 
in one locality ; there is labored breathing, but no physical signs of 
structural change of the lungs; there may be nausea and vomiting, 
but no tenderness on pressure over the stomach or any part of the 
abdomen; the urine may, or may not, be scanty; but, though it 
may have an increased quantity of urea and uric acid, it has neither TREATMENT OF FEVERS. 
175 
albumen, blood, nor casts, and pressure oyer the kidneys fails to elicit 
tenderness. There may be severe pain in the head, but still none of 
those symptoms pointing to special disease of the brain or its mem- 
branes. In short, the disease seems general, and no evidence of a 
local inflammation is present; and yet every practitioner, who sees 
many diseases in their beginning, knows that within twenty-four 
or forty-eight hours there is likely to be a severe local inflam- 
mation developed—it may be within the chest, the abdomen, or the 
cranium. 
In such a case what is the physician to do ? Is he to give a 
placebo and wait for whatever may turn up ? Wait for the dullness 
on percussion, the crepitant rale, or the characteristic sputa of pneu- 
monia ; or for the red tongue, the burning pain, the tenderness on 
pressure of gastritis; or the delirium, convulsions, or coma of ence- 
phalitis before he institutes active treatment ? Or, in an obscure 
case, is he to await the results of a post-mortem examination to clear 
up the diagnosis, through fear of acting without a full acquaintance 
with the nosology of the case ? In the case supposed, some two or 
three days might elapse before characteristic symptoms of local disease 
declared themselves, and the opportunity might be lost of putting 
any decided check on the severity or continuance of the morbid state. 
On the other hand, mischief might be done by striking a heavy and 
injudicious blow in the dark, and the opportunity of making the 
diagnosis by an autopsy might be hastened or insured. The question 
as to what course should be pursued in such cases would be differently 
answered by different authorities, and a satisfactory answer applicable 
to all cases cannot be given : yet an answer to this question is wrhat 
the young practitioner particularly wants. The question as to what is 
to be done in the case supposed will depend upon the answer to another 
question, viz., Have we any remedies applicable to this condition of 
fever—to the pyrexia! state with the inflammatory nidus, to this state 
of morbid actions common to accidental fevers and incipient inflam- 
mations—which are capable of arresting its course with safety to all 
other conditions of the system, and which are likely to do so when 
energetically and properly applied ? This question, I am sorry to 
think, m?y receive different answers from those who may be regarded 
as leaders of professional sentiment. 
In some of the specific fevers with the inflammatory nidus, such 
as small-pox and scarlatina, we know of no means by which they can 
be arrested, and our efforts here are confined to attempts at palliation 
and to conducting the case through its course. Still, in the specific 
fevers, as in those that are accidental or inflammatory, perhaps the 
greatest danger is from the continued high temperature, and the 176 
TREATMENT OF FEVERS. 
abatement of the excessive heat as an important palliative measure is 
called for. Continued excessive' body heat, whatever the cause, leads 
to degenerative processes and the typhoid state with all its disastrous 
consequences. The abatement of a high fever heat is always indi- 
cated, and it is palliative of organic suffering even where, as in 
specific fevers, it fails to arrest the course of the disease. 
The accidental fevers and the non-specific inflammations are not 
so persistent as most of the specific affections. Not only is the tem- 
perature capable of being lowered, but with this, other conditions are 
capable of being modified and the whole disease of being arrested ; and 
I have no hesitation in believing that the question proposed should be 
answered in the affirmative. Whatever opinions may be entertained 
by those hospital and consulting physicians who see diseases, as a rule, 
only in their more advanced stages, those practitioners who often see 
the attacks such as are under consideration in their beginning, and 
who combat them energetically and judiciously, will not doubt the 
efficacy of treatment, or hesitate as to what should be the answer to 
the question. Dr. Thomas K. Chambers, in an address delivered at 
the opening of the London School of Medicine for Women, 1879, 
said : “ The minds of successful physicians are very various in calibre ; 
but they possess in common certain qualities not inconsistent with this 
variety, which qualities are the true causes of success. All have a 
marked power of concentrating their attention upon the matter in 
hand, and seizing the point at issue.” He presents various illustra- 
tions of the importance of seizing upon the more important indica- 
tions, without always waiting for the settlement of all collateral ques- 
tions, and says, “ the successful physician will sometimes apply means 
to cure the condition discovered, before the conclusion of the diag- 
nosis.” The cases supposed are among these where the successful 
practitioner will act promptly. Not unfrequently some of the reme- 
dies already suggested will be sufficient to arrest the course of events ; 
but there are more powerful agents, and more efficient methods 
of using some of those already proposed, which now claim atten- 
tion. 
According to our present experience, and in my judgment, our 
most efficient Apyretics are, quinine, jaborandi, opium in free doses 
often combined with belladonna, aconite, veratrum viride, chloral 
hydrate, and in some forms of fever and inflammation, at least, sali- 
cylic acid or salicylate of soda. All these articles make a strong 
impression on the nervous system, which is so prominent an agent in 
the production of morbid phenomena; and they, perhaps, also act 
upon the conditions of the blood, the vessels, and the tissues, modify- 
ing directly molecular action. But in whatever way their effects are TREATMENT OF FEVERS. 
177 
produced, the result is abatement and frequently arrest of the fever 
and the inflammation, even after its processes have been fully inaugu- 
rated, and sometimes when they are all much advanced. The safest, 
and perhaps on the whole the most efficient of the articles is quinine. 
In doses of from ten to thirty grains, or smaller ones more frequently 
repeated, but so that at least twenty grains are present in the sys- 
tem at once, the apyretic and anti-inflammatory effects are unques- 
tionable and decided, and a speedy arrest of all the morbid processes 
by its prompt use very often occurs. This result will be more cer- 
tainly secured, at least in many cases, by the combination of an opiate, 
as morphine and ipecac., or a Dover’s powder, with the quinine, so as 
to secure a decidedly soothing and a perceptible narcotic effect. As a 
rule, when this impression of the quinine is fully made, and the tem- 
perature is brought down to near the normal standard, and a free 
perspiration induced, the remedy need not be continued long, or be 
many times repeated. In the meantime a cathartic or other elimi- 
native treatment, as before indicated, may be prescribed; but the 
quinine impression should be repeated in twenty-four, or thirty-six, or 
forty-eight hours, if the fever and other symptoms return. The effi- 
cacy, the comparative harmlessness, and therefore the propriety of 
this course cannot be too earnestly commended. As this treatment 
has already been recommended in the general treatment of inflamma- 
tions, and as there will be frequent occasions to speak of it again in 
describing the treatment of particular inflammatory diseases, nothing 
more need here be said, notwithstanding its very great importance. 
The jaborandi has wonderful power in inducing free sweating, in 
diminishing the action of the heart, and reducing feverish heat. It 
sometimes depresses the vital actions even alarmingly, and requires to 
be used with caution ; but its depressing effects, when not carried too 
far, are temporary, and in the early stage of a fever in a fairly vigor- 
ous person, the full diaphoretic and apyretic effect may be produced 
with reasonable safety. Its active principle—pilocarpin—may be used 
in place of the fluid extract. 
The aconite and veratrum viride operate as sedatives to the heart's 
action, and often reduce the temperature markedly and induce per- 
spiration, but they are more dangerous than quinine when carried to 
the extent of their full apyretic action, from the amount of depression 
produced; and in feeble patients or advanced stages of disease are 
often decidedly objectionable in the doses necessary to be efficacious. 
There are cases, however, where their utility cannot be questioned, 
and they present themselves among the antipyretic agents from which 
selections are to be made. A drop or two of the tinct. of aconite, fre- 
quently repeated until relaxation or nausea occurs, or similar though 178 
TREATMENT OF FEVERS. 
somewhat larger doses of the tinct. or fluid ext. of ver. vir., used in a 
similar manner, are the methods advised.* 
Chloral hydrate, in doses of from 40 to 80 grains, will usually cause 
a fall of temperature from 3° to 4° F., and at the same time induce 
sleep, and may be efficient in cutting short an accidental fever ; but 
in free doses, alarming and even fatal effects have followed. It must 
therefore be used cautiously, but it can generally be prescribed for per- 
sons free from idiosyncrasies. 
The efficacy of salicylic acid in rheumatic fever and inflammation 
is now generally acknowledged, and its application to ordinary fevers 
and inflammations has much testimony in its favor. It has not long 
been in use for apyretic purposes, and its exact value has not perhaps 
been determined. In the German and Swiss hospitals, it is to a large 
extent taking the place of quinine as an antipyretic. It is used in 
doses of a drachm or more, and is thought to disturb the nervous sys- 
tem less than the antipyretic doses of quinine. 
But full medicinally narcotic doses of opium, better perhaps in 
the form of morphine, either alone or combined with relaxing and 
eliminative articles to prevent its ordinary effects of diminishing most 
of the secretions, will often be exceedingly efficient in not only miti- 
gating symptoms and procuring rest, but in subduing fever and inflam- 
mation. Its combination with quinine has been spoken of, but of itself 
it is a powerful antipyretic and anti-inflammatory remedy. In devel- 
oped inflammations, such as peritonitis, where it fails to arrest the dis- 
ease, it diminishes shock, and tends to enable the patient to endure it. 
Digitalis has a reputation as an antipyretic, given in repeated 
doses, and continued for some time. It is, however, not as prompt 
and certain in producing this effect as most of the other articles men- 
tioned ; but it, too, may be placed among the articles from which a 
choice is to be made. Niemeyer strongly recommends it, in connection 
with quinine, in pneumonia and other inflammatory fevers. A speci- 
men prescription would be: 
B Sulph. Quinine grs. v 
Tinct. Digitalis tti,xv 
Phos. Acid, dilute ttixv 
M. 
To be taken properly diluted once in four or six hours. 
* To save the extension of the text with unnecessary details, the ordinary doses 
as recommended in works on Mat. Med. are understood unless particular quantities 
in reference to special agents are designated. The matter of dosage, however, the 
time and manner of administration, the varied and sometimes opposite effect cf 
large and small doses, is one of great importance, and, in many cases, special direc- 
tions as to doses will be required. TREATMENT OF FEVERS. 
179 
Various other remedies, some new and others old, have their advo- 
cates (gelseminum among the new, and tartrate of antimony and 
potassa among the old) as antipyretic agents; and while their useful- 
ness in certain cases is not denied, their efficacy is not equal to those 
before mentioned. Antimony is liable to do harm by its spansemic 
and permanently debilitating effects, and its irritation of the mucous 
membrane of the stomach and intestines. Various saline and neutral 
mixtures, as the citrate, acetate, and tartrate of potash, the acetate of 
ammonia and the salts of soda, produce some antipyretic effects, 
operating at the same time upon the secreting organs and eliminating 
effete matters from the system. The indications for their use have 
already been mentioned. 
The use of cold water and the bath in simple fevers, and the febrile 
state generally, is receiving much attention ; and experience with it 
is accumulating on a large scale. As a palliative in abating ex- 
cessive heat, when properly and systematically applied, it is ‘doubt- 
less of exceeding value—patients being saved by it who would other- 
wise inevitably perish. A temperature as high as 107° to 110° or 112°, 
if continued for any length of time, whatever the cause, produces such 
degenerative changes in the tissues, especially in the heart, as lead to 
suspension of function and death. By means of the bath or of affu- 
sions the temperature can be kept down, and such consequences pre- 
vented ; but the influence such treatment exerts on the continuance of 
fevers and inflammations, and in preventing their development when 
applied in the forming stages, has not been sufficiently ascertained. 
The use of cold water in specific fevers, and particular inflamma- 
tions, will receive attention when those diseases are discussed. The 
free internal use of water, either plain or flavored, cold or hot, accord- 
ing to the taste of the patient and the stage and condition of the fever, 
the state of the stomach, etc., is generally useful. It aids elimination 
of effete matters from the kidneys, skin, and intestines, often reduces 
temperature, relieves the dryness of the mouth and throat, and pro- 
motes in every way the comfort of the fever patient. Although the 
free use of water is advisable, excess is possible, overloading and 
distending the stomach, and producing irritation and vomiting. 
When these effects are not produced the supply should generally be 
unlimited. 
The space occupied with the pathology of the pyrexial state, and 
particularly that devoted to simple, non-specific fevers, may seem out 
of proportion to that which will be given to some of the particular 
and more severe diseases. But a knowledge of the general subject of 
fever will be the best, and, indeed, the only preparation for a more SPECIFIC FEVERS—MALARIAL FEVERS. 
180 
ready and full understanding of its different varieties ; and many of 
the principles, pathological and therapeutical, concerned in non-spe- 
cific fevers are applicable to other forms, and to the allied condition 
of inflammation as well. 
This full discussion of the simple fevers, which are less severe, and 
in themselves of less interest than many of the specific fevers, will 
obviate the necessity of so lengthy an account of the latter. 
Time will be saved, and a better knowledge of the particular spe- 
cific fevers obtained, by a careful study of what has preceded. 
SPECIFIC FEVERS. 
Specific fevers have already been defined substantially as those 
which depend upon peculiar poisons, which present some distinctive 
characteristics, and which ordinarily pursue a somewhat definite 
course. 
The present views respecting the character of the poison producing 
them, and some of the reasons for their entertainment, have also been 
given in discussing the general pathology of fevers, and additional 
facts and influences will be referred to in the account to be given of 
the special forms. Following the arrangement in our classification, 
the first in order are the 
MALARIAL FEVERS. 
The leading characteristic in the phenomena of these fevers, in a 
majority of cases, is a marked periodicity, and hence the name Period- 
ical Fevers has been applied, distinguishing them from those having 
less of this fluctuating character, and which are called Continued 
Fevers. 
Bristowe applies the term ague to all the varieties of malarial 
fevers, and defines ague as a “specific non-contagious fever produced 
by malaria, characterized by enlargement of the spleen and recurring 
attacks of fever, attended each with a cold, a hot, and a sweating 
stage, and having an indefinite duration, and a tendency to recur, 
which may last for many years or during a whole life.” But some 
forms of malarial fever are not characterized by the three stages, well 
defined, as indicated ; and although the spleen is more or less en- 
larged as a rule, yet it is enlarged almost, if not quite, as constantly 
in enteric or typhoid fever, if not to the same extent ; and this 
enlargement of the spleen is not sufficiently characteristic or severe AGUE. 
181 
to entitle it to be placed as the leading phenomenon of the disease. 
Although it has a tendency to recur, and in rare cases, and where 
neglected, it may do so for several years when the patient is removed 
from the exciting cause, yet it gives too strong an impression of its 
persistency to say that it may last during the whole of life. 
Those who have seen whole communities affected with it, who 
have seen them continue in the same locality, where individuals occa- 
sionally suffer from it, showing the cause in some degree to still exist, 
and yet have seen that same community as healthy, as vigorous, as 
enterprising, and as efficient as any other, come to look upon it as 
not so formidable and permanent an affection, when properly treated, 
as those knowing less about it suppose. 
It is unquestionably not communicable from person to person, 
and is as certainly dependent upon a peculiar specific poison; and, 
though its duration is not as definite as in other specific fevers, it yet 
has a tendency to a spontaneous termination, and its recurrences gen- 
erally in time lose their severity and persistency, and a good degree of 
acclimation, in a majority of cases, is soon acquired. Had all who had 
been attacked with the disease followed the advice given by authors 
whose observations have been in large cities, where the disease is 
almost unknown, and removed from the locality where they were 
attacked, the greater part of the Mississippi Valley and the North- 
west would have been abandoned ; and the great granary of the world 
would have been a wilderness, inhabited by wild beasts and roving 
savages, instead of being, as now, a great centre of enterprise and in- 
telligence. 
But a few sentences can give no adequate idea of this class of 
diseases, and a particular description of its different varieties is 
required. 
Although malarial fevers all depend upon the same general cause, 
are constantly running into each other, and are therefore specifically 
the same, yet the phenomena of the different varieties are so dissimi- 
lar as to require, for the purposes of description and study, the 
divisions made in the table of classification, into Intermittent, Remit- 
tent, and Pernicious forms. 
INTERMITTENT FEVER—AGUE. 
The intermittent variety is the least severe, but most characteristic 
form of the disease. In its somewhat milder forms it is generally 
called, in the localities of its greater prevalence, the common ague. 
This variety is marked by four well-defined conditions during each 
evolution of its phenomena. There is, first, the cold stage, or chill, 182 
AGUE—PHENOMENA, 
resembling the description of the cold stage of fevers in general, hut 
usually more decided than in other forms of fever. Sometimes pro- 
droma of general indisposition, with coated tongue, a sense of weight 
in the regions of the liver and spleen, and a slight jaundiced condi- 
tion precede; but often the attack is sudden. In the midst of the 
usual state of health the face becomes pale and shrunken, the lips 
blue, the hands cold and shriveled, and the nails purple or lead col- 
ored at their base. An intense sense of coldness seizes the whole 
body, the papillae of the skin often rising in prominences, giving the 
appearance of Avhat is called “ goose-flesh the teeth chatter, the 
whole body is agitated and shaking, as when plunged into cold water ; 
the breath is short, and the voice abrupt and interrupted. The patient 
seeks a fire ; but this gives little relief to the sensations ; thirst 
soon occurs; sometimes pain in different organs ; occasionally there 
are nausea and vomiting; a feeble and contracted pulse, and some- 
times great prostration of all the vital functions. 
This cold stage varies very much in intensity and duration, con- 
tinuing sometimes only some minutes, at others, two or three hours, 
or even longer; but usually from three quarters of an hour to an hour 
and a half, when the hot stage succeeds. During the cold stage, 
when the temperature of the extremities is low, that of the blood, as 
indicated by the thermometer in the deep cavities, and often even of 
the trunk, is above the normal. As less heat is lost during this stage 
from the small quantity of blood at the surface, and from the in- 
creased covering and the application of external warmth ; and as dur- 
ing the approach of the hot stage the increased heat production comes 
on with more force, the temperature rises very rapidly and obtains a 
great height, often 105° or 106°, and sometimes even more, and the 
hot stage is fully developed. The blood now comes to the surface, the 
face is red and expanded, the pulse becomes full and strong, the sense 
of heat intense, though for a time an occasional sense of creeping cold- 
ness will alternate. Pain now occurs in the head and back, and 
throughout the body, often very severely. There is great thirst, loss 
of appetite, sometimes nausea and vomiting ; the mind is excited, 
sometimes to delirium, and the sufferings of the patient are generally 
very great. The secretion of urine during the cold stage is usually 
abundant, and is of a pale color. During the hot stage it is more 
variable in amount, still often free, but now high colored, and con- 
taining free quantities of urea and urates. The tongue throughout 
is coated more or less; during the cold stage it is often bluish, but 
during the hot stage it is often red and dry. In short, the patient has 
all the phenomena of fever of a high grade of intensity. 
This hot stage is very variable in duration, sometimes continuing AGUE. 
183 
not more than an hour, at others, ten or twelve hours, but commonly, 
in what is called common ague, not more than four or five hours. 
The third or sweating stage now comes on, sometimes with a free 
sweat and rapid subsidence of the heat, and at other times the sweat 
breaks out to dry up again—the increased lieat-production continuing 
for a time. The abnormal temperature during the sweating stage 
entirely subsides, however; the pains disappear, and the patient, though 
feeling weak and languid, with an unpleasant taste in his mouth, and 
a disagreeable, peculiar odor of his reeking body, is, in his first ex- 
perience, no less astonished than gratified at his suddenly improved 
condition. This sweating stage also varies in its continuance from 
less than an hour to two or three hours. The sweat has an acid re- 
action, has abundant salts and organic matter, especially fat acids, to 
which its odor is chiefly due. The urine is acid, has a free quantity 
of pigment, and. generally abounds in urates and uric acid. The 
amount of urea is generally increased as the temperature increases, 
but during the sweating stage and the apyretic period it is often below 
the normal amount. 
The fourth condition, or that of apyrexia, follows the sweating; 
the appetite may return, and though the feelings of vigorous health 
are not experienced, and the tongue remains coated, etc., the phe- 
nomena of fever disappear. This state continues until the next par- 
oxysm, which, according to the type, may be twenty-four, forty-eight, 
or rarely seventy-two hours from the time of the first attack. 
The term Intermitting Fever is often applied to a variety rather 
more severe than the form just described, or at least to one where, 
during the period of apyrexia, the relief of the general symptoms is 
not so complete, and where the cold stage is not so well marked by 
convulsive shakings ; and, further, where the hot stage is rather more 
protracted. This distinction, however, is not always made, and the 
terms Intermitting Fever and Ague may be indiscriminately and prop- 
erly applied to all the cases where a period of apyrexia occurs. 
Left to itself, intermitting fever is variable and indefinite in its 
course and duration, but is generally protracted; and when sponta- 
neously subsiding after long continuance, it commonly leaves the 
system in an anaemic and debilitated state, with enlarged spleen, con- 
gested and otherwise altered liver, frequently with moderate dropsical 
conditions, and general derangement of the secretions, and with a 
special liability to recurrence of attacks. 
The other forms of malarial fever, the remittent and pernicious, 
are simply varieties with the intermittent of one species of periodical 
fever, but they differ so much in phenomena as to require a separate 
consideration. 184 
AG UE— VARIETIES. 
In common ague, as we have seen, the stages are well marked. 
The chill of from a few minutes to an hour or more, is followed by a 
fever usually of a longer continuance, and this by a relieving sweat 
and a period of the absence of these phenomena. The picture of ague 
would, however, be very incomplete if some marked deviations from 
this type were not mentioned. 
One of the most important in its effects, and therefore essential to 
he recognized, is what is popularly called “ Dumb Ague,” a state in 
which the ague cause is operating, often severely, but where the usual 
stages are not expressed. There are usually sensations of slight chilli- 
ness, and a moderate elevation of temperature, but no decided rigors 
or feverish hushing of the face, and generally there is an entire absence 
of the sweat. The blood-glands, the blood, and the secretions are more 
rapidly deteriorated and deranged than in the common cases of well- 
expressed ague. From the obscurity of the symptoms, these cases are 
sometimes not recognized, and are therefore neglected; but they 
require even more prompt treatment than the ordinary forms. 
In other cases paroxysmal neuralgias appear without a recognized 
chill or fever, more frequently affecting the right brow than other 
parts of the body, and often not as readily yielding to treatment as 
most other forms of malarial disease. The blood deterioration and 
glandular derangements are not as marked as in the “dumb ague.” 
In other cases, at the time of the paroxysm, active vomiting and 
purging occur, at first perhaps of bile, but at length of a serous fluid, 
and often so profuse as to simulate the symptoms of malignant cholera 
—with the “ washer-wo man’s ” hands, the cold sweats, extreme thirst, 
ashy pale or leaden surface, the severe cramps, and sometimes collapse 
and death. These results, however, are much more easily averted 
than in Asiatic cholera. Other unusual manifestations and compli- 
cations sometimes occur, and. other diseases attacking those whose 
systems arc affected with malaria, are modified by this influence, the 
symptoms often assuming a degree of periodicity not usual in such 
diseases. 
The period intervening between the cessation of one paroxysm and 
the commencement of the next, is called the Intermission ; that 
between the commencement of one and the commencement of the next, 
is called the Interval. There are different types of ague as to perio- 
dicity, and these types are determined by the length of the interval. 
In some the interval is twenty-four hours or thereabout, the parox- 
ysms occurring daily, and they are therefore called Quotidian Agues. 
In others the interval is forty-eight hours, more or less, and the 
paroxysms occur every second day. The name “ Tertian” is given to 
this type of ague. MALARIAL FEVERS. 
185 
When the paroxysm occurs only on each third day, as is very rarely 
the case in the Northwest, the term Quartan is used. 
Other varieties are mentioned where the interval is still longer, but 
they are too rare to require notice. 
There are what are called “ Double Tertians,” where a paroxysm 
occurs daily, but where those of alternate days correspond with each 
other in the hour of the attack and in their characters, while the 
immediately succeeding paroxysms do not thus correspond. There 
are also Anticipating and Retarding cases. In the former, usually 
commencing as a tertian, each paroxysm occurs earlier in the day than 
its predecessor : while in the latter, usually commencing as a quo- 
tidian, the attacks are later each day. In the one case the tertian 
may be converted into a quotidian, and in the other the quotidian 
into a tertian. In the anticipating variety the disease is regarded as 
becoming worse, in the retarding as better. Abrupt changes from 
the quotidian to the tertian, and from the tertian to the quotidian, 
also occur. 
Besides these there are very rarely erratic or irregular types, 
observing no strict order of periodicity. 
In quotidians the paroxysms more commonly occur early in the 
day, from eight to eleven o’clock, while in tertians they occur a few 
hours later, near midday, and sometimes in the afternoon. There is, 
however, no uniformity in this respect, and the length of the paroxysm 
does not depend upon the type as to the frequency of occurrence of the 
attacks. As already intimated, agues tend to self-limitation, but the 
period of spontaneous subsidence is exceedingly varied. A few parox- 
ysms, or even a single one, may be followed by spontaneous recovery ; 
or the disease, in varied forms, may continue for long periods. In 
spontaneous recoveries and returns of the disease, septenary periods 
are more frequently observed than others ; the changes are more likely 
to occur on the seventh, fourteenth, and twenty-first days from the 
preceding change than at other times. The reason for this, as for 
many other periodicities, the present state of our knowledge does not 
enable us to give. In the neglected and protracted cases, enlargement 
of the spleen, sometimes to great dimensions, is very apt to occur, and 
a depraved and cachectic condition c* an extreme character is some- 
times produced. Besides the spleen ; the liver, the mesenteric glands, 
the alimentary canal, the bronchi and lungs, and the brain, may suffer 
structurally, with corresponding changes of function. Blood poison- 
ing, ansemia, tissue perversions, neuralgias, hemorrhages, or dropsy 
may follow. These conditions, as accompaniments or sequelae, arc apt 
to attend intermittent fever, though when the disease is speedily 186 
A G UE—DIA GNOSIS. 
arrested the cure is often complete and permanent. The longer it is 
allowed to run, the more likely are relapses to occur, and the greater 
are the derangements of the spleen, the liver, the blood, and the gen- 
eral system. 
The long continuance of ague, or its frequent relapses, showing 
that the morbid influence continues in the system, often produce very 
serious results. The spleen becomes enlarged, and its blood-produc- 
ing functions perverted. The blood loses many of its red corpuscles, 
while the white increase in number, but diminish in size ; a dropsical 
tendency is manifested in oedema, especially of the lower extremities, 
and often by effusion in the peritoneum, and an anaemic appearance 
is marked. 
The liver is enlarged and otherwise structurally and functionally 
changed; a jaundiced appearance is commonly present, the urine is 
loaded with bile, the stools clay-colored, palpitations of the heart and 
venous hums appear ; epistaxis and profuse menstruations sometimes 
take place; the appetite is variable, sometimes nearly lost, and at 
others ravenous, but the digestion is imperfect, and the malarial 
cachexia is developed. The change of color in the skin and other 
tissues is not due alone to the presence in them of bile, but also to the 
conversion in the spleen of hasmatine into pigment, which becomes 
distributed over the body. This material often obstructs minute 
vessels, and doubtless does much mischief, and may conduce to the 
production of nephritis, sclerosis, and amyloid and other degenera- 
tions of different organs, neuralgias and various nervous affec- 
tions. All these results may follow from a neglected common ague, 
but they also follow more serious malarial diseases," and will be briefly 
referred to again. 
Diagnosis.—In the progress of common agues, local irritations, 
congestions, and sometimes inflammations may complicate the cases. 
When inflammatory complications are present, the type of fever is 
changed, the intermissions are lost or become less perfect, and each 
paroxysm of fever aggravates the local disease. In such cases the 
malarial element may be obscured, but it is to be distinguished by the 
locality of the patient, by his having had previous attacks, by the 
greater periodicity of the symptoms—aggravations at particular periods 
of the day, especially if such aggravations appear in the forenoons— 
and often by the fever being out of proportion to the amount of local 
disease, and not so fully following its changes. 
Ague is to be distinguished from Hectic Fever by the absence of 
chronic suppurative or other local disease ; by the more equal distri- 
bution of the feverish heat over the surface of the body ; and partic- 
ularly by the relieving, instead of the depressing and uncomfortable MALARIAL FEVERS. 
187 
sweat, and by its occurrence in the daytime, at least as often as in 
the night; also by the peculiar odor of the ague perspiration, by the 
exposure to the malarious influence, by the effect upon the spleen and 
liver, and by the general character of the symptoms and appearance 
of the patient. 
Prognosis.—The prognosis, under proper treatment, is exceed- 
ingly favorable as to the arrest of the course of the disease; and 
“common ague” is seldom immediately fatal when left to itself. 
Some cases, however, persist in recurring, especially if permitted to 
continue long before interruption ; and even in the common forms of 
the disease, alarming and even fatal results occasionally follow. 
Various historical persons. in England and elsewhere have died of 
ague; and Shakespeare, who is true to facts and nature, made his 
Ealstaff die of what Mrs. Quickly called a “quotidian tertian,” indi- 
cating that ague was not an uncommon cause of death at the time 
represented. The remitting form of malarial fever is much more 
dangerous, and the pernicious variety is fatal when left to itself. 
The severer forms of malarial fever, remitting and pernicious, re- 
semble other diseases from which they should be carefully distin- 
guished, but this hereafter. 
Etiology.—The cause of ague is now universally considered to 
be some poisonous material belonging to particular localities, which 
has received the name of malaria, or more distinctively, marsh miasm 
or paludal' miasm. The existence of this material has not been 
physically and conclusively demonstrated, but it has been satisfactorily 
inferred from its effects. 
Signor Tommasi, of Rome, and Professor Klebs, of Prague, in the 
spring of 1879, made some investigations into the physical cause of 
marsh fever, in which they report the discovery of a microscopic 
fungus in the Agro Romano, which they alleged produced the phe- 
nomena of ague in animals to which the fungi were administered. 
These experimenters gave the name of Bacillus Malarice to the fungus ; 
but these observations have not been sufficiently confirmed to enable 
us to regard the question settled as to the form of matter constituting 
the malarial poison. 
The particular class of diseases called malarial are found to pre- 
vail in certain localities, independent of the habits and all other con- 
ditions of the people. Persons going to these infected localities, who 
are not acclimated, take the disease, whether there happen to be others 
there affected with it or not; and proximity to, or avoidance of, the 
persons ill with the disease has no perceptible effect upon its occur- 
rence. In numerous instances, persons residing at a distance of from 188 
AG UE—CA USA TION. 
one to a few miles from a locality where the disease originates, remain 
free from it while there are no Avinds, or when the w'inds blow so as 
to carry the air from the infected locality away from their residences ; 
but when the wind changes so as to bring the air from the infected 
region to these persons, they take the disease. In other very numer- 
ous cases, persons remaining in localities free from the disease, and 
who have been exempt for long periods, have taken it when new soil 
has been broken up, or when a portion of the ground has been inun- 
dated, the water drawn off, and the earth exposed to the sun. Persons 
susceptible to the ague visiting in the night or early morning a par- 
ticular locality, as the marshy rice-fields of South Carolina, are almost 
sure to take the disease; while they can visit the same place in the 
daytime with comparative impunity. These, and numerous other 
similar facts, prove conclusively that there is an influence belonging 
to some localities, which does not belong to others, capable of produc- 
ing the disease ; and the facts respecting the influence of winds, 
together with other corroborating evidence, show satisfactorily that 
the influence is connected with a material substance. The nature of 
that substance, in the absence of its actual detection and of positive 
proof of the particular kind of substance producing the effect, must 
be conjectural; and various conjectures have been indulged. From 
numerous analogies and considerations there is the strongest proba- 
bility that the material is organic and vegetable, or in that border 
land between the vegetable and animal organisms. In what form it 
enters the body, whether it multiplies there, and if so, in what 
manner; and what changes it effects in order to produce the phe- 
nomena of the disease, arc matters entirely unknown, and respecting 
which it is unnecessary here to speculate. Of the conditions of 
localities which give rise to its production, we have more knowledge, 
and they are worthy of being carefully inquired into. 
Ague districts are found scattered here and there over all the zones 
of the earth except the frigid ; but the poison, as a rule, is more 
intense and more severe in its effects the nearer the equator. The 
localities of its production are usually not far above the sea-level, and 
are low compared with their surroundings ; and yet those living upon 
a bluff a few hundred feet above, but near, a low spot where the poison 
is supposed to be produced, are sometimes more seriously and more 
generally affected than those nearer the source and on a lowTer level. 
It seems to have a specific gravity which causes it, sometimes at least, 
to rise some distance above the surface, but it is not found in moun- 
tainous regions. These malaria-producing localities are usually moist 
and alluvial, with abundant vegetation ; but sometimes the poison is 
produced on comparatively dry and sandy plains when the virgin MALARIAL FEVERS. 
189 
soil is broken by the plow, or when deeper excavations are made. A 
certain amount and duration of summer heat seems necessary to its 
existence, and it is not produced during the frosts of winter. The 
season of the year when diseases from malaria most prevail in the 
Northwest is the latter part of summer and autumn ; and they are 
particularly likely to occur when the first part of the warm season is 
wet and the latter part dry. Drying of the soil after inundation, in 
a malarious region, is particularly productive of the poison. 
No single condition which has as yet been traced necessarily pro- 
duces this substance. It certainly is not high temperature alone, for 
some of the hottest regions are free from it. It cannot be water and 
aqueous vapor, for many of the most wet and foggy places are exempt 
from its influence, and it prevails more in the season of drought than 
of rain. It cannot depend simply upon decaying vegetable matter, as 
that takes place, sometimes on a large scale, where ague never comes, 
and ague often appears where no such decay is taking place. It cer- 
tainly does not depend on human excreta or contamination, or on the 
presence of animal matter in any form, as it is far less likely to prevail 
in crowded cities than in the open country. Notwithstanding this list 
of negations, the facts warrant certain positive conclusions respecting 
the conditions of its production. 
1. Malaria is produced in the soil and emanates from it in certain 
localities. 
2. The conditions of the soil and locality most favorable to its pro- 
duction are moisture, or alternations of moisture and dryness, with a 
free quantity of vegetable matter, in a low altitude, and where there 
is a large amount and long continuance of summer heat. 
3. The upturning of virgin soil, or soil long undisturbed, and its 
exposure to a summer sun. 
It is worthy of notice that these conditions are such as are favorable 
to vegetable life and growth, and they suggest the probability of the 
poison being a microscopic vegetable organism, but one which has as 
yet eluded distinct recognition. This will not be so surprising when 
we consider that with all the aids to our senses—the telescope for 
magnitudes and the microscope for the minute—we can still become 
cognizant of only a small area in the infinity of magnitude on the one 
hand, and of minuteness on the other. 
There are certain conditions favoring the spread and reception of 
this poison into the system and promoting its effects there, which are 
sufficiently obvious. It seems to be attracted by moisture, and is car- 
ried from the earth by fog and vapor, and to whatever height they 
may arise the poison may be carried. Hence exposure to the night or 
early morning air in malarious regions, when vapors rise and prevail, 190 
A G UE—CA USA TION. 
is particularly dangerous. This has long been understood, and 
Shakespeare makes Portia reproach Brutus for “ daring the vile con- 
tagion of the night” in malarious Home. Winds may carry the poi- 
son to a greater distance—sometimes for a few miles from its source, 
but not farther—and a sheet of water interposed, which attracts it, or 
a screen of wood, serves to some extent as a protection. In free mov- 
ing air, and especially when its oxygen is in an active condition of 
ozone, as it usually is in pine forests, the malaria is soon dispersed and 
oxidized, or in some way destroyed. Pine and cypress forests are 
regarded as opposing its effects. 
Acclimation — accustomed exposure to malaria — has a decided 
effect in preventing and modifying its action; but complete exemp- 
tion in all cases does not occur, at least until after some generations. 
The dark races, particularly the African, are much less subject to its 
influence than the white ; and this is doubtless due to the influence of 
acclimation, of accommodation and selection during unknown gener- 
ations in the malarious jungles of their native regions. Africans, at 
least after a few generations in lion-malarious regions, become subject 
to the influence of the poison when exposed to it. Negroes in our 
country not unfrequently have the ague. In Africa they generally, if 
not universally, escape in regions where white men are intensely 
affected. 
Though malaria is the essential cause of the whole ague series of 
diseases, yet there are certain predisposing causes which favor its 
effects. Those conditions are, fatigue, exposure—especially in the 
night—loss of rest, bad or insufficient food, irregularities, or anything 
which debilitates or deranges the system. 
The period of attack after exposure to the specific cause, or the 
period of its incubation:—the latent period of the poison—is exceed- 
ingly various. In what form the poison or its effects remain in the 
system during this period, and how it influences the organism or any 
of its parts, is not known. We only know that the exposed persons 
remain in apparently good health—it may be for a few days, or even 
for a few hours only, or it may be for some years—when the charac- 
teristic phenomena appear. Sometimes, however, the health seems to 
suffer in a general way, without definitely characteristic symptoms, 
for some time before the ordinary phenomena of ague occur; but not 
unfrequently there is no evidence of the presence of the malaria for 
long periods after any possible exposure to it at its sources, and then 
the disease suddenly appears. In these cases the attacks are apt to be 
recurrent and the disease more obstinate than when it appears soon 
after exposure and at the source of the poison. These facts are at 
present without satisfactory explanation. MALARIAL FEVERS. 
191 
Pathology.—We have considered the more perceptible phenomena 
cf intermitting fever, and mentioned the principal known facts of its 
causes. It now remains to give an account of its Morbid Anatomy and 
Pathology, and its treatment. 
In the absence of a knowledge of the character of the malarial 
poison, and the manner in which its effects are produced, we shall he 
prepared for the statement that its pathology is obscure; and we may 
add that morbid anatomy throws but little light upon it. We are 
confident that a poison, probably a living one, is taken into the sys- 
tem, and that by its own presence, or some peculiar substance or in- 
fluence, the production of which it induces, a changed state results, 
and that for an indefinite period, at irregular intervals, more or less 
distinctly periodical attacks of fever occur, attended with rapid de- 
struction of tissue, congestion of internal organs, high temperature, 
and the general perversions of a decided febrile state. We know 
further that the sweating stage tends to relieve the symptoms ; and 
from the freedom and peculiar odor of the perspiration, and the 
relief following, we infer that in the paroxysm some injurious material 
is eliminated from the system. But where the original poison lurks, 
why it acts periodically, and how it produces its effects, we have not 
learned. There is, however, reason to believe that, whatever effects 
may or may not be directly produced by the poison on molecules, 
cells, and fibres of the various tissues, or upon the blood-vessels or the 
blood, the lymphatics or the lymph, or upon the substance and func- 
tions of any particular organs, impressions upon the brain and nerves, 
and the action of this nervous system, especially the sympathetic, have 
much to do in the production of the morbid results. It is probable 
that the enlargement and other changes of the spleen, the liver, and 
other glands, and the modification of their functions, however im- 
portant they may he in inducing some of the morbid phenomena, are 
only secondary effects of deranged organic nerve action. 
The most constant anatomical lesion discoverable after death is en- 
largement of the spleen. This organ becomes distended with blood, but 
whether more than its anatomical structure and connections will account 
for in the general internal congestions which occur, or whether there is 
some special influence exerted upon that organ, is not fully determined. 
Probably some special affinity exists between the poison and the 
spleen, and a special influence is exerted upon it. It is mox-e suscepti- 
ble to a morbid influence from the poison than other parts of the sys- 
tem, as different articles—medicines and jxoisons—operate specially 
upon different organs. The liver is also generally engorged and in- 
creased in bulk, and sometimes degenerated (amyloid). Congestion 192 
A G UE— TREA TMENT. 
of considerable portions of the alimentary canal lias been observed, 
and hemorrhage sometimes takes place from the mucous surface into 
the substance of the organs, and in recent cases the spleen particularly 
is soft and friable, and of a deep wine color. Portal congestions occur 
in all forms of malarial fevers, and congestion of the liver sometimes 
produces the nutmeg appearance. 
In long-continued cases, where there have been many attacks, en- 
largement, hyperplasia, and induration of the spleen and liver are 
commonly found. Not unfrequently a dark or slaty discoloration of 
these organs is present, due, it is thought, to disintegration of blood 
corpuscles, and their conversion into pigment granules. In the liver 
minute extravasations of blood take place into the capsule of Glisson 
and the hepatic parenchyma, leading to the discoloration ; and in the 
spleen, similar changes of the blood in the intermediate blood-passages 
take place. These pigment granules in the spleen are apt to escape 
and enter the general circulation, and becoming arrested in the capil- 
laries of different organs, such as the liver, brain, and kidneys, cause 
them to be discolored, while interfering more or less with their func- 
tions. Various changes in the blood corpuscles have been noticed, 
but not with such frequency or uniformity of results as to justify 
definite statements on the subject. The proportion of white corpuscles 
is frequently very perceptibly increased, while the red corpuscles and 
the albumen are diminished, and the quantity of pigment is increased 
at the expense of the hsematine. The lesions of the blood-producing 
organs—the spleen, liver, lymphatic glands—and mucous membrane 
of the intestines, and the destructive effect of the fever heat, account 
for the impoverished and changed condition of the blood. 
TREATMENT OE INTERMITTING FEVER—AGUE. 
The treatment of this, as of other diseases, may be divided into 
prophylactic and remedial. The prophylactic treatment of ague will 
be inferred from the account given of its causes. There can be no 
doubt of the propriety of draining marshy, malarious districts, when 
practicable, so as to prevent the accumulation of stagnant water in 
wet times, and the subsequent drying off which so encourages the 
production of the miasm. Many infected localities have thus been 
made healthy. The clearing away from such localities of dead and 
decaying timber, and the underwood and jungle, will also he im- 
portant. The cultivation of new soil, though increasing the produc- 
tion of malaria in the earliest part of the process, results in the 
diminution and eradication of the miasm. As a rule, the older and 
more thoroughly cultivated a locality, the less ague occurs ; but it MALARIAL FEVERS. 
193 
should be stated that this rule is subject to exceptions, and that ague is 
occasionally found in old and well-cultivated localities. In the neigh- 
borhood of New York City this disease has prevailed for years past, 
and more recently it has appeared along the Connecticut River, and 
even among the hills of Western Massachusetts, where it was unknown 
before. In many places in the West, wdiere ague was exceedingly 
prevalent in the early settlement, it has almost, and in some places 
entirely disappeared, as the localities became more thoroughly culti- 
vated and densely inhabited. In and about Rome, though cultivated 
after a fashion for centuries, ague still prevails. 
The inhabitants of malarious regions, during the season of the pro- 
•duction of the poison, should be careful as to exposure in the night or 
early morning, when there is more of the poison in the air ; should avoid 
getting wet, or lying or sitting upon the ground ; should use only fresh, 
pure drinking water, or if this be not attainable, the water should be 
boiled; improper articles of food, excessive fatigue, and, in short, all 
debilitating and disturbing influences should be guarded against; and 
while persons are well no medicine is needed. The taking of repeated 
and long-continued doses of quinine, or other antimalarial specifics, for 
the purpose of preventing attacks, cannot be recommended. Should 
persons, as in the case of a marching army passing through a limited 
malarious region, be exposed but a short time to the poison, the sys- 
tem might perhaps with propriety be kept under the influence of the 
medicine while the exposure continued ; but this suggestion rests upon 
theoretical considerations rather than upon experimental facts. In 
order that quinine should have a reliable effect in counteracting the 
influence of malaria, the system must be well saturated with it, and 
large and repeated doses must be given. This cannot be borne in- 
definitely without injury, and if smaller doses are occasionally given 
and attacks occur, as they are liable to, the system, having become 
accustomed to the quinine, fails to respond to it as promptly and cer- 
tainly as in cases where it has not been thus used. 
Whatever may be the explanation, the fact is well known to those 
of large experience in malarious diseases, that in repeated and long- 
continued use, the antimalarial power of quinine is diminished, and 
in some cases almost entirely destroyed. In the common language of 
patients, it becomes “worn out.” In our late civil war, when the 
army of the Union was occupying the malarious Peninsula of Virginia, 
the practice was tried of giving daily rations of quinine and whiskey, 
but it was soon abandoned as useless, or worse than useless. In civil 
practice, with persons residing in a malarious region, this form of 
attempted prophylaxis is injurious. Even when attacks take place 
and are recurrent, great care should be taken that the virtues of qui- 194 
A G UE—TREA TMENT. 
nine be not “ worn out” by protracted use. The recommendation of 
Sir T. Watson, repeated by Bristowe, that persons residing in mala- 
rious regions, “ on going out should wear charcoal respirators,” from 
its impracticability, excites a smile ; and the further recommendation 
that they should “ also regularly take such remedies as are efficacious 
in curing ague,” must be condemned. The additional advice that 
“persons who are actually attacked with the disease should be removed 
to some healthy locality,” if strictly carried out among us, would have 
depopulated many of the fairest and now most healthy portions of our 
country. The best works of the best men, when dealing with subjects 
beyond their experience, are apt to be marred by similar impracticable 
or injurious recommendations. All practicable prophylaxis in this 
disease consists in improving the conditions of the locality, in avoid- 
ing night exposure (but here it must be remembered that air enters 
houses from without or respiration could not long be sustained), and 
in observing such hygienic regulations as tend to the preservation of 
vigorous health. When the disease occurs, it must be met by appro- 
priate therapeutical treatment, and to a description of this we shall 
now proceed, aided by such lights as a careful study of the subject 
and a long and varied experience with malarious affections may afford. 
The treatment of cases of intermittent fever is naturally divided 
into symptomatic, or that which is palliative of the paroxysm, and 
radical, or that which is curative of the disease. 
The Palliative Treatment will, of course, be varied by the stage 
of the disease and the particular symptoms presented. Dr. Wilson 
Philips long ago announced the doctrine that we should endeavor to 
put an end to each stage by inducing that which is to succeed it. 
According to this, in the cold stage we should, by heat, warm drinks, 
etc., endeavor to bring on the hot stage, and in the latter, the sweat- 
ing stage should be induced. 
The cold stage is frequently so short or so light as to require little 
attention, and in ordinary cases, though it may be somewhat pro- 
tracted and severe, little need be done. The patient naturally seeks 
external warmth, in which he may be indulged, but the relief obtained 
by it is not great. Special palliative means for this stage are required 
only when it is unusually severe, or when it occurs in the aged or 
feeble. In such cases the interference may be important. 
As the chief pathological condition is that of internal congestion, 
with contraction of the external vessels, the spasmodically contracted 
external vessels should be relaxed and the blood should be invited to 
the surface and extremities. External warmth and irritation, hot air 
or warm water, or mustard baths, warm packing, warm bottles, etc., 
as recommended in some cases of simple fever, will have some effect. MALARIAL FEVERS. 
195 
Blood may be retained in the extremities by their ligation, putting 
a fillet about the thighs and the arms near the shoulder, so as to 
detain a portion of the venous, but not to interrupt the arterial flow. 
This necessarily diminishes the quantity in the internal organs, and 
thus often produces great relief to those distended and suffering parts, 
and also to the sensations and general depressed condition of the 
patient. The chilly sensations are often by this means remarkably 
relieved. The free application of dry cups and the use of Junot’s 
cupping-boot are other means for accomplishing the same purpose. 
A bleeding will check the cold stage, as long ago shown by Dr. Mack- 
intosh, of Edinburgh, and might be properly practiced in cases of 
decided plethora, but it is almost always unnecessary, and would gen- 
erally be injurious by depriving the system of its needed circulating 
fluid, and tending to increase the anaemia and debility so constantly 
following the disease. Still, the injury and danger of the loss of blood 
are often exaggerated, and present relief to all the disturbing symp- 
toms would frequently be obtained by it. Wot only former practice, 
but the occurrence of spontaneous hemorrhages supports this statement. 
Other means for relaxing spasm of external vessels and relieving 
the interna] congestion and depression may be required. Opiates, 
chloroform, ether, camphor, ammonia, etc., are remedies applicable 
to this state. Chloroform in doses from half a drachm to a drachm, 
in a proper vehicle, by the stomach, generally produces very speedy 
and marked relief. Ether produces a somewhat similar but less 
powerful effect ; and a decided dose of laudanum, morphine, or some 
other form of opiate, will answer the indication admirably, especially 
if the patient is suffering from pain. When this cold and depressed 
stage is accompanied with profuse serous vomiting and purging, as is 
sometimes the case, opiates are imperatively demanded. 
The nitrite of amyl is said to be quite efficient in bringing on 
reaction and abbreviating the stage of chill. Pilocarpin has recently 
been reported as exerting a remarkable influence when administered as 
the chill is coming on, arresting it and substituting the sweating stage, 
and preventing the occurrence of the usual hot stage. It is also 
alleged that this treatment is radical, preventing the recurrence of 
paroxysms in a considerable proportion of the cases. It is administered 
hypodermically, in doses for an adult of from one twelfth to one sixth of 
a grain of the nitrate or muriate of the pilocarpin at the time the chill 
is about to occur, or it may be given in a corresponding dose of from 
one sixth to one fourth of a grain by the stomach, half an hour before 
the expected chill. Should these favorable reports be confirmed, we 
have an additional remedy for combating this disease ; but longer and 
more varied experience is required to establish its efficacy and safety. 196 
A G UE— TREA TMENT. 
In these depressing chills, warm drinks, spiced teas, hot coffee, 
etc., aid in relieving the depression. It is only in exceptional cases 
that any of these means will be needed, but when required, great 
promptness in the application, and discretion as to the selection, the 
size, and the repetition of doses, will be necessary. 
The sufferings of the patient are usually greater in the hot stage 
than in the cold, though the danger may not be as great as in the 
exceptional cases referred to. Although the fever is of so high a 
grade that, if long continued, serious consequences might follow, yet 
the system can endure a very severe fever for a short time, and during 
the period of apyrexia it, to a large extent, recovers its tone, and the 
rapid degenerations which attend continued fevers of so high a tem- 
perature are avoided. The sufferings to the senses of the patient, while 
the fever lasts, are great, and often demand palliation. 
The patient should be in a cool, well-ventilated room, his covering 
should be light, he should have plenty of cold drinks unless they 
oppress his stomach, which is not usual, but if so, he should take a 
small quantity often. Bits of ice may be allowed when desired or 
agreeable, and the application of cold, cool, or tepid water, or vinegar 
and water to the surface, as most agreeable, by sponging, packing, or 
affusion, is exceedingly grateful and relieving. Cold, to the head 
particularly, is useful, not by a small wet cloth placed now and then 
upon the forehead while the back of the head is buried in a hot 
feather pillow, but by means of large towels wrung out of ice-cold 
water and wrapped about the whole head, and changed as soon as they 
become a little warm, two such being used, one remaining in the water 
while the other is on the head. The general bath, where there are 
conveniences for it, would be useful, but the sponging is always avail- 
able, and, in severe cases, should not be neglected. To be most effect- 
ual it should be thorough, free quantities with large sponges being 
rapidly applied, and a blanket placed under the body to protect the 
bed. 
Not unfrequently nausea, vomiting, or severe gastric distress, with 
great thirst and intense general suffering, are present, calling for addi- 
tional measures of relief. Nothing is more efficient for this purpose 
than about one quarter of a grain of morphine, dissolved with twenty 
grains of tartaric acid, in half or two thirds of a tumbler of water, with 
about twenty grains of bicarbonate of soda dropped into the solution 
when ready to be taken, and the whole taken Avhile effervescing. The 
patient may often thus be transferred from a state of the most severe 
suffering—of pain in almost every part of the body—to one of abso- 
lute enjoyment, the contrast making him very happy and grateful. 
If we may say her instead of him, that gratitude will not disappear MALARIAL FEVERS. 
197 
with the effect of the dose. If the stomach should immediately reject 
such a draught, as is possible hut not probable, the morphine may be 
used hypodermically, or, which will often answer nearly as well, the 
morphine, in powder, may be dropped far back upon the tongue, and 
a tea-spoonful of water taken after it. Used in this way, it is speedily 
absorbed by the mucous membrane, and no act of vomiting is likely 
to dislodge it. After a few minutes, its rejection is impossible. If 
the paroxysm is protracted, similar effervescing mixtures may be 
repeated often, but generally without further additions of morphine ; 
or half a teaspoonful of a mixture of three parts of bitartrate of pot- 
ash and one of bicarbonate of soda, in half a tumbler of water, taken 
as it slowly effervesces, and repeated ad libitum, will be very grateful, 
and will act as a gentle laxative and diuretic. 
In the administration of soda or Seidlitz powders, instead of dis- 
solving the ingredient in separate quantities of water and adding the 
solutions together, one of the powders should first be dissolved in the 
necessary quantity of water, and the other added in a dry, well pul- 
verized state. This will secure a slower effervescence, and give time for 
it to be taken before it is dashed over, and before the carbonic acid 
has so nearly escaped. The powder most difficult of solution should 
first be dissolved in the water with the sugar, if that be used, and the 
other added when ready to be taken. 
What appear to be small matters of this kind in administration 
and management, are by no means so in their results, either in suc- 
cess in treatment or in obtaining and securing patients. They are, 
therefore, mentioned with such particularity. 
In children, not very unfrequently, convulsions occur, sometimes 
during the cold stage, oftener, however, in the early part of the hot 
stage, but while the internal congestion is still decided. In these pa- 
tients the cold stage is not so strongly marked as in the adult; there is 
more of the mingling of the cold and hot stages, but the congestion is 
as decided and the irritation as great, and, as is well known, their sus- 
ceptibility to convulsive movements is much greater. These convul- 
sions will be most speedily relieved by the administration of chloro- 
form, either by inhalation or by the mouth. The warm bath aids in 
producing relaxation ; while, if the fontanels be prominent, or evi- 
dence of fullness of the cerebral vessels is present, cold should be 
applied to the head and revulsives to other parts. As children are so 
liable to have gastric and intestinal irritation from undigested food or 
morbid secretions, emetics sometimes, and cathartics generally, are 
useful ; the latter aided in their speedy operation by enemas. They 
relieve the brain by their revulsive effect, as well as remove irritating 
matters from the alimentary canal. Castor-oil, sometimes with the 198 
A G UE—TREA TMENT. 
addition of a few drops of the oil of turpentine, or a grain or 
two of calomel, is generally preferred as a cathartic. By careful 
attention, and timely administration of the chloroform or other anaes- 
thetics, the convulsions can generally be controlled. In all such cases 
curative treatment, or treatment preventive of the recurrence of the 
paroxysms, must be promptly applied. This promptness should be 
observed in any case, either in children or adults, where severe or unu- 
sual symptoms occur. 
In the hot stage of ague, as well as in the cold, severe serous vom- 
iting and purging may come on, and occasionally bloody discharges 
from the bowels take place. Both the cold and the hot stages may 
be merged in an attack of cholera morbus, as already described. In 
these cases the most prompt measures are demanded. The great remedy 
here is opium in some form or combination. The use of morphine in 
the manner already described will often answer the indication, but 
still more effectual in arresting these discharges is the following 
compound: 
B Opium, 
Camphor Gum ad grs. ij 
Calomel grs. iij 
Sugar of Milk grs. xv 
M. 
Bub up into a very fine impalpable powder. This should be 
dropped into a tea-spoonful of water, and taken far back in the mouth, 
followed by a single small swallow of water. The most favorable time 
for its administration is immediately after an act of vomiting. The 
importance of the minute division especially, and the combination 
with the camphor, favoring its ready diffusion in the stomach and 
application to its walls, cannot be too strongly insisted upon when a 
speedy action is required ; and its administration with a small quan- 
tity of fluid is important. The dose may be repeated soon if the first 
appears to be rejected, or within an hour, more or less, if the symp- 
toms are not arrested. Discrimination as to quantity and repetition 
of doses, according to the effect produced, will of course be impor- 
tant, but a full medicinally narcotic effect is usually required. Free 
doses in these cases arc commonly well borne and demanded. Sina- 
pisms, or dry cups over the stomach, or the ligation of the extremities, 
may aid the effects of the other treatment. To secure the retention 
and effect of the powder, only very small quantities of fluid for some 
time after rnhst be taken into the stomach, or until an anodyne and 
quieting effect is produced. Any ordinary medicine diffused in a MALARIAL FEVERS. 
199 
large quantity of fluid in the stomach, especially when that fluid is 
being frequently rejected and replaced, can have little eft'ect, and if 
opium be in the form of a pill or a coarse powder, it is likely to have 
no effect at all. Neglect of these considerations may render treatment 
entirely nugatory in cases where the most prompt action of the medi- 
cine is essential. Exhaustion and collapse are liable to follow such 
attacks when not controlled. These violent symptoms are more likely 
to occur in the severer varieties of malarial fevers, but they sometimes 
appear in the strictly intermitting forms. 
The sweating stage requires no interference. The patient should 
be permitted, if not encouraged, to sweat; and nothing further than 
a tepid sponge bath, and a change of clothing after the sweating has 
subsided, is required. 
But the radical or curative treatment is most important, and is 
called for in all cases. Expectancy, or the “conducting through” 
system is entirely inapplicable here. We have means here of posi- 
tive and very effectual interference, and this should encourage 
us to hope that other means as effectual in other diseases may be 
found. 
We have for ague a class of special remedies well known and 
acknowledged as acting in some way very specifically upon the essential 
morbid condition, either by neutralizing the poison by a direct action 
upon it, or by so impressing the system as to render it insusceptible 
to its full effects. These points are well established, and what we 
now have to consider is the choice of articles, the particular methods 
of their use, and the collateral or necessary means which may be 
required to give them most effect, and to restore the system to its 
healthy state. The first question presenting itself is as to whether 
any preparatory treatment is required to give greater efficacy to the 
specific measures. On this, differences of opinion have been expressed. 
The experience of many years, and the witnessing of the different 
modes of management have furnished me with very positive opinions 
on this as on other points connected with this disease ; and I may be 
pardoned for expressing these opinions somewhat dogmatically. If 
called to a patient at a very early stage of the disease, as during the 
first paroxysm coming on suddenly in the midst of health, the bowels 
being open, the stomach not oppressed with undigested food, and 
the secretions not yet materially perverted, the specific antimalarial 
remedy may be given without preceding treatment, and the paroxysms 
may be thus arrested at once. If derangements of the secretions 
follow, or any other morbid states linger, they may be dealt with 
afterward according to their indications. The palliative treatment 
already described, in those cases where it is needed, is in a degree pre- 200 
A O UE— TREA TMENT. 
paratory; but as patients are generally seen, some other and more 
particularly preparatory measures are required. 
In the hot stage when somewhat protracted, as it usually is in the 
first paroxysm or two, a cooling saline cathartic, especially if preceded 
by a few grains of blue mass, hydrarg. cum creta, or the mild chloride 
of mercury, will act decidedly as a palliative to the fever and the 
symptoms generally, and at the same time will prepare the system 
for the more efficient and agreeable action of the specific remedy. 
In short, as patients are generally seen, after the disease has con- 
tinued some little time or when prodroma have occurred, where the 
tongue is coated, the eyes and skin yellow, the bowels perhaps con- 
stipated, and the secretions generally deficient and deranged, and 
where effete matters have already accumulated in the blood, elimi- 
native treatment, especially by a moderate mercurial and a saline 
cathartic, and sometimes by diaphoretics and diuretics as recom- 
mended in simple fevers, may with the greatest advantage precede 
the antiperiodic. 
The ultimate results are best where such preparatory treatment is 
instituted. As a rule, then, from four to eight grains of blue mass, 
with perhaps from fifteen to twenty grains of bicarbonate of soda 
should be given, followed in a few hours by a dose of citrate or sul- 
phate of magnesia, or sulphate of soda, or Rochelle salts, sufficient to 
secure a cathartic operation. This will modify the secretions, elimi- 
nate irritating and effete matters, and prepare the system for the more 
ready absorption and better operation of the antiperiodic or anti- 
malarial remedy. Dr. Livingstone found that in the intense malaria 
of the jungles of Africa, when his men were attacked with the fever, 
a decided cathartic followed by prompt doses of the antiperiodic 
produced the best results, and this is the general testimony of those 
who have had large experience in the disease. 
There can be no doubt of the superiority of the cinchona alkaloids, 
particularly quiiya and its salts, over all other known agents, as anti- 
malarial specifics. The sulphate is the article in more common use, 
and is the one intended when the single word quinine is used. 
After the management above indicated, in an ordinary case of ague, 
from 9j to 3ss of quinine should be divided into four or five doses, 
and, commencing with the first intermission, the doses should be 
repeated sufficiently often to have the whole taken some hours, if con- 
venient, before the time for the next paroxysm. The whole quantity 
needed should by all means be given during one intermission and 
within a few hours—should make but a single, or one continued 
impression. If the intermission is a short one, the type quotidian, 
and the paroxysm protracted, the doses must be repeated more fre- MALARIAL FEVERS. 
201 
quently, or diminished in number but increased in size; but on no 
account should less than the whole quantity needed be given during 
one intermission. Some cases will yield to less than twenty grains, 
but the larger doses are harmless and more certain and complete in 
results, and in all, excepting very unusual cases of remarkable impres- 
sibility or special idiosyncrasy, the quantity mentioned should be 
given. 
With some persons quinine produces a sense of fullness and con- 
fusion in the head, ringing or roaring in the ears, and temporary 
deafness, and, less frequently, a feeling of stricture in the chest, and a 
sense of suffocation. These nervous disturbances have received the 
name of “ quininism ” or “cinchonism.” They are always temporary, 
and may be said never to result in serious consequences. Some writ- 
ers regard these symptoms as evidences of the full medicinal effect of 
the quinine, and advise its suspension whenever they appear. To 
suppose that they indicate the full antimalarial influence of the qui- 
nine is a mistake; and where a prompt arrest of the disease is, from 
the occurrence of grave symptoms, important, this opinion, with the 
practice based upon it, is a very serious mistake. From fifteen to 
thirty grains of quinine should impress the system at one time, and 
as elimination commences in three or four hours after the medicine is 
administered, though the effect of a dose remains some hours longer, 
the propriety of its administration in large or very frequently repeated 
doses will be seen. Some advise the whole quantity necessary in a 
single dose, but it is more likely to be absorbed and to be effectual in 
its operation when given in a few frequently repeated doses. With 
some persons two or three grains of quinine will cause more or less of 
the symptoms of quininism, and often quite markedly; but that quan- 
tity will not arrest the paroxysms of the disease. This cinchonism is 
no adequate measure of the curative effect of the quinine, and as it is 
temporary and unimportant, it should not be regarded in administer- 
ing the remedy. It cannot be too distinctly urged that a certain quan- 
tity of the antidote is necessary to be in the system at one time in order 
to neutralize the malarious influence, and that quantity must be given. 
When it is given and absorbed, and especially after proper preparation, 
it does not fail to arrest ordinary agues, and is sufficient without 
repetition or the continuance of the remedy. The protracted use of 
quinine, as so frequently advised in some text-books, is unnecessary 
and often injurious. These views, if correct, as I am sure they are, 
should be particularly emphasized, as they are not only important, 
but are contrary to the more common recommendations on the sub- 
ject. I can but insist that the practice of giving small and long-con- 
tinued doses of quinine in ague, is treatment not only always less 202 
AO VE—TREA TMENT. 
effectual and less certain tlian the course here recommended, but is 
often bad. While many cases will not be arrested by this method, 
and will go into a chronic form, the system will become so accustomed 
to the use of quinine that it will fail to respond to its curative effects, 
even in large doses, and a greatly protracted continuance of the disease, 
with all its evil consequences, will often result. So many cases of this 
kind have fallen under my observation, which I am sure would have 
been avoided by prompt and efficient treatment at the beginning, that 
the strongest expressions on the subject can alone satisfy me. AS 
quinine is now well known to be a direct antipyretic remedy, diminish- 
ing in a short time feverish heat when given in free doses, it might be 
inferred that the best time for its administration would be in the 
height of the febrile paroxysm. Malarial, as well as other fevers, are 
capable of having their heat directly abated by free doses of quinine, 
and an influence in preventing a return of the paroxysms is exerted at 
the same time ; but experience has proved that this preventive effect 
is exerted more certainly and more powerfully when the medicine is 
given during the period of apyrexia. The reason of this may not be 
apparent, but this does not affect the fact. Dr. Binz, of Bonn, wdiose 
writings on various subjects have given his opinions weight, says 
ague is cured best by quinine in the period of apyrexia, when the 
poison is latent, and when the nervous system, the heart and respira- 
tory organs are free and more normal in their functions. It may be 
because, during the intermission, it is more readily absorbed from the 
stomach and received into the tissues; and the reason of its acting 
more efficiently after a cathartic and other eliminative treatment 
probably is, that it is more freely and promptly appropriated. At any 
rate, in some way it more readily reaches and acts upon the cause of 
the disease during an intermission, and after ‘‘ preparation.” The facts 
are far more important than the explanations; and they teach that 
eliminative or preparatory treatment is often important; and that 
quinine acts more efficiently and certainly when given in full quantity 
during one intermission. Directions differ as to the particular time 
during the intermission when the quinine should be administered. 
This is not a material point, provided the whole quantity is taken into 
the system, and produces its effect before the time for the next parox- 
ysm. As a rule, it is best to commence during or immediately after 
the sweating stage, and to give it, in from three to five doses, once in 
from two to three hours. 
The mode of administering it is worthy of attention. It is fre- 
quently advised to be given in solution, with the addition of sulphuric 
acid. It is efficient in this form, but is very unpleasant to the taste, 
and is more likely than in other forms to irritate the stomach. Com- MALARIAL FEVERS. 
203 
pressed masses or pills, especially when the pills are covered with 
gum, and have been long kept, are slow in dissolving in the stomach, 
and may fail to act in time ; or when the bowels are loose may pass 
through the alimentary canal without producing any effect. In cases 
of severity, requiring promptness, these accidents should be carefully 
guarded against. On the whole, perhaps the best method of admin- 
istering is in French wafers, or in gelatine capsules, which are known 
to be readily dissolved. When the bitter taste is not objectionable, 
there is no better method than to give it in a simple powder in any 
common vehicle. 
When all these precautions are taken, and the foregoing directions 
are carefully followed, nothing in medicine, and scarcely anything in 
physics or chemistry, is more certain than that, in common ague, 
prompt interruption of the paroxysms follows; and if the treatment be 
commenced at an early period of the disease, before the system has 
become saturated with the poison and more seriously deranged and 
depraved by its effects, the cure is generally permanent, at least until 
a considerable time of further exposure to its cause has occurred. 
The longer the disease is permitted to continue, the more likely it is 
to return when interrupted. Hence the importance of prompt and 
early treatment. 
Whether quinine produces its effects in arresting malarial fever by 
acting directly upon and destroying the poison, or by its impression 
on the system so as to render it insusceptible to the action of the 
malaria, is not determined. Some facts seem to show its operation in 
one way, and others in the other. 
It is known to be a powerful antiseptic and antizymotic, and it is 
believed, therefore, to act chemically upon the malarial ferment. 
But it is also known to act powerfully on the system, and to be 
capable of diminishing fever heat from whatever cause. It diminishes 
urea and uric acid, exerts apparently a direct influence upon the 
spleen, diminishing its vascularity and the formation of uric acid in 
that organ, which is alleged to be its chief source. It markedly 
diminishes the number of white blood corpuscles so abundant in the 
spleen. It acts directly upon protoplasm, it is said, independently of 
nerves, and yet it impresses the nervous system. It diminishes heat 
independent of changes in the heart’s action, and yet, in free doses, it 
diminishes the frequency and irritability, and often the force, of that 
action. The facts certainly indicate that it produces its effects in 
part, at least, by its action on the system. This view is further sup- 
ported by the additional fact, sufficiently proven by experience, that 
its effects may be markedly diminished or lost by its long-continued 
use. This must be from a changed state of the system, rather than of 204 
A Q UE—TREA TAIENT. 
the poison within it, which cannot he supposed to be long identical. 
It probably operates in arresting ague in both ways—by acting upon 
the poison and the system. But the full mode of its operation we are 
not at present able to determine, and must be content with knowing 
its singular power in arresting malarial and various other diseases. 
The after-treatment, if any be required, must be governed by the 
conditions present. If the organs resume their proper functions, if 
the bowels are regular, the tongue clean, and the appetite and 
nutrition normal, no treatment beyond proper hygienic precautions 
will be required. As already stated, the practice of continuing the 
use of quinine, in either large or small doses, is at least unnecessary, 
and is not advisable. If the disease has continued long, and there is 
marked anaemia and debility, the preparations of iron and other ton- 
ics may be required. If, as is very likely to be the case, the liver 
remains torpid and the secretions generally are deficient or perverted, 
and there is evidence of effete matter remaining in the system, elimi- 
nativcs will be demanded, and will often do more in restoring strength 
by improving nutrition, than tonics. Indeed, in many such cases, 
tonics, especially given alone, are injurious. A combination of elimi- 
natives and tonics will often be useful, or eliminatives for a few days, 
and tonics afterward. An old combination and a useful one, is sul- 
phate of magnesia or sulphate of soda and sulphate of iron in some 
bitter infusion, so that a drachm, more or less, of the laxative and two 
grains of the tonic, be taken three times a day. Dr. Graves’ mixture 
of sulphur, cream of tartar, carbonate of iron, and electuary of senna, 
may be well as combining tonic and eliminative properties. But 
sometimes eliminatives alone are required. Indeed this is often the 
case. 
A favorite with Dr. Golding Bird was acetate of potash, in scruple 
doses, three or four times a day. Lately, the tinct. of iodine has 
been strongly recommended as an antimalarial remedy; but, by 
noticing the reports, it is found to have been used in chronic and re- 
lapsing cases, and continued for some time, after other antiperiodics 
had been given ; and the question is suggested whether it is not its 
eliminative effect, rather than any specific antimalarial power, which 
has given it its reputation. It is very frequently found, in chronic 
cases that have often relapsed, and where the tendency to a spontane- 
ous termination is present, that a cathartic, followed by doses of ace- 
tate of potash, hydrochlorate of ammonia, or any similar depurative 
agent, will effect a prompt and often permanent arrest of the disease. 
Further experience is required to test the full efficacy of the iodine, 
and there is much reason to fear that if relied upon in acute or recent 
cases, disappointment would be the result. MALARIAL FEVERS 
205 
But whatever virtues other agents may have, all the pathological 
conditions in malarial fever are simultaneously destroyed or greatly 
modified by quinine, as by some fundamental change-producing cura- 
tive power. 
If there be much irritability of the stomach, or of the general sys- 
tem, an ordinary dose of morphine may be given just before or added 
to the first dose of quinine, and perhaps to one or two subsequent 
doses. The quinine by that means will be better borne, more readily 
retained and absorbed, and its antiperiodic effects increased and ren- 
dered more certain. Indeed, morphine alone exerts an anti malarial 
influence, as a decided dose will sometimes arrest the paroxysms. 
The other preparations of cinchona, though less reliable than 
quinine, are generally quite efficient in arresting ague, and as they are 
less expensive may often be used as substitutes. They, too, must be 
given in free doses in order to produce decided and prompt effects. 
Quinidia in but little larger doses, and cinchonia in twice the doses 
of quinine, are quite efficient. 
Though no other antimalarial remedy is as effectual or reliable as 
the preparations from the Peruvian bark, especially quinine, yet there 
are other medicines capable of arresting the ague. Among these, 
arsenic has the most established reputation. It is commonly given in 
the form of Fowler’s solution, in doses of from six to fifteen drops, 
largely diluted with water, and repeated in from three to six hours 
until the paroxysms are arrested. The French advise the arsenious 
acid simply, in sugar of milk, or in solution in distilled water, and in 
doses of from half to two or more centigrammes (from one fourteenth 
to a quarter of a grain), repeated once in a few hours. It is liable to 
irritate the stomach and bowels, and if the tongue becomes red, or is 
thoroughly coated with a silvery-looking fur, or the conjunctiva is 
irritated, and puffing occurs about the eyes, or if there is tenderness 
or pain at the epigastrium, or if nausea and vomiting, or diarrhoea 
come on, it must be discontinued, and eliminative and soothing reme- 
dies resorted to. In some chronic cases, where quinine has been fre- 
quently given, and its effects have diminished, arsenic may be substi- 
tuted with advantage. In recent cases, however, it is much less 
prompt and efficient. Similar preparation for its use is required as 
with quinine, but the same rule with regard to giving the necessary 
quantity during a single intermission is not applicable. 
Salicine is another article which has decided antimalarial powers. 
In doses somewhat larger than quinine, but given in a similar man- 
ner, it often acts very promptly in arresting the disease. When the 
preparations of bark are not well borne, as, for instance, in women of 
peculiar idiosyncrasies, where quinine induces uterine hemorrhage and 206 
AG UE—TREA TMENT. 
other unpleasant effects, the salicine may be substituted with great 
advantage. 
The eucalyptus globulus is another remedy which has come into use 
within a few years past, and its virtues as an antiperiodic are by some 
highly extolled. It certainly has antimalarial powers, and is said to act 
in all respects very similarly to quinine; but how far it may be relied 
upon as a substitute for that article, has not as yet been sufficiently 
determined. The most eligible preparation is the fluid extract given 
in drachm doses, and repeated once in three or four hours. In chronic 
cases I have frequently given it in connection with quinine, and it has 
seemed to me to increase the efficiency of the quinine, especially where 
the effects of the latter had been weakened by repeated use. 
Cornin, the active principle of Cornus Florida, deserves to be men- 
tioned as an antimalarial remedy, and may be used in the absence of 
the more efficient article. 
Hydrastin is another article having decided antimalarial virtues, 
and is regarded by some as next in power to the alkaloids of cin- 
chona. 
Chloroform will sometimes arrest the ague, and so will the sul- 
phites, berberina, and various other substances; but they are less 
reliable, and therefore should be depended upon only in exceptional 
cases. 
The tinct. of iodine, already referred to, is advised in doses of ten 
minims from three to five times a day, and the following mixture of 
iodine and carbolic acid has been recommended as highly efficient: 
IjL Acid Carbolic 3j 
Tinct. Iodine comp 3iij 
M. 
Four drops every four Lours in sufficient water. 
In chronic cases and for the removal of some morbid alterations 
produced by malaria, a combination of iodide of ammonium and 
arsenic is advised. To five grains of the former three drops of 
Fowler’s solution are added, and given three or four times a day. 
There are various other compounds recommended by different indi- 
vidual practitioners, but none have a sufficiently wide and established 
reputation to require particular mention. 
Whether other antimalarial remedies than quinine operate by 
directly acting upon and destroying the malarial poison, or whether 
they so impress the system as to render it insusceptible to its influ- 
ence, or whether they induce actions in the body which result in the 
destruction or expulsion of the poison, is at present unknown. MALARIAL FEVERS. 
207 
The treatment of an uncomplicated case of common ague is suf- 
ficiently simple, and may be summed up and repeated in a few words. 
As patients are usually seen, it consists in the administration of a 
cathartic—a mild mercurial, followed by a saline, being generally the 
best—and after its operation, during the next succeeding intermission, 
of from fifteen to thirty grains of quinine in from three to five doses. 
In many cases nothing more is required, but others may occur call- 
ing for the other means described. 
The relapsing cases are those which will give the physician most 
annoyance, and which will most severely tax his skill and patience. 
Here eliminative treatment must not be neglected ; and a few large 
doses of quinine, rapidly repeated, will often arrest the disease 
promptly and permanently, where smaller doses, at longer intervals, 
had been given for a long time without satisfactory results. When 
the attacks have several times returned at regular periods, as once in 
one, two, or three weeks after their interruption, an antiperiodic 
quantity of quinine, given the day before an expected return, may be 
effectual in preventing any further attacks. The habit of recurrence 
may thus be broken up. 
The Chronic Enlargement of the Spleen, as a sequel or accompa- 
niment of ague, is to be treated by effectually destroying the malarial 
influence by the means so fully dwelt upon ; and afterward, by 
keeping the bowels open, and by the use of iodide of potassium inter- 
nally, and by the daily application of the ointment of the biniodide of 
mercury over the region, thoroughly rubbed and heated in. until 
decided counter-irritation is produced. A 3ss, more or less, may be 
applied each time. Quinine seems to have a direct effect in dimin- 
ishing the calibre of the splenic vessels and the size of the organ, 
and, once in a few days, a few free doses of it should be given, the 
other means mentioned being continued through the interval. If 
much anaemia is present, iron should be added. These means are 
usually effectual, often speedily so, in removing the enlargement 
which has not continued too long, and which is the result of ague. 
When dropsical symptoms follow or accompany ague, the mala- 
rious influence should first be effectually removed, and then elimi- 
native and tonic remedies will be required. By removing the mala- 
rial influence its effects will tend to cease; but the eliminative 
cathartics, diuretics, and sometimes diaphoretics, will aid in remov- 
ing the accumulated fluids, carrying off at the same time other mor- 
bid materials from the system ; and then the use of tonics, such as 
the tincture of iron and other agents tending to improve digestion 
and nutrition, will aid in restoring health. 208 
REMITTENT FEVER. 
When what is called Dumb Ague occurs—the malarious poison 
operating injuriously upon the system, but without producing the 
ordinary phenomena of well-marked chill, fever, and sweating—the 
same general course of treatment should be pursued as in the more 
regular forms; and the remedies should be applied with even more 
promptness, as the deterioration of the system is more rapid than 
in well-expressed cases. The same preliminary eliminative meas- 
ures, the same prompt and efficient antimalarial remedies, will be 
required, and the same rules as to treatment afterward must be 
observed. The only material variation is, that, after the operation 
of the cathartic, the quinine may be commenced at once with less 
regard to periods, as no distinct paroxysms occur. Still there are 
periods of abatement of the symptoms, and such periods would be 
preferable for pushing the quin hie. Here, as elsewhere, a full anti- 
malarial quantity should be given within a few hours. This point is 
often repeated and insisted upon, as it is so important, and as many 
of the text-books, written by those practically unfamiliar with the 
disease, advise a different course. 
Various anomalous symptoms occur as the result of the malarious 
poison, all of which require the antimalarial treatment. They are 
generally marked by some degree of periodicit}7, but this is not always 
conspicuous ; and much care and discrimination may be necessary to 
detect the true character of the obscure cases. As the antimalarial 
treatment is comparatively so innocent, and is often useful in other 
than malarial diseases, it should be resorted to whenever there is 
reasonable suspicion of a malarious cause. 
In aguish localities other diseases are often modified by the ma- 
larial influence, assume a degree of periodicity, and require prompt 
antimalarial treatment. Frequently the removal of that element 
changes greatly and most favorably the Avliole character of the case ; 
and scarcely any condition of disease forbids the use of quinine when 
indicated by a malarial complication. 
REMITTENT MALARIAL FEVER. 
This is a severer form of malarial fever than common ague, marked 
by exacerbations and remissions, but without periods of apyrexia. 
The cause of all the malarial fevers being the same poison, remitting 
fever is but a modified variety of the same specific disease. Pro- 
duced by the same cause, it has many qualities in common with inter- 
mitting fever, and they shade off into each other, some cases not 
answering the ordinary descriptions of either ; and yet in their typical REMITTENT MALARIAL FEVER. 
209 
forms their phenomena are quite distinct, and in many respects dis- 
similar. 
In remitting fever there are the rudiments of the four stages so 
clearly marked in intermittents, but none except the second, or stage 
of fever, is fully developed. This stage is generally severe, and al- 
Avays protracted, while the abatements vary in duration and degree. 
The exacerbations vary in the time and frequency of their occurrence, 
and in their severity and danger. They may recur daily, presenting 
a quotidian type, or every second day, presenting a tertian; or they 
may be irregular, sometimes two or more exacerbations occurring in 
twenty-four hours. This fever is often accompanied with local irrita- 
tions, congestions, and inflammations of a decided character, and as 
these occur in the stomach, the intestines, the liver, or other organs, 
different varieties of the fever result. 
The leading symptoms are very similar to those of the hot stage 
of ague. The more decided attacks are sometimes preceded by 
prodroma—by gastric and hypochondriac uneasiness and sense of 
weight, by general pains, slight feverish sensations, deranged secre- 
tions, coated tongue, etc. Sometimes, however, the access is without 
premonitions. 
When the attack fully sets in, it is commonly abrupt, and the 
symptoms are decided. Usually, at first, rigors mingle with the sen- 
sations of heat, and sometimes the chill is quite marked, but seldom 
as much so as in ague. The temperature of central parts is always 
raised, and very soon external heat of all parts is manifest, even 
though sensations of coldness are by turns experienced. 
The pulse at the beginning is variable. It is often small during 
the rigors, but usually full and free as they disappear. While the 
chilliness is felt the lips are more or less blue, and there is often nau- 
sea, and sometimes vomiting. Soon the full hot stage is present; the 
lips lose their blueness; the whole surface is red, suffused, and ex- 
panded, the respiration and pulse are hurried—the latter not exceed- 
ingly rapid or tense, generally full and open, and not much above one 
hundred. There is much thirst, severe pain in the head, back, and 
limbs, and there are sensations of great general distress and weakness. 
Usually in from six to twelve hours there is some abatement of 
these severe symptoms, and there may be slight moisture. The tem- 
perature during the height of the fever being from 104° to 106°, con- 
tinues, at the abatement, decidedly above the normal, and sensible 
perspiration by no means always occurs. As the case goes on, the 
tongue becomes heavily coated, is often dry and hard, frequently red 
at the edges, and sometimes over its whole surface ; the secretions are 
greatly perverted; the spleen and liver congested and swollen, and 210 
CLINICAL PHENOMENA. 
sometimes inflamed; more or less yellowness of the eyes and skin 
often occurs; the urine is dark-colored and heavily loaded with urea, 
urates, uric acid, and often with bile ; and with many persons delirium 
is present, sometimes quite active, at other times low, while in other 
cases it is hut slight, and in many it is absent. These symptoms, 
with the fluctuations, may go on, without other material changes, for 
many days. If, however, the case be long neglected or badly treated 
by irritating emetics or cathartics, the remissions often diminish, the 
fever becoming more uniformly continuous and severe, gastrointesti- 
nal inflammation resulting, with tenderness of the epigastrium par- 
ticularly, and more or less of the whole abdomen. In these cases the 
tongue is coated and dark, or red and glazed, but in either case dry 
and hard ; great thirst and burning pain of the stomach are often pres- 
ent, with vomiting of yellowish, green, or bluish, brownish, or black- 
ish matter ; and sometimes diarrhceal—watery and briny, or dysenteric 
—mucous, and bloody discharges from the bowels take place. In other 
cases the liver, spleen, or brain suffers more, and occasionally, though 
rarely, a deeply jaundiced condition with almost bronzed skin appears. 
At any period of the disease free bilious discharges cause relief, not 
only of the discoloration, but of all the general symptoms. 
There may be severe pains, delirium, stupor, partial paralysis, and 
great depression from the more direct effect of the malarial poison 
upon the general system, without special local disease. 
Usually, when the disease is left to itself, in from one to three 
weeks a change of type or condition occurs. There is either abate- 
ment of the severity of the fever, the remissions increasing in length 
and degree until intermissions occur ; or a more continued, irritative, 
typhoidal fever supervenes, or death occurs. 
When marked spontaneous improvement takes place, it is usually 
accompanied by critical discharges, a free perspiration, bilious evacu- 
ations, or herpetic eruptions—often by all of these, simultaneously. 
Some cases, left to themselves, are protracted for many weeks, but 
result in final recovery, though for still longer periods with blood poi- 
soning and organic and vital impairments. Often, however, there 
comes at length failure of vital power; a small, feeble, frequent 
pulse; livid, yellow, or even rarely a bronzed skin ; tympanitis of the 
abdomen ; briny or mucous stools ; low delirium or stupor ; involun- 
tary discharges, pinched features, and death. 
Remitting malarial fevers are varied much in their peculiarities, 
their severity, their complications and their course, by climate, 
locality, season, and by constitutions and habits. As a rule, they are 
more severe the greater and longer continued is the season of heat; 
and in the Northwest, while agues may prevail in the spring and late REMITTENT MALARIAL FEVER. 
211 
autumn, in August and early September remitting forms are generally 
more prevalent. But both intermitting and remitting forms occur 
at the same time and in the same locality, and each may assume the 
form of the other, and both may run into a continued fever with no 
more variations than occur in typhoid or simple fevers ; and the 
various complications already mentioned may occur, increasing their 
severity and danger. Occasionally a malarious fever occurs with 
scarcely any remissions throughout its course ; and not unfrequently 
for the first few days the remissions are very slight. Not only may a 
malarial fever assume a typhoidal type, but a genuine typhoid fever 
may coexist with and complicate it; both the typhoid and malarial 
poison operating on the system at the same time, producing what 
has been called a typho-malarial fever. These cases will require to 
be noticed after describing typhoid fever. 
MORBID ANATOMY. 
The opportunities of post-mortem examinations have been more 
frequent in remitting than in intermitting fever, but as the diseases 
are specifically the same, the essential pathological conditions are 
similar. In acute cases, when death occurs, congestion and inflam- 
mation of various organs are usually found, congestions of the spleen 
and liver are constant, and these organs are generally otherwise 
changed. The spleen is of a dark wine color, enlarged and softened, 
and sometimes ruptured. Dark coloring matter from transformation 
of the red blood corpuscles is often found in its vessels, sometimes in 
great abundance, and their pigment is often deposited in other organs 
as well. The spleen is sometimes found inflamed ; and when several 
attacks have previously occurred, and the patient has been long sub- 
mitted to the malarial influence, this organ may be enormously en- 
larged by exudates and hyperplasias, and various degenerative changes 
may have taken place. In acute cases the liver is enlarged, is of a 
brown or slate color, or mixed gray and olive, the nutmeg appearance 
being sometimes presented. The pigmentation is sometimes marked. 
In more chronic cases the liver is often enlarged by exudations and 
by hyperplasia, is decidedly pigmented, and amyloid degenerations 
are sometimes found. Not unfrequently inflammatory changes are 
present—in acute cases, parenchymatous hepatitis sometimes goes on 
to suppuration ; and in cases of long exposure to malaria in low 
latitudes, chronic abscesses may be found as complications. 
In most cases where death occurs from a first attack of remitting 
fever, other organs are much congested or inflamed. The mucous 
membrane of the stomach and bowels is often intensely congested, 212 
DIAGNOSIS. 
and sometimes hemorrhagic—blood being infiltrated into its tissue 
and effused upon its surface, which accounts for the brown or black 
yomit and briny intestinal discharges which sometimes occur. Inflam- 
matory softenings and exudations are also often found. 
Pigmentary exudations are sometimes found in the brain, and 
occasionally that organ and its membranes are inflamed. 
Sometimes the lungs and the bronchi are involved in inflamma- 
tion ; but inflammations of the abdominal viscera are more frequent. 
The blood, as in cases of intermittents, is changed. The white 
corpuscles are increased and the red diminished. It is often loaded 
with pigment and bile, and sometimes with an excess of cholesterinc. 
In some cases the blood corpuscles have been found disorganized in 
large numbers, so that death has been supposed to be produced by 
necrsemia. 
Here, as in other fevers, the kidneys are sometimes found dis- 
eased, and the impairment of their functions, here as elsewhere, leads 
to retention of effete matters and blood poisoning. 
Diagnosis.—The Diagnosis of Remitting Fever is particularly 
important, as the treatment is specific ; and to distinguish it from 
some other conditions is sometimes by no means easy. In the early 
stage the phenomena are scarcely distinguishable from those of severe 
accidental fevers; and they as nearly resemble those of the occasional 
typhoids whose attacks are sudden and abrupt. There are some gen- 
eral features, however, which are distinguishable by careful and re- 
peated observations, but which it is more difficult to describe. The 
accurate and experienced observer, taking into account the locality 
and season, can usually come to an early and proper conclusion. 
Jaccoud mentions an icterode condition of malarial fever as the dis- 
tinguishing characteristic ; but this is by no means always present, 
and that condition is not unfrequently a symptom of accidental fever, 
and sometimes is present in typhoid. 
In all ordinary cases the severity of the early symptoms, the remit- 
ting character soon manifested, and the bilious derangement, with 
the absence of the common causes of accidental fever, and, above 
all, the malarious character of the locality, will leave but little diffi- 
culty in the diagnosis. As remitting fever generally appears in an 
epidemic form, other cases proven to be malarious will aid in making 
the diagnosis exceedingly probable, if not clear. 
Not only does it resemble typhoid and accidental fevers, but also 
the symptomatic fevers—inflammatory, hectic, and pyaemic. It is to 
be distinguished from the first by the common absence, at the early 
stage, of signs of local inflammation and by the remissions ; from hec- 
tic, by there being no chronic inflammation, suppuration, or tubercu- REMITTENT MALARIAL FEVER. 
213 
Ious degeneration, by the more equal distribution of heat over the 
surface, and by the absence of the peculiar disagreeable night sweats 
which occur in hectic. 
It is to be distinguished from pysemic fever by the presence in the 
latter of local disease or injury, by the more frequent repetition of 
chills, and more free sweats, etc., and by the less controllable charac- 
ter of the symptoms. But in the advanced stages of malarial fever, 
when local inflammations have occurred, and when the blood and 
tissues are poisoned by retained effete matters as well as by the mala- 
rial poison, the resemblance to typhoid fever, or to severe cases of 
primary inflammation, is so striking, as possibly to defy diagnosis in 
the absence of a full history of the case. For such history, therefore, 
we must ycarefully inquire. 
Prognosis.—The Prognosis is dependent upon the treatment. 
Left to itself, many cases would result unfavorably* especially in 
localities nearer the equator. The Jungle and Coast Fever of Africa, 
the Jungle Fever of the East Indies, the Panama Fever of Central 
America, the Roman Fever, and others, are not unfrequently fatal, 
even with the treatment they receive. As it occurs in the north- 
western portion of the United States of America it is usually severe, 
protracted, and not unfrequently fatal, without proper treatment; 
but with prompt and efficient treatment, the prognosis is very favor- 
able. Nearly all cases not only certainly but speedily recover. At 
least the progress of the disease can almost always be arrested. Re- 
currences not unfrequently follow; and, from repeated attacks, decided 
impairment of various organs and functions may result; but as a 
rule, permanently serious consequences may be averted. When the 
disease has been permitted to become protracted, convalescence is often 
slow and imperfect, organic changes of the liver, the spleen, and other 
organs having taken place, which may require much time for their 
removal. In all such cases, more or less lowering of vitality is a con- 
sequence. 
TREATMENT OF REMITTING FEVER. 
As remitting fever depends upon the same essential cause as the 
intermitting variety, and presents many similar symptoms, the gen- 
eral principles of treatment applicable to the one are also applicable to 
the other. There are, however, differences in the phenomena of the 
two varieties, and modifications as to details, which, in a disease so 
severe as that now under consideration, require pointing out. 
The first logical indication is to apply the antidote to the poison 
which is the cause of all the symptoms; and. if the patient he seen, 214 
TREATMENT. 
and the diagnosis made, before material local derangements have taken 
place, or effete matters have accumulated, and while the stomach is 
in a condition to readily absorb the medicine, the antimalarial remedy 
may be given at once in free apyrecic doses. Quinine, in the quantity 
of one or two scruples (the latter quantity in severe cases will be 
safest), given in from two to five doses, all within a few hours, will 
generally put an end to the case, and prevent all marked subsequent 
symptoms. If the tongue should become coated, the skin and con- 
junctiva icterode, or the bowels constipated, a blue pill or two, fol- 
lowed by an unirritating cathartic—a saline is generally best—will 
often complete the cure, and render any further medication unneces- 
sary. 
If, however, the liver or kidneys should still remain inactive, some 
further cholagogues and laxatives, or diuretics (acetate of potash in 
fl. ext. taraxicum, etc.) will be useful. 
If, from the depressing influence of the poison, or the great severity 
of the symptoms (the case approaching the pernicious variety), there 
be decided and immediate danger, the quinine should not be delayed, 
whatever special conditions may be present. A decided and prompt 
impression should be made, and remedies for the local derangements, 
and for eliminating the effete matters, should be given afterward. 
Quinine may here be given hypodermically with advantage, provided 
a clear solution sufficiently concentrated can be obtained. 
As patients are generally seen after the tongue has become coated, 
the secretions deranged, the liver, spleen, and other abdominal organs 
congested and irritated, and the portal circulation obstructed with all 
its consequences, palliative and “ preparatory ” treatment here, as in 
ague, is, as a rule, best. Though the antidotal treatment is indicated, 
and should be resorted to the moment it can be done to best advantage, 
yet that moment is not generally the one in which the patient is first 
seen, and other indications may first be fulfilled. The main indica- 
tion, however, should always be kept in mind. 
The cold stage, as it is seldom marked or severe, requires no par- 
ticular attention in ordinary cases. Should it in exceptional cases 
require palliation, the same means that were recommended in ague 
should be resorted to. 
The palliative measures for the pyrexia will, in the main, be the 
same as those advised in the hot stage of ague. The same bathing— 
sponging or packing with cold or tepid water—the same cold to the 
head, with cold and cooling drinks—the same effervescing mixtures, 
and, after evacuations, the same doses of morphine, when the stomach 
is irritable and the distress excessive. In plethoric patients with 
severe internal congestions, the same revulsive and depleting remedies, REMITTENT MALARIAL FEVER. 
215 
cuppings, leechings, ligation of extremities, or venesection will be re- 
quired. Should the choleraic symptoms—the vomiting and purging 
of serous fluid—occur (and this is more likely in remitting than in the 
intermitting variety of these fevers), the same doses of morphine put 
upon the tongue, or of opium, camphor, and calomel, rubbed up with 
sugar into an impalpable powder, and given in the same small quan- 
tity of water, with but little drink afterward until the stomach is 
quieted, when moye free drinking must be allowed to make up for the 
fluid which has been lost, will be demanded. As there is more likely 
to be severe and persistent irritation and inflammation of the stomach 
and other abdominal organs in remitting than in intermitting cases, in 
addition to the means mentioned, counter-irritation over the stomach 
is often required- A vesicant of cantharides produces a more perma- 
nent effect in allaying such irritation, but where a more immediate and 
temporary effect is required, sinapisms, ammonia, or a mixture of 
aqua ammonia and spirits of camphor, applied upon a cloth, and the 
vapor retained by some impervious material, will produce very active 
counter-irritation and speedy vesication. Repeated doses of morphine 
may be required, and this is certain to enter the blood and produce 
its effects when given hypodermically. 
But the remedies more particularly “ preparatory ” to the anti- 
malarial specifics are the eliminatives—especially the cholagogue 
cathartics. Some advise the use of emetics, and when the stomach is 
evidently loaded with undigested food or other irritating material, 
and when from this cause there is gastric distress without the ability 
to vomit, drinking freely of warm water to induce emesis will be 
well. In exceptional cases a mild emetic may be proper ; but the 
pain and the nausea are more frequently from irritation, congestion, 
or acute gastric catarrh ; very frequently from decided inflammation, 
rather than from a loaded state of the stomach, and an emetic in such 
a condition could hardly fail to increase rather than relieve the irrita- 
tion. Even when no signs of inflammation are present, an emetic 
not unfrcquently produces a decided gastritis in the congested and 
irritable state so commonly present in remittent fever. As a rule, 
emetics should be avoided, as tending to produce both inflammation 
and prostration. The irritability and tendency to inflammation of 
the whole gastro-intestinal membrane, render the administration of 
drastic or irritating cathartics exceedingly objectionable. Gamboge, 
scammony, podophyllin, tartarized antimony, and the whole list of 
drastic and irritating articles must be most scrupulously avoided. A 
gentle mercurial, modified if necessary by moderate doses of mor- 
phine, and followed by a mild but sufficient dose of a simple saline 
cathartic, will not only not increase the local irritation, but by indue- 216 
TREATMENT. 
ing free watery discharges of serous fluid from the mucous membrane, 
will unload the capillaries and the general portal vessels, relieve con- 
gestion, and produce a revulsive effect from the brain, besides elimi- 
nating effete matter from the blood and the whole system. They 
thus palliate the present condition and prepare the stomach for the 
more ready absorption, and the system for the more efficient action, 
of the quinine. By the use of these means, often combining or alter- 
nating with them diaphoretics and diuretics, the severity of the fever 
is abated, more decided remissions are likely to be obtained, some- 
times intermissions are induced, and then free doses of quinine given 
in the manner already repeatedly described, will produce a speedy 
interruption of the fever. If the stomach remains irritable and the 
remissions are imperfect, morphine should be given with the quinine, 
sometimes in very decided doses ; but the quinine must be no longer 
withheld, even if the fever is continuous. The more favorable time 
for its administration and its antimalarial effect is when the fever is 
less or least; but an abatement of the fever is by no means essential to 
its success; and when given in antipyretic doses it will produce the 
abatement of the fever, which favors its more complete antimalarial 
effect. The recommendation of nearly all the less recent writers to 
wait for an intermission, or for the fever to so far abate that a free 
perspiration is induced, before resorting to the quinine, is certainly 
wrong. Such abatement may not occur, and the case may go on 
from bad to worse ; and at best the cure will be very much and very 
unnecessarily delayed by following such advice. It should not be 
forgotten that quinine is itself an antipyretic when given in free 
doses, and in these free doses it induces the intermission so earnestly 
desired. It indeed induces a condition of apyrexia which becomes 
permanent; and the more certainly and effectually when the influence 
of morphine is obtained at the same time. This may seem inconsist- 
ent with the statement that in intermittents the best time for admin- 
istering the antiperiodic is during the intermission ; but the incon- 
sistency is only seeming, not real. Both statements are true. The 
quinine is more readily absorbed, produces its effects more certainly 
and in less quantity when given during an intermission or a marked 
remission ; but the spontaneous occurrence of such intermission is 
not essential to its antimalarial effect, and in sufficiently free doses 
its immediate apyrexic effect is in harmony with, and aids its anti- 
malarial operation. The statement substantially borrowed from 
another may here be repeated, that all the pathological conditions in 
malarial fever are by quinine simultaneously destroyed as by some 
central power. 
When, without proper treatment, an advanced stage of the disease REMITTENT MALARIAL FEVER. 
217 
has occurred, and the complications described are present, palliative 
measures should not be neglected, but the quinine must be given soon 
and in the free quantities indicated. This is the essential remedy. 
It should be combined with opiates when the stomach and bowels are 
irritable, and if rejected, or if it produces local distress of these 
organs, it may be given by enema, or, better still, hypodermically. 
A proper attention to diet and regimen will be required, as in other 
fevers; and eliminatives, laxatives, cholagogues, diaphoretics, diuret- 
ics, and counter-irritation, or stimulants and supporting measures, 
may be demanded as particular conditions prevail. 
This subject—treatment of remitting fever—is so important that 
repetitions may be justified if, by that means, a clearer or stronger 
impression can be made ; and with this view a summary of the treat- 
ment of this fever is added. 
The first logical indication is for the antidotal remedy, but others 
may precede in time. If called before local derangement or accumu- 
lation of effete matters occurs, we may give the antimalarial remedy at 
once. Or if there is great and immediate danger from severe symp- 
toms, it should not be delayed. Make a decided and prompt impres- 
sion with the quinine, and correct local derangements, and eliminate 
afterward. 
As patients generally are seen, “ preparatory ” treatment is best. 
Mitigate local congestions and inflammations, especially correct 
derangement of the secretions, and modify the conditions of the 
stomach, as thereby the specific treatment is most sure. 
Preparatory means are : moderate doses of mercurials, followed in 
a few hours by saline cathartics, repeated once or twice possibly; 
anodynes, sedatives, counter-irritants, revulsives, and, in plethoric 
patients, possibly bleeding, local and general. Immediate relief of 
symptoms of excitement is certain, but venesection is seldom required 
and may do ultimate harm by causing ansemia and debility. Other 
means will usually suffice, but occasionally bleeding is demanded. By 
relieving congestion the general vigor may be increased, and the 
oppressed pulse made more full and free. 
Bleeding is not so well borne in hot climates, and it should be used 
with great care in depression from congestion of the brain. Cold to 
the head, affusions, free dry cupping, or ligation of extremities are 
safer, and a skillful use of the bath is often required. 
Mercurial and saline cathartics are depurative, depleting, revulsive, 
and preparatory for specific treatment. Diaphoretics and diuretics 
are often useful. Effervescing mixtures, bitartrate of potash three parts 
to bicarbonate of soda one part, in the proportion of 3ss to half a turn- 218 
TREATMENT. 
bier of water, are to be taken immediately after mixing, as a cooling 
drink. When there is great irritation, especially after proper evacua- 
tions, morphine is not only relieving, but is permanently useful. 
Irritating emetics and cathartics do harm. Emetics of any kind 
are very seldom well borne. 
Cold water, internally and externally, often affords the greatest relief. 
These palliative and preparatory means may be continued as 
required, but only for a few days at most (often only a few hours) 
before the antidotal remedy is used. 
Do not wait, as was formerly taught, for an intermission; though 
if it come soon it is better. 
Give the quinine early. It is absorbed best, and is more active in 
arresting the disease, /if given during the remission. But it is not 
necessary to wait for even this. In severe cases give at once after a 
cathartic has operated. We may combine it with diaphoretics and 
diuretics. If there is much irritation add morphine, and sometimes 
other sedatives. Give a full antiperiodic quantity of quinine, more 
rather than less, if the fever is greater. Give from twenty to thirty- 
five grains in divided doses in a few hours, and then stop. 
By these means the fever will be broken, except in very rare cases. 
Dr. Livingstone, in Africa, in remitting as well as intermitting fevers, 
gave a mercurial cathartic, and after its operation gave ten grains of 
quinine once in from two to four hours, until three doses, or half a 
drachm, was administered. When this was retained the arrest of the 
fever was effected. 
If severe vomiting or retching occurs, the stomach may be washed 
out by giving freely of warm water, and then give a quarter of a grain 
of morphine, dropped dry on the root of the tongue, or in effervescing 
mixture, or hypodermically. 
Continue eliminatives if required, and palliate such symptoms as 
remain. 
At any time meet accidental complications. For hiccough, cups 
over stomach, chloroform, morphine, or camphor internally are proper 
remedies. 
If convulsions in children occur, arrest with chloroform or ether. 
Evacuate the bowels generally, and prevent the paroxysm of fever by 
quinine promptly and freely administered. 
Buzzing in the ears, deafness, etc., must not prevent the full 
quantity of quinine being given. These symptoms are no measure 
of its antimalarial power, and are of little consequence. 
In the premonitory stage, a free antimalarial quantity of quinine 
■will prevent the development if given in time, and more surely if pre- 
ceded by a cathartic. REMITTENT MALARIAL FEVER. 
219 
In all forms of malarial fever a full antimalarial quantity of qui- 
nine or its equivalent must be given during one intermission or 
remission, or within a few hours. 
This is essential to the best success. 
It will be observed that in malarial diseases and in many other 
derangements of the stomach and intestines and their accessory 
glands, moderate and occasional doses of blue mass or gray powder, 
to be followed by saline laxatives or cathartics, are here frequently 
advised. 
Whether this be right or wrong, it is not done as a matter of 
unthinking routine, and without considering the dangers of excessive 
mercurialization, or the claims of other agents which some think may 
answer as a substitute for this important remedy. This course is 
advised so often, because my experience and the experience of others 
have taught me that this moderate and continuous use of the mercu- 
rials is safe in the cases where it is recommended, and is best for the 
interests of the patient. Whatever be considered its mode of action, 
there is great uniformity of opinion among practical men as to its 
beneficial effects in a great number of cases where there is derange- 
ment of the secretions of the digestive organs, and its superiority over 
all other remedies in numerous cases. Podophyllin, irisin, leptan- 
drin, euonymin, and a variety of other articles, vegetable and min- 
eral, new and old, are useful in modifying secretions, and accomplish- 
ing many of the objects sought to be attained by the use of the mer- 
cury ; but none of them accomplish quite the same object. They 
either do not produce their effects so speedily, or their operations are 
accompanied by other undesirable consequences. 
Podophyllin is slow in its action, and generally drastic and irritat- 
ing when given in quantities sufficient to produce sensible effects; 
and much the same may be said of irisin and leptandrin. The euony- 
min has not been sufficiently used, especially in acute diseases, to 
establish a well-founded reputation ; and the ordinary cathartics, 
including the exceedingly useful salines, fail to accomplish by them- 
selves the results experienced from the additional use of the mercurials. 
They are not absolutely essential to success in the treatment of the 
malarial fevers, but I believe them to be necessary to the best success. 
I do not regret the caution, certainly, or even the timidity, which 
exists as to the use of this remedy. They tend to prevent excesses 
and accidents. It is better not to use mercurials at all than to use 
them excessively and recklessly. This, however, is the case with any 
powerful agent. But used with caution and moderation, mercury 
has a role which no other article can fully take. 220 
CONGESTIVE CHILLS. 
PERNICIOUS MALARIAL FEVERS—CONGEST!VE 
CHILLS. 
The term Pernicious has been applied to a variety of malarial 
fevers of an unusually severe, congestive, or collapsing form, proving 
fatal sometimes in the first, and never going beyond the fourth or 
fifth paroxysm, when unchecked. Without treatment it is among 
the most fatal of all diseases. 
The cause of this fatality is either the profound congestions of 
internal organs—more frequently of the brain—or the immediate 
depressing effect of the poison, so affecting the circulation and other 
functions as to cause collapse. We thus have the two forms of con- 
gestive and collapsing pernicious fever. When the first paroxysm is 
survived, there is a decided tendency to an intermission; and the 
great improvement in the symptoms which occurs is likely to lead one 
not acquainted with this form of the disease to a false security. 
Without treatment, each succeeding paroxysm is more severe until 
the fatal result. Whenever, therefore, the characteristic symptoms 
appear, the most prompt treatment is demanded. 
These symptoms will vary as one or other of the internal organs is 
most affected, and also according to the manner and degree of their 
affection. In the congestive variety, the brain is a frequent seat of 
the greatest local lesion ; and the symptoms will often strikingly re- 
semble those of apoplexy. 
The patient, usually attacked in the fore part of the day, becomes 
somewhat chilly, and has the sensation of an approaching paroxysm 
of common ague. Instead, however, of the usual phenomena develop- 
ing in the usual order, he becomes sleepy, stupid, and obtuse in sensi- 
bility and consciousness, and soon passes into a state of more or less 
profound coma. In this condition the temperature varies ; that of 
the internal parts of the body is perhaps invariably elevated, and in a 
majority of cases the external temperature is moderately increased 
also ; but the cutaneous circulation is sluggish, the skin has generally 
a purplish hue, and the head is hot, though the extremities may be 
cool. The pulse varies, but generally it is rather oppressed than free 
and full, and sometimes it is feeble at the wrist. The respiration is 
generally sIoav, labored, and often snoring; and sometimes moderate 
tetanic spasms occur. There may be such complete suspension of 
brain function that death occurs within a few hours. Otherwise, in 
from six to twelve, eighteen, or twenty-four hours the skin relaxes, and 
there is often a slight moisture of the surface, the patient gradually 
regains consciousness, and though feeling weak and often confused, he PERNICIOUS MALARIAL FEVERS—CONGESTIVE CHILLS. 
221 
may be able to sit up and take food, etc. The type may be either 
quotidian or tertian, and this can be foretold only when there have 
been preceding aguish symptoms occurring at periods which have 
revealed the type. Without treatment another paroxysm is sure 
to come, and to be more severe than the first, but with similar 
symptoms. 
When the congestive condition is chiefly in the abdominal organs, 
pain, depression, sometimes vomiting and purging, feeble pulse, cold 
extremities, and rapid exhaustion follow ; but the consciousness is not 
lost, and the mind may be clear. 
When the lungs are specially congested, the respiration is labored 
and rapid, and its results imperfect; the lips and surface are blue or 
leaden ; the pulse is oppressed ; an occasional cough, sometimes pul- 
monary hemorrhage, and depression and sinking follow. In other 
cases various internal organs are at the same time congested, varying 
the particular symptoms, but in all the greatest depression super- 
venes. 
In the collapsing variety, without symptoms of special congestions, 
the various functions fail—the heart and vascular system particularly 
—the pulse becomes very feeble, and at length ceases at the wrist; 
the extremities and the whole body become cold ; there is sometimes 
cold perspiration, and often complete collapse and speedy death. 
Though distinctions of this kind may be made in accordance with 
the different phenomena presenting themselves, yet back of these 
phenomena, and producing them, is the malarial poison, operating 
upon and through the organic nervous system, and producing in all 
the cases more or less congestion and depression at the same time. 
Dr. Dickson speaks of a necrsemic variety, where death and dis- 
organization of the blood corpuscles take place, and where there is 
persistent depression and inevitable somatic death. 
Prof. N. S. Davis, of Chicago, makes five clinical varieties— 
comatose, spasmodic, pulmonary, choleraic, and algid. The phenom- 
ena which these terms indicate are embraced in the description given. 
According as one or the other of the three organs more immedi- 
ately essential to life is most affected, death may occur by coma, 
asthenia, and more rarely by apncea. 
On post-mortem examination, congestions of the brain, spleen, 
liver, stomach, intestines, heart, and lungs, one or more, are often 
discovered, and the blood in some cases has been found disorganized. 
Diagnosis.—As the symptoms resemble those of other condi- 
tions, a careful inquiry into the history of the case, the influences to 
which the patient has been exposed, and the prevailing diseases at the 
time will be important in making the diagnosis. 222 
TREATMENT. 
A case is remembered where the attending physician failed to dis- 
tinguish the true nature of the disease, but where the diagnosis was 
made clear by learning, though too late, that the patient some time 
before had been in Central America, and had there been affected with 
Panama fever. It should be particularly distinguished from apoplexy, 
cerebro-spinal meningitis, and narcotic poisoning. 
It is much more frequent in the localities where the malarial poi- 
son is most intense, and in low latitudes, where the severer remitting 
forms of malarial fever are more prevalent, but it occasionally occurs 
in localities where ordinary ague most prevails. 
TREATMENT OF PERNICIOUS MALARIAL FEVER, 
The leading indication here, as in other malarial fevers, is to neu- 
tralize the poison which is the cause of all the phenomena; but the 
congestion must also he relieved and the rapidly failing vital powers 
sustained. 
Here the case is so urgent there should he no delay in attempting 
to fulfill the first indication. Quinine, in large, prompt, and repeated 
doses, should he given at once, and as there may be doubt as to its 
absorption from the stomach, it may be given at the same time by 
enema, and for its more certain and speedy introduction into the 
blood, by hypodermic injections. Used in this latter way there must 
be'a perfectly clear solution, and as this is not easily effected without 
a considerable quantity of fluid, injections may take place at several 
points at nearly the same time. From half a drachm to a drachm or 
more of quinine should be introduced into the system as soon as pos- 
sible, and in the meantime measures should be used to fulfill the other 
obvious indications. For congestion of the brain, cold may be applied 
to the head, heat to the extremities, dry cups to different parts of the 
body; or the limbs may be ligated, and sinapisms applied to the 
extremities and along the spine. Moist heat, as by bottles of hot 
water surrounded by wet cloths if the surface is dry, or by the bottles 
without the wet cloths if there is much perspiration, may be useful. 
The bowels should, if loaded, be opened by enemas, the head elevated, 
and every restraint to the return of the circulation removed. Similar 
revulsive, derivative, or “ balancive ” agents for other congestions, 
cups and sinapisms over the abdomen in congestion of its viscera, will 
be required. For the shock and depression stimulants should be used, 
such as hot coffee, ammonia, warm beef-tea well salted and spiced, 
camphor, ether, and sometimes hot alcohol and water. Whatever of 
these agents be selected, they should be given in moderate and repeated 
doses, but with care and discrimination, remembering that the nar- PERNICIOUS MALARIAL FEVERS—CONGESTIVE CUILLS. 
223 
cotics, such as alcohol, ether, and camphor, may depress and overcome 
vital action when given in too large doses. 
Prof. Davis advises that the patient be stripped and several gallons 
of cold water be dashed over the head and trunk, and then that he be 
quickly rolled up in dry flannel blankets for thirty minutes. If this 
is not followed by decided improvement, he advises its repetition, and 
if necessary, at the same intervals, for three or four times. This is 
claimed as theoretically correct, and to have the indorsement of 
clinical experience. Dr. Davis has used it successfully in two cases. 
Under some circumstances the sudden application of cold arouses 
the system, and is followed by increased functional activity; but the 
first effect is usually regarded as depressing, and a considerable degree 
of vital energy must be present to justify this course; and where it 
would be successful the other measures advised would probably be 
equally so. These other measures have the sanction of very much 
larger experience. 
When the vital actions are nearly overcome, and life is flickering 
on the verge of extinction, it would require some boldness to apply an 
agent which is generally held to produce at least temporary depres- 
sion. 
In these desperate cases great promptness and energy of treatment 
are essential. The patient, if possible, should not be left by the phy- 
sician except in the hands of the most intelligent, energetic, and expe- 
rienced persons, until the critical period is past. 
However important other agents may be as aids, nothing will ulti- 
mately avail but full quantities of antidotal remedies, and none are 
equal to quinine in an emergency of this kind. 
A drachm, more or less, must be given in divided doses; and here, 
as well as elsewhere, when vomiting, purging, or great irritation of 
the alimentary canal occurs, opiates may be combined with the quinine. 
Although the prognosis is so exceedingly unfavorable without 
treatment, the means pointed out, promptly and skillfully used, 
will generally succeed if not commenced too late. Here, as wrell as 
elsewhere, the antidotal action of the quinine is more certain when 
given during abatement of the symptoms ; but unless such abatement 
is certain, and this can very seldom be determined beforehand, it 
should not be waited for. The antidotal effect of the quinine must 
be secured as soon as possible, as the only safety. 
MALARIAL CACHEXIA. 
Cachectic conditions have already been mentioned as the result of 
long-continued malarial fevers. A condition of anajmia produced by 224 
MALARIAL CACHEXIA. 
the consumption of the blood during the fever stands between the 
fever and a confirmed cachexia. But a depressed condition, not de- 
pendent upon the consumption of blood, produced by the fever, may 
occur from the effect of the malarious poison without producing the 
ordinary phenomena of fever. What is called “dumb ague*’ is a 
condition presenting itself between the conditions of the normal fever 
phenomena and the absence of all fever, but where the malarious poison 
is operating upon the system and producing serious effects. In this 
latter condition not even the slight chilliness and the moderate fever 
occurring in “ dumb ague ” are perceived, but an anaemic and cachec- 
tic state gradually comes on. 
Two forms of this cachexia have been recognized. One depends 
upon enlargement of the spleen and the hydraemia accompanying it. 
This state may occur after repeated attacks of fever, or without such 
attacks. The spleen in these cases is tender, often painful, giving a 
sense of weight in the region; and on physical examination the 
splenic tumor may be detected. There will be dullness on percus- 
sion over a larger space, and generally on palpation the enlarged 
organ can be felt. The fingers can be pressed under its margin and 
the characteristic notch can be recognized. Dyspeptic symptoms gen- 
erally are present; there will be decided debility ; dyspnoea will occur 
on the slightest exertion ; systolic hasmic murmurs in the heart and 
large vessels will be heard ; the patient will be pale and thin, but no 
very grave consequences from this state of things will follow—the 
morbid state very readily yielding to proper treatment. 
Another form of cachexia, however, sometimes occurs, depending 
upon various visceral lesions—enlargement, degeneration, amyloid or 
otherwise, of the liver ; changes in the intestines, the lungs, and the 
brain, already mentioned in describing post-mortem appearances and 
sequoias of ague. 
Symptomatically, ascites is almost constant from the obstructed 
circulation through the liver ; a jaundiced condition may or may not 
be present; and if the kidneys are involved, as they often are, there 
will be albumen and perhaps casts in the urine. Amyloid degenera- 
tion of the intestines may occur, giving rise to a persistent diarrhoea. 
The melanaemia, already mentioned, is likely here to be present, and 
may give the skin a peculiar gray tint; and as deposits of this matter 
may take place in the brain, cerebral symptoms sometimes are ob- 
served. 
Cachectic oedemas are now added to the abdominal dropsy, either 
with or without thrombosis. When there is albuminuria, general 
anasarca commonly follows ; a low hectical fever may now occur, and 
the patient generally succumbs to the progress of the general wasting, TYPHOID FEVER. 
225 
or more speedily to some of the visceral lesions. Conditions of this 
kind were formerly not unfrequent in malarial regions, but since the 
general use of quinine and other antimalarial remedies they are very 
rare and the result of the neglect of proper treatment. These grave 
conditions are more likely to occur in hot climates and where the 
malaria is most intense. Their prevention is to he found in the effi- 
cient treatment of the malarious diseases, which has already been so 
fully described. 
When the cachexias actually are present, eliminatives are required 
for a short time, followed by decided antimalarial doses of quinine, 
from one to two scruples within a few hours, and then perhaps more 
moderate doses afterward with iron—the iodide of iron a good form ; 
and also in many cases it is well to obtain the alterative action of 
iodide of potassium upon the changed viscera. After continuing 
these means a few days, full doses of quinine should again be given ; 
and this course will arrest the progress of events, unless the structural 
changes are too far advanced. The fact that the malarial poison is 
capable of producing these effects without inducing the phenomena 
of fever, suggests the propriety of resorting to antimalarial treatment 
whenever, in a malarial region, symptoms of debility and general 
derangements occur, though none of the forms of distinct fever are 
manifest. 
TYPHOID FEVER. 
The word “ typhoid” literally means “like typhus,” and “ty- 
phus” means “stupor.” This latter word, typhus, is, however, 
applied to a particular form of specific, infectious fever, to be here- 
after described; and the word “typhous,” or “typhoidal,” or the 
“typhoid condition,” is applied to any low febrile state in which 
stupor, a dark, smoky countenance, a dry, dark tongue, tremulous and 
protruded with difficulty, sordes upon the teeth, a rapid, usually soft, 
and often an irregular and intermitting pulse, low delirium, and 
much depression and muscular weakness arc present. 
The term Typhoid Fever, and its synonyms, Enteric Fever, Pytho- 
genic Fever, Abdominal Typhus, Entero-mesenteric Fever, Typhia, 
etc., indicate an essential, idiopathic, specific fever, distinct in its origin 
and peculiar phenomena from all other fevers. The term “ typhoid,” 
however, is frequently used in the sense given to “typhous” and 
“typhoidal,” and a “typhoid state” is spoken of as belonging to 
various diseases, in malarial, pygemic, uraemic, and some inflamma- 
tory and tuberculous cases, when the low typhous condition referred 
to exists. 226 
CLINICA L PHENOMENA. 
As tlie distinct disease we are now to consider, Typhoid Fever may 
he defined as a specific fever produced by a peculiar poison usually 
found in connection with putrefying organic substances, particularly 
fecal matters in privies and sewers ; the poison being conveyed to the 
system sometimes by means of water and other ingesta, and some- 
times through the air. This poison has a period of. incubation, in 
which there is probably multiplication of its amount, and possible 
changes in its quality ; and it produces phenomena of various kinds, 
but essentially those of a fever, which usually comes on gradually 
with languor, malaise, feebleness, moderate chills, headache, and 
general pains, especially in the abdomen, back, and limbs, with a 
tendency to diarrhoea, and soon to tympanitis, tenderness and gur- 
gling on pressure in the right iliac region. As the disease advances, 
in the early part of the second week, a characteristic slight rose- 
colored eruption generally appears, showing itself first and chiefly on 
the abdomen, coming in successive crops, each small spot being visi- 
ble about three days; there is often slight epistaxis ; more or less 
ringing in the ears, and deafness ; the face is often purplish and irreg- 
ularly flushed; the tongue coated and sometimes dry, and, not unfre- 
quently, toward the latter stages, red and glazed; there is more or 
less restlessness, but sometimes somnolence ; frequently mild delirium, 
especially in a half-sleeping condition ; there is commonly a slight 
stuffy cough, Avhich will be developed by a full inspiration, with dry- 
ness of the throat and thirst not satisfactorily allayed by drinking. 
These symptoms commonly come on and disappear gradually, con- 
tinuing about three weeks, the case terminating in recovery in five 
or six weeks. Anatomically, typhoid or enteric fever may be de- 
fined as an inflammation, infiltration, and often ulceration of the 
intestinal glands, chiefly of Peyer’s patches in the lower part of the 
ilium, but often involving the solitary glands, and sometimes other 
tissues of the mucous membrane in the colon, and very rarely in the 
jejunum, as well as in the ilium. The mesentery and mesenteric 
glands, corresponding with the portion of the intestines affected, are 
also inflamed and infiltrated, and the spleen is enlarged, infiltrated, 
and softened ; and probably other blood glands are essentially more or 
less affected. 
There is so much in common between typhoid, typhus, relapsing, 
and accidental fevers, that they were formerly all called common 
continued fever, and the terms cynocha, cynochus, adynamic, 
ataxic, nervous, bilious, mucous, putrid, malignant, etc., were used 
as designating different varieties of the common fever, according to 
the peculiar views of each writer. 
The distinction between typhus and typhoid was first made by TYPHOID FEVER. 
227 
Prost, of France, in 1804, and more clearly, so far as the distinctive 
anatomical lesions are concerned, by Petit and Serres, in 1812; and 
their researches were followed up by other French physicians, particu- 
larly Louis, in 1S29, and Andral and Chomel, Bretonneau and Forget 
afterward; and by Drs. Nathan Smith, James Jackson, Gerard, and 
Bartlett, of this country; by Cramer, Diett, Thielman, and others in 
Germany ; and, finalty, by Jenner, Murchison, and numerous others 
in Great Britain ; so that the doctrine is now established, beyond any 
serious controversy, that these two fevers, typhoid and typhus, are dif- 
ferent in their origin, their specific cause, their course, their patho- 
logical anatomy, and their essential nature, and must be regarded as 
distinct diseases. 
The descriptive definition of typhoid fever already given, though 
presenting an outline of the most characteristic phenomena, would 
give a very imperfect impression of the disease without further 
details. 
The mode of attack and early symptoms present great varieties. 
Generally the invasion is gradual and its early course insidious, but in 
exceptional cases it is sudden and violent, and scarcely distinguishable 
from an attack of typhus, or malarial, or severe accidental fever. 
During the early period, in variable degrees, there will be irregular 
chills and flushes of heat, lassitude, and aching of limbs, increased 
frequency of pulse, and elevation of temperature, thirst and loss of 
appetite, with coating or redness of the tongue, with pain or a decided 
feeling of heaviness in the head, with drowsiness by day, and a dreamy, 
restless, half wakefulness by night, sometimes vomiting and often 
diarrhoea, or at least a sensitive condition of the bowels, which would 
cause a laxative to operate with unusual freedom, accompanied often 
with pain and abdominal tenderness in the csecal region ; and though 
these last symptoms are not unfrcquently absent at first, when pres- 
ent they aro strongly indicative of the disease. During the first few 
days, and even the first week, and sometimes in a case which will ulti- 
mately become severe, the patient may no-t be confined to his bed, 
and although the symptoms gradually increase in severity and num- 
ber, he may occasionally continue to attend to his ordinary business. 
By about the beginning of the second week, however, unless the case 
be exceptional, the symptoms become more fully developed and char- 
acteristic. The skin is now decidedly hot and usually dry, but some- 
times a sweat breaks out that soon dries up again ; the pulse is 
increased in frequency; the respiration is also accelerated, and the 
bronchial membrane is so much congested and irritated as often to 
produce a moderate or occasional cough. The tongue may continue 
comparatively clean and moist, there being only a thin whitish coat 228 
CLINICAL PHENOMENA. 
upon it, or it may be more heavily coated, red at the edges, and more 
inclined to be dry, and sometimes to present transverse cracks in tbe 
coating upon the dorsum. The throat is often so dry or sore as to 
make the voice husky and indistinct, and there may be frequent but 
unsuccessful efforts at clearing it from adherent mucus. The thirst 
is more decided; appetite usually nearly or quite lost; tympanitis 
occurs; the diarrhoea is generally though not always present, but 
when so the discharges are usually liquid or at least semi-fluid, and 
present the appearance of “pea soup” or “new cider," or have a 
muddy, yellowish aspect. Notwithstanding the frequent discharges, 
the tympanitis continues, and is sometimes greatest when there is 
most diarrhoea ; and the distention being chiefly of the colon, the abdo- 
men presents a “tub-shaped” rather than a “pot-shaped” appear- 
ance, as would be the case were the small intestines chiefly inflated. 
Delirium seldom occurs in the early stages of the fever unless there 
are brain complications, and by no means always at the fully devel- 
oped stage, though disease of the brain supervenes before the termi- 
nation of the case; but during the second and third weeks a mild 
delirium is very commonly present when the patient is left to himself 
or is in the semi-waking state. He generally answers intelligently, 
however, when fully aroused and addressed, but soon falls back into a 
wandering state, with strange and grotesque fancies. During this 
second week the eruption appears in about three quarters of the cases, 
Avhile it is entirely absent in the other fourth. These eruptive spots 
are very small, about the size of a head of a pin, are rose-red in color, 
slightly raised in the centre, of a lenticular form, disappear on press- 
ure, but soon reappear again when the finger is removed ; are upon 
the anterior aspect of the body, and mostly upon the abdomen ; are 
often few in number, and might readily escape notice unless searched 
for. At other times, however, they are more numerous and more 
conspicuous, extending over the body. They appear in succession, 
each continuing from two to four days—on an average three days— 
and they may be found in all stages at the same time : the stage of first 
appearance, of continuance, and of decline. Though generally they 
chiefly consist of enlargement of small vessels, and are lenticular, pre- 
senting the rounded form of segments of spheres, yet sometimes an 
effusion takes place at the centre, and they are then more or less acu- 
minated. These special features of the eruption are to be carefully 
observed, as, when they are distinctly marked, they are characteristic 
of typhoid fever, distinguishing it from all other affections. The 
slight nasal hemorrhages may occur at any time after the develop- 
ment, of the disease ; and the dullness of hearing, so frequent a symp- 
tom, usually continues until the subsidence of the fever. TYPHOID FEVER. 
229 
The temperature is an important element in the phenomena of 
typhoid fever, in reference to diagnosis, prognosis, and treatment. It 
is subject to variation in the rapidity of development and the height 
to which it rises; but in a typical case it is about as follows : 
Day. Morning-. Evening. 
1 98.6° 100.8° 
2 99.4° 101.4° 
3 100.4° 102.6° 
4 101.6° 104.0° 
5 103.5° ....104.4° 
6 103.6° 104.6° 
7 103.6° 104.6° 
After this the temperature in the morning and evening varies 
about one degree, or a little more, throughout most of the normal 
course of an uncomplicated case ; varying, however, more toward the 
close. The frecpiency of the pulse does not always correspond with 
the height of the temperature, and it is often much varied from time 
to time by exertion or external influences. It may vary from twenty 
to thirty beats in a minute by the patient’s simply rising up. If 
very fast or if extremely slow, as exceptionally occurs, the case is more 
severe. The higher and more continuous the temperature, the severer 
the disease. 
From the condition thus sketched, not far from the end of the 
second week, the patient may begin to improve and gradually recover. 
But in a large proportion of cases the patient either continues 
much the same for another week or more, or he becomes weaker and 
worse, and often passes toward, the end of the second week, into a more 
decidedly typhous condition. The elevation of temperature is main- 
tained, and. possibly increases ; the rash continues to come out; tlio 
tympanitis becomes greater; the diarrhoea persists ; the tongue be- 
comes dryer and harder; it is protruded with difficulty and in a 
trembling manner, is often fissured, sometimes glossy and red, at 
other times covered with a thick brown or nearly black coat ; sordes 
collect upon the teeth ; delirium, stupor, or wakefulness, or what is 
called ‘ ‘ coma-vigil ” is present ; the pulse is more rapid and more 
feeble, the general prostration increases ; complaints of headaches or 
other pains cease; the delirium becomes more constant and more 
profound, it may be muttering, busy, or violent; sometimes the patient 
declares himself well, and insists upon leaving his bed ; blood may be 
passed by stool, sometimes in small, and at other times in larger 
cpiantity, and tympanitis may become so great as to interfere with 230 
CLINICAL PHENOMENA. 
respiration by pressure upon the diaphragm. The patient may re- 
main in this condition for a week or more, when the symptoms gradu- 
ally abate; tbe fever becomes less, perspiration breaks out, sleep is 
more quiet; the mind becomes more clear; the tongue grows moist; 
the diarrhoea diminishes ; the appetite returns, the deafness disap- 
pears, and finally convalescence is established. In other cases matters 
will go on unfavorably. Tremors, subsultus tendinum, involuntary 
discharges, coma, failure of the heart’s action, and death ensue. 
In the milder cases, and when recovery is early, convalescence is 
often comparatively rapid, and is complete. Even in the more 
decided cases, the patient in a very few weeks may regain his strength 
and more than his usual flesh, and may feel a keen sense of renewed 
life. The hair, in all the well-marked cases, is likely to fall out 
some time later; but it is soon restored, and the patient returns 
to his usual condition. In other severe cases the convalescence is slow 
and imperfect; the mind, in rare instances, for a time may be left 
almost a blank ; in other cases the bowels may be irregular—alterna- 
tions of diarrhoea and constipation ; tenderness and pain in the abdo- 
men, especially in the right iliac region, may persist; and, though the 
appetite may be sufficient, much food or irritating articles may cause 
great distress, and an enfeebled and deranged state may linger for a 
long time and become permanent. Sometimes, though rarely, when 
convalescence seems to be established, a relapse takes place, and many 
of the phenomena arc repeated ; but much more frequently, when 
severe symptoms occur during convalescence, the condition is that of 
some local disease continuing, and being aggravated by imprudence 
or some other cause. 
The secretion of the kidneys, during the active stage of the dis- 
ease, has the common characteristics of febrile urine. The quantity 
of urea and uric acid varies with the quantity of food taken, with the 
activity of the fever, the rapidity of the consumption of the tissues, 
and the activity of the kidneys’ secreting function. The water of the 
urine is generally diminished, though not unfrequcntly it is aug- 
mented, while its specific gravity is at the same time increased by the 
larger amount of urea, uric acid, and salts, which it contains. The 
coloring matter is increased by the destruction of the blood cor- 
puscles; and sometimes the urine contains moderate quantities of 
bile or albumen. The more urea and uric acid it contains, with a 
given amount of fever and food, the less of these ingredients and 
other effete matters will be retained in the blood, and the less blood 
poisoning from these sources will occur. Should the kidneys bo dis- 
eased, so as to fail in tbeir eliminative function, uraemic and uricae- 
mic poisoning would follow. TYPHOID FEVER. 
231 
As the disease abates, area and uric acid are diminished, and the 
specific gravity of the urine becomes much less. In the favorable 
cases, when the specific fever poison has exhausted its power, the 
process of purification and repair is established; but the system often 
has a struggle to accomplish this object, and the temperature and 
other conditions may vacillate. While in the morning the tempera- 
ture may be down to nearly, or quite, the normal, in the evening it 
may rise to 103° or 104°; but the next morning it will again be down, 
and so, with fluctuation, the fever will at length disappear. 
The foregoing is intended as a description of the more important 
and ordinary symptoms of the common uncomplicated cases of 
typhoid fever ; but there are many deviations from this type which 
require notice in order to a proper understanding of this very frequent 
and important disease. 
Occasionally cases occur which are milder in character, and some- 
times, though rarefy, shorter in duration than the mildest already de- 
scribed. Not only does the patient not take his bed for the first 
week, but he may not take it at all. The temperature may not rise 
above 100°; the tongue may be but slightly coated ; there may be but 
very little or no diarrhoea, and yet some tenderness in the ilio-caecal 
region ; languor and depression will be felt, the sleep will be dreamy 
and less refreshing, the appetite poor, etc. 
This condition may continue for two weeks, more or less, when 
the patient resumes his former condition. Cases of this kind are often 
not recognized as typhoid fever, and they are now believed to bo much 
more frequent than was formerly supposed. Mild cases not unfre- 
quently occur in children, and many of the cases described as “ in- 
fantile remittents ” are now regarded as genuine typhoid. 
Not only may such mild cases occur, running a gentle course, but 
abortive cases are not very unfrequent. In these the typhoid poison 
evidently enters the system and produces some effect—induces some 
of the premonitory symptoms, and perhaps a distinct access of the 
disease ; but either the poison is expelled or the system resists its full 
and ordinary effects, and all symptoms soon disappear. Such patients 
are said to be “threatened” with the fever, but it ends in a practical 
threat. Sometimes what arc called “ walking ’’ cases occur, where the 
general symptoms are mild, but where the intestinal lesion may bo as 
great as in other cases, and where hemorrhage, rupture, peritonitis, 
or other grave symptoms may suddenly supervene. 
But on the other hand, there are cases of unusual severity from the 
beginning, where the typhoid poison acts with the greatest prompt- 
ness and violence, like a narcotico-acrid poison, producing speedy 232 
CLINICAL PHENOMENA. 
typhous symptoms—stupor, coma, and death. Such cases are very 
rare, but have been observed; and less rarely, instead of insidious 
attacks, sudden and active symptoms occur from the beginning, the 
temperature speedily rising to 105° or 10G°; or more, but the disease 
progressing with the development of the usual, though perhaps more 
than usually severe, phenomena. 
There are, besides, numerous variations from the more common 
type in the course of the disease. 
Grisolle divides the progress of the disease into three stages or 
septenary periods, while Jaccoud makes two periods—that of the 
typhic process, or the period of the action of the poison, and that of 
the period of (at least attempted) repair. The stages, pathological or 
clinical, depend on changes occurring, and not on days ; and changes 
are progressive, and varying in the time of their occurrence. The 
period of the poison’s direct action is neither definite nor distinguish- 
able from its more remote effects, or from the reactions of the system 
and the efforts at repair. There are therefore not sufficient grounds for 
designating definite stages, as there is a series of phenomena over- 
lapping each other, and mingling in a continued process of pathologi- 
cal changes and symptomatic manifestations. These vary in number, 
in character, in degree, and in the time of occurrence and continuance, 
rendering it impossible to give a description which will be applicable 
to all cases, and requiring a statement of many details in giving a 
satisfactory account of this fever. The phenomena are, however, 
grouped in such a manner as to furnish certain varieties, having 
somewhat distinctive physiognomies, and admitting of a loose classifi- 
cation. Grisolle makes these principal varieties — inflammatory, 
bilious, mucous, adynamic, ataxic, and latent. 
In what ho calls the Inflammatory variety, there is much excite- 
ment, a high full pulse, intense heat, great thirst, skin injected, urine 
red and scanty, the phenomena resembling those of fever accompany- 
ing active inflammation, or some forms of simple fever or of the hot 
stage of malarial fevers. This condition, however, is temporary, last- 
ing only about the first week, when the more typhoidal or adynamic 
symptoms supervene. 
The Bilious variety is marked by a yellow coat of the tongue, a 
bitter taste in the mouth, and an icterode tint of the skin, and it pre- 
vails most in the latter part of summer and autumn. Like the pre- 
ceding, it is merged, after a week or so, into a more adynamic form. 
The Mucous form is oftener seen in feeble, badly fed persons, in 
unhealthy situations. The face is comparatively pale and puffy, the 
tongue white, mouth pasty, and stools often mucous. There is gen- 
erally a catarrhal condition of the digestive mucous membrane. TYPHOID FEVER. 
233 
Here, as in the other forms, the adynamic condition sooner or later 
occurs. 
The distinctively Adynamic or Putrid form, is that which is most 
common in Paris and in many other large cities, and is also the form 
most commonly found in large hospitals. In Paris, it is said, one 
third of the cases are of this type primarily, and in nearly all the 
cases the adynamia occurs in the latter stages. In this variety there 
are great weakness and prostration, coma, feebleness, and sometimes 
slowness of the pulse; suppressed cutaneous circulation, and some- 
times coldness of the extremities; fetid dejections, dark tongue, 
sordes, passive hemorrhages, and a low condition in the vitality of the 
blood. 
The Ataxic, Nervous, or Cerebral variety, is marked by early deli- 
rium, perversion of the senses, subsultus tendinum, convulsions 
occasionally, cutaneous hyperaesthesia or anaesthesia ; the spinal and 
cerebral symptoms are commingled and scarcely distinguishable. 
But the different symptoms characterizing these varieties are 
mingled in different proportions in individual cases, so that it will often 
be almost impossible to say to which of these varieties a given case 
belongs, and, as already stated, both adynamic and ataxic symptoms 
commonly occur in the latter stages of all severe cases. 
The Latent form of Grisolle corresponds with the very mild forms 
already described. Frequently the diagnosis is not made at all, but 
in some cases violent and characteristic symptoms or complications 
occur in a later stage from perforation of the intestines, hemorrhage, 
or peritonitis. The result is fatal, and a post-mortem examination 
will confirm the diagnosis indicated by these symptoms. 
But, independent of these varieties, individual symptoms vary 
much in different cases. 
The temperature, the most important symptom or element in most 
cases, varies often decidedly from the typical standard given. Some- 
times the remissions are particularly marked, more so than in some of 
the varieties of malarial fever. Often the temperature increases about 
noon, and is at its height between 7 p.m. and midnight. After mid- 
night it falls gradually, and attains its minimum in the morning. 
In uncomplicated cases these daily fluctuations arc nearly constant, 
but vary from one to two or three, or rarely to even four degrees, in 
different cases. After about the end of the second week, in mild 
cases, the morning temperature may be very near the normal, the 
evening as high as before; but soon this too may decline, and the 
case, with fluctuations, goes on to convalescence. Some are of the 
opinion that the activity of the specific poison is normally not over 
about two weeks, and that the continuance of the symptoms after that 234 
CLINICAL PHENOMENA. 
time is due to the local lesions that have been induced, or to the 
degenerative processes in the general solid tissues, or the impurities 
and perversions of the fluids of the system. 
In severe cases, after the end of the first week, the high tempera- 
ture may be more constant and uniform than at the earlier period. 
In complications the thermal changes are various, and will be referred 
to in connection with the descriptions of such conditions. In the 
condition of collapse, however produced, the temperature generally 
falls, sometimes below the normal, but in other cases, before death, 
it sometimes rises to 108°; or even 110° or more, even independent of 
complications. 
The pulse varies greatly in frequency. In occasional very mild 
cases it is scarcely above the normal at any time. In other cases, and 
according to their severity, it rises to 90, 100, 120, or 140 or more; 
and when very rapid it usually becomes feeble. It is generally more 
rapid in the evening than in the morning, and in the latter than in 
the earlier stage of the disease. Occasionally it is abnormally slow, 
and even when the temperature is high it may sink to GO or 50 ; and 
Murchison mentions a case where it fell to 37 per minute. In one 
season, in Berkshire Co., Mass., in a particular locality, in several 
cases the frequency of pulsations was exceedingly low. In some severe 
cases, and rarely in cases not exceedingly severe, the pulse is dicrotus ; 
that is, two waves are felt at each pulsation of the heart; and other 
irregularities as to time or rhythm are sometimes noticed. The respi- 
ration is generally increased in frequency, and in a degree correspond- 
ing with the frequency of the pulse. If increased out of proportion 
to the pulse, it would commonly indicate pulmonary or bronchial com- 
plications. Still, disturbances of innervation will sometimes vary the 
frequency of respiration in either direction. It may, with such dis- 
turbances, particularly in hysterical persons, become very fast or very 
slow for a time, independent of structural changes. 
The appearance of the tongue varies not only with the period and 
severity of the fever, but independently of them. In some cases it 
remains almost normal throughout the illness, with only a slight 
whitish coat, or a little redness and dryness. More commonly it is 
covered, except at the margins, with a whitish brown fur, consisting 
of hyperplastic and adherent epithelium, with mingled mucus from 
the buccal membrane, which tends to become dry ; or the tongue may 
have a dry, red, glazed appearance, without prominent epithelium, 
but with, or without, flakes of adherent mucus ; and in either case, of 
coating or glazing, there may or may not be transverse fissures. 
The throat is often irritated, congested, and dry, and sometimes, 
as a complication, inflamed, and even, rarely, ulcerated. These condi- TYPHOID FEVER. 
235 
tions often give the patient great discomfort, especially when dried 
and tenacious mucus persistently adheres to the posterior pharynx. 
The condition of the stomach, and the capacity to bear food and 
medicines, will vary in different cases. Not unfrequently there is 
sickness, and sometimes vomiting, in the early stage of the fever, and 
occasionally this irritability continues throughout the disease; but 
usually, unless there is a complication of gastric inflammation, the 
sickness subsides after some days, and if food of a proper quality be 
administered in moderate quantities and at regular intervals, a toler- 
ance if not an appetite is established, and the nutrition of the patient 
is thus more satisfactorily kept up. Thirst is nearly always present, 
but it varies much in intensity, and in rare instances drink is not 
particularly craved. 
Diarrhoea, usually present, varies much in the frequency and 
copiousness of the discharges; and sometimes the bowels are even 
constipated. The diarrhoea! evacuations vary in liquidity, but are 
usually of a greenish or yellowish color, generally decidedly offensive, 
sometimes fetid, and not unfrequently mingled with blood. Pro- 
fuse hemorrhage from the bowels is one of the complications to be 
hereafter noticed. 
The urine, as already mentioned, is febrile in character; in the 
early stage it is scanty, high colored, and of high specific gravity, but 
later it becomes more copious, paler, and of lower specific gravity; 
yet it varies in all these respects in different cases. A small quantity 
of albumen may be detected during the third week in perhaps a third 
of the cases, and the quantity of common salt is usually diminished 
throughout. 
The skin, though commonly dry, is liable in many cases to become 
occasionally moist, and sometimes there is free sweating. In one local 
epidemic of great severity which I witnessed, profuse perspiration 
was a marked condition of most of the cases, continuing through the 
course of the disease, which was fatal in a larger proportion of cases 
than usual. Not unfrequently from the last of the second week per- 
spiration may be free, especially in the morning. Insensible perspira- 
tion in all forms of fever is more free than is generally supposed. The 
elevated temperature effects a speedy evaporation of the exuded 
moisture, and causes dryness where exhalation is nevertheless con- 
siderable. 
The eruption which has been described varies much in amount, 
and is not unfrequently absent ; but it varies but little in character 
when present. 
During convalescence perspiration is often profuse; and as the 
cuticle is altered and rendered less pervious, and perhaps looser, by the 236 
PATHOLOGICAL ANATOMY. 
continued fever, it is generally elevated in points by the pouring out 
of the sweat, constituting sudamina, or sweat blisters. These are 
most likely to appear about the anterior part of the chest and neck. 
The ringing in the ears and the dullness of hearing are very vari- 
able, and not unfrequently absent: so also with the slight bleeding 
from the nose ; but sometimes profuse epistaxis occurs, requiring in- 
terference. In most nasal hemorrhages, seizing between the thumb 
and finger the cartilaginous part of the organ, as close as possible to 
the nasal bones, pressing steadily and firmly so as to bring the 
surfaces of the pituitary membrane in contact, and holding them thus 
for several minutes, will arrest the bleeding. If this is not success- 
ful, plugging the nostrils may be required. 
The conjunctivae are seldom congested, the pupils are commonly 
dilated, and the vision is not generally much impaired. 
Delirium, when present, is variable in character and amount— 
generally mild, and occurring between sleeping and waking; it is 
sometimes profound, may be low and muttering, or more active and 
violent—and coma, subsultus tendinum, and convulsions in the ataxic 
varieties may occur. 
Few diseases are more variable in some of their phenomena, and 
yet none are more constant in others ; and no disease has more cer- 
tainly a specific identity. 
The different local complications that are liable to occur in typhoid 
fever will vary still more the symptoms and course of particular cases ; 
but these can be better understood after describing the pathological 
changes occurring in the course of the disease. 
PATHOLOGICAL ANATOMY. 
As the disease usually terminates before a long period of wasting, 
the cadaver is not extremely emaciated. The rigor mortis is marked, 
and the muscles are often red, being infiltrated with the coloring 
matter of the blood. The fibrine, the albumen, and the red corpuscles 
arc diminished, the blood discs are sometimes found broken down, 
while the proportion of the white globules is increased. Jaccoud 
speaks of typhoid leucocytes. 
The oxidation of the blood appears to be below the normal stand- 
ard, and the quantity of carbonic acid increased. The amount of 
sugar in the blood is also said to be above the normal, while some 
report that the urea in it is diminished. This poison is probably by 
no means uniform. Bacteria have been found in the blood, hut 
whether these have a necessary connection with the disease has not 
been determined. TYPHOID FEVER. 
237 
Of the lesions of organs, some are so constantly found as properly 
to be regarded as necessary to the disease; while others are found 
occasionally, and are so frequently absent as to be justly considered 
as accidental ; but these latter, when present, have often a great in- 
fluence upon the course and results of the disease. 
The necessary specific lesions are congestion, swelling, deposits 
in, often ulceration, and sometimes sloughing of, Peyer’s patches and 
the solitary glands, generally near the ilio-caecal valve; and hyper- 
emia, inflammation, and sometimes suppuration of the correspond- 
ing mesenteric glands, and enlargement, softening, and deposits in 
the spleen. These changes, which require a more particular descrip- 
tion, belong to typhoid fever, as the eruption does to measles or to 
small-pox. They may possibly be absent; but this is so rare as to 
constitute an abnormality of the proper conditions of the disease, and 
to make its genuineness doubtful. The lesions of the intestines prob- 
ably commence with the earlier symptoms of the fever. They have, 
in a sufficient number of cases, been observed as early as the fifth 
day. From the fifth to the eighth day, the portion of the ilium, 
where Peyer’s patches are involved, observed exteriorly, will present 
at the points affected a red, blue, or blackish color, impairing the 
transparency. In some cases a patch of false membrane has been 
observed upon the peritoneal surface, inflammation having extended 
to that membrane. This, however, is not common. Pressing the 
part between the thumb and finger, an inequality of thickness is felt, 
showing a tumefied condition of the glands. Examined from the 
internal surface, the swellings of the solitary glands are conical, 
rounded, and disseminated, and about the size of half a pea. Those 
of Peyer’s patches are on the part of the intestine opposite to the 
mesentery, are of a larger circumference, and more oval or irreg- 
ular in shape. They are from two to five centimetres in length, 
and one and a half to two or more in breadth. Their thickness 
varies much in different cases, from one to nine millimetres (from 
less than a line to one third of an inch). They present a more or less 
tumid margin, and a palish or pinkish Avhite color. 
Some of these patches are soft, and but slightly prominent, the 
surface foveated, or mammillated, or more smooth, and offering little 
resistance to pressure. When cut through, the mucous membrane of 
the intestine is found thickened, moist, and injected, presenting an 
appearance like the parenchyma of a cherry or a plum. The mem- 
brane over the swollen gland is softened and easily removed. Others 
of these patches are hard, more prominent, more shining in color, 
more elastic and firm to the touch, but friable. When cut through, 
they show a yellowish-white appearance ; they involve the mucous 238 
PA TUOLOGICAL ANA TOM Y. 
membrane, which undergoes the same changes as in the soft variety. 
The hard plaques are found in about one third of the post-mortem 
examinations, and are regarded as more grave lesions than the soft. 
The isolated follicles undergo the same changes. They differ only 
in being cone-shaped and smaller. The hard and soft swellings occur 
simultaneously, but unequally in different cases. Black points in the 
membrane are sometimes observed, looking like a newly-growing 
beard after shaving. These have been regarded by some as typhoid 
deposits ; but they are found in other cases than in typhoid fever, 
and are perhaps only anatomical peculiarities. 
The swellings of the glands attain their full development by the 
ninth or tenth day, sometimes a day or two earlier or later, when 
they may gradually subside ; the hyperaemia diminishes, the exudates 
become absorbed, or, more frequently, the contents become discharged 
with a simple rupture of the membranous covering of the glands, 
and a slow restoration takes place. In other, and generally in the 
severer cases of the disease, and not unfrequently in those cases where 
the general symptoms are mild, instead of this resolution from the 
ninth to the twelfth day, when the swellings attain their maximum, 
and rarely sooner (one case having been seen on the sixth day of the 
disease), ulceration occurs. 
This process commences in two ways. In one it begins at the 
margins of the swollen glands in the mucous membrane, extending to 
the diseased gland and gradually destroying it; in the other the soft- 
ening commences in the gland, it breaks down, and the destructive 
process extends to the membrane. Necrosis of the gland sometimes 
occurs suddenly, and an eschar is formed of it before the mucous mem- 
brane is destroyed, and this for a time may hold the necrosed gland 
in place; but soon the membrane is ulcerated, and the diseased or 
dead gland is thrown off in larger masses or smaller shreds. These, 
by careful searching with glasses arc sometimes detected in the stools, 
and when recognized become positive proofs of enteric fever. 
Both of these modes of ulceration may occur at the same time ; 
and the succeeding ulcerative process—the spread of the ulcers—may 
vary much in different cases. The ulcers at the seat of the agminated 
patches are generally oval but may be irregular. Those of the solitary 
glands are circular and generally limited, but sometimes extend 
farther. The margins of some of the ulcers are thick and salient like 
a collar ; others are thin, presenting no prominences; some are ad- 
herent, others are loose and undermined. The bottoms of some are 
covered with a brownish, slaty, gray, or yellowish granular mass, in 
larger or smaller quantity ; others are more clean and red, showing 
the muscular coat of the intestine thickened ; while in other cases the TYPHOID FEVER. 
239 
ulcerative process extends to this coat, and destroying it leaves only 
the thin peritoneal coat, which itself may undergo the ulcerative 
process, or softened and weakened may rupture. When this is the 
case the intestinal contents pass more or less freely into the peritoneal 
cavity, causing great shock, violent peritonitis, and death. In some 
rare cases the eschar involves all the coats of the intestines, and per- 
foration takes place at its falling off. In still other cases inflamma- 
tion occurs at the seat of the ulcer on the external surface of the 
peritoneal coat, adhesions form to other intestines, or to some sur- 
rounding parts, preventing perforation ; or such adhesions may be torn 
asunder by exertion or some physical cause, producing perforation in 
this way with its fatal consequences. A perforation may take place 
from a very small ulcer, and when there are few ulcers, they are, ac- 
cording to Grisolle, likely to penetrate deeper than when there are 
more. Penetration is quite as likely to occur in cases where disease of 
the intestinal glands is limited in extent, and where the symptoms are 
mild, as where the number involved is larger and the preceding symp- 
toms are more grave. The size of the penetration in the peritoneal 
membrane varies. It may be very small, not more than a line or two 
in extent, and yet give exit to intestinal contents sufficient to pro- 
duce the most disastrous results. If larger, a more profuse outflow 
is likely to occur, and a more profound shock and speedy death follow. 
Occasionally, though very rarely, there are recoveries after perfora- 
tions have occurred. The ground of hope is in the formation of ad- 
hesions and the prevention of the passage of intestinal contents into 
the peritoneal cavity. 
The number of diseased glands varies exceedingly in different 
cases. There may be a single patch, or thirty or forty patches—very 
few or many of the solitary glands. Though the chief seat is in the 
small intestine, and at the lower third of the ilium, yet the solitary 
glands in the caecum and ascending colon are not unfrequently 
affected (in about one third of the fatal cases), and in rare cases the 
glands in the jejunum are the seat of similar changes. Very rarely 
the solitary glands are affected in the colon and elsewhere, while 
Pcyer’s patches escape, and errors may occur when the examination is 
not extended beyond the patches and the lower ilium. In a very 
large majority of cases, however, the patches of agminated glands 
nearest the valve are first and most generally affected, and not unfre- 
quently are the exclusive seats of this peculiar intestinal lesion. 
Recent investigations by Dr. Klein seem to show that the smaller 
typhoid growths do not originate exclusively in the glands, but may 
arise in the lymphoid tissue of the mucous membrane. The micro- 
scope shows that the process, both in the intestines and mesenteric 240 
PA TIIOLOGICAL ANA TOMT. 
glands, is not only accompanied with hyperasmia, but with increased 
development of lymphatic cells and of giant cells not unlike those 
found in tubercle ; and also that there is rarefaction of the fibrous con- 
nective tissue. A microscopical fungus was also found in connection 
with these specific intestinal typhoid lesions. These fungi consisted 
of greenish spherical bodies, two or three times as large as the blood 
corpuscles; and micrococci, or spores of extreme minuteness, singly, 
in couples, or strings, or irregular clusters, were observed. These 
mycelial fungi were found on the surface of the mucous membrane 
and within the tubular glands, but they pervaded also the epithelium, 
and were especially abundant in the lymphatic spaces and channels, 
and in the small veins. They were also found in the diseased mesen- 
teric glands. Observations of this kind have not been sufficient to 
establish a definite connection between these fungi and the disease ; 
but the time may not be distant when the essential cause of this 
fever and these lesions will be conclusively shown to depend upon 
some microzyme or organic material, for which an antidote may be 
found. 
After six to eight weeks the intestinal ulcers become thin and flat- 
tened, the bottoms of a slate gray, or covered with a pellicle smooth 
and shining like a serous membrane ; the previous villosity being 
removed by the covering of the ulcerated surface, veritable cicatrices 
are formed and the ulcers are healed. 
The patches of diseased glands which have not ulcerated are atro- 
phied and depressed, are of a bluish gray or darker color, and toler- 
ably consistent. 
Both the hard and soft variety of swollen glands are capable of 
resolution, except in the reticulated form, when there is early destruc- 
tion of tissue. 
The mesenteric glands, as has already been stated, are almost 
always diseased when the intestines are affected, but they present dif- 
ferent appearances at different stages of the fever. From the fifth to 
the fifteenth day they are found hyperaemic and swollen, as large as 
filberts, or sometimes larger, and are red, friable, and softened. From 
the fifteenth to the twentieth day they are still more swollen and 
injected, and not unfrequently, when cut across, pus is found infil- 
trated in small points; but there is very seldom any.collection into an 
abscess. From the twentieth to the thirtieth day the swelling sub- 
sides, the glands becoming brownish, or of a violet color; and after 
thirty days they become gray, slate colored, and more consistent. 
Karely they undergo a lardaceous degeneration. 
The number of these glands affected corresponds with the extent of 
disease in the small intestines. In about three fourths of the cases the PATHOLOGICAL LESIONS. 
241 
mesocolic glands are somewhat swollen, but are less severely affected 
than the mesenteric. 
The remaining well-recognized essential lesion is of the spleen. 
From the fifth to the twentieth or twenty-fifth day this organ is found 
doubled, trebled, or quadrupled in size, of a dark wine color, friable 
and easily broken down into a pulpy mass. A similar condition, so 
far as the general appearance is concerned, is found in many fevers 
and some other diseases of debility; but, excepting in severe cases of 
malarial fever, it is nowhere so frequent or so marked as in typhoid 
fever. After thirty days its condition improves, though the patient 
dies later of the fever or its consequences ; indicating that while the 
typhoid poison is present and active the spleen suffers, and after its 
direct effects are exhausted the spleen improves, whatever other con- 
ditions may exist. It may remain more dense, however, until the 
fortieth or fiftieth day. In rare cases the spleen may be so much 
enlarged and softened as to have its peritoneal capsule ruptured, a 
fatal hemorrhage taking place into the peritoneum. 
According to Jaccoud, “ typhic neoplastic ” deposits, such as occur 
in the intestines, take place in the spleen and in other organs as well; 
and he avers that they are much more extensive than was formerly 
supposed. They are found in the “blood gland system” generally, 
and may have much to do in the production of the blood perversions 
which are important elements in the disease. These deposits are said 
to have been found in the stomach, in the general tissue of the intes- 
tines, in the liver, in the kidneys, and, in one case, in the coats of the 
bladder, as well as in the spleen, lymphatic glands, mesentery, etc. 
Lesions of other organs than those that have been described are 
not regarded as specific, but are such as may occur in other diseases, 
and may or may not be present in this. 
In fatal cases the pharynx and oesophagus are not unfrequently 
found inflamed, sometimes a false membrane is found upon the sur- 
face, and sometimes purulent infiltration is in the substance of the 
membrane and submucous tissue, and in other cases superficial ulcer- 
ations appear. 
The stomach is found perceptibly diseased in a considerable pro- 
portion (about two thirds) of the fatal cases, sometimes when not 
indicated by any marked symptoms during life. 
According to Grisolle, ulceration is present in one twelfth of the 
fatal cases ; the mucous membrane is softened and thickened in one 
fifth or more, and there are congestion and discoloration in others. 
The mucous coat of the intestines between the diseased glands is some- 
times found in a healthy condition, but in from three fifths to four 
fifths of the cases it is injected and softened, especially in those cases 242 
TYPHOID FEVER. 
terminating within the first two weeks. When death occurs after 
twenty days, this membrane is not so much affected; but it is often 
gray or slaty looking in consequence of previous injection. There are 
some perceptible lesions in the large intestines in a majority of cases. 
In three fourths of the cases there is some degree of softening, with or 
without injection in the caecum. In one fifth of the cases in Paris 
there are spots of abrasion or superficial ulcerations of the mucous 
membrane of the large intestines, but not always confined to the fol- 
licles. These ulcers are rarely cicatrized, even in protracted cases, 
indicating their development at a later stage of the fever. 
Sanguineous infiltrations are sometimes found in different portions 
of the intestines in cases where hemorrhage has occurred not long 
before death ; but these or similar appearances may be produced by 
imbibition of blood post mortem. 
The liver is softened in half of the cases, and the bile is quite 
fluid. The function of this organ is generally decidedly changed; 
and besides being softened, it is sometimes fatty, granular, of a gray- 
ish red, or grayish yellow color, and rarely it is found broken down. 
The lungs are found altered more or less in two thirds of the fatal 
cases. In a majority of the cases they are merely congested, but 
sometimes lobar or lobular pneumonia is present. The most common 
alteration, however, is what is called splenization—a subinflammatory 
affection in which there are passive hyperaemia and serous or sero-plastic 
effusions. The lung becomes of a violet color, is heavy, resistant, but 
more flabby than in hepatization ; when incised there is a flow of 
sero-sanguineons fluid, and the general appearance of the part affected 
is much like that of the spleen. The posterior part of both lungs is 
the most frequent seat of this change.- When pneumonia occurs, it is 
of rather a passive than active kind, more or less hypostatic—the 
exudate being less firm than in acute croupous pneumonitis—and it 
is not unfrequently lobular. Sometimes there is more hyperplasia of 
the pulmonary tissue than in ordinary splenization, presenting a con- 
dition of carnification. Very rarely abscess of the lung is formed ; 
but not unfrequently there is oedema of these organs, which may come 
on suddenly and prove terminal. 
Bronchial congestion is very frequent, and sometimes a decided 
bronchial catarrh is developed. Enlarged bronchial glands not un- 
frequeutly are found, and sometimes laryngeal and bronchial, as well 
as pharyngeal ulcerations are present. In occasional cases, tubercu- 
lous deposits occur during a protracted fever, developing soon into 
acute consumption, if the patient survives the fever. Occasionally, 
but more rarely, acute suppurative or sphacelating parotitis is found, 
and so are erysipelas, phlebitis, and infiltration of the heart and SYMPTOMATIC COMPLICATIONS. 
243 
arteries. More frequently degeneration of the heart, liver, and spleen 
takes place, and sometimes of the brain and spinal cord. 
The kidneys are sometimes softened, and suffer changes similar to 
the liver. These accidental changes, though probably influenced to 
some extent by the direct action of the typhoid poison, are thought 
by Juergensen to be chiefly dependent upon the degree and duration of 
the fever heat; and, according to this author, degeneration.produced 
by the fever heat, of the muscular tissue of the heart, causing asthenia, 
is among the most frequent causes of death. 
From this enumeration of the pathological lesions the symptom- 
atic complications can be readily understood. 
We have seen that peritonitis would almost necessarily result from 
perforation of the intestine; and we can readily imagine the severe 
pain, the profound shock, and the rapid and extensive inflammation 
which would follow. We have also seen that inflammation of the 
peritoneal coats of the intestine may occur from the extension of the 
inflammation of the follicles and tissues around them, without per- 
foration ; and this inflammation may extend more or less over the 
membrane, causing pain, tenderness, depression, and other symptoms 
of peritonitis. 
Another result of the ulceration is the opening of blood-vessels, 
and the occurrence of hemorrhage, which is sometimes profuse. 
The changes in the stomach may lead to nausea, vomiting, pain 
and intolerance of food and medicines—those in the lungs to dyspnoea, 
pain, expectoration, increase of fever, depression, and the develop- 
ment of the physical signs of the particular conditions, etc. 
Any material change in the brain or spinal cord will of course be 
followed by nervous perversions—and so of other changes. 
The complication most to he dreaded is peritonitis. When result- 
ing from perforation, which is most common, it is ushered in by 
severe pain, and often by a chill—the tympanitis is increased, the 
diarrhoea which had been present before may cease, the pulse becomes 
rapid and feeble, vomiting often occurs, and free quantities of a green 
or dark fluid may be ejected ; respiration becomes rapid and labored, 
and when there is great depression the pain may cease, the patient 
becomes collapsed, and death occurs from asthenia. In some cases of 
perforation the shock is so profound, the depression so rapid, and 
anaesthesia so speedy and great, that no pain is expressed—the patient 
collapsing and speedily sinking. In such sudden prostrations, though 
no pain or other ordinary symptoms of peritonitis are present, perfo- 
ration may be inferred, or at least should be suspected. Too much 244 
TYPHOID FEVER. 
food, extensive tympanitis, pressure upon the abdomen, or sudden 
exertion may favor the rupture; but not unfrequently it occurs sud- 
denly and unexpectedly, without any cause but the ulcerative process 
already described. It is an accident more frequently occurring in 
adolescents and adults than in children ; and when it arises from per- 
foration the patient seldom survives more than two days, and often 
succumbs much sooner. 
The cases of peritonitis not dependent upon perforation are not 
as violent in their onset, or rapid in their progress; but similar 
symptoms present themselves, and a similar result, sooner or later, 
usually, though not always, follows. I have known one patient to sur- 
vive even a perforation, but succumb to a subsequent one, some two 
or three weeks later, the post-mortem examination furnishing evi- 
dence of both accidents. 
Hemorrhage from the bowels more frequently occurs during the 
second or third week, when the ulcerative process is most active, and 
opening of vessels by the ulceration is the most common cause, 
though sometimes it occurs from extreme hypersemia by capillary 
oozing from other portions of the mucous membrane. In some cases 
there is an acute hemorrhagic diathesis revealed by repeated hemor- 
rhages, not only from the bowels but from the nose, marked also by 
petechias on different parts of the surface. This is more dangerous 
than the accidental hemorrhages from the intestinal ulcerations and 
congestions. The loss of blood may be slight—it may be mingled 
with other intestinal matter, and be scarcely distinguishable. When 
more free it may pass off speedily and in a comparatively fresh con- 
dition ; at other times it is retained longer and passes in the form of 
clots more or less firm; and in other cases still, it is mingled with 
fecal matter, and when retained for a length of time, becomes of a 
dark brown or black color, and may appear like dark coffee grounds 
settling in the bottom of the vessel. If profuse, it will be marked by 
pallor, diminution of temperature, lowering of the force of the pulse, 
and prostration of strength ; and may be followed by syncope and 
death. If less profuse, but still decided, it may be followed by 
marked relief to the febrile symptoms, and by convalescence soon 
after; and the danger of protracted debility from excessive loss of 
blood, though very great, is often overrated by our modern fears. I 
have seen hemorrhage in typhoid fever fatal, but I have often seen it 
followed by relief. Even in the latter stages of a very severe and pro- 
tracted case I have seen a comatose patient awaken, a tetanic arm 
relax, a hard, dry tongue become soft and moist, a temperature of 105° 
speedily brought down to the neighborhood of 100°, a dry skin bathed 
with gentle moisture, and convalescence,- thus commencing, progress SYMPTOMATIC COMPLICATIONS. 
245 
with quite the usual rapidity to a complete recovery, after a loss of 
blood, involuntarily passed from the bowels, that was reckoned by 
pints. Such an event may be regarded as a fortunate escape, as 
doubtless any considerably greater loss would have been fatal; and 
though nature happened to be successful, art would not be justified in 
so hazardous an imitation ; yet such a fact, and this is not a solitary 
one, should diminish our horror of a loss of blood, and moderate our 
denunciation of the fathers for their use of blood-letting as a remedial 
agent. I can also state that I have seen an immense loss of blood 
from the bowels, in a vigorous and plethoric young woman, in the 
early stage of what was regarded by an eminent and experienced 
attending physician as a case of typhoid fever, followed by an aston- 
ishing improvement in all the symptoms, and an early and complete 
convalescence. The fact must be admitted that in various inflam- 
mations a loss of blood, especially if from or near the inflamed parts, 
often produces the most marked relief, and is attended with less 
debilitating effects than many suppose. In the debility of even a 
protracted fever, it is not so much the diminished quantity as the 
perverted quality of the blood, that, combined with the depressing 
influence and local suffering, produces this debilitating effect. Any- 
thing which relieves the local disease tends to increase the strength of 
the patient; and hence a loss of blood, when not too great, may 
diminish rather than increase prostration. Such is sometimes the 
case in loss of blood from congested and inflamed intestines in typhoid 
fever. Its dangers, however, must be acknowledged. 
A general muco-intestinal inflammation complicates some cases of 
typhoid fever, in some instances occurring at an early stage, and in 
others at a more advanced period. There will then be increase of the 
abdominal symptoms, pain, tenderness, and diarrhoea, with mucous, or 
sometimes briny, discharges, meteorism, and more rapid prostration. 
The fever will be likely to be less remitting, and if the inflamma- 
tion should involve the muscular and peritoneal coats, the diarrhoea 
might cease, the tympanitis might increase greatly, and speedy sink- 
ing follow. This more general enteritis is much more likely to occur 
in children than in adults, and is a serious complication, particularly 
in young children. 
Complications of inflammation of the respiratory system are not 
unfrequent, and congestions of the bronchi and lungs are still more 
common. Generally there is more or less bronchial irritation, mani- 
fested by the cough developed by a full inspiration, by a tenacious 
sputum, and often by dry bronchial rales. 
When more decided inflammation occurs, there will be an increase 
of the symptoms and signs, more or less difficulty of breathing, and, if 246 
TYPHOID FEVER. 
the inflammation extends to the capillary tubes, as it sometimes does 
at an early period of the fever, great dyspnoea and cyanosis, and 
sometimes speedy suffocation and death, will follow. But the lung 
substance is liable to be affected, particularly toward the latter stages 
of the fever. There is often congestion of the posterior part of the 
lungs when the patient Ins long on his back, and a hypostatic pneu- 
monia is apt to occur, insidious in its approach, and resulting in 
splenization or a partial hepatization, with more liquid and less fibrin- 
ous exudation than exists in primary croupous pneumonia. More 
active attacks sometimes happen, marked by a sudden rise of temper- 
ature, pain in the part, bloody sputa, and the physical signs of 
pneumonitis, lobar and lobular. These complications are serious, 
and, when recovery takes place, the lung may be left in a consoli- 
dated condition from which it very slowly recovers. 
In some cases tuberculous or other degenerations follow; and, 
occasionally, without these preceding conditions, acute tuberculosis 
succeeds to typhoid fever. 
Pleuritic inflammation, sometimes resulting in empyema, may 
also complicate a case ; and all these conditions will present the 
symptoms and signs peculiar to their respective states, but they will 
be more or less obscured by the other conditions of the patient. These 
conditions require careful examination, and much depends upon the 
physical signs for their detection. As the bronchi and pleura may be 
involved at the same time, even the physical signs may be so obscured 
as to prevent an accurate differential diagnosis of the special condition; 
but the existence of some complicating inflammatory disease of the 
respiratory organs can be made out by proper attention to all the 
symptoms and signs. The bearing which such complications have 
upon prognosis and treatment demands special attention ; they are 
estimated to occur in one sixth or one seventh of the cases. 
In the weakened condition of the heart, and obstructed circulation 
of blood through the lungs, oedematous effusion into the latter organs 
is likely to take place, and sometimes it comes on so rapidly and 
extensively as to cause speedy suffocation and death. This accident 
is to be guarded against by keeping up the heart’s action and the gen- 
eral strength, and is to be detected by symptoms and signs which 
will be pointed out when we come to the diseases of the respiratory 
system. 
Cutaneous inflammations, erysipelatous and ecthvmatous, some- 
times complicate typhoid fever. 
Ecthyma occurs mostly upon the nates and the parts upon which 
the patient lies, and may be induced by the discharges where proper SYMPTOMATIC COMPLICATIONS. 
247 
attention is not given to them. The pustules may be few or numer- 
ous, and in low conditions they cicatrize slowly. 
Erysipelas generally attacks the face, and is less acute and rapid in 
its progress than when occurring as a primary disease. It is, how- 
ever, serious in its consequences when added to the other morbid con- 
ditions, and, according to Grisolle and others, one half die who are 
attacked with it. 
Otitis is not uncommon, especially in children. It does not mate- 
rially compromise life, but may lead to lasting deafness, and some- 
times the inflammation extends to the membranes of the brain. This 
becomes a dangerous complication. 
Inflammation of the parotid gland is another complication, not 
frequent, but, when occurring, it may be very serious in its conse- 
quences. The glands sometimes swell rapidly, sometimes suppurate, 
and sometimes sphacelate, and a large proportion of patients so 
affected succumb. It indicates a low and depraved condition of 
the blood and the general system, not only in typhoid fever, but in 
other diseases where it occurs. 
Eschars formerly occurred in Paris, according to Louis, in one 
sixth of the cases, but they are generally less frecjuent at the present 
time, except where they take the form of “bed-sores,” which, by 
proper precautions, can usually be avoided. When occurring upon 
parts not subjected to pressure, they indicate a very low condition of 
vitality, and are of very serious augury. % 
Inflammations, or other perceptible changes of the stomach, as 
already stated, are found in more than half of the fatal cases ; and 
in a less, but considerable, proportion of cases that recover, more or 
less gastric congestion, irritation, or inflammation, takes place. The 
symptoms are nausea, vomiting, epigastric pain and tenderness, a 
more than usually red tongue, and an intolerance of food. These 
symptoms, however, are not always marked when changes, especially 
softening of the mucous membrane, take place. 
When the length of the fever and the importance, toward the lat- 
ter stages, of the digestion of food in order to keep up the necessary 
nutrition are considered, the condition of the stomach must be 
regarded as an important matter, and should be carefully looked 
after. Too much care can hardly be exercised in avoiding irritation 
and conserving the forces of this organ. 
Congestion and inflammation of the brain occasionally complicate 
cases of typhoid fever, but most of the phenomena spoken of as 
“brain symptoms” are results of impure blood and its imperfect 
supply, and of the fever heat, which latter of itself is capable of seri- 
ously impairing the function, and, indeed, of producing structural 248 
TYPHOID FEVER. 
changes, in this organ. Profound delirium, coma, convulsions, etc., 
occurring late in the disease, when the course has been severe with 
high temperature, would not present evidence of inflammation and its 
consequences; but these and other peculiar brain symptoms occurring 
early in the fever, should excite suspicion, if they do not furnish proof 
of the existence of an inflammatory, or at least a congestive, compli- 
cation. The symptoms of organic brain lesions are so various, and so 
much resemble those from functional changes alone, that a differen- 
tial diagnosis is often difficult and sometimes impossible. If, how- 
ever, in connection with other decided brain symptoms, early in the 
fever, there be excessive heat of the head, with strong pulsation of the 
carotids, congestion of the eyes, and active delirium, running into a 
stupor from which the patient cannot be aroused, accompanied by 
paralysis and convulsions, or even without the latter extreme symp- 
toms, an inflammation of the brain or its membranes may be inferred. 
Sometimes these conditions are consecutive to an internal otitis, as 
already intimated, and when brain symptoms occur in connection 
with this complication, inflammation should at once be suspected. 
Parenchymatous hepatitis, marked by pain and swelling in the 
region of the liver, and increase of the fever, and sometimes by the 
occurrence of chills, with a jaundiced condition, occasionally compli- 
cates typhoid fever. If going on to suppuration, this condition, 
added to the phenomena belonging to the specific fever, is of serious 
import. 
Rarely pericarditis and myocarditis, marked by pain and irregu- 
larity of the heart’s action, take place; and degenerative changes of 
the heart from the high temperature more frequently occur. 
When the kidneys are involved in inflammatory or other serious 
changes, urea is likely to be retained and to produce its peculiar 
effects. This may not always be distinguished from other forms of 
blood poisoning ; but when the urine is scanty and decidedly albumin- 
ous or bloody, with uriniferous casts, inflammation would be distin- 
guished, and if not soon relieved, the most serious consequences will 
almost certainly follow. 
Inflammation and ulceration of the pharynx and larynx are suffi- 
ciently frequent and severe to require to be mentioned as complica- 
tions. They are marked by pain and impaired function of the parts, 
by impairment or loss of the power of speaking and swallowing, and 
may be accurately observed by the laryngoscope or simpler methods 
of exploration. In connection with other conditions, these compli- 
cations may contribute to a fatal result. 
Rupture of the spleen and hemorrhage into the peritoneum may 
occur, causing death by shock and collapse; or suppuration of the PROGNOSIS—CA USES OF DEATH. 
249 
mesenteric glands may produce fatal results, the inflammation being 
induced by rupture of an abscess into the same cavity. 
Prognosis.—Any of the foregoing complications will have much 
influence in varying the prognosis, rendering it more grave in pro- 
portion to the importance and severity of each. There is scarcely 
another disease in which life is threatened from so many sources, and 
where assurances of results can be given with less certainty. 
The general mortality in the hospitals of Paris is stated to be from 
eighteen to twenty-five per cent.; in Germany it has been much the 
same ; while in London hospitals it is given as fifteen or sixteen per 
cent. 
In private practice the mortality varies in different epidemics, but 
when the whole number of mild cases, some of which are not recog- 
nized, is taken into the account, it must be much less. In the mild- 
est cases the temperature never rises above 103°, and sometimes does 
not exceed 101° or 102°, and the disease does not continue more than 
ten or fourteen days. The cases are mild when the temperature does 
not go above 104°, and the continuance is not more than sixteen days. 
The disease is severe when the temperature is repeatedly above 105°, 
and when it continues three weeks or more. A fluctuating tempera- 
ture is more favorable than one that is almost uniformly high. But 
in any of the cases, even the mildest, complications or accidents may 
occur to render them dangerous or fatal ; so that the prognosis should 
always be guarded. Moderate cases without particular accidents may 
be dangerous in the aged, the very feeble, in asthmatics, and especially 
in the alcoholic intemperate. It is less likely to be fatal in those who 
totally abstain, than in those who indulge in alcohol in what is termed 
moderation. Fat persons are more likely to succumb than those that 
are lean and muscular, and plethory, as well as obesity, is an unfavor- 
able condition. 
Death sometimes, though rarely, occurs at an early period, within 
a few days of the access, by the direct depressing effect of the poison, 
or by extremely high temperature. It, however, generally occurs at 
the latter part of the second, or during the third and fourth week, and 
not unfrequently later, from the continuance of the disease or from 
its complications or sequelae, and sometimes from adynamia, exhaus- 
tion, and collapse. The ulcerations of the intestines may not heal, 
the diarrhoea and other abdominal symptoms may be kept up, and 
the patient become wTorn out late in the disease. 
According to Grisolle, most deaths occur in the third and fourth 
weeks respectively; some at the end of the second, some during the 
fifth week, fewer during the sixth, and fewest of all during the first. 
Death here, as in other cases, approaches by the heart, the brain, or 250 
TYPHOID FEVER. 
the lungs—but in uncomplicated cases the greatest danger is from 
failure of the heart, especially where this organ was previously weak, 
and from failure of the action of the brain; and these failures are 
chiefly determined by the height and continuance of the fever heat. 
Great frequency and feebleness of the pulse are indicative of the 
heart’s failure and are specially dangerous. As failure of the heart 
to carry on circulation is perhaps the most frequent ultimate or im- 
mediate cause of death in this disease, any condition previously exist- 
ing or occurring as the result of the fever, either in the heart itself, in 
the vessels, in the lungs, or in the course of the systemic circulation, 
tending to obstruct the results of the heart’s action, and to require 
more force to effect its work, must increase the danger. Hence, ob- 
structive organic disease of the heart or large vessels ; fatty degenera- 
tion or an obese heart; valvular disease ; or atheromatous or other 
diseases of the large arteries ; obstruction in the capillaries from 
whatever cause ; diseases of the lungs, such as asthma or emphysema ; 
deposits or degenerations within them of any kind, are known to in- 
crease the mortality in proportion to the degree of such obstructions. 
The causes of death, in addition to the failure of the functions of 
the heart and brain from fever heat and exhaustion of their power, 
are : 
1. Early implication of excretory organs and consequent increase 
of blood poisoning, or previous organic disease of the kidneys, or im- 
perfect purification of the blood from whatever cause. 
2. Peritonitis, with or without perforation of intestines, rupture 
of spleen, or extension from mesenteric glands. 
3. Hemorrhage from the bowels. 
4. Profuse and continued diarrhoea. 
5. Inflammation of the respiratory apparatus, or congestion and 
oedema of the lungs. 
6. Diffused inflammation of the stomach and intestines, with its 
consequences. 
7. Inflammation of the brain and membranes. 
8. Softening of the spleen, or severe inflammation of the mesen- 
teric glands. 
9. Inflammation and degeneration of the liver. 
10. Endocarditis and myocarditis. 
11. Parotitis and facial erysipelas. 
12. Inflammation, ulcerative or diphtheritic, of the throat. 
13. Sphacelations, or eschars, and extensive bed-sores. 
14. The occurrence of miscarriage, and its consequences in preg- 
nant women. PROGNOSIS—CAUSES OF DEATH. 
251 
15. Stagnation of the blood in the heart, lungs, or capillaries. 
Sex has but little influence on the mortality. 
Age has some effect. The prognosis is generally considered more 
grave in the first five years; and yet I have seen many very mild 
cases during this period. From fifteen to ttventy the cases are most 
favorable. From twenty to forty a little less so ; and above forty 
they are more fatal in proportion to advanced years. 
Although those who are depressed by anxiety, sorrow, bad hygienic 
conditions, and original feebleness of constitution, are, as a general 
rule, more likely to succumb, yet there are exceptions, and sometimes 
the most healthy and vigorous are cut down, while the less robust 
recover. 
The puerperal state makes the prognosis somewhat worse, but not 
so much, when at the full period of gestation, as might be supposed. 
Caseau thinks it has but little effect. 
It is thought by some that particular slowness of approach is apt 
to be followed by more severe forms, but there is no uniformity in 
this respect. 
There are various particular symptoms indicative of special danger. 
These are great tympanitis, involuntary stools, muguet, a very dry, 
hard, and dark tongue, and much delirium, especially if early and 
violent. Coma, if profound and persistent, is particularly unfavora- 
ble, and subsultus tendinum is grave. Convulsions and tetanic rigid- 
ity of the arms and legs are regarded as almost certainly fatal symp- 
toms, and yet after convulsions in children, and after rigidity of the 
arms in others, recoveries sometimes take place. 
Dysphagia from paralysis of the pharynx, and Hippocratic facies, 
when well marked, indicate a fatal termination. Extreme frequency 
of the pulse is always a bad sign, and extreme slowness without 
improvement of other symptoms is also bad. 
The Adynamic and Ataxic forms of the fever are most grave. 
All complications increase the danger. 
Intestinal perforation is nearly always fatal ; and yet, as already 
stated, very rarely, exceptional cases may escape. Death from this 
cause generally occurs within two days, and sometimes within a few 
hours; but in rare cases life is prolonged, the inflammation is 
bounded by adhesive exudates, and an abscess is formed. If it rupt- 
ures into the general peritoneum, a fatal result is nearly certain to 
occur; and this may be after a degree of improvement in the symp- 
toms has taken place. 
Peritonitis, without perforation, is very apt to be fatal, but not 
as certainly so as from perforation. 
Hemorrhage from the bowels is a grave symptom, as it is apt to be 252 
TYPHOID FEVER. 
extensive ; and especially as it indicates either decided and deep ulcer- 
ations, intense hypersemia, or a hemorrhagic dyscrasia. In Paris hos- 
pital practice when hemorrhage occurs one half die. But in private 
practice, and according to my observation, a much larger proportion 
recover. 
Eschars are bad signs, especially if unprovoked by pressure, irri- 
tating applications, such as blisters or sinapisms, or by filth and 
neglect. 
In facial erysipelas in hospital practice, one half are said to die; 
and it is a bad indication anywhere in typhoid fever. 
The general progress, or march of the fever, affords prognostic 
indications. When after a remission the symptoms become as severe 
as before, or more so, according to Cliomel, the prognosis is very 
grave, as these cases are almost always fatal. According to my own 
observations this statement requires some modification, but it may 
contain a general truth. Relapses, though not severer in themselves 
than the first attack, are more likely to be fatal by reason of the con- 
dition induced by the first. But no one condition affords such evi- 
dence of the general character of the fever, and is of more prognostic 
value, than the height of the temperature. If the temperature rises 
above 105° Fahr., and does not fall below that figure for twenty-four 
hours, the case is grave, whether or not there be perceptible compli- 
cations. If rising to 106° or 107° there is great danger ; and if going 
above these figures and persisting, death is almost inevitable. Some- 
times before death, according to Wunderlich, independent of compli- 
cations, it rises to 108°, or even to 110.3°. When pneumonia occurs, 
while the fever is running on with an ordinary temperature of 103° to 
105°, there will he a sudden rise independent of the evening exacer- 
bation ; and when such sudden rise occurs, however obscure other 
symptoms maybe, an inflammation should be suspected and carefully 
sought for by physical exploration. Pneumonia will generally be dis- 
covered, often involving the posterior and lower part of both lungs, 
and constituting a very serious complication. The use of the ther- 
mometer by the physician at every visit is important, and its still 
more frequent use by the attendants, with its readings regularly 
recorded, would furnish great aid not only to the prognosis, but to a 
more exact diagnosis of the general and special conditions upon which 
indications of treatment, as well as the prognosis, depend. The lower 
the temperature, if not abnormally low, the more favorable. How- 
ever, in collapse, or in great exhaustion from the loss of blood or 
profuse diarrhoea, the temperature may be low without improvement. 
Diagnosis.—When the regular and ordinary phenomena of 
typhoid fever are presented in their usual order, it is not difficult, DIAGNOSIS. 
253 
by taking them all into the account, to distinguish it from all other 
affections, although there is scarcely any symptom which of itself 
is pathognomonic. Some symptoms, however, have great diagnostic 
importance, as they are very seldom seen in other diseases. It is by 
considering the symptoms taken as a whole, or by adding one proba- 
bility to another, that we arrive at reliable conclusions. 
The most characteristic individual conditions and symptoms are : 
the gradual access; the diarrhoea, with peculiar discharges; the 
gurgling in the caecal region, increased or developed by pressure ; the 
distended, tub-shaped abdomen; the enlargement of the spleen, dis- 
coverable by physical examination ; the epistaxis, slight but repeated ; 
the intestinal hemorrhage ; buzzing in the ears and deafness; the 
peculiar dreamy delirium; a debility often out of proportion to other 
symptoms and the continuance of the disease; a decided and often 
persistent cephalalgia ; insomnia, and later stupor; toward the last, 
sudamina ; and particularly the lenticular, rose-colored spots, coming 
one after another about the beginning of the second week, each one 
continuing about three days, repeated for a week or two—these, with 
the appearance in the stools of fragments of Peyer’s glands, recogniz- 
able by careful examination with a lens, are sufficiently conclusive. 
In the absence of these more certain indications (and they are by no 
means always present), a union of several of the other phenomena will 
make the diagnosis satisfactory. 
But all cases are not alike, as we have seen; and not unfrequently 
the symptoms, especially in the early stages, are not characteristic. 
Diagnosis in this stage is often difficult, and sometimes impossible. 
Some other diseases strongly resemble some of the cases of typhoid 
fever. The premonitory stage of the eruptive fevers, before the char- 
acteristic cutaneous phenomena occur ; cases of inflammatory fever ; 
visceral phlegmasia; gastric fever; accidental fever, with gastric 
and intestinal irritation and derangement; malarial fevers; acute 
catarrhs, etc., have many similar phenomena. All, however, come on 
more rapidly, as a rule, than typhoid fever ; but exceptional typhoids 
are sometimes as rapid as they. We may have to wait for a fuller 
development before the nature of the case can be determined. If the 
weakness is quite marked, the insomnia persistent, if there is buzzing 
in the ears and dizziness, with a dryish tongue, and no evidence of 
local inflammation or other particular disease, we may presume 
typhoid fever to be present though many of the clearer evidences are 
absent. 
After the first, week the diagnosis can generally be made. If the 
ordinary and characteristic symptoms are not present, but the fever 
persists without other apparent causes, we are to act upon the pre- 254 
TYPHOID FEVER 
sumption of the typhoid character of the fever. An acute fever con- 
tinuing more than eight days, not malarial, and where a thorough and 
systematic examination fails to elicit evidence of local inflammation 
sufficient to account for it, and where typhus does not prevail, may be 
presumed to be typhoid, whatever special symptoms are absent. In 
distinguishing between primary inflammation and essential fever, an 
examination of the blood may aid the diagnosis. In inflammation the 
fibrine of the blood is increased; in fever it is not, but, on the con- 
trary, is often diminished. 
Age may aid in a presumptive diagnosis. The young and the 
adolescent are much more subject to it than the old—and in aged 
persons inflammations of the lungs are not unfrequently obscure or 
latent; and here the chest should be carefully examined. When this 
is skillfully done the local disease can almost always be detected. 
The inflammatory affections with their accompanying fevers most 
resembling typhoid fever are: thoracic inflammations, peritonitis 
(especially puerperal), phlebitis, cystitis, and some cases of hysteritis. 
The fever of Asiatic cholera in its period of reaction often remarkably 
resembles typhoid, and very similar intestinal lesions are likewise 
often found post mortem. Some cases of acute tuberculosis remark- 
ably resemble typhoid fever also, but these cases are rare, and will be 
particularly described under the head of tuberculous diseases. Severe 
enteritis, especially in children, may also much resemble typhoid 
fever. Meningitis, in some of its forms, much resembles the ataxic 
cases. A knowledge of these different diseases, with a careful com- 
parison of the symptoms and course of each, will generally enable the 
physician to clear up the diagnosis. 
But in rare cases all evidences may fail, and the diagnosis may not 
be completed until the post-mortem examination shows, or fails to 
show, the typical lesion. 
In cases of recovery the falling of the hair, which is more likely to 
occur after typhoid fever than after other affections, may confirm the 
diagnosis. 
Another sequela is inflammation of the lymphatics of the lower 
extremities, resembling phlegmasia dolens, but from which the patient 
commonly recovers, and wdiich may aid in confirming the previous 
existence of the fever ; so with imbecility and a mild mania, usually 
lasting a few weeks, but passing away as the nutrition of the brain is 
fully restored. 
A more ravenous appetite usually occurs after a typhoid fever 
from which a good recovery is made, than after other similar diseases. 
In some of the mildest, and especially in the abortive cases, the 
diagnosis will remain uncertain. CA USES. 
255 
The differential diagnosis between typhoid and typhus and relaps- 
ing fevers, and between typhoid and dysentery, will be better under- 
stood after those diseases have been described. 
CAUSES. 
The causes of typhoid fever have given rise to much investigation 
and discussion, and upon some points professional opinions are still 
at variance. To go over this field of discussion, or to enter into the 
details of my own observations, would extend this article on typhoid 
fever beyond the limits assigned to it; and I shall content myself with 
stating little more than the conclusions to which long-continued 
study and observation of the subject have brought me. 
That typhoid fever is a specific affection depending upon a pecul- 
iar material poison—a materies morbi—is now generally admitted. 
Though this material has thus far escaped positive physical detection 
and demonstration, yet, as in the case of malaria, the proofs in favor 
of its existence are too numerous and convincing to admit of rational 
doubt. The origin of this material, the precise conditions of its 
existence, its mode of production and increase, and its method of 
entrance into the system, and especially the manner in which it pro- 
duces its effects, are matters about which there is still obscurity. 
That this poison has its chief habitat out of the body, in putrefying 
organic matter, especially in human excreta, seems sufficiently estab- 
lished ; and that it often obtains access to the body through contami- 
nated drinking water and other ingesta appears also to be proven. It 
is equally clear to my comprehension, from numerous recorded facts 
as well as from personal observation, that the poison is capable of 
passing from its sources through the atmosphere to the system, and 
thus infecting it. The production, multiplication, dissemination, 
and susceptibility of the system to its influence—the causes leading to 
the disease—are favored by long-continued heat and drought; and the 
poison is more likely to take effect upon young persons than upon the 
aged, and upon recent residents of the infected region than upon 
permanent inhabitants. It is very much less liable to affect those 
who have once suffered from the disease ; and many persons, to how- 
ever much exposure they may be subjected, never have this fever. 
No age, sex, or condition, however, and no seasons of the year, no 
climates, and no countries are entirely exempt. 
When a local epidemic breaks out, its connection can almost in- 
variably be traced to foul privies, contaminated drinking water, milk 
watered from a foul source, or otherwise exposed to filth, imperfect 
sewerage, festering cesspools, or some source of organic putrescence. 256 
TYPHOID FEVER. 
This is so constant as to have caused Dr. Murchison, one of the 
very ablest writers on fevers, to call the disease Pythogenic Fever, indi- 
cating that it is “born of putridity.” These statements as to the 
etiology of typhoid fever no longer admit of controversy. They are 
sustained by too numerous and too well-authenticated facts to be 
seriously disputed. 
Without presenting in extended details the many reliably observed 
and recorded facts which sustain and illustrate t.he foregoing etiologi- 
cal statements, a remarkable local epidemic of this fever, which 
occurred under my own observation, is judged to be sufficiently impor- 
tant and typical to justify a brief account of it in a work of this kind. 
The facts in this striking case were thoroughly investigated, and 
the cause of the disease was sought for in a systematic, rigid, and, it 
was thought, exhaustive manner, by a committee consisting of Drs. 
C. L. Ford, Pliny Earl, and myself acting as chairman—all at that 
time being professors in Berkshire Medical College in Pittsfield, Mas- 
sachusetts, where the disease occurred. 
The facts elicited, of which an abstract will here be given, were 
published in the Boston Medical and Surgical Journal, and afterward 
in a pamphlet form. 
In the latter part of July, 1864, there commenced an outbreak of 
typhoid fever in “Maplewood Young Ladies’ Institute,” located in an 
elevated and previously healthy part of Pittsfield, a village of 5,000 
or 6,000 inhabitants, situated among the picturesque hills of Berk- 
shire, a favorite resort for health and pleasure. 
In this boarding-school, at the time of the outbreak, there were 
seventy-seven resident pupils, eight teachers, the principal and his 
family, which, together with the employed domestics, mostly females, 
constituted a household of one hundred and twelve persons, all board- 
ing and lodging in the establishment. Besides these there were a few 
young ladies, inhabitants of the town, who were at the school as day 
pupils. The season was uncommonly hot and dry, there was but 
little wind, and considerable sickness prevailed in the town—mostly 
derangements of the digestive organs—but during the whole season 
there was less typhoid fever than usual, aside from the cases occurring 
at Maplewood; and, according to the testimony of the physicians of 
the place, there were not more than about a dozen cases in all. 
In this household, from the 23d to the 29th of July, five persons 
were attacked with a severe fever ; and during that period, and up to 
the 10th of August, when a term ended and the school was closed, 
some thirty others were sufficiently indisposed to have the services of 
a physician. At the close of the school, or a few days before, some 
deaths having already occurred, the alarm was so great that all who CA USES. 
257 
were not too ill to be removed dispersed to their homes in different 
parts of New England and of the Middle and Western States, a con- 
siderable number performing the journey with the early stage of the 
fever upon them. 
Of the seventy-seven resident pupils, definite information was 
obtained by the committee of seventy-four. Of these seventy-four, 
sixty-six, or nearly ninety per cent., were more or less seriously ill at 
the time of the close of the school, or soon after; and fifty-one, or 
nearly seventy per cent., had well-marked, and almost all severe, 
typhoid fever, which proved fatal in thirteen cases. 
Gj-mnasium. 
55 ft. 
Chapel. 
West Building. 
East Building. 
A, Halls. B, Piazzas. C, Corridors. CC, Ladies” Corridors. D, Portico. E, Commodes. F, 
Sheds. G, Cabinet. H, Cottage. 
Of the whole number of one hundred and twelve persons residing 
in the Institute, fifty-six had the fever, and sixteen died. Two young 
ladies, sisters, residing in another part of the village, but who were 
day pupils at the school, had the fever severely ; and in a house on 
the opposite side of the street from the Institute grounds, some ten 
rods from the buildings, and in the direction of the prevailing winds 
at the time, two persons had a fever of the same type, and other mem- 
bers of the family suffered from gastro-intestinal derangements. 
As nearly every person in this locality was more or less ill, and 258 
TYPHOID FEVER. 
many of them with distinctive typhoid fever, while the disease did not 
prevail in other parts of the town, the existence of some local cause 
was naturally inferred, and such cause was sought for with the follow- 
ing results : 
The Institute buildings, situated on large and elevated grounds, 
with perhaps a superabundance of shade from the large number of 
ornamental trees and shrubs, but in a naturally healthy locality, con- 
sisted of the structures the ground-plan of which is given in the 
annexed diagram; and a description is added, copied from the report 
of the committee referred to. 
In the central building, consisting of two stories and a cellar, the 
first floor is occupied for recitation-rooms, cabinet, etc., and the sec- 
ond as a chapel and general study-room. The cellar contains fur- 
naces, coal, vegetables, etc. On either side of the chapel is a building 
consisting of three stories over a cellar. That upon the east is called 
the “ east building ; ” the other, the “ west building.” To the east 
building is attached a wing of two stories, with a basement. The 
basement of this wing, together with a part of the cellar or basement 
of the main building, is occupied as a kitchen and store-rooms ; the 
other part as a cellar proper, containing coal and furnaces for heating 
the parts above. The first floor of this building is occupied for par- 
lors, library, dining-room, and the apartments for the family of the 
principal. The two stories above are used as dormitories for the 
pupils—a lady teacher occupying one room on each floor. A hall 
passes through the centre of each of these stories, from east to west. 
The rooms of the pupils are upon both sides of the halls, opening into 
them, and receiving their heat from them in cold weather. The 
basement of the west building is occupied as a laundry ; and the other 
three stories as dormitories, arranged as in the two upper stories of 
the east building, and as shown in the diagram. 
The gymnasium is situated in the rear of the chapel, and consists 
of two stories and a cellar, or basement. The first floor has rooms 
chiefly for practice in music ; while the second, a large and high room, 
fifty-five by ninety feet, is used as a gymnasium proper. The base- 
ment is a depository for fuel, and contains the furnaces for heating 
the building. 
The privies were situated as marked in the diagram (commodes)— 
one near the north-east corner of the chapel, and the other not far 
from the north-east corner of the west building. 
The buildings were all connected by covered passage-ways or cor- 
ridors, and these covered ways were extended to the privies, as is also 
shown in the diagram. 
A few rods east of the north-east corner of the east building was CA USES. 
259 
situated, until removed in July, a barn, which had been there for 
many years, and the barnyard, which extended toward the east build- 
ing, was in part lower than the surrounding ground, containing water 
in which swine were reported to have wallowed, and which frequently 
emitted offensive odors. The kitchen drain opened some eighty or 
ninety feet from the comer of the building, and though an attempt 
was made by a temporary expedient to cover the course of the 
stream of slops flowing from the large kitchen, it was but partially 
effected, and in the hot weather unpleasant odors issued from this 
source. 
The drain from the laundry under the west building opened upon 
the surface of the ground fifty-six paces south-west from the south-west 
corner of the building, and thirty feet from the sidewalk of the public 
street; and the water from it, after being detained and partially 
absorbed, as alleged by the principal, in a large covered cesspool, 
issued at the point before mentioned, sometimes at least in a condition 
to annoy those who passed in its vicinity. The committee observed a 
small cesspool near this point, but it appeared at the time of their 
investigation not to have been recently used as a receptacle. 
The vaults of the old privies, which had both been removed when 
the committee made their inspection, were represented to them as 
having been shallow, and filled nearly to the surface of the ground 
with semifluid materials, as they were the receptacles of the slops from 
the chambers. 
One of them was once cleaned out at night in the course of the hot 
season before the outbreak. 
From ample testimony of the pupils and others, there was no 
doubt that the privy vaults particularly, and also the opening of the 
drains, emitted during the hot and dry weather decidedly, and some- 
times exceedingly, offensive odors, so that windows were obliged to be 
closed, particularly at night, to prevent the influx of the outer air, 
as the confined atmosphere within the rooms was less offensive than 
the air from without. 
Though some of the dormitories were small for the number of 
persons occupying them, and were not provided with any special or 
artificial means of ventilation, yet they were as they had been in pre- 
vious seasons of health, and, compared with other similar institutions, 
the crowding was not excessive. 
The bathing arrangements, discipline, exercises, and studies in the 
school were all such as are usual in well-conducted boarding-schools, 
were such as had existed for years before, and could scarcely be re- 
garded as objectionable. 
The diet, so far as could be ascertained, was sufficient and whole- 260 
TYPHOID FEVER 
some ; the water for drinking and domestic use was from hydraulic 
works of excellent construction, bringing it from a pure mountain 
lake in the neighborhood, and was used by others without unpleasant 
effects. 
On the principle of exclusion, and in view of other well-known 
facts, the condition of the privies, and possibly the drains, containing 
a poison which was received into the susceptible systems of young 
persons through the air, was concluded to be the essential cause of 
this terrible calamity. 
In further support of this conclusion it should be stated that 
though the morbid influence pervaded every part of the premises 
where the pupils roomed, and to which they resorted, it did not mani- 
fest itself quite equally in all the apartments. It showed more of its 
effects nearest the chief sources of the offensive effluvia. 
A farther quotation from the report of the committee will show 
more clearly the details of the facts already sketched, and cannot fail 
to give great force to the views expressed. 
The following table shows the number of pupils rooming on each 
floor of each building; the number sick on each floor, just before, 
at the time, or soon after the close of the school ; the number sick 
with fever at the same time ; the number of deaths in the building, 
and the number dying elsewhere ; the percentage of sickness ; the per- 
centage having fever, and the percentage of deaths of the cases of 
fever. 
Rooming in 
East Building. 
No. of 
Occupants. 
No. of 
Sick. 
No. Sick 
with Fever. 
No. of 
Deaths. 
Deaths in 
Buildings. 
Deaths out 
of Buildings. 
. _ 
Per cent, of 
Sickness. 
Per cent, of 
Fever. 
Per cent, of 
Deaths by 
Fever. 
Second Floor 
20 
17 
12 
1 
1 
0 
85.00 
60.00 
8.33 
Third Floor 
21 
21 
16 
4 
0 
4 
100.00 
76.19 
25.00 
Total 
41 
38 
28 
5 
1 
4 
92.68 
68.29 
17.85 
West Building. 
First Floor 
10 
9 
9 
4 
1 
3 
90.00 
90.00 
44.44 
Second Floor 
11 
10 
7 
1 
1 
0 
90.00 
63.63 
14.28 
Third Floor 
12 
9 
7 
3 
0 
3 
75.00 
58.33 
42.85 
Total 
33 
28 
23 
8 
2 
6 
84.84 
69.66 
,34.78 
Total of both Buildings 
74 
60 
51 
13 
3 
10 
89.18 
68.97 
25.49 
From this tabular statement, which may be seen at a glance, but 
which is worthy of careful study, and which the committee were 
able to make only after most extensive inquiries, continued for some 
months, and involving a correspondence with about a hundred per- CAUSES. 
261 
sons, it will be seen that the percentage of the number of cases of 
sickness in the east building was greater than that of those in the 
west; the percentage of fever, however, was greater in • the west 
building, and the percentage of mortality much greater there. By 
referring to the diagram of the grounds, it will be seen that the west 
building was more exposed to fgecal effluvia, by the closer prox- 
imity of one of the privies, and by the hall being directly connected 
witli it by a covered passage ; and the testimony of the pupils and 
their friends shows rather more complaint of the odors in the west 
building than in the east. On the other hand, the east building was 
much nearer the site of the old barn and the offensive pool near the 
opening of the kitchen drain ; and the privy on the east side of the 
chapel, though not communicating directly with the hall, yet indi- 
rectly, through the corridor, was represented as being, a part of the 
time, in a peculiarly bad state. This is the one which was cleaned out 
one night, producing the odor said to be so intense. The classes 
reciting in the “ Cabinet,” a room on the first floor of the chapel 
building, near the privy, were reported as being often much annoyed 
by the odor, especially when the windows were open. 
As to the amount of influence which the different degrees of crowd- 
ing exerted in predisposing to attacks, the facts are not sufficiently 
numerous to determine. The following, however, may be taken for 
what they are worth. 
In the west building three lady teachers roomed—one on each 
floor. On the first and second floors they occupied the rooms alone, 
and remained well. The one on the third floor roomed with a pupil, 
her sister, and both died after returning to their home. The south- 
east corner room of the west building—first floor—was occupied 
by three pupils. One died, and both the others had the fever 
severely. In the east building three teachers roomed, all in separate 
apartments. Of the two who were on the second floor, one had very 
severe typhoid fever and the other was not ill. The one on the 
third floor escaped the fever. Most of the rooms in both buildings 
were occupied, each by two pupils; and generally there was little 
difference in the crowding or the ventilation. 
From these, and so many other facts of which these are but types, 
the inference seems irresistible that typhoid fever is, often at least, 
produced by a poison emanating from foul privies, cesspools, and 
drains. But these facts do not solve the questions as to the original 
source of such poison, its essential nature, and the method of its mul- 
tiplication. Whatever may be the presumptions, they are not demon- 
strative 6f the fact that typhoid fever is always produced by such 
poisons, or by any extraneous influences. Neither do these facts, as 262 
TYPHOID FEVER. 
related, determine as to the contagiousness or non-contagiousness of 
the fever. They only prove that in these and similar cases the disease 
is produoed by an infection, by a poison, which in this case emanated 
from foul privies, and was communicated through the air. Other 
facts prove that a poison is communicated through drinking water 
and through milk ; but the literature on these points is too abun- 
dant and well known to require reproducing here. 
It has long been thought that typhoid fever has more than a single 
origin, and some of the most recent writers on the subject, as L. 
Colin, Professor of Epidemiology in the Military School of Val-de- 
Gras, France; S. Jaccoud, Professor of Pathology in the Faculty of 
Paris; the late Professor Grisolle, and others on the continent of 
Europe, as well as the late Dr. Murchison, one of the very ablest 
writers in the English language on the subject, hold this view. 
M. Colin enumerates five sources of the fever. 
1. Infection of man by man, producing a miasm of encombrement, 
as he calls it, where numbers together create an atmosphere, without 
previous specific germs, capable of inducing the disease. 
2. Putrid infections—a poison produced by organic, and especially 
excrementitious fermentations and decompositions—as in privies, 
sewers, etc., but without evidence of previous germs. 
3. Infection by drinking water or milk contaminated by foulness. 
4. Auto-infection—that is, the accumulation, from mal-nutrition 
and deficient elimination, of poisonous matters capable of inducing 
the malady. To this he attributes a large part of the causation. 
5. Contagion—but to this he attributes little comparative influ- 
ence, and where it operates as a cause, it is much more influenced 
by the atmospheric and other surroundings, and by the receptivity of 
the patients, than are other diseases exclusively contagious. 
M. Jaccoud recognizes three modes of production. 
1. Extrinsic—where there is a miasm produced out of the body, 
embracing the first three of M. Colin’s causes. 
2. Contagious—the transmission of a poison through faecal matter 
from the intestines of patients ill with the disease. 
3. Spontaneous—embracing M. Colin’s fourth cause, or auto-infec- 
tion, where the disease is generated within, from imperfect nutritive 
processes or deficient elimination. 
Dr. Murchison’s views are well known. While admitting its 
transmissibility under certain conditions, he contends strongly for its 
production de novo in putrescence of organic matter, particularly 
faecal, without any connection with original germs from typhoid 
patients. 
On the other hand, Dr. Budd and many others are of the opinion CA USES. 
263 
that a specific germ derived from the system of a typhoid patient is 
always essential to the production of the disease ; that this germ may 
preserve its vitality for a long time in faecal and other matter, and 
that when introduced into a susceptible system by any means, it be- 
comes the cause, and the only cause, of the disease. In other words, 
Dr. Budd and his adherents contend for the essential contagiousness 
of the disease, and that the only source of the production of the 
poison is in the bodies of typhoid patients. 
But even according to this view of the case, it must be admitted 
that this fever has no degree of contagiousness, in the ordinary accep- 
tation of that term, comparable with the eruptive fevers, such as 
small-pox or measles, since persons are seldom affected by coming in 
the vicinity of, or in contact with, typhoid patients ; and where one 
after another of these in the same locality is taken with the disease, 
all being exposed to the same general causes alike, it is generally 
impossible to say whether a poison is transmitted from one person to 
another, or whether the original cause or influence has operated alike 
on each. 
That the poison is not readily conveyed from person to person— 
from those laboring under the disease to others taking care of them, 
as is the case with small-pox and measles—was illustrated in the 
Maplewood fever, as it has been in so many other instances. 
In the dispersion of the patients to their homes, one or more cases 
of typhoid fever of a very virulent character were introduced into 
between forty and fifty families, and it must be supposed, and indeed it 
was known, that in those families there were many young persons and 
others susceptible to the disease ; but in not a single instance did the 
disease spread from these numerous foci. One young girl, a sister of 
one of the Maplewood patients, some three or four weeks after the lat- 
ter’s recovery, had an ordinary attack of typhoid fever; but this was 
the only case that occurred among some hundreds of persons avIio 
must have been exposed, including families, neighbors, and friends. 
So far as ascertained, no attempt at isolation had been made, and a 
single case among so many may reasonably be regarded as fortuitous 
or accidental. 
Still, it should be explicitly stated and borne in mind that other 
facts, in numerous instances, have occurred and been recorded where 
a locality free from typhoid fever has been made a focus for the 
spread of the disease, apparently by the advent of a person laboring 
under the affection. In such cases the facts generally seem to indi- 
cate that the poison is disseminated by the intestinal typhoid dis- 
charges being thrown, without disinfection, into the vaults of privies, 
where probably the poison, multiplying and undergoing changes, 264 
TYFIIOIB FEVER. 
finds its way through the air or ingesta, and produces its effects. It 
is possible that the germs escaping from the body of the sick, either 
by the bowels, the skin, or the lungs, pass more directly into the 
bodies of the well and produce the disease ; but it must be acknowl- 
edged that such cases are rare and doubtful. 
The question still remains as to whether the poison of typhoid 
fever is produced only in the bodies of the sick, or whether it has an 
external or spontaneous origin, or whether, in fact, the disease may 
not be produced by causes other than a single specific poison. 
In view of all the facts I have been able to gather, I am strongly 
inclined to the opinion that a single living germinal poison, capable of 
preserving its vitality for long periods, is the cause of typhoid fever ; 
that the primary origin of the material is involved in the obscurity 
which pertains to the beginnings of all the lowest forms of life ; that 
a material is produced, or rather multiplied and temporarily harbored, 
in the bodies of persons having the fever ; that it possesses but little 
capability, if any, of producing the disease in the condition in which 
it is expelled from the body; but that in faecal matter, and other 
forms of filth, it is capable of multiplying, undergoing changes, and 
becoming active when taken into the system, either in the air or 
the ingesta (water, milk, etc.), producing the disease in those that are 
susceptible; but that it is frequently taken into the system and 
expelled or destroyed without producing serious effects ; that the 
poison is produced both without the body and within it; and that 
typhoid fever may, therefore, properly bo called a miasmatic conta- 
gious disease, as it is by Liebermeister, the French writers, and 
others. This, it is true, is only a theory ; but let us see how it will 
tally with the facts so frequently observed, and which were typically 
presented at Maplewood. 
We will suppose that, by some means or other, a few, perhaps 
inactive, typhoid germs were introduced into the accumulated faecal 
matters in the privy vaults whose condition has been described. 
Finding a favorable nidus they multiplied with great rapidity, 
changed their form and character, rose with the effluvia into the 
atmosphere, passed into the bodies of these young persons, who, at 
the same time, inhaled quantities of decomposing matter in which 
these microzymes abound. In the external filth, or in the body, they 
acquired numbers and assumed characters which produced those 
changes in the fluids and tissues, causing the phenomena of fever. 
As they were expelled from the system, during the course of the dis- 
ease, in different places, they were not directly active, or did not pass 
into the systems of susceptible persons, and not finding a favorable 
soil for their development they became quiescent or perished. These CAUSES.. 
265 
germs are parasitic, but, like many other parasites in different stages 
of their transformations and different periods of their lives, they exist 
out of the body in which they produce their effects. It is so with the 
tape-worm, the trichina, and others. The diseased condition pro- 
duced by this trichina was once supposed to be an inorganic aerial 
poison, but it is now known to be parasitic. 
This view of the cause of typhoid fever is partly suggested by 
analogous facts of recent discovery. Cohnheim, in his recent work on 
Pathology, says: “ This theory no longer hangs in the air.” 
The discovery of the Recurrens Spirilla, by Obermeier, in the 
blood during the attack of relapsing fever, and their disappearance 
during the week of its absence, to appear again in equal numbers in 
the week of recurrence, is regarded by Cohnheim as an important step 
on the road to our knowledge of infectious diseases. 
A peculiar disease in cattle, not unfrequent in some parts of Ger- 
many, called the “ Milzbrand,” is found to be produced by a rodlike 
bacteridia. This illustrates the theory that has been suggested of the 
transformation of parasitic germs, and their ability to maintain their 
vitality out of the body, thus producing miasmatic contagious diseases. 
These rodlike bodies producing milzbrand in the cattle die soon, 
but they produce and leave spores which retain vitality under almost 
all circumstances—out of the body, in the soil. When these spores 
are introduced into the blood of an animal through an abrasion, they 
develop into bacilli, or active, rodlike bodies, and by their rapid in- 
crease, elongation, division, etc., the disease in the cattle is produced. 
When their active life is over, the disease abates, their sporules are 
thrown off and lie dormant indefinitely until they obtain an introduc- 
tion into the blood, when they develop and produce the disease. 
The production of “ Chicken Cholera,” as shown by the experi- 
ments of Pasteur, is another illustration of the views now receiving 
general assent. 
As applied to other diseases, this method of production is but an 
hypothesis, but the hypothesis commends itself as explaining many 
facts. Something of this kind may occur in the poison producing 
typhoid fever, certain conditions out of the system favoring the pres- 
ervation, multiplication, and activity of the microzymes, and certain 
conditions of the body favoring their activity within it in the produc- 
tion of disease. 
But whatever may be the specific material producing the fever, 
and whatever may be the mode of its production and action, there are 
certain conditions favoring the action of the poison, or at least favor- 
ing the occurrence of the disease, which are better understood. 
