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TREATISE 
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PRACTICE OF MEDICINE, 
BY 
GEORGE B. WOOD, M.D., 
PROFESSOR OF MATERIA MEDICA AND PHARMACY IN THE UNIVERSITY OF PENNSYLVANIA J 
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VOL. I. 
PHILADELPHIA: 
GRIGG, ELLIOT, AND CO. 
No. 14 NORTH FOURTH STREET. 
1849. Entered, according to the Act of Congress, in the year 1847, 
By George B. Wood, M. D., 
in the Clerk's Office of the District Court of the United States in and for the Eastern 
District of Pennsylvania. 
PHILADELPHIA: 
T. E. AND P. G. COLLINS. PRINTERS. TO 
N. CHAPMAN, M.D., 
AS 
A MARK OF RESPECT 
FOR 
HIS ATTAINMENTS AND SKILL IN MEDICINE; 
FOR 
HIS POSITION, FROM AGE AND SERVICE, 
AT 
THE HEAD OF THE MEDICAL PROFESSION IN THE UNITED STATES; 
AND FOR 
HIS MANY EXCELLENT QUALITIES OF HEAD AND OF HEART, 
THIS WORK 
IS AFFECTIONATELY INSCRIBED 
BY 
HIS FRIEND AND COLLEAGUE, 
THE AUTHOR. PREFACE 
TO THE 
FIRST EDITION. 
In adding another to the many valuable existing Treatises on the 
Practice of Medicine, the author may be reasonably expected to 
show upon what grounds he has ventured to advance a new claim 
to the public attention, already so fully occupied. He has no other 
excuse to offer than this; that he has written in obedience to im- 
pulses which he could not well resist. Having been engaged, for 
nearly thirty years, in public and private practice, and, during that 
time, devoted an almost exclusive attention to the study of diseases 
and their remedies, he has accumulated facts, and formed opinions, 
which have been long soliciting expression, with an urgency to 
which he has at length yielded, though unfeignedly distrustful of 
their sufficient value. 
It will be inferred, from what has been said, that the present work 
claims to be something more than a mere compilation. In giving 
it the form of a General Treatise on the Practice of Medicine, it was 
incumbent upon the author, in order to do justice to his readers, to 
gather from every attainable source the knowledge which he might 
deem important; and he has accordingly consulted numerous works 
upon the different branches of his subject, and made ample use of the 
materials which they afforded. But these materials have for the 
most part been maturely considered, have been submitted to the 
closest scrutiny of which he was capable, and have been re-arranged 
in accordance with his own best judgment. In relation to facts, 
which, from having been known for a certain length of time, have 
become the common property of the profession, he has not deemed 
it necessary to quote authorities; but, wherever the influence of a 
name was thought necessary to support a position, or justice to indi- 
viduals required that they should be noticed in connexion with their VI 
PREFACE. 
discoveries or opinions, lie has considered it his duty to make the 
requisite references in the text. 
As to those portions of the work which have been drawn from his 
own stores, the author does not wish to urge any strong claims to 
originality. The sources of our knowledge are so various, we learn 
so much from books, and hear so much from others, in addition to all 
that may be derived from our own observation, or result from our 
own reflection, that it would be extremely difficult for one who has 
lived long, and sought knowledge wherever it was to be found, to 
analyze what he may possess, and determine how much, if any, 
originated entirely with himself. 
It would be impossible to enumerate, in this place, all the sources 
to which the author is indebted for the materials of the work. Many 
of them are mentioned in connexion with the subjects, in relation to 
which they were particularly consulted. He wishes, however, to 
acknowledge a peculiar obligation to the several contributors to those 
excellent works, the " Dictionnaire de Medecine" the publication of 
which has been but recently completed in Paris, and " The System 
of Practical Medicine," arranged and edited by Dr. Alexander 
Tweedie. It will be seen, from the frequent references in the follow- 
ing pages, that he has also derived great aid from the American 
Journal of Medical Sciences, edited by Dr. Isaac Hays, which com- 
prises a body of the progressive medical knowledge of the last twenty 
years, especially of that contributed by the physicians of this coun- 
try, which it would be difficult to find elsewhere. Nor would the 
author be doing justice to his feelings, without acknowledging his 
indebtedness, for much of his practical information, to two individu- 
als; the late Dr. Joseph Parrish, his private preceptor, whose in- 
timacy it was long his happiness to enjoy, and whose peculiar views 
and modes of practice were as familiar to him as if they were his 
own; and Dr. N. Chapman, the present Professor of the Theory and 
Practice of Medicine in the University of Pennsylvania, under whose 
public instruction it was his good fortune to sit thirty years ago, 
and from whom were undoubtedly imbibed many of the facts and 
opinions which will be found detailed in the following treatise. 
In relation to the mode in which the work has been executed, the 
author has little to say. The reader will draw his own inferences, 
as to its merits, not from what he may find in the preface, but from 
the book itself. The author claims no indulgence on the score of 
haste. His leisure has been for several years devoted to the prepa- 
ration of the work, and there was no urgent necessity for its publi- PREFACE. 
VII 
cation, which could justify him in giving it prematurely to the world. 
It may possibly be thought by some that diseases of little import- 
ance have, in many instances, received an undue share of attention: 
but the author has proceeded upon the ground, that every disease, 
which is at all worthy of notice, should be well understood. Nothing 
more than is necessary to this object should be said of the most 
important disease; and nothing less of that which is least important. 
It may not be amiss to state, in addition, that, in using the first 
person singular, when speaking upon his own authority, the writer 
has been actuated by no spirit of egotism, but merely by a wish to 
express the fact, without affectation, in the shortest and simplest 
mode. 
The author is sensible of many imperfections in the work. He 
will undoubtedly discover others, when time shall have in some 
measure obviated the inevitable partiality of recent authorship. It 
will be his duty and his pleasure, should the work have the good 
fortune to reach a second edition, to correct, as far as may lie in his 
power, these defects, and. all others, which a just and candid criti- 
cism, hereby cordially invited, may point out. 
Philadelphia, January, 1847. PREFACE 
TO THE 
SECOND EDITION. 
The author has little to add to what has been said in the original 
preface. The rapid exhaustion of the first edition, and the urgency 
of the publishers for the completion of the second, have allowed him 
less time for revision than he could have wished; and the attention 
he has been able to give to the work has been still further limited 
by the circumstance, that the period, during which it has been going 
through the press, has coincided with that of his nfost engrossing 
duties in the School and the Hospital to which he is attached. 
Nevertheless, he has perused it with much care, has corrected many 
errors of the press and of inadvertence, has made various alterations 
in accordance with the suggestions of his own judgment and those 
which the kindness of criticism has offered, has supplied some defi- 
ciencies, and has endeavoured to incorporate in the Treatise, in 
greater or less extent, whatever of novelty and importance in 
pathology and therapeutics the last two years have brought forth. 
He ventures, therefore, to hope that the book may continue to 
enjoy some degree of that acceptance with the medical public, which 
was extended to it on its first appearance, and which, he may be 
permitted to say, was beyond his utmost expectations. 
Philadelphia, February, 1849, TABLE OE CONTENTS. 
PART I. 
GENERAL PATHOLOGY AND THERAPEUTICS. 
CHAPTER I. 
CONSTITUENT FORMS OF DISEASE. 
Section I. 
DISEASE OF THE FLUIDS. 
Section II. 
DISEASE OF THE SOLIDS. 
Subsection I. 
DISEASE FROM MECHANICAL AND CHEMICAL CAUSES. 
Subsection II. 
DISEASE FROM INFLUENCES UPON THE VITAL PROPERTIES. 
.Article I. Irritation. 
Article IL Inflammation. 
Article III. Depression. 
Article IV. Congestion. 
Article V. Fever. 
Article VI. Peculiar Morbid Products. 
1. Tuberculosis. - 2. Melanosis. - 3. Organized Non-malignant Products.- 
4. Carcinoma, or Cancer. - 5. Parasitic Animals. 
CHAPTER II. 
CAUSES OF DISEASE, OR ETIOLOGY. 
CHAPTER III. 
SYMPTOMATOLOGY, OR SEMEIOLOGY. 
Section I. 
SYMPTOMS OR SIGNS OF DISEASE. X 
TABLE OF CONTENTS. 
Section II. 
COURSE; DURATION, AND TERMINATION OF DISEASE. 
Section III. 
DIAGNOSIS. 
Section IV. 
PROGNOSIS. 
CHAPTER IV. 
GENERAL THERAPEUTICS. 
Section I. 
GENERAL INDICATIONS. 
O / ■ t fa ; . . . . 
Section II. 
GENERAL THERAPEUTIC PROCESSES. 
PART II. 
SPECIAL PATHOLOGY AND THERAPEUTICS. 
CLASS I. 
GENERAL DISEASES. 
Article I. Irritative Fever. 
Article II. Miasmatic Fever. 
1. Intermittent Fever. - 2. Remittent Fever. - 3. Pernicious Fever. 
Article III. Yellow Fever. 
Article. IV. Enteric, or Typhoid Fever. 
Article V Typhus Fever. 
Article VI. Plague. 
Article VII. Small-pox, or Variola. 
Article VIII. Vaccine Disease. 
Article IX. Chicken-pox, or Varicella. 
Article X. Measles, or Rubeola. 
Article XI. Scarlet Fever, or Scarlatina. 
Article XU- Erysipelas. 
Article XIII. Glanders. 
CLASS IL 
CONSTITUTIONAL DISEASES. 
Article I. Rheumatism. 
Article II. Gout. TABLE OF CONTENTS. 
XI 
CLASS III. 
LOCAL DISEASES. 
Section I. 
DISEASES OF THE DIGESTIVE SYSTEM. 
Subsection I. 
DISEASES OF THE MOUTH. 
Article I. Inflammation of the Mouth, or Stomatitis. 
Article II. Inflammation of the Tongue, or Glossitis. 
Article III. Morbid Dentition. 
Article IV. Toothache, or Odontalgia. 
Article V. Falling of the Teeth. 
Subsection II. 
DISEASES OF THE FAUCES, PHARYNX, AND (ESOPHAGUS. 
Article I. Inflammation of the Fauces, or Angina. 
Article II. Inflammation of the Tonsils, or Tonsillitis. 
Article III. Inflammation of the Pharynx, or Pharyngitis. 
Article IV. Inflammation of the CEsophagus, or (Esophagitis. 
Article V. Stricture of the CEsophagus. 
Subsection III. 
DISEASES OF THE STOMACH. 
Article I. Inflammation of the Stomach, or Gastritis. 
Article II. Cancer of the Stomach. 
Article III. Irritation of Stomach. 
1. Cardialgia. - 2. Gastralgia. - 3. Pyrosis. - 4. Spasm of the Stomach. 
5. Nausea and Vomiting. - 6. Sea-sickness. - 7. Sick-headache. 
8. Morbid Appetite. 
Article IV. Indigestion, or Dyspepsia. 
Subsection IV. 
DISEASES OF THE BOWELS. 
Article I. Inflammation of the Bowels. 
1. Inflammation of the Duodenum. - 2. Inflammation of the Small Intes- 
tines, or Enteritis. - 3. Dysentery. 
Article II. Cancer of the Bowels. 
Article III. Irritation of the Bowels. 
1. Diarrhoea. - 2. Colic. - 3. Lead Colic. 
Article IV. Constipation. 
Article V. Obstruction of the Bowels. 
Article VI. Worms in the Alimentary Canal. 
Article VII. Stricture of the Rectum. 
Article VIII. Hemorrhoids, or Piles. 
Article IX. Fissure of the Anus. 
Article X. Prolapsus Ani. XII 
TABLE OF CONTENTS. 
Subsection V. 
DISEASES OF THE STOMACH AND BOWELS CONJOINTLY. 
Article I. Cholera Morbus. 
Article II. Epidemic Cholera. 
Article III. Cholera Infantum. 
Article IV. Flatulence. 
Article V. Peritoneal Inflammation, or Peritonitis. 
Section II. 
DISEASES OF THE ABSORBENT SYSTEM. 
Article I. Inflammation of the Absorbents. 
Article II. Inflammation of the Absorbent Glands. 
Article III. Scrofulous Inflammation of the Glands, or External Scrofula. 
Article IV. Disease of the Bronchial Glands. 
Article V. Disease of the Mesenteric Glands. 
Section III. 
DISEASES OF THE RESPIRATORY SYSTEM. 
Subsection I. 
INFLAMMATION OF THE RESPIRATORY PASSAGES. 
Article I. Inflammation of the Nostrils. 
1. Acute Inflammation of the Nostrils, or Coryza. - 2. Chronic Inflamma- 
tion of the Nostrils, or Ozrena. 
Article II. Inflammation of the Larynx, or Laryngitis. 
1. Acute Laryngitis. - 2. Chronic Laryngitis. 
Article III. Inflammation of the Bronchia, or Bronchitis. 
1. Acute Bronchitis. - 2. Chronic Bronchitis. •- 3. Catarrh. - 4. Influenza. 
5. Croup. 
Subsection II. 
NERVOUS OR FUNCTIONAL DISEASES OF THE RESPIRATORY PASSAGES. 
Article I. Laryngeal Nervous Disease. 
1. Infantile Spasm of the Glottis.-2. Spasm of the Glottis in Adults. 
3. Suppression of the Voice, or Aphonia. 
Article II. Hooping-cough, or Pertussis. 
Article HI. Nervous Cough. 
Article IV. Asthma. 
Subsection III. 
ORGANIC DISEASE OF THE PULMONARY TISSUE AND PLEURA. 
Article I. Inflammation of the Lungs, or Pneumonia. 
Article II. Gangrene of the Lungs. 
Article III. Inflammation of the Pleura, or Pleurisy. 
Article IV. Pneumothorax. 
Article V. Emphysema of the Lungs. 
Article VI. Bronchial Dilatation. 
Article VII. Phthisis. 
Article VIII. Various Organic Affections of the Lungs. TABLE OF CONTENTS. 
XIII 
Subsection IV. 
FUNCTIONAL DISEASE OF THE PULMONARY TISSUE. 
.Article I. Loss of Breath, Apncea, or Asphyxia. 
Section IV. 
DISEASES OF THE CIRCULATORY SYSTEM. 
Subsection I. 
DISEASES OF THE HEART. 
Article I. Inflammation of the Pericardium, or Pericarditis. 
Article IL Inflammation of the Endocardium, or Endocarditis. 
Article III. Inflammation of the Heart, or Carditis. 
Article IV. Chronic Valvular Disease. 
Article V. Hypertrophy and Dilatation. 
Article VI. Various Organic Diseases of the Heart. 
Article VII. Functional or Nervous Diseases of the Heart. 
1. Palpitation. - 2: Syncope.- 3. Neuralgia of the Heart, or Angina 
Pectoris. 
Subsection II. 
DISEASES OF THE ARTERIES. 
Article I. Inflammation of the Arteries, or Arteritis. 
Article II. Ossification of the Arteries. 
Article III. Aneurism. 
Article IV. Arterial Palpitation. 
Subsection III. 
DISEASES OF THE VEINS. 
Article I. Inflammation of the Veins, or Phlebitis. 
1. Phlegmasia Dolens. ■-2. Metastatic Abscess.'--3. Chronic Phlebitis. 
Article II. Varicose Veins. 
Subsection IV. 
DISEASES OF THE BLOOD. 
Article I. Plethora. 
Article II. Anaemia. 
Article III. Scurvy, or Scorbutus. 
Article IV. Purpura. 
Subsection V. 
DISEASES OF THE BLOOD AND BLOOD-VESSELS CONJOINTLY. 
Article I. Hemorrhage. 
Article II. Hemorrhage from the Nostrils, or Epistaxis. 
Article III. Hemorrhage from the Mouth, or Stomatorrhagia. 
Article IV Hemorrhage from the Lungs, or Haemoptysis. 
Article V. Hemorrhage from the Stomach, or Haematemesis. 
Article VI. Hemorrhage of the Bowels, or Melaena. 
Article VIL Hemorrhage from the Rectum, or Bleeding Piles. XIV 
TABLE OF CONTENTS. 
Article VIII. Hemorrhage from the Urinary Organs, or Haematuria. 
Article IX. Hemorrhage from the Uterus. 
Article X. Hemorrhage from the Skin. 
Article XI. Hemorrhage from the Serous Membranes. 
Article XII. Hemorrhage of the Cellular and Parenchymatous Tissues. 
Section V. 
DSEASES OF THE ORGANS OF SECRETION. 
Subsection I. 
DISEASES OF THE SEROUS AND CELLULAR TISSUES. 
Article I. Dropsy. 
Article II. Anasarca. 
Article III. Dropsy of the Brain, or Hydrocephalus. 
Article IV. Dropsy of the Chest, or Hydrothorax. 
1. Pleural Dropsy. - 2. Pericardial Dropsy.-3. Pulmonary (Edema, or 
Dropsy of the Lungs. 
Article V. Abdominal Dropsy. 
1. Ascites. - 2. Encysted Dropsy. Ovarian Dropsy. 
Subsection II. 
DISEASES OF THE SKIN. 
Article I. Rashes. 
1. Erythema. - 2. Scarlet Rash, or Roseola. - 3. Nettle-rash, or Urticaria. 
Article II. Papulous Diseases, or Pimples. 
1. Strophulus. - 2. Lichen.'-3. Prurigo. 
Article III. Vesicular Diseases. 
1. Herpes.-2. Eczema. - 3. Scabies.'-'4. Miliary Eruption. - 5. Pem- 
phigus. - 6. Rupia. 
Article IV. Pustular Diseases. 
1. Ecthyma.- 2. Impetigo.- 3. Porrigo. -4. Acne.'-5. Rosacea.-6. Sy- 
cosis. 
Article V. Scaly Diseases. 
1. Psoriasis.-2. Lepra, or Leprosy. - 3. Pityriasis. - 4. Ichthyosis. 
Article VI. Tuberculated Diseases. 
1. Elephantiasis of the Greeks.-2. Elephantiasis of the Arabians.-3. Yaws, 
or Framboesia. 
Article VII. Discolorations, or Maculae. 
Subsection III. 
DISEASES OF THE SALIVARY GLANDS AND PANCREAS. 
Article I. Functional Diseases of the Salivary Glands. 
Article II. Inflammation of the Salivary Glands. 
Article III. Mumps. 
Article IV. Diseases of the Pancreas. 
Subsection IV. 
DISEASES OF THE LIVER AND ITS APPENDAGES. 
Article I. Inflammation of the Liver, or Hepatitis. TABLE OF CONTENTS. 
XV 
Article II. Non-inflammatory Organic Diseases of the Liver. 
1. Hypertrophy. •--2. Atrophy.- 3. Induration. - 4. Softening. - 5. Cir- 
rhosis. - 6. Fatty Liver. - 7. Tubercles. - 8. Serous Cysts and Hyda- 
tids. - 9. Malignant Affections. 
Article III. Functional Diseases of the Liver. 
1. Nervous Disorder. - 2. Circulatory Disorder.- 3. Secretory Disorder. 
Article IV. Diseases of the Biliary Passages, and Gall-bladder. 
1. Inflammation of the Ducts and Gall-bladder.--2. Biliary Calculi, or 
Gall-stones. - 3. Distension of the Gall-bladder. 
Article V. Jaundice. 
Subsection V. 
DISEASES OF THE SPLEEN-. 
Article I. Acute Splenitis. 
Article II. Chronic Splenitis. 
Article III. Non-inflammatory Diseases of the Spleen. 
Subsection VI. 
DISEASES OF THE URINARY ORGANS. 
Article I. Inflammation of the Kidneys, or Nephritis. 
Article II. Bright's Disease. 
Article III. Non-inflammatory Organic Diseases. 
Article IV. Inflammation of the Bladder, or Cystitis. 
Article V. Diseases of the Prostate. 
Article VI. Functional Disease of the Urinary Organs. 
1. Nervous Affections, including Neuralgia, Calculous Nephralgia, Spasm 
of the Bladder, Irritable Bladder, Paralysis or Debility of the Bladder, 
and Strangury. -2. Disorders of Secretion and Excretion. 
Article VII. Diuresis. 
Article VIII. Diabetes. 
Article IX. Suppression of Urine. 
Article X. Lithiasis. 
1. Uric Acid Lithiasis, or Lithic Gravel. - 2. Phosphatic Lithiasis. - 3. Ox- 
alic Lithiasis. 
Article XI. Retention of Urine. 
1. Renal Retention. - 2. Vesical Retention. 
Article XII. Incontinence of Urine. 
Section VI. 
DISEASES OF THE NERVOUS SYSTEM. 
Subsection I. 
DISEASES OF THE BRAIN. 
Article I. Inflammation of the Brain and its Membranes. 
1. Meningitis.'-2. Cerebritis. -3. Tuberculous Meningitis. 
Article II. Organic Diseases of the Brain. 
1. Hypertrophy of the Brain. •-• 2. Atrophy of the Brain. - 3. Tumours in 
the Brain. 
Article III. Apoplexy. XVI 
TABLE OF CONTENTS. 
Article IV. Functional Disease of the Brain. 
1. Nervous Irritation. - 2. Vascular Irritation, or Active Congestion. - 3. 
Depression. - 4. Mechanical, or Passive Congestion. - 5. Headache, 
or Cephalalgia. - 6. Stupor and Wakefulness. - 7. Ecstasy. - 8. Som- 
nambulism.- 9. Artificial Somnambulism.- 10. Convulsions.- 11. 
Catalepsy. 
Article V. Insanity. 
Article VI. Delirium Tremens. 
Article VII. Epilepsy. 
Article VIII. Chorea. 
Subsection II. 
DISEASES OF THE SPINAL MARROW. 
Article I. Inflammation of the Spinal Marrow and its Membranes. 
1. Spinal Meningitis. - 2. Myelitis. 
Article II. Organic Diseases of the Spinal Marrow. 
Article III. Functional Diseases of the Spinal Marrow.-Spinal Irritation. 
Article IV. Tetanus. 
Article V. Hydrophobia. 
Subsection III. 
DISEASES OF THE NERVES. 
Article I. Inflammation of the Nerves, or Neuritis. 
Article II. Neuralgia. 
Article III. Cramp. 
Article IV Hiccough, or Singultus. 
Subsection IV. 
DISEASES OF THE NERVOUS SYSTEM IN GENERAL. 
Article I. Palsy, or Paralysis. 
Article II. Hysteria. PRACTICE OF MEDICINE. 
PART I. 
GENERAL PATHOLOGY AND THERAPEUTICS. 
Prefatory Remarks. 
A Treatise on the Practice of Medicine, as the term is now generally 
understood, embraces all those branches of medical science, with the excep- 
tion of Midwifery and Surgery, which have a direct reference to the know- 
ledge and treatment of disease, and to the preservation of health. 
That department of the Practice which has for its object the knowledge, of 
disease is called pathology, and is divided into general pathology and spe- 
cial pathology, the former treating of what is common to diseases in general, 
or to a number of them, the latter of what is peculiar to individual diseases. 
The second great department of the Practice, or that which concerns the 
treatment of diseases, is called therapeutics, which may also be considered 
as general or special, according as it teaches the principles of treatment 
common to many complaints, or the particular course demanded by each 
one separately. The third department, which embraces the means of pre- 
venting disease, or in other words of preserving health, has received the name 
of HYGIENE. 
But, notwithstanding this scientific arrangement of the different subjects 
of practical medicine, it has been found that the natural mode of teaching it 
is the most effective. A stronger impression is made on the mind of the 
student, and one more available for practical purposes, by presenting him 
with a vivid picture of each disease in all its bearings, as it. must hereafter 
offer itself to his attention, than by distributing its dissected parts among 
the various sciences to which they respectively belong, and thus separating 
what he will afterwards be compelled to put together again in practice. The 
former plan, therefore, will be followed in the present work. But there are 
numerous points in relation both to pathology and therapeutics, which are 
common to many diseases, and which may with great propriety be treated of 
in general, so as at once to render the subsequent study of particular dis- 
eases more easy, and to spare the necessity for much and wearisome repeti- 
tion. Before proceeding, therefore, to an account of individual diseases, I 
propose to present, in the first part of the work, such principles and facts of 
universal or extensive applicability, as appear to me to be well established, 
avoiding speculation as much as possible, and seldom stopping to discuss the 2 
GENERAL PATHOLOGY. 
[PART I. 
numerous hypotheses which have risen and disappeared, in rapid succession, in 
this as in other branches of medicine. 
Definition of Disease.-Disease may be defined to be a derangement of 
the organization, or of one or more of the functions of the body. But this 
definition is defective, like almost all others referring to natural processes, 
which so run into one another, that a precise line of distinction can seldom 
be drawn between them. In the performance of every function, and in the 
condition of every organ, there is considerable diversity within the limits of 
health; and a state of things which, if continued, would constitute disease, 
may be so fugitive as not to merit the name; so that, both in point of degree 
and of duration, it is often impossible to say, of any particular variation 
from the ordinary condition of the system, whether it is healthy or morbid. 
For practical purposes, however, perfect accuracy of distinction is unneces- 
sary. Derangements have usually passed considerably beyond the boundary 
which separates health and disease, before they are brought to the notice of 
the physician. 
Division of the Subject.-In this part of the work I shall treat, first, of 
the constituent forms of disease, or of those derangements which, by their 
various combination, constitute diseases as' we ordinarily see them; secondly, 
of the causes of disease considered generally, forming the subordinate branch 
of pathological science denominated etiology ; thirdly, of the exploration of 
disease, in other words, the modes in which diseases may be recognized, one 
distinguished from another, and the whole course of each traced to its pro- 
bable termination-a branch of general pathology which may be designated 
as symptomatology; and fourthly, of the general principles of treatment, 
or general therapeutics. Whatever observations may be necessary on 
the subject of Hygiene will be most conveniently made in connexion with 
individual diseases. 
CHAPTER I. 
CONSTITUENT FORMS OF DISEASE. 
Prefatory Remarks. 
Diseases, viewed superficially, appear to be exceedingly numerous and 
diversified; but, when subjected to analysis, they are found to consist of a 
comparatively few constituent states of derangement, by the combination of 
which, in various modes, in relation to number, seat, and degree, that almost 
infinite apparent diversity is produced. These constituent morbid states bear 
to diseases, in their ordinary forms, the same relation that the proximate 
principles of organic bodies bear to these bodies as found in nature; the 
same, for example, that sugar, starch, gum, &c., do to the bark or root con- 
taining them. That they are themselves necessarily simple or elementary, 
is not maintained. Efforts have been made to reach the elements of disease; 
but not very successfully; because we have not yet learned the essential na- 
ture of the healthy actions, and cannot, therefore, understand their derange- 
ments. But, though we cannot push analysis satisfactorily to the absolute 
elements, we are able to appreciate to a great extent their less complex com- 
binations, forming the proximate ingredients of those numerous associations CHAP. I.] 
DISEASE OF THE FLUIDS. 
3 
of morbid states or actions usually called diseases. It may be admitted, as 
a self-evident proposition, that all diseases have their seat in the fluids or 
solids of the body, or in both. 
SECTION I. 
DISEASE OF THE FLUIDS. 
In relation to the fluids of the body, our pathological knowledge is very 
deficient. There can be no doubt that all of them are occasionally very 
unhealthy in their condition; and there can be as little doubt that, in this 
unhealthy condition, niany of them may become the sources of serious dis- 
ease. But the question is, whether the vitiated state of the fluids is original 
with them, or whether it arises from some disorder of the solids by which 
they are generated. During the prevalence of the Humoral Pathology, it 
was customary to ascribe most complaints to a morbid state of the liquids of 
the body; and, when this system was overthrown, medical sentiment turned 
with equal exclusiveness towards the solids. But at present an intermediate 
opinion is gaining ground; and the truth probably is, that, while the greater 
number of diseases have their origin in derangements either of the functions 
or structure of the organs, others consist essentially in a disordered state of 
the liquids, though even these usually find expression in complaints of the 
fixed structures. 
As all the fluids, with the exception of the lymph and chyle, are derived 
from the blood, and as the two former enter directly into the constitution of 
the latter, and convey into it all the deleterious principles which they may 
contain, the blood may be considered as the only fluid, subject to original 
morbid changes, or at least the only one to which we are to look as the pri- 
mary seat of diseases requiring our attention. The numerous liquid secre- 
tions, if deranged at the time of their formation, must be so in consequence 
of the diseased condition of the blood from which they are derived, or of the 
organs by which they are elaborated; if they become deranged after their 
formation, as sometimes happens with the bile, urine, and some other secre- 
tions, it must be owing to their undue detention, or to some undue influence 
of surrounding parts upon them, in either of which cases the solids are in 
fault. 
1. There can be no doubt that the blood is very frequently the source of 
diseases, by serving as a vehicle through which noxious substances are enabled 
to reach the parts upon which they act. Many poisons prove fatal by enter- 
ing the circulation through the medium of absorption; and the miasmatic 
and contagious effluvia probably operate on the system through the same 
channel. How far they act on the blood itself with which they are mingled, 
so as to change its constitution, and thus render it directly the seat of disease, 
is altogether uncertain. It is highly probable that such a change is some- 
times effected, and that the noxious agent, after entering the circulation, not 
only produces a morbid impression on the solids with which it is brought into 
contact by the blood, but also directly deteriorates the qualities of that fluid, 
and renders it less capable, or altogether incapable, of performing its due 
offices in the animal economy. Thus, the injection of putrid animal sub- 
stances into the veins is followed by a loss of coagulability in the blood, and 
a tendency to more speedy decomposition; and the same effects ha^ resulted 
from the influence of certain poisons. The blood, thus altered, appears no 
longer to furnish to the solids through which it flows the stimulus requisite 4 
GENERAL PATHOLOGY. 
[PART I. 
to the support of their healthy contraction; and the consequence of this, as 
well as of its own loss of cohesive affinity, is that it percolates through the 
tissues in every direction. Other phenomena result, analogous to those which 
follow exposure to putrid exhalations, or the Contagion of typhus; and the 
inference is that these agents operate in like manner directly on the'blood. 
But even here the question is not settled, whether the solids are affected 
exclusively through the agency of the altered fluid, or whether the same 
cause operates immediately upon both. 
2. There are other means by which the blood may become contaminated, 
besides the absorption of Uoxious substances extraneous to the system. The 
body itself occasionally affords similar supplies' of deleterious matter to the 
absorbents. Thus, the fetid contents of the intestines, if long retained, are 
often partially taken up and conveyed into the blood-vessels, with very inju- 
rious consequences to health; and, in cases of mortification, the putrid results 
of that process follow a similar course into the circulation, and produce effects 
not unlike those which follow the direct injection of decomposed organic sub- 
stances. Various morbid products, the results of deranged secretion, such as 
pus, and the sanies of unhealthy ulcers, are also occasionally absorbed, and 
vitiate the blood. It is believed by many that bile and urine, at least some 
of their characteristic principles, are absorbed in cases of unhealthy retention 
of these fluids, and operate injuriously through the circulation. 
3. Another source of derangement in the blood is the accumulation of cer- 
tain principles which are usually thrown off by the excretory functions, and 
which, when retained, are capable of exercising a highly injurious influence. 
This accumulation may result from a more rapid production of the principles 
in question, or from a diminished or suspended action of the organs by which 
they are naturally eliminated. Thus, uric acid is generated in the animal eco- 
nomy in a healthy state, but is thrown off by the kidneys so as not to be rea- 
dily discovered in the blood. In persons who live chiefly on animal food, and 
take little exercise, the quantity of this acid is sometimes very much increased, 
so that it is not only secreted in unusual abundance by the kidneys, consti- 
tuting gravel, but is also deposited in various other parts of the body, espe- 
cially in the joints and fibrous tissues. It is not improbable that its accu- 
mulation in the blood, under these circumstances, may be the cause of some 
of those peculiarities which distinguish gouty affections. Again, when the 
secretion of urine- is arrested, the urea, which commonly escapes with this 
excretion, remains in the blood, and imparts to it highly noxious properties. 
The same remark may be made of the colouring principle of the bile, which, 
upon a cessation of the hepatic secretion, becomes redundant in the blood, 
and, being thrown off by the skin and kidneys, produces jaundice. There is 
reason to believe that other principles, elaborated by the digestive or absorb- 
ent process, enter the current of the circulation, and prove innocent in health 
only because they are separated with the urinary, cutaneous, pulmonary, or 
intestinal secretion. Hence, probably, one of the sources of the numerous 
evils which result from the suppression of these secretions. In certain febrile 
conditions, the sour breath and sour perspiration evince the existence of an 
acid in the bipod, which probably aids other causes in sustaining the disease, 
and the elimination of which may be one of the advantages resulting from 
the use of diaphoretic medicines in these complaints. 
4. Hitherto, we have considered the blood as vitiated in consequence 
either of some foreign principle being admitted into it, or of the accumula- 
tion of some principle which, though naturally entering the circulation, is, in 
the healthy state, eliminated as fast as it enters. But it must also be re- 
garded as in a morbid state, when any one of its ordinary and essential con- CHAP. I.] 
DISEASE OF THE FLUIDS. 
5 
stituents becomes either greatly redundant or greatly deficient. Such a 
redundance or deficiency may result from the peculiar character of the food 
out of which the blood is elaborated, or from some modification in the func- 
tions concerned in its elaboration, including those which supply it with 
materials, as digestion and absorption, those which abstract materials from 
it, as secretion and nutrition, and those which contribute to both these ends, 
as circulation, respiration, and probably nervous action. According to An- 
dral, 1000 parts of healthy blood contain from 110 to 140 parts of the red 
corpuscles, from 2-5 to 3-5 parts of fibrin, and on the average 68 or 70 parts 
of pure albumen. Any excess or deficiency beyond these numbers must, in 
relation to the first two substances, be regarded as morbid; and any very 
considerable excess or deficiency, in relation to the last. 
Sometimes, under the influence of a rich diet and vigorous digestion, with 
a comparative deficiency in the nutritive process, the solid organic principles 
of the blood increase so much as to constitute a state of disease. The blood 
is intensely red, and, whefi. taken from the body, affords a larger and firmer 
coagulum than in health. It is in this state highly stimulating to the organs, 
and may give rise to a general excitement amounting to fever, or to some 
local inflammation or hemorrhage. 
Again, owing to the use of a meager diet, or to the influence of feeble 
digestion, combined, perhaps, with unusual vigour in the process of absorp- 
tion, a condition of the blood sometimes occurs in which the solid constituents 
are deficient, and the proportion of liquid excessive. Profuse hemorrhage, 
or frequent and large bleedings, produce the same effect by diminishing the 
volume of the circulating mass beyond the remunerating power of the digest- 
ive process, so that the deficiency must be supplied by the absorption of 
watery fluid. I have had under my care a case,An which bleeding had been 
so profusely employed that the vessels became filled with a turbid serum, 
which appeared, as it fell into the basin, like reddish dirty water, and, upon 
being allowed to stand, afforded a coagulum which bore an exceedingly small 
ratio to the liquid portion. This condition of the blood constitutes the disease 
called anaemia, which, as well as other consequences of excessive depletion, 
will be fully described hereafter. 
But not only is the blood liable to a general excess or deficiency of its 
organic constituents; there are also great diversities in the proportion which 
these constituents severally bear to each other; and excess or deficiency in 
any one of them may become a source of disease. Thus, an excess of the 
red corpuscles often occurs without any increase of the albumen or fibrin. 
This is indicated by a high degree of colour in the blood, a greater or less 
coloration of the seruln, a large but not unusually firm coagulum, and the 
uniform absence of the buffy coat. It constitutes an active plethoric condi- 
tion, and predisposes to fever and hemorrhage. If, in connexion with this 
excess of the red corpuscles, there be a deficiency of fibrin, the clot may 
still be large, but it will be unusually-soft, and, along with the tendency to 
fever and hemorrhage, will be a feeble state of the vital actions. Not un- 
frequently, the red corpuscles, instead of being in excess, become deficient; 
the other principles being either unaffected, positively increased, or dimin- 
ished in less proportion. In this state, the blood is less highly coloured, the 
coagulum small in proportion to the serum, and the surface of it often covered 
with a buffy coat; and the system exhibits the morbid phenomena of anaemia. 
This condition is induced by low living and the loss of blood; and it is a sin- 
gular fact that the red corpuscles suffer from these causes much more and 
sooner than the fibrin and albumen, though these latter principles are also at 
length diminished by depletion. 6 
GENERAL PATHOLOGY. 
[part I. 
An excess of the fibrin is equally common in disease. The signs of it are 
firmness and tenacity of the coagulum, and very often the appearance of the 
buffy coat on its surface. Though the fibrin is the coagulable part of the 
blood, yet its relative proportion must not always be judged of by the mere 
size or density of the clot. The degree of its firmness or tenacity is a better 
test. If the coagulum is at once large and very firm, the fibrin must be 
abundant; if voluminous and heavy, but soft, it may be deficient; the bulk 
of the clot being produced by an excess of the red corpuscles. The fibrin, 
too, appears to possess different degrees of contractile power; and, without 
reference to the red corpuscles; the quantity of it may be considerable in a 
small coagulum, and deficient in a large one; the clot being in the former 
case firm, tenacious, and capable of yielding little serum on pressure, in the 
latter, loose in its texture, and full of diffused serum. Excess of fibrin is 
one of the characteristics of the inflammatory state, being, however, a result 
of that state, rather than a cause of it. Yet it is highly probable that such 
an excess may predispose to inflammation, especially when associated with a 
superabundance of the colouring principle. 
Deficiency of fibrin results from insufficient food, from excessive fatigue 
by which it is consumed, and from various influences the mode of action of 
which is unknown, as in the low forms of fever. It is shown by a feeble 
coagulating power in the blood or the total want of it, by the smallness and 
softness of the coagulum when formed, and by the absence of the huffy 
coat. It probably predisposes to hemorrhages, and to diseases of a low or 
typhoid character; and interferes greatly with the reparative powers of the 
system. 
Albumen may also be excessive or deficient. A great excess of it may be 
known by the viscidity which it imparts to the serum, and which is sensible 
to the touch. Its quantity may be more precisely measured by the increased 
specific gravity of the serum, which in health is about 1-03, and by the amount 
of the coagulum which the serum yields when heated. The circumstances 
which contribute especially to its excess do not appear to have been well 
ascertained. That a superabundance of it is often connected with the inflam- 
matory condition, either as cause or effect, would .appear to be established by 
the experiments of Dr. Traill and M. Gendrin, who found nearly twice as, 
much albumen in the serum of the. blood in that condition as in health. (An- 
dral's Preets, &c., i., 534.) It must be confessed, however, that different 
results have been obtained by other experimenters. MM. Becquerel and 
Rodier found a diminished proportion of albumen in a number of cases of 
well-marked inflammation. (Simon's Chemistry, i.,252.) It has. been stated 
that the fibrin of the blood increases during inflammation. It is very pro- 
bable that this increase takes place at the expense of the albumen, which 
appears to be a less highly organized product. If this be the case, we can 
readily understand the different results obtained by experimenters. The albu- 
men may be excessive in the blood before and at the commencement of the 
inflammation, but may become deficient before the end of it, in consequence 
of conversion into fibrin. It is highly probable that an excess of albumen 
predisposes to inflammations, if it do not actually produce them; and its pre- 
dominance is supposed by some writers to favour the development of that form 
of inflammation usually denominated scrofulous. A deficiency of albumen 
may take place in consequence of an impoverished diet, great loss of blood, 
or morbid albuminous secretion, as in Bright's disease of the kidneys. It is 
important, as being supposed to constitute a predisposition to dropsy. 
The watery part of the blood, which, in consequence of a diminished sup- 
ply of the solid ingredients, is occasionally in very great excess, may become CHAP. I.] 
DISEASE OF THE FLUIDS. 
7 
as greatly deficient under the influence of rapid and abundant secretion, such, 
for example, as occurs in bad cases of malignant cholera. The blood then 
becomes thick, and flows with difficulty through the capillaries; the respiratory 
function, as well as the functions of nutrition and calorification, is imperfectly 
performed; the heart beats feebly; the nervous centres languish under the 
want of their accustomed stimulus; and the system either sinks irrecoverably 
into a state of universal prostration, or reacts slowly, and finds its way again 
to health through a long series of irregular sanguineous determinations, 
amounting often to inflammation. It is worthy of observation, that in the 
midst of the greatest prostration proceeding from this cause, the patient often 
has a degree of thirst equal to that which attends the highest febrile excite- 
ment. 
The salts of the blood escape with its watery portion; and much import- 
ance has been attached to this fact in a pathological point of view. Dr. 
Stevens has attempted, with some success, to show that the presence of saline 
matter is essential to the change of venous into arterial blood; and the black 
colour of the blood in cholera has been ascribed to a deficiency of its salts. 
This colour, however, may be attributed also in part to a concentration of the 
colouring matter, dependent upon the loss of much of the fibrin and albumen 
of the blood along with its watery portion, while the red corpuscles remain; 
for hematosin is black when isolated and in mass. Saline matter impairs the 
coagulability of the fibrin in blood out of the body. 
Fatty matter, which hag been proved to exist in healthy blood, becomes 
occasionally so abundant as to impart a whey-like appearance to the serum, 
and in some rare instances to render it white and opaque as if mixed with 
milk. Dr. Christison obtained on one occasion as much as five per cent, of 
fat from milky serum. But the influence which this condition of the blood 
may exert in producing disease in the solids has not been ascertained. 
It is well known that blood which does not undergo the change from venous 
to arterial in the lungs becomes unfit for the sustenance of life; but whether 
the result is owing to the accumulation of some carbonaceous principle which 
proves noxious when in excess, or to the want of that oxygenation which it 
is generally believed that the blood undergoes in the lungs, is a point which 
yet remains undecided. 
5. Lastly, the blood may become diseased by a change in the character, 
as well as in the relative quantity of ifs constituents; and this, independently 
of the entrance into it of any foreign principle.( In what way such' changes 
are effected is not precisely understood. There are not wanting facts to show 
that they may be produced by the action of the nerves. If, under perverted 
nervous influence, the products of secretion performed in the capillaries may 
become unhealthy, as is generally believed, there can be no difficulty in ad- 
mitting that the blood itself in these capillaries may undergo alteration from 
a similar cause. If nervous action be, as some suppose, analogous to the 
galvanic, we can readily understand that it may be capable of modifying the 
condition of the vital fluid submitted to it in the extreme, vessels, as water is 
decomposed when placed between the poles of a galvanic battery. We can 
conceive, also, that the constituents of the blood may be modified by the 
varying condition, within the body, of those subtle principles which exercise 
so powerful a chemical agency without it; viz., heat, light, and electricity. 
In the capillary circulation, moreover, where the particles of the blood come 
into exceedingly close relation with those of the solids, where, probably 
through the agency of the celLaction, molecules from the .former enter into 
the latter, and others again separating themselves from the solids take their 
place in the circulating mass, there may be a play of vital affinities, capable, 8 
GENERAL PATHOLOGY. 
[part I. 
when perverted, of producing a complete revolution in the state whether of 
the blood or of the structure which contains it. Again, the kind of food out 
of which the blood is made by the assimilative processes, may affect the cha- 
racter of its constituents as well as their proportion; as is abundantly proved 
in the case of scurvy, which is generally produced by a long continued absti- 
nence from fresh vegetable food, with other co-operating causes. 
Of the particular modifications which the blood undergoes from these and 
other causes, not much is known; and a wide field is here open for experi- 
mental research. That the colouring matter is often changed is to be inferred 
from the greatly altered colour of the blood in certain diseases, as in bad 
cases of scurvy and malignant fevers, in which it is sometimes almost black, 
and also from the fact that the red corpuscles are occasionally, in morbid 
states of the blood, found dissolved in the serum. The coagulability of the 
fibrin is sometimes so much augmented, or the forces which oppose it in the 
healthy state are so much diminished, that the blood becomes solidified in 
the vessels during life, and the resulting masses are asserted to have occa- 
sionally taken on an independent organization. On the other hand, the 
cohesive affinity of the particles of the fibrin is frequently much diminished, 
or entirely destroyed, so that the blood when taken from the body, or ex- 
amined in the vessels after death, is found to coagulate but feebly, and 
sometimes to be incapable of coagulation altogether. We find this condition 
in some cases of purpura, not to speak of scurvy, malignant fevers, and cer- 
tain poisonous affections, in which the cause of this change in the blood is 
wholly or in part derived from without. And here a pregnant question 
arises. This want of coagulability, or, as it is often called, this dissolved 
state of the blood, has been induced by the actual injection of putrid sub- 
stances into the circulation; and, at the same time, a set of phenomena have 
been presented by the solids, such as frequently attend malignant fevers, in 
which this same condition of the blqod exists. Now, if we admit that these 
phenomena are in the former case dependent on the altered state of the blood, 
induced by artificial means, we may reasonably ask whether in the latter case 
also they may not have their origin in a similar condition, brought about by 
natural causes. If this question be answered affirmatively, we must allow 
that the blood may possibly be the original seat of disease in many violent 
maladies. Such is generally admitted to be the case in hemorrhagic pur- 
pura and in scurvy; and the list will probably some time be considerably 
extended. 
But the blood, and the solids through which it circulates, are so intimately 
related, their mutual reactions are so constant and essential, that any disorder 
in one can scarcely exist without some change in the other, and, in every 
case of extensive disease, it may be very confidently asserted that both are 
more or less involved. Numerous experiments have established, that blood 
taken from a diseased animal, and injected into the veins of another in health, 
often produces the most fatal consequences; though the same operation, per- 
formed with the blood of a healthy animal, is usually followed by no serious 
results; thus proving that the blood participates in the disease of the solids. 
It is probable that, in many cases, morbid impressions are simultaneously 
made upon both. In many others, it is impossible to decide in which of the 
two the disease has its original seat. There are often chains of morbid actions 
of which each link constitutes a disease. Thus, some part of the body may 
be affected with extensive mortification, the putrid results of which may be 
absorbed into and contaminate the blood, which may then operate upon the 
system at large, producing a state of things analogous to typhus fever. Here 
the distinct links are, first, the mortification, secondly, the diseased, blood, and CHAP. I.] 
DISEASE OF THE SOLIDS. 
9 
thirdly, the typhoid condition; and whether the fluids or the solids be con- 
sidered as essentially the seat of the morbid action, depends upon the point 
in its progress to which the attention is directed. In the vast majority of 
cases, it is to the solids that attention is chiefly directed, because in them 
the alterations are more within the scope of observation, and from their nature 
are more susceptible of investigation. The structure of the solids, moreover, 
is vastly more diversified, and consequently their derangement involves a 
much greater variety of morbid action. Besides, the morbid states of the 
blood are yet little understood-, and are perhaps incapable of being fully in- 
vestigated in the present state of chemical knowledge. From all these causes 
it happens that, in a treatise on the practice of medicine, the condition of the 
blood is comparatively but seldom brought into view in its relation either to 
pathology or therapeutics. Still, no physician can do full justice to his 
patients, or contribute his due share to the advancement of medical science, 
who does not constantly bear in mind the important part played by that fluid, 
and its all pervading influence as well in disease as in health. 
SECTION II. 
DISEASE OF THE SOLIDS. 
It is not to be concluded, from the title here given, that' all the forms of 
disease treated of under this head are considered as having their seat ex- 
clusively in the solids. The object is only to convey the idea, that it is in 
this situation that they display their characteristic phenomena. They may 
be arranged in two divisions, one embracing those which proceed directly 
from purely mechanical or chemical causes, the other, those which result 
from some agency exerted upon the vital properties. 
SUBSECTION I. 
It is only the immediate effects of such causes that belong to this division. 
The secondary effects are consequent upon a disturbance in the functions 
produced by the injury already received, and belong, therefore, properly to 
the second division. Thus, by means of external force, the flesh is lacerated, 
or a bone is broken, in the living exactly as in the dead body; and the re- 
sulting wound or fracture is a mere mechanical effect; but the inflammation 
and fever which follow the injury are exclusively vital phenomena, and 
obedient to vital laws. Most of the affections belonging to this section fall 
within the domain of surgery, and others are so connected with the vital de- 
rangements to which they give rise, that they cannot be separately considered 
with advantage. Little more, therefore, need here be done than to arrange 
them under heads corresponding with the nature of their causes, so that the 
student may have a general view of the whole in a regular order. 
1. First in the series may be mentioned the effects of external violence; 
as contusions, wounds, fractures, and dislocations. These are purely me- 
chanical, and belong to the province of the surgeon; though their conse- 
quences often come under the notice of the physician, and will be treated of 
elsewhere. 
2. Analogous to the preceding are the results of certain chemical agents, 
so powerful as to produce immediate disorganization of the parts to which 
they are applied. They act either by so strong an affinity for one or more 
DISEASE EROM MECHANICAL OR CHEMICAL CAUSES. 10 
GENERAL PATHOLOGY. 
[part I. 
of the principles^ entering into the composition of the part as to overcome 
the resistance of its vitality, or by an influence which brings latent affinities 
existing between these principles into energetic action, and thereby produces 
new combinations entirely subversive of organization. Corrosive or caustic 
substances act in the former manner, intense heat, in the latter. If caustic 
substances, however, be applied in a certain state of dilution, or if heat be 
applied in a moderate degree, they do not then operate as chemical agents. 
Their affinities, or those which they call into play, are not sufficiently ener- 
getic to overcome the vital resistance. They operate merely as irritants or 
stimulants; and their effects must be ranked with those of other causes act- 
ing on the vital properties. Even a caustic effect, so far as this term refers 
merely to the death of any portion of the body, may result from such an 
influence, altogether independently of chemical laws. A part may be stimu- 
lated beyond its powers, and may thus lose its life in consequence of excessive 
excitement. Substances are capable of producing this effect which exhibit 
no action upon the dead body. Such results do not belong to this section, 
which embraces only the direct effects of a purely chemical influence, such 
as would also be experienced upon the application of the agent to the body 
after death. 
3. Next in order are the effects of gravitation. Under the influence of 
this principle, all the liquids have a tendency to settle into the most depend- 
ent part. The vital forces which maintain the circulation, and keep up a 
degree of contraction in all the living tissues, are sufficient in health to coun- 
teract any degree of this influence to which the system is ordinarily exposed. 
But, when excessive, it is capable of producing local derangements even in a 
state of general health. Thus, in consequence of long standing, the blood 
accumulates in the feet and legs beyond the fatigued power of the circulation 
to remove it, and the result is a varicose distension of the veins. Thus also 
the liquid which is everywhere moderately secreted by the cellular tissue, 
but which is ordinarily absorbed as fast as secreted, has, under similar cir- 
cumstances, a tendency to subside into the lower extremities, where it accu- 
mulates faster than the absorbents of those parts can remove it, and an 
edematous condition of the feet and legs results. Hence the varicose veins 
and swollen extremities to which soldiers on long and hurried marches, and 
other persons constantly on their feet, are liable. 
These results are much more striking when the force of the circulation 
and the organic contractility are morbidly feeble. Swelling of the legs often 
takes place under! such circumstances, even though the patient may not be 
more frequently than is usual in the erect posture; and the effect is of course 
greatly increased by an increase of the cause. Andral ascribes to this cause 
the mortification which sometimes occurs in the extremities of very old peo- 
ple. The forces which move the blood are too feeble to overcome the influ- 
ence of gravitation; the blood, therefore, stagnates; and the death of the part 
follows. 
4. The immediate consequences of a mechanical obstruction to the course 
of the circulating fluids are also among the diseases belonging to this section. 
When the venous trunks are the seat of the obstruction, congestion takes 
place in the part from which the vessels emptying into these trunks proceed, 
effusion of blood, or of serous fluid results from the distended state of the ca- 
pillaries, the functions nf the part are impaired or wholly deranged, and, if 
the obstruction be complete or nearly so, mortification occurs as a necessary 
consequence of the want of those properties in the retained blood which are 
essential to the support of all the vital actions. If, on the contrary, an artery 
be obstructed, the part in which it ramifies languishes from the want of blood, CHAP. I.] 
DISEASE FROM MECHANICAL CAUSES. 
11 
and may perish from the same cause, if the caliber of the -vessel be quite ob- 
literated, and the blood be unable to find its way through anastomosing 
branches. Obstruction of the absorbents gives rise to tumefaction, partly 
from the distended state of the vessels themselves behind the part affected, 
partly from the accumulation of effused fluid consequent upon deficient ab- 
sorption. The obstructing cause is often such as to affect more than one of 
these sets of vessels, and the results are modified accdrdingly. 
The causes of obstruction may be external, as ligatures around the limbs or 
neck, tight lacing, and pressure either by the weight of the body, or from 
some extraneous source;.or they may be internal, as tumours, enlarged or in- 
durated glands, aneurisms, the impregnated uterus, diseased contractions or 
thickening of the coats of the vessels, or the presence of coagulated blood or 
fibrin within their caliber. , , 
Obstruction to the course of the blood, and consequent congestions, may 
arise also from a loss of due proportion between the cavities of the heart, and 
from contraction or insufficiency of,the valves; but this subject will be fully 
considered under the head- of diseases of the heart. 
Any impediment to the capillary circulation in organs supplied by the 
ramification of large vessels conveying venous blood, must prove an obstruc- 
tion to the circulation in these vessels, and consequently a cause of congestion 
in those parts of the body from which they proceed. Thus, if the capillaries 
of the liver, whether from constriction produced by irritation, from debility, 
or from any other cause, cease to convey the blood through this org^n with 
the usual rapidity, the vena portarum becomes necessarily distended, and con- 
gestion takes place in the stomach, bowels, and all those parts the veins of 
which empty into that great trunk. So also, in the case of a similar impedi- 
ment suddenly produced in the capillary circulation of the lungs, as in the 
instance of death from asphyxia, the pulmonary arteries, the right cavities of 
the heart, and consequently the general venous system become congested, as 
is evinced by the bloated and livid countenance, the prominent eyes, and the 
whole surface injected with dark blood, giving the skin a mottled appearance. 
5. Obstructions in the excretory ducts of glands, or other passages intended 
for the escape of secreted fluids, give rise to a series of morbid phenomena, 
which, in their first step at least, must be considered in the light of mechanical 
affections.- The fluid of which the outlet is closed accumulates in the tubes 
or receptacles behind the point of obstruction, producing distension, which is 
in some instances enormous, and which, unless relieved, reSults in a rupture 
of the coats, and not unfrequently fatal effusion of the liquid into neighbour- 
ing parts. Another result is either a re-entrance into the circulation, by 
means of absorption, of the secreted fluid or some of its constituents, or the 
retention in the circulation of principles which would otherwise be thrown off 
by secretion; this process being arrested by the pressure of the accumulated 
fluid. As some of these principles are noxious when existing in excess in 
the blood, very serious effects are occasionally produced. Thus, when the 
duct which conveys the bile into the intestines is closed, this liquid necessa- 
rily accumulates behind the point of closure, and there is danger of rupture 
of the ducts or of the gall bladder, and of fatal effusion into the abdominal 
cavity. The colouring matter and probably other principles of the bile may 
be absorbed and conveyed into the blood-vessels; and, as the secretory action 
of the livei' is restrained by the pressure' of the fluid accumulated in the ducts, 
the bilious matter ceases to be thrown off so rapidly as usual, and consequently, 
from this cause also, becomes redundant in the blood. Here it acts as a 
poison, producing various morbid sensations, which are partially relieved by 
the escape of the offending cause by different emunctories, as by the skin and 12 
GENERAL PATHOLOGY. 
[PART I. 
kidneys, giving rise to jaundice. A similar train of consequences follows an 
obstruction of the ureters or urethra. 
The causes of such obstruction may be external to the tubes, as indurated 
tumours in neighbouring parts; or they may consist in an altered state of the 
coats of the tubes, as thickening or spasmodic contraction ; or, finally, they 
may be within the cavity of the tubes, as calculous concretions, or viscid and 
impacted secretions.- 
6. Lastly, under the head of mechanical affections, may be enumerated 
some of the immediate consequences qf obstruction in the respiratory passages 
and alimentary canal; as suffocation from a foreign body either in the larynx, 
or in the oesophagus pressing upon the trachea; inability to swallow from 
stricture of the oesophagus, from a foreign body in that tube, or from pressure 
made upon it by a tumour; and stoppage of the contents of the stomach and 
bowels from stricture, intussusceptio, strangulated hernia, or accumulated 
and hardened feces. But in these and other similar cases, the mechanical 
results are so intermingled with vital derangements, or so immediately fol- 
lowed by them, and the latter are so much the more important, that the 
cases may be most advantageously treated of in connexion with these derange- 
ments. 
SUBSECTION II. 
All living parts are endowed with the property of excitability, or in other 
words are capable of being brought into and maintained in action by the 
stimulus of certain agents either internal or external. The excitement thus 
produced is essential to the preservation of life, and is susceptible of consider- 
able variation in degree or extent, without exceeding or falling short of the 
limits of health. 
But, under the influence of certain causes, this excitement maybe increased 
or diminished so as to occasion uneasiness to the individual, and interfere 
with the due performance of the functions. Even under these circumstances, 
it can scarcely be considered in the light of disease, if the variation from the 
due standard be of very brief duration. Thus heat and cold, in the ordinary 
changes of the seasons, often produce painful impressions, the former with 
an augmented, the latter with a diminished action of the part affected; but if 
these impressions disappear immediately on the removal of the cause, leaving 
no permanent derangement, they do not constitute disease. It is, indeed, 
impossible to say where precisely, in the advance or retrocession of excite- 
ment, health ends and disease commences. 
The body or some one of its organs may be excited into morbidly increased 
action by the direct application of a stimulant, or may be brought indirectly 
into the same state through the agency of certain laws of the system hereafter 
to be stated. 
The morbid excitement may be such as to affect only the function of the 
part or organ which is the seat of it, or it may be attended with a change of 
structure. Some pathologists have, indeed, denied the existence, in any case, 
of functional without organic change. But, certainly, it is not impossible 
that a part may act in one way or another; that the heart, for example, may 
beat more or less frequently; that more or less liquid may separate from the 
blood; that a more or less rapid nutrition may take place, without alteration 
of structure. Whether, therefore, in all such cases, there is or is not organic 
change, must rest upon observation; and we every day witness instances of 
disease in which no such change is discoverable; as in the various neuralgic 
DISEASE FROM INFLUENCES UPON THE VITAL PROPERTIES. CHAP. I.] 
DISEASE AFFECTING THE VITAL PROPERTIES. 
13 
affections. As we cannot draw the line precisely between .health and disease, 
neither can we determine always where functional disorder ends and organic 
begins. The latter is usually preceded by the former; and, as a general rule, 
functional disorder long continued ends in structural lesion. 
But all disorder is by no means the consequence of augmented excitement. 
A depression of action below the standard of health is equally a morbid state. 
This may arise directly from the application of sedative agents, or the with- 
drawal of the ordinary healthy excitants, or indirectly in consequence of 
certain physiological laws, to be explained in another place. It maybe only 
functional, or may be attended with organic change, and result even in the 
death of the part affected. 
In the case both of morbid exaltation and morbid reduction of the vital 
actions, the excitement and depression may be in the line of health, though 
above or below it; or they may deviate from this line, and present peculiar 
characters independent altogether of mere difference in degree. This has 
been denied by certain pathologists, who maintain that all disease is a mere 
augmentation or diminution of the actions of health, and that one disease 
differs from another only in degree or locality. But the instances are so 
numerous, in which affections, occupying the same structure, present charac- 
ters entirely different, independently, to all appearance, of the grade of action, 
or even of peculiarities in the organization of the part affected, that the posi- 
tion above stated must be held true, unless the phenomena can be demonstrated 
to be other than they seem. To adduce only a single example; a gland in 
the groin may become the seat of different diseases, one of which shall result 
in the production of healthy pus, followed by speedy restoration to health, as 
common inflammation; a second, in the generation of a peculiar virus, capable 
of producing the same disease in-another, as syphilis; a third, in the deposi- 
tion of a cheesy matter, with slow suppuration and very lingering recovery, 
as scrofula; a fourth, in characteristic degeneration of structure, utterly dif- 
ferent from anything seen in health, or in other forms of disease, as cancer. 
No satisfactory explanation has yet been given of these and numerous other 
diversities, upon the principle of the unity of morbid action; and the beauty 
or simplicity of a theory is not a sufficient reason for admitting its validity, 
in opposition to4he evidence of the senses. 
There are, moreover, diseased conditions, which are.not in themselves neces- 
sarily connected with an elevation or depression of the vital actions, but ex- 
hibit a complete change or subversion of them, and the substitution of others 
entirely different, as if belonging to a new order of parts. 
On each of the morbid states alluded to in the preceding remarks, I shall 
offer some general observations, in order to avoid the repetitions which might 
otherwise be necessary in describing the various diseases of which they are 
the constituents. It is essential that they should receive specific names) so 
as to spare the continual use of circumlocution. I shall employ in general 
well known and accepted terms. Should the meaning here attached to them 
differ in any respect from their ordinary acceptation, I shall at least'endeavour 
to make their use in this work correspond with the explanation given in the 
outset/ 
That condition of super-excitement in which the functions are morbidly 
deranged, without obvious organic change, is called irritation. When the 
excitement is marked by peculiar characters, distinguishing it from the ordi- 
nary results of over-stimulation, it is designated as a specific irritation. The 
term irritation is also employed, even when organic changes take place, pro- 
vided they fall short of that peculiar condition, usually marked by redness, 
heat, pain, and tumefaction, and which is denominated inflammation. When 14 
GENERAL PATHOLOGY. 
[PART I. 
this condition occurs, the irritation is considered as merged in it, and the term 
is abandoned. Inflammation may also be marked, like the lower grade of 
excitement, by peculiar characters, materially differing from those which it 
presents in its ordinary form. Such deviations are distinguished by the name 
of specific inflammations. It is impossible in all cases to designate the pre- 
cise boundary between irritation and inflammation. The lower grades of the 
former and the higher grades of the latter are very clearly marked; but they 
run together in the interval. They are merely opposite extremes of the same 
line of excitement. 
That morbid condition in which the vital actions are reduced below the 
healthy standard is called depression. The name sedation has also been ap- 
plied to it; but I prefer the former, as more precisely expressive of the con- 
dition indicated. It differs from debility, which implies a loss or diminution 
of vital power; while, in the case of depression, this power may be undimin- 
ished, though temporarily restrained. It may consist in a simple reduction 
of the vital actions, or may be accompanied by peculiarities arising from the 
operation of peculiar causes, in which case it may be' denominated specific 
depression. It may, moreover, be purely functional, or attended with organic 
changes. In the latter case, its lowest grade is mortification or gangrene. 
Diseased conditions which ar6 entirely peculiar are of course designated by 
special names, which it will be sufficient to mention when the diseases them- 
selves are considered. 
I shall proceed now to treat of the several morbid states above indicated; 
viz., irritation, inflammation, and depression, with their general causes, laws, 
and effects. As one of the attendants upon these morbid states, and deserving 
of notice from its frequent occurrence, as well as for the great importance 
attached to it by modern pathologists, I shall next consider the subject of 
congestion. The next general topic will be fever, which, though not ele- 
mentary, is a most important constituent of numerous diseases, and, as it is 
perhaps incapable of analysis, may be advantageously considered among the 
simpler forms. ^Lastly, I shall treat, in a general way, of those peculiar 
morbid states, in which there is a complete change of the vital actions, and 
the production of new deposits or structures, giving rise to a series of phe- 
nomena peculiar to each of the states in question. Such are the tuberculous 
disease, melanosis, and cancer. Under these several heads, may be included 
all that can be advantageously said as preliminary to the consideration of 
those particular associations of morbid phenomena which are usually called 
diseases, and which, though in many instances merely the results, the symp- 
toms, as it were, of the real disease, will probably always receive a distinct 
and prominent attention, as it is in these associations that disease strikes the 
senses of the observer. i ■ ■ ■ ' 1 
•Article I. 
IRRITATION. 
Causes, Propagation, Transfer, &c., of Irritation.-Any morbid excite- 
ment of the vital actions not amounting to inflammation is denominated irri- 
tation. This may result directly from an excess of the ordinary agents 
necessary for the support of health, such as food, drink, air, heat, light, and 
electricity; from the action of substances having acrid or stimulant proper- 
ties, whether extraneous to the body, as various medicines and poisons, or CHAP. I.] 
IRRITATION. 
15 
produced within it, as acrid secretions, healthy secretions too long retained, 
products of chemical changes, parasitic animals, even the blood itself if too 
abundant or of altered qualities; from excessive or perverted mental action; 
and from various unknown causes, the existence of which is inferred from 
their apparent effects, as miasmath, contagion, and epidemic influence. 
Irritation may also result indirectly, through certain physiological laws, 
which determine this condition as the necessary consequence of other ante- 
cedent conditions. 
The human system appears to possess a certain amount of excitability. 
If this be calleci into excessive action, it is exhausted in proportion to the 
excess, and there is necessity for subsequent repose in order that it may be 
recruited. If, on the contrary, from a diminution of the wonted stimuli, or 
by the action of directly depressing agents, it is allowed to rest, or is re- 
strained, it is afterwards, upon the removal of the cause, proportionably 
augmented; and the amount of excitant agency, necessary under ordinary 
circumstances for the support of health, becomes now the cause of excessive 
and perhaps morbid action. Hence, depressing causes^' if of temporary du- 
ration, indirectly produce irritation by the reaction which results. This is 
probably true of the whole system, though the fact is denied by some patho- 
logists. It is certainly true of the several parts of the system. A familiar 
illustration is offered in the irritation which frequently takes place'in the 
hand, previously exposed to severe cold, upon entering a wa^rm apartment. 
A degree ,of heat which was before only sufficient to sustain the natural con- 
dition of the part, now that the excitability has accumulated through the 
sedative agency of the cold, becomes capable of producing an unhealthy ex- 
cess of action. This principle is very important, and of very frequent appli- 
cability in the explanation of morbid phenomena. 
There is another mode in which irritation may result indirectly from 
depressing causes. In the mode just described, the irritation occupies the 
precise seat of the antecedent depression, and succeeds it yin that now alluded 
to, it occurs in other organs, and is co-existent with the depression. When 
the healthy actions of a portion of the frame are reduced, the nervous energy 
and circulating fluid, being diminished in that part, necessarily accumulate 
elsewhere; and, if the cause continue to operate, a morbid excess of action, 
in other words, an irritation in some other part or organ is the consequence. 
This results in part from a mere change in the balance of the circulation, 
throwing an undue portion of blood, whifeh is itself a powerfully stimulating 
agent, upon a particular organ; but probably in part also from the operation 
of that physiological law by which the system, possessing a certain amount 
of excitability, experiences a temporary increase of this property in certain 
parts, when its exercise is restrained in others. Thus we have, at the same 
time, an increase of the excitability and of the exciting agent in the same 
portion of the body, and irritation naturally follows. This is an abundant 
source of disease. Many of the cases of internal irritation, having their 
origin in the external application of cold, may be considered as illustrations 
of the principle here stated. The blood, leaving the cutaneous capillaries, 
seeks certain inner parts of the body, which have at the same time acquired 
increased susceptibility to its stimulant action by the repression of the natural 
excitability of the surface; and irritation is established in some one of the 
organs most predisposed to that condition. 
Another fruitful source of irritation in particular parts is its previous ex- 
istence in other parts, with which- the first are sympathetically connected. 
All portions of the system are so bound together by a chain of sympathies, 
that a strong impression can scarcely be made on any *one spot, without 16 
GENERAL PATHOLOGY. 
[PART I. 
vibrating through the whole. But each particular part or organ is more 
closely associated in this way with certain parts or organs than with others, 
which, therefore, more strongly feel its disturbances, and are more easily 
brought into sympathetic irritation; that one of the associated organs being 
attacked, in preference to the remainder, with the secondary irritation, which 
is from other causes most predisposed to the disease. 
Continuity of parts of similar structure is most favourable to the rapid 
propagation of irritation. Thus, if one point in a serous or mucous mem- 
brane or of the skin becomes irritated, the disorder often spreads rapidly 
from that point, involving a large portion of the tissue affected before it 
ceases to advance. If an absorbent radicle is the seat of the irritation, it 
often extends quickly along the absorbent to the nearest gland, while the 
neighbouring parts are comparatively little affected. 
Continuity even of dissimilar structure is also favourable to the spread of 
irritation. An investing membrane frequently communicates disordered 
action to the organ which it covers, and one of the membranous coats of a 
canal to one or more of the others. What is more common, for example, 
than spasmodic contraction of the muscular coat of the alimentary canal, 
consequent upon irritation of the mucous membrane ? Irritation travelling 
along an absorbent, is not unfrequently communicated, in a greater or less 
degree, to the neighbouring cellular structure and integuments. 
Even contiguity of parts, without immediate connexion, favours the exten- 
sion of disordered action. Thus, irritation of the pleura costalis may be im- 
parted to the contiguous surface of the pleura pulmonalis, without extending 
through that portion of the membran'e which connects the two. 
But parts often sympathize strongly together which are distant from each 
other, and have no direct connexion. This happens probably through the 
instrumentality of the brain and spinal marrow, or the ganglia. Instances 
of the communication of irritation from one organ to another in this way are 
almost innumerable. The stomach and heart are especially rich in these 
sympathetic connexions, and suffer accordingly. Thus, gastric irritation, with 
nausea and vomiting, is a frequent attendant upon disorder of the brain, -of 
the parenchyma of the liver and spleen, and of the kidneys, not to speak of 
other portions of the alimentary canal itself; while irritation of the stomach 
is, in its turn, almost always radiated to one oi' more of these organs. The 
heart may be thrown into sympathetic disorder by strong irritation in any 
part of the body. Indeed, .the whole system is frequently made to sympa- 
thize directly or indirectly with the sufferings of any one of its organs; and 
almost every extensive disease, not resulting directly from contamination or 
alteration of the blood, is an example of disorder propagated from one or a 
few points in which it may have originated. 
It sometimes happens that an irritation, thus sympathetically produced, 
becomes the prominent disease; that from which it originated having very 
much diminished, or disappeared. In this case, a metastasis, or transfer of 
the diseased action, may be said to have occurred; though this phenomenon 
is more frequently the result of other causes; as, first, of the cure of a local 
irritation, while the general diathesis in which it may have originated remains, 
and which now throws its force upon some other part, as in the case of gout 
in the stomach succeeding its removal from the feet by cold applications; 
and, secondly, of the establishment of an irritation in a sound part by some 
independent agency, calling off' the irritation from its original seat, as when 
gout in the stomach is relieved by the application of mustard to the feet. 
Sometimes, instead of diminishing or disappearing, the original irritation 
acquires additional force by- reflection from the seat of the secondary or sym- CHAP. I.] 
IRRITATION. 
17 
pathetic disorder; as when the heart, excited by some local irritation to 
excessive action, sends an increased current of blood through the part affected, 
and thus stimulates it more highly. 
The facility with which irritation may be produced depends much upon 
the general condition of the system. Firm and vigorous health presents the 
greatest resistance to- the action of irritant causes. When excitability is dis- 
tributed in just proportion throughout the frame, and each organ performs 
its function duly, the usual causes of disease, finding no weak point to assail, 
will often pass harmless by. Elevation above the standard of health, and 
depression below that standard, equally provoke the attack of diseases of 
irritation. ' , • .. < . ' ft. 
A full plethoric habit, in which the blood is excessive in quantity and too 
rich in quality, though the complexion may be florid, the digestion good, the 
nutrition active, and the other functions apparently in perfect order, is by no 
means an evidence of vigorous health. Such a habit is, indeed, always on 
the borders of disease. The slightest irritant cause is sufficient to rouse the 
latent tendency into action. The blood is so stimulating and abundant as to 
maintain every organ at its highest point of action consistent with health; 
and a single additional drop of excitement is sufficient to make the action 
run over into disease. When irritation is excited under these circumstances, 
it is almost certain to fall upon the blood-vessels, and is apt very speedily to 
rise into inflammation, unless the over-excitement be quickly relieved by 
abundant secretion,, or by hemorrhage. Thus, persons returning from a long 
journey, in which exercise has invigorated their digestive and nutritive func- 
tions, and resuming sedentary habits, are exceedingly liable to inflammatory 
attacks. During their period of active exertion, the additional quantity of 
rich blood supplied by the invigorated digestion, is expended in the support 
of the excited functions, so that the healthy balance is preserved. But when, 
upon a return to comparative repose, the cause of this additional expenditure 
ceases, while the* appetite, yet unimpaired, and the digestive function tasked 
to the utmost, continue the additional supply, a plethoric state of system is 
established, and the slightest spark is sufficient to light up the flame of high 
vascular irritation, if not of inflammation. 
A system enfeebled by depletion, by abstinence, by imperfect digestion, or 
by any other cause, is perhaps not less liable to disorder from over-excite- 
ment; but the irritation in this case is apt to take place in a different order 
of parts, and to present different phenomenal Instead of attacking the capil- 
lary blood-vessels, and exhibiting excessive vascular action, it is disposed to 
seat itself in the nervous system, and to take on the form of neuralgia, spasm, 
convulsion, or other nervous disorder. The functions are often very much 
deranged without any discoverable 'organic affection, and with little disposi- 
tion to assume the inflammatory condition. Even the heart may be thrown 
into tumultuous movement, without ,alteration of its own structure, or the 
existence of any known local vascular irritation or inflammation to excite it. 
Thus, the irritation of gout, which in the plethoric fixes upon the blood- 
vessels, and very generally ends in inflammation, will in the debilitated, often 
exhibit itself in various harassing nervous disorders; as dyspepsia, spasm of 
the stomach and bowels, asthma, palpitation of the heart, vertigo, and neu- 
ralgia. Hence, the system when enfeebled is often said to be in an irritable 
state, because it is easily excited into disorder, and that disorder is apt to 
retain the form of irritation; while an opposite condition is called inflamma- 
tory, because any irritation excited almost always runs into inflammation. 
But, though a state of debility predisposes especially to nervous derangement 
and functional irritation, it would be a great mistake to suppose that it indis- 18 
GENERAL PATHOLOGY. 
[part I. 
poses to inflammation; on the contrary, this form of disease is more apt to 
occur, under such circumstances, than in perfect health. 
In various diseases, particular organs acquire increased irritability, and are 
thrown into disorder by causes which would produce no effect in health; and 
parts which have already been the seat of irritation are more liable than others 
to subsequent attacks. An exception to this latter rule is afforded in certain 
diseases, usually of a contagious and specific character, which in general affect 
the human subject but once; such as small-pox, measles, hooping-cough, &c. 
When an irritation has been produced, it often continues for a considerable 
time after the original cause has ceased to act. When the system, or any of 
its parts has been thrown into agitation, time is required for it to settle down 
into the. calmness of health; and, as with the surface of the sea after a storm, 
the commotion is sometimes greater after the removal of the cause than during 
its action. In cases, however, where the irritation assumes a permanent form, 
there is reason to ascribe its continuance to constitutional predisposition. 
It is maintained by some writers, that, as the system possesses only a cer- 
tain amount of excitability, a universal irritation cannot exist, and that, even 
admitting that an irritant may be applied to the whole system, it can affect 
only a part. But this does not necessarily follow. It must be admitted 
that the system has a limited amount of excitability; but it is not true that 
the whole of this excitability is called into play in health. It is easily con- 
ceivable that, by augmenting the stimulation applied to all the organs, the 
excitability in reserve may be brought into action, and a universal exaltation 
of the vital functions beyond the point of health result. Nor is the evidence 
of facts against this idea. It has not been and cannot be proved that no case 
of universal irritation has existed. But such a- case cannot be of long dura- 
tion. The excitability must soon be exhausted, and the system sink into a 
state of indirect depression. Nor, admitting the possible existence of such 
cases, can they be allowed to be common. It seldom happens that a stimu- 
lant agent is applied to the system universally, to which the peculiar and 
various susceptibilities of all the organs will respond, so that all shall be ex- 
cited to morbidly increased action. Even when the agent is a universal sti- 
mulant, still, certain organs are much more susceptible to its influence than 
others; and these, being first excited into a high degree of irritation, occupy 
all the reserved excitability, and even call off that of the other organs to such 
an extent as to render them, under existing circumstances, not only insus- 
ceptible to the stimulant impression, but in a certain degree to that also of 
their ordinary healthy excitants, so that they are left in a state of depression. 
Hence, the ordinary result of the morbid operation of even general stimulants 
is the establishment of irritation in one or more organs and depression in 
others; and this is still more common when the operation of the cause, as 
generally happens, is partial. In the great majority of diseases, therefore, 
there is a mixture of these two opposite conditions; though the predominance 
of the irritation, or of the depression, may give the peculiar character of the 
one or the other to the disease in general. 
The effects of irritation are often displayed in organs remote from its real 
seat. This happens when the disorder attacks a tissue or order of parts, 
upon the due action of which other parts depend for the ability to perform 
their peculiar functions. Thus, sensibility, muscular motion, and to a cer- 
tain extent secretion, depend upon. a due supply of nervous influence from 
the brain, spinal marrow, or nervous ganglia. Irritation, therefore, in either 
of these structures, or in the course of the nerves which convey their influence, 
may produce great disorder in one or more of the functions alluded to in any 
part of the body, even the most remote. Hence, paralytic, spasmodic, and CHAP. I.] 
IRRITATION. 
19 
convulsive affections, and innumerable derangements in the secretory func- 
tions, often depend exclusively upon disease in the nervous centres. 
It is highly probable that each particular function, dependent upon nerv- 
ous influence, receives its supply through nervous cords or fibrils devoted 
exclusively to itself, and connecting it with some particular nervous centre; 
in other words, with some portion of the brain or spinal marrow, or some one 
of, the ganglia, which presides especially over it. 
It has long been known that, in certain instances, the nerves of special 
sensibility are distinct from those of general sensibility, as in the organs of 
sight, hearing, and smell; and the fact is now believed to be true also in 
regard to taste. The fact that a certain degree of cold benumbs the sense 
of touch in the hand, while the sensibility to painful impressions, so fat from 
suffering diminution, is in reality augmented, and the fact also that in certain 
morbid states of the system the touch is often exceedingly acute, while the 
sensibility to painful impressions is so far lost that needles may be run into 
the hand, or a tooth extracted without apparent consciousness,* render the 
inference highly probable, that the nerves of touch are also distinct from those 
of general Sensibility. 
It has been demonstrated by Bell, Magendie, and others, that sensibility 
and the power of motion depend, in many instances, upon distinct nerves, 
though they may be connected in the same sheath; and analogy, as well as 
the phenomena both of health and disease, justifies-us in assuming the fact 
to be universal. But we may go further, and infer that each distinct part, 
in an association of parts devoted to the same office, has distinct nervous 
fibrils, by which it communicates with the source of its power; that each 
muscle, for example, is thus provided; as we cannot well otherwise conceive 
how the will could communicate with any particular muscle, to the exclusion 
of all the rest. We are thus provided with the means Of explaining numerous 
morbid phenomena, and conducted to a rational mode of treatment. Almost 
every variety of functional derangement, in almost every part of the body, 
may have an origin in irritation of a single point in the brain, spinal marrow, 
nervous ganglia,' or the nerves connecting these organs with the seat of the 
function-; and remedies addressed to the real seat of the disease may speedily 
relieve it, while, if confined to the apparent seat, they can be of no advantage. 
The importance, to the physician, of bearing in mind the general truths in- 
culcated in this section is incalculable. 
Phenomena, Effects, &c., of limitation.-The first observable phenomenon 
in the lower grades of irritation, is an exaltation of the function in the part 
affected. With an increase of the irritation, the function becomes more or 
less deranged, and in the higher grades undergoes an entire change, or is 
altogether suppressed. The symptoms consequently vary with the tissue, 
organ, or series of parts affected, and with the degree of the irritation. 
It is possible that irritation may be confined entirely to the nervous sys- 
tem, and may increase, derange, or suppress the various functions performed 
by that system or its parts, without a direct original participation of the ca- 
pillaries. Thus, the sensations may be sharpened or perverted, the emotions 
and intellectual operations elevated or deranged, and muscular movement 
invigorated, disordered, or suppressed, without any discoverable evidence of 
* As in the morbid state induced in females, with irritable nervous systems, by those 
operations performed under the name of animal magnetism. The author has seen too 
many instances of the kind alluded to in the text, to allow him to entertain a doubt upon 
the subject. He does not, however, wish to be understood, as ascribing any other influ- 
ence to these operations than one of an exclusively mental character. 20 
GENERAL PATHOLOGY. 
[PART I. 
antecedent vascular change. It may indeed be said, that the capillaries of 
the neurilema, or of the nervous substance itself, either in the nervous cen- 
tres, or the conducting cords, may be the seat of the irritation which thus 
interferes with the functions; and this is undoubtedly the case in many in- 
stances, as dissection has proved; but, in many other instances, neither exa- 
mination after death, nor investigation during life, has been able to detect 
such a source of the irritation; and its existence should not be assumed on 
mere theoretical grounds. Nevertheless, in any case even of primary nerv- 
ous irritation, the capillaries are apt to become secondarily involved; and 
perhaps in no case can the capillaries be the seat of irritation, without a par- 
ticipation of the nervous structure; so that in most instances the two systems 
mutually partake of the disorder, and contribute to the results. 
A phenomenon always present in local capillary irritation, whatever may 
be its seat, is an increased flow of blood to the part, and a consequent arterial 
congestion. In relation to the immediate cause of this congestion, there will 
be occasion to speak when upon the subject of inflammation. Of its existence 
there can be no doubt. It is evinced to the eye by the redness which follows 
the application of an irritant to the skin, or to any other exposed part. It 
is one of the first steps which nature takes in that series of changes which 
attend a persistent irritation, and is a necessary instrument for the accom- 
plishment of those changes. Independently of the results which flow from 
the vital influence of the blood thus accumulated, it frequently proves inju- 
rious mechanically by pressing upon and cramping the organ, and thus inter- 
fering with the due performance of its functions; as in the vertigo, or even 
apoplexy, which sometimes results from general congestion of the brain with- 
out any discoverable lesion, and the partial palsy which attends a similar 
congestion of the particular centre, from which the affected part is supplied 
with nervous influence. 
An altered condition of the sensibility is another change attendant upon 
irritation. If the excitement be moderate, there is merely an exaltation of 
the natural sensibility. Thus, in the early stage and lower grades of irrita- 
tion, the sight, hearing, taste, smell, and touch may become more acute when 
their organs respectively are affected; and the ordinary susceptibilities of 
particular parts to particular impressions are augmented. Very soon, how- 
ever, if the disorder continues or becomes of a higher grade, the sensibility is 
perverted, with the occurrence of deranged sensations, or is impaired, so that 
the appropriate stimuli do not make their usual impression, or is for a time 
altogether lost. 
Similar modifications' occur in the motive power, when the muscular tissue 
is affected. It is first increased, so that the muscle will act more vigorously 
under the same amount of stimulation; it is then perverted, so that the con- 
traction becomes irregular or spasmodic; and sometimes it is altogether lost 
under the violence of the irritation, as when the heart almost instantly ceases 
to beat, in cases of sudden translation to it of gouty, rheumatic, or neuralgic 
disorder. 
Digestion is also apparently invigorated under a moderate irritation, and 
becomes deranged as the irritation increases. Hence, most substances which 
are capable of inflaming the stomach, will in very small doses provoke a tem- 
porary increase of the appetite, and more rapid assimilation of the food. 
Absorption seems to be somewhat variously affected. It is a general law, 
that the - rapidity of absorption is inversely proportionate to the fulness of 
the blood-vessels. In capillary irritation, therefore, as the blood is usually 
accumulated in the vessels of the part affected, absorption should take place 
less rapidly than in the healthy state; and this seems to be the case. Ex- CHAP. I.] 
IRRITATION. 
21 
periment has proved, that substances which highly stimulate the surface to 
which they are applied are less apt to be absorbed, caeteris paribus, than others 
which produce no such effect; and the copious effusions which take place in 
closed cavities, in a state of irritation or inflammation, must result from the 
circumstance, that the increased secretion is not counterbalanced by a corre- 
sponding activity of absorption. Whether the result is- merely mechanical, 
depending upon the pressure of the blood in the distended capillaries, imped- 
ing the direct entrance of fluids through the coats of the venous radicles, and 
at the same time cramping the lymphatic vessels, or whether we are to con- 
sider that the absorbents do really not participate in the irritation, .is a point 
which it might be difficult to decide. The fact, however, is important in a 
therapeutical point of view. But, though absorption is usually impeded by 
any irritation which has the effect of producing, in whatever degree, a con- 
gested state of the capillaries, there would seem to be cases in which an irri- 
tative action in a part is not incompatible with increased absorption; as in 
cases of hypertrophy, where this function, though not invigorated in the 
same proportion as the secretory, must necessarily be more active than in 
health in order to produce the requisite symmetry of growth. Besides, the 
absorbents, when submitted to a direct and exclusive stimulation, obey the 
general rule; that is, if moderately excited, they perform their usual function 
more vigorously, but, under excessive excitement, are deranged or impeded 
in their action, or cease to. act altogether. Atrophy, general or local, may 
result from the former condition, morbid accumulation of secreted matter from 
the latter. 
The influence of irritation upon the function of secretion is of great prac- 
tical importance. In all the secretory organs, its first effect, if not excessive, 
is to increase the quantity of fluid without materially altering its qualities. 
In a somewhat higher grade, it changes the character as well as increases the 
amount of the secreted fluid. Thus, the mucous discharge from the nostrils, 
which, under a slight irritation, becomes somewhat more copious, retaining 
its usual bland qualities, is, in a higher grade of irritation, not only increased 
in quantity, but so far altered in quality as to excoriate the skin over which 
it passes. Thus also in the action- of calomel on the liver, a very small dose 
will often produce a modefate flow of healthy bile, while that which results 
from large doses is not unfrequently dark coloured and exceedingly acrid. 
There ate many diseases which consist essentially in increased secretion, con- 
sequent upon irritation of the secreting organs. Such frequently are diar- 
rhoea, cholera morbus, and various forms of dropsy; and whether the character 
of the fluid secreted in these cases is the same as in health, or is- in a greater 
or less degree modified, depends often upon the degree of the existing irrita- 
tion. 
In many instances, the secreting organ, under high irritation, throws out 
blood little if at all altered, probably through the same orifices by which the 
secreted fluid escapes in health. Hemorrhages frequently have their origin 
in this cause. 
When the irritation exceeds a certain point, the secretory process is dimin- 
ished or altogether arrested; and, under these circumstances, inflammation is 
apt to be established. 
The function of nutrition obeys the same law. It is promoted by a slight 
irritation, and impeded, deranged, or arrested by one of a more' violent char- 
acter. That condition of a part denominated hypertrophy, or excessive growth, 
appears to be the result of a mere augmentation of the nutritive process, con- 
sequent upon a moderate irritation in the part. The disorder may affect the 
whole of an organ, or only one or more of its constituents. Thus, the liver 22 
GENERAL PATHOLOGY. 
[part I. 
is sometimes enlarged, without any other apparent deviation from the healthy 
state. In this case the whole organ is probably the seat of an irritative 
action. In other instances, the intimate structure is deranged, in consequence 
of the augmentation of one of its components. 
To complete our general view of irritation, it remains only to call atten- 
tion to its secondary effects. These may be exhibited in the part imme- 
diately affected, or in other parts of the body. In the former situation, after 
the subsidence of the irritation, a state of depression usually occurs, in which 
the functions/are performed more feebly, or are for a time suspended. The 
over-fatigued organ requires a period of rest before it can return to its ordi- 
nary duties. This subject will be more fully considered under the head of 
depression. In parts of the body not the seat of the primary irritation, two 
things may occur. In the first place, those closely connected by sympathy 
with the seat of the disease, frequently participate in its disorder, and be- 
come secondarily irritated. In the second place, in consequence of the limited 
amount of excitability possessed by the system, parts which are affected 
neither with the primary nor the secondary irritation, are apt to be depressed 
in their action below their previous condition. We may artificially avail our- 
selves of this principle so as to relieve existing irritations, by establishing a 
more powerful one elsewhere. Upon this point there will be occasion to treat 
more fully hereafter. 
Among the important secondary effects of irritation, are also to be con- 
sidered the changes produced, and phenomena exhibited, in parts which 
depend for the due performance of their functions upon the regular action 
of the part affected. Now all the functions of the body are so closely con- 
nected, and so mutually dependent, that one cannot be materially deranged 
without more or less deranging the others. Hence an irritation, capable of 
throwing any one function into serious disorder, will interfere secondarily 
with others by depriving them of the influences requisite for their due per- 
formance, or engendering new influences of an injurious character. Thus, 
a derangement or suspension of the secretion of the gastric juice, will give 
rise to impaired digestion, in consequence of which less nutriment is thrown 
into the blood, which, therefore,, becomes less capable of supplying the due 
material and influence to the functions of innervation, secretion, and nutri- 
tion ; and thus disorder in all these functions may arise, as a secondary con- 
sequence of irritation of the stomach. This, it is evident, is a very -different 
mode of propagating disease from that which is effected through sympathy 
of parts, by which the original irritation is immediately transmitted from 
one organ to another, retaining its primary character in its new locality. 
But, though there is a mutual dependence, to a certain extent, in all the 
functions, yet certain parts are more intimately connected than others, and 
in some this connexion is so closer that irritation in the one finds its legiti- 
mate expression in derangements of the functions in another. The nervous 
centres hold such a commanding relation with the whole system: and irrita- 
tion in the brain, spinal marrow, and ganglia, is often recognized only by 
the disorder which it produces in the dependent functions. From what has 
been -said in this section, it will be readily inferred, that a vast number of 
morbid phenomena and effects are merely secondary consequences of irrita- 
tion in some other part of the system than that in which they are exhibited. 
Specific Irritations.-In relation to specific irritations, those, namely, in 
which the super-excitement deviates from the ordinary line of excessive action, 
few general observations can be made; as, from their very nature, they re- 
quire a special consideration. In relation to their origin, propagation, and 
effects, they are for the most part obedient to the general laws already stated. CHAP. I.] 
INFLAMMATION. 
23 
Their peculiarity is dependent upon some peculiar diathesis. or predisposition 
of system, which determines special effects from ordinary causes; or, as much 
more frequently happens, upon peculiarity in the nature of the cause. Thus, 
gouty and rheumatic irritation may be excited in systems, predisposed to 
these forms of disease, by any irritant cause; while the irritation of hooping 
cough is developed, in the ordinary state of system, by a peculiar contagious 
principle. All contagious diseases, soffar as they consist in irritation, may 
be placed in this category; for they are all peculiar, if in nothing else, at 
least in generating a poison similar in its effects to that which produced 
them. - :: - . . - . ' 
Article IL 
INFLAMMATION. 
This name is applied to a peculiar morbid condition, usually characterized 
by increased redness, increased heat, pain, and swelling. The co-existence 
of these phenomena in any one part, may be considered as sufficient evidence 
of inflammation in that part; although, if they persist for a very short period, 
there is always associated with them some modification of the secretory and 
nutritive processes; and, perhaps, such a modification might with propriety 
be included, with the other phenomena, in the definition. But the absence 
of one or more of the symptoms mentioned is not incompatible with the ex- 
istence of inflammation. Thus, pain is sometimes wholly wanting, and the 
increased redness and heat often disappear before the inflammatory action 
ceases. But almost every definition of natural processes is liable to similar 
imperfection; for the different processes are so allied, intermingled, or over- 
lapped, that scarcely any one is susceptible of being entirely isolated, even 
for the purpose of description. 
Inflammation is beyond all comparison the most important of diseased con- 
ditions; as it either attends, or forms an essential part of the great majority 
of serious diseases, and in most instances constitutes the chief source of dan- 
ger. Hence it requires to be-studied with peculiar care. I shall treat 1, of 
its general phenomena, progress, and results; 2, of its nature; 3, of its 
causes; 4, of its modifications in the different tissues; and 5, of those varie- 
ties which may deserve to be considered as specific. 
1. Redness.-This is usually the first observable phenomenon. It is of 
various intensity and shade, according to the degree of the inflammation, its 
stage, the part affected, the state erf the system, and the nature of the cause. 
Every grade of it is observable, from a light rose-colour to a deep crimson, 
or even purple. It may appear in points, in streaks, in minute ramifications, 
or quite uniform like the redness in blushing. It is generally most intense 
in one spot, and. as it recedes from this, gradually diminishes until lost in the 
healthy colour : but sometimes it has an abrupt boundary, and is of equal 
intensity, or very nearly so, throughout. The brighter hues generally attend 
ordinary active inflammation; the darker, that proceeding from some specific 
cause, or associated with a feeble action, or a gangrenous tendency. The 
redness often disappears under pressure by the finger, and returns upon the 
removal of the pressure ; the rapidity with which it returns measuring the 
activity of the circulation in the p*art. Sometimes, however, it cannot be 
1. Phenomena, Progress, and Results of Inflammation. 24 
GENERAL PATHOLOGY. 
[part i. 
removed by pressure, in consequence of the engorged state of the capillaries, 
and the extravasation of blood. The colour of inflamed parts is owing 
chiefly to an enlarged capacity of the existing capillary vessels, which thus 
admit a greater volume of blood; but in part also to the formation of new 
vessels, which, according to the observations of Kaltenbrunner and others, 
very speedily exhibit themselves after inflammation has been established. 
The intense redness exhibited in certain cases may-be ascribed, as suggested 
by Hunter, and subsequently proved by microscopic examination, to the pas- 
sage of the blood unchanged from the arteries into the veins. 
2. Heat.-With the increased redness, there is also, an increased tempe- 
rature of the part. This is usually more, sensible to the patient than to the 
observer ; though it may in general be detected by'the hand, and is rendered 
evident by the therniometer; but, from the experiments of Mr. Hunter, it 
would appear that it never exceeds the temperature of the blood in the heart. 
Consequently, when a part near the centre of circulation is inflamed, the in- 
crease of temperature is less than, under similar circumstances, in the extremi- 
ties, where the ordinary degree of heat is lower. Thus, according to Thomson, 
blisters on the chest seldom raise the temperature more than one or two 
degrees; while upon a remote part of the upper or dower extremities, they 
produce an elevation of five or six degrees, or even more. A part heated by 
inflammation resists the ordinary causes of refrigeration more than in health. 
Thus, Hunter found that the ear of a rabbit, inflamed in consequence of 
previous congelation, could not be frozen anew. The causes of the increased 
temperature are probably the greater quantity of blood in the capillaries, and 
an augmentation of that vital action upon which the evolution of heat depends. 
Thomson advances, as an objection to the latter of these causes, that the 
temperature does not exceed that of the blood in the heart; but it probably 
exceeds that of the blood on its way from the heart to the seat of inflamma- 
tion, particularly when this occupies a distant portion of one of the extremi- 
ties; so that the temperature of the inflamed part .cannot depend exclusively 
on that of the blood brought to it; and we know of no other source from 
which the caloric could be' supplied than the vital action alluded to. 
3. Pain.-Pain is commonly felt very soon after- the commencement of 
inflammation, and sometimes even precedes the redness. It varies exceed- 
ingly in degree and character; being, in some instances, so slight as to be 
scarcely perceptible, in others,- exquisitely severe; sometimes sharp or lanci- 
nating, at other times dull, heavy, or tensive; sometimes throbbing, and 
again pungent, prickling, burning, or merely itching, as in certain affections 
of the skin. Occasionally, it amounts only to soreness; the patient being 
scarcely conscious of pain unless the part affected is pressed upon or moved; 
and pressure or motion aggravates the suffering in all cases. It is, moreover, 
liable to remissions and exacerbations, and sometimes eVen intermits. These 
diversities are owing to differences in the seat, degree, stage, and character 
of the inflammation, and are often useful as one of the means of diagnosis. 
Parts having little or no sensibility in health, such as tendon, ligament, and 
serous membrane, often become exquisitely painful when inflamed. The 
pain is frequently felt in parts remote from the real seat of disease, as in the 
right shoulder from inflammation of the liver, in the glans penis from in- 
flammation of the neck of the bladder, and in the knee from inflammation of 
the hip. 
The cause of the pain is some unexplained modification in the state of the 
nerves. It may be aggravated by the pressure arising from the distended 
vessels, or the thickened neurilema, and is in many instances increased by 
each pulsation of the heart, producing what is called pulsative or throbbing CHAP. I.] 
INFLAMMATION. 
25 
pain; but pressure cannot be the sole cause; as, when applied in an equal 
or even greater degree in health, it produces no such effect; and pain often 
precedes tumefaction, and is even somewhat relieved by it. 
While the general sensibility is thus increased by inflammation, the special 
sensibility of each particular organ is diminished, or suspended. The touch, 
taste, smell, hearing, and sight are impaired when their several organs are 
inflamed; and the same is the case with what have been called the internal 
senses. In the irritation which often precedes the establishment of the in- 
flammatory process, the senses are sometimes rendered more acute; and the 
same result takes placd-, when a portion of the appendages of the proper 
organ is inflamed, and propagates only a sympathetic irritation to the nervous 
structure, or real seat of the sense; as, for example, in the ear and eye, in 
the former of which, inflammation of the cavity of the tympanum, or external 
meatus, is occasionally attended with increased acuteness of hearing, while 
the same condition of the exterior membranes in the latter may sharpen the. 
sensibility of the retina. But these are only apparent exceptions. The 
general proposition remains unaffected, that the senses are impaired by in- 
flammation established in their several -organs. The finger, which, when 
inflamed, becomes exquisitely painful at the contact of a foreign body, loses 
in part or wholly the sense of touch, by which a judgment might be formed 
of the shape, size, and peculiar character of the same body. 
4. Swelling.-The tumefaction which attends inflammation is subject 
to equal • diversities with the other phenomena. It is sometimes slight, as 
in the mucous membranes, sometimes enormous, as in the testicles and 
lymphatic glands. It may be circumscribed or diffused, prominent or flat, 
hard or soft, according to the circumstances of the case; and it varies of 
course in amount with the degree of the inflammation. Dependent at first 
on a mere increased influx of blood into the capillaries, it is afterwards greatly 
augmented by effusion into the structure of the part, and by a new organiza- 
tion or growth which takes place in the progress of the disorder. 
5. Modifications of Secretion.-It has been stated that, if inflamma- 
tion last any considerable time, there is always some modification of the 
secretory process. In its earliest stage, while yet the excitement has scarcely 
passed the boundary line of irritation, there is usually an increase of the 
normal secretion of the affected organ. But when the inflammation has be- 
come established, secretion is almost always diminished, or even quite sus- 
pended. Thus, the skin becomes dry when inflamed, and the serous and 
mucous membranes undergo a> similar change. Hence the dry cough which 
usually occurs at the commencement of bronchitis. But, in the progress of 
the disease, the secretory function is again brought into action, the secretion 
being even more abundant than in' health, and by this very copiousness 
relieving, in some measure, the violence of the inflammation. Hence the 
mucous discharge's in dysentery and catarrh, the serous effusion under the 
cuticle in erysipelas, and the similar effusion which takes place into the serous 
cavities, and the interstices of the cellular tissue. But the fluids thus effused 
are not precisely in their normal state. Instead of being perfectly bland, as 
in health, they are often very acrid, irritating and excoriating the parts with 
which they come into contact. They have more of the albumen of the blood 
than in health, and frequently contain portions of the blood itself, or its 
colouring matter, to the variable proportion of which they owe their various 
shades of yellow, red, or brown. In the progress of the disorder, they arej 
moreover, often mingled with more or less coagulable lymph and pus; two 
peculiar and characteristic products of inflammation, which require particular 
notice. 26 
GENERAL PATHOLOGY. 
[part I. 
Coagulable lymph is name applied by English writers to a substance 
effused from the vessels of an inflamed part, which, though it escapes in the 
liquid form, coagulates after effusion, and is capable of becoming organized,' 
and thus forming a new living'structure. This plastic substance appears, 
from chemical analysis, as well as from its physiological properties, to be 
closely analogous to, if it be not identical with, the fibrin of the blood. It 
appears to be sometimessecreted with little if any of the other constituents 
of the blood, but in general is mixed with serous fluid, and is probably thrown 
out of the blood-vessels in the form of liquor sanguinis, or fluid portion of the 
blood,, deprived of the red corpuscles, and possibly somewhat altered in the 
secretory process. Of this fluid, the fibrinous part concretes, while the albu- 
minous portion, remaining combined -with water and saline matters in the 
form of serum, fills and distends the cavities and interstitial spaces into which 
it may have been effused, or escapes in the form of flux from exposed sur^ 
faces, or those having a natural otitlet. The albumen may also become con- 
crete, but it probably differs from fibrin, or the proper coagulable lymph, in 
never undergoing organization. 
All that is absolutely essential to the organization of the effused fibrin is 
that it should be in contact with living tissue. When examined by the micro- 
scope, immediately after effusion/it is found to contain great numbers of 
minute granules of different sizes, and, besides these, multitudes of fibrils, 
and another set of minute bodies, which appear to be formed by an aggrega- 
tion of the granules, are often covered by a cellular envelope, and constitute 
what are called exudation corpuscles. Coagulation appears to depend upon 
the multiplication and interlacing of the fibrils referred to. After coagulation, 
the rudiments of blood-vessels speedily appear. Numerous red points are 
first seen; these lengthen- into lines, which quickly inosculate so as to form a 
continuous network; a communication is formed between this and the capil- 
laries of the contiguous tissue; and, in a wonderfully short space of time, a 
new structure is produced, possessing a more or less perfect organization. It 
is probable that the minute granules above referred to, in relation to which 
it is yet undetermined whether they escape from the blood-vessels, or are pro- 
duced in the extravasated fibrin, are the germs, nut of which are formed the 
exudation corpuscles or cells, which, together with the fibrils, generate, in 
some undetermined manner, the blood-vessels and other constituents of the 
new tissue. It may be readily conceived that, from deficient vitality in the 
effused fibrin, or from unfavourable circumstances in the position in which it 
may be extravasated, the process of organization may either never begin, or, 
having begun,, may prove imperfect or abortive. Hence it often happens that 
solid products are formed in inflammation, possibly out of the fibrin itself, 
which are amorphous and without life, and occasionally others which, though 
living, are altogether abnormal in their character. It has been rendered 
probable by Gerber and others, that the matter of tubercles consists of de- 
generated exudation corpuscles or fibrinous granules. 
Coagulable lymph is often secreted immediately after inflammation has 
been established. It forms solid flocculi swimming in the serous-effusion, or 
ordinary secretion of the part; coagulates upon inflamed surfaces in patches 
or extensive layers, constituting what have been denominated false, membranes; 
fills and consolidates the cells of the cellular and adipose tissues; and is even 
secreted into the substance of membranes, rendering them rough and opaque, 
when they were before smooth and transparent. To this, much of the tume- 
faction and hardness often attendant upon inflammation is ascribable. It is 
the agent of important results, both favourable and unfavourable. By its 
mere coagulation in certain positions, as for example upon the inner surface CHAP. I.] 
INFLAMMATION. 
27 
of the larynx, it interferes with functions essential to life, and thus occasions 
fatal Consequences.' At other times, it proves useful by confining effused 
fluids within certain limits, and thus preventing them from spreading mis- 
chief into the neighbouring parts, as in the case of abscesses, and of irritating 
effusions into the serous cavities;, or by surrounding foreign or noxious bodies 
with a coating by which they are isolated and rendered harmless. By its 
organization the opposite surfaces of inflamed membranes are often perma- 
nently united, as in the pleura, peritoneum, and synovial tissue. It constitutes 
the medium through which the divided faces of wounds, when brought into 
apposition, are reunited, and spaces produced by a violent solution of con- 
tinuity in any portion of the body are filled up by a new growth. In each 
of these latter cases, the inflammation, by which the effusion of coagulable 
lymph is produced is named by Mr. Hunter adhesive inflammation; but it 
differs in no respect from the affection originating without violence, and 
throwing out the same product upon the surface or in the tissue of organs. 
It is am important circumstance that, when separated parts are thus reunited, 
or lost parts replaced, the new structure partakes so far of the nature of the 
original, as in general not to interfere materially with the functions of the 
organ. Thus, in cellular tissue it is cellular, between divided tendons is" 
fibrous, and between broken bones is bony. But some tissues are never 
actually renewed, as the muscular, and the proper cutaneous tissue. 
Pus shows itself at a later stage of inflammation than the substance last 
mentioned. Very frequently the inflammatory affection ceases without yield- 
ing this product, and it is then said to end in resolution. If it persevere, 
however, pus generally makes its appearance, mingled at first in small pro- 
portion with the serum, coagulable lymph, or other secreted fluid, and 
gradually increasing till it becomes nearly or. quite unmixed. The process 
by which it is produced is called suppuration, which is merely a step in that 
complex succession of morbid actions denominated inflammation. It is wrong, 
therefore, to say of suppuration that it is one of the terminations of inflam- 
mation, or to use the name suppufative inflammation as expressive of a dis- 
•tinct character of this morbid state. The period at which pus first appears 
Varies from a few hours to many days. There is no living tissue, and no 
organized part of the body, in which it may not be produced. It is liable,to 
considerable diversity of character; but that produced in ordinary inflamma- 
tion, in a - sound state of the constitution, and called frequently healthy or 
laudable pus, because it often-acts an essential part in the repair of injury, 
and the restoration of a healthy condition of parts, has the following pro- 
perties. 
It is a whitish-yellow or slightly greenish, homogeneous, opaque liquid, 
somewhat thicker than cream, of a mawkish odour, and sweetish taste. It 
is not ropy between the fingers, and does not separate into two parts by 
standing. It is miscible with water; but insoluble in that fluid, in which it 
sinks as it were in a pulverulent form. In its ordinary state, it is neither 
alkaline nor acid; but sometimes exhibits the former condition when taken 
from scrofulous abscesses, and the,■ latter after exposure to the air. It is slow 
to putrefy. Hunter found it to differ from all other animal fluids which he 
examined, in being coagulated by muriate of ammonia. Experiments have 
been made in relation to its reaction with various chemical agents-; but the 
results obtained are of little practical importance. It dissolves rapidly in a 
solution of caustic potassa. Upon 'analysis, it yields albumen, extractive 
matter, a fatty matter, soda, chloride of sodium, phosphate of lime, and 
numerous other salts. Under the microscope, it appears to consist of small, 
round, and occasionally oval corpuscles, floating in a thin transparent liquid. 28 
GENERAL PATHOLOGY. 
[part I. 
The pus globules are larger than the red corpuscles of the blood, and than 
the greater number of the exudation corpuscles. When exposed to the action 
of distilled water, they seem to double their former size, and are hence sup- 
posed to be vesicular. The liquid in which they float is albuminous, and 
bears a considerable resemblance in chemical composition to the serum of the 
blood. (Simon's Chemistry, ii. 92.) 
Pus is often mixed with blood, and in various proportions with many other 
substances, which modify its character, such as serum, mucus, and coagulable 
lymph. It is often rendered exceedingly offensive to the. smell by contact 
with parts in a state of putrefaction, or by other causes: It differs also ma- 
terially in properties, even where no difference is observable by the sensed of 
chemical examination. The pus of syphilis, or of small-pox, cannot be dis- 
tinguished from that of a common abscess, though the latter is harmless, 
while the former is capable of producing the diseases respectively in which it 
originated. 
Authors are not agreed as to the precise mode in which pus is produced. 
By many it is believed to be the product of a secretory process. Gendrin, 
however, maintains that it results from some change in the blood, independ- 
ently of any action of the capillaries; and that this change may be effected 
either after the blood has been effused, or while it still remains' in the ves- 
sels; the pus, in the latter case, being allowed to pass out through the coats 
of the vessels unaltered. According to that author, when blood is effused in 
inflammation, it first coagulates: if suppuration do not take place, the serum 
is then absorbed, the red globules lose their cdlour, and the clot becomes 
organized; but, if the disorder advance to suppuration, the blood gradually 
loses its colour, and is changed into pus. Gendrin also believes that the 
fibrinous fluids, effused in the course of inflammation, are often converted into 
pus. They who consider pus to be the product of secretion, ascribe these 
apparent results to the gradual absorption of the effused blood and fibrin, 
and the gradual deposition of pus .in their place. Gerber believes that the 
pus corpuscles are produced by the degeneration of the exudation corpuscles, 
which form in fibrin after its extravasation. It is certainly not impossible 
that blood or fibrin may be changed into pus after exudation; but, when it is 
considered that pus, ready formed, is often thrown out abundantly from the 
surface of inflamed tissues, without any previous effusion of blood or fibrin, 
the inference appears necessary, that it is the direct product of a secretory 
action, performed upon the blood of the capillaries either by these vessels 
themselves, or by the ultimate cells. 
It is a doubtfijl point, whether pus is in all cases the product of inflamma- 
tion. It is occasionally found disseminated in tissues, or collected together 
in masses, in the lungs, liver, and Qther parts of the body, without any evi- 
dence of inflammation in these organs during life, and without any of the 
ordinary appearances which that affection leaves behind it after death. The 
pus appears to hsive been merely deposited by the vessels, without any co- 
existing derangement in the tissue. Such phenomena are not unfrequently 
observed in the cases of individuals who have recently suffered amputation 
or other'operation, by which a suppurative disease of longer or shorter con- 
tinuance has been removed. But they are also said to be presented in some 
rare instances, in which no inflammatory source of pus, existing at the time, 
or within a shdrt period previously, could be discovered. In the former case, 
the collections of pus may be ascribed to the previous absorption of that 
liquid from the suppurative source; and it is known that pus occasionally 
enters the circulation by absorption; as it has been found, both in veins and 
absorbents, proceeding from the neighbourhood of purulent deposits. But no CHAP. I.] 
INFLAMMATION. 
29 
such explanation can be given in the latter case. It has been suggested by 
Andral and Tessier, that there may exist a purulent diathesis, which may 
dispose to the formation and deposition of pus, jas the tuberculous diathesis 
does to that of tuberculous matter, without any essential complication with 
inflammatory action. Some suppose that pus, in these cases, is formed in 
the blood out of itsvhealthy constituents; and, where any suppurative focus 
exists, the change may be ascribed to the absorption of a portion of the pus, 
and the excitement by its presence in the blood of a sort of purulent fer- 
mentation. Others again believe, that it is the result of inflammation in the 
lining membrane of'the veins, or blood-vessels in general. 
When suppuration is established, the violence of the inflammation abates; 
and hence its occurrence has been erroneously considered as one of the termi- 
nations of inflammation. The pus may appear upon the free surface of mem- 
branes, or diffused in the interstices of the tissues, or collected together within 
the substance of the different structures, forming abscesses. 
6. Modifications of Nutkition, or Changes of Structure.-Along 
with the modification of the secretory process, the nutritive also undergoes 
material change. Not only is the inflamed part increased in size and density 
by the congestion and effusion which take place, but it often also becomes 
the seat of a new growth, as already explained, by the organization of the 
coagulable lymph. . ■ • ., ■ 
Softening-.-At the same time that the dimensions and density of the part 
are augmented, there is almost always, in acute inflammation, a diminution 
of cohesion, so that the texture is more, easily torn than in health. This 
occurs even in the early stage of the inflammatory process; in the more 
advanced stages, the softening usually increases; and, in some instances, the 
healthy tenacity of the texture is so much diminished, that after death the 
fing'er may be passed through it almost without resistance. This softening 
Often ends in a complete disorganization of a portion of the inflamed texture, 
which appears to break dowtq and is either removed by the absorbents, or 
dissolved in the purulent secretion, with which it seems to become identifibd. 
Induration.-It rarely happens that a part is hardened in a state of acute 
inflaminatiOn. It is necessary, however, that density should not be con- 
founded with induration. In the former, there may be greater weight and 
greater closeness of texture; but this is entirely consistent with increased 
friability. In hardening, on the contrary, the part is not only more dense, 
but it. resists more firmly every mechanical agency that niay tend to indent, 
rupture, or divide it. It is torn or cut with greatef difficulty, is often sono- 
rous when struck, and emits a peculiar sound under the knife. Density is 
often present in acute inflammation, hardening, as before mentioned, seldom. 
It often, however, attends chronic inflammation, and is frequently left behind 
when the inflamnlation ceases. In these cases, it arises from an organization 
of the coagulable lymph effused into the interstices of the tissue, and a con- 
sequent consolidation of this tissue, by the union of its surfaces. 
Ulceration.-Though, during the existence of acute inflammation, the ab- 
sorption of foreign bodies from the part affected is much dess vigorous than 
in- health, interstitial absorption appears often to be invigorated. Whenever 
fat is present in an inflamed part, it is, according to Gendrin, very quickly 
absorbed. A solution of continuity in the tissue affected is not unfrequently 
a result of the same process. This may occur upon the free surface of organs, 
in which case ulcers are produced, and the process is called ulcerative absorp- 
tion, or ulceration. It may also happen in the interior of the tissues, pre- 
paring a receptacle for the purulent secretion, and making a way for the 
resulting abscess to the surface. In the latter case, Mr. Hunter denominated 30 
GENERAL PATHOLOGY. 
[part i. 
it progressive absorption. There seems to be little difference in the character 
of the process in these two eases. 
The probable cause of ulceration is, in most cases, such a diminution of 
vitality, under the inflammatory process, as to diminish the resistance to the 
absorbent action, which is always going on even in health, but is then pro- 
perly balanced by-a due condition of the other functions. When a part dies, 
if the neighbouring parts are not too much debilitated, the absorbents imme- 
diately begin rto remove it. When a part approaches death, the same opera- 
tion commences in the more vigorous, or less exhausted structure, in contact 
with it. Certain specific inflammations are peculiarly disposed to ulceration; 
and it is more apt to occur, other things being equal, in a debilitated or de- 
praved than iii a sound state of health. • Pressure also promotes it. Acute 
inflammation, supervening on chronic, is very apt "to be attended with it, as 
the already debilitated part dannot resist the new excitement. 
Ulceration upon exposed surfaces, as upon the skin and alimentary mucous 
membrane, which are peculiarly liable to it, usually, commences in a single 
point, producing a small ulcer; which gradually spreads till it reaches its limits. 
Sometimes, however, it commences in several points at once, or in succession. 
It is frequently attended with .a- pricking pain, which varies very much .in 
different tissues, and different Varieties of inflammation. Occasionally, it is 
very slow and of -very small extent, and again is exceedingly rapid and de- 
structive. In the latter case, it is commonly denominated phagedenic. It 
occurs in every texture susceptible of inflammation. In bone, it constitutes 
caries. It is improper to say that inflammation terminates in ulceration. 
The latter is merely a step in the former complicated process, and is always 
attended with other marks of inflammation. It i^ by the coagulable lymph 
thrown out by the inflamed capillaries, and organized, that fatal hemorrhage 
is prevented from occurring from the divided vessels. Ulcerative absorption 
may precede suppuration, but it is almost always very speedily followed by 
the secretion of pus. When the. ulceration .ceases, the loss is restored, and 
the parts return to health by the process of granulation. 
Abscesses.-It has been stated that pus1 may be collected in cavities, in the 
interior of the different structures; and that these collections are called ab- 
scesses. This, in fact, is the ordinary result of suppuration, where there is 
no natural outlet for the pus.' The cavities which receive these collections 
are made, partly by the absorption of the softened tissue, partly, it has been 
supposed, by the breaking down and. decomposition of the tissue, and its solu- 
tion in the pus. After the abscess has been formed, it has a tendency to 
advance towards the surface of the body. This is an undeniable fact, for 
which it is easier to find a reason than a cause. The object undoubtedly is 
that the pus may have a safe outlet. What is the. immediate agency by which 
this outward direction is given has not been ascertained. On all sides, the 
abscess is surrounded with a barrier of the neighbouring tissues, consolidated 
by coagulable lymph, or of the lymph itself, organized and converted into a 
pseudo-membranous cyst or sac, which has the properties of absorption and 
secretion. But in that portion of the walls of the cavity which presents 
towards the surface of the body, ulcerative absorption takes place, preceded 
by the adhesion of the tissues to be absorbed, so as to confine the pus within 
its destined route. At length, the whole of the parts intervening between 
the abscess and the cuticle being removed, this is ruptured, and the pus 
discharged. Along with it, are frequently discharged portions of solid matter, 
sometimes resembling membrane, though unorganized, and consisting proba- 
bly in chief of coagulated fibrin. 
Where a dense tendinous or fibrous fascia, which is of very difficult CHAP. I.] 
INFLAMMATION. 
31 
absorption, intervenes between the abscess and the surface of the body, or 
any other obstacle exists to the direct outward passage of the pus, this fluid 
frequently makes for itself a circuitous route, and often produces great mis- 
chief in its course, by occasioning the absorption of those textures which 
most readily yield to this process, as cellular substance, muscle, and even 
bone.' . • ; - • ■ 
Sometimes, instead of reaching the'surface- of the body, the abscess opens 
into one of the interior cavities, and commits great havoc by the inflam- 
mation excited in the parts with, which the pus comes into contact. Some- 
times, also,' the barrier of coagulable lymph, which usually confines it, is 
defective or altogether wanting; and the pus, escaping into the cellular tis- 
sue, travels to, a considerable distance, destroying, and, as it were, dissect- 
ing out that tissue from the midst of others which have greater power of 
resistance/ . ' , 
When an abscess is discharged,, it not unfrequently happens that the edges 
of the orifice are absorbed, and an. open ulcer produced. But an abscess, 
from which' the pus has a free, escape, is in no respect different from an ulcer, 
except in the greater protection which it enjoys from the action of the air. It 
presents a similar suppurating surface, and is filled up by a similar process 
of granulation. 
Gangrene and Mortification.-In the course.of an attack of inflammation, 
a portion of the diseased strpcWre sometimes loses its vitality, and passes 
from under the influence of physiological to that of chemical laws. This loss 
of life in a part is denominated mortification, the resulting condition gan- 
grene or sphacelus. Many writers, however, following Galen, make a dis- 
tinction between gangrene and sphacelus, applying the former term to the 
state which iinmediately precedes the absolute death of an inflamed part, the 
latter to that which exists after its death. There is some convenience in this 
division; as we frequently have occasion to refer to that condition in which 
mortification, though strongly threatened or inevitable, is not completely 
accomplished. But this condition is, in fact, nothing more than one of the 
phases of inflammation, and can- scarcely receive a distinct name without 
some confusion. In using the term gangrene, therefore, I shall consider it 
as applicable to parts already dead; though the epithet gangrenous may 
sometimes be employed as expressive of a state allied or approaching to 
gapgrene. - . -. . - 
The immediate cause of gangrene, in inflammation, is probably a dispro- 
portion between the excitement of 3, .part and its powers of vitality, the latter 
being entirely exhausted by a gteat excess of the former. If the life of a part 
is feeble, a comparative slight elevation,of its actions may produce its death; 
if vigorous, a great excess of excitement is requisite to this result. Whatever, 
therefore, weakens a part, or excessively excites it, may dispose to gangrene; 
and those parts are most liable to this condition which are naturally the weak- 
est. There are certain states of system, and certain diseases, which are cha- 
racterized by a universal reduction of vital power, and in which inflammation 
is very apt to run into mortification; and there appear to exist certain specific 
inflammations, which are much, more liable to this'.result than inflammation 
of the ordinary character. The blood also is Sometimes in. a condition which 
strongly predisposes to gangrene, probably because it is unable to afford those 
supplies, and that healthy stimulus, which are requisite to vigorous health. 
Gangrene, moreover, may occur from obstruction to the circulation in the 
capillaries of the inflamed part. 
The approach of gangrene, in parts that can be seen, is usually marked by 
sufficiently striking phenomena. The circulation, though it still goes on in 32 
GENERAL PATHOLOGY. 
[PART I. 
the larger vessels, is much more languid, and, in a portion of the capillaries, 
is nearly or quite suspended ; the colour becomes much darker, assuming a 
purple-red or even livid hue; the sensibility is in general diminished, though 
a sense of burning is usually experienced, and very severe pain sometimes 
immediately precedes mortification; the temperature is lessened; the tume- 
faction, though often somewhat augmented, is attended with a softness and 
flaccidity not before existing, and is .apt to'have a doughy feel; and a dark, 
bloody, turbid serum is effused into the interstices of the affected tissue, or 
upon its surface. Absolute gangrene is evinced by a total cessation of circu- 
lation, so that the part will not bleed if cut into, an entire loss of sensibility, 
a change of colour to black,.-grayish, or livid, and a loss of the natural heat, 
unless in so far as caloric may be supplied from the neighbouring parts. At 
a period after the death of the part, differing according to the degree of ex- 
posure to the air, the temperature, and the amount of fluids present, chemical 
changes take place, attended with the' evolution of fetid gases, constituting 
what is- commonly called putrefaction. In this condition, the tissues are 
very much softened, so as to be easily broken or torn, and havq their inter- 
stices filled and often distended with fetid gases, and with brownish, turbid, 
and offensive liquids. But putrefaction must not be confounded with morti- 
fication. The latter often takes , place a Considerable time before the former 
makes its appearance ; so that the absence of an offensive smell is no proof 
that mortification has not occurred. Still, as spontaneous decomposition be- 
gins sooner or later, and as parts which have entirely lost the ordinary signs 
of life, sometimes resume vital actions and return to health, it is safest, as a 
general rule, not to admit the existence of gangrene, unless some evidence of 
decomposition is presented. . ' 
Inflammation never ends with the occurrence of mortification, unless the 
patient dies at the same time. On the contrary; this process is necessary for 
the repair of the injury sustained. The mortified part is encompassed with 
a border of inflammation, which, in parts open to inspection, appears as a red 
line, dividing the living from the dead structure. The immediate cause of 
this inflammation is probably the excitement produced by the contact of dead, 
and therefore foreign matter. It speedily results in ulceration, by which the 
mortified part is separated, and, if upon the exterior surface, or a surface com- 
municating externally, is thrown off in the fofm of what is denominated a- 
slough. An ulcer is thus left, which presents a suppurating surface, and is 
filled, as other healthy ulcers, by granulations. An account of mortification, 
occurring from other causes than inflammation, will fall properly under another 
head. z 
Granulation and Cicatrization.-It has been stated that, after the forma- 
tion of sores by ulcerative absorption, after the opening of abscesses, and after 
the separation of dead parts from the living in cases of mortification, a pro- 
cess of repair is commenced, called granulation, by which the loss is supplied, 
and the diseased parts return to health. This consists in the effusion of co- 
agulable lymph upon the diseased surface, and the organization of this lymph 
into small, red, shining conical eminences, forming a new surface, which be- 
comes the seat of a similar action, and so on successively till the cavity is 
filled up to the due level. At least this is the view which appears to be 
taken by Hunter and Thomson. According to Macartney, however, though 
granulations may sometimes be formed out of effused coagulable lymph, they 
are usually the product of deposition and organization, going on simultane- 
ously, as in ordinary growth. The process is generally, if not always, accom- 
panied with the formation of pus, which covers, and in some measure protects 
the new and tender growth. It is a step in the progress of inflammation, CHAP. I.] 
INFLAMMATION. 
33 
which is now directed towards health. That the action is essentially inflam- 
matory, is proved by the elevation of the temperature above that of surround- 
ing parts, by the increased vascularity of the surface upon which the granu- 
lations form, and by the production of pus. 
Three conditions have been mentioned above in which granulation takes 
place. A fourth is presented by wounds, the surfaces- of which cannot be 
brought into contact, or, if brought together, fail to unite directly by the ad- 
hesive inflammation, or first intention. But this subject belongs exclusively 
to surgery. • ' ' v 
Granulations have a strong tendency to unite. Hence, when developed, 
they coalesce, producing a constantly increasing contraction of the granulat- 
ing .surface; so that, when the, process is completed, the extent of the surface 
is usually much less than at first. If, moreover, two granulating surfaces 
are brought into contact, they are frequently joined together by the union of 
the opposite granulations. This mode of union is called by surgical writers 
union by the second' intention, while to that in which the divided edges coa- 
lesce through a layer of coagulable lymph, without pus or granulations, the 
name of union by the first intention has been applied. As Mr. Thomson has 
correctly observed, there does not seem to be a great difference between these 
modes of union. Both are effected through the effusion and organization of 
fibrin; and the only distinction is that, in the one case, the fibrin assumes a 
grain-like form, and pus is secreted, while these.circumstances are wanting in 
the other. {Thomson on Infiam., 2d Am. edo P- 331.) This is not the 
place to consider the question whether, the edges of wounds, as has been main- 
tained, can unite by the first intention without inflammation. The solution 
of this question belongs to the surgical writer. The new structure, resulting 
from the granulating process, often resembles the one of which it is intended 
to supply the loss, but is seldom identical with it. It contains not only 
blood-vessels, but nerves and absorbents also; as is proved, in relation to the 
former, by the sensibility of granulating surfaces, and, in relation to the lat- 
ter, by the ulcerative absorption which frequently occurs in them. 
When, in the progress of the process of reparation, the granulations have 
reached the level of the neighbouring surface, they cease to grow, lose their 
granular aspect, become flat at top, and gradually cover themselves with a 
coating somewhat.analogous to that which had originally existed. By En- 
glish surgeons the name cicatrix is applied to this new superficial structure, 
and cicatrization to the process producing it. Thus, in the healing of ulcers 
upon the surface of the body, the formation of new skin is called cicatrization, 
and the new skin itself a cicatrix. Some of the French writers extend the 
signification of these terms much farther, including under the former the 
whole process of reproduction, and under the latter the whole of the new 
structure. There is a convenience in giving the term cicatrix such an exten- 
sion as to embrace those evidences which the union of separated parts, and 
the reparation of lost parts, leave behind to indicate their having taken place. 
We frequently have occasion to refer to such evidences, discovered after death 
in the . interior structures, and it is well to have a general name by which 
they may be designated. But the term cicatrization is here restricted to the 
process first alluded to. t 
Summary.-It may not be improper to present a brief summary of the 
course of inflammation, so that it may be taken in at one view. The first 
evidences of its existence, as a general rule, are unusual redness and heat, 
with pain and swelling in the part. The secretions are first increased, then 
diminished or suspended, and again restored with much alteration. The 
serum and fibrin of the blood are effused, with more or less of the colouring 34 
GENERAL PATHOLOGY. 
[part I. 
matter, and frequently blood itself little if at all altered. When the inflam- 
mation is completely established, the following condition, according to Gen- 
drin, usually exists. In the centre or focus of inflammation is effused blood, 
often coagulated and mingled with a viscid serum.; at a short distance from 
the centre is coagulable lymph, of a semi-serous, semi-gelatinous appearance, 
and a reddish colour, with a little blood disseminated in streaks; somewhat 
further, the fluid is more serous, and of a yellowish colour; and in the con- 
fines of the inflammation is a colourless serum. In this condition, the effused 
and coagulated fibrin becomes the seat of organic action, by which new blood- 
vessels are formed in its substance, which connect themselves with the pre- 
viously existing capillaries, and thus produce a sort of growth in the part. 
There is, at the same time, in acute inflammation, and generally even in 
chronic, a softening of the structure, so that it may be more easily torn or 
broken. Should the progress of the inflammation now cease, the redness, 
heat, pain, and swelling begin to abate, and gradually disappear, the effused 
fluids are absorbed, and the parts return to their former condition, except that 
some hardness is Occasionally left behind, especially in chronic cases, arising 
from the effused and organized fibrin. The inflammation is then said to ter- 
minate in resolution. Frequently, after a somewhat profuse secretion or 
hemorrhage, the inflammatory action ceases; and the same result occurs in 
those cases in which the coagulable lymph effused serves as the bond of a 
vital union between surfaces naturally distinct, or produced by violence. In 
the former case, the inflammation is said to terminate in effusion, in the latter, 
in adhesion. It is obvious, however, that the effusion and adhesion are mere 
effects of the inflammatory action, and should not be considered as its termi- 
nations. 
Should the inflammation persist, a new condition of things • denominated 
suppuration takes place. The redness diminishes, the softness increases, and 
pus gradually mingles with the other fluids, or takes their place upon the 
surface, or in the interstices of the tissue. In the latter case, portions of the 
tissue are broken down, and either absorbed, or dissolved in the pus, which is 
usually collected in cavities; while, in the parts around these cavities, coagula- 
ble lymph exists, as in the earlier stage, and forms a barrier to the diffusion 
of the purulent liquid. These cavities are called abscesses. By means of 
ulcerative absorption, a passage is then made for the pus externally. Some- 
times absorption takes place in an inflamed part, producing an open sore, 
which is then called an ulcer, while the process is denominated ulceration. 
Sometimes a portion of the affected tissue or tissues undergoes mortification, 
or, in other words, loses its life, and is separated from the' other parts by 
absorption, leaving an open and suppurating ulcer. According as one or 
another of these various conditions is presented, the inflammation is said to 
terminate in suppuration, ulceration, or mortification. But the fact is, that 
these are mere incidents in the progress of inflammation, wdiich in the first 
two persists during their whole course, and in the last continues in the parts 
which have not lost their life, and is necessary for the separation of the dead 
parts. Neither of these, therefore, can strictly be considered as terminations 
of inflammation. 
The cavities of abscesses and ulcers, as well as those left by the sloughing of 
mortified parts, are filled up by a growth of granulations, which, when completed, 
cover themselves with a kind of skin or membranous structure, or in other words 
undergo cicatrization. Granulation and cicatrization have been considered as 
terminations of inflammation; but with as little reason as the phenomena or 
actions above alluded to. They are merely the last acts of this complicated CHAP. I.] 
INFLAMMATION. 
35 
process, which cannot legitimately he said to have any other termination than 
in resolution, that is, spontaneous subsidence, or in death. 
Such is the usual course of inflammation, so far as regards the parts in 
which it is seated. The period occupied by this course is exceedingly variable. 
Sometimes it is accomplished in a few days, and possibly in a few hours, 
sometimes' it requires weeks, months, or -even years ,for its completion. When 
protracted, it is denominated chronic inflammation, which is for the most part 
a mere continuance of an acute attack in a mitigated form, though not un- 
fre'quently the grade of excitement is at the commencement scarcely higher 
than that which is sustained throughout. 
Chronic inflammation is susceptible of all those diversities of action which 
have been already mentioned as characteristic of inflammation in general, 
though it is less apt to be attended with gangrene. There is frequently little 
or no observable increase of redness or heat, the pain is less than in the'acute, 
and the tumefaction differs often in being attended with induration instead of 
softening of the tissues. It owes its protracted duration usually to one of two 
circumstances, either to the continued operation of the cause, as where chronic 
gastritis is sustained by the7 habitual use of stimulating drinks, or to the exist- 
ence of some peculiar diathesis, • as the scrofulous, which predisposes to a slow 
march of the inflammation. The nature'of the part also has some influence, 
certain parts being more" disposed to the chronic form than others. There is 
no precise boundary line between the two states of inflammation. 
Some writers make a grade of inflammation between the acute and chronic, 
which they call subacute inflammation; and this term is convenient, as ex- 
pressive off' a condition in which the morbid action exceeds but little that 
which occurs in the chronic form, but is of a comparatively short duration, so 
that the case cannot come under this denomination, while it is excluded from 
that of the acute by the mildness' of its symptoms. 
Sometimes inflammation-runs its accustomed course, so far as relates to its 
effects upon the texture in which it is seated, with scarcely any of those evi- 
dences by which its existence in the interior parts of the body are usually 
detected, such as pain, disordered function, and constitutional disturbance. 
Under these circumstances, it is said to be latent, and often escapes attention 
until serioris injury has been inflicted. This is most apt to occur in. persons 
with little excitability of system, arising either from original constitution, 
from modes of life, or from previous disease. According to Dr. Alison, it is 
more frequent in the black than in the-white, in the old than in the young, 
in the poorly fgd than in those of luxurious habits; and is not uncommon 
in convalescents from acute diseases. Sometimes, however, the absence of 
pain and other obvious symptoms is<'ascribable to the simultaneous existence 
of some other disease which bluntsi or destroys the sensibility, as typhoid 
fever, for example, and paralytic affections. 
7. Effects of inflammation beyond its primary seat.-Our atten- 
tion has hitherto been directed to the local phenomena of inflammation. But 
its effects are by no means confined to its original seat. If severe or extensive, 
it always involves other parts, or the system at large, in disorder. As the 
functions of the inflamed organ are impaired or suspended during the exist- 
ence of the inflammation, other dependent or connected functions must neces- 
sarily suffer; and this is a fruitful source of derangement. The physician 
should always be on his guard upon this point; as it is by the observation 
of these secondary effects alone that he is, in some instances, enabled to trace 
inflammation to its real seat; and the effects themselves occasionally require 
his interference for their relief. Again, the vitiated products of an inflamed 
organ often occasion disorder in the parts with which they come into contact; 36 
GENERAL PATHOLOGY. 
[part I. 
as when' the acrid bile from an inflamed liver produces diarrhoea by irritating 
the mucous membrane of the bowels, and acrid urine from the inflamed kid- 
neys occasions irritation throughout the urinary passages. But, independ- 
ently of these sources of derangement, inflammation produces other very 
important effects beyond its immediate seat, which I shall now proceed to 
notice. 
Effects upon the Blood.-The character of the blood is considerably modi- 
fied during inflammation. The most striking result of the change is the pro- 
duction of that peculiar appearance called the huffy coat. This is a whitish, 
or yellowish-white, and sometimes greenish stratum, which is formed upon the 
upper surface of the blood during coagulation. Soft and viscid at the com- 
mencement of the coagulation, it is fully formed when the clot begins to con- 
tract and separate from the sides of the vessel, but does not attain its greatest 
density till the contraction of the clot is completed. It is then firm, elastic, 
diaphanous, strongly adherent to the cruor beneath, and shining upon its 
surface., which is often elevated at the edges and depressed in the centre, 
giving it what has been called a pupped appearance. Sometimes the coating 
remains soft, and of a gelatinous consistence, like size; and hence the blood 
which exhibits it is sometimes called sizy Ijlood. The huffy coat consists of 
fibrin with some serum mechanically intermingled. The proportion of fibrin 
in the clot beneath is much less than in the crust; and sometimes, when the 
latter is thick and firm, the remainder of the clot is very soft, and apparently 
consists almost exclusively of red corpuscles. 
It is a question how far .this appearance is characteristic of inflammation. 
Though very generally presented by the. blood of patients labouring under 
that affection, it is in some instances wanting; and it has been observed 
where no inflammation existed/as in the .advanced stages of pregnancy, and 
in cases of anaemia, in which^the proportion of red corpuscles is deficient in 
relation to the fibrin. But, with these exceptions, it may be considered as a 
sure evidence of inflammation. Out of eighteen hundred cases in which the 
blood was examined by Andral, it never had the huffy coat except in inflam- 
mation or anaemia. The cause of the huffy coat was conjecturally referred by 
Hunter to a slower coagulation of inflammatory blood, allowing the red glob- 
ules to subside in some measure before the clot was formed; and he inferred 
from an experiment, that the red globules themselves are heavier in inflam- 
matory than healthy blood. Gendlin, however, asserts that in the blood of 
inflammation the coagulation begins sooner, and is sooner completed than in 
that of health; and, though this is not. universally.true, it certainly is so 
occasionally in cases which exhibit the huffy coat. Yet from numerous expe- 
riments of this author it may be inferred, that whatever causes a more rapid 
coagulation of inflammatory blood interferes with the formation of the huffy 
coat, and that, when it coagulates very speedily, this coat is not exhibited, 
because the red globules have not the opportunity to subside before they are 
firmly embraced by the fibrin. Thus, when blood issues drop by drop from 
the orifice, or falls a great distance through the air, or is received in shallow 
or refrigerated vessels, it is less apt to show the buffy coat than under opposite 
circumstances; and, if agitated continually as it falls into the recipient, it does 
not exhibit the coat at all. The inflammatory crust is most striking when the 
blood is received in a deep, narrow, cylindrical vessel. 
It not unfrequently happens, that the first blood drawn in an inflammatory 
case is destitute of the buffy coat, while the portions subsequently taken 
exhibit it strongly. At the same time that the clot presents this appear- 
ance upon the surface, it is usually less bulky and firmer than in health, 
owing probably to the greater contractility of the fibrin. CHAP. I.] 
INFLAMMATION. 
37 
It has .been satisfactorily shown by the experiments of Andral and Gravar- 
ret, that the proportion of fibrin in the blood is very generally if not always 
augmented in inflammation, when, sufficiently severe or extensive to affect the 
system. From three parts in a thousand; which is the average proportion in 
health, it rises in ordinary qases to six or eight, and in some to nine or even 
ten parts. The increase commences-as soon as the inflammation is established, 
and ceases only when the process begins to decline. Even in anemic cases, 
and in low fevers in which the tendency of the disease is to a diminished pro- 
portion of fibrin, this principle becomes ^abnormally abundant when inflamma- 
tion supervenes. With the increase-of fibrin, the proportion of the red cor- 
puscles remains unaffected. It has before been stated that, according to some 
experiments, the albumen is diminished; a result which, if true, may be 
reasonably ascribed to its conversion into' fibrin.. There can be little doubt 
that the formation of the buffy coat is connected with this excess of fibrin. 
Hence it is often not observed in thh first portion of blood drawn early in the 
disease, because the fibrin is not yet sufficiently abundant. In anaemia, the 
only other disease in which the buffy coat is observed, though the quantity of 
fibrin may be abnormally small, it is yet generally if not'-always in excess in 
relation to the red corpuscles. According to, Andral, the fibrin newly formed 
in inflammation coagulates more slowly than the old. (Patholog. Haematol., 
Am. ed., p. 61.) 
Singular changes . are detected in the blood by means of the microscope 
during inflammation, connected no doubt with the increased production of 
fibrin. The'colourless globule's, called .lymph globules by Muller, which are 
said by Williams to be " pretty good representatives of the proportion of fibrin 
in the blood," (^Princip. of Med., Am. ed., p. 131,) are obviously increased 
in number, and may be'seen, after the application of an irritant to the part 
under examination, to move more slowly than the general current of the blood, 
as if from a tendency to adhere to the inner surface of the blood-vessels. 
These globules appear to be, nucleated, and to bear a close resemblance to 
those which are seen in the extravasated fibrin, called exudation corpuscles. 
They are also seen in the matter of the.buffy coat, while yet liquid. When 
this begins to Coagulate, fibrils form, which increase with great rapidity, inter- 
lacing among each other, and at length giving a solid consistence to the mass. 
It is most probable that the increased proportion of fibrin is generated in the 
inflamed vessels, and that the whole inass'becomes affected, in consequence of 
the constant passage of the blood which has been thus- altered into the general 
current. n 
In cases of indirect prostration, consequent upon great intensity of inflam- 
mation, the blood first drawn may be without the buffy coat, though it after- 
wards becomes sizy when the pulse and the heat of the surface rise, as they 
often do in such cases, under the use of the lancet. But, even at first, it is 
very different from the blood of patients in the direct debility of malignant or 
gangrenous diseases. In the former, though the clot forms slowly and is not 
dense, it is quite distinct from the serum; while in the latter, the serum is 
coloured by a blackish matter which subsides to the bottom of the vessel, and 
the clot is often completely dissolved, or not at all formed. 
Though, the increase of fibrin, and the .appearance of the buffy coat, are 
incident to inflammation in all parts of the body, they are most striking in 
acute articular rheumatism and pneumonia. 
Effects upon particular Organs.-It has already been stated, that the in- 
terruption or disturbance of function in any one organ, occasioned by inflam- 
mation, necessarily produces derangement in other associated or dependent 
functions. Another source of disturbance, in organs not immediately the seat 38 
GENERAL PATHOLOGY. 
[part I. 
of inflammation, is the concentration of the circulating fluids and nervous 
energy in the part affected, which leads to a deficiency of these vital agents 
elsewhere. This subject has been Considered under the head of irritation. A 
third source of disorder is the sympathetic -connexion between different parts 
of the body, by which a derangement in one is directly followed by derange- 
ment in another, independently of any peculiar relation between their func- 
tions. Thus, inflammation of the kidneys imparts irritation to the stomach, 
through such a sympathetic connexion, without any instrumentality of the 
altered function of the former organ. This is not The place to speak of such 
effects; as they may be more advantageously treated of under the heads of 
the phlegmasia of the several organs or structures respectively. It may, 
however, be proper here to mention, that the sympathetic affection may either 
amount to inflammation, or, as very often happens, may not exceed the grade 
of irritation. Positive inflammatory -action is most readily communicated, as 
a general rule, to organs in the immediate neighbourhood of the part first 
affected. In spreading, it makes its- way with greatest facility through iden- 
tical and continuous structures; as: from one point in the skin to the surround- 
ing parts of the skin, from a particular spot in a membrane to the surround- 
ing parts of that membrane, and from a point in arteries-, veins, or absorbents, 
along the course of these vessels -respectively. It passes also readily, though 
less so than in the former case, between connected but distinct structures, as 
from the skin to the cellular membrane immediately beneath it, and from the 
investing membranes of the viscera to the adjacent parts of the viscera them- 
selves.. Contiguous parts are, moreover, very liable to this direct communi- 
cation of-inflammation, as in^the instances of the opposing surfaces of the 
pleura or peritoneum, in which inflammation very often passes from one to 
the, other, without travelling through the long tract of membrane which con- 
nects these surfaces. When distant parts are syinpathetically affected, the 
secondary disorder is very apt to stop short at the point of irritation, though 
it not unfrequently amounts to inflammation. 
Constitutional Effects. - Symptomatic Fever. - When inflammation has 
attained a certain, degree of intensity or, -extent, it always brings the whole 
system,into derangement, causing that general condition which has been de- 
nominated, fever, and which, occurring under these circumstances, is distin- 
guished by the name of symptomatic fever. This general derangement may 
be in great measure attributed to that interruption,of associated or dependent 
functions, that irregular distribution of the circulating fluids and nervous 
energy, and that sympathetic affection of proximate and remote organs, which 
were alluded to in the preceding paragraph as among the results of inflamma- 
tion. It may in part also be ascribed to the changed condition of the blood; 
and it has been observed, that the excess of fibrin uniformly appears when 
the inflammation is sufficient to produce fever, and disappears when the fever 
ceases (Andralf But there is probably some further, and yet unexplained 
mode of action, by which fever is produced as a consequence of local inflam- 
mation. The charactor of the fever varies exceedingly , with the grade-and 
stage of the inflammation, the- nature of the cause producing it, and the pre- 
dispositions of the patient. It partakes, indeed, of all those diversities which 
are incident to fever arising from other causes. Thus, in relation to its type, 
it may be intermittent, remittent, or continued; in relation to the state of the 
constitutional forces, it may be sthenic, asthenic, or .of any intermediate con- 
dition; and, in relation to its grade, it may present every'shade of diversity 
from a scarcely appreciable derangement, to the most fatal malignancy. A 
detailed account of these various forms would be premature in this place. 
(See Fever^ It is sufficient here to say, in addition, that when the inflam- CHAP. I.] 
INFLAMMATION. 
39 
illation is severe and sudden in its onset, the constitutional symptoms generally 
make their appearance very speedily, andmr'e often, so far as can be observed, 
simultaneous in their commencement with the inflammation. In subacute 
and chronic inflammation, the fever is much less than in the acute, and is 
sometimes quite wanting; and the^same is the crfse in those instances in which 
the inflammation is, said to be latent. If the onset of fever should precede 
that of inflammation, as sometimes happens, the former cannot properly be 
considered as symptomatic of the latter. In this case, either the inflamma- 
tidn is the consequence of the fever, or both have, the .same cause. 
' Hectic Fever.-The advanced stages of inflammation are frequently attended 
with a peculiar morbid condition of system, which must be noticed here; as 
no other opportunity will be offered of giving it a distinct consideration. I 
allude to the affection denominated hectic fever (from (turns, habitual). It 
is not usually met with until after suppuration has taken place, and is much 
more common in the chronic than in the 'a<cute form of the disease. It scarcely 
deserves the' title of fever, as the term is defined in this work; for it wants 
the universality which characterizes that affection. (See' Fever.) Thus, the 
functions both of the stomach find brain are often unaffected; and the only 
derangements essential to it are those, primarily, of the circulation and calori- 
fleation, and secondarily, of secretion and nutrition. At all events, it is but 
an imperfect fever. It usually begins with increased frequency of pulse and 
heat of skin, oeburring generally towards evening, and subsiding before the 
beginning of the next flay. The heat'is especially felt in the hands and feet. 
After some time, the excitement of pulse continues, in a greater or less degree, 
through the day, with exacerbations in the evening, At length, decided 
paroxysms . occur, often preceded by chills, and subsiding with perspiration, 
though both of these accompaniments are. not unfrequently wanting. Gene- 
rally, there is only a remission of excitement between the paroxysms; but 
sometimes, a perfect intermission. The paroxysms usually occur daily, some- 
times in the morning after breakfast, but more frequently in the evening, 
when they are copimonly most severe. Occasionally they occur twice a day, 
and not unfrequently cease for a considerable time, to return with their former 
Violence. They are very irregular. 
When the hectic is fully formed, the pulse is generally very frequent, often, 
during the paroxysm, as much as 120 in the minute, and, even w'hen not fre- 
quent, is rendered so by slight causes. It has little strength,.but the beat is 
often quick, jerking, and as.if the result of irritation upon a weakened heart. 
The heat of skin during the paroxysm is Considerable, and sometimes distress- 
ing, though often unequal; the respiration is 'hurried, the face flushed, the 
eyes sparkling, and the whole surface dry. There are also dryness of the 
throat, and thirst. The appearance of the face is often highly characteristic. 
With a general paleness, there is a bright red and hot uflfi'equently circum- 
scribed flush upon the cheek, such as is apt to occur in delicate persons when 
they lie with the cheek upon the hand, or pressed against any other hard 
body. This is the more striking from its- contrast with the clearness of the 
conjunctiva, and the whiteness of the-rest of the skin. Another characteristic 
of the affection is a tendency to copious perspiration at night, especially towards 
morning. This often happens whether the patient sleeps or not; but is usu- 
-ally most abundant during sleep. It show's itself especially upon the head 
and upper part of the body. The urine is for the most part scanty and high 
Coloured, and sometimes deposits sediments, though it varies much in all these 
respects. The appetite is usually unimpaired, unless the stomach is the seat 
of the local disease. Sometimes it is even increased. The tongue is often 
clean; but is apt tef be smooth, especially in the last stage, when there is not 40 
GENERAL PATHOLOGY. 
[part I. 
unfrequently .a tendency of the whole mucous membrane of the mouth and 
fauces, to throw nut an aphthous exudation. The-affection is seldom attended 
with delirium,, or other signs of cerebral disturbance; and there is a remark- 
able exemption from nervous symptoms of all kinds, except such as result 
from debility. 
The patient in general loses flesh rapidly, and towards the close becomes 
exceedingly emaciated. Not unfrequently he is affected with diarrhoea at this 
stage; and the extremities, especially.the- feet and legs, are apt to be edCma- 
tous. The hair frequently becomes very thin, and the' finger nails curve for- 
ward at the ends. With all the exhaustion and loss of flesh, the patient is 
often enabled to sit up much of the time until very near death. At length, 
however, the strength is completely worn out, and life closes-, frequently with- 
out a struggle. Occasionally the mind gives way a little before death, in con- 
sequence, probably, of excessive-weakness. The duration of hectic fever is 
altogether indefinite, depending on the progress of the complaint producing it. 
Its march, however, is. almost always slow. It usually terminates fatally in 
consequence of the incurable nature of its cause; but it not unfrequently also 
ends in recovery. 
There has been much difference of opinion as to its cause. It is said some- 
times to occur as an original disease; but this is not probable; and, cages sup- 
posed to be idiopathic, have been afterwards traced to local affections. It is 
sometimes imitated in pure debility; but some of the features of the affection 
are almost always wanting. In all genuine cases, the union of general debility 
with' some local inflammatory affection may be detected. It would seem, 
then, to consist of the effects of a powerful irritation, acting upon a feeble 
frame. But is there not something more? In the vast majority of cases, the 
local affection is attended with suppuration;' and the supposition has been 
entertained, not without sbme show of reason, that the absorption of pus con- 
stitutes an essential part of the affection. It is asserted, however, that it 
sometimes results from great masses of local disease, as scirrhus, for. example, 
in which there is no pus. It is not confined to bases of disease affecting the 
interior structure of organs, but may result also from chronic inflammation 
with suppuration of surfaces, as of the .bronchia, bowels, urinary passages,'and 
skin. \ j . 
8. Fatal Effects of Inflammation.-Inflammation may prove fatal in either 
of the following modes. 1. It may suspend the action of the organ, in which 
it may be situated, and the due performance of -whose, function may be essen- 
tial to life. 2. By deranging the condition of a particular organ, it may pre- 
vent the due action of another and vital organ, as where inflammation closes 
the rima glottidis, and, by .thus preventing the access of air to the lungs, gives 
rise to fatal asphyxia. 3. When of great violence or extent, it may in such 
a manner affect the circulatory forces as completely to cramp them, and thus 
produce a fatal issue by a species of syncope; as we sometimes see in cases of 
peritonitis and severe dysentery, in which the heart beats with exceeding fee- 
bleness, and the skin is cold almost from the commencement, of the disease. 
4. It may elaborate products which, being absorbed or in some other way 
entering the circulation, may produce by their sedative agencies a typhoid 
condition and general prostration which shall end in death, as happens in 
inflammation of the veins, when pus is canoed into the general mass -of the 
blood. 5. Death frequently results from the debility induced by long con- 
tinued or extensive suppuration, or by gangrene in the inflamed part. 6. 
We can readily conceive, moreover,, that the constitutional excitement result- 
ing from inflammation, either from its great excess, or its long continuance, CHAP. I.] 
INFLAMMATION. 
41 
may be succeeded; by a collapse from which it may be impossible to rescue the 
patient. . \ 1 p ■ 
The appearances which inflammation leaves behind it after death will be 
most conveniently considered elsewhere. I will here merely state that these 
appearances are sometimes deceptive. It has been asserted that inflammation 
may prove fatal without leaving the ordinary traces behind it; the blood 
deserting the vessels at the point of death, or subsequently. But this may be 
considered as somewhat doubtful. It is .certain, however, that appearances 
closely resembling inflammation, so far as relates to congestion of the capilla- 
ries, or effusion of blood, are often presented in the bodies of those who have 
died a violent death, though previously in the full enjoyment of health; and 
much care is necessary not to confound such appearances with those of a real 
inflammatory origin. 
2. Nature of Inflammation. 
Microscopic Observations.-Before entering upon a consideration of the na- 
ture of inflammation, we shall find .advantage in referring to the results ob- 
tained by a microscopic examination of the process. Numerous observers 
have submitted inflamed parts, to such an examination, among whom may be 
particularly mentioned Wilson Philip, Thomson, Hastings, Gendrin, Kalten- 
brunner, and more recently, Gerber, Muller, Gulliver, Addison, and Williams. 
Although there is some diversity in the statements of these writers, yet on 
the whole the following' facts may be considered as pretty well established. 
The experiments were made upon the web of a frog's'foot, or other delicate 
structure which admitted the passage of light. 
Whenever a part is irritated, either mechanically or by a stimulant sub- 
stance, the capillaries are variably affected in relation to their diameter, being 
sometimes diminished in size, according to the observation of Wilson Philip and 
Hastings, sometimes immediately expanded, as from the application of salt in 
the experiments of Thomson, and sometimes apparently unaltered at first, as 
may be inferred from the statements of Gendrin. If not immediately dilated 
upon the application of the irritant, they very soon become so; and it is not 
till the occurrence of dilatation that the appearances of inflammation are pre- 
sented. Soon after the capillaries have begun to dilate, the current of blood, 
which was at first accelerated; becomes slower, at least in some of the .vessels; 
its movement appears to be uncertain or oscillatory; its direction is even in- 
verted ; and there seems to. be a convergent flow of the blood towards the 
point of irritation. Gendrin states that, if ^ needle be passed through a capil- 
lary in which the globules are seen to move, they instantly retrograde towards 
the place of puncture. Another phenomenon is one before alluded to, the ap- 
pearance, namely, of numerous colourless corpuscles, the lymph-globules of 
Muller, which seem to have an affinity for one another, and for the inner sur- 
face of the tube, along which they roll"slowly, and to which many of them 
adhere. Whether this adhesion arises from a vital attraction, or a mere me- 
chanical viscidity, has not been ascertained. In some instances, they accumu- 
late so largely as to block up the tube, and prevent the passage of the red 
corpuscles, though the colourless portion of the. blood may percolate through 
them. The retardation of the flow of blood becomes more and more deci4ed, 
until at length a complete stagnation takes place in some of the vessels, while 
in others the circulation continues, and in some of the larger may go on with 
a greater velocity than in health. In those instances in which the capillaries 
first contract under stimulation and afterwards expand, a reapplication of the 
stimulant, after the dilatation of the vessel and retardation of the blood, will 
produce again a temporary contraction, and a more rapid current, to be again 42 
GENERAL PATHOLOGY. 
[part I. 
followed by dilatation. In such a case, the original action of the irritant, in- 
stead of producing immediate redness^ cafises the part to be even paler than 
before; but the subsequent dilatation is accompanied by redness, which disap- 
pears when contraction is again produced, to return once more when the vessels 
expand. If now the stagnation persists, the blood, according to Hastings, 
assumes a darker colour, the capillaries are still further dilated, the part be- 
gins to soften, and at length portions appear to be detached, and a greater or 
less loss of substance is exhibited. By the same observer, the divided vessels 
around the solution of continuity were seen to pour out a whitish substance, 
in the midst of which new capillaries were formed, which connected themselves 
with the vessels previously existing. Other observers have discovered^ in the 
exuded lymph or fibrin, numerous granules, organized corpuscles (lymph- 
globules), and'fibrils, which appear to be the germs of the new growth. 
■ Theories of Inflammation.-Two opposite opinions have of late divided 
pathologists. Both parties admit that the capillaries are dilated/and-contain 
a larger amount of blood than, in health; but they differ widely as to the state< 
of action in the capillaries'. By one party it is maintained, that these vessels 
are in a state of increased actidiq at least in the early stage of the inflamma- 
tion, and that the phenomena are the direct result of an excessive exercise of 
the vital properties of the part affected; by the other, that they are in a con- 
dition of debility, at least in relation to the larger vessels from which they are 
derived, and that their expansion is the result of a loss of balance between the 
resisting force of the capillaries anchthe 'Dis a tergo. The former opinion,, sug- 
gested by Van Helmont and Stahl, was adopted by Haller, Cullen, Hunter, 
Bichat, and most of the other great pathologists of the past and present age, 
and perhaps still continues predominant; the latter was put forth by Vacc'a 
at Florence so early as 1765, was afterwards advocated by several pathologists, 
and especially by Mr. Allen, of Edinburgh, in his lectures; but did not attract 
general attention, till adopted and maintained by Wilson Philip, whose mi- 
croscopic observations appeared to give it support. 
The doctrine of debility of the capillaries maintains that, in'every case of 
inflammation, these .vessels, weakened either directly or indirectly by the cause 
of the .affection, become relaxed, and yield to the distending force with which 
the blood is sent into them' by the heart, or the arterial trunks from which 
they proceed. They are thus dilated, admit a larger quantity of blood, and 
give rise to the red colour which characterizes the onset of the inflammation. 
According to Wilson Philip, at the same time that the capillaries are debili- 
tated, the arteries by which they are supplied are stimulated to increased 
action, so that the disproportion between the resistance and power is still fur- 
ther augmented. The blood necessarily movds more slowly through the dis- 
tended vessels; and thus the retardation of the current in the capillaries, visi- 
ble by the microscope, and the increased action of. the arterial trunks leading 
to the inflamed part, which is obvious to the naked eye,-are equally accounted 
for. The advocates-of this doctrine, admitting -contractility as the only active 
vital property of the blood-vessels, maintain that it is impossible tb explain 
the phenomena of inflammation upon the principle of increased capillary action. 
The only mode, they assert, in which the capillaries-can evince increased action 
is by increased contraction; arid - this, so far from causing a slower flow of blood 
and increased redness, must? necessarily produce the opposite results of a more 
rapid current and greater paleness. These, they say, are the conditions actu- 
ally exhibited under the microscope, upon the application of certain stimulants. 
The expansion of the vessels which follows, and which is the first stop of in- 
flammation, results from the debility or relaxation consequent upon the ex- 
haustion of their excitability by the previous ' stimulation. When dilatation CHAP. I.] 
INFLAMMATION. 
43 
of the vessels immediately follows the application of the cause, it is to be 
ascribed to the immediately debilitating influence of the cause; for the ex- 
istence of a vital expansive property is, altogether denied by the advocates of 
this hypothesis. - ' • ' ' .Yr 
It appears to the author that this theory of inflammation, however ingenious, 
fails altogether to account for the retrogression of the blood which is observed, 
by aid of the microscope, in parts irritated and reddened. Were the expan- 
sion merely an effect of tiie pressure from behind, operating upon a diminished 
resistance, the increased capacity should be filled by the forward current of the 
blood, and not by a retrograde movement in the vessels beyond. Besides, if 
the dilatation be a result of debility or relaxation of the vessels, the greater 
the debility the greater should be the dilatation, and a loss of 'all vital power 
of resistance in the capillaries should be attended with the greatest possible 
amount of distension. But the reverse is the fact. When, by the operation 
of some powerful cause, the capillaries of a part of the body lose all or nearly 
all their vital poWer, instead, of dilatation and-consequent redness, we have pale- 
ness and a diminished supply of blood, which with difficulty penetrates the 
vessels. Such, for/ example, is the result of a violent blow paralyzing for the 
moment the vessels of the part. It js true that reaction may subsequently 
come on, and symptoms of inflammation make their appearance; but, in this 
case, the vital powers rise by their temporary suspension into increased energy, 
and the vessels cease to be in a state of debility at the moment when they 
begin to expand. Yet another difficulty in the way of this hypothesis is 
the direct, occurrence of expansion upon the application of certain irritants, 
as of common salt in the experiments of. Thomson, and of the point of a 
needle in those of Grcndrin. Why one irritant should produce direct debility 
of the vessel, while another produces the saine state indirectly, through the 
medium of a previous excitement, the theory does not satisfactorily explain. 
It will be inferred, from what has been said, that the author is inclined to 
the opinion which considers inflammation as the direct result of an increased 
vital action in the part affected. I shall proceed to state the grounds upon 
which this opinion is based, and some of the arguments which may be ad- 
duced in its support. In the first place, the theory of increased action requires 
the admission of a power of action in the capillaries, to a certain degree inde- 
pendent of the heart. The, existence of such a power is denied by some; but 
the arguments adduced in its favour appear to the author incontrovertible. 
This is not, however, the proper place for the discussion of that question, 
which belongs to works on physiplogy, to which the reader is referred. (See 
also Thomson on Inflammation.') 
The nature of the causes from which inflammation results would appear to 
indicate its active character. These, are almost always such a's, if applied in 
a moderate degree, produce merely a healthy excitement of the part, or ah 
exaltation of its ordinary functions, and give rise to inflammation only when 
the increased action has proceeded so far as to occasion obvious organic de- 
rangement. We see various degrees of excitement, in proportion to the 
amount of the cause applied, from the slightest increase of the healthy 
function up to inflammation; nor is it possible to say where, in the ascending 
scale, merely healthy excitement ends in irritation, or this in inflammation. 
Why should we suppose that, in this regular ascent, the nature of the action 
changes at once when evidences of its inflammatory character are presented? 
The following facts may be considered as evidences of the active character 
of inflammation. The artery supplying the inflamed part beats with greater 
force, an^, if divided, sends out the blood to a greater distance than in health. 
Although in some of the capillaries the circulation is retarded or even sus* 44 
GENERAL PATHOLOGY. 
[PART I. 
pended,, yet the whole quantity of blood entering and leaving the inflamed 
part in a given time is increased. It is asserted that when one hand is 
severely inflamed, the quantity of blood returned in a given time by the veins, 
is three or four times greater than that returned by the veins from the other 
hand. (Alison, in Tweedies Syst. of Praci. Med.} The ordinary pheno- 
mena presented in the early stages of inflammation are those which would be 
expected from an increased exertion of the vital power. Thus, we have in- 
creased heat, which can hardly be ascribed exclusively to the blood accumu- 
lated in the part in consequence of the expansion of the vessels; as there is 
reason to believe that the temperature exceeds that of. the blood before its 
arrival, especially in parts distant from the Centre of .circulation. It must, 
therefore, result from a more energetic exercise of that vital fuhetion which 
generates or evolves animal heat. , The - increased secretion which attends the 
earliest stage of inflammation, the new products which are' copiously elimi- 
nated in the more advanced stage, the exalted sensibility of the part affected, 
and the rapid generation of new structure, are all results which seem to imply 
either an elevated condition, or more vigorous exercise of the vital properties. 
The influence of topical remedies of a sedative character, such as cold and the 
preparations of lead, in relieving inflammation, affords further evidence to the 
same effect. 
The sudden expansion of the capillaries in inflammation has been con- 
sidered one of the greatest obstacles in the way of the theory of increased 
action. It is asserted that these vessels have no other active property than 
contractility, that it is only by yielding to pressure thatthey can be expanded, 
and that their dilatation therefore is a proof of their debility or relaxation, 
or at least of a diminution of their power of resistance compared with the 
force applied to them. But there is . no proof that the capillaries are not 
possessed of an active power of dilatation. The assertion that they have 
no such power is pure assumption. Its. existence rests on the same evidence 
as that of vital contractility. Two stimulants are applied, of which one is 
followed immediately by contraction, the other by dilatation of the capil- 
laries. We have as much right to assume • that the latter, is active as the 
former. We have been too much in the habit of considering visible contrac- 
tion as the result exclusively of muscular action. The existence of a mus- 
cular coat has not been proved in the capillaries, and there is no necessity to 
assume its existence. We can as easily conceive that, under a certain modi- 
fication of nervous influence, the succession of particles which may be con- 
sidered as constituting a circular ring - of a capillary tube, may approach 
each other so as to produce contraction, as if this were effected by a muscular 
fibre; and there is no greater difficulty in conceiving that, under a different 
modification of the same influence, the particles may repel or recede from 
each other, and thus produce dilatation. The nervous influence has been 
considered as strongly analogous to the galvanic. Now there would be no 
great difficulty in so arranging a circle of minute objects, as to cause them 
to approach or recede from each other, in other words to produce a contrac- 
tion or dilatation of the circle,, by a varied electrical current. The same 
result may take place in the living capillary, under a diversity of nervous 
influence, brought into play by diversity in the- circumstances of irritation. 
In both cases, in that of dilatation as well as that of contraction, the phe- 
nomena would be equally the result of a vital property called into action. 
There is no impossibility, therefore, in the existence of a vital active power of 
expansion. 
Admitting the existence of such a power, we shall find it very convenient 
in the explanation of various phenomena, physiological, as well as patholo- chap, i.] 
INFLAMMATION. 
45 
gical, which cannot otherwise be well accounted for. Blushing; determi- 
nation of blood to the head under the influence of certain mental emotions; 
the sudden expansion of the erectile tissues under- local or mental excitement; 
the sanguineous congestion of organs which have become the seat of a new 
or renewed vital action, as of the uterus in gestation, and the mammae in lac- 
tation; the analogous congestion of parts called into an increased exercise of 
their habitual function, as of the stomach during digestion, of the muscles 
during energetic contraction, of the secretory organs in inordinate secretion, 
and of any part whatever during rapid and unusual growth; these and other 
phenomena, in which an accumulatiqn of blood in the capillaries is exhibited, 
at the same time that these vessels are stimulated to -a more energetic per- 
formance of their proper office, would ^eem to imply that the dilatation, by 
which alone the congestion can be effected, is. of an active character. The 
cause of the congestion cannot exist in the heart or larger trunks; for an 
increased action of these organs would be felt equally in all parts of the body, 
and very often they remain perfectly tranquil during the occurrence of the 
local phenomena mentioned. The pperation is entirely local. The cause of 
excitement is applied; the capillaries dilate; and the blood rushes into them 
in .increased quantity under-the influence of atmospheric pressure. Hence 
the flow of blood to any part or organ which is excited by a stimulant to a 
more rapid or energetic performance of its office. Hence the retrograde 
movement of the current in the capillaries, and the general direction of the 
blood for the moment towards the centre of irritation,-and the seat of expan- 
sion, as observed by aid of the microscope. Hence, consequently, the con- 
gestion which is always the first observable change, in that series of changes 
which constitutes the process of inflammation. That the capillaries should 
sometimes contract, as shown by the microscope, upon the application of a 
stimulant, is not adverse to the opinion here advocated; for contractility and, 
dilatability are both considered as active. properties, and both may therefore 
be roused into operation by a stimulant, though we do not understand what 
are the precise circumstances which give a direction of the excitement rather 
to the one than to the other property. We only know that, whenever the 
irritation amounts to inflammation, the expansibility. is called into action. 
The reader' who may wish to prosecute this inquiry further, will find the 
arguments in support of the doctrine of an active dilatability of the capilla- 
ries, very fully stated in a paper by Dr. H. L. Hodge, in the W. Am. Med. 
and Surg. Jour., vol. vi. p. 1. 
The chief difficulty in the way of the theory of capillary excitement, is the 
fapt of the retardation and stagnation of the blood in several of the vessels. 
If the part is in a state of excessive action, how should it happen that certain 
vessels should cease to act altogether? This difficulty is removed by the 
result of recent microscopic researches. The rapid developement of the white 
fibrinous dr lymph globules in the vessels of the inflamed part, their slow 
movement and partial adhesion to the inner surface of the vessels and to one 
another, and their accumulation at last in such quantities as to arrest the 
movement of the red corpuscles, fully account for the stagnation alluded to. 
Now the production of these organized globules, probably out of the less 
vitalized albumen, is anything but an evidence of debilitated action. It is, 
on the contrary, the strongest proof that could be adduced of an increased 
exertion of vital power. Hence, in cases of low or feeble inflammation, in 
which, though vital action may be increased, the powers of the part are in- 
adequate to the developement of the requisite amount of vitalized fibrin for 
exudation, the want of this preservative principle leads to the most destructive 
results. Pus, or other wholly disorganized matter, takes the place of coagu- 46 
GENERAL PATHOLOGY. 
[part I. 
lable lymph; no boundary is set to the diffusion of these products; and the 
resulting injuries are inadequately repaired, from the insufficiency in quantity 
or quality of the great reparative agent. 
But, though the author believes there is always an increased action of'the 
capillaries in the course of inflammation, he does not consider that this of 
itself constitutes inflammation. The nervous function Of the part also under- 
goes material modification, of what nature cannot be understood until we 
become acquainted with the natfirn of nervous action. The absorbents are 
also involved in the disease, and are very important agents in effecting various 
changes which take place in the course of it. The blood itself, as has already 
been shown, undergoes important changes in the part affected, which probably 
form an essential constituent of the inflammatory process. Besides, though 
there is increased action of the Capillaries in the early stage, yet,some of these 
vessels, from exhaustion or some other cause, become, in the course of the 
affection, and often very speedily, the seat of a real debility, which occasion- 
ally sinks down into an entire loss of power, and even of life; and, in the 
advanced stages, this debility sometimes constitutes the prominent feature of 
the disease. Inflammation, therefore, is a very complicated process; not con- 
sisting exclusively of any one mode of derangement, nor occupying exclusively 
any one constituent of the tissues'. It is, however, in the opinion of the 
author, practically important to bear in mind, that it is the result of an un- 
healthy excitement, apd in its earliest stage is always attended with an un- 
healthy increase of action. 
Various other theories of inflammation have been broached at different 
times. Not to mention the vague notions entertained before the circulation 
of the blood was discovered, the theory of Boerhaave, which had for a long 
time great vogue, deserves a brief notice. By this celebrated author, inflam- 
mation was believed to depend upon obstruction of the capillaries, produced 
either by an unusual viscidity of the blood, or by the entrance of red globules 
into vessels not intended for their reception, and too small for their passage. 
To this latter circumstance he applied the name of error loci. The charac- 
teristic phenomena of inflammation were ascribed by him to the accumulation 
of blood behind the point of obstruction. The error of Boerhaave was in 
considering, as the cause of, inflammation, what is merely, when it occurs, 
one of its effects or attendant circumstances. The doctrine of obstruction 
has recently been strenuously advocated by Magendie, who asserts that arti- 
ficial inflammation is simply a mechanical result, arising from obstruction of 
the capillaries, and consequent distention of tbe neighbouring vessels. In 
the present state of our knowledge, however, no explanation is likely to be 
generally received which leaves out of view the vital properties of the part 
affected. Authors who admit the existence of an increased action in the in- 
flamed part, differ in relation to the precise nature of that action. Cullen 
imagined the existence of spasm in the extreme arteries, supporting an in- 
creased action in the course of them, and thus giving rise to the phenomena 
of inflammation. But it need scarcely be observed, that his opinion upon 
this point was quite conjectural; as the existence of such a spasm is altogether 
insusceptible of' proof. The opinions of Hunter were very nearly those which 
have been advocated in this work. He believed that there was an increased 
action' in the vessels, and at the same time an increased distention. Accord- 
ing to Hunter, however, inflammation is to be regarded as a salutary process, 
intended to restore parts which have suffered from violence or disease to their 
healthy state. This is undoubtedly true in many cases; but can scarcely be 
predicated of inflammation in general, which is often itself the direct result 
of the morbid cause, without any violence to the part, and without any dis- CHAP. I.] 
INFLAMMATION. 
47 
coverable intermediate disease. Dr. Alison has advanced opinions in relation 
to inflammation which are somewhat peculiar. He admits that the vital pro- 
perties of the inflamed part are concerned, and that there is to a certain extent 
an increase of the vital actions; but, not believing in the active dilatability of 
the capillaries, he is led to the supposition, in order to account for the accu- 
mulation of blood, that there is- a vital attraction between this fluid and the 
surrounding textures, which is increased in inflammation, and thus causes an 
increased flow to the part affected. This may possibly be the case; but such 
an attraction has never been demonstrated;* and it appears to the author, 
that sound induction would scarcely justify the assumption of its existence, 
in order to explain phenomena which fire quite as easily explicable upon the 
principle, that' the. universally admitted expansibility of the vessels is an 
active, and not merely a passive property. 
3. Causes of Inflammation,. 
As inflammation is the last step in the advance of excitement, being that 
condition in which irritation, as defined in this work, if increased beyond a 
certain point, necessarily terminates, it follows that its causes must be essen- 
tially the same as those of irritation,yonly greater in degree, or longer continued. 
The reader is, therefore, referred to the remarks upon irritation for a general 
account of these causes. Anything peculiar in their mode of action, or their 
direction, will be most appropriately Considered under the heads of the various 
special diseases they produce. It is sufficient here to observe, that among 
these causes there is this distinction, that, while some in their action often stop 
short at irritation, if applied only for a short time or in a slight degree, others 
necessarily result in inflammation. Thus, substances which wound, or 
corrode, or in any other way produce a 'Solution of continuity, often neces- 
sarily give rise to inflammation; since this js a- process essential to the resto- 
ration of the injured part. The presence of extraneous bodies within the 
organs, in like manner, occasions inflammation, which is requisite for their 
discharge by means of ulcerative absorption, or, if they should be retained, 
surrounds them' with an organized cyst, which prevents their irritant influence 
on the neighbouring parts. In the light of extraneous substances, may be 
regarded certain morbid secretions within the organs, which require the inter- 
vention of the inflammatory process for their elimination, and dead portions 
Of the body itself, which can be separated and replaced only by a similar 
instrumentality. Some irritant causes, though their morbid action may not 
necessarily result in inflammation, are more apt to produce it than others; 
such as alternations of temperature, and various morbific poisons. 
Certain conditions of system strongly predispose to inflammation; so that 
causes which, under other circumstances, would stop short at irritation, in 
these, are apt to occasion the higher, grade of excitement. Thus, richness 
and poverty of the' blood are both favourable to the morbid influence of ex- 
citant causes; but, in the former condition, this influence is more apt to result 
in inflammation, in the latter, in irritation merely. Superabundance of the 
red corpuscles, of albumen, and of fibrin, no doubt greatly aids the causes of 
inflammation, and is probably capable itself of producing that result, without 
the co-operation of other causes. The febrile movement operates powerfully 
* The partial adhesion to the coats of the vessel of the newly-developed lymph-glob- 
ules, ean hardly be admitted as an example of the attraction alluded to'; as, even admit- 
ting it to be vital, and not to depend upbn the viscidity of the globules, it does not occur 
until the vessels have .been visibly enlarged, and the first movements of the infla-.mma- 
tory process have already commenced. 48 
GENERAL PATHOLOGY. 
[part I. 
in favouring the production of inflammation, and often, indeed, acts not only 
as a predisposing, but as a direct cause.' 
4. Modifications of Inflammation by Tissue. 
No view of inflammation can be complete, which does not embrace an 
account of the modifications produced in it by the tissue in which it may 
occur. It is, however, only general notices that are required in this place; 
as the description of particular cases of inflammation, occupying particular 
structures, will necessarily embrace the details. Our attention will also be 
confined here to that form of inflammation which occurs in individuals without 
peculiar morbid predispositions, and is not induced by causes calculated to 
give it a peculiar character. The influence of tissue is felt, not only in the 
character of the inflammation in the part affected, but also in the sympathetic 
disturbance of other parts, or of the system generally; and it will be treated 
of, in each case, in relation to these two points. For much of what follows, 
it is proper that I should acknowledge my indebtedness to the work of 
Gendrin. 
1. Cellular and Adipose Tissues.'-These tissues, are considered under one 
head, as theii' only observable difference is in the -circumstance that the latter 
secretes a fatty matter, which is deposited in its cells. Inflammation of the 
ordinary character, occurring in these tissues near the surface of the body, is 
usually called phlegmon; and, as it is considered the type of this form of dis- 
ease, it has been customary to distinguish common inflammation, wherever it 
may exist, by the title of phlegmonous. The successive changes attending 
inflammation of the cellular tissue have been sufficiently described under the 
general head. Though quite insensible in health, this structure is often very 
painful when inflamed, and especially so when the part affected is confined by 
a fascia, or tendinous expansion. The character of the pain is usually aching 
rather than' sharp, and becomes pulsative when suppuration takes place. It 
is burning only when there is something peculiar in the affection, as in erysi- 
pelas and carbuncle, and, under these circumstances, indicates a tendency to 
gangrene. There is decided redness and much swelling, and the inflammation 
is very apt to proceed to suppuration. It not unfrequently leaves induration 
behind it, especially in its chronic form. 
As thb cellular tissue is iiot exposed to the direct action of external irritants, 
and lies almost without the ordinary circle of sympathies, it is less apt to be 
originally affected than most other tissues, and, when inflamed, is so, in most 
instances, in consequence of the propagation of inflammation from some con- 
tiguous structure, as from the skin and mucous membranes. From the same 
deficiency in sympathetic connexion, it produces, when inflamed, less disturb- 
ance in other parts, or in the 'system at large, than the 'Serous or mucous tis- 
sues, and is less readily reached by remedies acting through the constitution. 
Thomson states that the fever usually attending inflammation of the cellular 
tissue is of an asthenic character; but he probably refers rather to certain 
peculiar affections, such as anthrax or erysipelas phlegmomddes, than to 
phlegmon itself, which, when it gives rise' to fever, is generally attended with 
a grade of action above the standard of health. 
2. Serous Tissue.-Next to the skin and mucous membranes, this is per- 
haps most frequently inflamed. The cellular tissue, however, which connects 
the serous membranes with the organs or structure which they line or invest, 
always participates in the inflammation, and, according to Gendrin, is in fact 
usually its original seat. The inflammation may be confined to the serous 
and subjacent cellular tissue, or may also extend into the contiguous structure, CHAP. I.] 
INFLAMMATION. 
49 
especially when it is . of a somewhat analogous nature, as in the case of pleu- 
risy'extending into the lungs. - . 
An inflamed' serojrs membrane exhibits, at first, numerous red points or 
Streaks, in separate patches, which ultimately coalesce. Sometimes, however, 
instead of being reddened-, the membrane, as in the instance of the arachnoid, 
merely, loses its polish, and presents a milky appearance; and in other cases, 
this appearance is observable in the intervals between the red points. The 
subjacerit cellular tissue becomes infiltrated with serum, and causes the mem- 
brane itself to appear thickened. Losing also its tenacity, it allows the mem- 
brane to be more readily detached from the parts beneath, so that shreds may 
be separated after death. - , ' 
The serous exhalation increases, and generally accumulates in the cavity 
of the. membrane, unless theeinflammation be very slight or of small extent, 
in which Case it may be absorbed as fast as produced. In cases of intense 
inflammation, the exhalation is diminished qr arrested from that portion of 
the surface most affected; but this diminution is more than counterbalanced 
by the increase from the parts but slightly inflamed, or merely irritated, so 
that accumulation still takes place. The serous fluid is often reddened with 
blood, and sometimes unaltered blood is effused. 
In many instances, the inflamed membrane covers itself with a glutinous 
substance, which is sometimes disposed in layers, sometimes in distinct gran- 
ules, or a kind of network, and agglutinates the opposite serous surfaces, or,, 
if these are movable, is drawn out into connecting strings or filaments. This 
substance consists of fibrin, with a mixture of albuminous liquid. It gradu- 
ally becomes denser and more adherent, while the serous fluid, which was at 
first limpid, assumes a turbid appearance, and'contains floating flakes of a 
whitish or yellowish colour, and of the same character with that adherent to 
the surface. The latter is now penetrated with blood, becomes vascular and 
Organized, and is converted into that morbid structure denominated false, 
membrane. This process sometimes begins so early as twenty-four hours 
after the appearance of the effusion, sometimes much later, and sometimes 
does not'Occur for months. k"-. ■ ' ' - 
When the inflammation is so violent as to prove speedily fatal, no false 
membrane is found, but a bright redness, with small ccchymoses, and a little 
reddish-yellow serum. • 
Sometimes the subserous tissue is infiltrated with pus, and pus Or a puri- 
form liquid is found in the.cavity. This is-apt to be the case when the in- 
flammation continues long,-or an exacerbation comes on in its advanced stage, 
without immediately destroying life. . 
When the inflammation subsides, the -effused liquid is absorbed, and the 
false membrane, before of a red colour, gradually becomes paler, and at length 
takes on the appearance and character of. cellular "tissue. Permanent adhesions 
are thus frequently formed between opposite serous surfaces, especially in the 
pleura and peritoneum. „ " ' ' • 
In chronic inflammation, the redness is less vivid than in the acute, and is 
sometimes wanting-. There are greater thickening and density, in consequence 
partly qf changes in the subserqus tissue, partly of the incorporation of the 
false membrane with the original structure. The serous' membrane is more 
tenacious, but at the same time more difficult to be detached, because the 
cellular'tissue is also more tenacious. The surfacq is often rough and of a 
dull appearance, and is sometimes studded with small whitish granules, per- 
ceptible to the touch, but scarcely elevated, which have been mistaken for 
tubercles, but differ in being inseparable from the surface of t^e membrane, 
never encysted, and never softened. (Gendrin.} The fluid in the cavitv is 50 
GENERAL PATHOLOGY. 
[part I. 
often limpid; sometimes gelatinous; sometimes purulent, but generally yeL 
lowish-white or milky, with portions of coagulated matter floating in it. 
Though usually distended with liquid, the cavity is sometimes filled, wdlh a 
sort of cellular tissue resulting from organized false /membrane, which is in- 
filtrated with pus, and occasionally itself forms cavities, in which pus is col- 
lected, find confined. When a cure takes places the liquid is absorbed, the 
cavity contracts, and the new tissue becomes firm, and sometimes of a fibrous 
consistence. Often, however, the false membrane is entirely absent, espe- 
cially in those'cases in which the inflammation has been of a chronic character 
from the outset. The effused fluid occasionally remains after the cessation 
of the inflammation, constituting a kind of dropsy, but distinguishable from 
the genuine forms of that disease by the evidences of previous inflammation, 
presented in the thickened and altered tissue. The serous membrane and 
subjacent,cellular structure remain for a long time dense and indurated, and, 
as well as the false membrane, become sometimes • as hard as scirrhus, or 
assume even a cartilaginous or bony character. 
Ulceration seldom occurs in ordinary inflammation of the serous tissue. 
Sometimes, however, it does. take place in old cases, consequent upon the 
pressure of the accumulated fluid, which thus finds an exit/ It may arise 
also from gangrene, though this- is rare; 
Though insensible in the healthy state, the serous tissue becomes in general 
exceedingly painful when inflamed.. The pain is acute, and much increased^ 
by motion or pressure. The sharp character and severity of the pain serve, 
in some measure, to distinguish inflammation , of tpis tissue from that of the 
parenchymatous or mucous tissue in its neighbourhood. Sometimes, however, 
pain is almost or quite-wanting, as in certain cases- of pleurisy and pericarditis; 
and errors in diagnosis have not unfrequently .originated from this, cause. 
Serous inflammation is usually attended with a sthenic condition of the 
system, which bears and requires copious depletion. As a general rule, it is 
less apt than that of some other tissues to call distant, organs into active sym- 
pathy; and occasionally it ip known to exist to a considerable extent, without 
any other disturbance than pain and increased action of the,heart, and even 
these are sometimes wanting. 
Inflammation of the synovial membranes is very closely analogous to that 
of the serous; but it occurs less frequently, .and is less apt to be attended 
with effusion of coagulable lyinph, and consequent adhesions. When adhesion 
takes place in joints, it arises, for the most part, from ulceration and granu- 
lation. Except as the result of injury, or of rheumatism or gout, inflammation 
of the synovial membranes is generally chronic, and frequently associated with 
the Scrofulous diathesis. When acute, especially if traumatic, it is often very 
painful and severe, involving, the safety of the patient, and requiring active 
treatment. 
3. Fibrous, FibrO-cartildginqus, and Cartilaginous Tissues.-The fibrous 
tissue, including the periosteum, dura mater, aponeuroses, capsular ligaments, 
tendons, &c., is sometimes affected with inflammation, though much more fre- 
quently with the rheumatic and gouty than the ordinary form of that affectipn. 
The changes which it undergoes are those described under the general head. 
It becomes red. and sWollenc loses its fibrous texture and tenacity, so that it 
may be torn in any direction, and contracts adhesions to neighbouring parts, 
which participate in the inflammation. Acute inflammation of this tissue 
seldom eventuates in suppuration or gangrene. It affords, indeed, strong 
resistance to mortification when existing in its vicinity; and tendons have 
sometimes been found in a sound state in the midst of a slough. In chronic 
inflammation, the tissue is often much thickened, and undergoes an imperfect CHAP. I.] 
INFLAMMATION. 
51 
suppuration. When very long inflamed, it often loses entirely its' original 
character, and becomes cartilaginous or bony. Sometimes ossification and 
suppuration are going on together. 
The fibrous tissue is insensible in health, but often very painful when in- 
flamed; and the constitutional symptoms are sometimes very violent. 
The fibrg^cartilgges-a structure ■ intermediate between the fibrous and 
proper cartilaginous tissues, of which we have. examples in the intervertebral 
and interarticular cartilages, the annular ligainent of the radius, and the 
cornea-'are occasionally affected with inflammation, being much softened, 
reddish, and infiltrated with a turbid reddish fluid, which becomes sero-puru- 
lent, and is soiifetim.es collected in small abscesses in its substance. Inflam- 
mation of this tissue, however, is little known, and is not often original. 
Cartilages, axe but little exposed to inflammation, and some of them, as' 
those which form the articulating surfaces in movable joints, appear to be 
incapable of the process. It is - true that these cartilages sometimes disap- 
pear during long continued inflammation of the neighbouring bony structure; 
but their removal is probably .effected by absorption from without. Other 
cartilages, such as those, of the larynx, trachea,' and ribs, are scarcely suscep- 
tible of acute inflammation, but throw off portions from their surface, or ex- 
foliate when the perichondrium is inflamed. These are occasionally affected 
with chronic' inflammation, -which, however, according to Grendrin, begins in 
the perichondrium, and gradually modifies the cartilaginous structure, so as 
to make it approach to the fibrous. They are apt to ulcerate, and are some- 
times, as a conspcpence of chronic inflammation, converted into bone. They 
occasion little pain or constitutional disturbance; and that which does occur, 
during their inflammation, is probably .ascribable'' more to the accompanying 
inflammation of the neighbouring parts than to that of the cartilages them- 
selves. 
4. Cutaneous Tissue.-From the complex nature of this tissue, its nume- 
rous sympathies, and its peculiar exposure to the direct action of morbid causes, 
it is liable to a vast variety of inflammatory affections, differing in the parti- 
cular portion of the structure which they occupy, in their greater or less de- 
gree of violence, and in their nature. These diversities, being obvious to 
superficial observation, have been accurately traced, and are recognized for the 
most part as special diseases, requiring separate description. I shall here 
treat only of ordinary inflammation of the skin, as, for example, that produced 
by Spanish flies, or other direct irritant.. 
It often happens that the surface only is affected, the inflammation not ex- 
tending beyond the reticular layer immediately beneath the cuticle. Under 
these circumstances, there are generally a slight swelling, and a redness 
which disappears upon pressure, and returns upon its removal. If the inflam- 
mation be very slight, or subside speedily, the cuticle usually separates either 
in furfuraceous scales, or in larger portions, and the skin is left shining, and 
of a purplish or somewhat violet redness. If it be severer, or of longer dura- 
tion, a serous fluid is secreted, appearing, under the cuticle in small separate 
collections, which soon run together and . form a blister, and the surface at the 
same time generally becomes paler. The fluid is yellowish and somewhat 
viscid, sometimes acid, sometimes of a gelatinous appearance, and, if the in- 
flammation persist-, becomes at first reddish, then turbid, and ultimately puru- 
lent. Occasionally, when the (inflammation is very active, a whitish or 
yellowish-white layer of matter resembling coagulable lymph is produced 
beneath the cuticle, forming a kind of false membrane, which, however, is 
not organizable. The same appearance is often presented upon the surface 52 
GENERAL PATHOLOGY. 
[PART I. 
deprived of its cuticle, and irritated by some stimulating substance, as savine 
or mezereon. 
After death, in slight cases of brief duration, the appearances of inflamma- 
tion are entirely lost; but, if the inflammation has persisted for forty-eight 
hours, the skin is apt to offer a somewhat violet colour, and the cuticle sepa- 
rates sooner than in the uninflamed parts, upon the commencement of decom- 
position. In severe cases, even though lasting not more than a day, the rete 
mucosum appears injected, and somewhat thicker than in health, a similar 
injection is observable in the corium, and the affected part putrefies more 
readily than the rest of the skin. 
Inflammation may extend from the reticular layer beneath the cuticle to 
the true skin, and even to the subjacent cellular membrane. This is known, 
during life, by the sensation of hardness imparted to the finger, and by the 
redness not disappearing under pressure; after death, by the redness, want of 
tenacity, and occasional bloody infiltration of the skin. (^Gendrini) 
The corium may be the original seat of inflammation, which also frequently 
attacks especially or exclusively the sebaceous follicles. 
Ulceration is a frequent occurrence in the suppurating surface of the skin; 
and gangrene is probably more common in this than in any other tissue, 
unless perhaps the cellular. 
It has been said that inflammation is very much disposed to travel when it 
occurs in the skin. But this is true -only'of that variety denominated erysi- 
pelatous. Common inflammation does not usually extend so rapidly in (the 
skin as in some other tissues, particularly the serous membranes and ab- 
sorbents. Witness the effects of blisters and sinapisms, which are generally 
confined to the limits of the original application. 
The pain is apt to be burning, and, in the milder cases, is often of an itch- 
ing, tingling, or pricking character. The attending fever is seldom so 
energetic as that which marks inflammation of the serous tissue, and is not 
unfrequently decidedly asthenic. Cutaneous inflammation is not often dan- 
gerous, unless it involve a very large extent of surface. It is frequently, 
however, an attendant upon other diseases, which are highly dangerous, in 
consequence, not of the affection of the skin, but of disorder' in one or more 
off the interior organs; and in these diseases it sometimes proves advantageous 
by diverting irritation from more vital parts. It is a curious fact, that dis- 
eases attended with some variety of cutaneous inflammation are very often of 
a contagious nature, and, upon their disappearance, leave the system insus- 
ceptible to a second attack. The number of Strictly contagious diseases is 
few, which are not habitually accompanied with inflammation of the skin, in 
some form , or another/at some period of their course. 
5. Mucous Tissue.-This is perhaps more frequently inflamed than any 
other tissue, partly from its direct exposure to irritating (pauses, partly from 
its delicacy of structure, and the wide range of its sympathies. As in the 
case of the skin, different constituent portions of its structure may be affected, 
and great diversity may 'arise also from the state of health or constitution of 
the patient, or the nature of the cause. Whatever is specific will be reserved 
for future consideration. 
In inflammation of the mucous tissue, as it ordinarily occurs, there is red- 
ness, varying in intensity from a light pink or rose colour to a reddish-brown, 
sometimes punctuated or ramified and quite superficial, sometimes in patches, 
and occupying the whole thickness of the membrane. The tint is usually 
somewhat purplish, deepening with the advance of the disease, and becoming 
at length almost violet. The redness is generally most intense in the centre 
of the inflammation; gradually becoming paler as it recedes from this point; CHAP. I.] 
INFLAMMATION. 
53 
but, sometimes, .especially jn the alimentary mucous membrane, it is nearly 
uniform throughout, and marked by abrupt and well defined limits. The 
membrane is somewhat rough upon the surface, especially when papillary, 
and is more or less thickened. When rough, with minute prominences, it is 
said to be mamellonated. It may be easily separated from the parts beneath, 
in consequence of the Ibss of cohesion in the subjacent cellular tissue. Some- 
times the membrane itself is softened, so that it breaks under the forceps 
when attempts, are made to raise it) and there may be every degree of this 
softening, from a slight fragility up to perfect diffluence. 
In delicate membranes, a bloody ■serum infiltrates the sub-mucous" tissue; 
in thicker membranes, the same effusion takes place in the mucous tissue 
itself. Ill the advanced, stages of the inflainmation, the place of the serum is 
occupied by a purulent infiltration. In some cases) there is a very strong 
tendency to serous effusiony so as to produce an edem'atous condition, which, 
in certain positions, as in the neighbourhood of the glottis, is productive of no 
inconsiderable dagger. This is particularly apt to happen in patients with 
dropsical tendencies. In such cases, there is less redness than is ordinarily 
observable in others. 
The inflamed membrane' is at first drier than in health,' and rapidly absorbs 
fluids in contact with it; but the secretion soon increases in quantity, and is 
at the same'time altered, losing in great' measure its viscidity, and becoming 
serous,dimpid, and sometimes acrid. As -the inflammation advances, it becomes 
less copious, but more viscid and opaque, assuming a whitish or yellowish- 
white appearance. At the greatest height of the inflammation, the secretion 
is almost suspended; but is afterwards re-established, and at this time is fre- 
quently tinged with blood. If the disease persist, it often gradually assumes 
a purulent character, becomes more abundant, and at length takes on the 
appearance of pure pus; and this change is coeval with the purulent infiltra- 
tion of the membrane itself. When examined by the microscope, the dis- 
charge is found to consist of an amorphous and glutinous liquid, with granules 
or corpuscles of various sizes, and scales of the epithelium, which are con- 
stantly thrown off from mucous membranes with their proper secretion. 
It has been asserted that inflammation of the mucous membrane might 
exist, without leaving observable traces after death: but it could neither be 
severe, nor long continued; as the effusion and stasis of blood would in either 
of these cases reveal it. Gendrin states, as the result of his observations and 
experiments, that redness of the membrane, when beyond the point of mere 
vascular arborisation, does not disappear at the point of death. 
Pseudo-membranous or Plastic Inflammation}.-of the mu- 
cous membranes is sometimes attended with a secretion of albumino-fibrinous 
matter, which concretes, and forms false membranes on the surface; This is 
not so much dependent on the intensity of the disease as on the condition of 
the'blood, or some peculiarity in the constitution of the patient; for it appears 
in every grade of inflammation, from the slightest to the most severe. It is 
most common in children. Inflammation with such a tendency is called 
pseudo-membranous or plastic inflammation: It is not unfrequent in the air 
passages, and sometimes occurs in the alimentary canal. The membrane, in 
relation to its texture, is in the same condition as in ordinary cases; but the 
redness is not so deep, and there is less swelling. The coagulated matter, 
which is whitish or yellowish-white, and rather dense, appears at first in points 
or, patches, which spread, and at length coalesce, so as often to form complete 
tubes within the living ones. It is supposed by some to be capable of becoming 
organized; but Gendrin has never seen traces of vessels in the false mem- 
branes- which it forms, and Andral considers the apparent vessels, which have 54 
GENERAL PATHOLOGY. 
[part I. 
been observed communicating between them and the proper' membrane, as 
mere prolongations of the coagulated matter, dipping down into the mucous 
follicles. Sometimes these false membranes are gradually' thinned till they 
become like a delicate epidermis; sometimes they are softened and converted 
into a kind of thick muctis, or puriform matter; and sometimes they are sepa- 
rated from the mucous tissue by a layer of mucus or of pus beneath them, and 
are rejected either whole or in fragments. Occasionally, other parts of the 
same membrane upon which they are formed afford an abundant mucous or 
muco-purulent secretion. 
Follicular Inflammation.-Inflammation of the • mucous membrane may 
affect chiefly or exclusively the glandular follicles, producing' small, founded, 
prominent, more or less, pointed tumours, when the distinct follicles are 
inflamed; or flatfish and somewhat depressed tumours, consisting of aggre- 
gated follicles, with which, in the alimentary canal, the inflamed villi are also 
mingled, forming patches of some extent. But, without attention, a healthy 
erection of these mucous glands may be mistaken for inflammation. In the 
state of normal excitement, they are diaphanous, with a little degression mark- 
ing the orifice of the duct; in inflammation, opaque and reddish, with a plilo- 
gosed condition of the adjacent portions of membrane; and, as-the inflamma- 
tion advances, they lose entirely the follicular character, becoming merely 
small phlegmons. 
Chronic Inflammation.-In chronic inflammation, while the disease is at 
its height, there is usually a dark redness; but, in very old cases, or where 
the affection is slight, there is little discoloration, and sometimes none. The 
membrane is rough upon the surface, some what harder to the touch thail in 
health, thicker, dens,er, more cohesive, and capable of resisting maceration for 
a longer time. The follicles are often observable in an enlarged and indu- 
rated state; but in old cases they are apt to be confounded with the altered 
tissue. The mucous secretion is more copious than in health, more viscid,' of 
a grayish or yellowish-gray colour, and composed frequently of proper mucus 
and pus, which, upon being thrown into water, separate into two portions, one 
thick and ropy and floating on the surface, the other without cohesion and 
falling to the' bottom. In cases in which the inflammation is considerable, 
there is often'also much serous exhalation. 
In vely slight and old cases, there are only left a thickening of the mem- 
brane, and a slight vascular injection, with follicles mdre voluminous than in 
health. Such cases are known, during life, only by increased mucous or 
muco-purulent secretion, and are not always easily recognised after death. 
The most evident characters are infiltration of the subjacent cellular tissue, a 
slightly granular appearance of the surface, and a somewhat altered colour, 
which, if normally white, is now whitish-yellow with reddish streaks, or, if 
rose-coloured in health, is of a darker and more livid hue. After the cure of 
chronic inflammation, the vessels often remain enlarged and injected,.present- 
ing red ramifications in the substance or on the surface of the membrane, 
dividing till they are no longer perceptible, and appearing unconnected with 
any trunk; which last character distinguishes these injections from those of 
passive congestions. 
When acute supervenes upon chronic inflammation, the diseased tissue 
becomes again red and infiltrated, as well as the cellular tissue beneath, with 
blood or bloody serum. This effusion is soon succeeded by pus, and the mem- 
brane loses its tenacity, becomes friable or softened, and, in the case of the 
alimentary mucous membrane, is sometimes quite disorganized", and reduced 
to a pulpy or semi-liquid state. Sometimes, instead of this change, small red CHAP. I.] 
INFLAMMATION. 
55 
excrescences form in the membrane, which at length become gray, dense, and 
hardened, and remain after the inflammation has ceased. (Gdndrinj) 
Though, contrary to formerly received opinion, there may be copious sup- 
puration from mucous, membrane, without the slightest trace of ulceration, yet 
there is perhaps no tissue so liable to the ulcerative process , as this. If inflam- 
mation has persisted for a considerable length of time, it is rare, upon post- 
mortem examination, to find ulceration wanting. (Roche and Sanson.') It 
often occurs in original actite inflammation, but touch more commonly when 
this supervenes upon chronic, and is frequent also in the chronic form. Gen- 
drin states, that the character of the inflammation may, in some measure, be 
determined by the appearance of the Ulcer after death. If the edges are some- 
what prominent, rough, injected with blood, and covered, as well as the bot- 
tom, with a muco-purulent layer, it maybe inferred that the inflammation 
was acute. Hard, unequal, reverted' edges, separated from the base, with 
roughness and:a more or less livid redness of the bottom of the ulcer, indicate 
tronic inflammation. If the tissue around and at the bottom of the ulcer is 
ftened, puffed up, and bleeding, there is reason to believe that acute has 
supervened upon chronic inflammation. Ulchrs of the mucous membrane often 
heal with great facility. The commencement of cicatrization is marked by the 
edges being, flattened, pliable, as it were puckered, extending towards the 
centre, and covered with a muco-purulent secretion. Ulcers often penetrate 
quite through the substance of the mucous membrane into the tissue beneath, 
and occasionally open a passage through the side of the tube lined by the 
membrane,, and allow its contents to escape into the neighbouring cavity, with 
fatal effects. This latter event,' however, is not common; as coagulable 
lymph is usually thrown out, and forms adhesions which prevent such effu- 
sion. Mutous membrane. is also liable to gangrene, from the causes which 
produce this result in other tissues. 
The-sensation which attends inflammation of the mucous tissue varies much 
with the part affected. At the extremities of the passages lined by the mem- 
brane it is often acutely painful, while it is generally more dull in the inter- 
mediate portions; and it occasionally happens, that the sensation produced by 
inflammation in the course of the passage is. felt chiefly, if not exclusively, at 
the termination. Thus, irritation of the stomach is sometimes evinced by 
itching or other uneasiness in the nostrils; bronchial inflammation, by uneasi- 
ness in the throat; and inflammation of the lining membrane of the bladder, 
by pain at the. end of the penis: Generally speaking, the pain is less severe 
than in inflammation of the cellular, serous, or fibrous tissue. It is usually 
obtuse rather than acute, and is often scarcely feltpunless on motion or press- 
ure. Not unfrequcntly it is altogether Wanting. In acute inflammation, there 
is generally a considerable' feeling of heat, which is often also experienced in 
the chronic form. ■ . / ;' J ' . 
Inflammation of the mucous tissues is often attended with much sympa- 
thetic disturbance. When it occupies a portion of the membrane in which 
some excretory duct opens, an irritation is frequently extended to the gland 
from which the duct proceeds, either increasing and altering the secretion, or 
' diminishing if not arresting it, and sometimes terminating in inflammation 
of the gland. Hence the disordered hepatic functions, so common in inflam- 
mation of the duodenum. Every grade, of fever accompanies mucous inflam- 
mation,, from that of high excitement to the' lowest and most malignant forms. 
As' a general rule, in ordinary states of the constitution, and where the dis- 
ease has not originated from a peculiar cause, the fever may be considered, 
in relation to the grade of action, as intertnediate between that of serous and 56 
GENERAL PATHOLOGY. 
[PART I. 
that of cutaneous inflammation, supporting and requiring a greater amount of 
depletion than the latter, and a less amount than the-former. 
6. Glandular Tissue:-When moderately inflamed, this tissue is redder, 
more dense, more elastic, and less friable than in health. The lobules and 
even the glandular granules become more distinct, the interlobular cellular 
tissue being infiltrated with serum, and much less dense and cohesive than 
that proper to the gland. The capillaries and excretory ducts of the inflamed 
part are engorged with blood, and after death are quite impermeable by injec- 
tions, In cases of intense inflammation, the whole texture of the gland, both 
the strictly glandular and the interlobular, is more injected, of a deeper or 
darker red, and much more brittle. The secretion, in the' earlier stages, is 
increased in quantity, and altered in quality, approaching nearer to the. nature 
of serum, and sometimes tinged with blood- As the inflammation advances, 
the secretion diminishes, so as to be less than in health, becomes acrid and 
even bloody, and at the height of the. disease is suppressed in the most inflamed 
part, though still maintained by other portions of the glands , » 
Suppuration, which does not .take place with great facility, usually appears 
first in the interlobular cellular tissue, and afterwards, if the inflammation is 
intense, in the glandular also, which then becomes of a grayish-white colour, 
softens, and at length breaks down and dissolves in the pus. With this fluid 
is mingled a portion of the proper secretion of the gland, proceeding from 
parts bordering upon the inflammation, which are only irritated, and the 
excretory ducts of which are opened by the disorganizing process. Some- 
times pus is discharged by the excretory duct of the gland, proceeding either 
from the inflamed lining membrane of the ducts, or brought by them from 
the purulent collection with which they may communicate. Generally, how- 
ever, if the patient is not first exhausted, it makes its way by means of the 
combined ulcerative and adhesive processes,..as before described, either through 
the adjacent structures externally, or into some neighbouring cavity, which 
also has an outlet. 
When acute glandular inflammation becomes chronic, the redness is dimi- 
nished, the interlobular cellular tissue is rendered dense, and the blood-ves- 
sels, even the trunks without the gland, remain dilated. The tumefaction is 
less in the slowly advancing chronic inflammation than in that which suc- 
ceeds the acute, ^Gendi'in.') If the disease proceed to suppuration, this is 
apt to occur in the cellular tissue, which is softened and absorbed, while the 
enlarged glandular granules become more distinct, and as it were dissected. 
But the proper tissue of the gland is itself also sometimes destroyed by sup- 
puration, the granules or lobules being no longer distinguishable. Instead 
of being softened and suppurating, the gland occasionally becomes indurated, 
under chronic inflammation. Sometimes gangrene occurs; but this is rare. 
In general, the pain from inflamed glandular tissue is obtuse, and thus, in 
some instances, serves as a means of diagnosis between inflammation of the 
substance of the gland, and that of its investing serous coat. The direct influ- 
ence exerted upon other organs, or upon the system at large, is not equal to 
that proceeding from various other tissues, and does not correspond with the 
importance of the gland in the economy. Great destruction of the glandular 
structure, even in some of the most important of these organs, occasionally 
takes place, without being evinced by any very obvious or considerable dis- 
turbance of the constitution. The symptomatic fever is usually of a lower 
grade than that which attends inflammation of the serous or mucous tissues. 
In relation to the vascular, muscular, osseous, and nervous tissues, no gene- 
ral observations are requisite, as inflammation of each of these tissues consti- CHAP. I.] 
DEPRESSION. 
57 
tutes one or a few special diseases, in treating of which, anything of a general 
nature that cotdd be said here would be necessarily repeated. 
5. Specific Inflammation. 
There are nitmerous forms of diseased action which present' the essential 
characters of inflammation, and yet differ in some respects so materially from 
that affection in its ordinary form, as 'deservedly to be considered distinct in 
their nature. As these differ , as much among themselves as they do from 
ordinary inflammation, they may with propriety be denominated specific. It 
is not easy always to, determine, whether this specific character exists in the 
essential nature of the inflammatory action, or depends upon some modifica- 
tion impressed upon it by another co-existent disease. It is possible that, in 
some cases, one of these conditions may prevail, and in others, the other. 
Thus, the scrofulous appears to differ from other forms of chronic inflamma- 
tion, chiefly by the presence of tuberculous matter., or a curdy, cheese-like 
secretion, which owes its existence to a peculiar predisposition, and may either 
precede the inflammatory action and be the cause of its developement, or may 
result from the disturbance produced by the inflammation itself in peculiar 
constitutions. So also with the inflammation attending cancer, which appears 
to owe its peculiarity to the developement of a new structure,; in the midst of 
the healthy tissues.,. In syphilis, on the contrary, there is no observable 
morbid action- or product distinct from the inflammatory, to the presence of 
which, in each particular part, the inflammation of that part can be ascribed; 
and yet both its course and results prove it to fie a specific affection. In the 
former case, the peculiarity seems . to depend upon foreign admixture, in the 
latter, to be inherent in the inflammatory action. 
The specific character probably always has its origin in one of two circum- 
stances, either in peculiarity of predisposition, congenital or induced, as in scro- 
fula, rheumatism, gout, &c., or in the character of the exciting cause, as in 
syphilis, small-pox, and other contagious diseases. 
As it will be necessary, in treating of special diseases, to describe each of 
the specific inflammations under a separate head, it is unnecessary here to do 
more than to allude to their existence. Jhe most prominent of them are the 
scrofulous, the erysipelatous, the rheumatic, the gouty, the various exanthema- 
tous inflammations, as those of small-pox, measles, scarlatina, &c., the syphilitic 
and gonorrhoeal, and all other inflammatory effects of peculiar poisons, whether 
of animal, vegetable^ or mineral origin. 
Article HI. 
DEPRESSION. 
1. Nature-Subdivisions, &c.-There are three conditions in which the 
system is below the ordinary standard of health, and which, though if slight 
and of very brief duration they would scarcely be accounted morbid, are de- 
cidedly so when considerable or protracted. These three conditions are often 
confounded under the name of debility, or asthenia, but are essentially distinct, 
and sometimes require different if not opposite modes of treatment. It is, 
therefore, important to have clear conceptions of their nature, and to be able 
practically to distinguish them. The conditions alluded to are depression, 
debility, and diminished excitability. It must be borne in mind that action, 
the power to act, and the susceptibility to the influence of excitant agents, 58 
GENERAL PATHOLOGY. 
[part I. 
which is here denominated excitability, are different conditions or qualities of 
the system, hnd may each be reduced without a necessary reduction of the 
others. A morbid diminution of action is depression, a similar diminution of 
power is debility, and the term diminished excitability explains itself. 
These conditions may and often do co-exist; but a few remarks will show 
that they are distinct, and may exist separately; Thus, depression or dimin- 
ished action may result from a temporary abstraction of some wonted stimulus, 
or the direct restraining influence of some depressing agent, -and yet the real 
power and excitability may be unimpaired. You may restrain a strong horse 
with cords, but you do not, therefore, necessarily lessen his strength. Loosen 
the cords, and it will be found that all his 'energy remains. Thus, remove 
from the system, or a part of the system, the depressing agency, and, if it has 
not been long applied, the unimpaired -strength will be evinced by action at 
least as energetic, as that of health. The'excitability, so far from being neces- 
sarily diminished, is often increased, by causes producing temporary depression; 
as is proved by the reaction which immediately follows the withdrawal of 
the depressing cause, and which is ascribable only to an augmented suscep- 
tibility, by which the ordinary healthy excitants produce more than their usual 
effect. 
That power may be diminished, without a diminution of excitability, or of 
action, is no less true. It is notorious, that a debilitated system is often 
thrown into tumultuous disorder by causes which would produce no such 
effect in health. Thus, in an individual much reduced by an impoverished 
diet, or by depletion, how often do we observe a panting respiration, and an 
almost convulsive action of the heart, under a degree of bodily exertion which 
would1 havp scarcely discomposed these functions, in the ordinary state of the 
System! How often, under similar circumstances, do the slightest caused 
produce great nervous disturbance, amounting in the female to violent hysteria! 
These results can be accounted for only by admitting an increased excitability, 
which enables the same amount of excitant influence to produce a greater 
amount of effect. 
Again, diminished excitability may exist without essentially involving the 
existence of debility or depression. When a debilitated, but unduly excitable 
heart, is strengthened by suitable measures, it loses its excess of excitability 
as it acquires vigour; yet, by an increased application of stimulant means, it 
maybe made to act as tumultuously as'it did in its more excitable state, under 
a less amount of stimulation. Here then is diminished excitability, with 
increase of strength, and without diminution of action. 
It follows from what has been said, that the degree of depression is by no 
means a certain measure of diminished strength or,excitability. Yet this is 
often overlooked in practice, and patients with undiminished powers of system, 
and with perhaps an increased fund of excitability, are, in consequence of 
some temporary depression of the actions of health,, treated with stimulant 
measures, to their very great detriment; and, conversely, persons greatly de- 
bilitated, but with excessive action of some important orgari, dependent upon 
increased excitability, are no less injuriously depleted with a view to the re- 
duction of the excitement. There is no distinction more important to the 
young practitioner than that which I have here attempted to draw. 
Depression, like irritation, may be general or partial, affecting the whole 
system or a part. It seldom, however, happens that all the functions are 
simultaneously depressed, for any considerable length of time. Universal 
temporary depression is not uncommon; as in syncope, the collapse of low 
forms of disease, the prostration sometimes accompanying the cold stage of 
febrile affections, and that which often results from violent injury. Instances CHAP. I.] 
DEPRESSION. 
59 
of its longer continuance we have in the state of system which sometimes 
follows acute diseases of excitement, ,and in the gradual failure of old age, 
though the latter may perhaps be justly considered as one of the phases of 
health. But, as a general rule, even when the whole system is debilitated, 
the depression itself is partial, or even mingled with undue excitement; one 
or- more of the minor systems or organs being more or less irritated, while 
the remainder are depressed. 
In cases of partial depression, some particular region or organ may be 
affected, aS a limb, a gland, a muscle, &c.; or some system of parts, as the 
circulatory, absorbent, secretory, or nervous. 
Again, the depression may be merely functional, without observable organic 
change, even to the loss of life; or it may be' attended with derangement of 
the organization, as in some cases of softening, and in gangrene. 
As irritation may be ejther a simple increase, or an alteration with increase 
of the vital actions, so depression may be a mere reduction of these actions, 
the function being performed in the same manner, but less vigorously than 
in health, or may be attended with peculiar phenomena, differing entirely 
from the normal, and entitling the affection to the' name of specific. Thus, 
tiie depression consequent upon the loss of blood is entirely different from 
that which attends malignant fevers. The instances of specific depression 
will be treated of in connexion with the special diseases in which they occur. 
2. Causes of Depression.-Depression is either direct, dependent on the 
abstraction of the ordinary stimulus essential to healthy action, or on the 
operation of positively sedative agents; or it is indirect, resulting from the 
operation of certain laws of the system, which determine this condition, as a 
consequence of other antecedent conditions in the same or different parts of 
the body. The causes of depression may, therefore, be considered under the 
two corresponding heads of direct and indirect. 
a. Direct negative Causes.-As the vital actions-all depend upon the opera- 
tion of certain excitants upon the susceptibilities of the system, it follows 
that, upon the diminution or removal of these exCitapts, the actions must be 
diminished dr cease. Among the most" common and efficient cauS.es of de- 
pression are those which consist in such a diminution or removal. These 
will be- first considered. 
Reduction of the quantity or quality of the Uood.-The natural stimulus, 
within the system, essential to all its movements, is the blood. A due quan- 
tity and quality of this fluid are necessary to the support of the vital actions 
in their normal state. It would, therefore, be rationally inferred, that a loss 
of blood, or' such a change in its constitution as may render it less stimulat- 
ing, must, in the healthy state, be followed by depression. This result may 
flow from a direct loss of blood, whether spontaneous or artificial; from the 
loss of a portion of its constituents through excessive secretion; or from a 
diminished production, or altered quality in that produced, arising from de- 
ficiency in the quantity or quality of the food, or insufficiency in the pro- 
cesses of digestion, chylification, &c., by which the food is converted into 
blood. Hemorrhages, blood-letting, colliquative sweats, diarrhoea, diabetes, 
the operation of evacuant medicines,' a restricted or exclusively vegetable 
diet, indigestion and mesenteric disease interfering with the formation of 
chyle, should, therefore, all operate as causes of depression. It is possible, 
moreover, that certain substances introduced into the system may, by a che- 
mical influence on the blood, so far deteriorate its character as -to. disqualify 
it for its proper offices; though it would be difficult to point out any one 
substance, of which this could be said to be proved. It is, however, certain 
that, in some diseases, as in malignant fevers, for example, the blood does 60 
GENERAL PATHOLOGY. 
[part I. 
undergo great deterioration, either from the direct action of the poison intro- 
duced, or from derangement of the organs, and thus becomes wholly Unfit'to 
support the healthy actions, which are consequently greatly depressed. In 
all these cases, there may not only be depression of action, but there is also 
reduction of power or positive debility, which necessarily ensues when the 
organs are insufficiently supplied with that pabulum out of which they were 
formed, and on which they continue to depend for their existence. 
But it must be borne in mind, that a mere loss of blood, or a mere diminu- 
tion of its stimulant properties, without any positively noxious deterioration, 
though it may cause debility, does not necessarily diminish excitability. Ou 
the contrary, the organs feel more acutely the impression of other excitants, 
and are stimulated into excessive action by causes which would not have-"this 
effect in health. I have before alluded to the tumultuous disorder produced, 
under these circumstances, in the. respiratory and circulatory systems, by 
moderate muscular exertion, and in the-nervous system by slight causes of 
disturbance. Even without any apparent excitement, the heart very often 
acts with greatly increased frequency. This' phenomenon, however, is sus- 
ceptible of explanation. The nutrition, muscular contraction, digestion, and 
other functions constantly going on in the system, require a certain amount 
of blood for their support; and, in order to insure the requisite supply, 
nature has established such a sympathy between the parts in which these 
functions are performed and the heart, as to call the latter organ into in- 
creased action, when any deficiency is experienced. If all the functions are 
reduced in proportion to the reduction in the character or quantity of the 
blood, there will be no undue action of the heart. But if these functions are 
to be sustained in their usual state, if the individual eat as much, exercise as 
much, or perform other ordinary acts as much as usual, then, the supply of 
blood, under the ordinary impulse, is insufficient for the purpose, and the 
heart is compelled, by increased effort, to send a more rapid current, to make 
up for the deficiency in the dimensions of this current, or its quality. 
Again, it appears to be an established law, that an inverse relation of 
activity exists between the absorbent and circulatory functions, so that when 
the latter is depressed the former is elevated, and vice versa. The reason 
for this is, obviously, that any loss from the blood-vessels may be supplied 
by a more energetic absorption.; the cause, probably, either a diminution of 
pressure within the blood-vessels, so that fluids may more readily enter, or a 
reverse sympathy between the organs performing the two functions, or both 
combined. Hence, along with diminished action of the, heart, there is usually 
increased absorption; and, as the matter absorbed is not highly animalized, 
consisting chiefly of watery fluid, the result is a diluted condition, and less 
stimulant quality of the blood. This -very condition of the blood, rendering 
it incapable, though in sufficient quantity, of yielding a proper support to the 
several functions, is apt to provoke that excessive actions of the heart above 
alluded to, even in the ordinary condition of those functions. 
It has already been observed, that the nervous system acquires the same 
increased excitability, and is often brought into great disorder by comparatively 
slight causes. Hence, mental disturbance, wakefulness, restlessness, irregular 
muscular contraction, neuralgia, &c., are not unfrequent attendants upon a 
state of debility arising from depletion, abstinence, and other causes, that 
lessen the mass, or deteriorate the quality of the blood. 
From what has been stated it will be inferred, that a state of universal and 
constant 'depression is by no means the necessary consequence of the set of 
causes which we are now considering; that, on the contrary, absorption is 
generally promoted, and various other functions occasionally much excited; CHAP. I.] 
DEPRESSION. 
61 
and that, in order that the functions may be brought into a steady condition 
of depression, corresponding with the diminished quantity or quality of the 
blood, it is necessary that the ordinary amount of excitant agency to which 
these functions are exposed should be diminished also, or at least not increased. 
Hence, in cases of debility from hemorrhage and similar causes, a uniform 
depression of the Vital actions in general is not to be looked for, unless the 
amount or quality of food, the amount of muscular effort, and the exercise or 
gratification of the senses, passions, and moral faculties, be kept within or 
below the ordinary limits. 
But the irritation produced in systems debilitated and yet excitable, is not 
more uniform than the depression. The two conditions are apt to alternate, 
or one function ihay be depressed while- another is elevated, according to the 
nature and direction of the exciting causes. If these causes continue to 
operate, and the debility be not repaired, the excitability is also at length 
exhausted, and the patient sinks; or, what is perhaps more common, some 
fatal organic disease is brought on by the disturbance of the organs; or, 
finally, the patient falls a victim to some accidental complaint, which a more 
vigorous state of his system might have enabled him to resist or surmount. 
In relation to the effects of deficiency of food, either as to quantity or qua- 
lity, it remains to be added to the observations already made, that there are 
limits beyond which this cause, instead of producing a depression of the vital 
actions, gives rise occasionally to high irritation, amounting sometimes to de- 
lirium or insanity. This may arise from the reaction of the sensation of 
hunger upon the organs, or from the character of the blood, which, deriving 
its supplies exclusively from the absorption of the materials composing the 
body, must be wholly of animal origin, and is probably,; therefore, more irri- 
tating than in its healthy state. 
In relation to the action of evacuant medicines, it may be stated that most 
of them, while they reduce the quantity of the blood, act also as local irri- 
tants; and the irritation produced in one spot may sympathetically reach 
others; so that the debility which must to a certain degree result, is attended 
with a mixture of depression and excitement, varying according to the precise 
nature-of the cause. A ' 
Cold, or abstraction of beat.-A certain amount of heat being necessary 
to the living system, not only to preserve its constituent parts in the due phy- 
sical state for the performance of their'several offices, but also as one of the 
stimulants which support the vital actions, it follows that cold, which is 
nothing more than the diminution of heat, should be succeeded by a direct 
reduction of these actions. And such is the fact. The first' impression of 
cold is to diminish sensibility, circulation, secretion, and every other function 
in the part immediately affected. It is true, that pain is experienced from 
severe cold; but this is by no means necessarily an evidence of increased 
nervous action. It is, in fact, a frequent attendant upon a depressed condition 
of the nerves; and in this case is associated with a marked diminution of the 
special sensibility. Every one knows that the fingers, when aching with 
cold, are wholly incapable of exercising duly the sense of touch. It is true 
also, that there is contraction of the capillaries in the chilled part. Hence the 
goose-flesh appearance of the skin exposed to cold. But this does not arise 
from a stimulation applied to the contractility of the capillaries. It probably 
results, in part, from the physical law which determines expansion and con- 
traction, as the consequences respectively of an increase and diminution of 
temperature, and, in part, from the loss or diminution of that function in the 
capillaries, by which the circulation of blood in these vessels is effected, and 
which is evinced, as I have before attempted to show, to a certain extent, in an 62 
GENERAL PATHOLOGY. 
[PART I. 
active dilatation. All the immediate effects, then, of cold, are those of de-' 
pression. 
But this agent differs materially from that last mentioned in not diminish- 
ing, unless long or intensely applied, the power of the part. Heat is not like 
the blood, necessary both as a material for nutrition and a stimulant to action; 
It is only in the latter of these two capacities that it is required, and conse- 
quently its partial withdrawal is followed only by a diminution of action, arid 
not by a loss of power. Nor does moderate cold lessen the excitability, but 
rather increases it, probably by the short rest which it yields to this property 
by the diminution of its stimulus. It follows, therefore,, that the reduction of 
action by moderate cold is temporary. Even during the continuance of the 
cold, the power being unimpaired and the excitability increased, an augmented 
action ensues, usually designated as reaction, which, by producing in the part 
an increased evolution of heat, obviates the continued operation, of the prN 
ginal cause; and this reaction, unlike that which often- follows the application 
of excitants in real debility, is of a healthy and invigorating character, un- 
less, indeed, it amount, as.often happens, when the primary depression was 
considerable, to inflammation. Cold, therefore, though an immediately de- 
pressing agent, is secondarily corroborant, and is frequently applied for this 
purpose very effectively. 
The remarks made of the local effects of cold are true also-.of its. general 
operation upon the system; this operation being directly sedative or depress- 
ing, and indirectly tonic or excitant. Strictly speaking, however, it is not 
possible for a moderate degree- of cold to act directly upon the whole sys- 
tem; as, before it can reach the interior portions of the body, it excites a 
reaction which obviates its immediate effects. The remark, therefore, must 
be taken in the more limited sense of an extensive, rather than a universal 
operation. 
But, though moderate cold, both locally; and generally, often ultimately 
augments the vital actions, yet, if increased and continued, it is capable of 
entirely overcoming the tendency to reaction, and of producing a steady de- 
pression, which may end in the.death of the body, or a paj't. In either case, 
the whole of the vital actions are gradually diminished until they cease alto- 
gether: ' ' . 
It has been stated that, undet the temporary influence of cold, the vital 
power is not reduced along with the vital actions. Of course, where these 
actions are altogether arrested, life, which is sustained by them, ceases, and 
the vital power ceases with it. This is not contradictory to. the statement 
alluded to. But the continued operation of a considerable degree of cold 
does produce debility, and especially so, when the cold is united with an im- 
poverished diet. A part, by being long restrained, loses at length the power 
to act, though moderate rest might only invigorate it. In the reaction which 
generally succeeds exposure to cold, the increased exercise of the functions 
produces an increased expenditure of blood, which can only be sustained by a 
sufficient supply of aliment. The additional heat, therefore, which accom- 
panies, this reaction, and counteracts the external cold, is derived ultimately 
from the food. If this be deficient, the, reaction and its attendant increase of 
calorification cannot be sustained; and the system is left unprotected to the 
depressing influence of the cold. Hence the state of debility, into .which per- 
sons in the lowest stations of life are apt to fall, during winter, under the 
combined influence of cold and bad living, and which, in such individuals, is 
SO apt to end in the production of low forms of fever, or to induce the typhous 
state in diseases having another origin. 
6. Direct positive Causes.-The causes hitherto mentioned have been of a CHAP. I.] 
DEPRESSION. 
