1400 J

































































































































































































































































































































































































































































1
FEVER.
_____x_____

Autumnal fevers, in all their different forms,
are the result of marsh exhalations. It is proper, how-
ever, to state, that the maishes, mill-pounds, slaquant
pools, 06., an the most fruitful causes: yet we must
admit, that autumnal fevers occasionally appear in
high situations, & in plans which are generally reputed
healthy. During the puvalnec of the epidemic fever
in 1820-21, such plams suffered more than those which
were low, &, usually, much more subject to the disease.
This proves, that though many facts have been estab-
lished with regard to the cause of autumnal fevers;
yet we have still much to learn. It is certainly con-
trary to our usual experiences, that Germantown, which
has been called the Montpelier of America, should be
more sickly than so low a piece of land as that com-
monly called the Neck, lying below Philadelphia, between
the Delaware & Schuylhill. This, however, was the fact
during the fall of 1821; & such facts, though they may
oppose our puconceived opinians, it I, nevertheless our dir-
ty to record.
A question now arises,- what is this autumnal fever?
On this subject I shall make a few general observations,
  
































































































































































































































2
of a practical nature, without any attempt at theory.
Autumnal fiver is a disease which varies considerably
in different subjects, though they all may have been ex-
posed to the operation of the same cause. This difference
probably arises from those varieties of constitution, which
are either natural to individuals, or result from pecul-
iar habits & exposures. In the same family I have
seen every grade of disease from fevers exceedingly danger-
ous & malignant, to the common intermittent which
readily yields to the usual remedies.
There are two general forms of fever, which are the
offspring of marsh exhalations_ the remittent & inter-
mitten fiver. In the remittent there is a temporary
abatement of the violence of the [????ile] paroxysm; in
the intermittent a complete cessation of disease occurs for
a time, & is succeeded by another paroxysm. A person
who has been subjected to the influence of marsh exha-
lation, & is about to experience their usual effects, is
generally warned of the approach of disease by some
premonitory symptoms. Instead of being suddenly cast
down from a state of apparent health, he is generally
listless, through his body, followed by flushes of heat
pain in the head, back & limbs, sichness of stomach,
& sometimes vomiting of bilious matter. Our remit-
tents generally commence with a chill; but in mamy
instances, a distinct chill is wanting. Nausea is a very
 































































































































































































































3
Common accompaniment of this stage. Afetr the cold
stage, the system vacts; & we have a hot skin, excited pulse,
flushed faw, pain in the head, restlessness, with other symp-
toms that mark the existence of fever. These go on increasing,
till sometimes in the afternoon, the paroxysm generally gets to
its hight; A relaxes in the evening, & in the morning we
often find the patient with a moist &, comparatively, cool
skin; or, in other words, a remission has taken place.
Yet the intelligent practitioner soon perceives by the excited
state of the circulation, the appearances of the tongue, & the
general asput of the patient, that he is laboring under a
full-foimed fever. This will go on for 5, 7, or 9 days, or
even for a longer time. Occasionally it will assume the ty-
phoid form, & become very tedious.
Intermittent are much less to be duadid than remit-
tents; for, in the first, you have frequent intervals of com-
plete freedom from fever, when you have an opportunity
to pour in your remedies freely, & prevent a [r????enes] of
the paroxysm.
But there is a kind of mongul disease, between the in-
termittent & remittent, which, in many instances, is more
to be dreaded than either of the other forms. This accured
in a fus case in the epidemic which puvailed aomong
us in 1821, & since that period. Every day smething
like a chill accured, followed by an exaurbation of fever
with an imperfect intermission. Some of the most dan-
gerous cases I attended wre of this character.




















































































































































































































4
I will now make a few general observations on a
plain, common case of remittent fever, as it is usually
with in our country. When developed in a large propor-
tion of cases, may be managed with the happiest results.
When called to a patient with an open, full developed
case of common remittent fever, the first indication is to
evacuate the stomach & bowels. The practice of attempting,
in the first instance, to remove the nausea by antacids, &
tranquilize the stomach by anodynes, is generally improp-
er. To produce emesis, in this case, a combination of it
[illegible] x [illegible] wine, in the [illegible] of qxxx
of the formed to a dessert shornful of the  latter, is probably
the most suitable; recommending the patient to drink co-
piously of tepid drinks as soon as the vomiting common-
ces. The catharsis is best produced by a combination of
calomel & jalap, in the proportion of grx of the formed to
grxx of the latter. If this should not produce purging
in 4 or 5 hours, aquantity of the neutral salts should
be taken every hour, or every 2 hours, until the bowels 
are completely evacuated, & the stools lose their offensive
[ado??].
In a young & vigorous subject, of an inflammatory 
diathesis, where there is great restlessness, high arterial ac-
tion, intense pain in the head, & a burning heat in the
surface, v.s. may precede the foregoing remedies. Oc-
casionally bleeding is called for two or three times. But




















































































































































































































                                                    5
I wish to guard you against the idea, that by the fre-
quent use of the [la??ect], you will be enabled to subdue the
fever. This is a notion which has been productive of much
smichief. By bleeding in every paroxysm, with a view to
destroy febrile action, & thus cradical the disease- with-
out succeeding in your wish, you will exhaust the vital
power, & rend it less able to struggle against the force of
the disease. The remedy is often useful; but I have
no doubt that a vast number of case run their cause
happily, from their commencement to their termination,
without calling for the lancet; & I wish impuss you
with the conviction, that to attempt to cut short a fever by
repeated bleeding, is a very dangerous practice, a practice
which I conscientiously believe has produced a vast deal of
mischief. Local depletion is, in most cases, preferable 
to general bleeding. Cups or lurches applied to the head will
often as effectually remove the pain as the lancet, & with
much less disinsertion of strength.
When there is a dry, hot skin, great restlessness, & insa-
tiable thirst, cold ablution will be found quite as effectic-
al as v.s. in allaying thirst, diminishing the restlessness,
& restoring the natural state of the surface, without di-
minishing the strength of the patient. Brandy & water is
preferable to vinegar & water, because it more speedily evap-
nates. In the use of ablution, the shirtest attention should
be paid to the directions of Dr. Curric of Liverpool. He
found that the most advantageous time for using it is
















































































































































































































6
when the exacerbation is at its height, or immediately af-
ter it is begun; though he observes, “It may be word
at any time when there is no sense of chilliness pres-
ent; when the heat of the surface is steadily above what
is natural; & when there is no general or profuse pers-
piration”. It is inattention to these precepts that has
brought this invaluable remedy into disrepute.
When the patient complains of pain & uneasiness
in his head, attended with a flushed face & high febrile
excitement, his hair should be cut short; & if this
does not mitigate the violence of the symptoms, the
head should be shaved & freely exposed to cool air.
In case of high excitement, attended with violent pain,
great advantage will be derived from the application
of bladder of pounded us to the head, which should be
removed & reapplied as the sensations of the patient
indicate.
Attention should also be paid to circumstances gen-
erally of minor importance, in the estimation of those in
attendances on the pick; such as placing the patient in
a cool, will ventilated apartment, & allowing him a liberal
quantity of cool drinks, among which cool water is the
most valuable when there are no circumstances    to con-
traindicate its use, as the presence of a chill, or the stom-
ach & bowels bring under the full effect of a dose of ca-
thartic medicine.
Sudorifies are usually found beneficial; & during
















































































































































































































7
their administration tepid drinks should be given. The
most agreeable & beneficial article in this class of remedies,
is the citrate of potash, administered in the form of the effect-
vescent drawght. Antimonial medicines may occasion-
ally be given with divided advantage.
Blistering, in some cases, may be resorted to with
the most pleasing result; and if there is any remedy
capable of subduing fever, that remedy is, unques-
tionably, blistering with cantharides. It is peculiarly
adapted to cars attended with great [???asince??] & distress,
without any topical affection; where there are frequent
jactitations of the body, & the patient complains of pain & 
soreness in his limbs. In such cases large blisters ap-
plied to the arms or legs will very frequently be productive
of the happiest affect.
Tomis & stimulants are demanded, even in cases
which commencer with inflammatory symptoms and
require one or two bleedings, when, on the 5th on 7th day,
instead of a solution of the disease, we find it assum-
ing a low & continued form. In this low form of
fever the tongue is often loaded with a thick fur. If 
this fur cleave off suddenly, & leave the tongue clean,
red, & moist, it is generally, if not always, a sure in-
dication, that the patient will recover; though his
convalescence will be very protracted & tedious. If
the tongue clean suddenly, but remain dry & chopped,
the patient is in a very dangerous situation, as these
















































































































































































































8
Symptoms are indication of a fatal termination.
On the contrary, it is clean slowly, beginning at the
tip & edges, & advancing gradually to the center, we
may expert a speedy & happy termincation of the
disease & a rapid & perfect convalescence. When
the first appearance of cleaning is perceptible, in cases
when it cleans suddenly; when we have the first
induration of the loosening of the fur, we frequently
discover an alteration in the voice of the patient who
complains of a sore throat. This change of voice
& sore throat which, on many occasions, is to be
dreaded as indicative of great danger, is here to be
hailed as the harbinger of convalescence. If the [fo?]-
ces be examined at this period, they will be found
red a& glossy; evidently showing that they had been
convered with a fur similar to that of the tongue, & that
the clearing away of this fur, has caused the alteration
of the voice & soreness of the throat.
In these low forms of fevers all dipussing passions
of the mind should be carefully avoided, & all accident-
tal occurrences producing disappointment to the patient,
especially those relating to love affairs, should be careful-
ly kept from his hearing.
In this form of disease we not unfrequently meet with
a tympanitie abdomen. In such cases the intestines
have suffered so much from disease, & become so much
debilitated & exhausted, as to be incapable of properly con-   
















































































































































































































9
tracting on their contents; & their muscular fibers read-
ily yield to the expansion of the gasses they may hap-
pen to contain. An object of primary importance
in this state of things, is to maintain the peristaltic
action of the bowels by remedies calculated, at the
same time to stimulate & invigorate the system. The
best remedies for this purpose is the tincture of [?h?]-
barb with cardamom seed, warner’s gout cordial, and 
the spirit of turpentine.
It requires considerable attention to regulate the use
of stimulants in these extremely mow cases of disease; for,
in many instances, the quantity of stimulus which
is necessary to arouse the system from its state of tor-
por, woukd, if improperly continued, produce under
excitement & dangerous consequences. Where there is 
low, muttering delirium with dullness of sensation,
I have no hesitation of resorting to stimulation; but
when the sense are acute, with loquacity, & a dispo-
sition to make remarks on surrounding objects, I
am disposed to think the brain is underly excited,
& I feel an objection to employing wine, back, etc.
In such cases I generally apply a blister to the head;
Yet there are exceptions even to this rule.
Mercury as a remedy in remittent fever, has, at
times, attracted a considerable degree of attention. Dr.
Wistar, although he prescribed mercury liberally in some
disease, was accuse to its employment in this. I be- 
















































































































































































































10
lieve that in some particular cases, mercury given
with a view to correct the secretion  of the lives, may
be productive of the greatest advantage; but experi-
ence has fully convinced me that a salivation is not
capable of arresting the disease. In cases where active
evacuation is not admissible, & stimulants are not de-
manded, I have been greatly pleased with the effect of
calomel, in dose of 1/12 or 1/6 of a grain every hour, & continued
every day, or every other day for some time, agreeable to the
directions of Arpe who says it regulates the action of
the liver. Mercury thus administered, in these cases,
I consider as a remedy entitled to considerable attention
& confidence.
It is necessary that physicians should be acquaint-
ed with the fact, that occasionally in fever, we meet
with a state of the mouth similar to that which oc-
curs in cases of salivation from mercury; but where
that medicine has not been administered. Dr. Rush
once saw it in a case of pneumonia, & was severely 
ensured by the husband of the lady for having given
mercury to his wife without his consent; but no
mercury had been given. These cases of spontaneous
salivation require the antiphlogistine plan of treatment,
& where the subject is young & vigorous, V.S. may be
resorted to with advantage.
I will now direct your attention to some forms
of fever less rapid in their progress; but requiring great
  
















































































































































































































11
case to manage them successfully. Almost every sea-
son, either from peculiarity of constitution, or some other
cause, we find some case of remittent fever which de-
viate from the common cause. The remittent, as it
usually occurs, may be regarded as a very managea-
ble disease, & in a large majority of instances, the pa-
tient recovers; but occasionally it assumes a dif-
ferent asput, & it is my institution to give an account
of some of these anomalous cases.
Case of S.M.- The patient had been engaged
In building Fecinds meeting house in [????lfth] sheet,
a short distances from the building, to the west of it,
some ground had been overflown by the heavy rains,
He was daily exposed to the miasmata, & felt quite
unwell for several days before he was confined, he staid 
at home & was bled by his own direction. Find-
ing himself no better, he sent for me. When I
saw him he was complaining of great giddiness 
in the head, with some pain & general uneasiness
through his limbs, & A entirely forbade the use of
the lancet.
My attention was first directed to the free evac-
uation of his bowels, & for this purpose I directed a
cathartic. I advised a free circulation of iar in his
chamber, the liberal use of cold ablutions over the
     















































































































































































































12
Whole body, when the skin was permanently hot
& dry, & there was no sense of chilliness present.
On the second day of my attendance, something like
cholera occurred. Copious discharges of bile took place
from the stomach & bowels, & I perceived the pulse be-
gin to fail very perceptibly, so that I was under the
necessity of blistering his wrists, using [s??ap?sms], etc., and 
of employing occasionally the chalk julep. These ar-
rested the symptoms; & he continued almost in a sta-
tionary state, until the night of the 22. Previously
[?el???] water, etc., & cold ablutions when his fever required 
them. On the morning of the 23, I was alarmed with
the strong tendency of his system to sink. His parlor
was very fuble; his stomach, rather irritable; & every
symptom indicated great prostration. I resorted a-
gain to blisters & sinapisms, & employed wine and es-
sence of beef. I requested a consultation. My friend,
Dr. S.P. Griffilts, saw the patient with me; & our views
of the case corresponded exactly. To prop his system
was the prominent indication. During the 23 & 24th,
he discharged black blood from the mouth & gums, and
also a little from his nose. At this juncture his stomach
was irritable. Great benefit was derived from bathing
him freely with the decoction of cantharides in spirits
of turpentine, as directed by Dr. Hartshornd. It vescia-
ted him slightly from his throat to his abdomen. His      















































































































































































































13
extremities were often rubbed with the decoction diluted 
with oil. When the heat of his skin sunk below the
natural standard, the diligent use of this decoction was 
of great importance. In order to give tone to his stomach,
we gave him the extract of quassia in pills every hour.
After they had been given for some time, we gave gr iv
of volatile alkali every hour, followed by a glass of
the decoction of supentaria. We also plied him most
diligently with good Madeira & essence of beef. The
latter was afterward changed for essence of mutton; &
toward the conclusion, when he became tired of wine,
we gave him porter. Under this treatment he gradually
recovered, &, I hope to my humbling admiration. 
Case of G.F.- G.F. was a very delicate child, sub-
ject to diarrhea from an attack of which he had just
recovered. When the fever first singed him I was not
at all alarmed. For the first day or two, I contented
myself with simple treatment. On account of his
liability to diarrhea, his bowels were tenderly dealt with;
&, after a little evacuation, I relied on mild reme-
dies, such as the spirits [minder???], antimonial wine,
bathing the feet, & the application of [po?lt??s] to the sobs.
In this condition things continued for one or two days.
At the expiration of these, however, finding the dis-
ease becoming more serious, I resorted to blisters, which
did not succeed in arresting its progress. In a short  































































































































































































14
time the disease assumed its [gen????] character, and
proud to be a very dangerous malignant fever. The
blistered surfaces assumed a dark & bloody appearance;
the patient was in a state of constant delirium or stu-  
por; the pulse became slow; & all the symptoms indi-
cate the speedy approach of dissolution. I now resorted
to the stimulant plan of treatment. In consequence of
the laxative condition of the bowels, I directed Port wine,
which possesses the property of astringency to a consid-
erable extent. Dr. Physick was called in consultation, 
& Dr. Totts gave his assiduous attention to the patient.
In addition to the Port wine, which was spired & ad-
ministered at short intervals, Dr. Physick proposed the
volatile alkali. I was somewhat afraid of this - I
thought it probable, that Port wine & volatile alkali
would form, in the stomach, a neutral salt which
might act on the bowels, & reduce the strength of the
patient. It was tired, however, & no inconvenience oc-
curred. The attendants were directed to hinder the pa-
tient from sleeping long at a time, as this has a
great tendency to prostrate the system. Bark was al-
so exhibited in the course of the case. By the most
diligent care & scrupulous attention in the administra-
tion of the remedies just mentioned, he gradually recov-
ered.
The next season he was again attacked with fever.
Not yet thoroughly acquainted with his constitution,   
 


























































































































































































15
I calculated that I should be able, by an emetic of
ipecacuanha, by pediluvia, early blistering, & inducing
perspiration, to succeed in anesting the fever. I was a-
fraid of resorting so early to what I afterwards found
to be the proper practice. Two or three days elapsed be-
fore any effectual treatment was adopted. I then em-
ployed the back & wine, with with other stimulants & tories;
& connected with these, the use of blisters. Under this
treatment he was rescued from extreme danger.
Sometime after this spill, in the seceding year, he was
again attacked. Knowing the peculiarity of his constitution,
that when fever laid its hand upon him, it reduced him
to the lowest situation, & brought him into the very jaws 
of death, I determined not to delay active treatment, till
he should begin to sink. Instead, therefore, of losing time
by the use of sudorifies; after emptying the alimentary canal
by a small dose rhubarb, regardless of any remission in
the fever, I at once commenced with the use of back
& wine; &, to my great joy & the delight of an affectionate 
mother, the disease was arrested in a short time, & the
danger removed as by a charm. The back was prepared
by adding surpentaria & salt of lartar, & forming a hot i-
fusion in Maderia wine. A tea spoonful was given ev-
ery hour. I now believe that had I been well ac-
quainted with his constitution before the previous attacks,
I should have been able, by the same kind of treatment,
to have produced the same effect in his first illness. This  
 


























































































































































































16
example shows, that the common belief relative to the
importance of understanding the constitution of our
patients, is not without very good foundation.
Remittents of a mild, & even shore of an inflame-
matory character, run sometimes into a very protract-
ed form. I have often attended patients in thus sit-
uation. The disease is sometimes so inflammatory in
the commencement as to admit of one or two bleedings.
The patient goes on tolerably will till that period,( the
7th or 9th day.) when we might have reason to hope for
a solution of the fever. About this time the disease chan-
ges its form; loses that condition which would admit
of venesection or active depletion; & though in common 
it does not call for stimulant treatment; yet the system
languishes, & some support is necessary. In this kind of
fever, there is often a state of the tongue which, to young
practitioners, is exceedingly fallacious. In common it is
covered with a thick curst of fur: but in cases I am
more describing, about the 7th or 9th day, the tongue suddenly
cleans, & the fur breaks off, not as usual by degrees & com-
mencing at the edges of the tongue, but in large flakes & at
once. After it has become clean, instead of presenting the
natural papillary structure, it appears smooth & gen-
erally red. When I see this glassy appearance of the
tongue occur in cases of remittent fever, I am generally
confident that the disease will be protracted. In com-
mon the patient will recover; but he will be ill for
 
 


























































































































































































17
a long time, & often in some danger. Almost every
reason, before the end autumn, a physician in full
practice will have to deal with a few cases of this dis-
cription. When they run on in such a manned for a
long time, they are commonly called nervous fevers.
Sometimes the system is worn out, & the case termi-
nate fatally.
In order to illustrate the danger of tympanitie abdo-
men, I will relate the following case as an example:
Case of O.S.- I was sent for 9th mo. 1814, to see 
O.S. He was attacked with a mild remittent fever, &
at first view, there was nothing that led to the conclusion
that the disease was about to be very serious. It proceed-
ed, however, to the low state before described, & all our ef-
forts to rescue him were unavailing. Among the unfa-
thomable symptoms in the latter period of the disease, wre
profuse sweats. A gentle or even a propuse perspire-
tion, when we may sepert the crisis of a fever, may be regard-
ed as a favourable prognostic: but the frequent recommend
of profuse & spontaneous sweats in the latter period of a low
fever, so far from being hailed as a good omen, should be
considered as directly the reverse. Another unfavoura-
ble symptom in the last stage of this case, was tympa-
nites of the abdomen. When in a protracted fever, the
belly becomes tympanitic, or sounds like a drumb on being
struck, you may always consider the patient in extreme       

























































































































































































18
danger, & may generally predict a fatal termination.
This symptom depends on an approach in the bowels
to a state of death. Their tone is completely gone; & if
they were before irritable, they entirely lose their irrita-
bility. The reason of this plain. The tympanitic state
of the abdomen puts a stop to the peristaltic motion; the
bowels are very much distended, & the power of contract-
ing on their contents is lost. Sometimes I have seen ca-
ses of recovery; but these have been very raw. As an
instance of this nature, I will ralate the following:
Case of P.- In the autumn of 1821, I attended this
young man in consultation wish Dr. Mc [Ble??aw] 7
Eberle. He laboured under a low & protracted remit-
tent; & when I first saw him, his belly was tympa-
nitic to a great degree. We tried a strong decoction
of the beast red back with a large tea spoonful of Hux-
ham’s tincture, every two hours: also a [j??lap] com-
posed of half an ounce of spirits of turpentine & four
ounces of mucilage, a tble spoonful of which was
administered every two hours; & ten drops of laudanum
were given every four hours. His strength was support-
ed by essence of beef & Maderia wine. He took a glass
of wine every hour for several days. Under this treat-
ment he perfectly recovered. We derived much benefit 
in his case from the aromatic tincture of rhubarb as
a mild purge.
        

























































































































































































19
Case of I.L.- In the fall of 1821, I attended I.L. who
Had an attack of fever which commenced like a quotidi-
an, & with symptoms apparently mild. In a short
time, however, it assumed a mongul form, between an
intermittent & remittent, & the patient was soon reduced
to a state of extreme danger. About the 7th day, his pulse
was barely perceptible & his belly tympanitic. I was back,
volatile alkali, etc; but the patient grew worse. I then
tried the turpentine jielap which had a most ramark-
able effect. I also used the aromatic tincture of rhu-
barb for the perpose of maintaining the peristaltic action,
which, in these cases, is of vast importance. After an ap-
pount crisis the disease assumed quite a different [??ara?ter].
The patient became loquacious, & there was evidently a dis-
position to phrenitis. I laid aside stimulants & resorted 
to purgatives, & he recovered completely.
As remittent fevers will engage so much of your
Attention when you enter into practice, because almost ev-
ery neighbourhood is more important that we should dwell
on the subject more at large, than will be necessary for
some other disease. I will, therefore, detail to you a few 
cases, differing in some respects from those before related;
& will then communicate some observations on malignant 
intermittents. When treating of the causes which produce
malignant remittents, I might have mentioned a case,
to show that vegetable matter in a dead or decaying state,               

























































































































































































20
is capable of producing a formidable state of disease.
The case is the following:
Case of S.C.- This old man who had loved in
New Jersey all his life, finally fell a victim to a dread-
ful attack of bilious fever. For a few weeks before his
attack, the reason had been uncommonly wet. He had
a quantity of hay in his meadows, which, in conse-
quences of exposure to the rain, was much injured, and
so far advanced towards putrefaction as to be very offen-
sive. Having been engaged with his men in spread-
ing out this hay to dry, on his return home, he said
the smell was so offensive that he could scarcely
bear it. Soon after this he was attacked with some
disorder of the stomach & bowels, & felt chilly & quite
unwell; but did not confine himself to the house. His
indisposition commenced on 7th day; he attended meeting
the next day, when coma with a disposition in the sys-
tem to sink, became apparent. I saw him on first
day afternoon, His countenance had assumed a malignant
asput; his respiration was laborious, & a disposition to co-
ma was wident; though when roused he could give a cor-
rut answer to any question. His system was sinking. &
he was widently labouring under a retention of urine. I
introduced a catheter, & drew of a considerable quantity.
We endeavoured to prop his system by resorting to the most
powerful stimulants; but in vain. He died in a few     


























































































































































































21
hours after I lift him. It is remarkable that none
of his people who were exposed among the hay, were af-
fected with disease.
Another case I think worthy of attention; because
after back had been liberally employed, & had failed of
producing the desired effect, we changed the plan of treat-
ment, found the symptoms to improve, & afterwards re-
sorted to the back with great advantage.
Case of J.D.- The case commenced like a quotidi-
an with chill & fever followed by sweat everyday. The
patient complained considerably of the head; but his pulse
would not admit of bleeding. The state of the bowels was at-
tended to, & then serpentaria was employed. Afterward back
was used, but without arresting the disease. His stomach
was at first rather irritable; &, by the use of warm water,
he vomited freely.- He is subject to dyspepsia for which
I had once attended him. On the morning of the 27th, 
though he had taken [?ij] of the back in substance, the prece-
ding day, I was alarmed at finding him in a state of great
debility, with an extremely frequent & feeble pulse. I ordered 
madeira wine, & blisters to the wrists, & requested further advise
Dr. Wistar saw him with me. As the back had failed, we sus-
pended its use, & resorted to supentaria & seltzer water, with
blisters to the legs. The bowels, when his system admitted it,
were gently evacuated; & finding that his fever continued,
Dr. Wistar proposed antimonial powders, so as to nauseate 



























































































































































































22
the stomach. Their effect was watched closely, to observe
how they might be borne. They certainly produced a
happy effect, & a very distinct remission was observed.
Back was now tried again, & with success. The case was
[p???liar] in consequence of the great debility, & uncommon
frequency of pulse- I think it was 130 strokes in the min-
ute.
Case of A.K.- In the beginning of the 10th mouth,
1898, I was called to see this little girl who was extreme-
ly ill. She wa delirious; but her delirious was of a pe-
culiar character. Her hearing was acute, & her [??nsbil]-
ity to the impussion of surrounding objects was great.
In fact it seemed as if the affection of the head was of the
phrenetic character; & although there was great apparent
prostration, I delayed stimulants in consequence of the
great sensibility of her mind: for, as I have already told
you, whenever, in fever, I see low, muttering delirium 
with evidences of great debility, I have no fear of the head;
but when I observed an acute state of the mind, with a dis-
position to make observations on surrounding objects, togheth-
er with great quickness of having, I am inclined to believe that
the brain is excited, & stimulants, of consequences, improper. I
advised a blister to the head, which her parent opposed. About
this time her alvine discharges & her urine became bloody. Sordes 
collected about her mouth, & her tongue was brown & dry.
I now determined on the use of wine without reference 
To the head. After this Dr. Dorsey saw her with me. We

























































































































































































23
now blistered her head, & with the wine gave 8 or 10 drops
of laudanum every few hours. Notwithstanding the threat-
ning symptoms of her head, she completely recovered. But 
her tongue cleaned smooth, & her convalescence was very te-
dious. She had a frequent, febrile pulse for several weeks,
& back was used advantageously.
Case of Mary K.- On the 29th of the same month in
which I visited A.K., I was called to see her sister Ma-
ry who was attacked with chilliness, pain in the nhead &
bones, etc. I did not think that she required v.s.; but
cleared the first passages by an emetic & cathartic. A
most alarming state of debility followed these evacuations,
so that I was under the necessity of flying at once to blis-
ters, sinapisms, the free use of wine, & animal soups. These
remedies roused her. But, though she was rescued from
imminent danger, yet a low state of fever continued for
several weeks, & required the employment of wine, bark,
soups, oysters, opiates, & occasionally, mild cathartics. Ab-
lutions of brandy were also used with advantage. She recovered.
Case of E.K.- Another sister was attacked on the 3rd
of the 11th month. The first passages were cleared; but she
soon passed into every fuble state. Her tongue became
foul & dark, sordes collected about her lips & teeth, & she
complained greatly of her head: But from my experience
in her sister A’s case. I made this secondary considera-

























































































































































































24
tion. I had the hair shaved off, & for some days stim-
ulayed the scalp with mustard, & at last applied a blis-
ter. The extremities were also blistered. I gave her a-
bout a wine glassful of wine every hour, & a pap- spoon-
ful of Huxham’s tincture every two hours. I was par-
ticulary careful to keep the bowels open with gentle med-
icine, especially with rhubarb. About the crisis of the
disease, I thought it was all over with her. She had sev-
eral large & perfectly involuntary evacuations from the
bowels, which I consider a very dangerous symptom in
an adult. In young persons, I do not so much regard
it. One day I visited her soon after she had a large
involuntary evacuation in bed. At this time her coun-
tenance had a very unpromising asput; & her respire-
tion was laborious, amounting almost to low & frequent
groaning. I directed a blister to the breast, & gave her
strong wine whey very freely, & volatile alkati every
hour. She revived, & her tongue began to clean. The dark
coat broke away, & it cleaned rather smooth- a sure sign
of a tedious convalescence.
A little boy, brother to these young women, I also
attended at the same Time. He was very ill, I not
only blistered his head; but also his extremities. I applied
sinprisms to the scalp before blistering- This is, in some
cases, a good practice. He recovered under the same
plan of treatment, as that which was employed in the case
of his sister. His tongue cleaned smooth, & convalescence was tedious.
      
























































































































































































25
Case of B.A.- I was called to B.A. on the 27th of the 
10th month, 1818. He had been ill several days before I saw
him. His complaint applied to be a remittent, & from 
the apparent action in his system, I thought he would 
bear bleeding in addition to cleansing the first passages.
But his pulse soon became very weak; although he bore
the bleeding will; & his head notwithstanding all my
efforts, great debility succeeded- his tongue became al-
most back, Andes collected about his teeth & lips, his
pulse was very weak & frequent, & he was affected with
[subsult??] tendinum. I now commenced a smart stim-
ulating plan. I directed a glass of wine every hour, a
dessert spoonful of the best Huxham’s tincture every 2 hours,
with the free use of calvis fut jelly essence of beef, etc. His
head was shaved, & a sinapism applied to the scalp. My
friend, Dr. Mone, saw him with me. But before this,
finding that she remedies used did not rouse his sys-
tem as I wished. I put him upon the use of the tur-
pentine julap. A table spoonful was given every hour.
The effect of the turpentine was a most happy one. His
system responded to the treatment; his tongue cleaned
suddenly & smooth, & his recovery was consequently
slow. When he was in his most dangerous state, he was
unable to protrude the tongue- This I regard as a danger-
ous symptom. He was covered with a morbid sweat; &
one morning he was supposed dying: he was in a pro-
 
























































































































































































26
found coma; his pupils were contracted, & he could
neither speak nor swallow. I directed sinapisms,
& fritions with the decoction of cantharides & spirits
Of turpentine. Whether this coma depended on 20 or
30 drops of laudanum, taken in the night, I could
not say: be that as it may, it, happily, passed off. 
He discharged his urine involuntarily; but I believe
He did not his frees. After his tongue cleaned, he
Had a pulse of 120 for several weeks- I think I
have observed this pulse in convalescents when the
tongue clean smooth & glossy.
The turpentine is a most valuable remedy
in some of these cases; & when we wish to stimu-
late to a great extent. It is sometimes preferable to bran-
dy. It stimulates the system without producing any
direct determination to the brain, which is not the
case with ardent spirits. As it is liable to produce a
cathartic effect when given in large doses, it is proper
to administer it in small quantities frequently repeat
ed; &, if it should still purge, to add a little laudanum.
The turpentine may have a good effect in those cases, in
which the bowels are distended with flatus, & the abdomen 
becomes tympanitic. Tympanites of the abdomen is a very
dangerous symptom, form the cause which I have before
mentioned; the same remark will apply to distension of
the stomach. I recollect a fatal case of typhus, I once
saw with Dr. Perkins. The stomach of the patient was 
 

























































































































































































27
like an inanimate bag. When water was poured in-
to it, it could be distinctly heard gurgling in the vis-
cus, without the organ itself appearing to have any
contractile power. I have generally prescribed the
turpentine in this form: I direct half an ounce
of Pulo. Gum, Arab. & the same quantity of loaf sugar,
four ounces of cinnamon water, & 120 drops of opts of tur-
pentine. This is in the proportion of about 15 drops to each
table spoonful, which I direct to be given every hour.
I will now close the subject of remittent fever with
one or two remarks. Among the remedies proposed in 
this disease, mercury, at one time, held a distinguished
rank. My preceptor, the late Dr. Wistar, never had a
favourable opinion of mercury in remittents. A case
fell under his & my observation, which went to proud
that it is not capable of arresting the progress of the disease.
In the fall of 1817, I attended a patient in consultation
with Dr. Wistar & Gibhard. The case was a most violent
attack of bilious remittent, in a powerfully strong man,
about 30 years of age. He did about the 11th day from
his attack. In the early part of his illness, Dr. Gibhard,
after bleeding the patient, & giving him an emetic & a
cathartic, put him on the use of mercury. His mouth
was evidently rendered sore by the mercury: yet it did
not appear to cause the slightest change in his symp-
toms. In confirmation of this I will state, that in
the epidemic which occurred in the autumn 1822,
  









































































































































































28
Dr. Atlee informed me he had one female patient
that was several salivated without appearing in any
degree to arrest the fever. And Dr. John Wilson Moore
informed me that the same thing occurred in the 
Pennsylvania Hospital, during the period of his at-
tendance.
Although I do not believe that mercury will ar-
rest the progress of remittent fever; yet since reading
Arpis work an Marasmus, I feel satisfied that in
remittents, especially in the protracted forms of the di-
sease, & in nervous fever, as it is called, very small
doses of mercury may be advantageously employed. 
I [o???ah] not theoritcally , but practically . I often use
1/6 or ¼ of a grain every one or two hours. It sudden
interfuse with the ordinary modes of treatment; it ap-
pears to me to have, when given in this way, a most
wonderful influence over the lives, correcting the mor
bid [????tions] of the liver, & causing more healthy
bile to be [??ulged] into the intestines; thereby render-
ing them more soluble, & I believe doing, in some
way or other, much good. In pursuing this plan I
never desire to salivate.
In remittent fever, I have met with a few instances
of sore mouth, resembling that induced by mercury,
although none of this medicine had been administered. It
is will to be aware of this circumstance, so that should such
cases occur to you heafter, you may be prepared to answer
any charges which may be made to your disadvantage.     
































































































































































29

Malignant Intermittents.
__________X____________

Having completed the remarks which I had
to make an remittent fevers, as they occur out of the
usual course, I will now detail to you, a few cases
of malignant intermittents.
Case Of J.M.S.- The subject of the present note
had been down to Appoquiminink to superintend the
clearing of some wood-land. There he contracted his
disease. He returned sick, & I saw him at his brother’s
ours Schuylkill, At first it appeared like a quotidian;
& I thought on my second visit that it would yield
to the use of bark: but in this I was disappointed. His
disease suddenly assumed a malignant & alarming ap-
pearance. I think I never witnessed a more distress-
sing train of symptoms in the accession of a paroxysm.
He was in a state of extreme depression, & his nervous
system was excessively affected. He appeared every mo-
ment as if he would faint, insisted on having the win-
dows opened, & made most distressing efforts to vomit.
His pulse was extremely feeble; his skin cold, & his
respiration so much affected, that he complained of being
unable to get his breath. While the patient was thus
affected I saw him & gave some vol. sp. ammo. In
water, as this happened to be at hand: but it really
appeared to increase his distress. I placed a very large 
   




























































































































































30
blister over the region of the stomach, made the same
application to his extremities. I also employed hot ap-
plications, as sinapisms, etc.; & gave as internal stim-
ulants, Maderia wine, supentaria, porter, essence of
beef, calves feet jelly, etc, etc. The treatment was, in
many respect, similar to that of S.M,s.
In some cases of great prostration, I have observed
this difficulty of respiration do depend on a seeming     
consciousness of the patient, that some cause exists
which prevents the lungs from properly fulfilling their
office. This is particularly the case in typhus fever:
the patient makes most violent efforts to inhale, but
such is the extreme torpor of the nervous system, that
the lungs are incapable of oxygenating (decarbonizing) 
the blood; & hence the sense of suffocation which
the patient so distressfully exhibits. The breathing, in
such instances, reminds me of the horses of Duputregen 
which, when the 8th pair of nerves were divided, exhib-
ited the same laborious & heaving respiration.
The following interesting ease is more in detail.
Case of J.W- 6th mo. 5th, 1815. I was called
yesterday to J.W. whom I attended last fall in a com-
mon intermittent. In his present illness he appeared
he appeared to be labouring under a regular quotidian of a
few days standing, & was seen by my friend Dr. Gallaker
for me, which I was an a visit to Burlington. The Dr.
   

























































































































































31
had bled him, & given him an ernetick. I saw
him twice to-day, & in the evening found him with 
a most skin, & an absence of fever. I directed a de-
coction of supentaria to be taken cold, beginning ear-
ly in the morning.
7th. He was taken with his chill this day
, & I became  
extremely ill. I saw him about 12 o’clock, & found
his situation dangerous in the extreme. He was affect-
ed with violent, spasmodic pairs; sometimes in one
side, & then in the other; sometimes extending from
under the left clavicle downward towards the pubis- he
would scream out violently with the pain. His res-
piration was hurried; his pulse almost too frequent
for enumeration; his skin cold; his countenance 
shrunk; & it really appeared as if his system would
sink under the load of disease that now oppressed it.
His stomach, that vital part, which so often sympa-
thizes with, or rather is involved in, violent affections
of the nervous system, was affected with a seven retch-
ing, which appeared greatly to increase his distress.
I immediately resorted to the liberal use of lauda-
num, brandy loddy, ginger tea, & sinapisms exten-
sively applied. These last affected him smartly &
speedily. I directed his feet to be immersed in hot
water by placing them in a flat tub containing the
water, & put under the bed clothes. Thus occupied the
practice for about two hours. But as his system did      























































































































































32
not rise as I hope for. I direction friction of the
decoction of cantharides mixed with oil, to be made
to his lower extremities; & blister to be applied to his
wrist: a blister was also placed on his side. At any
desire Dr. Galliker saw him with me; & we at
once concluded to give bark a fair trial. We began
with it in substance, adding the tincture to each
dose; & by taking it in small quantities frequently,
he got down about [?i]. At this time his stomach
began to reject it. We then substituted a strong de-
coction, & gave a table spoonful every hour with
half a table spoonful of Huxham’s tincture: 30 drops
of laudanum were given occasionally when the patient
was restless. One of my pupils remained with him
during the night; & as it was desirable to support
his strength with nutriment, he took, frequently, es-
sence of beef & calves’ feet jelly.
8th. This morning he is still very weak; his
pulse is very small & fubble, & beats upwards of 120
strokes in a minute; his countenance is very yellow;
& his tongue is coated with a yellow fur. We directed
a continuance of the same plan, with the addition
of gr iii of opium in anticipation of the paroxysm,
which he most happily escaped. We found him,
however, in the evening, still with a frequent & very
fuble pulse; but, on the whole, rather improved. We
ordered a regular continuance of the back every hour,























































































































































33
& drinks & nourishment as before. One of my pupils was
again left to pass the night with him.
9th. He has taken his bark regularly, & is evidently a
little improved. But as we greatly dreaded the accession  of
the paroxysm, we gave him, at 10 o’clock. Gr iv of opium, &
continued the bark as before. The opium he as heretofore 
taken has had very little effect in causing sleep, & his
head been remarkably free from pain, & his intellect 
clear. Happily, for the poor fellow, he again escaped his
paroxysm this day. We continued the bark through the night.
10th. This morning we found him generally improved;
his strength increased; his pulse stronger & less frequent.
We directed his bark once an hour instead of half hour.
The patient recovered perfectly under the use of tonics par-
ticularly bark.
These cases of intermittent fever, happily, are rarely
met with in practice. When you see them you will
be alarmed, & will be under great apprehension of speedy
death. In the cold stage, the system seems to be weighed
down by the force of the disease, & rises with the almost
difficulty. Dr. Henson informed me that he had a
case of this kind at Camden. Though he visited the pa-
tient at the expected time of the accession of the paroxysm;
yet, notwithstanding all his efforts, the system sunk,
& the patient in the paroxysm.
The most distressing symptoms- a cold skin, shrunk,
& ghastly countenance, frequent & feeble pulse, violent    
























































































































































34
Agitation of the whole system, vomiting, & laborious ef-
forts at respiration, mark the cold stage of a malignant
intermittent fever.

Yellow Fever.
_____X______

This is certainly a very interesting disease, in-
asmuch as it has often carried terror with through the
principle cities of the United States. The time has been, & 
may again occur, when in some of our cities, it might
with propriety be denominated “the pestilence that walk-
[??h] in darkness, & wasteth at noon day.”
Previously to the description of the disease, it proper that
We should inquire whether it is contagious or non-conta-
gious; of domestic or of foreign origin.- Before we enter up-
on this inquiring, it may not be amiss to remark, that a 
most obstinate & melancholy dispute arose among the
physicians of this city, many years ago, relative to the sub-
ject which we are about to discuss. Yellow fever because
a medical Babel; a confusion of language arose, & many
unpleasant circumstances resulted. Two parties were found;
&, as among men engaged in polities, the democrats &
federalists; so among physicians, the contagionists & non-
contagionists were arrayed against each other. Some of
the most distinguished & worthy practitioners of Philadelphia
were warmly engaged in the dispute. Passion was enlisted,
personal feeling were excited, & I look back with regret






















































































































































35
on scenes which, as long as they are remembered, must
be painful. These contests exit no more: they have
gone down to the grave; & it is to be hoped that the dis-
position which accompanied them has departed forever.
When we reflect on the subject, we may exclaim, peace
to the memory of men of worth: if they erred in some
things, they were, on the whole, an honour to their
profession, & deserve to be remembered with gratitude.
But now, the present generation may take up the
subject with different feeling. We have never written
books; or, in other words, we have never staked our
reputation on the contagious or non-contagious nature
of yellow fever. The age of most of us forbade our being
engaged in the content of 1793. Hence we may now
coolly & philosophically examine into the question.
That yellow fever is, under certain circumstances, a
contagious disease; & that it may be introduced from
foreign countries, I do fully believe. As far back as
1762, or thereabouts, (I do not recollect the year precisely,) 
A striking instance was afforded in the city of Philadel-
Phia, of the contagious nature of yellow fever. A gentle-
man died in the West Indies of this disease, & his clothes
were sent home to his friend in Philadelphia. They were
placed in a store near the wharf; &, at the time in which
they were examined, it happened that a number of per-
son were present, & among the rest, the grandfather of Dr.
Samuel P. Lpiffitts. Several of these individual were seized  





















































































































































36
With the yellow fever, & in a short time died. From this
point the disease spread to the contiguous houses, & a great
alarm was excited through the tower.
But the destruction was not to be compared to what took
Place many years afterward. It is remarkable fact,
Which must be admitted by every one to be trice, that when-
ever the yellow fever has occurred in our city, it could al-
ways be traced to one point, & that point has always been
somewhere on the show of the Delaware. Soon after its
appearance, when several persons had fallen victims to its
fury, we could with considerable precision, have the
cases which occurred, either to a communication with the
sick, or to an exposure in that part of the city which
was the first starting point of the disease. At last, when
it became general, the tracing of particular cases was
entirely done away. Yet condom induces me to state,
that, so far as my observation extended in 1820, when
the cases were but few, I found no instances of conta-
gion from those who sickened out of the infected district.
Yet certain cases occurred about Duke sheet & its vicinity,
which I did not see, that were referred to exhalations 
from Peg’s run by some practitioners, & by other traced
to a boy who did in consequence, it was said. Of having
been in the infected district. The progress of the fever,
moreover, was, for some time, very gradual. Hence, after
we heard of the death of one, several days elapsed before ma-
ny others were seized. It seemed to be confined to partic-   



















































































































































37
ular neighbourhoods, spreading from house to house like
a devacuing fire. In this respect it differed essentially from
those disease which are the result of marsh miasmata. In
thses, when the complaint has once set in, it spreads with
considerable rapidity, & the whole country is, in a short space
of time, more or less affected.
Opposed to the doctrine that the yellow fever is a dis-
ease sui generis, & of a contagious nature, it was asserted
by many to be nothing more than the common bilious
fever, of our country, of a high grade. This was the fa-
vourite opinion of Dr. Rush. Now, it bilious fever of a
high grade depended upon the causes which produce this
disease, it would be reasonable to suppose, that in the sea-
sons when yellow fever prevailed in the city, those situa-
tions which were most exposed to march miasmata, would
be more affected with the complaint, & in amore malignant
form, than other parts: but the fact was precisely the reverse.
In the Neck, a strip of land lying between the rivers Dela-
ware & Schuylkill, below the city, where intermittent and
remittent fevers are very common, it is remarkable
that in some of the years, when the yellow fever prevailed 
in the city, the unhabitants were unusually healthy . This
was particularly the case in the year 1793. Fever depend-
ing on marsh miasmata affect the system again & again.
Indeed it seems as if there were an increased susceptibil-
ity in the patient to the disease, when again exposed to the
same cause. For example, let us suppose a person who,  



















































































































































38
year after year, has been subject to the fever & ague, to be
placed with another man, who has never been affected by
the complaint, in a situation exposed to the action of mias-
mata; so far from being the last, he will probably be
the first to experience it. Instead, therefore, of wearing out
the susceptibility to a return of the complaint, these fever
seem to increase it. Hence, in countries subject to the
fever & ague, we find persons whose constitutions are,
comparatively shattered by frequent attacks of this disease.
Nothing is more common than to see patients with the
ague-cake or enlarged sphere, & a yellow, sickly counte-
nance, which indicates a warn-out state of health. Now
yellow fever is exactly the reverse of this. I hold it to be a
principle, capable of the clearest proof. That persons who have
once been attacked with this fever, so far from being left
with an increased susceptibility, lose it almost, if not, en-
tirely. To illustrate this statement, a prominent fact can
be adduced: let us take the medical men as a body, &
begin in the year 1793; when the disease occurred in that
year, only one or two of the physicians then existing had ever
practiced in it; the rest had never seen it, nor had they 
ever been exposed to its influenced.- Dr. Rush, Physick,
Wistar, Griffitts, James, etc., were then, comparatively young
practitioners. What was the consequence? Scarcely  a
man of them escaped the disease: they were almost all
of them taken down, many were very ill, & a number
died. Well let us now mark those same men who
     

















































































































































39
stood the storm of ’93. What became of them? Since
that time many thousands have been swept away; but
has any one of these physicians been of the numbers? Not
a man. Few of them have ever had the disease. Dr. Phys-
ick pays says he has had it repeatedly. This I do not deny: but
I cannot help saying, that he had a very accommoda-
ting yellow fever. Of those who survived the storm of
1793, not a single man has died; whereas, during the
Yellow fever in 1798, & subsequent visitation of this epi-
demic, a large number of young & unseasoned practition-
ers, have been affected with the disease, & many have
fallen victims to its violence. Dr. S.P. lpiffitts is a man
whose authority I consider very high. For a long time he
was exposed to the yellow fever, & stood faithfully at his
post from the year ’93 to the present time. His testimony
is, that he has rarely, if ever, seen a decided case of a second
attack of yellow fever: at any rate, he will go this far;
that he has never seen an instance of death from a sec-
ond attack. This opinion would have been divided some
years ago by a great majority of physicians. But the
fact to which I will now refer you, is important to be
known. All soldiers in the army are registered, so that
they can be traced from one place to another, & can always
be discriminated. It so happened that when the yellow
fever raged at Gibralter, one or more of the regiments had
been affected in other countries. Among these was
not a single officer or private soldier attacked with the
   














































































































































40
fever, while their companions were dying around them
in great numbers, And I may remark, [??erdentally],
that at Gibralter, a rock bare & rising to an immense  
elevation above ocean, miasmata could not have
been the cause of the disease. The report of a committee
of physicians who were appointed to examine into the
nature of the yellow fever, as it occurred at Gibrater and
other places, is worthy of an attentive perusal. I admit
that it may possibly be taken a second time: But I
consider these cases as raw as secondary small-pox.
But in opposition to what I have said, it may be urged
that the yellow fever was not communicated in the
country; &, therefore, cannot be considered as conta-
gious; for those complaints which are universally ac-
knowledged to be contagious, as small pox, measles, etc.
are propagated alike in all situations. I admit free-
ly that the complaint under consideration seldom spreads 
in the country. I have lived in the yellow fever hospital,
in the neighbourhood of Philadelphia, for months, & sev-
eral hundred cases came under my notice. I have
seen the nurses lie down in the very beds where the
patients had been placed, & go to sleep in the wards, wraped
up in the clothes which had lately covered the sick, & even
the dead; & yet, I must acknowledge, that no instance
of death occurred among them, except one or two when
the patients had contracted the disease in the city. But
though the yellow fever seldom spreads in the country,  





























































































































41
Yet it sometimes does. Instances may be found, where un-
der peculiar circumstances, the disease was fatally com-
municated in the country. In the year 1808, a friend
named Kirkbright, from Bucks county, came to Phila-
delphia to attend the yearly meeting. He contracted
the fever, went home, & died. His daughter, who thro’-
out his sickness, acted as a faithful & ender nurse
to her father, received the disease & died also. Dr. Wistar
who staid near Germantown, recorded some instan-
ces, (& laid them before the college of physicians,) where
the communication of the fever was stricking. It was
brought from Philadelphia in the first place, & after-
ward spread from house to house; nor did it cease 
before several persons had fallen victims to it.
But even admitting that the yellow fever cannot spread
In the country: it argues no more than this: that the
Air of the country is not a soil congenial to its growth.
The city air is more congenial to it: here its seeds
sometimes spring up, flourish most luxuriantly, & 
produce, as their fruit, the most fatal consequences.
If we regard the variety of seeds in the vegetable world,
we shall find, that in the same soil, some will
flourish, which others will perish. The principle of
vitality exists in the seed; but its action depends on
its meeting with something capable of eliciting it. Thus
it is with yellow fever: in certain seasons, & in cer-
tain situation, its seed will remain inactive & perish;    





























































































































42 
while in crowded, & in the heat of summer, they
may meet with a soil perfectly adapted to them.
It disappears with frost. This must be admitted; &
Is one argument which would favors its origin from
Those cause which induce bilious fevers. But if this
Disease were a high grade of bilious fever, as the non-
contagious its have contended, how did it happen, that
in the year 1793, it was so little understood? Men of
the most distinguished [tal??ts] & respectability in their
profession, had been accustomed to treat bilious fever,
in all its varieties, for 20, 30, & even 40 years: yet
when the yellow fever came, every candid men will ac-
knowledge, that it was a peculiar disease which he had
never seen before, & one which he did not understand.
When it first appeared, I have been informed, (for I was
too young myself to know,) that a physician would
be called to a patient labouring under a fever; would
attend two, tree, or four days, & would then find a
pleasing remission which indeed him to expect, in a
few days, the complete restoration to health. If the
question were put to him.- Dr. how is your patient?
He would cheerfully answer, that he was rapidly recovering.
Perhaps the next day, or the day, if the question were put
to him, he would declare the melancholy fact, that his
patient was no more! Now had it been a high grade
of bilious fever, practitioners would have known more
about it. Dr. Rush used to tell us in his lectures, “Beware   



























































































































43
of the natural pulse, the natural tongue, & the nat-
ural skin, in yellow fever.” It is fact that fatal
cases have occurred with all these. This is contrary to
bilious fever, in its most malignant character. Di-
urnal exacerbations & remission may be observed in this
complaint, down to the very period of death.
The black vomit is another distinguishing mark.
The grissini black vomit, (though it has often been
attributed to bilious fever, seldom, if ever, attends it,)
was a very common symptom of yellow fever.- I
shall hereafter point out the difference between the gen-
uine black vomit, & the dark bile which is frequently
puked up in bilious disease.
While on this subject I may mention the walking.
cases. These constitute a very striking distinction between
the two complaints, being entirely unknown in com-
mon bilious fever. Let a man become ill of this dis-
ease- where shall we find him? He will be in bed, un-
less he may occasionally be excited to action be delirium.
But in the early stage, muscular debility is almost an in-
variable attendant of bilious fever. On the contrary, in
yellow fever, the strength will remain at a time when
the circulation is almost gone; I hence walking cases
are will understood by physicians accustomed to the
disease. Sometimes the patients walked in the street,
entirely pulseless; & droped down dead before any one
thought of their being seriously affect. Dr. Dorsey















44
Who was will acquainted with yellow fever, found a patient
in Market street, in this condition, He saw a crowd 
collected round a man: he steped up & placed his fingers
on the pulse; he found there was none to be felt; he un-
organized a case of yellow fever, & directed that then man
should be sent to the Hospital. Some of the people
around him, called him a fool, & denied that the com-
plaint was yellow fever. The patient came under my case
in the Hospital, & died in less than 24 hours. While I was
residing at the Hospital, a patient with a bundle on his
back, walked from the Neck, & presented himself for ad-
mission: he had no pulse, or it was barely perceptible. With-
in 24 hours he died. It was not uncommon for patients
to present themselves for admission, when, a person accus-
tomed to the complaint, would pronounce, that they must
certainly die. I recollect one case, when the man ran
about the lot, & stoned the nurse who pursue him; he
was, notwithstanding, destitute of a pulse. This is different
from any thing we meet with in bilious fever.
Sore throat & a red eye, particularly the former, were
symptoms which occasionally attended the walking cases.
I recollect a man with these symptoms, who was high-
ly offended, that wen should suppose him ill, & insisted
that nothing was matter with him. We who were
accustomed to the disorder, apprehended the almost danger,
& our apprehensions were soon justified by his death.
These cases I have mentioned to share, that the dif-
  
















45
ference is very great between bilious remittent, & yellow 
fever. Here a question might present itself to you;- what
advantage can be derived from an investigation of this kind?
Our object is to cure the disease; why should we spend time
in endeavouring to ascertain the manner of its propagation,
when, after all our efforts, the subject may remain undecided?
The answer is plain. As medical men we are placed in a
responsible & awful situation: we are looks up to as the
guardians of the publick health: upon our opinion, in
some measure, must be grounded the laws of our country;
& when we recollect that populous are most com-
monly the places visited by the disease, the subject pre-
sents itself in an important point of view. If the com-
plaint is contagious, it then becomes necessary to avail our-
selves of the means calculated to prevent its propagation.
Even if it is of domestic origin, it is important to investigate     
its causes- How important that circumspection & decision
should mark the conduct of the physician! Instead of
first spreading an unnecessary alarm by publicly an-
nouncing the first case he may meet with, let him place
the responsibility on the board of health, you can have no
idea of the affecting scenes which result from the pressure of
yellow fever in a large city. There an unusual alarm a-
mong the inhabitants, & the whole town exhibits an appear-
ance entirely different what we usually observe. I
myself have witnessed the day, when the streets of Philadelphia
have been at noon as silent as at midnight; when the    















46
hum of business, the sound of footsteps, & the nosing zattling
of pleasure carriages, have been entirely suspended, & scarce-
ly any sound was heard, except such as prouded from the
sick-cart & the hearse. Mary a time has our city been
clothed in sackcloth & mourning. Hence, it becomes of
vast importance, that we should investigate the causes of the
disease, & thus be enable to use the means which a Be-
neficent Providence may have placed in our hands to pre-
vent its occurrence, & to oppose its propagation.
This disease, as is common with all fevers, has a cold
stage, either exhibited in a distinct chill, or in that rigour
or sense of chilliness which ushers in febrile diseases. After
this, reaction of the system generally occur, though not in
all instances, & a fever is fully developed. It may be divi-
ded into three grades: as may be seen in families and
hospitals- the mild, the occur, & the disorganized, or where
they begin to die from the onset of the disease. At this early
stage of the business, we find such symptoms as usually
characterize fevers: viz. the hot & dry skin, great restless-
ness, pain in the head, etc. But generally speaking, the
eye of the practitioner, accustomed to the disease, early recog-
nizes a [p???lia?], &, I believe I may say, an indescribable 
expression of countenance which he may perfectly under-
stand, but will scarcely be able to explain- a certain ma-
lignant asput, a lurid hue of the countenance accom-
panies these cases, which is seldom met with in other
complaints.          
















47
The reaction of the system is sometimes so considerable as
to call for the lancet. Evacuations at this period of the dis-
ease are in many cases, useful, with the exception of one
mode which is common in other complaints of febrile char-
acter: I allude to the evacuation by amities. I believe
that among the contentions which took place among med-
ical man, not only as the cause, but also as to the
mode of treatment, a very little experience united them
in one point; viz. That amities are improper in yellow fe-
ver. I shall, in another part of the lectures, treat of the par-
ticular remedies adapted to this stage of the disease, into
a detail of which, I cannot afford time to enter, at present.
The yellow fever is, I think less liable to remissions, & takes
on more of the continued form than our common remittent.
The patient is frequently in a state of continued fever for three
days. About this time a change often occurs which is
very deceptive to young practitioner, or one unacquainted 
with the disease. He will visit his patient & find the fever
subdued, the skin cool, & the sick person free from pain &
in a very composed state. Even if he feel the pulse, he will,
in some instances, find it to possess very much of the nat-
ural character. He will be inclined to think that every thing
in going on well, & that a delightful remission has occurred.
Perhaps the only uneasiness which the patient experiences , is 
a slight sense of weight about the stomach. But the ex-
perienced practitioner sees the disease making its ravages 
on the system, & apprehends that fatal consequences are        















48
at hand. About this period a yellowness of the skin
often makes its appearance. A dark orange yellow spreads
over the whole body, but is particularly observable in the
eyes, face, & about the neck & breast. If we make the small-
est pressure on the epigastric region, we [ma?] now under-
stand at once, the danger & seat of the mischief. It often
happens that a slight pressure with the hand over the
stomach, makes the patient almost scream with pain;
and it was as much the custom to press on this part, to
ascertain the degree of tenderness, as it was to feel the pulse
of the patient. Such was our uniform practice at the Hos-
pital; a patient, I believe, never entered without being
subjected to this test. But I have seen some cases, even
with black vomit, without any peculiar tenderness on pres-
sure.
Hitherto the patient has been perfectly sensible; with-
out any delirium, & anticipating, perhaps, a speedy resto-
ration to health. But what follows? This deceitful calm
soon passes away, & the third stage is ushered in. It is
frequently manifested by that most terrific symptom black
vomit. The patient begins to throw up a great quantity of
black matter resembling coffee grounds. The pulse now
sinks; dissolved blood oozes from the gums, the tongue, the
kidneys by urine, & from blistered surfaces. For a day or
two before death, there is often a total absence of pulse at the
wrist. What is very remarkable, after these terrible symp-
toms have been fully developed, we observe, in many in-       















49
stances, a perfect clearness of intellect. I have witnessed
some affecting scenes after black vomit has been thrown
up, & the patient has been perfectly aware of the consequen-
ces. One case in the Hospital affected my feelings very
much. The patient was a young widow,(with one child,)
the daughter of a Baptist clergyman, & had been piously ed-
ucated. Soon after her admission, she threw up the black vom-
it. I happened to be in the ward at the time, & heard
her exclaim, when she first saw what she had thrown
up, “I am gone! I am gone!- Doctor, pray for me.”
She was perfectly aware of the consequences, & from that
moment expected, with composure, the fate that awaited
her. She wished to make her will, & requested me to write
it for her. I sat on the bed side & wrote while she dicta-
ted with as much clearness, as if she had been a state of 
perfect health.- I recollect another case: A man
whose whole family was brought with him to the Hospi-
tal, & whose wife was in another ward, was sized with
fatal symptoms. While in the dying state, he conversed
with me freely, & seemed perfectly aware of his situa-
tion. One question which he asked me, I shall always
remember:- “Doctor, are you married?” When I an-
swered in the negative,- he said, “If then you should
be taken away, you will have less to trouble you, then
one who is about to leave behind him a wife & six
helpless children.”- Another man only a few known
before his death, requested me to write his will. I
        















50
did so. It was about 12 o’clock at night; & before
morning he was dead.- To show the clearness of intel-
lect which was often observable in the last stage, I will
mention, that this patient informed me the exact
sum which he owed at a boarding house in this city;
& having some money in his pockets, called for his
clothes, counter out the sum, & requested the person who
Settled his affairs, to be informed that he owed so much,
& no more. This clearness of mind did not, however,
occur in all cases.
Same patients died without either hemorrhage or
black vomit. I briefly hinted, when speaking of the
walking cases, that these were among the fatal in-
stances of yellow fever, occurring without the symptoms
just mentioned. Yet we find in these cases, a set of
symptoms well understood, & general regarded as fatal.
If a patient presented himself to a physician accustom-
ed to yellow fever, with a malignant countenance, a   
friry red eye, & a throat somewhat sore; if upon
examination he was found to pass no urine, the case
was considered as certainly settle as if the patient were
dead in his coffin: although he might have been
walking about at the very same time. I witnessed
the case of a man, lately arrived from New-York who was
exceedingly offended at being placed in the hospital &
regarded as a sick man, when he considered himself per-
fectly well. But as we expected, so it happened- he 















51
died in a short time. Another case occurred with the same
train of symptoms, or, at least, an extremely malignant coun-
tenance & a deficiency in the secretion of urine. This man
died in 48 hours. He perspired most profusely; & this, as
I have before stated, instead of being salutary in the last
stage of fever, is often indicative of a fatal termination.
Some cases of yellow fever were marked with the most
profuse sweats, so that the patient appeared as if he had
been in a bath; these cases were not common.
I have seen a patient brought to the Hospital, able
to walk about, with his face perfectly purple. There was
that kind of death in the extreme vessels, that allowed
the dissolved blood to stagnate in their cavities; & the
countenance presented an appearance, than which nothing
can be conceived more awful. He died in a very short time.
In fatal cases of yellow fever,(as it was found upon dis-
section,) the stomach exhibited marks of very considerable
inflammation. Some patients were affected with coma from
the very commencement. When the disease first approached,
they feel into a state of lethargy, & slept away life, without
any suffering, or consciousness of their situation.
I have before mentioned, that, in some cases, we meet
with a natural tongue & natural pulse, & quoted to you
the expression of Dr. Rush.- “Beware of the natural tongue
& natural pulse”. In these cases, although the tongue & pulse
are natural, yet the countenance, that certain index to an ex-
perienced physician, discovers to one accustomed to the disease,        
     
 















52
that great danger is to be apprehended- they gen-
erally prove fatal.
Many patients, as I before observed, retain their in-
tellects unclouded till the last moment: but this is not
the case with all: I have observed the most distressing
delirium through the whole period of the complaint, par-
ticularly in the last stage. I remember the case of a
Danish sailor- a strong, athletic, & muscular man who,
in the dying condition, afforded the most distressing
spectate of furious delirium: he rolled & tossed himself
about, raved incessantly, used the most violent muscu-
lar exertions, & seemed to resist death with the several
struggles. For his own sake, & for the sake of the sick
by whom he was surrounded, it was necessary, however
unpleasant the expedient, to resort to the strait jacket;
& this confined, he was carried into one of the out houses     
while on the very point of dying.
To give you some idea of the appearances of yellow
fever as they presented themselves in this city, I will state
a case which I witnessed while a student of Dr. Wistar.
The patient was a young man in Greenleaf’s Alley. Dr.
Wistar attended him through his disease; &, on the night
of his death, I went to see him with the Dr. His head
had been shaved & covered with a blister; he was in bed,
& dissolved blood was oozing from his gums & nostrils.
Directly opposite to the head, the wall was smeared with
Blood & discoloured saliva which he spit against it. He   
















53
was steadily delirious, & his delirium was accompanied
with rises sardonicus, that griming, horrible laugh
which constitutes the most distressing expression of which
the countenance is susceptible. To crown the whole, there
was a black nurse in the room, his only attendant, who,
to avoid the danger of infection, had muffled up her mouth
with a dirty towel. I recollect that the impression made
on me by the spectacle, was a strong one. The patient died 
before morning.
I have spoken of the walking cases as constituting a
marked line of distinction between bilious & yellow fever.
These cases, when the patients were without pulse, were al-
most invariably fatal: yet one instance of recovery fell un-
der my notice at the Hospital; &, as it is interesting, I will
relate it. The patient was a female. At the time of her ad-
mission several other patients were brought in. one in par-
ticular was extremely ill; & both the nurses & myself were
engaged in giving our attention to this one, when the
woman alluded to come up into the room. I turned round,
put my had on her wrist, & found her without pulse: but
as she appeared strong, & did not seem to require imme-
diate attention, I requested her to sit down till I should
have finished what was requisite for the other. After a lit-
tle which, looking round, I found the patient gone. She
had been alarmed by the spectacle of the sick & dying,
& had made her escape as rapidly as she was able. I dis-
patched some nurses after her, who brought her back. She        

















54 
was perfectly pulseless. We placed her on a bed, & resorted
to the people treatment. But she resisted every thing that
was done for her.- She was an Irish Roman Catholic. She
fought & swore, & the nurse could do nothing with her.
Under these circumstances we resorted to a catholic purist
who daily attended the Hos[ital., & stating the case to
him, assured him that every thing depended upon the
diligent use of stimulants, particularly wine. He told us
in a tone of great confidence that he would make her 
take it. At our desire he spoke to the patient, & I remem-
ber his works- “Hut! woman, the Dr. tells me you
won’t drink the wine- won’t you drink it? Tis no sin
to drink now- won’t you drink it?” “yes”, she replied;
& there was no difficulty afterward. This was the
only instance of recovery where the pulse was absent.
I have not yet said much of the particular kinds
of pulse in this disease. In the early stage, as I have
before remarked, it is sometimes proper to employ the
lancet. But I wish to guard you against a particular
form of pulse, which is occasionally met with in yellow
fever. It was denominated by Dr. Rush, the gaseous 
pulse. I recollect one of the first cases which fell un-
der my notice, as it made a strong impression on my
mind. The patient was a young man, & was not ve-
ry far in the disease. His pulse bounded, apparently,
with great violence, & gave me the idea that the ar-
tery was twice the natural diameter. The first im-  

















55
pression from feeling the pulse was, that there exist-
ed violent, inflammatory action. But with the slight-
est pressure, it passed away under the fingers like a
bubble of air. This pulse is, in general, a very bad one.
In one instance I took away a few ounces of blood; but
the patient was soon disposed to faint, & finally died
with black vomit. The blood that is drawn from the
arm in this complaint is occasionally dissolved. It is
like tar, & its power of coagulation is lost.
I have been struck with the remarkable alterna-
tion between the brain & the stomach, which some-
times occurs in yellow fever. I have seen patients
with black vomit, & that of some continuance, sud-
denly relieved from this symptom by the superven-
tion of coma, & these circumstances often alternate with
each other. Sometimes there is coma & a quiescent 
stomach; at others, the head is sound & the stomach
irritable; & sometimes, (strange to tell,) even after
the appearance of black vomit, the patient mani-
fests a disposition for food. One of our patients of
this description , sat on the side of his bed, devouring 
the leg of a chicken.
Black vomit in unattended, in many patients, with
nausea- they have acid eructations. Violent con-
vulsions sometimes attend the last stage of yellow fever.
Much has been said of black vomit, & much
deserves to be said: because it is one of the most stro-     













56
king symptoms, after the appearance of which, the
patient rarely, if ever, recovers. I have heard of recov-
ery from black vomit, but never seen one;
with the exception, perhaps, of the case of the little child
where the flocculent appearances of black vomit was
once seen with the fluids ejected from the stomach.
But I hardly consider this as an instance of black
vomit. I once saw a case which appeared likely to
recover, & I was almost induced to believe that my
previous views were not correct. The patient was
put into a hot bath. The water was not merely warm,
so as to relax him, but hot for the purpose of stimu-
lating. It had a very good effect, & for the first day
or two, the symptoms were flatting. The pulse which
before was hardly perceptible, now became full & com-
paratively strong: but there was great tumefaction about
the throat, somewhat like carbuncles in the plague; &
it seemed that the mechanical pressure had some-
thing to do with the death of the patient. I had some
idea of opening the wind pipe: but considering all the
circumstances, & among others, the number of persons
among whom it must have been resorted to, & and
whom it might have produced some bad effect, I
declined performing the operation.
There have been many speculations as to the na-
ture of black vomit. My opinion is, that it is nothing
more nor less than dissolved blood, cast out from













57
the arteries of the stomach. (For further informa-
tion respecting my views of this subject, I refer you
to a piece published in Coxe’s Medical Museum, in
1806 or 7.) At the same time that I make this
observation, I reserve the liberty to state, that there
are appearances in the stomach resembling those in
malignant fever, without any previous inflamma-
tion. Hence it follows, that deductions from the
state of the stomach after death, are sometimes very
uncertain.
It now remains for me to enter upon the prac-
tice which was pursued in the treatment of yellow
fever.- But before I engage in this part of the lec-
ture. I consider it proper to detain you a little while
in making a few observations on a very important
subject; & that is relative to a law which governs
fever in general: whether the various diseases of this
kind which affect the human frame, are to be sub-
dued by active & powerful treatment, or whether they
will run a determined course. I believe that this
is worthy of deep consideration; because, according
to the opinion you form, your future practice will
be regulated. It is a maxim which you will often
hear, that violent diseases require violent reme-
dies. As it applied to some maladies which affect
the human body, I subscribe to its correctness; but
so far as it relates to yellow fever, I am thorough-      












58
ly inclined to believe, that violent practice is of serious
injury. Believing, as I do, that yellow fever, in com-
mon with other disease of the same class, possesses a
specific character, & runs a determined course, my ob-
ject is, not at once to strangle it by powerful practice,
but to endeavour by judicious measures, to conduct
it to a favourable crisis. Let us now view the practice
of a man who believes that the complaint is to be
subdued by active treatment: supposing the disease
to be violent, his remedies will be of the most active
kind; believing that great disorganization will re-
sult, if the force of the fever be not lessened by power-
ful depletion, he will unsheath the lancet with the
utmost boldness, & draw away blood in enormous 
quantities. He will also deplete from the bowels, and
use other active measures to subdue the fever. But rec-
ollect that he has to contend with a disease strongly
disposed to run into a law form, & that if he endeavour
to subdue or cut it short, instead of reliving the com-
plaint, he will conduct it more rapidly into this con-
dition. I therefore consider such views & such practice
hazardous to the patient, not only in yellow fever, but
also in all other fevers which have fallen under my
observation. The doctrine of subduing fever by violent
practice is, in my apprehension, a dangerous doctrine.
In pursuance of these views, it has happened, that even
the common remittents of our country, have been sub- 









59
jected to the most powerful treatment. The consequence 
has been, that many cases which, if left to nature alone,
would have terminated favourably, have been unman-
ageable. I entered the city Hospital under the full im-
pression of the correctness of suffocated excitement. I be-
lieved that yellow fever was a disease of suffocated excitement
in which the system was rendered prostrate by violent ac-
tion; & that, to bring the patient out of this condition,
powerful depletion was necessary: I was even afraid of de-
pleting too sparingly; for I had been taught, in those days
of theory, that if I were to open a vein & take away only
a small quantity of blood, it would be worse than nothing-
I should merely open the cage of the tiger, & give him
liberty to spread havoc around him. I was, therefore,
cautious against small depletion, believing it would let
the system loose, & be production of still greater disorgan-
ization. A little experience soon taught me that these
views were incorrect, & instead of the generally prevailing
doctrine, that disease was a unit; that all complaints 
were one & the same thing, differing only as they hap-
pened to be in different parts of the system. I was at length 
forced to believe that many of them possessed a specific char-
acter, were to be treated by remedies adapted to their particu-
lar condition. I am aware that there are exceptions; but I
fully believe in the doctrine of specific action. Thus a prac-
titioner according to the views which were formerly in vogue, 
would say that every case of inflammation must be sub-      









60
dued by the lancet. But every experienced physician will
acknowledge, that there are cases where the lancet does no
good, & is even injurious. I will call your attention 
to anthrax. The inflammation, in these cases, is discovered
by our organs of vision; it is proclaimed by the sensa-
tions & sufferings of the patient. Yet, if we undertake
to relieve it by the free use of the lancet, we shall incur 
great danger; whereas, by an opposite course of treatment,
the inflammation may frequently be made to give
way. I have this laid before you some general
views, preparatory to my entering on the treatment of
yellow fever.
Practitioners have differed essentially in the treatment
of this disease. Some of them, according to the impres-
sion, that violent complaints require violent remedies,
tested their opinions by their practice. In the first
place, as I before hinted, all seemed to agree that [???t-]
ies should be laid aside. In the common fevers of our
country, these were often resort to before the year ’93.
But for some years afterward, so great was the aversion
to this remedy, that it was scarcely ever employed in
the ordinary bilious disease. But the lancet was strong-
ly recommended, & was resorted to most powerfully. So far
as I can ascertain the disease appear to have assumed
different characters in different years. It is certain that
in some seasons it bore the loss of blood better than in
others. In the years ’93 & ’98, the practice of bloodletting   









61
obtained to a considerable extent. But in some of the sub-
sequent years, Dr. Rush found it necessary to be move
cautious in the use of the lancet. He declared his belief
that the disease had changed its type. He said that
in the early stage, he found some moisture on the skin;
& hence, nature clearly indicated the propriety of pro-
ducing perspiration: consequently, he bled less and
sweat more. This was his practice in one or two of
the last years. At the city Hospital, when the patient
came in, in the early stage of the complaint, we com-
menced, in some cases, with the use of the lancet: but
experience soon convinced us that the disease would
not will bear bleeding: hence, in a large proportion 
of cases, it was seldom, in many not at all, resorted to.
Upon the principle that violent disease require violent rem-
medies, mercury, that Sampson of medicine, was brought in-
to action against the destroyer. This remedy had many
advocates, & was used with a liberal hand. So far as
my experience went, I had no reason to be partial to the
medicine, when used so as to affect the whole system.
While I was a student of Dr. Wistar, I had an opportuni-
ty of seeing his practice in this disease. He was an ad-
vocate for mercury, & used it very liberally. He employed
it in almost every stage: but I must say, that his suc-
cess in the treatment of yellow fever by mercury, was far
less than in other disease which he was accustomed to man-
age. I had, therefore, no reason to be encouraged with       









62
the remedy. Dr. J.P. Lpeffitts used mercury on a plan
more accordant to my views. Instead of applying it
indiscriminately to every stage, he confined it to the
first. It was his practice to commence at once with
the use of calomel, of which he gave one pain every
two or three hours, steadily, through the night & day.
If it purged a little he had no objection. He went on
in this way through the inflammatory stage. He has
repeatedly said that he would not desire to give a
particle of mercury after the third day. By this time
he charged the system; & if inflammatory symptoms
ran high, he resorted to the lancet. After this he purged
with a decoction of senna; & his practice, I think, was
more successful than Dr. Wistar’s. the moderate use of
the lancet was occasionally admissible, &, in a few instan-
ces, when the head was affected, & the pulse tense & con-
tracted, it proved of some service. Cupping was also em-
ployed with advantage in local affections. But the prac-
tice at the Hospital was principally of this kind: When
the patient was admitted in the early stage, we were dis-
posed to evacuate the bowels very liberally, & also to induce
free perspiration: We sometimes used mercurial pur-
ges; but were generally content with milder articles, as jal-
ap, cream of tartar, castor oil, phosphate of soda, & others of
a like nature. The warm bath was a common & useful
remedy. After this we were in the habit of giving drinks
to promote perspiration. The decoction eupatorium perfo-    








63
liatum, or, as it was commonly called, bone-Act tea, with
warm lemonade, were commonly employed; & the pa-
tient was advised to drink of them freely. Among the
remedies useful in this stage to produce sweat, & to com-
pose the stomach, we thought highly of the saline draught 
given in the state of effervescence. If lemons or limes
could not be procured, we were content with vinegar.
This draught was highly calculated to compose the stom-
ach, allay irritation, & produce perspiration. The anti-
monial preparations, so commonly used in our remittent
fever, were inadmissible in yellow fever. Sometimes how-
ever, it would happen that the patient could not sweat;
the skin would be hot & dry, & all our attempts to produce
perspiration would be abortive. Endeavouring to excite it by
warm drinks, & by heaping on the bed-clothes, was productive 
of more harm than good- What, therefore, must be done?
We resorted to that most excellent practice, recommended
by Dr. Currie of Liverpool,- using cold ablutions & cold
drinks. I have often noticed patients asking for cold water,
cold water; & I have always answered, take & drink.
The aversion to cold water & air, formerly existing, was not
only irrational, but productive of much suffering to the pa-
tient. What is more natural than the practice of giving cold
water in fevers? The patient parched by the heat, longs for 
it as if he were in the deserts of Arabia. Cold ablution
is also an excellent remedy in yellow fever: it lesion the
distressing heat of the skin, & diminishes the fever, with-     








64
out reducing the general strength. We were much in the
habit of using it, & reaped considerable benefit. Through
every stage of the disease, we attended to the state of the
bowels; even after black vomit had begun to appear.
Sometimes evacuations were procured by gentle cathar-
tics, sometimes by injections, & frequently with advan-
tage. In fact, in the year 1805, purges were much
employed, & with considerable success. At the same
time, we kept in view the strength of the patient, and
therefore never employed the drastic purges. Blisters
were much resorted to, & I thought with great advan-
tage. The place which we considered as peculiarly prop-
er for a blister, was immediately over the stomach. We
knew the tendency of the disease to this organ, & it was
there that we were to expect the principal mischief. It
became the universal practice in the Hospital, not to
wait till we should discover serious symptoms of disorder 
in the stomach; but to anticipate the disease by the appli-
cation of a large blister over the part. This practice was, I
belive, beneficial. We were not then so will acquainted,
as we since have become, with the advantage of stimu-
lating applications, (especially Dr. Hartshorne’s decoction,) to
the surface of the body. In cases which came within the
reach of treatment, after the patient had got into a low
state, there was great necessity for supporting the system
through the remainder of the disease. By a neglect of this
caution, many patient were lost, if I may use the expres- 
 








65
sion, in the arms of victory. After the violent of the
disease was past, the patient was occasionally left in a state
of extreme debility, & life was supported only by the most
assiduous care. Hence this was one of the most import-
ant periods in the complaint. I often observed that pa-
tients who were admitted into the Hospital in the last
stage, & had previously received no medical attention,
did as well, & some of them better, than those for whom
a great deal had been done. The time when they required
most attention was when they had passed into the low
condition. 
Situated as I was, with the prevailing theories im-
pressed on my mind, I had a dual of stimulating
treatment. My ideas were constantly running on ex-
citement of the brain, & I was in continual fear of affect-
tion or disorganization. But, happily, there attended in
the Hospital with me, an old gentleman, Dr. Jamuel
Duffield, who, though no theorist, had much experience.
He & Dr. Church were the attending physician. I recol-
lect the case of a man, in which the stimulating plan 
was first tied x in which it proved succesful . The
situation of the patient had become very serious, &
much apprehension was entertained as to the issue.
Dr. Duffield proposed that we should enter at once on
the use of wine. I made the observation,- may-be
there is too much action for this remedy? The old
gentleman answered, “May-be the sky will tumble down-     








66
give him wine.” We did so, & he recovered. We were
afterward much in the habit of using wine & cordi-
al medicines. Bark never held a distinguished place
in the treatment of yellow fever.
I often felt extremely anxious for the patients labouring un- 
der great debility in the wards of the Hospital. The nurse could
scarcely yield the people attention: hence I had to watch by
night & by day; & if more success was experienced in that
year, it may principally be attributed to the great care that
was taken in nursing. Late at night I would frequently
walk through the wards with nurses, & point out to them
such patients as I thought demanded the most assiduous
attention. These I directed them to watch carefully; and
warned them, that, unless our directions were punctually
attended to, the patients would probably be found dead in
the morning. If I found the nurse neglect their duty,
they were watched closely; & if they still persisted in their
carelessness, they were dismissed. Often I have gone my
round & retired as if to bed; but in a short time retired
silently & unawares to the ward. Sometimes I have
found the nurse asleep. At length, however, by constant
attention, we established a system of good nursing, to
which many cures must be attributed.
But the great difficulty, in many cases, was, that the
stomach was excessively irritable- rejecting every thing
which was offered. By this circumstance, we were often foiled
in our treatment. At the very time that it was necessa-      







67
ry to support the system, the agent by which this was
to be accomplished refused its office, & the patient sunk
into a very low state of debility. Among the remedies
employed to allay this irritability of the stomach was
lime water & milk. A table spoonful of each of these often
remained when other things were rejected. Various other
plans were resorted to. The hot bath was employed in
some cases; & in one was attended with the effect of allay-
ing irritation & improving the pulse. On the recommenda-
tion of Dr. Physick, we also employed the spirits of turpentine.
He proposed it from the idea that the action in the stomach
was of a peculiar nature; &, if we could substitute a new
inflammation by means of the turpentine, we should be like-
ly to relieve the pre-existing disease. One, & even two tea spoons-
ful were given at a time; but we did not meet with much
encouragement to persevered. But though taken into the stom-
ach, this remedy proved of little use; yet in the form of
injection, given till it produced strangury, I thought it bene-
ficial. We administered it in larger doses than those in which
it is now prescribed; & perhaps it might have proved use-
ful, if it had been properly regulated.      