It is a disease of world-wide prevalence ; it may occur epidemically, 266 
TYPHOID FEVER. 
endemically, or sporadically; it attacks with great impartiality all 
ranks and conditions in life, in city and country, the weak and the 
strong, without much regard to crowding or isolation ; and may occur 
wherever there is faecal accumulation and fermentation, or foul sewer 
emanations. These are quite as likely to occur in the deep-walled 
vaults of the privies about the houses of the wealthy, as in the more 
shallow receptacles of the cottages of the poor ; or in the sewer-pipes 
opening into palatial residences in the city, as in the absence of all 
sewerage about the open rookeries of the squalid. 
Sex is without much influence upon its occurrence ; but age has a 
decided, effect. It is most frequent between fifteen and thirty, next 
perhaps between twelve and fifteen—not unfrcqucnt in children ; 
but after thirty it becomes more and more infrequent as age advances 
—but in rare cases it occurs in the old. It is more likely to prevail 
in autumn and summer, but it may appear at any season ; and is more 
apt to attack recent residents in a place where it is endemic than the 
older inhabitants. 
The great preventable cause is filth, chiefly accumulated faecal 
filth and sewer gases, especially when their emanations pass into 
houses, or in any way get into the drinking water—as where privies 
or leaking sewers are near wells. 
This somewhat extended discussion of the character and causes of 
typhoid fever has been thought to be required because of its wide- 
spread prevalence, its great frequency, its severity, and its destruction 
of so much young and vigorous life, and also because so many of the 
facts and principles which have been brought out apply with slight 
modifications to other infectious diseases. It is a typical specimen of 
specific fevers, and we shall make it a standard of comparison and 
point of departure in the account to be given of others of this class. 
Treatment of Typhoid Fever.—The treatment of typhoid 
fever is divided into Prophylactic and Curative. 
The Prophylactic treatment is suggested by a knowledge of the 
causes we have been considering, and consists in their avoidance or 
removal. It should ever be borne in mind that, whatever may be the 
specific poison essential to the causation, effete and decomposing 
organic matter favors its production and effects, that the malady is a 
“filth disease”—a “pyfchogenic fever.” 
As the most obnoxious form of filth is human excreta, its disposal 
requires primary attention. The common privies, constructed by 
excavating the earth and depositing the excreta in these receptacles, 
where they are allowed to remain indefinitely, are abominations, 
and should be abolished absolutely and entirely. If they are under TREATMENT. 
267 
cover and connected with the dwelling, they become doubly abomina- 
tions. 
If in porous soil, and their contents are not confined by tight walls, 
they are likely to soak through the earth, particularly if moist, and 
to percolate into the wells, polluting and poisoning the water. 
If the vaults are closed by cemented walls, there is no escape for 
the decomposing and horrible material but by passing off in gases and 
effluvia into the air. 
Murchison and others are of the opinion that these places are 
capable of generating the typhoid poison de novo ; but whether this be 
the case or not, there seems no doubt that when germs of the poison 
are introduced into them by the discharges of typhoid patients, or in 
any other way, they multiply with great rapidity, and are likely to 
pass off with the foul emanations. 
These foul gases form a nidus for the specific germs, and when 
together they enter the system, either by the air or in the ingesta, they 
are more likely to produce the fever than when the germs are intro- 
duced alone and more directly from those suffering from the disease. 
Much is said of overflowing privies and cesspools. Fullness to or near 
the surface is by no means necessary to injurious conditions. The 
destructive and offensive overfloiving is by the gases and effluvia, 
which are quite as ready to rise out of deep as shallow vaults ; and 
the deep vaults are much less likely to be cleaned out often than the 
shallow ones. Indeed the deeper vaults are more profound abomina- 
tions, most permanent, and less likely to be disinfected. Their offen- 
siveness and dangers are incapable of removal but by the constant and 
abundant use of dry earth or other disinfectants, and when these are 
efficiently used, an above-ground receptacle is far more easily managed 
and better in every respect. 
What is called the “Dry Earth System” for the disposal of 
excreta requires particular attention. Faecal deposits immediately 
covered with dry earth have all their offensiveness absorbed, become 
immediately changed mechanically and chemically, and are fitted to 
minister to vegetable growth in the soil to which, without bad odors 
or disgust, they may be transferred. 
This is not the place to enter into the economical bearings of this 
subject; but a statement of the principle of this system, in relation to 
decency, and especially to health, to the prevention of zymotic diseases, 
and particularly of typhoid fever, is proper here. Though so long, 
and still so often overlooked, this principle in human hygienics and 
decency is at least as old as Moses, whose directions respecting a 
paddle for each weapon were wTell adapted to the condition of the 
wandering Israelites ; and doubtless long before the time of that hygi- 268 
TYPHOID FEVER. 
enic reformer this was understood and practiced by the domestic 
felines, and with more than human wisdom and consistency has been 
continued by them ever since. 
Sewers, if imperfect, as unfortunately they are apt to be, are as 
dangerous as privies, especially if they permit the escape of gases and 
effluvia into dwellings, or leakage into water for domestic use. 
All suspected water or milk should be boiled before being taken. 
The addition of wine or any form of alcohol to the drinking water, 
unless in such quantities as to insure another form of poisoning, will 
not destroy the injurious materials within it. Cleanliness in its 
broadest sense—a virtue properly characterized as next to godliness, 
indeed it might be styled a part of godliness—is the great preventive 
remedy for typhoid fever and other zymotic diseases. 
There can be no doubt that decomposing matters in the system, 
whether generated and retained there or taken in from without, 
either in ingesta contaminated by sewage, or in the inhaled air con- 
taining emanations from night-soil, cesspools, or foul drains, either 
themselves produce disease, or serve as a nidus for specific germ poi- 
son. Filth has been defined as certain forms of matter out of place. 
Human filth consists of matter after its uses in the system have 
ceased, which is generally undergoing destructive changes, and which 
is offensive to the senses or noxious to the organism. The speedy 
removal of this and all other forms of offensive or noxious matters, 
and their return to the earth, where they are oxidized and undergo 
changes that destroy their offensive qualities, and fit them for use 
in entering into vegetable organisms, constitutes cleanliness. The 
prompt use of the means for accomplishing this constitutes the prac- 
tice of this virtue so strongly commended. It applies not only to the 
person, the clothing, the food, the furniture, and the dwelling, but to 
the air and the surroundings as well. 
As the specific germs of typhoid fever are believed to be chiefly in 
the intestinal discharges when leaving the body, the care and treat- 
ment of these evacuations becomes a matter of the utmost importance. 
As already directed, these discharges should be thoroughly disinfected 
or buried in dry trenches far from any sources of drinking water. 
The best and most convenient disinfectants for this purpose aro 
carbolic acid, chloride of zinc, permanganate of potash, chlorine 
solutions, iodine, and solutions of sulphurous acid. One or the other 
of these articles, in strong solution and free quantity, should be placed 
in the night-stool or bed-pan which is to receive the discharges, and 
not only poisonous qualities but offensive odors will thus be de- 
stroyed. 
“ Burnett’s Disinfecting Fluid ” consists of twenty-five grains of TREATMENT. 
269 
chloride of zinc to a fluid drachm of water. An ounce of thi£ to two 
pints of water makes a solution proper for use. 
Permanganate of potash is the basis of “ Condy’s Antiseptic 
Fluid.” Two or three drachms of this, or half an ounce of the tinct. 
of iodine, or proper quantities of some of the other articles should 
always be used. 
When articles of clothing are soiled by discharges, they should be 
disinfected. This can be done by soaking them in a mixture of two 
ounces of the solution of the permanganate of potash in a gallon of 
water, and afterward placing them in boiling water. Any articles 
may be disinfected by exposing them for two hours or so in an oven 
heated to 220° F. 
If these precautions are taken, the introduction of a case into a 
locality, in all probability, will not lead to a spread of the disease. 
The importance of preventive measures cannot be exaggerated, 
and it is far better to use many unnecessary precautions than to 
neglect those of the least consequence. 
Curative Treatment.—In the management of cases,besides the 
prophylactic and hygienic measures, which afford the best conditions 
of life, the leading indications are to antidote the poison ; to eliminate 
effete matters from the blood by the bowels, kidneys, liver, and skin; 
to abate extreme heat ; to quiet excessive cardiac and arterial excite- 
ment ; to modify the disease of Peyer’s patches and the solitary glands 
of the intestines ; to control too free diarrhoea; to relieve the acci- 
dental complications and all distressing symptoms, and toward the later 
stages of the disease particularly, to sustain the strength ; and all the 
way through by mitigating the severity of the symptoms to prevent 
the degeneration and failure of organs, and obviate the tendency to 
death. 
It may not be possible to fulfill all these indications, or to use 
means specially and directly tending to accomplish all these purposes. 
We know of no positive and certain means for specifically antidoting 
the poison in the body, and the conditions of the system may be such 
as to prevent efforts for accomplishing some of the other objects. 
They are objects, however, which it is desirable to attain ; but we 
must consider how many of them can be accomplished by means that 
will do no other or greater mischief. It is best here not to strike 
heavy blows in the dark, to use no perturbing measures which may 
do harm, without a specific and rational object in view, or where 
experience will not fully justify their use. Placing the patient under 
favorable life conditions and “ giving nature a chance,” is better than 
too much or injudicious interference. Since the disease, as a rule, 270 
TYPHOID FEVElt. 
will run its course, since it is not capable in the present state of our 
knowledge of being generally interrupted, as are the malarial fevers, 
it is the duty of the physician to conduct the patient through, as the 
mariner does his ship while the storm rages, and. when he is unable to 
bring it into a harbor. 
Two leading methods have been advocated and. pursued in the 
treatment of this disease—the Expectant and the Positive or Modify- 
ing. The expectant method—or placing the patient under as favorable 
hygienic conditions as possible, and not attempting to interfere with 
the course, and only in exceptional cases with the symptoms of the 
disease—was long a favorite in Germany, France, and elsewhere, and is 
still so with some practitioners; but it has of late yielded, in Germany 
especially, to more positive methods of interference. 
This Positive Method is divided into the Antidotal or Specific, 
the object of which is to neutralize or expel the poison, or at least to 
cut short the disease; and the Symptomatic, the object of which is 
to modify conditions and symptoms favorably, but still without 
attempting to arrest the disease ; simply to so mitigate phenomena 
as to enable the patient to endure it. 
As Antidotal, Specific, or Abortive agents—medicines for fulfilling 
the first indication mentioned—quinine, mercury, and iodine have 
been used. In some cases each of the agents, particularly mercury 
and quinine, has seemed to produce an antidotal effect, or to arrest 
the disease ; but neither of them has been used with sufficient success 
to establish a reputation as an abortive agent. They are, however, 
believed to be capable of rendering the disease milder, and of shorten- 
ing to some extent its course, and for this purpose they are used in 
the very early stages of the fever. Mercury has most testimony in its 
favor. Wunderlich, Nicmeyer, Parks, Wood, Harley, Liebermeister, 
and others advise it in the early stage ; and the authority of such 
names cannot be set aside as unworthy of regard. The views are not 
uniform as to its mode of action or the doses to be given. Some, as 
Dr. Harley, advise it particularly for its action upon the liver, believ- 
ing it to increase and modify its secretion, and to improve its general 
functions, regarding this organ as having much to do in the phenom- 
ena of the disease. Others think it tends to eliminate the poison, 
or to improve the condition of the stomach and bowels ; while others, 
without attempting to explain its particular mode of action, simply 
refer to personal experience and the testimony of statistics to prove 
its beneficial effects. 
Some recommend it in doses of three or four grains of blue mass, 
repeated once in three or four hours for one, two, or three days; 
others in ten-grain doses of calomel, repeated a few times, securing a TREATMENT. 
271 
cathartic effect; and the general testimony of those who have made a 
fair trial of it is, that it renders the disease more mild, and often 
diminishes its continuance. 
There is some statistical testimony in favor of the use of quinine 
in large doses as an abortive agent. But it certainly does not gen- 
erally succeed in arresting the disease, however useful it may be in 
mitigating some of its phenomena. It is quite possible that in many 
of the cases where it has produced an abortive effect, the disease has 
been malarial rather than typhoid—or at least the poison producing 
it has been different from that which causes the ordinary forms of the 
disease. Indeed, not unfrequently in particular localities, peculiar 
forms of fever occur, which are usually called typhoid, or sometimes 
bilious, etc., but which would seem to bo produced from an influence 
different from that which causes a typical typhoid fever. It is quite 
possible that some such cases may be controlled by quinine or other 
abortive agents, and we should not despair of ultimately being able to 
arrest typhoid fever, as we now can malarial fevers and rheumatism. 
Some cases of this fever spontaneously abort, the poison producing 
effects, but not its full action a3 in ordinary cases ; and it is not un- 
reasonable to suppose that therapeutical agents may favor such a 
result. In the present state of our knowledge, however, we cannot 
expect abortive effects, C3 a rule, from any agents at our command, 
and we are not justified in administering with that view powerful 
medicines that may do harm to the organism. I repeat, however, 
that general experience, and certainly my own, justifies the judicious 
use of mercury in the early stage of the disease, and occasionally con- 
ditions occur at a more advanced period when this article is useful. I 
have never given the largo doses of ten or twenty grains of calomel, a 
few times repeated, which have lately been advised, and therefore 
cannot speak of it from experience. I have, however, generally given 
a few—two or three—doses of two to four grains of blue mass, combined 
with ten or fifteen grains of bicarbonate of soda, followed in a few 
hours after the last dose with a very mild laxative, if the blue mass 
does not itself operate as such ; and the results enable me to recom- 
mend this as proper. Large doses may be more efficient, but such 
doses may do harm by irritating the gastro-intestinal membrane, and 
by occasionally producing mercurialization with its depressing con- 
sequences ; and the beneficial effects of such doses are not so positively- 
established as to incline me to their use. The moderate doses, fol- 
lowed by laxatives, are comparatively free from injurious or dangerous 
consequences, and are often markedly useful. 
The laxative to succeed the mercurial may be a mild saline, such 
as part of a bottle of liquid citrate of magnesia, a drachm or two of 272 
TYPHOID FEYEB. 
Rochelle salts, or of sulphate of soda in a large solution, or the fol- 
lowing castor-oil emulsion : 
R Oleo Ricini, Mucil. Acacia, 
Aqua Camphora ad Sj 
Sacch. Alba Sj 
M. 
For an emulsion. Dose, 3iij to 3iv. 
If there be much irritation of the bowels, five to ten drops of tinct. 
opium—or an equivalent quantity of some other opiate may be added ; 
or, if too active a catharsis is induced, more decided opiates may be 
given to check excessive and depressing effects. Occasionally a very 
slight laxative will cause a powerful effect. Much caution is there- 
fore necessary in the use of cathartics, even of the mildest kinds, and 
occasionally the diarrhoea is so early and so decided as to forbid their 
use entirely; but in such cases small doses of mercurials, combined 
if necessary with opiates, are not contraindicated. On the contrary, 
such a combination will tend to alter the conditions which result in 
these excessive discharges. Rather free evacuations are, however, 
desirable. Injurious materials may be thus eliminated, congestion 
relieved, and more severe inflammation prevented. 
In some cases, after a day or two, two or three of the mild mercu- 
rial doses may again be given once in three or four hours, and again 
followed by a gentle laxative if required. If the characteristic diar- 
rhoea is present and decided, the laxative may bo omitted ; and if tho 
discharges are excessive and debilitating, they may be moderated by 
opiates. Elimination, however, is desirable, and the evacuations 
should not be too much suppressed. 
Some have recommended the continuance of tho mercurials until 
their specific effects are produced, as indicated by the gums being 
touched. This cannot be done without producing a spanaemic effect 
and an ulcerative tendency, which could hardly fail to be injurious. 
Grisolle is of the opinion that mercury has no special advantage 
over other cathartics, but he thinks evacuant treatment with some 
of these articles useful in this fever, and advises their repetition 
from time to time during much of its course. "While unirritating 
laxatives are admissible, drastic purgatives must scrupulously bo 
avoided, as they will not only depress the patient, but will increase 
the intestinal inflammation. As the disease advances, and the patient 
becomes more debilitated, and the patches of Peyer have become 
ulcerated, all forms of cathartic should, as a rule, be avoided, and, in 
cases of constipation, enemas should be substituted. TREATMENT. 
273 
The testimony in favor of the preparations of iodine is not suffi- 
cient, in the absence of personal experience, to enable me to recom- 
mend its use. 
After the first few days of the continuance of the fever, all efforts 
to abort it, or to materially shorten or interrupt its course, will, as a 
rule, be futile ; and the object of treatment should be to conduct the 
case to a favorable termination. With this object in view, different 
modes of management have been advised and practiced, the extremes 
being a pure expectancy on the one hand, and the systematic anti- 
pyretic method of Liebermeister and others of the modern German 
school on the other. 
If the disease is mild, and no conditions are present other than 
those necessarily belonging to the fever, little more than expectancy 
is required. Proper hygienic management, the regular administra- 
tion of proper food, fresh air, frequent bathing, scrupulous cleanliness, 
and all the other conditions mentioned under the head of “the man- 
agement of fevers in general independent of medicines” must be 
observed. 
A mild eliminative course, the use of some gentle diuretic and 
diaphoretic mixture may alone be indicated. The folloAving will be 
found at least innocent, not unpleasant, and generally useful: 
D Liq. Ammonia Acetatis ... §ij 
Spts. Hit. Dulc 1] 
Syr. Ipecac ; fss 
M. 
Dose from one to three drachms every third or fourth hour, given 
in a free drink of water. This may be continued during a large part 
of the course of the disease. 
Some advise the mineral acids, Phosphoric, Hydrochloric, or Sul- 
phuric, very largely diluted, as having a sustaining effect, and cor- 
recting a tendency to excessive alkalinity of the blood. Antiseptics, 
such as chlorine, iodine, hyposulphites, carbolic acid, and creosote have 
also been advised with the view of preventing or diminishing putres- 
cency in the system. About a minim and a half of carbolic acid, with 
a minim of tincture of iodine, well diluted in Avater, has been recently 
recommended every hour or two fora time, and then in less frequently 
repeated doses ; this is said to diminish the fever and make the patient 
quite comfortable. Experience on a large scale has not as yet proved 
the efficacy of these remedies, as patients treated with antiseptics 
chiefly have not, it is said, recovered in greater proportions than where 
a more expectant method has been pursued. 274 
TYPHOID FEVER. 
Some, looking upon typhoid fever as a disease of debility, have 
advised what is called a tonic and stimulating treatment—bark and 
alcohol from an early period, and throughout its progress ; but many 
others declare that results do not justify this course. 
Others, again, have advised depletion by the lancet as a generally 
applicable remedy ; but it has fallen into disuse—is regarded by some 
as always injurious, and in uncomplicated cases it is certainly unnec- 
essary ; and if carried to any considerable extent it would generally, 
in the long run, be injurious. Yet there are cases where it may be 
used with decided advantage, where a plethoric state and certain con- 
gestive and inflammatory conditions are present. 
Though in uncomplicated cases pursuing their necessary course, 
the use of medicines, with the exception of the early evacuants, is 
of doubtful utility (and even the use of these is discouraged by seme 
modern writers), yet there can be no doubt that some particular symp- 
toms and complications may be mitigated by treatment, and various 
remedies are positively demanded in the management of many cases. 
If profuse and exhausting diarrhoea occurs, it should be moderated, 
but not entirely arrested, by opiates ar.d unirritating astringents. 
Among the astringents the subnitrate of bismuth, acetate of lead, 
tannic and gallic acids, and sulphuric acid should be mentioned. One 
of the most efficient remedies in controlling diarrhoea, and at the 
same time fulfilling other useful indications, is the emulsion of the 
oil of turpentine, with such additional quantities of laudanum as the 
case may require. The formula for the emulsion will be given further 
on. The ordinary doses of the other astringents, adapted to the sever- 
ity of the case and the conditions of the patient, are intended to be 
advised. Sometimes opiate and astringent enemas will be more effi- 
cient in allaying irritation of the bowels, and checking the diarrhoea, 
than when the medicines arc given by the mouth ; and this mode of 
their administration is particularly important when the stomach is 
intolerant of them. The following, for that purpose, is advised by Dr. 
Tanner: 
B Olei Terebinthinas min. 30 
Tinct. Kino. fl. drs. 2 
Extracti Opi. liquidi min. 10-25 
Mucil. Amyli. for oz. 2 
Make an enema. Use two or three times in twenty-four hours, 
as may be needed. 
In a strong and plethoric patient, with local congestions or inflam- 
mations, and a high arterial pressure, a bleeding may be of the great- TREATMENT. 
275 
est service. Local bleeding in cases of severe pain, when the blood 
can be taken from near the congested or inflamed part, will be more 
efficient in giving relief, writh a less debilitating effect, than when 
venesection is practiced. When severe congestion or inflammation of 
the intestines occurred, the application of leeches to the anus was 
formerly much practiced, and, as a rule, the relief was greater than 
when the same amount of blood was taken from other parts ; but the 
practice is attended by certain inconveniences, and sometimes by 
injurious local consequences, which have caused it to fall into disuse. 
From the involuntary discharges which, in severe cases, so fre- 
quently occur, the leech-bites are apt to inflame and suppurate, and, 
in very low cases, to become gangrenous. When leeches are applied 
in this situation, great care as to cleanliness and in protecting the 
bites from being irritated, is requisite. Though bleeding in any form 
in typhoid fever is generally not required, in exceptional cases it is 
essential to the best results. 
When there is much excitement of the heart and arteries, with a 
strong as well as rapid pulse, and a high temperature, veratrum viride 
or aconite, cautiously given, may be useful. A very rapid pulse, if 
feeble, contraindicates the use of these articles, which would further 
diminish the heart’s power. Digitalis, when there is much heat, with 
rapidity and feebleness of the heart’s action, is regarded as being indi- 
cated. Wunderlich, Niemeyer, and others, have much confidence in 
it, and there are doubtless cases where its judicious use is attended by 
beneficial results. It is, however, somewhat uncertain in its action, 
in some cases disturbing the nervous system more than it strengthens 
the heart or abates the fever; and a cumulative and too profound 
effect upon the heart, greatly slowing its action and thus obstructing 
the circulation, is possible from the quantity ordinarily advised. 
Wunderlich and others direct that from fifteen to twenty grains be 
infused in ten ounces of boiling water, and given in divided doses 
during each twenty-four hours. Others recommend it in powder, in 
about two-grain doses once in three to five hours, and Niemeyer par- 
ticularly advises it in connection with moderate doses of quinine, with 
a view to the abatement of the fever. 
My own use of digitalis in typhoid fever has not been sufficient, 
and, so far as tried, has not been apparently favorable enough to 
enable me to positively advise it, or do much more than refer to the 
testimony of others. 
If there is much pain or great restlessness, anodynes are indicated. 
The opiates, as a rule, are altogether most reliable, and various 276 
TYPHOID FEVER. 
preparations may be selected, adapted to the conditions of each 
case. 
Other articles may often be added to the opiate, modifying favor- 
ably the effects. 
The bromide of potassium or sodium, given in connection with 
morphine and camphor, may be useful. 
5 Bromide Potassium 3j 
Sulph. Morphia gr. j 
Gum Campliora grs. x 
Pulv. Ipecac grs. iij 
M. 
Make into six powders. One ; to be repeated as required. 
Or the mixture called Cloridium may agree well. 
Besides the officinal preparations, the following may serve as exam- 
ples of useful mixtures : B Hoffman’s Anodyne, Aromatic Spts. of 
Ammonia, Liquor Morphia, IT. S. P., aa fss; Camphor Water, 3ij. 
M. Dose, a table-spoonful as needed. 
Or : B Spts. Nit. Dulc., Chloric Ether, aa Sss ; Morphia Sulph., 
gr. j. M. Dose, a tea-spoonful, more or less, as may be required. 
In some cases morphine, hypodermically, will better fulfill the 
indication. 
When from idiosyncrasy, or any cause, opiates are not well borne, 
chloral hydrate, cautiously administered, or other anodyne and sooth- 
ing agents, may he substituted. The fluid extract of Jamaica dog- 
wood has lately been used as a substitute for opium with satisfactory 
results. 
When there is much determination of blood to the head, with 
restlessness, bromide of potassium in free doses, combined with other 
means, will be useful. The bromide is applicable when there is 
cerebral congestion, whether there be restlessness or stupor; and, as 
much heat of the head is generally present in such cases, cold may 
be applied to the head and neck with great advantage, either by 
ice-cap or towels dipped in ice-water and frequently changed, or 
by a cap of rubber tubes through which a stream of cold water is 
allowed to flow. In plethoric patients, local depletion by leeches may 
be demanded ; or, in other cases, free dry cupping will be better. If 
severe headache occurs from irritation, rather than from active con- 
gestion, anodynes and counter-irritation are indicated. If from inani- 
tion and exhaustion, food and stimulants are required. Much care in 
discriminating between these conditions is necessary—the force of the TREATMENT. 
277 
heart’s action particularly, and all the circumstances of the case must 
be observed, and their indications estimated. 
If there be pain in the abdomen, which is sometimes severe and 
depressing, opiates will generally be required, aided by fomentations, 
poultices, or water dressings, and, in obstinate cases, sometimes by 
leeches. Sometimes, after the fever has run its course, pain and 
tenderness of the abdomen continue from the condition of the ulcer- 
ated intestines, involving to some extent the peritoneum in inflam- 
mation. In such cases blisters over the abdomen, in addition to 
other measures, will often be markedly useful. 
If there be a persistent active diarrhoea, indicating, as it usually 
would, a more serious disease of Peyer’s patches and the solitary 
glands, perseverance with the opiates and astringents already men- 
tioned will often be required. Various prescriptions of opium and 
ipecac., of acetate of lead, of tannin, of alum, and of bismuth, are 
advised. Sulphuric acid, both from its tonic and astringent effects, 
is often used. 
B Dilute Sulph. Acid ttjxxx 
Tinct. Opi tti,x 
Decoction of Bark §ss 
M. 
Once in four hours. 
Or: 
B Acetate of Lead grs. ij-v 
Acetic Acid gtts. iij-v 
Acetate Morphia gr. | 
Cinnamon Water £jss 
M. 
Take once in four hours. 
Or nitrate of silver, in the more chronic cases, in doses of a 
quarter to half a grain, in compound soap pill, once in four or six 
hours. 
Some advise emulsions of oily substances with gum acacia and 
water—regarding small quantities of castor-oil in such mixtures as 
useful. 
But, as a rule, for the purpose of modifying the condition of the 
ulcerated intestinal glands, and thus controlling the dependent diar- 
rhoea, the turpentine emulsion is best. The formula, often modified 278 
TYPHOID FEVER. 
in the proportion of its ingredients to meet the conditions of particu- 
lar cases, which I have long used is as follows : 
01. Turpentine 3iijss 
Tinct. of Opium 3iij 
Gum Acacia, 
Sacch. Alba ad 
Aqua Camphora... %iij 
M. 
Make into a perfect emulsion by thorough trituration. Dose 3j? 
more or less, once in three to six hours. 
To each of these doses may sometimes be added with advantage, 
especially when there is much tympanitis from fermentation changes 
in the food, one or two grains of pure carbolic acid. I cannot too 
strongly recommend the turpentine emulsion in these cases, as it not 
only exerts a favorable effect upon the diseased intestines and the 
diarrhoea, but upon the general condition of the patient as well. The 
combination has seemed to me to soothe and sustain the nervous 
system, to moderately increase the secretions, to improve the condition 
of the bronchial membrane, and by its eliminative and stimulating 
effect to improve the state of the blood. 
I long ago learned the use of turpentine in these cases from Dr. 
G. B. Wood, and the opinion in its favor is supported by Graves, 
Huss, Wunderlich, Murchison, and many others. Convinced of its 
beneficial effects, independent of its local action upon the intestines, 
I have often prescribed it when no excessive diarrhoea or other marked 
abdominal symptoms were present. It has seemed to me not only to 
exert a very favorable influence upon the intestines after ulceration 
has occurred (indicated by the red glossy tongue, decided diarrhoea, 
etc.), as Dr. Wood and others so strongly contend, but to allay the 
preceding inflammation and to diminish the tendency to ulceration as 
well. The steady moderate impression of the laudanum and camphor, 
prevented from arresting the secretions and otherwise modified by the 
turpentine, enables the patient to bear the disease with less shock 
and suffering. But whatever the explanation, the general effect is 
often markedly beneficial. 
The chlorate of potash, in doses of from five to eight grains once 
in a few hours, may modify favorably the ulcerated Peyer’s glands, 
and also improve the blood. It has a gentle eliminative effect, but 
must be given in very small doses well diluted, or omitted altogether 
if it produces irritation of the gastro-intestinal mucous membrane. 
When there is much tympanitis the gas should be evacuated by TREATMENT. 
279 
placing the patient on the chest and knees, or in some position with 
the pelvis elevated above the rest of the body, and introducing care- 
fully into the rectum an elastic catheter. The position indicated 
facilitates the introduction of the tube and secures the evacuation of 
the gas as it tends to rise to the highest point by its light specific 
gravity and by the pressure of the viscera when in that position. It 
is well also to prevent distention, by a broad firm bandage around 
the abdomen, often with wet cloths or turpentine stupes beneath. 
Hemorrhage from the bowels, if from the capillary vessels and 
not too free, is often useful, as it is followed by amelioration of nearly 
all the symptoms ; but if it is profuse, fresh, or clotted, it is of course 
dangerous. As it is impossible to predict to what extent it may go 
when once commencing, means should, as a rule, be taken, even when 
it is moderate, to arrest the flow, and when profuse they must be vig- 
orously applied. For this purpose bladders of ice should be applied, 
particularly to the right side of the abdomen, and astringents used by 
the mouth or rectum, or both. The solution of perchloride of iron, 
in doses of thirty minims in a wine glass of water, from two to five 
grains of the acetate of lead, or from half a drachm to a drachm of 
the fl. ext. of ergot, or a full dose of ergotine hypodermically should 
be given. Or: 
Ij, Acetate of Lead grs. x 
Acetic Acid ttl x 
Acetate Morphia gr. ss 
Aqua pura fiv 
M. 
For an enema, given with hips elevated, and best through an elas- 
tic tube introduced into the colon. 
Or a solution of persulphate or perchloride of iron with morphine 
in twice the ordinary doses by the mouth, dissolved in about four 
ounces of water, given in the same way. More fluid, given at once, 
would be likely to he passed off immediately, and a smaller quantity 
would be less likely to reach or approach the bleeding point. Atten- 
tion to details, to the manner of administering remedies, of handling, 
moving, and nursing patients in so enfeebled and critical conditions, 
cannot be too strenuously insisted upon. 
In severe bronchitis interfering with respiration and oxygenation 
of the blood, dry cups freely applied, various expectorants, such as 
small doses of ipecac., three-grain doses of flowers of benzoin, and 
the turpentine emulsion may be required. Inhalations of steam, 280 
TYPHOID FEVER. 
simple or medicated, may aid expectoration, and modify favorably the 
condition of the membrane. Where other means fail to expel the 
accumulated mucus, an emetic may possibly be borne and required. 
If congestion of the lungs and the passive pneumonias so apt to 
occur are present, quinine in decided doses will be indicated; and the 
strength should be kept up by proper feeding and judicious stimula- 
tion ; and (acting mechanically, but often beneficially) dry cups may 
be applied to the limbs and lower part of the chest in free numbers. 
Jaccoud advises forty or fifty on the lower limbs and base of the chest, 
repeated morning and evening, when the broncho-pulmonary altera- 
tion becomes a source of danger. Ligation of the extremities would 
similarly answer the indication. 
Sordes should be removed from the mouth by the patient’s sucking 
slices of lemon or orange, aided by mechanical means if required. 
The condition of the bladder should be carefully observed, and the 
viscus should be completely evacuated twice a day, the catheter being 
used when necessary for that purpose. 
If perforation and acute peritonitis occur, opium should be given 
in free but not poisonous doses, pieces of hoop should keep the bed- 
covering from increasing the pain by their weight, light fomentations 
should be employed, and the patient kept perfectly quiet. 
It is well, in anticipation of the long course and exhausting effects 
of this fever upon the blood and tissues, to keep up as far as possible 
the nutrition of the patient from an early period of the disease, by the 
administration of such easily assimilable food as he can bear and 
appropriate. That the disease is one which tends to adynamia and 
exhaustion, that danger arises from such exhaustion, and that so far 
as possible it should be prevented, there can be no question. The 
question is, what measures will tend most to prevent this result. In 
disease as in health, assimilated food is the great source of force. 
Medicinal stimulants may increase activity and enable the organism 
to take and utilize more food, and thus indirectly sustain power. 
Various substances may check, remove, or modify morbid conditions, 
and thus prevent depression and exhaustion ; but the only source of 
permanent power is food. Hence the importance, in a protracted ex- 
hausting fever, of its judicious management. If more food is given 
than can be digested or appropriated, it will be a source of irritation 
and greater depression. The remedy does not then consist in free 
feeding, either in small quantities frequently repeated, or in larger 
ones more seldom given ; but in a judicious selection, adapted to the 
needs of the system and the capacity of appropriation. It will readily 
be seen that no positive and inflexible rule can be given as to the 
quantity or quality of the food ; for though typhoid fever has some TREATMENT. 
281 
features that are constant and measurably uniform, there are others, 
depending upon the peculiarities of the patient and the character of 
the complications, and indeed upon the severity of the essential dis- 
ease, which are exceedingly variable. 
But food should he given regularly and systematically, governed 
by the effects observed and by the judgment of the physician, and not 
entirely by the desires or aversions of the patient, and not at all by 
the whims and prejudices of ignorant nurses or injudicious friends. 
Milk mingled with moderate quantities of thoroughly cooked fari- 
naceous substances, should be the staple in most cases ; beef-tea 
should be added in the later stages especially, and sometimes very 
finely disintegrated tender muscle, slightly or not at all cooked. Eggs 
thoroughly beaten up, raw or very slightly cooked, and mingled with 
milk or water, and sweetened or not, as may be relished, often answer 
well. A proper, relishable quantity of salt should be added to each 
preparation. Milk has more food properties than beef-tea, but the 
latter is more stimulating and sometimes more easily assimilated, and 
is particularly required in the latter stages of the disease, and more 
depressed conditions of the patient. When the stomach is incapable 
of receiving and retaining the necessary quantity of food, these liquid 
preparations may be given by enema. Life can sometimes be sus- 
tained for long periods in this way. 
To give some idea of the quantity of food to be tried, it may be 
mentioned that a tea-cupful of milk, slightly diluted with water if 
very rich and creamy, with the addition sometimes of a spoonful of 
lime-water, and slightly thickened with well-cooked farina or finely 
pulverized cracker, may be borne once in four or six hours. It is 
often better to give it more frequently, and in smaller quantities at a 
time. Beef-tea in quantities of half a tea-cupful, more or less, at a 
time, may be alternated; more if the stomach is not disturbed or 
oppressed by it, and less if that effect is produced, or the food passes 
undigested. 
All agree that in the latter stages of the fever, in severe cases, 
when the powers of life are so far exhausted that they threaten to 
cease, every possible means should be resorted to in order to sustain 
their action and keep the patient alive until the crisis of the disease is 
passed. There is, however, diversity of opinion as to the means for 
accomplishing this end. In addition to the food, which all believe to 
be important, much confidence is placed by many in the action of 
medicinal tonics and stimulants, while others have less faith in their 
virtues. However interesting and important the subject, it would 
lengthen this article to an unjustifiable extent to give all the views of 
even eminent and authoritative writers upon it. 282 
TYPHOID FEVER. 
The articles more commonly advised are the preparations of Peru- 
vian bark, strychnine, ammonia, camphor, musk, and alcohol. That 
under certain circumstances all of these articles are capable, either 
directly or indirectly, of increasing temporarily vital activities, is gen- 
erally believed, and must be regarded as an accepted doctrine of thera- 
peutics. The manner of their action, and the degree of their power, 
is far from being settled. The greatest difference of opinion exists, or 
at least the most decided expressions of difference are, in relation to 
alcohol. Other questions than those of a strictly scientific and thera- 
peutical character have influenced opinions and expressions. On the 
one hand, personal experience, the habit of using alcoholics, and the 
real or fancied feeling of increased vigor after taking an habitual or 
an occasional potion of the article, incline many to the opinion that it 
is a sustainer of vital power, without rigidly considering whether that 
feeling is deceptive or the result of a habit—the relief of a feeling of 
depression and discomfort resulting from the indulgence itself. It 
would be difficult to persuade the opium eater that his favorite nar- 
cotic was not a genuine stimulant—an exciter of vital actions—when 
his habitual daily dose raises him from the most utter prostration and 
the depth of despondency to a sense of strength, to real activity, and 
a feeling of delight. To him, for the time being, it is a stimulant, 
though opium is essentially a narcotic and a paralyzer of many func- 
tions, and can scarcely be regarded, in the normal condition of the 
system, as a real exciter of any. Entertaining views of the stimulat- 
ing and sustaining effect of alcohol which are opposed by others, and 
indulging in a practice which some denounce, produces a partisan 
feeling which sometimes, at least, seems to interfere with a calm pro- 
fessional judgment. Custom and authority most naturally have an 
influence upon opinions and practice, preventing an unbiased decision, 
such as would be arrived at upon a new question removed from parti- 
san feeling. On the other hand, those holding decided opinions as to 
the injurious effects of alcohol in health, and who are strongly 
impressed with its terrible physical, social, and moral evils, are liable 
to have their opinions influenced in the other direction, and are 
inclined to conclude that an article which so certainly weakens a well 
man when taken in quantities to produce a perceptible effect, can 
hardly be regarded as a strengthener, par excellence, to a sick one. 
But while they may justly come to the conclusion that it ought not to 
be regarded as a pure and essential stimulant, they may unjustly con- 
clude that it has no virtues in sustaining action under the extraordi- 
nary conditions of a severe disease, and especially in persons who are 
habituated to its use. It should be regarded as a purely therapeutical 
question, and discussed as we would discuss the question of the action TREATMENT. 
283 
of opium, mercury, or arsenic, in a particular disease. But, consid- 
ered in this way, it is by no means easy to come to a positive conclu- 
sion as to its value in typhoid fever, or under what circumstances it 
should be given or withheld. While the weight of authority is in 
favor of its use in the latter stages and depressed conditions of typhoid 
fever, a majority of the best observers are opposed to its indiscrimi- 
nate use, and the recent statistics of the London hospitals show that 
those which use the least, down to an extreme minimum, have the 
smallest mortality. Other circumstances, however, may have deter- 
mined this result, and the question as to its value is an open one. 
My own belief, based upon long-continued observation, mostly among 
patients unaccustomed to the use of alcohol, is that such patients 
very seldom require it in typhoid fever; never at an early stage, and 
doubtfully at any time. Yet it has been my practice, and, following 
authority, it would still be, to resort to it where depression was 
extreme in advanced stages of the disease, and under the circum- 
stances and according to the rules to be described. 
I can well understand that with persons who have been accus- 
tomed all their lives, and their ancestors before them, to the daily 
use of alcohol, this article can be better borne in disease, and may 
be more needed than with those who have abstained from it or 
have taken it only occasionally. It may be that in European coun- 
tries, where the habits of the people are so different from ours, 
depriving a patient with this fever of his accustomed beverage would 
lead to more depression than would occur under its continuance ; 
and I am not prepared to positively deny that the patients of M. 
Jaccoud, of Paris, nearly all of whom are accustomed every day to 
take a considerable quantity of wine, may continue to take, as he 
recommends, about half a pint of claret in the twenty-four hours 
without injury, and perhaps with benefit, in this fever ; and that 
three or four grammes of the extract of bark may also be added. 
This he recommends with an increase of the alcohol, adding thirty 
grammes a day—or about an ounce of brandy—if the case be severe. 
But I feel confident that the patients I have had to deal with would 
be injured, rather than benefited, by even this moderate quantity of the 
alcohol, and that in ordinary cases it should be dispensed with entirely. 
The American country and village practitioner should not follow 
too closely, with his abstemious and previously healthy and vigorous 
patients, whom he sees at the beginning of their diseases, the direc- 
tions of physicians who have never seen patients outside of large 
European cities, and seldom till their diseases are advanced. The 
conditions of these classes are so different in so many respects, that 
the same directions will not always apply equally well to both. But 284 
TYPHOID FEVER. 
even in these large cities the indiscriminate and general alcoholic 
treatment is condemned by very many of the highest authority, and, 
in London, the comparative statistics are decidedly against the prac- 
tice. Those who advocate the general use of alcohol do so on two 
grounds, viz.: its stimulating and sustaining effect; and its supply 
of fuel to the fever, so that the tissues will not be so freely consumed 
in the production of heat. How far either of these supposed modes 
of action is real, are questions undecided. Though some small 
quantities of alcohol may be oxidized in the system (not more than 
an ounce and a half in the twenty-four hours in the physiological 
state, but possibly more in certain morbid conditions), yet it chiefly 
acts as a neurotic, and particularly as a narcotic. As such it often 
diminishes shock, and “the wear and tear” of the nervous system 
under suffering, and thus prevents exhaustion. Though it often seems 
to act as an excitant, it fails to develop more power in a healthy 
organism ; but it may increase activity in disease by counteracting a 
depressing agency, or often by paralyzing inhibitory nerve functions. 
Its effects are uncertain, and not capable of being estimated. It ex- 
pands capillary vessels, but diminishes their action ; and, by bringing 
more blood to the surface, may cause greater loss of heat and thus 
reduce the temperature ; and, though it is oxidized in small quantities, 
it commonly diminishes the oxidation of other substances, such as 
fat, in the system ; and it retards various other organic changes. Its 
food effects in health are certainly inconsiderable, if not null, and, as 
a rule, are probably the same in disease ; while its sustaining power, 
so far as it possesses any, is produced in a similar way to that of 
opium, by its impression upon the nervous system. That when there 
is a deficiency of oxidizable material in the system, a larger quantity 
of alcohol may be oxidized than in the normal state, is believed by 
many, and I am inclined to think it is true ; and, if such be the case, 
a real sustaining effect may be realized. But this will be uncertain in 
any given case, and is scarcely to be relied upon as a rule. It dis- 
turbs injuriously natural functions in health, and may do so even 
more in disease. Prescribing it is unsatisfactory, as we can never be 
confident beforehand whether the results of its administration will 
be harmful or beneficial. Harmfully, it may prevent the excretion 
of the fever poison ; it diminishes aeration of the blood, may impair 
the processes of nutrition, and often irritates and injures the mucous 
membrane of the stomach. In considerable quantity it neutralizes the 
gastric juice in the stomach and arrests digestion, though, in smaller 
doses, it may, by inviting the blood to the peptic glands, increase 
their secretion, and aid digestion temporarily after its impression and 
absorption. TREATMENT. 
285 
It may diminish the heart’s action by its direct narcotic or depress- 
ing power, or it may increase it indirectly by relieving shock, which 
may be still more depressing. 
It diminishes general healthy muscular power, as its direct effect, 
in proportion to the quantity taken, but may, in morbid conditions, 
increase it indirectly by relieving shock, sense of fatigue, or other 
depressing conditions. 
It may beneficially, in fever, diminish abnormal waste of tissue— 
may soothe the nervous system like opium or chloral, inducing sleep, 
and preventing wearing and exhaustion. The good in some cases 
may overbalance the evil, but it should be used in the light of modern 
physiological investigation, and the actual results of clinical experi- 
ence, rather than in a routine way from precedent and fashion, with- 
out considering the harm as well as the possible good it may do. 
Drs. Gairdner and Russell, of Glasgow, Sir Henry Thompson and Sir 
William Gull, Dr. Brinton, and especially Dr. Richardson, of London, 
and many others, condemn its general and free use in fevers. Some 
of these discard it entirely, others advise it in exceptional cases only. 
In the Vienna Hospital it is said now to be seldom used at all. 
It is not physiological or normal to the system, is injurious in 
health—is either a poison or a medicine, beneficial only in modify- 
ing morbid conditions. 
As with other narcotics, its effects upon the general functions, 
rather than upon the sensations merely, must determine the propriety 
of its medicinal use and continuance. When useful, its regulated and 
steady administration, rather than its unsystematic and fluctuating use, 
is important. To direct, “ Give as much (whisky, brandy, or wine) 
as the patient will take,” is not only loose and unscientific, but bad, 
and can hardly fail to do harm. 
In deciding upon the use of alcohol in a case, the condition of the 
circulating organs is most important to be observed. A very rapid, 
very feeble, or very slow pulse often indicates shock, which may be 
relieved by it. If, in a case of rapid pulse, the pulse is made more 
rapid by the alcohol, and especially if the face is flushed, it must be 
discontinued. 
In low delirium and stupor, caused by shock or adynamia, it may 
be tried; and also in subsultus tendinum. On the other hand, in 
throbbing headache and noisy acute delirium, it is generally regarded 
as being contraindicated. If there be suffusion of the eyes and suffi- 
cient cardiac pulse, it is not to be given. 
If the tongue be brown and dry, with general depression, it may 
be tried. If the tongue is made dryer the alcohol should be suspended 
—if more moist it may be continued. 286 
TYPHOID FEVER. 
In pyaemia, pneumonia, erysipelas, and other similar complica- 
tions, there is apt to be more shock, and the alcohol is more likely to 
be useful. But in these complications quinine is a much more impor- 
tant remedy, and should be given in free tonic, but not extreme seda- 
tive, doses. A continuous, and not a sudden and interrupted impres- 
sion should be made. Three, four, or five grains, once in three, or 
four, or six hours, would be indicated. 
It is in accordance with general observation in the case of opium 
and other narcotics, that their discontinuance in those habituated to 
their use commonly produces shock and temporary depression ; and it 
is often so with alcohol. It may be an unfavorable time for its dis- 
continuance when typhoid fever is present ; and, at any rate, it may 
be safely inferred that those accustomed to its use bear it better and 
require it more frequently in disease than those who habitually abstain 
from it. The previous habits of the patient must be taken into the 
account in prescribing this and other remedies in typhoid fever as 
in other diseases. The form of alcohol to be used is of some conse- 
quence ; the tastes and previous habits of the patient may be consulted ; 
but no form is so reliable, or the quantity so easily ascertained and 
regulated, as that of pure alcohol largely diluted with water. 
“Antipyretic Treatment.”—The consideration of one of the 
most important indications in typhoid fever, with the means for ful- 
filling it, has been left until the present, in order to give it more 
prominence. 
It is well established that a very high temperature, especially when 
constant and long continued, is of itself exceedingly disastrous, lead- 
ing to degeneration of tissues and failure of power; and that this 
condition is the one most to be dreaded, and if possible remedied, 
in typhoid fever. A more clear appreciation of this fact has led 
many modern physicians, and particularly those of the German school, 
to seek for safe and efficient agents for lowering the temperature. 
Systematic efforts for diminishing fever heat, as the chief thing to bo 
done in this disease, constitute what has been called the “Antipyretic 
method of the German school.” 
The two principal methods for reducing the high temperature are : 
1. The direct abstraction of heat by cold applications to the body, 
especially externally; and, 
2. Preventing the production of heat by medicinal agents, sup- 
posed to act largely upon the heat-producing nerve-centres, but also 
upon the nerves, vessels, and tissues—upon all parts concerned in its 
generation ; and also by agents wdiich produce increased loss of heat 
in a medium at the ordinary temperature, by bringing the blood TREATMENT. 
287 
more freely to the surface, and by causing perspiration and evapora- 
tion. 
The principal agent for directly abstracting the heat is the cool or 
cold bath ; and the chief medicinal agents for preventing its produc- 
tion are quinine and salicylate of soda, though the bath, it is con- 
tended, when properly used, acts also by diminishing production ; and 
the quinine and salicylate of soda, by causing perspiration and perhaps 
by other means, doubtless promote loss. Whatever may be their 
mode of action, they are the chief agents for preventing and diminish- 
ing the high temperature. 
Exposure to cold air abstracts heat; but when it causes contraction 
of superficial vessels the blood is driven to internal parts. This tends 
to the diminution of loss and the increased production and retention 
of internal heat. This physiological arrangement in health preserves 
the normal temperature, and in fever keeps up in a large degree the 
abnormal heat. 
The cold water bath abstracts heat more rapidly and thoroughly ; 
its effects are produced more deeply in the body ; and by a sedative, 
or at least by some peculiar systemic effect, the excessive production 
and retention of heat are prevented. By the bath, when thoroughly 
used, the temperature of the whole body is reduced, not only for the 
time in which it is used, but for a greater or less length of time after- 
ward. But immersion in cold water is not without possible injurious 
effects, and some are of the opinion that the dangers in typhoid fever 
are decided. 
It may be followed by great depression. The heat passing off 
rapidly may cause an exhausting effort on the part of the system to 
restore the temperature—the blood may be driven to internal organs 
and violent congestions produced ; so that, as with every other power- 
ful therapeutic agent, care and discrimination are necessary in its 
successful use, and much and varied experience will be required to 
ascertain its degree of safety and value, and the particular conditions 
which call for or forbid its employment. 
In hyperpyrexia the indications are to reduce the heat without 
causing exhaustion, and to prevent its excessive production without 
doing other harm. It is often easier to point out indications than to 
find and successfully apply the means for fulfilling them. A long 
experience in the hands of a few, and particularly a large recent 
experience of several German hospital physicians (Liebermeister, 
Ziemssen, Juergensen, etc.), as reported by these distinguished gentle- 
men, seem to show that the water bath properly regulated may, to a 
large extent at least, fulfill these indications—reducing heat and pre- 
venting its excessive production without danger to the organism. 288 
TYPHOID FEVER. 
Ziemssen advises, when the temperature rises to 104° F., to give a 
full-length bath at 94° F., gently rub the surface, and add cold water 
gradually, reducing the temperature of the bath to 08° F.; keeping 
the patient in the bath for twenty or thirty minutes, or until slight 
chilliness is felt, then remove to a comfortably warm bed, especially 
warm at the feet, and repeat the bath when the temperature again rises. 
Liebermeister’s plan is to put the patient in a bath of 68° F. for 
ten minutes, then put in a bed warm at the foot—repeating so as to 
keep the heat down. 
When only a moderate reduction of the heat takes place from the 
bath the blood is driven internally, and the heat production may be 
increased, as it is by the regulating power of the system after exposure 
to cold in health ; but the reduction of the heat may be forced beyond 
the regulating power of the system, and the temperature of the whole 
body lowered, externally and internally ; and the effect even in severe 
cases may be made to last for several hours. But the heat will in 
time come up, when the bath must be repeated—a persistent repeti- 
tion night and day—six, eight, or more baths in the twenty-four 
hours may be essential to the proper carrying out of this system. 
After a time, it is alleged, the production of heat is diminished, and 
the bath is not so frequently required. 
Ziemssen’s method would seem to be preferable to Liebermeister’s 
in feeble states, or where the propriety of the treatment is at all 
doubtful. 
Leibermeister and Ziemssen advise that the effect of the bath be 
aided by A ntipyretie Medicines, when it is not promptly efficient of 
itself in keeping the temperature down decidedly below the dangerous 
point. 
In the Vienna Hospital the reported practice is to place the patient 
in a bath at the temperature of G5° F., continuing it for twenty or 
thirty minutes, and repeating, as may be required, on an average in 
severe cases seven or eight times in the twenty-four hours. Great 
success is reported to have followed this exclusive treatment. 
There is certainly inconvenience, and in low and advanced cases 
with ulcerated bowels, some danger in removing a patient from his 
bed, and placing him in the bath. The Fever Cot of Dr. Kibbel 
obviates this handling of the patient, with its shock and fatigue, and 
allows the more free application of water to the trunk, where it is 
more needed than at the extremities, and it may be an improvement 
in method. 
M. Jaccoud recognizes the importance of reducing the temperature 
when excessive, and advises that when it rises to 39° C. (102.2° F.) 
cold lotions be applied twice a day. If rising to 39.5 C. (103. LF.) TREATMENT. 
289 
he applies the lotions three times a day, if to 40° 0., or more 
(104° F.), still more frequently. Instead of water he advises pure 
aromatic vinegar for the lotion; a blanket, over which is an oil-cloth, is 
placed under the patient, and the vinegar is freely and rapidly applied 
with large sponges to the entire body. The oil-cloth is then removed 
and the patient wrapped in the blanket until he is dry. The lotions 
are diminished in frequency as the fever declines, but are continued 
occasionally until it is quite gone. If cold sweats occur, as he says is 
sometimes the case, the lotions are to be discontinued, but there are 
no other contraindications to their use. 
In placing patients in the bath after the manner of Ziemssen and 
Liebermeister, the danger and inconvenience of handling can be re- 
duced to a minimum by lifting them upon a rubber or oil-cloth sheet 
with rods rolled up in the margin ; the sheet should remain under 
the patients in the bath, and may be gently pulled away after they 
are placed in the bed. Other methods of applying cold may be 
resorted to. 
The Antipyretic Medication consists in giving free doses of qui- 
nine, salicylate of soda, salicylic acid, digitalis, veratrum viride, aco- 
nite, or gelseminum. 
The three last-named articles are objectionable, especially in the 
advanced stages of the disease, when the danger from the heat is 
greatest, in consequence of their sedative action upon the heart. 
This is already weakened, perhaps degenerated, by the continuance of 
the fever, and it is the failure of the function of this organ which is 
the most frequent cause of death. The digitalis, as already stated, 
though sometimes useful, is uncertain in its action, and less decided 
in reducing the temperature. The salicylic acid, though exceedingly 
efficient in rheumatism in controlling the fever, has not been suf- 
ficiently tested in typhoid fever to justify its being spoken of here 
with the same confidence as the quinine. The salicylate of soda, 
however, has been largely used of late in some of the German and 
Swiss hospitals, and is thought to be nearly equal to the quinine in 
reducing the temperature when sufficiently large doses are given, and 
to disturb less the brain and nervous system. 
Quinine is the article which has been chiefly used by the German 
physicians in such numerous cases and with such favorable results as 
to commend it at least to attention and further trial. Liebermeister 
gives from twenty-two to forty-five grains at once, or within half an 
hour; but the dose is not to be repeated for twenty-four hours, and, 
generally, not sooner than forty-eight hours. If its action is satisfac- 
tory the temperature is reduced to about 100 F., or less. If this 290 
TYPHOID FEVER. 
result is not obtained, the dose is to be increased at the next time of 
its administration. If the temperature is brought down to 98° F., or 
lower, a smaller dose must be given the next time. 
It is alleged that it has been given in this manner in many hun - 
dred cases, without any seriously unfavorable effects properly attrib- 
utable to it, and that when it was used in connection with the baths, 
thus preventing the high temperature, the mortality in the hospital 
at Basel was reduced from the former percentage of 27.3 under 
expectant treatment, to 8.5 under the strict antipyretic treatment. 
The reports from other sources of the effects of quinine in typhoid 
fever have not been so favorable either as to the reduction of the heat 
or the mortality; but, so far as I know, the antipyretic treatment, 
whether in the use of the bath or of quinine, has nowhere been carried 
out in the same way as in Germany, Switzerland, and Austria. Very 
recently, in the Fever Hospital of London, the antipyretic treatment, 
particularly with the cold bath, has been vigorously pursued, and 
with, it is said, most satisfactory results. The patients are placed at 
once in a bath at the temperature of about 60° F., but are kept there 
for a comparatively short time, following the method of Lieber- 
meister rather than Zicmssen. Not only has the rate of mortality been 
low under this treatment, but the course of the fever is said to have 
been diminished in duration. It should be mentioned that Lieber- 
meister advises wine in moderation in connection with the use of the 
bath ; and when the heart’s action fails he relies much on camphor, 
musk, hot alcoholic mixtures, etc., to keep it in action. 
Jaccoud, in addition to the lotions for the reduction of the fever, 
when the temperature rises to 39.5° Cent. (103.1° F.) gives quinine in 
doses of from eight to fifteen grains, repeated until marked tempo- 
rary abatement of the fever occurs and the evening temperature is 
lowered. 
According to my experience, quinine in doses of from five to ten 
grains, and sometimes less, repeated once in from two to three hours, 
will reduce the temperature in a few hours from 104° or 105.5° F. to 
about 100.5° F., where it will usually remain from fifteen to thirty- 
six, or sometimes forty hours, when the quinine may be repeated if 
the temperature rises. 
This use of quinine to abate the heat, in addition to careful atten- 
tion to the other indications as they arise, has been my method of 
treating severe cases for some years past. 
During the summer of 1880, I had an opportunity of visiting the 
principal hospitals of Germany, Switzerland, Austria, and France, 
and making special inquiries respecting the antipyretic treatment of TREATMENT. 
291 
typhoid fever. I found this method much more used at Basel, 
Zurich, Leipzic, Berlin, and Vienna, than in Paris. While the testi- 
mony in all but the latter city was decidedly in its favor, there was no 
uniformity of opinion as to its value or the special means of carrying 
it out. The almost exclusive remedies made use of were the cool or 
cold bath and free doses of quinine and salicylate of soda ; but there 
were some diversities of opinion as to the comparative results of these 
agents, and also as to details in the manner of using each. One of 
the most enthusiastic advocates of this treatment was found in Prof. 
Gustav Huguenin, of the University of Zurich. From a personal 
interview, and afterward from a written statement of his views and 
method, the following abstract is made and presented as a specimen 
of the most advanced doctrines. 
He in substance says : 
The treatment of typhoid fever without complications has become 
very simple since the introduction of the antipyretic therapeutics. 
Two principal remedies are used, viz., first the cool bath, and secondly 
the salicylate of soda, or the salicylate of soda with muriate of quinine. 
The cool bath is used in the hospital at Zurich in all cases, light 
and severe. In light cases, when a rapid and thorough antipyretic is 
not so necessary, a bath of shorter duration is given. The tempera- 
ture of each patient is measured every hour, and other conditions 
observed in the beginning, in order to ascertain the “run of the 
fever,” which is very necessary, in order to judge of the way the 
salicylate of soda shall be given and the bath applied. In Light Cases 
the bath is given as soon as the temperature reaches 39.4° C. (102.2° 
F.), with a temperature of the bath from 12° to 15° C. (53.G°-59° F.) 
when the patient is robust, while if delicate and anxious, a tempera- 
ture from 20° to 25° C. (68° to 77° F.) is used at the beginning, and 
cold water is added gradually until the temperature reaches from 
16° to 12° 0. (G0.8°-53.6° F.), and the bath is continued from five 
to twelve minutes. It is often found necessary in more severe cases 
of the disease to give the bath when the body heat is 39°, or even 
38.5° C. (102.2°-101.3° F.). With the bath the salicylate is given, 
and for this purpose, particularly, it is necessary to know the run of 
the fever, because the salicylate must be given before the temperature 
reaches its height. 
In the second week of the disease the patient generally takes three 
grammes (forty-five grains) of the salicylate of soda in the morning, 
and the same dose in the afternoon. If the temperature increases 
gradually from four o’clock, so that at five it is 39° .0. (102.2° F.), the 
bath is given, and it sinks to 38° or 37.8° (100.4°-100.2° F.). 
In severe cases, particularly where delirium and sopor exist, the 292 
TYPHOID FEVER. 
bath is given when the body is at 39° C. (102.2° F.), in very severe 
cases at 38.5° C. (101.3° F.), the temperature of the bath 12° to 15° C. 
(53.6° to 59° F.) ; and as often as the body heat reaches the above fig- 
ures the bath must be repeated. It often happens that ten or twelve 
baths are required daily. In cases of coma, cold water is poured over 
the head from a height of about ten centimetres (four inches). To 
this treatment in some cases is added salicylate of soda, from eight 
to ten grammes (two to two and a half drachms) per day, from four 
to five grammes in the forenoon, and the same in the afternoon. 
A mixture of salicylate of soda and quinine is often preferred— 
from seven and a half to fifteen grains of quinine with a moderate 
quantity of the salicylate. By these means the fever is very power- 
fully influenced in the severe cases. 
Debility of the heart is not a contraindication either for the 
bath or the medicines. But when the debility of the heart is great, 
the patients receive, in addition, wine, in some cases as much as a litre 
(about two pints) a day, and sometimes, in addition, eighty to one 
hundred grammes (two and a half to three ounces) of rum or brandy 
with tea. Before and after each bath some wine is given, and dur- 
ing the bath the pulse and color of the skin are carefully watched. 
As to complications or particular symptoms, no form of delirium 
presents any contraindications, but, on the contrary, this symptom 
particularly calls for the antipyretic treatment. 
Inflammation and stenosis of the larynx particularly forbid the 
application of cold water. 
Lung complications, contrary to the opinion formerly entertained, 
are not considered contraindications. Bronchitis, Atelectasis, and 
Hypostatic congestion and inflammation are benefited by the cold 
water. Hemorrhage of the bowels is an immediate contraindication, 
but only so because of the danger to the ulcerated bowels by moving 
the patient in putting him into the bath. 
Thrombosis of the crural vessels is regarded as a contraindication. 
The occurrence of nephritis is not a contraindication. 
Prof. Huguenin says that the antipyretic treatment, not only in 
typhoid and typhus fevers, but in various other severe acute febrile 
and inflammatory diseases, demands experience and caution, but has 
a grand future. 
From the statistics of the Cantonal Hospital of Zurich, in which 
Prof. Huguenin is physician, the mortality of typhoid fever has 
been reduced from twenty-seven to ten per cent, since the adoption 
of this thorough antipyretic mode of treatment ; and he adds, “ we 
have never had, up to the present time, one unpleasant occurrence 
from this treatment.” TREATMENT. 
293 
The testimony, not only here, but in the fever hospitals of London 
and elsewhere, is that a partial and vacillating use of these means is 
of doubtful utility, but that success attends the rigid and systematic 
following out of the course. 
This method of treatment has been given in detail, as the success 
of any plan in any disease depends upon the faithful observance of the 
particulars of its essential features, and the practitioner who proposes 
to adopt it needs full directions as to all its details. 
The disease as occurring in different localities and conditions may 
be differently affected by the same treatment; but in the range of my 
observation in the West I have no doubt of the beneficial action of 
quinine, properly used, as an antipyretic agent, in cases where the 
temperature is high in typhoid fever. The bath, the fever cot, or the 
cold lotions, judiciously used, will be important aids in the reduction 
of excessive heat. 
Wider and longer experience may be required to establish the 
safety and full value of the antipyretic method as advised by Lieber- 
meister and Ziemssen ; but the testimony in its favor is constantly in- 
creasing, and is most positive from those who have been most thorough 
in its use. 
Bed-sores are to be prevented first by the use of all the means 
possible to abate the severity of the fever, then by changing the posi- 
tion of the patient, relieving the pressure from the tender parts by 
cushions under the surrounding parts, by removing all wrinkles from 
the linen, by scrupulous cleanliness, proper bathing, and by spirituous 
or astringent washes; and when sores occur, they should be treated 
by relieving them from pressure, by balsam of fir, by carbolic acid 
and oil dressings, and by gentle galvanic currents. 
After this account of the treatment of typhoid fever, and the 
various remedies which are applicable to its different conditions (so 
much extended in consequence of its exceeding importance), it re- 
mains only to state, in a summary manner, the general plan of treat- 
ment which in my judgment should be pursued. 
At the beginning of the attack mercurials should be given, fol- 
lowed by laxatives, unless the diarrhoea is decided. If not so profuse 
as to be decidedly exhausting, the diarrhoea should not be checked in 
the early stage, or completely suppressed at any stage. Great care 
should be exercised in the selection and doses of the laxative, so as to 
avoid too violent and irritating effects in the sensitive and diseased 
condition of the bowels which is present. After this early eliminative 
treatment, the bowels should be kept open, when they are inclined 
to constipation, by the gentlest means, often by enemas rather than 
laxatives. If, as is generally the case, there is diarrhoea, the move- 294 
TYPHOID FEVER. 
merits should not be entirely suppressed, but should be abated, when 
profuse and depressing, by the means mentioned. 
If the condition of the bowels requires no special attention, if the 
fever be not above 102° or 103.5° F., and no complications be present, 
simple hygienic management, attention to food, cleanliness, ventila- 
tion, occasional sponging, etc., are all that will be required. The 
gentle diaphoretic and diuretic mixture, a formula for which has been 
given, will be well, and, as a rule, the use of some medicine will be 
more satisfactory to the patient and friends than none at all. AVhen 
there is much diarrhoea, and especially tympanitis and tenderness, the 
turpentine emulsion should be given. It is often useful continued 
during a large part of the course of the disease. The special symp- 
toms and complications are to be met by the means described. If the 
temperature rises to 104° and above, especially in the morning, and 
is nearly uniform, no marked morning abatements occurring, means 
should generally be resorted to for reducing the fever heat. The 
application of water by the bath, fever cot, or by sponging (in spong- 
ing vinegar and water may be used if preferred), should be systemati- 
cally made, and if not sufficient to promptly reduce the heat, quinine 
or salicylate of soda should be given in such quantities as may be nec- 
essary to effect that object. My own experience indicates that seven 
or eight grains, and often less, repeated for a few times at intervals of 
two or three hours, will suffice to produce a remission. The quinine 
or salicylate of soda should then be omitted until its effects begin to 
pass off, when its repetition is called for. 
The intermitted use of the antipyretic, in free doses, is much less 
likely to produce disturbing effects than its continued administration. 
It is much better to make a decided impression with it, and then sus- 
pend its use, than to continue it in smaller doses, when the object is 
to reduce temperature. 
An account of the other means for fulfilling special indications 
need not be repeated. A single caution will be added. It is better 
not to apply remedies to every symptom that may seem to afford an 
indication, than to indulge in a polypharmacy. Much judgment and 
discretion are required in severe and complicated cases, in determin- 
ing not only what is to be done, but what is to be abstained from. 
The convalescence of typhoid patients should receive attention. 
The appetite, after a period of comparative starvation, and after the 
waste of the fever, is generally ravenous, and the self-government of 
the patient is in abeyance. The intestines have been ulcerated, and 
are still in the process of healing, and are therefore in a tender condi- 
tion. Coarse articles of food, and much of any kind, may do fatal 
mischief. Bland articles and in moderate quantities must be directed, TYPHO-MALARIAL FEVER. 
295 
and obedience to directions must be insisted upon, and if necessary 
enforced. Lifting, straining, or other forms of active exertion should 
be avoided until the intestines have had time to become sound. 
Typho-Malarial Fever.—When in a locality where malarial 
fevers abound a patient contracts typhoid fever, a modified form of 
disease is liable to be produced, which has received the name of 
typho-malarial fever. It is the result of the typhoid and malarial 
poisons operating on the system at the same time, and presents the 
mingled phenomena of typhoid fever and malarial fever. As these 
elements are mingled in different proportions in different cases, the 
symptoms are varied, and no description will apply to all. 
The access is generally more abrupt and violent than in pure 
typhoid ; the fever is constant, but is more violent at somewhat regu- 
lar periods, and the specific typhoid lesions of Peyer’s patches, of the 
mesenteric glands, and the spleen, are present, and the symptoms 
accompanying such lesions are more or less manifest. 
As the disease occurred in the army in our late civil war, ulcer- 
ation of the intestines beyond the usual limits of the common typhoid 
lesions, probably from a scorbutic condition, often occurred. 
The course of the disease is variable, but, without treatment, is 
severe and protracted, and not unfrequently fatal. A protracted diar- 
rhoea often follows it from a continuance of the intestinal disease ; and 
functional and organic diseases of the liver not unfrequentlyoccur. 
The treatment of this fever should be commenced by an eliminative 
laxative less active than in malarial fever, in consequence of the intes- 
tinal disease, and then full antimalarial doses of quinine, as in remit- 
ting fever, should be given. This will neutralize the malarial element, 
when the remaining fever should receive the same treatment as a sim- 
ple typhoid presenting similar phenomena. The free doses of quinine 
here, as well as elsewhere, will abate the feverish heat at the same time 
that they neutralize the malarial poison, though fever will return again 
more or less actively until the typhoid condition has run its course. 
It is unnecessary to enter into details, as the principles of treatment 
are the same as those which have been so fully discussed in the pre- 
ceding pages. Some physicians, among whom is Prof. Bartholow, 
question the existence of this fever and the propriety of applying to 
it a distinctive term, giving as a reason the existence of the specific 
typhoid lesions ; but the presence of such lesions, and of the special 
typhoid element, does not necessarily exclude the malarial. Both 
influences may operate on the system at the same time, and this is 
certainly sometimes the case ; and when so, the term typho-malarial 
may with propriety be applied to the resultant phenomena. 296 
TYPHUS FEVER. 
TYPHUS FEVER (EXAXTHEMATOUS TYPHUS). 
This has been defined, “a highly contagious fever, lasting from 
two to three weeks, and attended with a characteristic measly erup- 
tion, coming on from the fourth to the seventh day.” (Brietowe.) 
The fact that until very recent times typhus and typhoid fevers 
were not distinguished—that in all but the last edition of the classical 
work of Sir Thomas Watson, on the Practice of Medicine, a present 
living authority, they were described as varieties of the same affection 
—indicates that they must have much in common, and that many of 
the principles discussed in the article on Typhoid Fever are equally 
applicable to this affection. This will prevent the necessity of so 
extended a consideration of typhus as has been given to typhoid fever, 
and wye shall therefore only need to dwell upon the points in which 
the two diseases differ. 
Typhus is not as widely distributed and frequent in occurrence 
as typhoid fever. It is mostly confined to temperate climates, and it 
is doubtful whether it has ever occurred in tropical countries. It 
has occasionally appeared in all the countries of Europe, in our own 
country, and Canada ; but its particular home is in Great Britain, and 
it has raged in Ireland more than elsewhere. It is, doubtless, like the 
typhoid, dependent upon a particular specific poison ; but the poisons 
of these two forms of fever differ in their characters, and in the con- 
ditions of their production and spread. 
While the typhoid poison has it habitat, chiefly at least, in faecal 
filth, the typhus germs are particularly connected with the filth aris- 
ing from emanations from human bodies wdien crowded together in 
numbers in unventilated and uncleansed apartments. The same 
question exists as to the spontaneous production—the evolvement 
anew of the germinal matter without preceding germs of the same 
character—as in the case of typhoid. Murchison contends, with a great 
array of facts and much force of argument, for the production de novo 
of the specific material under the influence of crowding, filth, and 
famine ; and he is sustained in this view by the opinion of Jaceoud, 
Grisolle, and others. This poison must have had a beginning at some 
time, and the same conditions first producing it may do so at any 
time again ; but it is impossible to show in any given case of an out- 
break of the disease, however remote in space or time from other 
cases, that there were no latent germs brought into productive activity 
by favorable conditions. Under these circumstances the question 
must still remain open. But the important practical fact is, that 
typhus fever commences and spreads only from places where crowding 
and filth are present. PHENOMENA. 
297 
That the poison, however originating, is multiplied in the bodies of 
the sick, and is communicated from them to others admits of no doubt. 
Commencing in crowded prisons, in the holds of emigrant ships, 
or the cellars, garrets, or cabins of the poor, it spreads by contagiou 
to others—sometimes to the palaces of the rich, the judges of the 
courts, and too frequently to the physicians and nurses in attendance 
upon typhus patients. It is quite as likely to prove severe and fatal 
among the intelligent and well to do, when it attacks them, as among the 
ignorant and poor, the brain symptoms being more prominent among 
the intellectual and cultivated than among the rude and ignorant. 
It has so often accompanied poverty and famine, because these 
conditions lead to crowding and depression. It has seldom appeared 
in the Western States, and never, in my experience, except where it 
could be traced to recent emigrants from Europe; and it has never 
had, in these localities, any wide-spread prevalence. 
It essentially differs from typhoid fever in having no constant and 
specific internal lesions—particularly it differs in the absence of the 
disease of Peyer’s patches and the mesenteric glands—the internal 
lesions which occur being accidental rather than necessary, and mostly 
within the cranium and thorax. These lesions, particularly of the 
brain, are more frequent in typhus than in typhoid, and consist, as 
in cases of typhoid where these organs are affected, of congestions, 
inflammations and their consequences, of hyperaemia, effusions, soft- 
enings, etc.; and the degenerations are similar to those that occur in 
the last-named disease. 
The eruption, as already stated, is peculiar and characteristic, 
and is more frequently present and abundant than in typhoid fever. 
From its comparative constancy and abundance, it has suggested the 
name of Exanthematous Typhus, and, from its dark color, of Pete- 
chial Typhus. 
It embraces two factors—a mere mottling of the surface and dis- 
tinct dusky red spots. These are usually present at the same time, 
though the mottling precedes the development of the more distinct 
rash. The mottling is produced by the appearance of abundant, 
illy defined patches, not elevated, and disappearing on pressure, the 
individual points being scarcely perceptible. The rash resembles in 
appearance that of measles. The spots, however, are smaller and 
less elevated, and do not so frequently assume a crescentic form. 
They are slightly raised, fading at the margins. At first, while 
they have a brightisli color, they disappear on pressure, as they 
are produced by the stagnation of blood in the capillary vessels; 
but after a few days, owing to effusion of the coloring matter of 298 
TYPHUS FEVER. 
the blood into the tissues of the skin, they become darker, and the 
color is not removed by pressure. After some days they fade away, 
or blood corpuscles are effused, and they are converted into petechiae, 
which are more permanent. More or less of this eruption is almost 
invariably present; but it is less abundant, and of shorter continu- 
ance, in children than in adults. 
The rash is generally in proportion to the severity of the fever, 
and a free amount of petechiae, which sometimes occurs in the latter 
stage of the disease, is .regarded as an unfavorable indication. The 
eruption, then, is both a diagnostic and prognostic sign, and is there- 
fore worthy of careful attention. 
The action of the heart is rather more inclined to be weak, and to 
fail, than in typhoid—the first sound becoming inaudible, or decidedly 
less than the second. Symptoms referable to the nervous system— 
delirium, subsultus, etc.—and death by coma occur at an early period 
more frequently in typhus than in typhoid fever. 
“Coma vigil,” or the condition in which the patient lies with the 
eyes open, but nearly or quite devoid of sense, is more frequent in 
typhus than in typhoid. 
Typhus varies much in severity, and is sometimes so slight, and of 
such short continuance, as to render diagnosis very difficult unless 
aided by the surrounding circumstances and the prevalence of the 
disease. Owing to the absence of the abdominal lesions and the dan- 
gers attending them, the mortality in young persons is less than in 
typhoid ; but it increases rapidly in adult life, so that between fifty 
and fifty-five, according to the statistics of the London Fever Hospi- 
tal, the mortality is very nearly fifty per cent., and between seventy- 
five and eighty it is about eighty-five per cent. On the whole the 
mortality does not materially differ from that of typhoid fever. 
The full development of typhus fever is very generally preceded 
by prodroma—by pain in the head, neck, back, and limbs, by ano- 
rexia, restlessness, etc.—lasting a few days, more or less, when the 
fully developed access somewhat suddenly occurs. 
At the full onset there is usually a chill, which is possibly 
repeated. The fever comes to its height sooner than in typhoid ; the 
temperature is often speedily raised to from 103° to 106°, and oftener 
than in typhoid it reaches higher figures, from 106° to 109° F., and 
the surface frequently gives to the hand a burning, tingling sensation, 
which has caused the name of “calor mordax” to be applied to this 
peculiar heat. The muscular weakness in severe cases is great; there 
is generally a dusky or smoky color of the face, and an expression of 
profound apathy. The heat is generally quite evenly distributed over DIAGNOSIS. ) 
299 
the body, and there is less difference of temperature between morning 
and evening than in typhoid. The pulse is commonly rapid, often 
from one hundred and twenty to one hundred and forty, and there is 
an ammoniacal or cadaveric odor, differing from that of typhoid. 
The fever usually continues from thirteen to eighteen days, when, 
in favorable cases, the temperature commonly falls rapidly, coming to 
the normal standard in twenty-four hours, more or less. 
In unfavorable cases, the fatal termination is most frequently about 
the end of the second week or the beginning of the third, and is com- 
monly due to a combination of asthenia and coma. When it occurs 
at an earlier period it is often produced by congestion of the lungs, in 
addition to the other pathological conditions, and when much later, 
it is caused by some complication or sequel of the fever, as in an 
uncomplicated case the crisis is already passed, the fever subsiding 
within sixteen or eighteen days. 
The chief condition distinguishing typhus from typhoid is the 
specific abdominal lesions in the last, and their absence in the first. 
But in comparing them in various aspects, the following summary of 
differences will be recognized : 
Typhoid. 
Typhus. 
Access slow. 
Heat somewhat less, and varies 
more between night and morn- 
ing. 
Mind less disturbed at the early 
stage. 
Disease of Peyer’s glands, etc. 
Diarrhoea and tympanitis. 
Emaciation greater. 
Epistaxis often. 
Cutaneous eruption less abun- 
dant, less constant, lenticular, 
and rose-colored. 
Essential pathological lesions. 
Accidental lesions the result of fe- 
ver similar, but less of the brain. 
Less contagious. 
Caused by germs mostly in faecal 
filth. 
Duration longer. 
Defervescence slower. 
More rapid. 
Heat higher and more uniform. 
Delirium, stupor, and other nerv- 
ous symptoms earlier and more 
constant. 
None. 
Absent. 
Less. 
Seldom. 
More dark, diffused, and irregular 
in form. 
None. 
More of the brain. 
More contagious. 
Caused by germs mostly in crowd 
filth. 
Duration shorter. 
More rapid. 300 
TYPHUS FEVER. 
The preventive management in typhus, as in typhoid fever, is of 
the greatest consequence, and in this, as in other diseases, consists in 
avoiding the causes. 
Personal cleanliness and thorough ventilation, with proper food, 
are the great hygienic preventive measures ; and when the disease 
actually occurs, as it is so positively contagious by the effluvia that 
emanate from the sick, they should be isolated as much as possible, 
and the freest and most perfect ventilation of the sick room must be 
especially insisted upon ; the clothing and everything near the patient 
capable of absorbing the poison should be often changed, disinfected 
by heat or chemical agents, or burned. 
The room should be disinfected, and, in short, all the means to 
prevent personal contagion, or the carrying of the poison and its 
spread in fomites, should be sedulously used. As in typhoid fever, 
one attack confers comparative though not perfect immunity from 
subsequent ones; if possible, it is well to select as attendants upon 
typhus patients those who have had the disease, and young persons, if 
not protected, rather than old, as it is so much less dangerous with 
the young. 
The curative treatment is substantially the same as in typhoid 
fever, aside from the indications presented by the specific conditions 
of the abdominal organs and their consequences in the latter. 
There is no known specific remedy which can be relied upon to 
neutralize the poison and arrest the disease ; but there are the same 
indications for eliminating effete matter, the result of the feverish 
waste, and for abating the excessive heat, relieving distressing symp- 
toms, and finally, for sustaining the rapidly diminishing strength. 
The means for accomplishing these objects are also substantially the 
same as those employed in typhoid fever. 
Eliminative laxatives should be used in the early stage, and the 
bowels must be kept open throughout, and though there is less danger 
of cathartics irritating the intestines and operating profusely than in 
typhoid, there is quite as much necessity for avoiding debilitating 
effects from their excessive use. The kidneys should be gently excited 
to carry off the effete matters as well, and the skin, as another emunc- 
tory, should be kept as active as possible by means which will do no 
harm in other respects. The diaphoretic and diuretic mixture of 
acetate of ammonia, spirits of nitre, and syrup of ipecac, will be appli- 
cable here, as also the effervescing mixture of cream of tartar and 
bicarbonate of soda, the chlorate and other salts of potash and similar 
articles as in other fevers. 
TREATMENT. TEE A TMENT—PHENOMENA. 
301 
The mineral acids are favorites with some, but, like all other medi- 
cines having any local irritating properties, should be largely diluted. 
As adynamia and exhaustion are characteristics of this fever, the ali- 
mentation must be carefully attended to; and the same questions 
arise concerning the use of tonics and stimulants as in typhoid. As 
to the use of alcohol, opinions here differ, as in the other fever; but 
it is now generally agreed in England and Ireland, where the fever 
most prevails, that alcohol is not necessary in the ordinary cases, and 
especially in the earlier stages of the disease ; it is still, however, used by 
many in the latter stages where there is great depression, especially 
when the heart fails, and its first sound becomes much feebler than 
the second. When used, the same rules should bo observed as laid 
dowrn for typhoid fever. 
As to the use of the bath and quinine as antipyretic agents, experi- 
ments have not been made on the same large scale as in typhoid cases, 
but I can see no reason why these agents are not equally applicable in 
the one case as in the other. But here, particularly, the test of ex- 
perience has not been sufficient to determine the full value or dan- 
gers of the rigid antipyretic method. 
The complications and the particular distressing symptoms are to 
be managed on the same principles as the same conditions in typhoid 
fever. As there is a greater tendency to congestion and inflammation 
of the brain and to coma in typhus than in typhoid fever, more cau- 
tion is required in the use of opium, and the bromides are more fre- 
quently called for. 
The full account of the treatment of the conditions common to 
typhoid and typhus fever, given in the article on the former disease, 
renders any further details unnecessary. 
RELAPSING FEVER.—Famine Fever. 
This is a peculiar contagious disease originating in famine (but 
less dependent upon filth than typhoid or typhus), in which a fever 
rapidly comes on, and attains a high temperature, continuing about a 
week. It then disappears, the temperature sometimes falling decidedly 
below the normal; and generally all the conditions improve for about 
a week more, when the fever returns and continues for another week, 
after which it again disappears ; though it occasionally reappears a 
third, or very rarely even a fourth time after similar intervals. The 
patient then enjoys a period of exemption, which in some cases is per- 
manent, while in others the liability to attacks on exposure to the con- 
tagion in time returns. 302 
RELAPSING FEVER. 
So far as I am aware this fever has never had an outbreak in this 
country, except when the contagion was brought from abroad ; and it 
has prevailed more in Ireland and England than elsewhere. 
It is so rare in Paris that the works on the Practice of Medicine 
by Grisolle and Jaccoud do not mention it, and it might be passed by 
here as a disease not likely to come under the observation of American 
physicians, were it not that there arc some very interesting recently 
discovered facts connected with its pathology, which throw light upon 
the whole subject of specific contagious or infectious diseases. 
It recently, however, prevailed in Russia, and was introduced from 
that country into Germany, where it was frequently observed in tbe 
hospitals in the summer of 1880. 
It has no necessary lesions that have been recognized, unless it be 
enlargement and softening of the spleen. The liver is also enlarged, 
though not uniformly; but these conditions occur in other affections 
as well. 
In 1872, Dr. Obermeier detected in the blood of patients with re- 
lapsing fever a form of bacteria called “spirilla.” They are moving 
spiral filaments of extreme tenuity, measuring from y-sVo to of an 
inch in length. They appear in the blood in great numbers just 
before the rise of temperature or the access of the fever; continue 
while the fever continues, or rather they disappear just before the 
crisis of the week’s paroxysm of fever occurs. They again appear just 
before the next septenary access, disappearing again at the time of 
the next crisis. These observations have been repeated, so as to leave 
no doubt of the connection of these spirilla with the fever as a cause. 
They vary in number during the fever, and from the observations of 
Dr. Ileydenreich, of St. Petersburg, it appears that the spirilla are 
short lived, especially at fever heat, and that their varying quantity 
in the blood during the fever is due to the occurrence of successive 
germinations. The contagious character of this fever is established 
by many observed facts; and it is rendered exceedingly probable that 
the spirilla constitute the contagium, by the almost crucial experiment 
of inoculating with the blood containing these bodies, and thus produc- 
ing the disease; while inoculating with the blood of the same person 
during the intermission of the fever, when these bodies are not present, 
fails to produce it, as also does inoculating with any of the secretions. 
These facts resemble those observed in the Milzbrand, or Anthrax, 
or splenic fever of cattle, already referred to, and which is sometimes 
conveyed to man. 
The recently discovered facts of these cases are wonderfully con- 
firmatory of the germ theory of infectious diseases, and the actions of 
microzymes as the cause of their phenomena. PHENOMENA. 
303 
The question as to whether these spirilla, so connected with the 
phenomena of relapsing fever, are produced anew by famine, or 
whether the germs are hidden in ordinary conditions, and brought 
into activity and multiplied by the peculiar conditions of privation, 
is not determined. This involves the question of spontaneous gen- 
eration, and the fixed character of organisms ; hut from all the 
knowledge at present possessed, it seems probable that these organisms, 
in some stage or form of their life, have a continued existence, but 
that certain circumstances favor their rapid production, and their 
existence in sufficient abundance to cause the morbid effects. That a 
poison is multiplied in the body during the disease, and is communi- 
cated from the sick to the well, is fully established ; and this consti- 
tutes relapsing fever a genuinely contagious disease. It seems, how- 
ever, that the poison is not very diffusible—that it lingers about the 
person, is capable of being communicated by fomites, but that a con- 
siderable amount of exposure, remaining some time in the presence of 
the sick, and receiving a considerable quantity of the poison, is 
ordinarily necessary to the production of the disease, especially in 
those not suffering from want. Thorough ventilation and other 
prophylactic precautions generally prevent its spread. 
The period of incubation of the poison varies, but is generally 
rather shorter than that of typhus. 
The onset of the disease is commonly sudden. It is marked by 
chilliness or rigors, and by severe pain in the forehead, trunk, and 
limbs. Intense heat and dryness of the surface soon follow, with 
continuance of the pains and with giddiness, frequency of pulse, loss 
of appetite, etc. Perspirations sometimes alternate with dryness; 
occasionally the general symptoms continue only for three or four 
days, but generally for seven ; when, often preceded by a slight rigor, 
a free perspiration breaks out, lasting for a few hours, is followed by 
a remarkable reduction in the rate of the pulse and the temperature, 
and, with the exception of some lassitude, with almost complete 
restoration to health. 
During this paroxysm the fever ranges from 104° to 108.5° F.; 
the pulse from 110 to 140 ; the tongue has a thick, whitish fur, with 
red tip and edges; and, occasionally, toward the end of the par- 
oxysm, is dry and brown. There is extreme thirst; sometimes vom- 
iting ; and, in rare cases, slight haematemesis; the bowels are gener- 
ally constipated; there is often tenderness in the region of the liver 
and spleen, and, as before stated, these organs are more or less 
enlarged ; and in many cases, about the third or fourth day, there 
are some icterode symptoms. 
The urine varies in quantity, but, as in other fevers, generally 304 
RELAPSING FEVER. 
contains an excess of urea, and occasionally is albuminous, and even 
bloody; and, toward the close of the attack, suppression in rare cases 
takes place. The general pains in the body continue severe, and are 
sometimes largely in the joints, as if from rheumatic poison. For the 
most part the patient retains consciousness, but suffers from sleepless- 
ness or broken and dreamy slumbers. Delirium, however, sometimes 
maniacal, occasionally occurs near the crisis ; and in rare cases stu- 
por, coma, and even convulsions have occurred, probably due to urae- 
mic poisoning. 
There is not generally the congested, smoky, dull, puzzled aspect 
of typhus, and this difference is one of the means of distinguishing it 
from that affection. At the crisis the perspiration is occasionally 
accompanied or replaced by a diarrhoea; and in still rarer cases a 
hemorrhage from the nose, bowels, or elsewhere, occurs. There is 
no specific rash belonging to this disease ; but rarely, near the crisis, 
a petechial eruption appears. 
The temperature during the intermission may sink below the nor- 
mal, even from 9G° to 90.6° ; and the pulse may become as lowr as 
from 60 to 40 in a minute; though, from the weakness, it is liable to 
increase on exertion. The tongue commonly becomes clean, and the ap- 
petite is often voracious. Very rarely the patient, at the period of crisis, 
falls into a collapsed or typhoid condition ; but almost uniformly, after 
the fever abates, he is soon restored to a comparatively healthy state. 
This, in rare cases, is permanent, the attack, as described, being the 
only one; but generally, at the end of fourteen days, more or less, 
from the first attack, another ensues in almost precisely the same 
manner, and generally pursues a similar course, though the tempera- 
ture is sometimes higher, and the paroxysm is often somewhat shorter. 
It may not continue for more than three days before final convales- 
cence occurs, with the same phenomena as before. Other paroxysms, 
as before stated, may occur, but such cases are rare. 
The danger to life from this fever is slight. There are usually 
no severe local lesions ; the fever, though high, can bo endured for the 
shorter period of a week, and, during the intermission, the system has 
time to recuperate and gain the ability to endure the next paroxysm. 
Even among the poor and famished patients of the London Fever 
Hospital, the mortality shows only 4.75 per cent. The causes of 
death, when it occurs, may be from asthenia, collapse at the crisis, 
or from coma and other cerebral complications; also, from implica- 
tion of the kidneys and retained urea. 
Complete convalescence is often protracted, the full strength not 
being soon regained; but sequelae of a serious character seldom fol- 
low. Occasionally, however, pulmonary affections, as a low form of PHENOMENA— TREA TMENT. 
305 
pneumonia, or a diarrhoea or dysentery, may supervene. An ophthal- 
mia is not unfrequent, and is somewhat characteristic. 
Pregnant women almost invariably miscarry, at whatever period of 
gestation, when this fever occurs with them. The foetus, as a rule, 
dies, but the mother as generally recovers. 
Lesions of accidental complications are sometimes found on post- 
mortem examination ; the liver, as before stated, is often congested and 
enlarged, but otherwise apparently healthy; but the spleen is almost 
invariably much increased in size, is soft, and sometimes diffluent. 
This organ, so constantly affected in malarial, miliary, and typhoid 
fevers, seems peculiarly susceptible to a morbid impression from all 
fever poisons. 
How the germinal poison of relapsing fever causes the peculiar 
phenomena described is entirely unknown, and, indeed, it is not 
absolutely demonstrated that such germs are the cause of the phenom- 
ena—they may possibly be accidents only—but the strongest proba- 
bility exists of an essential causal relation, and a conviction to that 
effect is well-nigh irresistible. 
Treatment.—After what has preceded, the subject of the treat- 
ment of this fever may be briefly disposed of. The means of preven- 
tion are at once suggested. Providing the people with food and fuel 
in cases of destitution; and as prophylaxis, when the disease has 
broken out, isolation of the sick, thorough ventilation and cleanliness ; 
and as the contagion is generally communicated through the air, the 
use of antiseptic vapors, such as chlorine, iodine, and sulphurous acid 
in the sick room and about the patient is demanded. 
As there are no known means of arresting the course of the disease, 
the use of palliative treatment for relieving symptoms and prevent- 
ing or modifying complications, is the course to be advised. 
Undoubtedly gentle eliminative measures—laxatives, diuretics, and 
diaphoretics—will be useful; the excessive heat may be abated by cold 
sponging, or the bath ; the vomiting may be allayed by ice, efferves- 
cing mixtures, or anodynes ; the headache may be abated by cold ap- 
plications to the head, by bromide of potassium, and often, especially 
if sleeplessness is present, opiates may be added ; and if coma, with 
suppression of urine be present, more active eliminative cathartics, 
such as the salines, or cream of tartar and jalap, with the application 
of cupping glasses to the lumbar region, the warm bath, and perhaps 
the jaborandi may be required. 
Emetics, given in the early stage, have been thought by some to ren- 
der the disease milder, while bleeding, here as in other active fevers, 
has had its advocates ; and cases of congestion can be conceived of 
where this latter remedy may be useful. 306 
PLAGUE. 
Experience, so far as I am aware, has not determined the effects of 
quinine or salicylate of soda in this fever in controlling the heat or 
other symptoms. 
During the attack the food should be such as is proper in other 
similar diseases, and alcohol should be avoided, except perhaps in 
cases tending to collapse, or under the conditions already indicated in 
other fevers. 
In our own country, with such an extent of territory, variety of 
products, and abundance of food, we need not fear, for a long period to 
come, the occurrence of famine, and the consequent origination of this 
malady. In case of threatened importation, quarantine regulations 
should be enforced, as against other contagious diseases. 
Irregular forms of fever are sometimes met with, not answering to 
the description of any of the well-known types which have been de- 
scribed. In a majority of cases they more nearly resemble typhoid 
than any other of the specific fevers, but they have peculiarities, de- 
pending upon seasons and localities, and perhaps upon different kinds 
of poisons. 
Cases of this kind have been reported from different localities, but 
not always with sufficient accuracy and fullness to give just notions of 
all their peculiarities. Some of the unique specimens may not be re- 
peated, so that a description of them is less important; and, besides, 
the same general principles of treatment are applicable to them as to 
the fevers already described. The fevers which occurred in some 
portions of our army during our late civil war, and which received 
the name of'typho-malarial—fevers which certainly did not present in 
all of their phenomena the ordinary types of either typhoid or malarial 
fevers—serve as an illustration of the modifying influence of particu- 
lar circumstances, or the different character of the poison producing 
the fevers. 
In the management of such fevers the general principles so fully 
dwelt upon must govern, while the results of experience in the pre- 
vailing cases must not be neglected. 
PLAGUE (PESTILENTIA). 
The Plague is a contagious fever, in some respects resembling 
typhus, hut is distinguished from it by the absence of the peculiar 
rash of the latter, and by the presence of buboes, carbuncles, and gan- 
grenous pustules. 
It is known to have prevailed from at least an early period of the 
Christian era in Asia Minor and surrounding countries, where it still PHENOMENA—THE A TMENT. 
307 
lingers, and it has spread from its seat, at various times, over the Con- 
tinent of Europe. It last appeared in England in the great plague of 
1665, and has since not unfrequently spread as an epidemic beyond 
the bounds of the countries where it ordinarily exists. It has had no 
considerable prevalence in Europe within the experience of any of the 
present generation ; in 1878-9, however, there was an outbreak that 
spread into Russia and threatened and alarmed all Europe, but wras 
suppressed by vigorous sanitary measures. 
The conditions which favor its occurrence are the same as those 
which determine that of typhus—privation, filth, and overcrowding—• 
and it is apt to attack armies and the inhabitants of beleaguered cities. 
It has never prevailed in America, and as its strictly contagious char- 
acter is so well understood, it is hoped that proper quarantine and 
sanitary measures will be so constantly enforced as to free us from 
such a calamity. 
A degree of protection against subsequent attacks is produced by 
its occurrence, yet this is by no means perfect, as it has often occurred 
more than once in the same person. 
The contagion is communicated by the breath, by contact, by 
inoculation, and by fomites. In its late outbreak in Russia it was 
said to have been brought by a soldier in some article of clothing—a 
sash or shawl—taken from the dead body of a Turk during the late 
Turco-Russian war. 
The duration of incubation is uncertain. The symptoms are 
chills, rise of temperature, pain in the head, back, and limbs, giddi- 
ness, anxiety, and sickness, soon followed by great loss of muscular 
strength, great feebleness of the heart’s action, with a small, rapid, 
and irregular pulse, and great general prostration. The countenance 
is markedly dull and stupid in its expression, delirium and coma gen- 
erally soon following, and sometimes convulsions and speedy death. 
The tongue, thickly coated from the beginning, soon becomes dry and 
black, the bowels are apt to be loose, the urine scanty and sometimes 
suppressed, and hemorrhages from the mucous surfaces not unfre- 
quently take place. 
Within two or three days from the onset, petechise may or may 
not appear upon the surface, but characteristic swellings of glands in 
the groin, axilla, and neck appear ; and somewhat later carbuncles are 
developed in different situations, mostly on the extremities. The 
buboes enlarge and reach their height in eight or nine days, in case 
of so long survival, when they usually subside, but sometimes sup- 
purate. The carbuncles are far from being constant; they vary in 
size and intensity of inflammation, and in numbers from one to a 
dozen. 308 
DIPHTHERIA. 
Death may take place within twenty-four hours or may be delayed 
for several days, and sometimes until the second or third week ; but 
the specific disease before that time has expended its force, and those 
who die so late probably succumb to some of the complications. 
Before the buboes or “plague spots” appear, it is regarded as 
impossible to distinguisli plague from severe typhus; but the buboes, 
though in rare cases occurring in typhus, are much more frequent in 
plague ; the typhus rash, which, however, does not occur till after 
several days, is absent in plague ; and the greater and more speedy 
mortality in the latter disease will soon distinguish it from the former. 
Post mortem, there is a tendency to rapid decomposition ; the 
blood is imperfectly coagulated ; there is congestion, enlargement, and 
frequently softening of internal organs, often extravasation of blood 
in points beneath the mucous and serous surfaces, and swelling not 
only of the external lymphatic glands, but of those within the abdo- 
men and thorax, some being as large as a goose’s egg, while others 
are smaller ; and they may have undergone softening and sometimes 
suppuration. 
The preventive treatment of plague, which is infinitely of most 
importance, consists in avoiding the causes, in isolation, and the 
strictest quarantine. In the late outbreak in Russia, the inhabitants 
of villages where it appeared were removed from their homes and 
placed under the strictest military guard, and often their villages 
were burned ; a military cordon surrounded the whole infected region, 
and neither egress nor ingress was allowed. 
The curative treatment is entirely unsatisfactory. No specific 
remedies are known, and the principles of the treatment applicable to 
it are those appropriate to severe typhus fever. The local treatment 
of the buboes, carbuncles, and sphacelations should be emollient 
rather than irritating, as for similar affections under other circum- 
stances. While experience has not as yet proved the special efficacy 
of any measures, we should not despair of finding in the future some 
means for combating even so frightful an affection. 
DIPHTHERIA. 
AHGIKA MALIGNA.—CYNAMCHE MEMBRANACEA.—PUTRID SORE 
THROAT.—EPIDEMIC CROUP. 
This is an acute, specific, infections, and contagious disease, gener- 
ally prevailing epidemically. It is a general disease affecting the PHENOMENA—H1STOR Y—CA USA TION. 
309 
whole organism, but with peculiar local symptoms produced by a 
specific inflammation, chiefly of the fauces, nares, larynx, and trachea, 
which results in the formation of a characteristic membrane on these 
surfaces, resembling a skin or parchment, and giving the disease its 
name. 
The general phenomena are marked by a form of fever, in which 
there is a rapid development of anaemia and extreme debility—the 
evidences of severe blood poisoning. 
Its dependence upon a specific poison is proved by numerous 
facts, and its contagious character is demonstrated by its production 
by 'inoculation with the matter of the membrane. It is generally, 
however, communicated through the atmosphere, and the poison 
must therefore be capable of volatilization. 
From the fact of its being communicable by inoculation, some 
have regarded it as primarily local, becoming general from the local 
change; while others, with at least equal reason, knowing its com- 
municability through the air, and often observing general symptoms 
before the local changes are manifested, consider its primary condi- 
tion general, and the local lesions secondary. I see no inconsistency 
in regarding it as sometimes primarily local, and at others as prima- 
rily general. But the important fact is, that, as it presents itself for 
treatment, it is both a local and a general disease. The diphtheritic 
exudate is not absolutely confined to the throat or mucous membrane. 
It sometimes appears on wounded or excoriated surfaces which may 
happen to be present in a diphtheritic patient. It is of a whitish or 
grayish color, has sometimes sufficient coherence to admit of being 
removed by forceps in large patches, while at other times it is more 
tender and diffluent. When the membrane is tough, it is found to 
be fibrinous; when more flocculent and tender, it is chiefly composed 
of greenish corpuscles, pus, epithelial cells, and blood corpuscles min- 
gled together. 
Many low vegetable organisms—bacteria, micrococci—have been 
found in this membrane ; and Oertel, Heuter, and others, who have 
studied the disease with care, assert that these bacteria are not only 
in great abundance in the membranous exudate, but also in the 
lymphatic spaces of the subjacent corion, and more or less in other 
tissues; and these observers believe them to be the essential con- 
tagious material. Whether this is so, or whether their presence is 
accidental and occasional, rather than constant and essential, is not 
determined, as some observers, of perhaps equal authority, have 
sought for them in some cases unsuccessfully. That the poisonous 
material is in the membrane and the living parts beneath it, and from 
which it springs, whatever its form, or whatever else it may be, can- 310 
DTP II'l 'll Kit 1A. 
not be doubted; and that it may be absorbed from the diseased sur- 
faces,, affecting still further the system, is supported by sufficient evi- 
dence upon which to base pathological conclusions and therapeutical 
indications. 
This peculiar disease, although it has existed and been described 
at periods since ancient times, was unrecognized for the last few 
generations as a distinct affection until observed by Bretonneau, of 
France, and described in his treatise, in 1826. Since then it has 
spread to a considerable extent over Europe and America, prevailing 
extensively in France from 1855 to 1857. It Avas apparently imported 
from thence into *Great Britain, where it committed great ravages 
from 1859 to 1862. It first appeared in this country in California, 
in 1857, and has since made its appearance in innumerable places 
throughout the country, prevailing in different localities more or less 
epidemically, and in a greater or less severe form, up to the present 
time. Whether or not the poison was an importation into this coun- 
try, it has become indigenous, and has desolated many households 
throughout the land. It has prevailed at all seasons, and affects both 
children and adults, but is more common among young children, 
especially between the ages of three and six years, and is more fatal 
with them than with older persons. From observations carefully 
made, it is found to occur more frequently, and prevail more exten- 
sively, in localities and dwellings where filth prevails and the general 
sanitary conditions are bad ; but the contagion is sometimes effective 
in localities considered healthy, and in what are regarded as sanitary 
households. 
The contagion is not only carried directly from the sick to the 
well in the air, but may be communicated through fomites, where it 
may lie dormant and preserve its vitality for considerable periods 
before finding favorable conditions for its development and effects. 
Its inoculability is generally conceded, Oertel and others stating that 
they have often produced the disease in rabbits by introducing diph- 
theritic matter into the trachea ; but the reports of others, of experi- 
ments upon the lower animals, have not been so conclusive. It is said 
that Trousseau and others have inoculated themselves without effect ; 
but a few, or even many such failures, by no means prove that with 
others the poison may not take effect. Many persons are incapable of 
being affected by various diseases unquestionably contagious and inoc- 
ulable. However much exposed, many fail to take typhus fever and 
scarlatina as well as diphtheria. 
The disease is most likely to be communicated in its active stage; 
but patients, after convalescence, are believed to be capable of com- 
municating it for two or three weeks. VARIETIES—CLINICAL PHENOMENA. 
311 
The period of incubation varies, it is thought, from a few hours to 
seven or eight days. 
The invasion varies in its abruptness and the intensity of the ear- 
lier symptoms, even when the ultimate result is the same. In very 
many cases there is at first but a moderate febrile excitement, with 
debility and languor, and but a slight feeling of uneasiness in the 
throat. .This is often so slight that the patient makes no complaint 
of any local symptoms, and admits only a sense of languor and depres- 
sion. If an adult, he may continue his ordinary pursuits; and if a 
child, may simply mope. There will be pallor and a dull expression ; 
and, when examined, the throat will be found to present some points 
of moderate redness, which will gradually extend, and at length run- 
ning together, will present a more continuous and deeper red appear- 
ance. Now certainly, and often nearly as*soon as the redness begins, 
a whitish exudate will be seen, at first in patches and filmy ; but soon 
spreading and becoming thicker, the characteristic skinny or parch- 
ment appearance is presented, often resembling dirty wash-leather. 
It may be confined to the fauces, or it may spread over the whole 
mouth into the nares, and too frequently into the larynx and tra- 
chea, and sometimes into the bronchi, even to their minutest ramifi- 
cations. 
While this is going on the general and local sufferings increase in 
severity and gravity, evidences of blood poisoning present themselves, 
and a fatal depression may come on ; but more frequently the imme- 
diate cause of death is suffocation, produced by the swelling of the 
mucous membrane of the air-passages, and especially by their obstruc- 
tion from the false membrane. 
A more complete account of this important disease is required, and 
will be afforded, by a description of the leading varieties met with. 
These, as observed in different epidemics, and in different cases in the 
same general prevalence, are as follows : 
1. Mild diphtheria. 
2. Inflammatory. 
3. Insidious. 
4. Nasal. 
5. Primarily laryngeal. 
6. Secondarily laryngeal. 
7. Asthenic, adynamic, or malignant. 
1. Generally, when the disease is prevailing, a certain number of 
cases of the first variety will occur. The patient, with but little fever 
at any time, with scarcely any complaint of the throat, and only a 
slight feeling of indisposition, may have no occasion to take to his bed, 
or even to desist from his ordinary occupation. He has, however, 312 
DIPHTHERIA. 
some redness and a slight swelling of the mucous membrane of the 
throat, particularly of that part covering the tonsils, and often some 
swelling of the bodies of those glands. With this there may or may 
not be some patches of membrane, and when present they are com- 
monly thin and filmy, though occasionally thicker; but whether 
thinner or thicker, they are in small patches, are on the tonsils and 
pillars of the fauces, and disappear in a few days spontaneously, and 
may be hastened in their disappearance by proper treatment. These 
milder cases swell the percentage of recoveries, and often inspire great 
confidence in remedies which in severer cases are quite ineffectual. 
2. The second, or inflammatory variety, is much more violent in 
its phenomena and serious in its consequences. The onset is more 
abrupt, there is pain in the head and other parts of the body, often 
rigors and a higher grade of fever; but the more distinguishing 
feature of this variety is more deep and decided inflammation of the 
throat and glands of the neck, with more development of the usual 
symptoms of heat, redness, pain, and swelling than in other forms. 
The swelling about the throat and neck, involving not only the 
glands but the general tissue, is sometimes great, seriously interfering 
with deglutition and respiration ; and inflammation and swelling in 
some cases occur in the sockets of the eyes and in other parts. The 
false membrane here forms upon the mucous surface of the throat as 
in other cases; but the inflammatory swelling is much greater than 
in the ordinary or less inflammatory forms of the disease, constituting 
this a distinct variety, or presenting what may be called a complica- 
tion. 
3. The insidious variety is not uncommon. The symptoms at 
first are but little pronounced; there is no complaint made of the 
throat, the temperature is but slightly elevated, the patient is rather 
dull, and perhaps mopes, the appetite may be impaired but not lost, 
and the patient may not take to his bed or be confined to the house 
for two or three days ; but at length symptoms of more severity occur, 
particularly prostration of strength ; the membrane may or may not 
be excessive, but the most profound symptoms and a fatal result may 
follow in a few days. In some cases where the symptoms are in the 
earlier stage more severe, marked abatement of them takes place; but 
the hopes excited are not realized, severe symptoms before long 
returning, and a fatal issue following. 
4. In this variety the membrane sometimes forms primarily, or 
very early, in the nares, but more frequently it extends from the fauces 
to the Schneiderian membrane ; and when occurring there, the ab- 
sorption of poisonous matters by that delicate and vascular surface is 
likely to be so great that the danger to the patient is much increased ; CLINICAL PHENOMENA. 
313 
and this is therefore regarded as a well-marked variety of the disease. 
Blood poisoning, adynamia, and depression in a fatal form are apt to 
follow. 
5. The primary laryngeal variety is not common, and may be 
confounded with non-specific croup. When it does occur, the croupy 
cough, cooing respiration, and great dyspnoea will early appear, and 
in children especially, suffocation may soon result. 
6. The secondary laryngeal and tracheal variety, or that form 
where the specific inflammation and formation of the membrane 
begins above, and extends into the larynx, trachea, and occasionally 
into the bronchi, is much more common. In a majority of fatal cases 
this is the form of the disease ; and though blood poisoning and great 
depression commonly exist, and might of themselves prove fatal, yet 
suffocation is the direct cause of death. These are the cases which so 
often embarrass the physician, and which raise the question of tra- 
cheotomy or other mechanical interference. 
7. Malignant cases, or those where from blood poisoning ex- 
treme depression and speedy death occur, sometimes without much 
development of local symptoms, are much more frequent in some 
localities and epidemics than in others ; but they are not uncommon 
where the disease extensively prevails. The cases hearing this 
name are, however, not well defined, as the term is also applied to 
nasal and other varieties, where great depression and speedy death 
result. 
From this sketch of the different forms which the disease 
assumes, it will be observed that special phenomena present many 
varieties, and indeed there are peculiarities of individual cases which 
no distinctive classification will designate. Sometimes, in severe 
cases, the membrane will be comparatively slight and filmy, 
while in others the fauces and mouth will appear as if covered 
over with a thick paste, or a coating of plaster of Paris, more or less 
dingy. 
The exudate is generally superimposed upon the inflamed mucous 
membrane, rather than sunken into depressions of its surface ; but 
occasionally superficial ulcerations occur, and when the exudate 
is removed slight ragged depressions will be seen. Very rarely 
more extensive destruction of tissue occurs, and sphacelation is 
possible ; but the offensive odor so common, especially toward the 
latter stages of the disease, arises from the decomposition of the ex- 
udate, and not from sloughing of any of the proper tissues. When 
undergoing this decomposing process the diphtheritic membrane 
generally becomes darker in color, and more or less pultaceous or 
diffluent. 314 
DIPHTHERIA. 
In the inflammatory variety suppuration sometimes, though rarely, 
occurs in the tissues of the neck, and also rarely in the swollen tonsils. 
When suppurative inflammation occurs upon the surface of the mucous 
membrane, it tends to the separation of the exudate, and the pre- 
vention of the absorption of poisonous matter from it, and therefore 
this process should be encouraged. 
The temperature in diphtheria varies so much that no special 
degree can be regarded as characteristic. It may be very little above 
the normal in severe and fatal cases, and yet in some cases, especially 
where the larynx and trachea are the seat of the disease, the tempera- 
ture may rise to 106° or 107° F., and even more. 
The urine is febrile, and in one half or more of the cases is albu- 
minous, and presents hyaline casts; and occasionally it is bloody. 
These conditions are usually of short continuance, and are seldom 
followed by dropsy or uraemia, or by permanent lesions of the kid- 
neys. The mind in diphtheria is generally clear, excepting in the last 
stage of fatal cases. 
The duration of the disease varies very much, both in the favor- 
able and unfavorable cases. Death may take place within twenty- 
four hours, or may be delayed for two weeks—very rarely longer. In 
cases of recovery the membrane may form again and again, and the 
patient may be a long time in regaining his usual condition. In 
other cases the recovery is early and complete. 
The mode of death is by asthenia or apnoea, or by a combination 
of both, but seldom from the brain by coma. 
Prognosis.—The prognosis should be guarded. Mild cases may 
become severe, and, after apparent improvement, severe symptoms 
may return and the case become fatal. 
The characteristic sequel, occurring, however, only in a small pro- 
portion of cases, is paralysis, affecting more particularly the soft 
palate and other muscles about the throat, interfering with speech and 
deglutition, and often affecting also other parts—more frequently the 
lower extremities. The paralysis is seldom complete of any of the 
parts affected, but involves both the sensitive and motor functions. 
The paralysis sometimes commences in the palate and fauces soon 
after the separation of the false membrane; but much more frequently 
it comes on after convalescence seems established—a week or a month 
after the ordinary symptoms have disappeared. The first indication 
of the approach may be a nasal sound of the voice, and inability to 
sound some of the vowels. In attempting to swallow, a portion of 
the food may pass into the posterior nares. On examination the soft 
palate will be found flabby, and devoid of its ordinary sensibility. 
This condition may extend not only to other muscles of the throat DIAGNOSIS. 
315 
and to the lower extremities, but to the upper extremities, and, in 
rare cases, to the muscles of the trunk and the diaphragm; to the 
larynx, lungs, and heart; to the organs of special sense, and, in fact, 
to any part of the body, but observing no particular order, and per- 
haps never involving all parts at the same time. Sometimes in place 
of the paralysis, or mingling with it, will be hypenesthesia and neu- 
ralgic pains. 
This paralysis, however alarming to the patient, is very seldom 
fatal, and usually disappears in the course of a few weeks. The 
affected muscles retain their electric contractility, their bulk, and 
their proper texture. They are, therefore, in a condition to resume 
their functions when the deficiency of innervation is removed. 
Although the prognosis in this paralysis is generally so favorable, 
when the nerves from the medulla oblongata and the fourth ventricle 
are involved, respiration and the heart’s action may be fatally inter- 
fered with. 
Strangulation has been produced by food getting into the air-pas- 
sages, and, in a few instances, coma and convulsions have supervened 
and proved fatal; but all these accidents are rare. Occasionally, 
though rarely, during the paralysis, albumen is found in the urine; 
but the kidneys are very seldom permanently impaired. 
Diagnosis.—Diphtheria is liable to be confounded with scarla- 
tina, croup, tonsilitis, and erysipelas of the throat. It differs from 
all these affections, and a comparison will show the following distinc- 
tions : 
Diphtheria. 
Scarlatina. 
In children most. 
Often vomiting at first. 
External heat moderate. 
Little or no eruption. 
Throat moderately swollen. 
Exudate free. 
Tongue white coat. 
Hemorrhage sometimes. 
Recovery slow. 
Sloughing seldom. 
Attacks those who have had scarlet 
fever. 
Death often by laryngeal obstruc- 
tions. 
Sequel paralysis. 
In children most. 
Often vomiting at first. 
Great. 
Scarlet eruption. 
More swollen, red, and painful. 
Slight. 
Coat loose, tongue red, strawberry 
appearance. 
Seldom. 
More rapid. 
More frequent. 
Does not. 
Seldom. 
Dropsy. 316 
DIPHTHERIA. 
Diphtheria. 
Croup. 
Epidemic. 
Contagious. 
Chief seat above the glottis. 
Exudate extending to larynx. 
Croupy symptoms later. 
Asthenic. 
Danger from suffocation and sys- 
temic poisoning. 
Sporadic. 
Not. 
Below. 
Beginning there. 
Earlier—first. 
More sthenic. 
From suffocation chiefly. 
Diphtheria. 
Tonsilitis. 
Fever asthenic. 
Swelling at first slight. 
Pain slight. 
Difficulty of swallowing not usu- 
ally great. 
Suppuration seldom. 
Membrane marked. 
Sthenic. 
More. 
More severe. 
More. 
Frequent. 
Slight. 
Diphtheria. 
Erysipelas of Throat. 
More confined to throat. 
Exudate marked. 
No erysipelas of skin. 
More diffused—redder. 
Not. 
Skin usually involved. 
The prevailing diseases will aid in determining the nature of less 
distinctly marked cases. 
I am aware that many of high authority in the profession make 
no distinction between diphtheria and croup ; but that an inflamma- 
tion occurs in the larynx and trachea, resulting in the formation of a 
false membrane, which is not the specific diphtheritic membrane, and 
is not accompanied by the other diphtheritic conditions, I have no 
doubt; and I cannot question that a distinction should be made. 
Yet I must confess that for a number of years past I have not seen 
such cases as I saw twenty-five, thirty, and more years ago, entirely 
free from diphtheritic phenomena. 
The Pathological changes of structure necessary to diphtheria are 
limited to the inflamed parts which have been described. In most 
cases the affected parts are more or less congested, swollen, and infil- 
trated with inflammatory exudates. Generally these changes are 
comparatively superficial, but occasionally they are more deeply PATHOLOGY. 
317 
seated, and then suppuration in different points may occur and 
abscesses may form. The diphtheritic inflammation, however, does 
not tend to phlegmonous suppuration, and such results are compara- 
tively rare. The hypersemia and other changes of the mucous surface 
are accompanied with a thin mucous exudate at first, soon forming 
into an opaque layer, which increases by additional exudation upon 
its under surface and margins, and this material is attached to the 
mucous surface partly by its tenacity and partly by prolongations 
dipping into the follicles. At first this false membrane consists 
chiefly of the proliferated and changed epithelial cells, which are apt, 
from the shrinking of their protoplasm, to become stellate and cloudy 
in appearance. This in some cases, particularly in the pharynx, is 
the permanent condition of the exudate. In other instances, espe- 
cially in the air-passages, a fibrinous exudation takes place ; mingling 
with it, however, will be found leucocytes and corpuscular bodies, 
epithelium, blood, and pus; but soon these corpuscular elements dis- 
appear, some, probably, by elongating into fibres, others by destruc- 
tive transformations, and a fibrinous network of more firm consistence 
constitutes the ordinary false membrane of diphtheritic croup. 
In this, as in other forms of the membrane where blood and pus 
corpuscles are more abundant, bacteria are at least generally pres- 
ent, and also, as already stated, they have often been found in the 
tissues beneath. When suppuration occurs at the surface of the in- 
flamed mucous membrane, the false membrane becomes more readily 
detached. 
When the air-passages are seriously obstructed the lungs are apt 
to be collapsed in parts, especially where the exudate extends into the 
bronchial ramifications, and lobular pneumonia not unfrequently 
takes place. 
The kidneys are sometimes found enlarged and somewhat pale, 
and, under the microscope, fatty deposits may be found in the renal 
cells, and hyaline casts are seen in some of the tubules. 
In “malignant” cases, hemorrhagic infiltrations are found in 
various organs and under mucous and serous membranes; and as in 
other severe forms of fever, the muscular tissue of the heart some- 
times presents granular or fatty changes. 
The blood is, doubtless, seriously changed in its properties, though 
its physical changes are not always distinctly marked post mortem. 
The specific character of diphtheria, its dependence upon a poison, 
cannot be doubted ; but the positive character of that poison has not 
been demonstrated, and its mode of action in producing such serious 
results is unknown. The theory that the bacteria have to do in the 
causation is certainly plausible, and probably true ; but it lacks posi- 318 
DIPHTHERIA. 
tive proof. It is, however, declared that these bacterial parasites 
invade the brain, cord, and nerves, causing rupture of small vessels 
and slight hemorrhagic effusions, and this and the changes consequent 
upon it may account for the paralysis and some other symptoms 
observed. 
The particular cause of the paralysis, however, coming on after 
the other symptoms disappear—whether from the original poison still 
lingering in the system, or from some new element produced during 
the progress of the disease, or from some change effected in the tissues 
by the process of the fever, or from the action of the parasites—is not 
positively known. The lesion, however produced, or whatever its 
exact nature may be, seems located in the nerve-centres and nerves 
which control muscular motion and sensibility, rather than in those 
affecting nutrition or intellection. 
Diphtheria, though usually appearing as a distinct and independ- 
ent disease, attacking persons in previous health, is sometimes asso- 
ciated with other affections. It may occur during the course of 
measles, small-pox, typhus, typhoid, and puerperal fevers. It has 
analogies to scarlatina, and it seems probable that the materies morbi 
of the above infectious diseases favors the development and activity of 
the diphtheritic poison. At any rate, the presence of these affections 
does not prevent the action of the cause of diphtheria, and we have in 
this an illustration of the fact that two specific poisons may operate 
upon the system at the same time. 
The preventive treatment here, as in all other infectious, con- 
tagious, or zymotic diseases, requires particular attention ; and the 
same principles apply, and the same general measures are required as 
in the other diseases of this class which have been discussed. Cleanli- 
ness, ventilation, and the observance of all hygienic regulations as 
to the prevention of outbreaks ; and isolation, disinfection, cleanliness, 
and ventilation to prevent its spread are imperatively demanded. 
The curative treatment is general or local ; antidotal or sympto- 
matic ; of the primary disease, or of the sequelae. 
There is no general specific antidote—no known medicine which, 
when administered, is certain to neutralize the poison and arrest the 
disease—and yet there are some grounds for the belief that certain 
articles diminish the activity of the poison and abate its effects, if they 
do not entirely destroy it, or fully prevent its action. 
TREATMENT. TREATMENT. 
319 
The remedies most used with a view to antidotal effects are local 
applications to the seat of the specific inflammation and exudate. 
On the supposition that the bacteria are concerned in the causa- 
tion of the disease, and that they abound most in the exudate and 
the immediate parts producing it, spreading from these points as from 
a focus, penetrating the tissues, passing into the blood, and poison- 
ing the whole system; or that some poisonous material is produced 
locally which by absorption causes general septic effects, the object 
of local treatment is to destroy these parasites, or the septic mate- 
rial, Avhatever it may be, which is present; to abate the inflamma- 
tion, and to prevent absorption and the poisoning of the blood and 
tissues. 
This theory of the nature of the disease and its causation seems to 
me to be based upon evidence sufficient not only to justify, but to 
demand efforts for accomplishing these objects, and in my judgment 
such local, antidotal treatment is of much importance. 
The local inflammation is peculiar and specific, and needs to be 
not merely abated, but, if possible, arrested by removing its cause ; 
and as it is quite different, it should be distinguished from the process 
of repair which follows this and other lesions. Though there is an 
indication for arresting the specific inflammatory action, yet it should 
be borne in mind that the false membrane is most easily separated 
from the mucous surface by the process of suppuration, and that the 
pus discharged tends to prevent septic absorption. It may, there- 
fore, be an object to promote this process while the local disease con- 
tinues. 
Various local remedies have been recommended for accomplishing 
the different objects deemed desirable. 
Bretonneau, to whom the profession is indebted for the first sys- 
tematic account of modern diphtheria, recommended caustics—partic- 
ularly the strong mineral acids mingled with honey—for the purpose 
of destroying the false membrane and changing the action of the sur- 
face beneath ; and the caustic treatment, more frequently substituting 
nit. of silver for the nitric acid advised by Bretonneau, has been 
extensively followed. At the present time, however, it is in much 
less favor than formerly, and is to a large extent abandoned. The 
fungi are too deep and too much diffused to be effectually reached 
by these applications, and they have often been found to increase the 
local suffering without compensating benefits. The dissolving of the 
false membrane chemically might of itself be desirable, but this can- 
not be done without producing an irritating effect upon the living 
tissues. 
Astringents are less objectionable, and may be used ; but their effi- 320 
DIPHTHERIA. 
cacy is not great, and. they are not to be depended upon as important 
remedies. 
In high inflammatory conditions, with much local heat and swell- 
ing, ice may be applied externally to the neck, and bits may be re- 
peatedly taken into the mouth, and allowed to dissolve in the throat 
with decided advantage—abating the inflammation, and particularly 
relieving the pain of swallowing. This is palliative, diminishing the 
effects, rather than antidotal, operating upon the cause ; and yet the 
cold may diminish the activity of the morbid germs. It is often the 
case that palliative, and more radically curative results are produced 
by the same agents ; and when such actions are combined, the remedy 
is doubly indicated. In the more persistent and less actively inflam- 
matory glandular swellings, oily embrocations, or in still more sub- 
acute or chronic cases, iodine liniment may be useful. 
Covering the membranous patches with a pellicle of the ethereal 
tinct. of tolu, so as to exclude oxygen, has been recommended, and 
has been thought to prevent spreading. This may be useful, and 
would probably be innocent if it did not interfere with other and 
more efficient means. 
Steaming the throat early in the attack promotes secretion, which 
tends to wash away the parasites, and certainly to soothe the irrita- 
tion and abate inflammation : and later in the disease, when the mem- 
brane is adherent, it tends to promote suppuration, and thus pro- 
motes its removal and the prevention of septic absorption. Whatever 
else is done, steaming, frequent and repeated, from the relief of pres- 
ent suffering which it so generally affords, and from the hope, of more 
radical benefit which it offers, should be thoroughly practiced. 
Simple water may be used, or it may be variously medicated to 
meet different indications ; and the methods of its application are vari- 
ous. Heating and atomizing instruments are convenient and efficient, 
but are not always at hand ; and a vessel of hot water with a funnel, 
a coffee-pot with its spout, or a pitcher with a funnel of paper over 
it, may readily be extemporized, and where the patient is old enough 
to co-operate with the nurse in its use, these simple arrangements will 
answer the purpose. The steam is best used at a temperature of from 
113° to 122° F. 
Cohen advises that the room be kept at a temperature of about 
75°, and that the air of the apartment be constantly filled with steam 
by keeping hot water exposed, or by some other means. Some advise 
a tent, under which the patient may be kept, where the steam may be 
more thoroughly applied without having the air of the whole room so 
thoroughly saturated. The continued breathing of the water-laden 
air tends to prevent the exudate from drying down and forming a TREATMENT. 
321 
firm membrane, and promotes its expulsion. It will not, however, 
supersede the necessity of the more active steaming. 
To further prevent septic changes and poisonous absorption, some 
of the various antiseptic applications should be made use of. These 
may be applied upon a swab or brush, by means of gargles, by insuf- 
flation, or by atomizers and inhalations. With a patient of sufficient 
age and intelligence to manage them, gargles are perhaps safest, and, 
on the whole, best. 
Numerous antiseptic applications have been advised and made use 
of. Chlorine, carbolic acid, permanganate of potash, sulphurous 
acid, the hyposulphites, salicylic acid, iodine, bromine, and chloral 
hydrate, are those most to be relied upon. The following are among 
the best forms of prescriptions for these purposes : 
Dilute Chlorine Water fiij 
Alcohol 3j 
M. For a gargle. 
$ Carbolic Acid grs. ij or more 
Water 
M. For a gargle. 
Permanganate of Potash grs. iij 
Water §j 
M. 
This may be used once or twice an hour, and when the patient 
is unable to gargle, a quantity of the fluid may be injected into the 
throat with a syringe. Almost any child, if encouraged, will eject it. 
$ Hyposulphite of Soda or Magnesia..... 3j-3i j 
Water §j 
M. 
Use in same way. 
A solution of sulphurous acid, as strong as can be well borne, 
cautiously used, is one of the most efficient parasiticides and anti- 
septics. 
$ Salicylic Acid 3j 
Alcohol .... 3ss 
Water 5viij 
M. 
Use freely as a gargle. 322 
DIPHTHERIA. 
Salicylic Acid 3j 
Alcohol gfjts. x 
Water Ij 
M. 
Apply with a swab or soft brush. 
Or, the throat may he touched with a moist camel’s-hair brush 
dipped in the pure acid; or, a mixture of salicylic acid and gly- 
cerine, of the consistence of a paste, may be applied after washing out 
the throat. Half an ounce of glycerine will dissolve half a drachm of 
salicylic acid, if heated. Some of the acid will be deposited on cooling, 
but it will redissolve on heating. It may be used with warm water. 
Five grains of the salicylic acid to a drachm of glycerine can be given 
alone or with a little cream, and will act locally on the throat as a 
germicide, and upon the system generally as an antipyretic. 
1$ Tinct. of Iodine 3ss 
Water §iv 
M. 
Cautiously use as a gargle. 
Various mixtures, of different ingredients, are advised by different 
practitioners. As specimens: 
3 Liquor of Permanganate of Potash 
Chlorate of Potash 3jss 
Water Sviij 
M. 
For a gargle. 
As another disinfectant, the flowers of sulphur, applied by insuf- 
flation or blowing through a tube or quill into the throat, is strongly 
recommended by some ; and M. Jaccoud reports nineteen consecutive 
cases successfully treated in this way. The sulphur is also recom- 
mended to be given internally. 
When the nostrils are the seat of the exudate, there is more danger 
of absorption than from other parts; and steaming is less effectual, 
as it cannot so well be applied to the nasal membrane. Here the dis- 
infecting fluids should be used with a syringe frequently and thor- 
oughly, every hour or twTo, and so as to secure as complete a discharge 
from the nostrils as possible. The following is recommended as an 
injection for this purpose : $ Carbolic Acid, gtts. xxjv ; Glycerine, TREATMENT. 
323 
5ij; Water, 5vj. M. The steaming, notwithstanding these appli- 
cations, must be kept up as thoroiighly as may be, without disturb- 
ing too much the patient’s rest. 
I am aware that various caustic and astringent articles have much 
authority in their favor, and, used at an early period, before the 
poisonous germs have penetrated deeply, they may destroy them and 
arrest the process of the disease. But in order that such a result 
shall follow, they must be used not only early, but so as to reach 
every part of the diseased surface, and must act with sufficient power 
to destroy the organisms against which they are directed. This, in a 
majority of cases, especially in struggling and resisting children, is 
impossible; and the caustics have so often failed in their object, 
while inflicting mischief by their violent effects upon the tissues, 
that, as a rule, the more active ones should be dispensed with. 
Astringents, as already stated, are less dangerous, but also less effi- 
cient ; and while they may do some good, and should not therefore 
be condemned, they are less efficient than those more particularly 
antiseptic remedies which have been mentioned. 
The following mixture, recommended by Dr. J. Lewis Smith, to 
be applied to the fauces by a camel’s-hair brush, is thought to have a 
decided effect not only in converting the false membrane into an 
inert mass, but in putting a stop to the movements of the swarming 
bacteria. 
B Carbolic Acid, gtts. viij; Liquid Sulphate of Iron, 3ij or iij; 
Glycerine, 3j. M. Use two or three times a day, between spraying, 
where that process is thought advisable. 
Perhaps no article as an astringent and probable antiseptic has 
been more extensively used than the muriated tinct. of iron, applied 
to the part in full strength or diluted; and it is almost an equal 
favorite for internal use. That it is often useful botli as a local and 
general remedy, general experience will not allow us to deny ; but 
whether it is the best remedy for either purpose there are differences 
of opinion. While its usefulness is acknowledged its superiority is 
questioned. 
For checking the odor produced by the decomposition of the false 
membrane, the insufflation of a powder composed of one part of 
salicylic acid and seven of bismuth is said to be efficient. 
Lime-water has considerable power in acting chemically upon the 
false membrane, rendering it more diffluent and more easily detached, 
and is strongly recommended as a local application in different stages 
of the disease. 
Jaccoud strongly recommends “ Nolle’s Mixture.” It is com- 
posed as follows : 324 
DIPHTHERIA. 
R Lime-Water from 120 to 300 parts. 
Solution of Perchloride of Iron.. .2 to 8 “ 
Phenic Acid from 0.G to 1 part. 
Honev of Roses 30 parts. 
M. 
According to its liquidity it may be used as a gargle or with a 
swab. Diluted with six or eight times its weight of water, he recom- 
mends its use internally in spoonful doses once in two to four hours. 
As already intimated, the various disinfectants and astringents 
may be used by inhalation, or may be applied to the throat by an 
atomizer. The strength of solutions for this purpose must be varied 
in different cases, but will not differ materially from that of the 
gargles, prescriptions for which have already been given. 
As other specimens of prescriptions for inhalation by atomization— 
R Salicylic Acid, 3ss ; Glycerine, 3ij ; Lime-Water, 5viij. M. 
R Carbolic Acid, gtts. xxxij ; Glycerine, ; Lime-Water, 
Ivj. M. 
R Carbolic Acid, gtts. xxxij ; Chlorate of Potash, 3ffj • Glycer- 
ine, 5iij ; Water, 3v. M. (Prof. J. L. Smith.) 
Dr. C. E. Billington, of New York, who claims to have had a very 
large and successful experience in this disease, strongly advises the 
following course of treatment, chiefly directed to the local con- 
dition : 
R Chlorate of Potash, 3ij ; Glycerine, fss; Lime-Water, Sijss. 
M. Tea-spoonful for a child every half hour. Or, R Tinct. Chlo- 
ride of Iron, 3j ; Glycerine and Water, of each 3j. Dose the same. 
This last is not always applicable. 
Spray the throat very often by the hand atomizer, with R Car- 
bolic Acid, th,x ; Lime-Water, 5iv. M. In bad cases wash the 
affected part often by a syringe, with a weak tepid solution of com- 
mon salt. He condemns alcohol as overwhelming rather than sus- 
taining, and urges great care and exact compliance with directions in 
the use of the above means, and to carefully avoid irritation. 
The careful, systematic, and unremitting use of these local means, 
sometimes removing very gently such accumulations as may be pos- 
sible without irritating the living parts, so as to bring the antiseptics 
more thoroughly in contact with the tissues, will do much toward 
mitigating the severity of the disease and diminishing its danger. 
The exudate 'appearing in the larynx and trachea, especially in 
children, is particularly dangerous from its so frequently producing 
suffocation. It is difficult, often impossible, to restrict the extension 
of the membrane downward by any local means, and antiseptic and TREATMENT. 
325 
especially caustic measures cannot be effectually and safely applied to 
the internal surface of a child’s larynx. 
When suffocation is threatened, there is an indication for removing 
the membrane. There are three ways for attempting this, viz., me- 
chanically, chemically, and by tracheotomy. With an angular, blunt 
brush, aided by the laryngoscope, the membrane may sometimes be 
caught by it near the glottis, and with a rapid rotary motion portions 
may be removed. The procedure is a difficult one, and a failure to 
accomplish much in this manner, in the case of children especially, 
would be the rule. A trial, however, would be justified where suffo- 
cation was imminent, other means having failed, and when the last 
resort, tracheotomy, is dreaded. The other mechanical method is by 
inducing vomiting, in which act a loosened membrane is sometimes 
expelled. This effect will be aided by the nausea which precedes the 
emesis and induces a free and more liquid secretion from the throat, 
and by the process of steaming, which will at least moisten the parts, 
and has, moreover, a tendency to induce suppuration, the most effect- 
ual means for separating the false membrane. 
The inhalation of the spray of organic acids and of the alkalies 
has some chemical effect in softening the falke membrane. The 
lactic acid, of the strength of from five to ten per cent., is recom- 
mended to be used in spray by the atomizer. Lime-water is thought 
to be still more efficient inhaled in the same way. In the absence of 
an atomizer, hot water may be poured upon unslacked lime in a 
pitcher, and the fumes, as they arise, may be directed to the part by a 
newspaper or a towel in the form of an inverted funnel. 
A spray solution of six ounces of lime-water with fifteen minims of 
carbolic acid, to be used with an atomizer, is recommended for the 
same purpose. 
A solution of carbonate of potash or carb. of soda of the strength 
of 3j to 3j of water may have some solvent effect. None of these 
means, however, are reliable. These preparations cannot be applied 
with sufficient freedom and constancy to secure very marked results. 
The last resort is to tracheotomy, when suffocation is speedily 
threatened. The conditions for the success of this operation, it can 
readily be understood, are most unfavorable. Few would feel justified 
in resorting to so severe a procedure until so much obstruction to res- 
piration had occurred as to show suffocation to be inevitable without 
it. By this time the disease has advanced, and the system has already 
suffered shock. Diphtheria is a general as well as a local disease, and 
the suffocation is not the only condition threatening life. The exudate 
may continue to form, and to extend down the bronchi. The opera- 
tion itself is an additional shock. Experience has proved that, in a 326 
DIPHTHERIA. 
large proportion of cases, death follows, though relief to the obstructed 
breathing is obtained. Yet the operation is sometimes successful. 
Indeed many lives have been saved by it, and the procedure is not 
only justified but demanded where the disease is chiefly in the 
larynx and trachea, and other means have failed to arrest the 
formation of the membrane, or effect its expulsion, and where the 
respiration is becoming more and more obstructed without reasonable 
hope of avoiding suffocation. Though its performance unnecessarily 
would be an error, the operation may be delayed too long. Some rec- 
ommend that it should be resorted to whenever there is recession of 
the chest walls indicating obstruction to inspiration. It seems hardly 
proper to lay down a positive rule to this effect. All the conditions 
must be taken into account, and a sound judgment is demanded here, 
as in so many cases in the practice of the profession. As the opera- 
tion is a surgical one, its details will not be here described. It is 
proper however to say that in its performance the surgeon’s work has 
commenced, not ended. The tube must be watched and changed, and 
cleared as may be required. Medicated inhalations may take place 
through it. Some recommend dispensing with the tube entirely— 
making an opening* in the trachea, and holding the lips apart by 
hooks, adhesive plasters, and various contrivances. This, experience 
may show to be an improvement, as the tube in the trachea is cer- 
tainly a source of irritation. If this can be avoided, while freedom to 
the breathing is secured, the result must be more favorable. 
The local means which have been described, though occupying an 
important place in the treatment of diphtheria, must not supersede 
general measures. 
Constitutional treatment must not be neglected. It is perhaps too 
much the fashion of the present day to underrate the value of all 
treatment in specific diseases that run a course, and for which we 
know of no positive and certain antidotes. Though such diseases 
may not be completely arrested, they may nevertheless, to some ex- 
tent, be antidoted, their severity diminished, and their course abbre- 
viated. Such certainly is the case in many instances, at least, in 
cholera—perhaps the most formidable of the specific diseases—and 
such I believe is the case in diphtheria. 
From the large number of remedies which have been recommended 
and rejected in turn, the inference might be drawn that none of them 
can be of much value—and it is quite certain that no remedy has 
been discovered nor method devised, which is alwrays, or in a very 
large proportion of severe cases, successful. It is therefore proper to 
speak with becoming caution and reservation of the efficacy of any 
measures : and yet my own observation and experience have given me TREATMENT. 
327 
much confidence in the utility of the course of general treatment that 
I shall advise. 
The first indication here, as in all diseases depending upon specific 
poisons, is to antidote the poison. As already intimated, we know of 
no remedy which is certain to produce this effect. There are various 
articles which when brought in contact with bacteria in sufficient 
concentration destroy their vitality; hut it may be impossible to so 
saturate the system with these articles as to bring them in contact 
with the organisms in sufficient strength to destroy them, without 
injury to the patient ; and yet, on the other hand, it is quite possible 
that such articles may destroy some and diminish the activity or the 
production of others, so as to produce an antidotal effect, though it 
be imperfect. 
The leading articles supposed to have such effects, and to be 
capable of such use are, quinine, salicylic acid, sulpho-carbolate of 
soda, and alcohol. The positive or the comparative value of these 
remedies it is exceedingly difficult to determine. From the different 
degrees of severity of the disease, as it occurs at different times and in 
different localities, and from the great differences in individual cases 
in the same epidemic, reported successes or failures are unreliable 
guides. Many epidemics and cases are malignant, and not amenable 
to treatment by any known means; others are mild and will recover 
without treatment, or even under treatment that is bad. Yet here, 
as in other cases, however much we may be guided by general prin- 
ciples, experience is the test to which all practice must be brought. 
However discouraging this view may be to searchers for the truth, 
and however little consoling and helpful to those who have the 
responsibility of the lives of diphtheritic patients thrown upon them, 
it is the only one that expresses the actual state of the case. 
Each practitioner, after reviewing the literature of the disease, 
after considering what is known of its causes, its phenomena, and its 
nature, and especially after he has had personal observation and 
experience, must determine for himself the particular course to be 
pursued. Experience is the chief guide, and yet reports of local and 
limited experience are unreliable. It now remains to state briefly the 
course of general treatment in which, in my judgment, most confi- 
dence is to be placed. 
As diphtheria is unquestionably a disease attended with marked 
depression and weakness, all unnecessary debilitating measures should 
be carefully avoided. The patient should be placed under the most 
favorable hygienic conditions of pure air, proper temperature, and 
cleanliness, and as much nourishing food as can be digested and 
appropriated should be administered regularly, and not at too long 328 
DIPHTHERIA. 
intervals. Though at the very onset, if the health and appetite have 
been previously good, little food may be required for the first day or 
so, its administration should soon be insisted upon, and continued 
throughout the disease. Milk, farinaceous preparations, and beef-tea 
must be the staples; but rare, tender, and disintegrated meat may be 
added in moderate quantity when the stomach can bear it. 
While antidotal treatment aims at the destruction or elimination 
of the poison, symptomatic treatment has for its object the allaying 
of constitutional disturbance, the remedying of different complica- 
tions and special symptoms, and keeping up the strength so as to 
enable the patient to resist the disease. It is quite possible, that, to 
a greater or less extent, the same means may tend to the accomplish- 
ment of both these leading objects. When a patient is seen early in 
the attack, as a rule, an anodyne, diaphoretic and mild mercurial 
combined, should be given ; for an adult, a Dover’s powder (twelve 
to eighteen grains), and blue mass (four to eight grains). The throat 
should be thoroughly steamed—hops and vinegar are perhaps the 
best. (See the method described for tonsilitis.) The anodyne and 
alterative should be followed in a few hours by a laxative (a saline or 
castor-oil) in a sufficient dose to clear the alimentary canal of all 
accumulations, but not sufficient to exhaust the strength. Then the 
patient should be put upon quinine and chlorate of potash—from 
three to five grains of quinine, and from ten to fifteen grains of the 
chlorate, for an adult, and proportionate doses for a child, repeated 
once in from three to four hours, and steadily persevered with while 
the disease continues, or at least for several days. It might be sus- 
pended and alternated with other treatment, if thought best. Should 
the chlorate of potash evidently irritate the stomach, the quantity 
should be diminished; or it might be given in some bland fluid 
largely diluted. Often it will be best, when the stomach is at all irri- 
table, to give the quinine by itself, or with the addition of a small 
quantity of morphine, giving the chlorate largely diluted as a drink. 
If there be much pain or restlessness, an anodyne—morphine, or 
some form of opium, is most reliable—may be given from time to 
time as required. The bowels should be kept open by the mildest 
means, generally by enemas; and the local means, already described, 
faithfully persevered with. 
If there be much irritation of the stomach the chlorate may be 
omitted, and the irritation should be allayed by effervescing draughts, 
sinapisms over the epigastrium—not retained too long—and possibly 
morphine in more decided doses. If there is diarrhoea, it should be 
restrained by opiates and astringents, and whatever distressing symp- 
toms may arise should be relieved by appropriate means. In my TREATMENT. 
329 
judgment the quinine tends to diminish inflammation, exudation, 
and fever ; to equalize the circulation and allay suffering; and, in 
short, while it abates morbid processes, it sustains vital activities; 
and there seems to me reason to believe, that, at the same time, it 
exerts an antidotal effect upon the essential cause of the disease. 
That it antidotes most effectually the cause of malarial fever is well 
known; that it operates similarly, though to a les’s extent, on the 
cause of diphtheria, I believe. At any rate, the treatment with the 
quinine and chlorate of potash (the latter article improving the 
quality of the blood and acting as a gentle eliminative, and, perhaps, 
antiseptic), is, according to my observation and judgment, the best 
with which I am acquainted. 
The treatment with free doses of salicylic acid has been strongly 
recommended by some, and I am prepared to believe it may be useful 
—operating perhaps antidotally, and modifying febrile and inflam- 
matory symptoms—but I have not seen it tested in practice in this 
disease. 
The tinct. chloride of iron has long been a favorite remedy with 
many, often given in connection with quinine. I think it has some 
virtues; and in protracted and anaemic cases especially, it may be 
added to the quinine with decided advantage. 
The treatment by free and continuous doses of alcohol has very 
strong advocates, and nearly as strong opponents. Dr. E. W. Chap- 
man, of Brooklyn, Y. Y., is the principal champion of the alcoholic 
treatment. He does not employ it as a sustaining remedy, for it is to 
be presumed that his large experience with it has convinced him that 
this effect of the article lias been greatly overrated, but as an antidote 
or an antagonizer of the special morbid condition of the blood; but 
he gives it with quinine, and it may not he easy to say how much of 
his success, which is claimed to be great, is due to the quinine, and 
how much to the alcohol. He gives these articles from an early stage 
of the disease, and the alcohol in as large doses as can be borne with- 
out intoxication. 
I am not prepared to deny to it antidotal virtues, nor to say that 
it has no soothing or sustaining powers in the suffering and depressed 
conditions of diphtheria ; but I have much less confidence in its good 
effects than in those of quinine and chlorate of potash. In great 
depression and sinking it may be resorted to under the same indi- 
cations and regulations as in other diseases of depression and 
exhaustion. 
The sulpho-carbolate of soda has more recently come into use, and 
is spoken of favorably by some. I have not had sufficient opportunity 
of witnessing its effects to express an independent opinion respecting 330 
INFLUENZA. 
it. It is given in doses of from two to six grains, every two hours, to 
a child from one to three years old. 
The benzoate of soda is said to have been extensively used, and 
with success, especially in Russia. 
The bromide of ammonium, in doses of from two to fifteen grains 
every three hours, is advised by Dr. Bartholow, from a belief that 
this salt passes off chiefly by the mucous membrane of the mouth and 
throat, and modifies, in doing so, the local disease. For the preven- 
tion of the systemic affection the same author advises the liqiior 
iodinii compositus, one to five drops every four hours ; or the same, 
with the addition of half a part of carbolic acid, the dose of this com- 
pound being from one fourth of a drop to two drops, in water, every 
four hours. 
Recently jaborandi, or its active principle, pilocarpin, has been 
recommended in diphtheria. I have had no opportunity to witness its 
effects in this disease, but should think it contraindicated in feeble 
patients or in advanced stages of the affection. At its early stage and 
in vigorous subjects I think that the free secretion from the throat 
and the skin which it produces, might mitigate the severity of the 
disease. I venture to say that in such cases it is worthy of further 
trial. 
There are descriptions of many other special methods of treatment 
to be found in the medical journals of the day, each supported by 
reports of success. They nearly all denounce depleting measures, 
and many of them also condemn alcoholic medication. Many such 
accounts are worthy of attention, but too hasty conclusions should 
not be drawn from them. We should not abandon the hope that the 
nature of this, as well as of specific diseases depending on organic 
poisons, parasitic or otherwise, may hereafter be better understood, 
and more effectual antidotes discovered. 
For the paralysis sometimes following diphtheria, tonics are gen- 
erally advised. Elimination, in my judgment, is quite as frequently 
indicated ; and, as a rule, a course of iodide of potassium, or the 
acetate of potash, or a combination of the two, may precede or accom- 
pany the tonics. Where the cure is long delayed, quinine and strych- 
nine, with perhaps electricity, may be required. 
INFLUENZA.—EPIDEMIC CATARRHAL FEVER, 
This is a typical epidemic disorder of the general system, marked 
hy chilliness, fever, general pains, frontal headache, and much depres- 
sion of feeling and strength ; the chief local manifestation being a CAUSATION. 
331 
catarrhal congestion, inflammation, and morbid secretion of the mu- 
cous membrane of the upper air-passages ; but the disease is often 
accompanied with bronchitis, and sometimes with pneumonia, pleu- 
ritis, gastro-intestinal, and other inflammations. 
That the disease is constitutional or general, rather than local, 
and should be placed among the general affections, is shown by the 
fact that there is no constant fixed primary local change, and the gen- 
eral symptoms are out of proportion to the local lesions that may 
occur. Three varieties have been described, viz., Thoracic, Cerebral, 
and Abdominal, according as the local disturbance is greatest in one 
or the other of these cavities—but the thoracic is by far the most fre- 
quent. No distinct history of this affection can be traced beyond the 
fifteenth century ; but since then many extensive epidemics of it have 
occurred, appearing at different times in almost every part of the 
world. 
Its causes are obscure. It has long been believed to depend upon 
some atmospheric and telluric influences wdiose nature is still unde- 
termined. The view so strongly expressed years ago by Graves, that 
it depends upon conditions affecting the surface of the earth, inde- 
pendent of human productions, is declared by Jaccoud to hold to-day. 
But it has recently been declared one of the most contagious diseases, 
and to have been frequently conveyed from place to place, and from 
person to person, by intercommunication. Bristowe affirms that “its 
conveyance has frequently been traced from locality to locality by the 
direct agency of those wdio are suffering from it, and its diffusion in 
fresh localities from these infected emigrants as centres. It is certain, 
therefore, that it is infectious in a high degree, and that it may be 
imported by a contagium, which, like other contagia, is specific, mul- 
tiplies indefinitely in the body into which it has gained access, and is 
thence evolved in marvelous abundance.” He therefore rejects the 
theories of telluric and atmospheric influences, and assumes that its 
strictly contagious character is the true explanation of its epidemic 
diffusion, and that the virus is given off with the breath. All agree 
that it has never been imparted by inoculation ; that one attack does 
not prevent subsequent ones; that its seizures are not determined by 
age or sex ; that season has little or no influence upon it; that though 
it has sometimes seemed to be carried by winds, yet that it has marched 
against the wind ; that temperature has no influence ; that barometric 
and hygrometric states have little effect; and that the influence of 
hygienic conditions is not appreciable. 
While on the one hand it is declared to be carried by persons, as 
seen by the quotation above, on the other, Jaccoud states that its 
spread is not influenced by frequency of relations of persons, or by 332 
INFLUENZA. 
channels of communication—that thinly settled localities, out of the 
course of travel, become affected, while large cities in the route of 
communications escape. Jaccoud also states that “ in our hemisphere 
influenza travels from east to west in winter, and from west to east in 
spring. It has no ascertained period of incubation, a$ persons coming 
into the localities where it prevails often take it at once.” He regards 
these facts as proving the absence of contagion, and agrees with the 
statement of Grisolle, that “ nothing proves its contagiousness.” 
By a purely contagious disease is properly understood one in 
which a poison is generated in the bodies of the sick and communi- 
cated from the sick to the well, producing the same affection, and 
that the poison is produced in no other way. 
Considering the wonderful rapidity of its spread, large regions 
being attacked almost simultaneously, and whole countries being per- 
vaded in a short time by its presence, it would seem incredible that 
so much poison could be produced in so short a time in the bodies of 
the sick; and comparing its spread with that of a typical contagious 
disease, as small-pox, a belief in its exclusive contagiousness seems to 
be excluded. That the poison may be multiplied in the body cannot 
be positively denied, but that this is its only source certainly cannot 
be proved. When a disease is spreading from place to place with such 
rapidity, there are likely to be many instances of persons affected with 
it traveling from the infected locality to one soon to be invaded—but 
such coincidences or incidents do not prove that the disease is conveyed 
by such personal communication. One event following another does 
not necessarily prove a connection between them of cause and effect. 
Many facts, a large degree of constancy of relations, and the exclu- 
sion of other possibilities are required to establish causation in a case 
of this kind ; and it may well be doubted whether the facts will 
justify the conclusion that influenza is contagious. If it is conta- 
gious in any sense, it seems to me more consistent with the facts to 
place it under the head of “Miasmatic Contagious” affections—a 
term applied by Liebermeister and others to diseases the poisons of 
which may be produced and multiplied outside of the body as well 
as within it. 
The simpleiact is, we do not know the origin, the mode of multi- 
plication, or the nature of the influence which produces influenza. 
We are as far from positive knowledge on these points as the Italians 
were when they supposed the disease to be produced by the influence 
of the stars, and consequently gave it its present name. 
However interesting these speculations, we are more concerned 
with the facts. The disease appears from time to time in localities 
and wide-spread regions, independent of conditions that can be under- SYMPTOMATIC PHENOMENA. 
333 
stood and controlled. It varies in its severity and particular char- 
acter in different epidemics and in different individual cases in the 
same epidemic. It often attacks a very large proportion of the 
people of the place where it prevails. 
It seldom continues in the same locality more than five or six 
weeks, and its duration is sometimes much shorter. A similar dis- 
ease, spreading in a similar manner, affects the lower animals—espe- 
cially the horse—and this may or may not coincide with the human 
form of the malady. In the horse it is apt to be more severe—at least 
to prove fatal in a greater proportion of cases—than in men. 
An epidemic of influenza is sometimes followed by one of pneu- 
monia, and it is thought to have some connection with still other 
epidemics; hut as no constant or uniform relations have been observed, 
those that have occasionally occurred have probably been accidental. 
This epizootic in horses is strikingly similar to influenza in the 
human subject, both in its symptoms and mode of spreading, and 
it seems hardly possible that a disease, spreading so widely and with 
such rapidity as the epizootic, could be propagated by intercommuni- 
cation of horses. 
The phenomena and course of influenza require further descrip- 
tion. The disease commences, as already stated, by general febrile 
symptoms, chills, pains, etc., and local symptoms soon supervene 
resembling a severe coryza, or what is called a “bad cold.” There 
is often sneezing; the nose, possibly dry for a short time, soon dis- 
charges, at first, a watery, scalding fluid, which afterward becomes 
more mucous or muco-purulent; the lining of the frontal sinus is 
involved, accompanied frequently with severe frontal headache ; the 
eyes are often injected and watery; the throat is congested and irri- 
tated ; the membrane of the larynx is injected and swollen, and the 
voice hoarse ; a cough is developed, and is often frequent; the bron- 
chial tubes are generally more or less congested and their secretion 
modified, producing sometimes a dry and sometimes a moist cough ; 
and though the bronchial affection may be slight, and the inflamma- 
tion of the upper air-passages not severe, yet the sense of depression 
may be great, and the weakness and general suffering is greater than 
would be produced by a simple coryza of apparently equal local 
severity. The disease reaches its height in ordinary and compara- 
tively mild cases in a few days, and convalescence gradually takes 
place, the decline of the disease sometimes being accompanied with 
a diarrhoea, and often with a sweat. In adult persons removed from 
the extremes of life, in previous good health, it is very seldom danger- 
ous to life ; and, in such cases, never proves fatal unless there be more 
than the ordinary complications. In young children and old per- 334 
INFLUENZA. 
sons, and those debilitated by other diseases or suffering from affec- 
tions of the lungs, it not unfrequently terminates unfavorably; but 
in such cases there is almost always more or less inflammation of the 
capillary bronchi, the lungs, or some other part. 
Capillary bronchitis, in young children and in the aged, is not 
unfrequent, and is an exceedingly serious complication. Pneumonia 
also, whether lobular—which is most common—or lobar, is apt to be 
serious; and pleurisy, though more rare, is attended with danger 
when it occurs. The same may be said of other inflammations, when 
of much severity. These complications are to be distinguished by 
symptoms and signs, which will be described when we come to dis- 
eases of these parts. The symptoms common to all fevers, such as 
coating of the tongue, loss of appetite, increased temperature, febrile 
urine, etc., need not be more particularly described. 
In the Morbid Anatomy of influenza there is little or nothing 
that is distinctive. The inconstant complications present appearances 
such as would be present in primary affections of the same character, 
or such as accompany similar complications in other diseases. 
Hypenemiaof the mucous membrane of the upper air passages, and 
generally of the bronchial tubes also, is, however, present. Exuda- 
tions—mucous, and sometimes bloody—into the bronchial tubes are 
common, and often the membrane is softened. Sometimes a pulmo- 
nary congestion is present, but this should not be confounded with 
pneumonia. The lung is of a dark red or violet color, is more dense 
than normal, but still crepitates on pressure, and floats in water. 
The. parenchyma is somewhat more friable than normal, and there 
is often serous infiltration into it, as in complicated cases of typhoid 
fever and measles. According to Jaccoud, it resembles the condition 
produced by paralysis of the vagus nerve. 
Evidences of gastro-intestinal catarrh, hyperaemia, softening, etc., 
are sometimes found. These are all local manifestations of a general 
affection, and the variety in the lesions does not account for the vari- 
ous forms of the general disease found in different epidemics. 
In a majority of cases, when death occurs, it is caused by true 
pneumonia or capillary bronchitis. In the latter, false membrane 
may be found adhering to the surface of the tubes, or the bronchi 
may be filled with fibrinous concretions not adherent to their walls. 
These latter small cylindrical exudates are viscous, elastic, semi-trans- 
parent, though sometimes gray and opaque, like the pseudo-mem- 
brane. 
The false membranous casts lining the bronchi are often them- 
selves tubes, admitting the passage of air through them ; the fibrin- 
ous deposits, on the other hand, are not hollow tubes, but solid cylin- MORBID ANA TOMY—PROGNOSIS—TREA TMENT. 
335 
ders ; and under the microscope they present the appearance of a 
mixture of inflammatory fibrine and mucus, some amorphous gran- 
ules and pyoid globules in a tenacious liquid. As in other cases of 
capillary bronchitis, portions of lung will be found collapsed, while 
others will be emphysematous. USTot unfrequently the inflammation 
extends to the lung tissue, and the common conditions of lobular or 
lobar pneumonia are present. These need not here be particularly 
described. 
As further complications, the lesions of pleuritis and pericarditis 
are sometimes found. In young subjects and adults fibrinous concre- 
tions are not unfrequently found in the cavity of the heart; but in 
old persons the blood in the heart and vessels is generally fluid and 
dark. 
In some cases the patches of Peyer have been found hyperaemic 
and tumefied, and other portfons of the gastro-intestinal membrane 
are sometimes found in a similar state. Inflammation of the mem- 
brane of the brain has been found in rare cases. 
Influenza is distinguished from common acute catarrh, which in 
many respects it resembles, by the more severe general symptoms and 
greater depression with the same amount of local disease ; but it is 
particularly distinguished by its epidemic occurrence. 
In the beginning of the attack it resembles measles in some re- 
spects ; but the eruption and other distinctive characteristics of the 
latter disease, if it be present, will soon manifest themselves. 
Prognosis.—The prognosis is variable in different epidemics. 
As a rule, it is fatal only in the extremes of life, and the percentage 
of deaths in those attacked is small ; but the numbers affected are 
usually so great that the aggregate mortality in an epidemic becomes 
large. In London, Dublin, and elsewhere, the numbers of deaths 
from some epidemics of influenza have exceeded those from the much 
more frightful epidemic of cholera, because of the great difference in 
the numbers attacked. Though so very few healthy adults succumb 
to it, there are in every community so many young children and old 
or sickly and feeble persons who are attacked, that the great mortality 
is accounted for. 
In those predisposed to pulmonary phthisis, that disease, particu- 
larly in the caseous form, is apt to be developed by a severe attack of 
influenza. 
On the whole, then, it is not only an interesting, but an important 
and even formidable disease. 
Treatment.—Though in mild cases and in vigorous adult per- 
sons the disease is so short and so devoid of danger that little treat- 336 
INFLUENZA. 
ment is required, yet in infants, in the aged and the feeble, the great- 
est care in management is demanded. The different epidemics and 
cases vary so much in character and severity, that the treatment will 
require to be varied to meet the various indications. Still there is a 
general resemblance in all the cases, and some general principles of 
management may be laid down. 
As the great danger occurs in those whose vital powers are low, 
and as the disease is attended with depression, debilitating measures 
should be avoided. Still, cases can be conceived of where, from pul- 
monary complications, the congestion of the lungs or the brain might 
be so great as to demand the abstraction of blood to relieve such 
states on mechanical principles. Revulsive measures, however, would 
be safer, and should be thoroughly used when such congestions exist. 
If the patient be vigorous and plethoric, venesection might be prac- 
ticed as in other diseases where similar pathological conditions are 
present. In ordinary cases confinement to the house, a mild diet, 
simple drinks, and perhaps a solution of chlorate of potash, to which 
might be added some expectorant, as small doses of ipecac., a gentle 
laxative if the bowels be not freely open, will be all that will be re- 
quired. If there is much pain a Dover’s powder or a dose of morphine 
and ipecac., or some similar anodyne, will give relief. If the case be 
more severe in general symptoms, and especially if bronchitis of a se- 
verer grade, or pneumonia, be threatened, in my judgment, after per- 
haps a laxative if judged necessary, quinine should be given in doses of 
from four to eight grains, a full anodyne (morphine, Dover’s powder, 
etc.) being added to the first dose, and possibly to subsequent ones; 
and the quinine should be repeated once in from two or three to four 
or five hours, until half a drachm, more or less, has been given. The 
virtue of this remedy in arresting incipient inflammations under these 
and similar circumstances is, in my opinion, beyond question ; and its 
innocency has been tested too thoroughly to admit of any apprehen- 
sion of permanent injurious effects from its use in this manner. This 
remedy is applicable to children, adults, the aged and feeble alike. 
The opiates must be managed with care, especially in the case of 
young children and where asphyxia is threatened from obstruction to 
the air-passages. In the latter case opium is contra-indicated, cer- 
tainly in free doses, as it diminishes respiratory efforts. 
When there are accumulations in the air-passages, especially in 
children, emetics may be of the greatest service in removing the 
obstructions. An emetic at the onset of the disease is advised by 
some, who claim that it diminishes materially the severity of the 
symptoms. 
When any complicating inflammations are developed, they should PHENOMENA. 
337 
be treated on the same principles as inflammations of the same organs 
in other cases, taking into account the depressing influence of the influ- 
enza poison. As we shall have occasion to study these inflammations 
further on, the details of diagnosis and treatment of these conditions 
need not here be entered upon ; and the reader is referred to the articles 
on these subjects. Fomentations to the chest, moist inhalations, expec- 
torants, sorbefacients, etc., will come into use; but here, as in most 
other cases of pulmonary inflammation, the influence of quinine can- 
not safely be ignored or its administration neglected. In depressed 
conditions stimulants may be required, such as carbonate of ammonia, 
alcohol, etc., under the same rules as in other cases. Occasionally, 
marked typhoidal and adynamic conditions occur. Quinine, in tonic 
doses, after the first stronger impression is made by it, should be 
continued, and every real supporting measure should be resorted to. 
(See the articles on Bronchitis, Pneumonia, Pleuritis, (Edema of 
the Lungs, Coryza, etc.) 
HOOPIN G-COUGH.—PERTUSSIS. 
This is an infectious disease, generally continuing for several 
weeks, and very rarely occurring more than once in the same person. 
It is characterized by slight fever and symptoms resembling a com- 
mon acute catarrh at first, and afterward by a peculiar paroxysmal, 
spasmodic cough, which is likely to linger for weeks, and to return 
after subsiding, from exposure and taking cold. 
This affection is met with both in a sporadic and epidemic form, 
and is likely to occur in all children exposed to those having the dis- 
ease. This proves its contagiousness, and the peculiarity of the phe- 
nomena illustrates its specific character. It is generally more severe 
when it occurs in spring or autumn, and is not unfrequently accompa- 
nied with complications, rendering it severe and dangerous. It is com- 
monly a disease of childhood, probably because before adult life nearly 
all susceptible to it have been exposed, and adults are protected 
by its previous occurrence ; and yet it occasionally attacks grown per- 
sons, and may be with them, as with children, protracted and severe. 
The contagion is more likely to be communicated during the earlier 
stage of feverishness and catarrh, than later in the disease. 
After a latent period of a week, more or less, a moderate febrile 
condition occurs, with symptoms resembling a coryza, some redness of 
the eyes, irritation of the mucous membrane of the air-passages, and a 
bronchial cough. This stage may continue from one to two weeks, 
and sometimes even longer ; but at length the cough becomes more 338 
HOOPING-COUGH. 
paroxysmal, each paroxysm becoming more earnest and protracted, 
and soon the characteristic “ IIoop ” is developed, which renders the 
nature of the case unmistakable. 
The characteristic cough consists of paroxysms of rapid explosive 
expirations until the chest becomes completely emptied of its residual 
air. Proper respiration and pulmonary circulation being suspended, 
the face turns purple and is injected with venous blood, and suffoca- 
tion seems impending, when the explosive efforts cease and a forcible 
inspiration occurs with a loud crowing or hooping sound as the air 
passes through the restricted glottis; and this sound gives the name 
to the disease. After the chest is filled the explosive cough may or 
may not be renewed, and when thus renewed the same phenomena are 
repeated. Commonly at the final termination of the paroxysm a 
quantity of stringy mucus is expectorated, and not unfrequently, at 
the same time vomiting occurs. During the coughing, hemorrhage 
from the nose and others parts sometimes takes place, ecchymosisof the 
conjunctiva is not unfrequent, and occasionally streaks of blood will 
he seen in the phlegm thrown up. In feeble children great prostration, 
and even fainting, may occur at the close of the paroxysm ; but in 
ordinary uncomplicated cases the patients, after a brief period of rest, 
resume their amusements or occupations. 
These paroxysms are repeated at irregular intervals—there may be 
two or three a day, or as many every hour. When no complications 
set in, and the relief from symptoms during the intervals is quite 
complete, the general condition of the patient is not seriously affected, 
however frequent and severe the paroxysms of cough, unless, indeed, 
the paroxysms are so frequent as to seriously interfere with rest, or 
the vomiting so often repeated as to interfere with the digestion of 
food. Generally after vomiting the patient craves food, and should 
be indulged with proper articles that are digestible. 
Exposure to cold and wet is apt to increase the frequency and 
severity of the cough, and may induce inflammatory complications. 
These are not infrequent, and give to hooping-cough its chief dan- 
ger and fatality. It may prove fatal, especially in feeble children, by 
loss of food in frequent vomiting, possibly by repeated hemorrhages, 
occasionally by convulsions, cerebral congestions, hemorrhage or effu- 
sions, or by rupture of lung tissue and interlobular emphysema; but 
much more frequently by bronchial and pulmonary inflammations 
and their consequences. 
Bronchitis of the larger, and sometimes of the capillary tubes, 
broncho-pneumonia, and what is called catarrhal or lobular pneu- 
monia, are the most frequent complications. When the bronchial 
tubes going to a part of a lung are entirely obstructed, the air is apt COMPLICATIONS—PATEOLOG T. 
339 
to be absorbed from the air vesicles, producing collapse. In other 
cases of partial obstruction of tubes, the air passes in With forced 
inspiratory efforts more freely than it passes out, and vesicular 
emphysema results. These conditions may be mingled, some lobules 
being distended and others collapsed—both conditions interfering 
with the respiratory function and increasing the dyspnoea. These 
inflammatory pulmonary complications reveal themselves by diffi- 
culty of breathing, lividity of face, increased frequency of pulse, ele- 
vation of temperature, sibilant, sonorous, crepitant, and subcrepi- 
tant rales, without any necessary dullness on percussion—in short, by 
all the symptoms and signs which mark those inflammations occur- 
ring under other circumstances. When these inflammations are estab- 
lished, the cough often loses its peculiar hooping character, and the 
paroxysms are replaced by a frequent, bronchial, stuffy cough, though 
sometimes the characteristic paroxysms continue to recur. These 
inflammations, if not proving more speedily fatal, are apt to be pro- 
tracted from the irritation kept up by the specific disease, and the 
results are not unfrequently unfavorable. 
Statistics show that hooping-cough, with its complications, is 
among the most prolific causes of infant mortality under one year of 
age, and that more than half that die from it are under two years 
old, and’only a small per cent, (about six) are above the age of five. 
The Lesions observed after death are those of its complications, 
viz.: congestion of the mucous membrane of the larynx, and air-pas- 
sages generally, "with secretions into the bronchi, collapse of lung 
tissue in patches, lobular pneumonia, and vesicular emphysema ; and 
in children, interlobular emphysema. Congestion of the medulla 
oblongata and the pneumogastric nerves has been described; but it 
is doubtful whether this is essential and characteristic, or merely 
accidental, or the result of post-mortem changes. Nothing is more 
uncertain in its indications, as to conditions during life, than the 
slighter changes in the quantity of blood found in the nerve-centres 
and nerves after death. Enlargement of the bronchial glands has not 
unfrequently been found ; but this, it is thought, is accidental rather 
than characteristic and necessary. Indeed, morbid anatomy throws 
but little light on the nature of the disease. It is, however, fairly 
inferred that the virus which produces hooping-cough affects more or 
less the system generally, but expends its chief force upon the mucous 
membrane of the air-passages and upon the nerve-centres and nerves 
concerned in the respiratory mechanism, the peculiar paroxysmal 
attacks seeming to indicate a special nervous irritation. Whether 
these irritations of the nerve-centres are secondary to a morbid impres- 
sion upon the periphery of the respiratory nerves and the results of 340 
IIOOPING-CO UGH. 
reflex action, or whether a primary morbid impression is made upon 
the nerve-centres themselves, is not known. The fact known is, that 
both the mucous membrane and the periphery of the nerves terminating 
in it, and the nerve-centres supplying the nervous force, are irritated. 
The contagium is probably emitted from the mucous surfaces of the 
air-passages, and the morbid poison is doubtless there, wherever else 
it may be. 
Treatment.—The preventive treatment consists in avoiding 
exposure to those laboring under the disease, especially in its earlier 
stages. As it is so much more likely to prove fatal in children under 
two years of age, they, particularly, should be kept from exposure. 
While bad hygienic conditions will contribute to its fatality, they 
seem to have no perceptible influence upon its occurrence. 
When attacked with the disease the patient should be carefully 
protected from taking cold, but proper exposure to the open air in 
fair weather may be useful and important, after the first febrile 
symptoms have subsided. The diet should be regulated ; easily 
digested, but nourishing food allowed ; and the clothing should be 
adapted to the season; but if the weather be cold, damp, or change- 
able, flannel should be worn next the skin. 
A large number of remedies have been recommended for this 
affection. We know of no means for neutralizing the poison, but 
there are various agents capable of abating the severity and frequency 
of the cough, and, as many think, of diminishing the continuance of 
the disease. 
The remedy which has seemed to me to exert a decidedly pallia- 
tive effect, and which, for the last ten or twelve years I have most 
frequently used, is the bromide of potassium. It no doubt diminishes 
the sensibility of the mucous membrane of the air-passages and the 
reflex actions from its irritation—whether by operating directly upon 
the nerve-centres or upon the membrane and the periphery of the 
nerves, or upon both, may not positively be determined. The dose 
for an adult would be from fifteen to twenty-five grains, and a pro- 
portionate quantity to a child, three, four, or more times a day, in 
order to produce its full effect. In smaller quantities it produces a 
quieting influence, and when long continued the smaller doses may be 
given. Bromide of sodium or bromide of ammonium may be sub- 
stituted. Lately the bromide of potassium has been strongly recom- 
mended to be used in a five-per-cent, solution by inhalation ; the 
patient to inhale about 3v of this solution three times a day. In 
order to its success, which is said to be great in mitigating the 
cough and arresting the course of the disease, the inhalation must be TREATMENT. 
341 
thoroughly effected by means of an atomizer; this requires the per- 
sonal attention of the physician, until, at least, the attendants are 
well instructed in its use. Whether it is more efficient used in this 
mode than by the stomach remains to be further tested. 
The paroxysms of coughing are commonly preceded by sensations 
which give warning of their approach, and the prompt inhalation of 
chloroform or ether, in quantities far short of producing unconscious- 
ness, will generally prevent the fit of coughing for the time. By 
repeating the inhalations the habit of coughing may be broken in 
upon, and the tendency to the recurrence of the paroxysms lessened. 
Cases are reported of complete arrest of the disease in a short time 
by this means. In severe cases, as a palliative, if not as a curative 
measure, it seems worthy of trial. It would not interfere with other 
measures deemed necessary. Frictions to the spine night and morn- 
ing, with belladonna and soap liniment, are thought to have a sooth- 
ing effect. B Officinal Belladonna Liniment, 3iij; Glycerine, 3v ; 
Soap Liniment, M. Bubbed along the spine of the child for five 
minutes twice a day. Hydrocyanic acid, belladonna, stramonium, 
aconite, chloral, hydrochlorate of quinine, morphia and other prep- 
arations of opium, nitric acid, carbonate of potash, alum, assafoe- 
tida, arsenic, quinine, fumes emitted in purification of coal-gas, 
and many other articles have been recommended, and may have their 
places in the management of particular cases. When the inflam- 
matory complications occur, they should receive prompt and careful 
attention. A simple uncomplicated case of moderate severity, with 
proper hygienic management, may be left without medication, but 
the severer cases require efforts for their relief, and the complica- 
tions need to be promptly met. Here, as in other cases of inflam- 
mation of the pulmonary apparatus, as in influenza for example, 
prompt doses of quinine for a day or two will often have more effect 
in arresting the complications than any other remedy with which I 
am acquainted. 
If the bronchi are loaded, an emetic of ipecac, may be of great 
service, and, in short, the remedies required for bronchitis as a primary 
affection, or as accompanying other diseases, will be useful in these 
cases, modified in their application by the peculiar conditions present. 
MUMPS.—SPECIFIC PAROTITIS. 
This is a mild, contagions, febrile affection, the most marked phe- 
nomenon of which is a specific, non-suppurative inflammation of the 
salivary, and especially the parotid glands. 342 
MUMPS. 
Its contagious character is unquestionable; the contagium is car- 
ried through the air, and probably chiefly by the breath ; its period 
of incubation is usually about two weeks; the continuance of the dis- 
ease varies from one to two weeks, and in severe or complicated cases 
it may be more protracted ; and though it is seldom or never fatal, it 
is liable to metastases which occasionally induce severe symptoms, and 
are followed by unpleasant results. 
The access varies in different cases. Sometimes the first symptom 
noticed is a swelling and hardness behind the ramus of the jaw, or in 
some part of the parotid gland, with some stiffness of the jaws 
or difficulty in mastication and in opening the mouth. At other 
times a feeling of general indisposition and moderate febrile symp- 
toms are first noticed, continuing for some hours, or a day or 
more, when the glandular swelling commences. It involves gener- 
ally the whole parotid gland, and extends more or less to the sub- 
maxillary glands, and, to some extent, to the surrounding cellular 
tissue. The parts are hot, tender, and generally painful ; a fever, 
if not noticed previous to the swelling, is now present in a greater 
or less degree, with the usual accompanying phenomena, but seldom 
in a very severe form. Usually both parotids are affected, but some- 
times the local disease is confined to one side; and it is said that in 
such cases the other side may be subsequently attacked. 
The skin over the affected parts is often red, and a peculiar ex- 
pression is given to the physiognomy by the swelling of the posterior 
sides of the face. The inflammation sometimes extends to the fauces 
and tonsils, and down the neck externally beyond the limits of the 
salivary glands. The swelling usually increases gradually for three 
or four, and sometimes five or six days ; it then remains nearly station- 
ary, presenting hard elastic tumors for two or three days longer, and 
then gradually subsides. When increasing, and at its height, the 
pain is sometimes quite severe, and the tenderness is decided. 
It sometimes happens that during the progress of the mumps the 
inflammation of the salivary glands abates, and at the same time one 
or both testicles in the male, and more rarely the mammae or labia in 
the female, begin to swell, becoming inflamed, and in case of the 
male, the testicles often become extremely painful, and great depres- 
sion sometimes occurs. 
In other cases the testicles are not affected until about the time of 
the natural subsidence of the parotid inflammation, or even some 
little time afterward. In still more rare cases a metastasis of the 
local affection goes to the brain—at least that organ becomes affected, 
apparently from the action of the virus which causes the parotid in- 
flammation ; and this occurs at the time of the subsidence of the TREATMENT. 
343 
inflammation of the glands. The orchitis usually subsides without 
serious consequences; but sometimes, as in other cases of inflamma- 
tion of this gland, infiltration and contraction of the exudate take 
place, and atrophy of the organ follows. 
Nearly all persons take the mumps when exposed to the contagion, 
and, as in most other contagious affections, one attack usually protects 
against subsequent ones. No influences of sex, constitution, or ex- 
ternal conditions have any apparent effect upon the occurrence of the 
disease. 
Of the morbid anatomy of mumps little can be said, as its rare 
mortality has given very little opportunity for investigation. The 
inflammation of the glands, though specific and non-suppurative, 
is not known to differ anatomically from other inflammations pre- 
senting similar symptoms. There is, of course, infiltration into the 
connective tissue of inflammatory exudate, causing the hard elastic 
swelling, and that exudate usually extends a little beyond the glands. 
The treatment of mumps should be conducted on the same prin- 
ciples as that of other mild specific fevers and inflammations that 
will run their course. In ordinary cases nothing more need be done 
than to keep the patient from exposures ; to open the bowels with a 
saline laxative, and to direct a diet which is light and will not re- 
quire mastication. When the local inflammation is great, and the 
pain severe, fomentations or poultices may bo applied ; some recom- 
mend leeches, but they are seldom required ; anodynes may be admin- 
istered ; and if the fever be unusually high, diaphoretics and other 
means for its abatement may be useful. 
In case the testicles or mammae are affected, they should be treated 
as for other cases of inflammation of these parts—rest in bed, fomen- 
tations with a solution of muriate of ammonia in vinegar and water, 
suspension of the testicles, leeches perhaps in severe cases ; and sorbe- 
facients later. There is often much alarm when these glands are in- 
flamed, but generally the patient can be assured that no serious con- 
sequences will follow. 
When the brain or its membranes become affected, the treatment 
should be prompt and decided; cold should be applied to the head, 
leeches may be demanded; revulsive and eliminative cathartics and 
diuretics should be used ; counter-irritation should be vigorously ap- 
plied, and the latter, it is thought, will be more efficient if placed 
over the region of the parotids. 344 
DENGUE. 
DENGUE.—DANDY FEVER. 
This is a specific disease marked by high fever, inflammation of 
the joints, severe pain in the limbs, a peculiar rash, and a tendency, 
after abatement of the symptoms, to their repeated return, thus pro- 
tracting the affection for a few weeks, and often leaving the health 
impaired for a longer period. 
Nothing was known in our literature of this disease previous to 
the year 1789, when an affection called “Bone Fever” occurred as an 
epidemic in Java. The next year, 1790, Dr. Rush, of Philadelphia, 
described an outbreak of the disease in that city ; and, about the 
same time, a similar affection was reported to have occurred in Africa, 
Arabia, Persia, and elsewhere in Asia. In 1818 it occurred in Lima, 
South America ; in 1824 it broke out in a body of troops in Rangoon, 
Burmah. It spread from this locality as an infection. It was sup- 
posed to be introduced into the West India Islands from the East, 
and has since appeared in different epidemics in various tropical and 
semi-tropical climates, including many parts of the United States. 
It is thought to be contagious ; but whether the material producing 
it is generated exclusively in the bodies of the sick, has not been pos- 
itively ascertained. It is cpiite probable that, like influenza and 
some other infectious diseases, it is miasmatic contagious. 
In the suddenness of its attacks and the height of the fever, and 
in its abatements and relapses, it resembles relapsing or famine 
fever; in the inflammation of the joints, it resembles rheumatic 
gout; and in the eruption, which generally but not always occurs, 
it resembles measles and other acute exanthemata. It differs from 
all, however, in its ensemble of phenomena, and also to a greater or 
less degree in its individual symptoms. 
Little is known of the duration of the latent period of the poison, 
or whether any degree of protection from subsequent attacks is 
afforded by the occurrence of the disease. 
Moderate premonitory symptoms are sometimes experienced, but 
more frequently the invasion is abrupt. There is a high degree of 
fever, accompanied at first with a sense of chilliness, or more decided 
rigors, alternating with flushes of heat, dryness of skin, severe frontal 
headache with vertigo, pain in the eyeballs, along the spine, and in 
the limbs, and particularly in the joints ; and these latter symptoms are 
so severe as to have suggested the name of “Breakbone Fever,” while 
the general depression of feeling has suggested the further name of 
“ Breakheart Fever.” There is great excitement, rapidity, and hard- 
ness of the pulse, and rapid respiration ; a furred tongue, heat and HISTORY AND SYMPTOMS. 
345 
pain in the epigastrium, loss of appetite, and often nausea; great 
muscular prostration, and restlessness and insomnia. These symp- 
toms increase and soon become intense, the pulse often rising in fre- 
quency to 120, 130, or 140, and the pain in the joints, with stiffness 
and tenderness on motion, often becoming excessive, and shifting 
about as in rheumatism ; and the affected joints swell, particularly the 
smaller ones, as in gout. In the course of a day or two, however, a 
perspiration breaks out and the symptoms abate; but again, on the 
third, fourth, or fifth day of the disease, there will be some increase 
of the pain, and an eruption appears, first on the hands and feet, and 
then extending over the whole surface. This is a kind of erythema 
papulatum, not unlike an eruption that sometimes accompanies the 
active stage of rheumatic fever, or that rarely appears in some cases 
of malarial fever. This eruption is not invariably present, but it very 
generally makes its appearance, is attended with itching, but disap- 
pears on the second day, and is followed by some desquamation. 
With the subsidence of the rash, the symptoms all abate ; and on the 
fifth, sixth, or seventh day of the disease the patient becomes conva- 
lescent, and is soon comparatively well. In a short time, however, 
he experiences a relapse, but the attack is not quite so violent as the 
first, and lasts only two or three days; and this, after similar inter- 
vals of convalescence, is repeated a second, and perhaps a third time. 
After passing through these various attacks, the patient is left 
debilitated, with pain, swelling, and stiffness of the joints, and the 
health is not completely restored before ten or fourteen weeks. The 
stiffness and tenderness of the joints continuing after the patient is 
able to be about, and causing a stiff, circumspect, and apparently 
affected gait, gave it the name of dengue, meaning dandy, and our 
translation of “dandy fever” has come to be one of the names by 
which it is known. 
Notwithstanding these severe symptoms the disease does not seri- 
ously involve the vital organs, there is very rarely delirium or alarm- 
ing prostration, a good ultimate recovery is almost certain, tlwiigh in 
very exceptional cases, at the period of defervescence, death has been 
known to occur from syncope. 
Occasionally, in addition to the ordinary symptoms described, 
there is bleeding of the nose, swelling of the parotid glands, and sali- 
vation, swelling of the lymphatic glands or testicles, and jaundice and 
ophthalmia. 
These phenomena of dengue clearly indicate the existence of a 
peculiar poison which has its periods of revolution and action like 
that of ague, miliaria, and relapsing fever. The particular character 
of the poison, its place and mode of production, and the manner in 346 
DENGUE. 
which it acts, are points for future investigation. A belief in the 
organic, living character of the poison, in the light of what is known 
of germinal matter in the production of disease, cannot well be 
resisted. 
The Morbid Anatomy of dengue is also unknown beyond the infer- 
ences from the symptoms presented. An inflammation about the 
joints, and occasionally in the glands, is the chief structural change 
observed. From its resemblance in some respects to relapsing fever, 
a careful microscopic examination of the blood is suggested. 
The Treatment of dengue, while the profession is unacquainted 
with any specific for destroying the effect of the poison and arresting 
the course of the disease, must be symptomatic, and should be con- 
ducted on the same general principles as in other specific fevers which 
run their course. Fortunately in this disease vital organs so far 
escape, and the high fever in its paroxysms is of such short duration, 
that the system is seldom overpowered, and has time to recuperate its 
forces in the intervals of remission ; and finally the poison exhausts 
its force or is expelled. 
Eliminative treatment, emetics and purgatives, have been strongly 
recommended by those who have had experience in the disease, and 
their judicious use commends itself to the judgment of those who are 
not so completely swayed by ideas of “ supporting ” treatment as to 
lose sight of the facts that in this and similar diseases there is not 
only an original poison which may be excreted and ejected, but there 
are also injurious matters, the result of morbid action, that need to be 
gotten rid of, and which may be hastened in their elimination by 
evacuant medicines. The high fever may be abated by the ordi- 
nary means : cooling drinks, cold or tepid bath, sponging, diapho- 
retics, etc. 
Severe pain may be relieved by anodynes, morphine, or, as strongly 
recommended by some, by belladonna ; and for the stiffness and swell- 
ing of the joints, which remain after the acute stage is passed, the 
iodide’of potassium, acetate of potash, colchicum, etc., may be used ; 
and we should never cease to hope that some means may be' found to 
antagonize the poison which is the cause of the disease. 
Should dengue occur in my experience, I should try the effect of 
quinine or salicylic acid—agents which act as antidotes in other analo- 
gous diseases, and which would abate the fever and relieve distressing 
symptoms. In the practice of medicine, when many of the facts are 
unknown, experimental observations under the guidance of principles 
and analogies are not only justifiable but demanded for the advance- 
ment of science and the interests of humanity. The use of quinine, 
however, would not be specially experimental, as Moodem Sheriff, in GA USE-HISTORY. 
347 
an account of an epidemic occurring in Madras, in 1872, recommends 
it in doses of from three to five grains, every three or four hours, for 
the relief of the symptoms; and he speaks highly of it as a prophylac- 
tic also. 
MILIARY FEYER. 
The terms miliaria and miliary fever have been applied to various 
pathological states where there was a fever with sweating, and a 
peculiar eruption of small vesicles upon an inflamed base. Thus 
authors speak of puerperal miliaria and rheumatic miliaria, indicating 
that in puerperal fever and rheumatic fever a free sweating occurred 
with an eruption in vesicles on hyperasmic and slightly elevated points 
of the size of a millet seed. In the latter stages of typhoid fever, as 
is well known, minute “swreat blisters,” or elevations of the cuticle in 
small points occur, caused by the perspiration freely secreted from the 
sudoriparous glands not finding a free exit through the cuticle, but 
separating it in minute patches from the pale skin. These are called 
sudamina. When, however, there are similar vesicles upon reddened 
and inflamed points, with minute elevations in the true skin by hyper- 
aemia and deposits, whatever other conditions exist, the eruption is 
called miliary ; and when such eruption has occurred in connection 
with a fever which had no other specific character or name, it has 
been called miliary fever. 
The disease indicated by the term at the head of this article is a 
more specific affection, and yet one far from being uniform in all its 
characteristics and results. 
As far back as the tenth century there are accounts of epidemics 
of a disease marked by profuse sweating and an eruption such as 
described. 
After the battle of Bosworth, in August, 1486, a time distin- 
guished by extremely wet weather, an epidemic broke out soon after 
the victorious army returned to London, of formidable extent and 
fearful mortality. From its locality and the most prominent of its 
symptoms, it was called the “English sweating sickness.” The dis- 
ease seems to have disappeared, after this fearful outbreak, for more 
than one hundred and sixty years; but since then, though often at 
long intervals, many epidemics have occurred in nearly all the coun- 
tries of Europe of a disease more or less resembling this “sweating 
sickness,” and it has presented an occasional appearance up to the 
present time. For the last thirty years it has frequently appeared, 
particularly in France and Italy, but has not prevailed in Great 
Britain or this country, and the specific disease now known as miliary 348 
MILIARY FEVER. 
fever, or suette miliaire of the French, and Sch weiss or Friesel of the 
Germans, has nearly disappeared from our medical literature as well. 
Ilirsch, of Germany, has very thoroughly worked up the history 
and character of this affection, and from Zuelzer’s article in Ziems- 
sen’s Cyclopaedia of Medicine, and Grisolle and Jaccoud’s recent 
works on Practical Medicine, and from personal statements of phy- 
sicians in Eome who have had experience in a disease bearing this 
name, the account here given has been gleaned. 
Specific miliary fever almost always occurs in an epidemic form. 
It is not endemic, connected permanently with special localities like 
ague, but suddenly appears in particular places, remaining usually 
not more than a few weeks, and then entirely disappearing. It often 
attacks, in the locality of its prevalence, from ten to even forty or 
fifty per cent, of the inhabitants; but the cases vary greatly in 
severity—it sometimes being so mild that the patient is scarcely inter- 
rupted in his common avocations, and at other times proving fatal in 
a day or two, or even a few hours. It respects neither age, sex, nor 
condition ; but is rather more frequent with women than men, and in 
the vigorous age, between twenty and fifty, than at the extremes of 
life. It is confined to no season of the year; and yet it is more fre- 
quent in spring and summer than in autumn and winter, though not 
very unfrequent in the latter season. While, as a rule, malarial 
fevers prevail most in the latter part of summer and autumn, this 
appears more rarely in autumn than in any other portion of the year. 
It is not more severe in cases occurring in densely crowded cities than 
in more sparse rural districts. On the contrary, some assert that it 
diminishes in severity in proportion to the density of population. It has 
even been observed that during an epidemic it sometimes spares col- 
lections of persons in crowded barracks and prisons, while attacking 
others liygienically situated. There is no evidence of its having 
been carried by individuals beyond its original source, or of its being 
communicated from man to man—experiments of inoculation with 
the fluid of the vesicles have failed to produce effects—and hence its 
contagious character is generally denied. The cause and the disease 
seem to be strictly regional, and to depend on accidental, and gener- 
ally on transitory, conditions. It is not even climatic, as it has 
occurred in England, Italy, France, Germany, etc. It is generally 
thought to be connected with some condition of the soil, as it has 
often appeared after disturbing the soil by excavations, cleaning 
canals, and after inundations, etc., and yet it has appeared where no 
/such disturbances have taken place. Unlike most contagious dis- 
eases, its occurrence in an individual creates no immunity from future 
attacks. Though it is doubtless produced by a peculiar poison, yet, as SYMPTOMS. 
349 
in so many other cases, the exact nature and mode of production of 
the poison, and the manner in which it produces its effects, are mat- 
ters of conjecture. Though some have fancied it contagious, the facts 
of its occurrence and spread are so different from those of diseases 
which are inoculable and known to be contagious, that nearly all who 
have observed the disease agree in believing it non-contagious. Con- 
sidering the unsatisfactory character of the facts bearing upon the 
mode of production of the essential cause, we need not be longer 
detained with them here. 
The phenomena, symptomatology, and course of the affection, are 
now to be noted. Though the disease is so often formidable, in nearly 
all epidemics there are cases of extreme mildness and benignity. Such 
cases are not preceded in their characteristic symptoms by any per- 
ceptible fever, or other derangements, the patient simply breaking out 
in a profuse sweat, which lasts a variable time, sometimes abating and 
returning, and followed in a day or two by a miliary eruption such as 
has been described; and in five or six days all is over, the morbid 
cause seeming to be completely eliminated from the system. There is 
every grade of severity and variation of symptoms, from these mildest 
and simplest cases up to the most severe and complicated. 
In the more ordinary cases of greater but still moderate severity, a 
prodromal stage of two or three days’ duration occurs, consisting of 
feelings of indisposition, headache, pain in the limbs, want of appe- 
tite, weakness, especially of the extremities, and more or less chills, 
these last soon followed by a very decided fever, ending with the pro- 
fuse and characteristic sweat. When these premonitory conditions are 
wanting, the beginning is a profuse sweat, generally coming on in the 
night or toward evening. The pain in the head is now severe, and 
mostly frontal; there is general irritation of the skin, pain in the limbs, 
and often a peculiarly painful tingling sensation at the ends of the 
fingers. The pricking and tingling of the skin sometimes commences 
in the forehead and spreads over the whole body, at other times it 
occurs nearly simultaneously at different parts of the surface. The 
sweating is so profuse that the clothing, bedding, and even mattress 
and straw bed beneath, are saturated by it. While this sweating con- 
tinues a vast amount of heat must be generated in the system, as the 
temperature in severe cases is often very high, notwithstanding the 
loss of heat by the sweating and evaporation. The pulse is often rapid, 
generally above 130, though in some epidemics the excitement is not 
so great, the headache becomes intense, and in the more severe cases 
sometimes on the first, and at others on the second day, very distress- 
ing feelings of constriction in the chest and epigastrium, with precor- 
dial pain, and violent or more ataxic and tumultuous palpitations of 350 
MILIARY FEVER. 
the heart and abdominal aorta occur, these conditions often inducing 
the greatest depression and sometimes syncope and death. 
This profuse sweat, according to Jaccoud, has two sources of dan- 
ger, namely, the weakening of the patient’s general forces, and the 
obstruction of the circulation by the blood’s losing its watery element 
and becoming thickened. In this condition the heart may be over- 
powered, causing death by syncope or asthenia. According to this 
author, during the sweating the epigastric and thoracic distress is 
redoubled, the action of the heart indicates a struggle against an 
obstacle, and there is painful dyspnoea from the obstruction of circu- 
lation through the lungs. In this state delirium and convulsions may 
ensue, and paralysis of certain groups of muscles. In consequence of 
the loss of the watery portions of the blood the urine becomes scanty 
and dense, and the bowels often extremely constipated. 
In some epidemics and cases the fever, during the sweating, is not 
so great, and the pulse is not above 100, and sometimes less. At first 
the pulse is full, but as the sweating continues or recurs, it becomes 
small and contracted. 
The course of the fever varies. It may be continuous, with only 
seeming exacerbations; there may be several abatements and exacer- 
bations in a day ; and in certain epidemics the fever is distinctly 
remitting, the sweat ceasing and recurring with the abatement and 
increase of the fever. 
From the third to the seventh, and more rarely the tenth day, a 
peculiar creeping sensation in the skin announces the eruption. Of 
this there are two forms. First, the red, marked by minute red 
spots, moderately elevated small papules ; but the redness is effaced by 
pressure ; they are seldom upon the face, appear first on the anterior 
aspect of the chest and body, next on the back, and finally on the 
limbs. 
After a few hours, small vesicles filled with a transparent or 
slightly opaque fluid appear in the centre of the papules or red spots. 
The change from the papular to the vesicular form may be retarded, 
but if the patient survives it is sure to take place. The red eruption 
may be the only form, but on portions of the surface another form of 
eruption sometimes appears. Instead of the red and elevated spots, 
transparent vesicles make their appearance, the skin beneath the ele- 
vated cuticle preserving its natural color. The vesicles in these places 
are of a similar character to those of ordinary sudamina. 
The eruptions are regarded by Jaccoud as the effect of the profuse 
sweating, and as having little other character or significance. They 
seem to me to indicate, especially the red or papular variety, some- 
thing more : an irritation of the skin produced by a poison present in SYMPTOMS AND COURSE. 
351 
it, and probably being eliminated thereby. The eruption does not 
come out over the whole body simultaneously, nor progress steadily, 
but breaks out in paroxysms following the exacerbations of fever and 
sweat. When the eruption is finished, but generally not before, the 
fever and sweat diminish, the headache ceases, the epigastric and 
thoracic distress is less constant and severe, the dyspnoea ceases, 
the cerebral symptoms yield, and the patient approaches convales- 
cence. 
About the third day of the eruption the contents of the vesicles 
become opaque, the vesicles are soon ruptured or their contents dry 
down, the redness disappears, and from the fifth to the seventh day of 
the eruption desquamation of the cuticle occurs, sometimes in furfu- 
raceous scales, but more commonly in larger patches, like the peeling 
off of the cuticle after scarlatina. New but milder attacks of the 
sweating, fever, eruption, and desquamation may continue to recur 
more or less frequently for six or seven weeks, or even longer. 
The more severe and more continued symptoms do not last longer, 
as a rule, than from seven to sixteen days, though the relapses, in a 
milder form, may continue on indefinitely. 
After severe attacks convalescence is long and difficult. The 
patient continues to have palpitation and vertigo, and sometimes 
gastro-enteric catarrh, and other symptoms arising from changes in 
various organs. 
The immediate cause of death, its frequency, and the period of 
the disease in which it occurs, differ in different epidemics. It is 
most common during the febrile and sweating stage, or within the 
first week. In complicated cases, where structural changes in inter- 
nal organs are produced and become the causes of protracted symp- 
toms, and ultimately of death, that event may occur at a much later 
period. It not unfrequently occurs from the second to the fourth 
day, and sometimes much earlier, from collapse by cardiac paresis and 
speedy failure, or by cerebral accidents—delirium, convulsions, and 
coma—produced either by congestion of the brain or by the failure 
of a proper supply of oxygenated blood. It should be remembered 
that venous congestion of this organ arrests a proper supply of arterial 
blood in the minute vessels, and prevents the nourishment of the 
brain ; and that it causes cerebral symptoms and death as much, at 
least, by this means, as by direct pressure upon the originating and 
conducting organs of nervous force. Sometimes death is produced in 
biliary fever by repeated hemorrhages from mucous surfaces. In the 
more remitting forms the patient not unfrequently dies, apparently by 
the direct overpowering influence of the poison, as in some cases of 
pernicious malarial fever. The most common complications, causing 352 
MILIARY FEVER. 
death after two or three Aveeks, are : pneumonia, either croupous or 
catarrhal, and gastro-enteritis. 
The Diagnosis cannot be difficult when the epidemic characters, 
the initial symptoms, the peculiar SAveat, the eruption, the thoracic 
distress, and the desquamation are observed. It is more likely to be 
confounded with the free sweats and sudamina that occur at the 
abatement, or during the progress of some other diseases, as puerperal 
fever, typhoid fever, or rheumatism; but the special symptoms of 
these affections and the absence of the paroxysmal fever and the 
epigastric and thoracic distress will remove doubt. 
The Anatomical Changes in miliary fever have not been very 
thoroughly studied, but none have been reported which are char- 
acteristic or essential, or which will fully account for the violence of 
the symptoms. The most striking is, perhaps, the rapid occurrence 
of decomposition, Avhich is said by some to “begin almost during 
life. A feAV hours after death the skin is everywhere cedematous, 
frothy blood flows from the nose and mouth, and the odor of decom- 
position quickly prevails.” This important fact, as well as the phe- 
nomena of the disease during life, suggests the presence of bacteria 
or organic microzymes, whose effects on fermenting and decomposing 
processes are so well known. 
The internal organs show great hyperaemia—the lungs, bronchi, 
mucous membrane of the stomach and bowels, the liver, brain, and 
spleen are generally, if not always, hypersemic, and are often cedema- 
tous, and the spleen especially, is always congested, enlarged, soft- 
ened, and often friable. A A'esicular eruption is sometimes found on 
the mucous membrane of the mouth, stomach, and boAvels, as Avell as 
upon the skin. But these conditions, with perhaps the exception of 
the last mentioned, are common to all severe and fatal fevers. The 
heart is reported as soft, and the pericardium ecchymosed ; and Jac- 
coud suggests that in future inA-estigations thromboses and their 
attendants should be looked for on the one hand, and on the other, 
lesions of the muscle of the heart. These conditions are suggested 
by the profuse sweats condensing the blood, and by the cardiac symp- 
toms which occur in grave cases. 
In the foregoing account of this very peculiar and interesting 
disease, I have folloAved the deecriptions, but with some additional 
remarks, found in the works already mentioned ; but the account 
would not be complete without referring to a modification of this 
affection and a change of the circumstances under which it occurs, as 
given me orally by Dr. Valeri, of Rome, physician in chief to Santo 
Spirito Hospital. He informed me that for some time past (December, 
1879), a disease has occurred in different parts of Italy, rather spo- CASES. 
353 
radically than as an epidemic, first appearing in Tuscany, the attack 
commencing and progressing much like an ordinary typhoid fever 
until about the end of the third week, when, instead of convalescence, 
a paroxysm of high fever occurs, accompanied soon by a most pro- 
fuse sweat, commencing first on the forehead, but in a few minutes 
pouring fortli from every part of the body in most astonishing 
quantities, the fever being accompanied with the epigastric and 
thoracic distress already described, but apparently relieved by the 
sweating; and if the fever and distress occur without the sweat the 
patient soon dies. Differing from Jaccoud, Dr. Valeri regards the 
sweating as critical and relieving, and to be promoted rather than 
checked. The truth probably is, that an injurious material is elimi- 
nated by the sweating, and that the process is an important one for 
the relief of the system—is “an effort of nature” to get rid of an 
irritating and destructive agent, just as the heat and excitement of 
fever are regarded by many as an effort of the system to resist or expel 
an injurious agency. But with this sweat, as is often the case with 
the heat of fever, the “ effort of nature ” is too great, and the sweat- 
ing, as the fever, becomes itself a source of mischief and danger. 
Although the sweating may eliminate a poison, when it is so exces- 
sive it causes weakness, thickens the blood, and, as already stated, 
may tend to obstruct circulation and lead to fatal results. 
In these Roman cases, following a fever of a typhoidal type, as 
in the more ordinary forms commencing without such preceding 
fever, the paroxysms of fever and sweating are repeated, the same 
miliary eruption occurs, never appearing on the face, coming first 
and being most abundant about the neck and anterior aspect of the 
chest, and being followed by the same desquamation so characteristic 
in all the forms of miliary fever. In one case related to me where a 
post-mortem examination was made, the specific lesions of a preceding 
typhoid fever were present; and in another case, of an American 
gentleman who recovered, attacks of sweating occurred from time to 
time for many months afterward (as was stated often to be the case 
in other instances), but they were unaccompanied by other grave 
symptoms, and required no treatment. In another case, related to 
me by an intelligent American physician residing in Rome, that 
occurred in his own family, a fever came on of a remittent type, with 
some diarrhoea at first, with occasional moderate sweats and miliary 
eruptions, continuing about twenty days, when the more violent 
sweats, epigastric and thoracic distress, severe tingling pains in the 
extremities, and a more abundant miliary eruption occurred, with 
the usual constipation, and continued Avith the characteristic symp- 
toms of miliary fever for about three weeks longer. The exacerba- 354 
MILIARY FEVER. 
tions of fever and the paroxysms of distress were relieved by the 
sweating, the patient usually falling into a sleep after the swreat broke 
out—this sleep occurring from the exhaustion of the previous suffer- 
ing and the sudden relief obtained. The eruption, which repeatedly 
recurred, consisted of very minute hard points, upon which minute 
vesicles showed themselves, looking like exceedingly minute pearls, 
and followed by desquamation. In this case, a very peculiar putrescent 
odor commenced early, and continued during the disease, and the 
same odor of the breath and taste in the mouth continued to a greater 
or less extent for some weeks after. 
The diet in this case was chiefly milk, with a moderate quantity of 
lime-water—the milk in free quantity. A good recovery at length 
occurred. 
The disease in this instance was thought to be produced by the 
disturbing of the old Roman earth in some excavations made near the 
open window of the room habitually occupied by the patient. 
The late king of Italy, Victor Emmanuel, was reported to have died 
of miliary fever complicated with pleuro-pneumonia. In neither of 
these cases was the disease prevailing as an epidemic in the locality at 
the time of the attack. 
Treatment.—The treatment in miliary fever, as is usually the 
case in a disease so severe in its symptoms and so uncertain in its 
results, has been very various, different remedies having been favored 
at one time and condemned at another. In the first “sweating sick- 
ness ” in England the success of medication was so doubtful that the 
expectant method came to be adopted, and this has been designated as 
the “English method.” Afterward, in the great epidemics on the 
Continent, the belief was entertained that the sweating and eruptions 
were critical manifestations, and that they must be promoted by all 
kinds of diaphoretics, and by the warmest rooms and closest cover- 
ings. This method was continued for a long time, but was carried to 
such an excess, and followed by such results, as to cause a reaction. 
Bleeding, as might be supposed when the views of the physicians of 
the last century are remembered, had its time and was vigorously 
used, especially in cases where there was a feeling of suffocation and 
thoracic distress ; but though the symptoms were temporarily relieved 
by it, the depression that followed was attended by consequences 
which led to the abandonment of this practice. 
Antispasmodics and various nervines—valerian, camphor, and 
opium—were often used, with relief doubtless to some of the symp- 
toms, but without much effect upon the results of the disease. To 
excite diuresis, and perhaps to supply to the blood the fluidity lost by 
the sweating, Seltzer water and plain water in great quantities have TREATMENT. 
355 
been used, and some have added from forty to fifty drops of the chlo- 
ride of iron daily, especially where persistent delirium was present. 
Several active drugs, as corrosive sublimate, free quantities of chlo- 
rine water, and other antiseptic agents, have been used in the later 
epidemics in France during the last thirty years, but without such 
effects as to establish their efficiency or determine their positive 
value. 
In some of the late epidemics, ipecacuanha, from thirty to forty 
grains, in three doses, each repeated at short intervals to secure an 
emetic effect, has been praised as exceedingly useful, and it has the 
approval of Jaccoud and others; but the extraordinary efficiency 
claimed for it has not been demonstrated. 
The use of cutaneous irritants, sinapisms, ammoniacal liniments, 
blisters, etc., is very unanimously approved by those who have had 
experience in this disease. There can be little doubt of their tendency 
to reduce internal congestions and the precordial and epigastric dis- 
tress which is so great. Jaccoud, with the same indication in view, 
advises the extensive application of dry cups to the extremities and 
other parts of the surface. Hypodermic injections of morphine have 
received the approval of modern experience, when cautiously used, 
where the pain and suffering is great. In the case related by the 
American physician in Eome, a large belladonna plaster over the epi- 
gastrium afforded more relief of the epigastric and thoracic distress 
than any other measures resorted to. The general treatment was 
symptomatic and palliative rather than perturbing. 
Warm baths, sponging with various liquids, appear to do good; 
and compresses, hot and ice-cold, have been used ; but their compara- 
tive or positive value has not been determined. Warnings have been 
given against the use of purgatives in large doses, as being irritating 
and depressing ; but it cannot be objectionable to relieve the consti- 
pation, so common a symptom, by mild means, especially by enemas. 
Alcoholic stimulants, says Zuelzer, seem to be indicated only in the 
severest cases; and, it may be added, their usefulness is far from 
being proved. 
I have deferred mentioning quinine until the last, to give it more 
prominence. The periodicity of the attacks of fever and sweating 
long ago suggested its use, and since more has been understood of its 
physiological and general therapeutical action, and especially since its 
effects in this disease have been observed, Zuelzer says most observers 
are unanimous in recommending its use. Gresser, Cronzal, Parrot, 
and others advise it in large doses ; and Grisolle says in the remittent 
forms of a pernicious character this article, in a dose of one or two 
grammes—fifteen to thirty grains—will cut short the disease on the 356 
MILIARY FEVER. 
fourth or fifth day. He thinks, however, it is not applicable to all 
epidemics and. cases, and that it has often failed of success in the dis- 
ease as it has occurred in France during the fifteen years before his 
writing. Jaccoud also advises its use, especially in the remitting 
forms, which, as we have seen, are the common forms of the affec- 
tion. Jaccoud says : In simple, mild forms, a light diet and suitable 
hygienic regulations alone will be required ; that the indications from 
the gastric symptoms are to be met by an emetic, especially as an 
item of initial treatment; that the general treatment must be symp- 
tomatic, and that the adynamia and collapse furnish constant indi- 
cations for supporting rather than depressing measures. He advises 
that the covering should be light, the room properly ventilated; that 
the excessive temperature of the body should be reduced by cold, and 
that chloride of iron should be given to check the excessive sweats. 
In the Roman cases, quinine is thought by the physicians there, 
not to be indicated. The Roman physicians, however, have not learned 
the full power of quinine and its efficiency in large doses, even in the 
malarial fevers so common among them. Small and long-continued 
doses are still used in ague; but whether in Rome or our own country, 
such use of this article is much less efficient, and much more likely 
to be injurious, than larger doses soon discontinued; and those who 
have testified to the good effects of quinine in miliary fever, have 
used it in free doses, making a prompt but not long-continued 
impression. 
All agree that great care as to diet and exposure is important 
during convalescence, as a return of symptoms from imprudence is 
frequent. 
There are no known means of prevention but to leave the place 
wdiere the epidemic influence prevails. Fortunately it does not long 
continue epidemic in the same locality at a time. Its more endemic 
and sporadic occurrence in Rome has been referred to. 
' From the examination given this subject it seems reasonable to 
conclude, that miliary fever is a specific disease produced by a pecul- 
iar poison, but that the poison does not originate in the body and is 
not multiplied in it in a manner to be communicated to others, or at 
least this is .not the principal method of its production and spread; 
that it is a disease of variable severity and course, and of uncertain 
termination; and that it is therefore difficult to determine the value 
of treatment. The examination further shows that the weight of 
evidence, both from analogy and experience, is in favor of an emetic 
of ipecacuanha in the beginning of the disease ; of counter-irritation 
and cupping to relieve internal congestion; of diluent drinks—of 
Seltzer or simple water—to supply the loss to the blood produced by TREATMENT. 
357 
the profuse sweating ; and the testimony is in favor of administering 
quinine in decided antipyretic doses, wfitli the hope of abating the 
congestive and general symptoms, and of possibly exerting an anti- 
dotal influence upon the cause of the disease. Other remedies may 
be required for meeting special indications ; the diet should be prop- 
erly attended to; bathing should be practiced, and as far as possible 
the strength should be sustained when adynamia and depression are 
manifest. Here again we should hope for the discovery of specific 
remedies for directly antagonizing the cause of the disease. 
I have been induced to occupy so much space in the description of 
this disease on account of its scientific interest in relation to other 
epidemic diseases; and also by the fact that many of the ordinary 
text-books, English and American, contain no mention of it. Its 
points of resemblance to, and its contrast with, ague, cholera, yellow 
fever, diphtheria, influenza, typhoid and relapsing fevers, dengue, and 
the exanthemata, suggest exceedingly interesting questions of eti- 
ology, pathology, and therapeutics which await further elucidation; 
and the facts in regard to each of these diseases tend to throw light 
upon all the rest. 
Since the foregoing article was written, I have received, in answer 
to inquiries, a letter from Dr. Pantaleoni, one of the oldest and most 
reputable physicians in Italy, in which he questions the existence of 
miliary fever as a distinct disease. He does not deny the phenomena 
—the sweating and the eruption—but thinks them “ symptomatic and 
epiphenomenal,” of no more importance than ordinary sudamina 
and miliary eruptions in typhoid and puerperal fevers. In some of 
Dr. Valeri’s cases these symptoms seemed to have occurred as an ad- 
dition to, or a complication of, typhoid fevers—as epiphenomena—but 
they can hardly be considered of no importance. One very intelligent 
person whom I saw, who had recovered from the disease under 
Dr. Valeri’s care, and was one among many other cases from which he 
had derived his conclusions, was very positive in asserting that the 
most intense suffering preceded the paroxysms of sweating, and she 
fully believed that if the sweating, with the relief it brought, had not 
taken place, she could not long have endured the distress. This 
sweating disease which now occurs in Home, whether symptomatic of 
other affections, or as a principal disease of itself, is certainly different 
from the ancient “English sweating sickness,” and from the affection 
described by the French and German authors. That an idiopathic 
sweating sickness has existed in the past, and may therefore occur 
again, seems to mo to be supported by too much evidence and too high 
authority to be denied. Dr. Pantaleoni thinks the disease of the late 
king was pleuro-pneumonia, and should have been regarded and 358 
CEREBROSPINAL FEVER. 
treated as such, without reference to the sweating which doubtlessly 
occurred. Between these differences of views (and Dr. Pantaleoni 
does not stand alone in his opinions), we may not he able positively to 
decide; hut there are unquestionably cases of diseases in Tuscany and 
Rome, where sweating and a miliary eruption take place very differ- 
ent from anything which has recently been observed, either in this 
country or England. 
CEREBRO-SPINAL FEVER. 
EPIDEMIC CEREBRO-SPINAL MENINGITIS.—SPOTTED FEVER. 
This is a specific febrile affection, characterized by a violent and 
rapid development, sometimes by great depression and speedy collapse, 
by congestion, and if not too rapidly fatal, by inflammation of the 
membranes of the brain and spinal cord, with the symptoms accom- 
panying such inflammation ; and frequently by a mottled condition 
of the skin produced chiefly by irregular and excessive accumulation 
of blood in its vessels. 
This disease, under the names by which it is now known, had no 
place in medical literature until comparatively recent times. Though 
clinical analogies show a similar, and perhaps an identical, disease 
earlier, it was not until 1837 that its pathology was carefully studied, 
and it was fully recognized as it is at present understood. 
In 1805 a similar affection occurred in Geneva, Switzerland ; and 
long previous to that, in 1794, Dr. Bard described a disease under the 
title of “ Spotted Fever,” which occurred in Rhode Island and other 
parts of New England, and which is now regarded as essentially the 
same affection as that which broke out in France in 1837. In 1792 
Dr. Williams gave an account of it in North Carolina. In 1806 it 
appeared in Vermont and Massachusetts, and from that on to 1812 
and 1813 it occurred in Washington, Norfolk, Annapolis, some parts 
of Connecticut, the Canadas, Philadelphia and other parts of Penn- 
sylvania, in New Jersey, and again in Vermont and Massachusetts. 
For a few years after 1813 it was not heard of, but in 1816 it visited 
New York; in 1823, Middletown, Conn.; in 1828, Trumbull, Ohio; 
and since then it has appeared at different times in various places in 
this country up to the present time. 
From 1806 to 1822 evidences of its existence in several places on 
the continent of Europe are found. Its occurrence in a very virulent 
and fatal form in France, and particularly among troops in garrisons, 
in 1837, called especial attention to it, and its reappearance in this IIISTOR Y—GA USES. 
359 
country about the same time, and its continuance here and in some 
parts of Great Britain since, has made it familiar to all students of the 
profession by the frequent accounts given of it, and, unfortunately, to 
many physicians who have encountered it in practice. 