63 
negative character, consisting in the diminution of some wonted stimulus. 
There are others which, act directly and positively. Among these is warm 
water. The depressing effects of this agent are obvious in the local relaxation 
produced by warm fomentations.;or poultices, and the general relaxation, 
amounting sometimes Ao fainting, which results from the use of the warm 
bath. Similar relaxation, attended with nausea, is well known to succeed 
the use of warm water as a drink. The mode in which this cause operates 
will be explained under the general head of the causes of disease. 
Warm water appears not only to diminish action, but to impair both the 
power and excitability of. the part on which it acts. ITenCe we do not observe 
that reaction following its application, which -is' so apt to follow the application 
of .cold. On this account, it is often much preferable as a remedial agent. 
It may be said not to be universally depressing, as it often greatly promotes 
perspiration, whether taken internally or applied to the skin. But perspira- 
tion is often the .result of pure relaxation and debility of the skin; the serous 
fluid passing through the vessels, because they have not sufficient energy to 
resist it. Such is probably the case when it arises from the application of 
warm water, except, indeed, so far as the water may be absorbed, and act 
upon the secretory function by-the stimulus of distention. 
Numerous poisons act as depressing agents by a direct sedative power. 
Such are the contagion of typhus fever, the effluvium from congregated per- 
sons in unventilated rooms,-■hydro-sulphuric acid, hydrocyanic acid, digitalis, 
tobacco, the -preparations of lead, &c. 
To the same division belong the depressing passions, such as grief and fear, 
the influence-of which is often fatally felt at periods of public calamity, either 
in a greater tendency to low forms. of disease, or in greater susceptibility to 
any. prevailing epidemic. Some of the excitant passions also occasionally 
produce appearances of depression; as when, in a fit of violent anger, the face 
becomes pale instead of being flushed, as it usually is, and the pulse feeble 
instead of being excited. But these appearances are probably owing to a 
concentration of action in the brain, withdrawing it from other parts of the 
system, on the principle of revulsion, or crippling that organ in such a degree, 
that it is unable to transmit the influence necessary for the due action of the 
other organs; 
To the direct causes of depression belong also violent injuries done to any 
.particular part,, as by a severe blow,-, suspending immediately its functions, 
without any previous excitement. Here it is obvious that the action only, 
and not the powers of the part are depressed, unless, indeed, the violence has 
been sufficient to destroy its life; for) except in the latter case, reaction always 
follows the temporary depression, and generally ends in inflammation, often 
of a very high grade. 1 
c. Indirect Causes.-It is a well'established law of the animal economy, 
that undue action is followed by subsequent depression. The excitability is 
diminished by a-too energetic exercise, and will not for a time respond to the 
ordinary amount of stimulus. A temporary , diminution of action is, there- 
fore, a necessary result. In cases of violent excitement, the subsequent de- 
pression is proportionably great, sometimes even to the destruction of life; 
as where severe inflammation is succeeded by gangrene, and the stimulant 
operation of a poisonous quantity of opium, by fatal prostration. But, if 
this danger be avoided, the. excitability is gradually recruited by rest, and 
health is after a time restored. If, however,- previously to this return to the 
normal state, the organ or system be. again stimulated; as a greater amount 
of stimulation is requisite, so is the exhaustion of excitability, and the con- 
sequent depression greater. By a continued repetition of this course, a state 64 
GENERAL PATHOLOGY. 
[PART I. 
of great prostration is occasionally induced; and the diminished action is 
here attended with a diminution both of power and excitability. Examples 
of this kind we have in systems worn out by repeated and long continued 
excesses. . . ' . '• . 
Excitement in one part produces depression in another, upon the principle 
of revulsion, as already explained under the head of irritation. Thus, depres- 
sion, or a want of due action in the stomach, not unfrequently results from 
undue excitement of the brain, as in severe and continued study; and nothing 
is more common than deficient action in the extremities, in cases of a morbid 
excitement of some central organ. ' ' 
Disease, whether of excitement or depression, existing in a particular sys- 
tem or organ, and interfering with the proper performance of its functions, 
very often produces depression in the dependent functions. Thus, pressure 
upon the brain, or organic changes in its structure, are frequent causes of 
paralysis. Cases of depression from this cause are almost innumerable. 
Death, in fact; is in most instances only the last stage of depression in the 
vital actions, consequent upon disease in some one or more organs, whose 
integrity is necessary to the sustenance of' these.-actions. It is' obvious, how- 
ever, that it is, in general, not the depression, but the local disease which 
requires treatment; and, as this is often inflammatory, serious mistakes are 
sometimes made by stimulating for the apparent prostration, when depletion 
is required for the removal of its cause. We may rank in this category those 
cases of severe and occasionally fatal prostration, which result from a shock 
upon the nervous system, so powerful as to suspend or materially interfere 
with its functions. Such is -the prostration sometimes produced by concus- 
sion of the brain, by sudden and startling intelligence, by very severe sur- 
gical operations, &c,, 
It is highly probable, that the sympathy between our different organs is 
extended, as well to states of depression, as to those of excitement or irrita- 
tion. This is denied by some, and M. Begin maintains that it is impossible 
for a debilitated organ to transmit^ by sympathy, a similar condition to any 
other organ. -His opinion seems to be grounded upon the idea, that each 
sympathetic impression is necessarily the result of action in the impressing 
organ. But this is not essential, Sympathy between separate parts is such 
a connexion as enables one part to share in any impression made upon an- 
other, of whatever nature the impression may be; and it is as easy to con- 
ceive, that a depressing agency may propagate . its influence in this way, as 
one of excitement. We know that cold, applied externally, often arrests 
internal hemorrhages; as when cold water is applied to the head in epistaxis, 
to the armpits in haemoptysis, and over, the pubes in uterine hemorrhage. 
In all these instances,'the vessels of the internal mucous membrane partici- 
pate in the .depressing effect of the'cold upon the Cutaneous capillaries. 
3. Phenomena, Effects, &c., of Depression.-In every case of depres- 
sion, there is a diminution of activity in the function of the part, organ, or 
system affected. If the whole system is affected, all the functions are depressed. 
This seldom happens unless for a short period before death, or during some 
sudden collapse, as in syncope. It is wholly unnecessary to detail the symp- 
toms of depression, so far as they are obviously a mere diminution of the phe- 
nomena of health. To say'that sensation, muscular motion, and intellectual 
action are impaired, that digestion is less vigorous in all its departments, that 
absorption goes on more slowly, that the heart beats less frequently and more 
feebly, that secretion and nutrition are diminished, and that less animal heat 
is evolved, is merely to express the fact of the depression of these various 
functions. But phenomena frequently occur, which are strictly the results of CHAP. I.] 
DEPRESSION. 
65 
depressed action, and yet bear so much resemblance to those of super-excite- 
ment or irritation, that they may be and often are confounded with them, to 
the great detriment of the patient. These, therefore, it is important to dis- 
tinguish ; and, in reference to them, I shall run through The several functions, 
touching upon such points, in Oach, as may seem to deserve notice in a general 
treatise. 
Depression in the nervous system, though marked, in its extremes, by want 
of sensation and muscular motion, and a general failure in all the dependent 
vital actions, is frequently attended with irregular muscular movements Of a 
convulsive or spasmodic character, which might readily be mistaken for the 
effects of irritation. Such movements we sometimes see as the result of bleed- 
ing carried nearly or quite to syncope, and of the administration of sedative 
poisons, as hydrocyanic acid, which generally gives rise to convulsions in the 
midst of the greatest prostration, and almost at the point of death. How 
spasm should result from the two-opposite conditions of nervons irritation and 
depression, we, cannot certainly explain, without a more intimate knowledge 
of the nature of nervous action. It' is not difficult to give a hypothetical ex- 
planation. Allowing the nervons power to be analogous in its action to gal- 
vanism, we have only to suppose that a diminished supply is, in consequence 
of a depressed condition of the nervous' system, transmitted to the alternate 
particles of an ultimate muscular fibre, which, being thus brought into a 
negative state in relation to the neighbouring particles of the same fibre, would 
necessarily approach them and thus produce contraction; while the same 
result would follow a similar disturbance in the natural equilibrium of the 
fibre by the transmission of an excessive supply, in consequence of nervous 
irritation, to the same, or to the remaining set of particles. This, it is true, 
is mere speculation; but it is sufficient to show, that there is no necessary 
contradiction in the ascriptiofi of spasmodic muscular action to the two opposite 
causes mentioned; and the fact appears to be too well established to admit of 
reasonable denial. It is important in a therapeutical point of view; as it may 
often save us a vain search after some point of irritation which does not exist, 
and prevent the application of depressing remedied, when the morbid affection 
is its'elf the direct result of depression. But spasm is not the only disturbance 
consequent upon diminished nervous action, which might be mistaken for the 
effect of excitement. Restlessness, obstinate wakefulness, excessive pain and 
other deranged sensations in infinite variety, irregular perception, and an un- 
settled state of intellect amounting to delirium, may all result from positive 
nervous depression. 
In treating of dyspepsia, I shall hereafter have occasion to show, that various 
phenomena are the immediate consequences of a depression of the digestive 
function, which might easily be confounded with the effects of irritation or 
even inflammation of the organs conperned.. 
The function of absorption is not so obvious to examination as to afford the 
means of detecting accurately the nature of its irregularities. It is a well 
established fact, that the amount and rapidity of absorption are, to a certain 
degree, inversely proportionate to the fulness of the blood-vessels, and the ra- 
pidity of the circulation; so that the process is often most vigorous in a state 
of general debility and depression. But it is difficult to determine, whether 
this result arises from a positive invigoration of the absorbent apparatus, or 
from a mere passive admission of liquids into the vessels, in consequence of 
diminished resistance within, and relaxation of the coats of the vessels them- 
selves. 
Respiration is sometimes, by a direct reduction of the function, thrown 
into great disorder, which, without attention might easily be ascribed to an 66 
GENERAL PATHOLOGY. 
[part I. 
opposite cause. In very low forms of disease, in the last stage of diseases .of 
debility, even immediately antecedent to the dying struggle, or as a part of 
that struggle, we occasionally see hurried respiration, the most painful sense 
of oppression or suffocation, and violent voluntary ^efforts to expand the chest, 
without the least evidence of inflammation or irritation of the lungs. The 
same hurried breathing is not unffequently met with in infants, when debili- 
tated by disease or depletory treatment, especially in cases in which the lungs 
or bronchial membrane, having been previously inflamed, are left in a weak- 
ened condition upon the disappearance of the inflammation. In the latter 
case, the Occurrence of this condition has probably often been ascribed to, an 
increase of the inflammation, and fatally regarded as a signal for further de- 
pletion. It is not difficult to explain this agitated state of respiration. A 
due amount of activity in the'capillaries of the lungs is necessary to transmit 
the blood from the pulmonary arteries'to the pulmonary veins, and thus sus- 
tain the circulation. If the fiction of these vessels be depressed, there is to a 
certain extent a stagnation of the blood, the due quantity does not reach the 
left side of the heart, and the due supply is not sent over the system. Be- 
sides, in a depressed condition of the proper respiratory function, the change 
from venous to arterial blobd is more imperfectly effected; so that the blood 
which does circulate over the body is not in a condition to fulfil its various 
offices. Now this deficiency in the quantity and quality of the blood is felt 
in all the organs, and the sympathies which have been established for the 
regulation of the various mutually dependent functions, determine, as a result 
of this feeling in the organs, that the respiratory movements should be more 
rapidly effected, in other words, the muscles concerned in the office stimulated 
to increased action, in order that an increased supply of air, should be furnished 
to the lungs. It is- the' same feeling that leads to hurried respiration in- a 
very rarefied atmosphere, and in cases- of great fatigue; and, in these cases, 
the end for which the sympathy was established is obtained. But, in the 
cases before alluded to, the feeling is delusive; as it is not an increased Sup- 
ply of air that is wanted, but increased activity of the proper respiratory pro- 
cess-in other words, the due arterialization of the blood. The violent efforts, 
therefore, which are often made to breathe, do not afford relief; and, unless 
the existing depression of the function be obviated, the patient dies. It is 
obvious that relief must be sought for, in these cases, from sources very dif- 
ferent from those to which recourse is had in an excited condition of the lungs. 
Happily, the present modes of exploring, the condition of these organs, very 
greatly facilitate the forming of a correct diagnosis in the cases referred to. 
The circulation affords more" of these apparent anomalies than any other 
function. Allusion is not here had to the increased action of the heart, which 
is so frequent an attendant upon debility, and which, as before explained, is 
a positive irritation dependent on the increased stimulation and excitability of 
that organ. A depression in the action of the heart, without a corresponding 
depression in that of the extreme vessel's, necessarily causes the blood to accu- 
mulate in the large venous trunks, and in the organs in their immediate 
vicinity. The heart cannot send forth the blood so rapidly as it passes from 
the extreme arteries into the venous ramifications, and thence into the larger 
vessels, in its return towards the centre of the circulation. Hence arises en- 
gorgement or congestion of the venae cavse, the liver, brain, &c., which is a 
frequent attendant of diseases of debility, and is sometimes viewed, though I 
believe erroneously, as the most, prominent symptom, and that from which 
most danger is to be apprehended.. Such diseases have, therefore, been named 
congestive diseases; and attention has been particularly directed to the treatp 
ment of the congestive condition of the organs, with the effect of calling it CHAP. I.] 
DEPRESSION. 
67 
away from-the real fountain of mischief, the enfeebled action, namely, of the 
heart. It is not' here pretended to be denied, that engorgement of the internal 
organs does occasionally occur as an original affection, nor that, even when 
it proceeds from the cause alluded to, it may very properly be the subject of 
special treatment: but it is highly important, in the latter case, that our the-, 
rapeutical efforts should be directed.mainly a to, the state of the circulation, qr 
of the general forces in a failure of which the heart may participate, and that, 
in attempting to relieve what is nothing more than an effect, we should take 
care not to aggravate the cause. 
Sometimes, in enfeebled capillary circulation, there are paleness and shrink- 
ing of the part, as if the blood were not allowed to enter the vessels in the 
usual quantity ;• in other cases, the blood penetrates the vessels, but is moved 
slowly, and, being detained till it has assumed the. venous character, gives 
rise to a dark red colour, which is in some instances scarcely distinguishable 
from that which occdrs in certain stages or Varieties of inflammation. This 
resemblance is still further increased by the circumstance, that the caliber of 
the relaxed vessels is ' sometimes- augmented, probably from a loss of equili- 
brium between the forces which- carry the blood to and from the vessels 
affected. Even vessels before colourless then become of a deep red colour, 
and swollen, in consequence of the admission of a greater amount of blood. 
This state We observe not unfrequently in malignant diseases, and those of 
great debility. It is not uncommon for the conjunctiva of the eye) under 
these circumstances, to become r.ed and swollen; and the same thing occurs 
upon other membranes, and upon the skin. It is an entirely different condi- 
tion front that of inflammation; as it is attended with no pain or increase of 
heat, and none of those new products which mark that affection. It may, 
however, follow inflammation, which sometimes leaves the vessels enlarged 
and debilitated, after its own proper actions have'entirely ceased. We see it 
frequently in diseases, such as scurvy, attended with a .depraved condition of 
the blood, which, though it enters the capillaries, is incapable of affording 
them the amount of stimulus requisite for sustaining their healthy action. 
We see it also in persons whose circulation is enfeebled by age, particularly 
in the extremities, where the vital-contractility of the vessels is insufficient to 
resist the force of gravity. From the same cause, in cases of great debility, 
it may be observed as the mete result of position, in-the back, or in other 
dependent parts, sometimes even in the portion of the lung which may be 
lowermost. It is probable that an engorged state of debilitated capillaries, 
when observed, after death, in the ulterior organs, as in the mucous mem- 
brane of the stomach and bowels, has- often been mistaken for the immediate 
effect of inflammation. When this condition -Occurs externally, slight pres- 
sure will frequently induce gangrene by putting an entire stop to circulation 
in the part. - • ■ 
Another occasional attendant upon depression, which might be mistaken 
for an effect of irritation, is hemorrhage. This depends'upon debility of 
the blood-vessels, the coats of which are relaxed, and incapable of affording 
that vital resistance to the passage of liquids through them which is one of 
the characteristics of the healthy tissue. It probably never occurs from 
mere depression without positive debility. The vessels approach to that con- 
dition in which they arc after death, and in which it is well known that blood 
often percolates through them into the dependent parts of the body. This 
hemorrhage of debility is common in diseases in which the blood loses in part 
or altogether its coagulability, as in malignant typhus, and some cases of pur- 
pura and scurvy. It is apt to proceed from the mucous membranes, particularly 
from those of the nostrils and the bowels; and to a very slight extent is com- 68 
GENERAL PATHOLOGY. 
[part I. 
mon in the skin, constituting the petechias which are so often present in the 
above-mentioned diseases. 
The result which might be inferred from depression of the nutritive func- 
tion is atrophy, or loss of substance in the organs, which may be universal, 
affecting all parts of the body, or confined to some one part or organ. Atro- 
phy, however, is not always necessarily the result of depressed nutrition. It 
may, and probably often does originate from-an excessive activity of absorp- 
tion, the nutritive deposition not being diminished in quantity. This is pro* 
bably the case in those instances of universal emaciation which are accompa- 
nied with a good appetite, and apparently active digestion. But there is 
reason to believe that diminished, energy in the process of nutrition, instead 
of being attended with loss of substance, is sometimes actually productive of 
excessive growth. The amount of organizable matter eliminated from the 
vessels is by no means an accurate measure of the activity of the function. 
An excess of this matter may escape from debilitated capillaries from a want 
of the due degree of contractile action necessary to prevent its egress. Nutri- 
tion requires not only an elimination of the organizable material, but also a 
process of organization; and /it is only when this process is efficiently con- 
ducted, and in due relation with the excess of matter acted upon, that the 
function can be asserted to be in a state of positive excitement. If the 
organizing process is incomplete, or inadequate to' the conversion of the 
material into sound and healthy structure, nutrition may be, in fact, in a 
depressed state, even along with excessive growth. An example of this we 
have in fungous granulations, arising from .debility of the granulating surface; 
It is not uncommon for this sort of morbid growth to be prqduced in wounds 
or ulcers by local or depressing applications. Emollient poultices, which, in 
consequence of their nioisture, are positively depressing, often produce this 
effect when too long continued.. The weakened vessels allow the escape of 
an excess of material, while there is insufficient energy to produce a sound 
organization; and the new structure, though too abundant, is of a loose flabby 
consistence, incapable of performing the proper office of healthy granulations, 
and possesssed of a very feeble vitality. - 
In relation to secretion, though a diminution of the amount of secreted 
matter is the usual consequence of a depression of the function; yet the same 
condition is not unfrequently attended with a great increase of product beyond 
the normal quantity. The immediate cause is probably the same as in the 
cases of hemorrhage and excessive nutrition. The vascular pores or secreting 
orifices of the capillaries lose, in the relaxation of debility, that vital organic 
contraction which resists the mere mechanical exit of fluids, or that vital 
power of election and elaboration by which the peculiar secretory product is 
formed out of the blood, of which, therefore, the more fluid parts escape, often 
in great abundance, and with little modification. The profuse sweats so fre- 
quent in debilitated states of the system, and which are most abundant in 
sleep, because, in that condition, the organic actions in general, and conse- 
quently that of the skin, .are less energetic, than in the waking state, are 
examples, of this kind.A So are, in many instances, diabetes, diarrhoea, and 
dropsical effusion; and, in a less degree, the excessive pulmonary secretion 
which sometimes follows bronchial inflammation, after the inflammatory 
action has subsided, and the excessive secretion of a badly elaborated pus, 
which sometimes takes place from the debilitated or relaxed surface of ulcers. 
This excessive secretion, or perhaps we should rather call it exhalation, de- 
pendent on debility, is most common in a watery condition of the blood, in 
which the material for the exhalation is most abundantly offered, while the 
stimulant property, which tends to sustain the propel- healthy energy of the CHAP. I.] 
DEPRESSION. 
69 
secretory process, is diminished. There is another mode in which secretion 
is produced by a depressing or sedative agency. It has already been stated, 
that a certain degree of excitement checks secretion. The skin is usually 
dry in fevers, because excited beyond the point of perspiration. Depress the 
action of the over-stimulated vessels, and secretion is restored. Thus, the 
application of cold water to the hot' and dry surface of the body, in the febrile 
state, will often induce perspiration; and the same result' frequently follows 
the internal administration of nauseating substances which relax the skin. 
The influence of depression in indirectly inducing irritation, either in the 
same part, by increasing the excitability and thus giving rise to reaction, or 
in other parts, by directing away from its own seat a portion of the circu- 
lating fluid and nervous energy, and thus.concentrating, them elsewhere, has 
already been sufficiently treated of. 
Though depressing causes do not necessarily produce real debility when 
they act but for a short time, and, under the same circumstances, often in- 
crease excitability; yet, when long continued, they do occasion both debility 
and diminished excitability. A part which, if restrained from action for a 
brief period, will afterwards often act more energetically, under a long con- 
tinued restraint, loses at length its susceptibility and its p'ower of action, and 
becomes as it were paralyzed. Again, if the restraint be continued remit- 
tingly, so as to allow of occasional reaction, or steadily, in so moderate a 
degree that the accumulated excitability may at times overbalance the de- 
pressing cause, and occasion super-excitement, still, ultimate debility, or 
exhaustion is produced. The excitability is either worn out' by undue exer- 
cise, dr, the parts affected being thrown into irregular reaction beyond their 
depressed potvers, organic mischief results. When the depressing agent is 
intermittingly applied, with intervals sufficiently long to admit of the full 
influence of the natural recuperative powers, if the system escape immediate 
injury, no ultimate evil is experienced; but, on the contrary, an invigorating 
effect may be produced by rousing the sleeping energies into action. Thus, 
the occasional application of cold to the body, alternating, as in civilized life, 
with a comfortable temperature, often produces a healthy excitement by Ihe 
reaction which it calls forth; but, if long continued, with little or no remission, 
it either directly destroys life, or gibes rise to a general debility which causes 
the system to sink into a typhoid state, whenever attacked by disease; while, 
remittingly applied, it is apt to Occasion troublesome reaction, in which the 
excitement is not supported by the powers of the part, as in the case of frost- 
bite or chilblain,•'not unfrequently ending in ulceration or gangrene. 
Depression may end in organic changes quite as serious as those which 
follow, inflammation; nay, there is reason to believe, that two of the most 
important results of this kind which flow from the latter cause, may occasion- 
ally be produced in a direct manner by the former, namely, softening and 
mortification. • " ■ ' ' 
Softening.-This has already been treated of as one of-the effects of inflam- 
mation. But it not unfrequently happens that a part is found, upon examin- 
ation after death, to have completely lost its healthy tenacity, and even to 
have been reduced into a sort of pulp, without the least evidence, other than 
the softening itself, of inflammation having existed either in the part affected 
or the neighbourhood. The colour of the part is unchanged, there is no 
injection of the blood-vessels, and none of those peculiar effusionsbare ob- 
servable which invariably attend inflammation when severe and lasting. The 
result is most probably to be ascribed to a direct loss of vital power and action, 
interfering with the healthy performance of the ordinary nutritive process. 
In other words, it is a deranged and reduced nutrition of the part. That the 70 
GENERAL PATHOLOGY. 
[PART I. 
softening does not proceed from the absolute loss of vitality, and the entrance 
of the part 'within the domain of chemical laws, is evinced by7 the absence of 
fetor, which always attends putrefaction. Softening, therefore, differs from 
gangrene, though, in its extreme forms, it may end in the death of the part. 
It may arise either from the absence of those constituent particles or mole- 
cules upon which the hardness of particular structures depends, as in the case 
of rachitis, in which the earthy salts are not deposited in due proportion, or 
from a want of due firmness in all the particles; or of due vital cohesion 
between them. ' • , 
Softening may affect the tissues generally, rendering the bones brittle or 
flexible, the muscles flabby, the cellular tissue lax/ and all the soft parts of 
the body less firm and resistant, as in ■some cases of scrofula, in scurvy, and 
in persons living on a meagre'diet, in whom the blood is incapable of yielding 
proper support to the process of nutrition. The affection, moreover, may be 
confined to particular portions of the bpdy, as for example to a paralytic 
limb; or still more narrowly to soihe single organ, as the heart, the stomach, 
or the brain. It is not unfrequently quite circumscribed/and limited to a 
very narrow space. It is often associated with atrophy, and arises from the 
same causes. Even when the result of inflammation, it may, at least in its 
advanced stages, be still considered as directly flowing from a depressed con- 
dition of the nutritive function, consequent partly on the previous excessive 
excitement, partly on the local obstruction of the circulation; and, in this 
case, may be regarded as a forerunner of gangrene. 
Care is necessary, in post-mortem examinations, not to confound this con- 
dition with cadaveric softening, which may result from the infiltration of the 
solid parts with fluids, from the solvent action of the gastric juice, or from 
incipient putrefaction. 
Gangrene.-This has already been defined to be the death of a part, with- 
out the death of the whole body. From whatever cause it may remotely 
proceed,: it is obviously the direct and the last .result of a state of depression. 
If it follow an excitement too violent for the vitality of the part to support, 
it is nevertheless the immediate consequence of the depression which, neces- 
sarily ensues after such excitement. If it result from inflammation, through 
the interruption which this sometimes produces in the supply of blood, the 
direct cause is still the depression which arises from the absence of the vital 
and essential stimulus. If it be traceable to a complication of certain morbid 
poisons, or depraved states of health with inflammation, such as occurs in 
anthrax, hospital gangrene, malignant pustule, &c., it is to the depression 
occasioned partly by the direct 'agency of the-superadded cause, partly by the 
exhaustion consequent upon the inflammatory excitement, that the gangrene 
is to be ascribed. But it is often also the direct result of depression, without 
any pre-existing inflammation, or excessive action in the part affected. Such 
is the case with .gangrene following an interrupted supply of blood, occasioned 
by pressure upon the arteries, by the accidental destruction of the vessels, by 
the obliteration of their cavities by means- of coagulated blood or fibrin, or by 
certain diseases of the heart, which disable it from transmitting to the ex- 
tremities the necessary Quantity of blood for the support of their vital actions. 
Such al^o is the case with the gangrene produced by certain positively de- 
pressing agents, as excessive cold, large quantities of ergot, and local violence 
so great as to destroy the life of the part without previous'reaction. 
There is in gangrene a total absence of all the phenomena of life in th'e 
part. There is no sensibility, no circulation, no active movement whatever, 
no generation of animal heat. But these are not unequivocal signs of the 
loss of vitality. They may all exist, and. yet the part may be living, and, CHAP. I.] 
DEPRESSION. 
71 
with proper care, may be restored to its healthy actions, as not unfrequently 
happens after the apparent death of a part from cold, violence, or some 
mechanical interruption to the circulation. It is of the greatest practical 
importance that, in such cases, the apparent should*not be mistaken for real 
death; for a neglect? of the' proper measures of restoration will eventuate 
often in the most serious consequences. Tlie only certain sign that morti- 
fication has really taken place) is the commencement of putrefactions . This, 
under ordinary circumstances, always takes place sooner or later after the 
death of the part. But,.though indispensable as a sign of gangrene, this 
may have occurred, and mdy continue to exist for a considerable time, with- 
out it, as when it has resulted from cold, or in parts destitute ef fluids, or 
secluded from the contact of air. Sometimes putrefaction is concurrent with 
the mortification, especially when the latter is the Consequence of inflamma- 
tion, and the part is exposed to the conjoined influence of air, moisture, and 
warmth. Besides the loss of sensation, vital movement, and animal heat, 
there is generally, even in cases where putrefaction has not occurred, a change 
of colour and .consistence, dependent partly upon alterations antecedent to 
the loss of vitality, partly, to those simultaneous with the mortification. 
Putrefaction is the decomposition which occurs under the influence of chemical 
affinities. In this condition, there is an offensive odour consequent upon the 
disengagement of fetid gases, usually more or less emphysematous swelling, 
infiltration with dark, turbid liquid, and a loss of cohesion, sot that the tex- 
ture may be easily torn in any direction. In some instances, however, as in 
the affection denominated dry .gangrene, the parts are hard,' shrunk, and dry, 
like the flesh of mummies; and the smell, though fetid, is much less so than 
in ordinary cases. , ; 
In the state which precedes gangrene, in that which is presented by the 
living parts in the vicinity of the dead, of mingled with them during its pro- 
gress, and in the earlier or later occurrence of putrefaction, there are sources 
of such diversified and complicated phenomena, that it would be wholly out 
of place, in a general treatise, to attempt to describe all their possible com- 
binations. When the gangrene has originated jn inflammation, the pheno- 
mena of the latter affection, in its various stages, are mingled with those of 
the former. It may be proper* to mention here, that, though sensibility is 
usually diminished in the progress of the mortification, violent pain is some- 
times experienced, as in the gangrene which attacks the extremities of old 
persons. In such cases, the tierves appear to, preserve, for a time, their 
vitality in the midst of the mortified structure, and are thus exposed to irri- 
tation from the contact of what has now become foreign matter; or the pain 
may arise, as in neuralgia, from some inappreciable modification of the nervous 
tissue. Sometimes the mortification advances gradually, without any apparent 
disposition to set limits to its extension, till it has., destroyed the life of the 
patient. Generally, however, it is either confined to the spot originally 
affected, or is arrested at some.point of its progress; in which case, inflam- 
mation occurs in the living parts in contact with the dead, and the latter are 
separated by the ulcerative absorption, as already described under the head of 
inflammation; Occasionally, when the constitutional tendency to 'gangrene 
is strong, mortification recommences, after having been temporarily arrested; 
and this alternation may oebur several time^ till at length the affection 
ceases, or the patient dies. The period required for the separation of the 
slough is exceedingly various, according to the vigour of the constitution, 
and the nature of the part affected. Under favourable circumstances, as in 
persons of good constitutions and previously vigorous health, and in soft 
highly vital parts, the separation is effected in eight or ten days; but, under 72 
GENERAL PATHOLOGY. 
[part I. 
opposite circumstances, it is sometimes greatly protracted, even to two or 
three months or more. 
The degree of danger from gangrene varies with its extent, the importance 
of the organ affected, the previous condition of the patient, and the nature 
of the attendant diseases. When external, and of moderate extent, it seldom 
proves fatal; while a patient often very rapidly succumbs under a very limited 
internal mortification. Still, life is sometimes preserved, though a considera- 
ble portion of some internal organ may be gangrenous. Large portions of 
the bowels have sloughed away, and been discharged per anum, and yet the 
patient has struggled through. A previously feeble state of health, or the 
co-existence of some depressing malady, very greatly increases the danger., 
In cases of internal gangrene, the danger is also increased by the liability to 
the- absorption of the offensive and often very depressing products, which 
result from putrefaction. Other sources of danger, in cases of extensive gan- 
grene, are hemorrhage from the division of some large artery, which may 
slough without the establishment of the adhesive process, and the exhaustion 
consequent upon excessive suppuration, during or after the separation of the 
slough. Gangrene has sometimes proved curative by attacking exclusively 
some morbid structure, as the cancerous, for example, which, if not thus de- 
stroyed, would have gone onward to a fatal issue. As gangrene presents 
phenomena somewhat different according to the tissue which it occupies, it 
will be proper to trace it, at least briefly, through the different tissues. 
In the cellular tissue, gangrene is very apt to occur' as a consequence of 
carbuncle and erysipelas phlegmonodes, and when parts in a state of ordinary 
inflammation are bound down by strong fibrous expansions. It is sometimes 
in this situation very extensive, destroying the ..cellular tissue which connects 
other structures, and dissecting out, aS it were, muscles, tendons, blood- 
vessels, and nerves. When it affects the subcutaneous cellular or adipose 
membrane, the skin over the part affected often assumes a gangrenous appear- 
ance, and portions of it slough away, or numerous orifices are made by ulcer- 
ation, so as to permit the escape of the dead tissue. The colour of cellular 
membrane, in a state of gangrene, is a dirty white, or yellowish-white. By 
putrefaction it is converted partly into a grayish, very fetid pulp, which 
is often mixed with pus, and more or less with blood. When discharged 
through ulcerated openings 'in the skin, it often has the appearance of 
wet tow. 
The serous tissue seldom mortifies, unless in connexion with other tissues 
to which it is attached, as when all the coats of the bowel slough in strangu- 
lated hernia. When it does mortify, it becomes black, of a soft almost pulpy 
consistence, and excessively fetid • imparting, however small the extent of the 
gangrene, the same fetid odour to the liquid effused into the serous cavity, 
in which also it produces an evolution of offensive gases. When false mem- 
brane exists, it sometimes participates in the affection, presenting the same 
phenomena as the proper serous tissue. 
The fibrous tissue is among those in which gangrene is established with the 
greatest difficulty. This is especially true of tendon. Nevertheless, these 
structures do occasionally undergo mortification. Their appearance is at first 
little altered.; and it is sometimes- difficult to decide, by the colour alone, 
whether they are dead or living, until the appearance of a red line of inflam- 
mation indicates the limits of the gangrene. But, when long dead, of when 
the mortification is of slow occurrence, they lose their shining appearance, 
become grayish or of a dirty yellowish or ash colour, and soften so that they 
may be torn, .though they are longer in the process of separation than most 
other parts. CHAP. I.] 
DEPRESSION. 
73 
The skin, as has, been before stated; is perhaps more liable to gangrene 
than any other tissue. The appearances which it presents, immediately 
before the death of the part, have been already described. (Seepages 31 and 
32.) After mortification has taken place, the surface, if moist, is of a grayish 
or ash Colour; if dry, is darker and eyen blackish. When the gangrene has 
resulted from excessive cold, or sudden violence, the colour is at first often 
white or yellowish, and ultimately assumes a darker hue. The affected 
portion of skin is usually soft, though somewhat consistent; if the mortifi- 
cation has occurred during suppuration, it is still softer;, and, if the subcuta- 
neous cellular tissue has been at the same time inflamed, it is converted into 
a grayish pulp, and mingles with the ichorous pus from the parts beneath. 
In dry gangrene the skin is dry and'shrunk. 
In mucous tissue, which is occasionally, though not very frequently, the 
seat of gangrene, the mortified part is fetid and very soft, so that it may be 
readily removed by scraping with the back of a scalpel from the subjacent 
structure. The- colour is sometimes white at first, but is ultimately gray, 
slate-coloured, or blackish. When the gangrene is consequent upon inflam- 
mation, the neighbouring parts are usually of a livid redness, very soft, and 
considerably swollen from the infiltration of a fetid, bloody, serous fluid. 
In the glandular tissue, gangrene is not frequent, and, when it occurs, 
presents the ordinary appearances which characterize the affection. In the 
blood-vessels, it is exceedingly rare us an original affection, the vascular tissue 
having an extraordinary power of resisting mortification, and often remaining 
sound in the midst of a mass of gangrene. Little is known of the affection 
in the absorbents, though the lymphatic glands occasionally undergo mortifi- 
cation. Muscles, in a state pf gangrene, are usually of a dark livid colour, 
though sometimes, when not exposed to the air, they are yellowish or grayish, 
and are black in dry gangrene. G-'endrin states that gangrenous eschars of 
the heart are blackish or greenish. Mortification is very uncommon in nerves, 
unless when pervading the whole structure of which they form a part. It 
occasionally occurs in the brain, though rarely. In this structure, the gan- 
grenous part is gray or blackish, very soft, and very fetid. But fetor and 
softening are not certain signs of mortification; for the latter is often pro- 
duced by inflammation, and the former may occur from the decomposition of 
the pus, when from any cause, as in cases of external violence, air has admis- 
sion to the part. In bones, gangrene is not unfrequent, and is perhaps pro- 
duced more readily by an equal amount of cause than in any other tissue. 
The mortification of bones is attended with phenomena somewhat peculiar, 
which hate given it a distinct name, and have led to especial attention. It 
is usually denominated necrosis. Of this affection, however, as it is consi- 
dered as falling within the province of the surgeon, I shall not treat in this 
place. It is sufficient to say, that it may occur as a result of inflammation, 
which the feeble vitality of the tissue is unable to resist, or from direct 
depression through the agency of cold or an interrupted supply of blood, as 
when the periosteum or medullary membrane, upon which its nourishment 
depends, is separated from the bone or destroyed. The dead portion of the 
bone is separated by ulcerative absorption, and through the same agency is 
ultimately discharged, if the patient do not sink during the process. The 
mode of separation is highly interesting, and affords a beautiful illustration 
of the resources of the system; but the reader is referred to works on surgery. 
The effects upon the system produced by gangrene, when extensive or 
internal, especially when it affects a vital organ, are very striking. The 
pulse is very feeble and frequent, and often irregular; the skin is pale or of 
a sallow tinge, and is bathed in a cold clammy sweat; the respiration is dis- 74 
GENERAL PATHOLOGY. 
[PART I. 
ordered; the features are sunken, with an expression of wildness or great 
anxiety, though no pain may be felt, and the sudden cessation of any pre- 
existing pain is considered as an evidence of commencing mortification; there 
is usually great thirst, and frequently more or less nausea and vomiting; the 
abdomen is often tympanitic; and great disorder of the nervous system is 
evinced by subsultus tendinum, singultus, deranged sensations of various 
kinds, and even delirium. But these symptoms, which, occurring in the 
last stage of inflammation, and epecially when attended with a sudden cessa- 
tion of pain, were formerly very commonly considered as certain proofs of 
mortification, are now known frequently to take place in cases-which exhibit 
no appearances of gangrene after death. The probability, however, is, that, in 
many of these cases, gangrene is not discovered only because the patient sinks 
under the disease, before the local affection has had time to run into absolute 
mortification; and that, in others, though death may have occurred in the 
part, yet general death bas so speedily followed, that no time has been' allowed 
for the commencement of putrefaction, which, as before observed, is the only 
unequivocal sign of gangrene. 
Article IK 
CONGESTION. 
Tins may be defined to be, an unhealthy accumulation of blood in the 
blood-vessels of any part of the body. It often has its origin and chief seat 
in the capillaries; but it may extend also to the arterial and venous ramifica- 
tions, and even to the larger trunks. It is considered by some writers as of 
primary importance in disease; but it is always an effect of some pre-exist- 
ing morbid state or action; and it is a partial view which is directed to this 
effect alone, without embracing the other elements that enter into the com- 
plex phenomena presented by the part congested. There is probably no form 
of congestion which may not be traced to some one of the morbid affections 
already described; and its varieties have consequently been treated of along 
with the other phenomena, or effects of these states respectively. Yet a 
general connected view of the subject may, perhaps, be proper, in reference 
both to the real importance of congestion as itself, in many instances, a 
source of inconvenience or danger, and to the prominence which has of late 
been given to it by some-practical writers. 
There are three distinct sources of congestion; namely, 1, irritation or 
inflammation; 2, depression; and 3, some purely physical agency. When it 
proceeds from the first cause, it is-' obviously attended with phenomena of 
excitement, and is hence called active congestion f and, as the accumulation 
takes place more especially in the arterial ramifications, and the blood accu- 
mulated has usually the arterial character, it is sometimes also denominated 
arterial congestion. When produced by either of the two latter causes, the 
accumulation is merely a consequence of some interruption in the regular 
flow of the blood, and not of any positive agency, forcing or soliciting a 
greater amount than usual of that fluid, into the distended vessels. The con- 
gestion is, therefore, under these circumstances, called passive, and some- 
times, though perhaps with less propriety, venous; Yor, although the affection 
is in many instances confined chiefly to the veins, it is Hot necessarily so in 
all. I shall treat of congestion under two distinct heads, corresponding with 
these two conditions. , • CHAP. I.] 
CONGESTION. 
75 
1. Active, Congestion:-The reader must be familiar with the fact, so pro- 
minently stated on former occasions, that in every case of excessive capillary 
excitement, there is an increased flow of blood to the part affected, and an 
accumulation in the vessels of that part. Now any excessive or unhealthy 
excitement is, According to the views and nomenclature adopted in this work, 
either irritation or inflammation, the former ending where the latter begins. 
The congestion, therefore, is nothing" more -than a phenomenon of one of 
these affections. But authors usually* restrict the application of the term to 
that condition in which the vessels are merely engorged, and the peculiar 
symptoms Jof inflammation have not yet made their appearance. Conges- 
tion, therefore, in this limited sense, is simply a phenomenon" of irritation. 
To consider it as in itself the disease, is to take a mere sign for the sub- 
stance. Where is the real seat of the morbid action ? Certainly not in the 
blood. It must, therefore, be in the. Vessels themselves. Now an action of 
the vessels, though it may cause, cannot itself constitute congestion. This 
is consequently not the proper morbid action. The disease is, in fact, some 
peculiar modification, not well understood, of the solid tissues, of which a 
change in the innervation always probably constitutes an essential part, and 
which is induced by the operation of some excitant, unhealthy either in its 
nature or degree. In other words, it is irritation. They who regard the 
congestion exclusively, overlook altogether the important circumstance of the 
nervous derangement. 
Even within the limits of healthy excitement, much accumulation of blood 
often takes place, which is not called congestion, simply because it is not 
morbid. We have examples of this in the erectile tissues, as the nipple and 
the penis; in organs called after .a period of repose into renewed action, as 
the stomach during digestion, and the uterus during menstruation; and in 
parts, no matter where situated, which have more than their ordinary duty 
to perform. In these instances, there is often great distension, with increased 
redness and heat; but the parts return ^gain to their usual state in a short 
time, without having suffered injury or inconvenience. The process is en- 
tirely healthy. If, however, the excitement increase, or persist so as to 
induce a .derangement of function, it then amounts to irritation, and the 
attendant sanguineous engorgement is a real congestion. <From what has 
been said, it is evident that the causes of active congestion are those already 
treated of under the head of irritation. The same may be said of its phe- 
nomena and morbid effects. The latter, however, may be summed up-in a 
few words. There are distention, increased redness and heat, and usually 
spme unpleasant or deranged sensation, as a feeling of fulness, weight, or 
oppression; but no positive pain, unless the disease amount to inflammation. 
The functions of the part are always modified, being often increased, when 
the affection is moderate, and deranged, diminished, or altogether suspended, 
when it is severe. Hemorrhage from the distended vessels is not uncom- 
mon. It may arise either from a rupture of the vessel, or from an enlarge- 
ment of the ordinary secretory orifices, the latter of which events is pro- 
bably the most common. There is, besides, a derangement or suspension of 
those functions which are dependent for their proper exercise upon a certain 
influence from the part affected. Hence, disordered vision and hearing, 
disordered sensation generally, and paralytic affections, are often consequent 
upon congestion of the brain. Active congestion may even terminate in 
disorganization of the part, the result being ascribable, when not produced 
by inflammation, to a depression consequent upon a preceding excess of ex- 
citement. 
But I wish again to urge the consideration, that all these effects do not 76 
GENERAL PATHOLOGY. 
[PART I. 
proceed merely from the local accumulation of blood. This is undoubtedly 
an important circumstance, and may be the means through which much injury 
may be inflicted; but it is only a circumstance, and the judicious practitioner 
will look beyond it to the true pathological condition. It is fortunate, how- 
ever, that the means obviously calculated to relieve the congestion are gene- 
rally, in this variety,of. the affection, those most efficient in the cure of the dis- 
ease itself. Still, it is highly important to consider the particular character 
of the irritation in which they originate, as this will very much1 modify the 
extent, and, indeed, the nature of the treatment. 
2. Passive Congestion.-This condition is very different in its origin, cha- 
racter, and indications of cure from that just noticed. The blood is neither 
attracted nor forced, in unusual amount, into the vessels of the part, but 
accumulates in them, because not carried forward so rapidly as it enters with 
the ordinary movement of the circulation. The impediment to its onward 
progress may, as before stated, arise from two distinct sources; namely, from 
a want of a due degree of that action which is necessary to its transmission, 
that is, from depression, or from some physical difficulty or obstruction. 
The depression giving rise to congestion, may be general, or confined to a 
particular organ. Nothing is more common than the occurrence of this con- 
dition, in diseases attended with great and sudden prostration. The heart, 
participating in this prostration, is unable to transmit the blood so rapidly as 
it is conveyed towards it by the continued action of the capillaries, and by the 
forces which move the blood in the veins. This fluid, therefore, necessarily 
accumulates in the right side of- the heart, and the great venous trunks, and 
consequently in those organs with which these trunks more immediately com- 
municate, viz., in the brain, liver, and, through this latter organ, in the ab- 
dominal viscera in general. Instances of congestion from this cause are con- 
stantly occurring. A blow upon the head, or any severe shock, temporarily 
paralyzing the cerebral actions, certain mental emotions which tend to pro- 
duce syncope, the chill of fevers, especially those of a typhous or mfiligiiant 
character, and the prostration of violent intestinal and stomachic spasm, all 
occasion internal congestions consequent upon depression in the movements 
of the heart. But it would be a great error to ascribe the alarming phe- 
nomena which attend these affections, the feeble pulse, the cold extremities, 
the pale and shrunken skin, and the frequently suspended or impaired intel- 
lectual functionSj to the congestion, which is a mere effect of the prostration, 
and ceases when the heart resumes its usual energy. Yet there are not want- 
ing practitioners who overlook, in great measure, the collapse of the nervous 
system, and the feeble movements of the heart, overwhelmed as they both are 
under Some powerfully depressing influence, to 'search- for the chief source of 
danger in the internal sanguineous engorgement; and who direct their reme- 
dies accordingly. Indeed, so far has this mode of viewing things been carried, 
that.affections of the kind alluded to are not unfrequently distinguished by 
the title of congestive diseases; a mere effect being thus prominently set forth 
as the characteristic and most important feature. It is.scarcely necessary to 
say, that serious practical injury may grow out of this error, especially in cases 
where -the depression, as not unfrequently happens, is attended with real de- 
bility, and is not a mere fugitive result of some temporary cause. 
Congestions frequently also arise from local depression, affecting especially 
the capillaries of the part. From causes directly or indirectly operating on 
these vessels, such as have been already enumerated under the head of depres- 
sion, they become incapable of performing their usual part in sustaining the 
onward movement of the blood, which, therefore, accumulates in the vessels 
behind them, especially when these latter vessels happen to be the recipients CHAP. I.] 
CONGESTION. 
77 
of venous blood. Thus, when the capillaries of the lungs become depressed, 
the venous blood, carried regularly towards the right side of the heart, and 
thence sent into the pulmonary arteries, accumulates in the ramifications of 
these vessels, distends their trunks, and even loads the right ventricle, so as 
to produce great venous engorgement of the lungs and heart. So also in the 
liver. A depression of the capillary circulation in this organ, leads to accu- 
mulation in the whole portal system of veins, not only in its hepatic ramifi- 
cations, but in the vessels and their radicles, which convey the venous blood 
from the abdominal viscera to the vena portarum. Hence arise congestions 
of the stomach, bowels, spleen, and liver. Depression in the capillaries of a 
secreting Organ may also promote congestion by diminishing secretion. That 
portion of the blood which is usually thrown out by the secretory process, 
remains in the vessels, and produces a greater fulness than in their ordinary 
state. 
After inflammation, the capillary vessels are often left in an enlarged and 
relaxed condition, which admits the entrance of the blood, by means of the 
vis a ter go, in greater quantities than in the healthy state, and thus occa- 
sions congestion. In this case., the. congestion is entirely passive, and to be 
removed by means calculated directly to produce contraction in the vessels. 
An example is afforded in the blood-shot appearance of the conjunctiva, 
wholly destitute of symptoms of inflammatory excitement, which is occasion- 
ally left behind by a retiring ophthalmia. 
Congestion from purely physical causes is not uncommon. It is often-pro- 
duced, in a certain degree, by the mere force of gravitation. The blood accu- 
mulates in' the vessels of a dependent part of the body to an inconvenient 
extent, even in healthy by a too long continuance in a certain posture. But, 
in cases of debility, in which the vital actions are less capable of countervail- 
ing the opposing physical forces, such congestion is more common and more 
troublesome. For an obvious reason:, it is most apt to occur in the lower 
extremities; but it may also be observed in the posterior portions of the body, 
in individuals who from weakness are compelled to be long upon their backs; 
and it is asserted also to take place in the most dependent parts of the lungs, 
in the same individuals. This form of congestion is by some writers called 
hypostatic.* Whatever obstructs the return of blood along the veins towards 
the heart, is capable of producing passive accumulations in parts behind the 
point of obstruction. The causes of such obstruction have been treated of 
under the head of disease from mechanical causes.. (Seepage 11.) 
These passive congestions, whatever may be their source, are often pro- 
ductive of inconvenience, and sometimes of danger. There is often a sense 
of fulness, weight, or oppression accompanying them, but usually no increase 
of heat; on the contrary, sometimes a reduction of the habitual temperature 
of the part; and the .redness is of a dark, or purplish, or even blackish hue. 
The sensibility to ordinary impressions is often diminished. The serum of 
the blood is apt to escape from the vessels, producing oedema, or dropsy of 
the cellular tissue and serous cavities. Hemorrhage, of the kind denominated 
passive, is not uncommon; the blood appearing to percolate mechanically 
through the parietes of the debilitated vessels.' All the functions of the part 
or organ are more or less deranged, and even fatal disorganization may ensue. 
It is difficult, however, always to determine, how much of these injurious con- 
sequences is due to the mere congestion, and how much to the continued 
* The word is so employed by Trousseau in the Diet, de Med., article Congestion. An- 
dral confines it to the cadaveric congestion which first makes its appearance some time 
after death, in dependent parts of the body. 78 
GENERAL PATHOLOGY. 
[part I. 
operation, of the depressing cause. It is, in any event, however, very obvious, 
that the remedies must be addressed, not 4.0 the.mere abstraction of the blood, 
but to the removal of the cause upon which the congestion depends. When 
the affection is connected with general debility, this remark is peculiarly ap- 
plicable. Bleeding, in such cases, though it may have a temporary effect in 
diminishing the congestion, by lessening the current which is setting con- 
stantly towards the congested vessels, endangers an increase of the debility 
in which the congestion originates, and in which the chief danger lies. 
There are instances in which positive irritation originates in passive con- 
gestions; the blood accumulating in vessels which retain their healthy excita- 
bility, and stimulating these vessels into excessive action. Thus, in congestion 
of the portal system of veins, dependent upon a depressed condition of the 
capillary circulation of the liver, the venous, radicles in the intestinal mucous 
membrane share in the congestion, and are unable to receive the blood from 
the arterial radicles and capillaries, which, therefore, become distended and 
irritated. This irritation not unfrcquently relieves itself by profuse secretion; 
and severe and exhausting diarrhoeas result. 
The appearances of congestion may be presented after death, although 
none may have existed during life. These may occur at the moment of 
death, or not till some time afterwards. The contractility of the arteries 
appears to remain, for a .short period, after respiration and the-movements of 
the heart have ceased, so that these vessels empty themselves into the capil- 
laries, where the blood is retained, and presents, upon post-mortem examin- 
ation, the phenomena of congestion in various parts of the body. This is 
particularly apt to occur, when the patient has died in a plethoric state. 
Cadaveric congestion, occurring after death, is not uncommon, and, as in the 
former case, is most striking when the vessels are left, at the close of life, 
full of blood. From the influerice of gravity, this fluid seeks the. vessels of 
the most dependent parts; and, as the body commonly lies on the back, the 
appearances of congestion are most frequently presented in the skin and 
adipose tissue of the posterior parts of the body, in the meninges' which cover 
the cerebellum, the posterior lobes of the brain, and the spinal marrow, in 
the posterior portion of the lungs, and in those parts of the stomach and 
intestines which are lowermost in the supine position. (Andral.) It- is 
necessary to bear the facts here stated in mind, in order to avoid drawing 
false inferences from post-mortem examination. It may be proper to men- 
tion here, that cadaveric extravasation of blood also frequently takes place, 
staining red the parts, in the vicinity of the vessels from which the blood 
escapes, or forming collections more or less extensive in the cellular and 
serous tissues. According to Andral, it is only the scrum an! red globules 
that are thus extravasated, the fibrin remaining in the vessels. 
Article V. 
EEVER. 
The claims of fever to a distinct consideration in this place rest upon the 
fact, that it is a constituent of numerous diseases, and, though by no means 
simple in its nature, has not yet been, and probably never will be', satisfac- 
torily analyzed. It is necessary, in the first place, in order to avoid confusion, 
to call attention to two distinct applications of the term fever. It is used, 
in a general sense, to signify a peculiar morbid condition of the system com- CHAP. I.] 
FEVER. 
79 
mon to many diseases; in. a special sense, to designate these diseases individu- 
ally or-collectively. Thus, we say of certain complaints presenting certain 
characters, that they are fevers, and of each one of them, that it is a fever ; 
and distinguish the several complaints by some characteristic epithet, as when 
we speak of intermittent fever, typhus fever, yellow fever, &c.; while the term 
fever, in a general sense, is applied to the morbid affection of system found 
in each one and all of these diseases, and giving them, though in other 
respects widely different, that similarity of character which entitles them to 
their common name. It is in this latter sense, exclusively, that the term is 
here employed. This affection is sometimes palled the febrile movement, in 
order to express the idea that it consists of a series of actions, rather than of 
a particular morbid condition;, and the term is perhaps more strictly correct, 
if intended to embrace the whole progress of the affection, in its forming 
stage and decline, as well as in its state of complete developement. 
Much difficulty has been experienced in defining fever. There are certain 
symptoms, which, when associated,, leave no doubt of the existence of that 
affection; but t^ey are not all present at every stage, and in every case, of 
the diseases usually denominated fevers; and there is-no one of them which 
is not occasionally absent. This has been considered as an insurmountable 
obstacle in the way of a satisfactory definition. But the difficulty has arisen, 
in part, from confounding the special diseases with the morbid affection com- 
mon to all. Thus, a definition has been thought imperfect, if it embraced 
any morbid state or action not found in every particular case, and in every 
stage, of every febrile complaint. If eac|i one of these complaints is a fever, 
it is said, nothing can be an essential constituent of fever in general, which 
is-entirely absent iu any part of its progress, andvstilj less, if absent through- 
out its whole course. But the fact is, that, though each disease called a fever 
must, in order to be entitled to the name, present the phenomena of fever in 
general, at some period of its ordinary course; yet these phenomena do not 
constitute the whole affection, and may be quite wanting at certain stages of 
the disease, and even in some entire cases, which terminate fatally before 
they have gone through the regular series of morbid changes. Thus, in the 
fever and ague, the patient,-during the intermission, is undoubtedly labouring 
under the disease named intermittent .fever ; but he cannot be said to be 
affected with fever, in the general sense of that term. In those cases of 
malignant typhus, in which the system never rises out of the prostration of 
the chill at the outset, though the patient may be said to die of typhus fever, 
yet it cannot be assumed that he was in the morbid condition here called 
fever, having perished before that condition was established. A patient in 
the first, or forming stage of a febrile disease, is not in a state of fever. As 
well might we say, that a part whose actions are violently depressed by the 
sedative influence of severe cold, is in a state of inflammation, because in- 
flammation takes place when reaction ensues. The general depression which 
often ushers in fever, bears to it the same relation as the local depression 
bears to the shbsequcnt inflammation. In the first case, the patient may die, 
and in the second case, the part affected may die, before reaction; and then 
neither fever nor inflammation is-established. Hence the necessity, in order 
to attain precision, either in thought or description, to distinguish, as I have 
endeavoured to do, between the state of system called fever, and the various 
diseases called fevers in which this state occurs. 
Definition of Fever.-Fever is an acute affection of the system', in which 
all the functions are more or less deranged; the most striking phenomena 
being sensorial or nervous irregularity, increased frequency of pulse, increased 
heat, and disinclination for food. It will be observed that, according to this 80 
GENERAL PATHOLOGY. 
[part I. 
definition, the essence of the affection is universal derangement of the func- 
tions. The phenomena especially mentioned, are merely the expression of 
this derangement in the functions most prominently affected. But fever, not 
being a simple morbid action, may be only partially developed. Of the various 
derangements which enter into its constitution, one or more may be occasion- 
ally or temporarily absent. The circulation, for instance, instead of being 
excited, is sometimes, under certain extraordinary influences, in a state of 
depression, or even of apparent health. So also with the calorific function, 
which occasionally does not exceed the healthy standard, and still more fre- 
quently falls below it. Nevertheless, except in the forming stage, when fever 
is not yet established, and in the declining stage, when some of its peculiar 
movements have ceased, a frequent pulse and morbid increase of heat are 
very seldom wanting; and fever is not complete without some derangement 
of the circulatory and calorific functions. Indeed, so general and striking a 
phenomenon is heat in fever, that it has given origin to the name by which 
the affection has been designated in most languages. In relation to the other 
phenomena mentioned, such, namely, as indicate some degree of sensorial or 
nervous irregularity, and an impaired condition of the digestive function, they 
are never quite wanting in fully developed fever; and, in the details which 
follow, abundant evidence will be afforded, that not a single function is, under, 
the same circumstances, in a perfectly healthy state. 
The slightest consideration will show, that it is impossible, in a general 
view of fever, to present in detail all the phenomena which may occur in all 
its varieties. The affection is necessarily subject to great diversity. Not 
only is the general grade and course of action different in different cases, but 
the several functions are variously affected, both in the degree and character 
of their derangement; while the various associations of the functional dis- 
order, not to mention the complications to which fever is liable, increase the 
diversities which it offers almost beyond calculation. We must content our- 
selves with an account of the more common, striking, and characteristic 
phenomena, such as are exhibited by fever in its ordinary forms, omitting 
what is peculiar to the several varieties, until these varieties are treated of 
individually. 
1. Forming Stage.-Fever is seldom fully formed at once. Various pre- 
monitory symptoms often intimate its approach, before it can be said to have 
commenced. These constitute what is called the forming stage of fever. 
The first symptom is usually a sense of lassitude or weariness, attended with 
yawning and stretching. The muscles feel as if fatigued, and sometimes 
sore, as if they had been bruised. There is often an aching sensation in the 
joints and limbs, with slight pains in the back, and occasional chilliness; 
sometimes pain in the head or giddiness, diminished appetite, and even 
nausea. The patient is apt to be affected with disturbed sleep, mental con- 
fusion or debility, and depression of spirits; but not unfrequently complains 
of nothing but a vague uneasiness, or feeling of discomfort, which he is un- 
able to refer to any particular part, or to any particular cause. These symp- 
toms are exceedingly variable in degree and duration, sometimes continuing 
for several days, sometimes only for a few hours; and occasionally they are 
quite wanting. They are usually most protracted in fevers which run a long 
course, and shortest in those of high action and brief duration; but this is 
by no means universally true. It will be observed that they arc, for the 
most part, such as indicate derangement in the nervous functions. 
1. Phenomena of Fever. CHAP. I.] 
FEVER. 
81 
2. Cold stagey or Chill.-The occurrence of the cold stage is the first 
decided step in the febrile movement. The onset of this stage is sometimes 
abrupt and striking.; the patient passing into it at once from the slight and 
scarcely appreciable disorder of the preliminary stage, or even from a state 
of seeming health; Sometimes, on the contrary, the premonitory symptoms 
are gradually merged in those of the cold stage, so that it is impossible to 
decide at what point precisely the latter commences;' and there is every grade 
between these two extremes. There is usually at first a greater sensitiveness 
of the surface to the impression of cold, so that a current of cool air, or the 
contact of a cool body, produces a sense of chilliness, which runs momentarily 
through the frame, and then subsides. The feeling of cold, however, soon 
becomes more permanent, and quite independent of surrounding objects, 
beginning most commonly in the back, and extending to the limbs and over 
the body, producing rigors, shivering, chattering of the teeth, and sometimes 
universal tremors and even shaking, though the patient may be near a fire, 
or covered with blankets, in bed. In general, the sensation of chilliness is 
attended with a positive reduction of temperature upon the surface, especially 
in the extremities; but this is not always the case; and instances occur in 
which the 'Skin feels as warm as in health, or even warmer, to the hand of 
another person, while the patient is suffering with cold. On the contrary, 
the sensation is-sometimes'nearly or quite-wanting, while , the body feels cold 
to others, particularly in the extreme parts, as the hands, the feet, the ears, 
and the tip of the npse. In some cases, this want of the sensation of cold 
continues, throughout the chill, in others, it lasts but a short time, and the 
feelings ' of the patient come into harmony with his real state. The feeling 
varies in different cases, from a barely perceptible chilliness, to the sensation 
almost of freezing. The thermometer, placed under the tongue, or in the 
axilla, is said to be sometimes as low as 92°; while the temperature is much 
lower in the extremities. (Thomson on Inflammation!) 
The slight pains of the premonitory stage are increased greatly during the 
chill; or, if pain has not previously been felt, it now generally takes place 
in a greater or less degree, occupying chiefly the back and extremities, and 
not unfrequently affecting the head. The pain in the back and loins is some- 
times exceedingly severe, and even excruciating, especially in violent and 
very dangerous cases, as in malignant small-pox, malignant typhus, and bad 
cases of yellow fever; and the occurrence of these excessive pains in the 
back may usually be looked upon as an unfavourable; sign. The pains pecu- 
liar to this stage are wholly nervous, being unconnected with inflammation. 
There are usually other evidences also of sensorial derangement. Sensibility 
is often diminished, and the mental functions impaired; and even delirium 
occasionally occurs, although this is not common in the chill. 
The circulation, which even before the commencement of the cold stage is 
often languid, now becomes obviously depressed. The pulse is weak/small, 
often irregular, sometimes more frequent, sometimes less so than in health. 
The capillary circulation is slow and feeble. The face is pale, the features 
often shrunk, the skin generally pale and contracted, with the appearance of 
goose-flesh; and, in very bad cases, the fingers are sometime^ shrunk and 
wrinkled, as after long immersion of the hand in water. There is often a 
purplish or bluish appearance in the hands and feet, especially about the 
finger and toe nails, arising from a stagnation of the blood in the capillaries; 
and this appearance, with a feeling of coldness in the same parts to the hand 
of the observer, is occasionally the only phenomenon by which the chill, 
when very slight, is to be recognized. 
The respiration is short and somewhat hurried, and, in cases attended with 
' 82 
GENERAL PATHOLOGY. 
[part i. 
great prostration, is occasionally anxious and laboured; and both the breath- 
ing and the pulse are much accelerated by muscular exertion. 
Nausea and vomiting often occur during the chill, attended with thirst, 
and a dryish, clammy state of the mouth and fauces. 
The commencement of the cold stage is sometimes marked with drowsi- 
ness, which may increase to stupor, and end in a true apoplectic state, de- 
pendent upon congestion of the brain. In other cases, immense prostration 
of nervous energy occurs, with a failure in all the dependent functions. 
The pulse is exceedingly feeble, thread-like, and- scarcely perceptible; the 
skin cold, pallid, and shrhnk; and the sensorial functions almost abolished. 
The duration of the chill is very variable, in some cases not exceeding a 
few minutes, in others extending to hours and even days; and, in malignant 
diseases, the system not unfrequently fails to rise out of this state, of pros- 
tration. In these diseases, a doubtful struggle is sometimes maintained, for 
a considerable time, between the depressing agency and the powers of the 
system; a partial re-action taking place and then subsiding, to be followed 
by another equally unsuccessful effort to rally, and this oscillation continuing 
until the patient at length sinks, or the hot stage is established. The cases, 
however, are very few, in which, after the lapse of a certain period, the symp- 
toms of depression are not followed by those of excitement. It is not till 
this event has occurred that fever can be said to be fully formed. Occasion- 
ally, the cold stage is altogether wanting. 
3. Hot Stage.--The symptoms of the chill usually pass by degrees into 
those of the Hot stage. The coldness, subsides, and is succeeded by a sense 
of heat, which is at first not uncomfortable, but soOn becomes excessive and 
distressing. It is usually felt first about the face and eyes, and in the 
breath, then in the trunk, and ultimately in the extremities. Upon the sur- 
face it often alternates with the chilliness. If a limb be moved into a cooler 
spot in the bed, a shivering sensation of cold flashes, as it were, for a moment 
through the body; and there is often an alternation of heat and cold for 
some hours before the former becomes permanent. The sensation of heat is 
not confined to the surface, but extends also to the internal organs. Nor is 
the sensation delusive. The surface feels hot to the hand of another, and an 
elevation of temperature is indicated also by the thermometer, which, wThen 
placed under the tongue, rises in some instances as high as 107°, though it 
does not often exceed 105°. (Thomson on Inflammation.') 
At the same time that the heat increases, the circulation is also accelerated. 
The character, however, of the vascular reaction varies greatly. Usually, the 
pulse is full, strong, and quick, as well as frequent; but in some instances, 
and especially where the fever is sympathetic of inflammation in some highly 
vital part, it is small, contracted, and tense, or, to use an ordinary expression, 
corded; while in others, again, it is more feeble than in health, and is readily 
compressible, indicating that the heart, though irritated, is deficient in power. 
The degree of frequency is also exceedingly various, being sometimes little 
above that of health, but in the great majority of cases somewhere between 
90 and 110 in the minute, and occasionally much higher, reaching, in some 
instances, 130, 140, and even ICO. As a general rule, its frequency, during 
the continuance of the irritative action of the heart, is inversely proportionate 
to the energy of the system; so that it is greatest in fevers attended with 
deficient vital power, as in typhoid fevers and scarlatina. When the pulse is 
full and strong, or tense, indicating great energy in the circulating forces, it 
is seldom or never exceedingly frequent. 
Reaction, thus evident in the heart and upon the surface, takes place 
equally in the brain. The face is flushed, the head painful, the senses CHAP. I.] 
FEVER. 
83 
usually more acute, and the mental functions disordered. It very seldom 
happens, that symptoms of encephalic excitement are altogether wanting in 
established fever. In the great majority of cases, there is more or less pain 
in the head; and this is frequently severe, throbbing violently with every pul- 
sation of the heart, and constituting the greatest source of distress to the 
patient. But, even when positive pain is absent, there is usually some feeling 
of uneasiness, a sense of fulness, tension, weight, lightn'ess, or dizziness, 
attended generally with more or less confusion of thought, often amounting 
to delirium. The eyes are painfully sensitive to light, and the ears to sound; 
and both vision and hearing are Usually sharpened; though the reverse some- 
times happens, especially in relation to hearing, which, in a particular form 
of fever, is dull from the commencement. This increased sensibility, more- 
over, disappears in general with the progress of the fever. The senses of taste 
and smell are impaired, in consequence of the morbid state of the membranes 
in which they reside. Other symptoms, connected with disorder of the 
cerebro-spinal axis, are restlessness, disturbed sleep or morbid vigilance, a 
general and vague uneasiness, pains in the back, limbs, and other parts of the 
body, Ml of which are frequently present in fever, and some often in a very 
distressing degree. \ .7' 
The digestive organs are-always disordered. The appetite is entirely lost; 
and there is generally a disgust for food, and for warm drinks. Nausea and 
vomiting are not unfrequent. There is almost always thirst, which is some- 
times insatiable. Cold water and ice are usually very grateful to the patient. 
A disagreeable taste in the mouth is very common; and the tongue is almost 
always covered with fur, which is usually at first thin and white, then thick- 
ens and becomes yellowish, and sometimes assumes a brown or blackish colour. 
The end and the edges of the tongue, when not coated, are generally redder 
than in health. Sometimes the mouth remains quite moist; more commonly 
it is dryish and clammy; and occasionally it is quite dry, in consequence of 
a total suspension of the-mucous and salivary secretions. In some instances, 
the gums also appear to secrete a dark tenacious matter, which adheres to 
them and to the teeth. The bowels participate in the general disorder of the 
alimentary mucous membrane, being affected, for the most part, with consti- 
pation or diarrhoea; and the discharges are almost always unhealthy, either 
in colour, odour, or consistence. Constipation is most common, unless when 
the mucous membrane is inflamed or ulcerated. 
The secretions are always deranged in fever. When the disorder is at 
its height, they are usually deficient. Hence the dry skin, the burning eye, 
the dry tongue and mouth, the constipated bowels, the scanty and high 
coloured urine. In Other conditions of fever, especially in its decline, or when 
its violence has so far remitted as to permit the secretory organs to resume 
their functions, the quantity secreted is often in excess. Hence the copious 
perspiration, the serous and bilious diarrhoeas, and the profuse discharge of 
urine, which occur under the circumstances mentioned. The character as well 
as the amount of the secretion is also changed. The breath and perspiration 
often acquire a disagreeable odour, the urine is changed in colour and consist- 
ence, and the bile discharged from the stomach and bowels is seldom quite 
healthy in appearance. 
The respiration, which in the primary stage is short and hurried, becomes 
more free when the fever is fully developed, but still remains frequent; and 
there is very often a short, dry cough. 
All the symptoms enumerated are exceedingly modified in the various febrile 
affections, and are often complicated with others not essentially belonging to 
fever itself; as with those resulting from the incidental inflammation of differ- 84 
GENERAL PATHOLOGY. 
[part I. 
ent organs, from peculiar changes induced in the vital energies and the con- 
dition of the blood by the nature of the cause, and from certain organic de- 
rangements also referable to peculiarity of cause, such as the eruption in the 
exanthematous fevers, and the disease of the intestinal mucous follicles in 
enteric or typhoid fever. An account, however, of these complications belongs 
to the department of special diseases. Here we have only to consider what 
is incident to the febrile movement in general. 
The duration of fever is not less variable than its symptoms. It is impos- 
sible to say what exactly determines this duration. The nature of the cause, 
its intensity, the duration of its action, and the predispositions of the System, 
all, no doubt, have their influence. Sometimes fever ceases after a few hours, 
sometimes it continues for days, weeks, or months. Some of the diversities 
in its course will engage our attention directly; at present, it is best to com- 
plete a view of the affection, by giving the characteristic phenomena of its 
decline. ; ' , ' • ■ 
4. Declining Stage.-The term crisis has been applied to that period of 
fever at which it either takes a favourable change and begins to decline, or, 
failing in this result, goes on to a fatal issue. In some forms of fever, as in 
the exanthemata, there appears to be a disposition to end at certain fixed 
periods, a certain number of days, for instance, from their commencement; 
and these periods have been called critical days. But, in regard to fever in 
general, irrespective of the cause producing it, there is no reasdn to suppose 
that this disposition exists. It may, in a great many cases, be arrested by 
proper means, at any point of its progress; and, even if left to itself, will 
often run a course corresponding with the intensity of the cause, the previous 
state of the system, or the circumstances in which the system may be placed. 
Thus, the fever from a wound will cease when the inflammation of the wound 
is subdued. The fever from reaction after cold may cease in a few hours, if 
not sustained by favouring predispositions, or injudicious management; while, 
under opposite circumstances, it may run on for days. 
When fever begins to decline, the change is often marked by the occur- 
rence of some spontaneous evacuation, such as profuse perspiration, increased 
urine, bilious or serous discharges from the bowels, or hemorrhage. Hence, 
these have been called critical discharges. Occasionally, along with some one 
of these discharges, or in place of them, one or more abscesses form in various 
parts of the body, often containing large quantities of pus. These have been 
called critical abscesses. It has been conjectured that these evacuations were 
the means by which nature effected the cure of the complaint; and the idea 
at one time extensively prevailed, that, through - their instrumentality, offen- 
sive matters, which served to sustain the fever, were eliminated from the 
system. Without attempting here to confute this hypothetical notion, it is 
sufficient to say, that the discharges are the necessary results of a certain 
grade of irritation in the organs, and, if they serve to relieve the disorder in 
which they originate, it is only one of the numerous instances, in which 
nature has contrived to make noxious influences subservient to their own 
removal. By far the most frequent of the evacuations which attend the 
decline of fever, is perspiration. 
Along with the relaxation of skin, the, tongue, if before dry, begins to 
moisten, in consequence of the returning secretion of mucus and saliva; and 
most of the secretions, which have, before been locked up, now iriake their 
appearance in greater or less degree; The fur on the tongue also begins to 
be removed, and the surface of that organ to assume the healthy colour. 
This is one of the best evidences of the commencing decline of fever. The 
fur generally disappears first from the tip and edges of the tongue, and gradu- CHAP. I.] 
FEVER. 
85 
ally recedes "till wholly removed; but the process is often not completed for 
some time after convalescence has been established. Sometimes the coat of 
fur is thrown off in a different way. It is loosened by some organic change 
in the surface of the tongue, and large flakes of it separate at once, leaving 
the surface often red, smooth, and glossy. This also may be considered as 
a favourable sign in fever, though a protracted convalescence may often be 
anticipated. The tongue, in these cases, gradually becomes paler, and re- 
sumes its papillary appearance; but time is required for the completion of 
the process; and it is highly probable that some analogous condition of the 
gastro-intestinal mucous membrane exists, preventing a speedy return to 
health, though the proper disease may have disappeared; 
Simultaneously with the symptoms of amendment above mentioned, the 
pulse becomes less frequent, and, if previously hard and strong, is softened. 
But it very often happens that the frequency of pulse persists, to a certain 
degree, through the period of convalescence; and the slightest causes will, in 
many cases, throw the heart into tumultuous action. It is important that 
this should not be mistaken for the result of the continuance of fever. It 
arises from debility, and ceases when the organs have regained their normal 
state. 
The thirst and disinclination for food subside with the other symptoms of 
the febrile action, and the patient gradually recovers his appetite, which often 
becomes inconveniently exacting. Sometimes, however, atony of the stomach 
follows the subsidence of the febrile derangement of the organ, and the 
patient requires the cautious use of tonics to invigorate his appetite and 
digestion. 
Fever may terminate fatally at any period of its course. Even in the cold 
stage, the system is sometimes depressed by the violence of the cause below 
the point of reaction, and the patient dies of pure prostration. In the same 
stage, it is thought that death occasionally occurs from congestion of the 
internal organs, especially of the brain, by the retreat of the blood from the 
surface, and the inability of the heart to transmit it through the system. In 
the violence of febrile reaction,, fatal effects may ensue from excessive arterial 
congestion of the same organs, or from hemorrhage. But, usually, fever ter- 
minates fatally only after a considerable duration; and then, death, in the 
great majority of cases, depends upon disorganization of some vital organ or 
organs, consequent upon inflammations which have arisen during the course 
of the disease. Sometimes, however, the patient sinks from debility, resulting 
either from the direct influence of the original cause, from the altered state 
of the blood, from some profuse discharge by hemorrhage or secretion, or from 
the collapse which follows excessive excitement. 
Fever runs a very diversified and uncertain course. When produced by 
causes merely calculated to excite the functions, without any peculiarity of 
influence, and ceasing to operate immediately after having occasioned a morbid 
impression, it is altogether irregular in its duration, lasting for a few hours, 
or for many days, according to the previous condition of the system, Or the 
circumstances under which it may be placed at the time. When produced 
by pre-existing morbid states of particular organs, as by inflammation, it 
continues only so long as the local affection retains a certain degree-of activity; 
unless, indeed, there may be some latent cause which the disturbance of sys- 
tem calls into action; as, for example, when an individual has been exposed 
to marsh miasmata, and escapes their effects until inflammation, produced by 
2. Duration and Course of Fever. 86 
GENERAL PATHOLOGY. 
[part I. 
cold or other cause* excites a fever which brings the latent poison into play. 
The fever will, under such circumstances, continue altogether independently 
of the inflammation in which it originated. 
There are other cases of fever, in which, from the peculiar influence of the 
cause, the disease exhibits a disposition to cease at certain successive periods, 
and at length gives way at one of these periods, when the cause has lost a 
certain degree of its activity, or the system a certain amount of its suscepti- 
bility. Such are the miasmatic fevers. These may often be interrupted, by 
taking advantage of their periodical disposition to relax. 
But there are also fevers which run a determinate course, which no means 
in our power are sufficient to arrest, though the physician may often obviate 
their injurious effects, and conduct them to a safe termination. Of these, 
some continue a longer or shorter period, according to influences which we 
cannot fully appreciate; as the enteric or typhoid fever, which varies much 
in its duration, though, in cases which recover, it seldom continues a shorter 
period than two weeks. Others, again, run a definite or nearly definite 
course* terminating in general, when they end favourably, and are not com- 
plicated, in a certain number of days, as the small-pox, vaccine disease, 
measles, &c. k 
In relation to the course of fever, there are some points of great import- 
ance. Occasionally, we observe the febrile movement running, through its 
different stages of chill, re-action, and decline, in less than a single day, per- 
haps in a few hours, and then ceasing altogether. In such cases, the dis- 
ease has received the name of ephemera. Very often, however, after an 
interval of one, two, or three days, the fever recurs, and, having run the 
same course as before, again recurs at the same interval, and so on indefi- 
nitely. In this case, it is said to be intermittent or periodical; the period 
occupied by the febrile movement is called the paroxysm, and the inter- 
vening space, in. which there is a total absence of fever, the intermission or 
Upyrexia; while the term interval is applied to the. whole time, from the 
commencement of a particular paroxysm to that of the one preceding or 
succeeding it. The variable length of this interval has given origin to dif- 
ferent designations of intermittent fever, as the quotidian,- tertian, &c., ac- 
cording to its length. (See Intermittent Fever I) This habit of recurring at 
one interval rather than another is called the type of the fever, though the 
term is sometimes extended to express other peculiarities of form or charac- 
ter. All febrile diseases are not susceptible of the intermittent character; 
nor are fevers the only intermittent diseases^ Perhaps all merely functional 
disease is capable of becoming intermittent. The cause of periodicity I shall 
endeavour to explain in another place. This quality of diseases is highly 
important in a therapeutical point of view. The circumstance of periodicity 
does not give to fever the character of a peculiar disease, differing essentially 
from all other forms. Fever arising from any cause incapable of sustaining 
a constant disturbance in the functions, and yet not ceasing to act altogether 
with the production of the first paroxysm, may assume the form of an inter- 
mittent. Thus, irritation in the urethra has produced an attack of intermit- 
tent fever; and hectic fever, resulting from steady irritation in a debilitated 
system, approaches to it closely in character, and in some cases can scarcely 
be distinguished. In the great majority of instances, however, in which 
intermittent fever occurs, it is of miasmatic origin; and, as it requires a 
peculiar mode of treatment, I shall give it a distinct consideration among the 
fevers arising from the same cause. 
Fever often exhibits a tendency to the paroxysmal form, without being 
intermittent. The febrile action, after being fully established, subsides for CHAP. I.] 
FEVER. 
87 
a time, and then increases and again subsides, observing stated periods of 
augmentation and decline, but not disappearing entirely. In these cases, 
the period of increased excitement is called the exacerbation, that of dimin- 
ished excitement, the remission; and the fever is said to be remittent. 
Sometimes, the exacerbations and remissions are strongly marked; the 
former, like the paroxysm of an intermittent, being ushered in with a chill, 
and terminating with perspiration, and the latter, exhibiting a very moderate 
grade of febrile action. Sometimes, the exacerbation takes place without a 
chill, but subsides with perspiration, and vice versa; and very frequently 
there is neither chill nor perspiration, the fever simply rising and falling, 
without any peculiar attendant phenomena. As a general rule, the nearer 
the remission approaches to a perfect intermission, the more apt is the exacer- 
bation to exhibit the cold, the hot, and the sweating stages, and the more 
strongly marked are the chill and perspiration. The exacerbation most com- 
monly occurs- every day, sometimes every other day, and occasionally twice 
daily. (See Repiittent, Fever.) 
Fever which runs a steady course, without remission or intermission, is 
said to be continued. But, in the strictest sense of the word, there are pro- 
bably no continued fevers of any considerable duration. A fever may possi- 
bly proceed evenly, or with a constant'increase,'for two or three days; but 
even this is not common; and, beyond the last pientioned period, a continu- 
ance without any relaxation is scarcely compatible with physiological laws. 
In almost all fevers, from whatever cause they may arise, whether idiopathic 
oi' symptomatic) there are occasional exacerbations and remissions, usually 
occurring daily, sometimes even twice a-day; although these are often very 
slight, and very irregular in their recurrence. But, as there is a decided 
distinction between different febrile diseases in these respects, some offering 
marked exacerbations and remissions, occurring at somewhat regular inter- 
vals, approaching more or less closely to intermittents, and others being 
less strongly marked, and less ■ regular, it seems proper to recognize the 
difference by the name; and, therefore, the term remittent might with pro- 
priety be restricted to the former, and the term continued applied to the 
latter class. 
3. Grade of Fever. 
Fever varies in degree, from the mildest state, in which the febrile symp- 
toms are but just discoverable, up to the most severe and deadly; but there 
is another important distinction, which has reference to the grade of the 
vital forces; Two very striking varieties arise from this origin. In one, 
the susceptibilities and energies of the system are unimpaired, or even per- 
haps elevated above the ordinary standard. The influence of the causes 
of irritation is, therefore, felt keenly, and responded to vigorously. The 
febrile reaction is promptly established; the heart contracts energetically; 
the pulse is full and bounding, or small and contracted, but always firm; 
heat is largely developed; the face is flushed; the head painful; delirium, 
when present, is of the active character; the tongue is usually moist; in 
short, the symptoms are in general those of high and vigorous excitement. 
Under these circumstances, the fever has been called inflammatory ; partly, 
because a certain analogy has been observed between this condition of the 
system and the local condition existing in inflammation, and partly, because 
the fever, sympathetic of active inflammation, is usually more or less of this 
character. After Cullen, it is sometipies called synocha; but it should be 
understood that this is not a distinct disease, or variety of fever, but merely 88 
GENERAL PATHOLOGY. 
[part I. 
a particular state which fever, arising from various causes, and connected with 
various diseases, may assume in consequence of the existing condition of the 
system. 
In the other condition of fever alluded to, the grade of the vital forces is 
low. There may be susceptibility, but there is a want of energy in the sys- 
tem. However powerful may be the exciting cause, however disturbing its 
agency, though great agitation and disorder may be produced, yet all the 
resulting movements have the taint of weakness. In this case, the reaction 
is often slow, and is sometimes established with great difficulty. There is 
occasionally an apparent struggle between the depressing influences and the 
powers of the system, an alternation of chill and febrile excitement, for 
some time before the latter becomes continuous; and, in some instances, 
reaction never takes place, the patient dying in the cold stage. When the 
fever has been fully formed, the heart beats rapidly, but not strongly. The 
pulse is often very frequent, much 'more so than is usual in the former 
variety; but it is also very-feeble, yielding readily to pressure, and some- 
times, when rather full, imparting a sensation to the finger almost as if the 
vessel were filled with air. Though the heat of the surface may be greatly 
increased, yet it is uncertain, frequently alternating with coolness; or one 
part of the body is cold while another is hot; and the excitement is apt to 
give way to prostration or collapse. The tongue is generally dryish or quite 
dry, and covered with a dark fur; and sordes collect about the teeth. The 
sensorial functions are always impaired. Stupor and coma, or delirium, are 
common; and the delirium is usually of a low, muttering kind, indicating 
rather an enfeebled state of the brain than over-excitement. This con- 
dition of fever is called typhous, and sometimes asthenic, or by the French, 
adynamic. It is not essentially a distinct disease; but may occur in any 
febrile affection, even though resulting from inflammation, if the vital forces 
are greatly reduced. Thus, we occasionally have this condition of fever, 
not only in the diseases commonly known as typhus and typhoid fevers, but 
also in intermittents, in bilious remittents, in the various exanthemata, as 
small-pox and scarlatina, and in symptomatic fevers, as pneumonia and dys- 
entery. Care should be taken to distinguish the term typhous, as applied 
to this state of fever, from the term typhus, which is employed to designate 
a particular febrile complaint, having peculiar causes and a distinct course. 
Besides the two grades of fever above described, there are often interme- 
diate or mixed conditions, of which it is difficult to say to which they belong. 
Very often, the fever is inflammatory at the beginning, and typhous near 
the close. To this state of fever the name of synochus was given by Cullen, 
who has been followed by most English authors in his nomenclature. 
The state of the vital forces on which these different grades depend, may 
pre-exist, or may be induced by the cause or causes- of the fever itself. 
Whatever tends to increase the powers of the system predisposes to the 
inflammatory condition of fever; whatever diminishes these powers, to the 
typhous. Thus, vigorous exercise, pure air, a cheerful mind, a good appetite, 
and a full diet, place the system in a condition, partly through their invigo- 
rating influence upon the solids, partly by the rich fibrinous bright red blood 
which they produce, to assume the inflammatory grade of fever, when exposed 
to causes capable of inducing that affection. Ou the contrary, confinement, 
impure air, mental dejection, bad living, and the depressing influence of long 
continued cold, of sulphuretted hydrogen, and of other sedative agents, pro- 
duce a general deterioration of health, a languor in all the vital functions, and 
an impoverished or depraved condition of the blood, which very generally CHAP. I.] 
FEVER. 
89 
give to fever, by whatever cause induced, the typhous character.* But it 
also not unfrequently happens, that the exciting cause of the fever is itself of 
a depressing nature, in relation to some at least of the vital functions, and 
that a typhous condition of the system, as well as the febrile movement, 
results directly from its operation. Such, beyond all doubt, is the case with 
the poisonous effluvia which cause the proper typhus fever, and, to a certain 
extent, also, that which produces scarlatina. It is not improbable that these 
depressing agents operate, in some measure, in producing the tendency to 
prostration, by destroying the healthy character of the blood. At least, it is 
certain that the blood is often very much depraved in low cases of fever, and 
must contribute to the prostration by its unfitness for supporting the vital 
actions; although it is difficult to say how far its peculiarity depends on the 
direct action of the cause, and how far upon the deranged actions of the 
various organs, which the cause has put into movement. 
Before leaving this branch of the subject, I wish again to impress upon 
the reader, that the terms inflammatory, synochous, and typhous, as applied 
to fever, are merely expressive of different states of this affection, and not of 
distinct febrile diseases. 
4. Relation of Fever to Inflammation. 
In fevers of every type and every grade, inflammation of one or more 
organs is Very often observed, although, as may be inferred from what has 
been already said, the author does not believe that there is any necessary 
connexion between fever and that affection; and the fact appears to be, 
that the former frequently runs its whole course, without any positive proof, 
or even any strong probability, of the existence of ,the latter. Sometimes, 
the association of inflammation with fever is purely accidental; as, for exam- 
ple, when a febrile complaint is occasioned by some peculiar cause, in persons 
previously affected with inflammation; or when the latter affection is pro- 
duced by violence, or other extraneous cause, during the progress of fever. 
In all cases not purely accidental, inflammation co-existing with fever may be 
considered as bearing towards it one of these three relations. It is either 
I, the effect of the fever, or 2, the direct result of the same cause that pro- 
duces the fever, or 3, the cause of the fever. 
1. That inflammation should result from the febrile movement, is nothing 
more than might be expected from a knowledge of the causes and characters 
of these. two disorders. In the universal derangement of the functions in 
fever, many of them being in a state of over-excitement or irritation; in the 
constitution of the blood, which is often highly stimulating; and in the 
increased rapidity of the circulation; not to mention the irregular distribu- 
tion of the nervous influence; we have those very conditions which are 
most favourable to the developement of inflammation. How easy must it 
be, under these- circumstances, for the excitement in particular parts to pass 
the boundary which separates mere irritation from inflammatory action I It 
* Thus; it happened to the author to attend, on one occasion, in a large establishment 
(the Institution for the Deaf arid Dumb in Philadelphia), when the family were exposed 
to the effluvia arising from the contents of a privy which had flowed into the cellar, in 
consequence of the rupture of a wall which had confined therri. Inflammation of the 
lungs was at the time prevalent in the city, and not less than 30 members of the 
family were attacked with a fever, exhibiting evidences of bronchial or pneumonic 
inflammation. The fact which is particularly interesting at present is, that a large pro- 
portion of tfiese exhibited typhous symptoms; and in very few, if any, was copious 
depletion well borne. This result was ascribed to the depressing influence of the exha- 
lations, which predisposed the system to the low form of fever, even when attacked by 
.inflammatory disease. 90 
GENERAL PATHOLOGY. 
[PART I. 
is not, therefore, surprising, that fevers, of any considerable duration, should 
be almost always attended with inflammation of one or more organs, though, 
in the commencement, wholly free from any such complication. 
2. The causes which produce the general derangement of function called 
fever, may also operate on particular organs, so as < to produce inflammation; 
and the two conditions may thus be associated from the commencement. 
Thus, cold is believed to be capable of exciting the febrile movement without 
inflammation, and it is certainly capable of producing the latter without the 
former. A fair inference is, that it may produce the two, in some instances, 
conjointly. There is reason to believe that it actually does so. At least, it 
occasionally happens in the phlegmasia?, that the fever and inflammation cor- 
respond so- closely in their time of commencement, that it is difficult to con- 
ceive that one is the effect of the other. The patient has a chill, febrile 
reaction occurs, and, at the same time, the phenomena of inflammation. The 
two probably depend upon the same cause. In the exanthematous diseases, 
in which the characteristic eruption comes on at certain periods after the 
commencement of the complaint, it very probably Jesuits from the imme- 
diate influence of the cause. So also with the sore throat of scarlatina, and 
the catarrhal affection of measles, which, as they are certainly not the cause 
of the fever, and, commencing almost simultaneously, and sometimes even 
previously, can scarcely be considered as its effects, must be ascribed to the 
same source as the fever itself. 
3. The fact that inflammation produces fever is so well known as to re- 
quire no comment in this place. The fever attending wounds and all the 
phlegmasise are examples. 
From all these causes it happens, that inflammation is an almost invariable 
accompaniment of protracted fever ■ and the association is so frequent as to 
have led to the belief, on the part of many pathologists, that there is no such 
thing as an independent febrile movement, and that all fevers are in fact 
inflammations, the general disorder being nothing more than the effect of the 
local disease. Upon this point I shall have more to say, when discussing the 
different opinions upon the nature of fever. The reader is already aware that 
the opinion is not that of the author. 
5. Causes of Fever. 
Any cause capable of producing a powerful or very general impression on 
the system, either of an excitant or depressing character, is probably capable 
of producing fever. The various organs of the system are so connected by 
sympathy, or by mutual dependence, that they may be all brought into de- 
rangement by a certain amount of disease in one, or in any number of them. 
A slight affection of small extent, is generally insufficient to rouse these 
sympathies, and therefore continues local. But, if the affection involve 
several organs, even though slight in degree, it may extend to the whole, and 
give rise to general disorder. Any cause, therefore, capable of inducing 
irritation in any considerable number of organs, or over any considerable 
portion of the body, either by a direct impression, or by the reaction which 
follows depression, or by the super-excitement in certain parts resulting from 
depression in others, may occasion universal derangement, and consequently 
fever. It has before been stated, that a slight disorder of the functions, 
vanishing almost as soon as it occurs, without leaving injurious results behind 
it, can scarcely be accounted disease. This is true of the whole as well as of 
a part; and a general derangement of the system, in order to constitute fever, 
must have a certain duration. The cause, therefore, to be entitled to that 
name, must not be quite fugitive in it^ action. It follows, from what has CHAP. I.] 
FEVER. 
91 
been .said, that all the causes of irritation and depression, not quite local or 
circumscribed in their influence, may prove causes of fever. (See Irritation 
and Depression!) 
When inflammation becomes established, it continues for a certain length 
of time, and runs its course independently of its cause. It is the inflamma- 
tion, therefore, and not the agent which produced the inflammation, that 
must be considered as the cause, of the resulting fever. In northern latitudes, 
there is certainly no cause so operative as this. The fevers from inflamma- 
tion probably exceed in number those which arise from all other causes put 
together. How it is that the organic derangement of an inflamed part, is so 
much more provocative of fever than the functional disorder of the same part, 
in a state of irritation, must be explained chiefly by reference to the. greater 
intensity of the former affection, and its consequently more powerful appeal 
to the sympathies; but it is probable, also, that the change in the mass of 
blood, which acquires an increased proportion of fibrin during inflammation, 
may have something to do with the result. 
The facility with,which irritation or inflammation may produce fever, 
depends much upon the predisposition of the system. Sometimes, a slight 
degree of either will give rise to the febrile movement; in other instances, 
the system scarcely seems to feel them when extensive or intense. It is 
obvious, therefore, that some conditions of system in apparent health must 
be favourable, and others unfavourable to fever. In what these conditions 
consist is not well understood. They probably sometimes depend upon an 
unknown state of the nervous system, rendering the sympathies more or less 
active than usual; sometimes on the condition of the blood, which may in 
one case be more stimulant, and in the other less so than in perfect health. 
It is highly probable, that the retention of various recrcmentitious substances 
in the blood, may give to this fluid an irritating character, which may greatly 
favour the influence of some additional irritation; thus constituting a strong- 
predisposition to fever; and it is not impossible, that such an accumulation 
of unhealthy matters in the blood-vessels may of itself produce fever. But 
all this is more or less conjectural. We are in want of facts upon which to 
found a demonstration. There is, however, one well-ascertained condition, 
which frequently serves as the predisposition to febrile attacks. An irritation 
or inflammation is occasionally quite latent, insufficient to involve the system, 
and scarcely even attracting the serious attention of the patient. It may be 
slight in degree, or so chronic that the system has gradually become accus- 
tomed to its presence, and ceased to feel it. In this condition, for example, 
may be the stomach in intemperate persons, the liver in those exposed to 
great and continued heat, and the brain in those much agitated by perplexing 
or exciting thoughts. A slight additional cause is now sufficient to awaken 
fever; and it is not improbable, that many cases of this affection, the origin 
of which appears obscure, might be traced, if accurately examined, to this 
source. 
In relation to fevers arising from obvious sources of irritation, direct Or 
indirect, or from inflammation, it is worthy of observation, that they in 
general continue only during the influence of their cause, or quickly subside 
when the cadse has ceased to act. In some instances, it is possible that a 
fever, produced and long sustained by irritation, .may continue a certain 
length of time, through the influence of habit, after the original cause has 
disappeared; but the general rule is as above, stated. Thus, a fever resulting 
from the reaction after exposure, under certain circumstances, to cold, sub- 
sides very quickly, unless sustained by inflammation simultaneously produced; 
and the constitutional symptoms in pleurisy, pneumonia, gastritis, &c., dis- 92 
GENERAL PATHOLOGY. 
[part I. 
appear when the inflammation of the pleura, lungs, and stomach respectively 
is subdued. It is probable that what is called ephemeral fever thus has its 
origin in some transitory irritation. 
But there are numerous fevers, which, when once produced, run a certain 
course often quite protracted, and altogether independent of any renewed ap- 
plication of the cause. Whether the cause, in these cases, sets a certain con- 
catenation of morbid actions int6 motion, which must go on like those of the 
clock or watch till they have run down; or whether the morbific agent is ab- 
sorbed, and continues to exercise its injurious influence until finally elimi- 
nated by the efforts of the system; or whether this same agent has the power, 
either of assimilating, in some degree, to its own nature, by a sort of chemical 
action, the blood with which it circulates, or of so affecting the solids as to 
enable them to produce, out of the materials upon which they act, a similar 
substance, capable of continuing the primary impression until the system has 
become thoroughly accustomed to the new influence, as may be supposed to 
be the case in the contagious fevers,; all these are questions which have been 
much agitated, but never satisfactorily solved. The causes of such fevers 
may all be arranged, so far as they are known, under the heads of miasmata, 
contagion, and epidemic influence. Our knowledge in relation to the true 
nature of these causes is exceedingly vague and uncertain, and the real agents 
have never been isolated; but their origin, their modes of action, and the 
laws which regulate them, have been industriously investigated, and are to a 
certain extent known. As I shall have occasion ' to consider them particu- 
larly, in the chapter upon the general causes of disease, it is unnecessary to 
dwell upon them here. 
Upon a subject so important as fever, which has occupied so much of the 
attention of writers on medicine, in all ages, it is teemed proper, even in an 
elementary work like the present, to give a sketch of the most prominent 
opinions which have been entertained in relation to it, especially as in these 
opinions are involved, for the most part, the general medical doctrines of the 
times when they prevailed. 
Humoral Pathology.-The first hypothesis broached in relation to fever, 
and that which continued longest to command the faith of the medical world, 
ascribed it to a disordered condition of the fluids of the body. Hippocrates 
considered increased heat to be the. essence of' fever, and its proximate cause 
to be a superabundance of the bile, the black bile (atrabilis), the phlegm, or 
the blood. Galen had the same notion in relation to heat, and, carefully 
distinguishing the phlegmasim or inflammations from fevers properly so 
called, referred the latter to an alteration or putridity of the fluids; the 
varieties being produced severally by the bile, the black bile, the phlegm, and 
the blood. The idea also appears to have been entertained by the qhcients, 
that the commotion in the system was with the object of expelling the super- 
abundant or morbid humours, or of rendering them harmless. There were, 
of course, differences of opinion among ancient authors; and Celsus seems to 
have been not far from the truth, in treating of fever simply as a disease of 
the whole body. The Greek writers were followed by the Arabians; and, 
upon the revival of learning, were naturally the fountain from which the 
physicians of Europe drew their opinions. 
The discovery of the circulation of the blood induced some modification in 
these opinions, without essentially changing them. It was now understood, 
that the bile and phlegm were merely secretions from the blood; and this 
fluid came to be considered as the chief, if not exclusive, source of mischief. 
6. Theories of Fever. CHAP. I.] 
FEVER. 
93 
Not only in the case of fevers, but of all other diseases, it was supposed that 
the blood becomes contaminated or depraved, either by the reception of 
noxious substances from without, or in consequence of changes going on 
within the body; that the system is excited by the presence of these impuri- 
ties either to direct efforts for their expulsion, or to a course of elaborative 
action, so as to fit them for expulsion; and that, in the language of Syden- 
ham, " a disease is no more than a vigorous effort of nature to throw off the 
morbific matter, and thus recover the patient." This is the sum and sub- 
stance of the humoral pathology. According to this view, fever is only a 
violent effort of the system to rid itself of noxious matter; and the sweats, 
bilious discharges, turbid urine, suppurations, -and cutaneous eruptions, which 
so often attend fever, are merely different means by which this matter is ex- 
pelled. As to the nature of the morbific matter, and its mode of production, 
there was much difference of opinion., Chemical discovery was naturally 
brought to the aid of pathology; and the notions of an acid, alkaline, or 
earthy contamination, of the contest between acid and alkali, and of fermen- 
tation, were prominent among the almost infinite multitude of speculations. 
The idea of the necessity of a certain concoction, by which the morbific matter 
was to be prepared for expulsion, was perhaps the most practically injurious 
of these theoretical notions; as it led to the practice, under the idea that the 
febrile movement was necessary to the concocting process, of employing means 
rather to increase than to moderate that movement. Hence the hot drinks 
and close confinement, which were at one time so much used, and so fatal, in 
the treatment of small-pox and other febrile diseases. 
Among the modifications of opinion connected with the humoral origin of 
fever', were those of Boerhaave and Stahl. The former, while he admitted 
the influence of chemical changes in the fluids, ascribed fever not so much to 
contamination of the blood as to its greater thickness or viscidity, which 
caused it to stagnate in the extreme vessels, and thus brought on the cold 
stage of fevers, followed by all its train of excessive action. Stahl, conceiving 
that fever consisted in a plethoric or depraved condition of the fluids, imagined 
the existence of a superintending rational principle, called variously auto- 
crateia, anima medica, and vis medicatrix naturae, which, in this as in all 
other diseases, watched over and directed the movements of the system with 
a view to its preservation; so that fever, instead of being a morbid condition, 
was in fact a series of actions, under the guidance of this principle, for the 
removal of the real cause of offence, ■ This theory led to an expectant prac- 
tice, which contented itself with observing the efforts of nature, and taking 
care that nothing interfered with her objects. The theories both of Stahl 
and Boerhaave had a wide prevalence in the schools of Europe, and made an 
impression on the sentiments of the profession which has scarcely yet dis- 
appeared. 
Nervous Theories.-All the opinions, hitherto mentioned were upon the 
basis of the humoral pathology. To attempt to refute them, in) the present 
state of medical sentiment, would be quite supererogatory. They remained 
undisputed till the times of Hoffmann and Cullen. To the former belongs 
the credit of first leading the attention from the fluids to the solid structure, 
as the seat of the disease. Hoffmann sought, in the nervous system, the 
source of the mischief; and it is wonderful, considering the character of the 
symptoms, that the idea did not sooner occur to theorists. He believed the 
first step, in the establishment of fever, ^o be spasm of the capillaries; and 
the heat of skin and arterial excitement which follow, he considered as the 
mere re-action of the system, necessary to overcome this spasm. It was 
Cullen, however, who gave consistence and popularity to the new opinions, 94 
GENERAL PATHOLOGY. 
[part I. 
and completely overturned the old doctrines of humoralism in the estimation 
of the profession. The hypothesis of that celebrated teacher was, that, under 
the influence of some sedative agency upon the nervous system, the energy 
of the brain is diminished, and all the functions consequently debilitated, 
especially those of the extreme vessels; that, from the nature of the animal 
economy, and, probably, through the instrumentality of the vis medicatrix 
naturae, a spasmodic state of the extreme vessels occurs in connexion with 
the cold stage; that by this a degree of irritation is extended to the heart and 
large arteries, in which increased action is induced, constituting the hot stage; 
and that finally, through this excitement, energy is restored to the brain, and 
extended to the extreme vessels, thus overcoming the spasm of the capillaries, 
and allowing the excretion of sweat to take place, together with other evi- 
dences of relaxation. Cullen denied that any pre-existing morbid condition 
of the blood was the cause of fever, though he admitted that a change of the 
fluids occurred during the course of the affection, and as one of its effects; an 
opinion which had been previously advanced by Baglivi. 
Though the explanation of Cullen is greatly in advance of the old humor- 
alism, it is obviously altogether hypothetical, and in some of its parts contra- 
dictory to facts. The first step in the formation of fever is, probably, in 
general, as he maintains, a state of depression, exhibiting evidences of a 
sedative influence upon the nervous system; but all the rest of the theory is 
pure assumption. Leaving out of view the fanciful notion of the vis medica- 
trix naturae, there is no proof whatever of the existence of spasm of the ex- 
treme vessels. On the contrary, in the cold stage, they are in a state of col- 
lapse from their inability to receive and circulate the blood, and in the hot 
stage, though the secretory orifices appear to be closed, the vessels themselves 
are dilated, as is obvious from the fulness and redness of the surface. There 
is no proof, that spasm of the capillaries, even admitting its existence, is the 
cause of the febrile reaction of the heart and larger vessels; nor that this 
reaction produces relaxation of the capillaries. It is not even true, that 
symptoms of depression uniformly usher in the febrile movement, nor that 
the cold stage is the necessary cause of all that follows. Fever sometimes 
begins without obvious depression, and without chill; the system being at 
once introduced into the state' of arterial excitement. A general theory 
cannot be true which does not embrace all the particular cases. 
Not to speak of the theory of Brown, the contemporary and rival of Cullen, 
who considered fever, as all other diseases, to be nothing more than the effect 
of excessive or deficient excitement, the former constituting a state of indi- 
rect, the latter of direct debility, it will be proper to notice, in a few words, 
the doctrine of Dr. Darwin, which, embracing the two prominent principles 
of Dr. Brown, superadds a third equally essential, and explains, with much 
plausibility, many of the phenomena of fever. In the following explanation, 
I shall avoid the peculiar phraseology of Dr. Darwin, and employ terms with 
the signification of which the reader is already familiar. The principles 
alluded to are, 1, that all excitement of the organs is followed by a propor- 
tionate diminution of their power, or exhaustion; 2, that rest, or abstraction 
of the usual stimuli, renders the organs more susceptible to the subsequent 
action of the stimuli; and, 3, that the functions of different organs are so 
associated, that an increase or diminution in one is followed either by a 
similar change in another, by what Dr. Darwin calls direct sympathy, or by 
a reverse change, the increase of one being followed by a diminution, and the 
diminution by an increase of another, by what he denominates reverse sym- 
pathy. These principles are, in the main, correct, and are very extensively 
applicable in the explanation of morbid phenomena. If the first proposition CHAP. I.] 
FEVER. 
95 
be modified by the substitution of over-excitement for excitement simply, and 
if, in the third, the effect which he considers as resulting from reverse sym- 
pathy, be ascribed to revulsion, or to mere dependence of function, as when 
excitement in one organ embarrasses its operations, and thus impedes the 
action of some dependent organ, the principles stated will correspond with 
those which have been already inculcated in this work, and for the develope- 
ment of which much is due to the authors mentioned. To apply the princi- 
ples-in the cold stage, there is an abstraction of a certain amount of the 
ordinary stimulus, and consequently an increase of susceptibility in certain 
parts of the system, so that, upon the re-application of the stimulus, those 
parts are excited into excessive action, which, combined with the various 
derangements that take place through the influence of the sympathies, con- 
stitutes fever: and this is complicated by the results depending on the 
various nature and application of the morbid cause, whether it consists 
in the withdrawal of the healthy stimuli, in which case the debility is direct, 
or upon the application of stimuli in excess, in which case there is indirect 
debility, and whether the morbid impression is made especially upon' one 
organ, as the stomach, upon another, as the brain, or upon several simulta- 
neously.' Now, if in addition to the above principles, we admit the positively 
depressing influence of certain morbid agents, and the reactions which follow 
their application, which is but an extension of the second principle above 
mentioned, we shall have the means of explaining a great many of the phe- 
nomena of febrile diseases; though it must be confessed that there are many 
difficulties which remain unsolved by this hypothesis. 
Theories of Local Origin.-Hitherto, all writers had recognized the exist- 
ence of fever as a general disease, independent of any local lesion; while it 
was also admitted to arise frequently from inflammation of particular parts of 
the body. In the former case, it was called idiopathic or essential, in the 
latter symptomatic. It was reserved for the present century to dispute this 
position. It is true that Pinel considered each variety of fever to be con- 
nected essentially with some local disorder, as bilious fever with disease of the 
digestive organs, nervous fever with disease of the brain, &c.; but he did not 
deny the essential nature of the fever itself. Clutterbuck, who published, in 
1807, his ''"Inquiry into the Seat and Nature of Feverf was probably the 
first author who distinctly denied the existence of idiopathic or essential 
fevers, and asserted the uniform dependence of all fevers upon local inflamma- 
tion. Those which had hitherto been considered as idiopathic, he maintained 
to be nothing more than inflammation of the brain, and accordingly proposed 
for them the name of encephalitis. He supported his hypothesis by the argu- 
ments, that the brain is always affected in these fevers, as proved by the symp- 
toms, and the appearances frequently presented after death, and that the 
affection is identical in its phenomena, its mode of cure, and the structural 
lesions it leaves behind, with palpable and acknowledged phrenitis, or inflam- 
mation of the brain. Dr. Clutterbuc-k's views, however, made little impres- 
sion, and scarcely indeed attracted general attention, until brought forward in 
contradiction to the claims of a more celebrated author to originality, in the 
denial of the existence of idiopathic or essential fevers.* 
* Since the publication of the first edition of this work, I have seen a statement by 
Professor Giacomini, in a biographical notice of Tommasini of Parma, to the effect, that 
this celebrated Italian physician, in a work on fever published in 1805, put forth the doc- 
trine of the essential dependence of fever upon inflammation, thus preceding both Clut- 
terbuck and Broussais. " Tommasini," says his biographer,''placed the'seat of fever, 
according to the symptoms, in a phlogosis of this br that viscus, and frequently even in 
a diffuse phlogosis of the entire sanguiferous system." (Medico-Chirurg. Rev., N. S., vi. 273.) 
Note to second edition. 96 
GENERAL PATHOLOGY. 
[PART I 
Perhaps no individual, since the days of Cullen, has produced a greater 
impression on medical sentiment, all over the civilized world, and no one 
at any time, has exercised a greater influence, in his own particular country, 
over the opinions, the practice, and the spirit, of his profession, than Broussais, 
It is true that his theory of disease in general, and of fever in particular, is at 
present admitted in its full extent by very few; but it cannot be denied that 
he very much modified previous opinion, that he awakened a new spirit, and 
led the way in a new line of investigation, that he almost revolutionized the 
formerly inefficient therapeutics of his country, and has been in these various 
ways of incalculable service to medicine. It was, I believe, in 1816, that 
Broussais announced his doctrine of fever. He agreed with Clutterbuck in 
denying wholly the existence of essential fever, but differed from him in 
ascribing all those fevers, previously denominated idiopathic, to inflammation 
of the mucous membrane of the stomach, or that conjointly of the stomach 
and bowels. In other words, these fevers', according to Broussais, aye gastritis 
or gastro-enteritis. Indeed, he appears to have considered every case of dis- 
ease correspondent with our notion of fever, whether among those formerly 
classed as idiopathic, or among the symptomatic, to be, if not gastro-enteritis, 
at least complicated with that affection. Of traumatic fever he expressly 
states, that it is gastro-enteritis, excited by the inflammation of the wound, 
the irritation being transmitted from the wound to the brain, and thence 
reflected to the gastro-intestinal mucous membrane. Fever, in the abstract, 
he defines to be increased action of the heart, and increased heat of skin, 
producing a painful sensation. These are only constituent parts, and not the 
whole of what we mean by the term fever; but the observations which follow, 
if applicable to a part of the affection, are still more so to the whole. In- 
flammation of a part, he observes, when it extends beyond its primary seat, 
sends irritation to the brain, which reflects it to all the organs with which it 
is in communication, and consequently to the heart. When the irritation 
thus transmitted is sufficiently violent to produce fever, it is a grade of in- 
flammation. But, when inflammation is sufficiently intense to produce excite- 
ment of the heart, it is also sufficiently so to be transmitted to the stomach; 
consequently the stomach is inflamed in every case of fever. If, therefore, 
gastritis be not at the basis of every symptomatic fever, it is at least a uniform 
attendant. 
Another of the theories which maintain the local origin of fever, is that of 
Bouillaud, who considers the affection as symptomatic of irritation or general 
inflammation of the circulatory system, and peculiar forms of it as arising 
from its complication with inflammation of other structures, as of the ali- 
mentary canal, and cerebro-spinal system, with an altered condition of the 
blood, &c. 
Others agaip, of this school, content themselves with ascribing fever to 
local inflammation, without attempting to confine the inflammation essentially 
to any particular organ. 
Eclectic Theories.-The impression produced on general medical sentiment 
by the zeal of Broussais and his disciples, has been for some years gradually 
fading; and, without having returned fully to former opinions, pathologists 
have evinced a decided disinclination to accept the new. Indeed, there can- 
not at present be said to be any prevalent doctrine of fever. Each individual 
has the grounds before him, and judges for himself; and probably most per- 
sons, seeing a little truth and some error in every exclusive hypothesis, have 
selected a portion from each, and formed a sort of composite opinion, of which 
even the old gothic doctrine of the humoral pathologists constitutes a part. 
Perhaps among the most prominent of the general views recently put forth, CHAP. I.] 
FEVER. 
97 
are those of Dr. Southwood Smith, who maintains that fever is idiopathic, that 
it consists invariably and essentially of certain derangements, occurring in an 
invariable succession, namely, first, of the nervous or sensorial functions, 
secondly, of those of the circulation, and thirdly, of those of secretion and 
excretion; and that, though inflammation is something quite distinct from 
fever, it is nevertheless an almost constant attendant, constituting, in fact, 
that state of vascular excitement which marks the reaction of all febrile dis- 
eases. Dr. Smith admits of only two possible exceptions to the universality 
of this connexion of inflammation and fever; the first being in those very mild 
forms in which there is no opportunity of proving the existence of inflamma- 
tion by dissection, and the symptoms are not such as to prove it without this 
aid; the second, in those very severe cafses in which death takes place in the 
earliest stage, before inflammation could be developed. 
A disposition to return to the fluids, as at least an occasional source' of 
fever, has been evinced by some recent writers. Thus, Dr. Stevens asserts 
that the blood is altered essentially in character by the miasmatic cause of 
bilious and yellow fevers, evincing this change for days or even weeks before 
the fever appears. From this fact, Dr. Stevens thinks himself justified in 
assuming, that not only the particular fevers mentioned, but all other idio- 
pathic fevers depend on the diseased state of the circulating current. Dr. 
Stocker, of Dublin, (Smith on Fevers, p. 17,) Dr. Burne, of London, (Ibid.,) 
and more recently Dr. Davies, of Bath, ^Prov. Med. and Surg. Journ,, Jan. 
1847,) have maintained that typhus fever is essentially a morbid condition of 
the blood/ There can be no doubt that the blood is often greatly altered in 
these and other fevers; and it is possible that, in some instances, this alteration 
is primary, and the direct cause of the other changes; but, in the present 
state of our knowledge on this point, the assumption that all fevers, or even 
the particular fevers mentioned, are dependent on the morbid state of the 
blood, is quite unwarrantable. Very often, when examined in the early 
stages of fever, that fluid presents no appreciable change; and, even when its 
alteration has preceded an open attack of fever, it is possible that the result 
may have taken place in consequence, of morbid impressions already made 
upon the solids. 
7. Nature of Fever. 
That fever is a general disease, affecting all the functions, must be obvious 
to those who observe the phenomena which it presents. This is true, whether 
we consider the functions of associated parts, as of the apparatuses or systems 
which compose the general system, or those of particular organs. The pains 
in the head, back, and extremities, in the earlier stages, the various disordered 
sensations, the altered sensibility and muscular weakness, the mental debility 
or confusion, with many other occasional or constant phenomena, evince, 
beyond all possibility of doubt, derangement of the nervous system. The 
loss of appetite, loathing of food, diarrhoea or constipation, nausea, vomiting, 
&c., no less plainly indicate disordered digestion. That the circulatory func- 
tion, and, as a necessary consequence, that of absorption are deranged, is too 
obvious to require proof. The hurried or anxious breathing, and the often 
deficient arterialization of the blood, prove that respiration participates in the 
general disorder. Secretion is universally affected, being generally deficient, 
sometimes too copious, and often quite deranged. That the nutritive function 
is almost suspended, is proved by the length of time during which life is often 
sustained in fevers without food. The calorific function is almost invariably 
more active than in health, in fully developed fever. If each of the organs 
be taken in like manner successively, they will be found, without exception, 98 
GENERAL PATHOLOGY. 
[part I. 
to be more or less disordered. We are justified, therefore, in considering 
fever as a disease of the whole system. 
The question now arises, can this disease exist of itself, or is it necessarily 
connected with and dependent upon some local lesion; in other words, can it 
be essential or idiopathic, or is it always a,nd necessarily symptomatic? I 
believe that general opinion is' correct in considering it sometimes as one, and 
sometimes as the other. The advocates of the exclusive local dependence of 
fever, have thrown away much eloquence in combatting a chimera which they 
denominate ontology, as if their opponents believed in the existence of some- 
thing distinct and independent of the system, under the name of fever. All 
that is maintained by the essentialists is, that in fever all the functions are 
disordered, without any necessary dependence upon disease in one particular 
part. 
In maintaining the existence of essential fever, it is not necessary to support 
the notion of universality in the action of its cause. This may or may not be 
the case. The probability is, that some causes act locally on one organ ex- 
clusively, others act generally on several organs, some universally on all. But, 
when an essential fever arises from a cause acting upon a particular part, the 
first impression, after setting the febrile movement a going, is no longer ab- 
solutely necessary to it, and may cease altogether. Otherwise the fever would 
be symptomatic of the local affection. 
I propose in this place to offer some arguments in proof of the occasional 
independent existence, or idiopathic nature of fever. They who maintain a 
contrary opinion, with the exception of the humoral pathologists, ascribe fever 
to local inflammation exclusively. The arguments will, therefore, be directed 
especially to that point. 
1. Fever often occurs without exhibiting any certain, or even probable evi- 
dence of inflammation of any one organ, either at its origin or during its corn-se. 
There is always derangement of function ; but this is not necessarily connected 
with inflammation. Pain is sometimes wholly wanting, and when present, 
especially in the early stages, is often obviously of the neuralgic character. 
The most accurate examination fails to discover the usual physical signs of 
inflammation. It is true that, in fatal cases, dissection generally reveals ap- 
pearances which could only have resulted from this cause. But it must be 
borne in mind, that the febrile movement has a strong tendency to generate 
inflammation, and, though it may be entirely free from this complication at 
the commencement, will almost always induce it, if sufficiently protracted 
and severe to destroy life. Indeed, fever probably proves fatal, in the ma- 
jority of cases, through the instrumentality of the inflammation which it ex- 
cites. So far, therefore, are these appearances from proving the fever to have 
been produced by the inflammation, that it would be surprising were they ab- 
sent in a protracted and fatal case of this disease, though free from inflamma- 
tion at the commencement. The onset of the inflammation, when it takes 
place, is generally sufficiently striking to engage the attention of the phy- 
sician. But the post-mortem appearances of this affection are not always 
present, and, when they exist, are often in a degree, which evinces that it 
could have been the cause neither of the fever, nor of the fatal issue. In the 
absence, therefore, of proofs of inflammation, we have no right to assume its 
essential existence; and the disease should be taken for what it seems, namely, 
mere functional disorder. 
2. If fever always originated from local inflammation, there should be, in 
those varieties deemed idiopathic, as there is in the proper phlegmasia?, some 
pain or other indication of the local disorder previously to the commencement 
of the fever, It must be admitted, that this is not always the case in fevers chapCi.] 
FEVER. 
99 
universally considered as symptomatic; but it is so as a general rule; and, 
therefore, as a general rule also, evidences of inflammation should precede 
other fevers, if they are to be considered as pldegmasim. But this does not 
happen. In the great majority of cases of fever, usually called essential, there 
is no certain evidence whatever of antecedent inflammation. On the contrary, 
the preliminary symptoms are rather those of depression than excitement, and 
indicate disorder, rather in the nervous than the circulatory system. 
3. When fever arises from inflammation, we expect it, in general, to be 
.proportionate, in some measure, to the violence of its cause. We do not look 
for a very violent fever from a very slight inflammation. Now we often have 
fevers consisting of a single short paroxysm, or of recurring paroxysms, with 
perfect; intermissions; and,,in these cases, the febrile movement is frequently 
of the very highest grade. If the fever depended on inflammation, this also 
should be severe; and yet it is scarcely possible to conceive of a violent in- 
flammation, sufficient to produce intense fever, continuing only for three or 
four hours. Severe inflammation usually requires some time for its deyelope- 
mcnt, some time for its increase, and some time for its decline. It seems 
evident that an inflammation, capable of producing the.paroxysm of an inter- 
mittent, must be of so high a grade as scarcely to leave a doubt of its exist- 
ence ; and yet never till the present century did it- occur to the most observ- 
ing physicians, that inflammation is an invariable attendant upon this disease. 
If inflammation be the cause of intermittents, it must be internal; why does 
not external inflammation, which is obvious to the senses, occasionally pursue 
the same course, and give rise also to intermittent fever? The want of such 
cases'of external origin may justify the suspicion, that those persons may be 
mistaken who conjecture the existence of internal inflammation in intermit- 
tents; and if it be not the cause of this form of fever, there is reason to sup- 
pose that there has been an equal niistake in ascribing other forms, hitherto 
regarded as idiopathic, to the same cause. 
If the general truth be established, that fevers may exist independently of 
inflammation, those theories fall of course which ascribe them invariably to 
inflammation of some particular organ. Still, it may not be improper to offer 
a few observations upon the most prominent theories of this kind presented to 
the public. Clutterbuck, it has already been stated, seated all the fevers, 
usually called idiopathic, in the brain. A sufficient refutation of his theory 
is, that, though perhaps in all cases ,of fever there is more or less nervous 
disorder, yet often no symptoms exist which would call attention particularly 
to the brain, and very often dissection discovers no satisfactory evidence of 
inflammation in that organ,' or its appendages. But the doctrine of Broussais 
is more plausible, and has obtained much wider currency. I shall, therefore, 
present somewhat more at large the considerations opposed to it. The reader 
will recollect that Broussais7 theory regards fever as gastritis, or gastro-en- 
teritis; the intestines, according to that author,, always exhibiting marks of 
inflammation, when the stomach is found to have been inflamed, in fatal cases 
of fever. 
I admit fully, that the stomach is always disordered in fever. Evidence 
of this fact has already been presented. That the same organ is often inflamed 
is equally beyond doubt. The burning sensation, the uneasiness or pain in 
the epigastrium, the tenderness upon pressure, the frequent nausea or vomit- 
ing, as well as the appearances after death, are sufficient proofs of this fact. 
But pain, tenderness, and nausea, are not unfrequently wanting; and dissec- 
tion does not always reveal marks of inflammation. Even when supposed 
signs of inflammation have been discovered after death, they are- often in fact 
not at all to be relied on; as redness, both in patches and in_arborescent 100 
GENERAL PATHOLOGY. 
[part I. 
ramifications, is not unfrequently presented by stomachs perfectly healthy, in 
persons-for example, who have died by violence/ The late Dr. Parrish found 
the same appearance in the gastric mucous membrane of hogs, which had been 
bled to death at the shambles; and the most experienced pathologists say, that 
it is difficult, if not impossible, to discriminate between this merely physical 
phenomenon, and the redness of inflammation, unless some other marks of 
this diseased condition be presented. Thus, then, it appears, that the gastric 
mucous membrane is found, in cases of death from fever, without any signs 
of inflammation, and that often, when these signs apparently exist, they are 
in fact delusive. But the advocates for the gastric theory maintain, that in- 
flammation may have existed without leaving a trace discoverable upon post- 
mortem examination; and they appeal to the disappearance of the redness 
after death, in cases of superficial inflammation of the skin. It is, however, 
utterly impossible, from the very nature of the inflammatory process, that this 
should exist with sufficient violence, or of sufficient duration, to occasion death, 
without leaving some marks, either of congestion, effusion, softening, or other 
organic change, discoverable by close inspection. Even in the skin, unless 
exceedingly slight or transient, it produces some derangement of ^structure 
evident after death. The cases of poisoning by arsenic, in which the stomach 
retains its healthy colour after death, have been adduced in proof of the asser- 
tion, that, even after fatal inflammation, the redness may entirely disappear. 
But these cases are more reasonably explained upon the supposition, that the 
deadly influence of the poison upon the nervous system has destroyed life so 
speedily, that there was no time for the establishment of inflammation; just 
as the poisonous cause of fever occasionally proves fatal by its first depressing- 
influence, before reaction can take place. The inference, therefore, from the 
occasional perfectly healthy appearance of the stomach after death, that it was 
not inflamed during life, remains unaffected; and, if inflammation can be shown 
to be absent in a single case, the theory is disproved. 
But what are the evidences, independent of those offered by dissection, 
which are relied on to prove the invariable presence of gastritis ? The sen- 
sation of heat, the intense thirst, the relief afforded by cold drinks, and the 
distaste for hot and stimulating drinks, and for all kinds of food, have been 
mentioned. It is true that these symptoms are very generally present; but 
have we not also a'hot skin, and are not cool liquids as agreeable to the sur- 
face as to the stomach? and yet it is not maintained that the skin is inflamed. 
Thirst is not especially a sign of gastric inflammation. It perhaps more 
frequently indicates a particular' condition of the blood, which calls for dilu- 
tion,. The distaste for hot drinks may indicate the existence of gastric heat, 
but not necessarily inflammation. The distaste for food proves a loss of 
digestive power, and frequently exists in the state most opposite to inflamma- 
tion. Other indications of inflanmiation which have been mentioned, are 
nausea and vomiting, and the red and coated tongue. The first two are often 
present, but they are also frequently absent, and, even if they were invaria- 
ble attendants, would not prove the existence of inflammation; as they often 
indicate mere nervous irritation of the stomach, or of the centres which 
supply it with nervous influence; and are quite compatible with true debility 
of the organ. The red and furred tongue has very generally been consid- 
ered as indicative of gastric disorder; but the investigations of Louis and 
others have shown conclusively, that no certain inference can be drawn from 
the state of the tongue, in fevers, as to the state of the stomach. The 
tongue appears to feel, like all other parts of the body, the influence of the 
morbid cause. That it is so often disordered simultaneously with the sto- 
mach, proves that they are exposed to the same influence, not that the dis- CHAP. I.] 
FEVER. 
101 
order of one is dependent upon that of the other. lienee, the cleaning of 
the tongue is one of the best evidences of the decline of the fever. It is said 
that leeches to the epigastrium are speedily followed by improvement in the 
appearance of the tongue. This is often true, and the fair infererice is, that 
irritation or inflammation of stomach may exist in. such particular instances, 
and aggravate the general fever. But very often, also., no such effect is ex- 
perienced. Leeching to the temples would have a similar influence if cere- 
bral irritation should exist. It is not, however, intended to deny that there 
is a sympathetic connexion, to a certain extent, between' the tongue and the 
Stomach: the only point maintained is, that this connexion is not sufficiently 
close to justify the inference, that, because the tongue is red in fever, the sto- 
mach is inflamed. 
If gastritis were the cause of fever it should always precede it. We cer- 
tainly very often have evidences of derangement of stomach before the attack 
of fever; but there is no proof that this derangement is inflammation. It 
might as well be maintained that the nervous symptoms, which are much more 
prominent than the gastric, are proofs of the existence of inflammation of the 
brain. Besides, the gastric disturbance is by no means an invariable ante- 
cedent. I have known a severe febrile paroxysm to commence immediately 
after a hearty dinner. 
The phenomena of intermittent fever afford one of the strongest objections 
to the gastric hypothesis. This disease is cured by remedies which power- 
fully irritate the mucous membrane of the stomach. Quinia often produces 
great gastric irritation, and Peruvian bark still greater. Arsenic, wrhich is a 
powerful gastric irritant, is perhaps, next to quinia or bark, the most effectual 
remedy. Intermittent'S are occasionally cured by black or red pepper, taken 
between the paroxysms. When an organ is peculiarly disposed to inflamma- 
tion, the application of an irritant is generally supposed to favour the dispo- 
sition ; and substances of 'this kind are the last preventives we should be dis- 
posed to resort to. 
It is, therefore, by no means an established fact, that the fevers commonly 
considered as essential or idiopathic are gastro-enteritis; much less those 
denominated symptomatic. Undoubtedly fever may arise from inflamma- 
tion of the stomach and bowels; but it then takes rank with the other phleg- 
masirn. Nevertheless, gastritis is a frequent attendant upon fevers, much 
more-so than was believed before Broussais called attention to the fact; and 
there is no doubt, that the treatment of these diseases has been favourably 
modified by the new light thrown upon them by this author and his disciples. 
Admitting fevers to be in some instances idiopathic, in others symptomatic, 
the proper febrile movement, from whatever cause it may proceed, and how- 
ever it may be complicated in different cases, is of the same essential charac- 
ter. The functions are deranged, and in such a manner that all recognize the 
disorder wrhen they encounter it. There must, therefore, be something, in 
the different febrile diseases, common to the whole of them, and to this the 
name of fever properly belongs. 
It is an interesting question what is the nature of the derangements in 
the functions. The mere statement that they are universally disordered 
gives no definite notion of the disease. But it is by no means an easy task 
to explain the nature of the derangement. Some of the functions are in a 
state of irritation, some probably of depression; but if we attempt to review 
the whole of them, and point out which are in the one state, and which in the 
other, we find that in many instances the symptoms do not afford us grounds 
for a positive decision; and we can derive no aid- from organic changes; for 102 
GENERAL PATHOLOGY. 
[PART I. 
these, when they do occur, fte not essential. The order in which those states 
succeed each other, and the chain of mutual dependence-which connects them, 
equally elude our search. It is possible that there may be something pecu- 
liar in the irritation and depression. But if such peculiarity exist, we cannot 
point out its nature. Together with disorder of the -solids, there is very fre- 
quently an altered state of the blood; but the question has not yet been set- 
tled, whether this is an essential part of the disease, and important in the 
chain of causation, or a more incidental effect. We are thus in a condition of 
uncertainty upon almost all points. . c , 
Theorists have failed in endeavouring to trace the complicated disorders of 
fever to some common-source, and to point out a particular succession, a par- 
ticular and necessary line of march, in the progress of the affection. The 
universal disturbance of function which constitutes the disease may be brought 
about in various ways; and the starting point maybe entirely different in dif- 
ferent cases. Yet, among the great majority of cases, there is a close analogy 
in the mode of onset, which must be ascribed to some common principle. 
Whether the fever is idiopathic or symptomatic, the first decided step towards 
its formation, seems to be some morbid impression upon the nervous system, 
and this impression scents to be of a depressing nature. The phenomena im- 
mediately preceding, and those attendant on the chill, are for the most part 
unequivocally those of depression. The whole nervous system appears to 
have received a shock from the cause, cramping, and for a time deadening its 
energies. Something analogous to this we have in the effects of a severe sur- 
gical operation, of a severe injury in any part of the body, and of sudden 
alarming or afflictive intelligence. Along with the diminished exercise of the 
nervous function, is necessarily a diminution of all those functions dependent 
upon it. We may thus partially explain the condition of the chill; but there 
is something more which we do not fathom; something in which the chill of 
fever differs from other instances of nervous depression. Upon principles 
which have already been explained', the general prostration is succeeded by 
reaction, and the fever is then established. But there is here also something 
more than mere reaction. There is the continued action of the cause, a diver- 
sified play of sympathies in one case, a widely pervading influence from some 
unknown agent in another; and fever is not purely, as some have maintained, 
the resilience of the bowed down system. A proof of this is} that the febrile 
excitement is by no means proportionate, in all cases, to the initial nervous 
depression. To unravel this complicated web is in the present state of our 
knowledge impossible. We are too little acquainted with the precise recipro- 
cal action of the organs, with the nature of the nervous power by which this 
reciprocal action is maintained, and, in many instances, with the cause of the 
disease and its mode of operation, to enable us to advance far beyond conjec- 
ture. We know that the heart, arteries, and capillaries are in a state of 
super-excitement; that, under the combined influence of the nerves and blood- 
vessels, calorification is increased; that all the secreting surfaces, including 
that of the stomach, and all the secreting glands, and the whole process of 
nutrition, are deranged; sometimes probably being irritated, sometimes de- 
pressed, and sometimes peculiarly affected, under the influence of peculiar 
causes. s ' • ■ 
But in many instances of fever, even the imperfect concatenation above 
described is not evinced. Not unfrequCntly, the stage of chill is so slight as 
to preclude any idea of its agency in inducing the succeeding stage, and some- 
times it is entirely wanting. In these cases, we must suppose the various 
derangements constituting the fever to be induced by the exciting cause, 
without a preliminary action specially upon the nervous system. Either the CHAP. I.] 
TUBERCULOSIS. 
103 
cause enters the circulation, and reaches all the organs so as to act on all 
simidtaneously, or it affects some one part primarily, from which an influence 
is conveyed sympathetically over the system. The latter is Dr. Chapman's 
opinion, who traces most fevers to an original morbid impression made upon 
the 'stomach. His opinion was promulgated in lectures before the annuncia- 
tion of Broussais' hypothesis. But, in ascribing fever to a gastric origin, Dr. 
Chapman does not consider the affection of the stomach as necessarily inflam- 
mation, nor does he consider the original impression upon this organ necessary 
for the continuance (of the fever which it has set in motion. 
Article VI. 
PECULIAR MORBID PRODUCTS. 
The diseased conditions now to be considered are recognized by peculiar 
products, not necessarily the result of any exciting or depressing agency, 
whether ordinary or specific. They may be included under two divisions; 
the first embracing those in which the new product, if organized at all, has 
a very feeble, organization, the tendency of which is rathe/ to decay than to 
growth or reproduction; the second, those in which a new body is pro- 
duced, having a life of its. own, and capable of indefinite extension, if not 
of generation. 
I; UNORGANIZED, OR FEEBEY ORGANIZED PRODUCTS. 
The most important of these affections is, beyond all comparison, tubercu- 
lous or scrofulous disease. Melanosis may be ranked under the same head, 
as also, though with more doubtful propriety, may cirrhosis of the liver, and 
Bright's disease of the kidneys; The last two affections are special diseases, 
and will be treated of in the subsequent part of the work. The first two are 
general affections, exhibiting themselves by their peculiar deposits in various 
parts jof the body, where they give rise to phenomena differing according to 
the locality. Their presence and effects in the several positions in which 
the deposit. occurs, may be considered as constituting distinct diseases, and 
will be treated of as such. In this place, we are concerned with the general 
affections, independent of locality. 
TUBERCULOSIS. 
Syn. Tuberculous or Scrofulous Disease.'-Strumous Disease.-Scrophulosis. 
In certain states of the system, a solid extravasated matter is deposited in 
various parts of the body, which, from the shape ordinarily assumed by it, is 
called tubercle. The morbid state of system which leads to this deposition 
may be denominated the tuberculous diathesis. It is closely analogous, if not 
absolutely identical with that which usually precedes the developement of 
scrofulous tumours, and which is denominated scrofulous or strumous diathesis. 
In this work, they are considered as one affection. When this state of system 
becomes decidedly and obviously morbid, it is sometimes called tuberculous, 
scrofulous, or strumous cachexia. 
The tuberculous deposition takes place in one of two forms; either that of 
small, isolated bodies, or that of irregular infiltration into the tissues. In 
either case, the matter as first deposited may be gray, semi-transparent; and 
hard, or jcllow, opaque, and rather soft. According to Laennec and Louis, 104 
GENERAL PATHOLOGY. 
[part I. 
the deposit is originally of the former character, and afterwards assumes the 
latter. But the matter is often found in both conditions at the earliest period 
at which it can be examined; and it seems to the author, that, unless other- 
wise proved, it must be allowed to have been thus deposited. 
When in the form of gray, semi-transparent, hard,corpuscles, the tubercles 
have been variously denominated miliary tubercles, tuberculous granulations^ 
and gray semi-transparent granulations. They do not at first exceed a millet 
seed in size, but gradually increase till they become as large as a cherry-stone 
or larger. A yellow spot soon makes its appearance within them, which en- 
larged by degrees until the whole tubercle is converted into a yellow, opaque, 
curdy matter, so soft that it may be crushed between the fingers. Sometimes 
they are in this state when first observed. The process of change continues, 
the softness increases, and the tubercle at length breaks down into a pus-like 
matter, with which are often mingled portions of the tuberculous substance in 
a cheesy form. This sort of mixed matter may Sometimes be found in the 
centre of the tubercle, while the circumference remains still hard and unal- 
tered. Not unfrequently, numbers of the' miliary tubercles are aggregated 
together, forming a considerable mass ; in which case, several points of alter- 
ation may be observed in different parts of it. 
The infiltrated tubercle may be in the shape of large irregular masses, 
as in the lungs, of flattened patches, as upon the serous membranes, or of 
sheaths to the blood-vessels, as about the veins of the pia mater. (Louis.) 
It undergoes the same changes as the isolated tubercles, from the gray and 
semi-transparent,, through the yellow, opaque, and soft, to the semi-liquid pus- 
like matter. 
When thus mature, the tubercle excites inflammation and consequent 
ulceratiom in the surrounding tissue, by which, in many instances, a passage 
is made for the escape of its contents. The walls of the resulting cavity, 
which are sometimes lined by a sort of cyst, sometime^ consist only of the 
consolidated surrounding tissue, secrete pus, which continues to be discharged 
for a long time, often mixed with the curdy matter. In many instances, 
however, a healing process at length takes place, the cavity is filled, and a 
cicatrix only remains. This is especially the case in scrofulous affections of 
the lymphatic glands. Sometimes, there is. reason to believe that it takes 
place also in the lungs, though in the latter, the process of deposition and de- 
struction generally goes on more rapidly than that of reparation, and the result 
is fatal. Sometimes, instead of the series of changes above described, the 
tubercle undergoes another process, by which the organic matter is absorbed, 
and an earthy or chalk-like substance is deposited in its place. This may 
always be regarded as a favourable termination.* 
The time occupied in these transformations is very uncertain. Sometimes 
the tubercle remains long quiescent in its original form; and, when the change 
begins, it may be completed in a few weeks, or may continue in progress for 
years. Not unfrequently, the disturbance produced by the tubercles in the 
* According to Rokitansky, the famous. pathological anatomist of Vienna, the gray 
semitransparent granulations of Laennec, which are a variety of what he denominates 
simple fibrinous tubercle, never soften like yell'ow tubercle f and the only transformation 
they undergo is what he calls obsolescence, which takes place in the following manner. 
" After the tubercle has passed through its condition of crudity, it loses its shining appear- 
ance and increases in density, becomes converted into a small hard lump, and then 
shrivels into a tough, amorphous, or slightly fibrous, horny mass. This process is some- 
times accompanied with more or less of ossification, in which case the remains of the 
tubercle consist partly of a horny mass, and partly of bone-earth." The tubercle is now 
dead, and can undergo no further change of form. {Brit, For, Medtco-Cldrurg. Rev., 
Am- ed., i. 173.^ Note to second edition. CHAP. I.] 
TUBERCULOSIS. 
105 
tissue in which they are deposited proves fatal, before they have passed even 
their first stage. This is more apt to happen when they are deposited in 
vast numbers, as sometimes in the lungs and the serous membranes. 
Tubercles may be .formed in almost any portion of the body, and often fexist 
in many parts at the same time. They are most frequent inthe lungs, and, 
indeed, in adults, are seldom found in other parts, without existing also in 
greater or less number in that structure. This, however, is not a universal 
rule. In children, they are often found elsewhere) though wanting in the 
lungs. After the lungs, the parts most frequently affected are, according to 
Louis, first, the lymphatic glands; then the pleurae, the intestines, the spleen, 
the liver, the peritoneum, the mdmbranes of the brain, the brain itself, and 
the bones; and, lastly, the pericardium, stomach, kidneys, pancreas, &c.* In 
their various positrons, they produce great disturbance in the surrounding tis- 
sue, and give rise to morbid affections, which have received different names 
according to their "seat and character. Thus, in the lungs they produce 
phthisis; in the pleurae, chronic pleuritis; in the peritoneum, chronic perito- 
nitis and abdominal dropsy; in the mesenteric glands,, tabes mese'nterica; in 
the arachnoid, hydrocephalus; in the lymphatic glands, external scrofula; and 
in the bones, white, swellings, caries, necrosis, &c. 
All ages are liable to tuberculous disease, but the two extremes of life are 
most exempt. From the researches of M. Papavoine, it appears, that before 
the end of the second year, it very seldom occurs; from this period to the end 
of the fourth year', is more frequent, and from four to thirteen, is exceedingly 
frequept. After the -age of puberty, there is some exemption; but the liability 
returns towards that of maturity, and from eighteen to thirty-five or forty, is 
very great. After this it lessens, and the disease is rare in old age, at least 
as an original affection. 
It must be evident, from the foregoing account, that this is not a local 
disease. The tubercles can appear in so many different parts at the same 
time, only in consequence of some general depravation of the system. In 
what this depravation consists is not eyident. It has been thought to occur 
preferably in individuals who present certain natural physical traits. Thus, 
persons have been said to be peculiarly predisposed to it, who have a clear- 
white or rosy complexion; a soft, delicate skin; large lustrous blue eyes, with 
long eyelashes, and a pearly sclerotica; thickness of lips, especially the upper; 
a narrow flattened chest, with high shoulders; and, in childhood, a bright, 
active spirit, and precocious intellect. Dr. Wilshire has recently called atten- 
tion to a very hairy condition of the skin, in children, particularly on the 
forehead, arms, back of the neck, and between the shoulder blades, as pecu- 
liarly indicative of a tuberculous predisposition. {Lond. Med. Times, Ap. 10, 
1847.)< There is no doubt that persons with the above characters have often 
been .subjects of tuberculous disease; but too much stress was at one time laid 
upon the complexion, and the colour of the hair and eyes; Observation has 
shown, that about as large a proportion of persons with dark hair, dark eyes, 
* From a'personal observation of thirteen or fourteen thousand cases, Rokitansky gives 
the' following as the order of parts, in relation to their liability -to tubercle in the adult:- 
1. lungs, 2. intestinal canal, 3. lymphatic glands, especially the abdominal and bronchial, 
4. larynx, 5. serous membranes, especially the peritoneum. 6. arachnoid, 7. brain, 8. 
spleen, 9. kidney, 10. liver, 11. bones and periosteum, 12. uterus and fallopian tubes, 
13. testicles, prostate, and seminal vessels, 14. spinal cord, 15. muscles of animal life. 
This order, it will have been perceived, differs somewhat from that given by Louis. In 
children, the lymphatic glands and spleen are most frequently affected, and after these, 
the lungs, bronchial mucous membrane, brain, serous membranes, &c. (.Brit. For. 
Medico-Chirurg. Rev., Am. ed., i. 179.) Note to second edition. 106 
GENERAL PATHOLOGY. 
[part I. 
and a swarthy complexion are affected, as of those with opposite physical cha- 
racters. Negroes are, in this climate, more disposed to the disease than the 
whites. ' t > 
But more confidence may be placed in the sighs which indicate a com- 
mencing developement of disease, and which often long precede the deposi- 
tion of tubercle. Such are a pale, somewhat puffy countenance; swollen lips, 
which are apt to be sore and chapped in cold weather; tumefaction about the 
nostrils; occasional purulent discharges from the nQstrils or ears; a tendency 
to soreness of the eyes, and especially to a vesicular eruption upon the con- 
junctiva; vesicular eruptions behind the ears, and in different parts of the 
head and face; sourish or otherwise disagreeable exhalations from the skin; 
slight swelling and induration of the glands of the neck, and enlarged tonsils; 
a rickety condition of the bones; a weak but excitable pulse; flabby muscles; 
a rapid increase in height, without corresponding lateral developement; and 
general weakness, indicated by fatigue after moderate exertion. It is not to 
be supposed, that all these symptoms are present in every case; but enough 
of them frequently are so to justify solicitude, and to lead the prudent prac- 
titioner to the adoption of preventive measures. Not unfrequently, a slight 
febrile movement, rather occasional than persistent, is observed in addition 
to the. other phenomena; and, indeed, such a movement is sometimes the 
immediate forerunner or attendant upon a copious tuberculous deposition. 
The tuberculous diathesis is also characterized by the modified condition of 
the inflammatory process which it produces. Inflammation, occurring in sys- 
tems under its influence, very generally assumes a slow or chronic form, is 
accompanied with comparatively little heat or pain, and, after suppuration, 
leaves abscesses which heal very slowly, and are sometimes exceedingly obsti- 
nate. The affection, under these circumstances, is distinguished by the name 
of scrofulous inflammation. It is very often the immediate result of the 
tuberculous deposit, acting as a foreign body, and irritating the neighbouring 
parts; and the purulent discharge is frequently mixed with broken down 
tubercle in the form of curdy matter. But the deposition of tubercle is not a 
necessary attendant of all cases of scrofulous inflammation. The diathesis 
appears sometimes of itself to predispose to inflammation; and, when that 
process occurs from other causes, it assumes the peculiar scrofulous character, 
even though no tubercles may be present. 
After the formation of tubercles, and during their maturation and discharge, 
the systepi often sympathizes strongly, and there is almost always, at first, a 
simple irritative fever, and afterwards, when suppuration has become estab- 
lished, more or less hectic fever, which, in severe cases, rapidly exhausts the 
remaining strength. 
From the experiments of M. Dubois of Amiens it would appear, that the 
blood, in scrofulous cachexia, has a smaller proportion of coagulable matter 
in relation to the serum, and that the serum itself is of less specific gravity 
than in health; while the red colour of the liquid is, in some degree, inde- 
pendent of the red corpuscles, as if these had undergone a partial disintegration. 
(Diet. de Med., xxviii. 221.) The blood is, therefore, watery and impover- 
ished, and incapable of supplying the nutritive function sufficiently. Dr. Glover 
inferred, from a series of original experiments, that the albumen is increased 
and the blood corpuscles diminished. (Pathol. and Treat, of Scrofula, Lond., 
1846, p. 115.) In phthisis, according to Andral and Gavarrct, the proportion 
of the red corpuscles diminishes, and that of the fibrin increases with the 
advance of the disease. That of the red corpuscles is almost always below 
the healthy standard; that of fibrin often above it. But the increase of the CHAP. I.] 
TUBERCULOSIS. 
107 
fibrin is a result of the inflammation occasioned by the'tubercles; and we have 
no proof that it is in excess under other circumstances. 
What is the nature of this affection, denominated tuberculous disease, but 
of which the tubercle is-a mere incident, though a very general, characteristic, 
and most important incident? This question cannot be fully answered, in 
the present state of our knowledge. We know that, generally, the vital 
energies are enfeebled, and the blood impoverished or depraved. It is highly 
probable that the tendency to the tuberculous deposition is due directly to the 
condition of the blood. But the state of the blood must itself be dependent 
upon some deficiency or depravation of the functions by which it is elaborated, 
and we are thrown back upon some original vice in the organic constitution. 
A knowledge of the causes which favour the developement of the disease, 
may aid us somewhat in understanding its nature. These are almost all of a 
character fitted to lessen the energies-of the system, and to impoverish the 
blood. Insufficient food, confinement, want of fresh air and exercise, habitual 
exposure to cold, sensual excesses, great loss of blood or other depletion, and 
the depressing passions, greatly favour^ the developement of tubercles, and 
even appear capable sometimes of producing the diathesis. It has been found, 
by experiment, that tubercles' are generated in some of the lower animals by 
close confinement. But there are many individuals upon whom all these 
causes may be made to operate, and so intensely even as to produce fatal 
effects, without giving rise to this particular disease. Indeed,'it is probable 
that the great majority of mankind might perish, under these circumstances, 
and give no sign of tubercles. There is something more, therefore, than 
mere debility, There is some inherent peculiarity of the organization, gene- 
rally derived or inherited from the parent, which serves as the basis of the 
disease. The other causes are in general merely exciting. They, no doubt, 
often induce the disease, when it might otherwise never have been developed; 
but they are generally incapable of producing it, unless in subjects having 
some innate disposition towards it. In the great majority of fatal cases of 
tuberculous disease, the original and essential cause will probably be found to 
be an inherited peculiarity of organization. 
It has been supposed ly many that tubercle is a product of inflammation, 
and differs from other products of the same process only in consequence of 
the peculiar character of the fluids, or the deficient energy of the solids, or the 
conjectural circumstance, that the white vessels, or those carrying only colour- 
less blood, are especially affected. But a sufficient refutation of this opinion 
is, that, in a vast, number of cases, tubercles exist without any inflammation 
w-hatever, evinced either by the symptoms, or by । anatomical examination. 
No fact in pathology is better established than this. Undoubtedly, inflamma- 
tion is often found in connexion with them. But it is generally a result, and 
not a cause. It conies on after the tubercles have been formed, and not before 
them. There is, however, reason to believe, that the occurrence of inflam- 
mation, in an individual predisposed to tubercles, favours their production. 
It excites secretion, and, if the materials for tubercles are present, they will 
probably be deposited along with other secreted matters. 
The nature of tubercle has been a subject of some inquiry. Very different 
analytical results have been obtained by different chemists. A recent analysis 
by Dr. Glover gives for 200 grains of very pure tuberculous matter, in the 
crude state, 6-75 parts of fats, 7'50 of extractive matter soluble in alcohol and 
water, with loss, 0-45 of chlorides, 0-58 of earthy salts (phosphates), 0-50 of 
alkaline salts, 21'72 of protein residue, and 162-50 of water. (^Pathol. and 
Treat, of Scrof, p. 73.) The precise nature of the protein base of tubercle 
does not seem to have been satisfactorily determined. Some chemists profess 108 
GENERAL PATHOLOGY. 
[part I. 
to have found fibrin, others albumen, and others again casein and pyin. In 
the instance just stated, Dr. Glover could not detect a trace of either of the 
two last mentioned principles. In another experiment, he found what he 
considered to be albumen and pyin, but never succeeded in obtaining casein. 
M." Lebert discovered, by means of the microscope, molecular granules, proper 
tuberculous corpuscles, and an intervening unformed, or hyaline substance. 
The corpuscles are quite different from those of pus, and could not have been 
formed out of them, being smaller, less regularly spherical, often compacted 
together instead of being free and isolated, and containing some molecular, 
granules, but no nuclei, of which the pus globules contain from one to three. 
(Diet. de Med., xxix. 795.) The inference is, that tubercles cannot, as some 
have maintained, have originated from the consolidation of pus. These ob- 
servations were made upon matured, or yellow and softened tubercle. 'The 
gray granulations were found by Mr. Gulliver and Mr. Addison to contain 
granulated vesicles or cells, which degenerate by time into granulated cor- 
puscles without tunics, and into isolated granules, the latter of which are 
very numerous in the opaque tubercle. Wdliamd Princip. of Med., Armed., 
p. 320.) The observations of Drs. Bennet and Glover confirm .essentially 
those of M. Lebert. The characteristic constituent of tubercles is the 
granulated corpuscle, which is very numerous, and sometimes constitutes 
almost their whole substance. It is probably in general a degenerated cell, 
though not impossibly sometimes an imperfect original production. Besides 
thi^, there are vast numbers of very minute granules, which may be the 
result of a disintegration of the granulated corpuscles; Epithelial scales, fat 
globules, crystals of salts, and the detritus of tissues incorporated with the 
tubercle, are also sometimes seen by means of the microscope. (^Pathol. and 
Treat, of Scrof., p. 49.) The readiest explanation of the phenomena suc- 
cessively presented by tubercles, is that which supposes them to have a low 
and imperfect vitality as first secreted, to be nourished and grow like carti- 
lage by imbibition, and then, as a result of the law of their constitution, to 
undergo a series of changes ending in their complete disintegration. 
MELANOSIS. 
This is a very rare disease, though more common in the inferior animals 
than in man. It is characterized by the deposition, in various parts of the 
body, of a peculiar black or dark-coloured substance, which has given origin 
to the name. This substance is deposited either in isolated masses, in the 
substance of the tissues, upon the free surface of membranes, or, in the liquid 
form, in cavities whether natural or morbid. 
The'melanotic matter is most frequently in isolated bodies, which vary in 
magnitude from the size of a hemp-seed to that of an orange, and, in some 
rare instances, have been known much to exceed the latter dimensions. It is 
probable, however, that the larger masses are formed by the aggregation of 
the smaller. When single, these bodies are in general rather regularly 
spherical; but, when aggregated, are often very irregular, having a tuber- 
culated surface, and sometimes resembling, in appearance, a string of beads, 
or a bunch of grapes. Their colour is dark, but of different hues, sometimes 
reddish-brown, sometimes of a bistre or soot colour, and occasionally bluish, 
violaceous, or black. They differ also in consistence, Some having the firm- 
ness of a lymphatic gland, others the softness of suet, and others again being 
pultaceous or semifhud; and these different conditions may all exist in the CHAP. I.] 
MELANOSIS. 
109 
same person, at the same time. They are in general nearly or quite inodorous, 
though sometimes said to smell disagreeably. When rubbed between the 
fingers, they impart to them a temporary stain. No trace of organization has 
ever been detected in them; and, if any signs of vascularity, have been ob- 
served in the masses, it has been in the tissue which is occasionally involved 
in them, in consequence of the union of neighbouring deposits.' In general, 
they are in immediate contact with the tissue, in the midst of which they have 
been deposited; but, in some instances, they are- surrounded by what appears 
tb be a cyst, but which is probably nothing more than the condensed neigh- 
bouring structure. 
When the black matter is infiltrated in the tissues, it seems sometimes to 
unite with them molecularly,, colouring them uniformly, or appearing like dots 
produced by sprinkling dark granules over the surface. In this way it may 
unite with healthy structure, or with that which is diseased ; as, for example, 
with the indurated fibrinous products of chronic inflammation, with tubercle, 
with scirrhus, or with, medullary fungus. 
Occasionally it has been observed in small patches, upon the free surface 
of the serous membranes, especially of the peritoneum. Some believe that 
they have, also detected it on the mucous surfaces,; and persons arc not want- 
ing who consider the black discharges of nielmna and black vomit, as owing 
their colour to an identical product. It has bertainly been found, in the liquid 
form in cavities, either natural, as that of the abdomen, or formed by disease 
in one of the organs. ; . ■, 
After deposition, the matter increases by further secretion from the sur- 
rounding tissue, and'not by growth. Laennec supposed that the little tumours 
underwent a softening process, similar to that of tubercles, and, like them, 
discharged their contents through ulceration. But subsequent investigation 
has shown that they have no inherent tendency of that kind. By pressing 
upon surrounding parts, like any Other foreign body,, they sometimes excite 
inflammation, and its consequences, serous and fibrinous effusion, suppuration, 
and ulceration. But the melanotic bodies, in these causes, act mechanically. 
They are usually very slow in their progress. In those cases in which 
melanosis has been supposed to pursue an active course,, and to present the 
characters of tubercles or cancer, it has been the structure in which the black 
matter was deposited that has been the subject of the morbid process, and not 
the black matter itself, which has probably been quite innocent. 
Various analyses have been made of the matter of melanosis. They gene- 
rally agree in this one result, that it has the same character as the blood, 
though somewhat modified. Thus,, it contains albumen, fibrin, various saline 
ingredients, iron, and a colouring substance which bears a considerable resem- 
blance to that of the blood, and is probably derived from the red corpuscles. 
Some have supposed the melanotic deposit to be the same as the black pigment 
of the eye and hair, and of the skin in the, negro. It is said that white horses 
are more liable to it than those which are darker coloured, and old gray-haired 
persons, among human subjects, than the young; and a theory of its nature, 
deduced from these facts, ascribes the affection to a sort of metastatic deposit; 
the colouring matter, which is. no longer secreted in the hair, seeking an outlet 
in various parts of the body. Unfortunately, however, for this hypothesis, 
the complaint occurs also in dark-haired animals, and in men not yet gray. 
That is a much more probable theory, which considers the disease to be a 
sort of interior hemorrhage, similar to that which produces the black vomit in 
malignant fevers; the blood probably undergoing an imperfect secretory action, 
at the moment of extravasation.. But in the present state of our knowledge, 
all explanations are purely hypothetical. The affection is evidently connected 110 
GENERAL PATHOLOGY. 
[PART I. 
with a peculiar diathesis, or constitutional tendency; as the deposition often 
takes place in different and distant parts of the body at the same time; and 
the melanotic tumours are very seldom solitary. Nor will it be venturing 
much to suppose, that the extravasation of the black matter depends imme- 
diately upon a disordered condition of the blood. But what is the nature of 
this disorder, what its causes, and what its characteristic signs, independently 
of the mere act of deposition, are all points' upon which we are profoundly 
ignorant. 
The melanotic deposition, though most frequent in the cellular and adipose 
tissue, may take place in all parts of the body. It occurs, probably, more 
frequently in the liver or the lungs than in any other organ; but it has been 
observed also in the skin, upon the surface and in the substance of the serous 
membranes, in the coats of the blood-vessels, in the lymphatic glands, brain, 
kidneys, &c. In all these situations, it produces effects such as might be ex- 
pected from a foreign body, and symptoms which of course vary with the 
functions of the part. There are no signs by which melanotic disease can be 
distinguished, during life, from others producing similar disorder of the func- 
tions, except when the affection exists in the form of one or more characteristic 
tumours upon the skin. In such cases, any existing internal disorder of ap- 
parent organic origin, may, with some degree of confidence^ be ascribed in 
part or wholly to melanosis. 
II. ORGANIZED PRODUCTS.-MORBID GROWTHS. 
Morbid growths may be arranged in three subdivisions. The first embraces 
those in which the organized product bears a close resemblance to some healthy 
tissue, without any independent power of nutrition or reproduction, and with- 
out malignant tendency. To this section belong simple cysts, and non-malig- 
nant organized tumours. The second subdivision includes those morbid growths 
which have a peculiar organization, and which, along with a malignant tend- 
ency, and an apparent power of reproduction, have yet a close nutritive 
connexion with the system. Such are all the varieties of carcinoma. To the 
third subdivision belong all independent organized bodies, formed and existing 
within the system, yet having a distinct life of their own, and depending on 
the parts about them only for a convenient nidus, and the materials of nutri- 
tion. These are the parasitic animals, or entozoa, which, under the name of 
hydatids, worms, &c., infest the human frame: 
a. Organized Non-malignant Products. 
These may be. either cysts containing various products of secretion, or 
organized tumours with or without a cystiform envelope. 
1. Cysts.-Cavities are frequently formed in the body, containing liquid 
and solid matters, and bounded by membranous tunics, which, however, are 
the results of some of the processes previously treated of in this work, and 
do not, therefore, properly belong to the present section. Thus, matters 
foreign to the system, whether introduced from without, or the result of mor- 
bid processes within, excite inflammation in the surrounding tissues, and occa- 
sion the formation of a false membrane, which envelopes, and in some mea- 
sure isolates them. Again, certain natural cavities are sometimes irritated 
into unhealthy action, and, by the consequent excess of their secretion, ex- 
pand their walls, and sometimes acquire a great magnitude. Some of these 
are naturally closed, as the ovarian vesicles, the bursae of the tendohs, &c.; 
others are open in health, but are either unable to discharge the excess of CHAP. I.] 
CYSTS. 
111 
their secretion, as the sebaceous follicles of the skin, or become closed by an 
inflammatory adhesion, as the cells of the cellular or adipose tissue. Thirdly, 
in consequence of obstruction at the outlet of cavities, or in the course of 
tubes,, arising from inflammation, the presence of calculi, hardening of mucus, 
compression from without, &c., the healthy secretions accumulate behind the 
point of obstruction, and produce sometimes large tumours of an apparently- 
encysted character. Such, for example, is the tumour under the tongue deno- 
minated ranula, and dependent on obstruction in the salivary duct. None of 
these, however, belong to the class of morbid affections that we are now con- 
sidering. 
The cysts to which allusion is here made, are closed membranous bags, 
similar in appearance to serous membranes, capable of secreting from their 
inner surface, and closely connected, by their outer surface) with the tissues 
around them. Their contents are very diversified, both in consistence and 
nature; being either liquid, semi-liquid, or solid, and consisting of serous, san- 
guineous, dleaginouSy mucoid, or puruloid matter. Names have been given 
to them in accordance with the character of these contents. Thus, when the 
enclosed matter is watery, like the serum of the blood, they are said' to be 
serous; when of the consistence of honey, melicerous; when similar to fat, 
steatomatous ; and when of a soft pultacebus consistence, like concrete pus, 
atheromatous. 
They may be solitary or numerous, single or grouped together, and are of 
all sizes, from the smallest visible magnitude, up to that of a man's head, or 
larger. Their walls' occasionally become much thickened, and are liable to 
undergo various degeneration, in consequence of the deposit in their substance 
of cartilaginous, calcareous, or bony matter. They are sometimes, like the 
healthy tissues, attacked with inflammation, in consequence of which, blood, 
lymph, pus, &c., maybe mingled with the previous contents, of their cavi- 
ties. They occur in all parts of the body, except the cartilages, and perhaps 
the bones. In the abdomen, they occasionally give rise to that form of abdo- 
minal dropsy called encysted. 
These cysts are formed without preceding inflammation, or appreciable dis- 
ease of .any kind. They seem to be the mere result of a perverted nutrition. 
Probably, one of the microscopic cells or cell-germs, which form the bases of 
most of our tissues, takes on, in some inexplicable manner, a new mode of 
action, which issues in the. formation of a new body, having certain laws of 
its own, though with'a close resemblance, to some one of the healthy tissues, 
especially the areolar, or the serous. 'Though capable themselves, in conse- 
quence of the. accumulation of the secreted matter in their cavities, of an 
almost indefinite expansion, and often attaining a very great magnitude, they 
have no power of converting the neighbouring tissues into structure analo- 
gous to their own; nor have they any essential tendency to degeneration. 
They prove injurious, as a general rule, only by their physical properties, such 
as their consistence or bulk, or by appropriating to themselves the nutriment 
which was destined for the healthy tissues, and thus producing a general 
atrophy. 
But, in these modes, they are often the source of great inconvenience, and 
even danger. Their bulk and weight alone are occasionally the cause of much 
discomfort. They, derange the functions, not only of the organs in which 
they are formed, but also of others in their neighbourhood, by-displacing, 
compressing, or irritating them. Not unfrequently, inflammation is produced 
in the surrounding tissues, ending in their partial destruction by suppuration, 
ulceration, &c.,.or in a fibro-cartilaginous, cartilaginous, or osseous degenera- 
tion. They not unfrequently obstruct, in greater or less degree, the outlets 112 
GENERAL PATHOLOGY. 
[PART I. 
of secretory glands, the alimentary passages, the blood-vessels, and absorb- 
ents, and thereby produce serious and sometimes fatal ~ effects. They occa- 
sionally, burst from over distension, effusing their contents, with the most 
dangerous consequences, into neighbouring cavities. Finally, as before stated, 
they are themselves capable of taking on inflammation, and inducing many 
of the consequences, general and local, which follow that morbid process in 
the normal tissues.. 
These morbid growths are sometimes of local origin, and sometimes appear 
to depend upon a general depravation. But of their causes we know little or 
nothing. In relation to the modes of detecting them, the reader is referred 
to the diseases of the several organs in which they are produced. 
2. Organized Non-malignant Tumours.-In almost all the organs and 
tissues of the body, organized structures occasionally form, distinguishable 
by their bulk, consistence, or nature, from the structure in or upon which 
they are developed. These are often the result of morbid processes already 
described, such as the effusion of coagulable lymph from inflammation, or 
simple hypertrophy from excess of nutritive action, and, in such cases, do 
not belong to the. section of diseases now under consideration. But, not 
unfrequently, they occur without any previous discoverable disorder, or any 
morbid action whatever, other than that which is indicated by their own forma- 
tion. They are sometimes enclosed in a cyst, which may have been the origin 
of the morbid growth within it. The character of their structure is various. 
Sometimes it is simply fleshy, analogous .to that of condensed cellular tissue 
richly supplied with blood-vessels, in which case the diseased structure is 
called vascular sarcoma. Sometimes it is fatty, and denominated adipose 
sarcoma; sometimes contains fibro-cartilaginous or osseous matter, and re- 
ceives the designation of chondroma, or osteosarcoma. Polypous tumours 
sometimes belong to this class of morbid growths. 
The origin of these tumours is unknown. We may refer them, like the 
cysts just described, to the perversion of one or more of the nucleated cells or 
cell-gerins, which retain their power of propagation, under the ordinary nutri- 
tive influences of the system, and impart their peculiar properties to all the 
cells which spring from them. But the difficulty is only removed a step; for- 
we are utterly ignorant of the cause of this perversion. 
The tumours, so far as they are within reach, belong to the province of the 
surgeon. But, in some of the interior structures, they occasionally produce 
derangements which bring them under the notice of the physician. Their 
effects, in these situations, are for the most part simply mechanical, and ana- 
logous to those already described as resulting from cysts. Unfortunately, as 
they are without the circle of the ordinary systemic actions and susceptibili- 
ties, they are scarcely in any degree influenced by medical treatment. Some- 
times they become the seat of malignant action, and then belong to the follow- 
ing section. - 1 
b. Malignant Growths. 
CARCINOMA, OR CANCER. 
These are peculiar morbid structures, with the property of indefinite propa- 
gation, the power of displacing or transforming to their own nature all neigh- 
bouring tissues, and a tendency to ultimate self-degradation, and the destruction 
of life. They may be dormant for a considerable time, even for years; and 
an individual may go to his grave, at a good old age, of another disease, after CHAP. I.] 
CARCINOMA, OR CANCER. 
113 
having long borne their germs within him • but, if by any cause brought into 
action, their progress is essentially and irresistibly destructive. In this respect, 
they differ from tuberculous disease. Tubercles have an individual tendency 
towards health, but, in consequence of their abundant production, a general 
tendency to a fatal result. The structures under consideration have no repa- 
rative action. Their proclivity is altogether towards death. Hence they are 
very properly denominated malignant. 
Pathologists, are now generally disposed to include all these malignant growths 
under the general title of carcinoma, or cancer. These terins, especially the 
latter, have been frequently employed in a more restricted sense,. Thus, cancer 
has been confined by some to the ulcerative stage of scirrhus; while the 
epithet cancerous has been extended to malignant affections of analogous, cha- 
racter in any stage. There is a convenience, however, in having a general 
designation for all these structures; and the propriety of such a designation 
is indisputable, if the fact be admitted, that they are mere varieties of the 
same disease, which is highly probable. In support of this opinion, the con- 
siderations may be adduced, that all of them, in their earliest stage, often 
present certain common characters, however unlike they may afterwards, be- 
come; that all of them may occur in the same person, at the same, time, 
and, according to Dr. Carswell, in the same organ; that the characters of 
the different varieties may even be presented in the same tumour, at differ- 
ent stages; that, in the progress of the disease, the secondary affection some- 
times belongs to a variety different from that of the primary; and, lastly, that 
after the extirpation of one variety by the knife, another is apt to occur in 
the same, or another part of the body. 
Anatomical Characters. -Carcinoma consists essentially of a peculiar 
matter, contained in an areolar fibrousAssae, of various density, bearing a 
more or less close resemblance to cellular membrane. This peculiar matter 
appears, under the microscope, to contain-nucleated cells and molecules; the 
cells being chiefly globular, but sometimes-caudate or spindle-shaped, as if in 
the process of conversion into fibre^and much larger than the blood corpuscles. 
Dr. Bennet has observed that acetic acid has a marked effect on these cells, 
causing the cell-wall to become very transparent and faint, or to disappear, 
while the nucleus is rendered more distinct. According to Dr. Bennet, be- 
sides the fibrous tissue and the nucleated cells, there is a third essential con- 
stituent of cancer,-a gelatinous fluid, namely, in which the cells float; and, 
according to the predominance of these constituents respectively, will be the 
form which the disease will assume, being scirrhous with an excess of the fibrous 
tissue, of a. medullary consistence when the nucleated cells and molecules are 
numerous, and gelatinous when the fluid is abundant. 
The disease first appears in a small spot,.and gradually extends, or in several 
nearly contiguous spots, which coalesce. Either a portion of healthy tissue 
is converted molecularly into the carcinomatous, or a new growth occurs 
upon the surface of the tissue, without at first affecting its organization. In 
both cases, the disease spreads by degrees, degrading the neighbouring struc- 
tures to its own nature, and forming a tumour, which varies in shape, size, and 
consistence, according to the circumstances under which it is produced. It 
appears to maintain a vascular connexion with the surrounding parts; but the 
veins are often filled with the cancerous matter, so that it is impossible to 
inject them. Hence the varicose condition of the superficial veins, so often 
observed in scirrhous tumours. f ~ 
In relation to its form, it may be irregularly globular, when surrounded by 
a structure of equable density ; pear-shaped, fungiform, or like a cauliflower, 114 
GENERAL PATHOLOGY. 
[part I. 
when projecting from a free surface; in layers or patches, when in membran- 
ous tissues; and ramified, when the carcinomatous matter occupies the veins 
or absorbents. In bulk, it varies exceedingly, being sometimes smaller than 
a small shot, sometimes larger than the head of a man. Pressure seems in 
some measure to. restrain its growth. Its consistence may be very hard and 
almost stony, as in scirrhus; like that of the brain, as in the medullary form 
of the disease; gelatinous, as in the soft or gelatinous cancer; or liquid, like 
cream. Within the substance of a dense organ, the morbid structure is apt 
to be more dense than upon the surface. The colour is generally white or 
whitish, sometimes inclining to yellow, brown, or red, according as bile, blood, 
or other adventitious ingredient is present. When melanosis coincides with 
carcinoma, the latter is brown or blackish. 
It has- been already stated, that the disease consists of a peculiar carcinoma- 
tous matter, contained in the meshes of a cellular or fibrous tissue. The pecu- 
liar matter may present a uniform aspect, or may have a granular, radiated, 
or lobulated arTangement; the grains, lobule's, &c., being separated by the 
membranous expansion referred to. Sometimes the tumour consists almost 
wholly of fibrous tissue, and then bears a close resemblance to condensed cel- 
lular membrane. In this state, AndraL is disposed to consider it as hypertro- 
phied cellular tissue; but its t^dency to degradation, and to pass through all 
the changes of ordinary carcinomatous disease, stamps upon it a peculiar cha- 
racter. The tumour is almost always in some degree vascular; but, in the 
harder varieties, very few vessels can be discovered. In the soft they are 
abundant. The probability is, that the peculiar matter, in softening, under- 
goes a specie's of interior organization, of which"the production of vessels and 
membrane may be the result; as the vascularity is, at least not always, de- 
pendent upon the prolongation of the vessels from without. Sometimes, the 
whole tumour is enclosed in a serous cyst, in which case the carcinoma is said 
to be encysted. 
Examined chemically, the cancerous matter has been found to contain 
gelatin, albumen, fibrin, fatty matter, and water; but the results obtained by 
different chemists have not been uniform. 
Progress-The constant tendency of carcinoma, when in action, is to 
extend itself by encroaching upon the neighbouring tissues. But the rapid- 
ity of its progress differs greatly, and has some relation to the character of 
the tumour itself. The hard varieties usually advance much more slowly 
than the soft. The progress of the disease is affected also by the age of the 
patient; being much slower in the old than the young, and generally slow in 
proportion to the age. In the extension of the disease, contiguous parts are 
frequently involved^ even though they have no connexion in health. But, in 
such cases, a union appears to have been previously effected by the adhesive 
inflammation. Thus, cancer of the stomach often extends to the liver; that of 
the uterus, to the rectum, bladder, &c. The disease is also apt to travel along 
the absorbents, and to seize upon the lymphatic glands in its course. Hence, 
the glands of the axilla are exceedingly liable to become affected by cancer in 
the breast, and those of the groin, by cancer of the testicle. The propagation 
may be effected either by a sympathetic irritation, acting upon a cancerous 
predisposition, or, what, appears. mojfe probable, by a transplantation of the 
cancerous germs through the medium of the absorbents. The disease very 
frequently also extends ultimately to various distant organs. Thus, the lungs 
are very apt to suffer in cases of external carcinoma. It is possible, however, 
that the result may be owing rather to a general carcinomatous diathesis, than 
to the mere propagation of disease from a single point. 
One of the characters of advancing carcinoma is gradually to soften, and CHAP. I.] 
CARCINOMA, OR CANCER. 
115 
ultimately to ulcerate. The hard varieties are sometimes converted into the 
soft, and the soft become softer; and both, in the end, occasionally assume a 
diffluent consistence like that of cream. . The process of softening may com- 
mence in any part of the tumour. It is usually attended with increased vas- 
cularity. The disease, in almost all cases, if not sooner fatal by its influence 
upon vital organs^ or entirely destroyed by gangrene, ends in ulceration. The 
resulting ulcei* is of an aggravated character, with ragged, and inverted or 
everted edges, often deep excavations, a sanious and extremely offensive dis- 
charge, find a frequent disposition to bleed and to slough. Gangrene is a na- 
tural result of the interruption of the circulation, consequent upon the forma- 
tion of the carcinomatous matter-in the blood-vessels. In the. soft varieties 
especially, enormous sloughs sometimes separate; and instances have occurred, 
in which the whole diseased structure has thus beep destroyed and thrown off, 
with the effect of saving the life of the patient. Some believe that carcino- 
matous structure occasionally undergoes a dalcareous transformation, and thus 
loses its malignant character. Dr. Bennet has met with cases which he con- 
siders as affording conclusive evidence of this fact; and Rokitansky not only 
admits this mode of spontaneous cure, but another also, called saponification, 
by which the .matter of the cancerous cells is converted into fat, and forms 
emulsive or saponaceous compounds. But even those who believe in these 
modes of cure, admit that they are extremely rare. 
Seat:-Every organ, and almost every tissue of the body, are liable to be- 
come the seat of cancer. Certain parts are more apt to be affected than 
others; as the female mamma, the uterus, the stomach, and the testes. But 
the disease occurs also in the bowels, especially the rectum, in the oesophagus, 
the lungs, the liver, the kidneys, the brain, the eye, the tongue, the lips, and 
the lymphatic glands. Of the tissues, the cellular is most frequently attacked; 
the skin and mucous membranes are often affected; and the complaint is occa- 
sionally met with in the muscular, the vascular, and the bony structures. It 
seldom attacks the proper fibrous tissues, or cartilages. It is sometimes con- 
fined to one part or organ, sometimes occurs in several at the same time. It 
is not, however, often met with in the same organ on both sides of the body. 
In females it is more frequent than in males, occurring in the former more 
especially at the period when the catamenia cease, and in the latter between 
the ages _of 30 and 50. When it occurs in early life, it seizes most frequently 
upon the absorbent glands, the large joints, or the cellular tissue, and seldom 
upon the stomach, uterus, or mamma. From statistical researches by Dr. 
John Lie Conte, it would appear- that carcinomatous affections become rela- 
tively more frequent with increasing age, that women are more liable to the 
disease than men in the ratio of three to one, and that, in relation to the 
organs affected, the uterus is most liable, the stomach next, then the mamma, 
the liver, &c. (South.. Med. and Surg. Journ., May, 1846.) 
Symptoms and Effects.-The shape, consistence, and situation of carcinoma, 
have been already referred to. It is usually attended with pain at some pe- 
riod of its. progress) though this symptom is exceedingly irregular. Not unfre- 
quently, especially in the internal organs, it has made very great advances 
before producing any considerable uneasiness. The characteristic pain of 
carcinoma is^sharp and lancinating. Without any apparent cause, the patient, 
previously quite easy, feels upon a sudden an acute, sometimes excruciating 
pain, shooting through the part affected, and then ceasing for a time. But 
this is not experienced in all cases; nor is it confined to cancerous diseases, 
being a frequent form of neuralgia. It is when ulceration has extended to 
the surrounding tissues, that the patient suffers most; and now the pains are 
often exceedingly distressing. In the commencement, the pain frequently 116 
GENERAL PATHOLOGY. 
[part I. 
intermits. Towards the close, it may become almost constant, though still 
liable to remissions. 
The system always becomes affected in advancing carcinoma. It is said 
that a disposition to the disease is marked by a cachectic condition; but 
this is certainly not always the case; as cancer not unfrequCntly commences 
in the midst of apparent health. When the disease has advanced so far as to 
involve the system, when, for example, the stage of softening, gangrene, or 
ulceration has arrived, the patient very frequently has a peculiar wan, sallow 
paleness of complexion, which, with an expression of sadness, is almost cha- 
racteristic of carcinoma. Disordered digestion, general weakness, and emaci- 
ation are also common attendants upon the cancerous cachexia; but, in some 
cases, a considerable fulness of habit is maintained, even to the close of the 
complaint. In the advanced stages, the pulse is generally quickened, and 
febrile symptoms appear. 
In the regular course of carcinoma, the patient sinks under the exhaustion 
from pain, general irritation, excessive discharge, sloughing, &c.; but more 
frequently the disease terminates by interfering with the function of some 
organ essential to life; as of the stomach, lungs, brain, &c.; and most of the 
symptoms which it produces have their origin in the same source. These 
will be considered most conveniently under the head of special diseases of the 
organs. It not unfrequently terminates life by eroding the large blood-vessels. 
The same effect results more slowly by the closure of certain passages essential 
to life, as of the oesophagus, pylorus,, intestines, &c. By compression or ob- 
literation of the blood-vessels, it sometimes occasions venous congestion, and 
consequent dropsy; Thus, carcinoma in the liver gives rise to ascites, by im- 
peding the portal circulation; and in the pylorus, duodenum, ovary, and 
uterus, to dropsy of the lower extremities, by interfering with the return of 
blood through the great veins. 
Diagnosis.-The diagnosis of external cancer belongs to surgery, that of 
the disease occupying internal organs, to the department of special diseases; 
as the symptoms by which it is to be recognized, if at all, are chiefly those 
connected with the deranged functions of the organs respectively. The prac- 
titioner, however, may be aided' in forming his judgment by certain general 
considerations. The lancinating character of the pain, though by no means 
to be relied on, may be of some use in the diagnosis. The obstinacy of the 
disease, which resists all curative measures, and in general marches steadily 
onward, will also be taken into view. Another circumstance of importance 
is the peculiar cachectic appearance of the complexion, to which allusion has 
been already made. Occasionally, the tumour can be felt through the walls 
of the cavity containing it; and, when this is impossible, the practitioner may 
sometimes avail himself of percussion and auscultation with advantage. But 
the diagnosis is almost always more or less uncertain, when the tumour cannot 
be felt or seen. Dr. Bennet lays much stress upon the co-existence of a 
fibrous tissue-and the cell-structure already described, as a means of diagnosis, 
where the opportunity is afforded of examining the morbid structure micro- 
scopically; as in post-mortem examinations. The shape of the cells alone 
cannot be depended on, as it differs greatly, and there is no one characteristic 
form. The action of acetic acid, before referred to, is not more decisive; as a 
similar effect is produced upon epithelial cells. But Dr. Bennet is acquainted 
with no tissue in which such cells are deposited in a fibrous structure, and 
thinks that, whenever such an association is met with, we may be satisfied of 
the existence of cancer. In cutaneous cancer, the character of the cell, and 
the effect of acetic acid, may be sufficiently diagnostic; because the epidermic 
scales, unlike the epithelial, are not liable to be confounded with the carcino- 
matous. (Ed. Monthly Journ. of Med. March, 1847.) CHAP. I.] 
CARCINOMA, OR CANCER. 
117 
Mode, of origin.-From the observations of Dr. Carswell it appears, that 
carcinoma originates in a perversion either of nutrition or secretion. On ex- 
amining the initial steps of the disease in the parenchyma of an organ, it is 
observed first in a mere point, where the healthy structure has been replaced, 
molecule for molecule, by the unhealthy, and from which the same change is 
gradually extended in different directions ; or, if may occur in several distinct 
points, in the same vicinity, which afterwards run together. Upon the free 
surface of a membrane, on the contrary, the carcinomatous matter may be 
deposited without interfering at first with the organization of the membrane 
itself, which serves only for a base of attachment. A little reflection will 
show, that these processes are essentially the same; the diseased matter being, 
in both cases, separated from the blood; in the one, simply replacing the 
healthy tissue, which is removed; in the other, deposited without such dis- 
placement. In both, there is simply a perverted secretion. But whence 
proceeds this perversion ? Is it the result of a morbid condition of the secret- 
ing structure, whether this be the capillary vessels or the ultimate cells, or 
does it depend upon a diseased state of the blood ? Dr. Carswell is inclined to 
the latter opinion. He believes that the carcinomatous matter is formed in 
the blood, and founds his opinion upon the fact, that it is often seen in the 
veins, either loosely connected with their inner coat, or quite free from attach- 
ment, and having all the characters which it exhibits when observed elsewhere. 
To the inference drawn from this fact it may be objected, that the cancerous 
matter may have been absorbed into the veins from some contaminated source. 
But Dr. Carswell meets the objection by the assertion, that it sometimes exists 
in the veins when no carcinomatous disease can be found in any other situa- 
tion,. showing that, in these instances at least, it must have originated in the 
blood. It is seen only in the veins and capillaries, because, if formed in the 
arteries, it is carried forward, by the movement of the blood, to points where 
the current slackens, and allows it to be deposited. But further facts are 
wanting to a decision upon this question. Dr. Walshe, however, states that 
out of a vast number of post-mortem examinations, conducted by skilful men 
of all nations, he has never seen or heard of One, and found no one detailed in 
periodical works, confirmatory of this assertion of Dr. Carswell. ( Walske on 
Career, Boston, 1844, p. 52.) This much is highly probable, that one or 
more cell-germs, either entirely new and foreign to the body, or the result of 
some not understood perversion, escape into or upon one of the tissues, and 
become the centre of a new nutrition, and a new growth. One of these germs 
may be considered as an ovum from which a new animal is formed, which 
afterwards grows at the expense of the system. But whence these germs ? 
Can they have entered from without; can they have existed in the parent and 
descended to the child, and have remained dormant until circumstances favoured 
their developement; can they, in fine, have-, been formed in the body by the 
derangement of a pre-existing germ ? All these are questions which, in the 
present state of our knowledge, cannot be satisfactorily answered. 
Another question, in relation to the origin of carcinoma, is whether it can 
be propagated by contagion. Opinion has generally been opposed to this 
idea. An experiment of Langenbeck favours it. He injected cancerous 
matter into the veins of a dog, which was killed some weeks afterwards, when 
carcinomatous growths were discovered in the lungs. Dr. Watson states, that 
he has known of two instances in which cancer of the penis occurred in men, 
whose wives laboured under, the same disease in the uterus. Facts, however, 
on this side of the question, must be much more largely accumulated, before 
it can be decided in the affirmative. I have never myself known an instance 
of the propagation of cancer by contagion. Such a result, however, would be 118 
GENERAL PATHOLOGY. 
[part I. 
in accordance with the notion of the origination of the disease in a perverted 
cell. Such a cell transplanted to another body, might be supposed readily to 
adapt itself to its new position, and there to grow and propagate. It is not 
improbable that such a transplantation' occurs from one part of the same body 
to another part, and that thus the extension of the disease- to distant organs 
may be effected. At all events, if this be the case, a peculiar condition of 
system, a certain morbid diathesis, must exist, essential to the growth of the 
new germ, and without which it would be dormant or perish. This diathesis 
is probably sometimes inherited. Qf its causes and essential nature, we are 
quite ignorant. • . 
Varieties of Carcinoma.-Dr. Carswell arranges the carcinomatous diseases 
in two divisions, based upon the difference in their tendency to'organization; 
giving to one division, in which, this tendency is little observed, the name of 
scirrhoma, from scirrhus, which is the prototype of the division, and to the 
second, in which it is strong, that of cephaloma, from the brain-like consistence 
of the prominent variety. But this distinction might lead to the notion that, 
in one form of the disease, the peculiar carcinomatous matter is effete, and 
incapable of organization; while the''fact appears to be, that it always possesses 
the power, and not unfrequently exercises it; as, for example, when the scir- 
rhous is converted into the medullary carcinoma. I prefer the division which 
arranges the varieties into three groups, characterized severally by certain dis- 
tinctive qualities of consistence, growth, &c. These are 1, scirrhus, 2, medul- 
lary carcinoma, and 3, gelatinous cancer. 
1. Scirrhus.- Carcinomatous Sarcoma (Abernethy).-Stone Cancer.,-■ 
This is characterized by a hard, whitish, gray, or bluish-white, semi-transparent 
substance," presenting when cut a shining surface, and intersected by opaque, 
white or pale straw-coloured bands of fibrous, or condensed cellular tissue. 
Sometimes it has a decidedly lobulated arrangement like that of-the pancreas, 
and, when of this character, was called pancreatic sarcoma by Abernethy. 
Sometimes its appearance closely resembles that of boiled pork, whence the 
name of lardaceous tissue^ applied to it by the French writers. The fibrous 
tissue predominates in this variety. 
Scirrhous tissue is very dense and hard with a stone-like feel, and yields a 
peculiar creaking sound, when cut with a sharp knife. It is more frequently 
than the other varieties attended with the peculiar lancinating pain of carci- 
noma. Few blood-vessels can be detected in it. Its -growth is usually slow, 
and not unfrequently many years elapse before it terminates. It seldom 
attains a greater size than that of an orange. ( Walshe.} It is apt to contract 
adhesions to neighbouring structures, which is clearly seen when it is situated 
beneath the skin. In this case, the skin unites firmly with the tumour and 
at the same time shrinks considerably. This contraction of the neighbouring 
tissues is one of the characteristics df scirrhus. When softened, it is converted, 
according to Walshe, into a yellowish-brown, semi-transparent, jelly-like matter. 
Scirrhus is often solitary; only one tumour existing in the body at the same 
time. It is most frequently seated in the breast; and is less apt than the fol- 
lowing variety to attack different parts of the body. Hemorrhage within its 
structure, or from its ulcerated surface, is less frequent than in the soft carci- 
noma. Scirrhus seldom occurs before -puberty, and is most common in ad- 
vanced life. 
2. Medullary Carcinoma.-Medullary Sarcoma (Abernethy).-Encepha- 
loid Disease.-Cerebri form Disease.-Fungus Hnematodes (Hey). - Soft 
Cancer.-This consists of a dull white, opaque, softish matter, bearing a con- 
siderable resemblance to brain, with a lobulated arrangement. Hence the 
names of encephaloid and cerebriform disease employed by French writers. CHAP. I.] 
PARASITIC ANIMALS. 
119 
It owes its consistence to the predominance of the proper caEcjnomatous cells. 
The carcinomatous tissue contains, in this variety, numerous minute blood- 
vessels, the coats of which are very delicate, and easily rupture, giving rise to 
frequent hemorrhage, both within the tumour, and from its surface after 
ulceration. -Hence the tissue acquires a bloody appearance; from which cir- 
cumstance, as well as from its tendency to sprout rapidly out through the skin, 
after this has been opened, Hey was induced to give it the name of fungus 
heematodes. Sometimes, the tissue has greater firmness, resembling considera- 
bly a section of the boiled udder of a cow, whence it was called mammary 
sarcoma by Abernethy. When the vascular sarcoma, of the same author, 
assumes a malignant character, it must be ranked with this variety of carci- 
noma. Other names have been given to varieties of the. tumour, from certain 
supposed resemblances to objects in nature, as the solanaid, from its resem- 
blance to the potato, &c. 
In all its forms, medullary carcinoma is less hard and dense than scirrhus. 
It is often of very rapid growth, sometimes attaining its full size in a few 
weeks, and advancing with especial rapidity after ulceration. ■ It.spmetimes 
attains an enormous magnitude. It is not apt like scirrhus to contract adhe- 
sions, and, when beneath the skin, causes- this tissue to ulcerate by distension 
and pressure, rather than by communicating its own nature to it. When 
softened, it has a white, opaque, creamy appearance. ( Walshe.') It is in this 
form of carcinoma, that the peculiar matter of the disease is most frequently 
found in the veins and absorbents. The disease often exists at the same time 
in different organs, and there is scarcely a portion of the body in which it has 
not been found. It i§ very-apt to occur secondarily to the preceding form of 
cancer. It occurs most frequently in the, young, and often before puberty. 
3. Gelatinous Carcinoma.-Colloid Cancer.--Areolar Gelatinoid Cancer 
(Cruveilhier).- Gum Cancer.-This consists of a. jelly-like, transparent mat- 
ter, usually of a .yellowish, or greenish-yellow colour, which, when separated 
from the tissue, is soft,, but, as found in the tumour, has considerable firmness. 
The gelatinous constituent of carcinoma is here, obviously,, the predominant 
ingredient. It is contained in a vast number of cells of various size. It sel- 
dom occurs in more than one organ at the same time; and hitherto has been 
observed chiefly at the pyloric orifice of the stomach, and in the omentum; 
though it has also been seen in the bones, testis, and mamma. It has been 
met with only in adults. 
c. Parasitic Animals.-Entozoa. 
Strictly speaking, these may be regarded rather as causes of disease, than 
as pathological conditions; but, in the. present uncertainty as to their origin, 
it may not, perhaps, be amiss to consider them among those morbid products, 
which, in the absence of any precise knowledge of the real disease in which 
they originate, are by common consent placed in the rank of diseases. They 
are characterized by having an independent life of their own, with the power 
of reproduction or generation; and depend on the system only for convenient 
quarters and suitable nutriment. Almost every species of animal has its own 
peculiar parasites, and man is not an exception to the general rule. There is 
scarcely a portion of the human, frame which has not served as the dwelling 
of one or more of them; and it has been observed, that certain species have 
a peculiar predilection for certain organs, which they sometimes exclusively 
inhabit. ' 
In relation to their mode of origin, pathologists have long been divided 120 
GENERAL PATHOLOGY. 
[part I. 
between two hypotheses; one of which maintains that they are derived from 
distinct germs or ova, the product of preceding animals of the same species; 
the other, that they are the result of spontaneous or equivocal generation, in 
other words, spring into existence without parents, through some action going 
on within the system. Recourse should be had to the latter opinion, only 
upon satisfactory proof of the insufficiency of the former. The course of 
nature, so far as it can be observed, is so uniform in the propagation of living 
beings by others of the same specific character, that, when any uncertain case 
is presented, we are bound by a correct philosophy to refer it to the general 
rule, unless this can be shown not to be applicable. But no such inapplica- 
bility can be proved in the present instance; nor are there any difficulties 
which do not admit of explanation. Supposing the entozoa to have the same 
origin as other living beings in general, their germs must be derived from one 
of two sources; either they must have been received from the parent, and 
thus pre-existed in the body from birth, waiting for circumstances favourable 
to thgir developement, or they must have been derived from without. In 
favour of the former notion, is the fact that each species is confined, as a 
general rule, to a particular animal, like a plant to certain districts of country. 
But the explanation of this fact simply is, that the germ finds only in the 
particular animal in which it flourishes the condition of things favourable to 
its vital activity. A strong argument against the opinion, is the difficulty of 
supposing that the ovum or germ should have so long remained concealed in 
the same individual and his predecessors, possibly for many generations, with- 
out undergoing developement. The probabilities are greatly in favour of its 
external origin. It is said that the parasitic animals of the human frame 
have no prototype in nature. This is true of most of them, so far as observa- 
tion has extended. But, in the first place, the fact that no such prototypes 
have been discovered is no proof of their non-existence; and, secondly) ani- 
mals of the same species as the parasite may be constantly before us in the 
outer world, but with characters so different that they, cannot be recognized. 
It is highly probable that living beings, developed from ova in the human 
body, would be so modified by the peculiar circumstances of their position as 
to lose specific characteristics, which naturalists ordinarily deem essential. 
The eyeless fish of the Mammoth Cave of Kentucky are said by persons, quite 
competent to decide, to be identical with those in the ordinary streams of the 
country. If an animal can thus, in its developement from the ovum, lose an 
eye where it is not wanted, it may well lose other less important characters 
of mere form. It may well be, therefore, that of the innumerable germs 
which fill the external world, some may find admittance into our frames, and 
there expand into beings,, apparently different from anything around us. 
But it has been objected further, that not only are these parasites found in 
parts of the frame having an external communication, but also in closed 
cavities, in the interior of parenchymatous organs, and even in the foetus. In 
reply, it may be said, that wherever a blood corpuscle can circulate, there 
also may pass a living ovum; for the corpuscle, or at least a cell not larger 
than it, has within it the powers requisite for organization. Microscopic 
germs may enter our systems through the lungs or stomach, and circulate 
everywhere with the blood, and even pass along with nutriment into the 
foetus, though much larger in proportion to the resulting animals than an 
acorn to the oak. A positive argument in favour of the opinion here advo- 
cated, is the occurrence of certain entozoa only in certain regions of country, 
Thus the guinea worm is known only in certain parts of the East, and of the 
two species of tapeworm, one is confined chiefly to certain parts of Europe, 
where the other is comparatively little known.. (See Intestinal Worms.) CHAP. I.] 
PARASITIC ANIMALS. 
121 
Symptoms and Effects.-The presence of parasitic animals, when lodged in 
situations whence they cannot escape, and where they cannot be seen or felt, 
can be known only by their effects. Sometimes they escape from situations 
communicating externally, as from the stomach, bowels, and bladder, and are 
then readily recognized, > often when only in fragments. If in the humours 
of the eye, they may be seen, though such an event is exceedingly rare. 
When superficial, or of great magnitude, they may sometimes be felt through 
the integuments. In the natural cavities, where they can move freely, they 
often occasion discomfort and derangement of function by their motions. 
This happens especially in the alimentary canal. Wherever they may be 
situated, acting as foreign bodies, they are liable to produce injury by their 
bulky exciting irritation, if not inflammation, of the surrounding tissues, and 
giving rise to all the consequences heretofore alluded to as the result of the 
compression of organs, or the obstruction of passages, ducts, and blood-vessels. 
Sometimes the enormous magnitude they attain occasions, of itself, great 
inconvenience; as in some cases of encysted dropsy. Another'source of mis- 
chief is their occasional rupture from over-distension, and the effusion of their 
contents into the tissues or cavities of the body. They are liable, moreover, 
themselves to disease, as for example, to inflammation, which may occasion 
suppuration, ulceration, change of structure, &c., and involve the system in a 
state of great local and sympathetic disturbance. In some instances, more- 
over, in which they are very numerous, or of great size, they divert from the 
system a portion of the nutriment essential to its support. 
In some situations, especially in the brain, they are productive of great 
mischief by immediately interfering with the functions of the organ. In the 
stomach and bowels, too, they are often very injurious, not only by their 
direct effects, but through the various sympathies which connect the aliment- 
ary canal with other parts of the body. Sometimes they produce great de- 
struction of the organ in which they reside merely by their pressure. An 
instance is on record, in which the whole parenchyma of a kidney was thus 
destroyed by the presence of a Strongylus gigas. But the various phenomena 
produced by them, in particular localities, belong to the department of special 
diseases. 
It will be proper here to state, that, in the solid structures, the mischief 
which they might produce is generally much obviated by a provision of nature, 
which surrounds them with a cyst of condensed cellular tissue or false mem- 
brane, which serves to isolate them, and thus limits the resulting inconvenience 
chiefly to their bulk. As they often grow very slowly, the organ becomes 
accustomed to the gradually increasing pressure, and suffers, in general, less 
inconvenience than might be supposed. Sometimes, moreover, they never 
attain a considerable magnitude, and consequently produce few or no observa- 
ble effects. Thus, the Trichina spiralis, which is almost microscopic, some- 
times inhabits the muscles in great nuinbers, without apparently interfering 
with the action of these organs, or with the general health in any way. 
Causes.-Of these, except in the case of worms in the bowels, which will be 
treated of distinctly, we know little or nothing. It has been supposed that living 
in a warm damp atmosphere favours the production of the parasites. Certain 
kinds of food and drink have, been accused as the cause of their developement. 
It has before been stated, that some of them appear to be confined to certain 
districts of country, from which it may be inferred that exterior influences are 
not without effect. A feeble cachectic state of health frequently attends them; 
but it is often impossible to say how far this may have served as the cause, 
and how far it may be a mere effect. It is highly probable that a certain 122 
GENERAL PATHOLOGY. 
[PART I. 
condition of system is generally favourable, or necessary to their develope- 
ment; as their occurrence is comparatively rare, while there is no reason to 
suppose that'all may not be exposed to th e entrance of'their germs or ova. . 
Varieties.-These parasites are found of every grade of organization, from 
the lowest possible, up to one of considerable complexity; and have been 
ranked by Naturalists in distinct classes, genera, and species. In the follow- 
ing sketch, I follow very nearly the arrangement of Mr. Owen, as modified by 
Dr. Farre ip Tweedie's System of Practical Medicine. 
Class 1. Hydatid^.-Psychodiaria.-The first class, is denominated Psy- 
chodiaria, and includes the parasites usually called hydatids. They consist 
of a laminated globular sac, containing a transparent liquid, and are among 
the simplest of all living beings. They are nourished by imbibition. Two 
genera are included in the class; one, called Acephalacystis, signifying a cyst 
without a head, and distinguished by the generation of germs between the 
layers of its tunic, and their developement like buds upon the inner and outer 
surface; the other, Echinococcus, the characteristic peculiarity of which is, that 
it contains minute and very singular parasites, of a different form from its own, 
either attached to its inner surface, or floating in its cavity. Of the Acepha- 
locystis there are two species, distinguished from each other by the reproduc- 
tion occurring, in the one, upon the inner, and in the other, upon the outer 
surface. The former, named Acephalocyst is endogena, is the common hydatid 
of the human body; the latter, A. exogena, occurs in the inferior animals. A 
specimen, however, of the A. exogena is described by Dr. Farre, as having 
been taken from the brain of a coloured man in Barbadoes. 
Aeephalocystis. endogena.-The common acephalocyst, or hydatid, is a glo- 
bular membranous sac, composed of distinct layers, sometimes opaque, some- 
times nearly transparent, having a smooth surface externally, but somewhat 
unequal internally, and containing a limpid colourless liquid, which is said to 
have albuminous and gelatinous properties. A cyst formed from the neigh- 
bouring tissues usually surrounds it. Its nourishment takes place by imbibi- 
tion, and its young are produced like buds upon its inner surface, from which 
they separate, and float in the contained liquid. The hydatid is found of 
every size, from that of a hemp-seed to that of an orange, or even a child's 
head. The larger usually contain vast numbers of younger hydatids, of all 
sizes, which again contain others within themselves-, and the whole sometimes 
amount to thousands. ' > 
The cysts about them are liable to inflammation, and various degeneration, 
and occasionally secrete pus or other liquid, in which the hydatids float. 
Sometimes they are very thick and rugged, as in the liver; sometimes thin 
and delicate, as in the brain, where they are occasionally quite wanting. The 
cyst is always single, however numerous may be the hydatids it encloses, 
proving that they all sprang from one original parent. In fact, the lining of 
the cyst may be considered sometimes as the original hydatid, which has con- 
tracted adhesions with the enclosing sac. 
Hydatids, like other animals, are liable to perish. In such a case, their 
liquid matter is absorbed, their tunics collapse upon each other, and a tumour is 
formed, in which atheromatous, sebaceous, or tuberculous matter, is occasion- 
ally intermingled with the membrane. 
Their usual abode is in the parenchymatous organs, but they have occasion- 
ally been found also in the serous cavities, and even in the blood-vessels. 
They most frequently infest the liver, next the lungs, ovaries, spleen, kidneys, 
brain, &c.; and occasionally almost all parts of the body. Andral met with a 
hydatid in the blood of the pulmonary vein. Connected with the ovaries, and 
with different contents of the abdomen, they sometimes occasion encysted CHAP. I.] 
PARASITIC ANIMALS. 
123 
dropsies of enormous magnitude; at least, dissection, iri.such cases, reveals 
occasionally a great number of irregular cells, containing hydatids in different 
stages of their growth. 
Echinococcus.-This differs from the acephalocyst chiefly in its yellowish 
and tougher outer coating, and in containing, as before stated, numbers of 
a minute parasite, of an apparently different genus'' from itself. These ani- 
malcules, which are about the of an inch in length/are sometimes un- 
covered, and sometimes have a distinct cyst of their own. They have a 
head, afound which is a circlet of hooks, enabling them to attach themselves 
to the inner surface of the sac. Their structure would rank them with the 
following' class. The echinococcus inhabits the liver, spleen, omentum, 
brain, &c. Muller relates a case in which one of the genus was discharged 
with the urine. This hydatid may be smaller than a mustard sbed, or larger 
than a pigeon's egg; and numbers of them are sometimes found clustered 
together. There are no symptoms by which they can be detected during life. 
Class 2. Sterelmintha.-"These consist of a solid parenchymatous tex- 
ture, in which are excavated, as it were, the canals or cavities which serve the 
purposes of digestion. They have no separate teguriientary system. They 
have but one opening to the alimentary canal, and the sexes are placed upon 
the same individual." ' (Earrec) The genera belonging to this class, which 
appear to merit attention, are Cysticercus, the animalcule of Echinococcus, 
Taenia, Bothriocephalus, and Distoma. Of these, Taenia and Bothriocephalus 
will be treated of with other intestinal worms; and the animalcule of Echino- 
coccus has been sufficiently noticed above. 
Cysticercus.-This parasite has a nearly cylindrical, or slightly depressed 
body, ending in a caudal vesicle, and having a small roundish head upon a 
slender neck. The head is crowned by one or two rows of small hooks or 
recurved spines, by which it is enabled to attach itself to soft objects near it; 
and placed around it 'are four suckers, which are the mouths of the animal, 
through which it receives nourishment. The caudal vesicle contains a limpid 
serum, arid has caused the animal to be commonly ranked with the hydatids. 
The cysticercus is capable of an undulatory movement, of advancing or re- 
tracting the head, and expanding or contracting the caudal vesicle. It is 
always surrounded with an adventitious cyst. The different species of this 
parasite are not unfrequently found in the lower mammiferous animals. Some 
of them are occasionally met with in man, occupying the muscles, the brain, 
or the eye. But they are very rare. Their symptoms are quite obscure. 
Sometimes they occasion no unpleasant effects whatever. M. Renaud men- 
tions two cases, in one of which the'parasite was found in the brain, in the 
other, in the substance of the heart, without producing, during life, any ob- 
servable disorder in the functions of these organs. 
Distoma. Liver-fluke.-1The body is yellow or light-brown; ovate, elon- 
gated, flattened, and somewhat pointed at each end; and supplied with three 
apparent pores on its under surface, the posterior intended for adhesion and 
locomotion, the middle for generation, and the anterior for nourishment. This 
animal is very common in the gall-bladder and biliary ducts of the sheep, and 
is occasionally found in the same situations in man. It is supposed to feed 
upon the bile, or the mucus of the biliary passages and gall-bladder. , It pro- 
duces no symptoms by which it can be recognized, but has been sometimes 
discharged from the bowels. 
Class 3. Coelelmintha.-These are hollow cylindrical worms, having a dis- 
tinct alimentary canal with its own proper walls, a mouth and anus generally 
at opposite extremities, in most instances a distinct nervous system, and organs 
of generation on separate individuals. The genera belonging to this class, 124 
GENERAL PATHOLOGY. 
[part I. 
deemed worthy of .notice, are Trichina, Filaria, Tricocephalus, Strongylus, 
and Ascaris. Two others, Spiroptera and Dactylius, are described by Mr. 
Farre, but have been very rarely observed, perhaps each only in a single case, 
and both in the urine of females. Tricocephalus and Ascaris belong to the 
intestinal worms. • 
Trichina spiralis.-This species of Trichina is interesting from its extreme 
minuteness, its great numbers, and its peculiarity of position in the human 
body, rather than from its morbid effects. It is found in the muscles, to 
which it gives a gray speckled appearance, as if (l thickly sprinkled with .the 
eggs of some small insect. This appearance had been repeatedly noticed in 
dissections, but was not referred to the true cause until the year 1833, when 
Mr. Helton detected the presence of animalcules, which were afterwards more 
accurately described by Messrs. Paget, Owen, and Farre. The animal is 
contained in cysts, reseihbling minute white ovate grains, which cannot be 
distinctly examined without the aid of the microscope. They are about 
or of an inch long, and a third or half as broad, and consist of an outer 
and inner coat, within the latter of which may be seen, generally one, but 
sometimes two, or three minute coiled-up worms. For a description of the 
worm, the reader is referred to Dr. Farre's essay in Tweedie's System of 
Practical Medicine. These cysts are arranged in the muscle, with their long 
diameter parallel with the muscular fibre, and firmly adherent to the cellular 
tissue between tlie fibres. They abound more in the superficial than in the 
deep seated muscles, but, in persons affected with them, are generally pre- 
sent, in fewer or greater numbers, in almost all the muscles of the body, ex- 
cepting those of the heart, the stomach and bowels, and the bladder. The 
cases in which they have been noticed after death, in the dissecting rooms of 
London, have not been very unfrequent. No 'evidence has yet been pro- 
duced of any morbid influence exerted by them upon the system during life. 
They have been found in subjects carried off by sudden death, in the midst 
of health. 
Filaria.-Several species of this genus have been observed in man. Fi- 
laria medinensis is the noted Guinea or hair-worm, which is apt to attack the 
inhabitants of Upper Egypt, Nubia, Guinea, and other intertropical regions 
of Africa, being developed in the subcutaneous tissue, in various parts of the 
body, but more especially in the lower extremities and scrotum. It is a very 
long and very slender worm, being about half a line in thickness, and some- 
times as much as twelve feet in length. Every reader of travels must be 
familiar, from the writings of Bruce, with the effects of this parasite, and its 
mode of treatment; how it excites an itching or irritation at some point upon 
one of the extremities; how this is followed by a vesicle or pustule, after the 
opening of which, the head of the worm appears; by what careful and pa- 
tient manipulation it is necessary to withdraw the worm, so as to avoid break- 
ing it; and what severe inflammation, with suppuration, and long confinement 
and suffering, follow this accident, probably in consequence of the escape of 
innumerable young worms into the wound. This subject, however, belongs 
strictly to surgery. The Filaria oerdi, a much smaller species, has been 
found in the human eye, and the F. bronchialis in the bronchial gland; but 
they are* both exceedingly rare. 
Strongylus.-It is Only the N. gigas that is developed in the human sub- 
ject. It is an enormous parasite, being sometimes half an inch thick, and 
three feet long, though generally much smaller. The body is cylindrical, 
tapering towards each end, with circular striae, and two longitudinal depres- 
sions, an obtuse head, a circular mouth surrounded by six hemispherical 
papillae, and a tail, which, in the male; is strongly incurved, and ends in a CHAP. II.] 
GAUSES OF DISEASE. 
125 
sort of sac. The worm inhabits the kidney exclusively, of which it some- 
times produces great destruction, with much pain, bloody urine, &c. Cures 
have sometimes followed'the expulsion of the worm by the urethra; and one 
case is recorded in which worms were discharged through the integuments of 
the body, by means of an abscess, and consequent fistulous opening. 
Treatment of Parasites.-So far as concerns worms in the alimentary canal, 
the mode of treatment will be given under special diseases. Surgical methods 
of management belong to another department of therapeutics. The question 
for discussion in this place is whether ■ parasites, existing in other parts than 
the alimentary canal, can be affected by measures applied through the system. 
It is certain that various substances prove poisonous to them when directly 
applied; and it is not impossible that they may be reached even through the 
circulation. Klencke recommends the use of such agents, ■ and mentions 
cherry-laurel water, camphor, volatile oil of cubebs, oil of turpentine, copaiba, 
and acetic acid, as having a poisonous action upon hydatids. He employed 
electricity in one instance, with apparent success, in an individual who passed 
acephalocysts and echinococci with his urine. One pole of a small galvanic 
battery was introduced through a glass tube into the bladder, and the other 
was applied either to the lumbar region, the abdomen, or, by means of another 
glass tube, to the rectum. Dead parasites were passed about four hours after 
each application; and the patient was effectually cured. It has been suggested 
to introduce the current by means of acupuncture needles immediately into the 
tumour, when this measure is practicable. (.Lond. Med. Gaz., Oct., 1846.) 
It is probable that the death of a parasite, produced in these modes, would be 
followed by collapse and absorption; but the possibility of the production of 
severe and even fatal inflammation, especially in cases of great masses of 
hydatids, should induce caution in the use of directly irritating measures. 
CHAPTER II. 
CAUSES OF DISEASE.-ETIOLOGY. 
Whatever is capable of deranging any one of the functions, or any part 
of the structure of the body, whether it be a form 6f matter, or merely a 
quality, condition, or action, is entitled to be ranked among the causes of dis- 
ease. These, therefore, are exceedingly numerous, and may, indeed, be con- 
sidered as embracing almost everything in nature, at least everything which 
is brought in any way into relation with our bodies. Many attempts have 
been made to classify them. Thus, they have been divided into the internal 
and external, the general and local, the principal and accessary, the mechanic- 
al or chemical and physiological, the positive and negative, the proximate and 
remote, the predisposing and exciting or occasional, &c.; and subdivisions of 
them have received the names of occult, specific, determining, &c. Most of 
these terms explain themselves. In relation to some of them, it will be proper 
to make a few explanatory remarks. 
Some have denied that there can, strictly speaking, be any negative causes, 
and would, therefore, refuse this distinction to cold, abstinence, &c. But the 
objection is little more than a quibble. A certain diminution of heat, which 
is called cold, and a reduction in the amount of our daily food, which is called 
abstinence, are productive of positive, and sometimes very serious effects of a 126 
GENERAL PATHOLOGY. 
[part I. 
morbid character, and, by whatever name they may be designated, must be 
admitted to be causes of disease. 
It was formerly the custom to consider groups of symptoms as diseases, and 
the pathological conditions attended by these symptoms, as causes of disease. 
Hence arose the distinction of causes into the proximate and remote; the 
former term being applied to the real lesion, the latter to the cause of the 
lesion. Thus, in a case of diarrhoea, the discharge being considered as the 
disease, the inflammation of bowel in which it, may have originated, was called 
the proximate cause, and the cold which may have occasioned that inflamma- 
tion, the remote cause.' Now it is evident that the inflammation in diarrhoea 
is the true disease, and the discharge a mere symptom or effect. The nomen- 
clature, therefore, was inaccurate, and has been generally abandoned by recent 
writers. 
The distinction of predisposing and exciting, causes is better founded. Of 
the individuals who may bn exposed to any particular cause.of disease, some 
will be attacked, while others, though not especially protected, may escape. 
In the former, there must be a tendency to be affected by the disease, which 
does not exist in the latter. This tendency is denominated a predisposition, 
and its causes, predisposing causes; while the agents which may call the 
tendency into action are called exciting causes. Thus, an individual, exhausted 
and perspiring after fatigue, is exposed to cold, and attacked with pleurisy. 
The state of exhaustion and perspiration constitutes the predisposition; the 
fatiguing exercise, the predisposing cause; and the cold,- the exciting cause. 
But this distinction is by no means absolute.- A cause which is exciting in 
one case, may be predisposing in another. - Cold may produce an attack of 
inflammation, and thus act as an exciting qause; or, by its long continued 
influence, may occasion a depression, highly favourable to the developemcnt 
of some other disease, thus operating as a predisposing cause. Most of the 
morbid conditions of which the frame is susceptible, may constitute predis- 
positions to other complaints; and the exciting causes of the former, are the 
predisposing causes of the . latter. Nor are these two sets of causes essential 
in every case. An influence which ordinarily gives rise merely to a predis- 
position, will often of itself, by a longer continuance, produce the disease to 
which it predisposes; .and an exciting cause may be so active as to produce 
its effects in persons entirely exempt from any peculiar tendency towards 
them. While, therefore, this distinction may be admitted, it cannot be 
adopted as the basis of a classification; for the difference is not in the causes 
themselves, but in the circumstances of their application; and there are very 
few agents, which may not operate cither as exciting or predisposing causes, 
according to the mode in which they are made to act upon the system. 
Specific causes are those which produce exclusively one peculiar disease, 
which can be produced by no other cause. Such are the several contagions, 
and certain poisons. There are frequent instances in which a cause produces 
a peculiar and special effect; but in which this same effect may originate in 
other ways. Thus, the inhalation of carbonic acid occasions asphyxia, which 
may result also from drowning, hanging, &c. To such causes Chomel gives 
the name of determining. The name appears to me to belong more appropri- 
ately to causes, which, though they may occasion various morbid affections, 
give rise to one which' acknowledges no other origin. I would, for example, 
call miasmata the determining cause of bilious fever, because, whatever other 
affections that agent may produce, and whatever other circumstances may 
favour the production of the fever in question, the operation of miasmata is 
essential. 
To enumerate all the possible causes of disease would be an almost endless CHAP. II.] 
CAUSES OE DISEASE. 
127 
task. I shall endeavour first to take a general view of them, and afterwards 
to dwell more at large upon those which, from the extent of their operation, 
and diversity of their power, require a consideration separate from that of the 
individual diseases to which they belong. 
The causes of disease are either, 1, perversions of the ordinary exterior 
influences, necessary to the preservation or well-being of the system; 2, excess 
or deficiency of the actions or processes, in any degree under the control of the 
willy 3, noxious matters within the body, yet not forming a part of it; 4, de- 
rangement of the functions or structure of the system; or 5, agencies, of an 
injurious character, which have only an accidental relation with the system. 
1. It is obvious that, whatever influences are necessary to sustain the ordi- 
nary vital functions, must, if excessive, deficient, or perverted, give rise to 
disorder. Among the influences in question are those of atmospheric air, 
moisture, temperature, light, electricity, food, drink,, and clothing; to which 
may be added those essential to our moral well-being, consisting of all the 
relations which connect us with the living world around us. The air may 
prove hurtful by its impurity, its excessive pressure at great depths, or its 
levity at great elevations. Moisture may be injuriously deficient or- abundant. 
The temperature may be too high or too low, or may produce disease., by its 
sudden changes. Light and electricity may be too intense for health. Excess 
or deficiency in the quantity of food or drink, badness in its quality, or a want 
of due relation between the articles used and the powers of digestion, or the 
condition of the .system in other respects, may severally, or in conjunction, 
prove sources of disease. Clothing, under which may be included the cover- 
ing at night, may be superabundant, and thus produce the effects of excessive 
heat, or deficient, and thus expose the body to still greater injury from cold, 
or too tight so as injuriously to compress the trunk or the limbs; or may be 
composed of materials badly adapted to the season, or the peculiar health of 
the individual. Perhaps we may rank under this head the morbid influence 
of gravitation,. resulting from improper position, or too long a continuance in 
any one posture. The condition of our exterior moral relations, so powerfully 
influential over the mental, and consequently the physical health, is subject 
to constant fluctuations, and, either through undue excitement or undue de- 
pression, is very often productive of disease; It would be impossible to 
specify all the different exhibitions of this morbid cause. They are as end- 
less as are the objects of our affections, wishes, aversions, fears, pursuit, avoid- 
ance, or interest of any kind. . . u, 
2. Scarcely less essential to health than the due influence of exterior phy- 
sical and moral agents, is that of the processes of our system, which are, to a 
greater or less extent, regulated by the will. All the functions, in order to be 
preserved in their normal state, must be properly exercised; and- all those 
which relate to the outer world, must have their due portion of rest. Excess 
or deficiency, in either of these respects, may be a source of bodily derange- 
ment. ' Hence, we must rank in the list of morbid causes, over-exertion of 
body or mind; sedentary habits, and mental inactivity; the wear and tear of 
the passions; neglect of the intimations of hunger, thirst, or other wholesome 
want of the system, and over-indulgence of these appetites; inattention to 
the processes of defecation and micturition; and undue prolongation, or loss 
of sleep. . . 
3. Of noxious matters within the body, yet strictly extraneous to its organi- 
zation, we have intestinal worms and other parasitic animals, acid and aeriform 
products of fermentation in the prims vise, acrid or otherwise unhealthy 
secretions, retained excrcmentitious matter, and intestinal, biliary, and urinary 
concretions. 128 
GENERAL PATHOLOGY. 
[PART I. 
4. The causes belonging to the division of deranged function or structure, 
are as numerous as these derangements; for there is scarcely a single disease 
which may not serve as the cause of others. Concatenations of this kind 
belong to the study of the several diseases. There are, however, certain de- 
rangements, which are peculiarly prominent in the list of morbid causes, and 
which may be properly alluded to here. Such are mechanical impediments 
arising from stricture, compression, or obstruction of narrow passages, as of 
the alimentary canal, ureter, urethra, and biliary ducts; compression or dis- 
placement of vital organs, as the lungs, heart, brain, and abdominal viscera, 
by tumours or fluid collections; the suppression of habitual discharges, whe- 
ther healthy or morbid; undue reduction of the mass of blood by bleeding, 
hemorrhage, or excessive secretion; the transfer of irritation or inflammation 
from an external to an internal part, as in metastasis of rheumatism or gout, 
and retrocession of cutaneous eruptions; the sympathetic extension of irrita- 
tion ; and the morbid influence arising from dependence of function. 
5. The agencies which have no necessary relation to the system in health, 
but yet act upon it injuriously, are beyond all power of enumeration. They 
may be divided into 1, mechanical causes, as all wounding, bruising, or com- 
pressing bodies, and all which operate merely by excluding necessary vital 
agents, as by strangling, suffocating, &c.; 2, chemical causes, which act by 
decomposing the living tissues; and 3, vital or physiological causes, which act 
through the peculiar susceptibilities of the system, and their relation to these 
susceptibilities. In the last class must be ranked all stimulants not essential 
to health, such as- alcoholic liquors, condiments, coffee, tea, &c., which, though 
they may often be used, in moderation, without obvious mischief, are the 
sources of incalculable evil by their abuse; and all the non-chemical poisons, 
whether solid, liquid, or aeriform. Of the latter subdivision, some act appa- 
rently merely by stimulant or sedative properties, as opium, belladonna, digi- 
talis, tobacco, hydrocyanic acid, sulphuretted hydrogen, &c.; others produce 
peculiar and characteristic effects, as mercury, lead, arsenic, miasmata, and the 
different contagions. They may sometimes, possibly, act by mere contact 
with susceptible surfaces; but, much more generally, they are absorbed into 
the circulation, and carried with the blood throughout the system. There is 
no exposed surface of the body through which they may not find access; but 
the entrance through the cutaneous surface is most difficult, through that of 
the pulmonary air-cells probably most easy, and through the alimentary mu- 
cous membrane of intermediate facility. Under the same general head, may 
be conjecturally ranked epidemic influences, though these are truly occult 
causes, wholly unintelligible in the present state of our knowledge. 
Not unfrequently there is, for a particular disease, a chain of causes, run- 
ning upwards, through a greater or less number of links, to the first, from 
which they all depend. Thus, apoplexy may sometimes be traced backward, 
through hypertrophy of the left ventricle of the heart, obstruction or defi- 
ciency of the cardiac-valves, endocarditis, and external rheumatism, to cold; 
diarrhoea, through irritation of the intestinal mucous membrane, disordered 
biliary secretion, and hepatic congestion, to miasmatic influence; and dropsy, 
through general venous congestion, dilatation of the right ventricle of the 
heart, pulmonary obstruction, and chronic bronchitis, to the habitual inhala- 
tion of irritant powders. 
It very often happens, that numerous causes act on the system at the same 
time, and occasionally, in a similar manner. When these are such as to affect 
simultaneously great numbers of persons, the most devastating effects are ex- 
perienced. Thus, a dense population is sometimes exposed to the prostrating 
influences of meagre and unwholesome diet, impure air, contagious effluvia, CHAP. II.] 
CAUSES OE DISEASE.-HEAT. 
129 
and the depressing emotions, and are consequently swept off in vast numbers 
by typhus fever. 
In relation to the character arid mode of action of the different causes of 
disease, and the various circumstances of- their application, it would be 
entirely out of place to treat fully in a general essay. On these points, 
reference must be had to the accounts of the diseases which they severally 
produce. Much has been already said, under the head of the constituent 
forms of disease; and, when there is anything peculiar or specific in the 
cause of any particular complaint, it will be treated of in the department of 
special pathology. But there are various morbific agencies, which have so 
diversified an operation, or involve so much of disquisition in relation to their 
origin and nature, that there is no one disease; under which they can be appro- 
priately considered. These it will be most convenient to treat of in the pre- 
sent place. They may be ranked under the several heads of heat, cold, water 
in the liquid and aeriform states, electricity, light, atmospheric impurities, 
miasmata, epidemic influence, and contagion. 
Heat. 
Heat, in a certain degree, is essential to the healthy performance of all the 
functions. In excess, it becomes morbidly stimulant, increasing the frequency 
and force of the pulse, and either augmenting the organic actions, or disturb- 
ing them by over-excitement. By its general influence, it is capable of pro- 
ducing a febrile condition, and locally stimulates into inflammation. Beyond 
a certain degree, it loses its vital in its chemical agency, and produces the 
death of the part upon which it acts, by coagulating the albumen, and causing 
decomposition through a new play of affinities. It appears to stimulate cer- 
tain organs more than others, and especially the skin, liver, and alimentary 
mucous membrane. Irritation and inflammation of these structures are some- 
times the direct result of heat. Nature, however, has provided the means of 
relief, to a considerable extent, by the increase of secretion. Heat is pecu- 
liarly apt to induce profuse perspiration, which not only unloads the vessels 
of the skin, but, by the vaporization of the extravasated liquid, occasions an 
absolute reduction of temperature in the immediate vicinity, and thus protects 
the system at large. The liver (alsri is frequently relieved by an increased 
secretion of bile, and the bowels by a more active exhalation from their lining 
membrane. Hence bilious cholera and diarrhoea, which often probably pre- 
vent attacks of hepatitis, gastritis, or enteritis. Occasionally, heat also acts 
with great energy upon the brain, but rather in consequence of a direct appli- 
cation, than tlirough any especial affinity for the organ. Serious and even 
fatal cerebral irritation and congestion sometimes result from the immediate 
influence of the sun's rays upon the head, when insufficiently protected, as in 
the familiar case of the sun-stroke; and cooks are subject to all the conse- 
quences of general vascular fulness of the head, from the necessary exposure 
of that part of the body to the fire. Along with the effects mentioned, cer- 
tain other functions are somewhat differently affected. The kidneys not only 
do not directly feel the stimulus, but generally secrete much less than in 
health. The urine, however, is apt to be loaded with saline matters, and 
may become a source of irritation by this concentration, or by deposition in 
the passages. Urinary diseases have been noticed among the morbid effects 
of sleeping too warmly in feather beds. The circumstance that less evolution 
of heat is required in the system, when already overheated, renders the Oxida- 
tion of carbon less necessary, and consequently tends to reduce the activity of 
the pulmonary function. The lungs, therefore, are less excited than other 
organs, and hence their comparative freedom from disease in hot countries. 130 
GENERAL PATHOLOGY. 
[part I. 
Though the sensations and emotions, which may be deemed passive functions 
of the nervous system, do not seem to be impaired or diminished by a mode- 
rate excess of temperature, the more active functions, as those of muscular 
motion, and of intellect, are depressed; as evinced. by the general languor, 
and indisposition to exertion, whether of body or mind. The latter effects 
are ascribable to that conservative or compensating principle of the system, 
which provides that those actions of an already excited part which would tend 
to increase the excitement, should be rather checked than augmented; as a 
muscle, for example, refuses to contract when affected by rheumatic irrita- 
tion. ' • V , .. 
In consequence of the refrigerating effects of profuse perspiration, a very 
.high degree of temperature may be borne for a considerable time. Numerous 
instances are on record, in which individuals have remained, with perfect 
impunity, for several minutes, in ovens or apartments heated above the tem- 
perature of boiling water. The experiments of Dr. Fordyce and Dr. Blagden 
are well known, in which they bore, for a considerable time, and without 
much inconvenience, a temperature of 260° F.; while eggs were roasted hard, 
and beef-steaks cooked, by the mere heat of the air about them. Their pulse 
was much excited, but the interior temperature was not increased, nor was 
the breathing materially affected. It is said that the famous Chabert was in 
the habit of entering an oven, the temperature of which was between 400° 
and 600°. (Carpenter's Princip. of Hum. Physiol.') The non-conducting 
property of dry air has, undoubtedly, much to do with the impunity in such 
experiments. - 
There are other secondary effects of heat which merit notice. The organs, 
excited to unusual secretory efforts, become afterwards relaxed, and are, in 
this state., peculiarly liable to suffer from the influence of miasmata and cold. 