68
Typhus Fever.
_____X______

I propose to deliver some observation on malignant
typhus fever. Typhus fever, in the general acceptation of
the term, is very indefinite: because the term typhus may
be applied to almost all low forms of disease. Thus, a fever in
its commencement may be highly inflammatory; but in
its progress the patient may become weak & exhausted; &
before he dies the fever may receive the name- typhus. But 
I wish it to be understood that this condition of the system, which
may be induced by a variety of causes, is not that of which I
am about to treat. I am about to speck of disease of a
specific nature, to which the name of typhus fever has
been applied, & in which. However contrary the opinion 
may be to the systems of the day, there is, ab initio, a reduc-
tion of the vital powers of the system.
This complaint which has produced a vast deal of
Mischief in our country, first appeared under the name of
spotted fever, in the north & east. We heard of it in New Eng-
lang several years before it appeared in our borders.- The
present course of lecture I wish to be practical; I shall not,
therefore, speak of what I have heard or read, but of what
I myself have witnessed.
I will now simply narrate my first acquaintance with
the disease, as it occurred in the neighbourhood of Phila-
delphia. In the winter of 1812-13, the practitioners of
     







69
of this city hall their attention called to a violent com-
plaint which was raging in Camden, a village on the oppo-
site side of the river. We heard of several deaths. An oppor-
tunity soon presented to me of inquiring into the appearance
& nature of the disease. I was called into Camden to visit sam-
uel Poole. Here I met with Dr. Hendry, a very respectable prac-
titioner, who had seen many patients. He said that it was a
very inflammatory disease; that some persons were affected
with phrenitis, some with pneumonia; & in fine, that it
put on the forms of all the different phlegmasia. He also
said that the blood was very sizy. Poole was the first
patient I saw with the disease; & the case occurred in the
first month of the year 1813. The patient had been ill
several days before I saw him. As soon as I entered the
room I was struck with the malignant aspect presented
by the patient. Accustomed, as I had been, in yellow fever
& other malignant complaints, to observe the peculiar ex-
pression of the countenance, I could not fail to have any
attention arrested by the view presented to me. Before I
saw him he had been twice bled. In consequence of se-
vere erratic pains in his limbs, it was supposed that he
was affected with something like inflammatory rheuma-
tism. He died on the 7th day of his illness.
On the 21st of the same month, I was sent for to see
Sarah Poole, widow of Samuel, nine days after her husb-
and’s death. This case I had an opportunity of seeing
from the way commencement. I was informed by the        







70
messenger, than the patient was affected with quincy, a
disease to which she had been very subject. When I entered 
the room, I found that she had been attacked with a chill.
She complained of some soreness of the throat, & supposed
that she was seized with her old complaint, the quincy. 
Upon examination I found an cupipelatous inflamma-
tion of the fauces, but nothing which bore any resemblance 
to the two cynanche tonsillaris. I placed my fingers upon
the wrist, & instead of the active pulse of quincy, I found
a very full irritated one, which yielded directly to the
slighlest pressure. Her eye was of a dingy cast; I thought
I recognized at once, from what I had seen in the case
of her husband, a disease of a low grade & malignant char-
acter.
The treatment hitherto pressured, had in 7 cases, ter-
minated in death. The same plan had been followed by
the most respectable practitioners, wherever the disease first
appeared, & it is very probable that I should myself
have adopted it, had I not already taken the alarm.
The treatment had been adapted to an inflammatory
condition of the system, & seemed to be justified by the
sizes appearance of the blood. The doctrine of suffocated
excitement had, in many neighbourhoods, considerable
influence in determining this practice. With the view of
the case which I had taken, I determined to pursue an op-
posite course from that which had hitherto been adopted.
My practice was founded on the belief, that the disease was  
 




71
of a low grade, & should be treated, not with depleting,
but with supporting measure. The patient recovered.
soon after this, in the same village, a fresh crop cases
sprung up. The new plan of treatment which had been
adopted, was followed by a very satisfactory change in the
results; & the inhabitants, instead of being impressed, as hith-
erto, with the conviction that every one attacked with the
complaint must die, were rejoiced to find a number recov-
ered under a different mode of practice.
Soon after the disease occurred in Camden, it appeared
also in Philadelphia; & what is very remarkable, I first
observed it at the water’s edge. One of the first eases which
I saw in this city, was in water street, between market &
Arch. The patient was attacked on the 15th of the month,
& in the morning of the 16th, I was called to see him, a-
bout 12 hours after he was first taken. The disease passed
up from water street, & many cases occurred in the neigh-
bourhood of, & along, Arch street. Almost the only in-
stance, if not the only one, of this complaint which Dr.
Rush ever met with, he saw with me, at a less distance
than a square from my present dwelling house. It was but
a short time before his death; & I think it probable that he
contracted from this patient, the disease of which he died.
The case was a malignant one. When the Dr. entered the
room, he appeared surprised; & after we went out to con-
sult he made use of these very words: “Doctor, what can
this mean? What is it? It looks as if we should have       


72
petechiae”. He prescribed for a low form of disease; & soon
after was attacked with the complaint himself, which termi-
nated his valuable life.
Not only did this fever occur in the immediate neigh-
bourhood of the city: but it also appeared in the most
healthy situations, particularly in one to the northward
of Philadelphia. At some distance above Frankford, the
family of....sholcross was attacked, & I was called to
see them, month 2nd. 1813. When I saw them, three per-
sons had died & two lay very ill. In this place I had one
of the most unpleasant differences which ever occured to me ,
with a  practitioner who was also attending the family. He
declared that the disease was of a violent inflammatory char-
acter, & that the lancet should be employed. I conscien-
tiously resisted his opinion, & he retired from the responsibil-
ity of attendance. There were two more physicians engaged, 
one of whom had never attended before in the disease, &
the other had seen very little of it. They yielded to my
judgement, & thus I had to sustain the whole weight
of responsibility. The eyes of all the country were upon
me, & you cannot conceive the anxiety I experienced.
Happily, however, both the patients, a father & his only
son, recovered. From this time until warm weather
fairly set in, many cases of malignant typhus fever
occurred, & a number of our most respectable & distinguished
citizens fell victims to its violence.
It seemed to be the character of this complaint, in 



73
many instances, to produce a very great prostration of the
powers of the system. When the patient was taken with the
chill, or continued in the cold stage, he sunk into a state
of extreme debility, & in some instances reaction occurred
very slowly; in others at all. Persons who had previous-
ly debilitated by disease or intemperance, were particularly
liable to the fatal effects of the inalady; & in some of these
the system was so completely prostrated that it could never
be made to rise. When called to see a patient in this con-
dition, we found the extremities cold; the countenance, shrunk;
the pulse feeble, &. In some instances, absent; & generally the
most distressing retching to vomit, together with insatiable
thirst. In some of the low cases of typhus fever, we occa-
sionally found a degree of thirst which nothing could
allay; & what is very remarkable, & worthy of recollection, as
soon as we could bring about heat in the skin & action of
the pulse, we observed a decline of the thirst; & this decline
was in direct proportion to the elevation of the system.
I will here pause to remark, that excessive thirst
comes in two opposite conditions of the system. In fevers of
high excitement, we may often find a strong desire for drink;
but a thirst of a more distressing kind, & altogether insatia-
ble, arises from a condition of the system, in which the
blood is not propelled into the extreme vessels. These, denied
their usual supply, create the sense of thirst which I
have mentioned.
Delirium often occurred in the early stage, & it was
 


74
much less to be dreaded then, then when it did not ap-
pear till late in the complaint. I recollected the instance of
a young man, a son of Samuel Archer, who was attacked
with headache in the city, & rode out with his father to
their country seat. When he arrived, & had stept out
of the carriage, he was seized with the most violent
delirium, amounting almost to plunges. The family
was greatly alarmed, & dispatched the coachman imme-
diately to the city. Happily, I was at home, & was ena-
bled to obey the message without delay. I found the
patient with a feeble pulse & violent delirium. By immer-
sion of the feet in warm water, the application of sinapisms 
& proper internal treatment, the pulse was elevated & the de-
lirium subsided. He finally recovered. This is one state of
delirium which occurred in typhus fever. I have seen two
instances where the patients were absolutely affected with man-
ia. Of these one died; the other recovered. The manica was
distressing; because they not only showed ill- will toward
the people around them, but also a disposition to snap at
& bite their attendants.
Other patients were affected with erratic pains in their
trunk & limbs. These cases seemed to counterfeit inflam-
mation, but there was a marked difference observable.
We are not apt to find a limb in inflammation affected but
For a short time. There is always a degree of permanency 
Attending this affection; whereas, the pains alluded to
Were transient, & passed from one part of the body to 
 
  
     
 


75
Another like shocks of electricity. Another form of
the disease, & one common in some neighbourhoods 
more than in others, was that of pneumonia. Pneu-
monia typhoides was a name which obtained very of-
ten, some practitioners thought that the disease sel-
dom if ever occurred in any other form. So far as I
can judge from my notes, of those patients whom I saw
in the year 1813, not more than one third were affected
with pulmonic symptoms. In those cases where these
symptoms prevailed, there was generally pain in the
chest; sometimes on one side & sometimes on the other.
In addition to the pain dyspnea frequently occurred; &
what might almost as characteristic of the disease, dark,
bloody expectoration was observable. Sometimes the matter
discharged was not pure blood, but a peculiar secretion of
a dark orange colour. On other occasions it was nothing
but very dark blood. I remarked that whenever the
expectoration was free, the danger was less; when the dysp-
nea was constant & expectoration slight, the danger was
very great. The pneumonic was certainly, in many
instances, a very terrific form of the disease, as the lungs
which are a very vital part, were liable to be disorgan-
ized. But, as I shall endeavour to show, disorganiza-
tion of the lungs did not arise from excessive action,
but depended on a want of vital power; & hence these
organs were inundated & engorged, & the patient ex-
perienced the utmost distress.         
 
  
     
 


76
Diarrhea was an occasional attendant. This symp-
tom. I regarded as dangerous; I have seen it reduce the
system so low that nothing could raise it. One of the first
patients which Dr. Physick saw with this complaint was
in consultation with me. He was a man at Wicoff, in
Market street. He was extremely low, & the plan of treat-
ment was vigorous. When the Dr. was called in con-
sultation, my feelings were peculiarly distressing. Having
had an opportunity of forming my opinion relative to
the disease; having seen similar instances in Camden, &
thinking myself somewhat acquainted with its charac-
ter, I had found my judgement, & could not conscien-
tiously yield it up. At the same time, I was afraid
that Dr. Physick would adopt the idea, that the strength 
was to be raised not by stimulating, but by depleting meas-
ures. With my mind thus determind, & with such fears,
you may judge how extremely unpleasant were my feel-
ings, as we sat by the bed-side of the patient. But, happily
his judgement coincided with mine. He examined the
case most carefully, & when we left the room, he told me
that his first impression on seeing the patient, was, that
it would be necessary to use depletion: but he soon found
that this would not do, & cordially united with me in
the plan of treatment, I had adopted. The patient recover-
ed. The occurrence of diarrhea in certain form of dis-
ease, particularly when pulmonary symptoms existed, was
not altogether new to me. A long course of practice in   
  
     
 


77
The Philadelphia Dispensary, among persons in the lowest
situations in life, had taught me to know that spon-
taneous diarrhea, in the early stage of pulmonary affect-
tions, is a dangerous symptom. Cullen has hinted at it;
I know it to be the case.
Cholera was another form in which the complaint
appeared in the year 1819. It is not common in the
early part of spring to meet with cholera arising from
the usual causes; & we had a right to conclude, where
we saws several families with three, four, or even more,
of its members, all down with vomiting, purging, and
a feeble pulse, that this was only the prevailing disease
in another form.
I have not yet spoken particularly of the eyes and
countenance. There is a peculiar expression in the coun-
tenance in a patient affected with malignant fever,
which can be better understood than described. In
some cases of this disease, as in yellow fever, I have
seen the countenance nearly livid, as if oxygena-
tion (decarbonization) of the blood were imperfectly 
performed.
The extreme torpor of the whole nervous system in some
of these cases is remarkable. A want of sensation in
the surface of the body is, in some instances, strong-
ly manifested. I have also witnessed a total loss of
taste, so that the patient could not distinguish wine
from water. I have seen this torpor so great in      
 


78
the nerves of the skin, that blistered surfaces were in-
sensible to the most stimulating applications. The
case of a patient at woodbury was strikingly illus-
trative of this fact. She was the wife of Dr. Ayres.
I was called in during her illness, & received the fol-
lowing account from her husband. She had been
attacked severely & dangerously. The husband devo-
ted himself to his wife for several days; but think-
ing her better, he ventured to have her for a little while,
& visit his other patients. While he was gone, the nurse
& the patient thought proper to pressure an evacuation
from the bowels by an enema., which was accordingly
administered. The exertion which was used, & proba-
bly the evacuation which resulted, caused the patient
to fall into a severe sinking spill. When the hus-
band returned, he was not a little surprised & alarm-
ed at finding his wife in the utmost danger. She
was in a state of almost entire insensibility; & every
attempt to rouse her by the usual stimulating meas-
ures, entirely failed. The Dr. the took a fire-brand, &
applied it to her leg. This excited sensation & called
forth expression. But you will be surprised to find
that instead of complaining of pain, she rather express-
ed pleasure at the sensation occasioned by the appli-
cation. She requested it to be repeated, & this was done
several times. Having round her, in some measure,
by this means, he succeeded in getting her system up    


79
by the common remedies. He had applied an infec-
sion of Cayenne pepper over the blistered surfaces, without
producing any sensible effect. Half an hour afterward,
& subsequent to the use of the fire-brand, she complained
of pain & burning. Her recovery was complete.
The pulse in this disease is liable to considerable ver-
riation; but its general character is certainly that of wick
action. Sometimes, as in yellow fever, the pulse was
extremely deuptric. The first impression you would
receive was of high arterial action; but on a slight
pressure no resistance was afforded. The gaseous, or
at least an approach to the gaseous, pulse was very
common: but this was not always the case. There were
certainly some cases where tension of the pulse was
observable; & in another lecture I purpose to
consider this subject more particularly. I will here
remark that one of the most dangerous pulses in
typhus fever, was that in which some tension exist-
ed, & which was called by Dr. Rush, the synochula.
The tongue was often moist & nearly natural, as
in yellow fever; though generally it was brown & dry,
with sordes about the mouth. I was in several in-
stances much deceived with the cleaning of the tongue.
You may recollect an observation I made in a pre-
vious lecture,- that when the tongue cleans suddenly
& smooth, the case may in general be considered 
as safe, but very protracted. But in typhus fever
  


80
I have known the tongue to be moist & disposed to
clean; while, in several instances, the disease has been
near a fatal termination.
Spontaneous & clammy sweats, in the early, or in
any, stage, were unfavourable, as also were involun-
tary discharges from the bowels. Hemorrhage from
the lungs, nose, stomach, & kidneys, was another symp-
tom. Dissolved blood was also effused into the cellu-
lar texture, & constituted what are called, of malignant
typhus fever, are familiar with every practitioner ac-
quainted with the disease, & are particularly to be guar-
ded against. The patients will lie in bed, apparently
with considerable strength; & an indiscreet effort to rise,
especially if an evacuation from the bowels accompany it,
will sometimes bring on almost alarming syncope. The
circulation becomes extremely tanquid, & the attendants
are frightened by the situation of the patient. Consid-
erable muscular exertion should, in this complaint, be
particularly guarded against; as there is always a strong
tendency to these sinking spells. I one knew an in-
stance of a patient who died in attempting to walk from
the bed to the door. He was a poor man; his wife was
sick, & there was no one present to assist him. In his
effort to walk, he fell down dead in the room. These
sinking spells are dangerous in proportion to their du-
ration. Sometimes a little exertion brings on one of
   
        
  


81
them, which is speedily relieved by the proper remedies.
but if they continue long, the danger always in pro-
portion. Sometimes they assume the intermittent form; &
I knew two cases when the sinking spells regularly occurred,
& at length terminated in death:
I will now make some observation on the practice.
Before entering, however, on this subject, I will remark in  
general terms, that every epidemic, when it first appears,
Presents itself with peculiar varieties of form; & a certain
time is required before we can become acquainted
with its true character. Such was the case with this
disease; & the remark applies more or less every prac-
titioner who has treated it. Hence, when the typhus fe-
ver first appeared; when I witnessed the fatal effects
which resulted from the depleting plan, & perceived the
tendency in the system to sink; when I compared with
this the success which resulted from endeavouring to
support the system. I had a great of evacuation
in any shape: but subsequent experience has taught me,
that in some forms of this disease, certain kinds of evacua-
tion are not only safe, but advantageous. I might here
with property warn you against the doctrine of suffocated
excitement; but I shall take up the subject in another part,
& at present pass on to the practice.
I will now take a case of typhus fever in its common
form, & suppose it to occur in an individual of ordinary
health & strength. I will suppose that after the rigour or  
  
        
  


82
cold stage is over; that the system possesses sufficient
energy to react; that the febrile stage is completely evolved.
Under such circumstances, what is to be done? With my
present experience, I should sat at once, that the first
passages must be cleared; & for this purpose an emetic
may be administered with every happy effect. I am strong
advocate for the use of enmities in malignant typhus fever,
under the circumstances just mentioned. Cathartics & sudor-
ifics are also particularly adapted to the case I have described.
Hence, it was my common practice to administer 8 or 10gr
of calomel with from 20 to 30gr of ipecac; or else to prescribe 
a drachm of ipecac, to be divided into two doses, one to be giv-
en immediately; & if this should not operate in 20 or 30
minutes, the other to be taken. Diluting drinks were also
to be used copiously, to assist the operation of the emetic.
After this I directed some cathartic as Lee’s pills, or calo-
mel & jalap, to open the bowels & thoroughly cleanse the
first passages. Another formula I often resorted to was
a combination of the golden sulphur of antimony with cal-
omel & jalap. The proportions were gr x of calomel, gr x of
jalap, & gr viii of the golden Sulphur of antimony; the whole
to be divided into 3 parts, one of which wa given every one or two
hours. This preparation acts gently on the stomach, with con-
siduable certainly on the bowels, & also produces some
endency to the skin. In addition to this, after the bowels
have been thoroughly evacuated, the sudorific plan of treat-
ment is will adapted to the ease. With this view I direct
  

  
        
  


83
the feet & legs to be imersed in warm water; the patient
to be placed in a warm bed, & warm teas administered,
particularly the eupatorium perfoliatum, or some other in-
digenous plant. I also derived great benefit from the sa-
line draught as a sudorific. If limes or lemons are not
to be procured, you may substitute the spiritus mindereri.
This may be given in the dose of a table spoonful, if the
stomach will bear it, once an hour. It may be diluted
with mint water, or some other agreeable addition. Given
thus in the early stage, it acts as a gentle & certain sudo-
rific. This kind of evacuation I consider particularly
adapted to the early stage, when the disease is not in its
most severe & dangerous form.
Reelect that I consider fever as a disease, which, when
once completely formed, will run a determined course.
If the head is much affected, considerable benefit may be
derived from local depletion, particularly from the appli-
cation of cups of the temples. By the abstraction of blood
in this way, the patient is much retrieved, & less debility
follows than from bleeding at the arm. Cases may
arise, when a small quantity of blood may, perhaps,
be abstracted from the arm with advantage. But when
I consider the nature of the disease, I dare not take away
much blood; for I do not believe the mischief is occa-
tioned by excessive action. I had much rather see great
action, than a want of action.
Among the local applications particularly proper for  
  

  
        
  


84
this form of the disease, blisters hold a distinguished rank.
When the head is affected, blisters to the back of the neck
are very advantageous ; & applied to the extremities after
[??itable] evacuation, particularly if the patient is restless,
they are productive of considerable benefit. Among the
sweating remedies, the Dover’s powder deserve particu-
lar attention. When the patient is restless & distressed, af-
ter the requisite evacuation, 1½ gr of opium with 1 or 2 of ipecac,
taken at bed-time, will frequently tranquilize the irrita-
bility, & dispose to perspiration, especially when combined
with the use of warm teas. I can speak with some cer-
tainly of the advantage of this medicine. Under this state
of things if the case is mild & likely to be conducted to a
favourable issue, nothing occurs to call forth great anxiety.
But if sweating cannot be induced after a reasonable ef-
fort, do not push on with heating practice; but resort to
ablutions, etc. as recommended by Dr. Carric.
After two or three days, we sometimes find it necessary
to resort to a mild, cordial plan of treatment. In six
or seven days, the fever will, most probably, subside,
& the patient readily recover. It is very important prop-
erly to regulate the cordial treatment of this disease:
for, though it may be typhus fever, if the symptoms
do not call for stimulant practice, it should be care-
fully avoided. You should remember that the system
has received a blow; that it afterward reacts; & that the
practitioner is not to cure it instantly, but to watch and      

  
        
  


85
prescribe for the symptoms. If the patient does not sink,
there is no necessity for pouring down wine & brandy;
at the same time I wish you to understand that there
is a tendency to a low condition, to guard against which
your attention should always be directed: for if you do
not take care to meet the first appearance of sinking by
the proper remedies, the patient may fall into a state of
irreparable debility.
Among the remedies particularly proper to meet that
state which is midway between excessive action & prostra-
tion, the volatile alkali with an infusion of serpentaria,
is admirably suited. It is a pleasant stimulus, & acts
safely when stimulants of any kind are at all proper.
It may be given in the form of julap, in doses of a table spoon-
ful, containing 5 or 6 grs of the volatile alkali. It may be ta-
ken safely when wine or brandy would be injurious. In
this stage of the disease, & in fact in every other stage, I have
seen great advantage result from the use of animal diet. This
is contrary to the notions which were entertained by the old
practitioners. Cullen supposed animal food to be injurious,
even when it is proper to administer wine. But having expe-
rienced many opportunities of testing this point, I can cer-
tainly say, that animal soups have, in many instances,
produced very happy effects. But all these observations
apply to a form of the disease which may be regarded as
the least dangerous- a form which, by improper treatment,
may be rendered fatal; but, left to itself, may be conducted
to a favourable issue.     
     

  
        
  


86
But what must we do in those cold prostrate cases
which I have mentioned? What must we do in those     
cases in which all the prostration observable during 5
or 6 days of yellow fever, are collected in a few hours in
malignant typhus? What must we do where the patient
is extremely low, the pulse barely perceptible, the skin cold
as death, the stomach excessively irritable, & the distress al-
most indescribable? Under such circumstances there is
certainly no indication for resorting to emetics. It is true
that some practitioner in the state of New-York, declares, that
in the disease as it full under his observation, he depended on
emetics, & on these alone, in every stage. If the patient was
low he gave him an emetic to rouse him from his prostrate
condition; if he was in a state of excitement, he administered
an emetic to diminish action; & in fact he employed a prac-
tice as perfectly empirical as it is possible to conceive- using
the same remedy in all cases without any regard to the
system of the patient.
In the cases I have just alluded to, you should never
use an emetic; so far from it, all your endeavours should
be to tranquilize the stomach, to do away restlessness, to restore
heat to the surface, & to raise the pulse. To effect these ends
various expedients must be resorted to. Reaction is the main
object: it is the polar star by which all our measure should
be directed. How is this to be brought about? The skin
being cold as death, one of the first indications is to apply
stimulants to the surface of the body. We should always re-
  
        
  


87
member that in proportion to the want of action in the
skin, is the quantity of stimulant medicine necessary to
produce a certain effect; that a pint of wine will do as
much in an excited state of the surface, as a great
when this excitement is wanting, & the skin is cold and
insensible. Hence if becomes of great importance to en-
deavour to excite the surface of the body that we may
increase the effect of internal stimulants. Among
the measure calculated to meet this indication, sever-
al may be strongly recommended. A practice I have
adopted, is to wring flannel out of hot brandy or
spirits in which Cayenne pepper has been infused;
& to apply it as fomentations over the extremities and
trunk. I have seen this on some occasions very
useful: but I do not wish it to supersede the decoc-
tion of cantharides in spt of turpentine, as recom-
mended by Dr. Hartshorn. When, however, you
apply this decoction, you should remember not to use
it so as to excite very extensive vesciation. I have some-
times seen inconveniences arise from large blisters
accasioned by this application. Besides in cases where
the skin is very cold, it is of great advantage to be
able to apply heat: this is more effectually done by
wringing out flannels from heated spirits, & placing 
them hot on different parts of the body. If a hot
bath can be procured, it may be useful. North rec-
ommends hot blocks of hemlock. I have used hot  
  
        
  


88
bricks, & also hot sand in bags, placed around the patient.
But while our efforts are directed to restore heat to the surface,
we may suppose the stomach to be rebellious, & to refuse every
thing which is offered to it. What is here to be done? It is very
natural to try the effect of opium; but ten to one, it will be
thrown up as some as it is administered. Among the reme-
dies will calculated to meet this indication, I can recom-
mend spired Maderia wine. This is generally accepta-
ble to an irritable stomach. The spire increases the stimu-
lus of the wine, & renders it more acceptable than it would
be alone. But if good wine cannot be procured, or if the pa-
tient has been addicted to intemperance, spired brandy may
be substituted. Here it is proper to observe that the stomach
is always disposed to act violently if oppressed with great quan-
tities of any article. Hence small quantities of medicine
frequently repeated, produce a better effect, & are less liable to
irritate, than large doses given at longer intervals. Instead,
therefore of giving a whole, or even half, table spoonful of wine at
intervals of 15 minutes, it would be better to give only a tea spoonful
& repeat it every 5 minutes. When this plan does not succeed
in tranquilizing the stomach, stimulant applications should
be made over the whole epigastrium. Here sinapisms & blis-
ters present themselves for our choice. We should recollect that
blister are slow in their operation; & though their ultimate ef-
fects are very useful, yet these are not produced in time to an-
swer the purpose: sinapisms are, therefore, preferable. But there
is one application of which I am particularly fond in these
    
  
        
  


89
cases; I allude to the spiced plaster. This is made
by mixing equal parts of cayenne pepper, (or black pepper,) gin-
ger, & cloves, (or all-spire,) say two table spoonsful of each, & ad-
ding to these some rye meal, honey, & brandy. The whole
is then to be heated, & applied immediately on the epigas-
trium. The effect of this is often every great. But suppose
the stomach still to resist every measure resorted to;- what
is next to be done? You will then prescribe what experi-
ence has proved to be of great advantage, a large anodyne 
enema. I have seen the stomach reject every thing
which was effect, & the patient brought to the very gates
of death; & in the same case, I have seen the irritability of
the stomach soothed, & the patient finally rescued, by an ano-
dyne injection. It is prepared by mixing a tea spoonful of
laudanum & about a table spoonful of brandy with a little
starch or mucilage. ( This is adapted to cases attended wish
great prostration: in common cases, I do not use the brandy.)
After injecting it, it is to be retained by pressure upon the
anus.
I have not yet spoken of the particular treatment adapt-
ed to the cases of cholera & pneumonia. During the prev-
alence of the typhus fever I saw several persons in the
same family affected several with cholera. This form of
the disease has been particularly noticed by North in his
treatise on spotted fever; & the treatment recommended by
him is well adapted to the case. He observes that the pow-
erfully stimulant practice, particularly the case of alcoholic  
  


90
medicines, as brandy spirits, etc. is not well adapted to
choleia. So far as my observations have gone, I have found the
practice of North correct. Instead of distilled spirits, I have
found that good Port wine was admirably adapted to this form
of the complaint. At the same time, blisters, anodyne inject-
tions, & the spired plaster, should be resorted to. The last of
then remedies, applied immediately over the stomach, is
particularly well suited to some of these cases. The strength
of the patient should be supported by chicken broth, & such
like articles.
But the pneumonic form, which is generally termed 
pneumonia typhoides, is, in many instances, greatly to be dread-
ed. I have already mentioned the symptoms which char-
acterize the complaint. You may observe dark, bloody spec-
trum whrown up from the lungs, difficult respiration, with
pain in some part or other of the chest. The occurrence of
pain naturally excites the idea that it is accompanied with
inflammation. This often occurs, but not always. Acute
pain may exist in a part without inflammation of that
part. For pneumonia typhoides, dissection, in some in-
stances, manifests inflammation to a considerable extent: but
this inflammation is not of the phlegmonous character- it is
specific in its nature; & in its proper place, I intend to speck
of it more particularly.
I will now detail the practice which I would recom-
mend to you in the pneumonic cases. If the system has re-
acted, I would administer an emetic. I think emetics are 


91
particularly serviceable in this form of typhus fever. I have
known them to exert considerable influence in removing the 
pain. At the same we should clear the bowels by ca-
thartic medicine. If there is much action in the system,
perhaps a small quantity of blood may be taken away with
advantage. But I would in general prefer local bleed-
ing to venesection. Cupping has several advantages:- it
promotes external irritation, abstracts the blood immediate-
ly from the part affected, & does it so gradually that the system
has time to accommodate itself to the loss. After having evac-
uated the stomach & bowels, I would recommend the speedy
resort to extensive blistering over the affected part, & to the sudo-
rific plan of treatment. Among the remedies best adapted to
this form, is a combination of opium & ipecacuanha, admin-
istered every four hours, filling up the intervals with dilu-
ent drinks. If perspiration be not produced by these meas-
ures, the saline draught, or the spirits mindereri given
every hour, may be advantageously added to them. In
addition to these I would advise warm applications about
the patient. This plan generally succeeds in bringing on a
free diaphoresis; & I believe in the pneumonia form of the
disease, is often extremely salutary. If you find that the
patient is in a state of considerable debility; if the pulse is lan-
guid, & the evidences of prostration very compenous, some-
thing mow will be necessary than herb tea & the Doore’s 
power. You should then resort to vinous stimulants in
some shape, & if the patient has been a hard drinker, even
      


92
to brandy. But in my opinion wine, in this disease, is pref-
erable to ardent sprits. Yet there are exceptions to this rule;
& among brandy drinkers we are obliged to pursue a dif-
ferent course from that which we follow with the temper-
ate. Wine whey I regard as an excellent preparation. A-
mong the teas or infusions, I should mention that of ser-
pentaria, which is a most valuable medicine in this com-
plaint. Volatile alkali is a remedy from which we may
often derive great advantage. Sometimes it may be giv-
en in the form of bolus, in the dose of gr v every hour or
two; or in that of julap. If it be more agreeable to the stom-
ach of the patient.
In some of these cases, after the disease has passed the
3rd or 4th day & is verging towards a crisis, very great pros-
tration of strength comes on. The sweating process should
have its limits: A may be continued too long, so as to induce
great debility & weaken the patient. It is proper, therefore, to
keep this in view in the treatment of the disease. Some of
you may recollect the case of Joseph Scattergood. In that in-
stance when the patient had gone on very well to the 5th day,
extreme debility with a frequent pulse came on. Dr. Griffetts
& myself, immediately on perceiving the change, adopted an 
active plan of stimulating & supporting treatment. We derived 
great advantage from the use of a strong decoction of bock 
with the addition of Huxham’s tincture, & given in alterna-
tion with the volatile alkali. In addition to these, wine
& a nutrition diet were resort to. The anxiety I felt can   


93
scarcely be described. The patient was in the very prime
of life, an excellent husband & father, & surrounded by a nu-
merous family. By persisting in the treatment I have men-
tioned, he happily recovered.
There are some cases of pneumonia which, ab iritis,
are beyond the reach of medicine. The lungs from the mo-
ment of attack are disorganized, & the blow proves fa-
tal. I shall hereafter have occasion to speak more fully
on the subject.
I do not know that I need proceed further with
the different forms of this disease. But I wish to give
you some further views of the practice as applies to the
complaint generally. When the patient has passed the
first stage of the attack, after the system has reacted, &
has again begun to sink into a state of debility; or when
it is in a condition in which reaction does not take place,
your views should always be directed to support the strength.
For this purpose you should resort to stimulant practice.
But it is proper for me to remark that the patient may
be injured by the improper use of stimulants, as well as by
deptition. At the same time I must observe, that some
cases of typhus require a quantity of stimulant medicine
almost beyond relief. But when the patient is in that state
which calls for the constant & rigorous use of such remedies,
believing as I do that stimulants are edged tools in the
hands of a practitioner, I make it a point never to have
the patient long at a time, without watching the effect of


94
the medicine. I have generally been able to find judicious nur-
ses with whom I could leave my patients for several hours.
You should use stimulants till you bring the system as nearly
as possible to its natural state, & should not urge them beyond
this point; remembering always that the quantity of stimulus
necessary to effect this restoration of the system to the natural 
condition is far greater than what is necessary for retaining
it after it has been elevated. Hence, you should endeav-
our to impress the nurse with this simple truth; that if one
pint of wine is necessary to be administered during two hours
to raise the system to its natural state, one half the quan-
tity will maintain it there for the same length of time.
Another important wine is, that stimulants are transient
in their operation. They act by producing a momenta-
ry excitement. Hence we should have a two-fold object
in the treatment of typhus fever; first to rouse the patient
from extreme debility by the use of diffusible stimulants,
& then to pour in nourishment for the purpose of maintain-
ing strength. A variety of articles may be employed; but
none is deserving of a higher rank than the cosmec of beef.
In this preparation we have a concentrated from of animal
nourishment. Beside this, calve’s feet jelly, eggs, with wine
or brandy, & oysters, are very serviceable. It is astonishing
what a large quantity of oysters has been taken by patients in
typhus fever. In a state of very great debility, it is necessary
to give something very often; & in some instances I have direct-
ed one or two oysters to be swallowed every few minutes.   


95
Among the remedies resorted to in this low state of the
system, I have yet to speak of the spirits of turpentine. I
consider this remedy admirably well adapted to the prostrated
cases of typhus fever; & the more extensive my observation
have been, the more reason have I to be partial
to the medicine. For although there are some cases
when brandy is administered to a great extent with success;
yet feeling as I do, that it is an edged tool, I never
resort to it in large quantities, unless the patient is immediately
under my own eye. But spirits of turpentine
is not liable to this objection, The greatest fault that I can
find with it is, that it acts on the bowels if given in considerable
quantity. This tendency, however, may be counteracted
by the use of opium. I have usually administered
the spirits of turpentine in this form:
R Ol. Ferebinth. – qut cxx
Puls. Gum Arab.
Sacch. Alb….aa 3 ii
Aqua cinams… 3 iv M.
In this mixture there are about fifteen drops of the
spirits of turpentine to every table spoonful. This dose
may be given every half hour, generally in combination
with a few drops of laudanum. In some instances where
wine & brandy have failed of producing the desired effect, I
have seen the spirits of turpentine act most happily.
But cases sometimes occur when the option will not respond
to vigorous stimulant practice, after several hours

96
fair trial. This is an important fact. Instead of contin-
uing to dunch the patients with stimulants, I would ad-
vise you to try some new impression; perhaps an emetic
to rouse the stomach, may be useful. I have seen, in
the case of a boy, an injection/ which produced a free evac-
uation/ followed by a rise of pulse & an increase of strength, 
when stimulants were laid aside.
Take especial care that you do not confound a state
of intoxication with a case of real debility; because, in the state
denominated “dead drunk”, you frequently have a cool
skin & depressed pulse.
I would give you a caution relative to the extensive
use of blister in this complaint. I believe that exten-
sive blistering occasionally produces bad effects: they cause
vesication, & heep up a discharge from the skin which tends to
exhaust the patient. I have occasionally used them with
great advantage, merely as rubefacients. I apply them to
some part of the leg & let them remain only till they produce
redness: then taking them off, I apply them to some other
part. In this way they operate safely; whereas, if they were
left till vesication resulted, they could tend greatly to increase
the debility.
These may be regarded as general views relative to the dis-
ease of which we are treating. There are some other forms which
we meet with in practice; but a man who is once accustom-
ed to the complaint, & fairly aware of tis invidious & danger-
ous nature, will soon be able to recognize, & meet with ap-
    


97
propriate treatment, all the varieties which may occur. I
will again repeat me belief that typhus fever is a disease
sui generis, specific in its natural; that even the inflam-
mation which occurs in the course of it, differs from com-
mon inflammation; that the practitioner should consider
in the treatment of the complaint, that there is great rea-
son to fear want pf action, as well as diseased action of a 
peculiar kind.
When I was treating yellow fever, I gave you an amount
of some terrible symptoms which occurred in the last stage
of that complaint. Black vomit, hemorrhage from the nose, 
bowels, etc., blood oozing from the tongue & from blistered
surface; &, in some instances, though less common than
the others, petechial spots made their appearance. In ma-
lignant typhus all these effects were generally experienced 
in an earlier stage than in yellow fever; petechial spots ap-
peared much earlier; dark bloody spectrum was, in some
instances, corral with the attack; black vomit occurred,
but was not common; bloody wine was not an unfree-
quent symptom; &, in some instances speedy & fatal
disorganization of the lungs took place- the death blow was
given at first & the system never reacted. This will hap-
pen in some cases under any kind of treatment. Hence when
medical men, say that they always succeed in this com-
plaint; that they never lost a patient; that nothing more is    
necessary to secure the sick than to send for them,- (such
men I have heard of,) at least, I call in question their judge-


98
ment, if not their candour. In those instances where
the lungs are speedily disorganized, there is generally great
differently of breathing, heaving of the shoulders, dark, bloody
spectrum, etc.; but the expectoration is generally slight. I rec-
ollect the case of a young man of intemperate habits, who
on his journey from Abington to this city, was attacked with
a chill at the Fox-Chau [Fa???], which is about 3 miles
from the city. He reached home, however, & the family phy-
sician was sent for that evening. Next morning I was
called in. The system never reached; the lungs are complete-
ly engorged, & in a few hours the patient died.
I conceive that this disease anticipates all the vio-
lent symptoms of yellow fever, in its last stage, in a most
extraordinary manner. To illustrate this statement I will
mention the case of a child of Wm. I. Bill of this city.
He went out one morning in winter with his mother
in a sleigh & took a wide of several miles. On his return
he dined with the family; & although appeared a little
drooping, yet no alarm was excited. About 8 o’clock in
the evening, the child was so poorly, that they sent for
medical aid. Dr. Wistar was called on; but being unwell,
referred them to me. I saw the patient, & found the pulse
barely perceptible. There was a disposition to coma, with
mild delirium, & a great dread of falling, (which symp-
tom I had often witnessed in cases of typhus fever.) Before
6 o’clock the next morning the child died. The sense of
task in this instance, was so palsied, that the pa-
      



99
tient could perceive no difference between pure wine
& pure water. When he died he was as spotted as a
leopard.
A gentleman was in the habit of going to his store
every morning before breakfast. While there he was ta-
ken unwell, & with difficulty reached home. His phy-
sician, Dr. Dorsey, was requested to see him, which he did
early. Some blood was taken, & cathartick medicine admin-
istered. That evening at 10 o’clock I was called in consul-
tation; & while I was in the room the patient expired.
His countenance exhibited marks of the utmost malignan-
cy, & dissolved blood poured from his nostrils.
In some subjects that we meet with in practice,
There is more energy to struggle with the stroke of the dis-
ease- the system reacts, & the physician has some chance of
prescribing with advantage. I have compared the action
of the system with regard to the facility with which it yields
to the stroke of disease, & the energy with which it struggle a-
gainst it, to the multiplied varieties in the human charac-
ter. Some suddenly bend under affliction; & when any
thing untoward has occurred, give up all as lost; others re-
sist misfortune, & struggle manfully to the last. In some
families there is great tenacity of life. They withstand
shock after shock of disease, & their life is protracted to
old ages: other families possess less tenacity of life, & yield
speedily to morbid impressions.
I have spoken of the disorganization of the lungs in this
  
 
      



100
disease. I will mention to you some reflections which
have occurred to me on this subject. Every practitioner
accustomed to mark diseases as they arise, is fully aware
of the fact, that determinations to particular parts of the
body take place at particular seasons. Thus in hot weather,
disease is particularly determined to the stomach & bowels.
Hence cholera, dysentery, diarrhea, are very common
in the summer months. There is a strong dispose-
tion to disease of the stomach % bowels in consequence
of the heat; & hence when yellow fever appeared, these
parts were apt to feel the force of the complaint. In win-
ter & spring the determination is to the thorax; & you
are all familiar with colds, pleurisies, etc., which are the
diseasons of these seasons. When the temperature is re-
duced, & the weather often changes, the pulmonary sys-
tem is remarkably apt to suffer. In winter there is
a predisposition in this part to be acted on by any general
disease. From this we see reason why typhus pneu-
monia was so common in the winter & spring. In the
affection of the lungs which accompanies this complaint,
the dissolved blood percolates through the vessels which
are unable to resist it, & give to the part the appearance
of inflammation, look at the red eye in the last stage
of cholera:- can this result from excessive 
action? In children worn down to the lowest stage
of debility, when they are ere skin & bone, , & only a
day or two before their death, we may often perceive the 
 
      



101
red eye, resembling almost precisely a case of acute
opthalmia
. When this symptom is perceptible, depend up-       
on it, death is near at hand. The red eye in cholera is a put-
ty certain token of approaching dissolution. It cannot, therefore,
be supposed to be the result of excessive action. The same may be
said of the red eye in the advanced stage of typhus fever. By
the eye we often judge of the state of the brain. The eye is
the window of the brain, by means of which we can judge of
the operations that are going on within. Now when we
see dissolved blood leaking out into the cellular texture, and
forming petechial spots, can we be surprised that the spon-
gy texture of the lungs should particularly invite this kind
of diseased action? Hence the fatal disorganization which takes
place in these organs; & we may easily believe that the same
takes place in the brain. Here an important question pre-
sents itself.- How does the blood become dissolved? Is it bro-
ken down by excessive action? This is a doctrine believed 
by many; a doctrine which, when I was a student, was
taught from the professional chair – that the crasis of the blood
is broken down, its vital power extinguished by excessive action.
Even the appearances in survey were said to be from the
same cause. I am not an advocate for this doctrine. In
practice it is extremely dangerous. That instances may
occur of dissolved blood arising from excessive action I read-
ily admit. This is exemplified by the effect of lightning, ( I
do not think so.) The blood of persons who have been killed by
lightning is, we are informed, invariable found to be in a



102
dissolved state. But I believe that blood may become
dissolved by a direct abstraction of vital power. I found my
belief, not on theory, but observation, Dr. Wistar & myself
attended an old lady, 85 years of age. She was not con-
fined to her bed during our whole attendance; yet in
consequence of the affusion of dissolved blood into the cel-
lular texture, she was covered all over with petechial spots.
I can scarcely believe that all this mischief was produced
by excessive action. It was in fact nothing more than
the result of direct debility. Let us look at the causes
which operate in the production of [s????y]; & then ask
whether it is probable that the oozing of blood in this case
is the effect of excessive action. We find the disease in ships
during a long voyage, where the diet is impoverished, the
body confined, & the mind frequently anxious & depressed;
we find it also in besieged cities where the same causes
operate. What evidence is there that in typhus fever the
dissolved blood is the result of excessive action? Do the symp-
toms warrant the conclusion? Have we the strong, frequent
& full pulse of pleurisy & rheumatism, or the slow & laboured
pulse of apoplexy? On the contrary, we frequently have the
gaseous pulse; sometimes the feeble, creeping pulse, and
sometimes no pulse at all. In some instances the synoch-
ula pulse of Dr. Rush, which is small, frequent, & tense, may
be observed; & if I were called to select a case of difficult
management, & one which would most probably termi-
nate fatally, I would select that which in accompanied    


103
with the synochula pulse. We frequently meet with this
pulse when the general symptoms indicate extreme danger.
I remember nothing it in a patient who was at the time cov-
ered with petechial spots; & it continued to the day of his death.
Besides the condition of the pulse in typhus fever, we have
other symptoms of debility. Sometimes there is a very cold
skin, & great want of action in the surface: sometimes the
skin is very hot. Let us look at the operation of remedies.
In the early stage of pneumonia typhoides, the dark bloody
spectrum is diminished exactly in proportion to the elevation
of the system, produced by stimulants. Would this follow
if it were a disease of excessive action? I answer- no. I will
mention a case in point.
A gentleman once came under my care in conse-
quence of hemorrhage from the lungs. A large quantity
of florid blood was thrown up; but as stop was, after a
wile, put to discharge. But before I saw him, he had
complained of feeling chilly, & in consequence moved to-
wards the fire, & drank some warm coffee. The hemorrhage 
was renewed with violence. The pulse was feeble; but the
other symptoms imperiously demanded the lancet, & bleed-
ing relieved the patient. Now in this case, the practice prop-
er in typhus fever would have bled the patient to death.
What would have been the consequence of giving this man
wine whey & volatile alkali, when a little warm coffee
& the heat of the fire renewed the hemorrhage? The vessels
of the lungs would have exerted themselves so much that          
 


104
he would probably have bled to death. Contrast this case
with those in which a dark bloody spectrum is discharged
from the mouth. In the latter instance, in proportion as the
system is elevated, the discharge is diminished & the danger
lessened; in the former every attempt at stimulation in-
creases the hemorrhage, & the only way to put a stop to
it is to depress the system. In hemorrhage from the
lungs, as it commonly appears, every practitioner knows
that whatever tends to excite the circulation proportionally
increases the danger.
Appeal to the practitioners in whose neighbourhoods
the disease first appeared:- they often viewed it as an
inflammatory complaint; but by sad experience were
taught to change their opinion. Instances of synchope
& death have been known under the use of depleting reme-
dies. But it may be said that dissection unfolds an en-
gorged state of the vessels, & topical inflammation. Little
is to be drawn from this. Persons not accustomed to dis-
section are easily deceived by the gravitation of the blood
to the most depending parts. Even in the living state, the
blood oozes through the vessels into the cellular texture; & af-
ter death it sometimes leaks out entirely, & is found in the
lowest part of the body. Witness the case of Dr. Wistar, upon
dissection no blood was found in his vessels; but having
leaked from them was diffused into the cellular texture.
Hence the inference from the congestion of the vessels, that
there must have been increased action, is fallacious. But   


105
the inflammation is entitled to attention. I have, in
some instances of typhus fever seen undoubted symptoms
of inflammation; I have seen the lungs covered with a
membrane of coagulable lymph; I have seen them sink
in water like liver, & their cohesion so destroyed, that they
could be torn & penetrated by the finger with the utmost
facility. In this condition of these organs, I have some-
times seen genuine black vomit. Here an important ques-
tion arises,- must active inflammation invariably be
treated with the lancet? If inflammation is an unit,
differing only in degree, the treatment must be of a simi-
lar character. But I do not believe in the unity of dis-
ease: neither do I believe in the unity of inflammatory
action. I believe that inflammations are various; that
some assume a peculiar & specific character, & demand
a peculiar management. Take for instance the carbun-
cle or anthrax. Here is inflammation in a high degree:
the feelings of the patient proclaim it; we debut it by our
organs of vision. Here is an inflammation which runs
its course to the destruction of the part; the cellular texture
inflames & sloughs. But will any experienced man say
that anthrax may be cured by vigorous depletion by the
lancet? No. whatever theory may suggest, the experience 
of the oldest practitioners is directly opposite. A different plan
must be pursued in the treatment of the disease: you must
allay pain by opium, give [to??s], & apply blister & poultices
to the part affected; but you must not draw blood. I    
 


106
recollect, in the early period of any practice, before I was
aware of the nature of the disease, I had a patient affected
with anthrax, & directed leeches to be applied to the inflamed
part. Dr . Physick was called in consultation, I informed
him what I had done: at the same time I told him
I had not yet taken any blood from the arm. His reply
was, “No: bless your soul! no- nothing of that sort.” He
said that tonics & opium should be employed; & under
this treatment, the patient soon recovered. If anthrax
is to be managed by opium, tonics, & cordial remedies,
let us turn our attention from the outside to the inside,
& inquire if an internal inflammation does not some-
times take place, analogous in its nature to anthrax, and
yielding to the same treatment. I wish not at this
time to give a positive opinion as to the exact identity
of these inflammations; but most assuredly I can say,
that in typhus fever I have seen topical; pain relieved
by a practice which would greatly have exasperated the
acute phlegmonous inflammation.
On the whole, my views relative to malignant ty-
phus fever are., that it is a disease of low action in
which the patient may sink from direct debility; that
if the system have vigour enough to react, & the circula-
tion became increased, & at the same time local determi-
nation & inflammation take place, a little blood may,
in some instances, be drawn with advantage; that the
lancet, however, should be cautiously used, & emetics & ca-
  


107
thartics with cold ablutions employed in its place for the
reduction of action; that topical blooding by cups is prefer-
able to v.s. on two accounts, because it excites external irri-
tation & takes the blood more slowly, & nearer to the part
affected; that sweating may in some instances, be em-
ployed with safety, & even with considerable advantage:
but that this, like every other depleting measure, should
be limited, & not employed in the last stage: in fine,
that the doctrine of prostration arising from excessive ac-
tion, & to be relieved by bloodletting, is very hazardous; for
though I admit that a state of suffocated excitement
may, in some instances, exist; yet great judgement is
required to detect it, & for more mischief then benefit 
has arisen from the doctrine.

General View Of Fever.
_________x___________

I have now gone through an account of several descript-
tions of fever. This is a subject so interesting in a practical
point of view, & it is so necessary that you should be thor-
oughly grounded in a knowledge of it, that I have thought
it best to outer more particularly than I otherwise should
do into an account of this kind of disease. I wish now to
close the subject by taking a general view of fever as a
whole, & examining certain [theo?t??al] points connected with
it; & first, I shall speck of the premonitory signs of fever.   


108
A general lassitude & dullness are often manifested
by patients about to be attacked with fever. They feel in-
disposed to exertion, & are easily fatigued when they attempt
it. A loss of appetite, or irregular appetite, nausea, disturbed 
sleep, & a constipated state of the bowels are not unusual
premonitory signs. Sometimes the patient is disposed frequent-
ly to go to stool; but his passages are small & ineffectual.
A sense of rigour & chilliness are every common. Dr. Hew-
son informed me that when the typhus fever prevailed in
the prison, an attack was very generally preceded by consti-
pation of the bowels, & that a brisk purge, administered in
this stage often proved advantageous. Some years ago the
typhus fever existed in the Alens House, during my attend-
ance, & many persons were affected with the complaint.
These cases were generally brought down out of what is called
the long garret. At first the proper plan of management
was not understood; but it was soon discovered. As means
of prevention I directed that the rooms should be freely
ventilated; I also directed the students to go through the
wards & whenever they saw any one complaining of nausea,
listlessness, etc. that they should immediately order an emetic
of ipecacuanha. After the adoption of this mode of man-
agement, the cases became much less numerous, & much
milder. You should always remember, [when you have the
power,] to attacked fewer in its forming stage. Dr. Rush
and to insist strongly on the necessity of attending to this 
rule. “How much good have I done”, says he, “in the form-       
    
 


109
ing stage of fever, by pediluvium
I once attended two patients extremely ill of fever which
run into a low, protracted form, or wat used to be called
a low nervous fever. They recovered often being a long time
sick. sometime afterwards, I saw both these patients at-
tacked with what I thought premonitory signs of fever;
& had I permitted the disease to go on, they would proba-
bly have passed through the same tedious confinement as
before. In both cases I blistered the wrist immediately, &
the result was most happy.
I will now sum up the general principles of treat-
ment as regards fever. I have endeavoured to impress
you with the importance of evacuating the first passa-
ges; & also, in some instances, of resorting to general and
topical bloodletting, according to circumstances. After this
I mentioned sudorifies which often prove very advanta-
geous. But if sudorifies fail; if the skin remain hot &
dry, & the patient restless, a better mode of reducing febrile
action will be the use of cold ablutions; in some cases
when these are improper, you may safely resort to tepid ab-
lutions. I have been much pleased with the efficacy 
of blisters for local affections- to the head in delicium, to the
breast in pneumonia typhordes, etc. But there is a state
of the system when blisters come in very properly as a
general remedy. This is particularly the case when the
patient is very restless, throwing about limbs, con-
stantly changing the postion of his body, & after sighing
   
    
 


110
or in other words, when he has fallen into a state of
great nervous irritation. Here blisters often produce a
very happy effect. If called upon to mention the remedy
most powerful in arresting the progress of fever, (if indeed
it is to be arrested.) I should unhesitatingly say, that blis-
tering is that remedy.
[To?i?s] & stimulants are to be used according to the
derctions I have before given, remembering that it is
easier to maintain the proper strength of the system,
than to restore it after you have suffered it to sink too low.
That there is a possibility of elevating the system beyond
a proper point; that stimulants are not permanent in
their action, & hence it is necessary, in cases of great de-
bility, to interpose between the doses, some article that
is capable of supplying nourishment & permanent
strength- such as essence of beef, strong broths, & other
highly nourishing articles.
There is another fact in the low state of fevers to which
I wish to call your attention. It not unfrequently hap-
pens that patients are so low as to be insensible to the
calls of nature. I have known a vast collection of urine
in the bladder without the attention of the patient or the
phycian being called to the circumstance. I have wit-
nessed a case of low fever when the bladder was so much
distended as to reach nearly to the scrobiculus cordis, &
resembled the uterus in the 8th month of pregnancy: but
it was not discovered till too late. The water it is true was   
  
    
 


111
drawn off, but the patient soon died. In low forms of
fever, always make it a point to inquire into the state of
the bladder. I have known instances in which patients af-
fected with fever, by lying on their backs, have last all
power over the bladder; & it has been absolutely necessary 
to use the catheter every day for a considerable length of
time. If this accumulation goes on increasing, the water
at length comes away spontaneously; & practitioners at-
tributing this symptom to general debility, neglect the
catheter, the only method of procuring relief.
Particular attention should be paid to the limbs of
children in the low stages of disease, as there is danger
of their becoming permanently contracted if they remain
long in one position. Moreover, the parts on which the
patient lies being long subjected to pressure, sometimes
slough extensively, forming sores very difficult to man-
age. To prevent this, the position of the patient should
be frequently changed; & when it has happened, the pres-
sure should be taken off the excoriated parts by appro-
priate cushions.
These I have thrown out as general observations
on the subject of treatment; next I will make some
remarks on the usual signs of convalescence. When at-
tending a patient with fever, at the approach of the
critical days, I always look out for some symptoms
indicating that a solution of the disease is about to take
place. I have after hailed certain appearances that
   
  
    
 


112
might have escaped a superficial observed- I have
hailed them as the approach of the morning dawn.
The tongue is often an index of the state of the disease.
As a general rule, the tongue is furred in fever; & the
cleaning of it is often the first evidence of convalescence.
A man accustomed to examine the tongue, will discover
a disposition to clean on the tip & edges before a superfi-
cial observe would have his attention called to it. There
are two ways in which the tongue may clean. Most com-
monly the fur gradually disappears; & then a speedy res-
toration to health may be anticipated. Sometimes, however,
it breaks away at one; & under these circumstances, the
convalescence is tedious, paroxysms of fever often return,
& sometimes occur daily for many days; but the disease
gradually wears itself out, & the patient ultimately recovers.
Critical sweats are often signals of convalescence. I
have before told you that the fever with which I was
affected, from attending in the Howell family, (The Howell
family & the Doctor’s illness have not been alluded to before,) termi-
nated in a profuse sweat on the 7th day.
A reduction if the frequency of the pulse, when accom-
panied with other favourable symptoms, may be regarded
in a pleasant light: but unless the attendant symptoms
are considered this sign will often be found to fail. In
yellow fever, the pulse becomes moderate & natural, and
an inexperienced physician will be apt to suppose that
all is well, when another better acquainted with the dis-  
  
    
 


113
ease will predict a speedy dissolution. Patients will often
recover from fever with a frequent pulse; but under these
circumstances, I am disposed to keep watch, for fear that
some internal mischief may be going on.
The state of the bowels should also be regarded. In fe-  
ver the bowels are always in an unnatural condition; some-
times constipated: sometimes the reverse. Even if med-
iciness operate freely, you will find the passages not to be
natural & healthy, but often dark coloured or green, & ex-
ceedingly offensive. When these change, & yellow fecal evac-
uations are procured, you may then infer that the liver
which sympathizes with the general system, has now un-
dergone a change of action; that healthy bile is secreted; &
that convalescence is beginning to dawn. There are, however,
exceptions to this rule: in the case of a young man attended
by Dr. Moore, the evacuations from the bowels became per-
fectly natural but a short time before his death.
The urine is not so much attended to as it ought to
be, as affording signs of the state disease. Among the
old practitioners it was so closely observed, that they were
apt to neglect more important indications; & hence it came
came into neglect. But certainly, it is of great advantage
to attend to this excretion in fever. Dr. Wistar used to pray
much attention to it, & the same is the case at present with
Dr. Griffilts. When the fever abates there is said to be gener-
ally a deposition of lateritious sediment in the urine. I can
little on this subject from my own experience, as I   
    
 


114
have paid less attention than I should have done, to 
the urine as an index of the state of the disease.
Our accustomed to examine the countenance in fever,
will place much dependence on its expression, in forming
an opinion as to the approach of a favourable or unfavour-
able crisis. But in this case description can convey to
you no definite idea whatever. It is only by experience that
we are enabled to from a correct judgement from this
source.
When speaking of the signs indicating a predisposition
to fever, I mentioned that a change of habits after takes
place. For instance, a man so fond to tobacco that he
will give even bread for it, loses entirely his relish for this
article. But in convalescence, you find a return of old
habits among the very first signs. A desire for custom-
ary food, & what is a remarkable fact a desire particu-
larly for bread, is a very favourable symptom. I have
often been struck with the fact,that patients with a fever
will take food of certain kinds, but seldom wish for
bread. An experienced black nurse in the yellow fever
Hospital, in 1805, made a remark which I have since of-
ten thought of,- that all the patients who wanted bread
recovered: & though this is not universally the case, yet
I have no doubt that his observation was founded an ex-
perience. I once knew a patient exceeding low with ner-
vous fever, who in the dawn of convalescence, called inces-
santly for milk; & from that time he began to recover.
   


115
When then has been much delirium, & this subsides, it
may be regarded, in general, as a mark of convalescence.
But this is not always the case. We sometimes find delir-
ium continue raging to a very late period, when it subsides,
& the patient becomes perfectly calm, yet sinks speedily into
the grave. In protracted cases of nervous fever, we often
have the most decisive signs of convalescence before the mind
begins to act with regularity. In the case of the patient who
called so earnestly for milk, three months elapsed after this
time, before his delirium subsided.
I will now speak of the unfavourable signs in fever.
When the pulse is very much increased in frequency, be-
coming almost to rapid for enumeration, you may con-
clude that the case is going on very unfavourably. When
along with this you have subsultus tendinum, the danger
may be consider still greater. Sometimes, however, we
may be alarmed with the idea that the patient has sub-
sultus tendinum, when in fact, the motions of the muscles
are voluntary. In the case of a very amiable girl whom
I attended in consultation, as sitting by the bed side & feel-
ing her pulse, I felt a start of the tendons in her wrist.
Hoping that she might have voluntarily moved her fin-
gers, I made the inquiry of her, but found that she had
not been sensible of any motion; & I then drew a very un-
favourable angary from the occurrence, she was a corpse 
next morning.
A brown, dry, & chopped tongue may be regarded as a
              


116
bad sign; though patients often recover after this symp-
tom has appeared. But there is another kind of tongue,
particularly in old people, which is deceptive & very dan-
gerous. I have seen it in some cases:- the tongue becomes
moist, & seems disposed to clean. On examination, I have
found that it presented a mucous surface, retaining a
brownish colour, & imparting to an observer the idea that
the patient had been taking currant jelly, or some dark
coloured mucilaginous article. This is a very bad sign.
The evidence drawn from the appearance of the blood
is sometimes important. Ripperger, a cupper of large expe-
rience, in this city, has often been able to form a very cor-
rect prognosis in fever, & I have frequently been struck with
the truth of his prediction. In Dr. Wistar’s case, when he
had been cupped, Riperger, as he was coming out of the
room, said to me, “Doctor, he will die’. I asked him his
reasons for supposing so. He told me his blood was blue.
He then reminded me of the case of a patient I attended
in which he had observed the same appearance of the blood.
What he meant by this condition of the blood, I did not
exactly understand; but I am inclined to believe that his ob-
servations are correct, & that the blood is dissolved.
Delirium occurring in the latter stages of fever, particular-
ly when it is of that maniacal kind which induces the pa-
tient to snap & bite, is a most dangerous symptom. Con-
vulsions in the same stage are extremely dangerous, & very
generally fatal.
                    


117
Torpor of the whole system in the latter stages is a very
bad sign. When you see persons, who in health were re-
markable for delicacy of feeling, become careless about the
exposure of their bodies to the attendants; if at the same
time, there is a disposition to slip down in bed, & involunta-
ry evacuations of urine & feus take place, you may con-
sider the case as exceedingly dangerous, though not neces-
sarily fatal.
I will now say a few words on the dying state.
Let the disease be what it may, the appearances in this
state are very similar. In chronic cases you will discov-
erer a condensation of the fluids of the eye, & an apparent
film over the cornea. This is almost always a fatal sign.
But a still more sticking symptom is a peculiar kind
of respiration which comes on just before dissolution. The
muscles subservient to breathing, seem to be totally from
under the control of the will, & the patient is unable to pre-
vent that distressing frequency & hurry of respiration which
is to be regarded in so unfavourable light. This kind of breath-
ing is followed by those deep inspiration which mark the
dying state. The symptom which I have invariably found
to be fatal is a projection of the under jaw. After this has oc-
curred I always expect a fatal issue within 20 or 40 minutes.
I was once called to see a little girl with epileptic fits, whom
I had several times visited before in the same complaint.
When I entered the room I something peculiar in the
Case. There was among other symptoms a prodigious throb-     
                    


118
bing of the carotids. The patient had been bled before I
arrived. I told the parents there was something peculiar
in this attack; & while looking at the patient, I observed,
all at once, a projection of the under jaw. I was imme-
diately impressed with the conviction that death was near
at hand, & I had hardly time to prepare the minds of the
parents for the change which was about to take place, be-
fore the patient died.
We will now pass to other views of this interesting sub-
ject of fever; & first, we will examine the doctrine of criti-
cal days. Hippocrates taught that there are certain days
on which fever is disposed to come to a spontaneous crisis; &
the doctrine has not been without advocates from his
time to the present. Dr. Rush believed in critical days; &
though he employed the most active remedies in the treat-
ment of fever, yet he used them not with a view to cut
short the disease, but to prevent unpleasant consequences 
to the system during its continuance. Let us exam-
ine what is the course nature pursues in intermittent fever.
Suppose a patient to be affected with a tertian. First you
observe chilliness or rigour; sometimes so considerable as to
amount to a complete shaking ague. When this rigour sub-
sides, the system reacts, the skin becomes hot, the counte-
nance flushed, the pulse active, & the hot stage is com-
pletely developed. After this has continued for a short time,
nature brings about a solution of the fever. The heat abates, 
the frequency of pulse is diminished, a profuse perspiration 
 
                    


119
breaks out, & there is a complete absence of disease. The pa-
tient now walks about & pursue his usual avocations
till another paroxysm occurs. Here then is an example
of a crisis brought about by nature; &, as a general rule,
the same course is pursued- we have the same succession
of chill, fever, & sweat, whatever remedial measures may be
adopted to prevent it. But by interposing proper remedies
between the paroxysms we can prevent their recurrence, &
thus effect a cure. I wish you to observe, however, that
we do not break the disease; we only take advantage of an
interval allowed us by nature to prevent a return of fever.
If all this is true with regard to intermittents, why de-
ny that remittents may be governed by the same laws?
In remittents there is every day a diminution of the feb-
rile symptoms, & an apparent effort on the part of nature
to effect a solution. The effort, however, does not succeed,
& an exacerbation again takes place. This state of things
continues for a certain period- 3, 7, or 9 days, for instance,
when, sooner or later, according to the nature of the disease
& the constitution of the patient, a complete crisis is affected.
As in intermittents, every other day the fever is disposed to dis-
appear, & at last goes off on one of those days on which it would
have gone off, had the disease been a tertian fever. I do firmly
believe that remittents are governed by the same laws as
intermittents. We are led by this doctrine of critical days
to ask the question, whether by treatment we are able to cut
short a fever, or, in other words, to prevent it from running      
 
                    


120
a determinate course. This, as I shall soon show you, is
a deeply interesting & important consideration. I am prepared
so say, when fever is fairly formed; when it has passed over
the period of predisposition, or that space which immediate-
ly precedes the full establishment of the diseased associations,
that, as a general rule, it cannot be cut short. Its vio-
lence may be much moderated, & by proper treatment, it
will generally be conducted to a favourable issue; but it can-
not be arrested in its progress, at least, in the great majority
o cases. This is not a matter of mere speculation: it is
of the utmost practical importance. If fever is to be cut
short, it follows, that in violent cases, violent remedies
must be resorted to for their cure. Thus, in yellow fever, a
disease which runs its course in a few days, & is character-
ized by the utmost malignancy, if treatment is to cut it
short, the most vigorous measures must necessarily be em-
ployed. Now let us examine this paint, & ascertain the re-
sult of different kinds of practice. The time was when it was
generally believed, that it was scarcely possible to treat yellow
fever too actively; to draw too much blood, or to throw in 
too much mercury. This at one time was the fashionable
practice in our city. Other strong measures were also em-
ployed. But I believe that the practice of Dr. Monges will
be found as successful as that of any other physician in
Philadelphia, if not more so; & it was remarkably mild.
In some instances, in the early part of the disease, if much
action was evident, he drew a little blood; but he never em-

                    


121
ployed mercury. His practice was very simple, & not
calculated to cut short the fever, but to conduct it to a fa-
vourable issue. In the year 1805, in the city Hospital, the
practice in yellow fever became much more simple than it had
been in the preceding years, & the lancet was seldom resorted to.
The practice of that year was admitted to be equally successful,
If not more so, than in former years when a different course
was pursued. Let us now decent from the yellow fever to
our own indigenous fevers. Take a case of autumnal re-
mitten, & see how far a practice calculated to cut up the dis-
ease by the roots is preferable to mild measures, calculated
to conduct it to a favourable issue. Instances are not want-
ting in which practitioners have push on with the utmost
boldness in the management of autumnal fevers. In Lancas-
ter county, on the borders of the Susquehanna, a gentleman
gifted with strong talents by nature, & possessed of much
medical information, fixed himself with a view to practice.
He had written an inaugural essay on the unity of disease.
A fever arose in his neighbourhood, which, in the hands
of this physician, became a most mortal epidemic. In a
small circle as many as 52 deaths occurred. What was
the treatment? It was of a most violent character, & car-
ried to the utmost extent. Bleeding, profuse bleeding, was  
resorted to in every paroxysm; & whenever the fever rose
it was to be counteracted by depletion. What ere the conse-
qunces? His patients died around him in great numbers.
What was the result of an opposite course of treatment?                      


122
In the same neighbourhood, in the same disease, men
with not half his talents & medical attainments, guided  
by experience & common sense, & not under the influence
of theory, met with great success. In their hands, the
disease which he had found so fatal, became a moderate dis-
ease, & yield, as autumnal fevers generally do, to compar-
atively mild measures. Evacuations from the stomach and
bowels by emetics & cathartic, sweating, the occasional use
of the lancet when the symptoms run high, with blisters,
& back in the remission or intermissions, constituted the
routine of their practice. But by this practitioner back and
all tonics were utterly condemned; & even when the patient
exhibited symptoms of the utmost debility, no stimulant med-
iciness were allowed. I mention this instance to show how
fatal is false theory, even when the man who believes in it
is possessed of good natural talents.
There is another view of the subject which, however hu-
militating to the pride of medical science, must, neverthe-
less, be taken. I am very far from holding out the idea
that medical interference is entirely unnecessary in fever.
& that the best course is to leave the disease to natural alone.
I have said enough to convince you that I am not idle
myself in the treatment of such cases. But I have now to re-
late a fact which, at any rate, should make as pause be-
fore we adopt violent measures. A very respectable practitioner
who was a surgeon in the army during the late war, Dr. Fow-
bridge, informed me that, at a certain period he was so    
  


123
situated in the camp as to have the power of making a con-
parison between the effects of act, & the unassisted operations
of nature in cases of fever. At once time there were 30 pa-
tients sick with this disease, who had no medical attention 
whatever, & from circumstances which could not be avoid-
ed, were unable to obtain any. Yet the Dr. found that
they made out just as well as those had been un-
der treatment: the some proportion, as far as he could
judge, recovering in the one case as in the other. This is
a humiliating fact; but it is worth remembering. Be-
fore using severe measures in anticipation of certain events,
let us be certain that those events are likely to occur. I am
persuaded that violent measured have often done much
harm; as much, perhaps, as the disease would have pro-
duced if left entirely to itself.
There have been many peculations in the medical
would as to the cause of fever; & bottomed on these spec-
ulations many hypotheses have flourished for a time &
then passed away. At present there are some fashiona-
ble doctrines prevalent, which require a candid ex-
amination. One of these, to which I wish particularly to
call your attention, is that recently given to the world
under the name of an eminent French physician- I
mean Broussais. He teaches that all fevers depend on in-
testinal irritation. The mucous lining of the stomach &
bowels he considers peculiarly liable to inflammation, &
regards it as the primary seat of fever. Others tell us 


124
that fever is ushered in by an engaged state of the ve-
nous system, or a state of suffocated excitement- two theo-
ries which apply to the same circumstances; the first spoken  
of largely by Armstrong, the second supported by Dr.
Rush. There are some who maintain that in every
case of fever, the liver has much influence in its pro-
duction; while another set believe the brain, if not the
primary seat of the disease, is at least more or less in-
terested in it. Now I am willing to admit that,
to a certain extent, all these are correct in their opin-
ions. That we have local irritation & inflammation
in fever there is no double; but I am disposed to
consider this state of things, not as a cause, but as a
consequence, of fever. That fever may arise without
any inflammatory action of the system, I think I
do know; nay, I have known it to occur under a
precisely opposite condition. Profuse evacuations of blood
may produce it. I recollect the case of a lady who
had suffered from proper hemorrhage which had re-
duced her so low that her extremities were cold and
her pulse extremely feeble; yet the next day she was
affected with fever, & action enough existed in her
pulse to call for the lancet, if other circumstances had
not contraindicated its use. Dr. James who attended
the patient with one, observed that Dr. Deuman, or
some other celebrated [aco??he??] of London, speaks
of this as a circumstance not uncommon; & that       


125
patients rarely die of uterine hemorrhage from the mere loss
of blood, but from the fever which follows. In opposition to
the opinion that intestinal inflammation is the primary cause
of fever, let us take a case of common intermittent: in this
complaint the patient passes through the cold, the hot, & the
sweating stage, & is then for some time free from disease, till
another paroxysm commences. Now if inflammation were the
cause of the fever, this would remain as constantly present as
the inflammation itself; at any rate, the disease should
not be entirely removed by back & a generous diet- means
certainly calculated to exasperate a case depending on in-
flammatory action in the stomach & intestines. But
dissection it is said gives unquestionable evidence of
the existence of inflammation. Let us inquire what are
the prop on which this conclusion is grounded. By post
mortem examinations there is frequently discovered a red
& suffused condition of the vessels of the stomach & intes-
tines; & with many others, I was myself once inclined
to accept this appearance  as an evidence of inflamma-
tion: but I am now convinced that suffusion of the
mucous membrane may exist without such a cause.
I refer you to a paper in one of the numbers of the Eclec-
tic Repertory, by yellowly of London, in which it is sta-
ted by this physician, that having been induced to sus-
pect that the common evidences of inflammation were
not well grounded, he instituted a set of experiments to as-
certain the fact. He look for subjects men who had       


126
been recently executed for crimes, & of course had died in-
stantly without previous disease. In a large proportion
of these cases he found the same red appearance in the
stomach as had been observed under other circumstances,
& had given rise to the supposition that the patients died of
inflammation, the experiments of Dr. Seeds are peculiarly 
interesting, & illustrative of the views now given. He bled
a number of animals to death.; some suddenly; some grad-
ually; some from the arteries, & some from the veins; &
dissection gave appearances resembling inflammation. Not
only was the mucous membrane injected & red, but extensive
serous effusions were also found. I refer you to his paper
on the subject, published in one of the English Journals.
In [co???t] with Drs Emlen & Gebhard, I tried the exper-
iments on two hogs which were slaughtered; & the exper-
iments of Dr. Seeds were fully confirmed. In the Jour-
nal to which I referred you, another very valuable pa-
per will be found, published as a letter from Dr. Davy of
India to Dr. Mc Gregore of great Britain, calculated to
show certain deception appearances resembling inflame-
mation, which are discoverable after death by dissection.
By his observations & experiments we are taught that
the blood percolates through dead tissues, acting as a
mordant, & presenting appearances that might be refer-
red to inflammation, & which might deceive the most
experienced anatomists. At my request, Dr. Harlan repeat-
ed the experiments of Davy, & his statement proved to be true.              
 