It has generally occurred as a local epidemic, affecting particular 
localities of limited extent, and manifesting different degrees of sever- 
ity and modifications of form in different places, and at different 
times. For several years past it has been much less prevalent, but 
occasional limited outbreaks have occurred, and sporadic cases have 
now and then been met with. It has appeared in most of the coun- 
tries of Europe, presenting similar characteristics in all respects to 
those observed in France and in this country. In the winter of 
1842-3 a virulent local epidemic occurred in my own experience 
in the southern part of Michigan, and since that time, up to the 
present, I have encountered occasional cases. The disease seems to 
belong to places rather than to classes of persons, as age, sex, social 
condition, and ordinary sanitary circumstances have apparently little 
influence over the origin or spread of the affection. Still, men have 
been affected rather more than women, and some of the most violent 
and fatal occurrences have been in barracks, in prisons, or in institu- 
tions where numbers of persons are crowded together. This was par- 
ticularly the case in France, where frightful ravages on several occa- 
sions occurred in garrisons, while other portions of the population 
were not so severely affected. Other similar cases have occurred in 
this country. It has appeared more frequently in winter, wrhen con- 
finement indoors is more likely to take place. And these facts seem 
to indicate that crowding and want of ventilation may have some 
influence in its production and severity; and yet it has so often 
occurred in isolated and well-ventilated dwellings in sparsely popu- 
lated situations, as to render the importance of such influence ques- 
tionable. It occurs more among children and young persons than 
among older persons, but infants under six months are said to be 
exempt. 
The epidemic prevalence and its peculiar character point to a 
specific poison as its cause; but where and how that poison is pro- 
duced, are matters open to future investigation. The same uncer- 
tainty exists as in the case of dengue, miliary fever, and other similar 
affections; and while some facts, such as its relations to erysipelas, 
soon to be mentioned, seem to indicate a personal or contagious poi- 
son, the manner of its occurrence and spread is quite different from 
that of the diseases known to be contagious. Jaccoud asserts, with 
great positiveness, that the poison is not reproduced in the body 
affected, so that emanations from the patient produce no effect upon 360 
CEREBRO-SPINAL FEVER. 
others, and that personal contagion does not exist in the disease. He 
also regards it as doubtful whether materials from the locality of its 
prevalence are capable of being transported to other points and pro- 
ducing the disease. It extends in “ blocks,” as he expresses it, from 
place to place, passing over intermediate places. He excludes all 
modes of transmissibility except the aerial, and thinks that the 
atmospheric diffusibility is limited to a short distance, and that it 
has not the power of extension of most other infectious diseases. 
Drs. Burdon-Sanderson, Sidell, and others deny its contagious- 
ness, and the general experience of American physicians has led them 
to reject the doctrine of its strictly contagious character. 
Two views have been taken of the Nature of cerebro-spinal men- 
ingitis, some regarding it as a local disease to be classed with the 
phlegmasia—as differing from common inflammation of the mem- 
branes of the brain and spinal cord only in the fact of its occurring 
epidemically; while others, it seems to me with more reason, and at 
least in more accord with present prevailing pathological views, 
regard it as an essential fever, with meningitis as its chief local 
feature ; and place it, as I have done, among the specific febrile 
affections. 
The proofs of its specific character and its alliance with the 
fevers are to be found in a consideration of its causes, its symptoms, 
and its lesions. 
It appears to be independent of the general influences of climates, 
but bad ventilation and other hygienic faults, which render the 
organic expenditure superior to assimilation, and destructive meta- 
morphosis greater than elimination, it is thought favor the action, 
and possibly tend to produce the specific cause. There is, too evi- 
dently for doubt, some influence beyond the common causes of 
ordinary inflammation. Its relations to other maladies, to Erysipelas, 
Typhus and Typhoid fevers, to an Epizootic of similar character 
among hens and dogs, point in the same direction. But what is still 
more conclusive, it sometimes causes death before the inflammatory 
lesion has had time for development; and when the lesion occurs, its 
products resemble those of erysipelas more than those of common 
inflammation. The exudates may be either aqueous, cellular and 
plastic, or purulent. So they may be in common inflammation ; but 
the rapidity of their occurrence and the association of the meningitis 
with erysipelas in the same region not unfrequently, and sometimes 
in the same person, indicate a specific rather than a common form of 
inflammatory action. The lesions are not always limited to the mem- 
branes of the brain and cord, but the throat, the skin, the liver, the 
spleen, the mesentery, and kidneys may be involved. Again, the VARIETIES. 
361 
blood, it is alleged, does not present evidence of simple inflammatory 
dyscrasia. There is often the “ dissolved” blood of the older 
authors, distention of the globules, solution of the haem a tin in the 
serum, etc., which does not occur in the same manner in simple 
inflammation. 
Clinical forms show an affinity with the infectious diseases. It 
has a very violent and rapid form, a slower and less violent one, and 
an abortive form. Its course and progress are different from common 
inflammations. There is a want of correspondence between the pulse 
and the temperature ; this, however, often occurs in simple cerebral, 
spinal, and meningeal inflammations ; but there are exanthems, albu- 
minuria, and articular symptoms which common meningitis does not 
present. From these, and perhaps other considerations, cerebro- 
spinal meningitis must be regarded as a specific fever, allied to the 
typhus group, marked by epidemic diffusion, by a precocious and 
rapid inflammation of the nervous centres, and especially their 
envelopes, and frequently by cutaneous symptoms of a peculiar char- 
acter. If this view be correct, the meningitis bears a similar relation 
to the disease that the affection of Peyer’s glands does to typhoid 
fever, or that the eruption does to measles ; but with this difference, 
that the local manifestation is, from its severity and its location at 
the nerve-centres, a far more important element, producing more 
violent symptoms and determining to a far greater extent the result, 
than the cutaneous eruption of measles, or the lesions of the intes- 
tines in typhoid fever. 
The Symptomatology and course of this disease have striking 
features. Rapidity of march and clinical gravity are its general char- 
acteristics ; but all cases are not alike, and there are several varieties 
in these respects. 
1. There is a rapid, violent form, most threatening in appearance, 
and often speedily fatal. 
2. The more common form, not so violent and rapid, but still 
dangerous and often fatal. 
3. A latent form—insidious—not presenting the usual symptoms 
for some days, but at length manifesting violent phenomena, and often 
resulting in speedy death, when an autopsy shows the results of an 
inflammation that must have continued for some days before symp- 
toms of a marked character appeared. 
4. An abortive form—premonitory and early symptoms appearing, 
but soon yielding to the resisting powers of the system, or to appro- 
priate treatment. 
An idea of the first, or violent form, may best be conveyed by re- 
lating cases. A girl, eight years of age, was seized in the evening with a 362 
CEREBROSPINAL FEVER. 
chill, severe pain in the head, neck, and back. In three hours she was 
seen lying with her head thrown back, pupils moderately dilated and 
fixed, eyes turned up in the sockets, pulse variable, sometimes rapid 
and sometimes slow, and so weak as to be scarcely perceptible ; head 
and trunk warm, but not of high temperature, the extremities cold, 
purplish, and shriveled ; she was breathing slowly, with complete in- 
sensibility or unconsciousness ; and in three or four hours more death 
took place. An autopsy revealed no perceptible changes, not even 
hyperaemia of the brain or membranes. 
Another case, occurring in my own experience, though many years 
ago, is fresh in my memory. Mr. J. B. McK , a farmer, aged 
forty-three, of correct habits, in good hygienic circumstances, and 
previous good health, complained of moderate feverish symptoms, 
some pain in the head, and a sore throat. He was seen the same 
evening, when the mucous surface of the fauces, tonsils, and soft pal- 
ate was congested and thickened, but not so as to interfere with any 
functions. Slightly reddened streaks were observed on the skin 
extending from near the ear to about the junction of the anterior with 
the middle third of the clavicle ; the temperature was moderately ele- 
vated—probably about 102° F. (it was before the days of fever ther- 
mometers), and the pulse was about 100. Some mild prescription 
was made, I do not remember what; but he was not seen again until 
the next day about 10 o'clock A. m., when, on being hastily summoned, 
he was found in the most violent clonic convulsions, and during their 
intervals, which were short, the head was violently thrown back, and 
most of the muscles were in a state of tonic, spastic contraction. 
There was absolute unconsciousness, from which he was never aroused, 
the convulsions being repeated until death occurred three or four 
hours later. No medicine was given by the mouth, as swallowing was 
impossible. An enema was given to move the bowels, and, after con- 
sultation, a bleeding of about sixteen ounces was practiced, and mus- 
tard plasters were applied, but no impression was made upon the con- 
vulsions. This was before the days of hypodermic injections, of 
chloroform or ether inhalations for relieving convulsions, or the use 
of bromide of potassium for such purposes ; but I am persuaded that 
none of these, had they been known and used, would have altered 
the result. The man was strong before the attack, and was fully 
supplied with blood, and the quantity he lost had no marked effect; 
hut I must say that in other cases of less vigor, or where more blood 
was taken, it appeared to have the effect of hastening the sinking and 
the fatal result. No post-mortem examination was made. 
Numerous other cases are related, and a number have been seen by 
myself, where death occurred in from twelve to thirty-six hours, and VARIETIES—PHENOMENA. 
363 
in some indeed from three to ten hours. In some cases, not lasting 
oyer twelve hours, post-mortem appearances are not negative. Con- 
gestion of the brain, cord, and membranes, markedly increased cere- 
brospinal serosity, and some corpuscular exudates have been found 
in these rapid cases. 
2. The common cases, though less rapid and terrific, are still 
striking in their phenomena and alarming in their results. Premoni- 
tory symptoms lasting from one to several days are sometimes, but 
not generally, observed. When present they consist of malaise, some 
feverishness, pains in the head and back, and often in the limbs, ver- 
tigo, trembling, sometimes vomiting, and general nervous troubles. 
More commonly, or at least in very many cases, the attack is sudden, 
and in a few hours at most, severe and characteristic symptoms make 
their appearance. The patient, in full health, perhaps in sleep, is 
attacked, and often cries out in distress and alarm, with violent pain 
in the head, back of the neck, and lower in the spine. It is almost 
constant in occurrence, but variable in amount and precise locality, 
but is not usually increased on pressure. It is not unfrequently to 
some extent remitting, and sometimes intermitting, and often radiates 
from these centres along the course of the nerves. Cutaneous hyper- 
esthesia is often an early and persistent symptom; there is usually 
difficulty of motility, various contractions, particularly of the mus- 
cles, causing the head to be thrown back persistently—a marked and 
characteristic symptom—and trismus, cramps, and muscular trem- 
blings, are not unfrequent. General convulsions, tonic and clonic, 
are not very rare, but paralysis seldom occurs, as the anterior columns 
of the cord are not as likely to be seriously involved. There is 
debility and collapse, but it is not the same as paralysis. The intel- 
lect, usually intact at first, is invaded, in turn, more or less. Differ- 
ent forms of delirium occur, sometimes milder, and at others so vio- 
lent as to require physical restraint. The more violent excitement, 
whether muscular or mental, is followed, sometimes in a few hours, 
generally in a few days, by collapse and stupor, or milder halluci- 
nations if the patients are capable of being aroused ; and in cases of 
recovery, forgetfulness of all that occurred during the disease is not 
unfrequent. Some become maniacal from the cortical substance of 
the brain being involved; others lose the sense of hearing or sight; 
and in others more or less permanent and severe results from organic 
lesions of the nerve-centres follow. In some the greater amount of 
disease is in the brain and its membranes, while in others the cord 
and its envelopes are most affected, and the symptoms are correspond- 
ingly variable. In this, as in other inflammatory brain affections, 
vomiting is not unfrequently an early symptom. Each attack of 364 
CEREBROSPINAL FEVER. 
vomiting comes on suddenly, without any necessary sense of nausea, 
and independently of the contents of the stomach; but as the disease 
advances it usually disappears. Abdominal pains of a neuralgic 
character may occur about the same time ; constipation is frequently 
present, though diarrhoea sometimes occurs at a later period. The 
cutaneous symptoms, absent in about thirty-five per cent, of the 
Cases, but varying as to this in different epidemics, are not of uniform 
character. There may be a mere mottling from irregular congestions 
of the cutaneous vessels, chiefly of the veins and capillaries, and 
following the distribution of nervous filaments, or more distinct 
appearances of suggillations, or a rubeoliform eruption may appear, 
commencing on the hands and rapidly extending over the body, the 
redness disappearing on pressure, but returning on its removal; or, 
more rarely, there may be an eruption more resembling scarlatina; or 
erythema in spots and streaks ; or urticaria; or a herpetic eruption 
may occur, especially about the lips; or there may be distinct pete- 
chiae, the latter being an indication of danger. In an epidemic in 
Philadelphia, in 1866-7, in ninety-five cases thirty-six had petechias, 
thirteen had petechiae with a scarlatinaform eruption, and nine had 
erythematous spots, with appearances of urticaria. Sometimes the 
form of the eruption is illy determined, and not unfrequently compli- 
cated. In a majority of the cases I have seen, there has been either a 
purplish mottling or rounded erythematous spots. These appearances 
must have been common in the early occurrence of the disease in this 
country to have given it the name of “ Spotted Fever.” 
Pains in the joints, resembling those of rheumatism, sometimes 
occur; and suppurative inflammation of these parts occasionally fol- 
lows. 
The temperature is exceedingly variable; and no general state- 
ment as to its particular height or continuance, applicable to all 
cases, can be made. It is sometimes high during the first twenty- 
four hours, falling next day; and after that vacillating—sometimes 
in cases of great severity going below the normal. It is rarely as 
high as in most other fevers, there being no regular variation between 
morning and evening, and scarcely any relation between the degree 
of heat and the severity of the case, except that, when the tempera- 
ture falls below the normal, it is an evidence of collapse and an indi- 
cation of danger. The temperature is doubtless influenced by the 
seat of the lesion, and its vacillating and uncertain condition depends 
upon the morbid state of the nerve-centres ; but these relations have 
not been sufficiently ascertained to materially aid in the prognosis. 
The pulse is rarely above 100, or 110 ; is often between 80 and 
100 ; and there is no fixed relation between it and the temperature. PHENOMENA. 
365 
The fever in the course of the disease may he continuous and nearly 
uniform, remitting, or rarely intermitting. 
Albuminuria is nearly constant in some epidemics, generally 
early but transient; though sometimes it continues through the 
course of the disease, and appears about equally both in grave and 
mild cases. 
The ocular and auditory symptoms are numerous and varied. 
Pains in the orbits, dilatation, and, more rarely, contractions of the 
pupils, conjunctivitis and iritis, visual derangements and loss of 
vision, and derangement and loss of hearing, and sometimes both 
blindness and deafness are present, and occasionally permanent, from 
the brain lesions. Other lesions of function, as dysphagia, etc., may 
result. 
Various other pathological states may exist as complications ; such 
as pleuritis, pericarditis, peritonitis, and synovitis ; or pneumonia, 
bronchitis, gastritis, and enteritis, and sometimes parotitis. These 
complications are, of course, serious, and add to the dangers already 
so great; but it has been observed that the parotitis is not always as 
serious as it is apt to be in other low fevers. Perhaps it acts on the 
principle of a counter-irritation, relieving the cerebral inflammation. 
In an epidemic which I witnessed, and have already referred to, 
after a few weeks’ continuance of the occurrence of the disease in the 
usual form, it was followed by a series of cases, occurring for some 
months, distinctly complicated with erysipelas. Patients were attacked 
with general febrile symptoms, and a diffused inflammation of the 
mucous membrane of the throat. Under active diaphoretic treat- 
ment, with counter-irritation, this would often disappear in a few 
days, leaving the patient convalescent. In other cases the inflamma- 
tion of the throat would suddenly abate wTith the simultaneous ap- 
pearance of well-marked external erysipelas of the face or other parts 
of the surface ; while in still other cases, on the subsidence of the in- 
flammation of the throat cerebro-spinal meningitis occurred ; and in 
others still, a rapid and diffused inflammation of the peritoneum, 
pleura, gastro-intestinal, or bronchial membrane supervened, and in 
all these cases of internal attack death was likely to speedily take 
place ; while in the cases where external erysipelas appeared, recovery 
sooner or later was the very general result. I remember but one case 
where external erysipelas occurred, in my experience, where the patient 
did not recover, though sometimes quite deep tissues were involved, 
and the cases were protracted. At the same time, in the neighbor- 
hood, almost every wound was attended by diffused erysipelas; and 
puerperal women had hysteritis and peritonitis, and many of the 
latter succumbed to these forms of disease. A general influence pre- CEREBBO-SPINAL FEVER, 
366 
vailed, inducing a peculiar specific erysipelatous inflammation; and 
when it attacked vital organs, from its rapid diffusion and severe char- 
acter, the results were most disastrous. The case of J. B. McK , 
already related, occurred after the erysipelatous features had ap- 
peared. 
In the ordinary forms of spinal fever the duration of the disease 
in different epidemics, and in different cases in the same epidemic, is 
variable. In a majority of unfavorable cases death occurs from the 
fifth to the eighth day. Complications may result in death either 
earlier or much later; and when no organs other than the brain and 
spinal cord are affected, the patient may die after several weeks, from 
the results of the inflammatory lesions. In some cases I have seen, 
with some obscure brain symptoms continuing, persistent emaciation, 
from failure of ultimate assimilation and nutrition, has occurred, and 
this marasmic condition seemed to be the cause of death. 
In the favorable cases recovery may occur in two or three weeks ; 
though complications, or effusions at the nerve-centres which may 
finally be absorbed, may cause symptoms to continue much longer. 
Permanent defects of functions, physical or mental, as already stated, 
sometimes remain. 
The latent forms are analogous to the cases of Typhus Ambula- 
torius. These cases have been observed and described by Swedish 
physicians, and their leading characters have already been men- 
tioned. 
Abortive cases in some epidemics are not uncommon, especially at 
the period when the outbreak declines. Threatening symptoms like 
those of the premonitory stage of the severer cases occur, but a full 
development of all the characteristic phenomena does not take place, 
and convalescence is established in two or three days. A mild inter- 
mitting variety has been observed in Sweden, where paroxysms of 
considerable severity, but of short duration, have been repeated a few 
times at intervals of twelve hours, followed soon by convalescence. 
Prognosis.—In ordinary cases of the full development of the 
disease the mortality is great. The most favorable reports show a 
death-rate, when on any considerable scale, of thirty-three per cent., 
and usually it is from forty-five to seventy-five per cent., and in ex- 
ceptional cases, especially at the earlier period of an outbreak, 
nearly or quite all die. Several such instances in France and else- 
where have been reported. The poison or epidemic influence, what- 
ever it is, seems to have different degrees of concentration and vir- 
ulence at different times and places. 
The Pathological Anatomy of this disease, when it continues a 
sufficient length of time for its full development, is quite characteristic. MORBID ANATOMY—DIAGNOSIS. 
367 
The skin after death shows evidences of the suggillations and ecchy- 
moses so often seen in the coarse of the disease; the rigor mortis is 
generally well marked; in the protracted cases there is often much 
emaciation, and the muscles are found to have undergone more or less 
granular degenerations. The most characteristic anatomical changes, 
however, are in the cerebro-spinal axis. The dura mater and arach- 
noid, though usually more or less affected, are not as uniformly or as 
decidedly changed as the pia mater. This membrane is quite 
uniformly found congested, often greatly punctated with capillary 
hemorrhages, and rendered opaque and thickened by interstitial 
exudations. Leucocytes and purulent or pyoid cells are exuded into 
the membranes or upon their surfaces, often presenting a greenish or 
greenish-yellow appearance; and a more consistent or gelatinous 
material, composed of various cellular and coagulable elements, is often 
found in free quantities in the fissure of Sylvius, the infundibulum, 
the pons, and the cerebellum. Sometimes the Avhole convexity of the 
hemispheres is covered, and the sulci between the convolutions are 
filled by this exudation. While the membranes of the brain are thus 
affected, and the brain itself is hyperaemic and sometimes infiltrated, 
quite as characteristic, and often still more marked, changes appear in 
the membranes of the cord and in its substance. There are found here, 
hyperaemia, exudations of serum, pus, and gelatinous material, of 
greater or less thickness, in the spinal cavity, covering the roots of 
the nerves, and in cases of long standing pressing upon the cord and 
interrupting function. 
In the more protracted cases the heart muscles are soft and friable, 
having undergone granular degenerations in many of their fibres. 
The blood is usually dark and fluid, staining the walls of the vessels. 
The hepatic cells and epithelium of the tubes are often granular by 
deposit of fat; and in the breathing apparatus, bronchitis, catarrhal 
pneumonia, and other changes are sometimes found. 
The Diagnosis, when the disease is epidemic and well marked, is 
easily made in the majority of cases. It may, however, be confounded 
with tubercular meningitis and with typhoid fever. The suddenness 
of the attack, the intense headache and muscular rigidity, and the 
causeless vomiting ; the absence of diarrhoea, of the typical thermal 
lines, and of the typhoid eruption, etc., will distinguish it from 
typhoid fever. Tubercular meningitis is sporadic; it comes on grad- 
ually, or is preceded by prodromic symptoms; there is seldom the 
throwing back of the head ; there is an absence of the peculiar erup- 
tions ; and the general march of the disease is different. In both 
there is variability of symptoms, but the spinal meninges are not as 
much affected in tubercular cases? and the rhythm of the pulse and 368 
CEREBRO-SPINAL FEVER. 
respiration is more disturbed. A careful comparison of the fuller his- 
tory of the two affections will generally enable the physician to make 
the distinction. 
The Treatment of this disease, as its great mortality shows, has 
for the most part been unsatisfactory. 
The first indication, assuming the cause to be a specific poison, is 
to neutralize or expel that poison. But here, as in so many other 
cases, our knowledge, both of the poison and its antidotes, is so entirely 
at fault as to render all attempts at the fulfillment of this indication 
entirely experimental. Still, exciting a free perspiration at the be- 
ginning of an attack, I have so frequently seen followed by such 
marked and permanent relief as to suggest the possible expulsion of a 
poison in that process. But the more tangible pathological and symp- 
tomatic indications are, to abate the excitability of the cerebro-spinal 
apparatus; to prevent or diminish the fluxion to, and the anatomical 
changes in, those centres; and finally, to promote absorption of the 
inflammatory exudates, and in the course of the disease to meet any 
complications and distressing symptoms by appropriate measures. 
To meet the indication of allaying the excitability of the brain and 
cord, opium in large doses has been used in this country since 1808. 
The hypodermic injection of morphine is perhaps the most certain 
and efficient method of administering this drug. Large doses of 
Dover’s powder, or of morphine, ipecac., and bromide of potassium, 
would seem well calculated to fulfill the indication, and at the same 
time to induce the perspiration which seems desirable. Should emesis 
occur, no harm would be likely to result from it, and the dose might 
soon be repeated if rejected. Lately various articles have been used, 
related to opium in effects, but which are thought to be more efficient 
in controlling the amount of blood in the affected parts, and equally 
or more efficient in diminishing their excitability. For these pur- 
poses not only bromide of potassium in large and repeated doses, from 
forty to sixty grains or more once in two or three hours, but chloral 
hydrate, ergotine, and belladonna have been used. Cases have been 
reported of a grave character where these agents have seemed to have 
decidedly good effects. A grain of ergotine and one tenth of a grain 
of extract of belladonna every four hours, or chloral hydrate suffi- 
cient to bring the system under its full narcotic effect, have been 
strongly advised. 
The Calabar bean, from its alleged effect of diminishing spinal 
hypersemia, received for a time much attention and a faithful trial, 
but it has not fulfilled the hopes that were entertained of its beneficial 
action. 
For diminishing the fluxion to the nerve-centres, prompt and exten- TREATMENT. 
369 
sive counter-irritation seems called for. The fact that cutaneous 
erysipelas so markedly relieves and prevents internal inflammations in 
the cases where it occurs, and the general fact of the frequent abate- 
ment of the inflammation in one part when it occurs in another, sug- 
gest this remedy; and experience confirms the propriety of its use. 
The earlier the more efficient; for when decided anatomical changes 
have taken place the morbid processes cannot be so much influenced. 
Before they are fully established, the morbid action maybe diverted to 
less vital parts. Extensive applications of mustard, ammonia, or to a 
less extent cantharides, should be promptly made. I am quite con- 
fident that I have seen serious consequences averted by the early ap- 
plication of extensive counter-irritation, together with active diapho- 
retics, as large Dover’s powders, acetate of ammonia, warm drinks, etc. 
My experience was before the days of jaborandi; but I should now 
be inclined to try that agent in the early stage of these cases. I have 
made use of ext. of veratrum viride in the more sthenic cases, and 
with apparently beneficial results ; but depression of the heart’s action 
is often so marked a condition, that it should be used with great cau- 
tion, or not at all. Jaborandi often depresses the heart’s action to 
some extent, and therefore should be used cautiously, and its effects 
watched, but it is less depressing than the veratrum, and more 
diaphoretic, and should be preferred. At least it seems to me worthy 
of a full trial in the early stages of the disease. Dr. Stille advises 
the application of ice to the spine and head, and Jaccoud recom- 
mends cold lotions when the fever is high. These means are worthy 
of being considered, though their usefulness has not been established. 
The use of quinine in free sedative doses has been resorted to, by 
different American practitioners particularly, and very strongly recom- 
mended. The late Dr. Pitcher, of Detroit, among others, strongly 
approved of its use ; and though I have no sufficient personal obser- 
vation of its effects, my present vieAvs of its action would incline me to 
its use. Jaccoud and Grisolle doubt its good effects, except in inter- 
mitting cases, and the former says : “While some have had good effects 
from it, others have found it useless.” I can well understand that in 
advanced cases this, as well as other remedies, will have little or no 
effect; but still believe that in the very early stages this, as well as 
the other remedies suggested, may have decidedly good effects. 
The indication of promoting the absorption of the inflammatory 
exudates is to be fulfilled by the use of iodide of potassium and other 
sorbefacients and eliminatives, and perhaps also by blisters • but the 
efficiency of any of these measures cannot be relied upon. 
The bowels should at least be kept open, and, when the strength 
will allow, the revulsive and eliminative effects of cathartics may be 370 
CEREBROSPINAL FEVER. 
very useful. It is customary, when the strength fails and collapse 
occurs, to resort to supporting measures; but in the cases of acute 
depression they have but little effect. In the more protracted cases, 
with debility and depression, the best assimilable diet and tonic medi- 
cines should not be neglected. 
In cerebro-spinal meningitis, as in other inflammations, specific 
and non-specific, the question of blood-letting naturally arises. 
Those who regard the disease as a simple inflammation, rather than a 
fever with a specific inflammatory action, and who regard blood-let- 
ting as an important agent in reducing inflammation by allaying 
excitement and diminishing fluxion of blood to the affected part, 
would be inclined to the use of this agent in this disease; and some 
whose opinions on medical subjects are entitled to great respect, 
believe that a venesection, though not always efficient, still affords the 
best prospect of averting a severe and fatal result when practiced at 
an early period, and especially when vigor of the circulation and 
much blood-pressure are present. The influence of the loss of blood 
upon inflammatory actions in general was long exaggerated, and may 
still be in some minds, while not sufficiently appreciated in others ; 
but I think it must be admitted by all that it has less power over spe- 
cific inflammations depending upon a poison wThich it cannot remove 
or divert, than upon common inflammations not depending upon such 
poisons. Few could suppose that the loss of blood would arrest a 
variolous inflammation, or would recommend it for that purpose ; and 
on the supposition that in this disease there is a peculiar poison, and 
that the inflammation is specific, analogy would suggest the comparative 
inefficiency of the remedy in these cases. Besides, in specific inflam-, 
mations generally, and certainly in spinal fever, there is a marked 
tendency to depression and collapse, which theory suggests, and expe- 
rience proves, is likely to be increased by the loss of blood. From the 
little prospect there is of the bleeding relieving the inflammation, and 
the greater prospect of its aiding in the production of collapse, its 
general use would seem clearly to be contra-indicated. If the patient 
was decidedly plethoric—had more than the normal and proper quan- 
tity of blood—there could, perhaps, be no objection to diminishing it; 
or if, by its diminution, the general condition of the system were 
improved, or oppressed functions relieved, bleeding might be useful ; 
but the general state in these cases is far from demanding it, and no 
particular f unctions are likely to be relieved by it. In the epidemic 
occurring nearly forty years ago, to which I have referred, I witnessed 
sufficient trials of the remedy. In some few cases it seemed to pro- 
duce temporary relief, and in some it was hoped that it had an effect 
in preventing a fuller development of the local affection ; but in the TREATMENT. 
371 
large majority of cases no beneficial effects in any particular could be 
perceived; and in too many cases, as already stated, collapse and 
death were evidently hastened. The pulse would become small and 
flickering, and reaction could not be induced. On the whole, then, 
neither on theoretical principles nor from experience or authority, can 
bleeding be placed among the ordinary remedies for epidemic cerebro- 
spinal meningitis. 
To summarize the treatment which seems to promise most: If 
the patient be seen in the premonitory or early stage of the attack, 
he should speedily be brought under the influence of an anodyne and 
sedative diaphoretic; and pediluvia and external moist heat, followed 
by the extensive applications of sinapisms, should be used. The 
choice of internal agents should be between quinine in doses of six to 
ten or more grains, together with morphine in doses of one sixth to 
one third of a grain, the quinine certainly, and the morphine probably 
repeated once in two, three, or four hours according to effects : or 
opium, ipecac., and bromide of potassium, in free anodyne and diapho- 
retic doses; or jaborandi in quantities to induce its full diaphoretic 
action, or the chloral hydrate in narcotic doses. If the bowels have 
not been freely open, they should be moved with enemas, as these will 
not interfere witii the other measures. These narcotic and diapho- 
retic effects should be kept up for twenty-four hours, more or less, 
when, if the symptoms persist and the disease is fully developed, 
cathartics, in which a mercurial is combined, may or may not be 
given, according to the strength of the patient and the condition of 
the bowels ; and the ergot and belladonna, a blister to the neck and 
between the shoulders may be resorted to, or the blisters may be 
applied at a greater distance, or omitted, and ice may be applied to 
the head and spine. The continued use of the bromide of potassium, 
and later as effusions occur (and they occur at a comparatively early 
period), the iodide of potassium in as free and persistent doses as can 
well be borne, will aid, or at least tend to, the accomplishment of the 
desired results. 
Other methods may be tried in epidemics where these means 
entirely fail; but it must be remembered that toward the close of a 
local epidemic the cases become milder; and the last remedies used, 
though apparently more successful, may not be the best. It is easy 
to be deceived by this state of things, and many methods of treatment 
have obtained an undeserved but transient reputation, in this and in 
other epidemics, by the great differences in the severity of the cases 
to which they have been applied. 
Dengue, cerebro-spinal or spotted fever, and miliary fever, from 
their commonly occurring, but subordinate and inconstant cutaneous 372 
ERUPTIVE FEVERS. 
phenomena, may properly be regarded as a transition series, and placed 
between the continued and eruptive fevers, or the acute exanthemata, 
which are next to be considered. 
This class of affections, occurring more frequently among children 
than adults, as the first exposure, which is usually in early life, induces 
them, is treated of at greater length, with more detail of history and 
description, in treatises on Diseases of Children ; but an account of 
their essential features, and the important items of their management 
is expected in a work on the Practice of Medicine. These acute 
exanthemata present certain phenomena common to all of them alike, 
and indeed some features common to all the specific fevers ; but each 
has peculiarities in a definite series of events giving it a distinct 
individuality. 
The first feature, allying them not only to each other, but to the 
fevers we have been considering, is their dependence upon a specific 
poison as their cause. This fact no one questions, as the proof is 
amply demonstrable. 
The next feature common to their class is, that they are produced, 
so far as we have any evidence, by poisons generated exclusively in 
the bodies of those affected with the disease, and these poisons are 
transmitted from person to person, either by sensible contact, by in- 
oculation, or through the air; and this exclusive method of the 
production of the poisons and the propagation of the diseases, renders 
them strictly and typically contagious. They are said to be propa- 
gated by fomites ; but this does not differ essentially from the other 
modes, as the poison is simply attached to some substance, as clothing, 
etc., which retains and conveys it, as upon the inoculator's lancet, 
to act either by contact or through the air. 
Another quality which they have in common is, that with a gen- 
eral fever, they have each a peculiar cutaneous inflammation, consti- 
tuting a leading characteristic of the disease. Again, in all, one 
attack, as a rule, protects from subsequent attacks of the same affec- 
tion ; and in still another respect they agree, that when commencing, 
with some variations, but with scarcely exceptions, they persist in 
their course, and if not cut short by the death of the patient, pass 
through a somewhat definite series of changes. After the poison is 
received into the system, there is a period of incubation, in which the 
organic virus is doubtless multiplied, until it becomes sufficient in 
amount to produce its morbid effects on the fluids, the tissues, and 
the organs, usually in regular and systematic order. 
These features give a distinctive character to these affections, and 
place them in a well-defined class. PHENOMENA. 
373 
VARIOLA.—SMALL-POX. 
This, perhaps the most interesting, and when uncontrolled the 
most terrific of these affections, is first to be noticed. 
Small-pox may be defined a specific contagious fever, character- 
ized by severe pain in the loins during the earlier stage, and by a 
cutaneous inflammation appearing about the third day in hyperasmic 
points, speedily followed by deposits, causing a papular eruption, 
which passes on to a vesicular and ultimately a pustular form, with 
the formation of a minute slough at the point of its appearance in the 
skin, usually sufficient to leave a small pit or scar-mark as a per- 
manent evidence of the occurrence of the disease. 
This eruption attains its full development about the ninth day of 
its appearance, or the eleventh day of the disease ; after which it 
dries down and forms a crust, which, when falling off, leaves for some 
time a vascular and reddened spot, which in time loses its extra vas- 
cularity and presents a depressed point paler than the surrounding 
skin, constituting the permanent marks just mentioned. 
The period when this disease first made its appearance, and the 
manner of its origin are unknown. No distinct account has been 
found of it previous to the Christian era, and no recorded evidence 
of its epidemic prevalence is given before the sixth century. This by 
no means proves its non-existence before that time, but it could not 
have escaped the notice of Hippocrates and other voluminous early 
medical writers had it been of general prevalence in their times. It 
was not found to have existed in America before its discovery by 
Europeans; but it was soon after introduced by them, and has since 
that time, by the more free intercommunication of nations, spread 
over nearly the whole inhabited globe, and has at no time become en- 
tirely extinct. Its ravages for a long time were the terror of nations, 
and its wide-spread prevalences have caused the destruction of in- 
numerable lives. It has, however, in modern times been robbed of 
much of its terrors, first by the practice of inoculation, and since by 
Jenner’s discovery of vaccination ; and should that be thoroughly and 
universally practiced for a sufficient time, it is probable that the 
disease might be completely and forever extinguished. 
Very few persons of any age or condition are exempt from the in- 
fluence of the contagion when they are brought unprotected within 
its range. Fortunately, one attack, however mild, exempts the indi- 
vidual from all future occurrences of the malady, and yet in exceed- 
ingly rare instances, some have repetitions of the disease. Though 
greatly diminished in violence by inoculation—inserting into the skin 374 
SMALL-POX. 
a particle of the small-pox virus, and thus communicating the disease 
—though generally prevented or greatly modified by the practice of 
vaccination, to be described ; yet when at the present day it occurs in 
persons unprotected by either of these processes, it possesses the same 
virulence, and is attended under like circumstances with as great a 
mortality, as in the days of its frightful prevalence. 
The practice of inoculation, which, previous to vaccination, did 
so much for humanity, was introduced into England (and soon after- 
ward was adopted elsewhere in Europe and this country) by Lady 
Mary Wortley Montagu, who had Avitnessed its beneficial effects in 
Constantinople, Avhere it had been imported from Persia and China; 
and in justice to her sex, no less than to her memory, and as an evi- 
dence that women may benefit the world by services for the preven- 
tion and mitigation of disease, her name is mentioned, and her 
energy, zeal, and perseverance, in the presence of opposition, are 
acknowledged. 
The practice of small-pox inoculation, which has mostly gone out 
of use, simply because a better plan has been disco\rered, reduced the 
mortality in those receiving the disease in this Avay to an extreme 
minimum; and in like proportion prevented those disfigurations, 
Avhich to many, especially of the fair sex, had terrors scarcely less 
than the danger to life. 
The period of latency of the inoculated form of the disease, 
is seven or eight days. On the second day after the insertion of the 
matter, a small papule appears at the seat of the puncture, which, by 
the fourth day, is changed into an umbilicated vesicle depressed in 
the centre. On the seventh day the vesicle, or blister-like eruption, 
which before contained a fluid resembling lymph, is converted into a 
pustule by the effusion into it of purulent matter. About this time 
the lymphatic glands above ha\re become swollen and tender ; and on 
this, or the folloAving—eighth—day, rigors, feverishness, and other 
symptoms indicative of the invasion of the general disease occur. 
By the tenth or eleventh day the pustule is fully .developed, and at 
this time the variolous rash, or an eruption at some points away from 
the place of the insertion of the original matter, appears. By the 
fourteenth day the inoculated pustule has dried up into a crust, and 
the general eruption, which is usually scanty, in time gradually sub- 
sides. The system, Avith the exception of the rare cases referred to, 
becomes protected against any future occurrence of the disease. 
When Variola is taken in the usual, or, as it is called, “natu- 
ral” Avay, from inhalation of particles of poison in the air, the 
period of incubation is longer, generally from ten to sixteen days, 
usually tAvelve days. The disease may be taken from a small-pox PHENOMENA. 
375 
patient at any time from the first invasion until the separation of the 
last scab, and longer if the clothing be not all changed, destroyed, or 
perfectly disinfected, and the body, including the hair and all the 
appendages that may harbor any particle of the poison, thoroughly 
cleansed. The largest amount of the poison, however, is thought to 
be given off about the period of the maturation of the pustules, and 
the danger of communicating the disease at that time is greatest. 
The incubative stage of natural small-pox is almost invariably un- 
attended with appreciable symptoms. In rare cases, however, the 
patient suffers from some vague feelings of illness, such as languor, 
peevishness, and moderate uneasiness. The invasion is comparatively 
sudden, and marked by the usual febrile phenomena—rise of tem- 
perature, sensations of rigors, and heat—and differs from that of most 
other fevers by the frequent occurrence in the adult of copious perspi- 
ration. Severe stomach sickness is very often present, with anorexia, 
thirst, constipation in the adult, but often diarrhoea in children ; 
headache and pain in the limbs ; and almost invariably intense pain 
in the lumbar region of the spine ; drowsiness is often present, and 
not unfrequently delirium, stupor, or even coma; and in children 
there are apt to be convulsions. The headache is usually decidedly 
greater than that which accompanies the access of most other fevers, 
and maniacal excitement sometimes occurs. The most characteristic 
perhaps of the symptoms enumerated is the severe pain in the back. 
These lumbar pains are almost always decidedly out of proportion 
to the other symptoms (unless it be in some cases where the head- 
ache is equally severe), as compared with other febrile attacks with- 
out special local disease. The vomiting often occurs in many other 
febrile attacks, especially other eruptive fevers, as scarlatina, etc., and 
is not always present in attacks of small-pox, and constipation is too 
common a symptom to be specially characteristic of any disease. It 
is well to bear in mind the perspiration as aiding in the diagnosis, 
and yet it is not always present; and the convulsions, though not un- 
frequent in children in other cases at the commencement of a severe 
febrile attack, may, with other symptoms, throw a ray of light upon 
the obscurity which is often present at the beginning of the disease, 
before the characteristic eruption makes its appearance. The tem- 
perature in this stage of invasion usually rises rapidly to 104°, or even 
105.5°. The urine is febrile, and in one third of the cases is albu- 
minous, and may contain casts and blood ; this latter condition may 
continue during the active disease, but is commonly transient; and 
very seldom does permanent disease of the kidneys with its results 
occur. 
The sweating during this stage, so common in the milder forms 376 
SMALL-POX. 
of variola, and generally continuing more or less throughout its 
course, though much less conspicuous in the severer forms, is worthy 
of notice as a means of diagnosis. Special attention to all the early 
symptoms should be given in a suspected case, since the necessity of 
immediate isolation of the patient, to prevent the spread of this 
dread affection, renders an early diagnosis of great importance. 
The symptoms of this stage are in a general way severe in propor- 
tion to the severity of the case they usher in ; but yet I have seen very 
decided, in fact severe, symptoms—headache, backache, etc.—followed 
by a slight eruption, and a mild and even modified form of the malady. 
This, however, is not ordinarily the case, and high fever, great pain, 
and intense cerebral excitement are usually followed by the most 
grave after-conditions. 
These general symptoms attain their greatest severity on the third 
day, when the eruption makes its appearance, and as it advances 
the fever abates, the pains diminish or cease, and in ordinary dis- 
crete cases great apparent improvement in the general condition 
takes place. The eruption, though very generally appearing on the 
third day, may, especially in violent and speedily fatal cases, manifest 
itself on the second day, and in still other cases may be delayed to 
the fourth, and even later. In modified small-pox, where vaccination 
has been imperfect in its results, and has afforded only a partial 
protection, it is not unusual, with other irregularities, to find the 
variolous eruption preceded by a rose-colored efflorescence somewhat 
resembling the rash of scarlatina. In genuine or unmodified cases, 
threatening great severity and a very abundant eruption, there may 
be, on the second or third day, a patchy but diffused redness, with 
some swelling of the skin, especially of the face and upper part of the 
chest, etc., which very strikingly resembles the rash of measles, but 
which is the beginning of the variolous eruption in a thickly set 
papular form. In other cases an abundant petechial rash, chiefly 
about the sides of the chest and abdomen, and on the loins, will 
appear, foretelling the greatest danger. In all ordinary cases, how- 
ever, the eruption commences on the third day, in the form of small 
red points, first visible on the face, head, neck, and often early on the 
wrists, and within the next two days successively appearing on the 
upper part of the chest, the arms, the rest of the trunk, and then, or 
sometimes a little later, and always less abundantly, on the lower 
extremities. These spots in a very short time become little promi- 
nences, hard to the touch, feeling like shot imbedded in the skin, 
but, carefully observed, they are found hemispherical or somewhat 
pointed; they gradually become larger, and in the course of two or 
three days on the point of each there appears a vesicle or minute PHENOMENA. 
377 
blister, the whole being acuminated or cone-shaped. From this they 
go on increasing in area, the vesicles broaden and become more flat- 
tened, their contents, instead of being transparent, as at first, become 
milky; the central point, which at first was most prominent, has 
become comparatively depressed as the margins have increased; and 
about the sixth day of the eruption, and ninth of the disease, these 
vesicles become yellow pustules. In this transformation the central 
point, which was held down by little bands extending into the sub- 
stance of the true skin, has often become more prominent by the giv- 
ing way of these attachments, the pustules assume a rounded form, 
and now there is a marked increase in the inflammation that has been 
going on during their development. Each pustule is surrounded by 
an inflamed areola, the swelling at its base is increased, more purulent 
exudations are poured out, and the pock increases up to about the 
ninth day of the eruption, or twelfth of the disease, when the process 
of maturation, as it is called, is completed, the pock has attained its 
full development, varying somewhat, but usually about the size of a 
large pea. The inflammation now gradually subsides, the matter 
dries down and forms a scab, which in time falls off, leaving the 
marks already described. 
The periods of development and maturation mentioned are those 
belonging to the eruption on the face and neck, where it is usually 
more particularly noticed. On the rest of the trunk, and especially 
on the lower extremities, it is later by a day or two in its progress. 
The eruption is always more abundant on the face than elsewhere, 
particularly than upon the lower part of the trunk. When each 
pustule upon the face stands by itself, the case is called “distinct” 
or “ discrete ” small-pox. When the pustules run together on the 
face, though separate but near when papules, the case is called “'con- 
fluent ; ” and there is the greatest difference in the severity and 
danger of these forms, the latter being much the more grave. In 
these confluent cases, patches of greater or less size present little or 
no appearance of the distinct pustules described, but a continuous 
surface of inflammation, swelling, and suppuration; and if recovery 
takes place, there is a continuous crust, and finalty nearly continuous 
scar texture, with small pits thickly studded over the parts. The 
more distinct and the farther separated from each other, within a 
limit, the larger, as a rule, are the pustules. 
It should be noticed that the fluid in a pock in the vesicular stage 
is not all contained in a single apartment or cavity, but in several, 
like the divisions of an orange, concentrating at the centre, and held 
down there so as to give the umbilicated appearance as the develop- 
ment advances. At this central point the true skin is so involved 378 
SMALL-POX, 
tliat a minute slough often results, and when the suppurative con- 
dition occurs, the attachment of this affected portion to the sur- 
rounding tissue often gives way, and the pustule then loses the um- 
bilicated form which the vesicle retained. 
A careful study of the description of the eruption of small-pox at 
different periods, and particularly of the early stages, is exceedingly 
important for the purpose of making an accurate and positive diag- 
nosis, where the deepest interests of a whole community may depend 
upon a knowledge of the nature of a case. This study is rendered 
the more necessary as the disease in large country regions in many 
places so seldom occurs, that a physician for years in practice may 
never have seen a case, and pictorial illustrations of the disease are 
exceedingly rare. From the frequency of travel and the possibility 
of exposure, cases are liable to occur in any neighborhood; and 
the instances are not few where a diagnosis has not been made until 
many unprotected persons have been exposed and an epidemic pro- 
duced. The effect upon the reputation and standing of the physician 
avFo should make such a failure can be readily imagined. Careful 
attention to the different points mentioned would render a mistake 
impossible in an ordinary case after the eruption was well established 
and at all advanced. A very early diagnosis, though not always easy, 
is exceedingly desirable. The eruption, especially in severe cases, 
extends to the mucous membrane of the mouth and throat, interfer- 
ing with deglutition, and sometimes with respiration, and often 
seriously aggravating the sufferings and increasing the danger of the 
patient. Its appearances upon these surfaces and upon the skin are 
somewhat different. 
The general symptoms in small-pox up to the time of the eruption 
have been described. The abatement of these symptoms, which then 
takes place in ordinary discrete cases, is likely to continue until about 
the period of the commencement of the maturation of the pustules, 
the sixth or seventh day of the rash, or the ninth or tenth of the 
disease, when what is called the “secondary” or “ maturation fever” 
sets in with rigors, pain in the head and elsewhere, high temperature 
—105° F., more or less, and sometimes when fatal results are threat- 
ened, 107°, or possibly more—perhaps delirium, etc., lasting for three 
or four days, when, if the case be favorable, improvement takes place 
and convalescence occurs as the pustules dry down. After the fever 
of invasion subsides, and during the remission of the general symp- 
toms, and while the eruption goes on, some inconvenience is felt from 
the soreness or itching of the parts, but less than might be supposed. 
The eruption on the mucous membrane of the upper alimentary and 
air-passages gives more or less inconvenience, according to the severity PHENOMENA. 
379 
of the case. There is salivation, the voice becomes hoarse, a cough 
may occur, with difficulty of swallowing, etc. In the more mild cases 
these symptoms may be nearly or quite absent; and in still milder 
forms of the disease, which are not unfrequent, the secondary fever 
is slight, or nearly or quite absent; and the eruption soon dries down 
with little or no suppuration, and convalescence soon ensues. 
In confluent cases the course of events is quite different from that 
of the discrete variety just described. Instead of the marked change 
in the general symptoms when the eruption appears, there is compar- 
atively but slight abatement of the febrile phenomena—severe symp- 
toms continuing, and with still greater aggravation, as the matura- 
tion process commences and progresses. The fever, during this time, 
varies in its particular phenomena in different cases. Sometimes the 
excitement is high, the delirium active, restlessness great, etc. At 
other times, and more frequently, a lower and more typhoidal con- 
dition ensues. The pulse is feeble, but generally rapid, low mutter- 
ing delirium is present, subsultus occurs, and, not unfrequently, 
extreme depression, collapse of the eruption, coma and death result. 
In these confluent cases the eruption in and about the throat is com- 
monly abundant, adding to the distress and danger. When the 
patient struggles through this formidable type of the disease, the 
symptoms attain their maximum height with the completion of the 
maturation process, and then, with more or less continuance and 
fluctuation, abate. The face, during this process, has been greatly 
swollen, the lineaments of the countenance obliterated, and now a 
continuous and generally dark crust forms over the confluent erup- 
tion on the face, the pustules on all parts of the body dry down, and, 
during this desiccation, there is commonly great itching, and tho 
patient, especially if a child, needs watching and restraint to prevent 
violence to the parts by scratching, which might induce ulceration 
and greater disfigurement. 
While these processes are going on, a peculiar odor is exhaled from 
the patient, quite characteristic of tho disease, and with this, doubt- 
less, contagious particles are associated. 
The loosening and falling off of the scales usually takes place dur- 
ing the third week of the disease ; but the complete healing of all 
the sores, especially if any physical violence by scratching has been 
inflicted, may require a much longer time, and repeated crustings 
may appear. 
The great difference in the symptoms, course, and results of the 
disease, as appearing in the clearly discrete and in the confluent 
forms, even when the confluence is limited to a moderate portion of 
the face, is quite remarkable and not easily accounted for. The prog- 380 
SMALL-POX. 
nosis in a discrete ease is generally favorable, while in a confluent one 
it is always grave; and the fact of the confluence which is to take 
place can be judged of by the thick studding of the eruption in the 
early papular form. An early prognosis as to severity can usually 
be made by observing the character of the initiatory fever, and the 
abundance of the early eruption. 
In the foregoing account a description has been attempted of the 
ordinary uncomplicated forms of small-pox; but unfortunately for 
brevity of description and a ready and complete understanding of the 
disease, all cases do not follow these types, and there are varieties and 
complications to be noticed. 
In some cases, after the maturation is completed, instead of a sub- 
sidence of the symptoms and convalescence, various secondary condi- 
tions or complications arise which protract the morbid state or prove 
fatal. These are much more likely to occur in the confluent forms, 
but may also happen in the discrete. 
During the third or fourth week boils may appear on different 
parts of the body, and then, or later, larger suppurative points may 
make their appearance, sometimes subcutaneous, at others more deeply 
seated ; and occasionally they rapidly attain large dimensions. These 
processes maybe accompanied by distinct and characteristic symptoms 
of pyaemia, which may or may not prove fatal. 
In other cases erysipelatous attacks of the face, head, or other parts 
occur, attended, perhaps, with pyaemic symptoms ; and gangrene, more 
or less extensive, occasionally supervenes. Ophthalmia in other cases 
occurs, and often assumes a suppurative, ulcerative, or sloughing 
form, and the cornea is sometimes penetrated and vision destroyed. 
In other cases otitis follows with its consequences. 
Internal inflammations, particularly of the pleura, and also of the 
lungs and bronchi, sometimes occur during the active stage of the dis- 
ease, and may cause a speedily fatal result. At other times there are 
similar complications later, with rapidly suppurative tendencies. 
Severe inflammation or oedema of the larynx and glottis may ap- 
pear during the active stage of the disease, or occasionally later, re- 
sulting in suffocation. 
In cases where the lumbar pains are unusually severe, the spinal 
cord may be so much affected that partial, or more complete but tem- 
porary, paraplegia takes place, with loss of control over the bladder and 
rectum. 
Many varieties of small-pox are mentioned. We have already seen 
that some cases are particularly mild throughout, and it is sometimes 
with difficulty that the patient can be kept within doors and isolated. 
He has but little suffering himself, and is often remarkably indifferent VARIETIES AND COMPLICATIONS. 
381 
to, or unconscious of, the danger to which he exposes others by his 
presence among them, not seeming to realize that the mildest case 
may propagate the disease in its severest forms. Other exceptional 
cases may occur, as .already stated, where the usual symptoms of in- 
vasion are followed by very few pocks, which soon dry up and dis- 
appear. In still other exceptional cases, the disease appears in the 
usual way, and the pocks are numerous but discrete, yet at the period 
when suppuration usually takes place, the vesicles dry up. In neither 
of these cases is there any secondary fever, and recovery is speedy. 
The discrete and confluent varieties have been sufficiently described. 
The term “malignant” is applied to cases of unusual severity, and 
where death often takes place without the common developments of 
the disease. In these latter cases petechias and vibices are apt to 
occur, with bloody effusions into the pocks, giving them a very dark 
color, which has caused the name of “ black pox ” to be applied. 
A more distinct hemorrhagic variety of a very malignant character 
has rather recently been recognized in some epidemics and cases. 
An idea of this form can better be given by a description of cases. 
A cadaver was brought into the dissecting-room of a large medical 
school from some unknown source, which in its external aspect pre- 
sented slight puffiness of the skin of the face, and a moderately mot- 
tled appearance of the skin over different parts of the surface, some of 
the spots approaching in appearance petechiae and vibices, but not 
fully developed. Nothing was recognized by those having charge of 
the matter indicative of contagion, and the dissection was proceeded 
with. On coming to the internal organs hemorrhagic appearances 
were discovered, and the bladder particularly was filled with blood. 
Suspicion was at length excited, but too late to avoid the exposure of 
a large number of persons, among whom so many were entirely un- 
protected, or but partially protected, that an outbreak: of small-pox 
occurred. The disease appeared in its usual forms—mild, modified, 
discrete, and confluent—pursuing the usual courses ; but one case of 
the distinct hemorrhagic variety appeared. A young man, about 
twenty-three, in good health, and of correct habits, was seized with 
the usual symptoms of the invasive fever, of decided, but at first of 
no unusual severity. About the time the eruption should have ap- 
peared, a scanty mottling of the surface was seen, and some, very few, 
obscure petechial points. Vomiting had been severe and was con- 
tinued, and moderate quantities of blood were now thrown up. Blood 
oozed from the mucous membrane of the mouth, and large quantities 
of blood were passed from the bladder. The fever was not high at 
this time ; there was pain in the head, but the mind was fairly clear ; 
the patient began to sink, apparently as much from the loss of blood 382 
8.WA LL-POX. 
and the persistent vomiting as from the poison, and died in two or 
three days after the hemorrhage commenced, and five or six days 
from the invasion of the disease, hto post-mortem examination was 
held. This case was undoubtedly identical in character with the one 
which was the source of the contagion. 
It is worthy of remark, that by prompt vaccination, isolation as 
far as possible, and other precautionary measures, the disease did not 
extend to a single case in the community, beyond those exposed to 
the first source of contagion. The lessons to be derived from all the 
facts in this interesting account are too obvious to require pointing 
out. 
Small-pox occurring after vaccination, which has afforded a partial 
protection, is modified in its character, and is called “ Modified Small- 
pox,” or “ Varioloid.” It commences with the usual symptoms of the 
invasion of the disease in unprotected persons, and generally assumes 
the discrete form, but may, though rarely, the confluent, and still more 
rarely a malignant form sooner or later, for there is no absolute regu- 
larity in these cases ; but usually about the time that the inflamma- 
tion and fever of maturation should commence, the eruption begins 
to dry up, and but little or no fever appears. There is sometimes 
delirium, with other severe symptoms; but though there may be a 
degree of confluence of the eruption, suppuration rarely occurs ; and 
though there is every degree of modification, very generally the cases 
are comparatively mild and devoid of danger. They are capable of 
communicating the genuine small-pox to unprotected persons, and 
the same precautions as to isolation, etc., should be observed as in 
other cases of the variolous disease. 
The statistics of small-pox derived from small-pox hospitals are 
interesting in reference to Prognosis. They show that of persons of 
all ages and conditions received with the disease into such institu- 
tions, 6.5 per cent, of those who have been vaccinated perfectly or 
imperfectly die ; of those having good vaccine cicatrices, showing 
that the vaccination pustule had gone through its proper stages, 
about 2.5 per cent, die ; while of those not vaccinated at all, 37 per 
cent. die. In estimating the value of vaccination, it should be re- 
membered that nearly all who are properly and repeatedly vaccinated 
until the system is no longer affected by the vaccine virus, are com- 
pletely protected from the attacks of small-pox in any form ; and 
that those who have been vaccinated, but who take the disease, have 
the mortality in their cases reduced to the minimum mentioned. 
The statistics of the London Small-pox Hospital show that of dis- 
crete natural small-pox there was a mortality of 4 per cent., of semi- 
confluent, 8 per cent., while of the confluent there was a mortality of PROGNOSIS—MORBID ANA TOMY. 
383 
50 per cent. As to age, the lowest rate of mortality is between five 
and twenty. Under five it is much greater, and above thirty greater 
still. Children under one year very seldom recover, and patients above 
sixty are said never to recover. Pregnant women generally abort and 
die ; and the foetus is often visibly affected with the disease. In rare 
cases the pregnant woman, whether aborting or not, recovers. 
The Morbid Anatomy of small-pox is such as the clinical his- 
tory would suggest. The blood, in most cases, is dark and imperfectly 
coagulated, though fibrinous clots may bo found in the heart. In 
the malignant or hemorrhagic forms, extravasations of blood may be 
found beneath serous and mucous surfaces, and into the cavities of 
hollow organs. The heart may be flabby, the liver pale and softened, 
and the spleen, so susceptible to changes in all fevers, may be soft and 
pulpy. The tongue is usually covered with a thick coat, which may 
be detached in patches ; and the palate, fauces, and often the larynx, 
trachea, bronchial tubes, and the nasal fossae, are congested, filmy, 
and in points excoriated, showing that the eruption had appeared 
upon them. When the bronchi are much involved they are loaded 
with mucus or muco-purulent matter, and the lungs are generally 
congested and cedematous, and sometimes inflamed. In complicated 
cases the pleura and other organs may show evidences of inflammation 
and its consequences, of effusions, etc. 
The anatomy of the eruption is peculiar, and has already been 
alluded to in accounting for the clinical appearances. The papules— 
the first form of the eruption—are due partly to hypereemia and pro- 
liferation of the cells, or deposit in the tissue of the true skin, and 
partly to enlargement and vacuolation of the cells of the rete mucosum. 
The central distended cells of the thickened rete rupture and unite to 
form an irregular cavity. Into this and the surrounding vacuoles, 
serum and leucocytes exude from underlying vessels, and sometimes 
red blood discs are mingled with the other exudates. By the con- 
tinuance of these exudations the pock enlarges, and at length pus is 
produced as the inflammation increases, and by this change the vesicle 
becomes a pustule. The umbilicated form of the vesicle, which is some- 
times retained in the pustule, is due, as already stated, to the collection 
and attachment of bands in the centre, and the greater increase of the 
effusion in the circumference ; the cuticle forms the anterior or outer 
wall of the vesicle, and the corium forms the posterior, while par- 
titions run through from the centre to the circumference, constitut- 
ing it a multilocular cyst throughout. The suppurative and destruc- 
tive process does not necessarily affect the tissue of the true skin, and 
some pocks leave no permanent marks ; but more frequently the skin 
is so involved as to produce more or less pitting. 384 
SMALL-POX. 
Treatment.—The Preventive Treatment of small-pox, by far the 
most important, has already been suggested by the allusions to vac- 
cination and isolation. The great remedy is Vaccination, or the pro- 
duction of a disease derived from the cow, vastly milder than small- 
pox in man when occurring in the natural way, but which is found, 
as a very general rule, to prevent the latter disease. This will soon 
be more particularly considered. 
Over the essential processes of small-pox, when it occurs, the 
medicinal art has very little, and certainly no radical, control. When 
the poison is introduced into an unprotected system, it is almost cer- 
tain to produce its effects and develop the phenomena we have so par- 
ticularly described. Since we are unable to interrupt the course of 
the disease, our efforts must be confined to mitigating its severity, 
opposing any complications that may arise, and endeavoring to enable 
the patient to endure its effects. 
A popular author says: “In the mildest forms of small-pox 
medicinal treatment is scarcely called for; in the severest it is useless, 
and indeed under any circumstances it has but little influence over 
the course of the disease.” This is unfortunately too near the truth; 
but often symptoms may be palliated, and not unfrequently the 
scales of life and death are so nearly balanced, that the weight of a 
timely and judiciously applied therapeutic agent, though small, may 
turn them in favor of the patient, when without it they would fall 
the other way. 
Treatment may, then, be as important in this as in many other 
diseases, and should receive the physician’s best attention. The 
hygienic conditions of the sick-room should be carefully looked after. 
It should be airy, well ventilated, as free as possible from textile 
materials, scrupulously clean, and kept at a regulated temperature. 
Proper readily assimilated food should be regularly given, cooling 
drinks should be allowed, and the patient should be kept quiet and 
free from all annoyance. A simple diaphoretic mixture, as acetate of 
ammonia, spts. nit. dulc., with a small quantity of the syrup of ipecac., 
may be given, the bowels opened if constipated, and the discharges 
checked with opium, turpentine emulsion, or some other agent, if a 
diarrhoea occurs and is excessive. When there is much pain and 
restlessness, anodynes and soporifics may be required ; and any of the 
palliative measures adapted to most other severe fevers maybe resorted 
to as the conditions require. These obvious indications and simple 
means for then- fulfillment, all are agreed, should receive attention. 
Should anything more be attempted for the purpose of modifying 
more decidedly the specific morbid processes ? This question will be 
variously answered by different authorities. It should be borne in TREATMENT. 
385 
mind that though the poison of small-pox is specific and always essen- 
tially the same, yet its effects, at least so far as degree of morbid 
action is concerned, are very different in different cases, depending 
upon some different conditions, certainly, of the systems upon which 
it operates. The answer to the first question will depend upon the 
answer to this : Can anything be done to alter the conditions of the 
system so that the morbid processes will take a milder form, or be 
better borne by the patient ? From our knowledge of the powers of 
therapeutic agents, and from the analogies of other diseases, it does 
not seem unreasonable that this question should be answered in the 
affirmative. From the great variety in the character and severity of 
the morbid processes, and in the powers of endurance of the patient— 
the impossibility of knowing what would be the result without treat- 
ment in any given cases—the actual influence of any measures upon 
ultimate results is exceedingly difficult to determine. It must remain 
a matter of judgment and opinion rather than of demonstration, 
until some means have been applied more effectual and more decisive 
in results than any that have hitherto been used. From my own 
experience in the disease, both in private practice and in a small-pox 
hospital or pest-house, extending in all to a few hundred cases, I 
believe that certain remedies do have some effect upon the severity 
and fatality of cases. The treatment I have come to employ is some- 
thing as follows : In addition to the simple measures already pointed 
out, in cases threatening severity I have given, in the earlier periods 
of the eruption, the chlorate of potash, or chlorine water, or the 
sulphites, and in some instances carbolic acid. Watching their 
effects, I have endeavored to avoid giving these antiseptics in any 
quantity which should disturb the stomach or do injury to any of the 
functions of the body. Soon, in anticipation of the suppurative proc- 
ess and the exhaustion following it, I have given the tinct. ferri 
chloride, and persisted with it until convalescence was established. 
During this time the nutrition has been kept up as well as possible, 
not so much by an abundance as by a proper selection of food regu- 
larly given. Of course death has not been averted in all the cases of 
confluent small-pox. But it has seemed to me that the severity of 
the disease and the number of fatal cases have been diminished by 
this course. This is, however, a matter of opinion and judgment, 
and, as stated, cannot be demonstrated until results arc more uniform. 
In some cases quinine has been added to the iron ; and with my 
present views of the action of that remedy, I should be inclined to 
use it more freely and in a larger number, if not in all the cases. One 
of the great dangers in small-pox is the extent of suppuration that 
occurs, exhausting the already enfeebled vital powers. According to 386 
SMALL-P OX. 
reported experimental observations upon animals, and my own clinical 
experience, quinine strongly tends to diminish suppurative processes ; 
and if this be so, there seems a clear indication for its use in cases 
where suppuration is so extensive and exhausting. While operating- 
in this way its effects upon the system in other respects are not likely 
to be injurious. On the contrary, it tends to abate the excessive heat 
so often present, and sustains rather than depresses the vital actions. 
In order to produce its full effects, from three to five grains should be 
given once in from three to four or six hours, and if well borne, con- 
tinued while the suppurative danger lasts. The antiseptic remedies 
may be continued or not as judged proper. 
It will be observed that quinine has been recommended or sug- 
gested in most of the specific diseases we have been considering. This 
has not been done in a mere routine way, but from carefully con- 
sidered pathological and therapeutical facts and principles, and from 
the results of experience. Whether judiciously or not, it has not 
been advised thoughtlessly. If it has the powers I believe it to pos- 
sess, it is applicable to all similar conditions in the different diseases, 
and has not been mentioned too often. 
Various other palliative measures than those already referred to 
may be of use in managing a severe case of this disease. The sore- 
ness of the throat may be relieved by warm bland drinks, and perhaps 
by some astringent or gently stimulating applications. Opium is not 
only useful in assuaging severe pain and procuring rest, but in the 
secondary fever, especially when combined with quinine, it mitigates 
its severity, and, properly managed, enables the patient to endure bet- 
ter the shock of the extensive cutaneous disease. When collapse 
approaches or occurs, ammonia and alcohol are suggested, and perhaps 
should be given ; but the patient who is not kept from collapse by a 
proper diet—milk and farinaceous gruels, beef-tea, etc., often and 
regularly given—and by quinine, iron, and opium, will very seldom 
be aroused from it by any agents. 
Various methods of local treatment have been recommended for 
diminishing the cutaneous suffering, and the deformity following. 
Protecting the face from the light and air by some metallic foil, or by 
various other substances, has been advised and practiced, but without 
very important results. Some have recommended puncturing the 
vesicle, washing away its contents, and touching the bottom of the 
cavity with a point of nitrate of silver. The application of strong 
carbolic acid has also been advised. Experience, however, has not 
caused the profession to attach much importance to any of these 
methods ; but as, when carefully used, they will probably do no harm, 
a trial of them need not be discouraged. THE A TMENT—ITISTOIl T. 
387 
Washing the surface from time to time with warm water, and 
keeping it anointed with carbolized oil applied with a soft brush or 
feather, is, perhaps, as well as anything that can be done. Great 
attention to cleanliness is important; and, toward the decline of the 
disease, great care is necessary to keep the eyes from being affected 
by the discharges, and the various mucous orifices from being irri- 
tated by them. 
In the malignant and hemorrhagic forms of the disease, no treat- 
ment has been found efficient. So far as I have seen the report of 
cases of the peculiar hemorrhagic variety, illustrations of which were 
given, the death of the patient has been uniformly recorded. Still, 
efforts at relief should be made, guided by general principles. 
The various complications which occur in the variolous affection 
must be treated as each case may demand. They are for the most 
part inflammations, acute, severe, and rapid in their course ; and as 
they are much more likely to occur in the severest class of cases, their 
additional weight generally crushes the patient. Though they hre 
acute inflammations, they occur in a shocked and depressed condition 
of the system, and require soothing and supporting, rather than de- 
pressing measures. Quinine and opium, here as in other inflamma- 
tions of similar character, are the great remedies, or at least those 
which afford the most hope of relief. The erysipelas and the suppurat- 
ing conditions which occur as sequelae to the eruption stage, require 
the ordinary treatment for such inflammations, and for the pyaemic 
fever so likely to accompany them. Care as to exposure, and some- 
times a tonic course of treatment, are required during convalescence. 
COW-POX.—Vaccina. 
This is a disease which occurs in cattle, is contagious by inocula- 
tion, or the introduction of lymph produced in one animal into the 
skin of another, and is also communicable to man by the same proc- 
ess. The prevailing opinion now is, that it is identical with small- 
pox in man—was originally communicated from man to cows, and 
from cow to cow by the act of milking—that it is, in fact, small-pox 
modified by the peculiarity of the bovine system, and rendered vastly 
milder by such modification ; and that on the principle that conta- 
gious diseases usually occur but once in the same person, it prevents the 
recurrence of the disease (small-pox) in the human system once fully 
affected by it. The facts and arguments sustaining this conclusion 
seem to me sufficient, but it is not deemed necessary to detail them 
here. The important practical fact is now beyond any dispute that 388 
COW-POX. 
the vaccine disease, a mild affection imposing but little suffering and 
almost entirely devoid of danger, when thoroughly occurring in man, 
is, with rare exceptions, a protection against small-pox. This fact, 
so far as we have information) was first noticed, or a belief in it first 
entertained, over one hundred years ago among the dairy people of 
Gloucestershire, England. It is said a similar opinion was also enter- 
tained in Holstein, in a dairy region, and that a schoolmaster acting 
upon this belief vaccinated two children in 1771; while it is also de- 
clared that an English farmer in 1774 vaccinated his wife in order to 
render her insusceptible to small-pox, as others were observed to be 
who had taken the disease from the cow through accidental abrasions 
in the hands when milking. This belief and these alleged facts 
arrested the attention of Edward Jenner when he was an apprentice 
to an apothecary or a ,surgeon—in other words, when he was a medi- 
cal student—and inquiring into the matter, and instituting experi- 
ments in a scientific manner, he was able to publish to the world in 
1798 the “ discovery ” which has immortalized his name, and has 
proved a greater boon to the human race than was probably ever 
before conferred upon it by any one man. The practice of vaccina- 
tion has extended over the whole civilized world, and its value in 
preventing small-pox has been attested by general experience. If the 
practice of vaccination were universal and thorough, there can be no 
doubt that the small-pox would be completely extinguished. Where- 
ever the disease now prevails, it can always be traced to the neglect or 
imperfection of vaccination. 
The following tabular statement, derived from the records of the 
London Small-pox Hospital during twenty years, is illustrative of the 
importance of thorough vaccination : 
Patients admitted with small-pox. 
Numbers. 
Mortality 
per cent. 
1. 
Having one vaccine scar 
. 2001 
7.73 
2. 
Having two vaccine scars 
. 1446 
4.70 
3. 
Having three vaccine scars 
. 518 
1.95 
4. 
Having four or more vaccine scars 
. 544 
0.55 
5. 
Stated to have been vaccinated, but hav 
- 
ing no scar 
. 370 
23.57 
The mortality where vaccination had not been practiced at all was 
thirty-seven per cent. Another fact within my own experience illus- 
trates the value of vaccination in preventing the disease. 
The Second Regiment of Michigan Infantry, when mustered into 
the United States service in the spring of 1861, to serve during our 
late war, consisted of the full complement of one thousand men, be- PROTECTIVE POWER—PHENOMENA. 
389 
sides a number of officers, servants, laundresses, etc. Commencing 
with the colonel and his staff, and extending by companies to every 
soldier and other person, irrespective of previous vaccination, all con- 
nected with the regiment were vaccinated with ordinary humanized 
vaccine virus contained in recent crusts. It was found that between 
a quarter and a third of the young recruits—mostly from the agricul- 
tural population of the State—had never been vaccinated. Others 
had one and two scars, many of them indistinct and imperfect. Of 
the whole number seventy-five per cent, took the vaccine disease, and 
in a very large proportion of them it went through its regular course, 
showing that a large number who had been previously vaccinated were 
not protected from the recurrence of the vaccine disease, and were pre- 
sumed not to be perfectly protected against small-pox. Very few were 
so much affected by the operation as to be kept from ordinary mili- 
tary drill, and but a single accident followed, one man having erysip- 
elas some time after the vaccination. From recruits and officers’ 
servants coming into camp afterward, and having small-pox in the 
barracks and camp, the whole regiment were repeatedly and thor- 
oughly exposed to the contagion, but not a single one of the recently 
and properly vaccinated, not one of the thousand soldiers, or of other 
attendants, took the disease. Nothing could be more conclusive as 
to the preventive effects of vaccination than this experiment ; and 
nothing could more clearly show the importance of revaccination as a 
test of the perfection and continued efficacy of former vaccinations. 
This instance alone goes far to justify the statement, that if vaccina- 
tion were universally, thoroughly, and repeatedly practiced, small- 
pox would become extinct. 
The vaccine disease in the cow and in the human subject has a 
character and course essentially similar, and it will be sufficient to 
describe it as it appears in the latter. It is of much importance that 
every one who expects to practice vaccination should be familiar with 
its features. 
No specific change is observable at the point where the vaccine 
matter is inserted, until the end of the second or third day, and some- 
times, especially if the matter be not very fresh, somewhat later. At 
first a small congested papule appears. This gradually increases 
in size ; at length a little transparent effusion occurs, and on the 
fifth or sixth day, or a little later, the papule has become changed into 
a round grayish vesicle, with a somewhat depressed or umbilicated 
centre. By the eighth or ninth day it has become fully developed, 
and is a distinct and prominent vesicle, with a flat or a cupped (um- 
bilicated) surface, and containing a colorless fluid. Very soon the 
contents of the vesicle begin to lose their transparency as pus corpus- 390 
COW-POX. 
cles are effused into it, and now a red areola forms around, with 
swelling and hardness from exudations poured into the skin and sub- 
cutaneous tissue. This continues to increase for the next two days, 
the swelling being less toward the margin, and the areola attaining 
a diameter of from one to three inches. The pock in the meantime 
becomes somewhat larger, and its contents still more purulent. From 
the tenth to the twelfth day the pustule or vesicle begins to dry up, 
the surrounding inflammation subsides, and a mahogany-colored scab 
is formed, which has a circular form, a flattened surface, generally 
with a slightly depressed centre, and which after a time, usually the 
twentieth day or later, falls off, leaving a cicatrix slightly depressed, 
with little pits on its surface arranged in a circular or oval form. 
At the time of the development of the pock, and when the areola 
is about to appear, moderate and sometimes quite decided febrile 
symptoms occur, the glands above the seat of the pock are apt to be 
enlarged, tender, and somewhat painful ; and sometimes a rash with 
a few small vesicles appears upon the limb around the seat of the oper- 
ation, and occasionally extends to other parts of the body. In rare 
cases erysipelatous or other cutaneous affections follow vaccination, 
which are commonly attributed either to the insertion of impure 
virus or to a previous unhealthy condition of the system. 
Unless the vaccine eruption from humanized virus presents the 
appearances and pursues the course above described, there is sus- 
picion of its genuineness, and the operation with new matter should 
be repeated. 
When vaccination is performed directly from the cow, the progress 
of the eruption and its appearance may be somewhat modified, and 
both the local and general symptoms are more severe than from 
humanized lymph. By some its protective power is regarded as more 
certain, and the danger of communicating human diseases, however 
much or little that may be, is certainly avoided. There are now 
facilities for obtaining bovine lymph in this and most European 
countries, and there is a popular demand for vaccination with this 
virus. It is, perhaps, important to return occasionally to the original 
source for the lymph ; but when it has been transmitted only through 
healthy persons, free from specific diseases, and is taken from a perfect 
vesicle at the proper period, the humanized virus has all the proper- 
ties that can be desired. No success with bovine virus could be more 
satisfactory and perfect than that of the army experience referred to. 
If the vaccination be performed at several points, and the operation, 
after a time, be repeated until the susceptibility of the system to its 
influence is exhausted, the protection from small-pox, if not absolute, 
is about equal to that from the disease itself. PHENOMENA. 
391 
It is thought by many that the protection, though perfect at first, 
may in time be lost, especially when the operation is performed in 
infancy. Whether this be so or not, as a test of continued or present 
protective influence, revaccination should, by all means, be insisted 
upon. The fact of a partial “ working ” of the matter in revaecina- 
tions is not a positive proof that the person, if exposed to the small- 
pox in the usual way, would have taken the disease. Vaccinated 
persons who have been repeatedly exposed by attendance, as physicians 
and nurses, upon small-pox patients without effect, may nevertheless 
be affected to some extent by the insertion of vaccine virus. One, 
however, should not feel safe until the vaccine virus will no longer 
produce any of its specific effects. 
In cases of revaccination, one of three effects may follow. If the 
person be fully protected, not only from the contagion of small-pox, 
but from that of vaccine matter, no effect beyond a little local irrita- 
tion from the prick of the lancet and the introduction of a foreign 
matter will take place. If no protective influence exists, the typical 
pock will be developed ; but if there be merely impairment of the 
protection—if it be incomplete—a modified result follows. In this last 
case, the local effect is likely to come on early, and it may produce only 
a papule, which in a few days will disappear ; or an acuminated vesicle 
may form, attain its full development on the fifth or sixth day, and 
then dry down, forming a scab which will soon fall off. In some cases, 
while these changes are going on, the local and constitutional irritation 
is as great, or even greater, than where the vaccine disease is perfect. 
Other circumstances may modify the result of vaccination—such as 
the health of the vaccinated person, and the immature condition of 
the pock from which the lymph was taken; but when it is to any 
material degree modified, the result cannot be regarded as satisfactory, 
and the operation should be repeated. 
The anatomical structure of the vaccine pock is essentially the 
same as that of variola. The vesicle has the same arrangements as to 
apartments, and the little pits left in the cicatrix mark the number 
and situation of these divisions. 
That there are some dangers attending vaccination cannot be 
denied. Erysipelas of a severe grade resulted from the vaccination in 
one among the thousand soldiers referred to, although the same mat- 
ter was used for all. This and other cutaneous troubles occur in 
some, from the insertion of matter that in other persons produces no 
such effects. In other cases matter taken from persons subject to 
eruptions or other impurities of the system, may produce irritations 
that may be accompanied by various unpleasant effects ; our knowl- 
edge on this subject, however, is very imperfect. Lichen, eczema, 392 
COW-POX. 
and impetigo, diseases very common in children, sometimes follow 
vaccination, as they do other local irritations ; but there is no evidence 
that these diseases are inoculable, or in such cases are communicated 
on the principle of a contagion. That syphilis may be communicated 
by inoculating with the blood and other matters of a syphilitic per- 
son there is no doubt; but the cases where syphilis has been commu- 
nicated by vaccination are exceedingly rare, and these have been the 
result of ignorance or carelessness. There is to my knowledge no 
evidence whatever that the conditions which are vaguely called 
scrofula are thus communicated. Still, great pains should be taken to 
vaccinate with lymph known to be from a healthy person, in order to 
avoid all apprehension and possible danger. 
When an unprotected person has been exposed to small-pox, if 
vaccination is performed in time for the vaccine pustule to come to 
maturity before the period for the invasion of the variolous fever, 
the attack of small-pox will be prevented or modified according 
to the perfection of the vaccine disease. As the latent period of 
small-pox is usually twelve days, and the maturing of the vaccine 
vesicle occurs in nine or ten days, vaccination, if successfully per- 
formed not later than two, or perhaps three days after the exposure, 
will prevent the danger from small-pox. 
If the person has been previously vaccinated, but fears are enter- 
tained that the protection is not perfect, revaccination should be per- 
formed ; and as the pock of revaccination in a partially protected 
person attains its maturity two or three days sooner, revaccination 
within five, or possibly six days after exposure to the small-pox, may 
be of service in preventing an outbreak. 
Vaccination should be performed at as early a period in life as 
possible, especially in large cities where small-pox is seldom entirely 
absent; and everyAvhere if the disease is prevalent or threatened. 
Indeed, as a rule, every child should be vaccinated within the first 
three months of its life. It is desirable that it should be in good 
health, and free from any eruptive disease. In children or others, 
if the results of the vaccination are not perfect, the operation should be 
repeated ; and however perfect it may be in children, it is now held 
by most that revaccination should be performed about the period of 
puberty. The method most common in Europe is from arm to arm ; 
the lymph being taken from a vesicle about eight days after vaccina- 
tion, though from the fourth day and onward, if there be transparent 
lymph in the vesicle, the vaccination will be effectual. The lymph 
taken at this period is often dried, and preserved on ivory or quill 
points, and dissolved into a puncture when the operation is performed. 
Sometimes the lymph is preserved in two parts of glycerine, and when VACCINATION. 
393 
thus kept in a vial it is ready for use. Better still, it is taken by at- 
traction into capillary glass tubes, and when the extremities are her- 
metically sealed by melting in a lamp, the matter may be kept for a 
long time in a good state of preservation. An undisturbed pock 
dried upon the part, forming a clear mahogany-colored, circular, 
or slightly oval crust, and this crust, preserved from heat and air, 
and a small particle of it moistened and reduced to a lymph state by 
a minute quantity of water, just before using, furnishes a convenient 
and effectual form of the virus for ordinary use in vaccination. 
This is the method most commonly practiced in this country. The 
sooner the scab is used after it has fallen, the better, for in time it 
loses its efficacy; and yet it often preserves its activity for months, 
even when imperfectly protected. In the vaccination of the regiment 
referred to, the scab, or rather several scabs successively, were mois- 
tened and rubbed between pieces of glass until reduced to a tliickish 
lymph or semifluid mass ; and after a small puncture or a few 
scratches were made with the point of a lancet, a particle was 
taken on the point of the instrument and inserted into the wound of 
the skin. This, or something like this, is still the most common 
method of procedure, especially in country practice. The operation 
is usually and most conveniently performed on the outer and upper 
part of the arm, near the insertion of the deltoid muscle. The skin 
being drawn so as to be made tense, not less than three punctures 
should be made, at least half an inch apart, and of sufficient depth in 
the skin to open some small vessels and start a little blood. If the 
bleeding is at all considerable, as it should not be, a little time must 
be taken to allow it to cease. The virus should then be introduced, 
and the part undisturbed until the speck of blood that will ooze out 
has dried upon it. Different particular methods—a single oblique 
puncture ; a series of short, fine, cross scratches, rubbing the lymph 
into them after the little oozing of blood has been wiped away, and 
still others—are practiced, the object of all being to secure the applica- 
tion of a particle of the virus to a raw and absorbing surface, and to 
prevent its removal either by the flow of blood or any mechanical 
means. In conclusion, it may be repeated that early, universal, and 
repeated vaccination is demanded for the extinguishment of one of 
the most terrific and dangerous pests that has afflicted the human 
race. 
CHICKEN-POX. —Y ARICELLA. 
This is a mild, contagious, eruptive fever, characterized by the 
occurrence of small red spots upon the skin, often coming in succes- 394 
CHICKEN-POX. 
sive crops, usually sparsely scattered, which soon become papular and 
then vesicular, and which in two or three days dry down into scabs, 
that in a few days fall off, leaving a red spot which at length fades ; 
while in rare cases minute superficial pits remain. 
This disease, trivial in itself, is chiefly interesting from its re- 
semblance and relations to small-pox, with which it has often, both 
theoretically and practically, been confounded. Notwithstanding some 
of high authority, as Hebra, regard it as a modification of small-pox, 
it seems as clearly distinct from it as other specific diseases are from 
each other. Though both are alike contagious, the poison being com- 
municated through the air, the one is not taken from the other ; and 
though the occurrence of each prevents the recurrence of its like, 
they have no influence in preventing each other : and further, though 
the eruptions ‘have a slight resemblance, they are different in their 
anatomical features, and widely unlike in their course. 
The chicken-pox is so common an affection among children, it is 
so familiar not only to the profession but to the people, it is so benign 
in its character, and requires so little attention as to treatment, that 
only the briefest account of it is here required. Its symptoms and 
progress, and the peculiar character of the eruption, need to be borne 
in mind in order to certainly distinguish it from small-pox ; for if 
the latter should be regarded as chicken-pox, the gravest consequences 
in the spread of the disease might follow ; while if the reverse should 
occur, unnecessary alarm would be produced ; and in either case the 
reputation of the physician for professional knowledge and discrimi- 
nation would suffer. 
By calling to mind the phenomena of small-pox and the order of 
their occurrence and those of chicken-pox, the diagnosis ought not to 
be difficult. 
The period of incubation may not be different. In small-pox it is 
about twelve days ; in chicken-pox it is more uncertain—is placed by 
authors from one week to seventeen days. 
The invasive fever is severe in small-pox, and lasts three days; 
that of chicken-pox is usually slight, and precedes the eruption but a 
few hours. The eruption in small-pox appears first about the face 
and neck, and is always most on the face ; that of chicken-pox is gen- 
erally first and most on the trunk, back, and chest, and sometimes the 
face escapes. In small-pox the eruption becomes distinctly papular, 
early feeling like shot under the skin ; in chicken-pox much less so. 
In small-pox the papules gradually increase, and vesicles appear on 
the point in two or three days. In chicken-pox the papules are 
very slightly developed, and vesicles, though sometimes delayed for 
twenty-four, or even thirty-six or forty-eight hours, generally appear DIA GNOSIS-PHENOMENA. 
395 
in a shorter time, often in a very fewT hours. In small-pox the vesi- 
cles, at first pointed, soon become broader, flattened, and before long 
umbilicated; in chicken-pox they are more like simple, small blis- 
ters, often irregular in outline, flattened but seldom umbilicated, and 
are on a less elevated base. In small-pox the vesicle goes on increas- 
ing to the eighth or ninth day, when it becomes purulent, and the 
maturation fever occurs ; in chicken-pox the vesicles attain their full 
size in a day or two, then become milky, and shortly after dry down 
and form scabs. In small-pox the eruption, appearing first on the 
face and neck, gradually extends downward on the body, and appears 
on the lower extremities about two days later ; in chicken-pox no 
such gradual extension takes place, but frequent successive crops of 
the eruption appear, each passing on in its stages like the first, which 
has been described. In small-pox, as maturation occurs, a secondary 
fever sets in ; but the subsequent course need not be traced, as there 
is nothing corresponding with it in chicken-pox. The patient, in the 
latter disease, convalesces almost immediately, unless successive crops 
of the eruption appear; but when this takes place, the convalescence 
is seldom delayed longer than a week or ten days. 
In some cases of very mild or of modified small-pox there may be 
more obscurity and difficulty of diagnosis, but a careful comparison of 
the symptoms and a close observation of the exact character of the 
eruption, will be sufficient to make it clear. 
No important complications or sequehe of chicken-pox occur, but 
sometimes the patient is left for a time in a debilitated state. 
As to the treatment, little need be said, since scarcely any is 
required. Confinement to the house, possibly in more severe cases a 
saline laxative or a mild diaphoretic may be useful; and, if debility 
follows the attacks, gentle tonics or a change of air may be needed. 
MEASLES.—Rubeola (Morbille). 
This is a contagions exanthematous fever, characterized by a 
peculiar ruby-colored eruption appearing on the fourth day of the 
fever, and by a catarrhal condition of the respiratory membrane, con- 
gestion of the conjunctivas and lachrymation. 
There is no disease which gives off a contagion more promptly, or 
at an earlier period of the attack, or which is more likely to affect 
unprotected persons within its sphere of influence. The poison 
appears more volatile than that of small-pox or scarlatina ; it is given 
off freely the first day of the fever, and is not likely to be retained so 
long about the patient or in fomites. As with other contagious exan- 396 
MEASLES. 
thems, one attack generally protects against a subsequent one, though 
exceptions to this are more frequent in measles than in the other 
similar diseases. Now and then a second attack, and even a third, is 
met with. 
It sometimes appears in a sporadic form, but generally has its 
periods of prevalence, and not unfrequently occurs in more wide- 
spread epidemics. It is more frequent among children, since from 
its ready contagiousness few escape exposure until more advanced 
life. 
The latent period of measles varies—the limits probably being 
from seven to twenty-one days. It may be communicated by inocu- 
lation with the nasal mucus, when the symptoms are said to occur 
on the seventh or eighth day ; but when taken in the usual way, 
through the air, the disease does not usually appear before the twelfth 
or fourteenth day. There may be slight indisposition during the 
period of latency, but generally there is not, and the attack is abrupt, 
beginning with catarrhal symptoms, and a moderate fever manifest- 
ing the common phenomena of the febrile state. The mucous mem- 
brane of the nose particularly is early irritated, sneezing commonly 
occurs, and sometimes epistaxis and a thin mucous secretion takes 
place. The irritation of the mucous membrane rapidly extends to 
the frontal sinuses, the eyes, the throat, larynx, trachea, and bron- 
chial tubes, causing frontal headache, lachrymation, and intolerance 
of light, red patches upon the mouth and throat, and soreness, 
hoarseness, and a hacking cough. In children, convulsions some- 
times accompany the attack; but in other instances, the general 
svmptoms are so slight as not to attract attention. The skin is some- 
times dry, but in other cases periods of sweating occur. Sometimes 
on the third day a remission of the febrile symptoms takes place. 
On the fourth day of the invasion, sometimes as early as the lat- 
ter part of the third, and in others as late as the fifth, the feverish 
and catarrhal symptoms increase, the temperature rising, but usually 
not to a great height. The heat at its maximum, which is at the 
period of the full development of the rash, is seldom above 103° or 
104° F.; and now the eruption upon the skin makes its appear- 
ance, first on the forehead and temples at the margins of the hair, 
then spreading downward and invading the face,* chest, and arms, 
and finally the lower part of the trunk and the inferior extremities. 
The hands and feet do not escape. Even before the rash appears 
upon the sink, a mottled or spotty redness may be seen upon the 
palate and fauces, indicative of the character of the disease. 
Commencing on the fourth day, the rash usually attains its height 
two days later—on the sixth—though it may be three or four days in PHENOMENA. 
397 
fully coming out; but soon after its complete development it begins 
to fade in the order of its appearance. In ten or fourteen days after, 
a fine, furfuraceous desquamation results, and no local traces of the 
disease remain. 
When the eruption begins to fade the fever declines, sometimes to 
the normal standard of temperature, but usually to 101° or 100° F., 
where it remains for a day or two and then disappears. This outline 
history of an ordinary case may be varied in different ways. The in- 
flammation of the mucous surfaces may become more serious, consti- 
tuting a severe conjunctivitis ; or may extend up the Eustachian tubes 
producing an otitis; or may follow down the air-passages, constitut- 
ing a laryngitis, tracheitis, bronchitis of the larger or capillary tubes, 
and sometimes producing a peculiar catarrhal pneumonia. The 
measly catarrh sometimes extends to the mucous surface of the intes- 
tines, inducing a diarrhoea which may become dysenteric. The urine 
is febrile, and deposits often a sediment of urates, and sometimes at 
the height of the fever contains a little albumen. The chief pains 
experienced are from the frontal headache, the diarrhceal and dysen- 
teric irritation of the bowels, and the inflammation in the ears. 
When young children appear to suffer from severe and continued pain, 
otitis should be suspected. Slight mental wanderings in ordinary 
cases may sometimes be observed during the eruptive stage, but 
marked delirium is unusual except in the more severe and typhoidal 
cases. In such cases coma and convulsions may occur, and when they 
appear in the eruptive stage are of more serious augury than when 
occurring at the period of invasion. The particular character of the 
eruption remains to be described. At its first appearance it has a 
dusky pink or ruby color, produced by hypersemia of the cutaneous 
vessels—largely of the veins—but soon more or less exudatign takes 
place into the tissue of the skin in spots usually set closely together, 
constituting slightly elevated papules, which increase imsize until 
they attain, with the subcutaneous infiltration which occurs, a slight 
increase of elevation, and a line or twro in surface extension. They 
are darkest at the centre, fading toward their periphery, and momen- 
tarily fade on pressure. At first they are separate, though commonly 
in groups, which are generally said to assume a crescentic form ; but 
I have failed to recognize such distinct new-moon shapes as most 
authors would lead us to expect. In many cases when these spots 
attain their full size they run together, and as the elevation in some 
cases is considerable, the face is puffed up, and the ordinary lines and 
expressions of the features are obliterated. The spots at the decline 
of the eruption fade quickly, but the vessels are sometimes left in a 
relaxed condition, and dilate under various influences, causing an 398 
MEASLES. 
occasional flush of the countenance for some time after the disease is 
passed. 
Occasionally the eruption is delayed, or after appearing is sup- 
pressed; the symptoms are apt then to he very seriously aggravated : 
but they are relieved on the appearance of the rash. 
Measles, if without serious complications, is usually a compara- 
tively mild disorder, the ordinary stuffy cough from the eruption on 
the air-passages commonly disappears with the subsidence of the other 
phenomena, and the convalescence is completed from the tenth to the 
thirteenth day. Sometimes the disease is very mild—only slight 
feverishness, and a scattered eruption occurring, with but a moderate 
degree, or the absence of catarrhal symptoms. In some epidemics 
and cases, however, the most grave symptoms occur at an early period 
—the tongue is dry and dark, the eruption sometimes scanty and al- 
most black in color, or more distinctly petechial; delirium, subsultus, 
and other typhoid symptoms supervene, and the patient, collapsed or 
comatose, dies early. 
At other times the inflammatory complications referred to, partic- 
ularly of the air-passages and the lungs, render the cases most severe, 
and are the common causes of the unfavorable results which not un- 
frequently occur from this disease. When patients escape the first 
effects of the bronchial and pulmonary congestions and inflammations, 
sometimes a subacute or chronic disease is left, which is apt to result 
in the degenerations of consumption; and sometimes, especially in 
children, a troublesome diarrhoea is a sequel of an attack, from a con- 
tinuance of the catarrhal disease of the intestines. 
In the Morbid Anatomy of Measles there are no characteristic 
appearances of Internal organs, and none other than those which the 
existence of the complications suggests. In the malignant forms, 
when the patients die early, the blood is found dark and imperfectly 
coagulated, and congestions (more commonly hypostatic) of the lungs 
may be found, and the spleen and other organs may be abnormally 
loaded with blood. Later on, as death then occurs from the compli- 
cations, the evidences of such complications will be seen. These are 
most common in the bronchi and lungs, presenting, with some modi- 
fications, the appearances seen in fatal cases of bronchitis and pneu- 
monia under other circumstances. These peculiarities will be referred 
to when the diseases of the respiratory apparatus are described. 
Treatment.—The Prophylactic Treatment consists in avoiding 
exposure to the contagion. No other external circumstances or 
known internal conditions which can be induced or avoided have 
any ascertained influence upon its occurrence. When susceptible 
persons are exposed to the contagion they take the disease; and it TREATMENT. 
399 
is to be expected that, in communities, every one will, sooner or 
later, contract the affection. When in an epidemic or general preva- 
lence the type of the disease is severe, great pains should be taken to 
isolate patients and protect the well by avoiding exposure. If the 
form of the prevalent disease is mild, such percautions are, to say 
the least, less called for. The disease is, perhaps, less likely to be 
severe in childhood, after infancy is passed, than in adults, and when 
well over with, more security is felt. 
There is no known abortive treatment of the disease, and in ordi- 
nary uncomplicated cases pursuing the usual course there is no need 
of attempts to influence its progress. Symptoms, however, may be 
palliated, and in severe cases, and especially in complications, such 
palliation may be of essential consequence. Cases, therefore, should 
receive the attention and care of a physician, not necessarily to inter- 
fere with the disease, but to watch its progress and afford timely aid 
to the patient if required. In mild cases no medication will be called 
for. The ordinary hygienic conditions should be attended to, the 
patient kept in his room, and generally in his bed, and a light diet 
prescribed; the bowels should be prevented from being constipated; 
and it is common practice to advise some gentle diaphoretic mixture. 
I have usually prescribed the mixture of Liquor Ammoniee Acetatis, 
3iijss; Spts. Nit. Dul, Sjss; Syrup Ipecac., ij.—M. Two or three 
tea-spoonfuls to an adult, in a drink of water, once in from two to four 
hours. If there is great restlessness or much cough, a Dover’s pow- 
der, or some other form of opiate, may be given as required. For 
children an appropriate (small) quantity of elixir paregoric may bo 
added to the proper dose of the above mixture. If a moderate or tol- 
erably free perspiration is kept up, but excessive heat is avoided, the 
eruption appears more readily. This is desirable since the measly 
poison, which is doubtless eliminated by the skin, is thus more freely 
gotten rid of, and the disease is perhaps rendered less severe and 
dangerous. If any of the complications which have been referred to 
arise, they must be met early and promptly by measures adapted to 
their nature. To describe here the treatment in detail for bronchitis, 
broncho-pncumonia, and pneumonia, would be anticipating what will 
be more appropriately stated under the head of those diseases. That 
treatment, however, might be modified by the measly state, but such 
modifications, if any should be rendered necessary by the other con- 
ditions, would be readily suggested to an intelligent medical mind. 
If there arc abdominal complications, severe catarrh of the bowels, 
with diarrhoea, etc., they should be treated as in other cases pre- 
senting similar phenomena. In the unusual and malignant cases, where 
the system seems overcome by the poison of the disease, and especially 400 
GERMAN MEASLES. 
if the eruption should not make its appearance at the proper time, 
elimination by the skin and irritation of the surface should be in- 
duced by diaphoretics, simple warm baths, mustard baths, sinapisms, 
or stimulating frictions. The shock to the system should, if possible, 
be abated by soothing measures, and the failing strength should be 
sustained. The internal remedies here suggested are opium, quinine, 
alcohol, ammonia, camphor, and warm drinks, as ginger-tea, hot beef- 
tea, hot coffee, etc. These articles may be variously chosen, combined 
or alternated, to meet the particular conditions apparent, and in 
quantities adapted to the age and other states. If confined to one of 
the above medicines, I should, as a general rule, select quinine as 
likely to fulfill more indications than any of the others. It tends, in 
proper free doses, to relieve internal congestions, excite diaphoresis, 
abate excessive heat, and sustain the vital energies, and it is more 
likely than any of the others to exert an antidotal influence upon the 
poison. Opium and alcohol have their claims for relieving shock and 
sustaining the system under suffering, and ammonia and camphor 
may be useful as stimulants and diaphoretics. Too much, however, 
must not be done, and a judicious selection of measures should be 
made. 
In the typhoid forms a similar sustaining course will be called 
for ; and in any of these conditions, if pneumonic inflammations are 
developed or threatened, in my judgment the full antiphlogistic 
power of quinine, alternated perhaps with ammonia, and modified 
often by morphine, should be brought into requisition. 
GERMAN MEASLES. 
EPIDEMIC IiOSEOLA.—ROTIIELN. 
An eruptive fever of mild character, bearing these and still other 
names, has been recognized, more particularly in recent times, and 
requires to be noticed. In many of its features it strongly resembles 
measles, and has often been confounded with it. It has, however, 
points of decided difference, is evidently not produced by the same 
poison, as the one is not taken from the other, nor does the one pro- 
tect the system from the other, and the two cannot be regarded as 
specifically the same. It is believed to be contagious, and therefore 
to depend on a specific virus ; but it is less so than measles—a larger 
proportion of persons who are exposed to those who have it escape its 
influence—and it has by no means as extensive and general a preva- 
lence as the latter disease. CLINICAL PHENOMENA—“ STRAW MEASLES.” 
401 
The incubative period is thought to he about a week ; its invasion 
is often coincident with the rash, though not unfrequently there is 
slight indisposition for a day or two preceding the eruption ; but it 
is always of short duration, and without distinctive characters. The 
rash usually appears first on the face, but almost as soon upon the 
extremities, and rapidly spreads over the surface. It commonly 
attains its height on the second day of its appearance, and disappears 
in the course of the next two, three, or, at farthest, four days. The 
rash has a striking resemblance in color and general appearance to 
that of measles, but it is not pretended that it assumes the cres- 
centic form of grouping. These spots, when distinct, vary in size 
from a mere point to a line in diameter, and sometimes run to- 
gether over considerable spaces. They are commonly but slightly 
elevated above the level of the skin, but sometimes, especially on the 
face, they are more papular in form. They appear upon every part 
of the body, but more thickly upon the face, forearms, wrists, and 
the lower parts of the legs. This eruption is attended with consider- 
able itching, and is apt to be followed by a slight bran-like desqua- 
mation of the cuticle. The symptoms of coryza, so conspicuous in 
measles, are slight or absent, and are almost never a subject of com- 
plaint, though the eyes are generally red, and puncta, similar to 
those upon the skin, may commonly be seen in the throat. There is 
sometimes a little cough, and during the active stage of the eruption 
a slight degree of fever, but the patient often declares himself as feel- 
ing nearly or quite well ; and the affection is without recognized com- 
plications or sequelae, and entirely disappears within about a week. 
As the disease is so slight and devoid of serious consequences, no 
particular medicinal treatment is required. If in an exceptional case 
the symptoms should be more severe, they might be met by the 
remedies for moderate fevers already so frequently mentioned. 
“ Straw Measles.”—Within some years past an eruptive affec- 
tion has been described as produced by musty wheat straw, and has 
been called measles. I have had the opportunity of seeing two cases 
occurring at the same time in lads who had ’been assisting in tending 
a threshing machine on an Illinois farm, where musty wheat stacks 
were being threshed ; and the disease was evidently produced by the 
cryptogams upon the straw. The phenomena certainly resembled 
those of measles very strikingly, not only in the eruption but the 
symptoms of coryza ; but it did not seem to me that the affection 
should by any means be called measles, as it was produced by the 
dust of the straw and not from a contagion, and was not communi- 
cated to other children in the family who had never had measles. 
I did not witness the premonitory symptoms or the full course of 402 
SCARLET FEVER. 
the disease. I only saw the cases in the height of the affection, 
when, without any history, I should have supposed it measles, and 
learned the fact of its not being communicated afterward. I fancy 
the cases were identical with the “straw measles” that have been 
described. The straw when threshed emitted much dust, which Avas 
irritating to all who inhaled it, but produced these peculiar symp- 
toms only in the two lads mentioned. 
I also witnessed in the army, during the late war, cases of fever, 
coryza, and eruption of a similar character occurring with soldiers, in 
those Avho had previously had measles as well as in others, where 
straw had been used in the tents as a substitute for beds. The affec- 
tion usually subsided in a week or so without serious consequences. 
SCARLET FEVER.—Scaelatina. 
This is an acute, contagious, specific, eruptive fever, marked by a 
high grade of fever, the early appearance of a bright red or scarlet- 
colored punctate eruption, and generally by inflammation and often 
ulceration of the throat—the eruption followed by desquamation of 
the cuticle ; and not unfrequently as a sequel to the disease, by gen- 
eral anasarca, occurring as the result of a desquamative nephritis. 
There can be no doubt that scarlatina is a contagious disease, and 
still many never take it though repeatedly exposed to those suffering 
from it in its worst as well as its milder forms. It occurs more fre- 
quently among children than adults, probably because those suscep- 
tible to it are commonly exposed in early life ; and as in other conta- 
gious affections, one occurrence generally prevents subsequent attacks. 
The contagion of scarlet fever seems powerful and diffusive, and clings 
to rooms, clothing, and other fomites with great tenacity and for long 
periods. 
The incubative period is uncertain, varying from one or a very 
few days to many, and the period after the attack in which the 
patient is capable of communicating the affection is also uncertain. 
The infectiousness, however, is believed to be slight during the first 
two or three days, increasing then as the rash and sore throat are 
developed, and probably continuing until desquamation is completed. 
The degree of severity of this disease varies exceedingly, some 
cases being remarkably mild, while others are of the greatest severity 
and malignancy. Not only the degree but the character of the phe- 
nomena varies greatly in different cases; and though it has typical 
forms, such wide variations occur, that without lengthy descriptions 
it is difficult to give a correct notion of its different manifestations. CLINICAL PHENOMENA. 
403 
A primary division of scarlatina is into Scarlatina Simplex, and 
Scarlatina Anginosa ; in the former the throat escapes, at least with 
but slight congestion, and in the latter it is affected more seriously. 
There is another form more rare, where the faucial affection occurs, 
but where no characteristic eruption appears, and this variety receives 
the name of Scarlatina sine Eruptione. 
In a typical case the invasion is sudden, usually marked by chills, 
vomiting, and soreness in the throat, soon accompanied by great rise 
of temperature, rapidity of pulse, dryness of the skin, languor, drowsi- 
ness, dizziness, headache, general pains, slight coating of the tongue, 
sometimes diarrhoea, and other symptoms of an acute pyrexia. Those 
most characteristic are the sore throat, vomiting, remarkable increase 
of temperature, and frequency of the pulse, the temperature rising to 
105°, and sometimes higher, during the first day, and the pulse to 120, 
and in children often to 160 per minute. 
On the second day the rash makes its appearance, first perhaps 
upon the palate, then upon the chest, and soon, often simultaneously, 
upon the forearms, lower abdomen, and thighs ; and in the course of 
twenty-four hours, more or less, it becomes general, attaining its full 
development in two or three days, or on the third or fourth day of 
the disease. At first the eruption consists of minute, slightly'elevated, 
bright rose-colored points, separated from each other, but closely set; 
and soon increasing in size and in redness they run together, giving 
the skin an intense scarlet hue and nearly uniform redness ; but still 
the minute elevated points of greater redness can be seen on careful 
inspection. Occasionally the papules on the side of the neck and 
chest become vesicular, and generally there is more or less infiltration 
and swelling of the skin. The vivid redness which marks the most 
typical cases is not always present. The eruption is sometimes pale 
and almost imperceptible, and where it is more marked it may be 
limited to the parts of the body where it first makes its appearance; 
and when general, the redness is more intense on the chest, neck, 
abdomen, and inner part of the thighs, and, differing from small-pox, 
it is less marked upon the face. The feet and hands are often stiff 
with the eruption and its attendant oedema. 
As the rash becomes fully developed, the other symptoms increase 
in severity—the heat is greater, the pulse and respiration are more 
rapid ; the tongue is at first coated, though soon the enlarged papillae 
are likely to project through it, the coating begins to disappear from 
the tip, and in four or five days from the invasion the tongue presents 
the red, raw, or glazed appearance, with elevated papillae resembling 
a ripe strawberry, so characteristic of the disease. The soreness of the 
throat in the common anginose variety increases, presenting a livid 404 
SCARLET FEVER. 
or dusky redness of the tonsils, the pillars of the fauces, the soft palate, 
and the uvula; all are more or less swollen, and present upon the 
surface spots of adherent secretion. This swelling, extending more 
or less to the glands in the region, is accompanied by pain, tenderness 
behind the angle of the jaws, and difficulty of swallowing. The gen- 
eral symptoms increase in severity ; the muscular weakness increases ; 
the patient is dull, stupid, slow in answer, often delirious; but the 
vomiting commonly ceases, and the bowels usually become confined. 
From the fourth to the fifth day the rash begins to fade, and some- 
where between the sixth and twelfth day of the disease, or from the 
fifth to the tenth day of the rash, it has disappeared. General im- 
provement in favorable cases now occurs, though in others typhoid 
symptoms may make their appearance ; the throat symptoms become 
more severe—the tonsils perhaps suppurating, ulcerating, or slough- 
ing ; or in other cases the urine becomes smoky and scanty, is found 
to be albuminous, and to contain blood and casts, showing implica- 
tion of the kidneys; and sometimes this condition is accompanied 
with uraemic poisoning, and later generally with oedema and general 
dropsy. 
As the rash disappears, desquamation commences, but continues 
from a few days to some weeks before completion ; the cuticle peeling 
off in scales and patches, and sometimes upon the hands coming off 
like a glove. The implication of the kidneys with accompanying 
dropsy sometimes occurs earlier, but is more likely to manifest itself 
during or after the period of desquamation, and occurs as frequently 
after mild as after severe cases. 
As already stated, scarlet fever varies much in the degree of severity 
and in the special character of its symptoms, and deviations from the 
more typical form of the disease already sketched very often occur. 
The terms Mild, Severe, and Jdalignant scarlet fever are convenient and 
are generally used to indicate the grades of severity, and other terms 
are used indicative of deviations from the usual forms of the disease. 
Some cases are so extremely mild that the patient does not take to 
his bed, manifesting little or no illness, the inflammation of the fauces 
being slight and the eruption indistinct. In these cases the diagnosis 
may be difficult, and only to be made out by the prevalence of the 
disease and the occurrence of nephritis and dropsy as sequelae. This 
variety is called Scarlatina Latens, and is of interest chiefly on account 
of the sequelae, which are quite as likely to follow this as other forms. 
Scarlatina Simplex—the fever and the eruption without any af- 
fection of the fauces, at least beyond a little redness—is rare, but still 
instances occur. Faucial inflammation without an eruption (scarla- 
tina sine eruptione) not very unfrequently happens. In these cases CLINICAL PHENOMENA. 
405 
there may be considerable or but little fever ; and some persons who 
have had the disease, have irritation of the throat and slight indispo- 
sition whenever brought in contact with those laboring under the 
affection. But the irregular forms are not all of a mild character. 
Some are exceedingly severe and speedily fatal. Others of irregular 
form are severe, but not extremely so. Hyperpyrexia and extreme 
frequency of the pulse mark some cases. In others, violent and re- 
peated convulsions occur, from the intensity of the poison, and with- 
out the intervention of renal disease. In other cases there will be 
violent delirium ; and in still others the inflammation and swelling 
of the throat will be extreme, followed occasionally by extensive 
sloughing. In some of these severer cases the eruption is imperfectly 
developed or wanting, or is of a darker color than in the ordinary or 
typical forms of the disease. Malignant cases are those where the 
severity is so great that death occurs, or is imminent, in a day or two, 
or sometimes even in a few hours. Some cases succumb speedily from 
convulsions and coma. In these, the temperature may or may not be 
extreme. In still others, apparently overcome by the direct action of 
the poison, the patient falls into a state of stupor and collapse ; swell- 
ing of the throat may be present, but little or no eruption may ap- 
pear ; and the diagnosis would be doubtful but for the prevalence of 
the disease at the time, and the exclusion of other causes for such 
violent toxsemic symptoms. Very rarely hemorrhagic cases occur, 
resembling the hemorrhagic small-pox before described. In these the 
temperature may be very high, petechise appear, and hemorrhage 
from other parts than the skin takes place. Grave cerebral symptoms 
accompany nearly all the extraordinarily severe and malignant cases ; 
and when such symptoms are present, other conditions are likely to 
be much varied. 
Various complications—affections of a local character not necessa- 
rily belonging to the disease—are liable to occur. Among these are 
otitis, inflammation extending from the throat up the Eustachian 
tube, not unfrequcntly resulting in destruction of the tympanum, the 
discharge of the bones of the ear, and more or less loss of hearing ; 
entero-colitis in children ; inflammation of serous membranes, as of 
the peritoneum, pleura, pericardium, and endocardium, and of the 
fibrous structures about the joints, presenting the phenomena of artic- 
ular rheumatism, but probably from a poison differing from that of 
ordinary rheumatic fever; and all these sero-fibrous affections may 
be the result of imperfect elimination from the kidneys. Laryngitis, 
which may result in suffocation, gangrene of the mouth or noma, 
which may prove very serious, and coryza and ophthalmia, are still 
other conditions complicating some of the cases of this disease. 406 
SCARLET FEVER. 
Diphtheria is said sometimes to present itself as an intercurrent 
affection, a membrane forming, not of a pultaceous character, like 
that produced by simple pharyngitis, nor of the character of the exu- 
date usually produced in scarlatina, but the more firm structure char- 
acteristic of the diphtheritic state. 
The disease of the kidneys, tubal and parenchymatous nephritis, 
so often accompanying scarlet fever, may be regarded as a complica- 
tion, or as one of its natural results, though it occurs to any con- 
siderable degree in only a minority of cases. This disease of the 
kidneys, producing albuminuria, and generally dropsy, and not un- 
frequently uraemic poisoning, may occur while the scarlatinal disease 
is in progress ; but it is more frequent after other symptoms have 
disappeared, and as a sequel to the fever. In some of these cases the 
disease of the kidney is acute and rapid, accompanied with an active 
fever, uraemic poisoning and its consequences, coma and convulsions ; 
or dropsical accumulations come on speedily. In others, the kidney 
affection is more chronic, pursuing a slow and progressive course, the 
dropsy and anaemia being the more prominent symptoms. In some of 
these cases the symptoms are never severe and soon subside—the 
disease of the kidneys disappearing spontaneously in a manner similar 
to the disappearance of the rash. In others, there is greater severity 
and persistence ; and, in rare instances, suppression of urine occurs, 
and a fatal termination follows. In the milder cases the inflamma- 
tion is tubal and desquamative, while in the severer the inflammation 
often extends to the parenchyma of the organs, and occasionally per- 
manent changes result. In these cases of disease of the kidneys the 
urine becomes albuminous and sometimes bloody, and casts of the 
uriniferous tubes are often found, but in very many of them this 
condition passes off without serious results. Not unfrequently, how- 
ever, and perhaps oftener after mild than after severe cases of the 
primary disease, anasarca and uraemia result, which may be attended 
with severe headache, soon followed by eclampsia, coma, and death. 
The fatal cases from this cause are exceptional, and generally, under 
judicious management, the albuminuria disappears and the dropsical 
accumulations are absorbed away. But when the kidneys are more 
permanently affected, the albuminuria continues, and the dropsy may 
become excessive. Sometimes the dropsical conditions linger after 
the urine is no longer albuminous, and occasionally dropsy occurs 
where no albumen has appeared in that secretion. In such cases there 
will be anaemia from the previous blood poisoning. 
Morbid Anatomy.—On post-mortem examination of patients 
dying of scarlatina, most of the internal organs appear to the naked 
eye to be free from decided changes. The liver and kidneys, however, MORBID ANA TOM Y—DIA GNOSIS—TREA TMENT. 
407 
may be somewhat softened, and the blood imperfectly coagulated, but 
still fibrous clots are sometimes found in the right ventricle extend- 
ing into the pulmonary vessels. 
In the “malignant” or rapidly fatal cases, hypostatic congestion 
of the lungs is sometimes found, collapse of the lungs may occur, and 
also hemorrhage into the substance or on the surface of internal 
organs. The throat, in the anginose varieties which have continued 
longer, shows signs of inflammation and ulceration, and sometimes 
of gangrene. The glands of the intestines, both the solitary and 
Peyer's patches, are somewhat enlarged. When death results from 
complications or the sequelae of the disease, other gross changes are 
present, but they are such as occur in other than scarlet-fever cases, 
and will be described when the local diseases of the different organs 
are discussed. Recent and minute investigations have shown that 
inflammatory hyperaemia and proliferation occur not only in the skin, 
throat, mouth, and kidneys, but that the alimentary canal, the sali- 
vary glands, the pancreas, liver, lymphatic glands, and spleen show a 
tendency to similar changes. The endothelium and muscular coats 
of the small blood-vessels show germinations, with an accumulation 
of lymphoid cells in the tissues around. There is swelling and pro- 
liferation of cells in the rete mucosum, with serous effusion and 
migration of leucocytes between this layer and the epidermis, causing 
the tendency to the detachment of the latter. In the various epi- 
thelia, especially those of the renal tubules, changes resembling those 
in the skin occur; and in the interior of lymphatic glands, especially 
those in the region of the inflamed throat, there is said to be a dis- 
appearance of the lymphoid cells, and the appearance in their stead 
of giant cells containing many nuclei, which ultimately become 
fibrous. The kidney changes will be more particularly described 
when the various diseases of those organs are considered. 
Diagnosis.—The differential diagnosis of scarlatina is to be made 
by comparing the phenomena with those of the diseases which it re- 
sembles. In ordinary cases this is by no means difficult, as the rapid 
and excessive rise of the fever, the early appearance of the peculiar 
eruption, the soreness of the throat, the early white coat, followed by 
the “strawberry” appearance of the tongue, are quite characteristic. 
The unusual forms, especially the malignant variety, where convul- 
sions and death occur from the early blood poisoning, without the ap- 
pearance of the eruption, or a full development of the soreness of the 
throat, are often obscure. The prevalence of the disease and the 
violence of the symptoms will, however, aid in the diagnosis, and on 
the whole it is as clear as in most other diseases. 
Treatment.—From the great variety of phenomena presented 408 
SCARLET FEVER. 
in the different cases of scarlatina, and the uncertainty as to the power 
of therapeutic measures in controlling them, embarrassment can but 
be felt in endeavoring to give an account of the treatment which 
should be adopted. The prophylactic management, as in other con- 
tagious diseases, consists in isolation, in ventilation, in great care as 
to cleanliness, and in disinfection of the room, the furniture, and the 
clothing that has been exposed to the contagium. "While this contagion 
is uncertain in the production of effects, on account of differences in 
individuals as to susceptibility, it is yet very subtile and tenacious, 
and requires great care to prevent effects for a long time after the 
disease in which it has been produced has passed away. All the 
means necessary in preventing the contagion of small-pox or other 
contagious diseases should be used in this. The room should have as 
little furniture as possible, especially textile fabrics. Rags should he 
used instead of handkerchiefs about the patient, and burned up when 
soiled. Open vessels of disinfecting fluids should be kept in the room. 
The excreta should be received into vessels containing disinfectants. 
During desquamation it is advised that the whole surface be kept 
anointed with camphorated or carbolized olive oil, or, better still, 
perhaps, with carbolized cold cream or vaseline ; and after the disease 
has disappeared, the patient’s room should be made tight and fumi- 
gated with burning sulphur, keeping a cloud of sulphurous acid in it 
for several hours. Although all these precautions are rarely followed, 
they should be where exposure is to he avoided, especially where 
young persons are to come to a house where cases of the disease have 
lately occurred. 
In the Treatment of cases, as there are no known and certain 
means for antidoting the poison, the expectant or symptomatic plan 
is chiefly to he followed. Efforts, however, may be made to favor 
the elimination of the specific contagium and other morbid products 
which its operation induces, and certain medicines supposed to have 
some antidotal influence may be used. 
In the milder cases but little interference is required beyond 
proper hygienic management, confining the patient to the bed in a 
proper apartment, directing a light and suitable diet, seeing that the 
bowels are kept in proper condition—a gentle saline laxative often 
being advisable to favor the elimination of injurious materials from 
the intestines—and giving diaphoretics, such as the acetate of ammonia, 
spts. nit. dulc., and syr. ipecac. Other mixtures for effecting the same 
object with the skin, bringing out the eruption and abating the fever, 
may be useful, and will at least do no harm. In these mild, as well 
as in all other cases, much care should be taken during convalescence 
to have sufficient clothing, and to avoid exposure to cold and damp- TREATMENT. 
409 
ness; as such exposure, by checking the action of the skin, may excite 
the inflammation of the kidneys, so likely to occur. A free state of 
the bowels should be maintained, and this tends to relieve the burden 
thrown upon the kidneys ; and the diet, while nutritious, should be sim- 
ple, blalid, and unirritating. Spices and alcoholics should be avoided. 
This general course of treatment may be all that will be required 
in the cases of more severity which present the ordinary moderate form 
of the disease and where it pursues its regular course. When special 
symptoms present themselves, they must be met by such palliative 
measures as their particular conditions indicate. Excessive tempera- 
ture may be reduced by the cold or tepid bath, or wet pack, or fre- 
quent sponging, as well as by diaphoretics and antipyretic medicines. 
If the eruption is slow or scanty in appearance, the warm bath, oc- 
casionally repeated, may be very useful, as may also be more active 
diaphoretics. Doubtless poisonous materials escape from the skin, 
the throat, and the kidneys, in the ordinary progress of the disease, 
and their escape from the skin in the eruption is most abundant, and 
can be most safely promoted from this surface. The acetate of am- 
monia, when the eruption is deficient, may be freely given, or, what 
will be much more efficient as a diaphoretic, the jaborandi, or its 
active principle, pilocarpin. This remedy will often be of very great 
service in this disease, especially when the eruption does not appear 
or prematurely recedes, when the kidneys are congested and the urine 
is nearly suppressed, and when symptoms of uraemic poisoning are 
present or apprehended. The warm bath, dry cups to the loins, and 
the administration of jaborandi so as to secure its full diaphoretic 
effects, will often rescue a patient from a most perilous condition. If 
the patient is too weak to be put into the bath, or the facilities for it 
are not at hand, he may he packed in a warm wet sheet, covered with 
blankets, and kept there for an hour or more, until the diaphoresis is 
fully established and relief obtained. Should there be headache and 
delirium, cold may be applied to the head at the same time, and 
sinapisms to the extremities and other parts of the surface. Should 
such symptoms persist, elimination by the bowels may be of great ser- 
vice, and a cathartic which shall induce liquid discharges, as jalap 
and cream of tartar, when the strength will allow, or the cream of 
tartar combined with the sulphate of soda or magnesia, should be 
given. Urea and other materials which the kidneys should eliminate, 
when they fail in the performance of their functions, may be carried 
off by the intestines and the skin, and these should be excited to per- 
form this vicarious office. The relief which, under my observation, 
has been obtained by these measures, has been so striking that I am 
induced to emphasize the recommendation of their use. 410 
SCARLET FEVER. 
One source of danger is the severe inflammation, ulceration, and 
sloughing of the throat. For this state of things various local appli- 
cations are advised. A common domestic application is a thin slice 
of fat salt pork externally; and some of high professional authority 
advise it as among the best of external applications. 
When the external glands of the neck are much swollen, poultices 
or water dressings may be used. As it is believed that the system 
may be re-inoculated by the poison produced in the throat, the appli- 
cation of antiseptics to the internal surface seems indicated. Most of 
the remedies recommended in diphtheria may be useful in scarlatinal 
sore throat, and they need not be particularly described here. The 
steaming, the gargles, the sprays, the swabbing, and the insufflations, 
as best adapted to particular cases, may be called for (see Diphtheria). 
I know of no general treatment more likely to be of service than that 
recommended for diphtheria—quinine and chlorate of potash, the 
doses of the former varied to meet the different conditions—antipy- 
retic doses when hyperpyrexia is present, and antiseptic and sustaining 
doses in the suppurating and sloughing stages; and this article, in 
connection with the chlorate of potash, and perhaps other prepara- 
tions of chlorine, is as likely to counteract or .antidote the scarlatinal 
poison as any agents of which we have knowledge. Various other 
remedies, with reference to an antiseptic or antidotal effect, have been 
advised. The liquor soda chloratce, preparations of carbolic and sali- 
cylic acids, permanganate of potash, etc., maybe used locally; and 
chlorine, carbolic acid (one grain as a dose for an adult), salicylic 
acid (from six to fifteen grains for an adult) have been strongly rec- 
ommended. A chlorine mixture may be prepared by putting eight 
grains of the chlorate of potash, pulverized, into a pint bottle, and 
pouring upon it a drachm of strong hydrochloric acid. The mouth 
of the bottle should be closed until the violent action has ceased, 
when small quantities of water should be added from time to time, 
and the bottle shaken until it is filled. The whole pint may be taken 
by an adult in a day, and by children in proportionate quantities. 
The sodium sulpho-carbolate has been very highly recommended, as 
in diphtheria ; but it needs further testing ; and the sulphites of soda 
and magnesia are thought by some to have a degree of controlling 
effect over the disease. 
The cases of extreme severity, designated as malignant, when the 
system is speedily prostrated as by a narcotico-acrid poison, or when 
a hemorrhagic state is present, or when repeated convulsions and 
coma occur, offer little encouragement in the way of treatment. The 
tendency to death is so strong, and the course of the disease so rapid, 
'that no remedies seem able to avert the fatal result. Some writers, in TREA TMENT—IIIS TOR T. 
411 
these extreme cases, especially when death is threatened by asthenia, 
recommend the free use of alcohol, but its good effects are at least 
doubtful, though in accordance with authority it may he tried. Am- 
monia, quinine, hot or mustard baths, sinapisms, warm drinks, etc., 
may be tried, as they are suggested on rational principles; and when 
hemorrhages occur, attempts to control them by styptics, ergot, etc., 
as in other cases, should be made. In violent convulsions, ether or 
chloroform by inhalation may he given ; and whenever in any case 
there is a profuse diarrhoea, or great restlessness and pain, opiates, as 
in other diseases, will he indicated. The treatment of the albuminuria 
and dropsy occurring as sequelae, must be conducted on the same 
principles as in other cases of acute nephritic affections. The skin 
and intestines must be made, as much as possible, to do the work of 
the disabled kidneys—diaphoretics and cathartics must be used as 
they can be borne ; dry cups may be applied over the region of the 
kidneys ; the warm bath or warm pack repeatedly used ; cream of 
tartar water should be given as a drink, the jaborandi as the most 
effective diaphoretic, and such hydragogue cathartics administered as 
the strength of the patient and the condition of the intestines will 
justify. Later, for relieving the anaemia and debility so likely to be 
present, tincture of iron and other tonics may be demanded. 
The otitis and other comjjlications and sequelae must be treated as 
they would be when occurring in other cases, taking into account the 
condition of the system, as produced by the scarlatinal disease, which 
is generally that of debility and exhaustion. 
EPIDEMIC CHOLERA. 
ASIATIC CHOLERA. —CHOLERA ASPHYXIA. 
This is an infectious and epidemic disease of great severity and 
fatality, which has probably existed for a long time, and has pre- 
vailed in the Eastern world to an unknown extent; but as far as 
known in modern times it originated in India, where it appears to 
have existed as an endemic affection for an indefinite period ; but in 
other parts of the world it has only made visitations as an epidemic. 
Its history has been known to the civilized world only since 1817, 
when it commenced its march from the delta of the Ganges. Dur- 
ing the next fifteen years it spread over a large portion of the globe. 
It traveled northwestward through Asia and Europe, and reached our 
continent in 1832. It appeared again in 1834, when it disappeared 
until 1849, when it repeated its visits, and during that and the sub- 412 
EPIDEMIC CHOLERA. 
sequent years of 1850, ’51, and ’52, it prevailed in many localities, 
and came under my observation and care in Chicago during the three 
last-named seasons, and also, but to a less extent, in 1854. It made 
its appearance again in I860, and during that and the subsequent 
year, it visited many of the larger towns in different States, but its 
prevalence was not so extensive as on the former occasions. In 1873 
it Avas.again introduced into this country through the agency, as was 
supposed, of the mercantile marine, but its prevalence was less than 
on any previous visitation. 
Having seen much of this disease as it prevailed in Chicago in 
1851-1852, and 1854, and especially in 1852, when a very large num- 
ber of emigrants from Europe and others came under my charge 
as city physician, having witnessed the introduction of the disease 
and watched its spread, and having had under my personal care and 
treatment in a cholera hospital and the homes of the patients many 
hundreds of cases, I may be permitted to express individual opinions 
very strongly entertained, without so much reference to the views of 
others and the literature of the profession on the subject as might other- 
wise have been required. My opportunities of experience in its treat- 
ment (commenced both at an early and more advanced period of the 
disease) were exceedingly ample ; and taking charge of a large num- 
ber of cases as they came under municipal control, after being under 
the care of numerous other physicians, I witnessed the methods and 
results of a great variety of treatment, and formed opinions on that 
subject particularly, which subsequent study has not induced me to 
change. 
The literature of cholera is very extended ; and even an outline of 
it would extend this article beyond the limits necessarily set for it. 
An account of the disease will, therefore, be limited to a brief state- 
ment of what are believed to be its causes—essential, predisposing, 
and accessory ; of its phenomena, symptomatology, and pathology ; 
and a more particular account of its treatment, prophylactic and 
curative. 
Causes.—Although the specific entity of the cholera cause has 
never been identified and demonstrated, yet the exclusion of all other 
conditions as causes from the great variety of such conditions under 
which it appears, seems to leave nothing for our acceptance but a 
belief in a subtile material substance—a cholera poison. As no disease 
can occur without an antecedent producing it, and no specific, 
identical, and definite disease without a more or less specific cause 
operating upon or within the organism, we are at once forced to the 
conclusion that a disease like cholera, distinct and essentially identical 
in its character wherever it appears, far-spread and migratory, affect- C A USES. 
413 
ing alike a great variety of persons in different conditions and under 
diverse circumstances, must be produced by a special agency capable 
of spreading, and of entering and operating upon the system from 
without. As no agent of this kind can act where it is not, it has 
locality, and surrounds and pervades the bodies of those affected by it. 
If scientific observation has not yet been able to demonstrate the 
material of the cholera cause, it has shown with a degree of certainty 
that many suspected conditions cannot be that cause. 
Though the disease had its origin in a hot and moist climate, and 
is most likely to spread in one of that character, no particular condi- 
tion as to temperature or humidity can be considered as the essential 
cause, as it has prevailed in every climate, and at all seasons—in 
every state of the atmosphere as to dryness or humidity, density or 
rarity. Neither does it depend upon any appreciable electrical state, 
as it has been found by experiment that the most opposite electrical 
conditions exist where the disease prevails. Though certain relations 
seem to exist between this cause and paludal malaria or marsh mias- 
mata, yet the cause of cholera cannot be common malaria, as it has 
often prevailed where intermittents were never known, and has 
avoided, in its progress, many districts where these fevers most pre- 
vailed. Though the presence or absence of ozone may modify the 
action of the cholera cause, conditions as to ozone cannot be that cause 
itself, as cholera has prevailed both when there was an abundance and 
a deficiency of that material in the air. 
Not only is there uncertainty as to what the material is, but there 
is much obscurity as to many of the conditions and the mode of its 
production, of its multiplication and diffusion. However produced 
or propagated, it is certainly progressive. It comes to a locality, it 
acts, it goes away or becomes inert. As the idea cannot be enter- 
tained that it was so abundant in its original source as to spread un- 
increased over so large a part of the world as it repeatedly has done, 
it must be reinforced as it progresses by additions to its quantity. 
It can hardly be supposed to be the result of chemical actions, as we 
know of nothing analogous in inorganic matter; yet we are not au- 
thorized to positively deny that chemical changes may occur in some 
unknown ingredient in the atmosphere, induced on some principle of 
catalysis, producing a material capable of thus operating upon the 
system. The analogies, and certainly the general enlightened profes- 
sional sentiment of the present day point to living germs, and suggest 
parasitic organisms as the materies morbi of cholera. The germinal 
theory of specific diseases has already been spoken of, and need not 
further be discussed. If accepted, the law of propagation will account 
for the increase of the poison, and the diffusion may be by increase, 414 
EPIDEMIC CHOLERA. 
by winds, or by intercommunication. There seems to me little doubt 
that the atmosphere is the chief medium of diffusion, and that this 
poison may multiply and pass by spontaneous extension for consider- 
able distances through the air; but particles of the germinal matter 
may be carried by ships, by caravans, or by persons from one point to 
another ; and when thus brought into a locality containing the neces- 
sary ingredients and favorable conditions for its multiplication, the 
poison may be abundantly reproduced. 
It is thought by many that the poison of cholera is contained 
largely in the discharges from the intestines, and that finding access 
to water it is spread and communicated by this element. That it is 
capable of spreading, and being communicated in this manner, is 
indicated by various facts ; but that this is the exclusive or the chief 
means of its spread and communication the whole facts by no means 
show. 
A statement of the facts attending the appearance of cholera in 
Chicago, in May, 1852, according with so many other facts in other 
localities and at other times, will illustrate the view of its spread 
which is intended to be expressed. Previous to the appearance of the 
disease in that city it had commenced its ravages along the Mississippi 
river, had passed up the Illinois river and appeared in the town of La 
Salle, some fifty miles from Chicago. A canal connects La Salle with 
Chicago, and boats were frequently passing from one place to the 
other. A boat from La Salle, but without any cholera patients on 
board at any time, was placed in dry dock in Chicago for repairs. 
Several workmen were engaged upon it, and the first case of cholera 
which appeared in Chicago was in one of these workmen, who took 
the disease in a few days after commencing his work on the boat, and 
soon died at his home in the south part of the city. The next case 
was some two days later, in a man who had had no communication 
with the other case, and who resided in a low and filthy situation near 
the centre of the city, a third or half a mile from the dry dock, and a 
much greater distance from the place where the first case had occurred. 
This last case was seen by me in the last stages of the disease, and was 
speedily fatal. Within the next three or four days cases had occurred 
at various points in almost every part of the city, without our being 
able to trace any communication directly with other cases, and some of 
the patients were women and children, who had not left their houses * 
since the arrival of the boat from La Salle, which apparently brought 
the poison. From this time the disease prevailed more or less in every 
part of the city, but chiefly in the lowest situations, and in some dryer 
parts where water was used from wells, and was not, as in other situa- 
tions, brought from Lake Michigan. CA USES. 
415 
The conclusion that seems inevitable from this and many other 
similar instances is, that on this occasion, the cholera poison was 
brought in this canal-boat to Chicago, in the atmosphere, or attached 
to some of the freight. Finding there the conditions favorable for its 
multiplication, it was soon produced in sufficient quantity to pervade 
the whole city, producing its effects upon those most susceptible to its 
influence—at first upon a few, but soon, as it further multiplied, 
affecting large numbers, and continuing until the frosts of autumn 
and winter came, when it disappeared. 
During the summer there was a large emigration to the Northwest 
from Sweden, Norway, and Germany, all coming to Chicago for distri- 
bution. Some of these emigrants came by railroad, and some by lake 
steamers. In July and August, when the disease in Chicago was at 
its height, a company of these emigrants, hurried on from the sea- 
board, with the accumulated filth of their long voyage within, upon, 
and around them, would frequently be attacked in a few hours in 
large numbers, sometimes upon the steamer, or the dock, or in the 
place of their first lodging in the city ; and in these cases the disease 
ran a most rapid course. 
This showed that the incubation period of the poison was short, 
and that the debilitated and filthy condition of such emigrants ren- 
dered them peculiarly liable to its speedy action. 
The question of the contagiousness of cholera is one that has been 
much mooted, and, it must be confessed, sometimes without a clear 
appreciation of what constitutes a contagious disease. According to 
the definition already given, a contagious disease is one produced by a 
poison generated in the bodies of persons affected by the malady, and 
which is capable of transmission to others, producing the same spe- 
cific affection. "Unless the distinction is made between infection and 
contagion, vagueness and confusion will result. The term infection 
designates all morbid poisons which enter the body and infect it, 
while contagion is restricted to that class of poisons which is produced 
by the processes of the specific disease in the system, and is communi- 
cated to others, repeating the phenomena. 
The facts in the history of cholera do not prove that this poison is 
exclusively produced in the bodies of the sick; but, on the contrary, 
in my judgment, they indicate that the poison is often, at least, pro- 
duced independently of the bodies of those laboring under the disease, 
and that it is usually produced, multiplied, and diffused independently 
of those affected by it. The detailed reasons for this opinion the limits 
of this article will not allow to be stated. But that opinion, long since 
formed by reading the history of its progress and - its incursions, and 
confirmed by a careful observation of its occurrence and spread in 416 
EPIDEMIC CHOLERA. 
Chicago and other places in the West, has not been seriously shaken 
by all the authoritative opinions and ingenious arguments which have 
since appeared. Of nothing have I been more clearly convinced from 
general observation, than that when cholera is prevailing in a locality, 
those who come in contact with cholera patients are not perceptibly 
more liable to the disease than those who, exposed to the same general 
conditions, avoid such contact. I by no means affirm that the poison 
is to no extent or in no degree produced in the sick, but it seems to 
me clearly that it is not wholly or chiefly so produced. I cannot 
doubt that it is multiplied, if not exclusively, yet very largely, out- 
side of the bodies of cholera patients. 
While, therefore, not denying its possible contagiousness, I do dis- 
sent from the opinion that, as in small-pox, the poison is produced 
and multiplied exclusively, or even chiefly, in the bodies of the sick, 
and that the disease is ordinarily produced by this poison being con- 
veyed unchanged to others. The poison may have originated out of 
the body, and is certainly multiplied out of it. 
This view, so strongly impressed upon my own mind by the facts 
observed, is held by nearly all observers in India, who have drawn 
their conclusions from large experience and not from speculative 
theories. With the support of the large body of English physicians 
in the home of cholera, I am confirmed in the convictions which 
could hardly have been shaken by statements however authorita- 
tive. 
Though so much doubt exists as to the essential nature of the 
cholera cause and the particular method by which it produces its 
effects, yet the circumstances and conditions, as regards localities and 
persons, which favor the spread of the poison and render its action 
more effectual, are well established. Though in particular cases gen- 
eral rules are set at defiance, yet the facts respecting co-operating 
causes are sufficiently uniform to establish the general rules. 
Briefly and generally stated, the localities most liable to the 
spread of cholera, other things being equal, are those which are 
low, moist, and, particularly, filthy. Warm climates and seasons are 
more favorable than cold, and a densely populated region than one 
sparsely settled. It is more liable to follow water-courses and thor- 
oughfares, partly because these are usually more low, filthy, and densely 
populated ; and partly, no doubt, because the poison is conveyed by 
intercommunication. Still, in its progress it takes general, and some- 
times particular courses, in obedience to laws we do not understand. 
All experience has shown that the existence of decomposing organic 
material in the soil and the air favors the spread of the disease, prob- 
ably by furnishing a pabulum for the development of the poison, and CA USES. 
417 
a nidus for its existence and action in the bodies of those inhaling 
the foul air or imbibing foul ingesta, 
With regard to the classes of persons most liable in the same local- 
ities to be attacked and become its victims, the intemperate, the 
destitute, the filthy, the vicious, the enfeebled, the terrified, and the 
degraded, are immeasurably more subject to its ravages than those in 
opposite conditions. Yet, when the poison is abundant and possesses 
great activity, no class or condition can claim an exemption ; but the 
cases are so rare in which the poison is sufficiently intense to affect 
perfectly healthy persons, who place themselves under the most favor- 
able circumstances, and avoid all predisposing or accessory causes—in 
short, obey all the hygienic laws—that the violations of these laws be- 
come the conditions of attacks—in other words, the 'predisposing or 
accessory causes, in a vast majority of cases at least, become necessary 
antecedents to the production of the disease. So much have the hab- 
its and state of individuals to do with the prevalence or suppression 
of this scourge, that, as a general proposition, it may be stated that 
the “ cholera poison owes its potentiality to the conditions in which 
it finds the subjects of its invasion.” In this view of the subject, a 
knowledge and the avoidance of these particular predisposing causes 
become matters of the most vital importance. 
The existence of decomposing matter in the system has already 
been referred to as a condition favoring the operation of the cholera 
poison. This is a view now very generally entertained, not only in re- 
lation to cholera, but to other zymotic diseases as well. Dr. Wm. B. 
Carpenter, of London, arranges the generally recognized predisposing 
causes of these diseases under three heads, viz.: 1. Those which tend 
to introduce into the system decomposing njatter that has been gen- 
erated in some external source. 2. Those which occasion an increased 
production of decomposing matter in the system itself ; and, 3. Those 
which obstruct the elimination of the decomposing matter naturally 
or excessively generated within the system, or abnormally introduced 
into it from without. 
Under tho first head is ranked the ingestion of putrescent food, of 
water contaminated by sewage or other decomposing matter ; and the 
inspiration of air charged with putrescent or miasmatic emanations. 
Under the second, any unusual source of degeneration of tissues 
within the body, such as excessive muscular exercise, injuries, etc., 
and here may be added, fear, despondency, and other depressing pas- 
sions ; and the derangement of the secretions. 
Under the third, an insufficient supply of air, a high external tem- 
perature (which slackens the respiratory process), and the ingestion 
of alcohol; to which should be added, the sudden occurrence of a 418 
EPIDEMIC CHOLERA. 
cooler and moister atmosphere, as a rain-storm after unusual heat, 
checking secretion from the skin. If there be added to this category 
of causes insufficient food, and any influence not enumerated which 
may depress the vital energies—and particularly if there be added 
also those substances, whether in the shape of indigestible food, of 
medicines or of luxuries, which will irritate the mucous membrane of 
the stomach and bowels—we have the conditions predisposing to 
cholera. 
The history of cholera which occurred under my own observation 
in Chicago, during the seasons already referred to, corroborates, in- 
deed is the chief foundation of the views which have been taken of 
the etiology of the disease. The minutely recorded details might be 
of interest, but they are necessarily excluded by the limits I have 
assigned myself on this subject. 
With a reference to the following historical incident, I shall close 
the subject of the cause of cholera, and proceed to the other divisions 
of the general subject already indicated. 
Dr. Yerrollot, Physician to the French Embassy near the Sublime 
Porte, has written a minute history of the spread of the epidemic in 
1847 through Asia and a part of Europe. In describing its general 
spread and terrible ravages, from the shores of the Caspian Sea up 
the river Volga, among* the semi-civilized Mussulmans, and still more 
filthy and degraded Russians, he mentions with great but reasonable 
enthusiasm one place as a remarkable exception. 
“ There is a small Moravian colony called Sarepta, situated in a 
bend of the river, in the midst of the Kalmuck hordes, eulogized by 
all travelers for its remarkable industry and minute cleanliness, and 
for all other laudable and fortunate features of character. The cholera 
seemed to respect this sacred spot, passing by in 1830 and in 1848, 
without inflicting on it the least evil.” This fact, corroborated as it 
is by multitudes of others of like character, speaks volumes on the 
subject of prevention ; and the success which has attended the various 
sanitary measures in Europe, and, so far, in this country, during the 
recent visitations of the disease, confirms these general etiological 
views. If the inhabited globe were a Sarepta, this terrible scourge 
would disappear from it forever. The conditions for the origination, 
the multiplication, and extension of the poison would cease to exist, 
and there would be no subjects favorable to its attacks. 
Symptomatology.—The phenomena—the symptomatology and 
pathology of cholera—I propose to present but briefly. 
The external features or symptoms of the disease are of a striking 
character and are readily recognized. 
The disease is usually divided into four stages. These stages, as is CLINICAL PHENOMENA. 
419 
the case with the more or less arbitrary divisions into stages of most 
other diseases, run into each other, and are not always well defined; 
neither do they all exist in every instance, but in their general outline 
may commonly be observed. 
Tho, first is the Premonitory Stage, marked by general lassitude, 
dull pain above the eyes, sometimes constrictions in the calves of the 
legs, disturbed digestion, abdominal uneasiness, slightly coated tongue, 
and diarrhoea. This stage is not always observed, and when it is, is 
liable to vary much in the number, severity, and duration of the 
symptoms; but it usually may be traced, the premonitory diarrhoea, 
usually painless and watery, occurring in a very large proportion of 
the ordinary cases, and continuing from several hours to some days 
before the full development of the disease, or the arrival of the 
Second Stage, which is marked by active vomiting and purging of a 
fluid which soon becomes of a rice-water appearance ; by great thirst, 
coldness of the surface, severe spasmodic pain or cramps, particularly 
in the abdomen and extremities. In the commencement of this stage 
the pulse is sometimes a little excited, and not unfrequently quite 
firm; but it soon becomes more and more feeble as the impression of 
the poison is more profound, and as the exhausting discharges con- 
tinue. Toward the latter part of this stage, the surface becomes 
much shrunken and more or less blue, and may be comparatively dry, 
or covered with perspiration. When the disease is severe, this stage 
only lasts a few hours—in less violent cases it may last a day or 
more—when, if reaction and improvement do not occur, it passes 
into the 
Third, or Stage of Collapse, marked by loss of circulation, labored 
respiration ; the skin being shriveled, livid, and usually bathed with 
cold perspiration. The discharges sometimes continue in this stage, 
though less profusely ; at other times they are suspended, even that 
from the skin, either from exhaustion of the fluids of the system, or 
from a suspension of nearly all vital action. The pain and cramps 
sometimes continue in this stage, while in other cases they cease, the 
patient becoming more quiet and comatose. During some parts of 
the second stage a ringing in the ears usually occurs, and the voice 
becomes husky and peculiar. These symptoms usually continue 
throughout the remainder of the disease, the liuskiness of the voice 
increasing in the third stage, until the patient is able often only to 
articulate in a whisper. Those who survive the active onset of a 
severe attack, especially if the disease pass into the third stage, are 
liable to the 
Fourth Stage, presenting the characters of a low irritative fever, 
generally accompanied by protracted local congestions, or a low form 420 
EPIDEMIC CIIOLEEA. 
of inflammation of the mucous membrane of the intestines, partic- 
ularly of the follicles of the mesenteric glands, and other abdominal 
viscera, and of the brain and spinal marrow. Occasionally cases of 
cholera morbus, or what has been called English cholera, occur, and 
also serous vomiting and purging during the progress of malarial 
fevers, which, in their external symptoms, resemble very nearly 
genuine epidemic or Asiatic cholera ; yet they differ, as I apprehend, 
in the essential cause, and certainly as regards fatality—the former 
class of cases being almost always amenable to proper treatment, even 
if the treatment be not commenced until an advanced stage; while 
the mortality of the latter, when the same apparently advanced con- 
dition is permitted to occur, is too well known. Dissimilar causes 
not unfrequently produce similar, though perhaps not in every re- 
spect identical effects, and these cases of sporadic and accidental 
cholera are not produced by the specific poison which gives the epi- 
demic variety its virulence. 
The particular manner in which the cholera poison, when intro- 
duced into the system, produces its effects, is still a matter of conjec- 
ture. Whether by changing the chemico-vital relations of the blood, 
or by primarily attaching itself to the nervous or other tissues and 
changing their actions, we may not say ; but soon, and earliest, its 
effects are manifested upon the ganglionic nervous system. Though 
these nerves of organic life are not always found perceptibly changed 
in structure after death, they are sometimes softened and enlarged, 
and their functions in the progress of the disease are modified, dimin- 
ished, and in severe cases rapidly overpowered. That portion of the 
brain and nervous system which is engaged in thought and mental 
sensibility is left comparatively undisturbed; while all the func- 
tions depending upon the organic nerves, such as nutrition, secretion, 
exudation, circulation, and respiration, and their consequences, as 
animal heat, and the general movements of the system, are either 
enfeebled, suspended, or greatly modified. Digestion seems entirely 
suspended—glandular secretions, particularly of the liver and kidneys, 
are either suspended or greatly diminished. The circulation of the 
blood, so directly under the control of the organic nerves, is much 
retarded, apparently to a great extent, at least, by spasm of the 
smaller vessels of the surface; the vital fluid retiring to and congest- 
ing the internal organs. Respiration is diminished and labored ; the 
blood, consequently, is not well oxygenated, and animal heat is 
reduced. 
While these general morbid phenomena are occurring, and fre- 
quently as the first in the train of apparent symptoms, the circula- 
tion and secretion of the mucous membrane of the alimentary canal PATHOLOGICAL PHENOMENA. 
421 
become specially deranged. The ganglionic system everywhere, but 
more particularly in the stomach and intestines, governs the capillary 
circulation. The paralyzing, deranging influence of the cholera 
poison upon the organic nerves produces the derangement of action 
which causes the diarrhoea, and it increases in its effect during the 
more active stage of the disease. The blood flows into these vessels in 
unusual quantities, producing hyperaemia, irritation, and copious dis- 
charges, consisting of the thinner parts of the blood, which contain a 
large portion of its salts. The blood is thus deprived of its more 
fluid portions, of its salts, and, by diminished respiration, of its 
oxygen; and being, moreover, loaded with urea and the elements of 
bile, from the suppression of the secretions of the kidneys and liver, 
is unfit for the uses of the system. The spinal nerves then become 
deranged in their functions, and the most painful spasms occur. 
When the disease in a grave form arrives at this stage, and is uninflu- 
enced by treatment, collapse and death are the usual results. 
When, from.the somewhat less severe form of the disease, or greater 
powrnrs of endurance, a patient survives these conditions, the increased 
quantity of blood in the mucous membrane of the alimentary canal 
produces an inflammatory hyperaemia, and in many cases a decided 
degree of inflammation. There is usually, however, no organizable 
plastic matter poured out, but a material something like the exuda- 
tion of diphtheria ; and perhaps the most characteristic product of the 
disease is an infiltration of a peculiar granular matter into the mucous 
membrane, and particularly into the glands of the intestines. The 
investigations of Ilarner, of Pirogoff, and others, and the delineations 
of Lebert, go to show the inflammatory character in many cases of 
the hyperaemia and exudation, when death does not occur too soon 
to allow of its development. Not only the alimentary canal, but the 
membranes of the brain and spinal marrow sometimes, and more 
rarely the lungs, are involved in inflammation. 
The only marked appearance approaching to uniformity, in the 
bodies of those dying in the collapsed or asphyxiated state of cholera, 
is that of congestion or hyperaemia, with the peculiar infiltrations 
into the glands of the intestines already referred to, the latter espe- 
cially occurring oftener in the more protracted cases. 
Dr. George Johnson, of London, has attempted to show that 
the loss of the fluids of the blood is not the chief cause of the 
severe and fatal symptoms in cholera, but that they are due to the 
impeded passage of the blood through the lungs from the right to the 
left side of the heart; and that this obstruction is produced by a 
morbid contraction of the muscular coats of the pulmonary arteries, 
and that this contraction is in turn caused by a specific morbid poison 422 
EPIDEMIC CHOLERA. 
in the blood. It cannot be doubted that impeded circulation of the 
blood through the lungs, and imperfect oxygenation of that fluid, 
contribute largely to the fatal results ; but yet it is true that such 
obstruction of circulation and deficient oxygenation very seldom 
occur until the blood is rendered thick and incapable of circulation 
by loss of its fluids and salts, and by the retention within it of urea 
and the elements of bile—though probably the blood is rendered still 
more injurious by the presence, in addition, of a specific morbid 
poison. The loss of the fluids is by no means the sole cause of the 
fatal symptoms, as patients occasionally die without such loss; but 
such cases are the very rare exceptions, and in ninety-nine out of 
every hundred deaths from cholera, the loss of the fluids is a chief, 
and even essential element, in the complex condition producing the 
results. The practical importance of these pathological views will be 
more fully appreciated when the subject of treatment is considered. 
In reviewing the ground already passed over, it may be stated that 
cholera is essentially produced by a peculiar poison, the exact nature 
of which is not fully understood ; that this poison is aided in its pro- 
duction and diffusion by certain local conditions, the chief of which 
is filth; that the action of this poison in the system is promoted by 
the presence in the blood of decomposing organic materials ; that the 
effects of the poison are first manifested upon the ganglionic or organic 
system of nerves ; that very generally, among the earliest and most 
important morbid effects which the paralyzed and deranged condition 
of the nervous force produces, are congestion and irritation of the mu- 
cous membrane of the alimentary canal, and profuse exhalations from 
its surface, leading to a watery diarrhoea, and at length to violent vom- 
iting and purging of a nearly transparent fluid ; that losses of the fluid 
portions of the blood, together with the retention of certain excre- 
mentitious matters, aided probably by the peculiar cholera poison, so 
change the physical, chemical, and vital conditions of that fluid as to 
produce spasms of vessels, and cramps of various muscles ; to produce 
obstructed circulation and respiration, and finally collapse and death. 
That occasionally, though very rarely, the cholera poison effects such 
changes in the blood, and in the actions of the nervous system, as to 
suspend the necessary life functions and cause speedy death without 
the loss of fluids ; but that such cases are so few and exceptional as 
to afford no basis for a rule of practice in the ordinary forms of the 
disease. 
We are thus brought to the last and most important division of 
the subject: 
The Treatment of Cholera, Prophylactic and Curative. 
—The prophylactic management of this disease, so apt to be fatal TREATMENT. 
423 
when it has made an attack, and usually so easily prevented, is of the 
first importance, and of course consists in the avoidance of its causes. 
These causes having already been referred to, need not be repeated in 
detail, though a few particulars require a more special notice. 
The views entertained of the mode of propagation of the cholera 
poison, and the local character of many of the predisposing causes 
which give that poison its potency, and particularly my own observa- 
tion while acting as the Medical Adviser of the Board of Health of 
Chicago, have impressed me with the great importance of giving 
special attention to the particular localities especially affected in a 
city or town, and to the groups of persons among whom the disease 
may appear. 
In such particular localities where the disease is raging, it will 
usually be found that many are crowded together under unfavorable 
hygienic conditions; and when this is the case, no pains or expense 
should be spared to remove instantly every such condition, and to 
effect a dispersion of the persons thus grouped, due regard being had 
to the safety of others where these persons may be sent. If those who 
have been thus exposed to even a concentration of the poison are wrell 
washed in person and changed in apparel, and are, in their new situ- 
ation, placed in clean and w7ell-ventilated apartments, the danger to 
others among whom they may be placed will be extremely slight, 
even should the persons brought among them experience attacks. 
As there will usually be difficulty in finding places among others 
for persons fleeing from a locality specially infected, it would be a 
most wise and humane provision to have temporary buildings or tents 
erected in the most favorable positions in the neighborhood of an in- 
fected city, where such persons may be taken and provided for under 
the most rigid sanitary regulations. The propriety of such proced- 
ures, and their immense influence in arresting the progress of the 
disease and saving life, cannot be questioned, nor can they be too 
strongly insisted irpon by those who act as guardians of the public 
health. 
In a preceding passage the use of alcoholic drinks was simply men- 
tioned, on the authority of Dr. Carpenter, as a predisposing cause of 
cholera ; but as there is at least a remnant of a popular opinion linger- 
ing among some that these drinks act as preventives to the disease, the 
subject may be referred to in this connection. The results of all mod- 
ern research, and of the profoundest professional reasoning respecting 
the physiological action of alcohol, as well as all observation every- 
where of its influence upon cholera, concur in the conclusion that so 
far from being a preventive to the disease, however used, it especially 
predisposes to attacks, and renders the cases, when occurring, more 424 
EPIDEMIC CHOLERA. 
severe. It interferes with the process of respiration, favors the accu- 
mulation of effete and decomposing materials within the body, and 
tends to irritate the mucous membrane of the stomach and bowels. 
When taken in any considerable quantity, it cannot fail to irritate the 
nervous centres and derange the functions of organic as well as of ani- 
mal life, and it has not the slightest claim to be regarded as an anti- 
dote to the cholera poison. There are, indeed, no known specifics for 
destroying the cholera poison or of preventing, directly, its effects ; 
and all medication should be avoided unless symptoms occur. The 
system should be kept in as natural, as uniform, and as healthy a 
condition as possible, with the mind calm and confiding, yet active 
and cheerful. 
The therapeutics of the disease—the principles and details of its 
palliative and curative treatment—will be the next subject in order. 
Although cholera is a disease so uniform in its essential cause, and 
so identical in its nature, yet should an attempt be made to follow 
“authorities” in a description of its curative treatment, so many di- 
verse and conflicting statements would be met with requiring record, 
that the writer, the reader, and the inexperienced practitioner in the 
disease, inclined to be led by such a guide, would be alike confounded. 
Nothing, in fact, as to treatment in this disease, seems quite settled 
in the general mind of the profession; and this, taken in connection 
with the further fact that statistics upon a large scale, from the earli- 
est period of its authentic history to the present time, have shown that 
from forty-five to fifty-five per cent, of the genuine cholera attacks 
have proved fatal, would seem to indicate that there is little power, or 
at least choice, in remedies. Still there is both power and choice of 
remedies in the disease, and I cannot restrain an expression of the con- 
viction that there are few diseases more susceptible of being influenced 
in their results by treatment than this ; very few where the services 
of a prompt and skillful physician can be made more valuable. Most 
other acute diseases with which we meet will terminate favorably if 
left to themselves, while a large proportion of these will not; and 
when, in genuine cases, there is a large proportion of recoveries, as 
may be the case, the result is without doubt due to treatment, and 
demonstrates its great value. 
It would seem strange that a disease so uniform in its causes and 
course, and withal so capable of being influenced by remedies, should 
have remained so long a time under investigation, without a course of 
treatment being found, upon the adoption of which the profession 
generally would agree. But though the disease is thus essentially 
uniform and identical, there are numerous varieties as to several par- 
ticulars ; and more than this, there are contradictory elements and TREATMENT. 
425 
conflicting indications in each case ; and it is to he regretted that writ- 
ers generally have not analyzed these elements as closely, and pointed 
out the conflicting indications as discriminatively as is desirable. The 
arrival at fixed and generally accepted truths, when the problems are 
complicated, and dependent for their solution upon numerous obser- 
vations made by many persons, and upon the deductions of various 
minds of different constitutions, is necessarily a slow process. Unfor- 
tunately, also, for the arrival at truth, many who have speculated most 
upon cholera, and have furnished the profession with the largest por- 
tion of its literature on the subject, have seen very little or nothing 
of the disease. When all these circumstances are considered, we need 
not be so much surprised at the present state of the therapeutics of 
the affection. 
Though what is to follow may or may not add to the variety of 
opinions already recorded, it will not be confused and obscured by the 
statement and examination of many contradictory methods of treat- 
ment ; but there will be an attempt to give a description of the treat- 
ment only which my own experience, study, and reflections, have led 
me to regard as the best of which I have any knowledge. There is, 
however, no little difficulty in giving a clear, discriminative, and in- 
telligible description of the treatment which should be pursued as 
adapted to the different cases met with, and their various stages, in 
actual practice. Indeed, in the details of proper management, so 
much depends upon the peculiarities any particular case may pre- 
sent, the different degrees of rapidity with which it may pass 
through its different stages, the constitutional and other special con- 
ditions of the patient in various respects, the different manner in 
which remedies may be borne, the special impression upon various 
organs and functions which may be produced by them, etc.—so much 
of the appearances of the patient, from which we form conclusions, 
can be learned only by experience—and in the doses and timing of 
medicines so much must be left to the judgment, that a full and cor- 
rect representation of the best treatment, with all its adaptations, can- 
not without illustrations be made. 
As the best means, however, of approximating to such a represen- 
tation, I shall first express some general views of indications and the 
means of fulfilling them, based upon pathological and therapeutical 
principles, and afterward attempt a more minute and specific account 
of the manner in which I would apply these principles—of the special 
mode of procedure in the treatment of cases. 
In the absence of such a positive pathology as reveals clearly the 
nature and succession of the essential morbid actions, and points un- 
erringly to all the proper remedies—in the absence also of ascertained 426 
EPIDEMIC CHOLERA. 
specifics, the attention of the physician should rest upon such morbid 
conditions as he believes to be present, and his efforts should be di- 
rected to the correction or removal of such conditions ; and if the 
primary or essential diseased condition, and the means for directly 
removing it evade his knowledge or power, he must direct his efforts 
to the correction or removal of the obvious disturbances of the func- 
tions ; and thus, by putting the system as nearly as possible in its nor- 
mal condition, prepare it to endure the shock of the morbid cause, 
and assist it by every possible means, as a sailor would a dismantled 
ship, to weather the storm. 
It has already been stated that the cause of cholera makes an early 
and decided impression upon the ganglionic system of nerves—those 
nerves presiding over the respiratory, circulatory, secretory, and 
assimilative functions ; and that as a consequence these functions are, 
each in its peculiar mode, and all more or less seriously, disturbed. 
The stomach and bowels are generally the seat of such decided 
irritation, and the source of such peculiar and profuse discharges, 
that they are regarded by many who have written upon the subject 
as points of a primary and principal morbid impression. But 
whether the impression upon the mucous membrane is primary, or 
whether, as I believe, these morbid phenomena are the results of 
the impressions upon the nerves of organic life, the symptoms them- 
selves are of the greatest importance ; and in a large majority of in- 
stances require first, and most imperatively, the attention of the 
physician ; for, whatever may be said by those who have studied this 
subject in the closet rather than at the bedside, if this irritation be 
not allayed, and these discharges be not controlled, neither nourish- 
ments nor medicines are retained in the system, the patient is soon 
deprived of a largo part of the fluid portions of his blood, the remain- 
der becoming unfit for its uses, and he is soon exhausted, and often 
speedily carried beyond the reach even of hope. 
It must, however, be borne in mind that this irritation and these 
discharges are not the sole causes of the depression and collapse—in 
fact, that in some of the most rapidly fatal cases no evacuations 
occur—and that diminished circulation, diminished respiration, dimin- 
ished animal heat, and diminished glandular secretions (of the liver 
and kidneys) are more constant symptoms than profuse evacuations, 
and therefore, in the treatment, other conditions than the vomiting 
and purging are entitled to constant attention. In this view of the 
subject, the following leading indications are presented : 
1st. To arouse and maintain the sensibility and proper action of 
the organic nervous system ; and 
2d. To excite and correct the action of those organs whose natural TREATMENT. 
427 
functions have been suspended or perverted, whether from direct 
impressions upon them, or by a failure of that nervous influence upon 
’which their integrity depends; and in a more particular manner, often 
first in time as well as in importance, when the gastro-intestinal irri- 
tation and exhausting discharges are present, the indications are to 
allay that irritation and arrest the discharges. 
Now by what means shall these indications be fulfilled ? Unfor- 
tunately we are yet but little acquainted with any direct beneficial influ- 
ence of remedies over the organic nervous system. When this system 
is debilitated or deranged in chronic diseases, hygienic regulations are 
more efficient than any known specific medicines. But here the most 
prompt action is required. There is, in cholera, so much prostration, 
such an appearance and real danger of rapid sinking and fatal ex- 
haustion, so much spasm and pain, and such profuse discharges, that 
stimulants and anodynes are resorted to almost instinctively, and 
alcohol is often given ; and opium, though so useful when properly 
managed, may be administered with too much freedom, and is fre- 
quently used with far too little discrimination. 
There can be little doubt that opium, alcoholic mixtures, chloro- 
form, etc., particularly when given in free doses, tend to depress 
rather than exalt the energy of the nervous system of organic life. 
Though this may not bo the effect of these articles uniformly and in 
all doses, it certainly is often, and generally so, even in their primary 
actions, when administered in large quantities. If alcohol, in certain 
quantities and under certain circumstances, does temporarily excite 
the nerves, still by depriving the blood of its oxygen, diminishing the 
natural effects of respiration, and retarding other vital changes, its 
secondary effects become often powerfully depressing. The same is 
true of opium and other narcotics, in a greater or less degree. These 
facts should not be lost sight of; and while these articles may be 
useful, and opium particularly, even in pretty free doses, quite essen- 
tial for fulfilling the indications of allaying irritation, and arresting 
vomiting and purging, regard should always be paid to their de- 
pressing effects on the vital powers. No language can be too strong 
in condemning their use in large quantities, in the advanced stages of 
the disease. Both principles and experience go against the practice, 
and facts, under my own observation, have convinced me that many 
lives have been sacrificed by it. Alcohol is very seldom useful in 
cholera under aiiy circumstances. It not only fails to meet the indi- 
cation of sustaining the vital powers, but it also usually fails to exert 
a beneficial influence over the vomiting and purging; in fact, it 
increases the irritation of the mucous membrane, and disposes it, as 
well as the brain and other parts of the system, to inflammation and 428 
EPIDEMIC CHOLERA. 
its consequences, in case the patient survives the earlier stages of the 
disease. 
Opium, in proper doses and combinations, in the earlier stages of 
cholera, before the vital powers are much exhausted, and while irrita- 
tion of the stomach and bowels is the most prominent symptom, is 
the great remedy in the disease, or, at least, one of the prominent and 
essential items of a correct treatment. It is by far the most potent 
remedy we possess for allaying that irritation, arresting the flow of 
fluids to the mucous surface, and controlling the debilitating dis- 
charges ; and when these effects are produced by its use, the system, 
by other proper aids, is generally enabled to rally and struggle success- 
fully against the morbid influences. But when the powers of life are 
low, when the blood is deficient in oxygen, loaded and black with car- 
bon, the free administration of an article which in full doses produces 
even in healthy persons similar effects, can but be productive of 
severe and fatal results. I dwell upon this point because of its 
exceeding importance, and will recur to it again when describing the 
particular mode of managing cases. 
In selecting stimulants, then, to arouse the nervous energy, we 
should prefer those which will not diminish the oxygen of the blood, 
as some of the most constant and dangerous symptoms are produced 
by such diminution. Opium, alcohol, chloroform, and ether, as al- 
ready stated, have to a greater or less extent that effect. 
With reference to this indication, we shall experience better re- 
sults from such articles as quinine, coffee, mustard, ammonia, capsi- 
cum, camphor, cassia, valerian, and oil of turpentine. The bromide 
of ammonium has been suggested on theoretical grounds, as fulfilling 
the indication of regulating organic nervous action, but I am not 
able to say that the theory has been verified by actual experience in 
this disease. 
An emetic dose of salt and mustard is strongly recommended by 
some, and may have a good effect in arousing the organic nerves and 
changing the train of morbid actions. But if this is resorted to at 
all, it should only be considered as preliminary to other treatment, 
and during the period of quiet succeeding its immediate operation 
the introduction of other remedies must not be neglected. 
But there is another system of means for answering this indication 
of arousing the nervous energy, which is worthy of attention. We 
know that when the functions of the organic nerves are overcome and 
suspended -by a poisonous dose of prussic acid, opium, alcohol, or 
chloroform, the most effectual means of arousing them to action are 
sudden dasliings of cold water upon the surface, cold affusions con- 
tinued for a short time and repeated, and the abundant inhalation of TREATMENT. 
429 
fresh air, improved by the addition of the vapor of ammonia or oxy- 
gen gas. 
We might infer that this same system of means would he useful in 
cholera, and in many cases it has been so found. When these cold 
applications are used, during their intermissions, reaction should be 
encouraged by frictions, warm flannels, and sinapisms. 
I have used these cold affusions only in a few cases, and most of 
those were in a condition not favorable for the success of any treat- 
ment ; but I have generally been able to procure a degree of reaction, 
and the results of the experiments made impressed me favorably with 
the remedy. I consider it worthy of further trial. 
To fulfill the second general indication, viz.: that of exciting the 
dormant, and correcting the morbid action of the different distinct 
organs, such as the liver, stomach, kidneys, etc., thus endeavoring to 
restore, as far as possible, their different functions to their normal 
conditions, a variety of means must be used. 
To correct the exhalant and other functions of the stomach and 
bowels, to allay the irritation and arrest the profuse discharges, opium, 
in my opinion, as anticipated by preceding remarks, is the chief 
remedy. In order that it be retained and have a speedy effect, absti- 
nence from drinks in considerable quantities must be enjoined, and the 
medicine given in minute division, triturated with some other sub- 
stance ; and its effects may be aided by counter-irritation over the 
epigastrium, and indeed over the whole abdomen, and sometimes by 
various astringents. The acetate of lead is regarded by many as the 
most useful of the astringents ; but it affects the purging more than 
the vomiting, and controls this purging much more manifestly when 
given by enema, after an impression has been made upon the stomach 
with opium. When thus used in a moderate quantity of fluid, and 
combined with a quantity of laudanum varying with the condition of 
the patient, and the amount of opium previously taken, the effect is 
often most happy. 
To excite the liver to its natural secretion, and modify other secre- 
tions, thereby relieving the blood of much of its effete matter, calomel 
should be given in repeated doses. When thus operating it usually 
changes the whole character of the disease. The use of this article I 
consider of exceeding importance. My observations upon it have been 
careful and abundant, and I think I cannot be mistaken. The dis- 
charges may often be checked without its use, and temporary improve- 
ment produced; but unless the secretion of the liver be excited (and 
calomel, when properly given and retained, tends powerfully, and far 
more than any other article, to excite that secretion), the cholera dis- 
charges will again return, and severe consequences are likely to follow. 430 
EPIDEMIC CHOLERA. 
The indication for calomel exists in the early stages of the disease, 
and continues present until the symptoms are controlled, the action 
of the liver restored, or until a sufficient quantity is given to produce 
all the beneficial effects of which the medicine is capable. 
I am by no means insensible to the injurious effects, both proxi- 
mate and remote, which the free, or even moderate use of mercury,- 
under many circumstances, produces. I have no sympathy with that 
class of practitioners forever seeing some “ liver complaint,” or “ bil- 
ious obstructions,” and hurling heroic doses of calomel, or everlasting 
“ blue pills,” at these so often imaginary difficulties. But mercury 
is a medicine of power, and has its uses; and cholera is one of the 
diseases where its remedial virtues are greatest. In this disease it 
seldom produces salivation or other remote injurious consequences, 
and even if it did much more frequently, considering the extreme 
danger of the patient and the good effect it produces, we should be 
justified in its use. 
To excite the action of the kidneys, diuretics may be given when- 
ever the stomach will retain them, and when they will not interfere 
with other more necessary remedies, or produce any other unpleasant 
effects. Oil of turpentine and spts. nit. dulc., infusions of broom 
or juniper are among the best articles of this class. They are, how- 
ever, so uncertain in their operations, that they should not be given 
at the risk of disturbing the stomach or bowels. 
To counteract the deranged state of the sanguineous circulation, 
which is always great in the full-formed stage, amounting to a con- 
siderable degree of obstruction in the capillaries, and to a decided ob- 
struction of the circulation from the right to the left side of the heart 
through the lungs, with a general congestion of internal organs, vari- 
ous means have been suggested and practiced. Any course which 
will contribute to the first indication—that of arousing the nervous 
organic energy—will do much to accomplish this ; but there are 
other means which act more directly in effecting this object, among 
which is blood-letting. 
This may seem a desperate remedy, and certainly should be used 
with the greatest discrimination and caution. There is, however, 
much testimony in its favor entitled to the highest respect, and my 
own experience enables me to express the opinion with confidence, 
that there is a class of cases occurring in the robust and vigorous, 
marked by a degree of hardness of pulse, by a violence of pain and 
cramp, without very free discharges, where, at the proper time—the 
early stage of congestion—duly aided by other means, and these per- 
haps stimulants, it will operate most beneficially. McIntosh has 
long since shown, and his observations have been abundantly con- TREA TMENT. 
431 
firmed, that bleeding, in the congestive or cold stage of intermitting 
fever, affords the greatest temporary relief, and would be generally 
indicated in the cold stage of the ague, were it not for the more re- 
mote consequences, the continued debility and impoverishment of the 
blood which would follow. 
I have resorted to bleeding in cholera only in a small proportion 
of cases, as the large majority of those I have treated in the disease 
have been foreign emigrants, debilitated from recent sea voyages, or 
others whose vital powers were low; but whenever I have practiced it 
under the circumstances described, I have been pleased with the re- 
sult. The cramps, pains, blueness, and oppression of breathing have 
been relieved, and all the symptoms have taken a milder form. 
Another means for the relief of this congestion in cholera, less 
hazardous in its effects, is the use of dry cupping. The cups should 
be applied along the spine and over the abdomen. A large cup 
or common tumbler suddenly applied over the stomach will often 
produce a marked effect in allaying the nausea and vomiting, and 
enabling the stomach to retain medicines until they can make an 
impression. 
Nearly akin to this and to blood-letting, combining in some degree 
the advantages of both, and avoiding some of the disadvantages of the 
latter, is the ligation of the extremities, near the trunk, thereby de- 
taining for a time a portion of the blood in the vessels of the limbs, 
and when the necessity for its detention has passed by, allowing it to 
return into the general circulation. Whether the blood may not be 
deteriorated by this detention, so as to be in danger of unpleasant 
effects, has often suggested itself to me; but I have not been able to 
discover evidence that this is the case, and if it be not, this plan must 
possess some advantage over blood-letting. I have practiced it fre- 
quently, and with satisfactory results. Besides the general effects, it 
often relieves in a marked degree the cramps in the limbs thus treated. 
Sinapisms, frictions, external warmth, and other modes of cutaneous 
irritation, directly conduce to the relief of congestion, and sometimes 
act beneficially in arousing nervous energy. 
Quinine has already been referred to as being useful in fulfilling 
the indication of arousing and sustaining the nervous energy ; and by 
this mode of its operation, or in a more direct manner, its action tends 
decidedly to remove internal congestions—to equalize and free, as it 
were, the restrained and obstructed circulation. It thus' becomes a 
means, and a most powerful one, of answering the indication of regu- 
lating the deranged circulation, upon which so many serious conse- 
quences depend. Though I have no knowledge of its having been 
used hypodermically in cholera, I should have no hesitancy in inject- 432 
EPIDEMIC CHOLERA. 
ing a solution of it into the areolar tissues, where the indication for its 
use was present, and the stomach was not able to retain and absorb it. 
It might thus be given in the stage of the most active vomiting and 
purging, and probably would act as beneficially in this as in other 
stages of the disease. That it has an immediate effect in relieving 
the symptoms of congestion in malarious fevers, and that too perhaps 
independently of its antiperiodic influence, is quite certain ; and the 
analogy between the congestive state of a malarious fever and the 
algid condition of cholera is quite apparent. At all events, whatever 
the mode of its action—whether by sustaining the nervous energies, or 
by some other means more directly relieving the system of capillary, 
pulmonal, or general visceral obstruction and congestion, or by some 
peculiar antidotal influence neutralizing the effects of the cholera 
poison, as this article seems to neutralize the poison of periodic fevers 
—it has a decided beneficial effect in the disease, and after the stomach 
is quieted by opium, and very probably before, if used hypodermic- 
ally, the chances of recovery are decidedly enhanced by the adminis- 
tration, in divided doses, of from a scruple or half a drachm to a 
drachm of quinine. Where much opium has been given, it enables 
the system to bear that article better, preventing to a considerable 
extent its depressing effects. 
As cholera prevailed in Chicago, particularly in 1854, its cause 
was mingled with the malarious poison, and as is the case with various 
other diseases in the West and South, the cholera was modified by 
malaria, and, in most of the cases, assumed more or less of a periodi- 
cal type. A patient seized with a malarious chill, when the cholera 
poisou was present and acting upon the system, would have that chill 
merged into the phenomena of cholera. 
Profuse vomitings and purgings of a serous fluid, accompanied 
with cramps and other phenomena strikingly resembling genuine 
cholera, not unfrequently occur in malarious fevers when no epidemic 
cholera influence is present; and when such cholera influence prevails, 
the occurrence of the phenomena of fever will very often precipitate a 
cholera attach, and though the symptoms for the time being are con- 
trolled, they will recur with increased violence with the reappearance 
of another paroxysm of the fever—the weaker affection becoming 
merged in the stronger. In all such cases, a full antiperiodic quantity 
of quinine is an absolute necessity, and here certainly from half a 
drachm to a drachm, in divided doses, must be promptly introduced 
into the system, the whole being given some time before the period 
for the recurring paroxysm, which must be presumed to take place in 
twenty-four hours. The type may be tertian ; but as this cannot be 
known beforehand, and the return of another paroxysm would be TREATMENT. 
433 
likely to be fatal, action must be taken as though it were quotidian. 
A recurrence must be prevented. 
The importance of quinine in such eases is measured by the differ- 
ence between success and failure—between the life and death of the 
patient. There is here the imperative indication of interrupting the 
malarious paroxysm, which the quinine will do, while at the same time 
it fulfills the other indications before referred to. 
If these views are correct, and of their correctness I have the most 
abundant reasons to be assured, no language can be too strong in 
urging them upon the attention of the profession. The malarial in- 
fluence is by no means confined to the West and the South. In vari- 
ous localities in the Middle, and even Eastern States, Intermittent and 
Eemittent fevers, more or less perfectly marked, have a considerable 
prevalence, and the malarious poison, in sufficient quantity to modify 
other diseases, is still more widely diffused. Quinine is exceedingly 
important in the treatment of cholera everywhere, but is peculiarly 
and inexpressibly so in all those cases mingled with, and influenced 
by, the malarious poison. 
To correct that condition of the blood which arises from deficient 
respiration, and from a loss of its watery and albuminous portions 
and its salts in the discharges, free, full inspirations of the freshest 
air must be encouraged, and a solution of common salt and bicarbon- 
ate of soda may be given, when the stomach will, without incon- 
venience, retain it; and chicken broth or beef-tea, well salted, must 
not be omitted. The chlorate of potash is another article which, on 
chemical principles, and from its analogous effects in other diseases, 
would be suggested ; but I have no experience with this salt in chol- 
era, and can therefore only suggest its use. 
Saline solutions have not only been given by the mouth, to correct 
these conditions of the blood, but they have likewise been injected 
into the veins ; and in this, the object aimed at is commendable; but 
the operation of injecting the veins is a delicate and dangerous one, 
even under the most favorable circumstances of superior apparatus 
and skillful hands, and cannot be adopted with benefit in general 
practice. Its effects have been only temporary. 
We have now passed over the leading indications in the treatment 
of cholera, and have referred in somewhat general terms to the prin- 
cipal means by which those indications are to be fulfilled, and it 
now remains to attempt a more particular account of the details of 
procedure—of the particular stages and conditions indicating partic- 
ular remedies and combinations, and the dose and the timing of each 
article or compound applicable to the various conditions which occur. 
In doing this, it will be necessary to refer again to the different 434 
EPIDEMIC CHOLERA. 
remedial agents just considered, and something like repetition can- 
not he avoided; but it is better to repeat many things, rather than 
to fail in giving a distinct idea of the treatment to be pursued. It 
is not easy to combine in the same train of remarks the pathological 
and therapeutical principles involved, and the minute details of pro- 
cedure. 
In an active and severe case of cholera, the disease passes through 
so many stages in so short a time, and these stages are so variable in 
their duration, and each requires such modifications of treatment, 
that the patient, in order to be skillfully managed, must be visited very 
frequently; the amount of medicines taken and retained, and every 
symptom and condition must be particularly inquired into, and if the 
memory be at all treacherous, should be carefully noted down. The 
nurses must be faithful and sensible, and must have the most definite 
and explicit instructions in every particular. The physician must be 
cool and collected, and must have every faculty of his mind fully 
awake and concentrated upon the work. He who cannot come up to 
these requirements, who has not the health, or the vigor, or the cour- 
age—who has not indomitable perseverance and sleepless vigilance, 
and who, moreover, has not some definite ideas of the proper treat- 
ment, and some confidence in remedies, will consult his own peace of 
mind, and the interests of the community, by avoiding, as some do, 
the treatment of all cases of this disease. 
When, during the prevalence of epidemic cholera, a patient is 
affected with the premonitory symptoms of the disease, and especially 
if diarrhoea be present, he should immediately be sent to bed in a com- 
fortable and well-ventilated room, with warm covering, adapted, 
however, to the temperature. The state of the skin should be inquired 
into, and if not in perfect condition as regards cleanliness, a warm 
bath, or sponging with warm soap and water, or saleratus water, should 
be used. A powder, consisting of from one to three grains of opium, 
with the same amount of camphor, well triturated with sugar (or the 
equivalent of this powder in laudanum and spirits of camphor), should 
be immediately given, and if the discharges are inclined to be watery, 
colorless, and destitute of bile, from two to six grains of calomel, or 
its equivalent of blue pill, must be added. This dose must be re- 
peated in from an hour and a half to three or four hours, if the dis- 
charges are not completely arrested, and the sensations of abdominal 
uneasiness removed. After from eight to fifteen grains of calomel are 
given, unless the symptoms assume considerable severity, this article 
maybe omitted; but the opium and camphor must be continued until 
a decided narcotic influence is produced, or until all symptoms of the 
diarrhoea are removed. Should the diarrhoea not yield readily, acetate TREATMENT. 
435 
of lead or tannin should be added to the opium, in from two to four 
grain doses; or what is still more effectual, enemata of ten grains of 
the lead with a tea-spoonful of laudanum in three or four ounces of 
some simple fluid, plain water answering every purpose, at a temper- 
ature a little above that of the room, must be given and repeated once 
an hour, or oftener if not long retained, and if the discharges are not 
arrested. In many eases, a few grains of quinine (two, three, or four) 
given at first with each dose of the opium, will cause the latter article 
to be borne better, and the combined effect will be an improvement 
upon that produced without the quinine. I have often prescribed 
pills, containing sulph. morphine one fourth of a grain, and sulph. 
quinine two or three grains, one to be taken immediately, and re- 
peated once in from one to four hours as may be required ; and these 
doses in a majority of cases will be quite sufficient to arrest all the 
symptoms. The quinine may be continued until a scruple, or some- 
times more, has been given. Mercury, however, should not be omitted 
where any considerable severity of symptoms exists, and where the 
cholera tendency is manifest in the colorless condition of the dis- 
charges ; for, though without the mercury the symptoms may be 
arrested, they are much more liable, after a few hours, to return when 
this article is not used. Where mercurials, however, are used with 
opium, such returns of the symptoms are exceedingly rare. When, 
by these means, the discharges are completely arrested, the next day 
a mild laxative of syrup of rhubarb, or of equal parts of the syrup and 
tincture of rhubarb, or castor-oil, with a few drops of oil of turpentine 
and tinct. opium, may be given with advantage. A simple opiate 
should follow its operation, if there be pain or a tendency to a con- 
tinuance of the catharsis. At the commencement of the treatment, or 
at any time during its course, a sinapism to the abdomen may be use- 
ful. The blandest diet should be insisted upon, and the patient kept 
quiet until restored. These means are almost as certain to arrest the 
disease, if resorted to and persevered in, as quinine is to arrest an 
ordinary attack of intermittent fever. 
When the cholera is prevailing, physicians should strongly advise 
those who depend upon them for medical directions to keep about 
them medicines adapted to the disease, and should give them instruc- 
tions respecting their applications in case of emergency; but still, 
the rule should be to send for advice as soon as possible after symp- 
toms appear. Many lives may in this manner be saved. 
But the premonitory stage is sometimes absent, or so slight as not 
to receive attention, and is frequently so neglected, or so short in 
duration, as not to become the subject of treatment, and the case 
passes into the second stage—the full development of the active dis- 436 
EPIDEMIC CnOLERA. 
ease occurs before aid is sought. In the early part of this stage, 
before the deep blueness occurs, and while considerable warmth is 
present, especially if the disease seems to be of a forcible character, 
with severe pain and spasms, the treatment may commence by a 
moderate bleeding, or, safer, by ligation of the extremities, detaining 
in that manner a portion of the blood from the circulation. Several 
cups may be applied over the stomach and abdomen ; all drinks, in 
larger quantities than just sufficient to wet the passages, must be 
instantly and peremptorily prohibited, and, whether the preceding 
means be used or not, the following powder administered in a tea- 
spoonful of water : 
IJ Opium grs. ij 
Gum Camphor grs. ij 
Calomel grs. iij. to vj 
Sugar of Milk grs. xv 
M. 
Triturate very thoroughly. 
The minute division of the medicines by trituration, I regard as 
very important. Here the sugar of milk is preferred to common loaf- 
sugar, though the latter will answer. All the ingredients, when thus 
treated, will diffuse themselves readily, and will be extensively and 
speedily applied to, and will readily act upon the stomach ; while, 
if the opium and other articles be given, in pill or coarser powder, 
they will be much more liable to be rejected before they have time to 
act; or if retained, their effects will be more slow and cumulative, 
and that of the opium may be too profound at a later period, when a 
powerful narcotism will be liable to be fatal. 
If the treatment be commenced at a very early period in the second 
stage, and the circulation and respiration are still comparatively good, 
a quarter of a grain of morphine may be added to the first dose of the 
above powder. If there be evidence of matters upon the stomach not 
rejected, or if there be much cramp and retching, without the power 
of free emesis, an emetic dose of salt and mustard, or of sulpli. of zinc, 
may precede the administration of the powder, and in that case the 
temporary calm after vomiting must be seized upon to give the pow- 
der. When the vomiting is spontaneous, the calm succeeding it is 
the most favorable moment for administering a dose. When the dry 
cups come off, they must either be reapplied, or the regions of the 
stomach and bowels must be covered with a strong sinapism. Sina- 
pisms may also be applied to the extremities. If the first powder be 
rejected before it has had time to make an impression or to be ab- TREATMENT. 
437 
sorbed, another should be immediately given, omitting the morphine, 
however, in the second dose, if the first was retained as long as ten 
or fifteen minutes, or if there is evidence of any portion of it 
having been retained ; and after the second dose, it is not usually 
safe to add morphine to the two grains of opium, however frequent 
the vomiting may be. These powders may then be continued, some- 
times varying the proportions by increasing the calomel and dimin- 
ishing the opium, repeated once in from one to three hours, according 
to the severity of the symptoms, until either the discharges are ar- 
rested, a perceptible degree of anodyne and narcotic influence is 
produced, or the blue stage occurs. After one or two doses of the 
powder are given, and the vomiting has somewhat abated, and espe- 
cially if the treatment had commenced at a later period of the dis- 
ease, three or four grain doses of quinine should be administered 
once in one, two, or three hours, until a scruple, or half a drachm, 
or more has been given. Should the discharges be arrested or very 
materially abated, as they usually are after a short time under this 
treatment, the stomach will be in a condition to retain other articles, 
and other indications besides that of arresting the discharges can be 
attended to. Should a considerable degree of narcotism be present, a 
strong infusion of coffee must be given liberally, and continued until 
the symptom is no longer sufficient to excite uneasiness. Should 
there be much depression, carbonate of ammonia may be added to the 
quinine, or given by itself, and should the surface be dark, with con- 
siderable depression of the vital powers, common salt and the flour of 
mustard, in doses of from ten to fifteen grains each, may be given 
once in from one to two hours. At the same time, a few spoon- 
fuls of chicken broth or beef-tea, with rice water, well salted, may be 
given quite frequently, say every half hour. In the meantime, some 
fifteen to thirty or more grains of calomel have probably been given 
in the powders, and if so, no more will usually be required ; but if 
rice-water discharges still occasionally continue, five or six grain 
doses of this mineral may be continued without, the opium, or with 
a quantity of it so small as not to be incompatible with the safety of 
the patient. The extent to which the opium may be safely carried 
cannot be defined, and must be carefully judged of in each case by 
all the lights which close observation and experience can afford. 
If the treatment be commenced later in the disease than we have 
been supposing, opium must be used more sparingly, and as the point 
at which treatment has commenced advances toward or into the 
blue and collapsed stages, less must be used, until none can, with 
safety or a prospect of success, be given. 
Acetate of lead, in from two to four grain doses, may sometimes, 438 
EPIDEMIC CHOLERA. 
perhaps, be beneficially given, alternately with the opium, calomel, 
and camphor powders, especially if the purging be out of proportion 
to the vomiting. But the stomach has certain capacities for the en- 
during of medicines, beyond which it cannot be plied writh impu- 
nity. We cannot pour promiscuously into that organ, when irri- 
tated as in this disease, every article for which there seems to be an 
indication; and according to my observation, when acetate of lead, 
by the stomach, has been added to the treatment just described, 
the effect has not usually been so satisfactory as without it. In the 
condition, however, above referred to, when the purging is more se- 
vere than the vomiting, and continues after a partial calm has been 
effected by anodynes—or in the latter and lower stages of the disease, 
when this exhausting discharge continues—the effect of enemata of 
the lead, given as directed wThen describing the treatment of the pre- 
monitory stage, with such quantities of laudanum as may be borne, 
can scarcely be too highly praised. Tannin may be used as a substi- 
tute for the lead, is often quite as effectual, and, not unfrequently, 
is borne better by the stomach when used in that way. I have not 
unfrequently combined tannin with quinine, wThere the latter article 
was indicated, and purging was present, without producing unpleas- 
ant effects on the stomach, and with a manifest impression upon the 
purging. 
The above course of treatment, when commenced before the blue 
stage has thoroughly set in, will, according to my observations, in a 
very large proportion of cases—I should say in fair constitutions in 
nine cases out of ten—succeed in arresting the disease and procuring a 
favorable reaction. The after-treatment should be simple. 
I am aware that this statement of the success of this treatment is 
much more favorable than is usually found in the standard works 
respecting any mode of treating this formidable disease. For this 
reason the statement is made with some degree of hesitation, and not 
without due reflection. But a careful review of my own experience 
fully justifies it. It will be observed that the statement is not that 
nine out of ten of the cases of cholera, as usually met with in practice, 
can by any means be saved ; for frequently the disease, when the phy- 
sician is first called, will be so far advanced as to be beyond the reach 
of any treatment; and occasionally a case will be so rapid and severe 
as to resist the most prompt and timely measures; but in ordinary 
cases, in persons of fair constitution, the premonitory diarrhoea occur- 
ring and the full attack developing in the usual manner, if the treat- 
ment be commenced before the blue stage has supervened, and be 
followed up with promptness and skill, an exceedingly large propor- 
tion of cases will recover. TREATMENT. 
439 
If the bowels are not open after twenty-four or thirty-six hours 
from the period of reaction, a gentle laxative of castor-oil, with the 
addition of small quantities of oil of turpentine and laudanum, or an 
aperient of some of the preparations of rhubarb, in divided doses, may 
be given. If the stomach seems loaded with bile, as it not unfre- 
quently is at this period, a gentle emetic of salt and mustard will 
sometimes procure great relief. If the urinary secretion is not soon 
restored, or indeed in anticipation that it may not be, when the stom- 
ach and bowels become quieted, spts. nit. dulc. may be given in half 
tea-spoonful doses in water, frequently repeated, or other diuretics 
may be administered. Bland nourishment and drinks may be allowed, 
and the patient kept quiet. Sometimes gentle tonics may be useful. 
In some rare instances, after not very severe cases of cholera, but 
rather more frequently after the graver cases, the kidneys fail entirely 
to perform their functions, and the patient dies comatose from the 
poison of urea in the blood. Death usually occurs in from twenty- 
four to forty-eight hours after reaction ; and, according to my obser- 
vation, when the suppression of the secretion is complete, and coma- 
tose symptoms strongly resembling those of an overdose of opium 
supervene, no means within my knowledge will, as a rule, avert the 
fatal result. I have tried various stimulating diuretics, electricity, 
counter-irritation over kidneys, and cathartics, but with little effect. 
Where mercurials have been pretty freely used, and alcoholic 
stimulation has been avoided, it is seldom that severe congestions and 
inflammations of the brain and other organs occur after attacks which 
have not passed into the collapsed stage. Whenever these cases do 
occur, however, treatment must be conducted on general principles, 
bearing in mind that though there be inflammation, it occurs in a 
system much debilitated by a severe disease. If the brain and spinal 
marrow and their envelopes be the seat of the disease, blisters, mer- 
curials, and iodide of potassium would be indicated. If the stomach 
and bowels be the seat of the inflammation, blisters, a few minute 
mercurial doses, with small doses of morphine, followed perhaps by a 
mild laxative of castor-oil, and this succeeded by the following mix- 
ture will be well: 
B Oil of Turpentine, 
Tinct. of Opium aa f3ijss 
Gum Arabic, 
Sugar aa 
Camphor Water f Sij 
M. 
For an emulsion. A tea-spoonful once in three or four hours. 440 
EPIDEMIC CUOLERA. 
These secondary symptoms are varied, and sometimes protractedj 
requiring a variety of management, often embracing ultimately a gen- 
eral tonic course. 
But cases of cholera are frequently not seen until they are far 
advanced into the cold or blue stage, or have actually passed into the 
collapsed condition. 
While the pulse remains at the wrist there is sufficient hope to 
demand strenuous efforts, and even after it has disappeared, patients 
occasionally recover. The practitioner of close observation, of acute 
discernment, and of much experience in cholera, will be able almost 
at a glance to determine the probable fate of his patient, for there 
is a discernible point, beyond which, if he pass, all the chances are 
against his recovery. 
If the condition borders upon the fully collapsed or asphyxiated 
state, opium, as has already been stated and repeated, must not be 
given, or only in very small quantities. If the purging still continue, 
an enema of a solution of acetate of lead (fifteen or twenty grains), 
with perhaps a tea-spoonful of laudanum, may be used and repeated, 
with or without the laudanum, as circumstances may require. The 
cold affusion, or the rubbing in ice, may here be tried, followed by 
warm frictions, sinapisms, and warm blankets. The fullest inspira- 
tions of the freshest air may be insisted upon, and quinine, warm 
coffee, and carbonate of ammonia, two or three grains of the latter, 
and the same amount of the quinine, once an hour or two, alternated 
with doses of from ten to fifteen grains each of salt and mustard, may 
be given, not omitting the frequent administration of chicken or beef- 
tea, well salted. 
The chlorate of potash would here be suggested as possibly sup- 
plying oxygen to the blood, and improving the condition in other 
respects; and quinine, if not well borne or appropriated by the 
stomach, may be tried hypodermically. My experience in cholera 
occurred before the hypodermic syringe was in use as now ; but this 
method of administering quinine, morphine, and other remedies, is 
strongly suggested on rational principles, and I should not hesitate 
to give it a trial. Dry cupping along the spine may be added to the 
treatment with advantage. Besides these means, six or eight grains 
of calomel may be given once in an hour or two, until some twenty 
or more grains are used, not with reference so much to any immedi- 
ate effect, as to act after several hours upon the bilious secretion, 
should the vital powers be kept up for that length of time ; for, with- 
out that action upon the liver, the cholera discharges are liable to 
continue or return. 
The use of opium in cholera, so essential for the arresting of the TREATMENT. 
441 
discharges, and yet so liable when freely used to interfere with the 
function of respiration and produce other injurious effects, especially 
in the later stages of the disease, is of the utmost interest to the phy- 
sician who expects to meet with this affection, as the chief element 
of his skill in treating the disease will consist in his judgment and 
tact in the administration of this article. There is, on the one hand, 
the Scylla of allowing the intense irritation and profuse discharges to 
so alter the proportions of the constituents of the blood and exhaust 
the patient, as to carry him beyond hope, and, on the other hand, the 
Charybdis of too great narcotism, interfering with respiration and 
other functions to an extent equally dangerous. It requires skill and 
tact to steer between these rocks of destruction, and, in treating 
cholera, this passage must be made. 
Of the treatment of the fully collapsed state, I have little to say. 
I have seen a few such cases recover—that is, cases where the pulse 
could not he felt at the wrist, and where the loss of voice, the 
blue and shrunken condition of the surface, the extreme sunken 
and lustreless eye, and the slow laborious breathing corresponded 
with the arrested condition of the arterial circulation—but these 
are exceptions so rare that the influence of treatment is not ascer- 
tained. 
Some of the most remarkable recoveries of this kind which I have 
witnessed have been after large and repeated doses of calomel ; but 
of its manner of producing beneficial effects, or indeed of the fact of 
its producing any effects at all, I am by no means certain. 
In describing the treatment of the active or vomiting stage of 
cholera, it was mentioned that drinks should be avoided, excepting 
in tea-spoonful doses, or quantities just sufficient to moisten the mouth 
and throat, and the subject is again introduced here in order to make 
it more prominent. This I regard as an essential item of treatment 
in most cases. The objection to the drinking is, that while fluids in 
considerable quantities are taken into the stomach, vomiting will con- 
tinue and medicines will not be retained. A tea-spoonful of ice-water, 
or a very small piece of ice may be taken frequently, and will answer 
the purpose of quenching thirst. So important do I consider this 
point, that I would not take the responsibility of a case—would 
abandon a patient whose friends would not enforce the restriction 
where vomiting or the danger of vomiting existed. 
Time is so essential in the treatment of cholera, that it is very 
important that every practitioner have about his person several arti- 
cles of medicine ; and particularly if the powders of opium, camphor, 
calomel, and sugar, which I have recommended, be used, they should 
be carefully prepared, of good materials, thoroughly triturated, and 442 
EPIDEMIC CHOLERA. 
put up in packets accurately weighed. In a large practice much time 
and many lives may be saved by such precaution. 
The views of cholera and its treatment expressed in the preced- 
ing pages, are, as already intimated, the result of no small amount of 
experience (about two thousand cases of the disease during three sea- 
sons having come under my careful observation and management), 
and they are presented to the profession with much confidence in their 
correctness. The fact is not forgotten that diseases, however specific 
in their character, are modified in many of their features, and par- 
ticularly in their severity, and in the influence of remedies upon 
them, by local circumstances, and what is called the “prevailing con- 
stitution of the atmosphere.” It is quite possible that further expe- 
rience in other cholera epidemics, or in different localities, would 
modify my views as to the selection and efficacy of remedies; but until 
other and clearer light is thrown upon the subject, and other measures 
are shown to be more effectual, the course indicated would be pursued 
with a firm conviction of its being the one most worthy of approval in 
the present state of our knowledge. If the disease, as it may hereaf- 
ter appear, shall not differ in its features from those presented during 
the three years of its prevalence in Chicago, similar results from treat- 
ment would confidently be expected to follow. The cases treated were 
too numerous, were spread over too large a period, and were too fre- 
quently compared in their results with those occurring in the same 
localities and under similar circumstances, but differently managed— 
the whole series of observations were too carefully made, not to have 
the conclusions drawn from them held with firmness. 
The great desideratum in the treatment of cholera is some means 
which shall answer an indication above those we now labor to fulfill— 
that of directly and certainly neutralizing the cholera poison. The 
present state of pathological and therapeutical science strongly points 
to the discovery and application of antidotes to specific poisons ; and 
may we not hope that in the advancement of science, the hidden 
nature of the cholera germ will be revealed, and a remedy be found 
which will directly and surely destroy its effects ? He who shall be 
so fortunate as to make this discovery must ever be regarded as 
among the great benefactors of mankind ; and in celebrations of the 
triumphs of medical art his name will be associated and pronounced 
with those of Harvey, and Hunter, and Jenner. 
The preceding account of cholera and its treatment is a repro- 
duction, with but slight modifications, of views expressed several years 
ago, when my experience in the disease was fresh ; and since then I 
have had no further opportunity of personally observing and study- 
ing its character. Much since then has been written, and many ETIOLOGY AND PATHOLOGY. 
443 
authoritative and weighty statements have been made, especially upon 
its etiology. The views on the subject, so far as they are here ex- 
pressed, were based upon so much personal experience, so deliberately 
formed, and so firmly held, that nothing which I have since seen has 
materially changed them, and I have concluded to let them stand as 
individual opinions, not attempting a summary of general professional 
sentiments. 
YELLOW FEVER. 
This is a specific infectious disease, originating in tropical climates, 
and as it has prevailed in the United States, the poison has generally, 
if not invariably, been brought either directly or indirectly from the 
West India Islands. It has been imported into various places, but 
never prevails to any great extent except in comparatively low lati- 
tudes and during hot seasons. 
It is characterized by a comparatively sudden invasion, by a con- 
tinued type of fever, by a rapid development of severe symptoms, 
which often, however, have a temporary abatement, generally to return 
with increased severity; there is usually marked yellowness of the 
skin, the vomiting of a dark coffee-ground fluid ; there is albuminous 
and often scanty urine, and in a large proportion of cases there is 
rapid sinking and death. 
In several of its features it resembles some .severe cases of remit- 
ting fever, and has been thought by some to be but a modification of 
malarial disease. Its distinctive character is now so generally ad- 
mitted, that no argument is here needed to establish this fact. 
The history of yellow fever is unknown previous to about the 
middle of the seventeenth century, when the first recorded outbreak 
occurred in those tropical islands where its home has since been, and 
whence it has issued on so many occasions. In many instances it has 
seemed to acquire new vigor by its migration, especially when the 
poison has been carried to densely populated localities where the 
hygienic conditions were unfavorable—where the heat was great and 
filth abounded. 
In none of the specific diseases where a materies morbi has not 
been identified and demonstrated, are inferences of the existence of 
such a poison more clear and conclusive than in this ; and in none is 
there more uncertainty as to what it really is. The same arguments 
which prove the existence of a specific and probably germinal poison 
in malarial diseases and in cholera, are equally conclusive here; and 
in no other disease does the existence of certain physical conditions, 
especially a low temperature and frosts, have so much influence in 444 
TEL LOW FEVER. 
arresting its continuance. It has raged with great severity in many 
localities in the Southern United States, and nowhere perhaps more 
conspicuously than during the years 1878 and 1879 in Memphis, Tenn. 
The question as to the contagiousness of yellow fever, as well as of 
cholera, has often been mooted, and frequently with the same degree 
of vagueness as to what constitutes contagion. I have had no personal 
observation and experience with yellow fever, and my convictions are 
not of the same positiye character as in the case of cholera ; but from 
all the information I have been able to gather, I cannot doubt that 
this disease, like cholera, is dependent upon a specific, material, ger- 
minal poison; that such poison probably had its origin outside the 
human body, and that it certainly is multiplied outside the body, 
though it may also be multiplied within it—and possibly one stage 
of its development is necessarily within it, though that is by no 
means proven ; that the germs are capable of being attached to fomites 
and transported to great distances by ships and other means, and 
when brought to a locality where the heat, moisture, the presence of 
putrefying organic material (filth) in the soil and atmosphere are 
favorable, it multiplies with great rapidity, and affects persons sus- 
ceptible to its action ; that the whole atmosphere of a locality where 
it prevails contains the poison, and that, as in cholera, those in attend- 
ance upon the sick are not particularly more liable to take the dis- 
ease than others in the same general atmosphere. If by a contagious 
disease is meant one produced by a poison which is alone generated 
and multiplied in the bodies of the sick, and transmitted from person 
to person, yellow fever seems to me not contagious ; but the facts are 
such as to give plausibility to the theory of its being miasmatic con- 
tagious, according to the meaning given to that expression by Lieber- 
meister. By this is meant a disease produced by a poison which is 
multiplied outside of the body, and also in some of its stages, or to 
some extent, within it, but not necessarily and exclusively so. 
In the case of yellow fever there is no sufficient proof that the 
poison originates in the body, or that it must necessarily pass through 
it, producing the disease, before it affects the system of another ; and 
its exclusive contagiousness, in the sense that small-pox(is contagious, 
seems to me more than doubtful, if it is not positively disproved. 
The most important facts to be observed in reference to the pre- 
vention and spread of the disease are, that there is a poison which is 
the cause of the affection, that that poison is portable, capable of 
being carried to great distances ; that it is usually brought to other 
parts of the world and especially to our country from the Antilla 
Islands; that the local conditions favoring the multiplication of 
the poison are heat and filth ; and those favoring its operation upon ETIOLOGY AND PATHOLOGY—SYMPTOMS. 
445 
persons are intemperance, irregularities, recent residence in a locality, 
and absence of protection by previous attacks, and want of acclima- 
tion in a region of high temperature. The white race is much more 
subject to the disease than the colored. In its prevention, strict 
quarantine of vessels and persons from infected places, whether any 
on board the vessels are affected with the disease or not, or whether 
the persons from the infected places are sick or well, is of primary 
importance; while the greatest pains should be taken to preserve 
cleanliness, and improve the hygienic conditions of places liable to the 
introduction of the poison. 
While cultivating and manuring a field will not produce a crop of 
grain unless seed is sown, so sowing seed, however fruitful, upon a 
barren rock will not produce a harvest. The seed and the soil capable 
of germinating and sustaining it must be brought together in order 
to a productive yield. So with the free production and epidemic 
spread of yellow fever; the seeds in a condition capable of germina- 
tion must be present, and they must find conditions capable of sus- 
taining and developing them, or a crop of disease and a harvest of 
death will not follow. The conditions for this growth and its effects 
are a high temperature, effete or decomposing organic matter (filth), 
and the presence of unacclimated or susceptible persons. 
Symptoms.—Notwithstanding the specific character of yellow 
fever, it differs much in its severity and particular phenomena in 
different epidemics and in different individual cases. Sometimes the 
full complement of standard symptoms is present, sometimes they are 
imperfect and deficient, and sometimes displaced. At one time the 
diagnostic symptom is the supraorbital headache. At other times the 
tongue symptoms are alone diagnostic, or their equivalents are ex- 
pressed in the uvula and fauces. Intense surface heat, albumen early 
in the urine, and black vomit are among the later symptoms ; and 
smoky, pale urine, with perfect blood corpuscles, takes the place of the 
straw-colored or bilious urine, with its sediment of tube casts and 
epithelial matter. (Aitken.) 
In well-marked cases, besides the phenomena common to most 
severe febrile attacks, often the tongue is red at its tip and edges, with 
prominent papillae and a creamy surface. After a time the fur sepa- 
rates from the middle, or lies in wavy flakes ; then there is a separation, 
of the epithelium beginning at the tip, proceeding to the edges and 
down the raphe, and this separation may extend over the whole sur- 
face, obliterating the papillae—the tongue becoming smooth and dry- 
ish, and looking like a piece of raw beef. When this occurs, more or 
less oozing of blood takes place, coating the surface of the mouth, 
and collecting upon the teeth. The tongue then becomes much 446 
TELLOW FEVER. 
smaller and more pointed than in the early stage. Mosquito wounds 
are said sometimes to present an enlarged area of rose-colored spots, 
becoming hemorrhagic near the end in fatal cases. 
Bloody furuncles occur in some cases, so late, however, as to be 
regarded as sequelae, and are commonly situated on the wrists, and 
along the front of the legs, but may be in other places. On the legs 
they are often flat, purplish vesications, about the size of a pea, or a 
little larger. 
A variety of types, or forms of the disease, have been clinically rec- 
ognized by different writers. Thus one makes an algid form ; a 
sthenic form ; a hemorrhagic form ; a purpuric form ; and a typhoid 
form. Others make other groupings ; all of which show the variable 
character of the disease as to particular phenomena. 
In what is called the algid form there is the most rapid course and 
the greatest amount of early prostration of the vital powers, which 
are evidently overcome by the more direct action of the poison. The 
patient in his usual health may suddenly feel a shock as from a heavy 
blow on the back, and fall down into a collapsed state, and die within 
a few hours. 
The sthenic form is in decided contrast with the algid. It is more 
likely to occur in persons well developed, and in the vigor of life, and 
is characterized by strongly marked febrile symptoms, a high, full, 
hard pulse, flushed face, throbbing temples, high temperature, some- 
times going up to 107° F., or even more, with severe pain in the head 
and back—all the symptoms indicating a powerful reacting resistance 
to the poison on the part of the system. 
The hemorrhagic type, however, is one of the most characteristic 
and appalling. In this there is epigastric distress and pain on press- 
ure ; but the most marked condition is a tendency to profuse effu- 
sions of blood occurring simultaneously from different parts of the 
body. The cases are fatal at an early period, the temperature not ris- 
ing as high as in the sthenic forms, and after death the tissues are 
found infiltrated with blood. 
In what is called the purpuric form, the fever is well marked, and 
the conjunctive and skin are intensely yellow. Subcutaneous effu- 
sions of the coloring matter of the blood with various shades of color, 
and often with oedema around, constitute the purpuric spots. 
In wThat is called the typhous form, a variety of phenomena pre- 
vail. In some there is stupor and nervous depression at an early stage 
of the fever, with other typhoidal symptoms, to which are added the 
hemorrhagic phenomena ; wdiile in others the typhoidal symptoms 
follow the sthenic fever, or the algid condition, in the few cases where 
that is survived. COMMON FORMS. 
447 
Besides these severer forms, there are, during the prevalence of an 
epidemic, many cases in which the symptoms are of a mild character, 
even milder than in ordinary cases of malarial fever. 
The numerous varieties presented by this disease have occasioned 
great discrepancy and confusion in the different accounts given of it. 
It would protract this article too much to give even a short sketch of 
the many accounts of the disease which its literature contains, and in 
the absence of personal experience (this being one of the very few 
diseases I have not witnessed), proper discrimination could hardly be 
exercised. With even the ablest writers more or less blundering is 
often apparent when treating of diseases of which they have had no 
experience. 
Notwithstanding these different varieties, there are some features 
which are generally present ; and a more detailed account of the 
ordinary symptoms may be given which will apply to a majority of 
cases, and will give a clearer picture of the common forms of the 
disease. 
An attack of this fever, as already stated, is usually abrupt. In 
some cases, however, the more decided symptoms are preceded for 
from one to three days by languor, loss of appetite, headache, and 
chilly sensations. The full attack is generally marked by a chill of 
rather moderate intensity, succeeded by increase of temperature and 
the other common symptoms of the febrile state. The intensity of 
the fever varies in different cases ; in some it is high, and in others 
the heat of the surface is not much raised, and the pulse does not ex- 
ceed 100. The tongue is moist and more or less coated. Vomiting 
may occur early, but is rarely present until a later period of the 
disease. There is tenderness on pressure over the epigastrium, the 
boAvels are generally constipated, there is usually pain, sometimes in- 
tense, in the supraorbital region, in the back and lower limbs, espe- 
cially in the calves of the legs—the lumbar pains having an analogy 
to those of small-pox. The mind is usually clear, though there is 
sometimes delirium, which is very seldom violent, however, and is 
sometimes mirthful. “ The eyes are reddened, irritable, watery or 
tearful ; this is quite constant, and so marked as to constitute a 
diagnostic feature.” (Flint.) 
The fever continues for a period varying from a few hours to 
three days, when there follows an abatement or an entire cessation of 
it, and what is called the “ state of calm,” or sometimes the “ stage 
of reaction,” occurs. Some regard the stage of feverish excitement as 
constituting the disease proper, and all that follows as its sequelae. 
In some cases the cessation of the paroxysm of fever is the begin- 
ning of convalescence, which goes on to recovery. In the graver cases 448 
YELLOW FEVER. 
it is delusive; and after a period of some hours, or a day or more, new 
symptoms are developed, which are more distinctive of the affection 
than those which preceded. The pulse sometimes falls below the 
normal in frequency, and is often small, weak, and sometimes vibra- 
tory. The surface is often cool, especially of those parts wliicb are 
uncovered, and capillary congestion may be marked. 
Vomiting, if not already present, now comes on and is decided; 
and in a large proportion of fatal cases, and in some that recover, the 
matter vomited is very dark in color, resembling well-burned coffee 
grounds. This “ black vomit,” taken with other symptoms, is pa- 
thognomonic of the disease. This characteristic matter is due to the 
presence of blood, changed by the action of the gastric juice. Some- 
times this vomited material is red in color, the blood having under- 
gone but little change ; it is generally acid in its reaction, and com- 
paratively unirritating, though in rare cases it excoriates the throat 
and other parts with which it comes in contact. It is more or less 
abundant in different cases, is ejected sometimes with force, at other 
times it seems a mere act of regurgitation ; and it commonly ceases 
in fatal cases in from twelve to twent37-four hours before death. This 
black vomit which rarely occurs until the first stage is passed, is often 
preceded by vomiting of a limpid or opalescent matter ; and the ten- 
derness of the epigastrium, so often present in the first, is aggravated 
in this second stage, and is sometimes extreme. The tongue, some- 
times reddened, dryish, and raw in appearance, as already described, 
is in other cases moist and covered with a creamy coating; and some- 
times it preserves a nearly natural appearance. During this second 
stage the discharges from the bowels are frequently dark, or nearly 
black—of the appearance of molasses or of tar. This dark appear- 
ance is also due to the presence of altered blood; and when the func- 
tions of the kidneys are seriously interfered with, as is often the case, 
the constituents of the urine, such as uric acid and the triple phos- 
phates, are to be found in the stools. Diarrhoea seldom occurs, mete- 
orism is generally absent, and the abdomen is soft. 
Albumen in the urine is a very frequent, and an almost constant 
condition in severe and fatal cases, and frequently blood corpuscles 
and casts of uriniferous tubes are also found, and the perverted func- 
tion of the kidneys is among the causes of the great mortality which 
attends this disease. A scanty secretion, and sometimes total suppres- 
sion occurs in fatal cases, with the consequent retention of urea and 
other effete matters, and this poisonous action is an important feature 
of the disease. In the severe cases the urea and uric acid diminish 
and at length disappear, and are sometimes replaced by leucin and 
tyrosin, while albumen appears, and, as the disease advances, increases SYMPTOM A TIC PHENOMENA. 
449 
in amount. Usually tlie urine is of a deep color from the free 
quantity of blood pigment and bile pigment which it contains. 
The yellowness of the surface, from which the disease derives its 
common name, comes on in the second stage. The conjunctive also 
become yellow at the same time, and this, together with the previous 
redness, gives a peculiar and characteristic expression to the eyes. 
The jaundiced appearance of the skin and conjunctive is due to 
the presence of biliverdin, and the perverted function of the liver 
contributes to the severe and fatal effects. 
The yellowness is present only in a portion of the cases, mostly in 
those of a severe character. It continues after death, and in cases of 
recovery into the convalescent stage. 
In most severe cases there is hemorrhage into the stomach, bowels, 
and kidneys, and in the specially hemorrhagic cases from many other 
parts, as already described. 
Coma and convulsions occasionally occur, as would be expected 
from the uraemia which accompanies the disease of the kidneys ; and 
delirium, though generally absent in the second stage, is sometimes 
present. Occasionally the patient fancies himself well, or but slightly 
ill; and though muscular prostration is usually great, in exceptional 
cases he keeps up until almost the last. 
The physiognomy is much relied on by those familiar with the 
disease as a means of distinguishing its presence; while a peculiar 
odor is regarded as in a measure diagnostic. So many descriptive 
epithets are applied by writers, that it is difficult to obtain an impres- 
sion of all its peculiarities without seeing cases. 
The duration of this second stage varies from a few hours to a few 
days ; and when it is survived, a third stage supervenes, which may 
be one "of collapse and exhaustion, or of convulsions and coma, or of 
great restlessness, or an apparent freedom from suffering, all terminat- 
ing in death ; or this may be a stage of improvement resulting in 
convalescence. 
When patients recover from the first stage, or that of the primary 
fever, the convalescence may be rapid ; but if they pass into the 
second stage, with black vomit and other severe symptoms, such 
pathological changes have occurred as to render convalescence slow, 
and it is often accompanied with low typhoidal symptoms. Relapses 
are said sometimes to occur after convalescence seems to be advanced. 