Moreover, repeated excitement at length wears out the excitability of the 
organs, which consequently become, in some degree, insensible to the ordinary 
healthy excitants, and perform their proper duties less efficiently; while, from 
the constantly renewed irritation, they are apt to fall into a condition of 
chronic inflammation. Hence arise dyspepsia, portal congestion, constipation, 
chronic hepatic and gastro-intestinal inflammations, and various cutaneous 
eruptions. 
Heat is morbidly applied in various ways. Its local effects of burning and 
scalding are produced by the direct application of flame, or of heated solids or 
liquids, to the surface; and sometimes, it is received into the trachea, in the 
form of flame, with fatal results. Its general effects are produced through 
the medium of the atmospheric air in summer, or by confinement to heated 
rooms in winter, or by too much clothing, or sleeping too warmly, at all 
seasons. The effect of heat is much increased, when connected with water. 
Hence, the abuse of hot baths, and vapour-baths, may lead to disease. It 
may also act by means of hot liquids swallowed. 
Cold. 
In relation to the principles upon which cold acts, something has been 
already said under the head of depression, to which the reader is referred. 
In this place, it is proposed to give_ a more comprehensive view of its effects, 
as a morbific agent. On the occasion alluded to, cold was shown to be neces- 
sarily sedative or depressing. Under the local influence of cold, the tissues 
shrink, the capillaries circulate the blood less vigorously, secretion is checked, 
sensibility is impaired, and the part becomes pale from the want of blood, or 
purplish from its stagnation. Should the application continue with intensity, 
a deadly whiteness ensues, circulation ceases entirely, sensibility is lost, and, CHAP. II.] 
CAUSES OF DISEASE.-COLD. 
131 
though vital power is not immediately destroyed with the loss of action, local 
death soon follows unless the. cause be removed. When the influence is gene? 
ral, the whole surface undergoes the change above described; while the inte- 
rior functions exhibit a similar depression. The heart acts by degrees more 
and more feebly, a general torpor steals over the sehses, the movements be- 
come tottering from muscular weakness, and the benumbing influence extends 
at last to ,the brain, giving rise to wandering of the thoughts, drowsiness, and 
finally an irresistible propensity to sleep. Death speedily follows, and the 
body is surrendered to physical laws. 
But there are other, and very important effects of cold, which must not be 
left out of view. In the midst of its depressing action, as' above described, it 
produces a peculiar sensation, which we denominate the feeling of cold, and 
which is agreeable, or otherwise, according to its degree, and the previous 
state of the surface. When the application is made suddenly, and with con- 
siderable intensity, this sensation amounts to a shock upon the nervous system, 
which rouses up the energies of the interior, and leads to important results. 
Should the agency continue undiminished, this feeling of coldness is succeeded 
by positive pain, often very distressing, which is either local or more or less 
general, according to the extent to which the cause is applied. There is often 
also greatly increased sensitiveness to painful impressions, so that a slight 
blow upon the part occasions acute suffering; and all this takes place, while 
the circulatory actions, special sensibility, and nervous energy, are greatly 
impaired, as shown by the shrinking, pallor, numbness, and diminished power 
of motion. This peculiar, painful impression upon the nerves, in the midst 
of an otherwise universal depression, was no doubt intended to rouse the atten- 
tion of the individual to his condition, so that he might seek timely means of 
relief; while the sympathetic connexion of the sentient surfaces with the 
interior sources of vital action is such, that the powers of the system are also 
called forth, through its instrumentality, to obviate the evil as far as possible. 
With the continued action of the 'cause, however, this influence ceases, and 
the cold is completely triumphant. 
Consequent upon the strong impression just alluded to, is organic, reaction, 
which may be entirely local when the cold is applied to a limited space, but 
is general when the cause is general, or extensive in its operation. (See De- 
pression.') This reaction is often healthful, and the cold then proves indirectly 
invigorating; but it may also be carried so far as to become morbid. In the 
latter case, we have, from the local reaction, redness, swelling, and pain in the 
part impressed^ amounting frequently to inflammation; and, from the general 
reaction, accelerated circulation, increased heat, disordered digestion, &c., 
amounting often to fever. Now it is not only the part to which the cold is 
directly applied that undergoes depression, and subsequent reaction; but 
various other parts, also, which are connected sympathetically with the first. 
Thus, cold to the outer surface affects, in a similar manner, the skin which 
receives the impression, and the interior mucous surfaces to which it is con- 
veyed by sympathy, or, to speak more precisely, to which it is transmitted 
from the nervous centres that receive it from the skin. The morbid' effects 
are, indeed, more frequently developed internally than externally. In order 
that the effects of reaction after cold may be experienced, there must be a 
certain degree of energy in the system, and the' agent must not be too in- 
tensely, or too continuously applied. In a system previously exhausted, 
reaction may never take place; and, when the cold is intense, the efforts at 
reaction are in a greater or less degree repressed, and, if the cold continue, 
give way at length altogether. 
Another method in which cold may become a source of disease, is by the 132 
GENERAL PATHOLOGY. 
[PART I. 
concentration of blood, and of nervous energy, in the interior organs, conse- 
quent upon their retrocession from the skin, and the parts which sympathize 
with the skin. It is obvious that the quantity of blood is diminished in the 
superficial vessels. It must necessarily, therefore, be increased in those within. 
It is equally certain that nervous action is depressed upon the surface ; and it 
is highly probable that this also is concentrated in the interior organs. Excess 
of blood, and excess of nervous energy combined, cannot but frequently eventu- 
ate in disease. 
Still another, and probably one of the most important morbid effects of 
cold, is the suppression of perspiration, resulting from its sedative action 
upon the superficial capillaries. Perspiration is usually the result of some 
general excitement, as from exercise, heat, &c., which finds a safe issue by 
the skin. If this be closed, the excitement is necessarily directed to some 
one of the interior organs, and proves the cause of inflammation. Very pro- 
bably, also, the suppression may sometimes be injurious by preventing the 
escape of noxious matter from the blood. 
The power of resisting the injurious effects of cold, is in proportion to the 
vital energies of the system, and to the grade of its actions at the time. A 
vigorous person resists it better than one who is feeble; and a high degree of 
excitement often prevents its evil consequences. In the debility of conva- 
lescence, or in the exhaustion and relaxation which follow excessive actions, 
cold readily occasions morbid results. They who live on animal food can 
bear it better than others whose diet is exclusively vegetable. In febrile dis- 
ease, with the pulse frequent and the skin hot, it acts often most happily in 
allaying excitement, and, instead of proving a morbid agent, is remedial. 
Every one knows that cold is especially injurious when the skin is perspiring 
and relaxed, after exercise in hot weather. But, if applied during the con- 
tinuance of the exercise, the stimulus which this affords counteracts its sedative 
influence, and very often no evil results. Thus, when the skin is heated by 
a hot bath, or vapour-bath, so as to be decidedly above the healthy standard, 
even though perspiring, cold is generally innoxious; while it is much other- 
wise after immersion in a merely tepid bath, which relaxes instead of exciting 
the surface. Persons coming out of a hot bath sometimes plunge into the 
snow with perfect impunity; but the act would be very hazardous for one 
just out of a merely warm bath. Even mental preoccupation is preservative, 
in a considerable degree, against the morbid effects of cold. In its sympathetic 
operation, and, to a considerable degree, in its immediate operation, this agent 
acts through the nervous system; and, if that system is under powerful im- 
pressions of other kinds, it is less sensible to that of cold. Hence, maniacs 
often bear a degree of exposure, which would prove highly dangerous to the 
same persons in health. We seldom hear of any injury from the immersion 
of the body in baptism, even during the coldest weather. Habit also has 
great influence in obviating the morbid effects of this agent. They who are 
accustomed to cold, will bear a degree of it under which others would sink. 
Sleep usually favours the morbid action of cold by the relaxation of surface, 
and general diminution of action which attend it. Persons very frequently 
take cold, by exposure to the cause during sleep. 
From what has been said it may be inferred, that vicissitudes of cold and 
heat are more injurious than a steady prevalence of cold alone, unless in great 
excess. A tendency to moderate and healthful re-action is produced in the 
latter case, and sustained by the fresh support which the system constantly 
receives, through the invigorated appetite and digestion. In the former case, 
the stimulant effects of heat are sometimes superadded to the re-action of cold 
before this has subsided, and thus render morbid what might otherwise have CHAP. II.] 
CAUSES OF DISEASE. 
133 
remained within the limits of health. The cold, too, operating during the 
relaxation which follows heat, has a much greater effect than if there had 
been no such contrast. 
The effects of cold are much increased by currents of air. The atmosphere 
is a slow conductor, and the body cools very slowly when surrounded by the 
air at rest. But, when it is in motion, a fresh portion constantly takes the 
place of that which had been warmed by the surface, and thus greatly increases 
the rapidity with which the heat is abstracted. It is a common observation, 
that draughts of cold air are highly injurious. So also is the partial applica- 
tion of cold, especially to portions of the body unaccustomed to it. Many 
persons will begin to sneeze, or be sensible of a sore-throat almost immediately, 
if exposed to a current of cold air upon the back of their neck. The effects 
of cold are much increased by its association with moisture, in consequence of 
the much greater conducting power of the latter. 
It is believed that, in the above sketch of the operation of cold, the reader 
will find principles which will explain at least most of its effects in the pro- 
duction of disease. By its direct, local, depressing agency, it sometimes, 
when intense, destroys the life of the part, and, in a less degree, may pro- 
duce fatal prostration, when the organ upon which it acts has a wide circle 
of affinities. Such has often been the result of drinking freely of very cold 
water, when the body was hot and perspiring. Instances are not uncommon 
of persons being frozen to death, by exposure to the general influence of cold. 
The fact is, that the body is not really frozen, at least beyond the surface, 
before death. The fatal result is ascribable simply to the depressing influence 
of the cold. Such instances are most common among the intemperate, whose 
vital resistance is less than in health, and who are too often insensible to the 
danger, and therefore can take no means to obviate it. The long-continued 
influence of a more moderate degree of cold, is apt to wear out the powers of 
re-action, especially when aided by want of food, and other sedative agencies. 
A state of system is thus produced, highly favourable to typhous and scor- 
butic diseases; and, when the individual may be attacked with another dis- 
ease, even though inflammatory, it is apt to assume a low, asthenic, or typhoid 
character. I believe, also, that a strong predisposition may thus be developed 
to phthisis or scrofula, or an existing predisposition to these affections called 
into action. 
By the re-action which generally follows cold, it often gives rise to that 
troublesome affection commonly called chill-blain or frost-bite, and may gene- 
rate various other forms of cutaneous inflammation., There is reason to believe, 
that many cases of internal mucous inflammations arise in the same way. The 
admission of very cold air into the bronchial tubes is probably sometimes fol- 
lowed, upon subsequent exposure to heat, by a re-action amounting to bron- 
chitis. The same membrane, as well as that of the alimentary canal, may be 
affected in like manner by its sympathies with the skin. 
But, probably, a more frequent source of internal diseases from cold is the 
irregular direction given to the blood, and the nervous influence, by the de- 
pressed state of the surface, and the suppression of the perspiration. There 
is scarcely any form of internal inflammation, not of a specific character, which 
may not have its origin in this cause. The same may be said of irritations, 
of all grades, with congestion, increased secretion, or hemorrhage. Even 
specific diseases, which require a peculiar diathesis for their production, are 
often brought into positive existence through this action of cold. Illustrative 
examples of this principle of action we have in the phlegmasim of the brain, 
and of the thoracic and abdominal viscera, the active hemorrhages, diarrhoea, 
cholera, dropsy, rheumatism, and gout. 134 
GENERAL PATHOLOGY. 
[part I. 
Cold, as a morbid agent, most frequently affects us through the atmosphere. 
It often also operates through the instrumentality of water applied to the sur- 
face, as in the case of wet feet, and wet or damp clothing. Sometimes, though 
very rarely in comparison, its primary action is internal, as in the case already 
mentioned, of cold water taken into the stomach, when the body is perspiring 
from heat and previous exertion. 
The influence of water upon the system, when in excess, is decidedly seda- 
tive; and it differs in this respect from cold, that its depressing effects have 
no apparent tendency to produce re-action. Operating probably by penetrat- 
ing tjde tissues, it appears to increase the distance between the living mole- 
cules, to diminish their vital cohesion, and thus not only to lessen the action 
of the part, but also to impair its powers. This result happens, no matter to 
what surface the water is applied, or by what avenue it enters the system, 
provided only that it be in excess. Hence the relaxing effects of damp warm 
weather, of the tepid bath, of emollient poultices, and of warm water taken 
into the stomach. It will be readily inferred, that a frequent or habitual ex- 
posure to this cause of depression, must eventuate in diseases of debility, or at 
least must strongly predispose to them. The system is placed by it in a con- 
dition peculiarly favourable to the influence of cold, and is, therefore, rendered 
liable to inflammations; but the inflammatory affection partakes of the per- 
vading character of debility, and is apt to assume a low, sub-acute, or scrofu- 
lous, and sometimes very obstinate form. Taken copiously into the stomach, 
it impairs the energy of that organ, while it interferes with the process of 
digestion, by too largely diluting the food. The habit, therefore, of drinking 
copiously even of water, may induce dyspepsia. 
There is one effect of water, apparently stimulating; an increase, namely, 
of the secretions, - more especially of the urine and perspiration. When 
taken into the stomach, it is rapidly absorbed, and conveyed into the circula- 
tion, where, if in excess, it distends the vessels, and, by this distension, affords 
the stimulus necessary to secretion. It is, however, mechanically, and not by 
any inherent stimulating power, that it produces this effect. 
But water is seldom so employed or applied as to produce its own peculiar 
effects without modification. The condition by which its action is most fre- 
quently modified is temperature. It much oftener acts as the mere vehicle of 
heat, or of cold, than by its own peculiar powers. In order that the effects 
of water alone may be experienced, it must be applied so as to produce the 
impression neither of heat nor of coldness; in other words, it must be as nearly 
as possible of the temperature of the body externally, that is, tepid or luke- 
warm. It is very important to bear this fact in mind in practice. 
When the vehicle of heat, water becomes stimulant, whether used exter- 
nally or internally. It is true that its own peculiar influence must be exerted; 
but this is greatly overbalanced by the much more powerful influence of the 
heat, when the latter is at all considerable. There is, however, a point at 
which the two very nearly balance each other; and, if the object be to use 
the water merely for purposes of cleanliness, without a view to any impression 
whatever on the system, such a mean should be aimed at. The stimulant 
influence of the hot bath is exhibited in the universal redness of the skin, a 
feeling of agreeable cerebral excitement, and an accelerated pulse. Hot water 
in the stomach excites that organ to increased activity, and adds much to the 
effect of the tea,- coffee, &c., with which it is usually administered. In both 
cases, it may become a source of disease, either by over-stimulation, or by 
impairing the excitability of the system, or of the parts more especially excited. 
Water. chap, ii.] 
CAUSES OF DISEASE.-WATER. 
135 
There can be no doubt that the free use of hot drinks contributes to the pro- 
duction of dyspepsia. But there is another effect of heat and water combined 
which merits notice. It has before been stated, that water taken freely into 
the stomach promotes secretion. Hot water promotes especially the perspira- 
tory function. This it does, probably, in consequence of an impression of 
morbid heat, transmitted to the sensorium from the stomach, and other parts 
of the body, and reflected from the nervous centre to the skin. The end ob- 
tained, through this sympathetic influence, is the elimination of the excessive 
heat, which is carried off by the evaporation of the moisture at the surface. 
Were the- action to be directed to the kidneys, no effect of this kind would be 
produced. This excess of perspiration may sometimes be a cause of disease, 
though practically it is much more frequently a remedy. 
Water, associated with cold, greatly increases the effect of that agent, partly 
by superadding its own sedative influence, but probably in chief by its con- 
ducting power, which so much exceeds that of air. Hence, a cold damp 
atmosphere is much colder to the senses than a dry one at the same tempera- 
ture, and is, in the same degree, more apt to produce all the morbid effects of 
cold. The same may be said of wet clothing, compared with dry. Cool 
water, as a bath, is less relaxing than warm water, becauses it excites to reac- 
tion; but, after a certain time, this reaction ceases, and then the sedative 
effect both of the water and the cold is experienced. Hence, in bathing, even 
though the temperature may not be very low, the vital actions often become 
much enfeebled, and the individual is ultimately exhausted. In very cold 
water the effect is much more speedy. As hot water gives a direction of secre- 
tory action to the skin, so does cold to the kidneys. Externally applied, the 
latter checks perspiration, and thus throws the onus of unloading the blood- 
vessels upon the urinary organs. But, whether externally, or internally used, 
it probably operates on the kidneys by the same nervous instrumentality as 
that which directs the action of hot water to the skin; the end, in this instance, 
probably being, that the ordinary refrigerating process going on at the surface 
in health, might be diminished, so as to husband the heat; while, in order to 
prevent excess of liquid in the circulation, the kidneys are stimulated into 
extraordinary action. 
A morbid influence of moisture not yet mentioned deserves a brief notice. 
Through its affinity for miasmata, it is apt to become impregnated with that 
poison, and in the form of fogs, or mere aerial dampness, may produce serious 
effects on those who breathe it. 
. A certain amount of water in the air is not less essential to life, than water 
in the form of drink. A perfectly dry air is highly dangerous, in consequence 
of absorbing all the liquids of the body, to which it can have access. The 
fatal winds of the African dbsert are said to owe their deleterious influence to 
this, cause. The skin becomes arid, the mouth and fauces parched, and the 
bronchial tubes themselves dried up, so that the patient is unable to breathe, 
and speedily perishes. 
Light. 
Though so important to our comfort, and all our higher interests in this 
world, light does not appear to be a very powerful pathological agent. It has 
little observable influence over any of the functions or organs, except the one 
specially formed for the reception of its impressions. Upon the eye it acts as 
a stimulus, capable, when in great excess, of completely paralyzing the sense 
of vision, by exhausting the excitability of the retina, and, more moderately 
applied, of producing various degrees of irritation and inflammation in the 136 
GENERAL PATHOLOGY. 
[part I. 
organ. Its influence may even extend through the eye into the sensorium, 
and injuriously excite the brain. 
It is highly probable, that light influences our organic functions, in a manner 
analogous to that of its action upon plants, which are well known to lose their 
colour, and to have but a feeble growth, in the dark. Accordingly, it is ob- 
served that persons, long excluded from the light, become very pale, and of a 
lax and feeble habit of body, which disposes them strongly to scrofula and 
phthisis, and favours the production of scorbutic and dropsical affections. But, 
as persons thus excluded are usually shut out from other sources of health, 
as, for example, from exercise, fresh air, and cheerfulness of spirit, it is impos- 
sible to determine how much of the result is ascribable to the want of light, 
and how much to other causes. 
The wide diffusion of this principle^ the almost universality of its inter- 
ference in the physical processes which are going on around us,. and the pecu- 
liarity of the effects which it is known to produce upon the system, justify the 
conjecture that it is also a powerful agent in the generation of disease. When 
its nature and laws, and its relations to the system come to be better under- 
stood, it is highly probable that we shall find it to be one at least of those 
mysterious influences which so often disturb the vital processes, and spread 
havoc among organized beings, without our being able to discover whence they 
come, or whither they go, or where they dwell when apparently amongst us. 
The sense of oppression, languor, and general uneasiness, so often experienced 
before a thunder storm, and so completely dissipated with the occasion which 
produced it, is among, the proofs of a constant operation of atmospheric elec- 
tricity upon our system^, and of the dependence of our health upon a proper 
equilibrium of that principle. It must be confessed, however, that our know- 
ledge of the pathological agency of electricity is exceedingly limited. It does, 
indeed, appear to be confined to the fact, that it is a powerful stimulant to the 
nervous system, capable of increasing its action, in various degrees, and even 
of completely exhausting and prostrating it by one powerful shock, so as to 
produce local or universal palsy, and consequently immediate death. This 
effect .of electricity is experienced, as a natural result, only from lightning, 
which acts also, when the living body becomes a recipient of its current, in 
the same destructive manner as upon inorganic bodies; namely, by a mecha- 
nical rupture of parts, and by the destructive evolution of caloric. 
Electricity. 
Atmospheric Impurity. 
This is an abundant source of disease. But it is singular, how few of the 
numerous exhalations which render the air impure, are definitely known. 
Carbonic acid, carbonic oxide, the different forms of carburetted hydrogen, 
hydro-sulphuric acid, and sulphurous acid, are almost all that proceed from 
natural sources, or ordinary artificial processes, in quantities likely to prove 
injurious to health. Others, such as chlorine, muriatic acid gas, nitric oxide 
or nitrous acid vapour, and ammonia, are occasionally evolved in the labora- 
tory, or for purposes of fumigation, and prove the source of injury in some 
rare cases. But, besides these, numerous aeriform products, not well ascer- 
tained, are constantly evolved by vegetable and animah exhalation, by sponta- 
neous decomposition of organic or mineral substances, by combustion, by 
manufacturing operations, and by evaporation of every liquid on the face of 
the earth, which tend to contaminate the air, and render it more or less nox- 
ious to animal life. 
The morbid effects of all these aeriform products may be embraced under CHAP. II.] 
CAUSES OF DISEASE.-ATMOSPHERIC IMPURITY. 
137 
the following heads. In the first place, when sufficiently concentrated, they 
may destroy life by excluding atmospheric air from the lungs, and thus pro- 
ducing asphyxia. This they may do, either by entering the lungs, and thus 
taking the place of pure air, or, in consequence of their irritant properties, by 
causing spasm of the glottis. Secondly, they may be simply irritant, and act 
by producing inflammation of the air passages. Thirdly, they may be ab- 
sorbed both through the lungs, and through other avenues, as the skin, and 
the mucous membrane of the stomach, which they may reach along with the 
saliva; and, thus entering into the circulation, may exercise a poisonous influ- 
ence upon the whole, or any part of the system. A few remarks in relation 
to the several gases, the operation of which has been observed, will not be 
irrelevant. 
Carbonic acid is poisonous only when in a certain degree of concentration. 
In a very dilute state, it is always present in the lungs. When pure, it pro- 
bably causes a spasmodic closure of the glottis, and thus produces complete 
asphyxia. When so much diluted as to be allowed an entrance into the 
bronchia, it acts either by preventing the escape of carbonic acid from the 
blood, or by being absorbed into the blood. In either case, the result is the 
same; that is, an undue accumulation of carbonic acid in the circulating fluid, 
and a consequent narcotic action upon the brain; while the respiratory process 
ceases, from the want of action in the pulmonary capillaries. The symptoms, 
therefore, are those of asphyxia and cerebral oppression combined. (See 
Asphyxiad) 
In the quantities necessary for the production of the effects just mentioned, 
carbonic acid may be generated by combustion, respiration, fermentation, the 
preparation of lime, and various chemical processes which are going on in na- 
ture.' The most frequent source of danger is probably the burning of char- 
coal or anthracite, in close apartments. Partial, and, in some few instances, 
fatal effects, have resulted from the confinement of many persons in a small 
apartment, without ventilation. Brewers' vats have sometimes proved fatal 
to the workmen who have entered them. We now and then hear of deaths 
occasioned by persons sleeping, in cold weather, for the sake of the warmth, 
in the vicinity of lime-kilns. It is often owing to the accumulation of car- 
bonic acid, that death has resulted from the descent into old mines, pits, caves, 
&c. The weight of the gas causes it to maintain, for a time, its position in 
these depths, when generated there. 
Carbonic oxide appears, from the experiments of Mr. Higgins, of Dublin, 
to be powerfully narcotic, producing quickly, when inhaled in a pure state, a 
loss of sense and motion, followed, if the patient revive, by headache, drowsi- 
ness or stupor, giddiness, blindness, nausea, and a quick irregular pulse; and 
the same symptoms, in a milder degree, are produced by the inhalation of the 
diluted gas. It is said that this gas is evolved along'with carbonic acid from 
the slow combustion of charcoal; and we may thus, perhaps, account for the 
asserted fact, that the gaseous products of burning charcoal are more danger- 
ous than pure carbonic acid. 
Carburetted hydrogen can scarcely be very noxious, at least the form of it 
denominated light carburetted hydrogen, or fire-damp; as it is constantly in- 
haled by miners with impunity, even in mixtures which are highly explosive, 
when entered with an unprotected lamp. In a certain degree of concentration, 
however, it is capable of producing fatal effects; and symptoms of narcotic 
action, with great depression, have been observed before death, and in cases 
of recovery. But it is doubtful whether the apparent narcotism is anything 
more than the result of the venous congestion in the brain, consequent upon 
the suspension of the respiratory process. 138 
GENERAL PATHOLOGY. 
[PART I. 
Phydrosulphuric acid, or sulphuretted hydrogen, is undoubtedly a most vio- 
lent poison. It is capable of destroying life, no mattei' by what avenue it 
may enter the system, whether by the lungs, the stomach, the rectum, or the 
skin. According to Ghaussier, a horse was killed by breathing atmospheric 
air containing a 290th part of this gas. Nine quarts of it, injected into the 
anus of a horse, killed the animal in a minute; and a rabbit, whose body was 
surrounded with the gas, so as to affect only the skin, died in ten minutes. 
(■Christison on Poisons.) Symptoms of great nervous derangement, with im- 
mense prostration, result from its action. In minute quantities, it occasions 
nausea, drowsiness, and nervous pains; in larger quantities, either stupor or 
convulsions, with a cold skin and feeble irregular pulse, followed often by total 
insensibility and death; in a concentrated state, sudden prostration and fatal 
asphyxia. It appears, therefore, to be a. powerful sedative agent, acting espe- 
cially upon the brain and nervous system. There is good reason to believe 
that it is capable, when inhaled with the atmospheric air, in very small pro- 
portion, of inducing a typhoid state of fever, or at least of strongly predispos- 
ing to that condition, when fever may be excited by any other cause. Its 
most frequent source is in privies, whence it is exhaled with ammonia or its 
compounds, and possibly other noxious gases. 
Of sulphurous acid, as a morbific agent, little more is known than that it is 
a powerful irritant. So powerful, indeed, is it in this respect, that it could 
scarcely enter the lungs, in any considerable degree of concentration. It is 
produced, along with carbonic acid, in the combustion of anthracite coal, and 
adds greatly to the deleterious properties of the latter gas. 
Of chlorine, muriatic acid gas, nitrous acid vapours, and ammonia, it is 
unnecessary to say more than that they are violently irritant, and produce, in 
a certain state of concentration, speedy and severe inflammation of the air- 
passages, so far as they can penetrate. 
The unknown vapours, or gaseous bodies, which morbidly impregnate the 
atmosphere, require only a brief notice. They are generally most abundant 
where men are most collected together, and where, consequently, most abound 
the aeriform emanations from animal excretions, magazines of all sorts of pro- 
vision, the combustion of wood and coal, cooking in all its forms, and every 
variety of chemical process, which the wants of a large population require. 
Hence, the air of large cities is apt to be impure, and to a certain degree un- 
healthy. The effects of the air must be so varied, from its varied composition, 
as to defy analysis. But, generally, the energies of the system appear to be 
diminished, and the vital processes are carried on more feebly than in a pure 
air. This is often strikingly seen in the invigorating influence exerted by 
the air of the country upon invalids from cities. It is probably rather as a 
predisposing, than as an exciting cause of disease, that this impure air acts. 
Its influence is visible in the typhoid tendency often given to the fevers during 
winter, and in the extreme fatality of the infantile cholera of cities, during 
the heat of summer. Infants suffer more from this cause than adults, whose 
systems have become habituated to it; and young men from the country often 
undergo an acclimating attack of disease, before they become completely natu- 
ralized. 
Animal effluvia.-Under this head may, without any great violence, be 
arranged the effluvia which result from the decomposition of the exhalations 
and excretions of individuals of filthy habits, or crowded together in confined 
apartments.- Allusion is not had to those morbid emanations, which are the 
immediate result of a secretory process, and which have the power of generat- 
ing the same disease in others as that by which they were themselves pro- 
duced. Such effluvia belong to the category of contagions, and will be con- CHAP. II.] 
CAUSES OF DISEASE.-MIASMATA. 
139 
sidered under that head. The morbific emanations to which reference is now 
made, are the result of decomposition, which may have originated within the 
body, as in the case of the feces, but mor^frequently docs not commence until 
the secreted or excreted matter has been eliminated, as in the case of the 
urine, perspiration, saliva, and breath. Where due attention is paid to clean- 
liness and ventilation, such decomposition is productive of no evil; for expe- 
rience has abundantly shown, that the resulting products are only injurious 
when in a certain degree of concentration. Even when most copiously evolved, 
and under the most unfavourable circumstances, they are quickly diluted be- 
yond the noxious point by the contiguity of the open air; and their evil effects, 
therefore, are seldom or never experienced beyond a few feet from their place 
of origin. There is reason, indeed, to believe, that they adhere, to a certain 
extent, to the clothing and persons of individuals, and may thus be conveyed 
to a distance from their source; but it is very possible that, in such cases, it 
is less the effluvia themselves that are conveyed, than the materials out of 
which they are formed, which remain in the clothing or attached to the sur- 
face of the body. 
The nature of these effluvia is unknown. It is highly probable that sid- 
phuretted hydrogen is one of their ingredients. They generally have a dis- 
agreeable odour, which often strongly recals that of malignant typhus. They 
are generated usually in the hovels and cellars of the poor, in which many 
persons often dwell in the same small room, and where no attention is paid 
to personal cleanliness, or to proper ventilation. But they may be developed 
in any situation in which numbers are crowded together, as in prisons, infirm- 
aries, besieged fortresses, camps, and ships, when due regard to the health 
and comfort of the inmates is neglected. The winter season is peculiarly 
favourable to their influence, because economy in relation to fuel induces the 
inmates to close every access to the external air; so that the warmth neces- 
sary for the decomposition is produced, and the resulting effluvia are accumu- 
lated in the greatest possible degree. They are sedative or depressing in their 
action, and, while they lower the energies of the nervous system, probably 
tend also to corrupt the blood. Hence, they impress on all the diseases 
which result from other causes, a low or typhoid character; and, when suffi- 
ciently concentrated, are not unfrequently of themselves competent to the 
production of typhus fever. Among the effluvia just alluded to, are not in- 
cluded 'those which result from the putrefaction of the dead bodies of animals, 
or portions of them. Experience has shown that these are not apt to pro- 
duce disease, in any degree of concentration in which they are at all tolerable 
to the -sense of smell. Hence, butchers, skin dressers, glue manufacturers, 
&c., who are much exposed to these offensive effluvia, are not peculiarly liable 
to disease. 
There are certain aerial depravations, the. nature of which is not exactly 
known, but which, from their great importance as causes of disease, require a 
distinct notice. Such are the emanations usually denominated miasmata, or 
malaria, and those distemperatures of the atmosphere which occasion epi- 
demics. These I shall proceed to consider. 
Miasmata.-Malaria.-Marsh-miasmata. 
It has been observed that, in certain regions of country where abundant 
vegetable decomposition accompanies an occasional overflow of the soil, and 
at the season when this decomposition is most rife, a certain class of diseases 
is apt to prevail, entirely distinct from those which arise from irregularities, 
or changes in the sensible qualities of the atmosphere. This result has been 
usually ascribed to aeriform exhalations, which have received the name of 140 
GENERAL PATHOLOGY. 
[PART I. 
marsh miasmata, or malaria, the former intended to express their origin and 
nature, the latter simply the fact that they render the air unwholesome-. It 
was proposed by the late Dr. Edward Miller, of New York, to distinguish 
these effluvia from such as have their source in personal uncleanliness, by 
giving to the former the title of koino-miasmata, and to the latter that of 
idio-miasmata, the first implying a common or general, the second a private 
or peculiar origin. This nomenclature has been adopted by some practical 
writers; but there is no such relation between the two morbid causes as to 
render their association in one category desirable; and, in this work, the term 
miasmata is restricted exclusively to the paludal exhalations, while those from 
the person are noticed simply as one of the forms of atmospheric impurity. 
(See Animal effluvia, page 138.) 
The circumstances which appear to be essential to the production of mias- 
mata are heat, moisture, and vegetable decomposition. The peculiar morbid 
effects ascribed to this cause, and by which alone its existence can be recog- 
nized, seldom originate at a temperature under 60° F., even though vegetable 
decomposition may be going on. ■ At 80° they are often very prevalent, and 
are generally checked by the occurrence of frost. A certain continuance of 
the heat is not less necessary than a certain degree of it. Hence, miasmatic 
diseases scarcely ever prevail beyond the 56th degree of latitude; because, 
though many days in summer may be very hot, the warm season is short. 
The nearer we approach to the equator, the more violent, as a general rule, 
do they become) implying a greater intensity of the cause. Within the 
latitudes where there is a regular change of the seasons, they do not com- 
monly make their appearance until the middle, and often not till the close of 
summer. 
Moisture is necessary to the evolution of miasmata, but much of it often 
serves as a preventive. During heavy rains, for example, their morbid 
effects are less felt than after the rains have ceased, and the water has run off 
from the surface of the country, or been partially evaporated. In tropical 
latitudes, it is after the cessation of the rains, that the ravages of the mala- 
rious fevers commence; Surfaces, deeply covered with water, evolve less of 
the noxious effluvia than those which are but partially covered. It has been 
observed that, in very wet seasons, the lower grounds,< usually most unhealthy, 
are least affected; while the higher, which are ordinarily exempt from disease, 
become sickly. 
Vegetable decomposition has been mentioned among the requisites. That 
it is so, is inferred from numerous circumstances attendant upon the develope- 
ment of the morbific influence. In no situations is this so powerful as in the 
deltas, and along the banks of large tropical streams, which, in their period of 
flood, bring down the washings of the soil, loaded with vegetable remains, 
and, upon subsiding, leave them reeking in the hot sun. It is also peculiarly 
destructive, when grounds covered with a luxuriant vegetation are overflowed, 
so as to destroy the plants, and occasion their putrefaction. Hence, mias- 
matic diseases are apt to follow the submerging of meadows in order to in- 
crease their fertility, the forming of mill-ponds, and the damming of streams 
for the purposes of navigation. Neighbourhoods, before remarkably exempt 
from disease, have thus become very unhealthy, and have not ceased to be so 
until the vegetable matter, thus deprived of its life, has undergone complete 
decomposition. The draining of lakes, ponds, &c., is often followed by dis- 
ease; because the organic matters, previously lying quiescent in their beds, 
are brought into a renewed movement of chemical re-action by exposure to 
the sun's heat. Hence, too, the increase of disease which often follows the 
commencement of cultivation, in a newly settled country, in consequence of CHAP. II.] 
CAUSES OF DISEASE.-MIASMATA. 
141 
the turning up of the soil, loaded with vegetable remains. The digging of 
canals has often been noticed to produce similar effects, and probably from the 
same cause. The prevalence of miasmatic fevers in the latter part of sum- 
mer, and in autumn, may be ascribed, in part, to the circumstance, that vege- 
table life has, now very frequently run its course, and plants are consequently 
exposed to decay. A long continuance of dry weather, followed by warm 
rains, favours the evolution of miasmata, probably because the plants, which 
perish in the drought, suffer speedy decomposition under the conjoined influ- 
ence of the heat and moisture. 
It is a happy circumstance, that, though the first steps of civilization in a 
wild malarious region, often rather increase the production of the poisonous 
agent, yet, with the progress of cultivation, the country becomes more healthy 
even than it was originally, in consequence partly of draining and embank- 
ments, and partly, perhaps, of the productive growth to which the vegetable 
decay is made tributary.- The rotting of hemp in still water, and the spon- 
taneous decomposition of the indigo plant, in the preparation of that dye-stuff, 
are asserted to give rise to miasmatic fevers. 
One of the most interesting circumstances in relation to miasmata is their 
apparent affinity for moisture. Water appears to have the property of dis- 
solving- and retaining them, whether in a -proper liquid state, or in that semi- 
liquid form in which it constitutes fogs and mists. Numerous facts may be 
explained upon this principle. It is probably owing to this cause, that heavy 
and continued rains lessen the miasmatic influence. They wash the atmo- 
sphere clean of the noxious effluvia.- Hence, too, the protective influence of 
floods and of deep water, which dissolve the miasm as it is generated, and 
prevent its escape by retaining it in solution. The greatest danger is after 
the waters have so far subsided, or been so far evaporated, as to be unable 
longer to dissolve the proceeds of the vegetable putrefaction. It is said that, 
in tropical latitudes, the commencement of the rains is rather promotive of 
disease, partly, perhaps, by bringing down the miasmata from the upper air, 
partly by promoting the decomposition of the dead plants upon the surface of 
the earth. Upon the principle of this affinity, may also be explained the in- 
fluence of running water in obviating the effects of marsh effluvia. Salt 
marshes are thought to be less unwholesome than fresh; and some suppose 
that a meeting of salt and fresh water is peculiarly injurious. But it is un- 
necessary to adduce any especial influence of the salt in these instances. If 
salt marshes are less malarious than fresh, it is probably owing to the action 
of the tides, by means of which, in the former, the results of the vegetable 
decomposition are carried off by the flood; while the waters, in the latter, 
being more frequently stagnant, become saturated with the poison, and per- 
mit it to arise with the exhalation from their surface. At the points where 
the salt and fresh waters meet, there is often more stagnation than either 
above or below, because the flux and reflux of the tides are less than in the 
latter position, and the steady downward current of the former is wanting. 
Persons on board of ships, and those on the sides of lakes opposite to the 
source of the exhalation, are much less exposed to disease than those at an 
equal distance by land, because the intervening water dissolves the miasmata 
in their passage. 
It is probably owing to the affinity between miasmata and moisture, rather 
than, as some have supposed, to any superior specific gravity of these effluvia 
over the air, that the greatest danger generally exists near the surface of the 
earth. Thus, it has been observed that persons in low grounds are more 
exposed to sickness than those who live in elevated positions; and instances 
have been recorded, in which lodgers upon the lower floor of a house have 142 
GENERAL PATHOLOGY. 
[part I. 
been attacked, while those upon the upper have escaped. Fogs, in which 
the poisonous exhalation is probably dissolved, are well known to affect espe- 
cially the surface of streams, and the low lands in their neighbourhood; and 
very often their upper limits are but a few feet above the soil. 
For the same reason, the morning and evening air is peculiarly injurious; 
so much so that persons who go out of their houses only during the day, 
after the fogs have dispersed in the morning, and before the dews descend in 
the evening, are apt to escape altogether. I was formerly the attending phy- 
sician of a public institution, containing more than a hundred inmates, among 
whom, during the sickly seasons to which our vicinity was subject, autumnal 
fever was very prevalent, until the direction was given, and carried into 
effect, not to allow any one to go out before breakfast, or after tea. The 
miasmatic effluvium appears to rise- by the heat of the sun, and to be so dis- 
persed as to become innoxious, but to acquire a dangerous concentration by 
its union with the moisture, which forms the morning and evening dews. 
Exposure, in the middle of the night, is equally dangerous, and especially 
during sleep, when the power of resisting noxious agents is diminished. 
Hence the peculiar danger of sleeping in tents, in sickly regions. The sea- 
son at which miasmatic fevers commence, is generally that at which the 
greater coolness of the evening causes the formation of dews. I have been 
informed by a person conversant with the miasmatic districts of our country, 
that, in the vicinity of rapids, there is much more danger than along the 
banks of the streams where they flow calmly. If this be a fact, it admits of 
the ready explanation, that the water, loaded with the miasmata in solution, 
does no harm while confined within the banks, but becomes highly noxious, 
when driven up, in foam and spray, into the atmosphere, so as to be inhaled 
by the neighbouring residents. 
Another important fact is the influence of winds upon miasmatic exhala- 
tions. By reference to this, we are enabled to explain many apparent 
anomalies. It Occasionally happens that a low district, where the miasmata 
are extricated, is less unwholesome than a neighbouring elevation, towards 
which a prevalent wind blows over the source of production; and, from the 
same cause, one side of a mountain may be very sickly, while the opposite 
side is remarkably healthy. The bank of a stream, in the direction of the 
ordinary winds, is sometimes more sickly than the opposite bank, though the 
latter may be nearer the spot where the cause originates. Violent storms 
sometimes prove useful, by dispersing miasmata which may have accumulated 
in consequence of previous stagnation of the atmosphere. Winds appear to 
be capable of carrying miasmata, either enveloped in clouds and fogs or other- 
wise, a very considerable distance; according to McCullough, even so far as 
five or six miles. In this way, we may sometimes account for the occurrence 
of disease in spots, which seem to offer none of the circumstances, ordinarily 
considered essential to the production of malaria. Various impediments seem 
capable of turning off the deleterious current. Thus, hills or mountains pro- 
tect the regions beyond them, partly in this way, partly, perhaps, by their 
affinity for fogs and mists. A thick wood will occasionally divert the course 
of a miasmatic wind; and thus afford protection toadwelling or even a whole 
neighbourhood. The late Dr. Joseph Parrish, of Philadelphia, used to speak, 
in his practical lectures, of a case that fell under his observation, in which 
a family, previously in good health, was attacked with a violent and fatal 
fever, apparently in consequence of having cut an avenue, for- the sake of a 
more extensive view, through a wood which intervened between them and a 
large tract of marsh. Occasionally, a region of country is so formed, that a 
low marshy expanse terminates in a comparatively narrow passage through CHAP. II.] 
CAUSES OF DISEASE.-MIASMATA. 
143 
high grounds, serving as a sort of funnel, in which the miasmata arc concen- 
trated by prevalent winds. In such instances, the sides of the passage 
referred to are apt to be very- sickly. It is obvious that a low miasmatic 
source, surrounded on all sides by high grounds, must be exceedingly dan- 
gerous, from the necessary accumulation and concentration of the poison. 
There is reason to believe, that the miasm which produces such deleterious 
effects upon the animal system, is capable of contributing to the nourishment 
of vegetables. This, perhaps, is one of the reasons why bilious fevers prevail 
especially in autumn. The vegetation of spring and early summer is vigorous, 
and adequate to the consumption of all the products of the organic decompo- 
sition that may be going on in the soil. Among other products, the mias- 
matic exhalations may also be consumed. But, towards the close of the 
season, when many plants have run their course, and begun to decline, they 
cease to appropriate this as well as other food, which is therefore exhaled, if 
it do not remain in the soil. Thus, forests also may, in temperate latitudes, 
contribute to health. Besides protecting the soil from the rays of the sun, 
and thus moderating the temperature, they may consume miasmatic exhala- 
tions, either by absorbing them through their leaves, or by taking up by their 
roots the rain water which may become impregnated with them as it falls. 
Hence, the clearing away of woods is often followed, for a1 short time, by the 
prevalence of miasmatic disease.. In hot climates, however, where the tem- 
perature, even in the shade, is abundantly sufficient for the copious develope- 
ment of these effluvia, forests are thought to do harm by the material they 
supply for decomposition, the dampness which they promote, and the impedi- 
ment they offer to the diffusion of the poison, far more than they can do good 
by their consuming power. The green coating of fungous vegetation, which 
often covers the surface of shallow and stagnant ponds and ditches, in hot 
weather, serves probably as a preventive of disease, by appropriating as food 
the miasmata developed in the soil beneath. It is, therefore, never advisable 
to remove this scum; and it is not impossible that a violent rain may some- 
times do harm by breaking it up. Dr. Cartwright, of Natchez, ascribes 
extraordinary anti-miasmatic properties to, the Jussieua grandiflora, an aquatic 
plant growing abundantly in the stagnant waters of the southern section of 
Louisiana. He founds his belief on the facts, that the waters which it fre- 
quents are perfectly sweet and pure, while those similarly circumstanced, in 
other respects, are foul, and that the whole region of country inhabited by it 
is remarkably exempt from miasmatic diseases, though marked by all the 
characters which are found elsewhere to be most conducive to those affections. 
The plant derives its sustenance, not from the soil, but from the water, and 
thus consumes alhthe soluble products of vegetable decomposition as fast as 
they are formed. ( Western Journ. of Med. and Surg., i. 428.) 
Diseases, usually the result of miasmata, sometimes occur epidemically, 
with all the characters of the cases that are obviously of local origin. Whe- 
ther, in such instances, the cause may be the same as that of the identical 
endemic affections, it is impossible to determine; for the circumstances in 
relation to temperature, atmospheric moisture, and the character of vegetation, 
in the different seasons during which the epidemic has prevailed, have been 
so variable, that no tolerably certain inference can be deduced from them. 
From the fact, however, that the diseases usually appear at the same season, 
as well as from their identity of nature, there seems to be good reason for 
ascribing them to the same malarious influence. But the peculiar condition 
of things which causes the developement of this influence, over wide regions 
where it had been before little known, remains quite concealed. 
There is another extraordinary, and very important fact, in relation to 144 
GENERAL PATHOLOGY. 
[part I. 
miasmata, which must not be overlooked. These effluvia are neutralized, 
decomposed, or in some other way rendered innoxious, by the air of large 
cities. Though malarious diseases may rage around a city, and even invade 
the outskirts where the dwellings are comparatively few, yet they are unable 
to penetrate into the interior; and individuals who never leave the thickly 
built parts almost always escape. This fact is notorious in relation to the 
city of Rome; and we have seen it abundantly confirmed in the larger towns 
of the United States, in the neighbourhood of which these diseases have pre- 
vailed. What it is in the air of the city which is thus incompatible with 
malaria is unknown; but very probably it is connected with the results of 
combustion; for the fire and smoke of camps are asserted to have had the 
same effect; and I have been assured by persons inhabiting miasmatic dis- 
tricts of country, that they have been able to protect themselves against the 
poisonous effects, by maintaining fires in their houses during the sickly 
season. 
Of the precise nature of miasmata nothihg certain is known. Even their 
existence has been denied by 'some. In support of this negative opinion, it 
is averred, that the diseases usually considered as miasmatic have often oc- 
curred where there were no evidences whatever of vegetable decomposition, 
as, for example, in argillaceous and dry sandy soils, in mountainous districts, 
in islands almost destitute of vegetation, &c. For what can be said upon 
this point, the reader is referred to an elaborate paper by Dr. John Bell, in 
the Philadelphia Journal of the Medical and Physical Sciences (xi. 274), 
and to another by Dr. William Ferguson, on the nature and history of the 
marsh poison, in the Edinburgh Philosophical Transactions. But the facts 
adduced, in denial of vegetable decomposition, cannot in their nature be posi- 
tive; for, even though none may be visible to the observer, yet chemical 
examinatien would be requisite to prove the absence of organic matter in the 
soils; and then the fact, that the .effluvia may be conveyed by winds for miles, 
would render it necessary, in order to establish the negative proposition, not 
only that no organic matter should exist in the neighbouring soil, but that no 
source of * miasmatic exhalation should exist for many miles around. It is 
well known, that most soils, even when to the eye they show no trace of 
vegetable matter, yet abound in seeds of various plants, often even at great 
depths; and peculiar circumstances may lead to their decomposition, and the 
consequent exhalation of volatile products, though no such result may be 
obvious. Indeed, the microscope has laid open an otherwise invisible organic 
world, in which'all the changes with which we are familiar in the visible may 
take place, beyond the cognizance of the senses, and lead to aerial contamina- 
tion inconsistent with health. In the few instances, therefore, in which mias- 
matic fevers have prevailed, without an obvious possible source in vegetable 
putrefaction, we may well infer, that such a source nevertheless has existed; 
because, in the great majority of instances, these diseases can be traced clearly 
to that cause. So strong, indeed, is the evidence of this fact, that the great 
mass of observers, ever since the time of Lancisi, have agreed, and still agree, 
in ascribing the miasmatic influence, whatever may be its nature, to organic, 
and especially vegetable decomposition. The reader, however, will please 
to notice that I do not place yellow fever among the proper miasmatic dis- 
eases. But, even admitting that fevers apparently identical with those called 
miasmatic, have, in certain cases, originated without vegetable decomposition, 
it does not follow that they are not in general dependent upon that cause. 
Supposing it to be granted, that miasmatic influence is the result of some 
chemical change in vegetable products, we are still far from the solution of 
the question in regard to its nature. It has generally been considered as de- CHAP. II.] 
CAUSES OF DISEASE.-MIASMATA. 
145 
pendent on'gaseous exhalation; but chemists have never succeeded in satisfac- 
torily demonstrating the existence- of any noxious gas in miasmatic air, to 
which its effects could be ascribed. Carburetted hydrogen is a well known 
product of marshes; but it is equally well known to be wholly incompetent to 
the production of miasmatic fever. Otherwise, this disease would be most 
prevalent in mines, where the gas is most abundant. Professor Daniel de- 
tected, in 1841, sulphuretted hydrogen in the water of several African rivers, 
notorious as the sources of miasmatic effluvia; and it was inferred that this 
gas might be the poisonous ingredient in the mephitic air of marshes. But 
the known effects of sulphuretted hydrogen (hydrosulphuric acid) upon the 
system are wholly unlike those of marsh miasmata; and were it the cause 
of bilious fever, that disease ought to be most rife in cities, where the gas in 
question is most copiously generated. M. Boussingault detected organic 
matter in the air of marshes, by the agency of sulphuric acid. (Arch. Gen., 
2e. Ser., v. 641.) The fact, so far as it goes, gives support to the theory, 
which ascribes the poisonous influence of this air either to animalcules, or to 
microscopic fungi, which are supposed to find, in vegetable putrefaction, cir- 
cumstances favourable to their generation from pre-existent germs, and, by 
entering into our systems, and there propagating, to produce the diseases 
ascribed to miasmata. Plausible arguments may be adduced in favour of 
this hypothesis; but it is yet only hypothesis, find can never be established 
until the existence of such organic beings shall be demonstrated, and experi- 
ment shall have proved that they are- capable of affecting the system in this 
particular manner. By Sir James Murray it is maintained, that the true 
malarious agents are "electro-galvanic currents and accumulations," which 
produce disease by disturbing the electrical equilibrium in the body. (Dub- 
lin Med. Press, Nov. 27, 1844.) But the simple consideration, that such a 
disturbance is constantly produced,- under other circumstances, without giving 
origin to disease of the miasmatic character, is a sufficient refutation of that 
hypothesis. At present, we must be content with knowing the malarious 
influence only by its effects. I have spoken of it as the result of exhalations, 
effluvia, &c.; but I do not wish to be understood as necessarily expressing, 
by these terms, gaseous or aeriform bodies. I merely mean by them an 
emanation, of whatever character it may be, whether gaseous or impondera- 
ble, organic or inorganic, simple or complex, which proceeds, under certain 
circumstances, apparently from vegetable decomposition, and exercises a most 
powerful and most noxious influence over the well-being of our race. That 
this influence is not dependent on any state or combination of any known 
agents, such as heat, cold, moisture, dryness, electricity, &c., is evinced by 
the fact, that, so far as these agents are concerned, combinations altogether 
similar to those observed in malarious cases, frequently occur without similar 
effects. 
In what manner miasmata operate in producing disease cannot be known 
until we know their nature. The probability is, that they enter the circula- 
tion by means of absorption, find that the chief avenue through which they 
enter is the air-cells of the lungs. It is not impossible, that they may also 
be absorbed through the skin, and even through the mucous coat of the sto- 
mach, which they nlay enter with the saliva. A full meal, and the stimulant 
influence of ardent spirit, are supposed to afford some protection against them. 
Absorption is probably impeded by these means, and, thus far, they may act 
as preventives of the malarious influence; but just in proportion to the pro- 
tection which ardent spirit or other stimulant may yield, during the period 
of excitement, will be the greater liability to attack, when excitement shall 
be succeeded by depression. 146 
GENERAL PATHOLOGY. 
'[part I. 
The most striking and, characteristic morbid effects of miasmata, are inter- 
mittent and remittent bilious fevers; but they are believed also to be capable 
of producing diarrhoea, cholera, colic, dysentery, various hepatic and gastric 
derangements, and neuralgia. Inhabitants of miasmatic districts are apt, 
even when labouring under no well-marked and definite complaint, to exhibit 
signs of feeble health, in their spare habit of body, sallowness of complexion, 
uncertain appetite, and irregular bowels; and persons are not unfrequently 
found with enlarged spleen or liver, swollen abdomen, and even dropsical 
symptoms; but how far these are the direct effects of the miasmata, and how 
far of the febrile disqases, which are the acknowledged results of this ntorbid 
agent, it would not always be possible-to determine. Writers assert that the 
race is liable to degenerate, under their long continued influence, becoming 
smaller and weaker in their bodies, and less -vigorous in their intellect. 
^McCuliloch.') Even the inferior animals are said to be affected by them; 
and horses and cattle, transferred to miasmatic from healthy regions, are apt 
to sicken and die. The system, however, becomes habituated to them in 
time; and individuals who have survived until the middle period of life is 
passed, often live to an extreme old age. It is even asserted that the influ- 
ence becomes at length essential to health; and that old persons who have 
passed their life in miasmatic districts, are apt to sicken upon removal. The 
inhabitants of such districts are much less liable to malarious disease^ than 
strangers, who are almost always attacked in the sickly season. But, if life 
is spared for a few years, the susceptibility to the poisonous influence dimin- 
ishes, and the individual is said to have become acclimated. 
Epidemic Influence. 
Occasionally, diseases prevail temporarily throughout a more or less exten- 
sive range of country, strikingly different either in their character, or in their 
modes of approach, progress, and disappearance, from the ordinary complaints 
of the regions in which they occur. To these diseases the name of epidemic 
■is applied, expressive by its etymology, of the idea, that they come upon the 
community (snc upon, and people) from some extraneous source; while 
the ordinary complaints are called endemic (w in or among, and be- 
cause dependent on causes originating among the inhabitants, or within the 
country itself. The distinction is not very precise; and, frequently, it might 
be difficult to determine in which of the two classes any particular prevalent 
disease should be ranked. 
It is obvious that an epidemic, as above defined, may proceed from any 
cause of disease operating extensively, or with unusual violence, upon a whole 
community; as, for example, from extreme vicissitudes of weather, from the 
long continued prevalence of cold damp winds^ or of heat with moisture, and 
from miasmatic exhalations when unusually abundant, or carried in unusual 
directions by steady currents of air. In like manner, the term is often ex- 
tended to those widely prevalent diseases, which add their scourge to the 
evils of famine or national misfortune, and arise from the combined influ- 
ence of insufficient and unwholesome food, depressing emotions, and the nox- 
ious exhalations of crowded dwellings. 
In all these cases, the source of the disease is obvious, or may be traced 
with care. But, frequently, diseases of unusual character become prevalent, 
or those before familiar assume a new aspect, or rage with unwonted violence, 
without any discoverable cause. These are " the pestilence that walketh in 
darkness," and " the destruction that wasteth at noon-day." They have been 
observed as early as the earliest records of medicine; and were naturally attri- 
buted by the multitude to the anger of their deities. The more cultivated CHAP. II.] 
CAUSES OF DISEASE.-EPIDEMIC INFLUENCE. 
147 
have vainly attempted to trace their cause. Thus, they have been ascribed to 
some mysterious influence of the heavenly bodies, especially of the comets; to 
earthquakes and volcanoes emitting noxious matters into the air; to an altered 
electrical condition of the atmosphere; and to the rapid propagation and mi- 
gration of atmospheric animalcules. It is scarcely necessary to say, that each 
of these hypotheses is wholly destitute of proof; Perhaps the most plausible 
is the animalculat theory, which supposes that these, invisible beings, either 
in the state of germs or fully organized, penetrate into the system, and disturb 
by their presence the vital processes. There is a. strong analogy between the 
movements of certain epidemics, and those which might be supposed to be the 
result of animal impulses and caprices, in migrating swarms of insects; fbr 
example, at one time, directly onwards with a slow regular march, at another, 
halting, as if for rest; now in a compact body, with a broad sweeping front, 
then, again, in detachments diverging from the main line; sometimes leaving 
no blade of life unvisited, and again passing over large tracts untouched, and 
settling down devouringly on some distant and isolated spot; This theory 
also enables us to explain certain anomalies in the propagation of epidemic 
diseases, which have often embarrassed pathologists; how, for instance, with 
strong evidence of their non-contagious nature, they should sometimes appear 
to be spread by the movements of men, individually or in bodies, from affected 
neighbourhoods to others before untouched. The living germs, carried in 
clothing or merchandize, may find a congenial atmosphere in the new locality, 
and, propagating with the rapidity characteristic of insect life, may soon infect 
the whole vicinity. Other analogies are offered in the receding of the visita- 
tion, often as rapid as its approach, the occasional lingering of deserted frag- 
ments of the moving host ifi isolated neighbourhoods, and the subsequent 
temporary and relatively feeble revival of the pestilence, sometimes obseiwed, 
as though organic germs had been left behind to struggle into a short course 
of activity and propagation, under unfavourable circumstances. They who de- 
sire to prosecute this inquiry, may advantageously consult the a Medical Notes 
and Reflections" of Dr. Holland, who has fully considered, and seems disposed 
to adopt the animalcular theory. Like the other explanations, however, of 
the cause of epidemics, it must be looked upon, in the present state of Our 
knowledge, as purely hypothetical. It is highly probable, that there are un- 
known influences, atmospheric, terrestrial, or both, which are as essential to the 
sound state of our vital functions as those which are known, and the perversion 
of which must consequently occasion disease. Such may possibly be the 
origin of epidemics. But it is vain to speculate upon the subject. All that 
we can say, with certainty, is, that there must be some distempered condition 
of the circumstances around us, some secret power that is operating injuriously 
upon our system; and to this we give the name of epidemic influence. But, 
though we know nothing of the origin, or essential nature of this influence, 
we can observe and study its effects, and thus deduce the laws which appear 
to regulate its operations. The following are some of the laws alluded to. 
It would not be amiss to consider as epidemics only the diseases which origins 
ate in, or are affected by, the influence alluded to; and the observations 
which follow may be received with this limitation. 
1. This influence frequently gives rise to diseases, quite independently of 
any other known cause, as in the case of the influenza, of bholera, and of the 
typhous epidemic of 1812-13, &c. But it still more frequently exhibits itself 
in giving increased energy to other causes, enabling them to produce particu- 
lar diseases, under circumstances differing from those in which they are ordi- 
narily produced, and to an extent not attainable without its aid. Thus, 
small-pox, scarlatina, and other contagious eruptive affections, sometimes 148 
GENERAL PATHOLOGY. 
[PART I. 
become epidemic. Whether the. epidemic influence is alone sufficient to pro- 
duce them, without the co-operation of the specific contagion, is perhaps 
questionable. It is highly probable that it may be so; as these diseases 
occasionally occur epidemically, without any known communication between 
the individuals first attacked, and others previously affected. This being 
admitted; still, the epidemic influence is chiefly felt in giving to the system 
a stronger predisposition to the disease than exists under other circumstances; 
so that, -though persons may generally escape by carefully avoiding the spe- 
cific cause, yet many are now attacked who may have been frequently exposed 
to the contagion on former occasions without effect'; and the complaint often 
assumes a more violent character than belongs to it in ordinary years. Some- 
times, the epidemic influence predisposes to some one especially of the exan- 
themata, as to small-pox on one occasion, measles on another, &c.; sometimes, 
the-tendency seems to be towards eruptive diseases in general, so that all the 
exanthemata are more rife than usual, and occasionally new and anomalous 
forms of eruption appear. 
The same remarks are true of typhus fever. Sometimes true typhoid epi- 
demics occur without any known cause. On other occasions, the epidemic 
influence co-operates with the ordinary causes of the complaint, giving it a 
wider extension and greater malignity. It now occurs in confined and crowded 
places, which had before escaped. Thus, too, the typhus resulting from a 
general famine, and the depressing influence of national calamity, may become 
aggravated'by an epidemic influence, and be converted into a terrible pesti- 
lence. It has been thought that the same cause which predisposes to this 
form of disease, may also affect the crops unfavourably, so as to occasion 
famine ;• and the coincidence of famine and pestilence is thus further accounted 
for; but our information upon the subject is too vague to justify a positive 
opinion. 
Miasmatic diseases may, in the same way, become truly epidemic; not 
that they directly result from this concealed influence; but that the predispo- 
sition to them is greatly increased by some unknown cause; so that an amount 
of miasmatic exhalation, more or less of which is probably always floating in 
the air in warm weather, may now produce its peculiar effects, which, in ordi- 
nary seasons, would be wholly unfelt. Hence, probably, the late prevalence 
of intermittent and remittent fevers, during the summer and autumn, in por- 
tions of the Middle and Eastern States, in which these diseases were formerly 
almost unknown ; while the circumstances of these regions, in relation to the 
production of miasmata, remained, so far as could be discovered, the same as 
in preceding years. 
2. Sometimes the epidemic influence is felt, rather in giving a certain 
type or direction to existing diseases, than in rendering any one disease espe- 
cially prevalent. Thus, at one period, a low or typhoid tendency is given to 
most diseases, so that they will not bear depletion; at another, an inflam- 
matory character is impressed on them, requiring the lancet. Thus also, a 
particular direction may be given to particular organs; for example, in one 
season to the head, in another to the chest, and in a third to the alimentary 
canal. Hence the important practical inference, that the physician should 
not allow himself to become wedded to any one plan of treatment, in diseases 
apparently identical; because, under varying circumstances, they may put on 
characters demanding very different and even opposite modes of manage- 
ment. 
3. One of the established laws of epidemics is, that they give more or less 
of their own character to all other diseases. Thus, when cholera prevails, 
looseness of the bowels is very apt to be superadded to other affections; when CHAP. II.] 
CAUSES OF DISEASE.-EPIDEMIC INFLUENCE. 
149 
influenza, all other complaints become complicated with catarrhal disease. 
Under such circumstances, the accidental or endemic diseases are said to wear 
the livery of the epidemic. The result is nothing more than might have 
been anticipated. The morbid cause is universal, and operates more or less 
upon all. Many, however, while in perfect health, are able to resist it, and 
exhibit no morbid phenomena. But, if attacked with disease from some other 
cause, they lose, in some degree, this power of resistance, and yield to the 
epidemic influence, which, without superseding the existing affection, modi- 
fies it by superadding its own peculiar effects. 
4. The epidemic influence is sometimes confined within a narrow space, 
sometimes affects extensive regions, and sometimes encircles the globe. When 
if pervades a large portion of the earth, it is never present everywhere at the 
same time, but attacks different parts successively; in some instances ad- 
vancing regularly, and sweeping all before it, in others, irregular and dis- 
cursive in its progress, and leaving' many places untouched; occasionally 
rapid almost as the wind; and then again exceedingly slow, creeping, as it 
were, from one point to another, and occupying years in spreading over one 
extensive district. Opposing currents of wind do not obstruct its course; 
and this fact has been advanced as one of those favourable to the animalcular 
theory. ' . 
5. It often gives Warning of its approach, by some change in the character 
of prevailing diseases, by the occurrence here and there of a case analogous 
to the epidemic disease, or by a general tendency to slight affections of a 
similar character. Thus, the breaking out of cholera was often preceded by 
a general tendency to moderate diarrhoea. 
6. But the first effects of the cause, when in full action, are usually the 
most violent. At least, the cases which first occur, though comparatively 
few, are more malignant and of greater proportionate fatality than those 
which appeal* subsequently. This, perhaps, may be owing to the greater 
susceptibility of those first attacked. The most susceptible are of course the 
first to feel the morbific influence, and might be expected to suffer most from 
it. The proportion of fatal cases diminishes with the increased prevalence of 
the disease; until at length, before its disappearance, it becomes disarmed 
of much of its malignancy, and is often converted into a comparatively mild 
affection. 
7. The epidemic influence sometimes disappears entirely, after a short 
prevalence, sometimes'continues, with irregular intermissions,- for two, three, 
four, or even six years, and occasionally even longer. Thus, the influenza 
often vanishes entirely after a continuance of some weeks; but, in some in- 
stanCes, returns again when it appeared to have been about to take its final 
leave, and rages.with all its original violence. Cholera often visited the same 
place a second time, in the next or some subsequent year; and in India, after 
its epidemic prevalence, appeared to take up a fixed residence, and almost to 
become endemic. The miasmatic epidemic which made its appearance in the 
year 1820, in the neighbourhood of Philadelphia, and recurred annually for 
many years, left traces behind it which are yet visible. 
8. It has been a subject of frequent observation, that a certain epidemic 
tendency, after continuing for several years, will be followed by another of a 
different kind, which in its turn will give way to the former tendency, or to 
a third different from either; a short period of unusual exemption from dis- 
ease intervening, in each instance. Thus, from the year 1793 to 1807, there 
was a tendency to severe bilious or miasmatic diseases in this vicinity;.the 
yellow fever prevailing occasionally in Philadelphia, and bilious fever in the 
country. An interval of comparative health followed. In the winter of 150 
GENERAL PATHOLOGY. 
[part I. 
1812-13, the typhous epidemic made its appearance, and its influence upon 
the character of diseases continued to be felt as late as 1818 or 1819. In 
the summer of 1820, the typhous tendency was superseded by the miasmatic, 
and the occurrence of yellow fever in the city, and bilious intermittent and 
remittent in the country, marked the change. Though the yellow fever 
scarcely recurred after that season, yet the miasmatic fevers of the country 
continued to prevail for many years; and it was not until 1836, that typhus 
fever again prevailed among us, and then only to a very moderate extent. 
After that period, we may perhaps be considered as having enjoyed an interval 
of comparative exemption; until the summer and autumn of 1846, which, 
with the subsequent seasons, have been again sickly with the different forms 
of miasmatic fever. These remarks have reference only to the two epidemic 
constitutions especially alluded to. Epidemic tendencies to eruptive affections 
seem to run in somewhat similar, though not coincident cycles. Thus, after 
the introduction of vaccination, the small-pox seemed for many years to be 
almost entirely subdued, because no epidemic influence was superadded to 
that of contagion. We are now, and have been for more than twenty years, 
in the midst of an epidemic variolous cycle; and the disease lias seldom been 
entirely absent from among us. From the experience of the past, we may 
look forward with confidence to a period of renewed exemption,- when vacci- 
nation will again assert its complete supremacy, without the necessity, as at 
present, of a repetition of the, process. 
9. The lower animals appear to be affected by epidemic influences, and 
seasons of unusual fatality among them have coincided with those in which 
the human race have suffered; but how far the effects'are the same as upon 
man has not yet been accurately determined. 
Contagion. 
By this term, as expressive of a morbific cause, is meant any product of a 
peculiar disease, which is capable of producing the same disease in another 
person, and of thus propagating itself, and the complaint of which it is at 
once the cause and the effect, through any number of unprotected individuals. 
The disease thus propagated is said to be contagious. The terms infection 
and 'infectious are generally used in a similar sense, though perhaps with this 
difference, that these designations are limited most frequently to the castes in 
which the morbid impression may be received through the atmosphere; while 
contagion and contagious are applied indiscriminately to these, and to cases 
of propagation by contact. Thus, we speak of the infection of typhus feyer 
or Small-pox, and call these infectious diseases; but do not commonly apply 
the same terms to syphilis or the itch. All these diseases, however, are con- 
tagious, and their cause contagion. It is true, that some authors employ 
infection in a different sense. Thus, Chomel confines it to the action of the 
morbific exhalation which arises from the person, when numbers, either in 
health or sickness, are crowded together; and the resulting diseases he calls 
infectious. In this confusion of meaning, it is best to abandon these terms 
altogether, especially as we can express all that is esseiltial without them. 
The participle infected, however, may be used, in a general sense, to imply the 
condition of being tainted, or injuriously affected with certain qualities; as 
we say that the atmosphere is infected when it is loaded with the cause of 
disease, and that a locality, or district, is infected, in which such an atmo- 
sphere prevails. 
Contagion is usually the product of secretion or exhalation, and may be 
either in the Solid, liquid, or aeriform state. In the first two conditions, it 
acts either by simple contact, as in syphilis and gonorrhoea, or by application chap, ii.] 
CAUSES OF DISEASE.-CONTAGION. 
151 
to a wound or abraded surface, as in hydrophobia and vaccination. In the 
aerial- state, it acts through the medium of- the atmosphere, probably for the 
most part by inhalation into the lungs. In all its forms, it undoubtedly ope- 
rates through absorption, so far as constitutional effects are concerned. In 
certain instances, however, it appears to be confined to the surface affected, 
without contaminating the system. Such is the case in porrigo and .scabies. 
Some diseases are contagious exclusively by means of contact or insertion, as 
syphilis, hydrophobia, and the^vaccine disease; others possibly through the 
air alone, as hooping-cough, scarlatina, and typhus; and others again in both 
modes, as small-pox, chicken-pox, and, as some assert, measles. Indeed, it 
is by no means certain, that all the febrile contagious diseases 'might not be 
propagated by inoculation, were we acquainted with the proper matter to 
apply in each case.' , 
The contagious matter may be the product of local action in the diseased 
individual, as in syphilis, scabies, and porrigo, or may be connected with a 
general contamination of the system, and exhaled from all the free surfaces 
of the bpdy, as in small-pox, scarlatina, measles, and typhus. It has no 
sensible properties by which its poisonous character might be indicated, nor 
does it yield any evidence of its nature to chemical investigation. In some 
diseases, as in small-pox and typhus fever, it is often attended with a dis- 
agreeable odour; but it is by no means certain that it is. the matter of conta- 
gion itself that smells. In other instances, it is without odour, as in measles 
and hooping-cough. 
There is a great difference in the contagious power of the different exhala- 
tions. In some, it is feeble, and attacks few comparatively of those exposed 
to it, as in scarlatina; in others, very active, allowing few that are. unpro- 
tected to escape, as in small-pox. Contagion does not usually act at a great dis- 
tance from its source, though there is considerable difference also in this respect. 
Thus, typhous contagion seldom extends beyond a few feet in well ventilated 
apartments; while the variolous -will not unfrequently spread through all 
parts of a house from a single bed, and even from one house to another in 
the near vicinity. 
The effluvia are capable, in some instances, of attaching themselves to cloth- 
ing, merchandize, &c., and may thus be conveyed to great distances. It very 
rarely happens, however, that the mere entrance into the sick room is suffi- 
cient so far to impregnate the clothing, as to enable the wearer to become the 
instrument of spreading the disease. Hence, we scarcely ever hear of a phy- 
sician conveying the complaint from one person to another. Still, it would 
be prudent, in a practitioner attending upon very contagious diseases, such 
as bad cases of small-pox, to change his dress before visiting another patient. 
Instances not unfrequently occur, in which contagion is imparted by the 
clothes or bedding of a patient, or of persons in constant and close attendance 
upon him. Disease has thus been carried to very considerable distances, and 
caused to spread in places before uninfected. Fabrics of wool, silk, and cot- 
ton, are especially liable to act as foinites; but those of flax and hemp are 
not exempt. Hair may also serve as a vehicle. The greatest danger' is 
when boxes, containing clothing thus infected, are first opened. Insects 
have been suspected of conveying the contagion by alighting successively on 
the body of the patient, and on that of a susceptible individual. Fomites 
will often long retain the poison, though it is weakened, and at length de- 
stroyed by time. It is always safest to act upon the supposition that the 
period of its activity is indefinite, unless measures are taken to destroy it by 
chemical agency. - j \ 
The matter of contagion is said to be rendered inert by a heat of 120° F., 152 
GENERAL PATHOLOGY. 
[part I. 
and. consequently by any higher degree. Hence, the boiling or baking of 
infected clothing should render it harmless.\ Intense cold is thought also to 
impair the activity of the contagious matter. Nevertheless, diseases of this 
class occur more' abundantly in winter than in summer, owing, no doubt, to 
the confinement which is necessary, in the former season, to guard against 
the cold, and the consequent concentration of the morbific agent. Certain 
chemical substances have the power of completely decomposing contagious 
matter, especially chlorine, which is, therefore, much used for the purpose of 
disinfection. Its activity is also gradually impaired by time. It is said 
that the virulence of the poison is diminished by transmission through nume- 
rous individuals; and one contagious affection at least, namely syphilis,.would 
appear to have become milder by time; but the correctness of the general 
statement may well be disputed. < 
The time at which a contagious principle begins to show its effects, varies 
from two or three days to several weeks, after exposure. The resulting dis- 
eases are generally febrile, especially when the contagion is of the kind trans- 
missible through the atmosphere. The effect of certain, contagious principles 
on the system is essentially depressing, as that of typhus; and, in general, 
their operation is gather sedative than inflammatory; though this is by no 
means uniformly the case. The manner in which the disease, spreads is 
peculiar, and often affords the requisite criterion of its contagious nature. 
Thus, it does not at once seize upon great numbers, as an epidemic, or occur 
in several separate points within a given space at the Same .time, like- an en- 
demic; but spreads from individual to individual, or from house to house; 
and, when new cases occur at a distance from the original one, they can often 
be traced to it by the intervention of persons or fomites. Instead of origin- 
ally seizing a whole family, or several members of it, at one time, it generally 
first attacks a single individual, and, from two or three days to two or three 
weeks afterwards, several, others almost simultaneously. 
The febrile contagious diseases generally rpn a certain course, having, dis- 
tinct stages at certain intervals, and Terminating in a given number of days. 
This property is not absolute; but is so general and striking, as to be charac- 
teristic. 
Another peculiarity of the same set of diseases is, that one attack- in gene- 
ral secures the system against a second. This rule, however, is liable to 
frequent exceptions. It does not apply to the complaints imparted exclu- 
sively by contact. Indeed, one attack of syphilis is said to predispose to a 
second. 
There seems to be a certain incompatibility between the several contagious 
febrile complaints; so that, if an individual has been exposed to the causes 
of two of them, he will not usually be affected simultaneously with both ; but 
one will run its course, and, when it begins to decline, the other will appear; 
or the feebler one, if it have precedence, will be superseded for a time by the 
more powerful, and will return and finish its course, after the latter has sub- 
sided. Such is the case with measles and small-pox. Occasionally, however, 
we see two of these pomplaints apparently existing together, and modifying 
each other, as in the cases of measles and scarlet fever. 
A common character of all contagious diseases, , and, indeed, the one that 
renders, them such, is the power of reproducing the same kind of matter as 
that by which they were brought into existence. Nevertheless, it may be 
said that this rule is not absolutely universal. Thus, it is very doubtful whe- 
thei' the matter of hydrophobia can be reproduced in the human subject. A 
sufficient answer would be, that, if it cannot be reproduced, hydrophobia is 
not a contagious disease so far as man is concerned. chap, ii.] 
CAUSES OF DISEASE.-CONTAGION. 
153 
Many, perhaps all, of the contagious diseases may arise from other causes 
than their own peculiar contagion, and may afterwards propagate themselves 
in the ordinary mode. This is very commonly the case',with typhus fever. 
There is often an epidemic, tendency to certain contagious. diseases, which, 
under such circumstances, may, I believe, originate without other influence. 
Such a tendency, moreover, greatly increases the activity of the contagious 
cause; and it not unfrequently happens, during its prevalence, that persons 
before supposed to be sufficiently protected are attacked a second time. 
The contagious affections of inferior animals are sometimes- imparted to 
man, though probably somewhat modified. The vaccine disease, hydrophobia, 
the glanders of horses, and perhaps the malignant pustule, are examples of 
this kind. . < 
The nature and mode of action of the contagious principles are points-of 
great interest, which remain yet to be settled. There are twro circumstances 
which serve to distinguish them from other morbific agents, and which espe- 
cially merit notice. These are their power of reproduction in the human 
system, and the immunity which one attack generally gives - against their 
future influence. In this latter circumstance, there is a striking difference 
between them; for,, while most of them obey the general law just stated, 
others, such as the contagions of syphilis, gonorrhoea, psora, and porrigo, are 
capable of affecting the same individual as often as they may be brought into 
contact with him.. 
Two theories have been advanced to explain the action of these causes. 
By one they are considered in the light of ferments, which, entering the 
blood-vessels, occasion chemical changes, that result in a further production 
of similar contagious matter; as the fermentation of beer developes an addi- 
tional quantity of the same kind of yeast, by the presence of a little of 
which it was excited. This explains the reproduction- of the morbific agent. 
An attempt has been made to account for the fact of future exemption, by 
supposing that, in -every system, there exists as the consequence of the organic 
processes of growth, peculiar matters, each one of which, through the fermen- 
tation excited by the contagious cause, is itself converted into contagion, and 
eliminated; so that, on any future occasion, though the poison may be ab- 
sorbed, it will find no material to act on, and.will therefore be harmless. An 
explanation, so purely hypothetical, scarcely requires criticism. The objec- 
tion naturally suggests itself, that there should be so many distinct unneces- 
sary substances, generated and retained in the system, as if with no other 
purpose than to await the action of certain special morbific principles, to be 
received from without. 
The second theory considers contagion as the.influence of certain invisible 
organic agents, either aniinal or vegetable, which, fully developed,, dr in the 
state of germs, enter the blood-vessels, and there live and propagate to the 
no little disturbance of the system, which is at length excited into desperate 
efforts, and throws off the intruders and their whole brood, or perishes in the 
attempt. In support of this view, the argument has been advanced, that, in 
certain cutaneous affections, as porrigo, the cause has been proved to exist 
in microscopic fungi, the sporules or seeds of which become the medium of 
contagion; and, in the case of psora, tire disease is conveyed by animalcules 
of a peculiar character, which propagate in the skin. But the fact that, in 
these affections, no future exemption is secured, shows that they are essen- 
tially distinct in nature, and probably in cause, from the febrile or general 
contagious diseases; and there is nothing in the animalcular hypothesis, which 
affords even a plausible explanation of the immunity, secured by one attack 
of these latter complaints. 154 
GENERAL PATHOLOGY. 
[part I. 
Predispositions. 
Before leaving the subject of etiology, it is necessary that we should notice 
certain influences, which, though not always, strictly causes, have yet an im- 
portant agency in the production of disease. I have already spoken, in 
general te^ns,of the distinction between predisposing and exciting causes; 
and have treated somewhat fully of such as seemed to require particular 
attention, in a general treatise. At present, my object is to speak of the 
predispositions, in other words, the states of system which render it especially 
liable to the assaults of disease. These may be arranged in three divisions. 
The first includes certain conditions which are not in themselves deviations 
from health, and might with great propriety be denominated, after Chomel, 
aptitudes. To the second belong those states of system, not strictly healthy, 
which predispose to no one peculiar disease exclusively, but rather to some 
set of diseases, some general mode of derangement, or to almost any disease, 
according to the nature of the exciting cause. The third embraces what are 
usually denominated diatheses; that is, tendencies to some one special and 
peculiar disease, which is apt to appear whenever the body is excited or dis- 
turbed, no matter by what cause, and will occasionally break forth without 
any apparent cause whatever. These may indeed be considered, in some 
instances at least, rather as latent conditions of the peculiar disease, than as 
mere predispositions. Such are the gouty, the rheumatic, and the scrofulous 
diatheses. The proper place to treat of these is obviously in connexion with 
the several affections to which they belong. It is only the first two divisions 
which require particular notice in this place. Among the aptitudes, we may 
consider temperaments, idiosyncrasies, sepc, and age; among the predisposi- 
tions, hereditary tendencies, habit, the effects of climate, and the results of 
occupation, and modes of life. 
1. Temperaments.-Scarcely an individual, probably, can be found, whose 
organization is so well constituted, and so nicely balanced, as not to offer an 
aptitude to some particular disease or mode of derangement, rather than to 
another. Almost all have some deficient or predominant tissue or organ, 
some weaker or stronger susceptibility, some Inequality of function, or some 
peculiarity of sympathetic relation, which favours the action, or gives speciality 
to the direction of some morbific cause. These constitutional peculiarities, 
when they are such as affect classes of persons, are called temperaments, when 
confined to individuals, idiosyncrasies, 
The general rule, in relation to the temperaments, as predispositions to 
disease, is that a predominance either of developqment, or function, in any 
structure, organ, or system of the body, is apt to lead to disease of that part. 
Thus, the sanguine temperament, in which the circulatory system predomi- 
nates, predisposes to acute inflammations, hemorrhages, and fevers of a sthenic 
character; the lymphatic temperament, which is characterized by an excess of 
the colourless tissues, and deficiency of red blood, to scrofulous and dropsical 
affections; the nervous temperament, in which the cerebro-spinal system is in 
excess, or peculiarly excitable, to neuralgia, and the various forms of nervous 
disorder; and the bilious temperament, the name of which sufficiently indi- 
cates its character, to hepatic and dyspeptic diseases. 
2. Idiosyncrasies.-These are highly important. Many persons have pecu- 
liarities, either confined to themselves, or participated in by very few, which 
render them susceptible to nlorbid impressions from causes, which in general 
either produce no effect, or one entirely different. These are not indicated 
by external signs, and are to be ascertained only by experience. Thus, cer- 
tain kinds of food, usually very wholesome, may produce violent urticaria. CHAP. II.] 
CAUSES OF DISEASE.-PREDISPOSITIONS. 
155 
Exhalations, which are quite harmless to the great mass, excite,, in certain 
individuals, excessive irritation of the nostrils, fauces, or respiratory passages. 
Some very susceptible persons faint at the perception of odours, usually agree- 
able in their effects. So frequent are these peculiarities, and sometimes 'so 
important, especially in relation to the operation of medicines, that the phy- 
sician should make himself acquainted with the constitution of every new 
patient, as far as practicable, before1 prescribing for him, in any serious case. 
Inferences as to the morbid liabilities of individuals may sometimes be drawn 
from the shape or size of their organs. 
3. Sex,-This has great influence in giving peculiar morbid tendencies. 
Of course, each sex is prone to the diseases belonging to its own organs and 
functions. But, independently of these, women, in 'consequence of the greater 
excitability of their nervous system, are especially predisposed td .nervous 
complaints; and causes, which in men produce inflammation, will, in them 
give rise to mere functional disorder. Thus, gout and rheumatism, instead 
of assuming a frank inflammatory character, are apt to lurk in the female 
system, under the shapes of dyspepsia, palpitations, headache, and neuralgia 
in every shape. From the same cause, women are especially liable to spinal 
disorder, and to all the protean forms of hysteria. Their sexual peculiarities 
also impress on the general system predispositions, not immediately or neces- 
sarily connected with the several organs. Thus, about and soon after the age 
of puberty, they are strongly prone to chlorosis or anaemia. Child-bearing, 
though liable do its accidents, is probably on the whole favourable to health, 
by superseding constitutional morbid tendencies. But, when menstruation 
has permanently ceased,'these tendencies are apt to display themselves; and 
this, consequently, is the most dangerous period in the life of woman. It is 
now, especially, that cancerous affections occur. But if she escape the dan- 
gers of this period, she may reasonably hope to enjoy a long exemption from 
disease, and to live on to a good old age. Much of the peculiarity which is 
ordinarily observable in the female predispositions) is owing rather to their 
habits, than to <any natural cause. Hence, probably, in part, their tendencies 
to spinal deformity, pulmonary consumption, anemic complaints, and dys- 
pepsia. 
4. Age.-In consequence of the early developement of. the brain, and the 
exposure of the skin to a new and unaccustomed medium, very young infants 
are peculiarly predisposed to cephalic and cutaneous diseases. The rapid 
growth of the body, requiring a vigorous exercise of the digestive organs, 
afterwards make these also a centre of morbid action. The process of den- 
tition keeps up, during its continuance, a constant irritation, which, through 
the fresh and unimpaired sympathies, extends to the various functions, espe- 
cially those of the skin, alimentary canal, and brain, giving rise to frequent 
diseases of these parts. Vast numbers of children are carried off by complaints 
of the stomach and bowels, during the period of teething. The almost un- 
remitted excitement of the nervous system, either directly from the source of 
irritation, of as the instrument of all the sympathies, renders this system 
more liable to derangement than at any other period of life ; and causes which 
are ordinarily little felt, now frequently produce convulsions. By far the 
most dangerous period of life, is before the close of the third year. There is 
another source of danger, which continues in operation until after the com- 
pletion of the second dentition. In the inflammatory affections of children, 
at this age, there is a strong tendency to the secretion of coagulable lymph, 
and the consequent formation of false membrane, even upon the mucous sur- 
faces. Perhaps this may be owing to a predominance of fibrin in the blood, 
consequent upon the wants of the, nutritive process; but the explanation is 156 
GENERAL PATHOLOGY. 
[part I. 
altogether conjectural. It is this disposition which renders croup so fatal, 
at the age referred to. After the second dentition, until the age of puberty, 
is among the healthiest periods of life. Children are now scarcely predisposed 
to any other occasional affection than epistaxis. They arc, however, often 
exposed to the influence of the aerial contagions, such as measles, scarlatina, 
and hooping-cough, because they are old enough to be frequently abroad, and 
have not yet generally acquired the exemption which secures them in later 
life. The age of puberty is not peculiarly liable to any disorder in the male,; 
but, in the female, is not unfrequently accompanied with derangements of the 
uterine functions, and of the general health,, which may continue for years. 
Chorea, chlorosis, and hysteria, often have their origin at this period. With 
the exception alluded to, the healthfulness that succeeds the completion of 
the second dentition, continues onward until near the age at which rapid 
growth ceases. At the latter period is, another dangerous crisis. There is 
now a strong predisposition to hemorrhages, pulmonary consumption, and 
dyspeptic affections. The quantity of blood furnished by the digestive pro- 
cess, has not yet become exactly accommodated to the diminished wants of 
nutrition, and hence is apt to escape by irregular outlets. Perhaps the 
peculiar liability to phthisis may be explained by the same necessity for 
extravasation, which, in persons of the consumptive habit, takes the form of 
tuberculous deposit. The appetite, or at least the habit of eating, has not 
learned to adapt itself to the moderated powers of digestion, and the stomach 
is apt to be overworked. After maturity, when the body has attained its 
full expansion, and growth has ceased, there is again a period of comparative 
exemption from morbid tendencies, which continues, with the exception, in 
females, of a few years about the cessation of the menses, until life begins to 
decline. The functions are now all well balanced in the healthy individual, 
no organ is called on for,an excess of duty, and none, therefore, is especially 
'liable to derangement. But, when the period of decline has arrived, the 
balance is again disturbed, one organ fails too rapidly, another retains a dis- 
proportionate activity, and the general hardening of the tissues, incident to 
age, goes on with an unequal, and sometimes a dangerous speed. Hence, 
predispositions to various organic diseases accrue; apd the brain, the heart, 
and the. urinary and genital organs, are especially prone to suffer. In the 
degeneration of tissue that takes place, the characteristic properties of the 
ultimate Pells are sometimes perverted or lost; new laws regulate their nutri- 
tive process; and thus morbid growths are apt to be developed, such asscirrhus 
or cancer, which, though not exclusively, is especially a disease of advanced 
life. / 
5. Hereditary Tendency.-As we often resemble our parents in external 
form, so also do we inherit their internal peculiarities, and consequently all 
the morbid tendencies growing out of them. It is not diseases, generally 
speaking, that are inherited. It is only the peculiarities of structure or con- 
stitution, which serve as predisposition^ to disease. We are not born with 
the scrofula, gout, rheumatism, &c., of our parents, but only with that con- 
dition of .system which favours the devclopement of these affections, when 
other causes.operate. Tlie inherited diathesis, however, is often sufficiently 
strong to lead ultimately to the disease, without other cause. We see this 
fact constantly illustrated in consumption .and gout. Nay, the hereditary 
disease will often be developed, notwithstanding the most determined measures 
to prevent it, which sagacity and experience qan suggest. The inheritance 
may descend from either parent or both. It has been supposed that the 
peculiar diseases of the mother are more apt to be found in the son, and those 
of the father in the daughter; but the accuracy of the opinion may be doubted. CHAP. II.] 
CAUSES OE DISEASE.-PREDISPOSITIONS. 
157 
When, only one parent is affected, it often happens that the offspring escape 
entirely, taking after -the' healthy parent exclusively. But when both are 
diseased, and in the same way, the chances of escape on the part of the chil- 
dren are greatly diminished. Hence the danger of constant intermarriages 
between .near connexions, who may be supposed to have the safne defects of 
constitution. The morbid tendencies thus go on accumulating, from genera- 
tion to generation, until families, and even races, become extinct. Sometimes 
the hereditary malady passes over one generation, to fix upon the next. The 
child escapes, but the grandchild is affected. This fact admits of easy expla- 
nation. It is only the tefidency that is'received from the parent. This may 
remain latent, from the absence of causes calculated to call it into action; or 
counteracting circumstances may exist which shall prevent its developemcnt. 
The tendency is, nevertheless, handed down to the next generation, which 
may be less fortunate in relation to the influences that bear upon it. Occa- 
sionally, we observe family predispositions to disease, which have no proto- 
type in the immediate, or even remote ancestors. One child after another 
falls a victim to the same disease, from some inherent vice of constitution; 
and parents, themselves of sound health, may thus be completely stripped of 
their offspring. This sometimes happens from a vicious system of physical 
education, and is much more frequent among the rich than the poor. But, 
in other instances, the defect is received from the parent^and exists from 
birth. In such cases, however, the disease cannot, in strictness, be said to 
be hereditary. Complaints dependent on inherited peculiarities' of system, 
are apt to appear earlier in life than similar complaints of a different origin. 
6. Habit.-The influence of this principle is generally salutary. The 
system, frequently exposed to morbific causes, may be reconciled to them in 
the end, and cease to receive further injury. Persons thus become acclimated 
in unhealthy districts, and sometimes', when brought up in such districts from 
infancy, are gradually accustomed to the noxious influence/and appear not 
to suffer. Occasionally, however, habit constitutes a predisposition to disease. 
ThuSj when the system has adapted itself to certain influences, ordinarily 
injurious, they may become necessary to health; and an exposure to circum- 
stances, incompatible with their continuance, may lead to disorder. Hence 
an important practical rule, to withdraw'individuals cautiously, and by degrees, 
from a long accustomed exposure to what may even be deemed injurious 
agencies, unless immediate danger fe apprehended from them, or no other 
than a sudden breaking up of the dangerous habit Can be effectual. 
7. Effects of Climate.-These frequently constitute predispositions to dis- 
ease. In hot climates, the liver and its appendages are. kept in an undue 
state of excitement, both from the direct stimulant influence of heat upon 
that organ, and from the additional duty which it has to perform, in the 
elimination of carbonaceous matter. A certain excess of carbon is introduced 
with the food, which is thrown off partly by the lungs and skin, in the form 
of carbonic acid, partly by the liver in the form of fatty matter. That part 
of it which is converted into carbonic acid, answers the additional purpose of 
affording animal heat; but, as little of this is needed in hot countries, there 
is less of the acid formed, and a greater proportion of carbon must conse- 
quently escape by the liver. This organ is, therefore, overburdened with 
duty, while the lungs are spared. Hence is established a predisposition to 
biliary and gastro-intestinal diseases; and those of the lungs are compara- 
tively rare. In cold climates, the facts of the case are exactly reversed. 
Animal temperature is here especially wanted, and the carbon consequently 
finds its chief outlet through the pulmonary organs; the liver having propor- 
tionably less duty to perform. Under these circumstances, hepatic affections 158 
GENERAL PATHOLOGY. 
[PART I. 
are rare; while a strong predisposition exists to diseases of the lungs. In 
temperate latitudes, there is less exclusive tendency of disease to any one 
organ; but, in consequence of the frequent vicissitudes of weather, and the 
consequent varying conditions of the organs, there is a greater general tend- 
ency to inflammatory affections. The vicissitudes are felt more strongly when 
the climate is damp as well as variable, and the morbid tendency is also con- 
sequently stronger. Rheumatism and catarrhal affections are the most fre- 
quent results. In warm moist climates, the system is depressed by the 
sedative influence of the moisture, and a predisposition to low forms of disease 
is established. A hot dry climate is said' to predispose to diseases of the 
skin. Of the effects of impure air, as that of cities, for example, enough has' 
been said on a previous occasion. V 
8. Effects of Occupation, Modes of Life, &c.-The predispositions which 
flow from these causes are very numerous. It is, however^ impossible, in a 
general view like the present, to follow them in all their ramifications. They 
may generally be estimated by a reference to the various causes of diseases 
already enumerated, and ascertaining their bearing in each particular case. 
A few remarks on the subjects of diet, dress, and, employments, whether of 
business or pleasure, will close this essay. 
The habitual use of animal food in excess produces a superabundance and 
richness of the eblood, which strongly predisposes to inflammatory diseases, 
especially when a corresponding amount of exercise is not taken. An exclu- 
sive vegetable diet, may, on the Contrary, impoverish the blood, and occasion 
a general debility, predisposing to scrofulous and tuberculous affections, and 
various nervous derangements. Scanty and unwholesome, or putrid food, 
vitiates at once the fluids and solids of the body, and predisposes to scurvy 
and low forms of fever. Stimulating drinks and condiments favour directly 
the causes of irritation, and, by the relaxation which follows their use, lay 
the system open to the assaults of morbific causes in general. 
The predispositions produced by dress resolve themselves into those result- 
ing from heat, cold, and pressure, according as the clothing is too abundant, 
too scanty, or too tight. 
So far as the predispositions resulting from occupations of all kinds, includ- 
ing the pursuit of pleasure, are concerned, there are two prominent considera- 
tions to be kept in view; first, that over-exercise of the organs, by rendering 
them the centre of vascular and nervous excitement, strongly disposes them 
to inflammation from other causes; find, secondly, that the same over-exercise, 
if continued too long, may exhaust at length the excitability of the organs, 
and thus impairing their powers, may expose the system to all the morbid 
consequences of a failure of their functions, as well as generally, to the influ- 
ence of morbific causes through the resulting debility. 
CHAPTER III. 
SYMPTOMATOLOGY, OR SEMEIOLOGY. 
Symptoms are those effects of disease which are either sensible to the patient, 
or perceptible by the observer. Signs are the evidences by which disease is 
made known. All symptoms are necessarily signs; but there may be signs 
which are not symptoms. Thus, the age or sex of the patient may serve to CHAP. III.] 
SYMPTOMS OF DISEASE. 
159 
fix the character of some particular affection; and the cause of a disease, when 
known to us, often determines our opinion of its nature. These may, there- 
fore, be signs; but they cannot be considered as symptoms. 
Symptomatology, or Semeiology, is the science which treats of the symp- 
toms and signs of disease in all their relations. The course of a disease, so 
far as it can be observed, is the peculiar succession of its symptoms; the diag- 
nosis is the application of the symptoms and signs to the formation of an 
opinion as to its. nature; the prognosis is- the deduction of inferences from the 
symptoms as to its future progress or result. The course of disease, there- 
fore, its diagnosis, and prognosis, come within the province.of symptomatology. 
It will be most convenient to treat first of the symptoms or signs; then of 
the course, which may be considered as including the duration and termina- 
tions of disease; next of the diagnosis, under which will be included the 
methods of exploring disease; and, lastly, of the prognosis. 
SECTION I. 
SYMPTOMS OR SIGNS OF DISEASE. 
A division of symptoms has recently been made into those connected essen- 
tially with derangement of the vital properties; and those which consist in 
changes of the sensible properties of the system. The former have been va- 
riously denominated general, rational, and vital symptoms; the latter, phy- 
sical signs. A little reflection will show that the distinction is not very 
philosophical. Many of the general, rational, or vital symptoms are appre- 
ciable by .the senses.. Thus, the cries of pain are heard; the derangements 
of the pulse are felt; and convulsive movements are seen. On the other 
hand, many of the signte called physical arc clearly symptoms of some vital 
disturbance. Thus, the increased bulk of an organ, the modification of its 
healthy sounds, and alterations in its colour, are often immediate signs of 
changes in the vital actions. In these general remarks, therefore, I shall not 
follow the division alluded to; but, in the description of individual diseases, 
it will be most convenient, in many instances, to separate from the ordinary 
symptom's those signs which are elicited by certain processes, of compara- 
tively recent origin, as percussion and auscultation, and which have been 
distinguished by the designation of physical signs. Such a discrimina- 
tion is called for by the considerations, that these latter require a peculiar 
training in the.observer, in order to be fully appreciated, that they have not 
yet received the universal attention which they merit, and that, if treated of 
indiscriminately with those better known and understood, they might tend, 
with many, rather to confuse than to aid the diagnosis. 
It would be quite out of place, in this preliminary essay, to treat of all the 
symptoms severally. In the account of each disease, those which belong to 
that disease must, of necessity, be referred to; and to describe them now 
would be to render repetition unavoidable. Indeed, many of the phenomena 
which, under certain circumstances, are symptoms of disease, under others, 
are themselves diseases, and must, therefore, be fully discussed in the depart- 
ment of special pathology. Our attention here must be directed more espe- 
cially to those phenomena, which, being common to numerous diseases, require 
a general description in order to be fully understood, and of which a descrip- 
tion now will spare the necessity of much repetition hereafter. It will be 
necessary, moreover, to explain the nature of certain symptoms, whiph, not 
entering into the category of diseases, might otherwise not receive the special 160 
GENERAL PATHOLOGY. 
[PART I. 
notice which they merit. The reader, however, will understand, that our 
notice is to be directed, in this part of the work, to the symptoms themselves ; 
their relation with the several diseases which they indicate, being left for 
future consideration. In the following remarks, I shall pursue the natural 
order of the functions, beginning with digestion. 
1. Symptoms belonging to the Digestive Function.-Perhaps the 
most important of these are the symptoms presented by the tongue, which are 
here described more fully, in consequence of the great number of diseases in 
which they afford valuable indications. 
Tongue.-In drawing inferences from the condition of this organ, it is 
important to know, whether the appearances it may present are the result 
of local disease in the mouth, or of the sympathies which connect it with 
other parts of the system. In general, there is little difficulty in coming to 
a correct conclusion upon this point; and it is only necessary that the atten- 
tion should be directed towards it. The following remarks have reference 
only to the general indications offered by the tongue. This organ seems to 
have been designed as an index, to the eye as well as to the ear, of the .state 
of the system; so numerous and diversified are the morbid affections which 
modify its healthy appearance. It not only participates in all general de- 
rangements of the whole system, serving as one of the surest guides to a 
correct judgment in relation to the degree, progress, and precise stage of the 
disease; but especially also sympathizes with the different parts of the digest- 
ive tube, at one extremity of which it is placed. , 
The bulk of the tongue may be increased or diminished. Its enlargement, 
when not so considerable as to be very obvious, may often be known by the 
appearance of indentations on its sides, made by the pressure of the teeth. 
This is occasionally one of the first signs of the mercurial influence. Its con- 
traction, when not the mere effect of dryness, is usually the result of a dimin- 
ished supply of blood, and indicates either a general deficiency of the circulating 
fluid, or great feebleness of the heart's action. Like every other part naturally 
moist, it shrinks by drying; and, under such circumstances, no general infer- 
ence can be deduced from its mere loss of volume. 
Its colour is often greatly and significantly modified. Morbid floridness of 
the tongue is the consequence either of the condition of the blood, or of its 
greater abundance in the organ. In the former case, an unduly arterialized 
state of the mass of the blood is indicated; in the latter, either over-excite- 
ment of the circulation generally, or phlogosis of the stomach. Redness of 
the tongue, not the result of local causes exclusively, has been supposed by 
some pathologists to be an almost certain sign of gastric inflammation or irri-r 
tation. But this is far from being the case. It is often seen when no evidence 
of gastritis is presented, either by the symptoms or upon dissection, and is 
not unfrequently absent when that disease exists. Serious practical injury 
may result from this error. The red tongue can be considered as having 
special reference to the stomach, only when other symptoms point in the 
same direction; and, even then, is by no means a certain sign. A livid or 
purple colour of the tongue is usually dependent upon an insufficient aeration 
of the blood, and is. a valuable sign, in connexion with the same colour of the 
lips.. Not unfrequently the tongue is morbidly pale; and this state is a sign 
of deficiency of the blood in general, or of its red corpuscles in particular, or 
-of great prostration of the circulating forces. 
Its condition as to dryness and moisture, is often highly significant. But 
caution is necessary not to mistake dryness, from temporary and unimportant 
causes, for that which results from general disease. In persons who sleep 
habitually with their mouths open, the tongue is apt to be dry in the morn- CHAP. III.] 
SYMPTOMS OF DISEASE.-THE TONGUE. 
161 
ing; and the same cause often produces the same effect in sickness. On 
visiting a patient, we find the tongue unexpectedly dry, and begin to feel 
some apprehension, until we learn that the patient has been breathing for 
some time through the mouth alone. A, stoppage of the nostrils often gives 
rise to this phenomenon. In all doubtful cases, it is only necessary to request 
the patient to close his mouth, and then move the tongue about so as to 
moisten it. If he succeed satisfactorily, we may conclude that the dryness 
was accidental, and of no account. Another caution is requisite; to take 
care, namely, that a really dry tongue should not be mistaken for a moist 
one, in consequence of the patient having recently taken a liquid into his 
mouth. Dryness may exist in different degrees, from mere clamminess tQ 
perfect aridity. It depends on a deficiency of saliva, or of mucus, or both, 
and indicates a general tendency to diminished secretion. It not unfrequently 
occurs, as a sympathetic affection, in ulcerative inflammation of the small 
intestine. It affords sometimes the most important therapeutical indications, 
as will be fully shown hereafter. (See Enteric Fever.) 
The temperature of the tongue serves as a guide to that of the body gene- 
rally. When cold, it evinces, for the most part, great prostration of the 
powers of life. It proves that the process of calorification is failing at the 
very fountain; for the breath must be cool, before the tongue can become so 
in any considerable degree. This coldness of the tongue has been frequently 
noticed in severe cases of epidemic .cholera. But we must take care not to 
confound coldness from local causes, as from ice in the mouth, or from the 
patient having slept long with the mouth open in a cold atmosphere, with 
that proceeding from the state of the system. Heat of the tongue, except 
when arising from inflammation of the organ, may be considered as a sign of 
a general elevation of temperature. 
But the condition usually, denominated a furred tongue, is perhaps the 
most valuable diagnostic symptom afforded by that very important, little 
member. In this state, the tongue is covered with a morbid coating, which 
adheres so firmly that it cannot be removed, without removing a portion of 
the surface along with it. Occasionally, deposits take place from the saliva; 
but these are easily removable, and must be distinguished from the genuine 
fur. The -latter proceeds from a secretory process of the tongue itself, and 
seems to be incorporated with the superficial layer of its mucous coat. It is 
almost always confined to the upper surface, where the structure of the mem- 
brane is papillary. Though very generally a sign of disease, it is not always 
so. Some persons have a furred tongue habitually, more especially upon 
rising in the morning; and, though in the greater number of these, there is 
probably some chronic disorder of digestion, yet in others the health appears 
to be perfect. 
A furred tongue almost always accompanies fever, and is one of the most 
decided characteristics of that affection. Indeed, when considerable in degree, 
and not dependent upon stomatitis of any kind, it may very generally be 
regarded as a febrile symptom. When the fur is white, thickish, tolerably 
uniform, and accompanied with moisture, it usually indicates an open, active 
state of fever, in which, though the obvious symptoms may possibly be vio- 
lent, there is not apt to be any lurking mischief, nor any malignant tendency. 
When short, very adhesive, and rather scanty, permitting the redness of the 
tongue to appear through it, and attended with some disposition to dryness, 
it is often a sign of a protracted and obstinate form of fever, which is apt to 
assume a low, nervous, or typhoid form. A yellowish hue of the fur is usually 
indicative of bilious disorder, being produced either by the vomiting of bile, 
or, what is probably much more frequent, by direct secretion from the tongue, 162 
GENERAL PATHOLOGY. 
[PART I. 
consequent upon deficient secretion by the liver, or an excessive production 
of bilious matter in the blood. Not unfrequently, this colour of the tongue 
is accompanied with a bitter taste. It is common in miasmatic fevers, and 
hepatic diseases. A brown or black tongue, is usually indicative of a low 
state of the system, and an impaired condition of the blood. It is owing to 
the secretion of a dark matter, apparently identical with that which collects 
about the teeth and lips in typhous fevers; and probably consisting of blood 
modified in its passage out of the vessels. The same action would seem to 
take place in the tongue, as that which, in the stomach and bowels, occasions 
the black discharges so common in malignant fevers. ' It may depend on an 
enfeebled state of the secreting tissue, or a diseased state of the blood, or on 
both united. Very frequently, this darkness of the tongue supervenes upon 
a previously white coating, and indicates a deteriorated state of the vital 
forces, and probably of the blood. The caution should be observed, not to 
confound this discoloration with that which may proceed from accidental 
causes, as from the chewing of liquorice, tobacco, burnt coffee grains, &c. In 
many instances, the white fur of the tongue is modified by red points, which 
are the tops of the swollen and projecting papillae. This appearance is not 
uncommon in eruptive febrile diseases, especially scarlet fever and measles. 
When consequent upon a dyspeptic state of the stomach, the fur is most 
copious in the morning before breakfast. In some persons, emptiness of the 
stomach is''said always to induce this state of the tongue. 
The manner in which a furred tongue becomes clean affords valuable indi- 
cations. When the fur slowly recedes from the tip and edges, thinning gra- 
dually as it retires, it intimates a favourable convalescence. A portion of fur 
often lingers near the root of the tongue, long after the disease has given 
way. In another mode of cleaning, the fur loosens and separates in flakes, 
often beginning at the middle or near the root, sometimes in large patches, 
or over almost the whole tongue at once, leaving a smooth, red, glossy sur- 
face, as though the papillary structure had been lost. In such cases, if acute, 
and if the tongue remain moist, convalescence almost always takes place, 
though usually tedious, and sometimes very lingering. In threatening fevers, 
it is very desirable to witness this phenomenon; and, as it is often preceded 
by a feeling of soreness in the fauces, this may be considered, when it occurs 
in such cases, as an auspicious circumstance. Much stress was laid upon this 
as a prognostic symptom by the late Dr. Joseph Parrish, of Philadelphia. 
Sometimes the fur recurs once and again, before it ultimately disappears; 
and weeks and even months are- occasionally consumed, in the struggling and 
apparently uncertain advance of the system towards health. In less favour- 
able cases, the tongue, after having commenced the process of cleaning, as 
just described, or even after completing it, instead of continuing moist, be- 
comes as dry as a chip, with an aggravation of all the symptoms, and no little 
increase of danger. The indication is still more unfavourable, when, in addi- 
tion to its dryness, the surface becomes gashed, chapped, or fissured, or exhi- 
bits a rough, scaly appearance. 
This smooth, red, and glossy state of the tongue, sometimes with moisture, 
and sometimes with dryness, is not uncommon in chronic diseases, in which 
it is generally a bad sign, and is supposed to indicate serious organic derange- 
ment of the alimentary mucous membrane. A still worse condition, how- 
ever, is an aphthous state of the tongue, which is apt to come on in the ad- 
vanced Stages of chronic diseases, and is generally to be received, under these 
circumstances, as a fatal sign, though of itself, and occurring in ordinary 
health, it is in no degree alarming. 
A loss or depravation of taste is not uncommon, and is generally of little CHAP. III.] 
SYMPTOMS OF DISEASE. 
163 
consequence} depending upon a mere derangement of the surface which re- 
ceives the gustatory impressions. But, when of a paralytic nature, it is much 
more serious, as it generally indicates disease within the encephalon. 
The only other point requiring consideration refers to the movements of the 
tongue. When, in acute febrile diseases, these are not under the control of 
the patient; when, upon being requested to protrude the tongue, he is unable 
to do so; or when the organ trembles much in the attempt, the 'symptom is 
exceedingly unfavourable, indicating either very great general prostration, or 
dangerous cerebral disease. Of similar unfavourable prognostication, under 
the same circumstances, is the occurrence of a difficult and hesitating utter- 
ance, like stammering. The inclination of the tongue towards one side, when 
protruded, usually indicates palsy, and is one of the common attendants upon 
hemiplegia. 
Deglutition.-This is occasionally difficult, or impossible. The causes are, 
1, inability of the muscles concerned in the process to contract properly, 
either from a general prostration or derangement of nervous power, from 
paralysis, or from inflammation of the neighbouring parts; 2, contraction of 
the passage by stricture, or tumours compressing it from without; 3, too great 
bulk in the body to be swallowed; and 4, disease of the larynx, preventing an 
.accurate closure of the glottis, and consequently admitting the food or drink 
to enter that aperture upon every attempt to swallow, as when the epiglottis 
is ulcerated, or swollen and stiffened by inflammation. From this view of 
the causes of difficult deglutition, it is obvious that the symptom is of con- 
siderable importance, and that care is requisite not to misinterpret it. When 
the consequence of pure functional nervous disorder, as sometimes happens in 
hysteria, it is of little account; but, when arising from the other causes men- 
tioned, it often affords just ground for great solicitude. 
Appetite, and Desire for Drink.-The appetite for food may become ex- 
cessive, deficient, or depraved. The temporary loss of it is one of the most 
common results of disease, especially of fever, and its return one of the surest 
evidences of convalescence. So much is this the Case, that hunger, during 
the existence of fever, is considered a bad sign, indicating great derangement 
of the nervous system. It does not necessarily follow, from the loss of appe- 
tite, that the stomach must be diseased. The sense of hunger, though referred 
to the stomach, and often undoubtedly originating in that organ, is probably, 
in general, the result of impressions conveyed to the sensorium from all parts 
of the system, and arising from the consumption of the organized tissues 
everywhere, in the performance of the various vital functions. In disease, 
these processes may cease, and the sense of hunger must cease along with 
them. Food would, under these circumstances, burthen the system, and is, 
therefore, not called for. This is one and probably the most frequent cause 
of loss of appetite. It may result also from derangement of stomach, without 
any disease whatever elsewhere. Excess of appetite, or bouliynia, as the 
affection is technically denominated, is much less common than its deficiency. 
It may arise from a certain amount of irritation of stomach, from excessive 
consumption of the living tissues or of the blood, or from mere nervous de- 
rangement. Hence its occurrence, in certain forms of dyspepsia, in diabetes, 
and hysteria. Depraved appetite, or a desire for substances ordinarily dis- 
gusting, or wholly unfit for nutrition, is an occasional result of gastric disease, 
or of affections in which the nerves are deranged, as in hysteria or pregnancy. 
It is, however, a rare symptom. 
The desire for drink is morbidly excessive, even more frequently than the 
opposite state of the appetite for food. It is, moreover, very often in excess 
in those very cases in which the desire for food is lost, as in febrile diseases 164 
GENERAL PATHOLOGY. 
[PART I. 
generally. But thirst may arise from two very opposite conditions, which it 
is important not to confound; one, a condition of excitement, and. the other 
of depression. Like hunger, the sensation of thirst probably arises from im- 
pressions transmitted to the sensorium from all parts of the frame, wherever 
the blood circulates. That it is referred to the fauces, is no proof whatever 
that it originates there exclusively. Whenever the blood is in a state requir- 
ing dilution, an impression is received from it by all the tissues which it sup- 
plies, which impression, conveyed by the nerves to the brain, occasions the 
feeling of thirst. Hence, this sensation is experienced when the blood is hot 
and stimulating, as in.fevers and inflammations; and when it has become too 
much diminished by hemorrhage, or by excessive secretion or exhalation, as 
in cholera, colliquative sweats, diabetes, &c. Every one is familiar with the 
thirst of fever. That of the ..opposite condition of exhaustion is no less urgent. 
It is highly important that the distinction should be borne in mind; and that 
the mere existence of thirst should never be considered as a sufficient evidence 
of sanguineous congestion or excitement. Extreme thirst sometimes attends 
the lowest' states of prostration, in malignant diseases. The most pressing 
want, in some cases of this kind, is of cold water. This' has been considered 
as a sign that the blood is congested in the interior organs, and that depletion 
is requisite. It is, in fact, only a sign that the capillaries are everywhere 
nearly empty, and are making an urgent call, through the sensorium, for 
liquid to fill them. 
Nausea and Vomiting.-1These, together with various other derangements 
of stomach, will receive special notice hereafter. Reference is here made to 
them only to observe that, when nausea and vomiting are very obstinate, 
without any obvious cause, without, for example, any apparent disease of the 
stomach or other abdominal viseus, and without spinal tenderness, there is 
reason to fear that either an eruptive affection is maturing itself, or that the 
brain is diseased. , \ 
Defecation.-In relation to the symptoms afforded by this process, it is only 
necessary here to allude to their great importance, and to urge upon the stu- 
dent the necessity of attending to them. This is the more necessary, as they 
are often overlooked. The patient states that his bowels are regular, and the 
physician is satisfied with the information. But it very often happens that a 
most erroneous impression is conveyed. The patient, it is true, may have 
had an evacuation daily; but it may have been scanty, and quite insufficient 
to prevent large fecal accumulation. Instances even occur, in which there is 
apparent diarrhoea, but real and dangerous constipation. The physician, 
therefore, should always assure himself of the true state of the case. But the 
existence, or non-existence of constipation is not all that is to be attended to. 
The colour of the stpols, their consistence, and nature, are often most import- 
ant guides to the discovery of disease. The habit, therefore, of inspecting the 
evacuations of the sick, however disagreeable it may be, is indispensable to a 
proper performance of the duties of the physician. A false delicacy may, under 
other circumstances, lead only to inconvenience; in our profession, it is but 
too frequently fatal. 
2. Symptoms belonging to the Respiratory Function.-The absorb- 
ent system offers no symptoms which merit notice in this place. The same, 
however, cannot be said of the respiratory system. The symptoms presented 
by the latter are of the highest importance, as signs not only of diseases of 
the lungs, but of various other organs, and even of the system generally. 
Thus, respiration may be abnormally frequent or slow, rapid or prolonged, 
forcible or feeble; it may be irregular, wheezing, stertorous, spasmodic, or 
convulsive; it may also be peculiar in the association or succession of its CHAP. III.] 
SYMPTOMS OF DISEASE.-DYSPNCEA. 
165 
movements, or by attendant phenomena, as in sneezing, coughing, laughing, 
crying, sobbing, sighing, yawning, and hiccough. The temperature and odour 
of the expired air may become signs of disease. The breath is hot in fevers, 
and cool in certain diseases of great prostration, as in the collapse of cholera, 
and the last stage of malignant typhus. A sour smell of the breath indicates 
acid in the -circulation; an offensive smell, either gangrene of the lungs, a 
diseased state of the blood, mercurial action, or local diseases in the mouth, 
fauces, or nostrils. By its peculiar odour, poisonous substances which have 
been swallowed, can sometimes be detected, as alcohol, and prussic acid. The 
matter of expectoration affords other and most valuable signs. The various 
physical signs made evident by measurement, percussion, auscultation, &c., 
are of incalculable importance. Most of these, however, will be sufficiently 
considered under diseases of the respiratory organs. At present I shall only 
offer some observations upon dyspnoea and cough. 
Dyspnoea.-This literally signifies difficult breathing. The term may be 
so extended as to embrace all cases of increased frequency or force of respira- 
tion, attended-with obvious effort, and all others in which the sensations of 
the patient are painful, whether there be augmented movement or not. A 
patient may be unconscious of a disturbance which is very obvious to others', 
and very painfully conscious of a difficulty which others do not s6e. The 
affection, in both cases, is here ranked with dyspnoea. It is a very frequent 
symptom, dependent on very different pathological conditions, and offering 
the most opposite practical indications. In all its varieties, however, there must 
be one thing constant; and that is, an impression of a peculiar kind upon the 
nervous centre which presides over respiration. This may be transmitted to 
the centre from the various parts interested in the results of the function, or 
it may be the consequence of disordered action originating in the centre itself. 
In its higher grades, it constitutes or rather occasions, the sensation of want 
of breath s and, in all cases in which the efferent nerves are not defective, 
or the respiratory muscles paralyzed, it gives rise' to movements more or less 
excited of the organs of breathing. The remote cause of dyspnoea is usually 
a want of the due arterialization of the blood. From all parts of the system 
where this want is experienced, and especially, it is probable, from the pul- 
monary air-cells and bronchia, there goes up, through the afferent nerves, to 
the. medulla oblongata, an impression, which occasions the feeling of want of 
breath, and causes to be transmitted from that centre, through the efferent 
nerves, a motor impulse to the respiratory muscles. According to the degree 
of the want, is the strength of the sensation, and the energy of the consequent 
movements. In bad cases, the distress of the patient for want of breath is 
extreme; he gasps for air, his chest heaves laboriously, he is compelled to 
maintain the erect position, he cannot bear the windows or doors shut even 
in cold weather, and sometimes leans out of a window, as if in search of 
breath. The necessity of maintaining the erect position, called orthopnoea, is 
owing to the greater freedom in the expansion of the chest in this position, 
and the relief it affords from the pressure of the abdominal viscera, in the 
horizontal posture, upon the diaphragm. In the mildest cases, there may be 
only a slight feeling of uneasiness, or no uneasiness at all; and the only ap- 
parent morbid result is an increase in the frequency of respiration, of which 
the patient himself may not be sensibly. Between these two extremes there 
is every grade. 
Should the efferent nerves, or the muscles of respiration be paralyzed, then 
the patient may experience the greatest conceivable anxiety and oppression, 
amounting to a sense of suffocation, without any or with little violence of 
respiratory movement. Again, should the nervous centre lose its suscepti- 166 
GENERAL PATHOLOGY. 
[part I. 
bility under the influence of badly aerated blood, as not unfrequcritly happens, 
there may be neither sensation nor increased movement; and asphyxia, or a 
state approaching to it, is produced. It may happen, moreover, that irritation 
may exist in the nervous centre, independently of any deficiency in the aera- 
tion of the blood, as in nervous disease, and especially in hysteria; and this 
irritation, transmitted to the muscles of the chest, may produce hurried 
breathing or dyspnoea. 
The circumstances under which the main condition requisite to dyspnoea, 
the want of due aeration of the blood, may occur, are very diversified. 
Thus, the blood may be in a state of disorganization from malignant dis- 
ease, in which it is unable to undergo the requisite changes in the lungs; 
though, in such cases, the nervous centre is also apt to become unimpressible, 
and respiration languishes or ceases, instead of'being excited. Another con- 
dition is that in which the blood, from various causes, becomes-congested in 
the pulmonary capillaries, so as to impede the entrance of air into the cells, 
and at the same tinie retard the pulmonary circulation. A third condition 
is afforded by different diseases of the lungs, which produce consolidation, 
compression, or destruction of the pulmonary tissue, or fill the cells with 
liquid, so as to exclude the air. Inflammation of the lungs, bronchitis, 
pulmonary hemorrhage, pleuritic effusion, dropsy of the chest and pericar- 
dium, tumours of all kinds within the chest, pulmonary consumption, &c., 
operate, in excluding the air from portions of the lungs, in one of the 
modes just mentioned. The portion to which the air has access, is insuffi- 
cient properly to arterialize the blood; the condition requisite to dyspnoea 
is produced; and respiration is augmented, in order that the sound portion 
of the lungs may, by performing additional duty, counterbalance the loss 
of function in the diseased part. A fourth condition consists in the con- 
stricting of the air--passages by spasm, tumours, &c., so as' to impede the 
free access of air to the cells. An example of this is presented in spasmodic 
asthma. A fifth condition is that of disease of • certain muscles of respira- 
tion, either paralytic, rheumatic, or inflammatory, in which the muscles be- 
come unable to contract, and thus throw their duty upon the other muscles, 
which are stimulated to excessive action. Thus, when the diaphragm cannot 
descend, the ribs move much more in respiration than under ordinary cir- 
cumstances. Lastly, the fault may be in the air, which may be too much 
rarefied, or its place supplied by irrespirable gases, so that the blood cannot 
become duly aerated. From this sketch it will be seen, how various are the 
circumstances under which dyspnoea may be produced, and yet how import- 
ant to discriminate between them, as they often require peculiar plans of 
management. It is usually severest in acute diseases, in which the cause is 
sudden, and the sensibility of the nervous respiratory centres is yet unim- 
paired. 
Cough.-This is the sound produced by a sudden and forcible expiration, 
preceded by a temporary closure or resistance of the rima glottidis, in order 
to give additional impulse to the current of air. It is generally succeeded by 
a fuller than ordinary inspiration, in consequence of the exhaustion of the 
air in the lungs by the previous act. Occasionally, the rima glottidis is made 
tense during the inspiration, in which case, this also is attended with sound, as 
in hooping-cough. Cough, like dyspnoea, depends upon an impression re- 
ceived by the nervous centre, producing a sensation of tickling, pressure, ful- 
ness, or other uneasiness in the respiratory passages, especially the larynx 
and trachea, which then causes the transmission of motor influence from the 
centre to the muscles concerned. The object aimed at in the process, is CHAP. III.] 
SYMPTOMS OF DISEASE.-COUGH. 
167 
obviously the removal of matters in the air-tubes, which might interfere with 
respiration. 
The source of the impression made upon the sensorium is various. Most 
frequently, it is some irritation of the respiratory mucous membrane, either 
consequent upon the presence of foreign bodies, such as dust, acrid vapours, 
&c., admitted with the air, upon certain qualities of the air itself, as cold- 
ness and dampness, which operate by reaction, or upon substances extrava- 
Sated into the passages, as mucus, pus, bloody &c. Inflammation, from what- 
ever cause, acts as itself a source of uneasiness, both by producing effusion, 
and by exalting the sensibility of the membrane, whereby the ordinary 
healthful stimuli are converted into irritants; the air itself being sometimes 
sufficient, under these ..circumstances, to excite cough. Certain parts of the 
air-tubes are much more susceptible to this irritation than others. The 
glottis is especially sensitive, with the purpose,' no doubt, of guarding the 
entrance of the tube against injurious agents. Another source of the sen- 
sorial impression above alluded to, is some disturbance conducted by the 
afferent nerves of respiration, from parts not directly connected with the air- 
tubes, as the parenchyma of the lungs, the pleurae, the pericardium, the sto- 
mach, the liver, the bowels, the peritoneum, &c. It is probably through 
branches of the par vagum, directly or indirectly, that impressions from these 
various sources are conveyed to the medulla oblongata, and the brain. A 
third source of the impression is some inappreciable change in the nervous 
centre itself, or the respiratory nerves entering it, such as .occurs in hysteria, 
and sometimes in gouty or rheumatic individuals, producing nervous and 
spasmodic coughs, without any apparent disease of the thoracic or abdominal 
viscera. - < 
There, is great diversity in the character of the cough, which has received 
names corresponding with its peculiarities. Thus, we have the dry cough 
without, and the moist cough with expectoration; the short, hacking cough, 
resulting, from slight irritation, and the violent, spasmodic, and convulsive 
cough, from high degrees, or peculiar modifications, of the same cause; the 
occasional, the incessant, and the paroxysmal cough, from the mode of recur- 
rence; the hoarse, wheezing, barking, and shrill coughs, from modifications 
in the tension or capacity of the rima glottidis, or other portion of the respi- 
ratory tube; the hollow cough from its resonance in the enlarged bronchia, 
or pulmonary excavations; and finally, the laryngeal or guttural, the pec- 
toral, the hepatic, the stomachic, the verminous, &c., according to the part 
from which it may be supposed more especially to proceed, or the cause pro- 
ducing it. 
Expectoration.-Expectoration is the act of discharging the secretions or 
fluids of the air-passages. This is usually effected by coughing. Some- 
times, however, when the matter in the bronchia is very copious, it is thrown 
off in a full stream, by a simultaneous contraction of all the muscles of 
expiration, without any resistance whatever at the glottis. The process 
resembles vomiting, and it is sometimes difficult to determine whether the 
substances discharged have proceeded from the lungs, or from the stomach. 
Chomel calls it pectoral vomiting. It is in this manner that blood is some- 
times expectorated in violent attacks of haemoptysis. A third mode of ex- 
pectoration is that in which the liquid rises up gradually, and without any 
effort on the part of the patient, as far as the glottis or fauces, when, it is 
removed by hawking, The matters expectorated are called sputa. These 
will be treated of under the. special diseases in which they are severally met 
with. , > ■ 7' , . \ . 168 
GENERAL PATHOLOGY. 
[PART I. 
3. Symptoms belonging to the Circulatory Function.-The heart 
affords by its action, size, or position, numerous signs very important in diag- 
nosis. These will be considered when we reach the diseases of that organ. 
Upon the pulse, it is necessary to make some preliminary observations, as 
that phenomenon is constantly referred to throughout the work, and should 
be early understood. 
The Pulse.-The evidences of the pulse in disease are probably, on the 
whole, the most important that we can attain; but they are not without their 
fallacies, and much caution is often necessary to avoid wrong inferences. 
The pulse, in the ordinary acceptation of the term, is the beating of the arte- 
ries. In each pulsation, the vessel is slightly expanded, and sometimes 
laterally displaced, and then returns to its original size and position, after 
which there is an interval of rest. The influences concerned in its produc- 
tion and peculiarities, are those of the heart, the arteries themselves, and the 
blood. The heart gives the impulse by which the expanding wave of blood 
is carried onward, and the vessel contracts, either by its elasticity alone, or 
by some additional vital force. It is obvious that' the frequency of the pul- 
sations, and the regularity or irregularity of their succession, must depend 
upon the heart. The pulse at the wrist, when it can be felt, always corre- 
sponds with the systole of the ventricles, allowance being made for the Tery 
slight interval that must elapse, before the wave reaches so distant a part. 
To the heart's action must also be referred most of the other healthy charac- 
ters of the pulse; and for the source of its peculiarities in disease, we must 
look chiefly to the same organ. But the state of the arteries is not without 
its influence. These vessels are gifted, like all other living and movable 
tissues, with a certain degree of vital, contractility or tone, upon which their 
healthy firmness depends. Without this tone, they become relaxed and 
flaccid, yielding readily to the expanding force of the blood, and not rapidly 
recovering their dimensions when the impulse ceases. It is evident that, in 
this condition of the vessels, that portion of the heart's impulse which is 
employed in dilating the arteries, is not restored to the blood duly by the 
contraction of their coats, and is, therefore, partially lost before it reaches the 
extremities. Hence, the pulse, in such cases, is not a proper measure of the 
strength of the cardiac contraction. The latter may be strong, while the 
former is comparatively weak. Again, an excessive tension of the arterial 
coats may occasion a resistance to the finger, which might lead to improper 
inferences as to the force of the heart. Happily, however, there is a general 
correspondence between the arterial and cardiac pulsations, which renders 
the former, in the great majority of cases,, a tolerably correct measure of the 
latter. The quantity;of the blood also has undoubtedly some influence upon 
the character of the pulse. When it is in excess, the pulse is likely to be 
fuller than usual, when deficient, smaller. The rule, however, is not abso- 
lute. The pulse may be small, even in a plethoric state of the system, if 
some obstruction to the pulmonary circulation exist, causing congestion in 
the lungs and venous system, and preventing a due supply to the left ven- 
tricle. It is hardly probable that difference in the quality of the blood can 
act upon the pulse in any other way, than as it may affect the condition of 
the heart or the vascular coats. After this view of the causes of the pulse, it 
will be proper to give an account of its qualities. These may be included 
under the heads of frequency, quickness, mutual relation of the pulsations, 
volume, tension, strength, and subordinate movements. 
Frequency of the pulse has relation to the number of pulsations in a given 
time. This varies considerably within the limits of health. It differs greatly 
with the age. The following has been generally considered about the average CHAP. III.] 
SYMPTOMS OF DISEASE.-THE PULSE. 
169 
frequency in health, at different ages; viz. 130 to 140 in a minute soon after 
birth, from 100 to 120 in the second year, 90 in the eighth year, 80 at 
puberty, 65 to 75 in persons of middle age, and 55 to 65 in tire old. But 
the numbers are given very differently by authors; and the most opposite 
assertions have been-made upon the subject. Thus, according to M. Billard, 
the pulse of new-born infants is often as slow as that of adults ; and MM. 
Leuret and Mitivie state, as the result of numerous observations, that the 
pulse of the old is more frequent than that of the young; the mean for the 
former being 73, and for the latter 65. Dr. Pennock, of Philadelphia, found 
the average pulse in 170 men, of the mean age of 64.09 years, to be 71.83 
in the minute; and in 203 women, of the mean age of 70^57 years, to be 
78.02. (Am. down. of Med. Sci., N. S., xiv. 70.) Perhaps the pulse of the 
old has hitherto been thought slower than it really is; but, judging from my 
own observations, I am inclined to believe that the statement first made, with 
some allowance for too low an estimate in this respect, is not far from the 
truth; the individual being supposed to be sitting, when his pulse is counted. 
It is certain, however, that very many exceptions will be found; for there 
are few points in which men diffef more, physiologically, than in the fre- 
quency of the pulse. Thus, young persons are occasionally met with having 
a pulse below 60;- while in old men it is sometimes above 80; and constitu- 
tional idiosyncrasies have occurred, in which it has habitually exceeded 100, 
or fallen short of 30 or 40, without apparent disease. 
Sex influences the frequency of the pulse. In women it is said, on the 
average, to be ten beats in the minute more frequent than in men. There 
is certainly some difference; but this, I think, is beyond the reality. Tem- 
perament is not without effect. The pulse is usually more frequent in the 
nervous and sanguine, than in the bilious and phlegmatic. It is often more 
so in thin than in fat persons, and, as it is said, in those under, than in those 
over the middle size. 
The frequency is usually greater in the morning than in the evening, after 
a full meal than before it, in the standing than in the sitting posture, and in 
the sitting than the. lying. Exercise and mental excitement generally in- 
crease it, and in some persons greatly. The effect of posture may be resolved 
into that of muscular exertion. During sleep, the pulse is usually considera- 
bly slower than in the waking state. In health, whatever exercise of func- 
tion calls for a consumption of blood, tends, when increased, to excite the 
heart, and consequently to augment the frequency of the pulse. 
In all diseases of excitement, the tendency is to an increased frequency of 
pulse; but the converse of the proposition is not equally true. In diseases 
of depression and debility, the pulse is sometimes slower than natural; but 
very often it is more frequent. This generally arises from the existence of 
some source of irritation, in the midst of the depression or debility. Indeed, 
it often happens that debility is one cause of extreme frequency of pulse. A 
certain supply of blood is demanded by the functions, and the heart, being 
too feeble to act forcibly, is driven to excessive frequency of contraction in 
order to compensate for its want of strength. It is obvious that an irritant, 
under these circumstances, must be felt more in the increased frequency, than 
the increased strength, of the pulse. Even profuse hemorrhage, and exhaust- 
ing secretions, are often attended with frequency of pulse, especially upon the 
occasion of any muscular or mental effort. 
Slowness of pulse is the general result of depressing causes, so long as no 
source of excitement exists in the system. Even with such excitement, it 
will sometimes occur when the susceptibility of the heart has become ex- 
hausted, as towards the close of a fatal affection; and when the nervous 170 
GENERAL PATHOLOGY. 
[part I. 
centres, which are the medium through which, stimulation reaches the heart, 
become insensible by disease, as in inflammation of the substance of the brain, 
and in apoplexy. 
It follows from what has been said above, that little satisfactory inference 
can be drawn, as to the state of the system, from the mere frequency or 
slowness of the pulse, unconnected with its other qualities. It may, however, 
be admitted as generally true, that extreme frequency indicates irritation 
combined with debility. 
Quickness of pulse is different from frequency. The latter has reference 
to the succession of the pulsations, the former to each one separately. A 
frequent pulse is one in which the number of beats is greater than usual in a 
given time; a quick pulse, one in which each beat occupies less than the 
usual time, though the whole number may not be increased. This quality 
of the pulse is owing to the mode in which the ventricle contracts, and 
almost always indicates irritation, with little strength. The heart makes a 
quick, short, angry contraction, differing much from the somewhat prolonged 
and forcible contraction of real energy under excitement. The former is 
usually a sign of nervous disorder, the latter frequently of inflammation. 
The jerking pulse is a modification of that now under consideration. It is 
characterized by a quick, rather forcible beat, followed by a sudden, abrupt 
cessation, as if the direction of the current had suddenly changed. Dr. Hope 
considers this kind of pulse as, indicative of deficiency of the aortic valves, 
and consequent' regurgitation into the ventricle. Something like it may 
sometimes be observed in nervous affections. 
The mutual relation of the pulsations may refer to their succession, their 
comparative duration, or their strength. In all these respects, the pulse is 
often irregular. It need scarcely be stated, that the source of the irregularity 
is almost invariably in the heart. Occasionally, a pulsation is altogether 
omitted. This constitutes intermission of the pulse. The intermission may 
be regular, that is, may occur uniformly at the end of a certain number of 
pulsations;' but much more frequently, it is irregular. ' But every intermis- 
sion of the pulse at the wrist does not necessarily imply an intermission of 
the heart's action; for this may recur regularly, yet at times maybe so feeble, 
that the impulse does not reach the extremities. Hence, intermissions of 
the pulse are sometimes observed, when the pulsations are regular over the 
heart. But very frequently, along with intermissions of the pulse, there is 
irregularity in other respects. Several beats may occur rapidly in succes- 
sion, and then be followed by others at longer intervals; and those alternations 
are themselves frequently altogether irregular. A want of uniformity in the 
strength and duration of the several pulsations is also not unfrequent. One 
may be strong and another feeble, one quick, another prolonged.; and often 
several run on successively of one character, to be followed by one or more 
of the other. Sometimes all the irregularities mentioned, or most of them, 
occur in the same pulse, which may then be called hobbling. Another, but 
comparatively rare incident, is the interpolation of an additional pulsation 
between two others, which occur at the regular interval. 
The affections,of the pulse above described are very common in diseases of 
the heart, and, though they often indicate nothing more than functional or 
mere nervous disorder of that organ, yet, when constant or very frequent, are 
sufficient to justify suspicion of something worse, and should lead to a close 
examination. Irregularity of pulse is sometimes observed in perfectly healthy 
individuals, who live to old age without any alarming result. This is espe- 
cially the case with mere intermission, which is not uncommon in persons 
advanced in life. It has been noticed that habitual intermissions of the pulse, CHAP. III.] 
SYMPTOMS OF DISEASE.-THE PULSE. 
171 
in elderly people, sometimes disappear during acute disease, and return when 
the disease is passed. 
The volume of the pulse may be greater than usual, in which case it is said 
to bo full, or it may be less than usual, when it is said to be small or con- 
tracted. Fulness of the pulse may depend on general plethora, on a prolonged 
and forcible contraction of the ventricle, to a certain extent on relaxation of 
the arterial coats, and on obstruction in the capillaries, without diminished 
power of the heart. It may be associated with strength, or with feebleness 
of' pulsation. In the latter case, the pulse readily yields to the finger, and, 
in its extreme of debility, is sometimes called a gaseous pulse. It is not un- 
frequent in cases,of watery or impoverished blood. A small pulse may result 
from general deficiency of blood, from congestion in the venous system or 
larger interior organs, from feeble action of the heart, from great tonicity of 
the arterial coats, or from certain constringing agents, as cold and astringents. 
When very small, it is sonietimes Said td'be thread-likb. It maybe associated, 
like fulness, with strength or weakness. In the former case, the pulse is said 
to be corded. It often depends on the frequency of the heart's action, whether 
the pulse shall be large or small. Supposing the amount of blood circulated 
to be the same, the pulse will generally be small in proportion to its rapidity, 
and large in proportion to its slowness. 
Tension is that property of the pulse by which it resists compression. It 
may be considered as generally synonymous with hardness. There is one 
condition, however, in which the pulse may be hard without being tense. I 
allude to instances in which the coats of the artery have become cartilaginous, 
Or ossified. This often happens in the old, and the practitioner must be on 
his guard not to draw false inferences from it. True, tension of the pulse 
requires a union of considerable strength of action in the heart with tonic 
contraction of the' vascular coats. When very tense, and at the same time 
small, the pulse is sometimes called wiry. Softness of the pulse is synonymous 
with compressibility. It is usually indicative of general weakness, and, when 
connected with smallness, is often a sign of great prostration. 
The strength of the grilse depends chiefly upon the force with which the 
ventricle contracts, but in some measure also upon the tonicity of the artery 
itself, and the volume of the blood. Into the idea of a strong pulse enter not 
only vigour of impulse, but a steady resistance to pressure, and a certain 
degree of fulness. We may have a sharp, forcible beat; but, if not sustained 
by a certain amount of subsequent firmness, we should consider the pulse as 
indicating rather irritation than real energy. A very contracted pulse, how- 
ever tense, and however sharp the impulse, can scarcely be called a strong 
one. Fprce or momentum is, in the body as well as out of it, the product of 
velocity and mass. The more voluminous the pulse, the velocity being the 
same, the greater is its strength. Here then is a combination of all those 
conditions which indicate a general elevation of vital powers and actions; force 
in the heart's contractions, a high degree of general tonicity, and a large 
amount of blood. Hence, a strong pulse is rightly considered as a sign of a 
sthenic, or vigorous state of system. But it is not invariably so. Hyper- 
trophy of the left ventricle may give strength to the pulse, even though the 
general powers may be failing. In some persons affected with that disease, 
the pulse remains strong almost to the very close of life. It is highly im- 
portant, in judging of the condition of the system from the pulse, to bear in 
mind this effect of hypertrophy. Weakness is of course the opposite of strength 
of pulse. In this, the impulse is feeble, the tension is slight, and the volume 
often small. But, in cases of superabundance of an impoverished blood, or 
very slow action of the heart, or great relaxation of the arteries, or of all 172 
GENERAL PATHOLOGY. 
[part I. 
these conditions combined, there may he a full, and, at. the same time, a 
feeble pulse. It is important not to confound this character with strength. 
The feeble pulse may be distinguished by the weakness of the impulse, and 
by readily yielding to slight pressure. As strength of pulse generally indi- 
cates vigour of system, so weakness indicates debility. But, as in the former 
case, so in this, there are exceptions to the general rule. The heart may from 
particular causes act feebly, while the energies of the system at large are un- 
impaired. Thus, violent pulmonary congestion, of an active character, may 
so far impede the passage of blood through the lungs that it cannot reach the 
heart in due quantity, arid the pulse will be necessarily feeble. A mistake, 
in such a case, would be very apt to be fatal. Inflammation, even of a vigor- 
ous character, in the nervous centre which more immediately presides over 
the heart's actions, may so far reduce them as to- give weakness to the pulse, 
and a semblance of weakness to the system. Inflammation of the substance 
of the heart may have, the same effect. Excessive and continued nausea may, 
for a time, prostrate the circulatory forces, and produce the same phenomena; 
as in severe inflammation of the stomach or peritoneum. These are examples 
of depression of certaip vital actions, .but not of debility; depletion may be 
demanded instead of stimulation; and it is absolutely necessary that the young 
physician should enter upon the practice of his profession, properly guarded 
upon this point. 
By the subordinate movements of the pulse, I mean modifications of the 
regular impulse, other than mere differences in force or duration. Besides 
the steady, onward motion of the volume of blood, there are often subordinate 
currents within the stream, which make themselves sensible by communicat- 
ing a vibratory thrill to the coats. Hence the. thrilling pulse of aneurism, 
diseased heart, and anaemia. The cause of this, .as well as its indications, 
will be explained elsewhere. The trembling pulse is another modification. It 
probably depends upon successive efforts of the heart, in accomplishing one 
systole, and would indicate debility'of the organ. The rebounding pulse, on 
the contrary, may be the result of an excess of energy, inducing a second and 
subordinate contraction of the ventricle, by which it may be more completely 
emptied than by the regular systole alone. 
Some practical rules will close these remarks on the pulse. . The physician 
should always bear in mind the possible individual varieties of the pulse, and 
make due allowances. Thus, in some persons the arteries are large, in others 
small; in some thin and distensible, in others thick and rigid; in some 
again superficial, in others, deep-seated. All these peculiarities have a 
decided influence on the apparent character of the pulse. Occasionally 
the arteries deviate from the usual course. This is not unfrequently the 
case with the radial artery near the wrist, where the pulse is usually ex- 
amined. . Instead of retaining its ordinary position in front of the wrist, it 
winds, in these cases, round upon the back; and there might sometimes be 
danger of supposing the patient to be pulseless. A still more probable source 
of error, is in those cases in which the artery winds around to the back of the 
wrist, but sends onward a very small branch, which occupies the ordinary po- 
sition of the main vessel. I have known the pulse, under such circumstances, 
to be considered as evincing great debility. 
Great caution should be observed, while examining the pulse of nervous, 
excitable, or timid persons, to do so quietly and without any display of hurry 
or eagerness. In individuals of this character, the heart is often excited to 
increased frequency of action by the slightest causes, and it is impossible, un- 
der such circumstances, to draw any correct inferences from the pulse. It is 
usually best to wait until the first agitation occasioned by the visit has sub- 
sided, before attempting to examine the pulse; and the physician may often CHAP. III.] 
SYMPTOMS OF DISEASE.-THE BLOOD. 
173 
very advantageously engage the patient in conversation, so as to divert his 
attention away from disturbing subjects of thought. The pulse cannot be 
relied on immediately after bodily exercise, or mental emotion of any kind. 
The patient should be in the sitting or lying position, unless it be desirable 
to ascertain especially the effect of standing. 
It is best always, in a new case, to examine both wrists; as the artery of 
one side is sometimes larger than that of the other. Care should be taken 
that there be no pressure upon the artery in its course, as by the clothes in 
the axilla, by very tight sleeves^ by tumours, &c. It is usually advisable to 
apply three or four fingers at once to the artery • as the larger the surface of 
contact, the more accurate is the impression received. The fingers should 
alternately press upon the artery, and relax the pressure, so as to appreciate 
its degree of resistance. Where great accuracy is required, it is best to count 
by a watch; and the physician will save time, and secure greater precision, 
by using an instrument with a second hand, that makes four circuits in a 
minute. The pulse should generally be felt more than once at each visit. 
The physician thus becomes acquainted with its diversities, and will often 
have occasion to correct, if not reverse, upon the second examination, the con- 
clusions he may have formed from the first. When the pulsations are exces- 
sively rapid, exceeding, for instance, 150 or 160, so as with difficulty to be 
enumerated, it may be proper, as suggested by Chomel, to count only as high 
as ten, and then to go over the same ground again, instead of advancing into 
the higher numbers, the longer names of which occupy more time in their 
mental repetition. Should the pulse at the wrist, from any cause, not answer 
the desired purpose, it may be examined in the arm, in the neck, or at the 
temples. 
State of the Capillaries.-The state of the capillary circulation cannot 
always be correctly inferred from that of the .circulation generally, and some- 
times requires a distinct examination. By pressing the finger upon the skin, 
and observing the rapidity with which the blood returns into the whitened 
spot, we may ascertain the rate of the current through the capillaries. The 
colour also has much value as a symptom. When these vessels are sluggish, 
the skin is apt to assume a dark-red or purplish hue, which is sometimes very 
striking, and, when not dependent on the general condition of the blood, may 
be regarded, in connexion with the sign before mentioned, as a mark of de- 
bility. A florid colour, on the contrary, with a rapid movement of the blood, 
may be considered as an evidence of active excitement in these vessels. These 
signs are sometimes of considerable significance in cutaneous affections. It is 
occasionally important to be able to decide, whether redness upon the surface 
is the result of extravasation of blood, or simply of capillary injection. The 
test of pressure will generally determine this point. If the redness remain 
unaffected by the pressure, while the circulation is going on elsewhere, it may 
be referred to extravasation. 
Venous Symptoms.-The only sign connected with the veins, which requires 
notice here, is the occasional occurrence of a venous pulse. This sometimes 
results from a continuation of the heart's impulse through the capillaries, and 
may generally, in this case, be' considered as an evidence of high excitement 
of the circulation. In other instances, it is owing to a retrograde current, 
produced by the contraction of the right ventricle, and indicates an inaccurate 
closure of the tricuspid valve. This venous pulse is felt especially in the 
jugulars. 
State of the Blood.-This should always be examined when blood is drawn. 
By the characters which it offers to the eye, or to chemical or microscopical 
examination, important inferences may often be deduced as to the nature of the 174 
GENERAL PATHOLOGY. 
[PART I. 
disease; and the previous diagnosis confirmed or corrected. Occasionally; too, 
affections which had before been lurking unseen are thus clearly revealed. 
The morbid states of the blood, however, and their indications, are detailed 
elsewhere. The manner in which the blood issues from the opening is not 
without some value as a sign. An unusually forcible jet, and rapidity of 
flow, may be considered as evidences of energy in the circulatory movement; 
while the contrary inference may be drawn from an escape of the blood, drop 
by drop, when the opening into the vein is free, and there is no reason to 
suppose, that any merely temporary interference with the action of the heart 
may be the cause of the phenomenon. In the latter case, it not unfrequently 
happens that the current gradually increases,'and at last flows as vigorously 
as under ordinary circumstances. The symptoms presented by the blood 
must be observed incidentally; for it can scarcely ever be proper to bleed for 
this purpose alone. 
4. Symptoms belonging to the Functions of Nutrition and Secre- 
tion.-In relation to the symptoms connected with the former function, all 
that is necessary will be stated under special diseases. The most prominent 
of them are emaciation, softness and flaccidity of the tissues, and atrophy, 
indicating a deficiency of the process; obesity and hypertrophy, indicating its 
excess; and various organic changes of tissue, indicating its perversion. The 
symptoms afforded by the secretions, are often of the greatest importance, and 
should always be most carefully investigated. They consist in an increase, 
diminution, or perversion of the function. Sometimes there is a. general 
deficiency of all the secretions, as in certaiij cases of fever; but a general 
increase is scarcely possible. Much more frequently, the deficiency, as well 
as the increase, is confined to one or a few organs. When the increase is so 
great as to be exhausting, the affection is called colliquative. Thus, we say 
colliquative sweats,. colliquative diarrhoea, and colliquative diuresis. In per- 
version of the secretory function, the products are sometimes wholly different 
in character from those in health; being not unfrequently excessively irritant 
instead of bland, and sometimes yielding evidence to chemical re-agents of the 
presence of new constituents. In some instances, one secretory organ seems 
to perform the office of another; as where the colouring matter of bile is thrown 
out by the kidneys, when the liver ceases to secrete. The individual secre- 
tions which most require attention are those of the liver, the kidneys, and the 
skin. The symptoms connected with disordered hepatic secretion, are exhibited 
chiefly in the stools, which are a deep yellow, or clay-coloured, or dark, accord- 
ing as the secretion is too copious, deficient,''or deranged. Those connected 
with the kidneys are seen in the excess, the diminution or suppression, and 
the alteration of the urine, which presents a great diversity of quality and 
composition, indicative of peculiar and very serious diseases. Independently 
of its variation in. quantity, the perspiration also sometimes affords valuable 
signs by its quality, as when, by its sour smell, it indicates an excess of acid 
in the circulation, and by its offensiveness, an unhealthy state of the blood. 
All these symptoms, however, are fully noticed in connexion with the diseases 
they represent; and they are referred to here, only that the student may be 
impressed with the importance of making a close examination of them, in all 
serious cases. ; • ' ■ 
5. Symptoms belonging to the Calorific Function.-Though the 
human system is capable of supporting great extremes of temperature, for 
a short time, with impunity, yet that of the body itself is never very greatly 
above or below the mean standard of health, until vitality has ceased, or has 
been so far reduced, as to have surrendered the body, in great measure, to the 
action of physical and chemical laws. The mean temperature of the body is CHAP. III.] 
SYMPTOMS O.F DISEASE. 
175 
about 100° F. Dr. Davy found the greatest deviation from this standard, in 
the cases of 114 individuals whom he examined, to be in the downward direc- 
tion 96 j°, and in the upward 102°. But in disease, especially in fevers, the 
heat of the body not unfrequently rises to 106°, and in a case of tetanus, 
mentioned by Dr. Edwards, was 110£°; while in cholera, it has been reduced 
to 66° in some rare cases, and 20° below the average has not been uncommon. 
It must be recollected, however, in estimating the temperature in disease, that 
in health it is higher in the young and vigorous than in the old,-in the waking 
than in the sleeping state, near the heart than at the extremities, within the 
body than upon the surface, and that it, may be somewhat elevated by active 
muscular exertion, and exposure to a high temperature. To determine'accu- 
rately the heat of the body, it is necessary to employ the thermometer, the 
bulb of which should be placed under the tongue; but for all ordinary pur- 
poses the hand is sufficient. 
It must be borne in mind that the temperature .of the body, and the sensa- 
tions of heat or cold felt by the patient, are very different things. Generally, 
they coincide in a greater or less degree; but not always. Sometimes the 
patient experiences chilly sensations when his surface feels hot to a by-stander, 
as not unfrequently happens in the earlier stages of fever; and sometimes, on 
the other hand, he suffers greatly with a feeling of heat, when the surface of 
the body is really cold. These deranged sensations must be ascribed to 
nervous disorder. It is true that the heat, sometimes complained of by 
patients in malignant diseases when the skin is very cold, has been referred 
to sanguineous congestion of the internal organs; but the sense of heat is not 
confined to the interior1, in these cases. I have known complaints to be 
made also of heat of the surface, under the same circumstances. It is, I 
have no doubt, a perverted sensation, consequent on the derangement of the 
nervous system, just as light flashes sometimes before the diseased eye in 
darkness, and roaring sounds are heard in the. midst of profound silence. It 
is, moreover, for the most part, a very unfavourable symptom. 
The change of temperature may be general or local/and it not unfrequently 
happens that one portion of the body is affected in one way, and another in 
another. Thus, the head is often hot, while the extremities are cold. Attempts 
have been made to designate, by particular names, different modifications of 
the sensations of heat and cold. Thus, we have the expressions on the one 
hand of chilliness, coldness, and rigors or shivering; and on the other of 
warmth, heat,, burning, acrid heat, pungent or biting heat (color mordicans), 
&c. The shivering, trembling, and shaking which often attend the feeling 
and reality of cold, sometimes occur as mere nervous phenomena, without 
reference to the existing temperature of the body. 
6. Symptoms belonging to the Sensorial Functions.-These are 
exceedingly numerous. They embrace all derangements, not only of general 
and special sensation, as these terms are usually understood, but also of those 
feelings which proceed from the interior organs and tissues, and by which 
they make their wants and their sufferings known, such as nausea, hunger, 
thirst, breathlessness, &c. But these have already been considered, or will 
be considered hereafter, in connexion with the derangements of which they 
are the expressions. Our attention will at present be confined to the symp- 
toms afforded by derangements of general sensation, and of the several special 
senses of sight, hearing, &c. General sensation is deranged in two ways. 
Either it is, in the first place, defective or altogether wanting, or, secondly, it 
is disagreeably altered, constituting various kinds of uneasiness, which, for 
convenience sake, may all be classed together under the head of pain. It is 
only the latter that requires any general remarks. 176 
GENERAL PATHOLOGY. 
[part I. 
Pain.-This feeling is quite undefinable, and can be known only by those 
who have felt it. There can be no doubt that it resides exclusively in the 
nervous structure. It has various sources. Irritation or excessive excitement 
of the nervous function may produce it, either with or without vascular dis- 
ease. It is a very frequent attendant upon inflammation, and is ascribed by 
writers generally to the pressure made upon the nerves in this affection. 
But, as it very often precedes the inflammation, appearing to be the first ob- 
vious step in that process, and as a much greater amount of pressure upon 
the healthy nerves does not produce it, the probability is, that it is the direct 
result of the irritant cause acting on the nerves. But there appears, also to 
be a modification of the nerves, in which their sensibility is exalted, inde- 
pendently of any irritant agent, and in which pain is produced by ordinary 
agents which, in the healthy condition of the nerves, excite no sensation. It 
is possible, however, that this may be nothing more than an excitement, 
which, insufficient of itself to occasion uneasiness, may amount to pain when 
very slightly increased. Still, there are cases, and those by no means unfre- 
quent, in which pain is attended with no appreciable excitement of any kind, 
whether nervous or vascular; but, on the contrary, occurs in a state of posi- 
tive depression and debility, and even seems to be favoured by that state. 
Thus, a limb benumbed by cold, in which special sensation is almost lost, 
and vascular action is greatly diminished, often experiences exquisite pain; 
palsy is not unfrequently attended with the same, symptom; and neuralgia is 
a common result of general debility. It is, therefore, a great error to consider 
pain as always an evidence of inflammation. It is, indeed, in very many 
instances, most effectually relieved by means calculated most strongly to ag- 
gravate the latter affection. Nor is inflammation always attended with pain. 
There is reason to believe that pain is seated in nerves, wholly distinct from 
those devoted to the special sense of touch. Hence the sensation of pain in 
parts benumbed by cold; and hence, too, the complete insensibility to painful 
impressions in some instances of somnambulism, or the mesmeric state, as it 
is called, in which the sense of touch, and the other special senses, are acutely 
alive to impressions. 
Pain differs exceedingly in its modes of recurrence, degree, and character. 
Thus, it is fugitive or persistent, wandering or fixed, intermittent, remittent, 
or continued. In its different grades, it is slight, moderate, severe, violent, 
intense, excruciating, or agonizing. In character, it is dull or obtuse, sharp 
or acute, aching, smarting, &c.; and, in its different varieties, has received 
peculiar names from certain real or supposed analogies, as lancinating, cutting, 
stinging, pungent, boring, tearing or rending, gnawing, &c. When attended 
with a beating sensation, consequent upon the heart's action, it is called pul- 
sating or throbbing; when with a feeling of tightness, tensive; when with 
weight, heavy ; when with heat, burning,. There are also peculiar sensations, 
which, in excess, become positively painful, though they might not be con- 
sidered so in their slighter degrees. Such are itching, tickling, prickling, 
tingling, &c. To pain belongs also tenderness, or that property by which a 
part becomes positively, and sometimes acutely painful, by motion or pressure. 
Tenderness is considered by some as one of the most certain signs of inflam- 
mation. But, though it very commonly accompanies that process, it often 
exists without it. Thus, it not unfrequently attends neuralgia, and generally 
follows severe spasm, whether in the exterior muscles, or in the muscular coat 
of the stomach and bowels. This fact is of some practical importance; as the 
knowledge of it may spare many a patient an unnecessary and perhaps inju- 
rious loss of blood. Under pain, finally, we may rank those general and inde- 
finite sensations which are vaguely designated by the terms general uneasiness, CHAP. III.] 
SYMPTOMS OF DISEASE.-PAIN. 
177 
restlessness or inquietude, anxiety, and oppression ; sensations which indicate 
disorder of the nervous system, and are often useful as signs'. 
It has been stated above that pain is sometimes wandering, and sometimes 
fixed. Wandering or flying pains are frequently purely nervous or neuralgic, 
and fixed pains inflammatory; but the distinction is'by no means constant. 
This character, however, may often be employed as a diagnostic symptom. 
Thus, it may be doubted whether a pain in the side is symptomatic of pleu- 
ritis or pleurodynia. If fixed, the presumption is that it is the former; if 
Wandering from one point to another, that it is the latter. 
Pain is different in the different tissues. In the serous ■and synovial mem- 
branes, it is often severe, and sharp or acute; in the mucous membranes and 
parenchyma of the viscera, dull or obtuse, oppressive, heavy, &c.; in the skin, 
it is apt to be burning, itching, tingling, &c. 
It is not always that pain is felt in the spot where the cause of it exists. 
Thus, in irritation of stomach, it is often referred to the forehead and eyes; 
in hepatitis, to the shoulder; in inflamed hip-joint, to the knee; and in dis- 
ease along the course of any passage, to the outer extremity of the passage, as 
in the case of stone in the bladder, in which the pain is often felt at the end 
of the penis. 
In judging of the degree of pain in any particular case, we must not always 
be determined by the statements of the patient. Very different meanings are 
often attached to the same words by different individuals; and some have the 
habit of using terms of exaggeration for all their feelings. In such cases, we 
must be guided more by the expression of'the countenance, and the tone of 
the voice, than by what is said. If a person tell us, with perfectly composed' 
features, and a calm equable .tone of voice, that he is suffering excruciating 
pain, we shall be justified in estimating its severity greatly below the real 
value of the term. ■ 
Patients also have very different degrees of sensibility, and feel with differ- 
ent degrees of acuteness. Some persons are little sensitive to painful impres- 
sions of any kind, others suffer really and greatly from slight causes. Exter- 
nal cancer, which, in most individuals, is a source of extreme suffering, ap- 
pears in some scarcely to produce pain. 
Special Sensation.-The several senses, sight, hearing, smell, taste, and 
touch, are liable, like all other functions of the body, to be morbidly exalted, 
depressed, or perverted. They are very apt to be deranged, not only by 
direct morbific impressions, but also by irritating impressions proceeding 
from distant organs, and reflected upon them from their respective nervous 
centres. Hence the muscae volitantes, and the tinnitus aurium, which so 
frequently accompany derangement of stomach. But the symptoms con- 
nected with the senses, will be most advantageously treated of with the dis- 
eases of the senses respectively. 
7. Symptoms belonging to the Intellectual and Emotional Func- 
tions.-These are very numerous, embracing all the phenomena of deranged 
intellect, defective, augmented, or perverted memory, emotional excitement, 
whether pleasing or painful, depression of spirits, depraved dispositions and 
tastes, arid every variety of facial expression. Those forms of diminished, 
suspended, or disordered cerebral action, denominated heaviness, drowsiness, 
somnolence, stupor, lethargy, coma, vertigo, giddiness, dizziness, faintness, 
wakefulness, disturbed dreams, somnambulism, &c., may all be included in 
the same category. All the general remarks that are necessary, mfiy be 
arranged under the two heads of delirium and facial expression. It may, 
however, be proper to state, that some diseases have a remarkable tendency to 
produce cheerfulness, confidence, or resignation of spirit, as phthisis; while 178 
GENERAL PATHOLOGY. 
[part I. 
others evince an equally strong tendency to mental dejection and despondency, 
especially the gastric and hepatic affections. 
Delirium.-This is an acute and temporary disorder of the intellectual or 
perceptive faculties. When chronic, it becomes, insanity. It occurs much 
more readily in some persons than in others, under apparently the same cir- 
cumstances. There are individuals who become delirious with the slightest 
fever; while thbre are others who scarcely ever evince signs of mental aberra- 
tion, in the severest forms of febrile disease. The affection is more frequent 
in the young than the old, and in nervous persons than in those of a different 
temperament. It arises from different causes, producing the opposite condi- 
tions of irritation or depression of the cerebral functions, and especially from 
causes acting on the hemispheres. Those affecting the base of the brain are 
more apt to evince themselves by derangements of general sensation, or of 
the motive power. Meningeal affections are usually marked by delirium of 
the more active character, because the influence they extend into the cortical 
substance is sufficient to occasion irritation, without abolishing function; while 
original disease of the brain itself is apt to produce the latter effect, evinced, 
according to its degree, by impaired intellect, lethargy, coma, &c. Very fre- 
quently, the impressions which ascend to the brain from diseased organs in 
various parts of the body, especially the stomach, bowels, liver, and uterus, 
are sufficient to occasion delirium; and this is a more frequent effect of such 
causes than the abolition of function, because their effects are generally those 
of mere irritation, and stop short of organic disease. A want of due energy 
or action in the brain may be the occasion of delirium, as well as its excess. 
This is usually the result either of the withdrawal of some wonted stimulus, 
as in delirium tremens; of the languor which follows excessive excitement, 
as in the advanced stage of active delirium; or of the direct action of a seda- 
tive agent, as the poison of typhus fever, or the depraved blood of that dis- 
ease and of the last stages of cardiac and pectoral affections. Organic cerebral 
disease may produce one or the other condition of function, according to its 
degree and extent. If moderate, or in the early stage, it may exaggerate the 
function, especially of those parts not directly involved in the disease; if 
extensive, or in the advanced stage, its tendency is rather to impair power 
and function together. 
Delirium may, therefore, be active or passive. The active differs greatly 
in degree, being sometimes very mild, sometimes violent or furious, and of all 
intervening grades. The milder grades are usually evinced by some mental 
aberration, with little disposition to action; the higher grades by superadded 
violence of gesture, voice, and language. In the passive delirium, the brain 
acts wrongly, because it cannot elevate itself to the point for the due percep- 
tion of impressions, or the formation of judgments. Of this kind is the low 
muttering delirium of typhus. It often happens, in passive delirium, that an 
increase of the proper stimulus restores temporary correctness of thought. 
Thus, though the patient may be muttering sentences without apparent mean- 
ing; yet, if roused, and spoken to in a loud and distinct voice, he will often 
answer coherently and correctly. 
Sometimes, in delirium, there is a complete derangement of mind. The 
patient recognizes neither the persons nor the things around him. He is very 
apt to imagine himself in a strange place, and to insist upon returning home. 
This is often a bad sign. In other instances, the sensations and perceptions 
are correct, but the judgment is perverted. In others, again, only the per- 
ceptions are wrong, while the mind acts rightly upon the perception which it 
forms. Thus, the patient sees objects and hears sounds which do not exist, 
and acts as if those sights and sounds were real. When the fallacy of the CHAP. III.] 
SYMPTOMS OF DISEASE.-DELIRIUM. 
179 
perceptions or sensations is recognized by the patient himself, he cannot be 
said to be delirious. 
Facial Expression.-This is of the greatest importance, and should be care- 
fully studied by every practitioner. It is occasionally almost our sole depend- 
ence in diagnosis. Through it, we sometimes recognize the existence of pain, 
mental anxiety or depression, insanity y and even, in a general way, pectoral 
or abdominal disease, when other signs are either wanting, obscure, or not 
available. In the cases of children, of the insane, and of persons who may 
be disposed to deceive us, it is a peculiarly valuable resource. Many diseases 
are attended with a characteristic aspect of countenance, which will often be 
recognized by the experienced, so far at least as to suggest the disease to his 
mind. By a glance, we can often ascertain whether our patient has changed 
for the better or worse in our absence. But it is only by experience, and 
close observation, that this power is attained. The modifications and com- 
binations of feature which constitute expression, are too numerous, intricate, 
delicate, and evanescent, to admit of analysis, at least of profitable description. 
There are, however, certain changes in the face of a more tangible cha- 
racter, connected rather with the organic functions than the action of mind, 
which can be more accurately appreciated. The colour, shape, temperature, 
and various movements independent of expression, often yield important indi- 
cations. Thus, a bright red colour signifies one thing, a dark-red, purple, or 
violet colour another. In the former case, the blood is duly arterialized, and 
probably sent up vigorously into the head; in the latter, it is unduly carbon- 
aceous, and probably detained in the head by some obstruction to its return. 
Paleness also has its significations, as -of anaemia, debility, nausea, &c.; and 
there are different kinds of paleness having different meanings, as that of 
scrofula or phthisis, and that of cancer. Yellowness of face is well known to 
point to disease of the liver. The colour of the lips is peculiarly expressive, 
in its different tints of crimson, purple, and paleness. The features may be 
full, swollen, turgid; or they may be shrunk, contracted, fallen; in the former 
case indicating oedema, or congestion, active or passive; in the latter, exhaus- 
tion, prostration, general collapse, &c. The Hippocratic face, so named 
because described by Hippocrates, is often referred to by writers as marking 
the near approach of death. It is characterized by a general contraction of 
the features. The nose is pinched, the temples hollow, the eyes sunken, the 
ears cold and shrunk, the skin of the forehead tense, the lips parted and re- 
laxed, and the colour of the face pale or livid. Coldness of the ears and tip 
of the nose occasionally indicates the approach or presence of a chill, when 
other symptoms are wanting or ambiguous; and, in infantile cases, coolness 
of the cheeks, nose, and ears, sometimes enables us to decide upon the exist- 
ence of a degree of prostration requiring support, when we might be embar- 
rassed without that sign. Certain positions or movements of the features are 
sometimes also highly expressive. Thus, alternate contraction and expansion 
of the alas nasi frequently indicate dyspnoea; irregular motions of the eyes, 
with contracted or expanded pupil, disease of the brain; and a falling of the 
under jaw, the last agony. 
8. Symptoms belonging to the Motor Function.-These arise from a 
deficiency or complete want of muscular contraction, as in debility, palsy, or 
local disease of the muscles; from an excess of contraction, as in spasm, con- 
vulsions, and subsultus tendinum; or from irregular or perverted contraction, 
in which the muscles act under the will, but not to the end proposed, as in 
chorea. Under this head are included all the voluntary motions; the gestures, 
the manner of walking, running, &c.; the positions, as standing, sitting, and 180 
GENERAL PATHOLOGY. 
[part I. 
lying; and all the symptoms connected with the voice, and speech, as sup- 
pression of voice, hoarseness, shrillness, dumbness, stammering, &c. 
But these symptoms, and many others belonging to the different functions 
not here noticed, including those of the reproductive function, will be most 
advantageously studied in connexion with the several diseases in which they 
are found. Our limits do not permit of ampler details in this part of the 
work. ' . : 
SECTION II. 
COURSE, DURATION, AND TERMINATION OF DISEASE. 
By the course of disease, is meant the succession of its symptoms, in rela- 
tion both to order and rapidity. When, from the commencement to the 
termination, the symptoms show no disposition to abate, or when they regu- 
larly increase in violence up to the point at which recovery begins, or the 
patient sinks, the disease is said to be continued. Neither of these events, 
however, often happens, unless in diseases of very brief duration. More com- 
monly, the symptoms, after a shorter or longer continuance, abate considerably, 
without, however, entirely disappearing, and, having remained for a time in 
this state of relaxation, resume their original violence, again to abate as before; 
and this alternation of excitement and relaxation continues to the end. The 
disease, under these circumstances, is said to be remittent, ' the period of 
abatement is called the remission, and that of excitement the exacerbation. 
Frequently, all the symptoms yield entirely for a time, so as to leave regular 
intervals in which the patient is apparently free from disease. The complaint 
is then said to be intermittent, and the interval is called the' intermission; 
while the stage of excitement is designated as the paroxysm. 
The period at which the remission occurs, may depend on the nature of the 
morbid condition, and, in that case, is peculiar in each disease; as on the third 
or fourth day in sinall-pox, and on the second and third day in yellow fever. 
It may also depend on causes unconnected with any particular disease, and 
existing either in the constitution of the frame, or in the influences to which 
it is subjected from without; and, under the operation of these causes, the 
remission occurs, in most diseases, at similar intervals, usually once in twenty- 
four hours. It is a law of our physical as well as moral nature, that excite- 
ment, even under the constant influence of stimulating agencies, cannot be 
long sustained at a particular point of elevation. We see this every day in 
health. The various agents, such as food, drink, heat, light, &c., which are 
necessary to sustain the system in its proper condition, may be present in an 
equal degree throughout a given period; yet the excitement produced by them 
flags after a time, and sleep, with a general reduction of the vital actions, 
occurs. So, under the influence of some morbid excitement, the action flags 
for a time, though the application of the excitant be continued. During this 
state of comparative rest or diminished excitement, the system acquires new 
energies, which render it again susceptible to the influence of the stimulating 
agent, and the temporary reduction is, therefore, followed by a renewed eleva- 
tion of the diseased process. It has been before observed, that this change of 
remission and exacerbation usually takes place once in twenty-four hours. 
The cause of this is probably to be found in that habit of the system, acquired 
by the daily alternation of waking and sleeping. The excitability of the 
former condition being regularly diminished in the latter, a flux and reflux is 
established, which, though in cases of disease it may occasionally vary in the CHAP, nt.] 
COURSE AND DURATION OF DISEASE. 
181 
precise point of accession or decline, is still, as a general rule, experienced 
within the habitual limits. 
Upon the same principle, to a certain extent, may be explained the dis- 
position observable in intermittent diseases to a daily return of the paroxysm. 
The cause of the disease gives rise to the first paroxysm, at that period of the 
twenty-four hours, at which, in the advance or recession of the excitability, 
the system is in the most favourable condition for its action. The same con- 
dition is experienced about the same time on the following day, and the same 
result necessarily takes place, if the cause continue to operate. That the 
paroxysm should often ocCur every other day, and sometimes every third day, 
as in the tertian and quartan agues, must be referred to some unknown modi- 
fication in the character of the cause, or in the properties of the system, which 
prevents the equilibrium of health from being disturbed on the first favourable 
occasion, and enables the vital resistance to triumph over the morbid influence, 
till, weakened by continued assault, it is compelled at last to give way. 
Disease sometimes runs its course speedily, and sometimes is of long dura- 
tion. In the former case, it is said to be acute, in the latter, chronic. These 
terms, however, are not definite. There are no characteristic signs, which 
serve in every case to distinguish an acute from a chronic complaint; and the 
terms are not unfrequently employed to express different stages of the same 
affection; the disease being called acute in its earlier course, when the symp- 
toms are most severe, and chronic, when its duration has become protracted, 
and its violence considerably abated. 
There is another distinction between diseases, which is of ■ considerable 
practical importance. Some appear to have no definite course, duration, or 
end; being more or less variable in the succession of their symptoms, lasting 
a less or greater length of time, and terminating favourably or otherwise, 
according to circumstances in the constitution of the patient, and in his rela- 
tion to surrounding objects. ' Others, on the contrary, whatever may be the 
constitution, habits, of exposure of the patient, are disposed to pursue a cer- 
tain course, and in a given time to end in recovery, unless fatal disorganization 
arrests their progress, or derangements of structure of a less violent character, 
resulting from the disturbance into which the system has been thrown, impede 
their march towards health. A third set of diseases are those which exhibit 
no tendency to a favourable issue, and which, if left to themselves, and some- 
times in defiance of all treatment, go on gradually increasing in intensity till 
they ultimately destroy the patient. Examples of the first class are presented 
in rheumatic inflammation and neuralgia, of the second in small-pox and other 
exanthemata, and of the third in cancer. It is obvious that our treatment 
must be very much influenced by these differences in the tendencies of dis- 
ease; being directed to the subversion of the morbid action, in cases which 
admit of a direct cure, and to the prevention, as far as possible, of dangerous 
consequences in those which run a fixed course; while, in those of an incurable 
nature, we must be content with endeavours to alleviate the sufferings and 
protract the life of the patient. It is particularly important that the prac- 
titioner should bear in mind the disposition of many, perhaps we might say 
of most diseases, to terminate favourably after having run a certain course, 
provided fatal organic injury can, in the meantime, be prevented. With this 
conviction ever present to his mind, he will be less disposed to waste his own 
efforts, and the vigour of the patient, in yain attempts to effect an immediate 
cure; and, even in cases in which the disease may possibly be arrested in its 
progress, will often prefer such moderate measures as will insure ultimate 
recovery, in the natural course of things, to the chance of more speedy success 
from violent remedies, with the risk of serious mischief. 182 
GENERAL PATHOLOGY. 
[part I. 
Crisis.-The name of crisis is usually applied to the turning point of dis- 
ease ; the point at which it begins to give way, if its end is to be favourable, 
or to become decidedly worse, if unfavourable. This period is often attended 
with certain phenomena which mark the favourable or unfavourable change, 
and are, therefore, denominated critical symptoms. The most common of 
these are augmented secretions, hemorrhages, cutaneous eruptions, glandular 
swellings, and abscesses. The secretions are usually from the skin, bowels, 
and kidneys, constituting critical sweats, critical diarrhoea, and critical diu- 
resis. At one time, great importance was attache* to these discharges. It 
was supposed that they carried' the peculiar peccant'matter out of the system, 
thus proving positively curative; and any interference with them was strongly 
deprecated. Though this view of their influence is no longer entertained; yet 
they are still looked on by many as, in some instances, very useful, by re- 
moving irritation or congestion, or, when of an inflammatory character, by 
calling off diseased action from its seat, upon the principle of revulsion. In 
most cases of disease, however, there are no symptoms which can strictly be 
denominated critical; and, when they do occur, they may be considered, in 
general, as coming under one of the three following heads. They are either, 
first, regular results of the pre-existing morbid conditions, explicable upon 
ordinary pathological principles, as when the excited vessels of the skin in fever 
unload themselves by perspiration; or, secondly, transfers of disease from one 
organ to another, under various accidental influences, as when rheumatism ends 
in diarrhoea; or thirdly, new diseases supervening upon those already exist- 
ing, and superseding or increasing them, as the case may be, as when an attack 
of bleeding piles, occasioned by straining at stool, relieves an existing attack 
of-splenitis or hepatitis. 
Hippocrates believed that disease, in general, was more disposed to change 
at certain periods than at others; and he designated the 7th, 14th, 20th, 27th, 
34th, and 40th days, as constituting the periods alluded to, which he named 
critical days. It will be perceived that the intervals between the days men- 
tioned are very nearly a week; and Hippocrates considered the crisis as falling 
on the last day of each septenary period. He carried the doctrine1 further, 
and supposed that there were certain intermediate days, in which, though the 
tendency to change was not so strong as in those mentioned, yet that it existed 
in a certain degree; while there were others in which the disposition was still 
less, and others again in which a crisis never occurred. These notions of the 
father of medicine certainly do not apply, with any great accuracy, to diseases 
as they now exist; yet there appears to be some vague relation between dis- 
ease and weekly periods of time; for many complaints show a disposition to 
end in about seven days, more or less; and it is a subject of constant obser- 
vation, that miasmatic fevers, when they return after being checked, are apt 
to do so in one, two, or three weeks, or some other septenary period, most fre- 
quently perhaps at the end of the second week. This tendency is, in the pre- 
sent state of our knowledge, quite inexplicable. 
Termination.-A particular disease may terminate in convalescence, in 
some other disease, in the chronic form of the same disease, or in death. Con- 
valescence is sometimes sudden. There is an immediate transition from dis- 
ease to health. This is most apt to happen in nervous affections. But much 
more frequently the change is gradual. Among the first symptoms of conva- 
lescence from acute disease,, are generally a commencement of the cleaning of 
the tongue, and a diminution in the frequency of the pulse. The skin, if be- 
fore dry, is apt to become moist, the other secretions are gradually restored 
to their normal condition, and all the functions are in the end re-established. 
Emaciation, however, is usually more striking in convalescence than in the CHAP. III.] 
TERMINATION OF DISEASE.-DEATH. 
183 
previous illness. This may possibly be in part merely apparent, and the re- 
sult of the principle of association, which expects healthy looks in returning 
health; but it is probable that the nutritive process does not at first keep pace 
with the vigour of absorption, and that the. body for a time really loses more 
than it gains. Convalescence often goes on happily; but often also it is dis- 
turbed by unpleasant symptoms, and interrupted by drawbacks, consequent 
upon the irregular action of the debilitated or perverted functions. Copious 
night sweats are frequent; the appetite is sometimes feeble, and requires stim- 
ulation; the bowels are apt to be constipated; the pulse often remains frequent; 
and the patient is troubled with various nervous symptoms; such as restless- 
ness, wakefulness, and extraordinary dejection of spirits, or fanciful and hypo- 
chondriacal notions. These, however, gradually disappear, spontaneously, or 
under appropriate treatment; all the functions become active; and the oscilla- 
tion not unfrequently extends even beyond the original standard of health. 
The appetite becomes voracious, nutrition abnormally active, and the body 
swells considerably beyond its previous dimensions. The various sensibilities 
have been as it were regenerated, everything is for a time enjoyed with the 
zest of youth, and life has acquired new charms. Sometimes the increased 
fleshiness continues a confirmed habit of the body; but more frequently it 
subsides to the original level, and the individual becomes his former self again, 
with the exception, it may be, of the loss of some previous morbid tendency, 
or the acquisition of a new one. The hair is very apt to fall after se.vere 
illness, and sometimes does not return, especially in advanced life; but gene- 
rally its place is supplied by anew and equally luxuriant crop. It is thought 
that shaving the head has the effect of favouring the latter result. 
Sometimes convalescence is interrupted by a return of the disease, which is 
then said to have relapsed, and the new attack is called a relapse. Some dis- 
eases seldom if ever relapse.. This is .especially the case with those which de- 
pend on a specific poison, run a certain course, and are usually taken but once, 
as small-pox, measles, &c. These not unfrequently leave unpleasant sequelae 
behind them; but it is very rarely that they run over their course again. Others 
are very prone to relapse, as the miasmatic fevers, rheumatism, and the phleg- 
masiae generally. In relapses, the patient suffers under the disadvantage of 
the debility and unrepaired mischief of the first attack, and, therefore, not un- 
frequently sinks; though the real force of the returning, is usually less than 
that of the original disease. 
Convalescence is sometimes imperfect, and the health is not completely re- 
established for months or years, if ever. Sometimes a tendency to a new dis- 
ease is awakened. Thus, phthisis and scrofula frequently follow attacks of 
the exanthematous, fevers. Sometimes, an organ which has suffered in the 
disease cannot recover itself; sometimes, again, the character of the vital func- 
tions is permanently impaired in some inappreciable manner, and dropsy, 
anaemia, or other cachectic condition is established. 
Not unfrequently, an acute disease becomes chronic. The symptoms sub- 
side without disappearing. The result here is not a new disease called into 
action or generated by the old, but it is a continuance of the latter, with its 
essential characters, though much modified in degree, and sometimes in the 
phenomena. 
The termination in death may take place either by a general exhaustion of 
the powers of the system, so that the flame of life lessens and lessens until it 
goes out; or in consequence of the failure of one or more of the functions, the 
integrity of which is necessary to life. The latter mode of death is beyond 
all comparison the most frequent. It is seldom, indeed, that the vital powers 
give way so gradually and equally throughout the system, that it is impossible 184 
GENERAL PATHOLOGY. 
[part I. 
to say, that any one part or function suffers prominently, and becomes the 
immediate avenue by which life escapes. In almost all cases, whatever may 
be the nature of the disease, death approaches through one of three vital 
organs; namely, the lungs, the brain, or the heart. When respiration ceases, 
the blood can no longer circulate'through, the lungs. It is arrested in the 
capillaries of that organ, and death necessarily follows, unless the respiration 
is restored. The heart Ceases to act, and all other organs cease to act, because 
the necessary support of their functions is denied to them by the stoppage of 
the blood in the lungs. Death, under such circumstances; takes place by 
asphyxia, or as some denominate it, apnoea. The brain presides, as the cen- 
tre of the nervous actions, and the great link which binds the functions toge- 
ther, over all the vital processes; and none can go on without its continued 
influence. If the brain become powerless, respiration must cease, the circula- 
tion must cease, and life of course along with them. No special designation is 
applied to this mode of death. But both the lungs and the brain may be 
perfectly sound, and death may come through the heart; the morbid cause 
acting directly on that organ. In this case, death is said to take place by 
syncope. , 1 
For a longer or shorter period before death, certain symptoms usually appear 
which mark its inevitable approach. The patient, under these circumstances, 
is said to be dying. Sensation and consciousness are extremely imperfect or 
quite lost; the features are.collapsed and without expression; the under jaw 
is often.fallen; speech and deglutition are difficult or impossible; there is often 
rattling in the throat, from the inability of the patient to expectorate; respi- 
ration is irregular, at first sometimes hurried, but gradually becoming jess and 
less frequent, with intervals gradually lengthening until it ceases; the pulse 
is usually small and feeble, often irregular, and sometimes quite absent at the 
wrist long before death; the extremities are cool; the skin.often clammy, and 
the colour of the surface pale or somewhat livid; and not unfrequently a cada- 
verous odour may be perceived while the patient still lives. Sometimes death 
approaches by imperceptible degrees, and the patient passes quietly away as 
if falling into a breathless sleep;, sometimes nature' appears to rouse herself 
for a last struggle, and life ends in convulsions. This dying state is called 
the agony, though very improperly; for in most cases it is without a strug- 
gle, and very generally without pain or consciousness. Its duration is very 
various, sometimes not so much as an hour, sometimes several hours; and 
instances occur in which the phenomena continue for days before death. 
SECTION III. 
DIAGNOSIS. 
This term is employed in two senses, with a slight shade of difference. In 
the one sense, it signifies the act of determining the character of diseases, 
and, in relation to any particular case, of ascertaining what (jise^se it is with 
which the patient maybe affected; in the other, it distinguishes diseases from 
each othei' by comparing them, and, in relation to particular cases, ascertains 
what the disease is by determining what it is not. It is used here in both 
senses. A disease is sometimes so well characterized, that it is immediately 
known as soon as its symptoms are seen. In such a case, it would be quite 
supererogatory to bring under examination a number of other diseases, in 
order to show that, though their symptoms may be somewhat analogous to 
those of the case before us, they are not actually the disease in question. But,. CHAP. III.] 
DIAGNOSIS. 
185 
in many instances, the signs of very different diseases are so much alike, that 
without caution they might be readily confounded. In such instances, it is 
advisable to compare the symptoms carefully with those of all the diseases 
about which there might be doubt, and, determining which must be excluded, 
to narrow down the circle at last to the true one. 
It is always proper to look beyond the symptoms to the disease. We ought 
never to be content with putting certain morbid phenomena together, and 
calling them a disease; but should endeavour to penetrate to their source. 
Sometimes, it is true, our research will be fruitless, and we shall be com- 
pelled to remain content with the mere symptoms-; but, should we never 
proceed further than these, the science of pathology would soon cease to make 
progress. > ? ' 
Having determined the character of a disease, we Should next direct a 
particular attention to all the modifying circumstances; -such as the peculiar 
influence which-may have been exerted by the cause, the qualifying effects of 
various subordinate agencies, the secondary affections which may have sprung 
up, and all incidental complications. 
In making out the nature of a disease, when doubtful, it is sometimes ne- 
cessary to call to our aid every , kind of information which has any bearing 
upon the subject. We must carefully examine all the symptoms, must inquire 
into the cause, and nnist take into view all controlling influences, as age, sex, 
temperament, constitutional peculiarities whether original or acquired, habits 
of life, pursuits of pleasure pr business, climate, residence, &c. Accidental 
circumstances will sometimes aid uS considerably, when the patient is unable 
or unwilling to answer our questions. Thus, the remains of food in or .about 
the mouth, the colour imparted by substances which may have been chewed 
or swallowed to the tongue, teeth, and lips, the colour of the hands, stains 
upon the face and clothing, as of white lead, &e., are circumstances which may 
lead to valuable inferences as to what the patient may have taken, his trade, 
or the accidents to which he may have been expose^. In cases, however, 
which are not doubtful, a tod curious prying into all these circumstances 
should be avoided, as often vexatious, and'sometimes injurious to the patient, 
and at best a mere waste of time. 
Now there are certain symptoms belonging to each complaint, by which it 
may be more certainly distinguished than by others, and which, when found 
together, determine the nature of the disease. . These are called diagnostic 
symptoms. Those belonging to the several diseases should be fixed in the 
memory, so that when we go to the examination of any case, we may be pre- 
pared to recognize one of these characteristic groups, if presented, and thus 
come to a speedy conclusion. 
Again, there are diseases that' offer some one peculiar symptom, found in 
them, and under similar circumstances in no others, which fixes at once, when 
observed, the .character of the affection. Symptoms of this kind are named 
pathognomonic. Thus, an eruption of red spots like flea bites, preceded by a 
fever of three or four days, which subsides on their appearance, is a pathog- 
nomonic symptom of small-pox. But such symptoms arc unfortunately very 
rare. In the strictest sense of the terin, they are even rarer than, at first 
thought, they might be imagined to be; for there is almost always something 
more than the bare symptom itself, necessary to give it the characteristic cer- 
tainty. Thus, in the case- above alluded to, the red spots would have no force, 
unless accompanied with the circumstance's mentioned. 
Certain rules ought to be observed in conducting a diagnostic examination. 
The physician should guard against a too purely scientific or professional feel- 
ing. He should not regard his patient as a mere subject for medical analysis; 186 
GENERAL PATHOLOGY. 
[PART I. 
but should consult his feelings, prejudices, and mental peculiarities; and should 
endeavour, while attaining his own conclusions, to do so with as little that is 
disagreeable, and as much that is agreeable to the person chiefly interested as 
possible. Attention to this rule is not only useful to the business interests 
of the physician, by producing kindly impressions, but greatly promotes his 
immediate object, by securing the hearty co-operation of the patient, and the 
favourable effects of confidence in his ,medical adviser. Young physicians are 
peculiarly apt to err upon this point. 
In his examinations, the physician should put as few leading questions as 
possible. The patient is very apt to imagine that he feels what his attendant 
may suggest as possible or probable, and may, therefore, by his answers, inno- 
cently occasion or confirm an error. He should, at first at least, be induced 
to give an account of his own symptoms; the physician only interfering to 
secure a proper order to his remarks. 
It occasionally becomes necessary, in persons disposed, from false modesty 
or a worse cause, to conceal their symptoms, to set on foot a system of cross- 
examination; but this should be done in a manner least likely to excite un- 
kindness; and when, especially in the cases of young females, infonnatjon 
can be obtained from the mother or attendants, it is infinitely better to pro- 
cure it thus, at second hand, than to extort it by a sort of violence from the 
subject. • r 
In examining young children, great care must be taken to avoid exciting 
them. Perfectly correct inferences can seldom be drawn from the examina- 
tion of a crying and struggling infant. Mothers and nurses .are often greatly 
in fault in this respect. To secure temporary obedience, they often alarm the 
child by threats of what the physician will do, and thus render his medical 
attendant an object of terror. There is not the shadow of a doubt, that the 
most fatal consequences have ensued from this error on the part of weak or 
wicked care-takers of the young; and every physician should inculcate upon 
the parents, in whose families he may attend, the importance of teaching their 
children rather to love than to fear him. 
In pursuing his investigations, the physician should observe some order. 
He will thus save time, and gain clearer notions than by a belter skelter 
examination, which, in its devious course, must often return upon itself. In 
general, when the organ or function affected is obvious, this should first engage 
attention. Afterwards, or originally in cases of any degree of obscurity, it is 
probably the best course, first to take a survey of the exterior, and then to 
interrogate the several functions successively, beginning with the digestive, 
and following with the others in their natural order, as observed in the fore- 
going general history of symptoms, namely, the absorbent, the respiratory, 
the circulatory, the nutritive, the secretory, the sensorial, the intellectual and 
emotional, the motor, and the reproductive. One accustomed to examinations 
of this kind can run through the whole routine very rapidly, and often a glance 
at the function is sufficient to show that it is sound or otherwise. 
In order to complete the subject of diagnosis, it is necessary that, some 
account should be given of the modes of proceeding, and the implements to 
be employed. The exploratory processes which require distinct notice, may 
be included under the heads of inspection, palpation or the touch, pressure, 
succussion, percussion, tneasurerhent, and au^cultatioii. 
1. Inspection.-Very many symptoms are observed by simple inspection. 
This is obviously the case with most of those which are quite external. Such 
are the attitudes and movements of the patient, the general form of his body 
and the relation of its parts, the degree of fulness or emaciation general and 
local, the colour and other appearances of the skin, the condition of the several CHAP. III.] 
DIAGNOSIS.-EXPLORATORY PROCESSES. 
187 
features, the expression of the face, and all the other physical characteristics, 
so far as they are visible. We can, to a certain extent, penetrate by our 
vision, into the interior of the body. Thus, wq can examine the mouth and 
fauces directly by the eye. In the inspection of the fauces, the mouth should 
be opened as widely as possible, and the tongue, without being in the least 
protruded, should be depressed by the handle of a silver tablespoon, an ivory 
folder, or wooden spatula, or even the finger, if no more convenient instrument 
should be at hand. Many persons 'have the faculty of so opening. the mouth 
as to exhibit the fauces without the aid of an instrument. In others, the 
object can be accomplished by directing them to open the mouth, and then 
quickly make a short, and as it were spasmodic inspiration. In cases of 
infants, who cannot or will not protrude the tongue, the, mouth can often be 
sufficiently examined by allowing them to cry. Instruments, called speculums, 
have been invented for the inspection of internal parts, which the eye cannot 
reach. J>y this means, the state of the uterus can often be very advantage- 
ously ascertained; and the rectum, bladder, and throat have to a certain extent 
been examined in the same way. 
2. Touch.--Palpation.-In this process, the flat of the hand, or of one or 
more of the fingers, is laid gently, and without pressure, on the portion of 
surface to be examined. Care should be taken that the temperature of the 
hands should be as near the ordinary healthy medium as possible. In this 
way, we can judge of the temperature of the surface, of certain physical pro- 
perties of the skin, as its dryness or moisture, its harshness, roughness, soft- 
ness, smoothness, &c., and of certain internal movements, which are commu- 
nicated to the superficies of the body. One of these movements is a certain 
fremitus, thrill, or vibration, produced in certain morbid states by coughing, 
respiration, &c. Another is pulsation, whether natural or morbid. A third 
is fluctuation, which is felt by the hand applied in the manner above directed, 
when percussion is made in the same neighbourhood, or on the opposite side of 
a collection of liquid. A fourth is the movement of tumours, which is some- 
times made sensible to the hand by a change of position in the body, or by 
pressure with the other hand. In performing the process, the hand should 
be.applied accurately to the surface. Sometimes it will be proper that the 
skin should be protected by a thin covering of soft linen or muslin. 
Another mode of gaining information by the touch, is by introducing the 
index finger into the fauces or posterior nares, the vagina, or the rectum. 
The nail of the finger should always be cut short, in order to avoid wouflding 
or irritating the mucous membrane, and, in examinations per anum and 
vaginam, its surface should be well covered with lard or olive oil. 
3. Pressure.-This may be made by the bulbous ends of the fingers, or 
by the whole palm of the hand. It detects tenderness and deficient sensi- 
bility, hardness and softness, firmness and flaecidity, elasticity, and fluctuation. 
It occasions crepitation wdien the cellular tissue is filled with air, and pitting 
when it is edematous. It enables us to ascertain the existence of air in the 
bowels by giving rise to a gurgling sound. By means of it, too, we discover 
the force of the pulse, the rapidity of circulation in the capillaries, and whe- 
ther a red spot upon the skin is the result of extravasated blood or of inflam- 
mation. Generally, the pressure is made equably, with a force proportionate 
to the depth to be explored. Occasionally, however, advantage may accrue 
from a quick, short, pretty strong pressure with the ends of the fingers, in 
detecting deep seated tumours, especially in the abdomen. 
4, Succussion.-This term is applied to a quick shaking motion, communi- 
cated to the trunk of a patient. It may be effected by placing the hands 
upon the shoulders of the patient, and moving his body quickly backward and 188 
GENERAL PATHOLOGY. 
[part I. 
forward, or by putting one hand on each side of the chest, and moving it in 
the same manner laterally. When water and air exist together in a cavity, 
a sort of splashing sound may thus be produced, which serves io detect that 
particular morbid condition. 
5. Percussion.-This process consists in striking upon the surface with 
the view either of eliciting sound, by the nature of which a judgment may 
be made of the condition of the parts beneath, or of producing fluctuating 
or vibratory movements in liquids, by which their presence may be detected. 
When percussion is made over a'considerable cavity filled with air, a hollow, 
drum-like, or tympanitic sound is produced. An example of this sound is 
often afforded by the stomach and bowels, even in a perfectly healthy state. 
When the parts beneath are of a loose "texture, consisting of small cells con- 
taining air, the sound is less loud and hollow, but is still clear. Such is the 
sound elicited by percussing the chest, over the healthy lungs. When the 
subjacent substance is, solid or liquid, the sound is dull or flat;*and the 
degree of dullness or flatness is proportionate to the density and want of 
elasticity. An elastic body, like cartilage, is much more resonant than a soft, 
inelastic body, like muscle or fat. When, liquids are mixed with gases, a 
peculiar tone is often given to the drum-like sound. The nature of the sur- 
face percussed has some influence upon the sound elicited from beneath. 
Thus, percussion on a tense elastic surface produces a greater resonance than 
upon a slack inelastic one; because it is by the vibrations 'of the surface that 
sonorous movements are produced in the structure or masses underneath it. 
Percussion, as above stated, may also be made in reference to the sense of 
touch. By exciting fluctuation, by means of one hand, in this manner, in a 
collection of liquid, the movement may often be readily perceived by the flat 
of the other hand laid upon the surface. This is strikingly exemplified in 
abdominal dropsy, in which the liquid is readily detected by placing the palm 
of the left hand upon one side, and striking quickly with the fingers of the 
right hand on the opposite side. Percussion over a hydatid tumour produces 
in it a vibratory movement, which imparts a peculiar and characteristic thrill 
to*the hand upon the surface, as observed by M. Piorry. 
It is obvious that, by this process, we may discover the abnormal existence 
of solids or liquids in the interior where air should be, and, on the contrary, 
the existence of air where there should be none. We can also frequently 
detect the extent and degree of the morbid change. But it is equally obvious, 
that, in order to draw any just inferences, we must first have familiarized 
ourselves with the sounds emitted by the parts liable to examination in a 
state of health, and with the peculiar character of the sounds by which pecu- 
liar changes are indicated. Hence, every student should early begin to 
educate his ear in reference to this process, by frequent practice both upon 
the healthy and diseased subject. To Avenbrugger, who first published his 
observations in 1761, we are indebted for the first application of this process 
to the diagnosis' of diseases of the chest; but, since his time, it has been 
greatly extended and improved. At present, it is one of our most valuable 
means of diagnosis, not only in thoracic, but also in abdominal diseases. 
There are two modes in which percussion may be performed; to wit, im- 
mediately with the fingers upon the surface of the body, or by the interven- 
tion of some elastic solid. Practised in the former mode, it is said to be 
immediate, in the latter mediate. The former plan was employed by Aven- 
brugger, the latter was invented by M. Piorry, who gave the name of plex- 
imeter (from TCkifat, percussion, and petpov, measure), to the intervening 
body. - 
In immediate percussion, the ends of the four fingers, with the nails pared. CHAP. III.] 
DIAGNOSIS.-EXPLORATORY PROCESSES. 
189 
should be brought together at the same level, and supported by the thumb; 
and the impulse should be given perpendicularly to the surface. Another 
mode, sometimes very convenient, is to place one finger upon or near the 
surface, and to cause the next finger previously placed on the top of the first, 
to slip off from it with some force upon the skin. This is filliping. Or, 
when only a slight impression is desired, the surface may be tapped lightly 
by the fiat of one or more fingers near their tip. To prevent the clicking 
sound produced by the contact of the finger with the skin, which interferes 
somewhat with the sound to be elicited from beneath, it is advised to cover 
the surface with a piece of soft and thin, close-fitting muslin or linen. But 
this mode of percussion is often painful to the patient, and the difference in 
the nature of the surface percussed causes differences in the sounds produced, 
which it is difficult always justly to discriminate. Mediate percussion is, 
therefore, generally preferable. 
The instrument employed in mediate percussion may be a flat, oval, or 
circular piece of ivory, an inch or an inch and a half in diameter, a large 
silver coin, or a flat piece of firm caoutchouc, which is preferable to the others, 
as it makes less sound of its, own with the ends of the fingers. But, upon 
the whole, the best and certainly the most convenient pleximeter, is the left 
index or middle finger of the operator, with it^ flat surface fitted accurately 
to the part to be examined. Percussion is made with one, two or three fingers, 
the ends being placed together, and brought down perpendicularly upon the 
pleximeter. The nails should be short, so as to prevent the clicking sound 
produced by them. The blow shopld be quick, and made exclusively by the 
movement of the wrist, and never by that of the elbow, which would give too 
much force to the impulse. Some substitute for the fingers a very light ham- 
mer, the head of which may be made of wood or ivory, with its percussing 
surface protected by a softish, somewhat elastic substance, as felt or caoutchouc, 
so as to lessen the force, and prevent interfering sounds. Caution, however, 
is requisite, in the use of such an instrument, to avoid too heavy a blow. 
The force of the stroke must vary with the objects to be obtained, and the 
tenderness of the parts percussed. When it is desired to elicit the-sound of 
a deep-lying part, the force must be greater than when one more superficial 
is to be examined. Very different sounds are produced by varying the degree 
of force, when bodies of unequal density lie at different depths. 
The surface to be percussed should be naked, or slightly covered. The 
position of the body must be influenced by circumstances; and it is very 
often desirable to change the posture, while percussion is continued upon the 
same spot. In this way the motion of liquids, or of air in the body, may 
often be detected. 
By a judicious combination of touch, pressure, and percussion, many im- 
portant problems in diagnosis may be very satisfactorily solved, especially in 
relation to diseases of the chest and abdomen. 
Measurement.-By this process we ascertain the dimensions of different 
parts of the body more accurately than can be done by the eye. It enables 
us to determine whether the whole, or any particular portion is enlarged 
or diminished, or whether the due symmetry may have been lost by partial 
change of dimensions. In the healthy and normal state of the frame, the 
two sides very nearly correspond, the right being perhaps, as a general 
rule, somewhat larger, in consequence of its more frequent exercise. By 
discovering any considerable departure from this symmetry, we may often 
detect the existence of disease; though it is necessary to bear in mind, that 
natural deformities in this respect are not uncommon, without in any de- 
gree interfering with the health. Perhaps the most useful application of 190 
GENERAL PATHOLOGY. 
[PART I. 
this process is to the detection of any increase or diminution of bulk in a 
given time. 
The most convenient instrument for measurement is a tape of linen, or 
other unextensible material, about two yards in length, and graduated in 
inches and quarters, which may be kept wound up in a circular box. An- 
other instrument, by which the diameter of a part may be measured, is a 
large pair of compasses, called callipers, with blunt points, and a graduated 
scale, which serves to measure the angle, and consequently the distance be- 
tween the points. 
In applying this process, caution should be used not to make unequal pres- 
sure; and, when the measurement is to be comparative, to take care that it 
should be made at exactly the same, or at corresponding points, in the same 
position of the body, and in the same state of the function, if that be one of 
sensible motion. Thus, in determining the dimensions of the chest, we should 
make the examination at the same period of inspiration or expiration. In 
measuring the lengths of the lower limbs, reference should always be had to 
the obliquity of the pelvis. 
x Auscultation.-This term, in its technical sense, signifies the act of listen- 
ing to- the sounds developed in the interior of the body, and made sensible 
upon the surface. It was the justly celebrated Laennec who first applied the 
process to the diagnosis of disease. His discovery has been of incalculable 
importance to medical science. It was like a new sense given to our art, and 
has probably served more than any other single discovery, in the present cen- 
tury, to extend the boundaries of medical knowledge, and to give precision to 
what was before vaguely known. 
Auscultation is performed either directly by the ear applied to the surface, 
or indirectly by means of an instrument called the stethoscope. Performed 
in the former mode, it is said to be immediate, in the latter, mediate. Laen- 
nec preferred the use of the stethoscope; but his arguments in its favour 
have not been considered conclusive; and immediate auscultation is now 
generally preferred, unless under peculiar circumstances. The ear is the 
most convenient instrument. It is always at hand, and, by the facility with 
which it can be applied, and the quickness with which it can pass from point 
to point, saves much time. The head receives, by this plan, a support against 
the body of the patient; and the attention is not distracted by the necessity 
of holding it in an awkward, and sometimes painful position. The sounds 
are not confused by the noise which the instrument makes with every move- 
ment upon the ear, and the operator is spared the trouble of keeping it pro- 
perly fixed at both extremities. When the surface is uncleanly, it can be 
covered with a clean towel, or, if necessary, by a piece of soft and thin oil- 
cloth. There are, however, circumstances in which the stethoscope is prefer- 
able. In the cases of females, it must often be so upon a point of delicacy. 
When it is desirable to estimate sounds in a very narrow space, as over the 
valves of the heart, for example, the instrument is almost essential. It is 
also applicable to cases in which the place to be examined cannot be readily 
reached by the ear; as in the hollow which, in emaciated patients, often ex- 
ists beneath the clavicle. 
The stethoscope is a hollow cylinder of soft light wood, from five to seven 
inches long, with the bore a quarter of an inch in diameter, but, towards the 
base, enlarging into a funnel-shaped expansion, so as to admit sound from a 
larger surface. The diameter of the opening at the lower extremity should 
be an inch, or a little more. The upper end is fitted with an ear piece, which 
may be either flat or slightly convex, and is sometimes furnished with a nip- 
ple-shaped projection for insertion into the ear. When the instrument is CHAP. III.] 
DIAGNOSIS.-EXPLORATORY PROCESSES. 
191 
employed to detect sounds within very narrow limits, its larger extremity 
should be fitted with a conical piece of wood, having a bore through it cor- 
responding with that in the .upper portion of the instrument, so as to form a 
continuous equable tube. The sound is then conveyed distinctly to the ear 
only from the portion of surface corresponding with the narrowed opening of 
the instrument. 
A flexible tube has been introduced into use, as a substitute for the wooden 
stethoscope, by Dr. Pennock, of Philadelphia, who found it especially adapted 
to the investigation of the , sounds of the heart. It is made like the flexible 
ear-trumpet, is about eighteen inches long, and is provided at one end with a 
piece' of ivory to adapt it to the ear, and at the other with an expanded ter- 
mination for application to the chest. The advantage of this instrument in 
cardiac diseases is, that it does not, like the common stethoscope, convey to 
the ear the impulse along with the sounds of the heart. 
In applying the stethoscope, care must be taken that it be accurately adapted 
to the part as well as to the ear, and that, though held firmly, it should not 
be pressed forcibly, so as to occasion discomfort. 
Whether immediate or mediate auscultation be employed, the surface, as a 
general rule, should either be naked, or covered only with a slight and closely 
fitting material, of such a nature as not to rustle with movement. Some- 
times the sounds are so decided that they can be heard through a consider- 
able thickness of clothing; and, in such cases, the above caution may not 
be absolutely necessary. But there is always danger of confusing the 
sounds of the interior with those made by the friction of two layers of 
clothing upon the surface. It should not be forgotten, in employing this 
process, that there is often great danger of taking cold from the exposure of 
a naked, or but slightly covered surface to the cold air. The exterior air, 
therefore, should be duly warm, and the exposure should continue no longer 
than necessary. I have no doubt that patients, with disease of the chest, 
often suffer greatly from a neglect of this caution. It has been ascertained, 
that the muscles give rise, during their contraction, to a sound which is audi- 
ble in auscultation. When, therefore, the examination is made in reference 
to an internal part, the muscle which may be beneath the ear should always 
be in a state of relaxation. When stooping, as often happens, affects the 
hearing, and confuses the perceptions of the operator, he should perform the 
process either sittings or kneeling by the bedside. He should always also 
avoid constrained positions, which must tend to distract his attention. If he 
should happen to hear better with one ear than with the other, he should 
always employ the most delicate preferably. The sounds observed in auscul- 
tation, as well as their indications, will be subjects of detail under the par- 
ticular diseases in the diagnosis of which they are available. 
Auscultation and percussion may sometimes be advantageously united, as 
originally hinted by Laennec,* and conclusively shown by Drs. P. Cammann 
and A. Clark, of New York. (See New York Journ. of Med. and Surg., 
July, 1840.) By means of a stethoscope applied to the surface of the body, 
the ear will sometimes distinguish sounds produced by percussion, which are 
quite inappreciable without such aid. The precise limits of differeht organs, 
the existence and position of organic changes, and the continuity or separation 
of contiguous solid bodies, may thus be more certainly detected than by per- 
cussion alone. j". 
Chemical and Microscopical examinations may sometimes be employed by 
the practitioner with advantage in diagnosis, especially the former. Chemical 
• See Laennec on Mediate Auscultation, in the third article of chapt. iv., on Pneumo- 
thorax. 192 
GENERAL PATHOLOGY. 
[PART I. 
tests are indispensable in the detection of certain important morbid states of 
the urine, and they have been successfully applied- also to the detection of 
bile, and to the appreciation of the condition of the blood. The microscope 
has proved useful in detecting abnormal states of the milk of nurses, and 
will hereafter probably be frequently employed for the discovery of diseased 
conditions of the blood and Various secretions, and to distinguish one morbid 
product from another. 
SECTION IV. 
PROGNOSIS. 
This is the decision of the judgment as to the future course of any disease, 
including its changes and termination, and the periods at which they are 
likely to occur. We are guided, in making such a decision, by our know- 
ledge of the course which the same disease has ordinarily pursued, together 
with the peculiar circumstances which may modify the case under considera- 
tion. In most instances, only probable opinions can be formed of precise re- 
sults, though it very often happens, that the main result may be predicted, 
with great confidence, in general terms. Thus, certain diseases almost always 
end in recovery, others with a more than equal universality have a fatal ter- 
mination. But we cannot determine, with precision, the period of these 
changes. Some complaints run a specific course, having certain stages, and 
ending, as a general rule, about the same time. In relation to these, we may 
ordinarily make our predictions with some confidence. Others, again, without 
anything specific in their nature, are apt to terminate within certain limits^ 
as from seven to ten days; and these too occasionally admit of a tolerably cor- 
rect prognosis. But, even in cases of this kind, so many accidents occur to 
change the accustomed course, so many inappreciable influences are at work 
of which the effects cannot be calculated, that predictions should almost always 
be made with caution. A physician may gain some reputation by a happy 
guess, announced with an appearance of confidence; but the habit of making 
such guesses must often end in discreditable failure, and, at all events, is 
scarcely consistent with a proper self-respect. t 
In cases of great danger, yet not incurable, much caution is requisite in 
making the patient acquainted with his condition, as the effect on his mind 
might insure the worst issue to the disease. Yet moral considerations should 
have some weight; and a conscientious physician may well doubt the propriety 
of withholding information, which may be essential to higher interests even 
than those of life. Under these1 circumstances, it appears to me that no ex- 
clusive course can be pursued with propriety. As a general rule, it is proba- 
bly best that the patient should not be informed of his danger; butj should 
he seriously ask for information, and his mind appear to the physician in a 
state capable of properly using it, I do not think that it should be withheld. 
My own practice has usually been to warn the friends of the patient of his 
danger, and leave to them, who better understand his spiritual wants than 
the physician generally can do, the care of his interests in that respect, mak- 
ing them, however, fully understand whatever risk may be incurred. 
It has been stated above, that the peculiar circumstances which can have 
any modifying influence over the disease, must be taken into consideration in 
forming a prognosis. Age, sex, modes of life, place of residence, previous 
state of health, &c. &c., are circumstances of the kind alluded to. It not un- 
frequently happens, that certain diseases are peculiarly dangerous, under cer- CHAP. IV.] 
GENERAL THERAPEUTICS. 
193 
tain peculiar influences; while there are influences which add increased danger 
to diseases of all kinds which may be exposed to them. Extreme old age, 
the puerperal state, habitual intemperance, long continued mental distress, 
exhaustion from sensual excesses, and debility from previous disease, impover- 
ished diet, or impure air, usually augment the gravity of the disease, and con- 
sequently render the prognosis more unfavourable. Cases of disease at the 
commencement of epidemics are often much more severe than those which 
occur near their close. Youth, previous health, temperance, easy circum- 
stances, and a cheerful temperament, exercise a favourable influence on dis- 
ease, and of course on the prognosis. 
Certain symptoms, or conditions of system, may generally be considered as 
extremely unfavourable signs. Such is the case, in chronic diseases, with 
dropsy supervening upon organic affection, progressive emaciation without an 
obvious cause, and the appearance of aphthae in the mouth and fauces. Such, 
too, in the latter stage of disease, are the hippocratic countenance; involuntary 
fecal evacuations; a tendency to slide downward in bed; delirium, in which 
the patient wishes to return home when not absent from home., or in which, 
though greatly enfeebled by disease, he is yet able to rise out of bed and 
walk some distance; extreme subsultus tendinum; a disposition, alluded to by 
Chomel as an almost certain sign of approaching death, to draw the arm to- 
wards the body, when it is raised in order that the pulse may be felt; diffi- 
culty or impossibility of protruding the tongue, or trembling in that organ 
when it is protruded; difficulty of deglutition or speech; the absence of pulse; 
great coldness of the extremities; excessive frequency of breathing; hiccough; 
black vomit; and a purple or livid appearance of existing wounds or ulcers. 
Signs of a favourable issue are, the occurrence of critical symptoms when not 
extreme, and a gradual subsidence of the symptoms, indicated by cleaning 
of the tongue, a return of the pulse towards its healthy state, a return of the 
normal temperature of the skin, &c. (See Convalescence, p. 182.) 
CHAPTER IV. 
GENERAL THERAPEUTICS. 
It is a question of great importance, how far it may be proper for the phy- 
sician to interfere in the management of diseases. There is no doubt that 
too much may be and often has been done, and that as much evil may accrue 
from this cause as from doing too little. The young practitioner should be 
strongly impressed with the truth, that, in the great majority of cases, disease 
will end in recovery, whether under treatment or not. He is not to suppose 
that every instance of recovery under his management is a cure. The preva- 
lence of empiricism is, in a considerable degree, ascribable to the popular 
error, that a favourable termination of disease is always owing to the means 
employed. Patients often survive improper and even injurious treatment, 
and, believing themselves cured, naturally acquire confidence in the practi- 
tioner, or in the supposed remedy. Medical men may do much towards ob- 
viating the evil, by imbuing the popular mind with accurate notions in this 
respect. But they should especially guard themselves against a participation 
in the error. An impression that medicines are essential or important, in all 
cases, will often lead to their unnecessary, and even to their injurious cmploy- 194 
GENERAL THERAPEUTICS. 
[part I. 
ment. It cannot be doubted that diseases, which, if undisturbed, would have 
spontaneously terminated in health, have often received an unfavourable turn 
from officious interference. 
But it must not be inferred from what has been said, that the intervention 
of the physician is useless. On the contrary, even in the cases which 
would end favourably, if trusted to nature alone, he may often do much good 
by shortening the duration of the complaint, alleviating the sufferings of the 
patient, and preventing inconvenient if not dangerous sequelae. In many 
cases,, his aid is essential to the preservation of life. While, therefore, we 
guard ourselves against the evils of an overweening confidence in the efficacy 
of therapeutical measures, we should equally avoid the no less injurious influ- 
ence of utter scepticism. Such, however, is the nature of our art, that expe- 
rience or observation alone can give the necessary acumen for a proper deci- 
sion, as to the greater or less energy of the means required in most individual 
cases. The most that precept can do is to call attention to the importance of 
a just discrimination in this respect. 
In the treatment of disease, we should endeavour to be guided by certain 
rules or principles, and not surrender ourselves to the accidental suggestions 
of'the moment. The attempt should always be made, by a careful examina- 
tion into the nature, seat, cause, &c., of the disease, to deduce indications of 
treatment; in other words, reasons for the employment of certain influences 
calculated to prove remedial. The character of these influences being known, 
it then only remains to fulfil the indications which may have been deduced. 
It is the object of the present essay to present, first, certain general therapeu- 
tical indications, and, secondly, an account equally general of the remedial 
measures that may be employed to meet them. 
It often, however, happens, that the nature of the disease is so obscure as 
to offer no clear indications of treatment. Under such circumstances, we may 
obey the dictates of experience alone, and employ measures which have re- 
peatedly succeeded in similar cases, though not suggested by any rational view 
of the disease. The science of medicine is yet very imperfect; and we must 
often Content ourselves with means which we know to be useful, without un- 
derstanding fully their mode of action. \ 
In doubtful cases, when both reason and experience fail us, the best rule is 
to adopt the expectant plan ; that is, to do little or nothing which can strongly 
impress the system, and await further developements, trusting in the meantime 
to nature. Measures employed in the dark are much more likely to prove 
noxious than remedial. 
SECTION I. 
GENERAL INDICATIONS. 
1. The removal of the morbid cause is among the most important thera- 
peutical indications. In many cases, the disease is sustained solely by its 
continuance, and yields immediately when it ceases to operate. Thus, nerv- 
ous headaches often depend upon the habitual use of coffee, dyspepsia upon 
indigestible food with want of exercise, and colic upon irritant matters in the 
bowels; and the list might be extended through a long catalogue of diseases. 
In all such instances, little more is required of the physician than to ascertain 
and remove the cause. In other cases, though the disease may not yield im- 
mediately after the cause has ceased, it is greatly aggravated by its continu- 
ance, and often cannot be cured until after its removal. Thus, cholera CHAP. IV.] 
GENERAL INDICATIONS. 
195 
infantum frequently bids defiance to medicine, while the patient is confined 
to the air of cities; and the chronic hepatitis of hot climates can be cured, in 
many instances, only by residence in cold or' temperate latitudes. Here, atten- 
tion to the indication at present under consideration is indispensable. In a 
third set of cases, the cause either adds nothing, by its continuance, to the 
violence of the disease when once produced, as probably in small-pox, measles, 
scarlatina, &c., or ceases immediately after it has produced its effect, as often 
in inflammatory diseases resulting from cold. In such instances, attention to 
the cause is important, in a therapeutical point of view, only so far as a know- 
ledge of it may lead to a more correct estimate of the nature of the disease. 
In searching for the cause of disease, in reference to its removal, the attention 
must be directed not only to exterior agents, but to those also which may exist 
within the system. One morbid action or condition is very frequently the 
result of another; and, in such cases, the removal of the cause of the former 
affection often implies the cure of the latter. 
2. Attention having been directed to the cause of the disease, we should 
next inquire into its precise seat, and endeavour to ascertain whether or not 
this is primarily or essentially in the blood. If it prove to be so, the promi- 
nent indication will be to correct the state of that fluid. Much time is often 
lost by a neglect of this precaution. I have known cases to run on for 
weeks and months, obstinately resisting various courses of treatment, or, if 
apparently relieved for' a time, quickly relapsing into their previous condi- 
tion, which have yielded, immediately and permanently, to measures calcu- 
lated to restore the healthy condition of the blood. Of these measures, atten- 
tion to the diet is among the most effectual; though medicines and other 
remedial means are not without an important influence. As examples of 
diseases in which the blood is mainly concerned, the reader is referred to 
plethora, anemia, scurvy, and purpura. 
3. In relation to diseases affecting the solids, which include the vast majority 
of morbid affections, an obvious indication is. to restore their due grade to the 
vital actions, whether these be elevated or depressed, and whether the affection 
reside in a part or the whole of the system. Peculiarities in the character of 
the elevation or depression, or mere perversions of the vital actions, without 
any obvious deviation from the healthy grade, must be encountered by means 
which experience may have pointed out as best fitted to answer the end in 
view. 
4. The course, natural tendency, and natural termination of the disease 
afford important indications. 
The practitioner should, in the beginning, carefully note whether the disease 
is regularly intermittent or not. In the former case, no matter what may, in 
other respects, be the nature of the affection, it will almost always yield readily 
to treatment. Patients have often been unnecessarily exposed to protracted 
suffering, from a neglect of this precaution on the part of their attending phy- 
sician. Whenever complaints are made of fever, pain, or other disordered 
action or sensation, occurring at a particular time every day or every other 
day, and going off after a longer or shorter duration, with perfect freedom from 
the affection in the interval, there is every reason to expect that a cure may 
be effected, in the course of two or three days, by an energetic employment 
of the remedies denominated antiperiodic or anti-intermittent. These remedies 
will be fully detailed in the article upon the subject of intermittent fever. 
Should the disease be remittent, efforts should be made to bring it into the 
intermittent form, by the use of means calculated to resolve the paroxysm; 
and this may sometimes be accomplished by watching the process by which 
nature appears disposed to effect the same object, and assisting her by appro- 196 
GENERAL THERAPEUTICS. 
[part I. 
priate measures. Thus, the paroxysm of a remittent fever may sometimes be 
entirely resolved by favouring the natural tendency to perspiration, and the 
disease converted into an intermittent. In very many instances, remittent 
diseases, especially when the remission is considerable, will yield entirely to 
the anti-periodic treatment. 
Some diseases run a certain course, which cannot be interrupted unless by 
the destruction, or at the risk of life. Such are most of the exanthematous 
fevers. In these, when fully formed, it would be the height of folly to attempt, 
by violent measures, to interrupt their progress. The practitioner should be 
content with watching them through their course, removing or preventing 
injurious influences, moderating their violence, correcting as far as possible 
any tendency to fatal disorganization, and conducting them to a favourable 
issue. He should never forget that they have a certain term which cannot 
be shortened; and that, whatever may be done, it is of the utmost importance 
not so far to exhaust the strength of the system as to disable it from holding 
out to the end. 
Other diseases are indefinite in their course, having a tendency sooner or 
later, when not unusually violent, to a favourable termination, and often 
capable of being arrested or shortened. In the treatment of these, the prac- 
titioner should be influenced by the degree of apparent danger. Should they 
be very threatening, he would be justified in employing energetic measures to 
arrest them, even at some risk. Should they, on the contrary, be moderate, 
and likely to end spontaneously in health, he should be more cautious in the 
use of remedies, lest he may injuriously interfere with the processes of nature, 
and put at hazard what might otherwise be safe. Remedies should always 
bear a relation to the disease; and violence in therapeutics is never justifiable 
when moderation is adequate to the same good end. Another important rule, 
is not to change a plan of treatment which is doing well, in the mere hope of 
doing better. "Let well enough alone" is a vulgar maxim, not less applicable 
to therapeutics than to the ordinary concerns of life. 
A third set of diseases, though not incurable, have a natural tendency to a 
fatal termination, unless interrupted. These must be cheeked at all events, 
mild measures being employed if sufficient, but the most energetic if neces- 
sary. 
Lastly, there are diseases essentially fatal in their character, for which at 
least no remedies have yet been discovered. Here, we should make no vain 
attempts to effect cures by violent remedies, or excessive medication. These 
only tend to hasten the fatal issue by exhausting the resources of the system. 
Palliation and alleviation only should be aimed at. By preventing all aggra- 
vating influences, and employing means calculated to correct excessive action, 
or support failing strength, without undue exhaustion in the former case, or 
undue excitement in the latter, we may often greatly prolong life, and at the 
same time render it much more tolerable to the patient. In such cases, it is 
as important not to wear out the excitability of the system by excessive stimu- 
lation, as not to exhaust its strength directly by depletion. 
5. The stage of the disease should always be considered in the application 
of remedies. In the forming stage, diseases may sometimes be arrested at 
once by prompt and well-considered measures, which would be useless after 
they have been completely formed. A commencing catarrh may often be set 
aside by a dose of opium, which might greatly aggravate it when established. 
In the earlier stages, diseases almost always bear depletory measures better 
than in the advanced. A bleeding which would be beneficial in the first few 
days of a fever or inflammation, might be in the highest degree dangerous 
towards the close. The contrary is almost always the case with stimulants, CHAP, IV.] 
GENERAL INDICATIONS. 
197 
which are often requisite to support the system under the exhaustion of an 
advanced disease, though, if employed in the beginning, they would have been 
highly injurious. Inflammation, in which depletory and sedative measures 
are proper in the early stages, often calls for the use of tonics, or more power- 
ful stimulants, to obviate the exhaustion produced by the suppuration or gan- 
grene with which it closes. 
6. The supervention of another disease upon the original, or the aggravation 
of an attendant symptom into an importance exceeding that of the- primary 
affection, are circumstances which call for constant watchfulness on the part 
of the practitioner, and the occurrence of which often affords new indications 
of treatment. 
7. The condition of the system at the time of attack has a most important 
bearing upon the remedies, and should never be overlooked. The same dis- 
ease requires a very different treatment in persons of vigorous constitution, 
with a plethoric circulation, and healthy blood, from that which would be 
suitable in the feeble, the anemic, and those in whom the blood is depraved 
or vitiated. An amount of depletion which might be essential in the former, 
would prove highly dangerous if not fatal in the latter. Hence, it is'necessary 
to take into consideration the various circumstances in which the patient may 
be habitually placed, and those to which he may have been exposed previously 
to the commencement of the disease. 
Age is not without its influence. Infancy is more impressible than man- 
hood, and therefore requires more caution in the use of remedies. Though 
more rapid in the curative processes, it is yet more readily depressed below 
the point of reaction. The nervous system at this age is peculiarly suscep- 
tible, and frequent calls are made for remedies addressed to the support of 
that system. This fact is often fatally overlooked in the advanced stages of 
infantile diseases. Old age also demands caution. Though less susceptible 
than middle life, it is less capable of supporting excesses of any kind, and 
should, therefore, as a general rule, be treated with more reserve. As the 
blood is made less rapidly, it should be more sparingly abstracted; and greater 
care should be observed not to give medicines in over-doses. Even stimulants 
in excess are less safe than in earlier life, because there is generally some 
frailty in the organization, especially in the brain, which causes it to give way 
under any considerable excess of arterial action. 
Sex also has its peculiarities. Woman is to be treated in all respects more 
delicately than man. During menstruation, peculiar cafe is required, in the 
use of remedies, not to interfere with that process; and, as a general rule, 
unless treatment is imperiously required, it should either be suspended or 
moderated. Pregnancy also calls for certain cautions. Though it usually 
tolerates bleeding well, espe6ially when advanced, it contraindicates perturba- 
ting treatment, such as the use of violent emetics and cathartics. 
The sanguine temperament bears depletion better than the phlegmatic or 
nervous. 
Individual peculiarities or idiosyncrasies require a careful attention. The 
practitioner should listen respectfully to the representations of the patients as 
to any peculiar susceptibilities which he may possess, and, in the absence of 
such representations, should himself make inquiries upon the point. He will 
thus be spared many awkward, and some serious or even fatal accidents. 
Thus, death has resulted from the use of a moderate dose of calomel, which 
might have been avoided by a previous knowledge of the extraordinary sus- 
ceptibility of the patient to the mercurial impression. Remedies which ordi- 
narily produce no unpleasant effect whatever, act with excessive violence in 
some individuals. I know a lady, in whom the smallest quantity of a decoc- 
tion of pipsissewa ^Chimaphila umbellatd) produces excessive irritation of 198 
GENERAL THERAPEUTICS. 
[part I. 
the whole mucous membrane with which it comes in contact, with a fiery 
eruption upon the skin: 
Hereditary tendencies must not be overlooked. In a doubtful case, the 
scale may often with great propriety incline towards one or the other 'side, 
according to the known constitutional habits of the parent. The son of scro- 
fulous parents should, under certain circumstances, be treated very differently 
from one in whom no morbid hereditary tendency could be suspected. , 
Climate has a modifying influence over the effect of remedies. Neither 
bleeding nor general stimulation is so well borne by the inhabitants of hot 
countries as by those of temperate or cold latitudes; while the influence of 
calomel as a cathartic is perhaps in general better borne, in consequence of the 
less susceptibility of the liver. 