127
But when I refer to Broussais himself, & examine the
statement of some dissection he has given; & observe that
he has called that inflammation, which should be con-
sidered as the result of an opposite condition. I can place
very little reliance upon his conclusions. In a review of
Broussais’ work by Johnson of London, a case is extracted
which terminated fatally after a system of the most rigid star-
vation had been pursued for more than 20 days. On dis-
section it was found that the whole alimentary canal
was contracted so as to have its internal surfaces almost in
contact; & throughout the intestines, the mucous membrane
was dry & of a logwood colour, without any fecal contents.
Now this state of things, so far from being an evidence of
inflammation, I do sincerely believe to have originated
from the rigid system of starvation that had been em-
ployed.- so far will preconceived theoretical motions run
away with the judgment.
We are told that there is another proof of inflammation
afforded by dissection, viz. serous effusions into the various
cavities; as those of the brain, thorax, etc. Now I admit most
freely, that in certain cases of morbid action going on in
these parts, during an attack of fever, we have considera-
ble effusion; &, in some instances, a general dropsy will
occur, coextensive with the different cellular tissues of the
body. But this, so far from being universally the result
of excessive action, is often consequent upon debility. Let
us take a patient with fever worn out by the continuance     


128
or severity of the disease, & examine what is the state of the
system:- all its powers are laid low, sensibility is lost, the ac-
tion of the heart is manifested by a pulse barely perceptible, & we
have the cold, clamming surface of death. If effusion displays it-
self on the skin, as in the cold sweat preceding dissolution, may it
not also take place, in the same state of extreme debility, from
the occurs membrane lining the various cavities? The absor-
bents partaking of the general debility are so far unable to per-
form their office as to remove the fluids that is exhaled from
these membranes, & the consequence is an unnatural accu-
mulation. I once witnessed a case illustration of this state-
ment: a lad by a fall from a garret window received a
violent concussion of the brain, of which he died in a few
hours. When I was called to him, perceiving a fracture &
supposing the symptoms might depend upon compression
from effused blood, I took away by the trephine a portion
of the skull. Here then was fair opportunity for observa-
tion. A window, as it were, was made through the crani-
um, which permitted a view of the operations which ere
going on within. Had there been violent excitement, I
should certainly have witnessed it: but there was no pul-
sation perceptible: his system never reacted, & in a short
time he expired. On examination after death, serous effusion
was found in the brain. In this instance it could not have
been the result of excessive action- it was the last act of the
dying vessels; & as the absorbents were too feeble to perform their
part, an accumulation necessarily resulted.   


129
It is said that change of structure, an induration or thick-
ening of parts, is an evidence of previous inflammation. That
such changes may result from this cause I very well know;
but it by no means follows that they universally to be
attributed to it. Because while disease may exist in other
parts of the system besides the blood vessels, the absorbents may 
not properly perform function; & the result may be, that
what the actives deposit in the course of their health action,
the lymphatics may be too feeble to remove; & induration and
enlargement hence take place. The growth of steatomatous  
& other tumours of the like kind, is an exemplification of this
statement. In these enlargement occurs without the exist-
ence of inflammatory action.
By Armstrong & some others we are told that death
often results in fever from the engorgement of the veins
in the internal & vital organs. The brain is inundated;
the liver, lungs, and vessels of the intestines, are distended
with venous blood; & the system oppressed beneath the
burden sinks & the patient expires. This state of thing
is said to be proved upon dissection. But if a man pas-
sing along the street were to receive the full force of a
blow from a falling brick, & instantly expire,- what do you
suppose would be exhibited by dissection? The large ve-
nous trunks would be engorged with blood. In a state of
health there is a certain proportion between the quantity of
blood in the arteries & veins; but during the act of expi-
ring, the former vessels empty themselves into the latter         


130
& hence the appearance of venous congestion which has
so often been considered the cause, instead of the consequence, 
of death. The theory which attributes the alarming symp-
toms we often observe in the low state of fever to venous
congestion, appears to me to be a very limited & narrow view
of the case. We should rather look to the nervous system
as the seat of the mischief. When the brain & nerves 
become debilitated, & the usual supply of nervous influence
is not imparted to the blood vessels, the heart acts with
diminished vigour, & the blood, of course, accumulates
behind it in the large venous trunks. If the supply
be entirely cut off, the heart must cease to act, & death
will result, not from congestion, but rom nervous exhaust-
ion. Consider the effects which followed the division of the
8th pair of nerves in a horse, by the celebrated Dupuytren.
The most distressing symptoms were produced- his breath-
ing was excessively disturbed, violent efforts were made by
the animal to expand his thorax, & thus compensate for
the diminished power of the lungs: but all his efforts were
unable to afford relief. The symptoms went on increase-
ing, till the horse, in the utmost agony, expired. After
death the blood was found to be of a coaly blackness.
In some of the low forms of fever, when the energy of the
brain has been insufficient to furnish the due quantity of
nervous power to the lungs, I have been strongly reminded
of the above experiment.
We have further evidence that patients die from

      
 


131
imperfection of nervous power, without the blood vessels being at
all concerned in the event. In surgical operations the system
sometimes receives so violent a shock that if never reacts.
In these cases death is not to be attributed to impression on the
nervous system which prostrates the functions of life, & renders 
the various organs incapable of performing the task assigned
them.   
I have brought forward these facts to show that med-
ical  men are too apt to regard only one side of the question;
& to limit their views to congestion, inflammation, con-
sequent disorganization of the vital organs as a cause of death;
when, in fact, this termination often takes place in disease
without any thing more than a general sympathetic affect-
tion of the blood vessels. That in some cases of fever there
is strong local determination, & even inflammation, I
am not disposed to doubt; it is only the universality of
this occurrence that I call in question. I have indeed
not unfrequently witnessed cases when local excitement
was strongly marked. I once attended one of pupils
of the Alms-House, who was attacked with fever, attended
with so much excitement in the brain as to amount of phre-
nitis. The inflammatory action was indeed unequivocal, and
he was bled 100 ounces, before he recovered. From this you
may infer that I am not unwilling to employ the lancet
when the state of things sums to demand it.
But to conceive with Broussais that every fever is an          
      
 


132
inflammation of the nervous membrane of the stomach
& intestines, & to be treated by depletion, or, at any rate, un-
der all circumstances, by the most rigid anleptilogestic  
regimen, restricted even to a solution of gum tragacanth
or gum arabic, appears to me absurd & preposterous in 
the extreme. One of the cases of this kind brought forward
by Broussais in illustration of his principles, which ter-
minated fatally, was, in my opinion, as clear an in-
stance of death from absolute starvation as could be
adduced. The patient had been sometime sick with
fever, but he recovered gradually, & was at length restored
to tolerable health. All at once, however. He was again
yaken sick, & was put on the rigid diet prescribed by brous-
sais. Things went on this way for some time, when
it was found that the poor fellow, tormented with hun-
ger, ad procured some food from his comrades & con-
cealed it in his bed. (The patient was in one of the French
Hospital.) He was now restricted still more carefully than
ever. But there was no amendment; & for 10 or 30
days he continued wasting away, till at length he died, re-
duced almost to a skeleton. On dissection the caliber of
his intestines was found reduced almost to nothing; the
mucous coat was of a dark red colour, indicating, accord-
ing to Broussais, the previous existence of severe inflame-
mation; but in my opinion, the effect of the starving plan
of treatment which had been pursued.
It seems to me that this rigid system of diet is cal-        
      
 


133
culated to defeat the very object for which it is presented.
Its authors appear to have forgotten that then are ab-
sorbents which are constantly taking up the substance of
the body & conveying it into the circulation, & which act
with increased energy whenever a moderate supply of food
is withheld. Surgeons understand this perfectly. What
is more common than to remove tumours through the
agency of the absorbents? And what calls these more spee-
dily into operation than low diet, purging, etc? When,
therefore, a patient with fever is deprived of enough
food to supply the demands of nature, the body feeds
upon itself; & is, of course, supplied with that very
kind of food, the entrance of which into the blood ves-
sels is so much dreaded. Cellular membrane, fat,
muscle, bone, & marrow, are indiscriminately absorbed
by the lymphatics, & the circulation is supplied with
animal food, & that too in a diseased, & no doubt,
unwholesome condition.

Of the Pulse.
______x______

The knowledge of the pulse is, by common consent, re-
garded as truly important part of medical education.
Dr. Rush was in the practice of inculcating the necessity of
Studying the pulse; & he used to say in his lectures. If ever
He should crest a temple to medicine, he would inscribe
Over the door, “Let no man enter here who does not under-   
      
 


134
stand the pulse”. An important question here arises, at which
you may at first be startled:- may not too much reliance
be placed on the pulse abstractedly considered? I intend in 
this lecture to offer proofs in the affirmative. 
Before entering on the different varieties, I will make
a few remarks on feeling the pulse. For this purpose we
generally select the radial artery at the wrist, because it is
more accessible than any other. But it is right to under-
stand that the other arteries are capable of giving correct in-
dications as far as the pulse is concerned; & a knowledge
of this circumstance is important, particularly as relates to
children. These are frequently very averse to having their
wrist felt, & an account of their restlessness it is sometimes
impossible to form a correct judgement of the pulse from the
radial artery. In some instances of this kind, we can suc-
ceed very well by examining one of the tibial arteries. In
one instance where there was great objection on the part of
the child to my touching his arm, I succeeded without
any resistance in examining an artery of the foot. The tem-
ple is also a good situation for examining the pulse.
I will make another prelimiscary observation, relative to
the distribution of the arteries. You know very well the
course of the radial artery in common cases. But there are
not a few persons in whom it deviates from the common
direction by running round the radius. Instead of passing
the front of the bone, it makes a turn, in these instances, &
runs along the back of it. I myself have been deceived in         
	




135
several instances from the want of attending to this circum-
stance. Sometimes the radial artery bifurcates above the
wrist: only a small branch taking the usual direction. I
have seen cases in which it might be supposed that the per-
son was almost pulseless; yet by examining an artery in
some other situation, I have found as fine, bounding a pulse
as could be desired.
The pulse is very various in different individuals. In
some it is very slow, naturally; in others, frequent & exces-
sively irritable. I have compared it to the multifarious
operation of the human passions. How quick to anger do
we find some people, & how easily is their anger allayed!
Carry this to the pulse: how often do we find this excited
to violent action by the slightest causes, & how easily is it
allayed by proper treatment! Others, on the contrary, are
with difficulty round to anger; but their passions when
once excited are not easily subdued. The same is the
case with the pulse. Some constitutions endure to a most
astonishing extent, the operation of injurious causes, without
feeling the effects which we might naturally expect to re-
sult. In proof of this insusceptibility to be acted on by causes
we should naturally suppose to be injurious, I refer you
to a case of fractured leg, of a waggoner, related in my sur-
gical lectures.
In some constitutions the pulse is excited very easily.
The hectic pulse is sometimes induced by very slight cau-
ses. It is stated that Dr. Pitcairn had a very irritable          
	




136
pulse. Dissection should a slight degree of ossification
in the heart, which was supposed to be the sole cause
of this irritability in the arterial system.
In the jacred writing we are told that “a soft word
turneth away wrath”. Thus, in irritability of the arties
soothing treatment often answers better than the most co-
pious evacuations. An irritable pulse may, in some
persons, be allayed by nutritious aliment. I know a per-
son whose pulse is liable to be thrown into great agita-
tion, & to become every frequent; but may always be al-
layed by a hearty meal. I have myself made the obser-
vation; I have seen it become slow, full, & more nat-
ural, as the system was elevated by nutritious food.
In some people there is a disposition to sink imme-
diately & without a struggle under affliction; others rise
in proportion to their afflictions. We may apply this to the
pulse, particularly in chronic diseases. How often does
life remain in the heart & arteries, when death is in al-
most every other part. I will here give it as my opin-
ion, that we may frequently be led into great error, by
constant efforts to reduce the pulse. In many chronic
disease; in phthisis pulmonalis, for instance, it seems
as if the heart & arteries take on an irritable condition
which is never to be reduced. I have heretofore, when treat-
ing of typhus fever, alluded to the synochula pulse of Dr.
Rush, which is characterized by its smallness, frequency, &
tension. I now repeat, that in some chronic diseases,   
	




137
we find this pulse connected with a state of most alarm-
ing debility. I shall instance several cases illustrative of
this opinion, when I come to treat of pulmonary consump-
tion. I would have you make it an object of particular
study to distinguish between irritability & inflammation.
I have seen patients in hectic fever worn out by nervous
irritation, who, at the same time, had a pulse that, in
certain conditions of the system, would have authorized
me to unsheathe the lancet & bleed with freedom.- How
much mischief has been done in phthisis by a reliance
on the pulse! How important, then, to be able dis-
tinguish between irritability & inflammation!
There are some pulses which, I am safe in saying,
can never be reduced. I have compared the resistance
of the heart & arteries, in some of these cases to the tem-
per of Meg Merrillies, the celebrated gipsy queen. She
was a strong politician & a great advocate for Charles.
The mob of sterling, who were of the opposite party, caught
poor Meg on one occasion, & determined to duck her
into a change of polities. Having seized her they threw
her into a pond of water, & pulling her out again, deman-
ded of she was still for Charles. She continued obstinate,
& they repeated the operation several times, till she sunk
under it & died. So long as she retained the power of
utterance, whenever her head appeared above the water,
she constantly cried out, “Charly yet, Charly yet.” The
same is the case with the heart & arteries: deplete as   
   
	




138
much as you please, they will, in some instance, never give
way till the patient his prostrate in death. I was called to
an aged lady who was attacked with an epileptic fit. When
I entered the room, I saw death in her countenance & gen-
eral condition, except her pulse which was full & strong.
I sat down by her bed-side, & is something is always ex-
pected to be done immediately in cases of extreme danger,
I ordered sinapisms to be applied to her feet: but before
they were procured she expired. Another lady, aged 72 years,
died under my care. She declined very gradually for sev-
eral months, & for a number of days before her death, scarce-
ly any thing passed her lips; & yet her pulse possessed force
when the operation of death were conoprinous in every other
part of the system. And the dying state instead of being
marked with the cold, clammy skin, was attended by great
apparent febrile heat: while she hipporratic countenance,
& her eye was demined by that peculiar concretion of flu-
ids, which produces the philm on the cornea so often ob-
served in articulo mortis.
Soothing measures in these cases will often do
more than all the evacuants that can be employed. The
fact is, some persons have naturally a very tense pulse.
I may venture to make the assertion, which your own 
experience will in a few confirm, that a natural
pulse may sometimes be mistaken for a diseased one,
& long continued efforts made, under this impression, to re-
duce it. I advise you to be on your guard against such      
 
	




139
a mistake. If you feel a strong tense pulse, & at the
same time, directing your inquiries into other circumstan-
ces of the case, find the health good without any other symp-
tom of disease, you should conclude that the pulse may be  
natural. I will knew a respectable old lady who had a
pulse of this description. I have often felt it when she
was in a state of perfect health, & have told her that ma-
ny physicians unacquainted with its natural character,
would, without hesitation, advise her to be bled. I once
had a patient in the Alms-House who had been bled
profusely, & this to reduce a pulse which I had every
reason to believe was not a disease one. In 1821,
my pupil, Chevalier, from Georgia, came to me after
the lecture & requested me to feel his pulse. It was 
a most powerful one. Similar to synoches. He informed
me that in order to reduce it, he had, by medical direc-
tion, been confirmed to the house for two months, dieted,
bled ad deliquum, took digitalis, etc. All this failed;
he was happily permitted to escape from treatment, & it
was found to be his natural pulse!
The most experienced practitioners have been de-
ceived in the action of the heart. Dr. Wistar used to re-
late a very interesting anecdote which will go to prove
this assertion. While a medical student at Edinburgh, 
he with number of others, was performing some experi-
ments on animals. Among them one day was bled to death.
Just before he died, a practitioner of the first respectability.




140
who was much in the habit of feeling the pulse, entered
the room. They purposely conceited from him what they
had done, & requested him to lay his fingers on the arte-
ries of the dog, & tell them whether it was sthenic or asthen-
ic action which was going on. Accustomed as he was to
the pulse, he pronounced it to be sthenic action. This
may at first surprise you: but experience hereafter
will inform you, that in some diseases of great de-
bility, as dyspepsia, etc., the heart heart will palpitate 
with very great violence. We find the same thing in
some cases of nervous irritation. I was acquainted 
with a medical gentleman, Dr. Anderson, who told me
that so great was the irritability of his system, that even
a drink of milk would produce violent action in his
heart & arteries. Persons in a reduced condition may
acquire so much irritation of pulse, that practitioners
if they followed the example of the Chinese physician who
judge by the pulse alone, would be led into the most egre-
gious mistakes in practice. Always remember that palpi-
tation of the heart is sometimes met with in cases of ex-
treme debility, & is frequently associated with danger.
When treating of typhus fever, I mentioned the case of a
gentleman affected with hemoptysis, where other symptoms
more important than the pulse induced me to resort to
the lancet. The pulse was weak, but the evidences of active
hemorrhage were strong the man had previously been in
tolerable health except a cough; nor indeed was he even now        




141
laid prostrate, but was able to walk about the room. This
His countenance did not exhibit those appearances of lan-
guor which accompany cases of great debility. The blood was
fluid & the hemorage was evidently active. Under these
circumstances, without regard to the pulse, I used the lan-
cet. I employed it, moreover, time after and time, & found his
strength adequate to sustain the depletion. The effects pro-
duced were beneficial. I have observed this weak state
of the pulse, in more than one instance of active hemor-
rhage from the lungs. I am not, therefore, guided by
the pulse alone, but consider the symptoms collectively
& decide accordingly.
Inflamation of the bowels or peritoneum is some-
times attended with a state of pulse extremely deceptive to
the young practitioner. In cases of this kind I am very
much disposed to look for other symptoms, & to ground
my practice on what I observe distinct from the pulse.
Among the symptoms of these complaints, which are
enumerated in the books, no one is more important than
great tenderness of the abdomen on pressure. When we
find a patient whose countenance is marked with an ex-
pession of great distress; when we find in the same per-
son all the pain & uneasiness referred to the abdomen, &
at the same time, discover great tenderness on the slight-
est pressure over the past, I am strongly inclined to sus-
pect a great deal of internal mischief.
It is here proper to observe that tenderness of the abdomen
          




142
is not an infallible sign of inflammation. Colic often leaves the
bowels in a tender condition. It is occasioned by the severe
pinch of the disease. This state of the bowels may be compared
to the soreness felt in a muscle, as, for instance, the deltoid, after
a blow has been received upon the part. But more of this
when I come to speak of colic.
In some cases of opthalmia, it is not proper to consider the
pulse as a guide. Inflammation of the eye may proceed to
such an extent as to involve the organ in considerable danger
before the pulse will sympathize with the local affection. Dr.
Rush who was often very happy in his similes, used to tell us in
his lectures, that the pulse, in many instances, refused to sym-
pathize with an inflammatory affection of a small part for
a considerable time. He said, when the large vessels are inflamed,
as those of the thorax, etc., from their size & influence
over the whole system, the pulse is affected directly. He compared
them to the bells on the garments of the High Priest, during
the Law, which, when one was touched, all rung the same
tune. Thus with the great blood vessels; when one is touched
all ring the tune of inflammation: but when the small
vessels are first affected, a long time elapses before the
larger ones participate in the diseased action.
The proposition is certainly correct, & very important.
But this is particularly the case in one species of ophthalmia,
in which we should be guided much more by
the particular appearance of the disease, than by the
condition of the pulse. When I come to speak of ophthalmia,
    




143
opthalmia, in my surgical lectures, I shall notice this affec-
tion more particularly. It is now sufficient to remark
that unless prompt & powerful measures are employed, the
complaint will terminate in sloughing, & consequently, loss
of sight.
In 1818 I was called to see a respectable nurse, in con-
sultation with a very respectable physician of this city,
who, however, does not pay any attention to surgery, &
was not exactly aware of the nature of the case. The pa-
tient was laboring under the form of opthalmia of which
I have just spoken. Experience as I had been the dis
ease, & knowing the great importance of evacuating meas-
ures, I was influenced in the proposition of the lancet
much more by the appearance of the eye, than by any
information I could have derived from the pulse. The
lancet was resorted to; & though one eye was lost, the prac-
tice subsequently pressured, rescued the other from a sim-
ilar fate.
In peritonitis lent little dependence should be placed
upon the pulse. A lady of this city, the wife of a French
gentleman, was recommended to me by Dr. Monges who
was too unwell to attend her himself. On visiting her, I       
found her complaining of pain in the cavity of the abdo-
men, with great restlessness & distress. On feeling her pulse
I found it possessed little force, though the other symp-
toms induced me to doubt relative to the propriety of
stimulating measures. Aware that Dr. Monges was


144
well acquainted with her constitution, & know-
ing the importance of attending to this in all circum-
stances. I called on the Dr. & stated to him the condi-
tion of the patient. He said that experience in her case
taught him, that without reference to the pulse there
was a necessity for the lancet. I returned to the patient,
derected the loss of blood, & had the operation repeated
several time. The blood was sizy, & relief was afforded.
The information which I obtained from the Dr. was of great
importance. I treated the case as inflammatory, & she re-
covered. Had I managed it as I would have done a case
of prostrate action, it is very probable that the patient would
have died.    


145
Diseases
of the
Abdominal Viscera.
__________________
Cholera.

This is a disease common to all ages, but peculiarly
dangerous in infancy. As it occur in infants, it is call-
ed cholera infantum, & of this I shall treat in another
lecture; at present I shall enter into a consideration
of the disease as it generally affects adults.
Cholera consists in a vomiting & purging of bilious
matter, attended with painful gripes & spasms in the
limbs & abdominal muscles. Patients in a state of
pretty good health, are sometimes suddenly attacked
with serve vomiting & purging: but I believe it
frequently happens that, previous to the attack, so
predisposition to the disease exists for some times,
& that cholera is ushered in for the removal of an
offending cause.
The spasms attending cholera are sometimes
so serve, that men of considerable firmness, when
under their influence, will lose all command of
their feelings, & vent them in complaints loud
and distressing. When the disease proceeds to a
more advanced stage, (& I can tell you, that this    

 


146
stage, in some instances, is ushered in the course of a very
few hours,) you will be struck with the rapid prostration
of strength observable in the countenance of the patient,
particularly the eyes. I have seen the eyes, in a few hours,
sunk in their sockets in a manner truly extraordinary.
Along with this you will very commonly observe a
stridulous voice. In fact, great exhaustion comes on,
marked by a feeble pulse, cold, clamming sweats, and a
very frequent & insatiable desire for cold drinks, which,
although so vehemently craved, are almost invariably
pernicious. This description, I believe, will be found
to comprehend cholera in its common form, as it ap-
pears in adults.
When called to a patient in the situation I have
described, it is necessary for you to be thoroughly
acquainted with the mode of practice, so that no time
may be lost; for, in this this disease, as in some oth-
ers to which I have called your attention, the max-
im forcibly applies, “What thou doest, do quickly”.
In the very commencement of cholera, while the
pain is severe, & the bilious discharges from the stom-
ach & intestines are very copious, one of the primary
indications, on which the practice is to be grounded,
is free dilution with mild drinks. Sydenham rec-
ommends a remedy which, at the present day, I believe
to be entitled to great consideration: I eslum it an ex-
cellent remedy in cholera, & it is nothing more nor  


147
less than chicken water. Jissault who treats very
well of cholera, tells us that the disease is to cured
by draughts, by deluges of the most mitigating drinks.
My universal practice, in all cases of cholera, is to
obtain chicken water as soon as possible, even
if I should be called in the night. The chicken
should be cut in pieces, the bones mashed, & a gal-
lon of warm water poured on it & boiled for a time.
A little salt may be added to render it more pal-
atable. Of this the patient should drink most
copiously. No matter if it be returned from the
stomach; you should give it still, & completely 
wash out that viscus. I believe the chicken water
to be one of the most agreeable & one of the safest arti-
cles that can be employed. In addition, & alternated
with this remedy, I give some herb tea, particularly that
made from peppermint. These two are my great reme-
dies for dilution.
But in those cases where the pain & vomiting become
very distressing, our object should be, as speedily as possi-
ble to relieve the severe spasm to which our attention is call
ed. External application may, in many instances be
interposed, with the most extraordinary benefit, Sinapisms
to the extremities may be applied with very great ad-
vantage. But the spired plaster to which I have before
called your attention, (see p. 89.) is particularly use-
ful in cholera; I have employed it in many instances,   
 


148
& can speak of the benefit to be derived from it with
perfect confidence. But previously to the application
of this plaster, I generally employ another remedy
which is always readily procured; I allude to the in-
fusion of pepper with hot brandy. Out of this flan-
nels should be wrung as dry as possible, & applied,
as hot as they can be borne, over the stomach & bow-
els of the patient. I would prefer a piece of blanket
folded up, as it retains the heat longer than a piece
of thin flannel. It is of great consequence that the
heat should be retained for a long time: for if the
flannel should be allowed to become cool, it might
do more harm than good. As soon as the spiced
plaster is prepared, the flannels may be removed, &
the plaster substituted. Fomentations of the kind de-
scribed, tend very greatly to relieve the pain, & to allay
the irritability of the stomach. But if this plan
should be insufficient to afford relief, some other rem-
edy must be resorted to, & it is a general practice to
have recourse to opium. In some instances the
spasms are to violent, that a practice of this nature
is absolutely necessary. Here 30 drops of laudanum
may be given, & if then should not produce the de-
sired effect, the dose may be repeated till 90 drops
have been taken. This practice, however, is advisa-
ble only in violent cases. Dr. Wistar was opposed to the
use of opium, if any other plan could possible be de-    
 


149
vised for procuring the desired relief, without those un-
pleasant effects which he presumed sometimes result from
the use of this article. Acting on the belief that the disease
acquires free dilution for its cure; that the bilious evacu-
ations are an effort of nature for her own relief, & that
any medicines which would paralyze the secreting pow-
er, & lark up the bible in the system, must prove inju-
rous, he very generally resorted to spiced brandy where
other practitioners employed laudanum. His practice
was to give the spiced brandy, in doses of a tea spoon-
ful, frequently repeated, till the spasm was diminished 
or overcome. In cases of a milder character I have
succeeded very well with an article of this kind:
Take Salt of Jarlar, 3j
Laudanum, dps Lxxx
Mint Water, z iv
Some sugar may be mixed with it or not, according to
the taste of the patient. The dose is a table spoonful
repeated every hour, or if the case be violent, every half
hour, till relief is procured. If one or two doses succeed 
in allaying the pain, you may extend the period of
administering the next dose, till a renewal of calls for
it. Afterwards you may administer it pro ra nata.
Here it is proper to remark, that the spasms in the bow-
els which are observed in cholera, & which form so stri-
king a symptom in the disease, have, by some practition-
ers been referred to inflammation as their cause. Now   
   
 


150
here, I believe, that incorrect theory leads to dangerous
practice. As for myself, I think I can say, without
any disposition to boast, that I have rarely ever seen the
disease in any other than a manageable form: I would
except persons worn out by previous disease. In such cases
I have seen cholera evidently hasten the fatal issue; & the
venerable uncle of my wife, who lately died, is an example
of this kind. But I speak of it as an idiopathic disease,
occurring, as it often does, in persons of tolerably vigorous
health; & in such instances I have found it a manage-
able disease. I think I can say that I never saw a case
of cholera which required the lancet. My reasons for object-
ing to its use, in cases of this kind, are the following: In
the first place, I do not believe that any inflammation
exists. I believe that if we were always to associate pain
& inflammation, we should sometimes make great mistakes.
For certainly, acute pain may exist in a part without in-
flammation of that part. The disease is attended with
most profuse bilious evacuations from the stomach and
bowels. These evacuations in a few hours exhaust, even
a strong person, to a very great degree, & produce extreme
prostration. When, therefore, life is running out at every 
pore, & the physician is called upon to support the little
remnant of strength, why should he let his theory of in-
flammation come in & aid in letting it out still faster
by the abstraction of blood? If this were a disease of in-
flammation, I feel confident that the practice which I have     
   
 


151
pursued during my whole life, & which I derived from my
preceptor who followed it with great success, would have
proved highly injurious instead of beneficial. In enteritis
spiced brandy would certainly aggravate every symptom:
but in cholera, though in many instances accompanied with
dangerous & alarming symptoms, these will generally give
way to the course of practice proposed.
As the disease advances the debility & exhaustion are ex-
treme, & you will generally be under the necessity of most
assiduously watching the patient, & of introducing some-
thing stimulant & nutritive into the system. While this
plan is pursued external irritation is at the same  time,
peculiarly proper. Sinapisms & blisters may be interpose
with great advantage, & stimulating frictions are very
well suited to some cases of low cholera.
But there is one point to which I must call your 
attention: I have stated that in this disease the patient
generally labours under insatiable thirst, & almost always
has a desire for cold drinks. You have all heard me
say, that in same cases of fever, great benefit is derived 
from the use of cold drinks; & it often happens that the
language of nature ought to be attended to, as her voice
is predicated upon reason: but the language of nature
is not always true- sometimes like a child destitute of
judgement, she obeys she calls of inclination rather than
the suggestions of reason. Hence, cold drinks in cholera
are strongly craved by the patient; but if taken in large  
  
 


152
quantities they are injurious. The stomach & intestines
are in a state of spasm which is rather increased than di-
minished by the use of cold water. Lepit drinks are greatly
to be preferred. I believe that the thirst must be referred
to the same cause in cholera as in certain states of fever.
I told you that in fevers thirst depends on two oppo-
site states of the system:- in some cases it is accompa-
nied with a dry & hot skin, a quick & febrile pulse, etc.;
& under these circumstances it may be gratified with
advantage. But in cases of extreme prostration with a
cold skin & extremely feeble pulse, the insatiable thirst
which sometimes occurs is not to be relieved by drinks,
& is found to diminish exactly as the system is raised by
the judicious use of stimulants. This, I can venture to
assert, is exactly the case in cholera.
Sometimes, in the bilious vomiting of cholera, small
quantities of seltzer-water, or soda-water may be taken
with advantage. The saline draught in the state of
effervescence is suited to some of these conditions of the
stomach; so also are the Seidlitz powders; limo-water is
likewise a useful remedy. But I wish forcibly to im-
press on your minds the propriety of copious dilution
in the commencement of the case. If cholera is pre-
maturely arrested by the free use of opium when the pain
& spasms are violent, you may calculate that more fever
will subsequently arise, than if the bilious evacuations were
permitted to go on. But it occasionally happens in practice           
 


153
that we are forced to make a choice between difficulties,
& to take the lesser evil. In some of the extreme cases of
cholera, the lesser evil is to allay pain & spasm by opium
& external applications. Even if fever does come on, it
may be combatted by the proper remedies, & is much to
be preferred to that violent pucking & purging which threat-
en a speedy extinction of life.
After the first symptoms are arrested, it is necessary, for
some days, to treat the case with a good deal of care. Bil-
ious  accumulations in the alimentary canal should be
prevented, &, at the same time, you should guard against
producing debility of the stomach & bowels. Hence, in the
progress of the cure, rhubarb may be employed with advan-
tage. In some cases, the spiced syrup may be administered; 
in others, the article in substance, either alone or combined
with small quantities of magnesia. At the same time that
you keep up slight evacuation from the bowels, you
should employ some vegetable tonic, particularly colum-
bo. A tea may be made of this root combined with gin-
ger, & given in small doses frequently repeated through
the day. The diet should be plain & nutritious, & all vap-
id aliment should be avoided. The plan of treatment
which I have detailed is adapted to cholera in its common
form. The disease may be variously modified, & hence,
require a diversity of treatment. There may be cases in
which the interposition of evacuants would be useful; &
here calomel comes in vey advantageously.      
 


154
There is one more remedy to which I wish to call
your attention- a remedy which I have seen pre-
scribed with great advantage in a case that very
much resembled cholera: it was a case of extreme
prostration, with cold, clammy sweats & a feeble pulse,
& the usual stimulants failed to excite the system. Dr.
Physick was called in consultation, & finding that the
ordinary stimulants had been used to no purpose, pro-
posed the spirits of turpentine: this was given in doses
of 15 drops, frequently repeated, & succeeded most happily
in exciting the system. Warmth was restored to the skin,
action to the pulse, & the patient recovered. I have no
doubt that the spirits of turpentine, in some prostrated
cases of cholera, may be used with great benefit, especially
when the spiced brandy has failed to produce the desired 
effect.
It is of great importance in the treatment of summer dis-
eases, to be able to distinguish one from another. For, however
we may be told that disease is a unit, yet I must confess
that I am no friend to generalizing in practice. In order
to illustrate my meaning, I will mention an instance
which was related to me by Dr. Wistar. I have heard him
say that one of the most important consultations he ever
attended in all his life, was on an occation in which he
believed the life an amiable woman was in danger, &
when a few words from himself to the attending physi-   


155
cian, were probably the cause of preventing a fatal termi-
nation to the case. The lady by severe cholera was reduced
to the most alarming condition. A young practitioner was
in attendance, who considered the disease a case of dysentery.
He was treating it on the evacuant plan, & employed castor
oil in frequent doses. When Dr. Wistar saw the case, & exam-
ined into it, he retired into another room with the physician,
& all he had to say to set every thing right, was, “The disease
is cholera, not dysentery”. At once the plan of practice was
changed, & the lady recovered. It was his opinion that a
persistence, for a short time, in the plan which was then
in operation, would have sacrificed a valuable life.
Before closing the lecture, I wish for a few minutes,
to direct your attention to cholera as a prophylactic.
Perhaps you may be ready to smile at the term, & to en-
quire how a disease of so dangerous a character should
be instituted as a prevention of other disease. But such is
the fact: in the summer season there is a very strong
tendency in the system to bilious accumulation, &, as a
consequence, to febrile action. Hence, fever in summer
& autumn are frequent & dangerous. Now, I believe
that cholera is nothing more than a salutary effort
of nature to avert the impending evil. When fever has
set in, what do we do to arrest it? we bring on an ar-
tificial cholera; we give emetics & cathartics to un-
load the system & clear out the alimentary canal. Na-
ture does the same thing in cholera: the only differ- 
   
 


156
ence is, that the physician performs his part more ten-
derly. Nature is a rough doctor; & sometimes in en-
deavouring to avert an impending evil, she causes a
greater. Hence, we should always, as far as possible,
keep her intentions in view, assist her, when proper, by
mild means, & watch the time when it may be advisa-
ble to arrest her in the violence of her operations.
Cholera Infantum.
I shall now pass on to consider the disease which has re-
ceived the name of cholera infantum. I shall simply
define it to consist in the vomiting & purging of infants- it
is commonly called the summer complaint of children.
Among the principle causes of this disease, so often fa-
tal to our infant population, I shall place extreme heat
in crowded situations. This, in fact, is the chief cause of
cholera infantum. Irregularities in diet, no doubt, contrib-
ute to the production of the disease, & place the system in a
state to be more severely affected by it after it has commence
its attack. I am not aware that cholera is more preva-
lent in the latter than in the early part of summer, provi-
ded that the degree of heat is the same: whether it shall oc-
cur in the 6th or 8th month depends entirely on the tempera-
ture of these two periods. The summer of the year 1806
was remarkably healthy, & there was scarcely any disease,
even in the 8th mo. It was an unusually cool & pleasant
season; & it was to this cause that I attributed our exemp-      
      
   
 


157
tion, in remarkable degree, from cholera infantum.
In summer a few hot days will produce many cases of
the complaint; while, on the contrary, a few cool days will
as soon arrest its progress.
The cholera of adults, I have told you, if properly treat-
ed, is, in this country, rarely fatal. When, however, the
patient is worn down by previous disease, & his constitu-
tion much enfeebled, the complaint sometimes proves
very serious: but in general it is easily managed. To 
children, however, cholera is a very fatal disease. You
may be ready to inquire, “what is the cause of this”? I an-
swer,- on the tender infant heat has a much more
powerful effect, than on the adult who has for years been
exposed to its influence. Let any one take a walk in hot
weather through the dirty lanes & alleys of Philadelphia;
he will witness many instances of little children recli-
ning their heads, as if exhausted, on the necks of their moth-
ers, with a pallid countenance, a cool & clammy skin, a
shrunk neck, & other signs of debility, arising from their
confinement during the night, in close & hot apartments.
Another cause has great influence in rendering cholera
so fatal in its effects; I allude to the irritation of denti-
tion. In fact, diarrhea often supervenes on dentition, & is
sometimes necessary to save the little sufferers from death
by convulsions. Mothers & experienced nurses are well
aware of this fact. But when dentition is superadded to
cholera, in hot & crowded places, a fatal issue is often to be    
      
   
 


158
feared. It is frequently from this cause that our attempts
to cure cholera in confined situations prove abortive. I
have often compared our endeavours to cure the disease,
under these circumstances, to an attempt to remove in-
fammation in a part, while a thorn is striking in it:
we may resort to leeches, apply fomentations, poultices, etc.;
but as long as the thorn remains, the irritation will be
kept up. Precisely the same reasoning applies to the case
of the tender infant: while affected with cholera, if it con-
tinues exposed to the causes which produced the com-
plaint, there can be little chance of giving effected aid.
Some die in a very few days with this disease, & con-
vulsions are not an unfrequent occurrence at the close;
others continue for weeks, gradually wearing away,
till at last they die of exhaustion. Just before death, it
is not unusual to see the eye suffused with red blood,
resembling, in some respect, the appearance of inflam-
mation. This is occasioned by a relaxation of the ves-
sels, which allows red blood to pass into branches, that
in a healthy condition, only transmitted a colourless
fluid.
Having given this outline of a disease, so fatal to
an interesting part of the community, I now propose
to give an account of the treatment, which I consider
appropriate. And here I might open the subject with
an expression of a very respectable practitioner, the venera-
ble Samuel P. Griffitts, whose experience has been extensive.          
   
 


159
One day, in the part of my practice. I enquired 
of the Doctor what could be done to cure the summer
complaint of children. He replied: “Lance their gums
& send them out of town”. This I consider excellent ad-
vise. But we often meet with cases, where from pov-
erty or some other cause, it cannot be carried into ef-
fect; &, therefore, I must endeavour to give you an
account of the treatment which I deem most advan-
tageous.
When you are called to see a child much reduced,
with a cool & clammy skin, a shrunk neck, etc., accom-
panied with constant vomiting & purging.- what is to be
done? I generally commence with the chicken water.
But the plan of dilution cannot be carried so far in in-
fants as in adults: they do not comprehend the neces-
sity of the treatment, &, therefore; cannot be made to
cooperate with the physician. I have often found great
advantage from the use of small quantities of seltzer
or soda water, frequently repeated. This remedy is re-
freshing & grateful to the patient, & often allays the irri-
tability of the stomach. I am in the habit of direct-
ing it to be put up in half ounce vials, one of which
may be taken at a draught. In this way it is preserved
fresh, which cannot be effected on any other plan.
The sodari powders will answer very well in country
situations, where the mineral water cannot be obtained.
The best method of preparing them is to dissolve a pa-
 


160
per of the alkali & acid respectively, in different & equal
portions of water, & then to mingle a dessert spoonful of
each solution, whenever the remedy is to be administered.
Sometimes, however, the stomach rejects every thing
which can be introduced into it; & in such cases, it is
necessary to resort to external applications. These often
produce very striking effects. The spiced plaster is an
excellent remedy in cholera infantum: but as used
in infants it is prepared somewhat differently from
that which I mentioned to you I employ for adults.
(see  ) In infants the pepper may be left out, or
sparingly added.
It is now proper to produce some change in the se-
cretions of the alimentary canal. For this purpose I have
found the syrup of rhubarb an excellent remedy. The
dose to a child 8 or 9 months old is tea spoonful every
two hours, till it changes the colour of the evacuations.
Sometimes small doses of calomel may be given with
advantage; one sixth of a grain every half hour or hour,
is the proper dose, & may be repeated several times. I
have not had much experience with this remedy in
cholera infantum. It has been highly recommended
by Dr. Ayre in his work on marasmus. But the prac-
tice is not original with him: Dr. Millar of N. Y.
having long before recommended the same plan.
In many cases I have found the rhubarb sufficient
To effect the end desired.  
    



161
After the operation of the rhubarb, or small doses of calomel,
I have been disposed to restrain the evacuations by a
mild julap, calculated to remove acidity, at the same time
that it meets the other indication. It is the following:
Take Salt of Tartar .. 3i
Laudanum, drops vi
Gum Arabic,
Loaf Sugar, a a 3i
Cinnamon water, 3iss
The dose is a tea spoonful, to be taken every 2 or 3 hours. If
something more astringent is wanted, the cretaceous mixture
will answer very well.
Take Prepared Chalk, 3iss
Laudanum, drops vi
Gum Arabic,
Loaf Sugar, a a 3i
Cinnamon water 3iss
The dose is a tea spoonful every 1, 2, or 3 hours, according to
the urgency of the symptoms. But great care should be taken
to avoid arresting the evacuations from the bowels too
speedily. In this complaint. I have found that the spiced
syrup of rhubarb comes in very well, when you are in want
of something calculated gently to evacuate the bowels, while
it leaves a slight astringent effect behind it.
The feet & legs are often cold & clammy, & it is necessary that
the child should wear woolen stockings. Attention to the
warmth of the extremities is essential in this complaint.

162
But at the same time that we keep up action in the ex-
tremities, it is of the utmost importance that the child should
have the benefit of cool air. In addition to this, knowing the
influence which dentition has in perpetuating disorders of the
stomach & bowels, it is obvious that the irritation, as far as lies
in our power, should be removed. With this views, it is of great
importance to lance the gums if they be swollen. Even if there
should not be much swelling, it is best to lance them , as there
can be no possible danger from the operation. Some physicians,
however, think the operation improper before the gums are
considerably swollen & inflamed: but I am in the practice
of lancing them freely before they have attained this state, &
thus prevent much suffering to the child. No possible harm
can result from the practice. The objection often urged by moth-
ers & nurses, & countenanced I fear by some practitioners,
that after the wound has healed the tooth will find greater
difficulty in passing through the cicatrix, than it would thro’
the sound gum, is entirely pivolous & founded on incorrect
views. You all know that new found parts possess less vi-
tality than original structure; & in consequence, they are
much more liable to ulcerate & be absorbed. Hence, the cica-
trix, so far from affording an obstacle to the passage of the
tooth, is, in fact, favourable to it.
There is another circumstance to which I wish particu-
larly to call your attention. When dentition is connected with
cholera, after you have lanced the gums, I would advise you
to apply blisters behind the ears. This is a practice which I        
  


163
cannot too strongly recommend. I was led to it by observa-
tions on young children during the progress of dentition. At
this period nothing is more common than to find ulceration
behind the ears. Young practitioners & young mothers are
apt to be uneasy at these unsightly sores, & to attempt to re-
move them. I tried this plan in my younger days, but
experience induced me to abandon it. I have known the
healing of these ulcers to produce unpleasant affections, which
have been removed by restoring the sores: hence, applications
made with a view to heat them are injudicious. On the contra-
ry, when they are absent, it is proper to irritate nature by ap-
plying blisters to these parts. After the blisters have drawn, the
parts should be dressed by some stimulating ointment with
the view of keeping up the irritation. I will venture to assert
that you will be surprised to see the good effects resulting from
blisters when fairly brought into operation. They concentrate
the irritation in the skin, & of course, lessen that of the gums,
which is production of such unpleasant consequences in chol-
era. In recent & low cases of cholera blisters may also be ap-
plied to the wrists with advantage.
Attention should be paid to the diet of the child. As the
system is frequently much reduced, it becomes necessary to
support it with nourishing food. For this purpose animal
soups, as beef tea, essence of beef, etc., should be given in small
quantities, & be frequently repeated. Weak milk punch is some-
times very useful. Dr. Wistar used frequently to recommends
this article: but great care should be taken best the use of 
  
  


164
it should become habitual. Dr. Wistar once had a child un-
der his care with this complaint, & advised the use of milk
punch. The patient recovered, & he ceased his attendance.
Sometime afterward, being in the neighbourhood, he inquired
into the situation of the child, & was informed that the punch
was still continued! When told of the quantity the child
was in the practice of taking, he was really alarmed; so much
had habit rendered him able to bear. Fortunately, however,
he succeeded in breaking the habit, before it had become
too much confirmed.
After the more early symptoms of cholera have subsided,
I frequently direct an infusion of bark & cinnamon in lime
water, in the following proportions:
Take Best Back, coarsely powdered, Z ss
Cinamon,. . . . 3 ij
Lime water, . . Z viij
It should be suffered to stand a little while, & then decanted.
A dessert spoonful may be taken several times a day. Port
wine in small quantities is sometimes useful. The infusion
of the dew-berry has been highly recommended by Dr. Chap-
man; but I cannot say much of it from my own expe-
rience.
You will remember that all these remarks apply to
patients who cannot be removed into the country: but if this
is practicable, it should always be recommended. I would
those who cannot take their children out of town, to allow
them as much air as possible. Frequently when in the      
  


165
Dispensary have I directed the mother to go to the Center-
Square, or to the State-House yard, taking with her her
child & her work, & to remain there all the day in the shade
of the trees; if they lived near the Delaware, I told them
to cross the river, & remain all day with their children in
the woods. In this way, I have no doubt, several lives
have been saved. Happily, there now exists an establishment
near this city, where mothers are allowed to take their sick
children from their crowded & filthy situations, & have them
properly attended to. Since this Institution was founded, the
mortality of cholera infantum has, in the city of Philadel-
phia, greatly abated.
To the efficacy of the country air in this disease, I can bear
testimony in the case of my own children. One of them was
thought to be as far spent as it was possible to be without
dying. Some of our friends thought he was so low, that
to take him out of town would be an act of rashness. But
I thought it of little consequence whether he died at home
or in the country. The weather was very sultry; I fanned
him as we passed along in the boat, & it was with difficul-
ty that we could keep life in him. We arrived at his Grand-
father’s, near Burlington, about noon; & in the evening,
while sitting under the piazza, the little fellow lying on
his mother’s lap, commenced paddling or playing with
his hands, as he was accustomed to do when in health; &
from this time he gradually recovered.
Cholera not unfrequently assumes a chronic from. The  


166
patient escapes the danger of the first attack, but passes on
into a state of extreme emaciation & debility. In this situa-
tion the little sufferer continues for weeks, & is finally re-
lieved by death. With regard to this state of the disease, there
are some striking facts which prove the advantage of in-
dulging the child with that kind of food which nature
impels it to desire. Very generally some kind of salt food
is preferred. Dr. Wistar used to relate the case of a child who
was brought into the parlour while the family were at din-
ner. It was extremely weak & seemed to be in the very
last stage of cholera. It showed a very strong disposition
for some ham which was on the table. The black skin 
covering the ham was the part which it seemed particu-
larly to desire. It was gratified; & it did not discontinue
suking the piece till it had deprived it of all its nutritious
juices. From this time it began to recover,& ultimately got well.
There was another instance of a child under similar cir-
cumstances, which seemed very anxious to eat some butter
that was on the table. This child was also indulged, & it con-
tinued to devour the butter, lump after lump, till it had
made way with the whole. From this time it was allowed
as much butter as it desired, & under this plan it recovered.
I have heard of another well authenticated instance, where
a child was reduced to the lowest ebb of cholera. In this state
it showed a strong disposition for raw herring, which was gran-
ted to it. It was benefitted by the diet, & was afterward
plentifully supplied. So fond was it of the herring that it             


167
always cried for more whenever its stock was exhausted,
& was never satisfied without having one in its possession,
which it kept pressed to its bosom.
Dr. Wistar was so convinced of the importance
of this practice, that he used to tempt his little pa-
tients with small slices of ham. Some would eat it;
others seemed to have no desire for this kind of food. In
the latter case he did not press it on them. I have oft-
en prescribed the essence of ham in these protracted cases
of cholera. I direct the juice to be bottled up, to preserve it
from becoming rancid, & to be used as occasion requires.
Sometimes, in these little creatures the appetite is most
voracious: this is by no means a pleasant symptom.
In the progress of cholera an apthous state of the
mouth often occurs, indicating a similar condition of
the alimentary canal. This I regard as an unfavour-
able symptom: though one of the worst cases I ever
saw with this affection, ultimately got well. Nothing
seemed to do it so much good as a gargle of lime wa-
ter & back.
In some protracted cases of cholera, Dr. Griffitts is in
the habit of giving scalded lemonade to the child; & in
some instances with a very happy effect. He derived the
practice from an old woman. Early in the disease we
use absorbents: but in the last stage, the juice of the
lemon often proves soothing to the patient, & useful
in arresting the disease. It is also calculated to excite an           


168
appetite, & thus contributes towards strengthening the
system. The bark jacket is occasionally employed.
Warmth should always be preserved on the surface, &
for this purpose flannel next to the skin is important.
At the same time the child must have the benefit of
fresh air. But after all, the country air, so strongly rec-
commended by Dr. Rush, will do more than the whole
of the other remedies together; & will produce the desired
effect, when all the rest have failed.
Here you may say that you have heard nothing of 
bleeding. I do not believe that cholera is disease of
inflammation. Whatever disposition of this kind may
exist previous to the attack is removed by the copious 
alvine evacuations. Nature takes the lancet into her
own hand & depletes from the exhalent vessels, quits
sufficiently in most cases, & often too much. It may,
however, be proper to take a little blood in some instan-
ces, when the disease is accompanied with difficult denti-
tion: but even here great caution is necessary. In those
severe cases in which you find a cool skin, shrunk neck,
great prostration, etc., the lancet would certainly do more
harm than good.
Before closing the lecture, I will make a few remarks
on another part of the subject. Precaution is always better
than cure. Heat & a crowded population are the principal
causes of cholera. But how shall we remedy the heat?
One of the most important points is to keep the windows
         


169
open at night. This recommendation would startle
some medical men. “What! Kill the children by sud-
den draughts of cold night air?”- I had rather see them
die from this cause than from its seclusion. I have
seen great advantage result from this practice. Compare
two children treated in opposite modes: first look at the
child of a parent who has a great dread of night air; most
probably he is placed on a feather bed with his parents on
each side, & almost smothered with the bedclothes; perhaps
several other children are in the room, & the windows and
the doors are sheet. But look at him in the morning;
you will find him limber as a rag, all his animation
gone, without appetite, & just on the verge of an attack of
cholera. Now look at one differently managed. Instead of
a feather bed, he is put upon a mattress & by himself; the
windows & the doors are opened; plenty of fresh air, that
pabulum vita, without which life cannot be sustained, is al-
lowed him; & in the morning instead of exhibiting the sickly
aspect of the other, he presents quite a different appearance.
When I see the dread which some people evince of cool air
& cold water, it would seem as if they were considered the
most destructive poison, instead of being actually necessary
to existence. They are, in fact, prophylactics very necessary
to infants, & will calculated to ward off an attack of cholera.
The cold bath as a preventive of disease I consider very ben-
eficial.   
         


170
Poisons
Taken into the stomach. 
______________________

The importance of the stomach in the animal econ-
omy I presume is familiar to you all. I am now about
to take notice of some of its acute affections. In my sur-
gical lectures, I stated to you the danger which results
from sudden violence to this organ. I mentioned that
I had known instant death produced by a blow on the
stomach of an apprentice lad, given by a fellow apprentice.
I also noticed the case of a gentleman who from what I be-
lieve to have been spasm of the stomach, died in an instant.
I shall now proceed to consider those morbid impressions
made on the stomach by poisonous substances.
Effects of Arsenic.
Among the poisons which destroy life arsenic holds
the most conspicuous place. The effects of a large dose of
this article you can easily anticipate. By its corroding pow-
er it must certainly produce speedy dissolution. To illustrate
its effects, I will read to you a case.
Case of J.- I was called 10th mo. 4th, 1816, to one of
the principal clerks in a store in Market Street, who had
swallowed three ounces of arsenic about half an hour
before I saw him. He positively refused to have any thing             


171
done for his relief, & resisted most violently when any
attempts were made to force him to swallow. I attempt-
ed to wash out his stomach, but in vain. At last
I told him if he would take what I should direct,
it would make him die easier. This succeeded; & he
drank off, at different times, at last two quarts of the
albumen of eggs, & we got down some ipecacuanha:
but the business was unalterably fixed- he died while
I was with him. Drs. Mattghieu & Monges, two very
respectable French physicians, were also present. He must
have suffered extreme agony. He made frequent efforts
to vomit; his countenance was of a dark purple colour;
he complained of being cold, & several times requested to
be covered up warm. I suppose about one hour & a half
elapsed from the time he swallowed the poison till
his death.
In the afternoon, in the presence of the coroner & his in-
quest, also the two physicians already mentioned, I opened
the body & took out the stomach. Every part of the vil-
lous coat was as completely cauterized, as if a red hot iron
had seared it in every part. The intestines were just begin-
ning to be highly inflamed; but the stomach was at once
disorganized.
I wish here to make a few remarks relative to the improper
or careless use of arsenic for the destruction of vermin- a practice
which has in some instances been production of serious conse-
quences. A family in this city, some time ago, after eating                 


172
their dinner, were all, at least those of them who had
partaken of a certain dish, affected with vomiting & distress of
stomach. Happily the affection was slight, & they all recovered.
In this instance there was every reason to believe that the 
desear arso from the following cause: The family had re-
tired to the country on account of the yellow fever which was
then in the city: but previous to their going out, some arse-
nick was spread about, & a plate of salt was suffered to re-
main uncovered on the dresser. The cook had seasoned
the dish before alluded to with this salt, & there was every
reason to believe that the rats in passing to & fro in the
apartment, had frequently run over the salt & thus mixed
with it the arsenick in which they had been treading.
In a family attended by Dr. Griffitts, I once saw several
affected with vomiting at the same time; & in this case
the sickness was supposed to have resulted from some
rats having played in a barrel of flour which had been
left uncovered.
A few years ago a very interesting occurrence of a sim-
ilar nature took place in this city. A family, consisting
of a number of persons, after partaking of their usual meal,
were every one affected with vomiting, & some were extreme-
ly ill. The family physician, Dr. Neill, called me in con-
sultation, & I soon saw them. One youth was more vi-
olently affected than the rest. On the preceding day he
partook, with the family, of the food on the table, & was slight-
ly affected; but not so as to prevent him from eating                         


173
breakfast on the following morning; & he was the only one
of the family that did so. He thus took a double dose of the
deadly poison, & the quantity was so large that the effects were
fatal. These cases excited a great deal of alarm; & it was
reported that the yellow fever had made its appearance in
the house. Some of the friend of the patients stepped in,
in order to render them assistance; & although they thought
considerable care was taken, yet after a meal, they were
taken ill. Possible, however, this might have been the effect
of imagination.
A legal examination as to the cause of death was in-
stituted, & the medical attendants were called in for their
testimony. I opened the body in the presence of the coroner
& his jury, & found the stomach very red, & presenting such
an appearance as we find in malignant fever: But from
the preceding symptoms we had no doubt that he had
come to his death in consequence of some morbid impres-
sion made on the stomach; & we supposed that arsenic 
had made that impression. Unhappily for a poor girl
in the house, the master of the family was possessed of a
mind of a very peculiar structure. Instead of being disposed
to refer the whole to accident, he was obstinately under the
impression that it was the result of design, & that some one
had attempted to poison the family. In giving way to these
impressions, he could find no one on whom to fix suspi-
cion, but a servant woman in the house, who had a child
in the family. He inquired into her character & found that                               


174
it was not a good one. This confirmed his suspi-
cious, & he laid them open before the coroner’s inquest.
The coroner’s jury was fully impressed with the
suspicious of the master of the house, who was joined
in them by his mother-in-law. This case will show
you how important it is that the physician should
keep his mind free from prejudice, especially on occa-
sions where the life of a human being may depend
on his testimony. After hearing the allegations made
before the jury, Dr. Neill & myself, on our solemn qual-
ificatons, deposed as to the illness of the family, & among
the rest, of the woman & her child. But such was
the disposition on the part of the man to find her guil
ty, that our judgements were called in question, & it
was suggested that she had feigned illness & deceived
us. Hearing this, a thought suddenly flashed through
my mind, which I related to the jury. I had observed
that every one of the patients, affected with this com-
plaint had a white furred tongue. I proposed that
the members of the family, & the girl among the rest,
should be brought before the jury, & undergo on exam-
ination on this point. The coroner & jury were struck
with the propriety of the proposition, & a display of tongue
was accordingly made before them. The girl’s was found
to be as white, if not white, & more furred than any of the
rest. This single fact was sufficient to influence the
mind of the jury, & she was acquitted of the charge.                                   


175
But the unhappy man, still pursuing his object
with the eagerness of death itself, on his own responsibil-
ity, went before a magistrate & made such a declara-
tion that it was thought right to have the girl ar-
rested & thrown into prison. Here she was confined
several months, & when brought before the grand ju-
ry was discharged on a verdict of ignorances.
Effects of Laudanum.
It often happens that laudanum is given by
mistake in such doses as to produce fatal consequen-
ces. This usually occurs among children. It is gen-
erally supposed by the vulgar that laudanum be-
comes weak in proportion to its age; & I blush to say
that I have met with two medical men, in the course
of my practice, who were of the same opinion. You
must all be aware, on a little reflection, that lauda-
num, by the evaporation of the alcohol, is liable to be-
come turbid, if long kept in a loosely stopped bottle.
A portion of the opium is thus deposited, which was
before held in solution, & consequently the mixture
which remains must be a good deal stronger than
the original laudanum. Hence, the danger of giving
old laudanum to tender infants. I was once called
to a very young infant labouring under the clearly
marked symptoms of an over dose of laudanum.
On enquiring how much had been given, the moth-  
 


176
er told me three drops. I was induced to suspect
the correctness of her memory; but she insisted on
what she had mentioned. Happily, I arrived in 
time to reserve the child. After its recovery, pursuing
my inquiries, I went to the apothecary’s where the
medicine had been procured, & found that the lauda-
num had been poured off from the bottle in which
it had been originally made. This was very impru-
dent, & nearly destroyed the life of the child.
I have seen two cases in which death resulted from
giving an overdose of laudanum to infants of a
tender age. A child was affected with catarrhal
disease, for which its parents thought proper to give
it laudanum. They had a bottle in which some of
this article had been standing for a long time; &
thinking that medicines lost their strength by keep-
ing, they shook up the contents of the bottle, & gave
what they concluded would be a proper dose. The
child died in consequence. In the other case a neigh-
bour gave the child what she thought a safe dose;
but it so happened that it proved fatal to the tender
infant.- I mention these facts, because I consider
them of extreme importance in a practical point of
view. So strongly am I impressed with this convic-
tion, that there is not a family in the city, which I
am in the habit of attending, to the members of which
I have not explained my view on the subject.  


177
Some medical men are not aware of the im-
portance of caution on this point. I once met a
practitioner in the country, in consultation; & it was
concluded to give a dose of laudanum. I asked him
whether his laudanum was fresh, & told him my
experience with regard to it. He answered me very
politely; but I perceived that he could hardly refrain
from laughing at my timidity. I requested him to
allow me to examine the bottle which he carried a-
bout him. I shook it & found a considerable por-
tion of opium had been deposited. I pointed out
to him one single flake which was floating in the
liquid, & which, if given with a single drop to a very
young child, would, in all probability, destroy it.
Opium in the form of laudanum is frequently re-
sorted to with a view to suicide. I will mention
some of the most prominent symptoms produced
by an over dose of this article. When you recollect
the sympathy which exists between the stomach &
brain, you may readily conceive that an inordinate
dose of opium must exert a powerful influence on
the functions of this organ. Hence, in a short
time after taking the laudanum, in half an hour
or an hour, according to circumstances, the patient
begins to feel its influence very sensibly; & if the
dose has been large, stupor comes on. Along with
this you very generally find stertorous breathing, &



178
another symptom of apoplexy the slow, full & la-
boured pulse. Beside these, there is a livid colour of
the countenance which does not always occur in
apoplexy; but us an almost invariable consequence
of an over dose of laudanum. So much is this the
case, that I have been led to a knowledge of the cause
of the complaint by this appearance accompanied
with stupor, in cases where there was no reason to sup-
pose that the patient could have attempted suicide.
I think I have, in some instances, been struck with
a pupil morbidly contracted. These there, may be
regarded as the prominent symptoms; & you will read-
ily perceive that they very much resemble those of
apoplexy, with the exception of the livid countenance.
I was, not many years ago, called in consulta-
tion with a very respectable practitioner, to see a young
lady who, in his apprehension, was very singularly af-
fected. It was early in the morning when I saw her.
She had profound coma, stertorous breathing, & a livid
countenance. One of my first impressions was, that
the poor, unfortunate girl had been taking laudanum.
I suggested it to the physician who thought that this
was out of the question; & that, so far as he know, there
could be no cause of suspicion. I told him I should
return soon, & wished him to prepare the family for
some inquiries. Soon afterwards we commenced an
examination of the room, & we pretty quickly discov-  


179
ered, in the closet, a bottle which had contained
laudanum; but was now nearly empty. The name
of the apothecary was attached to it. A messenger 
was dispatched to make inquiries, who, on his re-
turn, informed us that the young lady had, the
preceding afternoon, procured the laudanum. There
could now be no room for doubt. The case, however,
had progressed too far for relief, & soon terminated fa-
tally.
I will now proceed to consider the plan of treat-
ment. Formerly, it was the usual practice to employ
emetics; & enormous doses of these articles were
sometimes administered. This practice, however, is
often ineffectual when a long time has elapsed after
taking the laudanum. I recollect in one case which
I saw with Dr. James, the quantity of tartar emetic,
ipecacuanha, & sulphate of rinz, which it was ne-
cessary to give before vomiting could be induced,
would almost exceed belief; so torpid was the stom-
ach, & so powerfully did it resist our attempts to make
an impression on it. In this case, titillation of the fau-
ces was also employed; some blood was taken from
the arm, a tobacco poultice applied to the epigastrium,
& the patient kept in a state of constant agitation. Ul-
timately, however, vomiting was brought on, & a recovery
was affected. On the succeeding day, swing to the violence
done to the parts, the patient laboured under a complete     


180
attack of croup. From this case it may be per-
ceived that, in some instances, the difficulty of
evacuating the stomach by emetics, is exceedingly
great. Even though the most powerful may be em-
ployed: & therefore, no experienced practitioner
will be induced to rely on them, when there are
other means to which he may resort with a better
chance of success. The means to which I allude
is the washing out of the stomach by the syringe 
& flexible tube. The use of these instruments, I have
before explained to you in my surgical lectures.
Yet, on some occasions, when we are unable to re-
sort to mechanical means, emetics must necessari-
ly constitute our main dependence.
It is here proper for me to remark that cases occur
in which we may resort to mechanical means, to
emetics, & other methods of evacuating the stomach;
&, though we may succeed in this point, yet the
patient will die. I had seen this several times
without fully understanding the nature of the case.
I mentioned it to Dr. Wistar who said that he had
observed the same thing. To illustrate what I have
advanced, I will state a case which fill under my ob-
servation.
To a child accustomed to receive laudanum when
in pain, the usual quantity was given: but unhap-
pily, of that turbid kind of which I have spoken.  
 
 


181
I was called in, & succeeded in evacuating the stom-
ach, & procuring a passage through the bowels; and
entertained strong hopes of a recovery. Still, however, there
was some stupor about the case; but the pulse was fre-
quent, instead of slow. Supposing that this was swing
to a small quantity of laudanum still remaining in
the stomach, I gave another emetick which operated
easily; but the child grew worse & worse, & finally died.
In another case an over dose was given to an
infant in consequence of a catarrhal affection. In
this instance also, I succeeded in bringing on vomit-
ing, & with the same result. But death, in this case,
seemed to proved from a different cause than that
just related. I supposed that the vessels of the lungs
were excited to a very high degree of action in conse-
quence of the stimulus of the laudanum; that effu-
sion had resulted, & that this had proved fatal to the
infant- The same thing occurred in a child whose
stomach I had washed out. Here I also believe death
occurred from effusion.
But the cases to which I wish particularly to call
your attention, are those in which the stomach & bow-
els have been evacuated, & yet the patient sinks from
debility. I will relate two instances. The first, as
you will perceive, terminated fatally; but so long
a time had elapsed before any medical treatment
was resorted to, that there was no chance of success.        


182
I have several times seen this in practice. There is a
certain point when the mischief has been accomplished;
disorganization has taken place, & after this all efforts to
afford relief are vain.
Case Y.- Sixth mo. 8th, 1818, I visited on Cooper’s Creek,
an amiable young woman, the daughter of respectable
& affection parents, who in a paroxysm had taken two oun-
ces of strong laudanum. Dr. Hendry of Haddonfield
was called in the first instance & dispatched a messenger
for me. The Doctor tried to excite vomiting by tartar emet-
ic. He also gave the citric acid very freely, & employed
a tobacco injection which, however, was directly returned.
Her pulse, he said, was slow, her countenance livid,
the action of her carotids very powerful. He bled her twice
before I saw her, & evidently, he said, with relief. But
such was her deplorable condition, that before the last
bleeding, she lost, according to his account, the power of
speech & deglutition. When I saw her she was capable
of understanding what was said to her, & gave replies
that manifested it: but her countenance was ghastly 
& inclined to the livid here; her pupils much contracted;
her pulse full, strong & rather frequent; her respire-
tion was labored- her shoulders appeared to rise too much
in breathing. I introduced a flexible tube into her stom-
ach, & by the use of the syringe, aided by the efforts of
the stomach itself, I was enabled to wash it out complete-
ly. While we were engaged in this process, the patient            


183
improved most astonishingly. Her intellect became per-
fectly clear; & she told me how she accomplished the
act; declaring she was not conscious what she was about,
or rather, that she knew not why she acted as she did.
She said that she knew that it was laudanum, & did
not wish to take it; & yet it seemed, she said, as if she must
do so, & then she took it. There appeared nothing like
fixed design to injure herself. She seemed very uneasy
about her little sister who was with her at the time. She
said that she was afraid she had given some laudanum
to the child, which did not appear to have been the case.
This was a proof of her not being aware of what she did.
I continued washing washing the stomach for at least
an hour, as she appeared to bear it very well. I used
warm water & chamomile tea: after this I injected castor
oil through the tuber, as I calculated that a good deal of
laudanum had passed into the bowels. I then withdrew
the tube, & proposed a strong injection of salt & water.
Sinapisms had been applied to the feet before I saw her;
& as I calculated on a good deal of debility, I proposed
to Dr. Hendry to apply a large mustard plaster over the
stomach; & informed him that I had known some
eases very deceptive, & dangerous in the extreme, after they
had appeared very flattering. I proposed his being on his
guard, ready to throw stimulants into the stomach, if the
symptoms of debility, which I expected, should become
alarming. I then went into another room, & being               


184
much fatigued, I sat down & took a dish of tea: when I left
the patient she was sitting up in bed. After tea I found her pulse
very frequent, & she was evidently changed for the worse. She
complained of being very dry. In a very few minutes after
this she was in a state of great restlessness & delirium, endeav-
ouring to walk about the room. She now had subsultus ten-
dinum, & her pulse could barely be perceived. I proposed the
free use of volatile alkali, warm, stimulating drinks, etc. etc.
I left her under painful apprehensions; & she died in a few
minutes after I left the house.- The laudanum was ta-
ken a little after 1 o’clock, P.M. I saw her about 7 o’clock
in the evening: no vomiting had been excited before I
saw her. If I should have another similar case, I will
not persevere so long in washing the stomach, & will re-
sort earlier to stimulants, such as ginger tea, brandy toddy, etc.  
I will now relate to you another case which termina-
ted differently, & in which I derived great advantage from
my previous experience.
Case 2.- On the 4th of 11th mo. 1818, about 11 o’clock at
night, just as I was about preparing for bed, I was
summoned in great haste by a dry-good merchant, rich, &
so far as I know, respectable, to see his wife, a middle
aged woman who had taken about one ounce of strong
old laudanum, equal perhaps to two ounces of common
laudanum, with an intention to destroy herself.- The name
I scrupulously withhold, from a settle determination to
avoid handing down to posterity events which ought, so 


185
far as regards the patients & their families, to be buried in ob-
livion. For, who can calculate on the distress & mischief that
a physician in extensive practice may occasion by indiscrim-
innately recording, or in any way giving publicity to the names
of patients who, from various causes, may be brought into
conditions which religion & humanity are called on to
deplore! On arriving at the house, I found a scene of
confusion & distress. The unhappy woman was in bed with
two of her infants- the elder, I suppose, under 4 years, the
younger under two years of age. The noise & confusion at-
tendant on their mother’s condition had roused them from
sleep. The elder wept, unconscious of the cause; the younger
was sitting perched up in bed, looking innocently at the
mother & those around, &, happily, unaffected by the atmos-
phere of wo by which it was surrounded. The poison was
just beginning to develops its effect; the countenance of the
patient was suffused to a great degree; the temporal arteries 
were remarkably turgid; the pulse at the wrist, slow, full,
& strong. She was not yet wraped in profound coma;
She was very averse to being disturbed: she wished to sleep,
& when she slept her breathing was stertorous. Finding her
in such a state, I called on Dr. Wood, who lived near the pa-
tient, to assist me; & I proceeded at once, with his aid, to
wash out the stomach. She appeared somewhat disposed to
resist, at first; but as it was an important moment for her,
I tried to appeal to her in strong language, & endeavoured to
rouse her feeling & to recall a love for life. She was capa-  
 


186
ble of understanding what was said, & would give ration-
al answers. I found the most assailable point in her dis-
tracted mind was the subject of her children, & here I
assailed her with all my force. Happily, maternal affect-
tion burst through the gloomy shades which surrounded
her, & I obtained from her a declaration that she was willing
to live for the sake of her children. I introduced a long
flexible tube through the nose, & by the aid of a syringe I
soon drew forth the laudanum. I now injected warm wa-
ter freely, & by discharging it from the syringe into a white
bason, I was enabled to perceive when it was colourless.
After repeated injections of warm water, it was, at last, return-
ed quite clear. As her countenance was still very much
suffused, & her pulse slow, full,& strong, I opened a vein
in her arm, & she lost about one pound of blood. Cold wa-
ter was applied to the head & dashed into the face with good
effect. Her countenance became more natural; but she was
very difficult to rouse. Our attention was now directed to
the stomach; well knowing, that as it had so lately been
subjected to a powerful narcotic impression, the sudden
abstraction of such a cause might be succeeded by atony
or spasm which would be productive of great danger. To
counteract this, a large sinapism of pure mustard with
vinegar, was applied over the stomach; sinapisms were al-
so applied to the legs, & strong ginger tea with the sp. cornu
cervi was given by the mouth. At this time her face was
pale & her skin cool. There was a great diminution of ex- 
    


187
citement, & her stomach was so torpid, that she could scarce-
ly feel any effect from a wine glassful of ginger tea with
two tea spoonsful of sp. cornu cervi added. The tea was giv-
en quite warm. In the course of about half an hour, I sup-
pose she took, in divided portion, as much as half an ounce
of the sp. cornu cervi & half a pint of ginger tea. She com-
plained very much of feeling cold, particularly about the
ankles. Hot irons were applied to her feet, & I directed fric-
tions of hot brandy & very strong cayenne pepper to her
legs, thighs & arms. All this did not appear to produce a-
ny effect. She was still cold; but was more easily roused
& when awake talked very sensibly. She seemed very
grateful for the efforts that had been made for her recovery;
but still her skin was preternaturally cool. Some warm
brandy & water was given several times, & tapioca or sago 
seasoned with brandy was directed. A little after 8 o’clock,
I left her under the care of my young friend, Dr. Wood, we
having jointly concluded to continue the efforts for procu-
ring reaction of the system. Next day I found her with
complete reaction & some fever. The parts to which the sin-
apisms had been applied became very much inflamed, &
several days elapsed before she regained her former health.
I had a long private conversation with this poor, afflicted
woman, in which she gave me a detailed description of
the temptations to suicide which had assailed her for sever-
ral years; & I was particularly struck by her stating to me
that on one occasion hearing of a lady who destroyed her-  


188
self (she was a patient of mine affected with insanity) she felt
after this, the temptation stronger than ever- it was almost
irresistible. This confirms me in what I have long believed,
that the practice of giving publicity to cases of suicide is
radically wrong.
From these cases,(& could adduce others,) you may un-
derstand the very great importance, where a powerful im-
pression has been made on the stomach by laudanum,
of recollecting that after great exertion there is apt to suc-
ceed a state of corresponding prostration; & that, after re-
moving from the stomach the offending cause, you
should not wait for debility to come on, but should
anticipate it by appropriate treatment. The volatile alka-
li, ginger tea, wine, brandy, etc., are very suitable in these
cases, especially the volatile alkali & ginger tea, as they
possess no narcotic power, & produce in consequence
no injurious influence on the brain. Laudanum pos-
sesses this power, & therefore would be improper to
counteract debility produced in this way. An anecdote 
related by Dr. Westar has a bearing on this point, & ex-
hibits, in a strong light, the sagacity of the celebrated
Dr. Cullen. A fellow student of Dr. Wistar, in Edin-
burgh, took several drachms of laudanum for an ex-
periment, he then showed himself to his fellow students,
used a good deal of exercise, & in the evening, after the
stimulating influence of the laudanum, he attended
the theatre. Here he fell into a fainting fit- his com-            


189
panions thronged about him, & held a consultation as
to what was to be done. Some thought, as the debility re-
sulted from an absence of the stimulus of the laudanum,
that some more of this article should be given. Happi-
ly, it occurred to them, to resort to Dr. Cullen, & to state the
case to him. That great man made this pithy remark;
“Why give an antispasmodic or stimulant possessing nar-
cotic powers, when you are able to resort to others without
them?” He sat down & wrote a prescription for musk.
This was given & the student recovered.
In this place I will make another remark relative
to the treatment of these laudanum cases. We are very
apprehensive of apoplexy, & there is, perhaps, some reason
to be so. But I consider the appearances presented by a
patient labouring under the effects of laudanum, to be
essentially different from that disease; & therefore, recol-
lecting that we have to contend with a state of things in
which the patient is liable to sink into great debility, we
should be cautious not to abstract blood too largely. Un-
less the symptoms of compression of the brain were very
urgent indeed, I should not, with my present views, abstract
a drop of blood. Those profuse bleedings which are neces-
sary in idiopathic apoplexy, are not judicious in the cases
of which I have been speaking. A case is somewhere re-
corded of a patient who narrowly escaped from death, where
laudanum had exerted its full influence on the stom-
ach. No physician was called till all the primary effects
 
        


190
of the laudanum had gone off, & nothing remained but
very great prostration. Stimulants were then adminis-
tered & the patient recovered.
In ordinary cases, the proper method of proceeding is
to empty the stomach by the tube, or by emetics, & then to
obviate the debility which is apt to follow by stimulating
treatment. The same remark will apply to those cases
in which ardent spirits have been taken in large quan-
tities. I have seen several instances where death has been
suddenly produced from this cause. A poor unfortu-
nate vagabond, already in a state of intoxication, undertook
for a wager to drink a pint of brandy. He did so & death
was the consequence. I have seen a child brought to the very
brink of the grave by ardent spirits incautiously taken- I
washed out the stomach & he recovered. Not long ago a gen-
tleman who was accustomed to take a certain quantity of
laudanum at night, before going to bed, & who also was
sometimes off his guard & took spirituous liquors in too large
quantities besides, spent an afternoon & evening in the
billiard-room, & drank occasionally with the others. At
bed time he was in a state of intoxication, & unfortunately
took his usual dose of laudanum. The effect of this super-
added to that of the ardent spirits was fatal; & in the morn-
ing he was found dead in his bed.
Dr. Brown, the celebrated author of the Brunonian Doc-
trine, was an example of the same kind. Dr. Barton who
was one of his student, used to relate, that after one of his
     
 
        


191
lectures, Dr. Brown complaining of being fatigued & in-
disposed, was told that this was a proper opportunity for test-
ing the correctness of his theory. He accordingly went home
& took a dose of brandy, which he followed by another of laud-
anum; & so went on drinking brandy & laudanum, till
his frame could bear no more, & his death was the con-
sequence.
Enteritis.
This, as you all know, is employed to signify inflam-
mation of the bowels, & may answer very well as a
general term. But I here to call your attention to a phys-
iological remark: Bichat has contributed very much
to extend our knowledge of diseases, by his observations on
the particular structures of the body. When we recollect
the extent & influence of these various structures, distribu-
ted over various parts of the system, we are enabled, in
some measure, to explain the remote sympathies we meet
with in practice; & it is no longer wonderful how im-
pressions made on certain parts, with a view to the cura-
tive process, may operate on others very distant. With
these prefatory remarks, I shall take up the considera-
tion of inflammation of the bowels, & shall treat of it
as attacking the particular structures which compose
this part of our system.    
     