The mildest forms of the disease present no very decided charac- 
teristic symptoms, and some can only be distinguished as yellow fever 
by its general prevalence. These are the cases, very numerous in 
some epidemics, which furnish statistics of great success with special 
modes of treatment. Those not very ill may often trust themselves to 450 
YELLOW FEVER. 
infinitesimals or to some particular nostrum, and statements of the 
success of treatment, if credited, are often very deceptive. 
In some instances great success in the treatment of Asiatic cholera 
has been boastingly reported by those who were employed chiefly in 
the treatment of the diarrhoeas, always so prevalent during an epi- 
demic of this disease. Such cases have been reported as cholera, and 
an immense proportion of recoveries has been attributed to the par- 
ticular professed methods of treatment. Those having the oppor- 
tunity of observing have testified that similar unfounded statements 
have been made in reference to the success of the treatment of yellow 
fever; but such false statistics can deceive those only who are un- 
acquainted with cholera, with yellow fever, and with the devices of 
unprincipled pretenders. 
Morbid Anatomy.—The morbid appearances post mortem are, 
as the clinical history would suggest, most conspicuous in the stomach 
and other portions of the alimentary canal, in the liver, and the kid- 
neys. The stomach generally presents redness, softening and thick- 
ening of the mucous membrane, or ecchymosed or purpuric spots, 
or the condition described as mammillation. The epithelium is 
usually intact. These appearances are not uniform, and some that 
have been described are probably cadaveric. 
The intestinal canal, in some cases, presents the appearance of red- 
ness in patches, and also points of ecchymosis and of softening ; and 
similar appearances are sometimes observed in the oesophagus. Both 
the stomach and bowels often contain more or less of the black mate- 
rials already described. The liver, in cases which continue long 
enough for the full development of the disease, is quite uniformly 
changed in appearance. In most instances it is unnaturally yellow or 
fawn colored, suggesting an acute fatty degeneration of the organ. 
On minute examination this is found to be the case. There are fatty 
infiltrations and fatty degeneration of the hepatic cells, and, in ad- 
vanced cases, there is a great abundance of fat-cells and granules. 
The kidneys, where albumen and blood are found in the urine, we 
should expect to find congested or inflamed, or in otherwise altered 
conditions, and such is generally the case. Hyperaemia is very com- 
monly present; the tubules, both straight and convoluted, have their 
epithelium affected with granular degeneration; and, in the pro- 
tracted cases, extended fatty degeneration follows. 
According to the accounts, however, there is not uniformity in this 
respect; and in the present state of knowledge the morbid anatomy 
does not offer a satisfactory explanation of all the phenomena of the 
disease. DIA GNOSIS—PROGNOSIS, 
451 
Nothing distinctive of the disease is found in the nerve-centres, 
though, as in other fevers, there are variations as to quantity of blood, 
and sometimes there are effusions. In the hemorrhagic varieties 
especially, extravasations of blood are found in the lungs and other 
organs, and sometimes upon their surfaces, as would be supposed. 
The morbid anatomy and histology of the disease await a more full 
investigation. 
Diagnosis.—The diagnosis is to be made by carefully observing 
the phenomena which have already been described. In the milder 
cases, and in the first stage of the more severe forms, all agree that 
the diagnosis, especially in the first cases of an epidemic, before its 
established prevalence furnishes any aid, is often very difficult. 
The cases that convalesce from the first stage would not generally 
be considered yellow fever, were not the disease prevailing, so strangely 
do many of them resemble febricula or accidental fevers. Other 
cases, however, present symptoms in the first stage more or less diag- 
nostic. These are, abruptness of the attack, severe pain in the back 
and limbs, and suffusion or redness of the eyes. As the disease ad- 
vances to the second stage, the diagnosis cannot, in a majority of 
cases, be difficult. It is perhaps more likely to be confounded with 
remitting fever than with any other affection, but a careful compari- 
son of their respective phenomena will make the distinction possible. 
Malarial fevers are thought to be sometimes associated with yellow 
fever, modifying the latter in its phenomena. Such an association 
would influence the treatment. 
Prognosis.—The general prognosis must be grave, as, according 
to the estimate of Dr. La Koche, the average mortality is 1 in 2.32. 
However, the rate of mortality differs greatly in different epidemics, 
and in different periods of the same epidemic, usually becoming less 
severe toward the period of its decline. 
The yellowness of the surface, the black vomit, the suppression of 
urine, and a general hemorrhagic condition, are unfavorable indica- 
tions. An early collapsed condition is, of course, indicative of a 
speedy unfavorable result, and coma and convulsions are evidences of 
very dangerous if not fatal urasmia. The favorable symptoms are a 
moderately slow pulse and moderate temperature, and a quiet stomach. 
Streaks of fresh blood during the black vomit, if the corpuscles are 
entire, are considered favorable. If the urinary secretion continues, 
and the vomiting is slight or abates, there may be hope. The urine 
simply albuminous is more favorable than where casts abound. A 
free, copious discharge of urine, however loaded with bile or blood, is 
a favorable sign. In cases of moderate severity unfavorable events are 
liable to occur, so that the prognosis should always be guarded. 452 
YELLOW FEVER. 
Treatment.—No part of the task of writing on yellow fever is 
so difficult and unsatisfactory as that of attempting a description of 
its proper treatment. 
As is the case in most other specific fevers, no reliable antidotal 
remedy has yet been discovered, and no course of treatment can be de- 
pended upon to cut short the disease. Quinine and opium have been 
claimed as acting antidotally, or as abortives, but the continued high 
rate of mortality seems to negative all such claims. That these reme- 
dies are often useful there may be reasons for believing ; that they will 
arrest malarial fevers, which are sometimes mistaken for yellow fever, is 
quite certain; and that they may exert a decided control over some 
complications, is exceedingly probable; but their effects in genuine 
and severe cases of this disease must be regarded as uncertain, if not 
entirely doubtful. 
From the fact that many cases are mild and tend to recovery, 
while others are malignant and certain to terminate in death, the 
effect of any treatment in a given case is exceedingly difficult to 
determine. The numerous remedies that have been accepted and 
rejected, praised and condemned, confirm this statement. 
As there are no specifics, the treatment must be guided by the 
rational indications present. It is an object to keep the bowels open, 
and to induce the skin and kidneys to act as freely as possible, with 
the hope of carrying off injurious materials and relieving internal 
congestions. Excessive action of any organ should be abated, and the 
different functions, as far as possible, should be regulated. 
The sthenic cases may require sedatives, as the wet sheet or cool 
bath. In all ordinary cases there seems to be a concurrence of testi- 
mony in favor of inducing and maintaining a free action of the skin. 
The use of cathartics, though questioned by some, is regarded by 
most as important; at least such use as is necessary to effect moderate 
evacuations, and to keep the bowels free from faecal accumulations. 
Some prefer the free and repeated use of enemas, exciting gently an 
extensive portion of the colon by the use of one and a half pints of 
warm water in which a table-spoonful of common salt has been dis- 
solved, adding also a table-spoonful of olive oil, or, in some cases, a 
drachm or two of oil of turpentine. Demulcent drinks are also regarded 
favorably when the redness of the tongue indicates a denuded or in- 
flamed state of the mucous membrane of the stomach and bowels. 
The food should be of the blandest kind—chicken-tea, arrow-root, 
barley-water, well-cooked gruels, with milk, to which lime-water may 
be added—taken in moderate quantity at a time, and repeated as the 
stomach will bear. The irritation of this organ should be allayed 
by all means possible. A few drops of chloroform in water, or an TREATMENT. 
453 
appropriate dose of chlorodyne, or a quarter of a grain of carbolic acid 
repeated once in two hours will often be of great service in producing 
that effect. All drastic medicines should be avoided, but small doses 
of calomel may be given, often combined with moderate doses of 
morphine, especially where the pain is severe. 
In the specially sthenic cases blood-letting has been practiced, and 
with alleged advantage. Where this was practiced convalescence was 
slower, but the immediate effect was thought to be beneficial. Leeches 
and counter-irritation over the stomach have also been applied with 
some benefit in these cases. Warm baths, cupping over the kidneys, 
and diaphoretics seem to be indicated at the period when the conges- 
tion of the kidneys is likely to result in diminution and suppression 
of the urine. I am unable to say to what extent it has been tried, 
but the use of jaborandi in such cases, from the analogy of its effects 
in other diseases, would seem to be worthy of a trial. Acetate of 
ammonia, potash, and soda have also been suggested. When the tem- 
perature is high, the cool bath, or wet pack, or sponging should be 
tried, and antipyretics—quinine, salicylate of soda, etc.—may be used 
by enema, if the stomach will not tolerate them. The stomach is 
generally too irritable to bear large doses of these medicines by the 
mouth. In the mild cases very little treatment may be required. 
Patients should at once be put in bed, calm and rest should be 
secured, perspiration should be induced, a dose of castor-oil should 
perhaps be given, and the case carefully watched, as the mildest 
cases may become severe; and whatever symptoms may arise should 
be met with such palliative measures as may seem indicated and can 
be borne. 
The free use of calomel has been advocated by some as of great 
importance, but others question its utility, and the testimony respect- 
ing its beneficial effects is not conclusive. 
Whenever a malarial influence is combined with this disease, there 
can be no question about the propriety of using prompt antiperiodic 
doses of quinine ; but its usefulness in other cases, as before stated, is 
not established. Counter-irritation, especially over the epigastrium 
when the stomach is irritable, tender, and congested, may be of mate- 
rial service in relieving internal determinations of blood. 
Chlorine mixtures, such as are recommended in scarlet fever, have 
been advised by some. 
In the malignant cases all measures fail—at least to do more than 
palliate some distressing symptoms. In all cases where great suffer- 
ing is experienced, anodynes may be given as may seem to be required. 
In short, while the physician, like the mariner, is unable to allay the 
storm, he must give his attention to managing, as best he may, to 454 
YELLOW FEVER. 
prevent the foundering of his craft. This, unfortunately, in yellow 
fever, he is too often unable to do. 
Various more radical measures have from time to time been 
advised; but the efficacy of no active perturbing agent has been 
established. Palliating and sustaining measures—meeting prominent 
indications on rational principles—are all that the present state of 
knowledge enables us with confidence to advise. 
The convalescence often requires to be managed with care. The 
stomach is frequently left in a debilitated and a more or less seriously 
injured condition, requiring a regulated diet and frequently other 
palliative measures. 
It is a gratifying fact that some of the diseases, such as small-pox, 
plague, and yellow fever, which are least under the control of curative 
agents, are most under the control of preventive means ; and so much 
more can be done in the way of prevention than of cure of this dis- 
ease, that preventive measures should command the best attention of 
the profession and the judicious aid of governments. This, it is 
gratifying to know, the subject is receiving. 
Since the preceding account was prepared, Dr. Domingas Freire, 
of Rio de Janeiro, has published a volume, in which he gives an ac- 
count of his researches in yellow fever during an epidemic, which, if 
confirmed by further investigations, will constitute the most important 
contribution yet made to our knowledge of the pathology and treat- 
ment of this disease. He states that he has found in the vomit of 
patients great numbers of bacteria and of round cellular organisms, to 
which he gives the name “ cryptococcus xanthogenicus. ” He has cul- 
tivated these microzymes and studied their development, and finds it 
corresponding with the stages of the fever. He has found the blood 
of patients to contain these organisms, and that at the time of the 
breaking up of the cryptococci a large quantity of yellow pigment is 
liberated, which colors the skin and the liquids, and produces a broken- 
down state of the blood, which favors hemorrhage. 
The organisms are then in a quiescent state for a time, and this 
corresponds with the calm of the disease. 
When the third stage supervenes, which is generally fatal, with 
profuse hemorrhages, small thready pulse, delirium and sinking, the 
blood, according to Dr. Freire, “can hardly be said to be blood, but 
an unformed mass of cryptococci, bacteria, vibriones, and debris of 
all sorts.” 
Regarding these organisms as the cause of the disease, Dr. F. 
has attempted to destroy them at an early stage of the fever by the 
use of the salicylate of soda. He reports eighty-eight cases treated, 
during the first three days of the affection, with the salicylate of soda, TREATMENT—PHENOMENA. 
455 
used by hypodermic injections in varying quantities from three to 
eight grains up to sixteen or twenty, with eighty-three recoveries, or 
a mortality of only seven per cent. 
The author promises farther accounts of his researches and the 
results of his treatment, and if the latter should prove as favorable 
as those reported, a great advance will have been made in the suc- 
cessful management of this formidable disease. Salicylate of soda can 
be given by the stomach in free quantities with safety, and this mode 
of administration may be found proper to be combined with hypoder- 
mic injections. 
EBYSIPELAS.—Erysipelatous Fever. 
Erysipelas is sometimes a primarily local affection, depending upon 
a local cause, but it is also sometimes an epidemic fever, dependent 
upon a cause which primarily impresses the general system. As a 
local or traumatic affection, depending upon wounds or local injuries, 
it belongs to surgery, and is more appropriately treated of in works on 
that branch of medical science. As a general affection with local 
manifestations—as a specific fever—it belongs to medicine, and as 
such it will be chiefly considered here. 
In the article on cerebro-spinal fever, erysipelas was mentioned as 
a complicating element, and its relations to that affection were con- 
sidered. 
As a general disease, erysipelas may be defined a specific infectious 
fever, accompanied by inflammation of a peculiar type affecting the 
skin and subcutaneous tissues, and sometimes the mucous membranes, 
serous surfaces, and other deeper tissues and internal organs. The 
fever is usually of an adynamic type, the inflammation has a tendency 
to spread upon surfaces, and to produce aplastic exudates. It some- 
times appears as an epidemic, prevailing over considerable areas, but 
is more frequently a local epidemic confined to particular localities. 
When erysipelas occurs as the result of a wound or injury, or 
spreads from a previously inflamed point, it is regarded as a sympto- 
matic or secondary affection, and is generally spoken of as traumatic 
erysipelas. When it occurs without such local cause, coming on 
spontaneously and as the primary affection, it is said to be idiopathic. 
When occurring in connection with wounds, it is sometimes induced 
by matter transferred from a patient with erysipelas, and applied to 
the wound by the instruments or hands of the surgeon or attendants ; 
and such erysipelatous matter or some form of poisonous material ap- 
pears to invade a locality, as a hospital or a particular neighborhood, 
and infect the wounded and others through the air. In some cases 456 
ERYSIPELAS. 
this is not only infections but contagious, particularly the phlegmo- 
nous variety, demanding great care as to isolation and the avoidance 
of the transferring of the poison from the diseased to the injured— 
to parturient or puerperal women, to newly born children, and to 
others less susceptible than these to its effects. 
It not unfrequently occurs “spontaneously ” or “idiopathically,” 
that is, without a wound or any abraded surface or previous disease 
in the patient ; commencing with general feverish symptoms, soon 
followed by the local inflammation, and evidently produced by some 
influence which operates upon the general system. This influence 
sometimes spreads in 'such a manner as to induce an epidemic preva- 
lence of the disease, and to manifest the character of a specific in- 
fectious fever. 
But from whatever cause induced, whether it be a local disease, as 
Hebra believes it always is, or whether it is sometimes a general dis- 
ease or a specific fever, as it certainly seems to be ; whether a specific 
poison produces it, or it occurs from some general condition of the 
system tending to such morbid action ; under whatever circumstances 
appearing, it presents certain peculiar characteristics which require 
description, and demand the attention of the physician as well as the 
surgeon and accoucheur. 
The earliest local change consists in a circumscribed blush or 
congestive redness, soon followed by inflammatory effusions (serum, 
lymph, and corpuscles) in the substance of the skin and the subcu- 
taneous tissue. This hypeixemia and effusion give rise to swelling; 
this swelling extends by continuity, generally with a clearly defined 
margin, though sometimes it shades off into the healthy skin. Ac- 
cording to the original smoothness or roughness of the surface, it may 
be glossy and shiny, or the markings may be exaggerated. The exten- 
sion varies in rapidity, it is generally gradual, often less than an inch 
in twenty-four hours, though sometimes more rapid, and occasion- 
ally it breaks out on distant points from time to time, when it is called 
“erratic.” As it gradually extends, the parts first affected begin to 
fade, resolution and desquamation following, and, in some instances, 
a large portion of the body is thus traversed. 
The depth and intensity of the inflammation vary in different 
cases, and the exudates -may be more or less abundant, sometimes pro- 
ducing an oedematous swelling, and at others free suppuration taking 
place ; but when thus effused, the pus, not being confined by plastic 
exudates in a distinct cavity or tvell-defined abscess, is infiltrated into 
the cellular tissue, producing what is called “ boggy ” swelling, and is 
apt, under fasciae or in loose textures, to extend to considerable dis- 
tances from its original seat. Sometimes, especially about the eyelids PHENOMENA. 
457 
and other parts of the face and head, the pus is found collected in 
more distinct abscesses. 
In other cases sloughing of connective tissue and of other struct- 
ures take place, and more or less wide-spread destruction results. In 
one case under observation, sloughing of one parotid gland occurred, 
with recovery and a permanent deep cavity behind the angle and 
ramus of the jaw. Sometimes serous and corpuscular, and occasion- 
ally purulent, exudates occur on the surface of the true skin and 
under the cuticle, constituting vesicles, bullae, or pustules; and the 
disease with these appearances is called E. vesiculosum, E. bullosum, 
E. pustulosum, or, when the exudate dries down into scabs, E. crus- 
tosum, according to the condition and appearance presented. Bullae 
containing sanious fluid, when superficial gangrene and subcutaneous 
sloughing occur, are often present, and sometimes when the lesions 
are not so severe. 
But erysipelas is not confined to the skin and tissues near it. It 
may extend to mucous or serous membranes, or, in fact, during an 
epidemic of the disease, internal parts may be the only seat of an 
inflammation unequivocally erysipelatous in character. The mucous 
membrane of the fauces, larynx, bronchi, or of the stomach, intes- 
tines, and any part of the alimentary canal, and the serous membranes 
as well—the pleura, pericardium, peritoneum, anti meninges of the 
brain and spinal cord—may be either the primary or secondary seat of 
this peculiar kind of inflammation. Sometimes a cutaneous and an 
internal erysipelas are present at the same time, but they are not apt 
to rage with equal severity, one or the other generally yielding to the 
counter-irritating effects of its apparently opposing condition. 
In erysipelas the veins, and especially the lymphatics, have a marked 
tendency to become affected. Red lines are frequently seen in their 
course, their glands are likely to be swollen and tender ; and some 
authors are of the opinion that the primary seat of the inflammation 
is in the lymphatic system. 
Phlebitis, with suppuration around and within the veins, occa- 
sionally takes place, and embolism and pycemia may follow. 
Some persons are subject to repeated attacks of cutaneous erysipe- 
las ; and in these it is sometimes very superficial, shading off into a 
mere congestive blush or merging into an erythema. 
In the early stage of erysipelas the blood contains an excess of 
fibrine and of white corpuscles, and later, as the disease continues, 
the blood tends to assume the appearance found in other low forms 
of fever. “ Post mortem it is generally found dark and fluid, or 
pitchy, with little tendency to coagulate and still less to the separa- 
tion of fi brine.” As is so common in low specific fevers, the internal 458 
ERYSIPELAS. 
organs are generally soft, and the liver, kidneys, lungs, and especially 
the spleen, are congested. Decided parenchymatous inflammation of 
the lungs and other organs is sometimes found. The general symp- 
toms and progress of the disease vary much according to the locality 
of the inflammation and the severity of the attack. In some of its 
epidemic forms it assumes a malignancy which few other diseases 
possess. In other cases it is comparatively mild and devoid of 
danger. When it affects internal organs it is always fraught with 
much danger from its great tendency to spread over large surfaces, 
and its course is often rapid toward a fatal termination. 
In idiopathic erysipelas the local phenomena are generally pre- 
ceded for several hours, or for two or three days, with feverish symp- 
toms, such as morbid sensations, loss of appetite, general pains, rigors, 
and increase of temperature. The disease in such cases cannot be 
entirely local—there must be some general morbid condition mani- 
fested by general symptoms finally resulting in the local phenomena. 
In ordinary sporadic cases the most frequent point of attack is some 
part of the face, particularly the bridge of the nose and adjoining 
regions. A blush of redness is seen, soon followed by obvious swell- 
ing, and accompanied by heat, tingling, and tenderness, and by an 
increase of the general temperature. There are headache, general 
pains, sometimes rigors, dryness of skin, increased frequency of pulse, 
furring of tongue, thirst, loss of appetite, high-colored urine, etc., 
the ordinary phenomena of a febrile movement. If the case be mild 
the inflammation may extend only over a part of the face, and con- 
valescence may soon occur. If the inflammation continues to spread 
and increases in severity, the pulse becomes more rapid and often 
feeble, the tongue more thickly coated and dry, and more or less 
delirium is apt to come on. The local disease may spread over the 
face and scalp and extend down upon the chest. Low typhoidal 
symptoms are apt now to supervene, delirium becoming more marked, 
the sleep more heavy and comatose, but fitful and disturbed. Some- 
times a diarrhoea with involuntary discharges comes on; but in the 
course of from six to ten days improvement generally begins, the 
inflammation has already subsided at the point where it commenced, 
it ceases to extend, and convalescence in a few days is established. 
In other cases the inflammation may have affected deeper parts, may 
linger in its original seat, suppuration may occur, especially about 
the eyes and in the lids, which have been closed bv the swelling; or 
the disease may continue to spread down the neck and upon the 
trunk, with more distinctly typhoid symptoms well marked, such as 
great prostration, low muttering delirium—though sometimes more 
violent—a dry dark tongue, and want of control over the evacuations ; PROGNOSIS—DIAGNOSIS. 
459 
and as the condition becomes still worse, the temperature may rise 
still higher, the skin may be bathed in sweat, the pulse rapid, weak, 
and perhaps irregular, and soon nearly imperceptible, the respiration 
quick, superficial, and noisy ; the delirium is succeeded by coma, and 
death soon follows. Sometimes, however, from very low conditions 
the patient rallies, and convalescence, after a protracted struggle, is at 
length established. 
In this erysipelatous, as in other fevers, the temperature is always 
above the normal, with the usual evening exacerbations, but it seldom 
rises above 106° F. When the inflammatory condition extends to any 
of the internal parts already mentioned, it is indicated by appropriate 
symptoms, and of course adds greatly to the danger. When it in- 
volves the throat, oedema of the glottis is very liable to occur, and 
death by suffocation may be sudden and unexpected. When the 
membranes both of the brain and spinal cord are involved, the phe- 
nomena of cerebro-spinal meningitis occur ; if those of the brain 
alone are implicated, there will be the symptoms of cerebral menin- 
gitis ; if the inflammation is confined to the membranes of the 
cord, there will be the corresponding symptoms of spinal meningitis; 
and when other internal parts are affected, corresponding symptoms 
will be manifested. 
When the local disease is confined to the cutis, it is called simple 
erysipelas; when it affects largely the subcutaneous tissue, it is 
called phlegmonous erysipelas; and the terms cedematous, suppu- 
rative, and gangrenous, are applied to the corresponding conditions 
designated. These are not distinct forms of the disease, as they run 
into each other according to the severity of the case, the general type 
it assumes, the previous condition of the system, and other circum- 
stances. 
Prognosis.—When internal organs are involved, the prognosis 
is always very grave ; but in a large proportion of cases of external 
or cutaneous erysipelas, under proper hygienic conditions, and with 
proper treatment, recovery takes place. The phlegmonous and gan- 
grenous forms are much more formidable than the simple. 
Diagnosis.—The diagnosis is easily made in a fully developed 
case ; but in its earlier stages and milder forms it may be confounded 
with erythema and urticaria, with the early stage of carbuncle, and 
with simple, diffuse, and superficial inflammation ; and in its epi- 
demic and internal forms with cerebro-spinal meningitis, with which 
sometimes it has some close relations, and with simple inflammation 
of various internal organs. The disease may commence in the throat, 
when it may be confounded with tonsilitis, pharyngitis, diphtheria, 
stomatitis, etc. 460 
ERYSIPELAS. 
Its external forms are to be distinguished by its progressive spread, 
by the infiltration and swelling of the skin presenting a well-defined 
margin, while the redness shades off into the healthy skin; and by 
the subsidence of the inflammation in a particular part, after the 
third, fourth, or fifth day, though it may be extending at its margins. 
A careful comparison of its phenomena with those of the other dis- 
eases which it resembles will serve to distinguish it. 
Treatment.—The prophylaxis of erysipelas is suggested by what 
has been stated of its causation and mode of occurrence. Isolation, 
cleanliness, ventilation, disinfection, etc., will be required as in other 
infectious diseases. It is frequent in hospitals under bad hygienic con- 
ditions, and is greatly influenced, especially in its traumatic forms, by 
imperfect sewerage and all sources of filth. There is an intimate relation 
between it and some forms of puerperal metritis, peritonitis, phlebitis, 
and lymphadenitis ; and great care should be taken that none of the 
matter, in however intangible a form, be conveyed by the hands, the 
clothing, or the hair of the accoucheur, to the parturient or puer- 
peral woman. When erysipelas is prevailing epidemically, puerperal 
women are exceedingly liable to the affections above indicated, and 
very severe and fatal forms of these affections are likely to occur, and 
therefore the most careful preventive precautions should be observed. 
The curative treatment of erysipelas is divided into local and 
general. 
For abating the severity of the local inflammation and arresting 
its spread, a variety of applications have been strongly recommended 
and extensively used. For stopping the spread of the disease, nitrate 
of silver, applied in substance by the stick, or in strong solution at 
the margin of the inflamed surface, covering a band of the diseased 
and healthy skin, and to a sufficient extent and of sufficient strength 
to cauterize several lines of surface, has long been a favorite mode of 
treatment. Another method has been the application of a blister of 
cantharides over a similar surface. Still another, similarly but more 
extensively applied over the whole inflamed surface, and to a greater 
extent on the sound skin, is the tinct. of iodine ; and still another, with 
the same object, is a strong solution of bromine. This latter article 
was used in some of the military hospitals during our late civil war, 
and was favorably reported upon by Dr. M. Goldsmith, Surgeon U. 
S. Volunteers. It was used of various strengths, according to the 
nature of the case and the locality of the disease. A continuous 
application with lint, covered by oil silk, was made to the face, of 
the following strength : Bromine, 3j ; Bromide Potassium, 3ss; 
Water, jx.—M. 
Much stronger solutions, up to nearly the full strength of the bro- TREATMENT. 
461 
mine, in gangrenous cases were applied by a swab once in four to six 
or eight hours; and in my own experience these applications have 
seemed to arrest the progress of the local disease. 
Considering erysipelas as a local affection, these applications which 
make a strong impression directly at the point of the spreading dis- 
ease, and thoroughly change the action there, would seem to be 
founded on rational principles, and it is found that they sometimes 
quite promptly check the spread of the disease. But erysipelas is cer- 
tainly not always an entirely local affection, and these articles not 
only often fail to mitigate the general symptoms, but also fail to check 
the local spread of the affection. When there is a strong general ten- 
dency to the continuance or spread of the inflammatory process, it 
overleaps the bounds attempted to be set for it, and in some cases the 
lesions produced by these applications seem to be the points of depart- 
ure for a more vigorous progress. 
Solutions of the sulphate of iron, acetate of lead, and various simi- 
lar discutient applications have been advised, but their utility, as a 
general practice, is doubtful. 
A poultice of bruised cranberries has a reputation as a domestic 
remedy, and I have not unfrequently seen it applied when it seemed 
to have an effect in checking the disease. The local application of 
tinct. of iron is frequently used, and is thought to be particularly 
useful in some cases. 
The following application has been strongly recommended in 
facial erysipelas. Carbolic acid and alcohol, aa, one part; oil turpen- 
tine, two parts; tinct. of iodine, one patt, and glycerine, five parts— 
the inflamed skin and its vicinity to be penciled with it every two 
hours. It is said to produce no pain, and the skin next day is usually 
found pale and wrinkled. The penciled parts should be covered by a 
thin layer of wadding. In many cases protecting the inflamed sur- 
face by sprinkling over it dry flour, or some other unirritating powder, 
or covering it with dry cotton wool, will be all the local application 
required. 
Whenever pus forms, as it is so apt to be widely diffused, it should 
be immediately evacuated by a free opening, and antiseptic dressings 
may be of decided use. Poultices with which chlorine or carbolic 
acid is mingled, or dressings with carbolized oil, with washes or in- 
jections of solutions of permanganate of potash may be indicated. 
When great tenderness of the tissues occurs, and there is danger of 
gangrene from restriction of the circulation, free incisions may be 
required. 
But as erysipelas, at least in many cases, must be regarded as a 
general rather than a strictly local disease, general remedies should 462 
ERYSIPELAS. 
not be neglected. As in most other febrile affections, the treatment 
may be properly commenced by the administration of an eliminative 
cathartic, which will increase the secretions, and clear the alimentary 
canal of any irritating materials. After this, besides administering 
such palliative remedies as particular symptoms may require, and at- 
tending to the proper administration of food, and regulating all other 
hygienic conditions, two articles of the Materia Medica present 
themselves as claiming particular attention. These are the tinct. 
chloride of iron and sulphate of quinine. I am very confident that 
both of these articles are capable of exerting a decided influence over 
the course of erysipelas. The tinct. of iron has perhaps the higher 
reputation, and has been more extensively used. In order that its full 
effects may be realized, it should be given in free and repeated doses, 
and persevered in until the symptoms are controlled. The proper 
quantity is from thirty to fifty minims, and sometimes even a drachm, 
once in from four to five hours. Given in these doses it will seldom 
fail to check the severity and shorten the progress of the disease ; and 
its effects are so manifest in many cases, as to have given the im- 
pression to many that it acts as a “ specific ” in this affection. 
During its use, the bowels should be kept open, generally by the oc- 
casional administration of a cathartic or laxative ; and anodynes or 
diaplioreties, as occasion may require, are not incompatible with its 
use. Quinine also lias decided effects upon the fever which accom- 
panies the progress of the disease, and which is often of a high grade 
and needs to be controlled. It also has an effect upon the increase of 
leucocytes, and the tendency to suppuration ; and, in short, upon the 
whole process of the fever and the inflammation. In order to its 
full beneficial effects, decided doses must be given, as from four or 
five to seven or eight grains, or more, once in from three to five hours, 
and it must be continued at least until its antipyretic effects are 
realized, when its anti-inflammatory effects ivill also be produced. 
As to the comparative efficiency of these two remedies, it may not be 
easy to decide. The quinine is more efficient in diminishing feverish 
heat, quieting the circulation, and inducing perspiration ; while the 
tinct. of iron may operate more specifically in counteracting the 
peculiar erysipelatous inflammation, or possibly in operating antido- 
tally upon the poison which must be supposed to be present, in many 
cases at least, as a cause of the phenomena. 
While the action of two powerful remedies at the same time often 
tends to produce confusion and less certain results, combinations are 
sometimes very efficient, and there appears no incompatibility, chemi- 
cally or therapeutically, between these agents, and I know of no serious 
objections to their simultaneous administration. In this peculiar THE A TMENT—DEFINITION. 
463 
form of inflammation and fever, one or the other, or both of these 
agents should be resorted to, as clinical experience may sanction their 
efficacy. 
Should great depression exist, alcohol is generally advised, and 
may be important in patients accustomed to its use; yet it must not 
be forgotten that the habitual, and especially the free indulgence in 
alcohol renders erysipelas much more severe and dangerous, and that 
there are doubts as to the directly stimulating and sustaining effects 
of this article in debility and exhaustion. If used, the same rules 
should be observed in its administration as in other low forms of 
fever. 
Should symptoms of pyaemia occur, they should be met as in other 
cases, but no two agents are probably more important in this con- 
dition than the quinine and iron. When there is great suffering and 
restlessness from any cause, anodynes may be required. Bromides 
may be useful in cerebral excitements, and also belladonna or atropine ; 
and eliminatives, such as diuretics, diaphoretics, and cholagogues, as 
well as laxatives, when the excretions arc deficient, may be required. 
When internal organs are attacked, the same general means should 
be used, for the same disease is to be contended with ; but they may 
be modified to meet particular conditions. When external and 
internal erysipelas are present at the same time, no direct or local 
efforts should be made to suppress the external affection ; and when 
internal parts alone are involved, external irritation with sinapisms 
and blisters is well worthy of a trial. A patient after a severe or pro- 
tracted attack of erysipelas is left debilitated and anaemic, and a good 
diet always, and tonic medicines often are indicated. Throughout 
the course of the disease, as much food as can be readily digested and 
appropriated should be given, and all the hygienic regulations proper 
in other severe acute affections should be observed. 
PYAEMIA AND SEPTICAEMIA. 
The word pyaemia literally signifies pus in the blood ; and septi- 
caemia signifies septic or decomposing or putrefying matter in that 
fluid. The terms, however, are often used as indicating the same 
general condition, viz., an acute and severe febrile disorder, due to 
the entrance into the blood of certain poisonous materials, or morbid 
organic matters, generally developed in the system by inflammatory 
processes or necrotic conditions. There is commonly the production 
of clots or emboli, which carried to the minuter vessels block up the 
arterioles of the lungs and other organs, and produce in them scattered 464 
P YE VIA—SEPTICEMIA. 
patches of congestion, hemorrhage, infarction, inflammation, sup- 
puration, or gangrene. 
The fever is of a peculiar type, usually marked by a sudden access, 
ushered in by a severe chill or rigor, accompanied or followed by 
decided elevation of temperature and free sweats. A remission then 
often occurs, to be followed in some hours by repetitions of the chills 
and sweats, which return at irregular intervals again and again. The 
high temperature and the sweating are present at the same time, the 
tongue becoming dry and hard, the pulse rapid and feeble, the bowels, 
which are often irritated, producing a diarrhoea, the vital powers 
often speedily declining, and death being the common result. 
This condition is more common in surgical than in medical cases, 
and for a more full account of it as occurring in connection with in- 
juries and operations, the reader is referred to works on surgery. The 
conditions, however, are numerous which give rise to pyaemia, and 
the accoucheur and gynaecologist often meet with it, and not unfre- 
quently the physician, as well as the surgeon. It is a frequent result 
of injuries, such as burns, scalds, bruises, lacerations, and compound 
fractures, especially of the long bones, and those of the head and 
pelvis. It frequently follows surgical operations, especially in large 
hospitals, and under unfavorable hygienic conditions, where anti- 
septic precautions are not taken, and especially where large raw sur- 
faces are produced, and where the bladder, prostate, urethra, rectum, 
and the bones or veins are concerned. It is also common after partu- 
rition, from the exposure of the uterine surface with its open veins to 
septic matter, and it constitutes one of the most common and fatal 
forms of puerperal fever. In suppurative inflammation of the bones, 
where the periosteum is detached and necrosis occurs, septic or puru- 
lent matter is apt to find access to the veins, arid to produce this con- 
dition, and in various specific or unhealthy inflammations, as in 
erysipelas, dissecting wounds, carbuncle, malignant pustule, and low 
forms of dysentery and other inflammations of the rectum with its 
abundance of large veins, pyaemia or septicsemia is liable to occur. 
Previous unhealthy conditions predispose to its idiopathic forms ; and 
contagious influences, and the presence of bacteria, by exciting septic 
changes, are now regarded as among the most frequent causes of the 
affection. These may operate on the vigorous as well as the feeble. 
The condition spoken of as “hospitalism,” where large numbers of 
wounded or puerperal patients are often crowded in small spaces, 
without proper air, space and ventilation, is connected with and finds 
its expression in pyaemia ; and under such conditions, and sometimes 
in spacious and well-ventilated institutions, morbid matters as causes 
are undoubtedly transmitted from person to person. Still, in many PATHOLOGICAL PHENOMENA. 
465 
instances pyaemia originates de novo, especially in internal inflamma- 
tions and where there is no breach of surface, but where the internal 
surfaces of veins are concerned, introducing into the blood inflam- 
matory products. In such cases the presence of bacteria, or of spe- 
cific germinal poisons may not be necessary to the production of this 
affection. 
On post-mortem examination the patches of disease already referred 
to, especially in the lungs, where the blood of the general venous sys- 
tem carrying clots and other morbid matters first comes into capillary 
vessels, are found in different stages of advancement. They are from 
the size of a pea to that of a walnut, or larger. These points are some- 
times apoplectic—blood effused into cavities—sometimes the blood is 
injected into the tissue from the rupture of capillary vessels (hemor- 
rhagic infarction), the spots being reddish black, or more or less 
faded in color ; sometimes they present the appearance of lobular 
pneumonia; sometimes they are partly broken down into a puri- 
form pulp, and at others there are distinct abscesses or gangrenous 
cavities. They are scattered in different portions of the lungs, but 
are most abundant at the surface, and there is usually more or less 
congestion and oedema of the general lung tissue, and occasionally 
decided pneumonic consolidation. When these diseased spots come 
to the surface, the pleura covering them will be found congested and 
inflamed, and an effusion of lymph to a greater or less extent is gen- 
erally observed, and sometimes- general pleurisy ensues. Subpleural 
petechias are common ; and the surface of the heart, as Avell as the 
lungs, often presents points of extravasations of blood ; and evidences 
of pericarditis and endocarditis are not unfrequently found. The 
liver, spleen, and kidneys are also often found affected in a similar 
manner to the lungs, the patches varying in size and particular 
appearances in consequence of the different structure of these organs. 
Small abscesses are common in the cortex of the kidneys ; and in other 
cases less advanced there are congestive spots, with intervening por- 
tions anaemic and paler than normal. The brain is not as commonly 
affected with pyaemic changes, but they arc not unfrequently found, 
though the extravasations are small in amount, and generally limited 
to the surface ; but patches of softening, like those found from 
embolism, but small in size, may occur in any part of the brain, and 
abscesses of a larger size may also be found. The meninges may be 
inflamed ; and the peritoneum and intestinal walls are sometimes 
affected like the pleura. The bones and joints are not unfrequently 
affected by the same general cause ; and the connective tissue and the 
muscles, the eye, the prostate, and the testes have also been found 
involved. The skin is sometimes moderately jaundiced, and occa- 466 
P TJEMIA—SEP TIC JEM I A. 
sionally presents petechiae ; and from the free sweating sudamina 
are common. 
As pyaemia or septicaemia is a blood poison, the conditions of the 
blood and of the vessels containing it are subjects of much interest. 
The general mass of the blood, and the greater part of the vessels, pre- 
sent no unusual appearances. Occasionally a small mass of disintegrated 
fibrine with some purulent corpuscles embedded in it has been found. 
The minute arteries leading to and distributed in the secondary 
patches already described, and the veins involved in the primary 
lesion which lias given rise to the mischief, are found in a morbid state. 
These small arteries are always found filled and obstructed with coag- 
ula or ordinary thrombi, or with disintegrated fibrine and corpuscles, 
mingled in some cases with what appear to be groups of pus cells. 
The veins of the parts which have been involved in the primary 
inflammation are generally found perceptibly diseased. Their pari- 
etes are thickened and indurated, and sometimes perforated by an 
ulcerative or some destructive process; and the interior is occupied 
by coagula, which are generally adherent and partially decolorized, 
and may be solid throughout, though generally the centre consists 
of a reddish or yellowish purulent pulp or fluid. A minute examina- 
tion shows this material to consist of disintegrated fibrine, or in some 
cases true pus. Between this and the venous walls is generally a layer 
of fibrine, and often a kind of diaphragm extends across the vein, 
shutting it off from the rest of the vessel. In other cases this septum 
is wanting, arid there is no impediment to prevent the free admixture 
of this broken-down fibrine and pus with the general circulation. 
It was formerly supposed that the secondary abscesses were mere 
passive deposits of pus, which had found its way from the primary seat 
of inflammation into the blood, and had been carried by it to parts 
where it was discovered. Pus, however, is not found to circulate in the 
blood in sufficient quantities to account for the abscesses in this way, 
and the theory of embolism now prevails. The diseased veins induce 
coagulation of blood, and send forth mingled fibrine and inflamma- 
tory corpuscles, which pass on through the heart and ultimately plug 
up the small arteries, exciting irritation and secondary inflammation, 
which result in the changes—the congestions, infarctions, suppura- 
tions, and gangrenes—observed. 
While this embolism may account for the local conditions, it will 
scarcely do so for the phenomena of the pysemic fever. A more subtle 
poisonous agent, a septic material, producing other changes in the 
blood and impressing the nerves and other tissues, is doubtless formed 
at the original seat of disease, and is absorbed into the blood, and 
probably into the lymphatic vessels as well. According to Virchow, PA TIIOL 0 QIC A L PHENOMENA—SYMPTOMS. 
467 
pyaemia is a twofold disease, embracing the phenomena due to 
embolism and those due to a more subtle poison. He thinks they' 
may exist independent of each other, and to the latter group of phe- 
nomena he applies the term “ Septicaemia.” This view seems con- 
firmed by what he alleged to be the fact, that patients die with symp- 
toms of pyaemia or septicaemia, when no evidences of embolism can be 
found—nothing being observed post mortem but congestions of some 
internal organs, and some slight extravasations of blood beneath 
serous surfaces, and a marked tendency to rapid decomposition. 
Bacteria are found in the blood of such subjects, and though found 
in others where no pyaemic symptoms occur, yet they are believed to 
have much to do in the production of this form of disease. 
From all the facts at present known, pyaemia, or septicaemia, is 
produced by the passage into the blood, through diseased vessels, 
veins, and probably lymphatics, of morbid and usually septic prod- 
ucts, partly solid find partly fluid, having special properties derived 
from the local disease where they originate. The presence of these 
matters usually causes more or less coagulation of blood and obstruc- 
tion of certain small arteries, inducing the local lesions in the lungs 
and elsewhere so commonly observed, and at the same time specific 
poisonous properties are communicated to the blood, and morbid 
impressions are made upon the nervous and other tissues, inducing 
the characteristic form of fever called pyaemic, or, more properly, 
septicaemic. M. Gu6rin suggests the term Pyohsemia, and contends 
for the superiority of the doctrine of miasms and ferment organisms as 
the cause of the affection; and states that the discovery by Pasteur of 
the figure of 8 microbion in the blood tends to sustain the strictly 
septic theory. 
The symptoms and progress of this affection have already been 
briefly sketched as it occurs in its ordinary acute and rapid form. 
There are, however, different degrees of severity, ‘depending, no 
doubt, upon the different amounts of the poison absorbed, and the dif- 
ferent degrees of virulence of that poison ; and the effects are more or 
less modified by the different degrees of susceptibility and power of 
endurance of the system. 
Prom the local lesions various symptoms arise. From those of the 
lungs, pain, cough, dyspnoea, sometimes expectoration, and certain 
physical signs are produced. From those of the liver, pain, tender- 
ness, often a moderate jaundiced condition, etc. 
From those of the stomach and boAvels, nausea, vomiting, and 
often, especially in septicaemic cases, diarrhoea, are induced. The 
lesions of other parts may present their appropriate symptoms, The 
characteristic mingling of chills, fever, and sweats may take on more 468 
P YjEMIA—SEP ticaemia . 
or less active forms, sometimes becoming subacute or even chronic, 
and assuming the character of hectic fever. Abscesses may form 
about the joints or elsewhere, and the patients may struggle through 
or succumb to a longer course of this irritating and debilitating dis- 
ease. In the acute cases the rigors may possibly be absent, though 
commonly present and characteristic, and they vary in frequency and 
continuance, are sometimes repeated at short intervals, and at others 
only once or twice a day, and often cease after the first few days. 
The accompanying fever fluctuates, often with great rapidity, the 
temperature speedily rising to 104° or 107°, or even more, and oc- 
casionally falling to a little above the normal. In other cases the 
temperature varies but little, maintaining a constant high standard. 
Death may be preceded by a condition of collapse, with low tempera- 
ture, or tho temperature may continue high; and sweating, which has 
alternated with dryness of the shin throughout the progress of the 
case, usually attends, in a colliquative form, the last stage. The res- 
piration is commonly rapid, independent of the local lesion of the 
lungs, often reaching from forty to sixty in the minute. 
The feebleness of the pulse is a marked condition, and its rapidity, 
especially on exertion, is generally great. As the disease progresses it 
often rises to one hundred and forty or one hundred and sixty per 
minute, and may become almost too fast to be counted. 
The jaundiced condition, so often present, does not always depend 
upon the pysemic deposits in the liver, but, as observed by Frerich, . 
whose authority is so high upon every subject pertaining to the liver, 
“the jaundice here appears to be the result of an impaired consump- 
tion of bile in the blood, arising from an abnormal condition of the 
metamorphic processes which go on in that fluid.” 
As destructive metamorphosis proceeds rapidly, urea is largely 
increased, and the urine sometimes contains a small quantity of 
albumen. 
The nervous symptoms are similar to those observed in typhus 
and other specific fevers, and need not be specially enumerated. 
Prognosis.—The prognosis, as already intimated, is exceedingly 
unfavorable ; though recovery sometimes takes place after the occur- 
rence of very severe symptoms ; and of course more frequently where 
the symptoms are mild. 
Diagnosis.—The diagnosis is not difficult where the disease oc- 
curs in connection with injuries, surgical operations, or the puerperal 
state. When it occurs in connection with erysipelas, carbuncle, 
dysentery, internal inflammations and suppurations, where its symp- 
toms resemble and are mingled with those proper to these diseased 
conditions, there may be more difficulty in distinguishing it. El A GNOSIS— TREA TMENT. 
469 
The special diseases for which pyaemia is more likely to be mis- 
taken are, typhus, typhoid, and severe malarial fevers ; internal acute 
inflammations of the lungs, liver, and urinary organs; and acute 
rheumatism. A careful comparison of phenomena will in many 
cases be required. When pyaemia is suspected, a careful local ex- 
amination for the discovery of some point of suppuration should be 
made. 
Treatment.—Unfortunately medicines have but little control 
over the established and more severe cases of pyaemia, and hence its 
prophylactic management becomes the more important. In surgical 
and obstetrical practice, especially in hospitals, preventive measures 
are of the utmost importance. Though the condition often occurs 
spontaneously from the absorption of morbid inflammatory matters, 
yet when pyamiia or erysipelas, however originating, appears among 
numbers of patients, there is a remarkable tendency to its spread, 
and great pains should be taken to prevent that result. 
Isolation, cleanliness, ventilation, disinfection, extra care not to 
allow matters to be conveyed from one patient to another, are essential. 
The great benefit of Lister’s method is now generally acknowledged. 
Great care in the management of the original seat of the disease 
leading to pyaemia will be important. Collections of matter should, 
if possible, be evacuated, foul abscesses cleansed, antiseptic injec- 
tions and washes often used, and every possible means employed to 
prevent absorption of septic matters. 
The indications for curative treatment are to eliminate the mor- 
bid matters from the blood and system ; to prevent septic changes 
there, and, if this be impracticable, to palliate the symptoms, and en- 
able the patient to endure the disease. 
The free sweating so likely to occur, while it suggests the possi- 
bility of the elimination of poisonous materials by the skin, seems to 
supersede the necessity of diaphoretics ; and the frequent occurrence 
of diarrhoea affords similar suggestions in regard to the bowels and 
the use of cathartics. But when the skin and bowels are not active, 
eliminative diaphoretics and cathartics, as the strength will bear, 
would seem to be indicated, with the hope of relieving the blood of 
some of its poisonous elements. 
The kidneys also might be gently excited to an increase of their 
function. For the prevention of septic changes, various antiseptic 
agents have been recommended. Among these the sulphites have 
most reputation, or at least have been most strongly recommended, 
particularly by Prof. Polli, of Milan. They have often been tried, 
but generally have failed to arrest the disease or save the life of the 
patient. 470 
P YJEM [A—SEP TICJE MIA. 
Quinine as an antiseptic and an antipyretic agent lias been sug- 
gested and tried, and is the agent most relied upon, and most fre- 
quently given. It may be given in antipyretic doses when the fever 
is high, and in smaller doses when its tonic and sustaining effects are 
required. It perhaps affords as much prospect of beneficial results as 
any other agent; but it, too, has generally been found unavailing. 
The tinct. of iron has had no better results, and, in fact, all curative 
treatment has been exceedingly unsatisfactory. The special symp- 
toms that may arise during the progress of a case may be palliated, 
especially may anodynes be given to relieve pain and procure rest, 
and these, with other soothing and sustaining measures, such as the 
particular pathological conditions and the symptoms suggest, may be 
of service not only in diminishing suffering, but possibly, in some 
'cases, in enabling the patient to survive the disease. 
Attention to all hygienic measures will, of course, be required, 
and the most easily digested and nourishing food should be given in 
as free quantities as the stomach can bear and the system appropriate. 
In the great depression which is a characteristic of the disease, alco- 
holics are generally advised and given. Their efficacy as sustaining 
agents is doubtful; and I fully agree with the opinion of Dr. Bristowe, 
as expressed in his article on this subject in Reynolds’ System of 
Medicine, that the practice of “ pouring in,” as it is called, lately 
fashionable with some practitioners, should bo condemned. 
Occasionally, though very rarely, pysemic symptoms occur, with the 
circumscribed spots in the lungs and elsewhere, not only without any 
external wound but without any primary suppuration in any part of 
the body. This may arise from morbid changes in the blood—large 
numbers of leucocytes being produced, and other materials causing 
emboli, infarction, suppuration, etc. A few such cases I have seen ; 
one in which the characteristic conditions were found in the lungs 
post mortem, but where a diligent search failed to discover any more 
primary inflammation. The treatment in such cases will not materi- 
ally vary from that of other cases where there is the more common 
primary suppurative condition. 
Some years ago Mr. James Paget (now Sir James), called the 
attention of the profession to a form of pysemic blood poisoning less 
violent in its symptoms and less rapid in its course than the ordinary 
forms of the disease which have been described. There are, hoAvever, 
collections of pus in the acute cases, often widely dispersed, and those 
conditions are often accompanied by rigors, profuse sweating, inflam- 
mation of veins and joints. It extends, with abatements and relapses, 
for many weeks or months, and at length becomes so mild as to affect THE A TMENT—PHENOMENA. 
471 
the health but little, and scarcely at all threatens life. The local 
evidences of this state are more common in the limbs than in internal 
organs, but they are not uncommon in the veins in the later stages of 
the disease. 
A somewhat similar condition occurs in some cases after fevers, 
and is spoken of as the “relic” of the fever. In some cases no local 
lesion producing suppuration as a primary state is found, and in these, 
as well as in the acute cases, leucocytes are multiplied in the blood, 
and may there be transformed into pus, and deposited with results 
not as severe and fatal as in the ordinary forms of the disease, but 
still often producing serious consequences. 
Glanders and hydrophobia, syphilis and gonorrhoea, arc placed 
by some authors among the specific infectious fevers, but as they are 
treated of in works on surgery they are omitted hero. Dysentery, 
though in some of its forms it is a specific fever, at other times is a 
local affection, and as its chief phenomena arc local, it will ho dealt 
with in connection with other intestinal diseases. 
Elephantiasis Graecorum is placed by Bristowe among the affections 
we have been considering, but as it has been placed among cutaneous 
diseases, and is treated of in surgical works, it will be omitted in this 
place. 
Before treating of diseases of particular organs and systems, there 
are several other general affections involving the whole organism, but 
not coming under the nead of infectious fevers, >or at least being dif- 
ferent in many of their features from those which have been discussed, 
and these will now claim attention. They are produced not by 
poisonous material taken in from without, but by conditions existing 
within the body. 
SCORBUTUS.-Scurvy. 
This is a condition of general malnutrition, produced by defi- 
cient or improper alimentation, especially by the absence of fresh 
vegetables and organic acids in the food. The disease is marked by a 
dull leaden pallor of the skin ; great bodily and mental weakness; 
difficulty of breathing on even slight exertion, without physical signs 
to account for it; oozing of a bloody fluid into various tissues, pre- 
senting petechiae and ecchymosed-looking spots upon the skin; gener- 
ally a spongy, swollen, and livid state of the gums, with a disposition 
to bleed on the slightest irritation, and often with an offensive odor 
of the breath. 472 
SCURVY. 
This disease is progressive, and tends to a slowly fatal result when 
the causes which produce it are continued; and in its less fully de- 
veloped forms it modifies other diseases Avith which the patient may 
he affected, particularly fevers and affections of the bowels. It was 
formerly very frequent on shipboard on long voyages, and has been a 
severe scourge to many armies. 
Deficiency of food of any kind will result in imperfect nutrition 
and debility, but the peculiar phenomena of scurvy do not appear 
when the supply of fresh vegetables has been sufficient, whatever 
other privations may exist, though the simultaneous deficiency of 
other articles of food, especially of fresh meat, aggravates the condi- 
tions. It Avas formerly supposed to be produced by the direct effect 
of a salt-meat diet, and though the disease is more speedily and 
severely developed Avhen persons are confined to such articles of diet, 
yet it has frequently appeared when fresh meat was used, but when 
fresh vegetables were not provided. When salted meat appears to 
produce or aggravate scurvy, it is rather from the deficient nutriment 
in the meat than from any positive effect of that kind of food ; as 
persons have often been known to have the disease who for many 
weeks before had lived on tea and bread and butter. 
It is asserted by Dr. Buzzard, that “ there is no case on record of 
scurvy occurring in a person avIio has been adequately supplied with 
fresh succulent vegetables of good quality; and that persons living 
upon salt meat may be prevented from having the scurvy by the regu- 
lar administration of fresh vegetables or the juice of lemons.” 
The causes of scurvy are Avell defined, and admit of no doubt. 
The leading phenomena have been briefly stated. More or less 
variation, howeA'er, occurs in different cases in the symptoms and 
course of the disease. Among the earliest symptoms are a pale, sal- 
low, or greenish tint of the skin, an aA'ersion to exertion, and a list- 
lessness of mind, an indifference to health as Avell as to other things. 
There are likely to be pains about the limbs and back, but the appe- 
tite may still remain good, though the bowels are apt to be consti- 
pated. There is no fever; and sleep, though sometimes dreamy, is 
not interrupted. Gradually petechiae make their appearance, usually 
first upon the legs and thighs, in small reddish-broAvn points, which 
in time run together and form irregular bruised-looking patches, but 
not elevated above the leATel of the skin. In some cases the eyes and 
their surroundings are at this stage the only parts wdiich present 
marked evidence of the disease. The integument of the lids and 
parts about may be puffed up into a bruised-looking swelling, and the 
sclerotic coat may present a swollen condition Avith brilliant redness, 
but without pain or a discharge. A puffy SAvelling, deeper than the PHENOMENA—MORBID ANA TOMY—DIAGNOSIS. 
473 
skin, especially about the popliteal spaces and corresponding parts 
about the elbows, often occurs. Sooner or later, and often at the 
same time with the early appearance of other phenomena, the gums 
are changed—sometimes at first becoming pale and contracted, they 
are afterward swollen and encroach upon the teeth, presenting a livid, 
spongy, and hemorrhagic appearance. They are not tender to the 
touch, but bleed—generally slightly, but sometimes freely—on being 
irritated. The teeth are likely to be loosened and may drop out; 
and, in severe and protracted cases, there is a tendency to superficial 
ulcerations and sloughings from slight injuries of the surface, espe- 
cially where the puffy swellings are situated. 
The anasmia progresses, the heart becomes weak, dyspnoea on the 
slightest exertion is great, and fits of syncope may come on with 
danger to life. In the latter stages of the disease the appetite 
is apt to fail, diarrhoea to come on, with offensive bloody stools, dis- 
turbance of vision, ringing in the ears, vertigo, want of sleep, and 
rarely delirium. 
In some cases thoracic complications arise, such as congestion of 
the lungs, with hemorrhages into their substance, effusions into the 
pleura, bronchial congestions, bloody expectorations, often with an 
offensive gangrenous odor. The duration is uncertain, but it may 
extend over many weeks, or even months. Death is usually due to 
failure of the heart’s action, either by syncope or asthenia, and may 
be hastened by the occurrence of hemorrhage. 
Morbid Anatomy.—Post mortem there is a tendency to rapid 
decomposition ; and extravasations of blood and other exudates from it 
are found not only in external parts but in internal organs, in the 
lung substance, beneath the pleura, in the walls of the heart, and 
under the pericardium, in the intestinal parictes, and beneath the 
peritoneum ; and bloody effusions are often observed in the serous 
cavities. The swellings, particularly about the joints, are not en- 
tirely produced by the effusions of blood, but are found to consist of 
fibrinous exudates, which become consolidated into more or less plastic 
material. The blood contains an excess of fibrine, but a deficiency 
in the number of red corpuscles, and is of abnormally low specific 
gravity. 
Diagnosis.—The diagnosis in the prevailing disease as on ship- 
board, among illy fed troops, etc., is not difficult. In isolated cases 
and in the early stage, and even in advanced conditions, it may not 
be readily recognized. Where there is any suspicion of the disease, 
inquiry into the diet should be minutely made ; and with this aid, a 
careful observation of the symptoms described can scarcely fail to 
result in correct conclusions. 474 
SCUR VT. 
There has been much speculation as to the special elements in 
fresh vegetables, the absence of which results in scurvy ; and also as 
to the intimate changes which take place in the blood and tissues in 
this disease which are the immediate causes of the phenomena. No 
satisfactory conclusions have been arrived at, and we need not be 
detained by an account of the theories which have been suggested. It 
is true that the blood is found specifically lighter than normal, and 
this would increase the tendency to exosmosis into the tissues ; but 
this fact fails to account for the other pathological conditions ob- 
served. 
Treatment.—The essential treatment of scurvy, both prophy- 
lactic and curative, consists in the use of fresh vegetables and fruits 
as a part of the dietary, and in their absence, of fresh lemon juice, or 
of pure lemon juice so prepared and preserved as to retain its natural 
properties. Other easily assimilated and nourishing food is also im- 
portant, but nothing will avail in restoring health without a supply 
of these needed ingredients. Potatoes, onions, carrots, turnips, cab- 
bage, celery, cresses, lemons, oranges, limes, grapes, apples—all green 
vegetables and fruits, are useful, but lemons and lime juice are found 
to be more easily assimilated, and more speedy in effects than other 
substances. The presence of diarrhoea affords no objection to the use of 
properly prepared vegetables, and particularly none to lemonade and 
other forms of citric acid. 
In addition, particular symptoms may require palliation by other 
and more strictly medicinal means. The diarrhoea, if severe and per- 
sistent, may be checked with nitrate of bismuth, turpentine emulsion, 
or other astringent and soothing medicines. The gums, when bleed- 
ing, may be brushed over with nitrate of silver, with washes of chloride 
of zinc, used with care and of the proper strength ; and for the offen- 
sive fetor of the breath, chlorine solutions, Condy’s fluid freely diluted, 
or other antiseptic washes may be used. 
When effusions take place into the cavities, iodide of potassium 
will be found useful in promoting absorption ; and tonics may be re- 
quired in cases of great debility. The specific antiscorbutics must be 
persisted in, however, and with these and the other obviously indi- 
cated palliative measures, great success generally results. 
In advanced cases care should betaken to prevent overexertion and 
syncope. 
Particular rules for preparing and issuing antiscorbutics on ship- 
board are given, which it is unnecessary here to specify in detail. 
The influence that the scorbutic state, even in its incipient con- 
ditions, has upon other diseases is important. Fevers occurring in 
such subjects assume a lower and more adynamic form, and diseases TEE A TMENT—PHENOMENA. 
475 
of the intestines, such as diarrhoea and dysentery, are more obstinate 
and protracted, and tend to the production of ulcerative processes. 
In the treatment of such diseases, in addition to the measures usually 
required for them, succulent fruits, lemon juice, etc., must be given 
as they can be borne. 
PURPURA. 
Purpura is a term applied to extravasations of blood or its color- 
ing matter into the skin, presenting purple-colored spots of various 
sizes and forms; and in many cases, at the same time, similar extrava- 
sations occur in deeper tissues and in internal organs. In this sense 
it is a symptom which may occur in connection with various diseases 
or pathological states, where either the vessels are so diseased and 
weakened, or the blood is so changed in its character or its pressure as 
to escape from its vessels into tissues, particularly the tissues of the 
skin. It sometimes thus occurs as a symptom of low fevers, consti- 
tuting the petechias, vibices, etc., mentioned in various diseases already 
described. 
It is not uncommon, as wc have seen, in scurvy, small-pox, 
measles, typhus, and occasionally in malarial fevers; and it is also 
met with in scarlatina, diphtheria, and pysemia, and, as we shall see, 
in some liver diseases, in obstructive heart disease, and in embolism. 
Sometimes this purpuric condition occurs without being a symp- 
tom of, or associated with, any other disease, and is the only pathologi- 
cal phenomenon recognized. It must, in such cases, be regarded as an 
idiopathic affection, and as such has a series of phenomena and a his- 
tory, not always the same, but sufficiently distinctive to entitle it to a 
separate consideration. 
The causes of this distinctive affection are exceedingly obscure. 
It occurs at all ages and in both sexes, but is perhaps more frequent 
in children than in adults. It is more frequent in feeble, ill-con- 
ditioned persons under unfavorable hygienic circumstances, but it is 
also met with in vigorous and healthy-looking individuals under favor- 
able hygienic conditions. It sometimes returns periodically, at inter- 
vals of three, six, or more months. 
The symptoms and progress vary in different cases. Sometimes it 
is preceded by vague premonitory symptoms, by lassitude, general 
pains, loss of appetite, etc., lasting for one, two, three, or even four 
weeks. At other times the attack is abrupt, in the midst of apparent 
health. The skin becomes studded more or less thickly with small, 
circular, dark red, or purple, almost black spots, varying in size from 476 
PURPURA. 
a mere point to two or three lines in diameter. They are not raised 
above the level of the skin, are not accompanied by pain or other mor- 
bid sensations, and do not disappear on pressure. They are usually 
most abundant on the lower part of the trunk and the lower limbs, 
but appear on other parts as well; and not unfrequently extravasations 
occur in the loose texture about the eyelids, under the conjunctivas, 
and under the mucous membrane of the mouth, tongue, lips, gums, 
etc. Appearing in moderate-sized rounded forms, the spots are called 
petecldce ; when in longer stripes, as sometimes happens, they are called 
vibices ; and in larger patches, ecchymoses ; while, when they occur 
in mere points, they are called stigmata. These spots consisting, like 
the discolorations after bruises, of blood out of the vessels, in the tis- 
sues, undergo the same changes of color as these latter ecchymoses, 
often turning greenish and then fading and disappearing. New crops, 
however, appear from time to time, and thus the symptom is con- 
tinued for two, three, or four weeks, or even longer. The larger ex- 
travasations are generally deeper than the skin, and attended with 
some degree of swelling. They may be so deep as not to discolor the 
skin at first, but may reveal themselves by the altered colors coming 
to the surface. Some slight mechanical violence may be concerned in 
their production, or they may occur without such cause. In all these 
cases there is more or less tendency to hemorrhage from mucous sur- 
faces, from the nose, gums, stomach, intestines, lungs, and kidneys, 
bladder, uterus, and vagina. In some cases the hemorrhage is slight, 
wdiile in others it is profuse and repeated. 
In the slighter cases the general health may not be seriously 
affected, but in those more severe, the general symptoms mentioned 
as ushering in some cases continue ; and when the more severe hemor- 
rhages occur, anaemia, depression, and debility will of course follow. 
The pulse becomes jerking, noises are heard in the ears, the vision is 
indistinct, motes float before the eyes, headache, restlessness, delirium, 
mania, or convulsions and death, in severe cases may occur. As the 
immediate cause of death is usually the loss of blood, the mode is by 
syncope or asthenia. Before death the temperature may be either 
increased or diminished from the normal. To the milder forms, with 
little or no hemorrhage, the term purpura simplex is applied—to the 
more severe, purpura hemorrhagica, where bleeding occurs from the 
mucous surfaces, or where the effusions in the skin and subcutaneous 
tissues are more extensive. 
Purpura urticans and purpura senilis are still other varieties, 
■where in the one case a burning irritation is felt with an inflammatory 
blush, and in the other the disease occurs as a consequence of old 
age. PHENOMENA—TREA TMENT. 
477 
On post-mortem examination very little is discovered Avhich throws 
light upon the nature of the disease. Hemorrhagic effusions are 
found not only in the skin and subcutaneous tissue, but under mu- 
cous and serous membranes, and, more rarely, in the substance of 
organs. Fatty degeneration of the heart and other parts have been 
found in protracted cases where hemorrhages had repeatedly oc- 
curred. 
The blood was found by Dr. Parkes, in a few cases, to contain an 
excess of iron and a diminution of solid constituents; but whether 
these conditions are so constantly present as to constitute a necessary 
feature of the disease, has not been proven. 
A similarity will be noticed between some of the phenomena of 
scurvy and purpura, but the latter is not dependent upon the same 
cause as the former, and is not cured by the use of fresh vegetables or 
lemon juice. There must, therefore, be a difference in these diseases, 
though the hemorrhagic phenomena are similar. Some have thought 
that purpura depended upon an altered condition of the blood, while 
others have regarded the vessels as chiefly in fault. In support of the 
first view is the fact that the injection of putrid matter into the veins 
of animals will cause ecchymoses in various situations, and the injec- 
tion of ammonia will cause hemorrhages. It has been suggested that 
changes in the conditions of the blood may produce an abnormal 
attraction between the blood and the walls of the vessels, causing 
obstruction in the capillaries and their rupture. The presence of a free 
quantity of bile in the blood is said to dissolve the walls of the blood 
discs, leaving the heematine free to ooze out into the tissues. But in 
purpura there is an escape of the blood discs, and though in inflam- 
mation some few red discs pass through the coats of the vessels, yet 
they cannot be supposed to pass out in such quantities as is the case 
in purpura, without a material change in the vessels themselves. A 
lardaceous degeneration of vessels has been found in some cases, but 
it has not been proven that such change is present in all cases ; and 
the exact pathology of the disease remains to be established. Rupture 
of capillary vessels must be assumed; but whether such rupture is pro- 
duced by some primary change in the blood acting upon the vessels, 
or whether the primary change is in the tissues of the vessels, has not 
been determined. 
Treatment.—In the absence of satisfactory knowledge of the 
pathology of purpura, its treatment has been empirical rather than 
founded on well-established rational principles. Regard should be 
paid to the tendencies of the patient and to his previous habits and 
conditions. All complicating affections must receive such attention 
as may be required. The remedies in cases of idiopathic purpura 478 
PURPURA. 
which have most testimony in their favor are cathartics, quinine, sul- 
phuric acid, the astringent preparations of iron, and the oil of 
turpentine. In the more sthenic forms, with cardiac and vascular 
excitement and elevated temperature, cathartics, such as a mercurial 
followed by sulph. soda or magnesia in a solution acidulated with 
sulph. acid, are apparently useful. Laxative doses may be repeated as 
occasion shall require, if they seem to be well borne. The value of 
quinine and tinct. of iron in tonic doses, the iron, especially, in free 
doses, seems to have been attested by experience. There is much tes- 
timony in favor of the oil of turpentine. This article may be given 
in the form of an emulsion, in doses of from fifteen or twenty drops 
up to a drachm or more, repeated a few' times a day for some time. 
It seems to tone up the vessels concerned, and the system at large, and 
tends to the prevention and arrest of the hemorrhage. Should the 
loss of blood be considerable, ergot and gallic acid should be tried in 
appropriate doses. When bleeding occurs from parts that may be 
reached by local means, these should be made use of. The tincture of 
larch bark in doses of ten or fifteen drops, repeated every hour, is re- 
ported to have exerted a decidedly beneficial influence. 
In a majority of idiopathic cases recovery takes place in a few 
weeks. Some are fatal within a few days, with high fever and typhoid 
symptoms. In such the quinine as an antipyretic is w'orthy of a trial. 
When death occurs at later periods, it is usually from repeated attacks 
of hemorrhage ; and for such cases every means, general and local, 
should be resorted to for the purpose of arresting the flow of blood. 
Here the ergot and astringents should be faithfully used. The claims 
of oil of turpentine as an astringent and stimulant should not be 
overlooked. Pretty free doses are generally required. As symp- 
tomatic of low forms of fever and other diseases, purpuric conditions 
are of grave import. They generally indicate a low state of the 
system, requiring tonic and supporting measures. 
Hrematophilia and Haemophilia are terms which designate a con- 
dition in which there is a congenital hemorrhagic tendency. The 
diathesis is generally not manifested in early infancy, though fatal 
umbilical hemorrhages in new-born children are attributed to it; but 
during the first and second year it becomes more marked, though 
occasionally its manifestation is delayed until a much later period. 
It is most marked in the comparatively earlier periods of life, and 
diminishes with the advance of years. 
In these cases of the innate hemorrhagic diathesis, there is a con- 
tinued oozing of blood following slight wounds, minute punctures, TREATMENT. 
479 
vaccination, superficial abrasion of the skin or mucous surface, and 
these bleedings are arrested with great difficulty. There is far less 
tendency to extraordinary hemorrhages from deep incised wounds 
than from these slight and superficial ones, so that the bleeding from 
a slight wound has been arrested by converting it into one deeper 
and of larger dimensions. But deep wounds, as from surgical opera- 
tions, are liable to be followed by secondary hemorrhages which may 
prove serious. Spontaneous hemorrhages are liable to occur from 
every mucous surface of the body of one affected with this diathesis, 
and in females, menorrhagia is a common occurrence. Bleedings 
are reported to have taken place even from the ears and skin, without 
any appearance of abrasion. Extravasations of blood are liable to 
occur from slight injuries, and a bruise to be followed by a bloody 
tumor in the part. 
This peculiar diathesis in many cases is inherited—“ running in 
families.” The majority of those afflicted are males; and though 
diminished sooner, it is seldom extinguished before the age of forty. 
The pathology of this state is unknown. It was formerly sup- 
posed that there was a want of coagulability in the blood from a 
deficiency of fibrine, and that it was thus deprived of one of the 
ordinary means of arresting its flow ; but this seems to have been 
disproved. We are therefore left to the conclusion that the diathesis 
depends upon some peculiar condition of the smaller blood-vessels, 
in which they fail to contract when severed, or at least fail to conduct 
themselves as in ordinary cases. The causes which result in this 
state of things are entirely beyond our knowledge, and we can only 
refer them to the mysteries of heredity and of original formations. 
We know of no means for the extinction of the diathesis but the 
celibacy of those affected with it. 
Treatment.—No treatment is known to have any effect upon 
the tendency, beyond that of keeping the system in good hygienic 
conditions, and removing any other diseases which may occur. When 
hemorrhage takes place all surgical means, as the use of styptics, 
cold, pressure, etc., are indicated, and internally the astringent prep- 
arations of iron, gallic acid, ergot, etc., may be tried. The douche, 
by numerous jets of cold water applied with force to the lower ex- 
tremities, has been particularly recommended. When so much blood 
has been lost as to result in anaemia, the use of iron and other meas- 
ures for remedying that condition is indicated. 480 
L E U COG Y TUJEMIA. 
LEUCOCYTHiEMIA.—Leukaemia. 
This is a morbid condition of the general system, progressive in 
character, and very commonly, if not always, fatal in results ; char- 
acterized by a marked and persistent increase in the number of white 
corpuscles in the blood, by diminution of the red discs, and by 
enlargement and other changes in the spleen, liver, and lymphatic 
glands of the intestines and of other parts. 
The number of white corpuscles in proportion to the red in the 
physiological state is variously estimated as one of the former to from. 
355 to 335 of the latter. The proportion of white corpuscles is often 
physiologically increased above this, temporarily, as after full meals 
and in pregnancy ; and it is also increased pathologically for a time 
in inflammation and fevers ; but in leucocythasmia the increase of the 
white corpuscles is much greater than occurs in the physiological 
state or in these other pathological conditions; and instead of being 
temporary the change is permanent and progressive. 
The temporary increase of the wdiite corpuscles as a symptomatic 
event in inflammation, fever, etc., is called Leucocytosis; while 
Leucocytlicemia indicates the greater, the more idiopathic, and the 
more permanent change. 
It is now generally believed, though demonstration is perhaps 
wanting, that the white corpuscles are produced in the spleen, the 
lymphatic glands, and the liver ; and that the red discs are produced 
from a farther change of the white globules. In leucocythaemia there 
is thought by some to be an increase in the activity of the organs 
producing these white corpuscles—at least there appears to be a 
hyperplasia of these white floating cells; but it is possible that the 
increased number of them in the blood is due to the arrest of their 
transformation into red discs. This latter view seems to me probable, 
as the morbid condition of the blood-producing organs found to exist 
in advanced stages of the disease, when the proportion of white cor- 
puscles is greatest, would seem to indicate imperfection and diminu- 
tion, rather than increase in their action. 
It is quite possible that in the early stages of the disease, when 
the blood-producing glands are excited and increased in their proper 
tissue, more than the normal quantity of white corpuscles is manu- 
factured, and that at a later period there is failure in their transfor- 
mation. Whichever view may be taken of these questions—and they 
are matters of theory and belief, rather than of knowledge and demon- 
stration—a very 'large proportion of white corpuscles is present, 
accompanied with marked diminution of the red discs; and this PHENOMENA—DIA GNOSIS—MOB BID A NA TOM Y. 
481 
state of things is accompanied and followed by very serious conse- 
quences. 
In the phenomena observed clinically, the first that may be 
noticed is an enlargement of the spleen or lymphatic glands, or both ; 
but soon, and sometimes before such changes are observed, there be- 
gins to be failure in the general vigor of the system, going on to 
more positive debility, anaemia, pallor, emaciation, and a cachectic 
state, with discoloration of the mucous membrane, palpitation, 
cephalalgia, dyspnoea on slight exertion, occasional feverishness which 
later becomes more permanent and hectical ; sometimes constipation 
and at others diarrhoea. These symptoms gradually augment, and 
continue from a few months to three or four years, averaging about 
fourteen months, until at length a pneumonia, a hemorrhage—not 
unfrequently cerebral—an exhausting diarrhoea, an asphyxiated state, 
or a failure of the heart’s action closes the scene. There may be 
temporary improvement, but a fatal result is said uniformly to follow. 
The etiology of this affection is obscure. It is rather more fre- 
quent in men than women, and in a large proportion of cases occurs in 
adult life. 
Although cachexias presenting in some respects similar phenomena 
occur in other conditions, as from malaria, scrofula, and syphilis, yet 
this differs from all other diseases, standing by itself as a peculiar 
affection. 
Diagnosis.—Its diagnosis cannot be determined by any one 
external symptom, nor with certainty by all of them together—the 
examination of the blood by the microscope and the detection of the 
large numbers of white corpuscles being the only test of the existence 
of the disease. 
In order that it may be conclusive, and the degree of progress may 
be observed, repeated examinations should be made, a drop of blood 
from a prick of a finger being taken from time to time. When re- 
peated examinations show the proportion of white and red corpuscles 
to be as one to fifteen or twenty, the diagnosis may be established ; 
but as the disease advances, one to four, three, or two, and in rare 
cases an even number of white and red may be found. 
Morbid Anatomy.—The morbid anatomy of leucocythsemia 
has been studied with much care. The most notable changes in the 
solid organs are found in the spleen, the liver, and the lymphatic 
glands. 
The spleen, involved in four fifths of the cases in the early stages 
of the disease, is enlarged by hyperplasia of its proper tissue, but later 
it undergoes degenerative changes. The capsule is generally thick- 
ened and hardened, and the connective tissue is proliferated ; and 482 
LEUCOC YTIIJEMIA. 
when death occurs in the advanced stages, hemorrhagic infarction is 
not uncommon. 
In two thirds of the cases the lymphatic glands are affected, and 
in essentially the same manner as the spleen. There is hyperplasia of 
the gland tissue, increase of connective tissue, thickening and hard- 
ening of the investing capsule, etc. 
The liver is usually found somewhat enlarged, but not quite as 
often or to as great extent as the spleen. 
The lesion extends over a considerable number of the lymphatic 
glands—by preference those of the neck, axilla, groin, mesentery, and 
the bronchial group. Sometimes the enlargement is confined to a 
part of the glands, sometimes it extends to many. The spleen may be 
enlarged without the glands, or the glands without the spleen, or all 
may be affected at the same time. All these changes are of much the 
same character. There is multiplication of the cells, nuclei, and 
granulations, and sometimes cheesy metamorphoses. 
The intestinal glands are sometimes, but not so often, affected by 
hypoplastic swelling. 
Changes are also found outside of the system of the blood glands, 
as in the pleura, pericardium, and other parts. The new formations 
are composed of free nuclei, small cells filled with nuclei, etc., sur- 
rounded by a thin membrane and detached from surrounding tissues. 
These products in the liver seem to come from the walls of the blood- 
vessels and the bile ducts ; and in the pleura and intestines from the 
connective-tissue corpuscles ; but cellular emigration forms a part of 
the adventitious products. The choroid coat of the eye and the brain 
may be the seat of these changes. The hemorrhages that occur in 
the brain and other viscera are produced by the obstruction of some 
branches of vessels from accumulation of leucocytes, the blood from 
this cause being forced into the collateral branches and rupturing 
them. 
The blood, as already stated, when examined during life, is found 
to contain an enormous proportion of white corpuscles. The same is 
observed after death. These white elements, however, vary in differ- 
ent forms of the disease. When the spleen is the seat of the greatest 
change, the cells are perfect, with one or a few small nuclei. When 
the chief lesion is in the lymphatic ganglia, or the glands of the in- 
testines, free nuclei are numerous, and there are many more cells of 
small size. These modifications constitute two varieties of leucocy- 
thsemia—splenic, and ganglionic or intestinal. 
The discovery has lately been made that in some cases, as after 
amputation, the marrow of the bones contains white corpuscles in 
great abundance, and in some instances they are supposed to have MORBID ANATOMY—TREATMENT. 
483 
been seen in stages of transition into red corpuscles. Hence, the 
inference has been that the marrow of the hones is one source of the 
production of blood corpuscles. 
Jaccoud expresses the opinion that in morbid conditions of the 
marrow of the hones we have another source of the abnornal amount 
of white corpuscles in this disease. 
The blood taken from the veins of the cadaver of one dying of this 
disease, presents a layer of grayish-yellow color formed by an accumu- 
lation of white elements of the blood. Often in a, defibrinated portion 
of blood there is a superficial layer, milky in color, entirely composed 
of white globules. The serum is clear and limpid. In the clots in 
the right side of the heart and large vessels, there are whitish points 
looking like pus, especially in the pulmouary arteries. There is twice 
as much of this matter in the spleen as in the jugular veins. By a 
careful examination it will be found that from five to fifteen per cent, 
of these white globules have undergone fatty degeneration. The 
blood is diminished in density, but the albumen, salts, and fibrine 
have undergone no constant changes. With the increase of the white 
corpuscles the red discs are diminished, so that the cell elements on 
the whole are below the physiological average. The blood resembles 
the splenic liquid, and is found to contain sarcodine, lactic acid, 
formic acid, acetic acid, leucin, and tyrosin, and it has an acid 
reaction. 
From the diminution of red discs, there is a deficiency of oxida- 
tion and of oxygen carriers ; and the sense of dyspnoea which occurs, 
arises in most instances from the want of oxygen in the tissues. 
Enlargement of the bronchial glands sometimes mechanically inter- 
feres with respiration and produces the same result. While there 
is constant dyspnoea on exertion, more severe paroxysms from press- 
ure upon the nerves of respiration by enlarged glands sometimes take 
place. There may be difficulty or loss of the power of swallowing 
and of speech, from the pressure of enlarged bronchial and cervical 
glands, as from tumors in the chest and neck. 
In the urine the urea is deficient, but uric acid and the urates are 
abundant—the natural results of diminished oxidation. Sarcosin and 
hippuric acid are generally present. 
Treatment.—The treatment of leucocythaemia is exceedingly 
unsatisfactory. Iron, quinine, and the iodine preparations would 
seem to be rationally indicated ; but though they may abate some of 
the conditions, they fail to cure the disease. In cases where the 
spleen is much enlarged, quinine, to the extent of 3ss, given in 
divided doses, but so that this quantity is taken in the course of 
twenty-four hours, and repeated once or twice a week, will, as I have 484 
LEUCOCYTEESM1A—HODGKIN’S DISEASE. 
several times witnessed, reduce the size of that organ quite remarka- 
bly and produce some general improvement for a time, and may pro- 
long life. The administration of phosphorus has in a few cases been 
thought to exert a curative effect, but it has failed in others. The 
injection of ergotine, hypodermically, has diminished notably the 
enlargement of the spleen and produced temporary improvement in 
other respects. It is advised that forty grains of ergotine be carefully 
mixed with thirty minims of glycerine, and enough distilled water 
to make 120 minims. Fifteen minims contain five grains, which 
may be injected every second day. Iodide of potassium, in free 
doses, has also diminished the enlarged spleen. 
In one well-marked case that fell under my observation some years 
ago, with enlarged spleen and where the white corpuscles were very 
abundant, the ointment of biniodide of mercury was ordered to be 
applied over the spleen, and rubbed and heated in after the direction 
of Aitken. Decided salivation was produced, followed by remarkable 
improvement. Indeed, several months afterward the patient, who 
came from a distance, was reported by his attending physician to be 
cured ; but he was lost sight of afterward, and the ultimate result of 
the case was not ascertained. Jaccoud remarks that mercury pro- 
duces temporary improvement, but that life is rather shortened than 
prolonged by its use. 
HODGKIN’S DISEASE.—LYMPHATIC ANiEMIA. 
This is an affection resembling in many of its phenomena leuco- 
cythgemia, and by Jaccoud called Pseudo-leukaemia. It has also been 
called lymphadenoma, and adenia or adenoid disease. 
It is characterized by progressive anaemia, and a decided enlarge- 
ment of lympathic glands, particularly about the neck and chest; and 
often in points where these glands are not usually seen. The affected 
glands are apt to he more enlarged than in leucocythaemia, and may 
he situated in various parts of the body, even in the brain and spinal 
cord. In some of the cases the spleen is enlarged, and in a smaller 
number the liver also. Like leucocythgemia, the disease is progressive 
and ultimately fatal, and its alliance in symptoms and progress to 
this affection is very marked. It differs from it, however, in the 
essential fact that the number and proportions of the white corpuscles 
of the blood are not usually increased, and never to anything like the 
extent that they are in leukaemia. As in the last-named disease, 
there may be fever of an intermitting or hectical character as the 
later stages approach, and hemorrhages are still more apt to occur. D1A GNOSIS—TIIEA TMENT—PHENOMENA. 
485 
Diagnosis.—The diagnosis is to be made out by the character of 
the tumors and the general symptoms ; and the disease is distinguished 
from leucocy thaemia by examining the blood. It more frequently occurs 
in males than females, and I have seen it more frequently in the 
adolescent or young adult. It may, however, occur at almost any 
age. The pressure of the enlarged glands often produces symptoms 
not necessarily belonging to the disease—such as dyspnoea, aphonia, 
dropsy, etc. 
Treatment.—The treatment is essentially the same in its indi- 
cations and results as in leucocythsemia. In one case of a young man 
who came under my observation, a profuse hemorrhage from the 
lungs or stomach, or both (the account given by the friends was not 
sufficiently clear to determine its source), was followed by great relief 
of the previous distressing symptoms, and what was more marvelous, 
by an almost complete removal of the large glandular tumors in a 
remarkably short time. The friends supposed a cure had been 
effected, as just before that event there had been a change of physi- 
cians, and the new man wras thought to have done wonders, and to 
have produced results different from those predicted ; but severe 
symptoms in a short time returned, and a fatal result soon followed. 
In another case, of an elderly woman, the red blood discs presented 
under the microscope a contracted, shriveled, and irregular appear- 
ance. 
Sooner or later, as a rule certainly, the termination is unfavorable, 
though in some cases arsenic is alleged to have had a curative effect. 
PERNICIOUS ANJEMIA. 
This is a disease where the deficiency of blood, especially of the 
red discs, is doubtless dependent upon some other pathological state— 
some defect in the blood glands of the system ; but as this defect has 
not been distinguished, the anaemia is spoken of as idiopathic. Its 
determinable pathological state is the anaemic ; and as this is persist- 
ent and so commonly results fatally, it is called pernicious, or “idio- 
pathic fatal anaemia.” The further term of anaematosis has been 
suggested. It differs from simple anaemia in being much more severe 
in its phenomena and results. Its characteristic is slowly progres- 
sive impairment of power, until death takes place from failure of the 
heart’s action, in from three months to a year. It resembles in some 
of its features the diseases last considered, but differs from leucocythae- 
mia in its less marked increase of white corpuscles, and from lym- 
phatic anaemia by the absence of the enlarged glands. 486 
PERNICIOUS ANAEMIA—SIMPLE ANAEMIA. 
The countenance shows intense anaemia by its excessive paleness 
or the absence of blood tints, though it is sometimes jaundiced or of 
a sallow straw-colored hue. An cedematous condition is often present, 
and in the latter stages general dropsy. The pulse is feeble and ac- 
celerated by exertion, and a sense of impending dissolution and fits of 
syncope are common. The impulse and sounds of the heart sIioav 
great weakness of the organ, and fatty degeneration of its substance 
is often found after death. Anaemic murmurs are of course marked. 
Hemorrhages, petechiae, eechymoses in the retina, cerebral effusions 
of blood, with their consequences, are frequent. There is dyspnoea, 
palpitation, often loss of appetite, but still the body is not greatly 
emaciated, and the mind is generally intact, at least until a late stage 
of the disease. Fever often occurs in irregular paroxysms, the tem- 
perature rising from 101° to 104°, as in the other allied affections. 
While leucocythaemia oftener appears in men, this disease is more com- 
mon in women, and not unfrequently is developed during pregnancy. 
Diagnosis.—It is distinguished from simple anaemia by its pro- 
gressive character and greater gravity ; from diseases of the kidneys by 
the absence of evidence of such affections on examination of the 
urine ; from phthisis, cancer, malaria, and other toxaemic and cachectic 
conditions by absence of their peculiar phenomena and history ; from 
leucocythaemia by the examination of the blood ; for though the red 
discs are few and much diminished in size, the leucocytes are not ma- 
terially increased. 
Treatment.—Treatment here, as in other allied affections, af- 
fords little hope of material benefit, and almost none of cure. The 
uncertainty of diagnosis in some cases may give grounds for hope and 
motive for effort, and the remedies for anaemia in general are indi- 
cated. They consist of the most nourishing and easily digested food, 
nutritive enemata when the stomach is weak or irritable, and the use 
of bitter and ferruginous tonics. The iodide of iron, the extract of 
malt, and the preparations of pepsin are perhaps worthy of a trial. 
SIMPLE ANiEMTA. 
Anaemia in general, or a deficiency of blood, including all its varie- 
ties, consists essentially in a loss of balance between blood formation 
and blood destruction. There is either a deficiency in the income, or 
an excess in the expenditure, or both combined. The deficiency of 
production may depend upon defects in quantity or quality of food, or 
deficiency of oxygen. 
Derangement in digestion, assimilation, or sanguification also re- PHENOMENA—TREA TMENT. 
487 
suits in a diminution of production ; and these conditions may depend 
upon a variety of causes affecting the blood-producing organs. 
Excessive blood destruction may be produced by excessive and pro- 
longed muscular or nervous action, excessive secretion, inflammatory 
effusions, hemorrhages, albuminuria, tuberculosis, fevers, various 
cachexias, poisons, etc. Heredity, age, sex, occupations, and various 
defective hygienic conditions may produce the result. 
Some of these conditions are temporary and removable, others are 
not so ; and when the anaemia is dependent upon some other disease 
or well-defined pathological state, it is spoken of as secondary, and is 
to be regarded as belonging to the primary affection. 
The term simple anaemia is applied where the condition is not de- 
pendent upon any other disease or well-defined and recognized path- 
ological state, but where the anaemia is the chief and apparently 
primary condition observed. 
The pallor of the skin and prolabia, the blue tint of the sclerotic 
coat of the eyes, the irritability of the heart, and the haemic murmurs 
—the common evidences of anaemia—are readily discovered. When 
not extreme, the face may be sufficiently tinted, especially under ex- 
citement, and then the other conditions must determine its presence. 
A variety of symptoms accompany anaemia and become evidences of its 
existence. The most marked are the phenomena referable to the nerv- 
ous system. These are more marked in women than in men, and anae- 
mia is more common in the female sex. They consist of neuralgias, 
hyperaesthesias, often of morbid emotions and excessive impressibility, 
mental depression and anxiety, and, not unfrequently, of undue ap- 
prehension of serious disease. Coldness of the extremities is common ; 
the heart is easily excited to rapid and often tumultuous action ; the 
respiration is increased by moderate exertion, or by mental emotions ; 
there is often tenderness along the spine and in the intercostal spaces ; 
but a diagnostic symptom which is quite conclusive .is a haemic mur- 
mur at the base of the heart, a venous hum heard when the stetho- 
scope is applied to the neck, and a systolic blowing sound heard in 
the carotid artery. 
Treatment.—The treatment of these forms of anaemia is more 
encouraging. The first and most important thing to engage the 
attention and efforts of the physician is the removal of the cause, 
whatever that may be. 
If the anaemia arises from lactation, the child should be taken 
from the breast; if from menorrhagia, bleeding piles, etc., these 
losses must be arrested ; if from derangements of the stomach which 
prevent the digestion of a proper quantity of food, they should be cor- 
rected, and a proper diet should be given. 488 
SIMPLE AN MI MI A. 
As there is diminution in the red blood discs, and as iron enters 
largely into their composition, the ingestion of iron would seem to be 
indicated, and experience has proved that this is the chief remedy. 
There are many preparations of this metal used in medicine, all 
possessing certain properties in common, but each having peculiar 
properties of its own which render it specially applicable to particular 
conditions. A change in the form of iron from time to time often 
increases the efficiency of the medicine, or blood food, as this article 
may be called. The citrate, lactate, sulphate, iron by hydrogen ; the 
muriated tincture, with dilute phosphoric acid; the pyrophosphate, 
and the dialyzed iron may be chosen from. Sometimes it is well to 
combine other agents with the iron—a preparation often very useful 
is the citrate of iron, quinine, and strychnia. 
In many cases the iron requires to be long continued. Unfortu- 
nately there are some persons upon whom iron produces unpleasant 
effects—such as a sense of fullness in the head, derangements of the 
digestive and generative systems, etc. There are others who fancy 
themselves unpleasantly affected without sufficient reason ; and, as a 
rule, a perseverance with moderate doses can be well borne. As 
ansemia generally depends upon wrong action in some of the organs 
of the body, alterative medicines continued for a time, will frequently 
produce a more marked beneficial effect than the iron. Thus the 
iodide of potassium, the chlorate of potash, and even small doses of 
mercury, will often change actions and commence an improvement 
which the iron had failed to effect. This, in my own experience, has 
been so frequently the case, that it seems to me attention should be 
particularly called to the fact. Recent fashion has tended too much, 
in various diseases, to the use of an exclusively ‘‘tonic and support- 
ing” course, neglecting alterative and eliminative measures. The 
bowels should always be regulated when constipated and deranged, and 
the secretions of the liver should often be modified. The chlorate of 
potash often exerts a peculiarly beneficial influence over the process 
of ultimate nutrition, and will sometimes remedy an anaemic con- 
dition which iron will fail to remove. 
The diet and other hygienic conditions should of course receive 
particular attention. Life should be as much as possible in the open 
air ; sea air and sea bathing with some, country or mountain air with 
others, and a variety of food, will be useful ; but with most a good pro- 
portion of nitrogenized food—beefsteak, roast beef, mutton, fowls, etc., 
will be required. Cod-liver oil and extract of malt will be beneficial 
to some. In simple amemia the patients may with truth be assured 
of the absence of serious organic disease, which they frequently so 
much fear ; and this assurance will often contribute largely to the cure. PHENOMENA. 
489 
CHLOROSIS. 
The term chlorosis is'given to a form of anaemia commonly occur- 
ring in young females not far from the period of puberty, and is con- 
nected with some derangement of the menstrual function, or with the 
development of the sexual system. It is characterized by the ordi- 
nary phenomena of the anaemic state, with the addition of a greenish 
tint of the complexion, which gives the disease its name. There is 
often a depraved appetite, a desire for clay, slate, chalk, or other in- 
digestible substances. 
The treatment will be the same as for other forms of anaemia, 
while special attention is given to the restoration or correction of the 
menstrual and other uterine and pelvic conditions. Change of air 
and associations, the management of the mind and the correction of 
all other morbid conditions of the body should receive attention. A 
more particular account of this condition and the means of managing 
it, will be found in works on Diseases of Women. 
ADDISON’S DISEASE.—BRONZED-SKIN DISEASE- 
SUPRARENAL MELASMA. 
Although this has been classed among local affections—as a dis- 
ease of the suprarenal capsules—yet the absence of well marked dis- 
ease in those organs in so many cases, and the prominence of general 
symptoms, and especially of anaemia, seem to entitle it to a place in 
this connection. 
This affection, first distinguished and fully described by Dr. Ad- 
dison, of Guy’s Hospital, London, and hence called by his name, is 
characterized by progressive debility and anaemia, but without great 
emaciation. It is, however, particularly distinguished by a peculiar 
discoloration of the skin, commencing on the parts most exposed to 
the light, as about the face and forehead, or sometimes on parts where 
a blister has been applied, but extending to different parts of the 
body—to the genital organs and inside the thighs, to the parts about 
the umbilicus and elsewhere. In some rare cases this discoloration is 
quite uniformly spread over the surface, causing the person to present 
the appearance of a mulatto, though often with more of a tinge of 
green ; while in others, the discoloration is slighter and more partial, 
though the general symptoms are the same. 
This discoloration, so important a characteristic of the disease, 
must be distinguished from that accompanying pityriasis niger ; from 490 
ADDISON’S DISEASE. 
protracted jaundice, where a very dark color is sometimes assumed; 
from the yellow-brown color of chloasma; the mossy appearance in 
some cases of pregnancy and debility from uterine and stomach dis- 
eases ; from the discolorations resulting from exposure to the sun and 
weather in hot regions ; and from filth and vermin anywhere. 
The symptoms and course of this affection are not materially dif- 
ferent from those of pernicious anaemias, and need not therefore be 
detailed at length. There is progressive debility, sometimes nausea 
and vomiting, not unfrequently cephalalgia, often a peculiar hard- 
ness or bony feeling of the fingers, and gradual failure of the heart’s 
force; the intellect remaining intact until near the last, when de- 
lirium, and finally coma, may supervene. 
The bronzed color usually increases gradually in area and deep- 
ens in intensity as the case progresses. A fatal termination is finally 
reached ; but the duration' of the disease varies from a few weeks, in 
exceptional cases, to several years, though in a majority of cases death 
takes place within a year. The mode of death is usually by gradual 
asthenia, though sometimes by syncope after exertion. It is seldom 
or never that coma is so profound as to suspend first the action of the 
brain. 
There has been much discussion as to the pathology of this dis- 
ease, and it is by no means fully settled. At one time, from the fact 
that in several cases a tuberculous disease of the suprarenal capsules 
was found on post-mortem examination of those dying of the affec- 
tion, it was supposed that the function of these bodies was to regulate 
the chromatogenous phenomena in the system, and that in conse- 
quence of their being diseased in this peculiar way the discoloration 
followed. The disease was therefore regarded as a local affection of 
these bodies, the bronzing and other symptoms following as a conse- 
quence. This restricted view can scarcely be maintained. Although 
in a majority of cases the suprarenal capsules are found diseased, 
this is not always the case; and in many instances no tubercular 
disorganization can be discovered. In a recent case, where a medical 
friend succumbed to the disease, the only thing observed about these 
capsules was that one was much smaller than the other; but this is 
often the case where no such disease has occurred. In this instance 
the disease was well marked in all its features ; it began with general 
weakness, the discoloration came on gradually and extended, and the 
disease continued several months after it was recognized. 
In the present state of our knowledge, notwithstanding the labors 
of Addison, Wilks, Robin, Pepper, and others, the pathology of the 
disease is obscure. It seems to me probable that its seat is in the 
organic or ganglionic nervous system, that a peculiar perversion of PA PROLOG Y—TREATMENT. 
491 
nutrition and coloration follows, and that the disease of the supra- 
renal capsules, so often found, is rather an incident or result of the 
organic nervous perversion than a cause of the symptoms. This 
opinion is suggested by the symptoms, but is strengthened by the fact 
that alterations in the solar plexus and semi-lunar ganglia have on 
several occasions been observed. The subject, however, requires fur- 
ther investigation ; the condition of all the organs and the blood 
should be more carefully examined, and attention should not be con- 
fined to the suprarenal capsules. 
Although the disease, after its full and unequivocal development, 
so far as it is known, has gone on to a fatal result, yet I have seen a 
few cases where an appearance like that of incipient Addison’s disease 
was followed by recovery. In these cases, after the existence for some 
time of debility and ansemia, with no other discoverable cause, dis- 
coloration of the forehead and face, of a character not distinguishable 
from that of this affection commenced; but in time, under the use of 
iodide of potassium, hydrochlorate of ammonia, and iodide of iron, 
the discoloration slowly disappeared, and health was restored. One 
case of a gentleman, formerly of Michigan, now in Kansas, was under 
observation and treatment for several months with symptoms such 
as described, but the patient has been in fair health for the last seven 
years. The bronzed appearance of the face, when last heard from, 
had disappeared. 
I am not prepared to affirm that these were cases of Addison’s dis- 
ease, but the symptoms were of a character to excite the strongest sus- 
picion that they were of that nature. Should other cases of a similar 
character occur to me, I should pursue a similar course, and not with- 
out hope of benefit. 
Dr. Flint refers to a case seen with Dr. Rockwell, where general 
electrization was followed by marked improvement after some thirty 
applications ; the improved condition continued for two years, when 
the strength suddenly gave way, and the patient died within twenty- 
four hours. 
Treatment. —The treatment of fully developed cases, though so 
unsuccessful, should not be entirely abandoned, as the progress of the 
disease may be delayed and the patient made more comfortable. A 
general tonic and alterative course seems to be indicated, and special 
distressing symptoms must be met as they arise. The vomiting, 
when it occurs, may be allayed by various means : by spts. of chloro- 
form in a mixture of glycerine, small doses of morphia, or by other 
anti-emetics. The strength should be kept up as much as possible by 
nutritious and easily digested food and tonic medicines. The phos- 
phate of iron, the hydrochlorate of ammonia, quinine and strychnine, 492 
DIABETES MELLITUS. 
ext. of malt, cod-liver oil, etc., may be tried. In excitement of the 
brain bromide of potassium would be indicated. In the early stage of 
the disease the salts of iodine, it seems to me, should have a fair trial. 
But as no articles have an established reputation as curative agents, a 
course of symptomatic and palliative treatment is chiefly to be pur- 
sued. In view of the past achievements in medical science and art, 
the hope may be entertained that the pathology of this affection will 
hereafter be better understood, and that some means, much more 
effectual than are now kuown, will be found for its relief. 
DIABETES MELLITUS.—GLYCOSURIA.—GLYCOIIiE- 
MIA. —MELITURIA. 
Diabetes Mellitus may be defined a constitutional disease, produced 
through errors in the process of assimilation, either in the stomach 
and intestines, in the solid viscera, especially in the liver, in the gen- 
eral tissues, or in the blood. It is characterized by an increase in the 
quantity of urine, which contains a saccharine substance resembling 
grape sugar ; this condition is accompanied with excessive thirst, 
often a ravenous appetite, but generally with progressive emaciation 
of the body. In many cases a wasting of the lungs by destructive 
changes occurs in the course of the disease ; in some there is impair- 
ment of vision, often by opacity of the lens ; generally there is a dry 
and harsh skin, not unfrequently constipated bowels, and often im- 
pairment of various brain functions. The disease is obstinate, some- 
times protracted and fluctuating, but in a large majority of cases 
ultimately fatal. Death may occur from general wasting and gradual 
failure of power, from intercurrent local affections, or from such 
changes in the blood as will more speedily interfere with its functions. 
Many isolated facts respecting this disease have been observed, but 
the full details of its pathology are not yet established. 
From time out of mind, cases of a large discharge of urine, with 
thirst and emaciation, a voracious appetite but progressive weakness, 
have been observed, to which the name of diabetes has been applied. 
About two hundred years ago it was discovered that such urine had 
generally a sweet taste, though in some rare cases a free flow had not 
that quality. This gave rise to the distinction of diabetes mellitus 
and insipidus. About a hundred years ago sugar in the blood was 
discovered in diabetic patients, constituting what is now called 
glycohaemia. Soon after this, sugar was separated from the urine; 
and soon it was found that the avoidance of sugar and starchy matters 
in the food, and confinement to an animal diet, diminished the quantity IIISTORT. 
493 
of the urine and the sugar in it. In 1815 it was found that the 
sugar of diabetes was like grape, and not like cane sugar. Some ten 
years later it was discovered that starch was converted into sugar in 
the alimentary canal; and a dozen years later sugar was found in 
matters vomited by diabetic patients. In 1848 Claude Bernard 
announced that animals as well as vegetables had a sugar-creating 
power, and that the liver was the organ in which elements were 
brought together which produced the saccharine matter. In a short 
time after, he also found that saccharine urine could be produced in 
animals by irritating mechanically the floor of the fourth cerebral 
ventricle. In 1853 it was further discovered that alcohol injected 
into the portal vessels produced sugar in the urine. Soon again it 
was found that this production of sugar in the liver goes on after 
death, and even when the liver is removed from the body. Previous 
to this time it was held, and is still taught by some, that the sugar 
formed normally and freely in the liver was burned off in the lungs ; 
but in 1856-7 it was announced that normal sugar formed in the 
liver was not burned in the lungs, but disappeared from the blood as 
it passed through the capillaries in the general tissues, and that the 
sugar was there appropriated to the nourishment of the tissues and 
the sustaining of the body. 
Soon after this it was further found that before albuminous sub- 
stances reached the state of sugar—albumen being capable of that 
conversion—they first passed through the transitional state of glyco- 
gen—a sort of animal starch, but a substance very readily passing 
into the condition of sugar. In 1859-60 a small quantity of sugar 
was found to exist in healthy urine ; a quite considerable quantity 
sometimes, especially after the ingestion of a free quantity of that 
substance ; and it is now well known that in lactation and pregnancy, 
and in various morbid states, sugar may appear in the urine without 
producing the other phenomena of diabetes, or being produced by 
that condition, and that saccharine urine does not necessarily imply 
diabetes, any more than albumen in the urine proves the existence of 
Bright’s disease. Albumen is in the urine in Bright’s disease, as 
sugar is in the urine in diabetes, but in both instances the respective 
substances may be produced by other causes. In 1871 it was found 
that in an advanced case of diabetes, with the continuance of the 
emaciation, the thirst, the debility and other general symptoms of the 
disease, a free watery diarrhoea completely replaced the free flow of 
urine, and it was found by a careful analysis that the discharges from 
the bowels contained a large quantity of sugar, even when a diet 
almost exclusively composed of animal food was taken. This case in 
a young man occurred under my own observation in the Hospital of 494 
DIABETES MEL LIT US. 
the University of Michigan, and the analysis of the intestinal dis- 
charges was made in the chemical laboratory of the University. 
Still later. Dr. Pavy announced that defibrinated arterial blood 
injected into the portal vessels causes saccharine urine ; and he sug- 
gests the theory that by vaso-muscular paralysis and distention of 
capillary vessels, blood passes rapidly from the arteries to the veins 
without losing its oxygen, and without being converted into venous 
blood, and that this causes the large production of sugar which 
enters the circulation and passes off in the urine, constituting the 
disease. It is found that the spores from the puff-ball, when inhaled, 
cause sugar in the urine; and it is suggested that these spores pro- 
duce this effect by paralyzing the vaso-motor nerves. 
It has been observed occasionally, and more than once by myself, 
that diabetic patients, in rare cases, in a stage of the disease not far 
advanced, die suddenly, or in a day or two, after severe symptoms occur, 
in a state of asphyxia. It has very recently been discovered that in these 
a rapid fatty degeneration of the blood occurs, or at least large quan- 
tities of fat are found in the blood, and large quantities of it accumu- 
late in the capillaries and small vessels of the lungs, obstructing the 
circulation and oxygenation of the blood, and causing death by 
apncea. In these cases not only is there fat embolism of the lungs, 
but the quantities of fat found in the blood are so great that they 
can be collected in large amounts. Notwithstanding these facts, and 
others which are well known to occur in the course of this disease, the 
manner in which the changes are brought about, and the real causes 
of the disease, are matters of conjecture. 
The formation of sugar somewhere in the organism, a fact admit- 
ting of no question, is not the result of simple oxidation producing 
heat, but a true assimilation, the sugar being produced in the form 
of glycogenous matter. This substance is present in all the tissues, 
and is not obtained alone from starch and sugar ingested, but also 
from albuminoids, and, in the absence of food, from the elements of 
the blood and the tissues of the body. In a diabetic patient, sugar 
often appears in the urine in considerable quantity, when he has long 
abstained not only from starch and sugar, but from all food, while 
the production of sugar and the wasting of the body prove that the 
sugar comes from the conversion of the elements of the blood and the 
tissues into this material. 
The gastro-intestinal theory advanced by Prout and others, that 
the sugar of diabetes was entirely formed in the alimentary canal in 
consequence of some wrong process of digestion there, is opposed by 
the fact that sugar in the alimentary canal is not normally absorbed 
directly into the blood as such, but is to a large extent at least formed PATHOLOGY. 
495 
into lactic and butyric acids ; and that when only .6 (six tenths) 
part in 100 of sugar are in the blood, sugar is readily found in the 
urine. But the theory is positively disproved by the fact just stated, 
that diabetes may exist when no starchy or saccharine food is taken, 
and the sugar appears in the urine when for a considerable time all 
food has been abstained from. 
The Hepatic theory, following the discovery by Bernard of the 
glycogenic function of the liver, was to the effect that in diabetes the 
liver becomes too active in the production of sugar, forming by an 
augmentation of its normal functional power more than can be burnt 
or changed in the lungs or elsewhere in the blood, or more than can 
be appropriated by the tissues, and hence the sugar goes into the urine. 
This excessive production of the sugar was thought to be less the result 
of any lesion of the liver itself than of the innervation controlling it. 
But this theory, which is still held by many, was opposed successfully, 
at least as an exclusive theory, by the observations and arguments of 
Pavy, who contended that the liver does not produce sugar by its 
physiological action ; but that it contains, in free quantities, glyco- 
gen, or what he calls Hepatine, to the production of which sugar 
carried from the alimentary canal to the liver contributes ; and that 
this hepatine post mortem is speedily converted into sugar ; and that 
when sugar is found in the liver, or in the hepatic vein, or right side 
of the heart, to any considerable extent, it is a post-mortem, or rather 
a pathological result, and not physiological. 
The pulmonary theory of diabetes was, that the sugar normally 
produced in the liver was physiologically burned in the lungs, but 
that in diabetes the lungs failed to perform that function, and allowed 
the sugar to pass on into the general circulation to be excreted by the 
kidneys. This theory is not sustained, as it is not shown that sugar is 
physiologically consumed in the lungs. On the contrary, the experi- 
ments of Pavy go to show that there is no more sugar in the blood 
entering the lungs than in that coming from them. 
Another theory is that the blood is the seat of the disease; that in 
it, and by means of its oxygen-carrying globules, the sugar produced 
in the liver, or gaining access to it from the alimentary canal, is physi- 
ologically oxidized, as the pulmonary theory held it to be, in the lungs; 
but that the blood, failing to perform that function, left the sugar to 
be eliminated by the kidneys. But this theory is unproven ; indeed it 
appears to be disproved by the same observations and facts which 
show the fallacy of the pulmonary hypothesis. 
Neither is it shown that sugar is oxidized in the systemic capilla- 
ries, but, on the contrary, as much sugar is found in the venous as in 
the arterial blood. 496 
DIABETES MELLITUS. 
It must be admitted, as stated by Jaccoud, that diabetes is not an 
exaggeration of a physiological action, not an increase of the physi- 
ological function of the liver, but a diseased action arising from causes 
not understood; an aberration in nutrition and assimilation which at 
first may be limited and partial, but in the progress of the disease 
becomes more complete. 
It is evident, from all the facts, that the source of the sugar is not 
always the same. That sugar and starch ingested furnish the ele- 
ments for a large part of the sugar which is produced in diabetes is 
evident from the fact that when these articles are taken much more 
diabetic sugar is produced than when they are excluded from the food. 
But it is evident they are not the only source, from the further fact 
that this sugar is produced in their absence. It seems probable that 
these substances taken into the stomach are, either in the form of sugar 
or of lactic or butyric acids, to a large extent taken into the portal 
veins and carried to the liver, contributing to the production in that 
organ of glycogen, and probably, physiologically, to a certain small 
proportion of sugar there ; that physiologically this glycogen is elabo- 
rated further in the liver into fat' and other materials for the supply- 
ing of force and the support of the tissues; that in the perverted 
action which occurs in diabetes, either the elements taken into the 
liver are not converted into glycogen, or, if so, are reconverted into 
sugar either by the direct but perverted influence of the liver, or, in 
its suspended influence, by the action of chemical laws ; that albumi- 
noid and fatty foods are capable, but to a more limited extent, of the 
same transformations as the amyloid and saccharine ; that the blood 
and materials from the tissues are also capable of similar transfor- 
mations ; and that sugar, Avhenever and however produced in the 
system and obtaining admission into the blood, is probably incapable, 
at any rate excepting to a limited extent, of further changes, and is 
carried out of the body generally by the kidneys, but in exceptional 
cases by the alimentary canal. 
The immediate causes originating these changes are obscure, but 
they probably have their seat in the brain and nervous system. This 
appears from the well-known fact that the nerve-centres not merely 
control influences, but all the functions of the body, animal and or- 
ganic, and from the further fact that irritations, injuries, and morbid 
conditions of those centres in the brain, medulla oblongata, and spinal 
cord, and even irritation of the pneumogastric and other nerves, seem 
capable of inducing saccharine urine and the other phenomena of 
diabetes. 
As nearly as the present state of our knowledge will enable us to 
determine, we may say, that diabetes is a neurosis, disturbing the har- PA PROLOG Y—PA THOLOGICAL ANA TOMY. 
497 
mony and proper action of the assimilative functions in such a man- 
ner as to produce more than the normal quantity of sugar in the 
system, and as a result the other changes which constitute diabetes. 
Dr. Harley, regarding the production of a certain amount of sugar 
and its appropriation in the system as physiological, makes two vari- 
eties of diabetes—one from the excessive formation of sugar, and the 
other from defective assimilation or appropriation of normally formed 
sugar by the tissues of the body, thus allowing of its running to 
waste in the system. If a portion of sugar is normally appropriated 
by the tissues, a supposition which no facts in our possession will en- 
able us to positively deny, it is likely that in some cases a diminished 
appropriation of the sugar is a prominent feature of the disease, and 
may contribute to the phenomena that arise. 
There are some clinical facts which seem to favor this view. 
Though most cases are benefited by an animal diet, which affords less 
material for the formation of sugar, it is affirmed that in other, but 
rare cases, confinement to such a diet does no good, but rather harm— 
a diet in which starchy and saccharine matters abound agreeing best. 
When excessive formation of sugar is the chief condition, the patient 
is not necessarily emaciated and weak. He may for a considerable 
time be fat and ruddy ; but where defective appropriation is the chief 
condition (if such a state is possible), emaciation is one of the earliest 
conditions, and the first to attract attention. That clinical varieties 
presenting these different features as to emaciation and loss of strength 
appear, must be well known to all practitioners of experience ; and it 
is possible that this view of Dr. Harley may furnish the explanation. 
This, however, is but a conjecture, but is one worthy of being consid- 
ered in so obscure a disease. 
The remote causes favoring the production of diabetes are various. 
The influence of age is not the same in the two sexes. In men it is 
more frequent between thirty and forty ; in women, between ten and 
thirty ; but it may occur at any age in either. Young girls and girls 
in their teens are more subject to it than boys, and with them it is 
usually rapid in its course. It is more common in men than in women ; 
heredity has some influence ; and some diseases, as gout and syphilis, 
and cold, depressing emotions, and some lesions of the spinal cord and 
brain tend to its production. 
Pathological Anatomy.—The changes always present are, the 
abnormal quantity of sugar in the blood, and an increased quantity of 
fat. This latter in rare instances is so great as to cause fatty 
embolism of the pulmonary vessels, and asphyxia and death. I 
recently saw in the possession of Mr. Hamilton, the Pathologist of 
the Edinburgh Royal Infirmary, a specimen of half a pint or so of 498 
DIABETES MELLITUS. 
blood, taken from a patient dying suddenly from diabetes, of which 
a large proportion was clear liquid fat. 
Various alterations of organs are sometimes found, but these are 
not characteristic or constant. There may be dilatation of the stomach 
and hypertrophy of its tunics ; the kidneys may be injected, enlarged, 
or flabby, sometimes softened and sometimes denuded of their tubular 
epithelium in consequence of overwork in carrying off so much 
saccharine urine ; other accidental affections, such as cysts and cal- 
culi, may occur, and in rare cases there may be a combination of 
Bright’s disease. 
Atrophy of the pancreas has not unfrequently been observed; and 
lesions of the liver are quite common. It may be hvperaemic, there is 
sometimes hyperplasia, hypertrophy, atrophy more rarely, and fatty 
infiltration of liver cells. In consumptive cases, dying slowly, hyper- 
aemia may not be observed. 
Nervous lesions are not rare, but they are not characteristic. 
There may be congestion, induration, softening, hemorrhagic spots, 
tumors, etc., in the fourth venticle, or in any part of the brain or 
spinal cord. 
Alterations of the peripheral nerves—hypertrophy of the renal 
plexus and the sympathetic—calcareous concretions on the nerves with 
degeneration of the neighboring nerve substance are sometimes found. 
Symptoms and Course.—The leading symptoms have already 
been alluded to in the definition of the disease. They may be divided 
into primary and secondary—the primary being constant, while the 
secondary may be wanting. 
The primary are glycosuria, polyuria, polydipsia, polyphagia, and 
autophagia. These, except the last, appear contemporaneously. The 
last, the consumption or feeding upon the tissues, generally occurs at 
a later period more markedly, though sometimes it is early in the 
history of the case. The appetite is not so uniformly increased as the 
thirst, and the increase of the quantity of the urine is not always de- 
cided, though usually it is marked, and is often very great. The 
sugar in the urine is the most constant symptom, and yet on an ani- 
mal diet that may temporarily disappear. 
In a fair and fully formed case of diabetes, the patient, a full- 
grown man, taking a usual diet, as much as the appetite demands, 
and as much drink as the thirst calls for, will pass 320 fluid ounces, 
or twenty pints, of urine in twenty-four hours, of the high specific 
gravity, chiefly in consequence of the sugar present, of 1.040. In 
this there will be 12,329 grs. of sugar and 1,559 grs. of urea. The 
quantity may vary much in each direction, but is more frequently 
below than above these figures. SYMPTOMATIC PHENOMENA. 
499 
There are sometimes intercurrent diseases which exert an influence 
upon the diabetic symptoms. Scarlatina, pneumonia, acute affec- 
tions of the intestines, and gastric fever are said to suppress the gly- 
cosuria ; while intermittent fever, variola, and pleurisy have not that 
effect. (Jaccoud.) 
The statements made by different authors respecting the quantity 
of urea excreted in the twenty-four hours vary. Some declare 
the quantity on the whole increased, others diminished. Undoubt- 
edly there are great differences in different cases. Where emaciation 
is progressing, the azotized tissues are being consumed, and while 
free quantities of azotized food are taken, the urea is increased. 
When emaciation is not rapidly progressing, and when but moderate 
quantities of food are taken, the urea is diminished. 
Uric acid does not undergo constant changes. Hippuric and 
phosphoric acids are not specially modified. Sulphates are said to be 
increased to double their normal quantity, and chlorides still more. 
Creatinin is sometimes, at least, enormously increased, according to 
some authorities to twenty times the normal amount. When this is 
the case, urea would be likely to be diminished. Albuminuria is 
sometimes present, but is not a constant symptom. The increase of 
urine produces increase of thirst, and they are usually proportionate. 
The increase of appetite, so common, may not occur when some special 
stomach derangements are present; and dyspepsia, gastralgia, acid 
eructations, vomiting, and diarrhoea may exist, the discharged mat- 
ters often containing sugar. As in the case already related, the diar- 
rhceal discharges may take the place of the polyuria and the glyco- 
suria. The autophagia—the feeding upon the tissues—is sooner or 
later a condition which occurs ; but it is developed at different times 
in the course of the disease. When the sugar is formed from the 
albumen of the food or the tissues, urea is increased. 
There are various secondary symptoms dependent on the different 
primary states. Those dependent on glycaemia, or the sugar in the 
blood, are, altered secretions, lesions of the teeth and gums, impo- 
tency, sterility, amenorrhcea, anthrax, erysipelas, boils, pneumonia 
—catarrhal and fibrinous—bronchitis, and gangrene. 
The phenomena dependent on the glycosuria are, irritation and 
redness of the meatus, pruritus, phimosis, balanitis, and fungoid 
growths about the fraenum and vulva. 
Those dependent on polyuria are, habitual constipation, dryness 
of the skin and mucous membranes, and great decrease in the pul- 
monary and cutaneous exhalations, the normal quantity of from 
12,000 to 15,000 grammes being reduced in extreme cases to 529 
grammes. (Jaccoud.) 500 
DIABETES MELLITUS. 
The phenomena due to the consumption of the tissues are, ulcera- 
tion of the lungs ; pulmonary phthisis of a peculiar form, distin- 
guished by the scantiness of secretions, rapidity in formation of 
cavities, and by the absence of haemoptysis ; cataract of a somewhat 
peculiar kind also, and amblyopia ; and nervous troubles, such as 
anaesthesia, hyperaesthesia, neuralgia, excessive sensations of cold, etc. 
The temperature is often lower than normal in the advanced 
stages, and some patients desire a very high external temperature to 
be comfortable. 
The progress of the disease varies. It may be slow, with remis- 
sions which may be mistaken for cures. In the first stage cures may 
possibly be effected. Death by gradual wasting and marasmus alone 
is rare, pulmonary and other lesions more commonly contributing to 
the result. 
Prognosis.—The prognosis is always grave, and the rapidity of 
the disease is usually much greater in the young than in those ad- 
vanced in age. It is often remarkably rapid in young girls. In one 
case which I observed in the family of a physician, death occurred in 
a Aveek or tAvo after the symptoms first attracted notice, though they 
had doubtless existed in moderation for some time before. 
Pulmonary lesions, troubles of sight, and cutaneous inflammations 
are unfavorable symptoms. 
Constant decrease in the polyuria and glycosuria, if not accom- 
panied with profuse saccharine perspiration or diarrhoea, is an en- 
couraging sign. 
Diagnosis.—The diagnosis of diabetes is to he made by observ- 
ing the symptoms Avhich ha\'e been described—particularly by the 
large quantity of urine passed, its high specific gravity, and its con- 
taining sugar as discovered by the proper tests. The peculiar fruity 
odor of the breath, the thirst, the emaciation notAvithstanding the 
free quantity of food, will aid. 
The presence of sugar in the urine distinguishes it from simple 
polyuria or diabetes insipidus. 
It should be borne in mind that moderate quantities of sugar, but 
sufficient to give its reaction with tests, are found in seA'eral other 
conditions than that of diabetes. It seems to be present normally in 
women during parturition, during lactation, and with some during 
pregnancy. It often occurs in paralytic patients ; it may result from 
Woavs upon the head; may occur in dyspeptics and the aged, and in 
children during dentition. Certain medicines—the nitrate of potash, 
oxide of carbon, the salts of mercury, etc., may cause sugar in the 
urine. Diabetes implies a persistence of saccharine urine, and the 
other associated conditions described. TREATMENT. 
501 
Treatment.—The most important item of treatment is the 
dietetic. There can be no doubt that starch is to a considerable extent 
converted into sugar in the mouth, stomach, and intestines ; and that 
the sugar so produced, as well as that ingested, though in part changed 
into other substances—especially lactic acid—to some extent at least 
finds its way, in part through the lacteals and the thoracic duct, 
directly into the blood, while other portions, either in the form of sugar 
or of other substances readily converted into it, go through the portal 
vessels into the liver and from it reach the blood ; and that starchy 
and saccharine matters produce more sugar to be carried out of the 
system than any other forms of food. Abstaining from these articles 
causes a diminution in the amount of sugar in the urine, and a conse- 
quent diminution in the quantity of urine passed, since it is the 
presence of sugar and the amount of water required for its solution 
and transportation out of the system which increases the flow. This 
must be regarded as palliative of the symptoms rather than curative 
of the disease ; but palliation here, as elsewhere, not unfrequently 
results in more radical improvement. As a rule, this dietetic plan is 
advisable, and it is certainly recommended by all standard authorities 
on the subject. It should generally be pursued until there is a pro- 
gressive decrease in the glycosuria ; and when this course is taken, 
there is usually a marked improvement in the general symptoms and 
condition of the patient. Unfortunately, however, this is not always 
the case. The quantity of sugar and urine excreted may be dimin- 
ished while the patient continues to lose flesh and strength ; the 
stomach becomes deranged, the appetite may fail, and improvement 
may follow a resort to a more ordinary or mixed and amylaceous diet. 
Such facts have induced Dr. Harley to make in his description the 
two varieties of the disease, and to regard cases of this kind as depend- 
ent more upon deficient appropriation of the elements of the sugar 
for the nourishment of the body and the production of force, than 
upon the excessive formation of sugar in the system. These excep- 
tional cases do not invalidate the rule; and often the improvement 
on an animal diet is very remarkable. As an instance, Dr. Pavy 
reports a case where, with an ordinary mixed diet, the patient passed 
10,500 grains of sugar in twenty-four hours, but when restricted to 
meat, beef-tea, and jelly without sugar, the quantity passed in the 
same time was but 594 grains ; and that as the sugar diminished the 
patient improved strikingly in appearance, health, and strength ; and 
what must be considered as exceptional, did not get tired of his diet. 
Greens were allowed, such as lettuce, spinach, cresses, etc., as they 
were found to do no harm. Dr. Pavy says, as long as the sugar is 
kept down to from 1.000 to 1,500 grains a day, his experience would 502 
DIABETES MELLITUS. 
indicate that the patient is not conscious of the existence of his com- 
plaint. The presence of a free quantity of sugar in the blood inter- 
feres Avith the performance of the normal function of that fluid ; but 
Avlien the quantity is small it may perform its proper office and com- 
parath'e health may be enjoyed. Where the increased formation of 
sugar is the chief morbid condition this treatment is efficient. It is 
worthy of a trial in all cases. The smaller the quantity of sugar 
passed through the system the better. It not only interferes Avith 
the proper function of the blood, acting as a foreign and poisonous 
agent, but it carries off other elements of food, washing them aA\ray 
in the flood of water necessary to hold in solution the sugar. The dia- 
betic patient, then, should be confined as much as possible, Avithout 
impairing nutrition, to an azotized diet—to albumen, fibrine, caseine, 
gelatine, and gluten—to flesh, eggs, etc. Lately a pure skim-milk 
diet has been strongly recommended. Should there be albuminous 
urine there might be a double indication for the milk diet. But a 
variety of azotized articles of food should generally be alloAved ; and 
if judicious selections be made, and pains be taken to render the 
articles acceptable to the taste as Avell as digestible and nutritious, 
and the articles be frequently varied, the azotized diet may often be 
continued for a long time. Dr. Flint advises that a diabetic patient 
ho furnished Avith a list of articles which may be alloAved, and of those 
which are forbidden. He gives the folloAving as articles of food and 
drink containing no starch and sugar, or a quantity so small as not 
to be practically important: 
“ 1. All kinds of meat and poultry (excluding liver) either boiled, 
roasted, grilled, or in the form of soup or jelly, with any kind of sea- 
soning or sauce Avhicli contains neither flour nor sugar. 
“2. Fish of every sort, inclush'e of turtle and terrapin, lobster, 
clams, crabs, shrimps, and oysters. 
“ 3. Eggs, cooked in any form, Avith the exception of SAveet 
omelets or sweetened custards. 
“ 4. Cream, cheese, butter, buttermilk, and, in moderate quantity, 
milk. 
“5. Cabbage, lettuce, cucumbers, pickles, spinach, beet tops, toma- 
toes, sorrel, endive or chickory, radishes, mushrooms, caulifloAver, 
Brussels sprouts, asparagus, truffles, dandelion, artichokes, oyster- 
plant, celery, spring onions, Avater-cresses, and olives. The alloAved 
vegetables may be eaten raw, boiled, fried, or made into salads. 
“6. Coffee and tea, Avith the addition of cream, and glycerine, if 
agreeable, as a substitute for sugar.” 
Dr. Flint includes some of the alcoholic drinks, but as these can 
seldom seiwe any useful purpose, and as experiments have shown that DIETARY. 
503 
introduced into the portal vessels of animals they cause the produc- 
tion of sugar, they should be excluded from the diabetic dietary, and, 
if used at all, should be prescribed for the purpose of fulfilling some 
special indication strictly as drugs. They can be required as such 
in this disease only very exceptionally. Water may be allowed in any 
reasonable quantity to quench thirst, and buttermilk, if relished, may 
also be permitted. 
8. “ Gluten bread, and bread made from finely ground bran after 
Champlin’s method. In the use of these substitutes for ordinary 
bread, much depends on the mode of preparation. They may be 
made palatable by the use of eggs and butter, together with varying 
modes of preparation. Pavy’s almond flour may be used for the sake 
of change. If these substitutes for wheaten bread become repulsive, 
thin slices of the latter, toasted very much, and almost charred, arc 
allowed in small quantity.” 
A gluten flour is prepared especially for diabetics by the “New 
York Health Company,” No. 74 Fourth Avenue, New York City, 
which is said to contain only a very small proportion of starch, and 
to make a very palatable bread. According to the accounts it meets 
the requirements in diabetic cases. Champlin’s bread is made of 
wheat bran, which has been boiled a short time and washed in two 
successive waters, and again washed in cold water and passed through 
a sieve to remove all starch. It is then thoroughly dried in a 
slow oven, and when perfectly crisp ground in a fine mill, and passed 
through a very fine sieve by the aid of a brush, and all that is not 
perfectly fine and soft is reground. Three troy ounces of this bran 
powder, three fresh eggs, one ounce and a half of butter, and rather les3 
than half a pint of milk, after melting the butter, arc to be thor- 
oughly mixed together, adding some agreeable spice. Immediately 
before putting into the oven, first thirty-five grains of sesquicarbo- 
nate of soda are to be stirred in, and then three drachms of dilute 
hydrochloric acid. The loaf should be baked in a basin, well buttered, 
for rather more than an hour. Biscuits may be prepared, omitting 
the soda and acid and a part of the milk. Sugar, bread of all kinds 
except such as indicated, macaroni, vermicelli, rice, Indian corn, bar- 
ley, oats, and all starchy grains arc forbidden. Potatoes, arrow-root, 
tapioca, sago, peas, beans, beets, carrots, parsnips, turnips, liver of 
all animals, and all saccharine fruits must be avoided. 
This anti-diabetic diet should be rigidly enforced for a time at 
least, and its effects observed. If borne by the stomach and attended 
by improvement, it should be persevered with. If not Avell borne, 
and improvement does not occur, it should not be long continued. 
Some of the interdicted articles may be allowed and the effect 504 
DIABETES MELLITUS. 
observed, the urine examined, and the further management of diet 
governed by the conditions of each case. The success in staying the 
progress of the disease will depend largely upon the care and skill 
exercised in carrying out the dietetic management. The importance 
of the matter has called for the details so fully given. In observing 
the effect of diet or of medicines on the conditions of the urine, ascer- 
taining by measurement the quantity passed in twenty-four hours, and 
its specific gravity as tested by the urinometer, will answer for ordinary 
practical purposes. The chemical tests for the presence of sugar and 
means of quantitative analysis are given in the special works on the 
subject of urine analysis, to which the reader is referred. 
To relieve the kidneys of their burden of work, the skin should be 
kept as active as possible by warm baths and frictions; and hot-air 
baths are often preferable. Cases are related of complete cures ap- 
parently affected by hot-air baths daily taken for a long time. 
Great care should be exercised to prevent exposure ; flannel should 
be worn next the skin, and all necessary means should be used to pre- 
vent the blood from being driven from the surface to internal organs. 
The cold bath has been recommended by some, but it should not be 
used unless a speedy reaction is certain ; and to remain in the water 
for any considerable length of time would be dangerous. Cases have 
been known to result fatally at an early stage of the disease after a 
protracted cold bath. 
Many medicinal agents have been employed, and cures have been 
reported as resulting ; but the articles are so various and the failures 
so common that but little confidence can be placed in any of them. 
It was stated that alkalies—soda and potash—injected into the por- 
tal vessels and carried into the liver of animals, prevented the conver- 
sion of glycogen into sugar, and before this was known, alkalies were 
administered as the result of the experience of their good effects. 
They usually lessen the amount of sugar. The bicarbonate of soda is 
recommended in doses of half an ounce in the course of the day, or as 
much as the stomach will bear. Combined with some bitter tonic 
larger doses will generally be borne, but the larger quantity mentioned 
will not always be tolerated long. The alkaline and saline waters of 
Vichy, or Eins, or Carlsbad, in Europe, are generally recommended 
with a course of bathing at these watering-places ; and patients very 
generally improve for a time, and sometimes permanently, by the 
courses there pursued. 
As the nervous system has much to do in the production of the 
disease, a soothing anodyne influence upon it often mitigates the 
severity of the symptoms. The two medicinal agents which, accord- 
ing to my observation, have most effect in diminishing the quantity TREATMENT. 
505 
of sugar and staving the progress of the disease, are the alkalies and 
opium. There are objections to their continued use, and particularly 
to opium ; hut it often stays the progress of the disease, and besides, 
in some cases, the sufferings from the perversions of the nervous system 
are so great as to justify its being prescribed, though a habit in its use 
be established. An occasional dose, a Dover’s powder at night, will 
often procure rest, induce action of the skin, and be of decided service 
temporarily ; but for the purpose of influencing materially the pro- 
duction of sugar and the course of the disease, the opium must be 
given in regularly repeated doses from one to three times a day. 
When there is pain to be relieved, and the medicine is long continued 
in order to keep up its anodyne effects, the dose, unfortunately, has to 
be increased, and the habit of opium-taking, one of the most inveterate 
of the narcotic-taking habits, is in danger of being established. This 
must be taken into the account. But in a case that is comparatively 
hopeless of recovery, or of a long continuance of life, that life may be 
prolonged and made much more comfortable by the drug. Where 
permanent improvement takes place and there is hope of cure, the 
physician must keep the control of this powerful agent for good or 
evil in his own hands, so as to have it discontinued when no longer 
needed. Other anodyne and narcotic substances may be useful for 
similar purposes. Conium maculatum, cannabis Indica, belladonna, 
and hydrocyanic acid are among the articles that have been used. 
When the stomach is irritable and vomiting is frequent, hydrocyanic 
acid is often particularly useful. When the pneumogastric nerves are 
supposed tube in fault, conium is thought to be indicated. In general 
cerebral irritation bromide of potassium deserves a trial. When the 
disease is chiefly from excess of formation of sugar from starchy and 
saccharine food, and the tissues are less preyed upon and assimilation 
less affected, the case is more hopeful. An animal diet, with the 
auxiliary aid from medicines, may then produce much effect. 
As dyspeptic symptoms are often present, they should receive at- 
tention and treatment according to their character. Constipation if 
present should be relieved, and any special symptoms should be palli- 
ated as they arise. For these purposes, as debility is so prominent a 
feature, tonics are not unfrequently required. Iron, quinine, strych- 
nine, phosphorus, ext. malt, cod-liver oil, pepsin, etc., may be useful 
for fulfilling various indications. 
When defective assimilation is a prominent condition, the nerve 
tonics may bo tried. Strychnia, phosphoric acid, the citrate, iodide, 
and bromide of iron would be suggested. Peroxide of hydrogen, 
ozonic ether, and electricity have been suggested and used, sometimes 
perhaps with benefit. 506 
DIABETES MELLITUS. 
Experimental treatment has been largely indulged in, and may be 
justifiable in a disease usually so persistent and fatal. 
Various articles, with the hope of producing some specific effects 
upon the disease, have been recommended, tried, and have fallen into 
disuse. 
Lactic acid as freely as the stomach will bear has been recom- 
mended by some Italian physicians, and was said to be very efficient; 
but its reputation has not been confirmed. 
Bakers’ yeast, in table-spoonful doses three or four times a day, has 
been used, and sometimes with decided temporary benefit. Ferment- 
ing cider, rennet, and milk just turning sour have also been advised. 
It has been supposed that these fermenting substances favored the 
conversion of glucose into lactic acid, and thus prevented the forma- 
tion of sugar. These, like some of the other remedies, are more ap- 
plicable where the chief difficulty is in the increased production of 
sugar, but would have little or no influence upon defects of assimila- 
tion. Indeed, abstaining from a vegetable diet may be quite ineffi- 
cient where the chief fault is in assimilation. In many cases where 
the sugar is diminished the disease is not cured, and sometimes the 
patient runs down faster from the restriction of the diet. In such 
cases the restoration of the ordinary diet, with a due admixture of 
animal and vegetable food may be demanded. Schultzen, as reported 
by Jaccoud, gave fifty grammes per day of pure glycerine, with alleged 
favorable results. 
His formula is : 
Pure Glycerine 50 
Lactic Acid 5 
Spring Water 100 
M. 
To be taken during tlie day. 
Others have increased the quantity to one hundred grammes, and 
as reported with still better results. 
Salicylic acid is said to have an influence in checking the forma- 
tion of sugar, and glycerine is the best medium for its administration 
in diabetes. A drachm of glycerine dissolves five grains of the acid. 
It may be given of that strength or weaker. 
For the “fat embolism ” no remedy has been suggested, and evi- 
dently nothing can be done but to keep in action the functions of the 
heart and lungs as long as possible. We are in the dark as to any 
measures for preventing the fatty changes of the blood, which are the 
cause of these sudden deaths which sometimes though rarely occur. TREA TMENT—PHENOMENA. 
507 
For the dependent or intercurrent conditions, such as local inflam- 
mations, wasting of the lungs, etc., the treatment*may require to be 
varied. 
Diabetes i3 not to be treated by its name, nor all cases in the same 
way, but according to their special requirements and the best lights 
that wc possess. 
It is fortunate that a disease so little under the control of remedies 
is so rare in occurrence. 
DIABETES INSIPIDUS. 
EXCESSIVE URINARY SECRETION 
Simple polyuria or hydruria or diuresis is a symptom which may 
accompany different conditions. In various states of nervous excite- 
ment, in hysteria, and under the influence of diuretic substances, 
large quantities of urine may pass; but these conditions, which are 
usually temporary, do not constitute the individual affection desig- 
nated by the term at the head of this article. In certain diseases of the 
kidneys—in some stages and some cases of Bright’s disease an in- 
creased flow of urine occurs, but this does not constitute the disease 
in question. 
This affection exists when there is a notable persistent increase in 
the quantity of urine, the specific gravity being very low, and when 
neither albumen nor renal casts are present, and when there is no 
other distinct recognized disease, either of the kidneys or other or- 
gans, upon which it depends. 
The quantity of urine passed varies much in different cases, but it 
may be ten or twenty times as much as the normal. 
In such a loss of water from the system there is thirst, but 
whether the thirst and the free drinking are the consequences of the 
hydruria, or its cause, it is not always easy to determine. The urine 
when in such immense quantities has not more solid matter in it 
often than common spring water, being sometimes of a specific gravity 
of not more than 1.002 ; and cases have been reported where patients 
have drank their own urine in large quantities, when common wrater 
was not readilyT obtainable. , 
In some cases of this affection there are no other symptoms than 
the diuresis and thirst, and the only suffering is from the inconven- 
ience of drinking so much, and voiding the urine so frequently. 
The danger in these cases is from the cerebral and kidney lesions 
which sometimes occur as causes, consequences, or concomitants of the 
affection. The disease is, however, obstinate, and left to itself usually 508 
DIABETES INSIPIDUS—DROPSY. 
persists until the patient succumbs, not so much from the diuresis, as 
from the other pathological states likely to appear. 
Not many opportunities have been presented for examining post- 
mortem changes, but various morbid conditions of the brain and 
sympathetic ganglia and of the kidneys have been found. Inflam- 
matory and degenerative changes have been found in the fourth 
ventricle; and tumors, syphilitic;, tuberculous, and others, have been 
observed in this region and in the cerebellum. Degeneration of the 
solar plexus has also been seen ; but the precise relation of these 
changes with the disease has not been ascertained. The kidneys have 
been found enlarged and hyperaemic, though sometimes the only 
change noticeable is dilatation of the tubules. 
Diagnosis.—Diabetes insipidus is distinguished from D. melli- 
tus by the absence of sugar in the urine and its light specific gravity, 
and from simple temporary diuresis by its persistence. 
Treatment.—In the treatment of the disease, as the special con- 
dition leading to the symptom is believed to be an abnormal dilata- 
tion of the renal vessels, the use of ergot and astringents with a view 
of causing contraction of these vessels is rationally indicated; and 
various cases have been reported as successfully treated by ergot, in 
doses of a drachm gradually increased to two drachms of the fluid 
extract, three times a day, continued for several weeks. 
Gallic acid, in doses of grs. xv three times a day, and valerian in 
large doses, have also been reported to be successful. A German 
physician has reported success with the use of a constant current of 
electricity employed along the spinal column and renal region. 
When of syphilitic origin, the antisyphilitic treatment with iodides 
and mercury will often be promptly successful. Jaborandi or pilocar- 
pin has been successful in some cases, and is worthy of a trial. The 
remedies to be selected from are iodide of potassium, ergot or 
ergotine, jaborandi or pilocarpin, and galvanism. 
Warm clothing should be used, and a warm climate is preferable. 
The general condition of the patient and the associated difficul- 
ties should of course receive attention. 
DROPSY. 
This is an accumulation of serous fluid in the tissues or cavities 
of the body outside of the blood-vessels and lymphatics, aud though 
not an original disease of itself, but a symptom of other pathological 
conditions, those conditions are so various, and this symptom is so 
distinctive, that it is entitled to a brief separate consideration. I) I A GNOSIS—ETIOL OGY. 
509 
When a dropsical fluid is effused generally throughout the common 
areolar tissue it is called (Jeneral Anasarca. AY hen it occurs more 
locally in the same tissue or in any particular organ, as of the lungs, 
it is called (Edema. AVhen effused in the peritoneal cavity it is called 
Ascites; when in the pleural cavity it is called Hydrothorax; in 
the pericardium, Ilydropericardium ; in the ventricles of the brain or 
between its membranes, Hydrocephalus ; in the tunica vaginalis testis, 
Hydrocele ; in the joints, Hydroarticuli, etc. When diffused more 
or less over the system it is said to be general ; and when affecting 
particular cavities or parts it is called local dropsy. Dropsical fluid 
thus effused consists of the serum of the blood, more or less altered 
in different cases ; but it contains albumen, salts, especially common 
salt, quite abundantly, and sometimes urea ; and when connected with 
inflammation, fibrine is often present, and coagulated flocculi are 
seen ; and it may contain corpuscles from the tissues, elements from 
the blood, cholesterine, and other substances. 
Diagnosis.—It is distinguished by the enlargement it causes, by 
the fluctuation which may be felt when in cavities, by pitting when 
in the external areolar tissue, and by the changed functions of various 
organs from the pressure and obstructions produced. In the chest it 
may be discovered by physical signs. 
Etiology.—Dropsy immediately depends upon mechanical ob- 
struction to the flow of blood along the veins, or upon the presence 
of irritative or inflammatory processes, or upon some morbid con- 
dition of the blood or blood-vessels, or upon some obstructive disease 
of the lymphatic vessels or glands ; upon too great pressure within 
the vessels, or upon some condition which modifies the normal 
osmosis, causing too much of the serum of the blood to pass out- 
wardly through the coats of the vessels. 
The more remote causes, which produce the particular conditions 
resulting in these effusions, are valvular or other diseases of the heart, 
obstructing the general circulation and causing greater internal pres- 
sure upon the venous system ; or more rarely by obstructed circulation 
through the lungs producing a similar effect ; or it may be caused by 
diseases of the kidneys which prevent a proper elimination of fluid 
and other materials from them, and thus cause accumulations in the 
blood and produce pressure and irritations resulting in effusions. In 
all these cases the dropsy is likely to be general. A general dropsy 
also occurs when the blood is so thin and watery that its density 
becomes lower than materials outside of the vessels, inducing exos- 
mosis from them. 
A more local peritoneal dropsy is produced by obstructed circula- 
tion through the liver, causing much congestion of the portal vessels; 510 
DROPSY. 
and other local dropsies are caused by obstruction of the veins or lym- 
phatics from any particular part by pressure or other causes; and 
dropsical effusions may be caused by irritation of the secreting sur- 
faces and tissues concerned. In many cases of dropsy there is a com- 
bination of causes. Should there be obstructed circulation, as through 
the lungs, or heart, or in the general capillary system, with an im- 
poverished state of the blood changing its osmotic relations, dropsy 
would be the more readily and extensively produced; and if to this 
were added deficient action of the kidneys or the drinking of larger 
quantities of fluid than could be eliminated by the emunctories, the 
dropsical condition would be still further increased. 
A local irritation or obstruction added to a general cause will often 
produce large accumulations of fluid in particular parts or cavities; 
thus, in diseases of the heart or kidneys, or in conditions of spanaemia, 
a slight pleurisy will cause effusion in one side of the chest; or, in 
these general conditions, obstruction of portal circulation by a nutmeg 
liver, etc., will cause a special peritoneal dropsy with but little effusion 
elsewhere. 
Disease of the kidneys is capable of producing dropsy in several 
different ways, viz., 1st. By failing to carry off sufficient water from 
the blood, thus increasing its bulk and pressure, diminishing its den- 
sity, and increasing its disposition to exosmosis; 2d. By failure to 
eliminate sufficient urea, leaving it in the blood to irritate the serous 
tissues ; 3d. By carrying albumen out of the blood, and thus impover- 
ishing it and further diminishing its density ; and, 4th. By obstruct- 
ing the circulation of blood through the kidneys, and thus producing 
arterial congestion and increasing arterial blood pressure. The man- 
ner in which venous and lymphatic obstructions produce dropsy is 
sufficiently obvious, and the manner in which local irritations and 
inflammations cause serous effusions has been already explained. 
Treatment.—The course and treatment of dropsy will depend 
upon its cause, or upon the character of the disease of which it is a 
symptom. 
As a rule, aside from mechanical methods—tapping, aspiration, 
and punctures—the most efficient means of ridding the system of the 
accumulated fluid is by the administration of hydrogogue cathartics. 
The use of diuretics, when the kidneys are not so diseased as to render 
them inadmissible or inefficient, is another method of removing the 
dropsy ; and the administration of diaphoretics still another. Cathar- 
tics, however, are more certain in their operation than either of the 
other class of remedies, though the hydrogogue diuretics, as juniper, 
broom, digitalis, squills, etc., especially in cardiac dropsy, are often 
very efficient; and sometimes when they fail to produce the proper TEE A TMENT—DEFINITION. 
511 
effects given by the mouth, fomentations of digitalis over the loins, or 
a liniment of one part each of tincture of digitalis, tinct. of squills, 
and tinct. of iodine, with two parts of soap liniment, applied freely to 
the abdomen and thighs with friction, will produce more diuretic 
effects. 
The jaborandi, or its active principle pilocarpin, generally operates 
very powerfully as a diaphoretic, carrying off large quantities of fluid, 
and, in cases of acute renal dropsy, is frequently an exceedingly efficient 
remedy. 
The more particular treatment of dropsy as a symptom of differ- 
ent forms of disease, will be described in connection with the diseases 
in which it occurs. 
GOUT.—PODAGRA. 
Gout and rheumatism are often associated together by writers as 
allied affections, and placed as local diseases under the head of dis- 
eases of the locomotor apparatus. They, however, affect other parts 
than those connected with locomotion, and depend upon conditions 
of the blood and of the assimilative processes, which are general rather 
than local in their seat and character, entitling them to be classed 
with the general rather than the local diseases. Though these two 
affections have features resembling each other, they differ markedly 
in other respects, in cause, pathology, and phenomena, and require a 
separate consideration. 
Gout, a common disease in England, but comparatively rare in 
this country, and particularly so in the West, is divided by some 
authors into regular and irregular varieties. 
Regular gout has been defined a specific form of articular inflam- 
mation, invariably accompanied with uric acid in the blood and the 
deposit of urate of soda in the tissues. 
Irregular gout is the same specific inflammation in non-articular 
tissues, or a disturbance of the functions of various organs, as the 
stomach, heart, etc., accompanied with the same abnormal state of 
the blood, and the same general diathesis of the system. Gout is 
also divided into entonic and atonic, or sthenic and asthenic, and the 
terms retrocedent and misplaced are applied to irregular cases where 
other parts than the joints are either secondarily or primarily affected. 
Regular gout, as already indicated, attacks a joint—the smaller 
joints usually—and there remains until the attack abates, the consti- 
tutional symptoms corresponding with the amount of local trouble, 
and disappearing as the local manifestation disappears. Retrocedent 
gout is where the inflammation and pain leave the external part and 512 
GOUT. 
involve internal organs; while misplaced gout is where the gouty 
inflammation affects internal organs from the beginning of the attack, 
producing various changes of function, sometimes of a very severe 
character. Entonic or sthenic gout is where the local inflammation 
is attended by fever, and increased force of vascular action. Atonic 
or asthenic, is where the force of action is below the natural standard, 
where there is less pain and inflammation of the joint and neighbor- 
ing parts, but yet a large degree, often, of general disturbance, depres- 
sion, and danger. 
A paroxysm of regular gout usually begins with a swelling of the 
ball of the great toe, which becomes exceedingly tender, red, glossy, 
painful, and tense ; the vessels are all filled, the arteries throbbing, 
and the part hot. The pain extends up the foot, motion of the part 
becomes difficult or impossible, and the patient is confined to his 
couch or his chair. There is a feeling of weakness and numbness of 
the part, as well as of pain. A feverish excitement accompanies these 
acute attacks; there is general elevation of temperature, thirst, loss 
or impairment of appetite, a rapid pulse, furred tongue, etc.; and 
these symptoms bear a close relation to the number of joints impli- 
cated, and to the intensity of the inflammation. The fever thus 
appears to be secondary, and dependent upon the inflammation of the 
joints. 
Though the pain is usually severe, in exceptional cases it may 
be slight or nearly absent. Though the small joints, and especially 
those of the toes, are much the most frequently affected, particularly 
in the earlier attacks, yet in time the large joints are often involved 
as well—least frequently, however, the largest—the hips and shoulders. 
After a few days the pain, swelling (which is largely oedematous), 
and fever abate, and before long disappear, without the occurrence of 
suppuration, and an interval of absence of symptoms is enjoyed—it 
may be a long one at first, but it is usually shorter afterward, and 
each succeeding fit is apt to be prolonged. Other joints than those 
at first affected become involved : the fingers, knuckles, wrists, ankles, 
knees, etc.; and as the disease progresses and becomes confirmed, 
deposits take place and permanent irregular enlargements about the 
joints occur, producing stiffening and even anchylosis. 
The kidneys have deposits in them, and are more or less seriously 
diseased, and the life of the patient is often rendered a burden to 
himself, and his irritability is apt to make it so to others. 
In retrocedent and misplaced gout the symptoms will depend 
upon the parts attacked. When the brain is involved, there will be 
nervous and often mental aberrations—pain, delirium, insanity, pos- 
sibly convulsions, and not unfrequentlv coma and death. S YMPTOMS-ETIOL OGY. 
513 
If the stomach be the seat, there will be gastric distress and great 
depression. If the lungs, there will be dyspnoea, pain, etc., in the 
chest; and when the heart is involved, there will be irregular, violent, 
or feeble pulsations, great distress and anxiety, and not unfrequently 
asthenia or syncope and death. 
Gouty attacks are often preceded by premonitory symptoms, such 
as derangements of digestion, cardialgia, coated tongue, a “erampy” 
state of the muscles, palpitation of the heart, asthmatic respiration, 
nervous irritation and depression, scanty and high-colored urine, etc. 
In other cases unusually good health and spirits may precede an attack 
—an apparent physiological excitement, to be followed by an explosion 
of gouty symptoms. 
In this disease the conditions of the blood are changed; and in 
chronic cases what are called chalk stones are found about the joints, 
upon the cartilages of the external ear, and elsewdiere, consisting of urate 
of soda ; and crystals of this salt are deposited in the articular surfaces 
of the joints, within or external to the tubuli uriniferi of the kidneys, 
and the secreting apparatus of these organs is injured. A shriveled, 
or what has received the name of “gouty kidney,” is frequently met 
with, and Dr. Garrod, whose authority on the subject of gout is of the 
highest character, is of the opinion that these changes are due to the 
deposits of urate of soda in their substance. Indeed his investiga- 
tions tend to show that the presence of urate of soda in the blood and 
in the tissues accounts for all the phenomena of the different forms of 
gout. Dr. Gairdner, of Glasgow University, whose opinions are 
always worthy of consideration, thinks that a state of plethora of the 
chyloidic organs and a general venous congestion are essential to the 
formation of the gouty diathesis, and are always present. 
Whatever other conditions may be present, there can be no doubt 
that uric acid and urate of soda in the system play an exceedingly 
important part in the production of the gouty phenomena. The de- 
posits of urate of soda are particularly liable to take place in parts re- 
mote from a current of blood, and hence they are found in the fibrous 
and cartilaginous structures of the joints. Dr. Garrod states that 
they are not found in the endocardium, as rheumatic deposits are, be- 
cause of the proximity of the blood flow ; but these deposits take 
place in the kidneys as often as elsewdiere, and the tissue of this organ 
certainly cannot be regarded as remote from a current of blood. 
Etiology.—Some of the causes of gout are dependent on the con- 
ditions of the system, and others upon extraneous influences. 
There can be no doubt that heredity has a decided effect in the 
production of gout. Gout in the offspring may not be of the same 
character as in the parent ; and an hereditary gouty tendency may 514 
GOUT. 
give a coloring and character to rheumatism, neuralgias, and dyspep- 
sias, rendering those affections more responsive to the remedial power 
of colchicnm and other remedies specially useful in gout. 
Gout is more frequent in men than in women, and in advanced 
more than in early life. The extraneous causes producing it are more 
likely to he present in men than in women, and in middle or advanced 
life than in youth; and the periodical fluxes of women tend to elimi- 
nate injurious materials and reduce plethora. After the menopause 
women are more subject to gout than before that event. 
The chief cause of gout, independent of the peculiarity of the 
system, is universally considered to be the use of alcoholic beverages. 
Pure alcohol or distilled spirits have less influence than the mixt- 
ure of alcohol with other ingredients in wine and beer ; but the 
stronger these articles are in alcohol, the greater is their effect in 
producing the disease. Says Dr. Garrod, “Alcohol, when in combi- 
nation with other substances, as in wines and malt liquors, becomes a 
potent cause of gout, and the greater the amount of spirits contained 
in such beverages, the more powerful their influence in producing the 
disease.” 
It is not known what particular ingredient in the wine imparts to 
the alcohol the quality of inducing the gout. It seems not to be the 
acid or the sugar; for, says Garrod, “the wines the least acjd and the 
liquors the least sweet are among the most baleful.” An excess of 
food, especially animal food, and this in connection with want of 
active bodily labor, contributes to the production of this malady. 
Rich made dishes, and all articles tending to induce indigestion may 
predispose to gout, and they certainly often derange the stomach and 
excite an attack in those predisposed to the disease. Indigestion, 
which causes an increased amount of acidity in the system, aids in the 
development of gout, causing a less alkaline condition of the blood, 
and hence favoring the insolubility and deposit of the urate of soda 
in the tissues ; and it may act by promoting the formation of uric acid 
itself. 
Nervous depression and shock tend to bring on attacks, and severe 
mental labor has a similar effect. 
Gout is less prevalent in the hot season than in the cold and tem- 
perate, and it abounds more in cold climates than in warm; but it is 
thought that more depends upon the habits of the people, upon the 
beverages they use, than upon the climate they inhabit. There is no 
gout in the central parts of Africa ; but neither are there the wines 
that are believed to cause it in Europe and elsewhere. The poison- 
ous effects of lead are manifested more readily in gouty patients than 
in others. The common opinion that gout is produced by high liv- D1A GNOSIS—PROGNOSIS. 
515 
ing, sluggish bodily habits, and indulgence in wine, is fully sustained 
by accurate observation. 
Diagnosis.—The diagnosis depends upon the character and seat 
of the local affection and upon the general state and symptoms. Gout 
has a peculiar preference for small joints, especially for the ball of 
the great toe, in its first invasion ; and the pain in a decided attack is 
usually very severe. The attacks are likely to occur at somewhat 
regular intervals, with periods of comparative exemption ; but when 
urate of soda is freely deposited in the tissues of the joints, there will 
be more or less pain, tenderness, and interference with the functions 
of the parts more constantly. The diseases with which it is most 
likely to be confounded are arthritis deformans or rheumatoid 
arthritis, chronic rheumatism, and in the irregular or misplaced 
varieties, common inflammation of internal organs. There may also 
be obscurity in cases of lead poisoning occurring in gouty patients. 
Indeed these two latter conditions are not unfrequently combined. 
The poisoning from lead not only occurs more readily in gouty 
persons, but the lead diminishes the excretion of uric acid and causes 
its accumulation in the blood, and this it is thought may produce 
attacks of gout. 
Arthritis deformans is steady and progressive in its course—does 
not come on in paroxysms, occurs among the poorly nourished, and 
is not accompanied by deposits of urate of soda. 
Chronic Rheumatism affects as often the larger joints, and the 
aponeurotic and muscular tissues ; there is an absence of the acute 
gouty paroxysms and of the urate of soda deposits. 
Misplaced gout occurs in persons subject to the ordinary forms of 
the disease, and the internal inflammations differ in their phenomena 
and course from common phlegmasias. 
Prognosis.—The prognosis of regular entonic gout is very 
favorable as to recovery from the attack, but by no means so favorable 
as to future exemption from the disease. In irregular and atonic 
gout the prognosis is much more unfavorable ; and where the stomach, 
the heart, or the brain is affected death may suddenly result. 
After one well-marked attack, without treatment or change of 
habits, the disease is almost sure to return ; and it may be added that 
its continuance in a chronic form not only renders life miserable, but 
tends to shorten its duration. If it attacks very young subjects, the 
prospect is bad—the older the person when the first attack occurs the 
more favorable. Hereditary cases are less tractable than the acquired. 
The appearance of chalk stones at the surface, even if confined to the 
helix of the ear, is an indication of internal deposits of urate of soda, 
and of a confirmed and obstinate case ; and all gouty persons are liable 516 
GOUT. 
to suffer more from accidents and exposure than the majority of 
other persons ; and the more the kidneys are implicated the less 
able are gouty subjects to withstand the effects of shock upon the 
system. 
A single fit of gout, however slight, should be received as a warn- 
ing that the patient cannot go on with his present mode of life with 
impunity; but that in most cases with a proper regimen and medicinal 
treatment he may be saved from the life of increasing suffering which 
may otherwise be expected. 
The Pathological Anatomy of gout will be inferred from what 
has already been stated of its phenomena. The articular surfaces of 
the affected joints are found covered with a whitish deposit, consisting 
of bundles of crystals of urate of soda, usually radiating from a centre. 
The joints most affected contain the greater amount of this material; 
and as the disease is more frequent in the smaller joints, these deposits 
are more marked in them, but are also found in the larger joints, 
and sometimes in the bones themselves. Thickening of tissues con- 
nected with the joints, produced by the inflammatory hyperplasias 
excited by these deposits and mingling with them, are also found, and 
in some old cases masses of urate of soda of various sizes are present, 
constituting the “ chalk stone” mentioned. The blood contains 
urate of soda, and uric acid is frequently present in the perspiration, 
and in the fluid found in serous cavities. 
Of changes in the internal organs the “ gouty kidney ” is most 
frequent. The kidneys are small, granular, and fibrous, and crystals 
of urate of soda are deposited in the tubules and intertubular tissues 
in such abundance that they may often be seen by the naked eye as 
white lines through its substance. 
Atheromatous and calcareous changes in the coats of the blood- 
vessels are very common in old gouty subjects. 
Treatment.—The treatment of gout is naturally divided into 
that of the paroxysm of the regular fit; that of management during 
the interval, with reference to preventing recurrence and removing 
the gouty habit; and the treatment of the irregular forms and the 
complications that may occur. 
The first question will be as to the necessity of treating a regular 
fit of gout at all. Some moderate cases will subside in a few days if 
the patient is careful of his diet; but if he lives in his usual high mode 
the attack will commonly be prolonged, often for weeks or months, 
with perhaps slight remissions, until strength and appetite fail, and an 
altered diet is enforced ; the paroxysm will then be exhausted. Dr. 
Garrod says the disease generally lasts long under infinitesimal doses. 
As a rule, then, treatment of the fit is useful. Considering the cause TREATMENT. 
517 
of gout and its painful phenomena, the treatment, we would infer, 
should be eliminative and soothing. 
Direct depletion with the lancet is very seldom necessary, and 
never except to relieve general symptoms. In vigorous plethoric sub- 
jects it may be useful for that purpose. Leeching near the inflamed 
part may produce some relief of the local symptoms when the pain is 
great. 
Purgatives in some form, to eliminate accumulations of effete 
matters, the result of repletion, are generally required; and diuretics 
and diaphoretics are indicated for the same general purpose. 
Opium diminishes some of the secretions, but it allays irritation so 
much, and relieves pain so decidedly, that, properly combined and 
timed so as not to check secretions or interfere with elimination, it is 
at least a great comfort, and is often much more. 
Oolchicum, however, is the great remedy in gout. It is regarded 
by many as a specific, and is undoubtedly the most frequently and the 
most decidedly useful remedy we possess. It sometimes, however, 
fails. 
When given in sufficient doses it acts slowly, but at length 
efficiently, as a purgative ; in the meantime, or in smaller doses, it 
increases notably the solid constituents of the urine, organic and inor- 
ganic, thus effecting elimination ; and besides, it has a peculiar effect 
upon the nervous sensibility directly, and by its sedative and anodyne 
influence it lessens notably the pain and allays the general symptoms. 
It is apt to cause nausea, but this is more endurable than the extreme 
pain, and this unpleasant effect may often be avoided or rendered 
transient. 
The wine of colchicum, prepared from the fresh root, is the best 
form. As colchicum in the market is chiefly produced in England, 
and as the root when dried loses much of its virtues, the wine prepared 
and imported from England is by far the most reliable preparation. 
Of that prepared in this country the wine of the seed is perhaps best. 
The strength is apt to vary as ordinarily obtained from the shops. Of 
a good specimen the dose is from ten to fifteen drops to 3ss. Of some 
preparations from one to two drachms will be required, and it may be 
repeated once in from three to eight hours. The active principle, 
colchicia, is said to be preferable to the crude drug. “It may be 
given advantageously with quinine, morphia, and compound ext. of 
colocynth.” (Bartholow.) 
Dr. Garrod gives colchicum in large doses, generally at his first visit. 
He says it often procures relief from pain very speedily, from its 
neurotic effect, without or before its eliminative operation. Its action 
is peculiar. It does eliminate from the kidneys ; but it appears also to 518 
GOUT. 
arrest the formation of uric acid in the system, and this leads to a 
diminution of urates in the urine. This effect being observed, has 
led to doubts as to its eliminative action ; but it is generally regarded 
as having a diuretic as well as a cathartic effect : but whatever the 
mode of its operation, its relieving effect upon the gouty condition is 
unquestionable, and its use is strongly indicated. It should generally 
be continued for some time, or until relief is procured to the pain 
and the other inflammatory and febrile symptoms. 
Some advise purgative doses of the sulphate and carbonate of 
magnesia with the colchicum, preceded by a blue pill, or by a dose of 
calomel orpodophyllin or colocynth—or by the mercurial in small and 
repeated doses. Podophyllin combined with soda or euonymin may 
serve as a substitute for the mercurial, especially where an idiosyn- 
crasy forbids it use. Saline diuretics may accompany or follow the 
use of the colchicum, thus increasing elimination. 
Salicylates have recently been employed in the same manner as in 
rheumatisms in the acute fits of gout, and the relief from them is said 
to be quite remarkable. 
Locally the painful part may be wrapped in carded cotton and 
covered completely with oiled silk, thus excluding the air and sudden 
changes of temperature. Anodyne applications may be made—such 
as preparations of belladonna and opium, atropia and morphine. 
As an example, If Atropia, gr. j ; Hydrochlorate of Morphia, grs. 
viij ; Water and Proof Spirits, aa 3ss. M. Apply with small pieces of 
lint, with oil silk over, and surround the whole by cotton batting. 
Where the swelling is great, and the case acute, leeches in the neigh- 
borhood procure relief; and blisters applied not too near the joint 
are always safe, often checking the progress of the disease and pro- 
curing immediate relief. 
The treatment during the interval with reference to avoiding a 
return, must consist first and chiefly in the correction of those habits 
which are the cause of the disease. A plain, simple diet, with but 
spare quantities of animal food must be adopted, and all alcoholics, 
and especially wine and malt liquors, must be avoided. As some 
gouty persons are apparently in good health during the interval of 
the paroxysms, this change of the dietary with them, together with 
the taking of active exercise—performing bodily work or regular 
walking, etc.—may be all that will be required. 
Others suffer during the interval with various disorders of the 
digestive functions ; with disturbed rest, irregular action of the 
heart; with cough, hemorrhoids, disturbed functions of the brain, 
irritable temper, giddiness, impaired vision, etc., indicating the mor- 
bid condition of the blood and the tissues, the presence of urate of TREATMENT. 
519 
soda and other effete and irritating matters in the system, and changes 
in the 'vascular and tissue actions. These symptoms should receive 
attention and treatment according to their character. The urine 
should be carefully examined, and its indications observed and fol- 
lowed. 
Lithic or uric acid, and the lithates or urates, usually abound. 
For this state the alkalies are usually recommended, and there can be 
no question that they are often useful. Potash and soda, or their car- 
bonates or salts with organic acids, are eliminative and chemically 
corrective of the acidity. A course of gentle saline purgatives, as a 
few drachms of sulphate of soda early each morning in a free drink 
of warm water, or some natural saline mineral water, etc., is often 
useful. As a means of elimination, both by the kidneys and the skin, 
the free internal use of water should not be overlooked. The benefi- 
cial effects of the natural mineral waters, saline and alkaline, depend 
largely upon the free quantity of the water taken ; and in ordering 
salines as eliminatives, they should generally be given in free quanti- 
ties of water. When large quantities of fluids are taken, they pass 
out of the system chiefly by the kidneys and skin; and in doing so 
they carry with them in solution more freely the materials to be 
removed. In Europe the waters of Vichy, Carlsbad, Wiesbaden, etc., 
are recommended, and, with the regimen prescribed at the same time, 
are often very useful. In this country the Vichy and other springs 
of Saratoga, the alkaline waters of Wisconsin, St. Catherines, Canada, 
the warm springs of Virginia, and the Hot Springs of Arkansas, and 
others of similar character, are useful. 
Oxalate of lime will sometimes be found in the urine. Then the 
nitro-hydrochloric acid will be indicated. Indeed, for remedying the 
lithiasis, this mineral acid, by promoting oxidation in the system, or 
by effecting some other change, often does more than the alkaline 
remedies. The latter are more palliative than radical. They neu- 
tralize the acidity present, but they may not prevent its production. 
The mineral acids, on the contrary, while they do not neutralize 
acidity, tend, by improving digestion and assimilation, to prevent its 
production. 
The salts of lithia have also been advised. They are said to 
increase the excretion of uric acid, and are thought to promote the 
solution and removal of urate of soda from the tissues. The citrate 
of lithia is the form commonly used. The phosphate of soda, and 
especially the phosphate of soda and ammonia—the latter in doses of 
ten or fifteen grains three times a day—are likely to be useful. 
Laxatives and tonics are in some cases required, and the tinct. of 
guaiacum combines these qualities, and is often serviceable. Dr. 520 
GOUT. 
Harley, of London, whose authority as an investigator and observer 
is high, affirms that quinine diminishes the production of uric acid 
in the system, and as its tonic properties are well known, when given 
in the proper moderate doses, there may be a double indication for 
its use. Both guaiacum and quinine may be continued a long time, 
if needed, without harm. In the chronic and atonic varieties, these 
articles are particularly indicated. Guaiacum may be given for a 
whole year. 
Gout often requires anodynes ; and, in cases of great depression, in 
the misplaced varieties especially, it may require, temporarily, stimu- 
lants. In some cases tinct. of opium may be required in large quan- 
tities, with ether, chloroform, spts. of lavender, warm brandy and 
water, ginger tea, etc. 
When the internal organs are affected, active counter-irritants and 
revulsives, such as mustard and hot turpentine applications, may be 
required ; and when there is coldness, external warmth with bottles of 
hot water may be useful. 
In cases of “ suppressed ” gout, where the gouty poison is affecting 
the system, spending its force on internal -organs, without manifest- 
ing the usual external phenomena, the kidneys and skin both being 
inactive, the heart irritable, and the tissues inclined to take on a low 
form of inflammatory change ; or where more violent symptoms of 
internal congestion are present, the jaborandi, or its active princi- 
ple, has already established for itself a reputation. In appropriate 
doses it first induces a temporary free salivation, soon followed by a 
profuse sweating and marked relief to the symptoms. Its efficacy is 
said to be increased by giving in connection large doses of bicarbo- 
nate of soda. In chronic cases colcliicum, in moderate and carefully 
regulated doses, often combined with quinine, may be given for a 
length of time, obtaining its specific effects. 
According to Dr. Garrod, in chronic cases, especially where there 
are nodes, and in neuralgias from inflammations of the coverings of 
the nerves or thickening of these coverings as the result of gouty in- 
flammation, iodide of potassium has much power. In cases where the 
neuralgic pains are worse in the warmth of the bed, the iodide is still 
more efficient. It is also particularly indicated in thickening around 
joints and in effusions in their cavities. If there be a syphilitic com- 
plication, or suspicion of it, the iodide is required in large doses. In 
the atonic cases, iron, quinine, and other tonics should be combined 
with the alterative and eliminative treatment, and a more nourishing 
but still unstimulating diet will be required. When the debility is 
too great to admit of active exercise, passive motion, frictions, mas- 
sage, and faradism, may be resorted to. Although these eliminative, TEE A TMENT—DEFINITIONS 
521 
alterative, and tonic medicines may be of great service, skillfully ad- 
ministered and properly adapted to each case, yet nothing will avail 
in removing the gouty condition but correct hygienic habits, and even 
all will fail where indulgence has gone too far either in the individual 
or his ancestors. Here, as in so many other cases, the physical sins of 
the fathers are visited upon the children to the third and fourth gen- 
eration. 
RHEUMATISM. 
ACUTE RHEUMATISM.—RHEUMATIC FEVER.—ACUTE ARTICULAR 
RHEUMATISM.—ACUTE ARTHRITIC RHEUMATISM. 
The term rheumatism is often used, even by professional men, in 
a loose and inexact manner. Acute rheumatism is a sufficiently well- 
defined disease, hut the terms “rheumatism” and “rheumatic” are 
often applied to nearly all pains which are somewhat more constant 
than those that are called “neuralgia” and “neuralgic,” but which 
are not accompanied by much constitutional disturbance. 
The aches and pains so common in gouty subjects with lithic acid 
in the blood and lithates of soda in the tissues, are popularly and often 
professionally called rheumatic. The darting pains of locomotor 
ataxia, and the periosteal affections of syphilis, arc sometimes called 
by the same name. All myalgias are spoken of as rheumatism, and 
various arthropathies, sciaticas, and “cricks” in the back have this 
appellation given to them. The term may be, as stated by Fothergill, 
a great comfort to those who are diagnostically weak, as it may cover 
a quantity of ignorance and satisfy the patient; but it often gives a 
false sense of security in grave affections, and leads to inefficient or 
wrong methods of treatment. Besides many painful conditions that 
have no claim to even a remote relationship to true rheumatism, there 
are several morbid states that have so great a degree of similarity to 
each other that they are designated as rheumatic by systematic writers. 
These are : 
1. Rheumatic fever, acute inflammatory rheumatism, bearing the 
different names at the head of this article. 
2. Subacute and chronic rheumatism. These forms often follow 
the acute ; but whether so, or whether more chronic from the begin- 
ning, they are of a similar pathological character, and depend, doubt- 
less, on the same specific cause. 
3. Muscular rheumatism. This, in the present opinion of most 
pathologists, should not be regarded as true rheumatism, smce it dif- 
fers from it in its essential cause, its phenomena, and its course. 522 
RHEUMATISM. 
4. Neuralgic rheumatism : is not recognized by all writers as a 
distinct form of rheumatism, but is regarded as the result of disease 
and thickening, probably rheumatic, of the fibrous covering of nerves, 
and consequent irritation and pain, and impaired function in those 
nerves. 
5. Rheumatoid arthritis. Polyarthritis deformans. Nodular 
rheumatism—formerly rheumatic gout, or synovial rheumatism ; now 
generally regarded, like “muscular rheumatism,” as not of the essen- 
tial character of true rheumatism at all. 
6. Gonorrhoeal rheumatism, which is also an affection dependent 
upon another cause, and pathologically distinct from true rheuma- 
tism. 
Acute rheumatism, or inflammatory rheumatic fever, may be de- 
fined a specific inflammation of the white fibrous structures of the 
body, more frequently those about the joints, attended with great 
febrile disturbance ; the inflammation commonly passing from one 
locality to another; not, as in gout, accompanied with deposits of 
urate of soda, and very seldom, if ever, when purely rheumatic, leading 
to suppuration in the tissues around the joints. 
Subacute rheumatism is the same affection as the acute, only 
manifested in a much less intense degree, with far less febrile disturb- 
ance, and generally, though not always, following the acute form of 
the disease. 
Etiology.—Rheumatic inflammation is spontaneous and primary, 
not depending upon traumatic causes, but upon peculiar conditions 
of the fluids and solids of the body ; and doubtless some poison, de- 
veloped by malassimilation in the system, is connected with its cau- 
sation. 
Attacks are frequently excited by exposure to cold and dampness, 
but the disease sometimes comes on when no such exposure has oc- 
curred, and may be induced by a variety of causes which produce 
changes in assimilation and nutrition. While gout appears chiefly 
among the wealthier classes who indulge in luxurious habits, rheuma- 
tism is quite as likely to appear among the poor, especially when they 
live in low and damp situations. Climate, seasons, and habits of the 
people have much to do in disposing to the disease. It is more fre- 
quent in damp and foggy climates, in temperate rather than in tropical 
or arctic regions ; in the changeable weather of spring and autumn, 
rather than in the more steady cold or warmth of winter and sum- 
mer ; and it is thought to be more common among a beer-drinking 
community than in one which abstains from such beverages. The 
conditions in England are very favorable to its production, and there 
it is among the most common of diseases. In England, rheumatism ETIOLOGY—MORBID ANATOMY. 
523 
is said to be much more prevalent in the eastern than in the western 
counties, and the difference is attributed to the influence of the north- 
east winds from the sea, to which the eastern portion of the country 
is much more exposed. 
There are marked differences as to its prevalence in different parts 
of our own extended country ; it is much more frequent, within the 
sphere of my special observation, in the Eastern States, and particu- 
larly in Maine, than in most parts of the West. The rheumatic tend- 
ency seems to be transmissible, though heredity has less influence 
upon it than upon gout. Among the causes connected with the 
individual, an azotized diet is thought to have some influence, and 
depressing passions and emotions are reckoned by some as tending to 
its production. All influences which lessen the force of the organism 
are considered as aiding causes; and yet the disease sometimes appears 
in great force in persons of apparently much vigor. Age has an 
influence in the occurrence of the disease. Where the predisposition 
is inherited it may manifest itself in early life. Where it is acquired 
it commonly appears later, oftenest from the twentieth to the twenty- 
fifth year, and the greater exposure explains its more frequent appear- 
ance in men than women. It is not unfrequent, however, in women. 
Cold acts in two ways in producing attacks ; by sudden action, caus- 
ing in a heated condition of the body a rapid fall of temperature and 
sudden checking of the secretion of the skin, without being followed 
in time by proper reaction ; and by a slower and more gradual action 
such as results from living in damp houses. The first condition is 
likely to precipitate attacks, the other to produce a disposition to the 
disease. Rheumatism may be regarded as self-propagating, as the 
occurrences of the disease appear to dispose the system to subsequent 
attacks; but the relapse does not imply exact similarity in the forms 
of the successive attacks. Thus, chronic attacks may follow acute 
ones, and rheumatic inflammation of the heart or other internal organs 
may succeed to those of the joints. 
Morbid Anafomy.—Anatomically the tissues involved are 
hyperaemic, and during the progress of the disease the fluxion to 
them is often decided ; but structural changes are less than occur in 
most other forms of inflammation with equal severity of symptoms. 
Still some hyperplasias occur, particularly in the subacute and chronic 
forms, and effusions, both serous and plastic, often take place. 
Jaceoud gives in substance the following anatomical conditions : 
1. The peri-cirticular tissues are not modified, or they are tumid 
from serous infiltration of the connective tissue. 
2. Small subcutaneous ecchymoses occasionally are present. 
3. Purulent infiltrations are very exceptional. 524 
RHEUMATISM. 
4. Tendinous sheaths are often intensely inflamed. 
As to the condition of the articular structures themselves : 
1. In the first stage there is simple fluxion. 
2. The traces of active hypereemia disappear after death, and the 
articulation, where the disease does not go beyond the first stage, 
appears normal. This latter fact, he says, has given rise to wrong 
conclusions regarding the character of rheumatic inflammation. 
3. Though fluxion may disappear, its effects may remain in the 
form of serous exudates. 
4. The presence of flaky, opalescent, turbid liquid is sometimes 
found in the joint. 
5. Besides the albumino-fibrinous debris, leucocytes, which he calls 
pus, may be present, even when the fluid gives no evidence of them 
to the naked eye. 
6. The synovial membrane is changed, presenting injection and 
opacity, and its epithelium is broken down ; and there are more exten- 
sive changes in cases of long standing or of unusual severity. In 
these more advanced stages the surface of the joint is unequal, hyper- 
sarcostic, in consequence of an active proliferating change in the 
structure, like that present in acute pleurisy. 
These lesions form an ascending series, from simple fluxion or 
hypersemia to fully developed inflammation. All the joints involved 
are not affected at the same time, and hence post mortem they do not 
all present the same lesions. The disease passes in its course some 
joints, leaving them almost untouched, and slightly, yet more mark- 
edly affecting others, while others still are attacked more severely, 
and the disease may inhere in them to the end. Different from gout, 
the larger joints, those of the knee and shoulder, are those oftenest 
affected. The tendinous sheaths and the bursae are often not changed, 
but they may be inflamed, and their contents may be serum abound- 
ing in leucocytes. The cartilages are rarely changed, yet they may be 
softened and velvety; or their entire substance, in protracted cases, 
may be destroyed, the ends of the bones being exposed. Such cases 
must be exceedingly rare, and possibly when they occur another ele- 
ment than the rheumatic has had to do in the case, as Dr. Garrod 
states that lie has not found such conditions, and has had proof that at 
least a dozen attacks of rheumatic inflammation may occur in a joint 
without any such change taking place. 
The osseous tissue of the epiphyses may be injected, and in rare 
cases of long standing the medullary tissue is the seat of notable 
hyperplasia. 
In monarticular rheumatism the lesions are the same; but when 
the whole force of the disease is expended upon one joint the changes PATHOLOGY. 
525 
are more rapid, and, with the same duration of the disease, the 
appearances are more advanced. The lesions produced by rheumatic 
inflammation, where other organs than the joints are affected, will be 
described under the heads of diseases of the particular organs—of the 
heart, brain, etc. 
The changes in the Hood, as bearing upon the pathology of rheu- 
matism, are of much importance and have long attracted attention, 
but there is not yet uniformity of statement in regard to all of them. 
The name, rheumatism, implies that the disease has been considered 
to be immediately dependent upon some change in the fluids. Though 
one set of pathologists, among them Cullen, and others of more 
recent times, regard the solids as essentially in fault, others believe 
the phenomena to be produced by the presence of some peculiar prin- 
ciple in the blood. It seems to me quite as likely to be in the lymph 
also ; and if a morbid condition of the fluids be the pathological 
cause of the symptoms, there must be either a substance foreign to 
the healthy body, or a modification or increase of some natural ingre- 
dient. 
Dr. Prout was the author of the suggestion that lactic acid was the 
morbid principle, and this has been a common view in the profession. 
Dr. B. W. Bichardson, whose activity in endeavoring to advance 
medical science is so well known, has given some support to this view 
by injecting lactic acid into the peritoneal cavity of dogs, and thereby 
producing peri- and endo-carditis, but the joints of the animals were 
not affected ; a longer series of experiments, with other substances as 
well as with lactic acid, is needed to establish the doctrine that the 
peculiar phenomena of rheumatism are produced by this substance. 
Some have supposed the symptoms to be produced by uric acid, 
though in smaller quantities than are necessary to cause those of 
gout. 
That there is an acid condition of the system in rheumatism must 
be admitted, as the urine, the perspiration, and the fluids of the body 
generally show diminished alkalinity or positive extra-acidity; but 
it is not proved that such acidity is the particular and only cause of 
the phenomena of the disease, and it is exceedingly probable that there 
is some other specific material concerned in their production which 
has not yet been isolated and distinguished. As attacks are so often 
supposed to be produced by exposure to cold, it has been thought 
that retained excretions from the skin exert a causative influence. 
There are, however, certain changes in the blood in rheumatic 
fever and inflammation that are perceptible, whatever relations they 
may bear to the disease, either as causes or consequences. As given 
by Jaccoud they are : 526 
RHEUMATISM. 
1. Excess of uric acid aud lactic acid. 
2. Great increase of fibrine—to several times its normal amount. 
3. Increased coagulability—inopexia. 
4. Diminished density of the serum, and decrease of albumen and 
of the blood corpuscles both white and red. 
5. Increase of extractive matters, of fat and of cholesterine. 
G. The greater the number of joints affected, the more marked will 
be the diminution in the albumen and the globules of the blood. 
These impoverishing processes produce the rheumatic anaemia. 
7. The haematopoietic function of the connective tissues in the 
diseased parts is destroyed. 
8. When rheumatic patients die with brain symptoms, without 
distinguishable lesions, the blood has other characters. There is an 
abnormal fluidity, it stains by infiltration the endocardium, and 
there is an increase in the quantity of urea. 
Autopsies in cases of rheumatism, chronic from the beginning and 
without severe general symptoms, have been rare, and the anatomical 
lesions are less understood. 
In the variety which attacks a single joint, and occasionally one 
other, with but mild symptoms, there are probably no decided lesions. 
In the more intense variety, with recognized lesions during life, there 
is swelling of the synovial membrane and the ligaments, hypertrophy, 
and at times fatty degeneration of the articular soft tissues, erosion 
of the cartilages, in some cases inflammation of the epiphyses, and 
hyperplasia of the medullary tissue. (Husse.) 
Chronic monarthritis, not rheumatic, leads to more profound dis- 
orders, often to fungous arthritis and white swellings. In cases where 
disease is confined to a single joint, there is a probability that the 
inflammation is not purely rheumatic, and varieties of lesions may 
take place. 
Symptoms and Course.—The symptoms and progress of acute 
rheumatism are not always the same, and the mode of invasion 
varies. Sometimes there are vague muscular and articular pains 
preceding for a day or so the more severe symptoms. In other cases 
there are more severe pains at the beginning, soon followed by a chill 
and the rheumatic fever. In still other cases, the local articular 
symptoms are preceded by laryngo-bronchial catarrh, or pleurisy, or 
pericarditis, etc., conditions which ordinarily appear during the prog- 
ress of rheumatism, when they are manifested at all with it. 
But however it begins, rheumatic fever is characterized by symp- 
toms of an acute nature both general and local. There is an active 
attack of fever, accompanied by an excited, bounding pulse, a furred 
tongue, loaded urine, commonly with urates, colored often with pur- SYMPTOMS 
527 
purine—especially when the disease becomes extended and the peri- 
cardium is involved ;—there is profuse perspiration, often coming on 
quite early, which has a decided acid reaction and a sour smell. 
These general symptoms are in the early stages often accompanied by 
wandering pains ; but soon these pains seize upon one or more of the 
larger joints, which become hot, red, and swollen, and exquisitely 
tender on pressure or from motion. The tumefaction is variable in 
amount, and there is no fixed relation between the violence of the 
pain and the degree of swelling. The skin, though commonly show- 
ing a blush, and sometimes a deep erythematous redness, especially 
when the smaller joints are affected, may be of the natural color, par- 
ticularly when the large joints are the seat of the disease. 
When the swelling and pain extend beyond the joints, it usually 
denotes the participation of the tendinous sheaths, or the fascia, or 
sometimes the fibrous structure in the muscles. Sometimes nodosities 
appear, due to hyperplasia of connective-tissue elements. 
Unlike inflammation of the joints from other causes of a local 
character, this rheumatic inflammation shifts its location repeatedly 
in many cases, and often rapidly from joint to joint. The amount of 
early swelling depends much upon the extension of the inflammation 
to the areolar tissue, and the amount of serous effusion into it. In 
some cases the inflammation is confined to the deeper parts, when 
there may be little or no redness, and the swelling will be only of the 
deeper tissues and more circumscribed. It may be confined to the 
capsular ligament, producing swelling only by causing effusion into 
the synovial cavity. In most instances the two varieties of swelling, 
the deep and superficial, are combined, and the more the deep tissues 
are involved the more obstinate the local disease is likely to be. 
The rheumatic fever is accompanied by a rapid occurrence of 
ansemia, and its severity and consequences are commonly in proportion 
to the number of parts affected. 
This disease may run its course from first to last without the im- 
plication of any internal organ ; but not unfrequently—and this gives 
rheumatism its greatest interest and danger—the disease attacks the 
investing or the lining membrane of the heart, the envelopes of the 
lungs, or those of the brain. Of the internal organs the heart is 
most frequently the seat of rheumatic inflammation—the pericar- 
dium, the endocardium, or the fibrous envelopes of the bands of mus- 
cular tissue may be affected. Formerly the involvement of internal 
organs was spoken of as a metastasis of the disease from the joints. It 
is no more a metastasis than the involvement of one joint after 
another, and the disease by no means necessarily disappears from the 
joints when other parts are involved. AVhen the inflammation seizes 528 
RHEUMATISM. 
the internal organs it is of the same character, and depends upon the 
same causes, as the inflammation of the joints; but from the con- 
tinued motion of the heart and its peculiar structure, the disease, 
when located in this organ, is modified in its continuance and results. 
Serous effusions into the pericardium, or plastic adhesion of its folds, 
or, more rarely, suppuration of its surfaces, may take place. The 
endocardium, when involved, is swollen and roughened; exudates 
of plastic matter are likely to take place upon its surface or within its 
substance; proliferation, as in other tissues, may occur; and as the 
most frequent seat of these changes is at the openings involving the 
valves, their functions are in danger of being seriously interfered with, 
and the contractions which follow are apt to be finally disastrous in 
their consequences. These will hereafter be described. The danger 
of cardiac complications is much influenced by the age of the patient, 
and the younger the patient the greater is this danger. Such com- 
plications are more likely to occur in delicate and impressible girls 
than in less susceptible boys. 
The particular character of rheumatic fever varies in different 
cases, and its phenomena are worthy of more special notice. The 
temperature varies, but is generally not as high as in scarlet fever or 
some of the other infectious diseases, varying from 102° to 104°. In 
exceptional cases, however, it is excessive, going up to 106°, 107°, and 
even to 110° or higher. In such cases there is the utmost danger, 
and its speedy reduction is imperatively called for. There is com- 
monly a free cutaneous circulation, but in protracted cases and when 
there is profuse sweating, the skin is sometimes pallid from the 
anasmia and the blanching sweats. The quantity of urine is com- 
monly small, in consequence of the fluid passing so freely from the 
skin, and a free sediment, consisting of urates and uric acid crystals 
mostly, is deposited on cooling. There is thirst, owing chiefly to the 
loss of water by diaphoresis, and constipation is apt to be present. 
Sudamina in many cases, and sometimes other cutaneous eruptions 
occur. This fever lasts while the active stage of the inflammation 
continues, which period, when uninfluenced by treatment, varies very 
much. As has been shown by Dr. Flint and others, some cases may 
spontaneously convalesce in a week or ten days, while others continue 
all the way up to six or eight weeks, and others still become chronic 
and go on indefinitely. When other parts than the joints are in- 
volved, the fever is likely to continue longer than when the joints 
alone are affected. 
Prognosis.—The prognosis as to life when the disease is con- 
fined to the articulations, is very favorable, and yet fatal results from 
various causes may occur. PROGNOSIS—D1A GNOSIS. 
529 
Death may occur from feebleness of the heart's action united with 
the increased quantity of fibrine in the blood and its greater coagula- 
bility, causing the formation of heart clots. 
Death may also result from rheumatic inflammation of the heart, 
the pleura, the peritoneum, the lungs, or the cerebral and spinal 
membranes. 
Cerebral symptoms rapidly followed by death sometimes occur, 
and may be caused by cerebral emboli, punctiform hemorrhages, or 
serous effusions. Hyperpyrexia may be a cause of death ; the func- 
tions of vital organs, particularly of the brain and heart, being sus- 
pended by the direct effect of the extreme heat. 
The symptoms in rheumatism are often remitting, and relapses 
after partial convalescence are apt to occur. The natural termina- 
tion is by lysis rather than crisis, and while its duration is not con- 
fined to any definite period, its mode of termination is not fixed. 
The inflamed joints may recover completely, which is usually the 
case when the disease is not of long continuance. When material 
structural changes occur, stiffening of the joints, enlargements and 
slight deformities are likely to be left; and a greater liability to 
attacks of the disease is always the consequence of even a single 
occurrence. 
A synovial inflammation of a single joint, with but little fever, and 
that at the beginning, with effusion of serum into the capsular liga- 
ment, occasionally takes place, but can scarcely be regarded as rheu- 
matic. However, genuine rheumatism may affect a single joint. 
The distinction must be made by considering the general conditions, 
as well as the peculiarity of the local change. 
The subacute varieties are those slower and milder forms which 
follow the acute, and need not be particularly described. They 
consist essentially of the conditions already described or intimated, 
and the phenomena not specially pointed out can be readily inferred 
from what has been stated. In cases subacute or becoming chronic, 
there is much less fever and general disturbance, and the local pain 
is not so severe. There is often, however, great difficulty of move- 
ment and decided tenderness on pressure, with some heat of the part, 
and sometimes a slight general fever. In these cases the heart is apt 
to suffer; sometimes the affection comes on insidiously—serious 
organic changes occurring before the patient is aware of material 
trouble. 
Diagnosis.—A well-marked case of acute rheumatism can 
scarcely be mistaken for any other disease ; still it may be confounded 
with periostitis, with acute or chronic synovitis, the hysterical joint, 
and with sciatica or lumbago. Some cases of pyaemia, of blood poison- 530 
RHEUMATISM. 
ing after measles or scarlatina, and occasionally cases of cerebral or 
spinal meningitis resemble acute rheumatism ; and rheumatoid arthri- 
tis, some cases of gout, and some of neuralgia may be mistaken for 
different forms of rheumatism. A proper comparison of the symp- 
toms and course of each of the affections will lead to a differential 
diagnosis, but such comparison need not here be made. 
Treatment.—A disease so long known and of so common occur- 
rence, continuing through so many epochs of professional opinion and 
varieties of practice, and withal a disease so often obstinate and pro- 
tracted, we should naturally suppose would have been subjected to a 
great variety of treatment, and this we find to have been the case. 
In the bleeding days of the past, this form of inflammation was 
thoroughly subjected to the ordeal of blood ; but before confidence was 
impaired in the power of the lancet over inflammations in general, 
many had discovered from experience that rheumatic inflammation 
was but little influenced in its continuance by blood-letting. It is now 
generally conceded that it not only fails to cure the disease, but when 
freely practiced, or indeed practiced to any considerable extent, ex- 
cept in the most robust and vigorous, it is harmful, and often mark- 
edly so, increasing irritability, and causing the poison to operate with 
more force, while lessening the power of endurance. It is thought 
that in the debility induced by it, the heart is more likely to become 
involved, and that all the dangers are increased. Yet in positive 
plethora there can be no serious objection to reducing the amount of 
blood to the normal standard. And when general symptoms, such 
as arise from congestion of the brain or lungs in an over-full system, 
require it, bleeding may bo practiced with decided relief. It, how- 
ever, should be remembered that blood impoverishment goes on rapidly 
during the continuance of the disease, and, as a rule, venesection is 
contraindicated. 
Cathartics have been much used, and are often useful, as in other 
cases of fever and inflammation, where it is desirable to remove from 
the system effete matters so abundantly produced, and to prevent fsecal 
accumulations. 
An occasional blue pill, followed by Rochelle salts, makes an ex- 
cellent eliminative cathartic ; and the Rochelle salts, which are com- 
posed of an organic acid with the bases, produce the effect of an alkali 
upon the blood and urine. Though active purgation is seldom re- 
quired, and the spanaemic effects of mercury are injurious, these 
articles, when used moderately and cautiously, may be of decided ser- 
vice in modifying the secretions and effecting elimination ; and at all 
events the bowels should be kept open and the tendency to constipation 
overcome. TREATMENT. 
531 
In my judgment it is too much the custom of the present day to 
neglect the use of cathartic medicines and other eliminatives in many 
forms of disease. Here, as in so many other cases, they not only 
eliminate effete matters from the system by the alimentary canal and 
associated organs, but they also moderate the intensity of febrile 
action, and often drive it from organs which are oppressed. They 
often also produce in these cases an alterative effect upon the diges- 
tive organs and functions, tending to correct that faulty digestion 
and assimilation, upon which the production of the poison of rheu- 
matism probably depends. 
Mercury, to the extent of producing its constitutional effects, has 
been advised and used; but there is no sufficient evidence that it 
shortens the course of the disease, mitigates its violence, or prevents 
its complications ; and in such quantities it often does harm to the 
system. It should therefore be discarded except in such quantities as 
may excite the secretions and aid in elimination without producing 
anaemia. When given, it should as a rule be followed by some article 
to secure its cathartic effect. Given under these restrictions it is often 
useful as an eliminative cliolagoguo and cathartic. Laennec, and 
others before and since his time, even down to Jaccoud, recommend 
tartrate of antimony ; some advise it in free contrastimulant doses as 
the chief reliance, especially in robust patients. Jaccoud declares it 
abridges the attack. In England and this country its use in this man- 
ner is generally, if not universally, abandoned ; and whatever its virt- 
ues, it has powerfully depressing and irritating effects, and, to say 
the least, we have better agents. I am not prepared to deny that in 
the more sthenic forms of the disease, with a hot and dry skin, and 
especially when there are pneumonic complications, it may serve a 
useful purpose as a sedative, diaphoretic, and spangemic, tending to 
prevent fibrous deposits. 
Veratrum viride has been recommended in a similar class of cases 
to that just indicated, and it may have its range of applicability, 
especially when the heart is involved or threatened, when its irri- 
tability is great, and before its strength is impaired. The drug is 
sedative, diaphoretic, and eliminative, and at one time was a decided 
favorite. It must be used with care, and should be abandoned when 
the heart’s power flags. 
Opium is another article which has been recommended as the chief 
reliance, not only for allaying pain, diminishing suffering, and pro- 
curing rest, but as the chief and almost exclusive curative agent. It 
was recommended in full medicinally narcotic doses, to be kept up 
until the disease yielded. Although its use in this manner is not now 
so much relied upon, it is an exceedingly useful article in connection 532 
RHEUMATISM. 
with other treatment, not only affording great relief from pain and 
procuring rest, but overcoming irritability and aiding in subduing the 
inflammation. 
Quinine has also been recommended as the chief agent in the treat- 
ment of rheumatism, given in large and repeated doses, to secure its 
antipyretic and antiphlogistic effects, and continued until the disease 
is overcome. At one time it was used by M. Briquet and other 
French physicians in full sedative doses, as high as seventy-five grains 
in twenty-four hours, and continued as long as the pain and fever 
lasted. It was alleged that accidents followed its use, such as con- 
gestion of the brain and alarming depression ; and in Paris it has 
fallen into comparative disuse in these large doses. Still, Drs. Garrod, 
Niemeyer, and others contend for its great utility in doses sufficient to 
quiet the febrile symptoms, even to the extent, sometimes, of disturb- 
ing the brain and stomach. Some would use it in very large doses, so 
as to procure at once its antipyretic effects, and then not repeat it for 
twenty-four or forty-eight hours. Dr. Garrod combines it with alka- 
lies. Combined with opium, or even alone, I do not doubt its great 
efficacy, and were there not another article still more efficient but oper- 
ating similarly, it should, in my judgment, be particularly recom- 
mended. Whenever a malarious influence is present it should with- 
out hesitation be given in full antiperiodic doses. 
Colchicum was a remedy often relied upon when the distinction 
between rheumatism and gout was not so clearly made as now. As an 
eliminative and purgative, and an agent for diminishing the formation 
of uric acid in the system, it may be useful; but it has not such a spe- 
cific effect upon rheumatism as it has upon gout. In some rheumatoid 
affections it has, however, much efficacy; and in pure rheumatism, 
especially in some of the sthenic forms, and in patients not very im- 
pressible and with good powers of endurance, it is not unfrequently 
useful. In combination with alkalies and other remedies it is thought 
to have the effect to increase their efficacy. 
In this country some years ago, the cimicifuga racemosa, or 
black cohosh, had a reputation and a run, especially in subacute 
cases; but it has not sustained the reputation which it at one time 
obtained. 
Stramonium has a reputation, especially in those forms of sub- 
acute or chronic rheumatism where a neuralgic element is prominent. 
I think it capable of doing good, in combination with other remedies, 
in cases of this kind. 
Guaiacum has long been used in chronic cases of rheumatism ac- 
companied with exhaustion and debility. It is a diaphoretic and 
stimulant, and often improves the tone of the stomach. In sufficient TREATMENT. 
533 
doses it will act as a laxative and diuretic. Its virtues depend upon 
its eliminative and stimulating action. 
The nitrate of potash has been extensively used in the acute forms 
of this disease. It has been given in doses of from a few grains to 
several drachms, or an ounce or more, in twenty-four hours. It is very 
apt to irritate the stomach in the larger doses, and the smaller ones 
cannot be relied upon to produce much effect. It, however, tends to 
diminish fibrine, and may have an influence in warding off embolism 
and internal complications. But its efficacy is not so striking as to be 
unequivocal. 
Lemon juice was strongly recommended, some years ago, by Dr. 
Reese, of London, as a cure for acute rheumatism. It was supposed 
that its excess of oxygen converted the lithic acid into urea and car- 
bonic acid, while its small quantity of the alkaline base aided in the 
curative effect. It had the virtue of novelty and simplicity, and of 
not being unpleasant to take, as well as the advantage of a plausible 
theory respecting its beneficial action, and it had a fashionable run. 
Its good effects are at least uncertain, and it has not sustained its 
reputation. In the form of lemonade it is a pleasant drink and use- 
ful diluent, and may be allowed to a rheumatic patient if it does not 
disagree with the stomach. 
Various other particular articles might be mentioned which have 
had their advocates, but which have failed to establish a general 
reputation, and none of those mentioned can be regarded as approach- 
ing to specifics, and most of them are of doubtful efficacy in the treat- 
ment of the disease. 
The alkaline treatment of rheumatism, brought forward several 
years ago, more particularly by Dr. Fuller, has sustained its reputa- 
tion longer than any of its predecessors, and there can be little doubt 
that it has decided virtues. 
Dr. Fuller says : “ Of the value of alkalies and their salts in acute 
rheumatism, it is impossible to speak too highly ; ” and when we con- 
sider that in this disease the whole system seems surcharged with acid 
—the acidity of the urine being doubled, the perspiration intensely 
acid, and the saliva losing its normal alkalinity, while the alvine dis- 
charges are loaded with acidity—and further considering the influ- 
ence which alkalies and their salts have in preventing fibrinous de- 
posits so liable to take place, we are easily led to believe that these 
remedies are useful. They certainly neutralize the acid to the extent 
of their chemical capacity, they depurate the blood by increasing 
secretions, and they tend to prevent fibrinous coagulation and de- 
posits. 
Whether the presence of this acidity is the cause of all the symp- 534 
RHEUMATISM. 
toms or not, there can be little doubt that it at least contributes to 
their production ; and so far as it can be neutralized, palliation at 
least must result. Long experience has abundantly sustained these 
rational conclusions. The alkaline treatment may not be the most 
efficient—it indeed is not—and it may not be entirely curative, but 
it can scarcely fail to be at least palliative. 
It consists in administering the alkalies, their carbonates, or their 
salts, with organic acids, in sufficient quantity, if the stomach will 
bear them, to neutralize the morbid acidity of the system ; the test of 
which will be the neutral, or better, the alkaline reaction of the urine. 
The carbonates of the alkalies or their salts, with organic acids, 
such as the acetates, the citrates, and the tartrates, can be borne by 
the stomach in much larger doses than the pure alkalies ; and taken 
into the circulation the organic acids are separated and decomposed, 
and the bases are left to produce their alkaline effect. 
The acetate, or bicarbonate, or citrate of potash, or the sodae et 
potass® tartras (Rochelle salts) are the forms commonly used. 
Dr. Dickinson, of London, contends that ten to twelve drachms 
of a mixture of the acetate and bicarbonate of potash should be given 
in the twenty-four hours in order to secure the best and most reliable 
results. As a specimen prescription : 
$ Acetate of Potash 3ss 
Bicarb, of Potash 3j-3jss 
Nitrate of Potash grs x 
M. 
To he given in free solution once in four hours ; or half the dose 
once in two hours. 
All stomachs will not bear as much ; but when the alkali is given 
and borne to this extent the system will soon be saturated with it, and 
the urine will lose its acidity. The effect of this treatment in abat- 
ing the severity, cutting short the duration, and preventing the 
extension of the disease to internal organs is unquestionably decided. 
Not that it is invariably successful in accomplishing all these objects ; 
but that it tends to their accomplishment, and often results in it, 
seems certain. In the prescription given the nitrate of potash may 
be omitted, or other modifications may be made, according to the 
condition of the patient, and the judgment of the physician; but 
persistence in the use of this or similar prescriptions sufficient to 
induce alkalinity of the urine, and to keep it alkaline until the disease 
subsides, constitutes what is known as the alkaline treatment of this 
disease. TREATMENT. 
535 
Other special indications may be fulfilled at the same time. The 
bowels may be moved if required, and for this purpose the Rochelle 
salts, as answering a double indication, should be preferred. An 
opiate may be given from time to time as required, and tinct. of 
chloride of iron may be given in debilitated cases, and a suitable regi- 
men adopted ; and this course is not incompatible with any local 
treatment that may be thought advisable. 
Trousseau’s treatment with what he calls “ Syrup of Lime,” is a 
modification of the ordinary alkaline treatment. His prescription 
was: 
$ Caustic Lime 3ij 
White Sugar Iviij 
Mix in a mortar and pour over it a pint of boiling water. After, 
add enough boiling water to make a pint, supplying the amount 
absorbed. This was to be filtered, and the dose was from ten to 
forty-five drops once in from two to four or six hours, given in 
milk. Others have recommended it highly; but it does not cause 
the urine to be alkaline, and it has never come into very general 
use. 
Dr. Garrod says that for years past he has made use of what he 
calls the quino-alkaline treatment, and regards it with great favor. 
Sulph. quinine is ordered to be rubbed up with a solution of bicar- 
bonate of potash, to which a little mucilage and some aromatic, as 
tinct. of cardamom, or spts. of chloroform are added, so that each 3jss 
dose will contain five grains of quinine and half a drachm of the 
potash—the quinine being reduced to a carbonate. This quantity 
is given to an adult every four hours until the symptoms have com- 
pletely abated. He says it does not increase the thirst or the fur of 
the tongue ; and while lowering the pulsations of the heart in fre- 
quency, it does not weaken them. The involvement of the heart 
does not contraindicate its use, though when this is the case leeching 
and blistering over the part may be made use of. The treatment 
recommended by M. Jaccoud, in the edition of his work on Practice 
of Medicine for 1879, in robust patients, when the temperature is 
beyond 103° F., is tartar emetic in large doses. Bringing the patient 
under its full influence every third day, he declares, abridges the 
attack. 
In cases of medium intensity, if the patient be robust, a single 
dose will be sufficient. If the patient be feeble, he advises quinine 
in large doses, together with digitalis, and with lemonade for drink, 
and that the joints be wrapped up. 
In debilitated cases he advises local treatment and the giving of 536 
RHEUMATISM. 
wine and quinine. In subacute cases he advises the alkaline treat- 
ment, with blisters; and in all cases, hypodermic injections of mor- 
phine to allay pain. When brain symptoms occur, with high fever, 
he uses the cold bath and cold affusions. 
When single joints are affected, counter-irritation and iodide of 
potassium, with sulphur baths—and later, passive motion to restore 
the movements ; and in the chronic cases, besides care to protect 
against cold and moisture, even when pain is absent, he advises iodide 
of potassium in large doses, and vapor baths, etc. ; and when the uric 
acid dyscrasia is present, the alkaline waters of Vichy, Carlsbad, and 
Ems, sulphur waters, thermal treatment, hydropathy, cold affusions, 
Russian baths, baths with vapor of turpentine, and a winter’s resi- 
dence in a warm dry climate are the means recommended. 
The treatment in acute rheumatism which for many years I pur- 
sued, with results which in the state of our knowledge at that time 
were to me very satisfactory, was substantially as follows : 
If seeing a patient soon after the attack suffering with much 
pain, a large Dover’s powder, or one fourth or one third of a grain of 
morphine and a grain or more of ipecac, and a few grains of blue 
mass were given, and repeated once or twice at intervals of four or six 
hours. This was followed by a free dose of Rochelle salts, repeated if 
necessary, to secure a cathartic effect, and this was again followed by 
something like the following prescription : 
R Acetate of Potash 3j 
Carbonate of Potash j 
Wine of Colchicurn 3]j—3jv 
Camphor Water ' lij 
M. 
A tea-spoonful once in from two to four or six hours ; reducing the 
colchicurn if much purging was produced, and increasing it if neces- 
sary to produce a loose state of the bowels. An opiate was given as 
might be necessary, to allay pain and procure rest. When the local 
symptoms were severe, in addition to this the joints wTere first covered 
with a loose cloth or sheet of patent lint, saturated in a solution of 
carb. of potash, an ounce to a pint of water, generally tepid. Oiled 
silk or gutta-percha cloth was carefully placed over this to prevent 
evaporation, and the whole enveloped in a large covering of cotton 
batting to keep the temperature of the part uniform. The alkaline 
wash was renewed from time to time, and the patient kept as quiet 
as possible in bed, wrapped in flannel blankets. 
Active symptoms were almost invariably removed in a very few TREATMENT. 
537 
days—as soon generally as the urine became alkaline ; but if tender- 
ness and swelling lingered in the joints, blisters were applied at a lit- 
tle distance, and sometimes repeated after the manner of Dr. Herbert 
Davies, of London, though not quite as vigorously as he advises. This 
treatment was very satisfactory, and would have been continued if, 
in the advancement of the art, something better had not been pre- 
sented. 
Since the anti-rheumatic virtues of salicylic acid have been known, 
the ordinary treatment I now pursue is as follows : I prefer at the 
beginning a cathartic, as I think the after-treatment will then 
be better borne both by the stomach and the brain. I then com- 
mence with a scruple, sometimes more and sometimes less, of sali- 
cylic acid and one fourth of a grain of morphine in a capsule, 
followed very soon by a scruple or half a drachm, more or less, of the 
bicarbonate of soda in a free drink of water. I repeat the acid and 
the soda, omitting the morphine—or repeating it only as may be 
required to keep up an anodyne effect, and to modify, as it is capable 
of doing, the possibly irritating effect of the acid—but repeating the 
salicylic acid and soda once in from two to four hours, until the tem- 
perature, pulse, and pain are reduced, and the active symptoms dis- 
appear. This generally requires not more than two or three drachms 
of the acid; and that quantity, so far as my experience will enable 
me to judge, can be borne without any specially unpleasant effects. 
It should, after this effect, be continued in more moderate doses for a 
time; and I think it well to give alkalies for some days, almost as 
vigorously as where they alone are relied upon to effect the cure. 
Without the continuance of the alkalies relapses not very unfre- 
quently occur, but with them they appear to be very rare. Of the 
very great—almost specific—efficacy of this treatment of rheumatism, 
my observation has thoroughly convinced me. 
The salicylate of soda is, perhaps, the more frequent form in 
which it is now given, but the above described mode of administra- 
tion has been found efficient and satisfactory. If the medicine be 
preferred in solution, the following formula will afford an eligible 
preparation : 
B Salicylic Acid Sjvss 
Bicarb. Soda 3iij 
Glycerine and Pure Water, of each giij 
M. 
Of this, one thirteenth part will contain about a scruple of the 
acid, the dose usually given. Another formula is : 538 
RHEUMATISM. 
Salicylic Acid 3j 
Carb. of Ammonia grs. y 
Bicarb, of Soda grs. v 
M. 
To be taken in solution or in a capsule. 
Larger proportionate doses than these of the salicylate of soda 
may be given and well borne, and, in severe cases, where the fever 
and pain do not readily yield, doses of a drachm, or even more, of the 
salicylate may be given, repeated as required to procure relief. In 
cases of much debility the tinct. of chloride of iron in free doses may 
follow the salicylate. 
Various explanations of the great effect of salicylic acid or salicy- 
late of soda in this disease have been attempted, based upon its physi- 
ological action. They have not, so far, been particularly satisfactory ; 
but its therapeutic effects are, marked relief of the pain, and a diminu- 
tion of the fever ; in a day or two after its administration the urine 
becomes abundant, its specific gravity, which before was high from its 
being loaded with urea, urates, and uric acid, becomes reduced, and 
the quantity of urea and uric acid are notably diminished. It appears 
to operate upon the causes producing the abnormal quantities of uric 
acid, and it is thought that this is done independently of the reduc- 
tion of the febrile temperature. In acute rheumatism the quantity of 
urea and uric acid in the urine is greatly increased, and when this 
process of its rapid production is arrested, either spontaneously or by 
the salicylate of soda, the symptoms markedly abate. 
In cases of chronic articular rheumatism the quantity of urea and 
uric acid is often, though not usually, rather diminished than in- 
creased, and in such cases the salicylate has little or no effect upon 
the disease. According to the observations made in the Faculty of 
Paris, the inference seems to be that the salicylate produces its most 
marked effects by checking the rapid production of urates and increas- 
ing the quantity of urine. Possibly by the polyuria, which according 
to the French observations is induced, some other more specific poison- 
ous material is eliminated from the system. The very profuse sweat- 
ing, which is the more immediate effect of the drug, may aid in the 
eliminative process. This diaphoretic effect is sometimes so great as 
to diminish temporarily and indirectly the flow of urine. Whatever 
the explanation, the fact is that in acute arthritic rheumatic inflam- 
mation and fever we know of no remedy so promptly efficient in ar- 
resting its progress as the salicylic acid or its salt with soda. Should 
it, however, fail in any case, the physician may resort to the other 
means so fully described. TEE A TMENT—COMPLICA TIONS. 
539 
Should a condition of hyperpyrexia appear, the temperature going 
up to 107°, 109°, or 111°, as has been known to occur in some rare 
cases, in addition to the antipyretic medicines, as the salicylic acid and 
quinine, the cold bath, or, where the means of using it are not avail- 
able, cold affusions, cold sponging, or the cold pack, must be promptly 
and efficiently employed. 
As already stated, rheumatic inflammation not unfrequently at- 
tacks internal organs, particularly the endocardium and pericardium, 
giving to the disease its chief danger, and justifying the detailed de- 
scription which has been given. As the heart is specially liable to be 
affected in children and young persons in whom the disease occurs, 
great watchfulness should be exercised with them, and in all cases the 
heart should be carefully examined daily. The symptoms of the heart 
affection may be obscure, and the physical signs must be observed in 
order to determine the presence of such lesions. As these fibrous 
structures are similar to those about the joints, they are subject to the 
same inflammatory processes, and may be attacked primarily; but 
generally the attacks occur after the disease commences in the joints, 
and these cardiac inflammations go on with the articular affection. 
There is usually pain in the region, a severe sense of oppression and 
debility, irregular action of the organ, and an increase in the fever when 
the heart becomes involved. The physical signs are blowing sounds from 
swelling and roughness of the endocardium, or friction sounds when 
the pericardium is the seat of the disease. When effusion occurs 
in the pericardial sack, distance of the sounds of the heart, dullness 
on percussion over a larger space, and often bulging, may be observed. 
When the heart or other internal organ is involved, the anti-rheu- 
matic treatment must be pushed with vigor ; and in addition, leeches 
and blisters are usually applied ; and particular symptoms are to be 
managed according to their indications. 
The more particular methods of detecting and treating these and 
other internal complications will be described in connection with 
other diseases of the respective organs. 
CHRONIC RHEUMATISM. 
By chronic rheumatism is understood an affection of the articula- 
tions and other fibrous structures, causing pain, especially on motion, 
with stiffness and some swelling. It is frequently the result of acute 
attacks ; but sometimes, especially after middle life, is chronic from 
the beginning. 540 
CHRONIC RHEUMATISM. 
The pain and soreness are usually limited to the articulations and 
their neighborhood ; the joints are somewhat swollen and the move- 
ments restrained ; there is but little redness or heat, except when the 
inflammation is more acute ; and the symptoms are much influenced 
by changes of temperature, by humidity of the atmosphere, and by 
exposures. 
Sometimes the joints creak on movement as the sheaths of the 
tendons become roughened and thickened ; and the difficulty of move- 
ment is greater in the morning, and is more or less relieved tempo- 
rarily by exercise or frictions. There is less migration of the disease 
from one joint to another than in acute rheumatism, and often the 
same joint is affected for a long time. Myalgia, or wdiat is called 
muscular rheumatism, may coincide, and in some cases the same kind 
of inflammation extends to the sheaths of the muscles. Some cases 
of this affection are exceedingly chronic and obstinate, lasting not 
only months, but years, fluctuating more or less in severity, and aggra- 
vated by cold, dampness, and exposure. 
The pathological changes are the same as those described in the 
protracted cases, which are the sequel of the acute. 
Heredity here, as in acute rheumatism, exerts an influence in 
causation ; and exposure, working in the water, a damp and change- 
able climate, and severe exercise act as causes—those joints being 
most affected which are most used. Depressing influences are also 
reckoned among the causes. 