The habits of the patient are of the highest importance^, and should always 
be investigated. Exhaustion from sensual excesses; debility and depravation 
of the blood from starvation, or from bad food and air; repletion from glut- 
tonous indulgence of the appetite; intemperance in the use of alcoholic 
drinks; and the influence of occupation and trades, should be taken into ac- 
count in prescribing. In persons accustomed to excessive eating and drink- 
ing, it should be recollected, that vast and fatal depression often follows the 
abstinence consequent upon attacks of illness, against which it is necessary 
that the practitioner should be on his guard. In such instances, particularly 
in those of drunkards, it is often necessary to support the tone of the nervous 
system by the continued use of stimulating drinks, even while the abstraction 
of blood from the arm is rendered necessary by an acute and dangerous attack 
of inflammation. 
Previous disease generally leaves a' debility which renders the patient 
less able to bear depleting or depressing measures. But there is another 
point of viewx in which this influence is to be considered. Peculiar dia- 
theses, such as the rheumatic, the gouty, the tuberculous, &c., often have a 
wonderfully modifying influence upon accidental diseases, upon which they 
are apt to impress more or less of their own character. No practitioner can 
do justice to his patients, who does not bear this fact in mind in prescribing. 
8. Coincident influences often greatly modify the morbid results of particu- 
lar causes. Of these, perhaps, the most important are the miasmatic influ- 
ence, and that of epidemics. Without attending to these, the practitioner must 
be liable to the most fatal blunders. It is well known that all the diseases of 
miasmatic regions assume a character more- or less analogous to that of the 
peculiar fevers by which they are infested. Fevers arising from other causes, 
and even the ordinary phlegmasim, occurring in the autumn and winter, ex- 
hibit generally the remittent aspect of the propel miasmatic fever, and, like 
it, require less depletion than in other situations, and often yield most happily 
to quinia. Epidemics are notorious for their quality of imparting something 
of their own nature to all other co-existing diseases. Now, sometimes the 
epidemic influence conduces -to a sthenic or vigorous state of system, some- 
times to an asthenic, feeble, or typhoid condition. In the former case, dis- 
eases ordinarily of a feeble character assume a degree of energy and eleva- 
tion which requires depletion; in the latter, inflammatory complaints, which 
usually yield most readily to copious bleeding, sometimes become so prostrate 
as to forbid evacuation, and even to require the support of active stimulation. 
This latter effect was frequently witnessed in this country, during the preva- 
lence of our great typhous epidemic. 
9. The pointings of nature should be watched for, and regarded in the 
treatment of diseases, even though they may be opposed to the deductions of 
our reason, and the whole previous course of our experience. Now and then, CHAP. IV.] 
THERAPEUTIC PROCESSES.-DEPLETION. 
199 
in the progress of a disease, the patient expresses a wish for some article of 
food or drink, some medicine, or some change, in other respects, in his man- 
agement, which seems to the physician altogether improper. As similar 
wishes are often the mere result of the restlessness and caprice of disease, it 
is,of course very properly denied by the physician. But, if the same wish is 
repeated time after time, resisting alike the authority of the physician, and 
the common sense of the patient himself, it acquires an altogether different 
value. It may now be looked upon as probably a real want of the system, an 
indication presented by nature, which ought to be indulged. At first, how- 
ever, it should be gratified cautiously, and in such a manner that little harm 
could result if it should happen to be a mistake. Should apparent good re- 
sult from the first careful trial, a greater latitude may be allowed; and the 
practitioner will often be gratified at witnessing a rapid recovery, dating from 
the moment of his judicious surrender of his own judgment to this imperious 
call of the system. 
10. It is a good general rule of practice, whatever may be the particular 
disease under treatment, to attend to the state of the functions, and to correct 
any disorder in them, even thotigh not directly connected with the disease. 
The bowels, especially, should be kept regular, and fecal accumulation sedu- 
lously guarded against. The secretions of the liver, skin, and kidneys, should 
be preserved as nearly as possible in a healthy state. Irregularities in the 
circulation, the diffusion of temperature, and the nervous actions, should also 
receive attention. As it is not always possible to determine how far diseases 
are mutually dependent, we may thus occasionally cut off, unknowingly, one 
of the roots of the principal affection, and render its cure comparatively easy. 
11. There are various effects of disease which require treatment, without 
reference to any morbid condition of the vital actions. Such are certain 
liquid accumulations, as in different forms of dropsy; organized solid pro- 
ducts of deranged secretion, as in the swelling and hardness which inflamma- 
tion often leaves behind it; and various solid deposits from the fluid secretions, 
as urinary and biliary calculi. These, however, as they constitute special 
diseases, and offer special indications, do not call for particular consideration 
in this place. - > ' ' • 
SECTION II. 
GENERAL THERAPEUTIC PROCESSES. 
These may be included under the heads of 1, depletion; 2, repletion; 3, 
dilution; 4, stimulation; 5, sedation; 6, revulsion; 7, supersession; 8, alter- 
ation; 9, chemical action; and 10, mechanical action. 
I. Depletion.-By this term, it is intended to express a diminution of 
the blood, in relation either to the whole mass, or to some one or more of its 
solid constituents. When a portion of the blood is abstracted, the quality as 
well as the quantity of that fluid is altered. One of the consequences of 
diminution in the contents of the blood-vessels is increased absorption; and, 
as water is absorbed in much greater proportion than the solid principles, the 
consequence is that the blood becomes diluted. It is, therefore, less stimu- 
lant, and less capable of affording the due support to the functions, almost all 
of which are directly dependent upon it. Depletion consequently tends, by a 
reduction both in the quantity and quality of the blood, to diminish the vital 
actions. It depresses especially the force of the heart, and of the whole cir- 
eulatory system. It diminishes also digestion, respiration, nutrition, secretion, 200 
GENERAL THERAPEUTICS. 
[part I. 
calorification, and the functions of animal life. This last effect is rendered 
obvious, when depletion is carried to any considerable extent. Languor, 
impaired sensation, deficient emotional and intellectual energy; muscular weak- 
ness, even faintness, and positive syncope, result from the failure of the .due 
influences of the blood upon the brain. But there is one function, that of 
absorption, which appears to be promoted. To supply the loss of blood, the 
liquids and solid tissues of the body are taken up with more than the usual 
rapidity, and water is copiously absorbed from the contents of the alimentary 
canal, and perhaps also from the external air. 
Applications?-The therapeutical applications of depletion are obvious. 
It is the great remedy in plethora, and in excess of vascular excitement, 
whether that excess amount to irritation merely, or to inflammation. San- 
guineous determination and congestion, hemorrhage, morbidly increased secre- 
tion, and other derangement of function, so far as these disorders are results 
of irritation, are to be combatted by means of it. In the treatment of inflam- 
mation it is invaluable; not only lessening the force with which the blood is 
driven into the inflamed part, but impairing those qualities of the vital fluid 
which most powerfully support that morbid process. 
Another application of depletion, dependent upon its influence over the 
absorbent process, is in the treatment of morbid effusions, the different forms 
of dropsy, for example, in which it is often employed with great efficacy, 
though requiring caution. (See Dropsy.') - Upon the same principle, it may 
be used in polysarca or morbid obesity. 
From what has been stated in a former place (see page 60), the reader is 
prepared to understand that depletion is not always purely sedative; and this 
is a very important therapeutical fact. The general rule may be considered 
as holding true, whenever the blood is in excess, as regards its animalized or 
vital constituents. Under these circumstances, therefore, the remedy may be 
employed without hesitation, if indicated by any obvious derangement. The 
same is true also, even in the ordinary state of the blood, as regards the im- 
mediate effects of depletion, and even its ultimate effects, when moderately 
used and properly guarded. But copious depletion, when mistakenly used, 
may act as an excitant instead of a depressing agent to certain functions, and 
especially those of the heart and nervous system. The functions of the sys- 
tem, feeling the want of their wonted support, make this want sensible to the 
nervous centres, which then transmit a stimulant impression to the heart, 
while, at the same time, they make known their own disturbance by various 
irregular nervous phenomena. Under no circumstances, is the heart thrown 
into, more violent commotion than, sometimes, through an impoverished con- 
dition of the blood. (See page 60, also Anaemia.} Depletion, therefore, 
especially the more direct and powerful kinds of it, should be employed with 
reserve in anemic states of the circulation, even though strongly indicated by 
other considerations. 
Means of Depletion.--Depletion may be effected either directly, by 
taking blood or promoting secretion, or indirectly, by diminishing the supplies 
through which the natural losses of that fluid are repaired. Beyond all com- 
parison, the most efficient of these measures is the immediate abstraction of 
blood from the vessels, either quickly through one large opening in a vein or 
artery, or by means which withdraw it slowly and through numerous small 
openings. The former is called general, the latter local bleeding. 
General Bleeding.-When blood is taken directly from an artery, the pro- 
cess is called arteriotomy; when from a vein, venesection. In the former, the 
temporal artery is almost always selected; but the operation is scarcely ever 
employed except in violent diseases of the brain, and is probably never neces- CHAP. IV.] 
THERAPEUTIC PROCESSES.-BLEEDING. 
201 
sary even then. Venesection is almost universally preferred. This is usually 
performed in the arm, at the bend of the elbow; and, where a vein sufficiently 
large can be' found in this position, there is seldom any necessity for having 
recourse to another. 
The general effects of bleeding are those already detailed as the result of 
depletion. Its peculiar effect is, at first, merely to diminish the quantity of 
the circulating mass by the amount abstracted, afterwards to lessen especially 
the proportion of red. corpuscles. It is true, that the whole amount of solid 
ingredients in relation to . the liquid is diminished; but the albumen and 
fibrin suffer less than the . coloured constituent,-probably because they are 
more readily supplied from the tissues and food, through the processes of 
digestion and absorption. Indeed, in inflammation, the proportion of fibrin, 
according to Andral, even increases up to a certain period, notwithstanding 
the loss of blood. But, as the red corpuscles are probably the most stimulat- 
ing ingredient, the effect of the bleeding is greatly to diminish the excitant 
properties of the blood, even in inflammation. 
The loss of a sufficient quantity of blood will aways produde syncope; but 
the amount requisite for this effect varies greatly in different individuals, and 
in different diseases. In plethora and inflammation, more is required than in 
health; in anaemia and asthenia, or typhous affections, less; the difference 
probably depending upon the more or less stimulant quality of the blood. 
Inflammation of the different tissues also has some effect upon the tolerance 
of the loss of blood. It is well known that posture has . great effect. When 
lying down, an individual will bear a greater loss, than when sitting, and in 
this position than when standing. This is owing partly to the effect of gravi- 
tation, favouring or otherwise, the pressure upon the brain; partly, to the 
greater amount of blood required to support the increased muscular action, in 
the two latter postures. According to Dr. Marshall Hall, the mean loss of 
blood requisite to produce the symptoms of commencing syncope, in the sitting 
or erect posture, is in health 15 ounces, in congestion of the brain from 40 
to 50 ounces, in inflammation of the serous, synovial, or fibrous membranes, 
from 30 to 40 ounces, in parenchymatous inflammations 30 ounces, in mucous 
and cutaneous inflammations, 16 ounces; while, in eruptive fevers, it is only 
12 to 14 ounces, in delirium tremens 10 to 12, in accidents before inflammation 
has, taken place, 8 to 10; and in chlorosis 8. But these are mere approxima- 
tions ; and the numbers are liable to very great diversities. Much depends 
upon the rapidity with which the blood is drawn. When it flows in a full 
stream, through a large orifice, faintness is induced by a much smaller quan- 
tity than when it is taken very slowly, or by small and repeated portions. 
The quantity of blood to be drawn, in any particular case, must vary not 
only with the tolerance of the individual or the disease, but with the particu- 
lar object to be accomplished. When strong determinations of blood to the 
brain, or the lungs, threaten death from cerebral or pulmonary apoplexy; or 
when violent inflammatory spasm puts life in immediate danger, as in some, 
cases of laryngitis; or when inflammation of extraordinary violence attacks 
some vital organ, the bleeding may often proceed till symptoms of approach- 
ing syncope appear. But, in ordinary cases of vascular irritation or inflam- 
mation, this is seldom necessary. It is usually sufficient, in these cases, to 
produce a sensible diminution in the force of the pulse; and it is safer to bleed 
a second time, if requisite, than to abstract too much at once: Bleeding to 
absolute syncope, in fixed affections, is injurious, independently of the mere 
quantity of blood lost. According to principles sufficiently developed in pre- 
vious' parts of this work, the repose of all the organs, during the state of faint- 
ing, increases their excitability; and, when action is restored, it is very apt to 202 
GENERAL THERAPEUTICS. 
[part I. 
run into extremes. Hence, the pulse becomes, under such circumstances, not 
unfrequently more excited and tumultuous, though less tense, than before the 
bleeding. 
The mode of taking blood , varies with the- indication to be fulfilled. If 
syncope or an approach to it be desirable, the orifice should be large; and if 
it be wished, as may not unfrequently happen, to produce the effect with as 
little loss of blood as possible, the patient should be bled sitting or standing. 
If, on the contrary, it is deemed important to take away a large amount of 
blood, without inducing syncope, the patient should be in A lying position, the 
orifice should be rather small, and the current occasionally stopped for a timO 
by the finger, so as to allow the heart and brain to accommodate themselves 
to the diminished tension of their vessels. 
In doubtful cases, in which the propriety of bleeding'may be uncertain, 
but in which the strength of inducement may be somewhat in its favour, the 
patient should be placed, if possible, in the sitting posture, or even upon 
his feet, and the operation should cease as soon as any signs of faintness ap- 
pear. ( ; . . - ' i 
Local Bleeding.-This is usually effected by cupping or leeches. The 
former is generally preferable, when the surface from which it is desirable to 
abstract blood is extensive, and not tender under pressure. It also adds the 
influence of revulsion, through the inflammation excited by the wounds, to 
that of depletion. Leeches are preferable when the part is tender, when the 
surface is irregular or of very loose texture, and when it is desirable to con- 
centrate the application within a very small space. They should always be 
used, preferably, in the cases of infants. In this work, when the number of 
leeches is mentioned, reference is always had to those of American growth, 
unless the fact is otherwise expressly stated. European leeches draw much 
more blood than the American, and, if employed in the number directed for 
the latter, might produce dangerous exhaustion. The American have the 
advantages of being more readily procured, more easily regulated in relation 
to the quantity of blood they draw, and less apt to be followed by obstinate 
hemorrhage. 
Local bleeding is often adequate, of itself, to the cure of inflammation, when 
this is moderate, and not attended with general excitement. It may also be 
advantageously employed in those doubtful cases, in which, while an indica- 
tion for the loss of blood is offered by the existence of inflammation, the 
general strength may be inadequate to support bleeding from the arm. But, 
most frequently, it is employed only as an adjuvant to general bleeding. 
When inflammation is accompanied with fever, and a sthenic state of system, 
cups or leeches, employed in any ordinary measure, are quite inadequate. 
The capillaries are, in such cases, rapidly refilled through the vis a tergo, and 
little impression is made on the disease. But, after excitement has been suf- 
ficiently subdued by the lancet, or general bleeding has been carried as far as 
may be deemed consistent with the strength of the patient, local bleeding 
may often be resorted to, with great advantage, to complete the cure. In 
infants, however, leeches will frequently answer all the purpose of bleeding 
from the arm. 
Local bleeding has the advantage over general, of producing a greater effect 
upon the local disease with less loss of blood. In order that it may act most 
effectively, the blood should be taken from the immediate vicinity of the in- 
flamed part, but not, as a general rule, from the inflamed vessels themselves; 
as the irritation of the wound sometimes increases the disease, which the de- 
pletion was intended to relieve. The remedy is often applied, with great ad- 
vantage, in cases of internal inflammation, to the outer surface directly over CHAP. IV.] 
THERAPEUTIC PROCESSES.-DEPLETION. 
203 
the part affected. Its efficacy, in such cases, can be readily understood, when 
the part inflamed has a direct vascular communication with the exterior sur- 
face, as in costal pleurisy. The blood may be conceived to proceed immedi- 
ately from the inflamed vessels. But the remedy proves scarcely less bene- 
ficial in the affections of organs which have no such direct connexion, as in 
mucous gastritis and in bronchitis. , Its mode of operating, under these cir- 
cumstances, is not so easily explained. Some have ascribed the result to de- 
rivation ; but they do not inform us why the same amount of blood, drawn in 
another place, would not answer the same purpose; why, for example, it must 
be taken from the epigastrium in mucous gastritis, and not from between the 
shoulders, from the breast, or some other part quite as closely connected, by 
vessels as the epigastrium with the mucous membrane of the stomach. I 
know no better explanation, than that which supposes a sympathy to exist 
between the internal organs and the corresponding portion of the outer sur- 
face, by which an impression made on the latter is propagated to the former, 
through some common nervous centre. This, however, is purely hypothetical. 
The quantity of blood which it may be proper, to take by cups or leeches 
has no precise limits. It may not be more than an ounce or two, or it may 
amount to ten or twelve ounces. Generally, from two to six or eight ounces 
will be sufficient. Each American leech may be estimated to draw a fluidrachm, 
or a little more. 
Increased Secretion.-This is another very useful mode of depletion. It 
not only unloads the circulation in general, but, in some cases, has the advan- 
tage over bleeding, of directly depleting from-the diseased vessels themselves, 
and thus of imitating a very frequent process of nature in the relief of irritation 
and inflammation. Thus, cathartics relieve mucous enteritis, expectorants 
bronchitis, and diuretics nephritis. It is not merely the watery parts of the 
blood that are thus evacuated, but its animalized constituents also, though the 
red corpuscles seldom pass through the secretory orifices. Upon the whole, 
this mode of depletion is much less efficacious than bleeding, in the relief of 
plethora and vascular excitement. But, for the purpose of promoting the 
absorption of effused fluids, it is even more efficacious; as a much larger 
amount of liquid may be safely abstracted from the blood-vessels by ificreased 
secretion than by bleeding, and consequently a greater amount of absorption 
produced. Another advantage which it possesses is the elimination of noxious 
matters from the blood-vessels; and there is reason to believe that much good 
is often effected in this way. 
The remedies most efficaciously employed with reference to depletion, upon 
this principle, are cathartics, diuretics, and diaphoretics. But all that increase 
secretion are occasionally useful, including expectorants, emmenagogues, siala- 
gogues, errhines, epispastics, issues, and setons. It is upon this principle, in 
part, that the warm, hot, and vapour baths act usefully in certain inflamma- 
tory affections. In the application of these various remedies, there is much 
room for discrimination; some being better adapted to one condition, others to 
another, and some being positively injurious where others are highly useful. 
This, however, is not the place to discuss their properties; and the reader is 
referred for information to works on the materia medica. It may be proper 
to mention - here, that such as are employed for the reduction of plethora or 
inflammatory excitement should be destitute of general stimulating properties, 
and that the most efficient are those which unite a sedative influence over the 
circulation with the power of increasing secretion. Such especially are the 
saline cathartics, and the antimonial diaphoretics and expeetdrants. A general 
rule applicable to all these medicines is, that, in cases of high vascular excite- 
ment, when the pulse is full and strong, and bleeding is otherwise indicated, 204 
GENERAL THERAPEUTICS. 
[part I. 
they should be preceded by that remedy. Secretion is often checked by excess 
of excitement in the secreting organ, and favoured by a reduction of the ex- 
citement. Besides, medicines are not easily absorbed, when the blood-vessels 
are full to distension. 
Indirect Depletion.-1This is effected by whatever prevents the usual amount 
of solid organic material from entering the circulation. Emetics and cathar- 
tics act. in this way, by discharging the partially digested food from the 
alimentary canal before it has entered the lacteals. But still more efficacious 
is a temporary abstinence from food, or a reduction of its quantity and quality. 
A few general remarks upon the subject of diet, as a method of indirect deple- 
tion, cannot be bettei' introduced-than in this place. 
Low Diet.,-Antiphlogistic Diet.-Abstinence.-Entire abstinence from 
food, though tolerated for a time, and a powerful antiphlogistic measure, 
becomes very injurious if too long persevered in. In a healthy state of 
digestion, it is indeed impracticable. But, even when the patient has no 
desire for food, it is very possible to carry abstinence too far. If the blood- 
vessels receive nothing from the alimentary canal, they draw upon tbie whole 
system for a supply, and the detritus of the tissues, conveyed into the circula- 
tion by the lymphatics, becomes a substitute for food. The blood is thus 
recruited by the most highly animalized products, and, instead of acquiring 
antiphlogistic properties, passes into the state most calculated to excite inflam- 
mation. It is always, therefore, safest, where the stomach will receive nutri- 
ment, even in cases of the highest excitement, to permit entire abstinence only 
for one or two days, and then to give food, inversely proportionate, in quality 
and quantity, to the grade of existing action. Three conditions are requisite 
in the substances employed as diet in inflammatory febrile affections; one that 
they should be feebly nutritive, the second that they should not be irritant by 
their insolubility or difficult digestion, and the third that they should not be 
stimulant to the system. In relation to the first condition, there should be a 
scale rising with the declining state of the excitement; in relation to the second, 
some relaxation is admissible as the stomach becomes less irritable; but, so 
long as a depletory course is called for, the third condition should be rigidly 
adhered to. The following is a hasty view of the different kinds of food which 
may enter into an antiphlogistic diet. The first and lowest in the scale con- 
sists of certain organic vegetable principles, which do not exist in the animal 
system, and must consequently undergo changes in the process of assimilation. 
They are the least nutritive of all articles of diet, are wholly destitute of sti- 
mulant properties, and, being readily soluble, are least apt to irritate the 
stomach. They are, moreover, easily isolated from other substances, and 
may, therefore, be given without injurious admixture. They answer precisely 
the requisitions for the diet adapted to the highest degree of febrile and inflam- 
matory excitement. Such are the different varieties of gum, starch, and 
sugar. They are closely analogous in composition; all of them consisting of 
carbon, oxygen, and hydrogen, the two latter ingredients being in exactly 
neutralizing proportions, as in water. There is some difference in their bland- 
ness, gum standing at the head of the list in this respect, then starch, and 
lastly sugar. The blandest of course are best adapted to the highest state of 
gastric irritation. Gum arabic, infusion of slippery elm or sassafras pith, 
arrow-root, sago, tapioca, barley-water, rice-water, refined sugar, and uncrys- 
talizable sugar Or molasses, are examples of this set of substances. Vegetable 
jelly or pectin, existing in the juice of various fruits and roots, may be consi- 
dered, in a dietetic point of view, as identical with gum. These substances 
should be administered in the state of solution, which may be more or less 
concentrated, according to the degree of nutrition required, but so that they CHAP. IV.] 
THERAPEUTIC PROCESSES.-LOW DIET. 
205 
may he conveniently u(sed for drink. They may be given separately or com- 
bined, and may often, with great propriety, be flavoured by one of the milder 
vegetable acids. These acids undergo digestion, and are, probably, like the 
principles mentioned, slightly nutritive; while the possession of refrigerant 
properties admirably adapts them to inflammatory affections. They are 
occasionally, however, somewhat irritant to the stomach. They exist in 
fruits, and are usually employed in the form of the expressed juice, or infu- 
sion of these fruits, or in jellies or syrups made from them; as in lemonade, 
orangeade, infusion of tamarinds, apple-water, currant jelly or blackberry jelly 
diffused in water, &c. Patients may be allowed occasionally to suck the 
juice of sweet oranges, and the better sorts of grapes, which are often highly 
grateful. 
The second kind of food consists of substances of the vegetable kingdom, 
supposed to be identical in composition with certain constituents of the human 
body, and, therefore, capable of entering into its constitution without change. 
These are albumen, gluten, and vegetable fixed oils. They are highly nutri- 
tive, but not stimulant, and are, therefore, well adapted for the support of the 
system, when the strength begins to decline, but a degree of excitement 
remains, requiring an antiphlogistic regimen. They are never used in an 
isolated state, but as they exist in nature, associated with the principles con- 
stituting the first class, namely, gum, starch, and sugar. They are found 
thus associated in the different grains. Gruel made of oatmeal or Indian 
'corn, Indian mush, boiled rice, wheat bread in the shape of panada, toasted 
wheat bread, water-crackers, &c., are forms in which these substances may be 
used. ' > 
In nature, the two sets of nutritious substances above spoken of are very 
frequently mingled with an indigestible principle called lignin or woody fibre, 
which appears to answer the purpose of stimulating the peristaltic movement 
of the bowels, and thus to keep- them regular. This frequently gives a fibrous 
and tenacious character to the substances in which it exists, rendering them 
difficult of solubility in the gastric juice, and therefore disposed to irritate a 
tender stomach. On this account, these articles are unfit for cases of febrile 
excitement in which the digestive organs are feeble; but, as they are in no 
degree stimulant to the system at large, they may be used in cases of mild 
or chronic inflammation, in which the system does not sympathize, and in 
which the digestive powers are not impaired. Such are the edible fruits, and 
the various garden vegetables. 
Another kind of food consists of animal principles closely analogous with 
the albumen and gluten of vegetables, and like them very nutritious, with 
but little of the stimulant power. These are albumen, fibrin, and casein, 
which are all supposed to be modifications of one peculiar nitrogenous prin- 
ciple/denominated protein, from which they are thought to differ merely in 
containing very minute proportions of sulphur and phosphorus. An example 
of albumen is the white of egg; but it exists, also, in a coagulated state, in 
most of the varieties of solid animal food brought upon the table, in the cook- 
ing of which it becomes insoluble. Very analogous to it is the casein or 
coagulable part of milk. Fibrin is the basis of muscle, and therefore exists 
in meats. According to the chemists, these principles are absolutely identi- 
cal with the similar principles of plants, the animal albumen with the vege- 
table, animal fibrin with vegetable gluten, and the casein of milk with a pecu- 
liar coagulable principle found in the seeds-of leguminous plants, and therefore 
called legumin. But an observant practitioner must, I think, hesitate to 
admit this entire identity; as he has been accustomed to see, from the varie- 
ties of food containing the animal principles alluded to, different effects upon 206 
GENERAL THERAPEUTICS. 
[part I. 
the system from those produced by the vegetable. To me, at least, milk and 
boiled meats, which consist chiefly of these principles, have always seemed 
more supporting, perhaps I might say more stimulant to the system than 
bread, or other food prepared from grains. There are few practitioners who 
would venture to allow a patient, with inflammation, to use the former as 
freely as the latter. But animal food, consisting of these principles, is cer- 
tainly less stimulating than other kinds of food from the same kingdom, and 
is therefore better adapted to the treatment of inflammatory complaints. 
They may be considered as intermediate between the most nutritious vege- 
table and a full animal diet, and are adapted to cases in which some reduc- 
tion of diet, but the least possible, is required. Milk has been mentioned as 
one of the varieties of this kind of food. The oily matter which it contains 
bears about the same practical relation to the vegetable oils, as its casein 
does to vegetable albumen. It is one of the first articles of food which may 
be permitted, in rising from the lower to the higher grades of diet. Tho- 
roughly boiled meats, from which the principles soluble in boiling water have 
been removed, while the fat has been melted out, consist almost entirely of 
albumen and fibrin, and may be placed very nearly in the same grade. Fish 
is also intermediate between vegetable and the more stimulating varieties of 
animal food. It must be obvious to every one, that, to secure the effects of 
indirect depletion from these more nutritious articles of diet, it is necessary 
that they should be given in quantities less than are adapted to the healthy 
state. 
There are other animal principles which are decidedly stimulant to the 
system, as well as highly nutritive, and therefore unfit constituents of a diet 
intended to be accessory to a depletory treatment. These will be alluded to 
under another head. 
II. Repletion.-By this term is here meant an increase of the quantity 
of the blood in general, or of its solid animalized ingredients. The circum- 
stances of disease under which this remedial process is desirable are the 
opposite of those requiring depletion; viz., general debility, a too scanty 
blood, and a condition of that fluid in which, though its bulk may be suffi- 
cient, there is an undue proportion of the watery ingredient. The means by 
which it may be accomplished are the free employment of a highly nutritious 
diet, and the use of remedies calculated to invigorate digestion and sanguifi- 
cation, such as moderate exercise, tonic and stimulant medicines, frictions, 
the cold bath, &c. 
III. Dilution.-By this is meant the copious internal use of water, 
whereby the liquids of the body are diluted, and rendered less excitant. The 
liquors o£ the stomach are first diluted, then the blood in consequence of the 
absorption of the water, and, lastly, the secretions, especially those of the 
skin and kidneys, in consequence of its passing out through these emuncto- 
ries. The therapeutical effect is to r61ieve irritation or inflammation of the 
surfaces with which the diluted fluid may be in contact, as the mucous mem- 
brane of the stomach, and that of the urinary passages, and to moderate 
general excitement by attenuating the blood. 
IV. Stimulation.-Stimulation, as here understood, is the exaltation 
of any or all of the vital functions above the state in which they may 
happen to exist at the time when the stimulating measures are resorted to. 
The subject in all its details is exceedingly copious, and would require, for 
its full developement, much more space than can be allowed to it in this 
work. We must content ourselves with a very general view of it. There 
is a vast diversity in stimulation. It differs in direction, degree, duration, 
and character. Perhaps the most convenient primary division of it is into 
general and local; the former being felt to a greater or less extent, through- CHAP. IV.] 
THERAPEUTIC PROCESSES.-STIMULATION. 
207 
out the body, the latter confined originally to a particular part or organ. 
A property common to all stimulation, which may therefore be mentioned 
here, is that it is followed, in the ordinary state of the system, by a degree 
of depression bearing some proportion to the previous excitement. There 
may be conditions of temporary prostration, in which stimulation may put 
the system in the power of resuming its ordinary grade of action, with- 
out subsequent depression; but these do not come within the general 
rule. The depression is consequent upon the temporary diminution of ex- 
citability, resulting from excessive action. If the stunulant influence be 
continued, it follows as a consequence of the diminished excitability, that 
more of the stimulant agent must be employed to produce the same effect, 
and the excitability is thus still further diminished; until, in the end, the 
system refuses entirely to respond to the- ordinary healthy excitants, and 
morbid and often fatal debility results. This is an evil against which it is 
necessary to be constantly upon our' guard, in the use of stimulant mea- 
sures. Another, scarcely less important, is the production of inflammation 
by the excessiye or repeated excitement to which the stimulated organ or 
system is exposed. These two cautions are applicable to every kind of stimu- 
lation. - 
1. General Stimulation.-It is barely possible- that stimulation should be 
absolutely universal. In whatever degree the functions generally may be 
excited, there is almost always some one or more that remain quiescent, or 
become depressed. Stimulation may be considered general, when any one of 
the vital properties or functions which belong to all parts of the frame is 
exalted, as contractility, or nutrition; or when one of the systems which per- 
vade the whole body is excited into increased action, as the circulatory or 
nervous. In such cases, the excitement is felt throughout the frame, though 
not in every function. 
The lowest grade of general stimulation is that produced by astringents, 
which operate on the organic contractility, and produce a general condensation 
or shrinking of the tissues. Orifices are thus contracted, the flesh becomes 
firmer, and the pulse somewhat more tense. TJierapeutically, excessive dis- 
charges whether secretory or hemorrhagic are checked, relaxed tissues invigo- 
rated, and the general strength promoted. But caution is requisite in the 
application of this principle. Discharges are often intended to. relieve con- 
gestions or inflammations, which would be fixed by their suppression; and the 
contraction of tissue may be carried so far as to interfere with the function of 
a part, instead of adding to its strength. 
Somewhat higher in the scale of stimulation is the action usually denomi- 
nated tonic. This is a moderate increase of the vital functions generally, 
produced rather slowly, and lasting for a considerable time. It is of vast 
importance in the treatment of moderate or chronic debility, when excitability 
remains but little impaired. It is indicated in the suppurative and gan- 
grenous stages of inflammation; in the advanced periods of febrile disease, 
when the strength begins to fail, and support is required to sustain life until 
the affection shall have run its course; in all complaints attended with feeble- 
ness of the vital actions, from poverty, or depravation of the blood, or the 
depressing'nature, either of the cause, or of coincident morbid influences; in 
the weakness from enfeebled digestion or exhausting discharges; and, finally, 
in the debility of convalescence. Among the agents by which tonic stimula- 
tion is effected, are a class of medicines denominated tonics, which may act 
directly upon the whole system, or especially upon the digestive function, 
thereby enriching the blood, and making that fluid the immediate excitant. 
Some medicines are supposed to give tonic powe'r to the blood by a direct 208 
GENERAL THERAPEUTICS. 
[part I. 
action upon that fluid. Such are the chalybeates. There are other import- 
ant agents, besides medicines. The cold bath, or a temporary exposure to 
cold air, in consequence of the reaction which follows its first depressing effect, 
is highly corroborant; and the use of ice internally, taken in small pieces, 
and swallowed very slowly, has also been highly recommended in low diseases, 
with the same view;* but these agents are obviously inapplicable to cases, 
in which the system is so far debilitated as to be unable to react efficiently. 
A wholesome and nourishing diet, succeeding an impoverished one, and pure 
fresh air to those wtu^have been confined to a close and vitiated atmosphere, 
have a powerful tonic influence. So also has moderate physical exercise, 
under similar circumstances of previous deprivation. Mental influences, 
moreover, have great effect. No tonic is, under many circumstances, more 
efficient than the cheering influences of social pleasures, domestic enjoyment, 
and a gentle exercise of the intellectual faculties, and all the kindlier 
emotions. 
A quicker and more rapid stimulation is sometimes distinguished by the 
name of diffusible. It usually affects more or less the functions of organic 
and of animal life, though, as proceeding from one cause, it may be more 
especially felt in the circulation and its dependent functions, from another, in 
the nervous system. Remedies calculated to increase the vigour of the circu- 
lation, and augment animal temperature, without any peculiar or direct influ- 
ence on the brain or nerves, may be called arterial stimulants. They are 
adapted to cases of considerable debility, in which active stimulation is indi- 
cated ; and are peculiarly applicable when, in such cases, there may exist any 
strong tendency to cerebral congestion or inflammation, as in the great pros- 
tration which sometimes precedes febrile disease, or threatens death in con- 
cussion of the brain. 
Stimulants which act chiefly upon the nervous system, may diffuse an 
apparently equable action over the whole of that system, or may concentrate 
their influence especially upon the brain. The former may be called nervous 
stimulants, though more commonly known by the name of antispasmodics. 
The latter I would propose tp denominate cerebral stimulants, in preference 
to the name of narcotics, which implies simply their stupefying property, and 
belongs also to medicines of very different powers. The nervous stimulants 
are indicated in all cases of nervous disorder attended with debility; such as 
spasm, wakefulness, general uneasiness, jactitation, mental depression, &c. 
Their mode of operation in restoring the nervous functions to their due state 
is not exactly understood.' They prove efficient, not only in cases of debility, 
but in those, also, in which the nervous system is disturbed without any de- 
preciation of the general strength, provided there be no vascular irritation or 
inflammation at the foundation of the disturbance. They may be said to act 
by equalizing the nervous excitement; but this explanation is too vague to be 
altogether satisfactory. Among the most efficient of them are musk, assafe- 
tida, and valerian. 
The cerebral stimulants, operating more extensively and powerfully upon 
the system, are more efficient than either of the other classes in cases of deep' 
debility, which call for all the resources of our art to support the failing 
strength, as in the low states of typhous disease. It is only in such cases as 
may be complicated with great cerebral congestion or inflammation, that they 
are contraindicated. Among medicines of this class, I rank alcohol, ether, 
opium, and camphor. In the use of all these stimulants, it must be remem- 
bered that the system sometimes puts on the appearance of debility, when in 
* Provincial Med. and Surg. Journ., Jan. 26, 1848, from the Revue MedicoChirurgicale. CHAP. iy.] 
THERAPEUTIC PROCESSES.-STIMULATING FOOD. 
209 
fact there is a general sthenic condition, and possibly a severe inflammation 
of some vital organ; and that a mistake, under these circumstances, might 
prove fatal. Instead of stimulation, depletion is often strongly indicated. 
Such are the cases in which the circulation fails in consequence of overpower- 
ing congestion or-inflammation of the brain, heart,'or lungs; these organs 
being incapacitated from performing their functions, and the dependent func- 
tions ceasing of course. The excessive nausea which sometimes attends acute 
mucous gastritis, may have the same apparent effect by prostrating the circu- 
lation. , .. r 
Heat may often be very advantageously resorted to1 in reference to its sti- 
mulating property. It may be applied by means of heated substances, such 
as heated bricks 'wrapped in flannel, bottles of hot water, bags of heated sand, 
oats, &c., or more generally by means of the hot air or vapour bath, or of 
the hot-water bath, the temperature1 of which may vary from 98° to 110°, 
according to the effect to be produced. In the use, however, of this agent, 
the tendency to subsequent depression, both by exhausting perspiration, and 
by the relaxation which follows excitement, must be borne in mind. 
A quick and powerful, but transient stimulation is often indicated in cases 
of great and sudden depression. The object is momentarily to rouse the 
system, after which, its own unimpaired energies will be sufficient for its 
support. A longer continued impression might be injurious, by adding to 
the .subsequent reaction. Syncope, and the prostration from certain poisons 
are examples of this kind; and the effect may often- be advantageously pro- 
duced by the sudden application of cold, as, for example, by cold water dashed 
upon the surface. The shock acts as a powerful temporary stimulus to the 
nervous system. (See page 131.) Ammoniacal remedies, applied to the 
nostrils, act in the same way. Sometimes .the excitement of strong emotion, 
when consciousness remains, produces a similar effect. Electro-magnetism is 
also a most powerful agent, under these circumstances. 
Certain, general stimulants have a determination to particular functions. 
Thus, mercury and iodine, which are moderate excitants of the system at 
large, are thought to have the peculiar property of stimulating the absorbents, 
and hence are employed for the resolution of chronic and indolent swellings. 
Nux vomica, along with a tonic power, has the property of stimulating espe- 
cially the motor nerves, and hence answers sometimes admirably as a remedy 
in functional palsy. 
Stimulating Food.-This may be the proper place to say a few words 
upon the subject of stimulating food. It has already been stated, that the 
most nutritious substances are vegetable and animal products containing albu- 
men, gluten or fibrin, and casein, to which oil may be added. These may no 
doubt prove stimulant, if in excess, by enriching and augmenting the blood; 
but they are not directly so, or at least in a very slight degree. Yet many 
animal substances, taken into the stomach, are directly and even powerfully 
stimulant. All persons of excitable systems have experienced this effect after 
eating freely of beef, pork, &c., even before these substances could have been 
converted into blood. They appear to operate by a primary stimulant impres- 
sion upon , the alimentary canal. But their effect is continued after digestion, 
probably from the more highly stimulant character they impart to the blood. 
Certain substances extracted by water from animal products have this charac- 
ter. Such probably is osmazome, or animal extractive. Such, moreover, 
may be gelatin, though its claim to be considered stimulating might be con- 
tested. Every one is familiar with the fact, that roasted or broiled meats are 
more stimulating than the boiled. This may be partly owing to some change 
which the proximate principles undergo, through the greater heat to which 210 
GENERAL THERAPEUTICS. 
[part I. 
the former are exposed; but it is probably ascribable, in chief, to the more sti- 
mulant character of the principles extracted by boiling. This is strongly exem- 
plified in the highly stimulating property of the preparation, sometimes made 
from beef and mutton, under the name of essence. The muscle, deprived of'fat, 
is cut up finely, and introduced, without water, into a narrow-necked bottle, 
which, after being loosely corked, is exposed for an hour or more to a boiling 
heat in a pot of water, in which it is so placed that the top of the bottle is above 
the surface of the liquid in the pot. At the end of the process, the liquor which 
may have formed in the bottle is poured off, and constitute^ the preparation 
in question. It is a concentrated solution of the soluble' principles, of the 
meat, is powerfully stimulant, and, in the quantity of from a teaspoonful to a 
tablespoonful, repeated at intervals of half an hour, an hour, or two hours, 
aids greatly in the support of the system in low forms of disease. Animal 
fat appears also to have a stimulant character. Hence, fat pork is an excel- 
lent diet for those who labour severely, and appear to require a strong impres- 
sion upon their digestive organs, and a very rich blood. Hence, too, the 
blubber of seals is much valued as an article of food among the Esquimaux, 
and other inhabitants of the frozen latitudes. The kinds, of food in ordinary 
use, to which the stimulating character especially belongs, are roasted, boiled, 
or fried pork, beef, and mutton, and, among poultry, goose, duck, arid turkey. 
The dark flesh of fowls is probably more stimulating than the white; that of 
tame animals, than wild of the same kind; and that of the full-grown, than 
the young. May it not be, that the more stimulating kinds of animal food 
owe their influence, at least in part, to the production of a greater proportion 
of the red corpuscles, which are probably the most excitant portion of the 
blood. 
Local Stimulation.-Local stimulation may have the effect of merely irri- 
tating or inflaming a part, or of exciting it to an increased performance of its 
peculiar function. In the former case, the object is usually to act revulsively, 
or to produce general stimulation by the sympathy of the system with the part 
affected. The agents employed for either purpose, so far as the external sur- 
face is concerned, are the rubefacients, epispastics, and escharotics. Occa- 
sionally, however, the object is entirely local. The vessels of a part may 
become relaxed and congested with blood, and, in consequence, an imperfect 
sort of inflammation may be sustained; or there may be ulceration, and the 
surface too feeble to take on the action necessary for the healing process. In 
either case, local stimulation sometimes answers an excellent purpose in re- 
moving 'the evil. s . 7 
But still more frequently, this remedial process is employed for the increase 
of function. The surface may be pale, dry, and inactive; the muscles may 
be enfeebled to paralysis; the senses of smell, taste, and touch, may be imper- 
fect from weakness; digestion may be feeble, and the bowels costive from 
deficient secretion, or want of due peristaltic movement; the liver, kidneys, 
or other secretory glands may be inert. The means used to restore the weak- 
ened functions, are medicine's and other remedies having a special influence 
over the functions severally. Hence the use of friction to the surface; the hot 
bath; the cold bath, used with a view to reaction; diaphoretics; errhines; 
masticatories; gastric stimulants, such as bitters, aromatics, and the mineral 
acids; emetics; cathartics; diuretics; expectorants; emmenagogues; and cho- 
lagogues to excite the liver, as mercury and nitromuriatic acid. Hence the 
employment of ergot to stimulate the uterus to contraction. 
Sometimes a local stimulant is employed to produce general depression; as 
in the case of the hydragogue cathartics, which, though they stimulate the 
bowels, depress the system in consequence of the depletion they produce. CHAP. IV.] 
THERAPEUTIC PROCESSES.-SEDATION. 
211 
V. Sedation, or Depression.-This implies a diminution of action. 
Like stimulation it may be general or local. General sedation may affect 
especially either the circulation and its dependent functions, or the nervous 
system. The agents which produce the former effect, I denominate arterial 
sedatives. They are the refrigerants of other writers, as they reduce tem- 
perature along with vascular action. They are indicated in excited states of 
the circulation,^and morbidly increased temperature, especially when the con- 
dition of the system is sthenic; though some of the milder of them may be 
employed even in general debility, provided there is a frequent pulse and a 
hot dry skin. The most powerful are probably the antimonials, which are 
often very efficient in inflammation and fever. The neutral alkaline salts, 
such as pitre and citrate of potassa, and the vegetable acids, as the citric 
and tartaric, have in some degree the same effect. Cold internally and ex- 
ternally is also powerfully sedative. It is usually employed in connexion with 
water" or ice. But its strong tendency to be followed by reaction should never 
be forgotten in these cases. Water alone is also powerfully sedative. It has 
this / effect whether taken internally or applied to thesurface. Inorder to 
obtain its purely sedative and relaxing effect, when externally employed, it 
should be in the form of a bath, and of a Lukewarm temperature, in other 
words, neither so hot nor cold as to add the effects of temperature to that of 
the water.* This has the advantage over the cold bath that it does not pro- 
duce reaction. Most depletory remedies are sedative; but of these sufficient 
has been said already. The 'agents which directly reduce the actions of the 
nervous system may be called nervous sedatives. They may act in two modes ; 
first, by' a direct depressing influence upon the whole nervous system, and, 
secondly, by so affecting the nervous centres as to render them incapable of 
duly receiving and transmitting impressions. Those which act in the first 
mode are directly and essentially sedative; those which act in the second 
mode may, on the contrary, be even stimulant to the nervous centre, and by 
the very excess of stimulation, may incapacitate that centre from the perform- 
ance' of its duty. Now there is a great practical difference in the application 
of these agents. While the direct sedatives may be employed in cases of 
nervous excitement, with little reference to any supposed tendency to cerebral 
disease; those which produce their effect through excitement and consequent 
congestion of the brain, are the last remedies which would be thought of, when 
that organ may be deemed in danger. Thus, hydrocyanic acid, digitalis, 
tobacco, and acetate of lead, may be employed where it might not be safe to 
use alcohol or opium. 
Local sedation may affect the whole of the tissues of a part, or more espe- 
cially the nervous. In the former relation, it is employed to repress inflam- 
mation, or vascular irritation as shown in morbid secretion, hemorrhage, or 
simply congestion. The. agents are chiefly cold, moisture, and the prepara- 
tions of lead. Cold, to produce its due effect, must be employed steadily, in 
order to prevent reaction, which might increase the disease. It is usually 
applied by means of cold water or ice; though the evaporation of ether or 
officinal alcohol has in some degree the-same effect. To obtain the legitimate 
relaxing effect of moisture, it must be neither hot nor cold. It is best applied 
in the form of emollient cataplasms, which are admirable remedies even in 
internal inflammations, when made to cover the external surface corresponding 
to the part affected. As in the case of leeches, some authors ascribe the an- 
tiphlogistic operation of cataplasms, under these circumstances, to revulsion. 
* Tbe temperature of the warm-bath should be about 90° or from that to 95°. Above 
the latter degree, it might become somewhat stimulating through its heat. 212 
GENERAL THERAPEUTICS. 
[part I. 
How then should they produce the same effect when applied directly to the 
inflamed surface, as they are known to do ? May not sympathies, connecting 
the outer with the corresponding inner portions of the body, have something 
to do with the result? The preparations of lead are much used locally as se-. 
datives, in inflammation of the skin and subcutaneous cellular tissue. They 
are best employed in solution, and, by reducing the temperature of the solu- 
tion, the conjoint effects of the medicine and of cold may be obtained. Local 
nervous sedation is very useful in neuralgic pains and spasms. The substances 
employed belong to the narcotics. Opium, camphor, belladonna, stramonium, 
hyoscyamus, conium, and tobacco, are among them. There is also another 
set of substances which have considerable effect locally in obtunding pain, by 
producing a partial paralysis of the part. Such are aconite and veratria, to 
which chloroform may be added. 
VI. Revulsion. -Derivation.-Counter-irritation.-Revulsion 
consists in the diversion of disease from one part of the system, by the produc- 
tion of inflammation, or irritation, in another part. The term derivation may 
extend also to cases in which the diversion is effected by a degree of excite- 
ment, which may still be within the limits of health. Counter-irritation, 
strictly defined, applies to the revulsive impression, rather than to the revul- 
sion itself. There is, in the human system, only a certain capacity of nervous 
action, and a certain amount of blood. When either the former or the latter 
is strongly directed to a particular part of the body, there is a tendency to its 
diminution elsewhere. This is absolutely necessary of the blood, and it is 
true to a great extent in relation to nervous action. Such a direction is given 
by the application of irritants of any kind. Hence, in order to relieve inflam- 
mation, any of the forms of vascular irritation, or mere nervous excitement, 
as indicated by pain or spasm, in any particular part of the body, we apply 
irritants, which, under these circumstances, are called revulsives, to some 
other part. This principle is of very extensive applicability in the cure off, 
disease. It often comes into play as an auxiliary force, in cases in which the 
remedy is used for other purposes. Thus, while emetics are employed to re- 
lieve spasmodic affections of the air-passages, in consequence of the relaxation 
they produce, they are probably also useful by a revulsive influence towards 
the stomach. Cathartics act very powerfully upon this principle in the relief of 
inflammations and congestions, though they may be employed chiefly in refer- 
ence to their depleting power. There is ho remedy, whatever, allowing it to 
have the power of producing excitement in any part of the body, which may 
not act as a revulsive. But the remedies usually employed, in especial refer- 
ence to this principle of action, are external irritants, such as hot water, rube- 
facients, epispastics, and caustics. Derivation may often be advantageously 
effected by exercise, calling off undue excitement' from internal organs to the 
exterior, or from one part of the body to another, and thus producing an equi- 
librium of the vital actions. 
The application of the principle of revulsion requires discrimination-. When 
the local affection consists rather in a determination of blood to the part affected 
than in inflammation, as in cases of vertigo threatening apoplexy, and of fre- 
quently recurring epistaxis or haemoptysis, the indication is to divert the 
general current of excitement'and of the blood to the most distant part of the 
body. Hence the use of strongly stimulating pediluvia, and of sinapisms to 
the legs, in cases of cerebral affection of the character just alluded to. But, 
when the disease is fixed in a part in the form of inflammation, it is necessary 
to bring the revulsive impression into nearer contiguity with the diseased part, 
though it may be proper also to employ remote revulsion as an adjuvant. 
Hence, in inflammation of the lining membrane, or of the contents of the great CHAP. IV.] 
THERAPEUTIC PROCESSES.-REVULSION. 
213 
cavities, the revulsive remedy is most advantageously applied over the outer 
surface of the parietes of these cavities, as over the abdomen in cases of peri- 
tonitis or enteritis, the chest in cases of pleurisy or pneumonia, and the scalp 
in those of encephalic inflammation. 
The revulsive influence of remedies is peculiarly indicated in cases of me- 
tastasis, or of diseases .which are especially liable to assume the metastatic 
form. In these cases,-the agent should be applied to a portion of the body, 
towards which there is a natural tendency of the morbid action to flow, and in 
which it would be safe; as, in gouty cases, to the feet, and in cases of retro- 
, cedent eruptions, to the part of the surface from which the retrocession has 
taken place. ' , . ■ 
Another important principle is, not to employ a highly irritant revulsive 
agent in inflammatory cases, during the greatest violence of' the disease. A 
strong impression upon the surface may sometimes prove useful in a commenc- 
ing inflammation, before any febrile action has been excited, and in the de- 
clining stages, when the fever has in some measure yielded to depletion, or in 
the ordinary course of the disease. But, during the existence of high consti- 
tutional excitement, the revulsive agent is not sufficient to unseat the inflam- 
mation, and, if of itself irritant, as in the instances of rubefacients and blis- 
ters, may add to the existing excitement, by the sympathy of the system with 
the superficial inflammation they produce. But, when the revulsive impres- 
sion is conjoined with copious depletion, as in the case of the' saline hydra- 
gogue cathartics, which produce a revulsion towards the whole lining membrane 
of the bowels, while they evacuate the contents of the blood-vessels, it may be 
resorted to even in the greatest height of the inflammation. The copious 
secretion prevents the excitement of an irritation in the bowels, sufficient to 
bring the constitution into sympathy.* 
When the local affection to be remedied is a mere nervous irritation, such 
as spasm or neuralgic pain, it is generally best to produce a quick, powerful, 
and transient revulsion; when inflammatory, especially when the inflamma- 
tion is severe, to sustain a more moderate impression for a longer time. 
Hence, the more active rubefacients; such as mustard and ammonia, are ap- 
plicable in the former case, and epispastics in the latter; 
VII. Supersession.f - By this process is meant the displacing or 
prevention of one affection by the establishment of another in the seat 
of it. It is a general, though by no means universal pathological law, 
that two powerful diseases cannot exist in the whole system, or any por- 
tion of it, at the same time. If, therefore, we can produce a new disease, 
in the exact position of one that may be existing or expected, we may 
possibly supersede the latter; and, if the new disease subsides spontane- 
ously without injury, we cure our patient. The operation' of numerous 
remedial agents is explained in this way. It is thus, for instance, that 
mercury is supposed to cure syphilis. But we have better examples in 
the powerful influence of certain antiperiodic remedies, such as quinia and 
arsenic, in the cure of intermittent diseases. They establish their own morbid 
impression, in the absence of the paroxysm; and the system, being thus 
* Of course, in the cases here referred to, it is taken for granted that there is no inflam- 
mation or undue excitement in the alimentary canal itself; as, under such circumstances, 
any counter-irritant or revulsive impression made upon the stomach and bowels, would 
be contra indicated. 
t The author has taken the liberty to employ this Word, because he could not find 
another exactly expressive of the same meaning; and the same excuse must serve him 
for having ventured to give a new meaning to the term repletion, employed in a preced- 
ing page. 214 
GENERAL THERAPEUTICS. 
[PART I. 
occupied at the moment when the, disease was to return, is incapable of ad- 
mitting it. In the same way may be explained the effects of blisters, opiates, 
emetics, or indeed any violent impression from any source, in the cure of 
paroxysmal diseases, if caused to be in full action at the time for the expected 
recurrence of the paroxysm. Mental influences are sometimes very powerful 
in the superseding not only of intermittent diseases, but of continued disease 
also, when of a merely functional character. 
The excitement of any strong emotion may have this effect; and the pre- 
occupation of the nervous system resulting from a strong' faith has often 
exhibited a wonderful influence. The same law holds in cases of purely local 
disease: It is probable that many cutaneous eruptions, and diseases of the 
mucous membrane of the alimentary canal and urinary passages, yield, upon 
this principle of supersession, to certain applications made to them directly, 
or, in the case of urinary diseases, through the route of the circulation. 
VIII. Alteration.-This name may be given to that operation of medi- 
cines by which they change existing morbid actions or states, without any 
observable effect upon the system. The medicines are usually called alteratives. 
They may produce their effects by changing the character of the blood, or the 
condition of the solids. Their precise mode of action is unknown, or at best 
conjectural. It will be perceived that the employment of the term is merely 
a convenient mode of classifying certain unintelligible results, which depend 
altogether for their acceptance upon the evidence of observation. In certain 
states of disease, we administer certain remedies without other observable 
effect than a cure. It is often very difficult, in such cases, to decide whether 
the result has proceeded from the remedy, or has happened in the ordinary 
course of the disease. It is at least highly probable, that a great many medi- 
cines have acquired a credit as alteratives which was due exclusively to 
nature. ' • 
Among the most striking illustrations of this operation of'medicines is that 
of mercury in the cure of inflammation. After due depletion, or when deple- 
tion is not indicated, no remedy has so powerful an antiphlogistic influence 
as mercury, urged to the point of affecting the system. Usually, its action is. 
evinced by soreness of the gums and some excitement of the circulation; but 
there is reason to believe that these have nothing to do with the therapeutic 
result, which indeed often takes place when they are not observed. The 
action of the remedy is therefore alterative. Other examples are afforded 
by iodine in scrofula, sarsaparilla in venereal disease, colchicum in rheuma- 
tism, &c. 
It is apparent that supersession and alteration may often lay claim to the 
same results. Thus, does mercury cure syphilis and inflammation by the 
substitution of its own transitory morbid effects for the existing disease, or 
does it merely alter the morbid into healthy actions? Upon the solution of 
this question it depends, whether the remedy is to be looked upon as a super- 
sedent or an alterative. 
IX. Chemical Influence.-Substances may be employed therapeutic- 
ally, in reference to their chemical influence, for two purposes; first, for the 
destruction of the tissues, as in the formation of issues, the removal of morbid 
ulcerated surfaces, &c.; secondly, for the neutralization of substances contained 
within the body, but not forming an essential part of it, as of an excess of 
acid in the primae vise, the blood, or the urinary secretion. It is not impos- 
sible that certain substances, taken internally, may produce curative effects 
through chemical re-actions with the vital constituents of the blood, or of the 
tissues; but too little is known of the subject to justify any positive statements. 
It is well known, that nitrate of silver has a powerful influence in subduing CHAP. IV.] 
THERAPEUTIC PROCESSES.-MECHANICAL INFLUENCE. 
215 
inflammation, whether of the mucous or cutaneous surfaces, when brought 
into direct contact with the inflamed part. It is also well known, that a 
chemical action takes place between it and the surface to which it is applied. 
But how far these two facts are connected, has not been determined. 
X. Mechanical Influence.-This is often very important in the 
treatment of diseases. Position may be made either to favour or counteract, 
through the agency of gravitation, the entrance of'blood into a part. Thus, 
when fainting is threatened from a want of the due pressure of the blood upon 
the brain, by placing the patient in a horizontal posture, the pressure is 
favoured, and the apprehended result prevented. Much more frequently, 
however,, the object is to diminish congestion or inflammation in a part, by 
diminishing the access of blood; and this is accomplished by elevating the 
part affected above its usual position. Thus, in an inflamed limb, the ex- 
tremity should be raised, instead of being allowed to retain its ordinary 
dependent position of health. 
Compression is another useful mechanical process, which may be made to 
diminish or increase the quantity of blood in a particular part of the body. 
Thus, the access of blood to a part may be lessened or cut off by pressure 
upon the arterial trunks which supply it; or the capillaries themselves may 
be emptied by direct and equable pressure made upon them. In the latter 
mode, especially, much good is often done in chronic inflammation, and pas- 
sive congestion. An accumulation of blood may be produced by pressing 
upon the veins and not upon the arteries, as when the tourniquet is applied 
not very tightly. This process may sometimes be useful by abstracting tem- 
porarily a quantity of blood from the general circulation, without ultimately 
losing it. Other advantageous effects of compression are to promote absorp- 
tion, and to afford mechanical support to relaxed parts, as in varicose veins of 
the legs, and to the abdomen after the operation of tapping. 
- Distension-sometimes acts usefully by stimulating a. part to increased action, 
as when large fluid injections are thrown, up the bowels. It may, however, 
be carried so far as to produce paralysis of the muscular fibre, and thus pre- 
vent all contraction. This is an important therapeutical fact. 
Friction may.be considered as a mechanical remedy. It acts partly by 
compressing the parts, partly by stimulating them. Employed for the latter 
effect, it is often a powerful agent in rousing and supporting the system in 
low disease, and in exciting the part itself when enfeebled; but it is more 
frequently and usefully employed for its effect in producing revulsion from 
within outwardly. 
The corering of surfaces, so as to protect them against irritating substances, 
and the contact of the air, is another useful mechanical process. Thus, de- 
mulcents protect inflamed mucous surfaces; and cataplasms, plasters, and 
cerates are employed for the same purpose upon the skin. PRACTICE OF MEDICINE. 
PART II. 
SPECIAL PATHOLOGY AND THERAPEUTICS. 
Prefatory Remarks. 
The object of this part of the work is to treat of diseases individually; 
and each will be considered separately in all its relations. 
Diseases are certain associations or groups of morbid states or phenomena, 
offered by nature to the notice of the observer. If examined carefully, they 
will be found to consist of two different sets; one, embracing all cases in which 
the true pathological condition gives its name to the disease, the other, those 
in which certain prominent effects or phenomena are considered as the disease; 
the real morbid condition being kept in the back ground. As examples of 
the former nray be adduced 'pleurisy, pneumonia, and gastritis, or inflamma- 
tion severally of the pleura, lungs, and stomach; .of the latter, diarrhoea, 
dropsy, and the hemorrhages, in which the title is derived from the secretion 
or effusion, in other words, from a mere effect of the proper pathological con- 
dition, from which the secretion or effusion proceeds. Some may object to 
the propriety of admitting the latter group into the list of diseases; but, as it 
is upon the effects alluded to that the attention is chiefly fixed, while the true 
pathological state may not be obvious, and may even be a subject of dispute, 
it will be most convenient to comply with the general custom; especially as, 
to the uninstructed, these phenomena will always constitute the several dis- 
eases, and names expressive of them will always hold their place in the com- 
mon language. Tn the physician, however, it is important to look beyond 
the phenomena to their causes, and to fix his attention upon these as the true 
objects of his concern. 
A vast amount of time and industry has been expended in the formation 
of systems of nosology. It is not the intention of the author to discuss their 
merits. Imperfect they all necessarily are; because diseases are not yet suffi- 
ciently understood to permit us, in all instances, to see clearly their mutual 
relations; and systems founded upon this basis must be constantly changing 
with new discoveries, and the adoption of new views. In this uncertainty, 
that plan of arrangement appears to the author to be the best, which is most 
convenient, and which may tend to direct the attention rather to what is posi- 
tively known, than to the conjectures and peculiar opinions of authors. Such 
a plan is the one based upon the seat of the disease, and this it is here pro- 
posed to adopt. CLASS I.] 
GENERAL DISEASES. 
217 
Diseases will be placed together, which are situated in the same parts; and 
no, other attention, in the mere arrangement, will be paid to their mutual 
relations, than to form distinct groups, in each division, of such as.may have 
the closest analogy. Upon comparing diseases, we find occasion to divide 
them into three great classes, having reference to their seat. The first, class 
includes those diseases which occupy the whole system at the same time, and 
in which all the functions are simultaneously deranged. To the second, be- 
long constitutional affections which may display themselves in local disease in 
any part or several parts of the system, but not in all at. the same time. The 
third class embraces all the proper local diseases, or those which essentially 
affect some particular structure or function, and in which, any general phe- 
nomena that may be presented, are only secondary. This portion of the work 
will, accordingly, be distributed into three divisions, corresponding with the 
classes mentioned. 
CLASS I. 
GENERAL DISEASES.. 
The only diseases which belong strictly to this division are fevers. No 
other acute affections involve, like these, all the functions of the body; and 
if, in certain chronic affections, the system may become in some instances 
universally diseased, it is only in the advanced stages; and this universality 
is not, as in fevers, an essential part of their constitution. 
It will be recollected that, in the essay upon fever, in the first part of this 
work, the distinction between the essential or idiopathic fevers, and the symp- 
tomatic, was fully recognized. It is only of the former that I propose to treat 
in this place. Symptomatic fever is dependent solely on the local affection, 
owes all its importance to that affection, and ceases along with it. In fact it 
is the inflammation that constitutes the disease. The phlegmasiae, therefore, 
as those diseases are called which consist of inflammation and consequent 
fever, are ranked along with the diseases of the organs in which they are 
severally seated. 
Idiopathic fevers have been variously divided and subdivided, and have 
received, a great diversity of names, according to the views of different writ- 
ers. Thus we have intermittent, remittent, and continued fevers; synocha, or 
inflammatory fever; typhous, asthenic^ or adynamic fevey ; and synochous 
or mixed fever, beginning as synocha and ending as typhous. To these, con- 
gestive fever has been recently added. But these diversifies have reference 
merely to difference of form, grade, oY type, and any one fever, that is, any 
febrile disease distinguished from others by the nature of its cause, may have 
all these different characters. Thus, the same fever, produced by the same 
cause, may be in different individuals, or in the same individual under dif- 
ferent circumstances, either intermittent, remittent, or continued,, inflamma- 
tory, typhous, synochous, or congestive. Again, many distinct fevers have 
been made out of accidental complications; such as gastric, g astro-enter itic, 
hepatic, and- cerebral fevers, so called in consequence of the predominance of 
disease in the several organs which gave origin to the names. But this 
nomenclature, so far as it has been applied to idiopathic fevers generally, is 
incorrect; as it would seem to imply some essential difference between the 
diseases thus distinguished, whereas they may be absolutely the same disease, 
merely diversified by the occurrence of inflammation or irritation in one 
organ rather than in another. But, in very many instances, the diseases 218 
SPECIAL PATHOLOGY. 
[PART II. 
named as above have been nothing more than cases of phlegmasiae, and would 
have been more properly entitled gastritis, gastro-enteritis, hepatitis, and en- 
cephalitis. It appears to me that, in the arrangement of fevers, we should 
endeavour to find out some essential difference between them, something 
which characterizes them as distinct diseases, peculiar in their phenomena and 
nature, and incapable of being converted into each other; Now such a basis 
of arrangement is offered in the peculiarity of the cause. ' Upon examining 
the' various fevers considered essential or idiopathic, we find that, as a general 
rule, certain individuals are produced by one cause, others by another, others 
again by a third, and so on through almost the whole list; and we find fur- 
ther, that those produced by one of these causes cannot be produced by an- 
other, each set requiring its own particular cause. Here, then, is an excel- 
lent, and, as it appears to me, quite unobjectionable ground of association. 
The cases produced by the same cause /may very properly be treated as 
belonging to the same disease ; and any incidental peculiarities of form, type, 
&c., should serve only as the ground of varieties. These different diseases 
have only one thing in common; namely, that all are attended with that 
proximate constituent of disease, called abstractly fever, or febrile movement. 
There is only one among them, in the arrangement of which, upon this plan, 
any great difficulty exists; and the difficulty, in this instance, arises'from our 
ignorance of the cause. Nevertheless, in relation to that particular affection, 
there is so much to identify it in its phenomena, course, circumstances of occur- 
rence, and anatomical characters, that we can scarcely deny its claims to indi- 
viduality, though its cause is hidden, or at best obscure. The disease alluded 
to is that denominated variously, continued fever, nervous fever, slow or pro- 
tracted remittent, typhoid fever, typhia mitior, dothinenteritis, &c., and which 
I propose to denominate enteric fewer. It will be seen also that I place in one 
category, all the cases of fever in which the' causes, whatever their nature may 
be, act only as simple irritants. / 
Proceeding upon the plan above laid down, I shall treat of the following 
fevers, as distinct diseases, viz.:- 
1. Irritative fever, 
2. Miasmatic or bilious fever, 
3. Yellow fever, 
4. Enteric, or typhoid fever, 
5. Typhus fever, 
6. Plague, 
7. Small-pox, or variola, 
8. Vaccine disease, or vaccina, 
9. Chicken-pox, or varicella, 
10. Measles, or rubeola, 
11. Scarlet fever, or scarlatina, and, 
12. Erysipelas. 
Of several of these there are varieties which require distinct notice, and 
some of them distinct designations. Thus, miasmatic or bilious fever is dis- 
tinguished into intermittent, and remittent, each of which may be mild or 
malignant, or, to use a phraseology now fashionable, inflammatory or con- 
gestive. Of the fevers above mentioned some have circumstances in common 
\vhich might serve to associate them in distinct subdivisions. Thus, some 
arc propagated by contagion, and are hence called contagious fevers; some 
have the property, in common, that they are attended with an eruptive affec- 
tion, and are denominated eruptive or exanthematous fevers. Now it happens 
that these We in many instances interchangeable terms; most contagious 
fevers being exanthematous, and most of the exanthemata contagious. But 
this is not universally the case. The contagious and exanthematous fevers 
are entirely distinct individually; for, though they have certain points of 
similarity, each has its own peculiar traits, and its own peculiar cause; CLASS I.] 
IRRITATIVE FEVER. 
219 
Article I. 
IRRITATIVE FEVER. 
Under this term are included all cases of idiopathic fever resulting from 
causes of irritation, having nothing peculiar or specific in their mode of opera- 
tion. The caused may or may not he sufficient to produce inflammation. All 
that is necessary in its action is, that it should induce an over-excitement of 
one or more of the functions, which, being propagated by nervous communi- 
cation or otherwise to different parts of the system, may throw all the func- 
tions into a state of derangement, capable of sustaining itself, for a longer or 
shorter time, after the direct action of the cause shall have ceased. The fever, 
then, does not depend, like the phlegmasite, upon the continuance of any local 
disease; but, having been once excited, goes on by an independent action to 
its regular termination. It is obvious that there must be a pre-existing dispo- 
sition in the system to the febrile movement, in order that it should be thus 
independently sustained; seeing that a proper symptomatic fever, even though 
the local affection be much more violent than that which is necessary to the 
generation of idiopathic irritative fever, subsides immediately with the subsi- 
dence of the inflammation. 
Symptoms.-Irritative fever begins with feelings of languor, weariness, 
&c., succeeded by a chill of longer or shorter duration, which gives way to 
febrile re-action, as described under the head of fever in general. Sometimes 
it begins abruptly with the chill, without the usual premonitory symptoms; 
and sometimes even the chill is dispensed with, though this event is compara- 
tively rare. The degree of febrile re-action is exceedingly various. It may 
be so slight as scarcely to attract notice, or it may have all the violence of 
which the system is susceptible. There are usually a hot dry skin, frequent 
pulse, quickened breathing, furred tongue, headache, loss of appetite, thirst, 
constipation of the bowels, scanty urine, and diminution of the secretions 
generally. The pulse is sometimes very much increased in frequency, even 
more so than in most other fevers. It is often as high as 120 in the minute, 
and sometimes mounts to 130, 140, and, as has been asserted, even'to 150 or 
160. In most cases, however, it is considerably below the least of the num- 
bers stated. It differs not less in strength and fulness than in frequency. 
Sometimes it is strong, full, and moderately accelerated, sometimes small and 
feeble; and the latter is most apt to be the case when the frequency is greatest. 
The blood, when drawn, is usually florid, coagulates rather speedily, and ex- 
hibits no appearance of the inflammatory crust. This is a point in which the 
affection differs strikingly from the phlegmasia?, in which the buffy coat is 
almost always found. There is occasionally slight inflammation associated 
with the fever, most frequently in the fauces, Or some portion of the aliment- 
ary or pulmonary mucous membrane; but this is wholly insufficient to account 
for the symptoms, and is often wanting entirely. When present, it probably 
depends upon the same cause as the fever. 
The duration of the fever is often not more than a day. In this case it is 
called ephemera. But it frequently continues for two, three, or four days, and 
sometimes it may run on to the seventh or tenth day. When thus prolonged, 
it is apt to become somewhat remittent, relaxing in the morning, and under- 
going exacerbation in the afternoon or evening. The duration is altogether 
uncertain, and cannot be previously calculated. I have, in the evening, seen 
patients affected with violent and alarming fever, which had every appearance 
of a long continuance, and upon repeating my visit in the morning, have found 220 
GENERAL DISEASES.-FEVERS. 
[part II. 
them almost or quite free from disease. Under proper treatment, the fever 
seldom lasts more than four or five days. If it run on beyond this period, it 
will generally be found to be associated with some inflammation which sus- 
tains it. 
, The decline of the fever is frequently attended with increase of the secre- 
tions. Perspiration is most common, and serves to mark the 'Crisis of the dis- 
ease, if it be not the cause of it. The urine, which is passed at this period is 
apt to let fall a reddish sediment upon cooling., Occasionally the fever is 
carried otf by a diarrhoea. 
The grade of the disease is generally inflammatory; and the fever may 
often be considered as an example of the syndcha,' or pure inflammatory fever 
of Cullen. But occasionally, the general actions of the system, though 
excited, have the taint of feebleness. A low fever somewhat of the typhous 
character is developed, though infinitely less dangerous than the genuine 
typhus. The previously debilitated condition of the patient, a depraved state 
of his blood from bad living, or exposure for some time to depressing influ- 
ences, as of certain epidemics, exhalations from privies, &c., may account for 
this adynamic character. 
In some instances, the disease appears to assume the intermittent form. 
At least, I do not know how otherwise to account for those cases of intermit- 
tent fever, which we sometimes meet with in situations beyond any suspicion 
of miasmata, and in individuals who, so far as can be ascertained, have never 
been exposed to their influence; Other diseases, as neuralgia, rheumatism, 
gout, &c., sometimes assume a regular periodical form, and why may not 
fever ? If we suppose the constant operation of some irritant cause, sufficient 
to excite a paroxysm of fever, when the. system, in the course of its diurnal 
changes, is in a condition favourable for its action, but insufficient to resist 
the natural tendencies to a solution of the paroxysm, we have all the condi- 
tions requisite for the production of an intermittent fever. The disease, 
however, in this form, does not materially differ, in its symptoms or thera- 
peutic indications, from the miasmatic intermittent, to which, therefore, the 
reader is referred. It will be sufficient to state, in this place, that the irrita- 
tive intermittent, if indeed there be such a form of fever, is less: apt to be 
complicated with bilious disorder than the miasmatic^ and, as might be anti- 
cipated from the nature of the cause, is more apt to terminate spontaneously 
after a few paroxysms. 
The infantile remittent of authors^ so fay as it is a distinct .affection, is an 
example of simple irritative fever. Under that name, however, have been 
described several different diseases, resembling each other only in their febrile 
and remittent character, and in the circumstance of occurring in children. 
Gastritis, enteritis, mesenteric adenitis, hepatitis, tubercular disease of the 
lungs and bowels, and especially enteric or typhoid fever, have been Con- 
founded under the vague title of infantile remittent. I believe that all the 
protracted or chronic cases of this disease, as described in the books, may be 
referred to one of the above affections, or some other of a similar character. 
Yet there can be no doubt, I think, that a remittent irritative fever, corre- 
sponding with the definition given, at the head of this article, does frequently 
occur in young children. The causes of its greater frequency with them, 
than with others, are probably the greater impressibility of their systems, and 
the more persistent character of the irritations to which they are exposed, 
such as teething, worms, and crudities of all kinds in the stomach and bowels. 
It is not to be understood that childhood gives anything peculiar to the nature 
of the disease. The fever may be and often is ephemeral, with children as 
with older persons; but it is more apt to be persistent in the former than the CLASS I.] 
IRRITATIVE FEVER. 
221 
latter, and to continue on for several days in the remittejit form. In this 
ease, it exhibits usually more or less of the following character. 
Children from two to ^ight years old are most subject to the complaint. 
Sometimes the fever approaches gradually, sometimes occurs quite abruptly 
in the midst of apparently excellent health. Indeed, the child is not unfre- 
quently attacked after some unusual indulgence of his appetite. It is seldom 
that any other symptom of a chill is observed than some remaining coldness 
of the extremities, after the surface generally has become hot. This is per- 
haps owing to the circumstance, that the disease is not usually noticed until 
the fever has become established. Whcri first visited, the child' has a hot 
skin, a frequent pulse, sqpietimes amounting to 140 or even 160 in a minute, 
a furred and dryish tongue, quickened breathing, thirst, aversion for food, 
sometimes riausea and vomiting, and generally constipation of the bowels. 
There is also obvious disorder of the nervous system. If able to express 
himself, the child often complains of pain in the head; but otherwise, is rest- 
less and fretful, or, if quiet, is heavy and disposed to sleep. Starting in sleep, 
and twitchings of the tendons are very frequent, and sometimes the onset of 
the fever is accompanied with convulsions. After a few hours, the violence 
of the Symptoms abates; and, on thri following morning, the child is found 
with a cooler skin, a less frequent pulse, a moister mouth, less nervous dis- 
turbance, and a brighter,arid more lively expression. As the day advances, 
the fever again rises with similar symptoms as at first; and thus the disease 
continues, with daily remissions and exacerbations, till its close. In some 
cases, however, the remission is much less decided than in others; and occa- 
sionally it might be difficult to determine at what period in the twenty-four 
hours the febrile symptoms were most violent. Throughout the complaint, 
the tendency to constipation generally continues; and the passages, when 
procured, are apt to have an unhealthy appearance and odour, being clay- 
coloured, black, or greenish, with undigested food often intermingled, and 
very offensive. Occasionally there are large fecal accumulations in the bowels. 
The urine is scanty, and sometimes almost or quite suppressed. The breath 
is often sour, and of a peculiar heavy odorir, characteristic of febrile disease 
in children. Delirium is not unfrequent; but still more frequently there is 
drowsiness, amounting sometimes even to stupor or coma, which is usually 
most striking during the exacerbations. Occasionally the child picks its 
nostrils and lips, so as to make them bleed; and in the advanced stages picks 
also at his clothing, or the bed-clothes, or at whatever other object is near 
him, even at imaginary objects in the air; but this phenomenon is not con- 
fined to this form of fever, nor to children, though much more common, and 
a much less dangerous sign in them than in adults. 
The disease runs on variously from five to fen days, or even two weeks; 
but, in the protracted cases, there is always reason to apprehend the existence 
of positive iriflainmation-, generally within the abdomen, to which the com- 
plaint'owes its continuance and danger. Unless in consequence of the super- 
vention of inflammation, which places the disease among the phlegmasiae, it 
almost always ends in recovery. The paroxysms generally become shorter 
and milder; purgative medicines operate more readily, and bring away more 
healthy discharges; the 'urine becomes more copious;, the heat of skin and 
frequency of pulse abate; the tongue begins to clean, and the appetite to 
return; and health is gradually re-established. 
It is not always easy to distinguish the true infantile remittent from the 
phlegmasiae of the bowels, The occurrence of diarrhoea or of dysenteric 
stools, with a tumid abdomen and persistent tenderness upon pressure in 
certain parts, and less decided remissions in the fever, are the most promi- 222 
GENERAL DISEASES.-FEVERS. 
[part II. 
nent diagnostic symptoms of the latter affections. Some authors have at- 
tempted to distinguish between this and the worm fever. I believe that they 
are- identical; worms being capable of exciting the fever in those predisposed 
to it, as well as any other irritant. The diagnosis between the infantile re- 
mittent and enteric or typhoid fever, will be better understood when the latter 
complaint has been studied. It will be sufficient to state, in this place, that, 
in the enteric fever, so far from a disposition to constipation, there is usually 
either diarrhoea, or a great facility of being acted on by cathartics-, so that 
the least doses will often operate. There is, besides, more meteorism of the 
abdomen, a more regular march of the fever, and altogether a . Severer grade 
of disease than in the infantile remittent. The drowsiness or stupor which 
often attends the latter complaint, may sometimes lead to the suspicion of 
cerebral disease; but the absence of violent screams and uncontrollable vomit- 
ing, in the earlier stages, and the ordinary'circumstances that the stupor in- 
creases and diminishes with the fever, that the patient can be roused without 
much difficulty, and that there is no great derangement of the pupil, no stra- 
bismus, and no paralysis, will generally prove sufficiently diagnostic. 
Causes.-These are very numerous. Whatever is capable of producing 
irritation in one or more of the important organs of the body, may give rise 
to this kind of fever. The most frequent cause is probably exposure to cold. 
Persons who have been caught in a cold rain, and remain for some time with 
their damp clothes upon them, are apt to be attacked. Greneral exposure 
seems more apt to induce irritative fever, partial exposure inflammation. In 
the former case, the disturbing influence is more widely diffused, and involves 
a greater number of functions, in the latter is more local. The moisture acts 
only by conveying away the heat more rapidly, and thus favouring the action 
of cold. This cause is always more efficient when it has been preceded by 
warmth, especially if attended with perspiration. Exposure to intense heat, 
or over-exertion in hot weather, may have the same effect. Errors of diet 
are frequent causes of irritative fever, and this is probably one reason of its 
greater frequency among the young. Teething and worms may be ranked 
among the causes. I have often witnessed fevers of this kind, lasting from 
one to four days, during the prevalence of febrile epidemics, as if the epi- 
demic cause has been able to act as an irritant, though, from the previous 
protection of the individual, unable to produce its specific effects upon the 
system. Such was the case especially during the variolous epidemic, which 
prevailed in Philadelphia in the winter of 1845-6. 
But it is doubtful whether these causes would be sufficient to operate with- 
out the existence of a predisposition. In what the predisposition consists it 
is impossible to say with certainty. It is probably connected with an altered 
state of the blood, which may have an undue proportion of the red globules, 
or be otherwise rendered more than usually stimulating. It is highly proba- 
ble that this condition alone may, in some instances, be sufficient to induce 
an attack of fever, without the aid of any exciting cause whatever. 
Age appears to have some influence. The young are more liable to the 
disease than the old, and persons below the age of maturity than those above. 
When blood is rapidly elaborated to supply the calls of a vigorous nutrition, 
anything which interrupts its regular expenditure may lead to plethora, and 
consequently to fever. In the old, moreover, irritability is much diminished, 
and irritant causes therefore less efficient. 
Treatment.-In ordinary cases, this is very simple. In some instances, 
when the pulse is full and strong, the colour of the surface heightened, and 
considerable pain is felt in the head, it will be proper to take from twelve to 
sixteen ounces of blood from an adult; but this remedy is seldom necessary. CLASS I.] 
IRRITATIVE FEVER. 
223 
Generally, an efficient cathartic, followed by refrigerant diaphoretics, will be 
sufficient, with a proper attention to regimen, to effect a cure. In the choice 
of the cathartic, the physician should be guided by circumstances. If he find 
nothing but febrile excitement, with or without a little redness of the fauces, 
he should prescribe sulphate of magnesia, or a combination of this with infu- 
sion of senna. Should symptoms of acid in the stomach be conjoined with 
the others, magnesia may be, added to the saline cathartic. Should sallowness 
of the skin, yellowness of the tongue, or discolouration of the evacuations of 
the bowels, with oppression about the epigastrium, indicate hepatic congestion, 
and deficiency of hepatic secretion, the indication would be offered for some 
cathartic combination containing calomel, as three or four of the compound 
cathartic pills, a dose of calomel an,d jalap, or of calomel and compound extract 
of colocynth. The neutral mixture or effervescing draught, with or without small 
doses of tartar emetic, is usually the best diaphoretic, when the skin is hot and 
dry, and the pulse excited. Sometimes, however, when the action is of a 
feeble typhus-like character, or when a good deal of general soreness, as occa- 
sionally happens, is associated with the fever, ten grains of the powder of 
ipecacuanha and opium, given at bedtime, will prove highly useful. Should 
the fever continue, the bowels ought to be kept regularly open by the saline 
cathartics, and the diaphoretics above mentioned given in the interval. Rest 
should be enjoined, all causes of excitement avoided, the diet should be exclu- 
sively vegetable, and no stimulating drinks whatever allowed. 
Should inflammation in any important organ be developed, sufficient to 
affect the system, the case must be treated exactly as an ordinary phlegmasia 
of that organ. 
In the infantile cases, especially in the infantile remittent, some modifica- 
tion of the treatment is requisite. Some recommend an emetic at the com- 
mencement of the disease. This 'may be useful when the stomach is loaded 
with undigested food; but, as a general rule, is not advisable. Perhaps the 
most effectual remedy in the early stage is a full purgative dose of calomel. 
This cathartic appears to exercise a peculiar influence over the disease. It is 
certainly more efficient than other medicines belonging to the same class, 
which operate on the bowels no less powerfully. I have often seen the dis- 
ease yield immediately to a full dose of calomel, after having been ineffectually 
treated with magnesia, castor oil, saltSj &c. For nearly thirty years, I have 
habitually used this medicine in the irritative fever of children, have never 
seen it do harm, and have very frequently found it to put an immediate end 
to the disease. I believe that, if given early, it will generally produce this 
effect, and thus prevent the protraction of the fever in the remittent form. 
How it operates, is a matter of conjecture. Perhaps it may do good by its 
powerful influence upon the liver, promoting a free secretion of bile, and unload- 
ing the portal circulation. Perhaps it may have a peculiar alterative effect. 
But the fact of its utility rests not upon theory, but experience. In order to 
avoid the sore mouth which, in some fever cases of children, it is liable to 
produce when long retained in the bowels, care should always be taken to ad- 
minister Some other cathartic, if it fail to operate freely in six or eight hours. 
From two to six grains of calomel, according to the age of the patient, three 
or four grains being the proper dose for a child during the third and fourth 
year, may be given in syrup or molasses, and followed, if necessary, in the 
time above mentioned, by a dose of castor oil or sulphate of magnesia. Should 
the bowels not be well evacuated in this way, the operation of the cathartic 
should be promoted by enemata. In cases of obstinate constipation, moderate 
doses of infusion of senna, with manna, fennel seed, and sulphate of magnesia, 
repeated at intervals of two hours, will be found very effectual. After the 224 
■ GENERAL DISEASES.-FEVERS. 
[PART II. 
bowels have been freely opened, should the fever continue, it may be treated 
with the neutral mixture, repeated every hour or two, in the dose of one or 
two fluidrachms, or, if the stomach be irritable, by a dose of the effervescing 
draught at the same interval. Along with the neutral mixture, when there 
is no sickness of stomach, small doses of antimonial wine, or of tartar emetic 
in aqueous solution, may be used, the quantity being so regulated as not to 
induce vomiting or severe nausea. The spirit of nitric ether is also an admi- 
rable adjuvant, in those cases in which there is much starting or twitching of 
the. tendons. The warm bath is useful under similar circumstances. This 
treatment is especially applicable in the febrile paroxysm, but it may also be 
employed, with smaller doses, or longer intervals between them, during the 
remission. 
Should convulsions have occurred or be threatened, in addition to the sweet 
spirit of nitre and the warm bath, as above recommepded, poulticps made with 
bruised garlic and flaxseed meal oi' bread and milk, should be applied around 
the feet, and the back should be bathed, along the spine, with brandy heated 
with garlic. It may sometimes be proper to take blood from the arm, or by 
leeches from the temples, and to make cold applications to the head; but 
these are by no mean's necessary in all cases. The practitioner must be influ- 
enced by the degree of arterial action, and the evidences of sanguineous deter- 
mination to the head. Convulsions in children are often the result of mere 
nervous disturbance, and do not require the lancet. When, however, they 
continue beyond a few minutes, or show a disposition to return, especially if 
there be no reason to suspect spasm in the intestines, it will be safest to take 
blood. 
Throughout the disease, the bowels should be kept daily opened. Magnesia, 
alone, or combined with one of the saline cathartics, as sulphate of magnesia, 
tartrate of potassa and soda, or phosphate of soda, will often be useful, n6t 
only as a laxative, but also as an antacid. Should the patient be feeble, it 
may be given with rhubarb. Sometimes it may be proper to repeat the calo- 
mel, though in smaller, doses than - at first. It would be especially indicated 
by whiteness or blackness of the stools. Under the same circumstances, if 
the alimentary canal should be delicate, blue mass may be substituted for the 
calomel. 
When the breath is sour, small doses of bicarbopate of soda or bicarbonate 
of potassa should be given, from four to six times a-day, dissolved in water 
or carbonic acid water. The latter salt should be preferred, when the urine 
is very scanty, in consequence of the diuretic properties of the saline com- 
pounds of potassa. 
Should the abdomen be painful or tender, it should be covered with an 
emollient cataplasm; and sometimes leeches and blistering may be necessary. 
In cases accompanied with vomiting, tcaspoonful doses of lime-water and 
milk, mixed in equal quantities, and given every hour, are often very service- 
able. In the same cases, aromatic poultices, or weak sinapisms should be 
applied over the stomach; and it may become necessary to employ an anodyne 
enema. 
There is usually so much aversion to food, that it is difficult to induce the 
child to take nourishment of any kind. This is an indication of nature which 
should not be slighted. Im the early stages, very little food is required, and 
that of the lightest character. Solution of gum arabic, in the proportion of 
an ounce to a pint, is generally sufficiently nutritive for the first day or two, 
while the fever is high; and it has the advantage that, having, little taste, the 
child will take it freely for drink, especially if it be made cold with a little 
ice. Barley, arrow-root, tapioca, sago, &c., may be given in the liquid form, CLASS I.] 
MIASMATIC FEVER. 
225 
when something rather more nutritious is required; and rennet whey is a good 
article of diet under similar circumstances. Milk aiid water, together with 
farinaceous substances, may be' employed in small quantities as the disease 
advances, and at last, it may become necessary to support the strength by 
animal broth or jellies. Care, however, should always be taken to give no- 
thing that can irritate the stomach or bowels. Cold water should be given 
frequently throughout the fever, and nothing is more grateful to the patient. 
During convalescence, the bowels, if disposed to constipation, should be 
kept open by the mildest laxatives, or by enemata; and the greatest caution 
should be observed, in relation to the diet, not to allow indigestible articles 
of food, nor. to permit too great an indulgence of the now sharpened appetite. 
On the other hand, if the patient is left feeble and without desire for food, 
and especially if he sweat copiously at night, it may be proper to administer 
the mineral acids, or simple bitters. 
Article II 
MIASMATIC FEVER. 
Under this name, are here included. all the forms of fever resulting from 
the influence of marsh miasmata. For an account of the nature of this agent, 
as far as known, the circumstances of its production, the situations in which 
its effect^ are experienced, and the manner in which it operates, the reader 
is referred to the dissertation upon the causes of disease in general. (See 
page 139.) 
Of the different cases of fever which originate in this cause, some are'/nter- 
mittent, some remittent, and some so little variable in their course, that they 
might, with as much propriety as almost any other instances of febrile disease, 
be considered as continued. But it is not in type or form only, that these 
fevers differ. Some are characterized by a sthenic or vigorous grade of action, 
such as is usually denominated inflammatory; others have a low or typhoid 
tendency, especially towards their close; and others again are from the com- 
mencement decidedly adynamic, asthenic, or malignant. In the last section 
are included the cases now fashionably denominated congestive. But all these 
varieties are essentially the same disease, modified by the degree of intensity 
in the cause, by the peculiar susceptibilities of the patient, or by some pre- 
vious or co-existing morbid influence. They are in fact as much one disease 
as are the different varieties of small-pox, measles, or scarlet fever. 
They exhibit this- identity of nature, in the first place, by their interchange- 
able character. The intermittent, for example, sometimes becomes remittent, 
the remittent often ends in the intermittent, and those cases which may be 
considered as continued, always, if of sufficient duration, exhibit a tendency 
to remit, and in the end sometimes to intermit. Indeed, the paroxysmal form 
appears to lie at the foundation of all of them; and, though it may sometimes 
be concealed by superadded phenomena, generally becomes evident upon a 
careful examination. Even the different grades show a disposition to run 
into one another. The inflammatory may become typhoid; and the lowest 
and most malignant cases often leave behind them a tendency, which, after 
the system has regained its energies, exhibits itself in the production of an 
intermittent or remittent of the ordinary kind. Again, in all the forms of 
miasmatic fever, there is a disposition to affect especially particular organs, as 
the spleen, liver, and stomach. All of them, moreover, occur at the same 226 
GENERAL DISEASES.-FEVERS. 
[PART II. 
season, in the same situations, and even in the same family; one individual 
being affected, perhaps, with one form, a second with another form, and a 
third with still another. Thus, in the same family, there may be, in the 
same season, a case of ordinary intermittent, one of remittent, and one of 
malignant or congestive fever. 
I shall treat of them under the divisions of 1, intermittent fever; 2, remit- 
tent fever, and 3,pernicious, malignant^ or congestive fever, which may be 
either intermittent or remittent. As the cases which might deserve to be 
called continued, exhibit, as before stated, during their course, if sufficiently 
protracted, a tendency to the remittent form, they may without impropriety 
be ranked in the second section. It will be understood that I do not include 
yellow fever among the miasmatic fevers. If resulting from a miasm at all, 
this disease is certainly not one of the effects of the ordinary marsh miasms. 
All the varieties of miasmatic fever occur most frequently, and, as original 
affections,, almost exclusively, in the latter part of the summer and in autumn. 
When they appear in the winter or spring, it is generally as returns of former 
attacks. Still, there are occasional cases of bilious fever, in its different forms, 
occurring in the latter seasons, without previous disease. In these, the tend- 
ency may be supposed to have lurked in the system, derived from exposure 
to the miasm during summer or autumn, and to become evident upon the 
application of some Exciting cause; though it is not impossible that, in spring 
or early in summer, the heat may sometimes be sufficiently great, and suffi- 
ciently protracted, to cause the evolution of miasmata in a dilute, and com- 
paratively inefficient form. 
INTERMITTENT FEVER. 
This disease is characterized by febrile paroxysms, recurring at stated times, 
and by the absence of fever between the paroxysms. The intervening period, 
from the end of one paroxysm to the commencement of the next, is called 
the intermission or apyrexia^ the whole period occupied by one paroxysm 
and the succeeding intermission, is called the interval. 
The type of the fever has reference to the length of the interval. There 
are three ordinary types; the quotidian, tertian, and quartan. In the quo- 
tidian, the paroxysm recurs every day, with an interval of about twenty-four 
hours; in the tertian, every other day, with an interval of forty-eight hours; and 
in the quartan, every third day, with an interval of seventy-two hours. The 
inventors of the two latter names considered the two nearest paroxysmal days, 
with the intervening day or days, as constituting one period, and thus counted 
every paroxysmal day twice in the succession. Other types are mentioned 
by authors; such as the quintan, sextan, septan, and octan, the last occurring 
at intervals of a week; but they are all very rare; and there arc probably 
few physicians who have seen any one of them. 
The regular types above mentioned are liable to numerous diversities. 
The quotidian is sometimes double, having two paroxysms every day. There 
is a double tertian, with a daily paroxysm, but occurring at different periods, 
or with different characters, on successive days; the paroxysms of alternate 
days exactly corresponding with each other. Thus, on the first and third 
day, the paroxysms may take place in the morning, and correspond with each 
other in grade and character; while on the second and fourth day, they shall 
occur in the afternoon, and in like manner correspond with each other, but 
differ from, those of the two other days. It thus appears that two tertians 
Syn.--Fever and Ague. CLASS I.] 
INTERMITTENT FEVER. 
227 
are going on at the same time, but at different periods of the twenty-four 
hours. Sometimes there arp two paroxysms in one day, and none in the 
next. This variety is distinguished by the name of duplicated or doubled 
tertian. The triple tertian has two paroxysms every other day, and one in 
the intervening day, that is, three instead of one in forty-eight hours. The 
double quartan is the variety in which, out of three days, two have each one 
paroxysm and the other none; the triple quartan, that in which there is a 
paroxysm every day, but the three- successive ^paroxysms differ from each 
other, while they correspond respectively with the three which follow. Other 
varieties are mentioned by writers, as the tripled and quadruple tertian, the 
doubled and tripled quartan, &c. &c.; but these distinctions are mere refine- 
ments, of no practical value, and exceedingly rare in nature, if, indeed, they 
have any other foundation than in the imagination of observers. Of all the 
varieties above enumerated, the double tertian is the only one which often 
occurs. It is said that cases have been noticed, in which the paroxysms are 
altogether irregular. These are distinguished by the title of erratic inter- 
mittents. 
Symptoms.-Each paroxysm of an intermittent, when quite regular and 
fully formed, consists of three stages; viz., the cold, the hot, and the sweat- 
ing stage, which usually succeed each other in the order mentioned. Vcry 
ofterf, the paroxysm is preceded by the ordinary preliminary symptoms of 
fever, such as feelings of languor or weariness, general uneasiness, stretching, 
yawning, &c. (see page 80); and occasionally these feelings, with perhaps 
some pain in the head and back, impaired appetite, and a scarcely observable 
degree of febrile excitement, constitute the whole apparent disease for seve- 
ral successive paroxysms. A person is seized with the above symptoms, or 
something like them, which after a few hours pass off, almost without notice, 
and are perhaps quite forgotten, until upon their recurrence the next day, or 
the day after, or upon a third occasion at the same interval, and each time 
with increased severity, the patient is reminded of the preceding attacks, and 
finds himself, or is informed by his physician that he is labouring under in- 
termittent fever. Attention to these imperfectly formed preliminary parox- 
ysms is often important; as the disease may be arrested by the adoption of 
proper measures at this early stage, and much subsequent inconvenience and 
discomfort spared the patient. Sometimes, however, the first regular parox- 
ysm seizes the patient in the midst of apparently good health, and wholly 
without warning. 
Cold, Stage.-After some yawning, stretching, &c., the patient experiences 
sensations of chilliness, especially in the limbs. These increase, and gradu- 
ally spread over the whole body, becoming often severe and distressing. Not 
unfrequently, the chilliness seems to run in longitudinal lines, as if little 
streamlets of ice cold water were trickling down the trunk. Along with this, 
the patient experiences shivering or trembling; rapid and successive shudders 
run through the frame; the teeth often chatter, sometimes loudly; and the bed- 
stead is occasionally shaken with the violence of the involuntary movements. 
These tremors, in connexion with the sensation of cold, are technically deno- 
minated rigors. The body often feels cold to an observer, especially the 
hands, feet, nose, ears, and cheek; but this is by no means uniformly the 
case. Sometimes the surface is hotter than in health, even when the patient 
experiences a feeling of severe cold. 
In connexion with the sensation of coldness, the surface is pale and con- 
tracted, and not unfrequently presents the rough appearance known under 
the name of goose-flesh, which is owing to the projection of the sebacious 
and capillary follicles, while the proper tissue of the skin shrinks. From the 228 
GENERAL DISEASES.-FEVERS. 
[part II. 
same cause, the hair sometimes bristles, as in fright. The hands are shrunken, 
the features contracted, the countenance pale, and the lips and ends of the 
fingers often purplish, or somewhat livid. 
Though the tongue is pale and moist, there is often thirst; all disposition 
for food is lost; and occasionally nausea, and vomiting of food, mucus, or 
bilious matter, are experienced. The breathing is irregular, and often hur- 
ried: and the patient has a feeling of oppression or weight in the epigas- 
trium or chest, which causes him to sigh deeply. There is sometimes also 
a short, dry cough. The pulse is small, in some instances quickened, even 
very much so, in others slow, often irregular and feeble. The secretions 
are generally scanty; but the urine is usually said to be pale, limpid, and 
copious. ./ 
The nervous system is much disordered. Independently of the tremors 
already alluded to, there is often severe pain, of a neuralgic character, in the 
back, loins, and extremities, and sometimes in the head. The temper is not 
unfrequently irritable, and the mind confused, dejected, and sometimes even 
wandering. Occasionally there is drowsiness, which, in some rare instances, 
deepens into stupor, coma, and even symptoms of apoplexy. 
The duration of the cold stage varies greatly. Sometimes it does not ex- 
ceed a few minutes, sometimes extends to three or four hours or more. On 
the average, it may perhaps be stated at about an hour. 
Hot Stage.-Pyrexia.-The passage from the chill to the hot stage is not 
abrupt. Rigors for a time alternate with flushes of heat;. The first sensa- 
tions of warmth are father agreeable than otherwise. A glow is felt about 
the face and temples, and the patient is conscious of increased heat of breath. 
Gradually the whole surface becomes hot; but even now, if a limb be moved 
into a cool part of the bed, sudden chills are felt, vibrating disagreeably 
through the frame. At length all traces of the cold stage disappear, and the 
patient is affected with a universal burning heat. The cheeks are flushed, 
the eyes sparkle, the surface is everywhere reddened, and the skin distended 
with blood. The evidence of increased heat is not confined to the sensations 
of the patient. The temperature of the body is positively'increased. For- 
dyce found it to be 105° by the thermometer, and Mackintosh states that he 
has known it to be as high as 110° in Great Britain, and 112° in warm cli- 
mates. The mouth is hot and dry; the ,tongue usually furred; and the 
patient generally complairis of great thirst, though this is not invariable. 
There is an utter disinclination for food, and occasionally nausea and vomit- 
ing. The respiration is more regular than in the chill, but is still accele- 
rated. The pulse is more frequent than in health, and is usually full and 
strong. In some cases, however, when the state of system is adynamic, it 
is at once frequent and feeble. All the secretions are diminished; the skin 
being dry as well as hot, and the urine scanty and often high coloured. The 
head is almost always painful, sometimes very much so; and the suffering 
from this cause, as well as the general violence of the febrile reaction, is often 
greater than is usual in remittent or continued fever. The pain is frequently 
throbbing, with a feeling of distension in the temples, and seems to be deep 
in the head; unlike that of the chill, which is generally superficial. There 
is frequently also pain in the back and limbs. Convulsions are not uncommon 
in children, at the commencement of the hot stage. Sometimes there is a 
.moderate delirium; but this is not common. In some instances, a rash-like, 
or a petechial eruption appears and disappears with the fever. The duration 
of the hot stage varies from two to eighteen hours or more, before it begins 
to abate. 
Sweating Stage.-Perspiration generally appears first upon the face and CLASS I.] 
INTERMITTENT EEVER. 
229 
breast, and gradually spreads over the surface. It is sometimes, slight, but 
generally copious, and occasionally very profuse. Upon its first appearance, 
the patient begins to feel some relief; and the. febrile symptoms gradually 
abate as it advances. The skin becomes cool, the excitement of the circula- 
tion subsides, the mouth is moistened, the headache disappears, and the patient 
frequently falls into a calm sleep, from which he awakes free from fever. The 
kidneys now resume their function, and the urine which is discharged very 
often deposits a lateritious sediment upon cooling. 
It has been frequently stated by writers, that each stage of the paroxysm, 
subsequent to the chill, is the immediate effect of the preceding stage, in 
other words, that the cold stage produces the hot, and the, hot the sweating. 
But this is scarcely probable, at least with regard to the first two stages, 
which bear no proportion to each other; a protracted and severe chill being 
frequently followed by less fever than a very slight, one, and the fever some- 
times occurring without any preceding chill whatever. The probability is, 
that, while the depression attendant upon the cold stage is naturally followed 
by some degree of febrile reaction, as a necessary consequence; the morbific 
cause, whatever it may be, is capable of producing the hot stage by a direct 
influence. 
The whole duration of the paroxysm varies greatly. ■ In many instances, 
it does not exceed three or four hours; while in others it runs on to within a 
very short time of the succeeding paroxysm, lasting sometimes in a quotidian 
eighteen hours, hi a tertian thirty-six, and in a quartan sixty. As a general 
rule, however, the paroxysm is longer in a quotidian than a tertian, and in 
this than a quartan. The average duration in the quotidian may perhaps be 
stated at ten or twelve hours, in the tertian at eight or ten hours, and in the 
quartan at five or six hours. But tile paroxysms generally shorten, as the 
disease becomes of longer continuance. 
The paroxysm is liable to other diversities. Sometimes the cold stage is 
very slight, and exhibits few of its characteristic symptoms. Cases are not 
uncommon in which the only discoverable signs are some blueness about the 
nails,, and a little coolness of the nose, ears, hands, and feet. This is espe- 
cially the case with young children. Occasionally, even these symptoms are 
wanting, and the paroxysm begins at once with 'the hot stage, without any 
preceding chill whatever. This is the form of the complaint called by the 
vulgar dumb ague, to distinguish it from the more common form, which is 
called shaking ague. Sometimes the sweating stage is wanting; the fever 
either gradually subsiding without any discharge, or the place of the perspi- 
ration being supplied by a diarrhoea, oi* copious flow of urine. The idea has 
been advanced, and seems plausible, that the dropsical effusion which occa- 
sionally attends an attack of intermittent fever, may be vicarious to the per- 
spiration. It is asserted, that the cold stage has, in some instances, passed 
into the sweating, without the intervention of febrile reaction; and that, in 
others, the whole paroxysm has consisted of perspiration without either chill 
or fever. But, in such cases, the disease, though it may be intermittent, can 
scarcely be said to merit the name of intermittent fever. In the double ter- 
tian, it sometimes happens that, of the two paroxysms, which serve as the 
prototypes of all the others, one may be regular in all its stages, while the 
other is destitute of chill, or in some other way peculiar. 
Among the vagaries of the paroxysm, a very singular one has been noticed, 
in which the affection is confined to a single limb, which passes through the 
several stages regularly, the remainder of the system being apparently undis- 
turbed. Various affections, occurring at regular intervals, without any other 
resemblance to intermittent fever than their paroxysmal character, have been 230 
GENERAL DISEASES.-FEVERS. 
[part II. 
considered as masked cases of the disease (febris intermittens larvata"). Among 
these may be enumerated neuralgia, rheumatism, epilepsy, hysteria, hiccough, 
petechial eruptions, and diarrhoea, all of which occasionally appear in the 
intermittent form, occurring daily or every other day at the same hour, with 
intervals of apparently perfect health. But it appears to me that they have 
as little claim to be considered intermittent fever, as the same affections, in 
their continuous form, would have to be considered continued fever. If they 
could be shown to be uniformly the result of miasmatic influence, there might 
be some foundation for this view of their nature; but the fact is, that they 
sometimes occur under circumstances in which miasmata could by no possi- 
bility have been the cause. 
Intermission, or Apyrexia.-After the paroxysm has subsided, the patient, 
though without fever, is. not usually quite free from all signs of disease. 
General languor, facility of fatigue, pains in the back and loins, uneasy sen- 
sations in the head and epigastrium, with some fur upon the tongue, and a 
feeble appetite, are not unfrequently left behind, in greater or less degree. 
The patient, moreover, is apt to have a pale or somewhat sallow complexion, 
and a sickly look. These, or analogous symptoms, are most common after 
the early paroxysms. Sometimes they are very slight, sometimes so con- 
siderable as, in connexion with a slight degree of heat of skin and frequency 
of pulse, to render the intermission imperfect. They generally diminish with 
the continuance of the disease; and at length the patient becomes apparently 
quite well in the intervals of his attacks; having, not unfrequently, the appe- 
tite, the digestion, and the general vigour, though not perhaps fully the 
aspect of health. To the above rule, howeyer, there are exceptions. Cases 
sometimes occur, in which the patient, even at the commencement, is quite 
as free from all signs of disease during the intermission, as in his most per- 
fect health. 
Course, Termination, &c.-It has been stated that, in the several types 
of intermittent fever, the paroxysms return at the same hour of the day. 
There is, however, often some variation in this respect. The commencement 
of a paroxysm, instead of being precisely at the same time of day as that of 
the preceding, may be an hour or two earlier, or an hour or two later; and it 
not unfrequently happens, that, if a little before the time upon one day, it is 
a little after it on the next, so that the mean between the extremes of diverg- 
ence is the regular hour. In some cases, instead of thus fluctuating backwards 
and forwards, each succeeding paroxysm occurs an hour or two earlier than 
its predecessor, so that the length of the intermission is regularly diminished. 
In other cases, it occurs an hour or two later, so as regularly to lengthen the 
intermission. In the former, the disease is said to be an anticipating, in the 
latter a retarding intermittent. One type may in this manner be converted 
into another. Thus, an anticipating quartan may become a tertian, and. an 
anticipating tertian a quotidian; while a retarding quotidian is changed into a 
tertian, and a retarding tertian into a quartan. It is obvious, that an antici- 
pating quotidian may pass from the intermittent to the remittent form. 
It is a remarkable fact, that the paroxysms seldom occur during the night. 
Perhaps sleep may in some way oppose a resistance to their attack. The 
rule is not universally, but generally true. In the vast majority of cases, 
the time of attack is between the hours of eight in the morning and eight in 
the evening; and it is worthy of observation, that, in the anticipating and 
retarding cases, when the receding or advancing paroxysm reaches the period 
of darkness, it is apt either to be arrested in its course, or to leap over the 
night, backward into the evening, or forward into the morning. Thus, the 
paroxysm of an anticipating tertian, occurring first at noon, and recurring CLASS I.] 
INTERMITTENT FEVER. 
231 
afterwards successively at the hours of ten, eight, and six, will, after attain- 
ing the last mentioned hour, either continue to recur at the same, or will 
return next time at about six or eight in the evening preceding the regular 
period. A retarding tertian, on the contrary, after reaching the confines of 
night, makes its next attack in the morning, subsequent to the regular day 
of return. (Fordyce d) 
It has been generally observed, that, the shorter the intermission, the 
earlier is the hour of the day at which the paroxysm is disposed to appeal-. 
Thus, the quotidian most frequently makes its attack in the morning, the 
tertian about noon, and the quartan in the afternoon. It is true that there 
are very frequent exceptions to this rule. Thus, the quotidian and tertian 
may change places, or may either of them occur in the afternoon; but the 
paroxysm of the quartan very rarely appears in the morning. Another 
result of observation is, that the longer the duration of the diseas,e, the later 
in the day are usually the returns. 'Hence, in old cases of intermittents, the 
paroxysms should occur in the afternoon. 
Reference has been made to the change of one type into another in the 
course of an anticipating or retarding intermittent. But the same conver- 
sion sometimes takes place abruptly. The most common change is from a 
type with frequent paroxysms, to another in which they are less frequent. 
Hence, a quotidian is more apt to become tertian, and a tertian quartan, than 
the reverse. 
Intermittents, if left to themselves, will not in general run on indefinitely. 
The milder cases not unfrequently terminate spontaneously with the seventh 
or eighth, and sometimes so early even as the fourth or fifth paroxysm. 
More than one-half of the tertian fevers which occurred in the infirmaries of 
the Scdpetriere of Paris, in the autumn of the sixth year of the Republic, 
terminated with the ninth paroxysm, or previously. The treatment employed 
was of the simplest kind, and calculated to have little effect upon the course 
of the disease. (Diet. de Med., xvi. 589.) According to Eordyce, quotidians 
usually end spontaneously in about ten weeks, tertians in about four months, 
and quartans in six, seven, or eight months. But occasionally, these diseases 
continue for a much Longer time, if not interrupted. 
When an intermittent has been'checked by any means whatever, it has a 
strong tendency to return, so that very slight causes will often provoke a 
fresh attack, and not unfrequently a recurrence will take place without any 
appreciable cause. Quartans are said to be most apt to relapse; but all the 
types are subject to the law. In these returns, there is a singular tendency 
to observe the septenary period. It has been said that quotidians are most 
apt to return at the end of a week, tertians of two weeks, and quartans of 
three. I have not noticed this peculiarity of the several types; but of the 
general fact there can be no doubt. In most instances, according to my own 
observation, the relapse takes place upon the fourteenth day from the occur- 
rence of the last paroxysm; and if this day be passed, then at the end of the 
third week, or at some future weekly period. An autumnal attack of inter- 
mittent is very frequently succeeded by another, at the opening of the warm 
weather, in the subsequent spring. The liability to the recurrence of the dis- 
ease continues for one or two years, and sometimes much longer. In general, 
the subsequent attacks, without a fresh exposure to the cause, are milder than 
the original. 
Grades and Complications.-Intermittent fever may be of a sthenic 
■character, with a vigorous reaction, a full strong pulse, a florid surface, and a 
pure rich blood; it may be asthenic, with unusual depression in the chill, 
a slow and uncertain reaction, a feeble though frequent pulse, a dusky or 232 
GENERAL DISEASES.-FEVERS. 
[part II. 
purplish hue of the skin, and a depraved, impoverished, or scanty blood; or 
it may be of any grade between these two extremes. In the first mentioned 
form, it is sometimes though erroneously said do be inflammatory ; for the con- 
dition mAy exist altogether independently of inflammation. In the second 
form, it may be.called simply feMe, when the blood is not depraved, and the 
general energies not greatly depressed; typhoid, when along with the debility 
there is a peculiar contamination or deprayation of the circulating fluid; and 
malignant, pernicious, or congestive,, when the powers of the. system are so 
much prostrated as to endanger a very speedy and fatal issuer' These differ- 
ences depend, not on the peculiar character of the. miasmatic cause, but upon 
the previous condition of the patient, or the influence of other causes acting 
conjointly with the miasmata. Most cases'occurring in temperate latitudes 
have more or less of the sthenic grade; and-the characters of this grade have 
been sufficiently detailed in the general description of the disease. The 
merely feeble cases are known by a general deficiency of energy in the reac- 
tion, and the marks of debility in the intermission, without peculiar symptoms 
of derangement, or any very alarming, signs of prostration. They are not 
uncommon among individuals reduced by previous indisposition. The typhoid 
cases may be recognized by the greater depression of the chill, the pungent 
heat of the skin during the reaction, the very frequent but comparatively 
small and feeble pulse, the more than ordinary dryness of the mouth, the 
brown colour of the'tongue, the tefidcncy to the production of sordes about 
the teeth, the dusky hue of the surface, and the greater frequency of nervous 
symptoms, as subsultus tendinum, jactitation, and low delirium. They are 
met with chiefly among persons previously exposed to the want of proper sus- 
tenance, fresh Mr, and the ordinary comforts of life, or at periods when an 
epidemic typhoid influence prevails in miasmatic districts. Of the malignant 
or pernicious, intermittent I shall treat separately; as it differs from the other 
forms strikingly in some of its symptoms, and requires that especial attention 
should be called to it, in consequence of its terrible fatality when mistaken, 
and inefficiently treated. 
Intermittent fever is not unfrequently associated with inflammation of an 
organ or organs of the body, and, in this state, has often been confounded 
with the higher grades of the ordinary sthenic form of the disease, under the 
name of inflammatory intermittent; the local affection having been overlooked 
or disregarded. The distinguishing general character of these complicated 
cases is the appearance of the huffy coat of the blood upon coagulation. 
Except in the pregnant state, and in anemic cases, which are in general 
readily recognized, this sign may be considered as conclusive of the existence 
of inflammation.' When this attends the sthenic state of the fever, a pecu- 
liar hardness of the pulse is superadded to its strength of impulse. But the 
inflammation may also be coincident with the typhoid character of the disease, 
in which case this hardness may be wanting. 
The organs most frequently affected are the stomach and bowels, the liver, 
the lungs, and the brain, or its investing membranes. To enumerate here 
all the symptoms characteristic of the phlegmasiae of these structures, would 
be to anticipate what must be stated fully hereafter. It will be sufficient to 
notice a few prominent symptoms, which may serve to fix attention upon the 
inflammation when it shall exist. When the stomach is inflamed, there are 
usually burning pain and tenderness upon pressure in the epigastrium, a 
craving for ice or cold drinks, and a more than ordinary degree of nausea 
and vomiting; substances which are ordinarily acceptable to the stomach, 
being often promptly rejected. Inflammation of the bowels is manifested by 
colicky pains in the abdomen, more or less tenderness over some particular CLASS I.] 
INTERMITTENT FEVER. 
233 
part of its surface, and diarrhoea, or dysenteric symptoms. The liver may be 
considered as the seat of inflammation, when there are pain and tenderness in 
the right hypochondrium, difficulty of lying on the left side, pain in the right 
shoulder, nausea and vomiting, discoloured evacuations from the bowels, yel- 
lowness of the skin, conjunctivas, or tongue, and a deep brown colour of the 
urine. These inflammations are most frequent in the summer and autumn. 
The symptoms of thoracic inflammation are different, according as the bron- 
chial membrane, the parenchyma of tlie lungs, or the pleura, is affected. In 
the first case, the ordinary catarrhal symptoms are presented; in the second, 
cough with a scanty, viscid, and rusty expectoration, and an obtuse pain in 
the chest; in the third, acute pain at some one point in the side. This com- 
plication is most frequent in winter and spring. Inflammation of the ence- 
phalon may be suspected, when the pain in the head is severe, the patient is 
paipfully sensitive to light or sound, the pupil is contracted, and delirium or 
convulsions are conjoined with the other symptoms. All these inflammatory 
complications are mosfi apt to occur in the. young and vigorous. They are 
proportionably more frequent in the quotidian than the tertian, and in the 
tertian than the quartan. Old persons are most subject to attacks of apoplexy 
or paralysis. 
The inflammation may be so severe as to keep up some febrile excitement, 
after the intermittent paroxysm has subsided. In this case a complete inter- 
mission is prevented. The disease at first presents the character of a remit- 
tent; but, as the inflammation diminishes, the inter-paroxysmal fever ceases, 
and the true character of the affection becomes manifest. When the inflam- 
matioii is not of a grade or extent to sustain a symptomatic fever, the 
intermission may be complete so far as regards frequency of pulse and heat 
of skin; but a close examination will often detect signs of the local affection 
in tenderness of the organ affected, a furred tongue, defective appetite, and a 
certain degree of hardness or resistance in the pulse, not ordinarily observed 
in the apyrexia. 
The inflammation which thus occasionally attends intermittent fever may 
have previously existed, or may have been called into action by the influence 
of the fever upon a predisposition, or may be coincident with the fever, 
and like it dependent immediately upon the miasmatic cause, or, finally, may 
be the result of exposure to some accidental cause in the progress of the 
disorder. > , ' '- 
Authors sometimes speak of gastric intermittents, and cerebral intermit- 
tents; but there is no foundation for such distinctions in nature. It is true 
that the stomach and brain are severally much more irritated in some cases 
than in others; but the same may be sajd of any one of the organs; and 
thus we should have subdivisions of the disease as numerous as the func- 
tions. The cases usually denominated as above, generally owe whatever 
peculiarity they may evince to complications of the intermittent fever with 
gastro-hepatic inflammation in the one case, and with some form of encepha- 
litis in the other. 
Effects.-If an intermittent be speedily checked, it will leave no other 
unpleasant consequence behind it than a disposition to return. But, if allowed 
to run on indefinitely, or if frequently provoked to return by a continued 
exposure to the cause, it sometimes produces very disagreeable effects. The 
most common of these is enlargement of the spleen. Miasmata appear capa- 
ble of producing disease in the spleen, liver, &c., by an immediate influence; 
and it is possible that affections of this kind, accompanying intermittents, 
may sometimes be the result of the same cause that gives rise to the fever; 
but it is very certain that they are frequently, and highly probable that they 234 
GENERAL DISEASES.-FEVERS. 
[part II. 
are much the most frequently, occasioned by the intermittent paroxysms. 
Indeed, the spleen can often be perceived to be enlarged during the cold 
stage. The blood which leaves the capillaries becomes congested in the vis- 
cera, and especially in the spleen, which is probably intended as a diverticu- 
lum, to prevent injury from such irregularities of the circulation to more 
important organs. The enlargement subsides somewhat in the apyrexia, but, 
returning again in greater degree in the subsequent paroxysm, becomes at 
length, in some instances, excessive; so that the spleen may be perceived ex- 
tending far into the abdomen, and occasionally occupying more than one-half 
of the cavity. It is generally also more or less indurated. In this state, it is 
commonly called ague cake, and is a well-known affection in miasmatic dis- 
tricts. It is said to be most common in the quartan, and least so in the 
quotidian. The more obstinate and long continued the disease, the more apt 
it is to be attended with this affection of the spleen. 
In like manner, the liver sometimes becomes enlarged and indurated; and, 
even when not sensibly increased in bulk, is often affected with chronic in- 
flammation or derangement of function, giving rise to jaundice, dyspepsia, 
diarrhoea, &c. 
The appearance of a patient labouring under chronic intermittent is cha- 
racteristic. His countenance has a sallow paleness, with frequently a sad or 
dejected expression, indicative of habitual depression of spirits. Feelings of 
languor, muscular weakness, and liability to fatigue upon slight exertion, are 
very common. The tongue is often furred, the appetite feeble, the discharges 
from the bowels clay-coloured or otherwise deranged, and the urine occasion- 
ally dark-brown as in jaundice. Sometimes the body is emaciated, some- 
times rather full, as if bloated. 
A very frequent result of protracted intermittent is dropsy. This affection 
sometimes occurs during the continuance of the disease, and, as before stated, 
has been ascribed in part to a vicarious secretion into the cellular tissue and 
serous cavities. But it is more frequent after the intermittent has been inter- 
rupted. Even in such cases, it may possibly be owing, in part, to the sub- 
stitution of a serous discharge for the perspiration to which the system was ac- 
customed, and to which the process of sanguification had become accommodated. 
I have found the Urine, in these cases, so far as I have examined it, to be albu- 
minous, and sometimes highly so. Yet the dropsy is in.general easily and often 
permanently cured. Hence it may be doubted whether the kidneys are, as has 
been supposed, organically diseased. Sometimes the urine i£ albuminous in 
intermittent fever, without any dropsical symptoms. (Archives Generales, 4e 
Ser., xv. 509.) Another source of dropsy in intermittents, is organic disease of 
the liver and spleen. The veins of the abdoihinal viscera, and sometimes of 
all that portion of the system drained by the branches of the ascending vena 
cava, become congested, in consequence of obstruction in the liver and spleen, 
and relieve themselves by effusion. This form of dropsy is often obstinate, 
and sometimes incurable; for, though relieved by remedies, it is apt to return 
so long as the cause continues. Yet, when the result of intermittents, it is 
much less hopeless than when springing from independent disease of the vis- 
cera; for there is always some prospect of removing it by eradicating the 
original affection. 
An attack of insanity has been known occasionally to follow the cure of an 
intermittent The latter disease is thought also to have been sometimes inju- 
rious by suspending menstruation, the lochial discharge, and the secretion of 
milk in women, and habitual hemorrhoidal discharges in men. 
But, while thus fruitful in mischief, intermittents have the credit, probably 
in some measure deserved, of being occasionally useful, by superseding other CLASS I.] 
INTERMITTENT FEVER. 
235 
diseases, and removing morbid tendencies which had before resisted treat- 
ment. They act in this way like medicines, which substitute a safe and 
temporary, for an unsafe or obstinate affection. It is more especially, though 
not exclusively, nervous diseases that are thus remedied. Among them are 
neuralgic affections, epilepsy, hysteria, asthma, dyspepsia, rheumatism, and 
various cutaneous diseases. Even mania is said to have been superseded by 
intermittent fever, and the tendency to pulmonary consumption has been 
thought, though probably on insufficient grounds, to be materially counter- 
acted by it.* 
Anatomical Characters.-The proper anatomical character of inter- 
mittent fever has -scarcely been ascertained. The- lesions which have gene- 
rally proved fatal, and which are those observed, upon dissection, are not 
essentially parts of the fever, being sometimes purely incidental, and some- 
times effects which might have been absent without affecting the integrity 
of the disease. Inflammation of the brain, and of its membranes, cere- 
bral congestion and effusion, gastritis, gastro-enteritis, pulmonary inflamma- 
tion and congestion, and various disease of the liver and spleen, are among 
the affections which have been most frequently observed, in persons who have 
died while labouring under intermittent fever. The liver has usually been 
found congested with blood, and of a dark purple or black colour. Enlarge- 
ment with or without change of structure, increased density, softening, and 
suppuration, are the lesions most frequently observed in that organ. The 
spleen has generally been found enlarged, and altered in texture, some- 
times broken down and softened, so as even to resemble coagulated blood 
enveloped in a membranous covering. Occasionally it has been ruptured, 
and dark or grumous blood has been met with in the cavity of the perito- 
neum. Suppuration of the viscus has also been noticed. (See Diseases of 
the Spleen. 
Causes.-Of the intermittent fever here treated of, miasmata are the 
essential cause. Some have supposed that all cases of intermittent fever 
have the same origin. Experience, however, is opposed to this opinion. 
We every now and then meet with instances which can by no possibility be 
traced to miasmata. Indeed, cases sometimes occur which proceed obviously 
from some temporary irritation, such as the introduction of instruments "into 
the urethra, indigestible food in the stomach, worms in the bowels, &c. The 
case of M. Brachet is interesting, as tending to show that habit may have the 
same effect. M. Brachet for seven successive nights,, at midnight, bathed in 
the river Saone, towards the close of October, when the water was cold. 
Retiring to bed after each bath, and covering himself warmly, he was affected 
with considerable reaction, which terminated in perspiration. At the end of 
the seventh day, he omitted the practice, but was nevertheless nightly, about 
the same hour, attacked with a regular intermittent paroxysm, consisting of 
the. cold, hot, and sweating stages, which returned for about a week, when it 
ceased spontaneously, upon the occurrence of an event which kept him out 
of his bed at the hour, and induced him to take a ride on horseback, which 
excited and warmed him. But cases of pure irritative intermittent are pro- 
bably rare; and the presumption, when we meet with a case of ague and 
fever, is that it is miasmatic. 
* It is proper to state that, in a review of the first edition of this work, in the New 
Orleans Medical and Surgical Journal for May, 1848, it is declared by the writer, who 
appears to have had an extensive experience in miasmatic diseases, that he has " never 
seen a case in which the occurrence of an intermittent, during the progress of another dis- 
ease, seemed of itself to have proved beneficial to that disease;" but, on the contrary, 
had generally observed a prejudicial influence of the new upon the original malady.-- 
Note io the second edition. 236 
GENERAL DISEASES.-FEVERS. 
[part II. 
Intermittent, being the mildest form of miasmatic fever, is that which 
ordinarily occurs in situations, and at periods, when the miasmatic influence 
is least intense, and in persons who from habit, or any other, cause, are least 
susceptible to injury from it. Though this particular cause may be essen- 
tial, yet there are others which very much assist its action. The poison seems 
to find a more ready entrance into the system, when exhausted by fatigue or 
hunger, debilitated by previous disease or mental depression, and during 
sleep. It often lurks in the system without obvious effect, for a longer or 
shorter period of time, causing rather a predisposition to the disease than the 
disease itself. Under these circumstances, any exciting cause may call the 
fever into action; and sometimes an attack is produced, which might have 
otherwise been avoided. Exposure to the heat of the sun, a cold bath, ex- 
cessive exertion, mental excitement, even a dose of purgative medicine, may 
thus give rise to a paroxysm. The contrast between the Cold of the mornings 
and evenings and the heat of tlie middle of the day, favours the developemcnt 
of the disease in the latter part of summer, and the beginning of autumn. 
Persons removing from a miasmatic region to a healthy one are often attacked, 
in consequence probably of the new-and excitant influences to which they are 
exposed. 
The disease is most common in the latter half of summer, and in autumn 
before the occurrence of severe frost. Sometimes it seems to occur epidemi- 
cally, making its appearance in situations where it was before almost unknown, 
and spreading over considerable districts; but still showing itself at the same 
season of the year. In the United States, it is occasionally met with in almost 
every part of the country where there are water and vegetation, except in 
certain mountainous regions, and through the greater portion of New Eng- 
land, whe^e it is scarcely known. 
The^time at which the disease attacks, after exposure to the miasmatic 
cause, is altogether indefinite. It may occur in a few hours, or not for 
weeks, or months. There is reason for the belief, that the cause may remain 
latent for a year or more, until called into action by favouring circumstances. 
Infants and old people arc less frequently affected than those of interme- 
diate ages, and women less than men, probably because they are less exposed 
to the cause. Children are certainly liable to it at the tenderest age, and it 
is thought to have attacked the foetus in the womb, as indicated by the peri- 
odical trembling in the uterus, of which the mother, when herself the subject 
of the disease, has been sensible in the interval of her own paroxysms. Ne- 
groes are much less susceptible of the disease than whites. 
Diagnosis.-The only diseases with which intermittent fever is liable to 
be confounded are hectic and remittent fever. Hectic fever, however, may 
in general be easily distinguished by the irregularity in the recurrence of 
its paroxysm, the comparative absence of headache, the excessive and pro- 
longed sweats at night, the clearer complexion and brighter eye, the frequent 
want of gastric derangement and fur on the tongue, the continued frequency 
of pulse throughout the interval, and the serious organic diseases of which 
the hectic is usually a mere symptom. Remittent fever is distinguishable 
only by the continuance of fever during the whole interval; and sometimes 
it is very difficult to decide whether the case belongs to the one or the other 
variety of disease. 
Prognosis.--In the uncomplicated form of intermittent fever, without 
malignant tendency, the prognosis is almost always favourable. I have never 
seen such a case eventuate fatally. It is possible that, when there is a dis- 
position to cerebral disease, with the brain perhaps already softened, fatal apo- 
plexy may be induced in the paroxysm, either from the venous congestion CLASS I.] 
INTERMITTENT FEVER. 
237 
of the cold stage, or the strong determination of blood in the stage of reaction. 
There is reason to believe that such a result does sometimes occur, especially 
in the old, and in the intemperate. Inflammation of any of the vital organs 
may of course give rise to danger. Instances of fatal effects from congestion 
and rupture of the spleen have occurred. But the chief danger of ordinary 
intermittent, is from those secondary affections which result from its neglect: 
such as chronic enlargement and induration of the liver and spleen, and 
dropsy. Even in these1 cases, however, the prognosis is more favourable than 
in similar affections proceeding from other causes. It is not uncommon to 
see cases of the cachexy of intermittents, with disease of the liver, jaundice, 
dropsy, &c., of apparently the most unpromising character, give way to ap- 
propriate treatment. , 
The more complete is the apyrexia, the more readily will the disease gene- 
rally yield. The postponement of the paroxysm by two or three hours or 
more at each recurrence is a favourable sign. So also is the appearance of 
an herpetic eruption about the lips and the alm nasi. Relapses usually 
yield more readily than the original disease; and the cases which occur in 
spring, more readily than those in autumn. Of the different types, as a gene- 
ral rule, the quartan is the most difficult of cure, and the tertian the easiest. 
Treatment.-The question was formerly much agitated, whether it was 
best to attempt to arrest intermittent fever, or to allow it to run its natural 
course. In favour of the latter plan it was urged, that a morbid matter ex- 
isted in the system, which the paroxysms tended to eliminate; that the disease 
acted favourably in preventing or removing other diseases, when permitted 
to have its full and unimpeded influence; and, lastly, that it was much less 
liable to return, when not interrupted. But this reasoning is fallacious. 
There is no proof that a morbid matter exists in the system, which is thrown 
off by the disease; if other complaints might sometimes be eradicated by its 
long continuance, the remedy would in general be worse than the evil; and 
observation has shown, that the longei' the disease has continued, the more 
liable does the system become to it, and the more difficult is it to be eradi- 
cated. Besides, so long as it lasts, there is constant danger of those various 
secondary diseases, more serious even than the original, which not unfrequently 
result from it. The inference is, that it should not be allowed to continue if 
it can be arrested; and the sooner it can be checked the better. Happily, it 
is almost always in our power to arrest it very speedily. 
In the Paroxysm.-In the great majority of cases, the paroxysm requires 
little treatment; and, eVen if it be left to nature, no serious harm will be 
likely to ensue. But there are some instances in which remedies are im- 
portant; and in almost all, the symptoms maybe more or less alleviated. 
During the Chill, the patient should lie in bed, and be covered warmly. Hot 
drink^ may be given, such as lemonade, toast-water, or infusion of balm; and 
heat applied externally, by means of hot pediluvia, or of heated bricks, bot- 
tles of hot water, bags filled with hot sknd or bran, &c., placed near the feet 
and along the body. When the chill is severe and protracted, the hot vapour 
bath may be employed, by raising the bed-clothes over the patient by means 
of crossed half hoops, and then placing hot moistened bricks wrapped in flan- 
nel near the body, or introducing a current of hot air and vapour, through a 
large conical curved tin tube, within the broad exterior end of which a cup of 
alcohol is burning, as in Jenning's vapour bath. 
Another excellent remedy, under similar circumstances, and especially 
when there is much pain or nervous disorder, is a grain of opium, or an equi- 
valent dose of one of its preparations. This often affords great relief to the 
patient, and sometimes shortens the chill, and moderates the subsequent fever. 238 
GENERAL DISEASES.-FEVERS. 
[PART II. 
Should the stomach be irritable, the anodyne may be given by the rectum. 
In this case, fifty or sixty drops of laudanum should be administered in two 
fluidounces of thin starch, or flaxseed mucilage. 
When there is great and threatening prostration of strength, as indicated 
by faintness, and a very feeble or almost absent pulse, it is necessary to stimu- 
late the patient; and, for this purpose, carbonate of ammonia and the oil of 
turpentine internally, and active rubefacients externally, are preferable to the 
alcoholic stimulants, because less likely to affect the head injuriously, when 
re-action shall have taken place. Nevertheless, it may become necessary to 
have recourse to wine, or even to brandy, especially in the cases of drunkards. 
Ether is sometimes applicable, in consequence of the rapidity and brevity of 
its action. The rubefacients will be most effective in these cases, when accom- 
panied with heat. Cayenne pepper heated in brandy, and hot oil of turpen- 
tine, should be applied by friction to the upper and lower extremities; and 
mustard cataplasms, previously warmed, may be applied to the inside of the 
thighs, and over the epigastrium. 
When the chill is attended with much oppression of stomach, nausea, and 
ineffectual efforts to vomit, an emetic dose of ipecacuanha may be given; or, 
if the patient is at the same time very feeble, a teaspoonful of powdered mus- 
tard diffused in warm water. Irritability of stomach should be treated, first, 
if the discharges are acrid, sour, or bilious, with a copious draught of warm 
water so as to wash out the stomach, and afterwards, if not relieved by this 
remedy, with a sinapism to the epigastrium, and an anodyne enema. 
In comatqse cases, reliance must be placed chiefly upon revulsion by exter- 
nal stimulants; but, should the symptoms be apoplectic; should there be ster- 
tor, for example, with a suffused face, and a slow laboured pulse, it may be- 
come necessary, in addition, to take blood from the arm, or by cups from the 
temples or back of the neck; the head being kept in an elevated position. 
Besides the remedies above mentioned, others have been recommended. 
One of these is the tourniquet applied to the thigh. This cannot act, as has 
been suggested, by throwing more blood upon the vital organs; for, if made 
so tight as to arrest circulation altogether, it leaves the same proportion of 
blood in the remainder of the system as before ; if applied so as to check the 
flow of blood in the, veins only, it accumulates blood in the limb, and thus 
abstracts it from the remainder of the system. So far, therefore, as the cir- 
culation is concerned, it can act only by diminishing the quantity of blood to 
be forwarded by the forces concerned; which, as I believe, is a very doubtful 
benefit. From the testimony, however, in relation to its effects, there can be 
no doubt that the remedy serves occasionally to shorten the paroxysm. But 
so will anything else which strongly excites the attention and interest of the 
patient, especially if, as in the present case, it be attended with disagreeable 
sensation. A few strokes with a lash would probably be as effectual as the 
remedy in question. 
Bleeding in the cold stage has been strongly advised, especially by Dr. 
Mackintosh and Mr. Twining. The former author asserts that, in the great 
majority of eases, it will cut short the cold stage, will rarely fail in stopping 
the paroxysm, and will often effect a cure of the disease. The amount of the 
requisite loss of blood is very uncertain, varying, according to the experience 
of Dr. Mackintosh, from an ounce and a half to twenty-four ounces. The 
tremors cease during the operation, the breathing becomes regular, the pains 
in the head and back vanish, the pulse becomes fuller and stronger, and a 
gentle moisture breaks out upon the surface of the body. The measure of 
the quantity taken must be the production of these effects; but, should the 
pulse fail under the operation, the wound in the arm must of course be closed CLASS I.] 
INTERMITTENT FEVER. 
239 
immediately. Mr. Twining speaks with scarcely less positiveness of the effi- 
cacy of the remedy; but he requires that it should be preceded by purging, 
that the blood should be drawn from a large orifice, as soon as the cold stage 
is fairly formed, with the patient in a recumbent posture, and that no more 
should be taken than is necessary to arrest the paroxysm. Other practition- 
ers have employed the remedy with various success-. The general result of 
the testimony appears to be, that the cold stage is often shortened, and the 
hot stage sometimes moderated; but that no such amount of benefit is experi- 
enced as to counterbalance the obvious objections to the measure. It has 
always appeared to me to be opposed to a sound pathology. The congestion 
of the cold stage is the result of a depressed condition of the nervous system, 
in which the heart and pulmonary capillaries participate. The blood, imper- 
fectly transmitted through the vessels of the lungs, and imperfectly forwarded 
by the heart, accumulates necessarily in the venous system behind these points 
of obstruction. It is not the accumulation of blood that produces the pros- 
tration, but this that causes the accumulation. How then can the abstraction 
of blood lessen the difficulty ? If the heart and lungs acted feebly because 
they were overloaded, then the removal of a part of the burthen might be 
useful; but the fact is, I believe; that they are overloaded because they act 
feebly. How then can the asserted effects of bleeding in the cold stage be 
accounted for? Partly, I believe, by the influence upon the imagination of 
the patient. I have no doubt that the mere tying of his arm, as in the ap- 
plication of the tourniquet, would have in a considerable degree the same 
effect. The loss of .an ounce or two of blood is said sometimes to have pro- 
duced a complete .solution of the paroxysm. Is it possible to conceive that 
the heart and lungs, and all the interior viscera, should have been overwhelmed 
by having in them one or two ounces of blood beyond their proper capacity; 
and is it not probable that the solution would have equally taken place, if, 
with the same amount of preparation, and an equal belief on the part of the 
patient that everything was going on favourably, no blood whatever had 
flowed ? Besides, a chill very often changes spontaneously, within the time 
that is occupied in the preliminaries and the operation of venesection. May 
it not be, that in many of the reported cases, the same result might have 
happened without the bleeding? I do not, however, assert, that the modified 
state of the impression of the blood upon the nervous tissue, consequent upon 
the loss of a portion of the impressing agent, may not sometimes hasten re- 
action when there is a strong disposition towards it; just as the impression of 
suddpn cold upon the surface, already chilled, will sometimes have the same 
effect. But, even allowing this to be the case, there are other means of ob- 
taining the result when desirable, which are not liable to the same objections. 
The loss of blood, when not necessary, should always be avoided, on account 
of its debilitating effects. Unless under peculiar circumstances, which have 
already been noticed, it is never indispensable in intermittents. There are 
cases in which it might reduce a prostration, but just within the control of 
remedies, below the point of reaction. Why then resort to it? 
In the hot stage, the patient should be placed upon a refrigerant treatment. 
He should be allowed cold drinks, in such quantities as not to oppress the 
stomach. The effervescing draught, given every hour or two, is an admirable 
remedy in these cases. It soothes the stomach, diminishes fever, promotes 
perspiration, and favours a solution of the paroxysm. It is also, when pro- 
perly prepared, usually very grateful to the patient. Its effects will be 
increased by the addition of small doses of tartar emetic, when there is no 
sickness of stomach. The antimonial, however, is seldom necessary, and 
should never be given in quantities sufficient to produce nausea. Should tl^e 240 
GENERAL DISEASES.-FEVERS. 
[part ir. 
materials for the preparation of the effervescing draught not be at command, 
twenty grains of the citrate of potassa, dissolved in water or carbonic etcid 
water, may be substituted. The solution of acetate of ammonia may be em- 
ployed for the same purpose; but it is much more disagreeable, and, according 
to my experience, not nearly so effectual. 
In very few cases will it be necessary to resort to other remedies. When 
the pulse is full, strong, and hard, with severe pain in the head, or pain in 
any other part, leading to the suspicion of inflammation, it may be proper to 
take some blood. Should the evidence of inflammation be unequivocal, the 
remedy should be resorted to without hesitation, unless the case present 
equally strong evidence of great debility. In the latter event, blood may 
often be advantageously taken by cups or leeches from the neighbourhood of 
the part affected. 
When the system is feeble, and especially when there is a tendency to a 
typhoid condition of the fever, the powder of ipecacuanha and opium (Dover's 
powder), in the dose of ten grains, is an excellent remedy. It may also be 
used in any case in which the patient suffers with nervous pains during the 
paroxysm, unless there are evidences of active cerebral deterihination or in- 
flammation. Dr. Lind recommends opium generally in the febrile stage, 
having found it almost always to abate the violence, and shorten the duration 
of the paroxysm. I have not employed it except under the circumstances, 
and in the mode mentioned above, and can, therefore, give no authoritative 
opinion of its use in ordinary cases; though I must confess it would be opposed 
to my views of its stimulant influence on the brain, to administer it in cases 
of strong sanguineous determination to that organ. 
Irritability of. stomach is generally best allayed by the effervescing draught, 
or small draughts of carbonic acid water. Should these fail, recourse can 
be had to the measures recommended for the same symptom in thercold 
stage. 
Some have recommended the external application of cold water. This no 
doubt relieves the febrile heat, and conduces to a solution of the paroxysm. 
It should not be employed when there is the least moisture upon the skin. 
It is most conveniently applied by sponging. Dr. Dickson, of Charleston, 
recommends the cold bath, but avoids it in the old, the infirm, and those 
labouring under pulmonary disease or diarrhoea. (Essays on Pathol, and 
Therap., i. 274.) 
In the sweating stage, nothing more is requisite than to take care that the 
patient be not exposed to cold, so as prematurely to check the discharge. 
In the Intermission.-This is the period for the effective treatment of inter- 
mittents. The course to be pursued is happily as simple as it is effectual. 
First, the bowels should be thoroughly evacuated, and then sulphate of quinia 
should be given freely. Formerly, it was customary to administer an emetic; 
but this practice is unnecessary, disagreeable, and sometimes mischievous, and 
has gone out of use. The only condition in which vomiting is clearly indi- 
cated, is when the stomach is loaded with undigested food, or oppressed and 
irritated by acrid accumulations. For the cathartic effect, calomel, as a gene- 
ral rule, is preferable to all other articles,of the class. It not only evacuates 
the bowels^ but unloads the congested liver. It should generally be com- 
bined for adults with some other purgative to insure its action. Three or 
four of the compound cathartic pills may be employed, or from five to fifteen 
grains of calomel, with a proportionate quantity of rhubarb, jalap, scammony, 
or compound extract of colocynth; or the dose of calomel may be given alone, 
and followed in six hours by a dose of sulphate of magnesia or castor oil. 
Y^hcn the apyrexia is very short, so as not to allow time for the action of a CLASS I.] 
INTERMITTENT FEVER. 
241 
purgative, and the subsequent administration of quinia, the calomel may be 
given during the paroxysm. In mild cases of ague, with no signs of biliary 
disorder or hepatic' congestion, it will be sufficient to evacuate the bowels 
thoroughly_by sulphate of magnesia, or one of the other saline cathartics, or 
by the infusion of senna with Epsom salt. 
As soon as possible after the bowels have been evacuated, it will be proper 
to commence with Peruvian bark, or one of its preparations. Of these be- 
yond comparison the most valuable is sulphate of quinia. Formerly, the 
barkin substance was found most effectual; but, in consequence of its bulk, 
and of the nauseating property of some of its ingredients, it was found impos- 
sible, in many instances, to administer it in sufficient quantities to produce 
its full effects; and hence it often happened, that cures were greatly protracted, 
and sometimes it was necessary to resort to other remedies. At present, it 
has been almost superseded by quinia, which appears to possess its antipe- 
riodic property in a very high degree, if not completely; and may be given 
in cases in which the' bark in substance would not be' borne. Moreover, by 
increasing the dose of quinia, to such a degree that no stomach would support 
an equivalent quantity of bark, we may obtain effects from the former, which 
could not be obtained from the latter. Various salts of quinia have been 
recommended; but no one I believe is superior in efficacy, or in any other 
valuable property, to the officinal sulphate. That medicine comes as near to 
the character of a specific in intermittent fever as possible. I have employed 
it extensively both in public and private practice, ever since it was first intro- 
duced into use; and, except in two instances, have never failed in arresting 
the paroxysm in regular uncomplicated intermittents; and, even in those 
instances/ which occurred early in my practice, I believe that it would have 
proved effectual had it been administered in the quantities in which we now 
give it in obstinate cases. It will often arrest the disease immediately, so 
that the patient shall not have another paroxysm, especially in the tertian 
and quartan, in which time is allowed, during the intermission, for evacuat- 
ing the bowels, and getting down a sufficient quantity of the medicine. If it 
fail with the first, it will generally succeed with the second paroxysm; and 
the cases are very rare in which a third will occur, supposing the intermission 
to be complete, and the proper previous preparation to have been made. 
When the first and second paroxysms return after its use, they are generally 
milder, and often postponed. All that we know of itp mode of action is, that, 
by its impression on the system, and especially, in all probability, on the 
brain or nervous system generally, it supersedes the paroxysm, on the princi- 
ple, that, as our frame is constituted, there is a strong indisposition in it to 
support, two morbid actions at the same time, in the same part. The regular 
return of the intermittent paroxysms appears to depend upon a concatenation 
of actions/ which, if broken in any one link, is either dropped altogether, or 
resumed only at a more distant period. 
There has been, and continues to be a difference of opinion upon the point, 
whether quinia should be given, in complicated intermittents, during the con- 
tinuance of any inflammation which may be associated with it. On the one 
side, it is maintained that the. quinia must, by its stimulating properties, 
aggravate the inflammation; while, in consequence of the constant irritation 
which this sustains in the system, it will fail to subdue the paroxysmal dis- 
ease. On the other side, it is answered, that quinia is capable, as proved by 
the result of innumerable trials, of arresting the intermittent paroxysms under 
the circumstances mentioned; that the stimulus of the paroxysmal pyrexia is 
infinitely greater, and infinitely more likely to support and aggravate the 
inflammation, than that of the quinia; and that, consequently, the sooner 242 
GENERAL DISEASES.-FEVERS. 
[part II. 
this medicine is administered the better. According to the former opinion, 
the inflammation should be first subdued by the lancet, cupping, &c., after 
which recourse may be had to the antiperiodic remedy; according to the lat- 
ter, the paroxysmal disease should be immediately arrested, and then, if the 
inflammation shall not cease at the same time, it can be treated in the ordi- 
nary manner. There is a simple rule which, I think, will serve the practi- 
tioner as a sufficient guide in relation to this disputed point. Whenever the 
intermission is complete, in other words, when it is quite exempt from fever, 
quinia may be given without hesitation, if the stomach will support it. If 
any existing inflammation is of so low a grade as not to induce symptomatic 
fever, it will scarcely oppose an obstacle to the antiperiodic action of quinia, 
and will be much more likely to yield after the paroxysms have ceased. 
Indeed, such inflammation is probably often supported by, if it do not origi- 
nate in, the fever of the paroxysm. When the inflammation is so extensive 
or severe as to induce fever, though the disease may have the paroxysmal 
form, .yet it will present rather the aspect of a remittent than an intermittent, 
as there will be fever steadily throughout the interval. In such cases, the 
use of quinia should be preceded by depletion, and other measures calculated 
to reduce the inflammation; but, as soon as a distinct intermission has been 
obtained, there should be no longer any delay in resorting to the antiperiodic 
remedy. When the inflammation is attended with typhoid symptoms, as not 
unfrequently happens in the southern and western portions of this country, 
especially in the winter, when typhoid pneumonia supervenes upon, or be- 
comes complicated with intermittent fever, it will be proper not to wait for a 
distinct intermission; but to administer the quinia as soon as the nature of 
the disease is clearly ascertained. I have seen the happiest effects result from 
this treatment; and have been informed by physicians residing in miasmatic 
regions, that they habitually employ it with great advantage. Not only is 
the intermittent interrupted, but the inflammation itself puts on a more 
favourable character under its influence. 
From twelve to twenty-four grains of the sulphate of quinia should be 
given between the paroxysms, and continued in this quantity until the dis- 
ease is arrested. The amount required is very different in different indivi- 
duals. Some are very easily affected by the medicine, as shown by the buzz- 
ing or roaring in the ears, and partial deafness which they experience, after 
having taken but a small quantity; while in others, very large quantities are 
requisite to produce the same effect. The cerebral sensations produced by 
the medicine may be considered as a sign of its action on the system; and, 
when they are experienced, it is usually unnecessary to push the quinia fur- 
ther than may be requisite to sustain them in a moderate degree. Should 
they be severe, the medicine should be suspended until they subside. It is 
seldom, however, that less than twelve grains, in each intermission, can be 
relied on. I have repeatedly known cases, treated for a considerable time 
with smaller doses without effect, to yield immediately to the medicine in 
larger quantities. When, therefore, the disease is not interrupted at the 
second paroxysm from the commencement of the treatment with quinia,, the 
medicine should be increased to any amount which may be necessary to pro- 
duce its peculiar effects upon the brain, whether that amount be the larger 
quantity above mentioned, or much more. 
Some physicians are in the habit of prescribing very large quantities of the 
sulphate, in all cases indiscriminately. From thirty to sixty, or even one 
hundred grains, have been given during twenty-four hours. These amounts 
may be required iu certain malignant cases, but seldom or never in the dis- 
ease, as it' ordinarily occurs. I do not remember ever to have found more CLASS I.] 
INTERMITTENT FEVER. 
243 
than twenty-four grains, in that period of time, necessary. These enormous 
doses are not without risk. There is reason to believe that permanent deaf- 
ness has resulted from them. One such case has come under my own obser- 
vation; at least the affection was ascribed to that cause by the attending 
physician. Where there is a tendency to cerebral inflammation, it would be 
very likely to be developed by large doses of quinia; and causes of this kind 
are upon record. Besides, to employ the quinia so profusely in ordinary cases, 
is to make great waste of a most valuable and a costly medicine, and thus 
unnecessarily to enhance the price. 
Upon the wdiole, I prefer the plan of administering the medicine in 
small doses frequently repeated, and of distributing it equably through the 
apyrexia, the time of sleep being as a general rule omitted. It is desirable 
that the rest of the patient should not be broken, if it can be avoided. Small 
doses, at short intervals, are preferable to large ones at long intervals;, because 
they afford a better opportunity for the absorption of the medicine. There 
can be little doubt that it operates by entering into the circulation; as it can 
be detected- in the urine by chemical tests. Another advantage of the small 
doses is, that they aye less likely to oppress or irritate the stomach. Some 
give the whole quantity requisite for a single intermission at one dose, which, 
according to one party, should be administered immediately after the parox- 
ysm, according to another, but a short time before it. There are circumstances 
which render such a course advisable; as, for example, when the period of 
the apyrexia is very brief, as sometimes happens in the quotidian; when it is 
of the utmost importance to interrupt the paroxysm, and there is but a short 
time to do it in; and when it is highly desirable not to interrupt sleep, and 
the period of the intermission corresponds exactly with that of rest. In such 
cases, the medicine should, if possible, always be given some hours before the 
expected recurrence of the paroxysm, so that time may be allowed for its 
absorption. Its operation should be in full vigour at that time. 
The medicine should not be given during the pyrexia, in ordinary cases. 
There is some danger that it may aggravate the fever and the cerebral affec- 
tion, while there is almost always time sufficient in the interval. It should 
always be persevered with, as long as the least vestige of a paroxysm remains. 
Should the physician suppose that he has conquered the disease, when he has 
reduced the violent ague and fever to a few disagreeable sensations at the 
regular period, and, under this supposition, omit the medicine, he will fre- 
quently be disappointed to find the paroxysms returning, and gradually resum- 
ing their original violence. When the paroxysm of a quotidian has been 
interrupted, it is proper always to continue the medicine for another day, until 
it be ascertained whether the disease may not be disposed to assume the ter- 
tian type; and, if the physician wish positive security, it may be advisable 
to carry the patient through the day when the paroxysm would return, 
were the disease to become quartan. This, however, is very rarely necessary. 
One or two grains of the sulphate may be given, under ordinary circum- 
stances, every hour or two hours, until the requisite quantity has been admin- 
istered. It is of1 little consequence, whether it be given in pill or solution. I 
have found the two forms equally effectual. The pill is generally dissolved 
with the utmost facility in the stomach, in consequence of the presence of an 
acid there. But the pill should be freshly made, when it is desirable that it 
should act promptly. The solution is generally preferable in the cases of 
very young children; and there are some persons who cannot, or who think 
that they cannot swallow a pill, and who must, therefore, have the medicine 
in the liquid form. Besides, when it is of great importance that it should 
act promptly, as there may possibly be no acid in the stomach, we may per- 244 
GENERAL DISEASES.-LEVERS. 
[part II. 
haps rely with more certainty on the. solution than the pill. The solution is 
made by acidulating the water employed. For this purpose, the aromatic1 
sulphuric acid or elixir of vitriol is the most elegant addition ; and, for every 
grain of the sulphate, one and a half minims of that preparation may be used.* 
Should the sulphate irritate the bowels, a few drops of laudanum, or a flui- 
drachm of paregoric elixir may be given occasionally. It has been recom- 
mended, in ca'ses attended with constipation, to administer rhubarb with the 
quinia or bark. This, however, is not a good plan, as it tends to carry the 
medicine too rapidly out of the reach of the absorbents. It would be better 
to administer the cathartic separately, and at a time when the quinia is not 
to be continued, as at bed-time. 
Should it be impossible to administer quinia by the stomach, in conse- 
quence of the irritability of that organ, it may be given with good effect by 
enema. A mixture- containing twelve grains of the .sulphate of quinia, thirty 
drops of laudanum, and two fluidounces of thin starch or flaxseed mucilage, 
with or without enough acetic acid to effect the solution of the sulphate, may 
be thrown up the rectum every six or eight hour's. This mode of adminis- 
tration may also be resorted to, when the urgency of the case requires that 
the medicine should be introduced by every avenue. It is sometimes also 
employed endermically, the sulphate being sprinkled upon a surface previously 
denuded of the cuticle by means of a blister. It is said to have acted effi- 
ciently in this way; but it is very apt to irritate the surface, and I have known 
considerable sloughing produced by it. When thus employed, it should be 
diluted with gum arabic, and applied in the same quantity as by the rectum, 
at least in cases of emergency. 
Advantage sometimes results from combining the sulphate of quinia with 
other medicines. Opium probably adds to its antiperiodic power, and, when 
otherwise indicated, may be employed in connexion with it in the quantity 
of from one to three grains in twenty-four hours. In cases accompanied with 
great insensibility of stomach, and consequent deficiency of absorbent powet, 
some gastric stimulant may be advantageously added to the sulphate. Of 
this nature are capsicum and black pepper. These are especially applicable 
to the cases of intemperate persons, and to those accustomed to the free use 
of stimulating condiments; and are probably more suitable to hot than to 
temperate latitudes. Some physicians employ piperin; but it is doubtful 
whether this is more efficacious than the black pepper itself from which it is 
derived. (See U. 8. Dispensatory, Art. Piper.') 
Various cheaper preparations of bark have sometimes been substituted for 
sulphate of quinia. An impure preparation, consisting of the sulphates of 
quinia and cinchonia, with some colouring matter, being the residue procured 
by evaporating the mother liquor left in the preparation of the officinal sul- 
phate, has frequently been sold under the name of extract of bark, impure 
sulphate of quinia, quinoidine, &c. In double the dose, it has the same effect 
as the sulphate; but no reliance can be placed upon its purity. 
If quinia should happen to fail in interrupting the paroxysms, recourse 
may be had to Peruvian bark in substance. The officinal yellow (Calisqya), 
or the best red bark should be preferred. From one to two ounces should 
be given during the intermission, in doses of a drachm or two at a time. A 
good method of administration is to introduce the whole quantity of bark to 
be taken during the day into a bottle, containing as many wincglassfuls of 
* B--Quinise sulphat. gr. xvi; Acid, sulphuric, aromat. fgss ; Aquae, fluvial., vel Aq. 
menth. pip., vel Aq. camphorap, f^ij. A teaspoonful every hour or two. Liquorice may- 
be added in the proportion of ij, in order to cover the taste, when the medicine is in- 
tended for children. CLASS I.] 
INTERMITTENT FEVER. 
245 
water as there are to be doses; then to shake the bottle well, and pour out a 
wineglassful for a dose. Five drops of aromatic sulphuric acid maybe added 
to the mixture, for every dose that it contains. Sometimes opium, is a very 
usefol addition; and, in debilitated cases, port wine may constitute a portion 
or the whole of the vehicle. (See U. & Dispensatory.} 
Kn elegant preparation of Peruvian bark, probably containing all its vir- 
tues, is the compound infusion of the U. S. Pharmacopoeia, made with the 
addition of elixir of vitriol. From one to two pints of this, between the 
paroxysms, will be requisite for the cure of intermittents. One of the tinc- 
tures of bark may with propriety be added to this preparation, or to the sul- 
phate of quinia, in cases of great debility, or in those of drunkards; from 
f$j to f^ss being given with each dose. As to the use of bark in the form 
of jackets, or cataplasms, or baths, it has been entirely superseded by the 
sulphate of quinia. ' . ' 
Various obvious inducements have led to an industrious search, at different 
times, for substitutes for Peruvian bark or quinia in the treatment of this 
disease. Many of these have been introduced to the notice of the profession, 
with the highest commendations; and not a few of them have ranked,' in the 
partial estimate of their recommenders, as equal if not superior to the Peruvian 
tonic. Few of them, however, have stood the test of trial; and not one has 
yet satisfied the profession generally of its claims to supersede the sulphate 
of quinia. In judging of the value of the strong testimony which is every 
now and then adduced in favour of some new remedy in intermittents, it 
must be recollected that this disease not unfrequently ceases spontaneously, 
and that it may very often be interrupted by anything calculated to make a 
strong impression on the mind of the patient. Thus, amulets and charms 
have frequently been supposed to cure the disease. Hence, too, the credit 
acquired by certain disgusting remedies, which produce a shudder when they 
are swallowed. The expedient of putting forward the hour hand of a clock, 
so as to make the patientebelieve' that the time for his chill has passed, is said 
to have sometimes had the effect of preventing its occurrence. Certain indi- 
viduals are supposed by the vulgar to possess a supernatural influence over 
the ague, which disappears at their command. I have known of two indi- 
viduals who were believed to possess this power, and who frequently'cured 
the disease by assuring the patient that he would miss his chill at a certain 
time. Here is the effect, of faith. It may thus be easily understood, how 
various substances having no real influence over the disease, should have 
acquired the credit of cures in the complaint. Physicians may legitimately 
make use of this principle of faith. By strong assurances that the patient 
will miss his paroxysm, if properly obedient to directions, the efficacy of the 
sulphate of quinia itself may sometimes be increased. 
But there are certain remedies which really possess some ahtiperiodic 
power, and are capable of effecting positive cures of the ague and fever, though 
none comparable with quinia. The one which approaches most nearly to it 
in efficacy is arsenic. In the form of solution of arsenite of potassa or Fow- 
ler's solution, this was much used before the discovery of quinia. It had the 
advantage over the bark of being tasteless, or nearly so, and therefore more 
readily administered to children, and persons of delicate stomachs. Even at 
present, we may sometimes perhaps advantageously recur to it in infantile 
cases, when solution of sulphates of quinia is obstinately rejected on account 
of its taste, and sufficient influence cannot be found to control the will of the 
patient. It may also be used sometimes beneficially, when the apyrexia is 
incomplete, and we may fear to administer quinia, in consequence of some 
existing phlegmasia. The dose of it is ten drops three times a day. It may 246 
GENERAL DISEASES.-EEVERS. 
[PART U. 
be continued until the disease is arrested; or until some oedema of the face, 
oppression of stomach, general tremors, or feelings of muscular weakness, 
evince the action of the medicine. It must then be suspended, lest the poison- 
ous effects of the arsenic shpuld be produced. I have known a case of universal 
anasarca apparently arise from its use in a child. 1^ cannot, in general, be 
continued with propriety much beyond a week. For infants, the dose must 
be diminished in proportion to the age. To a child a year or two old, a drop 
or two may be given three times a day. 
The salts of various other metals have, in some measure, the same anti- 
periodic power. Sulphate of copper is among the most efficient. It may be 
used in connexion with quinia, in the dose of one-fourth of a grain.* Sul- 
phate of zinc in the dose of a grain or two, and different salts of iron have 
had some reputation. Ferrocyanuret of iron, or Prussian llue, has been 
much lauded by some practitioners. It was introduced into practice by Dr. 
Zollickoffer, of Maryland, who considered it even superior to Peruvian bark. 
Dr. Samuel Jackson, formerly of Northumberland, Pennsylvania, employed 
it with great success, though he did not find it equal to the bark. Out of 
two hundred cases in Which it was given by him, it failed to produce an 
immediate suspension of the paroxysm only in a fifth or sixth of the cases, 
and in most of these proved successful in the second, third, or fourth interval. 
Dr. Zollickoffer' gave about six grains twice or three times Jr day; Dr. Jackson 
one or two drachms during the interval. (Am. Journ. of Med. Sci., ii. 335.) 
I used the medicine, when it first came into notice, in a few cases; but, 
though it was attended with some success, the bark proved so much more 
certainly efficacious, that I quickly abandoned it. Fordyce states that tartar 
emetic or ipecacuanha, given every four, five, or six hours, in doses as large 
as can be borne without nauseating, will often carry off the disease. Sulphur 
has been highly spoken of as an antiperiodic. Dr. Chapman gives a favour- 
able opinion of it; and Dr. Dickson, of Charleston, considers it a most valuable 
remedy in various intermittent diseases, and especially applicable to intermit- 
tent fever when the apyrexia is incomplete. Alum has long enjoyed some 
reputation. Tincture of iodine, in doses of thirty drops, repeated three times 
during the apyrexia, and increased, if necessary, to forty, fifty, or sixty drops, 
has been highly recommended in very obstinate'cases. (Am. Journ. of Med. 
Sei., M S. xiv., 223.) o 
Almost all the vegetable tonics and astringents have been employed in the 
treatment of intermittents. From the strong testimony in its favour, there 
is reason to think that our Cornus Florida, or dogwood bark, is not without 
efficacy. The barks of the wild cherry and tulip tree of this country, of 
different species of willozv, of the horsechesnut, of the oaks, of the mahogany 
and its congener Swietenia febrifuga ; all the simple Litters, as quassia, gen- 
tian, &c.; wormwood, chamomile, and eupatorium or Loneset; kino with 
nutmeg; pepper or piperin, sage, coffee, and a host of others Of the same 
classes, have been enumerated among antiperiodic remedies. Much was said 
at one time of the extraordinary efficacy of salicin, or the active principle of 
the willow'; and it is probably not without power, though greatly over- 
praised. Sulphate of bebeerin has been used with great asserted success; from 
a scruple to a drachm being given in the intermission, in doses of two grains 
each. Narcotina has been recently brought into notice by Dr. O'Shaugh- 
nessy, of Calcutta; and numerous cases have been adduced in proof of its 
efficacy. lie gave it in the dose of three grains three times a day, in con- 
* R-Cupri sulphat. gr. j; Opii pulv. gr. j ; Quinise sulphat. gr. viij; Acaciae pulv., 
Syrup, aa q. s. Misce et flam pil. no. iv. S. One lour times a clay. CLASS I.] 
INTERMITTENT FEVER. 
247 
nexion with muriatic acid. I have never been able to divest myself of the 
suspicion, that, as employed in India, it contained a portion of morphia. 
Charcoal, though greatly praised, is probably inert. The same may be very 
confidently said of gelatin, though this also has had its advocates. Spiders' 
web, in the dose of from five to ten grains every two, three, or four hours, 
originally employed by Dr. Gillespie, of the Isle of Man, was afterwards used 
successfully by Dr. Jackson in the West Indies, and Dr. Condie and others 
in this country (Notes to Watson's Practice, Am. ed.), and has enjoyed con- 
siderable reputation. All the above remedies have been employed in refer- 
ence to a supposed antiperiodic property. Many of them have undoubtedly 
cured intermittents; but all of them are liable to failure; and no one has yet 
approached the reputation of Peruvian bark. 
There is another mode of treating intermittents which is often effectual, 
and may sometimes be resorted to with advantage. It consists in making 
upon the system a strong and obvious impression, in immediate anticipation 
of the paroxysm, so as completely to pre-occupy the ground, and thus pre- 
clude the entrance of the disease. One of the most' efficacious measures of 
this kind is the employment of an emetic, so as to be in full operation at the 
moment when the paroxysm is expected. In this way, the decoction of bone- 
set (Eupatarium perfoliatuin), taken warm in the quantity of a small bowl 
full, the patient being covered in bed, will often prove effectual. It operates 
as an emetic, throws the patient moreover into a ^profuse perspiration, and sets 
aside the paroxysm, which generally does not return. This plan of treat- 
ment is admirably adapted to cases, in which there is a slight fever through- 
out the interval. I have repeatedly employed emetics, under these circum- 
stances, with great benefit. 
Opium given in a full dose, an hour or two before the paroxysm, operates 
in the same way, and more agreeably, though perhaps less effectually. Any 
other stimulant will occasionally have a similar effect. Brandy, musk, and 
ether have been employed. But the risk from all these medicines is, that, if 
they do not arrest the paroxysm, they may aggravate the fever, and endanger 
inflammation of the brain, should any tendency to that affection exist. 
Large blisters upon the extremities, applied so as to be in full operation 
at the time for the paroxysm, sometimes prevent its return. But they are 
applicable rather to remittents than to intermittents. Powerful rubefacients, 
Such as - mustard and ammonia, may be occasionally effectual in the; same 
manner. 
With this set of remedies may also be ranked the plan, said to have proved 
effectual in one very obstinate case, of pushing the patient without warning 
into deep water, and thus making a powerful impression at once upon his 
mind and body. Of analogous effect is the affusion of cold water, employed 
an hour or two before the paroxysm, in the form of a general shower bath, 
and of a local douche to the region of the spleen. 
When the return of one paroxysm has been prevented by any of the means 
above detailed,The disease is generally arrested for a time, and often perma- 
nently. But not unfrequently some functional disorder of the chylopoietic 
viscera remains, which requires attention; and advantage will often accrue 
from the use of a mercurial pill, every night or every other night, with atten- 
tion to the state of the bowels, for a week or a fortnight. It may also be 
useful, when the digestion is feeble, to administer one of the simple bitters. 
The nitromuriatic acid is an excellent remedy under these circumstances; but 
it should not be used in connexion with the mercurial. 
It has been stated, that relapses are frequent in this disease. They are 
indeed among the circumstances which give the practitioner most trouble. 248 
GENERAL DISEASES.-FEVERS. 
[PART II. 
I have found, however, by ascertaining the period at which the disease is 
disposed to return, which is generally remarkably regular in each ease, that 
the recurrence may almost always be prevented, and the disease finally 
eradicated, by a persevering system of anticipation. In most cases, the 
first recurring paroxysm shows itself about two weeks from the time of the 
last chill. All that is necessary is, two days before this period of ex- 
pected relapse, to give as much sulphate of quinia as might be requisite to 
arrest the disease if formed; namely, from six to twelve grains each day. 
This plan should afterwards be continued weekly for a month or two. At 
the end of the latter period, the disposition is generally very much subdued, 
though perhaps not fully eradicated; as exciting causes may afterwards 
induce a recurrence of the disease. This, when it takes place, should im- 
mediately be met with quinia, no matter how slight or imperfect the first 
recurring paroxysm may be, and the same plan of anticipation pursued as 
before. . 
Sometimes, these relapsing cases may be advantageously treated by .placing 
the patient upon the steady use of three or four grains of quinia daily for 
two or three months. I have found also the infusion of wild cherry bark, 
in the dose of a wineglassful four times'a day, continued in the same man- 
ner, apparently effectual. Wormwood has had considerable reputation as a 
preventive of relapses. It is used in the form of tincture, or infusion, and 
given twice or. three times a day. In some instances, however, the disposi- 
tion to relapse is so adhesive, as to resist everything in the shape of medi- 
cine that can be employed. It may be corrected for a time, but shows itself 
whenever the patient may be off his guard, sometimes after it may have been 
supposed to be thoroughly eradicated. In these cases, however, by arresting 
the disease as soon as it appears, mischief is prevented, and ultimately, in 
the course, of one, two, or three years, the morbid tendency appears to 
exhaust itself. Great advantage often accrues by changing completely the 
circumstances in which the patient may be placed, and bringing a new set of 
influences to bear upon him. A voyage to sea, foreign travel, long journeys 
on horseback, &c., often completely eradicate, the tendency. 
The diet of-a patient, during the continuance of the disease, should be light, 
digestible, nutritious, and unstimulating. For the first day or two, he should 
generally avoid animal food, and afterwards use the lighter kinds, such as 
milk, butter, soft boiled eggs, and boiled meats, in connexion with farinaceous 
substances, and easily digested vegetables. Stimulating drinks should not 
be used. Fie should always avoid eating a full meal, within two or three 
hours of the expected paroxysm, as the food does not digest during the fever, 
and sometimes serves as a source of injurious irritation. When the intermis- 
sion is complete, it is quite unnecessary that the patient should confine him- 
self to the house; though he should avoid fatigue. In some old cases, violent 
exercise on horseback between the paroxysms has been found remedial. 
Prevention.-Miasmatic regions should be avoided, from the- first of July 
to the occurrence of black frost in the autumn. They who are compelled to 
reside in, or pass through them, at this season, should especially avoid the 
morning and evening air, and should never sleep out at nights. If necessa- 
rily exposed at these times, it should not be with the stomach empty, nor 
after fatigue or exhaustion of any kind. The intense heat of the sun in the 
middle of the day should be avoided or guarded against, and all kinds of ex- 
cess should be scrupulously shunned. Individuals should be careful not to 
expose themselves to cold when heated, and never to remain long in wet 
clothes. Great alternations of temperature are very apt to induce the dis- 
ease. The use of a fine gauze veil, or something equivalent to it, has been CLASS I.] 
REMITTENT FEVER. 
249 
recommended, under the impression that it might exclude the miasmata. A 
much more effectual measure is to keep the system steadily under the mode- 
rate influence of quinia or Peruvian bark. My friend, Dr. Samuel Jackson, 
late of Northumberland, has informed me, that he kept himself in this way 
perfectly well during a Season in which miasmatic disease was exceedingly 
prevalent, and he was compelled to undergo all kinds of exposure, at all hours 
of the day and night. 
Perhaps the use of certain articles of diet may.tend to counteract the effects 
of malaria. Frazer, in his travels in Persia (p. 16), states that in Mazande- 
ran, a low, wooded, and very moist district upon the borders of the Caspian, 
which is very sickly, the inhabitants are in the habit of eating garlic freely, 
asserting that it is necessary to protect them against the complaints of the 
climate. . - x 
REMITTENT FEVER. 
Syn.-Bilious Fever.-Bilious Remittent Fever. 
Besides the disease last treated of, two distinct fevers are endemic in tire 
United States; one, the variety of miasmatic fever usually called remittent, 
which prevails in the latter part of summer and in autumn; the other, the 
complaint known by the names of common continued fever-, typhoid fever, do- 
thinenteritis, &c., which occurs most frequently during cold weather. So pe- 
culiarly are they diseases respectively of the seasons mentioned, that the 
former may be considered as the autumnal, the latter as the winter endemic 
of our country. Either of them, however, may occur at any period of the 
year; and the two not unfrequently exist at the same time. As they often 
bear no inconsiderable resemblance to each other, and yet require, in some 
respects, very different treatment, it is of great importance that they should 
be distinguished; and the attention of the student is called to them in this 
place, in order that he may have his mind especially directed to their diagnostic 
characters. This is the more necqssary, as the two diseases have been, and 
still are not unfrequently confounded by practitioners. 
Remittent or bilious fever occurs more or less in almost all,parts of the 
United States, lying between the Northern Lakes and the Gulf of Mexico, 
but is much more frequent in the middle and southern sections than in the 
northern. In some parts of New England, it appears to be almost unknown; 
the common endemic fever of those regions being probably the winter fever 
above alluded to. It is rare in the mountainous and hilly districts of our 
country, except where tire re are large streams or standing water; also, in the 
dry sandy regions covered with pine forests, and in the middle of cities. 
Hence, these are frequently the resort of the inhabitants of miasmatic districts 
during the sickly season. The situations in which the disease is most preva- 
lent are the valleys of streams, the borders of lakes or ponds, the neighbour- 
hood of marshes, and the rich prairies of our Western States. Sometimes it 
occurs as a kind of epidemic in regions usually healthy, and occasionally rages 
in them with great violence. It is in general a much more serious disease in 
the southern and south-western sections of the United States, than in those 
portions of the North which are still within the limits of its prevalence. But 
the disease is not confined to this country. It is endemic almost everywhere 
in hot climates, and especially where heat, moisture, and decaying vegetable 
matter act conjointly. (See fllasmata, p. 139.) Comparatively mild in tem- 
perate latitudes, it becomes extremely fatal in many places within the tropics. 
It is the disease of whose ravages in the East Indies, Africa, the Mediterranean, 250 
GENERAL DISEASES.-FEVERS. 
[PART II. 
and South America, we have heard so much; which has depopulated the 
Campagna of Rome, and rendered intertropical Africa uninhabitable by whites. 
It must not, however, be confounded with the yellow fever, which, as will 
hereafter be seen, is quite a distinct disease. It was probably this fever that 
was best known to the Greek and Roman physicians, and upon which the 
descriptions'of ancient medical writers were chiefly founded. 
The disease has received numerous names, all of which are liable to objec- 
tion. It is undoubtedly remittent; but there are other fevers which are more 
or less remittent, and cases of this fever sometimes occur in which it is diffi- 
cult to detect any remission. It is also Inlious; but so also is yellow fever 
in at least an .equal degree; and' it -often happens that the one which we are 
considering does not show any special disorder of the hepatic function. It 
has frequently received names from the localities where it prevails. Thus, 
we hear of the African fever, the Bengal fever, the Mediterranean fever, the 
Walcheren fever, &c. &c. The complaint, as it prevails on the borders of our 
inland seas, is called Lake fever; the people of cities which are exempt from 
it, while the surrounding districts' are affected, often name it country fever; 
and the inhabitants of healthy uplands are apt to designate it river fever or 
marsh fever, from some stream or marsh in their vicinity, the 'borders of 
which are infested by it. All these are one and the same disease, and there- 
fore improperly named. If its exclusive miasmatic origin be admitted, the 
title of miasmatic remittent would perhaps be the least objectionable of any 
hitherto given to it. I ■ shall, however, call it indifferently remittent and 
bilious fever; and, when these terms are employed without qualification, they 
may be considered as belonging to the disease in question. 
Types.-It has already been stated, that miasmatic remittent fever is essen- 
tially the same disease as .the intermittent. The two affections sometimes 
approach each other so closely in form, that it may be impossible, in relation 
to a particular case, to decide to which of them it belongs. In intermittents 
there is often some degree of morbid action, and in remittents often very little, 
between the paroxysms; and it is not always possible to determine, whether 
the morbid action that exists does or does not amount to fever. If it be pro- 
nounced not to bp fever, the disease must be considered intermittent; if fever, 
remittent. In the latter affection theiA is every grade, from the doubtful 
form just alluded to, up to an almost uniform continuous fever. 
In many cases, the paroxysms of remittent occur at regular stated intervals, 
like those of intermittent, and, like them, consist of the cold, hot, and sweat- 
ing stages, though in general less distinct and decided. In other cases, with 
the same regularity in the recurrence of the paroxysms, there is no cold stage 
after that of the accession of the- disease, and the sweating stage is either 
slight or wanting. In others again, the fever merely fluctuates in its course, 
at one time rising into a moderate exacerbation, at another falling into a 
moderate remission, without forming well defined paroxysms. Instances, 
moreover, do occur, though they are comparatively rare and always short, in 
which the fever pursues a uniform course, without discoverable relaxation, and 
sometimes with a regular increase, to the crisis. 
All the above conditions may occur in the same case. At tire commence- 
ment, there may be two or more regular paroxysms as in intermittent; after- 
wards the paroxysms may recur regularly without the chill or the perspira- 
tion ; and at length the fever may assume the continued form, and thus run 
on to its termination. Or, the disease may commence as continued fever, 
may after a time become paroxysmal or remittent, and may finally end in 
intermittent. 
Remittent fever has the same types as the intermittent. The most fre- CLASS I.] 
REMITTENT FEVER. 
251 
quent is the quotidian, with a paroxysm occurring at about the same hour 
every day. The tertian, with its every other day paroxysm, is not uncommon. 
The quartan is very rare. Next, perhaps, to the quotidian is the double ter- 
tian, having a daily paroxysm, but that of one day differing from that of the 
next, and the alternate paroxysms resembling each other both in character 
and time of occurrence. Thus,, the paroxysm may occur one day in the morn- 
ing, and the next in the evening; and all the, morning paroxysms shall be. 
regular, while those of the evening shall be in some manner modified, either 
very light and short, or without chill or perspiration, or attended with nausea, 
while those of the morning are attended with headache. A remittent may 
always be considered of the double tertian type, when, having an exacerbation 
every < ,'y, it is yet much worse on alternate days. Sometimes two exacerba- 
tions occur in one day, and only one in the next; and cases are occasionally 
met with, in which the principle of association between the exacerbations 
cannot be.traced; as they every now and then make their appearance irregu- 
larly, and when least expected. 
Some difference exists among writers as to the time of day at which the 
paroxysms of remittent fever are most apt to commence. The first onset of 
the disease appears to take place indifferently at any hour of the day; some- 
times in the forenoon, sometimes in the afternoon, and Occasionally even in 
the night, and the tendency is afterwards for the paroxysms to return about 
the same hour. But, when the disease approaches the continued form, and 
the commencement and termination of the exacerbations'are not precisely 
marked, the disposition generally is to an increase of the febrile action in the 
evening, and a decline in the morning. 
Grades.-There are two distinct modes in which we may estimate the 
grade of the. fever; first, in reference to its greater or less violence, and, 
secondly, in reference to the greater or less energy of system which attends 
it. In both respects, bilious fever varies greatly. As regards the violence 
of the disease, it may be of all conceivable grades, from a mildness which 
scarcely confines the patient, or requires the interposition of remedies, to 
a severity which demands the promptest treatment to preserve life, and 
against which all the resources of nature and art occasionally fail. The 
degree too of the energy of system may be very different, and may give rise 
to marked varieties of the disease. The state of system may be sthenic, with 
the blood rich and abundant, and all the vital functions full of vigour; or it 
may be feeble, asthenic, or adynamic, with the vital forces exhausted by pre- 
vious disease, intemperance, or other debilitating cause. In these two condi- 
tions, the resulting febrile action partakes of the character of the vital func- 
tions; being in the former generally open, well developed, energetic, or, to 
use an epithet very commonly employed by writers, inflammatory; in the 
latter, often feeble with deficient reaction, and a tendency to prostration, and, 
when the blood is at the same time depraved, with the addition of symptoms 
usually denominated typhous. The term inflammatory, as above used, is not 
entirely correct; for it is not intended to imply the existence of any positive 
inflammation. It only means, that there is real strength or energy as well as 
excitement in the vital functions. Nay, inflammation is not at all incompa- 
tible with the contrary state; for we often observe it in cases of the asthenic, 
adynamic, or typhous form of the disease. It is necessary constantly to bear 
this distinction in mind, in the treatment of bilious fever; remedies being 
well borne and even required in the one case, which might prove in the highest 
degree dangerous in the other. In very many cases, it happens that the 
strength of system is in an intermediate state, being neither materially ele- 
vated above, nor prostrated below, the medium standard of health. The 252 
GENERAL DISEASES.-FEVERS. 
[part it. 
symptoms detailed immediately below are those of cases in which the vital 
powers are not materially depressed. 
Symptoms.-For one or two days or more before the commencement of 
the fever, the patient is Very often affected more or less with feelings of gene- 
ral discomfort, weariness, or languor, a sense of weight, fulness, or indescrib- 
able uneasiness at the epigastrium, deficiency of appetite, disordered taste, 
slight pain or uneasiness in the head, especially over the brow, and fugitive 
pains or soreness in different parts of the body. If the tongue is examined, 
it may appear slightly furred near the root, perhaps the pulse may be a little 
excited, and the complexion somewhat dingy or sallow. These symptoms, 
however, exist in various degrees in different cases, and some of them are 
frequently wanting. Sometimes they are felt,, with or without alternating 
sensations of chilliness and warmth, at a particular time every day or every 
other day, with intervals of healthful feeling, until at length they deepen 
into regular paroxysms. During this preliminary period, the patient is going 
about, and engaged, though languidly, in his ordinary avocations. In many 
cases, no such premonitory symptoms are observable, and the patient is at- 
tacked in the midst of apparently good health. 
The, disease usually commences with sensations of chilliness, amounting 
often to rigors; and a slight coolness of the extremities is generally sensible 
to the observer. The face is usually pale, and the lips purplish. The pulse 
is small, depressed, and not unfrequently irregular. Occasionally, there are 
nausea and vomiting, thirst, and pain in the loins and extremities. The dura- 
tion of the chill varies from a few minutes to an hour or more; but it is seldom 
so severe, or long-continued as in intermittent fever. Not unfrequently, the 
only sign of this stage,is a sense of chilliness alternating with flashes of heat; 
while, to the by-stander, the surface feels uniformly warmer than in health. 
For some hours after reaction, the patient is frequently liable to this chilly 
sensation, upon every change of posture which brings his skin, into contact 
with a cooler portion of the bed. When febrile reaction has been established, 
the patient feels uncomfortably hot, the skin is hot and parched, the surface 
generally somewhat reddened and expanded, the respiration hurried, and the 
pulse increased in frequency'arid fulness, and often also in force. At this 
stage of the complaint, however, the pulse is in ordinary cases not very fre- 
quent; being sometimes as low as 90 in the minute, and not often exceeding 
116 or 120. It is usually open, well-developed, and sufficiently forcible, but 
not commonly very hard or tense. The tongue is almost always somewhat 
coated, but the fur is generally thin at this early period. There is a complete 
loss of appetite, amounting even to a feeling of loathing for food; sometimes 
with, sometimes without, nausea and vomiting. Thirst is a very frequent, 
though not constant symptom. The face is usually flushed, and the eyes 
suffused; and the patient almost always complains of headache, which is often 
severe, tensive, or throbbing, and is in most instances the source of greater 
suffering than any other cause. There are also frequently pains more or less 
severe in the back, loins, and extremities. Though very seldom delirious, the 
patient is restless, and wakeful. When not delirious, he is always sensible 
of great muscular weakness, and usually finds it necessary to keep his bed. 
These symptoms continue without abatement, for a considerable time, 
usually from six to eighteen hours, after which they begin to relax, with the 
appearance of moisture about the neck and face. This gradually increases, 
until the whole body is covered with a gentle perspiration; and the patient 
now experiences so much relief, that he often falls into a quiet sleep, from 
which he awakens refreshed, and apparently much improved. The headache, 
thirst, and nausea have greatly abated, or quite disappeared; the pulse has CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
253 
become almost natural; the skin is cool and soft,' the tongue often shows a 
disposition to clean; and food is sometimes received, if not with relish, at least 
without disgust. This is the remission. It is frequently less complete than 
above described; but, in almost all cases of ordinary bilious fever, occurs in a 
greater or less degree. It is exceedingly variable in duration, in some cases 
lasting n6t more than two or three hours, in others a whole day; being shorter 
or longer according as the type of the fever may be quotidian or tertian. 
Another paroxysm of fever then takes place, sometimes, like the first, begin- 
ning with a chill and subsiding with perspiration, but frequently also without 
either the one or the other. This ends in due time in another remission; and 
thus the alternation continues, each successive exacerbation becoming, as a 
general rule, more severe and protracted, and each remission less decided and 
shorter, until the disease attains its maximum of severity; when, though in 
many instances the remissions are still distinct, yet it often happens that they 
are quite otherwise, and that the only evidence of fluctuation in the course of 
the fever is, that the pulse beats a few strokes less frequently, the skin is 
somewhat cooler, and the sufferings of the patient somewhat less, in the morn- 
ing than in the evening. In this stage, the following symptoms are presented; 
and it may not be imjproper to repeat, that, in some cases, the disease starts 
into existence in this comparatively continuous form, and presents the symp- 
toms' alluded to almost from the outset. 
The pulse is usually more frequent than at first; and occasionally much 
more so, being sometimes above 120 in the minute. It has also not unfre- 
quently acquired increased tension and force, by the developement of inflam- 
mation in one or more of the organs. The heat and dryness of the skin have 
also been augmented. The tongue is now thickly and uniformly covered with 
a whitish or yellowish-white coating, which, as the disease advances, often 
becomes brown or blackish, especially in the centre'. In moderate cases, the 
tongue is usually rather moist throughout-the disease; but, in those of a higher 
grade, it not unfrequently becomes dry or dryish, and sometimes chapped or 
fissured upon the surface. It is qccasionally disposed to be dry in the pa- 
roxysm, and to become moist in the remission. At the sides, where not 
covered with fur, it is usually red, and not unfrequently indented by the teeth, 
in consequence of being somewhat swollen. Sometimes the patient is troubled 
with uneasy sensations in the back part of the tongue, or in the fauces, which 
cause an almost constant hawking, with the discharge of a glairy mucus. The 
author well remembers that, in a severe attack of this kind, One of his most 
uncomfortable sensations, in a certain stage of the disease, was a feeling as if 
there were a loose hair in the fauces. In the great majority of cases, there is 
more or less tenderness upon pressure in the epigastrium. Sometimes this is 
excessive, so that the patient cannot bear with equanimity even the touch of 
the fingers. There is very frequently also a feeling of weight or oppression in 
the region of the stomach; and occasionally also a burning pain, which is in 
some instances almost intolerable. The epigastric tenderness and pain are not 
in general experienced, in any considerable degree, before the third or fourth 
day, and are apt to increase with the progress of the disease. They are among 
its most striking characters. With these symptoms, there is very often an 
irritable, sometimes an excessively irritable state of the stomach. Nausea 
and vomiting are very frequent attendants ilpon bilious fever. Though occa- 
sionally present at the beginning, they are more troublesome, as a general 
rule, when the disease is at its height. The matter ejected is usually of a 
yellowish, greenish, grass-green, bluish, or brownish colour, and a bitter, acrid 
taste; sometimes a glairy mucus; and, in many cases, whatever is swallowed. 
It is not unfrequently difficult to induce the stomach to retain cither medicine 254 
GENERAL DISEASES.-FEVERS. 
[part II. 
or drink. The nausea is often so great as to produce some temporary weak- 
ness of pulse, and damp relaxation of the skin; and, when it is. severe, the 
headache is diminished, and delirium, if previously existing., often calmed. It 
must not, however, be understood, that nausea and vomiting are constant 
attendants on bilious fever. Many mild cases run their whole course without 
these phenomena; and, in some very severe cases in which disease seems to 
be concentrated in the brain, the stomach apparently escapes. The bowels 
are usually constipated, especially in the early stages; and it is said that pur- 
gatives sometimes act with great difficulty. This, however, does not corre- 
spond with my own observation. I have seldom found much difficulty in 
procuring free alvine evacuations, though it must be acknowledged, that the 
bowels are much less readily operated on by medicines than in the enteric or 
typhoid fever. The stools are generally disordered, sometimes dark-coloured 
and offensive, sometimes showing a deficiency of bile, but more commonly 
bilious, with some shade of yellow, green, or black. At a somewhat advanced 
period of the complaint, a bilious diarrhoea not unfrequently sets in, and 
dysenteric symptoms sometimes make their appearance. In some instances, 
looseness of the bowels exist from the commencement; and, as vomiting is 
apt to be present at the same time, the complaint is ushered in with a kind 
of cholera morbus. If worms exist in the bowels, they are generally dis- 
charged. 
The urine is scanty, nnd often yellowish-brown, or reddish and turbid, and, 
in the latter stages, of a dark reddish-brown colour. Early in the • disease, 
and in all stages when the paroxysmal form is very distinct, it has a tendency 
to become more copious in the remissions, and, though clear upon being dis- 
charged, to deposit a lateritious sediment upon cooling. 
One of the most striking characteristics of the disease, though not present 
in all cases, is a yellowish hue of the skin and of the white of the eyes. This 
sometimes makes its appearance at the beginning, but more frequently not 
till about the third or fifth day of the disease. It is often uniform over the 
whole body, and before the close is sometimes very intense. In some bad 
cases, it assumes a dark or bronzed hue. Occasionally the yellow matter is 
secreted upon the surface, so as to stain yellow a white handkerchief when 
rubbed upon the skin. It is said to be less intense, as a general rule, in those 
cases in which there is a copious bilious diarrhoea. Under the .same circum- 
stances, the urine is usually of a very dark yellowish-brown colour. 
The nervous system also participates strongly in the disease. No symptom 
is more common or constant than headache. Xevy frequently it begins with 
the fever, and, though moderated in the remissions, does not wholly leave 
the patient during its continuance, unless removed by remedies. Along with 
the headache there is frequently vertigo, with singing or roaring in the ears; 
and occasionally intolerance of light or sound, beating of the carotids, redness 
of the conjunctiva, flushing of the face, &c., indicating a strong vascular 
determination to the brain, if not positive meningitis. The throbbing head- 
ache of the first paroxysms generally settles into uniform dull sensation as the 
disease advances; and the violent pains in the back and limbs become more 
moderate, or cease. Delirium, though not very frequent at the commence- 
ment as the disease ordinarily appears, is now apt to set in; generally, how- 
ever, not with severity, showing itself rather by a confusion of thought, 
especially when the patient wakes from sleep, than by any violence of action 
or speech. Sometimes there is drowsiness or stupor, sometimes apoplectic or 
paralytic symptoms, and sometimes also tetanic spasms; but the two latter 
sets of symptoms are rare. I have-seen a case of decided palsy of one side 
of the body, which yielded immediately to a copious bleeding. Another not CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
255 
unfrequent disorder of the nervous system is obstinate wakefulness, with rest- 
lessness and jactitation; and these may occur even in moderate forms of the 
disease. Hiccough is an occasional and very troublesome symptom, sometimes 
appearing early, but in general not till near the close. 
Such are the symptoms which attend bilious fever when fully formed, and 
in the middle or somewhat advanced periods of its course. The student must 
bear in mind, that they are not all present in the same c3.se; indeed, some of 
them are mutually incompatible, and cannot therefore exist together; but all 
of them are so often to be met with, that they could not be omitted in an 
account of the complaint. Various other incidental phenomena occur, which it 
is unnecessary to mention, as they are in no respect peculiar, and may take 
place in almost any febrile disease. 
If the disease retain a distinct paroxysmal character, it generally runs on, 
when not interrupted, for two or three weeks, or more, terminating at last 
either by spontaneous solution at the end of one of the paroxysms, which 
goes off usually with a more than ordinarily profuse perspiration, or in a 
regular intermittent, or in a kind of low typhoid affection such as I shall 
describe directly. 
If, as is more common in the somewhat severe cases, it approach the con- 
tinued-form, it generally advances, with more or fewer of the symptoms above 
enumerated, to some point of time between the seventh and fifteenth days, 
when it either declines, or ends fatally, or takes on a new character. When 
it is to terminate favourably, it either declines slowly from the culminating 
point, with a gradual subsidence of all the symptoms; or ends abruptly with a 
profuse perspiration, or with the occurrence of diarrhoea or diuresis; or changes 
into the intermittent form. The first and the last of these modes of termina- 
tion are, perhaps, the most frequent. The first signs of a favourable change 
are usually a steady diminution in the frequency of pulse; a return of moisture 
to the tongue, with an obvious disposition in the fur to withdraw from the 
tip and edges; and a softer, moister, and cQoler state of the skin. The one 
most to be relied upon, is probably the gradual cleaning of the tongue from 
its end and borders. Along with these signs of amendment, all the other 
phenomena of the disease gradually subside, and the patient enters into a con- 
valescence which is apt to be permanent. When the disease goes off with a 
profuse perspiration, it has been observed that this is sometimes offensive to 
the smell. The diarrhoea, which occasionally appears to take the place of 
the perspiration, is usually bilious. Copious black tar-like discharges some- 
times occur towards the close of severe bilious fever, and are considered as-a 
favourable sign, especially in cases which have been attended with congestion 
and torpidity of the liver. A vesicular eruption upon the lips is apt to occur 
about the period of convalescence, and is also regarded as favourable. 
In the immense majority of cases of bilious fever, recovery takes place in 
one of the above modes. But, in consequence of exhaustion following excess 
of excitement, or of disorganization produced by inflammation, or possibly 
from a loss or depravation of the vital properties of the blood, death frequently 
ensues in bad, and badly managed cases of the disease. Instead of the favour- 
able symptoms above mentioned, as indicative of convalescence, others of an 
alarming character make their appearance. The pulse becomes more frequent, 
and at the same time smaller and more feeble, till at length it can scarcely be 
felt, and sometimes ceases entirely at the wrist some hours before death; 
coldness, beginning in the hands and feet, gradually extends upwards through 
the limbs, and even invades the trunk; the skin assumes a dusky, livid, or 
purplish hue, or, if yelloW previously, becomes of a dark almost bronzed ap- 
pearance; the extremities arc covered with a clammy sweat; the tongue is 256 
GENERAL DISEASES.-EEVERS. 
[part II. 
dark-brown, clammy or dry, and sometimes chapped; hiccough not unfre- 
qucntly occurs, sometimes with eructation of dark matter from the stomach; 
the abdomen is often tympanitic; black liquid matters, or dark blood, dr a 
reddish serum like the washings of flesh, arc discharged) often involuntarily, 
from the bowels; the urine is dark-brown, fetid, and scanty, or quite sup- 
pressed; the features are collapsed, and the eyes often of a turbid or muddy 
appearance; low delirium, followed by stupor or coma, takes place; and 'the 
patient passes, usually without consciousness, into the dying state. Death, 
under these circumstances, generally occurs between the seventh and four- 
teenth days of the disease. 
In not a few cases, however, instead of following either of the courses above 
indicated, the disease, somewhere from the ninth to the twelfth day, takes on 
a new character, very much resembling that so frequently met with in enteric 
fever. All regularity in the recurrence of the paroxysms now generally Ceases. 
The pulse becomes very frequent, often rising to 120 in , the minute, and. 
sometimes reaching or even exceeding 140, while it is small and rather feeble. 
The skin is dry, and either universally hot, or cold in some places and hot 
in others. The tongue is dry or dryish, often contracted, and of a brown or 
blackish colour. Sordes often collect about the teeth, tongue, and lips. The 
sufferings from nausea, vomiting, and headache, diminish or cease. The 
bowels, though in some cases costive, are in others loose, with unhealthy dis- 
charges, dark, bloody, or dysenteric. The urine is scanty or suppressed, or is 
retained, producing sometimes great distension of the bladder. Stupor or 
low delirium, with subsultus tendinum, picking of the bed clothes, slipping 
down in the bed, &c., supersedes the former cephalic symptoms. Not unfre- 
quently the patient thinks himself in a strange place, and, insisting upon 
returning home, sometimes rises from his bed, and sinks exhausted upon the 
floor. At length, if relief is not obtained, profound coma sets in, the pulse 
sinks to nothing, the surface becomes cold, the countenance assumes the Hip- 
pocratic expression, and death speedily follows. When the fever takes on the 
character here described, it is often much protracted; sometimes running on 
for three or four weeks, or even longer. But, even in this form, it is very 
frequently curable. When it is about to take a favourable turn, the tongue 
becomes somewhat moist, and often, instead of cleaning from the edges and 
tip, throws off its fur in flakes first from the middle,-or indifferently from any 
portion of the surface, which is left red and smooth, as if deprived of its papil- 
lary structure. Under these circumstances, convalescence may be expected, 
though it is always rather slow. In other cases, the tongue cleans in the 
ordinary manner, and then fee may look for a more rapid recovery. Other 
favourable symptoms are the subsidence of delirium, the return of conscious- 
ness, and a more healthy condition of the various secretions.- But the pulse 
often remains frequent for a considerable time after convalescence has com- 
menced; febrile exacerbations occasionally take place; and the patient sweats 
much during sleep. Gradually, however, the system regains strength, the 
mischief done to the various organs is repaired, and health is at length firmly 
re-established. Even this form of the fever sometimes ends in intermittent, 
and thus proves that it was not, what it might otherwise be thought to be, a 
pure case of enteric or typhoid fever. 
Modifications.-1The above description applies to bilious fever in its ordinary 
forms. But few diseases are more protean in their character than this. It 
would be utterly impossible, within the limits to which we are confined, to 
detail the various appearances described by authors, as exhibited by the dis- 
ease in different places, and under different circumstances. I shall briefly 
allude to a few of the more prominent varieties; merely premising, that in all CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
257 
of them there are evident, in some of the cases, certain signs, either full 
blown, or as it were embryo tic,which mark the disease as miasmatic or bilious 
fever; more especially gastric irritation, yellowness of the skin, and a tend- 
ency to the regular paroxysmal form. 
Sometimes the disease starts at once into existence with alarming violence. 
After a slight chill, or without any chill whatever, the patient may be seized 
with excruciating pains in the head, back, and limbs, a feeling of stricture 
across the chest, exquisite suffering in the epigastrium, incessant and enormous 
vomiting of bilious matter, by which the head is somewhat relieved, unquench- 
able thirst, and quickly supervening yellowness of the skin and eyes; the 
pulse being either frequent or slow, and the skin hot or cool, without mate- 
rially affecting the condition of the case. Persons similarly exposed with 
those attacked as above, are occasionally seized with violent delirium at the 
very outset, rendering them dangerous to others and to themselves. Seamen 
on board ship endeavour to jump overboard, though this may possibly be less 
from a disposition to self-destruction, than from an instinctive tendency to 
seek relief in the water. Sometimes the delirium is followed and relieved by 
the occurrence of the gastric symptoms already- mentioned. After an uncer- 
tain duration, the violence of the attack subsides, and a remission follows, 
which gives way in its turn to a second paroxysm, and so on to the end. 
Notwithstanding the fierceness of the access, the disease frequently yields to 
remedies with great facility. 
In the form of the disease above referred to, though there is great func- 
tional disorder in the encephalon, the stomach and liver appear to be the real 
centre of attack. In another form, it expends .almost its whole force upon the 
brain. The patient is seized with coma, resembling almost precisely an apo- 
plectic attack, though without paralysis. The face is red and turgid, the 
carotids throb, the pulse is full and strong without being very frequent, the 
respiration is slow and sometimes stertorous, and the pupils usually dilated. 
All the symptoms are those of strong determination of blood to the brain. 
After a certain continuance, a remission takes place, and the patient recovers 
his consciousness, to fall again at the regular period into the comatose condi- 
tion. It is generally by the remission alone that the nature of the disease 
can be ascertained. Sometimes death ensues from disorganization of tlie 
brain. Sometimes a collapse takes place, with symptoms such as. those al- 
ready enumerated in fatal cases of bilious fever. The disease, however, often 
yields to energetic treatment. Occasionally there is paroxysmal stupor alone, 
without apoplectic symptoms. 
Another and most frightful form of bilious fever is the collapsed condition, 
generally known in this country by the name of congestive fever, which will 
be treated of under a different head. It may be proper, however, to observe, 
in this place, that an ordinary attack of bilious fever may, without warning, 
take on the form called congestive; and, unless the practitioner is prepared 
for the event, will almost certainly prove fatal. The great danger is, that 
when the patient is raised, perhaps, with great effort, out of the paroxysm into 
which he has fallen, the practitioner may consider the amendment as the be- 
ginning of convalescence, and thus omit the measures necessary to ward off 
the death which is approaching with the subsequent paroxysm. The fact is 
mentioned here, in order that the young practitioner may be put upon his 
guard. Whenever, in bilious fever, a paroxysm occurs, of peculiar severity 
and danger, it should always be looked upon, when receding, as doing so only 
in order to return with increased and perhaps fatal violence. It does not fol- 
low, that it necessarily must return in this manner; but it is always safest 
thus to regard it. 258 
GENERAL DISEASES.-FEVERS. 
[part II. 
Bilious fever is often greatly modified by accompanying inflammation of 
one or more of the important organs. Perhaps the stomach is the one most 
frequently attacked. It is rare that a fatal case of bilious fever occurs, with- 
out some sign of gastric inflammation. The most striking evidences of such 
a condition during life, are burning pain in the epigastrium, tenderness on 
pressure, and obstinate vomiting. Inflammation of the bowels is not uncom- 
mon. It occurs most frequently in the advanced stages, and is indicated 
by diarrhoea, tympanitic distension of the abdomen, and, when the sensibility 
of the patient is unimpaired, by colicky pains, and some tenderness on pres- 
sure. Dysentery is, in some seasons, frequently associated with remittent 
fever. The liver, though always functionally deranged, is not often inflamed. 
Hence, there is seldom pain upon pressure in the right hypochondrium, though 
this does occur in some cases. The spleen is occasionally painful and consi- 
derably swollen, as shown by the dulness on percussion below the margin of 
the left short ribs. Inflammation of the lungs is not common in autumnal 
fevers; but the pneumonia, which follows these fevers in the winter, is very 
apt to be complicated with symptoms of miasmatic origin. The probability 
is that, in some at least of these cases, there is a conjunction of pneumonia 
and bilious fever. The encephalon is often inflamed in some one of its parts. 
Most frequently, the membranes are affected; and then we have severe head- 
ache, active delirium, vertigo and tinnitus aurium, intolerance of light and 
sound, and often contracted pupils, ending, if not relieved, in coma, and at 
length in great and fatal prostration. Occasionally, though much more rarely, 
the substance of the brain is separately the seat of inflammation. This may 
be suspected, when there is original and persistent stupor or coma, without 
typhoid symptoms. Sometimes, severe rheumatic pains are coincident with 
bilious fever. I have known a patient with this disease to be confined for 
many days to one position upon his back, without the possibility of moving 
his body, in consequence of rheumatism of the muscles of the trunk. Under 
such circumstances, the spinal marrow may be suspected to be in fault. 
Bilious fever is sometimes of a low, adynamic, or typhous character from 
the commencement. This may be the result of a previous exposure to causes 
calculated to depress the vital powers, and to deprave the blood; but it pro- 
bably most frequently arises from the co-operation of a typhoid epidemic 
influence with miasmata. In such cases, connected with more or fewer of 
the characteristic symptoms of bilious fever before enumerated, are, at a com- 
paratively early period in the disease, a dark and dryish tongue, with sordes 
about the gums and teeth; dark al vine evacuations, becoming in the end in- 
voluntary; flatulent distension of the abdomen; irregularity of respiration; a 
pulse either frequent or slow, slender or full, regular or irregular, but always 
feeble and readily compressible, and sometimes almost fluttering; a strong 
tendency to passive hemorrhage, as shown by oozing of blood from the gums, 
discharges of dark blood from the bowels, and petechias and vibices upon the 
skin; a dusky, livid, or purplish hue of the surface, often combined with the 
yellow of the bilious disease; irregular distribution of heat over the body; 
and the early occurrence of low delirium, stupor, or coma, or, in their absence, 
of great restlessness, jactitation, anxiety, and mental depression. 
Authors have made varieties of bilious fever founded on the predominance 
of certain local symptoms, as the gastric, when the stoinach is especially 
involved, and the hepatic when the liver is supposed to be prominently 
affected; but upon the same basis we might erect many other varieties, as the 
cerebral, the pulmonary, the intestinal, &c. This is a quite unnecessary 
complication of nomenclature, and might lead to the erroneous conclusion, 
that there was something essentially different in the character of the affections. CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
259 
Duration.-The average duration of bilious fever, in all its forms, may be 
stated at about fourteen or fifteen days. It sometimes ends as early as the 
fifth or seventh, often about the ninth or eleventh day; and is sometimes 
greatly protracted,, even to four weeks or more. In malignant cases, it some- 
times destroys life as early as the third day or even earlier; but such instances 
are comparatively rare. Under appropriate treatment, it is often much short- 
ened. ( ■ * A . . 
Convalescence.-In mild cases, the convalescence is often rapid and in all 
respects favourable. But in the severer cases, in which considerable organic 
injury has been inflicted on the system, or the vital functions have been 
greatly perverted or prostrated, the return to health is not unfrequently 
through a course of varied, and sometimes of very protracted suffering. The 
pulse remains frequent, the tongue more or less furred, especially about the 
root, the appetite languid, the digestion imperfect, and the bowels disposed to 
constipation or looseness. Copious sweats at night annoy the patient, and 
serve to maintain the weakness in which they originate. The nervous system 
is often deranged, as evinced by wakefulness or disturbed sleep, hypochon- 
driacal notions, depressed spirits, neuralgic pains, &c. Sometimes enlarged 
spleen, and diseased liver are left behind, giving rise to dyspeptic symptoms, 
jaundice, dropsy, and various bowel disorder. When the appetite returns it 
is very often voracious, and much caution is necessary to guard against over- 
tasking the yet feeble organs of digestion. Relapses are not uncommon. 
Anatomical Characters.-As might be anticipated from the symptoms of 
the disease, various organs are often found, in different cases, to present signs 
of inflammation after death. Mucous gastritis is probably the most frequent 
lesion, and is discovered, in a greater or less degree, in most of the cases 
examined. But it is asserted to be sometimes wanting, and frequently so 
moderate in degree, as to be altogether insufficient to account for the phe- 
nomena.of the disease. 
The mucous membrane of the bowels is also often inflamed. Dr. Steward- 
son observed that the mucous glands of Brunner in the duodenum were 
developed in an extraordinary degree; but this is not a uniform lesion. 
Ulceration in the track of the bowels has also been noticed; but, of the 
numerous cases examined by Drs. Gerhard, Stewardson, and Swett, not one 
was found to exhibit inflammation and ulceration of the elliptical patches of 
Peyer's glands, such as characterize the enteric or typhoid fever. It is true, 
that this lesion is. said to have been noticed by others; but the accounts we 
have seen are too vague to be considered as authoritative. It is necessary to 
the ibrmation of a proper judgment, that the course and symptoms of the 
case examined should be minutely recorded, at least sufficiently so to enable 
us to decide upon the nature of the disease. There is reason to believe, that 
cases of true enteric fever have sometimes been mistaken for bilious or remit- 
tent fever, and lesions belonging to the former, placed to the account of the 
latter. 
Signs of inflammation of the membranes of the brain, and of congestion of 
that organ, have been not unfrequently noticed. Sometimes also the lungs 
have been found inflamed, and still more frequently congested. The heart is 
sometimes softened and flaccid. But there is nothing peculiar to remittent 
fever in these phenomena. 
The liver is often enlarged, and generally more or less softened; but un- 
equivocal marks of inflammation are seldom found. The most striking phe- 
nomenon revealed by dissection is a complete loss of its natural reddish-brown 
colour, and the substitution of a bronze or slate colour, or of both variously 
mingled, upon the external surface of the organ, and of a uniform olive or 260 
GENERAL DISEASES.-FEVERS. 
[part II. 
light bronze upon its cut surfaces. The distinction between the lighter and 
deeper colours in the interior structure of the organ, existing in health, is no 
longer observable, or at least is much diminished. This alteration of colour 
was first distinctly described by Dr. Stewardson, of Philadelphia, in a paper 
published in the American Journal of Medical Sciences, for April, 1841 
(vol i., n. s., p. 289); and has since been noticed by other observers, among 
whom may be particularly mentioned Dr. Swett, of the New York Hospital 
(Ibid., ix. 29), and Drs, Anderson and Frick, of the Baltimore Almshouse 
Infirmary (Ibid., xi. 312). It was found in all the fatal cases of remittent 
fever examined by these physicians, and may be regarded as one of the cha- 
racteristics of the disease. It may possibly depend, as suggested by Dr. 
Stille (Ibid., p. 323), upon a distension of the biliary ducts with bile, and of 
the venous ramifications with blood; and this congestion will account also for 
the frequent enlargement of the organ. It should be stated that Dr. Boling, 
of Montgomery, Alabama, denies having met with this change of colour, in 
most of the cases which he has examined of fatal bilious fever, occurring in 
his vicinity. In a large proportion of cases, so far as he was able to judge, 
"the organ was entirely healthy;" and, when otherwise, it was only the con- 
cave surface that had changed colour, this being of a "uniform bluish-slate 
colour extending to about the depth of a quarter of an inch," with a well 
defined line of demarcation separating it from the unaltered part. (Ibid., xii. 
53.) Dr. Boling gives no detail of the symptoms, during life, of the particular 
cases of which he made post-mortem examinations. In almost all the cases, 
in which the state of the gall-bladder has been noted, it was found full of a 
dark, sometimes almost black, viscid bile, not unlike molasses in colour and 
consistence. 
The spleen is almost always enlarged, often to four or five times its 
healthy dimensions, or even more. It is also generally softened, so much 
so, in many instances, as to be pultaceous, and to resemble loosely clotted 
blood. Sometimes its colour is black, sometimes reddish, like the lees of red 
wine. 
The blood in bilious fever, as drawn near the commencement of the dis- 
ease, generally coagulates without presenting the huffy coat. At a more 
advanced stage, however, it often becomes buffy, and even cupped, probably 
in consequence of the developement of inflammation. Dr. Frick, of Balti- 
more, found the fibrin above the average of health in four out of five cases 
examined by him, and the red corpuscles to be increased in all but one. (Am. 
Journ. of Med. Sci., N. S., xv. 30.) Meli discovered, in the blood of bilious 
fever, a considerable quantity of the colouring and fatty principles of the bile. 
(Diet, de Med., xv. 284.) In violent cases, it has been found partially dis- 
organized, the colouring matter being diffused through the serum, and not 
separable by filtration. In malignant and typhous cases, it has sometimes 
been found black, and either wholly or partially uncoagulable. 
Causes.-The essential cause of bilious1 remittent is probably the miasma 
which proceeds from marshes, &c. Many believe that, while produced by 
this cause, it may also proceed from others, especially a high degree of heat 
combined with moisture. If this were the case, why should we not see it 
originating in the midst of our cities, where the heat is intense, and moisture 
often abundant ? Why does it not occur constantly among seamen, navigating 
equatorial seas, whether long from port or not ? The fact is well known, that 
the crews of ships within the tropics remain free from the disease, so long as 
they keep at a certain distance from the shore. They may be affected with 
scurvy, dysentery, diarrhoea, and various phlegmasia); but they escape bilious 
fever. Let them, however, approach a miasmatic coast, and it often happens, CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
261 
that almost the whole crew are seized with the disease. They are also often 
affected with it after leaving port, until the period during which the cause 
may be latent in the system is passed. It is true' that instances are on re- 
cord, in which the disease is asserted to have raged fearfully in barren islands, 
with little vegetation upon their surface, and offering no possible source of 
these poisonous effluvia. But our information on these points is generally too 
vague to be relied on. We do not know whether some lurking source of 
miasmata may not exist, and have escaped a careless search. We cannot by 
any means be certain that the diseases alluded,to were, in all instances, really 
bilious fever. They may have possibly in some instances been yellow fever, 
which has often been Confounded with the bilious; they may have been in 
Others merely gastro-hepatic or cerebral inflammations, or these mingled with 
a diseased condition of the blood, arising from impure and confined air, or 
other causes such as occasionally produce typhus fever.* It so frequently 
happens that communities escape bilious fever, though long exposed to exces- 
sive heat, if unattended with vegetable decomposition, and so seldom escape 
it entirely, when the latter cause is conjoined with the former, that the few 
irtstances which have been adduced in contravention of the rule, cannot but 
be looked upon with some suspicion- at least, the inference is justifiable, that 
they might probably be reconciled to the rule, were all the circumstances 
accurately known. 
There cannot be a doubt, that remittent fever results from the same cause 
as the intermittent; The former probably occurs preferably to the latter, 
when the cause is highly concentrated and powerful, or the system of the 
patient peculiarly susceptible. Hence, intermiftents are more common, rela- 
tively, in the cooler latitudes, at the commencement oi- near the close of the 
sickly season, in situations least exposed to the access of the poison, or when 
its source has begun to fail, and in persons who, from residence in miasmatic 
regions, are in some measure protected against it. Remittents; on the con- 
trary, prevail most in hot climates, in the midst of the sickly season, in places 
where the exhalations are most abundant and have the best opportunity to 
het, and among individuals least protected by habit against their influence. 
(See Miasmata, page 139.) ' 
Remittents sometimes appear to prevail epidemically, spreading over wide 
districts of country, which had previously been exempt. But, even under 
these circumstances, it is probable that the essential cause is the same. Cer- 
* Cases of this kind occurred in the city of Philadelphia, in the year 1821. The dis- 
ease was confined to the black population of one of the filthiest portions of the city, and 
occurred at the commencement of the severe heats. It was of a most malignant charac- 
ter, and often carried off the patient on the fifth arid sixth day. Alopg with the chili 
and. subsequent reaction, common to all febrile diseases, there was a severe burning pain 
in the epigastrium, with great tenderness at the commencement .of the disease; and the Signs 
of gastric disorder were usually prominent throughout, But, along with this, were great 
depression of system, and the ordinary typhous, symptoms of a dark tongue, low delirium, 
subsultus tendinum, coma, &c. Bilious vomiting and purging were very frequent; and 
a yellow or muddy appearance of the conjunctiva not uncommon. A vomiting of black 
matter sometimes preceded death. Dissection revealed inflammation of the stomach, 
duodenum, and bowels; and the blood was in one instance completely disorganized, and 
incapable of coagulation. That this was not bilious fever, though attended with yellow 
eyes and bilious evacuations, and though the fever usually remitted somewhat in the 
first 24 hours, is evinced by the considerations, that it occurred in the beginning instead 
of the close of Summer, among the blacks instead of the whites, and was in no case fol- 
lowed by an. intermittent. It is very possible that such affections as the above, occur- 
ring in crowded garrisons, in hot climates, may have been mistaken.for npalignant bilious 
fever. See an account of the epidemic by Dr. G. Emerson, in the Philad. Journ. of the 
Med. and Phys. Sciences, iii. 193. 262 
GENERAL DISEASES.-FEVERS. 
[part II. 
tain seasons appear to favour the clevelopement of miasmata; and a strong 
proof that, even in apparent epid'emics, it is really these emanations that act 
is, that the disease still occurs in the latter part of summer, and in the au- 
tumn. We do not hear of epidemics Of remittent fever in the winter. It 
has been observed that seasons in which long-continued drought, sufficient to 
destroy vegetation, is followed by great heat and rains, and those in which 
long-continued rains are followed by very hot and dry weather, are favourable 
to the prevalence of remittent fever. 
But there is no doubt that,, as in intermittents, various causes may excite 
the disease sooner than it would have occurred under the influence of the 
miasmata alone, and that, with the aid of certain other causes, miasmata will 
often produce the disease, when it might have failed without them; but, in 
all cases, the miasmatic influence is necessary. In relation to these co-operat- 
ing causes, it is unnecessary to add anything to what has been already'said1 
under intermittent fever. They are precisely the same in the two affections. 
It is a singular fact, that the negro, though not entirely exempt from 
miasmatic fever, is. much less liable to it, and, when attacked, suffers less 
from it, as a general rule, than the white. Hence, the coast of Africa, which 
is so fatal to persons of our colour, is favourable to the negro; and the latter 
lives and works in the rice fields of Carolina, at seasons when a single night 
spent among them would be death to his master. Persons who dwell in 
miasmatic districts, are much less susceptible to the disease than strangers 
who incidentally visit them; and, after complete recovery from one attack of 
remittent fever, the visitor acquires, in a certain degree, the same comparative 
insusceptibility, or, in other words,-becomes in some measure acclimated. 
The period at which the disease occurs, after exposure to the cause, is very 
different in different cases. Instances are said to have happened, in which 
the poison has been so concentrated and powerful as to produce its effects 
immediately. Generally, however, it lies apparently dormant for a period 
varying from pne to two weeks, and sometimes- much longer. It is no un- 
common event for persons, coming into our northern cities from miasmatic 
regions, to be attacked with remittent in the winter, though they may have 
escaped during the previous summer and autumn. I have repeatedly witnessed 
such cases among the students of medicine, who attend the Philadelphia schools 
in the winter. v 
Nature,-The opinion which referred all the phenomena of bilious fever to 
gastritis scarcely requires to be combatted, now that it no longer meets with 
supporters. Another and more plausible view is that which considers the 
disease as the supcraddition, to intermittent fever, of acute inflammation of 
one or more of the organs, especially the stomach, liver, or brain. A constant 
symptomatic fever is sustained by the inflammation, which is-conjoined with 
that of the intermittent disease during the paroxysm, but exists alone in the 
remission. It is highly probable that cases of this kind do occasionally 
occur; that an intermittent does sometimes assume the appearance of a remit- 
tent, by the intermixture of one of the, , phlegmasia?. But that remittents 
generally are not of this character* is evinced by the fact, that in many 
instance's no inflammation whatever can be shown to exist early in the dis- 
ease, even when the fever is most continuous; and That, when gastritis or 
encephalitis occurs, it is almost always as a secondary disease, making its 
appearance several days after the commencement of the attack. Not unfre- 
quently, indeed, mild cases run their whole course, without signs of any local 
affection sufficient to induce fever. 
Some consider remittent fever as identical with the enteric or typhoid fever; 
but it is difficult to conceive how this opinion can be entertained by persons CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
263 
familiar with the symptoms and course of the two affections. In their marked 
and characteristic forms, they are strikingly different; as will be shown when 
the latter disease is especially treated of. It is true that there are cases of 
remittent fever, which, at certain periods of their progress, are not readily dis- 
tinguishable from the enteric. Such, especially, are those in which bilious 
fever assumes a typhoid form in its advanced stages. But it is not impossible, 
and, as appears to me, not improbable, that the two diseases sometimes co- 
exist. The causes of both, operating at the same time, may be readily sup- 
posed to produce a sort of mixed or mongrel affection; and this may be the 
case with the form of bilious fever just referred to. 
Miasmatic fever differs from other forms of fever, in consequence of some- 
thing peculiar in the operation of its cause. What this peculiarity is, cannot 
be certainly determined, in the present state of our knowledge. The informa- 
tion derived from post-mortem examination does not greatly aid us. The 
lesions are the same as those frequently met with in other febrile diseases. 
Inflammations of the stomach, the bowels, the brain, &c., are common attend- 
ants on fevers. Nor is the softening of tissue, as of the gastric mucous 
membrane, the heart, the liver, and the spleen, which has been noticed in 
fatal cases of bilious fever, peculiar to that disease; It is found wherever the 
blood has become so depraved as to be unable properly to support the nutrition 
of the organs. The only peculiarity which has been discovered is the colour 
of the liver. How far this may be connected with the peculiar and distinctive 
pathology of the disease, it would not be easy to determine. Tt is probably 
the result of an over-production of bilious matter in the system; and this 
would appear to be one of the direct and peculiar effects of the cause. It is 
not in bilious fever, as in jaundice, that the liver does not act, and that the 
biliary principles being thus prevented from escaping by their usual outlet, 
accumulate in the blood, and are then thrown off by the skin. . On the con- 
trary, though there may be cases in which the liver is congested beyond the 
power of -secretion, yet, in the great majority, that organ acts even more 
vigorously than in health, as is evinced by the bilious vomiting, bilious stools, 
and abundance of bile found in the gall-bladder after death. Whence then 
proceeds the yellow colour of the surface, and the jaundiced condition of the 
urine? • Undoubtedly, from an excessive production of the biliary principles 
in the blood. These principles have been detected in the blood by chemical 
examination. They are produced in it probably through the agency of the 
cause, and, being injurious in this excess, seek an escape through all the 
emunctories, not the liver only, but the skin, kidneys, and possibly also the 
mucous membranes. Still, this excess of bilious matter in the blood is only 
•one of the peculiarities of the disease. It cannot be the only one; for such 
an excess frequently exists without prodiicing remittent fever. Can its 
elimination from the blood have anything to do with the cure or prevention 
of the disease? Can it be in thi^ way that calomel acts? Very often an 
attack of remittent fever is preceded by symptoms of epigastric uneasiness, 
which indicate portal congestion. There is some reason to think, that a spon- 
taneous attack of cholera morbus at this period, or the somewhat similar 
operation of a full dose of calomel, occasionally prevents the developemcnt of 
the fever. Can it be by carrying out of the system the excess of the biliary 
principles, which may have been accumulating in the blood, and which may 
have been stimulating the liver for a, time beyond the secreting point, that 
the agents alluded to produce the effect ascribed to them ? Perhaps, in thus 
turning our attention to the blood, we are entering upon a track which may 
at length lead us at least nearer to the truth. The peculiar disposition of the 
morbid effects of miasmata to assume the regular paroxysmal form remains 264 
GENERAL DISEASES.-FEVERS. 
[PART II. 
to be explained. Nothing at present known yields us the least aid upon this 
point. We may consider, as the source of periodicity, the diurnal changes 
in our system consequent upon the alternation of sleeping and waking; but 
we ,can give no reason why miasmata should elicit the effect more than any 
other cause. 
Diagnosis.-Little need be said upon this subject here. The diseases with 
which bilious fever may be most readily confounded will be treated of here- 
after ; and the means of diagnosis will be better understood, after the reader 
has become acquainted with their symptoms. Besides intermittent, of which 
enough has been already said, the complaints which are most likely to be 
confounded with bilious fever, are the enteric and yellow fevers. To these 
the reader is referred. But there are certain phlegmasia) with which the 
disease might, without care, be similarly confounded. Such especially are 
gastritis and duodenitis, when connected, as they often are, particularly the 
latter, with functional disturbance' of the liver. Here the. paroxysmal form 
of bilious fever comes to our aid, and very frequently of itself enables us to 
reach a just conclusion. The following may be considered, in a general way, 
as the most characteristic phenomena, of remittent fever;-1, the regular pa- 
roxysmal character, and disposition to begin and to end in intermittent fever; 
2, the epigastric uneasiness and irritability of stomach, so prominent in many 
instances throughout the complaint; 3, the almost constant symptom of pain 
or uneasiness in the head; and 4, the evidences of excess of bilious produc- 
tion, exhibited in the vomiting and purging of bile, the yellow skin and eyes, 
and the jaundiced urine. But the student must be upon his guard not to 
expect all these symptoms in every case of the disease. Other circumstances, 
which will materially aid the diagnosis, are the season of the year, the place 
where the disease may have been contracted, the exposure of the patient, and 
the length of time that may have elapsed since the exposure. Thus, if the 
fever appear in August or September, originate in a miasmatic district, and 
make its appearance. from one ter three weeks after the patient has been ob- 
viously exposed to miasmatic influence, the inference would be very much in 
favour- of the conclusion, that it is a bilious remittent. 
Prognosis.-This is generally favourable. The milder forms of the disease 
almost always end in recovery unless abused, and the severest often yield to 
prompt and suitable treatment. There is, perhaps, noHisease, in which the 
resources of our profession are more happily displayed than in the worst forms 
of bilious fever. Fearfully fatal under neglect or mismanagement, they may, 
in the great majority of cases, be conducted by proper treatment to a favoura- 
ble issue. 
Simple cases are usually less dangerous than such as are complicated with 
inflammation; those distinctly paroxysmal than the more continuous; and 
those attended with a vigorous or sthenic state of system, than the low, typhous, 
or malignant. In acclimated persons, the danger may generally be considered 
less, other circumstances being equal, than in the unacclimated; in the negro 
than in the white; in the temperate than the intemperate; in.those previously 
healthy, than in the diseased and debilitated. Signs of an approaching 
favourable change are a short or postponed paroxysm, a greater or longer 
remission, the occurrence of perspiration as the fever subsides, a disposition in 
the tongue to clean, and a general diminution of the other symptoms, as the 
frequency of pulse, heat of skin, headache, and gastric irritation. The oppo- 
sites of these signs are of course unfavourable, but do not by any means uni- 
formly indicate great danger. Among, the really alarming and often fatal 
symptoms, are great frequency of pulse, permanent coldness of the surface, 
low delirium or coma in the advanced stage,, excessive subsultus, hiccough CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
265 
with eructation of black matter, hemorrhage from the bowels, involuntary- 
evacuations, suppression of urine, and the Hippocratic countenance. 