 
        


192
Peritonitis.
In the books you will read of inflammation of the
peritoneum, of the omentum, of the peritoneal covering of
the liver, spleen, etc.: but, in fact, these are all the same
disease, as they involve the same membrane. The perito-
neum, you know, is a serous membrane lining the in-
ternal cavity of the abdomen, investing the stomach, intes-
tines, livers, spleen, mesentery, etc.; & by its folds forming the
omentum, the mesocolon, & other structures to be met with in
the abdomen. Now the inflammation of this membrane is
essentially distinct from that of the mucous membrane, li-
ning the stomach & intestinal canal.
The evidences of peritoneal inflammation, as manifested
by its symptoms during life, & by dissection after death, are
such as I shall state to you: The coagulating lymph being
thrown out from the blood, produces very serious consequen-
ces. That this is the case is satisfactorily proved by referring
to what is observed on dissection. We find almost the entire
mass of the intestinal tube, in many instances, in a state
of adhesion. I will here remark that peritoneal inflam-
mation is much more to be dreaded, than inflammation
of the mucous membrane. It affects a part which, as Dr.
Rush used to say, has no back door- no passage for the dis-
charge of redundant secretions.  
Idiopathic peritonitis, or that arising without the in-
fliction of any injury on the part, as far as my experience
has gone, is a rare disease. You will easily understand, 
 
        


193
that it may frequently occur as the consequence of wounds,
bruises, strangulated hernia, etc. It is also said to be an attend-
ant of puerperal fever. Of this I have little experience, & shall,
therefore, say little. But I now speak of pure peritoneal
inflammation, occurring without any injury to which the
parts, may have been subjected. This, though not a com-
mon disease, I have occasionally met with in practice.
It is attended with fever, a great deal of pain & distress, &
much tenderness on pressure. Along with these, there is
sometimes a pulse of a very peculiar character, which may
deceive a young practitioner, & lead him into bad practice.
In my lecture on the pulse, I referred to some cases of
peritoneal inflammation. I mentioned the case of a
lady whom I saw on the recommendation of Dr. Monges,
whose pulse was so weak that I was afraid to use the
lancet. But consulting Dr. Monges, who had been in the
habit of attending her, I was informed by him, that noth-
ing but the lancet would answer, & that she would
bear it very well. I used it & with the happiest effect.
I also mentioned the case of a young lady, who had a
weak pulse, but was affected with pain & tenderness in
the abdomen. I directed her to be bled; but the bleed-
er, after taking a small quantity, said that she would
not bear the lass of more without fainting. I bled her
myself; the pulse rose under the lancet, & much benefit
resulted.
These cases prove that the pulse, in peritoneal in-   
  
        


194
flammation is not to be relied on. If a patient be affect-
ed by chill, succeeded by fever, with pain & tenderness
of the abdomen, even though the heat of skin & strength
of pulse may be absent, yet I would advise you cau-
tiously, in the first instance, to try what would be the
effect of abstracting blood. Mere tenderness of the parts, how-
ever, is not a sufficient warrant for employing the lan-
cet. Some cases of dyspepsia & cholic are accompanied
with tenderness of the abdomen, without, I believe, the
stighlist degree of inflammation. It may be result from 
distension of the bowels by flatus, or it may be simply
the soreness which, in every case, is apt to succeed spasm 
of the muscular fibro. Here is a necessity for great deli-
cacy of judgement in deciding between the two affections.
If you find the tenderness occurring in a dyspeptic pa-
tient, especially if he has been eating some flatulent arti-
cle of food, & by striking the abdomen, you perceive the ex-
istence of flatus, you should be cautious how you want to 
the lancet. Suppose then you are called to a patient who
has been suddenly attacked with severe pain & tenderness
in the bowels, with great anxiety & distress of stomach; &
on examination, you find the tongue furred; suppose that
these symptoms continue, the pain & tenderness increase,
accompanied with restlessness, thirst, heat of skin, etc.; and
at length, the patient suddenly obtains relief- under these
circumstances you may very safely conclude that you
have had a case of peritoneal inflammation. The sud-        
     
  
        


195
den relief sometimes experienced by patients with this
complaint, is apt to deceive the unexperienced practi-
tioner, & induce him to believe that the violence of the
complaint is past. But the skillful physician, when he
examines the pulse & finds it exceedingly feeble, observes
the hippocratic countenance, & the cool clammy sweat
bedewing the whole surface of the body; & at the same-
time sees that the patient & his friend are deceiving
themselves with the hopes of a speedy recovery, will feel
it his duty to inform some of them, at least, if not the
patient himself, that they are labouring under an error,
& that they must prepare themselves for a speedy & fatal
termination. Either mortification has taken, or, if not
this, something like suppuration has occurred over the
whole surface of the peritoneum. But this does not in-
variably happen. I have known violent pain & anxiety
amounting even to agony, in several cases which ter-
minated fatally, to continue to the very last moment.
The disease, in some instances, may approach very insid-
iously, may make fatal inroads into the system before
the patient & his friends are aware of the danger; & I have
met with one ease to which I was not called till the fatal
stroke was given.
Having taken this view of the symptoms of peritonitis,
& of the general appearances on dissection, I will devote a few
minutes to the practice. You may easily suppose that the
lancet is indispensable. In some instances v.s. must be  
        


196
carried to a considerable extent. In addition, it is proper to un-
load the bowels of any furelent matter contained in them.
What cathartic shall we select? Shall it be of a mild or dras-
tic character? For my own part I have thus far depended
on the milder cathartics, as the neutral salts, castor oil, etc.
Together with these I administer demulcent drinks, as bar-
ley water, flaxseed tea, etc., direct large injections of the same
articles to soothe & quiet, & to give, as it were, a warm bath
to the intestines.
But there are some diversities of practice. In accounts
from the other side of the water, I learn that the spirit of
turpentine is largely administered, with happy effects, in ca-
ses of puerperal fever. Here I am on untrodden ground,
& therefore, cannot speak positively. The modus operandi
of the medicine, as stated by some of those who recom-
mend it, is, that it acts by stimulating the lining mem-
brane of the intestines to increased secretion, & thus indi-
rectly proves a depleting remedy. You must recollect
that I am now stating the opinions & experience of oth-
ers. I confess I have had views somewhat analogous
with regard to the operation of the sencha snakeroot in
croup. I have supposed that it might first stimu-
late the mucous membrane of the bronchia, & that this
effect might be followed by a copious secretion. But you
must remember that in croup we at the same time
freely employ the lancet. Among those who depend on
turpentine in the management of puerperal fever
             



197
venesection is little or not at all resorted to.
Besides the remedies mentioned, local depletion by
means of cups or leeches, is of great importance; & coun-
ter impressions by the use of fomentations & blisters should
not be neglected. With regard to fomentations, we should
be regulated by the feeling of the patient. If he should
be relieved by them, they must be continued; but if no
such effect is produced, they should be laid aside. In the
case of the young lady to which I have before alluded, fric-
tions of turpentine, over the whole surface of the abdomen,
were employed, & continued so long that slight vesication
was produced. Dr. Dewees thinks that spirits of turpen-
tine thus applied, is better in puerperal fever, than even
blisters. But I have great confidence in the flies, in per-
itoneal inflammation, & a large blister over the abdomen
in an important remedy.
This is a general outline of the necessary practice. It
must be left to the practitioner to fill it up, according to
the particular circumstances of the case. Sometimes the
warm bath may be advantageously used, united with other
remedies calculated to bring on determination to the surface,
& cause a relaxation & softness of the skin.
I have stated that peritoneal inflammation sometimes ap-
proaches very insidiously. In illustration of this fact I will
now detail to you two cases which have a bearing on the subject.
Case.- S. W. wife of E. W., about 40 years of age, was safely
delivered of her second child about 6 weeks before her death. 

              



198
Dr. James attended her on the occasion. She was re-
markably brave for the first 3 weeks; but soon after this
she complained of pain in the abdomen, & had some ten-
derness on pressured. For these symptoms, Dr. James di-
rected her to be bled several times, used cathartics, etc.
Under this plan she was greatly relieved, & recovered so
far as to get down stairs, & even to ride out. But the Dr.
had very properly directed that the ride should not be
repeated, unless she was evidently sensible of being the
better for it. This appeared to have been the case; for the
repeated the ride the next day, the 25th of the 12 mo. On
her return that day, she lost a good appetite, & at dinner
ate pretty freely of beets & vinegar. About 12 o’clock that
night she was attacked with violent colic. Dr. James saw
her in the morning. His efforts were directed to evacuate
the bowels & allay pain. Various expedients were adopted
without success. Her stomach was exceedingly irritable,
& her bowels obstinately confined. On the evening of the
27th, I was called in consultation. At this time her
pulse was extremely frequent; her vomiting appeared
bilious, & even stercoraceous; there was restlessness and
distress without any pain; her abdomen was very
termed; her tongue quite moist & natural. I proposed
a trial of Jenning’s steam bath, also an anodyne enema
to compose her. A blister had been applied to the abdo-
men. I examined careful to ascertain whether there was
any thing like incarcerated hernia, but found none.   
 
   
              



199
Some purgative pills prescribed by Dr. James were
continued. On visiting her again that night, I
found her situation not improved; though the baths
had proved very grateful, & the enema had relieved 
her, yet her pulse was extremely frequent & feeble; she
was covered with perspiration; there was a total absence
of pain, & a decline of strength, with obstinate constipa-
tion. Various injections having been used by Dr.
James, we concluded to give her some calomel & opi-
um for the night, & left her with very anxious feelings.
On the 28th we saw her in the morning, & several times
afterward; but we saw her a dying patient- Her nails
were livid: her pulse barely perceptible; though her in-
tellect was as clear as a cloudless sky, & she displayed, in
a remarkable degree, the power of true religion upon
the mind. She departed about 2 o’clock, A.M., about
20 hours after I first visited her.- I ought to mention
that my beloved friend, Dr. Griffitts, was called in about
2 hours before her death. On the succeeding evening, in
the presence of Drs. Griffetts & James, I made the fol-
lowing dissection:
On opening the abdomen, I found a complete and
universal adhesion of the intestines, in consequence
of peritoneal inflammation. A small quantity of
lymph, of a purulent appearance, was found in the
cavity. The left ovarium was enlarged- I imagine
its cavity would have contained a pint of fluid. On 
              



200
opening this ovarium, I found the remains of a
foctus- a part of the jaw with several teeth, & a con-
siderable quantity of hair. The hair was quite
long, & the whole was enveloped in a mass of sebaceous
matter.
Case of H.- The other case to which I alluded was
that of the son of W. H. of this city. I was not called
to attend till medical aid was unavailing. For
a week previous to his death, he complained of
pain in his belly; yet he came down stairs, and
kept about. But the pain & distress must have
been great; for whenever he attempted to walk, he
went in a bent posture. The parents were not aware of
his critical situation, till a short time previous to his
death. Some after I saw him the pain subsided: but
I marked the symptoms which, in these cases, are the
sure precursors of dissolution.
On dissection, the appearances were very similar
to those presented in the preceding case. There was
not so much adhesion; but there were marks of u-
niversal inflammation of the peritoneum, & effusion
resembling purulent matter.
In the same family, soon after the death of the
boy just mentioned, a younger brother complained of
pain in his bowels; & though I should have been
disposed to treat it as trifling, had it not been for the
other case; yet with this before me, I bled him sever-   



201
al times, & had the satisfaction of seeing him re-
cover. I believe had it been left alone, the case
would have pursued the same course as the prece-
ding.
These instances evidently show that the disease
may make its attacked very insidiously, & that the
lest signs of it must be promptly met by the
practitioner. I will read you another case which
tends to illustrate some points relative to this disease.
Case of Peritoneal Inflammation & Peripneumonia
Notha.- On the morning of the 2nd of 2nd mo.
1811, I was requested by O.O. to visit a servant
girl in his family, aged 16 years. On inquiry it
appeared that she had been affected with a cough for
some days, but not so severe as to confine her. On
the 31st of 1st month (two days before I saw her,) she
complained of pain in the abdomen. In the night she
was seized with violent vomiting. Next day she appear-
ed better; but became worse again at night, & the
family feeling uneasy respecting her, I was called in.
I found her complaining of severe pain in the ab-
domen, which was extremely tender to the touch. She
also experienced some pain in the shoulder & back.
Her countenance indicated great distress, & her breath-
ing was rather laborious: but the affection of the breast
seemed lost in the acute suffering which she referred
to the abdomen. The pulse was rather contracted, some-

  



202
what tense & frequent. Her bowels were constipated,
& had been so for several days: her tongue was moist.
I directed 3i of castor oil every 2 hours, also occasion-
al injection, containing 3ij of the sulphate of soda. Ten
ounces of blood were ordered to be taken from the arm.
In the afternoon, I was informed that she felt easier
for about an hour after bleeding: but the symptoms had
now returned with all their former violence. I direct-
ed a continuance of the oil & injection, & 16 oz of blood
to be taken, provided the patient should bear it well.
At 10 o’clock at night, I saw her again, & was inform-
ed that she did not bear the abstraction of more
that 10 oz, & nearly fainted when this was lost.
The bleeder said he could get no more. Her bow-
els were still constipated, & every former symp-
tom of danger remained unabated. A very large
blister was now direct, which covered the whole ab-
domen. The oil was also ordered to be given occa-
sionally through the night, as her stomach should
be found to bear it. Next morning I found her
asleep, & as the blister was to remain on until
12 o’clock, I did not disturb her. On seeing her
after the blister was dressed, it was very evident that
no salutary impression had been made on her
system since the preceding evening. The bowels
continued constipated, notwithstanding all the oils,
injections etc., & she had some strangury. I directed  
  



203
a very strong infusion of senna with sulphate
of soda dissolved in it- a tea cupful every hour; also
soda water to relieve the strangury. Her pulse seemed
to forbid bleeding. About 10 o’clock at night I found
her in a most alarming condition- the pain in her ab-
domen was extremely severe; her countenance indicated
great distress; her wrists were cool; her pulse was slow, ea-
sily compressed & evidently sinking; her tongue was clam-
my, but brown. She had vomited repeatedly since I
last saw her. She was very restless & thirsty, & her bowels
were still constipated. I directed a warm bath, & after-
wards a renewal of the blister over the abdomen, as the
first had not drawn very well; also calomel in pills
two grams every 2 hours, instead of the senna: I likewise
directed a camphor julap, with laudanum, to be taken
occasionally, when very restless, & an enema composed
of venet turpentine 3i, suspended in a pint of the mu-
cilage of gum arabic.
4th.- I was informed this morning, that her stomach
ejected every thing: of course no medicine of any con-
sequence had been taken since my last visit. Her coun-
tenance was now Hippocratic; her wrists cool, & her pulse
almost gone. She had great pain & restlessness, & vomited
very dark coloured bilious matter. Attempts were made
to allay the irritability of the stomach by lime water and
milk, seltzer water, etc. etc.; but all to no purpose. An ano-
dyne enama was directed, which seemed to lull a little;      
  



204
but about 2 o’clock death relieved her of her sufferings.
She complained of pain to the last.
Dissection about 22 hours after death exhibited the following
appearances: The omentum was found spread over the
intestines & closely agglutinated to them by adhesive inflame-
mation. The texture of the omentum was more tender
than natural. The small intestines were found very
closely adhering to each other- their anterior surface,
particularly, being covered with a coat of coagulating
lymph. Several ounces of fluid, probably 8, were effused
into the cavity of the abdomen: it appeared to be a mixture
of pus & serum. The intestines in several parts, seemed
inclined to a dark gangrenous colour: this was especial-
ly evident in the cecum. The whole intestinal tube, as
well as the appendicula vermiformis, was distended with
flatus & liquid feces. The convex surface of the liver
was agglutinated to the parities of the abdomen & to the
diaphragm, in consequence of inflammation. The stom-
ach was considerably distended with flatus, & contained
some dark coloured matter. The thorax, particularly on
on the left side, contained an effusion of bloody colorend
serum; & into the cellular texture of both lungs, there was
a considerable effusion of blood. In some parts small
portion of coagulated blood were apparent. The heart ap-
peared natural, but very small.
Remarks.- Is it not probable that the adhesions be-
tween the small intestines, & also their agglutination to the      
  



205
diaphragm, prevented their peristaltic motion, & in this
way induced constipation? Does not this prove the
propriety of lenient- cathartics in such cases? Had peri-
toneal inflammation simply produced death, it is prob-
able that the patient would have lived several days
longer, & would have been quite free from pain several
hours before death. May not the catarrhal affection which
terminated in peripneumonia notha, be deemed the more
immediate cause of death?
Now, in reviewing the practice in this case, I believe it
might have been amended. I think it would have been
better to have carried the plan of depletion to a greater ex-
tent. But at that time I had not so much experience
as at present, & the fainting at the second bleeding in-
duced me to refrain from ordering a repetition of the opera-
tion. If I had another similar case, I should bleed
freely, & should operate myself instead of trusting to a
bleeder. There was one circumstance that contraindica-
ted the very powerful use of the lancet. The different-
ly of respiration was such as to induce the suspicion that
effusion had taken place in the lungs; & under these cir-
cumstances it would be improper to carry U.S. to such an
extent as might otherwise have been advisable.- In this
case we are presented with an often suspected cause of consti-
pation, viz. adhesions of the bowels to each other, in consequence
of coagulating lymph being thrown out by inflammation.
Before closing the subject of peritoneal inflammation,    
  



206
it will be proper for me to call your attention to another
very interesting subject; & in doing so, I will make this
remark: Practitioners should be very careful not to suffer
their minds to be biased by preconceived opinions.
You should observe, & record your observations, though they
may contradict your theories. Now we have been accustomed,
& very properly, to consider the inflammation of the bowels,
which is evinced on dissection by the presence of effused coagulating
lymph, as a proof of high inflammatory action
in the system. When on examination after death, we find
such effusion, we conclude that so much inflammation
must have required powerful depletion by the lancet. I
will now state, that, by dissection we may find these
adhesions in consequence of the effusion of coagulating
lymph, yet at the very time it took place every thing
like depletory treatment was forbidden. This only goes to
show that exceptions may occur from constitutional peculiarities;
& that these should never be converted into
general rules applicable to other cases. However contrary
to theory, such is the fact, that the blood vessels of the
serous membranes can take one such kind of actions as
may induce affusion of coagulating lymph, when, instead
of an inflammatory condition of the system, a state
of extreme debility exists; & that this effort is as much an
act of expiring nature, as the production of black-vomit in
yellow fever. To prove this, I need only refer you to the
case of P. W. (See Diseases of the Thoracic viscera, vol. page)

207
By a long course of suffering, her system was gradu-
ally worn out, dropsy was the result; we were looking
for death for months before it occurred, & just as she was
brought down to the lowest state of existence, she was at-
tacked with violent pain in the abdomen, & in that con-
dition of distress & agony, she expired. Upon examina-
tion after death, it was found that the small intes-
tines exhibited evident proof of recent inflammation.
They were of a dark red colour, & a small quantity of recent
lymph had been effused. Some serum also was found
in the abdominal cavity.
But a case much more extraordinary was that of A. K.
(see vol. page) He became dropsical, was reduced to
a state of emaciation really wonderful, &, in the last stage
of life, was attacked with pain in the abdomen. On dissect-
tion, after removing about a bucket full of serous fluid, the
viscera were brought into view. The omentum was indura-
ted & diseased; the small intestines were agglutinated in
many parts by slight adhesions resulting from the effu-
sion of recent lymph; the liver was covered with a simi-
lar coat; the pylorus was greatly enlarged & indurated, and
other morbid appearances were presented.
These cases are rare, & have seldom been noticed. Dr.
Puic tells me that the fact has been mentioned by Bichat
in his lectures to his class, in Paris. These cases go to prove
the correctness of the opinion advanced by Gregory, in his essay
on inflammation. He thinks inflammation may oc-         
  



208
cur in cases attended with extreme prostration, in the very
last moments of life. And I am of the opinion that we
fall into a great error when we resort to bleeding to pre-
vent inflammation previous to performing surgical ope-
rations: for so far from preventing it. I believe, as I sta-
ted on a former occasion, that it induces a state of things
calculated to favour the production of inflammation.
Having spoken of Inflammation of the Peritoneal
membrane, I will now go on to consider that of the
mucous membrane. The mucous membrane is very
extensively diffused. It commences at the mouth & na-
res, & after lining these two cavities, pact of it extends down
the trachea & accompanies all the ramifications of the
bronchia, while the other part lines the esophagus, stom-
ach & intestines, & terminates at the anus. Inflammation
of this structure is a frequent cause of disease. At present
I shall confine my observations to that portion of it
which constitutes the lining membrane of the alimenta-
ry canal. There are various kinds of morbid action
which may take place in this particular structure. In
some cases of dyspepsia, particularly among intemperate
people, & occasionally among persons of temperate habits
at a late period of life, there is an erythematous condition
of the alimentary canal, as indicated by the red & smooth
tongue. This may generally be considered as a fatal symp-
tom in diseases of this description. But there is an in-   


209
flammatory condition of the mucous membrane,
more common than this, which forms a conspicuous
symptom in a disease of which all of you have heard,
& some of you have seen; I allude to
Dysentery.
This is a disease in which inflammation of the mu-
cous membrane of the intestines is very strongly marked.
You may very naturally inquire,- what evidence have
we of this particular affection of the mucous membrane?
By referring to the symptoms of dysentery, you can have
no doubt of the fact. Let us consider what takes place
in inflammatory affections of the schneiderian mem-
brane. There is first a serous discharge with sneezing, &
at last a more concrete or thickened mucus is secreted.
The same thing occurs in the pulmonary system; and
when resolution is about to take place, we find a thick
mucus thrown off from the lungs. In the mucus mem-
brane lining the intestinal canal, the case is a little dif-
ferent. When inflammation attacks this part, we do
not have so much thin, serous discharge, as from the
nose; but still, the secretions are evidently increased.
This leads me to remark that inflammation of the
serous membranes is more dangerous than that of
the mucous; because the latter, as it were, carry the
lancet in their own hand, & are capable of depleting   


210
themselves. When, therefore, inflammation invades
this part of the bowels, the vessels secrete more freely
& the patient discharges great quantities of mucus and
sometimes blood. You are aware that a little increase
of action in the arteries of the nose induces epistaxis; the
same thing occurs in the alimentary canal.
Dysentery is better understood by the practitioners of
the country than by those of the city. In the country
the disease is often epidemic, prevailing almost universally,
& is sometimes very fatal in its effects. In the city, as
far as I know,judging both from my own experienced
& what I have heard from our oldest physicians, it is never
known as an epidemic. Sporadic cases often occur,
but the disease never becomes general. In some seasons
dysentery, in certain districts of the country, is extremely
fatal. I have heard that it once occurred in the neigh-
bourhood of Chester county, where it proved as mortal in
proportion to the number of inhabitants, as ever the yellow
fever did in the city of Philadelphia. In these instances,
the fatality, I think, may be attributed to some
cause superadded to the mere affection of the bowels. I
suspect that this may be traced to the same source which
gives rise to such fatality as sometimes occurs in the bilious
fevers of our country. It is not improbable that
the two diseases often unite to produce those terrible epidemics
which, in some situations, are as much to be
dreaded as yellow fever in the city.

211
A patient attacked with dysentery feels an unea-
siness in his bowels, with a disposition to go frequent-
ly to stool, & when there makes very considerable ef-
forts, without an ability to procure much relief. Some-
times the disease commences with rigours; but this is
by no means universal. If proper methods are not
adopted the irritation of the mucous membrane in-
creases, accompanied with violent pain & constantly
repeated, but unavailing efforts to evacuate the bowels.
If the stools be examined, the physician will soon
perceive that the mucous membrane has been secre-
ting a considerable quantity of a peculiar fluid which,
in general, is tinged with blood. Occasionally the blood
is in considerable quantities. Sometimes there will be
found a kind of curdled mucus which is mixed with
serous fluid, & bears a resemblance to what, in com-
mon language, is called “scraped guts.” Nothing like a
natural evacuation occurs. These symptoms go on in-
creasing; & if proper treatment be not interposed, or, as is
often the case, if improper articles are administered, the
patient becomes worse & worse, & often ultimately dies. Some-
times dysentery terminates life in a very short period. I
have known a fine vigorous man die in five days, of
an attack of this disease. I many cases it assumes a very
protracted form; chronic dysentery is familiar to every
practitioner. Persons going from this climate to the trop-
ics are very apt to be attacked with dysentery, the acute                


212	
symptoms of which pass off, & the disease becomes chron-
ic & continues for a long time.
Dysentery may be considered as a febrile condition of
the system, blended with an inflammatory affection of the
mucous membrane of the intestinal canal. There is a
striking difference between cases of this complaint, & those
in which the peritoneum is involved. In dysentery the
patient will often bear pressure on the abdomen without
being sensible of acute pain, as in peritonitis. I have
often seen dysentery connected with a strong active pulse,
indicating a high degree of inflammatory action; and
of the two evils, if I must contend with a severe case of
dysentery, I had much rather meet with one where this
high degree of inflammatory excitement should exist,
than one attended with a languid circulation & malig-
nant symptoms. The practitioner is often able to form
some idea as to the severity of the disease, from the fa-
cility with which he can procure fecal evacuations by
cathartic medicines. Perhaps there is no disease in which
there is greater liability to dangerous error than in dys-
entery; & among the common people, this error very
generally obtains. A patient rises frequently, perhaps
five or six times in an hour, & it is found that at each 
time, there is some little discharge. Under these cir-
cumstances, it is not uncommon for himself & his
friends to imagine that he is purged almost to death.
Most unhappily for the poor patient, a system of stim- 
      


213
ulating & astringent treatment is at once adopted.
Instead of carrying off the disease by purgatives, the
attendants are very apt to give burnt brandy, spiced
wine, & a variety of astringent articles, to stop what
they conceive to be a lax. From the nature of the case,
it may easily be understood, that articles of this kind
must invariable prove pernicious; & in many cases,
may pave the way to death. Hence, when called to a
patient, affected with a complaint in his bowels, you
should be exceedingly careful, to ascertain, at the very
threshold, the exact nature of the disease, whether it
is dysentery or diarrhea. In the latter complaint the
patient is often disposed to go to stood, & some pain
precedes each attempt to procure an evacuation;
but copious discharges take place, & the patient is for
the time, relieved. But in dysentery, let the patient go
to stool a hundred times a day, if you please, no re-
life is experienced- no true feculent evacuations are pro-
cured.
I will no proceed to consider the general princi-
ples on which the treatment of this disease is to be con-
ducted. In those cases in which the pulse is decided-
ly strong & active, I regard the use of the lancet as as-
sential. But in midway cases, where the condition
of the system seems to forbid the use of the lancet,
& at the same time the symptoms seem to indicate the
Necessity of abstracting blood, leeches or cups applied to        
   
      


214
The abdomen are very beneficial. Instances, how-
ever, very frequently occur, where the pulse is small,
frequent, irritable, & without strength; & here, as a
general rule, the primary indication is to unlock
the bowels, & procure natural evacuations. If, howev-
er, the stomach is irritable, & this irritability depends
on bilious accumulations, or other offensive matters
in the stomach, an emetic may be resorted to with great
advantage. But the cathartic plan is that principal-
ly to be relied on. In the commencement of dysen-
tery the mercurial cathartics will often be found to
answer an excellent purpose. But they should gener-
ally be followed up with those of a milder character.
After a dose of calomel alone, or of calomel & jalap,
castor oil is a cathartic which comes in very appropri-
ately. This last article, in the early stage of the dis-
ease, cannot possible do any harm. As much as
the stomach will bear may be given with safety;
for whatever there may be more than sufficient
to produce the desired effect, is discharged by the bow-
els, lubricating the surface over which it passes.
But you will not unfrequently find patients whose
stomachs will not bear the castor oil; & in these cases it
becomes necessary to resort to other remedies. The neutral
salts, particularly the Epsom salts, may, under these
circumstances, be very properly employed- salts are more
grateful to the stomach when dissolved in seltzer water.           
   
      


215
In some cases advantage will result from combining
them with small doses of ipecacuanha or tartar emetic.
In addition I direct large mucilaginous injections
to allay the pain & irritability of the bowels. Flaxseed
tea with, or without, oil will answer the purpose very
well. When the pain & irritation are very great, ano-
dyne injections, made by adding a tea spoonful of laud-
anum to a small quantity of starch, are an excellent
remedy. Demulcent drinks, as  flaxseed tea, barley
water, etc., are excellent auxiliaries, & should not be
neglected. A mixture of mint & mallows used to be
a great favourite with Dr. Wistar. A solution of gum-
arabic copiously drank is very beneficial. Your
object remember is to march forward till you have
obtained natural evacuations; & for this purpose,
immence quantities of medicine are sometimes
necessary. But you may inquire,- is this practice
to be pursued night & day, & is the patient to have
no rest? My course is to pursue the cathartic plan
till I have procured feculent discharges, which I
generally accomplish in 24 hours, & then to afford
the patient some rest at night by means of an opi-
ate. But this should not be given alone: two
other indications are to be answered at the same time-
one to produce determination to the surface, & the
other, which irritability is allayed by the operate, to
introduce something which shall tend to relieve the  


216
stricture of the bowels, & assist in the cathartic operation.
With a view of these indications, I direct the opium to
be combined with ipecac & calomel. I have often al-
lowed my patients to lie by for hours on this medicine.
No time is lost. A determination to the skin, which is
a point of great importance, is produced by the ipecac,
& the calomel serves to cooperate in evacuating the bow-
els. One grain of opium, one & a half of ipecac, & ten
of calomel, may be given at bed time. This produ-
ces rest & prepares the system for the administration,
in the morning, of castor oil, epsom salts, or some
other cathartic which may agree better with the stom-
ach. This practice is adapted to the early stages of the
disease: but after its continuance for some time, I
often use opium & ipecac without calomel.
But cases occur in which other remedies than
those which have been mentioned are required, you
may have been using castor oil & epsom salts for
a long time, & still wishing to keep up the action of
the intestines, may look for something which, while
it operates gently on the bowels, serves also for nu-
triment. For this purpose I can speak favoura-
bly of the oil of butter. I direct some of the best
sweet butter to be procured, & to be washed several
times in cold water till all the salt is removed:
boiling water is then to be poured over it: this lique-
fies it & it rises to the surface in the form of an oil.     
 


217
I use this in the dose of a table spoonful, & from this
up to a wine glassful, every hour or two hours. It may al-
so be advantageously employed in the form of an enema.
I have often found it to allay irritation, & to operate very hap-
pily as a laxative. Hence, as a medium practice, when you
wish to suspend for a short time the active cathartics, & at the
same time, keep up some slight action in the bowels, the oil
of butter is a very appropriate remedy.
In some cases of dysentery, I have seen a combination
of tonics & cathartics very useful. I once attended a patient se-
verely affected with this disease, in whose case calomel, castor
oil, etc., had been employed, & yet the complaint continued. I
then directed an infusion of bark & rhubarb in the dose of a
wine glassful every hour. This was given in the forenoon &
castor oil was administered in the evening; & a very happy ef-
fect resulted. In another instance, 3 ½ of good bark with 3 ij
of rhubarb were infused in one pint of water, & a wine glassful
was given every 2 hours. On the same principle we some-
times find the other tonus, as colombo, etc., very useful. I have
known Dr. Griffitts to prescribe a combination of columbo &
rhubarb in powder.
We are sometimes compelled in dysentery to resort to some
mild cathartic combined with an opiate. Hence the olea-
ginous mixture is, in some instances, very advantageous.
In the progress of the disease, our views are not confined
simply to the evacuation of the bowels, but we also attempt
to make some impression on the system. In some cases
  


218
the dysenteric patient, in the progress of the complaint, sinks
very low, & requires something to support his strength. This
is sometimes the primary indication. To fulfil it various
remedies of a stimulating & nutritive nature, as wine why,
etc., may be employed. The spirits of turpentine has been
employed in some forms of dysentery; but I believe not
very successfully. But there is a remedy from which Dr.
Emlen informs me he has derived great benefit: I allude
to the warm bath. It should be used two or three times a
day. It relaxes the skin, determines to the surface, renders
the system susceptible to the operation of medicines, & makes
a favourable impression on the disease.
Great benefit is often derived from blistering, & there
is no part to which this remedy can be better applied
than to the abdomen. Sometimes blisters to the wrists
are useful. In bad cases I can highly recommend the
employment of blisters. In young children who are ex-
ceedingly restless, & who can not be made sensible of the
utility of the remedy, it may be deferred longer.
Occasionally instances occur attended with so great debility 
as to render evacuating remedies improper, till the
system has, in some measure, recovered its energy. A
case of this kind occurred to Dr. Hartshorm & myself.
We relieved pain by opium, used supporting measures,
& had to lay pretty much upon our oars till the system 
rose, before we could resort to evacuants: but by
assiduous attention the patient recovered.  


219
A respectable practitioner in Burlington, Dr. Cole, informs
me that when he wishes to procure a copious evacuation
from the bowels the next day, he generally gives a large
dose of opium at night. He thinks that opium renders
the intestines susceptible to the operation of cathartic medicine.
I have seen dysentery combined with intermittent
fever; & in these cases I have found bark very useful.
There was a respectable practitioner in the neighbourhood
of Darby, Dr. Gardner, (now dead) who made great use of
bark in one season when the dysentery was prevalent is
that plan. He was so successful as to be induced to
believe, that the disease would yield to this remedy
on all occasions- here he was too sanguine.
I have occasionally seen dysentery terminate in
diarrhea, & the strength of the patient to fail rapidly.
During the summer of 1821, I had a case of this kind,
a few days before death the stool changed, became bilious
& natural; but the patient sunk rapidly, & though considerable 
efforts were made to support him; yet they
proved abortive & he died.
You will often find dysentery a very obstinate disease.
Sometimes you will be flattered by procuring natural
evacuations; & yet, when the medicines are withdrawn,
the same disordered stools return, you should impress
it on your patients that this will be likely to happen,
& that they must not be discouraged by the change.           


220
Sometimes a troublesome excoriation takes place about
the anus. The propers are an ointment made of opium
& lard, anodyne fomentations, etc., I was once sent for
to Norristown to see a patient who had been affected
with dysentery. He appeared to be cured of this disease;
lent in consequence of excoriation about the anus, these
parts were kept in a state of constant irritation. The
remedies above mentioned were resorted to & he recovered.
For diet in the acute stage of dysentery, I would
confine my patients to mucilaginous articles of the
most simple & mildest character. Flaxseed tea barley
water, rice water, etc., are often resorted to. As the disease
advances the food may become more nutritious than was
at first allowable. When the bowels are weak, the various 
preparation of rice, which you know is slightly
astringent, may be advantageously employed. All 
articles should be avoided. Fissault (I believe it
is,) recommends the use of ripe fruits throughout
the disease; but my own experience does not allow
me to agree with him. In the early stages even
ripe fruits disorder the stomach, induce flatulence, &
occasion irritability & distress of the bowels. In some sta-
ges of the complaint, perhaps, they may be safely em-
ployed. I have known Dr. to recommend
black berries in certain cases.
After the disease has assumed the chrome form        


221
it is of the utmost importance to wear flannel next
the skin. To keep up heat & action in the surface is absolutely 
necessary.
After the dysenteric symptoms have disappeared, &
the patient is left in a state of debility, the vegetable
tonics may be interposed with great advantage. Columbo, 
quassia, cascarilla, etc., are often very useful. In convalescence 
the stools are very apt to be frequent & sometimes 
dysenteric. I have known the spiced syrup of
rhubarb, with a few drops of laudanum, given occasionally, 
to be very useful.
Another point to which your attention should be
particularly directed is the mode of preventing dysentery. 
In some country neighbourhood, I believe the
disease is much more prevalent than it otherwise would
be, in consequence of the indulgence in the use of improper 
articles of food, & of exposure to such causes as must
inevitably weaken the tone of the bowels. I do not propose 
to enter at present into the consideration of this subject. 
I spoke of it at large in my lectures on vegetable
physiology; & I have published some papers relative to
it in the Village Record printed at Westchester, under the
title of “Essay on Health.” In these I have endeavoured
to point out the causes leading to the complaint, & the
proper methods of prevention; & to them, therefore, I refer 
you for further information.
Before closing the consideration of dysentery in its        


1222
acute form, I will just observe, that in a conversation
with Dr. Physick, he told me he had found no disease
which was of more difficult management, & which caused
him more trouble than dysentery; & that the remedy
which he had found most effectual was a liberal bleeding
in the commencement without reference to the pulse. This
I tell you, because the authority of so experienced a physician 
as Dr. Physick is of great wright. I have already
mentioned that in my own practice, I am not in the
habit of employing the lancet, unless called for by an active 
& strong pulse.- I have been informed by an intelligent 
country physician that some of their cases of
dysentery are so malignant & prostrate the patient so
speedily as to forbid the lancet.
On the whole, I must confess, that my experience
in dysentery has not been very extensive; I do not, therefore, 
speak with that degree of assurance, in the treatment
of this complaint, that I sometimes do when treating
of diseases with which I am better acquainted.
Chronic Dysentery
.and
Diarrhea.
_______x________
Dysentery sometimes assumes a chronic form,
& then becomes exceedingly troublesome to those afflicted
with it. This is the case also with diarrhea. Of recent     
        


223
diarrhea I do not propose to speak; but shall confine
myself to the chronic from of the complaint. In these
disease, the bowels seem to acquire a habit, & the system 
accommodates itself to this habit; & the patient continues 
to suffer for weeks or even months before he is
wore down.
I was consulted in 1820, in a case of chronic dysentery, 
occurring in one of the inferior offices of the congress
frgate. The disease had continued 8 months, when he
came under my care in consultation with Dr. Atlec. Various 
modes had been tired for relief. When I discovered
the nature of the case, & found the want of action on the
surface of the body, one of the first indications in the
treatment which presented itself to me, was to restore heat
& action to this part. I believed that without attending
to this point, all our efforts to correct the disorder of the
bowels would be unavailing. With this view then I
advised the warm salt bath to be taken daily. Convinced
that in some of these cases which have been of long standing, 
the hepatic system is brought into sympathy, & that
a revolution in this system may be production of
good effects, I proposed to Dr. Atlec to put the patient
on the use of calomel in small doses, say 1/6 of a grain
every 2 hours; & on the following day, to give some
mild cathartic, possessing tonic properties, an infusion
of rhubarb, for example. This was to be pursued till
the discharges should become natural in their appearance.      
        


224
The use then of calomel in minute doses, succeeded
on the next day by the infusion of rhubarb, a table
spoonful every 2 hours, & combined with daily emersion
in the warm salt bath, effected a cure, & the patient is
now completed will.- I should add that flannel
clothing next the skin was an essential part of the
treatment. The practice recommended by Dr. Dewy and
Chapman of applying a flannel roller round the abdomen 
is worthy of great of attention.
A proper regulation of the diet is of the utmost consequence 
in these complaints. The least irregularity in
this respect may prevent the good effects of all our remeddies, 
& completed undo all that has been effected.
The patient should scrupulously abstain from all kind
of fresh fruits & vegetables. This as a general rule is
certainty a good one; but cases sometimes occur where
vegetables prove very beneficial: I was consulted by a
lady from the western country, whose bowels had been
in a disordered condition for some time, & she had
been very regular in her diet; at length a decided
predilection for fruits & vegetables took possession of her
mind- the employed them & recovered. But in most
cases these articles are improper; & even if the disease
has been cured, they are very apt to occasion a relapse.
Chronic diarrhea is a more frequent complaint
than chronic dysentery. The patient is often affected
with frequent & profuse discharges; all the aliment           


225
is rapidly carried off; & unless relief is procured, the patient 
is at last completely worn out. Great emaciation
with a total loss of action in the surface takes place, and
death is the result.- I know no better way of illustrating 
this disease as it usually appears, than by reading
to you a case attended by Dr. Wood & myself, the account
of which he has furnished me with.
“Case of J. C.- J. C., between 25 & 30 years of age, had
been frequently subject to attacks of hepatic colic, in the
last of which a cure was effected by the use of mercury
so as to excite a very slight salivation. This occurred in
the spring of 1818. From that period he enjoyed better
health than for a long time before. In the latter part of
the fall, or in the commencement of the winter, of 1819, he
undertook a journey to the westward on horseback. His
manner of living was extremely irregular. Sometimes
he made only two meals in the day; sometimes, when
he made the usual number, it was at irregular intervals, 
& under various circumstances of rest & fatigue. This
method of living, united with exposure to all kinds of weather, 
& with fatigue far beyond any to which he had been
the subject of disease, produced a complaint of a nature
extremely severe, protracted & dangerous. At various
stage of his progress he was so severely handled, that
he was forced to apply for medical aid, from which
he only derived temporary relief. When, on his return,
  
 


226
he first applied to me, he had been labouring under
the complaint for 3 or 4 months. At this time, which
was about the latter end of February 1820, he complained
of a constant & extremely distressing pain just above the
pubis. His bowels were irregular, sometimes more loose,
sometimes more constipated, than usual. His urine was
entirely limped & in excessive quantity, so much so as
almost to constitute diabetes. I gave him some directions,
& did not see him again for several days. At the
end of a week he sent for me to his lodgings. In the
mean time, by the recommendation of a gentleman
with whom he boarded, he had taken several very
powerful purges. His bowels were now in a very disordered 
state. His stools in the 24 hours exceeded 30
in number, & during the night he was constantly jumping 
in & out of bed. The colour of the evacuations was
very dark, & in consistence they resembled tar. Sometimes 
they looked as if mixed with dissolved blood, and
in the subsequent course of the complaint, they were
generally of this nature. The pain which he suffered
was almost intolerable. The seat of it was in the small
of his back, in his bowels, &, sympathetically, in his
knees. So violent was the pain in the last situation, that
he frequently observed, he would willingly suffer amputation, 
if it would bring him relief. He no longer
complained of the pain over the pubis which had before
trouble him so much. The suffering was always more   
 
  
 


227
acute for several minutes before a stool. He was
much troubled with flatulence. His appetite was never 
entirely destroyed, as, through the whole course of the
complaint, he was able to make one, two, or three meals
in the day. His tongue was generally covered with fur.
His urine was still secreted in immense quantities, &
of a limped colour. This symptom, however, soon gave
way to the plan of diet which was adopted. As may
be supposed from so severe a local disease, his constitution 
suffered very considerably. His pulse was rarely
slower than 100 in the minute, & at the same time was
rather feeble. His nervous system was very much disordered, 
& he was now & then seized with spells very much
resembling hysteria. His spirits were always much appressed. 
I never saw a living being more emaciated.
The flesh had almost all wasted away from his limbs;
the bones projected at his hips & back as if they could
make their way through the skin; & his abdomen was
shrunk almost to nothing. It appeared surprising to
me how so much matter could be secreted into the bowels, 
as passed in the course of the day.
Dr. Parrish saw him with me in consultation. He
was put on such a diet as was calculated to be most easy 
of digestion; as eggs, oysters, mutton, beef, toasted or stale
bread, with rye coffee or chocolate for breakfast & supper.
All fresh vegetables were excluded without a single exception. 
To thus diet he adhered rigidly throughout the disease.

   
     
 
  
 


228
With a view to connect the disordered action of the liver,
which was conceive to be the principle cause of the
disease, we direct the use of calomel in the dose of 1/6
of a grain every half hour, till 3 gains should be taken
in the day. As it had been ascertained that any thing
astringent increased the pain & irritation, it was thought
best not to venture on this plan till the alvine secretions 
should be corrected. An opiate at night, however,
was ordered; but proving injurious, it was afterwards
omitted. To remove the irritation of the bowels in some
measure, the oil of butter was directed. For a little while
this answered a good purpose; but after a few days it be-
came disagreeable to  the stomach, & was rejected. It was prescribed 
in doses of a table spoonful every 2 hours every other
day, the calomel pills being given on the alternate days.
By pursuing this plan for some time, the discharges from
the bowels again assumed a feculent appearance; but the
diarrhea continued, & the pain was very severe, though less
so than before. A blister was now applied over the abdomen, 
which gave considerable relief, & enable us to administer 
an opiate at night with evident advantage. After 
the blister healed, it was again applied, & with a salutary
effect. The calomel & oil of butter were omitted.
Continuing without much improvement, the warm bath
impregnated with salt was direct to be taken every night
at bedtime, & followed by 30 or 40 drops of laudanum. The
effects of the bath were wonderful. When he first entered
    

   
     
 
  
 


229
it, he was so weak as to be totally unable to assist himself, 
& on the second time he fainted: but the disorder was
much improved. The pain was diminished, & the night
was passed without disturbance. The treatment hitherto
pursued had prepared the system for the administration of
astringents. According, a preparation of galls & brandy
with an infusion of cascarilla was employed; & under
this plan, with a continuance of the bath, he ultimately
recovered. Once or twice afterwards he relapsed, but was
restored to health by the same means. After the removal
of the disease, his appetite became voracious, he increased
rapidly in flesh, & has ever since remained in perfect
health.”
I have now proceeded for enough in the subject
of chronic diarrhea & dysentery to convince you of the
very great importance of attending to the surface of the 
body, & the extremities. The warm salt bath, flannel
next the skin, & flannel socks dusted with Cayenne pepper, 
are remedies of vast importance. I have also proceded 
for enough to show, that when connected with
derangement of the hepatic system, the disease should
be treated with small doses of calomel, alternated
with cathartic medicine, particularly such as possess
the tonic & laxative power combined, as rhubarb for
example.
But it is necessary to resort also to other remedies
in the treatment of chronic diseases of the alimentary canal.         

   
     
 
  
 


230
Among these the astringents hold a distinguished rank. It
frequently happens that these may be interposed with very
great advantage. A great variety of articles have been recommended. 
The spiced syrup of rhubarb, which, though not
purely astringent, combines this power with the laxative, is
a preparation much employed in this city in certain cases
of diarrhea. It is more aromatic & stimulant than the
simple syrup, &, in small doses, combined with a few
drops of laudanum, I have occasionally found it very
useful. A dessert spoonful with 5 drops of laudanum,
may be given 3 or 4 times in the 24 hours. But among
the astringent preparations, few will be found more efficacious, 
than the syrup of galls made in the following
manner: Take 3ii of the best Aleppo galls, coarsely powdered,
place them in a cup capable of containing 5 or 6 ounces
of fluid, & fill the vessel with the best old French brandy.
On the top of the cup forks or skewers are then to be placed,
& on these pieces of loaf sugar to be laid: the brandy is
then to be set on fire, & allowed to burn as long as there is
sufficient alcohol to supply the combustion. The sugar
melts & drops into the cup; &, as it disappears, fresh quantities 
are to be added, till the brandy ceases to burn. At the
close of the process you have a syrup of galls, which is to
be strained off from the coarse powder. This is a powerful
astringent, & not unpleasant to the taste. When you wish
to make it aromatic, you may add a little cinnamon on
cloves to the galls. one single tea spoonful of this syrup      
   
     
 
  
 


231
is sufficient for a dose. I have used it from this quantity 
up to a dessert spoonful, sometimes by itself, sometimes 
combined with the testaceous mixture.
Kino is an astringent much resorted to in these cases
of chronic disease. It is generally employed in the shape
of tincture, & is most commonly combined with other articles. 
Some remedies uniting tonic with aromatic properties, 
are employed with considerable advantage in chronic 
diarrhea & dysentery. Cascarilla is particularly adopted 
to some of these cases. It is used in the form of decoction, 
in the dose of a wine glassful 6 or 7 times a day.
In addition, the other tonics, may be occasionally employed, 
as Colombo quassia, etc.
Before the case of J. C. I had under my care a young
lawyer of some eminence from the state of Maryland. In
that instance the same practice was pursues as in the case
already detailed, with the exception of the calomel. The
warm salt bath, the syrup of galls, with an attention to
diet were all resorted to, & with success. I never had a
more satisfactory case, either in the happy termination,
or in the lively expression of gratitude on the part of the
patient. He has several times, when in Philadelphia,
called on me to express his thanks for the services I rendered 
him.
In the treatment of diarrhea you frequently hear
of the testaceous mixture. This preparation has often
a very salutary effect, given in combination with a  
 
        
     
 
  
 


232
little laudanum & some astringent article. I was
consulted by an old lady who laboured under chronic
diarrhea for several years. It was not of that debilitating 
kind we often meet with; but it subjected the
patient to a great deal of inconvenience. I regulated
her diet, & at once put her on the use of the testaceous
mixture with astringent articles. The effect was wonderful. 
The diarrhea was speedily checked. Finding
so sudden an effect produced, I began to be fearful,
lest the cessation of a discharge to which the system
had been subject so many years, might be followed
by dangerous consequences; especially as the patient was
at a time of life when the catamenia are about to disappear. 
I warned her if she should be sensible of disease 
in her head, that she should immediately stop with
the medicine, & invite back her old complaint. The preparation 
I employed was the following:
Take Prepared oyster shells, - 3vi
Gum Arabic,
Loaf Sugar, a a 3ij
Tinct of Kino, f3ij
Tinct of cinnamon, Zj
Laudanum, drop, Lx
Pure water, zv
The ingredients were well rubbed together, & a 6 oz mixture 
was thus formed of which a table spoonful was used
for a dose. The patient soon became acquainted with the 

        
     
 
  
 


233
proper method of regulating the article; & she completely 
succeeded in arresting the disease which had
caused her so much trouble. I might here mention 
that in forming the testaceous mixture, my
friend Dr. Griffitts, does not use gum Arabic & sugar
- he employs simple water & generally adds the
comp. sp. of lavender.- The decoction of logwood &
the decoction of galls ae also occasionally employed.
I have used the pomegranate in decoction, but am
not very partial to it.
It now remains for me to state, that after having
attended to the restoration of heat & action to the surface; 
after having corrected the functional derangement 
of the liver; after having employed astringents
to check profuse evacuations, & anodyne injections
with opiates at night to relieve irritation, we shall
often completely fail in effecting a cure, unless we
attend also to the diet. There is no disease in which
correct rules as to the dietetic management of the
patient are more essential, than in chronic diarrhea.
The patient may be going on very well, & you may
be faltering yourselves with the prospect of a speedy
cure, when all your efforts may be thwarted at once
by a slight irregularity in diet. The patient should
be restrained from every species of fresh fruit & vegetables; 
& even the potatoc should be prohibited. The farinaceous 
articles, among which rice may be consid-

        
     
 
  
 


234
ered as the best are very well suited to the disease. Rice
certainly possesses some astringent properties. It may be
used simply boiled, or in the shape of rice & milk. There
is a pudding prepared from this article, which I have often 
recommended to my patients. The rice is to be first well
boiled, so as to render it soft & easy of digestion. It is then
to be mixed with milk & sugar, & baked in an oven exactly
as the common rice pudding. The French practitioners prepare 
what they call the cream of rice, which occasionally
answers very well. A lady of my acquaintance has imposed
on the French method. She puts rice into a considerable
quantity of water, & boils it several hours very gradually
till it is rendered exceedingly soft; she then rubs it over
a sieve, so that the liquid & softest portions pass through.
This is seasoned with rose water & a little nutmeg grated
over it. Eaten with milk or cream it forms a very
pleasant article of diet. Besides rice other farinaceous articles 
may be used, such as arrow root, sage, etc. Tapioca
gum arabic, & other articles of the same kind are also proper.
Crachers are very suitable; they are preferable to common
bread. There are some cases which are much benefitted
by the use of milk. I recollect one of the most obstinate
cases of diarrhea which resisted the skill of the most eminent 
physicians, (Dr. Wistar among the number,) recovered
under the daily use of new milk with plenty of nutmeg
grated over it. But I have generally been in the
practice of directing certain articles to be added to the milk. 
    

        
     
 
  
 


235
Among these roasted flour holds a high rank. It should
be roasted like coffee in a pan till it becomes brown; milk
with this has, sometimes, a very happy effect. There is another 
preparation which is familiar to mothers & nurses, and
with which physicians ought to be acquainted. Some flour is
tied in a rag & boiled for several hours till it becomes as hard
as chalk. It is then grated & used for thickening milk, & for
making pap. In all the different shapes in which milk
is prepared, I am fond of adding some aromatic. Solid food
will sometimes answer very well in diarrhea; & boiled mutton 
or boiled fowl is perhaps the best. In some instances astringent 
drinks, as, for instance, good old Port wine, used in
moderation, are beneficial.
But in chronic diarrhea, as well as in dyspepsia, you
will occasionally find that articles you would hardly have
thought likely to produce a beneficial effect, will bring about 
a cure. Dr. Wistar related to me an anecdote which illustrates 
this position. He was himself affected with tenderness 
of the bowels; & a trifling matter would bring on diarrhea 
which, when it did attacked him, rapidly reduced his
strength. He told me that on one occasion, when he was
affected in this way, it happened that he had some bottled
malt liquor in his house, which had remained there a
considerable time, & had become somewhat sour. From
some cause or other he took a little of this hard ale, & found
to his surprise, that it proved useful & that he recovered
under its use. Sometimes after this he had a patient similar-     

        
     
 
  
 


236
by situated, & in his case he tried the same remedy. He sent
him some of his ale, & the patient recovered under the use of it.
Another time the same man was again attacked, & being useable 
to procure from the bottling cellars any of the liquor he
wanted, he sent word to Dr. Wistar that he would be much
pleased to make an exchange with him, promising for every
bottle of his hard ale, to send him another of the best.
Dr. Physick related to me an anecdote of a case of diarrhea
which was cured by the use of sound cider through the day,
& at night a dose of aromatic tincture of rhubarb with
cardamom seed, as prepared by some of the apothecaries,
& particularly by John Hart of this city.
On the whole, before closing the subject of diarrhea and
dysentery, I wish to veal to your remembrance a few
general observations. In the first place, always attend to
the surface & endeavour to restore heat & action to it, & also
to the extremities. 2nd. Endeavour to correct the functional 
derangements of the hepatic system, where there is
reason to believe that such derangements exist; & if there
is organic disease remove it if possible with the utmost diligence. 
3rd. At this point resort to astringent remedies, varying 
them according to the circumstances of the case. 4th.
If there is considerable irritation, allay it by anodyne injecttions 
& opiates, particularly at night; & 5th. Attend most scrupulously 
to the diet of the patient; for, unless this is done
all your care & attention will often be unavailing. At
the same time you should remember, that, as in dyspep-         
        
     
 
  
 


237
sia, exceptions to general rules with regard to diet occasionally 
occur, & should not be disregarded. In all cases
you should watch the pointing of the system, & gradually 
allow the patient to revert to his former diet.
Rheumatism affecting the Intestines.
_______________x___________________
I shall commence the present lecture with sine observations 
on an acute disease which I shall call rheumatism
affecting the intestines. The same observations will generally
apply to gout affecting the same part.
The disease of which I am about to speak is observed
in persons subject to gout & rheumatism. If I am called
to a patient who has been subject to these disease affecting
muscular parts, & find that he has been suddenly attacked
with severe pain in the bowels resembling colic; that this
pain is rather paroxysmal than otherwise, & especially if I
ascertain that the pain had been suddenly removed by friction 
or other means from the extremities, I entertain little
doubt that translated gout or rheumatism is the cause
of the symptoms.
In the course of my practice I have met with a few
cases, such as I am about to describe. I have in some
instances known the pulse to be laboured & tense, indicating 
an active state of the circulation. In these cases the
practice must be materially different from what would       
        
     
 
  
 


238
be proper in such as are attended with a debilitated
state of the circulation. I consider it of the utmost importance 
to fix in the mind some general indications
on which our practice is to be founded. Thus, in a patient 
affected with violent pain, & that pain paroxysmal
in its character, & attended with an excited state
of the circulation, one of the first indications would
be to reduce this excitement by the abstraction of
blood. In addition to this, it is important by proper
measures to evacuate the alimentary canal. For whether 
the disease arises from inflammation or simples spasm,
it is certainly necessary to remove any mass of feculent
matter that might remain & produce irritation.
But suppose the pain to be extreme; suppose the suffering 
to be so great, that the patient is unable to wait
for the regular operation of cathartics, & it becomes necessary 
to adopt some immediate measures of relief;
you will then see the necessity of combining with the
cathartic some remedy calculated to allay pain & resolve
spasm- opium will answer this indication; & a combination 
of calomel & opium answers very well in some
of these cases. Besides this, we should have in view
other articles which may have the effect of resolving
spasm, & which may be called in as auxiliaries to opium, 
or, if the symptom are not very urgent, to supply 
its place. Several of the antispasmodics will answer
this purpose. Our of the best & most easily obtained                
     
 
  
 


239 
is asafetida; & I have known it to produce the
happiest effects in the form of enema. We have also the
musk: but this article is very expensive, & economy,
in many instances, would prevent a resort to it, unless,
in case of necessity. The rectified oil of amber & ether
come tin very well. But the assafectida, from much
experience, I consider a very important antispasmodic,
& entitled to much attention.
But the indications do not end here. Not only have
we to reduce vascular action & remove spasm; but we
must also resort to counter irritation, especially when
there is reason to believe that the disease is the result
of metastasis. Hence, you can easily understand the importance 
of sinapisms. If the pain in the bowels arises
from the recession of gout or rheumatism from the extremities, 
nothing can be more natural, than to endeavour
to bring it back again; & for this purpose, mustard plasters 
applied to the feet & ankles are very important remeddies. 
Dr. Barton, the late professor of the practice,
who was himself very subject to attacks of gout, was very 
much opposed to the use of sinapisms & stimulating
applications of any kind to the extremities when the pain
was seated in these parts. He feared, & justly too, that
they might repel the disease to parts of greater vital
importance. But in cases when metastasis had taken place, 
he thought the remedy excellent. Dr. Barton, 
perhaps, had as much experience in gout as any  
   
 
  
 


240
other physician- he had 7 or 8 brothers all of whom
were subject to the disease. The Dr. informed me
that one of his brothers had an attack of gout in his
feet, & the pain was so severe, that he wished to have
mustard plasters applied: he had an several occasions
experienced great relief from them, when the disease
had receded from the extremities; & he was in hopes
that the same beneficial effect would result from
their application when the pain was seated in these
parts; but the Dr. objected to their use for the reason
already given. His brother, however, persisted in his
entreaties, & the Doctor’s remonstrances were vain the
sinapisms were applied, & that night he was seized
with violent pain in his chest.
If you find coldness of the surface, as will sometimes 
be the case, it will be desirable to restore warmth;
& for this purpose, fomentations & the warm bath
may be resorted to with advantage. If the pain
should continue obstinate & severe, notwithstanding
the use of the remedies mentioned, counter irritation
by means of blisters in the neighbourhood of the
part affected, may be advantageously interposed.
I will now relate one or two cases to illustrate the
practical principles I have advanced.
Case of J. G.- In the spring of the year 1810, I attended 
an elderly gentleman in this city, who had an
arrack of the gout. He was seized with violent pain
        
   
 
  
 


241
in the left side of the abdomen accompanied with
frequent emotations. The pain was situated about the sigmoid 
flexure of the colon, & occasionally darted into the back.
Whenever the pain was considerable, his pulse was remarkably 
strong & active. The pain was not constant, but occurred
in paroxysms. It was necessary to bleed him, & he bore the
loss of blood well. The operation was repeated several times, &
so strong proff of its being required was, that it always afforded 
relief. It was also necessary to evacuate the alimentary
canal. For his purpose castor oil was given in large doses,
& purgative injections were administered, till the bowels
were completely emptied. After this injections of assafetida
were directed, which relieved him greatly. Sinapisms were
also applied. Dr. Physick saw him with me three times.
He advised the use of anodyne enemata, which had a very
happy effect, & proposed 10 drops of the rectified oil of
amber every 4 hours. By pursuing this plan the patient
happily recovered.
About two years afterward, I attended this patient with
the same disease; but in this instance, it took hold of the
stomach. The same course of treatment was not exactly
indicated in the present, as in the formed, attack. Sinapisms 
were applied to the feet, opiates & strong ginger tea
were given; &, at the same time, the bowels were kept
freely open by caster oil & injections. In the course of the
attack, several chills occurred for which volatile alkali
was given with advantage; & before the close of the case,
 
   
   
 
  
 


242
on account of the debility which supervened, mustard whey
& other stimulants were employed. Tonics completed the
Care.- In the first instance, as you have perceived, the
intestines were attacked & depletion was required; in the
second, the stomach was the seat of the disease, & stimulants 
& tonics were demanded.
Calomel combined with opium has been very much
employed of late as a purgative in disease of this discerption; 
though oil with laudanum will, perhaps, in
many instances, answer equally as well.
Case of J. C.- In the year 1810, I was consulted in the
case of J. C. who had a violent pain in the cavity of the abdomen, 
attended with constipation of the bowels, & an active
state of the pulse. When I saw him, Dr. Park had been
prescribing, & had followed the usual course. The warm bath
& bleeding had been used, & attempts had been made to evacuate 
the bowels. But he was still in very great pain; and
perceiving that the pulse was full, strong, & very active,
I proposed to the Dr. that we should resort to the lancet once
mow. An injection of tobacco had been tired, but not having 
succeeded, I advised the use of it the second time- This
was before I was so well acquainted, as at present, with the
dangerous consequences which sometimes result from the
use of tobacco enemata; & if a similar case were now to occur, 
I very much doubt whether I should resort to the
remedy. In this instance, however, it was given, &, united 
with the bleeding, entirely relieved the pain. The patient        
   
 
  
 


243
said he felt as if a structure in his bowels was giving way.
At this time, moreover, his system was very irritable,
in consequence of which I proposed to the Dr. to give him
a julap composed of ether & musk. This was done, & in addition, 
large injections of asafetida were given. A strong
infusion of senna was used, also a decoction of columbo.
These remedies afforded him very great relief.
This patient was subject to occasional attacks of rheumatism 
in muscular parts. Hence, from the nature of
the case, these could be no doubt that the present affecttion 
was rheumatism of the intestines.
I have stated that in some cases we may resort to the
lancet with freedom; & I have related a case illustrative
of this position. But it proper for me to state that cases
may arise where a resort to the lancet would be injudicious.
We find a great diversity in patients subject to gout. In some
there is a disposition to reaction after the stroke has been given; 
in others, on the contrary, there is a disposition to sink
& become prostrate. Now if a patient with gout or rheumatism 
is suddenly attacked with pain in the bowels, &
this pain is accompanied with prostration; if the pulse
is feeble & the skin cool, surely it would not be proper
to resort to the lancet, let the suffering be ever so great.
Sufficient time cannot have been afforded for inflammation
to take place, & the pain is solely the result of spasm. If
you take up the idea that the prostration results from excessive 
excitement, & have recourse to V.S. to retrieve it,
    
  
       
 
  
 


244
you may rest assured that you labour under a great mistake. 
The practice of confounding pain & inflammation
necessarily leads into great error. I wish to impress you
with the importance of distinguishing between these two
conditions. When the pain is great, & an excited state of the
circulation exists, it is proper to bleed before resorting to antispasmodics: 
but when the system has been laid low
by the stroke of disease, you should not proceed on the
supposition, that it is an inflammatory affection. When
treating of cholera, I had occasion to call your attention
to the same thing. Violent pain attends some cases of this
disease, dependent purely on spasm of the muscular fiber;
& to treat this as an inflammatory affection, would certainly
be to endanger the life of the patient.

Colica Pictonum.
_______x________

I now pass on to consider some other spasmodic of
futious of the alimentary canal. These form an interesting 
class of diseases, which occasionally claim the attention
of the medical practitioner. It may happen that in cases
of this kind, the pain & distress will be located in the
abdomen: but it may also happen that a severe spasmodic 
affection of the bowels will not display itself within
the belly, but will mislead the practitioner by calling off
his attention to some remote part, as the brain for instance.
  

    
  
       
 
  
 


245
I shall have occasion to illustrate this fact by cases. At present 
I shall consider the disease which has been denominated
cobia pritonum or painter’s colic.
This affection generally depends on the poison of lead,
& we meet with it very frequently among those who work
in this article. This disease is painful: but so far as my
experience has gone, is not very dangerous: at any rate
it will generally yield to appropriate treatment, if applied
early. The patient is affected with severe pain, & a twisting 
sensation in the bowels. We often meet with a slow
bounding pulse, such as sometimes occurs in translated
gout or rheumatism: but there is not the same condition 
as in enteritis. There is not the same degree of excitement 
& fever as occurs in this disease. It differs also
from enteritis in the much greater length of its duration.
Invariably, so far as my observation has gone, it is attended 
with obstinate constipation of the bowels. This state of
things goes on, & unless efficient treatment be interposed,
the patient will suffer a great deal of pain, & may in the
end be worn out by the disease.
It has not fallen to my lot to witness a great many
cases of cobia pritonum, though I have seen a number. 
Certain districts of country in Europe are subject
to it. In the neighbourhood of lead mines it was very prevalent, 
& continued to be so until a prophylactic plan was
instituted, which, it is said, has maternally lessened the
number of cases. This consists in the daily use of sweet      
  

    
  
       
 
  
 


246
oil. In places which have been subject to the disease, it
is common to take a wine glassful of sweet oil every morning; 
& the consequences of the practice have been very beneficial.   
A gentleman of this city. E. H., a friend of mine, & a
plumber by profession, was repeatedly attacked with colica 
putonum. He told me that always after soldering
he would be affected severely by the poisonous fumes of
the lead; & generally several days would elapse before
the muscles of his arms would be restored to their natural 
state. Often when engaged in this business, his hand
would shake as much as if he had been in the habit of
drinking; though he was a remarkably temperate man.
I find the following notice of his case in one of my ledgers:
Case of E. H.- 10 mo. 1810. I am really afraid this
worth man will never relinquish this business he is
engaged in, until he falls a victim to the baneful influence 
of lead on his system. This is the third attack of the
painter’s or plumber’s colic, which has brought his life into
great jeopardy. He possesses a strong hereditary predisposition 
to gout, & the present attack seemed a combination
of the two diseases. He had frequent eructations, & occasionally 
severe pain in his knees. The disease commenced
with pain & a sense of twisting or spasm in his bowels. His
pulse was slow & tense. When first called, I bled him freely, 
ordered cathartic pills, fomentations to the abdomen, etc,          
     
    
  
       
 
  
 


247
but without effect. Anodyne injections relieved him
greatly, but did not reach the cause of the disease. I
tried him also with several large doses of much without
benefit. At my request Dr. Parke was called in, who
has always attended him with me before; & we readily 
agreed to enter on the use of mercury, the only remedy
that has ever yet radially removed the complaint. We
gave him 3i of calomel in the course of the night, & about 
gr x next day. This answered the purpose, & produced 
ptyalism which has, in his case, always succeeded.
But it is worthy of remark that the relief is obtained several days 
before the discharges from the bowels are copious. 
It seems as if the spasm or stricture, is removed
by the action of the mercury, & then several days are required 
before the tone of the intestines is so far restored
as to allow them to expel their contents. After we ceased to
give the calomel, I thought, during one day, small doses of
the volatile alkali relieved him considerably of his languor.
The columbo & chamomile in decoction were exhibited advantageously 
with a view to the restoration of tone to the intestines.
Mercury effects his mouth instead of his gums. In one
of his former attacks, the action of mercury on his tongue
was such, that for two weeks he was unable to speak; &
at that time he said he would never again take the article. 
I knew him to be of a firm & determined temper; 
& when I was again called, was not surprised to
     
     
    
  
       
 
  
 


248
find him obstinate in his unwillingness to take mercury. 
I told him I believed he would have to come to
it at last: but I first attempted to relieve him by other
means, as I have already detailed. At length, however,
worn out by the pain he suffered, he submitted to the
use of mercury. In every subsequent attack, the same
article has been resorted to, & a cure has always been effected.
In other instances, I have often met with colica pictonum, 
when the same remedy was necessary. A short
time, however, may be devoted with safely, if circumstances 
render it desirable, to the employment of other
measures; for the disease, so far as I know, is not speedily 
fatal. There are seldom any inflammatory symptoms. 
One case, if I recollect right, I relieved by the
liberal use of Jalap & cream of tartar. The patient was
accustomed to grind paints in a cellar, & generally had
a pitcher of water standing by him, of which he occasionally drank. 
The dust from the paint formed a pellicle on the water, & this was swallowed with the rest. The
consequence was, that he was seized with a violent fit
of colica pictomens. In this case I believe I succeeded in 
effecting a cure without resorting to mercury.
But the general result of my experience has been,
that mercury is the only remedy on which reliance is
to be placed, & that this should be carried so far as to produce 
ptyalism. The spasm is thus relaxed, & the
       
     
     
    
  
       
 
  
 


249
pain, of course, diminished; & after a few days have
elapsed, the intestines evacuate large quantities of feculent 
matter. Minor remedies, as the warm bath,
blisters, injections, etc., may be employed; but you will
recollect that mercury is that on which your reliance
should be placed.- It was first recommended by an
English physician who resided in a district where the
disease was prevalent.
Combination of calomel & opium, particularly at night,
with the occasional use of anodyne injections through the
day, I consider very appropriate in the treatment of this
complaint. Two or 2½ grains of opium & 10 grains of calomel 
will be sufficient to be given at night, & with
this the patient may be allowed to rest till morning.
Spasm of the Intestinal
Canal in Children.
_________x____________
I now pass on to the consideration of spasm of the intestiness, 
as I have observed it in infants. This is a disease
with you will occasionally have to contend. Several grades 
of spasm may be observed in the infantile
state. The severe wind colic of children is a spasmodic
affection of the alimentary canal. But I wish now to direct 
your attention to an affection much more serious, which
sometimes groves fatal, but may generally be made to yield.
         
     
     
    
  
       
 
  
 


250
Occasionally in the course of my practice, I have met
with children suddenly attacked with epileptic fits, differing 
essentially from common epilepsy. Instead of
the stupor which generally succeeds an attack of genuine
epilepsy, the child often recovers his reason immediately
after the fit, & looks as if nothing had happened. This
occurs several times a day. If you examine closely, you
will find the child laboring under a sense of uneasiness 
in the cavity of the abdomen. So far as I have
seen, the disease generally goes off; but sometimes it
proves fatal. When this occurs, the fit returns, time after
time, & the little suffered, worn out by the frequent attacks,
at length expires.
I propose to give you some cases which have fallen
under my observation; in doing so, I shall be the more
particular, as I consider the subject to be very important,
& as the little sufferers are unable to describe their own feeling, 
it rests of course with the observation of the nurse,
mother, or practitioner, to decide upon the nature of the
case. It is possible, in some instances, when the fits return
very frequently, that the brain which at first only sympathized
with the intestinal disease, may at length itself become affected; 
but I wish you to recollect that the primary affection 
is seated in the bowels.
Case of J. R. J’s child.- 1812, 7 mon. The subject of the present 
note was an infant of only a few months old. From all
the circumstances of the case, I was induced to attribute
      
         
     
     
    
  
       
 
  
 


251
her disease to a spasmodic affection of the bowels produced 
by flatus. The fits were very frequent. On her recovery 
from them, she appeared, immediately, to know those
about her; & she was affected with nothing like the coma 
supervening epilepsy. I directed her bowels to be
opened, had her once bled, used the warm bath, fennel
seed tea, also the tincture of assafoetida, & the recovered.
I was afterwards called to attend another child of the same
parents: but this one died. Thinking that the disease
might result from the mother’s milk, I advised, that if
she should have another, it should never take the breast;
but that a wet nurse should be procured from the beginning. 
My advise was attended to, and the next infant 
escaped without an attack of the complaint.- In
cases when a wet nurse can not be procured, the diet of
the mother should be regulated- she should avoid all
flatulent food.
Case of Convulsions from Intestinal Irritation.- The
subject of this note was a remarkably fine boy, aged
about 9 months. He had several convulsions before I
saw him. They came on suddenly, & were of short duration. 
One day his mother brought him to town in the carriage, 
called at my house, & told me he had a fit that
day. I lanced his gums freely, directed his bowels to be
opened, as they were constipated, his spine to be bathed with
garlic & brandy, & lac assafoetida to be given.
11 mo. 2nd. 1818.- I was called out in the night in con-
      
         
     
     
    
  
       
 
  
 


252
sequence of Dickenson having had two violent convulsions 
in pretty quick succession. I found him with a
cool skin, a blue appearance about the mouth; but
evidently with a clear intellect. The child almost immediately 
on coming out of a fit, appeared to know those
to whom he had been accustomed. As his pulse appeared
somewhat tense, with a view to the solution of spasm, as
well as to place the system in a condition that antispasmodics 
might act with more effect, I immediately bled him
freely. He fainted under the operation, & had a discharge
from his bowels. Soon after he had another fit, which
on his being put into the warm bath, subsided in two
minutes. I gave him some lac assafoetida, & in doing
so, perceived that he discharged flatters from the stomach.
I ascertained that the child suffered a great deal of pain,
which was manifested by his stiffening himself and
screaming very frequently. I now gave an enema 
of assafoetida with 9 drops of laudanum; & directed
if he was not relieved, one drop of laudanum & a little
become easy. I also directed a large spiced plaster for
the abdomen. Dr. Harlan staid with him through
the night. I requested, if will enough, that he might
be brought to town in the morning, in order to have
him near me. He passed the night very comfortably; 
but towards daylight he had another convulsion,
more violent than any of the preceding. He was again       
         
     
     
    
  
       
 
  
 


253
put into the warm bath, & Dr. Harlan, very properly 
lanced his gums again, & gave him a mixture
consisting of one drop of laudanum, 4 drops of spirits of
hartshorn & a little magnesia, & applied a pair of blisters 
to his legs.
12th. He was brought to town, & the ride seemed to do
him good. Being impressed with the belief that
spasm of the bowels produced the convulsions, & that this
was caused by acidity, I directed a tea spoonful of the
infusion of hickory ashes & soot, to be given every 2
hours; the mixture of laudanum, spirit of hartshorn &
magnesia to be repeated at the sane interval, if in
pain; the abdomen to be bathed with brandy, sweet
oil & a little laudanum; & with a view to make a
strong impression on his nervous system, without nauseating 
his stomach, I ordered his spine to be bathed
with the rectified oil of amber & sweet oil. I visited
him frequently, & was encouraged by finding his
skin become warm & his face a little flushed- it looked 
like a determination to the surface, which I wished
to see. He had not occasion to take his laudanum
more than two or three times in the day, as he appeared
easy without it.
13th. I was sent for early. He had one very slight
convulsion about midnight; & as he was restless,
his mother was afraid of another. I watched him &
listened to his language, for infants have a language,         
     
    
  
       
 
  
 


254
& happy the physician who understands it. I thought
I understood from him, that the pain had left his
bowels; but that he was very uncomfortable and
thirsty. He was teased, & he felt disposed to make it known
by fretting. His skin was warm & his face flushed.
I gave him some cool water. He took it with avidity,
& it made him more comfortable. I again lanced
his gums, to do away irritation from that cause. I directed 
the medicines to be laid aside, & ordered a dose
of oil to clear the bowels: but before this was given
he sunk into a refreshing sleep in which he continued 
the principal part of the morning. About noon
the oil was administered. He again became fretful,
& the cold water was renewed. As the air seemed to revive him, 
I directed him to be carried out into the
yard; & there the little lamb soon fell asleep. The afternoon
& night were passed, on the whole, very comfortably, 
& the little patient escaped without a convulsion.
14th. He had no convulsion this day, though he
was threatened several times. I gave him musk
julap, about one grain in a dose, or rather less. This
was several times repeated with great success. His
bowels were opened with an injection of fennel seed
tea & oil, & the spiced plaster was applied to the abdomen. 
This part was also bath occasionally with
sweet oil, brandy & laudanum, & drinks were giv-
      
    
  
       
 
  
 


255
en as before. I allowed his mother to give him
the breast. Her mind was more composed, & I had
placed her for several days on a strict animal diet, 
with ginger tea occasionally as a drink.
15th. The child was reported this morning to have
had some fever in the night; but the musk was
given several times. He was said to have fretted a
good deal. I found him quite fretful from uneasy
feelings, I believed; but hoped the disposition to convulsions 
had passed over. I directed a good dose of
castor oil, & if he should be feverish or restless, to give
a little sweet spirits of niter, & to recur to the external
applications if required. In the early part of the
afternoon, on calling in, I found him quite uneasy.
The oil had operated freely, & he had taken some musk
without being relieved so much as I hoped he would
be. I therefore directed one drop of laudanum to be
given. Late in the evening, I called again, & was
much alarmed at his situation.- It is here necessary 
to sate, that two of the other children, viz. Elizabeth 
& Gustavus were now down with catarrhal fever. 
I had on the preceding evening bled Elizabeth
& blistered her on the breast. What then must have
been my anxiety to see this little suffered after having 
already gone through so much, now violently
seized with the same disease! His breathing was extremely 
laborious, his skin hot, his pulse active, &             
    
  
       
 
  
 


260
this state had been precede by a chill. I looked at
him with feelings of great anxiety; & as I looked
it seemed as if every moment brought with it increasing 
danger. I do not know when I have seen
a more violent & alarming case. I had him bled
freely, gave him an emetic of ipecac, & directed, if
not relieved, a blister to his breast. I expected 5 grains
of ipecac would have excited his stomach; but his
kind female attendants found it necessary to repeat
the dose three times afterward, making a scruple in
the whole. Even this did not excite full vomiting:
but it relieved his breathing so much, that a blister
was not applied.
16th. On my visiting him this morning I was much
pleased in observing a favourable change in his symptoms. 
The activity of his pulse was reduced, & his respiration 
was far more natural. I directed 3 grains
of calomel every 4 hours, until it should operate.
I visited him frequently in the course of the day: &
early in the afternoon, after the calomel had operated
freely, finding him considerable restless & feverish, I
directed him to be put into the warm bath. This was
done. He remained about 10 minutes in the bath &
was relieved by it. Afterwards small doses of sweet
spirits of niter & antimonial wine given; & on
visiting him late at night, he appeared so easy, that
I ordered the medicine to be continued only when he    
  
       
 
  
 


261
might be awake, & that when asleep he should not
be disturbed.
17th. 18th, & 19th. During these three days so material
change occurred. He went on gradually mending; tho’
he had some slight turns which alarmed his affectionate mother. 
I found it important to attend particularly to the state
of the bowels. Occasionally the warm bath, & bathing his
abdomen with laudanum, brandy & sweet oil were resorted
to. He recovered.
Case of Convulsions from Intestinal Spasm.
2nd mo. 18th, 1821.- Died yesterday an infant of E. C. aged about 
5 months. This lovely little creature had been affected
with attacks of epilepsy for several weeks before its death.
As frirst several days intervened between the attacks, &, what
was remarkable, they came on at one stated time, about,
or a little after daylight. They come on instantaneously without
any warning; & directly after an attack, the child would
be quite sensible & even playful. From the best judgement 
I could form of the case, I concluded it was the
result of spasm in the bowels, & directed my treatment
accordingly. I attended particularly to the diet of the mother, 
advised abstinence from every description of flatulent
food; &, at the same time, adopted a course of purging
with castor oil for the infant, attended to the correction of
acidity by the alkaline infusion, as in the case just related, 
& occasionally employed carminatives & antispasmodics, 
as fennel seed tea, assafoetida, etc. The spiced plaster             
  
       
 
  
 


262
with frictions of garlic & brandy, alternated with the
oil of amber combined with laudanum & sweet oil,
was also used. I frequently directed the warm bath;
& as there was, at one period, so much regularity in
the approach of the paroxysms, I several times endeavoured 
to anticipate them by an opiate. But all
these plans fails. They gave relief, but did not cure
the disease. I used several calomel purges in alternation 
with oil, & the bowels were kept in very free state.
The stools often appeared very natural, while the fits still
continued to recur. I tried the oil of amber internally,
& used, very cautiously, anodyne enemata; but without 
any permanent benefit. The epileptic paroxysms
were more frequent; the belly was often tympanitic; &
in order to relieve this, I directed that the air should
be abstracted from the bowels by means of the dry syringe- 
introducing it & then drawing out the piston.
I suggested a change of the milk; & for a short time
a nurse in the neighbourhood was obtained- this was
towards the close of the case. The fits became more
severe & distressing. Leeches were twice applied to the
head, blister were placed behind the ears, etc, etc.; but all
in vain- it still grew worse. Between the fits it had
several spasms or semi-fits- it would scream out &
appear to be in pain, The attendants remarked, that they
could “hear the wind rise in his body”. At one time I
directed chicken water instead of milk in any shape;          
       
 
  
 


263
& a musk julap also used, which, at one time, appeared 
to afford relief: but notwithstanding all this, the
little lamb took its departure for heaven.
Dissection.- The intestines exhibited strong evidence of
having been under the influence of severe spasm.
More than half the small intestines were irregularly
contracted & diminished in size- their caliber being much
smaller than natural; the gall bladder contained a light
coloured glairy fluid; the heart & lungs were perfectly natural. 
I did not examine the brain, as I thought sufficient 
evidence of the cause of death was found in the
bowels. The omentum was found lying closely folded up,
in the form of a small rope: it lay on the arch of the colon.
I have given these two cases, the one successful,
the other unsuccessful, that, in the latter, you might
have an opportunity of seeing the state of things disclosed 
by dissection. In reviewing the latter case, I
propose as an improvement, a more early resort to
the lancet, instead of leeches. This would, probably, have
induced relaxation, & enabled the other remedies to act
more effectually. A blister to the abdomen might have
had a salutary influence.
I have since attended a case of this kind with Dr.
wood. I proposed the lancet- not with a view to guard
against inflammation, but to resolve spasm, & to put
the system in a condition favourable to the operation of
antispasmodics. We derived great advantage from the musk  
  
 


264
julap, laudanum, & a large blister over the abdomen.
General Principles.- If then you are called to a child
affected with epileptic fits; if the convulsions are transient, 
& are not succeeded by coma; but the child recovers 
its reason immediately after the fit, appears pert, &
looks about him as if nothing had happed; &, at the
same time, the bowels are affected with pain & acidity,
you may fairly conclude that the disease is the result of
intestinal spasm.
Indications.- In a case of the kind I have described, if it be
obstinate, you should relax spasm by V.S., or leeches & the warm
bath; evacuate the bowels by means of calomel, oil, etc.; apply
a large blister over the abdomen; correct acidity by the constant
use of the alkaline infusion; allay pain by opiates given by
the mouth, or in the form of anodyne injection; resolve spasm
by the free use of musk, oil of amber, & lac assafoetida, particularly 
the latter, administered both by the mouth & in the form
of enemata; use the oil of amber, laudanum, & sweet oil, or
garlic & brandy, externally; &, if the belly be tympanitic, extract
the platers by means of the dry syringe.
I will now mention two other cases of mixed nature.
Case of W. R’s Child.- 1st mon. 1822. I lately attended
the child of W. R. with croup. I resorted to V.S. blister
to the throat, calomel, antimonial wine, seneka, etc. The        
symptoms of croup went off, but were succeeded by strong
convulsions. On enquiring, I found the stool were very acid,
& the child evidently had pain in its bowels. I laid aside



265
all treatment for croup, gave a tea spoonful of the alkaline
infusion frequently, resorted to the warm bath, & applied
very freely to the spine & breast, a liniment composed of
oil of amber & laudanum, of each a tea spoonful, sweet
oil & brandy of each a table spoonful. Poultices of bread
& milk with the oil of amber were applied to the feet. In
addition, the lar assafoetida was given both by the mouth
& rectum, A surprising change for the better ensued, &
the child happily recovered.- How important that the
plan of treatment was changed! What would have been
the consequence, if antimonials, calomel, seneka, etc., had
been continued!
Case of Catarrh and Colic.
3 mo. 20th, 1822. While I was absent yesterday in the
country, a sucking infant of A. F. was attacked with
severe dyspnea & fever. My friend & formed pupil, Dr.
Emlen, saw it for me. He directed bleeding, a cathartic,
antimonials, etc., to subdue the inflammation. I saw the
patient with Dr. Emlen the following evening: it was then
extremely ill. On examining the case I found that the primary 
affection was removed: but the little creature, as I
listened to its language, told me that the bowels were in a
state of great pain- in fact, I saw a counterpart, almost,
of W. R’s child. The stool were green. I proposed the
same general plan of treatment, as in the preceding case,
viz, the alkaline infusion, lar assafoetida, & the liniment
used externally, etc. The result was most happy- he recovered. 
   