Diagnosis.—The diseases most resembling chronic rheumatism 
are, synovitis, neuralgia, myalgia, and rheumatoid arthritis. It is to 
be distinguished from these conditions by a careful comparison of the 
phenomena. 
The Prognosis as to life is favorable, but as to speedy and com- 
plete recovery, it is unfavorable. Still, many cases recover, and more 
or less relief can generally be effected. 
Treatment.—The most efficient remedies for acute rheumatism 
or rheumatic fever have far less effect upon the chronic affection. 
Colcbicum, guaiacum, conium, cohosh, and various other articles 
formerly held in repute, have lost much of their reputation. The 
general remedies now held in esteem are iodide of potassium, cod-liver 
oil, muriate of ammonia, the bromide and lithium salts, arsenic, and 
saline and sulphurous mineral waters. 
Any of the above remedies must be persevered in a long time to 
produce much effect. 
Bartholow speaks highly of the bromide of lithia. 
Local remedies are often useful. The method of active friction, 
movements, and pressure, known as massage, is often useful. Striking TR EA TMENT—PHENOMENA. 
541 
cures are sometimes effected by it. A current of galvanic electricity, 
of large volume but low intensity, will often be useful when system- 
atically applied. Warm baths, steam baths, Turkish or Russian 
baths, with douches to the parts, have much reputation, and are some- 
times, but not always, efficient. After a bath or douche, frictions 
with cod-liver oil will sometimes be of service. Mud baths are used 
in some parts of Germany, and, it is said, with good effect. 
Many of the cases will try the patience and confidence both of the 
physician and patient, but continued perseverance will not unfre- 
quently be crowned with good results. 
RHEUMATOID ARTHRITIS. 
POLYARTHRITIS DEFORMANS.—NODULAR RHEUMATISM.—RHEUMATIC 
GOUT.—CHRONIC RHEUMATIC ARTHRITIS. 
This is a peculiar chronic and obstinate joint affection, resembling, 
but not identical with, ordinary chronic rheumatism, characterized by 
irritative outgrowths of the cartilages and synovial fringes of the 
joints, associated with destructive changes of those parts of the carti- 
lages subjected to most pressure, and by the development of bony and 
articular lesions, which produce deformities, and often in time immo- 
bility of the joints affected. 
There are two varieties of this affection : one primary, and gradual 
in approach and in its course throughout; the other, secondary to 
acute attacks of ordinary rheumatism, but becoming chronic, though 
with exacerbations and remissions more marked than in the primary 
variety. The primary forms of the disease appear at a somewhat 
later period of life, and are more common than the secondary. 
This disease occurs oftener in women than in men, and in damp 
and cold localities or dwellings, and, unlike gout, is more common 
with persons in poorer circumstances, and with restricted rather than 
luxurious modes of living. It is not a disease of modern origin, as 
bones found among ancient ruins have presented the characteristic 
deformities of the affection. In some cases observed by Lebert, a 
uric acid dyscrasia was present ; but generally this is not the case, 
and the pathological cause is not known. 
SYMPTOMATIC AND PATHOLOGICAL PHENOMENA. 
In the primary form the lesions are often confined to the small 
joints of the hands and feet, but they sometimes extend to the larger 542 
RHEUMATOID ARTHRITIS. 
joints, and even to those of the vertebrae. In the secondary variety 
the larger joints, as well as the smaller, are more likely to be involved, 
notably those of the elbows and the knees. 
In both forms the anatomical lesions are the same. 
The morbid changes are chiefly in the articular cartilages and the 
synovial fringes. The central portions of the cartilages acquire a 
villose character, and are worn away by degrees, while the margins 
are irregularly enlarged by hyperplasia. The synovial folds and 
glands are thickened, and may form circumscribed masses, which may 
be detached and act as foreign bodies in the joints. These morbid 
enlargements are at first fibrous, but at length they become cartilag- 
inous, and later in the disease become converted into bone, and a per- 
manent, immovable, anchylosed condition results. The ligaments 
are thickened and often contracted, the ends of the bones are enlarged, 
horny growths are projected, certain muscles are permanently con- 
tracted, hyperplasia and retraction of neighboring connective tissue 
occur, especially in the plantar and palmar regions, and the charac- 
teristic luxations, subluxations, and deformities result. In the earlier 
stages soft and liquid exudates take place, but as the disease advances 
they become dry, hard, and firm. 
In the variety secondary to ordinary rheumatism, cardiac lesions 
may be present, such as pericarditis, arterial atheroma, and enlarge- 
ment of the organ, but seldom valvular lesions, and in most cases the 
heart is unaffected. 
The symptoms and progress of the two varieties of rheumatoid 
arthritis are somewhat different. When the disease is secondary to 
acute rheumatism, the pain, particularly in the small joints, remains 
after the subsidence of the fever and the symptoms in the large 
joints, except perhaps in the knees and elbows. When primary, it 
has a gradual accession, and occasions little or no general symptoms. 
The pains, however, are decided. They may be rending, lancinating, or 
contusive, are usually severe, and generally precede the occurrence of 
any apparent change of structure by some days, or even weeks. The 
pain is increased by pressure, and in its progress, if not in the begin- 
ning, the disease is bilateral, and generally symmetrical. The hands 
are commonly attacked first, and the feet later ; but at length both 
extremities and a large number of joints become involved. The 
swelling at first is due to moist exudates and tumefaction of tissues; 
and when this turgescence abates, it is then due to the enlargements 
of the cartilages and the heads of the bones. 
Contractions of muscles near the joint may be due to reflex action 
from the pain in the articulation, or from irritation and pain extend- 
ing to the muscles themselves. PHENOMENA—TREA TMENT. 
543 
Luxations or subluxations are common when the disease is ad- 
vanced ; the phalanges may be displaced upon one another, the fin- 
gers being bent like a roof, while the thumb is free ; and the fingers 
are also bent upon the metacarpus, with the wrist often inclined to 
the ulnar side. In severe and advanced cases the elbows and knees 
are involved—deformed and immovable, generally flexed at nearly 
right angles ; and at a latter stage, though the pain and active disease 
subside, the patient is a helpless cripple. A woman about forty wras 
brought to the University hospital in apparently good general health, 
and then suffering but little pain. The knees and elbows were at 
right angles and fixed; the wrists, fingers, and other joints were 
immovable ; the shoulders and hips very slightly movable, and she 
was consequently unable to stand, to feed or dress herself, and was 
more helpless than an infant. Another patient, a man, soon after- 
ward was brought in a similar condition. In the first case treatment 
was judged to be useless, and scarcely anything was advised. In the 
other case an effort was made for a few weeks by general treatment, 
iodine applications and electricity, frictions and passive motions, and 
some impression was made upon the enlargement and immobility of 
the joints ; but he was sent by public charity from a distant part of 
the State, and as no promise could be given of a cure, he "was removed 
to become an object of permanent support in his own county. 
Prognosis.—When the disease is advanced and the joints have 
become fixed, the prognosis as to cure is exceedingly unfavorable— 
perhaps it may be said hopeless. In the early stages there is more 
hope, and effort should be made, but complete success is very rare. 
Treatment.—In the treatment one object is to prevent deformity 
and the fixing of joints in positions of inconvenience and uselessness. 
Something may be done by keeping the parts in the best positions, 
the knees and hips so that in case of partial or complete anchylosis 
the more inconvenient positions may be avoided. Something may 
perhaps be done by extension and passive motion, to preserve mobility, 
te and massage may be tried with some hope of benefit.” Aside 
from these precautions the general medicinal treatment will be 
influenced by the views which may be entertained of the pathology 
of the disease, and its relations to rheumatism and gout. It is rarely 
attended with the profuse acid perspirations, the febrile urine, and 
the visceral complications which belong to acute rheumatism ; and 
it has not the primary attacks in the great toe, the constant deposits 
of urates of soda, the distinctly intermitting character, and the lithi- 
asis which belong to gout. On the other hand, it is an inflammation 
of the same structures which are affected in these diseases, and it 544 
MUSCULAR RHEUMATISM. 
successively attacks different joints as in rheumatism, and many of 
its phenomena and results strongly resemble those of the other dis- 
eases named. It is difficult to determine its relations to these affec- 
tions ; and experience has not been sufficiently definite in results to 
determine the best modes of procedure. 
At the early stage of the disease, however, treatment has been 
pursued similar to that for subacute forms of rheumatism. Jac- 
coud and others recommend iodide of potassium, Fowler’s solu- 
tion, arsenious acid, arsenical and alkaline local baths, applications 
of tinct. of iodine, general hot baths, baths of the vapor of turpen- 
tine, mineral waters, constant currents of electricity, inunctions of 
parts with mercurial preparations, etc. 
Jaccoud advises the following for bathing the affected joints : 
IJ Carbonate of Soda ?iij 
Arsenite of Soda grs. xv-xxx 
Water §xv 
M. 
The general health should receive attention. Laxatives and tonics, 
iron, etc., may often be required. 
Gruaiacum, as in cases of chronic rheumatism and gout, is advised, 
and every means to improve the general condition of the patient which 
maybe indicated should be used. Various tonics, cod-liver oil, etc., 
may be of use. Hot fomentations to the parts have been thought to 
be useful, and Trousseau advised the burying of the joints in sand 
at a temperature of 140° or 150° F., and keeping them there for an 
hour or two at a time, three times a day. 
Sometimes the progress of the disease is arrested and its effects 
mostly removed, or it may be confined to a few joints ; but the influ- 
ence of treatment in producing these results has not been accurately 
ascertained. 
The name Muscular Rheumatism is applied to pains resembling 
rheumatism, which occur in other situations and in other tissues than 
the joints—in the muscles, aponeuroses, intermuscular membranes, the 
sheaths of nerves and vessels, and even in the periosteum. Both the 
names at the head of this article are inappropriate, as these pains are 
not confined to the muscles; and the first name is doubly so, since 
there is no more resemblance between this affection and true rheuma- 
tism than there is between many other diseases which are not regarded 
as having any special relation to each other. Pains situated in mus- 
MUSCULAR RHEUMATISM. —MYALGIA. PHENOMENA. 
545 
cles are properly called myalgias ; those in nerves are neuralgias ; but 
custom has not established the use of any name indicative in its 
etymology of all the pains above designated. 
These pains are unaccompanied with fever, or marked general 
symptoms ; but when situated in muscles and their sheaths there is 
pain on motion, often severe, and the function of the part is impaired. 
Myalgias may affect any of the muscles of the body. They are 
arranged by Valleix into a number of groups, with names according 
to their location, but they are of the same general character where- 
ever occurring. 
Myalgia may be acute, subacute, or chronic. In the acute cases 
there are severe, cramp-like, or stitchy pains whenever contraction of 
the muscle is excited, while there is little or possibly none when the 
part is at perfect rest. What is called a crick in the back or the neck, 
is a specimen of this affection. There is usually some tenderness on 
pressure ; though firm and constant pressure, preventing motion, may 
cause relief. 
The acute form of the disease varies in duration from a few hours 
to a week. In the subacute forms the pains are less severe but more 
protracted, and these cases may result in a chronic disease continuing 
for Aveeks and months. Lumbar myalgia, or lumbago, is the most fre- 
quent of these affections, and some persons are particularly liable to 
attacks, and may not be free from more or less suffering for long 
periods. 
The name “ nervous rheumatism ” has been applied to cases where 
no lesions were discoverable, while that of “vascular rheumatism” has 
been used to designate those cases where slight tumefaction or other 
structural changes are discoverable. 
Fluxion is a condition perhaps existing in all cases, and it may 
exist alone or may produce serous exudations. Indeed, in the more 
intense kinds, fibrinous exudations and infiltrations may take place, 
producing nodosities or hardness and stiffness in the muscles affected. 
The neurilemma may be involved in a similar morbid action, caus- 
ing then pain in the course of the nerves, and various functional dis- 
turbances, motor, sensitive, and nutritive. 
When the sheaths of vessels are involved, the vessels may be pressed 
upon, as are the nerves, and from this pressure upon the nerves and 
vessels paralysis, generally partial, and atrophy may follow. 
The acute variety of myalgia attacks a single muscle or a group of 
muscles, remaining constantly, but with variable degrees of severity, 
until the attack subsides and the symptoms disappear. 
In the chronic form there may be a persistence of the pain and 
tenderness in one or several muscles, followed by anatomical changes ; 546 
MUSCULAR RHEUMATISM. 
and in another chronic variety there are rapid changes of location and 
fluctuations in the severity of the symptoms. 
In the acute variety very little or no anatomical change can be dis- 
covered post mortem, where death occurs from accidents during its 
continuance; hut this does not prove the absence of hyperaemia during 
life, and sometimes a degree of tumefaction is discoverable. In the 
dorso-lumbar region and in the neck there is a forced inclination 
toward the affected side, producing in the neck torticollis. When 
the seat is in the intercostal and thoracic muscles, constituting pleuro- 
dynia, the respiration will be interfered with, etc. 
Treatment.—In acute cases the treatment is chiefly local. Many 
cases will be decidedly and promptly relieved by external heat, as by 
heating a smoothing iron to 212° in boiling water and passing it over 
the part with a cloth intervening, but heating the part as much as the 
sensations ■will bear. This may be continued for several minutes at a 
time, and repeated from time to time. The thermal button, passed 
rapidly over the part, will also often give speedy relief ; or hot fomen- 
tations, a vapor bath, a mustard poultice, or a chloroform or some 
other irritating liniment may be useful. Shampooing is often quite 
efficient. 
In more severe and obstinate cases narcotics and diaphoretics— 
morphine hypodermically, or a Dover’s powder internally—will be 
useful. In the treatment of the more chronic cases attention must 
be given to the general health. The bowels and digestive organs 
should be regulated, and all present pathological conditions removed. 
One of the most effectual means of relieving some cases is the use of 
electricity—the constant current, continued and repeated as may be 
required. Dr. Garrod recommends the acetate of ammonia in large 
doses, combined with some alkaline salt, as the bicarbonate of potash 
with iodide of potassium. “ The time, however, soon arrives,” he adds, 
“ when the use of some medicinal agent, as quinine, which exerts a 
marked influence on the nervous system is required, and this may be 
advantageously combined with other remedies. Sometimes large 
doses of hydroclilorate of ammonia are useful ; and in gouty habits 
colchicum alone, or in combination with other medicines, may be pre- 
scribed with much benefit.” Probably no one remedy will check the 
disease in as many cases as the sulph. of quinia in free doses con- 
tinued for twenty-four hours, so as to obtain its full neurotic and 
sedative effects. In some of the chronic cases, with sluggish capillary 
circulation, guaiacum, sassafras, mezereon, witch-hazel, turpentine, 
or balsams may do much good. Sulphur, as contained in natural 
waters, and arsenic may be tried in obstinate cases. Sometimes, in 
cases of even long standing, a few hypodermic injections of morphine PHENOMENA. 
547 
or atropine will cause very great improvement. Even the counter- 
irritant effect of acupuncture will sometimes cause relief. Frictions, 
electricity, and shampooing are generally useful to relievo the stiff- 
ness often left after the pain has subsided. Flannel next tlio skin, 
and protection from cold, with proper nourishing diet, arc among the 
hygienic measures required. 
Gonorrhoeal rheumatism is usually described in connection with 
the other so-called rheumatic affections; but as it is different in its 
cause and pathology from genuine rheumatism, it is more appropri- 
ately considered in connection with the disease to which it belongs, 
and is specially treated of in works on surgery. 
In some cases of scarlatina and other diseases, poisonous and effete 
materials are left in the system which produce symptoms resembling 
rheumatism ; but the effects from such causes differ from genuine 
rheumatism, and should not be confounded with that disease. The 
phenomena differ in different cases ; but they all, as a rule, require 
eliminative treatment, while soothing and supporting measures may 
be necessary, adapted to the particular circumstances of each case. LOCAL DISEASES. 
In an exact and positive science, a strictly systematic arrangement 
and a correct classification of the subjects are important features. 
In a complex and inexact science, where some of the facts and 
principles are unknown or not established, a perfect classification is 
impossible. 
Medicine has not yet attained to the condition of an exact science, 
and though constantly advancing, must, by its complex nature, linger, 
it is feared indefinitely, in the long list of the inexact sciences. 
As a perfect scientific classification is at present impossible, noth- 
ing of this character has here been attempted. A simple plan has 
been adopted of grouping together those subjects which seem to have 
most in common, and of following an order in taking up subjects ac- 
cording to their dependencies upon each other. Thus it seemed 
proper to give attention first to those general facts and principles 
which are at the foundation of all diseases ; then to consider the dif- 
ferent elementary pathological states; and lastly, to proceed to the 
various aggregates of these elements which constitute the different 
particular diseases. 
In dealing with the distinct affections, it seemed to me proper to 
discuss first those where the whole organism is essentially affected— 
the so-called general diseases ; and next, those where some particular 
organ or system is the principal seat of the affection—or the so-called 
local diseases. This arrangement seems natural and appropriate ; 
but yet (and here the imperfection of the classification becomes mani- 
fest) no serious disease, which is called local, is confined, either in its 
current phenomena or its effects, to any one organ or system ; and 
no general disease has its morbid processes so balanced that all parts 
of the body are affected with equal severity. This most primary 
division of diseases into general and local is far from resting upon a 
basis of exact scientific propriety. Scarcely a disease among those 
general affections already discussed is without some special local 
lesions ; and none, of any importance, that are to be treated of among 
the local affections, will have their morbid conditions exclusively con- 
fined to a single or a few organs. It is not surprising, in the absence 
548 LOCAL DISEASES. 
549 
of a well-defined line of demarkation, that upon the basis on which 
the arrangement has proceeded, there should be differences of opinion 
as to which of some diseases should be called general and which local; 
and several diseases are placed among the general affections which 
many, perhaps most, writers place among the local. Thus gout 
and rheumatism are by most placed among local diseases—diseases 
affecting the locomotor apparatus ; and diabetes is placed among the 
local diseases—and most absurdly among those of the kidneys. There 
are some diseases still to be described, such as croupous pneumonia, 
phthisis, etc., which are very doubtfully placed among the local affec- 
tions. They, however, have such intimate relations with other dis- 
eases of the lungs as to render their consideration in connection with 
them desirable. In truth, diseases not being special entities, but mere 
phenomenal deviations from the normal structures and functions, con- 
sist, even when most specific, of conditions so variable, and the differ- 
ent parts of the organism are in such intimate sympathy with each 
other, that precise distinctions cannot always be made, and an accu- 
rate and perfectly defined classification is impracticable. 
Having described those affections which are best entitled to be 
considered as “general” diseases, we now come to the consideration 
of those which are commonly spoken of as “local.” 
DISEASES OF THE ALIMENTARY CANAL AND 
DIGESTIVE SYSTEM. 
By the alimentary canal is understood the tube lined with a mu- 
cous membrane, which commences with the lips and extends to the 
extremity of the intestinal opening. The digestive system includes this 
tube and the glands which furnish secretions opening into it, and 
which furnish elements that aid in the digestive process. The lac- 
teals, which take up certain portions of the food from the intestinal 
tube, and the veins, wrhich have their origin in the membrane of the 
stomach and the intestines and carry other elements of the food to 
the liver, are also parts of the digestive system. 
Diseases of the Mouth, though not the most frequent or 
most important, will be taken first in the order. 
The conditions of the mouth, especially of the tongue, often 
afford important indications as to the general state of the system, and 
particularly the state of the digestive organs. AVe look at the tongue, 
the gums, and the throat in most cases of disease. Their dryness or 
moisture, the presence or absence of coating of the tongue, the char- 
acter of the coating, the redness or paleness of the organ, its fiabbi- 550 
STOMATITIS. 
ness or hardness, its patchy appearance, etc., are matters of impor- 
tance in diagnosis. There are morbid sensations experienced in the 
mouth, as unpleasant tastes in perverted secretions, and a sense of 
dryness in fever. There are eruptions in the mouth in the exan- 
thems, bleeding of the gums and bad odors in scurvy, and the collec- 
tion of sordes in low forms of disease. 
But local affections of the parts may cause pain, soreness, heat, 
dryness, perverted or profuse secretions, or disturbed tastes. These 
local conditions may interfere with functions, as mastication, suck- 
ing, deglutition, and speech, and even breathing may be interfered 
with, as the mouth belongs both to the digestive and the respiratory 
system. 
STOMATITIS. 
Stomatitis, or inflammation of the mouth, is not unfrequent, and 
presents several varieties. 
Inflammation of the mucous membrane of the mouth is frequently 
connected with some general disease, of which it is one of the local 
expressions. In this secondary form it may be caused by scarlatina 
or measles, or by syphilis or scrofula, and it then becomes a part of 
the phenomena of those respective diseases. 
But besides these, we have as idiopathic affections simple, erv- 
thematous or catarrhal, follicular or papillary, vesicular or aphthous, 
ulcerous or ulcero-membranous, and parasitic stomatitis or thrush. 
Simple or erythematous inflammation of the mouth is often pro- 
duced by local causes, as from irritating teeth, abuse of spices, chew- 
ing tobacco, and in children by dentition. It is allied to catarrh of 
the stomach, and in females may be produced by the conditions of 
the menstrual epoch. 
It commences with hyperaemia, and is followed by moderate infil- 
tration and tumefaction of the mucous membrane, buccal, palatal, etc. 
At first there is diminished secretion, and then the secretion is 
increased both of the surface and the glands. 
It may commence in spots and spread, or a larger surface may be 
simultaneously attacked. The epithelium is changed and often 
thrown off, and erosions occur. The causes may be local, and this 
catarrhal condition may be primary, but very frequently the stomach 
and bowels are primarily disturbed in their secretions and functions, 
and the stomatitis is secondary. 
The inflammation may be more intense in certain follicles or 
papillae, constituting the papillary variety. At first there will be 
little, raised, red spots, hard from obstructed follicles or from slight VARIETIES. 
551 
deposits. Then effusions occur, elevating and soon rupturing the epi- 
thelium, leaving small abraded surfaces or ulcers with redness around. 
When whitish or whitish-yellow spots appear upon the inside of 
the lips, cheeks, palate, or tongue, looking like drops of tallow with 
more or less redness around, occurring often in numbers and some- 
times running together, they are called aphtha}. These are points of 
effusive inflammation, corresponding to herpetic vesicles on the skin. 
The exudates are corpuscular more or less, and may be quite plastic 
or croupous. Epithelial cells variously altered are mingled with 
them ; they soon exfoliate leaving small ulcers, or at least raw sur- 
faces. The symptoms are pain, smarting, salivation, feverishness, 
irritation increased by taking food or speaking, etc. 
This form of stomatitis, like the simple variety, may occur at any 
age, but is more common in children and young people. It may be 
produced by the same local irritants as in the simple erythematous 
cases. It may also be produced by derangement of digestion, pro- 
longed diarrhoea in children, and by febrile affections in older per- 
sons. It is not unfrequent in the puerperal state ; and it may, from 
some extraneous influences, assume an epidemic form, more particu- 
larly in the variable weather of spring and fall. 
More decided ulcerative processes with a membranous exudate may 
occur, constituting uicero-membranous stomatitis. This may occur, 
exceptionally, from local irritations, in children that are in good con- 
dition. Oftener, however, it occurs in those living in low, moist 
situations, with crowding, and insufficient or improper food. In 
adults it usually begins on the margins of the gums of the lower inci- 
sor teeth, and is called gingivitis ulcerosa. The gums are much con- 
gested, are spongy, bleed readily, become fungous, and separate from 
the teeth. In connection with these ulcerative conditions exudates in 
patches may occur and spread, becoming gray, dark, and pulpy, and, 
when detached, leaving bleeding surfaces with red, raised margins. 
There is much pain and soreness, greatly increased by taking anything 
into the mouth ; the neighboring glands are swollen, and the breath is 
very fetid from the destructive changes in the part and the decompo- 
sition of the exudates. 
The constitutional symptoms are usually not very severe, though 
there is depression and slight fever. 
This uicero-membranous stomatitis is sometimes epidemic, espe- 
cially in hospitals, asylums for children, and in barracks or camps 
among soldiers, and is supposed to bo propagated by contagion. Spo- 
radic cases, however, are not unfrequent. 
Somewhat resembling the herpetic or aphthous sore mouth, yet dif- 
fering from it, is the peculiar affection called muguet, or thrush, or 552 
MERCURIAL STOMATITIS. 
white month. At first red patches are seen, more diffused than the 
isolated spots in aphthae, and upon these white points appear, soon 
coalescing and forming patches which look like curdled milk, and are 
rather easily wiped away. This material consists of an abundant ac- 
cumulation of altered epithelium, some fatty material, and other exu- 
dative matter, in which are found sporules of a parasitic fungus called 
the Oidium Albicans. By some the implanting of this parasitic material 
is regarded as the primary cause of the disease, while others (Jaccoud, 
etc.) state that the development of parasites is not primary, but forms 
the second stage of the disease. Berg, Vogel, and others state that at 
the onset there is a stomatitis with a painful hyperaemia ; that the 
membrane becomes at first dry, glittering, and hot; the saliva dis- 
tinctly acid; and that this acidity is the chief condition for the devel- 
opment of the parasitic vegetable. The epithelial cells form rapidly, 
fall off in some situations and accumulate in others, and in this mate- 
rial the fungoid germs of the air find congenial conditions for their 
growth, and the white material constituting the characteristic appear- 
ance is the result. 
It occurs frequently in young infants, without apparent preceding 
disease, but in adults it is usually an attendant upon severe diseases 
and low conditions of the system. In the last stages of consumption 
and in advanced stages of some acute diseases, as adynamical pneu- 
monia, it not unfrequently occurs. It is favored by crowding, bad 
ventilation, and organic debility. It is said the Oidium Albicans is 
never developed except on pavement epithelium. When swallowed, 
the sporules may produce fermentation, irritation, and consequent 
diarrhoea, but they do not grow upon the membranes of the stomach 
and intestines covered with cylindrical epithelium. They often ex- 
tend into the oesophagus, but not into the air-passages beyond the 
superior vocal chords. When found about the anus, it is not, as is 
sometimes supposed, an evidence of their development throughout the 
extent of the alimentary canal. 
MERCURIAL STOMATITIS. 
A peculiar form of stomatitis results from taking the more active 
preparations or an excessive quantity of mercury into the system, or 
from the ordinary mild preparations in moderate quantities being 
converted into the more active forms by other substances met with in 
the system. 
Some persons, particularly those of a delicate organization, are 
especially susceptible to the influence of mercury, and are readily PHENOMENA—DIA GNOSIS. 
553 
salivated by small doses. Children are less liable to salivation than 
adults, but they are susceptible to the mercurial poisoning from large 
and repeated doses, and when injuriously affected serious conse- 
quences—extensive ulceration or sloughing of the mouth, and other 
low inflammatory or ulcerative processes—are likely to occur. 
Mercurial stomatitis and salivation can usually be distinguished 
by the history of mercurial exposure. It is ushered in by a metallic 
taste in the mouth, tenderness and redness of the gums, and sensi- 
tiveness of the teeth, and generally by a free salivation. When the 
jaws are brought together there is a sensation as if the teeth were 
lengthened. Occasionally the mouth for a time is dry, but the sali- 
vary glands are irritated by the mercury, and their secretion is usually 
very largely increased. The breath is extremely fetid, and the odor 
is regarded as characteristic ; but in gingivitis ulcerosa, and where 
membranous exudates undergo decomposition, an odor is produced 
which, though not identical, may be mistaken for that of the mercu- 
rial sore mouth. The tongue is sometimes much inflamed and 
swollen, even to the extent of protruding from the mouth. There are 
in these severe cases much pain, often sleeplessness and headache, 
some feverishness, and rarely even delirium ; and in exceptional cases, 
especially in low conditions of the system, extensive ulceration and 
sloughing of the gums and cheeks may result. In the severe cases 
emaciation and anaemia, particularly the latter, rapidly follow, many 
of the blood discs being destroyed by the poison. 
This affection is usually followed by recovery, but when much 
ulceration or sloughing takes place, deformities remain. Anaemia and 
debility continue for some time, and the patient, for a considerable 
period at least, is more susceptible than before to a similar effect from 
exposure to the mercury. From one who has once been severely 
salivated, mercury must bo withheld, or administered with the greatest 
caution, and only where the necessity is great. 
Not only the mouth is made sore, but the salivary glands, besides 
being excited to increased secretion, are irritated in such a manner as 
often to become inflamed and swollen. 
Diagnosis.—It should be borne in mind, lest a false diagnosis 
be made and an injustice be done, that the salivary glands may be 
irritated and inflamed, or ptyalism may be induced, without mercury. 
With some, iodide of potassium produces that effect; and occasionally 
copper and antimony, cyanuret of potassium and nitrate of silver 
have a similar action. 
Ptyalism may occur spontaneously in pregnancy and some other 
conditions. In many of the diseases of the mouth, already described, 
a profuse salivary secretion is a symptom. 554 
MERCURIAL STOMATITIS. 
Irritation of the excretory duct of a gland increases the secretion 
of the gland. The diseases of the mucous membrane of the mouth, 
by involving the salivary ducts, excite the salivary secretion, and 
when such increased secretion accompanies an ulcerated condition, or 
where a membranous exudation undergoes decomposition, a fetid 
odor is produced, which, with the increased salivation, may easily be 
mistaken for mercurial ptyalism. An opinion of mercurialization 
therefore should not be hastily expressed. 
Treatment.—The treatment for mercurial stomatitis and sali- 
vation, being somewhat peculiar, may be given before describing that 
Avhich is applicable to other forms of inflammation of the mouth. 
The indications here are to eliminate the mercury from the system, 
or neutralize its action, and to soothe the inflammation and suffering 
it produces ; and finally, to restore the blood and strength which have 
been lost. 
To produce elimination and to remove any mercury possibly 
remaining in the alimentary canal, a purgative—generally a saline— 
should at once be prescribed. This should be repeated as may be 
required, and in addition diaphoretics and diuretics will aid in the 
elimination. In the meantime, or immediately after the operation of 
the cathartic, the patient should be put upon the chlorate of potash, 
in doses of from ten to fifteen grains, repeated once in a few hours. 
This drug seems to have a special influence in counteracting the 
effect of mercury, both upon the blood and the mouth. Locally, 
fomentations may be applied to the swollen glands, and various 
washes to the mouth. Holding for a short time in the mouth some 
warm water with which a few drops of oil of turpentine have been 
mingled, and repeating this from time to time, will often increase 
the flow of saliva and relieve the inflammation and pain. Dry flour 
of sulphur taken into the mouth often produces relief. When ulcera- 
tion occurs, touching the ulcerated surfaces with a solution of chloride 
of zinc, two or three grains to the ounce, or a weaker solution used 
as a wash, is quite efficient. Various astringents, as alum, tannin, 
and borax, have been advised, and they may modify beneficially the 
inflamed or ulcerated tissues ; but the salivary secretion should not be 
directly checked, as it certainly is a source of relief to the inflamed 
glands, and probably aids in eliminating the mercury. 
After the active symptoms have subsided, but not before, the 
iodide of potassium may be cautiously given, with a view of con- 
verting any mercury that may remain in the tissues into active forms 
and eliminating it from the system. If given while much mercury is 
still present, and before the active symptoms disappear, they generally 
will be materially aggravated, as the mercury converted into the TREATMENT OF STOMATITIS. 
555 
active iodide will increase the symptoms while passing out. Admin- 
istering an ordinary dose of calomel or blue pill at the same time with 
the use of iodide of potassium would be likely to be followed by severe 
effects, and is therefore to be avoided. 
The irritation of the salivary glands and throat produced by iodide 
of potassium will soon subside on discontinuing the medicine; but 
this result will be hastened, and relief obtained, by a saline cathartic, 
and by fomentations or steaming locally applied. When irritation of 
these parts from other metals occurs, their elimination should be 
hastened, and when the irritation has continued long from these or 
other causes, astringents may he used. 
The Treatment of other forms of stomatitis will consist in the first 
place in removing the causes. 
Those causes may be general—acting on the system at large, or 
local—acting directly upon the month. In most cases there is some 
general condition acting as a cause. Mercury produces its effects by 
acting through the general system, and not by any local application, 
and various general derangements find their expression in some of the 
forms of stomatitis. Age has an influence, as children are more 
liable to these affections than adults, though they may occur at any 
period, and not unfrequently in advanced life ; and bad hygienic con- 
ditions as well as ill health dispose to them. 
The exciting causes arc local irritations, dentition, diseased teeth, 
accumulations of tartar, alternation of hot and cold drinks, abuse of 
spices, chewing tobacco, taking cold, poisons in the blood, contagions, 
etc. They so frequently depend on derangements of the stomach and 
bowels that the conditions of those organs require particular attention 
in treatment. In certain states, with foul matters in the stomach, an 
emetic may give prompt relief. In other cases, and much more fre- 
quently, laxatives, antacids, and alteratives are required. All hygienic 
conditions will require attention—ventilation, a regulated diet, bath- 
ing, etc.—and all sources of local irritation must be removed. 
The local treatment should be first soothing when the irritation is 
acute, and afterward and sometimes early, alterative. . Astringents, 
mild caustics—such as touching the aphthous spots with nitrate of 
silver or a solution of chloride of zinc—borax, alum, solutions of 
tannin, or decoctions of various vegetable astringents will be useful. 
The chlorate of potash, both for local and general use, is a favorite 
and very efficient remedy. It may be used locally in a saturated 
solution, and given internally in repeated ordinary doses, adapted to 
the age and condition of the patient. 
In thrush or muguet the parasites must be destroyed. There are 
various parasiticides, and as these sporules of the oidium albicans are 556 
NOMA 
upon the surface of the mucous membrane, they may be destroyed by 
local means. The sulphurous acid in solution, of such strength as 
can be borne, is particularly efficient, and so are solutions of car- 
bolic acid or creosote, salicylic acid, etc.; or various mild astringents, 
as borax and honey, sage tea and borax, or alum, are frequently suc- 
cessful. 
Often the patients are debilitated and require to have the strength 
sustained by good diet and tonics. Preparations of iron, quinine, and 
other bitter tonics may be demanded. 
Attention to the condition of the stomach must not be neglected, 
and the treatment should often be begun by the use of alteratives and 
laxatives, as a little gray powder followed by rhubarb and soda, rhu- 
barb and magnesia, or castor-oil. These or similar articles, with some 
aromatic, may require repetition. If diarrhoea be present and debili- 
tating, it may require controlling by mild astringents and opiates. 
The turpentine emulsion is often particularly useful, to each dose of 
which may be added, with advantage, a part of a grain of carbolic 
acid. Chalk mixtures are favorites with some, but not with me. 
Lime-water with milk will often be useful. As an astringent and 
tonic in cases of weakness, anaemia, and irritability of the intestinal 
membrane, the liquor ferri ternitratis is an excellent preparation. 
NOMA. 
Sometimes more severe ulceration and sloughing of the mouth 
occurs, constituting a disease called Cancrum Oris, or Noma. It 
occurs almost exclusively in children under twelve years of age, and 
mainly in those from one to five. It appears mostly in low conditions 
of the system, in anaemia from inanition or other causes, and not 
unfrequently follows measles and other acute affections. 
The gangrene may commence at any one point of the mucous 
membrane of the cheeks or lips, or at different points at the same 
time. It perhaps more frequently commences at the reflection of the 
membrane from the cheeks on the lower jaw. It may begin with a 
small ulcer, which may be the origin of a superficial slough. Some- 
times with liyperaemia there are exudations and swelling of the cheek, 
and oedematous conditions of the lips and other parts, and in all cases 
a grayish or black sloughy patch surrounded by an intensely congested 
and livid circle of tissue appears, coagula form in the vessels, and 
the slough tends to spread in area and depth, preceded by congestion 
and infiltration. The cheek, upon the outside, often becomes tense 
and livid, and sometimes a slough involves the whole thickness of the PHENOMENA—TREA TMENT. 
557 
tissues. The gums may be eaten away, the alveoli necrosed, and if 
life continues, the teeth and portions of the jaw may exfoliate, and the 
destructive process may extend to the soft palate, fauces, and tongue. 
When the cheek is perforated the work of destruction may go on 
indefinitely till the patient succumbs. The character cf the slough- 
ing is like that of moist gangrene elsewhere. 
The general symptoms are often less severe than would be sup- 
posed. The gangrene may have made considerable progress before 
attracting much attention ; and often after much extension the pain 
is trifling and the appetite may be preserved. There is, however, 
more or less salivation, the discharge being bloody and offensive, and 
the neighboring glands are swollen. But the pulse rises in frequency 
and becomes small and feeble ; the surface becomes pale and cold ; 
drowsiness, and sometimes delirium, comes on ; diarrhoea may set in ; 
and death from failure of the heart’s action occurs. In other cases 
the progress of the sloughing is checked, and recovery takes place, 
with more or less deformity, contraction of cicatrices restraining the 
action of the jaws, etc. 
A gangrenous affection of a similar character may commence in 
the fauces or pharynx, in some cases from diphtheria or scarlet 
fever, or from an intense tonsilitis. It may, however, occur inde- 
pendently of these, and from causes which produce the ordinary 
noma. In these cases the local and general symptoms are somewhat 
similar to those just mentioned ; but the situation of the lesion causes 
the pain, difficulty of swallowing, and distress to be greater, and the 
final result is the same. 
These gangrenous conditions are often popularly attributed to the 
effects of mercury; prosecutions for malpractice have been based 
upon such cases, and not unfrequently severe censures have been 
passed upon physicians and their reputations have been impaired. 
Great care in diagnosis should be exercised, as well as caution in the 
expression of opinions, lest injustice be done, not only to individuals 
but to the profession and medical science. 
Treatment.—As these gangrenous affections are indicative of a 
low condition of the system, and are connected with an adynamic and 
debilitated state, it is of the first importance to maintain the strength 
of the patient. To this end the most nutritious and digestible 
articles of food must be regularly given, and tonic medicines admin- 
istered. Quinine and chlorate of potash must be the main reliance ; 
but diffusible stimulants, the tinct. of bark, etc., and, in the more 
protracted cases, preparations of iron may be required. If the chlo- 
rate of potash irritates the stomach, it must be omitted or the quantity 
reduced ; but the quinine should be continued, though not in sedative 558 
GLOSSITIS. 
doses. Opium may also be of great service, not merely to procure 
rest, but to aid in relieving the system from shock, and in checking 
the progress of the disease. The local treatment will consist in keep- 
ing the parts clean ; washing them frequently with antiseptic fluids, 
with solutions of chlorine, chlorate or permanganate of potash, sali- 
cylic or carbolic acid, etc.; and it is generally advised that the gan- 
grenous tracts themselves should be freely treated with escliarotics. 
Those that have most authority in their favor are pure hydrochloric 
or nitric acid, carefully applied, or the actual cautery. Either chlo- 
ride of zinc or bromine will act very efficiently as an escharotic, or 
the Vienna paste may be used. 
Complications sometimes occur, such as pneumonia and diarrhoea ; 
in most cases probably due to purulent, or rather septic infection. 
From this arises the greater necessity of destroying the slough with 
escharotics, and applying the antiseptic washes to destroy the decom- 
posing matters and prevent their absorption. The complications 
must be treated according to their conditions. 
Inflammation of the gums in dentition, though belonging to the 
special diseases of children, so often falls under the care of the gen- 
eral practitioner as to call for a passing notice. In ordinary cases the 
eruption of the teeth, especially in the first dentition, gives more or 
less uneasiness and irritation, if not absolute pain. Doubtless more 
ills are often attributed to teething than belong to it; but previous to 
the complete eruption, and at the time, the gums concerned are some- 
times decidedly inflamed and very painful, and even suppuration and 
ulceration may occur. The irritation of the gums may cause feverish- 
ness, restlessness, diarrhoea, especially in the summer months, and 
even convulsions. These symptoms may be mitigated by various items 
of treatment; but in the large majority of cases, when the teeth are 
sufficiently advanced to be prominent and these symptoms occur, the 
most speedy and efficacious treatment is to freely lance the inflamed 
gums, cutting down entirely to the teeth ; especially if convulsions 
occur the gums must be effectually divided. 
GLOSSITIS. 
The tongue, in common with other internal portions of the mouth, 
is subject to superficial inflammationsarising from physical or chemical 
injuries, from derangements of the stomach, etc. It is the seat of 
aphthse, of thrush, and of diphtheritic and other specific inflamma- 
tions. It is liable to he bitten in epilepsy and other convulsions, and 
to be irritated and ulcerated by the rough angles of imperfect teeth. PHENOMENA. 
559 
Occasionally a phlegmonous or deep-seated inflammation of this 
organ occurs, presenting very painful symptoms. It may be the 
result of mechanical injuries, of the application of caustic substances, 
of the sting of insects, or of the action of mercury. It may occur as 
a disease secondary to pysemia, to typhus, and it is said, to rheuma- 
tism ; it is often much swollen in small-pox, and sometimes in con- 
sequence of other diseases of the mouth and throat. It sometimes 
occurs independently of all such causes as an idiopathic affection. 
Phlegmonous acute inflammation of the tongue may be preceded 
for a short time, like many other inflammations, by feverishness and a 
sense of chilliness, or the pain, swelling, etc., of the tongue may be 
among the first noticeable symptoms. A rise of temperature is, how- 
ever, soon present. The whole tongue is usually involved, hut the 
inflammation may be unilateral. Whether it be the primary seat of 
the disease, or secondary by extension from other parts, the usual 
phenomena of inflammation occur—hyperaemia, proliferation, exuda- 
tions, corpuscular and fibrinous—causing the swelling. The surface 
is involved, the mucous membrane thickened, and on the dorsum 
particularly the epithelium accumulates, often mingled with bloody 
matters, giving the tongue a dark, and sometimes almost a black 
appearance. 
This inflammation is painful, and sometimes so extensive as to 
cause the tongue to fill the mouth, to protrude between the teeth, and 
to extend back and interfere not only with deglutition, but with res- 
piration also, and of course with speech. 
It may terminate in resolution, in suppuration, or in more or less 
induration, and more rarely in gangrene. The course may be rapid 
or more slow ; it sometimes becomes chronic after an acute attack, 
and sometimes is chronic from the beginning, with induration among 
the early conditions. Cases of chronic glossitis may be partial, pro- 
duced by friction from sharp fragments of the teeth, or by tartar 
upon them, and the increase of connective tissue and solid exuda- 
tions in a limited part will present the appearance of a tumor. It 
may even be mistaken for a cancer, and should be distinguished from 
it by carefully observing the history and appearance. It may also be 
confounded with syphilitic enlargement or gummata ; in the latter 
case, however, there will be a history of syphilis, and a yielding to 
anti-syphilitic treatment. 
Sometimes a peculiar chronic form of glossitis occurs, the tongue 
being enlarged, dry, fissured, and often very painful. This has been 
observed in syphilitic patients, and the question may then be pre- 
sented, whether it is the effect of syphilis or of the mercury taken for 
its cure. 560 
CYNANCHE. 
In nervous, hypochondriacal women, a papillary form of glossitis is 
sometimes observed. The papillae on the back part of the tongue are 
prominent, red, hard, hot, painful, and produce great uneasiness and 
irritation. 
Jaccoud has seen cases in men who were smokers, and he attributes 
it in these cases to that cause. 
The sufferings of a patient from glossitis are usually out of pro- 
portion to his danger. The pain is often great, but the sense and 
fear of intending suffocation in severe cases may be very great and 
sufficient to prevent all rest and peace. 
Treatment.—This is to be conducted on the same general prin- 
ciples as for other local inflammations. When the glossitis is superfi- 
cial, the treatment will be the same as already described for stomatitis. 
Deep-seated, acute cases require energetic measures. Soothing 
and cleansing washes should be used, leeches may be applied to the 
tongue itself, or to the swollen parts externally, followed by fomen- 
tations ; or if the swelling be great, longitudinal incisions should be 
made in the tongue. Such incisions thoroughly made are generally 
very efficacious in reducing the swelling and procuring relief; and if 
an abscess forms it should at once be freely opened. 
Internally a saline cathartic should early be given, and the bowels 
kept open ; and febrifuge treatment as in other inflammations will be 
required. Febrifuge doses of quinine in severe cases should have a 
trial, and opiates, used however with caution when suffocation is 
threatened, may procure great relief. Steaming as for tonsilitis, 
early, and repeated from time to time, is also useful. Tracheotomy 
is the last resort in case suffocation is seriously threatened. In cases 
at all protracted, care must be taken respecting foods—liquid prepa- 
rations must be given ; and in case swallowing is impossible they may 
be introduced by the stomach-pump through the nose, or can be 
given by enema. 
In chronic cases the cause must be observed and removed ; sor- 
befacients, iodides, etc., should be used ; and in some cases surgical 
interference may be demanded. To the fissured variety astringents 
and nitrate of silver locally are advised. The caustic is to be applied 
in the fissures and over the surface generally. 
INFLAMMATION OF THE THROAT.—CYNANCHE.— 
ANGINA. 
Inflammations of the throat are divided into catarrhal, superficial 
or erythematous, and deep-seated or phlegmonous. They are also PHENOMENA. 
561 
divided according to the particular part of the throat which is spe- 
cially the seat of the inflammation. 
The general terms indicating inflammation of the throat as a 
whole are used, because the disease very seldom affects any one part 
without involving the rest. The parts are so intimately connected 
by proximity, by similarity of structure, and by nervous and vascular 
supply, that these inflammatory diseases may properly be considered 
together. When an inflammation commences at one point it gener- 
ally extends to others, and the whole throat is often simultaneously 
attacked. The disease in each particular part has some peculiarities, 
but the chief distinction as to the parts involved is made between the 
superficial and deep-seated varieties. The specific character of the 
inflammation also influences its course and treatment, much more 
than the region in which it is situated. 
An inflammation of the throat may be primary or idiopathic, or 
secondary and symptomatic of some other disease. 
Thus, a sore throat may occur from extension of the disease from 
the mouth, tongue, nose, or larynx; and it may occur as a part or a 
complication of the exanthemata or other acute affections. It is almost 
constant in scarlatina and small-pox ; very frequent, though not so 
severe, in measles; and not unfrequent in erysipelas, typhoid fever, 
pneumonia, rheumatism, and some of the cutaneous affections ; and 
there are some chronic diseases, as syphilis, phthisis, stomach derange- 
ments, etc., that are accompanied with soreness of the throat. 
The most common cause of all the acute or idiopathic sore throats 
is “catching cold.” This may occur from exposure when over- 
heated, from change of weather, or change of warm clothing to thinner 
garments, from wetting the feet, partial exposures, and other similar 
familiar causes. Using hot and cold ingesta at the same meal; irri- 
tating substances in the atmosphere ; the use of certain medicinal 
or poisonous agents, as mercury, iodine, bromine, antimony, zinc, 
alcohol, belladonna, stramonium, tobacco, etc., may act as causes. 
Excessive use of the voice, or excessive indulgence in condiments and 
rich food ; reflex influences from distant organs (as the heart, stomach 
and intestines, liver, genito-urinary organs, etc.) are also classed among 
the causes. The influence of these latter causes affects the mucous 
membrane much more than the deeper parts. 
Acute catarrhal inflammation of the mucous membrane covering 
the fauces, tonsils, soft palate, uvula, pharynx, etc., is perhaps the most 
common form of sore throat. In ordinary mild cases it is but a slight 
affair, and often attracts but little attention. As the result of taking 
cold, the same conditions of hypergemia, at first diminished and after- 
ward increased secretions, occur. In short, the condition of irritation 562 
CTNANCHE. 
and mild inflammation affects tlie Schneiderian and laryngeal, as well 
as the fancal and pharyngeal membranes, and a catarrhal sore throat 
results. From its not unfrequent greater severity, or its longer con- 
tinuance, it becomes a subject of care and treatment. It is generally 
accompanied with slight feverishness, and in the severer forms there 
may be rigors with decided feelings of indisposition, the temperature 
rising to 101° or 102°. In these cases the mucous membrane is in- 
tensely red, and more or less swollen, and there is oedema of the 
mucous and submucous tissue. When this extends to the glottis and 
larynx, hoarseness and dyspnoea are apt to result. There is a sense of 
accumulation within the throat, and a disposition to clear it by hawk- 
ing or swallowing. The uvula is elongated, often to the extent of 
producing irritation and cough, by its falling upon the epiglottis or 
the roots of the tongue. This affection continues commonly for only 
a few days, and is without danger except in the very rare cases where 
there is oedema of the glottis. 
Treatment.—The treatment, where treatment is called for, may 
be commenced with a Dover’s powder or a dose of morphine, with free 
steaming of the throat, and this followed the next day by a saline 
cathartic. Should the stomach be loaded with a full meal, especially 
of food not the most digestible, a mild emetic might, with great 
advantage, precede all other measures. If the inflammation persists, 
a few free doses of quinine, or quinine and chlorate of potash, may be 
given, and this will very generally shorten materially the course of the 
disease. If much oedema occurs, scarification wTi 11 be useful, and some- 
times the cedematous and elongated uvula may be clipped off, thus 
relieving the irritation it causes. Astringents, as solutions of alum, 
borax, or tannin, are generally recommended, and in advanced stages 
may be useful; but in the earlier stages the inhalation of warm vapor, 
and fomentations externally, are more efficient in favoring resolution. 
Stimulating gargles are, as a rule, contra-indicated in the acute stages. 
Sipping mucilaginous liquids procures relief, and some advise taking 
into the throat and swallowing small pieces of ice. Astringents and 
ice on the one hand, and relaxants, steam,'and warmth on the other, 
though opposite modes of treatment, may both be useful, abating the 
inflammation, but in different ways. The one by constringing the 
vessels and suppressing action, the other by promoting secretion and 
unloading the vessels and tissues, and soothing irritation. In some 
cases one may be the better plan, and in others the other; but, as a 
rule, I prefer the warmth and steaming; still, whichever plan is 
adopted, it should not be alternated with the other. The diet should 
consist of liquid foods, milk mingled with farinaceous substances in a 
fluid form, preparations of eggs, etc., wdiile swallowing is painful. TREATMENT. 
563 
The patient should be confined to his room at least, and often to his 
bed or lounge, and the extremities kept warm by suitable covering 
after more heat has for a time been applied to the feet. This is an 
important item of the best treatment. 
A variety of faucal and pharyngeal inflammation is occasionally 
observed where a more or less abundant secretion of glutinous matter 
from the follicles gives rise to a white or ash-colored exudate upon the 
membrane. 
This pultaceous deposit may be mistaken for the diphtheritic mem- 
brane. It differs from it in its composition and character, and par- 
ticularly in the accompanying general affection. This exudate is 
transient, is easily wiped away except where it dips into the follicular 
depressions in the tonsils and cannot be readily reached. This variety 
of acute sore throat is as benign as the ordinary form, and requires 
only the same treatment. It is important to distinguish it from diph- 
theria, as otherwise statistics of therapeutical success in the latter dis- 
ease become vitiated. 
Another variety of superficial inflammatory sore throat is charac- 
terized by serous infiltration into the submucous tissue, and is known 
as cedematous angina. It is often developed suddenly, and produces 
more or less difficulty of swallowing and breathing. Should the 
oedema extend to the glottis, the dyspnoea might be severe and danger- 
ous, requiring surgical interference, scarification of the glottis, or even 
laryngotomy. In all ordinary cases, however, no other treatment is 
required than that which is applicable to the other varieties. 
CHRONIC INFLAMMATION OF THE MUCOUS MEMBRANE OF THE THROAT. 
—CHRONIC PHARYNGITIS.—CHRONIC FOLLICULAR PHARYNGITIS. 
— CHRONIC CATARRH OF THE THROAT. 
This is a frequent, a troublesome, and an obstinate affection, more 
frequent in men than in women, and oftener found among profes- 
sional and business men, and among students, than among the com- 
mon laboring classes. 
This inflammation may be idiopathic or traumatic, apparently 
primary, or secondary to other morbid conditions. 
It may be an element of diphtheria following that disease, or of 
tuberculosis, or syphilis, or scrofula, or cancer, or of gout, rheuma- 
tism, or erysipelas, of albuminuria, of glandular swellings, of tumors 
or strictures of the part; it may follow the exanthematic fevers, it may 
be associated with diseases of the skin ; not unfrequently with nervous 
affections, hut more frequently than with any, or possibly with all the 564 
CHRONIC PHARYNGITIS. 
rest, it is associated with, and very often dependent upon, diseases of 
the digestive apparatus, particularly of the stomach. 
The mucous membrane of the throat is particularly prone to 
chronic disease. It is exposed to many irritating impressions ; it is 
liable to he affected by the extension of skin diseases; it is constantly 
in use, and is in close sympathy with the stomach. 
In its treatment no continuous applications can be made, and the 
morbid condition often resists those that can be only temporarily 
applied. 
The membrane, in these cases of chronic pharyngitis, is reddened, 
the surface, though sometimes smooth, is generally rough and irregu- 
lar, presenting a granular or mammillated appearance. The secretion 
is affected ; sometimes it is diminished, and the throat is dry and glossy ; 
at other times it is increased, and of course is perverted, and is often 
tenacious and adherent. Normally the effusion moistening the sur- 
face of the membrane is serous, but under this inflammatory irrita- 
tion the epithelial cells are rapidly but imperfectly produced, mingled 
sometimes with leucocytes, constituting mucus, with a variable quan- 
tity of serous and more solid material, producing a more or less tena- 
cious coating of the surface, which excites frequent effort to clear it 
from the throat. Sometimes the secretion remains quite serous, and, 
when abundant, it collects in drops, looks like granulations, and may 
be mistaken for them. When the surface is abraded of its epithelium 
it presents the appearance of an ulcer. 
The unevenness of the surface is in part from hypertrophy of the 
follicles, and in part from the rapid proliferation of the epithelial cells 
pushing up in points. Not only mucus, but pus may be produced 
without the occurrence of the ulcerative process, or the full destruc- 
tion of the epithelial covering—a secretion taking place from the 
follicles. 
Sometimes the exudate is fibrinous, and the water evaporating 
from the albuminoid matter, a pellicle is formed of considerable 
thickness and firmness, which is with difficulty removed. 
Chronic inflammation of the throat may commence in the mouth, 
nasal passages, or the larynx, but more frequently its original seat is 
in the pharynx, and it may be confined chiefly to that part. It not 
unfrequently extends to the air-passages, though seldom to the 
oesophagus, and laryngitis often follows pharyngitis. Contiguous 
sympathy, and the more remote sympathy with the stomach operate 
both ways. The irritation of the pharynx often involves the larynx, 
and that of the larynx the pharynx. So an irritation of the throat 
affects the stomach, and that of the stomach the throat. 
The causes of the chronic sore throat—besides the inflammation DIA GNOSIS—PROGNOSIS— TREA TMEN T. 
565 
or the diseases with which it is associated and of which it forms ail 
element—are, exposure to cold and dampness, the inhalation of dust, 
the breathing of the atmosphere in workshops, mills, laboratories, etc., 
the inhalation of tobacco smoke, the alternate use of hot and cold 
drinks, ice-cream followed by hot coffee, and the free use of ice-water 
with a hot dinner. Though occurring in others, it is frequent in 
those who use alcohol, and in many cases is clearly traceable to alco- 
holism. Its connection with, and dependence upon, other morbid 
conditions must not be overlooked. 
Diagnosis.—The diagnosis is to be made by the symptoms of un- 
comfortable sensations in the part, by the disposition to be frequently 
clearing the throat, etc., but more particularly by a careful inspection 
of the part. For this purpose an angular tongue depressor is conven- 
ient, and in some cases sufficient; but to determine the extent of 
the disease, and especially the condition of the glottis and deeper 
parts, the laryngoscope is important. This consists essentially of a 
mirror which throws a strong and concentrated light into the throat, 
with another small mirror placed at an angle of about 120 degrees, 
with a long handle, and which is held in the throat in such positions 
as to reflect images of the parts out of the direct line of vision. After 
some practice in the manipulation, all the parts, even to the interior 
of the larynx, can be made open to accurate observation. 
This chronic follicular pharyngitis is particularly frequent in our 
American towns, and from its obstinacy it often comes under the 
notice of physicians. Its particular history in each case requires to 
be understood. The manner of attack varies. It is sometimes the 
result of more acute inflammations, but it oftener comes on gradually. 
When so, there is noticed first uneasiness and a sense of dryness, or 
a secretion of tenacious muco-plastic matter which produces irritation, 
sometimes a cough, especially in the morning, and nearly always a 
disposition to clear the throat. The voice is apt to be husky, and 
not to be fully depended upon, and there is often a perceptible degree 
of hoarseness. As the Eustachian tubes are apt to be involved, there 
is sometimes impairment of hearing. 
Prognosis.—The prognosis is favorable as to immediate danger, 
but not as to speedy cure. Left to itself, with the continuance of the 
causes which have contributed to produce it, it usually continues on 
indefinitely. It is often exceedingly obstinate under the best manage- 
ment, and generally requires a protracted course of treatment for its 
removal. 
Treatment.—The treatment is both general and local. In the 
general treatment reference must be had to the causes which produce 
it. The indigestion, the constipation, the sedentary life, the neglect 566 
CHRONIC PHARYNGITIS. 
of the skin, the exposures, the improper ingesta, the public speaking, 
and the emotional excitements which are among the more frequent 
causes, must all, as far as possible, be removed. Still the part cannot 
be entirely at rest; more or less exposure will occur, and the treat- 
ment is not as successful as could be desired. As it must usually be 
protracted the patient should generally, in the beginning, be so 
informed. 
The improvement of the general health should be a principal 
object. The strictest attention should be given to avoiding the 
causes, and to complying with all hygienic conditions. Particularly 
should attention be given to correcting the state of the stomach and 
bowels, so often at fault in these cases. 
The urine should be examined, and it will sometimes be found 
that the lithates abound, or that the peculiar perversion of digestion 
and assimilation which results in the production of oxalate of lime in 
the blood and tissues, with its appearance in the urine, is present. 
These various conditions and their particular treatment need not 
here be detailed ; they will be described in other connections. What 
is called an alterative and a laxative course will often be required. 
Small doses of mercury, as the to the of a grain of the bichlo- 
ride, once or twice a day for some days, or for tAvo weeks, or possibly 
more, Avith mild doses of some saline laxative occasionally, will often 
be found very useful. This should often be followed by an alterative 
course of iodide of potassium, or the iodide might be given without 
the preceding mercurial. FoAvler’s solution, in ordinary doses, is 
another article Avhich is sometimes thought to be useful. In some 
cases tonics are required, but more frequently alteratives and elimi- 
natives are needed. If oxaluria be found to exist, the nitro-liydro- 
chloric acid will be found useful; and, in short, the general treatment 
must be governed by the general condition of the system and the 
particular symptoms observed. The internal use of the fluid extract 
of hamamelis, or witch-hazel, sometimes appears to produce a decided 
and somewhat specific action upon this condition of the throat. I have 
given it in connection with iodide of potassium, and also alone, with 
apparent decided effects. It is held in very high esteem in this and 
other affections by some Avliose opinions, based upon experience, are 
entitled to respect. It is Avorthy of more extensive trial in chronic 
pharyngeal inflammations. 
The local application most frequently used, and which is often very 
useful, is the nitrate of silver. After clearing away the mucus by 
syringing or mopping out the throat, a solution of the pure nitrate, 
of the strength of from forty to sixty grains to the ounce of distilled 
water, or even up to a saturated solution, may be applied with a TREATMENT. 
567 
small, soft sponge, or a camel’s-hair brnsli, and repeated once in two, 
three, or four days, according to the effect. Although this is some- 
times useful, there are times when it is of no benefit, and it may 
increase the irritation. It will sometimes relieve the symptoms for a 
time, and then cease to have any beneficial effect. In other cases it 
may for a time aggravate the symptoms, but by perseverance in its 
use good effects will at length be realized. In obstinate cases the 
follicles may be split, and a stick of the caustic applied to the incision. 
If the silver fails after a fair trial, the chloride of zinc, or the iodide 
of zinc, or iodine, in different preparations and of different strengths, 
may be applied. Atomized fluids, alterative and astringent, weaker 
or stronger, and more or less frequently, may be used. Whatever the 
application, the mucus, sometimes thick and adherent, which so often 
covers the surface, must be removed before the application will pro- 
duce its full effect. Sometimes an application of glycerine and tan- 
nin, made with a brush—from half a drachm to two drachms of tan- 
nin to an ounce of glycerine—will do excellent service. The chlorate 
o-f potash, locally applied in strong solution, or in the form of loz- 
enges, and the chlorate taken internally will often procure relief. 
A little glycerine taken frequently upon the tongue will not only 
relieve the sense of dryness and irritation, but may modify more per- 
manently the inflamed surface. 
The nasal douche, with warm water holding in solution a little salt, 
will clear away any obstruction in the posterior nares; but free cold 
injections into the throat sometimes induce inflammations of the 
internal ear, and should be avoided. 
The local treatment should be conducted on the same principles 
as in a case of chronic conjunctivitis, and no positive course can be 
laid down beforehand and rigidly adhered to. The practitioner 
must be governed by the effects produced and by his experienced 
judgment. 
Lately it has been recommended that the actual cautery, by means 
of the galvano-cautery, be applied in obstinate cases that resist other 
measures ; but it has not as yet been sufficiently used to test its com- 
parative efficacy or its applicability. 
The bromide of potassium and bromide of sodium are supposed to 
operate somewhat particularly upon the throat, diminishing its sensi- 
bility and allaying irritation. Various anodynes, such as conium 
maculatum, hyoscyamus, lactucarium, and preparations of opium, 
procure relief to the symptoms; but care must be taken, in chronic 
cases of this kind, that habits of narcotism be not established. Vari- 
ous lozenges containing cubebs, with conium, and small doses of ipecac, 
made up with extract of liquorice, often produce a soothing effect, at 568 
CHRONIC PHARYNGITIS. 
least temporarily, and may aid in the cure. Time, patience, and per- 
severance, with the strictest observance of hygienic rules, the avoid- 
ance of alcohol, tobacco, and all other injurious influences, will be 
necessary to the best success. As a last resort, a change of climate 
may be tried. 
CHEESY DEPOSITS IN THE FOLLICLES OF THE TONSILS. 
Another variety of chronic inflammation of the throat, or a com- 
plicating symptom of this disease, requires to be noticed. The fol- 
licles of the tonsils have formed within them little masses of an 
unctuous, light-colored, cheesy-looking substance, which project from 
the surface, are easily removed by a spatula or a probe, and, when 
pressed upon, are readily crushed, emitting a fetid odor. This form 
of the affection may occur in men or women, and has been seen at dif- 
ferent ages, but more frequently, in my experience, in young adults. 
As these little concretions are not unfrequently thrown out by cough- 
ing, they are sometimes mistaken for tuberculous matter, and may 
excite much alarm. 
They are not of serious import, and these cases require treatment 
similar to those where this condition does not exist. The application 
of a strong solution of nitrate of silver to the tonsils will generally 
check the production of this cheesy matter. 
These simpler diseases of the throat should be carefully distin- 
guished from syphilitic affections of these parts. There is far less 
tendency to ulceration in those which have been described than in the 
syphilitic, and the further characteristics of the latter are redness 
more in patches, the color more livid, but with whitish patches from 
thickening of the epithelium ; and the principal lesion is seated upon 
the soft palate. 
Extending and eroding ulcers of this part cause suspicions of 
syphilis ; and other lesions of a specific character, together with the 
history of the case, will make the diagnosis clear. 
The inflammation in chronic pharyngitis may extend to the 
larynx, though it is not likely to do so ; but when this is the case, 
special restrictions as to the use of the voice are necessary. A sore 
throat may occur in consumptive persons, and the larynx in them 
is frequently affected by tuberculous deposits and ulcerative processes, 
hut ordinary pharyngitis is not indicative of a consumptive tendency. 
The prognosis, therefore, though not favorable as to a speedy cure, is 
not unfavorable as to the life of the patient. 
Sometimes, but very rarely, a slow ulcerative process occurs in the 
throat, independent of any syphilitic influence. It is recognized by RETRO-PIIAR YNGEAL ABSCESS. 
569 
excluding the history and all other evidence of the syphilitic taint. 
It occurs in debilitated conditions of the system, and requires to be 
treated as other similar ulcerations, by tonics, alterative applications, 
etc. 
ACUTE PHLEGMONOUS INFLAMMATIONS OF THE 
THROAT. 
These are inflammations of a parenchymatous character, having 
their chief seat in the tissues deeper than the mucous membrane. 
They are not unfrequent. There are varieties as to the character and 
particular seat of the inflammation ; but they are all marked by pain, 
more or less difficulty of swallowing, perceptible swelling, and febrile 
movement. There is change of voice, often cough, and more or less 
deafness, and sometimes dyspnoea ; and a proper examination will 
show not only the general character, but the particular location of 
the disease. 
RETRO-PHARYNGEAL ABSCESS. — POST—PHARYNGEAL PHLEGMON. 
This is a phlegmonous inflammation resulting in suppuration, 
having its seat beneath the mucous membrane covering the wall of 
the pharynx, in front of the cervical vertebrae. It may occur as a 
primary inflammation in the loose connective tissue beneath the mem- 
brane, especially in children ; or from extension of inflammation 
from the tonsils, or from the deep cervical or the bronchial lymphatic 
glands ; or it may be the result of primary disease in the bodies of the 
cervical vertebrae. 
The acute primary cases are marked by pain, tumefaction, and 
febrile movement, and the attack may be abrupt, and the progress to 
suppuration rapid. In the secondary cases the progress will be slower, 
but varied in this respect by the character of the primary disease. 
There will be difficulty of swallowing, and often of breathing, and 
thickness of the voice ; and particularly when from caries of the ver- 
tebrae there will be pain on moving the head, which becomes more or 
less fixed in its position, the neck often much swollen externally; and 
in all the cases, on examination with the finger, carried gently over 
the base of the tongue, a hard, brawny tumor will be felt in the early 
stage, but a soft, fluctuating one as free suppuration occurs. 
The usual changes in the character of the symptoms take place as 
suppuration is established ; and, left to itself, the abscess may be dis- 
charged into the lower pharynx, or the pus may extend downward 
into the posterior mediastinum and may be discharged into the pleural 570 
PHLEGMONOUS SORE THROAT. 
sac ; or may penetrate the oesophagus, the trachea, or even the carotid 
artery. 
Etiology.—The primary attacks may be excited by cold and the 
other common causes of inflammations of the throat; and in this form 
of the disease childhood is a predisposing condition. 
The most common predisposing causes, however, are syphilis and 
struma, inducing caries of the bones or suppuration of the glands. 
When it extends from inflammation and suppuration of the tonsils, 
the same causes which produce that affection are operative in this. 
The course, severity, and danger of these abscesses will depend 
upon the causes and accompanying conditions. They will be more 
protracted in the strumous and syphilitic cases, and any form may 
he severe and dangerous if neglected. 
Prognosis.—In cases left to themselves the prognosis is gen- 
erally grave, and death may occur from the matters traveling and 
invading distant parts ; from producing suffocation by pressing upon 
the glottis and larynx; from oedema of the glottis ; or upon the 
rupture of the abscess, from the matters filling up the air-passages. 
When the abscess is associated with caries of the vertebrae, or with 
extensive glandular disease, the patient may be worn out by these 
affections and by ulcerative processes after the abscess is discharged. 
In more rare cases, the inability to swallow may be absolute, con- 
tributing to a fatal result. 
Diagnosis.—The disease is to he distinguished by the symptoms 
which have been described, and particularly by the ocular and digital 
examination. The pain in swallowing, the difficulty of breathing, the 
muffled voice, and the history of the case will aid in the diagnosis. 
The dyspnoea should be distinguished from that of croup. It 
arises in pharyngeal disease often from oedema of the glottis, and in 
this case, for obvious mechanical reasons, the inspiration is more 
difficult than the expiration, while in croup inspiration and expira- 
tion are nearly equally affected. 
Treatment.—In acute and primary cases the general treatment 
will not differ from that of tonsilitis, and should be pursued with at 
least equal vigor, as, unchecked, the results are so much more grave. 
When suppuration occurs, which is to be ascertained by careful 
digital examination, the abscess should be freely opened, and as low 
as necessary or possible, to evacuate all the matter. 
The incision should be made in the mesial line, in order to avoid 
vessels of considerable size ; and when the collection of matter is behind 
the tonsils, the greatest care is necessary not to wound the vessels of 
the neck, and in these cases the trochar or aspirator will be safer. 
In oedema of the glottis threatening suffocation, incisions into the TONSILITIS—PROGNOSIS. 
571 
cedematous part and letting out the serum will be important. An 
angular bistoury, guided by the finger, may suffice, but the laryn- 
goscope will aid in this somewhat difficult operation. 
Laryngotomy, or tracheotomy, as in other obstructions to respira- 
tion in the throat, must be held in reserve as a last resort. In glandu- 
lar and carious complications, or where an ulcerative process follows, 
treatment adapted to these conditions will be required. 
TONSILITIS.—AMYGDALITIS.—QUINSY. 
This is a phlegmonous or parenchymatous inflammation of the 
tonsils, extending more or less to the neighboring parts, and some- 
times involving the salivary glands. There is a strong tendency in 
this inflammation to suppuration, but it may spontaneously terminate 
in resolution, and resolution may very often be induced by treatment. 
The inflammation may extend to the glottis, pharynx, and larynx, 
inducing oedema of the glottis and seriously obstructing respiration. 
This, however, is not frequent; and the only difficulty of breathing 
is usually from the great swelling of the tonsils which sometimes 
occurs. 
The symptoms of tonsilitis are usually marked, and the course of 
the disease rapid. 
The access is generally abrupt. There is a chill and active fever; 
the pulse is bounding, and the temperature goes up to 103°, 104°, or 
even 105°. There is pain, marked difficulty of swallowing, and a 
thick voice. A proper external examination will detect tumefactions 
deep behind the angles of the jaw, and by looking into the throat the 
whole fauces and pharynx will be found hyperaemic, the uvula will be 
swollen and resting often upon a tonsil, and the tonsils themselves 
will often appear like two balls of flesh, approaching and sometimes 
meeting each other, and filling up the throat. 
The disease is sometimes more gradual in its access, and the swell- 
ing may not be as great. 
Prognosis.—The prognosis is very favorable, unless there is 
serious interference with respiration by the extreme swelling, or by 
the inflammation extending to the air-passages. 
It may terminate in resolution, suppuration, or possibly gangrene. 
When in resolution, the termination may be in a very few days ; 
but when suppuration takes place, the case is more protracted. A 
gangrenous termination is very rare, and its course uncertain. The 
disease may linger and become subacute ; and where repeated attacks 
occur, as is not unfrequently the case, the tonsils may become hyper- 
trophied, producing the usual result of such enlargements. 572 
TONSILITIS. 
Diagnosis.—It is to be distinguished from post-pharyngeal 
abscess, from diphtheria, from scarlatina anginosa, from erysipelas 
of the throat, from acute catarrhal inflammation or pharyngitis, from 
parotitis, and laryngitis. A comparison with diphtheria has been 
made (see page 31G). The difference between this and the other affec- 
tions named will be sufficiently obvious without being particularly 
pointed out. 
Treatment.—The treatment of tonsilitis is important, as, when 
early undertaken, the disease is much under the control of remedies. 
Without giving an account of the numerous methods which have been 
recommended, I will do little more than describe a course of treat- 
ment the main features of which were long ago received from Prof. J. 
Delamater, and the efficacy of which has been proven by all my sub- 
sequent experience. 
On seeing a patient, especially early in the attack, an opiate, as a 
free dose of Dover’s powder, should at once be given. A decoction of 
hops is to be made, and after the strength has been largely extracted 
by the hot water, vinegar is to be added in an amount approaching 
that of the hop decoction, and the whole heated together. While this 
preparation is going on, a brick may be broken into fragments about 
the size of a hen’s egg, and put into the fire. The hops, vinegar, and 
water should then be put all together into a pan, taken into the lap, 
and the head and pan covered with a blanket. Pieces of the hot 
brick, from time to time, should be dropped into the pan, and the 
volume of steam produced should be allowed to envelop the throat 
and face, and should be inhaled as warm and as freely as can be 
borne, air being admitted more freely, from time to time, as may be 
necessary. This steaming process may be kept up for from twenty to 
forty minutes. The hops, with perhaps an addition of some meal to 
make a more consistent poultice, and a little mustard, to produce a 
moderate amount of counter-irritation, are to be applied in a muslin 
bag to the throat, and the patient allowed to rest quietly in bed, well 
covered. The Dover’s powder, the steaming, and the poultice, may 
be repeated in a few hours, as may be deemed necessary. According 
to the testimony of Prof. Delamater, fully confirmed by my own 
experience, this treatment, when applied early, will check the inflam- 
mation very markedly, and almost invariably prevent suppuration. 
The next day, or a little later, a saline cathartic should be given, and 
if the treatment is commenced early, a cure will very soon be effected. 
If the inflammation has gone so far that suppuration cannot be pre- 
vented, the symptoms will still be greatly relieved, and the spread and 
extent of the inflammation diminished. 
In advanced or more severe and obstinate cases, scarification of TREATMENT. 
573 
the tonsils—quite decided incisions into them—will generally pro- 
cure marked additional relief. When suppuration occurs, which may 
usually be distinguished by the softened feel of the tumor, the abscess 
should be opened ; and in all uses of a cutting instrument about the 
parts, the blade should be guarded by being wound to within half an 
inch or so of the point, and the back of the knife should be kept 
toward the vessels, and the cutting toward the mesial line of the body. 
Besides, the head and hands, especially of a child, should be firmly 
held, to prevent accidents from struggling. Later, astringent gargles 
may be used; but earlier, the steaming process is much more efficient. 
Other particular processes of steaming may answer the indication, but 
I have found none quite as efficient as the one described. 
If, instead of the simple Dover’s powder or other form of opiate, 
five or six grains of quinine for an adult be added, and repeated a few 
times, the resolution will be still more certainly effected. The opiate, 
with the steaming, etc., is so generally successful that the addition of 
the quinine is not often required. Where, however, the steaming 
cannot be properly carried out, the quinine, in the doses indicated, 
often combined with chlorate of potash and carried to the extent of 
from a scruple to twenty-five or thirty grains, will very seldom fail to 
jn’oducc resolution. 
It may be well simply to add that gum guaiacum in doses of from 
ten to twenty grains, or from half a drachm to a drachm of the tinct- 
ure, given once in from two to four hours, is said to be very efficient 
in producing resolution. Some persons are particularly liable to the 
recurrence of tonsilitis with rapid suppuration; but even in these cases, 
where the treatment recommended is promptly applied, suppuration 
may generally be prevented. 
A form of sore throat has been described, of which I have seen 
not a few instances, under the name of Spreading Quinsy or Epidemic 
Quinsy. 
It is marked by lassitude, pain in the limbs and back, slight chills, 
disordered stomach, decided fever (temperature from 101° to 104°), 
pricking sensations in the throat, hawking, etc. The tonsils are 
enlarged and inflamed, the redness extending over the pharynx, 
fauces, and uvula. Yellowish opaque spots are sometimes seen in 
large patches after the disease has continued some little time, but 
they are easily detached. 
There is tenderness under the jaw, and pain in swallowing, and the 
salivary glands are generally somewhat swollen. The tonsils are not 
as much enlarged as in ordinary quinsy, and not as much inclined to 
suppuration. 
The general symptoms are quite severe; there is more depression 574 
EPIDEMIC QUINSY. 
than in common quinsy, sometimes delirium in the evening ; the 
urine is febrile hut not albuminous ; there is much weakness during 
the fever, and it often continues afterward; and when the disease is 
left to its course the active symptoms last about a week. 
It is a Filth Disease, and is apt to occur on exposure to sewer gas 
or other decomposing substances. It has often been observed in 
workers in the dissecting-room when material is not well preserved. 
On one occasion under my observation a family of several persons, 
otherwise well cared for, were all taken ill a day or two after the 
cleaning out of a common privy which was situated in an out-build- 
ing, but under a continuous roof with the dwelling. During the 
cleaning a terrible stench pervaded the whole house for several hours. 
The disease in all these cases was characteristically such as described. 
Treatment.—The best treatment consists in the administration 
of a cathartic, followed by a diaphoretic, but particularly by quinine 
in doses sufficient to produce its antidotal and antipyretic effects. 
Five or six grains should be given at a dose, and repeated several 
times at intervals of a few hours, in combination with ten or twelve 
grains of chlorate of potash ; and when there is much pain and rest- 
lessness, an occasional anodyne should be added; and the steaming 
process for soothing the local affection should be used. Recover}7 
takes place in a much shorter time when these means are ]3romptly 
resorted to. 
Chronic Enlargement of the tonsils, as removal is often required, 
is generally considered surgical, and need not here be described. In 
the earlier stages of these enlargements, iodine in the form of tincture 
locally applied, and some preparation of it taken internally, will 
sometimes cause absorption and prevent the necessity of a resort to 
extirpation. 
An acute disease formerly described as Malignant Sore Throat, 
or as Phagedenic or Ulcerated Sore Throat, in many of the cases 
perhaps identical with diphtheria, though in others apparently differ- 
ent from it, has been recognized. It resembles the sore throat of 
scarlatina, is a low typhoid form of disease, and is probably connected 
with a blood poison. Its course has varied, and it has not been 
well defined. There is, however, a depressing influence and a gangre- 
nous tendency. 
Treatment.—The treatment should consist in giving a good diet 
—beef-tea, preparations of eggs and milk—and in the administration 
of quinine and chlorate of potash, tincture of iron, stimulants, etc. 
Steaming and antiseptic gargles, as in diphtheria, will also be appli- 
cable. Salicylic acid with carb. of ammonia and soda may be tried 
internally. (ESOPHAGITIS. 
575 
DISEASES OF THE (ESOPHAGUS. 
There are several morbid conditions of the oesophagus met with 
occasionally, some of which, requiring manipulations, are generally 
treated of in works of surgery, and more properly belong to them. 
Some, however, occur in connection with medical cases, and require 
a brief notice here. 
(ESOPHAGITIS. 
Inflammation of the oesophagus is comparatively rare, and when 
existing is sometimes unrecognized. It may be either primary, or sec- 
ondary to some other affection. When primary, it is usually due to 
some obvious external cause, such as the swallowing of irritating mate- 
rials, caustics, too hot or too cold substances, angular bodies, etc. 
The secondary variety may result from the extension of inflammation 
from the parts above; or it may be an element or expression of an 
infectious disease, as small-pox, scarlatina, typhoid or typhus fever, 
and pyaemia. 
A primary inflammation in this part does not differ materially 
from the same kind of inflammation in other mucous surfaces. If it 
continues long, hyperplasia of the submucous tissue and contraction 
of the tube is likely to occur ; and if limited to the cardiac portion 
this stenosis may cause dilatation above. Suppuration may take 
place in the tissue, and abscesses form, or ulcerations may result, 
especially from the action of caustics or the mechanical irritation of 
foreign bodies. 
Tartarizcd antimony may cause a pustular or pseudo-membranous 
form of inflammation, occupying the lower part of the tube ; or caus- 
tics may destroy tissue which will result in rupture if sufficiently 
deep, or in stricture from the' contracting cicatrix. 
When there is extension of the bucco-pharyngeal inflammation, it 
partakes of the character of that from which it originates, and may 
be erythematous, aphthous, or parasitic. An inflammation may appear 
here toward the end of grave diseases, such as typhoid fever, pyaemia, 
cholera, cancer, tuberculosis, and suppuration of the urinary organs 
and the joints. In these cases the inflammation is of a catarrhal or 
diphtheritic character ; though when consequent to small-pox, it is 
distinctly pustular, but coincident with the formation of false mem- 
brane. 
Any of the forms of inflammation may be unrecognized during 
their continuance—the catarrhal, because the symptoms are not pro- 
nounced ; those from the extension of the disease from above, because 576 
DISEASES OF THE (ESOPHAGUS. 
the symptoms may be attributed to the original affection; and those 
occurring in connection with the grave diseases, because the dysphagia, 
which is the chief symptom of all lesions of the oesophagus, may be 
attributed to the prostration produced by the primary disease. 
But in inflammation of the oesophagus, when not obscured by 
other conditions, there is pain in the course of the tube, about the 
fork of the sternum, between the shoulders, or in the superior part of 
the epigastrium. This pain is not usually continuous, but is most 
during the act of deglutition and for some time afterward. The 
bolus may be prevented from passing down by spasmodic contraction 
of the tube, and may return by regurgitation, or, more rarely, by an 
act of vomiting. When thus rejected it is usually covered with mu- 
cus, which may be tinted with blood. When the bloody character of 
the regurgitated or vomited matter is constant, it indicates ulceration, 
and in the membranous variety fragments of false membrane may be 
discovered. 
Pressure deep down in the cervical region may detect tenderness 
there, and serous infiltration outside of the oesophagus, in this 
region, may possibly press upon the trachea and cause difficulty of 
breathing. 
As in other inflammations fever will be present. 
The introduction of a sound will give pain, but will show absence 
of organic constriction, and on its withdrawal, covered with mucus, 
deglutition for the time will be improved. These symptoms and 
signs, when observed, will lead to a diagnosis. 
Treatment.—The treatment must be conducted on general prin- 
ciples. When stomatitis or pharyngitis is also present, the treatment 
applicable to those conditions will suffice for this. 
In severe cases accompanied with much febrile reaction leeching 
and cupping are advised. Ice may be held in the mouth, and small 
quantities of ice-water frequently swallowed, or iced slippery-elm 
water, or other mucilaginous drinks. Revulsives, sinapisms, blisters, 
or pustulations externally over the inflamed part, may be applied ; 
laxatives should be given, and local sedatives and anodynes will give 
relief. Should much hemorrhage occur, ice must be insisted upon, 
and astringents may be required ; but a moderate bleeding from the 
part need not be interfered with, as it would be likely to be followed 
by relief. When the acute stage is past, Jaccoud recommends large 
doses of iodide of potassium to promote absorption and prevent con- 
striction. 
STRICTURE OF THE (ESOPHAGUS.—STENOSIS OF THE (ESOPHAGUS. 
Constriction of the oesophagus, so as to interfere with the passage of STRICTURE OF CESOPIIAO US— SYMPTOMS. 
577 
food into the stomach, may be either organic, from structural change, 
or functional, from spasmodic contraction. In addition to these con- 
ditions the passage may be obstructed by foreign substances within it, 
or by pressure upon it from without by tumors or by other means. 
Structural alterations in the walls of the oesophagus, constituting 
organic strictures, may include hypertrophy and a limited induration, 
thickening and contraction of cicatricial tissue from previous loss of 
the normal structure by ulceration or the action of caustics, and 
tumors or neoplastic growths in the walls of the canal. 
A limited hypertrophy and induration may be caused by inflam- 
mations, such as have been described ; and these inflammations by the 
causes then mentioned. Syphilitic deposits and changes may be a 
cause of such stricture. 
Constriction from neoplasms, in the majority of cases, is from 
cancerous growths; and these may be scirrhous, encephaloid, or epi- 
thelial. Cancer here is very generally primary, and is situated near 
one or the other extremity of the tube, seldom in the middle. Other 
tumors, such as tuberculous productions or fibroid growths, ordina- 
rily pediculated, may occur, but they are rare. 
External pressure upon the tube may be from cancer in the medi- 
astinum, morbid growths in the bronchial glands, aneurisms of the 
aorta, subclavian, or carotid arteries, or anomalous positions of the 
subclavian artery. Constrictions are most likely to occur in those 
parts of the tube which are normally narrowest, viz., either in the 
cardiac region or at the junction of the cervical and dorsal vertebras. 
There is usually a single stricture, but there may be more ; and the 
degree varies from slight diminution of the calibre to complete oblit- 
eration of the passage. When the stenosis is so great as to materially 
obstruct the passage of the ingesta and cause their accumulation, dila- 
tation (sometimes to a great extent) is likely to occur in the part 
above. This may be general and symmetrical, or unilateral, or ir- 
regular, according to the condition of the tube , and the part below 
the stricture may become atrophied or otherwise changed. 
Symptoms.—The symptoms do not always correspond in severity 
with the gravity of the case. Dysphagia is of course the chief symp- 
tom. At first it may be manifested only at the commencement or 
close of a meal, and the patient has to use fluids in order to swallow 
with more ease. 
The dysphagia gradually increases; only fluid or semi-fluid arti- 
cles can be swallowed, and at length the food is regurgitated. Gen- 
erally there is little or no pain until the food reaches the obstacle; 
then there is pain along the side and back, and behind the sternum— 
the pain not being always felt at the seat of the stricture. 578 
DISEASES OF THE (ESOPHAGUS 
A peculiar sound is sometimes heard by auscultation as the fluid 
passes through the narrow opening, and the precise location of the 
stricture can thus be ascertained. When the obstruction is high up, 
regurgitation will occur almost immediately after the food is taken. 
If low down, and especially after there is time for dilatation of the 
oesophagus above the stricture, food in considerable quantities may 
remain for a much longer time ; but, while remaining, a painful sense 
of constriction will be felt in the chest. In cancerous constriction 
mucus and other secretions are apt to accumulate, and be rejected 
only by great effort; and the cancerous cachexia is developed. The 
stricture in these cases, though there is danger in the manipulation, 
may sometimes be temporarily diminished by the introduction of 
dilating instruments; but the disease is progressive, and the patient 
dies from the combined effect of the cancerous dyscrasia and inanition. 
Strictures from inflammation or cicatricial contractions may often 
be cured. 
Diagnosis.—The diagnosis of an organic obstruction is made by 
the dysphagia slowly coming on and persisting ; and percussion and 
auscultation of the chest may reveal an obstacle, such as a tumor, out- 
side of the oesophagus ; but the introduction of an exploring instru- 
ment will give more precise knowledge of the existence, location, and 
extent of the stricture. The tube of the stomach-pump, or in case 
of extreme contraction, an clastic catheter will serve the purpose ; 
but for the object merely of exploration, smooth round balls, securely 
attached to smooth, slender, and clastic pieces of whalebone of the 
proper length serve the purpose best. Ivory balls constructed for 
the purpose, or common “ marbles” prepared by drilling holes 
through the centre and securely fastening the whalebone through 
them, will answer the purpose perfectly. When balls of different 
sizes are introduced, they show not only the position and calibre of 
the stricture, but its longitudinal extent. After passing a stricture 
they arc free to pass on, as the small size of the whalebone will pre- 
vent its being grasped so as to obstruct the motion of the exploring 
instrument. 
The withdrawal, as well as the introduction of the instrument, 
affords evidence of the extent of the stricture. 
The history and appearance will afford indications of the nature 
of the obstructing cause. 
Treatment.—The treatment of stricture from cancer can only 
be palliative, and the introduction of exploring or dilating instru- 
ments is not without danger. 
When cancerous softening and ulceration are present, a false pas- 
sage is liable to be made and followed more speedily by a fatal result. THE A TMENT. 
579 
Still, relief is often obtained by the occasional careful introduction of 
the tube of the stomach-pump, or some other suitable dilating pro- 
bang. In, one case in my own experience life was prolonged for 
many weeks, even in an ulcerated cancerous tumor, high up in the 
oesophagus, by the occasional introduction of a good-sized probang, 
the use of which was alone able to preserve the power of swallowing. 
The danger was appreciated, but the power of swallowing was lost, 
and there were no other means for its restoration and for keeping the 
passage open : therefore the necessity of the case and the wishes of 
the patient justified the procedure. 
Obstructions produced by pressure from without the oesophagus 
may often be relieved by similar means. Cases, however, have occurred 
where an aneurism has been penetrated and a fatal hemorrhage has 
immediately followed. Where an aneurism is the cause of the 
obstruction, the probang is particularly dangerous. 
In cases of stricture from inflammatory thickening, or the con- 
traction of cicatricial texture, mercury and iodide of potassium may 
have an influence in causing absorption of exudates, and possibly in 
softening recent cicatrices; but the chief reliance is upon dilating 
probangs, repeatedly and perseveringly used. In introducing an in- 
strument, unless it be particularly flexible, into the oesophagus, the 
head must be thrown backward so as to make the passage from the 
mouth to the stomach as straight a line as possible ; and in case the 
stricture is narrow, a cone-shaped probang—perhaps at first an 
elastic male urethral bougie, and later larger instruments—the tube 
of the stomach-pump, or double conical or spindle-shaped solid 
probangs attached to whalebone handles, should be carried through 
the stricture. This operation should be repeated from time to time, 
larger instruments being used each time as may be required, thus 
producing mechanical dilatation of the stricture, and often restoring 
the function of the oesophagus. Very satisfactory results not un- 
frequently follow. 
A long course of manipulations is sometimes necessary ; and after 
apparently complete dilatation, the stricture may return, requiring a 
repetition of the operations. As in cases of stricture of the urethra, 
an occasional introduction of an instrument may be required to keep 
the passage free. In cases where little or no food has been received 
into the stomach for some time, and where swallowing, notwithstand- 
ing the introduction of an instrument, is still difficult, an elastic 
catheter or the tube of the stomach-pump must be used, and milk, 
broths, or other liquid food injected. This mode of feeding may be 
repeated until deglutition is established. In one case of this kind, 
which occurred, in my experience, the patient arrived from a long 580 
DISEASES OF TEE (ESOPHAGUS. 
distance at the very point of starvation from a cicatricial stricture 
involving the very lowest part of the oesophagus and the cardiac orifice 
of the stomach ; and milk was injected through the open extremity 
of a rectal tube pressed down upon the stricture and the fluid forced 
into the stomach, even before a catheter could be passed through the 
minute opening. At the next attempt a small catheter was passed 
through the stricture, and liquid was injected through it. The 
patient, a lady, was fed in this way for days, until spindle-shaped pro- 
bangs, at first of very small size, but gradually larger, attached to 
whalebone handles, accomplished the dilatation so that she at length 
was able to swallow ordinary food. She was sent home supplied Avith 
dilating instruments, which her physician occasionally introduced 
for some months afterward. 
SPASMODIC STRICTURES OF THE (ESOPHAGUS.—FUNCTIONAL STENOSIS 
OF THE (ESOPHAGUS. 
Etiology.—This may be produced by a variety of causes, and is 
a symptom of several morbid conditions. It may be excited by an 
inflammation of the oesophagus itself, or of the larynx or epiglottis. 
It is often a symptom of hysteria, sometimes of epilepsy, and is an 
almost constant attendant upon hydrophobia and tetanus. It may 
depend upon diseases of the spinal cord or the cervical vertebrae ; but 
perhaps the most frequent cause is lesion of the brain. In hysteria 
and other conditions, it is often a reflex morbid action, following 
some obscure law of sympathy. It is more frequent in women than 
in men, and I have observed it about equally in young women and in 
those of middle and somewhat advanced life. The predisposing con- 
ditions are the nervous or hysterical temperament, pregnancy, the 
menopause, and some general diseases. 
The imagination, fear, anger, and other disturbing mental influ- 
ences, exert a large control over this symptom. 
Cases are related where the fear of hydrophobia produced spasms 
of the pharynx and cesophagus resembling the symptoms of that 
disease. 
Various irritating substances swallowed may excite it, and the 
apprehension of those who have suffered from it may cause its return. 
Symptoms.—The onset of spasmodic stricture of the oesophagus 
usually is sudden. There may be a severe, constricting, distressing 
pain with the difficulty or impossibility of swallowing. 
Some may be able to swallow warm drinks, but reject cold; while 
with others the reverse will be the case. 
The spasm may be in the upper or lower part of the oesophagus, or SPASMODIC STRICTURE. 
581 
in both—modifying by its locality the particular symptoms. There 
are other coincident symptoms besides the mere difficulty of swallow- 
ing, some of which continue during the interval of attempts to swal- 
low, but are aggravated by such attempts. They are contractions of 
the cervical muscles, painful respiration, the ejection of free quanti- 
ties of saliva and mucus, and sometimes fainting or great depression. 
The face often expresses extreme distress, the veins of the neck are 
turgescent, the pulse may be small and frequent, and even general 
convulsive movements may take place, and for the time deglutition 
is impossible. 
These severer paroxysms have been termed “Epileptiform Neu- 
ralgia of the Vagus.” Oftener, however, the contractions are less 
paroxysmal and violent, but more mild and continuous, with irregu- 
lar remissions and exacerbations. 
Diagnosis.—There is usually not much difficulty in the diagnosis 
of these cases. 
The suddenness of the onset, the causes that may be traced, the 
intermittence of the symptoms, and the presence of other nervous 
disorders generally render them distinguishable. 
Still, these exacerbations and remissions may be united with an 
incipient organic change, so that a positive assertion of a simple 
spasmodic affection would not in all cases be justifiable. In doubt- 
ful cases the use of a large sound must determine as to the presence 
of an organic change. If a good-sized instrument can be passed with 
readiness, or with even some moderate force—and especially if in 
succeeding attempts no difficulty is experienced, or the obstruction 
felt is not always at the same point—the diagnosis will be sufficiently 
clear. 
Sometimes a paralysis of the oesophagus exists which interferes 
with deglutition. Then the sound is more easily introduced even 
than in the natural state, and the food is not regurgitated. Besides, 
paralysis is permanent, while spasm is intermittent or remittent. 
Auscultation of the oesophagus—listening with the stethoscope 
along its course behind the trachea, and on the left side of the spine 
below—may aid in diagnosis. Here, as elsewhere in auscultation, 
becoming familiar with the sounds produced in the part in the nor- 
mal state is essential to the proper recognition of the deviations which 
occur in disease. Both the normal and morbid sounds are produced 
at the moment of deglutition, when they should be carefully observed. 
Prognosis.—The prognosis in simple spasmodic stricture of the 
oesophagus is favorable as to immediate fatal results. Death occurs 
in hydrophobia, but from the general effect of the venom, rather than 
from closure of this organ; and in some cases of hydrophobia there 582 
DISEASES OF TEE (ESOPHAGUS. 
has been found not only coarctation, but also change of tissue in the 
walls of the tube. 
Though spasm of the oesophagus is usually a more or less acute 
affection, it may become chronic, and the prognosis as to speedy cure 
may be doubtful. Cases lasting many years are reported ; and I have 
seen one case, at least, that had passed through the hands of several 
ph)rsicians, and had lasted with pretty constant symptoms for a long 
period. 
Treatment.—In case of complete stricture, the first and most 
pressing indication is to feed the patient. For accomplishing this 
purpose the introduction of a probang will generally be called for, 
thus overcoming the spasm, and convincing the patient that there is 
not a complete and impenetrable closure (which is often feared), and 
thus giving confidence and greater success in efforts at swallowing. 
This will generally not only enable the patient to swallow for the time 
being, but will often produce much more permanent results. Should 
the power of deglutition fail to be speedily restored, food should be 
injected into the stomach through the tube of a stomach-pump, while 
other means are being used for overcoming the morbid state. A large 
instrument in all these cases is better than a small one, and far less 
likely to do harm. A steady pressure for some little time may be 
required to tire out the contracting muscle, and, after the stricture 
is passed, the instrument should be allowed to remain for some little 
time, care being taken by proper position of the head, and other 
means, to prevent pressure upon the glottis or larynx, so as to inter- 
fere too much with respiration. A single introduction of a sound may 
be sufficient. 
In case the oesophagus is very sensitive, the administration of a full 
opiate may precede the use of the instrument, and the opiate alone may 
enable the patient to swallow. Or, just before the operation, suffi- 
cient ether or chloroform may be inhaled to produce partial, but not 
complete, anaesthesia. Other narcotics, as belladonna, hyoscyamus, 
etc., have been advised; and also the smearing of the sound with 
extract of belladonna before using it. Morphine or atropine, or a 
combination of the two, may be used hypodermically. In hysterical 
cases, assafcetida, valerian, bromide of potassium, and other narcotic 
remedies, such as the general condition may indicate, should not be 
neglected. 
Jaccoud and Ilomberger report cases cured by the simultaneous 
administration of belladonna and iodide of potassium. 
The general health in all cases should receive attention ; and all 
pathological conditions of the nerve-centres, or of other parts which 
by reflex action may operate as causes, must be special objects of REGIONS. 
583 
treatment. A permanent cure cannot be expected until the nervous 
state and all other conditions upon which the symptom depends arc 
mitigated or removed. 
DISEASES OF THE ABDOMINAL DIGESTIVE 
ORGANS. 
In pursuing the study of the Diseases of the Digestive System, we 
come to those within the abdomen. As there will be occasion to 
mention symptoms as located in different parts of the abdominal 
cavity, it will be important to bear in mind the different regions 
which have received particular names, and the organs situated in 
each of these regions. The surface of the abdomen has been artifi- 
cially mapped out into nine unequal regions. This is done by drawing 
two horizontal lines across the abdomen—one from the lowest point 
to which the ribs descend on the one side to the other ; and the other 
line from the highest point in the crest of one iliac bone to the other. 
These are intersected by two other lines, one on each side, from the 
cartilage of the eighth rib above to the centre of Poupart’s ligament 
below. The regions between the two vertical lines, commencing 
above, are respectively called the epigastrium, the umbilical region, 
and the hypogastrium; and the three on each side of these are called, 
beginning in like manner above, the hypochondrium, the lumbar 
region, and the iliac region. 
The epigastric region is occupied mainly by apart of the stomach, 
most of the left and a portion of the right lobe of the liver, and more 
deeply by the hepatic vessels, the pancreas, the cceliac axis, and semi- 
lunar ganglia. The central regions below the epigastric—the umbili- 
cal and hypogastric—are occupied by the convolutions of the small 
intestines; but across the upper part of the umbilical extends the 
transverse colon, and into the hypogastric is pushed up the distended 
bladder; and the gravid uterus, as it rises out of the pelvis, occupies 
this region, and as pregnancy advances, fills a large portion of the 
abdomen. Deep in these regions are the lower part of the duodenum 
above (some of it being usually in the epigastrium), and the mesentery 
and its glands and vessels below. In the right hypochondrium is situ- 
ated the lower edge of the right lobe of the liver, with the gall-bladder 
(the mass of the liver being in the concavity of the diaphragm), and 
the hepatic flexure of the colon ; and, deeper, most of the first and 
second part of the duodenum; and, deeper still, the upper part of the 
right kidney and the right suprarenal capsule. 
The left hypochondrium contains the lower portion of the spleen 584 
DISEASES OF THE ABDOMEN. 
(the rest of it being in the concavity of the diaphragm, with a portion 
of the stomach), the left portion of the stomach, the splenic flexure 
of the colon, and, deeper, the upper part of the left kidney and the 
corresponding suprarenal capsule. The right lumbar region contains 
the ascending colon, a part of the convolutions of the small intestines 
—and this, with the left, contains a very large part of these convolu- 
tions when the gravid uterus rises high in the abdomen—and farther 
hack, or deeper, the lower part of the right kidney. 
In the left lumbar region are situated the descending colon, con- 
volutions of the small intestines, and, deeper, the lower portion of the 
left kidney. 
In the right iliac region is the caecum, and in the left the sigmoid 
flexure of the colon, and in both a small portion of the convolutions 
of the small intestines. 
It is important to observe that the positions of the abdominal 
organs are not all fixed, but are more or less movable in health, and 
that in disease they are often greatly displaced. 
The stomach occupies more or less space, according to the amount 
of its distention; and when it is the seat of a tumor—as a cancer of 
the pyloric end—it is apt to descend into the umbilical region, and 
possibly even lower. 
The colon, in its transverse portion, may lie much lower than 
stated ; and the liver, when enlarged or jrashed down by distention of 
the cavity of the chest, as in effusions in the pleura, may occupy a 
position much lower. 
On the contrary, it may be pushed up higher in the distention of 
the abdomen by the pregnant uterus, by an ovarian tumor or ascitic 
effusion; and the same may be said of the spleen. 
The kidneys, too, by elongation and looseness of their attach- 
ments, may occupy different positions, and what is called a floating 
kidney is now and then observed. 
Apart from the examination of the viscera in the pelvis, the ex- 
amination of the abdomen proper includes the methods by inspection, 
palpation, percussion, and auscultation. 
In investigating diseases of the organs of the abdomen, physical 
examinations are often of great importance, and should not be 
neglected. 
Frequently much may be ascertained by simple inspection. The 
form is often changed, and sometimes characteristically, in different 
diseases. In great emaciation, in dysentery, and in some cases of 
cerebral disease, particularly in children, the abdomen is often flat- 
tened and even concave. On the other hand, in various diseases it is 
distended by dropsical effusions, by gaseous distention of the stomach PHYSICAL EXAMINATION. 
585 
and bowels, by enlargement of solid organs, or by the presence of 
morbid growths. Enlargement of the parietes by fat, or by anasar- 
cous effusion, may be distinguished from distention of the abdominal 
cavity by the deep depression of the umbilicus in the former state, 
but not in the latter. When distention is from gases in the stomach 
or bowels, and the walls are thin, the outlines of the stomach and 
colon, and of the convolutions of the small intestines may be seen, and 
when from accumulations of faecal matter in the colon, the outline of 
that organ may be distinctly observed. When the abdomen is moder- 
ately distended by fluid in the peritoneum, the patient in lying upon 
the back will have expansion of the abdomen laterally and distention 
in the lumbar regions. When in the upright position the distention 
will be more below, unless the intestines are distended at the same 
time. The distentions due to enlargement of solid organs, or to 
tumors, are seldom symmetrical. When the stomach is much dis- 
tended, and the walls of the abdomen are thin, its peristaltic contrac- 
tions are often very visible ; and the same to a less extent may be said 
of the intestines. In inflammations or paralysis affecting the dia- 
phragm, and in peritonitis, the abdominal Avails are quiescent in res- 
piration ; whereas in obstructions to the free entrance of air into the 
upper part of the lungs, the respiratory movements are largely in the 
diaphragm, and the abdomen is correspondingly distended in inspira- 
tion, and contracted in expiration. Certain conditions of the parietes 
have their significance. 
The eruptions of typhoid and typhus fevers are chiefly observed on 
the abdomen; and in tumors, in ascites, and in obstructions of the 
portal veins or vena cava, the external abdominal veins are generally 
dilated. The pointing of abscesses, the existence of parietal inflam- 
mation or tumors, or the presence of hernias v/ill of course be percep- 
tible to the eye. When ascites, tumors, or 'any other conditions have 
for some time largely distended the abdomen, the atrophic lines which 
so commonly follow child-bearing are apt to be present. 
By palpation we observe many of the conditions noticed by in- 
spection, Avith even more distinctness and precision, besides discover- 
ing different degrees of hardness, softness, elasticity, and resistance of 
the abdominal Avails and the parts beneath ; and can often determine 
the existence, the size, shape, character, and relation of tumors, and 
changes of the organs which the eye could not detect. Besides the 
fluctuation of fluids, the expansion, pulsations and thrill of aneurisms, 
the vibrations from certain inflammatory deposits, and the peristaltic 
movements of the stomach and boAvels, the condition of their Avails 
and the nature of their contents can often be observed by the sense of 
touch with a positiveness Avhicli no other sense can give. 586 
DISEASES OF THE ABDOMEN. 
When no resistance is offered and the walls of the abdomen are 
thin and flaccid, these manipulations are often very satisfactory ; but 
when the walls are thick and tiie muscles are rigid, as they unfortu- 
nately are apt to be, the conditions of the parts within are seriously 
obscured. Every means should be used, by exercise of the will of the 
patient, by a favorable position upon the back with the shoulders 
elevated, by taking advantage of respiratory movements, by taking 
time for excitement to subside, and sometimes under the relaxation of 
anaesthetics, to overcome the rigidity of the abdominal muscles in 
cases requiring careful investigation. The sensations communicated 
to the hands by different conditions will be referred to when describ- 
ing those special states. 
Percussion is another important method of physical examination. 
In striking in the usual method with the fingers or a percussing 
instrument and pleximeter over the stomach or intestines, containing 
as they usually do more or less gas, a resonant sound is produced. 
When striking in the same manner over a solid organ, as the liver 
or the spleen, especially when enlarged, or the bladder when distended 
with urine, a dull sound is produced. The stomach and intestinal 
resonance is quite different in character from that of the lungs ; is 
higher pitched and more drumlike, but varies in loudness, in pitch, 
and in quality, according to the size of the hollow organ, the 
amount of its distention with gas, and the absence of solid substance 
in its walls or its cavity; and the resonance is also influenced by 
the thickness of the abdominal walls and the amount of fat in the 
omentum. 
Thus, percussion over the stomach gives lower pitched and deeper 
sound than over an intestine; and the colon, when empty of solid 
matter and distended, gives a much lower pitched and deeper note 
than a small intestine. When there is a general distention of the 
abdomen with gas, the sound is markedly drumlike or tympanitic, 
and the resonance great. 
Though percussion for the most part is dull over the liver, yet 
when its thinner margin overlaps the distended stomach or the intes- 
tine, a blow of considerable force will elicit a sound more or less 
hollow. On the other hand, when an intestine lies over a solid part, 
as enlarged mesenteric glands, or the spleen, or a tumor, etc., a slight 
tap will give an intestinal sound, but by pressing the finger of the 
left hand, when used as a pleximeter, firmly upon the part, the intes- 
tine may be flattened down or pressed to one side, and a blow of some 
force will bring out the flat or dull sound. Careful practice will 
make one familiar with the sounds of different parts, and knowledge 
of great value as to the existence, position, source, and relations of PHYSICAL EXAMINATION. 
587 
tumors, or abnormal solid enlargements, can be obtained by this mode 
of examination. A slight tap, as with the nail of the middle finger 
in filliping, will give indications of the character of the parts imme- 
diately beneath the walls or the surface, while a stronger blow indi- 
cates the condition of deeper parts. 
Auscultation is of less value in examining the abdomen in ordinary 
cases. Various gurgling and musical sounds may be heard by placing 
the stethoscope over the stomach or intestines, but they are of little 
significance in determining morbid or healthy conditions. Arterial 
murmurs produced by aneurisms, or by tumors pressing upon arteries, 
may be heard and are of importance ; also venous murmurs in con- 
nection with the pregnant uterus, with various tumors, or dilated 
veins ; and the foetal heart may be heard, and friction sounds also 
when the peritoneum is thickened ana roughened by inflammation 
and solid exudates. 
Tbe anatomy of the stomach and its associated organs, and the 
physiology of the digestive process, are presumed to be familiar to all 
who take up the study of their diseases. 
The facts regarding the different parts of the digestive process, 
their relations to each other, and their absolute and relative impor- 
tance, as observed and confirmed by modern scientific investigation, 
should be not only understood but borne in mind. The functions of 
mastication, insalivation, and deglutition; the mechanical motion of 
the stomach, its secretion of the digestive substances, their chemical 
action upon the food, the formation of peptones, their removal by 
dialysis, the passage of a part of the ingesta into the intestines, the 
action of the secretions from the pancreas, the liver, and the intes- 
tines themselves, which the food there meets with ; the action of the 
liver upon those portions of the ingesta and their products carried into 
it, the course of the materials taken up by the lacteals and poured 
into the blood, and the disposal of the exuviae—processes so important 
to be well performed, and so liable to derangement—must be kept in 
view in studying the diseases, organic or functional, of the digestive 
apparatus. 
DISEASES OF THE STOMACH. 
Diseases of the stomach are very common, and some of them are 
very obscure. It has been remarked that there is no subject about 
which our patients make so many inquiries, and about which we arc 
able to tell them so little. The stomach has been declared by the groat 
Poet of Nature, “the storehouse and workshop of the whole body,” 
and from its relations through dependence of function and through 588 
DISEASES OF TEE STOMACH. 
sympathy to the rest of the system, its derangements must be of great 
importance. 
With some exceptions its morbid conditions are not capable of 
being physically examined and distinguished as are diseases of the 
heart and lungs; the effusions that may be produced do not accumu- 
late to afford signs, but are washed away, and the hyperaemia so com- 
mon during the living processes of disease may, to a large extent, 
disappear after death, obscuring the evidences of pathological states 
usually afforded by post-mortem examinations. Besides, the gastric 
juice being a chemical agent, and during life being prevented from 
acting on the stomach itself by the neutralizing influence of the cir- 
culating blood, if freely present in the stomach after death, may 
digest its walls, producing softening or destruction of tissue, which 
may be mistaken for the erosion of poisons or the lesions of disease. 
Even during life, in low conditions of the system with little blood 
and feeble circulation, if by reflex irritation or other causes much 
digestive fluid is in the stomach, its mucous surface may be chemi- 
cally acted upon, and the traces of it seen immediately after death. 
When such results are feared from the action of the gastric juice, 
alkalies and alcohol will neutralize its action and may be given for 
that purpose. 
In cases of sudden death after a meal, especially in warm weather 
or if the body be in a warm place, the digestion of the stomach is 
likely to occur ; and this must be remembered when, in cases of sus- 
picion, an investigation is being made. 
HYPEREMIA. 
The diseases of the stomach are divided into organic and functional. 
Of the diseases attended by perceptible structural changes, simple 
hyporEemia is among the mildest and the most common. 
According to the observations of Beaumont and others, the quan- 
tity of blood in the vessels of the stomach during the process of normal 
digestion is much larger than when it is in a quiescent state; and under 
a moderate degree of irritation, from improper ingesta or reflex action, 
or from various other causes the amount very readily becomes excessive. 
Hyperaemia here, as elsewhere, may be either active or passive. 
The active form results from irritating impressions, of whatever kind, 
upon the stomach—from improper ingesta, from “ taking cold,” 
from retention of effete matters in the system, from reflex irritation, 
from vicarious menstruation, etc. 
The passive form is produced by obstruction of the return circula- 
tion, either through the liver, the heart, or the lungs. It arises from IIYPEEJEM1A. 
589 
mechanical causes, and is chiefly venous, while the active is dependent 
more upon dynamical influences and is more arterial. 
Any structural change or functional inactivity which causes ob- 
struction of circulation through the liver, congests the portal system 
of vessels, and induces splenic, pancreatic, and intestinal as well as 
gastric hyperaemia. The spleen and stomach vary more in the amount 
of blood they contain than the other abdominal organs—the spleen 
especially, as it seems to be a reservoir for receiving much of the ex- 
cess of blood in the portal system ; but the accumulation in this organ 
is not attended by the same consequences as that in the stomach. 
In obstructive disease of the liver, as cirrhosis, congestion, inflam- 
mation, etc., or in functional inactivity of the organ, in valvular and 
other obstructive organic disease of the heart, in asthma, emphysema, 
and other diseases of the lungs interfering with circulation through 
them, the stomach suffers more or less from congestion. "With this 
abnormal increase of blood its functional activity is modified and 
impaired ; there will be perversion of nutrition of its membrane, and 
consequent perversion of the secretion of the peptic glands, and mod- 
ifications of the process of digestion. 
There is a morbid susceptibility of the organ, and hemorrhage, 
inflammation, and even ulceration may follow. More or less dyspep- 
tic symptoms are in such cases almost constant. Gastric uneasiness 
or distress, irregularity of the digestion of food, a coated tongue 
and unpleasant taste, sometimes constipation and sometimes diarrhoea, 
headache, lassitude, nausea, etc., may result. In various other dis- 
eases—in fevers, jaundice, Bright’s disease, cholera, affections of the 
heart and lungs, etc.—gastric congestion is present. Simple hyperae- 
mia is often merged into inflammation of the stomach, and the two 
conditions may be considered together. 
GASTRITIS. 
GASTRIC CATARRH.—ACUTE GASTRITIS. 
Inflammation of the stomach is not an unfrequent condition. It 
often follows simple congestion or hyperaemia, and is produced by the 
same causes. 
Hyperaemia is an element of inflammation ; and here, as elsewhere, 
the latter is the natural result and complement of the former. 
In some cases of gastritis the inflammation is confined to the 
mucous surface, while in others the submucous tissue is involved. 
A superficial inflammation of the mucous membrane presents the 
common characteristics of catarrhal or mucous phlegmasia, and may 590 
GASTRITIS. 
be either acute or chronic. Inflammation of the submucous tissue, 
or interstitial inflammation in the acute form, is called phlegmonous 
gastritis; and in the chronic form, with exudates organizing in the 
tissues, or hyperplasia of the tissues constituting thickening and con- 
traction, has received the name of sclerosis of the stomach, or, by 
some, of gastric cirrhosis. 
Toxic gastritis, or inflammation from the effects of powerful irri- 
tant poisons, differs from the more spontaneous inflammations. This 
always affects the mucous surface, and often deeper parts, depending 
in this respect upon the amount and character of the poisonous or 
irritating agent; and it differs in the depth, intensity, and special 
character of its lesions and in the symptoms presented, from the ordi- 
nary spontaneous or catarrhal form of disease. 
Acute gastric catarrh is a very common disease, and has various 
forms and types. In its milder varieties it includes what are some- 
times called “ bilious attacks,” or, among the French, “gastric embar- 
rassment;” in its more intense forms it is called “gastric fever.” 
Under the chronic varieties arc a number of illy defined morbid states 
termed dyspepsias or inflammatory indigestions. No other terms, 
however, are necessary than acute and chronic gastritis, all others 
being of doubtful pathological propriety. The term catarrh, how- 
ever, has come to be so generally used as signifying a superficial 
inflammation of a mucous membrane, that it has become proper from 
custom. 
Etiology.—The causes of gastritis, as already stated, are similar 
to those producing hypenemia, but of a more intense character, or 
operating upon a more susceptible organ. 
Like other catarrhs, it is sometimes the result of taking cold ; 
though in ordinary exposures the air-passages are more likely to be 
affected. Gastric catarrh, however, often coincides with other catar- 
rhal affections, and, like them, may be produced by changes in the 
weather. 
When such exposures and changes affect the system without the 
morbid action being specialty localized, it is called “ catarrhal fever.” 
But at any season this gastric irritation and inflammation may be 
caused by improper ingesta, habitual or occasional. 
Food insufficiently masticated, or of too high or too low a temper- 
ature, or in excessive quantities ; or food of improper quality; the 
abuse of stews and fats, of cheese and pork, of game and lobsters, of 
mixed and too highly spiced dishes; or the ingestion of substances 
undergoing fermentation or putrefactive changes may cause the dis- 
ease. A common cause is the use of alcoholic drinks, and the habitual 
use of other narcotics, as opium. CA USES—MORBID ANA TOMY—SYMPTOMS. 
591 
Sedentary habits, intense preoccupation, intellectual or emotional; 
irregularity in the time of meals ; working immediately after eating, 
etc., are among the causes. 
Symptomatic catarrh is very common in the course of most febrile 
diseases, exanthematous, malarial, etc. 
Long abstinence, great insufficiency of food, or confinement to 
a single nutrient principle, as albumen or starch, may cause inflam- 
mation. 
Dr. Chambers gives as the causes of catarrh of the stomach, fever, 
debility, the use of alcohol, previous attacks, as predisposing, and 
overloading the stomach, difficulties of digestion, decomposing food, 
changes of temperature, and exposure, as exciting causes. 
Morbid Anatomy.—The anatomical changes are similar to 
those which occur in other catarrhal inflammations. There arc liy- 
peraemia, and the secretion of altered mucus, lymph, or pus; but 
these exudates pass olf with other contents of the stomach. There 
are frequently spots of ecchymosis, sometimes erosions, and some- 
times thickening and hardening or softening of the membrane. 
The secretion of proper gastric juice is greatly diminished or al- 
together arrested, and the reaction of the liquid in the stomach in 
severe cases is often alkaline. 
Softening and blackening of the membrane and alterations of the 
consistence of the submucous tissue are often found, but arc regarded 
by Jaccoud as post-mortem changes. 
Symptoms.—When gastritis is dependent upon obstructed cir- 
culation through the liver, heart, or lungs, it usually comes on slowly 
and tends to be chronic ; when dependent upon indigestion or al- 
coholism, as the cause here is also chronic, the onset is commonly 
gradual. In these cases, for several days before the occurrence of 
the more marked symptoms, the appetite will be diminished, diges- 
tion weak and painful; there will be disturbed sleep, inability to per- 
form active work, general malaise; often severe frontal headache, 
aggravated by noise and light, and by sudden movements. The 
characteristic symptoms being now developed, there will be pain in 
the epigastrium, increased on pressure, the tongue coated with a 
whitish or yellowish fur, while the edges are red, and the papillae 
are often seen ; the tongue and buccal membrane are often congested 
and dry, perverting the taste; anorexia and thirst are decided; acid 
drinks are sometimes specially desired ; nausea is very common ; and 
vomiting is a frequent symptom. 
The vomited matter, at first, is undigested food, and then mucus 
often tinged with bile. Sometimes there is much retching with little 
emesis, the matter ejected being streaked with blood. When caused 592 
GASTRITIS. 
by indigestion the vomiting may he copious, at first, of undigested ali- 
mentary substances undergoing fermentation, and this often gives rise 
to gases causing eructations or tympanitic distention. Sometimes con- 
stipation follows ; but if irritating substances pass into the intestines, 
a diarrhoea may result, accompanied by intestinal pain, the discharges 
being greenish, liquid, offensive, and irritating, but often followed, as 
may be the vomiting, by great relief. 
In some of these crises there is but little fever, and after free evac- 
uations all the symptoms may soon disappear. 
When an acute gastritis is brought on by atmospheric influences 
or exposures, the access is usually abrupt and accompanied, or even 
preceded, by marked fever, often assuming a remittent type. The 
temperature may rise in the evening to 103° or 104°, but abates in the 
morning, the fever being accompanied by headache, pain in the 
stomach, and over the body generally, and often simulating more 
severe and specific fevers. 
The skin may bo quite hot and dry, but the nausea and vomiting 
are usually accompanied by fits of cutaneous moisture. When the fever 
is of a high grade, in excitable persons there may be delirium ; but this 
is quite unusual, the general excitement commonly not being great. 
In any of the forms of severe acute gastritis, there are generally 
severe burning and shooting pains in the stomach and lower part of 
the chest, in front and between the shoulders, and often reflex pain 
in more distant parts of the chest. The gastric pain is accompanied 
with rigidity and retraction of the abdominal muscles. 
There is aggravation of the pain on drawing a long breath, and 
consequently shallow and thoracic respiration ; and there may be 
rejection of whatever is taken into the stomach. Distressing hic- 
cough is likely to occur ; and when all these symptoms are present, 
there is apt to be a small and rapid pulse, a tendency to faintness, 
and to collapse. 
The severity of the inflammation influences more the continuance 
than the height of the fever. In the severe variety the fever may 
continue a week or more; in the milder forms from this cause, it 
may terminate in two or three days, the crisis being accompanied bv 
free evacuations, profuse sweating, and sometimes a herpetic eruption 
upon the lips. The stomach is left in a more or less enfeebled and 
irritated state, and becomes more liable to subsequent attacks from 
various causes. In some cases the disease is much more intense than 
in the ordinary cases described. The tongue may be very red and 
glazed, sometimes very dry and hard, and the fever, though not higher 
at first, is more persistent and protracted, and the prostration may be 
great. The pulse- may become rapid and feeble, the countenance DIA GNOSIS—PROGNOSIS. 
593 
pinched and depressed, and, though even in these severe cases the 
prognosis is generally favorable, sinking and death from asthenia 
sometimes occur. In some cases, and especially in warm and moist 
climates where there are malarious influences, there is a free flow of 
bile into the stomach and intestines, with bilious vomiting and diar- 
rhoea ; the free discharges, whether spontaneous or induced by the 
proper mild measures, procuring much relief. 
Diagnosis.—In diagnosis there is little difficulty in determining 
by the red tongue, the epigastric pain and tenderness, the nausea 
and vomiting, etc., the presence of gastric irritation and inflammation ; 
but when preceded by a fever—by cephalagia and other general symp- 
toms—it is not always easily distinguishable from a complication with 
typhoid and other essential fevers. But in simple gastritis the fever 
is higher on the first and second days than in ordinary cases of slowly 
approaching typhoid, and the morning remissions may be more 
marked. The fever accompanying simple gastric catarrh is more 
irregular in its progress than in typhoid ; it does not go on with the 
same regular march; has not the characteristic eruption, or the gur- 
gling in the caacum ; and it usually terminates either by crisis or lysis 
about, and often before, the end of the first week. It is, besides, 
more apt to be accompanied by constipation than diarrhoea, while 
the tendency to diarrhoea in typhoid is well marked. Some cases, 
however, will be obscure until time lias developed their more posi- 
tive characteristics. 
The bilious form may be mistaken for catarrhal jaundice, here- 
after to be described ; but in the latter case the bile is retained rather 
than discharged, and the yellowness of the skin and eyes, and the 
dark color of the urine are much more marked. Complications, how- 
ever, may exist, and catarrhal inflammation may occur in the stom- 
ach, the intestines, and the bile ducts at the same time, producing a 
mixture of gastric, intestinal, and icterode symptoms. 
Prognosis.—In reference both to prognosis and treatment, the 
fact should be recognized that stomachs vary very much in their sus- 
ceptibility and power of endurance, and in the degree of their sympa- 
thetic relations to the rest of the system. 
Some stomachs will bear much, and others but little. With some 
large quantities of irritant poisons will be resisted or endured, while 
with others a large meal, a draught of cold water when the body is 
heated, or the taking of various medicines usually well borne, may 
produce much mischief. 
Noxious matters in the blood, as in fevers, or Bright’s disease, and 
other causes, may excite inflammation in the stomach, producing 
complications of gastritis, with various other affections. 594 
GASTRITIS. 
The prognosis of simple gastritis is, on the whole, favorable ; but, 
in some cases, depression and death may speedily occur, and in others 
decided structural changes may occur, and the disease may become 
protracted, with various results. When gastritis accompanies other 
diseases it often adds to their severity and danger. 
Treatment.—The treatment of primary hyperaemia and catar- 
rhal inflammation of the stomach is very simple. 
If there be evidence of foul matters in the stomach, as undigested 
and fermenting articles of food, irritating secretions, or any kind of 
improper ingesta acting as a cause, evacuation should be promoted, 
but by the mildest means. Drinking freely of warm water, and tick- 
ling the throat to excite emesis, may be very effectual in washing out 
the stomach. 
. If there is acidity of the stomach, an alkali may be added to the 
water ; this will render the matters in the stomach less irritating, and 
sometimes promotes emesis; but if it does not produce vomiting, it 
favors the downward passage of the contents, to be discharged by the 
bowels. The passages from the bowels should further be encouraged 
by enemas, if required, and sometimes by saline and alkaline laxa- 
tives. 
Possibly an emetic of ipecacuanha, or perhaps better, apomorphia, 
used hypodermically, in the dose of from one twelfth to one sixth of 
a grain, may do more good by removing foul matter and inducing per- 
spiration, than harm by any local irritating action. The evacuation 
and washing out of the stomach by means of the tube of the stomach 
pump acting as a siphon, or by the use of the pump itself, has 
lately been recommended and practiced in these and other more 
chronic. cases where there are foul matters in the stomach. This 
process is regarded as less irritating and quite as effectual as that of 
exciting emesis. When the operation is carefully performed, so as not 
to produce mechanical injury, there can be no doubt of its usefulness 
in cases to which it is adapted. When the tube is used without the 
pump (and the objection to the latter is the possibility of drawing 
portions of the mucous membrane into the openings of the tube), 
after its introduction its outer end should be elevated, and water, 
simple or containing alkaline or antiseptic substances, should be 
poured into it, conveniently by the aid of a funnel, or by another 
tube from an elevated vessel, until the stomach is filled. The patient 
should then lie upon his side, and the tube, still filled with the fluid, 
should be lowered beneath the level of the body ; being thus con- 
verted into a siphon, it will empty the stomach unless it becomes 
clogged by solid substances. In that case the pump may be applied, 
and in this manner the contents of the stomach may be evacuated. TREATMENT. 
595 
A tube may now be found in the market more soft and pliable than 
the common tube of the stomach-pump, and which answers excel- 
lently as a siphon. After the contents are thus removed, the organ 
may be washed out by a weak alkaline solution, as of carbonate of 
soda. In ordinary practice such a procedure, though simple enough 
in itself, at first appears formidable to a patient, and will seldom 
be resorted to. Indeed, in most cases of gastritis, especially when 
produced by the common causes of acute catarrh, no special mat- 
ters are in the stomach which require evacuation. 
Even in cases dependent upon improper ingesta, the irritating 
materials have often passed from the stomach, either by vomiting or 
by the pylorus, before the physician is called, and there are the results 
of the irritation—the inflammation—to deal ivith, rather than the 
irritating causes. 
In all such cases, and in all other cases after evacuation, rest of 
the organ is most important. Often for a day or two, or longer, no 
food may be taken into the stomach, and only cooling drinks. All 
alcoholics and spices should be entirely avoided, and when food be- 
comes necessary, only the blandest articles, such as farinaceous sub- 
stances thoroughly cooked and mingled with milk, should be used. 
Starchy foods, when properly prepared, tax most stomachs less than 
albuminous; and certain digestive changes go on in the stomach in 
starchy matters without the action of the gastric juice. 
This simple treatment, giving the stomach and the whole system 
rest, the patient usually being kept in bed, may be sufficient to over- 
come the disease. 
If, however, the inflammation be severe, more interference may be 
required. If the patient be plethoric a venesection may be useful, 
and not unfrequently leeches may afford relief. These measures are 
seldom required, as we have other means for abating inflammatory 
action. 
Nothing, as a rule, will procure so much relief to the present 
suffering, or be so efficient in checking the inflammation, as proper 
doses of morphine. 
A quarter of a grain, more or less, but sufficient to produce a 
decided anodyne effect, may be given by the stomach, dropped upon 
the root of the tongue with a sip of water after, or administered hypo- 
dermically, and repeated once in from three to six hours—the size of 
the dose and the frequency of the repetitions depending upon the 
susceptibility of the patient and the severity of the inflammation ; 
but sufficient should be given to keep up a soothing, anodyne, and anti- 
phlogistic effect. Ice-water may be used for drink, but not so much 
as to cause distress, nausea, and vomiting, as free quantities may do. 596 
GASTRITIS. 
Mustard plasters or fomentations over the epigastrium will often pro- 
cure relief ; and if the case does not readily yield, a blister of can- 
tharides should be applied. 
This measure has been tested too often to leave a doubt as to its 
efficacy in such cases. If the ordinary cerate is used, the skin should 
be rubbed over with warm vinegar before it is applied, and the surface 
of the plaster, immediately before its application, should be smeared 
over with a few drops of the oil of turpentine. This, without inter- 
fering with the vesicating action, or the efficacy of the blister, will 
materially diminish the pain of its action, which is a matter of con- 
sequence in an irritable or sensitive patient. 
Abstinence from food should here be practiced for a day or two, or 
more ; and the bowels, if their condition so requires, should, as a rule 
at least, be acted upon by enemas, rather than laxatives by the 
stomach. If the inflammation still remains severe after the system 
requires nourishment, it should be given by enema. Broth, milk, or 
chemically digested foods in a liquid form, will be taken up from 
the bowels, and the system may be sustained almost indefinitely 
by intestinal alimentation. Should the secretions be much per- 
verted, the tongue heavily coated, there can be little doubt of the 
usefulness of a few small doses of calomel, often not more than a 
grain or the fraction of a grain, combined with the morphine. Free 
doses of mercurials are objectionable on various accounts, and are 
quite unnecessary at least, and in many cases this article may be en- 
tirely dispensed with. 
There are, however, cases where its effects are peculiarly benefi- 
cial ; whether its action is explicable or not, its efficacy is amply con- 
firmed by experience. In many cases carbonic acid water is grateful 
and useful, and sometimes effervescing mixtures in small doses often 
repeated, or mild neutral mixtures may do good. They must, however, 
be used in moderate quantities and in weak solution, and be at once dis- 
continued when they produce uneasiness or discomfort in the stomach. 
In cases of gastric catarrh arising from a sudden checking of perspi- 
ration (taking cold), securing a free sweat by means of the warm bath, 
or some form of vapor bath, with the use of diaphoretics which will 
not irritate the stomach, will often be of the greatest service. Pilo- 
carpin hypodermically will cause free perspiration without irritating 
the stomach, and may be worthy of a trial in some cases. 
If much depression occurs, stimulants may be required ; but as 
nearly all these articles are local irritants to an inflamed part, they 
must be administered, if at all, by enema or hypodermically. 
If the inflammation extends to the peritoneal coat, it is likely to 
spread farther on that membrane, and is dangerous. Otherwise few THE A TMENT—PHENOMENA. 
597 
cases of acute gastritis are fatal, though in exceptional instances, as 
already stated, rapid asthenia and death occur. 
After the acute symptoms are past, and sometimes, as already 
stated, from the beginning, the treatment should be chiefly or entirely 
hygienic. Bland food only, and in moderation, should be taken for a 
considerable time ; and if much debility remains, gentle tonics, such 
as small doses of quinine, or other vegetable bitters, or the milder 
preparations of iron ; or if irritability of the stomach continues, 
moderate doses of bismuth with lupulin, and perhaps quinine, may be 
useful. As a rule, however, care as to diet and regimen will be all 
that will be required during convalescence. 
CHRONIC GASTRITIS.—INFLAMMATORY DYS- 
PEPSIA. 
The more chronic cases of congestion and inflammation of the 
stomach often require a more varied course of management. 
Special reference here must be had to the causes of the disease, as 
they are generally in continuance, keeping up the effect. 
In these cases the symptoms are much less acute, hut they are 
similar in character to those described. In some cases, often indeed, 
the appetite continues, and more food is taken than is digested. 
There is slowness and imperfection of this process. 
There is often pain, particularly after meals, there is tenderness 
of the epigastrium, a furred tongue with red edges, and in long con- 
tinued cases it becomes patchy and mapped—some parts being clean 
and smooth, others coated, rough, and sometimes fissured. The food 
not being readily digested, and a morbid mucus being secreted which 
readily undergoes fermentation and decomposition, various foul and 
irritating products result. Among these are lactic, acetic, carbonic, 
and butyric acids, causing heartburn, irritation, pain, distention, etc. 
Habitual constipation may follow ; or there may he occasional attacks 
of diarrhoea from irritative materials passing into the intestines. We 
have, in short, all the symptoms of dyspepsia, with the addition of 
epigastric tenderness, and a redder tongue, and commonly with more 
or less rigidity of the abdominal muscles. 
Pain in the stomach may be absent; there may be only a sense of 
warmth ; or instead of a diminished appetite there may be a craving 
for food. But the taking of the food is often followed by pain, and 
sometimes vomiting, or at least by a sense of fullness and weight, and 
as gas is generally evolved, there is a tendency to eructations. The 
breath is usually offensive and sometimes fetid, and the eructations 598 
CHRONIC GASTRITIS. 
may have the odor of sulphureted hydrogen. The temperature is 
slightly elevated in many cases, but rarely exceeds 100°, and some- 
times sensations of chilliness are experienced. 
The elevation of temperature is commonly so slight that the dis- 
ease is generally spoken of as apyretic ; and for a considerable time 
in its gradual approach only the symptoms of ordinary dyspepsia 
appear, and pain even on pressure may be very moderate. 
The distention of the stomach after meals is often perceptible, 
and this, with the increased sensibility, sometimes causes the patient 
to loosen his clothing. The heart is usually sympathetically disturbed 
more or less, and there is often palpitation after meals. Wnen vom- 
iting occurs an hour or two after meals, there is an abundance of 
mucus in the matters discharged, and the azotized foods are somewhat 
changed, but not in the physiological sense of digestion. This quite 
marked change in the food, but not the change of proper digestion, 
Jaccoud regards as peculiar to gastric catarrh ; and be also states that 
“salivation is a constant symptom.” In alcoholic catarrh the 
patient is very apt to vomit early in the morning. In catarrh accom- 
panied by dilatation of the stomach, the vomited matter is found to 
contain sarcina ventriculi. As a result in protracted cases there is 
emaciation and mental as well as physical debility; melancholy and 
hypochondriasis are apt to occur. 
This disease, when neglected, often lasts for months and years, 
and may end in chronic ulceration, in stenosis of the pylorus, or in 
death by marasmus. It is susceptible of cure as a rule, and the more 
recent the case, and the younger the patient, the more favorable.- In 
the aged it is often obstinate, and may long remain stationary. 
Diagnosis.—The diagnosis is to be arrived at by observing the 
symptoms so fully described. It may be mistaken for ulcer of the 
stomach, and possibly for atonic dyspepsia ; but it is most liable to be 
mistaken for cancer. 
The chief points of difference are that in cancer the first symptoms 
come on gradually, and are not due to causes of catarrh. The patient, 
in cancer, is past thirty-five, while in chronic catarrh he may be 
younger. The pains are more active and lancinating in cancer, and 
more likely to be present when the stomach is empty. Vomiting may 
occur in either, but, until cancer is advanced, it is less frequent and 
less watery and mucous. 
In the early stage of cancer the breath is more pure, and catarrh 
of the mouth is less likely to be present. Cancer is progressive, the 
cancerous cachexia is developed, vomiting of blood and offensive mat- 
ter, where the cancer is an open one, often occurs, and a tumor can 
usually be detected. TREATMENT. 
599 
It may bo difficult to distinguish it from ulcer of the stomach, 
but in a solitary ulcer the pain is more local and more distinctly 
referred to a particular point, there is more likely to be hemorrhage, 
and the case is more obstinate. 
The tenderness on pressure, the red tongue, the slight elevation of 
temperature, will distinguish it from dyspepsia. In gastralgia the 
pain is more paroxysmal and less dependent upon the presence of 
food. 
Treatment.—As already stated, the treatment is not as simple 
as in acute cases, but some of the same principles are applicable here. 
Attention should at once be given to the removal of the cause. 
When due to obstructed circulation through the liver, the heart, or 
the lungs, every effort possible should be made to remove such ob- 
struction. 
Unloading of the congested state of the portal system is called for, 
and this is best done by cathartics ; the salines, as a rule, are prefer- 
able, and in many cases should be repeatedly given. In all cases con- 
stipation must be overcome and prevented. 
When the symptoms approach those that occur in the acute stage, 
the diet must be very limited and exceedingly bland ; leeches to the 
epigastrium, and especially blisters, may be required, and morphine 
temporarily, or hyoscyamus, or belladonna, will often be demanded. 
The chronic form of gastric catarrh, so often consequent upon the 
acute, should be prevented by prompt attention to the latter. In 
these cases Jaccoud thinks emetics have been too much neglected ; and 
there are, doubtless, cases where either by emetics or the use of the 
siphon, washing out the stomach is useful. Leube states that among 
emetics in these cases, ajjomorphia in doses of from a twelfth to a 
sixth of a grain, used hypodermically, is to be preferred; it being 
efficient, and in this manner not irritating materially the stomach. 
In all cases the diet must receive particular attention. The food 
must be moderate in quantity, well masticated, easy of digestion, and 
unirritating. 
Some will digest starchy foods best, while others do best with more 
azotized aliments. Each case must be observed by itself, as no rule 
will apply to all alike. In most cases, especially when symptoms are 
at all acute, a milk and farinaceous diet will be best borne. 
When collections of gases occur from fermentation of undigested 
foods, antiseptics and absorbents, as small doses of creosote, carbolic 
or salicylic acid, the sulphites, or such absorbents as charcoal, mag- 
nesia, or bismuth will be useful. When there is deficiency in the 
acidity of the gastric juice, the mineral acids well diluted may be very 
useful, given in connection with the meals. The alkalies will tern- 600 
CHRONIC GASTRITIS. 
porarily relieve the symptoms produced by acidity from the fermenta- 
tion of food, and will facilitate the passage of these irritating matters 
from the stomach. If used habitually, however, they are apt to do 
more harm than good, and should be avoided, particularly when the 
digestive process is in progress, unless the fermentative changes are 
entirely superseding the natural digestive actions. 
The management of these dyspeptic symptoms will be more par- 
ticularly described under the head of Functional Derangements of the 
Stomach, to which the reader is referred. 
But there is another set of measures applicable to these conditions 
of chronic gastritis which require attention. In chronic buccal and 
pharyngeal catarrh, in similar conditions of the bladder and con- 
juncture and other mucous surfaces, astringents and mild caustics 
locally acting as alteratives are often exceedingly useful. 
In a similar manner, local alteratives may change favorably the 
conditions of the chronically inflamed mucous surface of the stomach. 
Among the articles operating in this way are nit. of silver, sulphate 
of copper, sulph. of iron, and sulph. of zinc, and the terebinthian and 
balsamic preparations. According to my observations the nitrate of 
silver and the terebinthian and balsamic preparations are most likely 
to be useful. 
The nitrate of silver is best given in the form of a pill with opium 
or the extract of belladonna. The dose of the silver in these cases is 
from one fourth to three fourths, and sometimes as high as a grain, 
three times a day for a length of time. Often only a few doses should 
be given, and then suspended for a few days to observe its effects 
before they are renewed. It should always be given upon an empty 
stomach, and great care should be taken of the diet during its use. 
If great irritability exists, or is produced by the silver, the patient 
may be fed for a day or two by the rectum, or a table-spoonful of 
milk, Avith a third or half the quantity of lime-Avater, may be given 
every hour, returning slowly to a more varied but still bland diet. 
Some prefer opium with the silver in quarter or half grain doses, 
more or less, while others choose extract of belladonna. Lebert and 
Jaccoud prefer the latter. The dose of a good article should be from 
one eighth to one half a grain. 
As Avith its application to other inflamed surfaces, the nitrate of 
silver should not be continued too long, and its effects should be care- 
fully observed. 
I have found the oil of turpentine, ghren in emulsion Avith small 
doses of laudanum, very efficient in cases of this kind in changing 
the condition of the inflamed mucous surface. A tea-spoonful of the 
ordinary emulsion (see formula on page 274) may be given three or TREATMENT. 
601 
four times a day. This, not as powerful in its local action, may be 
continued for a longer time than the silver, and with less absolute 
restrictions as to diet. The balsam of copaiva, and other balsamic 
articles, in appropriate doses and preparations, may also be of service, 
and so may other alterative and astringent articles. 
In the gastritis of drunkards deeper tissues are apt to be involved, 
and scattered superficial ulcerations are not unfrequent. These cases 
are to he treated by securing abstinence from the alcoholic poison- 
ing (a matter often difficult to accomplish), and, if the disease has not 
gone too far, surprising improvement may result; but too often such 
changes have occurred as render every effort unavailing. 
Jaccoud recommends in these cases a proper trial of the hydro- 
pathic method of treatment. In other cases as well, it may he worthy 
of trial. 
The cures of these cases which often take place at the thermal and 
mineral springs, such as Yichy, Carlsbad, Ems, Kissingen, Baden- 
Baden, etc., so frequently resorted to on the continent of Europe, sug- 
gest the use of weak saline waters in free quantities as eliminatives 
and diluents. I have often seen patients improve on small doses of 
sulphate of soda, with still smaller quantities of the carbonate and 
of common salt, taken early in the morning in a large quantity of 
warm water, flavored with some aromatic substance if desired, and 
perhaps repeated once or twice a day, when other methods of treat- 
ment had been used with indifferent results. 
SUBMUCOUS GASTKITIS.—PHLEGMONOUS INFLAMMATION OF THE 
WALLS OF THE STOMACH. 
The acute form of suppurative inflammation of the coats of the 
stomach is very rare, and its clinical history is not distinctive. There 
is purulent infiltration of the submucous layers of the stomach, with 
thickening of the walls, the mucous membrane being hyperaemic and 
turgescent, sometimes presenting circumscribed ulcerations. 
The muscular coat is changed in color, and is gelatiniform in con- 
sistence ; the serous layer is opaque and injected, and covered with 
false membrane ; sometimes adhesions and limitations occurring, and 
at other times more diffused peritoneal inflammation. Inflammation 
may occur also in the pleura and the pericardium. 
The inflammation in the stomach itself may be diffused over a 
considerable part of the wall, or may be limited, forming abscesses in 
the submucous tissue. It has been studied mostly in fatal cases ; but 
recovery is possible, the abscesses discharging into the stomach and 
cicatricial tissue following, which may contract and cause narrowing 602 
SUBMUCOUS GASTRITIS. 
of the pyloric or cardiac orifice, or deformity of the body of the 
stomach. 
The symptoms are of a severe character in acute cases—pain, ten- 
derness, vomiting, fever, general prostration—and often death occurs 
by peritonitis or collapse. 
In some cases of less acuteness, abscesses may form which will last 
for several months. As the abscesses form there will be partial abate- 
ment of the pain and tenderness, but distressing dyspeptic symptoms 
follow, with vomiting and a hectical fever; cr signs of perforation are 
presented. 
Differential Diagnosis.—It is to be distinguished from ordi- 
nary gastritis, gastro-enteritis, and circumscribed peritonitis by the 
fever and general symptoms being more severe, by the pain not being 
materially aggravated by the movements of the patient, and by the 
gastric region offering a feeling of very much increased resistance. 
Still, a positive diagnosis must be regarded as very difficult, and often 
tliq post-mortem examination alone will be conclusive. 
This inflammation may be primary or secondary. The causes of 
the primary are obscure ; the secondary variety is sometimes seen in 
typhoid fever, in variola, and especially in pyaemia, and then the local 
symptoms may be masked by the general disease. 
Treatment.—The treatment, which is generally unsatisfactory, 
must be symptomatic, and will not differ materially from that for 
other forms of acute inflammation of the organ. It is thought by 
some late authorities that the early use of cold gives the most rational 
chance of success. 
Interstitial Chronic Gastritis, or Plastic Inflammation of the 
Walls of the Stomach, Cirrhosis of the Stomach, is a more frequent 
disease. In this there is hyperplasia of the connective and muscular 
tissues, the infiltration of lymph and consequent thickening of the 
walls, which may become hard, firm, and contracted; or they may 
undergo degenerative processes. When fibroid tissue is formed in the 
coats of the stomach, like other false membrane, it contracts, often 
reducing the capacity of the stomach and causing stricture of its ori- 
fices. It may follow chronic catarrh of the stomach from ordinary 
causes, but it is commonly produced by alcoholism, and is intractable, 
and generally sooner or later fatal. If detected sufficiently early, and 
the alcohol is discontinued, with other appropriate treatment—sooth- 
ing measures, eliinitiatives, and counter-irritation, etc.—the progress 
of the disease may sometimes be checked ; but after a certain amount 
of advancement, it is fatal. Palliative symptomatic treatment will 
be required. Opiates, bismuth, turpentine, balsams, antacids, tonics, PHENOMENA—1)1 A GNOSIS—TREA TMENT. 
603 
oxide of zinc, and great attention to diet, may afford relief. Iodide 
of potassium, with the view of preventing further deposits and of pro- 
moting absorption, may be indicated and borne in some cases, and, 
when it does not irritate the stomach, may be persevered with. 
TOXIC GASTKITIS. 
Chemical injuries and inflammation from corrosive poisons some- 
times occur from accident or design, and require a brief notice. 
Acids and alkalies, when swallowed in sufficient quantities and 
in concentrated forms, unite chemically with the tissues, destroying 
their vitality, and often their substance. When not in sufficient 
quantity, or concentrated enough to produce this effect, they excite 
inflammation, which may result in necrosis or ulceration, or, before 
such changes have time to occur, in the death of the patient. 
Various other articles, such as arsenious acid, phosphorus, the salts 
of silver, copper, mercury, etc., and different vegetable irritant 
poisons produce their effects by exciting inflammation. 
The same agents are apt to act on the mouth, pharynx, and oesoph- 
agus, and they may retain their activity after leaving the stomach, 
and cause lesions of the intestines. 
Each substance has its peculiarity of action and effects, which are 
described in works on Toxicology. 
Diagnosis.—The diagnosis will be made by the circumstances 
of the attack and the time and manner of taking the poison. Symp- 
toms usually occur suddenly in the midst of health. There is great 
pain, commonly vomiting, and generally there is more or less blood 
in the discharges ; the pulse becomes small, skin cold, face often 
blue, countenance shrunken, etc., and death may be speedy. If the 
patient survives a sufficient length of time, symptoms of inflammation 
—gastric, intestinal, or peritoneal, or all together—occur, and death 
or recovery follows according to the severity of the poisonous impres- 
sion and the power of endurance of the patient. 
Treatment.—The treatment at first, aside from the free drink- 
ing of fluids, and the encouraging of vomiting, or the use of the 
stomach-pump, must be governed by the character of the poison, by 
a knowledge of its chemical qualities and the antidotes which may 
neutralize them, the details of which will not here be noticed. 
The inflammation which follows is to be managed on general 
principles by the use of soothing and sustaining measures ; opiates, 
demulcents, fomentations, etc., being the chief measures to which we 
should resort. In sustaining the patient, rectal alimentation is to be 
borne in mind. Whatever may be thought of the digestive power of the 604 
TOXIC GASTRITIS. 
lower bowels, there is no question of their power of absorbing aliment- 
ary substances, Avhen introduced into them, which have been already 
chemically digested out of the body, or mixed with digestive elements. 
The experiments of Prof. Brown-Sequard are quite conclusive. 
By the use of a mixture of meat and pancreas, twelve to fourteen 
ounces of the meat to five or six ounces of the pancreas injected per 
day, he has kept patients not only alive but without loss of weight 
for weeks, in one case for more than three months. When the pan- 
creas is quite fresh, the whole mixture, reduced to a pulpy mass in a 
mortar, and mixed with a fluid, is used, one half at a time, as an ene- 
ma, and the digestion is so complete that no trace of the tissue of either 
substance can be found in the well-formed faeces which are passed. 
The plan of Prof. Mayet, of Lyons, may be an improvement upon 
that of Prof. Brown-Sequard. He bruises the pancreas in a mortar 
with tepid water at about the temperature of 37° C., and then presses 
in a cloth the pulp obtained. 
The liquid thus procured is triturated with the lean meat, which 
has been chopped and freed from fibrous parts, to which is added the 
yolk of an egg. This mixture is left to stand two hours, kept at the 
same temperature, and then thrown into the rectum, first cleared out 
by an oily enema. This digested material is thought to be more 
easily and more readily and completely absorbed than the mixture 
in which the fibre of the pancreas is retained. 
In all forms of gastric inflammation, degeneration of the epithe- 
lium, the tubes, and of the secreting structure may occur. 
These parts may become atrophied, or many of them may be de- 
stroyed, the secreting function being permanently affected. This 
will lead to weakness of digestion ever after. In such cases, per- 
petual care of the diet and mode of life will be required. Strict 
hygienic rules must be constantly observed. 
Pepsin and mineral acids will for the time aid the digestive 
processes, and various tonics may be temporarily useful in giving 
more vigor to the system. Any intercurrent morbid states must, if 
possible, be removed ; and the palliation of the particular symptoms 
that may arise should be attempted. 
The use of alcohol in such cases, though sometimes soothing 
sensations and giving temporary relief, quite as often—even at the 
time—produces disturbance; and for permanent and ultimate effects 
it cannot generally be recommended. 
This expression may be contrary to some opinions of high au- 
thority, which are entitled to the most respectful consideration ; but 
I do not doubt that the science and experience of the future will sus- 
tain its correctness. PHENOMENA. 
605 
SIMPLE ULCER OF THE STOMACH. 
Different names have been given to the disease now to be con- 
sidered, such as chronic solitary ulcer, round ulcer, penetrating ulcer, 
etc., but all are not chronic, neither are they all solitary, round, or 
penetrating; though many of them have all these characteristics. 
The term simple ulcer is perhaps least objectionable. 
Gastric ulcer is, however, a specimen of a peculiar kind of ulcer 
which may occur in the terminal part of the oesophagus and in the 
duodenum, as well as in the stomach, and is thought by Leube to be 
analogous to the corroding ulcer of the neck of the uterus. The de- 
struction of substance in the more recent ulcers is greater at the surface 
than in deeper tissues ; but in older ulcers the walls are more perpen- 
dicular. Generally they are nearly circular, though rarely irregular 
in form, and often look as if the superficial layers were clean cut as 
by a punch. The edges are generally hard and thickened, and in the 
older ones the inflammatory infiltration is marked. In recent cases 
it is much less so ; and while in some there is a disposition to pene- 
trate, in others exudates take place at the base, and the walls are 
thick and firm, or a more granular mass may give the appearance of 
a morbid growth. Beyond the immediate surrounding of the ulcer the 
mucous membrance is usually comparatively healthy, though in some 
cases a more extended gastric catarrh is present. The loss of tissue 
may involve the mucous membrane alone, or it may extend to the 
muscular coat or the peritoneum, when, if inflammatory adhesions to 
other parts have not been formed, perforation into the peritoneal 
cavity occurs with the usual result of a fatal peritonitis. Should 
such adhesion take place, the neighboring organ, as the pancreas, may 
form the base of the ulcer. 
The size of the ulcer varies from that of a large pea (such as I 
have seen penetrating the duodenum), or even smaller (as one shown 
me by Prof. Cohnheim, which penetrated an artery and caused 
repeated and finally fatal hemorrhage), to one described by Cruveil- 
liier, which was six and one half inches in length by three and one 
third in width. 
The situation of the ulcer is more frequently upon the posterior 
than the anterior wall of the stomach, but it is not unfrequently in 
the pyloric region. Usually there is but a solitary ulcer, though in 
some cases there are more, and occasionally two or more run together, 
especially near the pylorus. 
As met with in the cadaver, the ulcer is sometimes open and some- 
times partially or completely cicatrized, the cicatrices being contracted 606 
SIMPLE GASTRIC ULCER. 
and the stomach more or less deformed. The smaller cicatrizations, by 
the folding of the surrounding membrane, have a puckered and often 
radiated appearance, and when situated near the orifices, stenosis 
of the cardia or pylorus may be the result. The peristaltic move- 
ments, and the contraction and expansion of the stomach by food 
or gas tend to prevent adhesions, especially upon the lower curva- 
ture, and hence there is greater danger of perforation into the peri- 
toneum of ulcers upon the anterior than the posterior portion of the 
organ. 
When adhesions take place, and the liver, pancreas, or spleen forms 
the base of the ulcer, inflammation is likely to extend into the paren- 
chyma of the organ, forming cavities or bands of adhesive matter ; the 
course is uncertain, and cicatrization even then sometimes occurs. 
Adhesions to the walls of the abdomen have resulted, though very 
rarely, in an external fistula ; while in other rare cases the diaphragm, 
the colon, and the lower part of the duodenum, have been penetrated, 
and communications established with these intestines. The cicatricial 
adhesions may undergo destructive changes and give way, and tlie 
same results as from primary penetration take place. 
Hemorrhage is likely to occur, in ulcer of the stomach, from 
erosion of vessels ; and when the ulceration is deep the larger vessels 
may be opened and the hemorrhage may be profuse and fatal. Some- 
times the veins in the neighborhood of a comparatively superficial 
ulcer become varicose, and, as they are involved by the ulcerative 
process, afford a free flow of blood ; but usually the hemorrhages are 
from smaller vessels, and are not profuse. In the case referred to as 
seen in Prof. Cohnhcim’s pathological laboratory, a penetrating ulcer, 
so small as only to admit of an ordinary-sized probe, extended 
obliquely through the mucous membrane, eroding the coats of a blood- 
vessel, and when the stomach became empty hemorrhage occurred; 
but when it was distended with food the bleeding was arrested. This 
continued for weeks, and at length the patient succumbed from loss of 
blood. The diagnosis was of course obscure, and the nature of the 
case was revealed only by the post-mortem examination. 
Gastric ulcers are apt to be complicated with other diseased con- 
ditions, particularly of the circulatory and respiratory systems. Post- 
mortem examinations show them to be more frequent than clinical 
observation would lead us to suppose, as some cases are not marked 
with sufficiently distinctive symptoms to lead to a diagnosis during 
life. 
Etiology.—The immediate pathological causes of these ulcers 
would seem to be diminished or interrupted circulation of blood in a 
portion of the stomach, resulting in diminished alkalinity in that ETIOLOG Y—SYMPTOMS. 
607 
situation, and diminished resistance to the action of the acid gastric 
juice, which consequently acts upon the tissue, commencing the de- 
structive process. Anything which interferes with the circulation, or 
which increases the acidity of the gastric secretion, will contribute to 
the result. 
This local stasis, or diminished circulation, may result from com- 
mon catarrhal inflammation, from mechanical obstruction by athero- 
matous or fatty degeneration of the small vessels, or their obstruction 
by thromboses or emboli, or by similar obstruction of the larger gastric 
veins or of other portal vessels. 
This form of ulceration may possibly originate in more superficial 
or aphthous ulcerations ; the contractions and expansions of the 
stomach, and the corroding action of the gastric juice preventing 
healing, and carrying on the destructive process. 
Among the more remote or predisposing causes are sex (it is more 
common in women than in men), age (oftener in advanced life), fee- 
bleness of constitution, excesses in eating or drinking, chlorosis, and 
especially tuberculosis and the puerperal state. Among the exciting 
causes as given by Jaccoud are chills, too hot drinks, too cold drinks 
when the body is heated, and especially the free use of spirituous 
liquors. 
Eespecting the influence of this last cause Jaccoud believes there 
is no doubt, and he thinks it operates by provoking acid fermen- 
tation in the contents of the stomach, which, added to the gastric 
secretion, overcomes the alkalinity of the blood circulating in the 
vessels. 
Ulcers of this specific character in the duodenum are less frequent 
than in the stomach, and generally are found in the part nearest the 
pylorus ; but they occur oftener in men than in women, and more 
frequently in middle life than nearer its extremes ; and a form of 
ulceration of this intestine is caused by burns of the skin. 
Symptoms.—The symptoms and progress of ulcers of the 
stomach vary in different cases, and the diagnosis is not unfrequently 
obscure. 
A person in comparatively good health, with perhaps some slight 
and occasional pains in the stomach, but not such as to attract much 
attention, may bo seized with a sudden and intense peritonitis, or 
with severe distress in the stomach with vomiting of blood, in either 
case resulting in death in a few hours, or in one, two, or three days. 
In such sudden cases, on post-mortem examination, an ulcer will 
be found, probably not large in circumference, but penetrating deeply, 
having made its way through all the coats of the stomach, so as to 
allow its contents to pass into the peritoneal cavity ; or having opened 608 
GASTRIC ULCER. 
large vessels and involved the deeper tissues, producing the hemorrhage 
and the distress, and in both cases the collapse and the death of the 
patient. 
Such an ulcer, though commonly in the stomach, may be found 
in the duodenum. 
Another rapid or acute variety has the same termination, but is 
not as sudden, and before its conclusion has a collection of symptoms 
resembling those of toxic gastritis; and in either of these cases the 
question of poisoning may be raised, to be settled only by an autopsy. 
By far the most common variety is the chronic. The chief char- 
acteristic symptoms here are pain and vomiting, the pain being limited 
to the location of the ulcer. When this is on the anterior surface the 
pain will be near the ensiform cartilage, and when on the posterior 
surface it is deep or at the back. This pain is notably increased by 
the ingestion of food, and generally by pressure, by tight clothing, or 
by active movements. Sometimes, in addition to this more constant 
pain, there are paroxysms of severe shooting pains producing intense 
agony. The most rational explanation of this severe suffering is that 
successive nerve filaments are attacked in the progress of the ulcer. 
The vomiting, provoked by the same causes which produce the 
pain, often accompanies it. When the ulcer is near the cardia it may 
occur when food is taken, or soon after; while if at the pylorus, it is 
more apt to take place as the food is passing that orifice, some time 
after the meal. It may occur when the patient is fasting, and in that 
case the matter ejected consists of mucus often tinged with bile. The 
vomited matter not unfrequently contains blood. It may be com- 
paratively fresh or clotted, or, when it has remained for some time in 
the stomach, it resembles coffee grounds. 
Various dyspeptic symptoms are usually present, and constipation 
of the bowels is not unfrequent. In this chronic form the disease 
may continue almost indefinitely, at least for several years, remaining 
nearly stationary or increasing or diminishing in severity; and the 
symptoms often fluctuate, with marked aggravations and remissions. 
It may terminate in complete recovery, or in incomplete cure, with 
cicatrices and adhesions which interfere with the movements of the 
stomach, or produce mbre or less stenosis of the openings; and when 
obstructing the pylorus, lead to dilatation and muscular hypertrophy. 
It may also terminate in death by exhaustion, by hemorrhage, or by 
perforation. 
Prognosis.—The prognosis in ulcer of the stomach is serious. 
Even where the ulcer heals there is a liability to relapses, and the cica- 
tricial tissue, by its contraction, interferes with the function of the 
organ. DIA GNOSIS—TREA TMENT. 
609 
Diagnosis.—Ulcer of the stomach may be confounded with 
chronic gastritis, with cancer of the part, or with atonic dyspepsia. 
It is to be distinguished from gastritis by the more local character of 
the pain—persisting at a fixed point—by the greater obstinacy of the 
disease, and by the far more frequent occurrence of hemorrhage. It 
differs from cancer by its often being stationary and more protracted, 
while cancer is progressive and seldom continues longer than eighteen 
months after its detection. It is also distinguished by the absence of 
the cancerous cachexia, and of a tumor which in cancer is generally 
discoverable, especially as the disease becomes advanced. There is 
apt to be vomiting and hemorrhage in both diseases, but when the 
cancer becomes an open one the hemorrhage is more frequent, and 
very offensive matters are likely to be ejected. While ulcer may occur 
at any period of life, cancer very seldom occurs before thirty-five. 
It is to be distinguished from functional dyspepsia by the more 
persistent character of the symptoms, by tenderness, by the pain 
being more definitely located, and more uniformly increased after 
meals, by more frequent vomiting, and by the occurrence of hemor- 
rhage. 
Hematemesis may be caused by a variety of other conditions, as, 
when there is a general tendency to hemorrhage in the system; in 
purpura, etc.; in malarial, yellow, and other fevers; in mechanical 
congestion from hepatic, cardiac, or pulmonary obstruction, as coin- 
cident with menstruation or as vicarious of it, and, finally, in cancer. 
When these conditions are excluded, the vomiting of blood, espe- 
cially if repeated, becomes an evidence of ulcer. 
Treatment.—The treatment of ulcer of the stomach is chiefly 
dietetic. As far as possible, expansion of the stomach by food, drinks, 
or flatulency, must be prevented, and the object should be to give it a 
minimum of work, and of the lightest kind. The strictest diet 
must be observed. It must be moderate in quantity and bland in 
quality. Milk and thoroughly cooked farinaceous food, milk and 
lime-water, soft boiled eggs, and solutions of meat with pancreas, or 
meat digested with a strong acid solution of pepsin in a sealed vessel 
at a temperature higher than that of the body, thus reduced to a 
fine emulsion containing more or less of peptones, should be the diet. 
In the proper management there must be no interruption of the 
dietetic restrictions. A single coarse meal may undo the results of a 
long course of cure. 
In addition to this dietetic plan, excessive acidity must, if possi- 
ble, be prevented from accumulating and remaining in the stomach. 
Alkalies, though often giving temporary relief, are on the whole 
of very questionable utility. It is impossible to regulate the quantity 610 
GASTRIC ULCER. 
so as to neutralize only the excess of acid ; and when more than that 
is given, it interferes with the digestion of the food, and the fermen- 
tation which is likely to follow often produces more acid—lactic, 
butyric, and carbonic—than existed before. Thus irritation of the 
stomach, flatulence, heartburn, etc., are increased. The occasional 
complete evacuation of the stomach of its accumulated contents is 
often here, as in gastritis, followed by much relief. 
The stomach-pump or siphon has in these cases been used ; but 
the possibility of irritating, or even penetrating the ulcer by the intro- 
duction of the tube, constitutes an objection to this mode of pro- 
cedure in ordinary practice. Emetics are objectionable for obvious 
reasons. As a means of evacuating the stomach, weak saline solu- 
tions, taken warm in free quantities early in the morning, an hour or 
so before breakfast, are strongly recommended, particularly by Leube 
and other German writers. The waters of the saline thermal springs 
of Germany, especially Carlsbad, have long been resorted to, and 
often with marked success, in cases of chronic gastritis and ulcer. 
The ingredients in this water are sulphate of soda, carbonate of soda, 
and common salt—the first in much the larger quantity. The prac- 
tice at the springs is to drink a free quantity—often from a pint to a 
quart of the water—in moderate amounts at a time, but repeated 
every few minutes until the requisite quantity is taken, no food being 
allowed for an hour or so after. 
Before this time the solution, with other contents of the stomach, 
will have passed out of it, and soon after one or two watery stools are 
produced. This practice may be substantially imitated anywhere. 
A table-spoonful, more or less, of a mixture of sulphate of soda, carbo- 
nate of soda, and common salt, in the proportions of eight or ten 
parts of the first to one each of the last two, may be put into a pint 
of warm water, with any unirritating flavoring material that may be 
desired, and a quarter of it at a time may be drank once in a few 
minutes, until the whole is taken. The effect is essentially the same 
as that from drinking the water at the springs as above described. The 
quantity of the salt mixture may be varied according to the laxative 
effect, but the quantity of water is to remain the same—about a pint. 
The success of this treatment, in connection with the proper diet, 
in ulcer of the stomach has been well attested ; and the great relief 
which this remedy is capable of affording in subacute and chronic 
gastritis, with congestion and deficient secretion of the liver, I have 
often witnessed. The careful experiments of Dr. Rutherford to test 
the cholagogue effects of different substances have shown that, upon 
the animal the subject of the experiments, the sulphate of soda 
increased the flow of the bile more than any other of the salines. TREATMENT. 
611 
With the increased secretion of the liver a more free circulation of 
blood through that organ occurs, and portal congestion is relieved. 
This effect may aid in relieving the congestion and other morbid con- 
ditions of the stomach. 
Leube’s method of treating gastric ulcer is as follows ; and the 
plan commends itself to my judgment: 
“ The patient is confined to his bed during the course of treat- 
ment ; hot poultices are applied to the abdomen (at night a cold com- 
press, or ice, if hemorrhage be threatened), and active movements of 
the body are avoided as much as possible. During the first few days 
Carlsbad salt (one table-spoonful to a pint of lukewarm water), is 
given in the morning. If the salt fail to properly evacuate the 
stomach, the stomach-pump may be cautiously used, and the gastric 
surface washed with lukewarm water. The diet of the patient con- 
sists, at the start, of one pot of the beef solution per diem, corre- 
sponding to half a pound of beef, and to this I usually add, for break- 
fast and dinner, some milk and a few pieces of rusk which should not 
be swallowed until they have become thoroughly softened and mas- 
ticated. The beef solution is taken pure, or it may be stirred in 
bouillon with a little of Liebig’s extract of meat, and a little salt 
added or not, as desired. All the food should have a lukewarm tem- 
perature. After from two or three weeks, I place the patient upon 
a light diet, consisting of pigeon, chicken, puree of potatoes, thicker 
soups, wheat bread, etc. ; and after eight days longer I gradually 
return to coarser food.” (Ziemssen’s Cyclopaedia, vol. vii. p. 225.) 
The only criticism I would make upon this is, that in many cases, 
at least, the restricted diet should be much longer continued, as the 
“return to coarser food” might arrest a healing process, or break 
up a recent cicatricial tissue. Entire abstinence from food by the 
stomach for two weeks, and rectal alimentation, may be required in 
some cases of gastric ulcer. 
In addition, especially when this plan is not satisfactory in its 
results, the subnitrate of bismuth in doses of from five to ten grains 
(some advise it in much larger quantities), with or without a twelfth 
of a grain of morphine, three times a day, may be given. This 
remedy has long maintained a reputation in diseases of the stomach 
with irritation of the organ, and has undoubted virtues in many 
cases. The nitrate of silver has also been recommended and used 
with reference to a local alterative effect upon the ulcer; but it is 
not easy to understand how the small quantity that may be safely 
given can produce much local effect upon so small a part of the 
extended surface of the stomach. Besides, the common salt it w'ould 
be almost sure to meet with in the stomach would soon neutralize 
its caustic properties. Still, there is testimony in its favor, and it 612 
GASTRIC ULCER. 
may be tried in obstinate cases. Fuller doses than the sixth or a 
quarter of a grain may be ventured upon where other means have failed. 
The turpentine emulsion (see formula) may exert a beneficial 
alterative effect, and where other means are unsuccessful it should 
have a trial. A proper dose would be from eight to fifteen drops, 
thoroughly emulsified with gum and sugar, with a few drops of 
laudanum, or a corresponding quantity of morphine, three or four 
times a day. Where the food is inclined to undergo fermentation 
changes, a drop or two of carbolic acid or of creosote may be added to 
each dose of the emulsion. Absorbents, such as charcoal, very finely 
powdered, and magnesia, may be used when gases are troublesome. 
For the relief of the severe pain fiothing is so efficient as mor- 
phine in appropriate doses, but where it disagrees, other narcotics, 
as hyoscyamus, belladonna, etc., may be substituted. Small doses of 
the muriated tinct. of iron, three or four drops in a wine-glassful 
of water, several times a day, are said to often relieve pain, and such 
use cannot be objectionable. 
In some cases of tenderness and constant pain, counter-irritation 
Avith mustard, or, more effectual, a fly blister, affords relief. Where 
the pain and tenderness is local, fixed, and superficial, indicating that 
the anterior wall of the stomach is the seat of the ulcer, the Avearing 
of a small ice bag over the part, or the application of a feAV leeches is 
advised. 
Where there is much distention by gas, and it is not relieved by 
charcoal, the attempt may be cautiously made to relieve it by the 
stomach-pump or siphon. 
The vomiting is most certainly relieved by the strict confinement 
to unirritating food. If this does not succeed, morphine, swalloAving 
small pieces of ice, a drop or two, or more, of creosote in two or three 
table-spoonfuls of water, or a few drops of the tinct. of iodine in some 
mucilaginous vehicle may be tried. Both the morphine and the 
creosote are certainly, sometimes, quite efficient. 
When the hematemesis occurs, the patient must be kept perfectly 
quiet upon his back, pieces of ice may be swalloAved, and fifteen drops 
of a solution of ergotine (made by taking ergotine fifteen grains, 
Avater two drachms, and alcohol forty minims), may be injected hypo- 
dermically, and repeated if required. Local astringents, taken into 
the stomach, may also be used, such as acetate of lead Avith an opiate, 
tannic or gallic acid, and the astringent preparations of iron. There 
is a disposition in the profession to avoid these remedies, lest they pro- 
duce irritation of the abraded surface of the ulcer; but in extreme 
cases the temptation to use them should not, perhaps, be resisted. 
Cold over the epigastrium may be applied, and warmth and mustard TREATMENT. 
613 
plaster to the extremities. Here, as in other cases of dangerous inter- 
nal hemorrhages, the ligation of the extremities, so as to retain a 
larger amount of blood than normal in the veins, cannot fail, when 
properly managed, to contribute to the safety of the patient. 
During the hemorrhage, and fora time after, all food should be ab- 
stained from, and if necessary the patient supported by nutrient enemas. 
In all cases the bowels should be kept open. The artificial Carls- 
bad salt, in the cases to which it is adapted, will be sufficient; in other 
cases enemas may be required, while in others a laxative pill, com- 
posed chiefly of aloes and hyoscyamus, acting principally, as it will, on 
the large intestines, will effect the object without material irritation 
of the stomach. 
In anaemic, and especially chlorotic patients, preparations of iron 
are important ; and those should be selected which are least injurious 
in their effects upon the digestive organs. The lactate, pyrophosphate, 
etc., are eligible preparations. 
When perforation occurs, free doses of opium, fomentations, abso- 
lute rest, abstinence from food by the stomach, and if great distention 
of the intestines or stomach is present, the rectal tube or the stomach 
tube, carefully used, may give exit to the gases. We can usually 
do nothing more than to mitigate suffering and induce euthanasia. 
In many cases where the gastric ulcer heals, sequelae are left which 
require treatment for a long time. Cicatricial contractions, adhesions 
of the stomach to other organs, cardialgia, defective secretion, dimin- 
ished peristaltic motions, stricture of the cardia or pylorus, with 
their consequences, may follow, requiring much care. 
Perpetual attention to the diet is of primary importance, and other 
measures will be required as each case may demand. The danger 
of relapses must be borne in mind, and proper precautions must be 
taken for their prevention. 
Abscesses of the liver sometimes form adhesions with the stomach 
and open through into its cavity, forming a fistulous opening in its 
walls. There will be symptoms much like those of simple ulcer, but 
there will be the evidences of suppurative inflammation of the liver 
preceding. The treatment will be symptomatic, with care of diet. 
Hepatic abscesses will be treated of under diseases of the liver. 
ULCER OF THE DUODENUM. 
Symptoms and Treatment.—In ulcer of the duodenum the 
symptoms are more obscure, and the severest pain will be later after 
meals. Penetration here is apt to occur with even less warning than 
m case of ulcer of the stomach. 
The treatment will be similar to that described as applicable in 614 
TUMORS OF THE STOMACH, 
cases of gastric ulcer ; though the diet need not be quite as strict. 
Only such food, however, should be allowed as will be readily changed 
into unirritating chyme. 
Small scattered ulcers sometimes occur in the stomach and duode- 
num, with a general catarrhal or diffused inflammation of the mucous 
coat of the stomach. 
This form of ulceration is sometimes found in alcoholism, and 
in certain other cachectic conditions of the system. These cases 
may be either acute or chronic. The symptoms are not particularly 
distinctive, but resemble those of solitary ulcer combined with 
gastritis. There will be pain, vomiting, tenderness, hemorrhage, 
etc. The pain, however, will not be as strictly localized as in solitary 
ulcer, and the symptoms will resemble more those of gastritis. 
The treatment will not differ materially from that which has 
already been described for gastritis and solitary gastric ulcers. 
TUMOKS OF THE STOMACH. 
Tumors, as distinguished from concretions, are neoplastic growths 
of tissue—are parts of the body and subject to its laws. Nutrition 
occurs in them all, hut it is a modified nutrition in character, 
amount, or location. 
All morbid growths have some analogy to some natural growth of 
tissue. A heterologous growth is one different from the tissue of the 
part in which it is found, but not necessarily entirely different from 
all normal structures. Some growths, however, have but a remote 
analogy to natural tissues, and such are likely to he more destructive 
in character ; but all heterologous growths are not malignant. In all 
tumors there are several stages. 
1st. A stage of irritation in which a morbid process commences— 
a modified nutrition and proliferation begins. 
2d. More distinct granulation and cellulation takes place, and a 
tumor growth appears. In this embryonic or germinal state the 
structure is not distinctive. 
3d. In this third stage “ differentiation ” takes place, and the dis- 
tinctive features of particular tumors appear. 
4th. A full development of specific characteristics occurs, and the 
tumor has attained its maturity, its adult existence. 
5th. In this last stage retrogressive metamorphosis commences and 
progresses, such as fatty degeneration, softening, calcification, necro- 
sis, breaking up and destruction, as in advanced cancer. Different 
tumors vary in the rapidity of their development and their life-period. 
The more benign tumors, as a rule, differ least from normal tissues, TUMOBS. 
615 
and some are nearly or quite as persistent in their continuance and 
structure as the natural parts. Others are shorter in their life-con- 
tinuance, tend to destruction, and yet arc inclined to spread, involv- 
ing other parts in their own character and fate, and are therefore 
malignant. 
Different tumors have different origins, and are divided into 
classes according to that origin. WTe have those which are— 
1st. Exudations from the blood. 
2d. Those derived from secretions retained in receptacles, dilating 
them, with cysts formed about them, as the sebaceous tumors. 
3d. Proliferation of tissues, modified and increased, hyperplasias, 
such as occur in nodes, exostoses, and enlarged glands. 
4th. Specific and often complex tumors, where growths occur 
which are more modified from the natural. To this class belong can- 
cers, lupus, etc. The more juicy a tumor the more likely it is to 
spread, and the more vascular the more active. 
There are various classes of particular tumors with more specific 
characters and names, which were referred to in the general patho- 
logical statements in the earlier part of this work. 
Several varieties of these tumors occur in the walls of the stomach. 
Some of them are very rare, but all of them are possible. There are 
fibroids, sarcomata, lipomata, papillomata, myomata, adenomata, 
tubercles, and carcinomata. The kind which is of the chief and almost 
exclusive clinical importance is the last, as cancers of the stomach are 
much more frequent than any, and indeed all the rest, and they are 
the only variety which can with any precision be diagnosticated. It 
is well to know, however, that other tumors than cancers may occur 
in the stomach, so that in the absence of the cancerous cachexia and 
other characteristic signs, more hope may be entertained than other- 
wise would be possible when a tumor in the part is discovered. 
CANCER OF THE STOMACH. 
It would lead too far from the object of this work, and would oc- 
cupy too much space, to enter into a full discussion of the minute 
pathology of the different forms of malignant or cancerous affections 
of the stomach, especially as statements upon various points, by recent 
pathologists, so widely differ. 
It will be sufficient for the present purpose to state that gastric 
cancer is a neoplasm, having its origin, as some contend, in the cylin-' 
drical epithelia of the glands of the mucous membrane, proliferating in 
a downward direction, and growing more actively as the cancer ele- 
ments reach the deeper parts. Whether it always commences in the 616 
CANCER OF THE STOMACH 
epifchclia of the glands of the mucous membrane, or sometimes in 
other elements of the parts as well, all the tissues in the location of 
the neoplasm sooner or later become involved, and according to the 
special forms of development taken by the stroma, or by the cancer 
cells, different varieties of gastric cancer, differing in their appearance 
and microscopical structure, are produced. . Presenting many mi- 
nuter differences in the particular character of their elements, and 
often shading off into each other and mixing their different qualities, 
three general forms have long been recognized, under which all the 
varieties may be included. These are : 
1. Fibrous Cancer, or Scirrhus. 
2. Medullary Cancer—Cerebriform or Soft Cancer. 
3. Colloid or Gelatinous Cancer, or Alveolar Cancer. 
The Scirrhus and Soft Cancers are distinguished from each other 
by the different degrees of development of the fibrous stroma and the 
comparative number of cancer cells. In the hard variety the fibres 
are much more abundant, while in the soft the cells compose the 
greater part of the substance, and are but loosely held together by a 
slight connective fibrous tissue. The third variety, or Colloid Can- 
cer, is characterized by a change of the cancer cells themselves into a 
glue-like substance, giving the appearance and name to this form of 
the neoplasm. 
A fibrous gastric cancer, by far the most common form of the 
disease, may appear as a distinct, firm, more or less rounded, but 
nodular tumor, in any part of the stomach walls, or as more diffused 
or in bands, producing thickening and contraction of the parts where 
situated. It is, however, most frequently located at or near the 
pyloric or cardiac opening—much oftener at the pyloric—and in that 
case is apt to present an annular thickening, constituting a dense 
mass, with nodules projecting internally, the proper coats of the 
stomach at the place being no longer distinguishable ; and usually 
more or less contraction of the orifice takes place. The peritoneal 
coat of the stomach is the last to be involved in the cancerous degen- 
erations, and then adhesions often take place to surrounding parts. 
In time ulceration, or a more rapid necrosis, occurs upon the internal 
surface of the mass, with the offensive and often bloody discharges 
characteristic of open cancer. 
Microscopically this form of tumor shows a large development of 
connective tissue, with roundish, oblong, or caudated cancer cells, 
disposed in nests among the fibres. 
Soft or Cerebriform Cancer is composed of nodular or roundish 
protuberances extending over a larger portion of the walls, and tend- 
ing more readily to degenerate and break down into ulcers. Ragged VARIETIES. 
617 
tufts are often seen on the ulcerated surfaces, and on microscopical 
examination the cancer cells are found to predominate over the fibrous 
structure. 
Colloid or Alveolar Cancer is characterized by such an arrangement 
of the connective tissue as to form unusually large spaces or alveoli, 
which, instead of being filled with cancer cells, have within them a 
gelatinous or mucous substance resembling soft glue, resulting from 
a metamorphosis of cancer cells. This form of cancer is juicy and 
inclined to spread, much more at least than the fibrous, and is usually 
disseminated quite diffusely ; but it is slow in taking on the ulcerative 
process, is longer, therefore, in its continuance, and sometimes pro- 
duces an enormous tumor involving the omentum and other parts. 
It is rare, not occurring in more than eight per cent, of the cases of 
gastric cancer ; but, like all other varieties, it is persistent, and finally 
results in the death of the patient. 
Villous, melanotic, and other varieties of cancer are spoken of, but 
they may all be placed in one or other of the three classes described. 
Not unfrequently two or more of the different structures de- 
scribed are found in the same tumor, producing more or less irregu- 
larity in form and feel as to hardness and softness, affording, when pres- 
ent, a feature quite indicative of cancer. Not unfrequently, in the 
advanced stages of scirrlius, enceplialoid nodules shoot up from the 
denuded surface, more vascular and far more cellular than the original 
tumor, and more readily taking on ulcerative and destructive processes. 
Cancers of the stomach are generally primary, and are often lim- 
ited to that organ; but they are sometimes secondary to cancerous 
formations elsewhere, and not unfrequently the liver and other organs 
become affected from extension of the cancer from the stomach. 
In some cases the secondary development is greater than the primary. 
Various anatomical results follow gastric cancers. In the most 
common forms, when a scirrhus is situated at the pylorus, it some- 
times becomes adherent to the neighboring parts, and is fixed and 
immovable. At other times no such adhesions form, and the weight of 
the tumor causes a descent of the stomach, and the tumor is often 
felt as low as the umbilicus, and sometimes it reaches even the pubis. 
As another result, a stricture is often formed at the pylorus, and from 
this may follow great distention of the stomach, which may cause the 
tumor to be situated in the right iliac region, and generally in these 
situations it is readily moved. These locations of the tumor are apt to 
lead to errors of diagnosis, which must be guarded against by a careful 
physical examination, and inquiry into the history of the case. It 
will usually be found that the tumor first appeared above, and grad- 
ually descended to the lower position. 618 
CANCER OF THE STOMACH. 
When the cancer occurs at the cardiac orifice, it is not in the same 
manner detectable by physical examination, and dilatation of the 
stomach does not follow ; and when situated in the body of the organ, 
it is not unfrequently at the lesser curvature, and often produces 
deformity—an hour-glass shape, or other modification of its form. 
The muscular walls may be hypertrophied, or distended and 
attenuated; and the mucous membrane in the neighborhood of the 
cancer, and sometimes throughout more or less of its extent, usually 
presents evidences of chronic gastritis. 
Cancer of the stomach may be complicated with round ulcer, and 
a disease commencing in ulceration, or other lesions may at length 
assume a cancerous form. (Wagner.) 
It may also be complicated with diseases of other organs—with 
pneumonia, oedema of the lungs, pleurisy, thrombosis of the veins, 
etc., and particularly with tuberculosis. 
Etiology.—The essential cause of cancer in the stomach, as in 
other situations, is obscure. Age has an influence, as it very seldom 
occurs before thirty-five, and its greatest frequency is about the fif- 
tieth year. Sex has but little influence, as it is about as frequent in 
women as in men. Other lesions of the stomach may predispose to 
cancer, and various other conditions are thought to exert a causative 
influence. It is said to be rare in Oriental countries, and to be most 
common in the higher classes of society, and this may suggest the 
influence of alcoholics in producing it. It is more frequent in those 
who indulge in excesses at the table; and it is thought also to be 
favored by prolonged chagrin and depressing emotions ; by excessive 
intellectual work, and a solitary and sedentary life ; by defects of diet, 
and especially by alcoholism. 
A predisposition—a constitutional cancerous tendency — often 
hereditary, is the most efficient cause. 
The stomach is more subject to the occurrence of cancer than any 
other internal organ except the uterus, and this may be due to the 
fact that it is exposed to a greater variety of irritating influences than 
most other organs. 
Symptoms, Course, and Diagnosis.—The symptoms, course, 
and diagnosis of this disease are now to be noticed. The subjective 
symptoms, though affording in some cases presumptive evidences of 
cancer of the stomach, are not diagnostic. In some cases of cancer- 
ous infiltration of the walls away from the openings, the lesion may 
not be discovered, because of the absence of any characteristic symp- 
toms. In other cases a diagnosis can be made only by exclusion. 
There may be neither dyspepsia, vomiting, nor tumor present, but 
continuous emaciation and a cachectic state, with the peculiar fawn- SYMPTOMS, CO UBSE, AND DIAGNOSIS. 
619 
yellow or ashy-pale color, languor, and weakness, with at length slight 
oedema, such as present themselves in other cases of cancer, and which 
are to be accounted for only on the supposition of the existence of 
that disease ; and in such cases, when the cancer can bo detected no- 
where else, experience indicates the stomach as its location. 
In the majority of cases, however, cancer has a more marked and 
characteristic course. There is an early period of dyspeptic symp- 
toms, of various disorders of digestion, of pain and often vomiting. 
Cases of cancer of the stomach do not occur in early life, and have 
no relation to other diseases which might induce dyspeptic symptoms, 
and are accompanied usually by a sad, gloomy, irritable condition, a 
disposition to seek solitude and to brood over the disease. There is 
often, though not always, pam. It is sometimes lancinating, but may 
be more contusive, is localized in the epigastrium, increased on pres- 
sure and by food, but is less active than that from simple ulcer, 
though generally more continuous. The pain, however, is not suffi- 
ciently distinctive in character to be pathognomonic, notwithstanding 
all that is said about the peculiar “lancinating” pain of cancer. 
The digestive disturbances are seldom absent, and are of impor- 
tance in the diagnosis, but in themselves are scarcely distinguishable 
from those of chronic gastric catarrh. But with the slow and pain- 
ful digestion, the pyrosis and loss of appetite, etc., there is uniformly 
and markedly more emaciation, progressive and persistent, than in 
simple catarrh. 
Vomiting, though absent in some cases at first, is not unfrequently 
present at an early period ; the matter thrown up is glairy and stringy 
when the patient is fasting, and sometimes is black and characteristic ; 
and in either form, when occurring in advanced life in a person not 
given to alcoholism, is suspicious of cancer. 
Hematemesis is a frequent but not a constant symptom, occurring, 
according to Bristowe, in forty-two percent, of the cases ; and when 
the hemorrhage is not rapid and profuse, the blood is of the coffee 
ground appearance. 
Constipation as a rule is present, until breaking down of the cancer 
occurs, when diarrhoea is apt to be excited by the irritating dis- 
charges. 
As the disease advances, the cachectic period arrives, not present- 
ing all its characteristics at once, but coming on gradually, by emacia- 
tion, change of the color of the face to an ashy greenness, or a green- 
ish pallor. A hectic fever, with scanty urine, and a moderate degree 
of dropsical effusion follow. 
Generally—in about eighty per cent, of the cases—a tumor is discov- 
erable, often of a distinct and circumscribed form, but sometimes more 620 
CANCER OF THE STOMACH 
of a diffused infiltration. Scirrhus of the pylorus is generally dis- 
tinctly felt, but its location varies; it develops slowly, and seldom 
obtains a large size. 
The encephaloid form advances more rapidly, is apt to be more 
nodular or diffused in form, and is more elastic to the touch. The 
colloid is slower in its course, but usually more extensive in its dif- 
fusion, and often attains a large size. Percussion over the tumor does 
not give as flat a sound as over the liver, but still a degree of dullness 
is present, proportioned to its size and situation. 
On palpation there is a degree of sensibility, not so much of the 
tumor itself as of its surroundings ; and sometimes it pulsates from 
its position over an artery. The physical examination is best made 
when the stomach is empty. 
The ordinary symptoms of cancer of the stomach—the gastric 
derangements, the vomiting, loss of strength, epigastric pain, and 
signs of a tumor—are modified by complications which occasionally 
take place. Narrowing of the pylorus may produce much distention 
of the stomach and hypertrophy of the walls ; or, when situated near 
the cardia, there may be a more general contraction and narrowness of 
the organ. 
Perforation, hemorrhage, extension of the growth to other parts, 
the kind of cancer, the rapidity and extent of its development, will 
further modify the symptoms presented. 
The duration of a cancer of the stomach varies with the kind, the 
location, and the direction of its growth, and is from one to three, 
and in rare cases of colloid to five years from its incipiency. In a 
majority of cases it continues not far from one year to a year and a 
half from the time of presenting distinctive symptoms, but often much 
less. Its termination is in death, produced by exhaustion, and some- 
times inanition, and more rarely by hemorrhage or perforation. 
Treatment.—The treatment is symptomatic and palliative, and 
much as in simple ulcer and chronic gastritis. Exhaustion and inani- 
tion are to be retarded by careful feeding; the pain, vomiting, and 
hemorrhage to be managed as in ulcer; the bowels are to he kept 
open by appropriate means, and all special symptoms treated by 
remedies adapted to their character. A repetition of the particular 
measures, and a specification of all the details of management are 
unnecessary. Vomiting will often be allayed by a drop or two of 
creosote, or by carbolic acid, benzine, nitro-glycerine, bisulphide of 
carbon, and various other remedies. The use of anodynes will usually 
be required, and a proper selection so as to afford the most relief with 
the least unpleasant consequences should be made. Morphine is the 
most efficient for relieving pain, but it produces constipation, and it TREATMENT. 
621 
may be reserved for the latter stages, hyoscyamus, belladonna, and 
conium being used, while they are sufficient to relieve the suffering. 
Chloral hydrate may be called for to produce sleep. 
Various specific remedies have been recommended and tried, with 
the hope of controlling the progress of the disease, of destroying, or 
at least checking, the cancerous growths, and overcoming the cachexia, 
No such specific has as yet been found, and all efforts at cure have so 
far proved abortive. 
Some particular palliative remedies may be mentioned. The offen- 
sive putrefying changes which occur in open cancer, of the food taken 
as well as of the discharges from the ulcerated surfaces, may be 
checked by antiseptics ; by carbolic acid, creosote, the sulphites, 
salicylic acid, etc., in proper doses. 
Gases may be absorbed by charcoal or magnesia ; occasionally the 
stomach, with care, may be washed out with advantage. Hemorrhage 
and perforation will require the same treatment as in ulcer ; and the 
complications, of whatever character, must be met by appropriate 
means. 
The hope of finding remedies for the cancerous state should not be 
abandoned, but at present the prospect seems remote and uncertain. 
It is feared that the foregoingremark is literally true, notwithstand- 
ing the reports of Prof. John Clay, of Birmingham, England, and 
some others, of the success of Chian turpentine. This remedy, lately 
introduced into use, is alleged to destroy cancerous growths which are 
external, where the diagnosis is positive, and where the process of cure 
can be watched. Cancers of the uterus particularly are reported to 
have been cured, even when the treatment was commenced in advanced 
stages, and Prof. Clay reports that it is equally successful in cancer of 
the stomach. 
The Chian turpentine is said to be more likely to be digested, and 
therefore more successful, when rubbed up with sulphur. The dose 
is from five to ten grains three times a day, and it must be persevered 
in for several months in order that its effects may be fully realized. 
Some, after a trial, have declared it useless ; but Prof. Clay affirms 
that either a genuine article has not been used, or that it has not been 
properly prepared and administered, or has not been persevered in a 
sufficient length of time. Further experience is required to settle the 
question of its efficacy. 
Prof. Bartholow says that ‘ ‘ of all the remedial measures proposed 
there is no prescription which is so generally useful in these cases [in 
removing distressing symptoms; he does not claim the removal of the 
disease] as equal parts of pure carbolic acid and tincture of iodine, of 
which two drops may be administered in water three times a day.” 622 
HEMORRHAGE OF THE STOMACH. 
Arsenic, in the form of Fowler’s solution, has long had a reputa- 
tion with some for retarding the growth of the epithelial form of can- 
cer, and in small doses of one or two drops in water, three times a 
day, it is thought to have some power in allaying the pain. Prof. 
Bartholow advises the persistent use of both of the last two mentioned 
remedies, each at different hours of the day. 
HEMORRHAGE OF THE STOMACH.—GASTROR- 
RHAGIA.—HEMATEMESIS. 
A flow of blood into the stomach is called gastrorrhagia ; the vom- 
iting of blood is called hematemesis ; the former is the cause, and the 
latter the result; but this result does not always follow the cause. 
Hemorrhage of the stomach may arise from a variety of causes. 
It has already been alluded to as caused by ulcer, by cancer, by in- 
tense congestion, and by catarrh of the mucous membrane. 
The immediate or essential cause of hemorrhage of the stomach, 
as of other parts, is a diminished power of resistance in the wall of the 
vessels as compared ivith the hlood-pressure within their cavities. The 
more remote causes producing this disproportion between the blood- 
pressure and the resistance ate very various. Some produce increase 
of pressure, and others diminution of resistance. In a majority of 
cases of spontaneous hemorrhage both these conditions are present— 
diminished resistance and increased pressure—acting in combination. 
When blood flows there is presumably a solution of continuity in 
the vessels ; but recent investigations of Cohnheim seem to show that 
red blood corpuscles may pass through the coats of vessels in a manner 
similar to what is known to be the case with the leucocytes, without 
their rupture, by a simple diapedesis, and that circumscribed hemor- 
rhagic erosions sometimes originate in this way. 
There may be direct injuries to the vessels, mechanical or chemi- 
cal, destroying their continuity, or so weakening them that the blood- 
pressure within effects a rupture. 
There may be disease of the walls of the vessels, degenerations— 
fatty, atheromatous, or inflammatory—or there may be varices or 
aneurisms leading to rupture. 
There may be venous stasis in the walls of the stomach, caused by 
obstructed circulation through the liver, as in cirrhosis, in phlebitis, 
in icterus, and in the pressure of hydatids, and by obstruction of cir- 
culation through the ascending vena cava, the heart, or lungs. There 
may be congestion arising from suppression of an habitual hemor- 
rhoidal discharge, or of the catamenial flux, which may give rise to PA TEOLOG Y—CA USES. 
623 
the loss of blood either by causing rupture of vessels, or by the press- 
ure of the blood through their porous walls. 
In new-born children hemorrhage of the stomach or intestines may 
occur, during the first few days of life, from feebleness of the heart’s 
action and imperfect circulation through the lungs. 
But arterial or active congestion may result in rupture of the 
walls of the capillaries, though this is much more rare ; and in many 
cases attributed to “lateral fluxion,” it is quite possible that degen- 
eration and weakening of the vessels may play a part in the causation. 
In the hemorrhagic diathesis, in chlorosis, in scorbutus, in yelloio 
and malarial fevers, and in acute yellow atrophy of the liver, gastric 
hemorrhage occurs, and may be due either to weakening in the coats 
of the vessels, to congestion and increased blood-pressure, to changes 
in the blood itself, or to some or all of the causes combined. In 
hemorrhages occurring in connection with chronic diseases of the 
spleen, the blood is changed in quality in a manner which may favor 
its loss ; but in such diseases of the spleen there is apt to be obstruc- 
tion somewhere which causes portal congestion, and thus contributes 
to the result. 
Blood appears in the stomach sometimes from other sources than 
its own vessels. In bleeding from the nose, the pharynx, or the 
lungs, the blood may be swallowed and accumulate in the stomach 
until vomiting is induced. It may be swallowed by the infant dur- 
ing birth, and give rise to the vomiting of blood, or to melaenic pas- 
sages from the bowels, leading to a false diagnosis in all these cases as 
to lesions in the stomach. Indeed, it is possible that in ulceration of 
the duodenum, or other portions of the upper intestines, blood may 
pass into the stomach from below. 
When blood, from whatever source, remains in the stomach for 
any length of time, it is changed by the gastric juice, and is thrown 
up from the stomach, or passes from the bowels, of a dark color 
resembling coffee grounds as vomited, or tarry matters as passed by 
stools. 
When hemorrhage takes place into the tissues of the stomach 
walls, instead of upon their surface, it produces what are now called 
hemorrhagic erosions. In these cases there is rupture of capillaries 
deeper in the tissues, favored undoubtedly by the contractions of the 
stomach in vomiting and during digestion, and the erosions of the 
tissues follow, aided by the action of the gastric secretion where 
stagnation is present. These erosions are more frequent in women 
about the period of the cessation of the menses. 
A scale of causes of gastric hemorrhage, arranged according to 
their frequency, has been given. Aside from those produced by yel- 624 
HEMORRHAGE OF THE STOMACH 
low fever, and some grave malarial fevers which are local in their 
prevalence, the causes said to be most frequent, in the order in which 
they are mentioned, are simple ulcer, cancer, hemorrhagic erosion 
and mechanical obstruction of the vessels, poisoning, wounds, foreign 
bodies, scorbutic and other dyscrasias, inflammation of the mucous 
membrane, rupture of large aneurisms, and vicarious hemorrhages. 
Women more frequently vomit blood than men ; but it is a less 
serious symptom with them, especially when it occurs about the men- 
strual period. It may occur at any age, but it is more frequent at 
certain periods with women, in consequence of its relations to the 
menstrual functions. 
Mental excitement, strains and concussions of the body, and over- 
distention of the stomach, may act as exciting causes when a predis- 
position exists in the state of the vessels, the circulation, or the blood. 
Morbid Anatomy.—The anatomical lesio?is, from what has 
been stated as to causation, will be seen to be various. 
The only constant one is the presence of blood in the stomach, 
usually in a clotted form, either in larger masses or in smaller parti- 
cles, suspended in liquid and of a blackish color. Ulcers, cancers, 
villous growths, erosions, hyperasmia, etc., may be found; but some- 
times the vessels are so completely emptied as to present a pale and 
flaccid appearance of the coats of the stomach, and, in some cases, no 
rupture of vessels can be detected, the blood having passed through 
their unruptured coats. These cases must be exceedingly rare, as it 
is difficult to understand how sufficient blood to produce death 
should in this way be exuded. 
Symptoms.—The symptoms of hemorrhage of the stomach will 
be slight or severe, according to the amount of blood lost and the 
accompanying conditions. 
Traumatic and supplementary hemorrhages may occur in a state 
of previous health, but all others are consecutive phenomena, pre- 
ceded by other pathological states, and usually by more or less marked 
symptoms. 
In cases of medium intensity, which are the most frequent, gas- 
trorrhagia is characterized at its onset by a feeling of weight, of 
fullness, and of heat in the epigastrium ; and if the bleeding is con- 
siderable there will be nausea, a sense of depression and peculiar 
uneasiness ; the pulse will be feeble ; there will be pallor of the sur- 
face ; syncope may occur ; and on percussion, instead of the hollow 
stomach sound there is a degree of dullness, more or less pronounced, 
according to the amount of the hemorrhage. 
As a rule, any considerable amount of blood in the stomach 
induces vomiting, and in the midst of the symptoms of depression, by SYMPTOMS—DIA GNOSIS. 
625 
an effort, a variable quantity of bloody liquid is ejected. The vomit- 
ing in some cases is accompanied by a convulsive cough, which may 
give an appearance of the blood coming from the lungs. If the blood 
is flowing rapidly, the vomiting will be the more frequently repeated, 
and the color will be brighter. In moderate cases the blood will be 
dark, partly liquid and partly clotted. If from the rupture of a large 
artery, the blood is arterial, and if speedily thrown up from a stomach 
previously empty, it will be fresh and comparatively florid. 
Ilematemesis of “ coffee-ground ” appearance and of an offensive 
odor is characteristic of open cancer; that of liquid blood and of 
small black clots is usually from stasis, and is capillary ; when more 
florid or in large clots, it is usually from a simple ulcer, or from 
rupture of an aneurism. When the hemorrhage is slight the blood 
may be more or less digested, or may all pass off by the bowels, and 
in all cases, more or less is likely to pass by stool, which is then of a 
black color. It may in such cases be difficult to distinguish it from 
hemorrhage of the bowels. 
In order to estimate the quantity lost, that passing from the 
bowels must be taken into the account. 
Often a moderate hemorrhage from the stomach leaves an amount 
of physical and mental depression not to be accounted for by the 
mere loss of blood, but when it is supplementary to suppressed hem- 
orrhoids, or vicarious of menstruation, it is usually well borne. When 
the cause is permanent, as is often the case, the hemorrhage is likely 
to recur, and even that from transient causes often leaves a greater 
liability to its recurrence. 
Though in a majority of cases patients recover from the immediate 
effects of gastrorrliagia, yet death may follow from exhaustion, pos- 
sibly from strangulation in the act of vomiting in the condition of 
great feebleness ; and when hemorrhage is excessive death may occur 
without any evacuation. The loss of blood and the anjemia follow- 
ing may hasten to a fatal termination the course of other diseases. 
Diagnosis.—The diagnosis of gastric hemorrhage is to be made 
by observing the phenomena already sufficiently described ; and in 
distinguishing its causes, the previous history of the patient must be 
carefully noted. 
The discharge of blood is the conclusive symptom ; but this may 
be simulated, especially when passed from the bowels, by the black 
discharges caused by iron, by bismuth, by mercury, by vitiated bile, 
by charcoal, and by port wine. In all doubtful cases an exami- 
nation by the microscope should be made; but when the blood has 
long continued in the alimentary canal the corpuscles may be de- 
stroyed and the blood pigment only remain. It is to be distinguished 626 
HEMORRHAGE OF THE STOMACH. 
from hemorrhage from the lungs, by the mode of discharge, the 
character of the blood, the previous disease, the physical signs in the 
lungs, and the presence or absence of bloody expectoration after, and 
the discharge or not of blood from the bowels. A more particular 
comparison will be made when the subject of haemoptysis is discussed. 
Prognosis.—The prognosis will depend upon the amount of the 
bleeding, and particularly upon the cause and accompanying con- 
ditions. When it is supplementary or vicarious, and not excessive, 
it is not serious, and is often relieving ; while a free hemorrhage may 
be fatal, and when caused by cancer, by cirrhosis of the liver, or by 
the ulceration of drunkards, the case is most unfavorable. When 
produced by temporary congestion it is nearly devoid of danger or of 
serious consequences. 
Occasionally a case of free gastric hemorrhage occurs without 
previous or subsequent disease, so far as can be discovered, excepting 
such as may arise from the loss of blood. Drs. Chambers and Flint 
give accounts of such cases, and a few, not so extreme as some of 
those related, have come under my observation. However, cases 
where no other pathological state can be discovered are rare. hen 
hemorrhage arises from a simple solitary ulcer, it is more grave, but 
may not be serious. 
An exceedingly small ulcer, but one eroding an artery, producing 
scarcely any other symptoms than those caused by the hemorrhage, 
may, by the frequent occurrence and long continuance of the bleeding, 
cause death by anaemia. A case of this kind occurred at Leipsic, 
under the care of Prof. Wagner. 
The patient for a long time had gastric hemorrhage occurring 
when the stomach was empty, but not when it was full, the cause of 
which could not be discovered. Post-mortem a very careful examination 
of the stomach was made, when a penetrating ulcer was found, so minute 
as to admit only a small-sized probe. The ulcer, penetrating obliquely 
through the mucous coat, and opening an artery beneath, gave rise 
to the bleeding, which was arrested, when the stomach was filled, by 
the lateral pressure upon the narrow fistulous canal. The recent 
specimen was shown me by Prof. Cohnheim, and a bristle was in the 
opening, indicating its course and extent. It was in the body of the 
stomach, some distance from either extremity, was not surrounded by 
any inflammatory blush, and the whole organ was unusually pale and 
anaemic. 
As it occurs in fevers, gastric hemorrhage is seldom of itself 
dangerous, but often indicates a pathological condition which is so. 
Treatment.—Supplementary or vicarious hemorrhage from the 
stomach, if not abundant, calls for no very active interference. Like TREATMENT. 
627 
the menstrual flow, it usually ceases spontaneously when the men- 
strual excitement is past. However, means should be resorted to for 
restoring the normal menstruation. In cases where the catamenia 
desert their natural channel, it will be well, says Dr. Watson, to en- 
deavor to solicit the discharge toward its right direction by placing 
leeches upon the groins immediately before the period when the vica- 
rious menstruation is expected, and by putting the feet at the same 
time in hot water, or even placing the patient in a warm hip bath. At 
the same time the stomach should be kept quiet, and iced drinks and 
other similar mild measures may be used. 
In all other instances the cases should be carefully watched, and 
active interference is often demanded. 
The object of treatment is to arrest the loss of blood, and to pre- 
vent the recurrence of the phenomena. To arrest the flow the patient 
should be placed in a recumbent position, and absolute rest should be 
enjoined. An opiate should be given at once to allay excitement and 
prevent peristaltic motion ; and as blood is in the stomach, with which 
the medicine is liable to be commingled and rejected before absorp- 
tion, morphine should be placed dry upon the tongue, and a tea- 
spoonful. or two of water taken after, or it may be administered hypo- 
dermically. This, with abstinence from food by the stomach until 
the danger is past, and the occasional swallowing of ice or ice-cold 
water, may be all that is required. If the bowels are costive they 
should be moved by an enema, and the patient may require support, 
for some time, by nourishing injections. As much as possible the 
stomach should be at rest, and no food should be taken into it. The 
utility and propriety of introducing astringents into the stomach, 
although formerly regarded as unquestionable, are at the present 
time sub juclice. While still advised by most authors, some are of 
the opinion that they are as likely to produce irritation and increase 
the flow as to arrest or check it, and that, on the whole, the patients 
do as well or better without them. 
As is the case with many other therapeutical questions, this is one 
difficult to decide by direct experiment, since the continuance of the 
flow is so variable and uncertain when left to itself. From the well- 
known physiological effects of the less irritating astringents, and from 
what we often witness of their power when applied to external bleed- 
ing surfaces under our inspection, I cannot doubt their capability of 
checking the flow from small vessels, and, as a rule, in severe and 
threatening cases they should be used. The danger, however, of pro- 
ducing irritation or inflammation, and leading later to a renewal of 
the hemorrhage, should be borne in mind ; the least irritating should 
be selected, and in some cases, at least, they may be dispensed with 628 
GASTRIC HEMORRHAGE. 
entirely. There is not the same objection to the use of cold as to 
styptics, and a free use of ice, internally and externally, may without 
hesitation be resorted to. The effect of ergot in causing contraction 
of vessels and checking the flow of blood, especially from smaller ves- 
sels, is generally acknowledged ; and when used hypodermically, no 
irritation to the stomach is produced. Fifteen drops of a solution of 
one part of ergotine to ten of water is advised, and it may be repeated 
as required. Pieces of ice may be swallowed and allowed to melt in 
the stomach, and ice bags or bladders, or cloths dipped in ice-water 
may be placed over the stomach and frequently renewed. The blood 
may be drawn to other parts of the body by rubefacients and cups ; 
and a means more efficient than either of these, and free from serious 
objections, consists in ligating the extremities in such a manner as to 
compress the superficial veins without interfering with the circulation 
in the arteries, thus detaining a quantity of blood in their vessels and 
tissues, and preventing its loss. This simple process, or the use of 
Junot’s boot, which acts on the same principle, has been too much 
overlooked and neglected by the profession in cases of hemorrhage 
and sudden congestions of internal organs. 
With a given quantity of blood in the system, the more there is in 
one part the less there must be in others, and all the good effects of 
bleeding from the arm, which the fathers so much depended upon for 
checking internal hemorrhages, may be realized without the. actual 
loss of blood and its after consequences. A much larger quantity of 
blood than the normal may be made to remain in the extremities by 
proper ligation, and striking relief to the congested internal organs 
may thus be produced. The anastomosis of the superficial with the 
deep veins prevents absolute stagnation of blood and injury from that 
cause ; and after the hemorrhage is checked, the vessels closed, and the 
immediate danger passed, whether from hemorrhage or other fluxes, 
or from congestion, the blood can be allowed its free circulation, and 
is saved to the system. 
The use of cold, the hypodermic injection of ergotine, and the 
ligation of the extremities may supersede the use, and thus avoid the 
irritating effects, of astringents by the stomach. Should these latter, 
however, be resorted to, the choice will be between alum, tannic or 
gallic acid, acetate of lead, the persulphate or pernitrate of iron, and 
some other mineral and vegetable astringents, given in sufficient doses 
to produce a local effect; and they will be most efficient when taken 
immediately after an act of vomiting, when the stomach is empty. 
In each particular case the judgment of the practitioner must 
determine the necessity and extent of interference, and the particular 
means to be used. In extreme cases, where stimulants seem demanded, TREATMENT. 
629 
they must be given by the rectum, 10 avoid irritating the morbid 
stomach. 
The after-treatment must be conducted on general principles, and 
the pathological conditions giving rise to the hemorrhage must receive 
the most careful attention. 
Hemorrhage from the intestines will be marked by similar general 
symptoms, with the exception that vomiting will be absent, and more 
speedy and generally larger discharges of blood will take place by 
stool. The essential conditions of the flow of blood are the same, and 
the causes leading to it are various but in many respects similar, and 
the treatment is to be conducted on the same general principles. 
Details have been given for the management of intestinal hemorrhage 
in typhoid fever, and the subject may again be briefly referred to in 
connection with other diseases of the intestines. 
GASTRIC OBSTRUCTION’ AND DILATATION. 
In the account of inflammation of the deeper tissues of the 
stomach, of tumors and ulcerations of the organs, mention was made 
of obstructions at and near the pylorus, and the dilatation consequent 
upon them. The disease which most frequently causes stenosis of the 
pylorus is cancer. Next to this the cicatrices after ulceration ; next, 
hyperplasia of the fibroid tissue, with contraction and induration; 
and, more rarely, polypoid and other tumors; enlargement of the 
pancreas ; adhesions, and pressure from without. 
Obstruction from any of these causes may be more or less com- 
plete, and the symptoms will be correspondingly severe. When the 
obstruction is only sufficient to cause delay in the passage of matters 
from the stomach, there will be a sense of fullness, and probably 
symptoms indicative of chemical changes occurring in the ingesta. 
In such cases, especially if the obstruction be considerable, vomit- 
ing is likely to occur after intervals which allow of the accumulation 
of food—it may be from one to two or three days—and then large 
quantities will often be ejected. As the result of such obstruction, 
dilatation of the stomach sooner or later occurs. Such dilatation is 
sometimes very great. In one case a patient from a neighboring State 
Avas presented at my clinic, in whom the stomach occupied nearly the 
whole of the abdomen, and from the extraordinary thinness of the 
abdominal walls, the vermicular motions of the distended organ pro- 
duced a very striking and singular phenomenon. In some cases the 
enlargement resembles pregnancy, or dropsy, or an ovarian tumor, but 
it is to be distinguished from these by a careful observation and com- 
parison of the phenomena. 630 
GASTIilO DILATATION. 
Symptoms.—The evidences of pyloric obstruction and great 
dilatation will be found in the free vomiting at considerable intervals, 
the egesta consisting of partially digested food undergoing chemical 
changes, and mingled often with mucus, and, in some cases of cancer, 
with “ coffee-ground ” materials, and frequently containing sarcinas. 
The vomiting reduces the enlargement, relieves dyspnoea and other 
morbid sensations which may be caused by it, and brings the hollow 
tympanitic resonance on percussion peculiar to the stomach into a 
smaller space. The tympanitis, owing to the position of the fluid 
which is present with the gases in the stomach, will be observed over 
a larger and lower space, when the patient is lying upon the back 
than when in the erect position. 
By auscultation over the stomach a ringing, hollow, amphoric 
sound may often be heard when liquids are swallowed, and an unusual 
splashing is often produced by movements of the body, resembling 
that caused by succussion in hydro-pneumothorax. Various manip- 
ulations with hollow sounds or siphon tubes have lately been resorted 
to, to determine the size of the stomach, the amount of the fluid 
within it, and the force of its contractions. When the tube first 
passes the cardiac orifice, pressure occurs and air is expelled. The 
distance the tube may be passed beyond this point will determine the 
extent of the distention ; and by forcing air into the tube, the point 
where it reaches the fluid will be determined by the bubbling that 
may be heard when the ear or stethoscope is applied over the part. 
The introduction of instruments should be conducted with great 
caution where an ulcer or open cancer is suspected. As stomach 
digestion is likely to be very imperfect, emaciation and debility fol- 
low. The bowels are usually constipated, the urine is apt to be 
scanty, and we have superadded to the symptoms those peculiar to 
the disease which causes the obstruction. 
Dilatation of the stomach may be the result of weakness, paraly- 
sis, or of degenerative changes of the muscular coat without pyloric 
obstruction. 
The affection is less grave, the dilatation is not generally as great, 
and the case is more likely to be remedied when pyloric obstruction 
does not exist. 
Treatment.—In this, as in so many other gastric affections, the 
most important part of treatment is dietetic. Articles should be 
selected which are nourishing, most easily digested, least likely to 
produce gas, and which are found by experience to be best adapted 
to the case. The quantity should be governed by the amount the 
stomach is found capable of properly digesting. Digestion may be 
promoted by pepsin, hydrochloric acid, and bitter tonics. Remedies TREATMENT. 
631 
to increase the tone of the muscular fibres are indicated, particularly 
in cases dependent upon atony without obstruction. Strychnia or nux 
vomica, usually with small doses of quinine and iron, best fulfills this 
indication. 
Mild saline laxatives, which promote the passage of the contents 
of the stomach into the intestines, and which keep the bowels open, 
sometimes produce relief. 
When spontaneous vomiting does not occur, and the stomach is 
loaded and oppressed with accumulations, emesis may sometimes be 
easily induced by drinking warm water and tickling the throat. 
Where this does not succeed, the use of the stomach-pump or siphon 
tube, as recommended by Kussmaul and others, may be resorted to. 
The contents of the stomach should not be too often removed, 
lest the system be deprived of nourishment. All that can be digested 
and appropriated should be allowed to remain. 
The tonic effect of a galvanic current passed through the organ 
may be of service in the atonic cases, and a broad bandage accurately 
and comfortably applied to the abdomen may give useful mechanical 
support. Cold rubbing over the dilated stomach, together with a dry 
diet, has recently been advised. 
If the obstruction is so great, and nutrition is so much interfered 
with as to cause danger of death from inanition, rectal alimentation 
becomes the last resort. 
FUNCTIONAL DISEASES OF THE STOMACH. 
By functional disease of the stomach is understood morbid 
changes, or perversion of action not produced by perceptible struct- 
ural changes. 
In the different organic diseases of the stomach we have been 
considering, the functions of the organ are more or less interfered 
with. Imperfect digestion, indigestion, dyspepsia or apepsia, diffi- 
culty or absence of the digestive process has been seen to have 
resulted. 
But without any considerable disease of the stomach itself, with- 
out, at all events, perceptible structural disease, difficulty of digestion, 
at least of a temporary character, may occur. 
An overmeal, improper articles of food, a sudden shock, a strong 
mental impression, excessive fatigue, great exposure, or a debauch, 
may arrest the process of digestion more or less perfectly, leading to 
various distressing symptoms. In such cases the food is likely to 
undergo fermentative processes in the stomach, developing very irri- 632 
DYSPEPSIA. 
tating materials, causing pain, gastralgia or colic, headache, nausea, 
vomiting, constipation and diarrhoea, and various other disturbances 
of the organism. 
Temporary diseases of other organs, or various injuries to them, 
may arrest or render difficult the process of digestion, without the 
existence of any real, or at least permanent, trouble in the stomach. 
Treatment.—The treatment of such cases would be suggested 
by each particular cause. For irritating articles in the stomach an 
emetic or the use of the stomach-pump would often be the best 
remedy. If such articles were in the intestines, a cathartic would 
be indicated. If acidity in the stomach was abundant and irritating, 
an alkali would procure relief. In the meantime, if the symptoms 
were distressing, soothing remedies, some warm drinks, a hot foot- 
bath, fomentations or a sinapism over the stomach, a dose of cam- 
phor or paregoric, a carminative, *cr a decided opiate would relieve 
the suffering, and give time for removing the causes. 