Treatment.-It does not often happen that we see the patient in the cold 
stage; which, moreover, is in general too brief, and in .other respects incon- 
siderable, to require treatment. Sometimes, however,. it is unusually pro- 
longed, and the system unusually depressed, so. that the intervention of 
remedies becomes desirable. Under these circumstances, the case may be 
treated in the manner recommended in the cold stage of intermittents. 
After reaction, attention should, as a general rule, be first directed to the 
alimentary canal. At one time, it was strongly recommended to begin the 
treatment with an emetic; and many still adhere to the practice. But, though 
in some instances this class of medicines appears to exercise a favourable in- 
fluence upon the fever, moderating the. frequency of pulse and heat of skin, 
and calming cerebral excitement, yet, in others, it aggravates existing irrita- 
tion of stomach, and perhaps determines the supervention of gastritis. This 
danger is generally thought to outweigh the probable advantage, and emetics 
have, therefore, fallen into comparative disuse. There is, however, one con- 
dition, early in the disease, which occasionally justifies and even demands 
their employment. Allusion is had to the presence of irritating, substances 
in the stomach. These produce all the evil effects of emetics, and more con- 
tinuously. The indication, therefore, for their evacuation is obvious. The 
offending matters are undigested substances that may have been swallowed, or 
acrid accumulations in the stomach from chemical change, perverted secretion, 
or regurgitation. The former may be supposed to exist when the attack has 
come on very shortly after a full meal, or after indulgence in unwholesome 
food or drink. The presence of the latter is indicated by a feeling of epigas- 
tric oppression, severe nausea, and frequent but ineffectual efforts to vomit; 
the patient now and then discharging a mouthful of very sour or sharp colour- 
less fluid, or of bitter and acrid bile. In either case, a gentle emetic is of 
great use, sometimes putting an end at once to the oppression, sickness of 
stomach and retching, and either preventing gastric inflammation, or causing 
it to be less severe.* Ipecacuanha is generally preferable, for this purpose, 
to tartar emetic, as it accomplishes the same object with less irritation. The 
emetic should be assisted by draughts of warm water, or warm chamomile tea, 
which serve more effectually to cleanse the'stomach. But, should the signs 
be those of existing gastritis, as burning pain in the epigastrium, tenderness 
on pressure, and the discharge merely of drinks that may be swallowed, an 
emetic could do nothing but harm. In the great majority of cases, it maybe 
safely and perhaps advantageously dispensed with. 
An active cathartic is almost always indicated. Either the portal circula- 
tion, including that of the liver, is congested, or the bowels are loaded with 
fecal and bilious accumulations, which act as a. constant source of irritation 
and discomfort. Depletion, and derivation from the brain, are also desirable 
in this stage of the disease. On all these accounts, it is proper to give a full 
dose of purgative medicine.. Calomel is beyond all comparison the best adapted 
to the case. It remains better than most others upon the stomach, and has a 
special tendency to act upon the liver, the secretory function of which it 
promotes, and thereby unloads the portal-circle, while it also tends to free the 
blood from The biliary matter which may have becomq redundant in that fluid. 
Experience, moreover, has almost universally pronounced in its favour. From 
five to fifteen or twenty grains of it may be given alone, and followed, in six 
* I would especially call the attention of the reader to the fact, that these remarks 
apply to the early stage of the disease. 266 
GENERAL DISEASES.-FEVERS. 
[PART II. 
or eight hours, by half an ounce or an oupce of sulphate of magnesia, or other 
saline cathartic; or it may be administered in combination with some other 
purgative, as rhubarb, jalap, or compound extract,of colocynth; eight or ten 
grains of each being given for a dose. Three or four of the compound 
cathartic pills of the U.S. Pharmacopoeia, will also answer admirably well in 
many cases. Should the bowels not yield to these medicines, and especially 
if the stomach should be at the same time irritable, I know nothing better 
than the infusion of senna with Epsom salt, manna, and cardamom or fennel 
seed, of which a small wineglassful may be administered every two hours till 
it operates.* Sometimes, when the bowels are extraordinarily obstinate, or 
the stomach very irritable, it becomes necessary to have recourse to purgative 
enemata. (See Colic.') 
The cathartic should be given, whether the patient be Seen first during the 
paroxysm, or the remission. It will sometimes be better received by the sto- 
mach, and operate more kindly, in the latter state than the former. Should 
the patient be unable to take calomel, as sometimes happens, in consequence 
of an idiosyncrasy which causes this medicine to occasion excessive pain in 
the stomach and bowels, the mercurial pill may be substituted, in the dose of 
ten or fifteen grains, combined with extract of jalap, rhubarb, &c. 
After the bowels have been thoroughly evacuated, it will be sufficient, as a 
general rule, during the remainder of the complaint, to keep them open once 
or twice daily. This is often effected by the medicines which are given for 
other purposes. If not, half an ounce or less of sulphate of magnesia, sul- 
phate of soda, tartrate of potassa and soda, or other saline purgative, a Seid- 
litz powder, a drachm of magnesia, or three or four fluidrachms of castor oil, 
may be given as circumstances seem to require. Sometimes it will be more 
convenient, and answer equally well, to effect the object by means of ene- 
mata. 
Another remedy, sonietimes of great importance in the early stage of bilious 
fever, is bleeding. There are, however, many cases in which it is altogether 
unnecessary, and many in which it is positively hurtful. When the powers 
of life are feeble, or the system depressed by the co-operation of sedative 
agents with the main cause of the disease, it may even prostrate below the 
point of reaction. This is especially the case in tropical climates, where the 
continued influence of heat produces habitual relaxation, and fatal collapse in 
bilious fevers is not uncommon. The same may also be the case with per- 
sons debilitated by previous disease, or by intemperance, and in whom a 
typhous influence is operating, conjointly with the miasmatic. Bleeding, 
therefore, must not be indiscriminately resorted to. It is wholly powerless 
in the eradication, or even in the control of the febrile movement. The force 
of the pulse may be reduced, and the strength of the body exhausted, and 
yet the fever shall not have abated an iota of its violence, or its duration. 
The only legitimate object of venesection, in remittent fever, is the prevention 
of organic injury from inflammation, or local determinations of blood. But as 
these are very frequently the immediate cause of death, it is often of the utmost 
importance to be able to control them, and bleeding is among our most effi- 
cient means for this ^purpose. Hence, the indication for this remedy is the 
positive or apprehended existence of inflammation, or of some active sanguine- 
ous congestion. But, though these constitute indications, there may be others 
which more than counterbalance them, and bleeding is not always admissible 
even in cases of inflammation. This may exist in connexion with an asthenic, 
* R - Senrise §ss; Mannee opt., Magnesia? sulphat. aa §j; {Cardamom^ vel Fceniduli, 
contus. 3'j J Aquae bullient. Oj. Fiat infusum. CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
267 
as well as a sthenic state of system; and it is very possible, in the former 
case, that in attempting to reduce the local disease, we maytexhaust the little 
remaining strength, and thus disable the system from supporting the course 
of morbid actibns, requisite to the restoration of health. There must, there- 
fore; be not only inflammatioh; or threatening active congestion, or a reason- 
able fear of them; but also sufficient general energy to support the system 
through the disease, after the blood has been lost. 
Blood may be taken from the arm, in patients previously healthy and of 
vigorous constitution, when the pulse is full, strong, and tense, the face 
flushed, and the pain in the head considerable; and especially when these 
symptoms persist after the free operation of a purgative. When intolerance 
of light and sound, active delirium, coma, or hemiplegia is superadded to the 
above symptoms, the indication is still stronger; and no time should be lost 
in having recourse to the remedy. The same may be said of cases in which 
the-signs of inflammation of the stomach, liver, or lungs, are conjoined with 
a strong excited pulse. Great relief is sometimes speedily afforded to these 
local symptoms by the loss of blood. From twelve to twenty ounces may be 
taken At once; the caution being always observed, to stop the flow as soon as 
a decided impression is made on the pulse, or any marks of faintness appear. 
There are two conditions, sometimes occurring in remittent fever, which 
demand the loss of blood, though this may at first sight appear to be contra- 
indicated. One of these is the complication of acute gastritis with excessive 
nausea, which, by repressing the force of the pulse, and producing coolness 
and relaxation of the surface, suggests the idea of great prostration, when in 
fact the vital energies are unimpaired, and the apparent depression is the 
effect of excessive irritation of one of the vital organs. It is highly important, 
under such circumstances, to be able to detect the real state of the disease 
through the mask of debility. If such a condition occur early in the case, if, 
upon the Occasional subsidence of the nausea, the pulse resume its force, and 
the skin its febrile temperature, if burning pain or great tenderness in the 
epigastrium clearly reveal inflammation of the stomach, and if, finally, the 
colour of the surface do not indicate the existence of depraved blood, and 
malignant or typhoid debility, it may be taken for granted that bleeding is 
called for, and there should be no hesitation in resorting to the lancet. Not 
unfrequcntly the nausea will be found to diminish, and the pulse to rise, as 
the blood flows. . The latter event may be considered, as a clear proof that the 
remedy was indicated. In doubtful cases, it may be proper to bleed cau- 
tiously, stopping the orifice after taking a few ounces to ascertain the effect, 
and, if the pulse be found to flag, and the apparent prostration to increase, 
then to abandon the measure altogether; but, under opposite circumstances, 
to resume it, and continue till the requisite quantity has been dost. 
The second condition is associated with inflammation of the brain. Some- 
times, in connexion with cerebritis, the general organic actions of the system 
flag, in consequence of the interference of the disease with the functions of the 
great, nervous centre, which exercises in health a controlling and supporting 
influence over most of the vital operations. Besides the stupor or coma, which 
marks the, cerebral disease, there is a small, feeble, and irregular pulse, with 
an uncertain temperature of the surface, which might lead to the inference of 
debility, were the practitioner not upon his guard. As in the last mentioned 
case, the stage of the disease, and the general signs which indicate the state 
of the blood, may lead to the suspicion, that the apparent debility is nothing 
more than a depression produced by the local inflammatory affection. Here 
bleeding should be tried with the same caution as in the preceding case, being 268 
GENERAL DISEASES.-FEVERS. 
[PART II. 
abandoned if the pulse should flag further, and persevered in, if found to 
increase the vigour of the circulation. 
In either of the cases above mentioned, if may be proper by sinapisms to 
the epigastrium or extremities, hot pediluvia, or rubefacient frictions, to call 
off excitement from the diseased organ, and rouse the circulation, both cardiac 
and capillary, before reSorting to the lancet, or in conjunction with it. Not 
only may the nature of the case be thus more clearly developed; but the vital 
actions may be supported under the loss of blood, until time shall be allowed 
for the oppressed organ to resume its function, after the removal of its load. 
For the same reason, in those cases of depression dependent on or connected 
with nausea, opium may be employed to relieve this condition, preparatory to 
the use of the,lancet". j . 
It is usually not in the very onset of the disease, that the indications for 
bleeding are most strongly presented. The first paroxysm is often less violent 
than those which follow,, and, when inflammation takes place, it is generally 
two or three days, or even longer, before unequivocal signs of it are presented. 
Whenever they are met ^ith, whether in the first or in subsequent paroxysms, 
along with the condition of the pulse referred to, then it is that bleeding 
should be einployed; but it must be remembered, that, in the advanced 
stages, the system has often become so exhausted, that. even the existence of 
inflammation is not a sufficient warrant for the use of the lancet. In all such 
instances, the requisite depletion may be more safely effected by leeches or 
cups in the vicinity of .the organ affected; and the subversion of the disease 
must be left to other means than the mere loss of blood. 
It is seldom that more than one full bleeding is required in bilious fever. 
A moderate tentative bleeding, of six or eight ounces, may often be advan- 
tageously repeated^ but, after the loss of twelve, sixteen, or twenty ounces of 
blood, or, it may be, in robust and plethoric men, as much as thirty ounces, 
whatever more is done in this way should be accomplished by local depletion. 
After the evacuation of the primae vise, and the use of the lancet, if that 
may have .been considered advisable, diaphoretics come in with great advan- 
tage. Some authors speak slightingly of these remedies. But, when we 
consider that nature very often brings about a partial or complete solution of 
the paroxysm of fever by sweating, the inference appears very reasonable, 
that we shall favour this result by promoting her own favourite process. Nor 
do I think that experience is opposed to this conclusion of the judgment. It 
has always appeared to me, that diaphoresis brought about by proper means, 
during the febrile exacerbation, often has a most happy effect in moderating 
its violence, shortening its duration, and rendering the subsequent remission 
more complete. Of course, the sweating is not to be induced by stimulating 
means. , In the early stages, the refrigerant diaphoretics only should be em- 
ployed. When the stomach is not in the least degree irritable, the antimo- 
nials may be used with advantage. From the twelfth to the sixth of a grain 
of tartai\ emetic may be given every hour or two, caution being observedpso 
to proportion the dose as not tb occasion excessive nausea. The antimonial 
or James' s powder has enjoyed much reputation, and the precipitated sulphuret 
bag similar properties; but neither of these is in any respect superior to the 
emetic tartar, while they are inferior to it in certainty of action, and uni- 
formity of dose. It has been very customary to combine the antimonial with 
nitre. This was at one time my own practice, in accordance with the recom- 
mendation in the books; but I have long abandoned it, having found no 
advantage from the nitre, sufficient to counterbalance its frequent irritant 
effect upon the stomach. 
The effervescing draught is, beyond all comparison, the best diaphoretic in CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
269 
bilious fever. But it should always be prepared with citric acid or lemon- 
juice and the carbonate of potassa, and of course, should have the citrate of 
potassa for its base. Not unfrequently acetic or tartaric acid is employed as 
a substitute for the citric, atid one of the carbonates of soda, for the carbonate 
or bicarbonate of potassa. But these are less acceptable to the stomach, and 
less powerfully diaphoretic, than the genuine preparation. For the exact 
mode of making it the reader is referred to the U. S. Dispensatory. I would 
here merely observe, that I always prefer fresh lemonjuice, when attainable, 
to a solution of citric acid, and the carbonate of potassa or salt of tartar to the 
bicarbonate. The mixture should never be considered as properly prepared, 
unless it effervesce. A dose, of it, in the state of effervescence, should be 
given every hour during the height of the exacerbation, and every two or three 
hours during the remission, until this becomes sufficiently decided for the 
employment of qumia. I feel very confident, that no practitioner- who has 
ever been in the habit of using the effervescing draught, properly prepared, 
in the treatment of bilious fever, will be disposed to abandon it. To the 
patient it is almost always, when given quite cold, agreeable and refreshing, 
and many call frequently for its repetition. It is one of the most efficacious 
means of correcting nausea and vomiting, and acts more certainly and power- 
fully as a diaphoretic than almost any other saline substance with which I am 
acquainted; tartar emetic itself scarcely constituting an exception. It some- 
times occasions griping pains in the stomach and bowels, with frequent small 
evacuations; but this tendency may be corrected by the addition of four or five 
drops of laudanum, or about twenty drops of the officinal solution of sulphate 
of morphia, to every other dose. Indeed, this addition may often be advan- 
tageously made, independently of the effect of the draught alluded to. It 
tends very happily to compose nervous disturbance, and aids the draught in 
correcting nausea. Sometimes, it even favours the diaphoretic action. 
When there is high sthenic action and no nausea, a little tartar emetic may 
be added to the preparation; and, in cases of nervous disorder, such as start- 
ings, restlessness, wakefulness, and general vague uneasiness, the spirit of 
nitric ether is an excellent adjuvant, in the quantity of from thirty to sixty 
drops in each dose. 
The neutral mixture (Liquor Potasses Citratis, U. S,)) which consists of 
the same materials already fully effervesced, is often substituted for the effer- 
vescing draught; but, from abundant experience of the two preparations, I 
almost always prefer the latter. The citrate of potassa itself may be used, in 
the dose of twenty or thirty grains, dissolved in a fluidounce of water, in 
place' of the draught, though much less agreeable, and less calculated to correct 
nausea. 
Solution ■ of acetate, of ammonia, or the spirit of mindererus, is much 
esteemed by some practitioners; but, after frequent trials with it, I have found 
it in all respects inferior to the preparations of citrate of potassa. 
In the advanced stages of the disease, or in asthenic cases, and especially 
in those associated with rheumatism, the powder of ipecacuanha and opium 
(Dover's powder), given in doses of ten grains, repeated every six or eight 
hours, is often an excellent remedy, operating most happily at once as a dia- 
phoretic, anodyne, and gentle stimulant. 
The warm hath is sometimes serviceable, in connexion with diaphoretics, 
in inducing relaxation of the surface. It is especially adapted to the cases of 
children. 
The external application of cold water is also highly beneficial, in the 
febrile exacerbations. Much comfort will be afforded by simply sponging the 
arms, feet, and face; but a more efficient method of application, in reference 270 
GENERAL DISEASES.-FEVERS. 
[part II. 
to a solution of the paroxysm, is that of affusion, as recommended by Dr. Currie 
of Liverpool. Dr. Dickson, who has had much experience with this remedy, 
considers it as an efficient and safe substitute for the lancet, and recommends 
it in the strongest terms.- In relation to the mode of using it he says; " seat 
your patient in a convenient receptacle, and pour over his head and naked 
body from some elevation a large stream of cold water; continue this until he 
is pale or his pulse loses its fulness, or his skin becomes corrugated and he 
shivers." He is then to be dried and replaced in bed. The surface is then 
completely relaxed, and a copious perspiration often follows.' The remedy 
should be employed only when the surface is universally hot and dry, without 
any sense of chilliness on the part of the patient. It is not applicable, accord- 
ing to Dr. Dickson, to patients of " feeble habit of body, much advanced in 
age, or much exhausted or enfeebled at the time," nor to cases attended with 
oppressed or inflamed lungs, or with diarrhoea. Should it occasion protracted 
chilliness and rigors, with continued discomfort to the patient, it should not 
be repeated. (Essays oh Pathology, and Therapeutics, i. 302.) 
In mild cases of remittent fever, few other remedies will be required besides 
those above detailed.. When the remissions are very distinct, and approach 
the character of intermissions, the cure may often be greatly hastened by the 
use of quina, as will be. stated more fully in a subsequent page. But violent 
and threatening cases demand additional treatment. 
Mercury has enjoyed a very high and merited reputation in this disease. 
It has been frequently observed, that few patients die of bilious fever whose 
systems have been brought under the influence of this remedy. The reply, 
indeed, has been made to this argument in its favour, that those cases only 
are susceptible to the action of mercury which can be cured by other means, 
or would get well spontaneously. But this is obviously assumption. Nor is 
the statement true. In cases which run their course in a few days, it is some- 
times impossible to affect the mouth; but these are by no means the only 
dangerous cases, nor indeed the majority of them. In most instances, the 
disease advances to the ninth day, or beyond it, before proving fatal. Of 
such cases, there are very few in which the mercurial influence cannot be 
established; and the inference is, that, were proper attempts made to esta- 
blish it, very few would end fatally. Another argument against the use of 
mercury is its liability to produce serious and even dangerous disease of the 
mouth. This very rarely happens, when the remedy is properly managed. I 
have never, in my public or private practice, witnessed a case of deformity or 
death from this cause. It is true that, from idiosyncrasies, patients are some- 
times violently affected by the medicine, however carefully employed. But 
this is no reason for abandoning its use altogether. There is no efficient 
remedy of which the same may not be said. Death has often resulted from 
erysipelas following wounds; but patients are not on this account to be de- 
prived of all the advantages resulting from the knife of the surgeon. 
Mercury is, after the lancet, infinitely the most powerful antiphlogistic 
remedy in our possession. Now most fatal cases of bilious fever probably 
become so, in consequence of the disorganizing effects of the inflammations 
that attend them. Yet such is the state of the system, that bleeding very 
frequently cannot be safely pushed to the point necessary for the eradication 
of these inflammations. Mercury is sometimes, under these circumstances, 
our only refuge. But it probably does good in other ways. By stimulating 
the liver, it aids the system in throwing off the-biliary matter which may 
offend it. The supposition is highly probable, that it otherwise alters the 
blood, so as to render it less pernicious in its influence upon the functions. 
But, whatever may be the explanation of its action, the fact of its beneficial CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
271 
influence rests upon experience. I will only adduce a single fact, out of thou- 
sands which might be advanced in its favour. In. the year4804, the crew of 
the Centurion, a British ship of war, lying in the harbour of Bombay, were 
attacked in great numbers with a very violent form of bilious fever. The dis- 
ease came on either with great distress in the epigastrium, and violent bilious 
vomiting, or with severe cephalic symptoms, amounting Sometimes to furious 
delirium. Bleeding was not employed in a single case; but calomel was 
given freely, arid generally with the effect of inducing ptyalism. Out of one 
hundred and fifty cases not one was lost. (Diet. de Med. v. 279.) 
It is not necessary to give mercury in all cases of bilious fever. The great 
majority will do well without it. But, when the disease is violent from the out- 
set, and does not soon show a disposition to yield to the remedies employed, 
or when it assumes a dangerous aspect in its course, there will always be a 
propriety in administering it in reference to its constitutional effects. The 
existence of considerable inflammation) whether in the stomach, brain, lungs, 
liver, or spleen, which cannot be' speedily conquered by direct depletion, 
always affords an indication for its use. In the low or typhous forms of the 
complaint, when the lancet is inadmissible, it is a most valuable resource. 
The immense quantities in which it has been sometimes employed are alto- 
gether unnecessary. Only a certain amount of the medicine can find access 
into the system from the alimentary canal, and all the rest is either inert, or 
only a source of irritation. It is not necessary to interrupt the treatment 
already detailed. Calomel, or the mercurial pill, may be given in alternation, 
or conjointly, with the other remedies. The former preparation is best adapted 
to the early stages of the disease. From half a grain to two grains may be 
given every hour, two, or three hours, according to the urgency of the symp- 
toms, and the known susceptibility of the patient. Let not those- who are 
accustomed to enormous doses of this medicine; smile at those here mentioned. 
Let them first try even the smallest dose, in a sufficient number of cases, and 
determine, from the results of their experience, whether it may not be suffi- 
cient. When the stomach is very irritable, doses of only one-sixth of a .grain, 
given every half hour or hour, and regularly persevered in, will often have a 
more decided constitutional effect than fifty times the quantity. The influ- 
ence of these small doses, in calming bilious vbmiting, is often most delight- 
ful. Should the bowels be very irritable, it will generally be advisable to 
combine the calomel with opium, and especially in the advanced stages. The 
medicine should be given regularly through the day; but should be omitted 
during six or eight hours at night, in order that the rest of the patient may 
be as little disturbed as possible. It is often proper to administer a somewhat 
larger than the ordinary dose at bedtime, with a grain or two of opium and 
the same quantity of ipecacuanha, if these be not contraindicated, the former 
by the state of the brain, and the latter by irritation of stomach. The refresh- 
ing effects of sleep are thus obtained, and the patient frequently awakens in a 
fine perspiration in the morning. 
Calomel is very frequently administered in combination with tartar emetic 
and nitre, in the form of the nitrous powders. This is no doubt often an 
efficient remedy; but all its effects may be obtained more agreeably, and less 
offensively to the stomach, by the mercurial alternating with the effervescing 
draught, as before recommended, When the system obstinately resists the 
mercurial impression, or the case is very urgent, recourse should be had also 
to the external use of the remedy, in the form of the mercurial ointment, 
which may be-applied by friction, or to blistered surfaces. 
The effects of mercury upon the gums should be watched for with great 
care; and, as soon as any evidence of its action is afforded, the remedy should 272 
GENERAL DISEASES.-FEVERS. 
[PART II. 
either be diminished or suspended, unless in cases of an almost desperate 
character. ' y ■ ' 
Sulphate of puinia is another all-important remedy, in the treatment of 
certain cases of bilious fever. It has before been stated, that, in ordinary 
cases, it will often shorten the duration of the disease, if given in the remis- 
sion, after this has become very decided, so as almost to amount to an inter- 
mission. Should no signs of cerebral or gastric inflammation be present, and 
the activity of the circulation have subsided or been subdued, this medicine 
may be ventured upon whenever the remission has the character above men- 
tioned. From twelve to eighteen grains, given in divided doses during the 
remission, will often be sufficient to prevent the paroxysm; and if not, a repe- 
tition of the same amount in the next interval will rarely fail. There are 
some who advise this treatment, in all cases of bilious fever, whether with 
very obvious remissions or not. Nay, they go so far as to maintain, that the 
medicine may be given without any reference to exacerbation or remission, 
being as little injurious in the former as in the latter. But, though I believe 
that there has been much of prejudice in the disinclination of medical men to 
use quinia under any other circumstances than those of complete intermission, 
a prejudice probably derived from the unpleasant effects produced by the 
powdered bark when given during the existence of fever, yet I am not-pre- 
pared to relinquish the old opinions as to the tonic and excitant properties of 
this medicine, and cannot but think that it may do much harm, if administered 
under circumstaflces of high arterial excitement, especially when attended 
with inflammatory tendencies of the brain. I am certain that I have seen it, 
in the large doses in which it has been recommended in remittents, give rise 
to serious injury, by fixing inflammation; and one fatal case of this kind camo 
under my notice in the Pennsylvania Hospital. It is the brain, in which 
most evil is to be apprehended from the abuse of quinia; because it is upon 
that organ that it operates most powerfully. That it should occasionally 
diminish tbe frequency of the pulse in febrile cases, js no proof of its essential 
sedative nature. Whatever cramps the functions of the brain, whether by 
over-stimulation or by depression, will have this effect. Opium in large doses 
often produces it. Yet opium is the last remedy we should think of employ- 
ing, in inflammatory or active congestive tendencies of the brain; and for the 
same reason, we should avoid quinia under similar circumstances, unless there 
were some danger to be averted by the use of it, greater than that of the 
apprehended cerebral disease. 
But there are circumstances, in bilious remittent fever, which render quinia 
of the utmost value. When a paroxysm of gteat virulence has occurred, from 
which the patient has been saved only by the most strenuous exertions, and 
there is every reason to fear that a similar one will prove fatal, recourse should 
be had to the sulphate of quinia, in the remissiorl, however imperfect or short 
it may be. When the fever has hitherto shown little or no tendency to remit, 
and the grade of violence is such that fatal results appear imminent, should 
the slightest remission show itself, and the symptoms not be those of cerebral 
inflammation or strong determination, the quinia should be poured in without 
stint. The more nearly a case approaches to the Above extremes, the stronger 
is the indication for the use of the antiperiodic medicine. I am entirely con- 
fident that I have seen lives saved by this treatment, which must have been 
inevitably lost under any other. The quantity of quinia given in the remis- 
sion, must be sufficient to bring the system under the influence of the medicine, 
if possible, before the period for the next paroxysm. So far as my observation 
has gone, from eighteen to twenty-four grains are sufficient, in any case not 
falling under the title of malignant or pernicious; and often less will answer. CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
273 
The doses must be regulated by the length of the remission. If this be 
short, they must be very large, and if of a few hours' duration only, the whole 
quantity must be taken in two or three doses., If the remission be long, the 
medicine should be equally distributed through it, care being taken that the 
whole shall have been administered two or three hours before the expected 
paroxysm. The reader must not be lect into the error of supposing, that the 
dangerous paroxysms above alluded to are characterized by excessive febrile 
excitement. On the contrary, there is often no remarkable degree of heat of 
skin, headache, or strength of pulse. The condition is rather marked by an 
extreme general distress, which the patient finds it impossible to describe, 
incessant jactitation, a feeling of burning heat while , the extremities may be 
cool to the observer, incessant vomiting, great frequency of pulse, &c. When 
these subside into a comparative calm, then is the moment for the adminis- 
tration of the quinia.* - " 
Nor should we be content with preventing a single paroxysm. The disease 
may be of the double tertian type, or may have a tendency to pass from the 
quotidian into the tertian. The remedy should, therefore, be continued until 
two daily paroxysms have been prevented; after which the patient may be 
considered safe. 
In the more regular paroxysmal forms of remittent fever, should quinia 
fail, or its use not be deemed advisable, the succession may often be effectually 
broken by an emetic, administered so as to be in full operation at the time of 
the expected paroxysm. For this purpose, tartar emetic would probably be 
more effectual than ipecacuanha, though I have seen the latter entirely suc- 
cessful, in several instances, when combined with six or eight grains of calomel. 
A pair of blisters upon the legs or arms, applied so as to be in full action at 
the time above referred to, will often have the same effect. This remedy was 
very much employed, before the introduction of quinia into use. Sinapisms 
operate in the same way. A full dose of opium, also, given in anticipation 
of the paroxysm, will occasionally prevent it. When employed for this pur- 
pose, it should be combined with an equal weight of ipecacuanha. 
When the disease has originally a typhous character, or sinks into that 
state in its course, the same remedies must be employed as in the proper 
typhus. (See Typhus Fever.) 
It was stated, in the description of the disease, that, if a favourable change 
did not take place from the ninth to the twelfth day, it was apt to alter its 
form, and assume many of the symptoms which characterize the advanced 
stages of the common enteric or typhoid fever. (Seepage 256.) In such 
cases, the tongue being dry, the skin dry, and the secretions generally deficient, 
* The question has been asked, why, if quinia is thus recommended in the violent 
cases as the most efficient remedy, it should not be employed also in the milder, in which 
it would probably prove still more effectual. I am not disposed to deny that many mild 
cases would yield to the remedy, employed even in the early stages, and without refer- 
ence to remission or exacerbation. Indeed, I cannot refuse credence to the many state- 
ments to this effect which have proceeded from highly respectable sources. But, though 
it may often prove useful, it sometimes confessedly fails, and sometimes, I believe, pro- 
duces evil effects by fixing, if not determining some inflammatory affection, especially in 
the brain, upon which it often acts so powerfully. Such a risk may very properly be 
incurred in cases of great danger from other sources; though it might be improper to 
incur it in mild cases, which may almost always be carried to a favourable issue without 
it. I think it not improbable that the influence of a warm climate upon the system may 
be such as to render it tolerant of quinia, under circumstances which have been gene- 
rally supposed to contra-indicate its employment; and a similar influence may be exerted 
by epidemic constitutions within particular limits; so that testimony in its favour should 
not be disregarded, even though contrary to our preconceived opinions, and even to our 
particular experience. (Note to Second Edition.') 274 
GENERAL DISEASES.-FEVERS. 
[part II. 
it is advisable, if the patient has not already been salivated, to give the mer- 
curial pill, in the dose of a grain every hour or two through the day, until 
the gums begin to exhibit some signs of its effect. Should diarrhoea exist at 
the same time, as often happens, about a sixth or quarter of a grain of opium, 
with the same-quantity of ipecacuanha, may be given with each pill. Should 
any tendency to the paroxysmal form be observed, sulphate of quinia should 
be administered; and the same remedy is sometimes indicated, and very use- 
fully employed as a tonic. For convenience sake, the mercurial pill with its 
adjuvants, and the /Sulphate of quinia, may be given together. After the 
mercurial influence has become evident, should no amendment be observed, 
oil of turpentine will often be found exceedingly efficient, in the dose of from 
ten to twenty drops every two hours. This acts as an alterative upon the 
inflamed, and probably ulcerated mucous membrane of the bowels. It may 
be given in emulsion with gum arabic, loaf sugar, and water, with the addition 
of a little laudanum, and of the sulphate of quinia should that still be indi- 
cated. Nitrate of silver may be used as an alterative under the same circum- 
stances. Should pressure upon the abdomen detect a tender spot, a few 
leeches may sometimes be applied advantageously; and in all cases, when 
there are diarrhoea and a tympanitic abdomen, this should be kept constantly 
covered with a large emollient cataplasm, to which a little mustard may be 
added, sufficient to sustain a slight feeling of warmth. Not unfrequently, 
the system sinks, in this form of the disease, into a very prostrate condition, 
requiring stimulants of a more or less powerful character to sustain life, until 
the course of the. disease is run. Infusion of serpentaria is a mild stimulant, 
well adapted to the least debilitated of these cases. If stronger stimulation is 
required, in addition to the quinia and oil of turpentine already mentioned, 
carbonate of ammonia, wine whey, mulled wine, brandy, milk punch, &c., 
may be used, according to the degree of prostration, and the previous habits 
of the patient; and external stimulation by means of the hot bath, sinapisms, 
cayenne pepper, oil of turpentine, or ammonia, should also be resorted to. 
Regular doses of opium, or one of its preparations, will often be useful by 
maintaining a gentle excitement, and quieting nervous disturbance. The 
practitioner should, under these circumstances, never despair; for recoveries 
sometimes take place from the lowest condition, short of the last agony. 
Various incidental disorders require attention; and their treatment is often 
not less important than that of the main disease. 
Gastric, disorder.-When there is frequent retching, with discharge occa- 
sionally of a mouthful of bile or other acrid liquor, effectual relief will often 
be afforded by washing out the stomach by copious draughts of warm water 
or chamomile tea, or even, in some instances, by a very mild emetic of ipe- 
cacuanha. Irritation existing in the coats of the stomach itself, and inde- 
pendently of its contents, should be treated by cataplasms made with powdered 
spices, or by sinapisms, or finally, if these fail, by a blister to the epigastrium, 
while an opiate is exhibited in small doses internally, or in a full dose by 
enema. It often happens that the end may be accomplished by the addition 
of the opiate to the medicine which may be given for other purposes, as to 
calomel, sulphate of quinia, &c. The effervescing draught often has a most 
happy effect in allaying vomiting. So also have small draughts of ice-cold 
carbonic acid water, which is moreover in general exceedingly grateful to the 
patient. In the somewhat advanced stages, lime-water and milk, mixed in 
equal proportions, may be given in the dose of half a wineglassful, every half 
hour or hour, with very great advantage; not only allaying the gastric irrita- 
tion, but yielding nutriment to the system in the most suitable form. Dr. 
Condie, after all other means have failed, has repeatedly seen vomiting promptly CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
275 
relieved, by a grain of acetate of lead every hour or two. (Am. ed. of Wat- 
son's Practice.) Should other means fail, a portion of the surface over the 
epigastrium may be denuded of the cuticle by means of a blister, and sprinkled 
with half a grain of powdered acetate of morphia. Sometimes irritants applied 
to the spine, or a few leeches or cups over some tender point, will arrest the 
vomiting, when measures directed more immediately to the stomach have 
proved unavailing. 
Should the stomach be inflamed, leeches or cups should be applied to the 
epigastrium. The greatest relief may often be afforded to the patient in this 
way. After bleeding, they sometimes act like a charm, hot only in affording 
comfort to the patient, but in ameliorating the general character of the com- 
plaint. From four to six or eight ounces of blood may be abstracted. After- 
wards, an emollient cataplasm should be applied, and kept for some time over 
the stomach, to be followed, if necessary, by a blister. 
Encephalic disorder.-In the early stages of the disease, when the head is 
hot and very painful, much ease may often be obtained by applying ice in 
bladders, or towels wet with ice-cold water, or placing the patient's head over 
a basin without the bed, and pouring over it a stream of cold water from a 
pitcher at a considerable height. While cold is thus applied to the head, 
revulsion may be effected towards the lower extremities by pediluvia of hot 
water, or mustard and water, especially when the feet and legs, as not unfre- 
quently happens, are cool. Chips or leeches to the temples, or to the nape of 
the neck, are most valuable adjuvants in the treatment of the disease, affording 
sometimes the most entire relief, after bleeding has been employed ineffectu- 
ally. When there is delirium or coma, besides the remedies just mentioned, 
the head may be shaved, and, if depletion has been carried sufficiently far 
without effect, the whole scalp should be covered with a blister. This is 
much more effectual than a blister to the back of the neck, which is often 
recommended. I have frequently applied the latter, but with no very decided 
impression; while the former has repeatedly appeared to be the means of pre- 
serving life. But it should not be postponed too long. The main cause of 
the disrepute into which blisters to the scalp have fallen, is probably the late 
period to which it has been customary to postpone their application. 
It is unnecessary to refer particularly to the inflammation of other organs; 
as it is to be treated in the same manner as original inflammation of these 
parts. 
Nervous disorder.-Restlessness, wakefulness, general uneasiness, &c., may 
often be relieved by small doses of the nervous stimulants, as compound spirit 
of sulphuric ether (Hoffmann's anodyne), spirit of nitric ether (sweet spirit of 
nitre), camphor water, camphorated tincture of opium, infusion of valerian, 
&c. These may be given pro re nata, and may sometimes be advantageously 
connected with other medicines. Thus, camphor water may be used as a 
vehicle, so that a tablespoonful shall be given for a dose every hour or two. 
Gentle and steady friction with the hand to the arms, legs, and feet, has some- 
times a most happy composing effect. Garlic poultices to the feet are also 
useful, especially in the cases of children. Sometimes great advantage is 
obtained from a pair of blisters to the arms or legs. Sleep may be procured 
in this way w'hen opiates are contraindicated; as when the brain is over- 
excited, while the extremities are cool. -Should opium not be contraindicated, 
it is on the whole the most effectual means for obviating morbid watchfulness. 
Sometimes, hyoscyamus, or lactucarium may produce the desired effect, when 
opium disagrees with the patient. Great advantage is often obtained from 
varying the preparation of opium, one answering a good purpose where ano- 
ther acts unkindly, and vice versa. Thus, a salt of morphia will occasion- 276 
GENERAL DISEASES.-FEVERS. 
[part II. 
ally put to sleep when opium will not; and the changes may be rung upon 
solid opium, Dover's powder, laudanum, paregoric, black drop, the acetated 
tincture, and the different salts of morphia. 
Hiccough, which is occasionally a very troublesome symptom, may be 
treated with camphor, assafetida, opium, valerian, &c.; but the most effectual 
remedy, by far, in cases of necessity, is musk. 
Convulsions in children require the warm bath, sinapisms to the extremi- 
ties, garlic poultices to the feet, friction with garlic and brandy to the spine, 
&c. Opium is one of the most effectual preventives when they depend on 
any other cause than inflammation, or active congestion of the brain. Should 
they occur paroxysmally, sulphate of quinia should be unhesitatingly em- 
ployed. 
Regimen.-No drink is so agreeable, and none on the whole more suitable, 
during the febrile exacerbations, than ice-cold water. It should be taken in 
small quantities, not exceeding two or three swallows at a time, and fre- 
quently. The patient also derives great comfort from small pieces of ice held 
in his mouth, and allowed slowly to dissolve. The drink may be varied by 
substituting, now and then, for pure water, orangeade or lemonade, or water 
flavoured with currant-jelly, blackberry-jelly, molasses, or a piece of freshly 
toasted bread. I have often found very acceptable to patients in fever, a 
beverage consisting of weak molasses and water, with a little lemonjuice, and 
a piece of toast, and kept cool by ice. Apple-water, or tamarind-water may 
also be used. 
The liquids above mentioned contain sufficient nutritive matter for the 
first day or two of the fever; but, as the complaint advances, something a 
little more nourishing may be given, as gum Arabic dissolved in water in 
the proportion of an ounce to the pint, and flavoured, if deemed advisable, 
by sugar, lemon-juice, .&c., barley-water, rice-water, or any other pure and 
weak farinaceous drink. The patient may also suck the juice of oranges, 
or swallow that of sweet grapes, taking care to discard the skin, pulp, and 
seeds. 
At a still more advanced period, especially in the remissions, and at all 
times in the remission if it be distinct, the patient may take a cup of black 
tea, with a piece of dry toast, morning and evening; or his strength may 
be supported by panada, by gruel of oatmeal, ground rice, or Indian-meal, to 
which a little milk may often be added, or by preparations of sago, tapioca, 
or arrow-root suitably flavoured. He may also be allowed a little well-roasted 
apple, or stewed fruit, care being taken that nothing hard or peculiarly diffi- 
cult of digestion, be admitted into the stomach. It is necessary that the 
physician should be provided with a diversity of articles of drink and food, in 
order to meet the incessant demands, the squeamish appetite, and the ever 
varying caprices of the sick. Happily, there is usually, during the fever, a 
disgust for food, which prevents the patient from taking it in injurious quan- 
tities, provided the injudicious interference of friends and nurses be guarded 
against. 
Should the failing strength require further support, as often happens in 
protracted and in typhoid cases, a little milk may be allowed, or animal broths, 
or jellies; and sometimes it becomes necessary to. have recourse to the most 
stimulating food, as essence of beef or mutton (seepage 210), milk-punch, 
egg and wine, &c. 
In convalescence it is very important to regulate the diet, both as to qua- 
lity and quantity. Bread and butter, buttered toast, or milk-toast, boiled 
rice, mealy potatoes, weak broths, soft-boiled or poached eggs, oysters, boiled 
flesh of poultry, the broiled breast of birds or chickens, and finally the more CLASS I.] 
BILIOUS, OR REMITTENT FEVER. 
277 
easily digested meats in general, may be used in the order suggested, begin- 
ning with the lighter, and gradually rising to the more nutritious substances. 
When the appetite is a little languid, I have found that it is often sufficiently 
stimulated by a little crisp broiled lean of ham, or frizzled dried beef. When 
it is excessive, as often happens, the greatest caution should be observed 
against over-indulgence. 
During the whole course of the disease, the patient's chamber should be 
well aired, and light and noise excluded. The covering should be just so 
much as is calculated to make the patient most comfortable. The bed and 
body linen should be frequently changed, all e^crementitious matter quickly 
removed, and the air of the chamber sweetened and rendered refreshing by 
burning sugar after each fecal evacuation, or by sprinkling the apartment with 
lavender-water, aromatic vinegar, or something of the kind. No persons 
should enter the room except the attendants, and all conversation upon busi- 
ness, or exciting subjects, should be as much as possible avoided. When 
convalescence has commenced, all that can recall unpleasant associations should 
be removed from the apartment, light should be gradually admitted, the society 
of friends cautiously restored, and the patient allowed to resume, by degrees, 
his ordinary habits. 
Convalescence. - This state, when imperfect, often requires continued 
medical supervision. The languid appetite must sometimes be encouraged, 
the general laxity of system counteracted, night sweats corrected, and various 
nervous disorders removed or quieted. The mineral acids often very happily 
meet the first three indications. Aromatic sulphuric acid (elixir of vitriol) is 
generally preferred; but the nitric, or nitro-muriatic may also be used; and 
the one last mentioned should be preferably employed, when the hepatic func- 
tion requires moderate stimulation. Sulphate of quinia, or the simple bit- 
ters, and the chalybeates are often advantageous as tonics; the last, especially, 
when the system is left anemic. Sometimes a little porter, ale, or wine will 
be found useful. 
Wakefulness, and other nervous symptoms, generally yield as the patient 
regains strength. In the meantime, it may be proper occasionally to admin- 
ister one of the nervous stimulants. Opium or hyoscyamus, or one of their 
preparations may sometimes be necessary to procure sleep, care being taken 
to withdraw them gradually, when no longer required. Hops, in the form 
of infusion or tincture, sometimes answer a good purpose under these circum- 
stances. 
Constipation should be overcome by a laxative diet, if possible; if not, by 
the mildest medicines, such as the confection of senna, magnesia when there 
is excess of acid in the stomach, rhubarb, a little castor oil, a Seidlitz pow- 
der, &c. Active purging must be scrupulously avoided; as it endangers a 
relapse. Diarrhoea sometimes requires the use of gentle astringents. If the 
stools are clay-coloured, or in any other way indicate hepatic disorder, a mer- 
curial pill, or a grain of calomel, may be given every night, or every other 
night, till the symptom disappears, the caution being observed, not to give 
nitro-muriatic acid at the same time. For the treatment required by any 
organic disease of the liver or spleen that may be left behind, the reader is 
referred to the articles upon diseases of those organs respectively. The pa- 
tient must be guarded against a too early exposure to fatigue. Some are 
anxious to regain strength by exercise beyond the powers of their system. 
They should be taught that nothing would be more likely than this to cause 
a return of the disease. 
In relation to prophylactic measures in this complaint, the reader is referred 
to intermittent fey&p. I will merely add, that many attacks of bilious fever 278 
GENERAL DISEASES.-FEVERS. 
[part II. 
might, in my opinion, be avoided, by taking a mercurial cathartic, when the 
peculiar epigastric uneasiness which so often precedes the disease is expe- 
rienced, and afterwards following the purgative with quinia in the quantity 
which would be necessary to prevent a paroxysm. I have no doubt, that the 
same measure which is capable of interrupting the paroxysms, when formed, 
is also capable of preventing the first paroxysm if properly timed. 
PERNICIOUS EEVER. 
Syn.-Congestive Fever.'-'Pernicious Intermittent.-Pernicious Remittent. 
I prefer the epithet pernicious, employed by the European continental 
writers to denote this form of miasmatic fever, to malignant or congestive; 
because, not having been generally applied to other diseases, it may be con- 
ventionally received as designative of a particular morbid state of great danger, 
to the exclusion of others which may be equally dangerous, but in a different 
way. The term malignant is either employed, in a general manner, to express 
extreme danger or fatality, or is appropriated to cases in which the blood has 
become greatly depraved, giving rise to certain peculiar phenomena, as in 
malignant typhus. If that epithet were applied to the affection in question, 
we could not refuse to embrace under it all extremely fatal varieties of bilious 
fever, or at least those which exhibit violent typhous symptoms. The term 
congestive is still more exceptionable; because, besides belonging to a vast 
number of other affections, of all possible degrees, and of wholly distinct 
characters, as, for example, to cases of arterial or active, as well as venous or 
passive congestion, it is, moreover, calculated to lead into erroneous views of 
the nature of the disease. It might be inferred, from the use of this epithet, 
that the congestion which certainly exists in this affection constitutes the 
essential part of it-the condition in which all the other symptoms have their 
origin, and from which danger is to be apprehended; whereas, as I shall 
attempt to show hereafter, it is a mere incidental phenomenon, and has little 
comparatively to do with the result. 
It is not to all dangerous cases of intermittent or remittent fever, that the 
epithet pernicious, as here employed, belongs. These affections may prove 
fatal, as before explained, by the supervention of various inflammations, by 
hemorrhagic effusion from ordinaiy causes within the cranium, chest, &c., by 
a typhous depravation of the blood, or by the gradual exhaustion of the vital 
powers through the excessive disturbance of the functions. None of these 
cases are necessarily included under the present heading. I propose to restrict 
the name to an affection, in which there is great and sudden prostration or 
depravation of the nervous power, or, to use a customary phrase, in which the 
innervation is extremely, and most dangerously, defective or deranged. 
It may be asked, why make a distinct affection of what is nothing more 
than a modification of an ordinary disease? The answer simply is, that its 
extreme danger, and yet often easy curability when early recognized, render 
it desirable that the practitioner should have a vivid impression of its charac- 
ter and importance, which may be best given by treating of it distinctly; 
while the danger of false pathological views may be readily guarded against 
by due explanation. 
This modification of miasmatic fever may be intermittent, remittent, or 
continued. But it is only when of two or three days duration, that it can be 
said to be of the last mentioned form; for, if the patient survive this period, 
and the disease persist, it will almost certainly become paroxysmal. Most CLASS I.] 
PERNICIOUS FEVER. 
279 
frequently, it is either intermittent, or exhibits a close approximation to that 
form; and happily, though often quotidian, its more common type is tertian. 
Symptoms, Course, &c..-The disease exhibits different phenomena, ac- 
cording to the direction of the morbid innervation. . Thus, in some cases the 
organic functions are especially affected, in others the animal. In the former, 
the evidences of disease are presented chiefly in the organs of digestion, 
respiration, circulation, calorification, and secretion; in the latter most promi- 
nently in the brain. There are differences also in the disease, as it is evinced 
most strikingly in one of the organic functions rather than in another, though 
most of them are simultaneously affected. Thus, the force of the morbific 
cause appears to fall, in some instances, directly and especially upon the 
heart, in others upon the alimentary canal, in others again upon the surface 
of the body, either in its function of secretion or calorification. 
The attack may occur at any time in the day, or in the night. Sometimes 
it comes on a,t once, with its own peculiar characters. More commonly, how- 
ever, the first symptoms are those of ordinary miasmatic fever, or at most 
equivocal. Thus, the patient may have been seized with a paroxysm, differ- 
ing apparently in nothing from that of a regular intermittent; and it is only 
in the second, or perhaps even in the third paroxysm, that the pernicious 
phenomena are exhibited. Or, the first symptoms may be chilliness, severe 
pains in the back, limbs, and head, frequency and irregularity of pulse, flashes 
of heat alternating with slight perspirations, &c., as if a remittent were en- 
deavouring to form itself; when gradually or suddenly, as the case may be, 
an alarming change becomes obvious, and the patient is seen to be in the 
midst of the greatest danger. Again, a remittent may have existed for seve- 
ral days, without showing any peculiar symptoms; and then, with or without 
warning, may assume the pernicious character. 
Disease in the Organic Functions.-When the disease is fully formed, and 
exists primarily in the organic functions, the following symptoms are presented, 
though not all of them necessarily in every case. There is something strik- 
ingly peculiar in the appearance of the patient. The face, hands, and feet 
are of a livid paleness; the features shrunk and impassive, or singularly ex- 
pressive of an amazement or alarm which the patient does not feel; the eyes 
often sunk in their sockets, though still clear and even bright; the skin con- 
tracted, and the fingers shrivelled as if long soaked, like those of a washer- 
woman, in soap and water; the extremities and sometimes even the trunk 
chillingly cold, though not sensibly so to the patient; the surface either par- 
tially moistened with a clammy perspiration, standing sometimes in large 
isolated drops like bullae upon the face and breast, or universally bathed in a 
profuse cold sweat. In some cases, the surface of the chest and abdomen is 
morbidly hot, while the extremities are cold. 
The tongue is sometimes pale and cold, sometimes dry, and sometimes 
again little altered from its previous state. There is almost always a feeling 
of epigastric weight or oppression, with tenderness upon strong pressure; and 
often of intense internal heat, with excessive and unquenchable thirst. This 
sense of burning heat and thirst is among the most striking symptoms, when 
taken in connexion with the positive reduction of temperature over the greater 
portion of the surface, and sometimes even within, as indicated by the tongue 
and breath. The patient calls incessantly for cold drinks, and can never be 
satisfied. u Oh that I could lie in the river!" " Oh that I could have a 
stream of cold water to flow through me I" are his frequent exclamations. 
(Parry, Am. Journ. of Med. Sci.^ N. S. vi. 29.) But whatever he drinks is 
usually rejected almost as soon as swallowed. Incessant vomiting is one of 
the most frequent symptoms. Sometimes, bile may be discharged, but gene- 280 
GENERAL DISEASES.-FEVERS. 
[part II. 
rally the matter thrown up is either what may have been swallowed, or a 
muco-serous fluid, occasionally tinged with blood. In many cases, there is 
only extreme retching, with little discharge. The bowels are sometimes con- 
fined, but oftener the reverse'; the dejections being exceedingly copious and 
frequent, in many instances not less than several times an hour. The dis- 
charges sometimes consist of a bloody serum, like the washings of flesh, some- 
times of blood nearly or quite pure, and cither dark-coloured and uncoagulable, 
or partially in clots. Several ounces of blood are not unfrequently lost with 
each evacuation. Torti, an Italian writer upon this disease, considers among 
the cases of pernicious intermittents those attended with copious bilious vomit- 
ing and purging, or dysenteric discharges with severe abdominal pains. But 
as these are incomparably less fatal than the, others, and depend rather upon 
vascular irritation or inflammation of the organs affected than upon morbid 
innervation, they do not come within the definition of the disease as here 
given. Indeed, the occurrence of bilious discharges may, in cases of perni- 
cious miasmatic fever, as in those of epidemic cholera, be looked upon as a 
favourable sign. In some cases, the abdomen is tympanitic; but this is not 
a common symptom. 
The state of the respiration is often highly characteristic. The breathing 
seems like a succession of deep sighs, and occasionally each inspiration is 
interrupted in its progress, and effected as if by a double effort. This last is 
considered by Dr. Parry as a fatal symptom. (Ibid., p. 29.) Occasionally, 
however, the respiration is hurried, irregular, and panting. The patient fre- 
quently complains that he cannot get his breath, and desires to be fanned, or 
longs for the external air. 
The pulse is small, irregular, sometimes corded, but often feeble and even 
fluttering. Occasionally it is intermittent. It is almost always very frequent, 
amounting to 120, and sometimes to 160 in the minute. Not unfrequently, 
it is quite absent at the wrist, though distinctly perceptible in the carotids. 
According to Dr. Boling, the action of the " heart is loud, strong, and tumult- 
uous.'" (Am. Journ. of Med. Sci., xi. 309.) This, of course, must have 
been so, in the cases observed by that writer. It is possible that the heart 
may have its natural share, and even more than its share of nervous energy, 
whilst the innervation of the extreme arteries and capillaries may be defective. 
But the remark does not correspond with my own observation. Generally, 
the heart, though for reasons explained elsewhere (see Pulse, p. 169) con- 
tracting very frequently, has appeared to me to be feeble, rather than ener- 
getic in its action. 
Along with the .symptoms above enumerated, there are often great restless- 
ness, general uneasiness, and jactitation. The patient, not aware of his ex- 
treme danger, and sometimes wondering at the anxiety' exhibited by his 
attendants, often attempts to rise from his bed, and, if not prevented, will 
■walk to the window or door of the apartment. The direct cerebral functions, 
including the action of the will upon the muscles, are singularly undisturbed, 
in the midst of the wreck of the organic life. The patient will sometimes 
walk about his room, hours after the pulse has ceased to be felt at his wrist. 
Occasionally, as in cholera, there is painful spasm of the muscles of the ex- 
tremities, especially of the calves of the legs. Indeed, the analogy between 
many of the symptoms above described, and those of epidemic cholera is very 
striking. 
As already mentioned, the course of the symptoms is various. Sometimes 
they continue as above described, with greater or less intensity, mingled, per- 
haps, with unsuccessful attempts at reaction, for a period varying from one 
to three days; when, unless relieved by remedial measures, they terminate CLASS I.] 
PERNICIOUS FEVER. 
281 
in death. The coldness increases, invading sometimes the whole body except 
a small portion near the heart; the respiration becomes slower and more 
sighing, with lengthening intervals between the acts; the pulse gradually 
sinks, and often quite ceases in the extremities for several hours before death; 
the cerebral functions at last fail; the countenance assumes the Hippocratic 
expression; and the patient usually dies tranquilly, as if falling into sleep. 
But much more frequently, after continuing for three or four hours, evi- 
dences begin to show themselves of a disposition to reaction. The skin 
becomes gradually warmer, the pulse fuller and stronger; and something like 
a febrile exacerbation usually takes place, though in no degree proportionate 
to the preceding prostration. Not unfrequently, repeated partial efforts of 
this kind are made, before reaction is accomplished; and sometimes the 
symptoms abate without the occurrence of a real access of fever. The warmth 
may be perceived gradually, but often very slowly, diffusing itself from the 
central parts of the body towards the extremities, the surface' at the same 
time losing its disagreeably clammy feel; the death-like hue and ghastly 
expression of the Countenance disappear; the vomiting and purging, if before 
existing, diminish greatly if they do not cease; the pulse resumes its ordinary 
fulness and strength, and at the same time becomes less frequent; and the 
patient seems as if about to be restored to health. 
Sometimes a degree of frequency of pulse remains, with uneasiness of sto- 
mach, some general languor or distress, and more or less of the other phe- 
nomena of the paroxysm. It is only a remission that has taken place. In 
other cases, the patient appeal's almost free from disease, with a natural pulse, 
a natural surface, some return even of appetite, and only a certain feeling of 
languor and perhaps of epigastric uneasiness remaining. This is an inter- 
mission. So far as concerns the treatment, the distinction is of little conse- 
quence; for the sanle measures are necessary in either case. Perhaps the 
chance of a favourable issue may be greater, in proportion to the completeness 
of the intermission. 
If the disease be not arrested by artificial means, the same train of symp- 
toms sets in at the corresponding hour of the following day, or the day after 
that, and usually with increased violence. This paroxysm often proves fatal; 
but often also the apparently overwhelming flood of disease ebbs once more, 
and affords to the patient another chance of safety. If this is lost, the third 
paroxysm is, in the great majority of cases, inevitably fatal. The symptoms 
preceding death are those already described, as sometimes occurring without 
any remission, within one, two, or three days of the first attack. It is not, 
however, every case of pernicious miasmatic fever that ends unfavourably, 
even without treatment. Sometimes nature proves* strong enough to resist 
the force of the disease; each succeeding paroxysm becomes milder and 
milder; and at length nothing but an ordinary intermittent is left. In other 
instances, the disease runs on with remissions, and cither subsides into an 
ordinary bilious fever, terminating in the ordinary way, or assumes a malig- 
nant typhoid character of various duration and issue. It is usually deemed a 
favourable incident, when copious alvine evacuations of a dark tar-like liquid 
take place from the bowels; as they indicate a restoration of the suspended 
action of the liver. 
It may be proper to notice some of the more prominent diversities in the 
variety of the disease above described; that, namely in which the organic 
functions are chiefly concerned. Sometimes the force of the disease appears 
to be directed especially to the heart, and the prominent phenomena are those 
of excessive prostration of the circulation. The patient is extremely weak, 
and becomes faint upon the least exertion, with excessive feebleness of pulse, 282 
GENERAL DISEASES.-FEVERS. 
[PART II. 
cold sweats, &c.; but without nausea, vomiting, purging, or abdominal distress 
of any kind. In this, as in the other forms, there may be one or two remis- 
sions or intermissions; but, unless saved by remedies, the patient dies at last 
of pure syncope. 
In other cases, the coldness is the most prominent symptom, gradually 
deepening as the paroxysm advances, and at length occupying almost the 
whole surface, without any primary extraordinary reduction of the pulse, 
and without disorder in the digestive functions. The heart at length gives 
way, and the patient perishes in the first or the second paroxysm. 
Again, instances frequently occur, in which more or less febrile action alter- 
nates or mingles with the signs of depression. Severe pains in the head, back, 
and limbs, flushes of heat followed by partial perspirations, a certain degree of 
fulness and strength of pulse, and hurried and oppressed breathing, mark these 
vain efforts of the system. They are the mere flashes of the, expiring taper; 
and finally give way before the force of the depressing causes. 
Sometimes, the paroxysm of an intermittent runs its usual course; but the 
perspiration with which it ends becomes exhaustingly profuse, and the perni- 
cious symptoms appear. 
Disease in the Animal Functions.-An equal diversity does not exist, in the 
cases of defective or deranged cerebral action, as in those in which the organic 
functions are primarily affected. In the former, the paroxysms are attended 
with a greater or less degree of stupor. Usually, they begin with simple 
drowsiness, the patient forgets quickly what he may have done, said, or desired; 
stops, when speaking, in the middle of a sentence, or uses one word for ano- 
ther; and often stammers. This dulness gradually increases into deep coma, 
from which the patient cannot be roused. The respiration is sometimes noisy, 
and stertorous as in apoplexy. . The pulse is full, and, though generally some- 
what accelerated, is much less so than in other cases, and occasionally is even 
slower than in health. It often, too, has considerable strength. Sometimes, 
there is a tetanic closure of the jaws; and, when they are forced open, and 
liquid introduced into the mouth, there is. found to be great difficulty, if not 
impossibility, of deglutition. Maillot, who treats of the disease as it occurred 
at Algiers, speaks of epileptic convulsions, with grinding of the teeth, and 
foaming at the lips, as having been sometimes observed. In some cases,. the 
comatose symptoms occur in the first paroxysm; but more frequently they 
are not completely established until the second; the first having differed from 
an ordinary paroxysm only in being attended with drowsiness, and a degree 
of slowness or hesitation in speech. If the comatose paroxysm do not end 
fatally, after a variable duration, some perspiration takes place, sensation 
gradually returns, and the patient may have no symptom of the disease 
remaining; though, more frequently, he continues somewhat soporose in the 
interval. The next paroxysm usually proves fatal, like an apoplectic attack, 
unless arrested. In some cases, the comatose symptoms are preceded by 
delirium. 
Dr. Boling, of Montgomery, Alabama, has noticed cases of remittent fever 
in which the morbid innervation took the character of tetanic spasms. After 
a few'febrile exacerbations, the approach of the paroxysm was marked by the 
occurrence of spasmodic phenomena, exactly resembling those of an attack of 
tetanus, which afterwards continued, increasing and diminishing in general 
with the exacerbations and remissions of the fever, until the close. In some 
instances, there was complete stupor or coma throughout the remainder of the 
disease; in others only during the paroxysms; and in most, some degree of 
intelligence remained. In no case did the disease extend beyond the fifth day 
after the supervention of spasm; and generally, if not arrested, it ended fatally CLASS I.] 
PERNICIOUS FEVER. 
283 
at an earlier period. Tlie result was generally unfavourable. (Ai Orleans 
Med. and Surg. Journ., iii. 733.) 
Diagnosis.-It is of the utmost importance to be able to distinguish this 
from the ordinary forms of miasmatic fever; because the safety of the patient 
depends upon the adoption of prompt and vigorous measures, which are not 
deemed necessary in other cases. When fully formed, the affection can 
scarcely be mistaken, if the practitioner be upon his guard. Its possible 
occurrence in any instance of bilious fever, should be borne in mind. I have 
no doubt whatever, that death frequently arises from a want of this caution. 
Cases of the kind have indeed fallen under my own observation. In the course 
of a bilious remittent, symptoms of a pernicious character appear, and yield 
perhaps after a time, either to the remedies employed, or in the regular course' 
of the disease. The amendment is very naturally supposed to be the com- 
mencement of convalescence, and no extraordinary measures of safety are 
resorted to. But the apparent retreat of the disease is only the preparation 
for a more vigorous onset, and, when the onset comes, in an unguarded state 
of the defences, it is irresistible. 
Not unfrequently, in the intermittent form of the disease, the first paroxysm 
offers nothing to alarm the physician; and, not apprehending anything serious 
in the second, he neglects a most important opportunity for the use of reme- 
dies. It is, therefore, highly desirable to know, whether there are any symp- 
toms in the preliminary paroxysm which prognosticate danger. Often there 
are such symptoms, which the physician should always be prepared to appre- 
ciate. An unusual paleness or lividness of the face; an absence of rigors or 
a sense of chilliness, while the extremities are really cold, and a want of 
uniform heat after reaction; a disposition to copious or frequent vomiting and 
purging, with a sense of unusual weight or oppression at the epigastrium; an 
extraordinary frequency, feebleness, or irregularity of the pulse; much anxiety, 
restlessness, or tossing about of the limbs, or a disposition to faintness; con- 
siderable delirium or drowsiness; a prolongation of the cold stage, and a less 
degree of febrile excitement than might have been anticipated; and the con- 
tinuance in the apyrexia of some mental confusion, sleepiness, faintness, or 
unusual anxiety and uneasiness; any of the above symptoms should be a suffi- 
cient warning to the practitioner, not tq delay for a moment, the measures 
requisite for interrupting the paroxysms. 
Anatomical Characters.-M. Maillot found in the cases which he exa- 
mined, amounting to thirteen in number, injection and opacity or opalescence 
of the arachnoid, injection of the pia mater, increased density and injection 
of the brain, deepened colour of the cortical substance, and limpid or bloody 
effusion in the ventricles. Similar marks of congestion in the spinal marrow 
were observed. The mucous membrane of the stomach was very often so 
much softened, that it might be scraped off in the form of pulp, sometimes 
thickened, in some instances bright red or blackish, and in others perfectly 
white. The duodenum, and portions of the jejunum and ileum, were similarly 
affected. Sometimes a great number of the isolated follicles were enlarged, 
without surrounding redness, sometimes punctuated patches of redness were 
observed. The colour was in some instances healthy, in others presented a 
blackish hue, with softness, and enlarged follicles. The liver was variously 
affected, being either red and soft like the tissue of the spleen, or enlarged, 
yellowish, dry, and brittle; or of enormous size and engorged with blood; or 
softened to the consistence of paste; or, finally, quite healthy. Of these 
alterations some were no doubt pre-existent. The spleen was always enlarged, 
generally much congested with blood, and either firm, or softened so as to 
resemble the lees of red wine, or of a pasty consistence and chocolate colour, 284 
GENERAL DISEASES.-FEVERS. 
[PART II. 
and in one instance ruptured. The contents of the chest were generally 
healthy. 
Cause.-The essential cause of this affection is undoubtedly the same as 
that of the ordinary forms of miasmatic fever. What it is that gives rise to 
its peculiar characters is unknown. We may say, in general terms, that it 
is probably a more intense action of the miasmatic poison, or an unusual 
susceptibility to its influence. Dr. Parry tells us that in Indiana, while ordi- 
nary bilious fever occupies the table lands, the pernicious form has been ob- 
served to prevail especially in the low grounds skirting the rivers. According 
to Dr. Lavender, of Selma, Alabama, intermittents and remittents are common 
in certain seasons when there is little or no pernicious fever. (Am. Journ. 
of Med. Sci., N. S., xvi. 44.) The latter is rare in the miasmatic districts 
of the Middle and Eastern section of the Union. I never saw a case in 
Philadelphia or the neighbourhood, except in the hospital among sailors 
recently from the southern coast, or among medical students from the South- 
ern and Southwestern States. Latitude, moreover, appears to have some 
influence upon the character of the disease; for, while in the countries liorth 
of the Ohio it generally assumes the intermittent form, in the State of Mis- 
sissippi, according to Dr. Wharton, this disposition is much less obvious. The 
weakness of old age, or previous disease, does not appear to constitute a pre- 
disposition; for, according to Dr. Parry, the greater number of fatal cases is 
between 25 and 35, and among the plethoric and robust (dm. J. of Med. 
Sci., N. S., vi. 28); and, according to Dr. Wharton, persons between 20 and 
30 are most subject to the disease. (Ibid., vii. 339.) The former of these 
observers never saw a case in an individual under 20; the latter states that 
the disease is comparatively rare under 10. A singular fact mentioned by 
Dr. Parry is, that, while new-comers in the miasmatic districts are much more 
subject to common bilious fever than the old residents, the latter are equally 
liable to the affection under consideration. M. Bricheteau, physician to the 
Hospital Necker, has published several cases, which would seem to prove that 
intermittents, occurring in old persons, and especially those debilitated by 
chronic disease, are apt to take on the pernicious character, and to prove ex- 
ceedingly fatal. (Archives Generates, 4e Ser., xiv. 184.) 
Nature.-What is it that imparts its peculiar character to the pernicious 
fever? Can it be inflammation? Is it possible that this process can be ex- 
tinguished and relighted, extinguished and relighted again, so suddenly? It 
has been suggested that, the general excitability being exhausted by the vio- 
lence of the paroxysm, the inflammation may continue to exist in the interval, 
and yet be unable to bring the system under its influence. But who can 
conceive of an acute and fatal inflammation of the mucous membrane of the 
stomach, with considerable appetite, or of the brain, with a perfectly sound intel- 
lect, and without headache or other cephalic uneasiness? Inflammation, in a 
certain degree, may co-exist with the'other phenomena; but it constitutes, in 
most cases, no portion of the danger; for all the difference between death, 
and a speedy restoration to health, lies in a few grains of quinia. Who has 
ever administered quinia, in ordinary cases of acute gastritis, or acute men- 
ingitis, with similar results? 
Is congestion the source of danger? I cannot think so. It is confessedly 
venous congestion that is present in these cases. We constantly meet with 
this condition in other complaints with no such results. We see it in syn- 
cope, when all the blood deserts the capillaries, and becomes concentrated in 
the veins and great organs. We see it in concussion of the brain, occasion- 
ally, in no less degree than in pernicious fever. We behold it in all cases of 
violent shock upon the nervous system, prostrating the power of that system, CLASS I.] 
PERNICIOUS FEVER. 
285 
and. consequently of the heart, as in severe surgical operations and violent 
injuries. Yet, in all these cases, it is not the congestion, but the nervous 
prostration that we fear. Let the latter be relieved, and the former ceases 
of course.* Congestion may occasionally do fatal mischief; as in cases of 
rupture of the spleen; but these are comparatively rare. 
It is in the peculiar state of the innervation, that we are to look for the 
source at once of the symptoms and the danger. This does not consist in a 
universal prostration of the nervous power. On the contrary, while defective 
in relation to certain functions, it may be unimpaired in others. Let us apply 
this view to an explanation of the symptoms. In the first place, in relation 
to the cases of collapse, in which the organic functions are especially con- 
cerned. This is prominently characterized by a want of action in the capil- 
laries and extreme arteries. Some suppose that these vessels are spasmodi- 
cally contracted. There is no evidence whatever of the existence of such 
spasm. They collapse simply because they contain no blood, just as they 
collapse in death. All parts of the organism receive a certain supply of nerv- 
ous influence, which is essential to the due performance of their functions. 
The extreme vessels are probably not less under that influence than other 
parts. Evidence of this fact is abundantly supplied by physiology. In the 
pernicious fever, the innervation of the extreme vessels fails, and they cannot, 
therefore, perform their part effectively in the circulation. The blood enters 
them with difficulty, in their enfeebled state, and is carried through them 
very slowly. Hence the paleness; and hence also the lividness of the sur- 
face, owing to the stagnation of. the blood. Prom the same approach to 
nervous death in these vessels, they allow the watery portions of the blood to 
ooze through them, almost as through dead membrane. Hence the profuse 
sweats. The coldpess obviously arises from the languid circulation, and defi- 
cient change of blood. This condition of the capillaries may co-exist with 
considerable power in the heart; for the want of innervation is not necessa- 
rily equal in the whole circulation. But sometimes the deficiency is ex- 
perienced first and specially by the heart. In such cases, syncope or a tend- 
ency to it is the prominent symptom. 
The function of respiration sometimes suffers from the same deficiency of 
innervation. The pulmonary capillaries cease to carry forward the blood with 
the usual rapidity, and the due aeration does not take -place. Hence the feel- 
ing of oppression of chest and want of breath, the deep sighing, &c. Some 
writers ascribe these phenomena to congestion of the lungs. They are the 
consequence of a want of proper decarbonization or oxidation of the blood, 
not of - mere congestion. In the cases of Maillot, the lungs were found re- 
markably free from disease after death. 
But how account for the oppression of stomach, and the copious vomiting 
and purging? Upon the same principles exactly. There is no feeling of 
the stomach, unless it may be excessive spasm, which is more insupportable 
than that arising from deficient innervation. This can be readily understood 
by those who have experienced the distressing sensations of a half paralyzed 
limb. The bloody serum, or pure blood, discharged from the stomach and 
bowels, escapes through the coats, of the vessels, exactly as blood percolates 
through the tissues after death; with this exception, that, as the vis a tergo 
still continues in.some degree, it adds a vital expelling force to that of mere 
physical transudation. The alimentary canal may be said to sweat, like the 
external surface. An appeal may be made to the discoloration, softening, 
* For an interesting paper on this subject by Dr. Isaac Parrish, of Philadelphia, the 
reader is referred to the .American Journal of the Medical Sciences, N. S., ix. 293. 286 
GENERAL DISEASES.-FEVERS. 
[PART II. 
&c., of the mucous membrane, as evidences of inflammation or congestion. 
I am not disposed to deny the existence of inflammation, in some degree, in 
this membrane. But it is quite insufficient to account for the symptoms. 
We do not witness the same phenomena in other cases of much more exten- 
sive inflammation. Besides, much of the softening of the tissue may be 
ascribed to depressed vitality, and much of the discoloration to the stagnation 
of blood, like the livid or purple colour of the skin. 
But the thirst and sense of internal heat; are they nob signs of congestion 
or inflammation ? By no means. Thirst is a common accompaniment of all 
conditions of disease in which the capillaries are emptied of their blood, and 
such is undoubtedly the source of it here. (See Thirst, page 164.) The heat 
can be referred only to morbid nervous influence. That there is no real in- 
crease of temperature within, is inferred from the state of the tongue. Besides, 
the sensation is not confined to the internal parts. • I have known patients to 
complain, under these circumstances, of distressing heat of surface, when their 
skin was positively much below the healthy temperature. This is merely 
another example of morbid innervation. It appears, then, that this defect or 
derangement of innervation lies at the basis of all the morbid phenomena of 
the organic functions. The congestion necessarily follows the prostration of 
the active circulating forces. The pulmonary capillaries, the heart, and the 
systemic capillaries are all enfeebled; the blood, therefore, collects in the 
veins and in the great internal organs, especially in those connected with the 
portal circulation. Hence the congestion of the liver and spleen. When the 
circulatory movements return with their wonted activity, under the restored 
innervation, the congestion is speedily dissipated. 
In the cerebral cases, the deranged innervation is experienced primarily 
and chiefly in the lobes of the brain. The organic functions are at first com- 
paratively unaffected, the heart often continuing to act with energy, and the 
surface to retain its warmth, when the patient is quite insensible. That the 
affection is chiefly nervous, is to be inferred from its periodicity. There may 
often be congestion; there may sometimes be inflammation of the brain. But 
the presence of an excess of blood is probably due less to increased determina- 
tion, than to stagnation in the capillaries. The colour of the cortical portion 
is described by M. Maillot as approaching to black. The brain differs from 
other organs in the circumstance of occupying a closed cavity, into which 
atmospheric pressure alone would force the blood, so that feebleness of the 
capillaries cannot here be followed by paleness as upon the surface. The 
vessels must always be full, or the vacuity must be compensated by effusion. 
Redness, therefore, and serum in the ventricles are not necessarily signs of 
over-excitement. But I am not disposed to maintain, that the cerebral affec- 
tion in these cases is certainly the result of diminished sensorial action. It 
may be so; or it may proceed from some other derangement of that action. 
All that I would maintain is, that the affection is essentially nervous; and 
that upon this the danger depends. The patient dies, not because he has too 
much blood in his brain, but because the brain becomes incapable, from the 
direct influence of the morbid cause, of performing the functions essential to 
life. This question is not merely speculative. It is on the contrary highly 
practical; and its decision, one way or the other, may greatly influence the 
treatment. If the disease be considered in the light of apoplexy or cerebritis, 
copious bleeding would suggest itself as the appropriate remedy; if it be nerv- 
ous, we must look for safety to some means capable of strongly impressing 
the nervous system. 
Prognosis.--This is exceedingly unfavourable in all cases, either not 
treated at all, or treated inefficiently. According to Dr. Parry, three-fourths CLASS I.] 
PERNICIOUS FEVER. 
287 
of the cases without treatment, or with the usual treatment for bilious fevers, 
end fatally. Under proper management, the. fesult varies greatly with the 
opportunities of the physician. If the disease be intermittent, and seen so 
that remedies can be applied during the whole intermission, the life of the 
patient may almost always be saved. If seen during the first or second 
paroxysms, the dangers of these may often be averted, and many recover. 
Few comparatively can be saved from the third pernicious paroxysm. In the 
remittent or continued form, the danger, one would suppose, must be greater; 
yet, out of 186 cases of all kinds, Maillot had 38 deaths or 1 in about 5; 
while 99 remittent or continued cases, gave only 19 deaths, or very nearly 
the same proportion. (Trait. des fievres, &c., p. 277.) This was under the 
quinia treatment. ■ Bailly gives the result of 886 cases in the hospitals at 
Rome, in 1818 and 1819, at 545 cures and 341 deaths, or one out of 2-6. 
( Trait. Anatomico-patholog. des fev. intermit. Append., p. 10.) Dr. Parry 
gives the general result of special treatment at 1 death in 8 cases. (Am. J. 
of Aled. Sei:, N. S., vi. 28.) Dr. Wharton states that the disease does not 
prove fatal in more than 1 case out of 12 or 15, "under proper treatment 
timely administered." (Ibid., vii. 339.) Of course, the general average of 
deaths must be greater than this; for all cases cannot be seen in time. 
Treatment.-If the patient is seen first in the paroxysm, the urgent indi- 
cation is as soon as possible to bring about reaction. Not long since, under 
the notion that congestion was the evil to be encountered, copious bleeding, 
and large doses of calomel, were the remedies most relied on by many prac- 
titioners. Experience, however, has proved the frequent inefficiency and 
even danger of this practice; and the profession generally are rapidly aban- 
doning it. In some of the cerebral cases, with a full and tolerably strong 
pulse, it is proper to abstract blood from the arm, and also to take it locally 
from the temples; but in all others, the remedy is much worse than useless. 
While the whole organic actions of the system are prostrate under the vast 
nervous depression, and life is running out with the serous discharges from 
the skin, and the sero-sanguineous discharges from the alimentary canal, to 
open another outlet in the arm seems as contrary to sound pathological prin- 
ciples, as it is opposed by multiplied experience. Exactly the opposite course 
should be pursued. Efforts should be made to rouse the nervous system from 
its lethargy, and to restore the organic actions; while further exhaustion is 
prevented by checking the profuse exhalation from the inner and outer sur- 
faces of the body. 
One of the most obvious remedies is artificial heat. Heated bricks, bottles 
filled with hot water, heated fiat irons, &c., may be placed along the limbs, 
without being in contact with them; the feet may be placed in hot water or 
mustard-water; or the whole body may be immersed, if convenient, in a hot 
bath of the temperature of 105° F. Sinapisms may be applied to the ex- 
tremities) and over the whole abdomen, or along the spine; or frictions may 
be made with heated Cayenne pepper and brandy, or hot oil of turpentine. 
Some recommend very strongly, as the most efficacious external remedy, espe- 
cially when the perspiration is profuse, dry friction over the whole body with 
Cayenne pepper or mustard; and I have no doubt of its usefulness. Besides 
the measures mentioned, a strong ammoniacal liniment may be applied along 
the spine, so as to excite redness over its whole length. Dr. Lewis of Alabama 
strongly recommends dry cupping over the spine. (N. Orleans Aled, and 
Surg. Joum., iv. 172.) To sustain a more steady excitement, blisters may 
be applied to the insides of the legs and arms. 
Nor should internal remedies be neglected. Opium is strongly indicated 
for its stimulant and anti-emetic properties, and for its influence in arresting 288 
GENERAL DISEASES.-FEVERS. 
[part II. 
alvine discharges. It is, upon the whole, most advantageously used in sub- 
stance. When the stomach is retentive, laudanum may be preferable from 
its somewhat quicker action; but it is more apt to be rejected than opium. 
When the latter offends the stomach, one of the salts of morphia may be sub- 
stituted in an equivalent dose. The only circumstance which would strongly 
contraindicate the use of opium is the existence of obvious disease of the brain, 
as shown by active delirium or stupor. Acetate of lead is an astringent pecu- 
liarly adapted to the case, and may be given, with great propriety, when the 
evacuations are copious, and especially when they are hemorrhagic. Kino, if 
borne by the stomach, may be added. As stimulants, the best are probably 
oil of turpentine and Cayenne pepper. But should these fail, recourse may 
be had, especially in the cases of syncope, to ammonia, wine, brandy, or ether. 
It is better, however, if possible, to get the patient through without alcoholic 
stimulus, which may possibly prove injurious in the subsequent reaction. 
Camphor is a favourite remedy with many practitioners; but I have little 
faith in it in these cases; and, in the existing irritability of stomach, it is 
best not too much to complicate prescriptions. Sulphate of quinia may be 
advantageously employed, even in the paroxysm, before reaction. It is indi- 
cated for its excitant influence upon the nervous centres, and is all important 
in reference to the next paroxysm. It may be given in any prostrate case, 
in which it can be borne by the stomach. Another remedy, which is decidedly 
called for, is calomel. The complete inactivity of the liver which exists in 
most cases demands interference, and, when the case approaches the continued 
form, it is of great importance to establish the mercurial influence. The 
proper combination of these remedies, and the regulation of their dose and 
time of administration, are scarcely less important than the remedies them- 
selves. As a general rule, when the head is not affected, and the discharges 
are copious, opium should be added to all the other medicines. 
In the worst cases, medicine should be given as often as every half hour 
until some excitement is evinced. Two grains of sulphate of quinia, two 
grains of calomel, and half a grain of opium, may be made into one or two 
pills, according to the patient's ability to swallow, which, along with one or 
two other pills containing five grains of Cayenne pepper, may be given every 
hour; while, at the intervening half hour, the patient, in cases attended with 
profuse alvine discharges, may take two grains of acetate of lead, five grains 
of kino, and half a grain of opium, made into two or three pills. When time 
is of the utmost consequence, the above doses may be increased; when there 
is more time to spare, the interval may be lengthened. Of course the pro- 
portions must vary to suit circumstances. So also must the articles employed. 
If the Cayenne pepper should not agree with the stomach, or appear insuffi- 
ciently excitant, twenty or thirty minims of the oil of turpentine may be 
substituted; and even considerably larger doses are,sometimes well borne; but 
the tendency of this medicine in large doses to purge must be remembered. 
Should the kino offend the stomach, it may be omitted. Of course, neither 
this nor the acetate of lead is to be employed, when there is no considerable 
diarrhoea, or hemorrhage from the bowels. The calomel may be suspended 
when the patient has taken from ten to twenty grains, and, at any time, if 
the least soreness of the gums should be perceived. 
It is sometimes long before reaction appears, but the practitioner should 
not be discouraged while life remains. The remedies above mentioned should 
be persevered in, with the addition, if necessary, of wine or brandy, until heat 
begins to be restored to the surface, and the pulse to acquire increased fulness. 
They may then be gradually relaxed; and, after reaction has been fairly CLASS I.], 
PERNICIOUS FEVER. 
289 
established, should be cautiously omitted. At this point the patient may be 
considered comparatively safe. 
It would be wrong not to mention that other means of producing reaction 
have been highly recommended. Some practitioners in dhe west and south- 
west habitually employ cold affusion, or the cold bath. Dr. Gustine, of 
Natchez, informed the author, that he had once immersed a patient, while in 
the lowest stage of a pernicious paroxysm, with a cold skin, and nearly or 
quite pulseless, but complaining bitterly of the burning heat which was con- 
suming him, ima bath of cold water, with the happiest effect. The remedy 
was agreeable to the patient; and he was allowed to remain until he began to 
feel somewhat chilly, when he was removed, wiped dry, and placed in bed. 
Reaction came on. delightfully, and his life was saved. Dr. Richmond, an 
old and experienced practitioner of Indianapolis, is in the habit of causing his 
patient to lie naked at full length, and of pouring cold water from a pitcher 
upon him from head to foot, until he begins to shiver, when he is wrapped in 
a blanket, and plied with stimulants diligently, internally and externally. I 
was assured, that this measure had proved effectual in several apparently 
desperate cases. Dr. Barbour, of St. Louis, Missouri, esteems the effusion of 
cold water above all other means in the treatment of this disease. (Observ. on 
Int., Remit., and Congest. Fever, St. Louis, 1847, p. 26.) The remedy is 
certainly one not to be hastily rejected. Nature seems to point it out by the 
burning heat of which the patient complains, and the great comfort he derives 
from the remedy. Nor is it irrational. The nervous system is chiefly in 
fault in these cases. Perhaps there is no stronger shock to that system than 
the one produced by the sudden impression of cold upon the skin. If there 
be any power of reaction left, it is apt to be awakened by this shock. But 
care must be taken not to carry the remedy beyond the production of a chilly 
seps^tion, or slight shivering. This is the condition of an ordinary chill, and 
it is wanting in the cold stage of pernicious fever. Perhaps the best mode of 
reducing the latter to the former, would be the employment of a measure 
calculated to produce the sensation of chilliness. 
Another remedy employed by some practitioners in the west and south, in 
the pernicious paroxysm, is an emetic. But of the particular circumstances 
under which they generally use it, I have not been informed. I can readily 
understand that it may sometimes rouse the system, and bring about reaction, 
when the, stomach is not already irritable. The remedy has long been em- 
ployed in the protracted chill of ordinary intermittents, as one mode of exciting 
reaction, though now generally superseded by less disagreeable remedies. 
When the paroxysm of pernicious fever is marked by coma, blood, as before 
observed, may be taken from the arm and temples, when the pulse is strong. 
In doubtful cases; it may be better to rely upon cups alone. Towels wet with 
ice-cold water should be placed around the head, or a bladder filled with 
pounded ice applied to it; while action is invited to the lower extremities by 
hot foot-baths, sinapisms, &c. If the patient can swallow, a dose of calomel 
should be given, followed by some other cathartic or an enema; but the chief 
reliance must be placed upon the treatment in the remission or intermission. 
After reaction has been produced, if the case do not eventuate in a decided 
remittent or intermittent, it is to be treated as ordinary bilious fever; care 
being taken to watch it vigilantly, and guard against any tendency to relapse 
into the prostrate state, which is not uncommon. If the bowels have been 
previously confined, the calomel which was given in the cold stage, should 
now be carried off by a dose of castor oil, or of a mixture of that medicine 
with oil of turpentine, which, under these circumstances,' is strongly recom- 
mended bv Dr Wharton. Its oneration mav sometimes he much facilitated. 290 
GENERAL DISEASES.-FEVERS. 
[part II. 
according to the same authority, by a hot bath. Dr. Wharton does not con- 
sider his patients safe, in this state of the disease, until he has obtained 
copious black tarry evacuations from the bowels. 
As soon as a remission or intermission has been obtained, there is but one 
course of treatment, and that is all important. There should be no delay for 
previous treatment; no waiting for a more perfect relief from this, that, or 
the other symptom. Such dallying has been but too often fatal. No matter 
whether the patient has been under treatment during the paroxysm or not, 
no matter how partial the remission, provided it be a remission, no matter at 
what period of the interval the practitioner may have been called, his first, 
his last, almost his only thought, should be sulphate of quinia. This is the 
remedy for the disease, and only this. At least none other approaches to it 
in efficacy; sulphate of quinia being considered merely as the representative 
of the virtues of Peruvian bark. From thirty to sixty grains of this salt 
should be given, from the commencement of one paroxysm to that of the next. 
If none has been given or retained, during the paroxysm, the whole should 
be administered in the remission or intermission. - The dose must be regulated 
by circumstances. When the disease is quotidian, with a short apyrexia, the 
doses must be large; when tertian, they may be smaller. They should be 
administered so that the whole quantity may be got down two or three hours 
before the time for the recurrence of the paroxysm. From two grains up to 
half the amount necessary for the whole interval, may be given at once. 
Nothing should deter from the administratibn of this remedy. Even exces- 
sive irritability of stomach is no sufficient contra-indication. If the quinia be 
rejected alone, it should be combined with opium or morphia; if still rejected, 
it should nevertheless be administered in the hope that a portion at least may 
be retained; and recourse should be had to enemata, and to the endermic 
application. If administered by injection, it should be mixed with laudanum 
or morphia, and should be given in double or triple the quantity that might 
be necessary by the mouth. If applied externally, a large blistered surface 
should be made over the epigastrium, and the salt applied very much diluted, 
in order to prevent inflammation, and consequent interference with absorp- 
tion. 
The paroxysm is thus almost always prevented, or, if not, is rendered much 
lighter than it would otherwise have been. But the sulphate of quinia should 
be continued, in quotidian cases, without abatement, unless in consideration of 
its effects upon the head, until the period for the second paroxysm is passed. 
The disease is then subdued; or at least all of it which belongs to the perni- 
cious fever. The remaining treatment, if any is requisite, must be conducted 
as in ordinary cases. > x 
Article III. 
YELLOW FEVER. 
Syn.-Typhus Icterodes {Cullen').-Bulam Fever {Pym').-Vomito Negro, Vomito 
prieto {Span). 
This is a peculiar disease, prevailing only within limited districts, and at 
certain seasons of the year. An average temperature of 79° or 80° F., con- 
tinued for two or three months, appears necessary for its production. It is, 
therefore, a disease of hot weather and warm climates. The season at which 
it usually appears, is the latter part of summer and beginning of autumn; CLASS I.] 
YELLOW FEVER. 
291 
and it always ceases with the occurrence of frost. It is very seldom met with 
north of 40°, because, though the summer heats may be very great, they are 
not sufficiently long continued. Nor is it diffused uniformly within its recog- 
nized limits. A singular and important fact in relation to this disease is, that 
it is confined almost exclusively to towns, or other' situations where human 
beings congregate, as to garrisoned forts, or ships. It is chiefly, moreover, 
in towns upon the sea-coast, or upon streams emptying into the ocean that it 
is met with. It seldom or never shows itself, as a prevailing disease, in a 
scattered population, or at a distance from navigable waters. Another inte- 
resting fact is, that it does not occur in all countries, where the circumstances 
apparently favourable to its production exist in an equal degree. Thus, 
while it is 'exceedingly common in the sea-port towns of intertropical America, 
and not unfrequent in those of south-western Europe, it is almost unknown 
in those of Asia, eastern Africa, and south-eastern Europe. We never hear 
of it in Canton, Calcutta,-Alexandria, Smyrna, or Constantinople; while 
every one is familiar with its ravages in Vera Cruz, Havana, New Orleans, 
Gibraltar, and Barcelona. The relative frequency of its occurrence in its 
different sites, bears some proportion to the duration arid intensity of the hot 
season. Thus, in many cities of the West Indies, and of the Mexican coast, 
it is scarcely ever absent during the hottest period of the year; in New Or- 
leans, Mobile, and Charleston, though exemption can never be counted on, 
yet the disease does not prevail every summer; and in Baltimore, Philadel- 
phia, and New York, it makes its appearance only at distant intervals. In 
the more southern latitudes it may be considered as endemic, in the northern 
as in some measure epidemic. 
bellow fever exhibits a great diversity of phenomena.' Epidemics of it, 
occurring in different places, appear, from the testimony of eye-witnesses, to 
have been marked by very different characters. Miasmatic exhalations have 
impressed upon it, in some instances, a close analogy in its syrdptoms and 
course with ordinary bilious fever. x The effluvia generated among the filth of 
congregated masses of people, may be readily supposed to have occasionally 
given it a typhous form. The scorbutic tendency of system, generated in 
garrisons and ships, must have often modified its symptoms. To describe 
minutely all the varieties arising from these, and other similar causes, would 
be incompatible with the objects of this work. An acquaintance with the 
characteristics of the disease, in its ordinary form, and with the morbid effects 
of the causes alluded to, in connexion with the- obvious influences to which 
the patient may be exposed, will generally enable the' practitioner to detect 
and discriminate its various complications. As in most other fevers, the state 
of system may in this be sthenic or asthenic, inflammatory or typhous.-• 
Owing to the different susceptibilities of individuals, and the variable intensity 
of the cause, there is every grade of violence, from a mildness in no way 
alarming, to the mosl fatal malignancy. Curious and inexplicable anomalies 
also not unfrequently occur, which defy classification. I shall first describe 
the disease as it most commonly appears, and then refer briefly to its diver- 
sities. 
Symptoms, Course, &c.--The attack is sometimes preceded by the - usual 
preliminary symptoms of fever (see page 80), but perhaps quite as frequently 
comes on abruptly, in the midst of ordinary health. It is said to occur very 
frequently in the night. There is usually some chilliness at the commence- 
ment, seldom, however, amounting to rigors or shivering; and this symptom 
is often altogether wanting. Among the most characteristic phenomena of 
the incipient stage are severe pains in the back and limbs. After febrile 
action has become established, the skin is hot and dry, the pulse frequent, the 292 
GENERAL DISEASES.-FEVERS. 
[PART II. 
respiration hurried, the face flushed, and the eyes red and watery. The 
tongue is usually moist and covered with a white fur, and the throat occa- 
sionally sore, so as to render deglutition difficult. Nausea or other uneasiness 
of the stomach, with or without vomiting, not unfrequently attends the dis- 
ease from the commencement; but, in the majority of cases, the gastric symp- 
toms are not fully developed until after the lapse of some time, perhaps from 
twelve to twenty-four hours, when they become very prominent. The patient 
complains of a burning pain, or a feeling of weight and tension, or a vague 
sense of oppression in the epigastrium; pressure upon this region generally 
occasions severe pain; and the stomach is exceedingly irritable, often rejecting 
everything that is swallowed, and throwing up its own morbid contents when 
undisturbed. The act of vomiting is often violent, with retching, and much 
distress from the extreme tenderness of the stomach. Flatulence is also occa- 
sionally a troublesome symptom. The desire for cold drinks is usually ex- 
treme; and ice, held in the mouth and slowly swallowed, is very grateful, in 
consequence of the intense gastric heat. The bowels arc ordinarily costive, 
and sometimes obstinately so; and, when discharges are obtained, they are 
generally unhealthy in appearance, and offensive. But the nervous symptoms 
are probably those from which the patient suffers most. There is almost 
always headache, generally in the forehead and eyes, and sometimes confined 
to one side. This is often exceedingly violent, and continues in a greater or 
less degree through the whole period of febrile excitement. The pains in the' 
back and limbs also, which often usher in the disease, continue after the fever 
has been fully formed, and are sometime^ insupportably severe, extorting 
groans and even screams from the patient. The mind is usually much dis- 
turbed in this stage. The patient is apprehensive, anxious, and exceedingly 
restless; and the countenance is strongly marked with the expression of these 
feelings. Delirium is not an uncommon symptom; and shows itself in vari- 
ous degrees, from slight mental confusion to maniacal violence, with a wild 
fiery look, and uncontrollable movements. Sometimes there is a greater or 
'less degree of stupor, through which, when short of coma, the signs of distress 
show themselves as through a veil. 
These febrile symptoms continue, usually with little or no remission, for a 
period varying from a few hours to three days, and sometimes even longer. 
The duration is shorter in the more violent cases, and longer in the mild; 
and in the latter is sometimes extended to four or five days, with a more 
decided tendency to remission. Having run its course, the fever subsides, 
and a great apparent amelioration of the disease is experienced. The skin 
becomes cooler and softer, the pulse nearly or quite natural, the respiration 
calm, and the stomach comparatively quiet. The headache, and the excruci- 
ating pains in the back, if not previously relieved, disappear; and the patient, 
freed from the distress of body and mind, becomes comparatively cheerful and 
hopeful, and not unfrequently confident of recovery. It is not unusual to 
find him sitting up, either in or out of bed, and to be told by him that he is 
quite well, But this is a delusive calm. Sometimes, indeed, convalescence 
dates from the subsidence of the fever, in mild cases; but generally the great 
struggle is yet to come. This apparent amelioration is not, in any respect, 
comparable to the remission or intermission of miasmatic fever. The disease 
still continues unabated. It is only that the febrile phenomena have disap- 
peared under the failing powers of the system. The struggle against the 
noxious influence has ceased for a time. The continuance of the fever would 
be a favourable rather than unfavourable sign; as it would evince a greater 
ability of the system to cope with its ferocious adversary. 
There are phenomena, even during this temporary calm, which evince the CLASS I.] 
YELLOW FEVER. 
293 
existence of undiminished danger. Upon pressure in the epigastrium, the 
tenderness, instead of being diminished, is found to be greater even than 
before. The redness of the conjunctiva, and the flush of the face may be 
gone; but in their, place is often a yellowish or orange colour, which gradu- 
ally extends itself, from the forehead, and eyes, to the face, neck, and chest, 
and ultimately, in a greater or less degree, over the whole body. The urine 
also has a yellow tinge, which, even though the discharge may appear in mass 
of a dark-brown colour, may be detected when it is in thin layers. The pulse 
is sometimes even slower than in health, and has been known to descend to 
40 in the minute. In bad cases, there is sometimes a little heaviness or 
stupor. This period of apparent abatement may continue but a few hours, 
or may be protracted for twenty-four hours. 
Another class of phenomena now ensue; those, namely, of debility or pros- 
tration. In severe cases the weakness is extreme. The pulse is quick, irregu- 
lar, and feeble; the skin is yellow, orange, or of a bronzed appearance; the 
blood appears often to be nearly stagnant in the capillaries, so that, when 
removed by pressure with the finger from a portion of the skin, the colour 
returns very slowly; the . dependent and extreme parts of the body, as the 
fingers, toes, scrotum, and back, become of a dark purplish hue. The tongue 
is now often brown and dryish in the centre, or smooth, red, and chapped; 
and sordes occasionally collect about the gums and teeth. The stomach 
resumes all its former irritability; everything swallowed is thrown up again; 
and amew matter is ejected, consisting of brown or blackish flakes or particles 
diffused in a colourless liquid, which may be at first slightly tinged by them, 
but ultimately becomes black and opaque. In very malignant cases, the con- 
dition of system above described may come on even so early as the first day; 
and occasionally, the extreme capillary prostration, with the purplish skin, 
and a pulse scarcely perceptible at the wrist, ensues, while the heart and 
large vessels are still beating tumultuously. The urine, often scanty and 
high-coloured during the fever, is now sometimes nearly natural, sometimes 
almost or quite suppressed, and occasionally, though rarely, retained. . At 
this stage of the disease, hemorrhage occasionally takes place from various 
parts of the body, especially from the mucous membranes. Blood oozes from 
the gums, the fissures in the tongue, the fauces, and the nostrils. It is some- 
times also vomited, or discharged by stool, or with the urine; and petechias 
and vibices, arising from its extravasation, appear upon the skin. The irri- 
tability and extreme distress of the febrile stage are now replaced by an extra- 
ordinary apathy; and the countenance expresses a quiet resignation, or gloomy 
indifference. The pulse at length almost ceases; the respiration becomes slow, 
sighing, and occasionally-interrupted by hiccough; the skin assumes a cold 
and clammy feel; the bowels often give way and - discharge large quantities 
of black matter, similar to that ejected by the stomach; low delirium sets in; 
an offensive odour sometimes exhales from the whole body; the eyes become 
sunken, and the countenance collapsed; and death takes place, often quietly, 
but sometimes in the midst of convulsions. Black vomit, yellowness of the 
skin, and hemorrhage, have been mentioned as attendants upon this last 
stage; but patients often die without them. 
Instead of pursuing this fatal course, the systeiii v6ry often reacts after the 
period of abatement, and a secondary fever sets in, which may be of various 
grades of violence, but may always be regarded as a salutary effort of nature, 
or at least as a sign that the vital energies are not yet exhausted. This 
febrile affection continues, without any special or peculiar symptoms, a varia- 
ble length of time; sometimes speedily terminating in health, with the ordi- 
nary signs of convalescence, sometimes ending in fatal exhaustion, and occa- 294 
GENERAL DISEASES.-FEVERS. 
[PART II. 
sionally running into a typhoid form, which may last, with variable results, 
for two or three weeks or more. 
When convalescence takes place from severe cases of yellow fever, it is 
commonly tedious, in consequence of the amount of repair which is necessary 
to restore the dilapidated organs; and the patient is often incommoded, in 
the course of it, by obstinate and unhealthy sores or abscesses in various parts 
of the body. 
From a review of the course of yellow fever; as above described, it will 
appear that it has usually three distinct stages. The first is that of the 
primary febrile action, which continues from a few hours to several days, 
on the average, perhaps, from thirty-six to sixty hours. The second is that 
of subsidence or abatement, in which the exhaustion of the excitability 
leaves the system in a state of temporary repose, and which may continue, in 
a greater or less degree, from twelve to twenty-four hours. The third stage 
is that of secondary fever, or collapse, according as the system has or has 
not the strength to rally under the depressing influences to which it is sub- 
jected. In fatal cases, death takes place most frequently on the fourth, fifth, 
or sixth day, though sometimes as early as the third, and sometimes as late 
as the ninth or even the eleventh day. In some rare instances, in which the 
disease runs into a protracted typhoid form, it may be postponed considerably 
longer. 
It has been already stated, that the disease is liable to great diversity. 
Most frequently, the action iu the first stage is inflammatory or sthenic, with 
a full, strong, and sometimes tense pulse. In other instances, the state of 
system is asthenic from the commencement; the pulse being very frequent 
and feeble during the febrile excitement, or the general strength being inade- 
quate to rally from beneath the first force of the blow, and the symptoms 
at the beginning being those of great prostration, especially .of tlie whole 
capillary system. In the fashionable language of the day, these cases are 
denominated congestive. Universal weakness, with obscure, and as it were 
paralytic pains in the back and lower extremities, and a sense of weight or 
stupefaction in the head; the skin dry, unctuous, or perspiring,, without tone, 
and without heat, unless near the centre of the body; the pulse sometimes 
frequent, and sometimes full, but often slow, always feeble, and occasion- 
ally almost wanting at the wrist, while the heart and carotids may be throb- 
bing tumultuously; the face pale or purplish, with an expression of counte- 
nance either stolid and apathetic, or sullen, or such as usually indicates a 
feeling of horror or intense agony; these are some of the symptoms which 
mark the most malignant cases. Occasionally the system evinces a dispo- 
sition to rally, and signs of febrile action are exhibited; but these for the 
most part quickly give way, and complete collapse ensues. Copious dis- 
charges-of black vomit, occasional hemorrhage and petechias, a dark ma- 
hogany or bronzed colour of the surface, and an almost entire annihilation 
of sensibility, precede death, which often takes place on the third or fourth 
day. 
Sometimes the patient is struck down suddenly with stupor or coma, and 
death is preceded by convulsions. Sometimes the most prominent symptoms 
are those of overwhelming precordial oppression, with a slow laboured respira- 
tion, and deep sighs and groans. Occasionally the force of the disease appears 
to be expended upon the stomach, producing incessant vomiting, with intense 
epigastric distress. In other instances, the animal functions seem to be at 
first almost untouched. The patient may be walking in the streets, and 
nothing call attention to his case, unless, it may be, an unusual expression of 
countenance. Upon his pulse being examined, it is found to be exceedingly CLASS I.] 
YELLOW FEVER. 
295 
feeble, if not quite absent at the wrist. Black vomit and death speedily 
ensue. These have been called walking cases. Again, there are instances in 
which the pulse is nearly natural, the tongue clean, and even the stomach 
calm, from the commencement; but great anxiety and distress, with excessive 
restlessness, give occasion for alarm; and the worst apprehensions are soon 
confirmed by the occurrence of black vomit and fatal prostration. Dr. Rush 
used to warn his pupils to beware of the natural tongue, and the natural pulse 
in yellow fever. 
But it must not be forgotten that, while these terrible cases are not unfre- 
quent during the prevalence of this pestilence, there are others also in which 
the disease puts on a very mild form, with the ordinary symptoms of mode- 
rate febrile excitement, which subside in three, four, or five days, very often 
with perspiration, leaving the patient quite convalescent; and that between 
these two extremes there is every possible diversity of grade. 
It will be proper, before closing an account of the symptoms, to call atten- 
tion to some of the more prominent of them severally. 
The pulse is usually, in the inflammatory cases, and in the febrile stage, 
from 100 to 120, with considerable force, and sometimes tense. Occasionally, 
it is jerking and even bounding. In the more feeble eases it is often very 
frequent, from 120 to 140 for example; but at the same time small and weak. 
In the same kind of cases, it is in some instances very full, and may readily 
deceive a careless observer; but it may be at once distinguished by yielding 
with great facility under the finger, as if filled with air. In the second stage, 
it becomes slower, sometimes more so than in health, and is not unfrequently 
nearly or quite natural. In the last state, it again increases in frequency, 
but is almost always rather feeble, and, in the prostrate condition, is small, 
extremely weak, often irregular, and sometimes pearly or quite absent for 
some time before death. In the asthenic cases, where there is little or no1 
reaction, it may have this latter character from the commencement. 
The countenance is peculiar in this disease. Allusion has already been 
made to its expression in different stages. But there is one characteristic 
condition which requires a more detailed notice. I allude to the colour of 
the conjunctiva, and that of the face. Even in the earliest period of the 
disease, the white of the eye is often reddened and turbid, and in bad cases 
appears sometimes almost as if bloodshot. At the same time the forehead 
and upper part of the face have a reddish colour, inclining somewhat to 
purple. I have never observed these phenomena so strikingly in the early 
stage of any other idiopathic fever as in this. They are, however, not always 
present. As before stated, this redness yields, in the course of the disease, to 
a yellow or orange colour. 
The yellowness of skin to which the disease owes its ordinary name, though 
a common, is by no means an invariable symptom. It begins usually about 
the third or fourth day, often with the commencement of the second stage. 
Appearing first in the conjunctiva, it extends successively to the forehead, 
face, neck, and chest, and sometimes affects the whole surface. It is said 
to be sometimes more intense and universal after death than before it. The 
tinge varies with the natural colour of the skin and the grade of the disease, 
from a deep lemon-yellow, to an orange colour, or even the hue of bronze; 
the latter being ascribable to its admixture with the dark red colour of the 
stagnant blood. Sometimes the colour is imparted to the perspiration, and 
tinges a handkerchief yellow. Different opinions have been entertained as to 
its origin. It is probably dependent upon a change in the blood, giving rise 
to an excessive production of the same colouring principle that imparts yel- 
lowness to the bile. It often affects the cellular and adipose tissue, as well 296 
GENERAL DISEASES.-FEVERS. 
[part II. 
as the skin, and has been observed in the bones. The same colouring matter 
is thrown out with the urine. In bad cases, the surface is often covered with 
petechias before death. In those of a milder character, Dr. Magruder noticed, 
in an epidemic which prevailed at Vicksburg in 1847, the frequent occurrence 
of a lichenous or exanthematous eruption, which was the precursor of conva- 
lescence. (W Orleans Med. & Surg. Journ., iv. 691.) 
The black vomit, so striking a symptom in this disease, does not usually 
make its appearance until in the second or third stage. The matters ejected 
from the stomach are' at first such as have been swallowed, and afterwards 
usually a little bile, probably from the gall-bladder, and the vitiated secretions 
of the stomach itself. These are sometimes so acrid as to inflame and exco- 
riate the oesophagus and fauces. The black vomit appears often at first in 
small quantities, and sometimes as if not fully formed, the flakes being less 
intensely black than they afterwards become. At least I observed this phe- 
nomenon, during the fever of 1820, in Philadelphia. It afterwards increases, 
and the quantity discharged is often enormous. The mode in which it is 
thrown up differs from ordinary vomiting. It appears to gush forth, as if 
■without effort on the part of the patient, and sometimes almost without his 
consciousness; being not unfrequently discharged upon the bedclothes. 
Sometimes it is ejected by mouthfuls, by a sort of regurgitation, and por- 
tions of it come up occasionally with hiccough. There are cases in which, 
though this matter may exist in the stomach, very little is discharged, in 
consequence of an utter loss of power, or of sensibility in the gastric coats. 
In such cases, a loud gurgling sound can often be heard upon every move- 
ment of the patient's body, owing to the presence of air and liquid together 
in the stomach; and there is often considerable fulness or distension of the 
epigastrium. . ■ ' A 
Black vomit is either nearly tasteless, or acid. Formerly it was thought 
to be black bile. Dr. Physiek suggested that it might be a secretion from 
the stomach, and supposed that it was thrown out in order to relieve the in- 
flamed vessels. At present, it is believed to be blood somewhat altered, 
either by a feeble secretory action of the gastric vessels, or by the acid which 
exists in the stomach. I am inclined to the opinion, that the vessels of the 
stomach really modify the blood in its exit from them. Were it dependent 
on the reaction of gastric acids, it should exchange its peculiar character for 
unaltered blood upon the free exhibition of magnesia, instead of remaining 
unaffected, as it actually does. Black vomit, though apparently homogeneous 
when discharged, separates upon standing into two parts; an insoluble black 
flaky matter, like coffee-grounds or soot, which subsides, and a clear viscid 
liquid, which occupies the upper part of the vessel. The insoluble matter is 
probably the altered coagulable principles of the blood, the clear liquid its 
serum. The presence of acid was detected by Dr. Cathrall, of Philadelphia. 
Dr. Rhees of the same city, discovered innumerable animalcules by means of 
the solar microscope. "When the matters fresh thrown from the stomach 
were examined, the animalculm were alive, and in constant motion; but if 
taken from the dead subject, oj; inspected after standing some time, they were 
always dead and quiescent. Comparative examinations were made of the 
discharges from the stomachs of patients ill with autumnal bilious and remit- 
tent, fevers, but no similar appearances were discovered." (S. Jackson, Phil. 
Journ. of Med. and Phys. Sciences, ii. 23.) 
Anatomical Characters.-The blood drawn during the progress of the dis- 
ease is almost always coagulable, and sometimes sizy; but the clot is usually 
softer than in health, and the huffy coat, when it occurs, is often of a gela- 
tinous consistence. It has been thought that, in malignant cases, the blood CLASS I.] 
YELLOW FEVER. 
297 
loses in great measure its vitality, becoming dark-coloured and dissolved. 
This may sometimes be the case, and, in most instances, the coagulability of 
that fluid is impaired. Upon examination after death, it is often observed 
in a liquid state, distending the veins, especially those connected with the 
portal system; but Dr. Hewson found that this blood, when removed from 
the body, coagulated upon standing ten or fifteen minutes. (Phil. J. of Med. 
& Phys. Sci., ii. 22.) 
It is unnecessary to give a detailed account of the changes observed after 
death in all the organs. As in other febrile diseases/ signs of- congestion or 
inflammation are'occasionally discovered in various parts of the body. Thus, 
the membranes of the brain are often injected, and, serum effused into the 
ventricles. The lungs, though generally healthy, sometimes show signs of 
sanguineous engorgement. Traces of inflammation are occasionally noticed 
in the kidneys and bladder. The liver is variously affected, being sometimes 
engorged with blood; sometimes dry, anemic, and of a yellow colour; rarely 
inflamed. The spleen is not materially affected, though occasionally engorged 
with blood. The chief force of the disease obviously falls upon the aliment- 
ary canal, especially upon the stomach. The oesophagus is sometimes found 
inflamed, and deprived of its epithelium, probably from the acrid matter 
vomited. - , . / • . 
The stomach generally contains more or less of the matter denominated 
black vomit, even in cases in which none was discharged during life. Some- 
times it is distended with this fluid. Occasionally it contains blood in differ- 
ent stages of alteration. According to Gillkrest, there is sometimes to be 
seen, adhering in large 'quantities to the mucous coat, a deep black homoge- 
neous substance, of a gelatinous consistence. The muscular and peritoneal 
coats are usually sound, but the mucous coat is in general partially or uni- 
versally reddened, sometimes thickened and softened, and sometimes, though 
rarely, eroded. The cardiac portion is usually more affected than the pyloric. 
Sometimes the membrane is wholly free from any signs of inflammation, or 
other appreciable lesion. (Harrison, N. Orleans Med. & Surg. Journ., Sept., 
1845.) Dr. Nott found this to be the fact in four out of eight cases examined 
by him at Mobile, in 1843. (Am. J. of Med. Sci., N. S., ix. 279.) The 
bowels often contain the characteristic black matter of the disease, though 
less liquid than that of the stomach; and their mucous membrane generally 
exhibits signs of inflammation here and there in patches. The glands of 
Peyer are seldom materially altered. The veins of the omentum and mesen- 
tery are usually distended with fluid blood. 
Some importance has been attached to the. appearance of the liver, in con- 
sequence of the observations made by Louis in the yellow fever of Gibraltar, 
in the year 1828. In all the cases examined by that celebrated pathologist, 
the liver was found in a peculiar friable, dry, anemic condition, paler than 
usually in health, and of a yellow colour. The same phenomenon was ob- 
served by Dr. Stewardson, of Philadelphia, in a case examined by him in 
the Pennsylvania Hospital. (Am. J. of Med. Sci., Jan. 1842.) It was 
supposed that thig state of the liver might be characteristic of the disease. 
But examinations, made both previously and subsequently to those of M. 
Louis, prove that the lesion is by no means universal. Thus, Dr. S. Jack- 
son, of Philadelphia, found the liver sometimes gorged with blood, sometimes 
quite anemic. (Phil. J. of Med. and Phys. Sci., ii. 21.) The same obser- 
vation was made by Dr. Harrison, of New Orleans, who ascribes the pale 
yellow colour sometimes observed chiefly to the loss of blood. (AC Orleans 
Med. and Surg. Journ., ii. 138.) Dr. Lewis states that he has observed the 
dry, brittle, straw-coloured liver, in most cases which had been attended with 298 
GENERAL DISEASES.-FEVERS. 
[part II. 
profuse hemorrhagic discharges. (Ibid., iv. 161.) According to-Dr. Dickson, 
of Charleston, the liver presents no constant appearances, being in some 
instances engorged with blood, in others soft, pale, and flabby, and in others 
again natural, so far as the eye could judge. (Essay on Pathol, and Therapy 
i. 357.) Dr. Nott found the yellow anemic condition present in only about 
one-third of the cases. (Am. J. of Med. Sci., April, 1845.) 
In various parts of the body extravasation of blood has been observed, 
especially in the cavities, and in the pulmonary parenchyma. 
Cause.-There can be little doubt that the cause of yellow fever is peculiar 
and specific, as much so as that of small-pox or scarlatina. But great diver- 
sities of opinion have existed upon this subject. Some of these it will be 
proper to examine in this place. 
A very prevalent hypothesis has been, that the causes of yellow and bilious 
fevers are identical; in other words that the former disease, as well as the 
latter, proceeds from marsh miasmata. The chief arguments in favour' of this 
notion are, that the two diseases prevail in hot countries, and at the same 
season of the year; that when the yellow fever becomes epidemic, the bilious 
fever is also apt to be peculiarly rife; that acclimated individuals are less 
liable to the attacks of both than the unacclimated; and, finally, that no 
essential difference exists between the symptoms and course of the two dis- 
eases. But these arguments will not bear examination. 
It is true that the two fevers prevail im hot countries, and in hot weather. 
So do cholera, dysentery, and hepatitis; yet no one considers these as identi- 
cal with yellow fever. But, though heat is essential to both, their localities, 
and other circumstances in relation to their prevalence, are very different. 
Bilious fever occurs abundantly, and even malignantly, in many situations 
where yellow fever is never seen. Thus, the former disease is not less preva- 
lent, nor less- fatal, in Asia, Eastern Europe, and Eastern Africa, where 
the latter is seldom heard of, than in the West Indies and other parts of 
tropical America, where it is very common. Bilious fever is quite as preva- 
lent, and quite as violent, in the interior of miasmatic countries as near the 
sea; yellow fever seldom or never occurs at any considerable distance from 
the sea-coast, or the borders of navigable streams. The latter disease is 
almost always confined to a dense population, as for example to pities and 
garrisons; one of the most striking circumstances in relation to the former is, 
that. its cause appears to be neutralized by the atmosphere of cities. Thus, 
Rome is healthy, while the plains, about it are devastated by miasmatic dis- 
eases. 
It is also true that the yellow and bilious fevers are apt to prevail at the 
same time, the former in cities, the latter in the country. But this is not 
always the case. Dr. Dickson states that, at Charleston, the yellow fever has 
often raged violently in the city, when the surrounding country was either 
not more sickly than usual, or remarkably exempt from disease. 
'Though acclimated persons are less liable to both diseases than strangers, 
yet this difference of susceptibility is infinitely greater in the yellow than the 
bilious fever. The former very seldom attacks an adult native in places 
where it is endemic, however fatally it may rage among-strangers; while no 
part of the population is entirely exempt from the latter in its localities. 
It is not true, that the symptoms of the two diseases are the same. They 
are, on the contrary, strikingly different. Though perfectly familiar with 
bilious fever, when I first saw a case of yellow fever, I was at once struck 
with the latter as something that I had never seen before. The febrile stage 
of yellow fever is continuous, like that of small-pox or measles, for one, two, 
or three days, and them ceases; while bilious fever has a tendency to remis- CLASS I.] 
YELLOW FEVER. 
299 
si on or intermission every day, or every other day, to the end of the disease. 
In the latter, the secretion of bile is usually increased, in the former dimin- 
ished. Though it is possible that the turbid conjunctiva) and purplish flush 
of the upper part of the face, so common in yellow fever, may occur in some 
cases of the bilious, they are uncommon in the latter, and I have never seen 
them in an equal degree. Gastric inflammation, though common to the two 
diseases, is much more striking, as a general rule, in the yellow fever. The 
black vomit of this disease is entirely different from the black discharges of 
bilious fever, which are homogeneous, -and consist of altered bile, not altered 
blood. Uncomplicated yellow fever never ends in regular intermittent; while 
this is an exceedingly frequent termination of bilious fever. It has been said 
that yellow fever is an aggravated form of the bilious; but this is not so. 
Many cases of the former are as mild as the mildest of the latter; and bilious 
fever is sometimes quite as malignant as the worst form of the yellow; yet, 
in both instances, the characteristic difference of symptoms is observable. 
An autumnal attack of bilious fever, so far from giving any future exemp- 
tion, is well known to dispose to a second attack in the following spring. 
The case is exactly the reverse with yellow fever. This disease seldom occurs 
more than once in the same person. It is true that this fact is denied by 
some; but it appears to me, that no impartial person can read the testimony 
upon the subject, and refuse credence to the statement. Second attacks of 
yellow fever are probably not more frequent than second attacks of small-pox; 
and, when they do occur, are generally light.* 
It is very possible, that the causes of the yellow and bilious fevers may 
sometimes co-operate, and thus produce modified cases. A patient may be 
attacked with yellow fever, while labouring under a remittent or intermittent, 
which will thus assume the characters of the former; or a predisposition to 
intermittent may exist which will exhibit itself after the cessation of the more 
violent disease. Cases of this kind have undoubtedly occurred, and lent some 
countenance to the notion of the identity of the two fevers. 
Dissection presents somewhat different phenomena in yellow and bilious 
fevers. The stomach is inflamed in both, but in the latter seldom if ever 
contains the true black vomit. The liver in yellow fever is often bright yel- 
low, dry, and anemic; in the bilious, it presents wholly different phenomena. 
(See Bilious fever.} The gall bladder in the latter is usually distended with 
black bile, in the former is seldom distended, and often contains less than in 
health. The spleen, in bilious fever, is almost always enlarged and softened, 
in the yellow it is often little if at all changed. 
From these considerations, it appears clear to me that these two diseases 
are quite distinct, and arise from wholly distinct causes. What, then, is the 
nature of the cause in yellow fever ? Is it, as many have supposed, a pecu- 
liar contagion? Few questions in pathology have been more largely, and 
more warmly discussed than this, which, therefore, requires a particular 
notice here. 
The contagious nature of yellow fever has been maintained upon the grounds, 
1, that it almost always occurs near wharves where vessels arrive from abroad 
and unload; 2, that it has thus been carried to isolated spots, where the dis- 
ease had never been known to prevail before; 3, that individuals, going from 
an infected neighbourhood into a healthy one, have become the centres of a 
new infection; and 4, that, like contagious diseases in general, it cannot be 
taken a second time. 
* It must, be recollected that second attacks of small pox, in a modified form, are not 
very uncommon during epidemic visitations of that disease. 300 
GENERAL DISEASES.-FEVERS. 
[PART II. 
But these arguments are met by powerfully opposing facts. Thus, in hos- 
pitals situated in healthy districts, though they may be crowded with yellow 
fever patients, the disease is never imparted to the nurses and other attend- 
ants. In cities where the disease prevails within limited districts, only those 
persons are attacked who reside in or visit the infected spot; and patients, 
seized in consequence of such exposure, and carried into healthy parts of the 
city, do not impart the disease to those about them. Hundreds of instances 
occur, in extensive epidemics, in which patients originally seized in cities are 
scattered through places in the country; and yet the instances are exceed- 
ingly rare, in which it is even pretended that the disease is thus communi- 
cated. Attempts have been made .to propagate the disease by inoculation 
with the blood and secretions of those affected, but without effect; and even 
the black vomit has been swallowed with impunity. It is obvious, that the 
argument drawn from the exemption afforded by one attack of the disease is 
only analogical, and is deserving of no weight unless supported by other posi- 
tive facts. 
For these and perhaps other reasons, the great majority of physicians who 
have had any opportunity of seeing yellow fever, altogether deny its contagious 
nature. This fact is rendered incontestable by the industry of the late Dr. 
Chervin, who personally collected the written opinions of almost all the prac- 
titioners who had seen yellow fever in portions of the West Indies, and on 
the Atlantic coast of the United States. The number was very small of those 
who expressed a belief in the existence of a contagious cause. It must not 
be denied, however, that this number has lately somewhat increased. The 
contagionists meet the opposing facts above stated by admitting, that the dis- 
ease is seldom imparted from one individual to another in a pure and per- 
fectly healthy atmosphere; and that it requires a certain corrupted condition 
of the air, in order that the personal effluvia may produce their effect. But 
this is contrary to all that we know of other admitted contagious diseases. 
There is not one of them which may not be imparted, in the purest state of 
the atmosphere, provided the contiguity be sufficiently clbse. It seems to me 
that the doctrine of the contagiousness of yellow fever, in the ordinary mean- 
ing of that term, is quite untenable. 
Can it be that the cause is a peculiar miasm, distinct from that which pro- 
duces bilious fever, but resembling it in being a product of the decomposition 
of organic substances? Marsh miasm is supposed to result from'vegetable 
putrefaction. That which produces yellow fever, if it be a miasm, must in 
some way be connected with animal matter; for it is generated, or at least is 
effective only where men congregate. Hence its origin in cities, garrisons, 
and occasionally in ships. In all these situations we have animal effluvia, or 
animal excrement, often mingled with vegetable matter in decay. Along 
wharves, and in docks into which the common sewers empty, we have these 
conditions in an eminent degree, ready to be called into operation when a high 
and long-continued temperature shall penetrate to the bottom of the water, and 
set the fermentation into movement; and it is well known, that these are the 
parts of cities where the yellow fever is most apt to break out. We hear 
nothing of yellow fever in the Spanish encampments on the Mexican coasts, 
during the conquest. It was only after cities sprang up that it made its 
appearance. In favour of the supposition of a miasm thus generated, are the 
facts that, as in ordinary remittents and intermittents, the cause is most ener- 
getic in the night, or in the evening and morning, while the ground and 
adjoining water are covered with fog or mist; that it seldom in temperate 
latitudes begins to exert its influence before the season when dew forms at 
night; and that it often gradually diffuses itself in all directions from some CLASS I.] 
YELLOW FEVER. 
301 
central spot. But, if the cause be a miasm, as supposed, how does it happen 
that this is not generated wherever the conditions above mentioned exist ? 
Why, for example, is it not produced in Calcutta, Cairo, Rome, &c., as well 
as at Havana, New Orleans, Philadelphia, or Gibraltar? Why is it occa- 
sionally developed in isolated spots, upon the arrival of an infected ship, 
though never known to exist in these spots before? Why is it sometimes 
communicated from one ship to another? We can easily understand, that a 
vessel, with foul bilgewater in her hold, and a crowded crew, in a hot cli- 
matej may generate a febrific miasm; or that another vessel sailing from an 
infected port may carry the poison shut up with the air under its hatches. 
We can also understand that either of these vessels, arriving in a port, may 
give the disease to those who may actually visit it, and breathe its foul air. 
But how explain that the disease shall then spread over a considerable space, 
and prevail for a considerable time, after the vessel has been thoroughly 
cleansed, or removed, and all the air proceeding from her been thoroughly 
dissipated ? 
Two theories have been advanced, either of which will explain these appa- 
rent anomalies, though it must be admitted that further proof is requisite 
before either can be received. According to one of them, a peculiar product 
is generated under the circumstances before mentioned, which is capable of 
acting as a ferment when it finds the proper materials to act upon, and of 
reproducing itself or a substance identical with it out of these materials, as 
yeast is generated during the vinous fermentation which yeast has set in mo- 
tion. The other theory supposes' the cause to be a living, organized, micro- 
scopic being, either animal or vegetable, which, produced out of pre-existing 
germs, under favourable circumstances, is capable of propagating itself indefi- 
nitely when these circumstances exist. According to either of these views, 
the ferment, or the developed germ, may be conveyed in ships, or even in 
the clothing,of individuals, from one spot to another; and, if it find the pro- 
per material to act upon, or the proper food to support it, with the tempera- 
ture essential to its activity, may spread itself indefinitely, and, though per- 
haps originally little more than a mere point, may poison the atmosphere of 
a whole city. Thus is explained the conveyance of the disease from place to 
place, without the necessity of appealing to the medium of. contagion. That 
it is not more frequently propagated to interior cities, may be owing to the 
less likelihood of the conveyance of the poison in the clothing of an indi- 
vidual than in the confined air of ships, where it may possibly be kept in 
existence by the same power of propagation. In favour of the theory which 
ascribes the disease to organic germs, is the fact, that it is endemic or origi- 
nal only in a comparatively small portion of those regions of the world, where 
albthe exterior circumstaiices would appear equally to favour its production. 
Organic germs have been planted by the Creator in certain parts of the earth; 
and that of the cause of yellow fever, supposing it to be organic, may have 
been originally limited, by the same fiat which produced it, to the warm lati- 
tudes of America. That it has reached Philadelphia and New York, upon 
this continent, and Gibraltar and Barcelona upon the old, rather than the 
more distant ports of the Mediterranean or the East Indies, may be owing to 
the less mercantile communication of the latter with the places of its produc- 
tion, or simply to their greater distance. 
But, whatever the special cause of yellow fever may be, it appears to be 
aided, in many instances, by a kind of epidemic influence, which prevails 
sometimes in a greater or less degree for years together, sometimes only at 
long and irregular intervals, and may be confined to one locality, or may 
spread over extensive regions. Thus, from the year 1762, when the yellow 302 
GENERAL DISEASES.-FEVERS. 
[part II. 
fever raged in Philadelphia, we hear nothing of it in the same city until 1793, 
after which it appeared occasionally until 1805. From the last-mentioned 
date until 1819, there was an almost complete exemption. In 1819 and 
1820, the disease appeared in most'of our large cities upon the Atlantic coast, 
from Charleston to Boston. This epidemic constitution only gives efficiency 
to the specific cause, and therefore never produces the disease when that cause 
does not exist. Perhaps a long continued elevation of temperature may con- 
tribute to this epidemic influence; but it is not alone sufficient, for there have 
been years of exemption, hotter than those in which the disease prevailed. 
Certain conditions appear to act as predispositions to the disease, and others 
to afford more or less protection against it. It has already been said that 
strangers, in situations where the disease is endemic, or prevails very fre- 
quently, are more liable to it than natives or old residents. Among the 
natives, children are much more apt to be affected than adults, who enjoy an 
almost entire exemption. Residents in places only occasionally attacked, and 
at distant intervals, are not more exempt than strangers. Females are said 
to be less liable to the disease than males; probably, however, because less 
exposed to the cause. Negroes are certainly much less under the influence 
of the morbific cause than the whites. They are not only less frequently 
attacked, but are also more mildly affected when attacked. The comparative 
exemption of adult natives, in the situations above alluded to, may be ascribed, 
in some instances, to their having once had the complaint, which seldom occurs 
twice in the same individual; but, in the greater number of cases, probably, 
to a gradual action of the cause from infancy, which has worn out the suscep- 
tibility to its influence, without having ever absolutely produced the disease. 
Various circumstances operate as exciting causes, calling into action the 
efficient and specific cause, which may have been lurking in the system. 
Anything which considerably disturbs the condition ■ of the system may have 
this effect. Among these causes may be mentioned exposure to cold and 
wet, or to the night dews, fatigue, intemperance in drinking, and excesses of 
all kinds. The influence of a sudden accession of cold weather in favouring 
the attack of the disease has been often noticed. Thus, though frost puts at 
once an end to the cause, yet it augments for a time the number of cases,3 by 
developing the disease in those upon whom the cause has already acted. 
Nature.-The reasons have been before given, why this disease should not 
be considered as a variety of bilious fever. Dr. Physick, whose post-mortem 
investigations established the very frequent existence of inflammation of the 
stomach, was disposed to regard gastritis as the essential part of the com- 
plaint. But the symptoms and course of the disease clearly show, that it is 
a mere attendant. Practitioners are everywhere familiar with gastritis; but 
yellow fever is seen only within comparatively restricted limits. Besides, 
dissections have shown that inflammation of the stomach, though very gene- 
rally, is not universally present, at least not in a degree at all adequate to 
the results produced. There can, I think, be no doubt, that yellow fever is 
an entirely peculiar and distinct disease. What are the precise pathological 
conditions essential to it are unknown. It is highly probable that the blood 
is prominently in fault, being deranged by the immediate, action of the mor- 
bific cause. The existence of innumerable animalcules in the black vomit, 
said to have been noticed by Dr. Reese, if confirmed by subsequent observa- 
tion, must be looked upon as a very significant fact. Microscopic observation 
of the blood itself might lead to important discoveries. 
Diagnosis.-The initial stage of most fevers has so many symptoms in 
common, that it is often very difficult if not impossible to discriminate between 
them in the outset. Yellow fever, for the first day or two, is not an exception CLASS I.] 
YELLOW FEVER. 
303 
to this rule. Nevertheless, there are often symptoms which may lead to a 
very probable inference, as to the nature of the disease. The severe pains 
in the loins and lower extremities, the turbid conjunctiva, and the darkish-red 
suffusion of the upper portion of the face, are such symptoms. At a more 
advanced period, the excessive irritability of stomach and epigastric tender- 
ness; the regular continuance of the fever, and its subsidence after a duration 
of one, two, or three days; the supervention of yellowness of the eyes and 
skin, when the fever subsides; the great prostration, or the febrile reaction 
which follows the subsidence, and finally the occurrence of black vomit, are 
the most important diagnostic signs. In forming a judgment as to the nature 
of any doubtful case, reference must also be had to the circumstances under 
which it Occurs; whether, for example, the disease is prevalent or not, whe- 
ther the conditions necessary for its production are present, and whether the 
patient may have been exposed to the cause of it elsewhere. 
Prognosis.-Yellow fever is a very fatal disease, being scarcely exceeded, 
in this respect, by any other acute febrile affection. It varies greatly in vio- 
lence, at different periods and places of its occurrence. Sometimes it is so 
virulent, that the great majority of those affected perish; in other instances, 
it is comparatively mild. When it occurs epidemically, the first cases are 
generally the most fatal, and sometimes almost all die. Afterwards, the dis- 
ease becomes milder, and, towards the close of the epidemic, it sometimes 
happens that almost all recover. Even within the same city, the violence of 
the disease may vary greatly in different spots. ThuSj in Philadelphia, in 
1820, out of twelve reported cases in one vicinity there was only a single 
recovery, Of seventy in another thirty recovered, and of four in a third three 
recovered. Perhaps the general average of deaths from yellow fever, pre- 
vailing epidemically, may be stated at one-third. Dr. Penner calculates that 
about one-eighth of those attacked died in New Orleans,'in the epidemic of 
1847, which was, however, of a relatively mild character. (W Orleans Med. 
and Surg. Jowm., y. 206.) According to Dr. Dickson, the proportion of 
fatal cases in Charleston is not more than one-fifth or one-sixth. The great 
experience of that distinguished practitioner, gives weight to the following 
quotation from his recent work on Pathology and Therapeutics. " The attack 
is apt to be violent, and its progress hasty, Tn the sanguineous and plethoric. 
For the intemperate there is almost no hope. National habits and modes of 
life have a decided influence. The Irish, Germans, and Scotch afford us the 
worst cases; Spaniards, Italians, and Frenchmen, are very apt to recover. 
Midway stand the Englishman, the northerner, and the mountaineer, or 
inhabitant of our interior country. Generally speaking, the more recently 
a stranger has come here [Charleston, S. CQ, the more severe his attack. 
Among the young children assailed, the ravages of this pestilence are very 
great." [Page 353.) 
In individual cases, unfavourable symptoms are excruciating pains in the 
forehead, back, and limbs; great frequency and feebleness of the pulse, a 
gaseous state of it, or its entire absence at the wrist; a blood-shot appearance 
of the conjunctiva, and a bronze or mahogany colour of the skin; a short 
and violent febrile stage; coma or convulsions; a slow respiration with deep 
sighs; hiccough; excessive restlessness, and a disposition to get out of bed 
and walk; an unnatural apathy, or an expression of dogged indifference in 
the advanced stages; a voracious appetite; suppression of urine; a universal 
hemorrhagic tendency, with petechiae; and, finally, the occurrence of black 
vomit. This last symptom is regarded as almost necessarily fatal; but occa- 
sional recoveries are mentioned by authors as having taken place after its 304 
GENERAL DISEASES.-FEVERS. 
[PART II. 
appearance. A total suppression of urine may be regarded as a certainly 
fatal symptom in adults. 
The absence of the above symptoms must of course be regarded as favour- 
able. A prolongation of the primary fever beyond the accustomed period, 
the occurrence of a moderate secondary fever, and the appearance of a gentle 
diaphoresis at any period from the fourth to the seventh day, are also favour- 
able signs. The occurrence of strangury from blisters, and of salivation from, 
mercury, may be regarded in the same light. The occurrence of dark bilious 
evacuations is sometimes a precursor of convalescence. The gradual cleaning 
of the tongue from the edges, along with a subsidence of vomiting, and a 
diminution of the epigastric tenderness, is highly favourable. 
Treatment.-There are many cases of yellow fevei' in which no treatment 
can be of any avail. The patient has received his death blow at the begin- 
ning. There are others, again, so mild that they get well spontaneously, 
under any kind of management, unless positively destructive. Hence the 
great uncertainty, in relation to the influence of remedies in this complaint. 
Under every kind of treatment, there are many deaths and many recoveries; 
and it is very difficult to determine, how far the treatment has had any influ- 
ence upon either result. The difficulty is increased by the circumstance, that, 
in different epidemics, and at different periods or in different localities of the 
same epidemic, there is great difference in the violence of the disease; so that 
a plan of treatment which is at one time apparently very successful, may be 
very unsuccessful at another. But there are many cases, of intermediate 
grades of violence, in which the chances may be nearly equal between life 
and death, and in which appropriate measures may incline the balance favour- 
ably. Treatment, therefore, may be very important in yellow fever. It may 
rescue the intermediate cases, and often perhaps prevent the mild from as- 
suming a dangerous form. In the conflict of sentiment between the different 
therapeutical plans, the judicious physician will select that which best accords 
with his pathological views; and, at all events, will shun hazardous measures 
unless very clearly indicated. The following method is that which has ap- 
peared to me most appropriate. 
Very early in the disease, while there is yet no great gastric irritability, 
and no tenderness of the epigastrium, it may be proper to give an emetic of 
ipecacuanha, in cases in which there may be reason to suspect a loaded state 
of the stomach. The slight and temporary irritation of the emetic, will be 
much less than that occasioned by the continued presence of undigested food 
or acrid secretions. But it must be remembered that the remedy is appli- 
cable only to the earliest stage, and under the circumstances mentioned. 
Should there be, at this stage, frequent attempts to vomit, with the discharge 
of only a little acrid matter, it would be proper to favour the efforts of the 
stomach by the administration of draughts of warm water or warm chamo- 
mile tea. 
The question must be decided at an early period, whether it will be requi- 
site to use the lancet. On all hands it is admitted, that, to be efficient, this 
must not be postponed; and it is generally considered a hazardous remedy, 
after the lapse of one or two days. Bleeding will not cure the disease; nor 
should it be employed vaguely with this view. The only legitimate indica- 
tion for the use of it, is to diminish the danger of disorganization from the 
violence of inflammatory excitement. If carried too far, it may do immense 
harm by increasing the prostration which follows the subsidence of the fever. 
It should be resorted to only when the pulse is tense and strong. When 
this is very frequent, or readily compressible, the lancet should riot be em- 
ployed. The enormous bleedings which have been recommended by some CLASS I.] 
YELLOW FEVER. 
305 
practitioners are^ in my opinion, too hazardous to be justifiable in any case. 
Not more blood should be taken than may be necessary to reduce the force 
of the pulse; and this seldom exceeds fifteen, twenty, or at most thirty 
ounces in a vigorous adult. Less than the lowest quantity mentioned will 
often be sufficient. In the great majority of cases it will not be necessary to 
bleed at all. 
A mercurial cathartic is almost always indicated. The constipation of the 
bowels, and hebetude of the liver call for this remedy. From ten to twenty 
grains of calomel should be given without delay, and followed in the course 
of a few hours by the sulphate of magnesia, or other saline cathartic. In 
some instances, where it may happen to accord better with the stoitiach and 
taste of the patient, castor oil may be substituted. Should the constipation 
be obstinate, recourse may be had to the infusion of senna in connexion with 
Epsom, Glauber's-, or Rochelle salt, or to croton oil. The last has been 
strongly recommended in the dose of two drops. Should the stomach be too 
irritable to retain any of these cathartics, purgative enemata should be sub- 
stituted, while the calomel is repeated, in such doses, and at such intervals, 
as circumstances may seem to require. After the bowels have been thoroughly 
evacuated, they should be kept open, during the remainder of the complaint, 
by moderate doses of the saline cathartics, magnesia, the Seidlitz powders, or 
enemata. Rhubarb and magnesia come in with propriety in the advanced 
stages; the former being indicated by its tonic, the latter by its antacid 
property. 
It will be necessary that the practitioner should decide, at a very early 
period, whether he will have recourse to mercury in the treatment of this 
disease. So far as danger in yellow fever may depend upon inflammation, 
the mercurial impression upon the system, as being one of the most efficient 
antiphlogistic means, is strongly indicated. Experience, too, would seem to 
pronounce in its favour; for it is admitted, on all hands, that patients almost 
always recover, if salivation can be effected in the early stage. But it is 
often difficult, and indeed quite impossible to bring about this result. Mer- 
cury seems incapable of taking hold of the more violent cases, however ener- 
getically it may be employed. Besides, in many cases, the progress of the 
disease is so rapid that there is not time for the remedy to act, before fatal 
symptoms appear. Hence, many practitioners exclude mercury from their 
plans of treatment. They assert that it will not act in fatal cases, and that 
those in which salivation can be effected would get well without it. But 
this reasoning does not seem to me to be sound. It cannot be known, cer- 
tainly, that the instances in which salivation occurs would end in recovery, 
under other measures. The circumstance, that, when the influence of mer- 
cury is experienced, the patient gets well, proves, at least, that the remedy 
can do no great harm. If, therefore, it is indicated upon general therapeuti- 
cal principles, if it is not injurious, and if its influence when experienced is 
always followed by favourable results, whether as mere consequences, or as 
effects, there can be no impropriety, and, as appears to me, there is a strong 
propriety in employing it. But there must be no delay. The plan must be 
commenced immediately, and persevered in to the end. In this rapid disease, 
the rule which is applicable to chronic cases, of suspending the remedy for a 
time when the gums are touched, must not be obeyed. Relaxation, under 
such circumstances, would be often to let the enemy escape in the moment of 
probable victory. The mercury should be persevered in, until the symptoms 
of the disease show a decided abatement. The best means of obtaining the 
impression is, after the administration of the purgative dose of calomel as 
above mentioned, to give a pill of two grains every hour or two without in- 306 
GENERAL DISEASES.-FEVERS. 
[part II. 
terruption, until the effect is produced. In very urgent cases, the quantity 
may be increased; in very mild ones diminished. Small doses, frequently 
repeated, are more efficient towards affecting the system than the same quan- 
tity in larger doses, and at longer intervals. Calomel is usually well borne 
by the stomach. It may even compose irritation of that organ. But, should 
the bowels be sufficiently, or more than sufficiently opened, it may not be 
improper to combine the remedy with opium. Recourse may be had also, 
if necessary, to mercurial frictions and mercurial dressings to blistered sur- 
faces, at the commencement of the second stage. It will be necessary to be 
more cautious with the use of mercury in infantile cases. 
But, whether the mercurial plan be adopted or not, it will be proper to 
employ febrifuge remedies during the existence of the fever. Nothing is 
more effectual in diminishing the heat, and composing the restlessness of this 
stage, than the external application of cold water. This application may be 
made by sponging the patient over the whole body, or by affusion. The 
latter mode is most effectual, and may be employed in the cases of robust 
individuals, not too far advanced in life. The patient being seated naked 
over a proper recipient, Cold water should be poured upon him until the skin 
becomes cool, and the frequency of the pulse abates, or until he begins to feel 
slightly chilly, when he should be wiped dry and placed in bed. The appli- 
cation may be repeated, when the heat, dryness of skin, and restlessness return. 
It is scarcely necessary to caution the practitioner against employing this 
measure, in any case in which the skin is not universally heated, and quite 
destitute of moisture. Where the constitution is feeble, and the grade of 
excitement lower, sponging with warm water, or the use of the warm bath 
would be preferable. Should the state of the system be positively asthenic, 
spirit may be substituted for water as a lotion, and the hot vapour bath, for 
the warm or cold bath. 
Internally, the refrigerant diaphoretics should be employed in this stage. 
Of these, none is so exactly suited to the case as the effervescing draught 
(see U. 8. Dispensatory), which, besides its diaphoretic operation, has the 
effect of frequently composing the excessive irritability of stomach. A 
dose of it may be given every hour or two, during the height of the fever. 
Nitre and the antimonials are less appropriate, because more apt to produce 
gastric irritation. When the pulse is very frequent and rather feeble, the 
Dover's powder may often be used advantageously, if not contraindicated by 
cerebral disease. ,In similar cases, infusion of serpentaria and spirit of nitric 
ether are appropriate remedies. The patient may be allowed to drink cold 
water frequently and in small quantities, or to chew and swallow small pieces 
of ice, which is usually very grateful, by allaying the burning heat of the 
stomach. Care must be taken, however, not to allow so large a quantity of 
ice to enter the stomach undissolved, as to endanger material depression. 
Iced carbonic acid water, in small draughts of about a wineglassful, is also 
very grateful, and useful in allaying gastric irritation. 
Attention must be paid to the head and the stomach. For the pain of the 
former, leeches or cups may be applied to the temples or nape of the neck; 
the hair should be thinned or cut off; towels wet with cold water, or bladders 
filled with pounded ice, should be placed in contact with the scalp; and, occa- 
sionally, when the heat is great, and the pain severe, cold water may be 
poured from a moderate height upon the head, held over a basin. At the 
same time, hot and stimulating pediluvia may be employed as revulsives. 
For the irritability of the stomach, the best remedies are those already men- 
tioned; viz., the effervescing draught, cold carbonic acid water, or small por- 
tions of ice. Small doses of one of the salts of morphia are sometimes useful, CLASS I.] 
YELLOW FEVER. 
307 
in connexion with the draught, or with other medicines. When pressure over 
the stomach occasions much pain, leeches may be applied to. the epigastrium, 
followed by warm fomentations or emollient cataplasms, unless the weight of 
these should render them too uncomfortable to the patient. Sinapisms are 
sometimes useful in the early stage. 
When the fever begins to decline, and the second stage commences, febri- 
fuge and depleting remedies must be abandoned, and, unless symptoms of 
convalescence are obvious, without suspending the mercurial treatment, mea- 
sures should be employed for counteracting the inflammation of stomach, and 
supporting the strength of the patient. . For the former purpose, I know 
nothing better than the acetate of lead, as recommended by the late Dr. 
Irvine, of Charleston, S. C. (Eclectic Repertory, x. 519). This remedy is not 
appropriate, to the febrile stage, nor was it employed in that stage by Dr. 
Irvine. The period for beginning with its use is when the heat of skin and 
frequency of pulse abate; while a yellow hue begins to show itself in the 
conjunctiva or face, and tenderness in the epigastrium indicates continued or 
increasing inflammation of the stomach. One or two grains should be given 
every hour or two, and the remedy continued until from thirty to forty grains 
have been taken. I have employed it in some bad cases, with the happiest 
results. In one of them, the matter ejected from the stomach had begun to 
assume thecflaky character of black vomit; and yet the patient recovered. I 
confess, however, that my experience with it has not been sufficiently ample 
to justify a positive recommendation, upon that ground alone. We employ 
the remedy, with great advantage, as a local application to mucous inflamma- 
tion, as in that of the rectum and urethra, when not attended with high vas- 
cular. excitement; and this is the exact condition presented by the gastric 
mucous membrane, in the second stage of yellow fever. Besides, the astrin- 
gent properties of the preparation may render it useful in preventing the 
black vomit, which is now admitted to be a sort of hemorrhage of the sto- 
mach. 
But the case should not be trusted to this remedy alone. The epigastrium 
should be covered by a large blister, and the same application may be made 
to the extremities, in order to support the system, and to direct excitement to 
the surface. Powdered acetate of morphia sprinkled upon the blistered sur-. 
face, over the pit of the stomach, will sometimes be useful in allaying gastric 
irritability. The strength must be sustained by mild nutriment. The farina- 
ceous drinks and weak animal broths, or a little milk and water, may be em- 
ployed for this purpose. Sometimes, advantage may accrue from the use of 
lime-water and milk, in the quantity of a tablespoonful of each every hour. 
Should the system show signs of sinking, it will be necessary to employ 
tonics and stimulant^, with a nutritious diet, proportioned to the wants of 
the case. Sulphate of quinia or the compound infusion of Peruvian bark, 
the mineral acids, capsicum, oil of turpentine, wine-whey, carbonate of ammo- 
nia, wine, brandy, egg-nog, milk-punch, strong animal broths or essences, are 
the chief means to be used; and from these, selections and combinations 
must be made, in accordance with the degree of prostration. None of them 
are specific. All that they can do is to support the strength of the system, 
until the disease shall spontaneously terminate. It is possible that the cap- 
sicum and oil of turpentine may sometimes be useful as alteratives to the 
mucous membrane of the stomach. Should any of these remedies occasion 
burning pain in the epigastrium, it must be omitted. Opium should be 
freely used, and may be combined with any one of them. The oil of tur- 
pentine with laudanum,*or one of the salts of morphia, is a combination 
sometimes especially useful. Of the oil from twenty drops to half a flui- 308 
GENERAL DISEASES.-FEVERS. 
[part II. 
drachm may be given at once, suspended in water, by means of gum Arabic, 
and repeated every hour. Stimulating frictions should also be used in very 
prostrate cases. Should hemorrhage from the stomach or bowels occur, it 
may be met with acetate of lead, nitrate of silver, kino, and pure tannic acid, 
severally or in combination; and opium should be added to whichever of 
these remedies may be employed. 
In the secondary fever, the treatment must be conducted upon general 
principles applicable to all febrile diseases; reference being always had to 
the strength of the system. 
In cases of a low form at the beginning, where reaction is deficient or alto- 
gether wanting, it will be necessary to use the means which are recommended 
in the last stages of ordinary cases. External stimulation by means of the 
hot bath and powerful rubefacients, tonics and stimulants by the stomach, and 
stimulating enemata of oil of turpentine, brandy, laudanum, &c., must be 
employed. I should generally prefer for internal use, in such cases, the oil 
of turpentine and sulphate of quinia. The latter remedy may be given in 
large doses, as much even as from five to ten grains every two or three hours, 
until some effect may appear to have been produced. Cases of this kind, 
however, too frequently bid defiance to medicine. 
In New Orleans, the practice of giving large doses of quinia very early 
in the disease, is asserted by some to have been attended with great success. 
According to Dr. Fenner, it was first introduced in the epidemic of 1841 by 
assistant surgeon Charles McCormick and Dr. A. J. Wedderburn; and has 
been since extensively employed. From fifteen to thirty grains of sulphate 
of quinia are given at once, sometimes uncombined, sometimes in connexion 
with opium or a mercurial cathartic or both, and with various accessory 
treatment, according to the particular views of the practitioner. Sometimes 
the quinia is repeated, in the same, or smaller doses. The febrile action is 
said to subside very speedily, and the patient frequently to enter almost imme- 
diately into convalescence; but, in other instances, though the primary fever 
may be apparently cut short, and the secondary fever prevented, yet the dis- 
ease marches steadily onward to black vomit and a fatal issue, as in violent 
cases treated in the ordinary mode. (Ai Orleans Med. & Surg. Journ., v. 
208.) 
Throughout the treatment, especial attention should be paid to the tho- 
rough ventilation of the apartment, and to the preservation of personal clean- 
liness by a frequent change of linen, and of the bedclothes. All excrementi- 
tious matter should be immediately removed. 
It is proper to state, before leaving the subject of the treatment of yellow 
fever, that some practitioners, especially in the French West Indies, have 
been in the habit of relying upon the mildest measures; trusting rather to 
the resources of the system, aided by the removal of noxious influences, than 
to any strong remedial impressions. In the first stage, demulcent beverages, 
chicken water with a little nitre, or other weak ptisans, perhaps a small bleed- 
ing when the excitement is great, a little magnesia now and then, fomenta- 
tions or poultices to the abdomen, or a few leeches to the epigastrium, and 
the warm bath; in the latter stages, preparations of bark, mineral acids, 
camphor injections, &c., constitute the routine of the treatment; and it has 
been asserted that the success of the plan is little if at all short of that of 
the more energetic methods usually employed. 
The prevention of the disease is even more important than its treatment. 
In relation to individuals, when circumstances prevent their leaving the place 
in which the disease prevails, they should select a residence in the highest 
and healthiest spots, should sleep preferably in the highest part of the house, CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
309 
should avoid the night air, should abstain from fatiguing exercise, exposure 
to alternations of temperature, and excesses of all kinds; should endeavour 
to maintain a cheerful and confident temper; should use a nutritious and 
wholesome but not stimulating diet; and, if compelled to enter any spot in 
which the atmosphere is known to be infected, should take care not to do so 
when the stomach is empty, or the body exhausted by perspiration or fatigue. 
Attempts to guard against the disease by low diet, bleeding and purging, or 
the use of mercury, are futile, and even worse than futile. The feebler the 
system, the less is it able to resist the entrance of the poison, or its influence 
when absorbed. 
The public also have important duties in this complaint. Letting alone 
the vexed question of quarantine, we may insist on the necessity of estab- 
lishing hospitals in healthy situations, of removing as far as possible all 
sources of noxious effluvia, of correcting such effluvia where known to exist 
by fumigations with chlorine, and finally, in our northern cities, where the 
limits of the infected neighbourhoods are often well defined, of removing the 
inhabitants from within these limits, and excluding the entrance of others by 
the temporary erection of fences across the streets or avenues. In places 
where the residents have become exempt from the disease by. habitual expo- 
sure to the cause, it will be sufficient to remove and exclude strangers and 
children from the infected districts. 
Article IV. 
ENTERIC EEVER. 
Syn.-Common Continued Fever.-Typhoid Fever.-Typhus mitior.-Nervous Fever.- 
Abdominal Typhus.-Enteromesenteric Fever.-Doth inenteritis.-Follicular Enteritis. 
This is a common febrile affection, presenting a considerable diversity of 
symptoms, yet having in general a certain recognizable character, and pro- 
bably constituting, in all its forms, one and the same disease. It is the 
ordinary endemic fever of Europe, and of those portions of the United 
States in which the miasmatic or bilious fevers do not prevail, and is more 
or less mingled with the latter within their own special limits. Indeed, the 
probability is that it belongs to the whole human family, and is to be found 
in all inhabited regions. Though long known in its different forms, its 
identity in these forms was not clearly perceived until after the researches 
of Xouis, which, by determining its anatomical, in connexion with its exte- 
rior character, gave us the means of recognizing it under every variety of 
aspect. 
The nomenclature of this disease is unsettled and perplexing. By some 
writers, it is denominated continued or common continued fever $ but this 
term is not sufficiently distinctive; as other fevers, equally common in many 
situations, are equally continued; and, in fact, English authors generally 
confound under the title two affections, which are probably quite distinct; 
namely, the disease under consideration and proper typhus fever. The name 
of typhoid fever, applied to the disease by Louis, and now much in use, is, I 
think, still more unfortunate. Independently of the fact, that the complaint 
is not essentially typhoid, and that it very often runs its whole course with- 
out any symptom analogous to those which characterize typhus fever, there 
is the strong objection, that any other febrile affection may equally assume 
the typhoid form; so that a mere epithet, applicable to a common condition 310 
GENERAL DISEASES.-FEVERS. 
[PART II. 
of disease, is thus appropriated to a distinct complaint, and must, inevitably, 
lead to frequent misconceptions. Bilious fever, yellow fever, the plague, the 
different exanthematous fevers, and all the phlegmasim may become typhoid, 
as well, though not, it is true, as frequently, as the one in question. It is 
highly desirable, therefore, that the name should be abandoned, though there 
is reason to apprehend that it has already taken root too deeply to be easily 
eradicated. There can be no doubt that the affection, denominated typhus 
mitior by the older writers, was very often that which we are now consider- 
ing; but the name is objectionable, as implying only a difference in degree 
between this and true malignant typhus. Nervous fever is less inappropriate 
than either of the preceding titles; as the disease is pre-eminently marked 
by nervous disorder, and the cases to which the name has been applied, have 
probably in general belonged to it. But almost all fevers, indeed we may 
say without qualification, all fevers are attended with some degree of nervous 
disorder; for this enters into the very definition of the term fever; and the 
title, therefore, is not sufficiently distinctive. Dothinenteritis (from Soetqv, 
pustule, and svte^ov, intestine) was a name conferred on the complaint by 
Bretonneau, and was intended to express the eruptive character of the intes- 
tinal affection which distinguishes it. Follicular enteritis had the same ori- 
gin. Both are objectionable upon the score, that they consider as essentially 
the disease what is a mere attendant, though a very common one. I propose 
the title of Enteric fever with some diffidence. It has the same basis as the 
Entero-mesenteric fever of M. Petit, but has the advantage over it of greater 
simplicity. It is merely intended to express the fact, that this fever is dis- 
tinguished from all other idiopathic fevers by the frequency and extent of 
intestinal disease. Other fevers are attended occasionally with disease of 
the bowels; this almost always, if not essentially. The intestinal affection is 
as characteristic of this disease as the eruption is of small-pox. 
Symptoms, Course, &c.-The disease sometimes begins abruptly by a chill, 
followed by the usual symptoms of fever; but, as it occurs in this country, it 
more frequently comes on insidiously, and increases gradually, so that it is 
often impossible to fix the precise point of commencement. The patient is 
uncomfortable, and complains, perhaps, of weariness, general uneasiness, sore- 
ness or numbness of the limbs, and often of a little headache; the skin is 
somewhat heated, the face flushed, and the pulse accelerated; the tongue, if 
examined, is found to be very slightly coated with a thin whitish fur; the 
appetite is impaired though not quite extinguished; and these symptoms con- 
tinue, with a slowly increasing intensity, but with a tendency to daily remis- 
sion, for several days, sometimes even for a week, before the patient feels 
himself sufficiently ill to take to his bed. Frequently, during this period, 
slight chilliness alternates with febrile sensations; -though it sometimes hap- 
pens that the patient complains of no chill whatever, and distinct rigors or 
shivering are rare. When the disease is completely formed, the chilliness 
ceases, and does not return, unless, perhaps, at the commencement of some 
incidental inflammation. There is also not unfrequently, during this inchoative 
stage, some looseness of bowels, amounting often to diarrhoea; and, when this 
is not the case, there is generally an extraordinary susceptibility to the action 
of cathartic medicine, which operates in much smaller doses than usual, or, if 
given in the full dose, produces more than the usual effect. 
The disease, being now fairly under way, exhibits the ordinary phenomena 
of fever; such as frequency of pulse, heat and dryness of skin, flushed face, 
pains in the head, complete loss of appetite, thirst, and great general weak- 
ness. But the symptoms are also somewhat peculiar. The pulse, though 
sometimes but moderately accelerated, not exceeding 90 or 100 in the mi- CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
311 
nute, and of considerable fulness and strength, is in other instances, and 
especially in females, very frequent, small, and compressible, often amounting 
to from 110 to 120. The flush in the face is of a somewhat more purple 
tint than in most other cases of fever; and, when it is absent, there is not 
unfrequently a dusky hue of the complexion, with a certain heaviness or dul- 
ness of expression, which may be very slight in some cases, but is very 
striking in others. Headache, in some degree, is very seldom absent; and 
not unfrequently it is the' chief subject of complaint. The patient also often 
experiences pains in his back, or limbs, and sometimes has a feeling of uni- 
versal soreness, as if bruised, or greatly fatigued. Sometimes there is much 
restlessness, with want of sleep. A characteristic symptom is, in many 
instances, the occurrence of bleeding at the nose, which, however, is generally 
slight, and no otherwise important than as a sign. In very many instances, 
a tendency is observed in the febrile symptoms to remission, sometimes daily, 
sometimes twice a day; and occasionally the exacerbations subside with slight 
perspiration; though this is much less frequent and more sparing in enteric, 
than in bilious or miasmatic fevers. 
These symptoms continue with little other change than a gradual increase, 
for several days. The pulse becomes more frequent and less strong; the skin 
acquires a heat and aridity which are often described as acrid or pungent; 
the obtuseness of countenance and duskiness of complexion deepen; the 
tongue remains slightly covered, or coats itself with a thicker fur, in either 
case showing a tendency to dryness or clamminess, and often appearing red 
at the tip and borders; the stomach, though often retentive, is sometimes 
irritable; diarrhoea is not unfrequent; transient pains are felt in the abdo- 
men, increased by pressure, especially in the right iliac region; and a slight 
degree of tympanitic distension in the bowels is discovered upon percussion, 
with a gurgling sound upon pressure by the hand. A cough frequently sets 
in, either dry, or accompanied with a slight mucous expectoration; and the 
physical signs of bronchitis are detected by the stethoscope. The urine is 
sometimes little changed, sometimes scanty, high-coloured, and offensive. 
Such is the course of the disease, until about the seventh or ninth day from 
the time of complete formation. 
Other symptoms are now superadded. The tongue, previously moist or 
clammy, often becomes quite dry, and assumes a brownish colour. Degluti- 
tion is sometimes painful or difficult. The abdomen is obviously distended, 
so as frequently to present a convex outline from the ensiform cartilage to the 
pubes, when the patient is on his back, and, upon percussion, sounds hollow 
or tympanitic. If the surface be carefully examined, red spots like flea-bites 
will show themselves, usually appearing at first in small numbers upon the 
abdomen, but afterwards increasing, and sometimes extending to the chest, 
and even to the limbs and face. At the same time, a close inspection will 
often detect an eruption of small vesicles, called sudamina, upon the neck, 
and upper part of the chest, and occasionally also on other parts of the body. 
The nervous symptoms assume a more decided character. Delirium or stupor 
often takes the place of the severe headache with which the patient had been 
tormented. Ringing or buzzing in the ears is followed by hardness of hear- 
ing, amounting sometimes to deafness. The eyes are often injected. The 
tongue is protruded with difficulty, and is occasionally observed to tremble in 
the effort. 
If the disease continue, a completely typhous condition is at length de- 
veloped. The tongue is often incrusted with a brown or black coating, or is 
dry, gashed, and sore; while dark sordes collect upon the teeth, gums, and 
lips. The pulse becomes exceedingly frequent and feeble. The surface is 312 
GENERAL DISEASES.-FEVERS. 
[PART II. 
either universally hot and dry, or hot in some parts while it is cool in others; 
and a peculiar unpleasant odour often exhales from the body; subsultus ten- 
dinum, twitching of the facial muscles, and even epileptiform spasms some- 
times make their appearance. The patient is very feeble, lying on his back, 
and often slipping involuntarily down in the bed. He picks at the bed- 
clothes, or at imaginary objects in the air; mutters half-formed, delirious 
sentences; or exhibits a profound coma; and sometimes, under the influence 
of a potent delirium, attempts to rise from his bed, and unless guarded, 
reaches the door of his chamber, and perhaps falls exhausted. Other occa- 
sional symptoms are involuntary fecal evacuations; retention of urine; he- 
morrhage from the bowels or nostrils; and petechias and vibices upon the 
skin. Vitality is so feeble in the skin, that blistered surfaces often slough, 
and gangrenous eschars are produced in parts exposed to continued pressure, 
as over the sacrum, or upon the hips. 
Finally, if the case is to- end unfavourably, the pulse gives way, and be- 
comes either excessively frequent and fluttering, or slow and scarcely percep- 
tible ; the extremities become cool and clammy, or the whole surface is bathed 
in a clammy sweat; the abdomen is often enormously distended; hiccough 
sometimes occurs; the countenance assumes the Hippocratic aspect; and life 
is quietly and almost insensibly extinguished. Sometimes, however, when 
the fatal issue takes place at an earlier period, death is preceded by apparently 
painful struggles or convulsions. 
When a favourable termination is to take place, the tongue becomes moist, 
and begins to clean itself gradually at the tip and edges; the pulse lessens in 
frequency and acquires greater fulness; the skin relaxes, becoming cooler and 
less dry; the stupor or delirium subsides; the patient pays more attention 
to things around him, and exhibits more solicitude for himself; the abdomi- 
nal distension diminishes, and some inclination for food returns, or at least 
less aversion for it is displayed. Convalescence, under these circumstances, 
speedily takes place; and not unfrequently the emaciation becomes more 
evident at this moment than it was before. 
In other instances, especially in severer and more protracted cases, the 
course is somewhat different. Instead of cleaning gradually from the edges, 
the tongue throws off its fur in flakes, generally at first from the centre or 
towards the base, leaving the surface smooth, red, and somewhat shining, as 
if the papillary structure had been partially destroyed. This state of the 
tongue is sometimes preceded by soreness of the fauces; and the velum pen- 
dulum and half arches will, if examined, be found covered with an exudation, 
which they are beginning to part with. This is usually a sign of an approach- 
ing amelioration of the symptoms. If the tongue, when thus cleaned, remain 
moist, convalescence may be pretty confidently expected, though it is always 
tedious. In some instances, the tongue coats itself over again, and again 
becomes clean; and this change may take place more than once. Occasion- 
ally, too, an aphthous exudation appears upon its surface. But still, if the 
moisture continue, the prognosis is ultimately favourable. 
If, however, at any time during the above cleaning process, or even after 
it has been completed, the tongue should become permanently dry, the symp- 
toms are again aggravated, and the patient again thrown into danger. I 
have ascribed this result to an increase of the intestinal disease, which is a 
prominent feature in the complaint, and have found it to yield most happily 
to treatment addressed to that affection. 
But, as before observed, the convalescence after this mode of cleaning of 
the tongue is always somewhat tedious, and often very much so. It implies 
a degree of mischief to the organization which time only can repair. Some- CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
313 
times months elapse before the patient recovers his usual health. The pulse 
remains long frequent, a febrile paroxysm somewhat resembling hectic occa- 
sionally appears every day, there are copious and debilitating sweats at night, 
the appetite is feeble, and the bowels disturbed by slight causes. Trouble- 
some nervous symptoms also frequently occur; such as wakefulness, depres- 
sion of spirits, weakened memory, childish fretfulness, and sometimes a kind 
of imperfect delirium or insanity, though this is rare. The lower extremi- 
ties sometimes become painful and edematous. Troublesome and tedious 
abscesses occasionally break out, especially near the parotid; and boils appear- 
in various parts of the body. At length, these symptoms gradually disappear, 
the appetite returns, and even becomes insatiable, and the patient rapidly 
acquires strength and flesh. Not unfrequently, the premature or excessive 
indulgence of the appetite causes disagreeable intestinal symptoms; and I 
have known it apparently to be the cause of a fatal relapse. The patient 
generally loses his hair, which, however, grows again; and the cuticle of the 
palms of the hands and soles of the feet is apt to desquamate. 
There is occasionally a fatal termination of this disease, of a peculiar cha- 
racter, which it is necessary to notice. The patient is suddenly seized, with- 
out any premonition of danger, perhaps even in the midst of convalescence, 
with violent pains in the abdomen, which is also exceedingly tender to the 
touch. Sometimes there is no pain; but only tenderness. The knees are 
drawn up, and the face assumes an anxious and even ghastly expression. 
Rigors, an exceedingly frequent and contracted pulse, obstinate vomiting, and 
constipation, are also frequent symptoms. A collapse of the circulation and 
of the surface precedes death, which takes place usually within a day or two, 
though life is sometimes prolonged for a week. The cause of these symptoms 
is a perforation of the intestine, and the escape of its liquid contents, produc- 
ing inflammation of the peritoneum. It is more frequently the mild than 
the aggravated cases of the disease, that are liable to this serious accident. 
It occurs at variable periods in the progress of the complaint, having been 
noticed as early as the twelfth day, and as late as the fortieth. 
The duration of this disease is uncertain, but usually protracted. Death 
occasionally takes place so early as the sixth or seventh day; but this is very 
Tare. Generally it occurs in the course of the second or third week, and 
sometimes not till the end of six weeks, or even later. The period of con- 
valescence is equally variable. It sometimes begins on the eighth or ninth 
day, but very rarely before the third week. Even the mildest cases run on 
to the fourteenth or fifteenth day; those of a severer character seldom become 
convalescent before the end of the third or fourth week; and not unfrequently 
we witness recoveries even after the sixth week. The average duration of 
cases may be stated at from twenty to thirty days. The disease seldom lasts 
longer than sixty days, though it has no fixed limits. 
Certain symptoms which occur in the course of the disease are so important, 
in reference to diagnosis or prognosis, as to require separate consideration. 
Diarrhoea, according to Louis, is an almost uniform symptom, having been 
absent in only three of the cases examined by him. It must be remembered, 
however, that the occurrence of liquid stools constitutes diarrhoea in the esti- 
mation of that author, though there may be only one daily. But even with 
this limitation, the observation is not applicable to the disease as it occurs in 
this country; at least as it has occurred within my own observation. Diar- 
rhoea is undoubtedly frequent, so much so, indeed, that it may be considered 
among the diagnostic symptoms; but it is also not unfrequently wanting. I 
have noticed, however, that, even when there is apparent constipation, the 
bowels are acted on by purgative medicine much more readily and abundantly 314 
GENERAL DISEASES.-FEVERS. 
[PART II. 
than in most other febrile diseases. So much is this the fact, that, in a doubt- 
ful case of fever, an unusual or extraordinary effect from purgative medicine 
should have some weight in influencing the decision as to the nature of the 
disease. The diarrhoea sometimes precedes the fever; but more frequently 
commences during the first twenty-four hours after the attack, and is occasion- 
ally postponed to a much later period. The stools may be only one or two 
daily, or more frequent, up to ten, twelve, or more. They are generally yel- 
lowish or brownish, and apparently healthy except in consistence. This is 
one of the remarkable features of the disease. While in other severe fevers 
the discharges are almost always greatly altered, in this, they often remain 
nearly natural, with the exception alluded to, throughout the complaint. 
Sometimes, however, they are black or bloody, especially in the advanced 
stages; and, in a relatively small number of cases, they are dysenteric. The 
diarrhoea undoubtedly depends upon the inflammation or irritation of the 
intestinal mucous membrane; but has not been found to bear any fixed rela- 
tion to the characteristic disease of the mucous follicles. It is generally 
attended with pains in the abdomen, which, though not usually very severe, 
are often troublesome. When wanting, they may sometimes be elicited by 
pressure. They may be present also when there is no diarrhoea. 
Tympanites, in a greater or less degree, is an almost constant attendant of 
enteric fever. I do not think I have ever witnessed a case without some de- 
gree of it. It does not begin with the disease; coming on usually about the 
seventh day, though sometimes as early as the third. At 'first it is not very 
obvious. There maybe a slight increase of tension in the abdominal parietes; 
but percussion is necessary to the certain detection of the symptom. It 
increases as the disease advances, and soon becomes obvious to the eye. In 
general it bears some proportion to the severity of the disease, being moderate 
in mild cases, and greater in the severe. Sometimes it is very great, causing 
an enormous distension of the abdomen, so as to interfere with respiration by 
pressure upon the diaphragm. Under these circumstances, it occasions great 
distress to the patient. It is also injurious by distending the bowels, so that 
they cannot act on their contents. This morbid collection of air is chiefly in 
the colon; the small intestines being comparatively little affected. 
The rose-coloured eruption is one of the most characteristic phenomena of 
enteric fever. This consists of small red spots, usually roundish, and about 
a line in diameter, though sometimes much larger, often slightly prominent, 
and disappearing under pressure with the finger, to return upon the removal 
of the pressure. They are never seen at the commencement of the disease, 
but generally first make their appearance between the seventh and fifteenth 
days, and occasionally later. They occur in general first and most numerously 
on the abdomen, extending afterwards to the breast, and occasionally also to 
the extremities, and even to the back and face, though very, rare in the last 
mentioned position. I have seen them abundant on the upper and inner part 
of the thighs, and confined to that place. Their number varies greatly, some- 
times not exceeding two or three, sometimes being almost countless. They 
appear in successive crops, each lasting three or four days, and then gradually 
fading, and the whole period of the eruption varies, according to Louis, from 
three to fifteen days. Though present in the great majority of cases, at some 
period in the progress of the disease, they are not so in all. Out of seventy 
cases referred to by Chomel and Genest, they were absent in sixteen, or about 
one-quarter. 
These spots must not be confounded with petechias, which also appear in 
this disease, but are by no means peculiar to it. The latter can scarcely be 
considered strictly as an eruption; consisting merely of blood extravasated in CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
315 
the skin. They are distinguishable usually by their more livid colour, by 
never projecting above the surface, and by not disappearing upon pressure. 
They occur much less frequently in enteric fever than the rose-coloured erup- 
tion, and are more common in genuine typhus fever than in that disease. 
Sometimes the hemorrhagic effusion is more extensive, constituting patches 
or vibices. 
Sudamina are small vesicles, generally about the size of a pin's head, but 
sometimes larger, either circular or oVal, and, in consequence of their minute- 
ness and transparency, often requiring to be viewed obliquely in order to be 
seen. They may frequently be detected by the touch. They oOcur usually 
on the neck and upper part of the chest, especially towards the shoulders, or 
near the axilla or groin; but may sometimes be seen upon the trunk and 
limbs; and I have known them to cover thickly almost the whole body, 
except the face. The period of their eruption is generally later than that of 
the red spots, being rarely earlier than the fourteenth day. They are also 
less constant, and less characteristic, occurring in other febrile affections as 
well as in that under consideration. 
Cough and the bronchial rales are very common in this complaint. The 
cough is either dry, or attended with a slight mucous expectoration, with very 
little or no soreness or sense of oppression in the chest. The dry, sonorous, 
and sibilant rales may be heard more or less extensively over the thorax, and 
are much greater in proportion to the amount of oppression or dyspnoea than 
in ordinary catarrhal affections. They thus afford an important diagnostic 
sign. They are not, however, present in all cases. Sometimes they begin 
with the disease; but more frequently not until the lapse of about a week. 
Occasionally, they give place to a crepitant or sub-crepitant rale, indicating 
the occurrence of inflammation in the parenchyma of the lungs. 
The pulse is generally frequent, sometimes in the early stages full and 
strong, sometimes even from the commencement rather feeble, and almost 
always becoming so as the disease advances. It is, however, very different 
in different cases. I have known it not more frequent than in health, and 
differing from the natural state only by its weakness. This, however, is 
exceedingly rare. A moderate degree of acceleration, with some fulness and 
strength, is not uncommon in mild cases, and in the early stages of those 
which are more severe. But if there be any one condition of pulse more 
characteristic than another, it is that of frequency, smallness, and want of 
strength. Such is often its condition at the outset; and, when this is not 
the case, there is a very general tendency to it in the progress of the disease. 
The number of pulsations is often at first from 110 to 120, and sometimes 
increases to 130, 140, and even to 160, before the close. In the last stage, 
the pulse, along with its frequency and feebleness, is occasionally irregular 
and intermittent; and Louis has found this condition, in most cases, asso- 
ciated with softening of the heart. Instead of increasing in frequency in the 
prostrate state of system, it sometimes becomes even slower than in health, 
and exceedingly feeble, indicating an absence of irritating influences, or an 
extraordinary insensibility to their action. In the former case, this condition 
of the pulse is favourable, in the latter it may be otherwise. 
Hemorrhage is a not unfrequent symptom of enteric fever. In the early 
stage, it takes place from the nostrils, and is highly characteristic. The epis- 
taxis is usually very moderate, often not exceeding a few drops, and very 
seldom in any degree alarming. In some rare cases, however, it is more 
copious, especially at a late period, and demands the interference of remedies. 
But, in relation to its effects, hemorrhage from the bowels, which occasionally 
takes place in the advanced stages, is much more important. This is often, 316 
GENERAL DISEASES.-FEVERS. 
[part II. 
at the same time, a bad sign, and injurious by the exhaustion it produces. 
It requires the careful attention of the practitioner, and the stools should 
always be examined in reference to it. In some instances, the blood is red 
and but little changed, in others it is blackish and disintegrated. Occasion- 
ally bleeding takes place from other mucous surfaces; and petechim are nothing 
more than examples of an interstitial hemorrhage. 
The nervous symptoms are peculiarly prominent in enteric fever. Head- 
ache has been already referred to as one of the most common and troublesome 
symptoms. It is very seldom entirely wanting- throughout the case. In 
general, it is heavy and dull rather than acute, most frequently occupying the 
forehead and eyes, though sometimes occurring in the back of the head, and 
sometimes affecting the' whole head. The.eyes are occasionally sore' to the 
touch, or upon motion. Not unfrequently, also, pain is felt between the 
shoulders, and in the loins and extremities; but this generally soon ceases. 
The headache usually continues for a week, after which it often gives way 
to stupor or delirium, and does not return when these are dissipated. 
Dulness or hebetude of mind is one of the most common symptoms, often 
appearing early in the disease, and showing itself in the expression of coun- 
tenance, which is apt to be blank, apathetic, or dejected. There is often an 
indisposition to be disturbed, and the patient answers questions reluctantly, 
or shortly, as if vexed. This heaviness usually increases as the disease pro- 
ceeds, till it amounts to drowsiness, stupor, and even coma; but this is seldom 
so profound that the patient cannot be roused by speaking to him in a loud 
voice. The stupefaction does not yield the comfort of sleep; for the patient 
often complains, in the midst of it, of a want of rest. Instead of it, there is 
sometimes morbid vigilance, with great restlessness and jactitation. 
Delirium often appears after several days, but usually not in any con- 
siderable degree until the seventh day or later. In general it is mild, indi- 
cating rather want of power in the brain than irritation. If the attention is 
strongly fixed, the mind often acts correctly; and it becomes wandering, only 
when left to itself. This wandering is especially observable upon waking 
from sleep, and in the night. In some instances, however, the delirium is 
violent and even furious, so that the patient screams loudly, and requires 
force to restrain him. Occasionally it is fantastic, and somewhat hysterical, 
inducing the strangest and most whimsical notions, and corresponding actions. 
Thus, I have known a patient to have the idea that he was taking a walk, 
and to imitate with the arms and legs, while lying in bed, the motions of 
that kind of exercise. A not unfrequent notion is, that he is absent from 
home. In the last stages of the disease, the delirium is apt to become low 
and muttering; the patient lying with his eyes half-closed, and uttering, in a 
low or whispering voice, broken sentences having only a vague connexion. 
Occasionally, however, even in this stage, it is violent; and the patient, un- 
less restrained, will rise from his bed, and even leave his chamber. The 
stupor and delirium occasionally alternate, and are not unfrequently combined. 
The latter is usually later in appearing than the former. 
Hardness of hearing is another highly characteristic symptom, which I 
have not observed so strikingly or frequently in any other febrile disease. 
Sometimes it is slight, sometimes so great as to amount almost to deafness. 
It does not usually occur in the first stage of the fever. It is not unfre- 
quently preceded or accompanied with tinnitus aurium. 
A tendency to sloughing of the skin is much more striking in the advanced 
than the early stages. It shows itself particularly when the surface has been 
inflamed, as by blisters or sinapisms, and when it is subjected to pressure and 
friction, as from the long continuance of the body in one position. Blisters CRASS I.] 
ENTERIC, OR TYPHOID FEVER. 
317 
are most apt to be followed by this effect, when applied furthest from the 
centre of circulation. The insensibility, more or less complete, which is so 
common in this disease, favours the production of eschars from pressure. 
The patient is not sensible of the mischief, and does not therefore change his 
position. The first effect is to produce a deep redness, which is followed by 
a separation of the cuticle, sloughing of the skin, and ultimately an ulcer, 
when the case is sufficiently protracted. The feeble capillary circulation, and 
diminished vitality of the surface, are the remote causes of the mischief. 
One other symptom deserves particular notice. I allude to the retention 
of urine, which is not unfrequent in the advanced stage. In consequence of 
the want of sensibility, urine accumulates in the bladder so as to produce 
considerable distension before the want of urination is felt; and then the 
muscular coat of the bladder has been put so much upon the stretch as to 
have lost its power of contraction, and the accumulation goes on increasing. 
Enormous distension is thus sometimes induced, endangering inflammation 
or rupture of the coats of the bladder. When a certain degree of sensibility 
remains, great uneasiness is produced, which is in some cases referred to its 
proper position by the patient, but in others only occasions restlessness and 
moaning. In complete insensibility, no consciousness of inconvenience is 
evinced. The practitioner is liable to be led into error by the fact, that a 
slight involuntary stillicidium of urine is apt to take place in these cases, 
which is, however, insufficient to prevent continued accumulation. In all 
cases of enteric fever, the physician should be constantly on his guard against 
this accident in the latter stages. Though concealed from the eye by the co- 
existence of tympanites, the distension of the bladder may be usually detected 
at once by the dulness which it yields on percussion over the pubes. 
M. Martin Solon has paid special attention to the state of the urine in 
this disease. He has found it to be more scanty, higher coloured, and denser 
than in health, equally acid if not more so, much more abundant in urea, 
and occasionally albuminous, especially in severe cases, in which this charac- 
ter of the secretion must be considered as an unfavourable sign. (MrcAweS 
Generales, 4e ser., xv. 545.) 
Varieties and Complications.-Though the description above given is 
applicable to the great majority of cases, there are peculiarities in not a few 
which require notice. 
In some instances, the disease presents no other symptoms than those of a 
moderate fever, with the characteristic phenomena of a slight diarrhoea or 
tendency towards it, some meteorism of the abdomen, and perhaps a few rose- 
coloured spots. The tongue remains soft, moist, and whitish throughout; 
there is no vomiting, no considerable disorder of the nervous system, no great 
prostration, in fine none of those peculiar symptoms usually denominated 
typhous. The disease runs its course in two or three weeks, sometimes even 
in a shorter time, and then subsides spontaneously, leaving no unpleasant 
effects. Such cases are often mistaken for miasmatic remittent, especially as 
they not unfrequently have a daily remission and exacerbation of the febrile 
symptoms. 
Occasionally we meet with cases in which diarrhoea is the prominent symp- 
tom; so much so as to lead to the conviction, upon a superficial examination, 
that the disease consists essentially of a chronic mucous inflammation of the 
bowels. There are increased frequency of pulse, a slightly furred tongue, and 
perhaps some restlessness, mental depression or disquietude, or other slight 
nervous symptom; but little or no headache or other sign of cerebral disor- 
der, little heat of skin, no great prostration, and no typhous phenomena. 
The disease may thus run on for several weeks, exciting little solicitude, 318 
GENERAL DISEASES.-FEVERS. 
[PART II. 
except by its obstinacy. I have been repeatedly called into consultation, in 
such cases, and have been able immediately to detect their true nature by an 
examination of the abdomen, which is always somewhat tympanitic, and often 
exhibits the rose-coloured spots. If not arrested, the case at length assumes 
a more characteristic form. The tongue becomes dry, the skin arid, the pulse 
more frequent, and the abdomen prominently tympanitic; stupor or delirium 
sets in; and the other symptoms, already enumerated as marking the last 
stage of the disease, make their appearance in greater or less severity. 
There is another class of cases, more rapid and violent in their character, 
in which the prominent symptoms are those of gastric or hepatic disorder, or 
of both. Along with the characteristic symptoms of the enteric fever, we 
have much nausea and vomiting, often of bilious matter, tenderness of the 
epigastrium, and not unfrequently yellowness of the conjunctiva or the skin. 
These cases are often mistaken for bilious fever. They are apt to run their 
course rapidly, and sometimes terminate fatally before the rose-coloured erup- 
tion has appeared. I have seen a case of this kind in consultation, which 
was considered by a skilful and experienced physician as bilious fever, but 
which I suspected to be enteric fever from the state of the bowels, connected 
with a commencing meteorism, and the character of the cerebral symptoms. 
The patient died in about a week, and the glandular patches of Peyer were 
found enormously enlarged. 
Sometimes the pectoral symptoms are most prominent. Instead of the 
ordinary dry or mucous cough and bronchial rales, with little or no oppres- 
sion, we have a tenacious or bloody expectoration, shortness or difficulty of 
breathing, sometimes pain in the chest, and the physical signs of crepitation 
and dulness. The dangers of pneumonia are now added to those of the proper 
fever. 
In other cases, the brain is especially involved. Delirium and stupor, one 
or both, and in various modifications, are the features which most attract 
attention. These may be connected with inflammation of the cerebral mem- 
branes, or strong sanguineous determination to the head: or they may be the 
consequence of deficient action in the brain, dependent cither on a direct loss 
of power, or an altered state of the blood. When occurring in the earlier 
stages, without the signs of generahprostration, they may be ascribed to the 
former cause; under contrary circumstances, though they may also sometimes 
depend upon positive excitement in the brain, it will as a general rule be 
safer to refer them to the latter. 
There is still another set of cases, in which the typhous element seems to 
predominate. From the beginning, there is an obvious deficiency of general 
power. The feeble, though perhaps frequent pulse, the obvious sensorial 
debility, the tendency to black sordes upon the tongue and teeth, the pete- 
chial and hemorrhagic disposition, the dark stools, the peculiar typhous odour, 
and the speedy and great prostration of strength, are evidences of this condi- 
tion of system. 
Frequently it happens, that the varieties above alluded to are more or less 
combined in the same case; and a still greater diversity may arise from the 
occurrence of inflammation in parts not particularly mentioned, as in the kid- 
neys or bladder, in the skin constituting erysipelas, in the joints imitating 
rheumatism, and in the spinal marrow giving rise to palsy. Lastly, there are 
occasionally cases, called latent by Louis, in which the peculiar symptoms of 
the disease are entirely wanting, and nothing exists to call attention to its 
true nature, until, perhaps, perforation of the bowels takes place, or death 
from some other cause reveals the existence of the peculiar intestinal disease. CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
319 
Anatomical Characters.--AAere is scarcely a single organ of the body, in 
which signs of inflammation are not sometimes found after death from enteric 
fever; for it is one of the peculiarities of this, affection, or possibly of the 
febrile movement, which in this affection is of unusual duration, to develope 
local disease of an inflammatory nature. But there are certain anatomical 
changes which are especially characteristic of enteric fever, and which are so 
seldom wanting that they may be considered as almost essential. Such is the 
affection of the elliptical patches of aggregated mucous follicles in the ileum, 
denominated the glands of Peyer. This is quite as characteristic of the dis- 
ease in question, as the peculiar pustular eruption is of small-pox. It has 
in fact come to be regarded almost as a necessary post-mortem test of the 
existence of the disease. The affection had been observed by various patho- 
logists, as by Stark, Petit, and Bretonneau; but it is to Louis that the credit 
is especially due of fixing its precise relation to this form of fever. The facts 
ascertained by the last mentioned pathologist in relation to the enteric fever 
of Europe, have been proved by the dissections of Drs. Gerhard, Jackson, 
Bartlett, and many others, to be equally applicable to the disease, as it pre- 
vails in the United States. 
The opportunity has not yet been offered of ascertaining the condition of 
the glands of Peyer in the earliest period of the disease. They have been 
examined, however, at all stages after the sixth day. At first the patches 
are observed to be thickened, and their surface elevated one, two, or even 
three lines above that of the surrounding mucous membrane. The largest 
are from two to three inches long, and from half an inch to an inch broad; 
the longest diameter being in the direction of the intestine. Some are smaller 
and more circular. Their edges are in general clearly defined, smooth, and 
regular, but sometimes irregular and ragged. Some of them are dark red, 
some pale, and others of an intermediate hue. There are two varieties of 
them, distinguished by Louis by the names of hard and soft. The former 
are hard to the touch, and, when dissected, are found to contain, beneath the 
mucous membrane, and resting upon the muscular coat, a layer of white or 
yellowish, firm, brittle matter, the cut surface of which is smooth and shining. 
The latter are softer, less elevated, and destitute of the whitish layer above 
mentioned; their elevation, when at all observable, being caused by an inflam- 
matory thickening of the mucous membrane covering the patches, and of the 
submucous cellular tissue. In these, the mucous surface appears at first 
granular or finely mamellonated, with innumerable small orifices, which give 
it a reticulated appearance; a condition which is ascribed by Louis to an en- 
largement of the several follicles. This character is lost in the progress of 
the affection; the surface becoming uniform, smooth, and still softer. Some- 
times the same elliptical patch exhibits both the forms just described, one in 
one part of it, the other in another; and often some of both varieties are 
found in the same case. The patches vary in number from one up to thirty, 
averaging perhaps ten or twelve. They appear upon the surface of the intes- 
tine opposite to the mesentery. They do not all originate at once, but in 
general come successively, those near the ileo-cmcal valve first appearing, and 
afterwards those higher up, even into the jejunum. The consequence of this 
successive appearance is a difference in the degree of their developemcnt, the 
oldest being most advanced. 
The hard patches may undergo resolution or ulceration; the soft always 
ulcerate. In the former, the matter deposited beneath the mucous membrane 
first softens, and separates from its connexions, so as to be thrown off when 
the mucous coat above it is removed. The surface is found in various stages 
of ulceration; but, when the process is completed, the whole patch constitutes 320 
GENERAL DISEASES.-FEVERS. 
[PART II. 
one ulcer, which sometimes remains of the original size, sometimes spreads, 
and is occasionally stained yellow by the bile. In some instances, the floor 
of the ulcer is the muscular coat; in others, in consequence of the destruction 
of that tissue, it is the peritoneal coat; and this occasionally is found pene- 
trated, so as to form a communication with the cavity of the peritoneum. Out 
of fifty-five cases which he examined, Louis found eight of perforation. Some- 
times there was only one orifice, sometimes two or three. The opening was 
in the centre of the ulcerated patches, and always in the vicinity of the caecum. 
The perforation is produced either by the progress of ulceration, by mortifica- 
tion of the uncovered peritoneal membrane, or by its rupture from force 
applied within the bowel. 
The ulcers are not necessarily fatal. On the contrary, dissection has 
afforded abundant proof that they have a tendency to heal. In the process, 
the elevated border is depressed, the cavity is filled by granulations, and the 
surface is ultimately covered with a new mucous membrane, which, though at 
first smooth, more glossy, and more tender than the healthy membrane, in 
the end cannot be distinguished from it. 
MM. Billiet and Barthez state, as the result of their observation, that, 
in the cases of children, the diseased patches are almost always of the soft 
variety, that the sub-mucous cellular tissue is rarely affected, that ulceration 
is slower in occurring than in adults, that the ulcer cicatrizes more rapidly, 
and that, in some instances, the inflamed patches, instead of ulcerating, 
undergo resolution. (Traite des Maladies des Enfants, ii. 353.) 
The solitary mucous follicles of the ileum, frequently denominated, though 
perhaps erroneously, the glands of Brunner, the glands properly so named 
being situated in the duodenum, are usually affected in the same manner as 
the glands of Peyer; being enlarged so as to be distinctly visible, and either 
hard or soft, ulcerated, &c. These diseased follicles are scattered, in larger 
or smaller numbers, over the whole circumference of the lower portion of the 
ileum, and are sometimes found also in the colon. Occasionally the elliptical 
patches are alone affected; and it is asserted that, in some rare instances, the 
solitary glands have been diseased without any affection of the patches; but, 
in general, they are both more or less diseased. The aggregated glands are 
more frequently ulcerated than the solitary. 
The mucous membrane of the ileum, between the affected glands, generally 
exhibits signs of disease, being sometimes thickened by sanguineous infiltra- 
tion, sometimes softened, and sometimes of a white or grayish colour, though 
more generally reddened. 
The mesenteric glands are as constantly diseased as the mucous follicles. 
Those corresponding with the morbid patches are most affected, but not exclu- 
sively so. The glands are reddened, enlarged, and softened, and sometimes 
exhibit traces of pus, though very rarely in such quantities as to form an 
abscess. As they become diseased with the patches, so do they also return 
along with these to the healthy state. The lymphatic glands elsewhere are 
also sometimes enlarged and reddened, but less frequently, and in less degree, 
than those corresponding with the diseased glands of Peyer. 
The lesions above described are those characteristic of the disease. There 
are numerous others, which, being incidental, require only a brief notice. 
Other parts of the alimentary canal, besides those mentioned, are often 
diseased. The pharynx was found by Louis in one-sixth of the cases 
either ulcerated, or coated with false membrane, or infiltrated with pus. The 
oesophagus was ulcerated about as frequently, the ulcers being generally small, 
and sometimes numerous. The gastric mucous membrane was more fre- 
quently quite natural than in subjects who had died of any other acute dis- CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
321 
ease; but it was nevertheless often morbid, being softened, reddened, thinned, 
mamellonated, ulcerated, &c. The softening, which is the most frequent lesion, 
though sometimes inflammatory, is thought not to be so in most instances. 
The duodenum is not often much affected. Its lesions are similar to those of 
the stomach. The colon is almost always distended with air, sometimes enor- 
mously so. Occasionally, isolated mucous follicles are found diseased like 
those of the small intestines; and a few small round patches, similar to those 
of the ileum, have been observed in a very few cases. The mucous mem- 
brane sometimes shows signs of inflammation, such as redness, softness, and 
ulceration. 
The spleen is in almost all cases more or less altered, being generally en- 
larged and softened, and sometimes very much so. In some instances, it is 
four or five times the usual size, and softened to the condition of a bloody 
pulp, through which the finger will pass readily in any direction. 
The liver is also frequently softened, though in a less degree, and is other- 
wise variously altered, but without any constant or characteristic lesion. The 
same may be said, in a still less degree, of the kidneys. The gall bladder and 
the urinary passages have been found inflamed, in a very few instances. The 
heart is sometimes softened, and the inner coat of the aorta tinged red with 
blood, probably from imbibition. In relation to the respiratory organs, the 
epiglottis and larynx are sometimes, though rarely ulcerated, or coated with 
inflammatory exudation; the bronchial membrane is oftened reddened; and 
signs of congestion, inflammation, or apoplectic sanguineous effusion, are 
observed in the parenchyma of the lungs. The brain exhibits fewer evidences 
of disease than might have been suspected from the symptoms. In a large 
proportion of cases it is quite healthy. Sometimes the membranes appear 
congested or inflamed; serous effusion has been observed; and the substance 
of the brain has exhibited red points when cut. But no satisfactory connex- 
ion has been traced between these lesions and the symptoms of cerebral dis- 
order evinced during life. 
The blood drawn during life often does not apparently differ from its con- 
dition in health. It coagulates firmly, and, unless the disease is attended 
with some accessory inflammation, exhibits no buffy coat. But if pleurisy, 
pneumonia, or rheumatism be superadded, the inflammatory crust appears, 
though usually soft, and sometimes gelatinous. Sometimes, in low typhous 
cases, the blood is either but partially coagulable, or wholly uncoagulable. It 
has been found in both states after death. When uncoagulated, it is some- 
times mingled with air. It generally contains a smaller proportion of fibrin 
than healthy blood. 
Many of the above phenomena indicate the existence of inflammation in 
connexion with the fever; but the softness which has been noticed in so many 
organs is thought by the best pathologists not to be inflammatory, but rather 
the result of a direct loss of vital cohesion in the organs, either from debility, 
or the state of the blood. 
Causes.-Nothing precisely is known of the cause of enteric fever. The 
circumstances of its production are very diversified. It is certainly often 
generated in situations where human beings are crowded together, with insuf- 
ficient or unwholesome food, and a confined and vitiated air. Hence, it appears 
to originate especially in prisons, badly ventilated hospitals, large cities, camps, 
and ships. Many of the patients, brought every year with this disease to the 
Pennsylvania Hospital, are poor emigrants from on board ships. I have 
repeatedly known the disease to occur in young men, serving as resident 
physicians in hospitals. It is a well known fact that young persons, coming 
from the country into large cities to reside, are very apt to be attacked witk 322 
GENERAL DISEASES.-FEVERS. 
[part II. 
it. This has been observed in Paris. I have often noticed it in Philadelphia. 
The older residents are less liable to be affected. 
From the above facts it might be inferred, that the disease is produced by 
effluvia from the human body, or human excretions in a state of decomposition. 
But it also not unfrequently originates in the pure air of the country. I have 
met with it in the healthiest regions of our middle states, even among the 
mountains. 
It has been thought by many to be contagious. Many strong facts have 
been adduced, both in Europe and the United States, in support of this 
opinion. Thus, an individual coming into a healthy vicinity, from some 
place where the disease prevails, is taken ill with it; and several days after- 
ward, others residing in the same house are seized, and the complaint spreads 
among the neighbouring population. Such instances are recorded by Dr. 
Austin Flint, of Buffalo, N. Y. (Am. Jour, of Med. Sei., N. S., x. 21), by 
Dr. Samuel Jackson, formerly of Northumberland, Penn. (Ibid., x. 349), by 
the late Dr. Nathan Smith, of Connecticut (Bartlett on Typhoid Fever, p. 
80), and by several French authors. But against the opinion of its ordinary 
contagiousness is the fact, that it is constantly springing up in isolated cases, 
without any possible communication, and that, in such instances, it is very 
seldom if ever communicated. Though I have seen much of the disease in 
private and public practice, I never knew an instance, in which it could be 
clearly shown to be the result of contagion. If contagious at all, it must be 
so only feebly, and under peculiar circumstances. 
It is very apt to prevail epidemically in country places; and one of its 
peculiar characters, when thus originating, is that it is apt to be confined to 
limited districts, in this respect very much resembling scarlet fever. In the 
British islands, it appears to be occasionally associated with the typhous epi- 
demics to which those regions are subject. 
Certain individuals are much more predisposed to it than others. Age has 
a great influence over this predisposition. It rarely attacks persons beyond 
thirty years of age, still more rarely those beyond forty, and almost never 
those beyond fifty. Of 255 cases observed by Louis and by Chomel, 78 were 
from fifteen to twenty; 95, from twenty to twenty-five; 54, from twenty-five 
to thirty; 22, from thirty to forty; 5, from forty to fifty; and only 1 above 
fifty. From this statement it would appear not to occur in children below 
puberty. But the cases above alluded to were in hospitals, where I presume 
children are not admitted. The fact, at any rate, is, that the disease does 
occur, and has been frequently noticed in very early life. I have repeatedly 
seen it in children under ten. 
It is generally admitted not to occur twice in the same person. This fact 
will explain its comparative unfrequency in the aged. Those who are sus- 
ceptible to the disease, will be likely to have it before they have attained 
middle life. The same fact has been adduced as an analogical argument in 
favour of its contagiousness. 
It may occur at any season, but is probably most common in the autumn 
and winter. Such at least has been my observation in the Pennsylvania 
Hospital. 
Fatigue, exposure to the sun, vicissitudes of weather, and mental disturb- 
ance, appear sometimes to have acted as exciting causes. 
On the whole, the most rational view of the etiology of enteric fever, in 
the present state of our knowledge, seems to be, that an inherent predisposition 
to this disease exists in many persons, analogous, in some measure, to the 
tuberculous, the gouty, and the rheumatic predisposition, which is liable to 
be called into action by various exciting causes, perhaps by almost any cause CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
323 
capable of considerably disturbing the vital functions; but that all persons do 
not have the predisposition, and that it is generally exhausted by one attack 
of the disease. Hence its occurrence after fatigue, exposure to heat and cold, 
mental anxiety, &c. It is not improbable that the effluvia engendered by 
decomposing animal excretions, the contagious miasm of typhus itself, epi- 
demic influence, and even marsh miasmata, may act as exciting causes of the 
disease in the predisposed. Admitting this to be the case, we are fur- 
nished with a clue to the varieties of character which it assumes. If the 
exciting cause have nothing of a depressing nature in it, we may have an 
open inflammatory or sthenic case. If it be depressing, as the contagion, 
animal exhalation, or epidemic influence which produces typhus, we shall 
have a low, asthenic, or typhous case; in other words, there may be typhus 
superadded to enteric fever. So also, marsh miasm, in calling the predis- 
position into action, may produce that sort of complication, which we occa- 
sionally witness, of the remittent or bilious and enteric fevers. Even the 
occasional apparent contagiousness of the disease may be explained upon the 
same principle. Supposing the true typhus to be superadded to the enteric 
fever, the contagion generated by the former may be sufficient to induce the 
latter in other individuals who may have the predisposition. Indeed the 
typhous state, in whatever disease it occurs, may be supposed capable of 
generating a miasm, which shall produce the same state in other persons, and 
at the same time excite other disorders to which the system may be predis- 
posed from inherent causes, or from external, such as epidemic influence. 
Hence, perhaps, the seeming contagiousness, sometimes, of typhous dysentery, 
malignant erysipelas, &c. 
Nature.-This disease has been supposed to be a mere gastro-enteritis. 
But inflammation of the stomach is often wanting; and the course of the 
symptoms is in general wholly different from that of ordinary mucous ente- 
ritis. Dissection, moreover, has proved a distinction between the two affec- 
tions by making known the diseased state of the glands of Peyer. Another 
opinion considers the disease, though differing from ordinary enteritis, as con- 
sisting essentially in the peculiar state of these glands; all the other phenomena 
resulting from this affection, just as the fevei- in pleurisy results from the 
inflammation of the pleura. But this is scarcely more tenable than the 
former. The general symptoms bear no certain relation in intensity to the 
degree of the local affection. It has, indeed, never been proved that this 
begins with the disease; and there is reason to believe that, in many cases at 
least, it may not commence till some days after the fever. Nor does there 
seem to be any necessary connexion between the intestinal affection, and 
various other symptoms, such as the frequent occurrence of epistaxis at the 
commencement, the great tendency to stupor, the frequent bronchial inflam- 
mation, the peculiar condition of the spleen, the rose-coloured eruption, &c. 
The great probability is, that the disease of the intestinal follicles is a sort of 
internal eruption, like that of small-pox upon the skin, and, like it, merely a 
characteristic attendant upon the complaint. It is not, indeed, certain, that 
this follicular affection is absolutely essential. As to the real nature of the 
fever, we are in the dark, as we are, in fact, in relation to all the essential 
fevers. It seems to bear a close relation to the exanthematous fevers, not 
only by the intestinal affection, which, as before stated, may be looked upon 
as an internal eruption, but also by the rose-coloured spots, which are so 
commonly present at some stage of the disease. How it happens that the 
complaint should be sometimes inflammatory, and sometimes typhous, has 
been already explained. Its tendency, even when inflammatory in the begin- 
ning, to assume a low form analogous to typhus in the end, is probably owing 324 
GENERAL DISEASES.-EEVERS. 
[part II. 
to the general loss of power incident to the long continuance of the fever, and 
especially to the depravation of the blood, arising from disease of the structures 
through which nutriment reaches the circulation, namely, the intestinal mucous 
membrane and the mesenteric glands. 
Diagnosis.-The most characteristic symptoms of this disease are the fre- 
quently slow and insidious mode of attack, the diarrhoea at the beginning or 
soon afterwards, the dull or heavy expression of countenance, the dusky line 
of the face, the tendency to epistaxis, the cough and bronchial rales, and, 
after the seventh or ninth day, the dryness of the tongue and general diminu- 
tion of the secretions, the rose-coloured eruption, the sudamina, the tympa- 
nitic abdomen, the deafness, the stupor or delirium, and the various signs 
indicative of the typhous state. The enlargement of the spleen, either sensi- 
ble to the touch or discoverable by percussion, may have some weight in the 
diagnosis. The duration of the disease, exceeding generally that of other 
fevers, is also an important diagnostic character. It must not, however, be 
understood, that all these symptoms are necessarily present in every case. 
The diagnosis may be very certain, though many of them should be absent. 
One of the diseases with which enteric fever is most frequently confounded 
is the remittent or bilious fever. The latter, however, may usually be dis- 
tinguished by its more regular and decided remissions, by the bilious vomiting 
and yellowness of skin which frequently attend it, by its shorter duration and 
its tendency to end in intermittent, and by the absence or comparative rarity 
of the characteristic symptoms of enteric fever, such as diarrhoea, epistaxis, 
dingy complexion, hebetude of expression, stupor, tympanites, and rose- 
coloured spots. Typhous symptoms are much less common in bilious than in 
enteric fever. Dissection confirms the diagnosis. While in bilious fever the 
stomach is more frequently inflamed, and the liver discoloured than in the 
enteric; the spleen is less diseased, and there is a total absence of the affec- 
tion of the glands of Peyer, and of the mesenteric glands, characteristic of 
the latter complaint. Sometimes, however, the diagnosis is very difficult, 
especially when the bilious fever assumes the protracted .typhoid form. I 
believe that, occasionally, the two complaints are commingled, in consequence 
of the co-operation of their causes. Thus, cases having all the essential cha- 
racters of enteric fever occasionally end in intermittent; and bilious fevers, or 
affections which cannot be distinguished from them, sometimes show the signs 
of enteric fever during their progress. 
The diagnosis between enteric and typhus fevers is reserved until we come 
to the latter of these affections. 
Inflammation of the membranes of the brain sometimes bears a close re- 
semblance, in the general aspect of the case, to enteric fever. But a close 
attention to the diagnostic characters above enumerated will generally enable 
the practitioner to reach a just conclusion. The diarrhoea, epistaxis, and 
heaviness without delirium in the first stage, and the tympanites, sudamina, 
and rose-coloured eruption of the second stage, are perhaps the most import- 
ant symptoms in this relation. 
I have before mentioned that cases of enteric fever are sometimes mistaken 
for mucous enteritis. But, though the discrimination may not always be 
easy, at all stages of the two complaints, yet there can be little difficulty 
when they are carefully observed throughout their course. 
The practitioner should generally avoid a hasty decision at the commence- 
ment of the complaint. Many fevers closely resemble each other in the 
beginning; and, for the first three or four days of enteric fever, it is often 
impossible to decide with certainty upon its character. 
Prognosis.-In this country, and as it has happened to fall under my CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
325 
observation, enteric fever, though a serious, is yet not a very fatal disease. It 
is, however, one of those complaints which put on very different degrees of 
violence, under different circumstances. From statistical reports it is certain, 
that, on some occasions, it is exceedingly fatal. In hospitals it may be ex- 
pected to be more so than in private practice. Out of 140 cases observed by 
Louis, 52, or more than one-third, terminated fatally; while in 134 treated 
by M. Piedaguel there were only 19 deaths, or about one-seventh (Diet. de 
Med., x. 480). In the Massachusetts General Hospital, the deaths, in the 
year 1830, were one in three and a half; in 1831, one in fourteen and a 
half; and in 1829, one in twenty-five. From November, 1836, to November, 
1838, there were fifty-five cases, without one death. (Bartlett on Typhoid and 
Typhus Fever, p. 100-1.) Nor does it appear, that this great difference in 
the result could be referred to any difference in the treatment. There can 
be no doubt that, while certain epidemics of enteric fever are very mild, 
others are very fatal; and that the grade of its severity as an endemic differs 
greatly in different years. 
Nevertheless, if I am to judge from my own observation hitherto, there 
are few serious diseases which exhibit more happily the controlling influence 
of treatment than this. It is true that the complaint cannot be suddenly 
interrupted in its progress; but I have no doubt that it may often be mate- 
rially shortened., and still more frequently conducted to a favourable issue, 
when, if without treatment, it would end in death. No case should be looked 
upon as absolutely desperate. There is no condition so low, no symptom 
so fatal, that death should be considered as inevitable. It is only in 
articulo mortis that the case should be given up. The most desperate state 
is probably that connected with intestinal perforation. Yet even here there 
is some slight chance of safety. The effused contents of the bowels may be 
confined by extravasated fibrin, and the intestinal opening may be closed, or 
a curable abscess pointing externally may take the place of diffused and fatal 
peritonitis. On the other hand, no case of the disease, however light it may 
be, can be looked upon as absolutely free from danger. All cases are liable 
to perforation, even the mildest. The prognosis, therefore, should always be 
cautious. Among the most unfavourable symptoms are steady and complete 
delirium, a notion on the part of the patient that nothing is the matter with 
him, profound coma, stertorous respiration, excessive subsultus or epileptic 
spasms, rigidity of the limbs and eyelids, abundant diarrhoea, hemorrhage 
from the bowels, involuntary discharges, great prostration, extreme frequency 
and feebleness of pulse, amounting to 130 or upwards, coldness and clammi- 
ness of the skin, colliquative sweats, and very great abdominal distension. 
Yet there is no one of these which has not been followed by recovery. The 
favourable symptoms are diminished frequency of pulse and heat of skin, 
increased consciousness and interest in surrounding objects, a restoration of 
healthy secretion, and a disposition in the iongue to become moist and clean. 
The younger the patient, and the better his previous state of health, the more 
favourable is the diagnosis. 
Treatment.-As there is often diarrhoea at the commencement, or,'if not 
diarrhoea, an unusual susceptibility to the influence of cathartic medicine, it 
is not advisable, as in most other fevers, to begin the treatment with a very 
active purge. Yet the bowels should be thoroughly evacuated, in order to 
obviate the injury arising from the contact of irritating matter with their 
lining membrane. A small dose of sulphate of magnesia or of castor oil will 
generally answer the purpose; and, when there is much existing irritation, 
the latter of these medicines should be preferred. Sometimes it may be ad- 
visable, when there is pain at the same time with diarrhoea, to administer 326 
GENERAL DISEASES.-FEVERS. 
[PART II. 
castor oil with fifteen or twenty drops of laudanum. Afterwards, throughout 
the complaint, the state of the bowels should be attended to. If the evacu- 
ations be spontaneous and free, as often happens, no opening medicine will 
be requisite. Should they, on the contrary, be scanty or wanting, means 
should be used to procure at least one full'discharge daily. The gentlest lax- 
atives, and those in small doses, will be sufficient. A fluidrachm or two of 
castor oil, a single Scidlitz powder, one or two drachms of Epsom salt, or half 
a drachm of magnesia may be given for a dose, and repeated if necessary. 
The magnesia should be preferred, when sourness of the breath indicates the 
presence of acid in the circulation. Rhubarb or one of its preparations is 
well adapted to the typhoid cases, in the latter stages. When the stomach is 
irritable, or cathartic medicines worry the patient, the same object may be 
effected by enemata. These should be mild in the early stages; but, at an 
advanced period of the disease, when the tympanites is considerable, may be 
very advantageously combined with the oil of turpentine. But I would again 
impress upon the young practitioner the necessity of avoiding irritating and 
drastic cathartics in this fever. 
The bowels having been evacuated, if necessary, the next indication is to 
obviate the febrile symptoms. When the pulse is full and strong, and san- 
guineous determination to the brain or other vital organ is obvious, blood 
may be taken from the arm to the amount of eight, twelve, or sixteen ounces; 
and cases occur in which it may bo proper to repeat this operation. The 
remedy, however, is wholly uncalled for in numerous cases, and might be 
positively injurious in others. It must be borne in mind, that the disease 
generally runs a certain course, and that this is sometimes very protracted. 
It is important, therefore, to husband the strength of the patient, especially 
as the natural tendency of the complaint is often to debility. Bleeding will 
not arrest it, and, if carried too far or improperly employed, may so prostrate 
the system as to cause it ultimately to sink under the malady. The main 
use of bleeding is to prevent local and disorganizing inflammation. When 
this indication is not presented, and the pulse is not very full and strong, it 
is best to omit the remedy altogether. It will seldoni be proper to employ it 
after the first four or five days; though local bleeding may be resorted to at 
almost any stage of the disease, when called for by inflammation or active con- 
gestion of particular organs, unless the symptoms be decidedly those of debility. 
Leeches or cups to the temples or back of the neck, in cases of cerebral fulness 
or excitement, and to the abdomen when tender to the touch, are often useful. 
Refrigerant diaphoretics should be employed from the commencement. 
Some recommend the antimonials; but they are in general too much disposed 
to irritate the bowels, and, when freely employed, have too sedative an influ- 
ence except in the earliest stages. I prefer the citrate of potassa, in the form 
of neutral mixture, or effervescing draught. (See U. 8. Dispensatory.') This 
may be given throughout the complaint, when the skin is hot and dry, and 
the pulse not very feeble. For the first few days, if the bowels should be 
quiet, the stomach not irritable, and the pulse pretty firm, this diaphoretic 
may be combined with small doses of tartar-emetic. When the nervous symp- 
toms begin to appear, spirit of nitric ether may be added to it; and, in all 
stages, should it produce uneasiness of stomach or bowels, it may be usefully 
combined with small doses of laudanum, solution of sulphate of morphia, or 
other preparation of opium. Some prefer solution of acetate of ammonia to 
the citrate of potassa. Either of these medicines may be given every two 
hours during tbe day, and in the night if the patient be awake and restless; 
but, in this fever, it is almost always best that the nights should be passed in 
sleep. For this purpose, when determination to the head, or the existence of CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
327 
stupoi' does not contraindicate the remedy, a dose of Dover's powder, or an 
equivalent quantity of opium and ipecacuanha in pill, or some other prepa- 
ration of opium which may agree better with the patient, may be given at 
bedtime. 
Cold ablutions are very useful in abating the heat of the surface. The 
legs, arms, and temples, should frequently be sponged with cold water; and, 
when the skin is uniformly hot and dry, the same application may be extended 
to the whole surface. In cases attended with much debility, diluted spirit 
may be substituted for pure water. The patient should also be allowed cold 
drinks, and, if he wish it, a little ice in his mouth, when not greatly pros- 
trate. 
Certain local affections often require attention. Severe headache may be 
treated by leeches, and applications of cold water or ice in bladders. For 
pains in the abdomen, with more or less flatulent distension, small local bleed- 
ings, warm fomentations or emollient cataplasms, and rubefacients or blisters 
may be used. Should considerable tenderness be found to exist in any part 
of the abdomen, whether at the epigastrium, in the right iliac region, or else- 
where, a few ounces of blood should be taken by leeches or cups from the ten- 
der spot. Large mush poultices, covering the whole abdomen, and kept 
steadily upon it day after day, are very useful. Sometimes it may be advisa- 
ble to mix a little mustard or other rubefacient with them. In obstinate cases 
of abdominal tenderness, it may be proper to apply a blister. The diarrhoea 
may generally be allowed to take its course; but, should it become exhausting, 
it should be checked by small doses of opium and ipecacuanha, to which ace- 
tate of lead, kino, extract of rhatany, or pure tannic acid may be added, if 
necessary. Nervous symptoms, such as restlessness, general uneasiness, jac- 
titation, wakefulness, and slight subsultus, may often be quieted by sweet spi- 
rit of nitre, Hoffmann's anodyne, or camphor water; and opiates maybe used 
for the same purpose when not contraindicated. 
In the more favourable cases of the disease, no other treatment than that 
above pointed out will be required. But very often, after the seventh or ninth 
day, a condition of things supervenes which must be met by other measures. 
There is now a general deficiency of secretion. The tongue is dry, the skin 
dry, and the urine scanty. The pulse, though perhaps more frequent, is nei- 
ther so full nor strong as at first. Some degree of delirium, or an increase of 
stupor often supervenes, and the abdomen becomes tympanitic. Without any 
diminution in the violence of the disease, a close examination will show that 
the energy of the vital actions has abated. Under these circumstances, I 
know of no remedy so effectual as mercury, given so as very slightly to affect 
the gums. It is indicated by the general failure of the secretions, and the 
general languor of the vital functions. It is also indicated as an antiphlogistic 
remedy. One of the great dangers is now disorganization from inflammation 
of some important organ. After direct depletion, nothing is so efficient in 
arresting this process as mercury. At the present stage of enteric fever, gene- 
ral bleeding is inadmissible; and the most that can be done, in the way of 
depletion, is occasionally to abstract a few ounces from the vicinity of the 
inflamed organ by leeches or cups. Besides, it is not improbable that mer- 
cury may serve in some degree to arrest the progress of disease in the glands 
of Peyer, and to promote resolution of the inflamed patches. But the impres- 
sion should be made in the mildest way. Large doses of calomel are out of 
the question. I usually prefer minute doses of the blue mass, given at short 
intervals, as, for example, a grain every two hours, until the mouth is affected. 
When the stomach is not irritable, this may with great propriety be associated 
with small doses of ipecacuanha, which tends to soften the skin and promote 328 
GENERAL DISEASES.-FEVERS. 
[part II. 
bronchial secretion; and opium is frequently also an excellent addition. In 
cases admitting this combination, the formula given below may be used.* 
Minute doses of calomel, as the quarter or sixth of a grain, may be substituted 
for the blue mass, if preferred by the practitioner. The neutral mixture may 
be omitted during the administration of this remedy, or may be given in con- 
nexion with it, according to the condition of the skin, and the state of the 
pulse, being always indicated when the surface is hot and dry, and the circu- 
lation accelerated, but not much enfeebled. The mercurial should be continued 
until the gums become slightly touched, and then either diminished gradually, 
or omitted. Under its influence, the tongue not unfrequently becomes moist, 
the skin relaxed, and all the other symptoms ameliorated; and the patient 
recovers without further treatment. Severe ptyalism should be < scrupulously 
guarded against. 
But, should the symptoms not yield; especially, should the tongue remain 
dry, and the abdominal distension undiminished, the oil of turpentine will 
prove an excellent remedy. I cannot too strongly impress upon the profes- 
sion my convictions of the importance of this medicine. It may be employed 
in all cases, in the advanced stages of this disease, when the tongue is dry, 
and the pulse not strong. But there is a particular condition, and that a not 
uncommon and sometimes a very dangerous condition, in which I have often 
employed it, and hitherto have in no one instance known it to fail. In the 
description of the symptoms, it was stated that, in the latter period of the 
disease, the tongue, instead of cleaning gradually from the edges and tip, 
often parts with its fur quickly and in large flakes, generally first from the 
middle or back part of the surface, which is left smooth and glossy, as if 
deprived of its papillae. It was also stated that, if, after this process, the 
tongue remain moist, a slow convalescence may be pretty confidently calcu- 
lated on. But it not unfrequently happens that, during the progress of the 
cleaning process, or after its completion, the surface of the tongue becomes 
quite dry, and the process, if not finished, is suspended. At the same time, 
there is generally an increase of the tympanites, and an aggravation, or cer- 
tainly no abatement, of the other symptoms. Two cases of this kind I had 
seen terminate fatally, one in my own practice, and a second in that of a 
medical friend. One of them was examined after death; and ulcers were 
found in the ileum near the ileo-ccecal valve. This case happened so early as 
the year 1823. Ascribing the aggravation of symptoms which attended the 
drying of the tongue, after cleaning, to the occurrence of ulceration in the 
ileum, I inferred that the oil of turpentine, which had been recommended in 
ulcerations of the intestines, might prove useful here, and determined to em- 
ploy it in similar cases. I did so, and, as before stated, have never yet found 
it to fail, under the circumstances mentioned, though I have had frequent 
occasion to resort to it, both in private and public practice. It acts in some 
measure as a stimulant, but chiefly, I believe, as an alterative to the ulcerated 
surfaces in the intestinal mucous membrane. It should be given in doses of 
from five to twenty drops every hour or two, and is best administered in emul- 
sion with gum arabic, loaf sugar, and water; a little laudanum being occasion- 
ally added, if it disturb either the stomach oi' the bowels. In the course of 
twenty-four, or at most forty-eight hours, some amelioration of the symptoms 
may be observed. The tongue becomes gradually moister, and covers itself 
with a whitish fur; the tympanitic distension ceases to augment, and after a 
* R.-Mass. pil. bydrarg. gr. xij; Ipecacuanhas pulv. gr. ij; Opii pulv. gr. ij; Aquae,' 
q. s. Misce et fiant pil. no. xij. S. One to be taken every hour, every hour and a half, 
or every two hours, according to the urgency of the case. CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
329 
time diminishes ; the pulse becomes less frequent, and the skin less dry and 
harsh ; and the patient enters slowly but regularly into convalescence, often 
without any other remedy. As the case improves, the quantity of the oil 
should be diminished; but care should be taken not to omit it too hastily. 
Not unfrequently, especially in the lower classes, the practitioner is not called 
upon until the disease has assumed the aspect above referred to. He finds 
the tongue red, smooth, and dry, the abdomen tympanitic, and other symp- 
toms which leave no doubt of the disease. I have known such cases to run 
on for a considerable time, without material change, under various treatment, 
and have then seen them yield immediately to this remedy. I will repeat, 
that the oil of turpentine may be used, with good hope of benefit, in any 
case of enteric fever, in the advanced stage, with a dry tongue, and a pulse 
not characterized by strength; but in the cases above referred to, with confi- 
dence of success, so far as a uniform experience of more than twenty years 
may be admitted as a ground of confidence.* 
The debility attendant upon the advanced stages of the disease, is very often 
such as to render the use of tonics and stimulants absolutely essential. The 
period at which it becomes necessary to have recourse to these medicines 
varies greatly in different cases. Sometimes, in very feeble constitutions, or 
during typhous epidemics, or when the patient has been exposed to peculiarly 
debilitating influences, it is very early after the commencement of the disease; 
but, much more frequently, it is not until some time in the second or third 
week. The practitioner must be influenced by the state of the pulse, that of 
the skin, and the general evidence of a typhous condition of the symptoms. 
When the pulse is at once slow and feeble, the skin cool, and the tongue and 
teeth incrusted with dark sordes, there can be no doubt of the propriety of 
using stimulants; and the happiest effects are sometimes experienced from 
them under such circumstances. But it much more frequently happens, that 
the pulse is very frequent while it is weak, and the skin at least partially hot; 
and, even under such circumstances, they are often essential. Sometimes it 
becomes necessary to pursue a tentative course. Should tonics or stimulants, 
carefully given, increase the frequency of pulse and heat of skin, and, instead 
of moderating, augment delirium or stupor, they must be omitted. Should 
they, on the contrary, lessen the frequency and increase the fulness of the 
pulse, relax the skin, moderate delirium, relieve nervous disorder, and promote 
refreshing sleep, they may be considered as acting favourably. The mildest 
should be first employed. The infusion of serpentaria with a little sweet spirit 
of nitre may be tried, and persevered in if it agree well with the stomach. 
The preparations of bark are also sometimes useful, though less so than in 
remittent or proper typhus. Either the compound infusion (U. S. Ph.), or 
sulphate of quinia may be employed, and these may be given in connexion 
with serpentaria. I have occasionally'found advantage in combining sulphate 
of quinia with the oil of turpentine. The medicine should be used in mode- 
rate doses frequently repeated, and omitted if found materially to disturb the 
stomach, or to increase the fever. The large doses of quinia, sometimes 
recommended, are, I believe, wholly inapplicable to this disease. This medi- 
cine acts in enteric fever only as a tonic, and not by its antiperiodic power. 
It is incapable of arresting the disease. I have frequently found it necessary 
to drop it in consequence of unpleasant effects. Wine-whey and carbonate of 
ammonia may be used when a more diffusible impression is indicated.^ In 
* See a paper by the author on the use of oil of turpentine in Fevers, in the N. Am. 
Med. and Surg. Journ., i. 272.-April. 1826. 
f Carbonate of ammonia should be given in doses varying from two and a half to ten 
grains, every hour or two, and is best administered in emulsion. The following formula 330 
GENERAL DISEASES.-FEVERS. 
[part II. 
many instances, it is necessary .to resort to the more powerful influence of 
pure wine, and even of brandy. In cases of sudden and great prostration, 
recourse may be had to sulphuric ether. Opium is an admirable remedy in 
this disease. In the latter stages, it proves useful by its stimulant power, 
and serves, throughout, various other important purposes, such as relieving 
nervous disorder, promoting sleep, checking diarrhoea, and inducing perspira- 
tion. It may be given whenever the pulse is not too full and strong, and the 
brain is not diseased. Should it augment delirium and stupor, it must be 
omitted. In the last stages., it should be given pretty freely when indicated 
as a stimulant; in the dose, for example, of half a grain or a grain every four, 
six, or eight hours. When coldness of the skin is connected with debility, 
powerful rubefacients should be used in connexion with the internal stimu- 
lants. Hot oil of turpentine, Cayenne pepper heated in brandy, or solution 
of ammonia properly diluted, may be rubbed upon the surface of the body, 
especially upon the extremities; sinapisms may be applied to the legs and 
arms; and blisters of Spanish flies to the inside of the thighs or to the trunk, 
care being taken not to leave them on longer than is necessary merely to pro- 
duce a rubefacient effect. Danger of sloughing from excessive stimulation to 
the extremities must be especially guarded against in enteric fever. Care 
must be taken to keep up the temperature of the surface also by artificial 
heat, as by hot bricks, bottles of hot water, &c. 
It is very important to attend to various local affections, or incidental com- 
plications, in the advanced stages. In cases of obstinate delirium or coma, 
great advantage is often derived from shaving'the head, and applying a blister 
over the whole scalp; nor should this remedy, as too often happens, be post- 
poned to so late a period that neither it, nor any other, can be of much avail. 
In excessive subsultus, great nervous restlessness, jactitation, &c., the anti- 
spasmodics have been recommended, as musk, assafcetida, and camphor. 
Sometimes they may be useful, but they often also fail, and the case must be 
trusted to remedies addressed to the general state of the system. Musk may 
be used in singultus, with great hope of benefit. Hemorrhage from the bowels 
should be arrested by acetate of lead, kino, or extract of rhatany, with opium. 