266
Case of Dysentery and Mania.
I have before stated that spasm of the intestines is
sometimes manifested by sympathetic affections of remote 
parts. In order to illustrate my position, I will
notice the case of J. G’s child who died under my
care. It was affected with dysenteric symptoms; &, in
the progress of the case, became delirious. But treating
it with a view to dysentery, the symptoms abated, & I supposed 
that the patient was convalescent. But soon after
the child grew worse, & became completely maniacal; so
much so that it was really distressing to see it. It showed
a disposition to snap & bite like a dog at whatever approached 
it. Under these circumstances, my attention was strongly 
directed to the head. I supposed that there must be some
serious cerebral affection to produce such a train of
symptoms. Notwithstanding all my efforts, however, my
little patient died. I obtained permission to open the body
& examine not only the brain, but also the abdomen.
There was no vestige, or if any, very slight marks indeed,
of disease of the brain. This was the conclusion of both Dr.
Hartshome & myself. But the small intestines exhibited,
at once, marks of the most violent spasm. In several
places, for an inch or two, their caliber was diminished almost 
to the size of a worm, & nearly half their length
appeared as if a tape had been tied round the gut. The
brain was sympathetically affected, & the maniacal symptoms 
arose altogether from severe spasm of the bowels.        
   



267
Reflecting on this circumstance, I recollected a fact which
occurred when I was a child. I had a favourite pup which,
on one occasion, running into  the street, was trod on by
a horse. I ran forward to snatch A from danger, &, in
the agony of the moment, it seized & bit me, its protector
& master. This I have no doubt, was the result of severe 
pain. Now the bowels are a tender & vital part,
& every spasmodic twitch is like a pinch to them, & must
cause a vast deal of pain.
Dr. Wistar related to me the case of a little girl, about
8 years of age, under this care, who continued maniacal
for 9 weeks; when all the symptoms of mania disappeared 
in consequence of a free discharge of ascarids from
the rectum. This is another proof that irritation of the
bowels may excite a sympathetic affection of the brain,
which may result in a disease operation of the mind.
Sometimes spasm of the bowels may be induced
by the introduction of improper articles into the stomach,
independent of mere flatulent food. I will read you
a case which fell under my notice in consultation with
Dr. Emlen, in the spring of the year 1821, in which death
was produced by eating an enormous quantity of orange peel.
Death from Orange Peel.
3rd mo. 13th, 1821. A.W. aged bout 16 months, a lovely
& interesting infant, was attacked about 3 o’clock yesterday 
morning, or at that time was first observed by the parents
to be unwell. She had, it appears, a hot skin & sick stom-




268
ach, & vomiting some undigested orange peel. The parents
recollected that, the preceding morning, she had picked up
the skin of an orange; & the little creature was in the habit
of devouring every thing of the kind that came in her way.
Dr. Emlen was called early in the morning. He found
her with a suffused, purple face, & a pulse so feeble as scarcely
to be felt, & too frequent for enumeration. He, very properly, 
lanced her gums; & then, after having ascertained
the fact relative to the orange peel, gave an emetic; ordered
the warm bath, sinapisms, injections, & castor oil. After
the operation of the emetic, she had three stools consisting
principally of orange peel. I was called in consultation
about 11 o’clock. The pulse was not perceptible at the
wrist; the countenance was livid; the innocent lamb was,
at times, in extreme pain, crying out in the most distressing
manner. It seemed on the borders of convulsions, tho’
they did not occur. We both suspected the bowels to be the
seat of the disease, & directed our attention to procure evacuations 
by means of oil & injections. A spiced plaster was
applied over the abdomen, & three drops of laudanum were
given by the mouth: but soon after this, death closed the
painful struggle.
Dissection.- The intestines exhibited marks of having
been affected by spasm. There were two portions of the
small intestines in a state of intus-susceptio. Dr. Harlan,
who made the dissection, opened the small intestines
with a pair of scissors from one end to the other. They
       




269
contained a large quantity of orange peel imperfectly
digested; also worms, There is strong reason to believe
that the orange peel was the cause of death.
I have now spoken of spasmodic affections of the
intestines in children; I have also spoken of the some
complaints in adults, as illustrated by cases of colica pictonum. 
But there is one interesting case among my notes
which I will read to you. It proves that adults, though
less sensible to the attacks of disease than infants, may be
effected with spasmodic complaints of the bowels, which
may gradually destroy life.
Case of Spasm of the Bowels with an Obstruction 
of the Ductus Communis Choledochus.
J. C., about 40 years of age, a very stout man,
was subject to occasional spells of violent colic which
generally terminated in a few hours; but nothing
would relieve him till he had vomited bile very copiously. 
A few days before his last confinement, he
had diarrhea, for which he took some rhubarb. He
sent for Dr. Lambert the 15th of 12th mo. I saw him on
the evening of the 16th. His pulse was very feeble, & his
whole system prostrated. His stomach rejected every
thing; he had frequent small stool; but they were
entirely destitute of bilious tinge- no bile was vomited.
Various attempts were made to relieve him; but in vain.
The secretion from the kidney was suspended for about
80 hours; but the day preceding death it returned.
       
       




270
He complained of one sore spot below the epigastric
region.
Dissection.- He small intestines were found contracted 
in several places. In some parts the diameter
was lessened, as if a piece of broad tape had been passed
round the bowels so as nearly to obliterate its cavity;
& at these points the intestine was thickened. The
colon contained a quantity of soft pasty feces. The
gall bladder was enormously distended with dark bile.
The pancreas was enlarged & hardened; & caused in
consequence, nearly a total obstruction in the ductus
communis choledochus. The pancreatic duct was
open. The liver presented a natural appearance.
The villous coat of the stomach was covered, in many
places, with patches of dark coloured blood, very similar 
to what occurs in some cases of malignant fever.
Causes.- It is probable that spasm in this case, took
place in consequence of a want of bile, resulting from a
partial obliteration of the duct. Bile is a necessary stimulus
to the intestines. Deprived of this they become debilitated.
This debility inclines to spasmodic action; & the patient is
gradually worn out by the pain he must necessarily experience. 
At first the passage through the duct was forced
by vomiting, & temporary relief was afforded: but when
the obstruction became so great as not to be overcome by the
efforts of nature, the patient gradually sunk.
     
         
       




271
Constipation.
_____x_______
Hitherto I have treated of constipation resulting from
inflammatory action as in peritonitis, or from spasm, as
in the various cases I have detailed. But I shall appropriate 
a portion of the present lecture to the consideration 
of that species of constipation which occasionally
occurs under a very obscure form, & which may be confounded 
with a disease entirely opposite, even with diarrhea.
It is a fact which I am enabled to assert
from some experience that feces may accumulate
in the colon or rectum, & there prove the source of
great irritation. The consequence of this irritation
is an increased secretion of fluids from the mucous coat
which, passing between the side of the bowel & this impacted 
mass, may be discharged per anum, & the practitioner, 
if not aware of the circumstances of the case,
may undertake by astringents to check the discharge,
when directly opposite treatment is demanded. This
affection may approach in a very insidious way. A
person may have daily evacuations from the alimentary
canal; it may happen that he will discharge a
part & retain a part, till ultimately the condition
alluded to is induced. You may easily suppose that
much pain & suffering must result; that the patient
will make great efforts to procure discharge; and
   
         
       




272
that he may have liquid ones, but without relief.
The neighbouring parts also become affected- the
pressure of the feces in the rectum may irritate the
bladder, & disease of this organ may be suspected as
the sole cause of the symptoms. The some remark
will apply to the uterine system. You will find a
description of this disease in the London Medical Observations 
& Inquiries. Dr. Fothergill relates a case of the
kind. He was called some miles out of London to visit 
a patient affected with obstinate diarrhea which had
resisted a variety of treatment. He found the patient in
great distress. Perceiving no relief followed the liquid discharges, 
his attention was directed to the cause; & he
supposed that the whole depended on the presence of impacted 
feces in the bowels. With this view he told the
apprentice of the apothecary to introduce his finger into
the rectum; & it immediately came in contact with a
mass of hardened feces. By his finger & other means
it was broken down & removed, & the patient was relieved. 
In the same volume, perhaps, you will
find an account of a lady similarly affected; but with
symptoms very obscure. At one time it was supposed
that the uterus was diseased; at another, the bladder.
Much was done, but nothing gave relief. Some
months elapsed before a practitioner was called in who
understood the nature of the case. He suspected the
presence of impacted feces; & an examination discov-
     
   
         
       




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ered them high up in the sigmoid flexure of the colon.
The mass was removed; but too late to save the patient.
I was aware of these cases in the early part of my practice; 
& it so happened that this knowledge was of great
importance to me in treating the disease. One of the
first cases which fell under my observation was that of S.
J. Some weeks after parturition, she was attacked with
great pain & distress in the abdomen. She told me that
she labored under a putrid lax; she gave it this name
on account of the fetor of the evacuations. On enquiring
into the case, & finding that she had been affected for
some time, & no relief had been experienced, I suspected 
at once the presence of hardened feces in the
bowels. At the time I was called, she was taking
opium, port wine & bark, with a view to strengthen
her & check the lax. I explained to the patient my
views of the case. She was able to comprehend them,
& fully disposed to enter on the plan of treatment proposed. 
I first directed cathartic medicine; & oil was
the article employed. It was retained by the stomach, 
& according as we had anticipated, brought away 
from the bowels a large quantity of feculent matter, 
to the indescribable relief of the patient. She told me
she suspected the mass had remained in the bowels 5 weeks;
& when it was discharged, the first evacuations were so
fetid as almost to make her faint.
About the same time, I was called to a little        
     
   
         
       




274
girl who seemed to be labouring under diarrhea.
But from the fact that no relief resulted from the
evacuation; that the irritation was still kept up;
& that so much fever was present as to require the lancet, 
I suspected the existence of accumulated feces.
Accordingly cathartics & injections were administered
till she discharged large quantities of feculent matter.
After this she recovered. Symptom of enteritis occurred,
& she required several bleedings, the warm bath, & a
Blister to the abdomen.
I have sometimes known a quantity of indurated
feces to be retained in the return without very serious
consequences. An old acquaintance applied to me in
consequence of a constipated state of the bowels. I directed
cathartic medicine: but there seemed to be some impediment 
to his evacuation. I explained to him what
I believed to be the nature of his case; & with his own
finger he broke down the mass, & relieved himself from
his complaint.
I have known this affection to occur in children. I
once had under my care a little boy who complained
of great distress in his bowels, strained very much at
stool, & passed a little blood. Finding the irritation
was kept up notwithstanding the discharges, I suspected
the presence of hardened feces. Injections were thrown
up, but they seemed to meet with some impediment.
On examination with the finger, my suspicions were
       
   
         
       




275
confirmed. By means of the finger & the handle of a
desert spoon, I succeeded in breaking down the mass
& bringing it away. Purgatives afterwards relieved him
entirely. The diet was now made soft & laxative; & he
ceased to be troubled with the complaint. In this case
constipation was probably occasioned by the use of milk,
as his diet had consisted principally of that article. I
have since had several cases which originated from the
same cause.
From these cases you may understand how necessary
it is to be on your guard, when called to patients apparently 
labouring under diarrhea; & how important to
distinguish the two complaints. There is a natural
difference in the symptoms. When I spoke of diarrhea,
I observed that the patient felt considerable uneasiness
when he went to stool; but that the discharges were
free, & relief was, in consequence, experienced. But in
the complaint now under consideration, there is great
straining & distress; the patient has liquid evacuations,
it is true, but they afford no relief.
After ascertaining the nature of the complaint the
treatment is obvious. If the mass of feces is high up
in the colon, you must depend on purgatives & injections.
Either castor oil or senna, or jalap with cream of tartar
will answer very well. If the feculent matter is in
the rectum, you may bring in the assistance of mechanical 
means. The warm bath may be used to relax, etc.          
       
   
         
       




276
There is one condition which may be confounded
with this deceptive constipation. I allude to those excoriations 
about the verge of the arms which sometimes
occur in dysentery & diarrhea. The skin in this part
is very tender, &, if excoriated, will cause extreme pain
after every effort to evacuate the bowels. The patient
may have a free discharge; & yet will remain a long
time on the close-stool, & will experience great irritation 
& distress. I have mentioned the case of a young
gentleman, about 7 miles from the city, whose family
as well as himself experienced great alarm on account
of the excessive pain which followed every attempt to
pass his feces. From the account of the patient, I was
induced to suspect excoriation; & on examination,
found it to be the case.
Nothing more is necessary in such cases than
to anoint the parts with a mixture of lard & laudanum,
or to apply a soft poultice to which laudanum may
be added. 
Dyspepsia.
____x_____
Dyspepsia may be defined to be a disease in which the stomach 
is incapacitated from digesting the food presented to it. The
consequence is that very considerable derangement of the animal
economy naturally results: because the influence of the stomach 
over the whole system is, as you are all aware, truly great.
  
 
       
   
         
       




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I shall commence with taking a view of the causes which
have the most important agency in producing the disease.
The most prominent of these, & one on which I wish particularly 
to dwell, is derived from the operations of the mind. The
influence of mind over matter is very great;  & the stomach is
often seriously affected by mental operations – many of these
have an important agency in inducing dyspepsia. Excessive
mental exertion, whether an subjects of a pleasurable or painful
nature, but particularly the latter, may be regarded as among
the most common causes of the disease. Severe study & close
confinement operate very unfavourably on the stomach. Hence
it happens that hard students are very apt to be affected with
dyspepsia. Professional men whose occupations lead to much
mental exertion, especially when they do not use much bodily 
exercise, are liable to suffer from this complaint. Physicians,
though they necessarily use considerable exercise in
attending their practice, yet suffer so much anxiety, are harrassed 
by so many cares, that they are peculiarly liable to
be affected with indigestion. Long continued depression of
mind is a cause which I have often seen to operate when it
was out of my power to afford relief. I have seen it in some
of our commercial men who had been unfortunate 
in their business. I was one day called on by a respecttable 
merchant of this city, who told me that he was affected
with a complaint in his breast, & wished to consult me on
the propriety of being bled. I soon, however, found that the
stomach & not the breast was the seat of the disease – he was
          
  
 
       
   
         
       




278
labouring under dyspepsia brought on by mental depression,
in consequence of failure in his business. Disappointment of
any kind, but particularly of the tender affections, may be
regarded as very strongly disposing to dyspepsia.
You should always remember the astonishing influence
which the mind exerts over the complaint. The practitioner
may go on dosing & dosing, till he has administered every
variety of medicine, & yet produce no benefit to his patient;
whereas, by taking a just view of the case, & examining into all
the means of relief, he may be the source of health & happiness 
to his patient, without being in the necessity of calling in
the aid of medicine.
Beside the mental affections there are many other causes 
which deserve attention. Intemperance in eating & drinking 
often induces debility of the stomach, & lays the foundation 
of obstinate dyspepsia. Sometimes indigestion from
strong drink gives rise to incurable disease. Voracious
eating, by which the food is not properly masticated, & an
extremely foul state of the mouth, owing to the presence of
a member of decayed teeth, & a neglect of the proper ablution,
may be enumerated among the causes which give rise to
dyspepsia.
Gout & rheumatism translated from muscular parts, occasionally 
take possession of the stomach, & produce all the
symptoms of indigestion. I have known cases of this complaint 
ushered in by pain in some particular part of the
body. Thus I have witnessed an attack of lumbago, which,         
  
 
       
   
         
       




279
after continuing for some time, has subjected, the stomach has
become the seat of disease, & obstinate dyspepsia ensued. The
same patient has been attacked with pain in the arm, the disappearance 
of which has been followed by an attack of indigestion. 
I have known an alternation of symptoms – the stomach 
being relieved by the occurrence of pain in some other part,
& vice versa.
No doubt there are many other causes: but I shall be content 
with those I have enumerated, referring you to book for
such as I have emitted to mention.
Dyspepsia generally commences by a depression of spirits,
which is unaccountable to the patient. He not unfrequently
complains of a since of distress & load at the stomach; sometimes 
of vertigo & pain in the head; or, as in the case of the
merchant just mentioned, the disease is referred to the chest.
But a medical man will generally discover the true seat. He
finds upon closely examining the patient, that he is affected with
uneasy sensations in his stomach after eating; that sour and
acrid eructations occasionally take place; that the bowels
are often painful in consequence of distension with flatus; &
that the evacuations are small & discoloured. Obstinate constipation 
is a frequent attendant. Sometimes the evacuations are
natural & of daily occurrence: but even in these cases they are
generally small. This fact proves that dyspepsia may exist
without any complaint of the liver; though hepatic disease has
great influence in producing the complaint – of this, however,
I shall speak more at large on some future occasion.
        
  
 
       
   
         
       




280
The tongue, in dyspepsia, is generally more or less furred, not
only in resent cases, but also in those of a chronic character.
But in some instances, & these are the worst cases, instead
of the furred tongue, we find it smooth, red, & glassy. I
have seen this occur in cases brought on by hard drinking,
which terminated fatally.
Another symptom which is an almost invariable attendant, 
is a want of action in the cutaneous vessels. Patients
with this disease, are apt to have cool skins, & are almost
always troubled with cold feet. To the latter I wish particularly 
to call your attention, as an important part of the curative 
plan is founded on it.
As the disease advances, the patient is affected with an indescribable 
distress of stomach, particularly after eating – it is
not an acute pain, but a disagreeable sensation, difficult
to define, yet perfectly understood by those who have felt it.
There is a sense of wright & distress about the region of the
epigastrium, which paralyses all the energies of the mind &
body. Along with this, eructations frequently occur; & sometimes 
spontaneous vomiting affords relief for a short time.
This discharge is often extremely sour; so much so, that I
have known the teeth as much on edge, as though the mouth
had been washed by an acid.
Some patients are very much affected with pain in the
bowels in consequence of the collection of flatters, by which they
are so distended, as to be rendered enable to discharge their
contents.      

  
 
       
   
         
       




281
Although vomiting, by throwing off the cause of offence, is,
in many cases, the only plan for obtaining immediate relief; yet
strange as it may appear, some patients obtain relief by taking
food into the stomach.
In aggravated forms of dyspepsia, the system is sometimes
very irritable; & so much arterial irritation takes places, that
the complaint is occasionally mistaken for fever. In cases of
long standing, severe palpitations of the heart are not uncommon 
attendants. Some patients are affected with a loss
of appetite, & a total indisposition for food: others, on the contrary, 
have a morbidly increased desire for food, & indulge in eating 
to excess, to their own great distress. The complaint in generally 
attended with loss of colour, & much emaciation is frequently 
the result of its long continuance.
I have met with some instances of dyspepsia in young
children. In one of these the disease was mistaken for a febrile 
condition, & treated accordingly, with nitrous powders &
antimonials. On seeing the case, & taking an account of all
the symptoms, I was convinced that he labored under dyspepsia. 
The plan of treatment was entirely changed; an invigorating 
course was substituted, & the child completely recovered.
I have stated that there is generally a tendency in the
disease to paralyze the exertions both of body & mind. This
disposition to inaction requires on the part of the patient,
strong efforts to resist it. In fact, his life frequently depends
on his determination to struggle against it. I have known
persons to give up the contest, yield to the force of the disease,
          


  
 
       
   
         
       




282
go to bed & die. I fully believe that some years ago,
such would have been my situation, had I not been
influenced by powerful motives to exertion. At one time
my friends thought me dangerously ill, & many of them
calculated certainly on my dying: happily it never entered
into my calculations that my complaint would terminate 
fatally. I was a husband & a parent, & the welfare of
a rising family depended wholly on my exertions. I recollect 
with surprise the fatigue of mind & body I underwent
at a time when all my friends thought me unfit to be
about, & were convinced that I was labouring under a
mortal disease.
Cheerful company & conversation have a most happy
influence in dissipating the distress to which dyspeptics are
subject. I have frequently when harassed by such uneasy 
feelings as I have alluded to, gone into the company
of my friends, engaged in some interesting subject of conversation, 
& forgotten, for a time, all my troubles. When the
conversation ceased, the mind returned to its former condition, 
& I again experienced all that sense of uneasiness
& distress, before so prominent.
As a consequence of dyspepsia, we often find the mind
partially deranged. Hypochondriasis is a common result;
& the most fearful apprehensions of evil are indulged by the
patient. This, however, is far from being invariably the case.
I have seen many dyspeptics without a single symptom
of hypochondriasis. I would here impress on you the vast                


  
 
       
   
         
       




283
importance of distinguishing between real & imaginary
disease. In the course of my practice, I have met with
hypochondriacs who have so accurately described certain
complaints with which they supposed themselves affected,
that I have been led to conclude that organic disease
must exist, when the mind was, in fact, the seat of the
disorder. I have known medical men to be completely
deceived, & persevere in a long & rigid course of treatment,
when the disease they were combatting existed only in the
mind of the patient. On one occasion I was consulted 
by a gentleman from the country, who was impressed
with the belief that he was labouring under very serious
& incurable disease of the omentum. He was in a state
of very great distress, & apprehended the most terrible result. 
On inquiring into the case, I found that he had
been confined for three months to his room, & had undergone 
a course of mercury. He told me he was very much
swelled, & said that the disease could be distinctly felt
through the parietics of the abdomen. On entering into an
examination, & exposing his abdomen, it presented as fine
& healthy a mass of fat as I ever saw. The whole case
was imaginary. The physician had fallen into the illusion, 
& by his plan of treatment had tended to confirm
the belief of the patient.- On another occasion a hypochondriac 
presented himself to me, laboring, as he said under 
a terrible disease of his fact. On examination, I
found that the disease was altogether imaginary; &, if
there really was any disease, it must have been of the
   


  
 
       
   
         
       




284
nature of tic doloreux. I supposed that it was a delusive 
sensation, depending altogether on disease of the
stomach. His physician, however, had been led astray
by his representations; & a practice had been established
as disagreeable to my feelings, as any that could possibly
be imagined. A seaton needle, armed with a skein of silk,
had been passed through the foot from the top of the bottom, 
between two of the metatarsal bones, & the silk was
suffered to remain! It had been in harvest times, & allowed 
to remain several weeks during the warmest part
of summer; & all this time, the patient was confined
to a rigidly low diet. It is almost a miracle that he escaped 
tetanus. The practice could be justified on no ground
whatever, & was totally irreconcilable with every sound
principle of medicine & surgery.
After an attack of dyspepsia has continued for a long
time; after various plans of treatment have been tried, &
all have proved unavailing, it not unfrequently happens 
that the stomach without any known cause, assumes 
a healthy condition, & the patient is relieved. Sometimes 
I have known the occurrence of a spontaneous bilious 
diarrhea to produce a cure of dyspepsia. In other
cases, great debility & emaciation occur, the bowels become
irritable, the tongue assumes a smooth & red appearance,
denoting an erythematous condition of the alimentary canal,
& the patient dies.
Dyspepsia is often complicated with peposis. An attack
of this complaint generally comes on in the way I shall
      
   


  
 
       
   
         
       




285
mention: after food has been taken, which proves offensive 
to the stomach; after the sensation of weight & uneasiness 
has occurred, the patient will feel a disposition to
throw off saliva. This continues to be discharged for
some time, till at length, the patient all at once feels
sensible of something resembling a spasm of the stomach.
I have in my own case been as sensible of spasmodic
action in this organ, as if I had seen it contract. As this
time there begins a free discharge of limpid fluid from
the mouth; & if the patient remain quiescent, it will run
out in a stream till it has made a little puddle on the
floor. This state of things lasts only a short time - generally 
from one to two or three minutes, & very seldom
longer than five. By this time the spasm is relaxed
& the patient relieved. The feelings of distress preceding
the water-brash frequently continue from ½ an hour to
1 or 2 hours. Occasionally I have known the contraction 
to go on so far as to produce vomiting. The matter 
discharged is generally as acid as can will be conceived.
 – Cardialgia often attends this disease.
Sometimes after dyspepsia has existed for a long
period; after the stomach has been subject to great distress, 
& the body is much emaciated, it happens that the
parts connected with this viscus become seriously diseased.
I have, in my collection of morbid anatomy, a stomach
in which the pylorus is enormously enlarged. The case
of the patient I will detail to you, & exhibit the preparation 
at a future lecture. In this instance distress of mind
     
   


  
 
       
   
         
       




286
seemed to be the principal agent in producing the disease.
I will here make a remark which falls, in part, within
the treatment to be pursued in the course of the disease. This
is to caution you, in the strongest terms, against the practice
of allowing dyspeptic patients to habituate themselves to the
use of ardent spirits in any form. Some most lamentable
cases of this kind have fallen under my observation. Patients
suffering severely from distress of stomach, & depression of mind,
are sometimes advised by their physicians to make use of
ardent spirits, with the view of obtaining relief. This practice 
has laid the foundation of a great deal of drunkenness
& subsequent misery, & has destroyed the usefulness of many
who would have otherwise been useful members of society.
I have an utter abhorrence of every thing like intoxication;
& I should even be afraid to trust myself so far as to employ 
brandy & water for my complaint. One glass affords
so much relief, & produces so great an elevation of spirits, that
the patient is most strongly tempted to repeat it, till he is, at
length, landed in habits of confirmed drunkenness. I have
seen this happen in genteel life. & to females as well as to
those of our own sex. A lady affected with dyspepsia
finding that a little Holland gin produced a very comfortable 
effect on her stomach, whenever she experienced an attack
of pain, very innocently resorted to this article. She went on
gradually increasing the dose, till at last she was in the habit
of drinking half a gallon of gin in a day! She ultimately destroyed 
herself by the practice. When I first saw her she was
in a state of infantile weakness; her circulation was ex-
       
     
   


  
 
       
   
         
       




287
ceedingly feeble & irritable, & her tongue was smooth & red.
She soon died. Before death there was an extraordinary
loss of power in the limbs. The same thing happened in the
case of a gentleman who was subject to dyspepsia & became
a victim to intemperance. At times violent pains would
attack his limbs & leave them utterly powerless. His condition 
was wretched in the extreme. At length he lost the
command over the sphincter ani, & it was necessary to employ 
diapers with him as with an infant. In another case,
that of a gentleman of this city, & much employed in
public affairs, the same thing occurred. He was led innocently 
into the practice by experiencing great relief from
small quantities of spirits; & excused himself by stating that
his physician had recommended this plan to him in
the commencement. This, however, the physician informed 
me was not the case.
I will here relate to you an anecdote told me by
Dr. Parke who when a young man pursuing his medical
studies in London, was intimately acquainted with Dr. Ino
Fothergill. Soon after he arrived in England, Dr. Fothergill
spoke to him in the highest terms of the advantages to be derived 
from the use of brandy & water in dyspepsia. Dr. Parke
resided a considerable time in London. When he was about
to return to this country, Dr. Fothergill took an opportunity
with him purposely to do away an error into which he had
led him. In the course of his practice so many of his patients 
had become habitual drunkards that he considered
it his duty to express, in the strongest term, his decided
 
   
       
     
   


  
 
       
   
         
       




288
disapprobation of the plan which he had before recommended.
Before entering on the treatment of dyspepsia, I will
take occasion to make a few observations on the importance
of distinguishing between colic arising from an accumulation 
of flatus in the bowels, in other words dyspeptic colic,
& that which depends on an inflammatory condition of the
system. A patient subject to dyspepsia is occasionally affectted 
with the most excruciating pain in the bowels. The practitioner 
called in under these circumstances, aware that little
dependence can be placed on the pulse in affections of these
parts, is apt to be led into the belief that there is a great deal
of inflammation, & that it is necessary to resort to the lancet.
If it be a case of dyspeptic colic, this practice is calculated to
do more harm than good. For, so far as my observation
has gone, dyspepsia is not a disease of high inflammatory
action; but as a general rule, depends on a diminution
of tone in the digestive system. Now in what manner
shall we distinguish the one from the other – how know
the difference between dyspeptic colic, & that arising from
an inflammatory state of the intestines? We shall generally
be able to distinguish by making inquiries as to what preceded. 
If the patient has been subject to dyspepsia, & was
at the time of attack labouring under the complaint; if he
has been repeatedly affected with severe pain in his bowels,
particularly after eating, & if this has soon disappeared
either with or without a discharge of flatus, we may very
fairly consider the case as dyspeptic colic. In enteritis, on
       
 
   
       
     
   


  
 
       
   
         
       




289
the contrary, after the disease sets in, it pretty certainly advances 
to a fatal termination, or a recovery takes place.
There are none of those sudden transitions from pain to
comparative case that you find in dyspepsia. It is important 
to distinguish between the two affections; because
bleeding which, in the one instance is the grand remedy,
in the other can do no good & might produce much
harm, especially if the case has been preceded by considerable 
debility.
I will now for a few moments, call your attention
to the physiological consideration of some parts of this
subject. You are aware that among the old physiologists 
an opinion was entertained relative to digestion, differing 
materially from that which is held by the moderns. 
It was supposed that fermentation had a great
deal to do with the digestive process. But the experiments
of Spallanzani & others dissipated this delusion, & clearly 
proved that the phenomena were all dependent on
the solvent power of the gastric liquor. Now this I firmly 
believe so far as regards the operation of the stomach
in health. But I also believe that in a state of disease
fomentation may go on, & that articles which readily undergo 
this process, if introduced into the stomach, will aggravate 
the complaint. Moreover, I am of the opinion
that the stomach itself, when in a disordered condition may
secute an acid which may be the cause of great distress
to the patient.
By consulting Spallanzani & other experimentalists you   
     
       
 
   
       
     
   


  
 
       
   
         
       




290
will find it established, that the stomach digests certain
kinds of food much more easily than others; &, as a
passing remark, I will state that, if my recollection is
correct, Spallanzani found that the aliments which
longest resisted the action of the gastric liquor, were such
as had been exposed to the operation of frying; for instance 
the crust which usually surrounds veal cullet.
In considering the treatment proper for dyspepsia,
in choosing that kind of diet which may be suitable
for the patient, it is necessary for physicians to take all
these circumstances into view. In a system of diatetic treatment, 
he would reject all such articles as are likely to pass
into the acetous fumentation. Hence one of his first directions 
to the patient would be to refrain from all fresh fruits
& vegetables, such as cabbages, turnips, beets, etc. And we rarely 
ever meet with a dyspeptic who does not inform us that
he is scarcely able to take these articles, particularly cabbage.
It is my rule to prohibit them all, without a single exception; 
I do not allow even the potato to be eaten.
There is another article of diet proper to be remembered – coffee 
generally exerts an injurious influence on the dyspeptic 
stomach; & tea also disagrees with many. The black
tea, however, is said to be less objectionable than the green.
All kinds of pastry or pye crust should be avoided. The
same remark will apply to hot cakes & hot bread, particularly 
buckwheat cakes & short-cakes. After mentioning
so may kinds of aliment to be laid aside, you will be
almost ready to inquire, - what is the patient to eat? This
     

       
 
   
       
     
   


  
 
       
   
         
       




291
will lead us to consider the kind of aliment proper for dyspeptics. 
And here I am prepared to say that as a general
rule, admitting however of some exceptions, solid animal
food, simply prepared is for more acceptable to the debilitated 
stomach than those acescent aliments just mentioned.
Hence beef, mutton, venison, poultry, etc. Should be preferred.
But as I have observed there are exceptions to this kind
of diet – I once had a patient who was rendered extremely 
uncomfortable whenever he took a small portion of
animal food in consequence of the distension by flatus
generated in his stomach & bowels. In some cases condiments 
answer very well; not only salt & pepper, but even
mustard & horse radish may be used. The last is an exception 
to the rule relative to fresh vegetable food.
In addition to these you should look out for some farinaceous 
articles which are capable of conveying nourishment 
without becoming acid. Hence the importance of
rice in dyspepsia. If boiled till it has become extremely
soft, it is in some cases will suited to the stomach. It
may be eaten with a little sugar & fresh butter. Stale bread,
bread made of unbolted flour, pretzels, & crackers, are allowable. 
The latter suit some stomachs very well, with
others they do not agree. Stale bread is decidedly preferable
to fresh & hot bread. There are other articles which answer 
very well for dyspeptics – soft boiled, or poached eggs,
are often digested easily when other aliments are rejected.
Oysters also are, in general, very suitable. But every thing
with these depends on the mode of cooking; there is no
    
     

       
 
   
       
     
   


  
 
       
   
         
       




292
article of food which is prepared more variously. They
are frequently fried, & in this state they should never be
given to a dyspeptic. Surrounded by that crust which
was found so strongly to resist the operation of the gastrick 
juice, & impregnated with a kind of empyreumatic
oil resulting from the melted butter, they must necessarily
be very indigestible. When eaten raw they are, on the contrary, 
very easy of digestion; & they should always be taken 
in this state or only slightly cooked. To raw oysters I have
heard that some object on the ground that they are living,
& as substances possessed of life cannot be acted on by
the gastric juice, they must be of difficult solution in
the stomach. This is frivolous: after being taken out
of the shell & subjected to the process of mastication, they
cannot, I think, possess so much life as to present
any obstacle to their easy digestion.
It sometimes happens that solid aliment will not
answer well in cases of dyspepsia. Under these circumstances 
I have found the essense of beef an excellent substatute. 
Taken with crackers or stale bread, it is sometimes
very acceptable to the stomach. Ham is, in some instances, 
very proper for dyspeptics.
So much for the common articles which may be selected 
from the table. Others do not occur to me at present; 
if I have omitted any they must fall under
the general rule, viz. That all those substances which are
of difficult solution in the gastric liquor, & are apt to
pass into a state of fumentation, must be avoided.
     
    
     

       
 
   
       
     
   


  
 
       
   
         
       




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These remarks apply to the meal taken at dinner. But
what may be used in the morning & evening as substitutes
for coffee & tea? – and here I would state that there is a
great variety in the stomachs of different individuals. In
searching for substitutes for coffee, we must consult the peculiarities 
of the patient himself. In some instances the rye
coffee, or even that made of barley, or wheat, when well prepared, 
with the addition of sugar & cream, will prove palatable 
& wholesome. Supposing that the stomach will not
bear this, we may resort to chocolate prepared so as to be divided 
of its oily constituents, or to milk. The latter article operates 
on some dyspeptics in the most friendly manner. For
weeks together, when affected with this disease, I have lived
almost exclusively on milk, & have found it very acceptable. 
Lime water & milk will be found a good substitute
for coffee & tea. I have drunk gallons of this article. But
substances which agree well at one time are inadmissible 
at another, & hence it is sometimes necessary to lay
aside milk. In such cases we may often resort with advantage 
to cream. Milk, you know, is composed of three
parts – the serous or whey, the caseous or cheese, & the oleaginous 
or cream. Hence the stomach in digesting milk
acts on a considerable quantity of curdy matter which is
very difficult of solution in the gastric juice. Cream, in a 
great measure, is free from this, & will therefore answer
in some instances where milk is found to disagree. If
neither milk nor cream should prove acceptable to the
stomach, a breakfast of eggs prepared as I shall mention
         
    
     

       
 
   
       
     
   


  
 
       
   
         
       




294
may be prescribe with advantage. I have often recommendded 
the yolks to be beaten up with loaf sugar & warm water, 
with the addition of ginger or a plenty of nutmeg, & taken 
as the morning meal. The water should not be boiling
hot, as in that case, it is apt to curdle the egg.
A good deal has been said about the proper kind of food;
a question now arises. – What articles are suitable as drink
to persons afflicted with dyspepsia? After much experience
I have come to the conclusion, that no fluid is so proper,
especially at meal times, as pure water taken in moderate
quantities. It should never be swallowed in large draughts;
as, in this case, it will often prove injurious.
The stomach will frequently be affected between meats,
particularly soon after eating, with those sensations extreme
distress to which I have before called your attention. To such
cases I have found the ginger tea admirably well adapted 
as a drink. It is calculated to impart a genial warmth
to the stomach, & is perfectly in offensive as regards both the
body & the mind. As to spirituous liquors, I have already 
expressed my opinion; that though they generally
yield a temporary relief, yet their consequences are so
much to be dreaded – the patient who begins to use them
is so apt to be landed in habits of confirmed drunkenness,
that they should be entirely proscribed in dyspepsia.
If stimulating drink is absolutely necessary, unquestionably
the best is sound old Madeira wine. It should be however, 
of the very best quality. The common low wines, by becoming 
acid, are calculated to disorder the stomach.
  
         
    
     

       
 
   
       
     
   


  
 
       
   
         
       




295
So much for the food & drink proper for patients with
this complaint. But the dietetic plan constitutes only a
part of the necessary treatment. There are other views which
must be taken, & to these I now proceed to call your attention.
I have before spoken of the state of the surface in dyspepsia. 
It frequently happens that a collapse of the surface
takes place, indicated by the pallid countenance, the cool
skin, & particularly by cold feet. The last is a very general 
symptom. To restore atrion to the extremities is of the
utmost importance in the cure of this disease. For this
purpose I will mention to you a very simple & yet efficacious 
plan, for the introduction of which, so far as I
know, we are indebted to Dr. Physick. The patient is to wear
under his stockings, socks of flannel which are to be well
powdered daily with red pepper. I have seen much good
result from this simple remedy. But it frequently happens,
when the patient has been long subjected to cold feet, that
the skin to brought into such a state of collapse that the
Cayenne pepper is unable to take hold, & the desired effect is
not produced, even though the application may be continued
for a considerable time. In such cases, I direct the feet to
be immersed every day in warm water, rendered more
stimulating by the addition of mustard, salt, or some other
article calculated to produce excitement. The feet when
taken out, are to be wiped dry, & the Cayenne peppered socks
are then to be applied. This plan seldom fails to bring about 
a genial warmth in the feet.

  
         
    
     

       
 
   
       
     
   


  
 
       
   
         
       




296
In addition to this, if there appears to be a want, if there
appears to be a want of action, a coolness of the whole surface, 
I have been in the habit of directing frictions with
fine salt over the whole body, till considerable cutaneous
excitement is produced. In the case of a lady subject to dyspepsia, 
in whom debility amounted almost to atrophy, I have
derived much advantage from the daily use of the tepid salt
bath. It was used by her during one whole winter, & both in
her opinion & my own, with a salutary effect. The salt bath
I have frequently recommended.
There are other modes of bringing about heat & action in the
surface of the body. Certain kinds of exercise, by giving an
impulse to the circulation, & determining to the skin are
very important for this purpose. Jumping the rope is an
excellent practice: but what for females is still better,
since it unites usefulness with health, is the habit of rubbing 
furniture. In the houses of our wealthy citizens,
where I am in the habit of attending, I often select some
particular article of furniture, & till my female patient
that I expect to see it kept bright by her own hand. This
practice is very useful when you wish to excite heat &
action in the skin. Riding on horseback also proves very
beneficial. But it is of the utmost importance rightly
to time exercise – to know when to be still, & when in action. 
The physician by an indiscreet recommendation
of exercise, without reference to the time of using it, may
do a great dial of harm. I lay it down as a general
rule in dyspepsia; that muscular exertion has consider-
 
     

  
         
    
     

       
 
   
       
     
   


  
 
       
   
         
       




297
able influence in retarding the digestive process in persons of delicate
habits. Hence, when you have to manage a system which requires a
concentration of all its energies in the stomach for digestion, you
should be very careful how you recommend exercise & muscular
exertion after eating. – I will mention an experiment which illustrates 
very strongly the position I have laid down. Two hounds
were both fed with a plentiful meal. One of them was allowed
to indulge his natural inclination of lounging about the house
& sleeping; the other was taken out on a hunt. After a certain
time had elapsed, both were killed. The one which had remained 
quiet had digested his food; in the other it was found that
the digestive process had been suspended. Now from this
fact, we may draw some very important practical inferences
in the management of dyspepsia. You see all at once the
propriety of advising to rest after eating, especially after dinner.
I am not disposed to recommend the habit of invariably retiring
to bed & taking an afternoon nap. This I conceive to be a bad
habit, especially for young people. But great advantage certainly 
results from remaining at rest for a short time. I know
from my own experience that if called to use much exertion
after a meal, when under the influence of dyspepsia, there
will be much distress & the stomach will be very likely to
discharge its contents. Always, therefore, keep this fact in view
when you prescribe for indigestion.
It sometimes happens that dyspeptic patients who, through
the day, are in the habit of using much exercise & of throwing 
off their food from the stomach, will nevertheless retain
the meal taken just before retiring to bed. For persons in
  

 
     

  
         
    
     

       
 
   
       
     
   


  
 
       
   
         
       




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full health, supper is an unnecessary meal, & in preshow
cases, there is some reason to suppose that it has laid the
foundation for apoplexy. But with dyspeptic patients who
are apt to vomit their food, I do know that supper is often 
a useful meal, & is apt to be better digested than any
other. I recollect the time, some years ago, when I was
very much afflicted in this way, & supper was almost the
only meal which was so far digested as to carry nutriment
into the system. The supper I have generally resorted to consist
either of eggs slightly done, or of oysters, sometimes raw, some-
times warmed in the shell, or stewed a little. There are, I
know, some patients with whom suppers totally disagree.
But this is not the only case in which we find exceptions to
general rules in dyspepsia: for the stomach is exceedingly
capricious & often sets rules at defiance.
Now, the digestion of the dyspeptic is specifically different
from that of a hard labouring man. The kind of food suited 
to the formed, the latter, particularly when compelled to use
more than a common proportion of exercise, would generally
dislike. The labourer requires strong aliment – something that
will keep his stomach employed, something that he can
feel. To support him under powerful exercise an appropriate 
stimulus to the stomach seems to be necessary.
Having said thus much relative to exercise. I will pass
on to the consideration of another subject. In the commencement 
I told you that causes operating on the mind, and
particularly those which occasion a state of mental anxiety,
contribute greatly to increase the distress of dyspeptics, & may
     
   

 
     

  
         
    
     

       
 
   
       
     
   


  
 
       
   
         
       




299
sometimes be regarded as giving origin to the disease; that in
some cases the causes are entirely beyond our control; and
that in others we can do much towards soothing the mind
& inducing a train of pleasant thoughts. Hence the advantage 
of travelling. By the change of scene & the variety 
of occurrences the mind is called off from its attention
to those objects which have a tendency to depress it, and to
aggravate the complaint. But merely to travel is only accomplishing 
half the descried object. When you advise a
patient to take a journey, you should not be content with
merely sending him forth to travel hither & thither, with
no other end in view than simply exercise. He should be
advised to make a journey to the sea shore, which I highly recommend; 
or directed to some mineral spring, & impressed
with the belief that the waters will be very advantageous to
his health. I am inclined to believe that the change of
scene, relaxation of mind, & the pleasures of society, have
as much to do as the waters themselves, at most of our
summer resorts. Some of the spring, however, are to be
excepted. The waters of Ballston & Saratoga are highly
charged with a number of medicinal articles. They frequently 
operate as a cathartic, & in this way prove useful in many
cases. They are also chalybeate & impregnated with carbonic
acid gas; & on both these accounts are well calculated to
given tone to the debilitated stomach.
As the bowels are very apt to be in an irregular state
in dyspeptic cases, it is a point of the utmost consequence
to attend particularly to restoring them to a proper condition.
   
     
   

 
     

  
         
    
     

       
 
   
       
     
   


  
 
       
   
         
       




300
In the commencement of an attack, when the patient has
a good deal of vigour, much advantage may result from
taking cathartic medicine, so as to keep up moderate purging
several times a week. But in cases of a chronic character,
it becomes absolutely necessary to put the bowels into a proper 
state. How is this to be done? Is medicine always
necessary? If they can be kept regular without resorting
to medicine; we should certainly not employ it. By regular 
habits much may be accomplished. The dyspeptic should
habituate himself to go to the privy every morning whether
he has a call or not. In this way the habit of daily evacuations 
may be established; & at length the bowels will
feel as uncomfortable if the custom be neglected, as from
the infraction of any other habit. Sometimes, however, this
plan is insufficient, & medicine must occasionally be taken. 
Standing first on the list as combining both a cathartic 
& tonic power, is undoubtedly rhubarb. This may
be taken in several ways. The best plan is to take several
simple rhubarb pills every night at bed time, so as to procure 
one or two evacuations in the day. Some patients
prefer chewing the root; others again like it best in the pulverized 
state; & in this respect the taste of the patient may
be consulted. But care must be taken, even in the use of
rhubarb; for the bowels may become so habituated to it, as to
be unable to do without it. An old lady whom I attended
at times for several years, informed me in her last illness
that for 30 years she has been accustomed to take a dose of
rhubarb every night; & the practice was continued till within
   
   
     
   

 
     

  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




301
two or three days of her death. So strongly was the habit fixed
that it was one of the last given up. She was between 70 & 80 years
of age.
Other articles may be advantageously combined with rhubarb.
The addition of a little soda in the state of sub carbonate, is sometimes 
useful. I have used with much advantage pills made
in the following manner:
Take Rhubarb.
Subcarb. Soda exsice aa 3½
Saponis -  gr s. M. f. pil. XX.
Instead of this, some patients will bear very well a combination 
of alou & rhubarb with a little calomel.
Take Alou
Rhubarb
Sulcarb. Soda exsice. aa 3ij
Calomel -   -    -    gr X
Oil caraway -   -    gut X
Extract Gentian. G. s. M. f. pil. XL.
This is one of the best formula for compound purgative pills
that you can resort to. I will mention another formula.
Take Alou
Rhubarb aa – 3i
Gamboge    gr V
Oil of caraway, gut. X
Mix and divide the mass into twenty pills, two of which
may be taken at once & repeated as often as circumstances
seem to require. The following formula may also answer
very well:
     
   

 
     

  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




302
R. Sal cinchonin, 3½
Sul carl. Soda, exsic. 3i
Capsicum 
Caryoph.
Aloc soc.    aa  gr.X.  M. f. pil. XX.
Two of these pills may be taken three times a day. you
may, in some cases, advantageously use the following:
R. Sal cinchonin. 3ij
Sulphas Ferri exic.
Capsicum aa 3i.
Caryoph. – grX M. f. pil. XX.
In some dyspeptic cases I have found the discharge very 
small & very dark. Here, before putting the patient on
any important treatment, it is right to bring about a change
in the bilious secretions; & for this purpose the plan of Ayre answers 
very well. This is to give calomel in small doses frequently repeated, 
say 1/6 of a grain every half hour, till two grains
have been taken, & next day a little rhubarb, & so on. This
will generally correct the disordered action of the liver, to produce 
yellow & more copious stools, & thus pave the way for the
administration of remedies to act on the stomach. So much for
the bowels. – I ought to mention, however, that some stomachs
will not bear medicine or food. In these cases the nitro - muriatic 
acid bath may be used as a pediluvium, or with frictions
over the region of the liver.
I have told you heretofore that in many cases of dyspepsia 
there is great acidity of stomach accompanied with a


  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




303
feeling of indescribable distress, to be conceived only by
those who have experienced it. To remove this sensation
many persons are in the habit of resorting to spirituous liquors
which generally yield some temporary relief. You already know
how highly I disapprove of this practice. I now wish to call your
attention to such remedies as will give relief without any danger 
to the morals. Various antacids are useful for this purpose. 
You are well aware that both the vegetable & mineral
alkalis have the effect of correcting acid. The same may be
said of the volatile alkali. Magnesia also has a happy effect
in this way. To neutralize the acid of the stomach, & at the
same time to operate on the bowels, this medicine may be
used with great advantage. The calcined magnesia may be
given in the dose of a tea spoonful at a time. A very handsome 
preparation of this article is what is called Cullen’s
liquid magnesia. This is generally acceptable to the stomach
& has a very happy effect as an antacid & laxative. To answer 
the same end. I would highly recommend the Seidlitz 
powders. These are prepared by our apothecaries in
imitation of the celebrated Seidlitz waters of Germany. One
of these powders taken an hour after dinner, when the
stomach is greatly distressed & the bowels are bound, will
often prove beneficial. But magnesia & Seidlitz powders 
are to be taken only when catharsis is desirable – sometimes 
this is not demanded; & then we have reference to
those antacids which do not affect the bowels. At the head
of the list, I would recommend the salt of tartar properly
     


  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




304
blended with the aromatic spirit of ammonia. In my
own case, I have never found any thing so effectual in
dissipating the uneasiness produced by acid in the stommach. 
I generally take from 10 to 20 grains of salt of tartar 
& add 15, 20, or 30 drops of the aromatic spirit of ammonia, 
& mix these with two table spoonful of cinnamon 
water, or simple water. I will give you a convenient 
formula for administering the medicine.
R. Sarb barb. Patass.
Sp. ammo. Vol.   aa 3 ij
Ague cinnamo.    -  z iv
From a dessert to a table spoonful of this may be put
into a wine glassful of water & taken at a dose.
In addition to these I will mention a remedy which
certainly deserves consideration, & which goes to show that
medical men should not too hastily despise an article
because it emenates from a source they may be inclined
to treat with contempt. Dr. Rush used to advise us in
his lectures to habituate ourselves to converse with nurses
& old women, as we might derive from them many
useful practical hints. Many years ago, in Bucks
county, there was an old farmer who united with his
business that of an empiric, & became remarkable for
his success in the cure of colic; so much so, that he was
sent for by all the country around him. The medicine
he employed was for a long time unknown. At last it
was found to be a preparation of hickory ashes and soot. 



  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




305
One of first cases I recollect of hearing in which this remedy 
was tried, was related to me by the late Dr. Woollens – it was
that of his mother. She was subject to attacks of colick, & in one
instance many remedies had been tried without effect, till this
article was resorted to. It produced the desired effect. Dr. Woollens 
mentioned it to Dr. Physick when he was under the influence 
of dyspepsia, who immediately seized hold of it, & was very
much pleased with its influence in his own case.
I direct it to be prepared in the following manner: One
quart of fresh burnt hickory ashes & a small tea cupful of soot
are to be mixed together & water gradually added till 3 quarts
have been used. I then direct it to stand for 48 hours. It
may then be decanted into bottles & corked up. The dose is a
small wine glassful 3 times a day; to be taken after eating.
If too strong, it may del diluted with water, so that the patient
may take for a dose a wine glassful of such a strength as may
be agreeable to him. In some cases of dyspepsia, this remedy
produces the most happy result. I have seen it effect a cure
of itself, when other methods of treatment had failed. A gentleman 
sent hither from Barbadoes on account of his health,
came under my care with this disease. His stomach was very
much troubled with acid. I placed him on the use of the alkaline 
infusion with a proper diet, & in a short time he recovered. 
So much was he pleased with the remedy that,[cross out]
he selected a quantity of hickory wood which he took
with him to the West Jordies.
There is an article which, at one time, acquired considerable
reputation for the relief of dyspepsia, especially when accompa-

  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




306
nied with acidity of stomach: I allude to the white oxide (subnitrate) 
of bismuth. I have no doubt that cases have occurred
which justify the high character given to it. But there are many 
in which it will not succeed. I have not had much experience 
with it: but in two cases which occurred to me, it, certainly 
seemed to produce some benefit. One patient had been
subject to intemperate habits, & was affected with great acidity
of stomach. I have known it used by a lady of my acquaintance, 
who for some time derived evident benefit from it.
Ultimately, however, as is generally the case with such articles, it
lost its effect & was laid aside.
In some cases where the stomach has lost its tone & the apetite 
is considerably impaired, I believe that advantage may
result from the use of some vegetable tonicks, as quassia, gentian, 
columbo, etc. Quassia is one of the best. I frequently prescribe 
it in cold infusion – half an ounce of the shavings to a
quart of water: some bitter orange peel may be added to improve 
the taste. After it has stood a sufficient time, the liquid
is to be duanted, & used in the dose of a wine glassful several
times a day. Dr. Wistar was in the habit of employing the extract 
of quassia. This is a handsome preparation, & from the
smallness of its bulk, may be conveniently administered in
the form of pill.
The chalybeate preparations may be resorted to when the stomach 
is week, & there is no inclination for food. Dr. Rush’s celebrated 
tonic powder was made of gr V of the rubigo ferri, gr X
of powdered columbo, & gr X of ginger. This is very useful in
debility of the stomach. There is a gentleman in this city,
     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




307
who entertains the belief that iron in a state of purity, has a
much better effect on the stomach, than any of its chemical preparations. 
I have occasionally employed it in the shape of filings,
& in one case it evidently had a salutary influence.
When there is great languor of the stomach & a disposition
to pain & uneasiness, I have occasionally prescribed with advantge 
aromatics in the form of pill.
Take Nutmeg
Mace
Cayenne pepper aa 3i
Conserve of roses g.s.
Mix & divide the mass into twenty pills, two or three of which
may be taken for a dose.
When the stomach is very irritable, & there is great diffaculty 
of retaining the aliment, the spiced plaster, made as I
have before told you (see   ) may be applied with considerable 
benefit. But there are some cases, (happily, they are
few) in which the stomach becomes so exceedingly irritable that
no aliment of any kind can be retained. Dr. Wistar in his lectures
used to mention a case of this kind, where there was great danger
that the patient would die from inanition. After exhausting all
the remedies which his judgement suggested, as applicable to the
case, without any advantage, he determined to let the stomach
entirely alone & to nourish the patient altogether by nutritious
injections. For nearly 3 weeks, the patient was sustained in this
way. Rick animal soups, without seasoning of any kind, (as
this by stimulating the rectum might cause them to be rejected,)
were thrown up several times a day. Thus the system was
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




308
nourished & the stomach allowed to rest till it had recruited
its powers & become able to retain the food introduced into it.
I have in a few cases irritated this practice; but though some
advantage resulted, I have never been so successful as Dr. Wistar 
was in the instance just related.
I might mention a great variety of other articles which are
employed in dyspepsia with more or less advantage; but it is
foreign from the design of these lectures to enumerate them all.
Before leaving the subject of idiopathic dyspepsia, & taking
up the consideration of the disease as connected with others, I wish
to call your attention to a subject exceedingly interesting: I allude 
to the caprices or vagaries of the stomach. I shall commence 
by saying a few words, relative to the language of this
organ. When treating of cholera infantum, you may recollect 
that I called your attention to the language of infants,
long before they had learned to converse by words. I mentioned 
that mothers & nurses who have such frequent opportunities 
of studying this language, acquire a better knowledge 
of the diseases of infancy, than is frequently possessed by
the experienced practitioner. In the same way the stomach 
has the power of expressing itself; & the physician who
wishes to become successful in the treatment of its diseases,
must pay attention to its language. It not unfrequently happens 
that patients labouring under dyspepsia have been led
through a long continued & systematic course of practice,
such as I have pointed out, & the physician after attending
them for months, finds that the disease continues unabated.
This is certainly mortifying. It may happen that anxious
     
    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




309
to gain his object, he may still preserve, & restrict his patients
to a rigid plan of diet; still, perhaps, he does not succeed. At
last the patient will inform him that he has felt a very strong
propensity for a particular kind of food. Dr., he often asks,
may I not eat this? By no means, is the reply – you will
certainly be injured if you do. The patient is disposed to submit; 
but still the stomach calls aloud for the article, till it
becomes impossible any longer to resist it. Frequently, however, 
we have false desires which may very properly be called
the spurious language of the stomach. A patient who has
long been sick, becomes fretful & uneasy, & seeing others enjoying 
themselves around him, without being able to participate 
in their pleasures, sets himself about searching for
some kind of food that may suit him. One article after
another becomes the object of his unsteady wishes, & perhaps
he may call for several in a single hour. This is the spurious 
language of the stomach, & is rarely attended to without
disadvantage. But when a strong propensity arises for some
particular article, for which no reason can be offered; when this
propensity is fixed & long continued, resisting every conviction
of what is proper or correct, & almost compelling the patient to
yield to it, we may then conclude that the stomach speaks
in the true dialect, & we should always obey its dictates.
Articles which at one time suit the stomach, at others will
not remain on it. Thus I have known a patient who for
some time lived exclusively on beef – he used it morning,
noon, & night; & it was the only substance which was not
rejected after eating. At last, however, the stomach revolted
    
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




310
& what had before been acceptable to it, now proves as certainly 
emetic as ipecacuanha. The same remark applies to
other articles. I have known milk for two or three weeks together
to be used to the exclusion of all other kinds of food; yet at
length it became disagreeable & could no longer be used with
comfort. Hence, when the stomach calls for certain articles, 
let the physician remember that they should not be
too long continued – they should be persisted in no longer
than they are found to be acceptable.
A gentleman in this city was, many years ago, attended
by Dr.   a very respectable practitioner, now deceased. I
have heard the Dr. Relate the anecdote, & the gentleman having 
since become a patient of mine, has confirmed the account. 
He was affected with dyspepsia accompanied with
great acidity of stomach. The Dr. led him through a long
course of antacid medicines, & subjected him to a very rigid
treatment. But after he had been attending him for 3 months,
the patient was no better. At length the stomach spoke, and
its language was irresistible. It called for pickles & vinegas – 
the very articles which, under ordinary circumstances,
would have been considered most injurious. He was compelled 
by this apparently morbid inclination to break thro’
the medical regulations. He soon found that the language 
was correct; & by persisting in the use of pickles
& vinegar, in a short time he recovered from the disease.
This anecdote was related at a meeting of the College of
Physicians, & gave rise to another of the same nature.
Dr. Henson mentioned the case of a lady who recovered
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




311
from dyspepsia in consequence of indulging in the use of
strong fat pork & Indian dumplings; two articles as little
likely to be recommended for this disease, as any two that
could be selected from the whole list of aliments.
Many instances of this kind might be cited, where the
stomach has called for a change of treatment, & where the call
has been advantageously obeyed. The great danger is for mistaking 
the spurious dialect for the true language. In the
one case the patient is constantly wavering in his desires,
in the other a fixed & unalterable propensity arises for a certain
thing, without which it seems impossible to satisfy the stomach.
With a knowledge of this fact, the physician will often succeed 
when others have failed. Hence, in my own practice,
after leading the patient through a regular course of treatment,
such as has been mentioned, & finding it unsuccessful, I attend 
to the language of the stomach. I even go so far as
to impress on the patient the importance of attending himself 
to his desires, & of endeavouring to discover whether there
is some prominent article for which he has a fixed propensity; 
& though this may seem improper, yet I encourage
him to give it a trial.
Among the vagaries of the stomach, it may be mentioned, 
that, on some occasions, articles which you would
suppose calculated to increase acidity, will in fact, correct
the unpleasant sensations arising from this course. I have
known purified sugar in the form for example, of sugar candy, 
to be taken by dyspeptics affected by acidity of stomach,
with striking advantage. Similar benefit has resulted in
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




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some instances from other saccharine articles, as the different
kinds of jellies. One of these, the guava jelly from the West
Indies, is admirable well suited to the dyspeptic stomach. On
some occasions I have found it to be well adapted to my own
case; on others, it has been rejected. I was once passing up
the river Delaware, & my stomach was in a condition to reject 
every thing offered to it – when I felt a strong desire for
a glass of lemonade. I gratified the desire, & was pleased to
find that all the unpleasant sensations were removed. Hence,
you may lay it down as a rule in practice, whenever a
patient labours under dyspepsia, after trying a systematic
course of treatment & finding it unavailing, you should let
the stomach speak, & you will often be gratified with the result.
Instruct the patient to avoid if possible the habit of vomiting 
his food. When the stomach becomes irritable & very generally 
rejects whatever is introduced into it, the habit may
become so fixed, that it shall look as regularly every day
for vomiting after eating, as the bowels do for their daily
evacuation. You should inculcate the necessity of overcomeing 
if possible, this disposition; & such advise to the patient
is the more necessary as he is apt to encourage the stomach
in throwing off the food, on account of the great relief which
he thus experiences. I will venture to assert that the patient 
may do a great deal in overcoming this propensity to
vomit. Sometimes you will find that it cannot be restrained; 
but at others, the mind has considerable control over
this viscus. I have been placed in situations where I have
felt a disposition to vomit, & might have done so with the
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




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greatest case, & yet I have restrained it for hours, till at
last it disappeared.
Some patients have lazy stomach which will grumble 
& growl all the time they are at work; yet, if you
Keep them to it, they will finally accomplish their task
& digest food.
With regard to medicinal articles too, which are apt
to produce nausea, I have some experience. I was convalescent 
from an attack of bilious fever, when Dr. Wistar 
& Griffitts who attended me, thought it important
that I should take Peruvian back. My stomach nauseated 
at the idea: but I was determined to overcome
this feeling, & to retain the medicine if possible. I tried
it, & was successful.
Before closing the subject, I will make a few remarks 
on a description of dyspepsia which has occasionally 
fallen under my notice, & has invariably proved
fatal. It occurs generally in elderly people, between
50 & 60 years of age, & attacks the temperate as well as
those of different habits. Suppose a man of this age, who
has lived temperately, & has hitherto enjoyed good health,
begins to lose his colour, grow thin, & to show a disposetion 
to break. The stomach becomes affected with dyspepsia; 
the patient has no appetite, & if he takes food it is
apt to be rejected. The bowels are often irritable, though
they are sometimes constipated. At last comes the red,
smooth tongue. This is always a bad sign in dyspepsia,
as it indicates an erythematous condition of the whole ali-
         
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




314
mentary canal, which it is difficult to correct. The patient, 
however, still keeps about; though he is very
pale & much emaciated or bloated. The lips lose their colour,
& the ears assume a deadly whiteness. The same is the
case with the hand; & sometimes I have observed a thickening 
& chalky appearance about the roots of the nails.
The patient gradually becomes weaker; his lips swell;
he totally loathes food, & at last sinks into the grave.
I have seen several cases of this kind, & have treated
them variously; but they have all proved fatal. I
have attempted to attend to the language of the stomach;
but it seemed as if this organ, having done its days work,
had become dumb, & spoke out. The complaint is more
common in males than in females; I have, however, occasionally 
seen it in woman.
As somewhat connected with this subject. I will
here relate a case of which I made a note at the time
of its occurrence.
1807, 7th mo.
Case of Scirrhus of the Stomach & Mesentery.
In company with my friends, Drs. S. P. Griffitts,
& S. Duffild, I examined the body of James Bright
who died of atrophy. He had previously been attended
for some time by Dr. Griffitts. He had experienced
great pain, which he always referred to the epigastric region. 
During his life, a very hard tumour could readily 
be perceived by pressure on the part. He had diarrhea
& frequent vomiting. There were several conjectures rel-
 
         
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




315
ative to the nature of the disease. It was uncertain whether
the tumour was an enlarged lobe of the liver, a diseased portion 
of omentum, or, as a French physician conjectured,
an enlarged spleen.
On opening the abdomen, we discovered the tumour to
be the pylorus, enlarged beyond what any one could have
supposed. The disease extended along the stomach, particularly 
its lesser curvature, & the coats were very much thickened. 
On laying open this viscus, a large tumour was found
on the internal coat, near the value of the pylorus – it was
equal in size to a small hen’s egg. The mesenteric gland
seemed to have united in one uniform mass of disease. It
was concluded they were enlarged 20 times their natural
size. Hence, we were not astonished at the man’s death;
but we were at a loss to conjecture how life could have
been supported so long as it was, under such distressing
circumstances.
I will now consider dyspepsia as connected with some
other diseases. – And here let me remark that in the work
of Wilson Philip, we read of dyspepsia as an inflammatory
disease; & a systematic description of its regular [cross out]
stages, changes of structure by inflammation, etc. etc. This
seems to be the fashionable doctrine of the day in England.
We hear of bleeding to reduce inflammation, etc.
I have no objection to leeches or cups – let them be tried.
But I am much more inclined to regard dyspepsia
as a disease depending, generally, on the want of due nervous 
excitement; & the disorder of the system, a state of irri-
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




316
tation, instead of inflammation. The experiments of Baron 
on rabbits go to show the power of the nerves in digestion.
The first disease which I shall notice as connected with
indigestion, is hepatitis. I related to you, in the early part
of my observations on dyspepsia, that I believed it might
occur as an idiopathic disease, while the functions of the liver 
are regularly performed. But the fact is well known to
every practitioner that the two diseases are sometimes closely 
connected. When we meet with them both affecting the
system at the same time, it is evident that the practitioner
should direct his principal attention to that which involves
the patient in the most immediate danger. Under this view
of the case, the hepatic affection must be first attended to.
If you should be called to a patient affected not only with
the symptoms of dyspepsia, but, super added to these, with
pain & uneasiness in the region of the liver, & with pain
darting to the shoulder; if, at the same time, he should
be unable to lie on his left side without inducing uneasiness 
in the right, you may conclude that he is affected
with hepatitis, & that the dyspepsia is probably sympathetic.
Having ascertained the existence of inflammation of the liver,
your views must now be directed to this as the primary
affection. Hence, it will happen that a course of practice
will be adopted, which would not be required for idiopathic
dyspepsia. It sometimes happens that there is so much
vascular action, that depletion becomes absolutely necessary,
& even the lancet may be advantageously resorted to. But
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




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the main remedy resorted to with a view to its general operation 
on the system, that can be depended on, is the judicious 
use of mercury. I have seen this remedy resorted to
with a view to its general operation on the system, with
great benefit, in hepatic dyspepsia. I recollect an instance
which, within a few years, has fallen under my observation,
where there was disease of the stomach accompanied with
an affection of the liver, & complicated with symptoms of
dropsical effusion, both in the abdomen & cellular mean-
brane; & yet by a proper regulation of the diet, with a cautions 
use of mercury, & afterwards by sending the patient on
a journey, there was a removal of all the unpleasant symptoms, 
& a perfect recovery established. In a late case, that
of Dr. Harlan, there was an example of hepatitis combined
with dyspepsia. Many of you know that the Dr. some
years ago, took a voyage to India. Soon after they set sail
for home, he was attacked with the fever of India, & became
ill on his passage. I am induced to believe that ever since,
he has been more or less affected with hepatic disease.
Lately his mind & body have both been much fatigued. He
has been engaged in a course of experiments on absorption, to
which he devoted several hours in the day amid the putrid
effluvia arising from dissected animals & nauseating tubs, in
warm weather. The result was an attack of dyspepsia; and
we soon saw that his old enemy, hepatitis, had not let go its
hold on his system. There was considerable fever, & for this
V.S. & a low diet were at first prescribed. But the only
remedy which ultimately proved effectual was mercury.
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




318
This urged to salivation, did away the dangerous & unpleasant 
symptoms; & he has since enjoyed very good health.
I should spoken under the head of dyspepsia, of cardialgra or
heartburn. It is a painful burning sensation, arising principally 
from accumulations of acid in the stomach blended
with the biliary secretion; & is to be relieved by those remedies 
which I have before mentioned as useful in correcting
acidity.
Dyspepsia may also be connected with gout & rheumatism; 
which may be transferred from muscular or external 
parts to the stomach. If the gout or rheumatism
be located in a safe part, as the extremities for instance,
even though the patient should be subjected to great pain,
yet you should be careful not to attempt, by local applications, 
to remove the disease. For by so doing you increase
the risk of a far qreater evil – you subject the patient to the
danger of a translation of disease to the internal organs, particularly 
the stomach. When the patient is at all subject
to translation of the disease, & complains to you of pain in some
external part, content yourselves with applying cotton or carded wool,
 & by no means attempt to remove it by severe
applications. But if you have ascertained the existence of
dyspepsia from translated gout or rheumatism, you should
pursue the plan of counter irritation. Endeavour by Cayenne
pepper, mustard, or other stimulants to the feet, to procure a
revulsion to that part. In addition, the internal remedies
which prove effectual in gout & rheumatism should be
employed; & one which I have found particularly advan-

     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




319
tageous, is the volatile tincture of guaiacum. A tea spoonful
of this may be taken 3 or 4 times a day in a wine glassful
of new milk, which I have found to be the most convenient
vehicle. It sheaths the acrimony of the medicine, & generally 
proves acceptable to the stomach.
Diseases of the Thoracic Viscera.
_______________ ________________

Phthisis Pulmonalis.