In cases of overfatigue or shock, rest and anodynes are required. 
In all cases remove the causes when they are recognizable and can 
be reached. 
The stomach should have a period of comparative rest before a 
return to the ordinary diet. 
DYSPEPSIA. 
This term signifies difficulty of digestion, but as indicating a more 
distinct disease it may be more specifically expressed by the phrase 
atonic dyspepsia. This indicates a form of indigestion due to a 
depressed or enfeebled state of the stomach. The term dyspepsia is 
not. however, always used in this strictest sense, and some latitude 
to its signification is allowed. 
Several special pathological causes may contribute to the result. 
Its proper pathogeny will require a latitude and freedom of state- 
ment. The subject is of a character that does not admit of as sys- 
tematic treatment as some other diseases. 
But derangements of digestion from functional disease of the 
stomach, more permanent than those temporary indigestions before 
referred to, may occur. Indeed diseases of this organ without per- 
ceptible structural changes are frequent, are often protracted, and 
produce great suffering. Many of these derangements are sympa- 
thetic, the result of morbid conditions of other parts. The stomach 
is an important centre of reflex impressions. 
Irritation of the fauces is well known to produce vomiting; and REFLEX IRRITATION. 
633 
so will sufficient irritation of the brain, the lungs, the liver, the kid- 
neys, the uterus, and other parts. Less degrees of irritation of any 
of these parts may produce various other effects upon the functions of 
the stomach, particularly upon its secretions. 
HYPERSECRETION'. 
By reflex action we have not only modifications of motor and sen- 
sory, but of circulatory, nutritive, and secretory functions ; indeed all 
functions may be changed by sympathetic or reflex impressions. The 
secretions of the stomach may be modified by such impressions, both 
in quality and quantity. Irritation of the lungs, for example, may 
cause an excessive or untimely secretion of the gastric fluid ; so that 
not unfrequently persons dying of consumption have so much of the 
gastric juice in the stomach at the time as to produce post-mortem 
digestion of its coats ; and before death the secretion may be so great 
as to cause acidity, irritation, “ heart-burn,” and pain. Normally 
the gastric juice is secreted in considerable quantities only when the 
stomach is stimulated by the presence of food, and when it is needed 
for its digestion. 
From reflex impressions, and in some abnormal conditions of the 
stomach itself, or the nerves supplying it, there may be an untimely 
and therefore morbid secretion, producing the effects just mentioned, 
and still others. 
Inflammatory and other diseases of the liver—the presence of gall- 
stones, of abscesses, etc.—sympathetically, and often severely, affect 
the stomach. 
Inflammation of the kidneys, partly through sympathy, and partly 
from the retention of urea and other effete matters in the blood, 
deranges the functions of the stomach, and often produces an excess 
as well as other perversions of its secretion. In many diseases of the 
uterus the subjective symptoms are often more severe in the stomach 
than in the primary and essential seat of the disease, and so in some 
affections of the nerve-centres. When an abnormally free secretion 
of gastric juice is produced, the food may be readily digested, but 
with disturbance of sensations, “ heart-burn,” etc.; and the secretion 
continuing after the food is disposed of, acidity, irritation, uneasiness 
and pain, and often vomiting result. In all such cases a diagnosis of 
the pathological state should be made, the primary seat of the disease 
ascertained, and this should receive prompt attention ; but measures 
for palliating the gastric symptoms should not be neglected. Some- 
times a local disease of the stomach, as ulcer or cancer, induces this 
hypersecretion. 634 
DYSPEPSIA 
Principles and items of treatment may be mentioned as we proceed 
in a statement of the pathogeny of this state. 
The “ heart-burn,” irritation, and distress occurring from exces- 
sive secretion of acidity when the stomach is empty of food, will be 
promptly, though usually but temporarily, relieved by an alkali. 
Large doses will sometimes be required to neutralize all the acid 
present. The carbonates of soda or potash, calcined magnesia, 
solutions of caustic potash, lime-water, etc., are the articles indi- 
cated. Most of the salts produced by the acids of the stomach with 
these bases are laxative; and as constipation is a frequent condi- 
tion in these cases, they fulfill another indication than that of neu- 
tralizing acids. 
The salts of lime, on the contrary, are moderately astringent, and 
when there is too great a tendency to intestinal evacuations lime may 
be selected. 
As a rule, the alkalies should be given after the food is digested— 
some two or three hours after a meal—as they might too effectually 
neutralize the gastric juice and interfere with digestion if given during 
the earlier stages of this process. Still, if the gastric secretion is in 
great excess, they may be given in more moderate quantities soon after 
meals. In the case of children and others whose diet is chiefly milk, 
lime-water may often be mingled with it to advantage. 
The proportion may be varied in different cases, but usually there 
should be about one part of the lime-water to three of milk. The 
lime-water not only neutralizes acidity, but prevents the milk from 
coagulating too speedily and in too large masses, and it also exerts an 
astringent and alterative effect upon the peptic glands. 
Other astringents may have an effect in diminishing the excessive 
secretion, and may be given some little time before meals. The sub- 
nitrate of bismuth is an absorbent, a gentle astringent, and a local 
anaesthetic, soothing gastric irritation and often acting very benefi- 
cially in cases of this kind. Given in doses of ten grains, more or less, 
before meals, its beneficial effects in these and various other stomach 
affections are often conspicuous. Vegetable astringents may also be 
useful. 
It should be borne in mind, that in all the disturbances of the 
functions of the stomach from reflex irritation, treatment applied to 
that organ is only palliative, and should usually be temporary. The 
radical or curative treatment must be directed to the primary disease. 
Diseases of the brain, of the uterus and the ovaries, of the liver, or 
the kidneys, may require the principal attention, though not unfre- 
quently the sufferings from the stomach are most conspicuous, and 
may divert attention from the real source of the mischief. The irri- DEFICIENT SECRETION. 
635 
tation of the first teething in children is a frequent source of derange- 
ment of the stomach and bowels, and both the condition of the gums 
and the dyspepsias and diarrhoeas which follow demand attention. 
In adults there is more likely to be constipation than diarrhoea in 
reflex irritation of the stomach, and this requires to be overcome by 
various laxatives which may be indicated. 
Excessive stomach secretion, though it may depend 011 disease of 
the stomach or the nerves supplying it, is generally reflex ; and it is 
demanded of the physician that he should be particular in tracing out 
the cause and removing it. 
A very important fact should be borne in mind, viz., that morbid 
sympathies are more active in anaemia and debility. Tonics are there- 
fore in these cases often indicated, especially the preparations of iron 
when anaemia is present. Bismuth is supposed to have some tonic 
effect as well as an astringent and soothing action, and this with its 
power of checking excessive secretion, and especially of allaying irri- 
tation of the stomach, renders it a particularly useful article in many 
cases. It may often be combined with lupulin and quinine with 
advantage, and it is applicable to other conditions, as well as to those 
under consideration.* 
DEFICIENT SECRETION. 
But the gastric secretion is more frequently deficient than exces- 
sive, and deficiency and perversion of this secretion are the most 
common immediate or pathological causes of indigestion. 
In catarrhal conditions of the stomach its secretions are variously 
perverted. There is often too much mucus enveloping the food and 
preventing the action of the digestive fluid upon it. In various mor- 
bid conditions of the blood the gastric fluid is perverted in quality as 
well as deficient in amount, and the same is true in most cases when 
the peptic glands are deranged in their activity, from whatever cause. 
Etiology.—The causes of deficient and perverted gastric secretion 
are very numerous, embracing both physical and mental influences. 
Whenever there is deficiency or perversion of the nutrition of the 
stomach, there will be a perversion of its secreting function. The 
conditions of healthy nutrition—a proper supply of healthy blood, a 
proper state of the part to be nourished, and a proper influence of 
the nervous system—are familiar. Any of these conditions may be 
defective in the case of the stomach, and when so, defective nutrition 
* Trisnitrate of Bismuth grs. x 
Lupulin grs. ijss 
Sulphate Quinine gr. j 
M. 
Sig.: Three times a day. 636 
DYSPEPSIA. 
and defective secretion, and consequent defective stomach function, 
will follow. 
In fevers and inflammations, in congestions and irritations, in 
excessive or deficient exercise, in improper alimentation, in excessive 
or deficient mental activity, in depressing passions—in short, in all 
conditions which unfavorably impress the system—the stomach suf- 
fers more or less, and hence its derangements are frequent. 
Excesses in food, though generally deranging and ultimately 
enfeebling the stomach, may in vigorous conditions of the system 
develop its power and lead to gluttony. More food than is needed 
being digested and appropriated, plethora or obesity, with their con- 
sequences, may follow, while the stomach’s power is not impaired. 
Commonly, however, the stomach suffers early from such excesses. 
Its powers overtaxed, its coats irritated, it suffers the “remorse” 
which violations of law, physical or moral, legitimately bring. 
In some cases of diminished gastric secretion there is a deficiency 
of the peptic glands, either congenital or from previous disease. 
Mental causes of deficient functional activity of the stomach are 
not unfrequent. Watchfulness, fear, anxiety, anger, remorse, exces- 
sive mental toil, excitement of any kind, when intense, may produce 
the effect. 
Deficient gastric secretion and deficient muscular activity of the 
stomach necessarily result in deficient, slow, and imperfect digestion. 
Symptoms.—There will be a sense of weight and uneasiness, 
often pain and cramps in the stomach, disturbed brain, heart, and 
liver actions, headache, confusion, disturbed sleep, palpitation, dysp- 
noea, yellow eyes and skin, costive bowels, deficient urine, and all 
the thousand morbid sensations and conditions which constitute the 
abnormalities of “dyspepsia.” 
The uncomfortable sensations and general disturbance of the 
organism in this disease may be explained in different ways. The 
effects are produced on the nervous system, and may be by sympa- 
thetic or reflex action, or by the chemical changes producing morbid 
matters, such as sulphureted hydrogen, butyric acid, oxalic acid, an 
excess of lactic acid, etc., which are absorbed into the blood and 
carried to the tissues. 
A certain amount of nervous energy is expended in the secretion 
of the digestive fluid, causing languor and depression of various 
functions ; and then the presence in the stomach of food, and the pro- 
ducts of its changes, makes an impression upon other parts, conveyed 
by sympathy, which changes the distribution of blood, and modifies 
the conditions of the nerve-centres and various organs. In morbid 
states the sympathetic effects are often severe, and a profound de- SYMPTOMS. 
637 
rangement of the whole nervous system occurs. The nerves of the 
stomach, especially, assume an abnormal state. The morbid con- 
dition may be confined almost exclusively to the nervous system, but 
derangement of the circulation, secretion, and motion, and further 
changes of digestion are likely to occur. The more the morbid con- 
dition is confined to the nerves, the greater the disproportion of the 
subjective symptoms (the morbid sensations of the patient) and the 
objective results of indigestion. 
In some of these cases, the digestion of food is fairly well per- 
formed, and the body is properly nourished ; but the sensations of the 
patient are very uncomfortable, and sooner or later the digestion is 
impaired. In time there will be wasting and marked deficiency of 
general power. 
Food digested and appropriated is a necessary condition of force. 
Its deficiency is an ultimate deficiency of working power. W hile too 
much food is bad, too little may be worse. For the former there are 
natural remedies in vomiting, diarrhoeas, free excretions, effusions, 
and hemorrhages. For the latter there are no such remedies. Noth- 
ing can take the place of food for any permanent effects. Food or 
failure are the alternatives. But food, taken into the stomach and 
not digested, undergoes changes from chemical action, which result 
in compounds of an irritating character, and produce a large portion 
of the distressing symptoms attending indigestion. These decompos- 
ing changes are excited by mucus and other morbid secretions of the 
stomach, and by the presence of Tomla Cerevisice and Sarcina Ven- 
triculi, which act as ferments. 
The kind of fermentation and the resultant substances produced 
vary in different cases, according to the character of the food taken 
and the nature of the ferment. For the most part, lactic, acetic, ox- 
alic, and butyric acid fermentations occur, but not unfrequently the 
alcoholic, and sometimes the putrefactive. As a result we have acidity 
in liquid and gaseous forms—lactic, acetic, butyric, and oxalic acids 
in solution as liquids, and carbonic acid in the gaseous form—besides 
sulphide of hydrogen and other gases and liquids, producing pyrosis, 
distention, pain, nausea and vomiting, eructations, foul breath, coated 
tongue, irregularity of the bowels—sometimes constipation, at other 
times diarrhoea — headache, dizziness, confusion, disturbed sleep, 
gloominess and depression, irregular action of the heart, morbid con- 
ditions of the urine ; all these aid in the production of the protean 
sensations and phenomena characteristic of indigestion. The con- 
ditions that contribute to these fermentative changes are, delayed 
digestion; the abnormal catalytic effects of the mucous secretion of 
the stomach ; retention of food, from obstruction of the pylorus ; the 638 
DYSPEPSIA. 
taking of substances into the stomach which are undergoing fermen- 
tation ; morbid conditions of the saliva and buccal secretions, produc- 
ing improper changes in the starchy substances during mastication; 
imperfect mastication, from defective teeth or too great haste in taking 
food ; improper articles of food and excessive quantities, particularly 
of saccharine and starchy compounds. While these conditions aid in 
producing the effect, the more essential cause is the deficiency of 
secretion of the normal gastric juice, and this, in its turn, is produced 
by the various causes, physical and mental, to which we have already 
alluded. 
Acidity and its consequences—pyrosis, “heart-burn,” etc.—are 
then dependent upon two distinct and opposite conditions, viz., 
hypersecretion of an acid gastric fluid; and a deficiency of that secre- 
tion, wuth consequent acid fermentative changes of the food. 
In curative treatment, as the causative and the pathological states, 
rather than mere symptoms, are the bases of indications, it is impor- 
tant to distinguish between these conditions. In order to do this the 
history of the case and all the circumstances must be taken into the 
account; and to aid in making the distinction, the following table, 
taken from the work on “Diseases of the Stomach,” by Dr. Wilson 
Fox, will bo of service : 
Acidity from Fermentation. 
Acidity from Hypersecretion. 
Flatulence. 
Common. 
Rare. 
Relation to Food. 
Usually the acidity is at its height 
some hours after meals, and is 
more marked in proportion to 
the quantity of food taken, 
and inversely to the digestive 
power. 
Occurs when the stomach is empty 
cr soon after food is taken, and 
is often great in intensity after 
a small meal. 
Pain. 
Less severe. 
More severe. 
Rarer. (?) 
Vomiting. 
More common. (?) 
Contains organic acids, and often 
torulee and sarcinae. 
The Vomited Matter. 
Commonly contains an excess of 
hydrochloric acid. TREATMENT. 
639 
Acidity from Fermentation. 
(continued.) 
Acidity from Hypersecretion. 
(CONTINUED.) 
Relations to other Phenomena. 
Occurs in connection with causes 
which impede digestion. 
Most common as a reflex symp- 
tom or in connection with 
nervous disturbance, or with 
ulcer or cancer of the stomach. 
It must, however, be confessed that no one symptom by which these 
conditions of morbid acidity are accompanied is positively distinctive 
of either variety, and in some cases only an approximate diagnosis 
can be made ; but generally, by a proper consideration of all the facts, 
a sufficiently clear conclusion can be arrived at to furnish a rational 
guide to treatment. In deficiency of secretion from atonic con- 
ditions, as distinguished from irritative and especially inflammatory 
states, there are, (1.) A less degree of gastric uneasiness, and an ab- 
sence of tenderness; (2.) A simple deficiency of appetite, and com- 
parative absence of thirst; (3.) The absence of fever ; and (4.) A pale, 
broad, and flabby state of the tongue, instead of a red, dryish, hard 
state of this organ. 
Treatment.—The principles of treatment in hypersecretion have 
already been stated. 
For deficient secretion, as it is dependent upon‘such a variety of 
causes, various remedial measures will be required. Not only are the 
causes numerous and varied, but the results following—the particular 
symptoms produced—are various also, requiring modifications of the 
particular management for their relief. 
Mere deficiency of gastric secretion, though often the chief ele- 
ment in indigestion, is not the only one. Diminished muscular 
action, diminished absorption, and a want of proper relations between 
the elements of the food and the conditions and activities of the 
stomach in various respects, may play* a part in the morbid process, 
and should be considered in determining the course of treatment to be 
pursued. The principal object of treatment, however, is to increase 
the gastric secretion, but all the conditions must be taken into the 
account in prescribing definitely for a particular case. 
Among the causes to be particularly remedied is the unsuitableness 
of food. It may not have the proper proportions of the different kinds 
of nutritious matter adapted to the powers of the stomach ; it may have 
too little or too much indigestible matter ; it may be improperly pre- 
pared ; may have undergone injurious changes; may be imperfectly 
masticated and insalivated; it may not have, the substances capable 
of stimulating the gastric secretion, etc.; and finally, there are the 640 
DYSPEPSIA. 
idiosyncrasies of some persons whose common digestion is good, but 
who cannot take certain articles without their “disagreeing” and 
producing unpleasant effects. 
The taking of too much and too little food has already been spoken 
of as among the causes of indigestion, and requires only to be referred 
to in speaking of treatment. 
Derangements of the movements of the stomach must not be over- 
looked in prescribing in indigestion. The motion effected by muscu- 
lar contraction of the walls brings the food in contact with the 
different parts of the organ, and finally at the proper time causes its 
expulsion. Deficiences in this action may result in morbid changes, 
even when there is a sufficient amount of digestive fluid ; or excessive 
peristaltic action may cause expulsion of the food from the stomach 
prematurely, and before the gastric juice has time to do its work. 
The particular symptoms which require attention and alleviation 
in prescribing are acidity, heart-burn, flatulence, eructations, pain, 
nausea, vomiting, constipation, headache, and other disturbances of 
the nervous system, abnormalities of the urinary secretion, of the gen- 
erative organs, of the circulation, of the respiration, of the skin, and 
of the general nutrition. 
In the form of indigestion we are considering—that from defi- 
ciency of secretion produced by an atonic state—the leading course of 
treatment should be tonic. The indications are to improve the quality 
and circulation of the blood; to give tone and vigor to the system at 
large, and especially to the secreting tissues of the stomach, thereby 
increasing their functional activity ; to temporarily aid the digestive 
process, by the addition of acid and peptic elements to the scanty gas- 
tric juice ; and to palliate distressing symptoms which maybe present. 
The means for accomplishing these objects are very properly 
divided into hygienic, regimenal and dietetic, and medicinal. The 
first is the more important. Without proper attention to hygienic 
regulations, drugs will often be*of little avail. 
All the habits of the patient as affecting health must be inquired 
into, and, when wrong, corrected. 
There must be regular hours for meals, giving the stomach its 
periods of labor and rest. In exceptional cases of great debility or 
exhaustion of the system, small quantities of food may be required 
often for a time ; but as a rule, and as a more permanent practice, 
especially whore patients are able to be up, meals should not be taken 
more than three or four times in the twenty-four hours, and always 
at regular intervals, the principal meals not being too late in the day. 
The gastric secretion is more abundant at the usual hour of meals, 
when these meals are taken at regular periods. The stomach then TREATMENT. 
641 
has rested and its energies have been recuperated. Besides, the 
stomach has its habits, as have other organs, and it will act more 
readily at its proper established periods. As a rule, the breakfast and 
dinner should be fuller meals than the supper—the dinner being taken 
but little after midday. The system should not be exhausted by 
overexertion, physical or mental, when the meal is taken, and there 
should be comparative rest during the process of digestion. These 
rules are important, and in severe cases must be insisted upon. 
There must, of course, be proper food, properly cooked, and taken 
in proper quantity. It should be nutritious, digestible, palatable, 
and adapted to the state of the stomach and wants of the system. It 
should be taken not too rapidly, should be thoroughly masticated 
and insalivated, and, if possible, taken with company and in a cheer- 
ful state of mind. Too much food is bad, but too little, if there is 
great deficiency, as already stated, is worse. 
The propriety of these general directions is readily understood, 
and they are easily given. The details of the proper selection of 
food, of directions as to its amount, and the determination as to its 
special adaptation to each case, must, however, be matters of care, of 
judgment, and, to .some extent, of experience. The proper prepara- 
tion of food is a matter of great importance. In severe cases, various 
methods of subjecting animal food to artificial digestion, before being 
taken, may be of great service. 
For ordinary cases of the protracted indigestions of the sedentary, 
the work of the stomach should not be made too light, but its powers 
should be conserved and developed by proper exercise. The same 
general principles are applicable as in conserving and developing 
muscular strength. In great muscular weakness much exertion is 
injurious; but after proper rest, moderate exercise, increasing as 
power increases, is essential to restoration. So with other activities 
of the system. So also with the stomach. Other favorable condi- 
tions must be secured, but the stomach must not be too much petted 
and kept in too great inaction if robust is to be obtained. G-reat 
care in management is, however, in many cases essential. Bathing, 
frictions, open air, proper muscular exercise, and rest proportioned to 
the conditions are important. The towels must le regulated. Con- 
stipation must be overcome. The importance of this cannot be exag- 
gerated. With this object in view, a regular habit of daily evacua- 
tion at a particular hour should be established. An effort at securing 
a movement at a regular period should not be neglected. Through 
the efforts of the will, aided if necessary by kneading the abdomen, 
a constipated habit may often be overcome. A free draught of water 
early in the morning will often aid these efforts, and if a scruple or 642 
DYSPEPSIA. 
more of common salt be added to the water a laxative effect is more 
sure to follow. The use of bread made of unbolted flour, or the swal- 
lowing at night of a table-spoonful of bran, or a similar quantity of 
flaxseed whole, continued for a time may assist in regulating the 
bowels. In some cases a medicinal laxative may be required. The 
following pill often answers the indication admirably : 
B Aloes Pure 3j 
Ext. Hjoscyamus 3j 
Ale. Ext. Nux Vom grs. xij 
Pulv. Ipecac grs. vj 
M.—Ft. pil. No. 30 or 60. 
One or two, more or less, should be given each night, continuously, 
until a regular habit is fully established. 
Often, after a time, the quantity will need to be materially dimin- 
ished, and only a sufficient amount of the medicine to produce a single 
satisfactory evacuation should, as a rule, be given. Sometimes, after 
a while, a sixth or a tenth part of a pill will suffice. A full, active 
cathartic, given at long and irregular intervals, is apt to be followed 
by greater constipation, but the nightly repetition of this compound 
very generally increases the tone of the intestines, and often estab- 
lishes a regular habit, and then the medicine may be discontinued. 
Other laxatives may fulfill the indication equally well, and in some 
cases even better, but this particular combination is adapted to a larger 
number of cases than any other which I have used. 
The fluid extract of cascara sagrada in doses of one quarter to one 
fluid drachm, or the solid extract in doses of from three to ten grains, 
often operates very satisfactorily in habitual constipation, but it is less 
certain in its effects, and less tonic in its action on the intestines, than 
the laxative pill above mentioned. 
The Carlsbad salt, given in doses of from one to four drachms in 
a pint of warm water, an hour before breakfast, if a warm aromatic, 
as a little ginger, be added, will produce less debilitating effect than 
might be supposed. It will pass out of the stomach in a short time, 
procuring a loose evariation in two or three hours, and only such 
quantity should be given as to produce that amount of action. 
My usual prescription is as follows : 
5 Sulph. of Soda 5jv 
Bicarb, of Soda 3jv 
Chloride of Sodium 3iij 
Pulv. Ginger 3ij 
M.—Pulverize. TREATMENT. 
643 
A change of air, of scenery, or of employment, is often necessary. 
Motives and an object in life should be furnished for the aimless. 
Recreation and rest are quite as important for the anxious and over- 
worked. Relief from the restraints of an artificial life ; coming nearer 
to nature in rural employments, or in a temporary life in the woods, 
often produces most beneficial changes. With some, a sea-voyage has 
a favorable effect. Very often a change of climate is useful. It has 
been said that the worst place for an invalid is that in which he 
became ill ; and in no disease is this remark nearer the truth than in 
this ; in scarcely any is a change more likely to be beneficial, 
especially if accompanied with the further change from an indoor and 
sedentary to an outdoor and more active life. 
The same general measures which tend to increase the gastric 
secretions will also tend to increase the tone and action of the muscu- 
lar coat. Deficient secretion and deficient muscular activity depend 
upon similar causes and require similar remedies. Exercise, electricity, 
and nux vomica are particularly applicable to conditions of muscular 
atony, and these remedies increase the secreting function as well as the 
muscular tone. 
The medicines, indicated in atonic dyspepsia, as well as the hygienic 
measures, are those which tend to increase tone and power. General 
tonics and stomachic stimulants may materially aid the hygienic 
measures. 
Among the tonics applicable, we have quinine, strychnine, salicin, 
iron, phosphorus, and the vegetable bitters generally. Columbo is 
thought by some to be peculiarly useful, from its general action on the 
system and its local effect upon the stomach. Stomachic stimulants, 
the spices, such as pepper, mustard, ginger, cardamom, etc., carefully 
used may be of temporary service in arousing the activities of the 
organ in strictly atonic cases, when there is a pale and flabby tongue, 
and no evidence of gastric irritation. Ipecacuanha in doses of from 
one quarter to one half a grain, or a grain, three times a day, is 
thought to have some peculiar power in exciting gastric secretion, and 
is often useful in these cases. 
The mineral acids—hydrochloric, nitric, and phosphoric—are 
often of decided use, not only acting as tonics, but by their chemical 
effects supplying a deficiency in the gastric secretion, and directly 
aiding the process of digestion. Lactic acid fulfills a similar indi- 
cation. 
Pepsin and pancreatin directly supply elements which aid diges- 
tive processes, and when good articles are secured, are of decided tem- 
porary benefit in bridging over a period of stomach inaction, aiding the 
nutrition of the stomach and the restoration of its secreting power. 644 
DYSPEPSIA. 
Ten grains of pepsin at meal-time will often produce a very sensible 
effect. The extract of malt—the diastase which it contains—also 
aids digestive processes, and has its places of usefulness. Strychnia 
is in some cases particularly useful. It seems to act strongly on the 
vaso-motor centres, and give tone to the circulation, and particularly 
to muscular activity. 
Various compound prescriptions will be found adapted to particu- 
lar cases. The elixir of the phosphate of iron, quinine, and strych- 
nine, with or without the addition of phosphoric acid, will often be 
specially useful. All the measures which give tone to the stomach 
and increase its secreting function tend to prevent the fermentative 
processes in the food, and the numerous distressing symptoms arising 
from that cause. In the absence of the stronger influence of the gas- 
tric juice and its chemical aids, fermentative processes are excited by 
changed mucus and by t oral a? and sarcinas, acting by catalysis. These 
changes are capable of being checked by various agents which destroy 
these ferments. Carbolic acid, creosote, and the sulphites are most 
efficient for this purpose. They may be given in sufficient quantity 
to check these processes without irritating the stomach, and as pallia- 
tive measures may be very useful. The stomach-pump or siphon, 
emetics, and cathartics, will of course clear away irritating mate- 
rials—the acids and the putrefying matters, the results of these fer- 
mentative changes in the food—while alkalies will neutralize the 
acidity, and pulverized charcoal will absorb gases and other foul mat- 
ters in the stomach, as it is well known to do out of it. 
When the alcoholic fermentation occurs, carbonic acid is evolved, 
producing distention, flatulency, and eructations, and this gas may 
cause effervescence in the vomited matters. This form of fermenta- 
tion is promoted by taking into the stomach new cider, wdne, or beer 
undergoing the fermentative process. New bread and preserves may 
have fermentative changes going on within them, and these articles, 
as well as many vegetables and saccharine substances, readily take on 
fermentative changes which cause heart-burn, pain, and all the 
symptoms attendant upon these fermentations of food. 
Oxalaemia or oxaluria, manifested by its peculiar symptoms, is 
not an unfrequent condition in these digestive derangements, a state 
to be more particularly noticed in another connection. 
Alkalies, in acidity from decomposition of food as well as from 
hypersecretion, afford temporary relief ; but long continued they are 
debilitating to the stomach, are apt to weaken or neutralize the gas- 
tric juice, and, unless very carefully managed as to the time of admin- 
istration and the quantity given, lead by an interference with diges- 
tion to an aggravation or production of the conditions they are given TREATMENT. 
645 
to relieve. Tonics—quinine, salicin, columbo, nux vomica, and various 
bitters—or the mineral acids, given with or soon after the taking of 
food, thus stimulating the secretion of gastric fluid and aiding the 
digestive process, are indicated ; and alkalies are to be given only 
when the stomach has had time to digest the food, but has failed to 
do so ; and when the acids from fermentation are remaining, and are 
producing severe symptoms from which the patient demands relief. 
"When acids are given at meal-time, alkalies some hours after may 
■sometimes be justified and required; but the free, repeated, and 
indiscriminate use of alkalies in these cases must be condemned. 
Bismuth and charcoal will often give relief, without interfering with 
digestion. , Magnesia and lime-water are less objectionable than the 
stronger alkalies, soda and potash. 
The removal or destruction of torulae and sarcinoe will often pre- 
vent the fermentative changes; and with this view the thorough 
washing out of the stomach by means of the stomach-pump, the 
siphon, or by an emetic, and the administration of these antiseptics, 
are often indicated. 
The production of butyric acid, and other irritating materials, 
sometimes excites spontaneous vomiting; or these substances pass- 
ing into the intestines may produce diarrhoea; or a brisk attack of 
cholera morbus may occur, clearing away the offending materials and 
producing relief. Too much irritation may sometimes be caused in 
these cases by emetics; but Kussmaul’s plan of washing out the 
stomach in a certain group of cases is undoubtedly admirable. 
The relations of the stomach and liver are important, and many of 
the diseases of the stomach are associated with those of the liver. 
Bile in excess in the liver or intestines, and especially if regurgitating 
into the stomach, produces uncomfortable symptoms, and great relief 
is often obtained by purging it away. Occasional doses of a mild 
mercurial, as a blue pill, or mercury with chalk, or the mild chloride, 
followed by a saline cathartic, from their effects upon the stomach, 
the intestines, and the liver, will procure relief which nothing else 
will give. 
These derangements, or bilious attacks as they are often and not 
improperly called, occur frequently with some, causing headache, 
malaise, foul tongue, etc.; and the passing off of accumulated secre- 
tions by catharsis affords great relief. 
Much fatty food, or a combination of fatty, saccharine, and albu- 
minous articles in “rich ” dishes, not only deranges the stomach but 
the liver also. The remedies for these “bilious” attacks are a plain 
and simple diet, with occasional cholagogues and laxatives, mercu- 
rials, salines, alkalies, etc. 646 
DYSPEPSIA. 
The question of the use of alcohol in cases of dyspepsia is one of 
very great scientific and professional importance, besides having rela- 
tions still broader which affect profoundly the general interests of 
society. In a work of this kind, however, we have only to do with 
its scientific and medical aspects, and the action of the article should 
be discussed in the same manner as that of opium, mercury, alkalies, 
or any other medicinal substance. 
Respecting its use in those cases of indigestion dependent upon 
or accompanied with organic disease, congestion, inflammatory or 
ulcerative conditions, there is a general agreement as to its inutility 
and generally injurious effects. 
Respecting its effects in cases of functional derangement, in atonic 
dyspepsia, where there is a deficiency of gastric secretion, there is not 
the same uniformity of opinion. The text-books abound in recom- 
mendations of its use in moderate quantities as an exciter of the 
secretions of the stomach, and the sensations of patients are appealed 
to as evidences of its useful effects. There are many, however, who 
deny (and, it must be conceded, on good grounds) the conclusiveness 
of sensations as to the ultimate utility of any of the narcotic substances, 
especially where a habit in their use is established; and they appeal 
to more scientific facts and principles, and to a broader observation 
and experience, to determine the beneficial or injurious action of this 
article in these affections. On this, as upon other controverted sub- 
jects, extreme views are apt to be taken, and an unprejudiced consid- 
eration of all the facts will be necessary in arriving at the truth. It 
must be regarded as a fact that the introduction of alcohol into the 
stomach causes relaxation of the blood-vessels and the consequent 
increase of the quantity of blood in the coats of the viscus. In some 
cases of anaemia of the organ this may cause an increase of the gastric 
secretion, and thus, for the time, result in promoting the digestive 
process. The alcohol, however, while it remains in any degree of con- 
centration in the stomach, has the direct effect of coagulating albu- 
men and of diminishing or neutralizing the action of the gastric juice, 
and thus interfering with digestion. Even when it has this directly 
injurious effect, which may be unnoticed when only a small quantity 
is present, it nevertheless, by its narcotic or anodyne action, often 
diminishes uncomfortable sensations, especially with those accustomed 
to its use; and it thus produces a false appearance of aiding di- 
gestion. 
This point, in my opinion, should be particularly emphasized. It 
can hardly be claimed that the frequent or habitual use of opium or 
tobacco is useful in dyspepsia of the atonic character w7e have been 
considering. But the habitual user of either of these articles, par- TREATMENT. 
647 
ticularly of opium, is wonderfully relieved in his sensations, and is 
stimulated to the performance of his various functions, by the taking 
of his accustomed dose. When the time for this has passed by, and 
the accustomed narcotic impression is not made, he is not only 
wretched in his sensations, but his various functions, including diges- 
tion, are wonderfully deranged. His heart’s action will often be feeble 
and irregular, his appetite will be lost, his digestion often suspended 
or greatly diminished, and his muscular strength prostrated. The 
taking of the poison which has produced these effects restores all, for 
the time being, to a vastly improved if not healthy state. It is much 
the same with the habitual user of tobacco. May not, indeed does 
not, the same principle apply in the use of the narcotic or stimulant 
(whatever it be called) alcohol ? 
Its action upon those habituated and those not habituated to its 
use is certainly quite different in various respects. The habitual user 
of alcohol has his feeling of strength and his power of exertion sensibly 
improved by his accustomed potation. The habitual abstainer is, on 
the other hand, weakened by a similar dose. 
The frequent assertion that alcohol has power to increase the 
action of the heart, must be taken with exceptions, perhaps more nu- 
merous than the rule. When it is given to a healthy person unaccus- 
tomed to its use, the sphygmograph does not show an increase in force 
of the heart’s action. Given to one accustomed to its use, or suffering 
from certain conditions of shock, or of severe disease, it does, some- 
times at least, increase the force of the heart. Given to a person in 
health and unaccustomed to its use, it reduces the temperature. Given 
to one accustomed to its use, especially to its large use, it does not 
diminish the temperature. (Ringer.) May not these facts account 
for the very contradictory results of experiments which are reported ; 
and also for the opposite opinions of observers as to its medicinal and 
dietetic use ? Is there not a wide-spread error on this subject, espe- 
cially among European Avriters, from overlooking the facts and princi- 
ples just stated ? Does it really increase gastric secretion and digestion 
in persons not accustomed to its use ? But where it really increases 
gastric secretion and is not in sufficient quantity, or of sufficient con- 
centration, to materially interfere by its presence with the action of 
the gastric juice, which it has caused to be secreted in freer quantity, 
and where by these means it temporarily aids digestion, does it per- 
manently increase the power of the stomach, and are its effects on the 
liver, the brain, and the general system, such as to demand or justify 
its use, at least for any considerable length of time ? This question, 
I believe, with the rarest possible exceptions, should be answered most 
decidedly in the negative. The effect of alcohol in any quantity, in 648 
B T8PEPSIA. 
any form of dilution or admixture, and to any extent, is far more 
likely on the whole to do harm than good in the average cases of atonic 
dyspepsia. The effect upon the liver, where it is so apt to accumu- 
late, is almost uniformly bad, and its general influence upon ultimate 
nutrition is unnatural and lowering, diminishing the proper vitality 
of tissues. In some cases it increases the amount of fat, but this effect 
is often the result of a lowered nutritive process, and an evidence of 
an unhealthy state. The danger of establishing an alcoholic habit is 
not to be ignored, as the ultimate interests as well as the immediate 
comfort of our patients are constantly to be considered. As to its effects 
upon the stomach and upon the whole system when taken in excess, 
there is no question. Says Dr. Ringer, “ Hand-book of Therapeutics,” 
pages 339 and 340, 8th English edition: “ After a variable time, 
the prolonged indulgence in alcoholic drinks seriously damages the 
stomach by producing chronic catarrh. The mucous membrane, 
coated with tenacious mucus, excites unhealthy fermentation of the 
food, while the structure of the membrane itself undergoes consider- 
able alteration through great increase of the connective tissue, which 
by its contraction obstructs and destroys the secreting follicles and 
their lining cells. The mucous membrane thus becomes thickened, 
hardened, and uneven ; and owing to obliteration of the orifices of 
the follicles, cysts form in its substance, and these enlarge from the 
accumulation of cells within them. In consequence of these serious 
changes, little gastric juice is poured out in response to the demand 
made by the food, while the unhealthy mucous coating of the stomach, 
by exciting morbid fermentations, induces the production of much 
gas, with various acids, as butyric, acetic, etc., Avhence acidity and 
lieart-burn. Morning vomiting of a scanty, sour, hitter, and tena- 
cious fluid is a characteristic symptom of this condition.” 
Who is to decide as to what is excess ? How can we tell when the 
treatment has gone far enough ? Certainly the sensations of the 
patient will not decide this question, as, after the effects described by 
Dr. Ringer have occurred, the accustomed dram relieves the symp- 
toms. 
Dr. Lionel S. Beale, in his work on Slight Ailments, says : “ People 
who seldom during a long life have felt really well, often find out for 
themselves, or they are told by too officious friends, that a little alco- 
hol just before a meal will afford relief. Brandy, gin, bitters of 
various forms, pick-me-ups, etc., are taken for this purpose, and a 
worse system has never been carried out. That bad habit of taking 
now and then ginger-brandy, cherry-brandy, or the worse one of 
imbibing strong sherry for relieving nausea, a sensation of hollowness 
or faintness, or fullness, or all-overishness, or what not, has been the TREATMENT. 
649 
ruin of thousands. Once in the habit of adopting this vicious practice, 
many find it a far more difficult matter to give it up than one would 
suppose.” * * * * 
“If a man cannot eat his dinner without swallowing a stimulant, 
he had better go without it.” * * * * 
“ Many admit that they began because they suffered from a sinking 
sensation, or nausea, or uneasiness about the stomach which troubled 
them from time to time, and could invariably be relieved by a little, 
brandy. ” 
“The little brandy gradually increased, and nausea and other un- 
pleasant sensations, instead of occurring once or twice in the day, oc- 
curred a great many times, and the victim will tell you he is obliged to 
resort to the remedy in order to do his work. Of those who act thus, 
many become slaves to alcohol, and then a more deplorable phase is 
reached. They are no longer able to abstain, all self-command is lost, 
and they fail to be able to control themselves in any way, while they 
will not submit to be influenced by others.” (pp. 43-44.) 
This is a professional opinion, the result of much physiological 
study and of practical observation and experience, and it is correct. 
Dr. Beale, however, immediately proceeds beyond his professional 
tether, and speaks disparagingly of those who, from this state of 
indulgence, overwhelmed with remorse, abstain entirely, and hate 
alcohol more than they loved it before, “ who give up the role of sin- 
ner and adopt that of saint,” and from being unable to govern them- 
selves, become determined to govern others, and express indignation 
against all who take or sell or produce alcohol, and think it hard that 
they are not able to punish every one who prefers wine to water, and 
who dares even to look at a stimulant. He goes on to show that his 
professional opinion was not influenced by any sympathy with the 
moral movement of the advocacy of total abstinence, by saying—with 
as much reason might power be given to convalescent lunatics to put 
all the sane people in strait waistcoats, or confine them in padded 
rooms, as to give these reformed men the power of restraining tem- 
perate people from indulging in the use of alcohol as they may think 
best. 
The moment he leaves his strictly professional grounds, he seems 
to forget that this moderate indulgence is the cause of the immoder- 
ation which he has just been so graphically depicting, and which he 
so much deplores. The position seems to be something like this : 
The use of alcohol is useless, is deceptive, is injurious and often de- 
plorable, and extremely dangerous ; but it is fanaticism to oppose it 
even by argument and persuasion, and absurdity and insanity to 
attempt to restrain its production and use ! 650 
DYSPEPSIA. 
But this is following Dr. Beale beyond the limits of professional 
discussion. With his professional opinion as quoted, I fully agree; 
with his non-professional sentiments on this subject, if I properly 
understand them, I have no sympathy. 
In view of all these facts and considerations I cannot advise the 
administration of alcohol in dyspepsia as a common practice, but, on 
the contrary, must condemn not only its indiscriminate, but its ordi- 
nary use. This, I cannot doubt, the ultimate judgment of the pro- 
fession will sustain. Indeed, the opinion is fast gaining ground among 
the most enlightened and unprejudiced members of the profession that 
the medicinal powers of alcohol have been greatly overrated, and that 
in dyspepsia the use of the article, in any of its forms, should be 
exceedingly limited. 
There is coming to be still greater unanimity as to its unnatural 
and positively injurious effects, however moderately used, in the 
physiological state; and as with other medicinal substances which 
have toxic properties and injurious effects in health, its use in patho- 
logical conditions can only be justified by its known remedial action 
in fulfilling useful therapeutical indications. The presumption is 
certainly always against the habitual or even the accustomed use of 
any agent having toxic properties, such as alcohol unquestionably pos- 
sesses. That presumption can only be removed, in particular morbid 
conditions, by the presence of rational indications which experience 
has proved the article capable of fulfilling. The question presented in 
each case of disease is, whether upon physiological and therapeutical 
principles, and judged by the results of enlightened experience, this 
presumption is removed. That it may be in exceptional instances of 
atonic dyspepsia, I do not deny ; but that such cases are very rare, is my 
most positive conviction. Certainly the long continued use of alcohol 
in any case of dyspepsia is attended by injuries and dangers which, in 
a strictly medical point of view, should, in my judgment, forbid such 
use. 
Among the most frequent conditions for which the dyspeptic seeks 
relief is the great acidity of the stomach and its consequent uneasi- 
ness, cardialgia, etc. This, it must be remembered, may be depend- 
ent upon either of the two causes already described : a profuse and 
untimely secretion of an acid gastric fluid, or the fermentation 
of food. This latter condition, it may be stated in recapitulation, 
occurs from a deficiency of proper gastric secretion and the presence 
of ferments which readily excite such chemical action. The results 
of these actions—the lactic, acetic, oxalic, carbonic, and butyric acids, 
the sulphide of hydrogen, and various other changing organic com- 
pounds, liquid and gaseous—by their presence in the stomach and A CIDITY—P Y 110 SIS— }VA TEL-B BASIL 
651 
intestines, and their absorption into the blood, give rise to a great 
portion of the symptoms of dyspepsia. 
The hypersecretion, most frequently dependent upon reflex irrita- 
tion, calls for a careful inquiry into the original sources of irritation 
and for efforts at their removal, while palliative measures for dimin- 
ishing the secretion and neutralizing its excessive action are also 
required. 
The deficient gastric secretion, and its consequences of fermenta- 
tion and its results, call for measures to increase the secretion or to 
supply its deficiency, and thus to prevent the fermentation changes. 
For this latter purpose the mineral acids are among the measures to 
which we should resort, not on the fanciful principle of “like cur- 
ing like,” but on the simpler and true principle of supplying a 
needed ingredient for digesting the food, and producing a tonic effect 
upon the stomach and the general system. These acids act in part on 
the same principle as pepsin and pancreatin, and in part as excitants 
and tonics increasing stomach action, and thus preventing the more 
passive chemical changes. They are more curative than pepsin and 
pancreatin in the principle of their action, as, in addition to their 
effects in directly aiding the digestion of food chemically, they tend to 
improve the condition of the stomach and that of the general system. 
Thus they have a double action, while pepsin simply operates 
upon the food, and most other tonics exclusively on the organism. 
It is, however, claimed for the extract of malt that the diastase 
acts upon the food, promoting digestive changes, while the hop modi- 
fies favorably organic processes. 
There are various particular symptoms occurring in dyspeptic 
states which have received particular designations, such as pyrosis, 
water-brash, and urticaria. 
Pyrosis, or heart-burn, may arise from a variety of particular 
conditions. It occurs in cancer and ulcer of the stomach, from exces- 
sive secretion arising from reflex action, and in some cases is not to be 
distinguished from the burning irritation in the stomach caused by 
the acids of fermentation. 
Water-lrash is sometimes used synonymously with pyrosis. It 
consists of paroxysms, at longer or shorter intervals, of a free watery 
secretion, sometimes chiefly from the salivary glands and the throat, 
when it is alkaline ; and at other times from the stomach, when it is 
acid. 
It is of frequent occurrence, or was formerly so, in Scotland, 
Sweden, and other northern European countries, among people Avho 
lived upon coarse and insufficient food; but it is occasionally met 
with elsewhere, and among all classes of persons. This profuse secre- 652 
DYSPEPSIA. 
tion often pours from the month (when from the stomach by an act 
of regurgitation rather than vomiting) in great quantities, and is 
accompanied with gastric pain, headache, giddiness, and much pros- 
tration. 
The paroxysms last from a few to several hours, and are some- 
times confounded with what are called “sick headaches.” 
The paroxysms generally exhaust themselves in a few hours, and 
may need but little treatment, and the means of their prevention do 
not materially differ from those recommended in dyspepsia presenting 
other phenomena. 
An improved and regulated diet, eliminatives and laxatives, often 
the saline (the Carlsbad salt, or snip, magnesia, 3j, three times a 
day, etc.) ; and tonics, nux vomica, quinine, and the mineral acids ; 
bismuth alone, or bismuth and tannin, etc., are the remedies from 
which selections are to be made. 
When the paroxysms are accompanied with great suffering, mor- 
phine, the bromide of sodium, and other anodyne measures may be 
required. 
Urticaria occasionally occurs from wrong digestion, and from the 
taking of particular articles of food, as fish, cheese, or honey. In 
such cases evacuants are demanded—emetics sometimes, but oftener 
cathartics—and the avoidance of the causes will of course be required. 
When the stomach and bowels are cleared of their irritating contents, 
the cutaneous irritation and inflammation usually soon subside. 
Some cases of urticaria depend upon more permanent causes, and 
may require other measures ; but those depending upon disagreement 
of particular ingesta require only evacuants, and the subsequent avoid- 
ance of the cause. 
Gastric neuralgia accompanies some cases of dyspepsia. Pain 
then is often present when the stomach is empty. Narcotics give 
temporary relief, and the severity of the suffering will often require 
their use. 
A belladonna plaster over the stomach will often produce a marked 
effect, keeping the pain in abeyance for considerable periods; but a 
steady pursuit of the remedies for the dyspeptic state, and for the 
general neuralgic condition, is chiefly to be relied upon. 
The remedies required will not differ from those demanded in 
other cases of dyspepsia and neuralgia, which present similar general 
conditions. 
The indigestion of drunkards is spoken of as a distinct variety. 
It is generally organic, dependent upon ulceration, hyperplasia, con- 
traction, etc., of the stomach. When well established and advanced 
the cases are very grave and the prognosis unfavorable. INDIGESTION OF THE AGED. 
653 
There is usually no hope without complete abstinence from the 
poison which has produced it, and this not unfrequently comes too 
late. 
The preparations of opium, the oxide of zinc in doses of from two 
to ten grains, the bromide of sodium, bitter infusions, the extract of 
malt, etc., may aid hygienic measures. 
When superficial scattered ulcerations exist, moderate doses of 
chlorate of potash, and of the terebintliinate preparations may be 
useful. 
While the dyspeptic symptoms of drunkards are functional, or 
before material organic changes have occurred, abstinence from the 
alcoholics will often be followed by marked and speedy relief. 
The indigestion of the aged from failure of power requires the 
use of tonics and stimulants. Quininej strychnine, the aromatic 
spirits of ammonia, spices, etc., will be of use. Wine in these cases 
is often prescribed, and sometimes it certainly appears to afford relief. 
That it should in these cases be advised with great caution has been 
strongly impressed upon me by the too frequent observance of the 
fact, that where the general powers are failing, discretion and self- 
control among them, habits of excess are sometimes speedily formed, 
and the last days of an exemplary life have thus in some instances 
been sadly obscured. 
Nothing is more melancholy than to see the driveling of intem- 
perance added to the imbecility of old age. It is better to forego 
some slight and doubtful benefit than to run so great a risk of such 
unpleasant consequences. 
With the aged the principal meal should be early in the day. A 
heavy supper, with or without alcoholics, has in numerous instances 
proved fatal. 
Sometimes alteratives and eliminatives are required in the dyspep- 
sias of advanced life as in other cases, but these must be used with 
caution when the vital powers are low. Generally aromatics or other 
stimulants and tonics should be combined or alternated with elimina- 
tive measures when they are required. With dyspeptics, some articles 
may be digested Avith difficulty, while others are readily appropriated. 
Thus meat, fruit, fat, or starchy foods may not be properly digested, 
and may give distress, while other articles are well borne. These 
peculiarities may depend upon a deficiency or perverted state of 
the particular secretions which should digest the articles disagree- 
ing ; or upon a morbid state of the portion of the alimentary 
canal most concerned in the digestion of these articles. Each 
case, therefore, should be studied by itself and its peculiarities re- 
garded. 654 
DYSPEPSIA. 
The salivary secretion may be deficient or perverted, leading 
especially to the less perfect digestion of the starchy foods. In such 
cases iodide of potassium, given in proper doses for two or three weeks, 
may be very useful. A few doses of some mercurial may first be 
given to modify that secretion. 
Where the albuminoids are not well digested, pepsin and the min- 
eral acids will aid the process. 
Where the fats disagree, pancreatin would be indicated. 
The effects of pepsin and pancreatin are temporary and palliative, 
rather-than permanently curative ; but they may bridge over a present 
deficiency of digestive power, and give time for the recuperative powers 
of the system, alone or aided by other remedies, to effect a more per- 
manent change. 
The diastase in malt is supposed to act chemically in aiding the 
digestive process of some foods more than other organic tonics, and 
that, together with the other ingredients of the malt, often produces a 
tonic and useful effect in different forms of indigestion. 
With some persons fluids are not readily absorbed, but remain long 
in the stomach, diluting the gastric juice and impeding digestion. In 
such cases moderate quantities only should be taken with the meals, 
and the conditions of osmosis should be considered, and those which 
are deficient should, as far as possible, be remedied. 
While a reasonable amount of attention should be given to the par- 
ticulars of diet on the part of those having weak digestion, and to the 
selection of articles which correct dietetic principles and a well ob- 
served personal experience have shown to be best, yet, on the other 
hand, too much attention may be given to the effects of food. Those 
who are constantly directing their attention to their stomachs, and 
watching sensations during digestion, are apt to develop a morbid 
sensitiveness of the digestive organs, and if the process of digestion is 
not positively impaired, it is accomplished with less comfort to the 
patient, and often becomes distressing. Where there is a tendency to 
this state of things the attention should be diverted from the digest- 
ive organs and processes, and where serious indigestion is not present, 
but where only morbid sensations are experienced during its process, 
those sensations should be ignored and the patient assured that they 
are of little consequence ; and he should be advised to take a varied 
but rational diet, following his appetite and instincts, within proper 
limits, in preference to any preconceived notions of what is best, or 
even in preference to the conclusions drawn from his experience, when 
in this state of mental suspicion, of certain articles or quantities of 
food. He who devotes himself to watching his sensations and looking 
for morbid ones will be pretty sure to find them, and in proportion to VOMITING. 
655 
the eagerness of his pursuit. The management of the mental state is 
far more important, in many such cases, than the administration of 
drugs, and yet medicines may be very useful, sometimes as placebos, 
exciting hope and satisfying the mind, but also on account of the 
changes in the functions and sensations which they may effect. 
In most cases there arc some real defects of digestion, but in many, 
far more perversions of sensations; and in such mixed cases, a course 
of judicious management will be required. Resort must bo had to 
medicinal treatment when clear indications are presented proper 
care must be used as to diet, but it is important to avoid a rigid 
system of exclusion which may result in partial starvation and a lower- 
ing of all the powers of the system, including the power of digestion. 
A general mild tonic course is in many cases indicated, and small 
doses of strychnine, acting as it does on the vaso-motor centres and 
increasing muscular tonicity, or bismuth and lupulin, moderate doses 
of quinine, etc., will often be found useful. The extremes of much 
medication and great restriction of diet, on the one hand, and the dis- 
carding of all medicines and an unlimited indulgence in articles and 
quantities of food which are not digestible or which produce une- 
quivocal derangements, on the other, should alike be avoided. 
VOMITING. 
Vomiting, often a symptom of indigestion, as it is also of various 
other pathological conditions, occasionally appears as the only recog- 
nizable morbid state, and may therefore sometimes be clinically con- 
sidered as an individual affection. When it depends upon other dis- 
eased conditions, they should receive the most careful attention, and 
remedies should be directed to their removal. 
Vomiting may depend upon disease of the brain, or other organs 
affecting the stomach by sympathetic or reflex action. It may 
depend upon inflammation of the stomach, or upon foul secretions, or 
upon improper articles or quantities of ingesta, or upon irritating 
materials the result of fermentation. Its occasional occurrence is 
often useful in relieving the stomach of irritating materials. It some- 
times, however, occurs very soon after food is taken, and with great 
persistency, caused by the stomach’s intolerance of almost every kind 
of ingesta. 
This form of vomiting is much more frequent in females than in 
males, and oftener in girls near the age of puberty than in women 
after this period. Though the vomiting occurs before the digestive 
process has had time to be advanced, and so large a part of the food 
is thrown up unchanged, yet it is remarkable that this may go on for 656 
DYSPEPSIA. 
a considerable period without any very material diminution of the 
strength or weight. 
Dependent as this peculiar kind of vomiting is upon morbid con- 
ditions of the nervous system, it should be classed among the neuroses, 
is somewhat analogous to the vomiting of pregnancy, and is commonly 
associated with a hysterical temperament. It is doubtless sometimes, 
if not generally, associated with some functional peculiarity of the 
uterine and ovarian organs. This affection is liable to be mistaken 
for ulcer or other organic disease of the stomach; but the absence of 
the characteristic pain and hemorrhage of gastric ulcer will serve to 
distinguish it from that condition ; and by exclusion of other struct- 
ural diseases, and by the presence of other evidences of the hysterical 
temperament the diagnosis can be made. 
Treatment.—The proper treatment of vomiting will depend upon 
the cause, and upon the form which it takes. As a symptom of gas- 
tric inflammation, ulcer, or other organic affection, the original dis- 
ease should form the chief indication for treatment. 
When dependent on inflammation, morphine, hydrocyanic acid, 
carbonic acid water, and counter-irritation, etc., will be required. 
When upon ulcer, the restriction of the diet, or intestinal alimenta- 
tion and the other remedies already advised for ulcer should be resorted 
to. So of other primary affections producing vomiting. In many 
cases bismuth, creosote, oxalate of cerium, spices, etc., may check the 
symptom. 
In the peculiar neuropathic vomiting described, these remedies 
should be tried, but they will often be found to fail. Trials of dif- 
ferent kinds of food, prepared and flavored in different ways to suit 
the taste, should be made, and if any particular article can be found 
which will be tolerated, others can usually soon be borne. 
Sometimes the administration of a very small quantity of food at 
very short intervals—once in a few minutes—will succeed. The 
patient may be allowed to take in moderate quantity any kind of 
food the appetite or fancy may prefer ; and it may be found that 
articles usually regarded as least easy of digestion will be tolerated, 
when others generally approved of are rejected. However, milk in 
small quantities, frequently repeated, is perhaps most likely to be 
retained, and it may be given either iced or very hot, Avith or Avith- 
out the addition of a little lime-water. Sometimes skimmed milk or 
buttermilk will answer better than other forms. Eaw or very rarely 
cooked meat, or hard biscuit, or crackers taken dry, may be tried. 
Indeed a great variety of articles may, in obstinate cases, be tried in 
succession. 
Sometimes, however, a period of complete rest of the stomach will ANOREXIA. 
657 
be most successful, the patient being supported by rectal alimenta- 
tion. After a time, food should again be given by the stomach, and, 
as soon as this is tolerated, the rectal method may be discontinued. 
Galvanization of the sympathetic and pneumogastric nerves, followed 
by general faradization, has been reported as useful. Hygienic and 
mental management, as in other nervous and hysterical cases, will 
be required. 
Prognosis.—Although this trouble is often protracted and obsti- 
nate, the ultimate prognosis, as in other hysterical cases, is favorable. 
When the stomach becomes tolerant of food, remedies to improve 
digestion and the general health, such as nerve tonics, iron, etc., will 
often be indicated. 
ANOREXIA. 
Anorexia, or loss of appetite more or less complete, is a frequent 
symptom of a great variety of diseases, but particularly of those of 
the stomach. 
But independent of these connections, so far as we can at present 
discover, it sometimes presents itself as an idiopathic affection, or at 
least as the chief morbid condition, resembling in this respect the 
vomiting just considered. This also occurs for the most part in girls 
or young women, and is often hysterical in its character. 
It is not uncommon to an extent sufficient to cause ansemia, 
debility, and more or less emaciation, and in rare cases it may become 
so extreme as to become alarming. 
It is sometimes accompanied with a desire for indigestible sub- 
stances, such as slate, chalk, charcoal, etc., and, still more rarely, for 
even disgusting articles. In many cases it is more serious than those 
moderate impairments of appetite considered under the title of the 
minor ailments. 
As this loss and these perversions of appetite are allied in pa- 
thology to the functional vomitings referred to, they require in many 
respects similar management. Since they are probably for the most 
part connected with certain evolutions of the sexual system, attention 
should be given to the functious of those organs, and remedies should 
be addressed to them as indications are presented. 
The diagnosis of functional anorexia is to be made by excluding 
other affections, and for this purpose a careful examination of all the 
organs and functions of the body, including an examination of the 
secretions and the blood, may be required. 
The prognosis, as in vomiting, is usually favorable, when the 
diagnosis is properly made. 
In the treatment of these cases of anorexia, the various tonics, 658 
DYSPEPSIA. 
especially the bitters, as quinine, strychnine, columbo, the aromatics, 
and the mineral acids, may, if necessary, be tried in succession. In 
extreme cases the will of the patient must be appealed to, and 
persuasion, and even compulsion may he required ; and the forced 
taking of food may be followed by a restoration of the appetite. In- 
jecting food into the stomach, or rectal alimentation, may be held 
in reserve as dernier ressorts. In the meantime remedies should be 
addressed to the mind, and the general condition of the nervous 
system. A change of scene and society, open air, the sea-shore, 
bathing, the bromides, etc., may all be useful in different cases. 
Flatulency is a frequent symptom in indigestion, and commonly 
arises from the decomposition of imperfectly digested food. It is 
believed also to arise from gases secreted by the stomach and intes- 
tines, and of course may be the result of air or gas swallowed. 
Some articles of food, as beans, turnips, etc., are more liable to 
produce flatulence than others. 
There are various vegetable stimulants, suet as anise-seed, ginger, 
the mints, etc., which act as carminatives, exciting the stomach to 
contraction and the expulsion of the gases; and anything which will 
render the digestion more complete tends to prevent the flatulence 
dependent upon fermentation of food. 
The treatment of flatulence will vary according to the cause and 
the condition existing. Care should be taken to avoid those articles 
of food which produce the symptoms ; the digestion should be im- 
proved, air should not be swallowed, and various carminatives may 
be given for temporary relief. 
In the treatment of various forms of indigestion, especially those 
arising from luxurious and sedentary habits, and from excesses in 
eating and drinking, a course of saline, laxative mineral waters; or of 
hydropathic treatment ; or the grape and movement cures, are often 
found very useful. 
The breaking up of the injurious habits, removal from the usual 
temptations, the adoption of a plain, simple, regular mode of living, 
under advice and rules, together with the free use of eliminatives, 
saline, or even simple water, will often effect the most beneficial 
changes ; and patients may with propriety be sent to watering-places, 
and to “ cures ” which are conducted on rational principles by prop- 
erly educated, sensible, and honest persons. here such places are 
from any cause not available, the measures and methods practiced at 
them may often be imitated at home with great advantage. 
The natural mineral waters can generally be imitated artificially 
with sufficient exactness. The water of the Carlsbad springs, for 
example, so frequently and so beneficially resorted to in Europe for ANOREXIA. 
659 
various digestive and other affections, can be imitated by adding sul- 
phate and carbonate of soda and chloride of sodium to hot water, and 
a free quantity of the proper dilution can be taken quite warm each 
morning, an hour or more before breakfast, as is the practice at the 
springs, and with similar effects. If a little extract of ginger be 
added, the effect is often better in cases of weakness and depression 
of the stomach. Proper exercise, baths, and a regulated diet can be 
prescribed and insisted upon at the patient’s home, and thus many of 
the benefits of distant and expensive watering-places and “cures” 
can be obtained by the masses of patients. All that is not quackery 
and deception at these places may be properly imitated by every 
physician according to his judgment and as he finds useful by expe- 
rience. 
Finally, it may be repeated, that in the treatment of indigestion 
the causes and the special forms of the disease must be carefully 
observed, the causes being avoided, and the different forms treated 
according to the indications presented. 
Errors of diet, whether of excess, of deficiency, or of improper 
articles, must be corrected. Inaction or excess of action of body or 
mind must alike be avoided or corrected. Diseases of other organs, 
as of the liver, the lungs, the kidneys, the uterus or ovaries, etc., 
must receive attention. Compression of the stomach by tight dress- 
ing, the abuse of purgatives, and the indulgence in every form of nar- 
cotic should be inquired into, their bearing upon the case considered, 
and everything believed to be injurious prohibited. Without these 
restrictive measures a cure is always doubtful, and often hopeless. 
With their proper enforcement and the use of proper therapeutic 
measures, a cure can very generally be effected. 
The medicines to be studied in reference to their effects upon 
dyspeptic affections are : laxatives and eliminatives, mercury, iodide 
of potassium, wahoo, witch-hazel, ipecacuanha, alkalies, acids, tonics 
—quinine, strychnine, salicin, lupulin, and the bitters generally— 
malt, bismuth, preparations of silver, pepsin, pancreatin, cod-liver 
oil, mineral waters and their substitutes ; creosote, carbolic acid, sali- 
cylic acid, sulphites, and laxative enemas. 
PARTICULAR PRESCRIPTION’S. 
B Bismuthi Subnitratis 3v 
Morpliiae Mnriatis gr. f-jss 
M.—Care. ft. pulv. No. xx. 
One immediately after the two principal meals. 
Dys. with irritable bowels. 660 
DYSPEPSIA. 
R Pot. Bitartratis 3iij 
Magnesiae Calc 3j-ij 
Jalapae Pulv grs. xv-xxx 
M.—At once. 
R Magnesiae Calc., 
Liquor Calcis, 
Aquae Destillatae aa f5ij 
Syrupi Aurantii Florum f?j 
M.—Table-spoonful, pro re nata. 
Antacid, in dyspeptic colic. 
R Magnesiae 3ss 
Spts. Lavandulae Comp f3ss 
Spts. Cari f3ijss 
Syrupi Zingiberis f3iij 
Aquae Menthae Pip f3ij 
M.—For two doses for flatulence. 
Easy. 
Mutton. 
Venison. 
Chicken. 
Turkey. 
Grouse. 
Beef-tea. 
Mutton Broth. 
Milk. 
Most fresh Fish. 
Oysters, soft parts. 
Stale Bread. 
Rice and Starches. 
Baked Apples. 
Oranges. 
Grapes. 
Strawberries. 
Peaches. 
Toast-water. 
DIGESTIBILITY OF FOODS. 
Moderate. 
Beef. 
Lamb. 
Rabbit. 
Duck. 
Young Pigeon. 
Wild Water-fowl. 
Snipe. 
Soups. 
Eggs. 
Butter. 
Pike. 
Trout. 
Stewed Oysters. 
Raw Oysters. 
Potatoes. 
Beets. Turnips. 
Cabbage. Spinach. 
Apples. 
Celery. 
Puddings. 
Common Bread. 
Cooked Fruits. 
Hard. 
Pork. 
Veal. (?) 
Goose. 
Liver. Heart. 
Salt Meat. 
Sausage. 
Hashes. (?) 
Mackerel. 
Eels. Herring. 
Halibut. 
Lobsters. 
Oil. Cheese. 
Melted Butter. 
Hew Bread. 
Muffins. 
Buttered Toast. 
Pastry. Cakes. 
Nuts. Pears. Plums. 
Cherries. Pineapples. 
Cucumbers. Onions. 
Peas. Beans. Pickles. 
Chocolate. FOODS. 
661 
DIGESTED MILK. 
$ Good Cow’s Milk 
Pure Pepsin grs. v 
Dilute Hydrochloric Acid gtts. jv 
Digest in water bath at 100° till clear. 
Neutralize acid with bicarb, of soda. 
But no positive rules as to diet can be given; and, as already 
stated, there may be injurious results from following too strictly 
specific rules, or relying too positively upon past experience. 
There is a saying that “one man’s meat is another’s poison,” 
which is an exaggerated statement of the fact that the same rules of 
diet will not apply equally to all; but this does not prevent the pro- 
priety of giving certain general directions which it will be well, or 
indeed important, for the average individual to follow. 
As a rule, meals should be taken three times a day; should con- 
sist of some variety; should contain both proteinaceous and carbona- 
ceous elements ; one meal should be digested before the next is taken ; 
there should be comparative rest during the more active stage of 
digestion of a full meal, but without sleep, though sometimes a very 
short nap is beneficial; and the principal meal of the day should be 
taken some hours before bed-time. 
As to quantity, no positive rule can be given. While there may 
be a quantity taken to satisfaction, satiety should generally be avoided ; 
but the appetite is not an infallible guide, and the quantity should 
be influenced by the amount of expenditure in work. 
There is certainly in the physiological condition no necessity for 
alcoholics, or other narcotic or semi-narcotic substances, but warm 
drinks during meals are by some persons better borne than cold. 
Abstaining from drinks during meals is by no means necessary, 
except in cases where fluids are not readily absorbed. An excess of 
fluids at meal-time may dilute the gastric juice too much, and thus 
interfere with digestion ; but ordinary quantities of fluid, in ordinary 
are readily absorbed and do not retard the digestive 
processes. 
The liability to impairment of digestion and nutrition in nearly 
all forms of disease, places the care of the stomach among the sub- 
jects of the greatest and most constant importance in the practice of 
all departments of the profession. Too much attention can scarcely 
be given to its study. 662 
GASTRALGIA AND GASTROENTERALGIA. 
GASTRALGIA AND GASTROENTERALGIA. 
Those terms are used to indicate paroxysmal pain in the gastric 
and intestinal regions, at the places of distribution of the vagus and 
sympathetic nerves, but independent of the immediate effect of irritat- 
ing ingesta, and of appreciable lesions of the coats of the stomach and 
intestines. This stands in a sense between diseases of the stomach 
and the intestines and those of the nervous system ; and, though 
inclining to the latter, may be briefly considered in this connection. 
Causes.—These neuropathic pains are most frequently produced 
by the causes of neuralgia in general; and they probably, though 
the fact has not as yet been demonstrated, depend essentially upon 
some material changes in the vagus and sympathetic nerves.' 
The repeated irritations and jDains caused by some alimentary sub- 
stances, such as lobsters, etc.; and by other ingesta, such as free 
quantities of spices, of coffee and tea, and alcoholic liquors, or various 
medicines too long continued—drastics, copaiba, etc.—are different 
from the form of paroxysmal pains now under consideration. 
Pressure upon the course of the nerves by morbid alterations, 
tumors, varices, etc., may be a cause of this pain, it being expressed 
in the terminal branches. It may also be caused by disease of the 
central nervous system ; by myelitis, cerebral or spinal sclerosis ; by 
lesions of the liver, pancreas, spleen, or kidneys; or of the utero- 
ovarian apparatus, the pain being produced by reflex action. 
Constitutional causes, such as chlorosis and anaemia, tuberculosis, 
prolonged lactation, sexual excesses, and involuntary seminal losses, 
sometimes produce the disease. It may occur as an expression of the 
gouty diathesis or of a general neurosis—hysterical or hypochon- 
driacal—or of still other conditions. 
It is sometimes independent of all recognizable causes, and has 
been said to be due to a spontaneous hyperassthesia of the nerves con- 
cerned, which explains nothing ; and it has also been attributed to an 
alteration of the gastric secretion, which i3 only a conjecture not con- 
firmed by proof. 
The disease may occur at any age, but is more frequent in women, 
and is thought to be favored by the artificial life or unfavorable 
hygienic conditions of large cities. 
Gastralgia may be acute, subacute, or chronic ; it is always par- 
oxysmal, but the period of recurrence varies greatly, and the duration 
of each paroxysm varies from a few minutes to some hours in the less 
acute cases. When it occurs at regular periods, as daily or every 
second day, it indicates, or at least suggests, a malarial cause. PHENOMENA. 
663 
In the more' acute cases the pain is sometimes very severe and 
overwhelming. It may come on suddenly without any premonition, 
or it may be preceded by increased salivary secretion, eructations, 
pyrosis, and nausea, and sometimes by vomiting ; it is more likely to 
occur when the stomach is empty than when it contains food. 
The pain may he gnawing, burning, contusive, contractive, or 
tearing, and is often agonizing. It is most severe in the epigastrium, 
but often extends to the back, and sometimes over the whole ab- 
domen. It is generally somewhat relieved by firm pressure made 
over a large surface, as by the palm of the hand, though increased by 
light pressure, and also by strong pressure upon small points, as by 
the ends of the fingers. The epigastrium, though raised when there 
is much gas in the stomach, is often retracted. 
When the pain is severe the features are usually pale and con- 
tracted, the extremities are cold, and sometimes bathed with a clammy 
sweat, faintness and even complete syncope sometimes, but rarely, 
occur, and reflex actions often take place, and in rare cases amount to 
general convulsions. 
Sometimes associated sensations are diffused to the various parts 
under the influence of the solar plexus, to the hypochondriac region, 
to the kidneys, spermatic cord, etc., while at other times and in the 
lighter forms there apparently is hyperaesthesia of the vagns only, 
this justifying the distinction of two varieties, the one involving the 
vagus chiefly or only, the other the solar plexus. From irritation of 
the vagus we have constriction of the oesophagus, a sense of burning 
in its course, sometimes great thirst, and various perversions of taste. 
Vertigo accompanied by different morbid sensations, often of 
emptiness in the head, a sense of falling, and momentary obscuration 
of sight, and sometimes staggering and even falling occur. 
These symptoms may excite suspicion of disease of the brain, but 
they are dependent upon the conditions of the stomach, are generally 
coincident with the neuralgic paroxysms, but may exist alone, or in 
connection with other stomach symptoms. 
At the termination of an attack there are often yawnings, a light 
sweat, and free secretion of urine. 
The digestion may be unimpaired, and the pain not at all produced 
by any articles of food taken. Indeed in some cases taking food is 
among the most effectual methods of relieving the pain. But pain of 
this paroxysmal and neuralgic character may be associated with flatu- 
lent dyspepsia, with acidity, or with the production of fetid gases 
from deficiency of gastric juice, and the decomposition of nitrogenous 
substances. In these dyspeptic complications there will usually be 
a foul tongue, unpleasant taste in the mouth, deranged bowels, etc. 664 
GASTRALGIA AND GASTROENTERALG 1 A. 
Diagnosis.—It is to be distinguished particularly from peri- 
tonitis, ulcer and cancer of the stomach—from peritonitis by the 
absence of fever and the decided tenderness on pressure ; from ulcer 
and cancer by the history of the case and the more frequent occur- 
rence of the pain during fasting, or at least by its not being in the 
same manner produced by taking food, by the absence of hemorrhage 
and other symptoms indicating these conditions, and by the presence 
often of a general neuropathic state. From other conditions, such as 
gastritis, biliary calculi, diseases of the transverse colon, of the duo- 
denum, or of the pancreas, or an aneurism of the abdominal aorta, 
etc., accompanied by pain in similar regions, gastralgia may be dis- 
tinguished by a careful and intelligent comparison of all the symp- 
toms and conditions. 
The accidental pains in the stomach produced by irritating ingesta, 
foul secretions, or the results of the decomposition of food, will be 
distinguished from the disease under consideration by the history and 
the accompanying circumstances of each case. 
Prognosis.—The course of these cases of gastralgia inclines to 
be chronic, but the duration depends upon the cause, as does also 
the prognosis as to a cure. The disease is seldom fatal; and if much 
feebleness and emaciation occur early, some other morbid condition 
is usually present. Though the prognosis is usually favorable, gas- 
tralgia may be but a symptom of grave lesions of the central nervous 
system which will have an unfavorable termination. 
Treatment.—In the case of simple gastralgia, independent of 
the presence of irritating materials in the stomach, opiates in proper 
(rather free) doses, or repeated at short intervals, will almost always 
bring the paroxysm to an abrupt and complete close. This will tend 
to establish the diagnosis. Morphine hypodermically is perhaps the 
quickest method of procuring relief, though when placed in a dry 
state far back upon the tongue, or introduced into the stomach when 
nearly empty, its effects are very prompt. The dose may be from one 
fourth to one half a grain to an adult, or even more where it has 
often before been given and its effects observed ; and if not effectual 
it may be repeated in suitable quantity in half an hour. Susceptibility 
to opiates varies very much in different cases, and is influenced by the 
severity of the pain and by their previous use. Proper caution should 
be exercised, but free quantities are usually borne, and required, when 
the pain is great. Spts. of camphor will sometimes produce decided 
relief, but it is less certain and efficient than the opiates, as are all 
other of the narcotic substances in all ordinary cases. It will be well 
to bear in mind, however, that an idiosyncrasy exists in some very 
rare cases, where opium and its various preparations not only fail to TREATMENT. 
665 
relievo suffering, but actually produce great distress—as in two or 
three cases I have known—not very unlike the gastralgia we are con- 
sidering. Even small doses will affect some very unfavorably, and 
larger ones still more. These cases are, however, so very rare and 
exceptional, that such an idiosyncrasy is not to be apprehended, 
unless previous experience has proved its existence. Where it does 
exist other anodynes must be substituted for the opiate. The inhala- 
tion of chloroform or ether will sometimes procure prompt relief. 
The hydrocyanic acid, chloral hydrate, and the other anodynes or 
narcotics, such as hyoscyamus, belladonna, lactucarium, etc., may be 
tried. A combination of morphine and atropine hypodermically will 
often answer well where morphine alone would not be 'well borne. 
Chlorodyne and various other compounds will be adapted to particu- 
lar cases. These means may be aided by sinapisms or hot fomenta- 
tions over the stomach, warmth to the extremities, or the drinking 
freely of warm diluents, etc. 
Whenever a pain in the stomach is accompanied, and may be sup- 
posed to be produced by irritating materials within it, evacuants, as by 
emetics or cathartics, or diluents or antidotes may be indicated ; but 
even in these cases anodynes may be required for the relief of the 
suffering before evacuation can be effected, and after its accomplish- 
•ment for allaying the irritation left behind. 
As to preventive measures, or the treatment of chronic cases, 
reference must be had to the cause. If the cause be anaemia, chloro- 
sis, gout, affections of the pelvic organs, errors of regimen, etc., 
attention must be given to them, and if removed, their effects will 
usually soon cease. When dependent upon organic diseases of the 
nervous system, on tuberculosis or any conditions not removable, the 
gastralgia, though capable of great palliation, may not be capable of 
radical cure. 
Each of the causes alluded to must be treated according to its 
nature and indications—anaemia and chlorosis by iron, malaria by 
quinine, impurities of the system hy eliminatives, dyspeptic cases by 
appropriate remedies for this affection, and so of other conditions. 
In many cases bismuth, operating as it does to some extent as a 
local anaesthetic to the stomach, modifying the hypersensibility of the 
gastric nerves, not only procures present relief of the pain, but in 
some cases effects a permanent cure. In order to obtain its full 
effects, from twenty to thirty grains of the carbonate, or nearly as 
much of the subnitrate, are required. When continued for a length 
of time, as it usually should be, somewhat smaller doses repeated three 
times a day will be the proper quantity. 
If the gastralgia is dependent upon improper alimentation, the diet 666 
GASTRALGIA AND GA S TRO ENT ERA L GIA. 
must be changed, the habitual use of tobacco, and often of coffee and 
tea, must he abandoned, the bowels must be regulated if constipated ; 
and if uterine or ovarian disease be the cause—and in females these 
organs and their functions should be inquired after, and if necessary 
carefully examined—treatment should be directed accordingly. 
When oxaluria is found to be present, the nitro-liydrochloric acid 
and other appropriate remedies should be given. 
The saline mineral waters of the continent of Europe are frequently 
resorted to in these cases with benefit, and I have found in several 
instances an artificial substitute (of moderately laxative saline doses 
in large dilution taken early in the morning, as already advised in 
some cases of indigestion) to be followed by very marked relief. 
The treatment by electricity of different forms of neuralgia, 
including this of which we are treating, has of late received much 
attention, and is doubtless of use in some cases; but its virtues 
have, by some specialists, been much exaggerated, though its skillful 
use should be tried in obstinate cases. Some advise that in neural- 
gia “ drugs should not be resorted to until after a thorough trial of 
electricity,” but even if this remedy be early used, indications which 
can be fulfilled by drugs and other means should not be neglected. 
The duty of the physician is to relieve and cure his patient by any 
means within his control, rather than to reserve the case for the trial 
of the efficacy of any particular remedy whose character is not fully 
established. There is, however, much testimony in favor of this 
remedy, and the fact of its efficacy in many cases must be accepted. 
When hysteria is present, antispasmodics and the bromide of po- 
tassium will palliate the symptoms, while nitrate of silver, arsenic, 
valerianate of quinine, and other tonics, will often be useful. 
In Stomachic Vertigo treatment should be chiefly directed to the 
conditions of the stomach, and may include a variety of remedies 
depending upon the special conditions presented. 
Neuralgic pains similar to those we have been considering have 
their chief seat in the intestines, and arise from similar causes and 
require similar treatment. They are to be distinguished from intesti- 
nal inflammation, strangulation of the intestines, typhilitis, and peri- 
typhilitis, and ulceration and rupture of the vermiform process, from 
common intestinal colic and nephritic colic, and from lumbo-abdom- 
inal neuralgia and myalgia, by the exclusion of these conditions. 
These affections are elsewhere considered, and a comparison need not 
here be entered upon. 
As palliative measures for gastralgia and enteralgia, the prepa- 
rations of opium, in a vast majority of cases, are far more efficient 
than any other remedy, but much care should be exercised in pre- DISEASES OF TEE INTESTINES. 
667 
scribing them, and they should be kept as much as possible in the 
hands of the physician, lest a habit of opium taking be established. 
The pains from lead poisoning are allied to those of neuralgia, and 
lead colic is by some authors treated of in connection with enteralgia, 
but it will be considered elsewhere. 
DISEASES OF THE INTESTINES. 
The intestines resemble the stomach in structure and function, 
and yet they differ from it in both these respects. They have the 
same number of coats, but the mucous membrane of the stomach is 
somewhat different in its structure, has a different set of glands within 
it, the size of this portion of the canal is greater, and its muscular 
action is quite unlike the uniform, vermicular, contracting motion of 
the intestines. While the food is moved about in different directions, 
and while the stomach sometimes contracts down in the centre so as 
to form a more or less complete partition in its cavity, the intestines 
very seldom have their vermicular motion reversed, and their contents 
have normally but one direction in their movement. 
The stomach, for the most part, secretes acid and the peptic fluid, 
and the secretions normally within it—with the exception of the sali- 
vary, buccal, pharyngeal, and oesophageal fluids swallowed—are its 
own. The intestinal secretion is alkaline, and these organs receive 
the alkaline secretion of those large glands—the liver and pancreas. 
The digestive functions of the intestines differ from those of the 
stomach. Their alkaline contents emulsify the fats, and they com- 
plete various processes commenced in the stomach. They have a 
special set of vessels, the lacteals, with mouths opening upon their 
internal surface, taking up certain elements of the food and conveying 
them by a special channel to the blood, and their veins absorb in a 
similar manner to the veins of the stomach ; and the materials taken 
up by both are conveyed through the portal vessels to the liver, and 
are acted upon by that organ. 
Different portions of the intestinal canal have different structures, 
and somewhat different functions. The duodenum resembles the 
stomach most, but it differs in its villi, in its having the beginning 
of the valvulae conniventes ; in its having the glands of Brunner ; in 
its alkaline secretion, and in receiving the common duct and the 
secretions from the liver and pancreas. From its peculiar relations to 
the pyloric end of the stomach, to the left lobe of the liver, and to 
the transverse colon, it is difficult to distinguish its pains and tender- 
ness from those of these other organs. 668 
DISEASES OF DUODENUM. 
Its diseases resemble those of the stomach more than do those of 
the other intestines. It is subject to ulcers closely resembling those 
of the stomach. Simple penetrating ulcers are sometimes found in 
it, with symptoms rather more mild, but with results much the same 
as gastric ulcers. To this fact I have already referred. 
Its diseases, however, for the most part, are shared with the other 
small intestines; but the ductus communis opening into it estab- 
lishes peculiar relations between it and the liver and pancreas. When 
the duodenum is congested, irritated, or inflamed, by spasm or swelling, 
that duct may he obstructed, and the free passage of bile and pancre- 
atic fluid may be prevented. 
Irritation of the excretory duct of a gland modifies, generally 
increases, its secretion. The liver and pancreas are doubtless not 
exceptions to this law. From an obstructed flow of bile jaundice 
may be produced, and from a much increased flow bilious diarrhoea 
or vomiting may result. 
Again, a catarrhal inflammation may by continuous sympathy 
extend from the duodenum to the gall ducts, or from these ducts to 
the duodenum, and the same is probably true in reference to the 
pancreas. Other parts of the intestines have their peculiarities. 
DISEASES OF THE DUODENUM. 
Symptoms.—Acute catarrhal inflammation of the duodenum, as 
of other portions of the small intestines, may occur, and may possibly 
be confined to that portion of the canal. It is accompanied by dull 
pain, moderate tenderness in the region; by a febrile movement gen- 
erally moderate, and often by jaundice. The tongue will be coated, the 
appetite impaired, and more or less digestive derangement will occur. 
Treatment.—The treatment will consist in the use of a light 
diet, in the administration of alkalies, and sometimes of sedatives, and, 
in severe cases, in the application of leeches, cup, blisters, etc. 
As, however, common acute inflammation of the duodenum is of 
a similar character, and is generally associated with the same disease 
in other portions of the small intestines, it need not be further dis- 
tinguished from that in them. 
The duodenum is particularly liable to ulceration in severe burns 
of the skin. Why and how this is, is not understood; but the fact 
has been so often observed, that it is believed to be more than a mere 
coincidence. Hemorrhages may be the result of such ulcerations, or of 
other diseases of the duodenum, but they are scarcely distinguish- 
able from hemorrhages from other portions of the small intestines, 
and require no peculiarities of treatment. VARIETIES. 
669 
The ulcerations from burns, even if the diagnosis could certainly 
be made, would perhaps require no other treatment than a bland diet 
and soothing measures. 
Inflammation of the duodenum, sometimes of an acute but oftener 
of a chronic character, may be the result of disease—inflammatory, 
ulcerative, cancerous, etc.—of the pylorus. It may be confined to the 
mucous membrane, or extend to deeper tissues. It could not with 
certainty be clinically distinguished from disease of the pylorus, and, 
if it could, it should not be treated differently from disease of that 
part. 
There maybe mechanical obstruction of the duodenum by cancer, 
by an enlarged pancreas, by hydatids, etc. There would be pain, 
depression, vomiting, but not fecal, probably not of bile, as the 
obstruction wrould be likely to be above the opening of the duct; and 
there would not be distention of the abdomen such as would occur 
were the obstruction much lower in the intestines. The treatment, 
as in most other cases of intestinal obstruction, especially of the small 
intestines high up, could only be palliative, with anodynes, etc. 
It may be well to remember that the duodenum may be digested 
post mortem under similar conditions to those of the digestion of the 
stomach and lower part of the oesophagus. 
DISEASES CHIEFLY OF THE SMALL INTESTINES 
IN GENERAL. 
INFLAMMATION- OF THE SMALL INTESTINES OFTEN EXTENDING TO 
THE LARGE. —ENTERITIS. —ENTERO-COLITIS. 
These terms define the diseases to be considered. There are three 
varieties of inflammation of these organs, viz., catarrhal, follicular, 
and phlegmonous. 
Catarrhal Inflammation is the most common, and is often called 
muco-enteritis. This is a diffused inflammation of the mucous mem- 
brane of these intestines, but is seldom uniform in severity in the dif- 
ferent parts, and rarely affects the whole surface of the small portion 
of the canal. It is generally most expressed in the ileum, but not 
uniformly so. Often it extends from the ileum to the colon, and then 
takes the name of ileo-colitis. 
Follicular Enteritis is where the inflammation is chiefly present 
in the intestinal follicles, and not so uniformly difEused over the 
mucous membrane. It is by no means always clinically distinguish- 
able from simple catarrhal enteritis, and its distinctive character is 670 
MUCO-ENTERITIS. 
chiefly interesting in a pathological point of view. It may practically 
be considered with the former. 
Phlegmonous Enteritis is an inflammation involving all the coats 
of the intestine—mucous, muscular, and peritoneal. It is usually 
confined to a more limited extent of intestine, is clinically distin- 
guishable, is pathologically and therapeutically, and therefore practi- 
cally, quite different from either of the other varieties, and will require 
to be treated of separately. 
MUCO-ENTERITIS.—INTESTINAL CATARRH. 
Of this disease Jaccoud makes the following 
1. Mild or Common. 
2. The Choleroid. 
3. The Typhoid. 
Acute, 
Varieties : 
Diarrhoea! form. 
Dysenteric form. 
Chronic, 
Of the Acute, the Choleroid and Typhoid might be called serious 
or grave, while the Common form is more benign. 
Pathologically, muco-enteritis is analogous to gastric catarrh. 
There is in both hyperaemia of the mucous membrane; at first it may 
be comparatively dry, but soon there is a hypersecretion, and often a 
more free transudation .of fluid. The increased secretion is chiefly 
mucus, but variable in consistence, according to the exudates mingled 
with it. There is more or less serum, not unfrequently blood, and 
sometimes fibrinous material exuded from the vessels. 
Morbid Anatomy.—Anatomically, in this disease, there are 
deep venous redness, inflammatory thickening, enlargement of fol- 
licles, and impaired cohesion. In more protracted cases the mucous 
membrane is sometimes condensed and hardened, congested, and 
studded with black pigmentary deposits. “ There is often atrophy 
of the Lieberkiihnian follicles, with granular or fatty degeneration 
of their epithelial contents, and atrophy, or sometimes enlargement, 
of the solitary and agminated glands.” 
Occasionally, in the more chronic cases, the exudate upon the sur- 
face forms a membranous pellicle in patches consisting of corpuscular 
elements held together by a coagulable exudation, and retained by 
prolongations into the follicles. In these conditions the disease is of 
a more severe character than in simple catarrh, the membrane is more 
thickened, and there is sometimes decided hemorrhage, suppuration, PHENOMENA. 
671 
or necrosis ensuing. In the milder cases of short duration the sub- 
mucous tissue is not changed, while in the more severe and protracted 
cases it is congested and infiltrated. In the chronic variety the red- 
ness is less marked, the membrane is darker, the slaty-colored follicles 
project, and in some cases there are polypoid growths upon the mem- 
brane. 
The muscular coat, often relaxed, may sometimes be hypertro- 
phied and contracted, giving rise to stricture. This, however, is 
infrequent. 
In infants especially the secretion may be abundant, giving rise to 
profuse diarrhoea; and post mortem the intestines may be full of a 
liquid transudate. 
Either the acute or the chronic form may result in ulceration, 
sometimes commencing in small suppurative points on the mucous 
surface, multiplying and spreading, possibly ending in perforation ; 
at other times the ulceration begins in the isolated follicles, constitut- 
ing cases of ulcerative follicular enteritis. These ulcers are round, 
of the size of a pea or a little larger, the borders are injected, and the 
bases are uneven. Some of these remain isolated, while others coalesce, 
forming more extensive lesions. These small ulcers may penetrate 
the intestine, though commonly they remain more superficial, and in 
favorable cases heal by cicatrization. They are more commonly 
located near the ileo-csecal valve, and may be so extensive as to destroy 
it; or by contractions of the cicatrices they may cause strictures 
which will obstruct the faecal passages. Such ulcerations not unfre- 
quently occur in tuberculosis. 
Where the disease is acute and terminates early, the post-mortem 
appearances are much less marked. The hyperaemia, which was 
doubtless intense during life, may to a great extent disappear after 
death ; and before ulceration, thickening, or much softening has had 
time to take place, no striking morbid appearances will present them- 
selves. A careful examination will, however, show changes in the 
epithelium and the follicles, faecal matters will often adhere to more 
diseased parts, and hyperaemia or ecchymosis will usually in some 
points be discovered. Commonly, however, the hyperaemia is readily 
distinguishable. 
Etiology.—Simple acute catarrhal enteritis, or colo-enteritis, 
is much more common in children than in adults, but it may occur 
at any age. It is much more frequent in the heat of summer than at 
other seasons, and is commonly called the “summer complaint.” It 
prevails to a much greater extent in cities than in the country, and 
is among the chief causes of the great infant mortality in our Ameri- 
can cities. 672 
M UCO-ENTERITIS. 
The particular causes of catarrhal enteritis are numerous. 
The inflammatory fluxions may be produced by local irritants 
applied to the membrane, by disorders of innervation affecting the 
vaso-motor system, by the suppression of other fluxions or discharges, 
by stasis from obstructed venous circulation, by atmospheric influ- 
ences, or it may occur as a symptom of some other disease. It may 
also be caused by peculiar poisons—sewer gases, the results of organic 
decompositions, etc. 
The mucous membrane of the intestines may be irritated and the 
disease produced by too much food, or food of an improper quality, 
by the passage into the intestines of food imperfectly elaborated by 
the stomach, or by irritating secretions. Young children at the 
breast, and especially at the time of weaning, are often seriously 
affected by the bad quality of the milk of the nurse, or by articles of 
food not adapted to the condition and power of the stomach, by too 
much fat, spices, unripe fruits, etc. But the best of nurses’ milk may 
disagree from a want of proper digestive capacity in the child. 
Retained faecal matter on the one hand, and the too free use of 
purgatives on the other, may also readily excite inflammation in a 
susceptible condition. Neutral salts are less irritating than most 
other cathartics. They operate to a large extent mechanically, by 
increasing the density of the intestinal fluid, and causing a serous 
exudation by exosmosis ; and yet when freely used, a more specific 
irritating effect is produced, and inflammation may follow. The 
influence of bile in producing irritation and exciting diarrhoea, has 
perhaps been exaggerated ; still, when abundant, and especially when 
vitiated, it may cause catarrhal enteritis. 
Burns of the skin, impressions of cold and moisture upon the feet 
and other parts of the body, and mental emotions, operate through 
the nervous system, changing the circulation through the vaso-motor 
filaments. Compensatory determinations of blood to the intestinal 
vessels may be caused by suppression of the discharge in hemorrhoids, 
the receding of articular gout, and the suppression of the menstrual 
flow. 
Catarrh of the intestines by stasis may be caused by obstructive 
disease in the liver, the heart, or the lungs, and by a varicose condi- 
tion of the abdominal veins. 
Intestinal catarrh from atmospherical influences may be produced 
by a sudden suppression of cutaneous circulation and transpiration, 
thus throwing more blood and additional work upon the mucous sur- 
face ; and besides, the atmosphere, especially in cities and in the heat 
of summer, is often loaded with poisonous effluvia. The heat also 
lessens respiration, diminishes the oxidation and combustion of car- SYMPTOMS AND COURSE. 
673 
bonaceous matters in the system, throws more eliminative work on 
the liver and intestines, causes portal congestion, and thus tends to 
the production of muco-enteritis. 
In tuberculosis, in pyaemia and septicaemia, in typhoid and erup- 
tive fevers, in Bright’s disease of the kidneys, in catarrh and other 
diseases of the stomach, and finally in the irritation of teething, 
symptomatic intestinal catarrh is liable to occur. 
SYMPTOMS AND COUESE OF MUCO-ENTERITIS. 
The symptoms in intestinal catarrh vary much in severity and in 
their progress, and not a little in their character in other respects. 
The milder variety, as occurring in adults or older children, 
especially when caused by local irritants to the membrane, is apt to 
come on suddenly, and generally not long after a full meal, or after 
taking irritating articles of food. If from any cause the food is not 
properly digested in the stomach, passing in a crude state into the 
intestines, these attacks are liable to occur. They commence with 
pains of moderate severity, most severe about the umbilicus, but 
moving in different directions about the abdomen. The patient, 
from the increased sensibility of the intestines, is conscious of their 
peristaltic movements. These colicky pains are usually accompanied 
by more or less flatulence, and are paroxysmal. They are not unfre- 
quently accompanied by a sense of nausea. After a few attacks of 
pain, evacuations take place—at first faecal—and in very light cases 
relief follows, and they assume no other character. The irritating 
materials are removed and the patient is soon restored to his usual 
condition. 
In more severe cases the pain and evacuations persist, the dis- 
charges become semi-fluid or liquid—often sero-mucous, they may be 
colored very yellow or more or less green with bile—but consist 
mostly of serous transudate and a secretion from the intestinal glands, 
containing also a free quantity of epithelium of young cells—often 
vibriones and fungi—and a considerable amount of chloride of sodium 
and triple phosphates, the reaction being usually alkaline. Their 
frequency varies, but usually there are from three to ten in the twenty- 
fours hours, after which the symptoms subside. In some cases, with 
all the other symptoms present the evacuations are few and slight, or 
they may not occur at all, though this is unusual. If not severe, the 
pain and other symptoms may subside in from a few hours to a few 
days, but the relief is not apt to be as complete as where free evacua- 
tions occur. 
In more intense cases the intestinal symptoms are often preceded 674 
MU CO-ENTERITIS. 
for a day or two, or more, by a general feeling of indisposition, by a 
foul tongue, painful digestion, borborygmus and distended abdomen. 
Soon stools occur of the character before mentioned, but with more 
frequency, and often their frequency is increased by even moderate 
quantities of food or drink. 
The patient feels weak and inclined to rest, but the appetite may 
not be greatly impaired, and only a moderate fever makes its appear- 
ance, and is remitting. The exacerbations occur in the evening, and 
usually are not marked until the second cr third day. In the benign 
forms the stools preserve their sero-mucous character, are liquid, and 
generally colored with bile. When the duodenum is much involved 
jaundice is likely to appear in a few days, and the stools may then 
become pale or ash-colored. 
When the upper portion of the intestines is the seat of the catarrh 
the stomach is likely to be involved, and there is less diarrhoea, the 
digestive troubles being most marked. The ileum and colon are com- 
monly the principal seat of the inflammation in the more typical 
cases. 
When the colon is the chief seat of this kind of inflammation, the 
stools are more frequent, more mucous, sometimes bloody, but less 
abundant, the disease thus merging into simple non-specific dysentery. 
In children the symptoms are essentially similar to those already 
detailed. The fever, however, is more decided; is remitting, with 
two or three exacerbations in the twenty-four hours ; the stools are 
apt to be more frequent, the disease is likely to be more protracted, 
and the results with delicate children more serious. The proportion 
of cases with them is greater in summer, as compared with other 
seasons, than with adults, and they are much more subject to the 
occurrence of the disease. The more severe types in children take the 
form of cholera infantum. This term, as used in this country, 
embraces those “summer complaints” of children generally under 
two years of age, marked by free and often frequent purging and 
vomiting, by great depression, and often by collapse and death. The 
evacuations early become watery, the disease runs a rapid course, is 
accompanied with great thirst, with feeble circulation, generally with 
coldness and blueness of the extremities, with sunken eyes and 
pinched and depressed countenance, and sometimes with cramps ; 
and it so nearly in the worst cases resembles epidemic cholera, that, 
were the latter prevailing, the diagnosis would be difficult, or in some 
cases nearly impossible. In cases continuing any considerable length 
of time, entero-colitis becomes manifest. 
A serious form of clioleroid catarrh occasionally attacks adults. 
This, too, chiefly occurs in warm weather. The onset is sudden, DIAGNOSIS. 
675 
marked by cramping pains in the abdomen, soon followed by copious 
purging and vomiting ; the discharges, at first of whatever may be 
in the stomach and intestines at the time of the attack, soon become 
watery and often colorless, as, whether the biliary secretions be sup- 
pressed or not, the serous exudation is so abundant as to give its 
character to the evacuations. In consequence of this great loss of 
the fluid portions of the blood, supposed to bo due to the paralysis of 
the intestinal vessels, there is extreme thirst, diminution of water in 
the urine, condensation of the blood, and slowness and feebleness of 
the circulation, lowering of the temperature, blueness of the face, 
cramps in the muscles, particularly of the extremities and abdomen, 
and a husky, peculiar voice. 
In this description symptoms almost identical with those of 
Asiatic cholera will be recognized. The disease has been termed 
English cholera, sporadic cholera, and cholera morbus. It occa- 
sionally accompanies malarial fevers in the region of their preva- 
lence, certainly in the new regions of the West, where formerly I have 
frequently encountered it, merging the paroxysms of chill, fever, and 
sweating into itself. 
In all these cases there is a decided fluxion to the intestinal canal, 
and, when it continues a sufficient length of time, all the essential 
phenomena of inflammation are presented. 
Diagnosis.—This disease is to be distinguished from Asiatic 
cholera not so much from the difference in the vomiting and purg- 
ing, as from there being less of the asphyxiated condition, and from 
the great difference in the result. 
Cholera morbus is seldom fatal except in children and in debili- 
tated adults or aged persons. It is usually promptly amenable to treat- 
ment, and even when left to itself, will often subside in a day or two ; 
at least the evacuations will materially diminish, and sleep and gen- 
eral relief from the more active symptoms will follow, and in time 
recovery takes place. Sero-mucous discharges, tenderness, pain, 
feverishness, and other symptoms of muco-enteritis not unfrequently 
supervene. 
When death results from the more active early symptoms, the 
transudations may continue when from paralysis of the gastrointesti- 
nal muscles the discharges cease. The blood thickens, the circulation 
fails, and death occurs from collapse. 
Typhoid Enteritis, another variety of intestinal catarrh, grave 
in character, occurring mostly in children during nursing or at the 
time of weaning, during dentition, and in the summer season, resem- 
bling in its pathology cholera infantum, but coming on more slowly, 
and not accompanied with the same severe vomiting and copious 676 
MUCO-ENTERITIS. 
purging, nor having its rapid course and tendency to collapse, is 
called by Jaccoud a typhoid form. In this form of the disease, 
frequent in this country, particularly in cities, the stomach is also 
affected, and the gastric symptoms are generally first in appearance. 
The child is sad and uneasy, with loss of appetite, though, from 
its thirst, often nursing or drinking milk freely, but vomiting it 
unchanged or simply curdled. Diarrhoea soon comes on, with acid 
liquid stools of a yellowish, yellowish green, or more deeply green 
color, while floating in the fluid are flakes of casein ; or the stools are 
sero-mucous, with occasionally streaks of blood. Chemically analyzed 
they are found to contain bile pigment, fatty acids, and some chloride 
of sodium. There is tenderness of the abdomen, meteorism often, and 
fever of a remitting type ; the temperature varies from 102° to 103.5° 
or more, and in the severer cases, under the combined influence of the 
want of properly digested food, the fever, the pain, and the exhaust- 
ing diarrhoea, the child soon becomes prostrated, its countenance 
assumes a pinched, depressed, and typhoidal expression ; it often lies, 
during the intervals between the discharges, in a somnolent state, with 
its eyes turned up and partly open ; the tongue becomes red at the 
point and edges, and often dry and darkish, the fever assuming a more 
or less distinctly typhoidal type, and if continuing long, as is not 
unfrequently the case, decided emaciation, with a wrinkled, harsh 
skin, supervenes, and the infant often has the appearance of age. The 
stools may become more solid, but fetid, varying in color, 
not unfrequently becoming pale, clayey, or slaty, though they are 
sometimes simply watery, scarcely staining the diaper. 
Vomiting rarely persists after the first two or three daj^s; the thirst 
is often great, but the child is sometimes averse to taking anything 
into its mouth. 
The disease may terminate in gradual improvement and recovery 
in from one to three weeks, though many children die within that 
time, death being preceded by coma with depressed fontanels, caused 
by cerebral anasmia and exhaustion. Occasionally convulsions occur, 
which may be terminal. Some cases pass into a more chronic state, 
with symptoms of diarrhoea, etc., often subsiding and reappearing at 
irregular periods. This form of disease is regarded by some as dis- 
tinctive typhoid fever, but many of the cases differ from that specific 
disease. 
Adolescents, and particularly young females, are sometimes attacked 
with muco-enteritis of the more severe and protracted kind. It occurs 
sometimes in cases of hysterical dysmenorrhoea with neuralgic compli- 
cations, presenting extreme tenderness of the abdomen, and other 
symptoms which to the uninitiated appear very alarming. Severe DIAGNOSIS. 
677 
inflammation extending to the peritoneum and other parts may be 
feared ; but the temperature is not very high, the tongue is not par- 
ticularly red or dry, the pulse not always rapid, and firm pressure 
upon the abdomen will he found to be borne better than slight. In 
some of these cases the disease is chronic and obstinate, the discharges 
mucous and often scanty, accompanied with tenesmus, and assuming 
many of the characteristics of chronic dysentery. 
In other cases of adults, the disease, at first comparatively mild, 
becomes chronic and obstinate, resulting in ulceration and other 
lesions of the intestines, in great depression and emaciation, and some- 
times in death. 
In our late civil war, from insufficient and improper articles of 
food, from exposure, malaria, and other anti-hygienic influences, a 
very severe form of enteric inflammation occurred, often complicated 
with a scorbutic state, and resulting in great mortality or in protracted 
impairment of health. Ulcerations of both the large and small intes- 
tines were frequent conditions—very general in the severe or pro- 
tracted cases—requiring often a long course of the most careful man- 
agement, dietetic, hygienic and medicinal ; and then sometimes 
disastrous or unsatisfactory results would follow. 
Other cases of more grave intestinal catarrh, produced by the 
various causes enumerated under the head of the etiology of the dis- 
ease, occur in adults, and are more or less severe and obstinate, depend- 
ing upon the character of the causes and other accompanying patho- 
logical conditions. Some are rapid in occurrence and course, others 
more gradual and protracted, agreeing in general features, but varying 
in particular symptoms. 
Diagnosis.—The diagnosis in the mild cases of intestinal catarrh 
is not difficult. In the severer cases the resemblance to typhoid fever 
is often marked ; but in children at the breast it is more easily made, 
as they are seldom subject to typhoid fever ; and when this does occur 
in somewhat older children, the circumstances under which it 
appears are usually different. Still, some cases even in young chil- 
dren are probably genuine typhoid fever, which have heretofore been 
regarded as simple muco-enteritis. 
In adults the diagnosis of the severer cases is not always easy, as, 
during the first week particularly of typhoid fever, the characteristic 
nervous symptoms, the epistaxis, the bronchial catarrh, the splenic 
enlargement, and the rose eruption, may be absent. The fever, how- 
ever, is more intense, more regular in its approach and increase, in 
typhoid fever ; the diarrhoeal discharges have more the appearance of 
“pea soup” or new cider, and are not so mucous in character, and 
the general aspects of the patients and the course of the cases are dif- 678 
MUCO-ENTERITIS. 
ferent. There is commonly more pain and general tenderness of the 
abdomen in enteritis than in typhoid, and when the abdomen is dis- 
tended, as it may be in either, the distention is more central in 
catarrhal inflammation, and the abdomen is “pot-shaped,” w'hile in 
typhoid the colon is more distended, and the abdomen is “tub- 
shaped.” 
In the chronic form of'intestinal catarrh secondary to the acute, 
the history of the case and the existence of the causes enumerated 
will aid the diagnosis ; and in those cases chronic from the beginning, 
the apyretic approach, the less prostration, the return of more severe 
symptoms at variable intervals, depending often on taking food, the 
tenesmus when the rectum is involved, etc., will lead to the distin- 
guishing of the disease. In these more chronic cases slowly approach- 
ing, the appetite and digestion may not, for some time, be much 
disturbed, but soon they will fail, and imperfectly digested aliment 
reaching the intestines, irritation, diarrhoea, or dysenteric discharges 
will make their appearance. 
Very generally, in muco-enteritis, discharges from the bowels are 
more frequent and more copious than normal, but this is not always 
the case. Sometimes even constipation is present, the catarrhal exu- 
dations are absent, the movements of the intestines weak and sluggish, 
and the intestinal contents are tenacious and retained. In these cases 
the suffering is greater ; the retained mucus exciting in the food and 
secretions decomposing changes, there is constant meteorism, disten- 
tion of the abdomen, interference more or less with respiration and 
circulation, and, where this variety is caused by mechanical stasis 
from' obstructive diseases of the liver, heart, or lungs, as is often the 
case, embarrassment to the respiration and circulation may become 
very great. The diagnosis in these cases, if a careful investigation is 
made, ought not to be difficult. 
Prognosis.—The course and termination of muco-enteritis, as 
the foregoing account shows, will vary much in different cases, but 
generally, especially in adults, the prognosis is favorable; and the 
same may be said of the ordinary, simple, accidental forms in 
children. 
In complicated cases the prognosis will depend upon the accompa- 
nying states—upon their severity and remediable character. In organic 
heart diseases, in consumption, in cirrhosis of the liver, in Bright’s 
disease of the kidney, etc., the prognosis is of course unfavorable. 
When severe ulceration occurs there is danger of perforation and its 
consequences ; and even if this does not produce perforation, or in 
any way prove fatal, the cases are apt to be much protracted and the 
recovery incomplete. TREATMENT. 
679 
The cases of muco-enteric inflammation produced by sewer gases 
and other miasmatic poisons vary in severity according to the peculiar 
character of the cause, and no very definite statement as to prognosis 
can be made. However, a very large proportion of such cases in 
adults terminate favorably. In children, the prognosis is not so 
favorable. 
The frequent occurrence and consequent great interest of muco- 
enteritis, has seemed to me to require as full a description, at least, 
as has been given of it, and a careful account of the principles of its 
management in the different varieties will be required. 
TREATMENT OF INTESTINAL CATARRH. 
In the mild forms of the simple variety of intestinal irritation and 
catarrh of those above infancy, depending upon excessive food or irri- 
tating ingesta, temporary fits of indigestion, or upon taking cold, 
very simple treatment in most cases will alone be required. In many 
cases the diarrhoea excited will lead to the removal of the irritating 
causes, the free exudation will unload the vessels and relieve the 
fluxion, and the disease will thus cure itself. The food, however, 
should be suspended, or only the lightest forms be taken ; mucilagi- 
nous drinks may be advised ; a cataplasm may be applied to the 
abdomen, and, if there be much irritation without free evacuations, 
a laxative, as a Seidlitz powder, a dose of citrate of magnesia, or of 
castor-oil, may be given, to which a few drops of spirits of camphor, 
or of elixir of paregoric or laudanum may be added, but not enough, 
of these latter articles to interfere with the operation of the laxative. 
After proper evacuations, should the irritation continue, an opiate 
may be given, and, in due time, repeated if required. It is impor- 
tant, however, that the early evacuations should not be prevented, as 
they are useful in the removal of the cause. 
In all cases the causal indication should be followed when it is 
possible. If the fluxion is the result of taking cold, diaphoretics are 
indicated. If no irritating materials are in the alimentary canal, a 
Dover’s powder may be given at once, and repeated, if required, 
until its full anodyne and diaphoretic effects are realized, aided in 
the latter effect by warm drinks and external warmth. 
Dysmenorrlicea, hemorrhoids, or gout, if actipg as causes, should 
be treated according to their own indications, while the condition of 
the bowels is palliated. Evacuations should not be prevented, but all 
means tending to irritate the congested and inflamed membrane should 
be avoided as far as possible, or as consistent with all the other indi- 
cations. 680 
MUCO-ENTERITIS. 
In the grayer forms of mu co-enteritis, with more pain, tenderness, 
and fever, with or without diarrhoeal evacuations, more energetic 
treatment is required. When the disease is chiefly confined to the 
mucous membrane, and especially when irritating materials are pre- 
sumed to be present, mild but efficient evacuants should at once be 
resorted to. A few grains of calomel, to which may be added five or 
six drops of laudanum, or from the twentieth to the sixteenth of a 
grain of morphine (and if the pain be violent and spasmodic, a larger 
quantity of the anodyne may be added without interfering with the 
evacuations), and soon after a decided dose of a saline cathartic— 
sulp. of magnesia, or sulp. of soda, or Rochelle salts—or a dose of 
castor-oil should be given, and the operation may be aided if necessary 
bv an enema. These cathartic medicines will produce very little irri- 
tation, less than would be produced by the retention of the matters 
that may have caused the inflammation, and a free secretion from the 
mucous surface tends to relieve the engorged vessels. The peristaltic 
contractions of the intestines induced by the cathartic are not particu- 
larly objectionable, as the muscular and peritoneal coats are not 
involved ; and the increased intestinal action temporarily produced by 
the medicine is likely to be followed by greater repose. After the 
evacuations, opiates are to be given in doses sufficient to produce 
decided anodyne effects, and to thoroughly allay the intestinal irrita- 
tion. If diarrhoea persists, it should not be abruptly checked by 
astringents, and indeed, while the inflammation possesses anything of 
an acute character, astringents should be avoided entirely, unless 
the copiousness of the discharges immediately produces severe exhaus- 
tion, and causes danger of collapse. Even then, opium is the chief 
remedy to be used to check the too profuse discharges. 
In sthenic cases leeches may be applied on the abdomen or near 
the anus, or in very plethoric and vigorous patients a venesection 
even might be justified. These measures, however, are not often 
required unless the patients are decidedly plethoric, the opiates and 
fomentations, and in some cases warm-water enemas, and sinapisms 
and other forms of counter-irritation being more effectual and less 
depressing. When plethora is present, the loss of blood may be a 
relief to the general system while diminishing the phlogistic state of 
the intestinal membrane. At a later period, if the disease persists 
and the diarrhoea is free, bismuth in doses of from fifteen to thirty 
grains, with proper doses of opium or morphine may be given, and 
when the case approaches a passive condition, with continuance of 
the diarrhoea, more decided astringents—as acetate of lead, tannin, or 
the astringent preparations of iron—may be useful. In many of the 
more subacute or chronic cases the turpentine emulsion, such as was TREATMENT. 
681 
recommended in the diarrhoea of typhoid fever, will be found particu- 
larly useful. (See formula, page 274.) 
During the progress of the disease alkalies should be given to pre- 
vent the intestinal contents from being acid and more irritating; or the 
carbonates of soda or potash freely diluted in mucilaginous drinks, 
and small doses of ipecac., combined with them or the opiates, may be 
useful as determining to the cutaneous surface. 
If the secretions be much perverted, the tongue foul, and the 
liver inactive, small doses of a mercurial—calomel, blue mass, or mer- 
curialized chalk—may be given for a short time, and if the discharges 
are not free, a mild laxative may occasionally be administered. The 
diet should be carefully guarded in all cases. Articles of food easily 
digested and leaving but little residuum should be selected, and at 
first but moderate quantities must be allowed. Milk, generally 
brought to a scald, with thoroughly cooked farinaceous substances 
intimately mingled with it, will generally be found best, though well 
made beef-tea, with a little cracker soaked in it, alternated with the 
milk, or milk and lime-water, two parts of the former with one of 
the latter, may be found to agree well. In some cases more solid 
food will be borne, and will give more substantial nourishment to the 
system ; such as rare, tender beef, a poached egg, thoroughly boiled 
rice, etc. ; but in all cases articles should be selected as completely 
digestible as possible, which will leave but a small quantity of rough 
residuum to pass over the inflamed surfaces of the bowels. In some 
cases where the stomach is irritable, and the case is complicated with 
gastritis, bits of ice swallowed procure relief ; and some recommend 
bags of ice applied over the stomach and bowels in acute cases. Some- 
times in advanced and persistent cases a blister applied over the 
abdomen procures marked relief. As in other cases, the surface of the 
part to which it is to be applied should be rubbed with warm vinegar 
until the skin is reddened, the cantharides plaster should have its 
surface moistened by a few drops of oil of turpentine immediately 
before its application ; and when the cuticle is raised, the blister 
should be dressed either by a very soft poultice, to be carefully changed, 
or by a thick padding of fine cotton-wool, allowed to remain without 
disturbance until the blister heals, unless the discharge from the 
blistered surface renders a new dressing desirable. 
In protracted cases with much exhaustion tonics may be required, 
and for this purpose tonic doses of quinine, and in anaemic cases the 
milder preparations of iron will be found best. 
In the intestinal catarrh of children the same general principles 
of treatment are applicable, and the same general plan should be pur- 
sued ; doses and details being adapted to the infantile state. The 682 
MUCO-ENTERITIS. 
food of infants is a matter of great consequence, and often of much 
difficulty, in this and other infantile diseases. The milk of a good 
nurse is, of course, the proper food of a young child, and if the 
mother does not fulfill this requirement, a suitable wet nurse, if pos- 
sible, should, as a rule, be obtained. If the disease comes on gradu- 
ally at the time of weaning, the procuring of a wet nurse may of itself 
suffice to restore health; but in most cases of muco-enteritis this is not 
sufficient. Indeed, in some instances other articles of food than hu- 
man milk agree better. There are many particular articles that are 
approved by different practitioners, and are described in special works 
on the food of infants, and on the diseases of infancy, to which the 
reader is referred. The subject is of such importance that it requires 
careful study, but the full details cannot be entered upon here. 
It is often found in general practice that the mother’s milk does 
not agree with the child, and the circumstances render the obtaining 
of a good wet nurse out of the question. In these cases good cow’s 
milk, properly managed as to the proportion of its ingredients, the 
quantity allowed, and the time and manner of giving it, will often be 
better than the milk of any procurable nurse. The cow should be 
healthy and not old, and for a young infant especially, her milk 
should be new. She should have a good clean pasture, free from 
weeds, such as garlic, etc., which would affect the milk; and in winter 
she should have a clean properly ventilated stable, and should be fed 
on fresh, clean hay, with but a small quantity of meal of any kind, 
and that mixed with pure water. The milk used for a child should 
be from the same cow. It should be allowed to stand a definite time, 
a certain proportion of the top to be taken, diluted with pure water, 
and a sufficient amount of sugar (better pure sugar of milk) should 
be added to approximate mother’s milk. The younger the child, the 
larger should be the proportion of cream and water, and consequently 
the smaller the proportion of the caseous element of the milk. This 
food should be given at regular intervals from a nursing-bottle kept 
scrupulously clean by frequent scalding in boiling water; to a well 
child not oftener than once in from three to four, or, in the night, 
once in six hours, and in quantities sufficient to fairly satisfy a healthy 
appetite—generally a free allowance—and the proportions of the in- 
gredients, the cream, milk, water, and sugar, should be carefully 
measured, not roughly guessed at, and the whole process should be 
carefully, steadily, and uniformly conducted. 
I have often known puny, fretful, and sickly children restored to 
health, vigor, and comfort by being taken from the mother’s breast 
and fed systematically upon this plan. When the child nurses, it 
should take its food at regular intervals; and to ward off attacks of TREATMENT. 
683 
intestinal catarrh all reasonable hygienic rules should bo observed. 
During the teething period the gums should be examined from time 
to time, and if swollen and inflamed they should be lanced deeply 
enough to reach the coming tooth. 
When an attack occurs the quantity of food should be more 
restricted, adapted with discretion to the particular case, under the 
direction of the physician, and not left to the chances of the crude 
notions of uninstructed mothers or ignorant nurses. If quantities of 
casein or curdled milk pass in the discharges, it is evidence that more 
of that ingredient has been taken than the stomach can digest, and 
that, instead of affording nourishment, it has become a source of irri- 
tation. Sometimes Liebig’s or other preparations of meat, very thor- 
oughly cooked farinaceous preparations mixed with diluted milk, 
pounded raw or very slightly cooked beef, beef-tea, etc., will be found 
to agree better than the milk alone; or milk may be improved by the 
addition of a little lime-water. No precise directions to be followed 
in all cases can be given, but attention to the subject of diet and regi- 
men must be unremitting in all cases of infantile intestinal catarrh. 
A single neglect or error in this respect may defeat all other efforts. 
In the medicinal treatment of this disease in children, great 
caution is required. The delicacy and impressibility of the child 
must be considered, and it must be borne in mind that opiates, 
especially if they have not been given before, can be borne in quan- 
tities proportionally much less than with most other medicines. 
Mothers and nurses must be instructed, where any discretion is left 
to them in giving medicine, respecting the great difference in strength 
between laudanum and paregoric, and doses of any active medicine 
must be calculated with accuracy, and should generally be prescribed 
much diluted, so as to render mistakes less liable to occur. 
Mild mercurials, especially when combined with an alkali, as soda, 
magnesia, or chalk, are generally well borne by children, and are fre- 
quently useful in correcting their stomach and intestinal derange- 
ments. But without going into minute details, which are more fully 
dwelt upon in works on diseases of children, I must content myself 
with repeating the statement that the same general principles must 
govern in the treatment of muco-enteritis in them as in adults. Al- 
terative laxatives in the first instance, opiates and alkalies afterward, 
oily emulsions not unfrequently, astringents and tonics at a later 
period, fomentations and mild counter-irritations to the abdomen, 
leeches in some sthenic cases, great care of food, warmth and flannel 
during convalescence, etc., will be the chief measures demanding 
attention. 
In the stage of exhaustion in intestinal catarrh, which results from 684 
CHRONIC MUCO-ENTERITIS. 
the starvation and discharges which accompany it, the coma that often 
occurs, to a superficial observer, resembles that from meningeal inflam- 
mation and effusion, and it may be supposed that some inflammatory 
disease or some hyperaemia or effusion has occurred in the head. The 
remark is sometimes made that ‘‘the disease has gone to the brain.” 
Should this opinion be followed by depleting measures of treatment— 
by leeches, cathartics, etc.—the most disastrous consequences would 
follow. The condition is that of cerebral anaemia, and the treatment 
indicated is supporting—nourishment, stimulants, and tonics. These 
should be resorted to, but with due regard to the state of the stomach 
and bowels. Quinine, ammonia, and alcohol, in free dilution, may be 
useful; but it should be borne in mind that for more permanent sup- 
porting effects foods are to be most relied upon. If the stomach 
rejects these articles they may be used by enema. 
CHRONIC MUCO-ENTERITIS. 
When muco-enteritis assumes a chronic form, either in adults or 
children, modifications of treatment will be demanded. Astringents 
and tonics, and local alteratives to the inflamed membrane may be 
required. I have already referred to the use of the turpentine emul- 
sion in subacute cases, and this preparation is often adapted to those 
of a more decidedly chronic character. The astringent preparations 
of iron are often very useful, and none more so than the preparation 
of the liquor ferri ternitratis of the pharmacopoeia. The muriated 
tincture and the persulphate, however, often answer well. Various veg- 
etable preparations, of which tannin is the most active principle, often 
are very useful. Some of them, such as geranium maculatum (spotted 
crane’s-bill), matico, hamamelis Virginica (witch-hazel), coto bark, etc., 
seem to possess properties that modify favorably the action of the tan- 
nin, which most of them contain, and may he used in proper doses.* 
Tannic and gallic acids, however, generally fulfill similar indications, 
and have the advantage of definite properties and uniform strength. 
With the view of preventing fermentation of foods, as well as of pro- 
ducing alterative local effects, carbolic and salicylic acids or creosote 
may be useful. Often these agents may be added in suitable doses to 
the turpentine emulsion. Preparations of bromine have also been 
recommended in chronic and ulcerative varieties. When aphthous con- 
ditions are present, either in the acute or the chronic form, chlorate 
* Formula for diarrhoea or subacute dysentery : ly7 FI. Ext. Coto Bark, gtts. 
x; Tr. Opii. Camp., 3j. M.—Dose, 3j. TREATMENT. 
685 
of potash, in moderate doses, will generally be found useful. As a 
tonic to the intestines in their relaxed condition in these chronic cases, 
strychnine has obtained a very favorable reputation, and is sometimes 
followed by very useful results when other measures have failed. In 
protracted cases it is worthy of a fair trial.* It is given by some in 
connection Avith nitric or sulphuric acid. In order to give it more 
prominence, I have reserved until the present an account of the use 
of nitrate of silver in cases of chronic mueo-enteritis. It may be 
given both by the mouth and by enema. When the lower part of the 
intestinal canal is the chief seat of the disease, its local use by direct 
application is more efficient than when the disease is higher up, and 
in this manner it is particularly applicable in chronic dysentery; 
but this and the disease we have been considering merge into each 
other, both being chronic inflammations of the mucous membrane, 
often accompanied with ulcerations, polypoid granulations, and other 
results of a long-continued inflammatory disease. 
Given by the mouth, the silver is best prescribed in pill with 
opium, in doses of from one fourth to one or even one and one half 
grains three or four times a day. • Its local application may be made to 
the rectum and colon, and possibly even higher in the canal, in the 
following manner ; First, the intestine should be washed out with an 
enema of warm water. Then the patient should be placed upon his 
chest and knees, the hips being as much elevated as possible ; a flexi- 
ble tube, a rectal tube, or a large flexible catheter, should be carefully 
introduced and carried as far up as possible without serious resistance, 
and into it a solution of nitrate of silver, of the strength of from ten 
to twenty grains to a pint of pure water, should be slowly injected to 
the amount of some four ounces. This maybe repeated, according as 
it is borne, once in one, two, or three days. Sometimes a much 
stronger solution, in smaller quantity, will be better (five or six grains 
to the 3j). This maybe followed after its evacuation—which usually 
soon takes place—by an injection of an aqueous solution of morphine. 
If ulceration exists low in the bowel within the reach of a specu- 
lum, a stick of nitrate of silver may be applied, as to other ill-con- 
ditioned ulcerations, with marked benefit. In children as well as in 
adults, nitrate of silver may be used either by the mouth or by enema 
in suitable cases, f 
Instances have been reported of remarkable success in very old 
* Nitric or Sulphuric Acid, gtts. lx; Strychnine, gr. jss; Water, §j. M. 
—Dose, a tea-spoonful in a drink of water. 
f Formula for child one year old. R. Argenti Nitrat., gr. j; Acid. Nitric. Dil., 
mviij ; Tinct. Opii Deod., niviij ; Mucil. Acacias, fss ; Syrup. Simp., §ss ; Aquae 
Cinnamoni, fj. M.—Tea-spoonful three times a day. (Bartholow.) 686 
CHRONIC MUCO-ENTERITIS. 
and obstinate cases with commercial nitric acid in place of the nitrate 
of silver, applied by wrapping a small piece of wet cotton around the 
end of a stick or whalebone, and dipping the swab in the acid, touch- 
ing lightly the swollen and ulcerated membrane, but not so as to pro- 
duce sloughing. The greater number of the cases thus reported were 
of chronic dysentery with ulcerations, but the treatment is equally 
applicable to such chronic ulcerations, whether of dysenteric or any 
other origin. The operation will require to be repeated a few times 
at intervals of some days, soothing treatment being applied in the 
meantime, with the greatest care of the diet, the patient often being 
confined strictly to milk. 
These severe applications must be used with caution, by means of 
a duckbill speculum, with the patient in Sim’s position, or upon the 
chest and knees, and often under the influence of an anaesthetic. 
In all cases of chronic as well as of acute muco-enteritis, the causal 
indication should be observed, and, as far as practicable, followed. 
Different forms of irritation and inflammation of the intestinal 
mucous membrane are often accompaniments of malarial diseases. 
In all such cases, quinine is an essential, and often a sovereign remedy. 
Indeed, in a region where a malarial influence is evident or suspected, 
I should not feel that I had done my full duty to the patient, in a 
case of much severity or of considerable continuance, unless I had 
administered an anti-malarial quantity of this agent. One will often 
be surprised at its efficacy in this as in many other inflammations, 
where there is no reason to suppose that paludal malaria has any- 
thing to do with the case. 
When the disease is dependent upon phthisis, Bright’s disease, 
obstructive disease of the liver or the heart, attention t© these con- 
ditions will be important; and palliation of the symptoms may be 
effected when a cure is hopeless. 
In some chronic cases of adults a strict milk diet is of service, and in 
all cases the diet should receive great care. Bismuth, or bismuth and 
pepsin, or either of these alone will often enable the patient to take food 
that otherwise could not be borne. Bismuth, in addition to its sooth- 
ing qualities, has an astringent effect, and is well adapted to some cases. 
A change of locality and climate will sometimes materially aid in 
the recovery of a patient, provided proper food and treatment can be 
secured on the way, and in the new locality. 
TREATMENT OF CHOLEROID FLUXION. 
In the choleroid form of fluxion to the digestive mucous mem- 
brane prompt treatment is often demanded. It is true that many TREATMENT OF CEOLEROID FLUXION. 
687 
eases after free evacuations will terminate favorably in a day or two 
without treatment; but it is also true that others accompanied with 
severe suffering will be protracted ; and though the vomiting will at 
length cease, and the purging abate, the irritation and inflammation 
will continue for many days, and may become chronic ; while some 
others, at an early period, will fall into collapse and die. 
In these cases, usually called cases of sporadic cholera or cholera 
morbus, the physician is seldom called until free evacuations have oc- 
curred and all irritating matters have been removed from the aliment- 
ary canal. Before this has taken place, the vomiting and purging 
should not bo interfered with. The vomiting may even be promoted 
by the drinking of free quantities of warm water ; but one will some- 
times be surprised to find that such a draught, especially if quite 
warm, arrests further emesis. 
After free evacuations, the material passed being watery and color- 
less, a full opiate should be given and but little fluid taken fora time ; 
a mustard plaster should be applied to the epigastrium and abdomen, 
and quiet and rest, as far as possible, enjoined. If the opiate is vom- 
ited up it should soon be repeated, and a repetition should take place 
every hour, more or less, until a soothing anodyne effect is obtained. 
A quarter, a third, or half a grain of sulph. of morphine, placed dry 
upon the tongue, and a small sip of water taken after it, will not be 
ejected, and its effect will soon be observed. Another excellent form 
of anodyne is two grains of opium, two of camphor, and perhaps three 
or four grains of calomel, rubbed into a very fine powder with loaf- 
sugar or sugar of milk, put into a single tea-spoonful of water, and 
taken with a sip of water after. This will also very generally be 
retained, and produce a speedy effect. In severe cases dry cups may 
be applied over the stomach and bowels, and, if the extremities are 
cold, warmth may be applied to them. Morphine used hypodermic- 
ally is sure to produce its effect, and in some cases this is the prefer- 
able method of administration. Prof. Bartholow strongly advises an 
injection, hypodermically, of a combination of morphia and atropia, 
from to £ of a grain of the morphia to yly of a grain of the atropia. 
A single injection, as well as a single free dose of morphia on the 
tongue, will often be sufficient to arrest promptly the symptoms. A 
repetition of the injection within an hour is seldom required, and not 
altogether safe, but may be necessary if the symptoms persist after 
that time. Great care is necessary, with young and susceptible per- 
sons, to avoid giving an overdose; but, when the proper quantity is 
administered, the effect is often very striking, the vomiting and 
purging speedily cease, the pulse increases in force, the cutane- 
ous circulation becomes more free, the surface grow’s warm, the 688 
CHRONIC MUCO-ENTERITIS. 
cramping pains are arrested, and but little further treatment will be 
required. 
If too long neglected the algid condition may occur, resembling 
the collapsed stage of Asiatic cholera. Then other means may be 
necessary to relieve this condition. Warm coffee, especially if large 
doses of the opiates have been given, or beef-tea well salted, with the 
addition of mustard, or a few grains of quinine repeated, may be 
required. In these algid conditions Bartholow advises hypodermic 
injections of chloral with morphia as more efficient than the morphia 
alone, or morphine with atropia. 
Other means may aid the remedies already mentioned. Sinapisms 
may be applied with advantage to the abdomen, pellets of ice swal- 
lowed will often be grateful, and carbonic acid water, in moderate 
quantity, will frequently be well borne. In many cases small doses of 
calomel have a correcting effect upon the secretions, and aid in allay- 
ing the more immediate symptoms. 
Some of the chlorodyne preparations are useful combinations in 
these cases, but the forms of anodynes already mentioned are suffi- 
cient for practical purposes. 
These means will almost never fail to control the violent symp- 
toms, and will generally prevent any serious consequences. If, how- 
ever, evidences of inflammation continue, the treatment must be con- 
ducted as already described for intestinal catarrh. If it occurs in con- 
nection with malarial fever, full antimalarial quantities of quinine 
must be given as soon as the stomach will tolerate the doses. It may, 
in' very exceptional cases, be necessary to give it hypodermically or 
by enema. 
TREATMENT OF CHOLERA INFANTUM. 
The choleroid form in children, or cholera infantum, requires 
very careful management, and unfortunately the best efforts not 
nnfrequently fail of success. The same general principles apply here 
as in the cholera morbus of adults. The gums should at once be 
examined, and if swollen and reddened, they should be divided. If 
there should be reasonable evidence of irritating matters in the 
stomach, an emetic of ipecacuanha should be given ; or, if the bowels 
have not been thoroughly evacuated, a laxative—a saline or castor-oil 
—should be given, or an enema administered. Usually, however, 
evacuations have fully occurred before the physician sees the patient, 
when means for allaying the irritation and arresting the discharges 
should be resorted to immediately. Opium, or its preparations, here, 
as in the adult, is the main reliance, and the same preparations and TREATMENT. 
689 
directions as before given are applicable liere; the great difference 
as to the dose for children, in the case of this drug, being observed. 
However, the symptoms are so violent, and the danger of speedy 
exhaustion and collapse is so great, that the remedy must be 
pushed to the verge of safety, and the discharges arrested as soon as 
possible. 
Sometimes small but repeated doses of acetate of lead and acetate 
of morphine seem more efficient in arresting the vomiting and purg- 
ing than the opiate alone or in other combinations. The mixture of 
opium, camphor, calomel, and sugar, reduced to an impalpable pow- 
der, given in appropriate does, will also be found an excellent prepa- 
ration. 
I am aware that the utility of the opium preparations is questioned 
by some of high' authority ; that their use with children is not with- 
out danger, and that in some cases they fail even to palliate the 
symptoms. But in most such cases all efforts will fail, and it is quite 
possible that sometimes other means for arresting the discharges may 
be preferable ; but cholera infantum is so similar in phenomena and 
pathology to cholera morbus in the adult, where the utility of opiates 
is so marked and unequivocal, that it can scarcely be questioned 
that, with proper precautions, bearing in mind the peculiar suscepti- 
bility of children to the narcotic action of these drugs, they may be of 
great benefit in this affection. According to my experience nothing 
is so likely to check the exhausting discharges; and where they are 
unchecked, death is the common result. Other prescriptions, such 
as bismuth and carbolic acid, five to ten grains of the former to one 
quarter or one half grain of the latter, every two hours, in a flavored 
emulsion (cinnamon water and gum arabic), to which an alkali may 
be added (bicarbonate of soda or potash), may be tried. Calomel 
alone, triturated in sugar and dropped on the tongue in small doses, 
often exerts a sedative and soothing effect, checking the vomiting 
Avhen other means fail. Oxide of zinc, and oxide and nitrate of silver, 
also Fowler’s solution in doses of one eighth to one quarter of a drop, 
have been advised; but want of experience with these articles, in these 
cases, does not allow me to express an opinion respecting their use. 
When all remedies are rejected by the stomach, as is sometimes the 
case, opiate and astringent enemas should be tried. Bits of ice 
may be wrapped in a cloth and placed in the mouth, and very small 
quantities of ice-water may be given to allay the thirst. Mild sina- 
pisms may be applied over the stomach and bowels, but some advise the 
application of cold. The feverish temperature is sometimes very high, 
occasionally amounting to a state of hyperpyrexia. Cold sponging, the 
cold pack, or the bath, becomes-an exceedingly important therapeutic 690 
M U C O-EJV TERIT1S. 
agent in such cases. The child may he carefully placed in a hath at 
a temperature of from 90° F. to 100°, and cold water may be gradually 
added until it is brought down to 80° F., or even to 65° or 60°, if 
well borne, and continued for from eight to twenty minutes, until the 
heat of the body is materially diminished. The bath should be 
repeated if the fever again rises, and several in the course of twenty- 
four hours may be demanded. Where the fever has been very high, 
it is to be presumed it will become so again ; and it should be antici- 
pated and checked by the bath when it begins markedly to rise. 
The bath may be aided, where the stomach will allow it, by anti- 
pyretic medicines—quinine, or salicylate of soda. 
After the profuse discharges are arrested and the more violent 
febrile symptoms, where they occur, are controlled, the subsequent 
management of the case is to be conducted on the same general plan 
as other cases of muco-enteritis with similar symptoms. If the pros- 
tration be great, stimulants and tonics may be required, but great 
care must be taken not to introduce into the stomach irritating sub- 
stances. Cholera infantum has been regarded by some as a specific 
pyrexial affection, produced by some peculiar poison generated in 
the heat of summer in populous places, mostly in large cities. Its 
analogy to malarial fever has suggested the use of quinine, and not 
unfrcquently a few decided doses of this remedy not only abate the 
fever but change favorably the character of the disease. When a 
malarious influence is present, it is of course an important remedy. 
A variety of special remedies and prescriptions have been advised, but 
there are no specifics for the disease, and it must be treated according 
to the symptoms presented. 
Great care must be taken of the diet throughout. When the 
danger of vomiting is past, more free quantities of water may be 
allowed, for if restricted, larger quantities of milk, either from the 
breast or bottle, are apt to be taken to quench the thirst, than can 
be digested, and thus the irritation is increased. Scalded milk 
diluted with lime-water will often be as well or better borne than 
any other form of nourishment. Removal to a healthy situation in 
the country is generally advised, and is often essential to restora- 
tion. 
In all such cases of enteritis, as the patient convalesces, care must 
be continued respecting the diet, and the patient must be guarded 
against taking cold. The feet should be well protected ; and under- 
garments of flannel should be worn, and often a flannel bandage 
should be applied about the abdomen. ETIOLOGY—SYMPTOMS. 
691 
PHLEGMONOUS INFLAMMATION OF THE INTES- 
TINES.—ENTERITIS. 
By these terms is understood an inflammation of the small intes- 
tines, involving not only their mucous, but their muscular and peri- 
toneal coats. This form of intestinal inflammation is much more 
rare, but much more severe and dangerous, than most of the varieties 
of intestinal catarrh. In this, Avhile all the coats of the intestines 
are involved, the inflammation does not extend to so largo a portion 
of the viscus as is usual in muco-enteritis. 
Etiology.—Attacks of this kind are more likely to occur in 
young persons, but may happen at any period of life. The exciting 
causes are those of inflammation in general—taking cold, the ingestion 
of irritating substances, accumulation and retention of fsecal matter, 
blows or other physical injuries, etc. I have seen several cases which 
occurred in young persons after an evening party in heated rooms 
where refreshments were freely taken, including nuts, and where after- 
ward there was exposure to cold on returning home. 
Symptoms.—The symptoms vary in severity and somewhat in 
character, depending upon the locality and extent of the part involved. 
In cases not depending upon mechanical injury or hernial strangula- 
tion, the patient is usually attacked with pain, at first resembling colic. 
Soon, however, and sometimes simultaneously with, or even preceding 
the pain, a chill is felt, followed by fever, often then with increase of 
the pain, which becomes more continuous, and is accompanied with 
tenderness and sometimes with tormina. Nausea and vomiting are 
not unfrequent at this stage, but are by no means constant symptoms. 
The pulse becomes rapid, and though often full at first, it at length 
becomes smaller, sometimes hard, and sometimes oppressed and 
feeble ; the countenance is contracted and indicates much suffering, 
the abdomen becomes distended and tympanitic; sometimes move- 
ments of the bowels take place, but more frequently there is consti- 
pation. If a cathartic is taken it usually fails to operate, at least 
satisfactorily, and the pain and suffering are increased by it. The 
tympanitis continues to increase, and in the severer cases the progress 
of the disease is rapid, the pulse becomes weaker and more frequent, 
hiccough becomes distressing, free vomiting of dark and sometimes 
stercoraceous matters comes on; the pain at length may cease or 
greatly abate, a clammy sweat breaks out, and collapse and death 
follow ; the fatal cases sometimes terminate within thirty-six or forty- 
eight hours, and are seldom delayed beyond a week. 
Sometimes the disease is more insidious in its approach. When 692 
PHLEGMONOUS ENTERITIS. 
the peritoneal coat is largely involved, the tenderness is marked, the 
pain is great, and the decubitus is dorsal with the knees drawn up. 
When the peritoneal coat is less involved, the inflammation being 
mostly in the .mucous and muscular tunics, the pain may he slight at 
first, and all the symptoms less marked and severe; but the disease 
is apt to go on, the muscular coat becomes paralyzed, constipation 
more or less complete takes place, the abdomen is distended, vomiting 
often supervenes, and the case may progress to a fatal termination, as 
in the forms which commence with more suffering. 
The intellect usually remains intact, but sometimes toward the 
last the mind wanders, or a deep somnolent or lethargic condition 
occurs. 
Though phlegmonous enteritis is so severe and dangerous, and so 
often fatal, yet the severity sometimes is less ; or under proper treat- 
ment the disease soon subsides, and recovery after a greater or less 
length of time takes place. 
Morbid Anatomy.—The morbid anatomy and pathology of this 
affection are worthy of particular notice. On 'post-mortem examina- 
tion a portion of intestine, commonly of the ileum or jejunum, is found 
injected, infiltrated, and thickened, and generally effusion has occurred 
from the peritoneal coat, and false membrane has formed upon its 
surface. In short, a portion of intestine, varying in length from several 
inches to several feet, presents all the evidences of a severe inflammatory 
process in the mucous, muscular, and serous coats. The serous surface 
often presents a dusky red, sometimes a slaty or purplish black color, 
due partly to its own engorgement, and partly to the condition of the 
parts beneath—its own congestion being often in streaks or patches. 
There are often blotches of subserous extravasations, and on the outer 
surface larger or smaller quantities of adherent lymph, and sometimes 
there is free sero-purulent extravasation. Often the folds between 
portions of intestine are filled with lymph, and when the case has con- 
tinued a sufficient length of time this lymph may be organized, and 
adhesions and fibrous bands may be formed. Death may be caused at 
a much later period by intestinal obstruction from this cause. The 
mucous and submucous tissues are generally thickened and softened, 
are more or less congested, presenting spots and streaks of extrava- 
sation, sometimes almost black from congestion and escape of blood 
into the tissue, sometimes of a paler color from infiltration of lymph 
or pus, and sometimes black from gangrene. 
Sometimes the inflammation extends from the inflamed intestine 
over a considerable portion of the peritoneal surface, causing more 
extensive effusions ; and occasionally rupture of the inflamed intestine 
has taken place. From the involvement of the muscular coat its DIAGNOSIS. 
693 
fibres are paralyzed, and the affected portion is generally distended 
with the faecal contents, and sometimes with extravasated blood. The 
line between the healthy and diseased portion of the intestine is gen- 
erally well marked, and often quite abrupt. While the inflamed part 
is paralyzed and distended, the part immediately below is contracted 
and nearly empty. The paralysis of the diseased part, and the con- 
traction of the irritated but uninflamed portion below, prevents the 
passage of fecal matter, and accounts for the constipation so common. 
Above the inflamed part there may also be more or less distention 
from the accumulation of liquid and fecal matter produced by the 
obstruction ; and this accumulation may be so great as to cause regur- 
gitation into the stomach, and induce the offensive vomiting which 
sometimes takes place before death. 
Diagnosis.—The diagnosis of Phlegmonous Enteritis should be 
carefully made, as it resembles some other diseases whose treatment 
should be different. It should particularly be distinguished from 
colic, from strangulated hernia, from the tenesmus of dysentery and 
the tormina of diarrhoea, from certain diseases of the brain, from poi- 
sons, from hysteria, and, what is less important, though often quite 
as difficult, from peritonitis, from renal calculi, and from mechanical 
obstruction, or ileus. 
It is to be distinguished from colic by the absence of fever and 
tenderness in the latter ; by the spasmodic character of the pain ; by 
the movements of the patient during the paroxysms of colic ; and by 
the relief which is obtained by fecal or gaseous discharges. It is dis- 
tinguished from strangulated hernia by the usually sudden occurrence 
of the latter without the preceding chill or fever ; by the strictly local, 
circumscribed focus of the pain and seat of the tenderness; by the 
more certain and repeated vomiting; and by the presence of a tumor. 
From the tenesmus of dysentery and the pain of diarrhoea, by the 
discharges in these affections, and by their general course ; from dis- 
eases of the brain, by the presence of other cerebral symptoms ; from 
irritant or corrosive poisons, by the history of the case, the taking of 
an irritant material, the burning pain in the stomach, and the more 
rapid progress ; from hysteria, by the absence of fever, by the greater 
tenderness on slight and less on firm pressure, by the free discharge of 
pale urine, and other hysterical phenomena; and it is to be distin- 
guished from peritonitis by the more diffused character of the pain and 
tenderness in the latter. Enteritis is distinguished from the passing 
of renal calculi by the location and more remitting character of the 
pain, the absence or slight character of the fever in renal colic, and, 
when the calculi are passing through the ureters, by the irritation and 
pain extending to the genital organs and down the thigh, and by the 694 
PHLEGMONOUS ENTERITIS. 
frequent micturition whicli occurs; and, finally, this disease is to be 
distinguished from mechanical obstruction by the history of the case, 
the presence often of an abdominal tumor, the more persistent and 
more stercoraceous vomiting, and by the less remediable character of 
the symptoms Avhen such obstruction exists. 
Prognosis.—The prognosis of Phlegmonous Enteritis is always 
grave, though it will depend upon the extent and severity of the 
inflammation, the state and power of endurance of the patient, and 
the treatment he may receive. 
Treatment.—In many cases of this disease, as the symptoms will 
generally be supposed by the patient and friends to be caused by some 
crude or irritating matter in the alimentary canal, when a physician is 
called, a cathartic, and sometimes a harsh one, has been taken. The 
distress has increased, and it is quite likely the cathartic has not oper- 
ated, or but slightly and imperfectly. The inflamed muscular fibres 
are already so paralyzed, and other portions of the intestinal muscles 
are thrown into such irregular action, that the proper, continuous, 
peristaltic motion is not produced, but increased irritation and afflux 
of blood, and increase of inflammation have been the result of the 
cathartic. Should additional cathartics be given, additional irritation 
and serious aggravation of the disease would, in all probability, be 
produced. 
The first thing to consider is the question of giving or withholding 
cathartics, and the impulse to rush to the administration of active 
purgatives must be resisted. If there is evidence that the bowels are 
loaded, and that the presence of their contents is the cause of the 
inflammation, a warm-water enema may, with great propriety, be 
given, and perhaps repeated ; and if the case is seen very early, or if 
the inflammation is confidently believed not to be so severe or so far 
advanced as to have paralyzed the intestine, and if there is good reason 
to think that an ordinary moderate dose of a saline or of castor-oil will 
procure evacuations and the removal of irritating matters, such dose 
may justifiably be given, and its effect aided by enemas. Beyond this 
the use of purgatives must not be carried ; and when the disease is at 
all advanced, and of such severity as to produce the paralyzed con- 
dition of the intestine indicated, the administration of cathartics, 
however mild, can hardly fail to do harm. The point as to the pro- 
priety of giving laxatives at all, however early in the disease, and 
whatever the circumstances, is one of great delicacy and difficulty, 
which should be left to the discretion of the physician after a careful 
diagnosis has been made and an intelligent and deliberate judgment 
formed, considering all the facts and probabilities of the case. 
Generally as patients are seen in this disease cathartics are entirely TREATMENT. 
695 
inadmissible. There can be no serious objection to the administration 
of a simple enema when faecal accumulations exist in the lower 
bowels at the beginning of the disease. Impacted faeces are not likely 
to bo in the small intestines, however, where the inflammation usually 
is seated, previous to its occurrence, as their contents are fluid or 
semi-fluid, and such impaction is not likely to be a cause of the attack. 
At all events, experience has abundantly proved that the use of active 
cathartics in cases of phlegmonous enteritis has produced great mis- 
chief, and the imperative rule of practice forbids them. 
No practice could be worse than the administration of gamboge, 
croton-oil, and similar articles in cases of this kind. The constipation 
is not usually to be overcome in this manner, the paralyzed and de- 
ranged intestine cannot thus be restored to its proper activity, and all 
excitement of the action of the intestine above can only drive its con- 
tents with more force into the paralyzed, distended, and inflamed por- 
tion, increasing the suffering and the disease. The inflamed part 
itself is irritated by the more direct action of the medicine, the blood 
is determined to it still more, and all its morbid conditions are likely 
to be increased. 
The indication in these cases is to allay irritation and overcome 
the inflammation. A leading object in the treatment of an acutely 
inflamed part is to keep it at rest. No remedy is so strongly and 
clearly indicated in phlegmonous enteritis as opium or its prepara- 
tions. A full dose of morphine or some other opiate should at once 
be given, and repeated as may be necessary to bring the system and 
keep it under its full anodyne effect. The effect upon the pupils, the 
respiration, the circulation and aeration of the blood, and all the con- 
ditions of the patient should be carefully watched, a too depressing 
narcotism on the one hand, and an action too feeble to induce the 
proper quieting effect on the other, should alike be avoided. The 
first dose of morphine may be from one fourth to one half grain, accord- 
ing to the susceptibility of the patient, and it should be repeated, 
perhaps in smaller doses, but always according to its effects, once in 
from three to four or five hours. Small doses of a mercurial may be 
added to prevent the opiate from diminishing too much the secre- 
tions ; and if there bo high excitement of the pulse with much cardiac 
force, veratrum viride or aconite maybe added to control that action. 
If, from the shock or other cause, the action of the heart becomes too 
feeble, the latter articles must be discontinued, but the effect of the 
opiate must be steadily maintained. 
The propriety of adding to the opiate free doses—from six to ten 
or fifteen grs.—of quinine, until the feverish heat is markedly dimin- 
ished, has not yet the sanction of long experience and general 696 
PHLEGMONOUS ENTERITIS. 
authority; but I cannot question, in many cases at least, not only its 
propriety, but its exceeding efficacy. The influence of this article as 
an antipyretic and anti-inflammatory remedy has already been dis- 
cussed, and these phlegmonous intestinal inflammations are not excep- 
tional in yielding to this remedy. Salicylate of soda may be found 
as useful, but as yet it has not been sufficiently used in cases of this 
kind to determine its value. 
The question of aiding the antipyretic and anti-inflammatory effect 
of these agents by the cold bath, or the local application of cold, is 
one of much interest, but as yet not fully decided. Fever might in 
this way be abated, but whether the blood might not be driven inter- 
nally, and the hyperaemia and inflammation of the intestines increased 
by the cold, especially by the general cold bath, is a point of the 
greatest interest, and requires to be more fully settled by general 
experience. Those who have used the bath most in typhoid fever say 
that hemorrhage of the bowels in that disease is, for the time, a 
contra-indication to the bath. Whether the danger consists in adding 
the shock of the bath to the depression from the loss of blood, or 
whether the danger is from driving the blood internally and increas- 
ing the flow, or from the physical disturbance and danger of rupture, 
has not been determined, or at least has not been generally and clearly 
expressed. The question of the general use of cold in enteritis must 
be regarded as sub judice. Testimony, however, is accumulating in 
its favor. 
But there are other measures worthy of consideration and use. 
Even so conservative a writer as Bristowe says : “The abstraction 
of blood is often of the greatest value. This is most efficacious early 
in the disease, and may be effected either by the opening of a vein in 
the arm, or by the application of ten, twenty, or thirty leeches to 
the surface of the belly.” I do not doubt the frequent efficacy of the 
abstraction of blood. It is by no means inconsistent wdtli the opium, 
or opium and quinine treatment, and in plethoric and vigorous 
patients, with a firm action of the heart, it is not only frequently 
advisable, but sometimes very important. It is, however, less to be 
relied upon than opium, or opium and quinine, and must not inter- 
fere with their use. Hot fomentations, and other light and warm 
applications generally soothe ; and not unfrequently mustard plasters 
or other mild counter-irritants give some relief. Enemas of warm 
wrater or some bland fluid, cautiously given, sometimes produce a 
soothing effect, but they must not be so given as to irritate the patient, 
or tease and agitate the inflamed intestines. When vomiting or hic- 
cough is troublesome and distressing, a mustard plaster, or, if they do 
not produce pain, dry cups over the epigastrium, may be applied ; TREATMENT. 
697 
and bits of ice, hydrocyanic acid, alkalies, or lime-water, and some- 
times moderate doses of creosote in some bland fluid may be tried. 
The last-named article I have sometimes seen produce a very prompt 
effect, arresting the hiccough and vomiting without increasing irrita- 
tion. When the vomiting is the result of the accumulation of fluids 
and of overdistention of the boAvels and regurgitation into the stomach 
from the obstructed passage downward, measures for quieting it are 
generally ineffectual, and not unfortunately so, as the discharge of 
these matters gives relief. 
The great prostration, which is so apt to be early manifested, is 
an evidence of shock rather than failure of the nutritive functions of 
the system, but still light and nourishing articles of food are indicated. 
They can usually be borne by the stomach only in small quantities, 
and may often be given best by enema. When the shock and depres- 
sion are very great, and not relieved by the opium and quinine, alco- 
holics may be given, generally best with beef-tea and a little lauda- 
num, by enema. When not well borne by the stomach, the opiates 
and quinine may be given by enema; or morphine certainly, and per- 
haps quinine, will sometimes be better given hypodermically. Mor- 
phine hypodermically, in doses of one fourth or one third of a grain 
may be given, but the quantity and repetition will depend upon the 
severity of the pain and the susceptibility or power of endurance of 
the patient; and the effect must be carefully watched, and the doses 
administered accordingly. Too profound an effect must not be pro- 
duced, and it is thought that by combining atropine with the mor- 
phine, the physiological or poisonous effects of the morphine may be 
antagonized, while the medicinal effect is increased, or at least not 
diminished. 
This combination for therapeutical purposes has not as yet ob- 
tained the general sanction of the profession from extended experi- 
ence, but is strongly recommended by a few writers whose opinions 
are worthy of respect. A quarter of a grain of morphine, and T|¥ of 
a grain of atropine, would be an ordinary dose to begin with in an 
adult, the time and size of subsequent doses to be governed by the 
effect. A steady, decided anodyne influence should be maintained. 
As the inflammation subsides, the action of the paralyzed intes- 
tine is restored, and as the spasm of the contracted part below is 
overcome, the bowels will usually move spontaneously, and often 
freely and repeatedly; but even should their movement be much 
delayed, nothing more should be done to promote it than simple 
injections of warm water, and, as a rule, these should be used only 
when a sense of uneasiness in the lower bowels indicates an accumu- 
lation of fa)cal matter there, and a tendency to, and desire for its evacu- 698 
TYPHLITIS AND PERITYPHLITIS. 
ation. I have not unfrequently known the inflammation to be revived 
after it had largely subsided, and the most disastrous consequences to 
follow the administration even of a dose of castor-oil, given because 
movements of the bowels were delayed. Too much caution on this 
point cannot be observed. When the patient is gradually improving, 
by all means “let well enough alone.” For the fact that no move- 
ment of the bowels has occurred for several days, or one or two weeks 
or more, when but little food containing residua has been taken, is of 
itself of very little consequence. It is, however, of the utmost con- 
sequence not to irritate a part just recovering from a severe inflam- 
mation, nor to fret and render a part more painful which is still 
inflamed, nor to subject to violence an intestine softened and en- 
feebled by the inflammatory process, and ready to undergo laceration. 
Where the inflammation lingers, a blister will often be of service. 
As convalescence advances, great care respecting food and ex- 
posure should be continued until the recovery of the diseased intes- 
tine is complete. 
INFLAMMATION OF THE CLECUM AND NEIGHBORING 
PARTS.—TYPHLITIS AND PERITYPHLITIS. 
Typhlitis is an inflammation of the walls of the cascum. When 
inflammation of the mucous surface occurs as a part of entero-colitis, 
it presents no peculiarities which entitle it to a separate consid- 
eration. Occurring by itself, it has special features that require 
notice. 
The disease may result from the ordinary causes of enteritis, the 
inflammation having that limited locality; but this is unusual. It 
commonly results from the presence of foreign bodies lodged there, or 
from the retention of faecal matter. It is often preceded by consti- 
pation, though occasionally by alternations of constipation and irri- 
tative or catarrhal diarrhoea. It is marked by pain in the right iliac 
fossa, generally continuous but exacerbating, and increased by press- 
ure ; by a sense of soreness, often produced by a jarring movement, 
as by stepping firmly upon the heel ; by an elongated cylindrical 
tumor, more or less distinctly defined, quite abruptly below but less 
so above; and by general sensations of uneasiness and depression. 
The tumefied condition, when considerable, is caused mostly by fsecal 
accumulations ; but some degree of enlargement is caused by thicken- 
ing of the walls of the intestine, and in these cases the muscular, as 
well as the mucous, coat is involved and more or less infiltrated. 
When the tumefaction is stercoraceous, it is quite dull on percussion ; PHENOMENA. 
699 
but when it is caused by swelling of the intestinal walls, it presents 
only a moderate decrease in the sonorousness. 
As the muscular coat is involved in the inflammation, it is usually 
more or less paralyzed, causing constipation at that point; but if a 
catarrhal irritation exists in other portions of the intestines, the 
faecal matter will be more or less liquid, may be forced through the 
short paralyzed portion, and diarrhoea may be present. The faecal 
accumulations are sometimes large, reaching to the ileo-caecal valve 
and causing occlusion of the intestine. When the inflammation is 
caused by foreign bodies, it is commonly more acute, and is accom- 
panied by some degree of fever ; but in the simple stercoraceous forms 
but little or no fever is perceptible. 
This form of caecal disease is not usually very severe, and com- 
monly terminates in resolution. It may, however, result in ulcera- 
tion and perforation, especially when produced by some foreign sub- 
stance ; and without such ulceration the inflammation may extend 
to surrounding parts, giving rise to perityphlitis, to peritoneal 
inflammation, or to infiltration and abscess of the cellular tissue in 
the iliac fossa in which the caecum is imbedded. Should ulcera- 
tion and perforation occur on the posterior portion of the intestine, 
where there is no peritoneum, an abscess might form and become 
encysted, and at length might be discharged into the intestine by 
reperforating its coats, or it might travel in other directions, some- 
times penetrating the bladder or rectum. 
The Appendix Vermiformis is also subject to inflammation, ulcera- 
tion, and perforation, causing peritonitis or encysted abscesses, Avliich 
may take a similar course, and in a majority of the severe and fatal 
cases of inflammation in this region this is the seat of the disease. 
Small foreign substances, such as clierry-pits, bits of bone, concretions 
of mucus, and faecal matters mixed with calcareous substances, lodg- 
ing in the vermiform process cause irritation and often a small ulcer, 
producing but moderate symptoms until penetration takes place, 
when matters from the intestines—gases, faecal substances, etc.—may 
pass into the peritoneal cavity and induce a speedy general peri- 
tonitis; or adhesive inflammation may take place, and an abscess 
form, which may open into the peritoneal cavity, or travel in various 
directions like those connected with caecal inflammations and per- 
forations. 
But per {typhlitis may occur without preceding inflammation and 
ulceration of the caecum or vermiform appendix, and its different 
forms will soon be considered. 
Diagnosis.—It is by no means easy to distinguish between typh- 
litis and perityphlitis, or between these and occlusion of the bowels TYPHLITIS AND PERITYPHLITIS. 
700 
from other causes. Comparisons, however, will be made after peri- 
typhlitis is described. In the milder forms of typhlitis there will be 
local fullness, soreness, and pain, without impaction; while in the 
severer forms there will be obstruction, with symptoms much like 
those which occur in obstruction in other pathological conditions. A 
cancer of the caecum, in its earlier stages, may present similar appear- 
ances, but its history and progress will be different; a harder, more 
distinct, and more nodulated tumor will be present, and the cancerous 
cachexia will at length make its appearance. 
Treatment.—When a moderate degree of irritation and tender- 
ness is felt in the region of the caecum, in connection with constipation, 
and on examination a tumefaction is found in the part, when the nor- 
mal sonorousness is absent on percussion, and when pressure with a 
single finger with some firmness for a little time leaves an indentation, 
the tumor is faecal and the difficulty is due to constipation. The judi- 
cious administration of cathartics, at first saline to induce a watery 
state of the intestinal contents, and afterward more tonic laxatives—in 
short, treating the constipation, directing a proper diet, etc., as will here- 
after be described for constipation—will usually be successful in over- 
coming the disease. Should tenderness, irritation, and pain continue, 
and some thickness of the cascal walls be discovered, in addition to 
the means necessary to keep the bowels open, counter irritation should 
be applied by some irritating liniment, or, better still, by a cantharides 
blister. The case should continue to receive attention, since the diffi- 
culty when it once occurs is apt to linger or frequently return. The 
muscular coat of the intestine becomes weakened, accumulations recur, 
and the case requires care as to food, exertion, and exposure, and often 
a continuance of treatment. 
When the disease depends upon other causes than constipation, 
they must be sought out, and if possible removed. If the symptoms 
are more acute, leeches should be applied, followed by fomentations, 
perfect rest should be enjoined, a bland diet prescribed, a general 
course as for local inflammations elsewhere should be pursued, not 
omitting blisters, which often have a very decided influence in con- 
trolling the inflammation. 
If ulceration and rupture are feared, great caution is required. 
Spanaemics should be avoided, since a plastic exudation, which will 
limit the threatened abscess, furnishes the only hope of preventing the 
diffusion of matter, with its most serious consequences. The bowels 
must be kept soluble, but active purgatives are inadmissible ; indeed, 
unless there is evidence of accumulation of faecal matter operating as a 
cause, the bowels should be kept quiet. Chlorate of potash in mod- 
erate doses might be given. Coarse food that leaves much residuum TREATMENT. 
701 
should be avoided ; rest in bed should be insisted upon ; and any gen- 
eral morbid condition of the system should be treated according to its 
character and indications. Various tonics, and especially the tincture 
of iron, may be useful to prevent spanaemia and to favor a plastic con- 
dition of the blood and tissues. 
The same course of management will be required when the vermi- 
form appendix is the seat of an inflammation, and an ulcerative proc- 
ess is apprehended. The symptoms, until a rupture takes place, may 
be indefinite. Some uneasiness and obscure tenderness, or occasional 
pains without tumefaction, may be all that is noticeable. The great- 
est care is now required, as the danger is greater than when the dis- 
ease is in the colon. In the latter case the rupture, if it occurs, is 
likely to be in the posterior part of the intestine, behind the perito- 
neum, through that part of the caecum not covered by that membrane. 
In case of perforation of the appendix, the discharge of gases and 
other intestinal contents will be within the peritoneum, and unless 
the ulcerative process is preceded by adhesive inflammation, the dis- 
charge will be loose in the cavity of the abdomen, and a violent and 
fatal peritonitis will, in all probability, be the result, A watchful 
care, positive rest, and the most judicious management will be re- 
quired when there is reason to suspect a foreign substance inducing 
an ulcerative process in the vermiform appendix. 
PERITYPHLITIS. 
Perityphlitis is an inflammation about the caecum, and whether 
originating outside of the caecum or its appendix, or occurring in con- 
sequence of disease of these parts, when established it presents other 
symptoms than those present when the disease is confined to the caecum 
or the appendix. The pain is now severer, the movement of the right 
thigh is painful and difficult, there is more fever and general disturb- 
ance, and the tumefaction is deeper and different in form. 
The term perityphlitis includes all the inflammations about the 
caecum ; but an inflammation with infiltration and a tendency to sup- 
puration occurs in the iliac fossa, behind the peritoneum, in the loose 
cellular tissue in that region, which is called by Jaccoud, “Phlegmon 
iliaque ; ” and others have proposed that it should be called paratyph- 
litis. It is a retro-caecal phlegmonous inflammation, and requires 
more particular notice. 
Etiology.—Its common causes are ulceration and perforation of 
the ileo-caecal appendix, especially when it gives rise to the formation 
of a stercoraceous abscess in this location. It may arise from faecal 
accumulations in the caecum and at the sigmoid flexure of the colon; 702 
PERITYPHLITIS. 
in the latter case it affects the left iliac fossa. Intestinal concretions, 
formations of the phosphates of lime and magnesia, or portions of 
various substances received as ingesta, lesions of the upper part of the 
rectum, and lastly the puerperal state, may give rise to these iliac 
phlegmons. These iliac phlegmons may also be caused by inflamma- 
tion of inguinal lymphatic glands (adenitis), by inflammation of the 
ovaries, or peri-uterine affections not puerperal; by renal, hepatic, and 
pleural suppurations descending to this part; and subaponeurotic 
abscesses may occur from psoas inflammations and caries of the verte- 
brae ; and they may also be caused by wounds, blows, excessive exer- 
tion, and by the action of cold. Subperitoneal phlegmons arising 
from intestinal lesions are commonly on the right side, those from 
uterine and peri-uterine disease are rather more frequent on the left. 
Anatomically these phlegmons present differences depending upon 
their causes, particular localities, and modes of termination. When 
produced by inflammation of the intestine from a foreign body or 
other cause, the abscesses are likely to be extended ; when due to 
adenitis they are more circumscribed, and are near the vessels, the 
pus in these cases tending upward in the abdomen, and not so much 
into the iliac fossa. In the puerperal state they are apt to extend 
rapidly and invade different parts. 
Peritonitis, circumscribed or general, frequently complicates these 
conditions, particularly in the puerperal cases. A purulent sac may 
extend, as stated by Grisolle, from the crural arch to the false ribs. 
If an abscess deep behind the peritoneum continues long, the 
psoas and neighboring muscles are apt to become involved and disor- 
ganized, the fibres becoming soft and black. The nerves are not 
generally affected seriously, but possibly they may be dissected out by 
the pus and some filaments may become detached. A case has been 
reported where the pus found its way into the vena cava. When per- 
foration of an intestine occurs from an ulcer or inflammation within 
it, feecal matter is apt to escape; but if reperforation occurs from the 
outside—if an abscess without opens into an intestine—the escape of 
faecal matter is said not to take place. 
Symptoms and Course.—When ulceration and rupture of the 
vermiform appendix occurs, violent peritonitis, marked by severe pain, 
probably a chill, a fever, a rapid pulse, abdominal tenderness, etc., is 
apt to come on suddenly. The pain and inflammation may be more 
limited, adhesions may take place, and a circumscribed abscess may 
form. It may afterward rupture into the peritoneum and excite a 
general peritonitis, or may take some other course—may open into the 
intestine, or come to the surface, or follow other directions. These 
cases are always dangerous and often speedily fatal. When the abscess SYMPTOMS AND COURSE. 
703 
opens externally, suppuration will usually continue for a length of 
time, and aside from other accidents may exhaust the patient. 
When ulceration and rupture of the caecum posterior to the peri- 
toneum occurs, pain more or less severe will be experienced, tender- 
ness in the part will increase, feverish symptoms will come on, a 
tumor will soon be felt deeper in the iliac fossa, and not unfrequently 
inflammation will extend to the peritoneum—almost necessarily if the 
rupture is through that part of the intestine covered by that mem- 
brane—the same as in perforation of the appendix, and similar severe 
symptoms will result. 
When the inflammation extends from the unruptured intestine, or 
originates in the other causes which have been mentioned, the abscess 
is not so abrupt, and the symptoms are less violent. There will, 
however, be pain and tenderness, there is sometimes a chill, and gen- 
erally more or less fever ; but the approach may be very insidious, 
and the first symptom attracting attention may be the presence of a 
tumor. Constipation is apt to precede and accompany most of the 
cases. 
A chill is more likely to mark the commencement of puerperal 
than other cases. The temperature, not notably increased in some, is 
from 100.5° to 102.5° F. in most cases, and rarely as high as 104.5° F. 
and above. The pulse will range from 80 or 90 to 120 in adults; the 
pain, though variable in intensity, is almost always present, and pres- 
sure increases it, and gives it a more cutting character. Sometimes 
it radiates from the point of the inflammation, and may be felt more 
severely at the epigastrium or elsewhere than at the seat of the dis- 
ease. Nausea and vomiting are often present, and, as already stated, 
constipation is a common symptom. As the disease advances and a 
rupture of the formed abscess takes place into the intestine, pus may 
be found in the stools, the tumor decreasing; and if the quantity of 
the purulent discharge diminishes gradually hopeful indications are 
presented. 
The most characteristic symptoms of an iliac p.._egmon are the 
tumefaction with pain and tenderness. The swelling more gradually 
appears, the deeper the location of the abscess. When beneath the 
aponeurosis the swelling is less, not as distinctly defined, and compar- 
atively immovable. When the phlegmon is due to adenitis, enlarged 
glands will generally be found in the folds of the groin. 
When the psoas and iliac muscles are involved, movements of 
the thigh, particularly full extension, will be decidedly painful, 
and more or less pain may be produced by such motion from the dis- 
turbance of the inflamed part when the muscles are not themselves 
involved. Sometimes by pressure of the tumor upon the lymphatics 704 
PERITYPHLITIS. 
and veins a local oedema is produced, and from pressure upon, 
or involvement of, the nerves severe lancinating pains may radiate 
toward the genital organs, and the groin of the affected side. 
When the inflammation does not arise from rupture of the intes- 
tine or its appendix, resolution may often be induced by early and 
efficient treatment; but when it arises from that cause, or is neglected 
in the earlier stage, as is so likely to be the case in hospital patients, 
resolution is a rare event. Only two out of twelve cases observed by 
Grisoile, and but nine out of seventy-three other reported cases ter- 
minated thus favorably. In puerperal cases resolution is still more 
rare. 
Suppuration and the formation of an abscess is the most common 
mode of termination, but the production of pus is often very slow, 
and may be delayed for two or three weeks, as the cellular tissue in 
which it occurs is not endowed with a high vital activity. 
The suppuration is generally announced by more fever, often pre- 
ceded by erratic chills, the temperature rising highest in the evening ; 
the skin often becomes moist or covered with an abundant sweat, the 
local pain may become throbbing or lancinating, the tumor is enlarged 
and softer, and soon becomes fluctuating ; at the same time evidences 
of nervous and vascular compression generally increase, and the con- 
stipation for the most part continues and may become more obstinate. 
If the patient survives, the pus usually finds an outlet, but it is 
possible that a moderate quantity of pus may he absorbed and recov- 
ery follow. 
The pus, as in the abscesses within the peritoneum, may take dif- 
ferent courses. In the order of frequency it may be evacuated 
through the abdominal walls, especially if aided by timely surgical 
interference ; it may appear below the crural arch, or pass up in the 
direction of the kidney, or toward the pelvis, though the last direc- 
tion is rare except on the left side. 
Perforation of the intestine is not very unfrequent, and it may 
occur at any time from two or three weeks to two or three months. 
Such perforation would be announced, as in the other cases, by a severe 
tearing pain, possibly at the time by diminished volume of the tumor 
and by purulent stools. 
In women the abscess not unfrequently opens into the vagina, 
especially on the left side ; it may enter the uterus, especially in puer- 
peral phlegmon ; or in still other cases it may empty into the bladder. 
Two cases of this kind have occurred under my observation, one 
puerperal and the other in a young woman ; both lingered for a long 
time, with frequent attacks of severe pain and almost constant puru- 
lent discharges with the urine at micturition ; both succumbed after DIAGNOSIS. 
705 
a few years, one from the prolonged suffering and exhaustion, and the 
other from an acute inflammatory attack in her enfeebled condition. 
An old abscess with thick firm walls and a fistulous opening into 
the bladder was the pathological condition found post mortem. In 
the other no autopsy was made, but the symptoms were too unequiv- 
ocal to admit of doubt. 
In the case reported where the pus entered the vena cava, death 
followed immediately. In very rare instances it has ascended and 
perforated severally the diaphragm, the pleura, and the lungs, and 
in cases still rarer, the pericardium. 
In cases where the abscess opens into the large intestine, recovery 
is usually the most rapid. Opened surgically through the abdominal 
walls, suppuration generally goes on for some weeks, and fistula and 
intestinal hernia may follow. 
A termination by gangrene is rare except in the phlegmons con- 
secutive to perforation of the caecum or of its appendix. In such 
cases, if opened externally, there generally issues an ichorous, sanious 
liquid, mixed with gas and faecal matter, and sometimes with shreds 
of dead tissue, almost always then followed by death. A less frequent 
termination is by phlebitis, with consecutive pyaemia, often with 
secondary abscess of the liver. 
Diagnosis.—The diagnosis of iliac phlegmon is made by observ- 
ing the history and phenomena which have been described. It is dis- 
tinguished from indolent tumefactions in this region by the fever, pain, 
and tenderness ; from iliac peritonitis by the more violent symptoms 
in the latter, and the different results of palpation in the two cases. 
It may not be easy to distinguish it from inflammation of the cae- 
cum itself—and inflammation of this part and its surroundings are 
often combined—but the tumefaction dependent upon faecal accumu- 
lations will admit of indentation, and will be diminished or removed by 
the operation of a cathartic. Filling the intestine with a large enema 
of warm water will possibly enable it to be traced and distinguished 
from a swelling beneath it. It may be distinguished from a cold or 
passive secondary abscess from disease of the spine or the iliac bone, 
by the longer continued previous history of such cases. 
A displaced, inflamed, or suppurating kidney might lead to a 
false diagnosis. 
Inflammation and enlargement of a lymphatic gland in the region 
may with difficulty be distinguished from an iliac phlegmon. In 
adenitis, however, the tumor is developed without other symptoms 
such as commonly precede or accompany phlegmon ; and if there be 
more than one tumor, they follow the course of the external iliac ves- 
sels. Some disease or injury in the course of the lymphatics below 706 
PERITYPHLITIS. 
may cause adenitis, and when no other disease is present, there is 
usually little or no febrile reaction ; and an inflammation of the glands 
generally, without other serious consequences, terminates in a cure. 
A cancer of the caecum or in the iliac fossa, an ovarian cyst, an 
inflamed uterine fibroid, or an abscess of the abdominal walls, might 
be mistaken for peratyphlitis, and require to be distinguished. 
A phlegmon simply subperitoneal is to be distinguished from one 
subaponeurotic by the more defined and exact location of the former 
in the iliac fossa, and its more rapid progress; the latter is more deep, 
less prominent, and less definitely circumscribed. 
Prognosis. — The prognosis of these affections in the eaecal re- 
gions, as the history already given indicates, is grave, but varies much 
with the particular form, the special location, and the course they 
may take, which cannot always be predicted. According to Grisolle, 
in seventy-three cases of phlegmon twenty deaths occurred ; and of 
seventeen puerperal phlegmons seven proved fatal. 
Evacuation through the abdominal walls, although the suppuration 
may be protracted, and accidents may occur, is, nevertheless, the 
most favorable mode ; those which open internally are always uncer- 
tain and grave. 
Treatment.—In perforation of the vermiform appendix or the 
C83cum, followed by extended and violent peritonitis, little else can 
be done or hoped for except to afford some palliation of the suffering 
by the administration of opiates and the application of fomentations. 
If the shock and depression are very great, ether or alcohol may be 
added to the opium, and two or three grains of quinine may also be 
given and repeated in two or three hours, or much larger doses may 
be given if the fever is high. A fatal result is to be expected, and 
cannot usually be long delayed. 
Sometimes, although perforation occurs, adhesive inflammation 
has preceded, and the intestinal contents are prevented from being 
diffused into the peritoneal cavity. In such cases there is hope, and 
the same remedies—opium, quinine, and fomentations, with perfect 
rest—will be the means most likely to save the patient. Spanaemics, 
in all these cases, should be avoided, as the more plastic the inflam- 
mation the more likely will be the confinement of the pus to limited 
abscesses, and the greater the safety of the patient. A proper digesti- 
ble diet should be given, fresh air allowed, and the most absolute quiet 
enjoined. 
In ordinary cases of perityphlitis not produced by perforation, rest 
and quiet should be insisted upon, leeches should be applied accord- 
ing to the condition of the patient and the severity of the case ; fomen- 
tations at first, and blisters afterward, should be applied ; warm or TREATMENT. 
707 
tepid baths may be used ; mild laxatives and enemas may be admin- 
istered to overcome constipation ; food must be prescribed which will 
leave the least residuum, and the patient should he put upon free doses 
of morphine and quinine as antiphlogistic or anti-inflammatory 
agents. The quinine, if not well borne by the stomach or the brain, 
should be suspended, or a single large dose may be given once in 
thirty-six or forty-eight hours; or the salicylate of soda in from one 
to three drachms, or even larger doses, may be given once in twenty- 
four or thirty-six hours, while a steady impression is kept up by the 
opiate. These means, with a repetition of the blisters, will not 
unfrequently prevent suppuration and cause the inflammation to ter- 
minate in resolution. 
If, however, suppuration occurs, if fluctuation is felt, and the pus 
approaches the surface, the abscess should be opened, perhaps most 
safely by the aspirator—certainly so, if the matter be deep—though 
some have advised that in subperitoneal abscesses of longer standing 
than twelve days, and where there is no evidence of adhesion to the 
abdominal walls, the opening should be with caustics, as Vienna 
paste. Evacuating the matter by the aspirator is preferable, and may 
be done with comparative safety at an early period. Some have advised 
aspiration as soon as evidences of suppuration are presented. Prof. 
Willard Parker, of New York, reported a case as long ago as 1867, in 
which an opening was made down to the seat of the suppuration, 
even before fluctuation was discovered ; and this plan has been em- 
ployed by several surgeons since, with reported success. Results 
have been so favorable, that one enthusiastic writer on the subject 
states that this mode of treating these cases “ may be said to have 
disarmed this disease of its terrors, and changed its issue from an 
almost invariably fatal result to the reverse.” 
Prof. Parker’s operation consisted in making an incision over the 
tumor, dividing the skin and subjacent tendinous and muscular 
layers, until the fascia transversalis was exposed. Then, with an 
exploring needle or fine trocar, the pus was searched for, and, when 
found, a free opening was made; and after the discharge of matter 
a tent was introduced, and the wound was kept open for several days. 
Although such favorable results have been reported, it must not be 
supposed that such an operation, in the uncertainty of the precise 
location of the pus, is without danger ; and the aspirator must be 
considered as safer, if it will answer the purpose of removing the mat- 
ter and preventing the continuance and traveling of the abscess. 
After suppuration has commenced, a tonic course—iron, quinine, 
and a nourishing diet—should be prescribed. Large faecal accumu- 
lations should not be allowed to take place in the bowels, but the 708 
PERIPROCTITIS. 
gentlest possible means should be used to overcome the constipation. 
Nothing more active than mild doses of salines or castor-oil, aided by 
emollient enemas, should, as a rule, be used. 
When these abscesses find a deeper outlet, little can be done except 
to palliate symptoms, correct all other morbid conditions, and support 
the strength of the patient. This, however, maybe much and should 
not be neglected. 
These diseases about the caecum, though not of very frequent 
occurrence, have so much pathological and practical interest, that 
they require the careful attention which has been given them here. 
PERIPROCTITIS. 
Periproctitis, or inflammation and abscess about the rectum, 
though coming within the province of surgery, requires a brief notice 
here. The disease has analogies with the inflammation about the 
caecum, and may depend upon somewhat similar causes. Sometimes, 
though rarely, penetrating ulcers of the rectum occur, and consequent 
inflammation and abscess. It may be connected with hemorrhoids, 
constipation, or fissure. It sometimes originates in the tissue without 
depending upon other local disease in the region, and is frequent in 
tuberculosis. It also not unfrequently depends upon pus in the pelvis, 
and even in the abdomen, which has gravitated to this point. These 
abscesses may rupture through into the rectum, or point externally 
near the anus, discharging very offensive pus. They present the 
symptoms of pain—though this may not be great—tenderness, and 
swelling, and whether rupturing into the intestine or externally first, 
openings both into the intestine and externally are likely to take 
place, and fistulas in ano to be established. This, however, does not 
always follow, and an early external opening is often followed by a 
speedy cure. 
Treatment.—The treatment consists in keeping the bowels open 
by mild means—laxatives or enemas,—in the occasional application 
of leeches early, in the use of emollient poultices, and in the open- 
ing of the abscess as soon as the presence of pus is clearly ascertained. 
The treatment of anal fistula requires surgical interference, and as 
the methods of procedure are described in all general works on sur- 
gery, they Avill be omitted here. 
The physician, however, has not unfrequently occasion to decide 
as to the advisability of an operation in these cases, which is not 
always easy. In tuberculosis an anal fistula, by a derivative action, 
often relieves markedly some of the symptoms in the chest and throat; 
but when the discharge from the fistula is free, there is an additional PHENOMENA. 
709 
source of exhaustion, and it becomes a question whether it shall be 
arrested. This will be referred to again, in considering phthisis pul- 
monalis. 
DISEASES OF THE COLON AND RECTUM. 
The term dysentery is used to designate an inflammation of the 
colon and rectum, producing pain and straining at stool—tormina 
and tenesmus—with scanty, but mucous and bloody discharges, usu- 
ally occurring frequently, but with little fecal matter. These spe- 
cial symptoms are accompanied by more or less general prostration 
and fever. 
These phenomena may be produced by a variety of causes, and 
may be associated with different conditions. 
A simple intestinal catarrh, depending upon any of the causes men- 
tioned when treating of that subject, when it involves the large intes- 
tines, and particularly the lower part of the colon and the rectum, 
will induce dysenteric symptoms. By the term “ dysentery,” however, 
as commonly used, something quite different from a simple recto- 
colitis, produced by irritating articles of food, drastic medicines, tak- 
ing cold, or other accidental causes, is understood. As produced by 
less apparent causes, especially as occurring endemically or epidem- 
ically, it is a more distinct and specific disease, a general affection 
with special local manifestations, zymotic in its cause, and so similar 
in many essential respects to the class of specific fevers, that, in the 
classification of fevers, I have placed it among them. 
The term dysentery, considered in its symptomatic signification, 
embraces two forms of disease, which' may be termed accidental and 
specific dysentery. 
DYSENTERY. — “ BLOODY FLUX.” 
1. ACCIDENTAL DYSENTERY. 
Accidental dysentery is sporadic and non-infectious; is usually, 
though not always, of a comparatively mild character; is commonly 
more amenable to treatment in its acute form, and usually runs a 
shorter, and always a less specific course. It is dependent upon or 
produced by the common causes of muco-enteritis, and is a common 
non-specific catarrh of the lower bowels. Its more frequent particu- 
lar causes are exposure to cold and moisture, improper articles of 
food, drastic medicines, irritating secretions, fecal accumulations, 
calculi or foreign substances in the part, obstructed circulation through 710 
PROCTITIS. 
the liver, lungs, or heart, causing venous congestion. The local 
symptoms resemble those of the more specific forms of the disease, 
but they are less persistent, and the general disturbance and depres- 
sion are not as great. The pathology agrees essentially with the 
ordinary forms of muco-enteritis, and need not be repeated. 
Its course is very variable, depending upon its cause and severity ; 
hut in many cases it is mild, lasting but a few days, or even not more 
than a day or two, and will commonly subside readily when its causes 
are removed. 
Treatment.—The treatment is essentially the same as that 
which has been described under the head of muco-enteritis or intes- 
tinal catarrh. The causal indications must be fulfilled. If irritating 
articles are in the alimentary canal, they should be removed by mild 
but efficient laxatives; if in the stomach, by an emetic of ipecac.; if 
the secretions are perverted, they should be corrected ; if there be 
obstruction at the liver or the other organs, it should, if possible, be 
removed ; if the disease arises from taking cold, perspiration should 
be induced; and in all cases, after proper evacuations, the irritated 
and inflamed intestine should be soothed. For this latter purpose, 
nothing is equal to the preparations of opium. A full dose of 
Dover’s powder, or a quarter of a grain of morphine with a grain or 
two of ipecac., or an enema of warm water, followed by one with an 
aqueous solution of opium or morphine, etc., will often put an end 
to all the painful symptoms. These means should be repeated and 
continued according to circumstances. 
A recto-colitis with dysenteric symptoms sometimes occurs in 
phthisis, bronchitis, pneumonia, malarial and otherfevers, and in some 
other affections. In some of these cases the treatment of the dysen- 
teric symptoms will be subordinate to that of the disease with which 
it is connected. When dysentery is complicated with malarial fever, 
the antimalarial remedies must not be delayed ; and in pneumonia, the 
dysenteric symptoms, by producing a revulsion, sometimes appear to 
relieve the pulmonary inflammation. When the intestinal disease 
requires treatment, as it generally does, it must be conducted on 
general principles, but always with reference to the other conditions. 
PROCTITIS. 
A simple catarrhal inflammation of the rectum alone sometimes 
occurs, presenting symptoms essentially the same as those mentioned 
as belonging to recto-colitis. This disease may he acute or chronic, 
and more or less mild or severe. There is a sense of uneasiness in the TREATMENT. 
711 
rectum, or of burning irritation, a disposition to go to stool, when 
there is much straining, and the passage of mucus, hut without com- 
plete relief, there being a sensation of something remaining, and the 
patient returns again and again to the close-stool, passing chiefly 
mucus and blood. This condition, called tenesmus, is particularly 
annoying and depressing. The sphincter ani is in a state of spasm, 
the pain radiates to the hips and back, and a sense of nausea and 
decided prostration is often felt. 
In severe cases the suffering is very great, the straining at stool is 
severe and constant, and sometimes results in a prolapsus of the rec- 
tum, which, grasped by the sphincter, presents an intensely congested 
and often very dark appearance. The neighboring organs sympathize, 
strangury is very likely to occur, and in females the menstrual flow, 
or more properly a uterine hemorrhage, may come on. The inflam- 
mation is likely to extend to the colon, the more so as faecal matter is 
often retained and accumulates in that viscus, and recto-colitis, or 
simple non-specific dysentery results. Inflammation may extend, 
though this is rare, to the peritoneum, with serious consequences fol- 
lowing. 
Etiology.—Besides the causes referred to as producing recto- 
colitis, displacement of the uterus in females and enlargement of the 
prostate gland in males, and hemorrhoidal tumors in either, may 
excite this form of disease. 
In ordinary milder cases the disease tends to recovery in a few 
days, but in the severer cases it may be more protracted, and peri- 
proctitis, and more rarely peritonitis, may follow. In the protracted 
cases, ulceration is likely to follow, the hemorrhoidal veins often 
become varicose, emboli may form, the liver may become secondarily 
affected, and severe, protracted, or fatal results may supervene. 
Diagnosis.—A complete diagnosis will often require a careful 
exploration of the parts, and the exclusion of other conditions. 
Prognosis.—The prognosis is generally favorable unless there is 
a dyscrasia, as tuberculosis, with which it is sometimes associated. 
Treatment.—The treatment of acute cases is essentially that 
which has been mentioned as applicable to recto-colitis. It would be a 
mistake to resort to astringents, or even opiates, with a view of arrest- 
ing the discharges, until free evacuations have been procured, for 
which purpose saline laxatives, often preceded by a mild mercurial, 
should be used. Soothing measures will then be required. Faecal 
matters should not be allowed to accumulate and become hard, and 
consequently irritating when passing ; but the bowels should be kept 
soluble by mild saline laxatives, or by castor-oil. 
In the chronic and ulcerative cases, local treatment will be re- 712 
DYSENTERY. 
quired, and will be more fully described under the head of chronic 
dysentery. In the cachectic cases, in tuberculosis, the remedies 
adapted to that condition are demanded. 
2. SPECIFIC DYSENTERY. 
This form of the disease is by far the most frequent, and is the 
one generally understood when the term dysentery is used. It is a 
peculiar febrile and inflammatory affection, generally regarded as 
zymotic, or depending upon a poison ; and is defined substantially by 
Jaccoud as “an ulcero-membranous, transmissible recto-colitis, 
characterized by tenesmus, griping, and repeated discharges of nmco- 
sanguinolent matter, and a general state more or less grave.” 
It may be either sporadic, endemic, or epidemic in its occurrence, 
and its severity varies much in individual cases, and in the general 
character of different endemics and epidemics. The sporadic cases, as 
a rule, are less severe than the others, though some endemics are very 
mild and others are exceedingly severe and fatal, while the more wide- 
spread epidemics are generally grave. 
It is not easy, or perhaps possible, to distinguish some specific cases 
which occur sporadically from accidental or non-specific recto-colitis, 
though a difference in cause at least exists. The common causes of 
the non-specific disease may, however, determine an attack of the 
specific, and it is possible the former may pass into the latter. 
Etiology.—Sporadic cases may attack any age or sex, and the 
disease has its maximum of frequency at the close of the summer 
season, when cold evenings and nights succeed the heat of the day. 
Various particular conditions favor the development of dysentery. 
They may be stated as some cosmic influences which we do not under- 
stand ; lying on moist ground without proper protection, especially in 
the night; the arrest of transpiration by cold and moisture, in any 
situation ; direct irritation of the membrane, as from improper food 
and drink, from unripe fruits, iced drinks, etc. In Asiatic cholera, 
when a general tendency to the disease prevails, special irritating 
causes may precipitate an attack ; so when a dysenteric zymosis is 
present but in moderate amount, these cooperating causes may be 
necessary to produce the disease in individual instances. This prin- 
ciple applies not only to the sporadic but to the endemic and epidemic 
forms as well. 
The unknown cosmic causes, or the presence of a specific dysen- 
teric poison, may become constant in a locality, causing the disease 
there to be endemic. When such influence or poison is in large quan- 
tity, and affects large numbers, the disease becomes epidemic. ETIOLOG T. 
713 
The nature of the influences essential to the production of en- 
demic and epidemic dysentery has given rise to much discussion, 
and involves the same questions which present themselves in all forms 
of specific zymotic diseases. The doctrine of special poisons is con- 
stantly gaining ground. Specific facts in regard to the cause of some 
diseases have been established, and thus the analogies of others have 
left but little doubt of the existence of peculiar organic poisons and 
their agency in the production of most endemic and epidemic diseases. 
Certain telluric conditions favor the production of peculiar poisons, 
and animal and vegetable decompositions seem to contribute to the 
same end; at least decomposing changes, either as causes or effects, 
are associated with such poisons or influences, and produce different 
peculiar diseases. Dysentery is one of this class. 
The specific cause of dysentery frequently coincides with that of 
paludal or malarial fevers; but this is by no means always the case, 
and some of the most severe endemics or local epidemics of dysentery 
have prevailed where malarial fevers are unknown. In other instances 
the dysenteric influence has seemed to have intimate relations with the 
typhus poison. A number of cases of dysentery collected together has 
often appeared to develop typhus fever. 
Certain practical facts respecting the genesis of dysentery seem 
sufficiently established. Organic and, particularly, animal matters in 
a state of decomposition, together with certain climatic influences, 
produce the disease ; but by what particular process is not known. 
The spread of the disease is favored by crowding, insufficient food, 
and excessive fatigue. 
In the countries particularly subject to it—in the hot regions, 
where it is endemic—these unfavorable hygienic influences, aided by 
the climate, produce the epidemic variety which so often spreads 
destruction and desolation in armies, fleets, and cities. 
The disease in this epidemic form usually first attacks the indi- 
viduals exposed to bad hygienic influences, and then others who come 
within the influence of what appears to be the poison, which many 
regard as being multiplied by the prevalence of the disease. 
Whether the poison is actually multiplied in the bodies of the 
sick, as is evidently the case in small-pox, scarlet fever, and other 
strictly contagious diseases, is not positively determined ; but that it 
is not exhausted or destroyed in the body of the patient is presumed ; 
and many believe that it exists in the excretions, and that the dysen- 
teric discharges are capable of communicating the affection to others. 
It varies greatly in severity in different epidemics, general or more 
local, and when prevailing over a large region it is often much more 
severe in some localities than in others, even when such localities are 714 
DYSENTERY. 
but a few miles, or, in some cases, in cities, but a few streets apart, 
and the general conditions of the patients seem to be the same. 
Independent of crowding, epidemic dysentery often appears in 
villages, or in sparsely settled farming neighborhoods, where there are 
no special appreciable hygienic conditions different from those that 
exist in other localities free from the disease ; but in such cases the 
severe local prevalence is generally preceded by sporadic cases, the 
disease gradually increasing in the number of attacks and in the 
severity of the individual cases. 
It is generally stated by authors that dysentery occurs oftener in 
moist hot weather, and this may be true as a general fact; but within 
my observation, in the rural districts of the West, it has appeared as a 
local epidemic, in several instances with the greatest severity, in hot 
and dry seasons and places. 
Not only does it differ in severity in different places when there is 
a general prevalence of the disease, but it differs in its type and in 
respect to particular symptoms in the different localities. For exam- 
ple, some years ago, when the disease was prevailing quite generally 
over a large region in Western Massachusetts, nearly all the cases in 
a particular neighborhood were attended with decided, and often 
very profuse, hemorrhage from the bowels ; while that peculiarity did 
not exist in other neighborhoods but a few miles distant. This is not 
a solitary instance of such particular deviations from the ordinary 
type generally prevailing. Facts of this kind tend to show that a 
special poison or influence is operative in producing the disease, and 
that it is more intense or of a more active character in some localities 
than in others. 
The question of contagion in this, as in some other diseases, is 
not easy to decide. The difficulty depends partly upon the particular 
signification given to the term, and partly upon the complicated 
character of the facts. If by a contagious disease is meant one pro- 
duced by a poison generated in the body of the person affected with 
the disease, and communicated to others, producing the same affec- 
tion, which is ordinarily produced in no other way, there is no suffi- 
cient proof that dysentery is contagious; indeed there is abundant 
proof that it is not. But if by contagion is meant the transmission 
of a disease from a sick person to a healthy one by a product emanat- 
ing from the sick person, whether generated or multiplied in the 
body, or merely passing through it, and if it is admitted in this defi- 
nition that the disease is often produced in other ways, then it is 
possible, and even probable, that dysentery is contagious, and that 
the contagion is in the alvine discharges, and consists of low forms 
of organisms. This subject, as well as others of a similar character, PATHOLOGICAL ANATOMY. 
715 
awaits further elucidation. How far, and in exactly what respects, 
sporadic and even accidental dysenteries differ from endemic and 
epidemic forms of the disease has not yet been determined. Unlike 
the diseases most clearly and characteristically contagious, one attack 
of dysentery, so far from conferring immunity from a future one, 
rather predisposes to a recurrence. 
PATHOLOGICAL AKATOMY. 
The structural changes properly belonging to the disease occupy 
the large intestines, and are usually most intense in the region of the 
sigmoid flexure of the colon. Their chief seat is in the minute glands 
of the mucous membrane and the (intervening) intertubular connec- 
tive tissue. Diseased conditions, especially in scorbutic cases, may 
extend to the small intestines. 
There are not unfrequently complicated cases, and secondary lesions 
are often found. Dysentery may be complicated with typhoid and ty- 
phus, and often with malarial fevers ; with congestion and obstruction 
of the liver, especially in hot climates and seasons, and in malarial 
regions ; with scorbutus, as in our late army experience ; with tuber- 
culous and syphilitic conditions ; and, as I observed in many cases 
in Chicago, with epidemic cholera—dysentery often following attacks 
of that disease. As secondary lesions we have abscess of the liver 
from absorption of pus or septic matter, or the formation of emboli 
carried to that organ ; disease of the mesocolic glands ; perirectal and 
pericolic inflammation and abscesses; peritonitis, sometimes from 
ulceration and rupture ; and contraction and obstruction of the intes- 
tines from the contraction of cicatrices after ulceration. 
The special intestinal lesions, during the progress of the disease, 
are : 
1st. Hyperaemia and exudations of mucus and blood, involving the 
mucous surface of the colon and rectum, the hyperaemia being more 
intense near the follicles. 
2d. Inflammation in the tubular follicles. 
3d. Inflammation in the solitary vesicles. 
4th. The tissue is infiltrated with a sero-sanguinolent material, 
which is most abundant in the submucous tissue, but may extend to 
the cellular and muscular coats; the mucous surface is denuded of 
its epithelium, while in some cases an exudate is poured out upon the 
surface, which tends to a sort of organization and the formation of a 
false membrane. 
5th. In the more severe and protracted cases, suppuration and 
ulcerations appear; destruction occurs at points in the false mem- 716 
DYSENTERY. 
brane and the proper tissues, involving the mucous membrane and its 
glands; and in scorbutic cases the ulceration extends often to the 
small intestines. 
6th. Sometimes casts of the intestines are formed from the false 
membrane, and are occasionally thrown off in larger or smaller tubes, 
segments, or patches. 
7th. In the severest cases, ecchymoses, extended suppurations, and 
sloughs of the general tissue occur, and a dark and ragged disorgani- 
zation results. 
The ulcerations, which seldom take place before the end of the 
second week, have different modes of production. 
They may arise from suppuration of the follicles, or from com- 
pression of the vessels by the interstitial exudate, which destroys 
nutrition in points and causes necrosis. In the latter case, the exu- 
date and the necrosed point will be thrown off together, and the ulcer- 
ated borders are irregular; while in the suppuration of the follicles, 
the small resulting ulcers are more regular. In either form the ulcer 
may spread and penetrate all the coats of the intestine and induce 
peritonitis. In other cases, or in studying the ulcerative process more 
minutely, it will be found that in the process of ulceration there 
will be : 
1st. Intumescence and softening of the solitary glands, and a 
breaking down of their structure by one or other of the processes 
before named, resulting in small ulcers. 
2d. The ulcers spread, and groups of these glands, with interven- 
ing tissue, become destroyed, and erosions are left. 
3d. There will be submucous inflammation and effusion, causing 
deeper ulcerations. 
4th. Intertubular inflammation, and inflammation at the base of 
the glands occur, followed by ulcerative processes. 
5tli. Submucous abscesses sometimes form, and possibly rupture 
into veins, but oftener they make their way through the mucous mem- 
brane, and the pus is discharged with the mucus, blood, and faeces, 
leaving an ulcer in the place of the abscess. 
6tb. When a croupous exudate, which may be poured out during 
these processes, is sufficiently organized, it may undergo an ulcerative 
process. 
When ulcerations of the intestines occur, the disease lingers and 
may become chronic. 
In chronic cases, atrophic and contracted conditions of the intes- 
tines involved often result, the cicatricial contractions, after extensive 
ulcerations, often become permanent, impairing perpetually their 
functions. SYMPTOMS. 
717 
Lesions of Peyers glands and of the mesenteric glands sometimes 
take place, and generally atrophy of the glandular parts of the intesti- 
nal canal ; lesions of the serous membranes and of solid organs, not 
only of the abdomen, but of the thorax, from pyaemia or embolism, 
may follow and seriously complicate dysentery. 
Complications of disease of the liver are frequent, especially in hot 
climates and malarious regions ; the liver disease, by obstructing por- 
tal circulation, sometimes becomes a cause, and at other times, by 
pyaemia or embolism, occurs as an effect of dysentery. 
Statements respecting conditions of the blood in this disease vary 
widely, and it is to be presumed, therefore, that its state differs in dif- 
ferent cases. 
As has already been intimated, there are various types of dysentery, 
dependent upon its different degrees of severity and its time of con- 
tinuance, and the different lesions as well as symptomatic phenomena 
presenting themselves. 
The difference between the accidental or non-specific cases and the 
more specific forms of the disease has been discussed. 
There are different general types of the specific disease. Besides 
the anatomical and particular local symptomatic peculiarities, the 
may be divided into two classes as regards the general con- 
dition and activity of the system, viz.: 1. Acute inflammatory or 
sthenic forms, where there is no special depression ; and, 2. Asthenic, 
adynamic, or typhoidal forms, where there is special depression of the 
vital powers and actions, the cases tending to malignancy. This last 
class seldom occurs except when the disease prevails as an epidemic, 
though in some limited localities very malignant cases sometimes 
appear. Between these there are numberless gradations, which it is 
impossible to specify. 
SYMPTOMATIC PHENOMENA. 
The symptoms or external phenomena of the disease next require 
attention. In some cases the onset is without marked prodroma, the 
pain, tenesmus, and slimy discharges suddenly appearing, in mild cases, 
without chills, and with almost no feyer. 
In cases of medium intensity the dysenteric symptoms are often 
preceded by what is apparently an ordinary intestinal catarrh. There 
is general malaise, lassitude, chills, and fever. This prodromic period 
may last from a few hours to two days. In a severe epidemic variety 
the attack is generally sudden, though it may be preceded by general 
symptoms. In some adynamic cases the depression is great from the 
beginning, the extremities and much of the surface are cold, and no 718 
DYSENTERY. 
external fever, in cases lasting but two or three days, is observed. Usu- 
ally, however, if the disease continues on, there is fever, generally 
quite markedly remitting, with evening exacerbations. 
In well-developed and established dysentery there is pain in the 
abdomen, increased on pressure, and generally greatest on the left 
side, near the brim of the pelvis. There is a sense of pressure or full- 
ness, as of a foreign body in the rectum, where the tactile or common 
sensibility is greater than in other parts of the intestinal canal, caus- 
ing repeated efforts at defecation. 
The evacuations, often fascal at first (as such matters may be in 
the lower bowels), or simply loose and catarrhal, soon become nearly 
or entirely mucous, with, or sometimes without, mingling of blood. 
Sometimes the matter resembles “frog’s spawn,” or a liquid contain- 
ing grains of sago. By the second or third day, if not before, the 
stools usually become bloody, and the thick mucus and blood in- 
timately mingled sometimes give them the appearance of pounded 
flesh. In the milder cases, after some discharge of mucus tinged with 
blood, and bearing epithelial debris, continuing from one to three 
days, the discharges may spontaneously cease, and the patient soon 
recover. 
In the severer cases, however, the blood in the stools is apt to 
increase, and membranous fragments may often be seen. When the 
follicles are attacked, the mucus is likely to be more solid, and its 
unmingled portions transparent. If faecal matters have not passed 
off, they are apt to form rounded, hard, or scybalous masses, and 
these occasionally appear in the stools. Their formation, retention, 
and passage may be an additional source of irritation. 
While the discharges are nearly pure mucus, or mucus with fresh 
blood, they may be almost odorless; but later, especially in hot cli- 
mates, the faecal matters may become more abundant, assuming a 
darker color, and containing solid debris and bilious and other ex- 
cretions, partly liquid, and sometimes very offensive. This offensive- 
ness may be the result of gangrene, and is, of course, a grave symptom. 
The frequency of stools is variable. These may, in milder cases, 
be not more than ten or twelve a day, while in other and the more 
severe cases, they may be exceedingly numerous, the patient with dif- 
ficulty being kept from rising every few minutes, or remaining almost 
constantly at stool. 
From the proximity of the rectum and bladder, the latter organ 
often sympathizes, and there is sometimes extreme vesical tenesmus 
and strangury, and not very unfrequently, especially in men past 
middle life, there is entire inability to pass urine. Irritation about 
the anal region, in children particularly, is apt to he decided, and COURSE AND PROGNOSIS. 
719 
eversion of the mucous surface, and even prolapsus of the intestine 
from the repeated straining sometimes occur. 
As to the more general symptoms, the weakness is usually marked, 
the features contracted and expressive of severe suffering ; the tongue 
is variable, but generally coated ; and the abdomen is usually con- 
tracted. In the severer cases, continuing for from one to three weeks, 
the fever is generally decided and may be severe ; the skin is usually 
dry, though it may occasionally be moist; the thirst is often great, 
and in the more typhoidal forms the pulse becomes feeble ; the tongue 
is dry and dark, sordes accumulate upon the teeth and gums; the 
eyes are much sunken, and the whole expression is that of great pros- 
tration. 
In some cases there are severe nervous disorders, delirium, sub- 
sultus tendinum, general trembling, and in children, not very rarely, 
convulsions. These symptoms are sympathetic and reflex, and not 
dependent on structural lesions of the brain. The mind usually re- 
mains intact. 
Vomiting early in the disease and at more advanced periods not 
unfrequently occurs, sometimes the result of reflex irritation, at other 
times in consequence of gastric catarrh, and in still other cases from 
a profuse and regurgitating bilious secretion. In the latter case the 
vomited material is yellow, or dark and bitter, and its ejection often 
affords relief. When the matter vomited is a colorless fluid, when 
there is no gastric pain or tenderness, and the tongue is not red, the 
vomiting is reflex and is not of serious significance. 
Course and Prognosis.—The continuance of dysentery is very 
variable. Mild cases may last but a short time—from two or three 
days to one wTeek. Very severe and malignant cases may also have a 
short course, soon terminating in collapse and death. Most cases 
continue from one to two, or perhaps three weeks—not a few longer— 
and some become chronic with ulcerations and other severe lesions, 
to which the patient finally succumbs ; while still others more or less 
perfectly recover after a long continuance of the disease. 
In the sporadic form it seldom terminates fatally, and even in 
ordinary epidemics in temperate latitudes a large proportion of cases 
recover. In exceptional epidemics, and especially with children, 
the mortality is very great. Some of the more unfavorable symp- 
toms are unusual depression, briny or very offensive discharges, invol- 
untary evacuations, very great and extended tenderness, delirium, 
coma or convulsions, any evidence of sloughing, or of markedly 
typhoidal symptoms. 
The particular causes of death are various, and this consideration 
may aid in the prognosis and afford indications of treatment. 720 
DYSENTERY. 
Death in the early stages is usually caused by the severity of the 
inflammatory and febrile shock ; by the blood poisoning often present; 
by the sloughing of the intestines which sometimes occurs; and by 
the exhaustion from the pain and the discharges. In the more pro- 
tracted cases the patient may be worn out by the continued suffering 
and discharges, and the want of proper nutrition. 
The accidents which may cause death, but which occur only in a 
small proportion of cases, are perforation of the intestines from ulcer- 
ation, gradual exhaustion from the destruction of the intestinal 
membrane, contraction of cicatrices after ulceration, and consequent 
obstruction of the bowels; and the very serious accident of pyaemia 
or septicaemia, from the absorption of pus and septic matters, and 
the formation of emboli. These emboli are produced by inflam- 
mation and ulceration, which invade the intestinal veins and cause 
serious blood poisoning, and this results in secondary inflammation 
and suppurations in the mesentery, liver, lungs, or elsewhere. 
Catarrhal diarrhoea sometimes follows dysentery, and relapses are 
liable to occur and to be grave. Death may result from free intesti- 
nal hemorrhage, though this is rare, and occasionally from peritoni- 
tis without perforation. 
As sequelae, in addition to occlusion, abscess of the liver, and 
other results already mentioned, perityphlitis and periproctitis, paraly- 
sis of the sphincter ani and other muscles, and a general marasmus 
may occur. 
The dysenteries of warm countries, and of hot seasons in malarious 
regions, have some peculiarities. The disease, as a rule, is more vio- 
lent ; its progress is marked by greater periodicity of the fever ; there 
are more frequent relapses, and serious complications of disease of the 
liver—congestions, phlegmonous and catarrhal inflammations, and 
jaundice ; and diseases of the spleen are more likely to take place. In 
such localities the disease is also more likely to pass into a chronic 
state. 
Chronic Dysentery requires notice. Dysentery is more likely to 
pass into the chronic form where the intestines have been frequently 
attacked, and the patients have thus been exhausted. Defective 
hygienic conditions and a want of proper treatment and care are the 
most frequent causes of the chronic form. In some epidemics, how- 
ever, such lesions so early take place as to induce in a modified form 
the continuance of the disease. 
Where an acute attack assumes the chronic form, after three or 
four weeks there is a mitigation of the symptoms ; the evacuations are 
less frequent, but they persist; they may become fetid, are often of a 
yellowish color, are very slightly bloody ; the pain and tenesmus cease DIA GNOSIS—TREA TMENT. 
721 
or become very slight; there is generally a voracious appetite, but 
emaciation continues ; the eyes, instead of regaining, continue to 
lose their expression ; the voice becomes husky, broken, and high- 
pitched ; the tongue, often smooth, glazed, or fissured ; the skin, 
inelastic and wrinkled ; the abdomen flattened; and death not unfre- 
quently follows from exhaustion, or from a sudden occurrence of an 
acute attack. Its duration is from some months to two or three years ; 
and, when it is once fully established with the dysenteric cachexia, 
it is exceedingly difficult to manage, and in many cases it resists all 
treatment, and death results. Ulcerations and other disorganized 
conditions of the intestines, and such a depraved condition of the 
general system have occurred as to render death in some cases only a 
question of time. 
Diagnosis.—The diagnosis of dysentery is not usually difficult; 
the entire symptoms taken together will make the case plain. It is 
distinguished from diarrhoea by the character, the small quantity, 
and the difficulty of the discharges in dysentery, and by the absence 
of fever in simple diarrhoea. It is distinguished from hemorrhage by 
the absence of mucus in the discharges, and of tenesmus in hemor- 
rhage. From hemorrhoids or fissure, together with diarrhoea, by 
the absence of the febrile symptoms, by the history of the case, and 
by an examination which will demonstrate the presence of these 
local affections. It is distinguished from typhoid fever with intesti- 
nal hemorrhage, by the peculiar characteristics of typhoid, by the 
free liquid discharges, by the tympanitic abdomen and the absence of 
mucus in the evacuations, and an absence also of the tenesmus and 
other special evidences of dysentery. 
TREATMENT. 
The authority of the profession in regard to the treatment of 
acute dysentery is far from being uniform. This will not be so 
surprising when the different forms which the disease may assume 
are taken into the account, as well as the different surrounding in- 
fluences and general conditions of patients, the complications which 
may exist, and the different stages of the disease in which the treat- 
ment is applied. 
In reference to treatment, the causes, the general tendency of the 
disease, the particular vital power of the patient, and the different 
stages or degrees of the anatomical changes going on, must all be con- 
sidered. 
In the first stage or degree of the disease the mucous membrane is 
hyperaemic, cedematous, and thickened, and the secretion from its sur- 722 
DYSENTERY. 
face is changed but scanty. There is soon, however, a freer secretion 
of mucus and blood, with corpuscular, and sometimes organizable or 
diphtheritic exudate, and destruction of the epithelium of the mem- 
brane. In the third degree of change there is ulceration, suppuration, 
more infiltration, and sometimes submucous abscesses; and in the 
fourth, or more severe degree of the disease, there is sloughing of the 
inflamed membrane. 
Besides the other complications—morbid conditions especially of 
the liver and other organs—which have been mentioned, the mesocolon 
and mesentery, with their glands, are generally hyperaemic and some- 
times suppurating. The existence of one or another of these various 
conditions must modify treatment, and a uniform plan for all forms 
and stages of the disease cannot be laid down. 
In the first place, the cause, if it can be recognized, must be taken 
into account. The “ natural history ” of the disease should be con- 
sidered, and it should be remembered that in a large majority of spo- 
radic cases of moderate intensity, with rest and proper diet, etc., the 
disease will spontaneously terminate in a few days by self-limitation. 
When dysentery is prevailing, prophylactic measures should not be 
neglected. Every source of putrescence should be removed or avoided; 
care should be taken of the diet and exposure ; and it will certainly be 
safer to isolate the sick as much as possible, to secure free ventilation, 
to disinfect the stools, the linen, and other articles used about the 
patient, to practice the greatest cleanliness, and to observe all the 
rules suggested in the case of typhoid fever and other diseases where 
there is reason to suspect infection. 
In the mild variety, especially if free fa?cal evacuations have pre- 
ceded, rest in the horizontal position, a warm bath, or sponging of 
the surface with warm water, to which is added a little soap or alkali, 
proper clothing, with a very plain, simple, unirritating diet which 
will leave but little residuum, taken in moderate quantity—such as 
scalded milk with a small quantity of thoroughly cooked farinaceous 
material, as corn-starch, tapioca, rice, farina, etc.—and demulcent 
drinks may be all that will be required. 
If fsecal matters to any extent are supposed to be in the intestines, 
mild laxatives or enemas to secure their removal are certainly in- 
dicated. 
A dose of castor-oil, with five or eight drops of laudanum or some 
spirits of camphor (the laudanum in small doses in such cases will 
not interfere with the operation of the oil), to be repeated if necessary, 
will answer the indication. If the pain and irritation be considerable 
after this, a dose of morphine, a Dover’s powder, or some other opiate, 
or an enema of starch and laudanum, or of an aqueous solution of TREATMENT. 
723 
an opiate, repeated as may be required, will certainly relieve the suf- 
fering, and, in my judgment, will tend to allay the inflammation and 
cut short the disease. 
The more difficult questions as to treatment do not pertain to 
these milder cases. Under the simplest measures here, or without 
any medication at all, the cases will terminate favorably, and various 
remedies have undoubtedly obtained a reputation as cures which they 
do not deserve. 
But medicines are capable of modifying the disease, and in the 
severer cases they may be very important. As already intimated, 
various methods have been strongly advised by different authors, and 
some of them have been almost as strongly disapproved of by others. 
Among these methods may be mentioned : (1) Active “ antiphlogis- 
tics”—evacuants, free abstraction of blood either by venesection or 
leeches ; (2) large and repeated doses of calomel with frequent saline 
purgatives, and even contra-stimulant doses of tartarized antimony ; 
(3) laxatives to secure fgecal, liquid, or diarrhoeal discharges, and then 
opium, keeping the bowels at rest as long as possible until the dysen- 
teric discharges reappear, when the cathartic is to be repeated, to be 
followed in turn by opium ; (4) the persistent use of moderate doses 
of cathartic salines ; (5) the repeated and continuous use of castor-oil, 
with other bland oily emulsions ; (6) free and continuous doses of 
opium ; (7) large doses of ipecacuanha, some desiring to secure its 
emetic effect in the early stage ; others trying to avoid the emetic 
operation, depending on a somewhat specific action to control the dis- 
ease ; and (8) the repeated use of cold water enemas, with the internal 
use of a non-purgative saline, as the nitrate of potash. 
Any of these methods may have their advantages in particular 
cases, but none of them can with propriety be exclusively pursued in 
all forms and stages of the disease. Remedies, in order to their best 
effects, must be adapted to the special condition of the cases treated. 
All of the conditions, to many of which Ave have referred, must be 
carefully considered. There are, however, some particular medicines 
which in most cases are applicable, and there are certain somewhat 
uniform courses of treatment which will be best for the average cases 
of the disease as it occurs in particular localities and in particular 
seasons, and some of these will be presented. 
The depleting treatment Avith free blood-letting can be applicable 
only in sthenic forms of the disease and in plethoric subjects. In 
such patients, when the inflammation is acute and the fever high, a 
venesection, or a good number of leeches applied to the more tender 
parts of the abdomen, or near the anus, will sometimes afford marked 
relief, and Avhere blood in the system is abundant, these measures can 724 
DYSENTERY. 
hardly he followed by any unpleasant effects. They will often be 
well borne at any time before much exhaustion has occurred. Bleed- 
ing, however, is seldom required, and is useful only in exceptional cases. 