In copious epistaxis, should the ordinary remedies fail, recourse must be had 
to plugging the nostrils both posteriorly and anteriorly. Erysipelas is best 
treated by mucilaginous applications, or by the local use of nitrate of silver 
or tincture of iodine. In cases of peritonitis from intestinal perforation, the 
only hope is in the use of large doses of opium, as proposed by Graves and 
Stokes, in connexion with perfect rest, and the avoidance of all substances 
internally, which can in any way disturb the bowels. To prevent the forma- 
tion of sloughs from pressure and friction, the patient's position should be 
frequently changed, small down pillows should be placed under the body, or 
hollow pillows so as to avoid pressure on prominent points; and the parts 
should be bathed occasionally with spirit, or protected by lead plaster. It is 
highly important to attend to the state of the bladder, and, if there be reten- 
tion of urine, to draw it off with a catheter. 
may be used. R.-Ammoniae carbonat. gij; Acacia; pulv., Saceh. alb. aa ^ij; Aq. menth. 
p., vel Aq. fiuv. f^.vj. Misce. From a teaspoonful to a tabi espoon fill to be taken every 
hour or two, diluted with a little water. Wine whey should be prepared by adding one 
part of good wine to two parts of boiling milk, and straining after coagulation. A small 
wineglassful of this may be given about once in two hours. Brandy is often advantageously 
administered in the form of milk-punch, made with equal parts of the milk and brandy, 
or two of the former to one of the latter, and given in doses of one, two, or three table- 
spoonfuls every hour or two. It is obvious that, in relation to the quantity of stimulus 
used, much must be left to the judgment of the practitioner. CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
331 
The above course of treatment, so far as medicines are concerned, is that 
which has appeared to me to be the most successful. It must not, however, 
be concealed, that others have been proposed, and their claims to superiority 
supported by appeals to experience. Some have strenuously recommended 
an emetic at the commencement, and purgatives afterwards, more or less 
active, throughout the disease. Others trust chiefly to bleeding in the early 
stages. I have been told that Dr. J. K. Mitchell, Professor of the Practice 
of Medicine in the Jefferson College of Philadelphia, has had great success 
with the internal use of nitrate of silver. My friend, Dr. John L. Atlee, of 
Lancaster, Pennsylvania, informs me that he has for many years been in the 
habit of depending chiefly upon acetate of lead, which he has found exceed- 
ingly effectual.* Alum and chloride of soda have also been severally recom- 
mended as having specific virtues. When there is reason to believe that 
the disease is complicated with remittent or bilious fever, and especially 
when, under such circumstances, it terminates in intermittent fever, sulphate 
of quinia should be used without hesitation, and with a freedom proportioned 
to the urgency of the symptoms. 
Attention to the diet is all important in enteric fever. In the early stages, 
it should be very light, consisting chiefly of liquid substances, which may also 
answer the purposes of drink. Solution of gum arabic, barley water, rice- 
water, toast and water, weak solutions of tapioca, sago, or arrowroot, very 
weak gruels of oatmeal or Indian meal, molasses and water, vegetable jellies 
mixed with water, and other similar preparations may be successively, or 
interchangeably employed; and the patient may be allowed, if he desire it, to 
swallow the juice of sweet grapes and oranges, taking care to reject the solid 
portions of these fruits. Cold lemonade or orangeade, carbonic acid water, 
and pure iced-water in moderation, may also be used as drinks. At a more 
advanced period, in the second week, for example, when the symptoms of 
debility begin to show themselves, it will be necessary to support the strength 
by a more nutritious diet, which however should not be stimulating. Pre- 
parations of tapioca, sago, or arrowroot, of a nearly gelatinous consistence, 
thick gruels, or panada, may now be given, flavoured with nutmeg or other 
spice, and sugar, and not unfrequently with wine. It will often be desirable 
to give these in certain quantities, at certain intervals, so as to insure that 
enough is taken. I have generally been in the habit of directing a wineglassful 
to be given every two or three hours, or less frequently, according to the ap- 
parent strength of the patient. A cup of tea may also be allowed, with dry 
* At my request, Dr. Atlee has furnished me with a particular account of his method 
of administering acetate of lead; and the following is an extract from his letter pn the 
subject, dated Lancaster, Nov. 4th, 1S48. "The primae vise are first unloaded by castor 
oil, sulphate of potash and rhubarb, or some of the milder neutral salts; and the patient 
immediately placed upon an absolute diet-and by this I mean cold water, toast-water, 
or a very weak gum water. Should the fever be prolonged beyond the third or fourth 
day, and its character become fairly established, I then resort to the acetate of lead, in 
doses of from one to three grains, carefully and perfectly dissolved in a few drops of 
vinegar and half an ounce of river or distilled water, and given every 2, 3, or 4 hours, 
according to the frequency of the symptoms; and the treatment is steadily persevered 
in as long as the enteric symptom® continue. In one or two instances, I have continued 
it for 14 or 15 days; during the whole of which period, there was no other internal 
medication, beyond an occasional small dose of castor oil. Of course, I have not used 
it to the exclusion of all the other established means of combatting fever; viz., local 
depletion, cold ablution, counter irritation, &c., &c, where these are indicated; but my 
confidence in the.effects of the lead has been so firmly established, that I do not always 
resort to them. Nor has it deceived me. I do not know that I have ever lost a patient, 
where the case was treated from the commencement, as above indicated."-Note to 
second edition. 332 
GENERAL DISEASES.-FEVERS. 
[part II. 
toast or a water-cracker, morning and evening. Still further on in this stage 
of the disease, milk, in small quantities frequently repeated, will often be 
found to suit the case admirably well. A tablespoonful of it may be given 
every hour or two through the day; and, if the stomach be irritable, it may 
very properly be associated with an equal quantity of lime-water. In the 
last, or prostrate stage, it is proper that the diet should be not only nutritious, 
but also stimulating. Animal broths or jellies may now be given; and, in 
the lowest cases, it is necessary to resort to egg beat up with wine, milk-punch, 
and the essence of beef or mutton. (Seeyqye 210.) 
Throughout the whole case, the greatest attention should be paid to clean- 
liness and ventilation; and, when the atmosphere cannot be sufficiently purified 
by these means, as sometimes happens when many patients are crowded 
together, recourse may be had to the corrective influence of chlorine. 
The period of convalescence often requires a close watchfulness on the part 
of the physician. The bowels should be kept daily open, if necessary, by 
the mildest laxatives or enemata; but active purgatives should be scrupulously 
avoided, as they endanger injury to the ulcerated surfaces, and sometimes 
induce relapses. Not unfrequently the patient is affected with profuse and 
exhausting sweats at night. These are ordinarily best encountered by the 
mineral acids and simple bitters. Convalescence appears to be sometimes 
very much retarded by a debility of the alimentary canal, which disables the 
ulcerated surfaces from healing. A species of hectic excitement is sustained 
for a long time. The pulse remains frequent, something like a febrile paroxysm 
occurs every afternoon, and the patient sweats copiously at night. Under these 
circumstances, I have found nothing so effectual as sulphate of quinia- The 
diet in convalescence should be nutritive, but mild and easily digested, and 
the patient should be especially guarded against an excessive indulgence of 
his appetite. I,have known death, after the apparent commencement of con- 
valescence, to result from the free use of peaches. Premature and fatiguing 
exertion should be avoided; and the patient should be brought gradually back 
to his accustomed modes of life, without any strain upon his mental or phy- 
sical powers. 
Article V. 
TYPHUS FEVER. 
Syn.'-Typhous Fever.-Typhus Gravior.'-'Spotted Fever.-Petechial Fever.-Putrid 
Fever.-Camp Fever.-Ship Fever.-Jail Fever.-Hospital Fever. 
The origin of the terms typhus, typhous, -and typhoid, (from stupor,) 
indicates the general character of the affections to which they have been ap- 
plied. But, as they have been rather vaguely used by authors, it will be 
proper to state precisely the meaning attached to them in this work. 
There is a peculiar febrile disease, distinct from all others, characterized by 
a peculiar group of symptoms, and produced p^bably by a peculiar cause, to 
which the name typhus, or typhus fever, is attached; the substantive term 
being used adjectively in the latter name, as we say ship fever, jail fever, &c. 
But a state of system, identical or closely analogous with that which charac- 
terizes typhus fever, is frequently met with in other febrile diseases, as a mere 
incidental accompaniment. To this state of system the epithet typhous or 
typhoid is applied, the latter being preferred to the former when it is wished 
to imply resemblance only, and not sameness. Thus, we speak of a typhous CLASS I.] 
TYPHUS FEVER. 
333 
or typhoid condition of bilious fever, yellow fever, small-pox, measles, pneu- 
monia, dysentery, &c., or, with greater brevity, of typhous pneumonia, typhous 
dysentery, &c.; by the latter phraseology, however, generally implying a more 
thorough incorporation of the typhous constituent with the principal affection 
than by the former. This distinction between the peculiar disease named 
typhus fever, and the analogous state of system met with in other diseases, 
indicated by the adjective epithets typhous and typhoid, it is important to 
bear constantly in mind, in order to avoid serious errors. 
The existence of such a disease as typhus fever is universally admitted. 
But opinions are not equally united in relation to its identity or iron-identity 
with the disease styled in this work enteric fever, but more generally known 
as typhoid fever, dothinenteritis, &c. Many consider the two as constituting 
varieties of the same disease, differing only in the superaddition of a certain 
intestinal affection, in the case of the enteric fever. A greater number pro- 
bably believe them to be entirely distinct, though having in many instances 
certain very striking points of resemblance. The latter opinion is the one 
adopted by the author. Differences between the two diseases sufficiently 
fundamental, in his estimation, to justify this opinion, will be pointed out 
under the heading of diagnosis. It is sufficient here to say, that, from the 
time of Huxham downwards, authors have observed such obvious and important 
differences in the symptoms and cause of fevers called typhous, that they have 
been compelled to give distinct descriptions of two varieties, designating the 
one as malignant typhus, typhus gravior, &c., the other as typhus mitior, 
nervous fever, &c.', and practitioners who have witnessed both have been 
under the necessity of making a similar discrimination in their own minds. 
While a student of medicine, and for some years after beginning to practise, 
I had many opportunities of seeing the proper typhus fever, which prevailed 
epidemically in different parts of the United States, beginning in New Eng- 
land so early as 1807, reaching our own neighbourhood in the winter of 
1812-13, and continuing to lurk in the lanes and alleys, among the crowded 
poor of Philadelphia, until the year 1820 or 1821, when it disappeared. The 
disease again showed itself in our city in the spring and summer of 1836, 
being confined, for the most part, to a certain portion of the population in the 
most wretched quarter of the town, and was soon afterwards once more extin- 
guished. During the eight or nine subsequent years, though prescribing in 
the Pennsylvania Hospital during one-third of each year, I saw only four 
cases of the disease, and all of these were in strangers. Yet, throughout all 
these periods of exemption, I had been constantly witnessing cases of a slow 
fever, often inflammatory in the beginning and becoming typhoid in its pro- 
gress, which was formerly designated among us as nervous fever, slow remit- 
tent, &c., differing alike from the epidemic typhus, and the endemic bilious 
remittents of our country. Upon the appearance of the excellent work of 
Louis on typhoid fever, I at once recognized that disease in his descriptions, 
and have since entertained no doubt whatever of its distinctive character. There 
are undoubtedly strong resemblances between certain cases of the enteric and 
typhus fevers; and, though in most instances easily distinguishable by the ob- 
vious symptoms, they were often confounded, until the work just alluded to 
placed us in possession of the means of a more accurate diagnosis. But it is 
highly probable that the two diseases are sometimes combined, in consequence 
of the simultaneous action of their causes; and hence the occasional difficulty of 
discrimination, which has induced many practitioners, especially the British, to 
consider them as in fact identical. But we might with as great propriety 
confound bilious remittent fever or pneumonia with typhus fever, because, 
when the latter becomes epidemic, the two former often take on a certain 334 
GENERAL DISEASES.-FEVERS. 
[PART IT. 
degree of its character, and thus give rise to mixed diseases. The enteric 
fever no doubt, during epidemics of typhus, assumes more of the typhous 
nature than under other circumstances, and is therefore more readily con- 
founded with that disease; though post-mortem examination will almost always 
detect the difference, even here.* 
Symptoms.-More frequently perhaps than in most other fevers, the pa- 
tient is affected preliminarily more or less with certain morbid sensations, 
such as pain, soreness, or a feeling as of weariness in the back and limbs, 
headache, fatigue after slight exertion, general uneasiness, constriction of the 
epigastrium, deficient appetite, or even nausea, mental depression or irritation, 
restlessness, and want of sleep. Sometimes the disease begins and advances 
so gradually, that it is difficult to fix the precise time of attack. But, in the 
great majority of cases, after a longer or shorter duration of some of the above 
symptoms, and occasionally without them, the patient is seized with chilliness 
and feelings of great debility, which compel him to take to his bed. There 
are usually at the same time sharp pains in the back, loins, head, and lower 
extremities, or in some one or more of these parts, which are sometimes ex- 
ceedingly severe and even excruciating. Occasionally, also, there are nausea 
and vomiting, though these are not common. This initial or cold stage varies 
greatly in degree and duration. Sometimes it is so slight as to be scarcely 
perceptible; sometimes exceedingly severe and protracted, with a cool and 
pale skin, shrunken and anxious features, a frequent, irregular, and very feeble 
pulse, great oppression, and universal prostration, in which death may occur 
with but feeble and ineffectual attempts at reaction, or without any reaction 
whatever. Cases of this kind, however, are very rare. In the vast majority 
of instances, febrile reaction occurs sooner or later, often in a very short time, 
sometimes not for twelve hours or more; and frequently there is an alterna- 
tion of chilliness and heat several times, before the latter becomes permanent. 
The febrile condition, when established, is. marked by the usual symptoms 
of a hot dry skin, accelerated pulse, hurried breathing, furred tongue, thirst, 
anorexia, and headache. The pulse at this period is often full, and possessed 
of a certain degree of strength; but it is generally easily compressible, and 
less firm and tense than in ordinary fevers, with much less appearance of ex- 
citement. The tongue is usually moist, and whitish or yellowish-white. 
Occasionally there is nausea or vomiting; but these are not ordinary symp- 
toms, and are often entirely absent throughout the complaint. The bowels 
are generally costive, and no stools are procured without medicine. Even at 
this early period, the appearance of the face is often peculiar, being of a dark- 
ish-red or dusky hue, with injection of the eyes, and sometimes congestion of 
the mucous membrane of the nostrils and fauces. The mind also exhibits 
signs of sluggishness, and the thoughts often have some degree of confusion. 
The headache, which is felt most commonly over the brows, is often exceed- 
* Since the above account was written, we have had ample opportunities of witnessing 
typhus fever in the Pennsylvania Hospital, occurring among the emigrants from Ireland 
during the years 1847 and 1848. Aly views have not been altered by these cases. 
Among the emigrants there were some with enteric fever, as there always had been, at 
the periods when none came with typhus. But the greater number, originating on ship- 
board, were of the latter affection. In general, there was little difficulty in making a 
diagnosis between the two classes of cases, during the progress of the disease; and, in 
every fatal case that occurred, the correctness of the diagnosis was established by the 
result of post-mortem examination. In accordance, however, with what has been stated 
in the text, there were one or two obscure cases, which may have been mixtures of the 
two diseases, but the precise pathological character of which we had no means of de- 
termining with certainty, as they recovered. (Note to second edition.') CLASS I.] 
TYPHUS FEVER. 
335 
ingly severe, feeling, to use an expression common with, the patients, as 
though the head would burst. 
These symptoms continue for several days, gradually increasing until the 
disease attains its height. The surface is now universally hot, with little dis- 
position to perspiration, and the heat is of that peculiar kind, usually called 
color mordicans or mordax, which produces in the hand a sense of pungency 
as well as burning. Examined by the thermometer, the temperature of the 
surface is usually from 100° to 106° F., and, in some rare cases, as high even 
as 109°. The pulse is remarkably frequent, and generally feeble, beating 
from 100 to 120 or 130, and sometimes as high as 140, 150, or even 160 in 
a minute, so that it can scarcely be counted. The respiration also is very 
frequent ; and, when examined by the stethoscope, is found feeble and imper- 
fect in the back and lower part of the chest, which is also dull on percussion. 
(Gerhardd) A paroxysmal tendency is often observed in the febrile symp- 
toms; an exacerbation generally taking place towards night, and a remission 
in the morning. 
A characteristic eruption now almost always makes its appearance, which 
gives the disease a right to be ranked among the exanthemata, and has served 
as the origin of the names of spotted and petechial fever sometimes applied to 
it. This consists of numerous small reddish spots, varying in size from that 
of mere specks to an eighth, a quarter, or even half an inch in diameter, 
though generally very minute. They are confined to no particular portion of 
the surface, occurring upon the neck, trunk, and extremities, and sometimes 
covering the whole body, giving it occasionally an appearance not unlike that 
of measles. The eruption is in general not elevated or scarcely elevated 
above the surface, and is variously coloured, red, purplish, violet, or almost 
black; being usually brighter coloured in the early stages, and in mild cases, 
and darker in the declining stage, and in malignant qases. Sometimes the 
spots disappear under the pressure of the finger, but in general slowly and 
imperfectly; and, when of a dark purple or livid hue, are usually not affected 
by pressure at all, being in fact true petechias. Sometimes they are very 
numerous, sometimes very few, and cases now and then occur in which they 
are wholly wanting. They appear at different periods, from the third to the 
thirteenth day, but usually from the fifth to the eighth; and generally last 
eleven or twelve days. Sometimes they fade for a time, and again appear in 
the progress of the case. They are occasionally accompanied with sudamina. 
Sometimes these little vesicles exist in great numbers over the body, without 
the red eruption. 
The tongue in this stage usually assumes a brownish colour, and becomes 
more or less dry, especially in the middle; while, in some cases, a dark sordes 
begins to collect upon the teeth, gums, and lips. Sometimes the tongue is 
clean, smooth, and glossy, and sometimes, in the progress of the disease, 
assumes an appearance not unlike that of raw beef. There is in general a 
total want of appetite, but less disgust for food than in most other fevers. 
The discharges from the bowels, procured by medicine, are often dark coloured 
and offensive. Sometimes diarrhoea comes on; and this was especially the 
case with the disease as it has lately appeared among the emigrants from 
Europe. The abdomen is sometimes quite flat, sometimes moderately swollen 
and tympanitic. The urine is usually scanty. The colour of the face deepens, 
sometimes into a dark red, purplish, or livid hue, which completely overspreads 
it; and the eyes have a turbid appearance. Occasionally there is bleeding at 
the nose. A peculiar and characteristic odour exhales from the body, which 
has been variously described, but which can be appreciated only by those who 
have once perceived it. I have noticed something similar to it in confined 336 
GENERAL DISEASES.-FEVERS. 
[part II. 
rooms, in which numbers of persons, diseased or otherwise, have been long 
crowded together, and no attention paid to ventilation or cleanliness. 
The nervous symptoms are now prominent. Though the headache and 
general pains may be less severe, there is often a universal tenderness of the 
skin, which causes the patient to shrink or complain when pressure is made 
upon any part of the body. Dizziness, confused vision, buzzing or ringing in 
the ears, and partial deafness are not uncommon symptoms. 
The characteristic stupor of the disease becomes more and more developed. 
Sometimes it deepens into profound coma; but this is comparatively rare. In 
general the patient can be roused with little difficulty, and will answer ques- 
tions, though slowly, often imperfectly, and with apparent reluctance. He 
pays little attention to objects around him, and his countenance frequently 
has the apathetic, expressionless character of drunkenness, though sometimes 
wild and anxious. When told to protrude his tongue, he often does so par- 
tially and with apparent difficulty, and when it is protruded forgets to draw 
it in again. Delirium frequently replaces, or is mingled with the stupor. In 
some instances, it is violent, but much more frequently, low and muttering. 
Notwithstanding the heaviness of the patient, he gets little refreshing sleep, 
and often appears as if in a troubled dream. Now and then great rest- 
lessness and jactitation occur, with muscular twitchings in various parts of 
the body. . 
Symptoms of debility are almost always mingled with those of perverted 
function. When consciousness remains, one of the most distressing sensa- 
tions is that of utter prostration and powerlessness. The patient often feels 
as if he were sinking downward into the earth, with nothing underneath to 
support him, and no power of his own to check his descent. This has been 
described to me after recovery, as a most horrible feeling, worse even than 
the most violent pain. A disposition to faint upon the slightest exertion is 
not uncommon, and fatal syncope sometimes occurs upon an attempt on the 
part of the patient to rise and walk. Even without any cause of this kind, 
sinking spells sometimes suddenly come on, in which life is in the greatest 
danger. Occasionally these follow immediately after long and profound sleep, 
which exhausts instead of refreshing the patient. Among the attendants upon 
this excessive debility is sometimes a sense of intense oppression at the chest, 
amounting almost to suffocation. The patient feels as if deprived of air, and 
labours painfully for breath, expanding the chest, and raising the shoulders 
as in an attack of violent pulmonary congestion. 
Should no favourable change take place at this period, the disease passes 
into the last stage, or that of prostration. The patient lies upon his back in 
bed, with his eyes half closed, and his mouth open, slipping downward from 
inability to maintain his position, and almost insensible to impressions from 
without. Along with stupor or low delirium, there are often subsultus tendi- 
num, picking at the bed-clothes or at imaginary objects in the air, and some- 
times spasmodic muscular movements amounting almost to convulsions. Oc- 
casionally the patient is troubled with hiccough. The pupil is sometimes 
dilated, sometimes extremely contracted. The tongue is often quite dry, the 
mouth loaded with brown or blackish sordes, and the breath offensive. De- 
glutition is often difficult from deficiency of muscular power. Occasionally 
involuntary discharges take place from the bowels or bladder, and sometimes 
the urine is suppressed. The surface has in great measure lost its sensibility, 
so that the strongest irritants make little impression; and I have heard of an 
instance in which a burning coal, applied to the epigastrium, gave rise only 
to an agreeable feeling. The extremities are cold; the skin pale; the fea- 
tures collapsed, and of an ashy hue. The pulse is sometimes frequent and CLASS I.] 
TYPHUS FEVER. 
337 
fluttering, sometimes even slower than in health, but always small and feeble, 
and at length scarcely to be felt, or quite absent at the wrist. 
Even in this state, however, the case is not desperate; and suitable reme- 
dies have often proved effective. But, should it terminate unfavourably, death 
usually approaches gradually, and without violence. The respiration becomes 
slower and slower, the pulse weaker and weaker, until at length the patient 
ceases to breathe, and the heart to beat. In some rare instances, death is pre- 
ceded by convulsions. When it takes place at an earlier period of the disease, 
it is more frequently violent, though even then it generally occurs through 
syncope, or in the midst of coma. 
When the disease takes a favourable turn, before the period of collapse, the 
event is generally indicated by a diminished frequency of pulse, a relaxed 
state of the skin, a return of moisture to the tongue with a disposition in its 
surface to clean, a gradual fading of the eruption, a subsidence of the nervous 
symptoms generally, and a return of consciousness. Not unfrequently, con- 
valescence is ushered in by some incident which may be considered as form- 
ing a crisis. Thus, a copious perspiration, or an unusual discharge of urine, 
is followed by a marked amelioration of the symptoms; or the patient falls 
into a gentle and quiet sleep, and, upon awaking, is found to have recovered 
his consciousness, and to be in all respects improved. When recovery takes 
place from the state of collapse, it is usually by a gradual and almost imper- 
ceptible amendment, under the supporting influence of remedies. The force 
of the disease has been exhausted, and it is the extreme debility alone which 
is to be counteracted. 
Convalescence is generally slow, as time is required not only for the sub- 
sidence of the morbid actions, but for the repair of the exhausted powers of 
the system. The hair is apt to fall, and the cuticle not unfrequently desqua- 
mates. The brain and nervous system generally are often long in regaining 
their previous energy; the intellect, and especially the memory, remaining 
imperfect for weeks or even months. In general, however, no ultimate incon- 
venience is experienced, and the restoration to health is perfect. Relapses 
are said sometimes to take place, but they are very rare. In the cases, how- 
ever, connected with diarrhoea, this affection is apt to recur after convalescence, 
in consequence of premature or excessive indulgence of the appetite.* Reco- 
very is also sometimes protracted by the occurrence of external abscesses, 
especially in the region of the parotids. 
The duration of the disease is variable. When it terminates favourably, 
it generally runs a course of three weeks or more, occupying one week in the 
advance, another in the formed state, and a third in the decline. Sometimes, 
however, when very mild, it terminates as early as from the seventh to the 
eleventh day, and in other cases runs on for four weeks. Fatal cases may 
end at any period. Death sometimes occurs, without reaction, in the first 
twenty-four hours, and is not unfrequent so early as the fifth or sixth day. 
But more commonly it does not take place until some time in the second 
week, apd is perhaps most frequent from the ninth to the twelfth day. It 
may also occur at a much later period. 
Varieties.-1These are such as arise from differences in degree, and from 
complications. Sometimes the disease is very mild, exhibiting only the ordi- 
* A very interesting account is given by Dr. J. B. Upham, of Boston, of a secondary 
diarrhoea, which came on in the convalescence from typhus, as it occurred in the Deer 
Island Hospital, and which proved very fatal. Dissection disclosed discoloration and 
great thickening of the mucous membrane of the ileum, which exhibited prominent 
transverse parallel ridges, without special disease of the solitary or aggregated follicles. 
(See Bost. Med: and Surg. Journ, xxxvii., 16, 31, &c.l 338 
GENERAL DISEASES.-FEVERS. 
[part II. 
nary symptoms of moderate fever, with some dulness or stupor, duskiness of 
complexion, and characteristic eruption, and terminating favourably without 
treatment. In other cases, it is exceedingly violent, the system sinking under 
the force of the first blow, and either never reacting, or but imperfectly. Such 
cases are now fashionably called congestive. Their danger probably depends 
not on sanguineous .congestion, but on the prostrating influence of the poison 
upon the nervous and circulatory systems. Between these extremes, there is 
every conceivable grade of violence. 
In some instances, the disease is characterized ,by an early ,and peculiar 
tendency to dissolution of the blood. This is indicated by the passive hemor- 
rhage which attends them, the abundance and purple or livid colour of the 
petechias, the fetidness of the breath, the disposition to gangrenous eschars, 
and the extreme prostration of the pulse. 
Another peculiarity is the absence, in certain cases, of all excitement of the 
pulse, and this without reference to the violence of the disease. Not only is 
the pulse unexcited, but it is even less frequent than in health, being some- 
times so low as fifty in the minute. 
The disease is very frequently associated with inflammation of some one or 
more of the organs, which considerably modifies its symptoms.and result. The 
most common complication is probably with pneumonia, to which the mechani- 
cal congestion of the blood in the posterior portions of the lungs may give a 
peculiar tendency. For an account of th,e diagnostic symptoms of this affec- 
tion the reader is referred to pneumonia. It may be inferred to exist when 
the patient coughs, and expectorates a rusty or bloody viscid matter; and the 
diagnosis would be confirmed by the absence of the respiratory murmur, the 
existence of a crepitant or subcrepitant rale, and dulness on percussion in the 
part affected. There is seldom much pain of the chest. This complication is 
most apt to exist in cold weather. In summer, the disease is more frequently 
associated with gastric, intestinal, or hepatic disorder. At that season, diar- 
rhoea or dysentery sometimes occurs, in consequence of inflammation of the 
ileum and colon; and vomiting, epigastric tenderness, yellowness of the skin, 
&c., from gastritis and derangement of the liver. Inflammation of the fauces 
is also not unfrequent, and the disease is pccasionally complicated with erysi- 
pelas. It is highly important that the practitioner should be aware of these 
inflammatory complications; as he might otherwise be apt to mistake the 
case for one of the ordinary phlegmasim, and treat it accordingly with fatal 
effect. 
Other varieties of typhus fever are those which arise from its connexion 
with other fevers, dependent upon a simultaneous action of their cause with 
its own. Thus, it may be, and probably not unfrequently is associated with 
enteric or typhoid, and remittent or bilious fever. 
Anatomical Characters.-Though various evidences of deranged structure 
are presented, upon dissection after death in the advanced stages of typhus, 
yet there is no one characteristic and essential lesion, unless, perhaps, the state 
of the blood, and the petechial eruption. All the others may be considered 
incidental. In cases of early death, no lesion whatever is found, to which the 
result can be attributed. 
Blood drawn during life, in the earliest stage, forms a soft, large, sometimes 
dark-coloured coagulum, without the buffy coat. In consequence of the de- 
velopement of inflammation, this appearance is sometimes presented at a later 
period. Blood drawn in the advanced stages is darker and more liquid, and, 
though it may still coagulate, does so more slowly, and forms a softer clot. 
Sometimes it is almost black. After death, it is found in the veins black, 
liquid, sometimes resembling molasses, and occasionally mixed with oily gio- CLASS I.] 
TYPHUS FEVER. 
339 
bules. When coagula are observed, which is rarely the case, they are very 
soft. From the experiments of Dr. Frick, it appears that the fibrin is gene- 
rally below, and the red corpuscles above their normal proportion. (Am. Journ. 
of Med. &£, N. S., xv. 31.) 
In general, a strong tendency to speedy putrefaction has been observed after 
death. 
Within the cranium, there is often venous congestion, with some serous 
effusion in the ventricles or beneath the arachnoid, and the substance of the 
brain is occasionally darker than in health, though in other cases unaltered, or 
even whiter. No clearly ascertained connexion exists between the stupor and 
the anatomical appearances of the brain. 
The mucous membrane of the nostrils, fauces, and respiratory passages, is 
generally reddened. The posterior and lower portion of the lungs is often 
solidified, of a dark-red colour, fragile, and impervious to the air, though with- 
out the granular appearance of hepatization. 
The gastric mucous membrane is often reddened, much softened, and some- 
times mamellonated; that of the intestinal canal is frequently free from dis- 
ease, though sometimes found inflamed, and even ulcerated, in cases compli- 
cated with diarrhoea or dysentery. No disease whatever is observed in the 
glands of Peyer, unless in a very few cases, which it is fair to ascribe to 
complication with enteric fever.* 
The spleen is very often quite healthy, though frequently also softened, and 
sometimes enlarged. The liver is either healthy, or softened and engorged 
with blood. The heart is sometimes natural, sometimes softened, f 
* Diarrhoea has been a frequent complication in the typhus which has recently pre- 
vailed among the emigrants. In the genuine cases, the appearances of the bowels, on 
dissection, were as stated in the text. Among the cases of fever in the Pennsylvania 
Hospital in the winter of 1847-8, was one of great severity, in which there were diar- 
rhoea and tympanites, but which, from the succession of symptoms, the character of the 
eruption,&c., was diagnosticated as typhus during life. On examination of this case after 
death, numerous gangrenous ulcers were found in the small intestines; but the solitary 
glands, the glands of Peyer, and the mesenteric glands were quite healthy. (Ante to second 
edition.') 
t Certain German pathologists, among whom are Rokitariski and Engel, have put 
forth an opinion, that there is a morbid condition of the blood in typhus fever, disposing it 
to the deposition of a peculiar typhous matter, which bears to the general state of system 
the same relation that tubercle does to the tuberculous cachexia. This deposit may take 
place in various organs, as the spleen, lungs, intestinal mucous membrane, mesenteric 
glands, &c. It is of a yellowish, reddish, or brownish colour, at first of a rather firm con- 
sistence, but ultimately softening, and in the end either absorbed, or discharged by ulcera- 
tion, &c. This notion appears to be applicable to enteric or typhoid fever; and some 
analogy between that affection and phthisis has long since been noticed, allowance being 
made for the acute character of the former, and the chronic character of the latter. Dr. 
Bennet, of Edinburgh, has noticed this deposit in the typhus which prevailed in that city 
in 1846-7. One of the peculiarities of that epidemic was the occurrence, in numerous 
instances, of the disease of the glands of Peyer, which he bad before seen only in three 
cases out of five hundredwhich had been examined by him in the course of three years. 
Out of sixty-three cases examined by him in 1846-7, ten presented the peculiar deposit 
alluded to in the spleen, fifteen something analogous to it in the lungs, and nineteen 
disease of the glands of Peyer, as described by Louis, &c. (Month. Journ. of Med. Sci., 
October, 1847.) Was not this affection at Edinburgh the true enteric or typhoid fever; 
and may not the character ascribed by the German pathologists to typhus in general 
be a peculiar feature of the former disease, distinguishing it from typhus? If the deposit 
were characteristic of what is in Great Britain known as typhus, and is in this work 
recognized by that name, why was it not found in more than three of the five hun- 
dred cases previously dissected by Dr. Bennet? The probability is, that the typhus of 
the German pathologists referred to is the true enteric or typhoid fever, and quite 
distinct from the typhus endemic of Great Britain, which is occasionally epidemic in the 
United States, and occasionally brought hither from abroad. (Note to second edition.) 340 
GENERAL DISEASES.-FEVERS. 
[part II. 
Causes.-The special causes of typhus fever are 1. the vitiated air resulting 
from the crowding of human beings in confined places, and 2. a peculiar con- 
tagion. The exhalations from the body and from the excretions probably 
undergo changes, resulting in the production of a poisonous aeriform matter, 
which, being absorbed into the system, gives rise to the disease in question. 
It is not necessary that the individuals who serve as the source of the poison 
should be diseased, though it is thought that certain complaints favour its pro- 
duction, such as dysentery, gangrene, &c. All that is absolutely essential is, 
that there should be numbers of persons crowffedAvithin confined and ill-ven- 
tilated places, in which the filth from the excretions is also allowed'to accumu- 
late. Hence, the disease has often made its appearance in camps, prisons, 
ships, hospitals, garrisoned cities, &c.; and hence, too, it is usually most 
prevalent among the lowest and most vicious, people, inhabiting the cellars, 
lanes, and closely built parts of cities. 
That, when once generated, the disease is capable of propagating itself by 
contagion is almost universally admitted. The facts in support of this opinion 
are too numerous and strong to be refuted. Thus, nurses and other attend- 
ants upon the sick are often seized with the complaint, without any other 
known cause. Armies are known frequently to have spread it in their march 
in places before healthy. Individuals attacked by it, have been removed into 
uninfected neighbourhoods, and have there become centres of infection. It 
appears even to be capable of being conveyed in clothing, to which the poison 
has been said to adhere for the space of three months. Yet the contagion is 
not powerful. When unsupported by peculiarly favourable influences, the 
disease soon Ceases to spread in healthy places. It is thought that the poison 
can act but a few feet from the point of emanation; and attendants upon the 
sick often escape, if great care is taken to ventilate the apartment, and observe 
perfect cleanliness. Of those exposed to it, moreover, a much larger propor- 
tion escape than in most other contagious diseases. It resembles these affec- 
tions in seldom occurring twice in the same individual. 
Besides the causes-above mentioned, epidemic influence undoubtedly some- 
times produces the disease. I have no doubt whalever, that the epidemics 
which caused such terrible ravages throughout a large portion of the United 
States, between the years 1807 and 1820, were of typhus fever; and it is well 
known frequently to occur in the same way in Europe, especially in Great 
Britain and Ireland. The other causes, too, are made much more effective 
by the co-operation of an epidemic state of the atmosphere. It is only in this 
way that we can account for the production of the disease, on certain occasions, 
under circumstances apparently quite the same as those under which it is 
escaped upon others. 
It may be a question whether all these causes are or are not identical. 
Considering the identical nature of the result, it would seem probable that 
the cause is the same; that-is, that the aeriform poison, generated in crowded 
places, differs in nothing from that evolved by the bodies of the sick, and that 
produced, in some inexplicable manner, during epidemics. If we suppose the 
poison to be a form of invisible animal or vegetable life, we approach one step 
nearer to a solution of the difficulty. 
Certain depressing agencies are capable of producing effects upon the sys- 
tem somewhat analogous to typhus. Unwholesome or insufficient food, long 
exposure to cold, the exhaustion of fatigue and excesses, continued anxiety, 
grief, fear, or other depressing emotion, nostalgia, and certain poisons, as sul- 
phuretted hydrogen, and ergot in large quantities, are among the causes of 
this kind. There can be no doubt that these favour the action of the special 
cause. Hence, typhus fever is apt to follow in the march of famine. Hence, CLASS I.] 
TYPHUS FEVER. 
341 
it is seldom or never completely eradicated from Ireland, where misery always 
serves to give activity to the germs which might otherwise lie hidden. But 
there is reason to doubt, whether mere depressing causes of a common nature 
can alone generate genuine typhus fever. 
The disease is confined to no particular time of life. Age appears to 
exercise little other influence than as it may affect the healthy vigour of 
the individual. The complaint is less common in infancy than in middle 
or advanced life. The two sexes are equally liable to it under the same 
exposure. Negroes would seem to be more readily affected than whites. 
It is not certain that season is of any account. The disease has prevailed 
at all times of the year. If there is any difference in this respect, it is in 
favour of the winter. The intense cold of that season, acting upon a poorly 
clad and badly housed population, must predispose to it; and the necessity 
of living in confined apartments must favour the action of the cause. In 
this country, the disease has certainly in general shown a preference for the 
winter. It is much more common in the temperate and cold than in the hot 
latitude's, perhaps because dwellings are so much more open tp the air in the 
latter. 
The length of time which may intervene between the exposure and attack 
is uncertain. Cases are on record in which the' disease appears to have been 
developed immediately; while in others several months are supposed to have 
elapsed. But such cases are always involved in some doubt. The period of 
incubation is generally from one to two weeks. 
Nature.-Of the nature of typhus fever we know little. It is certainly 
one of those diseases which are most clearly independent'of any local lesions. 
The probability is, that a poison is absorbed, which at once depresses the 
powers of the nervous system, and vitiates the blood. All the local conges- 
tions, and the low imperfect inflammations which attend the disease, are ob- 
viously secondary. 
Diagnosis.-The most characteristic symptoms of typhus are, along with 
fever, prostration of strength; a dark-red or dusky hue of the countenance, 
with suffusion of the eyes; Stupor; dark sorde's about the tongue, teeth, &c.; 
constipation of the bowels in the earliest stage; the peculiar odour; the pecu- 
liar eruption; and the collapse of the last stage. 
The disease with which it is most frequently confounded, and from which 
it is most important to distinguish it, is enteric or typhoid fever. The pro- 
fession is much indebted to Dr. Gerhard, of Philadelphia, for the means of an 
accurate diagnosis. It was in the results obtained by the careful post-mor- 
tem examinations, made in the Philadelphia Hospital by that distinguished 
pathologist, in conjunction with Dr. Pennock of the same city, and their no 
less careful investigation of the symptoms during life, that we first obtained 
positite proof of an essential distinction between the two diseases, which 
Louis himself had previously been disposed to consider identical. The fol- 
lowing are the most important points of difference. 
Typhus fever less frequently commences insensibly than the enteric, and is, 
upon the average, of considerably shorter duration. Instead of the diarrhoea, 
or extraordinary susceptibility to the action of purgatives, which almost uni- 
formly attends the latter disease, it is frequently accompanied with constipa- 
tion; and, when fecal discharges are obtained, they are usually darker and 
more offensive. But hemorrhage from the bowels, which is not unfrequent in 
the advanced stages of enteric fever, seldom occurs in typhus. In the latter 
complaint, epistaxis at the commencement is less frequent; there is more 
stupor and a darker colour of the face, more turbidness of the conjunctiva, 
and much greater debility. The eruption in typhus also differs from that of 342 
GENERAL DISEASES.-FEVERS. 
[part II. 
enteric fever. It generally commences earlier; is not elevated as the other; 
is less regularly round or oval; is of a darker, more livid hue; does not so 
readily disappear under pressure, and is often unaffected by it; is much more 
abundant; and, instead of being confined chiefly to the abdomen and chest, 
is found equally upon the extremities, and is often diffused over almost the 
whole body. There is sometimesrhowever, in typhus, am eruption of light 
red spots, easily removed by pressure, and closely resembling those of enteric 
fever; but they are mingled with the other kind over all parts of the surface, 
and not limited to the anterior part of the trunk. (Dr. F. W. Sargent, Am. 
J. of Med. Sci., N. S., xiv. 532.) In typhus fever the abdomen is often flat, 
and perfectly free from tympanites/ which is never the case in the enteric. 
The signs of consolidation of the posterior part of the lungs are much more 
frequently present in the former, and the dry sibilant rales of bronchial in- 
flammation in the latter. r 
The anatomical characters of the two diseases are very different. The 
peculiar disease of the glands of Peyer, and of the mesenteric glands, so 
constantly present in enteric fever, is never found in typhus, or so seldom 
as to lead to the suspicion of Some intermixture of diseases when it does 
occur. The spleen, too, is much less frequently enlarged and softened in the 
latter. 
There are other points of difference in the persons attacked, and the cir- 
cumstances under which the diseases originate. Thus, enteric fever almost 
never attacks the old, who are very frequent victims of typhus. The former 
disease is endemic in various countries, arises here and there (sporadically) 
without any obvious cause, and, if ever contagious, is very feebly and very 
rarely so; while typhus seldom occurs in isolated cases, is often long absent 
from countries where it occasionally prevails, is always contagious, and often 
epidemic. 
Nevertheless, there are cases which cannot be clearly distinguished; and, 
as before suggested, it is highly probable that the two diseases now and then 
exist conjointly. 
The other complaints with which typhus fever is most apt to be confounded, 
are idiopathic fevers, and the phlegmasiae, when they take upon them a 
typhous character. But in these, the distinguishing traits of the several dis- 
eases usually first make their appearance, and the typhoid symptoms come on 
in the course of the disease. The diagnosis is much aided, in all such cases, 
by our knowledge of the absence or presence of typhus, as a prevalent affec- 
tion. If it do not prevail, the presumption is that the case in question is one 
only of simulated typhus. 
Prognosis.-The mortality in typhus varies exceedingly, according to the 
violence of the epidemic cause, and the circumstances under which the disease 
occurs. Certain epidemics are much more destructive than others; and iff 
this, as in other diseases occurring epidemically, the cases which first appear 
are generally most fatal. In some instances, as large a proportion as one-half 
of the persons attacked have died. But this vastly exceeds the usual mor- 
tality. Perhaps the estimate of Drs. Barker and Cheyne, in relation to the 
Irish epidemic of 1817, 1818, and 1819, offers as near an approach to the 
true general average as can be attained. According to these authors, the 
general mortality was one in twenty-three. 
The disease is less fatal in early, than in middle or advanced life. Accord- 
ing to the reports of Dr. Gerhard (Am. Journ. of Med. Sciences, xix. 301), 
it is more apt to terminate unfavourably among the blacks than the whites. 
Previous debility, from whatever cause, whether disease, intemperance, excess 
of any kind, or old age, increases the danger. CLASS I.] 
TYPHUS FEVER. 
343 
The favourable signs have been already enumerated. The unfavourable 
are those indicating very great prostration, great alteration of the blood, or 
severe local disease. Among the first are an exceedingly feeble or an absent 
pulse, coldness and insensibility of the surface, a sudden fading of the eruption, 
and involuntary evacuations; among the second, abundant and dark-coloured 
petechim, copious hemorrhages, a very turbid conjunctiva, fetid breath, and a 
purple appearance of the extremities; among the third, violent delirium or 
profound coma, with h greatly expanded or greatly contracted pupil and ster- 
torous breathing, indicating disease of the brain; and excessive labour in 
respiration or shortness of breath, indicating extensive consolidation of the 
lungs. Yet, scarcely any condition is so desperate as to forbid all hope, and 
life has been preserved by a persevering application of remedies, even after 
apparent death. 
Treatment.-In the earliest stage, before reaction has commenced, little 
treatment is usually necessary; and, indeed, there is seldom an opportunity for 
prescribing, as the patient is not seen until after the stage is passed. Some- 
times, however, when it is more than ordinarily protracted or severe, it becomes 
necessary to employ remedies; and, -during the prevalence of epidemics of 
typhus, cases now and then occur, in which life may depend upon the timely 
interference of the physician. An emetic has been recommended, under these 
circumstances, in order to rouse the system out of its apparent torpor, and to 
direct action to the surface. It may sometimes be useful, when the depression 
is not great. Ipecacuanha or sulphate of zinc should be preferred. But the 
general indication .is to stimulate by such means as will not be likely to in- 
crease the fever too greatly, when it takes place, nor too strongly to add to 
the already existing tendency to the brain. The morbid cause is depressing 
the vital functions by its sedative power; and there is danger that they may 
be reduced below the point of reaction. External stimulants are the safest. 
The most powerful rubefacients, such as mustard, solution of ammonia, Cay- 
enne pepper, and oil of turpentine, should be applied to the extremities and 
along the spine; and these should be aided by external heat, by means of hot 
bricks, bottles of hot-water, &c., placed along the body, hot stimulating pedi- 
luvia, or, what would probably be most effectual, the hot bath. If internal 
stimulation should become necessary, carbonate of ammonia, or oil of turpen- 
tine, would be preferable to the alcoholic remedies, as less likely to affect the 
brain; but, where the prostration is excessive, recourse may be had to wine, 
brandy, or even ether. Cases, however, requiring this treatment are extremely 
rare. 
After the fever has become established, it may be proper, in cases of op- 
pressed stomach, to unload that viscus by means of a mild emetic; but in 
general this may be dispensed with, and the treatment commenced with an 
efficient cathartic, so as thoroughly to evacuate the bowels. Calomel and 
rhubarb are generally best adapted to the circumstances of the case; though, 
when the febrile reaction is high, with considerable strength of pulse, the 
saline purgatives may be preferred, with or without the addition of senna. 
Throughout the whole course of the disease, the bowels, if there be a tendency 
to constipation, should be kept open by cathartics. These are indicated by 
the necessity which exists of avoiding accumulations of excreted matter in the 
bowels, and the depressing effects arising from its absorption when retained. 
The dark, offensive substances which collect in the alimentary canal in typhus, 
probably act as a direct sedative to the system. Cathartics, therefore, so far 
from increasing the debility, tend, if properly selected and employed, to obviate 
it. I am sure that I have seen the system, in low states of typhus, rise under 
.the operation of medicines of this kind. No such contraindication exists here 344 
GENERAL DISEASES.-FEVERS. 
[part II. 
as in the enteric or typhoid fever. The only caution necessary is to graduate 
the activity of the medicine, its dose, and frequency of repetition, to the state 
of the system. In the early period of excitement, the object may be effected 
by small doses of some saline purgative; but later in the disease, rhubarb 
should be preferred, either alone, or combined with aloes. One of the tinc- 
tures of rhubarb may be employed, with great propriety, in the latest stage, 
when stimulation becomes necessary. Sometimes, it may be necessary to aid 
the cathartic by enemata, which may in general advantageously contain the 
oil of turpentine. 
The question as to the propriety of bleeding, in the early stage of the fever, 
has been much discussed. By some the remedy has been urged as of the 
greatest importance; by others it has been condemned as almost always in- 
jurious, and scarcely ever necessary. Probably the advocacy of it may haye 
been partly owing to the confounding of this disease with enteric fever, which 
is well known generally to bear bleeding well at the commencement. It is 
very certain, that, in genuine typhus, it is often capable of doing much harm; 
and death has frequently been the result of its injudicious use. During, the 
prevalence of the great typhous epidemics of this country before alluded to, 
it frequently happened that, upon the first arrival of the disease in a neigh- 
bourhood, not being understood by the physicians, and frequently presenting 
the complication of some local inflammation, it was treated by them, as they 
had been in the habit of treating other febrile and inflammatory diseases, with 
the free use of the lancet. The. consequences were in many instances very 
fatal. Such an instance occurred in the vicinity of Philadelphia. The dis- 
ease approached the city through the state of New Jersey, and prevailed for 
some time in the opposite village of Camden, before it crossed the Delaware. 
In that place, it was unknown, and was treated as an inflammatory affection, 
with almost uniformly fatal results. My friend and preceptor, the late Dr. Joseph 
Parrish, of Philadelphia, then a young practitioner, was called into the village 
at this juncture, and, having been prepared by the perusal of Dr. North's 
treatise on the disease as it had prevailed in New England, immediately 
adopted a different course of treatment, avoiding bleeding altogether, and 
using stimulants, with the effect of curing almost all the cases. He thus laid 
the foundation of that reputation as a skilful physican, which has never been 
exceeded in our city. I have heard of other reputations which began in the 
same way. So fatal was copious bleeding in that epidemic, that popular and 
to a great extent professional opinion received a set against it; and it was- 
some time after the disappearance of all tendency to the disease, before the 
fear of the remedy so far subsided as to permit its. judicious use, under cir- 
cumstances requiring it. 
But, though thus injurious if abused, there are undoubtedly cases of typhus 
fever in which bleeding may be moderately employed, with safety and advan- 
tage. It is highly probable that different epidemics may differ greatly in this 
respect; the loss of blood being much better borne in one than in another. 
The remedy is often very speedy and effectual in the relief of the headache, 
and other symptoms of cerebral disturbance, during the first few days. Its 
effects are said to be even more striking in this than in other febrile diseases. 
It may be r,esorted to when there is evidence of much and dangerous local 
determination of blood, with considerable strength of pulse. But even then, 
the quantity taken should be small. Little is required to diminish the force 
of the pulse, and there is danger of syncope, as well as of subsequent pros- 
tration from the loss of large quantities. Six or eight ounces are often suffi- 
cient, and more than twelve should seldom be abstracted at one operation. 
In the great majority of cases, it is altogether unnecessary. In those which CLASS I.] 
TYPHUS FEVER. 
345 
are at all doubtful, it is b6st to employ local bleeding. This is safer, and 
relatively more effectual. When the head is affected, the blood should be 
taken from the temples, or back of the neck, by cups or leeches. In pectoral 
inflammation, they may be applied between the shoulders. A very slight 
depletion may sometimes be usefully effected by means of dry cups, which 
withdraw a certain amount of blood from the circulation to the surface where 
they are applied. 
The febrile heat of the early stage is most effectually Relieved by the ex- 
ternal use of cold water. This may be dashed upon the patient, as recom- 
mended by Dr. Curriej or applied by sponging. The latter mode is preferable, 
when there is much debility. The remedy should never be used when there 
is any feeling of chilliness on the part of the patient, or any perspiration. 
Affusion would probably also be hazardous in cases complicated with pneu- 
monia. In doubtful cases, sponging with warm water should be preferred. 
Sometimes spirit, or spirit diluted with water, may be advantageously substi- 
tuted. The effect of these remedies is' to relieve the distressing heat, relax 
the skin, produce occasionally a gentle sweat, and greatly comfort the patient. 
The affusion is said sometimes to have apparently arrested the disease. 
The mild refrigerating diaphoretics may also be used, such as the neutral 
mixture, effervescing draught, solution of acetate of ammonia, and sweet 
spirit of nitre. Dover's powder is often very useful, by producing diaphoresis, 
quieting restlessness, and promoting sleep. It should, of course, not be em- 
ployed in comatose cases. When the fever is complicated with pectoral 
inflammation, no remedy is probably so effectual as a combination of opium, 
ipecacuanha, and calomel, given so as to keep the system moderately under 
an anodyne influence, and continued until it slightly affects the gums. Some- 
times gently stimulant infusions may be administered at the same time. In 
this country, the infusion of serpentaria has been frequently used. On the 
continent of Europe, they often employ the flowers of arnica, and sometimes 
contrayerva and angelica. 
Stimulants are essential in the treatment of typhus. Sometimes it is ne- 
cessary to administer them from the outset of the disease; but more frequently 
they are required only at an advanced period, when the feebleness of the 
pulse, the commencing dryness of the tongue, the sordes about the teeth, and 
often some coolness of the extremities, indicate the commencement of pros- 
tration. Upon the whole, the most efficient stimulants are Peruvian bark, 
wine, and opium. The bark was? formerly given in decoction, often made 
with wine, with the addition of serpentaria, Or aromatics. At present, sulphate 
of quinia is generally preferred as more convenient of administration, and 
more acceptable to the stomach. The dose may be a grain every two hours. 
Wine is usually given at first in the form of whey, made with two parts of 
boiling milk and one of Madeira, Sherry, or Teneriffe. Afterward, when 
stronger stimulation is required, it may be administered pure. The .quantity 
must of course be regulated by the degree of debility, and the effects pro- 
duced. It may not exceed a wineglassful in a day, or may amount to a quart. 
Porter or ale may be substituted, when more convenient, and preferred by 
the patient. Opium is administered in substance or tincture, in such quanti- 
ties, and at such intervals, as to maintain a regular excitement, without 
stupefaction. Prom half a grain to a grain may be given every four, six, or 
eight hours; and the quantity may be increased if necessary. Carbonate of 
ammonia is also a good stimulant, which may often be used advantageously, 
dissolved in water with the addition of gum arabic and loaf sugar to obtund 
its acrimony. Prom two and a half to ten grains may be given at a dose 
every hour or two. It is customary to begin with small quantities of wine- 346 
GENERAL DISEASES.-FEVERS. 
[PART II. 
whey and carbonate of ammoniaj alternately, each every second hour; in- 
creasing the dose, and adding the other stimulants, as the case is found to 
require them. Sometimes it is necessary to have recourse to brandy, or other 
form of proof spirit. Milk punch is admirably adapted to many of these 
cases, combinifig nutriment in the best form with a powerful stimulant. The 
oil of turpentine may also be used; and some have recommended phosphorus; 
but I have never employed it. 
Should the stimulants be found to increase the frequency of pulse, heat of 
skin, delirium, and stupor, they should be suspended, or the quantity reduced. 
If they strengthen without accelerating the pulse, relax the skin, and moderate 
delirium and stupor, they may be considered as doing good. 
For the sudden sinking spells, which sometimes occur and threaten the 
most serious consequences, active stimulants must be quickly used. Under 
these circumstances, sulphuric ether may be given in the dose of a fluidrachm. 
Long continued sleep occasionally exhausts patients in typhus fever exceed- 
ingly. It is best, therefore, unless sleep may from special causes be deemed 
very desirable, to wake the patient occasionally in order to administer his 
medicines. This too is necessary, in order to sustain a uniform remedial 
effect. ' ■ 
For the nervous symptoms, such as restlessness, jactitation, vague uneasi- 
ness, subsultus, &c., cainphor is often an admirable remedy in doses of from 
five to ten grains, given in emulsion. Musk is the most effectual remedy in 
singultus. 
External stimulation is of great importance in those cases in which the 
surface is cool. This is effected by means of sinapisms to the extremities; 
blisters to the thighs and trunk, allowed to remain only so long as is necessary 
to redden without vesicating; and by frictions with Cayenne pepper and hot 
brandy, oil of turpentine, liniment of turpentine, &c. In the lowest and most 
insensible conditions, the' electro-magnetic machine may be used; or the 
patient may be wrapped from head to foot in a blanket saturated with heated 
spirit, or, finally, the effect of a burning coal applied to the epigastrium may 
be tried. 
For violent headache, coma, and delirium, after the local abstraction of a 
little blood, if this be deemed necessary, it will be proper to thin or shave off 
the hair, to apply ice or cold water, and in tire latter stages to blister the 
back of the neck, or, what is preferable, the whole scalp. Sometimes great 
relief is afforded by warm fomentations about the head, where the cold appli- 
cations fail. 
For the measures requisite in cases complicated with inflammation of the 
lungs, the reader is referred to typhous pneumonia. Irritation of stomach 
and bowels is to be combatted by the ordinary measures, among which opiates 
internally, and revulsive applications or cataplasms externally, are not the least 
efficient. Dr. D. M. Reese, of New York, found great advantage in threaten- 
ing cases of diarrhoea, from injections of a solution of nitrate of silver, contain- 
ing a drachm of the nitrate in a pint of water. (New York Journ. of Med,, 
ix. 270.) 
The remarks made in reference to diet, under enteric fever, are applicable 
also here. It is even more necessary in typhous to throw a due amount of 
nutriment into the system; and, though for the first few days, it may be proper 
to confine the patient to farinaceous liquids, yet, as the disease advances, ani- 
mal broths become necessary, and in very feeble states we must have recourse 
to the animal essences, egg-nog, milk punch, &c. 
Prevention.-1There are few diseases in which more can be effected in the 
way of prevention than this. Thorough ventilation; perfect cleanliness in CLASS I.] 
PLAGUE. 
347 
clothing, person, and apartments; a wholesome and nutritious diet; and suffi- 
cient protection against cold, will go far towards securing impunity to indi- 
viduals necessarily exposed in some degree to the' cause of the disease. Per- 
sons not called upon by duty to attend the sick should avoid their presence. 
They who are compelled to enter within the sphere of infection should not do 
so on an empty stomach; they should avoid inhaling the breath of the patient, 
or the air in the very near vicinity of his surface; they should not swallow 
their saliva; and, on leaving the apartment, should wash their handsandface, 
and change their outer clothing. 
The apartment of the sick should be well aired; everything offensive 
should be removed without delay; the bed and body-linen of the patient 
should be frequently changed; and care should be taken that as few persons 
as possible should remain in the room. In hospitals, prisons, &c., it is of 
great importance to distribute the patients over as great a space as possible. 
Something may also be done by chemical means to change the character of 
the contaminated air. For this purpose, chlorine is the most effectual agent. 
A thorough fumigation with the gas should be employed when it is possible 
to obtain the apartment free from tenants; and, even while it is occupied by 
the patients, solutions of chloride of lime or soda may be exposed in it, the 
wood-work of the room .and the bedstead may be washed with them, the floor 
sprinkled with them, and they may even be added to the water used in' the 
sponging of the patient. 
Article VI. 
PLAGUE. 
Syn.-Pestis. 
Plague is a febrile disease characterized by buboes or swellings of the 
lymphatic glands, by carbuncles, and petechiae. As it does not appear upon 
this continent, and the author has never seen a case of it, a brief summary 
only of the more prominent facts in relation to it, as stated by eye-witnesses, 
will be given in the present work. 
The true home of the disease, where it prevails now, and has probably pre- 
vailed from the earliest periods of history, is in the regions bordering upon 
the eastern extremity of the Mediterranean and its tributaries. In the middle 
ages, and so late even as the sixteenth and seventeenth centuries, it occasion- 
ally visited western Europe, and was well known in Italy, France, England, 
and Germany. London and Paris suffered from it greatly in former times. 
But, for more than a century, the plague has been almost unknown in the west 
of Europe; the last remarkable visitation having been in 17'20, when Mar- 
seilles lost with it nearly one-half of her population. It is now limited chiefly 
to Egypt, Syria, Anatolia, Greece, and European Turkey; occasionally extend- 
ing northward into Russia, and westward as far as Malta. 
Symptoms, Course, &c.-1Tire disease usually makes its appearance, without 
premonition, with the ordinary symptoms of fever, such as chilliness, feelings 
of weariness, languor, or debility, precordial uneasiness, occasionally nausea 
and vomiting, headache, vertigo, a hot and dry skin, and a frequent pulse. 
Parting pains are felt in the groins, arm-pits, or oth^r parts of the body, which 
are soon followed by enlargement of one or more of the lymphatic glands, or 
by inflammation of the subcutaneous tissue constituting carbuncles. As the 
disease advances, the swellings usually go on increasing, while various symp- 348 
GENERAL DISEASES.-FEVERS. 
[part II. 
toms more or less alarming are rapidly developed. The tongue, at first some- 
what swollen, moist, and covered with a white fur, before the close of the 
disease, often becomes dry, brown or blackish, and sometimes fissured; while 
a dark sordes collects upon the gums, teeth, and lip's. There is often extreme 
thirst, and a sensation of burning heat internally. Severe pain is Tel t in the 
praecordia, with nausea and frequent vomiting; the matters discharged being 
whitish or blackish, and sometimes bloody. The bowels are usually consti- 
pated in the beginning; but in the end often become relaxed, with dark and 
offensive stools. The breathing is hurried or laboured; and the pulse va- 
riously affected, generally accelerated, sometimes full and. strong, though more 
frequently feeble, occasionally nearly natural, and in bad cases irregular or 
intermittent. The urine, in some instances, nearly healthy, is in others 
scanty, turbid, yellowish or blackish, and tinged with blood. Occasionally, 
moderate perspirations of a favourable character appear, while at other times 
they are copious and exhausting. The general strength is greatly prostrated; 
the patient, if he attempts to walk, has a staggering gait; and attacks ap- 
proaching to syncope are not uncommon. The eyes are red and turbid, the 
face flushed or even livid, and the expression of countenance often like that of 
a drunken man. The patient is confused in mind, delirious, stupid, or coma- 
tose; or extremely restless, agitated and alarmed; and often stammers when 
attempting to speak. 
The symptoms are not of uniform violence through the day. As in most 
other febrile diseases, there are remissions and exacerbations, which usually 
occur twice in twenty-four hours, the remission in the morning and towards 
evening, the, exacerbation in the middle of the day and night. The morning 
remission and nocturnal exacerbation, are commonly the greatest. Sometimes 
the abatement of symptoms in the remission is so considerable as to resemble 
convalescence. The subsidence of the febrile excitement is often attended 
with perspiration; and when this is considerable on the third or fifth day, it 
is regarded as favourable. From that time the exacerbations return with 
diminished violence, and there is a gradual amendment, though the disease 
may continue for a week or two longer before convalescence is established. 
In the meantime, the buboes and carbuncles have been going through their 
regular course, leaving abscesses or ulcers, which heal in a shorter or longer 
time. 
In fatal cases, the symptoms above enumerated assume their gravest cha- 
racter ; the pulse sinks; blood oozes from the mucous surfaces; petechias or 
vibices appear upon the skin; the surface becomes cold and clammy; trem- 
bling of the tongue, subsultus tendinum, and coma or low delirium indicate 
the faltering state of the nervous system; and death occurs, either without 
struggle, or preceded by delirious movements or convulsions. In cases of this 
kind, the buboes appear late, and do not advance to suppuration. Sometimes 
they disappear altogether. Death usually takes place in five or six days, 
though the case is sometimes protracted for a fortnight or longer. 
But there are many variations from the above routine of symptoms. In 
frequent instances, the disease is extremely mild, even without fever, and the 
patient walks about, complaining of nothing but buboes in the groin or axilla, 
or, if confined to bed, is so only in consequence of the pain produced in walk- 
ing by the local affection. In other instances, there is more or less fever with 
the buboes, and occasionally slight carbuncles, but without malignant symp- 
toms; and the attack terminates favourably in about two weeks. 
On the other hand, many exceedingly malignant cases occur, in which a 
fatal blow appears to be given at the very commencement. In some of these, 
there are symptoms of great nervous disorder, and universal prostration, which CLASS I.] 
PLAGUE. 
349 
end in death in less than twenty-four hours, without the developement of 
buboes or carbuncles, and without any signs of reaction. Occasionally a par- 
tial reaction takes place, with symptoms of fever; but the malignant phe- 
nomena, such as have been already noticed as attending the last stage of 
ordinary violent cases, greatly predominate. There may even be deceptive 
remissions; but they are soon followed by a return of the worst symptoms. 
Buboes and carbuncles may be formed; but the former do not advance to 
suppuration, nor the latter to the separation of the slough, .Petechia© and 
vibiees are not uncommon. Death takes place usually before the expiration 
of the third day, and seldom so late as the fifth. Cases of the kind here 
described occur most frequently at the beginning of an epidemic, and are 
almost always fatal. Sometimes'the patient dies suddenly, without any pre- 
liminary appreciable disorder. A few words upon buboes, carbuncles, and 
petechias, will close the symptomatology of the disease. 
Buboes are swellings of the lymphatic glands. They may show themselves 
either at the commencement of the disease, after the expiration of one or 
more days, or not until near the close; and they'are sometimes absent in bad 
cases. Their most frequent situation is upon the upper and inner part of the 
thigh, or in the groin. They also occur in the neck at the angle of the jaw, 
and in the axilla. The swelling may be confined to one, or may extend to 
several glands. The first sign of the affection is usually a shooting pain in 
the part, which precedes the tumefaction. Tn the beginning, there is no dis- 
coloration of the skin. The tumour is sometimes movable, but frequently 
adheres to the tissues beneath, especially in the more serious cases. In 
favourable cases, it gradually enlarges, suppurates, and in two or three weeks 
opens, and discharges pus; after which the abscess slowly heals, leaving a 
permanent scar. Sometimes the buboes disappear without suppuration. Tu- 
mours resembling buboes occasionally form in the subcutaneous tissue; and 
secondary buboes may result from the propagation of irritation from a car- 
buncle along the absorbents to the lymphatic glands. 
Carbuncles usually make their appearance later than the buboes, and may 
occur upon any part of the body, as the neck, back, chest, extremities, face, 
and even scalp. Sometimes there is only one or a few, sometimes they are 
very numerous, and not unfrequently they are quite wanting. They begin 
with a vesicle of a yellowish, purplish, or blackish colour, usually upon a red- 
dish base. This breaks, and is followed by a gangrenous spot, which extends, 
and forms a dark crust, sometimes two or three inches in diameter. In favour- 
able cases, this is attended with inflammation of the adjacent parts, which pro- 
duces ulceration, and the separation of the slough, leaving a sore of larger or 
smaller dimensions. Considerable destruction of parts thus sometimes takes 
place. In bad cases, the gangrenous part is apt to remain dry and adherent. 
Petechnee are red or purplish spots like fleabites, which usually become livid 
as the disease advances. They are often wanting, and occur only in bad cases. 
Sometimes, along with these spots, are irregular purplish or livid patches like 
bruises, or long stripes called vibiees; and cases occur in which the whole 
surface of the body has a mottled appearance. These discolorations are owing 
to the extravasation of blood; and occasionally ecchymoses or collections of 
effused blood form in the cellular tissue. 
Anatomical Characters.-The blood is generally coagulable, but more 
slowly and feebly than in health; and the serum floating above the clot is 
reddened by the disintegrated corpuscles. In some instances, the blood will 
not coagulate, and is then surmounted by floating drops of oil. (JBulardl) It 
is usually denser than in health, of a dark colour not brightening on exposure, 
and sometimes of a peculiar odour. The inflammatory crust does not appear 350 
GENERAL DISEASES.-FEVERS. 
[PART II. 
when it coagulates. After death, black coagula arc found in the ventricles, 
aorta and vena cava. 
Upon dissection, black spots of extravasation are observed through the vis- 
cera, as the heart, lungs, stomach and bowels, liver, &c., and even in the neu- 
rilema of the nerves. The-parenchyma of the solid viscera is generally en- 
gorged with black fluid blood; and hemorrhagic effusion often exists in the 
cellular tissue about the kidneys, and in the pelvis. One or more lymphatic 
glands are found enlarged, and engorged with blood, even when no Bubo was 
observable during life. The spleen is enlarged and softened. Signs of inflam- 
mation are found in various parts of the .body in protracted cases. 
Cause.-Great difference of opinion has existed, and still exists, in relation 
to the cause of plague. Some maintain that it is propagated exclusively by a 
peculiar contagion; others, while admitting its contagious nature, believe that 
it often occurs endemically or epidemically; and a third party reject the notion 
of contagion altogether, asserting that the disease originates exclusively either 
in local causes or epidemic influence. 
In order to come to any conclusion upon these points, it is necessary to 
recollect that sporadic cases of the disease are asserted to be existing at all 
times, in certain places, especially in Egypt; that, at certain seasons, the dis- 
ease rages more severely in these situations; and that, in other places, it occurs 
only occasionally, and at longer or shorter intervals, the inhabitants being per- 
fectly exempt from the disease in the mean time. 
It appears to me impossible to resist the testimony adduced in favour of the 
doctrine of contagion. Numerous instances are on record, in which a perfect 
isolation of large bodies of people has secured to them an entire or almost 
entire exemption, while the disease was raging around them; and positive 
proof appears to exist, that the disease has been communicated, through indi- 
viduals or fomites, from an infected to a healthy neighbourhood. Persons 
exposed to the cause of the disease in a sickly district, have removed to a dis- 
tant and healthy place, and,have there died of the plague; and shortly after- 
wards, numerous individuals of their own particular family have become 
affected. Besides, the almost universal opinion of the communities in which 
the disease prevails should be allowed some weight; as also should the fact, 
that the Franks in the. Levant, who take precautions against contagion, are 
much less frequently affected than the Turks, who are practical predestina- 
rians, and use no precaution. Inoculation with the pus of plague buboes has 
in some instances been followed by the disease, in others not. No positive 
inference can be deduced from this fact; for, as the operation was performed 
in infected neighbourhoods, the disease might have arisen from other causes. 
It would appear that certain individuals are insusceptible of the contagious 
influence under all circumstances; for of those exposed to it in the highest 
degree, during the prevalence of the disease, many escape. It would appear 
also, that the susceptibility of persons generally is much less under certain 
circumstances than under others; otherwise, the sporadic cases which are 
asserted to be always in existence, would be constantly acting as the centres 
of new infections. But these are no arguments against contagion altogether; 
for we find the same exactly to be the case with scarlet fever, and to a con- 
siderable extent with measles, both of which are contagious. It is generally 
supposed that the contagion may not only be imparted from individual to indi- 
vidual; but that it may be conveyed by means of clothing or articles of mer- 
chandize from place to place; though some, who even admit personal conta- 
gion, deny the latter mode of communication. Difference of opinion has also 
existed as to the necessity of actual contact; some supposing that the poison 
is communicated, like that of syphilis, only by the touch, others that it may CLASS I.] 
PLAGUE. 
351 
be exhaled in the aeriform state from the body, and, like that of other con- 
tagious feverk, act through the medium of the atmosphere. Analogy is in 
favour of the latter opinion. 
But, though contagion must be admitted to be a cause of plague, it is, I 
think, certainly not the only, or even the chief cause. There must be some 
other influence, acting sometimes in the production of sporadic cases, which 
can be traced to no particular origin, and sometimes, when from unknown 
causes increased in intensity and diffusion, producing a wide prevalence of 
the disease, having all the characters of an epidemic. What is the nature of 
this influence, or what its origin, has never been ascertained. Some have 
supposed that it is connected with effluvia from the filthy accumulations, and 
foul excretions of a crowded arid uncleanly population; but this opinion is 
met at once by the unanswerable argument, that such effluvia exist elsewhere, 
and under apparently the same circumstances, without producing the effect. 
Still, they certainly appear to favour the propagation of the disease; and 
there is some reason to think that the recent exemption of many places, for- 
merly afflicted with it, may be owing to their greater cleanliness and better- 
ventilation. But there is something more; and what that is remains to be 
determined. The idea of an origin in microscopic organic beings must sug- 
gest itself to every inquirer, but it is yet too little supported by facts to be 
considered in any other light than that of pure hypothesis; 
The epidemic prevalence of plague is evinced by the following facts. The 
disease appears at certain periods after a more or less complete exemption, 
affects at first a few individuals scattered in different spots and without per- 
sonal communication, rapidly increases until immense masses of the popula- 
tion are affected, then gradually declines, and at length ceases altogether, 
after a duration of three or four months. As in other malignant epidemics, 
the first cases are usually very severe and generally fatal; those at the close, 
are often very mild; and those in the middle period, of an intermediate degree 
of intensity. Nor is the disease usually confined to one city. A number of 
different places within certain limits are often affected simultaneously, without 
any communication, or so nearly at the same time, that the disease could not 
have been conveyed from one to the other by human agency. During the 
prevalence of the disease, other- low or malignant affections are apt to occur, 
showing some general distemperature of the air; and it is even asserted that 
the lower animals suffer. Temperature appears to have some influence over 
the morbific cause. It is thought that excessive heat, and intense cold, are 
both opposed to it. According to Sir Gilbert Blane, the disease cannot exist 
when the temperature is above 80° F., or a little below 60°. Hence, when 
it prevails during the spring in the Levant, it ceases in the summer; and, 
when during the latter part of summer or the beginning of autumn in colder 
latitudes, it is arrested by the approach of winter. 
Besides the essential or specific cause of the disease, there are circumstances 
which produce a peculiar predisposition to it, and others which appear to act 
as exciting causes. These, however, are similar to those already mentioned 
as producing a like effect in other diseases, having like this a specific cause. 
(See Yellow Fever, page 302.) 
Nature.-This is yet unknown. The probability, however, is, that a poison 
is absorbed, and alters at once the nature of the blood, and the condition of 
the tissues. 
Diagnosis^--When buboes, or carbuncles, or both appear, there can be 
little difficulty in distinguishing cases of plague. Without these characteristic 
phenomena, it can be decided with certainty that any given case is plague, 352 
GENERAL DISEASES.-FEVERS. 
[part II. 
only by its occurrence at the commencement, or in the midst of an epidemic 
prevalence of the disease. 
Prognosis.-This is an exceedingly fatal disease, not only in relation to the 
proportion of the sick who die, but of the whole population who are affected. 
Thus, it is estimated that in Marseilles, during the plague of 1720, out of a 
population of 90,000, the number of cases was 80,000 and of deaths 40,000; 
and in Moscow, in the year 1770-71, nearly if not quite one-half of the inha- 
bitants are thought to have perished. 
In individual cases, the unfavourable symptoms are great general depres- 
sion at the beginning, a tendency to syncope, a natural or intermittent pulse, 
with other unequivocal signs of a violent attack, the absence of buboes, the 
conjoint appearance of carbuncles and petechiae, and all the symptoms which 
generally characterize great malignancy, such as a drunken expression of 
countenance, muddiness of the conjunctiva, coma or low delirium, stammer- 
ing, excessive oppression of breath, severe precordial pains and vomiting, 
hemorrhages of dark blood, hiccough, black tongue, fetid breath, &c. Fa- 
vourable signs are the occurrence of buboes without fever, the early appear- 
ance and regular progress of buboes, the eruption of 'carbuncles with broad 
inflamed bases^ open and well-developed febrile action, moderate perspiration 
at the commencement of the remissions, and, generally, the absence of the 
symptoms above enumerated as of bad augury. 
Treatment.-Various plans of treatment have been employed, but all with 
such doubtful success, that the practitioner is thrown upon his general princi- 
ples. There is no specific for the plague. Emetics are recomlnended at the 
commencement of the disease by many practitioners. There is also a very 
common consent in the propriety of employing a biusk cathartic, to be fol- 
lowed by means calculated to keep the bowels regularly open during the 
continuance of the disease. Much difference of opinion exists as to the pro- 
priety of bleeding, some recommending this remedy, and others considering it 
not only useless, but positively injurious. The probability is that, as in other 
febrile diseases, it may be admissible in some cases; while in others it is 
entirely contraindicated. It should never be employed unless when the pulse 
is strong, and some local injury is threatened from excess of vascular action. 
M. Aubert, who began by employing depletory measures freely, ended by 
abandoning them altogether. Cold ablutions or affusions, and the use of the 
refrigerant saline diaphoretics, with spirit of nitric ether, are advised during 
the existence of fever with a hot dry skin. Cold acidulated drinks, such as 
lemonade, may be employed under the same circumstances. The Dover's 
powder may be substituted for the saline diaphoretics, when the pulse is feeble, 
and the nervous system disordered. Mercury, in reference to its constitu- 
tional impression, has been tried, but with no great success. Friction with 
olive oil was at one time highly lauded; but experience has not confirmed the 
first reports in its favour. In low cases, it is necessary to resort to tonics 
and diffusible stimulants. The local treatment is confined, by the best prac- 
titioners, to the use of emollient poultices to the buboes and carbuncles, and 
gently stimulant applications to the ulcers which follow them. Fetor may 
be corrected by washes of solution of chloride of lime. Cauterization of 
the buboes and carbuncles has been recommended by some, but is of doubtful 
efficacy. 
Prevention.-Much may no doubt be done by care, towards guarding against 
the attacks of the malady. It is only upon this ground, that we can explain 
the comparative exemption of European residents in the infected cities of the 
Levant. Frequent ablution with cold water, perfect cleanliness in clothing, 
moderation in eating, drinking, and the pursuit of pleasure, ventilation, and CLASS I.] 
SMALL-POX, OR VARIOLA. 
353 
the avoidance of crowded and filthy places, are important measures. Ventila- 
tion may be in some measure secured by making fires in the houses; and 
infected air may perhaps be purified by means of chlorine. But no means are 
so effective as removal from the limits within which the cause is acting. 
Whatever may be our speculative opinion in relation to contagion, a prudent 
caution would induce avoidance of all unnecessary communication with the 
sick, or contact with fomites which might have become infected with the 
poison. Bathing the skin with olive oil has been recommended very strongly 
as a prophylactic. Bleeding, purging, and low diet, employed for the same 
purpose, can have only an injurious effect. Inoculation has been tried, but 
with no favourable result. 
Article FIL 
SMALL-POX, or VARIOLA. 
This is a contagious disease, characterized by an initial fever of three or 
four days' duration, succeeded by an eruption which passes through the differ- 
ent stages of pimple, vesicle, and pustule, and arrives at maturity in about 
eight days. 
There is no proof that small-pox was known to the ancient Greeks or 
Romans. It appears to have prevailed in India and China from time imme- 
morial. Europe first became acquainted with it through the Arabians. It is 
said to have first shown itself in Arabia about the time of the birth of Maho- 
med, and to have invaded Syria, Egypt, and Southern Europe, with the armies 
of his successors. 
Two prominent varieties of the disease have been recognized by most writers 
upon the subject; the distinct and the confluent; the former characterized by 
the isolation of the pustules, the latter' by their coalescence. There are, 
besides, numerous complications and modifications of the disease, which merit 
attention. Most of the latter may be included under the title of varioloid. 
All cases of regular small-pox have three stages; 1, of the initial or erup- 
tive fever; 2, of the progress and maturation of the eruption; and 3, of the 
decline. Some treat of the period of incubation, or that which intervenes 
between the reception of the poison into the system and the attack of fever, 
as the first stage of the disease; but it is clearly no stage at all; for the dis- 
ease has not yet begun. Some uncertain feelings of disorder, such as often 
usher in febrile affections, may occasionally precede the attack of small-pox; 
but they are too slight, and too frequently quite wanting, to be considered as 
an essential part of the complaint. 
1. Distinct Small-pox.-The first stage commences usually with rigors 
of various intensity and duration, which are followed by heat of skin, accele- 
ration of the pulse, furred tongue, loss of appetite, thirst, epigastric uneasiness, 
often nausea and vomiting, headache, pains in the back and limbs, and general 
muscular weakness. These are the ordinary symptoms of fever, and there is 
nothing, in this stage of small-pox, to distinguish it with certainty from other 
febrile affections. If there is anything peculiar, it is in the violence of the 
pains in the small of the back, and the frequent occurrence of obstinate vomit- 
ing, which cannot be referred to gastric inflammation or cerebral disease, and 
which often resists all the remedies that can be applied. There are various 
Symptoms, Course, ^c. 354 
GENERAL DISEASES.-FEVERS. 
[PART II. 
other occasional symptoms. A tendency to perspiration is sometimes observa- 
ble. Soreness of throat, coryza, sneezing, and an excess of tears, are not 
uncommon. Active delirium sometimes occurs, with a flushed face, swollen 
features, and sparkling eyes. Some cases are attended with stupor, while in 
others the patient is wakeful, uneasy, and restless, or is affected with oppres- 
sion in breathing, and occasionally with severe pains in the chest. In chil- 
dren, the disease is not unfrequently ushered in with convulsions, which 
sometimes, though rarely, occur also in adults. The fever is often decidedly 
remittent, with daily exacerbations. It usually continues for three or four 
days, and then subsides upon the occurrence of the eruption. This generally 
commences in the course of the third day, though often so slight at first that 
it is not immediately observed. Minute bright red specks show themselves 
upon the face, soon afterwards upon the neck, upper part of the breast, and 
forearms, and at last upon all parts of the trunk and lower extremities. 
Sometimes, though very rarely, they appear first upon the limbs or trunk. 
The eruption is generally completed by the end of the fourth or beginning of 
the fifth day, at which time the fever has entirely disappeared. The subsi- 
dence of the fever is often rapid and even abrupt. At one visit, the patient 
is seen with headache, a hot skin, a frequent pulse, and perhaps vomiting; 
and at the next is found cool and comfortable, with a natural pulse and a 
retentive stomach, and, except for the eruption, which has shown itself in the 
meantime, apparently convalescent. 
The second stage may be considered as commencing when the eruption 
is fully out. In the alterations which this undergoes in different parts of 
the body, it follows an order corresponding with that of its coming forth, first 
changing upon the face, then on the trunk and arms, and lastly on the lower 
extremities. Scarcely prominent in the beginning, it very soon becomes ob- 
servably papular, and, upon the second or third day, a little clear lymph may 
be seen at the apex of each pimple, which has, therefore, been converted into 
a vesicle. On the third or fourth day, the pocks are distinctly formed, being 
round, and flattened on the top, in the centre of which is often a little depres- 
sion, giving to the eruption a characteristic umbilicated appearance. They 
are now hard to the touch, and are generally surrounded by an inflamed 
areola, which renders the skin red between them. From this period, they 
gradually increase in size, and change from vesicles into pustules; their liquid 
contents becoming more and more opaque, until at length quite purulent. As 
they approach their completion, they lose the umbilicated form, and become 
convex and apparently distended at top. Those upon the face are generally 
at the height, and begin to turn, on the eighth day of the eruption, the 
eleventh or twelfth of the disease; but it is two or three days later, and some- 
times still longer, before those upon the feet have attained maturity. The 
process by which the vesicles are changed into pustules is called their ma- 
turation. 
The quantity of the eruption is very different in different cases. Some- 
times the pustules are very few, sometimes so numerous as to cover almost 
the whole body, in such a manner, however, as to be quite isolated. 
Various interesting incidents occur in the progress of the eruption. Pa- 
tients often complain of tingling or itching, and the skin is more or less ten- 
der. An eruption also takes place upon the mucous membrane of the mouth, 
fauces, eyelids, prepuce, and female labia, which may be distinctly seen two 
or three days after the first appearance of that upon the skin, in the form of 
small circular white spots, which, however, contain neither lymph nor pus. 
Between these the membrane often becomes red and inflamed; and, on the 
seventh or eighth day of the disease, sore throat, swelling of the fauces, CLASS I.] 
SMALL-POX, OR VARIOLA. 
355 
painful deglutition, and salivation, are apt to come on, which are among the 
most disagreeable symptoms. The patient is sometimes very much annoyed 
by the necessity of constantly clearing his throat and mouth from the viscid 
secretion. 
With the progress of the pustules, there is generally more or less swelling 
of the skin, especially upon the face, where the feeling of burning and tension 
is often painful. The scalp is also occasionally much swollen. Both the ex- 
ternal tumefaction, and soreness of mouth with salivation, increase as the 
pustules approach maturation, and begin to subside as soon as these have 
reached their greatest height. 
During the period of maturation, the body of the patient exhales a peculiar 
and disagreeable odour, by which one familiar with the disease can generally 
recognize it. 
About the eighth or ninth day of the disease, a febrile action is again fre- 
quently developed, constituting what is properly called the secondary fever. 
Depending exclusively upon the sympathy of the constitution with the local 
disease, it is most violent, other things being equal, when the eruption is 
most copious; and, when this is scanty, may be quite wanting. There can 
be no doubt that a slighter amount of the eruption will excite the fever in 
some persons than others, owing to their greater predisposition to the disease. 
Some writers make a difference between this fever, and that which prevails in 
the confluent variety during the period of decline, calling the former the fever 
of maturation, and the latter the secondary fever. But there is no good 
ground for the distinction. In both cases, the fever depends upon the local 
affection; and that which exists in the decline of the eruption, is merely a 
continuation of that which attends the maturation, except in so far as any 
intercurrent inflammation may add its influence to that of the pustules. The 
distinctive character of the secondary fever is, that it is symptomatic, and 
not, like the primary fever, idiopathic. As it occurs in the distinct variety, 
it generally declines with the pustules. 
The third or declining stage is, in this variety, little more than a period of 
convalescence. About the eleventh or twelfth day, the pustules on the cheeks 
may be seen to become brown and dryish at top, or some of them break, and 
the liquid which oozes out concretes into a yellowish-brown crust; and from 
this time the process of desiccation goes rapidly on, the swelling of the face 
subsides, and at last only dry scabs remain, which begin to fall off from the 
face on the fourteenth or fifteenth day. 
But the eruption upon the extremities has scarcely yet arrived at its height, 
when that upon the face is declining; so that the hands and feet are now con- 
siderably swollen; and this is looked upon as a favourable sign, because it 
indicates a certain vigour in the constitution. It is not till three or four days 
after the scabs have formed upon the face, that the same process is completed 
upon the wrists and ankles. 
Many of the pustules, instead of forming a regular' scab, shrink away in 
consequence of absorption of their contained fluid, and nothing but a pellicle 
of cuticle is left, which separates by desquamation. This is especially the case 
with those upon the arms and legs; and I have repeatedly seen cases, in which 
there were scarcely any scabs upon the forearms, though they had been full 
of the eruption. It is generally believed that the pus is absorbed in these 
cases; but Gregory states that this is not the fact, as no pus exists in these 
pocks, but only a serous fluid. At all events, the pocks which thus shrink 
away are often to all appearance fully formed, and differ in nothing to the eye 
from those upon the face which form scabs. 
The eruption upon the mucous membrane is almost always resolved, with- 356 
GENERAL DISEASES.-EEVERS. 
[part ii. 
out the formation of ulcers, or anything that can be considered a scab. It 
is not the pock upon the conjunctiva or eyelid, that produces the ophthalmia 
from which such serious consequences sometimes follow, in bad cases of 
small-pox. 
The scabs fall off entirely between the fourteenth and twenty-first day. It 
is a singular fact, mentioned by Rayer and others, that when the skin has 
been previously inflamed, as in psoriasis, lichen, eczema, &c., the progress of 
maturation in variolous pustules is considerably hastened, so that the pocks on 
the inflamed spot commonly run through the whole of them stages within 
eight days. 
After the falling of the scabs, blotches of a reddish-brown colour are left 
behind, which sometimes continue for several months before they quite disap- 
pear. Some of the pustules, especially those of the face, in consequence of 
an ulcerative destruction of the true skin, leave scars or pits, which are never 
effaced. The surfaces from which the scabs have fallen, frequently afterwards 
undergo a furfuraceous desquamation. 
When the scabs begin to form, the fever declines, the tongue cleans, the 
appetite returns, and, by the time that the skin has been relieved of its bur- 
then, the patient has been fully restored to health. The whole course of the 
disease occupies from two to three weeks. 
2. Confluent Small-pox.-This is only a more aggravated form of the 
same disease, and there is every grade between the extremes of the two 
varieties. In the more fully confluent forms, the initial fever is more vio- 
lent, as a general rule, than in the distinct. The pain in the small of the 
back is more severe; convulsions, delirium, and stupor are more frequent; 
nausea and vomiting more distressing and obstinate; and the disease more 
liable to inflammatory or malignant complication. The delirium is occasion- 
ally violent and uncontrollable, and, though sometimes associated with signs 
of inflammatory congestion of the brain, is, in other cases, apparently de- 
pendent on excessive nervous irritation alone. Cough, dyspnoea, and pains in 
the chest are not uncommon, and the epigastrium and other parts of the 
abdomen are often painful, and extremely tender upon pressure. The erup- 
tion appears somewhat earlier than in the distinct variety, and is not attended 
with the same complete subsidence of the fever, which, however, almost always 
in some degree remits. 
The eruption is occasionally preceded by a roseolous or erythematous efflo- 
rescence upon the face and trunk. The variolous papulae appear thickly upon 
the face, in some cases so that scarcely any portion of healthy skin is visible* 
but more frequently leaving intervals of the surface comparatively unaffected. 
They are in general more distinct upon the body and limbs; but here also 
they are frequently more or less confluent; and it sometimes happens, that, 
while distinct upon the face, they are confluent on some other part of the 
body, as upon the anterior surface of the trunk, or on one of the limbs. In 
the latter cases, the symptoms are usually less violent. 
As the disease advances, the pocks are less regularly developed than in the 
distinct variety. They do not fill out so amply, nor rise so much above the 
surface. It often happens that large portions of the face are covered appa- 
rently with an almost uniform layer of pus beneath the epidermis, and some- 
times almost the whole face is thus affected. In such instances, the pustules 
appear to be fused into one mass of suppuration. The inflammation often 
extends to the subcutaneous cellular tissue, and not only is much of the 
proper skin destroyed by ulceration, but great havoc is made by the pus bur- 
rowing in the parts beneath it. 
The eruption in the mouth, fauces, &c., is more copious than in the distinct, CLASS I.] 
SMALL-POX, OR VARIOLA. 
357 
the consequent swelling and pain in these parts greater, and the salivation 
more abundant and distressing. Not unfrequently the eruption and attendant 
inflammation extend to the larynx and trachea, and to the larger divisions of 
the bronchia, producing cough, hoarseness, painful attempts at expectoration, 
and sometimes complete extinction of the voice. This is one of the most 
dangerous accompaniments of small-pox, causing death by suffocation, in some 
instances through the closure of the rima glottidis, in others by the clogging 
of the bronchial tubes with their viscid secretion. Consequent upon this con- 
dition in its advanced stages, and arising from a want of arterialization of the 
blood, is a dark discoloration of the surface, a livid or purplish hue of the 
eruption, feebleness of the pulse, coolness of the surface, and universal pros- 
tration. The deglutition, which is painful from the inflamed state of the 
fauces, becomes in some of these cases still more difficult, in consequence of 
the thickening of the epiglottis,'and the want of proper adaptation between it 
and the orifice of the glottis. The nostrils are often stuffed with the tough 
secretion, or closed by the swelling of the Schneiderian membrane, so as to 
render breathing through them impossible. 
• -'The surface also often swells greatly, especially the face and scalp. Such 
is the tumefaction, that the eyes are frequently closed, almost every feature 
obliterated, and the whole head enormously enlarged. The patient is occa- 
sionally troubled with phymosis or paraphymosis; buboes form in the groin; 
and parts of the surface where there is little eruption are sometimes affected 
by an erythematous inflammation. 
The eruption usually begins to turn, upon the face, about the tenth day of 
the disease, and, in place of the broad masses of suppuration, with its cuticular 
covering, the whole face is often invested with a mask of dark-coloured scabs, 
beneath which matter still exists, giving a soft mush-like feeling to the parts. 
Frequently, the matter oozes from beneath the scabs; and sometimes, when 
these are torn off or scratched, as they are apt to be in consequence of the 
insupportable itchiness which attends their formation, a bloody or ichorous 
discharge from the raw surfaces takes place. 
When, along with these phenomena, the intolerable fetor which exhales 
from the patient is taken into consideration, it may be easily conceived, that 
few objects in nature are more revolting to our senses and sensibilities, than 
a patient in this stage of a severe attack of confluent small-pox. 
The fever, which had remitted upon the occurrence of the eruption, but has 
never entirely left the patient, increases again on the eighth, ninth, or tenth 
day; and the new accession is often marked by the occurrence of rigors. This 
secondary fever may still have more or less of the sthenic character, which in 
some vigorous constitutions it never loses; but very often it assumes a low 
form, consequent partly upon the exhausted strength of the patient, and 
partly also, in all probability, upon the deteriorating effects of the absorbed 
pus, and putrid secretions, upon the blood. There is now a frequent and 
feeble pulse, a dark and dry tongue, low delirium, tremors, subsultus tendinum, 
great muscular weakness, occasionally involuntary evacuations, or perhaps 
retention of urine; and the patient, if no favourable change takes place, dies 
either from extreme exhaustion, or the interruption of some one of the vital 
functions through the severity of local disease. 
Should he survive the period of maturation, and pass into that of the decline 
of the eruption, he has still great dangers to encounter. It is now that dis- 
organizing inflammations are most apt to occur, in various parts of the body. 
Pseudo-membranous inflammation of the fauces and larynx, pneumonia, pleu- 
risy, diarrhoea or dysentery, and occasionally inflammation of the brain compli- 
cate the proper variolous symptoms, and often with fatal effect. It is now 358 
GENERAL DISEASES.-FEVERS. 
[PART II. 
that those destructive attacks of ophthalmia occur, which are apt to leave 
behind them the irreparable loss of one or both eyes. Sometimes the cornea 
sloughs, and the internal parts of the eye project through the opening. Some- 
times the whole eye is converted into an abscess. In milder cases, an opacity 
of the cornea is produced, which either remains permanent, or gradually dis- 
appears after several months. Obstinate abscesses of the ear are also occa- 
sionally formed. Erysipelas sometimes appears upon the face or elsewhere. 
Troublesome abscesses are not unfrequently developed in the head, neck, and 
limbs; boils break out over the surface of the body; and various eruptive 
affections, as the pustules of ecthyma, and the bullae of rupia, give rise to 
intractable sores, and greatly add to the distress of the patient. (Ray er. 
Even when other dangers have been escaped, an extraordinary tendency to 
suppuration sometimes remains in the cellular tissue, beneath the skin and 
among the muscles; and I recollect a case of this kind, in which the whole 
lower limbs appeared almost to dissolve into pus, and the patient sank under 
enormous abscesses near the end of the third week. Gangrene, also, some- 
times attacks the surface, and portions of the skin slough. 
Should the disease not prove fatal from some of the above causes, the 
patient enters at length into a slow convalescence. The scabs fall off, leaving 
behind them evidences of the ravages of the disease, in numerous pits, and 
not unfrequently in very unsightly scars and seams upon the face. Occasion- 
ally the recovery is attended with the loss of one, and more rarely of both 
eyes. Any existing tendency to scrofula or phthisis is apt to be developed; 
and the patient merely passes from one disease into another not less destructive. 
Desquamation is seldom completed, and health restored, under three or four 
weeks, and sometimes entire recovery is still further postponed. There are, 
however, cases of confluent small-pox which run a more kindly course; and 
which, after surmounting the dangers of maturation, go on without interruption 
to a favourable issue. It must be remembered, too, that there are various 
grades of confluence, some of which are but little more dangerous than the 
distinct form. Names have been conferred upon certain subordinate varieties, 
founded upon the amount or arrangement of the eruption; as the semi-con- 
fiuent, when the degree of confluence is moderate, and the coherent or corym- 
bose, when the pustules appear in clusters, with intervening spaces of sound 
skin; but such distinctions are of little importance. 
There is a condition of the disease, however, which merits a more particular 
notice. It is that usually designated as malignant small-pox, in consequence 
of its extraordinary virulence. Its peculiarity consists in the association, with 
the special effects of the variolous poison, of an asthenic state of system, which 
causes the patient to sink under the disease, at a comparatively early stage, 
and without the co-operation of those inflammatory complications, which are 
the ordinary sources of danger at this period. This state of system may be 
connected with any of the forms of small-pox, the distinct, the confluent, or 
even the modified form called varioloid. I have known a case of the last 
mentioned affection fatal in consequence of this associated malignancy. But 
it is much more frequently observed with the confluent than the other forms. 
It is evinced either, first, by an utter prostration of the nervous power, inducing 
inefficient re-action, with coma, delirium, or excessive restlessness and anxiety, 
and sometimes an imperfect developement of the eruption, or a sudden retro- 
cession of it when formed, or, secondly, by those symptoms which characterize 
a depraved condition of the blood, such as petechim or vibices, oozing of dark 
blood from the mucous membranes or abraded surfaces, a purplish or bloody 
and badly developed eruption, which fills partially, and rises but little above 
the surface, paleness or lividity of the intervening skin, a disposition to gan- CLASS I.] 
SMALL-POX, OR VARIOLA. 
359 
grene, oppressed breathing, an anxious countenance, and great feebleness of 
the circulation. Sometimes the signs of malignancy do not exhibit themselves 
in the primitive fever, unless perhaps by unusual severity of the lumbar pains; 
but in other instances they are striking almost from the beginning, and there 
is reason to believe that patients have sunk under them before the period of 
eruption. Death, however, generally takes place from the seventh to the 
ninth day of the disease. It is this form of the complaint to which the name 
of black small-pox (vanolee nigrse) has been sometimes applied. 
3. Varioloid, or Modified Small-Pox.-Different writers on small-pox 
had recognized various modifications of the disease, occurring especially during 
its epidemic prevalence, long before vaccination was known. Such were the 
variolous fever without eruption (variolee sine various'); the crystalline pock, 
in which the eruption continued vesicular; the stone-pock, horn-pock, and wart- 
pock (variola verrucosa, or v. cornea), in which the vesicles dried up into 
small tubercles, instead of proceeding onward to maturation; and several 
others which it would be profitless to enumerate. Most of these are now per- 
fectly familiar to us as the result of the modifying influence of vaccination, or 
previous small-pox, and are confounded under the general name of varioloid, 
which has, with great propriety, been given to the diversified forms of the 
disease originating in the cause alluded to. 
Some have considered the disease, which occurs in individuals partially pro- 
tected, to be a distinct affection, having a peculiar contagion of its own, and 
bearing to small-pox the same relation as varicella or chicken-pox. But that 
it is nothing more than a modified variola is proved by the facts, that it is 
produced by exposure to the contagion of small-pox, and is itself capable of 
producing small-pox in the unprotected. The great diversity, moreover, of 
its forms, taken in connexion with its identity of origin, would appear to show, 
that it could not be a peculiar disease resulting from the unmodified influence 
of a distinct cause, but must owe its diversity to the unequal degree of some 
protecting influence in the individuals attacked by it. This diversity is so 
great that it would be utterly impossible, within any moderate limits, to de- 
scribe minutely all the shapes which it assumes. There is, in fact, every 
shade between the slightest symptoms, scarcely recognizable as having affinity 
with small-pox, and the nearest possible approach to the regular disease. It 
will be sufficient to notice some of the more prominent of these varieties. 
I have not the least doubt, that the variolous fever occurs in some individu- 
als who want but little of being perfectly protected, without any eruption 
whatever. Such a fever, of about three days' duration, has frequently come 
under my notice during variolous epidemics, and could be explained in no 
other way than by reference to the prevalent influence. I have always ob- 
served it in persons who had been previously vaccinated or affected with 
smalt-pox. 
In cases attended with eruption, which are vastly more frequent than those 
just mentioned, the fever is of various grades of violence and duration, some- 
times commencing with rigors, exhibiting the characteristic symptoms of 
severe lumbar pains, headache, and obstinate vomiting, and terminating upon 
the third or fourth day, but in other instances slighter, shorter, and occasion- 
ally scarcely sufficient to attract notice. Judging from my own observation, 
I should say that, in the greater proportion of cases, it is very regular, bear- 
ing a much nearer resemblance to the fever of unmodified small-pox, than the 
subsequent eruption does to the eruption of the genuine disease. Indeed, one 
of the most striking circumstances, in connexion with varioloid, is the fre- 
quently slight proportion which the amount of eruption bears to the severity 360 
GENERAL DISEASES.-FEVERS. 
[part II. 
of the preceding fever. I have known a high fever lasting three days, to be 
followed by a single pock upon the breast. 
Another circumstance in the eruption, worthy of notice, is that occasionally 
the appearance of the proper papulm, as in the confluent small-pox, is pre- 
ceded by a scarlet efflorescence like that of scarlatina or roseola, which might 
be alarming were there not evidence of previous vaccination or inoculation, 
but, under these circumstances, is quite insignificant. It is often followed by 
a very small crop of the true varioloid eruption. 
Not unfrequently the eruption is copious, and, in some rare instances, it is 
even confluent. It much more frequently occurs first on the body, than is 
the case in the genuine disease. The character of the eruption, and its pro- 
gress, are not less diversified than its amount. Sometimes it never advances 
beyond the state of mere papula or pimple; though this is comparatively rare. 
In much the greater number of instances, it stops short in. the vesicular stage, 
or undergoes but a partial and imperfect suppuration, and begins to dry on 
the fourth or fifth day of the eruption, forming a small hard tubercle, which 
soon disappears. Sometimes the vesicles are scarcely umbilicated; or at least 
a much larger proportion of them are not umbilicated than in regular small- 
pox. On this account, it is occasionally difficult to distinguish the disease 
from varicella. In other instances,.again, the pock becomes clearly pustular; 
and it is not uncommon to see the three forms of pimple, vesicle, and pustule, 
in the same case, and at the same time. 
In many instances, the eruption runs its regular course, in all respects like 
that of genuine small-pox, becoming pustular, and even convex at top, but 
stopping one or two days sooner, on the sixth or seventh day of the eruption, 
for example, instead of the eighth or ninth. It has appeared to me that 
this difference has been sometimes the cause of safety to the patient; and I 
have looked with great anxiety for the signs of a commencing change upon 
the sixth day. 
Another striking difference between the severest forms of varioloid and 
genuine variola is the absence of odour in the former. This is generally 
quite wanting, and always, so far as I have observed, very slight compared 
with that which is exhaled at the same stage, and with an equal amount of 
eruption, in the unmodified disease. 
These two signs, the shorter duration of the eruption, and the comparative 
absence of odour, may be considered as diagnostic signs of varioloid. Any 
case without them must be looked upon as true small-pox. 
Secondary fever is very rare in varioloid; though it does occasionally take 
place in the severer cases. 
Varioloid is very seldom dangerous, and is much less apt than small-pox, 
with an equal amount of eruption, to leave pits behind it. Nevertheless, 
these do occasionally take place. The disease may also prove fatal. • But 
when it does so, it is generally in consequence of some accidental complication. 
The only two instances of death from varioloid which I ever witnessed arose, 
the one from a malignancy of system which caused a fatal termination before 
the complete maturation of the pustules, the other from the occurrence of 
inflammation of the brain, which, from the state of the patient's constitution 
at the time, would very probably have occurred in any other febrile disease. 
Notwithstanding the generally protective or modifying influence of previous 
vaccination or variola, it must be confessed, that genuine small-pox, perfect 
in all its stages, has sometimes followed these diseases; while, on the other 
hand, modified forms of the complaint have been noticed in persons who had 
never been affected with either of them. 
Before closing the symptomatology of small-pox, it will be proper to notice CLASS I.] 
SMALL-POX, OR.VARIOLA. 
361 
the fact, that it is sometimes materially modified by other eruptive affections, 
especially measles, scarlatina, and purpura, the simultaneous occurrence of 
which sometimes serves considerably to embarrass the diagnosis. In relation 
to measles, it has been observed that they will sometimes supersede a com- 
mencing variola,- which will return and finish its course, after the intercurrent 
disease has subsided. It has been already stated that small-pox favours the 
developement of scrofula and phthisis. It is said sometimes to have cured 
intermittent fever, and to have superseded some of the neuroses, as epilepsy, 
for example, at least for a time., 
Anatomical Characters. 
The only characteristic alterations are those upon the skin and mucous 
surfaces. It is true that signs of inflammation are often found in the lungs, 
pleura, membranes of the brain, &c.; but these lesions are neither constant 
nor essential, and offer nothing in small-pox to distinguish them from analo- 
gous changes in other diseases. Some importance has been attached to the 
redness sometimes observed upon the internal surface of the arteries; but 
this appears to be generally owing to mere imbibition of blood. In malig- 
nant cases, the blood is found to have undergone the same changes that have 
been noticed in other malignant diseases. When taken from the arm during 
life, it sometimes contains a small excess of fibrin, and, upon coagulation, 
exhibits the inflammatory crust, which, however, is usually soft and gelatin- 
ous. In typhoid cases, the proportion of fibrin is diminished. 
The structure of the pustule is peculiar. A portion of the true skin at its 
basis is reddened, and sometimes ulcerated. Upon the surface of this, and 
beneath the cuticle, is a disk of pseudo-membranous matter, which, in the 
earlier stages of the eruption, adheres to the inner surface of the cuticle, and 
less firmly to the chorion beneath it. The colour of this disk is dull-white, 
and its consistence rather friable. At a more advanced stage, a serous or 
purulent fluid is observed in small vacuities, or a winding cavity, between 
this adventitious product and the surface of the true skin; and, when the 
pustule is mature, a layer of pus separates it also from the cuticle. Accord- 
ing to Rayer, " the size, colour, and umbilicated depression of the pustules 
depend on the pseudo-membranous disk, secreted by the papillary body, in- 
flamed and elevated in the form of a zone." (Dis. of Skin, Am. ed., p. 154.) 
According to others, 11 the central depression is produced by a small cellular 
filament, the upper end of which answers to the epidermis, whilst the inferior 
extremity adheres to a kind of disk of the true skin more or less thick, from 
which extends a false membrane covering all the internal surface of the epi- 
dermis of the pustule. Towards the end of suppuration, this little bridle is 
no longer found, being ruptured in consequence of the distension." (Guer- 
sant et Blache. Diet, de Med., xxx. 566.) The conjunctiva, and mucous 
membranes of the nasal passages, mouth, pharynx, larynx, bronchia as far 
as the third division, prepuce in the male, and labia in the female, often 
exhibit, after death, traces of the eruption, either in minute exudations of 
false membrane, or in detached portions of epithelium, or grayish circular 
spots, a line or two in diameter, from which the epithelium has been removed. 
These spots contain no pus, do not scab, and leave no scar. The mucous 
membrane between them is more or less reddened. A few of these eruptive 
spots have also been observed in the oesophagus, but are rare. It is asserted 
that the proper variolous eruption never exists in the stomach and bowels. 
It is true that signs of inflammation are almost always presented by the 
alimentary mucous membrane, and not unfrequently small elevations are 
observed upon its surface, especially in the large intestines, in cases attended 362 
GENERAL DISEASES.-FEVERS. 
[PART II. 
with diarrhoea or dysentery; but these eminences are nothing more than in- 
flamed and enlarged mucous glands. 
Cause. 
The cause of small-pox is universally admitted to he a specific contagion. 
This is indeed one of the most contagious of diseases. There are very few 
not protected by vaccination, or a previous attack of the disease, who are not 
liable to be affected by it on exposure. Occasionally, an individual is met 
with who has resisted the effects of the contagion to old age; but even 
such persons are not secure; for instances are on record, in which, after fre- 
quent exposure to the cause of the disease without effect, a fatal attack has 
at length occurred, perhaps in advanced life; and, in persons who have 
escaped the disease in the natural way, it^has been produced by inoculation. 
Even the foetus in the womb is liable to be affected along with the mother; 
and it has been asserted that the effect has taken place, when the mother her- 
self was protected. The idea has been advanced, that some of those persons 
who seem exempt from the disease, may owe theft want of susceptibility to a 
previous attack of it in the foetal state. The contagion acts either through 
the air, or by contact, in the liquid or solid form, with the sound skin or the 
mucous membranes, or by insertion beneath the cuticle. What products of 
the diseased body are contagious is not exactly known; but the purulent con- 
tents of the pustules, and their dried scabs certainly are so; and it is asserted 
that the disease has resulted from bleeding with a lancet which had been used 
in a previous case, and not properly cleansed. 
Opinion is not settled, as to the period of the disease at which it is con- 
tagious; some believing it to be so only after the commencement of suppura- 
tion, while others, with greater prudence, consider it as capable of self-propa- 
gation, at any period after the first establishment of the fever. It is certain 
that the body retains the power of imparting the disease after death; according 
to Mr. Hawkins, for a period of at least ten or twelve days, even without con- 
tact. Some have supposed that the odour is connected with the contagious 
effluvia; but it certainly is not essential to their activity; for the disease may 
be propagated from cases in which there is no appreciable smell. The con- 
tagious principle attaches itself to clothing, which retains it sometimes for 
months, and it has been said for years, when confined.' But it appears to be 
easily dissipated in the air, so as to become inert; for the well authenticated 
instances are very few, in which physicians have conveyed it from one person 
to another. Attempts have been made to determine the distance from its 
source at which the volatile poison is capable of acting; but these are neces- 
sarily futile; for the distance must vary greatly with the degree of concentra- 
tion of the poison; and its activity is probably much greater in certain con- 
ditions of the atmosphere than others, as, for example, during the prevalence 
of a variolous epidemic. It is certain that the contagion may extend directly 
from a single chamber to all the individuals of a large house, and even to 
those of a neighbouring house. 
One attack of the disease protects the system, in most cases, against a sub- 
sequent attack; and, where it does not afford complete security, very generally 
modifies the recurrent affection, so as to render it harmless. It cannot, how- 
ever, be denied, that fatal cases of secondary small-pox now and then happen; 
and instances are related, in which the disease has occurred a third time in 
the same individual. Certain families appear to have an extraordinary sus- 
ceptibility to the variolous contagion, so that individuals belonging to them 
are much more liable to returns of the disease than others, and generally also 
have it more severely. CLASS I.] 
SMALL-POX, OR VARIOLA. 
363 
It is an interesting question, whether any other cause is capable of produc- 
ing small-pox than its peculiar contagion. It certainly appears often to occur 
epidemically. After an extraordinary exemption, perhaps for years, a city or 
district of country is suddenly invaded by it, and continues to be infested for 
a longer or shorter period, after which, the disease again declines, and soon 
for a time ceases to be heard of. It may thus return yearly, or at irregular 
but comparatively short intervals; until at length the epidemic influence 
seems to be exhausted, and a long and almost entire exemption is again 
enjoyed, interrupted only occasionally by cases arising from obvious contagion. 
It is especially during these visitations, that individuals supposed to be pro- 
tected by inoculation, vaccination, oi' any other cause, and who may have 
before freely exposed themselves to the contagion with impunity, are apt to 
suffer. Yet it is very doubtful, whether the epidemic influence has the 
power of originating the disease. It would, perhaps, be going too far to 
assert that it never does so. But the probability is that it operates simply 
by increasing, in some unknown manner, the susceptibility of the system, or 
by sharpening the virulence of the contagion, so that a smaller amount of it 
is capable of producing the disease than under ordinary circumstances. That 
it operates chiefly by increasing the susceptibility, may be inferred from the 
fact, that, during these epidemics of small-pox, there is often also an extra- 
ordinary tendency to certain other cutaneous diseases, or to eruptive affections 
in general. Variolous epidemics observe no regular rule of recurrence. They 
may approach at one season as well as at another. Sydenham, however, 
observed that, when they commence in the middle of winter, as in the month 
of January, they are apt to be more violent than when they make their ap- 
proach in spring, about the vernal equinox. 
In relation to the effect of the contagion, it does not appear that the pecu- 
liar character of the communicating case, has any influence upon the form or 
grade of the one produced. Thus, the severest confluent case may produce 
the mildest form of the distinct variety, and vice versa. 
The time which intervenes between the reception of the poison, and the 
beginning of the primary fever, is generally from nine to twelve days; but 
the attack' is asserted to occur sometimes so early as the fifth day, and in 
other instances to be postponed to the end of the second or third week. 
When regular small-pox has run through its whole course, or has reached 
an advanced stage, there can be no difficulty whatever in distinguishing it 
from all other diseases. Its symptoms are quite characteristic. But the 
same cannot be said of all its stages, nor of all its modifications. The initial 
fever offers no symptom by which it can be distinguished, with certainty, 
from other fevers. The most experienced physicians are sometimes deceived. 
Yet there is, in some cases, a certain aspect which may well induce suspicion. 
Severe pain in the lumbar region, for example, and excessive irritability of 
stomach, ascribable to no obvious cause, would be apt to direct the attention 
to small-pox; and, if the disease were prevalent at the time, would afford 
highly probable evidence of its variolous nature. Should a papular eruption 
now occur upon the third or fourth day, with a subsidence of the fever, the 
proof would be almost conclusive; and should the eruption shortly become 
vesicular, with an umbilicated summit, it would be quite so. 
There'may be some difficulty, for a moment, in distinguishing the variolous 
eruption, at its'first appearance, in a confluent case, from that of measles or 
febrile lichen; but, in the former of these complaints, the eruption is less 
prominent and distinct to the touch, in the latter, the preceding fever is of 
Diagnosis. 364 
GENERAL DISEASES.-EEVERS. 
[part II. 
much shorter duration. A day or two, however, must remove all difficulty 
by the further developement of the eruption. 
Varioloid, or modified small-pox, sometimes offers considerable difficulty in 
the diagnosis. In relation to those cases in which there is no eruption, there 
must always be some doubt. So also, perhaps, in those in which the eruption 
does not advance beyond the papular state; though the duration of the fever, 
and its complete subsidence at the appearance of the eruption, in connexion 
with a known exposure to variolous contagion, might be considered as almost 
decisive. Between certain cases of varioloid and varicella, or chicken-pox, 
there is absolutely no observable difference; but, in. general, the two com- 
plaints may be readily distinguished by the much shorter duration of the 
eruptive fever in the latter, and by the absence of umbilicated vesicles or 
pustules. 
Prognosis. 
Unmodified small-pox is a very fatal) and was formerly an exceedingly 
destructive disease. The general average of deaths is stated at one in four. 
Under favourable circumstances of living and treatment, it would undoubt- 
edly be much less. The varieties differ greatly in the degree of their 
danger. The distinct, when uncomplicated, is seldom fatal; the fully-formed 
confluent disease is always very dangerous) the malignant almost always 
ends in death. The fatal eases of varioloid are comparatively very few; and, 
in the vast majority of instances, the affection is quite trifling, except from 
the consideration, that it may be the source of danger to unprotected indi- 
viduals. 
" It may be considered a favourable sign when the disease pursues its regu- 
lar course towards desquamation, without any serious inflammatory complica- 
tion, and without malignancy; but cases sometimes occur, in which, without 
obvious cause, the vesicles or pustules suddenly shrink, and the patient sinks; 
and, until convalescence is completely established, there is never any positive 
security, in the confluent variety, against dangerous or fatal intercurrent 
disease. 
The signs which may be looked upon as especially unfavourable, though 
by no means all of them necessarily fatal, are excessive lumbar pains; the 
continuance of vomiting after the appearance of the eruption; violent deli- 
rium, coma, or convulsions in the first stage, except in children; great 
abundance and confluence of the eruption; the simultaneous appearance of 
the eruption over the whole body; a want of redness about the pock; a livid 
or purplish colour of the pustule; petechias and vibices, with passive hemor- 
rhage; imperfect developement of the pustules, or their sudden subsidence, 
without diminution of the other symptoms; appearance of the bullae of rupia 
among the pustules; sudden disappearance of swelling of the face and saliva- 
tion, and the want of swelling in the hands and feet, when the eruption is 
copious; great hoarseness or complete extinction of voice, with difficulty of 
respiration; the occurrence of pneumonia or pleurisy; convulsions or coma 
in the advanced stages; the suppression of urine, or involuntary discharges 
whether of urine or feces; and, finally, a disposition to the formation of large 
abscesses after the commencement of desquamation. 
The disease is more fatal at the two extremes of life than in its interme- 
diate stages. Plethora and debility are both unfavourable. The intemperate 
are very apt to die. The disease is often fatal, and always dangerous in 
pregnancy; and abortion not unfrequently ensues. 
Death may take place at any period of the disease, from the time of attack 
to the end of the fifth or sixth week. From a table of Dr. Gregory, it would CLASS I.] 
SMALL-POX. 
365 
appear that the greatest number die on the eighth day. Out of 168 fatal 
cases, 27 died on the eighth day, and 16, which was the next highest num- 
ber, on the eleventh. Comparing the different weeks, the mortality was much 
the greatest in the second, being 99; while in the first week it was 82, in 
the third 21, and in the fourth or later 16. (Tweedie's Sy st. of Pr act. Med.') 
But it should be observed that these were cases in a London hospital, in 
which there was no doubt a much greater malignancy, and consequently a 
tendency to earlier termination than in private practice. Judging from my 
own observation, I should suppose that the greatest number of deaths, under 
the latter circumstances, occur between the twelfth and eighteenth days. 
In few diseases has medical opinion undergone a more beneficial change 
than in this. Under the impression that the eruption was an effort of nature 
to rid the system of noxious matter, which if retained must prove fatal, it 
was formerly deemed important to favour instead of repressing the process. 
It was known that heating and stimulating measures promoted the eruption. 
Hence arose the practice of sedulously excluding fresh air from the sick 
room, heaping up bedclothes upon the patient, giving him hot drinks, and 
not unfrequently administering stimulants. Now that the greatest danger in 
small-pox is known to arise from the copiousness of the eruption, it will be 
readily understood, how fatal must have been the disease under the old sys- 
tem of practice. To Sydenham belongs the credit of changing the current 
of medical sentiment in this respect. Having practically ascertained the 
favourable effects of an opposite plan of treatment, he recommended it in his 
works; and refrigerant measures are now universally admitted to be the most 
efficient in the cure of the disease, as they certainly are the most agreeable 
to the patient. 
As the course of small-pox cannot be abruptly shortened, and as the dan- 
ger arises partly from the reaction of the copious, eruption upon the system, 
partly from intercurrent inflammation of the lungs, larynx, &c., and partly 
from the exhaustion consequent upon the long-continued irritation and dis- 
charge, it is clear that the important indications of treatment are, not to 
attempt by violent means to break up the complaint; but 1, to moderate the 
amount of pustulation without impairing the strength; 2, to obviate in all 
stages the effects of inflammation; and 3, to support the system when requi- 
site in the advanced stages. The comfort of the patient also should be 
studied, and means employed to relieve those painful annoyances, and allay 
those nervous disturbances, which are so incident to this complaint. The 
treatment is to be conducted upon general principles. There is no specific 
remedy in small-pox. 
In mild cases, which, if not disturbed, will of themselves run a favourable 
course, the physician should be contented with guarding the patient against 
injurious influences, such as heating drinks, stimulating food, confined air, 
and unnecessary exposure to cold; limiting himself, in regard to medicines, 
to refrigerant diaphoretics and cooling drinks during the fever, and to an occa- 
sional laxative if the bowels should be confined. 
In severer cases, it becomes necessary to interfere more efficiently. At 
the commencement of the primary fever, a full dose of some efficient cathar- 
tic should be given, as the compound cathartic pill of the U. S. Pharmaco- 
poeia, calomel and rhubarb, calomel and compound extract of colocynth or 
senna and salts; and afterwards the bowels should be kept open by saline 
cathartics, magnesia, castor oil, or rhubarb, as circumstances may seem to 
require. The Seidlitz powder will be found useful in some cases with irri- 
Treatment. 366 
GENERAL DISEASES.-FEVERS. 
[part II. 
table stomach. After the bowels have been well evacuated, saline diaphoretics 
should be given, especially the citrate of potassa, in the form of neutral mix- 
ture or effervescing draught; the latter being especially applicable, when 
there is a tendency to nausea and vomiting. The antimonials in small doses 
may be added, when the stomach is in no degree irritable. Nitrate of po- 
tassa, solution of acetate of ammonia, and spirit of nitric ether, may also be 
employed if deemed advisable. The skin, if very hot and dry, may be 
sponged with cool water; but care must be taken not to apply this too exten- 
sively; and, as a general rule, it may be safest to confine it to the arms and 
face. The necessity for caution in this respect arises from the proneness to 
internal inflammations. Sponging with warm water may be more freely em- 
ployed, and often affords relief. 
Should the pulse be full and strong, and evidences of inflammatory conges- 
tion be presented by any important organ, as the lungs, head, or stomach, 
blood may be taken moderately from the arm, and cups or leeches applied 
freely in the vicinity of the organ affected. In doubtful cases, the abstraction 
of blood should be exclusively local. Bleeding should never be used in the 
hope of eradicating the fever, or diminishing the amount of the eruption. It 
has been well ascertained to have neither of these effects, at least with the 
slightest approach to certainty. After the most copious loss of blood, the 
eruption is often quite as abundant as when the disease is left entirely to 
nature. It may possibly, indeed, sometimes keep back the eruption by 
exhausting the system; but the loss is here much greater than the gain. 
Sometimes, when the eruption seems to be kept back by powerful internal 
irritation, bleeding has the effect of hastening it. The practitioner should 
always bear in mind the long subsequent struggle, and how necessary it is 
to husband the strength against the last failing period. I repeat, the bleed- 
ing should be employed only to avert threatened danger from some import- 
ant organ. It is necessary not to be misguided by the pains which so com- 
monly attend severe small-pox in this stage. They are often purely nervous, 
especially those in the back, and so far from indicating depletion, are probably 
severest in the most asthenic state of the system. Even the pains in the 
head are also frequently nervous. The strength and fulness of pulse are a 
surer guide; and, in reference to the organs, bright redness and flushing of 
the face, great epigastric tenderness upon pressure, and the physical signs 
afforded by auscultation and percussion, taken in connexion with the pains, 
are more to be depended on than the pains themselves in the head, stomach, 
or chest. 
When there is much restlessness or wakefulness, severe neuralgic pains, 
with a frequent pulse, and no evident signs of cerebral congestion, much 
relief may often be obtained from opiates, especially in the form of Dover's 
powder, or of opium with ipecacuanha and calomel at bedtime. The warm 
bath also will often be useful, under such circumstances. For the vomiting, 
which is so troublesome a feature of the complaint, the effervescing draught, 
with a little morphia, black drop, or laudanum; small draughts of iced car- 
bonic acid water; a sinapism to the epigastrium; and, these failing, an 
anodyne enema, are the most efficacious remedies. Should the epigastrium 
be very tender, leeches and subsequent emollient cataplasms are indicated. 
For cerebral congestion, the hair should be thinned or removed, cold water 
or ice applied freely to the forehead and scalp, and cups or leeches to the 
temples or back of the neck; while excitement is invited towards the ex- 
tremities by hot or stimulating pediluvia, mustard to the legs, &c. Should 
symptoms of laryngeal or pectoral inflammation appear, local depletion and 
emollient cataplasms are indicated. The drinks should be such as have CLASS I.] 
SMALL-POX. 
367 
been recommended in other fevers, and should always be given cool. Cold 
water or lemonade is, perhaps, on the whole, the most acceptable to the 
patient. The diet should consist exclusively of mucilaginous, saccharine, or 
amylaceous liquids. 
In order to invite the eruption towards the lower extremities, and away 
from the face, some practitioners recommend warm pediluvia, and warm 
emollient cataplasms, or blisters to the legs. It is also advised, in cases of 
tardy eruption, with threatening constitutional symptoms, to have recourse 
to an emetic, the warm or vapour bath, diaphoretics, such as acetate of am- 
monia and Dover's powder, and, if necessary, to moderate stimulation. I can 
say nothing of these remedies, under the circumstances alluded to, from my 
own experience. 
After the appearance of the eruption, little treatment is required for some 
time. Should the fever continue, the refrigerant diaphoretics before men- 
tioned may also be continued, in diminished doses, and at longer intervals. 
Gentle laxatives are sometimes required to keep the bowels open. Nervous 
symptoms may often be quieted by spirit of nitric ether, Hoffmann's anodyne, 
or camphor water; and an opiate should be given at night, if necessary to 
procure sleep. The regimen should still be cooling; though food somewhat 
more nutritious may be allowed, such as gruels, panadas, toasted bread and 
tea, water crackers, roasted apples, oranges or grapes, milk and water, rennet 
whey, vegetable broth, &c.; reference, of course, being always had to the 
degree of excitement present. The diet, however, should be strictly anti- 
phlogistic. 
Upon the occurrence of secondary fever, the original diaphoretic and refri- 
gerant plan should be continued, in a degree corresponding to the excitement, 
and the apparent strength of the patient; and a still more guarded attention 
is necessary to the supervention of inflammations. Dor the relief of these, 
however, at this stage, more must be expected from local measures than 
general bleeding, which requires to be employed with great caution. Opiates 
may almost always be advantageously used at this period, and throughout the 
remainder of the disease, unless contraindicated by decided symptoms of cere- 
bral inflammation. They calm the nervous- disturbance, and render the 
system much less susceptible to the excessive annoyance of the local affection. 
Combined with calomel and ipecacuanha, opium is also an excellent remedy 
in the inflammations of this stage. Should they be severe enough to threaten 
life, the calomel may be very properly pushed to a moderate salivation, or till 
the gums are slightly touched. 
But there is another great danger to be guarded against in the advanced 
stages. It is often necessary to support the system under the prostrating 
effects of the abundant suppuration, and vast irritation of the pustules. When, 
therefore, any appearance of flagging is presented; when the pulse begins to 
weaken, the tongue to become dry and dark, and the extremities to show a 
want of due1 action, recourse should be had to tonics and stimulants, and to a 
nutritious diet, proportionate to the apparent wants of the system. The par- 
ticular remedies to be employed are sulphate of quinia or compound infusion 
of Peruvian bark, the mineral acids, the malt liquors, and wine either pure 
or in the shape of wine-whey. When the prostration is great, carbonate of 
ammonia, ether, and brandy may be added to the list. Camphor is an excel- 
lent addition to the other remedies in cases attended with nervous disturb- 
ance. When the surface is cold, external heat must be applied. The diet 
in these cases should be nutritious, and sometimes stimulating. Milk, animal 
broths, jellies or essences, and eggs, raw or soft boiled, may be used in addi- 
tion to the substances before employed. 368 
GENERAL DISEASES.-EEVERS. 
[part II. 
In the malignant cases, it is necessary to have recourse to this supporting 
plan of treatment early in the disease, or at any period when the symptoms 
of malignancy may show themselves; though it must be acknowledged that 
little good is to be expected from these or any other measures. 
It is necessary, throughout the complaint, to attend to the various inflam- 
matory complications. The method of treating these has already been 
pointed out. The only additional observation which seems to be required in 
this place is, that, when they occur in the advanced stages, they cannot be 
treated by depletion so freely as at the beginning; and that reliance must 
now be placed chiefly upon leeching, emollient applications, and blisters ex- 
ternally, and the careful use of mercury with opiates internally. The diarrhoea 
which occasionally attends the complaint must be treated on general princi- 
ples. (See Diarrhoea.} Convulsions, when they occur in the early stage, and 
are attended with an active pulse, require the treatment appropriate to active 
cerebral congestion. At a more advanced period, and when dependent on 
mere nervous irritation, they may sometimes, be advantageously treated with 
opiates, the nervous stimulants or antispasmodics, and the warm bath. 
Attention, throughout the case, should be paid to the diseased surfaces. 
Lotions of cool water, demulcent liquids, milk and water, or weak lead-water, 
may be applied to the face when much inflamed; purulent matters should be 
removed from the eyes by frequent washing; children should be prevented 
from scratching the pustules, which sometimes itch intolerably; moisture 
exuding from the pustules, or excoriated surfaces, should be absorbed by 
sprinkling them with rye meal, powdered starch, calamine, or tutty; or, if 
the parts are inflamed, they should be anointed with cold cream (unguentum 
aquae rosae, U. S. Ph.), or Goulard's cerate diluted with lard. The nostrils 
should be cleaned out in infants; and cooling or slightly astringent washes or 
gargles should be employed for the mouth and fauces. Should a pseudo- 
membranous exudation be observed in the fauces, it should be treated with a 
strong solution of nitrate of silver, or by that caustic in substance. 
In consequence of the repulsive deformity of face which frequently follows 
small-pox, it has always been an object of interest, to find some method of 
checking the progress of the eruption, and causing it to abort, so as to pre- 
vent pits and scars. The Arabian physicians were in the habit of opening 
the pustules after suppuration had commenced, of pressing out their liquid 
contents, and of then washing the surface with warm milk and water, decoc- 
tion of poppy-heads, &c.; and Rayer speaks favourably of the practice. But 
a more effectual method is that of cauterizing the pustules with nitrate of sil- 
ver, as recommended by Bretonneau and Serres. The former cauterized each 
pustule separately, the latter made the application to masses of the eruption. 
The best plan is probably to open each pock upon the face, as soon as it has 
become vesicular, either by a pointed probe or lancet, and then to apply a 
stick of nitrate of silver brought to a fine point, dr a very strong solution by 
means of a probe. The progress of the eruption is thus frequently completely 
arrested; and, at the end of a week, the scales fall off without leaving pits. 
To succeed, however, the operation must be performed as early as the second, 
or at farthest the third day. When the solution has been applied uniformly 
ovei- large surfaces, it has been found that the work of suppuration and ulcer- 
ation still goes on beneath the blackened cuticle. 
Still another method of causing the pustules to abort, is the use of the 
mercurial plaster, as recommended by M. Briquet, who deserves the credit of 
bringing the method into general notice, though known and practised by 
others before him. If applied at the very commencement of the eruption, it 
is asserted to have the effect of producing a resolution of the papulae; if during CLASS I.] 
SMALL-POX. 
369 
the vesicular stage, of causing them to dry up into tubercles, or at least pre- 
venting suppuration, and ultimate pits or scars. No injury results to the 
constitution from this abortion of the pustules, but, as is asserted, rather 
benefit from the diminished amount of irritation. The effect is ascribed to 
the specific action of the mercury; as other methods of excluding the air were 
not found so effectual. The emplastrum de Vigo, of the French Codex (see 
U. S. Dispensatory, article Emplastrum Hydrargyri^, is asserted to be more 
effectual than the mercurial ointment. I have employed the latter, however, 
with decided benefit. The application is usually confined to the face. The 
whole face should be covered by the plaster, as by a mask, openings being 
left for the eyes, nostrils, and mouth. The plaster may be removed after 
four or five days. If longer continued, it is apt to produce unpleasant irri- 
tation. The only hazard from this remedy is a mercurial salivation, which; 
however, does not usually occur, and should it do so, would perhaps be rather 
useful than injurious.* 
It is said that sulphur ointment, applied several times a day to the face, in 
the earliest stage of the eruption, has had the same effect. Dr. Samuel Jack- 
son, of Philadelphia, formerly of Northumberland, employed the tincture of 
iodine for the same purpose with apparent advantage. He applied the tinc- 
ture freely and continuously over the affected surface by means of a camel's 
hair pencil. Drs. F. Sargent and Goddard, of the same city, afterwards made 
the application in numerous cases; the former, with a decided effect in 
diminishing the inflammation and swelling, but with no appreciable influence 
on the pitting; the latter, with a complete prevention of pitting, even in con- 
fluent cases. (Med. Examiner, N. S., ii. 465.) It appears, however, from 
a communication in the British American Medical Journal Vox Nov. 1846, 
that the credit of having first employed tincture of iodine for this purpose 
belongs to Dr. Crawford, of Montreal, who applied it in a case so early as 
the year 1844. (See Ranking's Abstract, No. 5, p. 66.) 
During the period of desquamation, advantage will sometimes accrue from 
the occasional use of the warm bath; and the patient should always resort to 
this measure before again mixing with the world. 
Throughout the treatment, the greatest care should be taken to keep the 
apartment well ventilated, to change the clothing of the patient and his bed- 
clothes frequently, and to remove everything offensive from the chamber. 
Prevention. 
Perhaps the greatest triumph of modern medicine is the discovery of a sure 
preventive of small-pox. There are two modes of protecting the individual, 
inoculation and vaccination, the latter of which has the great advantage, that, 
so far as it goes, it protects the community also. The subject of inoculation 
I shall treat of in this place; that of vaccination is sufficiently important to 
entitle it to separate consideration, under a distinct head. 
By inoculation is technically meant the imparting of small-pox by the 
insertion of the virus into the skin. The disease thus produced, while infi- 
nitely milder and safer than when taken in the natural way, is scarcely less 
effectual in protecting against a second attack. It was, therefore, a happy 
discovery, and was employed with vast individual benefit before vaccination 
became known. It is said to have been practised from the earliest times in 
* A preparation employed in the Childrens' Hospital in Paris, and which succeeds 
"marvelously well," is made by incorporating together 25 parts of mercurial ointment, 
10 parts of yellow wax, and 6 parts of black pitch. It is said to be completely efficacious. 
(Journ. de Pharm., 3e ser ., viii. 282.) M. Briquet recommends mercurial ointment simply 
thickened with powdered starch. (Am. Journ. of Med. Sri., N. S., xiii. 438.) 370 
GENERAL DISEASES.-FEVERS. 
[part II. 
India, and was certainly familiar to the people of Turkey long before it be- 
came known in western Europe. It was introduced into England chiefly 
through the agency of the celebrated Lady Montagu, who became acquainted 
with it while residing in Turkey, as the wife of the British ambassador. 
Though much opposed at first, it gradually made its way into almost uni- 
versal adoption. 
Different modes of introducing the virus were employed, some of which 
were awkward, and unnecessarily painful. The most convenient, and one as 
effectual as any other, is, by means of a puncture in the arm, to insert a small 
portion of pus from a variolous pock, exactly as is done in the operation for 
vaccination. Much was said about the requisite preliminary preparation of 
the system, in order to secure a mild affection. But, according to the best 
testimony, the most favourable condition was that of perfect health; either 
plethora or debility being unfavourable. Hence, it was thought advisable 
that, for some time, before the operation, the patient should confine himself to 
a mild and moderate diet, and avoid stimulants of all kinds, as well as 
fatiguing exercise, and every kind of excess. 
The following is the course of the disease thus artificially produced. On 
the third or fourth day after the operation, a slight pricking pain is experi- 
enced in the part, a hard elevation may be felt by the finger, and a minute 
vesicle upon an inflamed base may be seen upon close examination. On the 
fifth day, the vesicle is well formed, and has an umbilicated appearance. 
This goes on increasing, and forms at length a small tumour like a phlegmon. 
At the end of the seventh day, rigors are felt, followed by fever; and, on 
the eighth or ninth, a variolous eruption makes its appearance in different 
parts of the body. This is almost always distinct, and generally moderate. 
One hundred pocks are a pretty full crop. A rose-coloured efflorescence often 
precedes the eruption on the eighth or ninth day. The pocks generally pass 
through the several stages, as in the distinct variety; though in some few 
instances they are said, to be abortive. In the meantime, the original pustule 
has been advancing, and, on the tenth or eleventh day, is surrounded by an 
irregular areola of inflammation, while the arm is often much swollen, and 
pus escapes from the tumour. No secondary fever occurs, and the pocks 
scab and desquamate kindly, seldom leaving any unpleasant effects behind. 
Occasionally inoculated small-pox proved fatal; but, where proper care 
was taken that the state of the system should be suitable before the operation, 
and that the patient should be preserved from injurious influences afterwards, 
the proportion of deaths was exceedingly small, not exceeding, according to- 
G-regory, one in five hundred. Small, however, as the danger is, it forms one 
objection to the operation; but another and much more serious one is, that, 
though it protects the individual inoculated, it makes him the centre of a 
contagious influence, and thus tends almost inevitably to keep up the disease 
in the community. Hence, society has deemed it necessary, in some places, 
to protect itself against mischief by forbidding the practice of inoculation, 
under a heavy penalty. CLASS I.] 
VACCINE DISEASE. 
371 
Article VIII. 
VACCINE DISEASE. 
This is a disease characterized by the existence upon the skin of one or 
more umbilicated vesicles;, by being communicable by means of inoculation, 
though not through the medium of the air; and by the property of render- 
ing the system, in a greater or less degree, insusceptible to the contagion of 
small-pox. The different names by which it is known all have reference to 
its origin from the cow. The term vaccination is used to signify the act of 
imparting the disease by the insertion of its peculiar virus into the skin. 
The fact that a disease occasionally appeared in the cow, capable of being 
imparted to man, and of securing him against small-pox, seems to have been 
long since known, and to a limited extent acted upon in different parts of the 
world, as in India, Persia, and South America (Diet, de Med., xxx. 393); 
and it was by the existence of a popular belief of this kind in his neighbour- 
hood, that Dr. Jenner was led to those investigations and experiments which 
have had such important results. Though not, therefore, the first to conceive 
or to practice the artificial communication of the vaccine disease, that cele- 
brated and most fortunate physician merits the exclusive credit of having 
brought the art into general and profitable use; and the idea of propagating 
the disease from individual to individual, after it was received from the cow, 
appears to have been quite original with him. Nor was the discovery a mere 
happy thought, which required only to be suggested in order to be established. 
On the contrary, it was only after a painful course of observation and trial, 
and amidst discouragements which would have extinguished a less ardent 
enthusiasm, that he succeeded at length in placing it upon a firm basis, and 
in gaining for it that universal acceptance which he lived to witness. To 
him, therefore, the world has almost unanimously ascribed the honour of the 
discovery; and the gift of 30,000 pounds sterling by the British Parliament, 
was but a small acknowledgment of the unspeakable benefit which he had 
conferred upon mankind. 
It was in the county of Gloucester, in England, that the first observations 
were made by Dr. Jenner. Being largely engaged in the practice of inocula- 
tion in that' neighbourhood, he found certain individuals who obstinately 
resisted the infection, and ascertained, in relation to these persons, that they 
had been affected with the complaint derived from cows, which was supposed 
to be a preservative against small-pox. The idea, occurred to him, that this 
might be artificially communicated with the same effect; and it was verified 
by experiment. The next step was the conception, before alluded to, of con- 
veying the disease from one person to another, which was equally verified. 
Having collected a sufficient amount of proofs, Dr. Jenner, in June, 1798, 
published his essay, entitled uInquiry into the causes and effects of the 
Variolas Vaccinae," in which he set these proofs forth with such effect as to 
excite immediate attention, and to enlist the enthusiastic co-operation of 
numerous individuals. New evidence was rapidly accumulated; and the 
practice of vaccination spread with great rapidity. In 1799 it reached the 
United States; in the following year it was admitted into France and other 
parts of continental Europe, and was even conveyed to India; and very soon 
there was scarcely any portion of the world which had not been made ac- 
quainted with it. 
Syn.-Cow-pox.-Kine-pock.-Vaccina.'-Vaccinia. 372 
GENERAL DISEASES.-FEVERS. 
[part II. 
Disease in the Cow.-The animal seems to suffer at first under what may 
be considered as the eruptive fever. Upon the third or fourth day, several 
small pocks appear upon the teats, and sometimes on the eyelids and nostrils, 
which gradually enlarge, assume the silvery appearance and umbilicated form 
characteristic of the vaccine vesicle, and, arriving at their height, begin to 
dry on the eleventh or twelfth day of the eruption. These pocks, broken in 
the act of milking, impart their contents to the hand of the operators, which 
become sore if accidentally abraded; The disease is not common in the cow, 
prevailing only in certain districts, and not always in these. Dr. Jenner 
supposed that it was conveyed to that animal from a complaint in the foot of 
the horse, denominated grease, the matter of which might attach itself to the 
hands of the ostlers, and, as men are in Gloucestershire employed in milking, 
might by them be imparted to the teats of the cow. But this supposition 
has not been confirmed by subsequent experiment. The idea has been ad- 
vanced, and is not without plausibility, that the complaint in the cow is the 
effect of the contagion of small-pox received from man, and modified in the 
system of the inferior animal. Dr. Jenner believed that small-pox and cow- 
pox were merely different forms of the same disease. Mr.'Ceely, of England, 
inoculated the cow with variolous matter, and, having introduced into the 
human subject some of the virus from the resulting pock, succeeded in pro- 
ducing a complaint, which was afterwards transmitted from individual to indi- 
vidual, with all the phenomena and effects of cow-pox. This experiment was 
repeated with the same results by Dr. John C. Martin, of Attleborough, 
Massachusetts, in 1835 (Med. Exam., iv. 782, from Bost. Med. and Surg. 
Journ.'), and by Dr. Basile Theile, of Kasan, in Dussia, in 1836 and 1838 
(see Am. J. of Med. Sei., N. S., ii. 467); and there would seem to be little 
doubt remaining upon the subject, if confidence can be placed in medical 
testimony. But it does not follow, even should these facts be admitted, that 
the diseases are the same; for it may be readily conceived, that a disease 
received from man into the system of an animal of a different species, shall 
be so far modified as to be essentially distinct in its nature; and the symp- 
toms and course of cow-pox, even omitting its incommunicability through 
the air, are so different from those of small-pox that the two cannot be con- 
founded. 
Symptoms, Course, &c.-Very soon after the insertion of the matter, a 
little inflammation arising from the puncture may generally be seen in the 
spot; but this disappears, and nothing is left but a slight trace of the wound. 
On the third day, or early in the fourth, a slight elevation is perceptible to 
the finger, and a little redness to the eye. By the fifth day, a small vesicle 
has formed, umbilicated at top, and containing a colourless, transparent, and 
viscid liquid. This gradually enlarges, and, on the sixth day, is generally 
surrounded by a very narrow circle of redness at the base. On the seventh 
day, the vesicle is well-formed, round, or oval, with a shining silvery appear- 
ance. During the eighth day, the hitherto slight border of redness spreads 
in all directions, forming a circular areola, which increases usually till the 
tenth day; and the vesicle at the same time enlarges, and becomes turgid 
with its fluid contents, especially at its circumference. The disease is now 
at its height. The pock is usually about one-third of an inch in diameter, 
between one and two lines in height, umbilicated at top, with frequently a 
minute scab or brownish scale in the centre, elsewhere of a pearly appear- 
ance, firm to the touch, and adherent to the skin. The areola is usually two 
inches or more in diameter, though varying with the age of the patient, is 
generally somewhat hard and swollen, and, when examined with the aid of a 
microscope, exhibits numerous minute vesicles upon the surface. There is CLASS I.] 
VACCINE DISEASE. 
373 
usually at this period an uneasy feeling of burning, itching, and tension; and 
the patient, if a child, is apt to be restless and fretful. On the eleventh day, 
the disease begins to decline. On the twelfth, the scab has considerably ex- 
tended over the top, the areola has become faint, and liquid taken from the 
pock is opaline, and somewhat turbid, and has lost much of its viscidity. 
On the thirteenth day, the matter is quite purulent, and, instead of being 
contained in distinct cells, as at first, is all collected in a single small cavity. 
On the fourteenth, the areola has become nearly if not quite invisible, and 
the pock has completely dried into a yellowish-brown scab. This gradually 
hardens, assumes a darker colour, becomes more prominent, and, near the 
end of the third, or during the fourth week, separates from the skin, leaving 
an oval or circular scar, which is at first deep and red, but in the end rises 
nearly to the level of the skin, and becomes white. The surface of the scar 
is characterized by numerous little depressions, probably corresponding with 
the cells of the vesicle. 
From the eighth to the tenth day of the eruption, the constitution ap- 
pears often to sympathize with the local affection, and a moderate febrile 
movement takes place. The glands in the axilla are often also swollen and 
painful. But these symptoms soon subside, without leaving any unpleasant 
effect. 
The course above described is that generally followed by the vaccine dis- 
ease; but it is liable to great diversity. The degree of severity is very dif- 
ferent in different cases. Sometimes the complaint is exceedingly mild, with 
a small vesicle and areola, and without pain in the axilla or fever; in other 
instances, along with considerable fever, the local affection is very severe; 
the areola extending further than usual, sometimes over nearly the whole 
arm, or even beyond it, with much swelling and pain, and assuming almost 
the character of erysipelas; while the axillary glands are much inflamed, 
and sometimes, though very rarely, suppurate. This severity is much more 
frequent in adults than children. The affection is almost always mild in 
infants, when ordinary matter is used. Sometimes the extension of the 
inflammation is ascribable to the too great number of insertions, made at 
such distances as to insure several separate pocks, the areolae of which coa- 
lesce. 
There is great difference also in the relative duration of the different 
stages, and of the whole duration of the complaint. The period of incuba- 
tion, or that which intervenes between the insertion of the matter, and the 
first appearance of the pock, is sometimes greatly lengthened; extending to 
one, two, or three weeks, or even more, instead of two or three days. Occa- 
sionally the matter appears to lie dormant, until excited into action by some 
new cause, as by another insertion; after which the two portions appear to 
act together, and the local affections march on, with equal pace, in the two 
positions. The period of maturation is also sometimes lengthened. In some 
instances, the whole process is shortened, and the affection runs through all 
its regular stages in seven days. 
Various anomalies, moreover, now and then occur in the developement of 
the local and general affection. Thus, it occasionally happens that there is 
no areola, or only a very narrow rim of redness about the base of the pock, 
and more frequently, that the areola is irregular in its form. The efficacy, 
however, of the vaccination does not appear in any degree diminished. Some- 
times, instead of the vesicle, there is nothing but a raw or ulcerated surface 
of the same size, surrounded by the areola. This is said to occur especially 
in scrofulous subjects. I have witnessed several such cases, and, upon sub- 
sequently testing them, have found the system equally protected as by the 374 
GENERAL DISEASES.-FEVERS. 
[part II. 
disease in its ordinary form. Occasionally the vesicle is broken by accident, 
and a suppurating sore produced; and the experiment has been tried of de- 
stroying it in its early stage, by means of nitrate of silver. In either case, 
it is asserted that the protective influence of the disease is not interfered with. 
There is even good reason to believe that a vaccine fever, perfectly protective 
against small-pox or revaccination, sometimes appears about the eighth day 
after vaccination, without any vesicle whatever; though such a case has never 
occurred to me. 
In all the above varieties, the disease may be considered as genuine. But 
sometimes a spurious affection results from vaccination, which affords no 
protection against small-pox. This generally arises from the use of bad 
matter, but it not improbably also results, in some instances, from peculiari- 
ties in the constitution of the patient. There is little difficulty in distin- 
guishing these cases. The inflammation almost always commences earlier 
than the genuine, sometimes almost immediately after the operation. The 
vesicle or pustule which forms is very fragile, breaking easily, and forming 
a soft yellowish crust, which separates upon the fifth or sixth day, sometimes 
leaving an ulcerated surface, which may be obstinate. The pock, in these 
cases, is conical, and somewhat pointed, not cylindrical, and umbilicated. 
The vaccination of those who have previously had the cow-pox, oi' small- 
pox, also gives rise to anomalies, which will be noticed under the head of 
revaccination. 
Anatomical Characters.-When the vaccine vesicle is dissected, upon the 
eighth or ninth day, there may be perceived, according to Gendrin, at the 
umbilicated depression in the centre, beneath a scale of the cuticle, a minute 
portion of pus, the quantity of which is proportionate to the extent of the 
wound made in the operation. When this is removed, the whole vesicle has 
a uniformly shining and silvery appearance, and, upon being opened, is found 
to contain a limpid fluid in small cells, arranged in two concentric rows, and 
formed in a pseudo-rtiembranous product, which has been thrown out between 
the true skin and the epidermis. Gregory states that the number of these 
cells is from ten to fourteen. 
The limpid vaccine fluid which begins to form, on the fourth or fifth day, 
in the cells of the Vesicle, is colourless, very viscid, and inodorous, drying on 
exposure to the air without losing its transparency, adhering to objects upon 
which it may be placed, readily soluble whether liquid or concrete in water, 
and, if excluded from the air, capable of being long kept without change, 
though slowly decomposed upon exposure to the air, especially in warm 
weather. A considerable degree of heat decomposes it quickly, and it is said 
to be rendered inert by extreme cold. On the tenth day of vaccination, the 
liquid is less viscid, somewhat turbid and opalescent; and is said to be mingled 
with some pus. On the thirteenth day, the characteristic lymph appears to 
have been wholly consolidated, and nothing is left but purulent matter, con- 
tained in a single cavity. 
I have, contrary to the usual practice of recent writers, denominated the 
pock a vesicle. It remains vesicular so long as it retains its peculiar cha- 
racter, and until it begins to decline; and the pus that may be present is 
probably not the result of a change in the lymph, but of a distinct action, and 
does not appear to have the property of communicating the disease. 
Susceptibility to the Disease.-This is very different in different persons. 
Some resist the disease altogether, though not previously protected in any 
known manner. However frequently the operation for vaccination may be 
performed on them, no effect is produced. Such cases, however, are very 
rare, and I do not recollect that one has ever occurred to me. It is by no CLASS I.] 
VACCINE DISEASE. 
375 
means uncommon to resist the first insertion of the virus, or even several 
insertions; but generally the individual becomes affected at last. There 
appears to be occasionally a want of susceptibility from some temporary 
cause; and the operation which may have often failed at one time, will, upon 
being repeated at an interval of some weeks or months, readily succeed. Fail- 
ures are often owing to defect in the virus, or imperfect' insertion; but, making 
all due allowance for these, we must admit that the fault sometimes lies in 
the condition or constitution of the person operated on. It is asserted that 
infants, immediately after birth, are less susceptible of the disease than when 
at the age of a month or six weeks. Bayer states that the operation fails 
twice out of three times, in infants three or four days old. It has been sup- 
posed that various other diseases materially affect the susceptibility to the 
vaccine, and modify its character. Dr. Jenner believed that certain eruptive 
diseases might so far modify it, as to interfere with its protective influence. 
M. Taupin, who vaccinated more than two thousand children in the Hopital 
des Enfans at Paris, under every variety of circumstances, and while under 
the influence of all the different diseases to which the inmates of that infirmary 
are liable, observed, that the vaccine disease was in no respect modified by 
diseases unattended with fever, except that the local affection was less active 
in persons of feeble constitution; that it was very slow of developement in 
advanced tuberculous affections, and ran through its several stages also slowly; 
that in typhoid fever, and severe inflammation of the viscera of the chest, the 
developement of the vesicle seldom took place, except in the decline of the 
disease; that a similar influence was not exerted by cerebral inflammation; 
that, in the febrile eruptive diseases, such as scarlatina, measles, roseola, urti- 
caria, and pemphigus, the vaccine complaint was always retarded when the 
operation was performed in their initiatory stage, and, if either of these dis- 
eases supervened upon vaccination, was suspended until that disease had run 
its course, and then resumed its march. (Diet, de Med., xxx. 406.) 
Protective Power.-1The vaccine disease owes all its importance to the pro- 
tection which it yields against the attack of small-pox. Dr. Jenner went so 
far as to express his belief, that it might become the instrument of extirpating 
that loathsome and destructive disease from the earth. This is probably going 
too far; for it is impossible to say that small-pox is not frequently springing 
up anew, independently of contagion; and it is not possible to secure every 
inhabitant of the earth against it. But this far we may go, that vaccination 
affords the best attainable security, greater even than that accruing from a 
previous attack of small-pox; and that, with due care, it will serve as an 
effectual safeguard in individual cases, almost without exception. 
It was formerly supposed that a single successful vaccination would prove, 
for all time, a certain preventive of small-pox; and the result appeared for 
many years to justify the opinion. Thousands upon thousands were tested 
in various ways after vaccination, and the protection so uniformly proved 
effectual, that scarcely a doubt was left upon the mind of the most skeptical. 
The few variolous cases that occurred after vaccination were ascribed to some 
defect in the operation, or some interference with the course of the vaccine 
disease by other morbid processes. But the occurrence of the variolous epi- 
demics which began to make their appearance in Europe in 1818, and in the 
United States in 1823, and in the course of which great numbers of the vac- 
cinated suffered more or less, tended very much to shake the confidence of 
the profession; and there were many who abandoned their faith in the pro- 
tective virtues of cow-pox altogether. It cannot now be denied, that a single 
vaccination does not afford the jpermanent security it was supposed to do. 376 
GENERAL DISEASES.-FEVERS. 
[part II. 
Probably, one-half of those vaccinated successfully are liable to more or less 
effect from the variolous contagion. 
It is chiefly during the epidemic prevalence of variola, that this disposition 
in vaccinated persons to be affected by the disease is observed. It has very 
seldom been noticed to any considerable extent at other times. Another 
interesting fact is, that children of eight years or under are rarely attacked, 
that from this time to the age of puberty cases begin to be more frequent, 
and that the greatest number occurs between the ages of fifteen and twenty- 
five. These two facts it is important to bear in mind. 
But, though vaccination, once performed, very often fails of affording com- 
plete protection against small-pox, yet it almost always modifies it very greatly, 
rendering it a comparatively mild and safe disease. - The modifications thus 
produced have been already treated of under the head of varioloid. It is 
sufficient here to state, that the complaint as it occurs after vaccination is 
very seldom fatal, and, in the vast majority of instances, leaves no unpleasant 
traces behind it. Though the cases of varioloid or secondary small-pox, oc- 
curring after a previous variolous attack, are proportionally less frequent than 
those which follow vaccination, yet they are not only proportionally, but in 
the aggregate, also, more fatal. Thus, of 484 cases of varioloid after vaccina- 
tion, reported by Dr. Thomson, of Edinburgh, only one proved fatal; while 
of 71 of secondary small-pox three died. Of 248 cases of natural and modified 
small-pox noticed by Drs. Bell and Mitchell, of Philadelphia, 64 were after 
vaccination with but one death, and 16 were after inoculated or natural small- 
pox with six deaths. In the course of my practice, though I have seen much 
of the disease, I have lost but one patient after vaccination; and in that 
instance death occurred, not from the violence of the varioloid disease, which 
was mild, but from the supervention of inflammation of the brain, consequent 
on the peculiar state of the patient's constitution at the time. Thus, it ap- 
pears that, if the protection afforded by vaccination is not perfect, it is yet 
superior to any other. 
If one vaccination does not completely protect against varioloid, neither 
does it against the vaccine disease itself. A second vaccination sometimes 
fails entirely; very often produces a modified cow-pox, which bears about the 
same relation to the genuine that varioloid does to variola, and might very 
properly be denominated vaccinoid; and, in a few instances, gives rise to a 
vesicle, which can in no respect be distinguished from the genuine. I think 
I have observed that a second vaccination is most effective in seasons when 
variolous epidemics prevail; and there is a remarkable coincidence between 
the vaccinoid and varioloid affections; so that the inference is perhaps justi- 
fiable, that, when a patient takes the vaccine disease a second time, it might 
be expected that he would be more or less affected by the contagion of small- 
pox, were he exposed to it. In relation to the proportion of those capable of 
receiving the vaccine disease more or less perfectly a second time, the annual 
reports of revaccinations performed in the Prussian army are highly interest- 
ing. About 40,000 soldiers have been annually revaccinated for several 
years; and, from a comparison of all the results, it appears that in about two- 
fifths of the cases " regular pustules" were produced, and in about one-fifth 
more "irregular pustules;" while in the remainder there was no effect what- 
ever. If, by the regulai' pustule, is here meant the vaccine vesicle in its 
legitimate form and course, as before described, these results are very extra- 
ordinary, and far beyond anything seen in this country. If a wider extension 
be given to the word regular, they may not differ greatly from the effects 
observed among us. At all events, a singular relation is here exhibited bo- 
tween the proportion of persons subject to the vaccinoid disease* apd of those CLASS I.] 
VACCINE DISEASE. 
377 
supposed to be liable to the varioloid, which has already been stated at about 
one-half of the vaccinated. 
The question may be reasonably asked, how it happens that the protection 
afforded by vaccination against small-pox is less complete than formerly. Is 
it owing to the wearing out of the influence of vaccination by time? Some 
suppose so; and they support their opinion by appealing to the fact, that chil- 
dren under eight years are seldom attacked. It is inferred, that the preserva- 
tive influence lasts about seven years. But the conclusion is not justified by 
the facts of'the case. In the first place, it does every now and then happen, 
that children under eight years old are attacked. Besides, vast numbers have 
been vaccinated at ages much beyond infancy, and it has not been observed 
that in these, the susceptibility to the disease returns in seven or any other 
given number of years. Besides, if the gradual failure of the vaccine pro- 
tective influence were the law, it ought to be more general. It ought not to 
happen, that about one-half of the vaccinated should be permanently protected, 
as is known to be the case. Finally, if there were such a supposed gradual 
wearing out of the vaccine influence, we ought to find the varioloid more and 
more readily produced, and more and more severe, the further it is removed 
from the period of vaccination, until at length it should be undistinguishable 
from the small-pox. Such is not the case. On the contrary, the suscepti- 
bility to the varioloid appears- to diminish after the twenty-fifth year of life. 
The probability, therefore, is, that the supposed wearing out of the vaccine 
influence is imaginary. The original question then recurs; what can be the 
cause of the insufficiency of protection in certain cases ? It may, I think, be 
explained by recurrence to two of the facts stated some time back; namely, 
the greater tendency to varioloid during the epidemic prevalence of small- 
pox, and its greater frequency between the ages of fifteen and twenty-five 
than at any other period of life. Thus, the security afforded by the vaccine' 
disease or small-pox, occurring in seasons when no epidemic influence exists, 
may be effectual under similar circumstances, but may fail during an epi- 
demic, when other forces are added to that of the contagious cause. Hence 
the occurrence of varioloid abundantly in Philadelphia in 1823, though it 
had been previously unknown, when no epidemic influence existed. That 
persons are most liable to the affection between fifteen and twenty-five would 
seem to show, that the changes which take place about the period of puberty, 
and continue in operation more or less until that of full maturity, which may 
be roughly placed at 25 or 30, are favourable to the developement of vario- 
lous disease; and that a degree of protection which might be sufficient either 
earlier or later in life is insufficient then. 
But, whatever may be the cause, the fact is certain, that vaccination fails 
to afford security against a modified form of small-pox in very many cases; 
and, though the resulting affection may be in general neither fatal nor deform- 
ing, yet it is inconvenient, may become the source of a further Spreading of 
the disease, and in some cases is very dangerous. It is important to find a 
remedy for these evils; and happily such a remedy is afforded in revac- 
cination. 
It is an important question, how far vaccination, performed after exposure 
to the cause of small-pox, is capable of preventing its occurrence, or modify- 
ing its course. So far as my observation has gone, and I believe the same 
result has been obtained by others, if the vaccine virus be inserted so early 
after exposure that the vesicle shall appear before the variolous fever has 
occurred, the small-pox will either be prevented altogether, or will be so far 
modified as to be harmless. Two cases which happened to me will illustrate 
this point. An infant at the breast of its mother, who was covered over with 378 
GENERAL DISEASES.-FEVERS. 
[part II. 
variolous eruption, was vaccinated before any appearance of the small-pox had 
been presented. The vaccine disease pursued its regular course, and reached 
its height on the ninth or tenth day; about which time some fever was ob- 
served, followed by a few abortive variolous pustules, which soon dried up 
without maturing, or producing any untoward symptoms whatever. A stu- 
dent of medicine, who had been exposed to variolous contagion, was vacci- 
nated successfully, and just as the vaccine vesicle approached maturity, was 
attacked with fever followed by a moderate eruption, which dried up about 
the fifth day. The inference is, that vaccination should always be resorted 
to as soon as possible after exposure, provided the small-pox has not already 
commenced. It has even been asserted that, if vaccine virus be freely intro- 
duced into the variolous eruption when it first shows itself, the latter will 
become abortive; but experiments have not confirmed this statement. 
Effects upon other Diseases.-The vaccine disease has been thought to have 
the power of modifying other diseases favourably, and even of superseding 
them. It certainly appears occasionally to set aside obstinate cutaneous 
eruptions. It is said to have cured various chronic inflammations, such as 
ophthalmia, otitis, and bronchitis. In hooping cough, it was at one time sup- 
posed to act as a remedy; but faith in its influence over this disease has been 
lost. It has been employed to destroy certain erectile tumours, through the 
inflammation produced by the insertion of the virus; and my preceptor, the 
late Dr. Parrish, once employed it, with some apparent effect, in order to 
induce an external direction to scrofula, by inserting the lymph abundantly 
in the vicinity of the cervical glands. The prejudice has prevailed, to a con- 
siderable extent, that it is apt to leave a disposition to cutaneous eruptions 
behind it. The fact appears to be, that a lichenous, roseolous, or eczematous 
eruption sometimes attends the maturation of the vesicle; but this is tempo- 
rary; and the eruptions that occasionally take place afterwards are probably 
those which are incident to childhood, and have only an accidental relation 
with the vaccine disease. 
Vaccination. 
I shall treat of this, first, in relation to those upon whom, and the time 
when, it should be practised; secondly, in relation to the matter to be em- 
ployed; and thirdly, in relation to the mode of performing the operation. 
1. Persons to be vaccinated.-As new-born infants are comparatively insus- 
ceptible of the disease, in consequence probably of the undeveloped state of 
their skin, the operation should generally be deferred till the sixth week or 
later. The third or fourth month is perhaps a still better period. It is best, 
under ordinary circumstances, to vaccinate only those in good health. Yet, 
in cases of urgency, as, for example, during the prevalence of a variolous 
epidemic, and especially when the individual has been exposed, or is likely 
to be exposed to the contagion, these precautions may be neglected, and the 
operation performed at once. It is easily repeated afterwards, should the 
vaccine disease not prove satisfactory. No particular preparation is in general 
required. In adult cases, however, when a plethoric or inflammatory condi- 
tion of system is obvious, it may be proper to give the patient a saline 
cathartic, and to put him upon a reduced diet, after the insertion of the virus. 
It is said that the operation is more apt to fail in extremely hot, or extremely 
cold, than in moderate weather. It should be performed preferably in spring 
or autumn, other things being equal. 
2. Matter employed.-The lymph taken from the vesicle on the fourth or 
fifth day, is said to be most efficient; but it retains its virtues, little impaired, 
till the eighth or ninth day. After this period it deteriorates, and, if taken CLASS I.] 
VACCINATION. 
379 
on the eleventh day, or later, is said seldom to succeed. Infantile virus is 
asserted to be stronger than that of adults. When several are vaccinated 
from the same vesicle, those are most apt to receive the disease who come 
first in order. 
The scab is certainly efficacious, and in this country is almost exclusively 
employed. It is, perhaps, rather less certain than lymph directly from the 
vesicle; but this is often difficult to be procured, and the scab keeps better 
than the dried virus, in any other shape. I have used it from the commence- 
ment of my practice, and remember only two instances in unprotected persons, 
in which I did nob sooner or later succeed with it. The scab retains its 
virtues for months, if preserved in a cold place; and, if at the same time 
excluded from the air, often continues efficacious for a year or more. It 
should not be carried long in the pocket, nor kept in a warm room, as it is 
readily decomposed by heat. When it is important to preserve it long, the 
scab should be thoroughly dried, then wrapped closely in tin foil, and well 
coated with wax. It should be umbilicated, of a reddish-brown or garnet 
colour, translucent, and brittle when dry. The advice has been given to 
reject a thin scale formed by the drying of the pus, in the middle of the scab. 
In Europe, much prejudice appears to exist against the use of the scab, which 
is certainly the most convenient form in which the matter can be kept, and 
has been found to answer every desirable purpose. In those few cases in 
which it fails, -recourse may be had to the lymph directly from the arm. 
Various means of preserving the lymph have been resorted to. Sometimes 
it is placed, in the liquid state, between two smooth pieces of glass, where it 
hardens. Sometimes it is introduced into fine tubes of glass, which are then 
hermetically sealed. Again, threads are moistened with it, then dried, and 
kept in close tubes. It is also occasionally collected on the points of lancets, 
where it is allowed to harden. 
In selecting matter, that should be preferred which comes from a healthy 
individual. Nevertheless, repeated trials appear to show, that the character 
of the virus is not affected by any co-existing disease. The following is 
given as the result of the experience of M. Taupin, who has had extraordi- 
nary opportunities for ascertaining the truth. " The matter taken from chil- 
dren affected with acute or chronic diseases, with essential fevers, typhoid 
affections, eruptive fevers, thoracic, abdominal, and cerebral inflammations, 
the neuroses, such as chorea, hysteria, epilepsy, &c., vras as energetic as if 
drawn from healthy children, gave rise to as copious and regular a vaccine 
disease, was as efficacious against small-pox, and transmitted no disease what- 
ever, whether acute or chronic, contagious or non-contagious." (Diet. de 
Med., xxx. 414.) A singular fact, also stated by M. Taupin, is, that he had 
on several occasions employed virus taken from children after death, but had 
uniformly failed, though the same cases were afterwards successfully vac- 
cinated. (Ibidd) A mixture of the vaccine and variolous poisons is said 
sometimes to produce only one disease, sometimes both, which afterwards run 
distinct courses. 
The notion has been widely prevalent, that the vaccine matter has become 
deteriorated by frequently passing through the human subject. I believe, 
however, that there is no ground for this opinion. It is true that matter 
derived immediately from the cow is more powerful, and generally produces 
more inflammation; but there is no proof whatever, that its preventive influ- 
ence is in any degree the greater on this account. It is said that this greater 
power is speedily lost by the passage of the virus through a few successive 
individuals. I have been in the habit of vaccinating, and of witnessing vac- 
cination, for more than thirty years; and, within my remembrance, there has 380 
GENERAL DISEASES.-FEVERS. 
[PART II. 
certainly been no material change in the appearance of the local affection, as 
we ordinarily perceive it, or in the constitutional symptoms. If the virus 
has deteriorated, those recently vaccinated should be affected with varioloid 
more frequently and severely than those long vaccinated, which is certainly 
not the case. In consequence of the notion just combatted, recourse has 
occasionally been had to the cow afresh; but I believe unnecessarily; and if 
Jenner's opinion is true, that there are several diseases to which the cow is 
subject, which may be mistaken for the genuine, there may be some danger 
of evil consequences. A few years since, a kind of matter was brought from 
Europe to this country, said to be extraordinarily efficacious. It produced, 
however, such violent inflammation, and such extensive sores, that physicians 
became alarmed, and I believe generally abandoned it. There is every reason 
to believe that such matter is less efficient, as a protective agent, than that 
ordinarily used. 
There would be some hazard, in the present state of our knowledge, in 
employing the virus which has been converted from variolous to vaccine by 
passing through the cow. It was stated, in most of the memoirs presented 
to the French Academy for their prize, that the disease produced in the cow 
by vaccination with ordinary vaccine matter from the human subject, is of the 
same mild character as in man, and that the virus undergoes no change. 
Others, however, came to a different conclusion; and the fact, that the matter 
is rendered more powerful by passing through the cow, is inferrible from 
thousands of experiments made in Bavaria, by direction of the government. 
(Watson's Lectures, 2d Am. ed., p. 1011.) 
The Operation.-The most convenient place for the insertion of the virus 
is the back of the forearm, about half way between the hand and elbow. The 
vesicle is in this situation least likely to be interfered with in nursing, or to 
be injured by tightness of the sleeves. In females, however, it is customary 
to vaccinate on the outer part of the arm, near the insertion of the deltoid; 
the object being to avoid an unsightly scar, in a part of the arm likely to be 
exposed. 
The plan of operation which I learned from my predecessors, and have 
uniformly pursued, is first to reduce the matter, if solid, to the consistence of 
pus, with water, upon a piece of glass; then, taking a little upon the point 
of a lancet, and holding the arm in the left hand so as to render the skin 
somewhat tense, to make three slight punctures obliquely under the cuticle, 
and gradually to work in the matter, till none is left on the lancet, or the 
surface of the skin. The punctures should be about a line apart, and at the 
three angles of an equilateral triangle. This number generally insures success, 
one taking, if the others fail; while, even if all are effective, only one pock 
results. Care should be taken not to draw much blood, as it is apt to wash 
out the virus. It is sufficient that a tinge of blood should be seen in the 
punctures. I have generally preferred a lancet not very sharp, as we are thus 
enabled to penetrate some distance under the cuticle, without causing the flow 
of blood. 
Various other modes of operating have been recommended. I shall refer 
only to one in considerable vogue, which consists in making several minute 
superficial incisions, crossing each other, with a very sharp lancet, and then 
applying the matter to the wounded surface. 
It has been recommended, when the skin is hard, to soften it with an 
emollient poultice before operating; and, when pale and inactive, to excite it 
by friction. These measures may be resorted to in cases of failure. 
If not successful at first, the operator should make repeated trials, and, 
failing with matter from the crust, should have recourse directly to the CLASS I.] 
REVACCINATION. 
381 
vesicle. Sometimes he will succeed by postponing the second operation for 
some weeks or months. 
Should doubt from any cause exist as to the genuineness of the disease, a 
good plan of testing it is to introduce a portion of virus into the other arm 
about the fourth or fifth day. If the disease is genuine, the new vesicle 
formed will correspond in its course with the original, and arrive at its height 
at the same time, though it will usually be smaller. If the second vaccina- 
tion is performed aftei' the sixth day, it is asserted that it fails altogether, 
because the system becomes by this time protected against a new impression, 
whether from vaccine or variolous matter. Should the test just mentioned 
fail, or not be resorted to, revaccination should be employed immediately, in 
all doubtful cases. 
Treatment.-In general little or nothing is required. Should the fever 
be high, and the local inflammation considerable, a saline cathartic may be 
given, the patient placed upon a vegetable diet, and cold water or lead-water 
applied to the arm. Cases sometimes occur, in which the loss of a little blood 
from the arm is advisable; but they are rare. Great care should be taken, 
in the progress of the disease, that the vesicle is not broken, or otherwise 
injured. 
Revaccination. 
This operation should be employed in every case which has not been tested 
by exposure to small-pox contagion, during an epidemic prevalence of the 
disease. The following are the reasons for this advice. 1. There can be no 
certainty that an individual, only once vaccinated, may not have an attack of 
modified small-pox on exposure; and, though the attack will probably be 
moderate, no one can predict, with confidence, that it may not be severe and 
even dangerous; and, at all events, it will be worse than a revaccination. 
2. Abundant experience has shown that a second vaccination, properly timed, 
is capable of supplying any deficiency of protection left by the first, in the vast 
majority of cases. I have been in the habit of revaccinating for twenty-three 
years; and, during that time, have seen no decided case of varioloid in any 
one that I have revaccinated, unless the patient had been exposed to the con- 
tagion of small-pox, and received it in his system before the operation. Even 
in such cases, the varioloid has been developed in but a very small proportion 
of them, and in these very mildly. A few instances of the efficacy of the 
plan, selected out of a great number, may tend to enforce the precept. In 
1823, a patient, the father of a large family, fell ill of secondary small-pox, 
and died. The house was full of persons of various ages, children and adults. 
They were all revaccinated, and not one had any symptom of small-pox. But 
in a family next door, in whom the operation was not performed, several were 
attacked with varioloid. About the same time, all the inmates of the insti- 
tution for the deaf and dumb in this city, amounting to about seventy, were 
revaccinated; and, though an epidemic small-pox was raging at the time 
around them, only two or three mild cases of eruption occurred, which might 
well have been owing to previous exposure. In the winter of 1845-6, a 
student of medicine died of confluent small-pox in a boarding house, contain- 
ing about thirty inmates. All of these were revaccinated, except three young 
men who had confidence in their security. Those who were revaccinated 
escaped; while the three persons alluded to were, as I was informed, affected 
with varioloid. The experiments made with revaccination in Germany have 
been so successful as to lead to its very extensive adoption. Of nearly 45,000 
soldiers revaccinated in 1841, in Prussia, only eight were attacked with vario- 
loid. " Before the order for revaccination was issued, the different barracks 382 
GENERAL DISEASES.-FEVERS. 
[PART II. 
used to be a prey to varioloid disease; it lias now, however, disappeared.'' 
(See Am. Journ. of Med.- Sci., vi. 248.) What possible reason then can 
there be for not employing revaccination universally? It can do no harm, 
and may secure from a loathsome, if not dangerous disease.* 
Some cautions, however, may be useful. As an increased susceptibility 
seems to be acquired after the eighth year of life, and especially about and 
subsequent to the age of puberty, it will be proper not to revaccinate, unless 
to ward oif immediate danger, until the fourteenth or fifteenth year. Con- 
sidering, moreover, that the varioloid is much more apt to occur during vario- 
lous epidemics than at other times, it will always be advisable to seize these 
occasions for revaccination. The efficacy of the resulting vaccinoid disease 
will very probably be greater, when the influence of the epidemic thus co- 
operates with that of contagion. It seems rational to suppose, that vaccina- 
tion also, at these seasons, would yield a more complete protection than when 
not aided by this additional influence. This, however, is a point for expe- 
rience to determine. 
It may be asked, whether vaccination should be employed in persons pre- 
viously affected with small-pox. I should unhesitatingly answer this ques- 
tion in the affirmative. It has been before stated that, though fewer persons 
are attacked with varioloid after inoculation or natural small-pox, than after 
vaccination, yet a greater number perish. The same protection that a second 
vaccination extends in one case, will probably be extended in the other, and 
is even more needed, at least so far as life is concerned. In a family of 
which all the younger members were revaccinated, and thus secured, the 
mother, believing herself safe, in consequence of having had a smart attack 
of inoculated small-pox in infancy, declined the operation. She was after- 
wards attacked pretty severely with varioloid, while all the rest of the family 
escaped. It is generally stated in the books, that vaccination after small-pox 
produces little or no effect. My own observation has been exactly the re- 
verse. I have very often noticed that the local affection closely resembled 
genuine cow-pox, both in its form and the succession of its stages, though 
there has generally been something which evinced a slight modification. Not 
unfrequently, the inflammation is much beyond the normal amount. I re- 
cently vaccinated a lady who had been inoculated in youth. The vesicle ran 
through its regular stages; but the arm was much inflamed and swollen, and 
the curious phenomenon was presented of a succession of circular areolae 
between the vesicle and the shoulder. 
The effects of revaccination are exceedingly various. Sometimes no in- 
flammation whatever is produced, except the slight degree of it resulting from 
the puncture. Such cases, however, are comparatively few. In relation to 
them, there is always some uncertainty, whether the matter has been pro- 
perly introduced, or was sufficiently active; and I should not so confidently 
rely upon the security of the revaccination, as if sufficient local disease had 
resulted, to prove that the operation was not a failure. In other instances, 
* Two cases of death after revaccination are noticed in the New York Journal of Medi- 
cine for November, 1848, p. 372; one, reported by Dr. Greig, in the North- Western Med. 
and Surg. Journal, of a person aged eighteen, who died eight days after vaccination, of 
inflammation and mortification of the arm; and the other, by the Editor of the Ohio 
Med. and Surg. Journal, of a child who died with convulsions, twenty-four hours after 
the insertion into its arm, by the mother, of thick yellow matter from a vaccine pock. 
Another child of the same parents, vaccinated at the same time from the same matter, 
was very ill, but recovered. The probability is that, in the first fatal case, the result 
was owing to some vice of constitution, and might have ensued from a common wound; 
and, in the second, a poisonous matter was introduced instead of the genuine vaccine 
virus. Neither case offers any argument against vaccination. (Note to second edition.') CLASS I.] 
CHICKEN-POX, OR VARICELLA. 
383 
a local impression is produced, but the resulting pock is quite spurious. On 
the day of the operation, or the following day, the patient feels an itching 
at the puncture, and a little irregular tumour is rapidly formed, which is 
sometimes tubercular, sometimes pustular or vesicular, but generally declines, 
and begins to dry, upon the fifth day, if not sooner. Sometimes these 
tumours are attended with considerable inflammation of the skin. In other 
cases, again, and these are numerous, there is a more or less near approach 
to the genuine disease; the vesicle being umbilicated, surrounded by an 
irregular and sometimes greatly swollen and painful areola, apd often run- 
ning on to the ninth or tenth day. Occasionally there is a good deal of 
constitutional disturbance, with fever, headache, pain in the axillary glands, 
&c. The matter from one of these vesicles will produce the genuine vac- 
cine disease in those not previously vaccinated, showing a strong analogy to 
the varioloid, the contagion of which causes small-pox in the unprotected. 
Yet there is almost always something in the secondary vaccine disease, 
which distinguishes it from the primary, to the eye of a person accustomed 
to both. 
In concluding the subject, I would again strongly urge the propriety of 
universal revaccination, as the means not only of promoting the comfort and 
possibly of saving the life of the individual, but also of preventing the spread 
of small-pox, and of ultimately eradicating it, if not from the globe, at least 
from extensive communities. 
Article IX. 
CHICKEN-POX, or VARICELLA. 
Syn.-Crystal li. 
This is a contagious eruptive disease, in which a slight fever, of short 
duration, is followed by vesicles which begin to dry on the fourth or fifth day. 
Symptoms, Course, &c.-The febrile symptoms usually appear without 
any observable chill, though in some instances they are ushered in by slight 
rigors. Along with the heat of skin, there is often headache, and occasionally 
vomiting. Not infrequently the fever is so slight as almost to escape notice, 
and sometimes it is quite wanting. It continues from a few hours to one or 
at most two days, and goes off with the occurrence of the eruption. This 
shows itself usually first upon the breast, shoulders, and back, whence it 
spreads to the scalp, face, and extremities. The face is less affected relatively 
than in small-pox. The pocks are sometimes numerous, though usually few, 
and almost always quite distinct. They first appear as small bright red spots, 
which quickly become vesicular, and sometimes they seem to break out in 
that form. The eruption is not infrequently attended with itching or ting- 
ling, which causes the child to scratch and rub the vesicles, and thus to break 
them, when they often appear as small formless red splotches. The unbroken 
vesicles are generally from the eighth to the sixth of an inch in diameter, 
occasionally somewhat larger, rounded at top, transparent, colourless or slightly 
yellow, and very delicate, so that they are easily ruptured. Sometimes they 
occur in successive crops for two or three days, and consequently appear in 
different stages of advancement. As they mature, they become a little yel- 
lowish, and somewhat opaque, so as, when at their height, on the fourth or 
fifth day, to have a pearly aspect. At this time they begin to shrink and 
dry; and, on the sixth day, small brown crusts appear, which gradually 
harden, and fall off on the ninth or tenth day, leaving the surface slightly 384 
GENERAL DISEASES.-FEVERS. 
[PART II. 
discoloured, but not depressed. The last crop is sometimes a day or two later 
than the first in reaching maturity, and separating. If much irritated, as by 
scratching or rubbing, the vesicles sometimes become pustular, and then occa- 
sionally leave pits. In certain rare cases of what seems to be varicella, um- 
bilicated vesicles appear mingled with the others, and sometimes leave behind 
them small, round, deep pits. I have considered such cases, when I have 
met with them, as varicella rather than varioloid, because no small-pox existed 
to which they could be traced. The conoidal and globular varieties, of 
Bateman's synopsis, are probably examples of varioloid. 
Cause.-1The only known cause of chicken-pox is a peculiar contagion, 
unless we admit that it sometimes originates in an epidemic influence. The 
contagion is not powerful; and it is doubtful whether the disease can be 
communicated by inoculation. It is certain that repeated attempts to propa- 
gate it in this way have failed; and the cases in which success is asserted to 
have been met with, may very possibly have been varioloid disease, which 
has often been confounded with chicken-pox. One attack protects the system 
against a second. The disease sometimes occurs epidemically; but whether 
independently of contagion is unknown. It is confined almost exclusively to 
children, though not entirely so. Cases have been observed in persons of 
middle age. 
Varicella was for a long time confounded with variola; but the distinction, 
when pointed out by Heberden and others, was generally recognized. Dr. 
John Thomson, of Edinburgh, revived the idea of their identity, considering 
them as different modifications of the same disease, and succeeded in creating 
doubts in many. But the following considerations are, I think, conclusive 
against that opinion. Chicken-pox often occurs in neighbourhoods where 
there is no small-pox; and epidemics of the former disease sometimes occur, 
without a case of the latter. It does not give rise to small-pox in the unpro- 
tected, but always to an affection having the same symptoms as the original 
disease. It occurs with identical characters, and with equal facility, in the 
vaccinated and unvaccinated, in those who have had and those who have not 
had small-pox; nor does it afford it the least protection against small-pox, or 
vaccination. The whole course of its symptoms is different from that of 
variola. The pock is essentially different from the variolous. It is a super- 
ficial vesicle, situated between the true skin and epidermis, without any 
pseudo-membranous product, and without any deep-seated disease of the 
corium. 
Diagnosis.-1The only affection with which varicella can be confounded is 
varioloid, in some of its varieties. Indeed, I have occasionally met with 
cases during the prevalence of small-pox, in relation to which it was impos- 
sible to decide, with certainty, whether they were variolous or varicellous. 
But generally, the distinction between modified small-pox and chicken-pox is 
sufficiently obvious. In the former, the fever is more severe and longer con- 
tinued. The eruption is much later in assuming the vesicular character, is 
often umbilicated, and often more or less pustular. There is, moreover, a 
greater elevation and hardening of the surface in the pimple, and at the base 
of the vesicle, which is much firmer than that of varicella. 
Treatment.-The disease is never dangerous, and almost always so mild as 
to be quite insignificant. Its chief importance, in fact, consists in the possi- 
bility of occasionally confounding it with varioloid. Little treatment is 
required. In the severer forms of it, a dose of magnesia or a saline laxative, 
cooling drinks, and an antiphlogistic regimen may be prescribed; and it is 
advisable, after the falling of the scabs, to immerse the child in a warm bath. 
So slight is the affection, that it is scarcely ever worth while to use any pre- 
cautions against its propagation. CLASS I.] 
MEASLES. 
385 
Article X. 
MEASLES, or RUBEOLA. 
This is a contagious febrile disease, characterized by catarrhal symptoms, 
and the occurrence of a rash upon the skin about the fourth day, without the 
disagpearance of the fever. There is no certainty that it was known to the 
ancients. The first accurate accounts of it are contained in the Arabian wri- 
ters. Rhazes described it under a distinct name in the ninth century. It 
was, however, long and strangely confounded with small-pox by the earlier 
modern physicians. 
Symptoms, Course, &c.-The disease often commences with feelings of las- 
situde, chilliness, aching in the limbs, &c., followed by frequent pulse, heat 
and dryness of skin, loss of appetite, furred tongue, occasionally headache, 
and all the other phenomena characteristic of fever. But, along with these 
phenomena, and not unfrequently antecedent to them, are the symptoms of 
irritation of- the mucous membrane of the eyes, nostrils, fauces, larynx, &c., 
such as profuse discharge of tears and suffusion of the eyes, sneezing and 
coryza, slight soreness of throat, roughness or huskiness of the voice, a dry, 
hard, and hoarse cough, and sometimes tightness of the chest and dyspnoea. 
In some instances there is epistaxis, and in some, epigastric pains, nausea, and 
vomiting. The bowels are usually constipated, but sometimes the reverse. 
In young children convulsions are not unfrequent, especially during the period 
of teething. There is every possible grade in the violence of this early stage. 
Occasionally it exhibits nothing more than the ordinary symptoms of moderate 
catarrh, with little or no observable fever; while in other cases the febrile 
action runs very high, and evidences of severe bronchial or pulmonary disease 
are presented. The symptoms generally increase i^ severity for two or three 
days, then occasionally remit, to return with undiminished if not increased 
force, upon the breaking out of the rash. If the fauces be examined a little 
before this event, the soft palate and uvula will often be observed to have a 
punctuated redness. The eruption generally begins to appear upon the fourth 
day or at the end of it; though sometimes it -considerably anticipates this 
period, and sometimes is postponed even to a week or ten days from the com- 
mencement. 
The rash occurs at first in small, red, distinct spots, like fleabites, which 
disappear under pressure. These show themselves first in the face and neck, 
then upon the trunk, and finally upon the limbs; and there is often an interval 
of two days between the occurrence of the eruption upon the forehead, cheek, 
chin, &c., and its completion in the lower extremities. The rash very quickly 
loses its isolated character, and becomes more or less confluent; arranging 
itself in irregular clusters, which are often somewhat crescentic, and almost 
always leave intervening spaces of the skin little if at all affected. It feels 
slightly rough under the fingers, and, though red, has a somewhat darkish 
tint. There is, however, great diversity in this respect, the rash being brighter 
when the fever is high, and usually somewhat more so on the face than else- 
where, probably on account of its great vascularity. In some cases, a more 
prominent or papular eruption mingles with the rash, in others, minute vesi- 
cles are here and there observable. The amount of eruption varies greatly, 
from a few isolated spots, which are all that show themselves in some cases, 
to an almost uniform redness which is observable in others. Occasionally, 
Syn.-Morbilli. 386 
GENERAL DISEASES.-FEVERS. 
[part II. 
instead of commencing in the face, it attacks first some other portion of the 
surface, especially if previously irritated or inflamed. In some cases, it does 
not spread, but confines itself to the circumscribed space in which it first ap- 
peared. When at its height, which is usually upon the second or third day 
of the eruption, it is frequently attended with a troublesome itching and heat 
of skin. In the fauces, the original punctuated redness now often clusters in 
irregular patches as on the skin; and red points are often seen projecting 
above the fur on the topgue. 
Neither the catarrhal symptoms, nor the fever, decline on the appearance 
of the eruption. Sometimes, indeed, they seem to be increased. The eyes 
are now frequently red, and the eyelids swollen, as well as, in a greater or less 
degree, the whole face. But if nausea and ■ vomiting, irregular abdominal 
pains, convulsions, or other signs of nervous disorder have occurred, they 
often cease when the rash is fairly out. The cough, though still hoarse, now 
becomes more loose, and a transparent mucus is expectorated. 
About the eighth day of the disease, or the fourth of the eruption, the 
rash, fever, and catarrhal symptoms begin to decline together. The decline 
commences in the face, where the redness is often much faded, while it is still 
bright upon the limbs. In some cases, however, the whole duration of the 
eruption does not exceed a day or two, and in others is prolonged to a week 
or more. The red colour gradually gives way to a dirty somewhat yellowish 
hue; and the cuticle separates in fine furfuraceous scales. But the desqua- 
mation is not uniform, being sometimes visible on the face or breast exclu- 
sively, sometimes limited only by the extent of the eruption, and, in other 
instances, wholly wanting. It may continue four or five days before it is 
completed, and is apt to be attended with itching. 
As the fever and eruption decline, the expectorated matter becomes thicker 
and more opaque; and considerable stress has been laid upon the appearance, 
which it sometimes assumes, of distinct greenish-yellow pellets, floating, in a 
flattened form, upon an abundance of glairy mucus, and which is considered 
as somewhat diagnostic. 
Occasionally, the pectoral symptoms, instead of diminishing at this stage, 
which is the regular course, continue and even become aggravated; and aus- 
cultation reveals all the signs of an extensive bronchitis, or of circumscribed 
pneumonia. This is the greatest danger of measles. Instead of bronchial or 
pulmonary inflammation, a diarrhoea not unfrequently sets in, which, when 
moderate, may be considered favourable; but is sometimes obstinate and 
troublesome. 
Diversities.-Measles offer numerous diversities besides those already men- 
tioned. The following are most worthy of notice. 
1. Owing to internal irritations in different parts, as the stomach, bowels, 
brain, &C-, the eruption is sometimes greatly delayed. Excessive purgation 
is thought occasionally to have the same effect; as also is anything which 
greatly debilitates the system, such as copious bleeding, some previous vice 
of constitution, or a malignant action of the cause. Under all these circum- 
stances, there is occasion for solicitude, and the occurrence of the eruption is 
sought for, either as in itself favourable, or at least of favourable augury. 
The same causes which retard the eruption may cause it to retrocede after 
having appeared; and a similar effect is ascribed occasionally to the influence 
of cold. The retrocession is apt to be followed by pains in-the bowels, diar- 
rhoea, dyspnoea, coma, convulsions, &e., indicating internal irritations, or by 
the signs of great prostration. Sometimes the rash returns again spontane- 
ously, with the relief of the alarming symptoms. The retrocession, here CLASS I.] 
MEASLES. 
387 
alluded to, must not be confounded with that early and altogether favourable 
disappearance of the rash, which sometimes occurs in slight cases. 
2. It is thought that a rubeolous fever sometimes occurs without eruption; 
though there may be difficulty in proving the fact. It is certain, that, in the 
midst of measles, in the same family even in which several individuals may 
be affected with the regular disease, cases are occasionally seen resembling it 
precisely in symptoms, course, and duration, with the single exception of the 
rash. The inference is at least plausible, that the affections have their origin 
in the same specific cause. 
3. Another affection, occasionally seen during rubeolous' epidemics, is an 
eruption having the characters and course of that of genuine measles, but 
without fever and catarrhal symptoms. This has been called Rubeola spuria, 
or Rubeola sine catarrho. According to Willan, it has no effect in protecting 
the system against an attack of the true disease. I have repeatedly observed 
such an eruption as the result of certain irritating substances taken into the 
stomach, when measles were not prevalent. May it not have a similar origin 
when occurring during epidemics of that disease? There is another state, 
which I believe is more frequent, and probably has stronger grounds to rank 
with true measles; namely, a fever accompanied by a rubeolous eruption, but 
without catarrh. 
4. Measles occasionally appear of a malignant character. Some cases of 
this kind may be intermingled with ordinary measles, arising from a depraved 
state of the constitution, a strong predisposition to the typhous condition, or 
the accidental conjunction.of some powerfully depressing cause with the spe- 
cific cause of measles. But more frequently they are the result of peculiarity 
in the epidemic influence; and are exceedingly rare in this country. The 
early stage may not materially differ from that of the ordinary disease, unless 
in a greater frequency and feebleness of pulse, more dyspnoea or epigastric 
oppression, and. a greater tendency to delirium, stupor, or other nervous dis- 
order. But occasionally the prostrating influence of the cause is felt at the 
outset, and only feeble and impeffect signs of reaction are witnessed. The 
eruption is apt to be irregular and partial, appearing and then disappearing; 
and the rash is often of a livid, purplish, or blackish colour, interspersed with 
petechiae, and accompanied with a disposition to passive hemorrhage. The 
abdominal and cerebral symptoms are those of malignant typhus; and affec- 
tions of the chest, when they occur, assume that condition of intense conges- 
tion, with feebleness of inflammatory action, and distressing insufficiency of 
function, which mark the pneumonia of the same disease. When the patient 
survives the immediate danger from syncope, coma, or asphyxia, he is still 
liable to be carried off by the exhausting diarrhoea, or obstinate bronchial dis- 
ease which remains. In consequence of the dark colour of the rash, this 
variety of measles has been called Rubeola nigra or blade, measles, though the 
same name might be appropriated to cases of the disease occurring in con- 
nexion with purpura or scurvy. 
5. Measles are liable to numerous complications. Among these, the most 
frequent and fatal is inflammation of the different organs. Bronchitis and 
pneumonia have been already mentioned. Enteritis with diarrhoea is not 
unfrequent. Ophthalmia is common and sometimes severe. Perhaps the 
most dangerous complication, when it occurs, is pseudo-membranous inflam- 
mation of the larynx. Such cases are almost always fatal; but happily they 
are rare. The same disease existing in the mouth and fauces is sometimes 
seen. Rubeola is sometimes associated with other eruptive affections. Thus, 
it occasionally runs a conjoint course with scarlatina, adding to the danger of 
that disease by directing its pseudo-membranous tendency to the larynx. A 388 
GENERAL DISEASES.-FEVERS. 
[part II. 
fatal case of that kind has occurred to me. It is said sometimes to exist in 
connexion with small-pox; though these affections probably more frequently 
have the effect of temporarily superseding each other, one being checked till 
the other has run its course, and then resuming its own. 
Measles occasionally have the effect of relieving or permanently displacing 
other diseases, especially certain obstinate cutaneous and nervous affections, 
among the latter of which hooping-cough may be particularly mentioned. It 
is, however, much more apt to leave disorders behind it. One of the most 
common of these is chronic inflammation of the- air passages, with hoarseness; 
and I have known a permanent loss of voice to have its origin in this disease. 
Other unpleasant consequences are obstinate inflammation of the eyelids, 
inflammation and suppuration of the ear, swellings of the cervical glands, boils 
in different parts of the body, and chronic diarrhoea. Measles are also well 
known to favour the developement of tubercles and scrofulous swellings in 
persons predisposed to them. 
Anatomical Characters.-When measles prove fatal, it is generally in con- 
sequence of inflammatory disorganization, the signs of which, therefore, will 
be found after death. But there is no peculiarity in these signs. When 
death has resulted from the uncomplicated disease, nothing is found but a 
general congestion of the internal organs, and especially of the mucous mem- 
branes. The blood in the vessels is fluid and blackish; and coagula are not 
found in the cavities of the heart. Andral and Gavarret found the fibrin 
seldom to exceed the* average of health, and generally to fall somewhat short 
of it; while the red corpuscles were in most instances above the normal 
standard. This proves the existence of a febrile, rather than an inflammatory 
character of the affection. 
Causes.-It can scarcely be doubted that there is one specific cause of 
measles; or that this is generated in the bodies of those affected with the 
disease, and is capable of acting upon others through the air. It is, there- 
fore, contagious. Some difference of opinion exists as to the possibility of 
communicating the disease by inoculation. Numerous trials have been made, 
many of which have been apparently successful, while others have failed. It 
is asserted, that the disease has been imparted by inserting into the skin blood 
taken from the eruptive spots, lymph from the small vesicles which sometimes 
exist in the disease, and even the tears and saliva. Though the circumstance, 
that these experiments have generally been made during epidemics, when all 
not protected are liable to disease, may throw some doubt upon the subject; 
yet the cases of asserted success are so numerous and varied, as to make 
the affirmative of the question greatly preponderate in the balance of pro- 
babilities. 
Though capable of being propagated by contagion, measles prevail much 
more at some periods than others; probably under a peculiar epidemic influ- 
ence. Whether this influence is sufficient of itself to produce the disease, or 
whether it merely acts by increasing the susceptibility to the contagious prin- 
ciple, may perhaps be considered uncertain. If the fact, quoted by Bayer, 
from an old author, that the disease was not known in the new world until 
the year 1518, when it was imported from Europe, could be relied on, it 
would go far to prove that epidemic influence is alone insufficient; but the 
testimony can hardly be admitted to have much weight; and the very fre- 
quent occurrence of the disease without any possibility of tracing it to personal 
communication, would lead to the opposite conclusion. Still, there is no 
impossibility in the production, at once by the human body, and by other 
unknown agencies in nature, of the same identical poison, whatever that may CLASS I.] 
MEASLES. 
389 
be. The difficulty would be removed one step, by admitting the vital cha- 
racter of contagions. (See Contagion.} 
Cold weather appears favourable to the production of the disease; as epide- 
mics of it are most frequent in winter. They occur, however, at all seasons. 
No age is exempt from the disease. It attacks the foetus in the womb, and 
old persons in their second childhood. Yet it is much more frequent in chil- 
dren than in adults. One reason of this may be a diminished susceptibility; 
yet a much stronger one is the fact, that most persons have the disease in 
early life, and can have it but once. There is a very general susceptibility to 
measles; and there are very few who are not attacked at one period or another 
of their lives. 
Though, as a general rule, the disease is capable of being taken but once; 
instances have undoubtedly occurred in which the same individual has been 
affected a second time. In this respect, measles.resemble all other contagious 
diseases. 
The period which intervenes between exposure to the cause, and the occur- 
rence of the disease, may be stated in general as about, a week, though it is 
sometimes considerably shorter, and sometimes as long as two or three weeks. 
In the inoculations performed by Home, the disease made its appearance upon 
the sixth day. 
Diagnosis.-In the early stage, measles may be readily mistaken for catar- 
rhal fever, though some writers speak of a hard, dry, loud, and hoarse cough 
by which it may generally be distinguished. There is almost always, how- 
ever, some uncertainty until the eruption appear; and cases in which no erup- 
tion occurs must necessarily be doubtful, especially when the influenza is at 
the time prevalent, or the changes of weather favour catarrhal affections. The 
only diseases liable to be confounded with measles, after the occurrence of the 
eruption, are small-pox, scarlatina, and roseola. In distinct small-pox, the 
subsidence of the fever is a sufficient diagnostic sign. In the confluent, when 
the fever persists, there may be some doubt at the moment of eruption; but 
in measles the rash is less observably prominent and hard under the fingers; 
and the question is very soon decided by the stationary character of the rubeo- 
lous eruption, while the variolous is rapidly becoming vesicular and umbili- 
'cated. The diagnosis between measles and scarlet fever will be given under 
the latter disease. From roseola measles are distinguished by the catarrhal 
symptoms; but measles without catarrh may be easily mistaken for that 
complaint; and, in its turn, roseola accidentally associated with catarrh may 
be mistaken for measles. 
Prognosis.-In ordinary uncomplicated measles, the prognosis is almost 
always favourable. The chief danger is from bronchial and pulmonary 
inflammation, and the danger is probably greater after the disease has begun 
to decline than during its regular course. The occurrence of pseudo-membran- 
ous croup is highly alarming, and very generally fatal. The malignant form 
of measles is also highly dangerous. Occasionally, too, the patient is carried 
off by supervening disease of the bowels, or of the brain. The danger is 
greater in the old than in the young, and in cold than in warm weather; and 
is aggravated by dentition, pregnancy, and the puerperal state. When occur- 
ring in the advanced stages of other diseases, measles are apt to carry off the 
patient. Among the unfavourable signs are unusual severity and continuance 
of the early fever, with postponement of the eruption; a sudden disappearance 
of the rash, in connexion with evidences of internal irritation or great pros- 
tration; severe dyspnoea, and other symptoms of considerable pulmonary 
inflammation; great restlessness,'delirium, or coma; a continuance of fever, 
cough, and dyspnoea, after the regular decline of the eruption; a complete 390 
GENERAL DISEASES.-FEVERS. 
[PART II. 
loss of voice with dyspnoea; and evidences of malignancy, such as a weak pulse, 
a livid colour of the rash, petechias, and passive hemorrhage. 
Treatment.-In the mildest forms of the disease, nothing more is requisite 
than to keep the patient on a low diet, attend to the state of the bowels, and 
prevent exposure to cold and wet. In the management of'measles generally, 
it should be borne in mind, that this disease does not bear exposure of the 
surface to cold as well as either scarlatina or small-pox. The tendency to 
bronchial and pulmonary inflammation renders caution in this respect pecu- 
liarly necessary. But neither should the patient be kept in a hot room, or 
oppressively covered with bedclothes. A good rule is to render the air and 
the covering comfortably warm. Children especially require care; as they are 
apt to be restless, and to throw off their covering. It is important, therefore, 
when the air of the chamber is at all cool, to watch them closely, both night 
and day. 
When the case is sufficiently severe for treatment, the proper remedies are 
saline laxatives; demulcent drinks, such as flaxseed tea, solution of gum 
arabic, infusion of slippery elm, decoctions of the saccharine fruits, &c., to 
which antimonial wine may be added in small quantities; and, when the skin 
is very hot and dry, the neutral mixture or effervescing draught, the patient 
being in this case confined to bed. Should signs of decided bronchitis or 
pneumonia present themselves, or the laryngeal inflammation be at all threat- 
ening, or convulsions with a tendency to stupor occur, blood may in ordinary 
well developed measles be taken with tolerable freedom; as the complaint 
generally bears the loss of it well. But no more should be drawn, during 
the course of the disease, than is necessary to guard against danger from the 
above causes; as excessive bleeding sometimes interferes with the occurrence 
of the eruption, or favours its retrocession if already out. The general bleed- 
ing may be aided by cups or leeches; and these should be preferred to the 
lancet in doubtful cases. In infants, it will seldom be necessary to take blood 
from the arm, when leeches can be commanded. 
Should the symptoms threaten croup, an emetic- of ipecacuanha or tartar 
emetic, followed by a purgative dose of calomel, and afterwards antimonial or 
ipecacuanha wine or syrup of ipecacuanha, in small and frequently repeated 
doses, will generally be sufficient to relieve them; and the same treatment, 
with the exception of the emetic, may be employed when there is oppression 
of the chest from bronchial inflammation. The warm bath and warm foment- 
ations, or emollient cataplasms, are sometimes also of advantage under these 
circumstances. 
Opiates are not generally advisable in the early stage; but, when the cough 
is very troublesome, hyoscyamus may be combined with the expectorants just 
mentioned. 
The eyelids, when inflamed, should be frequently moistened with demul- 
cent liquids, as mucilage of sassafras pith, which may also be used beneficially 
as a collyrium in inflammation of the conjunctiva. 
The same plan should be continued after the appearance of the eruption, 
and until it begins to decline. If at this period the cough should be trouble- 
some, opiates may be used moderately in connexion with expectorant medi- 
cines, such as the antimonials, ipecacuanha, and the syrups of squill and 
seneka. Should a fresh accession of acute bronchitis, or an attack of pneu- 
monia now supervene, they should be met promptly by general or local bleed- 
ing, blistering, and antimonials. The loss of blood is even more effectual in 
subduing inflammation at this stage than during the eruptive fever, and is 
quite as well borne by the patient. If these means fail, recourse should be 
had to the alterative use of calomel with ipecacuanha and opium. CLASS I.] 
MEASLES. 
391 
The retrocession of the eruption, and its retardation, occasionally require 
attention. Unless unpleasant symptoms should exist at the same time, it is 
best to leave the case to nature; but, when evidences of internal irritation or 
inflammation, or of considerable depression, are presented, prompt interference 
becomes necessary; and the object of the practitioner should be to call the 
disease to the surface. Among the most effectual measures for the purpose 
is the hot or vapour bath, which is applicable in almost all cases, whatever 
may be the pathological condition. If it be inconvenient to administer this, 
hot and stimulating pediluvia may be substituted. If the retrocession has 
arisen from exposure to cold, warm drinks should be given in addition, as 
infusion of balm, chamomile, or the dried mints; and, if there be at the same 
time gastrd-intestinal or nervous irritation, without any tendency to stupor, 
and without any considerable bronchial disease, a full dose of Dover's powder 
will be useful. Should decided inflammation of the interior organs accompany 
the retrocession, it may be necessary to take blood from the arm. In certain 
cases, not attended with nausea, an emetic has sometimes answered an excel- 
lent purpose. Should the fault lie in a debilitated state of the system, from 
excessive loss of blood, a typhous tendency, or other cause, it may be neces- 
sary to administer warm wine-whey, and the preparations of ether or ammonia 
internally, while sinapisms, stimulating frictions, and artificial heat are dili- 
gently applied externally. When irritation exists in one of the interior 
organs, a mustard plaster or blister immediately over the organ will be 
advisable. 
The convulsions which occur in, children in the early stage, often require 
nothing more than hot pediluvia, or the warm bath, and sinapisms to the 
limbs; and, indeed, often subside spontaneously without injury; but, when 
they are persistent, often repeated, or followed by stupor, in addition to the 
remedies just mentioned, blood may be taken from the arm or the temples, 
cold applied to the head, and a dose of calomel given internally. An emetic 
dose' of ipecacuanha sometimes proves very useful. Discrimination, however, 
is necessary; and the practitioner should endeavour to ascertain, whether the 
affection may not arise from some source of irritation extraneous to the brain, 
as the bowels for example, or the gums in dentition. In such cases, the 
remedies should be directed to the real seat of disorder. In all cages of this 
kind, bleeding should be employed with a proper caution. In the advanced 
stages of the disease, when convulsions occur, it is oftener probably from 
nervous irritation than cerebral congestion Or inflammation; and the nervous 
stimulants, as assafoetida, camphor, musk, and sometimes even opium, are 
more efficient than depletion; but the practitioner must be guided by the 
symptoms. 
Diarrhoea, if moderate, should not be disturbed; but, if profuse, painful or 
obstinate, it should be checked by means addressed to the existing pathological 
state of the bowels. (See Enteritis and Diarrhoea.') 
Malignant measles must be treated like other typhous diseases, by tonics 
and stimulants, a judicious use of laxatives, and, when attended with inflam- 
mation, by very cautious local depletion, blisters, and calomel with opium. 
(See Typhus Fever.') 
The diet, in ordinary measles, should be strictly antiphlogistic throughout 
the disease. During the existence of considerable fever, it should be chiefly 
in the liquid form. In cases attended with debility, it may be necessary to 
have recourse to milk, and animal, broths. 
During convalescence, care should be taken to guard the patient against 
the cold; and in winter he should not be allowed to leave the house until 392 
GENERAL DISEASES.-EEVERS. 
[part II. 
desquamation has been for several days entirely completed, and the catarrhal 
symptoms have disappeared. 
Attempts have been made to prevent measles, by inducing a mild form of 
disease by means of inoculation. An instance is quoted by MM. Guersant 
and Blache (Diet. de Med., xxvii. p. 684), in which the operation is said to 
have been performed in eleven hundred and twenty-two cases, with liquid 
taken from the patches, or with a tear of the patient, and failed only in seven 
out of every hundred. The resulting disease was mild, and in no case fatal. 
On the seventh day the fever appeared, on the ninth or tenth the eruption, 
on the fourteenth the desquamation, and on the seventeenth the patient was 
quite well. Ordinarily measles are so mild as scarcely to call for this mode 
of protection; but in malignant epidemics of the disease, it might be tried, 
under circumstances of great exposure. 
Article XI. 
SCARLET FEVER, or SCARLATINA. 
This is a contagious febrile disease, characterized by inflammation of the 
fauces, and a scarlet rash, appearing usually on. the second day, and ending 
in desquamation about the sixth or seventh day. 
Scarlet fever was long confounded with measles, and, even when distinctly 
described, appears from the names employed, to have been considered merely 
as a variety of that disease. Ingrassias is said to have been the first to allude 
to it as a peculiar affection, in a work published in 1556. It was afterwards 
noticed by Coyttar of Poictiers, in France, and by Morton in England; but 
Dr. Withering has the credit, among British physicians, of being the first who 
clearly and fully pointed out the differences between the two diseases, and 
established the claims of scarlatina to its present rank. 
Most authors describe three varieties of scarlet fever, the simple, the angi- 
nose, and the malignant, and each of them so precisely, that the student 
might very readily be led into the error of supposing them to be equally 
distinct in nature. But the fact is, that, though cases are not unfrequently 
observed in which the characters of each variety are tolerably well marked, 
yet it very often happens that they are blended together, so that it would be 
quite impossible to determine to which of them a particular case might belong. 
The disease is essentially the same in all its varieties, and produced by the 
same cause; and there is no better reason for distributing it into different 
sections, than for treating in the same manner most other febrile diseases. I 
shall, therefore, first describe it generally, and afterwards refer to its modifi- 
cations. 
Symptoms, Course, &c.-Either with or without the ordinary preliminaries 
of languor, weariness, rigors, and pains in the back and limbs, the fever sets 
in with a frequent pulse, hot dry skin, flushed face, furred tongue, anorexia, 
thirst, and great muscular weakness. Sometimes there are nausea and vomit- 
ing; sometimes also more or less headache, or other symptom of nervous 
disorder, such as restlessness, morbid vigilance, delirium, stupor, coma, or 
convulsions. In relation to the severity of its symptoms, the fever is of 
every possible grade, from a mildness scarcely amounting to disease, up to 
the highest point of violence and danger. 
Along with the fever, sometimes beginning with it, and sometimes a little 
after it, there is almost always more or less irritation or inflammation of. the CLASS I.] 
SCARLET FEVER. 
393 
fauces, which, upon being examined, appear red and not unfrequently swollen. 
The same colour is diffused over the interior of the mouth; and the tongue, 
though coated with a white, or yellowish-white fur, exhibits projecting red 
papillae upon its surface, and is red at the tip and edges. 
The rash makes its appearance, in most in-stances, upon the second day of 
the fever, often, however, earlier or later, and sometimes at the very com- 
mencement, so far as can be determined from the statements of the patient 
or his friends. ' It occurs usually first upon the neck, face, and breast, whence 
it gradually spreads over the trunk and extremities, occupying about twenty- 
four hours in its diffusion. Sometimes its course is the reverse of that stated. 
In the beginning, it is in minute red points, which rapidly coalesce in broad 
patches, and in the course of a few hours generally form a continuous scarlet 
blush over large portions of the surface. But great diversity exists, in dif- 
ferent cases, both in the amount and arrangement of the eruption. Some- 
times it is very scanty, presenting only a few scattered points here and there, 
or some patches of moderate extent; but much more frequently; it covers, in 
a greater or less degree, the whole body; being either uniformly diffused over 
the surface, or exhibiting this uniformity in certain parts, while in others it 
is punctuated or in patches. Thu redness is usually diffused equably over 
the face and neck, and appears with great intensity in the flexures of the 
joints, as in the groins, armpits, and bend of the knees and elbows. In 
certain cases, in the midst of the general blush, points of a deeper redness 
are observable. The colour has been corUpared to that of a boiled lobster; 
but it is usually, I think, of a somewhat darker hue. It disappears under 
pressure, and returns when the pressure is removed. Whatever increases 
the general excitement has a tendency to deepen it. Hence, the colour is 
most intense during the exacerbations of the fever, and is increased when the 
patient cries, or is otherwise agitated. The reddened surface is smooth to 
the finger; the rash being in no degree perceptibly elevated. Sometimes, 
however, it has a rough feel like that of. goose-flesh in certain parts of the 
body, as the limbs and anterior portion of the trunk, in consequence of the 
enlargement of the papillae. The skin itself is often slightly swollen, espe- 
cially in the face, hands, and feet; and the hands are rendered somewhat stiff 
in their movements. Along with the characteristic rash, may not unfre- 
quently be observed, upon the neck, in the arm pit, at the bend of the elbow, 
&c., a crop of small miliary vesicles, which make their appearance at different 
stages of the eruption. Minute pimples and pustules sometimes also mingle 
with it during its decline. The cutaneous affection is attended with a sense 
of burning, itching, or other irritation, which is sometimes very annoying to 
the patient, and interferes with sleep. 
The fever does not abate upon the appearance of the rash, but continues 
with various degrees of violence, throughout its whole progress. The pulse 
is usually very frequent, much more so than in febrile diseases generally of 
the same degree of violence. It is often 120, or 130 in the minute, and 
sometimes still more frequent. Occasionally it has considerable force, but 
this is not its predominant character. The skin is dry and burning hot, and 
the temperature, as indicated by the thermometer, is not unfrequently 105° 
or 106° of Fahrenheit, and is asserted to have reached 112°. The highest 
point, however, observed in the experiments of Andral, and those more re- 
cently made by M. Roger, was 41° Cent., equivalent very nearly to 106° F. 
(Diet, de Med., xviii. 155.) The fever often has exacerbations towards even- 
ing; and is occasionally attended with restlessness or delirium, and sometimes 
with comatose symptoms. The bowels are generally constipated; but some- 394 
GENERAL DISEASES.-FEVERS. 
[part II. 
times diarrhoea occurs in the advanced stage. Occasionally also, there is 
irritability of stomach; but this is not a very frequent symptom. 
The affection of the throat, in some cases, never exceeds that already no- 
ticed as occurring even before the appearance of the eruption. But very 
often it becomes the most prominent and distressing symptom, being attended 
with swelling within and without, painful deglutition, and sometimes impeded 
respiration. This feature of the disease will be more particularly noticed, in 
the description of the anginose variety. 
The disease attains its height usually from the fifth to the ninth day, when, 
in favourable cases, all the symptoms begin to decline. The rash fades, the 
miliary vesicles if present dry up, the heat of skin diminishes, the pulse be- 
comes slower and fuller, the throat affection abates, and the tongue, if it has 
not previously thrown off its fur, does so now, often, however, remaining for 
some time reddish, glossy, and with prominent papillae. Sometimes the 
amendment is accompanied with a profuse perspiration, or a diarrhoea, which 
may be regarded as critical; but they are very often wanting. 
Desquamation generally begins with the decline of the eruption. Some- 
times it is furfuraceous, but frequently the cuticle separates in small scales; 
and, when it is thick, as upon the palms of the hands and soles of the feet, 
it occasionally comes away in large flakes. I have known the whole cuticle 
of the palm and fingers to separate, so as to form a complete mould of the 
inside of the hand. The process of desquamation is often attended with a 
very troublesome itching and irritation, and sometimes with much tenderness 
of the skin. It is usually completed by the end of the second week, though 
sometimes delayed longer, in consequence of a succession of exfoliations. At 
this time, if no untoward complication has occurred, the, patient may be con- 
sidered as well, though not yet exempt from liability to unpleasant and even 
dangerous disease. 
But the course of the complaint is often much less favourable. Brom the 
beginning to the close, it is not free from danger. Death sometimes takes 
place in the first stage, even before reaction, from the overwhelming force of 
the shock upon the nervous system; and, at any subsequent period, the pa- 
tient is liable to the same result from coma or other violent cerebral affection, 
which often leaves no organic trace behind it. Inflammation occasionally 
attacks some vital part, especially one of the serous membranes, with fatal 
effect. Disease of the stomach and bowels sometimes carries off the patient, 
and instances have occurred in which affections of the larynx have been the 
cause of death. The patient may also sink from debility consequent upon 
the malignant character of the affection, the occurrence of gangrene of the 
throat, or the exhausting ■ purulent discharges incident to local affections, 
which are apt to remain after the proper disease has gone. 
Having given this general view of the complaint, I will now invite the 
attention of the reader to its prominent varieties. 
1. Scarlatina Simplex.-This is distinguished by the absence of the throat 
affection. There are only the fever and the fash. Such is the definition of 
scarlatina simplex; but the fact is, that complete exemption from inflamma- 
tion of the fauces is very rare; and a moderate degree of it would not be con- 
sidered as excluding the case from the present category. Redness and some 
degree of soreness in the fauces are scarcely less common than the eruption 
itself. 
• The simple variety of scarlet fever is often very mild. In some cases the 
patient is not even confined to bed. The first sign of disease which attracts 
attention is occasionally a scarlet blush upon the face and neck, which is 
attended with a slight febrile movement, and declines upon the fifth day, or CLASS I.] 
SCARLET FEVER. 
395 
sooner. But in other cases it is much more severe. There is a universal 
diffusion of the rash, which is of an intense redness, the heat of skin and fre- 
quency of pulse are extreme, and not unfrequently a slight delirium occurs, 
especially during the exacerbations of the fever at night. But, unless from 
some intercurrent inflammation, or concealed malignant tendency, or danger- 
ous sequela, there is little risk of life. 
2. Scarlatina Anginosa.-In this variety the affection of the fauces is 
prominent. Stiffness of the jaws, with soreness of throat, and pain in swal- 
lowing are often experienced at the commencement of the attack. The erup- 
tion is usually somewhat later in making its appearance than in the simple 
variety, sometimes occurring on the third instead of the second day. It is 
also, as a general rule, less copious and less diffused. Sometimes it is con- 
fined to a particular part, as the hand and forearm. I have seen it in 
distinct points, very sparsely scattered over the trunk. Not unfrequently it 
is in patches, with intervening portions of the skin of the natural colour. But 
very many instances also occur, in which the rash is nearly or quite general, 
and as intense and uniform as in the simple. Occasionally, after partially 
breaking out, it disappears, perhaps to return again after a longer or shorter 
interval; and this process is sometimes repeated more than once. The fever 
is ordinarily more severe than in scarlatina simplex, with a more frequent 
pulse, and a greater tendency to delirium or stupor. 
The inflammation of the fauces advances with the progress of the disease; 
and not unfrequently the eyes are red and irritated, though not usually 
watery, as in measles. The patient sometimes sneezes, has a dry cough, and 
a guttural voice; and hemorrhage sometimes occurs from the nostrils. Upon 
examination of the fauces, the tonsils, uvula, and soft palate are observed to 
be swollen and of a deep red colour; and patches of a concrete exudation, 
resembling false membrane, are generally seen upon the surface of the tonsils 
at an early period. These patches are of a dirty white, yellowish, or ash 
colour, and are sometimes very extensive, covering the surface of the fauces 
and spreading into the pharynx, as far as it can be seen. They are usually 
soft, so that they may not unfrequently be scraped off with an instrument. 
Formerly, they were thought to be the surfaces of ulcers, or gangrenous por- 
tions of the mucous membrane; but, when removed, they leave the surface 
for the most part merely reddened, and without organic change. Sometimes, 
however, they really do cover ulcerated or eroded surfaces, and may even be 
gangrenous. Occasionally they extend into the larynx, producing the symp- 
toms of pseudo-membranous croup; but this event is very rare. They often 
impart a very offensive odour to the breath. Along with this interior disease, 
there is almost always more or less swelling of the external parts, in the region 
of the parotid and submaxillary gland; and sometimes the tumefaction is very 
great. It has been supposed that the parotid is the seat of the inflammation; 
and this may sometimes be the case; but more frequently it is in the neigh- 
bouring cellular tissue, or the lymphatic glands. The external swelling is 
hard and painful, and sometimes prevents the patient from opening his mouth 
so far as to permit an inspection of the fauces. Deglutition is difficult and 
painful; and, when attempts are made to swallow liquids, they occasionally 
return through the nostrils. Sometimes the internal parts are so much 
swollen as to interfere with respiration. The patient is very much troubled 
with a viscid mucus, secreted in the fauces, which he cannot well swallow, 
and finds it difficult to discharge from the mouth. The lips are often cracked, 
invested here and there with crusts, and painful when parted. Not unfre- 
quently the mucous membrane of the nostrils partakes of the disease; the 
nasal passages are closed by the consequent swelling, and the crusts which 396 
GENERAL DISEASES.-FEVERS. 
[part II. 
form upon their surface; and the patient is compelled to breathe exclusively 
through the mouth, producing dryness of the tongue and lips. At a more 
advanced stage, a yellow and exceedingly offensive liquid is occasionally dis- 
charged from the nostrils, which is sometimes very acrid, and excoriates the 
orifices. A similar secretion from the fauces is swallowed, and probably con- 
duces to the production of the irritation of stomach and diarrhoea, which are 
occasional features of the disease towards its close. The discharges from the 
bowels are also sometimes acrid,, so as to excoriate the anus. The tongue is 
apt to lose its fur at an early period, becoming deep red, smooth and glossy, 
or somewhat rough, with projecting and enlarged papillae. The incrustations 
upon the fauces spontaneously separate, or undergo a gradual absorption; and 
the surface is left red, and sometimes, though not generally, excavated. The 
fading of the eruption begins a little later than in the simple form; and the 
fever and sore throat often continue, in some degree, for a few days after' the 
commencement of desquamation. Sometimes, indeed, when there has been 
much swelling about the neck, recovery is considerably postponed by the sup- 
puration which takes place; and various secondary affections are apt to occur, 
which protract the disease, and add much to its danger. Occasionally, the 
symptoms assume a typhous character before the close. This variety of the 
disease is much more apt to prove fatal 'than the simple; and, when recovery 
takes place, it is more frequently after a long struggle in the resistance and 
repair of organic mischief; but still, in by far the larger proportion of cases, 
the patient does well, and the disease subsides without accident, at the regular 
period. 
3. Scarlatina Maligna. - Cynanche Maligna.-Malignant Sore-throat.- 
The name of malignant scarlet fever is applied to certain cases of extreme 
violence, in which the system is at once overwhelmed by the force of the 
disease, or in which the symptoms evince, in the course of it, an extraordinary 
degree of weakness or depravity. Either the simple or anginose variety may 
offer this character; the affection of the throat not being essential to the ma- 
lignancy of the disease, though this part often suffers greatly. 
In some instances, the patient is completely prostrated in the very first 
stage. Now and then, during the prevalence of scarlet fever, cases are met 
with in which the patient is attacked at once, either with comatose symptoms, 
or with oppression, faintness, and great anxiety; the pulse being slender, 
feeble, frequent, and irregular; the surface either cool, or hot in one part and 
cold in another; the respiration preternaturally slow, or hurried and irregu- 
lar; the face pale or livid; and the muscles almost powerless. Feeble attempts 
may be made at reaction; febrile heat may be partially developed to disap- 
pear again; and even some violet specks may appear as if they were endeaT 
vouring to struggle through the skin. But the resistance of the system soon 
ceases, and the patient dies upon the second or third day. From a less degree 
of the above symptoms, reaction may take place, and a low fever may be esta- 
blished, with delirium, stupor, or mental inertness, a feeble circulation, a livid, 
purplish, or dark-red eruption, petechias or vibices, passive hemorrhage, invo- 
luntary alvine discharges, and, unless a favourable change is effected by reme- 
dies, death in a few daysi 
In other cases, in which there is greater energy of system, or less violence 
of the cause, the early symptoms are those of the anginose variety. The signs 
from which malignancy may be suspected, in such cases, are violent initial 
pains in the loins and extremities, a greater disposition to delirium or stupor, 
a somewhat weaker though not less frequent pulse, a later appearance of the 
eruption, which is sometimes postponed to the fourth day, its more reluctant 
or partial efflorescence, and its tendency to a darker hue. In the fauces also, CLASS I.] 
SCARLET FEVER. 
397 
the tint of the redness is deeper and more inclining to purple than in the 
sthenic anginose cases. As the disease advances, the symptoms assume a 
more decidedly typhous or malignant character. The pulse becomes feeble, 
and the skin less regularly heated; the eruption disappears, or turns of a 
livid or purplish colour; petechias and ecchymoses occasionally appear; the 
pseudo-membranous exudation in the fauces is of a more dirty or darker hue, 
and is sometimes almost black; the whole throat is of a deep red, approaching 
to a mahogany colour; true gangrenous eschars and deep ulceration often 
form, with occasionally considerable destruction of the soft parts; the odour 
of the breath is fetid; the tongue becomes brown, and, as well as the teeth 
and lips, incrusted with a dark sordes; blood oozes from fissures in the lips 
and tongue; the urine is sometimes bloody, and hemorrhage may take place 
from any one of the mucous surfaces; an exhausting diarrhoea sets in; gan- 
grenous eschars form on the sacrum, hips, &c.; and at length collapse takes 
place, with sunken features, ghastly expression, a cold clammy skin, a flutter- 
ing pulse, and involuntary stools, ending in death towards the close of the 
first, or in the course of the second week. Sometimes, however, the patient 
is conducted through all these untoward symptoms; and then, with a shat- 
tered system, has not unfrequently to struggle with exhausting abscesses, 
ulcers, and al vine discharges, which too frequently carry him off, though he 
may survive even these, and ultimately be restored to health. It need scarcely 
be said, in relation to this variety of scarlatina, that there is in nature every 
gradation of malignancy, from the slightest infusion of it into an ordinary case 
of the simple or anginose variety, up to its most deadly concentration in those 
cases which sink under the first touch of the disease. 
4. Scarlatina without Eruption.-It is certain, that cases of fever with sore 
throat sometimes occur, during the prevalence of scarlet fever, having all the 
symptoms, and running the exact course of that disease, whether in its milder 
or malignant forms, with the single exception, that the eruption is wanting. 
It is even stated by Willan, that such cases are capable of imparting scarlet 
fever. A singular fact with regard to some of them is, that itching of the skin 
and desquamation take place at the regular period. 
Sequelae.-Few diseases leave a longer train of evils behind them than 
scarlet fever. Among the most common and troublesome sequelae, are the 
abscesses which form in the vicinity of the parotid and submaxillary glands, 
and which are often very large and exhausting. Sometimes, the copious dis- 
charge of pus from these sources is more than the weakened system can bear; 
and the patient, after having survived scarlet fever, dies of hectic. At the 
best, they greatly protract convalescence; and the constitution, even after 
being freed from disease, is long in recovering its wonted strength. 
Sometimes an abscess opens into the external meatus, and gives occasion 
to long continued and exceedingly obstinate discharges of pus from the ear. 
The same result, with destruction of the bones of the ear, and ulceration of 
the membrana tympani, sometimes follows an abscess of the cavity of the 
tympanum. In other cases, the Eustachian tube is closed by union after 
ulceration, or by inflammatory thickening of its coats, so as to occasion hard- 
ness of hearing. Similar disease sometimes affects the nostrils, and scarlatina 
not unfrequently lays the foundation for obstinate ozena. Abscesses occasion- 
ally also form in the testis, and in the joints. 
Diarrhoea is another not unfrequent consequence of scarlatina, which some- 
times proves obstinate, and wears out the remaining strength of the patient, 
though it generally yields to judicious treatment. The stomach sometimes 
participates in the disease, and the patient passes from scarlatina into a trouble- 
some and dangerous gastro-enteritis. 398 
GENERAL DISEASES.-FEVERS. 