The study of this disease is most interesting to us all,
in as much as so large a portion of our species annually fall
victims to its violence; offering a melancholy proof that it
is still to be regarded as the opprobrium medicorum, & that
the practice hitherto pursued for the purpose of arresting its
progress, in a large proportion of cases, is inefficient, if not
injurious.
Consumption is a disease generally confined to early & middle 
life, though I have seen it in old age. I attended a marked 
case, which terminated in death, in an old lady 70 years of
age: but such instances are rare. We also see the same disease 
in tender infancy. Many a case of pulmonary consumption 
in children, has passed under the name of worms.
If I were to attempt a condensed description of this disease,
I should say that it is a complaint of the lungs attended
           

     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




320
with hectic fever; that the pulmonary affection terminates
at length in suppuration & purulent expectoration, and
death ensues.
The disease is generally hereditary. This is fact so thoroughly 
established, that I believe it is beyond all doubt.
The knowledge of this fact is interesting to us when called to
patients labouring under the disease. Because hereditary
consumption is much more to be dreaded, than the disease accidentally 
induced. But though it is hereditary, yet it is
a fact with which you ought to be acquainted, that it does
not always pass in a direct line from one generation to
the next. On the contrary, we have instances of one generation
escaping, & the succeeding affected with the complaint in its
full force. Thus, I am intimately acquainted with a family, 
some of whose members are remarkable for their longevity,
though their anustor by the maternal side died of pulmonary 
consumption. Out of 7 children of this family, 2
attained an age considerably beyond 80; one of the 7 died of
the disease; the remaining six lived to have families, and
none of them died of consumption: one for a number of 
year laboured under bronchitis, but ultimately died in
old age of hydrothorax; - this individual lost a daughter
of phthisis pulmonalis. Several of the children of one
of those who lived to be eighty, were affected with pulmonary
consumption, & died: so that it passed over him & over
5 of his brothers & sisters, to fix on the next generation.
In some instances this is a family disease. When we are
unable to discover any hereditary predisposition, & when the
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




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patients have lived in health to an extreme old age, the
children sometimes exhibit this predisposition to consumption,
& every one die. Such was the family of Dr. Crake, the physician 
& friend of Washington.
Some writers have divided this disease into a variety of
species. Now I am inclined to simplify this arrangement:
at any rate, I wish to distinguish certain affections which
resemble phthisis, & often pass for it, from the real disease. 
Thus, vomica should be distinguished from the true pulmonary 
consumption. Vomica may be accidentally induced;
they may arise without constitutional predisposition, as from
neglected pneumonia; & patients labouring under this complaint 
may recover. Catarrh may also arise & become
very obstinate, without any constitutional predisposition in
the system to pulmonary consumption. The bronchitis of
old people may be confounded with pulmonary consumption; 
but it is a different disease. But while I draw these
destinations, I am ready to admit that catarrhal disease
& pneumonic inflammation are apt to induce consumption 
when they act on a system possessing an acquired
or hereditary predisposition to the complaint. Hence, it is important 
for persons having this constitutional tendency, to
pursue such a prophylactic course of treatment as to place the
lungs in a condition to resist the disease when it makes its
attack.
Consumptive patients are very generally characterized by
a peculiar form of body. Hence we often find them tall &
very slender, possessing narrow chests, & not unfrequently
  
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




322
excellent teeth; & having their nails of a peculiarly delicate 
shape. Such persons are generally inclined to pulmonary 
consumption: but this is not invariably the case;
& I have sometimes seen persons with well formed chests
attacked with the disease. The persons first described often
possess great sensibility of mind, & not unfrequently an unusual 
degree of intelligence. They are generally subject to
considerable weakness of body. Slight causes are apt to affect
them considerably; & chilliness with flushes of heat, or what
may be called a febriculous state, may be discovered before
the disease has fairly invaded the system. It is not unusual
for persons of this character to complain of a sense of weakness
in the breast, & to have a slight hacking cough; &, that is
more to be dreaded than almost any thing else, a predisposition 
to hemoptysis. Hemoptysis may always be regarded
as an evidence of a weak pulmonary system. But it by no
means follows that every case of hemoptysis should be succeded 
y pulmonary consumption. When, however, we find
patients affected with occasional discharges of blood from the
lung, we may lay it down as an axiom, that they are in a
dangerous situation, & should be very closely evatetred. The
description of persons mentioned, generally possess an irritable 
state of the blood vessels & a frequent pulse. But remember 
that in my lecture on the pulse, I drew a very marked
distinction between a frequent pulse arising out of an naturally 
irritable condition of the arteries, & that kind of pulse
which proceeds from an inflammatory diathesis.
As the disease gains an increased ascendency in the
  
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




323
system, deviations from health become more & more apparent. 
Patients are often very feeble, so that a little exertion fatigues 
them; & this weakness goes on gradually increasing, &
at the same time, the body becomes emaciated. About this
stage, we may often discover a circumscribed hectic blush on
the check; & in females, that lovely & interesting part of the
community, a suppression of the catamenia is an almost
invariable attendant. If you examine these patients, and
endeavour to ascertain the history of their cases, you will
not unfrequently find, that at some period of their lives
they were subject to glandular swellings about the neck.
In the course of my practice, I have met with cases in which
the glandular affection of the neck had induced disease of
the absorbent which had become indurated, & might be traced
passing down & losing themselves in the cavity of the thorax.
This is an interesting fact, & one which I have had an opportunity 
of ascertaining by observation & confirming by dissection.
When the disease has fairly invaded the system, then,
as I stated in the commencement, hectic fever becomes clearly 
established. Chills occur at irregular intervals; fever
accompanied by flushes of heat succeeds; the circumscribed 
redness of the check is observed, & the paroxysm terminates 
in profuse sweats which impair the strength of
the patient. At this time frequency of the pulse becomes
established. You will rarely find it below 100, & very often
will meet with it at 120. The last is a common standard 
in cases of hectic fever. In forming my judgement
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




324
of cases in which I have been consulted, I have placed very
great reliance on the pulse. I have often been consulted by patients, 
have listened to a description of their symptoms, & knowing
that cough, chill, & fever may arise from causes not much
to be dreaded, I have said to myself, before placing my fingers 
on the pulse, every thing will depend on the condition of
the artery I am about to examine. If I find the pulse 120 the
case is fixed; if it be not so frequent, but merely indicates debility, 
how much shall I be rejoiced!
I shall not detain you long with a description of the latter 
stages of pulmonary consumption. It is sufficient to say,
when hectic fever commences, & the patient has a cough with
purulent expectoration, the emaciation increases, great debility
ensues, the night sweats become profuse, alternated with diarrhea, 
swelling of the legs appears, & death puts a period to the
suffering of the patient.
It may not be improper for me to mention, that in the latter 
stage of phthisis, the patient becomes extremely weak, has copious 
purulent expectoration, & the physician justly considers
that life depends on a continuance of the cough. If this cease expectoration 
will not take place, & suffocation must be the necessary 
consequence. This is really the case; & some of the most
agonizing instances are those when the patient wished to expectorate 
without having the power, & for a long time is approaching 
towards death, without being able to die. I have known
this state of things to continue for days. In some cases the
cough will leave the patient, & yet he will not die of suffocation. 
In these instances diarrhea will sometimes ensue.

         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




325
This will continue for days & even weeks, before the little
remnant of vitality is destroyed. Another symptom of the
last stage is occasionally met with, which is rare & will worthy 
of notice. I have seen three instances in which real mania 
accompanied pulmonary consumption: all the patients
were females. The maniacal symptoms were violent; but
they lasted only a few days, before death took place. The disease, 
however, is in general marked by great clearness of intellect, 
which continues till the latest period of existence.
If you examine the lungs of patients who have died of this
disease, you will be presented with appearances which easily
explain the cause of its mortality. Patients labouring under genuine 
phthisis pulmonalis, so far as my experience has gone,
are almost invariably affected with tubercles in the lungs. Sometimes 
these tubercles are diffused through both lungs; at other times
they are pretty much confined to one. If you make an incision 
into the lungs, you will open into a number of small abscesses; 
you will find an aggregated mass of disease, consisting
of tubercles in two states, & of abscesses containing pus. Some of
the tubercles are small & indurated; others are larger, & if cut into
are found to contain a soft cheesy matter. This state of the lungs
at once goes to show the difficulty of effecting a cure, after the
touch of the disease has been fairly lighted up. For admitting
that you could cure the abscess already formed, you have thousands 
of tubercles ready to pass into the same condition.
Having now given a general description of the complaint,
& of the appearances after death, I will commence some general 
observations on the practice which is commonly pursued
  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




326
in the treatment, I regret I cannot in the cure, of pulmonary 
consumption. It is not long since, in the University 
of Pennsylvania, there was an illustration of a practice in
this disease, founded on the opinion that it is of an inflammatory 
character, & that it requires a strict antiphlogistic plan
of treatment for its cure. With this view of the subject, you can
easily understand that a variety of remedies, calculated to
lessen arterial force, were resorted to. Among these the lancet
stood conspicuous; & in connexion with this, mercury was
employed with very great liberality. I will recollect, in passing 
though the wards of our Hospital, when that great
& distinguished physician, Dr. Rush, was at the head of the
clinical department, that this plan was most strictly pursued. 
But so far as my recollection goes, it was attended with
little or no benefit to the patients, & was generally more injurious 
than useful. In addition to this, a most rigid system
of dieting was considered necessary; & close confirmment in
a warm room formed part of the practice. One ward was
fitted up with stoves for the purpose of keeping the patients in
an artificially warm climate through the winter season. This
practice was not only common in the Hospital, but was also 
fashionable in the private practice of the city.
Besides bleeding & mercury, other remedies were proposed &
adopted. Thus the acetate of lead was used under the impression 
that it would reduce the frequency of the pulse, & improve 
the general condition of the patient.
We were instructed in that day to believe that the disease
had an inflammatory & a typhoid stage; & that when the
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




327
inflammatory condition was relieved by the vigorous use of
depleting remedies, it passed into one of a typhoid nature;
& that then we were to fill up the blood vessels by the use
of porter & beef stakes, & quiet irritation by opiates.
This constitutes a general outline of the plan taught
by Professor Rush. Other practitioners who were less attached 
to the mercurial treatment, & less disposed to carry
the lancet to so considerable an extent, resorted to another
practice. Thus, Professor Barton, also a physician to the
Hospital, was much attached to the use of emetics; he also
placed great confidence in Mosely’s vitriolic solution; &
he used Fowler’s solution with the utmost liberality.
Again, my beloved & respected perception, Dr. Wistar, was
almost enthusiastically attached to the use of digitalis; & he
had one patient, while I was a student, who really appeared
to recover under the long & dilligent employment of this article.
With these three different modes of practice milder remedies 
were occasionally introduced by all; as palliatives to
allay cough, blisters about the chest, etc. But under these
various modes, the poor patients generally went one course –
the disease bade defiance to treatment & terminated in death.
Where I commenced practice, I was much inclined
to pursue the plan advocated by Dr. Rush. The happy
manner he possessed of impressing his principles on the
minds of those who attended his lectures, & the ingenuity
& force with which he illustrated these principles, were apt
to captivate the mind. I commenced practice so far
a convert to his opinions, as to be disposed to test them by
       

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




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a fair trial. But in the course of a few years, experience, that
best of teachers, convinced me of the necessity of a change. Indeed,
I saw in consultation with Drs. Rush & Physick, one very striking 
example of the inefficacy of this plan of treating the disease.
The patient was a truly amiable & interesting young man who
was not more than 24 years of age. He was the oldest son of an
affectionate & anxious father who had lost his wife with pulmonary 
consumption. When the son was attacked, the father became 
immediately alarmed. His previous experience enabled
him to recognize in the son, the symptoms which with sorrow 
he had seen in the mother, & he was easily disposed to
avail himself of medical advise. The young man was brought
from his father’s residence in the country to this city, & arrangements 
were made for his spending the winter in a warm
climate artificially induced. He was placed in a very spacious
apartment, in which was a soap-stone stove. A thermometer
was suspended in the room, & a uniform heat was maintained 
by day & by night. One of the first nurses in the city
was selected to carry our directions into effect; & in fact everything 
that a parent having the command of great wealth
could bestow, was at our disposal. We had no excuse to plead.
The patient submitted to every direction, & all our orders were
faithfully obeyed. The treatment was commenced by a system
of very close dieting, with small & frequent bleedings, & the
use of mercury. After pursuing this plan for some time, &
finding that the mercury given by the mouth failed in affecting 
the system, we resorted to its external use. A taylor
was sent for to take his measure for a pair of flannel pan-

329
taloons, to be made with feet to them. When prepared, they
were spread on the inside with mercurial ointment, & drawn
on the patient. In this situation he remained some days: but
alas! instead of arresting the disease & allaying irritation, the
system became weakened, & ptyalism could not be induced. Under 
these circumstances we resolved on a change. Mercury was
laid aside, & we attempted the sweating plan. Sulphur was
also given, together with tar-water, which Dr. Physick thought
he had seen useful in similar cases. But no benefit resulted.
The father who watched with solicitude the progress of the case,
one day, in great distress, inquired whether Dr. Rush might be
called in consultation. This was readily consented to. There was
now three of us in daily attendance. I being the youngest, saw
him twice a day, & my colleagues every morning. The aulate of
lead was now given – 2 grs every 2 hours. This was continued
for several days. It did, it is true, diminish the frequency of the
pulse; brought on symptoms of colic, & was abandoned. Issues
were applied to the thorax; & at last we got to a period when it
was thought that the typhoid stage was so far developed, that
it was proper to commence a plan  to fill up the blood vessels.
Tonics of various kinds, the weaker & the stronger, were used in succession; 
but suffice it to say, all our efforts were unavailing. The
treatment was begun in the early part of winter, & in the spring
our patient died.
Next door, or next but one, resided a student of medicine,
(afterwards Dr. Samuel Hopkins of New Jersey). In the preceding
summer Hopkins had been attacked with hemoptysis. At that
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




330
time he was a student in the Pennsylvania Hospital. He
was under the care of Dr. Rush, & a system of vigorous depletion
was pursued. The hemoptysis passed away, but he was left
in considerable debility. He went into the country, & returned
in the fall; but his health did not permit him to resume his
studies in the Hospital. At the commencement of the winter
any person, on observing the two patients, would have supposed
that Hopkins was farther advanced in the disease, more reduced, 
& more likely to pass away than Smith, (which was the
name of the one who died.) Hopkins was pallid, emaciated,
& had cough & fever. As he was situated so near to medical aid,
three physicians attending daily in the neighbourhood, his
friends requested him to have the advise of some of the physicians 
of the city; but this he steadily refused. His unite with
whom he lived, one day candidly told me, that his nephew
refused, because he believed that the practice which would be
pursued would only tend to hasten a fatal issue to the disease.
The winter passed with nothing but a mild palliative treatment; 
as paregoric to allay cough, etc. Spring opened, & it found
Hopkins a living man; but poor Smith had been carried to
his grave.
Let us now trace the course of the disease in Hopkins, &
mark its termination. He went to Woodbury; his father purchased 
him a horse, & he commenced the life of a country
doctor. Strange as it may appear, he rode himself into a
state of very good health. He had an extensive practice; he
married & became the father of several children. He after-
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




331
terwards removed to this city, & fell a victim to typhus
fever, which he contracted during his attendance
on the practice of the Dispensary. This happened 10 or 12 years
after the winter of which I have spoken.
I often conversed with this gentleman on his case; & he
assured me that when he first commenced practice in Woodbury, 
he found nothing so effectual in relieving his distressing 
chilliness, as riding on horse-back. He said he often set
by a large fire, with the back of his chair covered with a thick
coat or blanket, without being able to keep himself warm.
While in this situation he would, perhaps, receive a call from
a patient, requiring him to mount his horse. He would do
so; &, as he rode, would feel better. After going a few miles,
the exercise would produce such an excitement in his system,
as to overcome this chilliness; &, as I have told you, he rode
himself into sound health.
These two young men lived contiguous to one another.
One who had all that affection & wealth could offer; who
was attended by two of the best & most distinguished physicians 
in the city; who was kept in an artificially warm
climate; & who had the careful attendance of one of our
first nurse, died. Hopkins, who refused all this aid,
depended on simple, domestic remedies; thus passed the
winter; spring opened; he commenced the life of a country 
doctor, & recovered.
These cases had a strong tendency to produce a change
in my opinions, which subsequent experience has confirmed;

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




332
& I proper, before leaving the subject, to furnish another
case in support of it. I shall then give the views which
my experience & observation have afforded me, as to the best
mode of managing the disease.
I shall now proceed to give some account of cases of
this disease which have been suspended or cured, by great
exertion on the part of the patient. The first that I shall
mention is that of Dr. Baldwin. He was a graduate of
this university, & a man of science – an excellent botanist
in particular. He belonged to a consumptive family; his
father & five brothers had fallen victims to the disease. He
settled in Wilmington, (Delaware,) where the disease commenced. 
He was fully aware of its nature; & calculated
on the fatal consequences which would soon result, unless 
some measures were employed to evert them. He
determined on a change of climate. Hence, in the winter
season, he embarked for Savannah, bearing with him letters
of introduction to persons of the first respectability in that place.
This was at least 5 or 6 years before his death. At the time of his
embarkation, his health was much impaired. On his arrival
at Savannah, as he afterward informed me, he made up his
mind to travel on foot to Milledgeville, the capital of Georgia,
which was distant upwards of 100 miles. His friends considered
him little short of maniac. Disregarding their sentiments,
however, he took from his trunk some necessary articles of clothing, 
tied them up in a pocket handkerchief, ran a stick thro’
the bundle, & placing it on his shoulder, trudged off through the
       

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




333
streets of Savannah, on his way to Milledgeville. On his rout
he endured considerable privations, - lodging in cabins, among
people as untutored as the wild men of the wilderness; & partaking 
of their homely fare of ham & corn bread. Sometime he
waded streams; but finally arrived without any material accident, 
at the capital of Georgia. There he met with Col. Hawkins, 
the agent of the United States among the southern Indians. 
This gentleman treated him with great attention, & invited 
him to attend him to his residence. He did so, & passed
the winter there. In the spring or summer, he found his health
nearly restored. On his return to St. Mary’s from the United
States agency, he learned that the naval surgeon on that station 
had died. At the request of some persons, he agreed to
supply the vacant place, till they could hear from Washington; 
and soon after a commission, appointing him naval
surgeon, was received from that place. He accepted it, settled
in the country, & remained several years free from disease. Not
long since, he left that station, & engaging in the capacity of botanist 
to the yellow stone expedition, he died on the journey. – I
have no doubt that his disease was suspended several years, by
the course of life he pursued.
During my attendance in the Philadelphia Dispensary, I
was occasionally struck with some patients, particularly one black
man who was under the necessity, either of using great exertion to
obtain a livelihood, or of becoming a tenant of the Alms-House.
The very great dislike which prevails among many of the poor
to being received into this Institution, operates as a powerful incen-        

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




334
tive to exertion. I remarked that some patients thus situated,
continued longer & bore the disease better than others whose circumstances 
were considered much more comfortable. There was one case
different from these, in which I felt a particular interest, & in which 
the efficacy of exertion in protracting the disease, was very evident. 
This was the case of Benedict D. Potts, a young physician who 
had pursued his studies with me; & a man whose amiable qualities 
& intrinsic worth were not generally known. Poor Potts
was attacked by a sad precursor of pulmonary consumption;
I allude to fistula in ono. The fistula was small, & I operated
on him in my office. Though small, however, yet it was very
much indisposed to heal; & a long time elapsed before it did heal.
Unhappily, soon afterwards he was attacked by hemoptysis, and
symptoms of consumption became manifest. He lived at least
one year longer than he would have done, if he had not been
prompted to exertion by the stimulus of necessity. He depended
on his practice for a livelihood; & I was surprised to see him one
day in his chamber throwing up blood, & in a few days again,
running about among his patients. In this way he protracted
for a considerable time the issue of the complaint.
A fine healthy looking practitioner from New England
brought a letter of introduction to me some years ago. I received
this account from him: - In early life he was affected with
pulmonary consumption; & while labouring under this disease
he commenced the life of a country doctor. It so happened,
that in the first season after he began practice, there was an
unusual degree of sickness. He was consequently under the
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




335
necessity of making a great deal of exertion, & the result was
a restoration of his health. In the course of conversation he told
me, (I copy his words.) “I have left a patient labouring under
pulmonary consumption with directions to ride 10 miles every
day, let the weather be what it might.” This was in the winter.
A respectable man in this city. Jos. Riley, a currier by trade,
soon after his marriage was affected with cough & hectic fever,
& came under my care. I felt great solicitude in the case,
& determined to try the efficacy of horse-back exercise. I advised
him to ride daily. He followed this plan through the winter,
& in the spring was evidently improved. The summer opened
on him, & in the course of it the camp of Dupont was formed.
It was during the late war. This young man became one of
the volunteers, & went down with the rest. He was subjected
to all the hardships of camp life; his health & strength increased, 
& he is now a hearty man, free from all symptoms
of pulmonary consumption.
A very remarkable case of this kind occurred in the family
of a friend of mine in this city. A little son laboured under
cough, hectic fever, profuse sweats, & great emaciation. I watched 
the case with a good deal of anxiety, & found it a difficult
matter to carry my occurs into effect. The solicitude of the friends
of the child, who visited the family, & who were constantly recommending 
one thing or other, had considerable influence
on the minds of the parents. To have a child so sick, without
any active practice being adopted, seemed to be incompatible
with the views of the visitors. Mercury was proposed; but hap-
 

    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




336
pily the parents listened to the suggestions of the physician.
No active practice was employed. As soon as spring opened,
he was sent into the country, & his father was directed to give
him all the benefit of air & exercise. He returned from pulmonary 
complaint, has since had hooping cough, & now
enjoy excellent health.
I shall close these cases by giving one more illustration
which to me was peculiarly striking. Shortly before the death
of Dr. Wistar, an interesting young lady was brought from Jersey 
to consult him for chill, fever, pain in the breast,
hacking cough, & considerable loss of voice. All these symptoms 
were very gloomy precursors. Dr. Wistar being absent
on a journey when the lady arrived, she came under my care,
& I paid her a visits before he returned. We entered very
fully into her case. After seeing our patient, the Doctor, who
had just felt the advantages of travelling over the mountains
& who took great delight in this kind of exercise, looked
round the room & made use of these words: “Doctor, don’t
you think it looks confined & close here? Don’t you think
it would be best to send her back to the country, & direct her
to ride every day?” I concurred heartily in the proposition.
We first put a seaton in her side, & then advised her to return
home & use exercise. The winter passed over. The following summer 
she visited Philadelphia, greatly improved in health. I
have since repeatedly inquired of her situation, & I was lately
pleased to hear that her health had been completely restored.
About the same time I attended, in consultation with



    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




337
a practitioner of the first respectability in this city, a young
woman who was attacked with hemoptysis, & laboured under 
hectic fever & cough. Now mark the history of this case.
Here it was suggested that there was an inflammatory state
of the system, & that the best way to subdue it was by depletion,
by a rigid antiphlogistic regimen, & by keeping the patient
at perfect rest. Rest was considered as a point of peculiar importance. 
The plan was put into operation. This was in the
beginning of fall; & a course very similar to that of young
Smith was adopted. Mercury & acetate of lead were tried; a
varity of plans were resorted to; but suffice it to say, the
patient died in a few months.
The following history of a case was drawn up by a gentleman 
of Ohio, & handed to me by his son Dr. Gillman:
“In the year 1804, Thadens M. Harris, a clergy man of Massachusetts, 
called at my house in Marietta; & from him
I received the following account. He had left Dorchester,
Mass. that spring, so very low in consumption that neither
he nor any of his friends had any idea he would be able to
reach Hartford, Conn. distant 100 miles. He arrived there
however, & though still very weak, he concluded to prossecute 
his journey to New York. When there, finding that he
was gaining strength, he was encouraged to proceed to the
western country. On his arrival at Marietta he was so well
as to be able to ride 40 miles a day, to preach; & was, in fact,
quite recovered. He returned to his parish in Dorchester in good
health; & two years ago I heard he was still well.”
“Marietta, 1823.”
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




338
My friend, Dr. Emlen, presented me with the following 
extract from “A Manual of the Climate & Disease of
Tropical Countries, etc. etc. By Colin Chisholm, M.D. F.R.S. etc.
etc.” Published in 1822. London.
(Dr. Chisholm in as old practitioner retired.)
On the subject of consumption, he says, “An active, bustling
occupation of time, with exposure to what may be called, & deemed
hardships; such as often occur in military service, during an
active campaign, or in maritime service of any kind, have sometimes 
produced a most wonderful change in a constitution broken 
down by phthisis. I have known instances of offices, in both
services, recover their health by seemingly inconsistent means.
One thing is most certain, that confinement to the atmosphere
of a room, or even house, is most highly prejudicial; it ren-
ders the person infinity more susceptible of cold, & thereby
tends to augment the evil which it is supposed calculated to
remedy”.
In opposition to these views, you will hear it strongly argued
by men of talents & large experience, that this is certainly an
inflammatory disease. Why then should you subject your patient 
to a course of practice which must certainly increase inflammatory 
action? Why do you direct him to ride over hill
& dale, & be jolted on horseback, when his system is in an inflammatory 
condition? This is opposite to all theory. But
it should be remembered, the lungs, the sear of the disease, the
very fountain of danger, cannot be put at rest. The reason
would apply strongly to an inflamed joint: I admit this fully.

     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




339
But it should ever be borne in mind, that from the moment 
we begin to breathe, to the latest period of our existence,
the lungs are never at rest. Hence, whatever reasons we may
give for the necessity of rest in inflamed joints & muscles, which
may be kept from motion, must fail entirely when applied
to the lungs.
In hectic fever, is there not a preternatural irritability of the
system? It is admitted by every one that this is the fact. Let
me ask again, do not depletion, low diet, & close confinement,
increase the irritability of the system. I advance it as a fact, which
I believe experience will substantiate, that if you take a robust
man, put him in a close room, bleed him repeatedly, diet
him strictly, keep up action on his bowels by purgative medicine, 
& allow not a breath of fresh air to blow upon him, his
pulse will become frequent & irritable, he will be affected with
night sweats; & I should not wonder if his blood should become 
sizy. If such would be the effect on a man in full
health, with how much greater force will the reasoning apply 
to a man already debilitated by disease? I can speak from
observation, that such a pulse will be reduced by a contrary
plan of treatment. I recollect one case of pulmonary consumption, 
in which, for some time, a rigid antiphlogistic diet was
pursued, & the pulse in consequence became very frequent and
irritable. The patient insisted on a change in his diet; & as soon
as he began to live more highly, his pulse became slower & fuller.
It not unfrequently happens that the practitioner is called
to see patients in the last stage, when no medical treatment
  
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




340
had been resorted to. From such cases may sometimes draw
important practical rules. Now, I firmly believe in the doctrine
of the vis medicatrix natura – as to the name, I care nothing about 
that; but for principle I do contend, & I consider it
of very great importance. It is true, that blood, bone, & muscle
are not endowed with mental intelligence: but though this is
the fact, I believe there is an innate principle in the system,
whose object is to preserve it from the dangers that surround it,
& to repair the dangers to which it is subject. We have heard it
said that life is a forced state; as if the action of surrounding
agent was continually necessary to keep it from dissolution; as if
it could only be maintained by the utmost efforts of these agents.
But if it be presumed that life is a forced state, it must be allowed 
that these agents can do no more than keep it in the state
in which they found it. They certainly cannot repair the injuries
to which the body is subjected. Let a large wound, or a loss of
substance, take place in the human subject; is this wound to
remain in the same situation? No: the system at once sets
about repairing the damage – granulation sprout up, & pus,
the purest & best of balsams, is secreted to defend them. In the
progress of the cure, the granulations rise to the surface, new
skin is formed, & the restorative process is completed. It will
do well enough for a theoretical physician to consider life as
a forced state: but the practical surgeon will inform him,
that the language of the system is entirely opposed to such a
hypothesis. Admitting then that there is an inherent power
in the system to repair damage, & partially to prevent disease; we
    
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




341
may go further, & draw a simile not altogether irrelevant to
the subject before us. Suppose an intelligent being arrested by
the hand of violence; suppose him confined & deprived of all
his natural privileges; now mark the expedients such a
man will resort to, to extricate himself from his difficulties.
Look at Sir Sidney Smith in the prisons of Paris. Immersed
as he was, he happily caught, through the window of his cell,
a female eye which viewed him with compassion, A regular 
correspondence was carried on by signs; so regular and
so systematically arranged, that even bills were drawn on his
friends in England, funds were procured, the vigilance of
the most active police eluded, & the prisoner restored to his
natural privileges. Apply this to the human system under 
the influence of disease. I trust I shall be able to prove,
before I finish the subject of pulmonary consumption, that
there is, in the human system, in some cases, a strong tendency 
to effect a natural cure, & that this natural cure
does sometimes take place. The system feeling itself invaded, 
& its natural privileges taken away, sets about relieving 
itself from its difficulties.
I began by telling you, that, in a large proportion
of cases, pulmonary consumption is nothing more nor less
than internal scrofula. I will now tell you, that this internal 
disease has been removed by the production of an
external disease of the same character. I shall also attempt
to show, that the external disease being repelled, or driven back
into the system, is capable of producing an internal disease.
     
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




342
which will prove fatal. This doctrine of metasis as applied
to scrofula & pulmonary consumption, is a very interesting one.
In order to illustrate the position, that external scrofula will
cure the internal disease, I refer you to the case of Hetly Kellen.
(see Eclectic Repertory, vol. 2. p. 201.) In addition to this I
have been consulted, in the course of my practice, by several
patients labouring under pulmonary disease which has been
relieved by external scrofula. A delicate looking young man
was brought to me from New Jersey. He had been subject
to cough, & had laboured under symptoms of pulmonary consumption, 
which had been relieved by the occurrence of an
abscess in his side. I had good reason to believe that this
abscess was connected with the lungs. Efforts had been made
to cure it; but happily, they had failed. I had no doubt
that the preservation of his life depended on his keeping up
this discharge. I gave advise accordingly. The case of a
young woman, in similar circumstances, afterwards came
under my notice; & I gave similar advise. In both, life
& health depended, most probably, on the continuance of
this external discharge.
In the Eclectic Repertory you will find several instances 
related, when on the disappearance of the external disease, 
the internal came on & destroyed the patient. These
facts have brought me to the conclusion, that scrofula is
a disease capable of being translated from the external to the
internal & vital parts, & vice versa. The doctrine of metastasis 
in some diseases is perfectly familiar to every prac-
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




343
titioner. When regular gout, for example, invades an external 
part, as the foot, when is the judicious practitioner
who, for one moment, would suppose it proper to apply repellants 
to the affected extremity? Why would this plan be
injurious? Because the gout which in the foot is harmless, 
by retroceding, may attack some vital part, & destroy
life. When gout affects vital parts, our object is as soon as
possible to invite it to some safe situation, & the place
selected is generally the feet. Scrofula is subject to precisely 
the same laws. The only difference is that the time
required for the production of the same effect is longer. In
gout the change is sudden; in scrofula it is slow, but certain. 
The practical inference to be drawn from these facts
is obvious to you all. External scrofula is, in many instances, 
a painful disease; & is very apt to occasion deformity,
which, among females especially, renders it hard to be borne,
as it generally takes hold of the glands about the neck.
The practitioner is frequently solicited by his patients to use repellent 
remedies, with the view of preventing this deformity,
& in some instances, he may succeed. But in the early part
of the lectures on this subject, I called your attention to the
fact, that in these cases of scrofulous swellings, in most
instances, a chain of diseased absorbents could be traced
passing down the neck, & losing themselves about the
clavicle. By dissection I have ascertained that they pass into 
the lungs. Now, exactly in proportion as repellent remedies 
drive away the external disease, so do they increase
      
      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




344
the danger of pulmonary affection. Hence in subjects constitutionally 
predisposed to phthisis, I would urge you to be
particularly careful to avoid measures calculated to produce 
the effects I have mentioned. Much rather should
you allow the scrofula to follow its natural course; much
rather should you promote suppuration than procure discussion; 
& this rule applies with peculiar force to young
people, especially young females about the period of the
appearance of the catamenia.
But here you might naturally observe, “we have
been enabled thus far to acquire some general views; but
is there any systematic plan of treatment, is there any
mode of prevention which, we all know, is better than cure?
May not some prophylactic plan be adopted with advantage?” 
This is a very interesting part of the subject; because
if we can observe the first approach of the enemy, or before his
appearance ascertain the avenues through which he is likely to
pass, we shall be more successful in preventing his inroads, &
in resisting his attacks. I shall endeavour to lay down a
few observations on this subject.
It is important in pursuing a prophylactic plan to commence 
early; & I believe that parents often fall into a fatal
error, arising out of an ill-directed tenderness. It is common
for parents, in selecting a situation for a weakly child, to direct 
his attention to some employment which subjects him
to as little exertion as possible. Hence an error is commited 
at the very threshold. Instead of closing such a trade     

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




345
as that of a watch-maker, tailor, etc. it be much better to
place the child under the direction of a farmer, where he may
have the full advantage of air & exercise; & if not a farmer,
there should be selected for him some other active out door
employment, as that of a brick-layer, or a carpenter. I have long
been convinced that fresh air & exercise are necessary for the
preservation of health, in persons predisposed to phthisis. In
addition to these, we are next to adopt measures calculated to
give tone & vigour to the pulmonary system. I have seen cases
in which there was a predisposition to pulmonary disease of a
fatal character, & when I had opportunity to pursue a
prophylactic treatment from early infancy. I directed with
this view, the inhalation of the femes of rosin & tar. I
founded this practice on a fact mentioned to me by a respectable 
merchant of New England, who had been much engaged 
in ship-building. He told me that he had rarely or
never seen a caulker die of pulmonary consumption. A
respectable physician of New Jersey, whose practice is extensive,
on being asked whether consumption was so common among
the pines as in other parts, answered, that so far as he recollected, 
it was not so common. This is another fact which
tends to strengthen my belief in the propriety of using fumes
of rosin & tar as a preventive.
I have cautioned you most scrupulously to avoid medling 
with scrofulous tumours situated externally. It now remains 
for me to state, that when the disease invades the system,
the facts previously noticed ought to be borne in mind. The
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




346
efforts of the system to relive itself should be constantly in the
eye of the practitioner. This observation naturally leads to some
curative plans, when the complaint has seized on the lungs.
What are these curative plans? What was the language of
nature in the case of Hitty Killen, to which I have referred you?
Scrofulous swellings took place in the axilla: nature pointed
out this as a situation for the external disease, with the view of
arresting that within. Recollect that a common seat of external 
scrofula is in the neck. When, therefore, the lungs are
affected, you should endeavour to excite this external disease.
How is this to be accomplished? It is true, that by blisters
seatons, etc. a great deal of good may be done in some of
these cases: but we may extend our practice further. I will
relate to you some instances which fell under my care.
In the summer of 1813, in the family of W.J. Miller, a respectable 
merchant then residing in this city, I was called to attend 
a black child, the son of one of the servants. It seemed to
be a great favourite with its master & mistress, & considerable interest 
was felt in the case. But on visiting it, I found it for advanced 
in consumption, or internal scrofula. The child soon
died. In progress of time the parents, who still remained in
the family, had another child, & this infant was attacked with
the same disease, accompanied with the same symptoms as
in the other case. The parents became alarmed, & the child was
placed under my care. It was affected with hectic fever and
cough, & was in the early stage of internal scrofula. I explained to
W. Miller & his wife the views I had taken of the dis-
        
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




347
ease, & my reasons for the mode of practice I was about to instatute. 
They entered heartily into my opinions, & the practice was
carried into effect. It was this: The child had been vaccinated, 
& I commenced the treatment as follows: With a
sharp lancet I made a number of superficial incissions
through the skin, commencing behind the ear, & carrying
them down the neck in the course of the glands which are usually 
affected in scrofula. Having done this, I introduced the
vaccine vims into the incissions through their whole course.
At the regular period of time, when the pustules were at their
height, I directed that the child should be brought to me.
When I saw him again, I was pleased to find very extensive
vesicles, accompanied by much tumefaction in the surrounding 
parts. This was the moment for perpetuating the plan
I had commenced. Instead of allowing the pustules to
take their regular course – to form a scab & pass away. I
began a very rough treatment with them: I scarified
them with a lancet, & took care to supply them well with
stimulating ointment. My object was to keep them sore as
long as possible. Directions to this effect were given to the
master & the parents; & happily for the child, they were
carried into operation. Weeks & even months passed away without 
our allowing the parts behind the ears to heal. We were
all pleased to see a gradual amendment in the child. I
examined it with great solicitude at various intervals. Scrofulous 
tumours appeared in the neck, & the child was at
length relieved of all its dangerous symptoms. I am
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




348
happy to add that he is still living, & I believe remains
free from pulmonary disease.
I tried the same thing in the family of the Morgans, in
this city, one of whose children I had previously subjected to dissection. 
The child in this instance, was extremely delicate, and
the remedy failed. There are the only cases in which I have
tried the plan. I cannot, therefore, say much from my own
experience; but from what I have seen, I should certainly
recommend the practice to your consideration.
In addition to this, it is proper for me to speak, in strong
terms, in favour of exercise on horse-back. Horse-back exercise,
or the motion of a rough carriage, I can strongly recommend
to patients who have any predisposition to the disease, or who
labour under it in its early stages. It is, I believe, a most
dangerous error, & one which has gained pretty universal
ascendency among us, to commence the early treatment of
pulmonary consumption with a system of medicine and
confinement. It is a very common thing for persons to say
to weakly young people, “Ah! Take care of that cough; nurse
yourself, or you will have to repent.” So far from nursing
themselves, it would be much better, if they could forget that
they had any cough at all. Instead of confining themselves 
to a close room, & thus increasing the irritability of the
system & hastening the approach of a disease they have so
much reason to dread, it is much safer for them to use
exercise & to expose themselves to the fresh air. I myself
possess a constitutional predisposition to pulmonary con-
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




349
sumption. I have lost a brother & sister with the complaint,
& others have been threatened. There was a time when
many of my friends & fellow citizens believed I was not
long for this world: but hitherto I have escaped; & I attribute
my safety, in a great measure, under Providence, to
exercise. In my practice, I always use a rough chair, & have
never allowed myself the luxury of an easy gig. This plan I
have followed for years, & I have much reason to be pleased with
it. To some patients exercise on foot is very suitable.
There were two physicians in this city, Drs. Gallaher and
Davis, both of whom experienced the benefit of exercise. Dr. Gallaher 
was strongly predisposed to phthisis, & had lost several of
his family with the disease. He made several journeys, & said
he experienced considerable advantage. Dr. Davis travelled
a good deal, & with benefit. He assured me that nothing relieved 
him so much as exercise in the fresh air. If he was
confined for a day, in consequence of bad weather, he always
felt worse. They both ultimately died of consumption.
A gentleman whose father died of this disease, applied
to me on his own account. I advised him to saw wood for
exercise. He did so through the winter. He generally sawed
in his parlour. He passed well through the winter, & now
enjoys pretty good health.
Hannel next the skin is an excellent auxiliary to exercise.
It has a tendency to protect the system against the sudden
variations of temperature to which our climate is liable.
Yet if the patient is weakened by perspiration in consequence
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




350
of the flannel, I should be much inclined to adopt the opinion
of Armstrong, that it should be taken off at night.
Another article may be used with great advantage, especially 
by female patients whose breasts & arms are more exposed
than ours. I have often urged them to wear the dressed rabbit 
skin, as it prepared by the furriers. It is called the bosom 
friend, & should be worn next the skin.
But while I urge the necessity of air & exercise, & along
with these am friendly to a change of climate in the winter
reason, I wish to be distinelly understood, that a change of climate 
serves no other purpose, than to place the patient in
such a situation as to enable him to take plenty of air and
regular exercise. Here I would interpose a caution. Most of
us have missed in practice, by allowing our patients to take
long voyages, when there was no reasonable prospect of advantage. 
I have now made up my mind, that when a
patient in the advanced stage of consumption, applies to
me for assistance, I will never recommend a change of climate. 
It is certainly better to die at home, than in a land
of strangers. The last patient of mine who removed, I did
not advise to go, but I did not discourage the voyage. I
would have been better had I done so; for soon after his
departure I heard of his death. If benefit is to result from
such a change, it must be in the early stage. Benefit does
sometimes result from long sea-voyages. The case of my
own brother is strongly corroborative of this assertion. Dr.
Wistar & myself attended him through the winter with
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




351
cough & hectic fever. We treated him on the principle that
he was labouring under an inflammatory disease. He grew
worse. Aware of this, he determined to go to sea & try what
would be the effect of a thorough change of climate. He
obtained the situation of supercargo to India, & performed
all the duties of a person in full health. He returned wonderfully 
improved. After this he went two other voyages, &
the disease during all this time was kept at bay. After the
third voyage the embargo took place, & prevented a fourth
for which he was preparing. The disease now soon gained
the ascendency, & he passed away.
With respect to diet, it is difficult to lay down any positive 
rules. This much, however, may be said, that food nutritions 
& of easy digestion is borne much better, than a priori, 
we should imagine. We should generally allow the
feeling of the patient to be our guide. If he is distressed
by animal food, his fever increased, & his cough exasperated, 
the patient & the physician will both think it best
that he should abstain from it. But if he find his feelings 
more comfortable after a meal of animal food, without 
any increase of fever or cough, I should not be affraid 
to allow it. I have been much struck with the manner 
in which consumptive patients bear strong food. Dr.
Potts assured me, even after he had abandoned all hope
of recovery, that one of the greatest sources of earthly enjoyment 
to him, was to sit down & take a meal of that
kind of food to which he had been accustomed when in health.
          
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




352
He assured me that he felt better after such a meal.
In the treatment of pulmonary consumption, we are
sometimes arrested by a symptom demanding a change
of plan; I allude to spitting of blood. When this occurs, it
must be obvious, that for a time, our mode of practice
must be changed. It is generally necessary to take blood
from the arm; & sometimes this must be repeated again
& again. The patient should be placed in a cool room,
salt should be given, & those remedies adopted which
are suitable to a case of hemoptysis. But I have myself 
sometimes missed it by pursuing this treatment too
far. It is proper for a few days, to keep the patient at perfect 
rest, abstain from conversation, & use no strong food.
But in a short time, the disposition goes away, & the patient 
may resume the plan on which alone he can properly 
found any ultimate hope of health. In some patients, 
even while the plan of air & exercise is going on,
if there should be much pain or uneasiness in the chest,
it may sometimes be proper to take blood. Venesection
will occasionally relieve congestion & procure relief. But
beware how you treat the complaint as an inflammatory
affection.
There is a fact connected with pulmonary consumption, 
which you will do well to attend to. Every practitioner 
is aware that there is a striking connexion between
phthisis & fistula in ano. One of the last cases of this kind
that came under my care was that of Edward Coxe. Esg.         
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




353
a very useful citizen of this place. I operated on him for
fistula in ana. It was not extensive: but long before it
healed, pulmonary consumption invaded the system, & he
fell a victim to it. This connexion between phthisis and
fistula in ano, has suggested that the disease of the lungs
might be translated to the return. I once attempted to
concentrate the disease in the neighbourhood of the rectum,
& with this view, directed small doses of aloes. Hemorrhoidal 
disease was produced; but I did not succeed in curing 
the patient. The idea, however, I hold out to you
for future consideration.
Before I bring my account of consumption to a dose
I will enumerate another interesting fact. This, however,
is a subject of extreme delicacy. As medical students, you
must be aware that it is important for you to be apprized
of many sexual diseases appertaining to females, which it
would be improper that others, not belonging to the profession, 
should be acquainted with. You should never make
the diseases of females the subject of conversation, particularly
before men not of the medical profession. It is a fact well
understood by medical men, that pulmonary consumption
is wonderfully suspended during pregnancy. This is no
longer a matter of doubt. Many instances have occurred, in
which the disease has been kept completely at bay by the ascendancy 
of uterine action. In the course of my practice,
I have observed that pregnancy not only suspends, but in
some instances, effects a cure, particularly when the patient
    
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




354
is young. In a family very subject to the disease, I was
called to a young married woman who was labouring
under it in the early stage. Soon after the symptoms of phthisis 
occurred, happily for her, she was in a situation which
rendered her likely to become a mother. The symptoms of the
disease disappeared, & she passed regularly the period of gestation.
She has since borne several children, & hitherto the disease has
been kept off. I have no doubt that she would long since
have been numbered with the dead, had she not become a mother.
I have another fact to communicate. In consumption
the catamenia are almost invariable absent; & while I have
urged the necessity of air & exercise, I have also kept an eye on
the uterine system, & endeavoured to promote its healthy action.
Emenagogues & tonics are the remedies I employ for the
purpose. To a lady affected with the disease, I [p??????ds]
pills made after the following recipe:
R. Puls. G. Myrrh
Sulph. Ferri cale. aa 3ij
Potas. Sub. Carb.
Japon. Venet. aa 3f
Aqua q.s. wt fiant pill. XL.
Two of these pills were taken two or three times a day, &
were persisted in for a considerable time. They brought about the
regular action of the uterus. – In another case I used
R. Sulph. Ferri. Cale. 3i
Aloc Socot. gr XV
Fereb. Ven. q.s. utfiant pill. XXX.
 
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




355
The dose was from two to four pills morning & evening.
Among the medicines used in consumption, I have found
tonics particularly important. Patients affected with chills,
flushes of heat, & occasional sweats, will be much benefitted 
by a judicious use of tonics. Back would be useful and
were it not for its effect in producing structure of the breast.
Other tonics, however, as gentian, quassia, etc. may be used.
The prunus Virginianus I have employed extensively. Fowlers 
solution is sometimes useful in arresting the symptoms 
of hectic fever. Pectorals & opiates, in some cases, are
indispensable; but if the patient can do without them, it would
be better.
_____________________________X____________________________

Peripneumonia Notha.
I now come to the description of a disease rapid in
its progress, & truly formidable in its nature; I allude to peripneumonia 
notha or bastard pleurisy. This is in fact a serous 
apoplexy of the lungs. So far as my experience has gone, it
is peculiar to elderly persons who have been previously diseased.
It may occur occasionally among drunkards in earlier life.
I know no better method of giving you a correct view of this
disease, than by describing some cases which I have had an
opportunity of attending.
Case of John Thompson. – John Thompson a respectable
old gentleman of this city, after having lived beyond his 70th
   
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




356
year, met with a most serve affliction – he lost his eldest, 
& one of the best of sons. Soon after this event, it was evident 
that it had made a most powerful impression on the
father. He was a man of strong mind, & acute feelings;
& possessing great firmness of character, he suppressed his
emotions. The consequence was, that they preyed on his
health; & it was soon observed that his system was failing.
He began, in common language, to break; & truly he broke
very fast. He lost his former healthy aspect; his countenance 
became pallid; his flesh fell away, & he was reduced
to a state of great emaciation. The first time I attended
him with this disease, was one night about 11 o’clock.
When I arrived at his house, I found him labouring under the
most distressing dyspnea, & it seemed from the panting respiration,
as if every grasp might be his last. Along with this there was
an almost incessant coughing, & frothy expectoration. He appeared
in a state of agony from the difficulty in his breathing. His face
was collapsed & shrunk, & he had a most dreadful aspect. On feeling 
his pulse, I found it strong but irregular: the stroke was quick
but not remarkable frequent. I regarded it as a case of serous apoplexy 
of the lungs. I supposed that there was a strong disposition
to effusion: that the expectoration, which was incessant, might yield
some relief; but that unless the vessels could be speedily unloaded, 
the patient must die. This was one of those cases in which
no time is to be lost, & in which the interposition of practice must be
prompt & powerful. I bled the patient; & as the blood began
to flow, there was an evident amelioration of the symptoms.
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




357
I went on bleeding, & the patient getting better, till 30 or 40 oz
of blood were abstracted. At the end of this process there was a
striking amendment in the symptoms. Immediately after
the bleeding, I used the fumes of rosin. This remedy was recommended 
by Dr. Rush in cases of peripneumonia notha;
& I had seen it most signally useful in one instance of the
disease that had fallen under my own observation. In the
case of this gentleman, the rosin was thrown on a shovelful
of live coals, & the patient was soon enveloped in a fog of
smoke. He inhaled it with pleasure, & felt relieved. In addition 
to the rosin, I considered it necessary to give internal 
expectorant which might at the same time operate on
the nervous system. With this view I gave the lac assafoetida.
This was alternated with a decoction of seneka, which you know
is a powerful expectorant. A large blister was applied to the
breast. – I saw this old gentleman in three attacks of the
disease, from all of which he recovered under the treatment I
have just detailed. He was finally worn out, & died at last
of hydro-thorax.
Case of Sarah Lippincott. – The subject of the present note
was a female truly lovely in old age. For sweetness of temper
& disposition she was equaled by few, & I doubt whether she was
surpassed by any. For some months before her attack her health
had been gradually declining; her countenance had shrunk,
& she had begun to exhibit the marks of old age. On the morning 
of the 13th of the 3rd mo. I was called to see her. On
inquiry I found that she had been much debilitated for
  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




358
several weeks; had been troubled with dyspnea, particularly
in ascending a flight of stairs; & for 3 weeks, in consequence of
a cough with which she was troubled, she had taken twelve
drops of laudanum every night. The night before I was
called, she had suffered extremely with a sick stomach; &
in the morning I found her with evident disease of the chest.
I suspected hydro-thorax; but as she could lay with her head
low, & there was no marked diminution of urine, I did not
make up my mind positively; but concluded to apply a large
blister to the chest, & wait a few hours for further light on the
case. Her pulse, at this time, was firm & without much
irritation. I visited her again in the afternoon. The blister
was on her breast; no material change had occurred, & I
concluded to give her 15 drops of laudanum at night, intending 
next morning to pursue some regular course of treatment. 
But about 10 o’clock I was suddenly summoned
to her to witness a state of agony, coupled with extreme danger, 
such as I have seldom seen. Just before I was called 
she was seized with most violent apoplexy of the lungs.
When I arrived she was panting for breath in the most distressing 
manner; unable to lie in bed, & in a state of the
most extreme suffering. Her skin was cold & clammy;
her countenance shrunk; her lips livid; her pulse, happily
for her, was strong; & unlike other cases I have seen, she
coughed but little. I proposed bleeding, to which she rather
objected. I applied sinapisms, & requested an immediate
consultation; for I was really afraid she would die in

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




359
a short time; & I was desirous of having some one of my
medical friends with me, that my views of the case might
be judged of, & the responsibility divided. Dr. Octo, who lived
near, saw her with me very soon. He fully concurred with
me in the use of the lancet; & although it appeared as if every
gasp would be her last, I tied up the arm & opened a vein.
As the blood flowed, there was a gradual abatement of her
distress; & we persevered until we had taken away about 40
oz. During the bleeding, particularly towards the conclusion, 
the livid colour of the lips changed, & the countenance
became more natural. After the bleeding we commenced
with the fumes of rosin, which were very grateful to her, and
evidently relieved her breathing. We next tried the volatile
julap: but this did not appear to suit the case. I then
gave her the following mixture:
R. Assafoetida 3iij
Mint Water zvj. Rubbed down.
The dose was a tablespoonful every hour, to which was added 
5 drops of antimonial wine. The very first dose of this
mixture afforded her relief. I remained with her till nearly 
2 o’clock in the morning, & then left her with directions
to continue the assafoetida & the fumes of rosin. Next morning, 
(the 14th,) at 9 o’clock, I found the patient quite as well
as we could expect, considering all circumstances. The blister
on her breast had drawn pretty well; her breathing was
still laborious; she coughed & expectorated some mucus,
but it was raised with difficulty. On considering the case
     

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




360
we concluded to draw a few ounces of bloods; hoping in this way
to relieve the lungs. I took away about 4 oz. When she complained 
of being sick. Her skin became more cool, though
her pulse did not materially vary. Although the quantity of
blood taken was so small, yet it really appeared to afford relief.
We now placed her on the use of a table spoonful of the decoction
of seneka every hour, & a wine glassful of wine whey in the intervening 
half hour. The whey was found of two parts of
milk & one of good Madura wine. In addition to these, we
advised an occasional dose of assafoetida whenever she was restless, 
& the continuance of the fumes of rosin. During the day,
as well as the preceding night, she slept a great deal; but her
naps were short, & her breathing at times very laborious, particularly 
during sleep. Her bowels were opened during the course
of the day. At one time she could not take the wine glassful 
of wine whey, & we allowed arrow-root seasoned with wine as
a change. During the next 24 hours the same practice, with
a little variation, was pursued, & an evident improvement was
observable. Her position in bed was natural; & she expectorated,
though not so freely as we could wish. Her respiration was not
yet natural. The rosin, at first so grateful & relieving, now
became disagreeable to her, & was omitted. The same general plan
of treatment was continued through the night of the 15th, which
was passed uncomfortably in consequence of the seneka purging
her more frequently than was desirable. She recovered from this
attack; but died in the early part of summer.
Now, in these two cases, you see a practice that is mixed, &
  

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




361
you might suppose it contradictory. On the one hand the
lancet is employed with great boldness, & on the other diffusible 
stimulants are resorted to. You would naturally inquire, 
how should this be? But you must recollect that
we are treating, not inflammation; but merely congestion
of particular vessels. You should recollect also that in some
very debilitated subjects, there is a strong tendency to local congestion 
without any inflammation. Thus, in the cases which
I have related, there was a strong determination of blood
to the lungs, producing an engorged state of those organs,
which, if suffered to continue, must have produced fatal 
consequence. This called for the lancet. But after the vessels 
were unloaded, & the hazard of effusion was thus removed, 
we had to contend with the danger from debility.
Hence, in this stage, wine whey & volatile alkali are very
appropriate; & at the same time to relieve the lungs still further, 
& to establish a natural outlet, less debilitating than V.S.
expectorants may be introduced with great advantage. Hence,
assafoetida, seneka, & rosin are employed. Besides its powers
as an expectorant, assafoetida proves useful by its operation on
the nervous system. Rosin sometimes produces the most
useful & striking effect.
If you arrive before effusion had occurred, & your patient
has a strong, active pulse, he may, probably, for that time,
escape. But if you find this dreadful condition of the pulmonary 
organs with a languid circulation, it is probable that
all your attempts will be unavailing. But let the pulse be
      
  

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




362
as it might, I should open a vein, & judge from the effects
produced, whether it would be proper to proceed.
Before closing the subject, I wish to call your attention
to another case which might be termed apoplexy of the
lungs, not from serum, but from blood.
Case. – During my attendance in the Philadelphia Dispensary, 
I was called one morning into some remote street,
to see a black man. He had been taken ill in the night
with extreme difficulty of breathing. When I saw him in the
morning, he was labouring under difficult respiration, free
from pain, & with a pulse barely perceptible. In this case
the fatal stroke had been given, & all my efforts to save
him were unavailing. I had an opportunity of making an
examination after death, & found that the lungs were completely 
engorged with blood.
You will recollect then that peripneumonia notha is an
apoplexy of the lungs, generally of a serous character, but occasionally 
without effusion of serum.
We not unfrequently have to witness serous effusion into
the lungs as one of the last symptoms of thoracic disease: it is
one of the most common terminations of pneumonia, when
the complaint ends fatally.
   
  

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




363
	Spasmodic Affections
		of the
	Respiratory Organs.
		Asthma.
	    ______X______

Asthma may be regarded as a spasmodic disease affecting 
the respiratory organs. I shall not enter into an accurate 
account of the disease & its treatment; but shall merely
make a few general observations.
Asthma is a hereditary complaint, & is often much more
alarming in appearance than in reality. I will almost
venture to say, that if you are accustomed to attend patients
in this disease, you will be extremely alarmed on witnessing
a paroxysm. You might suppose that it would destroy
life: yet the fact is, that patients affected with this disease,
often live to old age. Many persons have passed their 80th
year, who during their life have been more or less affected
with asthma.
In the commencement, in young & vigorous subjects, an
occasional use of the lancet is beneficial. But when it assumes
a chronic character, as it almost always does, I am accustomed 
to depend very much on the use of antispasmodics.
		Spasmodick Cough.
Occasionally I have met with patients who were
suddenly seized with a spell of almost incessant coughing,

   

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




364
which seemed as if it would wear them out, & fatigue them
almost to death. I once saw a case of this kind with Dr. Emlen, 
in which an emetic afforded immediate relief. Emetics
& antispasmodics are the proper remedies in this complaint.
Spasmodic cough, however, sometimes assumes a more chronic 
character; & then, without care, it may be confounded with
disease of an inflammatory character. From these it differs essentially, 
& would be aggravated by the antiphlogistic treatment.
In order to illustrate this disease, I will present you with a
case.
Case. – I once attended J.T. Longstreth’s wife through a
severe paroxysm of this disease. In several previous attacks,
I had adopted a plan of treatment rather of the antiphlogistic
character – antimonials were liberally employed, & opiates were
frequently exhibited. But I was led to remark in the course of
my attendance, that the remedies employed appeared to produce 
no effect. I attempted to quiet the cough with anodynes;
but I was disappointed. The usual pectoral mixture totally
failing in relieving it. She would get through the attack; but
I was not satisfied that any thing I did was of any real service. 
When I was called in another attack, I determined to pursue 
a different course; & instead of the antiphlogistic treatment,
to resort to the use of antispasmodics & a generous diet. As I had
failed in relieving the cough by the usual pectoral mixtures 
& anodynes, I made up my mind to try some other
plan. I put the patient on the use of a remedy which produced 
the most happy effect, & calmed the cough surpri-    
   

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




365
singly: it was a mixture which had for its base a most
active ingredient, the rectified oil of amber. The prescripttion 
was as follows:
R. Rut. ol. Of Amber, gut Lxxx.
Pulo. G. Arab.
Loaf Sugar, aa Zp.
Tinct. of Balsam Tolu 3ij
 Water. 3iv. M. 		Dose a table
spoonful, to be administered every one, two, or three hours,
prorenata. Besides this remedy, I found considerable
advantage from the infusion of valerian, in the proportion
of one ounce of the bruised root to one pound of water. The dose
was a wine glassful frequently repeated. The diet was generous. 
Treated on this plan, instead of remaining sick for three
weeks, as she had previously done, she recovered in a few days.
Case 2. – Sometime after the above case, I was called to see
a French Lady, in consultation with Dr. Monges, who laboured 
under the same disease. She was attacked with the cough
soon after confinement with a child. It proved very obstinate; 
& her friends were under the impression that she was
in a consumption. On hearing the account of the case given
by Dr. Monges, & making my own observations on the patient,
I was induced to believe that the cough arose from debility;
that it was spasmodic, not inflammatory; & was to treated,
not by antiphlogestic remedies, but by those of an opposite
description. I was struck, as in the former case, with the total 
inefficacy of the usual pectora mixtures in reliving
      
   

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




366
the cough. At the same time the absence of fever, & the
strong symptoms of debility confirmed me in my opinion as to
the proper course of conduct. I stated to Dr. Monges the case
of Mary Longstreth, & advised the oil of amber. He agreed with
me as to the propriety of it, & it was employed. It acted most happily; 
& the cough which had been extremely obstinate, yielded
to the remedy. The patient was kept on the tonic plan; & measures 
were adopted calculated to invigorate the system.
I have thought it proper to present you with these cases, to
prove the existence of a cough which has nothing to do with an
inflammatory condition of the lungs. If in the last case the idea
had been taken up that the cough, & the patient treated accordingly,
she would have been placed in a dangerous if not an incurable
condition.
Sometimes a particular kind of air will affect the pulmonary 
system, & induce cough. I recollect a patient in the AlmsHouse, 
who was affected with cough of a very obstinate nature,
which completely resisted the treatment usually resorted to.
At last he determined to have the institution; & the simple change
of air removed the cough.
Peculiar Catarrhal Affection
of
Children.
In the course of my practice among children, I have met
with a disease to which I wish particularly to invite your attention. 
It appears under the form of a catarrhal affection. The
         

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




367
patient appears, & really is, extremely ill. In some instances
it seems as if life were in the most imminent danger. The child
is affected with difficulty of breathing; & the dyspnea, though
constant, to greater or less degree, is yet much more violent
at one time than at another – assuming the paroxysmal type.
The paroxysm resembles that of asthma. In some instances
I have seen a cold skin, shrunk countenance, & cold check.
The last symptom is worthy of observation. I am much in
the habit, in the pulmonary diseases of children, of laying my
hand on the check, to ascertain its temperature. If I first it cold,
I consider the situation of the patient so critical as to call for
my close attention. The pulse is generally feeble; but, in some
cases, it has a little irritation which might lead an inexperienced 
practitioner into an opinion that the lancet is proper. I
have known this disease to occur when the catarrhal fever has
prevailed among children; & when, as a general rule, the lancet 
was proper. It seems as if the same cause, in persons of different 
constitution, might produce diseases requiring very different 
plans of treatment.
Case. – I will read you a case of this disease, as it occurred
in the child of Robert Buckhart, a bleeder in Front street.
I was called in the morning of the 11th of 7th mo. 1810, to
the infant daughter of Robert Buchark. Her breathing was
difficult, her pulse febrile in a moderate degree, & she had some
cough. I was informed that a few days past she had been affected 
with diarrhea which had ceased; her gums were swelled. I
lanced them immediately, & concluded that by restoring the diar-
             

  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




368
rhea, she would be relieved; & ordered some castor oil, &
also a stimulating liniment to rub the breast. On visiting her
in about 4 hours afterward, her breathing was more difficult,
& her bowels not moved. I directed a purge of calomel & an
enema, took a small quantity of blood from the arm, & directed 
antimonial wine in small doses. About 9 hours after
this, I was sent for in great haste; & on my arrival found that
her friends believed her to be dying; & really, from her appearance, 
I did not wonder at their alarm. She was apparently 
insensible; her respiration was extremely laborious; her countenance 
sunk, & her pulse very feeble. I should have given
the case up pretty much, as a gone one, had I not witnessed
recoveries under similar circumstances. I ordered the warm bath,
sinapisms to the feet, a large blister to the breast, injections containing 
assafoetida, & calomel, as the bowels continued constipated,
& my favourite medicine – gum assafoetida in mint water, given 
frequently & in large doses; & to the astonishment of almost
every person, the poor little creature recovered perfectly.
Dyspnea. – The little subject of the present memorandum,
was affected very similarly to R. Buckhart’s child; although the
prospect of immediate dissolution was not quite so threatening.
I was called in the night on account of extreme difficulty of
breathing, accompanied with a pallid countenance, cool
skin, & feeble pulse. The dyspnea varied; sometimes it would
be considerably better, then recur with violence. Throughout the
disease, the circulation seemed rather languid; hence no
bleeding was required. The treatment principally consisted


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




369
in warm bathing, a large blaster to the breast, opening the bowels 
with small doses of calomel, & the liberal use of assafoetida,
given by the mouth, & at night in the form of enema combined 
with a few drops of laudanum. Also the volatile julap
was employed occasionally as a substitute for the assafoetida.
After the more alarming symptoms were subdued, it was severily 
afflicted with colic which yield to mint water, fomentations, 
etc.
Since this last case, I have occasionally met with this
form of disease among children; & I have great reason to
be well satisfied with the use of assafoetida in the treatment
of it. But I think I can propose a very valuable addition:
I mean the fumes of rosin. In the family of Ino. Suffrain,
I have seen two cases of a most violent character, in which
I gave the lac assafoetida, attended with seneka; & the fumes
of rosin were liberally employed. This last remedy, so far from
being unpleasant, is, in general, exceedingly grateful. I kept
the room almost in a fog of smoke; & the respiration was in
consequence, much improved. In addition to these remedies
I employed blister to the chest, & the warm bath; & attended
to the state of the bowels. I am not sure that calomel answers 
better than castor oil, as an opening medicine.
In the use of assafoetida, in this disease, I am guided very 
much by the age of the child. I generally tell the mother
to give it of such a strength as the child can bear. For instance,
I direct 3i to be rubbed down with 3i or 3if of mint water;
& of this, a tea spoonful is the proper dose. You need not
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




370
fear giving too much of the medicine; for it contains no
narcotic principle. A tea spoonful of the lac assafoetida
is to be given one hour, & a dose of the decoction of seneka
the next. I continue the seneka, sometimes, till it produces 
vomiting.
I have found my success very considerable in this form
of disease in children. I believe an opposite practice, founded 
on a belief that it is an inflammatory affection, would
be likely to produce more mischief than benefit.
I have seen the same peculiar spasmodic respiration in
the latter periods of hooping-cough. This you will find a
very serious disease. A practice very similar to that above
related, I have seen singularly useful in some cases of pertussis, 
in the latter stage, accompanied with difficulty of
breathing. When this occurs, the disease is always dangerous.
While the little patient runs about, & vomits freely, & the respiration 
remains natural, there is seldom any danger. But
when we find no disposition to emesis, & at the same time
dyspnea makes its appearance, we must be closely on the
watch. The complaint in this case, is not generally inflammatory, 
but spasmodic; & antispasmodic, not antiphlogistic, 
measures, are appropriate. Assafoetida, the rectified oil
of amber, seneka, & the fumes of rosin are valuable remedies.
In one case I recollect, when this state of things appeared 
in the last stage of hooping-cough, & the danger was most
imminent, I saw nothing more useful than the steady employment 
of assafoetida & rosin. I have also known anodyne   
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




371
injections exceedingly useful in this case. But here let me
observe, that there is one rule with regard to this remedy,
which I wish you to remember. It is customary in the
administration of laudanum, as indeed of other medicines, to
give three times as much by the rectum as you would administer
by the mouth. But from observations which I have
made, although this rule is generally correct, yet I am
inclined to believe that constitutions vary much in this
respect; & that, in some individuals the comparative sensibility 
of the rectum to the stomach is much greater than
is commonly imagined. You should, therefore, be careful
not to let your calculations be too liberal. If you wish to
give an anodyne injection to child of one year old, with
this complaint, take a large tea spoonful of lac assafoetida
prepared as before mentioned, & add to it a dissert spoonful
of flaxseed tea. To this 6 or 8 drops of laudanum may be
added. This quantity is quite sufficient for the first trial.
If no unpleasant effects are produced, you can afterwards increase 
the quantity.
		Catarrhal Affection which Occurred
				in
		     John H. Cresson’s Family.
The parents of this family were most singularly afflicted in
the loss of their children. They followed to the grave six sons in succession 
– all of whom died in early infancy. The oldest was 14 mo.
the youngest 5 months. Of these 5 died of a disease which I am a-
  
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




372
bout to describe. I will here remark that the deaths were
confined to the male children. So fatal had this complaint
proved, that when a child was attacked, the parents considered
it as inevitably gone. The mother informed me that in one instance, 
a girl had been attacked & recovered without medical
treatment. The last of the five died under my care, & I had an
opportunity of seeing the disease from the commencement. The
other cases had been treated by antiphlogistic measures, as they
were supposed to depend on an inflammatory condition of the lungs.
That which fell under my care was managed differently; though
not exactly on the plan which I afterward adopted. The child
was delicate, & had some symptoms of pertussis blended with
the disease.
The complaint appeared in the form of a catarrhal affection,
with some cough, & steady difficulty of breathing as described in
the preceding cases; but in some of these there was more apparent 
action. The last one that died I had an opportunity of examining 
after death, I ascertained that there was not the slightest 
appearance of inflammation in the lungs. There was some effusion 
into these organs, such as we often meet with, & such as
may occur in cases of debility; but there was no effused lymph.
The knowledge derived from this dissection led me to reflect on
the subject, & I reasoned thus with myself. This child from
some cause which I cannot explain, possesses a constitutional
debility of the pulmonary organs. This constitutional debility
is peculiarly inviting to disease, & when the disease makes its appearance, 
death inevitably follows. Under this view I conclude
   
 
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




373
that a prophylactic treatment is all important. – My object
was to pursue some steady plan of prevention; some method
of invigorating the part constitutionally predisposed to debility, &
place the patient in a condition to resist the disease if it should
make its attack. The fact which was related to me by a gentleman 
of New-England, & which I mentioned on a former occasion, 
viz. that he had rarely if ever known a caulker affected
with pulmonary consumption, presented itself to my mind;
& I at one advised the parents to commence a course of
prophylactic treatment with the remaining children, & with
those which might afterwards be born. I advised them
to subject their children to the fumes of rosin at a certain
time every day. Having suffered so much, they were fully 
prepared to enter heartily into any plan I might direct.
Accordingly, with the remaining children, & one born
sometime afterward, this practice was pursued. The children
became fond of it. In progress of time, I was summoned
to see the infant (which had been subjected to the prophylactic 
treatment from its birth) labouring under this terrible 
malady. It was apparently extremely ill. I had determined, 
in my reflections on the subject, to lay aside all
idea of inflammation in any subsequent case. I employed
the following treatment: The room was enveloped in a
fog of rosin, & the child would paddle in the fumes with
delight. A blister was, at once, applied to the breast, &
the bowels were opened with castor oil. But I am inclined 
to believe, from what I have since seen, that a little
   
 
   
 
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




374
time was lost in waiting for the operation of the medicine.
I also prescribed a mixture containing rectified oil of
amber, alternated with seneka. With this practice I had
every reason to be delighted. The child shortly recovered; and
this was the first instance in which a son had passed thro
the disease. Since that time, I have attended the same
child in the same disease, with the same happy result.
I also attended, in the same complaint, two other children,
females, one of whom was extremely ill; & both recovered.
I will read you an account of the treatment, as drawn up
& presented to me by the parents.
“3rd mo. 16th, 1820. – Called Dr. Parrish to Mary & Sarah,
both of whom were very seriously indisposed. The decoction
of seneka snakeroot was immediately directed. At 9 o’clock,
P.M. gave Mary enough of it to occasion vomiting; at 10 o’clock,
applied poultices on her feet & a blister on the breast, & administered 
a tea spoonful & a half of the following mixture:
R. Ol, succin. rectif. qtt xxxiv
Sacch. Alba
Pulo. g. Arab. Aa 3j
Aq. Cennam. Simp. Zij
The seneka & the oil of amber were continued alternately thro’
the night. Her mother, who sat up during the night, was
struck with an obvious improvement about 2 o’clock in the
morning. The same treatment was afterward continued, tho’
not with so much regularity. This child has just completed 
her 3rd year; & in infancy had been raised from a very
  
   
 
   
 
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




375
low state by the application of similar remedies. Sarah, who
was only 6 months old, was treated in the same way, the
proportion in the dose being conformable to their ages. It was
observed in her case that the seneka operated powerfully on
the bowels, & occasioned a great prostration of strength as to render 
the discontinuance of it necessary. The quantity of the mixture 
of the oil of amber given her was half a tea spoonful every 
hour. About 2 o’clock, P.M. on the 17th, a great change
for the better had taken place, & the same treatment was continued. 
The night of the 17th was passed very comfortably 
by Sarah, & she was manifestly improved. The other
daughter was distressed through the night with violent
spells of coughing, which continued during the next day.
In the evening of the 18th, 15 drops of antimonial wine were
given in the decoction of seneka, & poultices were applied
to the feet. Sarah continued to mend through the day;
but was somewhat restless at night; & the snake-root
was resumed. Mary passed the night better than before.
On the 19th both of them were so much recovered that little
further medical attention was necessary.”
Fife case, in this family, I have treated on this plan,
and every one with success. – We have here an instance
of what may sometimes be done by clearly understanding
a disease. From its symptoms, the complaint might have
been mistaken for an inflammatory catarrh; & in some
instances was treated as such. The information I derived
form dissection, induced me to put inflammation entirely
   
   
 
   
 
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




376
out of the question. This goes to prove the necessity of
studying a disease more closely, & of endeavouring to acquire 
a knowledge of peculiarities of constitution, or, in
other words, of idiosyncrasies. The longer I live, the more
strongly I am convinced that idiosyncrasies of an important 
character, are sometimes met with in practice; and
much observation & considerable experience are necessary 
become we become fully aware of them. I regret to
say that I have known a time when experience was divided, 
& principles, not facts, were considered important 
to the practitioner. To this I do not consent. I only
regret that there is not more experience among us. If
medical men were more careful to keep a record of
their experience, medical science would be promoted, &
many patients would, no doubt, be rescued from the
grave.
From what I have said with regard to the disease
which prevailed in J.H. Cresson’s family, & from the cases 
which I before mentioned of another complaint in
children, & of the spasmodic cough of adults, you may gather 
that the pulmonary system is very liable to spasmodic
disease. In children complaints of this nature are very
difficult to be distinguished from those of an inflamematory 
character. Children are unable like adults, to
speck and to express their feelings. They cannot point out
the particular part of their body which is the seat of disease. 
As, therefore, we are cut off from vocal communi-
   
   
   
 
   
 
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




377
cation with this interesting class of patients, it becomes
the more necessary for us to study the language of nature
as it speaks in their actions. To understand this requires
much experience. An affectionate mother, or an attentive
nurse, generally knows more of the complaints of children 
than a young practitioner. I wish, therefore, strongly 
to impress on your minds the necessity of studying attentively 
the diseases of infants, & especially those of the
pulmonary organs.
			Pneumonia.
			____x____
	
You will find that practical writers, in pursuing nosological 
arrangements, draw a distinction between inflammation 
as it affects different parts of the cavity of the chest.
Thus we have the names of pneumonia, pleuritis, etc. But I
do not believe that any practical advantage can result from
a mere subdivision of the inflammatory affections of these
parts. I am inclined to the opinion that if active inflamemation 
affects the pleura, the lungs themselves will be brought
more or less into sympathy; or, on the other hand, if the substance 
of the lungs is involved in inflammatory disease, the
investing membrane will be likely to participate.
Patients affected with pneumonia are generally seized with
a chill. This is succeeded by fever, &, as a general rule, more
or less pain, (sometime very acute pain) is experienced in
some part of the thorax. The pain is often confined to one
 
   
 
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




378
side, every attempt to expand the chest by a deep inspiration 
generally increases it to a great degree. Hence, when
called to a patient with pneumonia, it is a general practice
to request him to take a long breath with a view of ascertaining 
this point. The effects to cough not unfrequently
excite a great deal of pain & distress. As the disease advances, 
some mitigation of the symptoms is commonly manifested 
by a more free expectoration. When this is the case,
we often find the disease disposed to yield. The expectorated
matter about the 5th day is not unfrequently tinged with
blood. This is circumstance which a young practitioner
should be fully aware of; & as Cullen justly remarks, “he
should not carry antiphlogistic treatment too far, from
apprehension of hemorrhage.” If the disease goes on happily, 
by the 7th day, we generally have a favourable crisis –
we have a decline of pain, easy respiration, copious expectoration, 
& an absence of fever. This may be regarded as a favourable 
issue of a common case of pneumonic inflammation. 
But in the course of your practice, you will be
called to witness cases of a different character. You will
find every effort to relieve the pain ineffectual. Sometimes
confined to one side, it will suddenly leave this & attack
the other. It is manifest that the disease has now invaded 
a new part, & at a time too when the system is less
able to resist it than at the commencement. An unmanageable 
& fatal case, not unfrequently terminates
about the same time as a favourable one; i.e, on the
     
 
   
 
     

 
  


  


  
     
       
 
      
    
     
         

      
       
     
   
       


    
      

    
     
    

     
      

  
        


         
          
     
  
     
 
    
  
    
       
        
  
     
 
 

    
 

     
  
         
    

       
 
   
       
     
   


  
 
       
   
         
       




379
7th day: & this termination is often by fatal effusion. You
will visit the patient, & find him labouring under extreme
difficulty of breathing, a rattling of mucus in the trachea,
expectoration almost entirely suspended, livid nails & lips,
cold clammy skin, a feeble pulse, & hippocratic countenance. 
Death soon closes the scene. These remark apply
to cases of an ordinary kind. But we occasionally meet
with symptoms very different from those described.
Sometimes the inflammation is suddenly transferred to the
brain; symptoms of phrenitis arise, & in one case which
fell under my observation, something like apoplexy closed
the scene. The occurrence of phrenitis in the progress of
pneumonia, is always to be regarded as extremely dangerous. 
There are other cases which pursue a still different
course. After having watched the patient with a great deal
of solicited & intent, & administered those remedies which
you may judge most suitable, you wait with anxiety for
the period of a favourable crisis. But this crisis does not
arrive. A mitigation, it is true, of the more violent symptoms 
takes place; there is less urgency in the pain, cough,
& respiration – if I may be allowed the term, a semi-crisis 
occurs. But still a great deal of mischief is going
on in the chest – the pulse becomes very irritable; a hectic
blush on the countenance is sometimes exhibited; a cough
harassing & often dry is observable; occasionally chills,
succeeded by flashes of heat & fever, & followed by sweats,
make their appearance; & in short, the practitioner per-



380
ceives that symptoms of hectic fever are wearing down
the patient. He understands fully what is to happen. There
is every reason to believe that vomica or abscess of the lungs
has formed, or is forming. Some of these cases of vomica will
in the end terminate favourable: & there have been instances 
where large collections of matter in the chest have been
discharged & the patients have recovered. The bursting of a
vomica is a thing well understood by every practitioner.
If this abscess find a ready outlet through the trachea, & its
contents are discharged in that way, the patient may sometimes 
recover. The recovery seems to be concluded on precisely 
the same principles that regulate inflammation of
any other part. After suppuration & the loss of substance by
ulceration, granulations may arrive & fill up the cavity,
& the parts become consolidated. In this way abscesses in
the lungs sometimes do well. It occasionally happens that
the abscess points externally; & the pus may be discharged
wither spontaneously or by a puncture through the parietis 
of the thorax. Cases of this kind may also do well.
But it sometimes happens that the vomica bursts & the
matter is effused, without an outlet, into the substance of
the lung itself. In this case immediate death not unfreequently 
occurs. Here I wish to be distinctly understood, as
drawing a very marked line between abscess of the
lungs as a consequence of common inflammation, and
real phthisis pulmonalis. The two complaints are frequently 
confounded, & the practitioner very honestly as-  

 



381
sumes to himself the credit of curing pulmonary consumption, 
when in fact nature has been curing a common 
abscess of the lungs on the same principles that she
would cure an abscess in any other part.
With this general outline of pneumonia before you, you
will be prepared to understand me when I say, that it is
a disease of local inflammation, attended with symptommatic 
fever; & that it requires, in common, a very free
use of the lancet. You will recollect that we have to
contend with inflammation in a part very vascular, &
easily excited to disease. The measures, therefore, should be
as prompt, & pushed to as great an extent, as the strength
of the patient will allow. In pursuance of the common 
course which has been adopted in the treatment
of fever, we might very naturally suppose that the
next step after relieving the blood vessels by the lancet,
should be to evacuate the bowels by brisk cathartics: but
I believe the experience of intelligent practitioners is against 
this plan. Drastic purges are not likely to be useful 
in pneumonic inflammation. It is, however, always
proper to unload the bowels by gentle purges; & for this
purpose epsom salts, castor oil, & similar articles may
be used. In addition to these, demulcent drinks are
strongly recommended. Haxored tea acidulated with
lime juice & barely water are particularly proper, especially 
in the early stage of the disease. Antimonial
medicines hold a high rank in the treatment of pneu-

 
 



382
monica; & hence, the common antimonial power is
very generally prescribed in the commencement of the
disease, after bleeding & gently evacuating the bowels. But
you should remember that you have to contend with
a very harassing cough, which jars the patient, & throws
him into violent pain; & that you must adopt some plan
to relieve this without increasing the febrile action. Some
practitioners are opposed to the use of opium, even in small
quantities, in the early stage. But a physician is frequently 
under the necessity of choosing between two difficulties,
& to adopt the course which will prove of the most advantage.
In the case before us, the lesser evil is to employ opium in
small doses, & in combination with some articles which
a tendency to determine to the surface. It is a common
practice with me to prescribe some pectoral mixture, even 
in the early stage. In selecting a formula I always
use laudanum in preference to the paregoric elixir. The
latter is objectionable on the ground that it contains a large
proportion of alcohol than laudanum does; & besides, there
is one or two articles in its composition not well suited
to the early stage of pneumonia. My object is to combine 
with the laudanum some expectorant, as antimonial 
wine, & to mix these with a rich mucilage. The following 
formula will answer very well:
R. Ext. Glycyrrh.
Pulo. G. Arab. aa 3fs
Tinet. Opii gut Lx


 
 



383
vin. Antimo. 3iii
Aq. Fontan 3vi. M.
Instead of the antimonial wine, you may use two
grains of tartar emetic. Some persons dislike liquorice:
for these loaf sugar may be substituted. The dose is a table 
spoonful which in the early stages of pneumonia
may be administered every 2, 3, or 4 hours according to
the urgency of the symptoms.
There is another part of the practice which I regard
as much more important, & about which physicians disagree. 
Much has been said about a blistering point,
we have heard a great deal about the general excitement
in the system, & are taught by some that this excitement
is greatly increased by blisters. It is necessary, therefore,
they say, to reduce the system by bleeding, etc. to the blisterring 
point: viz. to that point in which blisters may be
applied without danger of increasing the fever & the local
inflammation. To effect this requires, according to these
practitioners, 2 or 3 days. On this subject I wish to speak
with decision. I have had extensive opportunities of treating 
inflammation of the lungs, especially in the Philadelphia 
Dispensary; & I have no hesitation in saying that
I can bring a patient with pneumonia to the blistering
point as soon as I please. I wish no longer time than
is requisite to bleed the patient once & unload the bowels.
I can, at once, reduce the system sufficiently by the lancet; 
but I prefer waiting till the bowels have been evac-
 

 

 
 



384
uated, as it would be inconvenient for the patient to be
getting up & down with a blister on his side. The blister
should be large. In pneumonia I regard the inflammation 
as the cause of the fever with which it is connected; &
I believe it to be important for the practitioner to direct his
remedies early & promptly to the seat of the disease. Therefore, 
I would by all means, advise you to employ early 
blistering in pneumonic inflammation.
After the disease has lost the violent which generally attends 
its accession, I believe a judicious use of opiates at night,
as recommended by Cullen, to be particularly proper. Towards
the decline of the disease, a grain or a grain & a half of opium,
with one or two grains of ipecacuanha, will procure rest at
night, & the patient will often be greatly refreshed in the mourning. 
– But I should have observed, that in the progress of
the disease, for the first few days you will frequently be under 
the necessity of repeating the bleeding, sometimes twice
a day, or even oftener, if the symptoms are urgent.
There is one point to which I wish particularly to direct
your attention. When the disease is in its wane, it is not uncommon 
for free expectoration to take place, & for the matter 
to be tinged with blood. Here the young practitioner
should be on his guard. He might think that there was
some violent action in the lungs, & an additional call for
the lancet. Theory may say one thing, but experience
says another. The experienced practitioner will tell you
that there is a disposition in the pulmonary organs to re-
    

 

 
 



385
lieve themselves by free expectoration. Nature is holding
the lancet in her own hand, & is bleeding herself. She opens
a thousand little vessels in the lungs, & pours out mucus
sometimes mixed with blood. At this juncture, when
there is a decline of fever, & an increase of expectoration,
if the practitioner interfere & use the lancet freely, he may
materially interrupt the salutary efforts of the system;
he may lessen the vital power, diminish expectoration,
(which is important at this crisis,) & debilitate the patient
without making any salutary impression on the disease.
Hence, I should say that while it requires great judgement 
to determine on the extent to which blood may
be abstracted, it requires equal judgement to know the
stopping point.
This then, forms a general outline of the practice
adapted to common cases of pneumonia. But I regret
to say that you will often meet with cases of a very mixed 
character, which, from a variety of causes, will acquire
a deviation from the course which applies to patients generally. 
Thus you will see instances where the evidence of
pneumonic inflammation in the onset of the disease
is very obvious, & yet it is so combined with other symptoms, 
as to render the common practice inadmissible. We
sometimes meet with cases in which the disease is ushered 
in by diarrhea. I think I can say, as the result
of considerable experience, that I have never seen a
case of pneumonia ushered in by diarrhea, that has

    

 

 
 



386
not run into a low form of fever, & involved the patient
in great jeopardy. In such cases, the lancet, so far as
my experience has gone, cannot be used with that freedom 
with which it is employed in ordinary cases. Instead 
of it, blistering should be early resorted to. If any
blood is taken, it should be with great caution; & the best
method is to use cups.
In some cases of pneumonic inflammation, the
strength of the patient fails, & when expectoration is difficult, 
you will find it necessary to resort to measures
that will have a two-fold effect. Some remedy will be
necessary which, while it elevates the whole system, possesses 
at the same time expectorant qualities. For this
purpose the volatile alkali is admirably adapted. You
will also meet with instances in which seneka, (not proper 
in common cases,) will be obviously useful.
I wish now to give you a case or two of pneumonia
ushered in by diarrhea. I have stated that I never saw
an instance of this kind without finding it difficult of
management, & disposed to run into a low form of disease.
Case of Wm. Kempton & his wife. – When I was first
called both were labouring under diarrhea, with symptoms 
of pneumonia, & a low form of fever. The lancet was
not employed. On the contrary, mildly simulating measures 
were pursued, particularly with the husband. In
both cases blisters were applied on the breast with great
advantage. Serpentaria was used in the form of decoction.
    