Large and repeated doses of calomel are unnecessary, and in many 
cases would be very injurious and dangerous. In robust unsuscep- 
tible patients with “bilious” complications, a few decided doses, 
followed if need be, and as a rule, by a saline laxative or cathartic, 
may be of marked benefit ; and in hot climates and seasons, and in 
malarial districts especially, a few smaller doses of some mercurial, 
followed generally by laxatives, experience has proved to be useful. 
The mercurial modifies favorably the secretions and conditions of the 
stomach and bowels, favors the discharge of bile, and tends to unload 
the so often congested liver, and to relieve the portal circulation so 
often obstructed. The influence of portal congestion upon hvpersemia 
and inflammation of the abdominal viscera is well known. In anaemic, 
delicate, and impressible patients mercury must be used with great 
caution and in smaller doses, but with the proper precautions it may 
be as useful with them as with others. 
Saline purgatives and laxatives have their decided uses. In con- 
nection with mercurials, as just mentioned, and often by themselves, 
by increasing the watery secretion from the hypersemic mucous mem- 
brane, they unload its vessels, and often procure more relief in this 
way than they cause irritation by their specific exciting effect. They 
operate to a large extent by endosmosis, and not unfrequently pro- 
duce no perceptible irritation ; but their too frequent and excessive 
use may irritate, weaken, and depress too much, and they must be 
prescribed with great care and discretion. The authority of Breton- 
neau and Trousseau is quoted in favor of free doses of saline cathar- 
tics, but not as exclusive remedies in the disease. Trousseau, how- 
ever, in his zeal for evacuants, condemns any considerable use of 
opium. Dr. Woodward, in the Army Medical Report, relies much 
on saline purgatives, regarding sulphate of soda as the best. Early 
given, he says, they evacuate the intestines, increase secretion, and 
relieve portal congestion. He condemns astringents in the active 
stages and uses opium sparingly. Jaccoud likewise advises caution 
in the use of opium. 
Dr. Bartholow also regards saline evacuants as of the first impor- 
tance in the early stages of the disease, before the mucous membrane 
has begun the process of denudation, and prefers sulphate of mag- 
nesia acidulated with dilute sulphuric acid. He says, “ it serves a 
triple purpose ; it empties the canal of retained faeces ; it lessens 
hvperaemia by setting up an outward osmotic flow ; and its after 
effect is astringent and sedative.” TREATMENT. 
725 
Tartar emetic, in any quantity sufficient to exert an antiphlogistic 
effect, would be so sure to irritate the mucous surface that its use 
should be discarded. 
The method of giving laxatives or cathartics to secure fecal and 
liquid discharges, then opium to keep the bowels as long as possible 
at rest, and then laxatives and opium to be repeated, and so on dur- 
ing the active stage of the disease, lias been praised by some ; and 
in vigorous and unsusceptible patients may, for a time at least, be 
borne with advantage. But the frequent repetition of the cathartics 
is, in most cases, too irritating and debilitating, and as a general and 
indiscriminate practice cannot be advised. 
The continued use of small doses of laxative salines, as a drachm 
of sulphate of soda or phosphate of soda, or Rochelle salts, repeated 
once in four hours, called the “ saline” treatment, has its advocates, 
and in sthenic cases may be proper, if other means are used at the 
same time ; but as an exclusive or constant method I cannot ad- 
vise it. 
The repeated and continued use of larger or smaller doses of castor 
oil in nearly all stages of the disease, with other oily emulsions, is 
advocated by some with great earnestness. Dr. Pantaleoni, of Rome, 
one of the most prominent physicians in Italy, strongly advises this 
course, and claims almost uniform success in the treatment of dysen- 
tery as it occurs in that city, both among the natives and the foreign 
visitors. He gives it in doses sufficient to evacuate the bowels, and 
then in smaller quantities of a drachm or so, once in a few hours, 
giving occasionally freer doses when a cathartic effect is required. 
The discharges, it is alleged, are notably checked, even in the 
advanced stages, by this treatment. Others have advocated the same 
or a similar plan, but my own observation of the effects has not been 
sufficient to enable me to express a decided opinion. The late Dr. 
Z. Pitcher, of Detroit, well known to the profession, often used in his 
practice small (one or two tea-spoonfuls) and repeated doses of olive- 
oil, frequently combined with small doses of laudanum. 
The use of free and repeated doses of opium has many advocates, 
and few practitioners would treat a severe case of dysentery through- 
out, without the aid of this important drug. There are those, how- 
ever, of high authority, as we have seen, who condemn its general use, 
contending that the intestinal discharges should rather be promoted 
than checked ; and that though it procures temporary relief from pain, 
patients do better without it. These views are certainly worthy of 
being considered, and the effects of this article may be too much relied 
upon. Every physician of much experience has found that it some- 
times fails to procure relief from the tenesmus and frequent dis- 726 
DYSENTERY. 
charges, while it often tends to produce the retention of urine, so 
common in some cases, and sometimes to seriously disturb the nervous 
system. 
But after proper evacuations, and interspersed with other agents 
so that the secretions from the intestines and liver are not too much 
checked, it often affords, in proper doses, great relief to the suffering; 
and dysenteric inflammation does not so much differ from other in- 
flammations of the intestines that opium, acknowledged to he so use- 
ful in the latter in abating inflammatory action, is incapable of doing 
so in the former. It has its place, and an important one, as I believe, 
in the treatment of dysentery, and the interests of patients will not 
allow it to be entirely set aside in this disease. 
Ipecacuanha is another remedy about which there are differences 
of opinion as to its use in dysentery. It first obtained its introduction 
into practice about two hundred years ago, as a remedy in this affec- 
tion, and after nearly losing its reputation as an antidysenteric remedy 
for a long period, it has now regained it, and has been extravagantly 
praised of late by some when given in very large doses. It is said to 
be very extensively used in the severe dysenteries of India, and that 
since its general introduction the mortality in this disease has been 
reduced from 79.6 per one thousand cases, to 20.15 per one thousand. 
It should be understood that statistics of this kind respecting the use 
of any single medicine or method of treatment are not to be fully 
relied upon in determining its value. Diseases differ greatly in their 
severity at different times ; and often changes in hygienic conditions, 
or in various items of treatment, are introduced at the same time. 
However, the testimony in favor of ipecac, in dysentery is sufficient to 
demand for it careful investigation. Dr. Maclean, of the British army 
in India, gives from twenty-five to thirty grains at a single dose, in a 
small quantity of fluid, such as the syrup of orange peel, though per- 
haps it is better given in a wafer or capsule. He enjoins perfect quiet, 
and allows no drinks for three or four hours, wTith the view of pre- 
venting vomiting. In from eight to ten hours it is given again in 
doses of from ten to fifteen grains, repeated, if necessary, for days, 
until the symptoms are much improved. Others advise smaller doses 
repeated oftener, but so as, if possible, to prevent vomiting; while 
others still give it so as to induce vomiting at first, but endeavor by 
opiates, mustard to the epigastrium, and the withholding of much 
drink, to establish a tolerance afterward. Others give from thirty to 
sixty grains every four or five hours, and by opiates, etc., endeavor to 
prevent emesis. Dr. Bartholow mentions the following powder, to be 
taken at once: ty Ipecac., 3ss; Opium, gr.j; Pulv. Aromat., gr.v. M.— 
A sinapism is to be applied to the epigastrium, and an enema of starch TREATMENT. 
727 
and laudanum, or a hypodermic injection of morphine, is to be given. 
He has used fifteen-grain doses in milk, and found it often well borne ; 
but says that not unfrequently tolerance cannot be established, and 
that the remedy must be abandoned. Jaccoud says the ancient Bra- 
zilian method of giving the medicine is the best. Make an infusion 
of from 3ss to 3ij of ipecac, in from 5vjss to lx of water. This liquid 
is to be taken in appropriate free doses once or twice during the day, 
and continued for several days. In consequence of the nausea ipecac- 
uanha produces, patients are often with difficulty persuaded to take 
it; and its specific virtues in the disease are doubted by many, and by 
some denied. 
Dr, Woodward, in the United States Army Medical Report, ad- 
vises it in the early stages of some cases of dysentery as an emetic, 
but doubts its specific effects in the disease. On the contrary, accord- 
ing to Dr. Flint (Clin. Med., p. 284), Dr. A. A. Woodhall, of the 
army, shows “ conclusively that it is entitled to be called an abortive 
remedy.” Evidence on either side might be much further quoted, 
but without coming to positive conclusions as to the amount of benefit 
the remedy may afford. 
There can, however, be little doubt that in some cases of dysen- 
tery, ipecac., in free doses, produces decidedly favorable effects, 
especially in the dysenteries of hot climates, often causing a change 
in the character of the evacuations, producing what are called “ipe- 
cac. stools,” abating the fever, and allaying the inflammation. It is, 
therefore, worthy of further trial ; and it is to be hoped that the 
cases to which it is best adapted will ere long be determined. Judg- 
ing from the known physiological effects of the article and its thera- 
peutical action in other diseases, we should conclude it to be best 
adapted to strong and vigorous patients, not too far reduced by the 
disease, free from gastric irritation, and not sensitive to nauseant 
remedies. With such it may be tried ; hut I should be reluctant to 
persist long in its use where it did not seem to be well borne, or 
where it produced much depression. 
The treatment with repeated cold water enemas may be adapted 
to some cases, the water by its direct local effect diminishing the 
hyperaemia and the inflammation of the intestines. Enemas, how- 
ever, will frequently not be retained, especially in quantities sufficient 
to apply to any considerable portion of the intestine, and their fre- 
quent repetition becomes not unfrequently a source of irritation. 
When there is much gastric, duodenal, and enteric irritation, nitrate 
of potash could scarcely fail of increasing this condition. Great care 
should be exercised in the mode of administering enemas. A soft, 
elastic tube will be found least irritating ; and if the patient be placed 728 
DYSENTERY. 
in the “ knee and elbow,” or, better, in the “knee and chest” posi- 
tion, a soft tube may be introduced into the colon, and the inflamed 
intestine irrigated often with benefit. 
How, then, shall the ordinary cases of summer and autumn dysen- 
tery in our climate be treated ? My personal observation has been 
chiefly in the North-west—Southern Michigan, Chicago, and Northern 
Illinois—but it has extended to New England, and to the army of the 
Potomac in Virginia during our late civil war. These observations 
have continued many years, and embraced a large number of cases. 
The course my experience leads me to advise is as follows : When the 
disease commences in the ordinary manner of decided attacks, with 
the symptoms which have been sufficiently described, should there be 
evidence that the stomach is oppressed with undigested food or with 
bilious secretions, twenty grains of ipecacuanha, in a cup of warm 
water, may be given at once, and fifteen grains in half an hour if the 
first does not produce emesis, smaller doses being repeated as may be 
required to produce a free emetic effect. After the stomach is well 
washed out (warm water or weak chamomile tea being taken to facili- 
tate the vomiting), and the nausea has subsided, five or six grains of 
blue mass, or four or five grains of calomel, and an eighth of a grain 
of morphine, should be given, and a similar dose repeated in from 
three to five hours. Unless free diarrhoeal discharges follow from the 
effect of the ipecac, and the mercurial, in four hours after the last 
powder, a saline cathartic, sulphate of soda, sulphate of magnesia, 
or Rochelle salts, etc., in a dose of from four to eight drachms, well 
diluted, and perhaps in warm water, with some aromatic added, 
should be administered. Should this not produce a cathartic effect in 
four or five hours, the dose, in quantities thought necessary, should 
be repeated. After this operation an opiate should be given, with a 
moderate quantity of ipecacuanha—say one fourth grain of a salt of 
morphine, with from one to three or more grains of ipecac.—and the 
dose repeated sufficiently often to obtain a fair, decided anodyne effect 
of the morphine; and the quantity of ipecac, may be increased to 
the larger doses, if nausea is not produced and the patient is not made 
uncomfortable by it. In some cases, bismuth in free doses exerts a 
soothing effect and agrees well with the stomach. 
This treatment might be continued for one or two days at least, 
and the after-treatment should be governed by the conditions pre- 
sented. If the eyes are yellow and the tongue much coated, a few 
grains of a mercurial might then again be given ; and if only mucous 
and bloody discharges have occurred, and the patient’s strength has 
not been greatly impaired, this should be followed by another saline 
laxative; and this, again, by the opiates. Should the tenesmus be TREATMENT. 
729 
great, the opiates might be given by enema, in a moderate quantity of 
some bland fluid (thin, well-made starch answering a good purpose). 
When laudanum is the form of opiate it is commouly given in starch, 
but morphine or some aqueous preparation of opium is as well given 
in water. Opium or morphine suppositories, with cocoa butter, are 
ofteu better borne than enemas. In children, where neither enemas 
nor suppositories will be retained, morphine dissolved in glycerine, or 
mixed with a little fresh butter, may be applied by the finger of the 
nurse to the verge of the anus, or just within the sphincter, with a 
decidedly soothing effect. The quantity must be properly regulated, 
as absorption takes place, and a general as well as local effect is 
produced. 
Morphine, hypodermically, may be used here as in other cases, when 
thought advisable. Its general soothing effects are more marked, when 
used in this manner, than in any other. Should the pain be great in 
the abdomen, fomentations or inunctions of extract of belladonna 
might be applied. 
The laxatives might be repeated or not, according to the amount 
of fever, the strength of the patient, and the amount and character of 
the discharges. Should there be much fever, and should the case 
present no adynamic characteristics, saline laxatives in small doses 
may be repeated once in four or five hours, thus adopting the saline 
treatment. 
In any of the cases where laxatives or cathartics have been men- 
tioned, castor-oil may be used in place of the salines, and would be 
preferable where there was much debility, or where the salines pro- 
duced an irritating or depressing effect. Mucilaginous drinks, or 
emulsions of almond-oil, might be given in place of the small doses of 
the salines, in cases of a more adynamic character. 
If the disease persists for ten days or more, there will be reason to 
apprehend the advent of the suppurative stage, with denudation and 
ulcerations of the mucous membrane. The salines, as a rule, must 
now be discontinued, and oils and emulsions, if laxatives are required, 
should take their place. 
In this stage of the disease, and sometimes earlier, I have found 
much benefit from the use of the turpentine emulsion, to which refer- 
ence has several times been made, and for which a formula has already 
been given. I cannot too strongly express my opinion of the utility 
of this preparation in many cases at this stage of the disease. A simi- 
lar condition is now present to that which exists in the ulcerative 
stage of Peyer’s glands in typhoid fever, and in the advanced condition 
in other forms of muco-enteritis previously described. 
A formula is here repeated : 730 
DYSENTERY. 
3 Oil of Turpentine 3iijss 
Tinct. of Opium 3iij—jv 
Gum Arabic (pulv.), 
White Sugar aa 3ss 
Camphor Water liii 
M.—For emulsion. Dose 3j, once in four or six 
hours. 
Local alteratives and astringents may now be useful, the more 
unequivocally as the case approaches the chronic state. Injections 
of solutions of nitrate of silver, of the strength and in the manner 
described under the head of muco-enteritis, will often now be of the 
greatest service. Trousseau used from ten to twelve grains to eight 
ounces of water. Other local alteratives or astringents, such as the 
preparations of tannin, or vegetable infusions containing tannic or 
gallic acid as the basis ; sulpli. of zinc ; weak solutions of carbolic 
acid; the astringent preparations of iron; acetate of lead, three to five 
grains to the ounce ; chloride of zinc, one half to two grains to the 
ounce, etc., are articles from which selections may be made to act as 
astringent and alterative enemas. In the meantime the general 
treatment must be adapted to the condition which the case has 
assumed. Tonics and astringents internally may be required ; and 
throughout, the diet and all the hygienic arrangements will require 
careful attention. The diet and the internal remedies now will not 
differ materially from those advised in muco-enteritis. Dr. Bartlio- 
low says : “When destruction of the mucous membrane is beginning, 
the most effective remedies are corrosive sublimate, sulphate of 
copper, sulphate and oxide of zinc, acetate of lead, bismuth, arsenic, 
etc. Of this formidable list, sulphate of copper and arsenic are most 
effective. They ought to be combined with opium.” (Practice, p. 89.) 
He advises Fowler’s solution in doses of one drop with from five to 
twenty drops of deodorized tincture of opium every three hours. The 
sulphate of copper is advised in doses of one twentieth of a grain 
with one eighth or one twelfth of a grain of morphine every three 
hours. It must require very accurate discriminating powers to deter- 
mine how much of the good effects of these prescriptions is due to 
the arsenic or copper, and how much to the opiate. The proof of 
the real efficacy of these alterative articles in such doses needs con- 
firmation. The fluid extr. of coto bark has lately come into use in 
subacute stages of dysentery, and is highly spoken of by some whose 
opinions are worthy of respect. It is given in doses of ten or fifteen 
drops with a drachm of paregoric. 
When a malarial influence is present, and the symptoms present TREATMENT. 
731 
any periodicity indicative of that influence, quinine must be given in 
full antimalarial doses, but not long continued in such quantities. 
The very striking effects which I have so repeatedly seen from it, not 
only in controlling the fever and periodicity, but the inflammation of 
the intestines and the dysenteric symptoms as well, have led me do 
prescribe it in connection with opium, in cases where there was no 
reason to suspect the presence of a malarious influence ; and the bene- 
ficial effects in many cases of this kind have been almost as striking 
as where a malarial influence was evident. Dr. Woodward, in the 
Army Eeport before referred to, mentions the strikingly beneficial 
effects of quinine in antipyretic doses. The frequent reference to the 
use of full doses of quinine in various conditions of inflammation and 
fever may to some, not practically familiar with such use, seem 
routine and extravagant; but if it bo an antipyretic and antiphlogistic 
agent of great value, as I believe it is, it is applicable to a large num- 
ber of diseases where fever and inflammation are present, and there- 
fore requires to be frequently mentioned. 
The profession must ultimately become familiar with the fact, 
that most inflammations, as well as the febrile state, are materially 
influenced, and often abruptly terminated, by *‘ antipyretic ” doses of 
quinine. The effect of salicin, salicylic acid, or salicylate of soda 
may be similar, but I have not had experience with them in dysentery. 
Free antipyretic doses must be given, if anti-inflammatory effects are 
realized. In the most severe and malignant cases of dysentery, the 
same general principles apply as in the more ordinary forms of the 
disease, the treatment of which I have endeavored to describe. All 
depressing agents, however, must be avoided, and full antipyretic 
doses of quinine should be early given, and tonic doses may afterward 
be continued. 
In the sloughing stage of the severe cases supporting measures, 
tonics, and stimulants may be tried, and injections of permanganate 
of potash may be given ; but of course in such cases all efforts com- 
monly fail. 
Confirmed cases of chronic dysentery are exceedingly obstinate and 
often fatal. The treatment must be conducted on the same principles 
as in those cases where the disease is approaching and merging into 
that state. Tonics and astringents internally—the liquor ferri-ter- 
nitratis, sulph. of iron or copper with opium, the turpentine emul- 
sion, and other balsamic preparations, as described in chronic muco- 
enteritis, should be tried. The local application of nitrate of silver 
in stick, after cleansing the rectum, if the ulcerated surfaces can be 
reached ; or by injections when higher up, affords the greatest pros- 732 
DYSENTERY. 
pect of relief. Other local and internal remedies may be tried, such 
as nitric acid locally, strychnine and nitric acid, stimulants, etc., in- 
ternally, as already advised in similar or identical forms of muco- 
enteritis. A change of climate may succeed where other means 
fail. 
The complications of dysentery, such as pyaemia, abscess of the 
liver, etc., wdll call for the treatment which these affections demand 
in other cases, taking into account the dysenteric condition. Not 
only the more severe complicating accidents, but special symptoms 
occurring at any stage of dysentery will require attention and such 
treatment as their relief demands. The catheter must be used when 
the urine is retained, but with care, as the urethra and bladder are 
often exceedingly irritable, and more or less severely inflamed. 
Fomentations, the warm bath, etc., may afford relief, but the use of 
the catheter where there is much distention of the bladder must not 
be delayed. The mistake should be avoided of selecting too small an 
instrument where no firm organic stricture of the urethra exists. A 
good-sized instrument is more easily introduced and far less dangerous 
than a small one. 
Too much attention cannot well be given to the diet, but it will 
not differ from that applicable in other cases of muco-enteritis, and 
to the statements under that head the reader is referred. 
The sequelae, such as impairment of the function and contraction 
of the intestine, etc., must be treated by sustaining measures and 
hygienic regulations. 
An inflammation followed by ulceration of the lower intestines, 
with dysenteric symptoms, sometimes follows the free use of mercury 
—a condition of these parts being induced similar to that in mercurial 
stomatitis. The chlorate of potash at first, and the iodide of potas- 
sium afterward, as in other cases of mercurialization, will be required. 
It will be inferred from the discussion which has preceded, that 
astringents are disapproved of in the acute forms of dysentery. They 
can be useful only in very exceptional cases, and are generally de- 
cidedly hurtful. The temptation which some seem to have to resort 
to them must be resisted, and even opiates must be used with dis- 
cretion. An acute inflammation will be aggravated by an irritating 
astringent, and while the inflammation is present and active, the 
secretion and discharges unload the vessels and procure relief. Opium 
is given, not to suppress directly the secretion, but to allay irritation 
and check the inflammatory processes. Its action in checking the 
secretion, except as it does so by allaying inflammation, is not generally 
desirable. If it operated directly and only as an astringent, its effect TREATMENT. 
733 
in acute dysentery would, as a rule, be harmful. Its claims to be 
used in acute cases rest entirely on other properties. 
In describing the treatment of dysentery, I have deviated from the 
custom which I have adopted in most cases, of giving the treatment 
my experience and judgment lead me to think best, without entering 
upon particular descriptions of other methods which I cannot so fully 
approve. This, however, is a disease of such wide prevalence, and 
often of such great severity, occurring under such a variety of con- 
ditions, and presenting such different types and peculiarities, that I 
have felt bound to mention a variety of views which are entertained, 
and to describe a variety of methods which are in favor with those 
whose opinions are entitled to respect. I do not feel myself bound to 
any special method, and would encourage a choice of courses to bo 
pursued, according to the experience and judgment of each practitioner 
in the various localities and seasons, and in the various forms in which 
he meets the disease. The medicines for dysentery more particularly 
to be studied are—opium, saline cathartics, castor-oil, mercury, oily 
emulsions, ipecacuanha, astringents, turpentine emulsion, nitrate of 
silver, and quinine. 
HEMORRHOIDS. 
Hemorrhoids, especially so far as their local conditions and 
mechanical treatment are concerned, come under the province of 
surgery. No special description of this common affection will there- 
fore be given. But as complications or results of hepatic obstruction, 
portal congestion, and constipation, and as causing a variety of reflex 
irritations, and by the loss of blood, anaemia and debility, etc., they 
often come under the observation of the physician. 
The management of hemorrhoids, so far as the physician is spe- 
cially concerned, consists in the avoidance and removal of their chief 
causes, and in the treatment of the conditions which they induce. 
Perhaps the most frequent cause of this affection is constipation. 
The causes and treatment of this condition will bo considered in 
another connection, and need not here be entered upon. Obstructed 
portal circulation, the other prominent cause, will also receive atten- 
tion elsewhere ; and the various affections, the results of anaemia and 
reflex irritations, produced by hemorrhoids will also be treated of 
in their appropriate places. Nothing more need be said here than 
that the subject has much importance, as the disease is so frequent; 
and that the physician will often have occasion to deal with those 
conditions which lead to and result from this affection of the veins 
and tissues of the rectum. 
Much the same may be said respecting anal fissure. 734 
INTESTINAL HEMORRHAGE. 
Both of these affections should receive the prompt attention of the 
practitioner, and should, as soon as possible, be removed. Their 
influence upon other diseases and the general conditions of the sys- 
tem is too often overlooked. The directions in surgical works 
respecting the treatment of hemorrhoids and fissures are referred to. 
It may be well to state, however, that in the case of hemorrhoids, in 
the acute attacks of inflammation of these tumors which are liable to 
occur, prompt and immediate treatment when the irritation, pain, and 
swelling begin, by unloading the bowels with a simple enema, enjoin- 
ing absolute rest, and applying soothing and astringent preparations 
locally, such as a solution of acetate of lead and acetate of morphine, 
will frequently save much suffering. 
The removal of the tumors by surgical means, when they become 
permanent, constitutes the radical cure. 
INTESTINAL HEMORRHAGE. 
Passages of blood from the bowels have already been spoken of 
under other heads. 
The lower bowels are subject to hemorrhages from various causes, 
such as portal congestion, ulcerations which open vessels, malignant 
tumors, etc. Whenever such hemorrhage occurs, its source and cause 
should, if possible, be determined, and treatment applied according to 
the indications presented. The blood from this part of the intestinal 
canal is generally passed off soon after its emission from the vessels, 
and is, consequently, fresher and less black than that which comes 
from the stomach or upper intestines. Besides the general means of 
arresting hemorrhage, such as rest, internal astringents, ergot, opiates, 
etc., local means, cold and astringent injections, and when within 
reach, direct internal pressure, are indicated, and are more likely to 
be efficient than when the source of the bleeding is higher in the 
canal; and these means should be promptly applied as required. 
Pieces of ice introduced into the rectum and allowed to dissolve 
there will often be efficient, and injections of solutions of alum, 
perchloride of iron, tannin, etc., in quantities of about four ounces, 
or less when the source of the hemorrhage is very low—sufficient to 
reach the bleeding part, but not too much to be retained—are also 
applicable. Quiet and the horizontal position are very important; 
the bowels should be kept from moving for some days afterward by 
opium and restricted food ; and when a movement is about to occur, 
the ftecal matter should be liquefied as much as possible by injec- 
tions of cool or cold water. VARIETIES. 
735 
The anaemia and other derangements following intestinal hem- 
orrhages will require tonics—iron, bitters, etc.—and a proper generous 
diet, as after other losses of blood. 
The rectum is liable to a local inflammation and ulceration of its 
mucous surface independent of dysentery, as has already been de- 
scribed. Various causes—the presence of ascarides, long-continued 
constipation, the pressure of a retroverted uterus, or an enlarged 
prostate gland, or the presence of hemorrhoids, or fissures, etc.—pro- 
duce this state. 
A sense of uneasiness, tenderness and pain, and occasional mucous 
discharges would mark the condition. There would not, however, be 
the general history and general symptoms of dysentery. 
The treatment would consist in removing the causes, and in such 
local treatment—soothing, astringent, or alterative—generally by in- 
jections, as the particular condition may require. The principles 
of treatment will be the same as in other inflammations or ulcerations 
of mucous membranes. The direct application of a stick of nitrate 
of silver or the mitigated caustic might be proper here, as in the 
ulcerations of chronic dysentery. 
Polypoid growths and other tumors may appear in this situation, 
but they belong to surgery, and require only such attention from the 
physician as the general symptoms which may be induced demand. 
Removal by surgical means is the proper radical remedy. 
ACUTE PERITONITIS. 
Peritonitis is an inflammation of the serous membrane lining the 
abdominal cavity and investing the various organs which it contains. 
This inflammation may be acute or chronic, may be limited to a part 
of the membranes, when it is said to be local; or may extend over the 
whole surface, when it is general. It may be an independent, original 
affection, when it is said to be primary; or it may be the result of 
some other diseased condition, when it is secondary. 
The peritoneum is a membrane of such great extent, not only 
covering all the abdominal viscera, but increased by its various 
folds, that an inflammation of its entire surface is a formidable affec- 
tion. From variations, however, in the extent, intensity, and special 
character of the inflammations, the gravity of the disease varies in dif- 
ferent cases. Still, every form demands the earnest attention of the 
physician, and a careful account of its causes, symptoms, and treat- 
ment seems necessary. 
In the discussion of the process of inflammation, that which occurs 736 
PERITONITIS. 
in serous membranes was described, and as the peritoneum is a typical 
serous membrane, a special and minute pathological account of its 
inflammation will be unnecessary. Hypersemia, exudates within its 
tissue and upon its surface, serous, plastic, and purulent, with soften- 
ing, thickening, and other changes in its texture, mark the disease 
anatomically. 
Symptoms.—An attack of primary acute peritonitis sets in with 
a chill, followed by a high fever, sometimes at first with a full-bound- 
ing pulse ; but often the shock of the disease upon so extensive a 
surface produces depression and a contracted but rapid pulse, and 
sometimes quite speedy collapse ensues. 
Its chief local symptomatic phenomena are pain and tenderness. 
The pain is burning and lancinating, aggravated by motion, usually 
severe, and extends, when the inflammation is general, over the mem- 
brane to the whole abdomen ; but in most cases it is more intense in 
particular situations, oftener perhaps than elsewhere in the right iliac 
region. The tenderness is marked on pressure, on coughing or 
sneezing, and even the weight of the bedclothes is often distressing. 
The abdominal muscles are generally rigid, and as the disease ad- 
vances the abdomen usually becomes distended and tympanitic, some- 
times extremely so ; the bowels are commonly constipated, and vomit- 
ing is a frequent symptom. 
Free movements of the diaphragm give so much pain that the 
respiration is shallow and mostly thoracic, particularly when the 
difficulty of respiration is increased by the distention of the abdomen. 
From the tenderness, and the more or less paralyzed condition of the 
abdominal muscles, but slight expiratory efforts can be made, and 
therefore the voice is feeble. In the latter period of a severe case hic- 
cough is a frequent symptom, and the vomiting of a greenish or verv 
dark fluid is common. The face is haggard and expressive of severe 
suffering ; the patient lies upon his back with the knees drawn up to 
relieve the tension of the abdominal muscles and diminish pressure 
upon the viscera, as well as to prevent the weight and pressure from 
the bedclothes. Retention of urine not unfrequently occurs, requir- 
ing the use of the catheter. The pulse is frequent, and sometimes 
very small and feeble from tbe first, increasing in frequency and 
feebleness as the disease advances in severity ; though in the early 
stage it is sometimes more full, and often quite hard. In fatal cases 
the pulse becomes extremely frequent, weak, and often irregular, and 
may cease at the wrist some time before death. The temperature, 
especially of the extremities, varies in different cases. It may be 
only moderately elevated in the cavities, or may rise to 105° F. or DIAGNOSIS. 
737 
higher. In the collapsed condition the extremities become cold, and 
even the central temperature may fall below the normal. The suffer- 
ing usually ceases before consciousness is lost, and the mind is often 
intact almost to the very last, the patient becoming hopeful and 
almost cheerful while death is immediately impending. 
Occasionally cases occur in which the shock at the onset is so 
great and the collapse so speedy, that none of the usual suffering is 
experienced. In these cases the real nature of the disease may not be 
known until a post-mortem examination reveals the condition. In 
such cases poisoning, or improper treatment might be suspected, and 
an autopsy becomes very important. If the death is very speedy, but 
little exudate may be present, but a careful examination will not fail 
to show the nature of the disease. Cases have come Avithin my obser- 
vation where grave suspicion was remoA'ed only by the autopsy. 
Diagnosis.—The diseases which have some features of resem- 
blance to peritonitis, and from which it should be distinguished, 
are—enteritis ; enteralgia with dermal tenderness, especially in hys- 
terical Avomen ; colic, and possibly internal hernia, or other forms of 
intestinal obstruction. From muco-enteritis the diagnosis may be 
readily made by the less degree of pain and tenderness, and by the 
diarrhoea which accompanies the intestinal catarrh. From phleg- 
monous enteritis the distinction is not so easily made, nor is it so 
important, as the peritoneum is invobed in both, though to a more 
limited extent in enteritis ; and while the pain and tenderness are 
not so general, the treatment and prognosis are similar. 
It is of more importance not to confound peritonitis with colic, 
or the neuropathic affections. These are infinitely less serious, and 
do not require the same treatment. In colic the pain is more inter- 
mitting, and is generally relieved by pressure. The patient usually 
moves or throws himself about with freedom, while in peritonitis he 
instinctively avoids motion. In hysterical neuralgia there may be 
much cutaneous hyperesthesia, and great shrinking from slight press- 
ure ; but firm pressure upon a broad surface will be borne, and often 
wTith relief. In neither of these cases Avill there be the fever, Avhich 
is often preceded by a chill, nor the rapid pulse and profound shock 
of peritonitis. In exceptional cases there maybe difficulty of diag- 
nosis. Dr. Flint witnessed a case, supposed to be colic, where the 
patient, instead of keeping a fixed position, writhed in his distress, 
and did not take to his bed until shortly before death. The autopsy 
revealed acute peritonitis. In another case, where a similar condition 
was found post mortem, active vomiting and purging led to a diag- 
nosis of cholera. These cases were, hoAvever, probably complications, 
the symptoms of peritonitis being obscured by the other conditions. 738 
PERITONITIS. 
Etiology.—The causation of peritonitis is often important to be 
known, both with reference to diagnosis and prognosis, and some- 
times with reference to the treatment. Primary idiopathic peri- 
tonitis may occur from the ordinary causes of internal inflammation, 
and the disease may then present a typical form ; but it is more 
frequently secondary, the result of some other diseases or pathological 
conditions, or of injuries inflicted upon the peritoneum or neighbor- 
ing parts. 
When caused by exposure to cold and wet, etc., it may occur in 
the robust and healthy, but it is more likely to attack the delicate 
and impressible, and those laboring under other diseases—of the heart, 
lungs, liver, or kidneys. It is particularly liable to occur, either in 
an acute or more chronic form, in cirrhosis of the liver, in Bright’s 
disease of the kidneys, and in tuberculosis. Not unfrequently it is due 
to simple extension of inflammation from other parts—from the 
stomach, intestines, liver, spleen, kidneys, or bladder, and especially 
from the uterus in the puerperal state, or at the menstrual period; 
and often it is produced by operations upon, and applications to, the 
pelvic organs of females. It more frequently arises from inflamma- 
tion of the ovaries, uterus, and other female pelvic organs, especially 
after parturition and abortions, than from any other causes. 
As we have already seen, it is not an unfrequent occurrence from 
perforation of the intestines in typhoid fever, and from other forms 
of ulceration, from penetrating ulcerations of the stomach, the cae- 
cum, and the vermiform process, and from abscesses in the iliac 
region, etc. Rupture of an hepatic abscess, of the gall-bladder or 
bile ducts, of hydatid cysts, of ovarian cysts, or of psoas, renal, or 
other abscesses, may all cause the discharge of irritating matters into 
the peritoneal cavity, to be followed by peritonitis. Physical violence, 
such as wounds, blows, or lacerations of the abdominal walls, or of 
special abdominal and pelvic organs, is often followed by peritonitis ; 
and lastly, it may be the result of pyaemia, or of the transference of 
erysipelatous inflammation from the surface. Cases of this latter 
kind I have seen several times. 
Pathological Anatomy.—The exudates in peritonitis, where 
the disease continues a sufficient length of time to allow of its full 
development, are usually abundant. The inflammation, though it 
sometimes remains local, and generally is more intense in some parts 
than in others, very commonly spreads over the entire surface to a 
greater or less degree. 
When the inflammation is of a moderate grade, the effusion is 
chiefly serum. When it is of a higher grade, the exudate is fibrinous 
and corpuscular—coagulable lymph or false membrane—and in some PATHOLOGICAL ANATOMY. 
739 
cases it is chiefly purulent. In many cases these elements are more or 
less mingled. In a majority of acute cases, on post-mortem examina- 
tion, straw-colored, semi-transparent plastic matter will be found filling 
the sulci between the folds of the intestines, much more in some situ- 
ations than in others, while a serous fluid, sometimes tinted with 
blood, will be found at the flanks or gravitated into the pelvis. In 
this fluid, and sometimes adherent to the membrane or freely mingled 
with the more solid exudate, will be found pus corpuscles in more 
or less abundance. 
In milder but more protracted cases the abdomen will often be 
found distended with serum, in which may be flocculi of coagulable 
matter, or some pus corpuscles, or both ; but sometimes nearly pure 
serum is found. In other cases, especially in septic or pyaemic and 
puerperal peritonitis, the chief exudate may be pus. 
In cases of recovery, where the chief exudate is serum, it will often 
be readily absorbed away, leaving little or no trace of the disease 
behind. When plastic exudates are poured out, and remain in that 
form after the inflammation abates, organization is likely to take 
place, and the subsequent contraction of bands or masses of this false 
membrane may constrict the intestines and obstruct their function ; 
and sometimes, especially after repeated attacks, nearly the Avhole 
body of the intestines may be conglomerated into an inextricable mass. 
A case of this kind in a young unmarried woman came under my 
observation several years ago, where pregnancy was suspected from the 
presence of a rounded tumor which filled the abdomen, appearing and 
feeling much like the gravid uterus at the seventh or eighth month of 
gestation. A vaginal examination proved the non-existence of preg- 
nancy, and, not long after, complete occlusion of the intestines gave 
an opportunity for a post-mortem examination, which showed the 
condition of things above indicated. 
A hasty professional opinion of pregnancy had given an unquestion- 
ably virtuous young woman a great deal of annoyance and mental dis- 
tress. Single bands may form, embracing a loop of intestine, or a 
greater or less extent of intestine may be compressed and finally 
obstructed. 
These false membranes, without producing such serious conse- 
quences, may give rise to constipation and pain, and to subsequent 
attacks of inflammation. Sometimes plastic adhesions surround a 
quantity of pus, and distinct peritoneal abscesses result. These may 
find their way through into an intestine, the pus being discharged by 
stool. Where perforation of an intestine occurs, adhesive inflamma- 
tion may confine the intestinal matters, the peritonitis may be local, 
and a faecal abscess may form. The course of these abscesses will 740 
PERITONITIS. 
vary, some reopening an intestine, some bursting into the peritoneal 
cavity, some approaching the surface, etc. 
Prognosis.—This is always grave in peritonitis. Its course is 
very various, depending upon its extent and severity, and upon the 
power of endurance of the patient. The inflammation may soon be 
arrested, it may subside after some days or weeks, or it may become 
chronic. On the other hand, it may prove fatal in a day or two, or 
even in a few hours, or it may result in death in one, twro, or several 
weeks, or, by its accidents or consequences, at a much later period. 
Peritonitis dependent upon wounds, operations, and injuries, belongs 
to the province of surgery; and its peculiarities as connected with the 
puerperal state and with uterine and ovarian diseases, to the depart- 
ment of obstetrics and gynaecology, and need not here be particularly 
described. 
That form which depends upon gastric or intestinal perforation 
is of course sudden in occurrence, and is generally marked by severe 
pain and violent symptoms. In exceptional cases, however, the 
patient is overpowered by the shock, and falls into collapse without 
the usual suffering; and when rupture of the intestine occurs in a 
delirious or more or less comatose state of typhoid fever, the patient 
may not have sufficient sensibility to manifest the usual symptoms. 
In such cases the perforation and peritonitis can only be positively 
known after death. 
Treatment.—The principles of treatment in this formidable 
affection can soon be stated, though here, as elsewhere, their appli- 
cation requires discrimination and judgment. 
The disease is so rapid in its development, and the causes are of 
such a nature, that there is little opportunity to attempt their re- 
moval. We have to deal with consequences rather than causes, and, 
unfortunately, these are too often beyond our control. There are 
certain rational indications, however, which should be followed, as 
affording the greatest prospect of benefit. We have, as leading indi- 
cations or objects, to abate the inflammatory action, and to prevent 
or relieve the shock and depression which so severe and extensive an 
inflammation is sure to produce. In the early stage, before shock 
and depression are marked, means may be used for directly abating 
the inflammation. If the patient is vigorous and abounds in blood, 
and is not too much depressed from the shock of the onset, an early 
venesection, or the application of a good number of leeches to the 
abdomen, I cannot doubt, would be proper. I am fully aware of the 
statements by some, who are accepted as authorities, that as the 
patients die from asthenia—from failure of the heart’s action—blood- 
letting or other “debilitating” measures are contra-indicated. A TREATMENT. 
741 
moderate, or even considerable loss of blood, where there is a free and 
possibly a superabundant quantity in the system, thrown with great 
rapidity and often with unusual force, to inflamed parts, or accumu- 
lating in and oppressing particular organs, is by no means necessarily 
“debilitating.” On the contrary, the action of the respiratory and 
the circulating organs may become more free, the innervation mav bo 
improved, as the immediate effect of the abstraction of blood ; and if 
the inflammatory action be abated, the after-shock and depression 
will be lessened. 
But theoretical considerations must always be subordinate to the 
results of experience, when these are unequivocal. While I am not 
prepared to say that experience is unequivocal in favor of blood- 
letting in any cases of peritonitis, yet I believe that both theory and 
experience fully justify, if they do not positively demand, the use of 
this remedy under the circumstances above named. In many cases, 
however—in the majority as met with in practice, either from the 
time at which the patient is seen, or his condition as to the amount 
of blood, or the state of the circulation—I am quite as confident that 
bleeding would not be justified. It is impossible to express in precise 
language all the indications and contra-indications for the use of this 
remedy. It is easy to say that it must be left to the discretion and 
judgment of the physician ; but this is not sufficient for the informa- 
tion of the student, nor for the guidance of the inexperienced practi- 
tioner. But what can be said that is satisfactory ? If the patient is 
plethoric, the pulse strong, the lungs or the brain congested, there 
need be no hesitation. A bleeding may be well borne and useful 
where all of these conditions are not present. But when the shock is 
profound, the heart’s action feeble, and the depression great, the case 
is quite as clear ; bleeding is, of course, not to be practiced. In some 
of the intermediate cases there will be doubts, and when such doubts 
are felt it is better, perhaps, to desist from the practice. As patients 
are usually met with, venesection will very seldom be required, and the 
application of leeches in only a minority of cases. In deciding as to 
the use of this remedy, all the conditions must be taken into the 
account, and the judgment of the practitioner must determine. 
Respecting the means for soothing the sufferings of the patient, 
keeping the inflamed parts at rest, and preventing the severity of 
shock, there is happily less doubt. Opium is the great remedy in 
this disease. It should be given liberally, so as to relieve pain, and 
produce a decided medicinal effect, but not to the extreme of narco- 
tism. The susceptibility of patients differs so much that no positive 
rule can be given as to the dose, but a fair average would be two 
grains of opium or a fourth or third of a grain of a salt of morphine 742 
PERITONITIS. 
once in from three to five hours. Some adolescents, or young adults, 
are very susceptible to the effects of this remedy, and there must be 
caution in its administration, until the quantity that can be borne is 
ascertained. But a sufficient quantity should be given to contract the 
pupil, though not excessively ; to diminish the frequency of respira- 
tion, but not greatly ; and a steady, and not vacillating effect should 
be produced. Morphine hypodermically may be used with perhaps 
more prompt and more precise effect; and the addition of atropine 
is thought by some to render its therapeutic action more efficient. An 
average quantity used in this way would be one fourth of a grain of 
sulphate of morphine, with T|1F of a grain of sulphate of atropine, 
once in from three to six hours. But here the size and frequency of 
the dose must be left to the observation and judgment of the physician. 
There is no other alternative. Small mercurial doses may be added 
occasionally to prevent, if possible, so complete a suppression of some 
of the secretions as opium by itself might produce. Moderate quan- 
tities of a neutral mixture might also be given for the same purpose. 
Some advise, in addition, in the cases where the depression is not 
marked, the use of veratrum viride, aconite, or jaborandi, in cautious 
doses ; but their depressing effects upon the heart are as much to be 
feared as those of blood-letting. They must be used with caution. 
I have observed that those writers who have used quinine as an 
antipyretic in this, as in so many other inflammatory diseases, speak 
strongly of its good effects. Of its action in abating high tempera- 
ture there can be no doubt, and so far as that reduction is particularly 
desirable, the remedy for that purpose seems indicated ; and I must 
repeat the opinion, that its effects are not confined to the diminution 
of temperature, but that it operates also on other elements of the 
inflammatory process. It has the additional advantage, that even in 
doses sufficient to diminish the frequency of the pulse and produce 
free perspiration, it sustains rather than depresses the general life 
forces. I cannot doubt that bringing the patient under the full anti- 
pyretic effect of this remedy will, as a rule, decidedly tend to his 
benefit. So far from being incompatible with opium, it aids the sus- 
taining and soothing effect of that article in relieving shock. The 
opium as well as the quinine not only relieves shock, but tends pow- 
erfully to diminish inflammatory action. The use of these agents 
renders bleeding less necessary, and should reconcile its more ardent 
advocates to its present greatly diminished use. The quinine, in order 
to its proper effect, must be given in decided antipyretic doses. Here, 
as in other fevers and inflammations, the quinine should be given in 
a few free doses, frequently repeated, until a strong impression is 
made, or in a single large dose, and then suspended until the fever TREATMENT. 
743 
begins to return. This is the most efficient and least objectionable 
method. From twenty to thirty or forty grains should impress the 
system at the same time, but it is best introduced in divided doses of 
ten or fifteen grains. Such large doses must not, however, be long 
continued, lest injurious effects be produced on the brain and nervous 
system. 
The salicylate of soda in still more free doses may answer an equal 
or even better purpose, and it is at present largely superseding quinine 
as an antipyretic; but my own experience with it, except in rheuma- 
tism, has not been sufficient to enable me to speak of its use in these 
cases with the same confidence as of quinine. A combination of qui- 
nine and the salicylate is stated by Prof. Huguenin, of Zurich, to be 
especially efficacious in reducing temperature in typhoid fever, pneu- 
monia, and other cases where antipyretics arc required. 
One of the great improvements in modern practice is the avoidance 
of cathartics in peritonitis and phlegmonous enteritis. If at the com- 
mencement of the disease there is evidence that the rectum is loaded 
with faecal matter, there seems no objection to the administration of a 
warm water enema for the purpose of removing these accumulations 
without exciting the bowels much beyond this part; but after this the 
bowels must be kept at rest, and one of the objects in the administra- 
tion of opium is to produce that effect. The food taken must be such 
as leaves little residuum, and the bowels must be kept quiet until the 
inflammation disappears. They will then usually move spontaneously, 
and should be aided by no other means than, possibly, a simple enema 
of warm water. 
The avoidance of cathartics, especially in a fully developed or 
advanced stage, must be insisted upon, as a resort to one even of the 
mildest kind, such as castor-oil, will often bring back the inflamma- 
tion in a severe and fatal form when it had greatly subsided or 
nearly disappeared. A case of this kind is very distinctly remem- 
bered where improvement had gone steadily on for a week after the 
last movement of the bowels, when the attending physician yielded 
to the fears of serious consequences from the constipation, and di- 
rected a dose of castor-oil, which lighted up the embers of the expiring 
inflammation that sooii resulted fatally. Other cases are remem- 
bered where, during the active stages of the disease, a cathartic has 
immediately aggravated all the symptoms and turned the wavering 
scales in the wrong direction. 
Food with the least residuum, and no more than the stomach 
appears to digest, and the most perfect quiet to the inflamed bowels 
that can be secured, are essential items of proper treatment. A well- 
defined desire for a spontaneous movement, from faecal accumulations 744 
PERITONITIS. 
in the rectum, should not be resisted, and the passage may be facili- 
tated by a warm water enema very carefully administered. But the 
patient should not be raised from his recumbent position for the pur- 
pose of the evacuation, and the enema should be used only when the 
desire for a movement is felt. The use of cloths would be preferable 
to that of a bed-pan, so important is it that all motion, so far as pos- 
sible, should be avoided. Inattention to details, or wrong directions 
in what may appear to be trivial matters, may defeat all other efforts, 
however judicious. 
The question of external applications is one often mooted, and is 
by no means unimportant. The continuous steady application of cold 
water and warm water fomentations both had their advocates among 
those of high authority. At first view it might be supposed that if 
the one was useful the other must be injurious, but this does not 
follow. In external surgical inflammation, either warmth or cold, 
applied by water, may improve the condition of the same case; but 
one or the other will be preferable, according to the particular con- 
ditions. So probably in peritonitis. The object of the cold, applied 
so as to reach the inflamed part, is to c-onstringe the vessels and 
diminish the morbid molecular changes. The warmth is intended 
to soothe irritation and pain, and thus allay excitement and modify 
favorably the inflammatory processes. The application of water to 
the surface, independent of the temperature, whether by cloths, the 
spongiopilin, or a poultice, modifies the action not only of the cuta- 
neous nerves and vessels, but, by sympathy, of deeper parts. In deter- 
mining whether cold or warmth shall be used, the sensations of the 
patient should be consulted, but other conditions should also be con- 
sidered. If the patient is vigorous, the heat great, and the action of 
a more sthenic character, the cold will be better borne and more 
likely to be useful. On the other hand, if the patient is feeble and 
depressed, with nervous sensibility predominating, the warmth may 
answer a better purpose. For the application of cold in these cases 
Kibbel’s fever cot is the best contrivance. Prof. Thomas, of New 
York, has reported cases of peritonitis, after abdominal sections, 
where the application of cold wrater to the abdomen by meaus of the 
cot appeared to have a very decidedly beneficial effect, which has 
given encouragement to its use. It maybe as applicable to idiopathic 
as to traumatic peritonitis, where similar symptoms are presented. 
By means of the cot, water can be used at any temperature desired, 
with this advantage over the cold bath, that the extremities can 
be kept dry and warm. The construction and use of this cot has 
already been referred to. 
Counter-irritation, as by sinapisms or turpentine stupes (cloths TREATMENT. 
745 
wrung out of hot water and sprinkled with oil of turpentine) may 
also be useful. In whatever form of application, much weight must 
not rest upon the abdomen. 
In subacute forms of the disease, where the inflammation and its 
results linger, blisters to the abdomen, not too large or too frequently 
repeated, may be of essential service. The good effects of a blister 
in such cases are often quite striking. In severe cases and in the 
acute forms of the disease a large blister would be likely to add to 
the shock, and is contra-indicated. In subacute and more chronic 
cases, this danger does not exist, and the blisters aid the absorption of 
inflammatory products. In this stage applications of tinct. of iodine 
are useful, and, according to some, mercurial frictions also. Iodide of 
potassium may then often be given internally with much advantage. 
The diet should be a matter of much care throughout the disease, 
and should be governed by principles which have already repeatedly 
been stated. While proper nutrition is desirable, forcing upon the 
stomach food it cannot digest is, of course, particularly injurious 
where the intestines must take part in lodging or getting rid of the 
superfluous material, and where it is so desirable to keep them at rest. 
Particular symptoms may require palliation by special means 
other than those mentioned. Nausea and vomiting may require bits 
of ice, small effervescing draughts, hydrocyanic acid, sinapisms to the 
epigastrium, etc. ; and the condition of the stomach may require 
that other medicines should be given hypodermically, and food, and 
perhaps stimulants, by enema. Quinine, in the free doses necessary 
to produce antipyretic effects, may irritate the stomach. Dr. M. 
Charteris, of Glasgow, asserts that thirty grains of quinine and fif- 
teen of tartaric acid, dissolved in half an ounce of water, make a 
solution which may be freely injected hypodermically without local 
irritation. Not more than twenty minims should be injected at one 
point, but several injections may be simultaneously made. Artificially 
digested meats, milk, beef-tea, etc., with opiates, or quinine, or 
brandy if required, may be given by the rectum. Some cases are re- 
membered where obstinate vomiting which had resisted various other 
measures was promptly arrested after taking two drops of creosote in 
a little sweetened water. 
In case of great distention of the bowels by gases, a tube may be 
carefully introduced into the rectum and carried as high up as pos- 
sible, or as necessary to secure their escape. The introduction of the 
tube will be greatly facilitated by having the chest as low and the 
hips as high as possible, without too much physical disturbance of the 
patient. The knee and chest position is the one most desirable. 
When great depression occurs from the shock, besides the quinine 746 
PERITONITIS. 
and opium which are perhaps most reliable, alcohol, ammonia, etc., 
may be cautiously tried. Bartholow regards the salts of ammonia as 
important remedies in the advanced stages of acute peritonitis, and 
says, “ ten grains of the carbonate of ammonia in an ounce of the 
solution of the acetate, every four hours, when the exudation is going 
on, is, the author believes, a remedy of the highest utility.” 
When peritonitis accompanies and is dependent upon any other 
disease, reference must be had to its conditions in the treatment. 
After convalescence the liability to relapses must be remembered, 
and great caution as to exposure, exertion, food, etc., must for a con- 
siderable time be observed. 
A form of acute idiopathic suppurative peritonitis which occurs in 
children, and is caused by exposure to cold, has lately been described. 
Clinically it does not materially differ from other forms of acute 
peritonitis, but pus is produced in free quantities, and it is thought 
that it may depend upon some previous diseased condition of the 
intestines resulting in perforation. 
There is sometimes an enormous accumulation of gas of a very 
fetid character ; and pus has, in some cases, been evacuated through 
the rectum, vagina, bladder, or the abdominal parietes. It is prob- 
able that in some of these cases the chief seat of the inflammation is 
beneath the peritoneum, and the accumulation of the pus is without 
the peritoneal sac. 
The treatment will not materially differ from that described for 
other cases of peritonitis ; though to check the suppurative tendency, 
as well as to modify other conditions, quinine in antipyretic quantities 
will be particularly applicable. 
CHRONIC PERITONITIS. 
A subacute and more or less chronic form of peritonitis sometimes 
follows the acute, with liability to acute attacks. It is very seldom 
chronic from the beginning, except when it occurs as a symptom or 
complication of some other diseased condition. The most frequent 
cause of the chronic form is tuberculosis, but it not unfrequently 
accompanies Bright’s disease of the kidneys, and it also sometimes 
occurs in chronic alcoholism, but then for the most part where cirrhosis 
of the liver is present. It also presents itself in a chronic form in 
many cases of carcinoma Avithin the abdomen, in ovarian and other 
tumors, and in some diseases of the uterus and its appendages. Its 
dependence in a chronic form upon intestinal and adenoid mesenteric 
affections must be recognized. SYMPTOMS. 
747 
As a symptom or result of these other diseases it is more or less 
severe according to their nature ; hut it is generally exceedingly 
grave, and amenable only to palliative treatment. 
Its general symptoms, in all these cases, are pain and tenderness 
of the abdomen, a moderate degree of fever, and in most cases either 
effusion of serum or of plastic matter, or thickening of the membrane, 
often of the omentum, which presents a hard and irregular or 
roughened feeling on palpation. Tympanitis may or may not be 
present. 
Tubercular peritonitis is where inflammation is associated with 
tubercles in the membrane and elsewhere, and often with tuberculous 
ulcerations of the mucous membrane of the bowels. 
It sometimes occurs in what is called acute tuberculosis, where 
miliary tubercles are deposited in various organs of the body at the 
same time—lungs, liver, etc., and in other serous membranes, the 
pleura, etc., as well as in the peritoneum. It is accompanied by in- 
crease of temperature and other symptoms resembling typhoid fever, 
and w7ith an inflammation of the serous surfaces which is compar- 
atively mild, but persistent; and when occurring in the peritoneum 
the inflammation may be termed chronic or subacute peritonitis. 
This form of general acute tuberculous disease is generally fatal in a 
few weeks, and will be considered in another connection. 
Chronic tubercular peritonitis oftener occurs in connection with 
more chronic tuberculosis of the lungs and of other organs, and espe- 
cially of the intestines. In complicated cases, or in what is called 
abdominal phthisis, there are deposits of miliary tubercles in the peri- 
toneum, with a slow persistent inflammation. In some cases, particu- 
larly in children, the peritoneum is the chief, or almost exclusive seat of 
the local disease ; but generally the abdominal lymphatic glands are 
enlarged by free tubercular deposits. The symptoms are a rise of 
temperature and a rapid pulse ; the fever assumes a hectical form ; 
there will be debility, emaciation, pain and tenderness of the abdomen, 
though this may be slight, and generally, as the disease advances, 
the abdomen enlarges and is hard and nodular on palpation ; but often 
there is free serous effusion which may obscure the latter symptom. 
Anatomically the peritoneal tubercles are sometimes miliary and 
gray, of very small size, giving the whole membrane a roughened 
feeling and destroying its transparency. Sometimes these tubercles 
form lobulated masses up to the size of a hazel-nut, and assume the 
form of yellow tubercle. They are then of an opaque buff color, 
sometimes mottled with black points, and exhibiting the cheesy ap- 
pearance characteristic of this form of deposit, but modified by more 
or less fibroid matter, the result of the inflammatory process, mingled 748 
CHRONIC PERITONITIS. 
with them or surrounding them. Sometimes, but not often, tuber- 
cular layers of considerable thickness and extent, mingled with in- 
flammatory products, will be found between the intestines and else- 
where, causing the adhesion of parts ; but adhesions are commonly 
the result of effused lymph and the formation of false membrane 
which accompanies the morbid process. The large tubercular masses 
are generally few in number, but the small are innumerable, and 
sometimes, where the miliary tubercles alone are present, the peri- 
toneal surface is covered with a grayish lymph having more or less 
tenacity and toughness and agglutinating the organs together, and in 
it will be seen tuberculous points. 
Other evidences of inflammation will be present—hyperaemia, 
serous effusions, and sometimes pus or blood. The serous effusion is 
by far the most frequent and abundant, sometimes producing great 
distention. The tubercular deposits in the intestinal walls may 
soften, produce ulceration, and cause perforation of the intestines 
from without. 
In the progress of pulmonary phthisis tubercular deposits, and 
finally softening and ulceration, often occur in the intestinal mucous 
membrane. This condition is apt to be accompanied with more or 
less peritoneal inflammation, and if the intestinal ulcers penetrate all 
their coats, as is possible, an acute and violent peritonitis is the 
usual result. 
From the different character and amount of these diseased processes 
the symptoms will vary in number and intensity, and so far as point- 
ing to peritonitis they are sometimes quite obscure, overshadowed by 
the existing complications. 
The peritoneal tubercular disease sometimes creeps on insidiously, 
while in other cases it commences more abruptly with the ordinary 
symptoms of peritonitis; but in either case the symptoms at length 
merge into those of chronic peritonitis, and commonly progress 
more or less slowly to the end, the time varying from a few weeks to 
a year or two. 
The particular symptoms are pain and tenderness of the abdomen, 
but not great; a roughened irregular feel is observed on palpation ; 
the abdomen is almost characteristically enlarged by effusion into 
the peritoneum, by accumulations of gas in the intestines, and by 
enlargement of lymphatic glands. A hectical form of fever, with 
rapid pulse, and loss of flesh and strength, comes on, which, with 
some variations in intensity, usually persists in its course. When the 
disease is advanced, and the more extensive destructive changes 
alluded to have taken place, the result is only a question of time; 
but cases have occurred presenting all the usual appearance of tuber- SYMPTOMS—TREA TMENT. 
749 
cular peritonitis in the early stage, where, under treatment, recovery 
followed. 
Dr. McCall Anderson, of Glasgow, reports cases of the kind ; and 
under my own observation cases have occurred in which great im- 
provement certainly took place, and where the patients were dis- 
missed and lost sight of, apparently cured. Whether in the few 
instances so observed the symptoms returned, I regret to be unable to 
say. However it may be with particular cases (and the obscurity of 
an early diagnosis must render such cases doubtful), the general prog- 
nosis in tubercular peritonitis is in the highest degree unfavorable. 
The diagnosis is to be made by an observance of the phenomena 
described, and by excluding alcoholism, cirrhosis of the liver, Bright’s 
disease of the kidneys, and other local diseases within the abdomen ; 
and by the presence generally in adults, and often in children, of evi- 
dences of tubercles in other situations, especially in the lungs. 
Treatment.—The treatment of tubercular peritonitis will not 
differ from tuberculosis in other positions, with the inflammation 
usually accompanying it. That which seems to me indicated on 
therapeutical principles and as the result of experience, is as follows : 
When any degree of acuteness in the symptoms is present—pain, ten- 
derness, and fever—antipyretic doses of quinine and morphine should 
be promptly given. By keeping the patient a day or two under a 
proper influence of these medicines the fever and inflammation will 
be decidedly, though perhaps temporarily, checked ; yet the inflam- 
matory action is not likely to return in an acute form. If so, the treat- 
ment should be repeated. If the disease be at an early stage, the 
patient should be put upon iodide of potassium, in doses of from five 
to ten grains three times a day ; and this course should be pursued, 
if well borne, as it usually is, for some weeks, and the abdomen should 
be painted over, from time to time, with tincture of iodine sufficient 
to keep up a moderate degree of counter-irritation. In the meantime, 
especially if there be much weakness or emaciation, codliver oil and 
extract of malt should be given, commencing with moderate doses, 
but increasing, as the stomach will bear, to the full ordinary doses. 
The bowels should be regulated, and the patient, well protected from 
cold and dampness, should be in the open fresh air as much as possible. 
A good, substantial, easily digested, though not excessive diet 
should be given, and all proper hygienic rules observed. If at any 
time more acute symptoms occur, the quinine and opiate, or the lat- 
ter certainly, should be given, while the other treatment is temporarily 
suspended, but resumed when the more decided fever and inflam- 
matory action are subdued. After a time the iodide of iron may 
take the place of the iodide of potassium. If the disease advances, 750 
ASCITES. 
and the tubercles have softened, and the ulcerative stage supervenes, 
little or nothing more can be hoped from the preparations of iodine ; 
palliative and supporting treatment alone will be of use, and the 
character of the palliative measures will depend upon the particular 
symptoms. 
In chronic peritonitis not tuberculous, the cause must be sought 
for and must influence the treatment. The inflammation must be 
checked by the means already indicated. In chronic cases opium can- 
not be relied upon as in acute cases, and the bowels should not long 
be kept constipated. They must, in fact, be kept open, and if serous 
accumulations take place, even the milder forms of hydragogue cathar- 
tics may be useful. Alteratives, eliminatives, and counter-irritation 
will be the most important agents in the treatment, and the particular 
selection will depend upon the special conditions in each case. The 
bitartrate of potash, given so as to act as a laxative and diuretic, other 
more stimulating diuretics when the kidneys will bear them, mercuri- 
als in moderate quantities not unfrequently, with such other remedies 
as the accompanying diseases may demand, should be used. Blisters 
and iodine liniments will often be useful. The iodide of potassium, 
here, as in other chronic inflammations with exudates, may be re- 
quired. 
The chronic peritonitis of alcoholism, commonly connected with 
disease of the liver and other parts, is but a link in the chain of evils 
which the poison has fastened upon its victim, and a fatal result is 
almost sure to follow. However, some of the means already indicated 
may be tried. 
When such accumulation of fluid takes place in the abdomen as 
to interfere with respiration, and to produce great suffering, the 
fluid should be removed by paracentesis, though this operation in 
peritonitis should not be hastily resorted to. The bathing of the 
inflamed membrane in the fluid, and the gentle uniform pressure 
which it produces on the hypersemic vessels may diminish the inflam- 
matory action, and only when the symptoms caused by the pressure 
demand relief should tapping be performed. 
ASCITES.—Abdominal Dropsy. 
Ascites is an accumulation of serum within the peritoneal cavity, 
and this term, and especially that of abdominal dropsy, is commonly 
applied to such accumulations as are not caused by positive inflam- 
mation. There is, however, a modified action of the capillary vessels 
or lymphatics by which the balance between effusion and absorption ETIOLOG T. 
751 
is destroyed, the effusion greatly preponderating. This may be 
dependent upon some morbid process in the vessels of the peritoneal 
tissue ; upon some obstruction and consequent congestion of the 
portal vessels; upon some cause disturbing the systemic circulation ; 
or some change in the osmotic relations of the blood, and the fluid 
within the peritoneum. 
More or less effusion of serum attends most cases of even acute 
peritonitis, as we have seen, and a more free quantity the chronic 
forms. When this is inconsiderable or temporary it does not take 
the name of ascites, and only when it becomes a predominating con- 
dition is it called abdominal dropsy. 
Etiology.—Not only tubercle but cancer and other tumors 
within the abdomen cause serous accumulations; and the bursting 
of ovarian cysts or of hydatids may present a fluid within the peri- 
toneal cavity. 
The most characteristic form of ascites, where dropsy of the peri- 
toneal cavity alone exists, is produced by obstructed circulation of 
the portal blood through the liver. This may be produced by direct 
pressure upon the portal trunks, by tumors, or hydatids; but it is 
more likely to be due to disease within the liver, involving the hepatic 
capillaries and the veins which open into and flow from them. The 
most common liver disease producing this effect is cirrhosis, or the 
“ hobnail” or “ gin liver,” which produces its effect by a slow in- 
flammation and contraction of the fibrous capsule of the vessels. 
Obstruction of portal circulation may be produced in what is called 
the nutmeg liver ; and other degenerative processes in the organ may 
have to some extent the same effect. 
In obstruction of the systemic circulation, as from organic disease 
of the heart or the lungs, dropsy of the abdomen may occur in con- 
nection with dropsy of other cavities and tissues. It may also be pro- 
duced, as a feature of general dropsy, by disease of the kidneys, in 
which too little water is secreted, the albumen of the blood is lost, 
and urea is retained in the blood and tissues. By the accumulation 
of water in the system, by the thinning of the blood in the loss of 
albumen, and by the retention of urea irritating the fibrous tissues, 
effusion, endosmotic and irritative, occurs ; and dropsy of the peri- 
toneal cavity, as well as effusions elsewhere, follows. 
Dropsy may result from obstructed circulation through the gen- 
eral capillaries ; and the thinness of the blood which occurs in vari- 
ous cachexias and in simple anaemia may so change its osmotic rela- 
tions as to cause dropsy of this cavity as of other parts. Finally, more 
than one of these causes, local or general, may be combined in the 
production of the effect. 752 
ASCITES. 
The amount of fluid present in the peritoneal cavity varies from a 
few pints to several gallons. I have removed by tapping, in the same 
case, thirty quarts at once on several occasions, though it is seldom that 
the quantity exceeds four or live gallons. The fluid may be clear and 
quite pure serum ; it may be viscid, containing free quantities of 
albumen and fibrinogen, and fibrinous clots ; it may be opaline, or of 
a yellowish or greenish tinge, or turbid and colored with blood. It: is 
usually alkaline in its reaction, and its specific gravity is less than 
that of the serum of the blood. The bile acids, and creatin and creat- 
inin, are not unfrequently present in it. The peritoneum itself, 
when it contains this fluid long, especially in free quantities, under- 
goes changes in its structure. It becomes sodden, cloudy, and thick- 
ened, and sometimes there are evidences that inflammatory changes 
have occurred. 
The general symptoms and the progress of ascites will depend 
much upon the causes which produce it. The local phenomena can 
readily be understood. The enlargement of the abdomen when there 
is a free quantity of water is at once apparent. At the beginning, 
and when the quantity is small, there is more obscurity. When large 
it will change the centre of gravity of the bodj', and cause the head 
and shoulders to be thrown backward when the patient is standing or 
walking. The enlargement, when the fluid is free and not confined 
by adhesions, is usually round and uniform. When the patient is 
erect there is always flatness on percussion in the lower part of the 
abdomen ; but when the quantity of fluid is not very great, there is 
tympanitis above, from the lighter specific gravity and floating of the 
intestines. When the patient lies upon the back the flanks are dis- 
tended and dull on percussion ; and when there is a very large quan- 
tity of fluid, the liver, being specifically heavier, often sinks down 
from the ribs, and its margins may be felt. When fluid forms in the 
peritoneal cavity, fluctuation can be detected by palpation, and es- 
pecially by tapping upon one side or part while the hand is lightly 
held upon the other. By these and other signs it is generally easy to 
detect the presence of abdominal fluid ; but some cases, in conse- 
quence of complications, of old adhesions, large quantities of omen- 
tal or parietal fat, or an oedematous condition of the abdominal walls, 
may be obscure. A thin, single ovarian cyst may present appearances 
almost identical with ascites; and practitioners of some distinction 
have, with a view of relieving dropsy of the abdomen, plunged a tro- 
car into a gravid uterus. An examination, therefore, should be care- 
ful, and too hasty a conclusion should not be formed. 
Ascites, produced by whatever cause, is likely to press upon the 
iliac veins and the lymphatics, and cause oedema of the lower extremi- DIAGNOSIS—PROGNOSIS. 
753 
ties. This may early attract the attention of the patient; and short- 
ness of breath from pressure upon the diaphragm is a symptom which 
he generally soon feels. There will, of course, be a sense of weight, 
and often pain, or a feeling of distress. 
If there be a hernial sac, or a local weakness of any part of the 
abdominal walls, there may be protrusion, producing irregularities in 
the dropsical enlargement; and in women the recto-vaginal pouch 
may rarely be so distended as to protrude through the vulva and pre- 
sent a fluctuating tumor covered by the posterior wall of the vagina. 
The symptoms dependent upon the concomitant diseases will be 
considered elsewhere. 
Diagnosis.—Ascites should be distinguished from ovarian or 
other large tumors in the abdomen ; from chronic peritonitis with 
serous and plastic effusions ; from a much enlarged spleen ; from 
great accumulation of omental and parietal fat, and from pregnancy. 
A careful examination and comparison, and a rigid system of exclu- 
sion will often be required to make the differential diagnosis. A 
diagnosis, when there is a single large ovarian cyst, without an accurate 
history may be impossible. But the ovarian disease first appears on 
one side of the lower abdomen, and it is not till later that it so 
much resembles ascites. From ordinary ovarian tumors it is distin- 
guished chiefly by the more or less solidity and irregularity of the 
latter, and by the flanks being more sonorous on percussion when the 
patient lies upon the back. In ovarian and other tumors in the abdo- 
men, serous effusions may take place into the peritoneal cavity, caus- 
ing obscurity. In some cases a full diagnosis cannot be made until 
the fluid is evacuated. Obstructive disease of the liver, the heart, or 
the lungs, generally precedes ascites, and the history of the case and 
the concomitant conditions will throw light upon it. 
Ascites is to be distinguished from peritonitis by the pain, tender- 
ness, and other inflammatory symptoms accompanying the latter. An 
enlarged spleen commences from above, extends downward, is solid, 
its margin and outline can be felt, and the general symptoms will be 
different. 
Omental and parietal fat will not present the same phenomena of 
fluctuation ; in ascites the umbilicus will be projecting, while in pari- 
etal fat it is much depressed, and in omental fat it does not protrude. 
Pregnancy is to be distinguished by its own particular signs, which 
will not here be described. 
Prognosis.—The prognosis will depend upon the character of the 
original disease, of which the ascites is a symptom. That is usually 
of a severe and obstinate character, and ascites, therefore, is usually 
a grave affection. 754 
ASCITES. 
Treatment.—As ascites is a symptom of other morbid conditions 
upon which it depends, its treatment, to a large extent, is merged 
into that of the original disease. There are certain indications, how- 
ever, which the dropsy itself affords. 
A dry diet persevered in will diminish the effusion, and will call 
upon the absorbents of the peritoneum to supply the needed fluid to 
the blood. 
When the quantity of fluid is so great that its removal becomes an 
object, as sooner or later it generally does, there are good theoretical 
and practical reasons for increasing the discharge of fluid from the 
intestines, the kidneys, and the skin. 
Cathartics which produce watery stools are most certain in their 
effects in reducing the quantity of fluid in the blood, and thereby 
promoting endosmosis of the dropsical fluid into the vessels, and its 
ultimate expulsion. When the intestines will tolerate their use, they 
should be given and pushed as far as they can well be borne by the 
general system. 
Of these articles, elaterium is perhaps the most efficient. Given 
in doses of T17 to £ of a grain of a good article, repeated at intervals of 
two or three hours, and suspended when purging commences, copious 
watery stools are produced, and generally without much irritation or 
depression. There are exceptions to this, and where this article dis- 
agrees, jalap and cream of tartar, or one of the saline cathartics may 
be used. These articles, however, not unfrequently fail to relieve the 
dropsical accumulation, and in other instances they rapidly reduce 
the strength of the patient, or produce much irritation of the bowels. 
Diuretics sometimes operate quite efficiently, and in cases of de- 
bility or irritation of the bowels, and when the kidneys are not dis- 
eased, they should be tried before using the very active cathartics. 
Among the articles are mentioned juniper, broom, digitalis, squills, 
iodide of potassium, cream of tartar, and some other salines. 
Various combinations are more efficient than any one article by 
itself. Fomentations, with infusions of digitalis, applied to the loins, 
when absorption by the stomach does not readily take place, are said 
often to be quite efficient. 
Diaphoretics are sometimes useful, especially where neither the 
bowels will bear cathartics nor the kidneys diuretics. The most 
efficient of these articles is jaborandi or pilocarpin. Given in appro- 
priate doses it produces free sweating, and often the dropsical accu- 
mulation is materially diminished. The warm bath, and particularly 
the steam bath, will aid in the diaphoretic effect. 
But all these means often fail, or will reduce the strength of the 
patient more rapidly than they do the dropsical accumulation. The TREATMENT. 
755 
great palliative remedy is paracentesis. It may be resorted to too 
soon, and in inflammatory cases it is not without danger of increasing 
the inflammation. The uniform and constant pressure of the fluid 
may diminish materially the hyperaemia and check the rapidity of the 
effusion, and the exhausting effect of the disease may go on more 
rapidly after tapping. But when the accumulation is so great as 
seriously to interfere with respiration or other functions, and to pro- 
duce great discomfort, the aspirator or trocar should be used. When 
the trocar is used, a small incision with a sharp lancet or bistoury 
may be made through the skin in the linea alba, between the pubes 
and the umbilicus, the trocar following. 
Pressure should be kept up by a broad bandage around the abdo- 
men, frequently tightened while the water is flowing away, and 
fastened snugly, when the operation is completed. In cases wdiere the 
abdominal walls are much attenuated, I have made the incision by 
the snap of a spring lancet, and introduced a common silver female 
catheter through the opening. The operation is very simple, is ordi- 
narily almost entirely devoid of danger, and in non-inflammatory 
cases may often be resorted to early with the greatest propriety and ad- 
vantage. In some cases after the tapping the accumulation does not 
reappear, in many more, however, it does, and in some very rapidly; 
but the operation should be repeated as often as the distention is dis- 
tressing, and sometimes after many tappings the accumulations 
cease. Several American cases have been reported where tapping was 
practiced over one hundred times, and in one case one hundred and 
eighty times during ten years, with a cessation of the disease at the 
end of that time, the patient surviving for years afterward. I myself 
have tapped one patient ninety-two times within about four years, 
with at length a cessation of the accumulations. The case 'was in a 
female, where a peritonitis after an abortion was followed by dropsy. 
The urine was exceedingly scanty for the four years, and the ordinary 
diuretics had very little effect, and had for a long time been aban- 
doned. Cathartics debilitated the patient without having any material 
effect upon the drops}’, and were also abandoned. The skin was 
habitually dry, and nearly all the fluid taken into the system was 
thrown out by the peritoneal surface, and its cavity was filled to its 
extremest extent generally in about two weeks, making the operation 
as often as that imperative. The patient, naturally a strong and 
vigorous person, and accustomed to active labor, was able to be up and 
to attend to her household affairs, excepting for a day or so at the 
time of each tapping. 
When the effusion ceased, the patient had been partaking freely 
of water-melons and a decided diuresis followed. The disease did not 756 
CANCER OF THE PERITONEUM. 
return, but the patient died about two years after of dysentery. I did 
not see her long after the dropsy disappeared, but she was reported to 
be in fair health until the attack of the disease of -which she died. 
There was probably no serious obstruction to the circulation through 
the liver, and no evidence of special disturbance of the function of 
that organ, though the case occurred in a malarious region, and the 
spleen was somewhat enlarged. The pathological condition seemed 
to be a peculiar state of the vessels of the peritoneum, in which they 
gave exit to the serum of the blood. The long continuance and the 
final arrest of the disease were alike interesting, and, in my experience, 
singular. 
In treating of subacute peritonitis I cautioned against a too hasty 
resort to paracentesis ; and in cirrhosis of the liver I have thought 
an early tapping increased the effusion and exhaustion, and hastened 
the fatal termination of the disease ; but in ascites from a morbid but 
non-inflammatory condition of the peritoneum, early and repeated 
tappings are often demanded. When the object in any case is simply 
to relieve the patient of the fluid, the most direct, the most speedy, 
and the safest method is by the trocar. After such relief, other 
treatment is often more efficient. In all cases where the distention 
becomes particularly distressing, and other means have made but 
little impression, tapping is called for. 
Notwithstanding these favorable cases of hydro-peritoneum, it so 
frequently depends upon some other grave disease that its general 
prognosis is unfavorable. 
CANCER OF THE PERITONEUM. 
The peritoneum occasionally is the seat of malignant growths. 
They are often secondary, the result of extension from cancer of 
other abdominal or pelvic organs. Any of the forms of cancer may 
affect this membrane, and when primary, the seat is perhaps most 
frequently in the omentum. 
It is to he distinguished by pain, a tumor, or more frequently by 
discovering disseminated nodules of small size, and by the cancerous 
cachexia, -without evidence of its location in any other organ. When 
it occurs in connection with cancer of other parts, the locality of the 
pain and enlargement will point to the diagnosis. Here, as elsewhere, 
the cerebriform is most rapid in its progress, and the colloid least so, 
while the scirrhous form is intermediate. The colloid may attain 
very great dimensions, and the size of the abdomen may be further 
increased by serous effusions. When there is much fluid in the TEE A TMENT—PHENOMENA. 
757 
abdomen, the presence of the tumor may be obscured. In such cases 
paracentesis may be resorted to, when the tumor will be easily dis- 
tinguished. 
Nothing can be said of the treatment other than to advise the use 
of such palliative measures as are applicable to cancer in other situa- 
tions. 
Cancer of mesenteric or retro-peritoneal glands sometimes occurs. 
In this situation the tumor is deeper in the abdomen than when the 
omentum is the seat of the disease, but the symptoms and signs will 
not always permit the precise localization of growths of this kind. 
The course of the disease in this situation will not vary materially 
from that of peritoneal cancer, and nothing peculiar is required in 
the treatment. 
TUMORS OF THE INTESTINES. 
Non-malignant tumors of the intestines sometimes occur, the 
most frequent being pedunculated, fibrous, or polypoid growths, some- 
times very small and numerous and widely distributed upon the 
mucous membrane of both the large and small intestines ; but some- 
times larger and fewer, or even solitary. The larger ones are rarely 
found in the small intestines, but more frequently in the rectum. 
The clinical history of those in the small intestines is not known. 
Those in the rectum give rise to irritation, tenesmus, and bleeding, 
not unfrequently, and may be mistaken for hemorrhoids. 
They are to be distinguished only by a physical examination, and 
to be remedied by removal. 
Villous growths sometimes are found, and are, in some cases, ma- 
lignant. They are usually limited in extent, and sometimes encircle 
the bowels. 
These closer set, elongated, complex villi take their origin from 
thickened mucous and submucous tissue ; they may cause hemorrhage 
which is sometimes serious, and often cause diarrhceal or dysenteric 
symptoms. They are only distinguishable when in the rectum, and 
may then be proper objects of operative procedures. 
Malignant tumors of the intestines are occasionally met with. 
They correspond very closely with those of the stomach, and their 
pathological anatomy is essentially the same. 
We have here, as in the stomach, the three leading varieties : scir- 
rhous, encephaloid, and colloid or alveolar ; and in the rectum and at 
the anus we have, in addition, epithelioma. 
Besides these, adenoid cancer or cylindrical epithelioma, and sar- 
comatous and lymphadenomatous growths are by some distinguished, 758 
TUMORS OF THE INTESTINES. 
but they seem mere varieties of encephaloid cancer, and there appears 
no necessity of regarding them otherwise than as soft cancer. 
Of a malignant disease of the intestines, scirrhus is the most com- 
mon form. As in the stomach, cancer of the intestines commonly 
occurs after the age of forty, and is marked by a train of symptoms 
at first not very definite, but resembling chronic inflammation or 
ulceration ; but at length it is distinguishable by its history, its steady 
progress, and finally by the appearance of the cancerous cachexia, 
sometimes by intestinal obstructions, and more positively by the 
appearance of a tumor. There is sometimes a diarrhoea, but oftener 
constipation, and not unfrequently discharges of mucus and changed 
blood. When the cancer is situated in the rectum, at the sigmoid 
flexure of the colon, or more rarely elsewhere, stricture and final 
obstruction are apt to occur. In such cases the patient often suc- 
cumbs before the breaking down or ulcerative process takes place. 
Diagnosis.—The progress of the disease may be more or less 
rapid, but the result is always the same. The professional interest in 
these cases is chiefly in the diagnosis. This is to be made out by a 
careful observation of the history, b}r the persistent progress, and 
especially by the appearance of a constant and growing tumor, at 
least until ulceration occurs, when the tumor may possibly diminish ; 
but then the discharges and the advanced condition of the cachexia 
can leave little doubt. In case of the occurrence of general symptoms, 
but where no tumor of the abdomen is observed, an examination per 
rectum must be made, when a tumor will often be discovered. 
Treatment.—An epithelioma of the rectum may admit of an 
operation for its removal. Some successful cases are reported, but 
it is a desperate resort, and in the ordinary forms of scirrhus or cere- 
briform cancer the cases are hopeless. 
The treatment of cancer of the intestines, except in the rare cases 
of epithelioma of the lower part of the rectum, is simply palliative. 
In case of constipation or obstruction, saline laxatives, to secure a 
fluid or semi-fluid condition of the faeces, may afford much relief and 
prolong life. Articles of food containing indigestible substances 
should be carefully avoided, and the general hygienic management of 
the patient should receive attention. 
In one case of a medical gentleman, where from great obesity and 
the position and small size of the cancer no tumor could be felt, and 
a positive diagnosis was not made, acute intestinal obstruction 
occurred, and death in a few days. On post-mortem, examination a 
firm cancerous tumor was found, not larger than a small-sized orange, 
near the sigmoid flexure of the colon, so firmly closing the intestine 
that only a common-sized catheter could be passed through the open- TIIEA TMENT— ETIOLOG T—SYMPTOMS. 
759 
ing, and the immediate cause of the complete obstruction was the 
accumulation of a quantity of the seed capsules of apples at the point. 
These totally indigestible substances Avere too large to pass, and the 
most distressing consequences followed. 
Where there is a tendency to constipation, attempts should be 
made to relieve the pain with belladonna or hyoscyamus before opium 
is resorted to ; in extreme suffering the chloral hydrate or the 
inhalation of chloroform may be used ; but in many cases the opiates 
will be more efficient and will finally be required. Morphine, or mor- 
phine and atropine hypodermically, will be most efficient. 
Here, as in other cases of cancer, specific remedies—the Chian tur- 
pentine is at present most advised—may be tried when not of a 
character to do injury. They may be useful by affording the patient 
the satisfaction of knowing that something is being done, and by such 
trials a remedy may possibly some time be found. The cundurango 
has been thought, under competent professional observation, to have 
exerted a favorable influence upon cancerous disease, and some are still 
disposed to have confidence in its virtues. Its use may certainly be 
allowed. 
INTESTINAL OBSTKUCTION.—ILEUS.—THE ILIAC 
PASSION. 
Etiology.—Complete intestinal obstruction may be produced by 
a variety of conditions ; from the contraction of false membrane after 
peritonitis, and from cancer, as we have just seen ; from intussuscep- 
tion, or the slipping of one portion of intestine into another, like the 
inverted finger of a glove ; by the strangulation of an internal hernia ; 
by contraction of the cicatrices of old ulcerations ; by intestinal and 
biliary calculi; by hardened faecal matter and other foreign substances ; 
by slipping through an aperture in the diaphragm, the omentum, or 
the ligaments of the liver, uterus, etc. ; by attachments of the vermi- 
form process including an intestine, and by other disorganizing dis- 
eases in the region of the caecum; by twisting of the intestines, and 
by some other possible conditions. Indeed, paralysis of one portion 
of intestine from phlegmonous inflammation, and spasmodic con- 
traction of the part below, may result in obstruction, in faecal vomit- 
ing, and the symptoms described as the iliac passion. 
Common external strangulated hernia produces the same general 
symptoms, but this belongs to the province of surgery. 
Symptoms.—When obstruction and strangulation of a portion 
of intestine occur, a certain train of symptoms follows, whatever may 
be the special physical conditions. There will be a localized pain, 760 
INTESTINAL OBSTRUCTION 
increasing paroxysmally, suggestive of severe colic. A cathartic, if 
given, does not operate, or only the lower bowels are evacuated, and 
opiates fail to give complete relief. Vomiting soon comes on, of 
ingesta and bile at first, but at length of the contents of the intestines 
above the obstruction—of stercoraceous matter. The abdomen be- 
comes tympanitic ; localized tenderness may generally be discovered ; 
the pulse becomes frequent and small ; the surface is cold, and there 
are usually clammy sweats ; a collapsed condition follows, and death 
takes place, sometimes within a few hours, but at other times not till 
after twelve or fourteen days, the average being less than a week. 
As in enteritis and peritonitis, the mind usually remains intact, at 
least until near the very last. 
Diagnosis.—The making of a proper diagnosis is of the greatest 
importance. For the first few hours it is liable to be confounded with 
simple colic. Soon, however, the more fixed local character of the 
pain, its severity and obstinacy, and the appearance of tenderness will 
point to obstruction and strangulation. The faecal vomiting which 
follows will be still more conclusive, and the collapse, which may soon 
come on, will remove doubt. 
In all cases an external hernia must be sought for, whether the 
attention is directed to it or not, and sometimes one unsuspected by 
the patient may be found. This has been illustrated in my own 
experience. Its practical importance will at once be seen. 
Obstruction from other causes should be distinguished from that 
produced by intestinal and peritoneal inflammation, such as has 
already been described, though the importance of diagnosis in reference 
to treatment is not great. It may possibly be confounded with the 
effects of corrosive poisons, though the circumstances of the case and 
the special symptoms should lead to a ready distinction. 
It is often impossible to determine the particular physical condi- 
tion causing the obstruction or strangulation, and sometimes the 
symptoms of mechanical strangulation are closely simulated by func- 
tional derangements and obstructions. 
It is also sometimes impossible to ascertain with anything like 
precision the portion of the intestine obstructed. A judgment may, 
however, be formed by closely observing the phenomena. If the 
obstruction is near the sigmoid flexure, the faecal evacuations imme- 
diately after the attack will be small, or only such as may be in the 
rectum at the time. The situation of the pain and the point of the 
greater tenderness, and the distention of the colon, as discovered by 
palpation and percussion, will aid in localizing the difficulty. 
If this be at the ileum or caecum, there will be likely to be more 
abundant dejections at first, and the limitation of the distention to JA TUBS USG BP TIO N. 
761 
the small intestines. If situated still higher up, the vomiting will be 
less in quantity, but will sooner come on ; the distention will be less, 
and the urine scanty from less absorption of fluids. 
When the obstruction is caused by intussusception, the diagnosis 
as to the fact and the locality can often be made out with much cer- 
tainty and considerable precision. 
Intussusception of the intestine is not very unfrequent, especially 
in young subjects, and the cases are not as hopeless as in many of the 
other varieties of obstruction. 
An invaginated intestine does not necessarily become incarcerated 
and strangulated. If this does not occur, it often cannot be distin- 
guished. It is probable, however, that invagination sometimes takes 
place, and the intestine becomes restored without serious conse- 
quences. When obstruction and strangulation result, the symptoms 
are decided and sometimes are characteristic. A large proportion of 
cases are in children, but no period of life is exempt. The statistics 
show that more males than females suffer from this accident. In more 
than half of the cases the invagination is situated at the junction of 
the ileum and caecum—a portion of the ileum descending into the 
caecum through the ileo-caecal opening, or rather the lips of the ileo- 
cecal orifice descend into the cecum, carrying with them more or 
less of the ileum, forming the internal tube or layer, and then a con- 
siderable portion of the colon may become inverted. The next most 
frequent point is the sigmoid flexure of the colon, the small intestine 
being very seldom invaginated. 
In this accident, wherever occurring, the symptoms usually come 
on suddenly and without premonition, and not unfrequcntly with a 
sensation of slipping or of a peculiar motion in the part. Soon severe 
colic pains occur, and vomiting, tympanitis, a frequent and feeble 
pulse, with coldness of the surface and great depression, and all the 
usual symptoms of obstruction and strangulation already described 
appear. The fatal termination, which is the most common result, 
may, as in the other forms of ileus, be from collapse within a few 
hours, or not till after a week or more. One of the most character- 
istic symptoms is a discharge of bloody mucus, or sometimes more 
clear blood, after such sudden attacks of pain, and where hemorrhoids 
and polypi, and an attack of dysentery are excluded. The discharge 
of bloody mucus, and a tenesmic straining which may occur, espe- 
cially when the intussusception is low in the colon and involves the 
rectum, may readily without care be mistaken for dysentery. The 
suddenness and violence of the attack, the positive constipation of the 
bowels after the first discharges, and the stercoraceous vomiting and 
early collapse, will serve to distinguish this state from dysentery. As 762 
INTESTINAL OBSTRUCTION. 
an early diagnosis is important, in all cases of suspicion or doubt a 
digital or specular examination of the rectum should he made, and 
often the inverted intestine will be felt or seen. Another test, where 
the obstruction is low, is an inability to inject much fluid into the 
rectum without its forcible return. 
When the invagination is at the ileo-cascal junction, or in other 
parts of the colon, a tumor can often be felt by external palpation. 
It will usually be elongated, resisting and tender on pressure, and, of 
course, of recent origin, and more or less sudden in occurrence. 
The enlargement may extend from the caecum to the transverse 
colon, or it may be altogether situated in any limited portion of the 
intestine. Occurring at the ileo-caecal junction, the strangulation 
is often not complete, the shock may not be great, vomiting maj 
be deferred, tenderness may for a considerable time be absent, and 
the case is likely to be more protracted. Indeed, intussusception may 
occur not only without complete strangulation, but without complete 
obstruction of the passage of fascal matter, and the diagnosis, at least 
for some time, will then be obscure. In such cases, which, however, 
are rare, the difficulty may possibly continue for a long time. 
The cause of the descent of a portion of the bowel into that which 
immediately succeeds and is continuous with it would seem to be a 
comparative relaxation of the lower part, into which the upper part 
passes, and a comparative contraction of this upper part which passes 
down. 
As the result of this, three successive layers of the tube lie con- 
centrically, so that an instrument passed from without into the inner 
cavity would penetrate three intestinal walls, two mucous surfaces and 
two peritoneal surfaces being in contact, with another peritoneal sur- 
face over all, and another mucous surface internal to all. Besides 
this, by the descent of the inner portion the mesentery attached is 
drawn in, and the compression and obstructed venous circulation 
cause congestion and more or less thickening of all these parts, and a 
greater or less degree of obstruction in the passage of the intestinal 
contents. This, sometimes complete, at other times is only partial; 
and the effects following will be influenced by the degree of this 
obstruction. 
The obstruction of the circulation produces the condition called 
strangulation. The parts, when thus generally affected, become dark 
and swollen, the mucous and muscular coats nearly black, and the 
peritoneal coat of a slate color ; and when this continues for any con- 
siderable time sphacelation takes place. Frequently mucus and 
blood escape from the intensely congested mucous surface, causing 
the discharge before referred to. PATHOLOGY OF INTUSSUSCFjPTION— TREATMENT. 
763 
In cases where death of the part and the patient does not soon 
occur, a decided inflammatory action is set up; coagulable lymph is 
poured out upon the serous surfaces, increasing the swelling, and often 
agglutinating those surfaces together. The length of intestine involved 
in this invagination varies from a few inches to a few feet. 
If the patient survives a sufficient time, other changes follow. 
The inflammation may extend, and a general peritonitis result. In 
other cases the invagination continues to progress; sometimes ulcer- 
ative processes in the mucous membrane occur, and may penetrate all 
the coats. ' The most important event is the sloughing and separation 
of the strangulated portion of intestine. If firm adhesions have 
formed between the serous surfaces, as may sometimes, fortunately, 
be the case, the necrosed portion may be separated and discharged, 
and the patient recover. 
Too often, however, when sloughing occurs, faecal matter passes into 
the peritoneal cavity, and in consequence increases, but soon termi- 
nates, the sufferings of the patient. The discharge of the sphacelated 
blood more commonly occurs in from twenty to thirty days, though 
it may be considerably sooner or much later. The results of separa- 
tion are favorable, it is said, in about half of the cases ; while death, 
in the majority of instances in this disease, is produced by the shock 
of the strangulation, by the occurrence of diffused inflammation, or 
by the consequences of the obstruction. 
When death occurs from the shock, it is usually not long delayed. 
When from inflammation, it is within a week or ten days from the 
first severe inflammatory symptoms; and when from intestinal ob- 
struction, the locality of the obstruction will have much influence 
upon the continuance of life. If the obstruction be low in the intes- 
tines, and neither strangulation nor inflammation occurs, the patient, 
with proper care as to food, may survive several weeks, or even some 
months ; but the nearer the obstruction is to the stomach, the sooner, 
if unrelieved, will fatal results follow. From these statements it will 
be seen that the prognosis is exceedingly grave, but still that a recent 
case will not be without hope. 
Treatment of Ileus.—In the treatment of intestinal obstruc- 
tion and strangulation reference must be had to what we know or 
judge to be the cause, as well as to the particular symptoms present. 
Whenever symptoms of obstruction are accompanied by those of 
inflammation, unless the cause can be reached by some direct mechan- 
ical measures, the treatment must be the same as that advised for 
phlegmonous enteritis, or for local or general peritonitis. Purga- 
tives must be avoided, opium must be given in free doses, and the 
parts kept at rest, with such other antiphlogistic and antipyretic 764 
INTESTINAL OBSTRUCTION. 
remedies as acute inflammations demand. Food must be given in 
small quantities, and in a very digestible and liquid form, and all 
other details elsewhere described as proper in intestinal and peritoneal 
inflammations must be followed. 
The practice of giving powerful and repeated doses of cathartic 
medicines to overcome such mechanical obstructions as have been 
described, must on reflection, to any one understanding the pathology, 
appear not only useless, but injurious. Constipation arising from a 
sluggish state of the bowels, with ordinary accumulations, calls for 
purgatives, and may require those of an active kind ; but mechanical 
obstructions are apt to be increased rather than relieved by exciting 
peristaltic action, and certainly if the obstruction be not overcome, 
irritation, inflammation, and suffering will be increased. 
It is sad to know that in so severe a case so little can be done ; 
but it is sadder to do in blindness and ignorance what will increase 
the suffering and danger, and hasten a fatal result. 
Enemas may be tried ; and in some cases the administration of 
salines in sufficient doses to liquefy the intestinal contents, and thus 
promote their passage through restricted openings, without power- 
fully exciting peristaltic action, may be followed by relief; but if 
there is complete obstruction, these will be useless, and if inflamma- 
tion is present and decided, it will be likely to be increased. But 
when reasonable quantities fail of effect, or the evidences of complete 
mechanical obstruction become more conclusive, or strangulation and 
inflammation occur, all laxative remedies must be excluded. 
The only, or at least the principal, cases where saline laxatives 
should be ventured upon is where occlusion of the intestine is sup- 
posed not to be complete, and severe strangulation is not present, as in 
case of a cancerous tumor leaving a small passage, or where bands of 
false membrane or contracting cicatrices have left a small opening and 
have caused irritation, etc. In doubtful cases free quantities of water 
may be taken by the stomach, and simple enemas may be used. 
When intussusception is the cause of obstruction, the same direc- 
tions as to the use of cathartics and other general means will apply. 
Liquefying the intestinal contents may promote passages where the 
obstruction is not complete, but increasing peristaltic action would 
tend to increase the invagination and excite inflammation. As an 
almost absolute rule, therefore, cathartics must be avoided. Cases of 
intussusception have terminated spontaneously, but the probabilities 
are so remote as not to be taken into the account in the management 
of the disease. 
In the treatment of these cases two objects are to be aimed at '.first, TREATMENT. 
765 
to restore, if possible, the invaginated intestine to its proper state; 
and second, if that be impossible, to counteract severe inflammation, 
aid the patient to endure the suffering, and also to promote adhesion 
of the peritoneal surfaces of the invaginated intestine, at the point 
where it commences, and to aid, if possible, the separation by slough- 
ing of the strangulated portion, so as to leave a pervious canal. In 
what manner and to what extent can these objects be promoted ? 
As soon as the diagnosis is positively or even proximately estab- 
lished, efforts should be made to push back the invaginated intestine 
by pressure from below by means of water or air thrown up, in as free 
quantity as is possible or safe, into the rectum and colon. 
The abdomen should be kneaded during and after the injection, 
and the effect may be materially aided by reversing the position of 
the body—supporting the patient for a time with the pelvis higher 
than the chest. The prospect of success is not great, and is dimin- 
ished by the length of time the displacement continues; but the 
effort should be faithfully made. Too great force with the injections 
of air or water should not be used, as the intestine may be seriously 
injured or ruptured. 
If, from the length of time the difficulty has continued, there is 
reason to suppose that gangrene has taken place, for obvious reasons 
the injections must not be used; and before their use, wheu determined 
upon, the lower bowels should be cleared of their fsecal contents by 
enemas. Atmospheric air, carbonic acid gas, or simple water may 
be used with this hope of restoration. 
If this method fails after a fair trial (and some risk of doing harm 
by it may properly be run), the propriety of making an abdominal 
section and pulling out the invaginated intestine with the fingers 
must be considered. This has sometimes been successful, but there 
are serious objections to its performance. In the first place, there is 
danger in the operation from shock, from hemorrhage, and especially 
from inflammation. Secondly, by the time the diagnosis is fully 
established and the other efforts with the injections have been made, 
and failed, the feasibility of restoration has usually become doubtful. 
Adhesions may have been formed which had better not be disturbed, 
or gangrene may have taken place which it would be dangerous to 
meddle with, or the process of cure by separation and adhesion might 
be prevented. 
If, however, the diagnosis is early and clearly made, and the effort 
at reduction by the means described has been early tried and has 
failed, and all this before much inflammation is established, before 
adhesions are formed or gangrene has occurred, there would be a 
reasonable prospect of the success of the operation ; and in careful 766 
INTESTINAL OBSTRUCTION. 
and well-trained hands it may not only be justified but called for. 
Out of twenty reported cases which have been tabulated, seven have 
been successful, but there have probably been other unsuccessful 
cases that have not been reported. This is the case in many opera- 
tions, and such statistics must be received with some allowance. 
Prof. Sands, of New York, reports a case in detail, in an infant six 
months old, where the operation, performed eighteen hours after 
the attack, was successful. The intussusception was at the ileo-caecal 
junction. 
The success of the operation, as Prof. Flint remarks,* depends on 
its early performance. He thinks it will, in all probability, not prove 
successful if delayed over twenty-four hours after the occurrence of 
symptoms denoting the accident. It would seem to be more admis- 
sible in infants than in older subjects, as there would be little or no 
hope of a cure being effected in them by the sloughing process, while 
in older subjects more hope of this may be entertained. In deciding 
as to an operation all these conditions must be considered, and here, 
as everywhere, the judgment of the practitioner must determine. 
It is perhaps unnecessary to repeat—but in view of the temptation, 
when constipation exists, to resort to purgatives, it cannot be too 
strongly enforced—that cathartics must tend to increase the invagi- 
nation, and, later, to break up adhesions and destroy the chances of 
spontaneous cure. Where the fact of intussusception is established, 
with its consequent obstruction, cathartics of every kind are positively 
contra-indicated ; and in doubtful cases, where it may be supposed 
that irritation and spasmodic action of the intestines are producing 
the pain and constipation, it is, as a rule, far better to allay that irri- 
tation and spasm by anodynes, the warm bath, fomentations, etc., 
than to give cathartics with the view of removing irritating matters. 
Until spasm is overcome, cathartics are likely to fail to operate, and, 
when failing, must add to the irritation. Constipation may continue 
for days, and, in many cases, even for weeks, without serious conse- 
quences ; and a restless anxiety to “ move the bowels ” is uncalled for. 
Their proper movement, to be sure, is an evidence of an improved 
condition, and is generally accompanied with relief ; but this does not 
prove that efforts at procuring movements by cathartics will be use- 
ful. At all events, in intestinal invagination they are dangerous, and 
must not be given. On the contrary, measures to quiet peristaltic 
movements are important. Opiates, in doses sufficient to relieve pain, 
keep the parts at rest, and check the intensity and the spreading of the 
inflammation, are the chief agents to be relied upon for promoting 
* Yide Flint’s Clin. Med., p. 334. THE A TMENT—OBSTR VCTIONS WITEO UT STRANG ELATION. 
767 
the second object of treatment—the favoring of adhesions and cure 
by sloughing. 
It is true that success is very doubtful; but when no other course 
promises so much, this is the one to be pursued. It must be steadily 
continued, as in the severe abdominal inflammations which have 
already been described. Spansemics are to be avoided ; nourishing 
articles of food leaving as little residuum as possible are to be given ; 
the patient is to be kept absolutely quiet; the soothing effect of warm 
applications to the abdomen is to be obtained; and the patient is to be 
sustained by tonic doses of quinine and by other agents, as the symp- 
toms may require. 
In obstruction and strangulation, with symptoms of the “ iliac 
passion ” from other causes than intussusception, operative proced- 
ures—laparotomy—may be demanded. If there is reason to suspect 
internal hernia, or if there be a hernial sac, or any hint of such obstruc- 
tion, the patient should not be allowed to die without an effort at 
surgical relief. When the seat of the obstruction is detectable, and 
especially if in the lower part of the intestines, the operation for the 
formation of an artificial anus, either at or above the point of obstruc- 
tion, may be called for. Even where the location is doubtful, but 
obstruction and strangulation are certain, an exploratory operation, 
though unfortunately generally unsuccessful, may give the patient a 
last chance. Such cases come into the province of surgery, and need 
no farther discussion here. 
In all cases of obstruction where tympanitis is excessive, the 
application of ice to the abdomen, in accordance with Jaecoud’s 
recommendation,* may perhaps be tried ; but if unsuccessful, the 
intestine may be punctured through the abdominal walls by means of 
a very fine trocar, or the fine needle of an aspirator, or of a hypo- 
dermic syringe, and the gas allowed to escape. This operation is 
generally harmless, and may procure very great relief. 
Obstructions of the intestines without strangulation have already 
been referred to. These may be organic or functional, permanent or 
temporary, and the organic causes may be seated outside of the intes- 
tinal walls, within their substance, or within the canal. These causes 
may act by compression, contraction, or impaction, and the obstruc- 
tion may be complete or incomplete. 
Functional obstructions may be from paralysis, spasm, inverted or 
otherwise deranged peristaltic action. These functional obstructions, 
* Reference to last edition. 768 
IN TEST IN A L OBSTR UCTION. 
when dependent upon deficient peristalsis, or upon accumulations, as 
from impacted faeces or indigestible ingesta, such as chalk, slate, 
stones, fruit seeds, etc., may often be completely overcome by the use 
of cathartics. If dependent upon spasm, an antispasmodic, a warm 
bath, or an opiate may be successful, followed by enemas, or laxa- 
tives, etc. If dependent upon more serious structural changes, these 
means will fail, or produce only temporary relief. These latter 
changes usually come on slowly, are of course persistent, and their 
character must be judged of by the history of the case, the previous 
diseases, and all the phenomena presented. 
When complete occlusion occurs, in a greater or less time serious 
effects will follow. Distention from faecal matter and from gases 
will take place, and pain, vomiting, etc., come on—the sooner the 
higher up the obstruction. 
Digestion will be impaired, debility and emaciation will follow, 
local inflammations and ulcerations are apt to result, and perforation 
with all its consequences may terminate the case. Sooner or later, 
without some operative procedure, which, however, promises little, 
the patient will succumb, if not from other accidents from exhaustion 
and asthenia. 
If the obstruction does not amount to occlusion, but only to 
embarrassed movements, by care as to diet and keeping the bowels 
soluble, it may be tolerated indefinitely. 
The treatment of these cases of strictured bowels, as already inti- 
mated, will consist in giving food that has no indigestible and insolu- 
ble particles, and in keeping the faecal matters above the obstruction 
in a liquid or softened condition. 
Vegetables which contain woody fibre, seeds, stones, rinds, seed 
capsules, etc.,, must not be allowed. The gristle, hone, skin, and fascia 
of meats must be excluded. Milk with lime-water, or thickened with 
thoroughly cooked and perfectly soluble farinaceous matter, strong 
broths, and the tenderest meats, thoroughly masticated, must consti- 
tute the food. The fecal matter must be made soluble by saline lax- 
atives ; but active purgatives must be scrupulously avoided, as tend- 
ing to produce irritation and serious mischief. Large draughts of 
simple water, or with the addition of a little table-salt, may sometimes 
answer the purpose, if taken on an empty stomach, of keeping the 
feces soluble. 
In progressive cases where the obstruction becomes complete, or so 
nearly so as to be no longer tolerated, the only resource is colotomy, 
or opening the intestine and forming an artificial anus. This opera- 
tion is applicable where the obstruction is in the rectum, at the sig- OBSTRUCTIONS WITHOUT STRANGULATION—COLIC. 
769 
moid flexure, or transverse colon, and is less dangerous than was 
formerly supposed. The standard works on surgery give the particu- 
lars of this procedure. 
Strictures of the rectum and lower part of the colon sometimes 
admit of another remedial measure—of mechanical dilatation. 
When stricture occurs from contraction of cicatrices after ulcer- 
ative dysentery, from bands of false membrane, or other similar causes, 
the solid fsecal discharges will take a flattened or slender form, and 
constipation is generally produced. There will be pain, a sense of 
fullness in the part, straining at stool, etc. If, on examination, a 
structure is found within reach, an attempt may be cautiously made 
to dilate it by a graduated bougie. By means of different-sized balls 
on a flexible rod of whalebone, not only the calibre of the stricture 
can be ascertained, but, as in the case of the oesophagus, its longitu- 
dinal extent also. Proceeding on the same principle as in stricture 
of the oesophagus or the urethra, cone-shaped rectal bougies adapted 
to the condition of the part may be introduced from time to time, or 
sponge tents of proper sizes may be used, repeated as may be required 
and borne ; and in this way the greatest amount of relief may some- 
times be obtained. 
FUNCTIONAL DISEASES OF THE INTESTINES. 
Under this title are usually considered enteralgia, colic, and many 
cases of diarrhoea and constipation. 
Some account was given of enteralgia in connection with gastral- 
gia ; and as the causes and condition of the two affections are so sim- 
ilar, and they are so frequently combined, a separate consideration of 
the latter is hardly required. Besides, it is a part of the general sub- 
ject of Neuralgia, which will be discussed in a different connection. 
Intestinal colic is a more distinctive affection, and requires a more 
particular description. It consists of a severe twisting pain, mostly 
in the umbilical region, but without inflammation, and independent 
of serious organic or structural disease. It is generally accompanied 
by constipation, but sometimes by looseness of the bowels, and is 
intermitting or distinctly remitting. The dividing lines between 
what are called colic and enteralgia on the one hand, and intestinal 
catarrh on the other, are not always positively or distinctly drawn ; 
and yet the pain of colic is usually produced by some local irritating 
material in the intestines, while intestinal neuralgia or enteralgia is 
not; and intestinal catarrh is an inflammation, though sometimes a 770 
COLIC. 
slight one, of the mucous membrane of the intestine, while colic, 
though attended with some degree of hypersemia, and not unfrequently 
merging into inflammation, is irritative rather than inflammatory, 
and has more of the neuropathic and spasmodic element. 
Several varieties of colic are spoken of, viz. : 1. Flatulent or spas- 
modic. 2. Colic from irritating ingesta. 3. Colic from morbid 
secretions ; and, 4. Colic from the poison of lead—colica pictonum. 
These are not very distinctively marked in their phenomena, except 
the last, and the first three may with propriety be considered together. 
The distention of the intestines with gas, especially when produced 
by decomposition of food, or when it is a morbid secretion and of an 
irritative character, is apt to throw the intestines into irregular action 
and produce pain ; and this is likely to take an intermitting and spas- 
modic character. At any rate, in many cases of spasmodic intestinal 
pain, gas is present, its movements accompany the pain, and its 
expulsion relieves it. 
The colic pain from irritating ingesta and from morbid secretions 
is perhaps a little less intermitting, and not so changeable in its loca- 
tion ; but it has the same general character, and the varieties are not 
always clearly distinguishable. 
Etiology and Symptoms.—Among the predisposing causes 
of colic are anaemia, gout, dyspeptic conditions, and nervous impres- 
sibility. The particular exciting causes are various. Irritating in- 
gesta are perhaps the most frequent, but in these cases hyperaemia 
and a catarrhal state are apt to be excited. Exposure to cold is not 
an unfrequent cause, and indigestion is both a predisposing and ex- 
citing element. Certain mental emotions, as pity, compassion, and 
grief, are said to sometimes act as causes, as the expression “ bowels 
of compassion ” seems to indicate. 
All forms of colic have a decided neuropathic element. There is 
irregular action of the intestinal muscles, the pain is distinctly 
paroxysmal, the extremities are generally cold, there is often a 
shrunken expression of the countenance, and the skin is pale. Press- 
ure upon the abdomen is generally well borne and gives relief, the 
patient throws himself about and often walks the room in the parox- 
ysms of pain. He often feels depressed and alarmed, though the pain 
usually soon subsides, leaving no serious consequences behind. 
Diagnosis.—Colic should be distinguished from perforation of 
the intestines ; from the passage of gall-stones, and of renal calculi; 
from aneurism of the abdominal aorta ; from enteritis and peritonitis ; 
from acrid poisons ; and from strangulated hernia and other forms of 
mechanical obstruction. It has resemblances to all these conditions, 
and some care may be necessary to make the differential diagnosis. DIAGNOSIS. 
771 
Colic will be distinguished from perforation by the more profound 
and overwhelming distress, the greater shock, and the more constant 
pain in perforation, and by the speedy occurrence of symptoms of 
inflammation. The preceding history will also materially aid in the 
diagnosis. 
The pain of passing biliary calculi resembles that of ordinary 
colic, but the location of the pain is different ; there will usually be 
a history of preceding liver derangements, the patient is often 
jaundiced, vomiting is more likely to occur, tenderness in the region 
of the gall-duct is developed, and the relief from treatment is much 
less, until the calculus passes into the intestine, Avhen the pain sud- 
denly ceases, though more or less soreness is left behind. 
In the passage of renal calculi through the ureters the pain has 
still a different locality, is upon one side of the abdomen, and extends 
to the bladder, the genital organs, and the inside of the thigh ; and 
there is a frequent desire to micturate. Tenderness is also soon 
developed in the seat of the pain. 
In aneurism of the abdominal aorta paroxysms of severe pain are 
likely to occur, and the location is not materially different, but the 
pain is not of the twisting character of colic, there is not the same 
tolerance of, or relief from pressure, and the pain does not follow the 
motion of gases, the movements of the bowels are not as much affected, 
and vomiting is not as likely to occur. 
The special and conclusive evidence, however, of an aneurism is 
the detection of a pulsating tumor, having the characteristic aneuris- 
mal bruit and thrill. 
The distinction between colic and abdominal inflammations, en- 
teric or peritoneal, is very important to be made, as the prognosis and 
treatment will be so different. 
In colic there is often a degree of coldness of the extremities, but 
no distinct chill or rigor. There is an absence of fever, a slow rather 
than rapid pulse; the pain is more distinctly intermitting, while in 
inflammation it is remitting only, and often pretty steadily continu- 
ous ; and still more distinctive is the absence of tenderness in colic, 
the relief obtained by pressure, and the free movements of the patient; 
while in enteritis and peritonitis the tenderness is generally marked, 
and the patient lies still in bed. It must, however, be acknowledged, 
that in exceptional cases this latter distinction, though generally so 
important, may not be so clear. 
In corrosive poisoning a knowledge of the article swallowed, the 
immediate burning pain in the region of the stomach, the speedy and 
repeated vomiting, the rapid depression and speedy death, or the 
development of inflammation, and finally, the chemical detection of 772 
COL1G. 
the poison in the vomited matter, or in the stomach and bowels post 
mortem, will determine the diagnosis. 
Strangulated hernia is to be distinguished from colic by the his- 
tory of the case, the presence of a tumor, the fixed and local seat of 
the pain, the tenderness which will soon be developed, and the ster- 
coraceous vomiting as the case advances. 
The characteristics of the various forms of intestinal obstruction 
and strangulation the reader is supposed to have just studied in the 
preceding pages, and these are referred to. 
In the more purely neuralgic cases the attacks are apt to be 
repeated at somewhat regular intervals, there is no distention from 
gases, and they are usually independent of the taking of ingesta. In 
hysterical cases the abundant pale urine and the variable emotions 
will be characteristic. 
Great care is necessary in all cases of severe pain in the bowels to 
come to correct conclusions as to its character; as in no cases are mis- 
takes more likely to occur to the superficial observer, and in none are 
mistakes of a more serious character. 
Prognosis.—The prognosis in colic is favorable when the diag- 
nosis is clearly made. Severe pain in the bowels, however, always 
requires serious attention, as that which apparently commences as a 
colic may result in an inflammation, or prove indicative of serious 
obstruction. 
In the common accidental cases it is usually of short duration ; 
and the youth who is writhing in agony and alarm, and praying for 
relief to-day, may forget his fears and be as reckless and profane as 
ever to-morrow. 
There are some cases, however, which become habitual in their 
occasional return. Some are almost entirely neuropathic in character 
and others are connected with perverted intestinal secretions. 
Severe pains of a colicky character are sometimes associated with 
perverted secretions of the mucous follicles, and the production and 
discharge of balls of albuminous matter. These cases require treat- 
ment with reference to changing the condition of the follicles; and 
for this purpose the preparations of turpentine are thought to be par- 
ticularly useful. 
Treatment.—In the treatment of colic the causal indication 
must bo observed. 
The indications are to remove whatever irritating materials may 
be present producing the effect, and to allay the pain and spasms. 
Very frequently, it may be said generally, the second-named indi- 
cation requires to be fulfilled first in time. 
In gastralgia from irritating materials in the stomach an emetic TREATMENT. 
773 
which will operate speedily will often be the first and the only remedy 
required. 
In intestinal colic the offending materials cannot be so hastily dis- 
posed of. The spasmodic action of the intestines may delay or pre- 
vent the operation of cathartics ; and the indication first in time is 
to overcome the intestinal spasms and relieve the pain. 
This can sometimes be accomplished by heat applied over the 
abdomen and to the extremities, by warm and aromatic drinks, such 
as mint, anise-seed, or ginger tea, etc., or spts. of camphor and water, 
or warm spts. and water. A dose of sulph. ether or of chloroform by 
the stomach, or if the pain be very great ether or chloroform by 
inhalation, until sufficient anaesthetic effect is produced to arrest the 
pain, will often give very speedy relief. 
Heat to the abdomen may be applied by flannel cloths wrung out 
of water as hot as can be borne, and the temperature may be kept up 
by covering the cloths with relays of dinner plates, taken out of boil- 
ing water. But the most certain and permanently effectual anodyne 
is morphine, or some of the other preparations of opium. Free doses 
will be borne, and sometimes large doses will be required to quiet the 
pain. 
If the pain is very great, an opiate may be given, and immediately 
after chloroform or ether may be inhaled for immediate effect, and 
by the time this abates the opiate will have had time to produce 
its action. The morphine may be placed upon the tongue, or often, 
better still, it may be given hypodermically and as in other cases may 
be combined with atropia. 
A warm sinapism, or cloths sprinkled with turpentine placed over 
the abdomen, and hot plates over those, will often be more efficient 
than the heat and moisture alone. A warm pediluvium, or a general 
warm bath, will frequently aid in procuring relief. 
After the pain and spasm are overcome, a purgative will generally 
be needed. Its operation will expel irritating materials—gaseous, 
liquid, or solid—and the attack will thus usually be ended. 
A free dose of castor-oil, to which may be added half a drachm, 
more or less, of oil of turpentine—the two intimately mixed and 
given upon some warm fluid, such as mint tea or hot coffee (which 
latter goes far toward concealing the taste of the oil), will usually 
soon operate, notwithstanding the free doses of morphine that may 
have been given. 
Whenever an acid is suspected an alkali should be given, at what- 
ever stage of the treatment, either with the anodynes or with the 
cathartics. A saline cathartic with an alkali will often answer the 
purpose. More efficient, and comparatively unirritating, will be an 774 
LEAD COLIC. 
infusion of senna leaves and anise-seed, to which are added sulphate 
of magnesia and carbonate of soda. B Sennae Fol., 5ss; Sem. 
Anise, 3jss; Boiling Water, fviij or ?x. Infuse for half an hour in 
a covered vessel, pour off the tea, and add Sulp. Magnesia, 3vj • Carb. 
of Soda, 3j, for a draught. 
Jalap and cream of tartar—any decided but unirritating cathartic, 
aided if necessary by enemas—may be given to relieve the bowels of 
any irritating materials. If the secretions are particularly deranged, 
a mercurial may precede or be added to the cathartic portion. 
In the colics of hysteria a mixture of Hoffman’s anodyne and 
fluid extract of valerian, or the valerianate of ammonia, or, some- 
times better still, assafcetida by the stomach or by enema, will be 
effectual and safer than repeated recourse to opiates. The bromide 
of potassium, in various combinations, is also a remedy often useful 
in hysterical cases ; and in the flatulent colic of infants a few grains 
of the bromide in an infusion of anise-seed, repeated until relief is 
obtained, is often efficient, and safer than opiates. Soot tea, when 
open chimneys were more common, was formerly a domestic remedy 
for the colic of children, and the creosote, which it often contained, 
tended to arrest fermentative processes and relieve the pain. 
When repeated attacks of colic occur, the cause should be care- 
fully sought for and removed. These attacks often depend upon 
indigestion, and may merge into intestinal catarrh. The dyspepsia 
in such cases must receive attention. When it results from improper 
food this cause must be avoided, and so of all other causes. 
Whatever may the special cause of the attack—improper ingesta, 
flatulency, acidity, vitiated bile, or other foul secretions—the same 
general principles apply. First allay the pain and spasm, and then 
evacuate any irritating materials; and in all habitual and repeated 
attacks the cause must be specially looked for and removed. 
If, after spasmodic pain is quieted, and proper evacuations are 
effected, the pain remains and becomes more constant, intestinal 
catarrh or some form of inflammation should be suspected, and will 
usually be discovered. The treatment must then be adapted to this 
state of things. 
LEAD COLIC.—COLICA PICTONUM. 
This is a particular kind of colic dependent upon a special cause. 
Causes.—It is produced by lead poisoning, and occurs in con- 
nection with other symptoms, with a peculiar anremia and debility, 
with various nervous disorders and pains, and often with paralysis of C A USES. 
775 
the extensor muscles of the wrist, producing the “ dropped hand.” 
The lead is usually introduced into the system slowly, in small and 
repeated quantities, and its sources are various. 
It seems to have derived the name of colica pictonum from its 
former great prevalence in Poictou, where lead was habitually added 
to wine ; it prevailed in the West Indies, where leaden worms were 
used in distilling rum; and in Devonshire, England, where leaden, 
vessels were used in connection with the manufacture of cider. 
It is occasionally produced in this country by the storage of 
drinking water in leaden vessels, or by conducting it through leaden 
pipes ; and the softer the water, the less lime it contains, the more it 
acts upon the pipes, and the more likely it is to be contaminated with 
the lead. Lead poisoning is also produced by the use of beer or cider 
drawn through leaden faucets, by taking preserves or pickles kept in 
earthen vessels glazed with compounds of lead, and by the use of cer- 
tain cosmetics and hair-dyes, composed in part of salts of lead ; and 
also in snuff-takers, by the lead mingled with that absurd errhine. 
The poisoning is more common, however, among workers in lead, 
among manufacturers of lead paint, and among painters ; and some- 
times it occurs in printers, from constantly handling type composed 
in part of lead. It may be produced by sleeping in a room newly 
painted, the evaporation of the turpentine in the paint carrying 
small particles of the lead into the air which is inhaled. 
It is occasionally produced by the use of preparations of lead as 
medicines, either internally or as outward applications ; and although 
I am unable to call to mind a single case in my own experience where 
this has been the source of the poisoning, yet it should be borne in 
mind that not only lead but other substances used as medicines may 
act as poisons ; and that some persons, from causes we do not under- 
stand, are much more susceptible to the poisonous action of various 
substances, including lead, than others. It should also be remembered 
that some resist for a long time the action of some poisons, such as 
lead, mercury, arsenic, opium, tobacco, and alcohol, which in the 
same or in far less quantities will seriously injure the average indi- 
vidual, and that inferences of the innocuousness of articles from their 
use with impunity in certain cases are entirely unreliable and unsafe 
as bases of action. 
The form of lead most likely to produce poisonous effects is the 
carbonate, the common white paint; and workers in this should be 
particularly careful not to take it in their food, not to allow it to 
remain in connection with the surface—under their nails or elsewhere 
—and should be careful not to inhale the powder likely to arise in the 
air when it is handled in the dry state. Grinding the lead in water 776 
LEAD COLIC. 
or oil, instead of in the dry state, is said to have diminished materially 
the occurrence of lead poisoning in workers in lead manufactories. 
The effect of this poison, when slowly introduced into the system 
in the usual way, is commonly first manifested in a pallor of the 
countenance, or a sallow, earthy look, in more or less general failure 
of health, in loss of appetite often, in thirst, and sometimes in a 
sweetish taste in the mouth. Neuralgic pains and a sense of uneasiness 
are experienced ; and in those disposed to gout, the symptoms of the 
two affections are frequently mingled. 
Chronic albuminuria is said not unfrequently to occur in those 
who have been subject to the influence of lead. 
Diagnosis.—One diagnostic mark of the poison of lead, which 
has been made much of within some years past, is the formation of a 
blue line along the edges of the gums as they join the teeth. This, 
however, is not always marked or present at all in lead poisoning, it 
varies in distinctness -when present, modified by the amount of tartar 
upon the teeth, and is, moreover, produced by other causes, by impreg- 
nation of the system with copper and some other metallic substances. 
The most important and characteristic effects of the lead poison are the 
attacks of colic and a peculiar paralyzing action upon the nervous 
system. 
Lead colic usually comes on rather gradually, the pains not 
materially differing from other forms of colic, and is accompanied by 
obstinate constipation and often by vomiting. The pains appear to 
be due to a more or less paralyzed condition of portions of the muscles 
of the intestines, and the intense and irregular contraction of others. 
The regular proper peristaltic action of the bowels, which moves on 
and expels their contents, is interfered with, and this irregular painful 
action takes its place. The paroxysmal character of the intense pain 
is marked, but when the disease is fully established there is a duller 
pain, or a decided sense of uneasiness between the paroxysms. The 
pain is commonly more intense in the umbilical region, but is gener- 
ally more or less diffused and shifting—is not commonly aggravated, 
but often rather relieved, by pressure and friction, and the abdominal 
walls are usually retracted and tense. The vomiting may be early 
and sympathetic, or it may come on later, as the result of intestinal 
obstruction. 
Prognosis and General Phenomena.—Lead colic rarely 
proves fatal of itself, and the paroxysms subside, sometimes after a 
day or two, in other cases not till after several days, and with remis- 
sions they may continue longer. When one attack has occurred, 
unless exposure to the cause ceases, and the lead is eliminated from 
the system, other attacks sooner or later are almost sure to follow. PHENOMENA. 
777 
Fortunately the colic is rarely attended with fever, or by a distinct 
development of intestinal inflammation. 
The nervous disorders manifested in other directions are less par- 
oxysmal and more continuous than the colic ; but still many of them 
are very variable in their severity at different times. Various neural- 
gias and muscular paralyses, pain in the back and lower extremities, 
a sense of stricture about the body, the imperfect action of different 
muscles, etc., may occur, but the most frequent and most peculiar 
effect is the paralysis of the muscles supplied by the musculo-spiral 
nerve, and mainly its posterior osseous branch. The particular mus- 
cles most liable to be affected are, according to Duchenne, the extensor 
communis digitorum, extensor indicis, extensor minimi digiti, exten- 
sor secundi internodii pollicis, extensor carpi radialis brevior, extensor 
carpi radialis longior, extensor carpi ulnaris, extensor ossis metacarpi 
pollicis, and extensor primi internodii pollicis. 
The paralysis of these muscles (and others are enfeebled but 
seldom distinctly paralyzed) causes a peculiar dropping of the hand 
from the wrist joint. This may come on suddenly or gradually ; it is 
sometimes confined to one hand, usually the right, but it oftener 
affects both, though seldom equally. The paralyzed muscles waste 
rapidly, increasing the deformity ; and while retaining their electro- 
sensibility, lose more or less completely their .faradic contractility. 
There is no impairment of cutaneous sensibility ; but there is apt to 
be pain and tenderness in the situation of the affected muscles during 
the acute stage of this peculiar affection. 
Other muscles of the upper extremity, especially the deltoid and 
triceps, are sometimes but much more rarely affected, and in a 
similar way, by loss of power and faradic susceptibility, and by wast- 
ing. Sometimes the muscles of the lower extremities are affected, 
particularly the extensors of the foot and the leg; and occasionally 
the intercostal muscles and the diaphragm suffer. In exceedingly 
rare cases a large portion of the voluntary muscles are simultaneously 
affected, but in such instances it may be that some other element of 
disease is present than that produced by the lead. The duration of 
lead palsy is very various, extending from weeks to years. After relief 
it is liable to recur like the colic ; and attacks of the latter usually 
precede the paralysis. 
Epileptic or epileptiform attacks, coma, and other cerebral symp- 
toms sometimes come on in the course of lead poisoning. 
The longer symptoms of lead poisoning have continued, the more 
unfavorable the prognosis ; and the affection, when thoroughly estab- 
lished, is apt to be, in some of its consequences, permanent. 
Lead, when received into the system, is eliminated by various 778 
LEAD COLIC. 
emunctories, and with greater or less facility in different cases. A 
portion of it, however, is apt to be retained and to be deposited in 
various positions, in contact or in combination writh tissues. Why it 
should affect some parts rather than others depends upon affinities 
the nature of which is not known. It has been found post mortem in 
the heart, spleen, lungs, liver, kidneys, and intestinal walls, and also in 
the brain, spinal cord, and various muscular tissues. Aside from the 
presence of the poison, the changes of tissues in persons dying from 
lead poisoning are, so far as knowu, very undecisive. The intestines, 
in cases of lead colic, are said generally to be found, post mortem, con- 
tracted and empty, or some parts contracted and others dilated, and 
in this state intussusception sometimes occurs. Occasionally spots 
of hyperasmia are found, but full inflammation seldom. The para- 
lyzed and wasted muscles are often found to be remarkably pale or 
yellowish; but no material structural change is discovered by the 
microscope. The muscles are usually simply atrophied, but fatty 
degenerations sometimes occur in long-continued cases. Whether the 
intestines and other muscular parts are affected by the lead deposited 
in connection with the nervous matter which supplies them with 
power, or whether from deposits in the muscles themselves, is not yet 
positively determined ; but it is almost certain that in the voluntary 
muscles, and probably in the intestinal also, the chief morbid impres- 
sion is upon the nerves, either in their course or at their origin. 
The diagnosis of lead poisoning is important, whether the symp- 
toms manifested are those of colic, paralysis, or the more obscure 
nutritive and nervous affections. The known exposure to lead will, 
of course, aid in the diagnosis ; but the blue line of the gums, partic- 
ularly at their juncture with the incisor teeth, and the peculiar symp- 
toms which have been described, particularly the dropped hand, will 
lead to a conclusion. The symptoms, however, are sometimes obscure, 
and the sources of the poison may not be apparent or suspected. 
The excretion of lead from the system is chiefly by the kidneys, 
though it is sometimes detectable in the perspiration and the milk, 
and is, doubtless, sometimes in the contents of the intestines. In 
doubtful cases its detection in the urine may aid in the diagnosis, and 
this fluid should be tested for its presence. 
In distinguishing colic from severe pain in the bowels from other 
causes, from enteralgia, etc., the principle of exclusion must be em- 
ployed. The known exposure of the patient to lead, and the other 
signs of plumbism, will determine the nature of the case. 
Treatment.—In all forms of lead poisoning it is important to 
inquire into the sources of the lead, and to avoid further exposure. 
As prophylactic or antidotal to the more acute poisoning where lead TREATMENT. 
779 
has been swallowed, a pretty free use of diluted sulphuric acid will re- 
duce the carbonate or acetate, etc., to an insoluble sulphate, and cathar- 
tics should then be given to expel all that remains. If sulphuric acid 
be not at hand, the sulphate of magnesia or sulphate of soda will act 
both as a chemical antidote and as an expelling agent, and should be 
freely given. 
When an attack of lead colic is present, the severe pain and spas- 
modic action should be allayed by opiates, chloroform, fomentations, 
or, as some advise, cold by means of bladders of ice over the abdo- 
men ; and when the pain is thus checked, sulphate of magnesia or 
other cathartics, not with great nervousness and precipitancy, but in 
ordinary free doses and at proper intervals, should be given, and, if 
borne by the stomach, continued until, aided by large laxative enemas, 
a cathartic effect has been procured. 
Sir Thomas Watson advises ten grains of calomel with two of 
opium, to be followed by a saline cathartic or by castor-oil. In some 
cases the inhalation of chloroform or ether, as in other forms of colic, 
will be well, and other anodyne medicines may bo substituted for the 
opium where it is not well borne ; but as a rule the opiates, morphine 
dropped upon the tongue, or administered hypodermically, with or 
without atropine, will be found most efficient, and sometimes free 
and repeated doses will be required to overcome the severe pain. The 
use of electricity has been recommended for overcoming the spasmodic 
action, or rather for relieving the paralyzed state of portions of intes- 
tine, and thus restoring more proper action and relieving pain. In 
obstinate cases this should be tried. 
The general testimony of the profession is in favor of the use of 
cathartics to relieve the constipation as an important part of the treat- 
ment ; but the necessity of very large or of drastic doses may well be 
questioned. The pain may be enhanced by faecal accumulations, but 
this is not the cause of the suffering, and no unusual accumulations 
may be present. When there is no evidence of such accumulations, 
there need bo no haste in moving the bowels, and the leading indica- 
tion is to relieve the pain and the spasm. Large enemas of warm 
water or gruels may have a double effect of soothiug the pain and 
spasm and of moving the bowels, and are to be recommended. 
For eliminating the poison from the tissues the iodide of potas- 
sium has the greatest reputation. This article is supposed to enter 
into combination with the lead in the tissues, forming soluble com- 
pounds, and thus detaching the metal from the albumen with which 
it is associated, and preparing it for elimination from the system, 
which is chiefly effected by the kidneys. It is alleged that the lead 
is found in increased quantities in the urine after the administration 780 
LEAD POISONING. 
of the iodide. As free and as often-repeated and as long-continued 
doses as the system will well bear, or as may be necessary for the 
accomplishment of the object, are advised. It may sometimes be given 
in drachm doses three or four times a day. Baths, medicated with 
the sulphide of potassium in the proportion of two ounces to fifteen 
gallons, have been recommended. They will remove any lead which 
may escape from the surface of the skin, and are unobjectionable ; 
but there is no sufficient reason to suppose that they exert any special 
influence in eliminating the lead from the tissues. The same may 
probably be said of “electrical” and various other baths; they 
may be allowed or advised, but should not be relied upon to the 
exclusion of the iodide of potassium. Iodine ointments may be used 
where the stomach does not well bear the iodide, and when directly 
applied over the muscles, or in the course of the nerves implicated, as 
in the dropped hand, may be worthy of a trial. 
Alum has a reputation in cases of lead poisoning, and writers of 
authority say it appears to be useful; but on what principle it acts 
is not clearly stated. I know of no reason for supposing it to possess 
eliminative powers. Like sulphuric acid or the sulphate of magnesia, 
it may convert soluble into insoluble forms, and thus be useful when 
lead is in the alimentary canal. 
The elimination of the lead is the primary object in the treatment 
of all forms of chronic lead poisoning ; but remedies may be used for 
the removal of its effects. Among those for improving the general 
condition and removing the anaemia, iron and other tonics, with pure 
air, proper food, etc., may be very useful. The special treatment for 
the paralysis will consist in the use of electricity, applied secvndum 
artem, aided by the administration of strychnine. These remedies 
are particularly applicable to this form of paralysis after the lead is 
supposed to be eliminated, but where the paralysis continues from 
desuetude and atrophy of the muscles; frictions may also aid in 
restoring nutrition and proper action. 
Various means may be useful in preventing the introduction of 
lead into the system in persons whose occupation or circumstances 
expose them to the article. When an individual’s susceptibility is 
shown by the occurrence of symptoms, he should, if possible, avoid 
the occupation or circumstances which involve exposure. 
Free ventilation if the lead is inhaled within doors, frequent ab- 
lution if it enters by the skin, frequent changing of the clothing when 
it becomes saturated with the preparations of lead, the use of fine 
masks or moist sponges over the nose and mouth when the fumes or 
dust of lead are unavoidable, not taking food amidst surroundings of 
lead, or food that has been kept within reach of its dust, etc., are TEE A TMENT—CA USES. 
781 
among the means of prevention. It seems unnecessary to mention 
the avoidance of lead pipes for the conveyance of drinking water, or 
of leaden utensils for the storing of auy ingesta. 
Fortunately the use of leaden hair-dyes is much less frequent than 
it was some years ago, and it is to be presumed that the use of leaden 
cosmetics is confined to a few. 
CONSTIPATION.—FUNCTIONAL OBSTIPATION.—COS- 
TIVENESS.—HABITUAL SLUGGISH BOWELS. 
A deficiency in the frequency and amount of faecal evacuations 
constitutes constipation. The term costiveness is generally applied to 
the condition in which the evacuations are scanty, dry, and hard; and 
by functional obstipation is understood markedly unfrequent, defi- 
cient, and hardened dejections, or obstinate retention, where no 
mechanical obstruction to the evacuations exists. The expression 
“ habitual sluggish bowels ” is sufficiently explicit without a defini- 
tion. The term functional constipation will sufficiently express all 
these conditions, and this is a very frequent symptom of various mor- 
bid states. In treating of indigestion it was alluded to, and some- 
thing was said respecting its importance and the means for its relief. 
Etiology.—A great variety of more remote causes may produce 
constipation, but it is chiefly dependent upon two principal con- 
ditions, viz., a deficiency of intestinal secretion, and diminished in- 
testinal muscular activity. 
A feeble or diseased condition of the abdominal muscles, which 
usually aid in the expulsion of the intestinal contents, may also con- 
tribute to the condition. A deficiency of the biliary and pancreatic 
secretions may also tend to the same end ; and. indeed, a deficient 
secretion of bile, which deprives the intestines of a stimulant to their 
activity and a solvent of their contents, is not an unfrequent cause of 
this symptom. This deficiency of the - secretion of the accessory 
glands should be placed rather among the more remote causes than 
the immediate conditions of constipation. 
Deficiency in alimentation, or the taking of food with too little 
residual matter, often leads to constipation. Each species of the 
animal creation has an alimentary canal adapted in capacity to the 
food it habitually takes, and a certain amount of indigestible material, 
giving bulk to the faecal mass, is important to a proper mechanical 
stimulation of the intestinal muscles ; and when this is in too small 
quantity, deficient or deranged action is the result. The human 782 
CONSTIPATION. 
stomach and intestines have their adaptation to an amount of residual 
substance which best promotes their action. When this is deficient 
that action is deranged, the proper mechanical stimulus is not 
afforded, and constipation is the common result. Constipation from 
this cause may be less injurious than from some others, but secre- 
tions and excreta which remain long in the intestines may undergo 
changes and produce unpleasant effects. 
Want of proper muscular exercise is another cause of constipa- 
tion. When the voluntary part of the muscular system is inactive, 
the involuntary is apt to sympathize, and a general stagnation is apt 
to follow. 
Anaemia and general debility, from whatever cause, may produce 
a proportionate debility of the intestinal and abdominal muscles, 
which may result in constipation. 
A want of proper nervous sensibility, so that the presence of faecal 
matter in the intestines is not appreciated by the organism or the 
sensorium, is another cause of constipation. Under this head will 
come mental absorption and neglect to attend to the intimations of 
the senses with regard to evacuations. 
Habit lias much influence over the function of defecation, as over 
so many other functions of the body, and an habitual neglect of this 
may lead to its exceedingly deficient and irregular performance. 
Many of the causes which produce muscular inactivity produce 
deficient secretion also ; but there are some special causes which tend 
to produce deficient secretion of the intestines. A loss of the fluids 
of the system by free perspiration, or by excessive urinary secretion, 
as in diabetes, tends to this result. In various dyspeptic conditions 
and in feverish states this deficient intestinal secretion is marked, and 
a deficient action of the secretion of the intestinal follicles, independ- 
ent of other morbid conditions, may occur. 
Many, even of the enlightened members of the profession, do not 
fully appreciate how injurious are the effects of habitual constipation. 
The long-continued retention of matter which should be expelled, 
often undergoing putrefactive changes, is almost certain to be fol- 
lowed by the absorption of materials which contaminate the blood 
and the system. Moreover, the presence of mechanically or chemi- 
cally irritating materials continually impressing and more or less irri- 
tating the intestinal nerves, affects very unfavorably the whole nerv- 
ous system, especially in sensitive persons, and leads to a great variety 
of sensitive, motor, nutritive, and even mental abnormalities. 
Symptoms and Diagnosis.—The particular symptoms in- 
duced are various; pain, heaviness, and a feeling of confusion in the 
head, a coated tongue, foul breath, abdominal distention, uneasiness SYMPTOMS—TREATMENT. 
783 
and pain, loaded urine, hemorrhoidal tumors, indigestion, etc. When 
long continued, general derangement, and often permanent impair- 
ment of health ensues. 
The diagnosis would at first view seem to be easily made by in- 
quiring if the bowels are regular, or if evacuations regularly and daily 
occur. In some cases, however, this is not sufficient. Sometimes 
evacuations regularly, or even frequently take place, while large 
accumulations still exist. More exact information must be obtained 
not only as to the frequency, but as to the free and satisfactory charac- 
ter of the discharges ; often the abdomen should be examined by 
palpation and percussion, and it may even be necessary to explore the 
rectum by the finger or a sound to determine the fact of accumulations 
there. Faecal tumors will sometimes be found in the course of the 
colon. They are usually irregular in form, and may be hard and un- 
yielding, but generally by making firm pressure slowly with a single 
finger, an indentation is made, which could happen in no other 
tumor. 
Sometimes a patient complains of repeated attacks of diarrhoea, 
when it will be found on more particular inquiry that the actual dis- 
ease is constipation, the bowels remaining in that condition until the 
faecal accumulations are so great as to produce an irritation which 
results in an increased peristalsis, pain, etc., and these will be the 
symptoms complained of. The evacuations, though at the time 
painful, procure relief, to be followed again by the constipation. 
In the normal state and the ordinary condition of health, with a 
proper performance of all the functions, when a proper quantity of an 
ordinary quality of food is taken, an alvine evacuation occurs at least 
once every twenty-four hours. There are rare cases where good health 
appears to be enjoyed, but where evacuations are much less frequent. 
They are, however, exceptional and abnormal, and even such cases 
are likely to be followed, in time, by impaired health. As a rule, then, 
when movements of the bowels occur less frequently than once a 
day for any considerable time, constipation is present and requires 
attention. 
Treatment.—When this condition occurs temporarily from ac- 
cidental causes, and no condition such as enteritis or peritonitis is 
present to contra-indicate, a cathartic should be given or an enema 
administered to remove the symptom. The kind of cathartic to be 
chosen depends upon the character of the constipation, the length of 
time it has continued, whether it arises from mere sluggishness of 
muscular power, from deficient secretion, or some other morbid state. 
A mercurial followed by a saline is more efficient in increasing and 
modifying the secretion than most other cathartics. Aloes and senna 784 
CONSTIPA TION. 
act more upon the muscular contractility ; jalap nearly equally excites 
secretion and peristaltic action ; castor-oil lubricates the intestines 
and their contents, and excites vermicular motion ; and each cathar- 
tic has its own peculiar effect and adaptation to particular conditions. 
It is often the case that a cathartic which produces a decided 
effect is followed by a period of greater inaction of the bowels, but 
this should not prevent its administration when indicated by positive 
symptoms. 
Sometimes enemas will be sufficient to remove accumulations from 
the lower bowels, and they impress the system less than a cathartic of 
more positive and active qualities. 
Chronic or habitual constipation is often met with, and requires 
other management than the mere administration of cathartics. The 
causes here must be inquired into, and these, as well as the mere symp- 
tom, call for remedial measures. The treatment then must be partly 
in reference to removing the symptoms and partly in reference to the 
fulfillment of the causative indication. 
The immediate means for relieving the symptom embrace not only 
the use of cathartics and enemas, but various accessory measures. In 
large accumulations in the rectum, mechanical means may sometimes 
be required. The handle of a spoon is often recommended as a fitting 
instrument for the purpose. 
Certain articles of food, which by their mechanical or some other 
property increase peristaltic movements or intestinal secretions, and 
thus produce a laxative effect, are often useful. Preparations of corn 
meal, wheaten grits, unbolted flour, oatmeal, rye flour, etc., and the 
use of various vegetables and fruits, will often suffice to keep the 
bowels open. They produce their effects, for the most part, by the 
mechanical stimulation which their indigestible constituents afford to 
the muscles of the intestines. When these articles of food do not dis- 
turb the stomach and the digestion, they should often be preferred to 
medicines. Though they are more palliative than curative, their use 
for a length of time not unfrequently establishes a regular habit, 
which is a very important matter where an irregular habit has per- 
petuated constipation. Where an irregular habit is by any means 
broken up, and habits of regular evacuations established, the patient 
may often return to an ordinary diet, and particular measures may be 
discontinued while the new habit will be kept up. The particular 
dietetic measures must be governed, to a considerable extent, by the 
experience of the patient. Particular articles from the general list 
above given may be selected. Graham bread and cracked wheat, and 
oatmeal and ryemeal mushes, are among the best dietetic articles. 
They are highly nutritious as well as laxative. Among fresh vegeta- TREATMENT. 
785 
bles, tomatoes, peas, string beans, and the standard potatoes may be 
mentioned; and of fresh fruits, apples, peaches, grapes, and oranges 
are among the best. Of dried fruits, figs, raisins, and prunes deserve 
mention. A free drink of water some time before breakfast, more than 
will be readily absorbed from the stomach, and which passing into the 
intestines will supply to their costive contents the proper moisture, 
will sometimes serve an excellent purpose. The addition of half a 
drachm or a drachm of common salt, while not particularly unpalat- 
able, will add to the efficacy of the water. 
But these means are often ineffectual, or some conditions are pres- 
ent which require more particular modification, and medicinal meas- 
ures are demanded. 
Among the laxatives—for active cathartics should, as a rule, be 
given in habitual constipation only in exceptional cases, and for the 
most temporary effects—are a great number of articles from which 
combinations and selections may be made. Here the adaptation to 
particular cases is also important. The article and the dose should 
be such as to prevent faecal accumulations without producing purga- 
tion, and as far as possible to induce regular daily movements. To 
effect this, moderate, frequently small, but repeated doses will be 
required, often continued for a considerable time, until a regular 
habit is established. It cannot be too strongly impressed that, after 
accumulations that may be present at first are removed, the patient is 
not to be purged. The practice of taking active purges, allowing the 
bowels to remain torpid until large accumulations take place, and then 
repeating the purgative, is, in most cases, particularly pernicious. 
The constipation is liable, in this way, to be increased and confirmed. 
In some cases where the secretions of the intestines and accessory 
glands are deficient or perverted, a grain or two, more or less, of blue 
mass may be given every night or every second night for a few times 
in succession, and a drachm or two, more or less, of a laxative salt— 
sulph. of soda or magnesia, or phosphate of soda or Eochelle salts, 
given next morning in a half pint or a pint of water, often as warm 
as can well be taken, will be found to answer an excellent purpose. 
Often a little ginger or some other aromatic may be added to the 
potion. The morning saline draught may be continued as may be 
required, after the alterative has been discontinued. What are called 
“bitter waters” are often useful, such as Pfdlna, Janos, Seltzer, Apol- 
linaris, Congress water, etc. I have often prescribed an imitation of 
Carlsbad water, composed of sulph. of soda, carb. of soda, and com- 
mon salt, taken half an hour or an hour before breakfast, in a large 
drink of warm water, as mentioned when treating of the diseases of 
the stomach. 786 
CONSTIPATION. 
Where, however, there is muscular debility of the intestines, rather 
than a perversion of their secretions, other forms of laxatives are 
much more appropriate. A number of the vegetable laxatives, some 
new and some old, are available. Among these are aloes, colocynth, 
rhubarb, buckthorn, podophyllin, euonymin, cascara sagrada, and 
some others. 
The vegetable narcotics—belladonna and hyoscyamus—have some 
laxative properties, and when combined with more decided cathartic 
substances, by their soothing effects modify the “ griping” qualities 
of the more irritating articles, and promote their action. The nux 
vomica, or its most active principle strychnia, gives tone to debilitated 
muscles and promotes their activity. Ipecacuanha in small doses 
increases gastric and intestinal secretions, and thus tends to overcome 
costiveness. 
In the course of a long experience, I have observed the effect of a 
large number of laxative medicines and compounds in sluggish bowels 
or habitual constipation. The formula} for many of these prepara- 
tions may be found in various works; several are appended to this 
article ; but I have found no combination as effectual and unobjec- 
tionable, and applicable in as large a number of cases as the pill for 
which a formula was given in another place, but which is deemed 
proper to be repeated here. 
Aloes (purified) 3j 
Ext. Hyoscyamus 3j 
Ale. Ext. Nux Vomica grs. xij 
Puly. Ipecacuanha grs. yj 
M.—Ft. pil. No. xxx. 
One or two pills to be given each night, varying the quantity 
often by dividing a pill, or increasing the number, but so as to secure 
a satisfactory movement the next morning. This should be con- 
tinued steadily until the habit of regular movements is well estab- 
lished. The medicine may often then be withdrawn without inter- 
rupting the habit. 
The aloes is of course the chief laxative agent, operating mostly 
upon the large intestines, the hyoscyamus promoting its action and at 
the same time modifying its irritating effects, while the ipecac, pro- 
duces some effect upon the secretions, and the nux vomica more per- 
manently increases the tone and muscular power of the intestines. 
At all events, whatever may be the mode of its operation or char- 
acter of the explanation, a long experience in the use of this com- 
pound, the proportion of its ingredients being sometimes varied in TREATMENT. 
787 
particular cases, has induced me to be so particular in its recommen- 
dation. Various other compounds embracing similar ingredients, 
administered in view of similar therapeutical principles, may be equally 
efficient and better adapted to particular cases; but none on the whole 
has been found quite as satisfactory, and as often applicable, as this. 
In anaemic cases the simultaneous administration of preparations 
of iron, or iron and quinine, etc., will be called for. Indeed, what- 
ever other pathological condition may be present, operating as a cause 
of the constipation, must receive its appropriate treatment. 
The treatment of constipation with repeated and long-continued 
enemas, although affording temporary relief, must be considered as 
often objectionable. Although occasionally not only justifiable, but the 
best means that can be used, they do not tend to strengthen the intes- 
tines or increase their proper secretions, and too often they diminish 
that natural sensibility which induces an effort at evacuation when 
only a moderate quantity of faecal matter is in the rectum. In this 
way they tend to establish in the part a habit to act only when there 
is large mechanical distention, and thus promote and establish the 
condition they are intended to remedy. Dr. Flint remarks, “ repeated 
daily, they cease after a time to be effective, and they interfere with 
the recovery of the muscular power and sensibility of the rectum.”* 
Their great utility for temporary effect in many cases, especially of 
acute constipation, and when occasionally used, can but be appre- 
ciated—it is their continued and habitual use that is objectionable. 
But there are other means more important than medicines in the 
treatment, and especially in the prevention of habitual constipation. 
The importance of dietetic management has already been alluded to. 
A sufficient and varied diet, with a proportion of indigestible matter, 
the nutrient principles not too much concentrated, should be taken. 
A proper amount of exercise should be secured by persons of seden- 
tary pursuits, and, in short, all the ordinary hygienic rules should be 
observed. 
The most important means, however, of preventing this very com- 
mon affection is to establish regular habits of defecation, the same 
hour being observed each day, and sufficient time being given to the 
process to secure a thorough evacuation. No call of business, pleasure, 
or occupation should allow this “call of nature” to be interfered 
with. Remaining long upon the stool in ordinary cases is by no 
means necessary or useful. Such a habit rather tends to produce 
congestion of the lower bowels and to cause hemorrhoidal tumors or 
* Clinical Medicine, p. 352. 788 
CONSTIPATION. 
prolapsus ani ; and much straining at stool is often dangerous, 
especially when there is a tendency to cerebral congestion or apo- 
plexy. Still, a complete evacuation of the contents of the rectum is 
important, and all the necessary time should be taken to accomjilish 
it. If the bowels are sluggish in their action, kneading the abdomen 
may hasten and aid the process. The power of the will must be made 
available, and due attention must be given to a function so essential, 
the proper performance of which is so necessary to health and com- 
fort. In order to avoid the inducement to leave the closet too soon, 
the too frequently disgusting condition of these places should be 
remedied. Where a well-arranged water-closet is unattainable, as is 
often the case in the country, a properly constructed earth-closet 
should be provided, and this is easily accomplished everywhere, in 
country situations. More attention than is usually given to conven- 
iences of this kind is essential for reasons of decency, individual com- 
fort, and health, as well as for the avoidance of wide-spread zymotic 
diseases. 
Decent, cleanly, inodorous, and ornamental commodes are better 
evidences of civilization and refinement than statues and monuments 
or common house decorations. A small fraction of the expenditure 
which sometimes makes pretentious houses glaring, or to a refined taste 
hideous, would make these places cleanly and attractive which are 
often so injurious, dangerous, and revolting. The importance of 
establishing and keeping up regular habits of defecation, either by 
voluntary efforts, or when necessary by medicines, cannot be too 
highly estimated, or the practice be too strongly insisted upon. When 
the habitual hour arrives for this organic act, it usually brings with 
it the desire and the ability for its performance. 
By attending to the preventive regulations which have been recom- 
mended, the number of cases of habitual constipation would bo 
vastly diminished, and its many evil consequences obviated. 
The following prescriptions by others are made in accordance with 
the principles which have been stated in the preceding account, and 
are presented as specimens from which selections may be made in 
treating different cases of this very common complaint: 
W Ext. Aloes, Ext. Iiyoscyamus, of each 3j ; Ext. Nux Yom., grs. xij ; Oil of 
Anise, gtts. x. M.—For 00 pills. Dose, one or two each night. 
IyT Ext. Aloes, 3ss ; Ext. Nux Yom., grs. vj ; Ext. Iiyoscyamus, grs. xx ; 
Pulv. Ipecac., grs. ij. M.—For 20 pills. One at night. 
W Confection of Senna, ; Bitartrate of Potash, 3ij ; Precipitated Sulphur, 
Subcarbonate of Iron, of each 3j ; Honey or Syrup sufficient for an electuary. 
Two tea-spoonfuls each night, or one after each meal. 
Iy Aqueous Ext. Aloes, gr. ss to j ; Sulph. of Iron, grs. jss to ij. M.—For a 
pill. To be taken after each meal for a time, and then less and less frequently. TEE A TMENT— VARIETIES. 
789 
B? F. Ext. Caseara Sagrada, 3ss to 3jss. Taken at night or oftener. 
Yy Purified Oxgall, 3ij ; Oil of Caraway, qx ; Calc. Magnesia, q. s. M.—For 
80 pills. Two twice a day when deficiency of bile. 
Fy Ext. Stramonium, grs. x ; Cocoa Butter, q. s. M.—For 15 or 20 sup- 
positories. One or two in a day in pelvic irritation with constipation. 
DIARRHOEA. 
EXCESSIVE FUNCTIONAL DEFECATION. 
Diarrhoea is defined as too profuse, too frequent, and too liquid 
intestinal evacuations. 
It may be divided into functional and organic diarrhoea. In the 
latter there are structural changes in the intestines, such as inflam- 
mation or ulceration, while in the former no such marked changes exist. 
It may also be divided into symptomatic and idiopathic diarrhoea. 
In the former it is a symptom of, or is dependent upon, some other 
disease or distinct pathological condition ; while in the latter it is 
the principal or only morbid phenomenon noticeable—is itself the 
disease. 
It has already been considered as a symptom of muco-enteritis and 
ulceration of the intestines, of typhoid, malarial, and eruptive fevers, 
etc., and will hereafter be considered as a symptom of some diseases 
of the liver, of the kidneys, of phthisis, and other affections. 
Considered as an idiopathic disease, or in itself the principal affec- 
tion, it has several recognized varieties, depending upon the peculiar 
symptoms presented, and the causes producing them. The different 
varieties, however, run into each other, and the lines between the 
organic and functional, and the symptomatic and idiopathic, arc not 
strictly drawn or well defined. A rigid division and clear and posi- 
tive distinctions are not always necessary; but they are referred to 
for the purpose of giving more complete views of the different aspects 
the disease presents. 
Diarrhoea Crapulosa is where there are frequent faecal but liquid 
discharges. The contents of the small intestines are generally liquid, 
or at least semi-fluid, and if this matter is not retained in the large 
intestines, and if time is not given for the absorption of much of the 
liquid portion, the faecal matter will continue in a fluid state and be 
discharged in that form. Simple increased peristaltic action, there- 
fore, would cause liquid stools. But the same cause which usually 
produces increased peristaltic action also causes more or less increase 
of liquid intestinal secretion, so that too liquid evacuations are char- 
acteristic of this, as of other forms of diarrhoea. 790 
BIARRIKEA. 
This form of diarrhoea may be caused by repletion, by too great a 
quantity of digested food and blood, or it may be caused by taking 
more food than can be fully digested and appropriated. Improper 
qualities of food often cause irritation and increased peristalsis and 
secretion, and in these cases the effect resembles that of a cathartic, 
and is often relieving and useful. Various articles, as salads, veal, 
green corn, cucumbers, unripe fruits, etc., produce these effects in 
persons usually in good health. 
Often irregular, as well as increased, peristaltic action, accompa- 
nied by griping pains, attends many cases ; and sometimes distention 
of the abdomen, sickness of the stomach, with coated tongue and 
foul breath are present. But there is no chill or tenderness, and 
little or no fever. When chills, much fever, and tenderness and 
tenesmus occur, the case becomes one of muco-enteritis or intestinal 
catarrh. 
Not unfrequently a change of locality and mode of living induces 
this form of diarrhoea, the effect being generally attributed and often 
properly, to change of drinking water. 
Fear, and other forms of mental excitement not unfrequently 
induce diarrhoea. An approaching battle often has this effect upon 
new recruits, and sometimes upon veteran soldiers; and, with some 
speakers, the prospect of appearing before an audience produces simi- 
lar results. 
Most forms of diarrhoea are more likely to occur in summer and 
autumn than at other seasons of the year, and the same causes which 
produce muco-enteritis, operating less violently, cause irritation rather 
than inflammation, and in both instances diarrlioeal discharges. 
The diarrhoea is called Lienteric when the passages contain food 
undigested. A diarrhoea caused by improper articles of food gener- 
ally cures itself. It should be favored by diluent drinks rather thaij 
abruptly checked, and the cure may often be accelerated by laxative 
medicines. Anodynes may be needed afterward if there be much 
irritation or pain ; or a laxative and anodyne, as castor-oil and tinct. 
of opium, may be given together. 
A Bilious diarrhoea is one produced "by a profuse or perverted 
secretion of bile, irritating the intestines and thus causing the effect. 
It is more common in hot weather and climates, and where other 
bilious derangements occur. Bile when in excess, as it often is tem- 
porarily where its excretion is irregular, operates as a cathartic. It 
sometimes regurgitates into the stomach causing vomiting, and with 
the purging constitutes a form of cholera morbus. In such a case the 
evacuations should not be arrested until the offending materials are VARIETIES. 
791 
expelled. As in cases from improper ingesta, the evacuations, if not 
free, may be promoted by warm water or by emetics and laxatives. 
Ipecacuanha, Seidlitz powder, rhubarb, magnesia, etc., are among the 
remedies which will fulfill the indications. Mercurials and alkalies 
may be needed to correct the secretions or neutralize acidity. 
A serous diarrhoea sometimes occurs in albuminuria and dropsical 
conditions, when the blood is thin, and a free endosmotic effusion 
occurs into the intestinal cavity. 
Urea is often discharged and dropsical effusions are reduced by 
such a diarrhoea, and, as a rule, it should be encouraged rather than 
checked; it may often be imitated by cathartics with great advan- 
tage, especially where there are large dropsical accumulations, or 
where symptoms of uraemia are present. 
In diseases of the liver, with obstructed circulation through that 
organ, the portal congestion following is sometimes relieved by a 
diarrhoea. This, too, is not to be checked unless excessive and de- 
pressing. 
Diarrhoea sometimes arises from “ taking cold”—checking the 
circulation and secretion from the skin, and causing a determination 
of blood and a free secretion from the intestines. As the diarrhoea is 
likely to relieve the internal congestion, it should be directly inter- 
fered with only when excessive. The action of the skin should be 
restored as soon as possible, and the warm bath, diaphoretics, etc., 
will be useful. 
Diarrhoea from the Inhalation of Noxious Vapors, animal putrefac- 
tions, fgecal fermentations, etc., accompanied often by specific zymotic 
poisons, not unfrequently occurs, and sometimes in an epidemic form. 
Here, also, the evacuations tend to eliminate the poison from which 
the system suffers, and within proper limits may be useful. 
In many of the cases muco-enteritis is present, accompanying the 
diarrhoea ; and then the case should be treated for that disease in the 
manner already sufficiently described. 
A Critical Diarrhoea not unfrequently occurs in connection with 
the subsidence or turning-point of inflammations and fevers. During 
the progress of these diseases, effete matters accumulate in the system 
and are eliminated at their abatement in this way. The strength of 
the patient should be sustained as required, but these discharges arc 
to be checked only when dangerous from their profuseness. 
A Colliquative Diarrhoea, in low conditions of protracted diseases, 
and in connection with profuse sweats, occurs as collapse approaches or 
is established, and is often terminal. It should be checked as promptly 
as possible by stimulants, tonics, and astringents, where the nature of 792 
DIARRHOEA. 
the disease upon which it depends does not render all efforts hopeless 
and useless, and where such measures would only produce disturbance 
and annoyance. In the advanced stages of some acute diseases not 
necessarily fatal, the scale may he turned by the continuance or arrest 
of such a diarrhoea. In such a case, treatment may be of the utmost 
importance. Opiates, astringents, and stimulants, by the stomach and 
rectum, must be promptly and judiciously employed. 
The Camp Diarrhoea of our late war has already been considered 
under the head of mueo-enteritis, as that condition gave the disease its 
leading characteristic. 
So far, in the account of the disease, diarrhoea, for the most part, 
has been considered as at least a harmless, and generally a useful, 
process. But sometimes cases of diarrhoea occur where no good but 
only evil results are produced by the profuse discharges. In some of 
these cases, though no distinct pathological condition aside from the 
diarrhoea is recognizable, yet some morbid excitement in the secreting 
vessels and the muscular tissue of the intestines exists, probably from 
changed innervation of the parts, which is the immediate cause of the 
excessive discharges. 
In other cases—those before described—though the diarrhoea at 
first may be innocent or useful, yet it may be so violent or so pro- 
tracted as to demand arrest. Each case must be judged of by itself, 
and remedies for arresting the discharges must be resorted to or with- 
held according to its nature and tendencies. 
Causes.—Before describing the means for arresting these dis- 
charges, it may be well to recapitulate the causes which produce them. 
1st. Improper ingesta; water to which the person is unaccus- 
tomed ; and change of locality and habits; or irritating matter pro- 
duced by changes in food from imperfect digestion. 
2d. Checking the action of the surface by cold and moisture. 
3d. Exhaustion and debility. 
4th. Poisonous inhalations. 
5th. Zymotic poisons, sometimes local, and sometimes more gen- 
eral in prevalence. 
6th. Excessive secretion of irritating bile. 
7th. Obstructed circulation through the liver, and congestion of 
portal vessels. 
8th. (Edema of the intestinal membrane, and profuse endosmotic 
effusion in Bright’s disease. 
9th. Strumous disease, and suppurative processes in the system. 
10th. SepticaBmia and various blood poisonings. 
lltli. Inflammation and ulceration of the intestinal mucous mem- 
brane. CA USES—TREA TMENT. 
793 
12th. Critical conditions at the subsidence of inflammations and 
fevers. 
13th. Mental agitation and fright. 
14th. Typhoid, and eruptive, and other fevers. 
15th. Diseases of the mesentery interfering with absorption from 
the intestines. 
Treatment.—In treatment the cause and pathological condition 
must be carefully observed, and rational indications formed in the 
mind, and direct interference with the discharges must only occur 
when all the conditions of the case render it necessary. 
The treatment of symptomatic cases will be best considered in con- 
nection with the diseases in which they occur. 
The means to be used for arresting a diarrhoea will be varied by 
the cause which has produced it. 
Those more directly calculated to accomplish that object are opi- 
ates and astringents, and sometimes stimulants. Rest—a recumbent 
position in all acute cases—is always proper, and often important. 
The temperature and clothing should be regulated according to the 
conditions of each case, and as the sensations of the patient require. 
Warmth to the extremities is often called for, and sometimes over the 
bowels. 
The diet should be particularly guarded. In acute cases absti- 
nence for a day or so may bo enjoined. In many cases scalded milk, 
with which some plain water or lime-water and some thoroughly 
cooked farinaceous substance may be mingled, will be found useful; 
and in mild cases, free from inflammatory tendencies, black pepper 
may be added. 
In many cases a few doses of camphor in substance, in tincture, in 
the form of emulsion, or in camphor water, will suffice to check the 
discharges. 
In some cases a simple stimulant, such as tinct. of ginger, cinnamon- 
water or mint-water, will be useful and sufficient. A little brandy 
and water, or brandy in hot coffee will check some cases. Various 
astringent tinctures, as tinct. of blackberry or kino, etc., will often 
suffice. 
In many cases the subnitrate of bismuth, alone or mingled with a 
moderate quantity of pulverized cinnamon, in doses of fifteen or 
twent}r or more grains of the bismuth, will answer an excellent pur- 
pose. Sulphuric acid, acting as an astringent and tonic, has a repu- 
tation in diarrhoea, and sometimes is efficient. 
Chalk mixtures are often used, especially in the diarrhoeas of 
children. My own experience has not convinced me of their great 
efficiency, but authority is in their favor, and they may be tried. 794 
DIARRIICEA. 
Lime-water is more frequently useful. It is astringent and anti- 
acid, and given in milk prevents that article from coagulating in 
large masses, and corrects the acidity of the alimentary canal, so often 
present in these cases. 
In the severer cases, and especially where there is much pain, 
opium in some of its forms will be required, and is in most cases by 
far the most efficient remedy. A single dose, or a few doses, will often 
answer where other remedies have failed, and in cases of considerable 
severity should not long be withheld. It has the great advantage of 
being applicable, after the evacuations have removed irritating mat- 
ters, where there is a tendency to inflammation, when astringents and 
stimulants might increase the irritation. 
Some cases may require a combination of astringents and opiates. 
The more active astringents are tannin, acetate of lead, and the 
astringent preparations of iron. When .cases become subacute or 
chronic, the preparations of iron are often particularly applicable. 
It is seldom that diarrhoea becomes chronic unless more or less 
inflammatory action occurs, or ulcerative processes are set up; and 
this takes the case beyond the limits of simple functional diarrhoea. 
These cases have already been discussed. The fl. ext. of coto bark 
has become a favorite with many. 
Many cases border on an inflammatory condition, where it may be 
impossible to determine whether inflammation is present or not; and 
these will require treatment such as has been advised for intestinal 
catarrh. In some subacute cases the turpentine emulsion, or liquor 
ferri ternitratis, sulph. of iron and opium, nitrate of silver, balsamic 
preparations, subnitrate of bismuth, or some other astringent, often 
in frequent and repeated doses so as to keep up a continuous action, 
will be required. 
Jlot unfrequently mercurials, to modify the secretions of the 
mucous membranes and the liver, and these followed by laxatives, will 
do more than the astringents in arresting the disease. 
When diarrhoea depends upon imperfect digestion, gastric or in- 
testinal, the improvement of this process should be the chief object 
of treatment; and so of all the other causes that are discoverable and 
can be reached by remedies. 
Diarrhoea is seldom strictly idiopathic—is almost always when 
protracted symptomatic of some other pathological state, and its 
treatment must therefore be varied according to the more essential 
conditions. Those cases which approach nearest to the idiopathic 
type are dependent upon debility and relaxation of the intestines, 
with a morbid irritability, or extreme susceptibility to the impressions 
produced by their contents. Some are markedly neuropathic. In TREATMENT. 
795 
these cases tonics are often demanded. Quinine, iron, arsenic, 
strychnine, etc., as the general states of the system may require, will 
be the most efficient means of cure. At the same time astringents 
will palliate the symptoms, and aid in accomplishing the removal of 
the disease. 
When a malarial influence is present, the antimalarial remedies 
will, of course, be important. 
Sometimes large quantities of fat are passed in the stools, consti- 
tuting a form of fatty diarrhoea. These cases are rare, and have gener- 
ally proved fatal; but a few cases of recovery have been reported. 
This form of diarrhoea is supposed to be dependent upon disease of 
the pancreas, so that the fat taken in the food, or produced by any 
transformations, fails of being emulsified and appropriated by the 
system. Not only the pancreatic juice, but the bile acts as an emulsi- 
fier of fats, and an object of treatment would seem to be to increase 
the secretion of the pancreas and liver. We know very little of 
the effect of medidines upon the pancreas, but there are various 
substances that increase the secretion of the liver, and these may be 
indicated. 
Cases of fatty diarrhoea have been reported as cured by large doses 
of olive-oil, and also by the free use of alcohol ; but on what rational 
principles either of these articles operates it is difficult to understand ; 
and it is quite possible they have had nothing to do in effecting the 
cures reported. Other cases have been reported as cured by the use 
of pancreatic emulsion. The good effects of this article can be better 
understood. Not unfrequently the discharges in diarrhoea are clay 
or ash colored, and apparently contain no bile. In these cases the 
condition of the liver must be looked after, and means taken to restore 
its function. 
In chronic cases, great attention to all hygienic regulations is 
necessary, especially to warm clothing and proper diet, and often a 
change of climate effects favorable changes which medicines have 
failed to accomplish. 
Children are more subject to diarrhceal symptoms than adults, but 
in them muco-enteritis is so commonly present when these symptoms 
appear, especially for any length of time, that it is scarcely necessary 
to treat of the peculiarities of diarrhoea in them, independent of the 
inflammatory condition. They doubtless frequently have temporary 
attacks without distinct inflammation, but the same principles of 
treatment apply as in adults, and further repetitions are unneces- 
sary. 796 
DISEASES OF THE PANCREAS. 
DISEASES OF THE PANCREAS. 
The pancreas is subject to various morbid conditions, as is proved 
by post-mortem examinations, and inferred by the indigestion of fats 
and by some other symptoms during life. It is subject to inflamma- 
tions, suppurative, and plastic or intestinal; to degenerations, fatty 
and waxy ; to tuberculous and syphilitic deposits or productions, and 
to cystic and cancerous growths. All these conditions are rare, and 
their distinctive clinical history is almost unknown, as they, for 
the most part, are incapable of being clearly distinguished. The 
indigestion of fats, which may be distinguished by a fatty diarrhoea, 
and the fact that this substance habitually produces unpleasant symp- 
toms, leads to a suspicion of pancreatic disease; and pain, tumors, or 
tenderness in the region where it is situated, and which could not 
be located in other organs, might render disease of this organ proba- 
ble, if not certain. 
In a case Avithin my experience, where there Avere severe, repeated, 
and long-continued attacks of pain, a moderate-sized tumor was 
detected in the region of the pancreas, and the cancerous cachexia 
was apparent. Cancer of the stomach Avas rendered improbable by 
the absence of vomiting, and by there being no special aggravation 
of suffering from taking food, or other particular gastric symptoms ; 
and scirrhus of the pancreas Avas the diagnosis given, which an 
autopsy afterward confirmed. 
Cancer of the pancreas is not particularly rare. It is oftener 
secondary than primary, and appears nearly tAvice as often in males as 
in females. The suffering in these cases is very severe, paroxArsms of 
pain are often agonizing, probably from involvement of the solar 
plexus, and jaundice, dyspepsia, and dropsy may accompany its prog- 
ress. Its course is more or less rapid according to the variety of the 
cancer and the poAver of endurance of the patient, but it seldom per- 
sists beyond a year. 
A tumor of this organ, situated as it is so near to the aorta, is 
liable to have the pulsations of the artery communicated to it, and 
even to cause a blowing or thrilling murmur, and might be mistaken 
for an aneurism. But if the abdominal walls are sufficiently thin, so 
that the tumor may be grasped and elevated from its situation, the 
aneurismal character will be lost. 
The natural pancreas in emaciated persons with flattened abdo- 
men may be felt, and might be mistaken for some morbid growth, 
but proper care, with a recollection of its size, shape, and situation, 
will prevent such mistake. VARIETIES. 
797 
Calculi have been found, though very rarely, in the pancreatic 
ducts, and their passage would be likely to cause pain ; but in such a 
case it would be difficult, if not impossible, to distinguish it from the 
passage of biliary calculi. When in the common duct jaundice might 
be induced, and no distinction could be made unless an opportunity 
of examining the calculus should occur. 
The pancreatic fluid not only emulsifies fats, but changes starch 
into dextrine and grape sugar, and in fact is capable of producing 
most digestive changes in foods; and it seems to supplement other 
digestive actions and complete the process in articles which have 
escaped the action of the other fluids, but it is not absolutely essential 
to any of the digestive changes. This renders it more difficult to 
distinguish with positiveness its derangements. 
Inflammation resulting in suppuration, as already stated, may 
occur in the organ, but the symptoms, though they may be severe, are 
not distinctive. 
The difficulty of a differential diagnosis between the diseases of 
this and other parts in the region is less to be regretted, as the thera- 
peutical indications would scarcely be different if the distinctions 
could be more clearly made. The treatment would be much the same 
as for similar disease of the liver and spleen, which are more common, 
and soon to be discussed. It will be symptomatic, and in no way 
specific or peculiar. 
The spleen is a frequent seat of morbid changes. It is almost con- 
stantly congested and enlarged, more or less, in malarial and typhoid 
fevers, and very often in other fevers as well. In long-continued ague 
it sometimes attains very great size. In cirrhosis of the liver par- 
ticularly, and in all obstructions to the portal circulation, its very 
vascular structure renders it liable to congestive enlargements. It is 
commonly enlarged in pyaemia, and may be the seat of secondary 
abscess; and in leucocythaemia, probably as a cause of that con- 
dition, it is generally enlarged, and perhaps always in some morbid 
states. 
But the spleen is liable to disease independent of other morbid 
conditions. That which is best known pathologically, and is often 
recognizable clinically, is splenitis, sometimes suppurative, resulting 
in abscess, at other times in proliferating forms resulting in hyper- 
plasia, always accompanied by hypersemia and enlargement from dis- 
tention of vessels. Waxy or lardaceous degenerations, carcinoma, 
DISEASES OF THE SPLEEN. 798 
DISEASES OF TIIE SPLEEN. 
tubercular deposits, and hydatid cysts' also occur. It is also subject 
to atrophy and some other morbid processes. 
Hyperplasia, commonly spoken of as hypertrophy, is common from 
a variety of causes, and more or less of this usually occurs when simple 
congestion of the organ is long continued. 
Diagnosis.—Enlargement of the spleen, then, by congestion, 
inflammation, hyperplasias, tumors, etc., is a frequent condition, 
and is detectable by physical exploration. The normal size of the 
organ is, of course, the point of departure for conclusions in such 
examinations. 
The spleen varies in size within normal limits in different individ- 
uals of equal general bulk, and in the same individual in the physi- 
ological state at different times. 
It is movable by the looseness of its peritoneal attachment, and 
varies in its situation slightly, and in some persons considerably, by 
changes in the position of the body. Like other organs in the upper 
part of the abdomen, it follows the motions of the diaphragm to some 
extent, as it moves in respiration, and is changed in its position 
upward or backward by the distention of the stomach and intestines. 
Diseases of the chest which cause descent of the diaphragm press it 
downward, and sometimes the looseness of its attachment is so great 
that it descends, especially when its weight has been increased by dis- 
ease, to different positions in the abdomen, even so low as the pelvis. 
In many of these cases it can be moved about with freedom, and can 
be pushed up to its original position. In other cases, however, it may 
have become fixed by adhesions in its abnormal situation. 
When in its normal place and of its natural size, it is concealed in 
the concavity of the diaphragm, and, from its protection by the ribs, 
it can only be felt in very thin persons with flaccid abdominal walls, 
and then only when a full inspiration is taken. 
Its upper extremity, and general position and size, can, with a 
reasonable degree of accuracy, be determined by percussion. It will 
be found to vary from one to two inches in its situation by a deep 
inspiration and a forced expiration. Its posterior and inferior border 
is not so distinctly determinable in consequence of its close proximity 
to the left kidney; but the lower anterior extremity can be proxi- 
mately ascertained by contrasting the percussion note over it with the 
tympanitic sound of the stomach and colon. Its usual boundaries 
above and below are about the ninth and eleventh ribs. The anterior 
border does not quite reach the middle axillary line when the patient 
lies upon the right side, which is the best position for the examination 
by percussion. 
These points, for the purpose of an accurate examination in doubt- DIAGNOSIS. 
799 
ful cases, are important to be observed. As a rule, when the spleen 
is enlarged it extends chiefly downward, forward, and toward the 
median line. Its upper extremity is not much raised unless other 
abdominal enlargements push it up, or thoracic contractions draw it 
in that direction. When thore is any considerable enlargement its 
lower extremity can be examined, by palpation, and this is generally 
more satisfactory than by percussion. 
It gives to the touch a distinct sense of resistance below the ribs, 
and when the walls of the abdomen are not thick and resisting, its 
margin can be grasped by the hand. Unless affected by tumors— 
cancer, hydatids, etc.—or by an abscess, the hard and well-defined 
body is smooth to the touch, and it generally, when enlarged, retains 
its normal shape, and, by passing the fingers over the inner and lower 
part, the splenic notch, or hilus, can often be recognized, which would 
give assurance of its being the spleen. 
To distinguish it more clearly from thickening of the abdominal 
walls, it will be found movable beneath them, and will now, as in the 
normal condition, rise and fall vertically in the abdomen by the move- 
ments of the diaphragm in respiration. 
The spleen may be so much increased in size as to occupy a very 
large portion of the abdomen, resting upon the pubis or even pressing 
down into the pelvis; and in more than one instance I have seen it 
mistaken, in the opinion of medical men, for an ovarian tumor. 
Sometimes with an enlargement of less extent there is a displacement 
downward, so that the upper margin can bo felt more distinctly than 
the lower, and the tympanitic resonance of the stomach and colon 
being observed above the enlargement, such cases are well calculated 
to deceive the observer. Where the upper portion of the organ retains 
its position, the dullness on percussion extends above the margins of 
the ribs. 
In one case where a large quantity of peritoneal effusion was 
present, with an enlarged and greatly displaced spleen, the diagnosis 
was very obscure until a diminution of the fluid revealed the state of 
the case. The spleen was near the centre of the abdomen, more to 
the left, but extending to the right beyond the umbilicus ; was more 
than the breadth of the extended hand in its smallest diameter ; was 
movable to a limited extent in all directions, its right extremity 
being more free, and its complete outline distinctly discoverable. 
When this organ is enlarged by cancerous or hydatid tumors, or 
by abscesses, its surface is nodulated or irregular, of variable degrees 
of hardness or softness, and its outline is apt to be unsymmetrical. 
So particular a description of the mode of distinguishing the 
enlargement of the spleen has been deemed advisable in oonsequence 800 
DISEASES OF THE SPLEEN. 
of the frequency of its occurrence, especially in malarious regions, 
and from the obscurity of some cases, and the mistakes respecting 
them so many times observed. 
A brief account of the particular diseases of the spleen seems 
appropriate. 
CONGESTION OE THE SPLEEN-. 
Congestion of this organ is a condition of common occurrence, 
and arises from a variety of conditions, as already observed. The 
organ is so vascular, so loose in its structure, and so easily distended 
with blood, that it serves as a reservoir when portal congestion occurs, 
relieving other abdominal organs, more or less, of their surplus of 
this fluid. It contains more blood during the process of digestion 
than in other physiological states, and in a large number of general 
and local diseases the spleen suffers engorgement. 
In congestion the increased blood is in the small vessels and the 
intervascular blood passages, and the rapidity with which the spleen 
may be enlarged and diminished by this flow and ebb of blood is quite 
remarkable. It may attain without hyperplasia three or four times 
its normal size; and sometimes, as in fevers, becomes of a deep wine 
color, is pulpy, and may easily be lacerated, and sometimes is even 
diffluent. When the congestion is for a long time frequently repeated, 
as in a neglected ague, or is constant for a lengthened period, as in 
cirrhosis of the liver or obstructive disease of the heart, the enlarge- 
ment often becomes very much greater and more permanent, partly 
from the distention of the vessels, and partly from the hyperplasia 
produced by the continued presence of so much blood. 
Simple congestion of the spleen, or this consequent hyperplasia, 
frequently reveals itself by no other local symptoms than a sense of 
fullness and weight in the region, and even this may be unnoticed; 
but sometimes a pain is felt, and there is tenderness on pressure, 
especially when the distention is rapid or great. It is to be dis- 
covered by the method of physical exploration above described. 
Where the local symptoms are but slight, the function of the 
spleen as a blood-elaborating organ is to a greater or less extent 
impaired, and anaemia and debility are apt to follow. In many cases 
the sclerotic coat of the eye presents a peculiar blue appearance, and in 
malarious cases the attacks of ague are often persistently recurrent. 
When congestion of the spleen goes to the extent of rupture, as 
has been the case in rare instances of low fevers, the blood passing 
into the peritoneal cavity, a fatal peritonitis is likely soon to follow, CONGESTION. 
801 
unless the hemorrhage and shock are sufficient to cause more speedy 
death. 
Treatment.—The treatment of hypersemia of the spleen consists 
chiefly in endeavoring to remove the conditions upon which it depends. 
The treatment of the cause of portal obstruction will often be called for, 
and the relief of the portal congestion by cathartics will generally be 
found useful. 
The eradication of the malarial poison from the system, when that 
is the cause, will of course be required, and the prompt and thorough 
interruption of the aguish paroxysms is demanded. 
There are some remedies which appear to exert a somewhat specific 
influence on the distended vessels of the spleen, diminishing their 
calibre and relieving markedly and speedily the size of the organ. 
Ergot is thought to have such an effect; but the most striking results 
are produced by full doses of sulph. of quinine. This effect is so 
marked, that Piorry was of the opinion that the action of quinine in 
diminishing the enlargement of the congested spleen was the mode of 
its operation in arresting the ague. That its action upon the spleen 
is not entirely due to its antimalarial effect is proven by the fact, that 
it speedily and notably diminishes the size of the organ when its con- 
gested state is dependent upon other causes than malarial. 
A cathartic to unload as far as possible the portal vessels, and half 
a drachm or so of quinine, given in four or five doses in the course of 
twenty-four or thirty-six hours, will generally diminish the organ 
markedly and speedily, even when much hyperplasia is also present. 
Repeating this treatment once in a few days will often succeed in 
removing an enlargement which is great and has long continued. 
Hypertrophy of the spleen, or fleshy enlargement—a hyperplasia of 
the organ—is commonly the result of long-continued congestion, or 
of repeated attacks of some form of malarial fever. It may occur, 
however, as the result of obstructed circulation through the liver, or 
from a slow inflammatory process in the spleen itself. The vascularity 
of the enlarged organ is so great, and the circulation of the blood is 
so active, that in some cases a venous hum, similar to that heard at 
the base of the neck in some cases of anasmia, may be recognized by 
applying a stethoscope over the tumor. 
In some cases the spleen enlarges by an increased nutrition re- 
sembling the normal, producing increased structure apparently not 
very unlike that of the healthy organ. It is, however, a perversion 
of nutrition, as well as an increase, and the function of the organ is 
presumably impaired. When it goes on to an enormous enlargement, 
filling a large part of the abdominal cavity, there is anaemia, some- 802 
DISEASES OF THE SPLEEN. 
times intestinal hemorrhage, and occasionally abdominal dropsy ; but 
as the liver is generally also diseased at the same time, it is not easy 
to determine how much is due to the disease of the spleen, and how 
much to that of the liver, or, in fact, to disease of still other organs 
that may be affected at the same time. 
Prognosis.—It is distinguished by the physical examination, and 
its course is uncertain. In ordinary cases dependent upon malarial 
fever, the prognosis under proper treatment is favorable, the enlarge- 
ment yielding the more readily the less time it has continued; but in 
decided cases, a few weeks will generally be required to effect its com- 
plete removal. In some cases with great enlargement, and especially 
with serious hepatic complications, the prognosis is much more unfavor- 
able ; and even if the enlargement of the spleen be materially reduced 
in size, the patient may succumb to anaemia and general debility, or 
to hemorrhages and other systemic or local derangements. In one 
case under my observation, of enormous enlargement ultimately prov- 
ing fatal, the proportion of white corpuscles in the blood from all 
parts of the system was increased, and the blood taken from the spleen 
with a hypodermic syringe had a much larger proportion of white 
corpuscles than that of the general system, and the red discs were 
very irregular in form. This case came very late under my observa- 
tion and treatment, and though the size of the spleen was very notably 
diminished, and general improvement for a time occurred, a hem- 
orrhagic condition succeeded, and the final result was as above 
stated. 
Treatment.—The treatment of this enlargement of the spleen, as 
of congestion of the organ, will depend to some extent upon the cause 
which has produced it. That cause, whatever it may have been, should 
as far as possible be removed. As the hyperplasia is immediately de- 
pendent upon the hyperaemia, any treatment which will tend to dimin- 
ish the latter will have a corresponding effect upon the former. This 
rational inference is confirmed by experience. No remedy within my 
experience has been so effectual in speedily reducing the size of an 
enlarged and fleshy spleen as full doses of quinine given in the manner 
directed for hyperaemia. A cathartic preceding is useful here, as in 
simple congestion, and other means directly to bo mentioned have often 
great efficacy; but experience in repeated instances will not allow me 
to question the efficacy of quinine in those fleshy enlargements where 
hyperplasia is produced by a slow inflammatory process, or by other 
than malarial causes. 
In addition to the free doses of quinine repeated once in a few 
days or twice a week, the ointment of the biniodide of mercury 
applied externally with friction and heated in, and of such strength TREATMENT. 
803 
and quantity as to produce considerable external irritation, aids very 
much the curative process. 
In the intervals of administering the quinine, the iodide of potas- 
sium or the iodide of ammonium should be given. Of the iodide of 
potassium from eight to twenty grains may be given three times a 
day, if well borne by the stomach ; and of the iodide of ammonium 
from three to eight grains may be given with equal frequency. 
The fluid extract of ergot or the preparation called ergotino may 
be tried at the same time, or alternated with the other measures, or 
substituted for them, where for any reason they are not available. 
The fluid ext. of ergot may be given in doses of a drachm, more or 
less, three times a day, or the ergotine in appropriate doses either bv 
the mouth or hypodermically. 
Under whatever other treatment, the bowels should be kept well 
open ; and in case of anaemia, some of the salts of iron may be re- 
quired. 
These means seldom fail to produce a decided effect upon common 
splenic enlargements, and very generally effect a cure. 
INFLAMMATION OF THE SPLEEN. 
Splenitis as an acute idiopathic affection is rare. It is not so rare 
as the result of embolism, pyaemia, or morbid growths. 
Hemorrhagic infarction, followed by an inflammatory process, but 
not resulting in abscess, is occasionally found post mortem, and can 
sometimes be distinguished with tolerable certainty during life. 
Embolic blocking of vessels is a frequent cause of circumscribed 
splenitis. The infarctions may be in the substance or periphery of 
the organ, and may vary in size and number—in size from that of a 
pea to a hen's egg, and in number from one to several. They are 
wedge shaped, and when near together may coalesce. They undergo 
the usual changes, ultimately resulting in suppuration. A limiting 
membrane may incapsulate the pus, or in its absence a ragged disin- 
tegrating pulp may constitute the wall of the abscess, and the pus 
will tend to make its way to the surface of the organ, oftener toward 
the diaphragm than elsewhere, and may be discharged through the 
bronchi. If it breaks into the peritoneal cavity, a fatal peritonitis 
is likely to follow. 
If a patient affected with obstructive disease of the heart, or any 
affection likely to produce embolism, complains of chills, fever, pain, 
and tenderness in the region of the spleen, with moderate enlargement 
of that organ, this condition must be presumed. 
A primary inflammation resulting in suppuration and abscess is 804 
INFLAMMATION OF THE SPLEEN. 
very rare ; but secondary abscess from pyaemia or septicaemia may 
occur in the spleen, as in other internal organs. Such inflammation 
would be intimated by the common local and general signs of inflam- 
mation, but a positive diagnosis might be impossible unless an abscess 
of sufficient size should form to give increased bulk to the organ and 
afford a soft or fluctuating tumor. 
Treatment.—The treatment of such a case would not differ from 
that applicable to secondary inflammation and abscesses in pysemic 
or septicaemic conditions, and this is described elsewhere. 
The primary acute inflammations of the spleen will require the 
same treatment, essentially, as inflammation of the liver or the pan- 
creas. Should there be a chill followed by an inflammatory fever, 
with pain and tenderness in the region of the spleen, a cathartic 
should be given, fomentations, or dry cups, or both, should be applied 
to the region ; and if the pain and fever continue after the operation 
of the cathartic, six or eight grains of quinine with a quarter of a 
grain of morphine should be given, and the dose repeated once in 
from two to four hours, the quantity of morphine particularly being 
varied or omitted from the alternate doses, but sufficient being given 
to keep up a decided antipyretic effect of these agents for twenty-four 
or forty-eight hours. 
If the symptoms should continue, a blister, and perhaps leeches, 
might be applied, the bowels kept well open by saline cathartics, etc.; 
and, if the inflammation still persisted, after two days the quinine and 
morphine might be repeated. This treatment, adopted early, might 
be expected to arrest or notably abate the inflammatory process. 
Quinine is peculiarly adapted to the treatment of suppurative 
inflammation of the spleen, as it checks the production and migration 
of leucocytes, and diminishes particularly the amount of blood in the 
organ. Cathartics act by diminishing the blood pressure, especially 
of the portal vessels, and probably by a reflex impression also. If 
these means should not arrest the inflammatory process, either from its 
severity or because they were commenced too late, a more expectant 
plan should then be pursued. 
The bowels should be kept open, severe fever abated, fomentations 
or poultices applied, the strength kept up, and the results awaited as 
in other internal suppurative inflammations. 
Of eleven primary abscesses of the spleen collected and reported by 
Dr. Drake, the discharge of pus in six was by the bowels; in three 
externally; in one both externally and by the bowels; and in one 
there was no discharge of the matter. All but one recovered. Here, 
as in other diseases, the more favorable cases are likely to be reported, 
while the unfavorable ones, with perhaps an uncertain diagnosis, are ABSCESS— TREA TMENT—DEGENERA TION. 
805 
not. A larger proportion of abscess of the spleen than these statistics 
would indicate, it might be feared, would terminate unfavorably if 
left to their own course. The aspirator, as in other cases of internal 
abscesses, particularly those of the liver, should be resorted to, and the 
same rules respecting an opening, with a more free incision when 
adhesions have occurred and the matter approaches the surface, should 
be observed as in hepatic abscess. (See Abscess of Liver.) 
Chronic Interstitial Inflammation of the spleen, resulting in en- 
largement in some cases, and in contraction of the plastic exudate and 
atrophy, as in cirrhosis of the liver, in others, is not very infrequent. 
Its diagnosis may be obscure, but when discovered it should be treated 
as other chronic parenchymatous inflammations ; and when enlarge- 
ment is detected, by the same means already described for enlarged 
spleen. The biniodide ointment should be thoroughly used, and the 
iodide of potassium or the iodide of ammonium should be given per- 
severingly, the bowels kept free, and other symptoms attended to as 
they may arise. 
Simple atrophy of the spleen may occur from different causes. Its 
diagnosis is difficult, and often impossible, and its clinical and thera- 
peutical history is unknown. 
The spleen is as liable to lardaceous, amyloid, or waxy degener- 
ation as any other organ of the body, but is seldom so changed unless 
the liver and other organs are similarly affected at the same time. 
This form of degeneration is said first to affect “ the minute arte- 
rial twigs and the cells external to them with which they are in 
relation.” 
The organ in this disease undergoes gradual enlargement, and in 
some instances attains a great size. But as the liver generally, and 
often the kidneys are also involved, the patient commonly succumbs 
before much enlargement occurs. Post mortem its capsule is usually 
smooth and glistening, and in the early stage the parenchyma presents 
an appearance to which the name of sago spleen has been given,when it 
is thickly studded with grayish, translucent, rounded masses resembling 
boiled sago grains, separated from each other by proper spleen tissue. 
Later these morbid masses have coalesced, and the spleen on section 
presents a nearly uniform aspect, all parts resembling the translucent 
grains of the earlier stage. It yields little or no fluid on pressure, 
and pits when pressed by the finger like a mass of .stiff dough or wax. 
It is specifically heavy and is readily lacerated, resembling a larda- 
ceous or waxy mass. 
When this amyloid matter is thus diffused, the texture is rather 806 
INFLAMMATION OF THE SPLEEN 
firm, but it is easily cut, lias a brownish or yellowish-brown color, 
and the pulp, the trabeculae, the Malpighian bodies, and the vessels 
are all afiected by it. 
According to Prof. Eberth, of Zurich, not all the different nitro- 
geneous tissues are the seat of this amyloid deposit; it is not, however, 
confined in its consequences to the connective tissue group, but affects 
other tissues by compression and consequent atrophy. In the spleen it 
originates in the reticulated tissue, but not in the true gland structure. 
The test for this amyloid infiltration is Lugol’s solution of iodine 
brushed over the part, which colors the tissues yellowish, and the 
morbid deposit red or reddish brown, but on addition of sulphuric 
acid, while the yellow color is not changed, the red becomes a dark 
violet. 
This condition of the spleen is always associated with a depraved 
condition of the system—an anaemic cachexia, and often with dropsy 
and a hemorrhagic tendency. But, as before stated, this disease of 
the spleen is associated with a similar condition in other organs, and 
it is difficult to say how far the general symptoms are dependent upon 
the changes in the spleen. 
The prognosis is very unfavorable, and the best mode of treatment 
doubtful. Iron and the preparations of iodine are generally pre- 
scribed, and a general tonic course seems to be indicated. Good hy- 
gienic regulations are certainly required. 
Simple Cysts, and Hydatids, or echinococci, are sometimes found 
in the spleen, but usually at the same time in the liver and kidneys. 
When these are of considerable size the spleen presents an irregular 
enlargement; the course is usually slow, and always uncertain, and 
these cases require no special treatment different from that of similar 
affections of the liver. (See diseases of that organ.) 
Tubercles may occur in the spleen, as in other internal organs, in 
general tuberculosis, but they can seldom be recognized during life, 
and require no special treatment different from that called for in 
tuberculous disease of other parts. 
Cancer of the spleen is rare, and is very generally secondary—the 
cancerous growth extending commonly from the peritoneum. It 
usually occurs at different points in the organ. 
Ho very distinctive symptoms are presented, and the diagnosis 
can only be made when an irregular tumefaction of the organ is dis- 
covered and the cancerous cachexia is present. 
Palliative treatment, as of internal cancer elsewhere, is alone 
required. FUNCTIONS OF THE LIVER. 
807 
DISEASES OF THE LIVER. 
The size and position of the liver, its large development at a very 
early period of organic life, and the different functions it performs 
indicate its importance in the organism. In popular estimation its 
derangements have to do with a large portion of the common ills to 
which we are subject, and professional estimation gives this organ a 
conspicuous place in the physiology and pathology of the human 
system. 
As observed by Dr. Murchison (whose admirable writings on dis- 
eases of this organ will be freely drawn from in what is to follow), in 
many respects modern investigation tends to the revival of ancient 
opinions. Galen taught that the liver was a blood-producing organ, 
and this view was held for a long time. The discovery of the lacteals, 
more than two hundred years ago, caused this organ to fall from its 
high position, and until comparatively recently its only function was 
supposed to be that of secreting bile. It is now well known that a 
part of the nutrient materials taken into the alimentary canal passes 
into the veins, and mingles with the blood without taking the course 
of the lacteals. It is also known that these materials passing through 
the portal vessels into the liver are acted upon in its vessels and 
substance. It is known that starchy, saccharine, and even albu- 
minous substances, many of them first formed into glucose, are con- 
verted into glycogen and stored up in the liver for use ; that this 
glycogen is capable of being formed into sugar and also into fat; and 
it is now believed to be capable of conversion into blood materials— 
of being appropriated to the formation of blood corpuscles—as it is 
shown that the blood passing out of the liver through the hepatic 
veins contains many more corpuscles—often five to ten times more, 
it is alleged, especially of white corpuscles—than it has when entering 
the liver by the portal veins. The red blood discs after leaving the 
liver are said to have sharper outlines, to be less likely to aggregate 
into rolls, and to be less readily dissolved in water than before they 
have passed through the organ. 
This doctrine of the blood-producing function of the liver is com 
firmed by the fact that in foetal life, when the liver is formed, a very 
active process of blood-cell formation is set up in it, and the produc- 
tion of these corpuscles greatly diminishes or ceases in other parts. 
It would seem that in adult life a part of the glycogen secreted or 
elaborated in the cells of the liver combines with nitrogen and forms 
a nitrogenized protoplasm, capable of maintaining the nutrition of 
the blood and the tissues. Fat is also believed to be produced here 808 
DISEASES OF THE LIVER. 
from sugar, or the saccharine matter is changed into some other 
material which is afterward, either in the liver or elsewhere, converted 
into fat. 
Not only is it thus shown that the liver is a laborator of nutrient 
materials fitted to supply the tissues, and a blood-producing organ 
elaborating corpuscles, but modern research has rendered it probable 
that it acts as a blood-pur ifyiny organ—not merely by secreting bile 
and thus eliminating effete elements, but also by disintegrating worn- 
out blood corpuscles and albuminous matters, forming them into urea 
and uric acid, and preparing them for elimination by the kidneys. 
Albumen and fibrino are diminished in the blood as it passes through 
the liver. It is estimated by Brown-Sequard that 8G| ounces of fibrine 
are daily lost in the liver—or rather, that this amount disappears 
from the blood while passing through the digestive organs, including 
the liver, and it is believed that most of this work is performed by 
the latter organ. 
Assuming this to be the case, suspension of this action of the liver 
will account for the rapid increase of fibrine in the system which often 
occurs in rheumatism and other inflammatory affections ; but whether 
this is the true or the only explanation of hyperinosis cannot be re- 
garded as established. 
It is quite probable, at least, that while white blood corpuscles are 
formed in the liver, the worn-out red corpuscles are destroyed there 
—are disintegrated and changed into other forms of matter. 
The bile acids have the power of dissolving red corpuscles out of 
the body, and they probably do the same wfitli the worn-out ones, with 
low vitality, in the liver. The liver is certainly concerned in the 
formation of nitrogenous matter eliminated by the kidneys. Imper- 
fect formation of urea is among the most constant signs of functional 
derangements of the liver ; and when this organ is in great part inca- 
pacitated by destructive organic disease, urea is greatly diminished 
in the urine, or it entirely disappears from it. In such cases, less 
oxidized azotized materials, as leucin and tyrocin, take its place. In 
further proof of the production of urea in the liver, it is not only 
found in free quantity there, but there is much more in the hepatic 
than in the portal veins. 
The liver is probably not the only place where urea is formed ; 
other glands may have a similar action ; and even the decaying blood 
corpuscles in the circulating vessels may change into urea, but it 
cannot be doubted that the liver aids in the process. 
These disintegrating processes in the liver, as well as those that 
are formative, are accompanied with the production of heat; and the 
healthy liver is found to be four or five, and even six or seven degrees FUNCTIONS OF THE LIVER. 
809 
F. higher in temperature than the average of the blood in the system. 
The blood issuing from the liver in the hepatic veins is markedly 
warmer than that which enters it through the portal vessels. 
These facts seem to show that the liver is a particular source of 
animal heat. 
But another and the best known function of the liver is the secre- 
tion of bile. This material, according to the best estimates, is com- 
posed of water 859.2 parts, and solid residua 140.8, in 1000, on an 
average in a healthy state. According to the analyses the average 
solids of the bile consist of 
Grlycocliolate of Soda ) 
Taurocholate of Soda f 
Fat 9.2 
Cholesterin 2.6 
Bile Pigment 28.4 
Mucus 1.4 
Salts 7.7 
Total of Solids 140.7 
in 1000 of the bile. 
The yellow pigment is now called bilirubin. On standing it 
becomes oxidized and assumes a green color, and is then called 
biliverdin. 
Bilirubin is formed from blood pigment or haamoglobin in the 
hepatic cells, and this yellow bile pigment, when not excessive and in 
the physiological condition, is in turn converted into the coloring 
matter of the urine. 
The process of transformation is—blood pigment, bile pigment, 
urinary pigment. 
In a further analysis two bile acids are found—glycoeholic acid 
and taurochoiic acid. They are conjugate acids, the former being 
formed by the union of glycocol with cholic acid, the latter by the 
combination of glycocol with taurin. They are both derivations from 
albumen and contain nitrogen. Taurochoiic acid gives the bitter 
taste to the bile, and contains the sulphur found in that fluid. As 
soda is in bile, these acids are in combination with it, forming the 
salts already mentioned as constituents of the solid matters of the 
bile. 
Cholesterin is found in nerve matter, is supposed to be the debris 
resulting from nerve action, and is separated from the blood by the 
liver. 810 
DISEASES OF THE LIVER. 
When this separation is defective, and the cholesterin is retained 
in the blood, it is supposed to cause a species of blood poisoning— 
cholesteraemia. 
Whether some of these bile elements are found in the blood and 
tissues, and are simply separated by the liver, or whether they are 
formed in the liver by the combination there of other elements from 
the blood, is not quite settled. 
Some are of the opinion that bile pigment is preformed elsewhere 
in the system and separated by the liver; but others deny this, and 
the most recent investigations seem to show that the change of 
materials of the blood to bile pigment occurs in the liver. 
The distinction, made by Dr. Harley, of two forms of jaundice— 
one in which the bile acids are produced in the liver and reabsorbed, 
and the other in which the liver fails to separate the coloring matter 
from the blood—if the coloring matter, as well as the acids, is formed 
in the liver, is unfounded. 
It is shown that jaundice does not result from extirpation of the 
liver in frogs, as ursemia does from removal of the kidneys. Nor docs 
jaundice always occur, as it should if the bile pigment was preformed 
in the system, when extensive fatty or waxy degeneration of the liver 
takes place. 
The quantity of bile secreted by the healthy human liver, when a 
proper free quantity of food is taken, is estimated at about forty ounces 
per day. But a small portion of this is ordinarily discharged from the 
bowels, and it must, therefore, be reabsorbed or changed into some 
other material. As there is no evidence of such conversion of this 
substance, it must be held to be reabsorbed either in the biliary pas- 
sages or by the mucous membrane of the intestines. 
There is, doubtless, a constant secretion and reabsorption, not only 
of bile but of other fluids, into the alimentary canal, and the purging 
of cholera or diarrhoea may be as much from the failure of absorption 
as from profuse secretion. It is indeed thought that all the watery 
portions of the blood pass several times, during the twenty-four hours, 
into the alimentary canal and out again into the vessels, and it is sup- 
posed that this continual outpouring and inflowing aids metamorpho- 
sis. It is thought that at least twelve pints of gastric fluid are secreted 
and absorbed in a day ; the pancreas is believed to secrete the same 
amount; the salivary glands furnish about three pints in the same 
time, most of which is ordinarily swallowed ; and the liver is supposed 
to secrete not far from the same amount; while the quantity secreted 
and absorbed by the intestinal membrane, independent of the stomach 
and these large glands, cannot be estimated. From the extent of the 
intestinal surface and the great number of small glands it contains, it FUNCTIONS OF THE LIVEli. 
811 
is probably large. IIovv many times the materials of bile are secreted, 
taken up, and go the rounds of the circulation in the system, we have 
not the means of knowing. In the course of the circulation much of 
the bile is probably converted into products which are eliminated by 
the lungs, kidneys, and other organs ; and this whole process bears a 
necessary part in the purification of the blood, the assimilation of 
foods, and the sustaining of the system. 
The bile has important uses in the alimentary canal. It materially 
assists in the emulsification and absorption of fat, as is proved by ex- 
periments upon animals and by clinical observations ; and it probably 
also assists the absorption of albuminous foods. By its alkaline prop- 
erties it aids in neutralizing the acids which pass from the stomach 
into the duodenum, and it precipitates the peptones; and, in short, 
the bile with the pancreatic juice, mingled with the gastric secretion, 
aids in the completion of the digestive process in the case of many 
articles of food. The presence of bile in the intestines seems necessary 
for the proper formation of glycogen in the liver. This may be by its 
action through sympathy, or by its chemical action on food elements. 
It also renders faecal matters more soluble, and excites peristaltic intes- 
tinal action. 
But a portion of bile is excrementitious, and passes off with the 
stools. The coloring matter, bile acids, and cholesterin, either in their 
proper characters as discharged from the liver, or changed in compo- 
sition by their relation to other materials, are contained in normal 
excreta. 
To briefly recapitulate the functions of the liver, it must be stated 
that no less than three somewhat distinct but complex processes are 
performed by it. 
First. The formation of glycogen from alimentary matters, par- 
ticularly from starchy and saccharine substances brought to it by the 
portal vessels, storing up this material in the hepatic cells, and giving 
it out, as required, changed into fat, sugar, and other substances, to 
contribute to the maintenance of animal heat, to the general nutrition 
of the blood and the tissues, and to the development of white blood 
corpuscles. 
Second. The destructive metamorphosis, or the reducing to simple 
forms of albuminoid matters, whether from the food or the blood—the 
worn-out corpuscles, and especially the fibrine—forming from them 
urea, uric acid, and other nitrogenous products, which are subse- 
quently eliminated by the kidneys, animal heat being produced in 
these changes in the liver. 
Third. The secretion of bile, the greater part of which is reab- 
sorbed, and subserves useful purposes in the system ; and while in the 812 
DISEASES OF THE LIVER. 
alimentary canal it aids in the assimilation of fats and peptones, it 
probably also assists those chemical changes referred to as going on in 
the liver, and aids the portal circulation. A part of the bile, how- 
ever, is excrementitious, and in passing through the intestines it stim- 
ulates peristaltic action, prevents decomposition of the intestinal 
contents, and tends to produce a soluble state of the bowels. 
These are all very important functions, they are, moreover, often 
deranged, and their derangements produce more or less serious conse- 
quences. 
As a blood gland—a producer and purifier of the blood—as an 
organ of nutrition, elaborating materials for sustaining the organism— 
it holds a very high place, and one which, in these respects, has been 
too little understood or too often overlooked. It cannot be too 
strongly impressed that the liver, having other functions than the 
secretion of bile, embraces in its derangements other conditions than the 
diminution, the increase, and the altered character of that secretion. 
From what has been stated respecting the secretion and absorption 
of bile, it is apparent that the amount of bile discharged from the ali- 
mentary canal is not a necessary measure of the amount secreted. It 
may rather indicate the amount not absorbed, for if less be absorbed 
while only the usual quantity is secreted, more will be discharged; 
and any cathartic medicine or irritating article of food, by increasing 
peristaltic action and thus preventing the bile from remaining a suf- 
ficient length of time in the intestines to be absorbed, will cause a 
larger amount of bile to be discharged without producing a real 
increase of secretion. 
Irritation of an excretory duct of a gland usually increases the 
secretion of the gland. Taking a sapient or irritating substance into 
the mouth increases the secretion of the salivary glands, and a mote in 
the eye increases that of the lachrymal. So the irritation of cathartics 
upon the duodenum and the common duct of the liver and jjancrcas 
emptying into it, it is to be supposed, will increase the secretions of 
these glands, independent of any specific effect directly upon the gland 
itself. All this, however, does not render improbable the fact that 
some medicines have a specific effect, either through the blood or by a 
particular reflex action, in increasing and otherwise modifying the 
secretion as well as the excretion and extrusion of bile. This is a 
matter to be determined by experiments and clinical observations, 
care being taken to exclude errors and unwarranted conclusions. 
From those physiological facts and considerations (and physiology 
is always the foundation of pathology) it is evident that derangements 
of the action of the liver may cause disturbance of a large portion of 
the functions of the body. ABNORMAL NUTRITION. 
813 
FUNCTIONAL DISEASES OF THE LIVER. 
When the liver is organically diseased, its actions arc of course 
interfered with ; but, independent of material structural changes, its 
functions may be deranged, and a great variety of morbid consequences 
may result. 
As classified by Dr. Murchison, these derangements may involve : 
1. Abnormal nutrition. 
2. Abnormal elimination. 
3. Abnormal disintegration. 
4. Derangements of the organs of digestion. 
5. Derangements of the nervous system. 
6. Derangements of the organs of circulation. 
7. Derangements of the organs of respiration. 
8. Derangements of the urinary organs. 
9. Abnormal conditions of the skin. 
1. Abnormal Nutrition.—As the liver is concerned in the produc- 
tion of blood, we may have anaemia and spanaemia from its defective 
action. As it is concerned in the production of sugar, we may have 
an excess of that article produced in the system, constituting melitse- 
mia or diabetes mellitus. As this organ is concerned in the pro- 
duction of fat, we may have obesity, or a deficiency of fat in the sys- 
tem from its wrong action. 
If it produces too much fat, which is deposited in the general sys- 
tem and in the different tissues, there is inconvenient corpulence, with 
heaviness, weariness, especially after meals, shortness of breath, and 
often constipation, flatulence, and other dyspeptic derangements. 
Often beer and wine drinkers, and sometimes spirit drinkers, 
become fat and gross. They are often said to be “bloated” with 
liquor, and they have a lowered organic structure, diminished 
power, and greatly diminished endurance. Such persons are more 
liable to diseases of various kinds, and when diseased they are “bad 
subjects”—do not bear well diseases or surgical injuries or opera- 
tions. 
The irritation of the liver by the alcohol induces hyperaemia, and 
in that state a morbidly increased fat production may result. In 
other cases, when the irritation of the alcohol is greater, the produc- 
tion of fat may be diminished, and emaciation in chronic alcoholism 
sometimes results. Bacchus was represented by the ancients as cor- 
pulent, never as emaciated; but with the ancients alcohol was much 
diluted and used in the form of wine, not fortified by distilled alco- 
hol ; and this is less likely to cause emaciation than more concen- 814 
DISEASES OF THE LIVER. 
trated ardent spirits. Still, the wine and beer drunkard is sometimes 
thin, especially toward the last, though much more likely to have an 
excess of fat; and often, even though the fat diminishes, there are 
dropsical accumulations which produce a bloated condition. 
When from any cause the liver is so far impaired in its function 
that too little bile is secreted and passed into the intestines to emul- 
sify the fatty food, or to properly aid in the assimilation of albu- 
minous matters; or when there is serious derangement of its glyco- 
genetic function, emaciation will follow. When the glycogen is 
unduly changed to sugar, instead of being converted into fatty mat- 
ter, it passes into the urine and constitutes diabetes. Emaciation, 
then, is the common result. In some cases of liver diseases the pro- 
duction of glycogen may be insufficient for the formation of the 
necessary quantity of fat, and thus emaciation may follow. 
It is quite likely that in other wasting diseases, as in phthisis, the 
changes which so often occur in the liver contribute to the emaciation. 
But derangements of the liver functions may lead to a deficient 
elaboration of albuminous as well as of fatty nutrient materials, and 
the wasting of albuminoid tissues, as wTell as diminution of fat, may 
result. 
2. Abnormal Elimination.—Disease arises when the liver fails to 
perform its eliminative function. Such disease arises not only from 
retention of the elements of bile in the blood and tissues, but even 
more from a failure on the part of the liver to prepare materials 
which have become effete to be carried off by other organs, especially 
by the kidneys. 
When blood corpuscles become old, having performed their func- 
tions for a sufficient length of time, and when tissues become disin- 
tegrated in the performance of their functions or from age, all these 
worn-out materials need to be prepared for elimination—require to 
be made soluble and carried out of the system. If they are retained, 
tissue and blood poisoning follow. 
The ultimate form which these materials to the largest extent take 
is urea. Falling a little short of this more complete transformation, 
we have uric acid ; and still short of this, a dark coloring matter 
resembling it is sometimes found in the urine ; and leucin and tyrocin 
are other substances between worn-out tissues and urea. These sub- 
stances, or still less changed effete matters, when retained in the blood 
(as from the imperfect action of the liver and in their less reduced 
state they are apt to be), produce more injurious effects than the 
retention of bile or bile elements. 
Observations show that there may be large quantities of pure bile 
in the blood and tissues, almost to saturation, without serious conse- ABNORMAL DISINTEGRATION. 
815 
quences; and when ettyphoid symptoms” occur in jaundice and in 
the latter stage of cirrhosis or acute atrophy of the liver, blood poison- 
ing from the other matters referred to is more likely to be the cause 
of these symptoms than poisoning from the bile. However, large 
quantities of bile in the blood cannot be entirely innocent, and this 
secretion may undergo changes resulting in compounds which may be 
severe and fatal in their effects. 
The symptoms caused by deficient excretion of bile into the intes- 
tines are irregular, usually costive bowels, though there may be 
diarrhoea ; pale, clay-colored stools ; loss of appetite; a yellowish or 
whitish coated tongue ; a disagreeable, often bitter taste in the mouth, 
especially in the morning; a sallow’ skin and yellow conjunctiva} ; 
depression and drowsiness after meals ; languor and frontal headache ; 
and in this jaundiced condition there are frequent deposits of lithates 
in the urine, and almost constantly the coloring matter of the bile and 
more or less of its acids will be found in this secretion. 
These symptoms are commonly, and often at least properly, 
attributed to ‘‘ torpor of the liver.” They, at any rate, depend upon 
wrong liver conditions (though these are sometimes produced by 
obstruction of the excretory duct), and upon the morbid state of the 
blood consequent upon such wrrong liver actions. 
3. Abnormal Disintegration.—This is a matter not less important 
than deficient elimination, and it is intimately connected with it. 
Disintegration of albuminous matters is an important function of the 
liver, and a failure in its proper performance—a failure to convert 
effete albuminoid substances into soluble forms (urea, etc.)—produces 
morbid results that are often very serious. 