[part II. 
The serous membranes are not unfrequently attacked with inflammation, in 
the progress of scarlatina, or during its decline; and encephalitis, pleuritis, 
and peritonitis may be added to its legacies. Bronchial disease is less common 
after scarlatina than measles, though it occasionally happens. 
Pain and swelling of the large joints, closely resembling rheumatism, are 
another of the sequelae. 
But the most serious of all of them is dropsy. The patient is liable to this 
during desquamation, and for a considerable time afterwards, and the cause of 
it is by many supposed to be the premature exposure of the delicate skin to 
cold. I confess I doubt this cause, at least in most of the cases. According 
to my own observation, dropsy has occurred more frequently after mild than 
severe cases; and authors generally admit the equal liability of these different 
grades. It sometimes follows cases in which the skin was but very slightly 
diseased, and where no exposure to cold can be shown to have existed. It is 
generally in the form of anasarca, though sometimes of ascites, hydrothorax, 
hydropericardium, and even hydrocephalus. Heaviness, approaching to stupor, 
with other signs of cerebral disease, is a not unfrequent attendant on the 
dropsy of scarlatina. The affection almost always yields to treatment; but is 
occasionally dangerous when the heart or brain is involved; and is said some- 
times to cause death by serous effusion in the submucous cellular tissue of 
the glottis. I haVe seen only one fatal case, and in that. the heart was dis- 
eased. The affection is generally accompanied with albuminous urine, and is 
said to be associated with that state of the kidney, which has been observed 
in the early stage of Bright's disease. This, however, is not always the case. 
For other remarks on this sequela of scarlatina, the reader is referred to the 
article on dropsy. 
While thus productive of disease, scarlet fever has the credit of sometimes 
curing obstinate cutaneous eruptions, and nervous affections. 
Anatomical Characters.-Sometimes every trace of the eruption disappears 
after death; sometimes remains of it may be seen in purplish or livid spots. 
Upon cutting into the skin, the reticular tissue is found reddened and injected. 
I have known the cuticle, after death from a violent attack of scarlatina, to be 
removable, as after a blister. The redness sometimes also disappears from 
the fauces, though it often remains if the disease has continued beyond the 
third day. The concrete exudations are often seen, sometimes extending 
through the pharynx even to the oesophagus, but very seldom into the larynx. 
Indeed, the tendency to bronchial and pulmonary inflammation is much less 
in this disease than in measles. Various interior organs are congested; and, 
when inflammation of any tissue has supervened, the effects of it are seen 
after death. Among other parts, the alimentary mucous membrane frequently 
exhibits signs of inflammation; and, in some cases, the aggregate and isolated 
follicles have been found enlarged and softened, though in a much less degree 
than in enteric or typhoid fever. Nor is this phenomenon necessarily asso- 
ciated with the typhous state of scarlatina. Often, when the patient has died 
early, no lesions of any kind are discoverable, which can explain the result. 
The blood is in different states in different cases, in some thick, in others 
watery; in some dark, in others red; in some, finally, liquid, and in others 
coagulated. From the few observations of Andral and Gavarret, it would 
appear in life to preserve generally about the mean of fibrin, while the 
red corpuscles are increased; but a more extensive series of observations is 
required. 
Cause.-The cause of scarlatina is probably specific, and is generally be- 
lieved to be of a contagious nature. This has been doubted by some, and 
among them by the late Dr. Dewees, who stated that he had never seen "any CLASS I.] 
SCARLET FEVER. 
399 
decided proof that it had communicated itself in any one instance." The 
circumstance that one member of a family is usually first attacked, and after- 
wards others, at an interval of several days, is a strong fact in favour of con- 
tagion. The cause generally operates though the medium of the atmosphere. 
Whether the disease can be imparted by inoculation may be considered doubt- 
ful, though cases are reported in which the trial is said to have been made 
with success. 
Scarlet fever frequently occurs epidemically; and there is this peculiarity 
in the epidemics, that they are often very limited, being confined to a small 
district of country, a single city, or even one part of a city. It may, perhaps, 
be questionable, whether the epidemic influence itself produces the disease, or 
only favours the action of the specific cause. The former branch of the 
question is probably true; for cases undoubtedly often occur, which cannot be 
traced to communication with the sick, and in which, indeed, such communi- 
cation could scarcely have happened; as when the first case occurs in a 
secluded and perfectly healthy neighbourhood. 
The epidemic influence differs greatly in its effects in different instances, at 
one time giving rise to a mild, at another to a violent form of the disease; in 
some instances, imparting to it an inflammatory, in others an asthenic or 
typhous character; and occasionally causing a particular direction of the irri- 
tation, sometimes, for example to the bowels, sometimes to the air-passages, 
and sometimes with especial violence to the fauces. Thus, in one epidemic 
the patients almost, all recover; in another great numbers perish. In one, 
bleeding is well borne; in another it is very hazardous, and the patients die 
unless stimulated. 
Allowing the disease to be contagious, it certainly appears not to be very 
strongly so; at least there are great numbers who seem to be wholy insus- 
ceptible to its cause. I presume that, in this country, there is scarcely a 
community in which by far the larger proportion of the population does not 
escape altogether. It not infrequently happens that only a single individual 
in a family is affected. 
No age is entirely exempt from the disease, but children are much more 
liable to it than adults. Indeed, the susceptibility seems to diminish from 
puberty upwards. Of the adults exposed to the cause, few comparatively are 
attacked; and the instances of the complaint in persons above fifty are very 
rare. According to my own observation, men are much less frequently 
affected than women; but this may be owing in part to the greater exposure 
of the latter to the cause, as in nursing. -Persons thus exposed, though they 
may escape the disease., are often troubled with a greater or less degree of 
angina. I seldom attend cases of scarlet fever without having sore-throat. 
The disease prevails at all seasons. By some writers it is stated, that 
epidemics of scarlet fever are most frequent in the spring or summer, by 
others in the autumn or winter; and a fair inference is that they occur about 
equally in both. 
As a general rule, the disease occurs but once in the same individual; but 
exceptions have now and then been noticed, though Willan did not meet with 
one out of two thousand cases. It is probable that, in many instances in 
which the same individual is said to have had scarlatina twice, one of the 
attacks was of roseola. 
Whether the contagious property is possessed by the disease throughout its 
course, or whether only at a particular period, does not appear to have been 
determined. Some suppose that it is retained by the individual during con- 
valescence, and long afterward, and that contagion may lurk in fomites for 
months or years; but these opinions are at best doubtful. 400 
GENERAL DISEASES.-FEVERS. 
[part II. 
The period of incubation varies from two or three days to two weeks or 
more. It is probably in general about five days. 
Diagnosis.-In the early stage, before the appearance of the eruption, scar- 
latina may be readily mistaken for many other febrile diseases. The most 
characteristic symptoms are an extraordinary frequency of pulse, and the 
appearance of redness in the fauces. After the eruption, one of the com- 
plaints with which it may be most easily confounded is measles. From this, 
however, it may be distinguished by the absence of catarrhal symptoms, by 
the occurrence of the rash on the second instead of the fourth day, by the 
characteristic anginose affection, and by the peculiarity of the rash, which is 
of a brighter red colour, more punctuated in the beginning and more uniform 
at last, without the clustered or crescentic arrangement of the rubeolous erup- 
tion, and without its roughness. Sometimes the two diseases appear to be 
mingled in the same case, when both are prevalent. The means of distin- 
guishing scarlatina from roseola and erythema will be mentioned under the 
two latter diseases. 
Prognosis-There is probably no complaint in which the result is more 
uncertain than in this. The seemingly mildest cases sometimes assume a 
most malignant character, and patients suddenly die with profound sensorial 
derangement, when supposed to be quite free from danger; while, con- 
versely, cases apparently the most desperate sometimes end favourably. 
Besides, after the case has reached convalescence, even under the most 
favourable circumstances, there is a liability to the most serious secondary 
affections. 
There is, in certain individuals, an extraordinary tendency to the most 
violent and fatal form of scarlatina; and these individuals are often mem- 
bers of the same family. It not unfrequently happens that two or three 
children die in one family; and sometimes a whole family is thus desolated, 
upon the same or successive occasions, though the disease, prevailing at the 
time, may have no particular malignancy. In such families, the prognosis is 
always more unfavourable than in others; and especial care should be taken 
to guard them, until the susceptibility may be supposed to have worn out 
with age. 
The disease is generally dangerous in pregnancy, and the puerperal state. 
Under other circumstances, I have observed that women bear it better than 
men. In the latter, it is exceedingly prone to a fatal result. The cases in 
adult men of which I have had any personal knowledge, whether in my own 
practice or that of my medical friends, have been very few; and certainly 
more than one-half of them have terminated unfavourably. Of course, the 
instances of mere sore-throat, from exposure to the cause of disease, are not 
included in this statement. 
In judging of the probable result in any particular case, reference should 
be had to the character of the epidemic. When this is very mild, we may 
with some confidence predict a favourable issue under apparently favourable 
circumstances; when otherwise, we should be more guarded. 
Among the unfavourable signs are a late appearance, considerable defi- 
ciency, or sudden retrocession of the eruption, in connexion with other bad 
symptoms; continued delirium or profound coma; a livid or purple colour of 
the rash, with petechiae, ecchymoses, or hemorrhage; a livid appearance of 
the fauces, with gangrenous sloughs or ulcers; extension of the pseudo-mem- 
branous exudation into the larynx; the occurrence of severe intercurrent 
inflammation of the vital organs; gangrene of the extremities, or of the sacrum 
and hips where pressed upon; and great prostration, as indicated by a very 
feeble pulse, cold skin, and involuntary discharges. CLASS I.] 
SCARLET FEVER. 
401 
The absence of the above symptoms, and a gradual subsidence of the dis- 
ease, are favourable signs; but, as before stated, they cannot be relied on, in 
consequence of the changes to which the disease is liable; so that a guarded 
prognosis in scarlet fever is almost always prudent. 
Treatment.-In the vast majority of cases, scarlet fever would end favour- 
ably without treatment. Hence the reputation acquired by homoeopathy in 
this disease. When the symptoms are very mild, it is advisable to do little 
more than to keep the bowels open, to administer cooling drinks, to regulate 
the diet, and to see that the apartment is well ventilated, and of comfortable 
temperature. 
A gentle emetic at the outset of the disease is generally thought, and I 
believe justly, to have a most happy effect in modifying its future course. 
This remedy should, therefore, be administered in every case, when seen at 
that stage; for, though it may possibly not be necessary, yet it can do no 
harm, and it is impossible to foresee what is to be the character of the case. 
Ipecacuanha may be used, or a mixture of this with tartar emetic. 
In all cases, except those of great mildness, it will be proper, in children, 
to follow the emetic with a purgative dose of calomel, which, if it do not 
operate thoroughly in six or seven hours, should in its turn be followed by 
castor oil, magnesia, or one of the saline laxatives. Afterwards, the bowels 
should be kept open, if necessary, by cathartics, which should be accommo- 
dated to the circumstances of the case; those of a depletory character, such 
as sulphate of magnesia, being given if there is much excitement with con- 
siderable energy of system; the Seidlitz powder, when there are nausea and 
vomiting; magnesia, when there is evident acidity of the primae vise; castor 
oil, when there is abdominal pain; and rhubarb when the system is too feeble 
to admit of watery purgation. In the incidental diarrhoea, advantage will 
sometimes accrue from castor oil combined with laudanum; as the bowels are 
thus cleansed of the offensive secretions which are swallowed, while they are 
rendered less sensible of the irritant impression. Great care, however, must 
be taken not to purge to exhaustion. 
Is bleeding proper in scarlet fever? Some strenuously advocate the 
affirmative of this question, and recommend the remedy in almost all violent 
cases, in the early stage. Some consider it hazardous under any circum- 
stances. In relation to depletion in this disease, it should always be borne in 
mind, that the tendency of the system is usually to an asthenic state; that the 
causes is probably in general depressing in its tendency, though capable of 
rousing the energies of the system, in many cases, to an active resistance. It 
should also be remembered, that the influence of the cause is, in certain epi- 
demics, much less depressing than in others; so that while bleeding may be 
employed, with impunity, in one, it may be very dangerous in another. The 
inference from these considerations is, that bleeding should be used with much 
caution and reserve, and only when there is an obvious indication; as when 
symptoms of inflammation of one of the vital organs exist, and threaten great 
danger. For the mere inflammation of the fauces, it is seldom requisite. 
Indeed, it has in general little influence upon that affection, especially when 
accompanied with pseudo-membranous exudation. In no instance, even of 
decided inflammation, should it be resorted to when the pulse is feeble, and 
other signs indicate a malignant tendency. In all doubtful cases, it is best 
to have recourse to local depletion by leeches or cups. Should experience 
show that the disease, in any particular epidemic, is of a more than usually 
sthenic character, the remedy may be used with less reserve; should malign 
nancy be the predominant character, it should scarcely be used at all. I have 
seldom found it advisable to bleed in anv case : and do not remember the 402 
GENERAL DISEASES.-FEVERS. 
[part II. 
instance, in which it appeared to me that I had occasion to repent my absti- 
nence. " Dr. R. Williams, who has bestowed great attention on this point, 
has drawn up a table of different epidemics which have prevailed from 1763 
to 1834; and adds, that the conclusion which inevitably follows is, that the 
chances of recovery are diminished by the practice of bleeding, in the ratio of 
nearly four to one, as compared with the chances, supposing the patient not 
to have been bled." (Dr. Burrows, in Tweedie's Syst. of Pract. Med.} 
Whenever bleeding is resorted to, it is a good rule to place the patient in a 
sitting posture; as the failure of the pulse, in this position, will sooner give 
warning to arrest the flow of blood, than' in the horizontal. 
In cases of severe serous inflammation accompanying the disease, leeching 
or cupping may generally be employed with advantage. Leeching is also 
recommended when there is much external swelling about the jaws; but care 
must be taken, before it is used, that there is sufficient strength of pulse to 
bear the loss. Great external swelling sometimes exists, when it is of the 
utmost importance to husband the resources of the system. In the convul- 
sions of the early stage, it will often be proper to apply leeches to the tem- 
ples, or behind the ears. 
In all cases in which the skin is universally hot and dry, and the patient 
experiences no sensations of chilliness, the external application of cold water 
is highly useful. It relieves the pungent heat of the surface, quiets restless- 
ness, reduces the frequency of the pulse, and adds greatly to the comfort of 
the patient. I have generally preferred sponging; some recommend affusion. 
In doubtful cases, warm water may be substituted for cold. 
When the fever is well developed, a course of internal refrigerant treat- 
ment should be adopted. The patient should be allowed to drink cold water 
frequently though moderately, and to hold ice in his mouth if he desire it.* 
Small doses may be given every hour or two, during the day, of the neutral 
mixture, solution of acetate of ammonia, citrate of ammonia, or muriate of 
ammonia, to which, when the stomach is quite retentive, and the general 
condition of system is not asthenic, minute doses of tartar emetic may be 
added. When the stomach is irritable, the effervescing draught should be 
preferred. Nervous symptoms may be counteracted by the addition, to the 
diaphoretics just mentioned, of sweet spirit of nitre, Hoffmann's anodyne, or 
camphor water. Should a sour smell, as often happens, exhale from the 
patient, he should take bicarbonate of soda or of potassa, three or four times 
daily. I have found great apparent advantage, in cases attended with a very 
frequent pulse, from the use of tincture of digitalis, which, to an adult, may 
be given in doses of from five to ten drops every four hours. 
* Dr. Samuel Jackson of Philadelphia, formerly of Northumberland, has given to the 
public highly interesting statements of his success, in the treatment of ariginose cases of 
scarlatina, by means of ice kept constantly in the mouth and swallowed as it dissolved, 
and of chloride of soda as a local application to the fauces. The ice is to be used in 
small lumps, or, in the cases of infants not old enough to guard against swallowing the 
pieces undissolved, enclosed in a gauze bag. When the fever is very high, small quan- 
tities of the ice may be swallowed in the form of fine powder. In very young infants, 
ice cold water may be injected into the throat, and powdered ice may be swallowed, if 
there is much fever. To be successful, this practice must be maintained incessantly, 
night and day, until the inflammation has evidently yielded. The solution of chloride 
of soda is applied when the disease in the fauces becomes gangrenous. These simple 
remedies were found exceedingly efficient by Dr. Jackson, and by several other practi- 
tioners who had been induced to employ them upon his recommendation. They were 
not, however, used by him to the exclusion of other measures, such as bleeding, emetics, 
cathartics, antimonials, cold water to the head, warm water to the feet, &c, when cir- 
cumstances seemed to call for them; but the ice appears to have been the one most relied 
on in the anginose cases. (See Mm. Journ. of Med. Sei., xii 261 and 550; and xxii. 45 ; 
also Eberles Practice of Medicine, edited by Dr. George M'Clellan, i. 478.) CLASS I.] 
SCARLET FEVER. 
403 
But the practitioner should always be on the watch for symptoms of 
debility, and be prepared to counteract them. In some instances, they attend 
the case from the commencement, in others come on during its course. They 
are such as occur in the typhous state of fever. Whenever they are seen, no 
hesitation should exist in resorting to tonics or stimulants. Sulphate of 
quinia dissolved in one of the dilute mineral acids, or the compound infusion 
of Peruvian bark, is admirably adapted to many of these cases. But, when 
the debility is considerable, it is necessary to use substances which are more 
stimulating, such as capsicum, carbonate of ammonia, oil of.turpentine, and wine 
diluted with water, or in the form of wine-whey. The Germans prescribe the 
flowers of arnica, under these circumstances. When nervous symptoms are 
superadded to debility, musk, assafetida, camphor, or valerian may be employed. 
Animal broths or jellies should also be given, especially in the advanced stages, 
and when the blood is depraved. Swelling of the throat, or even comatose 
or delirious symptoms, should no't deter from the use of the above measures, 
when the signs of debility are evident. 
Should the eruption come forth sparingly, or retrocede, and at the same 
time threatening symptoms appear, efforts should be made to invite it to the 
surface by the hot bath, and the more active rubefacients. Urtication by 
means of the nettle has also been recommended. 
Solution of chlorine, and chlorate of potassa, have been recommended in 
the treatment of scarlatina. The aqua chlorinii of the Dublin Pharmacopoeia 
may be given in the dose of a fluidrachm for an adult, and ten drops for a 
child two years old,'three or four times a day. It may be given largely 
diluted, in one of the aromatic waters, and sweetened. Dr. Watson speaks 
very favourably of a solution of chlorate of potassa, in the proportion of a 
drachm to the pint, as a drink; of which from a pint to a pint and a-half 
may be used during the day. I have had no experience with either of the 
above remedies; but nitromuriatic acid, which contains free chlorine, is some- 
times useful, in the atonic forms of the complaint. 
Local Remedies.-These are important. In slight affection of the throat, 
it is sufficient to employ demulcent, acidulous, slightly astringent, or saline 
gargles; such as infusion of flaxseed or slippery elm, water acidulated with 
sulphuric or muriatic acid or vinegar, compound infusion of red roses, weak 
solutions of alum, nitre, or common salt, &c. When pseudo-membranous or 
gangrenous patches are observed in the fauces, and the colour of the mucous 
membrane is dark red, infusion of capsicum, or the powdered red pepper itself 
diffused in water or vinegar and water, is perhaps, on the whole, the best 
application. (See. U. 8. Dispensatory.') It certainly exercises a peculiar and 
very happy influence over this low species of inflammation. Very often the 
patient finds it soothing to the throat, even though burning to the mouth, in 
which the same condition of the membrane does not exist. The remedy is, 
I think, too much undervalued by recent writers. In children who cannot 
gargle, I apply it by means of a large camel's hair pencil, or some equivalent 
instrument, loaded with the powder mixed up with water, and turned about 
in the fauces. I have also used with advantage a strong solution of sulphate 
of zinc, containing fifteen or twenty grains in a fluidounce of water, as an 
application to the patches; and the nitrate of silver is also sometimes an 
excellent remedy, when the patches threaten to invade the larynx. Dr. 
Eberle speaks very favourably of a strong infusion of the root of the common 
wild indigo (Baptisia tinctoria) in putrid sore-throat. The offensive odour 
which proceeds from the throat, in some of these cases, may be corrected by 
gargles or washes of solutions of creasote, chloride of soda, and chloride of 404 
GENERAL DISEASES.- FEVERS. 
[part II. 
lime, or by diluted pyroligneous acid, which act also favourably upon the 
diseased surface. (See U S. Dispensatory i) 
Leeches may sometimes, as already stated, be used externally when there 
is considerable strength of pulse; and some also recommend blisters. I have 
employed these frequently, but not with much apparent advantage. In the 
asthenic cases the blistered surface is liable to slough. Perhaps, on the 
whole, the best external application is a large emollient poultice. Rubefa- 
cient applications to the throat, such as the liniment of ammonia, tincture of 
capsicum, or oil of turpentine diluted with olive oil, may also be used. 
During ■ convalescence, it is important to guard against exposure to cold 
air, to keep the bowels regularly open, and if the patient remain feeble, with 
a want of appetite, to invigorate the stomach and system by the mineral acids, 
quinia, or the simple bitters. 
The rules of diet applicable to other kinds of fever should be observed in 
this; and it is unnecessary to repeat them. 
The sequelae of the disease often require attention. When the external 
parts about the neck suppurate, emollient poultices should be applied, and 
the patient's strength supported by tonics and nutritious food. 
The diarrhoea and inflammatory affections which set in, must be treated as 
if these affections were original, reference-being had to the debilitated state 
of the system. But it is proper to observe that, when they occur after a mild 
attack of the disease, depletion is often very well borne; the depressing influ- 
ence of the poison having been removed. The brain must be especially 
watched, and, if symptoms of stupor supervene, blood' should generally be 
taken from the arm. For the treatment of dropsy consequent upon scarlet 
fever, the reader is referred to the subject of dropsy. 
Preventive Treatment.-It is peculiarly important to guard children against 
scarlatina; as the older they grow, the less liable they are to be attacked. 
Hence, they should be kept separate as far as possible from every source of 
infection; and free ventilation of the sick chamber should be employed, in 
order to dilute and dissipate the poison. Different prophylactic medicines 
have been recommended; among which belladonna enjoys perhaps the confi- 
dence of the greatest number of practitioners. Its use for this purpose was 
introduced by Hahnemann, on the ground that it produces effects analogous 
to those of scarlatina. I confess, though I have used belladonna much, I 
have never seen from it anything resembling scarlatina. But whatever may 
have been the origin of the practice, its value must be determined by experi- 
ence ; and many believe that they have employed it with great advantage. It 
is used in very small doses. Three grains of the extract are dissolved in a 
fluidounce of distilled water, and three drops of the solution given, twice a 
day, to a child under one year, to be increased one drop for every additional 
year. Another prophylactic is said to have been employed with great effect 
by several physicians of Groningen. It consists, for children from two to 
four years old, of a sixteenth or eighth of a grain of calomel, and the same 
quantity of the golden sulphur of antimony, with a little sugar or magnesia, 
given from once to four times daily. (.Diet, de Med-) I have had no expe- 
rience with either of the above prophylactics. CLASS I.] 
ERYSIPELAS. 
405 
Article XII. 
ERYSIPELAS. 
Syn.-Saint Anthony's Fire.'-Rose.-Ignis Sacer. 
The term Erysipelas was derived from the ancients, to whom the disease 
was known. It is a constitutional affection, characterized by a peculiar, 
spreading, circumscribed inflammation of the skin, with fever beginning a 
little before, simultaneously with, or a little after the local disease. 
Symptoms, Course, &c.-Languor, general uneasiness, aching pr soreness 
in the limbs and joints, chilliness, or rigors alternating with flushes of heat, 
are succeeded by a frequent pulse, hot skin, a furred tongue, anorexia, thirst, 
sometimes nausea and vomiting, headache, restlessness, muscular weakness, 
and not unfrequently soreness of tln?oat, or swelling of the lymphatic glands, 
in the vicinity of the part which is to be the seat of the cutaneous inflamma- 
tion, as of the neck in erysipelas of the face, and of the axilla or groin in that 
of the extremities. 
On the second or third day of the fever, though sometimes earlier and 
sometimes later, and occasionally as the first observable phenomenon, there 
may be seen, upon some part of the surface, a small reddish spot, usually 
somewhat elevated, painful, and tender to the touch. This may occur upon 
any portion of the body, but is much more frequent upon the face than else- 
where, especially upon the side of the nose, the cheek, or the rim of the ear. 
The inflamed spot gradually spreads, usually in all directions, though often 
more rapidly in one than in another, exhibiting almost always, as it advances, 
an irregular, abrupt, and somewhat elevated margin, which forms a striking 
boundary between the sound and the diseased skin. In some instances, the. 
border is less definite, though scarcely ever gradually shaded off, like ordinary 
inflammation, so that it cannot be traced. The diseased surface is red, often 
shining, hot to the hand, and generally harder than the sound skin. The 
redness disappears under the pressure of the finger, but quickly returns when 
the pressure is removed. The distance to which the inflammation extends 
differs greatly. In some instances it advances slowly, and is confined within 
narrow limits; in others, it spreads quickly over large portions of the sur- 
face; and, in certain comparatively rare cases, does not cease to make pro- 
gress, until it has invaded successively every part of the skin. Almost always 
its progress is continuous; but now and then instances occur, in which it 
attacks, in succession, separate and even distant parts of the body. 
In the face, it sometimes confines itself within the limits of the features, 
but generally has a tendency to spread upward to the scalp, and not unfre- 
quently extends over the whole head, and even downward to the neck, though 
rarely so far as the chest. 
There is usually considerable swelling, the skin being thickened and hard- 
ened, and the subcutaneous cellular tissue in general more or less distended, 
especially in parts of loose texture, as in the eyelids and about the eyes, in 
the scrotum and prepuce, and in the vulva, which parts are apt to become 
strikingly edematous. 
The face is often so much swollen that every characteristic feature is oblite- 
rated. The eyes are closed, the lips, nose, cheeks, and ears greatly enlarged, 
the nostrils so much obstructed that the patient cannot breathe through them, 
the mouth so stiff that he speaks with difficulty, and the external meatus 
sometimes so much narrowed as to interfere with hearing. When the disease 406 
GENERAL DISEASES.-FEVERS. 
[part II. 
extends over the scalp, this is usually much swollen and puffy, and the whole 
head sometimes enorinously enlarged. 
A burning, tensive, pricking, and smarting pain is usually experienced; 
and the parts are so tender that pressure produces much uneasiness. When 
the whole scalp is affected, it is difficult for the patient to find a comfortable 
position for the head. The pain, however, often remits. 
Sometimes the inflammation gradually rises for three or four days, then 
gradually subsides, without apparent effusion of any kind, and terminates in 
desquamation. But more frequently, about the third or fourth day, the cuticle 
is elevated by a serous liquid, which sometimes appears in the form of minute 
eczematous or miliary vesicles, sometimes blisters or blebs, like the bullae of 
pemphigus, from a quarter of an inch to an inch or more in diameter, which 
occasionally run together, so as to produce an extensive blistered surface. 
The surface is often moistened by exudation from these vesicles, or their rup- 
ture. On the fifth or sixth day they begin to dry, and on the seventh or 
eighth form small crusts or scales, which usually separate by the tenth, leaving 
the skin covered with a new cuticle. When the hands or feet have been 
affected, the cuticle sometimes separates entire, so as to form a mould of these 
parts. The redness and swelling subside at the same time,'and are nearly or 
quite gone when the crusts are fully formed. The whole duration of the 
inflammation is thus, in favourable cases, about a week, though sometimes 
shorter, especially in the young and healthy, and sometimes, from various 
causes, considerably protracted. Even after desquamation, it is sometimes 
long before the skin acquires its natural appearance and flexibility. 
The course of the disease often varies more or less from that above de- 
scribed. Thus, while the part first affected is going through the regular 
changes, the inflammation may have advanced to another part, which goes 
through its own periods of increment and decline; and so on with different 
parts successively; so that the case may be prolonged for a month or more. 
After the removal of the cuticle from the vesicated parts, the surface some- 
times continues to exude an acrid lymph for several days, and may even pass 
into a state of suppuration or ulceration, which greatly retards the cure. 
In some cases, the inflammation in the subcutaneous tissue ends in suppu- 
ration, and even in gangrene of the cellular tissue. In the former case, pus 
of a healthy appearance escapes through ulcerated openings in the skin; in 
the latter, grayish strings of the dead membrane, like wet tow, come away, 
along with a thin, ichorous, and fetid purulent discharge. The face sometimes 
presents the disease at once in its different forms; portions undergoing resolu- 
tion without vesication, others exhibiting vesicles on the surface, and others, 
as the parts about the eye, discharging pus and disorganized cellular tissue. 
The tissue beneath the scalp not unfrequently, in bad cases, passes into this 
gangrenous state, though the skin itself generally remains sound, except when 
ulcerated to permit the escape of the dead matter. But this condition of the 
disease is still more frequent upon the limbs and trunk. In these parts, the 
pus not being duly confined, as in phlegmonous inflammation, by the exuda- 
tion of coagulable lymph, often travels great distances, destroying the sub- 
cutaneous cellular and adipose tissue, dissecting the muscles, and involving 
life in great danger. I have seen a case, in which the skin over almost the 
whole front of the abdomen was thus separated from the muscles beneath. 
Even where recovery takes place in such eases, deformity may ensue from the 
resulting contraction, and difficulty of movement from the adhesions which 
may form among the muscles, or between them and the skin. Sometimes 
gangrene of the skin itself is added to the various mischief. This happens CLASS I.] 
ERYSIPELAS. 
407 
more especially in the extremities. It is obvious that, in all these cases, 
when not fatal, recovery must be considerably postponed. 
During the continuance of the cutaneous inflammation, the fever also con- 
tinues, and sometimes in a greatly aggravated form. In vigorous constitutions, 
with no asthenic tendency in the disease, the pulse remaihs full and tense, 
without being very frequent; and, unless the inflammation invades the scalp, 
though there may be a little occasional delirium, the fever has generally an 
open inflammatory character, and offers little to cause alarm. But, when the 
scalp is involved, symptoms of cerebral disorder are very often evinced, such 
as headache, tinnitus aurium, restlessness, and decided delirium, or, what is 
perhaps more frequent, and constitutes one of the most striking features of 
these cases, a tendency to. drowsiness, stupor, and even coma. The inflam- 
mation is supposed to penetrate through the cranium to the cerebral meninges; 
though fatal cases of this kind have occurred, in which no disease was dis- 
covered in the encephalon after death. 
I have known of one or more instances, in which inflammation appeared to 
reach the brain through the nostrils and ethmoidal cells, with fatal effect. In 
some instances, it passes from the skin into the mouth, travels into the respi- 
ratory and alimentary passages, and produces characteristic effects in these 
several situations. The lips are dry, tense, and shining; the interior of the 
mouth, including the tongue, is red and dry; the fauces are reddened, and 
the tonsils sometimes swollen; deglutition is painful; and gastritis with nausea 
and vomiting, and enteritis with diarrhoea have been supposed to arise from 
the same cause. Certain cases of death from erysipelas have been ascribed 
to pseudo-membranous exudation in the glottis, and others to effusion into the 
Submucous tissue in the same part, so as to close the passage against the ad- 
mission of air. 
Not unfrequently, the fever attendant on erysipelas is asthenic, either from 
the feeble constitution of the patient, the depraved state of his health at the 
time of attack, or the peculiarly depressing nature or malignancy of the cause 
producing the disease. Sometimes the asthenic or typhous symptoms are 
present from the beginning; but, in other instances, do not make their appear- 
ance till some time in the course of the complaint. It is scarcely necessary 
to repeat the symptoms, which are those of the typhous state in fevers gene- 
rally. The most prominent are a feeble and often very frequent pulse, a cool 
or irregularly heated surface, restlessness, subsultus, low delirium or stupor, 
a brown or black and dryish tongue, dark sordes about the lips and teeth, a 
purplish or livid colour of the inflamed surface, bloody serum in the vesicles, 
ecchymoses, and a strong tendency to gangrene. Internal inflammatory or 
congestive complications are not uncommon, but all of the same low and 
asthenic character. Diarrhoea, with black fetid stools, not unfrequently comes 
on before the close; and, if the patient do not sink under the immediate dis- 
ease, he is apt to be worn out by the suppurative and ulcerative processes, 
consequent upon the local mischief. 
Another evil incident to erysipelas, is the occasional metastasis of the 
external inflammation to some interior and vital organ. This is, perhaps, 
less frequent than might be supposed from the accounts of authors; but it 
may be every now and then observed. The greatest danger is probably of 
metastasis to the brain and heart, or their appendages. It is marked by a 
sudden disappearance of the external inflammation, and the simultaneous 
occurrence of symptoms of internal disturbance. Sometimes the external 
affection suddenly disappears, without any internal disorder. Under such 
circumstances, the incident, so far from being alarming, is satisfactory. The 
retrocession of the eruption is probably sometimes the result of the previous 408 
GENERAL DISEASES.-FEVERS. 
[part II. 
occurrence of the internal inflammation. But it is at least sometimes also 
the antecedent, and probable cause; as when repelled by cold, or certain local 
applications. I have known a case in which a solution of corrosive sublimate, 
applied to an erysipelatous inflammation upon the anterior of the chest in an 
old man, caused a speedy and entire disappearance of the cutaneous redness, 
followed by an enormous tumefaction of the subcutaneous tissue, which was 
swollen so as to resemble the mammae in women, and was of a stony hard- 
ness. The patient died. Sometimes the retrocession is probably owing to 
the sudden occurrence of great prostration. Such a case happened to me in 
the Pennsylvania Hospital. The erysipelas, which was facial, suddenly dis- 
appeared, and the patient became delirious, with an exceedingly feeble pulse, 
cold skin, and other evidences of profound debility. He was stimulated 
actively with milk-punch, &c.; the vital actions were restored, and with them 
the erysipelas, which afterwards terminated happily. 
But, notwithstanding these occasional protracted or dangerous cases, erysi- 
pelas, in the vast majority of instances, does well; the fever subsiding along 
with the inflammation, and recovery taking place in a period varying from 
five to twelve days. Death in private practice, under appropriate treatment, 
and in the absence of any malignant epidemic influence, is very rare, unless 
in persons of feeble health, or intemperate habits. 
Numerous varieties of erysipelas are referred to in practical works; and, 
though most of them are merely modifications, such as above described, it 
will be proper to notice some of them more distinctly. 
Erysipelas pldegmonodes, is a name conferred upon that form of the disease 
in which the inflammation extends deeply into the subcutaneous tissues. It 
is attended with greater pain and swelling than the more superficial variety, 
and usually with severer general symptoms. Suppuration and gangrene of 
the cellular membrane are not uncommon; and, when the disease, as some- 
times happens, penetrates beneath the fasciae, the sufferings of the patient are 
much aggravated by the compression of the inflamed parts, and much organic 
mischief may result from the confinement of the pus and sanious products 
of gangrene that are apt to form. This variety sometimes ends in the gan- 
grenous. 
Erysipelas erraticum.-E. ambulans.-Wandering erysipelas is that super- 
ficial form in which the inflammation, confined chiefly to the skin, and perhaps 
more especially to its reticular layer, spreads rapidly over the surface; not 
stopping, in some instances, until it has extended over the whole body. It 
seldom, however, covers the whole surface at once; but almost always fades 
and undergoes resolution in one part, while advancing in another. Sometimes, 
instead of travelling continuously over the body, it attacks successively distant 
and separate parts, as the face, for example, at one time, and one of the 
limbs at another. By some, the term E. erraticum is confined to the former, 
and E. ambulans to the latter of these forms. They are both peculiarly liable 
to metastasis, and this probably constitutes their chief danger. Though some- 
what tedious, they generally end in recovery unless in cases of retrocession, 
or when occurring in the advanced stage of other debilitating, diseases. 
Erysipelas oedematodes.-When erysipelas occurs in a cachectic state of 
system, with a tendency to serous effusion, it is apt to assume the edematous 
form; and the same condition is presented when the disease attacks parts 
already edematous, as, for instance, the legs of dropsical patients, which often 
become the seat of this kind of inflammation, in the advanced stages of the 
disease, and especially if punctured. The parts most commonly affected with 
edematous erysipelas are the lower extremities, the genitals, and more rarely 
the face. The colour of the surface is not so. deeply red as in' the other varie- CLASS I.] 
ERYSIPELAS. 
409 
ties; the skin appears stretched and shining, but not elastic; and the surface 
pits on pressure. This form of the disease, though it not unfrequently ends 
in resolution, is often attended by suppuration and sloughing of the cellular 
tissue, and sometimes by the death of portions of the skin. 
Erysipelas gangrsenosum.-The gangrenous tendency may either be origi- 
nal, dependent upon the depressing nature or malignancy of the cause, upon 
the depraved condition of the system, especially of the blood, or upon certain 
co-operating influences of a debilitating character, as confined and impure air, 
unwholesome or scanty food, &c.; or it may result from the excessive violence 
of the inflammation. In the former case, it may be obvious from the com- 
mencement of the disease; in the latter, it is not seen until an advanced 
period. The tendency is indicated by a peculiarly hot and burning pain, and 
a purple or livid hue of the redness. The near approach of the gangrene is 
shown by the slowness with which the blood returns after removal by pres- 
sure, or by its imperfect removal, a doughy feel of the parts, and the forma- 
tion of small blisters filled .with a turbid or reddish serum. The appearance 
of grayish or blackish spots beneath the separated epidermis, a total suspen- 
sion of the circulation in any part of the surface, a reduction of the pain, and 
a diminution of the temperature, indicate its positive existence. It is apt to 
occur when erysipelas attacks patients with typhoid fever, or infants soon after 
birth; and is not uncommon in hospitals, and during the prevalence of malig- 
nant erysipelatous epidemics. It is always indicative of great danger. The 
constitutional symptoms are of a typhoid character. 
The above varieties have reference to the character of the local affection. 
There are others having a different basis. Thus, the inflammation sometimes 
occurs without fever, generally as a consequence of wounds or other pre-exist- 
ing local disorder. It may then be styled local erysipelas, or simply erysipe- 
latous inflammation. Sometimes there is reason to believe that the fever 
occurs without the affection of the skin, as in other exanthematous diseases. 
This is shown particularly during the epidemic prevalence of the complaint, 
when fevers are often observed, in which the cutaneous inflammation appears 
to be superseded by that of one of the interim* organs or surfaces. Under 
such circumstances, the disease may be denominated erysipelatous fever. 
Occasionally cases are observed, in which the tongue, conjunctiva, and skin 
have a yellowish hue, the urine is dark yellow, and the alimentary canal 
exhibits evidences of bilious disorder. In this form the disease is called 
bilious erysipelas. Its peculiarities depend either upon a torpid state of the 
liver, or an excessive production of bilious matter in the blood. The name 
of malignant erysipelas is given to those terrible forms of the disease, gene- 
rally the result of epidemic causes, which exhibit the highest grade of the 
typhous condition, a strong disposition to gangrene, and all those phenomena 
which depend upon a disorganized condition of the blood. Some of theix* 
characteristic phenomena will be described, in a brief account, which I propose 
to give directly, of the epidemic erysipelas which raged in different parts of 
the United States, in the years 1842 and 1843, and subsequently, under the 
popular name of black tongue. Still another form which has been recognized 
by some as a distinct variety, with the title of erysipelas neonatorum, occurs 
in infants soon after birth. Sometimes, indeed, the child is said to be born 
with the disease upon it. The inflammation generally begins in some part of 
the abdomen, and spreads rapidly over the trunk, to the genital organs, the 
nates, and lower extremities. It may also begin upon the face or limbs. It 
is very much disposed to suppuration and gangrene, and is exceedingly fatal. 
The disease is said to be frequently associated with peritoneal inflammation. 
It appears to be more common in Europe than this country, and probably 410 
GENERAL DISEASES.-FEVERS. 
[part II. 
affects more especially the children born in crowded hospitals, than under 
ordinary circumstances. 
Anatomical Characters.-The blood drawn during life has the huffy 
coat. After death, the redness of the skin often disappears, but a brownish 
tinge is apt to be left behind; the epidermis easily separates; and the vascular 
rete, true skin, and subcutaneous cellular tissue exhibit marks of inflamma- 
tion. The small veins have been observed to be frequently red on their inner 
surface, and to be filled with pus; but, according to Bayer, this is by no 
means uniformly the case. Pus is often found in small abscesses, oi' diffused 
extensively in the cellular tissue and among the muscles. Sometimes small 
collections of pus are found in the substance of the large organs, as the lungs 
and liver. When death ensues from coma, serous effusion is sometimes 
observed under the arachnoid and in the ventricles, and the veins of the pia 
mater are distended; but sometimes, also, no morbid appearances are observed 
in the encephalon. Of course, the incidental inflammations which not unfre- 
quently supervene in erysipelas leave their ordinary effects behind them. 
Causes.-These are not altogether well understood. The disease has been 
ascribed to cold; stimulant articles of food and drink; excessive fatigue; vio- 
lent mental emotion, as of fear or anger; suppression of habitual discharges, 
as of the menstrual or hemorrhoidal flux, or from old ulcers; and even the 
transfer of rheumatic or gouty irritation. It may also originate in consequence 
of any undue excitement or irritation of the skin, as from the direct heat of the 
sun, burns, rubefacients, blisters, issues or setons, ulcers, wounds of all sorts, 
whether from surgical operations or accidental contusions, and even such 
slight injuries as the sting or bite of an insect, the wound of the lancet, or 
the scratch of a pin. In these cases, the inflammation spreads from the point 
previously diseased. 
But none of these caitses are capable, of themselves, of giving rise to ery- 
sipelas. In the vast majority of instances, they produce no such result, and 
even in persons in whom they cause the disease at one time, they very often 
fail to do so at others. There must, therefore, be something else; some- 
thing which predisposes the individual to this particular form of disease 
rather than to others. Such a predisposition appears to be possessed by some 
persons constitutionally. These have frequent attacks of erysipelas from 
some of the causes above mentioned, and sometimes without any apparent 
cause; the predisposition alone being sufficiently powerful to bring about 
the result, The attacks are sometimes periodical; certain persons having the 
disease once, twice, or oftener during the year; others, and especially women, 
every month. ' Not unfrequently, the predisposition is the consequence of 
disease. Dropsy predisposes to erysipelas, and the same is the case, to a 
certain extent, with everything that depraves the system. The intemperate 
are more liable to the disease than the temperate. Influences which tend 
to depress or debilitate the system, even without producing open disease, 
have the same effect. Hence, partly, the prevalence of erysipelas in hos- 
pitals. But there is also some unknown condition of the atmosphere, which 
greatly favours the production of the disease; so that, when this condition 
exists, the slightest causes will give rise to this form of inflammation, which, 
on other occasions, have no such effect. It is especially apt to be felt in 
large infirmaries; but is nevertheless independent of the ordinary circum- 
stances of those institutions; for no observable difference can be recognized 
between these circumstances, during the existence of this tendency, and at 
other times. It is occasionally so strong that the slightest irritation of the 
surface induces an attack of erysipelas; so that, upon those occasions, it 
is hazardous to bleed, leech, or apply a blister, not to mention serious sur- CLASS I.] 
ERYSIPELAS. 
411 
gieal operations, which are altogether unjustifiable. Wounds about the head 
are peculiarly liable to this unpleasant complication. It has been noticed 
that this predisposition to erysipelas exists in the ordinary wards of hos- 
pitals, at the same time that puerperal fever prevails in the lying-in wards. 
Some have ascribed the occurrence of erysipelas, under these circumstances, 
to contagion; and cases have been adduced, which seem strongly to sustain 
the opinion of the communicability of the disease. But the general medical 
sentiment is opposed to the doctrine; and, neither in public nor private prac- 
tice, have I ever seen a case in which there appeared to be any proof of a con- 
tagious origin. When typhus fever and erysipelas prevail together, there is 
no difficulty in accounting for apparent instances of this kind. An individual 
may receive the typhus by contagion, and erysipelas may develope itself at 
the same time under the prevailing influence; the febrile movement acting as 
the exciting cause of the latter complaint. 
No alternative remains but to ascribe the prevalent tendency to erysipelas, 
above mentioned, to epidemic influence. This sometimes acts upon a much 
more extensive scale, not only affecting limited localities, but wide regions of 
country. Destructive epidemics of erysipelas have occurred from time to 
time in Europe; and several parts of our own country have been ravaged by 
a similar epidemic, during the last few years. 
Epidemic Erysipelas of 1842, 1843, &c.-Blade Tongue.-The news- 
papers, a few years since, teemied with accounts of a destructive pestilence, 
appearing in remote and unconnected portions of the country, which, from 
one of its prominent symptoms, came to be known by the popular name of 
Idadc tongue. Several accounts of the disease have been published in the 
medical journals, to which I am indebted for the facts contained in the fol- 
lowing summary, as I have never had the opportunity of witnessing the dis- 
ease.* It prevailed in several' of the New England States, in those of the 
West and Northwest, and in the interior of Pennsylvania, during the years 
1842, 1843, and 1844; and I have heard accounts of it in isolated neigh- 
bourhoods in some of the Southern Atlantic States. The disease was of 
different grades of violence in different places, being sometimes so mild 
that almost every case recovered, in others so deadly that more than half of 
those attacked perished. It did not uniformly put on the appearance of 
erysipelas. In some places, most of the cases were of this character, in 
others not more than one in six, or even a smaller proportion; the affec- 
tion of the skin being replaced by some internal inflammation, generally of 
the mucous or serous tissues, though sometimes also of the parenchyma of 
the organs, especially of the lungs. But the external inflammation was 
the most common and characteristic symptom. It is a very interesting 
fact, recorded both by Dr. Sutton and by Drs. Hall and Dexter, that puer- 
peral fever was very prevalent at the same time, and in the same districts as 
the erysipelas; and some cases are stated, in which it appeared as though 
the former disease had been produced by contagion conveyed from the 
latter; while conversely, a slight prick of the finger of a physician, received 
in the post-mortem examination of a female who had died of puerperal fever, 
became the starting point of an extensive and severe erysipelatous inflam- 
mation. 
* The papers alluded to are those of Dr. George Sutton, of Aurora, Indiana, in the 
Western Lancet, for November, 1843; of Dr. Charles Hall, of Burlington, Vermont, and 
Dr. Geo. J. Dexter, of Lancaster, New Hampshire, published in the Am. Med. and Surg. 
Journ., for January, 1844; of Dr. D. Meeker, in the Illinois Medical and Surgical Journal, 
for June, 1844; and of Dr. Jesse Young, of Chester, Pennsylvania, in the Med. Examiner, 
for September, 1844. 412 
GENERAL DISEASES.-FEVERS. 
[part II. 
The disease very often began with difficulty of swallowing from inflam- 
mation of the fauces; and if otherwise, angina was very apt to ensue. The 
first general symptoms were feelings of lassitude, pains in the back, loins, 
extremities, head, &c., nausea and retching, a frequent and depressed pulse, 
a fetid breath, cold and contracted skin, shrunken features, anxiety of coun- 
tenance, and rigors more or less severe and protracted. The pains were 
often exceedingly acute, like those of neuralgia, shooting through various 
parts of the body, and sometimes darting from a finger or toe, the heel, &c.; 
and it was observed that the limb thus affected was apt to become the seat 
of the subsequent inflammation. After a variable continuance of some or all 
of the above symptoms, occasionally extending to twenty-four hours or longer, 
febrile reaction came on, with a hot skin, frequent pulse, great restlessness 
and. anxiety, delirium, furred tongue, &c. In the erysipelatous cases, the 
cutaneous inflammation appeared generally on the third or fourth day, though 
sometimes not earlier than the seventh. It was no uncommon event for the 
eruption to disappear suddenly; and this was generally an unfavourable sign. 
The inflammation had a strong tendency to gangrene, was not unfrequently 
attended with phlyctenoid or carbunculous tumours, and often ended in great 
destruction of the cellular tissue, muscles, lymphatic glands, &c., which were 
discharged in a mortified state,, with a thin, exceedingly acrid, and offensive 
liquid. "So corroding and acrid was the fluid, that the hardest steel was 
directly penetrated by it as by nitric acid." (Hall and Dexter^) The fever, 
though at first inflammatory, with considerable strength of pulse, quickly 
lapsed into the typhous state; and the loss of a small quantity of blood was 
often sufficient to induce syncope. The tongue, at first covered with a gray 
or yellowish coat, became brown or blackish as the disease advanced. He- 
morrhage was not uncommon in the latter stages. In some cases, the nerv- 
ous ■ symptoms were predominant, and occasionally the disease commenced 
with coma, from which the patient was never roused. When the erysipe- 
latous affection did not appear, and sometimes along with it, there was vio- 
lent internal inflammation. The mucous membrane of the fauces, mouth, 
nostrils, &c., was especially apt to suffer; and sometimes the swelling and 
pain in the throat, tongue, &c., were so great that deglutition was impossible. 
Occasionally the inflammation extended into the stomach, and even the 
bowels. Peritonitis and pleuritis were not uncommon, and were extremely 
fatal. In some places, pneumonia was also a frequent complication. The 
duration of the complaint was very uncertain. Sometimes death took place 
in two or three days, but more frequently about the eighth or tenth day, 
and occasionally much later. Convalescence frequently took place in about 
a week or ten days, as in ordinary erysipelas, but often also it was greatly 
protracted. 
Erysipelas from Wounds in Dissection, &c.-Another cause of erysipelas, 
which merits notice, is the exposure of a wound or abrasion of the hand to 
the liquids of the dead body in dissections, or even sometimes to the secretions 
of the living body, as occasionally happens to the accoucheur. An inflamma- 
tion generally runs up the absorbents of the arm, and not unfrequently spreads 
out into an erysipelatous affection not only of the arm, but also of the chest 
and neck, with the formation occasionally of immense abscesses, and great 
destruction of the cellular tissue. I have no doubt that the peculiar effect, 
in these cases, is owing to the nature of the poison. It is not merely the 
production of erysipelatous inflammation by a wound in persons predisposed 
to it; for in the different arts, where wounds of the hands are much more 
common, and exposure to irritant causes certainly not less so, how seldom do CLASS I.] 
ERYSIPELAS. 
413 
we witness similar effects! The fever which accompanies this form of the 
disease is apt to have a low, asthenic tendency. 
Erysipelas occurs at all seasons, but most frequently, as is asserted, in 
the spring and autumn. All ages are liable to it. Women are said to be 
more frequently affected than men. One attack offers no security against a 
second. 
Nature.-The inflammation in erysipelas is of a peculiar nature, and 
derives that peculiarity from some not understood state of system, or from 
some equally unknown peculiarity of the cause. That it differs from ordinary 
inflammation is proved by its disposition to spread, the distinct boundary it 
preserves in spreading, the severe burning which attends it, its tendency to 
gangrene, and the indisposition it evinces to the secretion of coagulable lymph, 
which is so characteristic a product of phlegmonous inflammation. In the 
disease now under consideration, it is obvious that the fever, though it may 
be aggravated by the local affection, is wholly independent of it in its origin; 
for it often precedes the inflammation by one, two, or three days. It is highly 
probable that, in cases of traumatic erysipelas, there may be the same consti- 
tutional state, but in a degree insufficient to excite fever without the aid of 
the local disease. 
Diagnosis.-It may be difficult or impossible to- distinguish the initial 
fever of erysipelas, before the appearance of the cutaneous affection, from 
many other febrile diseases; but Frank has pointed out a symptom which he 
considers diagnostic; and Chomel and Blache in relation to it make the fol- 
lowing observation: "Whenever a patient has exhibited, for twenty-four or 
forty-eight hours, an intense febrile movement, attended with pain, swelling, 
and tenderness of the lymphatic glands of the neck, we have not hesitated to 
announce the approaching developement of erysipelas, and in no case has the 
diagnosis been invalidated by the result." (Diet. de Med:, xii. 233.) 
After the occurrence of the inflammation, the only disease in relation to 
which there can be any difficulty is erythema, and from this erysipelas may 
be distinguished by the greater swelling and hardness, the well defined 
boundary, and the continuity of the diseased surface. 
Prognosis.-The grounds of prognosis in this disease have been, for the 
most part, already given in the description of its varieties. As it commonly 
appears in good constitutions, it very generally ends favourably. In erysipelas 
of the face, the chief danger arises from the brain becoming involved, and 
this is most likely to happen when the inflammation invades the scalp, though 
this last event often occurs without serious consequences. A sudden disap- 
pearance of the external disease, with the occurrence of symptoms indicating 
internal irritation or inflammation, is unfavourable. Such a metastasis is 
most likely to happen in the wandering variety. The phlegmonous form is, 
in other respects, more dangerous than the superficial. The gangrenous 
variety is very dangerous. The very old, the intemperate, and those already 
nearly worn out by previous disease, are apt to die. This is peculiarly the 
case in dropsy, in which a fatal erysipelas often attacks the swollen limbs, 
especially after punctures; but death, in these instances, is only a little has- 
tened. The disease is often fatal when it occurs near the close of febrile 
diseases; though recoveries also, under such circumstances, often take place. 
The prognosis is always more unfavourable in hospital than in private prac- 
tice. In new born children, the disease is exceedingly fatal; as it often also 
is when it occurs epidemically, and whenever it puts on a malignant form. 
Coma and continued delirium are always unfavourable symptoms. 
Sometimes erysipelas is productive of good. It has often permanently 
cured impetigo, psoriasis, and other obstinate cutaneous affections; and tern- 414 
GENERAL DISEASES.-FEVERS. 
[part II. 
porarily removed syphilitic disease upon the surface of the body. It is asserted 
even to have cured elephantiasis. 
Treatment.-I shall treat first of the general, and afterwards of the local 
measures. Mild cases require little interference. Rest, saline laxatives, 
refrigerant drinks, and a low diet, constitute the routine of treatment. The 
physician, however, should always be on the watch, prepared to counteract 
any threatening change that may occur. 
In severe cases, an emetic has been recommended at the commencement. 
This remedy is supposed to be peculiarly useful in the bilious form. It no 
doubt does good, when the stomach is loaded with bile or other irritating 
matters, and may also be beneficial, when the liver is torpid, by rousing it 
into activity. It may even have the effect, attributed to it in some of the 
other exanthemata,, of favourably modifying the future course of the disease. 
But I have myself found no such advantage from emetics, in ordinary cases, 
as to compensate for their inconvenience to the patient; and now seldom 
employ them. 
A brisk cathartic at the beginning is almost always proper.' Its energy 
should be graduated somewhat to the apparent violence of the case. Often 
a full dose of Epsom salt will be sufficient. When there is considerable 
fever, recourse may be had to senna and salts, or to calomel either alone or 
combined with other cathartics, as compound extract of colocynth, jalap, or 
rhubarb. The compound cathartic pill is an eligible preparation. When 
calomel is used alone, it should be followed by castor oil, or sulphate of mag- 
nesia. The mercurial is especially indicated whenever there is torpidity of 
the liver, or too much bilious matter in the circulation; consequently in most 
of the cases called bilious. After the bowels have been thoroughly evacuated, 
it will generally be sufficient to procure one or two passages daily, which 
should be done by means of saline cathartics during active febrile excitement, 
and rhubarb in the low or typhous states of the disease. Magnesia will 
sometimes be found useful to counteract acidity, and castor oil in states of 
intestinal irritation. 
Should the pulse be strong and full, and the inflammation severe and 
threatening, bleeding may be employed advantageously in the early stages, 
and in the young and vigorous with considerable freedom.- It may some- 
times even be repeated; but this is seldom necessary. Bleeding is not so 
well borne as in ordinary inflammation; and it often happens that the loss 
of a small quantity of blood produces a very decided impression on the- pulse 
and general strength. The habits of the patient, or his previous state of 
health, have often been such as strongly to contraindicate the remedy; and, 
under these circumstances, it should not be resorted to unless imperiously 
called for. In many cases, it is quite unnecessary, and, in not a- few, is posi- 
tively forbidden by the existing debility. It should be recollected that bleed- 
ing will not cure the erysipelatous inflammation, unless by inducing such a 
degree of depression as almost to prevent the blood from circulating in the 
capillaries; and this is always dangerous. The remedy, therefore, should 
not be employed for this purpose. It is indicated when danger of suppura- 
tion or gangrene may exist from the violence of the local disease, or some 
internal and vital organ may be threatened or attacked. It should always be 
employed when stupor, or other evidence of congestion or inflammation of the 
brain is. presented, unless, as unfortunately often happens, the pulse may be 
too feeble to permit it. In doubtful cases, the patient should sit erect during 
the bleeding, and the flow be stopped immediately upon the flagging of the 
pulse, or the slightest intimation of the approach of syncope. 
Cooling diaphoretics, such as the neutral mixture, effervescing draught, CLASS I.] 
ERYSIPELAS. 
415 
solution of acetate . or citrate of ammonia, muriate of ammonia, nitrate of 
potassa, and, when the stomach is not irritable, the antimonials, may be used 
during the active state of the fever. I am usually satisfied with the neutral 
mixture or effervescing draught, preferring the latter when the stomach is 
irritable, and adding, when this organ is quite retentive, and the fever de- 
cidedly sthenic, small quantities of tartar emetic. 
When the general action is feeble, whether at the commencement, or 
becoming so in the course of the disease, and especially when nervous symp- 
toms are exhibited, such as restlessness, wakefulness, and slight delirium, the 
combination of opium and ipecacuanha is an admirable remedy, which may 
be aided by the spirit of nitric ether, the compound spirit of sulphuric ether, 
camphor water, and the warm bath, if deemed advisable. The opiate, how- 
ever, should not be used in the somnolent or comatose cases. 
If, after sufficient depletion, the local symptoms are threatening, but with- 
out any complication of gangrene or malignancy, calomel or the blue mass 
should be added to the opium and ipecacuanha, and so used as to produce the 
slightest possible mercurial impression. Sometimes, when opium is contra- 
indicated, the calomel and ipecacuanha may be used without it. Foi' the 
doses in which these remedies should be employed, the reader is referred to 
former articles on febrile diseases. 
When the symptoms assume a typhous form, with a failing pulse, and 
perhaps a gangrenous tendency in the local affection, it becomes necessary to 
support the system by stimulants and nutritious food. Opium, sulphate of 
quinia, the mineral acids, carbonate of ammonia, wine-whey, animal broths 
and jellies, and, in extreme cases, milk-punch, egg and wine, &c., should be 
used; the stimulation being graduated to the degree of depression or debility. 
In the cases of drunkards, wine or brandy should be allowed freely, as soon 
as the system begins to falter, and moderately at the commencement, even 
though it may be necessary to bleed at the same time. 
When retrocession of the cutaneous inflammation takes place, if internal 
inflammation be the cause, bleeding should be employed as far as the patient 
can well bear it; but, if it be connected with debility, which probably happens 
quite as frequently, it will be necessary to stimulate. In either case, a blister, 
or an active rubefacient, as mustard, should be applied to the surface pre- 
viously inflamed, and the whole body, if convenient, immersed in a hot bath. 
During the exhaustion of the suppurative and gangrenous state, it is highly 
important to support the strength of the patient until the process is over; and 
quinia, the mineral acids, wine or the malt liquors, opium, and nutritious 
food, are the most suitable means. 
In the periodical cases, the chief object of the physician, in the intervals, 
should be to discover any deviation from health to which the tendency may 
be owing, and to apply his remedies accordingly. It should, however, be 
borne in mind, that the erysipelatous attack sometimes protects the system 
against a worse disease, and its prevention might, therefore, be a positive 
evil. It has appeared to me -that the blood is probably in fault in some of 
these cases, and that, by altering the condition of that fluid, we might safely 
prevent the return of the disease. With this view, I have employed a diet 
exclusively of bread and milk for a considerable time, and with apparent 
benefit. 
The diet should be regulated in erysipelas, as in other febrile diseases. 
Local Measures.-The head, or whatever other part may be affected, should 
be kept in as elevated a position as may be compatible with the comfort of 
the patient. An infinite diversity of local remedies has been proposed. 
Some doubt their propriety altogether, and prefer leaving the inflammation to 416 
GENERAL DISEASES.-FEVERS. 
[PART II. 
nature, at best with only slight alleviating means. My own opinion is, that 
local measures are often of great use, but that they should be employed with 
some caution. The external affection is not the whole disease. If suddenly 
repelled by applications, the irritation may retreat with fatal effect to some 
interior organ. It is best, therefore, not to aim at its subversion, but only to 
regulate it; to check its advance when disposed to proceed too far, to diminish 
its violence when likely to lead to unpleasant results, and at all times to alle- 
viate the uneasiness which it causes to the patient. 
Perhaps, on the whole, the most comforting, alleviating, and least hazard- 
ous application, is that of some bland mucilage, kept constantly upon the 
inflamed surface, by means of soft folded linen thoroughly saturated with it. 
I usually prefer the infusion of slippery elm as being the most agreeable; 
but the infusion of sassafras pith or flaxseed may also be employed, especial 
care being taken that the flaxseed is not rancid. Should the inflammation be 
severe, advantage may accrue from the use of a solution of acetate of lead, in 
the proportion of a drachm or two to the pint of water. Slight narcotic im- 
pregnation of the liquids employed, as by acetate of morphia, infusion of 
opium, decoction of poppy heads or lettuce, may not be improper, though not 
likely to be very useful. 
Should the inflammation be disposed to spread too far, and especially into 
inconvenient or dangerous positions, it becomes proper to arrest its course. 
This is especially necessary in facial erysipelas, when disposed to ascend into 
the scalp. It can very generally be accomplished by one of three measures; 
by blisters, nitrate of silvery or tincture of iodine. The last is probably, on 
the whole, the most convenient, and, where I have employed it, has generally 
answered well. A border, of an inch and a-half or two inches in breadth; 
should be drawn across the path of the advancing inflammation, one-half of 
the width to be upon the inflamed, and the other half on the sound skin. 
The tincture of iodine of the U. S. Pharmacopoeia may be employed, and 
applied freely over the surface mentioned, so as completely to discolour it; 
and the operation may be repeated daily, if found necessary, until the inflam- 
mation begins to decline. The colour imparted by the iodine is soon dissi- 
pated, and the cuticle to which it was applied generally desquamates. Blis- 
ters may be employed in the same way, and they generally succeed, though 
more inconvenient than the iodine. The nitrate of silver is also very effi- 
cient, though the discoloration of the skin is of longer duration; and I should 
not be disposed to apply it upon the face. The most effectual plan, is that of 
Higginbottom, who employs the stick itself, or a very strong solution, made 
with eight scruples of the nitrate and twelve drops of nitric acid in a fluid- 
ounce of distilled water. Should the inflammation leap over the border 
formed in either of these modes, it will usually be with mitigated severity, 
and it may be arrested by a repetition of the application upon the surface 
invaded. 
Some apply the last mentioned remedies to the whole surface inflamed; 
and there may be cases in which the apprehension of gangrene might render 
this plan advisable; but, after the experience I have had, I fear it under 
ordinary circumstances. I have known blisters, applied in this way, to be 
followed by extensive ulceration of the skin. 
Some allusion to other local measures which have been recommended may 
not be improper. Leeching has high authority in its favour. I fear, how- 
ever, the ulceration of the bites, and seldom use them. To obviate this dan- 
ger, it is advised to apply them to the sound surface in the vicinity of that 
inflamed. But, in the general predisposition to this form of inflammation, is 
there not some danger that the bites themselves may become new foci of the CLASS I.] 
ERYSIPELAS. 
417 
disease ? The only circumstance which calls strongly for this remedy is, I 
think, the existence of some threatening internal inflammation or irritation, 
especially of the brain. Under the same circumstances, it might be proper 
to apply a blister to the nape of the neck. 
A very common and simple application, more frequently used some years 
since than at present, is rye meal, or other dry, unirritating absorbent pow- 
der, plentifully sprinkled upon the inflamed surface. The object of the appli- 
cation is to absorb the acrid fluid, which sometimes exudes from the vesicles. 
It certainly alleviates, in some instances, the burning heat; but it is also Ijable 
to the inconvenience of forming hard crusts upon the surface. Whether it 
has any influence in reducing the inflammation is doubtful. Once, however, 
I enclosed a severely inflamed leg in a thick layer of this powder, with the 
apparent effect of immediately curing the inflammation. Possibly the result 
may have been a mere coincidence; possibly it may have been ascribable to 
the exclusion of atmospheric air. 
Mercurial ointment at one time enjoyed much credit as a local application. 
Simple ointment or lard was afterwards found about as effectual. Perhaps 
they both act by excluding the air. Payer, however, states that, in erysipelas 
of the face, he has often caused one side to be rubbed over with lard, and the 
other with mercurial ointment, and, on several occasions, one of these un- 
guents was applied to one side, while the other was left untouched; and he 
never perceived that the disease was influenced by any of these proceedings. 
(Diseases of the Skin, Am. Ed., p. 69.) Some apply lard, with the addition 
of acetate of lead. 
Solution of chloride of lime, in the proportion of half a drachm to a pint, 
solution of sulphate of iron and of corrosive sublimate, the liniment of Spa- 
nish flies (U. S. Ph.), raw cotton, and compression by means of a roller, are 
other means which are asserted to have been used with benefit. The appli- 
cation of cloths wet with ice-water has also had its advocates, and may be a 
useful measure in phlegmonoid erysipelas of the extremities. 
Dr. C. D. Meigs, of Philadelphia, has found Kentish's ointment a very 
useful application in erysipelas, especially in that of new-born children. His 
mode of employing it is to render basilicon ointment soft, but not fluid, by 
the addition of oil of turpentine, and then to rub it on the part with the fin- 
gers. (N. Am. Aled, and Surg. Journ., vi. 77.) 
Dr. P. Fahnestock, of Pittsburg, 'speaks in strong terms of the efficacy of 
creasote, as a local application, in different forms of erysipelas. He has never 
known the disease refuse to yield to this remedy. In the ordinary form of 
the complaint, it is generally sufficient to apply the purest creasote once over 
the whole surface inflamed, and somewhat beyond it, on the sound skin. The 
phlegmonous variety requires a more frequent repetition of the remedy. Ac- 
cording to Dr. Fahnestock, the application should immediately whiten the 
surface. (Am. Journ. of Aled. Sei., N. S., xvi., 252.) 
Deep incisions into the inflamed part have been employed with asserted 
benefit; and they are indispensable when the inflammation has extended 
beneath one of the fascia, and is producing organic mischief there. Another 
plan is that suggested by Dobson, and recommended by Bright, of making a 
very great number of minute punctures with the point of a lancet, and wiping 
off the blood as it flows. 
When the erysipelatous surface is covered with small blisters, it is advisable 
to open them so as to prevent their communication, and the consequent loss 
of the cuticle before a new one has formed. When a raw surface is produced, 
in consequence of the separation of the cuticle, and seems indisposed to heal, 
it may be dressed with advantage with Goulard's cerate. 418 
GENERAL DISEASES.-EEVERS, &C. 
[part it. 
The progress of gangrene may sometimes, possibly, be arrested by a blister 
applied over the surface. After it has taken place, the parts should be 
covered with emollient dressings, to which creasote, pyroligneous acid, or 
solution of chlorinated soda or lime may be added, both to correct fetor, and 
as gentle stimulants. 
Article XIII. 
GLANDERS. 
Syn.-Equinia (^Elliotson).-Morve (FrencA). 
This is a malignant febrile disease, contracted by man from glandered 
horses, and characterized by a peculiar inflammation of the nasal passages, 
and a peculiar pustular eruption upon the skin, occurring either separately or 
conjointly, and attended in general by suppurating, bloody, or gangrenous 
tumours. In modern times, attention has been but recently attracted to the 
disease. Isolated cases were recorded by different writers in Germany, Eng- 
land, France, and Italy, between the years 1821 and 1830; but the first satis- 
factory account of it was given by Dr. Elliotson, in the latter of these years, 
in a paper published in the London Medico-Chirurgical Transactions. Sub- 
sequently, various contributions on the subject have been made to the jour- 
nals; and several valuable treatises have been published, among which that 
of M. Rayer is probably the most elaborate. 
The name of equinia was proposed for the disease by Dr. Elliotson, intended 
to express its derivation from the horse; as that of vaccinia was before given 
to cow-pox. Dr. Shedel, in a dissertation contained in Tweedie's Library, 
adopts the name; but applies it also to a much milder affection, derived from 
the grease in horses, designating this by the title of equinia mitis, while he 
confers that of equinia glandulpsa upon the glanders. The former is a trivial 
eruption of phlyzacious pustules,, similar to those of ecthyma, which now and 
then occur on the hands of ostlers, &c., arising from the contact of an acrid 
discharge, proceeding from the heels of horses affected with the disorder of the 
feet called grease. The eruption is attended with slight febrile symptoms, 
runs a course of ten or twelve days, then begins to decline, scabs, and ulti- 
mately disappears, leaving small well-defined scars. It occasions little incon- 
venience to the patient, and is without danger. It does not bear the least 
resemblance to the malignant affection now under consideration; and the 
mere circumstance of originating from the horse, would scarcely seem to enti- 
tle it to the same designation, however qualified by epithets. The general 
adoption of one generic name for the two complaints might lead to the injuri- 
ous impression, that they were but different grades of the same affection. 
The disease which forms the subject of the present article, has been called 
simple glanders when it affects the nasal passages especially, and farcy 
glanders when attended by an eruption of small suppurative and ulcerative 
tumours, such as are denominated farcy in horses. But, though cases may 
occur with these distinctive marks, yet in most instances the symptoms are com- 
mingled; and, as both forms have the same cause, are equally destructive, 
and, so far as known, require no difference of treatment, there does not seem 
to be any necessity for separating them. A great difference has been noticed 
in the duration of the disease in different cases; and authors are generally 
agreed in treating of it under the two heads of acute and chronic glanders. CLASS I.] 
GLANDERS. 
419 
Symptoms of Acute Glanders.-When the disease has been imparted by 
accidental inoculation, in a period of time varying from two or three days to 
a week, inflammation occurs at the point where the poison was applied, and 
extends more or less along the absorbents, and into the neighbouring cellular 
tissue, with the occurrence of febrile symptoms. Sometimes, however, there 
is little or none of this preliminary affection, and sometimes, after having 
taken place, it subsides before the characteristic phenomena show themselves. 
In many instances, the disease commences without any apparent local cause, 
as if contracted through the atmosphere. 
The first symptoms are those of an attack of fever, such as general uneasi- 
ness, languor, weariness, rigors, sometimes nausea and vomiting, headache, 
&c., followed by a frequent pulse, hot dry skin, thirst, and a furred tongue. 
Along with these are acute pains in the joints, generally confined to the limbs, 
but sometimes affecting the trunk, bearing a close resemblance to those of 
rheumatism, for which they have in some instances been mistaken. These 
pains are among the most characteristic phenomena of the earliest stage of 
glanders, and occasionally precede for a considerable time the occurrence of 
other symptoms. Portions of the skin over the painful joint or joints, or 
upon the face, become red as in erysipelas; but soon assume a violet colour, 
and show the bad tendencies of the disease by vesicles and patches of gangrene. 
At a variable time from the commencement of the attack, usually, perhaps, 
in about a week, an eruption of phlyzaceous pustules takes place, most abun- 
dant on the face and limbs, about the size of the vaccine vesicle, having 
frequently a small red areola, sometimes umbilicated, and presenting occa- 
sionally a dark purple hue. They occur in successive crops, and appear, 
therefore, in different stages of progress at the same period of the disease. 
Along with these pustules are gangrenous bullae, especially on the face and 
scalp; prominent ecchymoses filled with a reddish sanious fluid, and having 
sometimes a gangrenous base; and tumours from an inch to three inches or 
more in diameter, which are at first hard and painful, but quickly suppurate, 
and form abscesses extending into 'the subcutaneous cellular tissue, and often 
deep into the substance of the muscles. 
At a still later period, sometimes not until a few days before the close of 
the complaint, the nostrils begin to discharge a mucous or purulent fluid, 
which is at first yellowish, afterwards dark from the admixture of blood, and 
often extremely offensive. In some instances, it is thin and sanious, but 
more frequently viscid and tenacious, adhering to the sides of the nostrils and 
to the upper lip, forming characteristic crusts, and excoriating the parts which 
it touches. Sometimes this secretion flows back into the fauces, and, being 
swallowed, does not appear externally. The nostrils are more or less ob- 
strUcted by the swelling of the membrane, even before the occurrence of 
the discharge, and become still more so afterwards, so as much to impede 
respiration. Gangrenous openings sometimes take place in the cartilaginous 
septum, so that a probe may pass from one nostril into the other. In 
certain cases, the discharge makes its appearance early in the disease; and 
in most, it is probable that, long before its occurrence, a close examination 
would exhibit evidences of inflammation in the Schneiderian membrane. 
The salivary glands are occasionally swollen; the mouth and fauces are in- 
flamed in spots or patches; and the larynx in some instances so much parti- 
cipates in the disorder, as to endanger suffocation by the closure of the glottis. 
The lungs are not unfrequently involved, and a cough occurs with rusty 
or adhesive expectoration. 
The face exhibits in a peculiar manner the ravages of the disease. The 
nose is red and swollen; a gangrenous inflammation extends to the lips, eye- 420 
GENERAL DISEASES.-FEVERS. 
[PART II. 
lids, and forehead; one or both eyes are closed by tumefaction; and eschars 
form, surrounded by a dark red or livid edematous border, with awful muti- 
lation of the features. 
The general symptoms are in accordance-with these local phenomena. The 
skin is hot; the tongue dry and coated; the respiration hurried or laborious 
and sometimes stertorous; the pulse frequent, small, and feeble. There is 
often extreme thirst. Diarrhoea is an almost constant symptom, with frequent, 
offensive discharges. The body exhales a fetid odour. The mind wanders, 
and delirium alternates with coma. At length involuntary discharges, and 
extreme prostration, indicate the immediate approach of death, which is the 
uniform termination of acute glanders. The duration of the disease varies 
in general from two to three weeks. Sometimes death takes place earlier 
than the former period, from some incidental cause, such as closure of the 
glottis, and occasionally it is postponed to the end of the fourth or fifth week. 
The symptoms enumerated do not all occur in every case, nor always in 
the order stated. In some instances, the nasal phenomena predominate, in 
others, the carbunculous or eruptive; and one of these sets of symptoms may 
occur to the exclusion of the other. But, whatever may be the precise course 
of the acute complaint, the event is invariably the same. The patients all 
die. I have seen the record of only one case that is said to have ended in 
recovery, and that was doubtful. (See Archives Generates, 4e ser., xiv. 89.) 
Symptoms of Chronic Glanders.-The cases which have been recorded as 
belonging to this variety of the affection are comparatively few, and its history 
is less satisfactorily made out than that of the acute form. Nevertheless, 
there seems no good reason to doubt that the complaint does occasionally 
assume a chronic character. In the mildest cases, the symptoms are some- 
times confined to the nasal passages and the communicating cavities, from 
which a very offensive discharge issues, sometimes glutinous, sometimes puru- 
lent or sanious. ' This form of the disease may get well under treatment; in 
which case, unless its origin be very clearly traced, its nature must always remain 
doubtful. In other instances, after a variable duration of several months, the 
nasal affection becomes complicated with tumours, acute symptoms supervene, 
and the patient speedily perishes. Instead of being at first restricted to the 
nostrils, the complaint may exhibit itself by pains in the joints, with spots of 
redness on the limbs, and suppurating tumours, which may continue for 
months, and at length, becoming complicated with disease of the nostrils, may 
run on to a fatal termination. There have been no instances of chronic glan- 
ders, in which the peculiar pustular eruption has existed. 
Anatomical Characters.-Besides the external lesions which are evident 
during life, dissection reveals bloody infiltration, gangrene, and suppuration 
of the cellular tissue; abscesses in the muscles; thickening, softening, and 
redness of the Schneiderian membrane, which is covered with a grayish 
mucus, and is studded with numerous minute yellowish elevations, of the size 
of a small shot, sometimes isolated, sometimes clustered, and filled with pus 
or a thick lymph; ulceration and gangrene of the same membrane, with denu- 
dation and caries of the bone, and sometimes an opening through the septum; 
the same eruptive appearances, to a certain extent, in the soft palate and the 
fauces; tumefaction of the glottis; and abscesses in the lungs, or more fre- 
quently the marks of lobular pneumonia abundantly diffused through those 
organs. The alimentary canal, the heart, and the large interior glands, are 
not prominently affected. The blood retains its coagulability, and does not 
present the dark tarry appearance sometimes observable in malignant fevers. 
Cause.-The cause is well ascertained to be a poison generated in the 
horse, and other animals of the same genus, as the ass and mule, affected with CLASS I.] 
GLANDERS. 
421 
glanders. The disease is imparted either by contact of the poisonous secre- 
tion with some abraded point on the surface; by its introduction into the 
stomach, as when the patient has drank out of the same vessel with the ani- 
mal; or through the medium of the atmosphere, though this last mode of 
communication is somewhat doubtful. Persons have been affected with 
it who have lodged in the same stable, or been otherwise in close com- 
munication with the diseased animal, without being able to trace it to direct 
contact of the matter with an abraded spot. The case of a woman is recorded 
who was supposed to have been attacked from working among horse-hair. 
Others have suffered in consequence of washing the linen of persons affected 
with the disease, showing that it is communicable from man to man. It 
appears that few individuals are susceptible of glanders; for the proportion of 
those who have been attacked after exposure is extremely small. It is said 
that the persons affected have generally been of intemperate habits, or of con- 
stitutions otherwise debilitated. 
Treatment.-In relation to the acute disease, all the methods of treatment 
hitherto employed having proved unavailing, it is scarcely worth while to occupy 
space by detailing them. The practitioner must be left to the guidance of 
his own medical principles. Having had no experience in the complaint, I 
do not feel authorized even to offer suggestions. In the chronic, affection, Dr. 
Elliotson found advantage from the injection of a solution of creasote into the 
nostrils, while the same medicine was given internally. Two cases in which 
only one nostril and the frontal sinuses were affected, are stated by him to 
have yielded to this remedy. Another case, which recovered under the care 
of Mr. Travers, was treated chiefly with emetics. 
CLASS II. 
CONSTITUTIONAL DISEASES, &c. 
The above title does not exactly designate the diseases belonging to this 
class. It is used, for the sake of brevity, with a somewhat arbitrary applica- 
tion. As already stated (see page 217), the second class embraces constitu- 
tional affections, which may display themselves in local disease of any part of 
the system, but not in all parts at the same time. This want of universality 
excludes them from the first class; and, as they frequently occupy several 
different organs at once, and may pass from any one organ to any Other during 
the same attack, they cannot be placed in the category of affections strictly 
local. 
The only diseases which I place in this class are rheumatism and gout. 
There are others that properly belong to it, but, for convenience sake, are 
considered elsewhere. One of these is scrofulous or tuberculous disease. This 
is certainly a constitutional affection, and may show itself in any one part, or 
in many parts of the system at the same time. But the local affections are 
of so fixed a character, are in some instances so strongly marked, and are so 
universally looked upon as constituting distinct diseases, that they are advan- 
tageously described rather in reference to their position than their nature. 
Hence, I have treated of what concerns the disease generally under general 
pathology, and propose to treat of its local exhibitions, as phthisis, external 
scrofula, mesenteric disease, &c., among the local affections belonging to the 
third class. The same remarks are applicable to carcinoma or cancer, and to 
melanosis. Syphilis, in its advanced stages, would also be attached to the 
present class, were it admitted into this work; but it is so generally con- 422 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
sidered as a surgical disease, and so fully treated of by surgical writers, that 
it may be omitted, without inconvenience, in a treatise upon the practice of 
medicine. With regard to rheumatism and gout, it may be thought that the 
fever which attends them should rank them in the first class; but fever is not 
a necessary accompaniment of these diseases; and, w'hen it occurs, is almost 
always secondary, and dependent on the local affection. 
Article I. 
RHEUMATISM. 
Rheumatism (from ^i^a, rheum or flux') is a constitutional affection, at- 
tended with a peculiar irritation or inflammation, to which all parts of the 
system are liable. Its general characters might have been described, in the 
first part of this work, under the heads of irritation and inflammation, as one 
of the specific forms of these affections; while its appearance in particular 
parts, organs, or tissues might have been reserved for the department of 
special diseases. But it so frequently occupies many parts, at the same time 
or successively, in the same attack, and presents so strong an individuality in 
whatever part it may exist, that it is most conveniently considered as one 
disease wherever it may appear, and therefore as belonging to this section of 
the work. It was formerly confounded with gout, under the common desig- 
nation of arthritis; and, according to Dr. Chapman, the application to it of 
the name rheumatism first occurs in Ballonius's treatise, "De Rheumatismo, 
&c.," published in Paris in 1642. It is considered by most writers to be 
peculiar to some one, or to a few of the tissues, as the fibrous, muscular, and 
serous. I believe that it may affect one or all of them; and proofs of the 
fact will, I think, be afforded, in the. course of the following description of 
the disease. 
Rheumatism may be divided, according to its seat, or its grade of excite- 
ment. Thus, some writers treat of it under the heads of articular and mus- 
cular rheumatism, the former occupying the joints, the latter the muscles; 
but the fact is, that, though the disease is often situated exclusively in, one or 
the other of these parts, it yet quite as frequently occupies both, to a greater 
or less extent, in the same attack. A better division is that founded upon 
difference in grade; and, for convenience of description, the four following 
varieties may be recognized:-1, the acute, in which violent local inflamma- 
tion is attended with considerable constitutional disturbance, or fever; 2, the 
subacute, in which the inflammation is less violent, and there is little or no 
fever; 3, the chronic, which is characterized by long duration, and the lowest 
grade of inflammatory action; and 4, the nervous, in which there is neither' 
inflammation nor fever, the disease consisting exclusively in irritation, and 
that directed especially to the nervous tissue. 
Syn.-Rbeumatismus. 
1. Acute Rheumatism. 
Symptoms, Course, &c.-Fever invariably attends this form of the disease. 
It is said sometimes to precede the inflammation; but this event is rare. The 
primary symptoms are generally local. In the great majority of cases, they 
show themselves in the extremities, and usually first in the lower. The dis- 
ease may be confined to a single joint, or to a part or the whole of one limb; 
but much more frequently it affects several limbs, and different portions of CLASS II.] 
RHEUMATISM. 
423 
the trunk, jointly or successively; and occasionally it involves almost the 
whole exterior of the body. It has been observed, however, that when this 
last event occurs, one side of the body is more severely affected than the 
other. The small joints, as those of the fingers and toes, are less frequently 
inflamed than the larger, as the ankle, knee, wrist, and elbow. 
Sometimes the complaint begins with a feeling of uneasiness or stiffness in 
the part, which soon amounts to soreness or positive pain, especially upon 
motion. In other instances, the first symptom is acute and violent pain. 
Heat and swelling soon come on; and, when the pain has been sharp and 
lancinating, it is very commonly moderated after tumefaction. Extreme 
soreness, however, remains, and the slightest movement of the part occasions 
suffering. The swelling is usually tense and elastic, and the surface often 
reddened, with a light rose colour gradually shading off into that of the 
healthy skin; but, in many instances, the natural colour is in no degree 
altered. 
Commencing generally in one part, the inflammation quickly extends to 
others, as from the ankle to the knee, or from the ankle or knee of one side 
to the corresponding joint on the other; then to the wrist or elbow; some- 
times in its progress attacking neighbouring parts, sometimes distant parts in 
succession; and often declining or disappearing in one seat, after fixing upon 
■another. The swelling of the deserted joint does not immediately subside 
with the pain, but usually becomes softer, and, instead of being firm and 
.elastic, will often'pit somewhat upon pressure. Not unfrequently, a joint is 
attacked a second time, and occasionally a third or fourth time,, or even more 
frequently, before the disease ends. In some cases, the inflammation is con- 
fined chiefly to the neighbourhood of the joints; in others, it affects more 
especially the muscles; in others again, both structures are involved, and 
indeed all the tissues; the whole limb being swollen, tense, and extremely 
tender. In the joints, the disease may be confined to the ligaments, or may 
affect also the synovial membrane. In the former case, the swelling is firm 
and elastic, in the latter often somewhat soft and fluctuating, in consequence 
of the increase of the synovial secretion. The latter condition is especially 
observable in the knee, where fluctuation may be perceived on each side of 
the patella. The swelling is usually greater in the more superficial joints, as 
the ankle, knee, and elbow, than in those more protected by muscles, as the 
hips and shoulders. In severe cases, the suffering is often very great. The 
pains, which are scarcely ever entirely absent, are at times almost excruciating, 
being described as tearing, rending, &c.; and the slightest movement, or the 
least jar or pressure, produces so much suffering that the patient does not 
dare to change his position, and dreads the approach of any one to his bed. 
Very soon after the local seizure, rigors and other symptoms of commenc- 
ing fever are experienced, followed by increased frequency of pulse, heat of 
skin, furred tongue, anorexia, thirst, and occasionally headache. The fever 
is almost always of the sthenic character, and generally of a violence propor- 
tionate to that of the local affection, though not invariably so. The pulse is 
full, strong, and usually not very frequent, varying from ninety to a hundred 
and ten, and probably, in the greater number of cases, not exceeding a hun- 
dred. Respiration is not sensibly disturbed, while the disease confines itself 
to external parts. The surface, though warm, is less heated than in most 
other fevers, and is often moist, sometimes indeed bathed in copious sweats, 
which have a peculiar sour and sickening smell, and have no effect in reliev- 
ing the inflammation or pain. The tongue is usually moist, and thickly 
covered with a whitish fur. There is seldom nausea or vomiting. The 
bowels are generally constipated, and sometimes obstinately so. The secre- 424 
CONSTITUTIONAL DISEASES, &C. 
[PART II. 
tions are little diminished, with the exception of the urine, which is scanty, 
high coloured, and disposed to let fall lateritious sediments upon cooling. 
The brain is usually remarkably exempt from disorder; the patient being 
seldom delirious, though not unfrequently deprived of sleep by the violence 
of his pains. I have, however, seen delirium a prominent symptom, without 
any reason to suspect positive cerebral inflammation. The fever is usually 
remittent, with exacerbations in the evening, which are often accompanied 
with an increase of the pains. These are consequently worse at night, and 
relax somewhat with the fever in the morning. 
The disease may run its course, and very often does so, without penetrat- 
ing any of the great cavities. But often, also, either by a simple extension, 
or by a metastasis of the inflammatory action, various internal organs become 
affected, and the case very seriously complicated. The most frequent of these 
complications is inflammation of the lining and investing membranes of the 
heart, constituting endocarditis and pericarditis. The fact that serious organic 
disease of the heart occasionally originates in rheumatism, and even the pecu- 
liar liability of the cardiac membranes to become inflamed, have been long 
known to the profession; but Bouillaud was the first to prove the frequency 
of the affection, and its existence in many cases in which the ordinary symp- 
toms would not have indicated it. According to that author, it occurs in the 
great majority of cases of acute rheumatism. Dr. Wm. Budd states that, out 
of forty-three cases of which he preserved accurate notes, the symptoms of 
rheumatic inflammation of the heart were unequivocal in twenty-one, of which 
five were pericarditis. (Tweedie's Syst. of Pract. Med.~) I am convinced that 
this is a much larger proportion than occurs in this country. Probably our 
energetic practice in acute rheumatism may be one cause of the difference. 
According to Dr. Budd, the period at which the cardiac disease comes on 
varies from the eighth to the twenty-seventh day. With us, acute rheuma- 
tism often terminates within these limits, and probably before the time at 
which the inflammation of the heart would ensue were the case to run its 
natural course. Endocarditis is much more frequent than pericarditis; and, 
when the latter occurs, it is very apt to be accompanied by the former. In 
the great majority of cases, both affections yield to proper remedies. Pericar- 
ditis is more immediately dangerous, endocarditis leaves the most unpleasant 
effects behind it. In the former, the two surfaces of the pericardium coalesce 
in case of recovery, and no disagreeable consequences ensue. In the latter, 
if not cured, disease of the valves is apt to remain, which is followed in time 
by hypertrophy and dilatation, and ultimately by death. For further details 
in relation to these affections, their symptoms, physical signs, anatomical 
characters, and results, the reader is referred to Diseases of the Heart. It 
may be proper in this place to state, that, whenever, in the course of acute 
rheumatism, pain and oppression in the precordial region, difficult or hurried 
breathing with or without cough, palpitation, increased frequency of pulse, 
and an anxious, disturbed, or peculiar expression of countenance, supervene, 
disease of the heart may always be suspected; and a close examination should 
be made, by means of auscultation and percussion, into the condition of that 
organ and its membranes. The cardiac affection may, indeed, occur without 
announcing itself by any of these symptoms, and, in its earlier stages, may 
entirely escape the attention of the practitioner, unless sought for by the 
means alluded to. In general, the occurrence of endocarditis or pericarditis 
is not attended by any material abatement of the external inflammation, so 
that they must be looked upon as an extension, and not as a transfer of the 
disease. A case, however, of acute rheumatism in a young lady occurred to 
ine, in which a retrocession of the inflammation from one of the lower extre- CLASS II.] 
RHEUMATISM. 
425 
mities, was followed by disease of the heart, which proved fatal in a few days. 
Either there was metastasis here, or the concentration of a powerful excite- 
ment in the central organ, called off the disease from the limb upon the prin- 
ciple of revulsion. It is said that rheumatism, affecting the ligamentous 
structure of joints, is more apt to extend to the heart than the same affection, 
seated in the synovial membranes. Children, when affected with inflamma- 
tory rheumatism, are much more liable to this complication than adults. 
Next to the membranes of the heart, the pleura is probably the most fre- 
quent seat of internal rheumatic inflammation. Pleuritis, however, seems, 
in most cases, to be an extension of the cardiac disease, or at least to occur 
simultaneously with it. The pleurisy of acute rheumatism differs apparently 
in nothing from the disease arising from other causes. (See Pleurisy. 
Sometimes the brain or its investing membranes are affected. There is 
reason to believe that the disease is seated more especially in the membranes, 
though an irritation is undoubtedly propagated to the cerebral substance. 
Disease of the heart has generally of late been observed in these cases, and 
the cerebral affection has been considered by some as depending upon the 
cardiac. The probability is, that the two are mere coincidences, depending 
upon a common cause. Pain in the head, with increased sensibility to light 
and sound, delirium, and coma, are signs of the extension of rheumatism to 
the brain. The use of large doses of quinia in acute rheumatism is said to 
have occasioned this complication, in some instances. 
The peritoneum is said to be sometimes though rarely affected. I do not 
remember to have witnessed an instance of the kind. Occasionally, violent 
affections of the stomach and bowels supervene in rheumatism, but oftener, I 
believe, in other forms of it than in the acute. The same may be said in 
relation to the kidneys. (See Subacute and Nervous Rheumatism.) 
A variety of acute rheumatism denominated bilious has sometimes been 
noticed, especially in miasmatic districts. Its peculiarities may be dependent 
upon two causes. The transfer or extension of rheumatic irritation to the 
liver may derange the functions of that organ, giving rise in some instances; 
to bilious vomiting from an excess of secretion, in others to yellowness of the 
tongue, conjunctiva, and skin, with bilious urine and clay-coloured stools, 
from a suspension of the secretion, as in jaundice. (See Jaundice.') But 
more frequently, the rheumatism is coincident with an attack of intermittent 
or remittent fever, and exhibits, along with its own peculiar phenomena, the 
bilious symptoms and paroxysmal character of those affections. 
The disease occasionally assumes an adynamic character, marked by di- 
minished force and increased frequency of pulse, copious sweats during sleep, 
a feeling of great debility, and a more than ordinary tendency to metastasis. 
The symptoms, however, are seldom or never of that peculiar kind denomi- 
nated typhous. 
The duration of acute rheumatism is uncertain. By proper remedial mea- 
sures it may frequently be arrested in a week or two; but sometimes it runs 
on for six weeks, two months, three months, or even longer. Perhaps from 
two to three weeks is the ordinary duration under judicious treatment from 
the beginning. In its course it not unfrequently exhibits alternations 
of amendment and aggravation; and sometimes, when everything promises 
fairly, the disease resumes, without obvious cause, all its original violence. 
In some cases, it appears like a succession of local attacks in different parts, 
each running a course of a week or ten days, and not unfrequently recurring 
again and again in the same part. In any one position, a decline of the dis- 
ease is indicated, first by the diminution ox' disappearance of the pain, then by 
a softening of the part, so that, instead of being tense and elastic as at first. 426 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
it will not unfrequently retain for some time the impression of the finger, and 
lastly by a gradual subsidence of the swelling. When the general disease is 
about to give way, new accessions of inflammation cease, or, if they occur, 
exhibit a much milder character; the violence of the pain everywhere sub- 
sides; the patient loses his excessive sensibility to impressions from without; 
and the febrile symptoms are moderated or disappear. Some swelling and 
soreness are apt to remain, for a considerable time, after the violence of the 
disease is passed; and weakness and stiffness of the joints and muscles are 
frequently left, after convalescence has been long established. In some cases, 
the febrile movement does not cease with the obvious inflammation, being 
kept up probably by some lurking affection of the internal organs, possibly 
by inflammation of the inner coat of the arteries. On the contrary, more or 
less local disease is not unfrequently left after the fever has gone, and the 
acute degenerates into chronic rheumatism. 
Anatomical Characters.-The blood abounds in fibrin, and almost always 
exhibits the huffy coat when drawn during life, and allowed to coagulate. 
Indeed, with the exception of pneumonia, there is no one of the phlegmasim, 
in which these characters exist so strongly as in acute articular rheumatism. 
In one instance, Andral and Gavarret found in 1000 parts of blood, 10'2 
parts of fibrin, the healthy standard being 3. But it is only during the ex- 
istence of the acute pain and fever that this excess is so striking. The pro- 
portion after their disappearance, though swelling and soreness may remain, 
is sometimes below the healthy mean. Dr. Garrod found in the blood of 
acute rheumatism no more uric acid than exists in that fluid in health; that 
is, only a trace. (Lond. Med. Gan., Feb. 1848.) 
After death, the synovial membranes have been found red and thickened, 
and the liquid in their cavities simply increased, without material alteration 
of character. In some rare instances, however, pus has been observed in the 
joints, and, still more rarely, false membrane and albuminous flocculi. The 
fibro-cartilages have also exhibited evidences of inflammation in softening 
and erosion. Urate of soda does not appear to have been, in any instance, 
detected in the joints. The muscles affected by the disease have presented a 
dark-red colour, with softening, and the effusion of a bloody serum into their 
interstitial cellular tissue. Signs of inflammation have also been noticed in 
the lining membrane of the arteries. The various internal inflammations 
which attend the disease leave the same effects behind them as under other 
circumstances. 
Causes.-Almost the only known exciting cause of acute rheumatism is 
cold. Moisture increases its effect, but, in all probability, only by serving as 
a more rapid conductor than the dry air. The cold operates most powerfully 
during perspiration from previous exercise or exposure to heat. Sleeping in 
damp sheets or upon the damp ground, the wearing of wet clothes, exposure 
to cold rains without subsequent change of dress, and sitting in a damp cold 
room, are examples of the kind of exposure which is apt to be followed by the 
disease. From a knowledge of the cause of rheumatism, it would be inferred 
that the complaint must be most prevalent in damp changeable climates, and, 
as relates to the seasons, in the latter part of autumn and in spring. 
But something more is requisite than cold. There must also be a peculiar 
state of system predisposing to this form of disease. There must be a rheu- 
matic diathesis. In what this diathesis consists has not been discovered. 
There are no signs by which its existence can be detected, with an approach 
to certainty. Large jointed, muscular, and lank frames are probably more 
frequently affected than those of opposite characteristics. Men are more sub- 
ject to the disease than women, but, in all probability, because more exposed CLASS II.] 
RHEUMATISM. 
427 
to vicissitudes of temperature. The predisposition is certainly much affected 
by age. Children under ten years, and adults over sixty, are seldom attacked; 
and the period of life at which the disease is most prevalent is probably be- 
tween fifteen and thirty-five or forty. Among the most powerful predisposing 
causes of the disease is a previous attack of it. At least, persons once affected 
are more liable to the complaint afterwards than they had previously been; and, 
when it occurs in the old, it is almost always in those who. have been attacked 
at an earlier period of life. I think it is no less certain that a predisposition 
to the disease is often inherited. It is very apt to exist in members of the 
same family, whether inherited or not. Debility appears to favour the pre- 
disposition; though full and vigorous health does not afford protection. The 
diathesis, when strong, is alone sufficient to generate the disease, without the 
aid of exciting causes. 
Diagnosis.-Gout is the only disease with which acute rheumatism is liable 
to be confounded; and from this it is in general readily distinguished. The 
same, however, cannot be said of some other forms of rheumatism. The diag- 
nostic symptoms will be more conveniently given under the head of gout. 
Prognosis.-Acute rheumatism, though an exceedingly painful disease, is 
in adults very seldom immediately fatal, and, if properly managed, rarely 
leaves any fatal effects behind it. If uncomplicated with the internal inflam- 
mations alluded to in the account of the symptoms, it may almost always be 
conducted to a favourable issue. Of these complications, the cerebral, though 
comparatively unfrequent, is probably, in proportion to the number of cases 
in which it occurs, most fatal. The dangers to be apprehended from endo- 
carditis and pericarditis have been already alluded to. I cannot, however, 
avoid expressing my conviction, that these dangers, so far as acute rheumatism 
is concerned, have been greatly exaggerated in some recent practical trea- 
tises. I do not remember to have met with more than a single case of fatal 
affection of the heart in adults, either during or subsequent to an attack of 
acute rheumatism, which I had the opportunity of seeing in its earlier stages. 
In children, however, the case is otherwise. In these, though the complaint 
is comparatively very rare, it is always dangerous, in consequence of its tend- 
ency to give rise to a condition of the heart, ending in fatal hypertrophy and 
dilatation. 
2. Subacute Rheumatism. 
Very many cases of rheumatism occur, so limited in extent, and attended 
with so little constitutional disturbance, as to have no claim to be ranked 
with the acute variety; while their brief duration excludes them from the 
chronic. These are embraced in the division at present under consideration. 
As in the preceding variety, the disease may in this affect either the muscles 
or the joints; but, while in the acute the joints are most frequently affected, in 
the subacute, the precedence belongs to the muscles. 
Symptoms, Course, &e.-Two or more joints maybe inflamed; but, in 
probably the greater number of instances, the disease is confined to one at the 
same time; as, with the grade of action often present in these cases, an exten- 
sion to several of the articulations simultaneously would give rise to decided 
fever, and thus constitute acute rheumatism. The local symptoms are not 
materially different from those described under the preceding variety. The 
pain, however, is usually less severe, amounting often only to slight aching 
or soreness. There is also less redness and heat, and the swelling is less 
tense and elastic. There is sometimes increased secretion of the synovial 
fluid, and that of the bursae, and fluctuation may be noticed in the vicinity of 
the joint, especially the knee. 428 
CONSTITUTIONAL DISEASES, &C. 
[PART II. 
In the muscular form, as in the articular, the disease may extend to several 
muscles, or be limited to one. It very frequently extends to several in the 
same neighbourhood, and concerned in the same office. In some instances, 
there is at first a feeling of soreness, which gradually increases until it 
amounts to a dull aching pain, which becomes acute when the muscle con- 
tracts. In others, the patient first becomes sensible of the complaint by a 
very severe sharp lancinating pain, which seizes the muscle upon some occa- 
sion when it is suddenly called into action, as upon attempting to rise from 
the sitting posture, to turn in bed, or to lift a burthen. The pain is some- 
times excruciating, so as to render the patient unwilling or unable to repeat 
the motion; and, when the part is necessarily moved, as in respiration, 
coughing, &c>, the suffering is very great. During the intervals of motion, 
there is generally also a sense of uneasiness or aching, with increased heat, 
and the part is usually more or less tender when pressed. Sometimes there 
is tumefaction; but it is seldom if ever considerable, and is often wanting. 
The pulse is sometimes excited, and the general heat increased; but the con- 
stitutional disturbance scarcely amounts to fever. Any of the external 
muscles may be affected, and the disease often takes a name according to its 
seat. The internal muscles are also often attacked either primarily or 
secondarily. <■ 
But this variety of rheumatism is not confined to the joints and muscles. 
It is probably capable of attacking any of the tissues. There is reason to 
believe that it sometimes seizes upon the nervous sheaths, producing pain 
upon pressure along their course, and extending an irritation to the nerves 
themselves, which is felt in pain and spasm of the parts to which they are 
distributed. Many of the severe and complicated nervous disorders, both- of 
external and internal parts, connected with tenderness of the spinal column 
when the spinous processes are pressed, are probably owing to subacute rheu- 
matism in the sheath of the spinal marrow. 
This variety of rheumatism is peculiarly liable to metastasis, certainly more 
so than either the acute or the chronic. In the acute, the inflammation is so 
severe as to give a strong direction of the disordered constitutional tendencies 
to its own seat; in the chronic, the disease appears often to be almost local, 
and to have no disposition to change. In the subacute, the constitutional 
tendency to rheumatic disease is strong, while the local affection is so feeble, 
that it readily yields to causes which give the irritation another direction. 
The variety is intermediate between the high inflammatory and the pure 
nervous forms. 
To complete a view of subacute rheumatism, it will be necessary to consider 
it in some of its more frequent and prominent seats. 
In the Scalp.-The subcutaneous muscular and fibrous tissue of the scalp 
is occasionally attacked with this form of rheumatism. It is known by 
headache, often quite severe, soreness of the scalp on pressure, pain on the 
movement of the occipito-frontalis muscle, and the presence of rheumatism 
previously, or at the same time, in some other part of the body. These 
symptoms will in general suffice to distinguish it from nervous or sick head- 
ache, for which, without care, it may be readily mistaken. In this latter 
affection, pressure, instead of causing pain, often yields relief. 
In the Eyes.-Rheumatism sometimes attacks the muscles of the eye, and 
sometimes its fibrous coat. In the former case, the motions of the ball are 
affected, and every movement which tends to put the diseased muscle on the 
stretch, or every attempt to contract it, occasions severe pain. When all the 
muscles are affected, the eye is held firmly in one position, from which it 
cannot move; but this is exceedingly rare. When the sclerotica is the seat CLASS II.] 
RHEUMATISM. 
429 
of the disease, the ball is painful to pressure, and a dull redness may some- 
times be seen through the conjunctiva; but it is very difficult to distinguish 
the affection from ordinary inflammation, except by taking into consideration 
the constitutional tendencies of the patient, and the state of his system at the 
time. 
In the Face.-The masseter muscle is sometimes affected with rheumatic 
inflammation, so that the patient cannot open his mouth, and great alarm is 
sometimes created under the apprehension of tetanus or locked jaw. It is 
sufficient for the physician to be aware of the occasional existence of such a 
condition of the muscle, to avoid all danger of so gross an error. 
In the Neck.-Under the name of stiff-neck, wry-neck, or torticollis, rheu- 
matism sometimes exists in the muscles of the side of the neck, especially in 
the sterno-mastoid. It may occupy both sides of the neck equally, in which 
case the head is held stiffly erect, and steadily looking forward; but much more 
frequently one side only is disordered, and the head is drawn towards that 
side, usually more or less obliquely. While the head is allowed to remain at 
rest, the patient is easy, or feels only a dull aching; but every movement is 
exquisitely painful. 
In the Parietes of the Chest.-Pleurodynia.-1This complaint is not unfre- 
quent. It is a rheumatic affection of the intercostals, and other muscles of 
the trunk, and is characterized by severe, acute, and generally shifting pain 
in the side upon taking a full breath or coughing, by soreness of the inter- 
costal spaces upon pressure, and by the general absence of fever. It resem- 
bles pleurisy considerably in its most obvious symptoms, and, when attended, 
as sometimes happens, by a, slight febrile movement, or by an accidental 
cough, the diagnosis is so uncertain that it can be made out only by attend- 
ing to the physical signs. (See Pleurisy.') The risk of confounding the two 
affections is increased by the fact, that, in consequence of the pain arising 
from the movement of the intercostal muscles, there is little expansion of the 
affected side of the chest, so that the respiratory murmur is less distinct, and 
percussion somewhat duller than in health. As other muscles about the chest 
are often affected at the same time, the diagnosis is sometimes aided by the 
occurrence of severe pain, upon attempting to twist or bend the trunk. 
In the Abdominal Parietes.-This is a very rare seat of rheumatism, which 
nevertheless does sometimes attack the abdominal muscles, producing symp- 
toms that might be mistaken for those of peritonitis, though distinguishable 
by the effect of movement, and the want of the constitutional symptoms of 
the former. 
In the Lumbar Muscles.-Lumbago.-This occupies the muscles situated 
in the small of the back, sometimes extending up the spine, sometimes shoot- 
ing round towards the abdomen. It may be upon one side exclusively, or 
upon both. It is often first recognized by the occurrence of a sharp pain, as 
if from the thrust of a knife, upon attempting to rise from the sitting posture, 
or to raise a burthen. When very severe, it confines the patient to bed, and 
in one position, from which he cannot move without exquisite suffering. In 
milder cases, the patient can often walk, but always stiffly, and generally par- 
tially bent forward upon the hips, with the spine perfectly rigid. It is not 
unfrequently attended with more or less febrile action, and may even be so 
severe and extensive as to come with great propriety under the division of 
acute rheumatism. In such a case, however, it usually forms a part of a 
more extensive affection. The effects of motion, and the tenderness on pres- 
sure, sufficiently distinguish it from the violent pains of malignant fevers. 
From inflammation of the kidneys it differs in wanting the peculiar direction 
of the pain towards the groin, the retraction of the kidneys, the irritation of 430 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
the urinary passages, and the nausea and vomiting which characterize that 
disease; as also in the more decided tenderness, and greater pain on certain 
motions which bring the muscles of the back into play. Disease of the spine 
occasions also severe lumbar pains, which are sometimes increased by motion; 
but there is less pain upon pressure, less acuteness in the symptoms, and more 
or less disorder in the functions of the lower extremities, which is wanting in 
lumbago. 
In Hie Hip.-Sciatica.-The parts about the hip are often attacked with 
rheumatism, which is seated sometimes in the muscles, sometimes in the joint 
or in the ligaments of the pelvis, and occasionally also, there is reason to 
believe, in the neurilema of the sciatic nerve, showing itself by tenderness 
along the course of that nerve, and pain with other disordered sensations in 
the corresponding thigh and leg. The simultaneous occurrence, or previous 
existence of rheumatism in other parts, is the surest diagnostic sign of this 
affection, which might otherwise be readily confounded with neuralgic, pains, 
or those having their origin in common inflammation. The steadiness of the 
pain, which is rather dull than acute, and its increase when the patient 
becomes warm in bed, are other signs of its rheumatic character. Sciatica, 
however, is more frequently chronic than either acute or subacute. 
In the Heart.-The subacute form of rheumatism is peculiarly apt to invade 
the internal parts of the body. I believe that it is more frequently the origin 
of serious organic disease of the heart than the acute variety; at least, of the 
cases of chronic cardiac disease originating in rheumatism which have come 
under my notice, I am confident that the larger number have succeeded exter- 
nal attacks of rheumatism, too moderate or limited to be considered as belong- 
ing to the acute variety, as defined in this work. It is this form, too, which 
is most likely to seize upon the muscular structure of the heart, producing, 
according to its severity, immediate death, or severe pains, palpitations, op- 
pression, &c., and not unfrequently terminating in a chronic affection with 
hypertrophy and dilatation of the organ. Cases of sudden death, leaving no 
satisfactory post-mortem evidences of their cause, are, I believe, occasionally 
attributable to the transfer to the cardiac substance, or the original occurrence 
in that substance, of a rheumatic irritation, so severe as wholly to disable the 
organ from contracting, at least that part of it which may be the subject of 
attack. 
In the Alimentary Canal.-Instances of subacute rheumatism in the oeso- 
phagus sometimes occur, attended with a feeling of constriction, and severe 
pain in swallowing, but they are rare. In the stomach it is not uncommon, 
producing, according as it attacks the muscular or mucous coat, severe pain, 
with a sense of constriction, and great tenderness on pressure, or a sense of 
heat, weight, and oppression, with nausea and vomiting; and sometimes the 
two sets of symptoms are combined. Another not unfrequent seat of rheu- 
matism, not sufficiently noticed, I think, by authors generally, is the muscular 
coat of the bowels. The patient complains of a constant aching in some por- 
tion of the bowel, especially of the ascending or descending colon, which is 
increased at times into the most violent pain, whenever the muscular coat is 
stimulated into contraction by the contents of the bowels, or the action of 
purgative medicine. Sometimes the muscle is so severely affected, that it 
ceases to be able to contract, and obstinate constipation ensues. There is 
generally tenderness on pressure, within a limited portion of the abdomen. 
The disease may often be recognized from occurring upon the retrocession of 
an external attack, or in individuals who are known to be subject to rheuma- 
tism. It differs from colic in being less decidedly spasmodic, and from ordi- 
nary inflammation of the whole thickness of the bowel, in the much less CLASS II.] 
RHEUMATISM. 
431 
violence of the constitutional disturbance. Rheumatism sometimes also 
attacks the mucous coat of the bowels, producing diarrhoea or dysentery. 
Every practitioner, I presume, is familiar with instances, in which subacute 
external rheumatism has alternated with one of these affections. There is no 
reason, whatever, for considering the disease essentially different in its two 
seats. 
In the Diaphragm.-Rheumatism sometimes attacks the diaphragm; and 
there is probably no seat in which it is more painful and distressing. A 
severe pain shoots from the epigastrium to the spine, sometimes through the 
body, sometimes circularly along the edge of the ribs, which, in violent cases, 
is increased to agony by every attempt to take a full inspiration. Breathing, 
which is performed chiefly by the ribs, is often very difficult and oppressed, 
and sometimes attended with feelings of suffocation. Hiccough, the sardonic 
laugh, and delirium, are said occasionally to attend the complaint. The swal- 
lowing of food produces acute pain at the point where the oesophagus pene- 
trates the diaphragm, and sometimes the food is rejected in consequence of 
the spasm thus excited. In some instances, only a portion of the- muscle is 
affected, and the pain may be confined to one side. 
In the Liver and Kidney.-In both these glands, attacks simulating ordi- 
nary inflammation occasionally happen, in rheumatic individuals, either 
originally or by metastasis, which I have no hesitation in classing with the 
other forms of internal subacute rheumatism. When the liver is affected, 
there are pain and tenderness in the right hypochondrium, often a jaundiced 
hue of the skin and conjunctiva, and sometimes bilious vomiting, or melgena. 
In the nephritic affection, there is pain in the back, extending to the abdomen, 
and shooting towards the groin, and sometimes retraction of the testicle, but 
not, so far as I have observed, the copious deposition of urates which charac- 
terizes gout, nor so urgent a disposition to frequent micturition as in ordinary 
nephritis. The complaint, whether in the liver or kidney, is attended, as a 
general rule, with much less fever than ordinary inflammation of these organs, 
and very seldom ends unfavourably. 
In relation to other organs little need be said. Neither the brain nor its 
membranes are often attacked with this form of rheumatism. There is reason 
to believe that the pleura sometimes becomes involved by its contiguity with 
the seat of the disease in pleurodynia; and it is not impossible that the in- 
flammation may sometimes penetrate from the abdominal muscles to the 
peritoneum. The uterus is, I believe, frequently the seat of rheumatism; 
and it has appeared to me, that some of the cases of dysmenorrhoea which 
have come under my notice, were nothing more than examples of this affec- 
tion.* Rheumatism also occasionally attacks the ovaries and testicles. It 
has even been noticed in the skin, either confined to one part, or attacking 
several parts successively, and exhibiting itself under the form of exquisite 
sensitiveness, so that the slightest friction produces severe pain, or as a steady 
aching or feeling of soreness, or a sharp prickling or darting pain of a neu- 
ralgic character, occurring at irregular intervals, and excited sometimes by 
the touch. (Archives Gen., 3e ser., xii. 120.) 
The duration of subacute rheumatism is exceedingly uncertain, and depends 
greatly upon the treatment. It is often relieved in two or three days, and 
sometimes runs on for w'eeks or months if neglected. In the latter case, 
however, it degenerates into the chronic form. Though much more readily 
subdued than the acute, it is much more liable to return quickly. 
* For some supposed cases of rheumatism of the uterus, see a paper by Dr. J. E 
Taylor, of New York, in the Amer. Journ. of Med. Sciences for July 1845. 432 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
Causes.-The causes are the same as those of the acute variety. The com- 
plaint is very apt to result from a partial exposure to cold, as from small 
currents of cold air, or the uncovering, in a cold place, of a part of the body 
usually protected. It is said that sudden muscular movements, or violent 
straining, are apt to induce the disease. They probably do so sometimes 
when a predisposition to it exists; but more frequently, when supposed to be 
the cause, they are merely the means by which the existence of the disease 
is first made known to the patient. When the constitutional tendency is 
very strong, it is probable that anything of an excitant character may serve 
to bring on the local affection, such as stimulant drinks, or heating articles 
of food. Some individuals have a peculiar predisposition to this form of rheu- 
matism. 
Diagnosis.-The suddenness of the attack, the severity of the local com- 
pared with the general symptoms, the sharpness of the pain upon movement 
when the muscles are concerned, the frequent mobility of the affection, and 
the utter absence of any tendency to suppuration, are characters by which 
subacute rheumatic inflammation may be distinguished from common inflam- 
mation occupying the same parts. 
Prognosis.-This is rarely otherwise than favourable. The disease is 
almost never fatal, unless when it seizes upon some vital organ, as the sto- 
mach, brain, or heart; and even then may very generally be relieved by 
appropriate remedies. The greatest danger is probably a sudden seizure of 
the muscular structure of the heart, so as to arrest its movements. Another 
danger is the production of chronic enlargement of that organ. 
3. Chronic Rheumatism. 
This variety of rheumatism may exist in the fibrous, synovial, or muscular 
tissue; but is most frequent in the joints. It may occur either as an original 
affection, or as the consequence of an acute or subacute attack. It is some- 
times limited to a single part, sometimes extends to several; and may be 
either fixed or movable. Generally speaking, however, it is more apt to be 
fixed firmly in its original seat than either of the other varieties. 
In relation to the joints, the swelling is generally not great, sometimes 
scarcely if at all visible, unless the synovial membrane is affected, when there 
is often tumefaction from the effused fluid. In old cases, however, the liga- 
ments are often thickened, and there is not unfrequently some effusion into 
the cellular tissue. Redness is generally quite wanting. There is, in almost 
all cases, more or less pain, which is obtuse and aching rather than acute, is 
often increased by the warmth of the bed at night, and is usually worst in 
damp chilly weather. Rheumatic patients can not unfrequently foretell a 
storm, from the pains produced by the damp cold winds that precede it. In 
some instances, however, there is little pain; but only a feeling of stiffness 
and weakness upon motion. The heat of the part is seldom increased. On 
the contrary, the patient often complains of chilly sensations, and these are 
sometimes the most unpleasant local effects of the disease. 
When the muscles are affected, they often waste away, shrink, and become 
shortened; and, when an opportunity has been offered of examining them 
after death, they have sometimes been found to contain a yellowish, translu- 
cent, gelatinous secretion in the cellular tissue connecting their fibres. 
There is generally a complete absence of fever in chronic rheumatism; 
unless in some cases in which disorganization of the joints has taken place, 
with purulent secretion, ulceration, &c., in consequence probably of the de- 
velopement of common or scrofulous inflammation. 
In obstinate and very old cases, there is often stiffness or immobility of the CLASS II.] 
RHEUMATISM. 
433 
joints, arising from contraction, thickening, and rigidity of the ligaments, and 
also, in some instances, from firm contraction or shortening of the muscles and 
tendons. The joints are often distorted by the same causes, especially the 
joints of the hand, in which the fingers are bent to one side, or abnormally 
extended or flexed; and it has been observed that the deformity of the one 
side corresponds singularly with that of the other, in shape and direction. 
Not unfrequently, in cases of long standing, the muscles affected become 
almost powerless, or even quite paralysed. 
The disease may generally be relieved or cured for a time, but is exceed- 
ingly apt to return. Sometimes it perseveres steadily, in spite of remedies, 
rendering the life of the patient miserable, and wearing him out at last by 
the incessant pains. In some instances, too, suppuration takes place in the 
joints, the synovial membrane ulcerates, the cartilages are absorbed, abscesses 
form in the soft parts and discharge externally; and the patient is at last 
worn out by hectic fever; or the denuded ends of the bone granulate and 
unite, forming complete anchylosis. But I have before mentioned my im- 
pression that, in these cases, common or scrofulous inflammation has been 
superinduced. It is highly probable that chronic diseases of the internal 
organs are occasionally of a rheumatic nature; and it is no unreasonable sup- 
position, that changes in the structure of the heart are, in many instances, the 
result of chronic rheumatism of that organ. 
The duration of chronic rheumatism is altogether irregular. It may con- 
tinue for months, years, or a lifetime. Many persons affected with it have 
intervals of comparative comfort, recovering their health more or less com- 
pletely during summer, to relapse again in winter, or varying with the con- 
dition of the weather, to the changes of which they become exceedingly sensi- 
tive, so as frequently to anticipate them, before they are obvious to others. 
The causes of this form of rheumatism are the same as of the acute; but the 
predisposition to it is not strongest in the same individuals. Age has great 
influence in this respect. The old are peculiarly liable to chronic rheumatism, 
though seldom attacked by the acute. 
The complaints with which it may be confounded are common and scrofu- 
lous inflammation, and sometimes possibly paralysis of certain muscles. From 
the former it may be distinguished by its occurrence in individuals known to 
be rheumatic, its frequently shifting character, especially in the earlier stages, 
the absence of any tendency to suppuration, the sense of coldness which some- 
times attends it, and its aggravation by wet damp weather, and by the warmth 
of the bed. A muscle may be deprived of the power of motion by rheu- 
matism or by palsy, but the march of the disease is so different that, if 
proper investigation be made, there can be little difficulty in forming a correct 
decision. 
4. Nervous Rheuviatism. 
Rheumatism very often assumes the form of irritation, without the least 
sign of inflammatory action. It may be directed especially to the nervous 
system, evincing itself by pain, or other disordered sensation, and by irregu- 
larities of the motive power; or it may affect any other portion of the body, 
or any one of the organs, producing derangement of function in the part or 
organ affected. The question may perhaps be asked, how it can, under 
these circumstances, be known to be rheumatism? The answer simply is, 
that these irritations often alternate with, supersede, or are superseded by 
inflammatory attacks of rheumatism, without the operation of any discovera- 
ble additional cause. A patient will be attacked with a neuralgic pain in 
the face, dyspeptic sensations in the stomach, or colicky pains in the bowels, 434 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
which will instantly cease upon the occurrence of an attack of subacute 
rheumatism in one of the joints or muscles, and return upon the retrocession 
of the latter affection. It is scarcely possible to resist the conclusion, that 
the same peculiar state of system, the same predisposition or diathesis, lies at 
the foundation of both these modes of derangement, which are, in fact, nothing 
more than the expressions of the real disease, the essence of which escapes our 
notice. 
But the particular disorders of sensation and function, which fall under this 
head, are so precisely like those of a similar variety of gout, that it would be 
useless repetition to treat of them particularly in this place; and I shall con- 
tent myself with referring the reader to the subject of nervous gout. In fact, 
the only mode of deciding, in relation to any one of these disorders, whether 
it belongs to rheumatism or to gout, is to notice with which of these diseases, 
in their inflammatory forms, it is apt to be associated or to alternate; and, if 
no such association or alternation exist in the case, which is a very rare cir- 
cumstance, then to ascertain what are the hereditary tendencies of the indi- 
vidual. Yet, that there is some real difference, though it may altogether escape 
our powers of observation, is proved by the fact, that, when the irritation is 
connected with inflammation, the latter almost always assumes the same form 
in the same individual, whether that form be gout or rheumatism. 
To give a very general idea of these derangements, it is sufficient here to 
state, that rheumatic irritation may assume the form of neuralgic pains in any 
part of the body; of vertigo, dizziness, headache, tinnitus aurium, perverted 
vision, &c., when it affects the brain; of hurried or irregular breathing, and 
even violent dyspnoea, in the respiratory apparatus; of palpitations, oppres- 
sion, and great precordial distress, in the heart; of dyspeptic sensations, nausea 
or vomiting, spasm, &c., in the stomach; of colicky pains in the bowels; and 
of painful sensation, and perverted function in the liver, kidneys, and genera- 
tive organs. 
The exciting causes of this variety of rheumatism are the same as of the 
others; but there is a different condition of system in the individuals subject 
to it, which determines this rather than the inflammatory forms. A predo- 
minance of the nervous temperament, sedentary habits, abstemious modes of 
living, and, generally, whatever tends to depress the powers of the system at 
large, may be considered as favouring the production of nervous rheumatism. 
Hence, it is most frequent in females, students, and professional men, espe- 
cially those of temperate lives. 
Though a painful, sometimes alarming, and in many instances a most 
harassing disease, it is not often really dangerous; and persons subject to it 
often live to an advanced age, and occasionally, after passing the prime of 
life, find the tendency to it to diminish or cease altogether. It is true that it 
sometimes seizes upon the heart, brain, lungs, or stomach with a fatal vio- 
lence; but these cases are rare; and, when death occurs in the course of the 
disease, it is much more frequently from the supervention of some organic affec- 
tion, than from the simple uncomplicated irritation. 
Nature of Rheumatism. 
Having taken a view of the different forms of rheumatism, we are now pre- 
pared to consider its nature. The opinion was at one time prevalent, that this 
disease was dependent on a peculiar offending matter pervading the system; 
and, even at the present time, there are not wanting persons who are disposed 
to ascribe its peculiarities to the abnormal presence of an acid in the circula- 
tion, which, according to Dr. Prout, is the lactic acid. But there is so utter CLASS II.] 
RHEUMATISM. 
435 
a want of proof as to the existence of any such offending cause in rheumatism 
generally, that the opinion must be looked on as purely speculative. 
Another notion is, that the disease is nothing more than ordinary inflam- 
mation, -owing any peculiarities which it may exhibit to the tissue in which it 
is seated. But the truth is that the disease is not necessarily inflammatory. 
It is often purely nervous, and no explanation of its nature is admissible, 
which does not take this fact into consideration. Besides, ordinary inflamma- 
tion, occupying precisely the same parts, presents different phenomena. 
All that we know of the real nature of the disease is, that it is peculiar, and 
that it owes this peculiarity, not to the character of the cause, but to some 
unexplained condition of the system, called the rheumatic predisposition or 
diathesis. I am inclined to the opinion, that this diathesis is in itself a morbid 
state, in fact, the true disease, and that the irritation and inflammation by 
which it is recognized, are merely symptoms of its full developement. That 
the rheumatic differs essentially from ordinary inflammation, is shown chiefly 
by its shifting character, its disposition to alternate with mere irritation or 
functional disorder, and the almost entire absence of any tendency to suppu- 
ration, even in the most violent cases. 
Treatment of Rheumatism. 
1. Or Acute Rheumatism.-When the pulse is full and tense, and the 
inflammation severe, bleeding should be employed with a freedom propor- 
tionate to the vigour of the patient's constitution, and to the resistance of the 
pulse. It is never proper to bleed for the pain alone. This is often extremely 
severe, where there is comparatively little activity of inflammation, or vigour 
of circulation. The pulse, and the obvious amount of local disease, as exhi- 
bited by the heat, swelling, tension, and redness, are much surer guides than 
the degree of pain. The loss of blood is generally borne well; and the opera- 
tion may often be repeated once and again, if called for by the symptoms. 
The quantity to be taken at each time must vary with the effects produced 
upon the circulation. The orifice should be closed as soon as the pulse begins 
to flag; and syncope, or an approach to it, should never be aimed at. Gene- 
rally, from twelve to twenty-four ounces may be taken from a robust indivi- 
dual, with a strong pulse. One or two full bleedings are generally sufficient; 
and, when the pulse begins to become more frequent, with diminished strength, 
the remedy should no longer be employed. 
It should be remembered that bleeding alone often fails to cure the disease. 
Carried to great excess, it may cause such a collapse of the vessels that they 
cannot support the inflammatory process; but the disease does not necessarily 
cease, under such circumstances, with the subsidence of the inflammation. 
The morbid tendency may still exist, and, though it may not be able to raise 
the vascular actions to inflammation, is still competent to the production of 
irritation even of a violent character. No longer attracted externally by the 
local disease, it may fix upon one of the internal and vital organs, with even 
fatal violence. Sudden death has resulted from an apparent transfer of rheu- 
matic irritation from the exterior to the heart, after copious depletion. The 
remedy must, therefore, be used with caution; and, though there are many 
cases in which it may be employed freely, there are many others in which it 
is of doubtful propriety, and some in which it is altogether forbidden. In 
feeble and anemic individuals, it should not be employed unless in obedience 
to some urgent necessity. 
Purging is probably not less efficacious than venesection. Nature occasion 
ally points out this remedy by curing an external attack, through the super- 
vention of diarrhoea. The purgation should be active, but not drastic. Senna 436 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
with sulphate of magnesia, jalap and bitartrate of potassa, and, when there is 
torpor or congestion of the liver, calomel, alone or in combination, are gene- 
rally suitable articles to begin with. The purgation should be repeated every 
other day; but, after the first or second occasion, it will usually be sufficient 
to employ sulphate of magnesia alone, or combined with magnesia and wine 
of colchicum, as recommended by Scudamore. This mixture is well adapted 
to cases originally mild, or in which the excitement has been reduced by 
depletion.* Should the bowels become irritable, the purgation should be 
suspended. An objection to purging is the difficulty of changing position; 
but this may generally be easily obviated by the skilful use of the bed-pan. 
The refrigerant diaphoretics are well adapted to the earliest and most in- 
flammatory stage of the disease. Tartar-emetic and nitre form an excellent 
combination. From one-twelfth to one-sixth of a grain of the former, and 
from five to ten grains of the latter, may be given dissolved in water, at inter- 
vals of one, two, or three hours. Citrate of potassa, in the form of neutral 
mixture or effervescing draught, may be used, if the former combination 
offend the stomach. These remedies may be aided by the occasional use of 
the warm bath, if not too inconvenient on account of the difficulty of moving 
the patient. The object, in the use of the diaphoretics above mentioned, is 
not so much to induce perspiration, as to sustain a moderate sedative impres- 
sion upon the circulation. The old plan of heaping bed-clothes upon the 
patient, and forcing copious sweat by draughts of hot water or herb teas, has 
been generally abandoned as commonly useless, if not injurious. 
Very soon after the commencement of the disease, the bowels having been 
thoroughly evacuated, and blood, if deemed advisable, taken from the arm, 
opium and ipecacuanha should be given at bed-time, to allay the violence of 
the pain, and procure sleep. A grain of each, repeated, if necessary, at the 
end of two hours, and increased somewhat as the system becomes accustomed 
to it, will generally be sufficient. The ipecacuanha is advisable to correct the 
stimulant tendency of the opium. After a few days, when excitement has 
been considerably subdued by depletion, this combination may be given 
steadily, at certain intervals, through the day and night, so as to keep the 
system always under its influence. Ten grains of Dover's powder may be 
given every four, six, or eight hours, according to the susceptibility of the 
patient to the opiate influence. Sometimes it will be found sufficient to give 
half the quantity. Should it be doubtful whether excitement has been suffi- 
ciently reduced for the remedy, as just recommended, the proportion of ipeca- 
cuanha may be doubled, unless found to nauseate the patient. 
When the pulse has lost its tension, and especially if it be rather feeble, 
advantage will accrue from combining powdered guaiac with the Dover's 
powder. The guaiac is supposed to exercise an alterative influence over the 
disease. From ten to twenty grains of it may be given with each dose.f 
Should these remedies have failed to make the desired impression at the 
end of ten days or two weeks, and should the disease assume in any respect 
a threatening character, it will be advisable to employ calomel with a view to 
its alterative influence. Advantage will often accrue from its use at an earlier 
period, with the opium and ipecacuanha, in the dose of two grains at bed-time. 
This quantity will sometimes of itself exercise a favourable influence, without 
* The following formula may be used. R.-Magnesias Sulphat. §ss; Magnesia; ^ss; 
Vin. Colch. Rad. fjss; Aquae fluv., vel Aq. Acid. Carbonic, q. s. Fiat haustus. 
f The following formula may be employed. R.-Opii pulv., Ipecac, pulv., aa gr. 
vj; Potassse Nitrat. gj; Guaiaci Resinse pulv. 5'ss- Misce, et divid. in chart, no. vj. 
S. One to be taken in syrup or mucilage, every four, six, or eight hours. CLASS II.] 
RHEUMATISM. 
437 
positive salivation, while it prepares the way for the more ready production 
of a decided mercurial impression, should this become desirable. I have no 
doubt whatever of the frequent controlling influence of mercury over acute 
rheumatism, at this stage. If employed early, before the requisite reduction 
of the general excitement, it may fail to remove the disease, while it adds to 
the other inconveniences that of a sore mouth, and to the existing excitement, 
the additional one produced by the mercury. It is seldom desirable to induce 
a copious salivation; and I always suspend the mercurial at the first decided 
indications of its action upon the mouth. 
It is at the same stage that colchicum proves most effectual. This may 
sometimes be tried advantageously before the mercurial, or may be given in 
aid of it. It is usually best combined with one of the salts of morphia; and 
this combination may be substituted for the Dover's powder; twenty or thirty 
drops of the wine of colchicum root, and a fluidrachm and a half of the solu- 
tion of sulphate of morphia, equivalent to about a grain of opium, being 
given every four, six, or eight hours. 
Occasionally an adynamic condition of system comes on in the course of 
the complaint, attended with very copious sweating during sleep, and some- 
times considerable nervous disturbance. Under these circumstances, I have 
been long in the habit of using sulphate of quinia, and have scarcely ever 
known it to fail, not only in obviating the debility, but also in greatly reliev- 
ing if not curing the disease. A grain maybe given every hour. More than 
this will seldom be required. It must be particularly remarked, that one of 
the conditions is the occurrence of copious sweats during sleep. This occa- 
sionally happens without the least alleviation of the pains, swelling, &c., and 
is probably the mere result of debility, with some irritation of the circula- 
tion. When there is considerable prostration, it may become desirable to 
administer carbonate of ammonia; and the ammoniated tincture of guaiac may 
now also be used with hope of benefit, in the dose of a fluidrachm every four 
hours, or less frequently. 
Should the heart or the brain become seriously involved, in the course of 
the disease, depletion by the lancet must be carried as far as it can be borne; 
leeches or cups must then be used freely; and these must be followed quickly 
by a large blister. In the cardiac affection, the cups may be applied between 
the shoulders, and a blister eight inches by ten over the region of the heart; 
in the cerebral, the head should be shaved, leeches or cups applied to the 
scalp and temples, and afterwards, should the symptoms continue alarm- 
ing, a blister over the whole head. Along with these means, calomel should 
be given promptly and freely, so as to induce a speedy ptyalism. Efforts 
should be made, in case of retrocession of the external disease, to invite it 
back to its original seat by sinapisms, or other active rubefacients, or by 
blisters, and, should the feet have been the part affected, by hot stimulating 
pediluvia. 
The same plan of treatment, in greater moderation, would be applicable 
to any other internal inflammation supervening upon acute rheumatism. 
In the form of the disease which occurs in miasmatic regions, and which 
has been already described under the name of bilious rheumatism, calomel 
should be given as a cathartic freely in the early stage, and recourse be had 
to quinia as soon as an intermission, or a very decided remission shall have 
been obtained. 
The local measures applicable to acute rheumatism have not yet been men- 
tioned. I believe that, upon the whole, the less that is done in this way the 
better. Should the disease be confined to one part, advantage might result 
from leeches; but to follow it up by this remedy, in its course over the body, 438 
CONSTITUTIONAL DISEASES, &C. 
[PART II. 
would be futile. Should the spinal column be found tender, with rheuma- 
tism in the lower section of the body, cups should be applied to the tender 
part. Perhaps the best plan, as a general rule, is to keep the affected part 
enveloped in soft flannel, lambs'-wool, or carded cotton; but these applica- 
tions should not be persevered in, if uncomfortable to the patient. Some- 
times, when the pain is excessive, emollient cataplasms with the addition of 
laudanum or other narcotic will afford relief. Dr. M. B. Smith, of Philadel- 
phia, has spoken highly to the author of the efficiency of the tobacco cata- 
plasm. Towards the decline of the complaint, when the parts are still 
somewhat swollen and painful, but the fever has subsided, anodyne and rube- 
facient lotions are sometimes useful, such as camphor liniment, the campho- 
rated tincture of soap with laudanum, and the same preparation with the 
addition of spirit of ammonia. At a still more advanced period, when the 
disease may seem peculiarly adhesive in one or a few parts, and threaten to 
become chronic, repeated blisters are the most efficient remedies; and, if the 
rheumatic pains are severe, acetate of morphia in powder may be sprinkled 
upon the blistered surface, denuded of the cuticle. Cold water, as an appli- 
cation to the inflammation of acute rheumatism, has been recommended; and 
it will no doubt often remove the local affection; but there would always be 
great hazard of serious internal disease. Flannel bandages, as recommended 
by Dr. Balfour, may be occasionally used with advantage, when the case 
threatens to assume the chronic form; but they are wholly inapplicable to 
the acute stage. They have been known to occasion a retrocession of the 
inflammation, and the supervention of severe cardiac disease. The hot bath 
comes in very usefully, in some cases, after the subsidence of fever and acute 
inflammation, when the surface is pale and inactive, and the local disease 
adhesive. It may be used daily. 
The above is the plan which I have usually employed in the treatment 
of acute rheumatism, and with results, upon the whole, so satisfactory as 
to indispose me to any experimental measures. It is, nevertheless, proper 
to allude to other modes of treatment, which have received more or less 
attention from the profession, and have been sanctioned by authoritative 
names. 
M. Bouillaud relies chiefly on large daily bleedings, with the free appli- 
cations of cups or leeches in the intervals. From robust patients, during 
the first four or five days, he takes by these methods an average quantity 
of four or five pounds; in very severe cases, as much as six, seven, or eight 
pounds; in mild cases only two or three pounds.' Under this plan, the 
medium duration of rheumatism in his hands is only one or two weeks, 
instead of six or eight; and, up to the publication of this treatise, there had 
been no death, even in cases complicated with disease of the heart. 
laud on Acute Rheumatism, translated by J. Kitchen, in Bell's Lib., p. 57.) 
Other practitioners have not met with the same success from this plan; while 
the records of medicine are not without cases of fatal results, attributed to 
excessive depletion. 
Dr. Hope, along with moderate depletion, recommended the early and 
vigorous use of calomel and opium, alternated with active purgation. The 
plan, which he adopted from Dr. Chambers, was, after full bleeding in the 
robust, but without that measure in the weak, to give eight or ten grains 
of calomel, with a grain and a-half of opium, every night, followed in the 
morning, by the infusion of senna with salts, sufficient to procure at least 
four or five stools. At the same time, a saline draught with fifteen or 
twenty minims of wine of colchicum, and five grains of Dover's powder, was 
administered three times a day. The calomel was omitted when the swell- CLASS II.] 
RHEUMATISM. 
439 
ing and pain greatly abated, or the gums became in the least tender. Ac- 
cording to Dr. Hope, the patients generally recovered under this plan in a 
week. 
The use of Peruvian bark in rheumatism is a very old practice. Within 
a few years, the plan of giving enormous quantities of sulphate of quinia, 
in the acute form of the disease, was proposed by M. Briquet, of Paris, 
and carried into effect with the most surprising results; the disease being 
almost as promptly cured as intermittent fever by the same remedy. From 
a drachm to a drachm and a-half were given daily, in divided portions. As 
might have been anticipated, though the external inflammation was often sup- 
pressed by the powerful influence of the remedy on the brain, yet that organ 
often became violently affected, and sometimes with fatal results. I consider 
the practice, at this risk, altogether unjustifiable. Sulphate of quinia is often, 
however, of great benefit in acute rheumatism, moderately administered; and 
I have already pointed out the circumstances under which it has appeared to 
me most effective. 
MM. Gendrin and Solon revived, in 1833, a plan, which had been long 
before proposed and abandoned, of treating the disease with large doses of 
nitre dissolved in large quantities of water. The mean quantity of the salt 
given daily was an ounce, dissolved in three quarts of water; and the average 
length of treatment was eight days. (Braithwaite's Retrospect^ viii. 26.) The 
practice is likely to fall again into neglect. The risk of injury to the sto- 
mach, from the large amount, as well of the liquid as of the salt, will proba- 
bly always be an insuperable objection to the general adoption of this plan. 
The same quantity of nitre, with a small quantity of water, would endanger 
poisonous effects. 
Among the other heroic plans of treatment is that of large doses of opium, 
as employed by Dr. Corrigan, of Dublin, who gave, on the average, ten or 
twelve grains of the narcotic daily, and in some instances more than double 
the amount. Full doses were given at first, and increased until decided relief 
was obtained, after which the medicine was continued in the same amount, 
until the disease had declined. The average duration of the treatment was 
nine days; and no evil effects were experienced. It might, however, be very 
dangerous, should a tendency exist to cerebral disease. 
Still another of the heroic plans, is the use of tartar emetic, in the quantity 
of twelve grains or more through the day, according to the contra-stimulant 
method. The danger from this plan, independently of the possible prostra- 
tion, would be the excitement of an irritation in the stomach, which might 
render it the focus of the rheumatic disease. The same objection lies against 
the repeated use of emetics. 
Phosphate of ammonia has been strongly recommended in rheumatism by 
Dr. T. H. Buckler, of Baltimore, under the impression that it tends to elimi- 
nate uric acid from the system, by forming with it a soluble urate of ammo- 
nia; the phosphoric acid being neutralized by the soda with which the uric 
acid may be combined in the blood. The salt is recommended in doses varying 
from ten to twenty grains, and given from three to six times in the twenty- 
four hours. It may be employed in all the different forms of rheumatism. 
(Am. J. of Med. Sci., N. S., xi. 108.) Dr. Samuel Edwards, of Bath, Eng- 
land, has published statements strongly confirmatory of those made by Dr. 
Buckler. (Prov. Med. and Surg. Journ., Nov. 17, 1847.) 
Alkaline remedies have been employed in the cure of rheumatism, on the 
ground of the essential acidity of the system in that complaint. Dr. S. Wright, 
of Birmingham, England, has for years depended chiefly on these remedies, 
and found them extraordinarily effectual. He prefers soda to the other alka- 440 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
lies, giving the bicarbonate internally, and applying the carbonate externally 
in baths. (Med. Times, June 5, 1847.) 
Dr. Ruschenberger, of the U. S. Navy, has found great advantage from 
cold water dressings to the joints, and the use of from three to six grains of 
opium at night, with an equal quantity of sulphate of quinia. (Am. Journ. of 
Med. Sci., N. 8., xiv. 268.) Dr. John Hastings has employed pyro-acetic 
spirit.both in acute and chronic rheumatism, and in gout, "with a success 
quite extraordinary." (Lancet, Jan. 16, 1847.) Iodide of potassium, sul- 
phur, and aconite, which have been lauded in acute rheumatism, are better 
adapted to the other varieties. 
2. Or Subacute Rheumatism.-In this variety, venesection is seldom 
requisite; though, when the patient is robust, and the pulse tolerably strong, 
a moderate bleeding will occasionally hasten the cure. Purging is highly 
useful. A full dose of sulphate of magnesia, or of this with infusion of senna, 
followed, every other day, with the mixture of magnesia, Epsom salt, and 
wine of colchicum root, already referred to, may be given in ordinary cases. 
Should the patient be too much weakened to permit a continuance of this 
course, his bowels may be kept open by sulphur, or a mixture of sulphur with 
magnesia, or with bitartrate of potassa. After the bowels have been once 
thoroughly evacuated, opium and ipecacuanha may be prescribed, either in 
the form of pill, or that of Dover's powder. This is often very effectual in 
subacute rheumatism, putting an almost immediate end to the complaint. A 
large dose of the opiate may be given at bed-time, and smaller doses regularly 
at intervals of four, six, or eight hours. Colchicum also displays very strong 
powers in this variety of the disease. It may be given alone, in doses of 
twenty drops of the wine of the root, or a grain of the acetic extract, repeated 
every four hours, and diminished or increased according to its effects. It is 
always desirable to procure from it some influence upon the skin, kidneys, or 
bowels; but to suspend it, or diminish the dose, when the stomach is nauseated. 
It may often be advantageously combined with the solution of sulphate of 
morphia, so as to keep the patient under a moderate narcotic impression; or 
the acetic extract may be combined in pill with the ipecacuanha and opium, 
in cases in which the stomach is not easily nauseated. 
Should the patient have a sour breath, or sour exhalations from the body, 
or should his urine exhibt an excess of uric acid, the alkaline remedies may 
be added, especially bicarbonate of potassa or of soda. 
The warm or hot bath is often very useful in this variety of the disease, 
and may be associated, with great propriety, in somewhat obstinate cases, with 
the Dover's powder, or colchicum. The hot bath is preferable when the 
actions of the system are feeble; and the skin pale and bloodless. 
Aconite, belladonna, stramonium, and conium, severally, or variously com- 
bined, maybe resorted to in obstinate cases; and sometimes act very promptly 
and efficiently in the cure. Somewhat similar, probably, in their action, are 
the decoctions of dulcamara and cimicifuga, which have been recommended. 
In debilitated cases, the ammoniated tincture of guaiac is an excellent remedy. 
Mercury would no doubt be as efficient in this as in the other varieties of 
rheumatism; but it is only in cases verging towards the chronic form, and 
threatening, if not arrested, to be of lasting inconvenience, that its employ- 
ment would be justifiable. 
Local Treatment.-When the inflammation is considerable and fixed, as in 
lumbago and pleurodynia, cups or leeches arc often very useful, and may be 
freely applied. They are, however, comparatively seldom required; as the 
disease, in the great majority of cases, yields in a few days without them. CLASS II.] 
RHEUMATISM. 
441 
"When the affection can be traced to the spinal column,' the blood should be 
taken, not from the seat of the pain, but the immediate vicinity of the tender 
spot in the spine; and the same remark is applicable to the subsequent use 
of rubefaction, blistering, or pustulation, should either of these methods of 
revulsion be deemed advisable. 
In relation, however, to the appropriateness of local irritant remedies in 
this variety of rheumatism, though they are often very efficient in unseating 
the disease, yet I have long entertained some doubt. This is a peculiarly 
changeable form of rheumatism, and dangerous metastasis to internal parts 
sometimes takes place. When a young practitioner, I witnessed fatal results, 
in an attack of lumbago, from the transfer of the irritation from the back to 
the interior organs of the chest, consequent upon the application of a blister 
to the lumbar region. The apprehension of similar results has since deterred 
me from the frequent use of repellent remedies, in cases of external subacute 
rheumatism. My practice has generally been to keep the part covered with 
flannel, carded wool, or cotton, or to leave it protected only by the ordinary 
clothing, of which a part, in this and all other kinds of rheumatism, should 
be flannel next the skin. But many practitioners freely use and recommend 
local irritant applications; such as Cayenne pepper with hot spirit, oil of tur- 
pentine, solution of ammonia, sinapisms, and blisters. Anodyne applications 
are also frequently employed, as camphor liniment, camphorated soap lini- 
ment or tincture with or without laudanum, plasters made with the extract 
of belladonna, or of aconite, &c. Ointment of iodide of potassium has been 
used with asserted benefit. Cold water has been recommended; but this I 
should consider very hazardous. It is in this form of rheumatism, and in the 
neuralgic, that acupuncturation has been most efficient. In some cases, as in 
stiff neck, heat may be very effectively employed, by placing a batch of carded 
tow or cotton over the part, and then applying a hot flat-iron. 
Internal rheumatism, belonging to this variety, must be treated upon the 
same principles as ordinary inflammation of the same organs, though it will 
seldom be necessary to push depletion to an equal extent. General or local 
bleeding or both, purging, blistering, the ordinary methods of recalling dis- 
ease to the external parts, and, if these fail, the use of mercury, are the chief 
remedial measures. The combination of opium, calomel, and ipecacuanha, 
often answers an excellent purpose. Sometimes, after due depletion, the dis- 
ease gives way to the use of colchicum, or aconite, when it has resisted other 
means; and all the general remedies, found useful in external rheumatism, 
may be employed in obstinate cases. 
Individuals who are very liable to this form of rheumatism, will find great 
advantage in watching its first approaches, and averting it by means of a full 
dose of one of the salts of morphia with wine of colchicum, at bedtime. Should 
this combination produce constipation, the addition of half an ouneg of one of 
the neutral salts will obviate the result. Great watchfulness, however, will 
be necessary to avoid the contracting of a habit of using the narcotic as a 
luxury rather than as a medicine. 
3. Of Chronic Rheumatism.-An immense variety of remedies has been 
employed in this complaint, many of which are probably quite useless, and 
owe their reputation to their introduction at one of those frequent conjunct- 
ures, when nature is on the point cf effecting a temporary cure. Of all the 
means which I have employed, none has seemed to me so effectual in obsti- 
nate cases, as mercury. It will, I am very certain, cure the disease, at least 
for a time, in the great majority of instances. I have repeatedly commenced 
my rounds in the Pennsylvania Hospital, with numbers of old rheumatic 
cases in the wards, and have been able to clear them out effectually by the use 442 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
of this remedy. By the late Dr. Otto, of Philadelphia, the attention of the 
medical public, in this country, was first strongly called to this application of 
mercury. (See Eclectic Repertory, ix. 528.) The disease will often give way 
to a moderate use of the remedy; but, when of long standing, it may require 
a perseverance for two or three weeks of decided ptyalism, to effect a cure. 
The remedy, however, is so inconvenient and disagreeable in its action, that 
efforts should always be made to relieve the patient by other means; at least, 
the mercurial plan should not be hastily and recklessly resorted to in ordinary 
cases. I will enumerate briefly the remedies and plans of treatment which 
appear to me to merit attention, mentioning first the general, and afterwards 
the local means. 
General bleeding is seldom required, or, indeed, admissible in chronic rheu- 
matism ; though sometimes, when the complaint approaches to the subacute 
form, and the patient is robust, a moderate quantity of blood may be taken 
from the arm with advantage. 
Purging is often of great use. The character of the cathartic employed 
should vary with the degree of activity in the local affection, and with the 
strength of the patient. When the disease is fixed in one of the large 
joints, and there is no apprehension from debility, a dose of jalap and cream 
of tartar, or of senna and salts, may be given twice a week, for a long time. 
When something milder is required, Scudamore's mixture, or one of the neu- 
tral salts alone may be used, as in the former varieties.. Sulphur is also fre- 
quently useful as a laxative. 
During the continuance of the purgative plan, the patient, if he suffer 
much from pain, may take the Dover's powder every night; and, if this be 
preceded by the hot bath, the curative effect will often be very decided'. 
At the same time, he may employ, during the day, some one, or some com- 
bination of those numerous medicines, which have proved useful in rheumatism 
by a supposed alterative action. As the precise mode in which these reme- 
dies do good is not known, they need not be employed with any great discri- 
mination. Those which the experience of the practitioner may suggest as 
likely to be most effective may be first tried, and others resorted to successively, 
as the exigencies of the case may require. Attention, however, should always 
be paid to the existing grade of excitement, and the remedies should be 
selected accordingly; those of a debilitating character being avoided when the 
patient is weak, and the stimulating when the condition of the system is 
decidedly sthenic. 
Of these alteratives, colchicum is one of the most efficient, and may be 
given three or four times a-day, in doses within the nauseating or purging 
point. This remedy has appeared to me most beneficial in those cases in 
which the local affection is migratory, and approaches the neuralgic form. 
Iodide of potassium has been of late very highly lauded. I have seen it much 
employed, sometimes with very happy effects, but more frequently with no 
advantage. I have found it most effectual in cases, in which there was reason 
to suspect a syphilitic origin. In some of these it has operated like a charm. 
It may be given in the dose of from five to twenty grains, three or four times 
a day; but its operation should be carefully watched, and the medicine omit- 
ted, or moderated, if it irritate the stomach, or produce any other unpleasant 
effect. Sulphur, besides being useful as a laxative, is an excellent alterative 
in chronic rheumatism, well adapted to mild cases, and sometimes of itself 
adequate to the cure. Guaiac has long enjoyed a high reputation in this 
disease. In the chronic variety, it is most frequently used in the form of 
simple or ammoniated tincture; but its stimulating properties should always 
be borne in mind. The other alterative diaphoretics are occasionally em- CLASS II.] 
RHEUMATISM. 
443 
ployed, most frequently in the form of compound decoction, or compound syrup 
of sarsaparilla, which is frequently associated with a mercurial course. Tur- 
pentine, or its volatile oil, and copaiba:, are occasionally used with advantage, 
and are especially recommended in chronic lumbago and sciatica. Dr. Chap- 
man speaks in strong terms of the efficacy of savine, which he introduced into 
the treatment of this disease. Some have found great advantage from capsi- 
cum very freely used. Arsenic has occasionally proved very efficacious, and 
is thought to be especially useful in cases in which the periosteum is affected. 
Other remedies which merit notice are cimicifuga, the berries and root of 
phytolacca decandra or the common poke, and xanthoxylum or prickly ash, 
for the mode of using whiph the reader is referred to the dispensatories. Cod- 
liver oil is very highly praised by the German practitioners. 
Various narcotics are much and usefully employed, especially when the 
disease is very painful, and somewhat neuralgic. The extracts or tinctures 
of belladonna, stramonium, conium, and aconite, are especially worthy of notice. 
They are usually given in connexion with some one or more of the other reme- 
dies mentioned. 
Various kinds of bathing are among the most efficacious methods of cure. 
The hot bath taken daily, and persevered in for a considerable time, often does 
much good; and obstinate local affections sometimes give way to a stream of 
hot water directed upon them, or the hot douche. A visit to the hot springs 
in Virginia may be recommended. Sulphur baths have also proved very use- 
ful, conjoined with the drinking of sulphurous waters. To obtain the advan- 
tages of this remedy, the patient may resort to some one of the sulphur springs 
among the mountains of Virginia, to the Blue Lick springs of Kentucky, or 
to the Springs of Avon and Sharon in New York. Sea bathing is sometimes 
beneficial; and I have no doubt that the plans of the hydropathists often break 
up obstinate cases of this complaint, by thoroughly changing the condition of 
the nervous system. Care should be taken, whenever cold bathing is em- 
ployed, that reaction should subsequently take place, and be sustained by 
friction and exercise. Vapour baths are also among the vaunted remedies for 
chronic rheumatism, and no doubt often prove efficacious. Very obstinate 
cases have yielded to the vapours of sulphur, and those of camphor are asserted 
to have been successfully employed. These vapours are applied by means of 
a wooden box, in which the body of the patient is confined, while his head 
projects. 
A long journey often acts very usefully as an alterative; and, perhaps, no 
means of cure is more effectual than residence in a warm climate during the 
colder seasons. Vigorous exercise sometimes proves an effectual remedy. 
The patient should always wear flannel next his skin, unJess in the very hot- 
test weather, when silk may be substituted. The diet must be adapted to the 
state of general excitement, and the degree of inflammation. Confinement to 
milk and vegetable food, or even to vegetable food alone, may sometimes be 
desirable; but generally it is sufficient to take care that the articles employed 
are digestible, and not likely to irritate the stomach. 
Local Remedies.-These are scarcely less numerous than the general. Oc- 
casional leeching or cupping is often very useful; but, when the disease is 
fixed permanently in one or a few parts, and does not change, repeated blis- 
tering is incomparably superior to all other remedies. The part should be 
covered with the blister, and, as quickly as one heals, it should be followed by 
another. Caustic issues and moxa are sometimes used; but I prefer blistering. 
Great benefit is said to have accrued from the application of iron, heated 
somewhat above the boiling point, and made to touch the surface of the 444 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
affected part, at various points, in quick succession.* In mild cases, rube- 
facient and anodyne liniments may be used with some benefit. A great 
variety of these liniments have been employed both in regular and empirical 
practice. They generally contain camphor, one or more volatile oils, such as 
those of origanum, rosemary, turpentine, and horsemint, and some preparation 
of opium. The vehicle is generally alcohol. Probably none are better than 
the officinal camphorated soap liniment, or camphorated tincture of soap, to 
which laudanum may be added. Ammoniacal liniments, with or without 
laudanum, are often used. The bitumens enter into some nostrums. Friction 
with castor oil has been recommended. The tincture of iodine has been ap- 
plied advantageously to the surface of the inflamed part. Plasters of aconite, 
belladonna, &c., may be used when the part is very painful. Other local 
remedial measures which have been recommended, and occasionally prove 
useful, are electricity; compression by means of a. flannel or- muslin roller; a 
thin covering of caoutchouc; the soap, ammoniac, or compound galbanum 
plaster, in affections of the joints; diligent frictions; and, in some instances, 
exercise, in others, rest, of the affected parts. 
4. Of Nervous Rheumatism.-The treatment of this affection is so exactly 
like that of the analogous variety ;f gout, that I shall content myself with 
referring the reader to that disease. 
Article IL 
GOUT. 
Syn.-Arthritis. 
This is a constitutional affection, exhibiting itself in a peculiar irritation or 
inflammation in various parts of the body, of which probably no one vital 
portion or tissue is at all times exempt. The modern name gout was derived 
from the Latin gutta (drop), probably through the French goutte, and owed 
its origin to an old pathological notion, that a peculiar liquid matter, upon 
which it was supposed that the disease depended, fell drop by drop into the 
affected joint. To the ancients, the disease was known under the general 
designation of arthritis; and particular names were given to it, according to 
the part in which it was seated, as podagra when in the foot, and chiragra 
when in the hand. 
Various divisions of the disease have been made by authors, and given rise 
to as many different designations. Thus gout is called regular or irregular, 
according as it pursues or deviates from the ordinary course; tonic or atonic, 
* This process is called firing. Dr. Corrigan, of Dublin, has suggested a neat mode of 
applying it, with very little pain to the patient. A thick iron wire, about two inches 
long, is at one end inserted into a small wooden handle, and, at the other end, which is 
slightly curved, attached to a disk of iron, one-quarter of an inch thick, and half an inch 
in diameter, and with its face quite flat. The disk of iron is to be heated in a spirit 
lamp, until the finger, placed on the wire half an inch above it, becomes uncomfortably 
hot, and is then to be applied very lightly to the skin, passing as rapidly as possible 
from, point to point, at intervals of half an inch, until the whole surface over the affected 
part lias been touched by it. The whole flat surface of the disk should be made to 
come in contact with the skin. The spots touched become instantly white, and in a 
few minutes the whole surface is reddened; but an eschar is never formed, and very 
seldom a blister, if the operation be well performed. Instant relief is often obtained, 
and not unfrequently a permanent cure is effected. Dr. McCormack, of Donegal, speaks 
in the strongest terms of the efficacy of this treatment. (See Braithwaite's Retrospect, N. Y. 
ed., xiii. 55, and xv. 82.) CLASS II.] 
GOUT. 
445 
according to the accompanying strength of system, and energy of local action; 
acute or chronic, according to its duration and violence; mispla.ced, when it 
appears originally in some part not ordinarily attacked by it; and retrocedent, 
when, having occurred externally, it leaves its position, to seize upon some 
interior organ. 
It has appeared to me that the disease may be most conveniently considered 
under the three divisions of the acute, the chronic, and the nervous gout. 
There are cases which might be denominated sub-acute; but they are much 
less frequent relatively than the analogous cases of rheumatism, and I have 
not deemed it necessary to make a distinct class of them. I shall first describe 
these varieties separately, and afterwards treat of them conjointly in relation 
to their causes, treatment, &c. 
Symptoms, Course, &c.-This form of the disease occurs generally in per- 
sons of vigorous constitution, and at an age when the powers of life are most 
fully developed. It is characterized by paroxysms of acute inflammation, 
generally confined at first to one spot, especially one of the smaller joints, and 
attended with fever. The disease appears to have a singular predilection for 
the metatarsal joint of the big toe. Sometimes it first attacks the ba 11 of the 
foot, or the ankle, and occasionally one of the finger joints, or the wrist. Of 
193 cases compared by Scudamore, 130 began in the joint of the great toe, 
and all but 8, in the smaller joints or the ankle of one or both feet. After 
the disease has repeatedly recurred, it often deviates from its original course, 
and the paroxysm may commence in any one of the joints of the body, or 
even in an interior organ, though it still shows a preference for the parts 
originally affected. 
In the ordinary regular form of the disease, the patient is seized, either 
after a longer or shorter duration of certain preliminary symptoms, or abruptly, 
in a state of apparently sound health, with acute pain in the large joint of 
the great toe, or in whatever other part is to be the seat of the inflammation. 
This pain is sometimes intensely severe, and is described by patients as tear- 
ing, rending, boring, piercing, &c., as if the joint were torn by pincers, or 
penetrated by a gimlet or a nail, or were under the action of a saw. At first, 
there is little or no appearance of inflammation; but the joint soon begins to 
swell, the skin becomes hot and of a bright red colour, and the tenderness is 
so exquisite that the least jar is intolerable, the weight even of the bed-clothes 
cannot be borne, and the patient dreads the approach of any one, lest by acci- 
dent the limb might be touched. A characteristic phenomenon of the gouty 
inflammation is the turgescence of the superficial veins, not only near the 
part, but for some distance up the limb. These symptoms continue with little 
abatement for six, eight, twelve, or even twenty-four hours, after which the 
excessive violence of the pain subsides, though the swelling rather increases 
than diminishes, becoming somewhat edematous, and appearing to contribute 
towards the relief of the previous acute suffering. 
The attack is apt to take place in the middle of the night, the patient being 
awakened out of sleep an hour or two after midnight by the violence of the 
pain. In such instances, the affection not unfrequently continues, with little 
relaxation, until about the same time on the following night, when the patient 
falls asleep, and wakes in the morning much relieved, and perhaps moderately 
perspiring. 
Simultaneously or nearly so, with the local affection, febrile symptoms 
make their appearance,- commencing usually with chilliness or rigors, which 
are followed by acceleration of pulse, increased heat of skin, especially of the 
1. Acute Grout. 446 
CONSTITUTIONAL DISEASES, &C. 
[PART II. 
face, loss of appetite, a furred tongue, constipated bowels, and scanty, high- 
coloured, lateritious urine. Not unfrequently the discharges from the bowels 
are pale, or green and offensive, indicating deficient or deranged action of the 
liver; and sometime? an unpleasant odour exhales from the surface. The 
febrile symptoms remit, along with those of the local affection. But the 
paroxysm is not yet ended. Both the inflammation and the fever undergo an 
exacerbation towards evening, which continues more or less through the night, 
to abate again in the morning; and this daily alternation goes on for a length 
of time, varying greatly in different cases, but, in the early stages of the com- 
plaint, generally not exceeding a week or ten days, and not unfrequently 
falling short of the first mentioned period. 
The pain and fever generally leave the patient before the swelling; and 
their disappearance is sometimes attended with a looseness of the bowels, or 
the occurrence of perspiration, or a copious discharge of urine, which deposits 
a lateritious sediment on cooling. The remaining tumefaction, which is 
usually edematous, now gradually subsides, and the affection terminates in a 
desquamation of the cuticle of the part, often attended with itching. 
After the first attacks of the disease, the affected joint is restored perfectly 
to its functions, and the patient generally enjoys, for some time, an unusual 
exemption from morbid sensations, and considers himself in better health than 
before. 
It is not always, however, that gout begins as above described. Some- 
times, before the occurrence of a severe and regular paroxysm, there are 
several slight attacks, at distant intervals, of pain and soreness in some part 
of the foot or hand, which are insufficient to confine the patient, and which 
he is often disposed to ascribe to a sprain, or other accident. In other in- 
stances, the attack begins moderately, and gradually increases until it becomes 
severe and febrile, and then as gradually subsides. 
The existence, in certain cases, of disordered symptoms preliminary to the 
onset of the paroxysm, has been already referred to. These are not unfre- 
quent. Indeed, to a greater or less extent, they are experienced in the great 
majority of cases. In character, degree, and duration, they are exceedingly 
diversified, being sometimes so mild as scarcely to attract attention, in other 
instances very distressing; occasionally lasting only a few days, and again 
persevering, with greater or less steadiness, for months or years. Most of 
them will be more particularly described under nervous gout; as they are 
often the same as those which characterize that variety of the disease. It is 
sufficient here to say that they are, for the most part, either simply neuralgic, 
or such as indicate mere disorder of function. Among the most prominent of 
the latter are dyspeptic sensations, an impaired or craving appetite, acid 
eructations, flatulence, deficient or deranged biliary secretion, a tendency to 
constipation or looseness, nephritic disorder, occasional palpitations and dys- 
pnoea, giddiness, buzzing or roaring in the ears, dimness or other disorder of 
vision, and emotional irregularities, as depression of spirits, hypochondriacal 
notions, and unusual irascibility of temper. Br. Cullen enumerates, among 
the premonitory symptoms, " the ceasing of a sweating which the feet had 
been commonly affected with before; an unusual coldness of the feet and legs; 
a frequent numbness, alternating with a sense of prickling along the whole of 
the lower extremities; frequent cramps of the muscles of the legs; and an 
unusual turgescence of the veins." Not unfrequently, an experienced gouty 
patient is enabled to foretell an approaching attack by the occurrence of some 
one or more of these symptoms. They generally disappear upon the breaking 
out of the paroxysm, and so harassing are they, in some instances, to the 
patient, that the inflammation of the joint is welcomed as a relief. After the CLASS II.] 
GOUT. 
447 
subsidence of the inflammation, if it has been severe and of the usual dura- 
tion, the system seems to have been cleared of some offending cause, and the 
patient enjoys for a time excellent health and spirits. 
It seldom happens that an individual has only a single paroxysm of acute 
gout. In some rare instances, the patient has been able, by a complete 
change of habits, to throw off the gouty tendency, and has escaped a second 
attack. But generally the disease recurs sooner or later. Sometimes, the 
second paroxysm does not occur for three or four years, or even longer;, but 
usually, it makes its appearance in a year; and the returns afterwards con- 
tinue to be annual, and, with remarkable uniformity, at about the same sea- 
son, even in the same month. As the disease advances, the length of the 
paroxysms increases, while the intervals between them shorten. Instead of 
lasting from five to ten days, as at first, they continue for two or three weeks, 
or longer; and, instead of returning annually,.they make their appearance 
twice a year, afterwards four times a year, and at last so frequently, that, with 
their longer duration, the patient is hardly ever quite exempt. At this stage, 
one paroxysm does not completely subside before another appears; so that 
the patient labours under a kind of remittent disease, except perhaps, for 
six or eight weeks in the middle of summer, when the gouty symptoms 
leave him. 
In its first returns, the disease is generally confined, as in the beginning, to 
a single joint, and often to the one originally attacked; but this tendency to 
fixation diminishes with the progress of the case, and at length the inflamma- 
tion occurs in some other joint, or, after appearing in one, passes into another, 
and thus sometimes successively attacks the joints of the foot, the ankle, the 
knee, the fingers, wrist, elbow, &c. In some instances, though thus migrat- 
ing from point to point, it occupies but one position at a time; in others, it 
affects several joints simultaneously, though even in these, one is generally 
more inflamed than the others. 
As the local affection thus extends, both in duration and position, it loses 
much of its violence. The pain is less intense than in the earlier attacks, 
and there is also less redness. The swelling, it is true, is often greater; but 
it is less tense, and more edematous. The grade of the inflammatory action 
has obviously lowered, corresponding, in this respect, with the diminished 
energy of the system. The joint, after the paroxysm is over, does not now 
so completely recover its natural healthy power as at first; but is apt to re- 
main stiff, and sometimes becomes almost incapable of motion. 
The febrile action is also less vigorous than in the earlier paroxysms; but 
the patient is more troubled with the internal symptoms before alluded to 
previously to his attack, and gets less thoroughly rid of them when the local 
affection subsides. During the continuance of the paroxysm, he is more 
liable to be affected with visceral disease; and attacks of gouty inflammation 
or irritation in the stomach, bowels, kidneys, liver, lungs, heart, and brain, 
are more apt to occur, whether originally, or in consequence of the retroces- 
sion of the external affection. 
In this advanced stage, the gout may be considered as having passed from 
the acute into the chronic state. 
Without losing its claim to be ranked as acute gout, the disease not unfre- 
qucntly, at all stages of its progress, retrocedes from the extremities to fix 
upon some interior organ, or attacks one of these organs, without having ap- 
peared externally, constituting what has been called misplaced gout. Either 
of these events may happen, through the influence of causes calculated to fix 
an irritation in any one of the viscera, and thus to invite the morbid tenden- 
cies of the system to concentrate themselves upon it. Retrocession may 448 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
result from anything which tends to put an end to the external inflammation, 
without, at the same time, correcting the general diathesis; as, for example, 
the application of cold to the affected joint. Fatal metastasis has often resulted 
from this cause. It may be stated, in general terms, that the greater the 
energy of the system, the stronger is its disposition to fix the disease in its 
highly inflammatory form, in its legitimate external seat; and that conse- 
quently, whatever tends to debilitate the system, renders the occurrence of 
retrocedent or misplaced gout more frequent. It may be proper to refer 
briefly to the phenomena of the disease in the more important organs. 
In the stomach, gout may occur in two distinct forms; the inflammatory, 
namely, and the nervous or functional. In the former, the symptoms are 
those of acute gastritis. There are burning pain, exquisite tenderness upon 
pressure, and not unfrequently nausea and vomiting. If not depressed by 
the state of nausea, the pulse has considerable volume and strength; but, in 
the other case, it may be slender and feeble, with a cool, pale, damp surface, 
which may readily be mistaken for evidence of debility. Sometimes the 
brain sympathizes with the stomach, and stupor attends the gastric inflam- 
mation. I have seen a case of this kind, in which the patient appeared per- 
fectly insensible to ordinary impressions, but exhibited, by a violent and con- 
vulsive start, evidence of extreme pain, when a very slight pressure was made 
on the epigastrium. It is important not to confound such cases with cerebral 
inflammation. The case in question yielded at once to remedies applied to 
the stomach. 
In the nervous or functional affection, there is either violent spasm, or 
oppression, great distress, nausea, and vomiting, according as the muscular 
or mucous coat is the seat of the irritation. But the burning pain is want- 
ing, the tenderness on pressure is less, and, instead of febrile action, there is 
often great prostration, with a cold clammy skin, and an alarming feebleness 
of the pulse. 
The bowels are sometimes attacked in the form of diarrhoea or of colic. In 
the heart, which, however, is rarely affected in acute gout, precordial oppres- 
sion, dyspnoea, sharp pains, and syncope more or less complete, may be pro- 
duced. In the lungs, symptoms of intense bronchial congestion sometimes 
appear, with difficult breathing, great anxiety and distress, a purplish or livid 
hue of the face and hands, a feeble pulse, and coolness of the surface. I have 
seen symptoms of this kind promptly relieved by the loss of blood from the 
arm. But sometimes the pulmonary symptoms are those rather of nervous 
than vascular irritation, and appear in the form merely of dyspnoea or asthma. 
The diaphragm is sometimes affected, with symptoms similar to those which 
occur in rheumatism of the same organ. The liver is less frequently inflamed 
than functionally deranged. Deficient, depraved, or superabundant secretion 
of bile is among the most common internal derangements of the system in 
gout; so common, indeed, that some have supposed the disease to be essen- 
tially connected with hepatic disorder. Hence the clay-coloured, soap-like, or 
green and offensive stools, and the bilious vomiting and purging, which often 
attend the gouty paroxysm. 
The kidneys are probably more frequently affected than any internal organ. 
Gravelly symptoms are not uncommon during the paroxysm, consequent upon 
the excess of uric acid or the urates in the urine. But genuine attacks of 
nephritis alternate, in some individuals, with external inflammation, and 
retrocedent gout occasionally attacks the same organs. It is not difficult to 
explain this fact. In gout, there is often an excessive production of uric 
acid, which, thrown off with the urine, irritates the pelvis of the kidney and 
its excretory duct, thus rendering these parts the centre of afflux for the CLASS II.] 
GOUT. 
449 
gouty tendencies, when anything may unseat the disease of the joints. Some- 
times the inflammation fixes on the urethra, producing purulent discharge, 
scalding pain upon the passage of urine, and other symptoms analogous to 
those of gonorrhoea. 
Occasionally, the gouty irritation appears to seize upon the skin, producing 
the phenomena of urticaria, erythema, or some other exanthematous eruption. 
The brain is sometimes attacked by a.cute gout, with the production of 
stupor, and occasionally of complete apoplexy or palsy. The eye may also 
suffer. One of the most obstinate examples of ophthalmia that have fallen 
under my notice, was in a gouty patient. The eye appeared to have become 
the .pointin which the force of the disease centred; and, though it was fre- 
quently relieved for a time, a new paroxysm would restore the inflammation; 
and the affection was thus sustained for more than a year, and did not yield 
at last, until the gouty tendencies appeared, of their own accord, to take an- 
other direction. It is unnecessary further to extend the list of parts which 
may become the seat of gouty inflammation. The probability is, that no part 
of the system, possessed of a capacity for the inflamlna;tory process, is entirely 
exempt. The organs most frequently and prominently affected, are probably 
the stomach and kidneys. It is often impossible, in relation to the attacks of 
misplaced gout, to determine, whether the inflammation is of the common 
kind, or of gouty origin. The occurrence of a regular paroxysm, and the 
consequent relief of the disease in its irregular seat, or the alternation of the 
two affections, is the best diagnostic sign. But one of these attacks, occur- 
ring in a gouty individual, may generally be suspected of the gouty taint, and 
treated accordingly with great effect. 
When the-gouty diathesis exists in a person of otherwise feeble health, or 
debilitated condition of system, though it may still show itself in the form of 
external inflammation, yet this will be of a lower grade than in more vigorous 
individuals, more disposed to change its position, and more apt consequently 
to fix upon the internal organs. In these cases, the internal affebtions often 
do not rise above the grade of nervous or functional disease, and, therefore, 
belong to nervous gout; but sometimes they are slightly inflammatory, though 
much less dangerous than similar affections attending the more sthenic cases. 
Gout is not generally regarded as a very dangerous disease; and many who 
suffer under it console themselves with the reflection, that it serves to guard 
the system against others more dangerous than itself. There is probably 
some truth in this impression. In gouty individuals, the causes which ordi- 
narily produce internal inflammation, may be directed by the peculiar tend- 
encies of the constitution to an external and comparatively safe position. Yet 
gout itself is not unfrequently fatal. In the earlier stages, the greatest danger 
is from internal seizure, whether original or by translation; and every now 
and then we hear of a victim to gout in the stomach, the brain, or the heart. 
These cases, however, are comparatively few. It is from the slow wearing 
influence of the disease, every year extending its sway more and more over 
the constitution, which every year becomes less and less able to resist it, that 
the greatest dangei- arises. The internal vital organs, by the frequent stress 
to which they are exposed, become at length so far weakened or deranged, 
that slight causes give rise to the most serious effects. Hence fatal attacks 
of apoplexy, of pulmonary congestion or inflammation, and of cardiac disease. 
But one of the most frequent terminations is in dropsy, consequent either 
upon general debility, or organic visceral disease, as of the heart, liver, lungs, 
&c. In this condition, however, the affection may be considered as having 
assumed the chronic form. 450 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
2. Chronic G-out. 
Symptoms, Course, &c.-Chronic gout is generally the result of a long con- 
tinuance of the acute, though sometimes the disease is of the chronic grade 
from its commencement. The period at which it takes on this form varies 
greatly in different persons; those of vigorous constitutions retaining the 
acute symptoms much longer than the feeble. The boundary between the 
two states of gout is altogether arbitrary. The one runs into the other by 
imperceptible gradations. The disease may be considered chronic, when the 
local affection is not sufficiently active to produce fever. 
In this condition of gout, the paroxysms are more frequent than in the 
acute, but much less, severe. There is often little pain unless upon motion 
of the joint. There, is also little increase of heat; and redness is either 
entirely absent, or of a purplish hue. When there is swelling, it is usually 
edematous. Not unfrequently, the synovial liquid of the joints, and the fluid 
of the neighbouring bursae, are so much increased as to produce a considerable 
appearance of tumefaction,, and to fluctuate obviously under pressure. This 
is particularly the case in the knee and the elbow. 
The paroxysms occur less regularly than in the acute form; sometimes 
coming at intervals of a month, sometimes of two or three months. They 
also last much longer; and it not unfrequently happens that they run into 
each other, a fresh attack coming on before the preceding one has quite sub- 
sided; so that the patient is scarcely ever free from disease. 
In some instances, the disease is fixed in certain joints; in others, is more 
or less moveable, wandering from joint to joint, now attacking one part and 
now another, and not unfrequently retroceding from the surface to seize upon 
one of the interior organs. In this latter form, the local affection is apt to 
be more painful, and to exhibit more redness than in the former; and the case 
might, perhaps, in many instances, be considered as rather a mixture of the 
acute variety, in its mildest grade, with more or less of the nervous, than as 
strictly chronic. 
In the more fixed form of chronic gout, the joints often become perma- 
nently altered, so as to bend with difficulty, and sometimes to be nearly or 
quite useless. This arises partly from a thickening or other structural 
change of the ligaments, partly from the deposition of insoluble earthy matter, 
like chalk, either in the cavity of the joint, or in the cellular tissue about it. 
This matter is first extravasated in a liquid, or semi-liquid state, and after- 
wards becomes dry by the absorption of the fluid parts. The tumours which 
it forms are called chalk stones. They vary in size from that of a mustard 
seed to that of a walnut, and are sometimes very numerous, forming, large 
masses about the knuckles and other joints. They have been found upon 
chemical analysis to consist chiefly of uric acid or its compounds, especially 
the urate of soda. Sometimes they contain also urate and phosphate of lime. 
By their pressure they cause an absorption of the soft parts, and their white 
surface may sometimes be seen through the cuticle, with which they have come 
into contact, in consequence of the destruction of the true skin. Occasionally, 
they produce much swelling in the neighbouring parts, with a purple redness 
which appears to threaten mortification, and the collection of a considerable 
quantity of serous fluid beneath the cuticle. This at last breaks, and the fluid 
escapes along with portions of the chalk-like matter, but without pus at this 
stage. Subsequently, however, suppurating ulcers are formed, which continue 
open for a long time, and prove very rebellious to treatment. The earthy 
matter, being contained in the cells of the areolar tissue, is not readily dis- 
charged, and art can do little to hasten the process. At length, however, CLASS II.] 
GOUT. 
451 
the whole of the offending cause is eliminated, and the ulcers heal; or cica- 
trization takes place, notwithstanding that portions of it may be retained in 
the tissue beneath. Old gouty individuals have sometimes been able to write 
with their knuckles, in consequence of the exposure of the chalky tumours in 
the vicinity of the joints. 
Another peculiarity of chronic gout is the formation of small hard nodosi- 
ties upon the surface or in the substance of the tendons. These sometimes 
increase till they attain a considerable size. In most instances, they are with- 
out pain, but not always so. They sometimes consist of the chalky matter 
surrounded by a dense membranous coating, sometimes apparently of the 
hypertrophied tissue of the tendon. 
Though fever is not a regular attendant upon chronic gout, and is often 
quite absent, a slight degree of it sometimes takes place, when a fresh acces- 
sion of inflammation occurs, or some internal disorder is superadded. The 
patient has a pale or sallow complexion, a flaccid state of the flesh,- and the 
general aspect as of one worn by long-continued ailment. He is frequently 
troubled with dyspeptic symptoms, functional disorder of the liver and kid- 
neys, irregularity of the bowels, and acute muscular pains, sometimes attended 
with cramps, in various pafts of the body. Unless cut off by some acute dis- 
ease which the debilitated state of his system is unable to resist, he at length 
falls into general dropsy, suffers with serous effusion in his chest, and dies 
most frequently from an interruption of the respiratory process. 
Anatomical Characters.-Dissection has revealed little that is of peculiar 
interest either in chronic or acute gout. In the former, the synovial mem- 
brane of the affected joint, and the inter articular cartilages, exhibit evidences 
of inflammation; the cartilages covering the articulating ends of the bones 
are sometimes partially absorbed; and the bones themselves near the joint, 
injected with blood, softened, and occasionally eroded. The external liga- 
ments, though less affected, are sometimes injected and thickened, and the 
muscles in the neighbourhood wasted or rigidly contracted. Layers of chalky 
matter are found, in some instances, either within the synovial membrane, or 
between it and the cartilages; and the same matter, without the joints, is 
observed in the cells of the cellular tissue, in the muscles, fasciae, ligaments, 
and periosteum. In cases of death from internal inflammation, the ordinary 
signs of that affection are exhibited; but pathological anatomy is not rich in 
records of this kind ;• partly, perhaps, because death from this cause seldom 
occurs in the hospitals. 
3. Nervous Grout. 
Symptoms, Course, &c.-This form of gout is sometimes quite distinct from 
the others; but is generally more or less mingled with them, constituting cases 
which have been described by various names, as irregular gout, atonic gout, 
movable chronic gout, &c. It is apt to affect persons who have inherited a 
gouty diathesis, but, from original temperament or abstemious habits, are little 
liable to inflammation. Women, and individuals generally of a nervous tem- 
perament, who have descended from gouty ancestors, are very liable to it. 
Sometimes all the members of a family are prone to it; or the female mem- 
bers may be affected with, this variety of the disease, while the males, from 
their more active habits, and freer lives, are attacked with the acute form. 
There is reason to believe that it is much more common than formerly, 
having, to a considerable degree, superseded the old-fashioned gout, probably 
in consequence of greater temperance in the modern modes of living. I have 
no doubt that much of the neuralgia, now so prevalent, is nothing more than 
gout or rheumatism in the nervous form. 452 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
It may be asked how the disease is known to be of the gouty character. It 
may be reasonably suspected to be so, when the person affected has had gouty 
parents or grandparents, and no other cause can be detected. Its frequent 
intermixture or alternation with slight attacks, or abortive efforts at external 
inflammatory gout, raises the suspicion pretty nearly to certainty. An indi- 
vidual has an attack of regular gout, which relieves him from various func- 
tional derangements, to which he has long been subject. Alarmed for the 
future, he changes his mode of life, Avoids all stimulating drinks, uses animal 
food in great moderation, and finds himself, for the remainder of his life, 
exempt or nearly so from inflammatory paroxysms, but, in place of them, is 
frequently harassed by this variety of the disease, in some one- or more of its 
protean forms. 
Nervous gout' shows itself in the form either of simple neuralgic pain, or 
functional disorder. The pains may be dull and constant, or sharp, lancinat- 
ing, and intermittent, and may occur in any part of the body. Sometimes 
they remain long fixed in certain parts; but are more frequently changeable, 
appearing now in one part and now in another, without any regularity in their 
course. I have known an individual who was for many years subject to a 
fixed pain in the region of the liver, without the least sign of hepatic derange- 
ment, and in whom the pain suddenly disappeared upon the occurrence of an 
attack of insanity, to return again when the insanity ceased. That the affec- 
tion was of the character supposed, was evinced by occasional external attacks 
of the disease in a subacute form. It is not uncommon for a fixed pain of 
this kind to continue for months in one spot, varying, however, very much in 
intensity, and sometimes scarcely noticed, and then to disappear without any 
obvious cause, to be followed at a shorter or longer interval, or immediately, 
by a similar pain elsewhere, or by some functional derangement of one of the 
internal organs. The right iliac region, the precordial region extending to 
the left arm, the right side of the chest, and the scalp, are not unfrequent 
seats of it. Hemicrania is one of the forms which the disease sometimes 
assumes. 
The severe shooting neuralgic pains are more especially apt to occur in 
the temples, cheeks, or front part of the upper and lower jaws, though they 
may also attack the extremities, particularly the smaller joints, the generative 
organs, the anus, and any one of the viscera. Not unfrequently, they attack 
the muscles, which thus become painful on contraction. t 
Sometimes these pains, as well as various functional disorder, are found to 
be dependent on the disease seated in one of the nervous centres, or in the 
neurilema of one of the larger nerves, from or through which nervous influ- 
ence is extended to the part affected. Thus, pains in the trunk and extremi- 
ties may proceed from the disease in some portion of the spinal marrow, 
or its envelope. But, in most instances, the pains can be traced to no such 
origin, appearing to be the direct result of the morbid cause acting on the 
part. 
Let us now turn our attention to the several functions. The digestive 
fibnetion is among those most frequently deranged. All the varieties of dis- 
ordered sensation which usually attend dyspepsia are experienced in this 
affection. Vague uneasiness in the epigastrium, a feeling of weight or oppres- 
sion, irregular appetite, cardialgia, sour or acrid eructations, flatulence, some- 
times nausea and vomiting, sometimes severe spasm, are among the prominent 
symptoms. The bowels are generally costive, occasionally loose, with frequent 
deficiency of bile, or other unhealthy condition of the stools. Colicky pains, 
and flatulent distension are not uncommon. Sometimes the patient suffers 
with severe neuralgic pains in the bowels. CLASS II.] 
GOUT. 
453 
The respiratory function is occasionally also much deranged. The larynx 
is now and then the seat of irritation, and the patient is worried with a fre- 
quent cough, which might well be mistaken for pectoral without dare. I have 
a patient subject to this form of gout, who was at one period afflicted with an 
incessant cough, which continued for months, and scarcely ceased for a minute 
except during sleep and meals. Paroxysms of oppression and dyspnoea, 
almost like those of spasmodic asthma, indicate the existence of the disease in 
the lungs. 
The circulatory system is often greatly disordered, as indicated by precor- 
dial oppression, palpitations, darting pains in the region of the heart, inter- 
mittent and irregular pulse, and sometimes syncope, or a strong tendency 
towards it. 
Of the secreting organs, the liver and kidneys are most frequently affected. 
When the irritation seizes upon the former, together with a dull pain in the 
side, or an indescribable uneasiness in the whole upper region of the abdo- 
men, there is frequently deficiency of bile, with pale or clay-coloured stools, 
and a sallow hue of the surface, or excessive secretion with bilious vomiting 
and purging, or black stools approaching to melaena; or there may be derange- 
ment of the secretion with little local uneasiness,' though the affection is 
almost always attended with degression of spirits. Excessive secretion of a 
pale urine, or a scanty secretion of a red urine loaded with uric acid, and 
sometimes a dull pain in the small of the back, or pains like those of gravel, 
indicate that the kidneys are affected. 
The sensorial functions are often greatly disturbed. Vertigo, dizziness, 
tinnitus aurium, perverted vision, muscae volitantes, and violent headaches 
are common symptoms. These cephalic attacks are often very sudden. A 
person will be feeling perfectly well, and as if capable of performing any duty 
effectively; when suddenly he will be seized with vertiginous pain in the head, 
with roaring or other distracting noises in his ears, and often some perversion 
of vision, and immediately all his energy is lost, and he feels himself quite 
incompetent to the least exertion. Sometimes the eyes become extremely 
sensitive, so that any attempt to use them, even for a few minutes, occasions 
intolerable pain. Every variety of mental depression accompanies these affec- 
tions of the head. The spinal marrow and nerves become not unfrequently 
the seat of irritation, which displays itself in irregular muscular contractions, 
cramps or spasms, and occasionally a vague and unaccountable uneasiness, 
extending through the limbs, with, a universal feeling of oppression, heat, 
anxiety, weariness, soreness, &c., which they only can fully appreciate who 
have felt them. 
These various disorders usually occur quite irregularly, the irritation being 
sometimes in one part, sometimes in another; in certain instances, fixed for 
days, weeks, or months in a single organ or function, in others, rapidly chang- 
ing its seat; occasionally leaving the patient entirely, with the most exquisite 
sense of freedom from suffering, and the best hopes for the future, then re- 
turning, and often without apparent cause, with all its former violence. 
Not unfrequently, the disease assumes a regularly intermittent form, 
returning at a certain hour every day, and leaving the patient entirely in the 
interval. 
As before stated, an attack of subacute inflammation occasionally takes 
place in an exterior joint or muscle, and affords a temporary relief to the 
nervous irritation; and there are, perhaps, few patients in whom, at one period 
or another, the disease does not afford this evidence of its nature. 
This form of gout does not often directly destroy life. Sometimes a quick 
and violent seizure of one of the vital organs, as the heart or brain, appears 454 
CONSTITUTIONAL DISEASES, &C. 
[PART II. 
completely to arrest the function, and thus to occasion sudden death; but 
instances of this kind are rare. More commonly, the patient lives many 
years, perhaps in some instances surmounting the affection, but more fre- 
quently falling a victim to some incidental disease, or worn out at last by 
chronic organic derangements in which the functional disorder may finally 
terminate. 
The most frequent cause of gout is inheritance. This not only gives a 
predisposition, but is sufficient of itself, wholly without aid from other causes, 
and even in opposition to whatever influences can be brought against it, to 
give rise to the disease. It does not follow, that every child of gouty parents 
must inherit the diathesis. On the contrary, many escape entirely. But the 
proportion of those affected is so great, as to offer a strong warning to all who 
are thus descended, to use every possible preventive measure. Of 522 gouty 
patients, of whom Sir C. Scudamore collected information, 322, or nearly 
two-thirds could trace the disease to a parent, grandparent, uncle, or aunt. 
( Watson's Lectures.") 
But, though so frequently hereditary, there is no doubt that the gouty 
diathesis may be created. Persons out of classes in society among whom the 
disease is almost unknown, if removed from the sphere occupied by their fore- 
fathers, and introduced into modes of life which dispose to the complaint, are 
frequently attacked with it. It is generally believed that the most efficient 
causes in generating the gouty diathesis, and' consequently in promoting it 
when inherited, are the use of animal food in undue proportion, especially of 
high-seasoned meats and soups, indulgence in alcoholic drinks, and sedentary 
habits. Vigorous exercise may, to a considerable extent, obviate the effects 
of high living, by consuming the excess of blood in the support of the func- 
tions. 
From the nature of its causes, the disease would naturally be looked for 
among the wealthy and luxurious, or their descendants; and it certainly is 
much more common in the higher than the humbler walks of life. It is very 
rare among an agricultural or hard-working population, in any part of the 
globe. Yet the same causes will produce the disease among any class of 
people; and persons in the lowest grades of society are found to be attacked 
by it, when they imitate the luxurious habits of their superiors; as the keepers 
of petty inns, and household servants in the wealthy families of Europe. It 
has been supposed that intellectual superiority favours the developement of 
gout; but, if the disease has been common among men celebrated for their 
mental powers, it has probably been much more from the union of sedentary 
with convivial habits, than from any influence either of superior talent or its 
exercise. 
In relation to the influence of alcoholic drinks, though there is little or no 
difference of opinion as to the general fact; yet writers are by no means 
agreed as to the varieties which are most apt to produce the effect. Some 
have supposed that the light, acescent wines peculiarly predispose to gout. 
It is probably true that the use of them will often bring on a paroxysm of 
the disease, in those who have the diathesis, more quickly than the stronger 
wines, perhaps by irritating the stomach; but it is certainly not true that 
they are more apt to generate the diathesis; for the agricultural classes of 
France, who use the lighter wines often as their common drink, are said to 
be almost wholly exempt from the disease; while the English gentlemen, 
who drink freely of port and other stronger wines, are said to be more fre- 
quently than any other people affected with it. The same may be said of 
Causes of G-out. CLASS II.] 
GOUT. 
455 
cider, which has been accused of inducing gout. It may act sometimes as an 
exciting cause, but will probably seldom produce the predisposition. Other- 
wise, gout would, .have been formerly much more common than it was among 
the people of New England, and the middle Atlantic states, in which this 
drink was very commonly employed by the country people. The very free 
use of the malt liquors, particularly of the stronger kinds, has frequently been 
known to generate the disease, even among the lowest classes of the popula- 
tion. It is probable that strong porter, and the stronger wines, are more 
conducive to the disease than other alcoholic drinks. The distilled liquors, 
when freely indulged in, though they sometimes contribute to the production 
of gout, appear generally to exhaust the excitability of the system below the 
point requisite for the developement of that disease, and conduce rather to 
internal visceral disorder, with a tendency to the mania of drunkards. It is 
probable that habits of vigorous exercise, in persons who use strong drinks to 
great excess, so far from warding off gout, as they do in moderate drinkers, 
have a tendency to generate it, by sustaining a certain degree of energy in 
the system, which seems requisite for the developement of the diathesis.* 
From what has been said it may be inferred, that, so far as alcoholic drinks 
are concerned as causes of gout, it is not so much the particular variety used, 
as the'mode of using them that has the effect. No matter what kind may be 
employed, if it be taken in such quantities, and with such associations as to 
food and exercise, as to support a certain degree of vigour of system in the 
midst of the repletion and excess, it may give rise to the disease. If it be 
too feeble to produce this degree of excitement, or so strong and so much 
abused as speedily to exhaust the excitability and powers of the system, gout 
will probably not result in either case. 
It is a remarkable fact, that, according to the best testimony, acute gout 
has very much diminished of late years. This is said to be true in England. 
It certainly is so in this part of the United States. The fact can be ascribed 
only to the greater prevalence of temperance. Even persons who drink, sel- 
dom carry the indulgences of the table to that beastly extreme, which was 
common less than half a century ago. But, though inflammatory gout has 
greatly diminished, I believe that the nervous form of it has increased; because 
temperance, or even abstemiousness, cannot eradicate the diathesis when 
existing, though it may subdue the tendency to inflammation; and they who 
would, under the old habits of life, have been attacked with the disease in its 
old-fashioned form, now have it in the shape of neuralgia and functional disorder. 
It has been imagined, that liability to gout was indicated by the possession 
of certain sensible characters of body; but the notion has been contradicted 
by experience; as the disease exists in persons of every variety of structure 
and outward appearance. 
Season is not without its influence. The first paroxysm of gout is very apt 
to occur about the vernal equinox; and, if the affection return semi-annually, 
the attacks are usually made in the spring and autumn. 
Age has certainly much to do with the developement of gout. The disease 
generally makes its first appearance between the twentieth and fiftieth year, 
and most frequently from the twenty-fifth to the thirty-fifeh or fortieth. It 
is exceedingly rare before the age of puberty; though Dr. Chapman has known 
* A fact strongly illustrative of this statement is mentioned by Dr. William Budd, in 
bis Essay on Gout, in Tweedie's System of Practical Medicine. A body of workmen is 
employed on the Thames, in a peculiarly fatiguing duty, requiring frequent exposure to 
inclement weather, and labour both by night and day. In consideration of this expo- 
sure and fatigue, they have a large allowance of liquor; and each man drinks daily two 
or three gallons of porter, besides, in general, a considerable quantity of spirit. Among 
these men, gout is remarkably frequent. 456 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
it to occur in a boy of thirteen. It also very rarely begins in old age. I 
have, however, attended a gentleman of near eighty in his first attack. 
All writers agree in the statement, that the disease is much more frequent 
in men than women. In relation to the acute and chronic forms of gout, 
there can be no doubt of the fact. But in its nervous forms, judging from 
my own observation, I should say that the contrary is true. The female 
descendants of gouty ancestors are exceedingly prone to nervous gout. Their 
temperate habits prevent the inflammatory explosions of the disease to which 
the males are so liable; while their sedentary lives interfere with the attain- 
ment of that strength of constitution, which would enable their systems to 
resist the inherited morbid tendency. 
It is thought that a damp variable climate is peculiarly favourable to the 
generation of the gouty diathesis. The disease is certainly rare among the 
inhabitants of intertropical regions, and is less common at the extreme North 
than in the temperate latitudes, where the weather is more variable. Its 
great prevalence in England has been ascribed partly to the climate; but it 
probably depends much more on the habits of the people. 
The exciting causes of the gouty paroxysm are exceedingly numerous. 
Whatever, in fact, disturbs materially the condition of health, whether it be 
of an excitant or debilitating character, is probably capable of bringing on an 
attack. Exposure to cold, violent exercise, a debauch at table, venereal ex- 
cesses, paroxysms of anger or other strong emotion, indigestible food, articles 
of diet which disagree with the idiosyncrasy of the patient, vegetable acids, 
and local injuries of all kinds, such as falls, bruises, sprains, and even the 
wearing of a tight boot, may act as exciting causes. I have repeatedly known 
the nervous form of the disease to fix, in the shape of neuralgia, upon a part 
which had been' bruised or otherwise injured. A severe sprain sometimes 
leaves behind it a condition of the joint, which long afterwards determines 
this as the seat of an attack of acute gout. 
The Humoral Pathology taught that the phenomena of gout were owing 
to a peculiar peccant matter existing in the system, which it was the business 
of the paroxysm to eliminate. This opinion, abandoned after the times of 
Cullen, appears to be again gaining ground, and ranks at present among its 
advocates men of high name in the profession, of whom not the least con- 
spicuous is Dr. Holland. (See Medical Notes and Reflections.') The fact 
which lends the strongest support to this opinion, is the tendency evinced in 
gout to the excessive production of uric acid. Not only is that acid thrown 
out in excess in the urine, giving rise to frequent lateritious sediments; but 
it is also often deposited in the joints, or their vicinity, in the state of urate 
of soda or of lime. Dr. A. B. Garrod, of London, has actually obtained uric 
acid, in the shape of urate of soda, from the blood of persons labouring under 
gout. The use of an excess of animal food, with insufficient exercise, which 
disposes to an excessive production of uric acid, predisposes also to gout; and 
the uric acid lithiasis, or gravel, not unfrequently alternates with that com- 
plaint. But these arguments, as web as others drawn from the movable 
character of the local disease, as if it depended upon an offending matter car- 
ried everywhere with the blood, and from the relief experienced after the 
paroxysm, as if the offending matter had been discharged, appear to me to be 
inconclusive. 
Uric acid, I think, certainly cannot be the matter in question. This sub- 
stance is generated in excess, and thrown out by the kidneys, in many diseases 
in which no sign of gout is exhibited; and cases of gout often exist, especially 
in its irregular forms, in which there is no evidence whatever of an excess of 
Nature of Gout. CLASS II.] 
GOUT. 
457 
uric acid. Nor can I exactly perceive, how the production and elimination 
of this matter, if not itself essential to gout, should lend any support to the 
idea of the existence of some other unknown and concealed matter, which is 
the real offending cause. It is possible that.there may be such a substance; 
but its existence, not to mention its nature and properties, has certainly never 
yet been demonstrated. 
Some pathologists search for the origin of gout in disease of a particular 
organ. The disciples of Broussais consider it simply an inflammation, which 
they would denominate gastro-artliritis from its supposed chief seats. Dr. 
Chapman refers its origin to some disease of the digestive organs. It has 
even been supposed to be essentially connected with disease of the liver. The 
fac£, I think, is, that its nature is yet unknown; and, though the uneasiness 
of a state of acknowledged ignorance will probably continue to induce the 
formation of hypotheses, in which the mind may find a temporary rest; yet, 
until some new light is obtained, they can be nothing more than conjectures, 
which will probably in the end prove to be without foundation. It appears 
to me, however, that no explanation of the nature of gout can be correct, 
which does not take into view the nervous phenomena. The violent pain 
which often precedes the inflammation, the frequent attacks of pure neuralgia, 
the rapid and almost instantaneous transfer of disease from one part to an- 
other, even the most distant, together with the frequent sensorial disturbance, 
and striking emotional phenomena, evince, I think, beyond doubt, a strong 
participation of the nervous system in the pathological condition, whatever 
that may be. 
All, of a general nature, that we can fairly deduce from the symptoms, is, 
that there is a morbid state of the system, which probably involves all its 
essential constituents, and which evinces itself now and then by peculiar local 
phenomena, which may be either purely nervous, purely functional, or inflam- 
matory. That the inflammation is peculiar or specific, is proved by its shifting 
character, and indisposition to the secretion of coagulable lymph or pus.- 
Diagnosis. 
The only disease with which acute or chronic gout is liable to be confounded 
is rheumatism. There is no difficulty in discriminating well marked cases of 
these diseases; but it must be confessed, that there are cases in which the 
diagnosis is difficult if not impossible; and it is not at all improbable, that 
the two complaints sometimes co-exist, fused, as it were, into one. 
That the diseases are different,, is evinced, independently of the symptoms, 
by the difference in their origin, and in the subjects attacked by them. Thus, 
gout is much more frequently hereditary, and much less frequently generated 
by obvious causes, than rheumatism. The former almost never attacks chil- 
dren under puberty, the latter does so not unfrequently, though it must be 
confessed that it is more common in adults. Gout is found most frequently 
among the wealthy, the luxurious, and the physically idle, and is seldom 
heard of among those subjected to labour, privations, exposure, and hardships. 
Exactly the reverse is the case with rheumatism. The circumstance, more- 
over, already alluded to, that uric acid has been found by Dr. Garrod, in 
abnormal proportion, in the blood of persons affected with gout, while only a 
trace of it can be detected in the blood of acute rheumatism, must be received 
as an evidence of the difference of the two diseases. 
The diagnostic symptoms of gout, in relation to rheumatism, are, chiefly, 
the more frequent preliminary occurrence of disordered digestion and various 
functional derangement; the disposition of the disease to fix itself upon the 
small joints; its paroxysmal form, and tendency to recur at certain periods; 
the more remittent character of the fever; the greater violence of the pain; 458 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
the brighter redness of the inflamed part; its greater tumefaction and more 
decided tendency to oedema; and finally, the desquamation which follows the 
subsidence of the swelling. When gout has become chronic, and fixed upon 
a number of parts, the diagnosis is more difficult. The history of the case 
will, under such circumstances, afford much assistance. It may be said, in 
general terms, that the swelling is more apt to be edematous in gout, and the 
local affection to retrpeede, or to leave one part and fix on another; while in 
pure rheumatism there is probably no deposition of the urates in the joints. 
Nervous gout can be distinguished from the same form of rheumatism, with 
any approach to certainty, only by the character of the external inflammation, 
which occasionally occurs in both affections, and in each may assume the form 
characteristic of the particular disease. 
Of the prognosis of gout sufficient has been said in the description of the 
several varieties. 
1. Acute Gout.-The treatment in acute gout naturally divides itself into 
that which is proper in the paroxysms, and that adapted to the intervals. It 
was formerly a prevalent opinion, which is still retained by many, that, the 
paroxysm should be allowed to exhaust itself, with little or no interference 
from the physician. Being designed to carry off offending matter, or at least 
morbid tendencies, it was supposed that any measures calculated to shorten 
it, would cause its office to be left unaccomplished, and the system exposed to 
fresh attacks, possibly in unsafe positions. Retrocession to some internal 
organ was greatly feared; and, as a vigorous condition of system was con- 
sidered favourable to an external direction of the disease, all depletory mea- 
sures were especially apprehended. It was, indeed, no uncommon practice of 
gouty patients to indulge freely in wine, even during the continuance of the 
inflammation, with the view of sustaining it, and of guarding the stomach 
against attack. While there was some truth in this reasoning, the practice 
founded on it was carried much too far; and the consequences were, that the 
disease was often greatly aggravated, the sufferings of the patient unnecessa- 
rily increased, and life probably not unfrequently shortened. But we should 
take care not to suffer the bad consequences of the abuse of a sound principle 
to lead us to abandon it. The paroxysm in gout is certainly not the whole 
disease. There is undoubtedly a morbid state of system to which the parox- 
ysm is owing, and which it has a tendency to relieve, if allowed to run its 
course. It is no less true, that the removal of the paroxysm has no effect in 
removing the state of system alluded to. If, therefore, by remedies addressed 
exclusively to the former, we succeed in cutting it short, we may very possibly 
leave the latter still in existence, and ready to display itself by some assault, 
it may be, upon one of the joints as before, or, it may be, upon one of the 
interior and vital organs. The most prudent procedure, therefore, would 
appear to be, to allow the inflammation of the joint to complete its course; 
contenting ourselves with moderating its violence if excessive, and endeavour- 
ing to render the patient as comfortable as possible. But we may do more 
than this. We may endeavour to supersede the office of the paroxysm by 
addressing our remedies to the morbid state of system; and, if we succeed in 
favourably modifying this, we shall find the local disease disposed to subside 
without our direct interference. Such, it appears to me, are the correct prin- 
ciples of treatment in the paroxysm of acute gout. 
But what are the remedies calculated to modify the constitutional affection ? 
It is experience only which can teach us; for, ignorant of the nature of the 
general affection, we have no foundation for a purely rational treatment. 
Bleeding has been proposed. But this remedy has been found to exercise no 
Treatment. CLASS II.] 
GOUT. 
459 
influence 'over the proper disease. It may lessen the fever, and cure the 
inflammation of the joint; but it leaves the source of the evil untouched, 
while, if incautiously employed, it impairs the vigour of the constitution, and 
certainly favours the production of various functional disorder. I have known 
gout, treated by bleeding at each paroxysm, to end prematurely in fatal dropsy. 
The only proper ground for the employment of this remedy is the existence 
of danger to life, or risk of serious inconvenience from the violence of the 
local inflammation, or of the general excitement. When the former is exter- 
nal, and no vital organ appears to be threatened by the latter, it is, as a gene- 
ral rule, best to avoid the lancet. 
The same objection does not lie against moderate purging, which appears, 
indeed, to exercise a favourable influence over the proper disease. Two cau- 
tions should be observed in the use of this remedy; the one,mot to carry it 
to the point of exhaustion; the other to employ such substances as are not 
likely to irritate the mucous coat strongly, so as to make this a centre of afflux 
to the disease, and thus to relieve the inflammation of the joint, by inducing 
an attack of gout in the stomach or bowels. As the liver is frequently torpid 
or deranged, and there is often an excess of acid in the primm vim, mercurials 
and antacids would seem to be indicated. A moderate dose of calomel, or of 
the mercurial pill, may be given in connexion with rhubarb, and afterwards 
followed by magnesia, with Epsom salt or other saline cathartic. Should the 
bowels be torpid, infusion of senna may be used in addition. Afterwards, 
throughout the attack, one or two stools should be procured daily, if neces- 
sary, by means of liquid or common magnesia, or one of the neutral salts, or 
by the two combined. Should there be colicky pains, with an irritable con- 
dition of the bowels, and small, ineffectual discharges, castor oil with lauda- 
num or morphia should be preferred. 
But the most effectual remedy in the gouty paroxysm is colchicum. This 
was introduced into use under the impression that it was the main ingredient 
in the famous eau medicinale d'Husson, which formerly enjoyed a great repu- 
tation in the treatment of this disease. When first used, it was generally 
given in large doses, so as often to purge and vomit; and, in this way, was 
found not unfrequently to shorten very much, or set aside the paroxysm; but 
serious consequences were asserted to have occasionally resulted; and the 
medicine is now given with greater caution, and without evil results. It cer- 
tainly exercises an extraordinary influence over the disease. But in what 
manner it does good has not been determined. Some suppose that it acts 
merely by a revulsive influence, drawing off the external disease from the 
joint, by establishing irritation in the alimentary canal. It certainly does 
frequently produce nausea, and more or less catharsis in the doses in which it 
is ordinarily given; but the same curative influence does not proceed from an 
equal or much greater amount of the same effects from other substances. It 
very generally promotes the secretion of the skin and kidneys; and the idea 
has been entertained that it cures gout by eliminating some offending matter 
by one of these emunctories; but other diaphoretics and diuretics have not 
been found equally beneficial; and colchicum is believed to be useful even 
when it produces no sensible effect whatever. It has no decided narcotic pro- 
perty, and therefore cannot act as an anodyne. It is supposed by some to 
have a chemical influence over the poison of gout; and has been said to alter 
the character of the urine. Dr. Holland thinks that it renders this secretion 
sensibly more alkaline. But it need scarcely be said that the chemical theory 
of its action is purely conjectural. It remains only to consider it as an alter- 
ative; which is the same as to say that we do not understand its mode of 
action. The general conviction of its usefulness rests only on experience. 460 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
The objection has been made to its employment that, though it may relieve 
the existing paroxysm, it leaves the patient liable to a more speedy return. 
But this view seems to have been theoretical, and has not been confirmed by 
experience. Different authors recommend different preparations, and seem to 
attach importance to their particular mode of exhibiting the remedy. Any 
one of its preparations will, I believe, answer the purpose, which is capable 
of producing the effects of the medicine on the system. I generally prefer 
the wine of the root, as the most certain, from its mode of preparation; being 
a saturated vinous infusion. When the medicine is desired in the form of 
pill, the acetic -extract may be used. After the bowels have been well eva- 
cuated, from fifteen to thirty minims of the wine, or from one to three grains 
of the extract, may be given every four, six, or eight hours, according to the 
urgency of the case, and the susceptibility of the patient's system. This 
quantity, if the preparation be properly made, will often produce excessive 
nausea, or much intestinal irritation, and will require to be reduced. In other 
cases, it will be necessary to augment the dose somewhat, in order to insure 
its effect. Given in this way, colchicum often greatly moderates and abbre- 
viates the paroxysm; and, as it does so rather by acting upon the real disease, 
than merely on the inflammation, its effects are attended with no injury. In 
order to eradicate the existing tendency, Dr. Budd insists upon the necessity 
of continuing the use of the colchicum in small doses, for some time after all 
the symptoms of gout have disappeared. This is certainly rational practice, 
if the medicine has really, as it is supposed to have, a direct influence over 
the gouty state of the system. Ten or fifteen drops may now be given twice 
or three times daily. Should the medicine purge too much, this tendency 
may be controlled by the addition of a little laudanum. When there is little 
febrile action, and the pain is severe, one of the salts of morphia may be added 
in full dose to the colchicum, with much comfort to the patient. 
Colchicum may also, with great propriety, be associated with any purgative 
which may from time to time be given to the patient; the wine being pre- 
ferred, if the medicine is given in the form of a draught, the extract, if in 
pill. The mixture recommended by Scudamore, of colchicum, magnesia, and 
sulphate of magnesia, is an excellent purgative in gout.* 
When the liver is torpid, the extract of colchicum may be given at bed- 
time, with from three to five grains of the blue mass, and followed by the 
laxative draught above alluded to in the morning. 
When the urine is very scanty or heavily loaded with uric acid, so as to 
irritate the kidneys and urinary passages, half a drachm of the bicarbonate 
of potassa or of soda may be given three or four times a day in carbonic acid 
water, and the colchicum may be administered at the same time. Some- 
times the spirit of nitric ether may be advantageously added to the draught, 
especially when the patient is restless, or otherwise affected with nervous 
disorder. 
Sometimes much comfort accrues from a full dose of Dover's powder at 
bed-time. It should not, however, be given until the inflammatory and febrile 
symptoms, if considerable, shall have abated. 
In relation to the local affection directly, the less that is done, as a general 
rule, the better. It was formerly the custom to wrap the part in carded wool 
or warm flannels, with the view of cherishing the external disease, and pre- 
venting retrocession to the stomach or other internal organ; and this was 
certainly preferable to the repellent plan which some have advised. It pro- 
* I am in the habit of using the following formula pt.-Magnesife gss; Magnes. 
Sulphat. ^ss; Vin. Colchic. Rad. h^xx; Aqme fluv., yeL Aq. Acid. Carbon, f^ij. Fiat 
haustus. CLASS II.] 
GOUT. 
461 
bably, however, sometimes occasioned an unnecessary amount of inflammation, 
and led to ultimate injury of the joint, which might have been avoided. In 
ordinary cases, the joint may be lightly covered, so as to protect it from cold, 
and left to the operation of those measures which it may be deemed proper to 
address to the constitution. Should the inflammation be unusually violent or 
obstinate, it may not be amiss to apply a few leeches, though this should 
always be done with caution. Some recommend anodyne and evaporating 
lotions, with the view of moderately reducing the heat, and relieving the pain; 
and, when these are excessive, such applications may not be improper, if kept 
within due bounds. Scudamore's plan, which he found to afford relief in 
numerous cases, and to do injury in none, was to apply to the inflamed joint 
a lukewarm mixture, of three parts of camphor water (Aqua Camphorm, U. S.), 
undone of alcohol, by means of linen compresses, composed of six or eight 
folds, or of bread poultices, saturated with the liquid. When this was removed, 
tile part was lightly covered with flannel. Some bathe the joint with camphor 
liniment; others steam it, or employ pediluvia of warm water; and others 
again apply warm emollient cataplasms, with or without anodyne additions, as 
the decoction of poppy-heads, hops, camphor, &c. I have sometimes used a 
warm mixture of tincture of camphor with milk, applied by means of linen 
compresses, and frequently renewed. 
The practice of immersing the feet in cold water cannot be too strongly 
condemned. It often, no doubt, affords immediate or speedy relief, and 
sometimes with impunity; but there is always great danger that the dis- 
ease may seize with fatal violence on some internal part. An instance 
has been reported to me, upon the best authority, in which a gentleman, 
anxious for speedy relief, and contrary to the advice of his physician, 
ordered a bucket of cold water to be taken into his chamber at bed-time, with 
the view of employing it in this way. In the morning, he was found dead 
in his bed. 
Should the joint remain swollen and edematous, after convalescence, advan- 
tage will often accrue from the application of moderate pressure by means of 
a flannel or muslin bandage. 
When acute gout attacks one of the internal organs, either originally or 
by retrocession from the exterior, the case must be treated, if of an inflam- 
matory nature, as inflammation of the same part would be treated arising 
from ordinary causes. Bleeding is here often necessary to save life. The 
greatest danger now arises from the local disease, and this must be relieved, 
at whatever cost may be necessary. All other considerations must yield to 
the present urgency. When the pulse is strong in these eases, there can 
be no doubt as to the propriety of using the lancet. But sometimes, when 
the disease attacks the stomach, lungs, or heart, the symptoms are appa- 
rently those of great depression; the skin being pale and cool, the pulse 
small and feeble, and the strength greatly prostrated. But this depression 
may be consequent upon the crippled state of the organs upon which the 
general functions depend, and not upon real debility; and bleeding may 
still be indicated as the most efficient means of relieving the organ. It 
should, however, be used with caution. The physician should himself super- 
intend the operation, should keep his fingers on the pulse while the blood 
is flowing, and close the orifice if he find the circulation becoming feeble. 
Generally, however, the pulse will rise under the operation, and thus justify 
the measure. 
Local bleeding, fomentations or emollient cataplasms, sinapisms, and blis- 
ters, in the vicinity of the inflamed organ, may also be resorted to. But 
there is one measure of the utmost importance, which is applicable in all 
cases; and that is the application of irritants to the part from which the gout 462 
CONSTITUTIONAL DISEASES, &C. 
[PART IT. 
may have receded, or which may be its ordinary seat when external, in order 
to invite the disease back to a safe position. If one of the joints of the foot 
has been affected, pediluvia of hot water, rendered more stimulating by mus- 
tard or Cayenne pepper, should be employed; and the application should be 
continued as long as the patient can conveniently bear it. To render the 
impression more permanent, the foot-bath may be followed, if necessary, by 
sinapisms, or other active rubefacients, or by blisters. The necessity of thus 
attempting to draw the disease to the extremities, in all cases of severe in- 
ternal gout, cannot be too strongly insisted on. 
When the retrocedent disease attacks the stomach in the form of irritation 
merely, producing, as it sometimes does, violent spasm of that organ, it is 
necessary to procure relief by means of powerful anodynes, or nervous stimu- 
lants. The most effectual is opium, which may be given in doses twice or 
three times as large as those for ordinary purposes, and still further increased 
if necessary. Laudanum, or one of the other licjuid preparations of opium 
should be employed, as more prompt than the solid drug. Its operation may 
be aided by aromatic spirit of ammonia, sulphuric ether, or musk, if neces- 
sary. If the stomach reject these medicines they may be administered by 
enema. A sinapism should also be applied as speedily as possible to the epi- 
gastrium. 
In the treatment of the gouty paroxysm, reference must always be had to 
the constitution and habits of the patient. The remedies which may be em- 
ployed safely and efficiently in individuals of strong constitutions, and tem- 
perate habits, may prove too powerful for the feeble and intemperate. In the 
latter, purgative tinctures, as the tincture of rhubarb, or the tincture of rhu- 
barb and senna (Warner's gout cordial), may be substituted for, or added to 
the cathartics ordinarily used. They may generally be very appropriately 
conjoined with magnesia. Colchicum must be employed with more reserve; 
and greater care should be taken not to produce retrocession by injudicious 
applications to the external disease. It is often necessary to allow the patient 
to continue the use of his accustomed beverage, for fear that its sudden ab- 
straction may produce too great prostration. It should, however, be dimin- 
ished in quantity. . 
The diet, during the paroxysm, may be regulated somewhat by the inclina- 
tions of the patient. If so much affected by the fever as to be averse to food, 
he may be confined to gruels or other farinaceous drinks; if he still retain an 
appetite, he may take solid vegetable substances, with a limited allowance of 
the lighter and more easily digested kinds of animal food, as milk, oysters, 
soft boiled eggs, boiled fowl, &c., when there is reason to fear a failure of 
strength. The previous habits of the patient must here also be taken into 
view; immoderate eaters, and those who use chiefly high seasoned animal 
food, not bearing abstinence so well as the temperate, and often rapidly sink- 
ing upon the withdrawing of their accustomed support. 
During convalescence, care should be taken not to permit too rapid a return 
to habits of indulgence; the food should continue light, digestible, and unir- 
ritating; and the bowels should be kept regularly open. 
The treatment in the interval is highly important. If the same course 
of life which induced the disease, or favoured its attack, be continued, there 
can be little hope of averting future paroxysms, unless at a cost greater 
than that of the paroxysms themselves, and the patient must surrender 
himself to that long course of steadily increasing disease, and ultimate 
death, which has been already described as the general lot of gouty subjects. 
The complaint cannot safely be averted by any course of known remedial 
agents. Various attempts have been made to cure gout by medicines; but 
they have all proved to be failures. The famous Portland powder, em- CLASS II.] 
GOUT. 
463 
ployed, in variously modified forms, from the time of Galen, to that of Cul- 
len, has fallen entirely into disuse,' in consequence of the fatal effects 
which followed it. Consisting chiefly of tonic or stimulating ingredients, 
and continued for a great length of time, it probably made the stomach a 
centre of afflux to the gouty irritation, and thus prevented the external 
paroxysms; but Cullen states that, in every instance which he knew of its 
exhibition for the length of time prescribed, the patients were affected with 
many symptoms of atonic gout, "and all, soon after finishing vtheir course 
of the medicine, were attacked with apoplexy, asthma, or dropsy, which 
proved fatal." There is only one safe mode of curing gout; and that is 
strictly and perseveringly to avoid all its causes. If this plan is begun soon 
after the first developemcnt of the disease, and the constitutional tendencies 
to it are not irresistible, there may be some hope of escaping it in future, 
and good reason to expect, that, if not eradicated, it may be very favour- 
ably modified, and disarmed in great measure of its violence and danger. 
Temperance in eating, a rigid abstinence from all stimulating drinks, the 
avoidance of excesses of all kinds, and steady habits of moderate exercise, 
both on foot and on horseback, so as to keep the digestive organs in a 
healthy state, are the chief prophylactic measures required. In relation 
to the diet, it should be light and of easy digestion, not entirely vegetable, 
but with a smaller proportion of animal food than is usually indulged in, 
and prepared with little condiment of a stimulant character. (See Dyspep- 
sia. ) Care must be taken also to keep the bowels in a regular state, to 
correct any derangement of the hepatic or nephritic function) to obviate 
any temporary excess of acid in the primae vim or in the circulation, and to 
avoid all the known exciting causes of the paroxysm. For these purposes, 
an occasional use may be made of mild laxatives, such as rhubarb, mag- 
nesia water, Saratoga water, &c., of the antacids, as the bicarbonates of po- 
tassa and soda, and of the blue pill as an alterative. But caution is neces- 
sary not to get into the habit of depending upon these or any other medicines. 
Occasionally, when a paroxysm is threatened, it may be averted by a mild 
cathartic of magnesia, sulphate of magnesia, and wine of colchicum. Among 
the prophylactic measures, the wearing of flannel next the skin must not be 
neglected. 
Even in those who have long suffered with gouty paroxysms, much may 
be done, by the prophylactic measures, above recommended, towards mode- 
rating the force of the disease; though a cure is not to be expected. In 
elderly persons, who have been long in the habit of indulging in wines, it is 
scarcely desirable to attempt the breaking up of the habit. There may be 
some danger that, in removing this artificial support, the natural powers may 
prove so much decayed as to be insufficient for the sustenance of life; and, in 
all cases, due attention should be paid to the danger of a sudden change of 
long established habits. 
2. Chronic Gout.-As there is no precise boundary line between this 
variety of gout and the acute, there is of course no such line in the treatment. 
It may be said, in general terms, that bleeding from the arm is never neces- 
sary or proper, in chronic gout, for external inflammation. Moderate purg- 
ing may be employed in the paroxysm, when the bowels are disposed to 
constipation; but substances should be selected which are not likely to debili- 
tate, as rhubarb, aloes, sulphur, or magnesia, which may be given separately, 
or variously combined, according to the circumstances of the case, and, when 
there is considerable debility, may be very properly conjoined with aromatics 
and cordials, as with compound tincture of cardamom, compound spirit of 
lavender, tincture of rhubarb, or tincture of rhubarb and senna. Colchicum 
may also be used; but with more caution than in the acute form. Pain 464 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
and restlessness may be quieted by opiates with or without ipecacuanha, 
or, if these disagree with the patient, by hyoscyamus, stramonium, or bella- 
donna. , 
In the remissions of the disease, attention should be paid to the general 
health, and all the functions kept as free from disorder as possible. It may 
happen that the internal affections, so common in certain cases of chronic 
gout, may have so much of the inflammatory character, as to require local 
depletion by cups or leeches; and even bleeding may sometimes be impe- 
riously demanded to save life, when the disease seizes on one of the vital 
organs; but this remedy should be employed with much reserve. Revulsion 
by sinapisms, strong solution of ammonia, oil of turpentine, blisters, &c., as 
near as may be to the part affected, is here always indicated; while attempts 
should also be made to invite the disease to its ordinary external position by 
hot water and the rubefacients. 
More frequently, the internal disorders are simply functional, and should 
be treated as recommended for similar conditions in the more purely nervous 
variety. An anemic state, of the system should be corrected by the simple 
bitters and chalybeates. If the patient sweat profusely, sulphate of quinia 
may be used. The debility may even be such as occasionally to call for car- 
bonate of ammonia, and the alcoholic drinks. Arnica and the simple or 
ammoniated tincture of guaiac may be given, in the hope that, along with 
their stimulant effects, they may exercise an alterative influence over the 
disease. Acidity of stomach and other dyspeptic symptoms, constipation or 
looseness of the bowels, derangement of the hepatic and renal secretions, and, 
in women, disorder of menstruation, should all receive attention, and be 
treated as recommended for these conditions when occurring as original affec- 
tions. Dryness and want of action of the surface should be corrected by 
frictions, and the use of either the hot or cold bath, according to the reacting 
powers of the system, the former being preferred when this power is feeble, 
the latter when it is still considerable. There is little doubt, that the famous 
water-cure may prove useful in some of these cases of chronic gout, when the 
excitability of the system has not been exhausted. Dr. Seymour recommends 
benzoate of ammonia or of potassa, in cases in which there is a tendency to 
the deposition of urate, of soda in the joints, and thinks he has found deposits 
of this kind, already in existence, to diminish under its use. (Med. Gazette, 
May 14, 1847.) 
The diet should be that recommended for dyspepsia; and the patient 
should be extremely careful to clothe himself warmly, with woollen garments 
next to the skin, and to avoid all unnecessary exposure to cold and wet. He 
should especially avoid such exposure when not exercising. Sleeping in damp 
sheets, sitting in a cold damp room, or allowing the feet to remain wet when 
at rest, arc very hazardous for patients with chronic gout. Moderate exer- 
cise, in a pure atmosphere, is highly useful. Excessive mental exertion 
should be avoided with as much care as ail other excesses; and the patient 
should make it a study to cultivate equanimity of mind, and to subdue all 
tendencies to the indulgence of a fretful, melancholy, or irascible temper. 
Gouty patients may be assured, that they will often greatly prolong their life, 
as well as render it more comfortable, by an observance of the last-mentioned 
rule. 
Great advantage sometimes accrues, in this variety of gout, from visits to 
the watering places, and the use of the waters both internally and externally. 
The hot springs of Virginia are sometimes very beneficial. So also are the 
sulphur springs of Virginia, Kentucky, and New York. For anemic cases, 
the chalybeate springs may be recommended, as those of Bedford, Schooley's 
Mountain, Brandywine, &c. For deranged hepatic secretion and general dis- CLASS II.] 
GOUT. 
465 
order of digestion, especially with a tendency to constipation, those of Saratoga 
should be preferred. It is not only the mineral waters that act usefully; 
but the exercise of the journey, the pure air, and the agreeable relaxation and 
social pleasures of these resorts. Sea-bathing sometimes also proves benefi- 
cial. A residence during the winter in a warm climate is very desirable for 
chronic gouty patients. 
In relation to the local treatment, when the disease is seated in' one joint, 
and apparently fixed there, it may be proper, if permanent injury to the joint 
is threatened, to employ leeching and subsequent blistering; and it may be 
proper to repeat the blister several times. But, when the disease has any 
disposition to change its seat, these measures are inappropriate. In the latter 
case, if any other application is made than a light covering of flannel, it 
should be something very lenient in its action, as emollient or anodyne cata- 
plasms, mild camphorated lotions, &c. Some have recommended a covering 
of oiled silk, or thin layers of caoutchouc, so as to ednfine the perspiration of 
the part, and thus make a kind of vapour bath about it. 