 

 
 



387
We employed weak wine whey. Irritability at night was
allayed by opium, & the heat & dryness of the skin were relieved 
by febrifuge draughts. – They both recovered contrary 
to expectation. The form of the disease, I had reason
to believe, was, in both cases connected with mental depression.
I will now read some observations which I made
on pneumonia, during my attendance on the Philadelphia 
Dispensary in 3rd & 4th months, 1807.
Many cases of pneumonia have came under my care; and
as far as my experience has gone, great caution is requisite
in the management of the disease: For, although it is presumable 
that extensive evacuations are always necessary in
the commencemen, yet variation from this practice is, in
some instances, necessary. Instances have occurred, in my practice, 
of an early disposition in the disease to take on a typhoid
form, as is indicated by disturbed sleep, accompanied with
a low, muttering delirium when dosing. In two cases I have
known a spontaneous diarrhea to appear, combined with
the above symptoms. At the same time the skin will
be hot, & the pulse of a peculiar kind – perhaps we might
call it hobbling. At one moment it conveys the idea
of arterial force; at another of debility – a combination of
weakness & moderate strength that is not a little perplexing.
If called in the early stage to a situated, I have not withheld
the lancet; but, at the same time, I have used it with
caution. The case of Wm. Bompard was of this description. 
I think it was on the 13th day of the disease that I
      
    

 

 
 



388
first saw him. He had been once bled; but when I
visited him the state of his pulse was such that I thought
it most prudent to substitute sups to the breast for the
lancet. A large blister was applied after the cups. I directed 
the antimonial powder & pectoral mixture; but
such was the irritable state of the pulse, & so profuse the
purging occasioned by the powders that I was obliged
to omit them. His situation was embarrassing. The serpentaria 
in decoction was order with a view of supporting 
the system & with a view of promoting expectoration.
On the following day, I began with my favorite remedy, 
ipecacuanha & calomel, to which a little opium was
added. As the diarrhea was soon checked, & the medicine 
did not seem to run off by the bowels, the opium 
was omitted. The patient became comatose. Cups
were now ordered to the head, & a large blister between the
shoulders. The coma left him, & he became delirious. At
this time his bowels were constipated. On visiting him
one morning, I believe the 7th day of his illness, I found
him dressed & sitting in the shoe-maker’s shop, insisting
that he was quite well while his whole appearance indicated 
extreme illness. While in this delirious state, I
requested my friend, Dr. Griffitts to see him with me. His
pulse was at this time was more active than it was in
the fore part of his illness. The Dr. Advised me to purge
him freely with calomel; to have his head shaved & a blis-
     
      
    

 

 
 



389
ter applied to it. The hair was cut off: but as the family 
would not allow blister to the head, it was applied
to the back of the neck. Five grains of calomel were directed
every 3 hours till it operated; 3fs was taken before even
a moderate effect was produced on the bowels. From this time
he began to recover. When the affection of the brain
was most violent, the disease of the breast was for the time,
entirely suspended.
Another patient in Prune street came under my notice 
with pneumonia, who, at the same time, had diarrhea. 
His skin was hot & dry, & his pulse throbbing.
Typhoid symptoms soon appeared, such as muttering delirium, 
etc. He was relieved by a small bleeding, & by blistering. 
But the poor fellow would not be controlled;
he continued to walk out & take care of his horse, even
the day previous to that on which he died. He had been
accustomed to the intemperate use of ardent spirits. On visiting 
him one morning, I found him labouring under
the symptoms of pneumonia notha. His countenance
was livid, his respiration laborious, his pulse nearly
gone; & in a few hours he died.
In cases when the disease will not admit of extensive
evacuation by the lancet, (which in acute pneumonia with
a tense pulse, is certainly a most important remedy,) calomel 
is my sheet anchor. I generally give it in combination 
with ipecacuanha. When the symptoms are urgent, 
I give qr ii of calomel, & qri of ipecac every 2 hours.
 
     
     
      
    

 

 
 



390
Sometimes it is necessary to add a little opium, if the
purgative effect is inordinate. Blisters are also an important 
remedy.
In a previous lecture I spoke of some of the fatal cases 
of pneumonia terminating in effusion. As the following 
is rather an unusual case, & I had an opportunity of making 
an examination after death, I will detail it to you.
Case of Rebecca Robinson. – She was 29 years of age
when admitted as a patient of the Phil. Dispensary. I visited 
her in the afternoon of the 23rd of the 3d mo. 1806; and
found her complaining of severe pain in the right side of
the thorax, attended with a cough which always increased the
pain. I immediately directed the loss of 12 or 16 oz. of blood
as the pulse required. As the bowels were constipated, I ordered
small doses of Glauber’s salts, to be repeated every two hours
till they operated, & advised the free use of demulcent drinks,
particularly flax-seed tea. I also prescribed a pectoral mixture 
to allay the cough. On the morning of the 24th, I visited 
her again. The symptoms were rather less urgent; but the
pulse being tense, I directed the loss of 12 oz. of blood, & prescribed
the antimonial powder, in addition to the pectoral mixture;
& a large blister was applied over the seat of pain. In the
afternoon I found her complaining greatly of the blister,
& was informed the pain had left her side: but I could
not help suspecting that her anxiety to get rid of the blister, 
induced her to give this account. As the pulse was still
tense, although the cough was a little abated, I thought it
     
     
     
      
    

 

 
 



391
right to direct another bleeding, & to pursue the same
plan as before, during the night. On the morning of the
25th, she appeared very much relieved from pain; the
cough had abated, but still the pulse was contracted &
tense. V.S. to 10oz. was directed. In the afternoon the pulse
began to flag, & the pain had ceased: but it was evident
from her appearance that the danger was increased. In
the morning she would make almost a full inspiration,
with little difficulty; but now there was a sense of uneasiness 
at the breast. I directed a blister to be applied to it
immediately. On the morning of the 26th, I was informed 
that she had passed an extremely restless night, and
had thrown up some blood. Every symptom now indicated 
the utmost danger. Respiration was very laborious, 
the wrists were cold, the pulse was scarcely perceptible,
there was no pain, some cough remained; but expectration 
which had been free, had now nearly ceased.
Another large blister was applied over the breast, & sinapisms
to the ankles. Stimulants were exhibited freely, as wine, wine
whey, serpentaria & assafoetida; the latter articles with a
views not only to their stimulant, but also to their expectorant 
qualities. Every exertion, however, was fruitless. Her
respiration became more laborious, & she died at 10 o’clock
on the night of the 26th.
Upon opening the body, 18 hours after death, the following 
appearances presented: The omentum was found adhering 
to the peritoneum, & the upper part of the liver was ag-
  
     
      
    

 

 
 



392
glutinated to the diaphragm by adhesive inflammation.
The right side of the thorax contained at last 2 quarts
of an extremely fetid & brown or chocolate coloured fluid, 
approaching to black; & several lumps of coagulated
blood were found in the cavity, & some were adhering
to the pleura on the side of the thorax. The lung pressured
its soft texture, & several parts of it bore the appearance of
incipient gangrene. The diaphragm, on the right side,
was very much thickened & its muscular texture quite
obliterated: it was of a firm consistence & of a dull white
colour. On the other side it presented its natural appearance, 
& the left lung was very little changed by disease;
the right was fixed to the diaphragm by two processes of
the same texture & colour as the diseased portion of the diaphragm. 
The pericardium contained about two ounces
of a light brown fluid, & a few shreds of coagulable lymph
of a whitish colour floating in it.
Upon further inquiry, it appeared that she had borne
3 children; that her husband deserted her about 12 years
before her death; that she had laboured under suppression
of the calamenia for 3 years, & that during this time she
had occasionally had a cough.
Pneumonia is often to be met with of a mixed character, 
in which case, owing to some constitutional peculiarity, 
or other cause, we are unable to pursue the course which
has been stated to be proper in favourable cases of the disease. 
You will meet with persons, in the course of your
     

  
     
      
    

 

 
 



393
practice, who are subject to a constitutional cough. Elderly
people of spare habit & pallid countenance are frequently
subject to cough & copious expectoration. This cough continues
for many years, & the lungs become so accustomed to the constant 
drain, that it is absolutely necessary to the very existence 
of the person so affected; & that which in common cases
would be regarded as a disease, in these individuals constitutes
a state of things essential to the preservation of life. When in
such persons the cough ceases, they become extremely ill, & during 
their illness the return of the cough is hailed as the messenger 
of life & health to the patient. I wish to put you an
your guard against mistakes with respect to this class of patients. 
In winter & spring they are often attacked with increased 
difficulty of breathing, & with some symptoms of pneumonic 
inflammation, with a loss of the cough. Here if we
were to pursue a course of treatment such as in common
pneumonia in persons of vigorous habits, we should rarely 
fail of doing more harm than good. Depletion must
be resorted to with the utmost caution. In some cases the
lancet must be altogether omitted; in others it may be cautiously 
employed; but even in these the use of cups should
be preferred. Your principal reliance should be on early blistering, 
expectorants, & if the strength fail, mild stimulants.
Among these wine & volatile alkali hold a distinguished
rank. With the volatile alkali you may very advantageously 
alternate some powerful expectorant, as seneka. I have
been in the habit of combining seneka & liquorire. I direct
        

  
     
      
    

 

 
 



394
3fs of bruised seneka & 3j of bruised liquorice root to be put
into 3 half pints of water & reduced by boiling to a pint.
This is a mixture very well suited to some of these cases.
But I wish to impress on you the fact that these persons 
will not bear extensive depletion. The cases will go
on for several days, the respiration will be extremely laborious, 
& the countenance shrunk; but as soon as you can
obtain a return of cough, they get better, & ultimately recover 
entirely. I am not prepared to say how the fumes of
rosin would act in these cases; but I am inclined to believe
that they would be well adapted to some of them.
Pneumonia occasionally requires another kind of practice. 
You will meet with cases in which you can employ
a little depletion; but not so much as you may desire. You
may apprehend that unless something more is done, effusion 
will take place; & you are desirous of instituting some
mode of practice which may prevent it. I know no better
method of conveying to you my meaning than by reading
some observations I made when my mind was anxious about 
several cases of this kind which occurred to me while
I was practicing as Dispensary physician.
7th mo. 4th, 1806. – Having finished a term of attendance
at the Phil. Dispensary of 4 months, I have taken the pen to
notice some occurrences relative to my patients in that Institution. 
– In the 3rd & 4th months, a number of cases of pneumonia 
come under my care. The first patient I lost
with that complaint was Polly Garrison, a woman in Mead
    
        

  
     
      
    

 

 
 



395
alley. She was in the 6th day of the disease when I first
saw her. She had been once or twice bled; but at this
time I did not think the lancet proper. I directed a
blister to be applied to the side, gave a mixture containing
tartarized antimony & nitre, & prescribed in the evening a decoction 
of seneka. Next morning I found that she lost medicine 
had not been procured. She was now labouring under
all the alarming symptoms of effusion – a livid countenance,
extremely laborious respiration, slight delirium, etc. Another
large blister was applied to the breast, & the volatile alkali was
administered in the form of julap – all in vain; she died in the
evening, on the 7th of the disease.
John Peters, a French black, was brought into the Poor-House
sometime in the same month. The poor creature was in a deplorable 
state, covered with filth & rags. He had been picked
up in the street on an extremely cold morning, & sent to the house
by one of the guardians of the poor. He was complaining of
pain in the side, which he said was occasioned by a blow on
the ribs; but it was evidently the effect of pneumonic inflamemation. 
Bleeding, blistering, & the antiphlogistic regimen appeared 
to be successfully employed, & poor John so for recovered
as to be able to walk about his room. But still a hoarseness
& an evident disease of his breast continued, under which I think
he must have laboured sometime previous to his admission.
I put him on the use of digitates: but the poor fellow was
at last seized with chilliness, & great difficulty of breathing;
& was affected with the common symptoms attending an ab-
 
    
        

  
     
      
    

 

 
 



396
scess in the chest. Seneka was pushed very smartly, blisters 
were applied, & at last volatile alkali & other stimulants
were employed – all to no purpose: he died several weeks
after his admission.
Several cases which terminated successfully are worth
recording. – Isaac Roach had been labouring under
pneumonic inflammation, I believe, for six days before
I saw him. He had been once bled. When I found him,
he was complaining of considerable pain, & had a troublesome 
cough. I bled him that evening; but found that
his pulse would not bear much depletion. The bleeding
with a large blister relieved him immediately; & he as well
as his friends thought he was on the recovery. But his
symptoms spoke a different languague; for, although he
was able to get down stairs, yet it was evident that the disease 
was gaining force in his chest. The quantity of urine
daily diminished, a sense of wright & uneasiness in the
breast ensured, & hydro-thorax was clearly present. The squill  
& calomel given in such doses as to induce a gentle salivation, 
very happily relieved him, & he was restored to his usual
health.
A very stout young Irishman came under my care after 
he had been ill about 6 days. During that time very
little had been done for him. Possibly he had been once bled.
His case assumed an alarming aspect. His respiration was
laborious, his pulse laboring, & the symptoms of incipient
effusion brought to my mind the many fatal cases I had
   
    
        

  
     
      
    

 

 
 



397
been compelled to witness. I reasoned thus with myself: 
What shall be done? Bleeding, by lessening the
quantity of blood in lungs may relieve my patient;
but the strength of the system is at this moment so much
diminished, that if any sudden evacuation should induce
syncope, I fear the power of reaction may be lost, and
the event prove fatal. But something must be done,
or in all human probability, the patient will die. When
effusion is about to take place, or has actually occurred,
in the cranium, for example, on what remedy do we
chiefly depend for the relief of the patient? Is it not mercury? 
In the present case then, it is evident that to bring
about a free expectoration, to arrest the progress of effusion,
& at the same time to watch carefully the state of the system, 
& if possible to determine with accuracy at what moment 
evacuations should cease & restoratives substituted, is truly 
desirable. With this view of the subject I took away a few
ounces of blood from the arm, carefully watching the effect
on the pulse. A large blister was applied to the chest, & a decoction 
of seneka with a view to its expectorant effect, alternated
occasionally with small doses of ipecacuanna & calomel, was
freely administered. He was also cupped on his breast the next
day. Mercurial frictions were used every 3 hours to the thighs
& a large blister was applied between the shoulders. I attended
him very assiduously for several days, sometimes visiting him
4 or 5 times in 24 hours; & although my patient at time rambled 
& frequently picked at the bedclothes, yet I had the pleas-
       
    
        

  
     
      
    

 

 
 



398
ure to see him recover. When I thought it proper to discontinue 
the ipecac & calomel, & seneca, I substituted the serpentaria. 
This with the frequent use of nourishment in small quantities, 
very happily, restored him, with the blessing of Providence,
to his former health.
I was called soon after the dreadful fire in Dock street, to
see an Italian sailor in Swanson st. who had exposed himself
considerably at that time. I found him labouring under
pneumonic inflammation. He had been ill several days
& had been once bled. His pulse was not very action. I drew
a few ounces of blood from his arm, blistered him, & used the common 
plan of treatment. Next day I bled him again. In both
instances the blood was sizy. On the morning of the 7th day
he had a wildness in his countenance, & a watchfulness which
indicated the approach of phrenitis. In a few hours he was 
furious. I directed cups to the head, applied a large blister
between his shoulders, & gave ipecac & calomel. Next morning 
I had the satisfaction of seeing him perfectly calm &
free from fever. His medicines were now discontinued, and
light nourishment, in small quantities, was frequently administered. 
He recovered perfectly.
Mary Luff, a poor unfortunate female who had fallen 
into habits of drunkenness, soon after a debauch, was attacked
with convulsions. On recovering from these, she was seized
with pneumonia, & I was then called to visit her. When I
saw her, she had very acute pain in the thorax, cough, bitter
taste in the mouth, occasional vomiting, & high fever. Her
            

  
     
      
    

 

 
 



399
disease, in fact, strongly resembled bilious pleurisy. The
lancet was freely used, & calomel was exhibited with a liberal 
hand. Blisters to the part affected, which were dressed with
mercurial ointment; & the usual remedies, as the pectoral
mixture, demulcent drinks, etc. were also resorted to. These
measures, vigorously pursued, had a most happy effect.
Ptyalism was induced, & on the 7th day a favourable crisis
occurred. And Mary was eventually restored to health; but
I am sorry to say I believe she was not to virtue.
There is another form of pneumonia, which I wish
you to become acquainted with. It is not uncommon in
the spring of the year, for a practitioner to meet with a disease 
of a mongrel character. Cases of this description I have
not unfrequently met with in the latter part of the 5th and
beginning of the 6th month. This disease has the inflammatory 
diathesis of the winter & spring months, diluted, if
I may be allowed the expression, with the diseases of warm
weather. Sometimes there are intermissions, particularly in
the morning; sometimes a better & then a worse day. Thus
we have pneumonia connected with something like intermittent 
fever. In the treatment, I have found it safest to
keep the pulmonary symptoms principally in view. 
is generally required; blisters to the breast, gentle cathartics, 
antimonials, etc. Yet bear in mind that we must not
evacuate more than is clearly demanded, lest we lay the
foundation for subsequent debility, & perhaps a tedious intermittent.  
           

  
     
      
    

 

 
 



400
		Measles.

My intention, at this time, is to continue the subject
of inflammatory affections of the pulmonary organs; & I
shall first notice an Epidemic disease which occasionally
prevails in our country, & which rarely visits us oftener than
once in 3 or 4 years: I mean measles.
This may be viewed every much in the light of an in-
flammatory catarrhal affection: it is attended with cory-
za, cough, & a peculiar appearance about the eyes. But
in the course of this catarrhal disease, the patient is affected
with eruptions which appear on the face & extend pretty gen-
erally over the body. Cases of measles are, in general, meld
& manageable. But you will find intelligent mothers & nur
ses not unfrequently very fearful about the consequences
that may result from the disease. The complaint, as it has
appeared in one city for a number of years past, very generally
yields to plain & simple treatment. As it is an inflammato-
ry disease, you can easily comprehend the general principles
on which the treatment must be conducted. Severe cases of mea-
sles almost invariably require the lancet; & sometimes it is ne-
cessary to resort to it again & again. Generally speaking one
or two bleedings are sufficient in common cases. In addition
to this remedy, attention must be paid to the state of the bowels
which should be kept open by purgatives. A free use of dil-
uent drinks; & if the cough is severe, pectoral medicines,
     
           

  
     
      
    

 

 
 



401
with occasional blistering about the thorax & throat constitute 
the remainder of the treatment.
When this disease, in its progress, effects the trachea, & croup
is connected with it, I consider the case as requiring particular 
care. The last time the measles prevailing, I lost a fine
little boy whose wind-pipe became involved; & I had occasion
to regret that I did not resort to more early blistering.
I have known the disposition to inflammatory disease not
only invade the mucous membrane lining the lungs; but I
have seen the same tendency in the mucous membrane lining
the alimentary canal. I have witnessed some instances of
severe bowel complaints supervening an attack of measles.
I have also had one case where vomica supervened, & the
patient finally died.
You will occasionally meet with cases of this complaint
which depart from the usual course. Thus, in common cases, 
the eruption seldom appears later than the 3rd or 4th
day; sometimes earlier: but I have met with instances
when the patient has been very ill, though many days had
elapsed before the appearance of the eruption. I will read you
a case as an example.
Case of Franklin Jones. – 5th mo. 29th, 1808. I was called
in the evening to visit the son of Isaac C. Jones, a fine little
boy, aged about 14 months. I found him labouring under
considerable fever, with a pulse full & tense & some cough.
His mother thought his throat was sore. She informed me
that he had not been well for several days, Particularly
 
     
           

  
     
      
    

 

 
 



402
in the morning. But he had never been seriously indisposed 
until 11 o’clock that morning, when he appeared
to have a chill, followed by fever which was accompanied
by staring. From the history of the case I immediately suspected 
measles, as they were very prevalent, & especially as
they had lately appeared in the family. I directed him to
lose 4 oz. of blood & to have a mild cathartic, with a solution 
of gum arabic in water for his common drink.
Next morning he was a little relieved, & in the evening considerably 
so – his fever having abated. On the morning of
the 3rd day he was more poorly. Attention was paid to the
state of the bowels – they were kept open by senna in decoction. 
The mild drink was continued. I looked every day for
the eruption, & was quite disappointed on the 4th day, as it
did not appear. The symptoms became more alarming.
His exacerbations of fever were always more alarming in
the morning than in the evening; & a disposition to somnolency,
which I perceived in the early part of his attack
was on the 5th day, greatly increased. It seemed almost
impossible to rouse him. His eyes were about half closed;
his head was hot, & his feet were cold. He sometimes waked
up; & when he did, it was generally with a scream. But
still he would take the breast; although his mother remarked
that he did so rather a view to palliate his uneasy
feelings, than from a desire to take nourishment. I now
prescribed some powders, containing each 2 grains of calomel 
& 4 of powdered rhubarb, to be taken every hour until
       
     
           

  
     
      
    

 

 
 



403
they operated. His stools were green at this time. One of
the powders operated sufficiently. I saw him about 3
o’clock, P.M. & finding him still in the comatose state,
I felt alarmed & thought of applying blisters. But as the
parents had lost a child with hydrocephalus, & were uneasy
as to this, I was very desirous of having a consultation.
Although the pupils were not dilated, there was no strabismus, 
& I was aware that coma often attends eruptive 
fevers, yet I thought he had an aversion to light.
Dr. Barton met me on the evening of the 3rd of 6th mo. –
the 6th day of the child’s illness. The pulse was frequent, yet
sufficiently full. We soon agreed as to the propriety of applying 
blisters to the wrists: & although our remedies made
some little impression on the disease, yet nothing seemed
to have a marked effect, till on the 10th day of his illness
he became covered with a fine crop of measles. His comatose 
symptoms vanished; the eruption continued out
about 3 days, & little Franklin, to the great joy of us
all, was finally restored to health. – In the course of his
illness he had a hard troublesome cough, for which a
blister was applied to the breast: but a solution of assafoetida 
in mint water appeared to give the most relief.
Note. – This boy I attended through an attack of scarlet
fever where the same peculiarity relative to the time of
the appearance of the eruption occurred. I have since
ssen several similar cases.
         
     
           

  
     
      
    

 

 
 



404
Influenza.
When engaged in practice, you will sometimes be called
to treat catarrhal fever as an epidemic disease, under the
name of influenza. I will read you a history of the disease, 
as it occurred in 1807; taken from my notes which
I made at the time.
This most extraordinary epidemic seems to have spread
in every direction. The first account we received of it in
this city, was from New-York about the 8th of 8th month. At
that time, it was reported that five thousand persons in that
city were affected with the disease. About the same time that
these reports arrived from N.Y. a few cases appeared in Phil.
It soon spread like wild-fire; & by the middle of the month,
or a little later, scarcely a family was free from it. In some
instances, whole families were affected at the same time, &
I think it perfectly safe to conclude that not less than
80.000 of inhabitants of this city have been more or less
affected with it. The adjacent country has not escaped.
I have heard of a family in Upper Darby in which 15 persons
have been affected with it.
The symptoms of the disease seem worthy of notice; & I
shall attempt to give them by describing my own case, for
I had a violent attack. For several days previous to my illness, 
I saw sensible of unusual lassitude when I walked
or exerted myself much. On the first day of my indisposi-
  
         
     
           

  
     
      
    

 

 
 



405
tion I rose rather earlier than usual. I was soon sensible 
of an unpleasant feeling in my eyes: it was not pain,
but rather a sensation of heat or burning. This was soon
propagated to the cheek; & I presently discovered some fever.
Professional engagements called me from home; but a
pain in the head, back & limbs convinced me that care
for myself was necessary. I returned from visiting my
patients, & went to bed about noon. My fever was now
high; a full inspiration produced a sense of rawness,
as it is called, in my chest; but I did not cough. In the
early part of the afternoon, I lost 12 oz. of blood & took a
cathartic. It operated at night, & by drinking largely
of barley-water & abstaining from stimulating diet, I felt
relieved, & thought myself nearly well on the succeeding day.
But I now began to have a copious discharge from the schneiderian 
membrane, which was soon followed by a cough.
This was hard & dry, & rendered it necessary for me to lose
14 oz. of blood. I was relieved by the bleeding: but it was
at least 10 days from the time of my attack before I was
free from the cough.
In some cases a chill, fever & cough ushered in the
disease: in others, pain in the head, back, & bones; & the
cough followed a few days after. But I believe that in
every case, the breast was more or less affected. It appeared
to me that most of the patients had a better & a worse day,
as in a tertian. The cough was very troublesome & hard
to remove. Mild cases were soon relieved by diluent     
           
     
           

  
     
      
    

 

 
 



406
drinks, low diet, & a gentle cathartic of salts or oil. But
in some instances, I have found two bleedings necessary
to subdue the inflammatory symptoms. In addition to this
a large blister was often applied to the chest; & the antimonial
powder (without calomel) employed. Under this treatment
the most urgent cases would soon yield. As a disposition
to the intermitting form of fever was observable, & the back was
contra-indicated on account of the pulmonary affection, I directed 
cold chamomile & centamy teas, to be taken freely,
(after the urgent symptoms were subdued) particularly in the
morning.
Although so many thousands were affected; yet it is
worthy of observation, that very few instances of death occurred.
But has already shown that neglect in the early stage of
the complaint has laid the foundation for diseases which
will finally prove fatal. Some have already occurred,
& one under my own notice.
An intemperate man had been labouring under the
disease for 10 days; & during that time had taken his daily 
allowance of ardent spirits. When I was called he was
labouring under very acute pneumonic inflammation,
& died in about 5 days.
Others have had hemoptysis; & the foundation for pulmonary 
consumption is laid in many persons who are predisposed 
to that opprobrium medicorum. Several deaths
have taken place in consequence of the rupture of blood-
vessels in the lungs. The son of my venerable friend, Dr.

           
     
           

  
     
      
    

 

 
 



407
Duffrild, afforded an instance of this kind. He was a
youth of 19. The attack of influenza was mild; but the
rupture of a vessel terminated his life in about 48 hours.
Another remarkable circumstance is worthy of record; &
that is the unusual number of deaths among persons who
had arrived at extreme old age, say between 80 & 90. I presume 
the influenza has had an agency in the death of most
if not all of them. In one week, in this city, no less than
six, between 80 & 90, & one of 107 year, were reported
in the bill of mortality. The news-papers from every quarter, 
give daily information of the departure of this venerable 
class of the community. In the bill for last week 9
cases of death from influenza were reported; but including
the whole number reported from the commencement of
the epidemic, I do not think there has been more than
30. From this number the aged persons are understood
to be exempt.
I will now read some remarks made on the disease
as it occurred in 1805.
11th mo. This Epidemic has again been very general in
the city. It commenced as before to the northward & eastward.
We heard of it in New-England & in the city of New-York. From
The 15th to the 19th of 10th mo. I visited 4 patients with the
disease. They were travelers & had passed through N.Y.
But as early as the 9th of the month, I had once case of a delicate 
female who was very ill with it though she had not
been absent from the city. About the latter end of the mo.

   

           
     
           

  
     
      
    

 

 
 



408
it began to be general; & in the early part of the 11th
month it was at its height. It was remarkable to see
with what rapidity it spread. It really seemed as if there
were few who escaped. In many families, every individual, 
I believe, was more or less affected. I suppose that at
least 4/5 of the population were subjected to the disease. During 
its prevalence I was almost worn out by fatigue;
for a considerable number of our most respectable practitioners 
were confined by it. I heard of one family that
sent to 5 physicians in succession & found them all sick.
I suppose I made from 50 to 60, & perhaps more, visits
in a day; & often prescribed for several patients in one
house; so that the number of patients was from 70 to 90.
With respect to the symptoms & treatment, there was a very
exact resemblance to the disease as described in 1807. I found
some patients to complain most severely of pain across the
hips & upper parts of the thighs. Generally one or two bleedings
were necessary; in a few cases I bled the patients 4 or 5 times.
Some patients, particularly during their paroxysms in the
afternoon, had a great sense of fullness, or stuffing in
the breast, which was very distressing. The inflammation
in some cases, amounted to pleurisy.
Few fatal cases have occurred; & these have been among
very aged people, or patients nearly worn out by other
diseases. I have not met with an instance of death where
the constitution was vigorous. Several cases have come
under my care in which after recovery, the patient has
      

           
     
           

  
     
      
    

 

 
 



409
been attacked by a smart chill & fever, generally of
a remitting character: in some an intermitting form
has appeared. These cases, however, are general manageable. 
I am now attending an elderly gentleman
in consultation with Dr. Parke, where the fever has run
into typhus mitior. Although I suffered a severe
attack in 1807; yet the present year, I escaped; at any
rate, I have not been laid up. I had a slight soreness
of the throat. My worthy friend, Dr. Griffitt, who escaped
in 1807, was pretty smartly handled.
Influenza is sometimes very dangerous to persons
labouring under previous disease of the lungs, particularly 
to such as are predisposed to pulmonary consumption 
& hemoptysis. I have witness some melancholy
cases of another kind. During the prevalence of the disease
in 1815, I attended, with Dr. Mathieu, a young man
from New-England who was affected with disease of the
spleen. He was anxious to return home, being the only
child of a widowed mother. But just at this juncture,
the influenza took hold of his system, already nearly
exhausted, & in a few days he fell a victim to it.
10th, mo. 1820. – There are a few cases of influenza
now in the city. One which is very interesting, is now under 
the case of Dr. Chapman & myself: A young lady,
at a boarding school in this city, was affected with autumnal 
fever, & was attended by Dr. Monges, Chapman
& myself. Her disorder was protracted & dangerous. How-
 
 
 



410
ever, with great care & attention, we ultimately had the
satisfaction of seeing her in a state of complete convalescence. 
Just at this juncture, when she was able to leave
her bed & sit up occasionally, the influenza took hold of
her. In her usual health, it would probably not have
been severe enough to confine her to room: but acting 
on a system previously debilitated, it has rendered
her situation the most dangerous that can be imagined.
There is great difficulty of breathing, with heaving of the
chest, & a pulse often as frequent as 160 in a minute. There
has been lent one ground of hope; & that is her power of
expectoration. She did expectorate freely: but to day we
feel an unusual degree of solicitude, because this power
is failing. If she should continue any length of time
in her present condition, the case must terminate fatally.
Note. – The above prediction was verified – she died.
Diseases of the Heart.
________x________
When we contemplate the structure & functions of the
heart, we must be aware that every thing connected with
its disease is peculiarly important & interesting. While I make
this declaration I am under the necessity of adding the
painful information that some of the complaints of this
organ are entirely beyond human control. When you rec-




 
 



411
ollect that the heart is the fountain of the circulation
& that it is an a state of perpetual action, you can readily
understand that this continual motion is very much
opposed to the cure of organic disease of the part.
I shall commence with the more simple & less dangerous 
forms of disease, & gradually rise to those of higher
importance.
Palpitation of the Heart.
Some persons are peculiarly liable to this disease.
From slight causes the heart is thrown into most violent
convulsive action; the patient is subjected to very considerable
inconveince; he is often greatly alarmed, & sometimes 
not without cause. Palpitation of the heart seems
to depend on a peculiar irritable condition of that organ.
Some persons possess naturally a very irritable state
of system, highly susceptible to slight impressions; & in
them palpitation of the heart is induced by trivial causes. 
Of these causes, I hardly need mention that fear
& other mental emotions have great influence. But
this peculiar condition of the heart is also induced by causes 
more gradual in their operation, & more difficult
to be removed than emotions of the mind. Thus any thing
calculated to debilitate the system may lay the foundation 
for this complaint. It is an occasional attendant 
on dyspepsia. Persons subject to this disease sometimes 
suffer much from palpitation of the heart.

   




 
 



412
Among the remedies which may be regarded as useful, I
have found that tonics & antispasmodics hold an important
place. When it depends on a peculiar irritable state of the
system, the indication is evidently to counteract this state
by remedies of the classes just mentioned, & to give tone to
the whole frame. Among the antispasmodics, assafoetida &
Hoffman’s anodyne are most useful. In a case which lately 
fell under my care, & which was attended by great nervous
irritability, I derived great advantage from a combination
of these articles. If I recollect right, about 3fs of assafoetida
was rubbed down with 3vj of mint water & 3iij of Hoffman’s
anodyne added. Of this the patient took a table spoonful
several times a day; & he told me that he derived extraordinary 
relief from it. I do not, however, intend to enter into particular 
details of practice, but to give general observations.
You will remember then that tonics & antispasmodics are
generally useful in palpitation of the heart arising from nervous 
irritability, or simple weakness of the system.
Syncope.
Passing from simple palpitation of the heart, I go on
to consider an opposite state of that organ, a state in which its
action, from various causes, is momentarily suspended &
syncope, or, as it is commonly called, fainting occurs.
Syncope may be regarded as a temporary death. Sometimes 
from causes very trivial in their nature, persons will
fall into this state; the action of the heart will be for a mo-
   
 
 
   




 
 



413
ment suspended, & they will lay without sensation or
motion. If this were to continue for any length of time,
the functions of life would cease forever. But syncope
as we generally meet with it, is little to be apprehended.
The system speeding rallies, & the patient in a few minutes is
restored to his accustomed health. But I here speak of syncope 
produced by accidental causes, & in persons who previously 
enjoyed considerable health & vigour. When it occurs 
in the latter stages of disease, even if induced by causes
purely accidental, it is sometimes very dangerous. When
the excitability of system has been reduced by any complaint, 
& it has thus been rendered less able to rally its forces, 
it is sometimes completely overpowed by syncope, & reaction 
never occurs. Hence in some cases of malignant typhus 
fever fainting is much to be dreaded. I have known
a patient, on attempting to walk across the floor, fall down
& instantly expire. In nervous fever syncope is sometimes
dangerous. You have heard of cases where death has resulted 
from profuse evacuations. Patients who have been long
ill, when under the influence of powerful purging, sometimes 
die in the act of catharsis. I mention this because
an important practical precept may be derived from it: -
that in diseases of a low character we should as much
as possible economize the strength of the patient, & prevent
undue exertion. Hence when the bowels are to be opened,
instead of suffering the patient to rise, I insist on his remaining 
in bed & using the pan.


     
   
 
 
   




 
 



414
Syncope in its common form requires little treatment.
Sometimes laying the head low, sprinkling cold water in
the face, & applying volatiles to the nose will be sufficient
to restore action; & the patient will recover. But if it occurs
in patients previously exhausted, more effectual remedies are
necessary. The internal administration of volatile alkali, wine,
etc. & the external application of sinapisms & other rubefacients
will be necessary.
In the course of my practice I have met with some cases
which I denominate protracted syncope. These are particularly 
interesting to the medical practitioner: because as I know
from my own experience, there is a possibility of blending
them with other forms of disease; & the mistake may prove fatal 
to the patient. I know no better mode of giving you my
ideas upon this subject, than by imparting my own experience. 
I will therefore relate to you the first case which
came under my notice.
Case. – in the early part of my practice I was, one
morning, called from my bed to see a woman in water
street, who, it was said, was extremely ill. I found her in
the most imminent danger: - her respiration was distressingly
laborious; her countenance was marked with extreme anxiety; 
her pulse was barely perceptible; & she was under the most
fearful apprehensions of immediate dissolution. She entreated
me with the utmost earnestness to do something to relieve her.
When I cast my eye on the woman my first impression
was, that it was a case of suffocated excitement; that the  
 


     
   
 
 
   




 
 



415
system was engorged with blood, & was incapable of acting on
account of being pressed down by disease. Happily, I did
not act on first impressions; but inquired into the history 
of the case. I found that just before my visit she
had been delivered of a child by a midwife who had just
left her. They informed me that she had had an unusually 
dry labour – the membranes having ruptured some
hours before the birth of the child. The consequence was
that the system was completely worn out, & had passed into
the condition just described. I could not, however, divest
myself of the idea of disease of the thorax. But instead of
acting, I ran to Dr. Griffitts’ (who lived in the neighbourhood) 
& stated the case to him. His advise was nearly
in these words: “Pour down the volatile alkali, as much
as she can take”. I ran back & immediately put the practice 
into operation. External stimulation by sinapisms, etc
was resorted to, & volatile alkali & other internal stimulants 
were also employed. A blister was applied to the
chest. In a few hours the patient was free from danger.
Now, in this instance, had I acted on the presumption that
the case was one of suffocated excitement, it is probable that
the heart, already unable to perform its functions, by the
loss of a few ounces of blood, would have been put into such
a situation, as to have ceased to beat forever.
Case. – Sometime after this case, I saw another bearing
some resemblance to it; but not so dangerous. The patient
was a young woman who had been attacked soon after
     
 
 


     
   
 
 
   




 
 



416
bleeding. It seemed as if the action of the heart had been
lowered to a point just sufficient to support life, & no more.
In this case there was the same difficulty of breathing ; the
same expression of anxiety & distress; the same apprehensions
of death. By the administration of external & internal stimulants, 
& by the liberal use of assafoetida, she was restored to
health.
In some of the early volumes of the Eclectic Repertory you
will find detailed several cases bearing some resemblance
to those just state.
Spasm of the Heart.
The heart is subject, in some instances, to a very dangerous 
form of spasmodic disease. Whether the cause operates primarily 
on this organ or secondarily through any other part
of the body (for example, the stomach,); whether the disease
be simple spasm accidentally induced, or depend upon an
arthritic condition, in which case, it must be regarded as very 
dangerous. – Sudden spasm of the heart may depend
on gout of the irregular form. Hence gouty patients sometimes 
die suddenly. The heart may also be affected thro’
the medium of the stomach. From some inexplicable cause
the stomach & heart are sometimes almost simultaneous 
affected, in such manner as immediately to extinguish
life.
Case. – To illustrate this I will relate the case of Stacy
Bispham – He was a young merchant of great respectability
  
 
 
 


     
   
 
 
   




 
 



417
A short time previous to his death, perhaps a week or ten
days, he called to consult me about some uneasy sensations
in the region of his stomach & chest. Knowing him to be
much devoted to the business of his counting house, I advised 
him to relax a little, & to ride occasionally on horseback. 
His habits were remarkably sober & temperate. Sometime 
after this I was called suddenly to see this gentleman: 
I found that at his counting-house he had been
suddenly seized with the uneasy feelings I have alluded
to. He had walked home; & just after he entered the parlour 
he fainted. The family were in great alarm, & I
was sent for. When I arrived I found him exactly in
the condition of a person just recovering from a fainting
fit – his countenance was pale, & his pulse feeble; but
he was intelligent, & there was no sign of any affection of
the head. I remained for a considerable time, & gave such
remedies as were calculated to excite the system. Either, wine,
& the diffusible stimuli, were liberally administered; at
the same time external irritation was resorted to. The system 
gradually reacted, & when I left him he was apparently 
recovered. But feeling uneasy about the case, it being about 
noon when I first called, I visited him as often as three
time before bed time. At my last visit he seemed to have recovered 
ntirely; & I expected no return of the disorder. I directed 
that he should not go to the counting-house that
day, but remain till I should call. In the course of the
evening he remarked to one of his friends, that if he had

   
 
 
 


     
   
 
 
   




 
 



418
not recovered, he would have had a very easy death, for
he was perfectly free from pain. Next day, previous to my
calling, I received this history: - that he felt himself
considerably better, got up & walked about the room. He
read the news-paper, & had some conversation with his
wife in which he informed her that he felt better than at
any time before his last attack. He had just taken an egg
with a little Madeira Wine, & was in the act of eating a cracker, 
when in a moment, almost in the twinkling of an eye,
he dropped dead. The only person that saw him, except his
wife, with the least appearance of life, was a servant girl
who ran into the room. She said that she heard something 
like a groan or grasp after she entered. Dr. Physick, 
who lived next door, & some of the neighbours ran in immediately, 
but saw no symptom of life. It is probable that a
sudden spasm of the heart destroyed him. As soon as I arrived 
I placed him in a warm bath, inflated his lungs,
& treated on the same plan as in cases from drowing.
But all was in vain – there was never after a vestige of
vitality. I made an examination of the contents of the thorax 
& stomach; but found every thing perfectly natural.
This case may be considered as different in some respects
from angina pectoris.
Angina Pectoris.
This is not a common disease. It has occasionally
fallen under my observation, but not often. It consists
     
 
 
 


     
   
 
 
   




 
 



419
partly of spasm of the heart; but the spasm is communicated 
to other parts. A pain in the arm frequently precedes
or accompanies the affection of the heart. The attack is
brought on by any exertion as ascending a flight of stairs.
Patients labouring under angina pectoris are frequently
obliged suddenly to stop in the act of extion, in consequence
of the occurrence of this painful spasmodic affection.
You will find that the biographer of Hunter gives a
detail of the disease as it affected that distinguished man,
It seem, in his case, that the stomach partook largely
in it. On the first attack he was sensible of pain about 
the stomach; soon after this his heart ceased to
act, & he seems to have believed that life was maintained 
merely by his voluntary exertions to expand the
chest; but I suspect that these exertions were a consequence 
of a natural sense of their necessity, rather than
a deliberate act of the judgement & the will. You will
find that in this case, the disease could be brought on
by slight exertions: but it never occurred in its most
aggravated form, under the exertion were conjoined with
some violent emotion of the mind. It was in one of those
violent paroxysms of rage of which his irritable temper
subjected him, that he was seized with that attack which
terminated his existence.
I have known angina pectoris to continue several
years before the patient died. A widow lady of this city
consulted me full five years previous to her death, with
   

     
 
 
 


     
   
 
 
   




 
 



420
these symptoms: - pain in the arm with palpitation &
spasm of the heart were induced by any over exertion;
but she pursued her usual avocations; & from her appearance, 
one would not have been aware of her danger. 
I was called in consultation to see her. Various expedients 
were resorted to; but I am inclined to believe that
in this complaint there is not much to be done. It appears 
sometimes to depend on an arthritic condition of
the system; & John Hunter used to derive great relief
from the occurrence of a gouty paroxysm. One morning 
the daughter rose & observed her mother in a sweat
sleep, as she thought it, went down stairs to prepare for
breakfast. But it was the sleep of death. She was lying
on her side; & it is probable that which she was in this position, 
a spasm terminated her existence.
I have nothing to say from my own experience
as to the successful treatment of this disease. Dr. Rush
thought that occasional bleeding was useful. The French
speak of continual blistering with approbation. But my
experience is so limited that I can give no decided opinion.
Rheumatism of the Heart.
I shall now call your attention to a disease of the heart
which does not frequently occur, & as far as I know,   
is not often mentioned by practical writers. If I recollect 
right, Dr. Pitcairn spoke of the disease to Dr. Baily
who has given a description of it. You will find an inter-

     
 
 
 


     
   
 
 
   




 
 



421
esting account of a rheumatic affection of the heart in
the 1st vol. of the Eclectic Repertory, by Dr. Dundas. It has
fallen to my lot to see a few cases of this rare disease.
Rheumatism of the heart, so far as my observation goes
(& the experience of Dundas is similar,) occurs most commonly 
in young people. Young persons who have been
subject to attacks of inflammatory rheumatism, (which
is rare in early life) are apt to be affect with this disease.
Rheumatism of the heart consists in most violent pulsations 
of this organ unattended with pain. On laying
the hand on the heart of the patient, you are very much
struck with the violence of the pulsations, & receive the
impression that the heart is of enormous size. Along
with this, you can easily believe that there will be a corresponding 
morbid derangement of the pulse. This in
some cases is very irregular – the stroke being sometimes
violent with considerable tension, & at others intermitting.
Some of these cases continue for years.
Case of Zilla Jones. – This young lady died, under my
care, of rheumatism of the heart; & after her death I had an
opportunity of examining the body. She had suffered in
early life from inflammatory rheumatism. She was
about 21 years old at the time of her death; & the disease
which terminated her life was of about 2 years continuance.
At times her respiration was laborious, & she could lay with
her head low. Towards the latter stage of the complaint, she
was trouble with edema of limbs; & a few days before
    

     
 
 
 


     
   
 
 
   




 
 



422
her death she was affected with acute mania. On dissecttion 
I found adhesions on the left side, between the pericardium 
& the pleura, & universal adhesion between the
pericardium & heart. The ventricles were exceedingly enlarged, 
& the right one was very thin. There was a slight
ossification of the valves of the right auricle.
Inflammation of the Heart.
The heart, like other muscles, is subject to inflammation.
There is one fact worthy of particular notice – inflammation 
of those parts (muscles) which are subservient to locomotion, 
is attended with much pain: but there may be severe 
inflammation of the heart unaccompanied with pain.
I will recollect a case which terminated fatally under the
care of Dr. Wistar, at the dissection of which I was present.
The whole surface of the heart was covered with a coat of
coagulable lymph, as also was the internal surface of the
pericardium. I have often heard the Dr. Say that the patient 
did not complain of acute pain, but of a sense of
weight & uneasiness under the sternum. It was treated
on the same principles as a case of pneumonia; viz. with
bleeding, blistering, etc. but without avail.
During the period that I lectured for Dr. Davis, there
was brought into the dissecting room & exhibited to the
  
    

     
 
 
 


     
   
 
 
   




 
 



423
class an example of this kind: but we had unfortunately
no history of the case. The heart & the internal surface of the
pericardium were completely covered with a coat of coagulable 
lymph, which could be peeled off with the fingers, & was
of a colour resembling that of rennet whey.
Some years ago, while I was attending on the Alms-House
a case occurred of inflammation & suppuration within the
pericardium, complicated, however, with an accident.
Whether the inflammation of the heart was owing to the
injury, or whether it had taken place before it is impossible 
to decide. I will give you an outline of the case.
Case of Charles Sheppard. – Charles Sheppard, aged 32
years, was admitted into the Alms-House, 6th mo. 16th, 1819,
in consequence of an injury about the upper part of his
breast. Owing to the diseased state of the parts on his admittance, 
the precise nature of the injury could not be ascertained: 
but a luxation of the clavicle from the sternum
was suspected. Suppuration took place about the upper
part of the sternum, accompanied with a weak pulse &
general debility. For this wine, porter, & a nourishing diet 
were directed. Opium was given to relieve pain. A termour 
burst in the neck & discharged pus. The patient continued 
to sink. After a few days he complained of uneasiness 
& anxiety in the chest, with some cough & a great
deal of pain. Before he died he was affected with difficulty 
of breathing.
On dissection collections of matter were found near
     

     
 
 
 


     
   
 
 
   




 
 



424
the upper end of the sternum, exterior to the pleura. Adhesions 
had taken place on the right side between the lungs
& pleura, but not on the left. About 3 pints of water were
found effused into the cavity of the thorax. The lungs had a
healthy appearance. The knife was by accident pushed
into the pericardium, & a quantity of pus immediately
flowed out. On enlarging the opening, the cavity was
found filled with pus, & no less than a quart was taken
away. That first obtained was fluid & of a bright yellow
colour; lent towards the last it was found in coagulated
lumps, resembling cheese curds in appearance & consistence. 
The apex of the heart was towards the sternum &
adhered firmly to the pericardium.
I have brought forward these cases to show that within
the pericardium we occasionally find not only inflammation 
with effusion of coagulable lymph, but also the secretion
of genuine purulent matter, & that to a very great extent.
Scrofulous Inflammation
of the Heart.
Case of Geo. Haydock. – This child had been afflicted
almost from its birth. I think I never heard so peculiar
a cough in an infant before. A person in an adjoining
room might have reasonably concluded that the cough
proceeded from a man of 70, instead of an infant of a few
weeks. He had also an examphalos. When about 3 months
old I attended thro’ a violent attack of pneumonia 
 
 


     
   
 
 
   




 
 



425
which required bleeding & blistering. A blister on the breast
produced a most surprising alteration for the better
at a time when his case appeared almost hopeless. Although 
he recovered from the immediate danger of the attack, 
yet his cough, which he had immediately after
birth, still continued. He was at times afflicted most
grievously with colic. Such a train of symptoms naturally 
called for a variety of remedies; & poor George had
a great deal done for him during a part of his short stay
among us. But nothing seemed to make any favourable 
& durable impression. He was taken into the country; 
his cough continued; & from accounts, he occasionally 
discharged purulent matter. He had also sickness
of stomach. A few days before his death, he was seized
with convulsions which recurred frequently. He was now
quite insensible. The day previous to his death I saw him.
His pulse was very frequent, & yet possessed some strength.
His pupils were very much dilated, & quite insensible to
light. From his appearance, & accounts received of his state,
as it had been for several days, I was ready to suspect hydrocephalus. 
He died about 7 o’clock in the evening.
As I was about 4 miles distant, Eden Haydock, the
father of the child, kindly informed me of the event, expressing 
his willingness to allow an examination to be made.
Next morning, accompanied by my friend, Dr. Tucker of
Burlington, I proceeded to the dissection. On opening
the abdomen the mesenteric glands were found to be
 
 


     
   
 
 
   




 
 



426
closely adhering; but when it was removed, the whole external 
surface of the ventricles was seen covered with a number 
of small points or tubercles, of a whitish appearance, which
entirely obscured the view of the muscular fibus of the ventricles. 
But on cutting into them, they appeared natural,
as also did the valves & the chordae tendinae. The tubercles
did not resemble the crust formed during acute inflammation: 
for this production is like a membrane which
can readily peeled off, while the tubercles were immovable,
& must have been of scrofulous origin. The child was of
a light complexion, having fine flaxen hair.
I once saw a woman dissected at the Alms-House
with the same appearance on the surface of the heart.
From these cases you perceive that scrofulous disease may
affect the heart itself.
_______________________________
In the course of your practice you will be very
much at a loss to find diagnostic symptoms between diseases 
of the heart & hydro-thorax. There is a complaint
of this organ which may easily be confounded with dropsy 
of the chest. I know no better mode of illustrating my
meaning than by stating a case which fell under my
observation, & which I had an opportunity of examining
after death.
Case of Penelope Whitehead. – 2nd mo. 1818. The subject 
of the present notice was a woman of exemplary piety
   


     
   
 
 
   




 
 



427
She was the mother of a large family of children, &
had passed over the critical period of the cessation of
the catamenia, several years before the present attack
of disease. She came under my care in the fall of the
year 1816, & at the time laboured under diabetes. This
disease was preceded & attended by considerable mental 
anxiety. I placed her upon a rigid animal diet,
which was continued for several weeks, & with the
happiest effect; for the disease entirely subsided. But
it was only a transient calm; a scene of complicated 
suffering was about to open. It was not long
after the cessation of the diabetes before I was called to
her in consequence of dyspnea which appeared to me
to resemble that of hydrothorax: I was the more inclined 
to subject the latter disease, at the dippnea supervened 
diabets. AT this time she was still, for the most
part, living on animal food; & I hope that by allowing 
her the free use of fresh vegetable food, I should bring
on a return of diabetes, & thus relieve the breast, But I was
disappointed; for the urine did not increase as I expected,
& the dyspnea continued & at times was quite distressing. 
Failing in object by a return to vegetable diet, I
proceeded to the use of diveretics; first squill, then squill &
calomel. Continuing for some time under this treatment
she evidently improved, & on the opening of pleasant weather
in the spring, she went to the city of Washington on a vist
to one of her friends. While there she experienced several



     
   
 
 
   




 
 



428
severe attacks of difficult respiration: but they soon subsided, 
& she would then enjoy herself considerably. In proof
of this I was informed that, while at Washington, she visited
the tomb of the great chieftain on the bank of the Potomack.
The party went in a boat. They ascended a very high bank,
& there was no young person in the company who accomplished 
it with more ease, & skipped about with more apparent 
pleasure than out patient. This I considered a very 
intersrting fact; & it produced serious doubts in my mind
as to the existence of hydro-thorax, especially when taken in
connexion with other circumstances which I propose to
notice. Soon after her return from Washington she had a
violent attack of dyspnea, & I saw her. Her respiration was
laborious & not most distressing. But I was struck with the
perfectly natural state of the pulse as it regarded force,
frequency, & regularity. By the use of antispasmodics, such
as volatile alkali, assafoetida, etc. etc. she was soon relieved;
but she was ever after this subject to violent paroxysms
which I will now more particularly describe. These paroxysms 
always commenced with a loss of sleep which was
very distressing. During the whole time she complained
of being unable to sleep; at least nature would appear to
be exhausted, & being fairly worn down, sleep would come
to her relief, & the paroxysm would terminate. During these
paroxysms she was affected with great acidity of the stomach,
& other very prominent dyspectick symptoms. Great difficulty 
arose in the treatment at these periods, in consequence of

 
  



     
   
 
 
   




 
 



429
her inability to use opium in almost any shape. Such was
the extreme distress of stomach that followed its use, that
the generally preferred to suffer from want of sleep than
to employ it. Even in the form of injection it affected her
unpleasantly. But by applying it in poultices to her hands
& feet, & using it largely in a spired plaster applied over
the stomach, I thought she was sometimes much relieved.
Almost all the antispasmodics were alternately used.
On the solution of a paroxysm she would resume her
domestic cares; & I have frequently left her one day almost 
in a dying state, & the next day, on calling, be informed 
that she was riding out, or else find her down stairs with
the family. She would now lay with her hand low in bed,
& there was no unusual pausity of urine.
The summer of 1817 had now opened upon her. She had
often derived benefit from visits to the sea shore, & was desirous
of trying it once more. To this I consented, & she
set out for Long Branch. The weather was very hot. She
was greatly fatigued on the road, & travelled down during 
one of her paroxysms, sleeping none at night. On
her arrival at the shore, she was nearly exhausted. Her
pulse was irregular, her feet swelled, & her dyspnea distressing. 
A medical gentleman, who happened to be in
the house, was requested to see her. He had not been
accustomed to the case, & I was not surprised at his being 
alarmed. But he pronounced a rather too hasty & positive 
decision. From a very superficial examination   
   

 
  



     
   
 
 
   




 
 



430
he decided that it was hydro-thorax without doubt, and
advised her immediate removal from the shore. So in
a few hours, & in the midst of a most distressing paroxysm
she was hurried away. She assured me that the very few
hours she was there, the air was reviving to her when it blew
from the ocean. With great difficulty she reached Bordentown.
Her husband came on to the city & consulted me. I wrote to
Dr. Burns, & gave him a statement of the case. She was now
placed on the use of the tincture of digitalis, & the alkaline
infusion was resorted to for the relief of her dyspeptic symptoms 
which were very distressing. While she was at Bordentown 
I paid her one visit. I found her with very considerable
anarsaceous swelling of the lower extremities. The
air of Bordentown seemed to suit her very well. She remained 
there during the hot weather & returned home in
the autumn wonderfully recovered. She was now considered 
a well woman. She walked about among her friends
as usual, attended public worship, & the change was truly 
a pleasant one. But even this was only a transcient 
calm. In the early part of the winter, she had evident proof
that her suffering was about to be renewed.
Paroxysms of dyspnea again occurred. I resorted to digitalis, squill
& mercury, blisters to the breast, etc. while the most scrupulous 
attention was paid to the regulation of her stomach
by animal diet & by alkaline medicines. I wished for
a consultation, & Dr. Wistar was called. He fully concurred 
in the use of diuretics, antispasmodics, etc. About
 

   

 
  



     
   
 
 
   




 
 



431
this time I observed that her paroxysms returned at shorter 
intervals & between the periods she evidently suffered more
inconvenience than she had formerly done. The dyspeptic
symptoms were distressing, & her debility was gradually increasing. 
Paucity of urine was more evident than it had
been. She found it more difficult to lay with her head low,
& sometimes her pulse was irregular. Her lower extremities
were anasareous. Another change is worthy of remark: errotic, 
& as I supposed, arthritic pains were evident; & in several 
of her paroxysms I observed that she had considerable
pain in the stomach & bowels. When this was the case, the
dyspnea was less severe; & this led to the supposition that
arthritis had a considerable influence in the symptoms.
There was now an evident exasperation of the symptoms
in her paroxysms, & the intervals were very short. For several 
weeks before her death, Dr. Wistar & myself expected
every hour would be her last. One day I had to leave her &
go to the Alms-House: but Dr. Wistar remained for a long
time, & by the use of sinapismsm, spiced brandy, volatiles, etc.
she revived, although her nails were livid, & her breathing
extremely laborious. When the state of the stomach would allow, 
we generally resorted to diuretics, often of the milder kind,
as scabies, juniper berries, etc.; & with respect to the diet, we allowed 
her to take vegetable food, or any other kind that was
agreeable to the stomach. About this stage of the case
my beloved friend, Dr. Wistar, was taken ill, & died. In one
of the last consultations we had in her case, he mentioned
 
 

   

 
  



     
   
 
 
   




 
 



432
the great importance of examining all those cases, after death,
& stated that a gentleman had died as was supposed, of
hydro-thorax; but on examination it proved to be a disease
of the heart. The first visit I paid my patient after the
death of my medical father, the afflicted lady clasped her
feeble hands, & raising her eyes in a devotional manner,
exclaimed, “Who would have thought that Dr. Wistar would
have gone before me!” But the period was now approaching 
when she was to be released; not, however, without much
suffering: for at times she experienced great pain which
would suddenly shift from place to place. Sometimes it
would be very violent in some muscular part; then her breathing 
would be more easy & the pain in the abdominal cavity
relieved. But when it left the muscles her distress was always 
increased, either in the thorax or abdomen. Her anasarcous 
symptoms were distressing, & punctures were resorted
to. During violent pain we were compelled to use laudanum. 
The sickness following its employment was less than
had formerly been the cases. While Dr. Wistar attended her
we observed that she sometimes discharged a little blood
in the mucous she expectorated. It was now more considerable, 
but did not come up in large quantities, as in the case
of a sudden rupture of a vessel. But I ought not to omit
mentioning that the disposition to erratic pain was manifested 
in the neck of the bladder, & produced such distressing 
ischuria that I was afraid the catheter would be necessary. 
For the last two days of her life, she was at times
   
    
 
 

   

 
  



     
   
 
 
   




 
 



433
in a state of agony, & she referred her pain principally to her bowels; 
& although opiates were used freely, yet the pain continued
almost almost to the last moment of existence. She died on
the first day of the 2nd mo. 1818.
On the morning of the 4th, my friend Dr. J.J. Hewson accompanied 
& assisted me in the examination. On opening the
thorax there was no appearance of dropsy of the chest, or unnatural 
effusion within the pericardium. A small & apparently
old adhesion existed between the right lung & pleura near
its lower part. The heart, particularly the ventricles, was much
enlarged, & a slight ossification of the valves on the left side
was found. On laying open the abdomen, the liver was
found much enlarged & diseased, & the small intestines exhabited 
evident proof of recent inflammation. They were
of a dark red colour, & a small quantity of lymph had recently 
been effused. Some serum was found in the abdominal 
cavity.
Affections of the Heart deemed
Incurable.
I will now proceed to consider some organic affections of
the heart, which, so far as I know, are entirely beyond our control. 
Hitherto I have spoken of cases which though dangerous
yet present to the physician some faint hope that he may be
useful. But the diseases which I am now about to describe, arrising 
sometimes from accident, sometimes without any assignable 
cause, are totally without our power to remedy. As an
     
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



434
instance in which accident had a considerable influence in
producing the disease, I will relate the
Case of William Hunter. – He was a young man, by trade
a bricklayer. I was called to see him about the middle of the
4th mo. 1808. He complained of cough & difficulty of breathing,
which greatly increased by any sudden exertion, His countenance 
was generally pallid; but sometimes it had a hectic
blush. He was not emaciated. His feet were slightly edematous.
On hearing his statement, I was induced to suspect phthisis
pulmonalis, & requested him to show me some of the matter
which he expectorated. I found it was not purulent. The first
time I felt his pulse, I was very much struck with its peculiarity 
– it intermitted after every 2nd or 3rd stroke, & impacted 
an indescribable sensation to the finger. As the lungs
did not appear to be ulcerated, I was led to examine in order
to ascertain the state of the heart. No sooner did I lay my
hand on the left side, than I was instantly convinced the
disease of my patient was seated in the heart, or the great vessels 
in its vicinity. That there was a monstrous enlargement 
of the fountain of circulation, was placed beyond a doubt
in my mind. Its motion seemed strong, but extremely laborious. 
On asking the patient how long he had been sensible 
of this great beating of his heart, he said it was about 2
years; that he first observed it after a very heavy lift which
strained him considerably. He informed me that it seemed at
times as if his heart would beat through his breast.
The case seemed to admit of no remedy, & palliatives were
      
   
    
 
 

   

 
  



     
   
 
 
   




 
 



435
all that appeared to me to be indicated. With this view
I prescribed a pectoral mixture for his cough, & candidly
gave an opinion to his friends that it was out of my power
to do any thing for his effectual relief. I continued to
visit him occasionally for about 2 weeks. Three or four
days before his death, his appetite was impaired, & he appeared 
rather more feeble, though he was not confined
to his room. One morning I was sent for, & informed
on my arrival, that the night previous he had been attacked 
with a violent pain in his right side, for which
he had lost about 8 oz. of blood. As the pain was still severe, 
I advised the application of a blister over the part affected. 
This had the desired effect; for, on visiting him at
nigh, I found him quite free from pain. His pulse possessed 
the same peculiarities, but was rather more feeble, &
he was sweating profusely. During the night, or rather
about 9 o’clock in the morning, while in the act of receiving 
a drink from his sister, he suddenly expired.
On examining the thorax about 20 hours after death,
in the presence of Drs. James, Fairlamb, & Clack, I found
the lungs perfectly natural in appearance, without adhesions 
or tubercles. The pericardium contained about 8 oz.
of water, which, when taken away presented an appearance 
novel & highly interesting. The auricles of the heart
were enlarged beyond conception; the superior & inferior
cava were also greatly enlarged. The arteries were perfectly
natural. From these appearances we could not hesitate
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



436
to pronounce it a varicose state of the venous system
in the vicinity of the heart, as well as an enlargement of
the amicles of the heart.
I am now about to state anoth case which may be
denominated
Apoplexy of the Heart;
& from the best information I could gather, I am strongly 
inclined to believe, that the interposition of proper practice, 
some hours previous to the occurrence of this condition,
might have saved the life of the patient. It is the
Case of Sarah Ashton. – The patient was about 50 years
of age, short, of a full habit, & at that time of life when diseases 
from plethora are to be expected. Previous to this attack
I attended her with common catarrh. My attendance continued 
from the 12th to the 20th of the 3rd month, 1812.
I left her improved, if not entirely well. Sex days afterward
I received the following account: On the day she was affected
with the illness I am about to describe, she was sensible thro’
the day of a violent beating at the heart, with a sense of fullness 
about the chest. In the course of the afternoon she went
into the garden to superintend some of the operations that were
going on there, when she was suddenly taken with a severe
chill, followed by most distressing dyspnea; & she became
extremely ill. I was sent for & soon saw her. Her respiration 
was extremely laborious. As soon as I laid my hand
on her pulse, I was struck with a remarkable deviation
from the natural condition: there were frequent pauses or
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



437
intermissions, & then a quick stroke would follow, which
was at one time feeble, at another strong. Throughout
the disease, she was totally unable to lie in a horizontal
posture. Dr. Greffitts attended her with me. A variety
of practice was resorted to. She lived till the 12th of the
4th mo. No benefit was derived from what was done for
her, except some transient relief from the use of antispasmodics. 
Towards the latter period of the complaint the extremities
became edematous.
An examination after death, the heart was found to be
the seat of this distressing disease. A slight adhesion was
found between the left lung & the pleura costalis, in a small
spot. In the inferior & posterior part of both lungs, there was
an effusion of bloody serum. The pericardium contained
about 6 drachms of bloody coloured serum. The ventricles
were enlarged & altered in their structure. There appeared
to be an effusion of blood among the muscular fibers; &
their cohesion was so much weakened that they were readily
torn asunder. The aorta was enlarged to twice or thrice its
natural diameter, & the enlargement extended beyond its
curve. The pulmonary artery was enlarged nearly in a
corresponding proportion. The coats of both were very thin,
& the application of little force to the aorta caused it to tear.
The valves of the heart were natural, except a slight ossification 
of one of the mitral valves.
In this case, as the altered state of the pulse was coeval
with the attack, I infer that there was a sudden rush of
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



438
blood to the heart & lungs, which caused an effusion into
the latter, & a great distension of the formed – producing
in fact, an incursion of the heart & aorta. If the distension 
had proceeded a little further, the consequence must
have been immediate death. Had the patient been aware
of the impending danger, & had a physician been consulted 
previous to the occurrence of disorganization, it is altogether
probable that copious bleeding might have rescued her
from the disease which so painfully terminated her life.
The state of the aorta explains the irregularity of the
pulse. For it appears that several pulsations of the heart
must have been requisite in order to throw sufficient
blood into that vessel to induce it to act on its contents;
& thus to propel the volume of blood forwards to the remote 
parts of the system. While this process was going
on, the pauses in the pulse must have taken place.
This, then, I consider an interesting case. If I were again 
called to any case, & should find, in a plethora subject, 
violent action of the heart, continuing for several
hours, & differing from common palpitation which, like
spasm, comes on speedily & speedily ceases, I should
certainly think it right to relieve the blood vessels by
bleeding as soon as possible.
I once attended a woman by the name of Hoffner
who died of aneurism of the aorta. In her case the disease
was induced suddenly, & came on during a catarrhal attack.   
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



439
You will find many observations on disease of the
heart in several practical works. Corvisart, a celebrated
French physician, has written a work especially on diseases 
of the heart. So far as I can gather, his practice is
merely palliative. He speaks of continued blistering as
one of the plans most likely to afford relief. Dr. Warren of
Boston has also written an essay on the diseases of the heart;
& describes several cases, among which is that of the
governor of Massachusetts.
Corvisart speaks of percussion as one of the methods
of deciding on the nature of diseases within the thorax.
I have not, however, much confidence in the plan.
Sometimes a practitioner is agreeably disappointed.
He meets, or supposes he meets, with a case entirely beyond
his control, & afterwards has the pleasure of perceiving that
he was mistaken in his calculation. A case fell under the
care of Dr. Wistar, which he was in the habit of relating
to his pupils. A man applied to him labouring, as
he thought, under disease of the heart. It so happened
that the Dr. in his inquiries into the case, either took up
the idea that it might be hydro-thorax; or considering 
that the use of squill & calomel would be of no 
disservice, thought it proper to try this remedy before giving 
the patient up. He was surprised to find that the
patient improved under its use, till at length all the
violent symptoms disappeared, & a perfect cure was affected.
The disease might possibly have been dropsy of the pericardium.
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



440
This when distended rises above the great vessels, and
might easily have given to the doctor the idea of an
enlarged heart.
The French physicians speak of cures of organic affections 
of the heart or large vessels, particularly of aneurism 
of the aorta. Their plan of treatment is one I
have never put into practice, & I am not prepared to
say that I shall adopt it, till further experience shall
have proved its efficacy. The plan proposed is to bleed
the patient almost to death, & by repeated bleedings to
keep his as low as possible without destroying life. They
say that in this way, by unloading the vessels & taking
off all distension, they gradually contract till they are
restored to their natural diameter. This is their mode
of treating enlarged vessels in the vicinity of the heart.
I think it proper to state the practice to you; though in
the present state of experience I am not prepared to adopt 
it.
Hydro-thorax.
This disease is commonly known by the name of
dropsy of the chest; & consists in an effusion of scrum
within the cavity of the pleura. It is much more common 
than idiopathic affections of the heat. We meet with
is oftener in advanced than in early life: but it is not altogether 
confined to old age – sometimes we meet with
 
  
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



441
it is middle aged, & even in young people. But it must
be regarded as a rare occurrence in the early period of life.
You will not unfrequently meet with persons in advanced 
life, who until a short period before an attack
of hydro-thorax, or rather of those symptoms which may
be regarded as preludes of the disease, may have enjoyed
tolerable health. But when you meet with an old
person who is beginning to break fast, in other words
loses a good deal of his vigour; whose countenance
form a florid colour becomes pallid, you may fairly 
suspect that such a man is about to be visited with
hydro-thorax.
This disease is generally attended with a train of
symptoms well understood by intelligent practitioners. 
A patient such as I have described, finds that
any effort at muscular exertion speedily fatigues him,
& brings on a disposition to pant. If, for example, he attemps 
to ascend a flight of stairs, or an elevated piece of
ground suddenly, some shortness of breath come on,
& admonishes him that he must be sparing in his exertions. 
About this time the urine secreted is small
in quantity & high coloured; & the patient feels the
necessity of having one or two additional pillows at
night. He is unable without considerable difficulty to
lay with his hand as low as usual; he is also subject to
palpitations of the heart, which sometimes occasion
great distress. The practitioner will discover, in a large    
  
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



442
proportion of cases an irregular state of the circulation.
Frequent pauses or intermissions in the pulse will be
observed, & in some instances an unusual degree of firmness 
or tension in the stroke: Perhaps there will be some
cough: but this is not necessarily characteristic. As
the disease advances, edematous limbs make their
appearance; & it is very common for patients with this
disease to have anasarcous swelling. Some patients,
moreover, are sensible, in turning about in bed, in rising up, 
or in lying down, of the motion of a fluid in
the cavity of the thorax. In some instances I have known
dyspeptic symptoms to occur; & patients labouring under 
hydrothorax suffer a very distressing aggravation
of their symptoms, if they make use of food which disagrees 
with the stomach.
This disease is sometimes of long continuance. But there
is one circumstance attendant on it, of which you should
be aware; I allude to a disposition in the disease, from
some unknown cause to terminate very suddenly & most
unexpectedly. Nothing is more common than for a patient
in hydro-thorax to die instanter, while engaged in his usual
avocations. In the course of my practice, I have met with
repeated instances of its sudden termination, I know two
respectable elderly women to die at a time when no one
supposed them in immediate danger. One of them was
at tea when she died. I could state several other instances; 
but these are sufficient. 
 
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



443
Occasionally we see the patient worn out in a gradual 
way; & he then suffers extremely from the most distressing 
dyspnea.
I have stated that patients with hydro-thorax are
unable to lie with their heads low: but one case fell under 
my observation in the Alms House, which was an exception 
to this rule. In this instance the patient could lie
with his head low. From this circumstance I was disposed 
to think that the disease might be asthma: but
dissection proved it to be hydro-thorax, & there was an
unusual quantity of serum in the cavity.
Another case fell under my notice which was examined
after death by Dr. Price. It was the following:
3rd mo. 28th, 1821. Attended a dissection made by Dr.
William Price in the case of a young man by trade a shoemaker. 
I saw him twice a few days before his death. I
suspected hydro-thorax. He had been a long time affected
with dyspnea; but it was remarkable that he could
lay with his head low. The pericardium contained at
least a quart of whey-coloured, offensive fluid. The heart
was quite small, & covered entirely with a purulent coloured
soft matter; seemingly a mixture of pus & lymph. The
internal surface of the pericardium was lined with the
same. Both sides of the thorax contained a large quantity 
of fluid. The lungs were natural. The stomach contained 
an hour-glass contraction which appeared to have
been of some duration. The pancreas were indurated.
     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



444
In the cavity of this pelvis were found several ounces of
yellow gelatinous matter which appeared to be lymph.
I once lost a patient in my hospital practice whose
thorax was full of water, & who could lay with his
head low, as in the above cases. – It is unusual for
patients labouring under hydro-thorax to be able to lie
with their heads low: I suspect it occurs most frequently 
when the thorax is full of fluid; & that under
such circumstances, change of position will produce less
effect.
Having given this general description of the disease, 
it is now proper to consider the treatment. And
here, at the threshold of this part of the subject, I have
to announce the melancholy truth, that in old people
so far as my experience has gone, the complaint is
incurable. The patient may be greatly relieved from
his sufferings, & his life may be protracted; but I believe 
he can never be cured. As I shall state hereafter
persons early in life, or even of middle age, may sometimes 
get well. The principle remedies are diuretics.
It seems, in the management of this disease, as if every
thing depends on our being able to bring on a very free
flow of urine. If you fail in attaining this object, your
failure will be truly serious. In practice you will find
that some patients are more susceptible than others to the
action of diuretics, & in them the chance of affording relief 
is much greater.