This failure seems to occur in congestion of the organ, in fevers, 
and in more severe organic liver affections. As the result of over- 
eating, or of taking improper ingesta—of imposing too much work on 
the liver—we have, besides impairment of organic actions in the tis- 
sues, from a want of proper renewal, lithuria—insoluble lithates in the 
urine, and more or less of effete matter retained in the blood and in 
the organs, deranging action in different ways. 
The symptoms in such cases are feelings of weight at the epigas- 
trium, flatulent and distended bowels, heart-burn and eructations, 
weariness and aching of the limbs, sleepiness after meals, a furred 
tongue, and a foul mouth. The appetite is variable ; catarrhal secre- 
tions often occur ; constipation with alternate diarrhoea is not un- 
frequent ; there are frontal headaches and restless nights; and some- 
times vertigo, dimness of sight, and other symptoms of general 
derangement. 
In persons thus affected, though these uncomfortable sensations 816 
DISEASES OF THE LIVER. 
may lead to a desire for narcotic excitants, and may be temporarily 
relieved by them, yet any degree of alcoholic indulgence increases the 
ultimate morbid results. Any considerable indulgence in rich foods 
—oily and saccharine—also increases the symptoms. 
Such patients, says Ur. Murchison, find that they must be careful 
of food and drinks. One first gives up malt liquors, and in succession 
port wine, Madeira, champagne, etc. He then tries brandy or whis- 
key largely diluted with water. “ At last,” quoting the wrords of Dr. 
Murchison, “unless he is misled by the fashionable, but to my mind 
erroneous, doctrine of the present day, that alcohol in one form or 
another is necessary for digestion, or to enable a man to get through 
his mental or bodily work, he finds that he enjoys best health when 
he abstains altogether from wines and spirits in any form or quantity, 
and drinks plain water.” 
Such a person, if he consults his interests, cuts off articles of rich 
food one after another, until he comes down to a plain, simple diet 
in moderate quantity. 
This morbid condition, Dr. Murchison says, is extremely com- 
mon in England, and Sir Henry Thompson, as distinguished in 
surgery as Dr. Murchison is in medicine, says, “few are aware of 
the great mischief which what is regarded as the moderate use of 
fermented liquors is doing in England.” We have, continues Dr. 
Murchison, as the result of this state of things, gout, urinary calculi, 
biliary calculi, degeneration of the kidneys, structural disease of the 
liver, and, in fact, lowering and degeneration of tissue throughout the 
body. 
With the approach to old age there is, in those indulging in alcohol, 
a tendency of the tissues throughout the body to undergo degeneration 
and decay ; fatty and calcareous matter being substituted for the 
normal .structures. 
In corroboration of these views he quotes Mr. Barlowr’s article in 
the Medical Times and Gazette on the subject, Sir Henry Halford, 
Dr. Marshall Hall, Andral, Lobstein, and others of the highest 
authority in the profession. 
Persons affected with this form of derangement, and addicted to 
these even very moderate alcoholic habits, are specially liable to local 
inflammations and constitutional diseases. 
The influence of spirit drinking, not merely upon the liver and 
the nutrition, but especially upon the nervous system, in this country 
and wherever it is indulged, is too wrell known to all who without 
prejudice give the subject serious attention. The habit of drinking 
early in the day, and especially between meals, is, without dissent from 
any scientific source, regarded as particularly injurious ; and so far ABNOR RAL DIS1NTEQRA TIOAf. 
817 
from affording strength for bodily work, even temporarily, to one in 
the physiological condition, it weakens and deranges all real capacity ; 
and the habit of indulgence after the day’s work is done, though some- 
times soothing the nervous system and promoting a kind of narcotic 
sleep, gradually perverts the general organism, and particularly tho 
nervous system, and creates an appetite which too often seeks exces- 
sive indulgence, bringing with it all the moral as well as physical 
results of intemperance. ; 
A full consideration of the subject of functional diseases of the 
liver would require a more extended account of the phenomena, pre- 
sented by different organs than the limits of this article will allow. 
Some of the effects upon the digestive system have already been 
alluded to. The variable conditions of the tongue and the appetite, 
the bitter taste in the mouth, the flatulency, constipation or diarrhoea, 
the vitiated stools, intestinal hemorrhages, hemorrhoidal tumors, 
hepatic pains, jaundice, etc., might afford materials for more ex- 
tended descriptions. . 
The effects on the Nervous System, the aching pains in the limbs, 
pain in the shoulder, hepatic neuralgia, depressing feelings of lassi- 
tude, severe cramps in the legs, headache, vertigo, and noises in the 
ears, sleeplessness, depression of spirits, irritability of temper, and 
the occasional more severe cerebral symptoms, convulsions, delirium, 
and a typhoid state, might all bear a fuller description. 
The Derangements of the Circulatory System produced by this 
cause are not insignificant. Palpitation, fluttering and irregular 
action of the heart, exaggeration of the pulsation of the large arteries, 
intermissions of the pulse, feeble circulation, ana) mi a with its irregu- 
larities, and angina pectoris, might be mentioned. 
Under the head of Derangement of the Respiratory Organs we 
have chronic catarrh of the fauces, chronic bronchitis, spasmodic 
asthma, etc. 
Under that of the Urinary Organs are deposits of lithates and 
lithic acid, renal and vesicular calculi, bile, leucin and tyrocin in the 
urine, cystitis and various diseases of the kidneys. 
The Diseases of the Skin which may be produced by derangements 
of the liver are numerous. Eczema, psoriasis, lichen, erythema, urti-: 
caria, boils and carbuncles,pruritis,pigment spots,etc.,'would be named. 
It is not intended to be intimated that all the sjunptoms which 
have been named are the exclusive product of diseases of the liver; 
but derangements of this gland, which performs such very important, 
functions in the organism, are often connected with the causation of 
all these affections; and not unfrequently by remedying the hepatic 
disease these symptoms will be removed. 818 
DISEASES OF THE LIVER. 
JAUNDICE.—CHOLiEMIA.—ICTEEUS. 
By these terms is understood bile in the blood, in the tissues, and 
often in the excretions of the kidneys and skin, giving certain tissues 
and secretions a yellow color. 
Although this is a symptom of various particular pathological 
states, it sometimes presents itself with sufficient distinctness of phe- 
nomena to entitle it to a separate consideration. 
Etiology.—There are two leading varieties or classes of jaundice, 
with reference to causes, viz.: 
1. Those dependent upon mechanical obstruction of the excre- 
tory bile ducts, or upon causes preventing the flow of bile, after its 
secretion, into the duodenum, its retention and consequent absorp- 
tion ; and 
2. Those cases of the affection in which no such impediment 
exists. 
The first class may be caused by foreign bodies in the ducts, such 
as gall-stones and inspissated bile, hydatids detached from the inter- 
nal parts of the liver, or foreign bodies from the intestines. Obstruc- 
tion of the ducts may be from inflammatory swelling of their coats or 
inflammatory exudates into them. The ducts may also be strictured 
so as to be practically obliterated by inflammation around them, or 
from congenital deficiencies, from ulceration and cicatricial contrac- 
tion within them, or from ulceration of the duodenum. Tumors in 
the ducts, at their orifices or in their course, pressing upon them from 
without, such as cancers, hydatids, etc., may produce the result; and 
even spasmodic strictures are believed to be capable of producing tem- 
porary obstruction sufficient to cause the symptom. 
All the cases of jaundice from these causes are organic, and, in 
strictness, should be excluded from the discussion of functional dis- 
eases of the liver. 
The second class of cases are independent not only of those obstruc- 
tions of the ducts, but, for the most part, of other appreciable struct- 
ural changes, and properly come under the head of functional 
affections. 
Jaundice, independent of these mechanical causes, may be pro- 
duced by the poisons of various specific fevers, such as yellow 
fever, the malarial, relapsing, typhoid, typhus, and scarlet fevers. It 
occurs also from snake poison, from phosphorus, mercury, and cop- 
per, and occasionally from chloroform and ether used as anaesthetics. 
It occurs not unfrequently in pyaemia, sometimes in concussion of the 
brain, and even from intense mental emotion. In some of these cases JA UNDICE— VARIETIES—PA THOLOG Y. 
819 
there seems to be failure of power, deficient innervation in the organ, 
which interferes with the proper metamorphosis of the bile. 
Deficient oxygenation of the blood seems sometimes to produce a 
jaundiced condition. 
Excessive secretion of bile—more than can undergo the normal 
changes—and excessive absorption of it into the blood may produce 
jaundice. This excessive secretion may be produced by a moderate 
degree of irritation or excitement, and a hyperaemic condition of the 
organ. 
Lastly, a condition of constipation, in which the excrementitious 
portion of the bile is retained in the intestines until there is absorp- 
tion of materials not readily changed into other forms, may result in 
the accumulation of bile in the blood and the tissues, constituting 
jaundice. 
The opinion seems to have prevailed among writers that mere 
deficiencij of secretion is capable of producing jaundice, and that it is, 
in fact, a frequent cause of it. If, however, all the elements of the 
bile are formed in the liver, it is difficult to conceive how the accu- 
mulation of material in the blood and tissues can result from merely 
diminished secretion. We can readily understand that the disease 
may be produced by some deficiency of proper liver action, at least of 
the metamorphic or transforming power, if of no other; and it is well 
known as a clinical fact that medicinal agents which impress and 
apparently excite its activity, and which certainly increase excretion 
and discharge of bile, mitigate and remove the icterode symptoms. 
Articles which have this effect are called cholagogues; and there 
are various articles which unquestionably have the effect of increasing 
the secretion and excretion of bile, and many cases of jaundice are 
markedly relieved by them. Especially are those cases promptly and 
decidedly benefited where the tongue is coated, the eyes and skin are 
yellowish, the urine loaded, the head heavy or painful, with a sense 
of weight in the region of the liver, and particularly when these 
symptoms come on rather suddenly, and where a malarial influence is 
present, or after rich food has been freely taken. 
Pathology.—Prof. Ererich, of Berlin, whose writings, especially 
on the liver, are so well known, has given an explanation of the cases 
of jaundice not dependent on obstruction, founded, as he alleges, 
upon sufficient scientific observation. 
This explanation is certainly ingenious, and seems neither irrational 
nor improbable. He says a large portion of the colorless bile acids 
found in the liver is either directly taken up into the blood in the 
hepatic veins, or is absorbed into the circulation after passing into the 
bowels. Under ordinary circumstances, these bile acids, after being 820 
DISEASES OF THE LIVER. 
taken into the blood, become oxidized and assist in forming the large 
quantities of taurin found in the healthy lungs and in the pigment of 
the urine. These normal metamorphoses, however, are liable to be 
interrupted by nervous agencies, by poisons in the blood, and by other 
causes; and then these bile acids, not being sufficiently oxidized for 
conversion into taurin, are changed into bile pigments in the blood, 
and the result is jaundice. 
In support of this view is the alleged fact that bile pigment can be 
produced artificially by the action of sulphuric acid upon the bile 
acids, and the much more conclusive fact, if it be established, that 
colorless bile acids injected into the veins of dogs are converted in 
their blood into bile pigment. 
These experimental results are, however, still subjects of contro- 
versy, though the weight of testimony seems to be in favor of the con- 
clusion that the bile acids undergo this transformation. 
Dr. Murchison teaches that the absorption of the bile pigments, as 
well as the bile acids, is constantly going on, chiefly from the intes- 
tines ; but that, under normal circumstances, its accumulation in the 
blood and tissues, in sufficient quantities to cause discoloration, is pre- 
vented by its transformation into other substances. When this trans- 
formation does not occur, jaundice is produced. When certain poisons 
are introduced into the blood, or certain influences are exerted upon 
the system, this transformation is perverted, and the icterus follows. 
These methods of the production of jaundice are not inconsistent 
with each other, and jaundice may be produced in both these ways— 
by the transformation of bile acid into bile pigment, according to 
Frerich, and by failure of the transformation of bile pigment, accord- 
ing to Murchison. 
Assuming either or both of these views to be correct, those medi- 
cines which increase the flow or excretion of bile, and speedily carry it 
out of the system, will prevent the absorption, to the same extent, of 
both the acids and the pigment, and consequently both the change of 
acids into pigment and the quantity of pigment unchanged will be 
less, and the icterode condition will be diminished or prevented. 
If, on the other hand, the doctrine of Harley and others be true, 
that bile pigments are preformed in the system, in the tissues and the 
blood, and arc merely separated by the liver, then those articles which 
increase the secretion of the liver will be indicated. 
Whatever theoretical views may be correct or erroneous, the prac- 
tical fact remains that the medicines which cause increased bile flow 
and discharge tend to prevent and relieve jaundice. 
Most of the articles thought to be eholagogues are cathartics, and 
whether they operate entirely by impressing primarily the intestines, JA UNDICE—PATIIOLOGT. 
821 
or by exciting directly the liver, the practical result is the same—bile 
is removed, and the jaundiced condition is mitigated. 
Patients are accustomed to say (and this is acquiesced in by many 
physicians) that they are “bilious,” that the “liver is torpid,” and in 
chronic cases of ill health, that they have “liver complaint,” and 
these expressions are often used without definite ideas of what they 
indicate. Indeed, the expression “liver complaint” is often used to 
cover ignorance, and to signify any general derangement the nature of 
which is not understood. 
There is, in fact, with those most scientific in their methods and 
most careful and skillful in their diagnoses, much obscurity about 
functional diseases of the liver. There are no positive means of deter- 
mining the extent, or even the fact, of excessive bilious secretion. 
The presence of bile in the stomach is only an evidence of regurgita- 
tion, and an increased discharge from the bowels may only show that 
less bile than usual is absorbed. 
A jaundiced condition may indicate an obstruction of the bile 
ducts from any one of many causes, or from any one of the many 
functional derangements which have been pointed out. The different 
and conflicting pathological views that are entertained indicate 
obscurities and uncertainties on this subject. 
It may be, after ail, that jaundice, in those cases which are 
regarded as not dependent upon obstruction, is produced by spasmodic 
contraction and obstruction of the ducts, and the reabsorption of the 
bile from the mucous surface of the liver. 
But notwithstanding these obscurities, there is much that is known 
or fairly inferred respecting even the functional diseases of this impor- 
tant organ, and it undoubtedly exerts a Avide influence upon various 
morbid processes. A careful study of li\Ter diseases is demanded of 
every practitioner, alike on account of their frequency, their impor- 
tance, and their obscurity, 
The relations of the urine with diseases of the lnrer is a subject of 
interest, and should be observed in the present light of chemical and 
microscopical science. Excluding diseases of the kidney itself, the 
condition of the urine is in many cases an excellent index of the liver 
action. In jaundice, especially from obstruction of the gall ducts, 
the urine contains free quantities of the bile acids as well as bile pig- 
ments, and its condition is a more positive eAndence of the disease 
than yellowness of the skin, as the latter may be produced by other 
causes. In deficient action of the liver in preparing albuminous mat- 
ters for excretion, there will be a deficiency of urea, and often a free 
quantity of leucin and tyrocin in the urine, indicating the imperfect 
transformations. When the liver produces an abnormal quantity of 822 
DISEASES OF THE LIVER. 
sugar, that article immediately manifests itself in the urine, and the 
amount of wrong action is measured by the quantity of sugar in this 
excretion. 
In many of the derangements depending upon the wrong actions 
of the liver which have been pointed out, the liver is often said to be 
“torpid,” with a degree of propriety. It certainly acts imperfectly. 
Mercury, podophyllin, euonymin, alkalies and salines are said to excite 
the liver. They certainly produce cholagogue effects : that is, they 
cause an increase of flow and discharge of bile; and they certainly in 
many cases of moderate jaundiced conditions remove speedily the 
symptoms. 
Experiments upon animals, and especially those so carefully made 
and so fully and accurately reported by Dr. Rutherford, of Edinburgh, 
in 1878, tend to confirm the conclusions from clinical experience. 
Still, these experiments with dogs, by making a fistulous opening and 
inserting a tube into the excretory duct of the liver or the gall-bladder, 
ligating the duct below, forcing the flow of bile through the tube, 
and observing the amount discharged after the administration of 
various medicines, is by no means a conclusive test of the cholagogue 
and curative effect of these medicines in human diseases to which 
they are applicable. Of this no one is more fully aware than the 
judicious and careful experimenter—unless it be the experienced and 
closely observing medical practitioner. 
Many experiments, with mercury for example, have been incon- 
clusive and unsatisfactory ; and especially so as the conclusions from 
them have been opposed by an immense amount of clinical ex- 
perience. 
The fallacies of the sweeping conclusions from these experiments 
will appear by considering the conditions of their performance. 
In the first place, the effect of mercury upon the liver in its healthy 
condition may be different from that in its diseased states. The dog’s 
liver experimented upon is supposed to be healthy, except so far as it 
is disturbed by the operation in producing the fistula, and this dis- 
turbance produces effects very different from those conditions which 
are present in the diseases for which the medicine is prescribed. 
Medicines generally have different effects in health and disease, 
and also in different kinds of morbid conditions. 
Again, an impression made upon the excretory duct of an organ, 
increasing its secretion, maybe transmitted by continuous sympathy— 
the impression being conveyed along the duct. This mode of com- 
munication would be interrupted by the ligation and opening of the 
duct. 
Again, an article which would stimulate the liver to an increased JA UNDICE— CA USES. 
823 
secretion might at the same time increase its absorbing and transform- 
ing function ; so that there might not be an increased discharge of 
bile though there was an increased secretion. Various metamorphoses 
of bile, as of other substances, doubtless occur in the liver ; and its 
greater activity under the influence of a medicine might consist in its 
effecting more of these changes, and in causing more rapid disposal 
of bile, as well as in its increased secretion. In this way the secretion 
of bile might be increased, while its discharge might be even dimin- 
ished. 
The liver, then, may be excited in its functions—mercury may 
have a specific cliolagogue influence without producing increase in the 
discharge of bile. 
Dr. Bennett’s experiments, which have so often been referred to as 
showing that mercury has no cholagogue effect upon the liver, and 
that it is useless in the various bilious derangements for which it has 
been so generally prescribed, are at least inconclusive, if not com- 
pletely valueless and misleading. 
Moreover, the much more extended and much more careful ex- 
periments of Dr. Rutherford have tended to show that the bichloride 
of mercury, into which a part of the calomel and blue mass given is 
supposed to be converted, does markedly increase the liver’s secretion 
and the flow of bile. 
But clinical observations and experience must be the test of the 
activity and beneficial effects of mercury in liver derangements—on 
this the practical physician relies. 
Causes.—The causes of these wrong actions of the liver are 
numerous. 
When the structure of an organ is morbidly changed its function 
is of course deranged. The structural diseases of the liver will be 
considered further on. 
Disorders of the stomach and intestines may cause functional dis- 
eases of the liver, and it is often difficult to say whether the liver 
derangement is primary or secondary. The results of imperfect 
stomach digestion—imperfectly elaborated materials carried by the 
portal vessels to the liver—may prove a source of irritation to that 
organ; and this, in turn,.by the disturbance of its functions, will 
react upon the whole organism, and often especially upon the 
stomach. 
Constipation and other morbid conditions of the bowels operate in 
a similar way. 
Diseases of the heart and lungs, by interfering with the circulation, 
affect this organ and produce in it wrong actions. 
In all diseases attended by fever—symptomatic or idiopathic, 824 
DISEASES OF THE LIVER. 
specific or non-specific—the functions of the liver are disturbed. The 
liver seems to play an important part in the pathology of the pyrexial 
condition. It usually becomes enlarged during a fever, “its gland 
cells are swollen out with minute albuminous granules, and there is 
an increased disintegration of albuminous matter, and an increased 
production of urea, uric acid, and less oxidized products.” This, 
however, can hardly be regarded as chiefly the result of a morbid 
action of the liver. There is a general increased disintegration of the 
tissues throughout the body, and the liver has to prepare this effete 
material for elimination. It has more than the normal amount of 
work thrown upon it, and its size is increased. Permanent derange- 
ment of the organ may be caused by an attack of fever. 
: The malarial poison doubtless acts upon the liver, independent of 
the fever phenomena which it also induces, and thus both directly 
and indirectly deranges its functions. 
Primary functional diseases of the liver, as well as those dependent 
upon other diseases, may be produced by a variety of causes. 
The first and most important of these is errors in regard toingesta 
—to foods and drinks. 
In England these errors among the higher classes are perhaps more 
common than among us; but they are exceedingly common every- 
where, and in different ways among all classes. 
“There can be no doubt,” says Dr. Murchison, “that the present 
system of living, and especially the consumption of even what are 
regarded as average quantities of rich food and stimulating drinks, 
contributes largely to derange the liver.” 
When more food is taken than can be properly elaborated, the 
power of a strong organism may dispose of the surplus without 
material harm, but derangement is exceedingly apt to follow. If 
more is taken than can be digested in the alimentary canal, it proves 
a source of irritation there, and if more is taken into the portal 
vessels than can be properly elaborated by the liver, this organ is 
irritated by it; or if, passing on, more is taken into the lungs than 
can be properly oxidized, or more is taken into the general current of 
the blood than can be appropriated by the tissues, the labor of carry- 
ing the surplus out of the system is thrown upon the excreting 
Organs, and much of this falls upon the liver. If the excreting 
organs are unable to carry off all these surplus materials, their reten- 
tion in the system will produce general derangement, and not unfre- 
quently hyperplasias of particular parts will result. Sometimes even 
worse and more speedy consequences follow from the chemical changes 
which these materials undergo, induced it may be by specific fer- 
ments producing poisonous materials. C A USES. 
825 
If, in connection with too much food, an article is introduced 
which is either more or less than a food, Avhich irritates tissues and 
checks normal metamorphosis and elimination, morbid results are still 
more likely to' follow. 
The liver is probably more likely to be deranged by these con- 
ditions than any other organ of the body. 
Rich, saccharine, and fatty foods in excess are more likely to 
injure the liver than albuminous foods. Cooked articles having a 
large proportion of sugar and fats are more likely to do harm—are 
much more likely to derange the liver—than plain meats. 
“But,” says Dr. Murchison, “of all ingesta, the various alcoholic 
drinks are most apt to derange the liver. They do so in two ways : 
First, They may cause persistent congestion of the liver. Even small 
quantities of alcohol in healthy persons produce a temporary hepatic 
congestion ; but if alcohol is taken in excess or too frequently, the 
congestion of the liver becomes permanent, and the functions of the 
organ are deranged. Like results may ensue from comparatively 
small quantities in certain persons. * * * Of course if the con- 
gestion be long maintained structural diseases may follow. 
“But, secondly,” continues Dr. M., “wines and other alcoholic 
drinks often cause derangement of the liver which a corresponding 
quantity of pure alcohol would not produce, and which, in fact, can- 
not be accounted for by any one ingredient of the offending liquid— 
neither by the free acid, the ether, the salts, gum, sugar, or extractive 
matter. 
“This general rule, however, I believe holds good : that the 
injurious effect of alcoholic beverages upon the liver increases in 
direct ratio with the amount of sugar, plus alcohol, which they 
contain. * * * 
“In accordance with this view, the alcoholic drinks which are 
found, from experience, to be most apt to disagree with the liver, are 
malt liquors of all sorts, but especially porter and the stronger forms 
of mild ale, port wine, Madeira, Tokay, Malaga, sweet Champagne, 
dark sherries, liqueurs, and brandy ; while those which are least likely 
to derange the functions of the organs are claret, hock, Moselle, dry 
sherry, and gin or whiskey largely diluted.” 
This purely professional testimony from one standing among the 
very foremost men of the profession of his time, with all the influence 
of general custom operating upon him, and with such opportunities 
for observation as must have been enjoyed by a leading practitioner in 
London, should have much weight, and should cause those who advo- 
cate the general use of wine and beer as a measure of health and tem- 
perance, to examine the subject with more care. 826 
DISEASES OF THE LIVER. 
The direct effect of alcohol on the brain is much the same in 
proportion to the amount used, in whatever mixture it occurs; and 
if beer and wine injure the liver more than gin and whiskey when 
largely diluted, it is difficult to see what is to be gained on the score 
of health by substituting wine for whiskey. 
According to testimony from California, their strong wines are 
quite as injurious as whiskey, where the same amount of alcohol is 
taken. Most of the common wines of the continent of Europe con- 
tain but little alcohol, and are taken by the masses of the people with 
water, and frequently do little more than give a flavor to the water. 
Used in this, manner their effects are slight; but where the stronger 
wines are taken with any freedom, the injurious effects are apparent 
there as elsewhere. The greater danger from the use of ardent spirits 
consists in the greater facility of getting a larger quantity of the alco- 
hol. AVhen the alcohol is taken in a more concentrated form, how- 
ever, its irritating effects upon the liver are greater, as is shown by the 
larger number of cases of cirrhosis among spirit drinkers. 
Another cause of functional disease of the liver is a deficient 
supply of oxygen. Oxidation is lessened by sedentary habits, by 
confinement within doors and in limited quantities of air. The 
circulation of blood through the liver is retarded by the same means. 
Active respiration promotes circulation and increases the amount of 
oxidation, and exercise promotes respiration. Want of exercise, there- 
fore, is a cause of functional disease of the liver, and a very important 
one. 
A high temperature favors certain functional derangements of this 
organ. The air is more rarefied when heated, and oxidation is not as 
perfectly effected. Less production of animal heat is required to 
keep up the temperature to the normal standard, and more work is 
thrown upon the liver to eliminate carbonaceous substances not 
burned in the lungs. 
A high temperature tends to produce degeneration of liver tissue, 
causing in animals subjected to it minute granules in the secreting 
cells, similar to those sometimes produced by fevers. 
Nervous influences may derange the liver. The brain and nerves 
control more or less all secretions, and in fact all functions, and the 
functions of the liver are not exceptions. Though the production of 
diabetic sugar takes place in the liver, there is believed to be a brain 
influence back of that which induces this wrong action of the organ. 
Prolonged mental anxiety, excessive mental exertion, change the 
action of the liver, inducing litlisemia and other morbid conditions, 
and sometimes even structural disease. If to these conditions of 
mental anxiety and excessive labor is added the use of alcohol and CAUSES—HEPATIC CONGESTION. 
827 
other agencies disturbing the liver, all the conditions are made 
worse. 
Acute atrophy, gall-stones, and cancer are more frequent in per- 
sons who are subject to mental worry and fatigue ; and it is believed 
that these are more than coincidences. 
Another cause of functional derangements of the liver to be men- 
tioned is a constitutional predisposition. This is not unfrequently 
inherited; and where such constitutional tendency exists, all other 
causes should be avoided. Care as to food, drink, exercise, etc., will 
be particularly required. 
Lastly, various poisons derange the liver’s action. The poison of 
alcohol, of chloroform and ether, of various mineral substances, of 
malaria, and other specific fever causes, have already been mentioned. 
Phosphorus deranges the liver’s action, and has been thought some- 
times to cause a disease resembling acute atrophy of the organ. 
Curare and other substances affect the liver by impressing the nervous 
system, especially the splanchnic nerves and the semi-lunar ganglia. 
Besides these poisons taken from without, substances are often 
engendered in the system, from malnutrition, which act as poisons 
upon the liver. 
HEPATIC CONGESTION OR HYPERSEMIA. 
Congestion of the liver is a condition standing between func- 
tional and organic diseases, and partaking of the character of each. 
It is an increased quantity of blood in the organ—but that cannot 
occur without changing the function. It may be present without 
producing any other material structural change. 
When moderate it changes the functional activity without materi- 
ally modifying structure ; but when great the organ is much en- 
larged, not only by distention with blood, but by the hyperplasia 
which follows; and many of the causes which have been mentioned as 
inducing functional derangements produce more or less hypersemia. 
Ilypersemia is also a condition accompanying most of the more 
decided structural changes. 
Pathology.—Before proceeding to describe the treatment of func- 
tional diseases of the liver, a more particular account of its congestion 
will be given. 
From the peculiarities of its vascular apparatus, and its anatom- 
ical relations to other organs, the liver is more exposed to hypersemia 
than perhaps any other part of the body. With its double sets of 
capillaries, and its larger vessels destitute of valves, placed in such 
relations to the heart and lungs on the one side, and to the portal vessels 828 
DISEASES OF THE LIVER. 
on the other, dependent to some extent upon the pressure of the dia- 
phragm above and the abdominal muscles below for aiding its circu- 
lation, it suffers passive congestion from every obstruction to the flow 
of blood through the heart and lungs, and from deficient action of 
compressing muscles. 
On the other hand, its constant exposure to irritating matters 
which may be brought to it by the portal vessels renders it peculiarly 
liable to active congestions. 
The quantity of blood in the liver varies normally. It is increased 
after a meal, especially if the food contains much fat and sugar, and 
still more if the meal is a large one. 
Fluxion by augmentation of the pressure of blood from the portal 
vessels is observed physiologically only as a temporary condition 
during digestion, when these vessels are turgescent from gastric and 
intestinal absorption. The congestion becomes more permanent 
pathologically in great eaters and those habitually indulging in irri- 
tating ingesta which find their way into these vessels. 
Suppression of menstruation or of an accustomed hemorrhoidal 
flux produces a compensatory distention of the vessels of the liver, as 
of other abdominal organs. 
Irritative fluxions or more active congestions are very frequent. 
They maybe produced by “ traumatism ” or by the results of in- 
juries, and by inflammation and its products in other parts ; from 
morbid matters found in the livei*, and from irritating substances 
taken into the portal vessels from the alimentary canal; or from the 
absorption of poisons. 
Many of the causes already referred to as changing the liver func- 
tions cause irritative congestion. Jaccoud mentions alcohol, spices, 
marsh miasm, dysenteric and typhoid poisons, phosphorus, lead, etc. 
He also speaks of fluxions of a nervous origin—from active mental 
emotions—fear or anger; from irritation of the spinal cord, electri- 
zation of the vagus, and section of the splanchnic nerves. Extirpa- 
tion of the coeliac ganglia, as the experiments of Bernard and Frerich 
on animals show, causes very great hyperaemia of the liver, and curare 
and some other poisons produce a similar effect. Injury of the semi- 
lunar ganglia may cause fluxion ; and stasis or passive congestion 
results from pressure ivithin the inferior vena cava, by lesions of the 
heart, the pericardium, or the lungs, by feebleness of the heart or the 
respiratory muscles, by valvular lesions obstructing circulation, or by 
pressure upon the vena cava above the hepatic vein, or upon the 
hepatic vein itself, by tumors or other causes. This passive or venous 
form of congestion from obstruction above the liver causes a greater 
amount of distention than the active, irritating, and arterial form. CONGESTION—MORBID ANATOMY. 
829 
I have seen the greatest amount of congestion of the liver from 
capillary bronchitis occurring in an old asthmatic patient. 
Morbid Anatomy.—Anatomically the liver is increased in vol- 
ume without being changed in form. The surface is of a dark red or 
violet color ; the peritoneal covering is stretched and glistening in 
severe cases ; the vessels are dilated ; but the hepatic cells are normal. 
As a result of the congestion, ora complication with it, the cells may 
present at certain points the first traces of an albuminous infiltration 
or of fatty degeneration. These alterations, however, are by no means 
constant, and according to Bamberger their relations to congestion are 
not clear. 
In recent congestions the cut surface of the liver is uniform in 
color, but in those long continued it has a variegated appearance which 
has given it the name of nutmeg liver. This appearance occurs in 
obstruction—passive congestion—and is due to the fact that the central 
veins of the lobules are with blood, and these parts are 
of a darker color, while the perilobular or interlobular veins are less 
distended, and the parts where they are found are of a lighter color. 
When the stasis is from obstruction of the vena cava or hepatic 
veins, the radicles of these veins are distended, while the terminal 
branches of the portal vein are not materially affected. 
Stasis of the bile, which sometimes occurs, may make this varie- 
gated appearance still more striking, as the bile colors most the 
portions surrounding the central veins. 
This state of the liver so constantly follows chronic obstructive 
disease of the heart, that it has received the name from Jaccoud of 
“ cardiac liver.” 
In more decidedly advanced stages the “ cardiac liver ” under- 
goes other changes which take the case out of the condition of simple 
congestion. In time the tissue begins to be atrophied and becomes 
granular, and rgay be mistaken for primary cirrhosis, hereafter to be 
described. 
In the much advanced “cardiac liver” the hepatic cells disappear 
from the meshes of the dilated veins in consequence of their pressure 
upon them, while the peripheral ones remain intact. 
The cardiac liver has not the hardness of the sclerotic liver of 
cirrhosis, which latter consists of hyperplasia, and afterward con- 
traction of the fibrous structure of the organ, and consequent pressure 
upon its vessels, cutting off circulation and causing atrophy. 
In cardiac liver the process is passive—a simple disturbance of 
circulation. In cirrhosis the process is an active one—is an intersti- 
tial hepatitis. 
The stasis produced by cardiac disease extends not only to the 830 
DISEASES OF THE LIVER. 
liver but throughout the sphere of the portal circulation. The 
spleen, at first turgescent, may become small and harder like the liver; 
and the gastro-intestinal mucous membrane is hyperaemic, and not 
unfrequently affected with catarrhal inflammation. A chronic con- 
gestion of the kidneys may also be dependent upon the same cause. 
Symptoms.—The symptoms and means of distinguishing con- 
gestion of the liver are not always distinct and characteristic, yet 
they are usually sufficiently so for the purposes of diagnosis. 
In compensatory and irritative fluxions, there are abnormal sensa- 
tions in the region. When decided, there is a sense of weight and 
tension, of uneasiness from pressure of clothing, some obstruction to 
easy respiration ; and there is changed function of the organ. More 
or less of an ieterode condition is generally observed in a day or two 
after the attack ; there are gastro-intestinal derangements and other 
symptoms already described as functional disturbances of the liver 
and their effects; and there are often slight but perceptible febrile 
movements in acute cases. 
An attack of acute congestion usually begins with a feeling of 
malaise; some pains in the limbs and back; headache; a yellowish- 
coated tongue ; loss of appetite, and sometimes nausea and loathing of 
food. 
When the congestion is great the liver is sensibly, sometimes 
markedly, enlarged ; but the mode of its detection will be described 
later. 
In warm climates and malarious regions hypersecretion of bile 
often occurs, causing bilious diarrhoea and vomiting. When a mild 
jaundiced appearance is present, when there is a yellow sclerotic and 
muddy complexion, and the other functional derangements already 
described, without evidences of inflammation or obstruction of the 
ducts, hyperaemia may be presumed to be the pathological condition ; 
especially when the symptoms come on suddenly and are preceded bv 
the common causes of congestion. There will generally be chilliness, 
headache, and more decided fever and soreness when the simple con- 
gestion has merged into an inflammation. This often occurs, and 
suppuration is not a very rare result in hot and malarious countries 
and where dysentery prevails. 
If hepatic congestion is produced by accidental or temporary 
causes, it disappears in a few days, especially under proper treatment. 
If due to more permanent causes—to bad hygiene, habitual excesses, 
etc.—it is apt to last as long as its cause, and may become stationary 
and fixed, or progressive and serious in its results. 
Fluxion of nervous origin is sudden and short, and may produce 
neither painful sensations nor perceptible tumefaction ; and the exist- CONGESTION—DIA GNOSIS. 
831 
ence of actual congestion may be doubtful, only functional changes 
being appreciable. But more or less icterus is usually present, and 
probably some degree, at least, of abnormal blood pressure. 
This nervous icterus may be accompanied by no other phenomena 
than those produced by the passage of bile, and chiefly its coloring 
matter, into the blood, as in these cases bile acids are seldom found in 
the urine, and there may be an absence of gastric or intestinal 
troubles. There is a yellow coloring of the skin and conjunctive that 
sometimes is very marked, and some slowing of the pulse, but scarcely 
any other morbid conditions. 
The most marked examples of this which I have seen have followed 
the administration of anesthetics. 
Passive congestion, or stasis from cardiac or pulmonary disease, 
generally becomes chronic, as these diseases are more often of a chronic 
character, and it varies in intensity according to the amount of 
obstruction. As the circulation through the lungs is more or less 
interrupted, cyanosis is usually present; and gastro-intestinal catarrh 
and other morbid conditions of the abdominal organs and functions, 
which have already been sufficiently referred to, may occur. The 
blood pressure in the hepatic veins soon extends more or less to the 
portal vessels, and absorption of nutrient materials from the aliment- 
ary canal is interfered with. When the congestion is sufficiently 
severe and long continued, inanition and emaciation follow. Serious 
gastric and intestinal symptoms may occur, and sometimes ascites 
results. 
Diagnosis.—Hepatic congestion may be confounded with jaun- 
dice from catarrh and obstruction of the biliary ducts; but in the latter 
case the icterus is more marked, there is a greater abundance of bile 
in the urine, more tenderness in the region of the liver and the 
epigastrium, and evidence of gastric and duodenal catarrh. The 
chronic cases of congestion of the liver dependent upon cardiac and 
pulmonary obstruction will be distinguished by a physical examina- 
tion of the heart and lungs ; and the contraction of the liver, which 
finally occurs, will be distinguished from cirrhosis by the history of 
the case and the concomitant conditions. 
When any considerable congestion of the liver exists, functional 
derangements follow; but wrong action of this organ may occur with- 
out the existence of congestion. Though these conditions so fre- 
quently coincide, they are not identical, and some distinction in their 
treatment will be required. It will be well to consider first the means 
useful in preventing and relieving the condition of congestion, and 
afterward those which may tend to correct the various perversions of 
function, from whatever cause arising, which have been described. 832 
DISEASES OF THE LIVER. 
Treatment.—In attempting to prevent or relieve congestion of 
the liver, the causal indication must be observed and followed. 
If of a passive form and dependent upon disease of the heart or the 
lungs, these affections must be treated according to their conditions. 
Radical treatment must he applied when there is hope of a cure, and 
palliative when the nature of the disease, as is too often the case, pre- 
cludes such hope. These diseases and their management will, of 
course, require separate discussion. 
When the hyperaemia is irritative and fluxional, dependent upon 
improprieties and excesses in diet, these errors must be corrected. 
Rich food, spices, and especially alcohol in all its forms, must be for- 
bidden. The plainest, simplest diet sufficient to sustain the patient 
must be insisted upon. Poultices, counter-irritation by sinapisms, 
stimulating liniments, or, in severe cases, by blisters, will give relief 
to suffering. Leeches or cupping, dry or with scarification, according 
to the general state of the system, will tend to lessen pain and the 
congestive state. 
A warm pack or warm bath will sometimes be very soothing. 
The medicines most frequently required are cathartics. They 
unload the portal vessels, and diminish the amount of, or remove 
altogether, irritating matters that might otherwise be carried to the 
liver. They are rationally indicated, and experience proves their 
great utility. 
No articles are better adapted to most of the cases than a mercu- 
rial—from three to eight grains of blue mass, or a fewr grains of calo- 
mel—followed in three or four hours by a saline purgative. The 
action of the different saline cathartics is very similar, but none of 
them are better in their effects than sulphate of soda. According to 
the experiments of Dr. Rutherford, it increases the secretions of bile 
more than any of the others. The purgatives should be repeated as 
required, but the mercurial must not be carried to the production of 
constitutional or salivating effects. A few doses only—often not 
more than one—will be required in the acute cases ; and if the patient 
be delicate, ansemic, or particularly susceptible to impressions, the 
mercurial may be omitted. It is by no means essential to the treat- 
ment, but experience shows that more relief is obtained by this than 
by any other form of cathartic medicine. 
In persistent cases other eliminatives besides cathartics may be 
required. Acetate of potash, in quantities of from one to two drachms 
in the twenty-four hours ; or the citrate of potash or the carbonate 
of soda, in similar quantities, may be given. 
Hydrochlorate of ammonia, in doses of from fifteen to thirty 
grains, repeated three or four times a day, is a favorite remedy with IITPE1UEMIA— THE A TMENT. 
833 
many. It seems to have a resolvent effect, when hyperplasia is sus- 
pected. Iodide of potassium or iodide of sodium may be used with 
reference to the same indication. Phosphate of soda is a favorite with 
some. 
Various vegetable preparations have a reputation where slight 
icterode conditions are present. Podophyllin, leptandrin, euonymin, 
and iridine have been most used for that purpose. The podophyllin 
is a powerful cathartic, and is often severe and protracted in its 
operation when given in free doses. In smaller doses it appears to 
have a cholagogue effect, without irritating materially the bowels. 
Iridine, according to Dr. Rutherford’s experiments, increases secretions 
from the liver, but irritates the intestinal membrane. Euonymin is 
reported by the same experimenter to increase the secretion of the 
liver without irritating the intestines, and the article is in favor with 
the so-called Eclectic physicians and others who have made use of it. 
It is given in doses of one to five grains, repeated a few times a day ; 
and iridine is given in similar quantities. 
If there is reason to suspect a malarious influence as a cause of the 
congestion, efficient antimalarial treatment must be promptly insti- 
tuted. Nothing then is so efficient as full doses of quinine after the 
operation of a cathartic or two. The quinine, as a rule, should not 
be long continued, but a full antimalarial impression should be made. 
Indeed, independent of malarial conditions, quinine alone, in anti- 
pyretic doses, or in combination with morphine, and perhaps with 
the addition of atropine—as so often advised by Prof. Bartholow—will 
act very efficiently in diminishing hepatic congestion, and may avert 
an acute hepatitis. Eliminatives afterward will usually be required 
—the salines already mentioned being most efficient. 
In protracted cases with debility, after proper elimination, the 
mineral acids—especially dilute nitric and nitro-hydrochloric acid— 
may be found useful. In debilitated or anaemic cases, preparations of 
iron and various bitter tonics may be added. 
The nitro-hydrochloric acid baths have a reputation. As an exam- 
ple : Ijt Strong Hydrochloric Acid, l'\] ; Nitric Acid, §j. M., and 
add this to two gallons of Avatef, to be used blood warm, as a local bath 
to feet, and by cloths to the region of the liver, night and morning. 
It should not be forgotten that although the course of medical treat- 
ment above imperfectly outlined is useful and often important, yet 
to avoid and remove if possible the causes is far more important. It 
should also be borne in mind that the causes which produce conges- 
tion, particularly irritative fluxion, if more severe or long continued, 
are apt to result in inflammation and other more serious organic 
changes, and these are to be guarded against in the treatment. 834 
DISEASES OF THE LIVER. 
The treatment of more distinctly functional disorders of the liver 
remains to be considered. 
It is doubtful whether in any case a purely functional disease 
exists—whether some degree of structural change is not always 
present. 
At any rate, in these affections of the liver, the line is not always 
easily drawn between those that are regarded as functional, and those 
that are accompanied by slight structural changes. It is proposed 
here to treat of the management of those changes of function which 
are not known to belong to any particular structural changes. 
In the treatment of those phenomena, consisting of or arising 
from abnormal disintegration and elimination, the proper regulation 
of hygienic conditions, and especially of diet, is most important. The 
diet should be plain and simple, as already advised in hyperaemia. 
In habitual lithgemia the patient should avoid taking much sac- 
charine and oily food—especially cooked dishes containing both sugar 
and fatty matter—and all highly seasoned dishes. He should take stale 
rather than new bread, plain mutton or other easily digested meat, 
white fish, soles, etc., poultry plainly cooked, eggs, and if agreeing 
well, milk, the last chiefly in the morning. He should be careful not 
to take a large quantity of farinaceous food, and should be very 
moderate in the use of vegetables. His drinks should be plain water, 
or diluents such as soda-water, or Seltzer water, or any of the saline 
natural waters. 
Alcohol should be specially avoided. Dr. Murchison, whose ex- 
perience in such cases has been large, says there is no danger to the 
nervous system from its sudden withdrawal, however freely and long 
it lias been used, and that the sensations of “sinking at the stomach ” 
and “craving” are kept up by its use. 
A free supply of oxygen—of open, fresh, condensed air—is very 
important. The more free the supply of oxygen, the more will effete 
matters be burned up in the system. 
Muscular exercise, as the strength and the condition will allow, is 
important ; but according to Parkes it does not always materially 
increase the excretion of nitrogen. It* however, favors oxidation of 
all matters requiring that process, by favoring free respiration. It is 
generally agreed that sea-air is best. Nitrogenous and sulphur-holding 
tissues are more rapidly oxidized by it; and sea-bathing, if it can be 
borne, aids the process. 
According to my experience the nitro-liydrochloric acid, given 
well diluted and in warm water, if it agrees better with the stomach, 
promotes oxidation in the system, and is particularly useful in those 
cases where a deficiency of this process results in the production of TREATMENT. 
835 
oxalate of lime, as indicated by its irritation of the tissues and its 
appearance in the urine. In the interior of our continent, and away 
from the sea, oxaluria has seemed to me more frequent than near the 
coast. My observations have been mostly made in southern Michigan 
and near the coast of Maine, and the contrast has been marked. In 
the mingled air of the pine forests and the sea, oxidation seems more 
active. But in these cases of deficient disintegration and elimination 
of effete matters, aperients and cholagopues are perhaps the most im- 
portant medicines. They should, as a rule, be given whether consti- 
pation is present or not. Aperients bring away bile and redundant 
and effete products in the portal system. Salines eliminate most, and 
the natural waters of saline aperient springs are generally useful. 
Where the circumstances of the patient will not render these readily 
available, they may be imitated artificially. The salts of soda, potash, 
and magnesia are similar in their general effect, though each has its 
peculiar action. 
These salts have little affinity for normal animal textures, and 
excite few changes in them. In moderate quantities they excite but 
little the peristaltic movements of the intestines, but by increasing 
exosmosis, they prevent the reabsorption of fluids so constantly poured 
out, and eliminate them from the system. 
Whatever their mode of action, their beneficial effects are often 
striking. They should not, as a rule, or certainly not for any length 
of time, be given to the extent of producing active purging, but so as 
to keep the bowels free and the discharges thin. 
Cholagogues are also useful. Among these mercury holds a 
prominent place. According to Murchison, and in the estimation of 
most practical physicians, it occupies a pre-eminent place. Says this 
writer: “ The practical physician gives a dose of calomel, finds the 
quantity of bile in the motions greatly increased, and his patient’s 
state much improved : he argues that the liver has been stimulated 
by the mercury to an increased secretion of bile, and that to this 
cause his patient’s improvement is due. The physiologist, on the 
other hand, ties the common bile duct in one of the lower animals, 
produces a fistulous opening into the gall-bladder, and then finds that 
calomel has no effect on, if it does not diminish, the amount of bile 
that drains away from the fistula.” 
But these experiments, as has already been shown, do not justify 
all the inferences drawn from them. They are, moreover, contradic- 
tory. Although Rutherford did not find that calomel, while retain- 
ing that form, produced effects upon the secretion of bile in the dog, 
yet he found that corrosive sublimate did materially increase the bile 836 
DISEASES OF THE LIVER. 
flow, and the calomel is supposed to be transformed into that article 
—it certainly takes some form in which it is absorbed—before it pro- 
duces its full cholagogue effect. But admitting that it does not always 
increase the secretion of bile, it prevents its reabsorption from the 
intestinal canal, and carries it away. Bile is increased in the dis- 
charges, and not only bile, but leucin and tyrosin are increased also, 
and doubtless various other excrementitious substances, the absorp- 
tion of which would do harm. 
Mercury, by increasing the discharge of bile, will lessen its amount 
in the system, and will also lessen the amount of disintegrated albu 
men circulating in the portal blood, and thus the loaded liver will be 
more effectually relieved than if the medicine merely stimulated the 
gland to increased secretion. 
If mercury merely stimulated the liver, it might increase rather 
than diminish hepatic congestion. It may act upon the 
gall ducts and liver in a reflex manner, by the impression made upon 
the gastric and intestinal membrane. The mode of its action is, to a 
large extent, a matter of speculation, but it does good in various dis- 
eases of the liver, in whatever way it accomplishes the result. Patients 
so declare, and so the physician observes. It often does what nothing 
else will in relieving a variety of gastro-intestinal and hepatic derange- 
ments. Undoubtedly the practice of taking large or small doses may 
often produce very injurious results. The effect of mercury, when in 
free quantities in the system, upon the tissues and the blood, is often 
exceedingly disastrous. It must always be given with caution, and in 
these affections should be followed by laxatives, to prevent its retention 
in the alimentary canal, and a transformation and absorption to a 
greater extent than is useful or safe. Large doses are unnecessary, 
and are occasionally injurious when happening to meet with agents in 
the alimentary canal which transform a large quantity into a soluble 
and active form. Even a fraction of a grain of calomel or blue mass, 
when well triturated with a considerable quantity of sugar, will often 
produce the desired effect, and a few such doses repeated at short 
intervals will often be better than larger ones given at once. 
Occasionally, when inflammatory exudates are supposed to be 
deposited in the liver, the mercury may be repeated until some mod- 
erate constitutional effect is produced, short, however, of ptyalism. It 
tends to produce the disintegration of effused fibrine, rendering it more 
fluid, and promoting its absorption. In this way it may improve the 
functions of the liver when such inflammatory exudates interfere with 
them. An exact diagnosis is often impossible, and the good effects 
realized in some more protracted cases may depend upon this mode of 
its action rather than its direct modifying effect upon its functions. TREATMENT. 
837 
That mercury, when applied to distant parts of the body, reaches 
the liver, is proved by its having been found in the bile of animals 
treated by mercurial frictions. Its effects in syphilis and various other 
conditions are undoubted, and clinical experience is overwhelming in 
favor of its use in various hepatic diseases. 
Podophyllin is thought to act similarly, but it irritates the bowels 
much more, though it may be used as a substitute for it where, for 
any reason, there are real objections to the use of mercury. 
Euonymin is worthy of further trials, and may be found to answer 
many indications. It has not yet been tested by the general pro- 
fession. 
Taraxicum has been recommended as a cholagogue of a mild char- 
acter, and I have frequently used the fluid extract, as much for a 
vehicle in administering acetate of potash as for any well-defined 
therapeutical effects of its own, and have certainly realized good 
results from the compound in mildly jaundiced conditions, especially 
in malarious cases. 
Colocynth, aloes, jalap, senna, and other cathartics, have more or 
less cholagogue effect, and may be used beneficially in various combi- 
nations. 
Alkalies in various liver derangements are often useful. They 
are thought to promote oxidizing actions, and increase the disinte- 
gration of sulphur-holding materials. They effect chemical changes 
in the liver, often beneficially. They may, however, derange gastric 
digestion, and should not be too long continued. Even where they 
appear to be strongly indicated, their use must be suspended from 
time to time, and as a rule, in protracted cases, they should be com- 
bined with vegetable bitters. 
Chlorine, bromine, and iodine are thought to increase oxidation 
in the system. The chloride of ammonium is thought to be pre- 
eminent for this purpose, where the liver is at fault. It has much 
reputation in India, where “sluggish livers” abound. Scruple doses 
three times a day improve the portal circulation and relieve many of 
these wrong actions of the liver. This article is very permanent in 
its composition, and may be used either with acids or alkalies. It is, 
however, thought to be unsafe to use it at the same time with consid- 
erable mercurial doses, lest it should convert the milder forms into 
the bichloride. The benzoate of soda, or better, the benzoate of 
ammonia, according to some recent observations, increases the secre- 
tion and flow of the bile, and in doses of fifteen grains three or four 
times a day has been followed by good results in deficient liver action. 
The mineral acids—the nitric especially—are thought to have 
cholagogue actions. They affect the functional activity of the liver 838 
DISEASES OF THE LIVER. 
perhaps less than alkalies, but may he given after meals, aiding as 
they often do the process of digestion, while at the same time alkalies 
may be given after that process is completed and before the next meal 
is taken. 
The more active tonics in these cases often disagree. Eliminatives 
frequently increase strength more than tonics, and are much more 
frequently indicated. 
The chlorate of potash improves ultimate nutrition very often, and 
probably does so in part by its action on the liver. It is thought to 
aid oxidation, and in various low conditions of the system, with defi- 
cient glandular action, it produces a beneficial effect. 
The use of nitro-liydrochloric acid, often for a long time, cannot 
be too highly recommended in those cases where oxalate of lime 
appears in free quantity in the urine. 
Opium is generally contra-indicated in these functional diseases of 
the liver, and particularly when there is lithaemia. It diminishes 
oxidation, secretion, and elimination, constipates the bowels, and favors 
portal congestion. In diabetes, where there is excessive waste and 
elimination, it is often very useful. It probably modifies the action 
of the vaso-motor nerves of the hepatic vessels, a reflex paralysis of 
which is thought to be one of the causes of this disease. If anodynes 
are required, belladonna or hyoscyamus should be selected when the 
liver’s action is deficient. 
I am fully aware that comparatively more space has been devoted 
to the discussion of the confessedly obscure functional diseases of the 
liver than is usual in works of this kind ; and it is always more agree- 
able to dwell on subjects susceptible of more demonstration and 
admitting of less doubt. But the importance of the subject, and the 
brief manner in which it is discussed in many of the general works 
on the practice of medicine will, it is hoped, justify the course pur- 
sued. 
Diseases of this kind are of very frequent occurrence almost 
everywhere, and especially in the south and west of this country, and 
their neglect leads to very serious results. 
The object has been to state the principles, as fully as they are 
known or reasonably conjectured, upon which the treatment of these 
affections should be conducted. The details, and the adaptation of 
the various remedies to special cases, must be matters of judgment 
based upon the teachings of experience and such scientific knowledge 
as we possess. 
The custom of some to attribute very vaguely and empirically 
almost every ailment to the liver has driven others to the opposite 
extreme of almost ignoring in pathology and therapeutics this very TREA TMEJS T—ENLARGEMENT. 
839 
important organ. Even the importance of dietetic management is 
sometimes spoken of very lightly, and in some popular medical works 
the well and the sick alike, with but slight reservations, are advised to 
take whatever foods or drinks they may desire. Whatever mischief 
may be done by watching too closely the sensations produced by every 
article of food taken, and by too great restrictions as to diet (and 
mischief is unquestionably sometimes done in this way), infinitely 
more harm is done by disregarding proper dietetic and hygienic prin- 
ciples, following perverted appetites, and indulging in injurious habits. 
Nothing has been more strongly impressed upon my mind by long 
observation and experience than the importance of observing hygienic 
regulations, not only as regards general and public conditions, such 
as proper sewerage, ventilation, pure water, etc., but private and indi- 
vidual conditions and personal habits as well. I have felt impelled, 
on what has been judged every proper occasion, to express, both by 
inference and explicit declarations, convictions so strongly felt. 
Some, who recognize the importance of certain hygienic regula- 
tions, denounce or speak slightingly of medical interference in de- 
rangements of the liver and stomach. 
A distinguished gentleman, who has done great honor to the liter- 
ature of our country, who was educated in the profession, but who is 
a wit and a poet rather than a physician, has somewhere said, “When 
the tongue is foul, scrape and wash it and regulate the diet; to 
call in the aid of mercury and other drugs, is like calling in the 
police or a posse comitatus when a box of ashes is to be emptied.” 
This is certainly witty, and, in reference to some cases of temporary 
derangement, is also true. But as a statement to be applied gener- 
ally to cases of a foul tongue, it is far more witty than scientific. 
The police or the posse comitatus are often required to remove the 
cause, often very serious, of such a nuisance and index of evil as a 
foul tongue. 
ORGANIC DISEASES OF THE LIVER. 
There are various morbid changes which affect the structure of 
the liver. Some of these increase and others diminish its bulk, while 
others may do neither, but still may change its structural character. 
We have arrested development rarely; atrophy, contraction, and 
diminution of size, not very unfrequently; and enlargement often. 
It may be enlarged by hyperaemia or congestion, as we have 
already seen. When this is the case the enlargement is generally 
uniform throughout the organ, and its smoothness of surface and 
proper proportions are preserved. 840 
ORGANIC DISEASES OF THE LIVER. 
It is also enlarged by inflammation. As in other inflammations, 
the enlargement is dependent upon engorgement with blood, effusions 
of inflammatory products, and hyperplasia of tissue. 
It is subject to a slow form of enlargement by hypertrophy, by 
fatty accumulations within it—“ fatty liver ”—by a waxy, lardaceous, or 
amyloid degeneration and accumulation, by cancerous and other morbid 
growths and deposits, by the development of hydatids, and the accu- 
mulations of biliary concretions; and lastly, its size may be increased 
by accumulation of bile in the gall-bladder, in the larger gall ducts, 
and in their minuter ramifications in the substance of the liver. 
The liver may be diminished by simple, slow atrophy; by acute, 
or what is called yellow atrophy ; by red atrophy ; by simple indura- 
tion ; by a degree of degenerative change and contraction from long- 
continued congestion; and more frequently than from any other 
cause, by an irregular atrophied condition produced by a chronic 
inflammation and contraction of the interstitial tissue or the capsule 
of Glisson (cirrhosis). 
These are structural changes which may occur, and are apparent 
by a physical examination. In order to detect such changes, a knowl- 
edge of the natural position and size of the liver is required. 
The normal liver occupies the right hypochondrium, and extends 
beyond the median line into the left hypochondrium, and above it 
adapts itself to the concavity of the diaphragm. AVlien the body is in 
the recumbent position the lower edge is so completely in the concavity 
of the diaphragm, that it is concealed by the lower part of the chest, 
excepting the left lobe, which lies uncovered by the ribs or their carti- 
lages in the upper part of the epigastrium. The position of the 
lower margin varies, however, by the acts of respiration. In inspira- 
tion, when the diaphragm descends it pushes down the liver, so that 
in taking a full breath it may be felt just at or below the margin of 
the ribs, while in expiration it recedes again more fully under the 
walls of the chest. In the erect position its weight causes it to sink 
slightly in the abdomen. 
We judge of the space occupied by the liver, and consequently of 
its size, by the area of dullness or flatness on percussion, and by pal- 
pation when below the ribs. It should be mentioned that without 
change in size the liver is sometimes changed in position and form. 
In women who lace tightly, especially if the practice is commenced in 
girlhood, and in a few other exceptional cases, the liver is found two 
or three inches or more below the margins of the ribs, and while it is 
increased in vertical it is lessened in lateral diameter, and a more or 
less deep sulcus may be produced in it by the wearing of a tight nar- 
row belt about the waist. PHYSIC A L EX AMIN A TIO N. 
841 
The ordinary extent of percussion dullness in the right perpen- 
dicular mammary line, in adult persons of common size, is four inches, 
and the upper line of dullness is usually at the fifth interspace or the 
sixth rib. The dullness in the right axillary line is four and a half or 
five inches, and extends above the seventh interspace; and in the 
right dorsal region the dullness is four inches, and extends above the 
tenth interspace ; and in the sternal or median line the percussion 
dullness is from three to four inches. There are slight variations from 
this, depending upon the size and conformation of the person ; and the 
line of dullness changes about an inch in full inspiration and expira- 
tion, and it is also slightly changed by the erect or recumbent position. 
The upper line of dullness is slightly curved, convex above. This is 
a point of some importance in distinguishing between an enlarged 
liver and thoracic effusion, or a “ spurious enlargement.” 
Congenital malformations of the liver are possible, but are exceed- 
ingly rare. All these marks then may be changed, but there will be 
no symptoms as the result of such malformations, and the conditions 
will be permanent. 
The liver is proportionally larger in early life. In adults it is about 
one fortieth of the weight of the whole body. When the body weight 
is one hundred and sixty, the liver will weigh four pounds. Previous 
to puberty the proportionate weight is one thirtieth, and in young 
children it may be one twentieth. 
The projection of the sternum and deformity of the chest called 
“pigeon breast,” may give the appearance of enlargement of the liver ; 
and various diseases of the chest, chiefly effusion in the right pleura 
and very great effusion in the pericardium, may, by pressing the liver 
downward and increasing the area of dullness, deceive one who does 
not inquire into the history of the case and observe all the physical 
signs and rational symptoms. 
In effusion the bulging is uniform, the upper margin of the dull- 
ness is usually in a straight line, and when the fluid is free in the chest 
the line varies with the position of the body, and the liver is not so 
much depressed by a free inspiration. In enlargement of the liver, 
more markedly than in effusion, there is eversion of the cartilages by 
pressure beneath them. Complications may render the diagnosis dif- 
ficult. There may be a tumor, or a collection of fluid between the 
diaphragm and the liver, which may defy detection. Dropsy of the 
abdomen or the ovaries may lead to errors, but a careful examination in 
these cases will make the diagnosis satisfactory. Impacted faeces in the 
transverse colon may simulate hepatic enlargement; the faecal tumor, 
however, will usually be irregular and nodulated, and will often extend 
beyond the position of the liver; but the most characteristic sign of 842 
HEPATITIS. 
faecal accumulation is its susceptibility of indentation ; and its dis- 
appearance on the administration of cathartics and enemas will be 
conclusive. 
An abnormal condition of the abdominal parietes, rigidity of the 
muscles, or inflammation and swelling, may resemble liver enlarge- 
ment, The tumefaction and soreness, however, will be more exter- 
nal, there will usually be tenderness, certainly if there be phlegmonous 
inflammation, and the general symptoms will be different. 
Cancer of the peritoneum in the region of the liver may be con- 
founded with tumors of that organ ; and when adhesive conglomera- 
tions occur, the distinction may be very difficult. 
Tympanitis could only deceive a superficial observer, as percussion 
would readily show the difference between distention from gas and 
that from a solid substance. 
SPECIAL ORGANIC DISEASES OF THE LIVER. 
As congestion of the liver has already been considered, a repetition 
would be out of place. 
It may be remarked, however,tthat hyperaemia not only appears as 
a distinct condition, but also precedes and accompanies inflamma- 
tions and other morbid changes; and as an accompaniment of other 
pathological states it must not be ignored. It will therefore be 
referred to in connection with other diseases, of which it constitutes a 
part. 
HEPATITIS.—INFLAMMATION OF THE LlYER. 
There are several varieties of inflammation of the liver, recognized 
anatomically and clinically. Besides the divisions into primary and 
secondary, and into acute and chronic, we have catarrhal, ulcerative, 
phlegmonous, suppurative, pyasmic, phlebitic, gangrenous, and plastic 
or adhesive inflammations. 
CATARRHAL HEPATITIS. 
By catarrhal inflammation of the liver is understood an inflamma- 
tion of its mucous surface, or the internal lining membrane of the 
gall ducts and gall-bladder. That of the ducts has received the name 
of angiocholitis; and that of the gall-bladder cholecystitis. When 
the gall-bladder alone is inflamed, it is in nearly all cases due to calculi 
within it, or to inspissated bile. In other cases it accompanies inflam- CATARIIHAL HEPATITIS—MORBID ANATOMY—SYMPTOMS. 
843 
illation of the ducts; but it is not always involved when they are affected. 
Catarrh of the liver has characteristics in common with other catarrhal 
inflammations, such as those of the stomach and bowels or the 
bronchial tubes. From the resemblance of the ramifications of the 
bile ducts through the liver to those of the bronchi through the lungs, 
the phrase “ bronchitis of the liver” has been used as expressive of 
that resemblance. 
The inflammation of this membrane may be primary and idio- 
pathic, or secondary and symptomatic of other states, and the primary 
variety may arise from taking cold, from the influence of seasons 
(it is more likely to occur in spring and autumn), and as it occasion- 
ally appears epidemically, it may be supposed to depend upon some 
peculiar zymotic influence. The secondary forms may be due to 
calculi, to gastro-enteric catarrh extending to the gall ducts, or to 
other diseases of the liver and of other parts of the body. Jaccoud 
places alcoholism among the most frequent causes ; and it sometimes 
complicates malarial and other forms of disease. 
Morbid Anatomy.—The morbid anatomy is similar to that of 
inflammation of other mucous membranes. The surface is injected, 
turgescent, and covered with mucus from the hypersecretion which 
occurs ; and this mucus contains epithelium, mostly in an embryonic 
state, mucine, etc., as in other similar catarrhal conditions. 
The inflammation may occupy the mucous surface of the liver 
generally, including the gall-bladder, or any limited portion of it. 
Sometimes it is limited to the extra-hepatic portion of the canal, and 
the mucous accumulation may be confined to the duodenal mouth of 
the ductus choledochus. In duodenal catarrh it is not rarely the 
case that this duct is affected only at its extremity, but sufficiently to 
arrest the excretion of the bile. In that which accompanies the 
infectious fevers, this is sometimes the case. As the catarrhal inflam- 
mation subsides, the bile again freely flows ; but if the condition be 
long continued, the liver ducts and gall-bladder become much dis- 
tended, and atrophy of the liver substance may result from the pressure. 
Symptoms.—This form of hepatitis is marked by the moderate 
febrile excitement usual in mucous inflammations, by some degree of 
tenderness on pressure, especially over the gall-bladder when it is in- 
volved, and by a feeling of weight and uneasiness, and sometimes of 
pain, in the region of the organ. 
A general congestion of the liver accompanies this form of inflam- 
mation, and this, together with the swelling of the numerous tubes 
and the accumulation of bile in them so likely to occur, causes 
moderate enlargement of the organ, with a smooth, uniform surface as 
far as can be discovered by palpation. 844 
HEPATITIS. 
The gall-bladder, however, is often so much distended as to be dis- 
tinctly felt, or even seen, as a pear-shaped tumefaction below the 
margin of the ribs. 
As the gall ducts become obstructed from swelling and from 
mucous or semi-plastic exudations, the bile is absorbed from them, 
producing in from two to three days decided symptoms of jaundice. 
The urine is loaded with bile, is of a dark mahogany color, and when 
tested, shows the presence of bile acids. The skin and eyes are 
yellow; and bile not passing into the intestines the stools are clay- 
colored. The bile acids may not be abundant in the urine, as they are 
readily decomposed in the blood when the system is in a proper state. 
When the inflammation commences in the stomach or duodenum 
and extends to the bile ducts, as is often the case, there will be more 
tenderness of the epigastrium and greater disturbance of the functions 
of the stomach and bowels. Dyspeptic symptoms are usually pres- 
ent to a greater or less extent. There is a feeling of heaviness and 
Sleepiness, the pulse often becomes slow, and other evidences of a gen- 
eral disturbance of the system occur. The bowels are generally con- 
stipated, but there is occasionally, though rarely, diarrhoea, and the 
stools, besides presenting the clayey or ash color belonging to all forms 
of jaundice, are often mingled with mucus discharged from the ducts. 
This condition constitutes the most common form of acute jaundice. 
This form of disease, without very severe symptoms, may continue 
for several weeks, though it usually terminates in a shorter period. 
Etiology.—Catarrhal inflammation of the liver is sometimes 
dependent upon some general cause—upon some zymotic influence 
or atmospheric conditions—as it occasionally prevails epidemically. 
Much oftener, however, it occurs sporadically, and is produced by the 
common causes of catarrhal inflammation, exposure to cold, checking 
perspiration, etc.; and not unfrequently the inflammation commences 
in the stomach and intestines and extends to the gall ducts. It is often 
complicated in its more chronic forms with other pathological con- 
ditions of the liver, and is dependent upon them. The presence of 
gall-stones in the ducts or the gall-bladder may be a cause ; and 
pyaemic and septicaemic conditions may give rise to catarrhal as well 
as phlegmonous inflammation of the organ. 
Diagnosis.—As in bronchitis or muco-enteritis, the usual ex- 
udate upon the gall ducts is mucus, but in rare cases it assumes a 
plastic or croupous character, and sometimes it is largely purulent, 
The croupous variety can only be distinguished post mortem, and 
the suppurative form can be proximately diagnosed by the greater 
severity of symptoms, and the appearance of pus in the alvine dis- 
charges. DIA GNOSIS—Pit 0 GNOSIS— TEE A TMENT. 
845 
Catarrh of the biliary passages, before obstruction has caused 
jaundice, might be confounded with simple congestion, with the 
initial symptoms of acute yellow atrophy, and with catarrhal gastro- 
enteritis. After jaundice appears, it may be confounded witli this 
condition arising from other causes—such as obstruction of the ducts 
from inspissated bile ; from impressions made upon the nervous sys- 
tem, or from various structural changes of the liver. A proper inquiry 
into the history of the case, and a comparison of the phenomena will 
render the diagnosis sufficiently certain to lead to correct principles 
of treatment. 
Prognosis.—In the ordinary cases of hepatic catarrh the prog- 
nosis is favorable; the inflammation subsides in a week or two, and 
the obstruction and its consequences disappear in one, two, or three 
weeks later. As the obstruction of the ducts is removed the bile 
passes off, the liver assumes its proper functions, the bile is reabsorbed 
from the tissues, and the health is restored. 
Sometimes, however, resolution is delayed, and the case becomes 
chronic, while in rarer instances complete organic strictures are pro- 
duced, and serious consequences to the hepatic structures result. 
Recent observations by Charcot and others have shown that mechani- 
cal blocking up of the ducts may lead to degenerative changes of the 
parenchyma of the organ. Interstitial hepatitis, increase of connec- 
tive tissue, fibroid and fatty degenerations, and atrophy of the gland 
cells may soon follow. The changes may be more general, from 
obstruction of the main excretory duct, or local and in patches, from 
complete obstruction of smaller branches. These are serious and 
may be fatal consequences. 
Treatment.—As there is hypersemia of the liver generally, as 
well as inflammation of its mucous surface, the treatment will not 
differ greatly from that recommended for congestion of the organ. 
As, however, there is apt to be present a catarrhal state of the stomach, 
and especially of the duodenum, reference must be had to that con- 
dition also. When dependent upon gastro-duodenitis that state fur- 
nishes an indication for treatment. 
The diet should be bland and moderate in quantity ; generally 
milk and farinaceous substances are best, and the simplest drinks* 
only should be allowed. 
Cathartics are much depended upon, but, as a rule, they should 
be of an unirritating character, especially when the membrane of the 
alimentary canal is involved. Cholagogues are suggested by the 
jaundiced condition, but articles to excite biliary secretion are not 
particularly indicated, as the jaundice is from the obstructed flow, 
and not from the deficient secretion of bile. To overcome the inflam- 846 
HEPATITIS. 
mation of the tubes, and thus remove the swelling, the elfusions, and 
the obstruction, and to relieve the general portal congestion, are the 
principal objects of treatment. Moderate saline cathartics, with an 
occasional small dose of a mercurial, are useful, but they should not 
be carried to excess. A fraction of a grain of calomel rubbed up with 
sugar allays irritation of the mucous membrane, and is followed by 
beneficial results. When the tenderness is decided and the patient 
vigorous, leeches or cupping applied over the region will produce 
relief. Fomentations and poultices are also useful, but if the case is 
at all severe or obstinate, blisters will be found more efficacious. I 
have had no more satisfactory results from any treatment than from a 
good-sized blister over the region of the liver and the epigastrium, in 
cases of acute jaundice from catarrh of the liver. The use of alkalies, 
especially the carbonates of soda, tends to supply to the alimentary 
canal the alkalinity of which it is deprived by the obstruction to the 
flow of bile and pancreatic fluid through the common duct, and alka- 
lies possibly do good in some other ways. But in whatever way oper- 
ating, alkalies and salines are often prescribed, and are thought to be 
useful. Diuretics may aid the kidneys in carrying off the elements of 
bile from the blood and tissues, and should be used. Frerichs advises 
lemon-juice as a diuretic for this purpose. The saline diuretics are 
most used. 
Diaphoretics may also aid elimination, and, as in other catarrhal 
inflammations, by determining to the surface they procure relief. 
Quinine in full doses, especially when a malarial influence is pres- 
ent, will usually be followed by marked benefit. 
It is a source of gratification to me that views long ago derived 
from my own experience, and for years past taught to successive 
classes, respecting the antiphlogistic effects of quinine, are of late 
corroborated by the statements of others high in the confidence of the 
profession. The recent work of Prof. Flint on Clinical Medicine, 
and Prof. Bartholow’s Practice of Medicine, afford evidences of the 
advancement of American professional opinion in this direction. In 
the treatment of the early stage of this affection the latter says : 
“Whether malaria is or is not an element in the case, two antipyretic 
doses of quinia (10-15 grains) should be given daily until jaundice 
appears, and for a few days subsequent to its full development.” 
The propriety of continuing the quinine so long might be ques- 
tioned, but the utility of its early administration does not, with me, 
admit of doubt. 
Prof. Wagner, of Leipsic, advises the free use of buttermilk, and, 
as a domestic remedy, sour cider is sometimes used. Whether either 
of these and various other articles that are advised are really useful, it TREATMENT— SECONDARY ABSCESS. 
847 
is not easy to decide, since their effects are never speedy and striking, 
and the disease usually subsides of itself in a week or two, or three. 
Whatever complications may bo present should receive attention, 
especially the conditions of the stomach and bowels. When intestinal 
digestion is supposed to be particularly imperfect, and the bowels are 
otherwise deranged from the absence of bile in them, inspissated 
oxgall would seem to be indicated, and, according to Dr. Harley, is 
often very useful. 
In Germany and France a course of the natural mineral waters, 
such as the Carlsbad, Ems, and Vichy, is advised where symptoms of 
a jaundiced condition linger. These waters are often doubtless use- 
ful, and artificial preparations may be substituted for them. When 
the appetite is not restored after the subsidence of other symptoms, 
and the patient remains weak, the bitter tonics and mineral acids may 
be found useful. Constipation must not be allowed to continue. 
The phosphate or sulphate of soda, in doses of a drachm or more 
three times a day, kept up while the jaundice lingers, will often serve 
a useful purpose. Euonymin and iridine taken at night, followed by 
a saline in the morning, are thought to be efficient in aiding the 
eliminative action of the liver. The benzoate of ammonia may be 
useful here, as in functional torpidity of the organ. 
The diet should receive attention. Easily digested foods should 
be directed. 
But the more permanent mechanical obstructions of the gall ducts 
by calculi, tumors, etc., and the management of the obstinate jaun- 
diced conditions following, will be referred to hereafter. 
Ulcerative inflammation of the ducts is not easily distinguishable, 
clinically. But when this occurs the case is more persistent and 
severe, and muco-purulent and bloody matter may be found in the 
discharges. The treatment of these cases will not differ materially 
from those already described. A tonic and sustaining course will be 
more likely to be required. 
ACUTE PHLEGMONOUS AND SUPPURATIVE IN- 
FLAMMATION OF THE LIVER. 
This affection, sufficiently defined by its title, may be primary and 
idiopathic, or secondary—dependent upon other pathological states. 
SECONDARY HEPATIC ABSCESS. 
Secondary inflammations and abscesses of the liver have often been 848 
PHLEGMON 0 US HEP A TITIS. 
referred to, as the result of pyaemia from suppurations in surgical cases, 
in dysentery, in abscesses elsewhere, etc. Ulceration of the gall-blad- 
der or bile ducts may lead to the same result. 
Whenever pus or decomposing matter or small emboli obtain 
access to, or are found in any of the portal veins, they first come into 
capillary vessels and are likely to be lodged in the substance of the 
liver. These materials being in the veins of the systemic circulation 
are more likely to be lodged in the lungs, but may be in the liver as 
well. However introduced, tlieir presence in the liver excites irrita- 
tion, inflammation, and the suppurative process; and small circum- 
scribed abscesses, often extensively scattered through the organ, are thus 
produced. The preceding conditions, the general symptoms of pyae- 
mia : elevated temperature, repeated chills, free sweats, dry tongue, 
rapid pulse, depression, etc., together with the local symptoms of 
pain, often tenderness, and moderate enlargement, will mark the cases 
and lead to the diagnosis. Where the case is protracted sufficiently 
and the abscesses are few, they may become larger, presenting irregu- 
lar bulging, and possibly fluctuations may be detected. Generally, 
however, the abscesses are small and scattered, many of them deep 
seated, and fluctuation or much bulging is not discoverable. When 
the abscesses are near the surface the pain and tenderness are usually 
marked, but if they -are deep seated or central the pain may be 
slight or absent, and the tenderness obscure. When the inflammation 
extends to the peritoneal surface the pain and tenderness are much 
more decided, the breathing is likely to be short and thoracic, and 
the other symptoms of a local, or sometimes of a more general peri- 
tonitis are present. 
More or less jaundice is often present, as the pressure of the 
abscesses is apt to interrupt the excretion of some parts, and cause 
absorption of the accumulated bile. As only a moderate part of the 
liver substance is usually involved, the portal circulation is not much 
interfered with. 
In these cases of pyaemic or secondary abscesses the disease is very 
severe, the course is usually rapid, and the termination fatal. Some- 
times cases are more protracted, and recovery may take place. Much 
will depend upon the extent and character of the original disease and 
the severity of the pyaemic symptoms. 
These pyaemic cases are to be prevented, if possible, by attention to 
the primary conditions giving rise to them. Abscesses from which 
there is danger of the taking of pus into the circulation are to be 
early opened, antiseptic dressings are to be carefully used, and anti- 
septic medicines may be given internally. 
Treatment. —In the treatment of pyaemic cases, no depletion is THE A TMENT—IDIOPATHIC HEP A TITIS. 
849 
to be practiced ; fomentations and poultices will tend to relieve the 
pain, anodynes may be given as required, and quinine, salicylic acid, 
carbolic acid, the sulphites, and perhaps mineral acids, as in other 
cases of septicaemia, may be used. 
For the vomiting which is likely to occur, ice, effervescing mixt- 
ures, bismuth, carbolic acid, creosote, morphine hypodermically or 
on the tongue, and counter-irritation—as by sinapisms or small blisters 
—may be useful. 
Beef-tea, milk, etc., must be given as can be borne ; and if alcohol 
is given, it must be largely diluted or in the form of milk punch or 
with syrup and the yolk of egg. 
IDIOPATHIC AND TRAUMATIC PHLEGMONOUS 
HEPATITIS. 
Etiology and Phenomena.—Primary, idiopathic, phlegmon- 
ous inflammation of the liver occasionally occurs in high latitudes, 
but with much greater frequency in hot climates and seasons and in 
malarious regions. 
An inflammation of the parenchyma of the liver tending to sup- 
puration may occur in any climate, when excited by local injuries, by 
adventitious growths or hydatids, by extension of inflammation from 
the ducts or veins of the organ or from other neighboring parts, 
independent of pyaemia or embolism. Such an inflammation may 
also be induced by pre-existing congestions of the liver, produced by 
obstructive heart disease ; or it may be excited by irritating ingesta. 
An increase of the causes producing congestion may produce 
parenchymatous inflammation tending to suppuration. 
It usually affects only a portion of the gland, the other parts 
remaining sufficiently free to perform function, and to allow of a fair 
degree of portal circulation. 
Inflammation of the parenchyma of the liver affects mainly the 
connective tissue and the small vessels which permeate and sustain 
the proper gland elements. The vessels become dilated and engorged, 
and the blood contains a superabundance of leucocytes ; inflammatory 
exudates are poured out infiltrating the tissue ; embryonic tissues are 
developed yi the wralls of the small vessels and ducts, and the con- 
nective structure generally in the inflamed part of the liver. The 
proper liver cells become swollen and opaque, and are sometimes 
replaced by fatty or pigmental deposits. The appearance presented 
by the inflamed tissue differs in different cases according to the 
cause, the degree, the stage, and the peculiar kind of the inflamma- 850 
DISEASES OF THE LIVER. 
tory process. In some cases there are opacity and lightness of tint, 
doughiness of consistence, and enlargement of the lobules. The 
swollen hepatic cells press upon the vessels and prevent their disten- 
tion with blood, and also prevent much exudation. This pallid 
and swollen portion is usually surrounded by a hyperasmic area ; and 
when a large portion of the liver is involved, it commonly presents a 
marbled appearance. An inflammation may be so general and uni- 
form throughout the organ as to present only the light or yellow 
appearance, and it is believed by some that the condition known as 
“ yellow atrophy” of the liver is a diffused inflammation of this 
kind. 
Suppurative hepatitis resulting in abscess is circumscribed and 
intense. Suppuration, as in other abscesses, commences in the central 
point of the inflamed part, which becomes paler; embryonic cells 
make their appearance in large numbers ; the hepatic cells become 
granular and are disintegrated ; the connective tissue also liquefies and 
disappears ; leucocytes are poured out, and a collection of pus is formed. 
The surrounding portion of the gland is hyperaemic, and the suppura- 
tion and congestion may spread, involving a considerable portion of 
the organ. There arc sometimes several. foci of inflammation and 
suppuration, sometimes ultimately merging into one irregular cavity, 
in which hang filaments of tissue which have longer resisted the 
destructive processes. 
The pus of a hepatic abscess varies in appearance, but is usually 
more or less mingled with bile, and is often of a glairy appearance 
and greenish hue. Idiopathic hepatic abscesses are usually solitary, 
though there may be two or more at the same time ; but when 
numerous, there is reason to suspect pyeemia as the cause. Pus from 
a primary abscess in the liver may, however, enter portal veins, and 
thus produce suppuration in different *foci. Pus may also enter the 
hepatic veins, producing similar results, if the passage into the vena 
cava be obstructed. An abscess invading a hepatic duct may be dis- 
charged through the bile channels into the bowels ; or if the duct be 
obstructed, the pus may penetrate other parts of the liver, causing in 
like manner extension of the suppurative process in the organ. 
An hepatic abscess may travel in various directions. When it 
comes to the surface of the liver, adhesions may form between the 
peritoneal surfaces, and the matter may be discharged through the 
abdominal parietes, or through the diaphragm into the pleural cavity, 
into the lung and through the bronchi, or more rarely into the peri- 
cardium. Or taking other directions the pus may be discharged into 
the stomach, the colon, or duodenum ; or adhesions failing to form, 
it may pass into the peritoneal cavity. In some more rare instances HEPATIC ABSCESS— SYMPTOMS. 
851 
the matter may burrow and infiltrate tissues, or getting behind the 
peritoneum it may pass downward, discharging into the caecum, the 
rectum, or vagina; or it may take the course of an ordinary psoas 
abscess. A firm membrane may sometimes encyst the pus, when it 
may undergo fatty, cheesy, or calcareous degenerations. 
The symptoms accompanying an ordinary case of acute hepatitis 
are rigors, often many times repeated ; fever, pain, and tenderness in 
the part, the pain sometimes extending to the shoulder ; disturbed 
respiration, and frequently a moderate degree of jaundice. On physi- 
cal examination, the liver will be found more or less enlarged, but 
not uniformly as in simple congestion, as the whole organ is not 
affected, at least to the same extent. When the inflammation involves 
the surface, the pain and tenderness will he more severe and sharp in 
character, and all the local symptoms better marked. While it is in 
the central portion of the gland the local symptoms will sometimes 
be very obscure. There will be more or less enlargement, but it may 
not be readily detected, especially when the posterior part of the liver 
is the seat of the disease. There will be a sense of weight and un- 
easiness, especially on pressure, or on a change of position, or in tak- 
ing a full breath, but there may be no decided pain, or if occprring 
it will be dull in character ; and the febrile and other general symp- 
toms may be slight. In some cases chills and fever occur at regular 
intervals, simulating ague, especially when suppuration has taken 
place. 
Diagnosis of pus in the liver is claimed to have been made by 
certain brain symptoms, and the results of aspiration, it is alleged, 
have confirmed the diagnosis ; but the claim has not been substan- 
tiated by sufficient general experience to entitle it to confidence. 
The inflammation may terminate in resolution, in suppuration, 
in induration, or in other structural changes, such as have been 
described. Resolution may occur within a few days, or at a later 
period ; and suppuration may take place within a week, or at an 
indefinite period thereafter. 
The evidence of resolution will be a subsidence, more or less rapid 
and complete, of all the symptoms ; but often a degree of congestion 
and impaired function will linger /or a considerable time. The 
symptoms of suppuration are often at first vague and obscure. There 
will, however, usually be some change in the character of the fever, 
it becoming more remitting, with occasional sweats, and sometimes 
with repeated chills. If it be extensive, there will often be extreme 
prostration, a feeble pulse, pallor of countenance, and profuse sweats, 
and sometimes complete collapse and death. When an abscess 
forms, if it is of considerable size and on the anterior part of the 852 
DISEASES OF THE LIVER 
organ, the tumefaction will become more prominent, projecting 
below the ribs, and commonly presenting a somewhat smooth, rounded 
mass. As it progresses, especially if the abdominal walls are not 
thick or rigid, a sense of fluctuation may be distinguished. Wherever 
situated, the area of hepatic dullness will be increased, but if pos- 
teriorly or deep, the local bulging may not be perceived, and the 
anterior margin of the liver may be pressed down below the margin 
of the ribs, presenting a uniformity as in cases of simple congestion. 
When the left lobe is the seat of the disease, the abscess is more easily 
detected, though if it be deep and small it may escape recognition. 
When near the upper part of the liver, and to the right, it may press 
up the diaphragm and lung, interfering with respiration, and causing 
flatness on percussion as high as the right nipple, and even consid- 
erably above it. If more to the left, it may displace to some extent 
the heart. When it presses upon and involves the diaphragm, not 
only is difficulty of breathing induced, but hiccough and a hacking 
cough are likely to occur. The stomach may be pressed upon and 
displaced, and nausea and vomiting may be induced. 
Although during the course of hepatic inflammation and abscess 
there is usually a fever which is readily distinguishable, the tempera- 
ture seldom rises above 102° or 103°, and is sometimes but very 
slightly above the normal. In protracted cases the fever is apt to 
assume a hectical character, and chills, exacerbations of fever, and 
sweats sometimes occur with a regularity and severity simulating 
very perfectly an ague. The yielding of the fever to quinine only 
very temporarily, together with the local symptoms, and the more 
or less jaundiced condition so often present, will distinguish it from 
malarial fever. In some cases the digestive organs are but little dis- 
turbed, while in others, a coated tongue, nausea, vomiting, derange- 
ments of the bowels, etc., are marked. 
Diagnosis.—The differential diagnosis in hepatic inflammation 
and abscess is to be made by observing all the phenomena which have 
been described. It should be distinguished from hydatids (which so 
far as a physical examination is concerned it may resemble) by its 
more recent history, by the greater amount of fever, tenderness, and 
pain, and the greater disturbance of the general system. The trocar, 
which may be required therapeutically in either case, may serve for 
the purpose of diagnosis. By its use in abscess, pus, and generally 
fragments of liver structure will be obtained, while in hydatid cysts a 
straw-colored serous fluid, containing the characteristic echinococcus 
hooklets, will be produced. 
It should be distinguished also from inflammation and distention 
of the gall-bladder ; and this may be done by observing the peculiar ABSCESS—DIA GNOSIS—PROGNOSIS. 
853 
pear-shape, and the locality of the latter and its more elastic feel ; 
and it is distinguished from abscess of the abdominal parietes by the 
manner of attack, the earlier appearance of tenderness and swelling 
when the disease is in the abdominal walls, by the characters of the 
general symptoms, and by a careful physical examination. Dr. Flint 
gives as a method, quoted from Ziemssen’s Handbuch, for distinguish- 
ing an abscess in the walls from that of the liver, the following : 
Introduce a long needle into the abscess. The part above the in- 
tegument will be moved by the diaphragmatic movements if the 
abscess be in the liver, and it will remain motionless if the abscess be 
not hepatic. 
Primary inflammation and abscess is to be distinguished from 
pyaemic abscesses by the history of a preceding suppurative disease, 
and by the peculiar symptoms of blood poisoning in pyaemia. 
An abscess of the liver pointing upward to the diaphragm may 
readily be confounded with a pleural abscess in the lower part of the 
right side, or with pleuritic effusion in that side, bound down by 
adhesions. The distinction can usually be made by observing the his- 
tory of the case and by a careful physical examination. 
Prognosis.—The prognosis in primary phlegmonous hepatitis is 
variable. It is far less dangerous than pyaemic, but when an abscess 
forms the case is one of much gravity, the course of the disease is apt 
to be protracted, and the result is doubtful. An external pointing 
and a discharge through the abdominal parietes would seem to be most 
favorable; but still perhaps as large a proportion recover where the 
matter finds its way through the diaphragm and lungs, and is dis- 
charged by expectoration. More or less impairment of the lung would 
follow, but where there is no consumptive tendency, this mode of dis- 
charge may be considered to be about as favorable as any other. 
A discharge into the colon is rather favorable, Avliile into the 
stomach it is less so, and into the peritoneal cavity it is very generally 
fatal. I have, however, seen one case where the pus from a large 
acute hepatic abscess was discharged partly into the colon and partly 
into the peritoneum, and still the patient recovered. The diagnosis 
could scarcely have been mistaken, as simultaneously with the sudden 
subsidence of a large fluctuating tumor below the right ribs, a free 
discharge of pus took place from the bowels, and a distinctly fluctuating 
fluid mass as suddenly appeared in the depending part of the abdomen, 
which very slowly disappeared. The preceding symptoms rendered 
abscess of the liver unquestionable. The patient was a vigorous 
farmer, of middle age; he was almost in a collapsed condition when 
the abscess discharged, and his life was despaired of for some time 
after ; but scarcely any peritonitis was excited, and gradual improve- 854 
DISEASES OF THE LIVER. 
ment and final recovery resulted. This case must, however, be 
regarded as a most exceptional one. 
Not only is death in this disease liable to occur from the accidents 
of the abscess involving other parts, but the patient may be worn out 
by the long continuance of the disease, and he is quite as likely to suc- 
cumb to shock, to the impairment of functions, and to blood poison- 
ing during the acute stage. Patients, however, sometimes recover 
from almost every condition accompanying this affection, and a case, 
however unpromising, should not be entirely despaired of. Recovery 
from encysted abscesses without discharge, Avhere the size is not great, 
is probably not remarkably unfrequent. Some impairment of the 
organ will, however, remain, and subsequent hepatic disease is more 
likely to occur. 
Treatment.—The early treatment of phlegmonous hepatitis 
tending to suppuration is of more importance than the later manage- 
ment of the abscesses, inasmuch as resolution may often be induced. 
An early diagnosis should therefore be made, if possible, and prompt 
attention given the case. The views derived from hospital and consul- 
tation experience as to the impossibility of arresting and aborting inter- 
nal acute inflammatory affections, must not govern the practitioner who 
sees diseases in their early stages. When symptoms occur which indi- 
cate intense hepatic congestion and inflammation, when there has been 
a chill followed by fever, accompanied with pain and tenderness of the 
part, and the patient is full of blood, a venesection, or the application 
of wet cups or several leeches, will lessen the hyperaemia, and may 
materially aid in arresting the inflammatory process. A large poul- 
tice or fomentations afterward, or a warm bath, may contribute to the 
same end, and should not be neglected. At a somewhat later period 
a blister may be of material service. 
But internal remedies are of still greater importance. The prompt 
administration of a purgative is usually required. It unloads the 
portal vessels, and tends to reduce the hyperamda of the liver. A mer- 
curial, followed soon after by a saline or a dose of jalap and cream of 
tartar, experience proves to be efficient and useful. Diaphoretics, de- 
termining the blood to the surface and eliminating from the numerous 
pores of the skin, relieve internal congestion, so important an element 
of the inflammatory process. Various sedative agents, as veratrum 
viride, aconite, etc., tend to the same result. Alkaline and saline 
diuretics are also useful in eliminating by the kidneys, and in abating 
inflammatory action. However, the prompt use, after the proper evac- 
uations from the bowels, of antipyretic doses of quinine or salicylate 
of soda is more efficient in arresting the fever and other inflammatory 
processes, and will often effect a speedy resolution. The addition of ABSCESS—TREATMENT. 
855 
morphine to the quinine will increase its abortive effect. The object 
of treatment at this early stage is to prevent suppuration, which is of 
such serious import. Treatment of this kind, judiciously managed, 
in cases where the disease is more advanced and where suppuration is 
inevitable, will tend to diminish its extent—a matter of the greatest 
importance. 
But if evidences of suppuration have occurred, and an abscess is 
detected pointing toward the surface, poultices should be used and 
results awaited. Even in such cases, if the fever be high, the anti- 
pyretic effect of quinine or salicylate of soda will be called for, and 
the extent of the suppurative process will be likely to be lessened by 
the action of these agents. 
Wherever the abscess is situated, the safety of the patient is pro- 
moted by the process of adhesive inflammation, which confines the 
pus within bounds and prevents its discharge into the peritoneal or 
pleural cavity. Spanasmics should therefore be avoided at this stage, 
and plasticity encouraged. Quinine continued in tonic doses, tincture 
of iron, acids, and a better diet will he called for. The bowels should 
be kept open, the symptoms treated as they arise, and the progress of 
events carefully watched. The patient should always be sent to bed 
as soon as symptoms occur; opiates may be given at any time, when 
there is much pain and restlessness, and when these do not interfere 
with the operation of cathartic medicines; and, as stated, they aid 
the effect of quinine and salicylic acid in their antipyretic and anti- 
inflammatory effects. 
The question of opening an hepatic abscess is one of interest and 
importance. It is sometimes very slow in pointing. If it is approach- 
ing the surface, and the parietes of the abdomen are involved, and 
exudates are deposited in them, there is evidence that adhesions have 
formed between the peritoneal surfaces, and the probabilities are in 
favor of an external opening and discharge. When fluctuation is dis- 
covered at the most prominent point, and is so distinct as to indicate 
that the pus is already in the abdominal parietes, and especially if 
there be a blush of the skin, a tolerably free opening with a scalpel 
or bistoury should be made. If the abscesses are multiple, and do not 
communicate with each other, the relief will be less, but the opening 
is proper when the above conditions exist. 
If, however, an abscess is detected, but not involving the abdomi- 
nal walls, and if no evidence is afforded of peritoneal adhesions, the 
aspirator should be used, especially if some time has elapsed without 
there being evidence of the proper adhesions. Drawing off the mat- 
ter with this instrument, and repeating the process from time to 
time, will give relief and lessen the chances of an internal discharge. 856 
DISEASES OF THE LIVER. 
This is one of the improvements of modern practice, effected by 
ingenious mechanical contrivances. 
When a free opening is made, antiseptic dressings will be proper, 
as in the opening of other abscesses ; and the use of the drainage 
tube and washing out with antiseptic fluids, as with a solution of 
permanganate of potash (gr. i to §i), or a weak solution of carbolic 
acid, etc., as in other large abscesses, may be required. In chronic 
cases, during all these processes, supporting measures—quinine and 
other bitter tonics, iron, mineral acids, etc., with as nourishing and 
digestible a diet as possible—must be used. The same general course 
must be pursued when the discharge is through the diaphragm or 
elsewhere. In some cases eliminatives from time to time may be 
required. 
NON-SUPPURATIVE PARENCHYMATOUS HEPATITIS. 
In some cases of parenchymatous hepatitis suppuration does not 
take place, but the inflammation becomes chronic, with various more 
plastic exudates and structural changes. The early treatment will 
not differ from that described ; but later, the iodide of potassium, 
hydrochlorate of ammonia, mercurials carefully used, blisters or 
setons, and a gentle tonic course will be useful. 
Gangrenous inflammations of the liver sometimes occur. They 
are not positively distinguishable clinically, but may be suspected 
when there is great depression. The symptoms will of course indicate 
supporting measures, and as the cases are usually fatal, a post-mortem 
examination will clear up the diagnosis. 
Suppuration at different points in the liver sometimes follows 
complete obstruction of the ductus communis from biliary calculi or 
other causes. Dr. Flint has observed in such cases thrombosis of the 
hepatic veins. 
The treatment will be the same as in other cases presenting similar 
symptoms. 
INFLAMMATION OF THE FIBROUS STRUCTURE OF THE LIVER. 
Inflammations of fibrous structures are generally adhesive rather 
than suppurative, and this is the case in the liver. 
Perihepatitis, or inflammation of the peritoneal covering of the 
liver, may occur. It will present the characteristics of local peritoni- 
tis, with perhaps some more disturbance of the liver’s function. If 
the peritoneal covering of the intestines is not involved, there will be 
less necessity for avoiding cathartics ; but otherwise the phenomena 
and treatment will he the same as in other cases of limited peritonitis. HEPATIC SCLEROSIS. 
857 
INFLAMMATION OF THE CONNECTIVE TISSUE OF THE LIVER. —OF THE 
CAPSULE OF GLISSON.—CIRRHOSIS OF THE LIVER.—INTERSTITIAL 
HEPATITIS.—HEPATIC SCLEROSIS. 
Inflammation of this stricture maybe acute, but it is very generally 
chronic, or if more or less acute at first it becomes chronic, consti- 
tuting the peculiar and not uncommon disease cirrhosis, or “hob- 
nail ” liver. 
Morbid Anatomy.—The morbid anatomy of this disease has 
many interesting features, and requires a somewhat particular descrip- 
tion, and a comparison with other forms of diseased liver structure 
which resemble it. 
This, as is generally the case writh inflammation of interstitial 
fibrous structures, is plastic. Embryonic cells appear in all the 
fibrous structures, but chiefly in the fibrous coats of the vessels, and 
in the fibrous tissues more immediately surrounding them. In this 
process the portal veins are particularly involved. These hyperplasias 
undergo conversion into cicatricial fibroid tissue, and, following the 
law of such tissue, gradually contract. This obstructs the circulation 
of blood through different vessels, but mostly through the portal 
veins, which causes portal congestion and its results. The nutrient 
vessels of the liver are compressed more or less—more at some points 
than others—and its nutrition is thus interfered with. The hepatic 
lobules are seldom implicated in the inflammation, but their surround- 
ing connective tissue is involved, and contracts in the same manner 
as that of the capsule of Glisson surrounding the portal and other 
vessels—compressing, flattening, and producing atrophy of the cells, 
and causing more or less of them to disappear. Some of the liver 
cells, however, retain their integrity, at least for a long time, and 
more or less bile is secreted ; and as the smaller biliary ducts are not 
so much implicated, they remain pervious, the bile secreted is not 
as a rule retained, and jaundice rarely occurs. 
It is a curious fact that this adventitious tissue, unlike cicatricial 
tissue generally, is itself fairly vascular, which contributes to such 
nutrition of the cells as occurs, and helps to keep up their function. 
The liver, surrounded by a fibrous structure which is involved and 
permeated throughout by a net-work of fibrous tissue undergoing 
these inflammatory changes and contractions, is compressed, its 
nutrition is diminished, and a general atrophy or diminution of the 
organ takes place ; but particular smaller parts being more affected 
than others, a nodulated appearance results, which gives it the name 
of hobnail liver. The color of some portions may be nearly natural, 
but for the most part it presents a pale and mottled yellowish color, 858 
DISEASES OF THE LIVED. 
and hence the name of cirrhosis of the liver has been given. The 
islets of yellow secreting tissue scattered through the organ and sur- 
rounded by the somewhat palish adventitious tissue, give the appear- 
ance of yellow peas distributed in a mass of grayish wax. 
As this form of disease is almost always (and according to Murchi- 
son the genuine variety is invariably) induced by alcohol, especially 
by ardent spirits taken without much dilution, the name of “gin 
liver” has been applied to it. 
In the earliest stage of the disease, when a hypersemic condition 
exists, and the deposits and hyperplasia first occur, the liver is moder- 
ately and quite uniformly enlarged; but as the contraction takes place 
and circulation is cut off, atrophy results, and sometimes is extreme. 
In tracing the pathological anatomy of this disease more minutely, 
it is found that in the first phase, as just stated, the volume of the 
liver is increased ; and it is also increased in density. If the surface 
is now granulous, the number of projections is in inverse ratio to the 
volume of the organ, and they sometimes escape recognition. At this 
period of the disease, on cutting into the parenchyma, it is found not 
only hypersemic, but impregnated with a viscous, bluish-gray matter, 
while normal tissue presents the appearance of more or less prominent 
islets. The color may be normal, or brownish, green or grayish, from 
fatty and pigmentary deposits. 
The second stage is marked by induration, due to the more com- 
plete evolution of the connective-tissue hyperplasia, and often by 
the diminution and deformity of the organ. The structure is now 
firm, cannot be penetrated by the finger, gives resistance to the knife, 
is almost ligneous, and has an almost fibro-cartilaginous appearance. 
It grates under the knife, the cut surface has a glistening appearance, 
but shows some grayish and lardaceous patches, with streaks of yel- 
lowish substance formed by the surviving hepatic lobules. 
Microscopic examination shows the grayish veins or streaks com- 
posed of connective tissue encircled by concentric zones of cell groups, 
often spindle shaped. Where the newly formed connective tissue is 
least the hepatic cells remain intact, while in other regions they are 
fatty, pigmented, or totally destroyed. The pigmentation is the result 
of biliary stagnation, which, from compression, occurs in points. 
Some of the liver cells may present amyloid infiltration. Most of the 
biliary canals are well preserved and are easily seen where the hepatic 
cells have disappeared. The branches and trunks of the vena porta 
are seen, and exceptionally there is observed in them a general throm- 
bosis from stasis of the blood, but the intrahepatic capillaries are 
occluded and effaced w here the cells are destroyed. The hepatic arte- 
ries may be dilated, and the branches may penetrate the newly formed HEPATIC SCLEROSIS. 
859 
connective tissue supplying its nutrition. The radicles of the sub- 
hepatic veins are obliterated, ending in fibrous transformations, and 
these vessels lose their connection with the portal capillaries. 
The anatomical changes described finally lead to obstruction of the 
course of the blood in the portal and subhepatic veins, to stasis in 
the portal system, and derangement of the chyloportic functions, to 
derangement of the secretory function of the liver and its final sup- 
pression, and to equal derangement of the other functions of the 
organ in transforming nutrient materials, producing and purifying 
the blood, and in influencing the process of digestion and general 
nutrition. 
Allied Conditions.—There are other forms of contraction of 
the liver resembling, but not identical with, time cirrhosis. 
Passive hyperaemia from mechanical obstruction in the heart or 
lungs may cause hyperplasia, firmness of structure, and a granular 
state resembling cirrhosis, but the atrophy is more in the centre of the 
lobules, while in true cirrhosis it is more at the circumference. In 
this congestive form of disease the parts supplied by the hepatic vein 
in time become depressed, while the parts receiving the portal blood 
stand out as granules. In the early stage of this congestive change 
wo have the “ nutmeg ” liver, later the atrophy is more general, many 
of the vessels become obliterated, and the disease resembles but is not 
true cirrhosis. 
Another form of atrophy described by Murchison may present a 
nodular appearance, but the fibrous structure is not hypertrophied and 
contracted, and the liver is soft. This is not the true gin liver. 
Another form of diminution of the liver arises from repeated 
attacks of perihepatitis, the peritoneal covering becoming infiltrated 
and covered by plastic material, which, contracting, compresses the 
whole organ, obstructs its circulation and nutrition, and causes 
atrophy. In this case it presents a dense, smooth surface, different 
from the “ hobnail ” liver. 
Syphilitic Hepatitis produces a condition of induration with 
masses of gummata which have been changed into opaque, buff-colored, 
dense, tough masses, of various forms and size. This condition also 
resembles cirrhosis, but the diseased process usually commences at the 
surface of the organ and extends toward the deeper parts, the peculiar 
masses are imbedded in a dense adventitious structure which is con- 
tinuous with the changed gummata on the one side, and with the 
normal tissue on the other, blending them together and preventing 
their ready separation. Some of these masses have cavities within 
them, and in some points fibrous or cicatricial structures are found 
without the gummata within them. Contractions and depressions 860 
DISEASES OF THE LIVER. 
upon the surface of the liver are often found ; but this form of dis- 
ease, in its cause and specific character, is quite different from the 
drunkard’s liver. 
In fibroid tumors of the liver, which sometimes are found, there 
will of course be nodulations, and often depressions or fissures resem- 
bling cicatrices; but a proper examination of a specimen wdll readily 
distinguish this pathological state from cirrhosis. 
Again, in the chronic atrophy of French, or the red atrophy of 
Rokitansky, the liver is lessened in size ; but there are no nodula- 
tions or granulations of the outer surface, nor necessarily any thick- 
ening of the capsule. In this disease the secreting tissue is hyperae- 
mic and bluish red, and the change is uniform in the organ. In this 
rare form of disease the adult organ has been known to be reduced to 
twenty-four ounces, and, as in other forms of atrophy of this gland, 
the small portal vessels are to a greater or less extent obliterated and 
portal circulation is obstructed. This condition is seen in some cases 
of chronic ague, and also in some instances of cancer of the stomach, 
and in ulcerative dysentery. 
True cirrhosis, where alcoholism prevails, is more common than 
any of the other forms of atrophy of the liver. It is a chronic affec- 
tion, usually extending over several years. Dr. Murchison makes 
two stages: The first stage, before the destruction of the minute 
branches of the portal vein ; and the seoond, after such destruction. 
Symptoms.—The disease is insidious in its approaches, and in the 
first stage the symptoms are obscure. There is generally no perceptible 
fever, and no phenomena in this early stage distinguishing it from the 
other conditions of incipient chronic alcoholism. There will usually, 
however, be disordered digestion, feelings of languor and depression, 
etc.,which will be relieved by a dram, and this will encourage the patient 
to continue in his indulgence. He may never have been drunk, or 
specially incapacitated for his business, and may not consider himself 
an intemperate man. If he consults a physician for these symptoms, 
he is not likely to inform him of the full extent of his indulgence in 
his beverages, and may not be warned of the necessity of entire absti- 
nence. I have not unfrequently seen cases where the symptoms gave 
the greatest reason to suspect the beginning of cirrhosis, and where 
the subsequent history proved the suspicion well founded, in which 
the patient had been professionally advised to continue the use of the 
spirits “ to relieve the dyspepsia, and keep up the strength and tone 
of the system.” The patient may have been urged not to apply him- 
self so closely to business, to go more into society, or to travel, and 
often to place himself in situations where the opportunity and the CIRRHOSIS—S YMPTOMS. 
861 
temptations to indulgence were increased—some directions may have 
been given about diet, and some “ tonic” prescribed. 
Cases might be mentioned where complete abandonment of 
alcohol was urged, but where the patient intimated that ‘4 doctors 
differed,” and indulged his inclinations until confirmed cirrhosis 
resulted. Patients will feel more justified in the indulgence when 
they find, as is frequently the case, that a temporary suspension of 
their accustomed dram increases their uncomfortable feelings, while 
resuming the indulgence produces temporary relief. In some cases, 
when the physician is applied to, there will be occasional vomiting, 
and a dull pain and slight tenderness in the region of the liver. A 
careful examination might detect a slight enlargement, and only 
simple congestion of the liver might bo suspected; and this indeed 
might be the fact ; but these symptoms occurring in habitual drinkers 
should excite suspicions of early cirrhosis, and demand the most 
strenuous efforts to avert the impending calamity. 
In some cases the early symptoms are more marked. Acute con- 
gestion may be apparent. There may be some fever, very noticeable 
pain and tenderness in the liver, with more decided enlargement, and 
often with gastro-intestinal catarrh, accompanied by vomiting, purg- 
ing, loss of appetite, etc. The gastro-intestinal symptoms may 
mask those of the liver, and absorb the entire attention of the patient 
and the physician, but such symptoms in a drinking person demand 
a careful investigation of the conditions of the liver. 
In the first clinical stage the mode of invasion and the particular 
symptoms vary, but are divided by Jaccoud into three groups, viz. : 
symptoms of subacute hepatitis ; of gastro-intestinal derangements; 
and dropsical accumulations. In the first mode of attack the initial 
phenomena are more marked. There is a dull pain in the region, 
increased size of the liver, and often icterus. This condition may 
persist for several months, but it is often varied by a more acute 
phase—by increased pain, some febrile movement, etc.; such attacks 
continue a few days and are followed by increase in the size of the 
organ, and a jaundiced appearance. The most frequent mode of 
onset is by the gastro-intestinal symptoms, slow and difficult diges- 
tion, tympanitis often, alternate constipation and diarrhoea, the 
latter often becoming persistent as the disease advances; and other 
not distinctly characteristic symptoms already spoken of. In many, 
perhaps the majority of cases, the earliest symptoms are so obscure 
as not to be recognized as indicating cirrhosis, until ascites, pro- 
duced by the obstruction of portal circulation, makes its appearance. 
The second stage of Murchison has now occurred. 
In this second stage of cirrhosis the symptoms are more clearly 862 
DISEASES OF THE LIVER. 
marked. Though there may be little or no pain or soreness in the 
region, the evidences of obstructed portal circulation are prominent. 
Congestion of the abdominal organs, generally increasing their bulk 
and giving rise to more decided derangement of their functions, will 
be observed; a moderate catarrhal inflammation of the gastro-intes- 
tinal mucous membrane is often present. The abdomen is often still 
more distended with gas, and at length with serum in the peritoneal 
cavity. The spleen, from its peculiar vascularity, generally becomes 
distended with blood, and this is followed by hyperplasia and more 
solid and very perceptible enlargement in at least one half the cases. 
It may, however, be sclerosed so as to prevent enlargement. There 
is enlargement of the superficial veins of the abdomen, especially on 
the right side between the sternum and umbilicus, in most of the 
advanced cases. Any pressure on the vena cava or hepatic veins 
which obstructs circulation may cause this, as well as obstruction in 
the liver. When the vena cava is thus obstructed, the lower extrem- 
ities will be likely to bo varicose as well. From the portal obstruc- 
tion, hemorrhoids, hemorrhages, a more decided gastritis and en- 
teritis may be produced, and sometimes pain in the liver; but pain 
is not a prominent symptom, and is often absent. A moderate 
jaundiced condition may occur in the stage of congestion and early 
inflammation as before mentioned; and in cases far advanced there is 
usually a persistent sallowness, but it is not great. In rare cases 
shortly before death there has occurred deep jaundice with evidences 
of blood poisoning—with purpuric spots, coma, and convulsions ; but 
during the ordinary progress of the developed disease, if decided 
jaundice occurs, some complication should be suspected. Still, some 
of the bile ducts are occasionally obstructed, and a moderate degree 
of jaundice without any special complication may result. The 
urine is generally high colored, and often quite dark in appearance, 
because the coloring matter of the blood is not changed into bile pig- 
ment and excreted by the liver, but is separated by the kidneys. 
The digestive functions are various ; but whatever their apparent 
condition, there is progressive emaciation and debility, and the 
patient at length dies from exhaustion. 
The most characteristic conditions and most conclusive evidences 
of cirrhosis remain to be more particularly noticed, viz., ascites 
without peritonitis, and diminution of the size of the liver, ascertained 
by the diminished area of its peculiar dullness on percussion. The 
congested condition of the abdominal veins gives rise to serous effusion 
in the abdominal cavity, sooner or later, in nearly all the cases. The 
peritoneal sac gradually becomes filled with a yellow serum, often to 
a great extent, and although the fluid may be temporarily diminished CIRRHOSIS—DIA GNOSIS. 
863 
by purgatives and diuretics, or even by diaphoretics, or may be drawn 
off by paracentesis, it will accumulate again, and the dropsy is per- 
sistent. It is at first, and often for a long time, strictly confined to the 
abdomen ; but when there is a large accumulation, from its pressure 
upon the iliac veins, secondary oedema of the legs and feet, and of the 
scrotum and labia, often results. It is distinguished from dropsy 
arising from obstructive disease of the heart, or from organic disease 
of the kidneys, by its being confined to the abdomen, and its extend- 
ing to the lower extremities only as the result of pressure. The press- 
ure upon the renal vessels may be followed by some albumen in the 
urine, but there will be no renal casts, unless there is a complication 
of kidney disease, which by the way is not uncommon. 
Diagnosis.—The method of distinguishing the size of the liver, 
its natural dimensions, etc., has been sufficiently pointed out. 
The diagnosis of cirrhosis is to be made by observing the phe- 
nomena described, and by the history of the drinking of spirits often 
but little diluted. 
Murchison is explicit in the statement of his opinion, though all 
do not agree with him, that true cirrhosis is always produced by 
alcohol. Other forms of atrophy of the liver which have been 
referred to are produced by other causes; and they must be distin- 
guished from this by the history of the symptoms and by the previous 
diseases and conditions. 
It should be distinguished from suppurative phlebitis of the 
liver, which may present similar symptoms to acute interstitial hepa- 
titis ; but this is a rapid disease, death usually occurring in a few 
days. From cancer of the liver it is to be distinguished by exclu- 
sion. 
Fatty liver sometimes occurs in drunkards, in great eaters who 
lead a sedentary life, and in some consumptives. But here the 
liver is sensibly enlarged, and the part presented to palpation is 
soft rather than sclerosed. Hydatid cysts, multilocular echinococci, 
and adenoid tumors may present some phenomena resembling sclerosis, 
but the aggregate symptoms are different, and in all the cases the 
liver is enlarged rather than lessened in bulk. 
The dropsy of cirrhosis is to be distinguished from cardiac or 
renal by its being entirely or chiefly abdominal, while the other 
varieties are general, affecting the upper parts of the body as well ; 
and also by the absence of other evidence of heart or kidney disease. 
When atrophy of the liver arises from contraction of its peritoneal 
capsule, portal obstruction and its consequences may follow; but 
there will be the history of previous peritonitis, or acute inflamma- 
tion in the region, and there may not be the history of spirit drinking. 864 
DISEASES OF THE LIVER. 
In syphilitic atrophy there will be the history of syphilis, of 
chancres, and the constitutional symptoms of this disease. 
When atrophy arises from long-continued passive congestion of 
the liver, from obstructed circulation through the heart and lungs, 
the evidences of disease of those organs will aid the diagnosis. 
The “red atrophy” alluded to has usually a history of malarial 
poisoning, or of dysenteric or cancerous disease, and not that of alco- 
holism. 
The ascites arising from peritonitis, acute or chronic, has the 
history of these conditions—has pain, tenderness, etc., preceding. 
Some cases of chronic peritonitis are produced by alcoholism, and 
sometimes it will be difficult to determine to what extent the disease 
of the liver is responsible for the symptom ; and when there is a large 
accumulation of water in the abdomen, the physical signs determin- 
ing the size of the liver will be obscured. After paracentesis, should 
that be called for, the question of atrophy of the liver and its nodu- 
lated condition can usually be ascertained, and the diagnosis more 
fully made. » 
Prognosis.—The prognosis in this disease is most unfavorable. 
When fully developed, it goes on sooner or later to a fatal result. Its 
continuance depends upon the rapidity of its development, the symp- 
toms it may produce, the complications that may arise, and the power 
of endurance of the patient. Several months usually elapse after 
decided symptoms present themselves, and sometimes a few years. 
Treatment.—The physician is seldom consulted in the early 
stage of this disease, and if he is, it is usually for other symptoms than 
those necessarily pointing to the liver, and the diagnosis is therefore 
not often made sufficiently early to render treatment of permanent 
avail. 
If a patient, habitually indulging in alcohol to any considerable 
extent, complains of nervousness, dyspeptic symptoms, and failing 
strength, cirrhosis should be suspected, and every means resorted to 
to prevent its results. It should be understood that it is not so much 
occasional drunkenness, with periods of comparative or entire absti- 
nence, as daily continuous tippling which produces this and many 
other alcoholic affections. The moral effects of excessive, periodical, 
and frequent drunkenness may be much worse; but, if there be inter- 
vals of sobriety, the physical effects are not so serious as where con- 
stant free indulgence is practiced, though positive drunkenness may 
never have occurred, This can never, from the physician’s stand- 
point, be too clearly presented or too strongly impressed. 
In the treatment of a case developed or suspected, the causal indi- 
cation is the first to be fulfilled. The alcohol must be stopped. But CIRRHOSIS—TREA TMENT. 
865 
the taste and the habit, hereditary Gr acquired, are usually already 
well established, and it is generally difficult to effect the reform. 
From the numerous cases of reformation produced in the habitually 
intemperate by associated efforts, we should, however, be encouraged 
to hope for the success of professional persuasion and authority. 
Not only should the alcohol be cut off in all its forms, but the 
diet should be regulated ; spices and rich dishes should be avoided, 
and a plain and simple, but sufficient, diet should be ordered. The 
desires of the patient should be consulted and indulged within certain 
bounds, but those bounds should not be beyond a simple and reasona- 
ble diet. Exercise in the open air should be enjoined. This is very 
important, as all experience and analogy show. The bowels should be 
kept free by saline laxatives. Small doses of cholagogues may be 
useful, and the alkalies or their salts, with organic acids, may properly 
be prescribed. Mercurials are recommended by Jaccoud, and may be 
proper where the alcoholic cachexia is not too far advanced. 
In this stage of a slow inflammatory action, when the embry- 
onic cells are forming into adventitious tissue, I do not doubt that 
iodide of potassium, in decided and persistent doses, tends to check 
and remove such conditions. Should it derange the stomach or pro- 
duce any injurious effects, they should not be overlooked ; but it can 
generally be well borne in doses of from five to ten or more grains 
three times a day, and, as this disease is chronic, the remedy must be 
chronic also. The iodide of ammonia may be used as a substitute, 
with some bitter infusion, should it agree better with the stomach. 
Should there be great nervous irritability, bromide of potassium might 
be given at the same time in appropriate doses, or substituted for the 
iodide for a time. Iodine frictions may also be applied over the liver, 
or some other form of counter-irritation used. After a time, and 
especially in debilitated cases, the syrup of iodide of iron may be pre- 
scribed. Iodine ointment, especially if enlargement is still the condi- 
tion, should be persevered with. 
Stillingia has been recommended in this stage of cirrhosis, but it 
has not sufficient reputation in this disease to be spoken of with any 
degree of confidence. 
Prof. Bartholow expresses confidence in a “ group of remedies 
which have a selective action on the liver, the metals chiefly, gold, 
silver, copper, arsenic, mercury, and phosphorus, which have the prop- 
erty of improving the nutrition of the liver, if used in a small quan- 
tity for a long period. The most efficient are the chlorides of gold 
and sodium, the corrosive chloride of mercury, Fowler’s solution, and 
phosphorus in the form of phosphites or phosphates.”—(Practice 
Med., p. 150.) 866 
DISEASES OF THE LIVER. 
When the stomach is irritable he advises two drops of Fowler’s 
solution, with two to five drops of tinet. of opium, t. i. d. In other 
eases the chloride of gold and sodium one thirtieth of a grain, or cor- 
rosive sublimate one sixtieth of a grain, as often. The facts upon 
which these opinions are based are not given, but the well known 
effects of mercury in small doses long continued render it credible that 
it may modify the morbid nutrition of the organ, and tend to remove 
the fibroid plastic material which is produced in cirrhosis. Experi- 
ence and analogy would lead us to hope for more beneficial effects 
from iodide of potassium and from mercury, and the alterative effect 
of these articles may be tried in the early stages of this disease. 
When much contraction occurs, no known treatment will avail 
m removing the pathological state. The object of treatment then 
should be to check the rapidity of the morbid processes and increase 
the endurance of the system : in other words, to prolong life and 
make it as comfortable as possible. The appetite and digestion should, 
as far as possible, be conserved and improved, and an easily digested 
and sufficient dietary allowed. Tonics, in some cases, may be useful, 
such as quinine, iron, nux vomica, mineral acids, etc., according to 
the indications. The bowels should be kept well open, and an occa- 
sional purgative will often procure relief and be well borne. 
If a diarrhoea is present, and is severe and exhausting, it may bo 
checked by appropriate remedies, but the dropsical accumulations are 
more rapid when the bowels are confined. 
For the ascites hydragogue purgatives are the most efficient medi- 
cines, but they often debilitate too much, and are not well borne in 
feeble conditions. Diuretics may also be used, such as juniper, broom, 
digitalis, squills, cream of tartar, etc. Fomenting the liver with an 
infusion of digitalis has been recommended, and some advise the use 
of muriate of ammonia, both with reference to its diuretic effect and 
its action on the liver. 
When the breathing is seriously interfered with by the pressure of 
the fluid, tapping must be resorted to, and may be repeated as required, 
but it should be delayed as long as possible, as after the fluid is drawn 
off it accumulates Avith greater rapidity, and the strength often seems 
to be more rapidly reduced. 
Hemorrhage from the stomach or bowels, so likely from the con- 
gestion to occur, should be treated as already advised in cases Avhere 
the blood Aoavs from capillary vessels. Quiet, anodynes, astringents, 
and especially ergotine hypodermically, are indicated. The loss of 
blood may be so great as to prove fatal, but sometimes patients regain 
a. comfortable degree of health for a time, after even a free loss of 
blood. TREA TMENT—HYPERTROPHIC CIRRHOSIS. 
867 
Hemorrhoids and other conditions due to this disease must be 
treated according to their indications. By careful and judicious man- 
agement life may sometimes be prolonged for a comparatively long 
period; and I can but believe that if treatment be instituted suf- 
ficiently early, a curative effect may not unfrequently be realized. At 
least a decided effort should be made to prevent its development in 
those cases where it has not commenced but is threatened. 
In mqre acute or subacute cases of interstitial hepatitis, early anti- 
phlogistic measures may be resorted to: cups, blisters, salines, cathar- 
tics, diaphoretics, etc. ; later, iodide of potassium or bromides, with 
iodine ointment externally. In more gradual cases, besides the hygi- 
enic regulations, milder antiphlogistics and eliminatives will be re- 
quired. The nervous system, when it is much disturbed by with- 
holding the alcohol, may require to be managed with opiates, chloral 
hydrate, and bromides, together with salines, iodide of potassium, or 
minute doses of mercury, as may be borne; iodine externally, and 
sometimes tonics later, will be useful. As much exercise in the open 
air as can be well taken is always important. 
When a decided alcoholic cachexia is present with this local dis- 
ease the case is most discouraging, scarcely admitting of even pallia- 
tion. The retribution for the folly of such indulgence in the use of a 
delusive poison is then sure. Not only the liver, but the kidneys, the 
lungs, the brain, and other organs, may be in similar perverted con- 
ditions. 
HYPERTROPHIC CIRRHOSIS. 
A morbid anatomical condition of the liver under this title has 
lately been more particularly described by Hanot, Charcot, and 
others, and requires here a brief notice. Its causes have not as yet 
been clearly established, and unlike the atrophic variety just con- 
sidered, it is not proven to be dependent upon the use of alcohol. 
In this condition, as its name implies, the liver is enlarged, some- 
times to twice or even three times its normal size ; is less nodulated 
upon the surface than the hobnail liver, and retains its normal form, 
with its sharp anterior edge. It is said to be extremely dense in 
texture, and its interior is largely infiltrated with dense, grayish, 
slightly translucent connective tissue. It does not constitute a dis- 
tinct net-work, but is a diffused growth in which portions of hepatic 
parenchyma are scattered irregularly in small yellowish masses. In 
some parts there is more, and in others scarcely any, of the natural 
structure of the liver, and what there is varies in color from orange 
to green. 868 
DISEASES OF THE LIVER 
The fibroid growth in its minute structure does not differ materi- 
ally from that in ordinary cirrhosis, but it commences from the inter- 
lobular branches of bile ducts which occupy the periphery of the 
lobules. 
Commencing here, the portal vessels are at an advanced period 
involved, and many of the lobules are attacked and destroyed. The 
affected docts, instead of being compressed by contracting exudate, 
are thickened and dilated, though the smaller branches aye often 
blocked up with thin accumulated contents. The liver cells are 
atrophied, colored witli biliary pigment, and often fatty. In this 
form of disease the ducts, notwithstanding their enlargement, are 
chiefly obstructed by the fibroid growth, and not the portal veins, as 
is the case in atrophic cirrhosis. As a consequence, the portal circu- 
lation is less obstructed, while the gall ducts are more blocked up. 
The symptoms differ from those of ordinary cirrhosis and corre- 
spond with the anatomical states. Instead of portal congestion and 
its consequences—ascites, hemorrhages, etc.—there is jaundice occur- 
ring early in the disease, becoming decided and continuing through- 
out its course. 
This icterode condition is followed by all the concomitants and 
results of chronic persistent jaundice. The disease is one of middle 
life, is slow in its progress ; there are the usual derangements of the 
gastro-intestinal organs, gradual emaciation and failure of strength, 
with the blood poisoning of other forms of jaundice, and the final 
failure of vital functions. 
One case, judged to be of this disease in an advanced stage, lately 
came under my observation. It soon after terminated fatally, but an 
autopsy could not be obtained. The patient, a man in middle life, 
had long been accustomed to a rather free use of alcoholic drinks, was 
profoundly jaundiced, the liver was markedly enlarged, and some 
ascites was present. He was anaemic and greatly debilitated, and no 
treatment produced any beneficial effect. 
The sanction of professional authority cannot as yet be given 
to any particular course of treatment in a disease so insufficiently 
observed. 
From what is known of its pathology and symptoms, the treat- 
ment in the early stage should not differ materially from that appli- 
cable to atrophic cirrhosis, and later the jaundiced condition will call 
for eliminative as well as supporting measures. 
Syphilitic hepatitis, already referred to, may occur either in 
children from inherited syphilis, or in adults as secondary to the 
acquired disease. 
In the earlier stages of the deposits of gummata and the hyper- ACUTE YELLOW ATROPHY. 
869 
plasias following it, before the conversion of the latter into fibroid 
contracting tissue, the liver is enlarged, and the condition resembles 
hypertrophic cirrhosis more than the atrophic form ; but, as the dis- 
ease advances, it resembles more the latter. The symptoms vary ; 
sometimes there will be jaundiced conditions, and at others more 
evidence of portal obstruction; and the general functions of the liver 
will be impaired in proportion to the extent of the parts involved. 
There is usually more pain in the part than in ordinary cirrhosis, and 
there will be a combination of the syphilitic and the hepatic cachexias. 
Besides the symptomatic treatment called for by the disturbance of 
the liver’s condition, the antisyphilitic treatment—iodide of potassium 
and mercury—is demanded, as in other forms of secondary syphilis. 
Fortunately cases of this kind are not frequent, even in syphilitic 
patients, and they will seldom occur to one in an ordinary practice. 
ACUTE YELLOW ATROPHY OF THE LIVER.—MA- 
LIGNANT JAUNDICE.—TYPHOID ICTERUS. 
This is a rare, obscure, severe, and generally a rapidly fatal dis- 
ease, accompanied with decided symptoms of jaundice, and evidences 
of failure of the various functions of the liver. 
Its causes are obscure. It occurs more frequently in women than 
in men, and is often connected with pregnancy or the puerperal 
state. It occurs also in some dissipated and syphilitic patients, and 
is said to be more common in rather early than in advanced life. 
The typhus and malarial poisons have been thought by some to have 
to do in its production. 
Symptoms.—Its symptomatic phenomena are marked, though 
not uniform. Its attacks are frequently abrupt, but m some cases are 
preceded for some time by gastro-intestinal irritation and moderate 
general indisposition. 
Among the first severe symptoms are vomiting of coffee-ground, 
hemorrhagic material, intense headache, and great restlessness. 
Delirium, low and muttering, or noisy, and sometimes even maniacal, 
with insomnia, succeeds. There is agitation and tremulousness, and 
often convulsions appear, either local or general—sometimes mere 
rigors, and at others, epileptiform or tetanic. Soon this condition of 
excitement and agitation passes into one of quietness and stupor, and 
this deepens into profound coma, generally with dilated punils and 
stertorous breathing. The pulse during the excitement is subject to 
remarkable variations in frequency ; but as coma sets in it is more 
unif3rmly rapid, and gradually diminishes in force unt-il it can no 870 
DISEASES OF THE LIVER. 
longer be felt at the wrist. The tongue becomes coated, and at length 
dry, brown, or black, with sordes upon the teeth. There is often 
uneasiness and tenderness in the hepatic region ; and a careful exam- 
ination will show more or less diminution of the area of hepatic dull- 
ness. The bowels are usually confined, and as the disease advances 
the discharges, when induced, are free from the color of bile. 
The urine becomes loaded with bile elements, and its urea and 
phosphates diminish or entirely disappear, to be replaced by leucin, 
tyrocin, and extractive matters, which sometimes form a greenish- 
yellow sediment. The skin is often cool and dry; and the jaundiced 
discoloration, which may precede, accompany, or succeed the more 
violent symptoms, becomes marked, but seldom attains a very high 
degree of intensity. Two remarkable features are worthy of special 
notice: a total absence of febrile temperature, which is said to be 
frequent; and a general hemorrhagic tendency. The latter is shown 
in the haematemesis already mentioned, in petechias and extravasations 
of blood beneath the skin, and by hemorrhages from the nose, bowels, 
and other mucous surfaces. 
The termination is almost uniformly fatal, and may occur within 
twelve or twenty-four hours ; but usually it is between the second 
and fifth day from the occurrence of severe symptoms, though it is 
rarely delayed beyond a week. These remarkable phenomena indicate 
the suspension of the liver functions which were enumerated in the 
preliminary remarks on liver diseases, and illustrate the important 
character of those functions. 
Pathology.—The morbid anatomy, which is striking and charac- 
teristic, shows such rapid and extensive changes in the liver structure 
as are incompatible with hepatic functions, and confirms the view of 
the varied functions and important office of this organ in the system. 
Post mortem the liver is found quite often of nearly its natural size, but 
usually it is much shrunken, often to one half and even to one third 
its proper bulk, with the surface wrinkled and flabby. Internally it 
is of a pale yellow color, without evidence of vascular injection, and 
with scarcely an indication of its constituent lobules. The bile ducts 
and gall-bladder contain little or no bile, showing that its secretion 
had been suspended. On examination with the microscope, the 
secreting hepatic cells are found to have almost or entirely disappeared, 
and in their place are deposits of granular matter and oil globules, 
with some bile pigment. Leucin and tyrocin, which the liver has 
failed to change into urea, are sometimes found in the hepatic sub- 
stance and the hepatic veins. Other organs are sometimes found 
affected, but not to a great Extent. The spleen is usually somewhat 
enlarged ; occasionally some fatty change has occurred in the glandu- ACUTE YELLOW ATROPHY—TREATMENT. 
871 
lar epithelium of the kidneys ; extravasations of blood have taken 
place under the surface of the peritoneum, pleura, and pericardium, 
in various mucous membranes, and sometimes in the lungs, liver, 
spleen, and kidneys; and chemical examination shows large quanti- 
ties of leucin and other excretory matters in the blood. 
AVhether the lesions of the liver are primary, or the result of some 
general blood disease, is not positively established; but there seems 
little ground to doubt that the severe and fatal symptoms are chiefly 
due to the hepatic lesions, and Bright and Frerich regard those lesions 
as primary. That they are the most essential elements of the disease 
seems quite clear. The cause of these lesions may be the absorption 
or development of some noxious substance in the blood allied to those 
producing septicaemia or infectious fevers, and these may produce 
morbid effects upon other parts as well as the liver; but the disease of 
this organ is still the great cause of the results which follow. Whether 
the change in the liver is strictly an inflammatory process, or whether 
morbid changes different from those of inflammation occur, is not so 
clear; but that some inflammatory phenomena are present appears 
from the rapidity of the changes and the products which are found. 
The probability of the essential inflammatory character of the disease 
has appeared such as to cause the term “ General Parenchymatous 
Hepatitis” to be applied to it ; but whether this designation without 
much qualification is justified, is a matter sub judice. 
The prognosis, as already intimated, is exceedingly grave, indeed 
is generally regarded as fatal. The earlier stages are more or less 
irregular in their duration, but the last stage follows a more uniform 
course. After the jaundice the rise of temperature and the insomnia 
supervene, and life very rarely continues a week. Five days is about 
the average period. 
Treatment.—The treatment of this malignant form of disease is 
exceedingly unsatisfactory. Various remedies have been recommended 
and tried, among them active cathartics in the early stage, the local 
abstraction of blood and other antiphlogistic measures, and it is possible 
that benefit has arisen from them ; but in the earliest stage it is impos- 
sible to be sure of the diagnosis—a supposed case of the disease may be 
one of common jaundice from catarrh of the ducts—and when the disease 
is fully developed and the malignant character is manifest, no reme- 
dies have been successful. Frerich mentions a case supposed to be of 
this disease, which recovered under the use of cathartics and mineral 
acids. Under the supposition that the disease is a diffuse inflamma- 
tion of the parenchymatous structure of the liver, Bartholow advises 
free doses of quinine, and as it will probably do no harm, and from 
the analogy of its effects in other cases, it is, in my judgment, worthy 872 
DISEASES OF THE LIVER. 
of a trial, especially in those cases where febrile conditions are present. 
Phosphorus is also suggested, given early from the notion of its acting 
specially upon the liver, and with the hope that an antagonism may 
he discovered between the action of this remedy and the disease. In 
a disease so desperate, experimentation of this kind is not only justifi- 
able but commendable. Nothing can be hoped from remedies unless 
early given. Tissues destroyed cannot be restored. However, all 
rational indications should, as far as practicable, be fulfilled. The 
more prominent and distressing symptoms should be palliated, the 
vomiting checked, the hemorrhage arrested, the constipation overcome, 
the action of the skin and kidneys promoted, the stage of excitement 
should be soothed, and during the stage of stupor, coma, and failure of 
the heart’s action, the strength, so far as possible, should be sustained. 
The ordinary means for fulfilling these indications should be used. 
FATTY DEGENERATION OF THE LIVER. 
The liver, like other organs of the body, is subject to fatty degen- 
erations, the fat taking the place of the proper tissues. 
In phthisis the liver not unfrequently suffers in this manner, and 
more or less fatty change occurs in various other diseases of the liver 
itself. When there is a general tendency to fatty degeneration of the 
system, marked by its usual signs, the liver is apt to be affected. 
In fatty degeneration there is lowering of nutritive power, either 
in the system at large or in the particular part involved, as the cause 
of the condition ; and simple loss of functional power, and of all 
form§ of activity, is the result of this degenerative change. The size 
of the organ is not changed in pure degeneration, and there are no 
means of positively distinguishing this condition clinically ; but it 
may be inferred when there is failure of liver function, and when 
fatty changes are found elsewhere in the system. It may also be pre- 
sumed to exist when the functions of the organ are much impaired 
in cases of pulmonary phthisis. 
As in other cases of fatty degeneration, the treatment is support- 
ing. There are no specific remedies, but every means should be 
resorted to for the purpose of improving nutrition—dietetic measures 
and tonics, etc., according to the particular indications presented. 
FATTY LIVER. 
By fatty liver is understood accumulations of fat in the organ, 
which do not,, however, necessarily replace the normal tissues. More fatty liver—morbid anatomy—symptoms. 
873 
or less fat may be deposited in the liver, especially in persons inclined 
to obesity, while the person is in fair health, and without special 
impairment of the function of the organ. 
When, however, the quantity of fat is great, the function of the 
liver is interfered with, and this excessive quantity is the result of 
some morbid process. In some cases there seems to be an association 
of fatty accumulation and fatty degeneration—large quantities of fat 
being deposited, and to a greater or less extent taking the place of the 
normal tissue—the latter being absorbed away by the pressure of the 
fat, or, by a change of nutrition, the fat taking the place of the protel- 
nacious matter of the structure. 
Etiology.—Among the causes leading to these morbid conditions 
are enumerated chronic alcoholism (but where the indulgence is less 
excessive and the alcohol more diluted than in cases of cirrhosis) ; 
excessive alimentation with want of exercise ; some diseases of the 
heart and lungs; certain cachexias—lardaceous degeneration and 
tuberculous conditions ; and in cirrhosis and other diseases of the 
liver fatty conditions are often present. 
Morbid Anatomy.—The morbid anatomy varies in different 
cases, and in different stages of the same case. In the milder and loss 
morbid forms of fatty liver, produced by want of exercise and free 
alimentation, or where there is a disposition to general obesity, the fat 
is probably deposited chiefly in the connective tissue, and the liver is 
enlarged without any change in its proper parenchymatous tissue. 
In other cases, in the early stage, fat globules of small size are 
found scattered in the substance of the hepatic cells. In more 
advanced stages, many of these globules have enlarged by coalescence 
of smaller ones and by fresh deposits ; and this process may go on 
until the liver cells, distended with their oily contents, have much the 
appearance of adipose tissue. 
The deposit of fat is said always to commence at the periphery of 
the hepatic lobules, and is often limited to that part, and when the 
change is more advanced and general, it is most at the surface of 
these divisions. The liver thus affected becomes coarse, dull, opaque, 
and soft, the proper color yielding to that of the fat. The part 
when cut or handled is distinctly greasy. The fat mainly consists of 
olein and margarin, with traces of cholesterin, and in extreme cases 
forty-five per cent, of the whole hepatic substance has been found to 
consist of fat. 
By these accumulations the liver is enlarged, sometimes to a very 
great extent; but the enlargement is generally uniform, and the 
proportions of different parts are nearly preserved. 
Symptoms.—The symptoms of fatty liver will vary in different 874 
DISEASES OF THE LIVER. 
cases. When fat replaces the proper tissue, the function will of course 
be impaired, and in proportion to such replacement. When the fat 
merely accumulates without such replacement, the function is less or 
not at all affected, and no special symptoms may be induced. When the 
accumulation is great, there will be a sense of fullness, weight, and un- 
easiness in the region ; the gall ducts may be pressed upon and a jaun- 
diced condition produced ; and when degenerative processes occur, and 
the liver fails to perform any of its functions, the symptoms already 
referred to as evidences of other structural diseases of the liver will 
ensue. Debility, anasmia, digestive derangements, morbid conditions 
of the urine, etc., will be present. As fatty changes are, however, so 
often associated with other morbid conditions, it will often be impos- 
sible to determine what symptoms are due to the fatty, and what to 
the other changes. 
The enlargement is distinguished by percussion and palpation, and 
its fatty character may be inferred from all the conditions of the 
case, excluding other affections. 
Treatment*.—The treatment of fatty liver will vary in different 
cases. When it depends upon excesses in food or drink, and upon 
sedentary habits, these causes must obviously be removed. A saline 
and eliminative course of treatment, with exercise in the open air and 
sunlight, will be useful. The reverse of the conditions which produce 
enormously fatty livers in geese stuffed with food and kept without 
exercise in the dark, must be insisted upon. 
When it depends upon other diseases of the liver itself, these must 
receive particular attention. The taking chiefly of albuminous 
rather than liydrocarbonaceous foods, tends to diminish the produc- 
tion of fat, and should be advised in these cases where other con- 
ditions do not forbid. There are no specific medicines which have 
an established reputation in this form of disease. The general plan 
of treatment for obesity would be applicable in some cases. 
WAXY, LARDACEOUS, OR AMYLOID LIVER. 
Phenomena and Diagnosis.—This is a degenerative change 
in the liver, in which there is a deposit having the appearance of 
wax, or lard, or boiled starch, and which when treated with iodine 
gives a reaction resembling that of starch. Hence its names. In this 
disease there is much uniform enlargement of the organ, with a 
general condition of angemia and debility, slow in progress, but 
usually progressive and persistent. It is apt to occur in disease of 
the bones and in protracted suppurations, and is sometimes associated AMYLOID LIVER—PROGNOSIS—MORBID ANATOMY. 
875 
with chronic phthisis, with syphilitic clyscrasia, and other cachectic 
conditions. The spleen is usually affected in a similar manner at the 
same time, and not unfrequently the kidnej-s and other organs. It is 
sometimes associated with leucasmic conditions ; and when it reaches 
an advanced stage is almost always fatal. In some cases, however, as 
when it arises from disease of the bones, or from protracted suppura- 
tion, the removal of the original morbid condition will, it is thought, 
arrest the lardaceous degenerative process when not too far advanced. 
Though generally associated and apparently caused by other morbid 
states, it sometimes appears as the original, or at least the principal 
recognizable condition. 
The diagnosis, before sufficient enlargement has occurred to be 
detected by physical examination, is perhaps impossible; and after 
such enlargement it must depend much upon evidences of causation, 
the occurrence of similar degenerations in other parts, upon the 
anaemia and debility which are present, the derangement of the 
bowels, a persistent diarrhoea which is sometimes an attendant, and 
the exclusion of other hepatic diseases. 
Peritoneal dropsy and jaundice rarely attend the disease, and pain 
referable to the region is usually absent. Leucin and tyrocin are 
usually found in the urine, but this is only indicative of the failure 
of liver power from whatever cause, and is not distinctly character- 
istic of a lardaceous liver. It may, however, be taken into the account 
in determining the diagnosis. 
Amyloid liver is particularly to be distinguished from fatty liver, 
cancer, inflammatory enlargements and suppurations, and from 
hydatids. The history, the accompanying conditions, and the par- 
ticular character of the enlargement as discovered by palpation, will 
serve to make the differential diagnosis. 
Prognosis.—This, as already intimated, is exceedingly grave, 
and when the disease is much advanced, is fatal. It is, liowmver, 
thought that some cases have recovered; but the uncertainty of an 
early diagnosis, especially in idiopathic cases, is such as to leave doubt 
on that subject. As before stated, when it depends upon causes which 
are removable, such as suppuration and diseases of the bones, recovery 
is possible. 
Morbid Anatomy.—The morbid anatomy, according to Rind- 
fleisch, is as follows : 
The lardaceous change takes place in what he calls the arterial 
zone of the hepatic lobules, situated midway between their centre 
and periphery, and involves both the minute arteries and capillaries 
of the part, and also the hepatic cells. The morbid process, however, 876 
DISEASES OF THE LIVER. 
soon extends to the central part of the lobules, and after a time to 
the periphery as well. The change is attended with thickening of 
the affected vessels, which also become homogeneous and pellucid. 
There is also considerable enlargement of the hepatic cells, which 
lose their normal appearance and resemble small vitreous masses, 
which in time break down into irregular fragments. 
In its gross appearance the lardaceous liver is smooth, heavy, and 
of a doughy consistence; and if uniformly affected, as is usually the 
case, it presents a homogeneous surface of a grayish tint, with a pecul- 
iar glistening or semi-transparent waxy aspect. It is usually free from 
biliary and sanguineous congestion, and from much moisture. Cir- 
rhotic, fatty, and syphilitic changes are sometimes associated with it. 
The increase in bulk of a lardaceous liver is a slow process, and 
may extend over some years, but the size which it attains is sometimes 
very great; its weight sometimes being from ten to fifteen pounds. 
The cachectic symptoms which occur in cases of lardaceous liver 
may in part be due to the causes producing this disease ; but admit- 
ting the views taken of the functions of the liver to be correct, there 
can be no doubt that its extensive disorganization is sufficient to 
account for the disastrous results which follow. 
If the liver has an important part in the production of blood, 
anrnmia is the natural result of its degeneration; and the general 
failure of power, cedematous effusions, etc., would as naturally 
follow. The co-existence of similar disease of the kidneys, spleen, 
and other organs, would of course add to the general derangement. 
Treatment.—The treatment of lardaceous liver will consist chiefly 
in endeavors to remove the causes which produce it, and to sustain the 
energies of the system. If there be diseases of the bones, suppurative 
processes, malarial poisoning, a syphilitic condition, or other morbid 
states tending to the production of the disease, they should receive care- 
ful treatment. Aside from fulfilling the causal indication, supporting 
and palliative treatment will be required. A proper dietary should 
be prescribed, bitter and ferruginous tonics may be given, and the 
effects of muriate of ammonia, iodide of potassium, syrup of iodide 
of iron and manganese, or of iodide of ammonium, may be tried. 
In one case the muriate of ammonia, in scruple doses three times 
a day, continued for some weeks, wras well borne by the stomach, 
and appeared to produce improvement of the general symptoms ; and 
there was certainly a check in the progress of the disease which lasted 
for some months, after much advancement had been made; but the 
disease at length resumed its course and terminated in the usual fatal 
way. The post-mortem examination showed the lardaceous liver, but 
no other morbid condition was present which would account for the HYDATIDS. 
877 
disease or the consequences which followed. This, as well as some 
other cases which have been observed, appeared to me to be idiopathic, 
rather than symptomatic of any other morbid state. 
HYDATID TUMORS OF THE LIVER.—ECHINOCOC- 
CUS OF THE LIVER.—CYSTIC DEGENERATION 
OF THE LIVER. 
By these terms is meant cystic growths in the liver, produced by 
and containing the scolex of the immature stage of the taenia echino- 
coccus. The minute embryos of this parasite gain access from with- 
out to the intestines, and reach the liver either by the portal veins or 
the bile ducts, and by their presence excite the formation of cysts, 
sometimes one, but often more, which may attain a very great size. 
These growths, then, depend upon the presence of parasites, which 
ultimately undergo a variety of transformations that will not here be 
traced. Various parts of the body are subject to the presence of these 
echinococci and acephalocysts, but the liver is more so than perhaps 
any other organ. Though very common in some countries they are rare 
in this, and their description need not therefore occupy much space. 
In the liver, hydatid tumors are often solitary, but there may be 
two or more ; and sometimes they are in other parts of the abdomen 
as well. They vary much in size, are sometimes very small, when 
they produce no symptoms, but they may be as large as a child’s head, 
and may contain several pints of fluid. They are slow in develop- 
ment, and may continue ten, fifteen, and even, it is thought, twenty or 
thirty years. 
They are globular in form, unless their development is interfered 
with by fibrous bands or some mechanical causes. They seem to 
originate in the hepatic substance, displacing it as they expand, and 
causing a fibroid growth around, which incapsulates them, consti- 
tuting the cyst. This cyst'is filled with a nearly transparent fluid of 
low specific gravity, but containing common salt. This constitutes 
the cysticercus, or the larval form of a variety of tape-worm having 
its common home in the dog and the wolf. From these animals, 
generally from their intestinal excreta, the germs find their way into 
the human body. 
In some cases the hydatid, commencing first as a minute globular 
body, undergoes no change but that of increase of size ; but in most 
cases other cysts are formed in the walls of the primary cysts, which 
often develop and repeat in their growth all the characters of the 
parent hydatid. 878 
DISEASES OF THE LIVER. 
The result, with which we are ncnv interested, is a tumor or 
tumors in the liver, which in time are so large as to be discovered on 
palpation, and in their progress may cause pressure, irritation, and 
inflammation, and thus interfere with the functions of the liver and 
other organs. Not unfrequently the parasites contained in these 
cysts die, when the tumor degenerates and contracts. 
But the cysts may be ruptured, and inflammation and suppuration, 
sometimes of a fatal character, may follow. 
Symptoms.—These tumors seldom produce pain unless by their 
pressure, or when inflammation is excited. Their growth is so grad- 
ual that the parts become accustomed to the pressure, and it is not 
until they attain a considerable size that they produce symptoms or can 
be detected. By their pressure upon the bile ducts they may cause 
obstruction and jaundice, but this is unusual. When situated near the 
hilus of the liver, they may not only obstruct the bile ducts but the 
portal vessels, producing the results of portal obstruction. In case 
of great enlargement a variety of symptoms may be produced by the 
pressure, according to the direction the tumor takes. These can 
readily be imagined and need not be particularly described. When 
the case comes under the observation of the physician, a tumor is 
commonly felt in the abdomen, and the question will arise as to its 
character. Hydatids are generally rounded in form, and tense and 
elastic to the touch, and frequently present a peculiar thrill on per- 
cussion. By placing one hand flat upon the tumor, and percussing 
sharply with the fingers of the other, a peculiar long-sustained tremor 
is felt, which has been compared to the “ tremor felt on an iron rail- 
road bridge when a train of cars is passing over it.” 
A well-defined tumor, evidently connected with the liver, present- 
ing these signs, unattended by pain, fever, or any cachexia, with a 
very slow growth, and which has long continued, can scarcely be con- 
founded with any other affection. It may, however, extend upward, 
and, when of large size, press up the diaphragm and lung, and simu- 
late effusion in the chest, or consolidation of the lower part of the 
lung. Extending downward it may simulate fluid in the peritoneum. 
The history of the case, the descent of the tumor from above down- 
ward, its not extending to the flanks, and the irregular enlargement 
of the abdomen, etc., will distinguish it from this affection. 
It may be distinguished from distention of the gall-bladder by the 
situation and pear-shape of the latter, and by the absence of jaundice. 
Abdominal aneurism is excluded by the absence of the aneurismal 
pulsation and thrill, and by the severe pain so often attending aneu- 
rism ; but if an hydatid tumor is situated over the aorta, a pulsation 
may be communicated to it which may strongly resemble an aneurism. II YD A TIDS— TREA TMENT. 
879 
But a demonstrative diagnosis can be made by obtaining some of 
the fluid by means of an exploring puncture with a hypodermic 
syringe and exploring trocar, or an aspirator. This fluid may con- 
tain fragments of the parasites—the characteristic booklets—or shreds 
of the striated hydatid membrane ; but, without these signs, the 
quality of the fluid itself is characteristic. It is limpid or slightly 
opalescent, it is alkaline, with a specific gravity very slightly, if at all, 
above water ; it is free from albumen and urea, but is strongly impreg- 
nated with common, salt, which throws down an abundant white pre- 
cipitate when treated with a solution of nitrate of silver. Such care- 
ful exploration would do no harm should the tumor be an aneurism, 
or cancer, or anything else, and should, therefore, be resorted to when- 
ever there is doubt. 
Treatment.—The treatment of hydatids of the liver is a matter 
of importance. Several accidents may happen with them, producing 
effects more or less serious, indeed not unfrequently fatal. They may 
burst, and the contents be discharged in situations where they will do 
much harm. There may be suppuration within the sac ; when large 
they may do harm by pressure, and they are seldom cured when left 
to themselves. 
The object of treatment should be to destroy the vitality of the 
echinococci and the parent cyst. Of course no medicine taken into 
the stomach can be supposed to produce that effect. The electric 
current, through the tumor by needles introduced into the 
sac, has been found to accomplish the desired result. 
A better method, however, is to remove the fluid by aspiration, 
which has been found to be successful in destroying the parasites. 
The operation is simple, and usually devoid of danger. The aspira- 
tor should be introduced at the point nearest the surface. If not suc- 
cessful, or if another tumor should make it* appearance, the operation 
can be repeated. Injecting the cyst with a very weak solution of 
iodine has been advised, and if the simple withdrawing of the fluid 
should fail, this might be tried. 
If an hydatid sac should suppurate, it should be opened with the 
proper precaution and treated substantially like an hepatic abscess, 
which, in fact, it has become. By a careful examination of the pus, 
some of the minute hooklets, which are peculiarly indestructible, may 
be found, and these would determine the hydatid origin of the 
abscess. 
The occurrence of other accidents, such as rupturing, or pointing, 
or pressing in deep and inaccessible directions, producing inflamma- 
tion, pain, etc., must be treated by palliative measures, according to 
symptoms ; but the aspirator must be brought into requisition when- 880 
DISEASES OF THE LIVER. 
ever available, and in most cases this very useful instrument can be 
made so. 
After the evacuation of a large cyst by this instrument, a bandage 
should be applied about the body to keep the walls as closely together 
as possible, and the patient should be kept very quiet. Should even a 
moderate quantity of fluid escape into the peritoneum, severe perito- 
nitis would be likely to follow. It should be mentioned that a serous 
fluid is generally exuded into the sack after the operation, and often 
distends it to its former dimensions ; but this fluid destroys the life of 
the parasite, and when this is accomplished'the fluid will generally be 
absorbed and the cyst ultimately become obliterated. A repetition of 
the operation is seldom necessary. 
In places Avhere dogs are numerous, and where, without proper 
precautions as to cleanliness, they are in intimate relations with 
human beings, hydatids are common. In Iceland they produce a 
large proportion of the mortality ; and in some other localities where 
dogs abound, and their excrements become mingled with the dry 
dust of the streets, germs are taken into the lungs, and hydatids are 
developed there in numerous cases. These facts suggest the prophy- 
lactic measures—the avoidance in every way of the excrement of 
dogs. 
Simple cysts are sometimes found in the liver ; and are unfre- 
quently in connection with cysts in the kidneys and other parts of 
the body. 0 
They vary in size from simple points to that of an orange. They 
are sometimes solitary, and are then usually situated near the centre 
of the anterior edge of the organ. Sometimes they are present in 
very large numbers, variously grouped, and of different sizes. 
Neighboring cysts sometimes coalesce, forming more irregular single 
ones. They have generally thin walls, which are lined with pave- 
ment epithelium, and are usually filled with a transparent serous 
fluid. Some of the smaller cysts contain a darker gluey mass, similar 
to some cysts found in the kidney. 
These cysts have no clinical history, and as a rule are only recog- 
nized post mortem. They contain no echinococci, and should not 
be confounded with hydatids. 
The liver fluke—distoma liepatica—a leecli-like parasite of two or 
three inches or more in length, has been found in the human liver 
occupying the biliary ducts. These parasites in some situations are 
often found in sheep, producing in them a peculiar form of anaemic 
disease ; but in the human subject the clinical history of their effects 
is unknown ; and this simple mention of the subject is sufficient in a 
strictly practical work. CANCER. 
881 
CANCER OF THE LIVER. 
This is not an uncommon affection. The liver is sometimes the 
original seat of a cancerous growth, but much more frequently the 
disease in this organ is secondary. It is very common in cancer of 
the stomach, as has already been mentioned. After the extirpation 
of cancerous tumors in other situations, the liver is not unfrequently 
the seat of a new development. 
All the different kinds of cancer—cerebriform, scirrhous, colloid, 
and melanotic—are found in this organ. There are sometimes distinct 
nodulated tumors, hard or soft, of different sizes, or there may be a 
combination of both ; and at other times, but more rarely, there is 
extensive and nearly uniform cancerous infiltration. The liver then 
often attains a large size, sometimes nearly filling the abdomen, and 
presenting, on 'post-mortem inspection, a marbled appearance with 
many shades of color. 
When cancerous tumors come to the surface of the liver, they 
generally approach to a circular form, and as they grow more at the 
margins than in the centre, they are apt to present a cupped appear- 
ance, with a depression in the centre, appreciable to the touch. 
When observed, this appearance is quite characteristic, and will aid 
in the diagnosis. It is not always present, however. Springing from 
a harder mass beneath, soft, elastic points are frequently observed; 
and this too is quite characteristic of cancer. While the marginal 
growth is going on, in the central part the process of disintegration 
and decay may commence, and on cutting the tumor through, a 
cavity may be found filled with a disintegrated mass or a watery or 
milky fluid. 
The cerebriform cancer is the kind most frequently met with ; 
but besides the others already enumerated, cylindrical-celled epithe- 
lioma or adenoma, secondary for the most part to the same disease of 
the stomach or intestines, is sometimes found. There may be distinct, 
independent tumors, but the change seems more particularly to affect 
the capsule of G-lisson and the interlobular tracts, and sometimes fol- 
lows up the ramifications of the portal vessels in continuous prolonga- 
tions, or developing here and there moderate-sized tumors. In cancer 
of the omentum, the liver is apt to be secondarily affected ; the mor- 
bid process being propagated along the capsule of Glisson, involves 
and compresses the veins and ducts, obstructing circulation or causing 
jaundice. Cancerous enlargement of lymphatic glands in the region 
may occur, and interfere with the vessels and their circulation. 
The symptoms of malignant disease of the liver are not wfidcly 882 
DISEASES OF THE LIVER. 
different from those which attend other structural diseases of the 
organ which have been described. There are alterations in the form 
and size of the organ, with local pain and tenderness—the latter not 
so much in the tumor itself, as in its surroundings. There is impair- 
ment of functional activity by pressure upon, and involvement of the 
hepatic structure; sometimes there is mechanical interference with 
other organs; there is impairment of general nutrition; and sooner 
or later the cancerous cachexia appears. 
The change in form and size has already been indicated, and a 
careful examination will detect the peculiarities. The diagnosis will 
be obscure early, and it will be impossible in a given case to deter- 
mine the commencement of the disease. It is much more easily dis- 
tinguished when a primary cancerous disease has been present eise- 
Avhere. Then any change in the condition or functions of the liver 
will at once §xcite suspicion. No definite diagnosis, however, can be 
made until a tumor or enlargement is discoverable, and then the 
peculiar characteristics will be noticeable, and the diagnosis may be 
arrived at. 
The disease, like every other form of internal cancer, is always fatal; 
and usually within six months from the time of detection.* 
Diagnosis.—Its steadily and rapidly progressive character will 
constitute one means of diagnosis. When a biliary duct of consider- 
able size is obstructed by a cancerous growth, decided jaundice may be 
induced ; and in a case recently under observation, where a scirrhous 
tumor was found to have completely obstructed the common duct, 
the jaundice for some ten days before death was exceedingly deep and 
intense. • 
Although the pain, the cachexia, and the tumor of the liver are 
* This statement, at present, must be regarded as justifiable, though supposed 
cases of cure have been reported. One remarkable case has lately been stated to 
me from an entirely reliable non-professional source, but which occurred under 
very competent and even eminent professional observation. 
A lady of distinction was affected with a cancerous growth of the uterine cer- 
vix, which was removed by a surgical operation. 
Soon after, a tumefaction of the liver commenced, which was pronounced can- 
cerous by three eminent practitioners. 
The husband, a gentleman standing high in the scientific world, requested a 
trial of the cundurango, an article which a few years ago produced so much sensa- 
tion as a cure for cancer. It was used freely, and in a few weeks the tumor dis- 
appeared. The article has beencontimied since, and the lady, after some three 
years of its use, is now in fair health. Whether there was an error in diag- 
nosis it is impossible to say ; but the entire failure of the remedy to produce any 
effect on cancer in numerous other cases destroys confidence in its virtues, if it 
does not prove it useless. BILIARY CALCULI—PHENOMENA. 
883 
generally present, death may in exceptional cases result when none 
of -these conditions are marked. When the cancerous degeneration is 
in the interior of the organ there may be no pain or appearance of a 
tumor, and no perceptible enlargement; and occasionally the flesh 
keeps up, with an absence of the special cachectic appearance, till near 
the last. Jaundice is frequently absent; and dropsical effusion in 
the peritoneum, though sometimes occurring, is generally not marked. 
Carcinoma of the liver should be distinguished particularly from 
chronic abscess and inflammatory induration, from hydatids, and 
from amyloid degeneration and enlargement. The nodulated, irregu- 
lar enlargement, the history, the persistent development, and the can- 
cerous cachexia will serve to distinguish it from other affections. In 
those rare cases where the cancerous infiltration is uniform there may 
be difficulty in distinguishing it from an amyloid liver, but there is 
generally a history of cancer elsewhere which will aid the diagnosis. 
Treatment.—The treatment of cancer of the liver must be symp- 
tomatic and palliative. The pain or soreness during the earlier stages, 
when moderate in degree, may be relieved sufficiently by external ano- 
dyne applications, and the internal use of belladonna, conium, or hyos- 
cyamus. For the severer cases and the latter stages, opium and its 
preparations are more efficient and should not be withheld. Whatever 
particular symptoms may appear should receive proper attention. 
If peritoneal effusion is too great to be borne, tapping, rather than 
the administration of hydragogue cathartics, should be resorted to. 
Measures should be used to keep up the strength and endurance of 
the patient; a good diet, and often tonic medicines—the object being 
to prolong life and relieve suffering as much as possible. Specific 
remedies, such as the cundurango and Chian turpentine, may be tried 
when borne without injury, but the effects are too doubtful to inspire 
much hope. 
BILIARY CALCULI.—GALL-STOYES. 
Phenomena.—These are concretions formed in the gall-bladder 
or the bile ducts, from the elements normally held in solution in the 
bile. There are several varieties, depending on their composition. 
Some are composed chiefly of cholesterin, some of cholochrome, 
some of bile acids, some of fatty acids, and some of carbonate of lime. 
A large proportion, however, are mixtures of two or more of these 
elements in varying but considerable quantities. 
Cholesterin is the most abundant ingredient—on an average 
seventy to eighty per cent, of the entire material—and calculi com- 
posed of this alone are light colored, have a somewhat crystalline frac- 884 
DISEASES OF THE LIVER. 
ture, and readily float upon water. Most of these gall-stones, how- 
ever, are of a yellowish brown color, though some are reddish or 
greenish black, varying in specific gravity, most being lighter, but 
some heavier, than water. They vary in size from small granules to a 
mass which will nearly fill the gall-bladder, though such extreme 
size is very unusual. They seldom exceed the size of a pigeon’s egg, 
and the most common size is aboht that of a beech nut. There is 
sometimes a solitary one, but generally they are multiple, and some- 
times exceedingly numerous, including the smaller ones, amounting 
to hundreds. They may be all collected in the gall-bladder, or may 
be in groups in dilatations of the ducts, or may be scattered in differ- 
ent parts, isolated from each other. When isolated they generally 
assume a rounded form, but when together they take more irregular, 
and ofteu somewhat angular shapes.; and commonly have one or 
more facets from pressure against each other. They are usually 
smooth upon the surface, but sometimes granular and rough, and 
most of them have a soapy feel. Cut through so as to expose the 
interior, they are sometimes uniform in appearance, though in other 
cases there is a centre mostly composed of pigmentary matter, some- 
times shrunken in appearance. Around this is a zone of variable 
thickness which is more homogeneous, but marked with radial lines, 
and around this still another larger zone concentrically striated. 
The different laminae often differ in composition, and the outer shell 
of a large calculus is often composed largely of the salts of lime. 
The cliolesterin in the bile is normally held in solution by the 
taurocholate of soda. When this latter is deficient, precipitation of 
the cliolesterin is the result; but this is in small crystals, and would 
pass off through the jlucts with the bile provided no obstruction 
existed. However, when retained in the ducts or long in the gall- 
bladder, aggregations occur and calculi are thus formed. The color- 
ing matters, which often form the nucleus of the gall-stones, are 
detained from similar causes, and similar results follow; but doubt- 
less the morbid quality of the bile, as well as the condition of the 
ducts, contributes to the production of the calculi. According to 
Jaccoud, the most frequent cause of the formation of these calculi is 
the partial decomposition of the biliary fluid by the mucus cast off 
in inflammation of the ducts and gall-bladder, diminishing its solv- 
ent power. When a calculus is formed, its presence in the biliary 
passages both excites irritation and inflammation, and causes obstruc- 
tion of a free flow of the bile ; and hence one calculus is so likely to 
be followed by another, and large- accumulations quite frequently 
occur. 
The results of biliary calculi vary. Not unfrequently they pro- BILIARY CALCULI. 
885 
duce no symptoms, as they are sometimes found in the gall-bladder or 
bile ducts, post mortem, when their presence had not been suspected. 
When, however, they pass from the gall-bladder or the deeper parts of 
the liver, where they may have been long imbedded, into the ducts, 
and are in course of exit, and especially when in the common duct, 
they often cause severe attacks of pain, or fits of the most severe 
“ bilious or hepatic colic.” The symptoms of this are a severe, sud- 
den, often catching, tearing, or burning in the region, coming on in 
paroxysms, or with marked exacerbations, often accompanied with 
faintness, retching and vomiting, a depressed pulse, and not (infre- 
quently rigors, commonly followed by more or less tenderness and a 
jaundiced condition. The pain is sometimes not as severe, and it 
generally radiates more or less to the umbilical region or lower part of 
the abdomen, to the back or top of the shoulder; and often a severe 
sense of tightness or constriction is felt. The obstruction of the ducts 
by the calculus is not always sufficient, however, to cause jaundice, 
and the calculus often passes into the intestine with sudden relief of 
the pain and rapid subsidence of all the symptoms. The calculi may 
then be found in the stools, which will be the only absolute proof of 
their passage, or, indeed, of their existence. This search, in such 
cases, should be made. The stools, for some days afterward, should 
be mixed with water, and should be reduced to a liquid state, by 
stirring with a stick, and, when poured out upon the ground or passed 
through a sieve, the calculi, if present, will be discovered. 
Sometimes fits of pain come on, lasting for hours or a day or two, 
and gradually subside without the sudden relief, and without the pas- 
sage of a calculus. The paroxysms are then likely to be repeated 
before long, and when a calculus passes which has facets upon it, 
others are left behind, and other similar attacks are liable to occur. 
In some cases the pain may suddenly cease by the calculus slipping 
back into the gall-bladder or passing into a more distensible portion of 
the duct, and ceasing its motion. The attacks, in these cases, are 
liable-to be soon renewed. Inspissated bile, or calculi but feebly con- 
solidated, may produce similar symptoms, and, when passed into the 
intestines, may be disintegrated so as not to be recognized in the 
stools ; or calculi passed from the liver may be lodged for an indefi- 
nite period in the caecum or other part of the intestines, so that find- 
ing no calculi in the stools is not proof of their non-existence, while 
finding them is demonstrative of the diagnosis. 
In cases where the calculi are in the gall-bladder they may remain 
there and become impacted, causing inflammation of that part, with 
more steady pain and soreness, with febrile symptoms ; and suppura- 
tive and ulcerative processes may be induced. Sometimes the calculi 886 
DISEASES OF THE LIVER. 
and the pus at length pass through the duct and are discharged from 
the bowels; but in other cases an ulcerative process may cause a rup- 
ture of the gall cyst, with passage of its contents into the peritoneum, 
or adhesions may form and the matter may take various courses—■ 
sometimes into the colon, the stomach, or other parts of the alimen- 
tary canal, etc., or through the abdominal parietes. The calculi may 
become impacted within the liver or after leaving it, and similar inflam- 
matory, suppurative and ulcerative processes may follow. These per- 
forating processes may entail protracted suffering, or more speedily 
prove fatal. A complete obstruction of the common duct is also fol- 
lowed by fatal results. Occasionally, though rarely, death is produced 
by the shock of an attack of the severe, agonizing, paroxysmal pain, 
vomiting, etc., which constitute the biliary colic, this final event 
being preceded by convulsions, sometimes by great depression, colliq- 
uative sweats, and collapse. In the ordinary cases, though the pain 
is severe and the vomiting may be very troublesome, there is usually 
but little fever, though a degree of soreness follows, and commonly, 
after a day or two, more or less jaundice occurs. 
Not unfrequently, especially where gall-stones are impacted in the 
liver, an enlargement of that organ becomes sufficient to be detected 
by a physical examination. This would be due partly to the accumu- 
lation of calculi, and partly to the congestive and inflammatory swelling 
and the hyperplasias likely to result. 
In biliary calculi two kinds of pain, it will be observed from the 
preceding statement, are felt, viz., the paroxysmal agonizing pain, 
indicating the movements or passage of the gall-stones ; and the con- 
stant dull pain, indicative of the local irritative and inflammatory 
effects produced by the prolonged presence of the calculi in the liver, 
gall-bladder, or ducts. 
Attacks of colic from calculi are to be distinguished from liepa- 
talgia or neuralgic pain in the liver, from gastralgia and enteralgia, 
and from ordinary colic from improper ingesta, etc. The differential 
diagnosis is to be made by observing the locality of the pain, by the 
absence of soreness, of jaundice, and of calculi in the stools in the 
neuralgic pains, and by the history of the case! These attacks may 
be confounded by a superficial observer with peritonitis ; and in some 
cases peritonitis follows an attack. The symptoms of this latter con- 
dition need not again be described. 
The diagnosis of gall-stones, when not producing attacks of severe 
pain, is obscure, and their presence can scarcely be distinguished 
from some other liver affections. 
Prognosis.—A favorable opinion can usually be given when an 
attack of hepatic colic occurs, but fatal results may follow ; and the BILIART CALCULI—PROGNOSIS— TREATMENT. 
887 
prognosis as to complete recovery from the disease—the expulsion of 
the calculi and relief from further attacks—is uncertain. 
Treatment.—The treatment of biliary calculi is divided into 
that of the paroxysms of pain they induce, and that for a prevention 
of their formation and for the relief of the more permanent morbid 
states with which they are associated. 
The paroxysms, which are often the first marked indication of the 
existence of gall-stones, are to be treated by fomentations or the 
warm bath, and the free administrations of anodynes or anaesthetics. 
Free and repeated doses of an opiate, generally morphine hypodermi- 
cally, will be required, and when this is not sufficient to keep the 
pain within the bounds of endurance, the effect may be aided by the 
inhalation from time to time of ether or chloroform. These anaes- 
thetics may be used in quantities less than are necessary to produce 
complete unconsciousness, but sufficient to control the spasmodic 
action and the severity of the pain. 
Where opium is not well borne, belladonna may be substituted, 
and in some cases it succeeds better—producing, it is thought, a more 
relaxing effect than the opiates. The latter, however, are very gener- 
ally more reliable and efficient, and, as a rule, should be used. A 
combination of morphine and atropia gr. of morphine and gr. 
of atropia at a dose, used hypodermically—has been advised, and is 
perhaps still more efficient. 
Large draughts of water, as warm as can be taken, made alkaline 
by bicarbonate of soda, will act as an internal fomentation and cor- 
rect any acidity that may be present in the stomach. If rejected, the 
draught should be repeated, as it often renders the vomiting less 
distressing. 
Sulphuric ether and the oil of turpentine, three parts of the former 
to two of the latter, formerly had a reputation and were supposed to 
act as solvents to the calculi; but they certainly cannot be supposed 
to be brought in contact with them in sufficient quantity to have any 
effect by that mode of operation in relieving a paroxysm; and it is 
doubtful whether they possess any useful virtues in these cases. From 
half a fluid drachm to a drachm was advised as a dose, and the smaller 
quantity was directed to be taken every morning for a year or more. 
For the relief of the paroxysm, and as a means of expelling the 
calculi, the late Dr. Z. Pitcher, of Detroit, advised large enemas of 
tartar emetic and laudanum, in a proper vehicle (a drachm of lau- 
danum with from three to six grains of tartar emetic in a pint of water) 
producing in this way thorough relaxation and an anodyne effect, to be 
followed soon after by a very large quantity of olive-oil by the stomach. 
This course has still a local reputation of being peculiarly successful. 888 
DISEASES OF THE LIVER. 
The very large doses of olive-oil have been so often reported as followed 
by the expulsion of biliary calculi as to render the remedy worthy of 
trial. As soon as the pain is checked by anodynes, and the stomach 
will retain it, from four to six or eight ounces, or even more, of the 
oil is to be given, and when the cathartic effect occurs, the gall-stones 
are not unfrequently found in the evacuations. The dose after 
several hours may be repeated if necessary. 
But however important the treatment of the paroxysms—and by 
the judicious use of the means mentioned very great relief can gener- 
ally be produced—the preventive treatment, or the removal of the 
calculi and of those morbid conditions of the liver, the bile, and the 
general system which constitute the real disease, is more important 
still. Efforts may be made, during the interval of the paroxysms, 
to remove the calculi ; and, besides other means, the method of Dr. 
Pitcher may be tried, and repeated at proper intervals, if not at first 
successful. 
The first object to be aimed at is the correction of the general 
health, and the removal of such pathological conditions of the liver 
as may be detected. 
The conditions of the digestive organs should receive attention. 
The alimentation and general habits should be regulated. A simple, 
moderate, and easily digested diet, containing but little starchy and 
fatty matter, must be enjoined. 
Frequently a course of small and repeated doses of mercury, as a 
grain or two of blue mass every night, for a week or so, and then less 
frequently, or in smaller doses, will be found useful; or the twentieth 
or tenth of a grain of the biniodide of mercury once a day, continued 
for one, two, three, or more weeks, but not carried to the production of 
salivation or anaBmia ; and when the bowels are kept free with saline 
laxatives, most certainly this treatment is often followed by good 
effects. On the supposition that some slow congestive or inflamma- 
tory action has been going on in the liver, producing hyperplasia of 
the ducts or of the tissues in their neighborhood, obstructing the free 
flow of bile, and by its detention thus favoring precipitation of its 
solid constituents; or on the supposition that its secretion is abnor- 
mal, and the bile itself has not its proper composition or proper pro- 
portion of ingredients ; or regarding the catarrhal inflammation and 
its resulting mucus as producing changes in the bile and diminishing 
its solvent power, we may account for the good effects which experi- 
ence teaches that mercury so often has in such cases by modifying 
these conditions. 
Podophyllin, euonymin, lcptandrin, etc., may also, by exerting a 
modifying influence upon the liver’s secretion, correct morbid states BILIAR Y CALCULI— TREA TMENT. 
889 
which tend to the production of calculi, and these articles are be- 
lieved often to do good. 
But alkalies, especially soda, and diluents are most to be relied 
upon. Both theory and experience point to their use. As cho- 
lesterin is believed to be kept in solution by the taurate of soda, sup- 
plying one of these ingredients favors that action ; and the free use of 
diluents certainly renders the bile more liquid, as experiments upon 
animals prove, and the greater liquidity of the bile must tend to keep 
its solid constituents in a dissolved state and prevent precipitation. 
Theoretically, the cholate of soda would be specially indicated ; and 
this has been recommended by different practitioners. The dose pre- 
scribed has been from five to seven or eight grains twice a day, to be 
suspended from time to time and for considerable periods, if gastric 
irritation occurs. It has not yet been sufficiently used to test thor- 
oughly its efficacy. 
The hydrated succinate of the peroxide of iron, an ounce and 
a half to six and a half ounces of water, a table-spoonful after each 
meal—the remedy to be continued for several months—has been 
recommended ; but, as in the case of the preceding remedy, its prac- 
tical utility can hardly have been sufficiently tested. Both of these 
articles are perhaps worthy of further trial. 
When alkalies are used for a long time, they must be given so as 
to interfere as little as possible with digestion, and the salts with 
organic acids should, as a rule, be preferred. 
The acetate, the tartrate, or the citrate of soda, given after diges- 
tion is completed and in free solution, should be persevered in. Even 
if these articles do not act as solvents upon calculi already formed, 
they tend to prevent their formation, and should be continued faith- 
fully. Phosphate of soda, in doses of from sijss to 3j, in a large 
solution before each meal, for several months, is particularly advised 
by Prof. Bartholow, and may be quite as useful as the other salts of 
soda recommended. If decomposition of the salt takes place in the 
system, the phosphorus may exert some peculiar effect upon the liver, 
and the soda may produce its peculiar alkaline effect on the bile. 
W hatever its mode of action, experience seems to have shown that a 
long, persistent use of this salt is often followed by decided beneficial 
effects. 
Other salines, particularly the sulphate of soda, which, according to 
the experiments of Dr. Rutherford, markedly increases the flow of bile, 
will also be of service. The waters of Carlsbad, so celebrated in the 
treatment of biliary calculi, contain this salt as their chief ingredient. 
The “cure” at this favorite spring consists in drinking early in the 
morning, an hour or more before breakfast, a large quantity of this 890 
DISEASES OF THE LIVER. 
water, sufficient to produce a laxative effect; and this is pursued for 
some weeks. Other alkaline and saline springs have a reputation in 
these cases, and hot spring baths cause absorption of water from the 
surface and wash out the system. 
Whatever else is done, the free drinking of water should be prac- 
ticed. Habits of out-door exercise in pure air are particularly im- 
portant. 
Special symptoms should be met, as they arise, with appropriate 
remedies. 
JAUNDICE.—CHOLiEMIA. 
By jaundice is understood, as heretofore stated, the presence of 
bile in the blood, the tissues, and the urine, and generally a defi- 
ciency of it in the alimentary canal and in the alvine discharges. 
The icterode or jaundiced condition has already been spoken of 
as a symptom of various pathological states, and some remarks have 
been made upon its pathology as it presents itself in different condi- 
tions. A few more observations of a practical character, especially 
upon its diagnosis and treatment, seem to be called for. 
The general phenomena—the yellowness of the skin, the adnata, 
and other tissues ; the presence of bile elements in the urine; the 
dyspeptic symptoms; sleepiness, heaviness, etc., and occasional evi- 
dences of severe blood poisoning, have been mentioned. Usually, 
however, other symptoms, due to the pathological conditions of which 
the jaundice is one of the expressions, are present. Many of these 
symptoms were also pointed out when the diseased states producing 
them were described. 
Diagnosis.—In the diagnosis of a case in which the icterode con- 
dition appears to be present, the tracing out of all the pathological con- 
ditions is required ; but to distinguish the jaundiced condition from 
all the appearances resembling it is important. There are several 
diseases presenting appearances more or less simulating jaundice, for 
which it may be mistaken, and from which it should be differentially 
diagnosticated. 
1. Chlorosis. In this there is a yellowish skin, but it has a green- 
ish shade, and the eyes instead of being yellow are pearly white; 
there is pallor of the prolabia, anaemic murmurs of the heart, and 
usually amenorrhoea. The freedom of the urine from bile is the most 
conclusive test, and the examination of this secretion in a doubtful 
case should never be neglected. 
2. The cancerous cachexia often presents a degree of yellowness of 
the skin, but it is a grayish yellow, with often a greenish tinge, not JA UNDICE—DIAGNOSIS. 
891 
as deep a color as is usual in jaundice, and the conjunctiva and the 
urine are clear. Some other visceral diseases may cause sallowness, 
but without jaundice. 
3. In malarial fever, long continued, a yellowness of the skin is 
seen, but if the eyes and urine are clear, a jaundiced condition is not 
present. Jaundice, however, often complicates malarious diseases. 
4. The lead cachexia produces a sallow complexion, hut the color 
is different from jaundice, other evidences of the lead poisoning are 
present, and the clear eyes and urine are again important diagnostic 
features. 
5. Fatty degeneration of the skin, in persons of light complexion, 
presents an appearance much resembling moderate jaundice. There 
is also not unfrequently an amount of yellowish subconjunctival fat, 
giving a yellow appearance to the eyes. This change of color comes 
on slowly, there is general and persistent debility, and the urine test 
of jaundice is absent. 
6. The yellowness of the skin of infants three or four days old 
resembles jaundice, and is often called so ; but it depends, usually at 
least, upon a change in the blood in the skin, and differs from 
jaundice. 
7. The bronzed skin of Addison’s disease may bo mistaken for 
jaundice. The color, however, is darker, with less of a yellow tint; it 
approaches gradually, is less uniform over the body, and the eyes 
and the urine are again clear. 
8. Exposure to the sun in hot climates produces a color which may 
suggest jaundice ; but the absence of other symptoms of jaundice, 
and the urine test, will prevent confounding the conditions. 
9. The change in the pigmentary condition of the skin in differ- 
ent parts of the body, called cholasma or “ liver spots,” does not con- 
stitute jaundice ; and the mossy color of the face in some cases of 
anaemia, pregnancy, etc., differs widely from jaundice ; and both of 
these should readily be distinguished from it by the tests of the eyes 
and urine already repeatedly mentioned. 
10. Jaundice may be feigned by coloring the skin with turmeric ; 
but the eyes cannot be colored, and the urine will not contain bile. 
11. The color of the urine, as will be noticed, is an important 
indication of jaundice, but there may be other coloring matters in 
the urine besides bile. Blood especially gives the urine a dark color, 
and the particular microscopic and chemical tests must be used. The 
blood corpuscles can be seen by the microscope ; and when bile is 
present, the peculiar play of colors when treated with nitric acid, and 
the other special tests for bile pigment and bile acids, must be 
observed. 892 
DISEASES OF THE LIVER. 
In jaundice, not only the skin and eyes, but all the tissues of the 
body may be tinged with bile, and it may be detected in the blood ; 
and not only does the excretion from the kidneys contain bile, but 
often the perspiration also, and in such quantity as to give a marked 
yellow stain to the linen. 
The tint of the skin varies from a light yellow to a deep olive hue 
is often deeper in some situations than in others ; and sometimes a 
bronzed color is seen. 
There is a bitter taste in the mouth, with deranged appetite and. 
digestion ; a slow pulse, sometimes twenty or thirty beats below the 
normal ; often a yellow vision, more or less debility, and not unfre- 
quently quite decided cerebral symptoms; but these latter are gener- 
ally due to other conditions than the mere retention of bile. The 
failure of the metamorpliic function of the liver—failure to prepare 
effete matters for elimination—and their retention in the blood and 
tissues are more likely to be the cause of the cerebral disturbance. 
The two classes of jaundice are to be borne in mind : the one in 
which there is a mechanical impediment to the flow of bile ; and the 
other in which there is no such impediment. The pathology of the 
first is more clear. That of the second has points which are still in 
dispute, but which have been sufficiently pointed out. 
Treatment.—In the treatment of jaundice the pathological con- 
ditions must govern ; and these have been dwelt upon. But the symp- 
toms must at the same time be palliated. There are two classes of phe- 
nomena which require attention in removing the symptomatic effects 
of the pathological conditions—or the jaundiced state. These are, 1st. 
Those arising from bile in the blood and tissues; and 2d. Those from 
absence of bile in the alimentary canal. For the first condition— 
bile in the system—eliminatives are indicated—cathartics, diuretics, 
diaphoretics and cholagogues. Various articles under each of these 
heads have a reputation, and properly employed are useful. For the 
second—a want of bile in the alimentary canal—ox gall in capsules is 
the chief remedy. It is thought that bitter tonics—quinine especially 
—and alkalies may to some extent supply the place of bile in the intes- 
tines ; but the bile of the ox contains all the essential elements of 
human bile, and is exactly the article needed to aid the digestive 
processes, which the secretion of the human liver accomplishes. 
The cholate of soda, an element of the bile, has also been pre- 
scribed in doses of ten grains three times a day. This and the bitters 
and alkalies may be used as aids to the intestinal digestive process, 
especially in the absence of the oxgall. 
It should be borne in mind that when the ductus communis chole- JA UNDICE—TREATMENT. 
893 
dochus is obstructed, the pancreatic secretion is prevented from enter- 
ing the intestine, as well as the bile ; and this may suggest the use of 
animal pancreatin as well as oxgall; and it is impossible to say how 
much influence the retention and reabsorption of the pancreatic fluid 
may have upon the system. The possibility of morbid effects from 
the presence of this secretion in the blood also suggests eliminatives. 
When the liver is distended by bile in the ducts, and the gall 
bladder is full and tense, giving rise to pain and irritation, the suf- 
fering may be palliated by anodynes and fomentations, and the taking 
of much fluid should be avoided. The larger the quantity of fluid 
taken, the larger will probably be the bulk of bile secreted. 
It must not be forgotten that jaundice is a symptom of a variety of 
pathological conditions, the overcoming of which may require a variety 
of means, and that it cannot be properly treated by its name. The 
treatment for the common form of jaundice arising from catarrh 
of the bile ducts has been given. Various other pathological con- 
ditions producing jaundice among their effects, have been treated of, 
and need not be further discussed. 
When jaundice arises from faulty innervation, nerve stimulants or 
nerve sedatives, according to the condition, may be called for. If 
from deficient oxygen, the means for supplying it are to be used— 
fresh air, proper exercise, etc.—and some medicines appear to promote 
oxidation in the system, and among them are chlorate of potash and 
nitro-hydrochloric acid. 
If jaundice arises from an excessive secretion of bile, flooding the 
stomach and bowels and being absorbed in excessive quantities from 
their surface, emetics and cathartics are the obvious remedies. 
If it arises from constipation—the bile not passing off, and being 
consequently absorbed—cathartics are too obviously indicated to re- 
quire to be dwelt upon. If from congestion or malaria, the remedies 
for these conditions are required. If from a typhoid state or from 
particular poisons, eliminative and supporting measures, according to 
the conditions, will be required. All this “goes without saying.” 
A great variety of particular medicines for jaundiced conditions 
under different circumstances have been named. Thus the natural 
alkaline and saline mineral waters, or their chemical imitations, 
especially in jaundice from catarrh of the duodenum and gall ducts, 
are advised. The phosphate of soda appears to be a special favorite 
with Prof. Bartholow in this as well as in cases of gall-stones, and, 
given in doses of a drachm, more or less, well diluted, every four 
hours, it is doubtless an excellent remedy in many cases. The sul- 
phate of soda is in no way inferior given in a similar way, and may be 
more efficient in exciting bilious excretion. 894 
DISEASES OF THE LIVER. 
The sulphate of manganese, in half a drachm or drachm doses, 
three times a day, has a reputation, and is doubtless useful in some 
cases. The chloride of ammonium is often applicable, especially in 
the subacute cases with catarrhal conditions. 
Hydrastis has a reputation, especially with the “eclectic” prac- 
titioners, and so has stillingia and irisine. The euonymin has long 
been in use by the eclectics and as a domestic remedy in this country, 
and since the report of Dr. Rutherford, before referred to, it has 
attracted the attention of the profession more generally as a cliola- 
gogue. 
Podophyllin has also long been used, and in small doses, in combi- 
nation with alkalies, is often useful. But its irritating effects upon 
the intestines, and its drastic action as a cathartic, must be remem- 
bered. The old remedies, aloes and rhubarb, have their uses in cases 
of “torpid liver” and bowels ; and it is scarcely necessary to say that 
in jaundice associated with malarial fevers, quinine is the most impor- 
tant remedy, and arsenic and the various other antimalarials will be 
useful in the cases to which they are appropriate. 
The action and use of mercury has, perhaps, been sufficiently dis- 
cussed. Notwithstanding its utility has been so much questioned, and 
its excessive use has been so justly and yet often so excessively con- 
demned, it maintains its reputation with most practical physicians, 
and in various morbid hepatic and gastro-intestinal conditions, accom- 
panied with some jaundiced states, it has no equal for efficiency in the 
materia medica. 
STENOSIS, OR STOPPAGE OF THE BILE DUCTS. 
Complete occlusion of the biliary passages, from whatever cause, as 
from cancer of the pancreas, of the duodenum, or other neighboring 
parts, the impaction of calculi, adhesion of opposed surfaces by 
inflammation, etc., or by pressure of hydatids or other tumors, results 
in serious consequences. When the ductus communis choledochus 
is completely closed, the liver at once becomes distended with bile, 
absorption soon takes place, and jaundice results—often intense ; and 
if death does not soon follow from blood poisoning, as has occurred 
in my experience in at least three cases, the liver undergoes destruc- 
tive changes, and death in time results. When branches of the duct are 
occluded, the part of the liver with which the occluded ducts are con- 
nected suffers more or less disorganizing processes, and the general 
effects will be in proportion to the extent of the parts involved. 
The occlusion of the cystic duct is not attended by the same effect 
upon the parenchyma of the liver, but the gall-bladder becomes dis- HEPATIC PHLEBITIS. 
895 
tended by the accumulation of an altered mucus, and calculi are some- 
times found impacted within it. A pear-shaped tumor will be found 
projecting from under the liver, inflammation and suppuration may 
be excited, adhesive inflammation may take place, and this cystic 
abscess may follow the course of other hepatic abscesses. A quantity 
of pus, mucus, decomposed bile, and biliary calculi may be dis- 
charged externally through the parietes of the abdomen, or may burst 
into the stomach, intestines, or peritoneal cavity, with various results. 
Recovery, long suffering, or death may be the consequence. 
The treatment must be conducted on the same principles as in 
other hepatic abscesses—but for the most part it will be symptomatic 
and palliative. 
HEPATIC PHLEBITIS. 
Suppurative inflammation of the portal and hepatic veins may 
occur, 'out generally as a secondary affection. Ulceration in various 
parts of the intestinal canal, abscess of the mesenteric glands or of the 
liver, may induce this inflammation of the portal vessels, and suppu- 
rative disease of the liver may extend to the hepatic vessels. The 
clinical history of these affections is not definitely known and not dis- 
tinctive from other pygernic, inflammatory, and febrile conditions, 
and an autopsy can alone reveal the exact diagnosis. 
The symptoms will be severe, and the results fatal. 
Post mortem the veins will he found with their tunics thickened 
and infiltrated ; variously discolored, fibrinous, and purulent exuda- 
tions and thrombi are in the veins ; and when the disease is suffi- 
ciently long continued, emboli and secondary abscesses may be found 
in the liver and elsewhere in the body. 
The diagnosis is obscure ; but when, after ulcerative or suppurative 
disease in the abdomen, pain and tenderness occur in the course of 
the portal vessels outside of the liver and extend to that organ, 
hepatic tenderness and swelling come on, jaundice supervenes, and 
pysemic fever is developed, hepatic phlebitis may be suspected, and 
death may be expected in from a few days to a few weeks. 
As in other pyasmic and septicaemic fevers the temperature rises 
to 105° or 106° F.; chills, sweats, and diarrhoea take place; a dry, 
hard tongue, a rapid pulse, low delirium, great prostration, and other 
typhoidal phenomena occur, and death follows either by coma or 
asthenia. 
Treatment is of little avail, but such as has already been recom- 
mended in pysemic fever may be resorted to ; quinine may be given to 
abate the fever, and, if possible, to check suppuration ; fomentations 896 
DISEASES OF THE LIVER. 
may be applied over the side and abdomen, and morphia administered 
hypodermically to relieve the pain and diminish shock. Proper 
nourishing and supporting agents, as in other similar conditions, will 
be required. 
thrombosis of the portal veins may occur in the conditions just 
described, and in various other obstructive diseases, as in cirrhosis, 
chronic atrophy, cancer, and other tumors. 
The symptoms, if recognizable, would be a sudden increase of the 
evidences of portal obstruction—such as intestinal and splenic con- 
gestion, a watery diarrhoea, distention of hemorrhoidal veins and of 
the communicating veins over the abdomen, and general derange- 
ment and prostration. If the obstruction approaches completeness, 
death will soon follow. Ammonia has been suggested as a remedy 
tending to dissolve' coagula, but the prospect of introducing a suffi- 
cient quantity into the veins to effect that object seems too remote 
and uncertain to justify much hope. Carbonate of ammonia, in 
doses of from four to eight grains, in a proper vehicle, may be given 
once in three hours. An injection of one part of aqua ammonia to 
two of water into any convenient vein has been proposed ; and it is 
alleged that such an injection into veins has been proven to be inno- 
cent. I am-not, however, prepared to recommend the experiment. 
Aneurism of the hepatic artery has occurred in a few instances. 
Attacks of severe pain not otherwise accounted for may occur in the 
region of the liver, and if the tumor becomes large it may be felt 
pulsating like other aneurisms. Jaundice is likely to be produced 
from pressure upon the duct, and the various liver functions are likely 
to be interfered with. The aneurism sooner or later ruptures, and 
death takes place from hemorrhage, generally into the peritoneum. 
No radical treatment is likely to be efficient, but the sufferings may 
be diminished by anodynes aud other palliative measures. INDEX. 
A 
Acetonaemia, 22. 
Acidity from fermentation and hyper- 
secretion compared, 638. 
treatment of, 639. 
Acquired disease, 36. 
Addison’s disease, 489. 
Etiology, 30. 
Ague, 181. 
stages of, 182. 
quotidian, tertian, 184. 
intermission, intervals, 184. 
quartan, 185. 
tertian, double, 185. 
erratic, irregular, 185. 
diagnosis of, 186. 
prognosis, etiology, 187. 
conditions of its production, 188-9. 
acclimation in, 190. 
predisposing causes, 190. 
poison, latent period, 190. 
pathology of, 191. 
treatment of, 192. 
prophylaxis, 192-3. 
medicinal—palliative, 194. 
treatment of cold stage, 194-5. 
of hot stage, 196. 
of convulsions of children, 197. 
of vomiting and purging, 198. 
radical, 199. 
preparatory, 201. 
quinine in, 200. 
after-treatment, 204. 
iodine in, 204. 
arsenic in, 205. 
salicin in, 205. 
eucalyptus globulus in, 206. 
cornin, hydrastin in, 206. 
relapsing—treatment of, 207. 
enlarged spleen in, 207. 
dumb—treatment of, 208. 
dropsy in, 207. 
complicating other diseases, 208. 
Alcohol in dyspepsia, 646. 
natural decay, 85. 
Dr. O’Connor on, 86. 
Alimentary canal, diseases of, 549. 
Anaemia, general, 21. 
local, 44. 
pernicious, 485. 
diagnosis, 486. 
treatment, 486. 
simple, 486. 
treatment, 487. 
Anhydrsemia, 21. 
Antagonism, 26. 
Appetite, loss of, 139. 
voracious, 140. 
Apyretics, 176. 
quinine and opium, 177. 
jaborandi, aconite, 177. 
veratrum viride, 177. 
chloral hydrate, 178. 
salicylic acid, 178. 
morphine, digitalis, 178. 
cold water, 179. 
Art of medicine, definition of, 4. 
Ascites, 750. 
etiology, 751. 
diagnosis, 753. 
prognosis, 753. 
treatment, 754. 
Asiatic cholera, 411. 
causes, 412. 
symptoms, 418. 
stages, 419. 
pathology, 420. 
Asthenic disease, 37. 
Atony defined, 47. 
Atrophy defined, 45. 
B 
Bacon, quotation from, 10. 
Beale, Dr. Lionel, on cause of fevers, 120. 
Bennett’s, Dr., views, 109. 
Bile duets, stenosis of, 894. 
Biliary calculi, 883. 
Biology, definition of, 4. 
Bioplasm, 12. 
Bioplastic molecules, 13. 
Bites of insects, 150. 
Blood, changes of in lungs, 19. 
coagulation of, 19. 
897 898 
INDEX. 
Blood, diseases of, 21. 
functions of, 17. 
Blood and lymph concerned in healthy 
and morbid actions, 17. 
poisons in, 19. 
Blood pressure, 100. 
Blood, properties of, 18. 
relations to tissues, 20. 
Bloody flux, 709. 
Brain and nerves in causing disease, 22. 
Breath, offensive, 139. 
Bristowe’s, Dr., views, 108. 
Bronzed skin disease, 489. 
Burdon, Sanderson’s observations, 117. 
C 
Cachexia defined, 50. 
Cancer of stomach, 615. 
varieties, 616. 
etiology, 618. 
symptoms, 618. 
treatment, 620. 
Carbolic acid in fever, 118. 
Carbonic acid, excess of in blood, 22. 
Cells, as units of life, 12. 
Cell districts, 16. 
Cells from cells, 13. 
Cells, in tissues and in fluids, 16. 
Cell life, 13. 
Cells, life functions performed by, 16. 
Cerebro-spinal fever, 358. 
Chicken-pox, 393. 
Chlorosis, 489. 
Cholsemia, 22. 
Cholera, epidemic, 411. 
treatment of, 422. 
infantum, 674. 
treatment of, 688. 
Choleroid catarrh, 674. 
diagnosis of, 675. 
fluxion, 686. 
treatment, 686. 
Cholesteraemia, 22. 
Cicatricial tissue, 72. 
Classification, 34. 
Colds, treatment of, 156. 
Colic, 769. 
etiology, 770. 
symptoms, 770. 
diagnosis, 772. 
prognosis, etc., 772. 
treatment, 772. 
Collapse defined, 48. 
Complex processes, elementary, 34. 
Conditions of life, 5. 
Congenital disease, 30. 
Congestion defined, 49. 
Congestive chills, 220. 
Constipation, 781. 
Constitutional disease, 37. 
Contagious disease, 35. 
Contractions, 47. 
Costiveness—habitual, 781. 
etiology, 781. 
symptoms, 782. 
diagnosis, 782. 
treatment, 788. 
Cow-pox—vaccine, 887. 
Cynanche, 560. 
D 
Death, modes of, 86. 
Debility defined, 48. 
Degeneration defined, 44. 
Dengue, 344. 
Dependence of function, 25. 
Depression defined, 47. 
Destructive changes in inflammation, 
105. 
remedies for, 105. 
Diabetes mellitus, 492. 
insipidus, 508. 
Diagnosis, 30. 
nosological, 95. 
etiological, 95. 
therapeutical, 95. 
Diarrhoea, 789. 
crapulosa, 789. 
lienteric, 790. 
bilious, 790. 
zymotic, 50. 
critical, 791. 
colliquative, 791. 
causes, 792. 
treatment, 793. 
Diathesis defined, 50. 
scrofulous, 80. 
strumous, 80. 
tuberculous, 80. 
Diathetic disease, 37. 
Dicrotic pulse, 102. 
Digestive organs, diseases of, 583. 
system, diseases of, 549. 
Dilatations, 47. 
Diphtheria, 308. 
bacteria in, 309. 
varieties of, 311. 
prognosis, 314. 
compared with other diseases, 315. 
pathology of, 316. 
treatment of, 318. 
local, 319. 
constitutional, 326. 
Disease, a state of the system, 6. 
phenomenal, 6. 
causes of, 30. . , . 
compared to a wrong-going piece of 
mechanism, 7. 
conditions modifying, 38. 
definition of, 6. 
elementary constituents of, 30. 
elements of, 33. 
functional, 30. 
organic, 30. INDEX. 
899 
Dropsy, defined, 44. 
Drowsiness, 145. 
Dumb ague, 184. 
Duodenum, disease of, 668. 
Dysentery, specific, 712. 
etiology of, 712. 
pathological anatomy of, 715. 
symptoms of, 717. 
diagnosis of, 721. 
treatment of, 721. 
chronic, 731. 
complications in, 732. 
Dyspepsia, functional, 632. 
inflammatory, 597. 
diagnosis, 598. 
treatment, 599. 
E 
Effusions in inflammation, 105. 
remedies for, 105. 
Emaciation defined, 49. 
Embolism, 21. 
Enteritis, phlegmonous, 691. 
etiology, 691. 
symptoms, 691. 
morbid anatomy, 692. 
diagnosis, 693. 
prognosis, 694. 
treatment, 694. 
Epidemic cerebro-spinal meningitis, 358 
nature of, 360. 
symptoms, 361. 
varieties, 361. 
diagnosis, 361. 
prognosis, 363. 
treatment, 368. 
Epidemic disease, 34. 
roseola, 400. 
Erysipelas, 458. 
prognosis, 459. 
diagnosis, 459. 
treatment, 460. 
Etiology, 30. 
Euthanasia, 85. 
F 
Faecal exuviae absorbed, 22. 
False membrane, 70. 
Fatty infiltration defined, 49. 
Fever, 110. 
Fevers, classification of, 128. 
accidental or simple, 160. 
idiopathic, 159. 
specific, 123. 
symptomatic or irritative, 157. 
intermittent, phenomena of, 181. 
malarial, 180. 
remittent, 208. 
indications of treatment in, 161. 
non-medicinal management of, 162. 
Fevers, room, heating in, 162. 
ventilation in, 162. 
light, bed, cleanliness in, 163. 
disinfection, bathing, 164. 
treatment of simple, 164. 
persons in room, 164. 
nursing, food in, 165. 
evacuations, 166. 
bed-sores, moving, 167. 
directions, manner in sick room, 167. 
causal indications to be fulfilled in 
treatment of, 168. 
from repletion, taking cold, 169. 
from suppressed secretions, 171. 
from nervous impressions, 173. 
undeveloped stages of, 174. 
specific, 180. 
Fissures of tongue, chronic, 137. 
Force, definition of, 2. 
Function defined, 11. 
dependent on nutrition, 11. 
G 
Gall-stones, 883. 
Gangrene defined, 45. 
Gastralgia, 662. 
Gastric catarrh, 589. 
etiology, 590. 
morbid anatomy, 591. 
symptoms, 591. 
diagnosis, 593. 
prognosis, 593. 
treatment, 594. 
dilatation, 629. 
symptoms of, 630. 
treatment, 630. 
hyperaemia, 588. 
neuralgia, 652. 
ulcer, 605. 
etiology, 606. 
symptoms, 607. 
prognosis, 608. 
diagnosis, 609. 
treatment, 609. 
Gastritis, acute, 589. 
chronic, 597. 
submucous, 601. 
phlegmonous, 601. 
diagnosis, 602. 
treatment, 602. 
interstitial, 602. 
toxic, 603. 
Gastroenteralgia, 662. 
causes, 662. 
phenomena, 663. 
diagnosis, 664. 
prognosis, 664. 
treatment, 664. 
Gastrorrhagia, 622. 
morbid anatomy, 624. 
symptoms, 624. 
German measles, 400. 900 
INDEX. 
Glossitis, 558. 
treatment of, 560. 
Glychannia, 22. 
Glycohaemia, 492. 
Glycosuria, 492. 
Gout (see Podagra), 507. 
II 
j Hasmatophiiia, 478. 
| Haemophilia, 478. 
treatment, 479. 
Health, definition of, 5. 
Heat, animal, production of, 111. 
a force, 112. 
molecular motion, 112. 
result of chemical action, 112. 
food, its source, 112. 
friction a cause of, 112. 
electricity a cause of, 112. 
loss of, 113. 
of fever, 113. 
diurnal changes of, 113. 
animal, oxidation not its only source, 
119. 
Hsematemesis, 622. 
diagnosis, 625. 
prognosis, 626. 
treatment, 626. 
Hemorrhage, capillary, moderate, 158. 
defined, 43. 
of stomach, 622. 
Hemorrhoids, 733. 
Hepatic abscess, 850. 
diagnosis, 853. 
prognosis, 853. 
treatment, 854. 
Hepatic phlebitis, 895. 
Hepatitis, catarrhal, 842. 
morbid anatomy of, 843. 
symptoms, 843. 
etiology, etc., 844. 
treatment, 845. 
phlegmonous, 847. 
idiopathic, 849. 
secondary, 847. 
Hepatitis, non-suppurative, 856. 
Hereditary disease, 36. 
Hodgkin’s disease, 484. 
Hooping cough, 337. 
pathology, 339. 
treatment, 340. 
Hydraemia, 21. 
Hygiene, 94. 
Hyperaemia, active, remedies for, 104. 
passive, remedies for, 104. 
Hyperaemaesthesia defined, 47. 
Hypalbuminosis, 21. 
Ilyperalbuminosis, 21. 
Ilyperinosis, 21. 
Hyperplasia defined, 47. 
Hypersecretion of stomach and fermen- 
tation compared, 638. 
Hypertrophy defined, 46. 
Hypinosis, *21. 
I 
Ichorrhaemia, 22. 
Idiopathic disease, 31. 
Ileus, 579. 
treatment, 763. 
Iliac passion, 759. 
Indigestion of the aged, 653. 
of drunkards, 652. 
Infectious diseases, theory of, 124. 
Inflammation—definitions of, 51 to 54. 
pathology of, 55 to 63. 
particular processes of, 55 to 61. 
causes of, 74. 
general symptoms of, 75. 
symptoms of, 74. 
varieties of, 78. 
terminations of, 80. 
therapeutics of, 89. 
principles of treatment of, 103. 
elements of, and remedies for each, 
104. 
fever in, remedies for, 106. 
increased albumen in, remedies for, 
106. 
effete matter in, 106. 
shock in, remedies for, 106. 
septic matter in, remedies for, 106. 
increase of fibrine in, remedies for 
106. 
effused products, remedies for, 107. 
extreme heat, remedies for, 107. 
debility, remedies for, 107. 
care of stomach in, 107. 
curability of, 108. 
general rules for treating, 110. 
Inflammatory exudates, 64. 
changes in, 73. 
fever, 75. 
swelling, 74. 
Influenza, 330. 
causation of, 331. 
symptoms of, 333. 
morbid anatomy of, 334. 
prognosis of, 335. 
treatment, 335. 
Inhibitory nerves, influence of, 28. 
Intercurrent disease, 37. 
Intermitting disease, 36. 
Intestinal hemorrhage, 734. 
obstruction, 759. 
Intestines, diseases of, 667. 
tumors of, 757. 
diagnosis, 758. 
treatment, 758. 
Intussusception, 761. 
J 
Jaundice, 818. 
varieties, 819. 
pathology of, 819. INDEX. 
901 
L 
Lead colic, 774. 
causes, 774. 
diagnosis, 776. 
prognosis, 776. 
treatment, 778. 
Leucoeythaemia—Leukaemia, 480. 
Leyden’s, Prof., investigations of fever, 
118. 
Life cells of tissues and in fluids, func- 
tions performed by, 16. 
definition of, 4. 
Life principle, its nature, 3. 
Lipaemia, 21. 
Liver, cancer of, 881. 
diagnosis, 882. 
treatment. 883. 
cirrhosis of (see Sclerosis), 857. 
congestion of, 827. 
pathology, 827. 
diagnosis, 831. 
treatment, 832. 
diseases of, 807. 
functions of, 807. 
functional diseases of, 813. 
treatment, 817. 
fatty, 872. 
etiology, 873. 
morbid anatomy, 873. 
symptoms, 873. 
treatment, 874. 
fatty degeneration of, 872. 
hydatids of, 877. 
symptoms, 878. 
treatment, 879. 
hypertrophic cirrhosis of, 867. 
organic diseases of, 839. 
sclerosis, 857. 
morbid anatomy of, 857. 
symptoms, 860. 
diagnosis, 863. 
prognosis, 864. 
treatment, 864. 
waxy or amyloid, 874. 
symptoms, 874. 
morbid anatomy, 875. 
treatment, 876. 
yellow atrophy of, 869. 
symptoms, 869. 
pathology, 870. 
treatment, 871. 
Lymph, 70. 
M 
Malarial cachexia, 223. 
Malignant disease, 36. 
Matter, common properties of, 2. 
in living bodies, 3. 
definition of, 2. 
dead and living, 2. 
Measles, 394. 
Medicine, definition of, 1. • 
what it includes, 1. 
Mental influence, 27. 
Mesmerism, 29. 
Miliary fever, 347. 
treatment, 354. 
Minor diseases, 130. 
Morbid action, extension of, 24. 
Mouth, diseases of, 549. 
Muco-enteritis, 670. 
varieties, 670. 
morbid anatomy of, 670. 
etiology of, 671. 
symptoms of, 676. 
chronic, 684. 
treatment, 684. 
Mumps, 341. 
treatment of, 343. 
Murchison, Dr., on regimen in liver dis- 
eases, 825. 
Myalgia, 544. 
N 
Nature to be aided, 9. 
Nausea, 142. 
Necraemia, 21. 
Necrobiosis defined, 45. 
Necrosis defined, 45. 
Nerves in inflammation, 62. 
irritation of, remedies for, 105. 
Nervous control of circulation, 122. 
Nervousness, 146. 
Non-inflammatory changes, 88. 
Nutrition, definition of, 11. 
conditions of healthy 11. 
O 
Observations, physiological and path- 
ological, 11. 
Obstructions of intestines, 759. 
etiology of, 759. 
symptoms of, 759. . 
diagnosis of, 760. 
treatment of, 761. 
Obstruction without strangulation, 767. 
treatment of, 768. 
(Esophagus, diseases of, 575. 
inflammation of, 575. 
treatment of, 576. 
stricture of, 576. 
cancer of, 577. 
diagnosis, 578. 
treatment, 578. 
stricture, spasmodic, of, 580. 
etiology, 580. 
symptoms, 580. 
diagnosis, 581. 
prognosis, 581. 
treatment, 582. 
Order of studying disease, 29. 
Oxalaemia, 22. 902 
INDEX. 
P 
Pains, rheumatic, 148. 
Pancreas, disease of, 796. 
Pathological actions modified, 11. 
physiological action, 16. 
Pathological state, 5. 
Pathology, definition of, 1. 
general, special, 2. 
the science of indications, 96. 
Periproctitis, 708. 
treatment of, 708. 
Peritoneum, cancer of, 756. 
Peritonitis, acute, 735. 
symptoms, 736. 
diagnosis, 737. 
treatment, 740. 
etiology, 738. 
pathological anatomy, 738. 
prognosis, 740. 
chronic, 746. 
symptoms of, 747. 
tubercular, 747. 
pathological anatomy of, 747. 
treatment, 749. 
alcoholic, 750. 
Perityphlitis, 701. 
etiology, 701. 
symptoms and course, 702. 
diagnosis, 705. 
prognosis, 706. 
treatment, 706. 
Pernicious anaemia, 485. 
diagnosis of, 486. 
treatment of, 486. 
malarial fever, 220. 
Persons to be treated, 9. 
Perspiration matter retained, 22. 
Pharyngitis, chronic, 563. 
diagnosis, 564. 
prognosis, 565. 
treatment, 565. 
Physiology, definition of, 4. 
Physiological and pathological observa- 
tions, 11. 
Physiological state, 4. 
Plague, 306. 
Plethory, 21. 
Podagra, 511. 
etiology, 511. 
diagnosis, 513. 
prognosis, 515. 
treatment, 515. 
Poisons in blood, 22. 
Portal veins, thrombosis of, 896. 
Principles and Practice of Medicine, Sub- 
jects of, 4. 
Proctitis, 710. 
Prognosis, 31 and 35. 
Prophylaxis, 94. 
Protoplasm, simple, 3. 
Pulse, 97. 
frequency of, 98. 
relations to temperature, 99. 
Pulse, qualities of, 99. 
rules for examination, 100. 
Purpura, 475. 
Pus, 65. 
origin of, 66. 
laudable, 68. 
ichorous, 68. 
fetid, 68. 
septic, 68. 
Pyaema, 22. 
and septicasmia, 463. 
pathology, 465. 
prognosis, 468. 
diagnosis, 468. 
treatment, 469. 
Pyrexia, 110. 
Pyrosis, 651. 
Q 
Quinsy, 571. 
phenomena, 571. 
treatment, 572. 
epidemic, 543. 
R 
Reflex action, 25. 
Relapsing disease, 36. 
fever, 301. 
treatment of, 302. 
Remak’s cell layers, 14. 
Remedial treatment, objects of, 95. 
Remitting disease, 36. 
Retro-pharyngeal abscess, 569. 
Rheumatism, acute, 521. 
varieties of, 521. 
etiology, 522. 
morbid anatomy, 523. 
pathology, 525. 
symptoms and course, 526. 
prognosis, 528. 
treatment. 530. 
chronic, 539. 
diagnosis, 540. 
prognosis, 540. 
treatment, 540. 
Rheumatic arthritis, 541. 
prognosis, 543. 
treatment, 543. 
Rheumatism, muscular, 544. 
treatment, 546. 
Rotheln, 400. 
Rubeola, 595. 
treatment, 595. 
S 
Scarlatina, 402. 
morbid anatomy, 406. 
diagnosis, 407. 
treatment, 407. INDEX. 
903 
Scarlet fever, 402. 
Scheme of medical science, 2. 
Science of medicine, 4. 
definition of, 4. 
Scorbutus, 471. 
Scurvy, 471. 
morbid anatomy, 473. 
Secondary disease, 37. 
Semiology, 30. 
Septicaemia, 22. 
Shock defined, 48. 
Sluggish bowels, 781. 
Small intestines, disease of, 669. 
Small-pox, 373. 
phenomena, 374. 
malignant, 381. 
hemorrhagic, 381. 
prognosis, 382. 
morbid anatomy, 383. 
treatment, 384. 
Specific disease, 37. 
Sporadic disease, 34. 
Sthenic disease, 37. 
Stomach, diseases of, 587. 
Stomachic vertigo, 666. 
Stomatitis, 550. 
mercurial, 552. 
diagnosis, 553. 
treatment, 554. 
Straw measles, 401. 
Supra-renal melaemia, 589. 
treatment, 581. 
Sympathy, 25. 
special, 26. 
greater in disease and weakness, 27. 
between persons, 28. 
Symptoms, 30. 
Symptomatology, 30. 
Syncope. 48. 
T 
Therapeutics, definition of, 1. 
Tissue action, nerveless, 23. 
influence of alkalies on, 24. 
acids on, 24. 
digitalis on, 24. 
antiarin on, 24. 
Tissue action, muscarin on, 24. 
pilocarpin on, 24. 
atropine on, 24. 
Tonsilitis (see Quinsy), 571. 
IT 
Ulcer of duodenum, 613. 
Ulceration defined, 45. 
Undetermined blood changes, 22. 
Uraemia, 22. 
Urea, sources of, 117 
Uricaemia, 22. 
V 
Variola (see Small-pox), 873. 
Varicella (see Chictcen-pox), 393. 
Varioloid, 482. 
Vaso-motor action, 23. 
Virchow’s view of fever, 221. 
Vital stimuli, 5. 
Vomiting, 655. 
treatment of, 656. 
W 
Wakefulness, 145. 
Y 
Yellow fever, 443. 
miasmatic contagious, 444. 
symptoms, 445. 
varieties, 446. 
morbid anatomy, 450. 
diagnosis, 451. 
prognosis, 451. 
treatment, 452. 
Z 
Zymotic disease, 35. 
poison, 22.