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



445
In as much as hydro-thorax is not to be regarded as
a disease of inflammation, I believe it seldom happens
that a resort to the lancet will be attended with great benefit. 
In some instance where is a good deal of strength
in the patient, occasional bleeding will afford some transient 
relief. There is a great variety of remedies resorted
to in this complaint. I shall consider several of the most
prominent, & give my opinion of others as I pass along.
I once saw a case of hydro-thorax in a middle aged
man, under the case of Dr. Wistar, which really appeared 
to be cured. (at least for several years,) by digitalis,
after mercury & squill had failed. Digitalis was used
with diligence for some time till it produces a marked
effect on the system. But although this medicine is extensively 
resorted to by practitioners, in hydro-thorax, yet my
experience has not been strong in its favour. I have
often used it as a change with other articles. – I once
saw a case in the Alms-House which appeared to be successfully 
treated by the use of cream of tartar & gamboge.
But no remedy in my hands has been equal to the
calomel & squill. I think I can enumerate, in my practice 
3 cases of recovery from well formed hydro-thorax
where squill & calomel were the principle remedies which
were employed. But neither of these patients was far
advanced in life: they were about the middle age. I lately 
had an opportunity of seeing one of them, after a lapse
of 7 or 8 years. I met him in the street, & I can assure
   
  



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



446
you I greeted him with great pleasure. He informed me that
he remained free from disease. Calomel was used in these cases
in small quantities, so as just to affect the mouth. The plan I
generally adopt in the exhibition of squill & calomel is the following: 
I begin with one grain of calomel three times a day:
at the same time I give one grain of squill three times a day.
But as it is the object to increase the squill as far as the stomach 
& bowels will bear, without at the same time, increasing
the calomel, I easily accomplish this by giving the two mediciness 
separately. I go on augmenting the dose of the squill
till it affects the stomach & bowels. If I can get as high as
6 or 8 grains a day, so much the better: but if the squill is
good, the stomach will seldom bear so much. This plan is
pursued till a free diuresis comes on, or till the system is
affected the mercury. If the mercurial action is induced
I lay aside the calomel, but still continue the squill. At
the same time that these medicines are employed, a number 
of diuretic drinks may be interposed with advantage. Among these, 
as a pleasant beverage, & possessing certainly diuretic 
properties, is an infusion of juniper berries. Zj of the berries, 
bruised, are to be infused in a pint of boiling water; & used
ad libertum. Parsley, watermelon seeds, scabies, horsemint,
may all be employed. It is proper to change from one to
the other to suit the nature of the case, or the taste of the
patient.
In addition to the squill & calomel, I have lately met
with a case in which very considerable relief was produced
 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



447
by the steady use of nitrate of potash. This I would advise 
to be taken gradually till the dose is increased to as
much as the stomach & bowels will bear. From one to
two drachms may be given daily, in divided doses, and
dissolved in pleasant drinks. In the instance alluded to
the patient was an elderly gentleman under the care of
Dr. James &  myself. By persisting in the use of nitro
combined with various diuretic drinks, we brought on
a very copious flow of limpid urine. (The limpid appearance 
of the urine is one of the best tests of diuresis.)
The patient in consequence became much better. But
as he is an old man, I have no idea that he will ever
get entirely well. In this case there was a great deal of
edema, which distended the limbs exceedingly, & mounted 
up the abdomen, & took possession of the penis &
scrotum. (In cases of anasarcous swellings, we frequently 
find the penis & scrotum enormously enlarged.) He
was greatly relieved by small punctures made with a
very sharp lancet, about the feet & legs. It was formerly
the custom to scarify the lower extremities with the view of drawing
off the fluid more rapidly: but I must warn you against
this practice. Nothing is more dangerous to the patient;
as inflammation & troublesome suppuration, if not gangrene, 
would very probably come on. But punctures
with a very sharp lancet, made so as just to penetrate
the skin are generally safe, & often yield very great advantage. 
But even with all the care that can be taken
 

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



448
I have known inflammation to take place around the punctures. 
In this case, a great quantity of water ran off thro’
the punctures; so much that in a few hours the patient
was surrounded with a puddle & his clothes became so wet
that it was necessary to change them frequently.
In cases of anasarcous swelling it would be highly
improper to apply blisters as they are apt to induce gangrene.
Patients labouring under hydro-thorax, if their extremities 
are anasarcous, should always be subjected to certain
cautions. They should be warned against approaching
too near a fire. Inattention to this caution, in case when
the circulation in the surface is very feeble has been productive 
of serious consequences – I have known mortification
to result in several instances. They should also be advised 
every thing like sudden exertion. All their movements
should be made with care. They should never attempt
to ascend stairs or elevated ground suddenly. For this kind
of exertion is apt to bring on dyspnea & palpitation of the
heart, & endangers that speedy termination in death, so
frequently in this disease. A patient in this situation, however,
will bear riding in a carriage, or even on horse-back with
very great advantage, while muscular exertion would be
very hazardous. Dr. Wistar was strongly impressed with
this opinion; & supposing himself to labour under the
disease, used to spend a great deal of time, during the summer, 
in riding on horseback, or in a carriage; & I have heard
 
 
    
 

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



449
him say that he had never known a case in which injury
resulted from such a practice.
The bowels should not be allowed to become costive; but
the diuretic medicines which are administered generally have
the effect of keeping them free.
With respect to diet, it must be regulated by circumstances. 
Some patients bear very well a diet of plain solid food;
especially if there are dyspeptic symptoms, it is advisable to
resort to that kind of aliment which is most acceptable to
the stomach. Dyspepsia very much aggravates dyspnea
& suffering in the disease.
There is another remedy to which I wish to call your
attention, before leaving this part of the subject. I have
certainly seen it very useful in the case of a middle aged
person who applied to me. It is an infusion of ginger, horseradish, 
mustard seed, juniper berries, & (if it can be obtained)
parsley root, in cider. This is in fact, forming in cider a
tincture of these articles. With respect to the precise quantity
I am not very particular. The cider should be old &
sound, & free from adulteration. The common sweet cider, 
which is frequently adulterated with honey, is altogether
unfit for the purpose. This tincture may be taken in the
dose of a wine glassful four times a day; & at the same time
the juniper berry tea with the sweet spirits of nitro may be
used as a drink. A tea spoonful of the sp. Nit. dules may be
taken in a tea cupful of the infusion three or four times a
day.  
   
 
    
 

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



450
Hydro-thorax is not unfrequently complicated with
gout; & when these two are blended, even in a young
person, the case must be considered as exceedingly difficult 
of management. As a complicated case of disease, I
know no better place than this, to introduce the following.
The patient was a friend of mine, & was engaged in the lead
business.
Case of Eden Haydock. – Eden Haydock was a most
industrious & temperate man. He was by trade a plumber,
& the poison of bad soon began to manifest itself in his system. 
(See his case detailed under the head of colica pictonum. p.246)
He also possessed a strong hereditary tendency to gout; and
suffered greatly with this disease from early life. It was often
irregular, generally affecting his head, for which he was frequently
cupped. At one time his kidneys were affected, and
I thought uva cersi relieved him. I once saw him labouring 
under a violent attack of croup which I had good
reason to believe was nothing more than gout in the larynx.
He had several fits of regular gout, which I greatly
preferred to any other form. – In his case we have a clear evidence 
that a life of great industry & temperance will not always 
counteract a strong hereditary tendency to gout.
But with all his bodily maladies it was really matter
of surprise to see how he would exert himself, & how quickly, 
after being extremely ill, he would again engage most industrily 
in his business.
In the course of the summer of 1818, he suffered severe-
 
    
    
 

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



451
ly with dyspepsia, & moderately with diabetes. In addition
to these he had something like gutta serena. His sight failed
considerably & his nervous system was very much affected.
He had great tremours & frequent spasms or jerks.
Finding himself unable to pursue his business, he took
a journey to Ballston, Saratoga, & the sea shore; but returned 
without material benefit. Not only did dyspepsia
& nervous twitching harass him continually; but in addition 
to these, anasarcous swelling of his legs & dyspnea
made their appearance; giving some reason to suspect
effusion into the thorax, or some disease of the heart, as
he had frequent palpitations. But his affections did not
end here; irregular gout often harassed him; & I was
in continual fear that seizing suddenly on some vital
part; it would extinguish life in a moment. These fears were
nearly realized; for one day in coming out of the water closet, 
after having had an operation from the bowels, he was
suddenly attacked with what appeared to be apoplexy.
From information it appears that insensibility was complete, 
& respiration so stertorous that he could be heard down
stairs. My friend, Dr. Griffitts happened to be near the house
at the time, & was called in at a most critical moment
He bled Eden freely, & the symptoms abated. I was sent
for & saw him with Dr. Griffitts that evening. We bled
him again blistered his head, etc. He recovered from this attack, 
& with our advise, went on a visit to his father-in-law’s
at Mount Holly. There he became worse, & soon returned.
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



452
He was now attended by Drs. Park, Griffitts & myself, also 
by his brother Dr. Haydock. We tried several plans, but
without effect. His constitution was completely broken up.
The last few days of his life, he really appeared to have some
return of his old complaint, constipation. His strength failed &
he died.
Dr. Horner, at my request, examined the body, & found
a considerable effusion of serum in the left side of the thorax.
The pericardium was largely distended with water. The brain
was perfectly natural. The colon was found to have a structure,
that was probably of long standing. The bowels was thickened
for the space of about an inch in width, & this thickness incircled 
the whole gut.
I have read this as a case of complicated character, when
gout & hydro-thorax were blended together, & the powers of
lead broke down the constitution, & reduced the system to
the condition you have heard described.
A similar case fell under the care of Drs. Hartshorne,
Wistar, & myself, which I believe to have been hydro-thorax
accompanied by symptoms which I shall notice.
Case of James Lee, Esq. – The subject of this case was
in the prime of life, a remarkably stout built man, accustomed 
to use a great deal of exercise, & to take stimulants, freely.
One of the striking features of his disease was an extremely irregular 
action of the heart. The pause in the pulse were long
& frequent: & during sleep & about the time of dropping to
sleep, he was singularly distressed & moaned very much. He
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



453
He ascribed this distress to a fear of being enable to breathe
if he was not constantly on the watch; & said he often felt
as if it was necessary to make voluntary exertion to breathe.
We kept him upon plain & rather low diet; & cut off the
use of all stimulants. We used the squill; & he took, I believe, 
some laudanum at night. Under this plan he 
surprisingly. His pulse became quite regular, and
he seemed well. He went to Burlington on business for
a few days. Here he departed from the plan of living prescribed,
& returned with his pulse in the same state as before. He
was again relieved; & when he set out for home (Port Elizabeth, N.J.) 
we recommended a life of strict temperance, as
the only possible plan of preserving his health.
About a year afterward he consulted me in consequence
of a return of the disease. He had lived temperately for a considerable 
time; but on a slaying party was induced to give
in to his old habits, & the complaint returned.
Here it is proper for me to state that I have seen the
complaint quite early in life in consequence of indulgence
in intemperance. Not long since I saw a man about 30
years of age, who laboured under hydro-thorax. Unhappily
for him, it could be traced to the intemperate use of ardent
spirits. He died instantly while taking a walk.
One of the patients, owed his complaint to intemperance.
Another of them, who was a man not beyond the middle age, 
was attacked with hydro-thorax after pneumonia.
This patient got well under the use of squill & calomel.
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



454
Before closing the subject I must again call your
attention to the importance of the diuretic treatment in this
disease. I must also mention as palliatives cups & blisters. 
Temperance in living is very important. But as regards 
the permanent cure of hydro-thorax, diuretics must
be principally relied on. Mercury has considerable influence 
in preparing the system for the use of diuretics:
but remember that to bring on a copious flow of urine
is your object in this disease.
To give you an idea of the importance in which diuretics 
were held by the celebrated. Fothergill, I will state an
anecdote which I used to have related by Dr. wistar. Humphrey 
Marshall, a botanist of some note in Chester Co.
Penn. for a long time maintained a correspondence with
Dr. Fothergill of London. – I think I have heard it said that
Dr. F. in his zeal to promote science in America, assisted
him with his purse. This gentleman stated to Dr. Wistar that
Dr. F. hardly ever wrote to him without impressing on
him the importance of discovering some certain & powerful
diuretic. Now Dr. F. was a man of extensive experience,
& felt, as every other experienced practitioner must, the importance 
of diuretics in the treatment of dropsy.
It now remains for me to inform you that in practice
you will often feel embarrassed in deciding on cases of
hydro-thorax. As I have in the case of Penelope
Whitehead, you may have an assemblage of most of the
symptoms attending the effusion of serum into the cavi-
  
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



455
ties of the chest, without any effusion existing at the time.
You will recollect that she was subject to distressing dyspnea, 
& that there was a train of symptoms very severe &
ultimately fatal: & yet dissection proved that the complaint 
was not hydro-thorax; but that all the symptoms
arose from disease of the heart. In this as well as in all
other cases which I shall mention, the operation of diuretics 
did not procure the relief which might have been expected.
The paroxysms of dyspnea were more transient than they
usually are in hydro-thorax; at one time she would seem
to be brought to the very brink of the grave, & the next day she
would be down stairs engaged, as the mistress of a large
family, in domestic avocations.
A truly respectable physician & excellent man, Dr, J.
Stokes, of Moorestown, N.J. fell a victim to a disease which
was generally thought to have been hydro-thorax; though I
was of a diffirent opinion. Unfortunately, I had not an opportunity 
of ascertaining its real nature by dissection. He
was subject, like Penelope Whitehead, to most distressing spells
of dyspnea, & at the same time was acted on very freely
by diuretics. He had none of that marked diminution
of urine so observable in hydro-thorax; nor did diuresis
produce that relief which it usually does in the disease.
He could also lie with his head low; but this, as I before
mentioned, is not to be depended upon as a certain diagnostic. 
However, several weeks before his death, a tumour
was distinctly perceived through the integuments of the ab-
       
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



456
domen. His legs were much swelled; & I was induced to
believe that this affection arose from the tumour just mentioned, 
on the vains, & lymphatics of the abdomen. The occurrence
of this tumour, in connexion with the fact that the action of
the kidneys was natural, & that considerable diuresis could be
produced without yielding relief, led me to believe that it
was not hydro-thorax of which he died.
Another case fell under the care of Dr. Griffitts & myself, 
which, in some respect, bore a strong resemblance to
hydro-thorax; but I had good reason to believe that all the
symptoms depended on inordinate obesity. In addition to
this the patient was subject to gout. It was the
Case of John C, Well. – This case terminated fatally;
& I believe was occasioned principally by mechanical impediment 
to respiration, in consequence of a morbid accumulation 
of fat. The patient was really a burthen to himself. 
For a long time he was unable to lie down in bed;
but generally reclined on a sofa or sat in a chair. His wife
informed me that for the last two years, he had frequently
been in the habit of sleeping whole nights in his chair 
in the parlour. Along with obesity he suffered greatly with
gout. In consequence of sitting constantly, the pressure on his
seat & the back part of his thighs was such as to produce an
impediment to the circulation, & in this was cause the most
distressing anasarcous swellings of the lower extremities, accompanied 
with a discoloured state of the skin which really 
threatened gangrene. Vesications actually did occur,
 
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



457
& produce superficial ulceration. There was a great disposition 
to somnolency, & the mental faculties of the patient
were evidently impaired. Dr. Griffitts saw him with me
occasionally. At first, for the relief of his respiration and
stupor, bleeding & cupping were employed, together with
blisters to the breast, all without any material benefit. Soon
after this a copious expectoration of matter which really appeared
to be purulent took place. But still the difficulty of breathing 
continued, & when he coughed he seemed almost in a
state of strangulation. His countenance became of a dark
purple colour. We tried him with calomel & squill, which
caused a flow of urine in cataracts (as he expressed it;) but all
to no purpose. A mechanical impediment bid defiance
to every thing. We were obliged to use tonics. He continued
to ride out occasionally until the day preceding his death.
He was found dead in his bed. It is probable he died in a
paroxysm of coughing. The rapid advancement if putrefaction 
after death was beyond almost any parallel. I was
informed by a person who attended the funeral, that the
stench in the house was almost insupportable. They were
obliged to lash the coffin with ropes to keep it from bursting.
Even the sexton told me he was forced to vomit.
A few years since a man named Dixon, extremely corpulent, 
& disposed in the same way to somnolency, was found
dead in his bed.
You will perceive by the cases I have stated, that I
lay great stress on determining between hydro-thorax, and
    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



458
diseases resembling it, upon the action of the kidneys.
In some cases when dyspnea has formed a prominent
symptom, there is a free & natural discharge of urine:
in other cases, where the fact may be doubtful, diuretics
will operate profusely, & yet procure no relief. When
you meet with instances of this kind, you may consider
them as not hydro-thorax.
Some practical writers have proposed tapping in cases 
of hydro-thorax. I have never seen the practice tried;
& for my own part have no particular desire to try it.
It is always attended with some hazard, & the result
is very doubtful. In a case of dropsy which occurred in
Virginia, an attempt was made to tap the thorax: but
the complaint proved to be dropsy of the pericardium.
This membrane was punctured & the water evacuated;
but the patient died almost immediately.
Diseases of the Head
_________x__________
Hydrocephalus.
This disease as it name implies consists in an effusion
of serous fluid into the ventricles of the brain; & in common language
is denominated dropsy of the brain. I regard hydrocephalus 
as primary affection of the brain; or in other words on
 
    
    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



459
idiopathic disease of this part. That the brain may be brought
into sympathy with various parts of the body is a fact which
I will most readily admit. I propose in fact, in the course of
my observations, to make some remarks on the sympathies of the
brain. But I wish you distinctly to understand that I consider 
real hydrocephalus on idiopathic affection.
Hydrocephalus is very frequently found to be an hereditary disease. 
I presume that there very few physicians in extensive
practice who have not been called upon to see children in the
same family labouring under the complaint. The knowledge
of this fact is surely important; because in families where this
constitutional predisposition is known to prevail, the physician 
is more on the alert, & is disposed to regard every complaint
of the head, however slight may be the appearances as serious
enough to require very close attention.
Hydrocephalus when fairly formed is very generally fatal; 
& when I hear of its being frequently treated with success,
I am much inclined to suppose that the gentlemen who give
these reports are mistaken as to the character of the complaint; for
some diseases which are my manageable bear a close resemblance 
to this.
Dissections show effusions of serous matter into the cavities 
of the brain. In some the quantity is very considerable,
amounting to half a pint; in others it is very small, down as
low as one once, or even less. From observing the similarity of
symptoms in cases which have proved fatal, & also the dissimitanity 
in the quantity of effused fluid, as manifested by dissect-
 
    
    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



460
tion, I have been led to conclude  that there may be, & often
is a fatal, & I may be allowed the expression, an hydrocephalic, 
action going on in the brain, without the effects of this 
action being very strikingly displayed by effusion.
Because, whether there is a considerable quantity of water in
the brain, or only a very small quantity, the same order of symptoms 
occurs, especially in the latter stage.
You will find in practical writers various causes assigned
for this disease. I shall not undertake at present to enumerate 
all. But I will briefly remark that constitutional predisposition 
is to be regarded in a very serious light; & that
any causes that are calculated to interrupt or disturb the healthy
functions of the brain, occurring in an individual with this
constitutional predisposition, may excite the fatal action
& evolve the disease of which we are now about to treat.
Among the most prominent causes assigned for this disease
by practitioners in general, are blows on the head. Now, conformably 
to the view I have just taken, I can easily conceive that
a blow on the head would be much more dangerous when
received by a child with this constitutional predisposition, than
when inflicted on another child who has it not. But I regard
blows on the head as seldom the cause of the disease separate
from constitutional tendency; & my reasons for this belief are
the following: I attended in the Phil. Dispensary between
six & seven years, & during that time had a very extensive opportunity 
of visiting among the poor, & I saw, of consequence,
a vast deal of practice. So far as my experience goes, I
      
    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



461
can pretty safely assert, that hydrocephalus is not more
common in the lower walks of life than in the higher circles.
In fact, if called on to decide the point, with my present views,
I should say that the balance is in favour of genteel life.
Now, did it depend on blows on the head, it would certainly
be a more common disease among the children of the poor
than among those of the affluent. Those who are acquainted
with the difficulties with which the poor have to contend are
aware that not unfrequently the father & mother of a family
are compelled to go abroad to their work, & leave a large flock
of very young children under the care of the eldest daughter
who herself may not be more than 8 or 10 years of age. A
child so situated will receive 10 blows or falls where one that
is faithfully nursed will receive one. Hence the disease
should be more common among the poor than the rich;
the reverse of which, however, is the case.
Hydrocephalus is an extremely obscure & often a very insidious 
disease: I wish to fix this in your minds as an important 
principle. – I find it difficult to undertake a satisfactory 
description of this disease in its early stage, as I know
of no one diagnostic symptom. But if called on to speak of
any one in particular, I should say that an irritable stomach, 
as a general rule, is a very common attendant of the early
stages of hydrocephalus; & it is not uncommon, at the same
time, to meet with constipation of the bowels. In addition to
these you will find an irregular febrile state – the child appearing 
not very sick, nor yet altogether well. This mild febrile
 
 

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



462
disposition sometimes disappears sometimes appears in the
form of an intermittent; sometimes in theta of a mild, but
very very irregular remittent. I have been very much
deceived by the intermissions in this disease: because, reasoning 
a priori, they are entirely opposite to any thing
we might expect. If for example, the disease is fairly formed,
& so important an organ as the brain materially affected,
we could hardly calculate that the patient would be, for
hours together, exempt from those symptoms which mark
disease of the brain. Such, however, is the fact; & having
been deceived myself, I wish to guard you from falling into 
the same error. Further, as there is so much uncertainly
in this disease, I wish you to be aware that an intelligent
nurse or an affectionate mother is frequently apt to take
the alarm before the practitioner is all prepared for the impending 
danger. Hence, I wish to impress on you the
propriety of not treating lightly the fears of the mother or
female attendant who, being constantly with the child &
comparing its present state with the state of health, & more-
over observing all those little matters which, in the aggregate,
are so important, are capable of forming a pretty good judgement 
as to the nature of the complaint. I recollect attending 
in a family in this city, a respectable old lady who had
been extremely ill. Dr. Hewson & myself were in attendance
together. In the course of our visits we were frequently requested
by the lady of the house to examine a child of hers, an infant
of 6 months; & by the solicitations of the mother we
  

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



463
were induced to pay some attention to the child as we passed 
along to the room of the grandmother. We both thought
that the fears of the mother induced her to apprehend danger, 
where, in fact, there was no cause for apprehension.
She frequently told us that something was the matter with
its head. Some slight medicines were administered; but
we resorted to nothing active. At last, however, hydrocephalus 
developed itself in its most alarming form, & in a
short time the infant died.
On another occasion I was called to a respectable
family, in this city, with a truly respectable physician: - 
& here I can impart to you an useful practical lesson.
This gentleman was attending one of the children of the
family with what appeared to him to be a very slight disease, 
& probably in the same situation I should have
been of the same opinion. He saw nothing in the child
to excite his apprehension; but the female part of the family 
were under great fears, & a consultation was proposed.
This the gentleman declined, stating as his reason was too
slight to render it necessary. Here he erred: for I consider 
it to be the right of the patient, or his friend, to have a
consultation whenever they please; & as the practitioner
in attendance bears no part of the expense, he has no right
to say it shall, or it shall not be. – After continuing for
a day or two he became alarmed & requested a consultation 
himself. I saw the child with him; & it proved to be
one of those very obscure cases which develops themselves
    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



464
just at the dose of the disease. As you may readily imagine, 
the case terminated fatally.
One symptom further of the first stage I would
here mention, as stated to me by my departed friend,
Dr. Wistar. In the case of his own child, who was extremely 
ill with hydrocephalus, he was struck a week
or two before he became seriously alarmed, with a disposition
on the part of the child to press its head against
his breast, whenever he took it up to carress it. This was
evidently caused by an uneasy sensation in its head for
which it derived some relief from pressure.
Another symptom I might mention, which in
some very violent cases may be met with in the early	
stage: I allude to sudden & violent screams, without our
being able to assign any cause. Sometimes, however, if
the child is old enough, he complains of pain in the head.
By these sudden screams, the irregular fever, the constipated 
bowels, the irritable stomach, etc. we are sometimes
enable to detect the approach of hydrocephalus. As relates
to the secretion of the kidneys, I have been repeatedly disappointed 
by finding that it went on well. And as to the pulse,
I do not know that it can be distinguished from that which
accompanies other febrile conditions of the system.
I have thus stated some of the most prominent symptoms 
which characterize the early stage. When the complaint
passes along to its more advanced form, other symptoms
occasionally become very obvious. Among these, I will
    
  
    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



465
consider the condition of the eye. In many cases the
pupil is very largely dilated, strabismus occurs, & sometimes
a loss of vision, This state of the pupil may not appear
till a very late period of the disease; & I believe, in
the latter stages, it is always observed. – I will here make
a remark on the pupil which I consider important. In
the most healthy state of the brain, the pupil is liable to
dilatation under circumstances which I am about to state
to you; & a knowledge of this fact is of consequence: because, 
when you are searching for symptoms in some
obscure cases of disease, to enable you to form a correct
judgement, it is absolutely necessary to distinguish healthy
from morbid actions. Thus, if you have a child under
your care, & suspect the existence of hydrocephalus, upon
entering the room while the child is asleep & examining
the eye, you will find the pupil contracted: but the instant 
that you rouse the child & its eyes open, the pupil
suddenly dilates. This might induce you to suspect that
some mischief was going on. Dr. Wistar & myself once attended 
the child of a gentleman in this city, who had previously 
lost one with hydrocephalus. The little fellow had
some obscure symptoms, & to be on the safe side, we shaved
& blistered his head. In the course of our examinations, that
condition of the pupil was very manifest. It struck me
as possible that this might be the natural state of things;
& I suggested to the Doctor the propriety of examining the other
children who were then asleep in another room. We ac-
    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



466
cordingly entered their chamber, & upon trial found exactly 
the same result. While they were in a sound sleep the pupil 
remained contracted; but it instantly dilated when they
awoke. The Dr. requested me, when I returned home, to examine 
my own children; I did so, & found a like result.
There is another symptom which is not an uncommon
attendant of this disease, particularly in the latter stage, tho’
it may occur of the complaint. This may certainly be regarded
as a very unfavourable symptom: I allude to a rolling
motion of the head.
Though the pulse, early in the complaint, has the same
character as in fevers generally; yet in the latter stages a change
almost always takes place – it becomes slow, full, & irregular.
I have often observed at this period a throbbing motion of
the carotids, giving the idea that the blood was driven
forward into the head, & there meeting with some resistance,
communited a peculiar jar to the great arteries leading to the
brain. The same thing may be observed in some cases of
effusion of blood within the cranium.
Hydrocephalus is mostly closed by convulsions. Some-
times a day or two previous to death hemiplegia takes
place. I have this distinctly marked in dropsy of the brain.
From all these views, you may understand that this
disease is very obscure; & in order to illustrate several of the
points I have stated, & particularly the insidious & obscure
nature of the complaint, I will present you with an account 
of the following cases:
   
    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



467
2nd mo. 15th, 1820. Case of Dr. Hewson’s Child. – The
longer I live, the more I am convinced that hydrocephalus
is often a very insidious disease. I was this day engaged in the
examination of a very lovely infant, aged 2 years & 5 months,
the son of my esteemed friend Dr. Tho. J. Hewson. The child had
been sick for 2 weeks; the first week but slightly indisposed with
occasional sickness of stomach & rather a constipated state of
the bowels; but with very little fever. It was thought
probable that worms might have some agency in his indisposition; 
& I believe some vermifuges were given. About one
week after the child was first taken sick, Dr. Otto was requested
to visit him; & from the obscurity of the case, he as well as
Dr. Hewson began to suspect the head as the seat of the disease, 
merely consequence of the situation of the stomach &
bowels. A system of alvine evacuations was attempted, & was
partially accomplished; but not being followed by that improvement 
which was desired, I was called in consultation
on the evening of the 10th instant. At this time I found him
with perfect clearness of intellect: no intolerance of light; no-
contraction of the brow; no rolling motion of the head; an eye
& countenance perfectly natural, & a pulse nearly 120 in the
minute, but rather variable. As his stomach was disposed
to be irritable, a blister had been applied to it. when he felt
pain either in the seat of the blister, or in the bowels, he was perfectly 
sensible & would refer to the part. Thus he would say
his belly ached, etc. but when asked respecting his head, he
would acknowledge that it hurt him. His sleep & position
    
   
    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



468
in bed were perfectly natural. On the morning of the
11th, we found that some senna tea taken during the night
had procured several pretty free discharges from the bowels; but
still he was not well. He had pretty generally a slight exacerbation 
of fever about 10’clock every day, & something like
sordes appeared on his lips & gums. I entertained a hope that
it might be fever of the remitting form, although somewhat
obscure; but still, as a measure of safety, it was concluded
to shave & blister the head in anticipation of a more developed
form of hydrocephalus. This was done in the morning. In
the course of the night, the blister produced some strangury
& tenesmus. It was removed on the 12th, & a poultice was
applied to the head. On the evening of the 12th, we were informed 
that in the afternoon, he had several times screamed out
in his sleep, & for the first time complained of his head. But
alas! His pulse now told us what we might expect – it was reduced 
to between 10 & 80 strokes in the minute & was very irregular; it was truly a hydrocephalus pulse, & we now began
to have afflicting evidence that our gloomy anticipations were
well founded. Dr. Otto & myself parted from our friend Hewson 
pretty late that evening, with very gloomy feelings. It was
concluded to keep up a gentle action on the bowels. But
how were we surprised next morning, (the 13th,) when we were
informed by the father that our little patient had passed an
excellent night, & was better. We found that his pulse had
entirely lost the character it had assumed the preceding evening;
beating at this time 120 strokes in the minute. His intellect

    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



469
was perfectly clear, & there was not the slightest complaint
or appearance of uneasiness in the head. His vision was
good; the pupils were perfectly natural; there was no intolerance 
of light, or rolling motion of the head. He would
ask for drink, & take the cup into his own hands. The day
passed away very pleasantly. The bowels were moved three
or four times, & the urine was freely passed. Late in the
evening when we left him, we observed a disposition to slowness 
of pulse; but in no other respects was there any thing to
alarm us. It appears that towards morning he awoke
& was evidently delirious. Soon after this violent convulsions
ensued, & about 8 o’clock, on the morning of the 14th he died.
Dr. Harlan made the examination for Dr. Otto & myself; 
& reported that he found no water in the right ventricle; 
but from the left & from the third & fourth ventricles
he procured about 6 oz. of serous fluid. The vessels of the
brain appeared as if injected with blood. The cavity of
the thorax & abdomen presented no unusual appearance,
except that the great curvature of the stomach had undergone 
a very considerable digestion.
The fact of the pulse regaining its frequency after it
had assumed the slow & irregular beat of hydrocephalus, is
to be regarded as somewhat unusual: but I have seen
a similar instance in the Daughter of my friend, Dr. Otto,
whom I attended last fall in consultation with Dr. Hewson. 
In making this remark relative to the pulse, I
do not allude to the frequent pulse which almost inva-
   
  

    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



470
riably occurs in the very last stage of hydrocephalus,
& often attended with convulsions etc. etc. – it is a very different 
thing from this.
On the subject of the treatment of hydrocephalus, I
shall not detain you very long. We will now presume
that we have before us a case of this disease fully formed
& that no doubt remains on the mind of the practitioner as
to its real nature – what mode of practice ought we to institute 
for the cure? Those who regard the disease as consisting 
in a primary affection of the stomach, & a sympathetic 
affection of the brain, place great reliance on the use of
emetics I am unable to speak either for or against the practice 
from my own experience. Because considering the irritable 
condition of the stomach observed in this disease as depending, 
not on a primary disorder of that viscus, but as originating 
from the sympathy existing between the stomach
& the brain, my attention has always been directed principally 
to the head. As constipation of the bowels is very generally 
an attendant upon hydrocephalus, the propriety of emptying 
the alimentary canal by catharsis is very obvious. 
Hence, in the beginning, I am friendly to brisk purging; 
& through the whole course of the disease, I am desirous 
of keeping the bowels, at any rate, in a soluble condition, 
If heat of skin & an active state of pulse, manifesting 
considerable febrile excitement, exist, general & topical bleeding, 
I believe may be advantageously employed. Leeches to
the head I consider as a very valuable part of the treatment.
  


  

    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



471
But the remedies which I have proposed, though very proper 
in their places, are not alone to be relied on. I think I
can say, that I have seen blisters over the whole head of the
most essential service. It is a practice which I invariably
pursue myself, & which I strongly recommend to you.
I have stated that idiopathic hydrocephalus, when fairly
formed, rarely terminates in any other way than in death.
But in the course of my practice I have seen two or three,
certainly two, well formed cases of the disease, which eventuated 
in perfect recovery. At least they were so fully formed
that had the patients died, as I expected, I should not have
had any hesitation in pronouncing them hydrocephalus. One
poor child I attended in the early period of my practice.
In the progress of the case several convulsions took place;
& in addition to other alarming symptoms, hemiplegia
made its appearance. This child recovered. The recovery was
slow; but it was perfect. If my memory serves me right the
patient was bled two or three times, & the bowels were kept
open with calomel. But the remedy which appeared to me
to be the most serviceable was a blister to the head. This was
maintained for a long time, - not only for weeks, but even
for months. I was very apprehensive, in this case, that the
disease would leave a condition of the intellect even worse
than death itself. I watched the child occasionally for
several years, & was really fearful that it would be an idiot: 
but happily I was mistaken in my prognostic. Every 
appearance of the complaint wore off; & when last I
  


  

    

    
     
   
  
    
  
 	

 



     
    
 

  
   
  
  
   
    
 
 

   

 
  



     
   
 
 
   




 
 



472
saw him, which was several years after his first attack, he
appeared to be a very sensible, & if his mother might be believed,
“a very smart child”. Perhaps maternal fondness
may have exaggerated his powers of mind; but it is very
certain that not a vestige of the disease remained.
I once attended, with Dr. Perkins of this city, a child of
charles Harper, that was very ill with symptoms of hydrocephalus. 
Contrary to all our expectations, he recovered. The bowels
were opened & leeched were applied; but I believe that a blister 
to the head had the most important agency in effecting
the cure.
But it is necessary for me to call your attention to another
remedy which has been very strongly recommended by some
practitioners of deserved eminence, who have carried the practice 
to a very great extent: I allude to the use of mercury
with a view to its salivant power, or rather its peculiar power 
on the whole system. That great, & justly distinguished
physician. Dr. Wistar, was strongly attacked to the use of mercury 
in hydrocephalus; & the quantity which he employed
in some cases was very great indeed. In the case of his
own child, now a fine, healthy, & intelligent boy, mercury
was carried to a very great extent. But I must acknowledge 
that I am opposed to the use of this article, to the extent 
to which it has been used in some cases of hydrocephalus. 
Instances have occurred where the remedy has proved
worse than the disease; where after the symptoms of hydrocephalus 
have disappeared, the patient has finally
     


473
fallen a victim to the violence of the medicine which was
administered to cure him. This generally occurs at a period 
of life when mercury pushed to any extent is very injurious
to the constitution. Dr. Rush, who was a strong advocate for
mercury in many diseases, was opposed to its extensive employment 
in children under 10 years of age. So that considering 
the hazzard incurred by a very strenuous employment 
of mercury; & recollecting that it does not always succeed, 
even when pushed to its utmost extent; remembering
too that under a milder practice, we occasionally witness
a recovery – taking, I say, all these circumstances into consideration. 
I am not by any means satisfied to use this
remedy very extensively in the cure of hydrocephalus. With
a view to its purgative effect, & in small quantities, to its
operation on the system, I have no objection. But to lay the
patient in a bed of strong mercurial ointment, & use pound
after pound of this articles, is a practice which I confess I
cannot approve.
Sympathetic Affections of the Head.
Having taken these general views of the treatment to be followed 
in cases of genuine hydrocephalus, I now pass on to the
consideration of some diseases of the head, which are the result
of sympathy. Every practitioner is familiar with the fact that
there are various affections of the head which depend on the
sympathy of the brain with remote parts. You are all aware
        


474
that the brain & stomach have a very remarkable sympathy 
with each other. Every days experience assures us of this
fact. It is offered as an argument that hydrocephalus is primarily 
seated in the stomach, because the disease is generally ushered 
in by an irritable state of that viscus, indicated by nausea
& vomiting. Now if we examine this position, we shall find that
the occurrence of nausea & vomiting cannot be given as a proof
that in every instance, the stomach is primarily affected. Because 
surgery teaches us that the stomach may be most violently 
irritated from a primary disease of the head. I need
go no further than to call your attention to concussion of
the brain. A person will fall & receive a severe blow on the
head, which will produce what is commonly called stunning. 
What is the order of symptoms in such cases? One of
the first is a very irritable condition of the stomach – severe
vomiting is a very common attendant of concussion of the
barin. I have known the irritable condition of the stomach
to last for a day or two; & then all the symptoms to disappear 
& the patient do well. But the fact is familiar to every 
surgeon that a blow on the head will cause sickness
of the stomach. Hence why must we resort to a primary affection 
of the stomach to explain a disease of the head, when
it is certain that affections of the head may be followed by an
irritable stomach as a consequence? That stimulants act
on the brain through the intervention, we all know – the common 
habit of drunkenness shows this. Strong drink taken
into the stomach is very speedily followed by morbid im-
  
           


475
Pressions on the brain – the same thing follows repletion, or
distending the stomach with food. This fact was exemplified
in the case of a little boy, the son of Elisha English. He
partook largely of animal food, & soon after dinner, while
playing, he fell down in a state of stupor & complete insensibility. 
When I saw him his pupils were largely dilated, his
skin cool, & pulse slow. A kind of apoplectic condition had
taken place, depending on the engorgement or overloading
of the stomach. This state of things was relieved by emetics
copiously administered, which brought up a large quantity
of undigested aliment.
The difference between sympathetic affections of the brain
& primary disease of that organ, is very considerable as regards 
the issue of cases. In inebriety to which we have just
alluded, where the brain is so highly excited, we know very
well, & daily experience teaches us that dangerous consequences 
seldom result. And in the case of repletion which I related   
an emetic relieved the patient at once from danger.
It has been stated that the stomach from its peculiar organization 
is much more likely to be affected by morbid causes, 
so as to produce disease of the brain, than the brain is to
be primarily affected. It appears to me that this reasoning
is not regulated by sound principles. That the stomach
is susceptible of being acted on by a variety of causes, we
will all readily admit: but when we view the structure
of the brain, the blood vessels ramifying through it, & the
membranes investing it, we can as readily conceive that mor-
           


476
bid causes should act directly on that organ, as that they
should first produce disease in the stomach, & then sympathetically 
affect it. Disorders of the stomach are exceedingly 
common; but genuine hydrocephalus, on the contrary, 
is rare. In speaking thus, I wish to be understood as
making a distinction between the genuine & sympathetic
disease.
Among the diseases of sympathy with the stomach causing
apparent disease of the brain, I will call your attention to
yellow fever. In this complaint I have seen the most profound
& deadly coma, evidently depending on primary disease 
of the stomach & alimentary canal. I have seen this,
& on dissection have found a natural brain. But in hydrocephalus 
we rarely if ever discover a natural appearance of
this organ.
The heart & brain sympathize with each other. You will
find in the works of Corvisart & Warren, who have both written 
treatises on the diseases of the heart, that patients are very 
apt to be affected with maniacal symptoms & evidences
of diseased brain, depending on the sympathy of this organ
with the heart. In the case of a young, I met with a disease 
of the heart, which terminated fatally: I made a dissection 
& ascertained the fact. In this case fair formed mania 
occurred in the latter stages. In my lectures on consumption, 
I told you I had seen several cases of that disease 
accompanied with acute mania in their last stage.
I was once called by the late Dr. Wollens to see with him
   
           


477
a patient in the Northern Liberties, affected with a most extraordinary 
disease of the head. It could scarcely be called
pain; but there was a sense of continual buzzing which kept
the patient in a state of uneasiness. Large opiates had been
administered by the mouth, & evacuations of various kinds had
been resorted to before I visited him. In this instance finding 
that opiates by the mouth had failed, & conceiving that
an impression on some remote part might be more effecttual 
I advised an anodyne enema. This was given with the
most happy effect. In the course of my attendance, Dr. Wollens
stated that some symptoms of hepatic disease had been perceptible. 
But so severe was the complaint in the head that we
seemed to lose sight of the liver, & all our efforts were directed
to the brain. Soon afterward the patient died. Dissection exhibited 
to us a very large abscess of the liver. In this instance
Dr. Wollens offered an explanation of the symptoms of the brain,
entitled to credit from its ingenuity. He observed that in
many cases of inflammation of the liver so much complaint 
was made of pain in the shoulder, that practitioners 
had been induced, in some instances, to apply a blister
to the part; but without any pleasant effect. If the shoulder 
is effected to such a degree from disease of the liver, why
may not the brain also sympathize with it? And in this
case there can be no doubt that the complaint in the head
was sympathetic, depending entirely on the hepatic disease.
The bowels, in some instances, sympathize with the brain,
& in a most extraordinary manner. As a confirmation
  
 

   
           


478
of this, I refer you to the case of Jos. Gibbon, child (see p. )
in which mania of a very unpleasant nature was induced
by a spasmodic affection of bowels; also to the case of a
little girl, attended by Dr. Wistar, (see p. ) that fell into
a state of mania which continued for 3 weeks, & then suddenly 
disappeared in consequence of the discharge of a large number 
of ascarides from the rectum.
Violent affections of the head we will know, depend in
many instances on primary disease of the stomach. Among
these affections not the least unpleasant is the sick-headach.
This is a disease to which some individuals are peculiarly
liable. The suffering & apprehensions of danger during the
paroxysm afford no little uneasiness; yet it may continue
for years without danger. – For an excellent paper on sick
headach, I refer you to the posthumous works of Dr. Fothergill 
who was himself afflicted with the disease.
All these cases are calculated to show that the brain
may be affected in consequence of sympathy with various
parts of the body – not only is the stomach to be regarded
as a point sympathizing with the brain; but even the
heart & the contents of the thorax, may be so affected as
to produce apparent disorders of the head; the same may
be said of the small intestines, the rectum & the liver.
But it is of great importance in a practical point of
view to ascertain the seat of disease so as to attack it with
the fairest prospect of success; & with my views of idiopathic 
hydrocephalus, that practice which is directed to the
    

  
 

   
           


479
stomach is not conformable with my notions of what is
proper. I wish particularly to impress on you that an irritable 
stomach is no more to be regarded as the cause of
hydrocephalus, than the same condition, under other circumstances, 
is of concussion of the brain. Hence the practice of
giving emetics does not appear to me exactly accordant
to my views; & yet if experience shall prove it
most successful, I hold myself ready to adopt it.
In the course of my practice, I have sometimes been
very much at a loss to distinguish between idiopathic disease 
of the brain, & that which depends on certain conditions 
in fever. The infantile remittent described by Dr. Butter 
(whose work deserves your attention) is characterized thro.
every stage by a strong disposition to coma. I have seen
the coma continue many days. At one time I thought
I had discovered a certain diagnostic between this fever
& hydrocephalus. It was this: When coma occurs in
hydrocephalus, it generally happens that the child is not
in an irritable state. It is a difficult matter to excite it;
& you may handle & move it about without disturbing
it: whereas, in the infantile remittent, the coma is accompanied 
with an irritable condition of the mind, & a
fretful disposition. When you attempt to make an examination, 
the child turns quite round & seems unwilling
to be disturbed. By this circumstance I thought I should
be able to distinguish between the two complaints. But subsequence 
experience has led me to the conclusion that
 
  
 

   
           


480
this is not an infallible diagnostic symptom. For I
have seen an irritable condition of the mind in hydrocephalus, 
which might be excited even after coma
had appreared. But in cases of other diseases which have
fallen under my observation, I have never met with the
hydrocephalic pulse. To this pulse I have before particularly 
called your attention. I mentioned the case of
Dr. Hewson’s child, & also that of Dr. Otto’s. In the formed
the only circumstance which enable us to decide positively,
as to the nature of the disease, was the peculiar pulse. It was
slow & irregular; & what is remarkable, gave way to that
frequent pulse which is peculiar to fever; but it again returned. 
I once had, in consultation with Dr. Neil a patient 
of Dr. Hewson’s under my care, a yound lady by the
name of Marcoo, whose case had every appearance of
hydrocephalus except the pulse; & contrary to every rational 
expectation, we had the pleasure to see her recover.
Every practitioner meets with some very observe cases
relative to which he is unable to decide whether they are hydrocephalus 
or not; & I believe that many instances of
recovery from reputed hydrocephalus, are nothing more
than the common infantile remittent of our country.

 
  
 

   
           


481
Apoplexy.
Apoplexy consists in a distension or rupture of some
of the blood vessels of the brain. This is a very distinct disease 
from epilepsy: - & just at the threshold of the subject, it
may be proper to devote a few minutes in drawing a line
of distinction between them; because I regard a proper diagnosis 
in this case, not merely as a matter of curiosity, but
also as a matter of real utility. Apoplexy requires a different
course of treatment from that which is demanded in many
cases of epilepsy, particularly when this complaint is of a chronic 
character. How are we to distinguish between them?
In both there is insensibility; in both the patient is suffering
under what is called a fit. One of the most remarkable points
of difference is this: In epilepsy we see struggling, & in
many instances, violent muscular exertion: whereas, in apoplexy 
there is generally a quiescent condition of the muscles.
In the latter disease we find a slow, laborious pulse, which
is seldom so marked in the former. Epilepsy is a disease
of frequent occurrence; it often acquires a chronic character, 
& may continue for many years. I think I have
seen great mischief in practice from confounding the two
diseases. I recollect a case of chronic epilepsy where
depletion was carried to an extent altogether remarkable
& the patient unnecessary brought into imminent danger.
    

 
  
 

   
           


482
Apoplexy & palsy may be regarded as grades of the
same disease; & it is not uncommon for apoplexy to terminate 
in hemiplegia or a parolytic affection of the side. Apoplexy 
is not unfrequently preceded by some premonitory
symptoms; & I am inclined to believe that there are few
physicians of any experience who if applied to at a proper
period, would not be able to ward off the disease in many
instances. If you find a patient under an obtuse state of mind
with heaviness & a disposition to sleep, with a full, slow
& powerful pulse, & giddiness of the head, you may suspect 
that an attack of apoplexy is approaching. Under such
circumstances pretty smart depletion will often prevent
the occurrence of the fit.
I have known one instance where the disease was preceded 
by an universally irritable state of mind. The case was
that of a young lawyer who had previously consulted a
young practitioner of medicine, a friend of his, who not fully 
appreciating the nature of the disease, directed an emetic.
The very same night that he took this, an apoplectic fit seized
him, which terminated in palsy of the right side, from which
he has not yet recovered, though several years have elapsed
since the occurrence of the attack.
Dr. Rush divided apoplexy into two species – the white
& the red. The white, as you may easily imagine, is by
far the most dangerous & fatal form of the disease: for
we mean by this term that condition where effusion has
   
  

 
  
 

   
           


483
has absolutely taken place. But in the red apoplexy there
is reason to believe that nothing more exist than simple 
distension of the vessels, which may be removed by a timely 
interposition of the lancet, & fatal consequence thus prevented.
The termination of apoplexy is, in some instances, instantaneous 
– death seems as suddenly induced as if a bullet
had passed through the brain, I once saw a case not quite
so sudden as this, which was attended with a condition
of the mind somewhat peculiar. An old black man, 80
or 90 years of age, was in the habit of attending Frinds     
Meeting in Arch Street – One day he fell down in the meeting 
house in an apoplectic fit: he was carried out into
the yard, & I saw him immediately. He recovered so far
as to give correct answers to some question which were part
to him, complained of sick stomach, & perhaps in less than
5 minutes afterwards expired.
Red apoplexy may sometimes be most happily treated,
if vigorous measures are interposed at the right time. I was
once called, with Dr. Griffitts to the father of Dr. Harlan, who
was attacked, as he was walking through market, with a fit
of apoplexy which produced hemiplegia. But in this instance, 
the timely interposition of proper practice dissipated
all the dangerous symptoms, & in a few days he was about
as before; & he has since continued free from the disease.
Apoplexy occurs at every period of life; though it is
more common after the middle age, & in advanced life.
   
  
 

   
           


484
Even the most tender age is not exempt from the apoplectic 
stroke, & it is not uncommon for persons in the
most active period of life to fall victims to the disease. I
once attended a young lady under 20 years of age, with
a slight paralytic affection of the mouth, which appeared
to interfere very little with her ordinary avocations.
She was treated with evacuations, & seemed to be getting better. 
Soon after this, I was suddenly called in the morning.
Dr. Chapman, (who lived near & had also been called,) was
already there. But we arrived merely to see her expire.
We read in books, & the opinion too is generally received,
that certain configurations of the body predispose to apoplexy. 
Thus a short neck & a large head are supposed
to be an inviting state to the disease; & I believe that the
opinion is not without some foundation. But it by
no means happens that persons of an opposite conformation 
are free from the disease. I have known it to
occur in persons of a most remarkable delicate form,
who were not marked with any of those peculiarities
which are supposed to indicate a predisposition to the disease.
The state of the mind in this disease varies most
surprisingly. Although we generally find it locked
up in a state of profound coma, when the attack is violent 
& deadly: yet in the case of old Primus, the black
to whom I have alluded, there were signs of considerable 
intelligence. In a case of fatal apoplexy, where the
pupil was dilated, the pulse laborious, & every thing in-
       

   
           


485
dicated great danger, I have seen a condition of mind
that truly astonished me. I recollect being called to a
Swiss gentleman, residing above Bristol, whose name
was Leopold Nattnaugle. When I saw him, he was in
the state just described; yet his intellect was so far capable 
of bursting the barriers of disease which surrounded it
that he recognized me, & told me that he knew my father
& brother. Yet when allowed to rest he fell into a state
of coma with that stutorous respiration which forms
so prominent a symptom of the disease. He finally died.
Dr. Chandler, a medical character & a Methodist preacher, 
was seized with an apoplectic fit while standing in
the pulpit in the act of preaching. His intellect was
also remarkably clear: but he never recovered from the
attack – he lingered along & finally died.
Though the pupil is generally dilated; yet I have
seen cases of apoplexy where it was contracted. This you
will readily believe, when I call your attention to cases
of compressed brain in which great variety is observable
in the state of the pupil – this being often largely dilated,
& in many instances morbidly contracted.
Having given this general outline of apoplexy, &
considered it as a disease in which there is an under determination 
of blood to the head, where the vessels the vessels 
are in a state of very great distension, & rupture often
ensues, it is now proper for me to mention those indication 
of cure on which the practice ought to be grounded.

   
 
       

   
           


486
In red apoplexy, when you are called to a patient with
a flushed face, slow, powerful & laborious pulse, stutorous 
breathing, & other symptoms indication of the most ex-
treme danger, you cannot but be impressed with the importance 
of this injunction; :what those doest, do qickly.”
This is moment for decision & vigorous practice. To unload 
the blood-vessels promptly is the first indication; & if
the symptoms are very urgent we are to resort to other parts
beside the arm. When you recollect how accessible is the temporal 
artery, & with what entire safety it may be divided,
your own good sense will suggest to you the propriety of
opening one or both of these vessels. I have seen the circulation 
so powerful in the temporal arteries, that a considerable 
amount of blood has been obtained from them
in a short space of time. I have sometimes, after bleeding
pretty freely, removed the bandage from the arm, & allowed
the blood to flow simply from the impulse of circulation;
for it is much safer for the blood to find vent through
an orifice in the arm, than for the vessels to relieve themselves
by effusion on the brain. – I was once called to a patient, named
James Higgins, who had been several years labouring under hemiplegia, 
when he was attacked with a fit of apoplexy which proved
his last. The violent action in the temporal arteries induced me to
open both, & so forcible was the stream that it occasioned musical
sounds as it struck against the sides of the tumbler. In the
case of my respected friend & worthy neighbor, Dr. Dunlop, who
was predisposed to apoplexy, & had suffered under several attacks,
   

   
 
       

   
           


487
upon calling in accidentally to visit him, I found his
face flushed & other symptoms amounting almost to
another attack. I opened the temporal artery, & in a small
space of time obtained 16 or 20 oz. of blood. He was sickened
by the operation & I stopped it. – To illustrate my practice
with regard to bleeding in apoplexy, I will state one or
more cases which have occurred to me.
Case of Nathan Field. – This old gentleman possessing
a powerful constitution & a very plethoric habit of body
was attacked with red apoplexy, or rather the disease was
in its forming stage & had hardly developed itself. He
had been engaged in a cellar in sawing or splitting wood,
& had used considerable exertion. Soon after coming out of
the cellar he was attacked, & was found in this condition. His
face was very much flushed, his pulse very strong & slow, there
was an obtuse state of mind, but not perfect insensibility: his
speech was very thick, & there was considerable loss of power in
one side of his body. Under these circumstances, I immediately 
opened a vein, & bled him freely. Guided by the state of
his pulse I let the blood flow till 60 oz had been abstracted
from his arm. By this time there was an evident abatement
of the dangerous symptoms, & his arm was tied up. Dr. Griffitts 
saw him with me in consultation. After this he was upped 
freely. By these means & by the use of other remidies
which appeared appropriate, a recovery was effected.
Case of Amos Taylor. – He had been for some days previous 
to the attack affected with an unusual degree of heav-
 
   

   
 
       

   
           


488
iness. He was much dis posed to sleep, nodded frequently in
his chair, & was affected with vertigo. This condition of thing
lasted for some days. If a physician had been made acquainted 
with these circumstances, & proper measures had
been employed, the attack would probably have been warded off. 
Late one night, I was sitting in my parlous reading 
or writing, when his son-in-law came running down
with great precipitation & requested me to see his father immediately. 
I ran up, & it was happy for the family that
I had not gone to bed: for, from the violence of the symptoms 
I think it probable that before I could have dressed
myself, the case would have terminated fatally. When
I came, I found him with deep stutorous respiration, a laborious 
pulse, & a total quiescence in his muscular system.
I at once recognized apoplexy, & immediately resorted to the
lancet for his relief. I abstracted about 40 oz. of blood. At
this time his pulse gave way, & something like syncope occurred, 
which very much alarmed us. From this, however,
he recovered. The immediate danger disappeared; & though
he still labours under hemiplegia & a partial loss of speech,
yet we are not without hopes that the power of his muscles
& his speech may be restored, & a life of much usefulness
preserved for his family & friends.
Note. – 1825. The gentleman above alluded to has not yet
recovered the power of distinct articulation. He has considerable 
acuteness of mind, & is able to calculate, etc.
In addition to local bleeding from the temporal artery
     
 
   

   
 
       

   
           


489
& general bleeding from the arm, in cases like the preceding, you
can easily understand the absolutely necessity of unloading the
bowels by active purging & by injections. After these have been
thoroughly evacuated, I believe, in many instances, great benefit 
will result from the exhibition of calomel with a view to
its effects on the whole system. Dr. Griffitts is much in the habit 
of purging with calomel alone. Thus, he administers 5 gr
at intervals of a few hours; so that at the same time they
open the bowels, by lying in the stomach, they also produce
the general mercurial impression. But I prefer brisk purging 
in the first instance, & afterwards a resort to calomel
in small doses with a view to its action on the system. Tho’
no absorbents have been discovered in the brain, yet the dissections 
of Abernethy & others show that lesions have been
produced by apoplectic effusion, & traces of them left, though
the effused fluid has been removed.
In addition to these general remedies, it is also proper to
resort to cupping on the temples, forehead & neck, & to extensive 
blistering over the scalp. I wish strongly to impress on
you the necessity of employing blisters, which should be large
& kept open for some time by stimulating dressings.
With respect to the treatment necessary for the paralysis
which occurs after apoplexy, I shall for the present wave
the consideration of it, till another time.
Having taken this general view of the disease itself
& of the treatment as applied to the common form of apoplexy,
in its more hopeful condition, I have only to remark, that
  

 
   

   
 
       

   
           


490
in the white apoplexy of Dr. Rush there is little chance afforded 
us of doing any thing: & yet even here, though you
have a very slight prospect of success, if the pulse will admit, 
you should resort to the lancet & ascertain how far
evacuation can be borne. But if the pulse falters, & cold,
clammy sweats are observed, vigorous depleting measures
should certainly be avoided.
While speaking of apoplexy as it commonly appears, &
of the treatment which answers so well in certain cases, it is
necessary for me to inform you that exceptions to the rules
laid down, will occasionally be met with in practice.
Perhaps it is in consequence of meeting with some of these exceptions, 
that certain respectable practitioners consider the abstraction 
of blood as of doubtful propriety. Dr. Fothergill, if
my memory serves me right, was rather opposed to V.S.
carried to any great extent in this disease. Perhaps he fell
in with some of the exceptions alluded to, & suffered himself 
to be influenced too much by his own experience.
I once attended, for Dr. Griffitts, a patient who was attacked 
a few hours before I saw him with apoplexies, & hemiplegia 
partially induced. When I visited him, the symptoms 
appeared to me to require the free use of depleting measures. 
I bled him, but not to the extent of the cases which I
have before mentioned. Cups were also applied to the head.
Soon after this I left him & informed Dr. Griffitts that I
had seen his patient & wished him to visit him soon. He did
so, & found that he had fallen into state of most alarm-
  
 
  

 
   

   
 
       

   
           


491
ing debility: so much so that it was necessary to resort to
wine-whey, sinapisms, etc. to rouse him. These remedies produced 
a temporary affect; but he ultimately died.
But a much more extraordinary case than this sometime 
afterward fell under my observation. The mother of
Dr. Perkins was attacked with what appeared to be apoplexy,
& at the same time, with hemiplegia. I was requested to
See her with her son – Dr. Thomas had also visited her. When
I saw her Dr. Perkins told me that he had attempted depletion; 
but found that she could not bear it. I thought
it was with the Dr. as it is sometimes with me when called 
on to prescribe for any of my own family – I supposed
that his feelings had got the better of his judgement, & that
he was not so capable of deciding on what was proper, &
what improper, as another who was not so close interested.
I was disposed to try what would be the effect of some evacuation. 
Dr. Thomas remained with her during the night;
some cups were applied; but by a small abstraction of blood,
the pulse was seriously affected, & further depletion could
not be borne. We therefore desisted from the depleting plan,
& the old lady got well under very mild treatment.
I thought it proper to mention these exceptions, so that
you may be on your guard if you should chance to fall
in with similar ones. You should not, however, be so
influenced by them as to lessen your confidence in blood-
letting as a general remedy, which long experience has
proved in the majority of instances to be the most suitable,
& in many cases absolutely necessary.
    
 
  

 
   

   
 
       

   
           


492
I now wish to make a few remarks relative to apoplexy
& palsy in very old people. Some of them will not bear
much depletion, & yet do well. My honoured mother is
an instance. Two cups bled her sufficiently. She was affected 
with hemiplegia, and almost a total loss of power
in the whole frame. Gentle laxatives, a blister, mustard whey,
etc. were employed, & she recovered. Other cases of a similar
kind have occurred. James Jones, an old man who
lived out of town was seized with apoplexy, & hemiplegia
ensued. He was visited by Dr. James. As the patient was
very old, the case was considered hopeless, & the Dr. thought
it unnecessary to repeat his visits. Sometime afterwards
the Dr. saw a man riding down Arch street on a young
horse: & who should it be but his old patient, James Jones!
He rode up to the Dr. & asked him if he had seen a stray horse,
& told him that he was in pursuit of one which had escaped
from his field. – The result of this case shows the impropriety 
of abandoning the patient till death ensues.
Dr. Phineas Bond, an old & highly respected practitioner, 
(long since dead,) was in the practice of purging patients 
that were predisposed to apoplexy, with allow, for the
express purpose of bringing on hemorrhoids. This practice
I consider important in many cases. When there is an
affection of the head, which is obstinate – resisting the usual
remedies – ask your patient if he has ever had hemorrhoidal 
tumours, or a discharge of blood from the hemorrhoidal 
vessels. There are some men who have discharges of

    
 
  

 
   

   
 
       

   
           


493
blood from these vessels which occur with as much regularity
as the catamenia in females. I know a man who has a discharge
of blood from the hemorrhoidal vessels which occurs regularly once
a month. When patients of this description have affections of the
head in consequence of a suppression of these periodical evacuations, 
you will see the necessity of resorting to active purges.
Some people are subject to vertigo. This may be induced by
a variety of causes – it may be occasioned by the too free use of
strong tea & coffee, etc: it may also depend on a deranged state
of the stomach. I had a patient under my care who was
troubled with this affection. He staggered about, & in all his
movements appeared like a man intoxicated. I regulated the
stomach in the first place; but this did not remove the affection 
of the head. On inquiry I found he had been subject to
hemorrhoids. I then brought on piles by active purging. I
also bled him from the hemorrhoidal vessels, which he acknowledge 
did him more good than any other remedy that had been
tried. Dr. Physick was called in consultation. We concluded
to give him a good diet; & this seemed to afford him some relief. 
Dr. Physick said that he had found 15 drops of laudanum
occasionally given, to prove beneficial in some of these cases.
We resorted to it, & apparently with some advantage. The Dr.
suggested the idea that his disease was not altogether real; that
much of it might depend on previous habits – having been accustomed 
to totter on his staff, this practice had become habitual; 
& that it might be associated with hypochondriasis.
I next resorted to sternutatories – first turpeth mineral, then
 
     
 

    
 
  

 
   

   
 
       

   
           


494
poke-root, for the purpose of relieving the vessels of the brain by a
discharge from the nose.
Disease of the Head resembling Hysteria.
I now wish to call your attention to some cases of diseased
head resembling in their symptoms the common forms of hysteria; 
but not exactly resembling that complaint.
10 mo. 30th, 1818. Died this day Thomas Dunn, aged 22
years, a journeyman blacksmith of Joseph Gatchel. The patient 
called on me in the afternoon of the 27th, complaining of
severe pain in the head. His pulse at this time was not tense.
I directed him to go home & be cupped, & ordered an emetic
of ipecacuanha. In less than half an hour, I was sent for in
haste. I could not go immediately; but sent Charles Mattack,
one of my pupils, with directions to have him cupped; to omit
the emetic till I should see him, & to apply sinapisms to
his feet. For I had some doubts as to the propriety of an emetic
if the affection of the head should prove idiopathic; & from
the sudden message I began to conclude that the case was more
serious than I at first apprehended. Soon after he had been
cupped I visited him, & was informed that on his return he
appeared delirious, & that several persons were required to hold
him. When I saw him he was quite sensible, his pulse was more
excited, & he complained of severe pain in the head, particularly 
in the forehead. I directed some blood to be taken from the
arm, & order a cathartic. In the evening I gave him pills of
     
 
     
 

    
 
  

 
   

   
 
       

   
           


495
assafetida & applied a blister to the nope of the neck, as he had
considerable restlessness with severe nervous spells, & pain in
the head. In the course of the night he became so ill that he
was again bled. The assafetida was continued. My friend
Dr. Moore, (living near,) saw him in the night. He had injections 
administered which operated. His stomach became irritable 
in the course of the day, & he generally rejected all his
medicines. From this time his bowels were rather confined.
The next morning he said that he was much better: but in
the course of the day he grew worse. His nervous spells were
frequent, & he had a convulsion; & Joseph Gatchel’s wife informed me, 
that his lips & nails were blue. When I saw him in
the evening he was sweating most profusely. His pulse was
full & rather frequent, but not tense. He did not speak; but
he appeared to understand what was said to him. He turned
round towards the candle, & (mark the fact) his eye appeared
natural, & the pupil contracted before the candle. I asked
him to put out his tongue, which he would not do; & when
I urged it, he evidently clenched his jaws more firmly.
Indeed he had precisely the appearance of an hysterical patient 
who was affronted at the idea of the disease being
known, & determined to make himself appear to superficial
observes as very ill. In the course of the day I directed his
head to be shaved & his scalp cupped. In the evening I ordered 
a large blister over the scalp & frictions of strong mercurial
ointment. I observed this evening that he scratched his lip-a
proof that he was awake to very slight impressions. His mother
  
 
     
 

    
 
  

 
   

   
 
       

   
           


496
told me that he read the newspaper this morning; & J. Gatchel 
said, that in the course of the evening, he played with his
brother’s watch chain, at a time when he did not speak. This
was a case worthy of close attention; for early the next morning, 
the poor patient died.
The nervous spells with which he was affected bore a most
striking resemblance to a case of hysteria. I should have regarded 
the disease as such, & told J. Gatchel that I was inclined 
to believe it nothing more: but happily for my subsequent 
reflections, I also mentioned that two cases bearing a
strong resemblance to it had fallen under my notice, both of
which proved fatal. One of these cases was that of the wife of
Thomas Field. In both of them I pursued active treatment. In
the case before me I also thought it proper to act as if there
were serious disease of the brain; & I now rejoice that I did
so; for had I treated it lightly as common hysteria, I should
have felt very unpleasant on finding him dead. I was particularly 
alarmed when I heard of his blue nails during a nervous 
spell. I concluded that this must have resulted from
something more serious than an affection of the nerves.
The patient often complained of pain in his head, especially
when shoeing horses. He had formerly been intemperate; but
for the last two years of his life he had been a sober man.
The day after his death I examined the body. The brain
appeared turgid with blood – the vessels seemed to be injected,
& the right ventricle contained more fluid than natural.
Over the whole surface of the brain there appeared some se-
      
  
 
     
 

    
 
  

 
   

   
 
       

   
           


497
rous effusion. I should suppose an ounce & an half or tow
ounces of serum might have been collected. The brain perhaps
might be said to be bloated.
On opening the thorax there was found the effect of some complaint 
of the chest; but not recent. The left lung was partially
adhering to the pleura by some old & firmly organized bands.
The pericardium contained about 3 oz. of serum.
I thought it proper to throw these cases before you, as you
may hereafter meet with such in your practice. They resemble
hysteria; but in their result they are very different from this complaint.
Gout in the Head.
While on the subject of diseases of the head, I will call your attention 
to translated gout. It not unfrequently happens that
persons affected with the gout are subject to very considerable
danger, in consequence of its receding from the extremities & attacking 
the brain. Sometimes the phenomena of apoplexy depend
on translated gout; & the train of symptoms which arises, demand
a treatment in many respects similar. But when you have ascertained 
that gout in the head exists, & discovered from which
of the extremities it has receded, while you direct those remedies
which circumstances call for, as bleeding, cupping, etc. I wish
you to be impressed with the necessity of making, as early as
possible, strong impressions on the fact previously affected.
For this purpose sinapisms should be applied; these invite a
return of the disease to the situation before occupied where, tho’
        
  
 
     
 

    
 
  

 
   

   
 
       

   
           


498
painful, it is much less alarming & dangerous. Sometimes
gout in the head assumes a chronic form. The same may be
said of rheumatism. If it puts on a violent form, the same general 
plan of treatment is indicated; if of a more chronic character, 
those remedies should be employed which are adapted
to the treatment of chronic rheumatism. I have used the
guaiacum, particularly the volatile tincture, occasional cupping, 
& blister behind the care, with advantage.
Nervous Headach, Hemicrania, etc.
There is an affection of the head to which I wish particularly 
to call your attention, it is one which you will occasionally 
meet with in practice; & you will some day acknowledge 
that the information now imparted to you, has not
been altogether unavailing. I allude to hemecrania. By
this I mean a painful affection of the head, generally confined 
to one side, & not unfrequently recurring at stated periods 
like intermittent fever. During the paroxysm the
suffering of the patient is extreme. In a case which not
long since fell under my notice, the lady declared, that
it really seemed as if her “eye would burst out with pain”.
Now, I believe hemicrania to be generally connected
with a peculiar disordered condition of the nervous system;
& that if it were considered as a disease of inflammatory
character, & measure were adopted accordingly, I am
  
    
  
 
     
 

    
 
  

 
   

   
 
       

   
           


499
inclined to the opinion that the object of relieving the patient 
would not readily be obtained; but, on the contrary,
that the suffering would be increased & the cure protracted.
I recollect that in the early period of my practice. I attended 
a young lady with this disease. I had resorted to
several plans, particularly of the evacuating kind. Cupping 
had been used, & some temporary benefit seemed to
result; but the effect was not lasting, & the disease frequently 
recurred. Dr. Wistar was called in consultation.
He proposed that the patient should take the infusion of
valerian root in the dose of a wine glassful every two
hours. Under this plan she recovered. Dr. Barton in
his lectures was in the habit of recommending a combination 
of valerian & bark.
I believe that in some instances the stomach has a
very strong influence in maintaining these unpleasant.
I will read you some remarks which I committed to writing 
soon after the occurrence of a case which I attended.
3rd mo. 1820. – I have lately had several cases of hemicrania, 
or headach confined to one side of the head, & generally 
to one spot; for example, over the eye. In some instances 
it is periodical like intermittent fever. The case of
George R. Rhun’s wife was a striking one – the pain came
on every day about noon & went off in the evening. She
informed me it felt as if her “eye would burst out,” so
acute was the pain, I directed her bowels to be well opened; 
& as I suspected she had acidity of stomach, I di-
     
   



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rected a wine glassful of the alkaline infusion three times
a day, & gave her that sovereign remedy in these cases –
an infusion of valerian & bark. I directed an ounce of
the bruised valerian root to be infused in one pint of hot
water, & the mixture to stand till cold. The liquor was then
to be decanted & a wine glassful taken every hour, beginning 
early in the morning & adding a small tea
spoonful of bark to each dose. If the pain should come
on, the use of it was to be suspended. She took in this
manner, for the space of two or three days, about one
pint of the infusion of valerian & half an ounce of bark
daily; & most satisfactorily recovered her usual health.
During the treatment I directed a solid diet, such as
beef, mutton, oysters, etc. etc. & paid particular attention
to keep her feet warm with Cayenne peppered sock.
Inflammation & pain in the frontal sinuses, I
have met with in the course of my practice, & have noted 
cases. But this disease differs in its periodical attacks. 
Whenever I find headach confined to one side of
the head & assuming a periodical form, I always suspect 
a peculiar morbid condition of the nervous system, 
which will require antispasmodics & tonics to effect 
a cure.
I attended a gentle some time ago, in whose case
two modes of practice were tested. He had been under
the care of a highly respectable practitioner several years
before, with the same disease. The affection was sup-
 
     
   



501
posed to be rheumatic, & the remedies were of a depleting
character. He was confined for 3 weeks during which time
he suffered a great deal; & at last the disease seemed to wear
itself out without any appropriate effect from the mediciness. 
When I saw him in another attack, I put him on
the plan above mentioned, & endeavoured to impress him
with the belief that for the first day or two no benefit would
be derived; & so it happened. For the first two days, he thought
the complaint not relieved, but rather aggravated. He soon
however became better, & before many days was entirely
cured.
Affections of the head depending on disease of the stomach, 
& even on disordered action of the liver, occasionally
fall under our notice. I once attended, in consultation
with a respectable physician, a lady labouring under the
most violent headach. It occurred at irregular intervals
somewhat like an intermittent. It bore some resemblance
to the case of hemicrania of which I have spoken: but in
some respects it was different. The bowels having been
properly opened, the valerian & bark were tried: but the
remedy failed of producing that permanent effect which
I had desired. Some temporary relief was obtained; but
the disease soon occurred, & became as painful as ever.
Before the relapse I had left off attending, & the physician 
who was first called tried the lancet twice but without 
any beneficial effect. The disease still remained
unsubdued; & at his request I was again called in con-
     
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
     
   



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sultation. Having found the tonic & antispasmodic plan
unavailing. I proposed that our attention should be directed 
particularly to the hepatic system, & with this view
that we should examine the state of the alvine excretions,
to see if they were of a natural appearance or otherwise.
The evacuations were of a dark green colour, rather solid, &
nothing like the stools which we see in health. I proposed
that we should put her upon an alterative plan somewhat
similar to that recommended by Ayre in his work on marasmus. 
We gave her 1/6 of a grain of calomel every hour
till she had taken 12 doses. On the following day the
infusion of rhubarb was given in order to aid the calomel 
in evacuating the bowels, which was several times
repeated. By this plan we succeeded in procuring an
entire change in the alvine evacuations. We then found
that we had attacked the disease in the situation which
it really occupied; & that our failure before was owing
to our ignorance of this point. By the judicious use of
tonics, aided by a proper diet, which was principally of
animal food, & by occasional excise in a carriage, we
happily restored her to a state of health. But we were very 
near failing entirely in consequence of the occurrence
of some circumstances which produced mental depresssion. 
We observed a disposition to a recurrence of the disease: 
but fortunately the mental anxiety disappeared
& our patient regained her health.
Hence in those obstinate headachs denominated
     
     
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
     
   



503
nervous headachs, rheumatism of the head, etc. I would
advise you to attend carefully to the appearance of the
evacuations, & if their coutoue should indicate diseased
action of the liver, that you endeavour to relieve this by
small doses of calomel alternated with mild laxatives, especially 
rhubarb. This I consider as an excellent plan for
restoring the healthy action of the liver. I would also advise 
you to pay particular attention to the condition of the
surface, as recommended in dyspepsia.
You will occasionally meet with cases of headach
in which relief may be derived from very simple remedies.
One of these is the application of ether to the forehead.
The head is liable to be severely affected by carious teeth.
In this case we can generally trace the sufferings of the patient 
to some one or other of the teeth affected. I recollect
being called to a lady labouring under very severe
headach. Upon closely examining the patient I discovered
that the symptoms arose from carious teeth. I, therefore,
directed that they should be extracted, & relief was obtained.
In obstinate cases of headach you should always direct your
attention particularly to the teeth. A dentist once informed
me that an old lady applied to him with what she conceived
to be rheumatism of the head. Various remedies had been used
without relief. When he examined her mouth, he found several
teeth very much decayed, & the stumps of others which had
entirely gone. He extracted them, & thus succeeded in effecting 
a perfect cure.



                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
     
   



505
Disease of the Head after Parturition.
I have met with several cases of cephalic disease occurring 
in females after parturition, which I consider worthy of attention. 
In two cases the patients were affected with convulsions. 
Convulsions previous to delivery are generally regarded
as very dangerous. In these two cases, however, I had the pleasure 
of seeing the patients recover their health, although the
prognostic was certainly discouraging.
Case – wife of Charles French. – 8th mo. 1812. This was
a very extraordinary case taken in all its parts. I was called 
to the patient about 10 days after her delivery & received
the following account: For two or three days after her
confinement she was doing bravely: but at the end of
that time, she was seized with a pain in her face, which seemed
to affect her like the toothach. This pain soon receded from
the face & took possession of the head, for which, by direction
of Dr. Dunlap, her acoucheur, she was twice bled & blistered
on the back of her neck; but without relief. He gave her
opiates at night; as there appeared to be intermissions in
the morning he attempted the use of bark, which however
did not suit the case & was omitted. At the request of
Dr. Dunlap she was placed under my care as family physician. 
When I saw her the action of her pulse was very
little increased, but she still complained of pain in the
head. Her skin was cool. I directed a repetition of the opi- 

  



                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
     
   



506
ate which she seemed desirous of taking. I was rather
inclined to attribute her disease to a rheumatic affection of
the head, & I left her that night intending to visit her in
the morning in regular course. But before sunrise her
husband called on me, requesting my immediate attention
in consequence of her being attacked with a convulsion.
When I arrived she had come out of the struggle, but was quite
lost. I ordered cups to the head immediately, sinapisms to
the feet, & a laxative enema. I also directed the fore part of
the head to be shaved, & if she not relieved, a blister to be
applied. The cupping procured temporary relief. But early 
in the afternoon she was attacked with another convulsion. 
I got to her just as she was recovering from it. She appeared 
to be in great distress, & quite incapable of expressing
herself. The blister was immediately applied. I requested a
consultation, & my worthy perception met me. On hearing
an account of the case, he encouraged me by saying that he
had met with a very similar instance in a puerperal woman, 
which subsided in a very short time under very
mild treatment. As the Dr. appeared highly pleased with
the treatment, it was of course continued, with the addition
of a decoction of senna & manna. This plan was diligently
pursued for several days, & the bowels were kept freely
open. The blister on the head drew very finely & was of great
service. – Her mind was very singularly affect. Her
memory for words was almost obliterated. She could not
recollect even the names of her own children; & yet at
     




507
the same time she had a perfect consciousness of every
thing about her, & was entirely aware of her inability
to express herself as she wished, & several times mentioned
it. As was predicted by Dr. Wistar, this unpleasant state
gradually subsided, & she was restored to the usual exercise 
of her mental powers.
Since the above see I have seen a young man who
is consequence of a violent concussion of the brain, laboured
under the same state of mind. He was aware of
the circumstances which were passing around him; but
his memory for names was gone, & he had no power of
expressing himself. He wished to speak to his father of Indian 
corn; but was totally unable to recollect the name,
& was forced to resort to motions to explain himself.
Since the case of Mary French, I was called in consultation 
to an amiable young lady at Burlington, who
some days after parturition was seized with similar convulsions. 
She was confined with the first child. The
same practice was employed as in the former instance,
& the result was equally happy. Though every thing 
for a few days looked gloomy, & there was great reason
to apprehend the most unpleasant result; yet I was enabled 
to cheer them by an account both of my own previous
experience & that of Dr. Wistar; & I relate these cases that,
under similar circumstances, you may enjoy the same
advantage.