Little can be done locally for the removal of the gouty concretions. When 
the part ulcerates, it should be dressed with poultices, and nature may be 
somewhat aided by mechanical, and possibly by chemical means, in removing 
the deposition; but not much can be done in this way, in consequence of the 
enclosure of the urate within the cells of the areolar tissue. Should gan- 
grenous symptoms present themselves, the yeast poultice, or cataplasms made 
somewhat stimulating by the addition of creasote, or of some alcoholic liquor, 
as porter or beer, may be employed. 
The nodosities that form upon the tendons and fasciae, will often yield to 
steady external counter-irritation, by means of the galbanum or ammoniac 
plaster, one of the turpentines, or repeated blistering. 
For the contraction of the muscles, and stiffening of the joints, little more 
can be done than to immerse the part frequently in warm water, to employ 
the hot douche occasionally, and to induce the patient, by frequent efforts 
of his own, to endeavour to regain his command over the movements of the 
limb. 
3. Nervous Gout.-This very diversified disease, which shows itself in 
almost all parts of the body, and in almost every variety of form, requires an 
equal diversity of treatment; and the ingenuity of the practitioner is often 
severely tried, to find out modes of relief which shall at the same time accord 
with his own sense of propriety, and the incessant demands of his patient. 
Much, however, can be done towards removing present symptoms, and obtain- 
ing a longer or shorter respite from suffering; and sometimes possibly the 
patient may surmount the disease; but, though life may be prolonged not un- 
frequently to old age, it is rare that an individual, constitutionally liable to 
the complaint, does not continue during life to be at times more or less 
affected by it. I wish the reader to understand, that the following observa- 
tions apply as well to the rheumatic, as to the gouty affection. 
One universal rule in these cases is, whenever the faintest disposition is 
shown by nature to give an external direction to the disease, to encourage 
her efforts by means calculated to attract irritation to the surface, and espe- 
cially to the extremities. These have been already sufficiently detailed. 
Much may be expected from a judicious use of medicines supposed to have 
an alterative influence over the disease, such as colchicum, guaiacum, aconite, 
veratria, arnica, sulphur, iodine, arsenic, &c.; care being taken, in their use, 
not to allow them materially to disturb the stomach or bowels. 
When the system is anemic, as not unfrequently happens, recourse should 
be had to the preparations of iron, simple bitters, and a nutritious diet. 466 
CONSTITUTIONAL DISEASES, &C. 
[part II. 
Whenever the disease is intermittent, no matter what form it may assume, 
whether that of neuralgic pain, spasm, or functional derangement of some 
one of the organs, provided there is any approach to regularity in the recur- 
rence of the paroxysm, sulphate of quinia should be freely employed, and 
will almost always succeed very speedily. The practitioner may often spare 
his patient long and exquisite suffering, by being always upon the watch for 
this intermittence, and prepared at once to take advantage of it. Not unfre- 
quently, when at first quite irregular, it assumes the regular periodical form 
under the use of alterative or tonic treatment, and will then yield to the 
salt of quinia. Twelve, eighteen, or twenty-four grains, should be given 
in the intervals between the paroxysms, or even more, if required to bring 
on the peculiar cerebral phenomena which characterize the action of the medi- 
cine. 
In the severe neuralgic forms, it often becomes absolutely necessary to have 
recourse to anodynes. When the attack is of some internal organ, as of the 
stomach, bowels, heart, &c., opium or some one of its preparations must be 
given, and often in very large doses, for example, double, triple, or quadruple 
the ordinary quantity, before relief can be obtained. The opiate may often 
be usefully combined with colchicum; and I am much in the habit, in these 
cases, of prescribing a mixture of solution of sulphate of morphia, and the 
wine of colchicum root. But whenever the urgency of the case will admit of 
having recourse to some other narcotic, and especially when the pains are 
external, one of these should be preferred to opium, from the great danger 
that the patient may be led into the habit of its abuse. The extracts of bel- 
ladonna and stramonium are often very efficient, especially the former. 
A very powerful remedy, in the purer neuralgic forms, is the subcarbonate 
of iron in large doses, say a drachm three or four times a-day; and temporary 
cures will often be effected by the combined use of this medicine and the 
extract of belladonna. I think that I have seen more cases of pure gouty 
and rheumatic neuralgia, without inflammation, get well under this combina- 
tion, than under any other single plan of treatment, except that of quinia in 
intermittent cases. 
In these neuralgic forms, moreover, large doses of sulphate of quinia will often 
effect cures, even when there is no regular intermission. It will frequently 
be necessary to push the remedy to the extent of twenty-four or thirty grains 
in the twenty-four hours. This is especially useful when the disease assumes 
the form of hemicrania; but in these, as well as in other cases, it may be 
advantageously combined with the oil of valerian. The effect of the remedy 
is not unfrequently to aggravate the headache, for the first day or two, after 
which the complaint gradually diminishes, and ceases altogether in three or 
four days or a week. Hemicrania seldom fails to yield to this treatment. 
It is scarcely necessary to follow the disease through the various internal 
organs; as the functional disorder which it produces in each closely resembles 
that proceeding from other causes, and requires the same treatment. Thus, 
when it attacks the stomach in the form of dyspepsia, or of gastrodynia, it 
must be treated exactly as those affections are usually treated. (See Diseases 
of the Stomach.') The same may be said of the form of colic, which it not 
unfrequently assumes. Deficient or deranged action of the liver, which is a 
very common attendant upon this, as well as other forms of gout, requires 
the occasional use of the mercurial pill or small doses of calomel, care being 
taken not to carry the remedy so far as to affect the gums. Nitro-muriatic 
acid is sometimes also very useful in these cases, but should not be given in 
connexion with the mercurial. Taraxacum and the alkalies sometimes prove 
useful, and may be alternated with the other remedies. Constipation of the CLASS II.] 
GOUT. 
467 
bowels should be obviated by laxatives, as rhubarb, sulphur, magnesia, Chel- 
tenham salt, Saratoga water, &c., or by a regulation of the diet, as by the use 
of bran bread, tomatoes, &c. Nephritic disorder may be treated with the 
alkaline bicarbonates, and sometimes, when the urine is excessive, by nar- 
cotics and astringents, or by terebinthinate remedies. Palpitations, and pre- 
cordial oppression,, will often yield to the aromatic spirit of ammonia, Hoff- 
mann's anodyne, oil of valerian, assafetida, or musk; and dyspnoea, when 
purely spasmodic, may be treated in the same way. 
In relation to all these affections, and others of analogous character, the 
general rules already given must be borne in mind, of relieving violent pains 
by opiates or other narcotics, of endeavouring to give an external direction to 
the disease by hot fomentations, rubefacients, blisters, &c., and of addressing 
remedies to the constitution with the view of subverting the disease, as col- 
chicum, quinia, &c. Not unfrequently, also, even when there is no reason to 
believe that there is any inflammation, leeching in the neighbourhood of the 
part, or even the loss of blood from the arm, will afford great relief in painful 
internal affections. When the disease seizes upon the head, these last remedies 
are especially useful. G-dUty or rheumatic headache often yields very happily 
to a few leeches or cups to the temples, or nape of the neck. But bleeding 
mtist always be used with some reserve; as, though it may afford relief, it 
does not eradicate the tendency, and, too frequently repeated, may produce 
an anemic condition, favourable to the perseverance of the disease. Another 
important fact to be borne in mind is, that in many of these cases of disor- 
dered function and neuralgic pains, the real cause is an attack of the disease 
in the ligaments or internal membranes of the spinal column, producing irri- 
tation in the spinal marrow, and consequently in all its dependent functions. 
In such cases, the remedies must be addressed especially to the spine. 
Besides the local measures already referred to, various others may be used 
with much temporary benefit, in the more painful forms of the disease. Emol- 
lient, anodyne, and rubefacient embrocations or cataplasms; frictions with aco- 
nite, veratria, and colchicum, in ointment, or strong spirituous solution; plas- 
ters of belladonna and stramonium; morphia sprinkled on the skin denuded 
of the cuticle; have all been employed, and with excellent apparent results; 
but, in this affection, it is not always possible to determine how much is 
owing to the peculiar virtues of the remedy, how much to the mere process 
employed in its application, and how much to the mind of the patient. I 
have repeatedly known gentle and continued friction with the hand to dissi- 
pate the pain entirely for a time; and nothing is more common than for the 
same effect to follow any strong mental movement, whether emotional or intel- 
lectual. 
In this variety of gout, it is especially necessary to invigorate the constitu- 
tion; for which purpose moderate exercise, pure air, a nutritious but easily 
digested and unstimulating diet, the pleasures of agreeable social intercourse, 
and the avoidance of all excesses, whether mental or physical, are the chief 
measures to be relied on. More even than in chronic gout, will advantage 
accrue from travelling, frequenting the watering places, &c. Any plan of life, 
which, while it favours health in general, places the system of the patient 
under entirely new influences, will often prove of the greatest benefit, and 
sometimes completely renovate the constitution. Hence the advantages of a 
foreign tour and residence. Hence the wonderful revolution sometimes effected 
in the health by a change of fortune, which reduces the patient from the luxu- 
ries, indolence, and self-indulgences of wealth, to the necessity of daily exer- 
tion for a livelihood. Hence, probably, also, in part, the advantage which 
has frequently accrued, in such cases, from the famous water-cure. 468 
LOCAL DISEASES. 
[part ii. 
CLASS III. 
LOCAL DISEASES. 
This is much the largest of the three classes in which diseases are arranged 
in the present treatise. It embraces all those which have their seat primarily 
or essentially in any one organ, tissue, or function. The local affection is 
often accompanied with constitutional symptoms; but these are secondary, 
as in the phlegmasia), in which the fever depends upon the inflammation. It 
is true that, among the following diseases, are also many which are results of 
constitutional derangement; but, in these instances, the local affection is so 
striking and important as chiefly to engage attention, and always to have 
ranked among diseases, with a distinct title; while the constitutional disor- 
der, from which it may have sprung, is often concealed and unknown. Such 
are the local tuberculous affections, many instances of dropsy, and not a few 
cutaneous eruptions. 
I have preferred the several functions as the basis of arrangement in this 
class, to the regions of the body; because it' often happens that a particular 
disease, though confined to one function, overleaps the region, and may in fact 
occupy several regions, as dropsy occurring atj the same time in the chest, 
abdomen, and external areolar tissue. In the order of the functions, I begin 
with that which nature has placed first and lowest in the scale, and follow 
her course through the remainder. Pursuant to this plan, the diseases con- 
nected with the digestive system come first in order; then those of the ab- 
sorbent system; and afterwards successively those of the respiratory, circu- 
latory, secretory, nervous, and reproductive systems. 
In each group of diseases, those which consist in inflammation of the parts 
concerned are first treated of; because they are in general better understood 
and more easily recognized, and consequently, when known, serve as stand- 
ards of comparison for the more obscure functional affections. 
SECTION I. 
DISEASES OF THE DIGESTIVE SYSTEM. 
These are most conveniently distributed into minor groups, connected seve- 
rally with distinct portions of the digestive tube. The first embraces diseases 
of the mouth, the second those of the fauces, pharynx, and oesophagus, the 
third those of the stomach, and the fourth those of the bowels. But, as there 
are several affections which occupy the stomach and bowels jointly, a fifth 
group is made including such diseases, together with those of the peritoneum, 
which may be considered as an appendage. 
SUBSECTION I. 
DISEASES OF THE MOUTH. 
In this subdivision are included, 1. the different forms of inflammation of 
the mucous membrane of the mouth; 2. inflammation of the tongue; 3. mor- 
bid states of dentition; and 4. diseases of the teeth, under the general heads 
of toothache and falling of the teeth. CLASS III.] 
469 
INFLAMMATION OF THE MOUTH. 
Article I. 
INFLAMMATION OF THE MOUTH, or STOMATITIS. 
The term stomatitis (from ctopa, moutK) is applied to inflammation of the 
mucous membrane of the mouth. The disease appears under various forms. 
The inflammation may be diffused equably over portions or the whole of the 
membrane, or may occupy chiefly or exclusively the mucous follicles. When 
diffused, it may present no peculiar secretory product, or may cover the sur- 
face with a consistent curd-like exudation. It may be attended with eruption, 
ulceration, or gangrene, and receive from each of these attendants the character 
of a distinct variety. In fine, it may be peculiar from the nature of the cause, 
as when it accompanies scurvy or is the result of mercurial action. It will 
be most convenient to treat of each of these forms separately. 
1. Common Diffused Inflammation.-This appears in reddened some- 
what elevated patches, or occupies large portions of the surface, sometimes 
extending apparently over the whole mouth. In some cases, it is superficial, 
with little or no swelling, and may be designated as erythematous; in others, 
it occupies the whole thickness of the membrane, extending sometimes to the 
submucous tissue, and even to neighbouring structures, as the sublingual and 
submaxillary glands, and the absorbent glands of the neck, and occasions con- 
siderable tumefaction in all these parts. In the erythematous form, it is 
characterized by redness, a sense of heat, and sometimes considerable tender- 
ness, but is not usually attended with acute pain; when deeper in the tissue, 
it is often very painful. Portions of the epithelium sometimes becomes opaque, 
giving an appearance of whiteness in streaks or patches. Occasionally this 
coating is elevated in blisters, or even detached like the cuticle from the skin 
in scalds. Superficial ulcerations not unfrequently occur, which may spread 
over considerable portions of the membrane. In certain states of the consti- 
tution, the ulcerative tendency is very strong, and deep and extensive sores 
occur, which are sometimes attended with gangrene. There is often a copious 
flow of saliva; though, in some instances, this secretion, as well as that of the 
mucous follicles, is checked, and the mouth is clammy or dry. The sense of 
taste is usually more or less impaired, and speech and mastication are often 
difficult and painful. When the tongue is affected, its surface is in general 
at first covered with a whitish fur, through which the red and swollen follicles 
may often be seen projecting. This fur sometimes breaks off, leaving the 
surface red, smooth, and glossy, with here and there prominent follicles, and 
very sensitive to the contact of even mild substances; or the surface may be 
dry, hard, and gashed, with painful fissures. When the gums are involved, 
they swell, and rise up between the teeth, around the neck of which they not 
unfrequently ulcerate. In some rare instances, this ulceration is very obsti- 
nate, and does not cease until it has extended into the socket, and destroyed 
altogether the connexions of the teeth, which become loosened and fall out, 
after which the gum will heal. Ordinary stomatitis is seldom so violent as 
to induce symptomatic fever. 
Causes.--The form of inflammation of the mouth above described, is more 
frequently a complication of other diseases than an original affection. When 
of the latter character, it is generally caused by the direct action of irritant 
bodies, as by scalding drinks, acrid or corrosive substances taken into the 
mouth, or unhealthy secretions from decayed teeth. The sharp edge or spicula 470 
LOCAL DISEASES. 
[part II. 
of a broken tooth sometimes give rise to much inflammation, and even deep 
and obstinate ulcers, especially of the tongue. The tartar which collects about 
the neck of the teeth often keeps up a, state of chronic inflammation of the 
gum, which sometimes ends in destructive ulceration. Stomatitis may also 
result from the reaction which follows the long continued contact of very cold 
substances, such as ice, with the interior of the mouth. It sometimes proceeds 
from the propagation of inflammation from the fauces, and is a frequent con- 
sequence of gastric irritation, produced by sour or acrid matter in the stomach. 
Drunkards seem peculiarly predisposed to it. Of the constitutional causes 
none are so frequent as the state of fever, which, whatever may be its par- 
ticular character, is very apt to affect the mouth, and not unfrequently occa- 
sions inflammation. 
Treatment.-In the acute stage, little treatment is required. In some 
very severe cases, in which the neighbouring parts are involved, leeches 
beneath the jaw or over the parotid may be advisable. But, in general, cool- 
ing and demulcent liquids locally, magnesia or one of the saline cathartics 
internally, with a soft and spare diet, from which meat is excluded, constitute 
all that is requisite. Where the inflammation results from some corrosive 
substance taken into the mouth, almond oil spread over the surface will be 
found a useful application. In the latter stages, and in chronic cases, astrin- 
gent washes, such as weak solutions of acetate of lead, sulphate of zinc, and 
alum may be advantageously applied; and, if ulcers exist which are indisposed 
to heal, their surface may be touched with a very strong solution of sulphate 
of zinc, sulphate of copper, or nitrate of silver, care being taken that the ap- 
plication do not extend beyond the limits of the ulcer. In cases accompanied 
with gangrene, washes of chloride of soda, chloride of lime, or aqueous solution 
of creasote may be used. Should the inflammation depend upon the condition 
of the teeth, whether upon sharp edges or points wounding the adjacent parts, 
or upon acrid secretions, or the deposition of tartar about the neck of the 
tooth, care should be taken to correct the evil. 
2. Diffused Inflammation with Curdy Exudation.- Thrush.-In- 
fantile sore-mouth.-Magnet, of the French writers.-As this affection, though 
it may occur at all ages, is far more common in early infancy than at any 
other period, it is here described as it appears in the infant. A superficial or 
erythematic inflammation is first observed, which, in two or three days, or 
even in a shorter time, presents small whitish points at the angles of the 
mouth, or on the inside of the lower lip. These increase in number, and 
coalesce, forming patches, consisting of a whitish curd-like matter; and the 
affection gradually extends to the tongue, the roof of the mouth, and the 
inside of the cheeks, and not unfrequently reaches the fauces and even pha- 
rynx. The exudation is sometimes thick and covers the whole surface, but 
is more commonly in irregularly scattered patches and points. It occasionally 
assumes a yellowish or brownish colour, and the latter is considered as an 
unfavourable sign. After a time it falls off; but its place is supplied by a 
new exudation; and this change may occur several times. The mouth of the 
infant is hot, .and the nipple of the nurse not unfrequently excoriated. When 
the throat is affected, the voice is apt to be hoarse. The complaint is some- 
times preceded, and is often attended by diarrhoea, with flatus and colicky 
pains; and the stools are frequently green and slimy. The child also vomits 
green matter, smelling strongly sour; and the breath often has an acid odour. 
Redness about the anus is not uncommon, dependent probably on the acrid 
discharges. It is asserted that masses of the caseous matter are sometimes 
found in the stools, showing that the affection has extended to the bowels. 
The child is often somnolent, especially in the worst cases. The affection is CLASS III.] 
INFLAMMATION OF THE MOUTH. 
471 
sometimes entirely local, but, in the greater number of cases, is attended with 
some acceleration of the pulse and febrile heat. As it usually occurs, it is 
without danger, but, when the stomach and bowels become involved, in chil- 
dren of bad habits of body, it often proves fatal. Generally, however, in fatal 
cases, the affection of the mouth is a mere complication of some independent 
disease, which is the cause of death. The complaint is of no certain duration, 
sometimes, when merely local, terminating favourably in a few days, some- 
times becoming chronic, and lasting for several weeks. It often returns 
after apparent cure, and this may happen repeatedly during a period of 
several months. 
It appears from dissection that the disease sometimes extends into the oeso- 
phagus, as far as the cardiac orifice, presenting the same appearance as in the 
mouth. -Patches of the exudation have even been observed in the stomach 
and small intestines; and a case is on record in which it was found lining the 
lower end of the ileum, and the whole of the large intestines as far as the 
anus. (Revue Med., Juin, 1830.) But this is comparatively a rare event; 
and the gastric and intestinal irritation which so often attends the disease, 
does not seem to be the result of its extension, in an unaltered form, to the 
alimentary canal. The matter thrown out upon the inflamed surface is 
thought to be analogous to false membrane, but it does not assume the same 
firm consistence, and never becomes organized. It may in general be easily 
separated from the surface, which is not ulcerated. It is ascribed by M. 
Gruby, of Vienna, to a cryptogamous vegetation. Dr. Berg, of Stockholm, 
considers the white exudation to be a mixture of thickened epithelial cells 
with a fungous parasite which attaches itself to them. (Braithwaite, s Retro- 
spect, xvi. 144.) 
Though most common among very young infants, the disease is not con- 
fined to any age, and not unfrequently attacks adults. But, in the latter 
case, it is almost always a consequence of other diseases, especially of long 
continued affections in which the alimentary canal is primarily or second- 
arily involved. It is not uncommon in the last stage of phthisis; and, when- 
ever it occurs in the chronic complaints of adults, must be considered as an 
unfavourable sign, indicating for the most part the breaking up of the consti- 
tution. 
Causes.-The causes of this variety of stomatitis are not always evident. 
It is very apt to occur in situations, such as foundling hospitals, where the 
air is impure and the diet unwholesome. Children prematurely born, or 
brought up by the hand, or nursed by unhealthy women, are more liable 
to be affected than others. In fact, whatever tends to impair the health and 
vigour of the infant, to induce acidity of stomach or other gastric or intesti- 
nal disorder, disposes to its occurrence. Yet it often comes on, under apparently 
the most favourable circumstances, and in healthy well-fed children, and must 
be ascribed to some inappreciable modification of the infantile constitution. 
There is no reason to consider it contagious, and it is independent of vicis- 
situdes of temperature. It seems occasionally to assume something like an 
epidemic character, being more than usually prevalent in certain families, or 
certain neighbourhoods, without any obvious cause. 
Treatment.-In cases which are purely local, little or no constitutional 
treatment is required. Costiveness should be obviated by an occasional 
dose of castor oil, or of magnesia; and fever by small doses of the neutral 
mixture, or, if attended with acidity, by one of the alkaline carbonates. 
Should diarrhoea occur, with green stools, magnesia may be given alone or 
combined with rhubarb; or, if the child be too weak for purgatives, pre- 
pared chalk or oystershell may be substituted; or the two may be alter- 472 
LOCAL DISEASES. 
[PART II. 
nated. Whichever of these antacids is used, it may be advantageously 
administered in some aromatic water, as that of spearmint, peppermint, or 
fennel, and combined with small portions of laudanum.* Emollient ene- 
mata, and poultices over the abdomen, may be employed to relieve the 
intestinal irritation. Dr. Dewees recommends a fluidrachm of fresh butter, 
melted and washed by means of hot water, to be given three times daily, 
when the discharges are small and bloody. Vomiting may be treated with 
lime-water and milk, emollient poultices, fomentations, or rubefacients to 
the epigastrium, or, if these fail, by anodyne enemata. It may sometimes 
be advisable, though very rarely, to apply a few leeches to the epigastrium 
or anus. In cases of great debility, infusion of bark, or sulphate of quinia 
in solution, with a little laudanum or paregoric elixir, may be resorted to. 
The best diet is the milk, of the mother if healthy, or of a healthy nurse, 
who should avoid acescent food. In cases, however, attended with much 
gastric or intestinal irritation, it may be proper to substitute, wholly or in 
part, drinks of farinaceous or demulcent substances, such as barley, arrow- 
root, and gum arabic, prepared with little or no sugar. In debilitated cases, 
rich broths, without fatty matter, should be given. Care should always be 
taken to keep the apartment well ventilated, and that the infant breathes a 
pure air. 
In relation to local applications, some writers recommend only demulcent 
liquids in the early stages, such as infusion, of flaxseed or marsh-mallow, 
solution of gum arabic, or almond emulsion; while others approve of the 
use of borax, either dissolved in honey, or in the form of powder mixed with 
sugar. One part of borax to eight or ten of loaf sugar are the proportions 
usually adopted; but Dr. Dewees directs equal parts. A small pinch of the 
mixture should be placed on the tongue, and the infant allowed to spread it 
over the mouth. When the irritation is severe, Bateman recommends an 
emollient combination suggested by Van Swieten, consisting of cream, yolk 
of eggs, and syrup of poppies. In the advanced stages, when the disease 
is somewhat obstinate, a solution of sulphate of zinc in the proportion of 
two grains or more to a fluidounce of water, with a little honey, will be found 
sometimes useful. In the same stage, rose water acidulated with muriatic 
or sulphuric acid, and solutions of alum, chlorinated soda, and nitrate of 
silver, are also occasionally used.f These applications should be made care- 
fully, from four to eight times a day, with a camel's hair pencil, or a pencil 
of lint, and the greatest caution should be observed not to irritate the inflamed 
parts by rubbing them. No attempts should ever be made to remove the 
white exudation forcibly. 
In adults, the same local applications may be made, and the mouth may be 
frequently washed with cold water, or solution of acetate of lead. 
3. Follicular Inflammation.-The mucous follicles may be affected 
with inflammation independently of the neighbouring parts, or in connexion 
with them. In the latter case, they are distinguished as small red eminences 
* R.-Magnesia? <Jss; Rhei. pulv. gr. xv; Misce etdivid. in cbart.no. vj. S. One fora 
dose. R.-Magnesite ^ij; Acaciae pulv., Sacch. alb. aa gj; Aq. Menth. P., Aq. fluv. 
aa f^j. Misce. S. A teaspoonful, every two or three hours till it operates. R-Cretas 
ppt. vel Testae ppt. Jj ; Tinot. opii. Tt^iv; Acacia? pulv., Sacch. alb. aa ; Aq. Cinnam. 
f^ss; Aq. fluv. f^iss. Misce. S. A teaspoonful every three or four hours, in diarrhoea. 
t R-Acid. Sulphuric Dilut., vel Acid. Muriat. fgj ; Syrup, vel Meilis f^j; Aq. Rosse 
f§ij Misce. R.-Alumin, gr. x ; Meilis f^ss; Aq. Rosse f3iss. Misce. R.-Liq. Sodae 
Chlorinat. f^iss; Aquae Rosse f^iss. Misce. R.-Argenti Nitrat. gr. j ; Aq. Destillat. f^j. 
Misce. Some recommend a much stronger solution of nitrate of silver, containing from 
five to eight grains of the salt to a fluidounce of distilled, water; but such a solution 
should not be applied oftener than once or twice a day. CLASS III.] 
INFLAMMATION OF THE MOUTH. 
473 
projecting beyond the general reddened surface of the membrane, and are 
particularly observable upon the tongue and soft palate. When independ- 
ently inflamed, they are, according to M. Billard, the source of those small 
round or oval ulcers, which are so common in the mouth, and have long been 
known by the name of aphthae. That these muciparous glands are occasion- 
ally the seat of aphthous ulcerations there can be no doubt; but a much 
more common source of them is the affection which will be noticed in the next 
section. As described by M. Billard, the inflamed follicles may be sometimes 
felt by the finger before they can be clearly distinguished.by the eye. When 
first distinctly visible they are in the form of minute, hard, round, whitish 
eminences, surrounded by a circle of redness. If the inflammation should 
not subside, the little tumours soften in the centre and ulcerate, and the sur- 
face of the ulcers is covered with a whitish adhering matter. These ulcers 
are usually distinct; but, when numerous follicles in the same vicinity are 
inflamed, they become confluent, and form a continuous whitish ulcerated 
surface of considerable extent. This affection, according to M. Billard, is apt 
to appear at the period of dentition; but it sometimes also attacks adults, and 
is asserted to occur in early infancy, when it is usually confounded with the 
thrush. In its confluent form, it is said frequently to attend the last stages 
of the exanthematous fevers, and of various chronic complaints, such as 
phthisis, cancer, and chronic inflammation of the abdominal viscera. The 
treatment is not different from that of the following variety of stomatitis. 
4. Eruptive or Vesicular Inflammation.-Aphthae.--The term aphthae 
was employed by the ancients to signify various inflammatory affections of the 
mucous membrane of the mouth. Willan proposed to restrict it to a peculiar 
vesicular eruption upon the membrane, but committed the error of confound- 
ing with this affection the thrush of early infancy, which, in general, as 
already described, is attended neither with eruption nor ulceration. The two 
complaints are quite distinct and should not be similarly designated. The 
term thrush, in this work, is applied to the infantile soTe-mouth already treated 
of; while aphthae, in compliance with very general usage, is extended to all 
those small ulcers, with whitish surfaces, which so frequently appear in the 
mouth, whatever may be their origin. Their most frequent source is proba- 
bly the vesicular eruption, which constitutes the subject of this section. The 
vesicle is small, oval or roundish, white or pearl-coloured, and consists of a 
transparent serous fluid under the elevated epithelium. In a few days, the 
epithelium breaks, the serum escapes, and a small ulcer forms, more or less 
painful, with a whitish bottom, and usually a red circle of inflammation 
around it. The vesicles are sometimes distinct and scattered, sometimes 
numerous and confluent. The distinct variety, though painful, is a light 
affection, continuing in general only a few days or a week, and is usually 
confined to the mouth. It produces little or no constitutional disorder, though 
it may be associated with fever and gastric irritation as an effect. It attacks 
equally children and adults; but is said not to be very common in early 
infancy. In adults it is frequently occasioned by the irritation of decayed 
teeth. The confluent variety is much more severe and obstinate. This fre- 
quently extends into the fauces and pharynx, and is even said to reach the 
intestinal canal, though it may be doubted whether the affection of the sto- 
mach and bowels is identical with that of the mouth. When it occupies the 
fauces, it renders deglutition painful. It is sometimes attended with gastric 
uneasiness, vomiting, intestinal pains, ,and diarrhoea. Fever occasionally pre- 
cedes it, and moderates without entirely ceasing upon the appearance of the 
eruption. The fever sometimes assumes the typhoid character. The com- 
plaint is not common. It occurs most frequently in adults, and is said to 474 
LOCAL DISEASES. 
[part II. 
attack preferably women in childbed. It may continue for several weeks, 
and sometimes prove fatal. 
Treatment.-In ordinary cases, no general treatment is required. Mag- 
nesia may be given to correct acidity, and the diet regulated by the state of 
the stomach. In the severer cases, fever should be obviated by refrigerant 
cathartics and diaphoretics, and by a liquid farinaceous or demulcent diet; 
When the disease attacks' the fauces or pharynx, occasions painful swallow- 
ing, and is attended with much fever and a strong pulse, general bleeding 
may become necessary, and subsequently the application of leeches to the 
throat. Diarrhoea must be counteracted by the usual remedies calculated to 
relieve intestinal irritation, among which may be mentioned as especially 
useful, emollient applications to the abdomen, and the warm bath. When 
the fever assumes the typhoid form, a tonic and supporting treatment may be 
required. 
In the early stages, the local treatment should consist of demulcent appli- 
cations, as flaxseed tea, mucilage of gum arabic, or almond emulsion, with or 
without a little laudanum, or some preparation of morphia. But, after the 
inflammation has somewhat subsided, and ulcers are left indisposed to heal, 
astringent washes may be resorted to. Solutions of acetate of lead, sulphate 
of zinc, and alum; water acidulated with sulphuric or muriatic acid, and 
sweetened with the honey of roses; and various vegetable astringent and 
tonic infusions have been recommended. The author, usually employs a 
strong solution of sulphate of zinc, in the proportion of 15 or 20 grains to 
the ounce of water, which he applies by means of a camel's hair pencil ex- 
clusively to the ulcers, with the almost uniform effect of disposing them to 
heal; and, even in the eruptive stage, this application will often be found to 
effect an almost immediate cure. Equally effectual are probably the nitrate 
of silver and sulphate of copper, applied to the ulcers, either in strong solu- 
tion or in the solid form. 
5. Ulcerative Inflammation.- Cancmm Oris.- Canker. - Any in- 
flammation of the mouth may be attended with ulceration; but the complaint 
here referred to is essentially ulcerative, appearing in this form at the com- 
mencement, and presenting characters which entitle it to rank as a distinct 
affection. Dr. Symonds considers cancrum oris as a synonyme of gangrene 
of the mouth; but such is not the ordinary application of the term. It is 
true that the ulcers, usually called canker, may, in constitutions predisposed 
to gangrene, terminate in that affection, but in the great majority of cases 
they do not appear to have such a tendency, and are a comparatively innocent 
disease. 
The complaint usually makes its1 appearance in the gums or inside of the 
cheeks or lips; -though it may occur in any part of the mouth, or • in the 
fauces. When first noticed it is in the form of an ulcer, often of considerable 
size, with a yellowish-white or grayish surface, and an inflamed border. The 
neighbouring parts are also inflamed and swollen, and, when the ulcer is in 
the cheek or lips, the tumefaction is observed externally, the check of the 
side affected being red, shining, and prominent. The swelling in the mouth 
is sometimes so considerable as to render an examination of the sore difficult. 
There is a very copious flow of saliva; and the breath is very offensive, though 
the fetor is distinct from that of gangrene. The ulcer is generally painful, 
and is usually attended with fever and constipation. It may continue for 
weeks or even months without very serious consequences; though, when upon 
the gums, it sometimes lays bare the alveolar processes. I have never known 
it to penetrate through the cheek, nor to end fatally; though what might be 
the ultimate consequences of continued neglect I am unable to say. I have 
always found it to yield to treatment. CLASS III.] 
INFLAMMATION OF THE MOUTH. 
475 
Patches of pseuddrmembranous. inflammation now arid then occur in the 
mouth, bearing much resemblance to the ulcerative affection above described, 
and possibly constituting, in many instances, its first stage. The patches 
covered with the plastic effusion are whitish at first, then grayish, and some- 
times at last livid or blackish. In consequence of the inflammation around 
them, they appear set in the membrane, and hence bear a close resemblance 
to ulcers. They end either by a gradual absorption of the pseudo-membranous 
matter, or by a destruction of a portion of the mucous tissue, when an ulcer 
results. 
The causes of the eancrum oris are obscure. It generally occurs in children 
from two to six years old; has been ascribed to a debilitated habit of body, 
arising from deficient or improper food, bad air, want of cleanliness, &c.'; and 
is said- to prevail most among the poor. I have seen it, however, in children 
otherwise apparently healthy, well fed, and well provided for in all respects; 
and am disposed to consider it as dependent upon some inappreciable derange- 
ment of the digestive function. 
Treatment.-From two to six grains of calomel may be given at the com- 
mencement, either associated with some other cathartic, such as rhubarb or 
jalap, in order to insure its operation upon the bowels, or followed, should it 
not operate in six or eight hours, by a dose of castor oil. The bowels may 
afterwards be kept open by the occasional administration of castor oil, mag- 
nesia or its carbonate, or the sulphate of magnesia; small doses of the neutral 
mixture, or of antimonial wine should be given when the fever is considerable; 
and, if the breath should be sour, a few grains of the bicarbonate of soda in 
carbonic acid water, repeated three or four times a day, will be found useful. 
In protracted cases, attended with debility, it may be found advisable to have 
recourse to the mineral acids, and infusion of bark or sulphate of quinia. In 
the febrile state, the diet should consist exclusively of farinaceous liquids. In 
the absence of fever, milk may be allowed; and, in cases of debility, animal 
broth, jelly, &c. Sour and acescent food should be avoided. 
But the local treatment is chiefly to be relied on. Various applications 
have been recommended. Among these are mouth waters of tincture of myrrh 
with Peruvian bark, dilute mineral acids with honey, and solution of alum. 
I have found nothing so useful as a solution of sulphate of zinc, in the pro- 
portion of fifteen or twenty grains to the fluidounce of water, applied twice or 
three times a day to the ulcer, by means of a camel's-hair pencil, and con- 
tinued until the yellowish-white exudation is removed, and the surface assumes 
a reddish hue. With this application I have in no instance failed to effect a 
cure. It is highly probable that strong solutions of sulphate of copper or 
nitrate of silver, which have been recommended, would prove equally effectual. 
The pseudo-membranous patches above described may be treated in the same 
manner. 
6. Sore-mouth of Nursing-women.-There is a form of ulcerative in- 
flammation of the mouth, peculiar to women while suckling; or in the advanced 
stage of pregnancy. It was described by Dr. E. Hale, in a communication 
to the Massachusetts Medical Society, published in 1830, and subsequently 
by Dr. F. F. Backus in the American Journal of the Medical Sciences for 
January, 1841. It comes on with a loss of taste, and a sensation described 
as similar to that produced by scalding liquids, and is sometimes very sudden 
in its attack. .. According to Dr. Hale, one or more minute, hard, painful 
tumours occur, at the beginning of the complaint, on the side of the tongue, 
which, after a time, ulcerate, producing, very painful sores, with hard elevated 
borders, and a circle of inflammation around them. According to Dr. Backus, 
the ulcers often do not make their appearance until a considerable time after 
the commencement of the inflammation. They gradually increase in size, 476 
LOCAL DISEASES. 
[part II. 
while others appear upon the tongue and inside of the cheeks, and the inflam- 
mation sometimes extends over the whole mouth. The surface is red and 
extremely tender and painful, so that no drinks or food can be borne but 
those of the blandest character. The tongue is not coated, but is red and 
smooth, and there is a copious flow Of saliva. The disease is at first local, 
being unattended with fever or loss of appetite; but, if not arrested, it is apt 
to extend to the fauces and oesophagus; the stomach and bowels become irri- 
tated ; diarrhoea often takes place; and the patient falls into a state of great 
debility and emaciation, which sometimes terminates in death. The cause is 
some influence exerted on the system by nursing, or by the advanced state of 
pregnancy; as persons are not affected under other circumstances, and the 
disease always gives way upon the weaning of the child. What is the nature, 
however, of this influence is unknown. It does not seem to be connected 
with any pre-existing condition of health, or character of constitution. The 
complaint is apt to recur in subsequent nursings; and Dr. Hale thinks that, 
when pregnant women are attacked, it is in consequence of a predisposition 
acquired from having had the disease while nursing on a previous occasion. 
It appears to be especially prevalent in particular localities. 
The most efficient, remedies are said to be tonics and laxatives. Dr. Hale 
gave sulphate of quinia or infusion of Peruvian bark, serpentaria, ale or 
porter, and Seidlitz powders or rhubarb; Dr. Backus, a combination of car- 
bonate of iron, rhubarb, aloes, and ipecacuanha, in the form of pills. The 
diet should be of milk and farinaceous substances. As local applications, 
mild astringent infusions, or a solution of nitrate of silver are recommended. 
Should these remedies fail, the child should be removed from the breast; and 
a cure then speedily takes place. Since the publication of the first edition of 
this work, a note has appeared in the New York Journal of Medicine (x. 
372), from Dr. H. D. Holt, in which the writer states that the disease has 
invariably yielded, under his observation, in less than forty-eight hours, to 
iodide of potassium, given in the dose of five grains three times a-day. Dr. 
R. Wilcox has met with uniform success from the decoction of smart-weed 
(Polygonum punctatum of Elliot), made by boiling an ounce of the dried leaves 
and tops in a pint of water for twenty minutes, and applied to the affected part 
every hour through the day. (Am. Med. and Surg. Journ., N. S., xvi. 248.) 
7. Gangrenous Inflammation.- Gangrxna Oris. - Sloughing Pha- 
gedeena of the Mouth.-Necrosis Infantilis.--Gangrene may originate in the 
mouth, as elsewhere, from inflammation, in consequence either of the violence 
of the affection or of constitutional predisposition; but the complaint which it 
is intended to designate by the above title is one of peculiar character, occur- 
ring under peculiar circumstances, and presenting peculiar phenomena. In- 
deed, it is an unsettled point, whether it has in general any dependence upon 
inflammation. By many the gangrene is considered as an original affection, 
and the inflammation which sometimes attends it rather as an effect than a 
cause. The probability is that it depends upon a peculiar morbid condition 
of system, which is sometimes capable of immediately producing it, but more 
frequently acts as a predisposition merely; inflammation or ulceration of what- 
ever kind serving as the exciting cause, which, calls this predisposition into 
action. In this way, the ulcer described in a previous section as canker of the 
mouth may sometimes be the first stage of the true gangrsena oris. 
Gangrene of the mouth occurs usually in children between the periods of 
the first and second dentition, though accounts are not wanting of its occa- 
sional occurrence also in adults. It is not often seen by the practitioner in 
its earliest stages. When it first attracts notice, it commonly exhibits a 
whitish or ash-coloured eschar, situated upon the gums, most frequently be- CLASS III.] 
INFLAMMATION OF THE MOUTH. 
477 
tween the lower incisors, though it may occur in any part of the mouth or 
fauces, and is often seated on the inside of one of the cheeks. This ulcer is 
sometimes, though not generally, preceded by a slight degree of inflammatory 
redness and swelling. When on the inside of the cheek, it is usually accom- 
panied with considerable swelling, so that the cheek, appears externally quite 
prominent; and this is sometimes the first mark of the disease which attracts 
notice. The exterior surface of the cheek is for the most part polished and 
whiter than in health. In this stage the child suffers little or no pain; nor 
are any striking constitutional phenomena presented. There is often an air 
of languor and weakness about the little patient; but the functions are appa- 
rently regular, and the usual avocations or amusements are not interrupted. 
There are seldom any signs of fever. . As the complaint advances, the slough 
spreads,.the saliva flows copiously, and the breath becomes- excessively fetid. 
The disease penetrates to the bony structure, necrosis of the alveolar processes 
takes place, and the teeth are loosened and fall out, with portions of their 
bony sockets. An acrid fluid is poured out by the sloughing and ulcerating 
surface, which inflames and excoriates the inner surface of the mouth, and, 
by thus over-exciting the enfeebled structure, gives rise to new centres, of 
mortification. Upon the swollen cheek externally, a pale ash-coloured spot 
sometimes makes its appearance, which becomes livid or black, and spreads 
rapidly, till much of the cheek is destroyed; and portions of the upper jaw, 
and even the palatal and ethmoidal bones, are said to have been, in some 
instances, involved in the mortification; but death usually takes place before 
the disease has had time to effect so much local mischief. In the progress of 
the gangrene, a febrile action sets in, probably occasioned, in part, by inflam- 
mation of the mouth and throat, resulting from the sloughs and the acrid dis- 
charges, and, in part, by the putrid matter swallowed by the patient. The 
pulse is frequent and feeble, and the child very restless and morbidly wake- 
ful. There is often, in the advanced stages, an almost total inability to take 
food, which tends to increase the debility. An exhausting diarrhoea, more- 
over, sets in towards the close of the disorder. Death is preceded by cold 
extremities, and the other customary evidences of extreme exhaustion. 
The disease seldom occurs after the period of the second dentition. It is 
most apt to attack children of debilitated constitutions, resulting from habitual 
exposure to a vitiated air, (and the use of unwholesome or insufficient food. 
Hence, it is most prevalent in miasmatic districts, and in public establish- 
ments where children are crowded together. It is a frequent sequela of other 
diseases, especially of intermittent and remittent fever, and the exanthemata. 
Mercury has sometimes been accused of producing it, though generally upon 
insufficient grounds. It is possible that the mercurial sore-mouth may some- 
times have degenerated into this complaint, in persons predisposed to it. The 
opinion is highly probable, which ascribes the constitutional predisposition to 
the disease to a depraved condition of the blood. It is not unfrequently com- 
plicated with pneumonia, which greatly increases the danger. Of twenty-one 
fatal cases, Rilliet and Barthez found this complication in nineteen. (Traite 
des Maladies des' Enfants, ii. 152.) 
Treatment.-The disease, when taken in hand in an early stage, is almost 
always curable; but, after considerable sloughing, especially of the cheek, is 
generally fatal. The remedies addressed to the constitution are those calcu- 
lated to support the strength of the patient. Sulphate of quinia, or infusion 
of Peruvian bark, the mineral acids, and a nutritious diet, are usually advisa- 
ble. In cases of great debility, wine whey, with carbonate of ammonia or 
camphor, and animal broths should be resorted to. Constipation should be 
obviated by rhubarb, with or without magnesia; and opiates should be giyen 
throughout the complaint to relieve restlessness and pain. 478 
LOCAL DISEASES. 
[part II. 
But local measures are most to be relied on. As soon as a white or ash- 
coloured surface appears, some escharotic substance should be freely applied 
to it. Dr. B. II. Coates, of Philadelphia, who has seen much of the disease, 
has found a strong solution of sulphate of copper, in the proportion of half a 
drachm of the sulphate to a fluidounce of water, applied two or three times 
daily, so as to touch every portion of the diseased surface, by far the most 
effectual remedy. (TV. Am. Med. and Surg. Journg vol. ii. p. 20.) Solid 
nitrate of silver, ora strong solution of the salt if sloughs are already formed, 
the mineral acids, and undiluted tincture of chloride of iron, have also been 
recommended as topical applications, and will in most cases be found effectual. 
The same may be said of a solution of sulphate of zinc, in the proportion of 
half a drachm to the fluidounce. Tincture of myrrh, decoction -of Peruvian 
bark, and solution of alum have been employed; but are of little use, unless 
in promoting the healing process after the separation of the slough. The 
mouth should be washed with solution of chloride of soda or of creasote, to 
correct the fetor. The removal of the loosened teeth will sometimes be found 
useful, as their presence serves as a source of irritation, and sometimes inter- 
feres with the application of remedies to the whole surface diseased. When a 
gangrenous spot appears on the cheek, M. Billard advises, as the most effect- 
ual remedy, to make a crucial incision in the affected part, and to fill it with 
the butter of antimony, or to apply the actual cautery. The charcoal, carrot, 
or fermenting poultice, may be applied when the gangrene advances, the parts 
being frequently washed with an aqueous solution of creasote. 
8. Mercurial Inflammation of the Mouth.-Mercurial Stomatitis.-• 
There are various morbid states of the mouth depending upon peculiar gene- 
ral diseases, such as the scorbutic and syphilitic ulcers, and the variolous 
pustules; but these are more properly treated of under the heads of the dis- 
eases severally, of which they constitute a part. The effects of mercury upon 
the mouth may with the greater propriety be considered in this place, as an 
account of its general effects upon the system does not come within the plan 
of the present work. 
Among the first indications of the action of mercury are often a metallic 
taste in the mouth, like that of brass or copper,1 and Some increase of the 
saliva. At the same time, a close examination will detect a slight redness 
and swelling of the gums, particularly about the necks of the lower incisors, 
while somewhat below their edge, a broad white line may often be observed, 
depending on opacity of the epithelium. The patient soon begins to feel some 
uneasiness, complaining of soreness when the gums are pressed, and of pain 
when the teeth are forcibly closed together. There is also a sense of stiffness 
about the jaws when the mouth is opened, and the teeth feel as if projecting 
above their usual level. The flow of saliva increases, the inflammation ex- 
tends, the gums and palate become obviously swollen, and the tongue covers 
itself with a yellowish-white or brownish fur, and is often so much enlarged 
as to exhibit the impressions of the teeth when projected from the mouth. 
The throat frequently becomes sore, and the cheeks, and salivary and absorb- 
ent glands, swollen and painful. There is often severe toothache or pain in 
the jaws. A whitish exudation along the edges of the gums is very common. 
The breath, which, from the beginning, and sometimes even before the appear- 
ance of any one of the symptoms mentioned, has a peculiar disagreeable odour, 
now becomes exceedingly offensive, and in bad cases almost intolerable. Ul- 
ceration often occurs, especially about the necks of the teeth, which are-con- 
sequently loosened, and in the cheeks, lips, and fauces. The ulcers often 
have their origin in a vesicular eruption, such as that already described. (See 
page 473.) The whole mouth with its appendages is sometimes so much CLASS III.] 
INFLAMMATION OF THE MOUTH. 
479 
swollen that it can scarcely be opened; and the tongue so much enlarged as 
to project beyond the lips. The patient is now nearly or quite unable to 
articulate, or to.masticate lais food, and sometimes can scarcely swallow. A 
case was related by Dr. Physick, in his lectures, in which an obstinate dislo- 
cation of the jaw resulted from the enormous tumefaction of the tongue. He- 
morrhage is not an unfrequent attendant upon these, bad cases, and is some- 
times so profuse as to be alarming. Sloughing also- takes place, and portions 
of the jaw bone are occasionally laid bare. There is always, in the severe 
cashes, more or less fever, which is partly symptomatic of the local affection, 
partly the direct effect of the mercury. Death, from the exhausting influence 
of the irritation, want of nourishment, and hemorrhage, has occurred in nu- 
merous instances; but the patient generally recovers from the worst forms of 
th'e affection, though sometimes with a deformed mouth. The tongue and 
cheek have occasionally adhered at points where their ulcerated surfaces were 
in contact, and a surgical operation has been necessary to remove the evil. 
Some individuals are exceedingly susceptible to sore-mouth from mercury; 
the smallest quantity of the mineral being sufficient to produce severe effects. 
Others again are scarcely affected, in this way, by any quantity of the medi- 
cine which can be administered. The preoccupation of the. system by a very 
violent disease presents, in many instances, a complete obstacle to its action 
upon the mouth. Thus, in yellow fever it is sometimes utterly impossible to 
induce the mercurial salivation. 
Treatment.-Mild cases of this affection require no treatment. In severe 
cases, it is usually advisable to keep the bowels loose by saline cathartics, 
to confine the patient to a liquid farinaceous or milk diet, and to allay nervous 
irritation and pain by opium. In some rare instances, where the inflamma- 
tion is intense and the pulse strong, it may be proper to draw blood from the 
arm. Care should be taken that the patient be clothed in flannel, and breathe 
a pure air. The compound decoction of sarsaparilla, to the amount of a quart 
daily, has been recommended as a diluent. The internal use of chlorate of 
potassa has also been recommended as highly useful, though requiring cau- 
tion. (See Am. Journ. of Med. Sei., N. S., xiii. 169.) 
In the local treatment, it is usually sufficient to wash the mouth and throat 
with warm demulcent liquids, or mild astringent decoctions or infusions. Of 
the former, barley-water,, flaxseed tea, and infusion of sassafras pith or benne 
leaves; of the latter, common green tea, decoction of galls or black alder, and 
infusion of red roses, or of the berries or inner bark of the upland sumach 
may be employed. The astringent preparations should be weak, and may be 
advantageously associated with laudanum. Perhaps no wash for the mouth 
is preferable to a solution of acetate of lead, in the proportion of two or three 
grains to the fluidounce. A solution of alum may also be employed; and, 
when ulcers exist, a strong solution of sulphate of zinc or nitrate of silver may 
be applied by a camel's hair pencil to the ulcerated surface. Half a drachm 
of nitrate of silver may, for this purpose, be dissolved in a fluidounce of dis- 
tilled water. To correct the fetor, washes made with chloride of soda or of 
lime, or with creasote, will be found most effectual. Tar smeared over 
the surface,of the mouth has been recommended. Dr. Wilcox, of Elmira, 
New York, has obtained extraordinary success, from, the use of a decoction of 
the smart-weed, employed in the same manner as recommended in the sore- 
mouth of nursing women. (See page 476.) When the inflammation and 
swelling are great, leeches may be applied under the lower jaw, or over the 
parotids. I have found blisters to the sides of the face and neck very useful 
in relieving pain. 480 
LOCAL DISEASES. 
[part II. 
Article II. 
INFLAMMATION OF THE TONGUE, or GLOSSITIS. 
The-term Glossitis (from tongue) is here applied to inflammation 
of the substance of the tongue; inflammation of the mucous membrane of 
that organ having been included in stomatitis. This is often very sudden in its 
attack, and rapid in. its progress. Some portion of the tongue, most commonly 
the anterior part, becomes red, painful, and swollen, and, in the course of a 
few hours, the inflammation extends throughout the organ, which- enlarges so 
much as to fill the whole mouth, to force open the jaws, and sometimes to 
project considerably beyond the teeth and lips. The floor of the mouth is 
obviously much depressed, the soft palate elevated, and the epiglottis, in some 
instances, so much pressed down as to endanger suffocation. Deglutition is 
very difficult, if not impossible; and the patient is wholly unable to articu- 
late. The tongue is usually red or dark-coloured, and dry upon the surface; 
though sometimes it is moist, and covered with a thick whitish or yellowish 
fur. Not unfrequcntly. the neighbouring parts participate in the inflamma- 
tion. The system sympathizes, and a quick strong pulse, and hot skin usually 
exist in the earlier stages.; but, as the complaint advances, and respiration 
becomes embarrassed, the pulseffoses its strength, and cold sweats occur. The 
inflammation may terminate in resolution; but, if not interrupted by remedial 
treatment, it is apt to run into suppuration or gangrene, unless, indeed, the 
patient previously die of suffocation, or of apoplexy from the impeded return of 
blood from the head. Sometimes permanent induration is left upon the sub- 
sidence of the inflammation. Less destruction is produced by gangrene than 
might be imagined from the large sloughs thrown off by the tongup; for, 
when the organ shrinks to its original size, the loss is often found incon- 
siderable. 
Causesj--Glossitis may result from the usual causes of inflammation. Per- 
haps the most frequent causbGs- direct injury, resulting from irritating or cor- 
rosive substances, scalding drinks, wounds or bruises, or the bites or stings of 
venomous insects. Sometimes the affection is produced by a direct propaga- 
tion of inflammation from the tonsils, and it occasionally arises in the course 
of exanthematous fevers. In some instances, the chief force of the mercurial 
action appears to fall upon the tongue, and to produce immense tumefaction. 
Treatment.-The rapid and dangerous character of this disease requires 
prompt and efficient treatment. As much blood should be immediately taken 
from the arm as the strength will permit, and the bleeding should be repeated 
once and again, if necessary to arrest the progress of the inflammation. If 
deglutition is possible,'the patient should be purged freely with sulphate of 
magnesia, or with this salt combined with infusion of senna, or with some 
other active cathartic. Should it be impossible to administer medicines by 
the mouth, the bowels should be kept open by enemata. The diet should 
consist exclusively of farinaceous drinks. When the patient is unable to 
swallow liquids, thirst may be alleviated by bathing, copious diluent enenlata, 
and the cautious application of lemon-juice to the surface of the tongue. 
The remedy on which, however, after general bleeding, the chief reliance 
must be placed, are leeches applied beneath the lower jaw, and to the upper 
anterior part of the throat. To be efficient, it is necessary that the bleeding 
should be very copious. As many as one hundred American leeches may be CLASS III.] 
MORBID DENTITION. 
481 
applied at once, if the strength of the patient permit. They should have 
been preceded by venesection. Some recommend their application directly 
to the tongue; but, in general, leeches act better when applied in the vicinity 
of an inflamed organ than immediately to it; as the irritation from their 
bites is sometimes very injuriously superadded to the existing disease. The' 
opening of the ranular veins has also been recommended; but it is not always 
easy to reach them in the swollen state of the tongue; and there is danger of 
wounding the ranular arteries in the operation. The cases seen by the author 
have always yielded to the free use of leeches externally, beneath the floor of 
the mouth, after suitable general depletion. After the leeching, emollient 
poultices may be employed; or recourse may be had to blisters. But, should 
leeches not be attainable, or should they have been employed without success, 
and the danger of suffocation appear imminent, free incisions should be made 
into the substance of the tongue, one on each side of the median line, extend- 
ing from the base to the tip. Care, however, should be taken, not to make 
them so deep as to endanger the wounding of the ranular arteries. Blood 
flows freely from the incisions, and the size of the tongue is rapidly dimi- 
nished. Another advantage is the escape of the pus, if suppuration should 
have taken place. If, notwithstanding all these measures, suffocation is 
threatened, it will be necessary to open the larynx; and cases may exist so 
immediately dangerous, that this operation should be at once resorted to, 
without awaiting the slower effect of other means of relief. 
If an abscess form in the tongue, it should be opened by a bistoury, and 
mild emulsions or .mucilaginous liquids, with the addition of honey of roses 
or simple oxymel, may be afterwards applied. Should the healing process be 
slow, it may be advantageously stimulated by tincture of myrrh and decoc- 
tion of bark, or other analogous washes. In cases of gangrene, the mouth 
should be washed with chloride of lime or of soda, aqueous solution of crea- 
sote, or decoction of bark acidulated with the mineral acids. 
Article III. 
MORBID DENTITION. 
It has long been observed that, during the process of dentition, children 
are more liable to disease than at other times, and that this is the most fatal 
period of life. It is probable, however, that the influence of the process has 
been much exaggerated. It occupies a large portion of that stage of growth, 
when the susceptibilities of the system are most acute by nature, and least 
blunted by habit, and when morbific causes in general must have the greatest 
influence. It is at this time of life also that exposure usually begins, and 
the child becomes liable to those diseases, such as measles, hooping-cough, 
&c., which occur but once. It is moreover, during dentition, that the change 
of diet usually takes place from the milk of the mother to other and unaccus- 
tomed kinds of food, and that the maternal milk itself becomes deteriorated 
by the institution of new or suspended physiological processes. Independ- 
ently of teething, therefore, it would be inferred, that this period of life must 
be unusually fatal; and it is an error to ascribe the result exclusively to that 
process. Still, there can be no doubt that it exercises an important influence, 
and that its derangements are among the most fruitful sources of danger to 
infant life. The pressure of the growing teeth upon the surrounding parts 
almost necessarily occasions some uneasiness, and frequently produces so 482 
LOCAL DISEASES. 
[PART II. 
much irritation and inflammation as not only to cause great local suffering to 
the child, but also to call various functions into sympathetic disorder, and 
even to set on foot serious organic diseases. This is easily understood, when 
it is considered that, in infancy, not only are the susceptibilities most acute, 
but the sympathies also peculiarly active, from the necessity in which the 
system is placed, in the rapid developement of all its parts, to guard against 
irregular results by the rapid diffusion of impressions from each part to every 
other. 
The investing membrane of the tooth, and the gum over it, against which 
the body presses in its progress, and which is absorbed in consequence of this 
pressure, are the parts which chiefly suffer; though it is highly probable that 
the roQts also occasion distress, during their developement, by incommoding 
the dental nerves. The irritation thus occasioned is probably often product- 
ive of tingling, itching, or other vague uneasiness, different from pain, and 
even more difficult to be borne; for the child instinctively seeks relief by 
biting upon hard substances, or otherwise pressing them against his gums; 
the slight pain thus occasioned being more tolerable than the sensation which 
it displaces. This irritation may sometimes even occasion serious constitu- 
tional disturbance, especially of a nervous character; for such disturbance 
has been apparently relieved by lancing the gums, even when no obvious 
inflammation existed. The feeling of relief from pressure may be expe- 
rienced, even when the gum is considerably swollen, hot, and painful; but, 
when the surface becomes of a deep red, or assumes that vesicular appearance 
which sometimes precedes the eruptiom of the tooth, it is usually exceedingly 
tender to the touch. During difficult dentition, the saliva flows more freely; 
the child becomes fretful, peevish, restless, and wakeful at night, frequently 
putting his fingers into the mouth, and sometimes screaming violently, and 
almost incessantly. In some instances, the inflammation extends to neigh- 
bouring parts, affecting the absorbent and salivary glands, and the mouth 
becomes hot and dry. 
The sympathetic effects of teething are generally in proportion to the local 
affection, which is greatest when many teeth are advancing at the same time. 
They bear also some relation to the constitution and age. Delicate children 
usually suffer more than the robust, because the process is more protracted; 
and the danger is greater in premature than in late dentition, because the 
susceptibilities of the system are greater. • From the peculiar mobility of the 
nervous system of infants, this is very apt to suffer, especially the brain. 
Hence restlessness, wakefulness, occasional spasmodic movements, and even 
convulsions. The respiratory organs sometimes participate in the nervous 
derangement; and there is reason to believe that spasm of the glottis, and 
very obstinate coughs, may originate in this source. But the irritation is 
most frequently directed to the alimentary canal. Looseness of the bowels is 
a very common attendant on teething, and, when not severe, may be consid- 
ered as a salutary effort to relieve or prevent more dangerous affections, espe- 
cially of the brain. Sometimes, however, it assumes itself a dangerous 
character, being attended with vomiting and great prostration, or becoming 
protracted, and wearing out the strength of the patient. The skin is also a 
frequent seat of the sympathetic irritation, and various eruptive affections are 
apt to appear during dentition. Among these, a pustular and ulcerative or 
scabby disorder behind the ears is not uncommon. The circulation generally 
participates more or less in the irritation; and fever not unfrequently occurs. 
Besides all these direct results of diseased dentition, it is apt to aggravate 
almost all co-existing diseases. CLASS III.] 
MORBID DENTITION. 
483 
Treatment.-The child should in general be exposed to cool fresh air, and 
the bowels, if at all disposed to costiveness, should be kept open by a laxative 
diet, or by mild cathartics, such as manna, magnesia, or castor-oil. If there 
should be much fever with costiveness, a dose of calomel will often be found 
useful. In this case, cool drinks, and some of the refrigerant diaphoretics 
may also be given, particularly the neutral mixture, and the spirit of nitric 
ether, which often has a happy effect in controlling irregular nervous action. 
The -stomach should never be loaded with food, and the diet should be light 
and of easy digestion, and proportioned to the degree of existing excitement. 
Attendant or consequent diseases must be treated as when they occur under 
other circumstances; reference, however, being always had to the fact, that 
diarrhoea and cutaneous eruptions often afford a safe outlet to the irritation, 
and should not be too hastily removed, lest this might fall dangerously upon 
the brain. The disorder behind the ears is apt to be unsightly and trouble- 
some ; and mothers wire often anxious for its cure; but it should rather be 
encouraged than removed; and the late Dr. Parrish, of Philadelphia, used to 
insist upon the importance, not only of not interfering'with this salutary pro- 
cess of nature, but even of imitating it, in cases of much obstinacy or danger, 
by keeping blisters open in the same situation. 
The local treatment of diseased dentition is highly important. When a 
mere irritation exists, 'without much, inflammation or disturbance of the health, 
it may be sufficient to allow the child to chew upon some hard substance, as 
a smooth piece of wood or ivory; but, when the gums are swollen, and any 
derangement in the functions occurs, incisions should be made without hesita- 
tion down to the teeth, so as to divide both the gum and the investing mem- 
brane. These may be made by a gum-lancet, or a sharp penknife, and should 
always be free. Over the front teeth, the incision should be single, but over 
the double teeth of a, crucial form. Lancing the gums often affords great and 
immediate relief. It is useful, in some measure, by the bleeding which ensues, 
and is therefore not always without benefit, even when superficial; but its 
chief advantage is the liberation of the tooth, and the removal of the tension 
of the gum and membrane. The objection which has been urged against it, 
that the incision often heals before the tooth appears, and thus leaves a scar 
more difficult to penetrate than the original gum, is altogether without foun- 
dation. So far from affording an increased resistance to the progress of the 
tooth, the scar partakes of that diminished vitality of all new formed parts, 
which causes them to yield to the absorbent process more readily than the 
original structure. It is asserted that lancing the gums is sometimes useful, 
even when no swelling appears, by relieving the tension and irritation of the 
parts immediately around the tooth. Some caution, however, is here requisite; 
as too early a division of the capsule which secretes the enamel of the tooth 
may interfere with the proper formation of that structure; andGuersent states, 
as the result of his observation, that teeth, thus prematurely exposed, make 
their way through the gums more slowly than the others. (Diet. de Med., x. 
139.) Should the inflammation be obstinate or extensive, and not yield to 
the division of the gums, a few leeches may be applied upon the outside of 
the jaws, and a pair of blisters behind the ears; and the blisters may be re- 
peated, or kept open by stimulating dressings. 484 
LOCAL DISEASES. 
[part II. 
Article IV. 
TOOTHACHE, or ODONTALGIA. 
Toothache scarcely deserves the name of a disease, being merely a symptom 
of various morbid states of the affected part; but, as it is in general the most 
prominent circumstance in connexion with the affection which it accompanies, 
and that to which the attention of the practitioner is chiefly called; and as it 
affords the means of connecting in one view several disorders of the teeth, or 
their 'appendages, which scarcely deserve a distinct heading in a work like 
the present, it is employed as a title to this article. 
Toothache offers every possible variety in degree, character, and duration. 
The pain runs through all the grades which intervene between a slight sensa- 
tion of uneasiness and insupportable agony. It may be dull, aching, heavy, 
sharp, pungent, throbbing, grinding, or lancinating. It may be continued or 
paroxysmal, remittent or intermittent, and regular or irregular in its recur- 
rence. It may come in flashes, and as suddenly disappear; or may continue 
a long time with little variation. Its varieties will be best considered under 
the different pathological conditions which it attends. 
1. Nervous, or Neuralgic Toothache.-A purely neuralgic condition 
of the teeth is not uncommon. The affection may be seated in the nerve of a 
single tooth; but it much more commonly occupies the nervous trunk from 
which several teeth are supplied; and not unfrequently affects rather the jaw 
than the teeth themselves. The pain is in general of the acute character, some- 
times mild in the beginning, gradually increasing in intensity, and as gradually 
declining; but usually very irregular, at one time moderate, at another severe, 
and occasionally darting with excruciating violence through the dental arches. 
Not unfrequently it assumes a regularly intermittent form. Instead of pain, 
strictly speaking, the sensation is sometimes of that kind which is indicated 
when we say that the teeth are on edge, and is apt to be excited by certain 
harsh sounds, such as that produced in the filing of saw teeth, by mental in- 
quietude, and by the contact of acids or other irritant substances. Neuralgic 
toothache sometimes persists, with intervals of exemption, for a great length 
of time, and becomes the torment of the patient's existence. The diagnosis 
is occasionally difficult. When, however, it occurs in sound teeth, is parox- 
ysmal in its character, is attended with little or no swelling of the external 
parts, occupies a considerable portion of the jaw, and especially when it alter- 
nates or is associated-with pain of the .same character in other parts of the 
face, there can be little doubt as to its real nature. 
This variety of toothache may depend on a morbid state of the nerve or 
nerves which are the immediate seat of it, but more frequently originates in 
a condition of the nervous system, such as disposes to neuralgic pains gene- 
rally. This will be considered under the head of neuralgia. With an existing 
predisposition, it is sometimes invited by caries, but very frequently occurs 
in teeth which are perfectly sound. Almost anything -which disturbs the 
system may serve as an exciting cause; but the most frequent causes are 
probably vicissitudes of weather, and the application of very cold or very hot 
substances to the teeth, especially in alternation. The disease appears to be 
sometimes sympathetic with morbid states of the stomach or other distant 
organs; and not unfrequently occurs in persons of a gouty or rheumatic dia- 
thesis. CLASS III.] 
TOOTHACHE. 
485 
Treatment.-In plethoric cases,-with a strong tense pulse, general bleeding 
may be employed; but this is seldom necessary or advisable, and in cases of 
debility might aggravate the affection. In the latter cases, after due evacua- 
tion of the bowels, tonic medicines, especially the subcarbonate of iron, in 
doses of one or two drachms three or four times a day, and the sulphate of 
quinia freely administered, are often useful, and sometimes will effect a cure. 
The narcotics are also beneficial. The, extracts of belladonna, stramonium, 
hyoscyamus, conium, and aconite, may be employed singly or in combination. 
Opium or some of its preparations are occasionally necessary to relieve the 
violence of the pain. When the neuralgic affection can be traced to sympathy 
with disease elsewhere, this should be corrected. Thus, antacids should be 
given in acidity of stomach, laxatives in constipation of the bowels, the blue 
mass or calomel in deranged or deficient hepatic secretion, aloes or other em- 
menagogue in amenorrhoea; and not unfrequently the co-existence of two or 
more of these affections calls for the simultaneous use of the appropriate reme- 
dies. If a rheumatic or gouty diathesis be suspected, wine of colchicum, hot 
pediluvia, and other means adapted to these disorders may be tried. Peru- 
vian bark or sulphate of quinia will be found an almost certain remedy in 
regular intermittent cases, and often useful in others. Mercury is sometimes 
effectual,, when the disease has resisted all other treatment. In fact, whatever 
alters materially the distribution of nervous influence, and changes the condi- 
tion of the system offers a chance of benefit. Hence"'the employment of 
general frictions, and of cold and hot baths, sometimes proves advantageous. 
In very obstinate cases,; a total change of scene and habits is often highly 
beneficial. An excursion to some watering-place, a protracted journey, and 
especially a sea voyage, with long continued foreign travel, will often effect 
permanent cures when the- catalogue of medicines has been exhausted in 
vain. The diet should be accommodated to the condition of the system, and 
of the digestive organs. 
The local treatment consists of leeching in plethoric cases, anodyne embro- 
cations Or poultices, sinapisms and other rubefacient, applications, frictions with 
veratria or strong tincture of aconite, blisters with a salt of morphia sprinkled 
on the denuded surface, moxa in the course of the nerves or on the side of 
the neck, cold water or ice to the cheek, steaming the face with the vapour of 
hot water, either pure or combined with volatile narcotics, tobacco fumiga- 
tions, irritant and anodyne masticatories, errhines, electricity or galvanism, 
and all other topical means employed in the treatment of neuralgia. (See 
Neuralgia.') When a single tooth is affected, relief is sometimes afforded by 
its extraction; but this measure often fails, and always when several teeth are 
involved. Carious teeth should generally be removed in these cases, if the 
affection has proceeded far. 
2. Inflammatory Toothache.-This may exist with or without caries; 
but is in the great majority of instances dependent upon that affection. Before 
proceeding, therefore, to an account of its phenomena, it will be proper to say 
a few words on the subject of carious teeth. 
Caries is an affection of the interior or bony structure of the teeth, the 
enamel being without vitality, and not therefore subject to morbid action. 
Some have denied to this disease a claim to the title of caries; because 
nerves and blood-vessels have not been traced in the substance of the teeth, 
and no process of absorption or granulation, by which the diseased part can 
be separated, and its place supplied by new structure, takes place. Thos. Bell, 
however, maintains that nerves and blood-vessels do exist, the former, because 
the tooth has a certain degree of sensation, the latter,, because a red injection 
may occasionally be observed in its substance, and a yellowish colour is some- 486 
LOCAL DISEASES. 
[PART II. 
times imparted to it in jaundice. (Bell's Notes to Hunter on the Teeth.} There 
can scarcely be a doubt, that the bony portion of the tooth is organized, and 
is therefore subject to morbid action; and, though this may not present ex- 
actly the phenomena observed in caries of bones of a higher degree of organi- 
zation, it approaches somewhat towards it in character. 
Caries sometimes begins on the internal surface of the tooth, and extends 
outward, exhibiting usually, as the first evidence of its existence, a dark 
appearance beneath the enamel. f Good's Study of Mpdf But, much more 
frequently, it proceeds from without inward, commencing in the bone imme- 
diately beneath the enamel, and. exhibiting a yellowish or brownish spot in 
this situation. The tissue is. softened, and a small cavity formed, which after 
a time communicates externally by the crumbling of the unsupported enamel 
over it. The substance of the tooth now decays more rapidly; and the caries, 
exhibiting a yellowish, brownish, or blackish colour, gradually approaches the 
central cavity of the tooth, which is at length opened. The caries is said to 
advance most rapidly in those cases in which the surface is yellowish. At first 
there is little or no suffering; but, when the disease has reached the cavity of 
the tooth, the pulp becomes sensible to lieat, cold, and the action of irritant 
substances, and pain is experienced. At length inflammation takes place, 
which speedily advances to suppuration, and the pulp is gradually destroyed 
by ulceration or gangrene. The body of the tooth, deprived of the nourish- 
ment which it received from the pulp, decays entirely, leaving only the outer 
coating of enamel, which then breaks off by degrees, until nothing but the 
roots are-left. These usually, though not always, cease to give pain. In 
some cases, especially when the surface is black or very dark, the caries ad- 
vances very slowly, or is altogether arrested. In such cases, the surface is 
commonly also harder and less friable than in the yellowish caries. 
This decay of the teeth is not necessarily attended with pain. Occasionally 
the affection runs through its whole course, with little or no suffering to the 
individual; and sometimes, after having been painful, it ceases at certain 
periods of life to be so/though the process of decay may continue. In some 
instances of caries without toothache, the irritation appears to be felt sympa- 
thetically in other parts; and painfid affections of the head, ears, and eyes, 
have ceased upon the extraction of a decayed tooth, which had never ached. 
The most frequent cause of caries is probably some condition of the bone 
acquired during its formation, in consequence of peculiarity of constitution, or 
the state of health existing at the time. Thus, persons affected with scro- 
fula or scurvy, during dentition, are apt to be affected with decay of the teeth 
in after life. There is reason also to believe, that the predisposition is some- 
times hereditary. Women and young children are more subject to the disease 
than men. The direct or exciting causes are either such as destroy the 
integrity of the enamel, and thereby expose the bone to the influence of irri- 
tant substances, or such as operate directly upon its vital susceptibilities. 
Among the former are acids and other corrosive substances taken into the 
mouth, sour eructations from the stomach, depraved salivary or mucous secre- 
tions, the sordes which collect about uncleaned teeth, the contact or near 
vicinity of a carious surface in another tooth, the attrition of opposing surfaces 
of the teeth, and all kinds of mechanical violence. Of the latter, the princi- 
pal are heat and cold suddenly applied, and especially in quick alternation. 
Hence it is, perhaps, in part, that caries of the teeth is more common in 
civilized life, where hot drinks are habitually used, than among savages. The 
very free use of sugar, as an article of diet, is thought by many to be a fre- 
quent cause of the disease. Some have ascribed its effects to direct action on 
the teeth; but it is more probable that it operates, if at all, by impairing CLASS III.] 
TOOTHACHE. 
487 
digestion. Whatever deranges the digestive function may occasion caries 
indirectly, by giving rise to acrid and corrosive eructations,< and by altering 
the secretions which are poured into the mouth. Nevertheless, sugar is cer- 
tainly strongly irritant to the dental nerves; as is evinced by the severe tooth- 
ache so often occasioned by its contact with a carious surface. 
When the caries is slight, and especially when it occupies the sides of the 
teeth, it/ may often be arrested by removing the diseased portion with the 
file; and the same end may be attained by filling the cavity with some me- 
tallic substance, such as lead, tin foil, or gold leaf, so as to exclude the air 
and all irritant bodies. Plugging may be resorted to in all cases when the 
tooth has not begun to ache, or when it has ached but moderately and for a 
short time. ' ' ' . 
Having premised these remarks respecting . caries of the teeth, we are 
prepared to enter upon the consideration of inflammatory toothache. It is 
proper previously to state, that, in carious -teeth, and in those deprived of 
their enamel without being absolutely carious, pain may be produced by the 
contact of irritant bodies, without the existence of inflammation. But the 
action thus excited, when not purely neuralgic; is an irritation which is 
the first step towards inflammation, and will inevitably lead to it if con- 
tinued. The inflammation which occasions toothache may be seated in 
the pulp of the Tooth, in the cord which enters its lower extremity, or in the 
periosteum investing its roots, and reflected over the interior of the alveolar 
cavity. Sometimes this inflammation terminates in resolution, without pro- 
ducing any swelling of the gum; and, in such cases, especially when the tooth 
itself is sound, the diagnosis is not easy between the inflammatory and neu- 
ralgic toothache. But the former is usually confined to one tooth, while the 
latter generally extends -to several. Besides, the pain in the inflammatory 
variety is less sharp, less irregular, and less disposed to the paroxysmal form. 
Most Commonly, however, after the '•pain has continued a short time, some 
external swelling appears. At. first the pain is usually moderate, and it may 
continue thus throughout; but generally it increases, and at length becomes 
intense, in consequence probably of the pressure to. which the swollen and 
inflamed parts are subjected by,the unyielding bone around them. The tooth 
is at the same time very tender; and any force applied to it greatly increases 
the pain. The inflammation is propagated by contiguous sympathy to the 
gum and other parts of the face, which become much swollen; and the 
swelling sometimes extends to the salivary and absorbent glands, and even 
to the tonsils. The violence of the pain often ■ abates somewhat, upon the 
occurrence of this external inflammation, which appears to act as a revul- 
sive. The tumefaction not unfrequently subsides, without the occurrence of 
suppuration, and the toothache ceases for a time. Very frequently, how- 
ever, an abscess forms either in the gum, upon the upper or lower jaws, in 
the roof of the mouth, or, more rarely, in the .substance of the cheek. There 
is often much constitutional disturbance, with fever, headache, and inability 
to .sleep. The pain, during the suppurative stage, is usually pulsative or 
throbbing. The abscess at length opens and relief is obtained. The - dura- 
tion of an attack of this kind is usually six or seven days, though sometimes 
much longer. When the abscess is seated in tile palate, it is generally of 
slower progress, and sometimes continues for weeks or months without opening; 
but in the latter case the pain is not acute. The patient, though relieved for 
a time, is liable to constant returns of the affection in cases of carious teeth, 
until these are wholly destroyed in the course of the disease, or arc artificially 
removed. 
Suppuration also takes place in the pulp or dental cord. If an opening 488 
LOCAL DISEASES. 
[part II. 
exist into the central cavity of the tooth, (the pus may be discharged by this 
route; but if there be no such outlet, the matter accumulating, occasions in- 
flammation and absorption of the socket, and thus makes itself a way out, 
either between the tooth and the gum, or directly through the latter, forming 
an abscess in its substance. When this opens, the pain is relieved; but the 
opening is apt to become- fistulous, and a continual purulent discharge to be 
maintained until the tooth is wholly removed.' 
There is some distinction between the symptoms of the inflammation seated 
in the different parts. above referred to. When it is in the pulp alone, the 
tooth is painful upon percussion, but suffers less when pressed against the 
opposite tooth, as in the closing of the jaws. The pain.is often exceedingly 
severe, and is increased by hot' and cold liquids taken into the mouth. Some- 
times, in these cases, a fungous growth projects through the carious cavity. 
This, if inconvenient, may be removed by excision or by caustic. When the 
inflammation occupies the cord, the pain is seated deep in the jaws, and is 
much increased by closing the'teeth firmly. It may be dull or acute ; but is 
less excruciating than that of the pulp, and is not equally affected by hot and 
cold liquids. When the tooth is-, extracted in these cases, pus is often disco- 
vered about the extremity of the root, and is sometimes collected in a small 
pouch. If the upper molar teeth are affected, the inflammation sometimes 
extends to the antrum, producing very serious results. When the periosteum 
of the root is the seat of inflammation, the pain is deep in the jaws, and the 
tooth feels elevated above its usual level, and is often somewhat loose. Clos- 
ing the teeth is here also very painful. Rheumatic inflammation is apt to 
attack this part. 
The most frequent cause of these inflammatory affections is the exposure of 
the pulp, consequent upon caries, or other.destruction of the tooth. They may 
result also from vicissitudes of temperature, retrocession of cutaneous erup- 
tions, the suppression of accustomed discharges, the translation of rheumatic 
or gouty inflammation from other parts, the pressure of osseous concretion^ in 
the cavity of the tooth, and from direct violence. 
Treatment.--Little general treatment as requisite. Saline cathartics, and 
abstinence from animal food may be recommended when the inflammation 
affects the neighbouring parts; and an opiate at night is generally advisable 
when the pain is severe. The loss of blood may become necessary if there 
should be strong determination to the brain. 
Much may be done .locally to afford relief, and hasten the cure. The 
means employed are sedative, anodyne, and revulsive applications, and deple- 
tory measures, either within the mouth or externally. Among these mea- 
sures are brandy, or tincture of camphor held for a short time in the-mouth; 
the chewing or smoking of tobacco; various masticatories, such as ginger, 
calamus, pellitory, &c.; poultices to the face, either simply emollient, or ren- 
dered anodyne by the admixture of laudanum, hops, &c.; anodyne lotions, 
as tincture of camphor with laudanum; rubefacient applications, as capsicum, 
ginger, and mustard in the form of cataplasm; blisters to the side or back 
of the neck, or behind the ears; steaming the face and head with the va- 
pours of hot watery scarification of the gums; and, finally, leeches outside 
of the face or to the gums, when the inflammation is considerable, and it is 
deemed highly desirable to bring- about resolution. In most cases, the 
milder of these means are abundantly sufficient; as.the disease is very gene- 
rally soon relieved by suppuration, and the discharge of the pus. After the 
abscess has formed, it should be opened if it .do not speedily discharge itself; 
and, when it occupies the substance of the cheek, care should be taken to CLASS III.J 
TOOTHACHE. 
489 
make an early opening inwardly, lest it might break externally and leave an 
unsightly scar. 
When caries exists, in addition to the means just mentioned, applications 
may be made to the cavity of the tooth itself. These are usually such as 
relieve pain by their anodyne, or obtund sensibility by their excessively irri- 
tant action. They consist chiefly of laudanum or opium, in reference to the 
former effect; and of certain volatile oils, as those of cinnamon, cloves, and 
cajeput, in reference to the latter. The most efficient of these applications, 
in the experience of the author, is creasote. Put undiluted into the carious 
cavity,' this substance not only relieves, but also for a time often effectually 
cures toothache. It probably acts both by obtunding the sensibility of the 
pulp, and by coagulating any albuminous matter which may be present, and 
thus forming a barrier against the external air. A solution of copal in chlo- 
roform has been strongly recommended. It is applied upon a piece of cotton, 
which should be saturated with the solution. The chloroform relieves the 
pain, and the copal, by its adhesiveness, retains the cotton in the cavity, and 
protects it from the air. (Journ. de Pharm. et de Clwm., xiv. 125.) Strong 
astringent substances, such as galls and catechu,, are sometimes used; but they 
answer better as preventives than as cures, and are not infrequently employed 
to prepare the carious tooth for plugging. When' liquids are employed they 
should be introduced into the cavity on cotton. If opium is used, care should 
be taken, that the quantity be not so great as if swallowed to do serious injury. 
Attempts are sometimes made to effect a permanent cure of toothache by de- 
stroying the nerve by means of a heated wire, or removing it by means of 
suitable instruments; but, though sometimes successful, they often fail in 
unskilful hands, and are. not generally advisable. > 
When a tooth frequently becomes painful, and is too far gone to be saved, 
especially if the general health suffer, it should be extracted. In cases of 
dental fistulas, it is generally advisable to remove the tooth, or such part of it 
as remains. The first teeth in children may be freely extracted, when carious 
and painful, as they are followed by others. But, in deciding as to the pro- 
priety of extraction, it should always be borne in mind, that, when the per- 
manent teeth are removed, the alveolar processes of the jaws are absorbed, 
and the cheeks or lips fall in, producing an appearance of old age. Besides, 
a carious tooth is oftqn useful in mastication, in the intervals of pain. An- 
other consideration worthy of attention is, that the occurrence of caries of the 
teeth sometimes appears to act as a derivative from the lungs, and to afford 
relief in pulmonary complaints. In such cases, the teeth should be allowed 
to remain. 
3. Rheumatic and Gouty Toothache.-This is either neuralgic or in- 
flammatory, and might have come, accordingly, under one or the other of the 
two preceding heads. But there is something peculiar in its character, which 
often serves to distinguish it from toothache of a different origin, and demands 
a somewhat peculiar treatment. It may, in general, be recognized by its 
occurrence in individuals of a rheumatic or gouty predisposition, by the simul- 
taneous or immediately antecedent existence of these diseases in other parts 
of the body, by its extension for the most part through several teeth or even 
the whole jaw, and by the fact, that it is seldom or never attended with sup- 
puration. The pain is, in the inflammatory variety, rather dull than acute. 
It is very apt to be induced by vicissitudes in the weather. It may occur 
either in carious or sound teeth. In most cases, it is probably seated in the 
periosteum about the root, or the lining of the alveolar cavity, or even on the 
external surface of the jaw, rather than in the pulp, or in the dental cord. In 
addition to the local measures above enumerated, the constitutional treatment 490 
LOCAL DISEASES. 
[part II. 
may be employed, which is applicable to other forms of rheumatism or gout; 
and efforts may be made by stimulating pediluvia to invite the disease, if 
thought advisable, to the lower extremities. 
4. Toothache from Ex,ostosis.-As a consequence of inflammation, or 
from some other cause, the periosteum about the root of the teeth sometimes 
become^ ossified, and a bony deposition takes place so closely connected with 
the root, as to have been taken for exostosis. It is possible that a proper 
exostosis of the fang may also occur; but the affection, as ordinarily observed, 
has its seat originally in the periosteum. The tumour has been known to 
acquire considerable size and.to occasion great inconvenience. The pain is at 
first slight, but becomes very severe in the advanced stage of the affection, in 
consequence of pressure upon the sensitive parts. There are no means of dis- 
tinguishing this with certainty, from, other forms of toothache; but it may be 
suspected, when the pain is constant, when it is not materially increased by 
closing the teeth or by striking them, and when no external inflammation is 
observable. It is said to occur most frequently in persons of a .rheumatic or 
gouty habit. In the advanced stage, there is no other remedy than extrac- 
tion. According to Hr. Good, it may be cured in the early, stage by leeches 
and mercurial ointment; though it must be confessed that the great obscurity 
of the diagnosis throws some doubt over the accuracy of this statement. 
It is due to M. J. E. Oudet to state, that many of the facts detailed in this 
article are derived from his elaborate essay on the teeth, contained in the 
Dictionnqin de Medetina \ • 
Article V. 
FALLING OF THE TEETH. 
The absorption of the socket, and consequent loss of the teeth, which is apt 
to occur in advanced life, is to be regarded rather as a physiological than a 
morbid process. But, in consequence of certain diseases affecting the alveoli 
and gums, the teeth occasionally fall out prematurely, although not themselves 
apparently diseased. This happens in scurvy, in cankej' and gangrene of the 
mouth, and occasionally as a consequence of mercurial inffammation of the 
gums. In carious teeth, after the loss of the body by the advance of the dis- 
ease, the roots are sometimes cast off through the ulceration and absorption of 
the alveoli, occasioned by their irritative influence. These affections, however, 
have already been, or will hereafter be noticed. The object, in this Section, 
is to call attention to two morbid conditions, which lead to the same result, 
and are not elsewhere described in this work. 
In one of these affections, the gums swell and assume a deep red colour, 
and the inflammation appears to be propagated into the alveoli, producing a 
thickening of the periosteum, and a consequent eleyation of the tooth above 
its ordinary level. This condition is relieved after a short time, but again 
recurs, and by its frequent returns, the tooth is lifted out of the socket, while 
the gum retreats from the neck, leaving portions of the roots exposed. The 
bony alveoli, thus in a certain degree unoccupied, appear to undergo absorp- 
tion; and the tooth, deprived of its support, and separated by the ulceration 
of the gum from its soft connexions, at length falls. The gum then heals, 
and the patient, who has usually suffered considerably during the progress of 
the affection, is restored to comfort. The disease commonly attacks a few 
teeth at once, commencing sometimes with the incisors, sometimes with the CLASS III.] 
FALLING OF THE TEETH. 
491 
molares, and, though it occasionally produces only a partial loss of the teeth, 
in other cases, does not cease until it has destroyed the whole. It seldom 
occurs before the thirtieth year. It appears, in some instances, to result from 
long continued mental trouble, and is said especially to affect women during 
pregnancy, and about the period of the cessation of the menses. Its causes, 
however, are not well known.. The remedies indicated are those calculated 
to relieve inflammation of the gums; but they generally fail. 
The other affection has been named by Jourdain, conjoint suppuration of 
the gums and sockets. It usually comes on insidiously, showing itself at first 
only by a slight obzing of purulent matter-from behind the edges of the gums, 
when they are pressed. Sometimes, however, the gums are swollen and soft, 
disposed to bleed, and ; somewhat painful before suppuration; and, in a few 
instances, a real phlegmonous abscess in the gum is the commencement of the 
disease. The periosteum of the fang and of the socket after a time takes on 
the suppurative process, and matter escapes freely between the gums and 
teeth. The portion anterior to the tooth is generally first affected, but the 
whole socket is ultimately involved. The gums, at first of their natural 
polour, now become deep-red, and the teeth loose and painful. The bony 
socket is absorbed, first anteriorly and then behind; and the gums come into 
contact with the roots. This excites additional inflammation, and the ulcera- 
tive process at length separates the gum from the teeth, which then fall out, 
if not previously removed by the dentist dr surgeon. After the loss of the 
teeth, the gums heal without difficulty. This complaint, as a general rule, 
attacks the incisors first. It occurs usually between the ages of thirty-five 
and fifty, more frequently in women than in men, and especially about the 
period of the cessation of the menses. Oudet thinks he has observed, that 
those females who have not suckled their children are more subject to it than 
others. Among the causes of it enumerated by that author are residence in 
low and damp places, the action of mercury, the presen.ce of tartar about the 
teeth, depressing emotions, suppression of hemorrhoidal discharges, retroces- 
sion of cutaneous eruptions, and certain disorders affecting the system, such 
as scrofula and syphilis. It appears also to be sometimes hereditary. M. 
Oudet considers the purulent discharge in this affection as in some instances 
salutary, by preventing or suspending serious diseases. I once attended a 
female with tubercular- consumption, who was several years labouring under 
such an affection of the gums, and in whom the symptoms of phthisis were 
not developed until this affection ceased, in consequence of the loss of all her 
teeth. The circumstance that the loss of the teeth is uniformly followed by 
the healing of the gums has led to the idea, that the complaint might be occa- 
sioned by the presence of teeth previously deprived of their vitality; but there 
is no sufficient proof of this fact, at least there is strong reason to believe that 
the disease has its origin, sometimes at least, in constitutional causes. The 
prospect of a cure is slight. In the early stages, it is possible that the appli- 
cation of nitrate of silver, or other caustic substance, to the whole diseased 
surface of the gum, might prove serviceable. M. Bourdet advises the actual 
cautery, applied by means of a flat and delicate instrument inserted between 
the gum and tooth, to the depth of the destruction of the socket. If this 
application, repeated once or twice, should fail, he advises the removal by the 
scissors of all that portion of gum which has been deprived of the bone which 
it covered. The most effectual modei of affording relief is to extract the teeth 
as they become loose. During the local treatment, attention should be paid 
to the general health; and, where any tendency to pulmonary disease may be 
suspected, it may be advisable to attempt its prevention by the establishment 
of an issue. , . > 492 
LOCAL DISEASES. 
[PART II. 
SUBSECTION IL 
DISEASES of THE FAUCES, PHARYNX, AND (ESOPHAGUS 
Article I. 
INFLAMMATION OF THE FAUCES, or ANGINA. 
Under the name of fauces, are included the velum pendulum, the half 
arches, the uvula, the tonsils, and the upper part of the pharynx; in other 
words, all those parts, behind the mouth, which become visible when the 
jaws are widely opened, and the tongue depressed. These parts may be 
attacked, like the mouth, by thrush and aphthae, which, however, present 
nothing peculiar in this situation, and have been already fully considered. 
Nor shall I treat here of those forms of inflammation of the fauces which 
occur as- attendants upon other diseases, such as scarlatina, small-pox, and 
syphilis.' The forms of inflammation now to be considered, may be embraced 
under the heads of 1, the common; 2, the pseudo-membranous ; 3, the ulcera- 
tive-; and 4, the gangrenous or malignant, all affecting the mucous membrane. 
Inflammation of the tonsils will be separately treated. 
K Common Inflammation of the Fauces.-Sore-throat.-Simple An- 
gina.-Angina Simplex.-The first evidence of the complaint is usually some 
pain in swallowing. The fauces, if examined, are found to be of a bright red 
colour, and occasionally somewhat swollen, and, in the advanced stages, often 
exhibit small whitish patches, especially on the .surface of the tonsils, consist- 
ing probably of coagulable Lymph, effused by the inflamed follicles. The red- 
ness may occupy one or both sides of the throat; the velum, or the pharynx, 
or may be diffused over the whole. The patient has a feeling of heat and 
dryness in the throat, with constant soreness, which becomes acute pain when 
he attempts to swallow. The pain is in general greatest in the morning, in 
consequence partly of the position of the head favouring the access of the 
blood, partly of the dryness resulting from the mouth being kept open during 
sleep. Drinks occasionally regurgitate through the nostrils. The voice is 
sometimes nasal, but more frequently Hoarse, in consequence of the extension 
of irritation to the glottis. A viscid mucus is after a time secreted, which 
leads to frequent efforts to clear the fauces, and, when discharged, is some- 
times mingled with blood. In some cases, the secretion of mucus is abun- 
dant, and these are usually attended with less redness and pain. They are 
considered by some as constituting a distinct variety Of the complaint, and 
called catarrhal inflammation. They are apt to occur in persons of feeble 
constitution, with impoverished blood. 
The uvula is sometimes much swollen and elongated, in consequence of 
effusion into its tissue. In this case, there is added to the other symptoms a 
frequent disposition to swallow, and to clear the glottis by coughing, or by 
expelling the air through the nostrils, and sometimes vomiting is produced. 
The disease often runs its course without producing fever; but frequently 
also the constitution sympathizes, and the febrile movement, with chilliness, 
heat, frequent pulse, headache, and loss of appetite, occurs. The fever is 
usually of the- sthenic character; but sometimes is typhoid, and, in certain 
cases, is attended with an exceedingly frequent pulse like that of scarlatina. 
In these cases, the colour of the inflamed membrane is usually deeper than 
ordinary; and the flushed appearance of the face and neck marks a still closer 
analogy with scarlet fever, CLASS III.] 
INFLAMMATION OF THE FAUCES. 
493 
The inflammation runs on for several days, and then gradually declines, 
terminating almost always in resolution. In some rare cases, suppuration 
takes place in the. substance of the uvula or soft palate, and gangrene may 
occur in persons of debilitated and unhealthy constitution. The tonsils some- 
times inflame, and the external parts participate in the disease; the jaws 
becoming stiff and painful, and the absorbent glands swelling. The most 
unpleasant ordinary result, however, is the travelling of the inflammation 
downward into the larynx, and even into the lungs; and, in some persons, 
severe bronchitis is very apt to follow an attack of simple angina, if not early 
arrested. 
Chronic Angina.-Inflammation of the fauces often becomes chronic, in 
which case there is a constant feeling of heat and uneasiness with some red- 
ness of the parts, which, with alternations of remission and exacerbation, may 
continue for many months. In such cases,, the membrane sometimes appears 
irregularly thickened, or exhibits here and there small eminences produced 
by the enlarged follicles, particularly observable on the soft palate and the 
pharynx. These, granulations are often covered with a matter resembling the 
white of eggs, or a muco-purulent secretion. They are sometimes so nume- 
rous in the pharynx as to give its surface a mamellonated' Appearance, and 
occasionally are associated in long prominences,, or ridge^ like pillars lying 
upon the membrane. The name of granular or follicular angina has been 
adopted by some writers for this variety. Ulcers, also sometimes form, either 
superficial, affecting only the surface of the membrane, and then disposed to 
spread irregularly so as to occupy large portions of the fauces, or deeper 
seated, penetrating through the membrane, and eyen into the structure beneath 
it, and, in rare instances, producing considerable loss , of substance. In such 
cases, however,, the result is in general attributable either to a debilitated 
state of system, or to some vice of constitution, such aS a scrofulous or scor- 
butic tendency, or a syphilitic contamination. The affection is often attended 
with an habitual hawking, in order to clear the fauces, or to get rid of the 
uneasy sensation, as of something present in the throat, which may be delusive. 
A dry laryngeal epugh is not uncommon, arising from the extension of the 
irritation to the glottis. In some persons, the disease ceases entirely for a 
time, and again recurs from the slightest cause, proving exceedingly inconve- 
nient by its disposition to extend into the throat or chest. 
OnP of the consequences of repeated or long continued inflammation of the 
fauces is a chronic enlargement of the uvula, which proves very inconvenient, 
by the irritation which it produces about the root pf the tongue and the glottis. 
Long continued and serious coughs have arisen from this cause, or been sus- 
tained by it. 
Causes.-The most frequent cause of this complaint is exposure to cold 
and moisture; and it is, therefore, most apt to occur in the cool damp weather 
of the spring and autumn. In some persons, the slightest partial application 
of cold to any part of the body, when they are warm or perspiring, is suffi- 
cient to produce it. There is reason also to believe, that it may arise from 
the reaction which follows the direct effect of very cold air upon the fauces. 
Irritating or corrosive substances swallowed, and acrid eructations from the 
stomach, also occasion it. The inflammation appears sometimes to be of the 
nature of rheumatism or gout, as it alternates with these affections elsewhere. 
It is often sustained, especially in its chronic forms, by disorder of the sto- 
mach, irritation being propagated by sympathy from that organ, or kept up 
by acrid eructations. Hence, in these forms, it is very common among pro- 
fessional men of sedentary habits. The acute disease occurs at all periods of 
life, but is most frequent with the ypung. 494 
LOCAL DISEASES. 
[PART II. 
Treatment.-T£ taken at the commencement, this complaint may usually 
be cut short by a dose or two of sulphate of magnesia, or other saline cathartic, 
abstinence from animal food, and the use of a gargle made by dissolving alum 
in water in the proportion .of 15 or 20 grains to the fluidounce, and employed 
twice daily. For persons in whom the disease is apt to end in laryngitis or 
bronchitis, it is highly important to obtain this result. 
At a more, advanced period, or in severe cases, this treatment will not 
always succeed, and alum appears sometimes to aggravate the inflammation. 
In such cases, it may be advisable, if there be fever and headache, with a 
strong, pulse, to take blood from the arm. An active saline cathartic every 
day or every other day, with the use of refrigerating diaphoretics, as the 
neutral mixture and tartar emetic, may also be usefully employed. Emetics 
have been recommended; but, though occasionally beneficial, they are unne- 
cessarily violent, and are not often used. The diet should be strictly vegeta- 
ble, and liquids- or soft substances, as piush, are preferable to solid food. 
Should the general powers of the system be very feeble, and the attendant 
fever of a typhoid character, which, however, is a very rare event, the deple- 
tory treatment should be very moderately employed, or altogether avoided; 
and it might even become necessary to resort to stimulation. When the dis- 
ease is associated with acidity of stomach, small doses of magnesia frequently 
repeated will be found useful; and I have known a purgative dose of calomel 
effectual in cases complicated with hepatic derangement. 
Externally, rubefacients, such as the liniment of ammonia, the tincture of 
Cayenne pepper, oil of turpentine, or sinapisms may be employed; the neck 
being guarded against the cold by a piece of flannel around it. Leeches, 
however, applied beneath the ears or under the jaw, will be found the most 
effectual external remedy; but, when there is much fever, they should be 
preceded by venesection. In obstinate cases, blisters on the sides or back of 
the neck may be resorted to; but they are seldom necessary. 
The most appropriate applications to the inflamed parts are mucilaginous, 
or very mild astringent gargles. Infusion of flaxseed, slippery elm, or sassa- 
fras pith, and decoction of marsh mallow are, perhaps, the best. Sage tea, 
infusion of galls, decoction of oak bark or pomegranate rind, and solution of 
acetate of lead in the proportion of two grains to the fluidounce, or of alum 
with five grains to the fluidounce, may also be employed, and will sometimes 
prove useful by facilitating the discharge of the viscid mucus, and even dimi- 
nishing the inflammation. If, however, they increase the discomfort of the 
patient, they should be omitted. Very frequent gargling should be avoided, 
as productive, of too much movement in the inflamed parts. A very strong 
solution of nitrate of silver, and powdered alum applied by blowing through 
a tube directly to the part, have been recommended, and often effect speedy 
cures; but they are seldom necessary. 
It is advisable that the patient should speak little, should resist the disposi- 
tion to frequent hawking and swallowing, and should keep the head as mudh 
as he conveniently can in an erect position. 
In the chronic disease, astringent and caustic applications to the inflamed 
membrane are among the most effectual remedies. Should weak solutions of 
acetate of lead, sulphate of zinc, alum, and nitrate .of silver, employed as gar- 
gles, fail, very strong solutions of the same salts may be applied by means of 
a camel's-hair pencil, or of a stick having a piece of sponge attached to it, or 
a narrow strip of old linen wrapped several times round one end of the stick, 
with its edge projecting. Of these salts, the most effectual is perhaps the 
nitrate of silver, which may be used even in the solid state, in very obstinate 
cases; great care being taken that none of the caustic breaks off, and escapes CLASS III.] 
INFLAMMATION OF THE FAUCES. 
495 
into the stomach, or lodges in the throat. The mineral acids, more or less 
diluted, have been recommended for the same purpose. At the same time, 
external irritation may be kept up by blisters, or pustulation with croton oil 
or tartar emetic. But all local measures sometimes fail, unless assisted by 
remedies addressed to the system. Disorder of the stomach should be cor- 
rected by antacids, tonics, a properly regulated diet, or other appropriate 
means. A small dose of magnesia daily is often very useful. Constipation 
or diarrhoea should be obviated, hepatic, derangement corrected by alterative 
doses of mercurial pill or calomel, and, in general, all such measures adopted 
as may be necessary to restore and sustain health. When there is reason to 
suspect a gouty taint, wine of colchicum may be employed with the other 
remedies. A long journey, or.a voyage and residence for a short time in a 
foreign climate, are often found effectual.' The chronic form of the disease is 
not unfrequently a source, of great trouble, especially when associated, as it 
very often is, with a similar affection of the larynx; and the physician is 
urgently pressed to afford relief. When other means fail, mercury may be 
employed with reasonable hope of benefit from its revolutionizing influence. 
In the relaxed and edematous condition of the uvula, which follows acute 
inflammation, or attends the chronic form of it, recourse inay bp had to the 
astringent gargles above mentioned, or to stimulant substances, as powdered 
pepper, ginger, or tincture of capsicum, applied directly to the part. A piece 
of catechu kept constantly in the mouth, and allowed slowly to dissolve, is 
also highly useful. When the uvula is hypertrophied, and resists measures 
for reducing its size, it should be amputated, if productive of any unpleasant 
effects.- . ' • • 
2. Pseudo-membranous, Inflammation oe the Fauces.-Membranous 
Angina. - Angina membranacea. - Dipbitheritis.*-This is characterized by 
the exudation of' fibrinous and albuminous matter, in the form of a pellicle, 
upon the surface of the membrane, underneath the'.epithelium. Its precise 
nature was first satisfactorily shown by Bretonneau, from whom it received 
the name diphtheritis, derived from the Greek 8^0^a, skin or hide. 
Symptoms.-The disease commences with some redness of the fauces and 
uneasiness, such as occur in ordinary sore-throat, but usually in a less degree. 
This condition lasts but a very short time, before the exudation commences; 
and, when first seen by the physician, the surface almost always exhibits 
small, irregularly circumscribed, whitish, yellowish-white, or ash-coloured 
patches, sometimes seated in a portion only of the fauces, sometimes scattered 
here and there over almost their whole extent. These patches bear no incon- 
siderable resemblance to superficial sloughs, or to the surface of ulcers, for 
both of which they have not unfrequently been mistaken; but it has been 
shown by the most careful microscopic, observations, that they consist of a con- 
crete exudation similar to false membrane, and that the surface of the mem- 
brane beneath them has not necessarily undergone any loss of substance. In 
some instances, they are translucent. Their consistence is various, occasion- 
ally pultaceous, but more frequently somewhat dense and even tough. The 
membrane around them is inflamed and reddened, and the tonsils are usually 
more or less swollen, as are frequently also the cervical and submaxillary 
glands, and'sometimes even the parotids. , 
In mild cases, such as often occur sporadically, the patches are few, more 
regularly circumscribed than in the severer forms, and not disposed to spread; 
while there is little tumefaction either of the tonsils or the external parts, and 
little or no fever. They are apt, however, to be attended with much pain in 
swallowing. In the severer cases, the patches spread with greater or less 
rapidity, sometimes in the course of a few hours coalescing and covering the 496 
LOCAL DISEASES. 
[part II. 
whole fauces, but more frequently advancing rather slowly, and leaving por- 
tions of the membrane uncovered. There is commonly more of the exudation 
on one side than on the other; and on that where it is most abundant, the 
swelling of the tonsils and external parts is greatest. The deglutition now 
becomes more difficult, and liquids often return by the nostrils in attempts to 
swallow. The patches, soon after they are completely formed, begin to be 
removed, sometimes separating in strips, sometimes softening and mixing with 
the fluids of the mouth, and in a few cases disappearing by absorption. They 
are often renewed, occasionally several times, each time becoming whiter and 
thinner, till at length they leave the surface, covered with a puriform mucus. . 
The process of separation usually lasts eight or ten days. (Guersent.') 
During its progress, it is attended with the discharge of some blood, and 
copious vitiated secretions, which occasion much hawking and spitting, and 
have a very offensive odour. There is often also a flow of extremely fetid 
sanies from the nostril's, indicating the extension of the disease to the nasal 
passages. The odour of the discharges in these cases has tended-to-ponfirm 
the erroneous idea, that the disease was essentially gangrenous. In the course 
of the complaint, the disposition to exudation often travels downwards, and 
the larynx, trachea, and. even bronchia, become lined with false membrane, 
which obstructs respiration, and very generally leads to fatal results. This 
extension of the disease constitutes, indeed, its chief danger. It may come 
on at any period, from the first appearance of the patches to the seventh or 
eighth day, (Guersent,} and is indicated by those changes in the voice and 
respiration which characterize pseudo-membranous croup. (See Pseudo- 
membranous' Croup.) , 
When the local affection is considerable, the system is brought into sym- 
pathy, and fever is developed-. The stomach is sometimes irritable, and the 
bowels, though at first generally disposed to constipation, are apt, towards the 
close of the disease, to be affected with a fetid diarrhoea. Both of these results 
are ascribable to the acrimony of the liquid secreted in the fauces, more or less 
of which is swallowed. In gopd constitutions, the fever is usually sthenic; 
but sometimes, especially when the disease prevails epidemically, it has a 
typhoid or malignant character; and this condition of the system reacts on 
the local affection. In the former case, the inflamed membrane is bright red, 
the patches white and of a firm consistence, and the pulse full and strong. In 
the latter, the membrane, when visible, is purplish or livid, and the exudation 
yellowish or ash-coloured,- or darkened by the bloody liquid effused, and often 
of a soft pultaceous consistence. The discharges from the mouth and nostrils 
are excessively acrid and offensive, and often mixed with a dark blood which 
oozes from the fauces, and even from the gums and lips. Occasionally, obsti- 
nate hemorrhage from the nostrils takes place. The pulse is rapid and feeble; 
the delirium of the early stages is succeeded by coma; and the whole system 
is in a state of great prostration. Between the two conditions here presented 
there are various grades, in which their characteristic symptoms are mpre or 
less mingled or modified. In the malignant cases, the system is probably 
under some poisonous influenpe, superadded to that of the local affection. Such 
cases are happily rare. 
The duration of the disease, when severe, is usually two or three weeks or 
more. Except in its malignant form, or when it occurs in constitutions pre- 
viously much enfeebled, or assumes the character of pseudo-membranous 
croup, the prognosis is favourable. 
Causes.-The causes of ordinary angina will give rise to the pseudo-mem- 
branous variety in those predisposed to it. What constitutes this predisposition, 
however, is not known, although probably ascribable to some peculiar state of CLASS III.] 
INFLAMMATION OF THE FAUCES. 
497 
the blood. . The disease is said to be most prevalent in moist seasons and 
countries, in temperate latitudes. It prevails sometimes epidemically, though 
confined within comparatively narrow limits. It occasionally attacks a single 
household, .as a boarding-school, for example, without extending to others in 
the same vicinity; and, when prevalent in any particular place, it is apt to 
select certain families, of which several individuals suffer, while most of the 
neighbouring families escape entirely. This result has been ascribed to con- 
tagion; but, as several persons in a family are often seized about the same 
time, it may with greater propriety be-referred to . similarity of constitution 
and of exposure. Nevertheless, there is reason to believe that the disease is 
occasionally contagious, especially in its epidemic and malignant form. From 
its resemblance to the malignant sore-throat of Fothergill, Huxham, and 
others, with wh-ich it is by some writers maintained to be identical, and from 
the simultaneous occurrence of both these affections with epidemic scarlatina, 
and the close analogy of their local symptoms with the throat affection of that 
disease, the inference is not without plausibility, that they may all be pro- 
duced by the same cause, in those cases in which they have an epidemic, or 
contagious character. • , . h . 
The disease- occurs' at all times of life, but is most, common in infancy and 
early childhood, and is-very rare in old age. 
Diagnosis^-The only complaints with which this can be confounded are 
common angina, ulcerated and gangrenous or malignant sore-throat, and 
pseudo-membranous croup. From the first it is readily distinguishable by 
the exudation in the fauces. It is usually without the excavated surface of 
the ulcerated variety, and the proper gangrenous sloughs of the malignant; 
though both of these conditions may sometimes be presented after the false 
membrane has been thrown off; and there is occasionally a mixture of these 
affections in the same case. It is only in those instances in which the exuda- 
tion extends into the larynx, that this complaint can be confounded with 
pseudo-membranous croup. The latter affection, however, differs by com- 
mencing in the larynx, arid in seldom or never being associated with those 
typhoid or malignant symptoms, which are occasionally present in the former. 
Treatment.-In the mildest cases, little general treatment is required. The 
patient may take a dose of Sulphate of magnesia, or some other saline cathartic, 
and should strictly avoid animal food. In somewhat severer cases, with 
moderate fever, the cathartic may be repealed, and antimonials and the neu- 
tral mixture administered at short intervals. When the pulse is full and 
strong, blood should be taken freely from the arm, especially in adults; but 
venesection does not exercise the same controlling influence oyer this, as over 
the common inflammation; at least, it does not obviate the tendency to the 
plastic effusion; and, in some instances, in consequence of the feebleness of 
system, is not well borne. When the symptoms are threatening, either from 
the general condition of system, or the disposition in the local disease to enter 
the respiratory passages, calomel should be resorted to, Under these circum- 
stances, no general means of cure is so effectual as the establishment of the 
mercurial influence. If the patches should have reached the glottis, or be 
extended towards it, a full purgative dose of calomel should be given, and the 
medicine afterwards continued in doses of from half a grain to two grains, 
every hour or two, until the mouth is affected, or the disease -relieved. Even 
young children, under these circumstances, bear calomel well in the quantity 
mentioned. Should it irritate the stomach and bowels very much, the dose 
may be diminished, or the mercurial pill, and frictions with mercurial oint- 
ment substituted. Emetics have been recommended; but they scarcely modify 
the peculiar character of the affection; and are only sometimes useful, in the 498 
LOCAL DISEASES. 
[PART II. 
advanced stages, by promoting the expulsion of the false membrane from the 
larynx. Should the symptoms be malignant, with great depression, Peruvian 
bark or quinia, wine-whey, carbonate of ammonia, and animal broths may be 
required. 
The exterior local treatment is not very important. Leeches may be used 
as an adjuvant to the lancet, or as a substitute for it in doubtful cases; and 
recourse may be had to rubefacients and blisters, as mentioned under the 
head of common inflammation of the fauces. 
By far the most important remedies -are those addressed immediately to the 
part affected. By these the peculiar character of the inflammation, upon 
which its danger chiefly depends, may be changed; and, if the disease has 
not already reached the larynx, its progress may be arrested. In the slighter 
forms, a solution of sulphate of zinc, containing fifteen- or twenty grains of 
the salt in a fluidounce, applied daily or twice a day to the pseudo-membranous 
patches, will be found sufficient. When a stronger impression is required, 
caustic substances must be employed. Of these the best is nitrate of silver, 
which may be applied either in the solid state, or dissolved in six or eight 
parts of water. Muriatic acid is highly recommended by some writers, and 
in the worst eases is used undiluted. In those of slower progress, it may be 
diluted more or less according to the impression desired. Alum is another 
very efficient application. It is used in saturated solution, or in the form of 
a very fine powder, which is applied directly to the part by blowing it through 
a tube adapted to the purpose. These substances should be allowed to come 
in contact, as little as possible, with any other part of the surface than those 
covered with the exudation. The liquids may be applied by means of a large 
camel's hair ■pencil, or of a piece of sponge or soft linen attached to the end 
of a stick. In the intervals between the caustic applications, mucilaginous 
gargles, sweetened or not with honey of roses, may be beneficially used. A 
gargle made of a fluidrachm of chlorinated soda and four fluidounces of water, 
is recommended in cases attended with fetid discharge. Howard's calomel, 
applied to the diseased surface by means of a tube, was advised by Breton- 
neau; but its chief advantages are probably derived from the portion of it 
which may be swallowed. 
3. Ulcerative Inflammation of the Fauces.- Ulcerated Sore- Throat. 
-Ulcers in the fauces are an occasional result of common angina, especially in 
its chronic state, and are attendants upon various constitutional affections both 
acute and chronic, as scarlatina, small-pox, syphilis, and the mercurial action. 
But they sometimes also occur as an original disease, at least they are present 
when the case first conies under medical notice. It is highly probable that 
many of the cases, commonly considered as ulcerative, may be really exam- 
ples of pseudo-membranous inflammation; but- this is certainly not the ease 
with Others, as, after the removal of the, whitish surface which they at first 
present, an actual loss of substance is observed. 
Attention is first called to the throat by the occurrence of a sharp pain in 
swallowing; and, when the fauces are examined, one or more roundish or oval 
whitish spots exhibit themselves, surrounded by a red and inflamed margin. 
'The pain which they occasion upon any movement of the fauces is sharper 
than that of ordinary angina, though there is less heat or uneasiness in the 
interval. The sensation is like that produced by something sharp sticking in 
the part. The spots sometimes remain very nearly of their original dimen- 
sions, sometimes spread considerably. The whitish matter after a while dis- 
appears, leaving a red, excavated, somewhat irregular surface, which, in healthy 
constitutions, speedily rises to the proper level and cicatrizes. In some in- 
stances, there is a complete absence of febrile action; in others, fever occurs, CLASS III.] 
INFLAMMATION OF THE TONSILS. 
499 
and in this case the pulse is apt to be very frequent, as in scarlatina, to the 
milder forms of which the affection bears a considerable resemblance, except 
in the absence of the eruption. 
The general treatment is essentially the same as in ordinary angina, though 
depletion is much less efficient, and bleeding seldom called for. By far the 
most efficient remedies are local; and the best of these are solutions of sul- 
phate of zinc, sulphate of copper, or nitrate of silver, applied exclusively to 
the whitish surface, and continued daily, or twice a day, until the colour is 
changed to red. The, solutions should contain from ten to twenty grains of 
the salt in a fluidounce. In cases unattended with constitutional disturbance, 
a cure may be expected in a few days. 
4. Gangrenous Inflammation of the Fauces.-Angina maligna.- 
Cynanche maligna.-Malignant Sore-throat.-It is very doubtful whether 
any distinct disease exists which merits this' title. There is no doubt that 
gangrene occasionally attends inflammation of the fauces of all varieties. In 
common angina, pseudo-membranous angina, and even ordinary inflammation 
of the tonsils, portions of the mucous membrane, and of the structure beneath 
it, sometimes lose their life; and true gangrenous sloughs are formed. This 
result almost always depends'either on some pre-existing state of the blood, 
or of the system in general, predisposing to mortification, or upon some gene- 
ral disease independent of the throat affection, coexisting with it, as in the 
typhoid forms of fever. In the malignant cases of pseudo-membranous angina, 
the surface beneath the exudations is sometimes found covered with a slough, 
the result of mortification. (Evanson and Maunselld) Thrush and aphthae, 
occurring in the fauces, sometimes become gangrenous; and the infantile 
affection, denominated gangrene of the mouth, may have its seat in the same 
part. Indeed, whenever intense inflammation of the fauces occurs in persons 
whose health lias been depraved by insufficient or unwholesome nourishment, 
or who are affected by some malignant or typhoid disease, or dark red or livid 
eruption, or in whom mortification exists in some other part of the body, we 
may apprehend gangrene, especially in the cases of children. The malignant 
sore-throat described by Fothergill and Huxham, and by Dr. Cullen under 
the name of Cynanche maligna, is now almost universally admitted to be a 
modification of scarlatina; the local and constitutional symptoms being pre- 
cisely the same as those which attend the worst forms of that complaint, ex- 
cept that, in some instances, comparatively few, the scarlet eruption is absent. 
In relation, therefore, to the causes and treatment of this affection, it is unne- 
cessary to say anything in the present place; the subject having been suffi- 
ciently considered under the head of scarlet fever. 
Article II. 
INFLAMMATION OF THE TONSILS, or TONSILLITIS. 
Syn.-Cynancbe tonsillaris.-Angina tonsillaris.-Amygdalitis.-Quinsy. 
By these- terms is here meant inflammation of the substance of the tonsils, 
that of the mucous membrane covering it being included under some one of 
the forms of angina already treated of. Sometimes only one tonsil is affected, 
but more frequently both. 
Symptoms.-The local affection is first indicated by difficulty in swallow- 
ing, a sense of heat in the fauces, and a constant uneasiness, which gradually 
increases until it amounts to severe pain. This often shoots through the ear, 500 
LOCAL DISEASES. 
[PART II. 
and the patient sometimes refers it chiefly to that part. The difficulty of 
swallowing increases, each attempt being attended with an expressive con- 
traction of the features, and an almost convulsive action of the muscles con- 
cerned; liquids are apt to pass into the nostrils; and, in severe cases, when 
both tonsils are involved, deglutition becomes almost or quite impossible. 
At the same time, there is a constant disposition to swallow, in order to free 
the fauces from a tenacious colourless mucus, which is also discharged by 
frequent hawking and spitting. The voice is much changed, assuming a 
nasal character, and, when the disease is at the height, is sometimes quite 
suppressed. The hearing is also frequently impaired, in consequence probably 
of obstruction of the Eustachian tubes. The respiration is not much affected, 
unless in very bad cases, with great swelling of the tonsils, when a sense of 
suffocation is sometimes experienced. Upon being examined, the fauces ex- 
hibit at first redness, with some projection of one or both of the tonsils, 
which gradually increase in size, and, if both are affected, at length almost 
or quite touch each other. Their surface frequently exhibits a white concrete 
matter, in spots oi* diffused, which is the result of morbid secretion, apparently 
from dhe mucous follicles. The uvula is usually much swollen and elongated, 
and the soft palate inflamed. There is also almost always more or less ex- 
ternal inflammation, with swelling of the cervical glands and the cellular 
tissue, ahd so •much stiffness of the jaws, that, when the disease is at its 
height, the mouth can sometimes scarcely be opened. The tongue is heavily 
furred. 
The fever is of the sthenic character, and is often very considerable, with 
headache, and a full, strong pulse. The rigors with which the fever com- 
mences, sometimes precede any obvious inflammation of the tonsils for some 
hours, or even a day; but much more commonly, the general and local affec- 
tion begin at the same time, or the latter precedes the former. The patient 
generally experiences great restlessness with inability to sleep. In some 
cases, there is little or no fever, and the patient does not' lose his appetite 
throughout the attack. 
When the inflammation is slight, or is actively treated, it often ends in 
resolution; but, under ordinary circumstances, suppuration is the more usual 
result. The establishment of this process is known by the occurrence of 
slight rigors, and by the greater softness of the tumour to the touch, which 
may not unfrequently discover fluctuation. Sometimes an elevated pale spot 
is seen, indicating a disposition of the abscess to open at that point. At this 
stage of the disease, the sufferings of the patient are often very great; 'and 
the relief obtained by the discharge of the abscess is most delightful. This 
is hastened by the efforts which the patient makes in coughing, swallowing, 
or clearing his throat. It often occurs in the night, and the patient falling 
to sleep, wakes in the morning entirely relieved, without being conscious of 
the time when the change took place. The pus is usually swallowed, though 
occasionally portions of it are discharged by the mouth. After the opening 
of the abscess, recovery is rapid. The disease is usually about a week in 
arriving at its height, though sometimes not more than five or six days, and 
sometimes as much as ten days or two weeks. In some very rare cases, the 
abscess has opened externally, and still more rarely the pus has dissected its 
way down into the lungs, and produced fatal inflammation. 
After the relief of the acute symptoms, the tonsils are not unfrequently 
left in a swollen and indurated state; and this is especially apt to be the case 
in persons of a scrofulous habit, and in those frequently attacked with the 
complaint. Sometimes the tumefaction becomes at length so great as to be 
seriously inconvenient, producing difficulty of deglutition, and an alteration CLASS III.] 
INFLAMMATION OF THE TONSILS. 
501 
of the voice. The tonsils, moreover, may; come into this hypertrophied con- 
dition, in consequence of a chronic irritation or inflammation, without any 
preceding acute symptoms. 
Inflammation of the tonsils almost invariably terminates favourably, unless 
complicated with some vice of constitution, which would render inflammation, 
wherever seated, hazardous. Suffocation is mentioned among its dangers; but 
this must be a very rare occurrence, unless the larynx becomes involved in 
the inflammation. I have never witnessed a fatal case. 
Causes.-By far the most frequent cause of this disease is exposure to 
changes of temperature, especially to partial cold, when the body is warm and 
perspiring. Hence, the complaint is most prevalent in seasons when the 
weather is changeable, as in the latter part of autumn and beginning of win- 
ter, and in spring. It seems sometimes to be influenced by the epidemic 
constitution of the atmosphere, and is apt to prevail along with scarlet fever 
and measles. - It not unfrequently occurs in scarlatina and small-pox, though 
materially modified by the character of the affection. It is less,disposed to 
suppuration, when a mere attendant upon these complaints, than in its ordi- 
nary state. Certain individuals are very subject to it; and in these the slight- 
est exposure is often sufficient to bring on an attack. It is not common in 
infancy, or in advanced life; and those who have been very subject to it in 
youth and adult age, generally lose their susceptibility to its causes when 
they become old. 
Treatment.-At the" period of the complaint at which the physician is 
called, it is generally difficult to prevent suppuration, unless by an' energy of 
depletory treatment, which may lead to more unpleasant consequences than 
the disease; and the most copious admissible depletion often fails. It is, 
therefore, Scarcely advisable to aim at effecting resolution, unless in the early 
stage. The moderate depletion, which will at .first often check the complaint, 
will, at a more advanced period, be found useful by moderating the violence 
of the inflammation, and consequently diminishing suppuration. This is, 
therefore, in general, the appropriate treatment. When the pulse is full and 
strong, the system plethoric, and the -head painful, blood should be taken 
from the arm, and, in severe cases, the bleeding maybe repeated. But, if 
the patient was previously feeble, or has been subject to frequent returns of 
the complaint, venesection as-a general rule is better avoided. A brisk purge 
of calomel and jalap, or of senna tea with sulphate of magnesia, may be given 
at first, and the bowels afterwards kept freely open with some one of the 
saline cathartics. Generally speaking, however, no other cathartic is requi- 
site than Epsom salt. In the intervals, the circulation should be kept down 
by small doses of tartar emetic, and bysrefrigerant drinks. Emetics have 
been recommended; but they have little influence over the progress of the 
complaint when formed. In the very commencement, they may arrest it, 
and, in advanced suppuration, may give relief by breaking the abscess; but 
for the latter purpose other means are preferable. Opium, or the -powder of 
opium and ipecacuanha, should be given at night, in cases of great restless- 
ness and want of sleep. The diet should be low, consisting of soft or fluid 
substances, as mush with molasses, and mucilaginous or farinaceous liquids. 
When the appetite remains, vegetable broth will usually be acceptable to the 
patient. 
Not much can be expected from external local treatment. Leeches, how- 
ever, may be employed, though less useful than in simple angina. Various 
rubefacient applications and blisters may also be used, as recommended in 
that complaint. Perhaps the best external application is an emollient poul- 502 
LOCAL DISEASES. 
[part II. 
tice of bread and milk, flaxseed meal, Indian mush, or mashed potatoes, so 
large as to embrace the whole throat in front and on the sides. 
Gargles are useful only by alleviating the discomfort. of the patient; and 
enabling him to discharge the viscid mucus which lines the fauces. Muci- 
laginous, acidulous, or slightly astringent liquids, may be employed for this 
purpose; such as infusion of flaxseed, sassafras, or slippery elm bark, vinegar 
and water, infusion of red roses or of sage sweetened with honey of roses, and 
a very weak solution of alum. Simple warm water used as a gargle often 
gives-some relief. Scarification of the tonsils, and powdered alum applied to 
their surface- have been recommended. It is asserted by M. Toirac, that 
cauterization of the surface of the tonsil by nitrate of silver, in the early 
stage of 'the disease, almost always arrests it. (dm. Journ. of Med. Sei., 5, 
211.) I have seen this result in several cases. When suppuration has com- 
menced, gargling with warm water, or milk and water, or a decoction of figs 
in milk, and the inhalation of warm vapour, have been thought to advance 
it. When fluctuation can be detected by the finger, the abscess should be 
opened. 
In chronic enlargement of the tonsils, occasional scarifications, with the 
intermediate application of strong astringent solutions, especially that of alum, 
may be resorted to with some hope of advantage. Repeated leeching, blis- 
ters, and frictions with mercurial or iodine ointment have been used, but with 
no very-satisfactory results. Dr. Symonds has found most benefit from the daily 
application of nitrate of silver, in substance or solution. Tincture of iodine, 
applied occasionally to the tumour, is said to have effected cures. All these 
measures, however, are apt to fail; and it is frequently necessary to remove 
the enlarged tonsils by excision. 
Article III. 
INFLAMMATION OF THE PHARYNX, or PHARYNGITIS. 
Inflammation of that portion of the pharynx which can be seen when the 
tongue is depressed, belongs to inflammation of the fauces, and has been 
treated of under that head. When it occurs alone, it is characterized by 
pain, and the absence Of alteration of the voice. Inflammation of the invi- 
sible portion of the pharynx is much less common. Its diagnostic symp- 
toms are pain in swallowing, opposite to the top of the larynx, and tender- 
ness on pressure from without immediately behind the larynx, without 
redness in the fauces or change of voice. It is seldom attended with fever, 
and is not often dangerous. It terminates usually in resolution; but the 
inflammation sometimes extends to the cellular structure posterior to the pha- 
rynx, when suppuration may take place, and an abscess result, extremely 
dangerous in its consequences. There is nothing peculiar in the causes of 
pharyngitis. Like inflammation of the fauces, it may be of the ordinary 
character, or pseudo-membranous, and like it may assume a chronic form. It 
is to be treated, moreover, in the same way, except that little good is to be 
expected from gargles, or direct applications to the part, when out of the reach 
of vision. 
Abscess of the Pharynx.-Collections of pus form in the cellular structure 
around the pharynx, in various positions, and from various causes. But the 
affection here referred to is seated in the cellular tissue posterior to the pha- 
rynx, between it and the cervical vertebrae. It is not a frequent, but is CLASS III.] 
INFLAMMATION OF THE (ESOPHAGUS. 
503 
nevertheless an important complaint. When behind the upper part of the 
pharynx, it may be known by a projection in the back of the fauces, visible 
to the eye when the jaws can be sufficiently opened, and sensible to the 
finger, ^hich at the same time detects fluctuation. When lower down, it 
is not so easily recognized. Deep-seated pain in the region of the pharynx, 
tenderness upon pressure from without, stiffness of the neck, great difficulty 
of deglutition followed by absolute inability to swallow, suppression of the 
voice, and the most distressing dyspnoea, attended with laborious efforts to 
inspire, are symptoms which should lead the physician to suspect its exist- 
ence, and, if it be invisible, to attempt by the careful introduction of a sto- 
mach tube to ascertain whether the passage is closed. The danger in these 
cases arises partly from inanition, but chiefly from pressure upon the larynx, 
producing suffocation. Several fatal cases are on record; and it is highly 
probable that many others have occurred, which have been mistaken for 
laryngeal disease. The.chief diagnostic symptoms are the seat of pain, and 
the inability to swallow. There is usually considerable fever, and some- 
times cephalic symptoms, which tend to direct attention away from the real 
danger. The abscess is more dangerous in the lowei' than the upper part of 
the pharynx. , 
This affection may attend the advanced stage of certain fevers, or may 
result simply from inflammation of the pharynx, as before. stated. It may 
also be produced by disease of the cervical vertebrae. As hitherto observed, 
it has been most common in children under four years old; but it may occur 
at any age. ~ 
The treatment consists simply in opening the abscess; and the chief cau- 
tions requisite are to avoid making too deep an incision, and to strike as nearly 
as maybe the middle line, so as to avoid any considerable artery. Dr. Aber- 
crombie relates three cases of children, who were apparently rescued from 
suffocation in this way. Should the abscess be out of sight, and beyond the 
reach of the finger, the cutting instrument should be sheathed in a tube, until 
in contact with the tumour. 
Article IV. 
INFLAMMATION OF THE (ESOPHAGUS, or (ESOPHAGITIS. 
This is a veiy rare affection, unless originating from the direct application 
of irritating substances, Or from mechanical violence. 
Symptoms, &c.-A sense of heat and of pain, increased by swallowing, 
and frequently referred to the lower, extremity of the pharynx, or to the car- 
diac orifice of the stomach, no matter'what part of the tube may be affected, 
is the. earliest symptom. , Sometimes the pain is felt between the shoulders, 
or is referred to the larynx. Tenderness upon strong pressure from without 
is experienced, if the disease is seated in the upper part of the oesophagus. 
Deglutition is usually more or less difficult, and sometimes impossible. The 
complaint is said to be frequently attended with hiccough, and sometimes 
with the eructation of a glairy mucus, and with vomiting. There is usually 
little or no fever. The inflammation generally terminates by resolution, 
though suppuration sometimes takes place, and an abscess may form between 
the mucous membrane and the muscular coat. Ulcers occasionally result. 
The inflammation may also be of the pseudo-membranous character, in which 
case it is usually propagated from the fauces or larynx, though it does occa- 504 
LOCAL DISEASES. 
[part II. 
sionally originate in the oesophagus, and has been known to occupy its whole 
extent. The vomiting of flakes, or a tube of false membrane, would lead to 
the suspicion of its character. In some cases of oesophagitis, the mucous 
follicles are exclusively affected; but this cannot be ascertained during life. 
The disease occasionally becomes chronic, in which case, we have the ordinary 
symptoms of the acute in a moderated form, and especially a copious discharge 
of mucus by the mouth. 
Causes.-1The usual causes are acrid, corrosive, or very hot substances swal- 
lowed, and mechanical violence from sharp, rough, or hard bodies introduced 
into the oesophagus, or from undue efforts by the surgeon in the use of the 
stomach tube, the bougie, or the probang. The disease may also be propa- 
gated downward from the fauces, or upwards from the stomach. It has been 
ascribed, in some instances, to the retrocession of cutaneous eruptions, and of 
rheumatism. There is little doubt that the muscular coat sometimes becomes 
the seat of the latter affection. 
Treatment.-Venesection when the pulse is strong and excited, saline 
cathartics, stimulating pediluvia, a liquid farinaceous diet, repeated leeching 
or cupping, emollient poultices, and, in the advanced stages, blisters upon the 
neck, or between the shoulders, constitute the chief remedies. In chronic 
cases, revulsion should be sustained by a perpetual blister, by pustulation with 
croton oil or tartar emetic, or by a seton. Should the case not yield to other 
measures, mercury should be resorted to; and this should be employed early, 
if-there is reason to believe that the inflammation is pseudo-membranous. 
When inability to swallow exists, attempts may be made to support the pa- 
tient by nourishing liquids injected into the bowels. 
Article V. 
STRICTURE OF THE (ESOPHAGUS. 
1. Organic Stricture.-The consideration of this subject belongs strictly 
to the surgeon; as it is by surgical means that relief is to be afforded. A few 
remarks, therefore, will be sufficient. The complaint is indicated by difficulty 
of deglutition, at first moderate, but gradually increasing so that the patient 
can at length swallow nothing but liquids, or ceases to swallow even these, 
and dies of inanition. Sometimes, however, the stricture continues many 
years without perceptible increase. It may arise from thickening of the 
coats consequent upon inflammation, from contraction produced by the healing 
of an ulcer, from excrescences growing out of the mucous membrane, from 
scirrhus, from cartilaginous or osseous degeneration of the tube, or from the 
pressure of exterior tumours. Among its effects is a dilatation of the oesopha- 
gus above the place of stricture, sometimes- to a very great extent. When 
there' is much pain, leeching, blistering, and narcotics may be employed. 
When it originates in inflammation, some advantage may be hoped from a 
careful course of mercury, or the internal and local use of iodine. Caustic 
to the strictured part has been employed by some English surgeons; but 
the only means upon which much reliance can be placed is the use of the 
bougie. 
2. Spasm of the (Esophagus.-This is a morbid muscular contraction of 
the tube producing more or less difficulty of swallowing. 
Symptoms.-The spasm generally comes on suddenly, often, for the first 
time, during a meal. Upon an attempt to swallow, the food is arrested, and CLASS III.] 
STRICTURE OF THE (ESOPHAGUS. 
505 
is either rejected immediately and with force, or is retained for a time, and 
then rises by regurgitation. The former event is apt to occur when the stricture 
is near the upper extremity, the latter when it is hear the lower. Occasion- 
ally, after the food has been a short time in contact with the stricture, this 
gives way and allows it to pass into the stomach. In some instances, solids 
can be swallowed better than liquids, and the reverse is sometimes the case; 
but in general any sort of food is sufficient to excite the spasm, when the 
morbid susceptibility exists. Severe pain often attends the spasmodic action, 
and the irritation occasionally extends to the larynx or lungs, producing much 
embarrassment of respiration, with a feeling of Impending suffocation. Even 
where no effort at deglutition is made, there is frequently present a sense of 
constriction, and, in some cases, a feeling as of a ball ascending in the throat, 
or moving from one part to the.other. This is the globus hystericus of older 
writers. Hiccough and vomiting sometimes accompany the affection. Its 
duration is exceedingly various. An attack may consist of a single paroxysm, 
lasting only a few hours, or the spasmodic action may continue with exacer- 
bations and remissions, and occasional complete intermissions, for months or 
years. Like most other nervous affections, it sometimes assumes the regular 
intermittent form. 
From organic stricture, the only complaint with which it can be confounded, 
it may in general be readily distinguished by the suddenness of the attack, 
by the occasional absence of all the symptoms, so that the patient can swallow 
easily, and by the other evidences of nervous disorder with which it is fre- 
quently attended. A large bougie can also be passed with facility in periods 
of relaxation, and, even when arrested by the spasm, if held for some time 
against the stricture, will often be allowed to enter. 
Causes.-Irritation of the mucous coat, from whatever cause, may produce 
the spasm when a predisposition to it exists. It is sometimes excited by in- 
flammation of the oesophagus. Among the causes may be mentioned acrid 
substances swallowed, cold drinks during perspiration, partial exposure to cold 
air, violent and depressing emotions, the operation of the imagination, and 
the influence of disease existing elsewhere, as of dentition, organic affections 
of the larynx, stomach, and uterus, and inflammation of the upper part of the 
spinal marrow. The predisposition usually consists in an excitable state of 
the nervous system, such as exists in hysteria, hypochondriasis, and generally 
in an anemic debilitated condition of body. 
Treatment.-The indications of cure are first to relieve the local affection, 
and secondly to correct the predisposition. The first is answered by remedies 
suited to relax the spasm directly, and to diminish the nervous excitability of 
the part, so as to prevent the disposition to its recurrence. If inflammation 
exist, it should be removed by the means already indicated. If the affection 
be purely nervous, recourse may be had to narcotic cataplasms, as of tobacco, 
henbane, or hemlock, to acetate or sulphate of morphia upon a blistered sur- 
face, to rubefacients, epispastics, pustulating substances, or a seton applied to 
the back of the neck, and to the internal use of antispasmodics and narcotics, 
such as assafetida, valerian, Hoffmann's anodyne, camphor, opium, henbane, 
and hemlock. Much good is said to have resulted from very cold drinks, and 
even ice swallowed by the patient. 
To meet the second indication, remedies must be employed calculated to 
remove the disease of other organs with which the spasm may be associated, 
and to correct any existing morbid state of system. These remedies are de- 
tailed elsewhere. It is sufficient here to mention, that it is. usually desirable 
to invigorate the general health by chalybeates or other tonics, exercise, fresh 506 
LOCAL DISEASES. 
[part II. 
air, a nutritious diet, the avoidance of coffee, tea, and tobacco as habitual 
luxuries, and attention to the bowels and the various secretions. 
In the regularly intermittent form of the complaint, sulphate of quinia will 
prove effectual. 
SUBSECTION III. 
DISEASES OE THE STOMACH. 
Article L 
INFLAMMATION OF THE STOMACH, or GASTRITIS. 
The inflammation in this disease is usually seated in the mucous membrane, 
and the submucous cellular tissue; though it sometimes extends to the other 
coats, and may even involve the whole stomach. The peritoneal coat is sel- 
dom exclusively affected, unless in cases of general peritonitis, to which dis- 
ease, therefore, inflammation of that coat properly belongs. Gastritis exists 
under the two forms of acute and chronic. Some make an intermediate grade 
which they call subacute; but there is scarcely sufficient ground for this dis- 
tinction in any peculiarity of character, or precise degree of violence. 
Acute Gastritis.-This is by no means common as an independent 
affection, though very frequently found associated with other diseases, of which 
it niay be either an effect, or a mere attendant, having its origin in the same 
cause. FeW organs resist so firmly the ordinary direct causes of inflammation 
as the stomach, and few are so readily affected through the sympathies. The 
object of this provision is evident. An organ so important in its functions, 
and so much exposed to irritant influence from without, would be constantly 
suffering, and causing the system to suffer, if readily excited into inflammation 
by an excess of such influence; while, if undisturbed by inflammation, or 
morbid excitement in other organs, it would continue to furnish, through the 
function of digestion, materials to the blood calculated to sustain the disease. 
Symptoms.-In severe cases of acute gastritis, there is usually a burning 
pain in the epigastrium, with incessant nausea and vomiting, commencing 
with the attack, and continuing, with greater or less intensity, till near the 
close. The pain is increased by pressure from without, and by a deep inspi- 
ration, and is sometimes excruciating in the act of vomiting. The substances 
thrown up from the stomach are at first the food or chyme, and afterwards 
bile or mucus, and whatever may be swallowed, and are sometimes more or 
less deeply tinged with blood. There is occasionally considerable difficulty of 
deglutition, in consequence of spasm of the oesophagus or cardiac orifice. The 
thirst is intense, and the patient is constantly calling for cold water, although, 
if taken freely, it produces uneasiness and oppression by the distension of the 
stomach, and is often immediately rejected. The tongue is at first usually 
covered in the middle and posterior part with a whitish fur, while its tip and 
edges are red, and red papillae are visible through the coating; but sometimes 
it is red, smooth, dryish, and without fur, from the commencement. The 
bowels are almost always constipated, unless they participate in the inflamma- 
tion, in which case they are looser than in health. The patient lies on his 
back, is apt to be low spirited, is restless and unable to sleep, and has a 
feeling of great debility, with an expression of countenance indicating anxiety 
and distress. The pulse is frequent and sometimes full, but usually small CLASS III.] 
INFLAMMATION OF THE STOMACH. 
507 
and corded; the respiration often short and hurried; the skin hot and dry; 
and the urine high coloured. A hard, dry cough, occasionally assuming a 
paroxysmal character, is also mentioned among the symptoms. 
Should the disease now take a favourable turn, the pain and vomiting 
abate; the tongue becomes paler and moister, the pulse slower, fuller, and 
less corded, the skin cooler and softer; and sometimes a general moisture of 
the surface, or relaxation of the bowels, evinces that the crisis is passed. But, 
should it advance unfavourably, the tongue, if before coated, becomes smooth, 
red, and dry, and. towards the close is occasionally covered, as well as the 
inside of the check, with a thrush-like exudation; the skin becomes cool and 
pale, and the pulse more frequent, feeble, and thread-like; the body emaciates 
rapidly; debility and restlessness increase; delirium frequently occurs; hic- 
cough harasses the patient; active vomiting is succeeded by mere regurgita- 
tion ; instead of mucus or bile, a black matter like coffee grounds is sometimes 
ejected; the tenderness on pressure diminishes, and pain sometimes ceases 
entirely; the countenance sinks, and assumes a haggard aspect; and death 
occurs, preceded by cold extremities, a scarcely perceptible pulse, and other 
evidences of extreme exhaustion. The complete suspension of pain, 'without 
amelioration in other respects, is an unfavourable sign. In some rare instances, 
in the latter stage, the pain suddenly increases and becomes more diffused, 
and extreme tenderness upon pressure is felt over the 'whole abdomen, which 
swells and assumes a tympanitic condition. In such cases, the stomach has 
been perforated, and peritoneal inflammation has been produced by the fluids, 
which have escaped through the opening. Inevitable death speedily follows 
this event. When the stomach has been disorganized from the commence- 
ment by the'violence of the cause, as when one of the concentrated mineral 
acids has been swallowed, great prostration comes bn almost immediately, with 
a cold, clammy skin, and a very feeble pulse; and death soon takes place.\ 
In milder forms of the disease, the symptoms above enumerated as charac- 
terizing the earlier stages, are experienced in a less degree. Sometimes, 
instead of severe pain, there is merely a feeling of oppression, weight, or con- 
striction; instead of obstinate and incessant vomiting, merely a slight nausea, 
or a disposition to vomit ingesta. The pulse, too, in such cases, is usually 
more full and developed. Epigastric tenderness is very seldom absent Oc- 
casionally, even in severe gastritis, there is a want of all the characteristic 
symptoms; so that the first evidence of the nature of the'complaint is that 
afforded by dissection. This is sometimes attributable to the fact, that various 
secondary or sympathetic affections, such as severe headache' or delirium, pains 
in the back or limbs, or irritation of some portion of the pulmonary apparatus, 
become so prominent as to act revulsively in relation to the gastric sensibili- 
ties, and thus to mask the real disease. When gastritis attends other diseases, 
it is peculiarly liable to be thus concealed, as in that form of derangement of 
drunkards which immediately follows an occasional debauch, and in which it 
is highly important that it should be recognized. (^oAes.) The duration of 
acute gastritis is very variable. In violent cases, as from corrosive poison, 
death, in some instances, takes place in less than twenty-four hours; while in 
others, the disease continues from two to six weeks, and then, if not fatal, ends 
in a slow convalescence, or subsides into chronic gastritis of indefinite duration. 
Milder cases of the disease often yield speedily to appropriate treatment; 
but, if not taken in time, may run on for weeks, and at last assume the chronic 
form. 
Anatomical Characters.-The stomach is more or less contracted, sometimes 
so as not to exceed the transverse colon in size. The mucous membrane is 
often much wrinkled, and sometimes covered with a viscid or puruloid mucus, 508 
LOCAL DISEASES. 
[part II. 
upon the removal of which it exhibits the usual marks of inflammation. The 
colour is either bright-red, brownish, or livid-red, or blackish-brown, and is 
more or less diffused over the stomach • sometimes extending over the whole 
mucous surface, sometimes confined to a portion of it, most commonly the 
fundus, and usually deepest in this part. The redness may be uniform, in 
patches or stripes of greater or less extent, or in points, or stellate, or arbores- 
cent with innumerable capillary ramifications, or branching with larger trunks. 
Sometimes it is found of one form in one part of the stomach, and of a differ- 
ent form in another. The darker shades of colour, the brown and black for 
example, are, according to Andral, very seldom found in acute gastritis, and 
only in cases of great intensity and brief duration, such as result from the 
corrosive poisons. Ecchymosis is not unfrequent, usually in patches, some- 
times in insulated spots in the submucous tissue, producing small prominences 
on the surface. The mucous follicles often exhibit evidence of increased de- 
velopement in small reddened eminences. The discoloured portion of the 
membrane is generally thickened, and more or less softened-, so that it is 
more easily torn than in health. Sometimes it is reduced to the state of a 
soft pulp. These various alterations may be confined strictly to the mucous 
membrane, or may penetrate one or more of the remaining coats; and Andral 
relates a case, in which the whole of the coats of the left half of the stomach 
were in a friable, * almost pulpy condition. Eschars are occasionally seen 
with purulent secretion, oedema, emphysema, and other accompaniments of 
disorganization, and the consequent vital process of separation, in various states 
of advancement. Ulcers are rare, as a result of acute gastritis, except in cases 
of poisoning. 
It is highly important, in a toxicological point of view, that the post- 
mortem evidences of gastric inflammation should not be mistaken. It was 
at one time generally supposed that redness was a sufficient indication; and 
it was taken for granted that any stomach which presented this appearance 
had been inflamed. Yellowly, however, by experiments made in 1813, satis- 
factorily proved, that stomachs previously in a healthy state, often appeared 
much reddened after death; and observations made since that period by Andral 
and others go to show, that no modification of colour alone can be admitted as 
certain proof of inflammation. All the varieties of . shade, and all the diver- 
sities of arrangement above stated, may result from causes wholly independent 
of that condition. Not to mention irritation, or mere healthy excitement, 
which often occasions intense redness of the mucous membrane, the same 
effect is produced by congestion of the portal circle, or any other cause ob- 
structing the return of blood from the stomach, and by agencies operating at 
the time of dissolution, and after death, particularly gravitation, which causes 
the blood to settle in the most dependent parts of the stomach. The fact, 
moreover, should be borne in mind, that the gastric mucous membrane, in 
very young subjects, is of a rosy hue in health. Even softening of the mem- 
brane cannot always be relied on; as it may be entirely cadaveric, resulting 
from the action of the gastric juice, or from incipient putrefaction; and, in 
very low states of the system, the vital properties may be so much enfeebled 
in parts which have become the seat of a passive sanguineous congestion, that 
the chemical forces may predominate, even during life, and produce a mate- 
rial change of consistence. It should also be remembered, that the healthy 
consistence of the membrane is different in different parts, being firmer near 
the pylorus than in the remainder of the stomach. Notwithstanding these 
difficulties, however, there is usually, in cases of real inflammation, abundant 
evidence of its having existed, in the state of the stomach after death. The CLASS III.] 
INFLAMMATION OF THE STOMACH. 
509 
facts just mentioned should only serve as a caution, not to mistake for proofs 
of inflammation, appearances which may have had a wholly different origin. 
Causes.-Acute gastritis is rarely produced by those vicissitudes of temper- 
ature, which are so often the cause of other inflammations. It most frequently 
results from caustic or irritant substances taken into the stomach. The cot- 
rosive mineral, and acrid vegetable poisons often prove fatal in this way. 
Milder stimulants, such as alcoholic drinks, the stronger condiments, and 
even an excess of food, sometimes produce acute inflammation of the stomach, 
but rarely unless in cases where a strong predisposition exists. Large draughts 
of very cold water after fatiguing and exhausting exertion, when the body is 
heated and perspiring, are among the- causes. Very severe cases sometimes 
result from the translation of acute gout or rheumatism. Andral relates a 
striking case of this kind, in which a predisposition to disease of the stomach 
appeared to be occasioned by distress of mind. But the state of convalescence 
from certain acute diseases, especially cholera, and the previous existence of 
chronic inflammation of the stomach, constitute the strongest predisposition. 
It is in these conditions, that excess in eating and drinking most frequently 
brings on an attack of acute gastritis. 
But this, disease occurs much more frequently, as an attendant upon other 
diseases, than as an original or independent affection. It is peculiarly apt to 
occur in the course of idiopathic fevers, particularly in the bilious remittent 
and yellow fevers, and not unfrequently also attends the exanthemata and 
phlegmasiae. It is sometimes lighted up in the advanced stages of phthisis. 
In some instances, it is very difficult, nay impossible to decide, whether the 
gastritis be the original, or a secondary affection. The decision, however, is 
of the less consequence; as, in either.case, a prominent indication would be 
to combat the disease of the stomach; as this is at least one of the chief 
sources of danger. 
General Treatment.-Should the gastritis have been caused by a corrosive 
or acrid poison, and the stomach not yet fully evacuated, the first object in 
the treatment should be to remove the offending matter, either by means of 
copious draughts of warm water, or other bland liquid, or, if these should be 
insufficient, by means of a gentle emetic of ipecacuanha accompanied with 
free dilution. At the same time, substances should be administered calcu- 
lated to act as antidotes by neutralizing the poison; and, after the stomach 
has been thoroughly cleansed, castor oil or sulphate of magnesia should be 
given along with the antidote, in order to evacuate any portion of the poison 
which may have passed into the bowels. The inflammation is then to be 
treated as if it had arisen from other causes, attention being always paid to 
whatever peculiar condition of the system may have arisen from peculiar pro- 
perties in the poison, and to the fact, that, if great organic injury has been 
inflicted, the powers of the system are too much prostrated to admit of copious 
depletion. 
In the early stage of gastritis, if the patient has not been previously de- 
bilitated, and the system is not under the influence of some powerfully 
depressing agent, as in typhus fever, and the case of certain poisons, blood 
should be taken freely from the arm; and, if the pulse and general strength 
do not fail under the loss, the bleeding should be repeated once and again, 
until a decided impression is made on the disease. The pulse and muscular 
strength of the patient are not to be taken as exclusive guides in acute gas- 
tritis. They both feel the depressing influence of the attending nausea, and 
will often rise under depletion, in consequence of the diminished force of the 
disease in which the nausea originates. Besides, a certain energy of stomach 
seems necessary to support the actions of the circulatory system, and, when 510 
LOCAL DISEASES. 
[PART II. 
the functions of that organ are wholly suppressed by excessive inflammation, 
the heart, though irritated, contracts with comparatively little force. Dimin- 
ish the inflammation, and the heart resumes its power. Venesection is safe, 
so long as the pulse, as it not unfrequently does, rises and becomes more 
developed under the lancet. 
As constipation is an almost uniform attendant on uncomplicated gastritis, 
cathartics would appear to be indicated; but medicines of any kind taken 
internally are apt to be rejected, or to aggravate the inflammation; and most 
authors recommend either their very sparing employment, or a total abstinence 
from them. Nevertheless, from five to fifteen grains of calomel may often be 
usefully given, in the earlier stage, after the due loss of blood. This cathartic 
is but slightly if at all irritant to the inflamed membrane, and is sometimes 
retained with the effect of calming the stomach, when other substances, even 
small quantities of cold water, are rejected. Besides, it operates favourably 
by unloading the portal veins through the secretion of bile, and thereby 
diminishing congestion in the stomach. The bowels should afterwards be 
kept open by the frequent use of enemata. In some cases, when medicines 
are tolerated, a little castor oil or carbonate of magnesia, or other mild cathar- 
tic, may be administered with advantage; but, if found to disturb the stomach, 
they should not be persevered in. The effervescing draught will often ope- 
rate favourably by promoting perspiration and reducing fever; but this also 
will sometimes prove irritant, and must be relinquished. Opium, or one of 
the salts of morphia, may be given when the first violence of the inflamma- 
tion has subsided. A full dose may be administered at bedtime, and repeated 
in an hour or two if it should not procure rest. Calomel may often be use- 
fully combined with the opium, and, if the disease does not appear disposed 
to yield to depletion, may be repeated at such intervals as to bring the system 
carefully under the mercurial influence. Half a grain or a grain of opium 
with one or two grains of calomel, in the form of pill, repeated every four, 
six, or eight hours, will generally be sufficient for the purpose. When the 
vomiting is obstinate, and easily excited, so that even these medicines cannot 
be retained, advantage will accrue from enemata of laudanum with a solution 
of starch or flaxseed tea. Throughout the complaint, stimulating pediluvia, 
or other measures for exciting action in the lower extremities, should be em- 
ployed when these are pale and cold. In the last and most prostrate stage, 
when all the symptoms indicate threatened or existing gangrene, the most 
efficient remedy is the oil of turpentine, combined with laudanum or a salt of 
morphia, and given frequently in small doses. I have seen one apparently 
desperate case recover, under the use of this combination. 
The patient should not be allowed to drink largely; but he will derive 
relief from occasionally swallowing a mouthful of very cold water, or from 
keeping ice in his mouth, and swallowing it as it dissolves. Few measures 
will be found more grateful than this, while it proves positively useful in 
the relief of the inflammation. Stokes recommends that small pieces of 
the ice should be swallowed undissolved, after they have remained in the 
mouth a short time, so as to round off the angles. Iced lemonade, or car- 
bonic acid water may sometimes be favourably substituted for pure water. 
In the early stages, no other nutriment should be allowed than a solution 
of gum arabic, weak barley-water, or some other mucilaginous or farinaceous 
drink; and even these may be dispensed with at first; but, in the more ad- 
vanced stages, when the debility is great, and an absolute necessity exists for 
the support afforded by nourishment, fresh milk mixed with lime-water will 
be found both grateful and useful. These should be given in small quantities 
frequently repeated, as from half a fluidounce to a fluidounce of each every CLASS III.] 
INFLAMMATION OF THE STOMACH. 
511 
hour. In a still more advanced stage, chicken broth, plain cream, or ice 
cream may be carefully administered, In convalescence, the utmost caution 
should be observed to guard the patient against imprudence in eating, as 
nothing would be more likely to occasion a relapse. 
Local Treatment.--No one remedy in the treatment of acute gastritis is 
more important than leeches to the epigastrium. These should be resorted 
to after bleeding, and immediately in cases where bleeding is deemed unne- 
cessary or inadmissible, and should be repeated occasionally until the symp- 
toms give way. The most \ decided relief is often experienced from this 
remedy, in some instances even while the leeches are drawing. Some writers 
recommend them to the exclusion, or nearly so, of general bleeding; but I 
am convinced that this is a great mistake. The principle upon which leech- 
ing operates with so much advantage is not obvious. Some refer it to revul- 
sion, and the direction of the current of blood from the stomach to the sur- 
face. But in this way the leeches should prove equally useful applied to the 
sides or back, as these parts are nearer even than the epigastrium to the source 
whence the stomach receives its supply of blood. May not the result be 
ascribed to some undefined sympathy between the epigastrium and the gastric 
mucous membrane? In the intervals between the leechings, warm fomenta- 
tions, or light emollient cataplasms should be applied over the region of the 
stomach, unless found very oppressive by their weight. Care, however, must 
be taken that they do not produce too copious a flow of blood from the leech- 
bites. Cold applications, and even ice, have been recommended as preferable 
to warm fomentations; but I can say nothing of this remedy from expe- 
rience. In the advanced stages, decided benefit will sometimes accrue from 
blistering, and advantage may be taken of the raw surface thus obtained, to 
hasten a mercurial impression by applying dressings of mercurial ointment, or 
to relieve nausea and vomiting by the endermic use of the acetate or sulphate 
of morphia. 
It is scarcely necessary to state that the above plan of treatment may be 
applied, in various degrees, and with various modifications, according to the 
nature of the case, as well to the inflammation of stomach which attends-Other 
diseases, as to idiopathic gastritis^ 
Chronic Gastritis.-There is no distinct line of division between this 
and the former variety of gastritis. The extremes could not be confounded; 
but of the numerous intermediate grades, it would often be difficult to decide 
which might belong to the one, and which to the other variety. If the prac- 
titioner, however, observe the same gradation in the treatment, which he finds 
in the character of the disease, no harm can result. 
Symptoms.-When not the result of the acute form, chronic gastritis in 
general approaches so gradually, that it seldom attracts the serious attention 
of the patient, or comes before the notice of the physician, until it has ex- 
isted a considerable time. The first symptoms are usually some uneasiness 
in the region of the stomach after eating, more or less derangement of the 
appetite, and a feeling of general discomfort during digestion, with occa- 
sional headache, and vague pains or soreness in the limbs as if from fatigue. 
Sometimes nausea and vomiting occur at the commencement. The symp- 
toms gradually increase in intensity and diversity ; and the disease puts on 
a great variety of aspects, dependent on the degree, extent, stage, cause, 
and character of the inflammation, the tissue or part affected, the constitu- 
tion and habits of the patient, and the almost infinite diversity of sympa- 
thetic derangements. In almost all cases, perhaps in all, there is more or 
less epigastric uneasiness. This generally amounts to pain, which, however, 
is exceedingly variable, being sometimes acute, lancinating, or spasmodic, 512 
LOCAL DISEASES. 
[PART II. 
sometimes slight, dull, and little more than soreness. Frequently there is 
a sense of heat or burning, which sometimes extends up the oesophagus, 
or over the chest, particularly on the left side, and is hence called heart- 
burn. Instead of pain, there is often a feeling of fulness and distension, or 
of weight, or constriction, or of gnawing at the epigastrium, which is for the 
most part also, though not invariably, sore when pressed. The uneasiness 
is sometimes general over the epigastric region, or even extends under the 
ribs on both sides, and under the sternum; -but, in other cases, it is shifting, 
or confined to one spot; and this occasionally answers to the particular part 
of the stomach affected. Frequently also pain is felt in other places, as in 
various parts of the chest, in the shoulder and arm, and in the back imme- 
diately behind the region of the stomach. The sensation is seldom constant; 
but has exacerbations and remissions, or entirely intermits, and is generally 
worse immediately after eating, or during digestion. It sometimes commences 
at a certain period after a meal. 
The appetite is variable in different cases, and sometimes in the same case. 
Occasionally it is little affected; and, in such cases, there is reason to think 
that the inflammation is very moderate, or confined to a comparatively small 
portion of the stomach. Very generally, however, it is deranged, for the 
most part diminished, sometimes nearly or quite lost, and occasionally craving. 
In the last case, though the patient may begin to take food eagerly, yet the 
disposition is apt to pass away after a small portion has been swallowed, and 
is even followed by a feeling of disgust. Instead of a genuine appetite, there 
is often a sensation as of hollowness or sinking at the stomach, with a feeling 
of faintness, which leads to the desire for food, and is sometimes relieved by 
it. The same want of the system is, in some instances, expressed by a head- 
ache or dry cough, which ceases after a meal. The patient sometimes dreads 
food from the remembrance of the uneasiness it has occasioned. The taste is 
often vitiated, and substances leave an impression of sourness in the mouth 
after being swallowed. There is usually thirst, with a desire for cold drinks, 
which, if moderately taken, afford relief; while hot and stimulating drinks 
increase the uneasiness. Sometimes, however, the thirst is not greater than 
in health. 
Large quantities of gas are sometimes evolved in the stomach, which occa- 
sion frequent belching. The gas is in some instances inodorous, in others 
fetid and irritating. Eructations of sour and acrid liquids are not uncommon. 
Vomiting is also a frequent attendant. It occurs seldom at the commence- 
ment of the attack, but is apt to become more frequent, and, at length, in 
some cases, attains such a degree, that not a meal, and scarcely a mouthful of 
food, can be swallowed without being discharged. It is wonderful how long 
patients sometimes live, and even retain their flesh, who vomit apparently all 
their food. Portions, however, must remain and be digested. The matters 
vomited are food, bile, mucus, sour and acrid liquids, which seem to excoriate 
the throat in their passage, and, in some instances, blood mixed or unmixed, 
fresh or altered by the action of the gastric juice. Sometimes, especially in 
the latter stages, and when ulceration exists, a dark matter resembling coffee- 
grounds is discharged from the stomach, and is also found in the alvine evacua- 
tions. This is blood somewhat modified by an imperfect secretory effort of 
the vessels. The discharge of these various substances often affords so much 
relief to the patient, that he acquires the very injurious habit of throwing 
them up voluntarily. In some cases, large quantities of a glairy fluid like 
the uncoagulated white of eggs, or of the ordinary mucus of the stomach, or 
of a tasteless colourless liquid like saliva, are discharged, often rather by a 
species of eructation than by vomiting. CLASS III.] 
CHRONIC INFLAMMATION OF THE STOMACH. 
513 
Constipation almost invariably exists, unless in cases in which the inflam- 
mation extends to the bowels. 
The tongue is, in some rare cases, little if at all affected; but generally it 
is either coated more or less with a whitish or yellowish fur, with the red- 
dened papillae projecting, or is red and smooth, or has the papillae enlarged 
and reddened without other change. It is seldom so dry as in acute gastritis, 
but is often clammy or dryish, especially in the morning, or after sleep. In 
the advanced stages, it is occasionally covered with kphthae, or a thrush-like 
exudation. This is supposed to indicate ulceration of the stomach, and is 
usually an unfavourable, though by no means necessarily a fatal sign. 
The pulse is sometimes scarcely more frequent than in health, and may 
even be less so. Occasionally it is irregular and intermittent. Usually, how- 
ever, it is somewhat increased in frequency and tension. In some instances, 
there is a slight febrile paroxysm after eating; and, in the advanced stages, 
the pulse' often becomes very frequent; and even hectic fever may set in. 
Except in this latter state, the skin is almost invariably dry, and sometimes 
even harsh, with a disposition to eruptive affections of various kinds, especially 
urticaria. The soles of the feet, and the palms of the hands, are in some 
persons distressingly hot; while in others there is a disposition to coldness of 
the extremities. ' , 
The secretions are almost always more or less deranged. The saliva is not 
unfrequently sour, the bile scanty, superabundant, or deranged, and the urine 
variously disordered. 
The nutritive process is differently affected in different cases. Sometimes 
the patient appears not to lose flesh for a considerable time after the com- 
mencement of the disease, and, in a few instances, retains his fulness till near 
the close. But usually there is great emaciation. 
The sympathetic disorders of the nervous system are almost infinitely 
numerous and diversified. Among the more common may be enumerated 
headache, giddiness, perverted vision, muscae volitantes, buzzing or roaring 
in the ears, dyspnoea, a dry hard cough, palpitations, violent pulsations in the 
epigastrium, a general feeling of uneasiness, vague pains in the extremities, 
and great mental anxiety or dejection, with perverted feelings, and notions 
amounting sometimes to hypochondriasis. 
The duration of the disease is usually considerable, not unfrequently for 
years. It seldom marches steadily forward, but is liable to frequent changes; 
the patient sometimes approaching to recovery and then relapsing, and going 
through this alternation several times before recovery or death. Under 
favourable circumstances of position, constitution, and treatment, the disease 
very generally terminates favourably, unless complicated; and the patient 
sometimes recovers from the most alarming symptoms. Even large ulcers 
heal. But death is not an unfrequent result. It is usually preceded by 
great emaciation and debility, sometimes by hectic fever; and the patient often 
sinks under a complication of visceral affection, originating in sympathy with 
the stomach, but constituting ultimately the chief source of danger. The 
fatal result is sometimes immediately produced by an attack of peritonitis, 
consequent upon the escape of the contents of the stomach, through an ulcer- 
ated opening in that viscus, into the cavity of the abdomen. The ulcer having 
destroyed nearly the whole thickness of the coats, the remaining slender por- 
tion is ruptured by some mechanical violence, as by over-distension of the 
stomach, the act of vomiting, or by voluntary straining. The penetration, 
however, of the coats of the stomach is not necessarily fatal. The diseased 
surface contracts adhesions with that of some adjacent viscus, the body of 
which thus forms a floor for the ulcer. The liver, spleen, or pancreas may 514 
LOCAL DISEASES. 
[part II. 
serve tins useful purpose. Sometimes the stomach and colon become united, 
and communicate so that the contents of the former escape through the latter. 
These results, however, are more common in cancer of the stomach than in 
ulceration of the ordinary character. 
It has been mentioned that numerous varieties of chronic gastritis exist. 
Sometimes the symptoms are comparatively mild from the commencement, 
and continue so through its whole course. In other cases, though mild in 
the beginning, and for a variable length of time afterwards, they gradually 
increase, until the case assumes a serious aspect. In others again, they exhibit 
an alarming intensity almost from the outset. In a few instances, the com- 
plaint runs on in its mildpst form for a long time, and then suddenly breaks 
out into fatal violence. Under such circumstances, there is reason to suppose 
that the inflammation may have been confined to a small portion of the sto- 
mach, but, ending in ulceration, exhibits at length evidences of great organic 
mischief. This condition may be suspected, when vomiting of blood, or of 
matter like coffee-grounds, supervenes upon the ordinary symptoms of chronic 
gastritis. The inference, however, is by no means positive, as both these 
results may occur without any solution of continuity in the mucous membrane. 
Perforation of the stomach is another of those cases in which the course of 
the disease is very insidious. Every now and then a case occurs, in which 
the patient, previously in tolerable health, or complaining occasionally of 
some stomachic uneasiness, is suddenly seized with severe pain, and dies 
with all the phenomena of peritonitis. Dissection reveals an ulcerated open- 
ing in the stomach. Here, an ulcer so small, or so little sensitive as scarcely 
to have made itself felt, has opened a way through all the coats, and allowed 
the gastric contents to escape into the peritoneal cavity. Another variety of 
the disease is so peculiar as to merit a separate paragraph. 
Under the name of (jastrorrhoea, modern writers describe an affection, cha- 
racterized by the copious discharge from the stomach of a glairy fluid, usually 
insipid and inodorous, bearing a close resemblance in appearance to the unco- 
agulated white of eggs, or of mucus in its ordinary form. The vomiting 
occurs most commonly in the morning, as if the fluid had collected in the 
stomach during sleep; but it may take place at any time; and a singular cir- 
cumstance is, that the matter is often thrown off after eating, without a simul- 
taneous discharge of the food. The vomiting is usually very easy, sometimes 
in fact little more than a species of regurgitation. The disease may be con- 
sidered as a sort of catarrh of the stomach. It is sometimes attended with the 
ordinary phenomena of chronic gastritis; but, in other cases, neither exhibits 
during life, nor leaves after death, evidences of inflammation. Still, like the 
similar affection of the nostrils and the bladder, it probably originates, even 
in the latter cases, in an inflammatory condition, or at least irritation of the 
mucous membrane, which has given way to the discharge, while the secreting 
vessels retain their new mode of acting. It is often a mild disease; but, in 
some instances, runs a long course, and at last ends fatally, especially in old 
persons. 
Anatomical Characters.-The portions of the mucous membrane which had 
been inflamed usually exhibit a brown, grayish-slate, or. blackish colour, 
arranged in the different modes mentioned under acute gastritis. The colour 
is sometimes, though rarely, red. In some instances, innumerable minute 
black points are observed, so close together as to give to the whole surface of 
the membrane a black or dark-gray appearance. When examined by the 
microscope, these points prove to be villi injected with blood. Occasionally 
dull white patches of greater or less extent are observed, considerably lighter 
than the healthy membrane. The mucous coat is very often thickened, some- CLASS III.] 
CHRONIC INFLAMMATION OF THE STOMACH. 
515 
times to a considerable extent, sometimes only in small spots. The increased 
developement is occasionally confined to the mucous follicles, which form 
numerous granules either disseminated through the membrane, or collected in 
clusters, and are sometimes so large as to give to the surface a mammellated 
appearance. Sometimes the membrane is found thinner than in health. It 
is almost always altered in consistence, being frequently indurated, but still 
more frequently softened. Ulceration is also not unusual, though less com- 
mon than in inflammation of the ileum and colon. The mucous membrane 
exhibits either slight superficial erosions, or small isolated ulcers from inflam- 
mation of the follicles, or larger and deeper ulcers, which sometimes penetrate 
into the other coats of the stomach, or even through them. In the latter case, 
the stomach is not unfrequently found adhering to the neighbouring viscera, 
the substance of which forms the bottom of the ulcer. The points in which 
chronic gastritis differs from the acute, in relation to post-mortem appearances, 
are chiefly, that in the former the colour is usually dark as above stated, indu- 
ration frequent, and ulceration not uncommon; while in the latter, the colour 
is usually red, induration scarcely ever present, and ulceration rare. 
It is important not to confound real pathological appearances with those 
which are merely cadaveric. It has been proved by Dr. Carswell that the 
colour of the blood, remaining in the vessels of the stomach, is often darkened 
by the gastric juice so as to resemble that of chronic inflammation. In this 
case, however, the blood has not usually been extravasated, and as it were 
incorporated with the membrane, as in gastritis. John Hunter long ago 
ascertained that softening and even destruction of the coats of the stomach 
might take place after death, from the action of the gastric juice. This was 
afterwards disputed; but the fact is now established beyond reasonable doubt. 
Cadaveric softening is usually found in the fundus,, or in that part towards 
which the liquids in the stomach gravitate from the position of the body. It 
may be confined to the mucous membrane, or may extend to the whole of the 
coats. The excavations are usually in patches of various extent, with thin, 
soft, irregular, and sometimes fringed edges, unlike the swollen, often abrupt, 
and hardened borders of ulcers. Sometimes the softening is found in bands 
or stripes, when the stomach is wrinkled so as to bring the summit of the 
folds only into contact with the gastric juice. When these softened or exca- 
vated spots are stained of a brown or chocolate colour by the action of the 
juice upon the blood, the liability to form a wrong opinion is increased. One 
means of diagnosis is afforded by the fact, that the cadaveric softening is most 
apt to occur in the cases of individuals who were in good health, and had eaten 
a short time before death. Care must also be taken not to confound the soft- 
ening of putrefaction with that of inflammation. It is, moreover, by no means 
certain, that softening of a texture may not result from other morbid vital 
processes besides the inflammatory. 
Causes.-Chronic gastritis occasionally follows the acute; but, in the great 
majority of cases, it is an independent affection, resulting for the most part 
from long persisting, or frequently repeated irritation. The abuse of alcoholic 
liquors, habitual excess in eating, the employment of indigestible food as 
ordinary diet, and the excessive use of medicines, are among the most fre- 
quent causes. Congestion of the portal circulation, and the sympathetic irri- 
tation arising from disease in other organs, especially in the liver and spleen, 
may also give rise to the complaint. It is a frequent attendant upon phthisis, 
especially in the latter stages; and the tuberculous diathesis communicates to 
it an extraordinary obstinacy when it arises from other causes. But no dis- 
ease is so productive of chronic gastritis as dyspepsia; and the two affections 
are so frequently associated, that by some authors they are considered iden- 516 
LOCAL DISEASES. 
[part II. 
tical. This subject will be discussed under dyspepsia. It is sufficient here 
to say that the chronic inflammation, which so often accompanies or follows 
that complaint, may be ascribed in great measure to the constant irritation of 
the undigested, or badly digested, or chemically altered food, and of the acrid 
and otherwise disordered secretions, which take the place of the healthy sto- 
machic fluids, in consequence of the impaired energy of the organ. 
Diagnosis.-The only complaints with which chronic gastritis is liable to 
be confounded, are cancerous and other organic affections of the stomach, gas- 
tralgia and analogous nervous affections, and dyspepsia. For the diagnostic 
characters in each of these cases, the reader is referred to the several diseases 
mentioned. 
Treatment.-The first and most important indication, in the treatment of 
chronic gastritis, is the removal of the cause. As the disease in most in- 
stances either arises from irritating ingesta, or is sustained by them, and in 
all instances is aggravated by this cause, it is indispensably necessary to sub- 
ject the patient to strict dietetic regulations. This, indeed, is often all that 
is necessary to effect a cure. But the same diet is not applicable to all con- 
ditions of the disease. It is necessary, in regulating it, to have reference to 
the stage and degree of the inflammation, and the state of the system. It 
must be borne in mind, that the organ inflamed is that through which the 
system is nourished, and that, although it might be desirable in reference to 
the organ alone to restrict the diet most rigidly, yet the general debility may 
be such as to present still stronger claims to observance. Besides, the sto- 
mach itself may be injured by extreme abstinence, where the system is call- 
ing for support. Such are the sympathies of this viscus with the remainder 
of the body, that the suffering arising from deficient nutriment in every part 
is reflected upon it with especial force, and the stomach may thus be irritated 
in the midst of starvation. In this state of sympathetic suffering, its secre- 
tions are deranged, and themselves become an additional source of irritation. 
Hence, there is sometimes danger from that extreme abstinence upon which 
some authors have insisted; and patients have rapidly improved under a 
nutritious diet, after a long and fruitless abstemiousness. No precise rule 
can be laid down for all circumstances, except that in every case the food 
allowed should be of the kind most easily digested; as indigestible food, 
whether highly nutritious or otherwise, acts as a powerful irritant to the sto- 
mach. When the inflammation borders on the acute, and a slight febrile 
action exists, with a loss of appetite, farinaceous or mucilaginous liquids, such 
as solutions of tapioca, sago, arrow-root, and gum Arabic, and decoction of 
barley, should be exclusively used. If the disease be quite chronic, and with- 
out fever on the one hand, or debility on the other, a more nutritious diet 
maybe used, consisting of stale bread, crackers, boiled rice, mush, and gruels; 
care being always taken that the solid substances should be thoroughly masti- 
cated. In cases of general debility, the diet may be improved by the addi- 
tion of milk or fresh cream. In some instances, great advantage will accrue 
from restricting the patient to milk exclusively. This is especially useful in 
the cases attended with obstinate vomiting. The milk may, under such cir- 
cumstances, be usefully mixed with one-third, or one-half, or an equal bulk 
of lime-water. I have found few means so effectual in relieving this exceed- 
ingly unpleasant form of chronic gastritis, as the exclusive use of such a diet. 
Patients who for weeks and months have scarcely been able to retain a meal, 
and who have been reduced to the lowest state of emaciation, have expe- 
rienced an almost immediate change for the better under this treatment. As 
the symptoms improve, bread or crackers may be used with the milk and 
lime-water, and the latter ingredient may be gradually omitted. When the CLASS III.] 
CHRONIC INFLAMMATION OF THE STOMACH. 
517 
debility is considerable, a more nutritious animal diet sometimes becomes 
necessary. Oysters raw or roasted, soft boiled eggs, animal jellies, the white 
flesh of poultry and wild fowl, mutton, venison, &c., may be used; the caution 
being always observed to select only those meats which are easily digested. 
Boiled meats will also in general be preferable to those cooked in other modes. 
Of course, the diet will be varied in the same case according to the indica- 
tions; and it will generally be proper, after persevering for a considerable 
time with a rigid antiphlogistic regimen, to allow a gradual improvement, as 
the patient is found to bear it. Attention should always be paid to the calls 
of the stomach; and, when the patient perseveringly demands certain articles 
of food, even though they may seem improper, the physician will often do 
well to allow their use, cautiously at first, and afterwards freely, should they 
be found, as they often will be, to agree well with the stomach. 
Alcoholic drinks should in all cases be scrupulously avoided; except when 
the habitual and intemperate use of them may render a cautious withdrawal 
of them advisable. Coffee and tea should also be avoided; at least, only 
black tea should be allowed, and that weak. The patient may drink infusion 
of cocoa, or sweetened milk and water at breakfast and tea. On the whole, 
however, cold water is the best beverage. Whatever drink may be allowed, 
it should be taken in moderate quantities at a time, so as not to distend the 
stomach. 
By the means above mentioned, without the aid of medicines, cures may 
often be effected; but it is necessary to persevere long, and to guard the 
patient a^inst any premature relaxation of the dietetic plan. A single 
debauch, or indulgence for a short time in forbidden food, may undo the 
work of months. 
Other remedies, however, will often prove useful as adjuvants. Should 
the local symptoms be severe and the pulse strong, blood may sometimes be 
taken from the arm with advantage; but general bleeding is very rarely re- 
quired. Perhaps the most effectual measure, next to a proper regulation of 
the diet, is local bleeding from the epigastrium by leeches or cups. Leeches 
are generally preferred; as the pressure of the cups may prove hurtful to the 
stomach. It is usually better to take a small quantity of blood, and to repeat 
the operation occasionally, than to exhaust the patient by large numbers of 
leeches at once. Revulsion by means of small blisters on the epigastrium, 
frequently repeated, or of croton oil or tartar-emetic applied so as to pustulate, 
is often highly useful. Should the tartar-emetic, however, sicken the stomach, 
as it sometimes appears to do when externally applied, it should be omitted. 
Costiveness must be obviated by means of laxatives, or cathartic enemata, or 
both combined. The free use of medicines of any kind by the stomach is 
injurious; but enemata are of themselves scarcely sufficient to meet the indi- 
cation to evacuate the upper as well as the lower bowels. The gentlest laxa- 
tives should be selected and sparingly used. Magnesia is one of the best, as 
it answers the purpose of an antacid, which is often wanted. Rhubarb, 
castor oil, and the Seidlitz powder may also be employed. The same end 
may often be advantageously accomplished by a laxative diet of bran bread, 
or rye mush, or of stewed fruits when these are found not to irritate the sto- 
mach. Attention should be paid to the skin. Frictions with the flesh-brush, 
the warm or hot bath, according to the degree of excitement, and flannel 
next the skin are all useful. Opium and ipecacuanha at bed-time sometimes 
answer a good purpose, by producing perspiration, as well as by enabling the 
patient to sleep. When there is great local suffering with general restlessness, 
small doses of the acetate or sulphate of morphia may be given occasionally 
with advantage; but care is always requisite to avoid establishing an injurious 518 
LOCAL DISEASES. 
[PART II. 
habit, which the patient may have difficulty in breaking. Hydrocyanic acid 
has been recommended under the same circumstances. The feet should be 
kept warm, if necessary, by rubefacient applications. Congestion of the 
portal circle, visceral disease, whether functional or organic, and, in the fe- 
male, disorder of the menstrual function, should be relieved by appropriate 
remedies; regard being always had to the probability of injuring the stomach 
by irritating medicines. 
When the measures above detailed do not answer, especially when there is 
reason to suspect the existence of ulcers, recourse may be had to the altera- 
tive remedies, which prove so useful as local applications in similar affections 
of the mouth and fauces. Sub-nitrate of bismuth, the sulphates of iron, 
zinc, and copper, and the nitrate and oxide of silver, have all been usefully 
employed. The nitrate of silver has recently attracted considerable atten- 
tion, and has been given in larger doses than were formerly thought advisa- 
ble. From one-quarter of a grain to a grain is often administered two or 
three times a day without disadvantage. Cures, in apparently desperate 
cases, are sometimes obtained by nitrate of silver thus employed. I have 
repeatedly seen patients rescued by this remedy, for whom all other hope had 
been abandoned. It has appeared to me to be peculiarly advantageous in 
those cases, frequently attended with vomiting, in which the tongue is smooth 
and glossy, as if deprived of the papillary structure. I cannot too strongly 
express my conviction of its great usefulness in chronic gastritis of this charac- 
ter. It is generally advisable to combine the metallic salts with small doses 
of opium, or one of the salts of morphia. Minute doses of me^purial pill, 
with or without ipecacuanha, according as the stomach will or will not tolerate 
the latter medicine, are also highly useful. A grain of the mercurial pill 
(blue mass), with a sixth of a grain of ipecacuanha, may be repeated every 
two or three hours through the day, until the gums are very slightly touched. 
Tonics in the advanced stages are sometimes useful, probably by giving to 
the vessels relaxed by the previous inflammation sufficient energy to take on 
a healthy action, and resume their ordinary functions. The chalybeates and 
simple bitters should be preferred. Oil of turpentine and copaiba have also 
been recommended. 
In gastrorrhoea, which is often rather a condition consequent upon pre- 
vious inflammation than itself inflammatory, the treatment by the mineral 
alteratives above mentioned, and by tonics, is peculiarly applicable. Should 
symptoms of inflammation exist, they should be combatted in the ordinary 
manner. Should they be absent, the treatment may be commenced by an 
emetic of ipecacuanha followed by a calomel purge; and the bowels should 
afterwards be kept open by preparations of rhubarb or aloes, or a combina- 
tion of the two. The vegetable bitters, chalybeates, and mineral acids may 
be used; but most confidence is generally placed in the sub-nitrate of bis- 
muth and nitrate of silver, the latter remedy being given in the dose of half 
a grain or a grain twice a day. Opium or some one of its preparations 
may be combined with the mineral salts, to relieve pain and check secre- 
tion. Copaiba and the turpentines, or their volatile oil, may be given with 
a view to their alterative action on the mucous membrane. These also may 
be usefully combined with opiates. The diet should in general be nutritious 
and digestible, consisting chiefly of farinaceous substances and animal food. 
During the course of the treatment, in every form of chronic gastritis, 
efforts should be constantly made to prevent the mind from reacting inju- 
riously on the stomach, and at the same time to remove excitement from 
this organ by diffusing it equably over the whole system. Hence the im- 
portance of regular though not violent exercise, of relaxation from the cares CLASS III.] 
CANCER OF THE STOMACH. 
519 
and anxieties of business, and of agreeable mental occupation. A complete 
change of scene often proves serviceable. Excursions to different parts of 
the country, visits to the springs and to the sea-shore, sea voyages, and a 
residence or travelling abroad, often prove effectual, when much move- 
ment is not contra-indicated, in bringing about a cure, or confirming convar 
lescence. 
Article IL 
CANCER OF THE STOMACH. 
Under this head are included those scirrhous, encephaloid, and ulcera- 
tive affections of the stomach, which, in all their stages, and under every 
variety of treatment, have a fatal tendency. There is little doubt that the 
mere results of chronic inflammation, neglected or abused, have often been 
mistaken for cancer; and there are also cases in which it would be difficult or 
impossible to determine, even upon an inspection of the diseased parts, to 
which of these complaints they should be referred. But, notwithstanding 
the opinion of some pathologists, that all the cases usually called cancer of 
the stomach are in fact nothing more than examples of chronic inflammation, 
the belief is general, and as appears to me well grounded, that genuine 
scirrhus and genuine medullary fungus, may attack the stomach as well as 
other organs, and that, wherever they occur, they are entirely distinct from 
common inflammation, and constitute diseases sui generis, distinguished 
among other characters by their inevitable tendency, when in action, towards 
a fatal result. 
Symptoms and Diagnosis.-The symptoms of cancer of the stomach are 
so nearly those of chronic inflammation, that it is often impossible to distin- 
guish the two complaints during life. It is unnecessary, therefore, to notice 
any other characters of the disease than those to which some value has been 
attached in reference to diagnosis. 
The pain, which is almost always experienced, in a greater or less degree, 
and is sometimes excruciating, varies very much in its character. Lancinat- 
ing pains have been thought to be diagnostic of cancer in the stomach, as of 
the same complaint elsewhere; but the fact has been well ascertained,- that 
such pains occur occasionally in chronic gastritis, and are by no means pre- 
sent in all cases of cancer. 
Vomiting is a very common, and very distressing symptom; but is some- 
times wanting; and, in many instances, is unfrequent at the commencement. 
At first, the patient discharges his food or a glairy mucus; afterwards, toge- 
ther with these, sour, bitter, or acrid fluids; and, in the end, not unfrequently, 
blood, or a black matter which has been compared to soot and water, or to 
coffee-grounds. This black vomit, which has been looked on as characteristic, 
is, in fact, common to cancer and chronic gastritis. But, though not a cer- 
tain sign, the character of the vomiting assists in forming a precise diagnosis, 
and sometimes points to the seat of the disease. Thus, when the food is re- 
jected after it has been swallowed, and before it has entered the stomach, or 
when, after entering the stomach, it is retained, but quickly occasions excessive 
nausea and the discharge of a glairy mucus, there is reason to suppose that 
the cardiac orifice may be affected. If the stomach reject almost everything 
which it receives, after having retained it for some time, the probability is 
that the pylorus is in a scirrhous state, and resists the passage of the chyme. 520 
LOCAL DISEASES. 
[PART II. 
When, after frequent vomiting, the patient ceases to be troubled in this way, 
but is seized with a severe and exhausting diarrhoea, it may be inferred that 
the mucous membrane at the pylorus has been destroyed by ulceration, and 
thus opened a wider passage. Generally speaking, when the mucous coat 
has become disorganized, there is less vomiting, as the sensibilities through 
which this action is excited reside chiefly in that membrane. The bowels 
are usually obstinately constipated, though diarrhoea sometimes occurs towards 
the close. 
The cachectic countenance of cancerous patients is one of the most charac- 
teristic symptoms. The complexion has a peculiar yellowish-white, waxen 
appearance, which is not often met with in other complaints. 
But the most certain diagnostic symptom is a tumour in the epigastrium. 
This is discovered at various periods in the progress of the complaint, and of 
course is obvious in proportion to the emaciation. It is most readily per- 
ceivable when in the pylorus, or great curvature of the stomach. Sometimes, 
however, the absorbent glands in the vicinity of the stomach are much swol- 
len, and other tumours in the same neighbourhood may be mistaken for 
scirrhus. But, when the tumour is associated with the other symptoms above 
mentioned, there can be little doubt of its carcinomatous character. 
The progress of cancer of the stomach, and its duration, are very variable. 
Sometimes the complaint runs its course in a few months, sometimes continues 
for many years. Occasionally it appears to be latent for a long time, and then 
to start at once into vigorous action; and instances are not wanting, in which 
the symptoms have so much remitted as to give hope of cure, but have again 
returned with increased severity. Death usually occurs from the exhaustion 
of combined irritation and deficient nutrition, and is preceded in general by 
great emaciation, and a long and wearisome period of diversified suffering. It 
is sometimes hastened by ulcerative openings into the cavity of the abdomen, 
producing peritoneal inflammation. The tortures of hunger are added to the 
other sufferings, when the disease affects the cardia. 
Anatomical Characters.-The stomach is sometimes much contracted, with 
thickened coats, and sometimes greatly enlarged. The latter is apt to be the 
case when the pylorus is diseased. The interior surface is usually covered 
with a brown mucus. The cancerous disease may occupy the whole stomach, 
or any part of it; but is most frequent at the two orifices, and especially at 
the pyloric. It is sometimes limited by these orifices, and sometimes extends 
beyond them into the oesophagus or duodenum. The appearances vary with 
the period at which the patient dies. When the tumour is not destroyed by 
ulceration, the inner coats of the stomach are found in general more or less 
confounded together, into a whitish, indurated, semi-cartilaginous mass, from 
two or three lines to several inches in thickness. The peritoneal coat is 
much less liable to be affected than the others, and often remains free from 
disease. The muscular, mucous, and intervening cellular coats may often be 
recognized in a state of greater or less alteration. Sometimes the disease is 
confined chiefly to the submucous cellular tissue, and sometimes to the mucous 
membrane itself. 
Instead of this thickening of the coats, the disease occasionally consists of 
a roundish mass or masses, projecting from the submucous tissue, or the 
mucous membrane, into the stomach. Instead of being indurated and white, 
the tumour is sometimes of a soft or medullary consistence, and red, as if 
injected with blood, resembling fungus haematodes. In another form of cancer 
described by Cruveilhier, the parietes of the stomach are thickened, and, instead 
of their usual structure, present numerous cells separated by fibrous partitions, 
and filled with a gelatinous deposit. CLASS III.] 
CANCER OF THE STOMACH. 
521 
In a more advanced state of the disease, ulcers are found with hard, elevated, 
and reverted edges, and a surface irregular with fungoid excrescences, and 
often exhibiting the open orifices of blood-vessels of considerable magnitude. 
They are found in different stages of their progress, showing a disposition to 
extend both in breadth and depth, and not unfrequently perforating the coats 
of the stomach. In this case, the peritoneal coat is often found to have con- 
tracted adhesions with the liver, spleen, pancreas, or other neighbouring organ, 
the substance of which is thus penetrated by the disease, and forms the basis 
of the cancerous ulcer. Sometimes the adhesion is formed with the colon or 
diaphragm, and the contents of the stomach thus escape into the bowels or 
lungs. Again, the ulcer is seen opening directly into the cavity of the abdo- 
men, which exhibits the marks of severe peritoneal inflammation. Cases are 
on record in which the carcinomatous affection has extended anteriorly to the 
abdominal parietes, or posteriorly to the spine, before the fatal issue. 
Causes.-Cancer in the stomach arises probably from the same causes as those 
which produce cancer elsewhere. What these causes are is uncertain. We 
must be content with ascribing the result to a peculiar predisposition of system 
or diathesis; but of the origin of this diathesis we know nothing. It is highly 
probable that whatever irritates or inflames the stomach may call the predis- 
position into action. It is certain that the disease is at least aggravated by 
such influences. The abuse of alcoholic liquors, excesses in eating, and the 
employment of tonic and stimulant medicines, which are often administered 
in the early stage of cancer of the stomach, under the impression that it is 
dyspepsia, hasten the progress of the complaint, and perhaps call it prema- 
turely into existence. The depressing emotions are thought to favour its 
production; and Napoleon, on the Island of St. Helena, may be cited as an 
example. 
The disease is exceedingly rare before puberty, and seldom occurs until 
after the twenty-fifth year. It is most common in middle life; but is not 
unfrequently met with in the old. Males are said to be more subject to it 
than females. 
Treatment.-This must be entirely palliative. All that can be expected is 
to protract life, and alleviate suffering. For this purpose, nothing is so im- 
portant as to regulate the diet properly. As a general rule, no stronger drink 
should be allowed than water, and spices and other condiments should be 
avoided. The food should be mild, easily digestible, and nutritious, so as not 
to stimulate the stomach cither by its quality or quantity. It may consist of 
the farinaceous substances, milk, cream, boiled meats, broths, oysters, &c. 
Nothing, on the whole, is so suitable as milk. Large quantities either of 
food or drink should not be taken at once. The bowels should be kept open 
by enemata, or by the mildest laxatives. Attention should be paid to the 
skin as in chronic gastritis. Acidity may be corrected by the bicarbonate of 
soda or of potassa, or by lime-water with milk as food. A few leeches occa- 
sionally applied to the epigastrium, and revulsion towards the same place by 
means of rubefacients or epispastics, will sometimes prove useful by diminish- 
ing inflammation. To relieve the pain or local distress, to quiet irritation, 
and promote sleep, it is necessary to resort to anodynes; and the preparations 
of opium are the most effectual. The salts of morphia, or the black drop, 
are probably the best of these for the purpose. The extracts of hemlock and 
henbane, and lactucarium may be used as adjuvants of opium, or as substi- 
tutes. Sometimes it is best to administer opium or laudanum by enema, or 
to sprinkle acetate of morphia, in powder, upon a raw blistered surface in the 
epigastrium. 522 
LOCAL DISEASES. 
[part II. 
Urticle HL 
IRRITATION OF STOMACH. 
By this term is meant any morbid excitement of the stomach, not amount- 
ing to inflammation. Instances of disorder of this kind are exceedingly com- 
mon, although not usually associated by writers under this name, and often 
too much neglected in practical treatises. Though seldom in itself dangerous, 
irritation of stomach is in many of its forms very distressing to the patient, 
and, if not arrested, very often terminates in gastritis, either chronic or acute. 
It presents itself in a variety of forms, dependent on the tissue or function 
affected, the nature of the cause, and the previous condition of the stomach 
or the system. It sometimes affects the capillaries especially, sometimes the 
nerves exclusively, and often both at the same time. Though most frequently 
merely the antecedent of inflammation of the stomach, and very often only a 
secondary or attendant affection of other diseases, it yet has in numerous 
instances an independent existence, and therefore requires an independent 
consideration. I shall treat of its different forms first in relation to the 
causes, and secondly in relation to the phenomena. This will necessarily 
lead to repetition, but is necessary to a satisfactory view of the subject. 
1. In Relation to its Causes. 
Irritation from Congestion of the Portal Veins.-From a slug- 
gish state of the portal capillaries of the liver, or from other causes, the blood 
frequently accumulates in the veins which supply the vena portarum, and 
consequently in the capillaries of the stomach, which are excited into morbid 
action by the unusual amount of stimulus. The affection is attended with a 
sense of fulness, weight, or uneasiness in the epigastrium, sometimes amount- 
ing to pain. The appetite is somewhat impaired, the tongue often slightly 
furred near the root, the stools scanty, or light coloured from deficiency of 
bile, the complexion sometimes sallow, and the mind irritable or depressed, 
and disposed to view everything in a gloomy light. The condition is one of 
those to which the name of bilious complaint is often vaguely applied. It is 
a frequent antecedent to bilious fevers, cholera morbus, jaundice, and vomit- 
ing of blood; and there is reason to believe that some of these diseases might 
often be prevented by its timely treatment. It occurs most commonly at the 
commencement, or during the prevalence of hot weather, but is found at all 
seasons. A full dose of the compound cathartic pill, or qther active purgative 
combination containing calomel, or the mercurial pill, with a farinaceous diet 
for a day or two, will frequently remove the complaint, Should the hepatic 
secretion not be sufficiently restored in this way, a mercurial pill, or a grain 
of calomel may be given at night, and followed by a mild laxative in the 
morning, and this plan continued every day, or every other day, until the 
passages indicate that the liver is acting freely. Very frequently this altera- 
tive treatment will be sufficient, without the antecedent use of a brisk cathartic. 
Irritation from the Gastric Contents.-The cases are very nume- 
rous, in which the excitement of stomach produced by irritating substances 
contained in it, though so slight or brief as not to be entitled to the name of 
inflammation, is yet sufficiently beyond the line of health to call for the notice 
of the physician. The symptoms, in such cases, are exceedingly diversified. 
The patient generally experiences more or less epigastric uneasiness, which is CLASS III.] 
IRRITATIOX OF STOMACH. 
523 
of a variable character, sometimes not exceeding a morbid feeling of heat, or 
a slight gnawing sensation, sometimes amounting to burning pain, or cardi- 
algia, and occasionally gastralgic or spasmodic. Some of the most violent 
cases of spasm of the stomach that I have witnessed, have arisen from the 
presence of indigestible food. This uneasiness is frequently associated with 
nausea, and occasional but ineffectual efforts to vomit, or with eructations of 
fetid, sour, acrid, or bitter fluid, according to the nature of the cause. The 
pulse is generally slow, sometimes more feeble than in health, the skin often 
cool, and the tongue either unaltered, or slightly furred towards the root, or 
covered with a clammy mucus. Among the sympathetic affections are often 
supra-orbital headache, pains in the loins and extremities, general malaise, 
chilliness, urticaria or other cutaneous eruption, and sometimes a loss of sense 
and motion as in apoplexy. In children and delicate females, the nervous 
disorder amounts sometimes to convulsions. When the sympathetic affection 
is considerable, the gastric symptoms are usually masked, and wrong infer- 
ences may be drawn. Under these circumstances, the existence of nausea, or 
some tenderness on pressure in the epigastrium, will often indicate the real 
seat of the disease. After a variable period, either full vomiting takes place, 
or the contents of the stomach pass downward through the pylorus; and, in 
both cases, prompt relief is obtained. Occasionally, however, when the irri- 
tation has been considerable and protracted, the depression following the 
excitement is so great as to incapacitate the stomach, for one or two days or 
more, for the proper performance of its functions. Should the cause continue 
to act, inflammation becomes established. 
Excess in drinking or eating; indigestible food; substances which from 
idiosyncrasy disagree with the patient; acrid medicines and poisons; the pro- 
ducts of acid fermentation, or other chemical change in the food after it has 
been swallowed; excess of acid in the gastric liquors, and other acrid secre- 
tions of the stomach; bile which has ascended from the duodenum; worms in 
the stomach; such are the most frequent agents in the production of this 
variety of gastric irritation. There is some little difference in the operation 
of these causes. Thus, indigestible food is most apt to produce spasm of the 
stomach, acid or other acrid matters to occasion cardialgia, and excess of bile 
probably to provoke vomiting. The results may take place in a stomach 
otherwise healthy, if the cause be sufficiently intense; but, when the irritation 
proceeds from substances used as food, it is most easily induced by eating 
heartily when the stomach is temporarily debilitated, as after violent exercise, 
by which nervous energy is diverted from the viscera to the muscles. The 
character of the offending agent may often be known by the taste or colour 
of the matter discharged by eructation. Worms are often indicated by a 
sense of choking, and frequent ineffectual efforts to vomit, as if there were 
some foreign body in the oesophagus. 
Treatment.-This is very simple. In mild cases, abstinence or the use of 
a very restricted diet for a day or two will be sufficient. In severer cases, the 
most effectual remedy is an emetic. When the patient is disposed to vomit, 
large draughts of warm water, or of warm chamomile tea, will often be suffi- 
cient to evacuate the stomach. I have seen the most violent stomachic spasm, 
which had resisted powerful anodynes and nervous stimulants, give way im- 
mediately after vomiting produced by a copious draught of warm molasses 
and water. When an emetic is necessary, ipecacuanha should be preferred, 
and its administration accompanied with free dilution. Large draughts of 
warm water sometimes prove useful without emesis, probably in part by dilut- 
ing the acrid contents of the stomach, in part by promoting the peristaltic 
motion downward by means of the distension they occasion. After the 524 
LOCAL DISEASES. 
[part II. 
evacuation of the stomach, an aperient may often be advantageously given; 
such as magnesia, one of the saline cathartics, especially the Seidlitz powder, 
castor oil, infusion of rhubarb, &c. If the cause of irritation be an acid matter, 
the antacids may be resorted to originally. Magnesia is the most efficient; 
but the carbonates and bicarbonates of soda and of potassa, and, in cases of 
enfeebled stomach, some one of the preparations of ammonia, particularly the 
aromatic spirit, may be used. The remedies applicable in the case of worms 
will be mentioned, when the effects of these parasites are treated of. Should 
spasm continue after the removal of the cause, it must be treated as hereafter 
indicated, by anodynes, nervous stimulants, and revulsives to the epigastrium. 
Irritation from Gout and Rheumatism.-These diseases affecting 
the stomach sometimes produce inflammation, but more frequently irritation 
merely, which may be seated in the mucous membrane, or in the muscular 
coat. In the former case, it is attended with a vague uneasiness in the epi- 
gastrium, and all the other symptoms which characterize dyspepsia, so that it 
would be difficult to distinguish the affections except by reference to the mode 
of onset and of relief, which in gout and rheumatism are often sudden, being 
consequent the one upon a retrocession of the disease from some other part 
to the stomach, the other upon its transfer again to the original seat, or else- 
where. Even when the gouty or rheumatic seizure occurs primarily in the 
stomach, it may generally be recognized by its disposition to alternate with 
pains in other parts. When the affection is seated in the muscular coat, it 
generally produces spasms, which in some cases are exceedingly violent. 
The remedies especially applicable to the gouty or rheumatic disease have 
been treated of elsewhere. It is sufficient here to say that, when the gastric 
symptoms are urgent, revulsion towards the extremities should be effected by 
sinapisms oi* hot and stimulating pediluvia, and the local symptoms relieved 
by anodynes, given either by the mouth or by the rectum, according as the 
stomach is retentive or otherwise. When the affection is purely spasmodic, 
nervous stimulants may be conjoined with the anodyne. Emollient and ano- 
dyne applications to the epigastrium may also be used, but by far the most 
efficient external remedy is a sinapism of pure mustard immediately over the 
stomach, kept on for half an hour or an hour, or as long as the patient can 
well support it. 
Irritation from Spinal Disorder, &c.-G-astric irritation arising 
from functional or organic disorder in the spinal marrow, semilunar ganglions, 
or other sources of nervous supply to the stomach, is a very common affec- 
tion, especially in females, and is often very injuriously confounded with dys- 
pepsia. It is attended, in different cases, by almost every variety of symp- 
tom by which the stomach is capable of expressing its suffering. All kinds 
of pain mentioned under chronic gastritis are occasionally experienced, from 
the vague distressing uneasiness of epigastrium so common in dyspepsia, up 
to violent spasm. The uneasiness referred to is sometimes more intole- 
rable than acute pain, and is occasionally attended with great restlessness, 
mental dejection, and even with convulsions. In some cases, the most pro- 
minent symptom is vomiting, which is incessant and excessive, so that the 
patient can retain scarcely anything upon the stomach. The tongue is gene- 
rally clean, or but slightly furred, and the appetite very variable, being in 
some cases wholly wanting, and in others unimpaired. Occasionally slight 
febrile symptoms appear. The duration is altogether uncertain, sometimes 
for a few hours only, sometimes for days, weeks, and even months or years. 
It is obvious that those cases must be the most obstinate, which depend on 
organic disease of the spine. Such cases are easily recognized. So also 
are those in which the spine is painful on being pressed, in the region CLASS III.] 
IRRITATION OF STOMACH.-CARDIALGM. 
525 
opposite to the stomach. The most obscure cases are those in which the 
ganglia or nervous plexuses are the source of the mischief. These must 
always be more or less conjectural. It is always important, in doubtful gas- 
tric affections, to make pressure on the spinous processes of the vertebrae; 
as very often a seat will thus be discovered for the effectual application of 
remedies. 
Treatment.-This must be directed especially to the spine. It will be 
vain, as a general rule, to address remedies to the stomach. Temporary re- 
lief may be obtained from anodynes, especially, according to M. Barbier, 
from the preparations of codeia, when the solar plexus is the source of irrita- 
tion. But the symptoms return with undiminished force upon the suspension 
of the medicine. The most effectual remedy is leeching or cupping upon the 
spine, at the point where tenderness is discovered upon pressure. Almost 
instant relief is sometimes obtained in this way. It is often, however, neces- 
sary to repeat the local bleeding, and, in some cases, several times before a 
cure is accomplished. When the complaint does not yield to this remedy, 
blisters may be applied over the spine at the spot affected; and, in cases of a 
chronic character, pustulation by croton oil or tartar emetic, sustained for a 
considerable time, will be found very useful. In very obstinate cases, setons, 
issues, or moxa may become advisable. The diet should consist chiefly of 
farinaceous substances, as stale bread, crackers, boiled rice, gruels, &c., in 
acute cases; but, when the appetite is unimpaired, the light and most digesti- 
ble kinds of animal food may be employed. The bowels must be kept regu- 
larly open by mild aperients or enemata. 
Irritation from Sympathy.-Such is the connexion between the sto- 
mach and other parts of the system, that it suffers more or less with almost 
every severe disease wherever it may be seated. Thus, it- is one of the first 
organs to participate in that general movement denominated fever, no matter 
what may be the origin of the affection. A violent injury in any part of the 
body is not unfrequently attended with nausea and vomiting. But the organs 
with which the stomach appears to have the closest connexion, are the brain, 
the abdominal viscera, and the parts concerned in the reproductive function, 
especially the uterus. Of the phenomena, however, which arise through 
sympathy with these organs, as well as of the requisite mode of treatment, 
it is unnecessary to speak here; as they will be fully considered under other 
heads. 
It is necessary to consider gastric irritation also in the varieties afforded by 
its varying phenomena. These frequently occur separately, or in distinct 
groups, having the aspect of distinct diseases, and as such are sometimes 
treated of by authors. It is true that they are often variously mingled to- 
gether, and that they not unfrequently occur merely as symptoms of other 
diseases; but, as they also frequently appear more or less isolated, and are 
the most striking object to the eye of the practitioner, it is advisable to give 
them a separate consideration. 
Cardialgia.-This term is often confounded with gastrodynia and gas- 
tralgia, and, from its origin and a%yo$), would appear to signify 
nothing more than pain about the cardiac orifice. But it is also frequently 
used as synonymous with heartburn; and it will be found convenient to 
restrict its application to that painful feeling of heat or burning, which so 
often attends inflammation or irritation of the gastric mucous membrane. 
This sensation may, indeed, be considered as characteristic of inflammation 
or vascular irritation of the stomach, in contradistinction to mere nervous irrv 
2. In relation to the Phenomena. 526 
LOCAL DISEASES. 
[part II. 
tation. It is a very common attendant upon the presence of acrid matters in 
the stomach, and has been looked upon almost as diagnostic of acidity. It is 
to be relieved, of course, by the remedies calculated to cure the pathological 
condition of which it is a symptom. 
Gastralgia.- Gastrodynia.-These terms, as their origin indicates, sim- 
ply imply pain in the stomach. I employ them to express pure or simple 
pain, without those complications of morbid sensation which so often occur in 
stomachic affections. This is not unfrequently present in gastritis, whether 
acute or chronic; but it is also very often purely nervous, without any appre- 
ciable vascular disease; in other words, is a true neuralgia of the stomach. In 
this light I now propose to consider it. 
Causes.-G-astralgia may proceed from disease of the spinal marrow or 
sympathetic nerve, from gout or rheumatism affecting the stomach, or from 
certain not very accurately defined conditions of the system, which constitute 
a predisposition to neuralgia in general. It not unfrequently occurs in the 
convalescence from acute diseases, and in debility from other causes, such as 
meagre diet, impaired digestion, profuse evacuations, and especially the loss 
of blood. Anemic and hysterical females are very subject to it. Anxiety of 
mind, and the habitual influence of strong and contending emotions, frequently 
act as predisposing causes. When the predisposition exists, the slightest 
cause is sufficient to bring on an attack of the pain. Any disturbing emotion, 
any local affection which may react sympathetically on the stomach, even the 
mildest articles of food or of drink, are capable of inducing a paroxysm. 
Diagnosis.-The only affection with which pure gastralgia is liable to be 
confounded is inflammation of the stomach. It wants the febrile symptoms, 
the great prostration, the nausea and vomiting, and the steady course which 
mark acute gastritis, for which, therefore, it can scarcely be mistaken. From 
the chronic form of the disease it is not always so easily distinguished; the 
symptoms in the latter being so variable, that it is impossible to institute a 
precise comparison applicable to all cases. No one symptom in the following 
catalogue can be considered as uniformly diagnostic; but the whole, taken 
together, will lead almost always to a correct conclusion. 
The pain in gastralgia is usually severe, uncomplicated, and often capricious, 
occurring irregularly, and sometimes leaving the patient altogether for a time. 
Instead of being increased, it is often relieved by pressure, though this is not 
invariably the case. In chronic gastritis, it is usually dull, often complicated 
with burning or other disordered sensation, more steady, seldom being entirely 
wanting, and almost always aggravated by pressure in the epigastrium. In 
the former affection, the appetite, though variable, is often undiminished, vomit- 
ing and excessive thirst unusual, and digestion frequently as vigorous as in 
health; in the latter, the appetite usually suffers, nausea and vomiting are 
not uncommon, the patient is apt to be annoyed with thirst, and digestion is 
almost always impaired. The tongue in gastralgia is not unfrequently healthy, 
the skin cool, and the pulse quite undisturbed; while, in chronic gastritis, 
though the same condition of these parts may sometimes exist, the contrary 
is more frequently the case. The neuralgic affection may be attended with 
various sympathetic nervous disturbances, such as dyspnoea, palpitation, rest- 
lessness, morbid vigilance, &c.; but wants the extreme emaciation, and hectic 
symptoms which mark the advanced stage of the inflammation. The spirits 
in both are usually depressed, but in gastralgia are more variable, being ex- 
cessively low during the paroxysms, and again bright and cheerful when the 
pain remits or retires. Hot and stimulating drinks, in general, aggravate 
chronic gastritis, while they often relieve gastralgia. In both, constipation 
is an almost constant attendant, unless the case is complicated with chronic CLASS III.] 
IRRITATION OF STOMACH.-GASTRALGIA. 
527 
enteritis, which is much more likely to happen in the inflammatory than in 
the nervous affection. Not unfrequently the two affections are combined in 
the same case, and the diagnosis thus obscured. In doubtful cases, it is safest 
to treat the disease as chronic inflammation, and, if the measures employed 
fail, then to address our remedies to the neuralgic condition. 
Treatment.-The most urgent indication, in severe cases, is for immediate 
relief from pain. For this purpose, anodynes must be used internally, and a 
strong impression made upon the epigastrium by rubefacient or epispastic appli- 
cations. Opium, or some one of its preparations, is the most efficient anodyne; 
but other narcotics, as hyoscyamus, stramonium, belladonna, extract of hemp, 
and lactucarium, separate or combined, may often be advantageously resorted to, 
especially when it is necessary to sustain a constant impression for a consider- 
able time. Hydrocyanic acid has also been highly recommended; and it is 
probable that the smoking of tobacco might sometimes prove beneficial. Where 
a sudden, but fugitive.external impression is desired, a sinapism should be 
applied over the stomach; when the impression is to be more permanent, a 
blister of Spanish flies. Both indications may be met by the use of strong 
solution of ammonia. Advantage will sometimes be found in sprinkling 
the acetate or sulphate of morphia over the blistered surface, deprived of the 
cuticle. t . •. ; . . i 4 . 
A second indication is to change that condition, whether of the stomach or 
of the system, upon which the predisposition to the disease depends. When 
the gastralgia is associated with debility, as in convalescence from febrile dis- 
eases, this object may often be effected by the use of tonics. I have seen the 
affection speedily give way to the pure vegetable bitters, or to quinia. The 
former may be given in infusion with aromatics, and a little senna or rhubarb. 
The latter is an almost certain remedy when the disease is regularly intermit- 
tent. In anemic cases the chalybeates are preferable. The alterative mineral 
tonics have enjoyed great reputation in the disease. Nitrate of silver was 
recommended by Dr. James Johnson: but subnitrate of bismuth has been 
more employed. The latter preparation should be given in the dose of from 
three to five grains three times a-day. All these remedies may be advan- 
tageously combined with opium or the narcotic extracts. It should always 
be ascertained whether the disease is connected with spinal irritation, and if 
so, the remedies should be applied accordingly. (Seepage 525.) If it be of 
rheumatic or gouty origin, in addition to other measures, stimulant applica- 
tions should be made to the extremities. To meet this same indication, all 
those means should be employed which are requisite for confirming the general 
health, such as exercise in the open air, sleeping in well ventilated apartments, 
and in summer upon mattrasses instead of feather beds, relaxation from the 
anxieties and fatigues of business, and cheerful society and agreeable recreation 
when attainable. Great advantage will often accrue from visits to the water- 
ing-places, a sea-voyage, or a protracted journey or residence abroad. Sea- 
bathing, or the occasional use of the shower-bath, may be added to the other 
measures. 
In order to avoid occasional sources of irritation, the diet should be care- 
fully regulated. The rules which will be given hereafter, under the head of 
dyspepsia, are applicable in the present case. Advantage is sometimes ex- 
perienced from stimulating drinks, as a little brandy and water during meals; 
but the moral hazard is, on the whole, greater than any probable physical 
benefit. 
Pyrosis.- Waterbrash.-The term pyrosis has been differently employed, 
sometimes to signify merely a burning pain in the epigastric region, some- 
times as the title of a peculiar affection usually called waterbrash. I follow 528 
LOCAL DISEASES. 
[part II. 
the example of Cullen, whose authority has almost fixed the meaning of the 
words among English and American physicians, in using the term cardialgia 
for the former purpose, and pyrosis exclusively for the latter; although it 
must be confessed, that this application of the words is not supported by their 
derivation. Cullen's description of the disorder now under consideration has 
scarcely been improved by subsequent writers. 
Pyrosis usually occurs in paroxysms. It commences with a sense of con- 
striction and pain at the pit of the stomach, which is increased by an attempt 
to assume the erect posture, and thus causes the patient to lean forward. 
The pain is often very severe, and is sometimes attended with a burning sen- 
sation.. After a while, the patient discharges by eructation considerable 
quantities of a thin watery fluid, which is generally quite tasteless, though 
sometimes, probably from accidental causes, sour or acrid. Under this dis- 
charge, the pain gradually lessens, and ultimately ceases altogether. The 
fluid is not usually thrown off at once, but by repeated eructations, which 
continue for a considerable time. The attacks most commonly occur in the 
morning or forenoon, when the stomach is empty, but often also at other 
periods. When they have once occurred, they are apt to be repeated at vary- 
ing intervals for a great length of time. In the intervals, the patient is often 
exempt from dyspeptic or other morbid gastric symptoms, thus proving that 
the affection is not essentially dependent upon dyspepsia, or chronic inflam- 
mation of the stomach, although it may be associated with those diseases. 
Causes.-The causes of pyrosis are not well understood. It occurs most 
frequently among those who are meagerly fed, and at the same time indulge 
in spirituous liquors. Hence, it is said to be common in Scotland and Ire- 
land, where the lower classes live chiefly on oatmeal and potatoes, and have 
been in the habit of using whisky freely. Linnaeus mentions that it is preva- 
lent in Lapland. But it is confined to no class, nor to any particular mode 
of life. It seldom, however, occurs before the age of puberty, or in old peo- 
ple. According to Cullen, its attacks may be brought on by cold applied to 
the lower extremities, or by any considerable emotion of the mind, but for 
the most part occur without any known exciting cause. 
Nature.-As to the nature of the affection, we may infer from the symp- 
toms that it is a combination of gastralgia with vascular irritation of the mu- 
cous membrane, occurring paroxysmally, and relieved at each attack by a 
copious elimination of fluid from the exhalent vessels of the stomach. The 
pain does not appear to be produced by the presence of the fluid, which is 
usually quite bland; but to be relieved by the production of the fluid. In 
this respect it differs entirely from cardialgia, in which the uneasiness is ex- 
cited by the irritating character of the contents of the stomach. The two 
affections, however, may co-exist, especially in dyspeptic cases; and in such 
we may have the burning pain, and acrid or sour discharges, along with the 
paroxysms of pyrosis. The complaint is confounded by some writers with 
gastrorrhoea, or catarrh of the stomach. But in the latter, the discharge is 
mucous, and proceeds probably from the mucous follicles, either inflamed, or 
in that relaxed condition which sometimes follows inflammation. 
Treatment.-The pain may be relieved by opiates or other narcotics, as in 
gastralgia, conjoined if necessary with revulsive applications to the epigas- 
trium. If the liquid discharged be sour, magnesia, bicarbonate of soda or 
potassa, or aromatic spirit of ammonia may be united with the anodyne. But 
this treatment is only palliative. The curative processes must be applied in 
the intervals. If chronic gastritis exist, the measures should first be directed 
to the cure of that affection. If there be no inflammation, the patient should 
be put upon the course of treatment, as respects medicine, regimen, and CLASS III.] 
IRRITATION OF STOMACH. 
529 
modes of life, applicable to dyspepsia. Some particular remedies, however, 
have been recommended as especially useful in this affection. Among these 
the most prominent is sub-nitrate of bismuth, given as directed under gastral- 
gia. Nitrate of silver may also be employed with prospect of advantage: 
Oxide and sulphate of zinc have been recommended. Linnaeus speaks favour- 
ably of nux vomica. This may be given in the dose of five" grains three 
times a day, or its active principle strychnia, in the dose of from a twelfth to 
a sixth of a grain. Much may be expected from sulphate of quinia freely 
administered, in cases entirely free from symptoms of inflammation. Dr. 
Caldwell states that he has known cures effected by the use of lime water and 
milk, with blisters to the epigastrium. (Notes to Cullen's First Lines. ') 
Spasm of the Stomach.- Cramp of the Stomach.-By these terms is 
meant any painful morbid contraction of the muscular coat of the stomach. 
The ordinary peristaltic movement may become painful, in consequence of an 
inflamed or highly sensitive state of the muscular fibre, or of the parts moved 
by its contractions. In such cases, the affection is not spasmodic. Spasm of 
the involuntary muscles bears the same relation to their ordinary healthy 
contraction, that a similar affection of the voluntary muscles does to their 
voluntary movements. These are often painful without being spasmodic, as 
for example in rheumatism. To constitute spasm of the stomach, therefore, 
it is necessary that the:contraction should not only be painful, but unusual, 
either in degree or direction. This disorder is very analogous to gastralgia; 
but, in the latter, there is not necessarily any unusual movement of the sto- 
mach. The two conditions, however, often co-exist. 
Spasm of the stomach is characterized by a sense of pain and stricture or 
contraction in the epigastrium, occurring in paroxysms, with a remission or 
complete intermission of pain in the intervals. The stomach sometimes feels 
as if drawn towards the back, sometimes as if gathered into a ball. The pain 
varies somewhat in position, being diffused over' the epigastrium, or confined 
to a portion of it, according as the whole or a part of the stomach is affected. 
Sometimes it extends up into the breast, when the oesophagus participates in 
the spasm. During the paroxysm, the patient usually holds himself in a bent 
position. Nevertheless, the pain so far from being increased, is ordinarily 
somewhat relieved by pressure from without, although, after the subsidence 
of the spasm, the stomach is left sore and tender to external impression. 
This is an important fact, in reference to diagnosis. All violent spasmodic 
action is apt to be followed by a feeling of soreness or tenderness, as if the 
part had been severely pinched. Tenderness in the epigastrium, therefore, 
remaining after a paroxysm of gastric spasm, must not be considered as an 
evidence of inflammation. The pain is in various degrees, from a slight fugi- 
tive affection, which scarcely merits notice, up to the most violent of which the 
human frame is susceptible. Perhaps no physical agony is greater than that of 
the severest spasm of the stomach. Strong and determined men sometimes 
scream under its violence. In moderate cases, little sympathetic disturbance 
of any kind is experienced; the pulse and skin both remaining nearly in their 
ordinary state. But, when the spasm is violent, a shock is extended through 
the nervous centres to the whole system, somewhat analogous to that which 
results from a sudden and severe injury. The skin becomes cool and clammy, 
a cold sweat stands upon the brow, and the pulse is reduced in strength so as 
sometimes to become fluttering, or scarcely perceptible. Indeed the shock is 
occasionally fatal; the vital actions ceasing entirely, under the tremendous 
concentration of nervous energy in the stomach. Thus, death sometimes 
occurs from the effects of indigestible food, or of gout translated from some 
other organ to the stomach. Nausea and vomiting are not usual concomitants 530 
LOCAL DISEASES. 
[PART II. 
of spasm of the stomach, unless when the latter depends upon some offend- 
ing matter in the viscus. In such cases, the nausea is experienced between 
the paroxysms, being replaced during their continuance by the more violent 
sensation. In the act of vomiting, the stomach often contracts spasmodically, 
and occasions excruciating pain. 
Causes. - Whatever irritates the mucous coat may throw the muscular 
sympathetically into spasm, especially when there is a strong predisposition 
to that affection. Hence, it is .frequently caused by indigestible food, such as 
boiled cabbage, cucumbers, lobsters, &c. ; by substances which disagrep with 
the stomach in consequence of idiosyncrasy; and by irritating matters in the 
stomach, whether the result of alteration in the foocl or of secretion, as acid in 
excess, acrid gastric juice, and bile regurgitating from the duodenum. In all 
these cases, the occurrence of nausea in the intervals between the spasms, and 
occasional eructations or abortive efforts to vomit, will sometimes serve to 
indicate the nature of the cause. Another common cause is a collection of 
air, either resulting from the fermenting food, or from a secretory act of the 
stomach. This will often be indicated by belching. Spasm of the stomach 
may be occasioned also by congestion of the portal system of veins, by irrita- 
tion of the spinal marrow or sympathetic nerve, by gout or rheumatism, by 
cold externally applied, especially to the extremities, and by very cold water 
taken into the stomach, when the body is overheated or perspiring. In many 
persons, a strong predisposition to the affection exists. We find it especially 
in those debilitated by improper indulgences, irregular modes of life, the long 
continuance of depressing emotions, or certain chronic disorders affecting par- 
ticularly the nervous system. Hysterical females, and gouty and dyspeptic 
individuals are peculiarly subject to it. When the predisposition exists 
strongly, very slight causes are sufficient to bring it into action. The least 
irregularity of diet, or any unusual emotion, especially of an agitating charac- 
ter, even mental association without emotion, may serve as an exciting cause. 
I have heard of a female, in whom the smell of an apple was sufficient to 
induce an attack of spasm in the stomach. 
Treatment;-This must vary with the cause, and the precise measures 
necessary will be indicated in connexion with the complaints of which this 
affection is an accompaniment. It will be sufficient here to point out the 
remedies in a general way. If the spasm proceed from offending matters in 
the stomach, especially from undigested food, these should be evacuated by 
an emetic of ipecacuanha, which should be followed by a mild cathartic. 
When the affection is not severe, it will be sufficient, instead of the emetic, to 
administer a dose of castor oil with laudanum. If the offending matter be 
acid, magnesia or other antacid should be given; and the aromatic spirit of 
ammonia will be found peculiarly useful from its stimulant properties. After 
vomiting, if that should be deemed necessary, and if not, immediately, re- 
course must be had to anodynes. In severe cases, two or three grains of 
opium, or an equivalent dose of laudanum, black-drop, or one of the salts of 
morphia, should be given at once, and repeated every half hour or hour till 
relief is obtained. The opiate may in general be given in connexion with 
the cathartic or antacid, when these are considered necessary. In the absence 
of all inflammation, or high vascular excitement of the stomach, certain sti- 
mulants, especially the nervous, such as Hoffmann's anodyne, ether, musk, and 
the preparations of ammonia, may be usefully conjoined with the anodyne. 
If the spasm be caused or accompanied by flatus, the aromatics may be freely 
used, as the essence of peppermint, spearmint, or pennyroyal, ginger tea, the 
compound spirit of lavender, compound tincture of cardamom, oil of turpen- 
tine, &c. External applications, such as have been mentioned under gastral- CLASS III.] 
IRRITATION OF STOMACH.-NAUSEA AND VOMITING. 
531 
gia, should never be neglected. The most efficient, on the whole, is a sina- 
pism of pure mustard. Obstinate spasm of the stomach has yielded immediately 
to the revulsion produced by a large cupping-glass applied to the epigastrium. 
When there is evidence of considerable vascular excitement of the stomach, 
or the disease is inflammatory, it is advisable to take blood from the arm, 
and in some cases to bleed largely. Cups or leeches to the epigastrium 
may be superadded, or substituted, according to circumstances. When portal 
congestion or hepatic disease exists, the anodyne remedies should be united 
with, or followed by, a dose of calomel. Should the spine be in fault, the 
remedies should be applied to that part. (See page 525.) In gouty and rheu- 
matic cases, the irritation should be invited to the extremities by rubefacient 
applications. To relieve the predisposition to Spasm, the treatment must be 
directed according to the condition of the system and the particular state of 
the stomach. The measures recommended in gastralgia will be found useful 
here. 
Nausea and Vomiting.-The stomach throws up its contents in two 
different modes; first, by regurgitation or eructation, which is effected by the 
contraction of the stomach, assisted sometimes by the voluntary contraction 
of the diaphragm and abdominal muscles; and secondly, by vomiting, which 
is the result of various combined involuntary movements, made through the 
instrumentality of the brain. The former is not essentially a morbid action, 
as it often occurs in health. It is to the latter that the following observations 
refer. 
Phenomena.-Vomiting is very generally, though not always, preceded by 
the peculiar condition denominated nausea, or sickness of stomach. This is 
a distressing sensation always referred to the stomach, unattended with pain, 
and of so peculiar a character as not to admit of description. It is accompa- 
nied, in various degrees, with a feeling of general languor and debility, a small, 
feeble, often irregular pulse, a pale, cool, and moist skin, general muscular 
relaxation, rigors and trembling, sunken features, and an increased flow of 
saliva, and probably also of bile. At different periods after the commence- 
ment of the nausea, varying from a few seconds to several hours, the diaphragm 
and abdominal muscles contract suddenly and convulsively upon the stomach, 
the muscular coat of which also contracts; while the oesophagus, which is 
ordinarily in a state of constriction at the cardiac orifice, relaxes so as to 
allow the passage of the gastric contents upwards. All these movements are 
simultaneous. In some instances, the oesophagus appears to relax only par- 
tially, or not at all; and then those ineffectual efforts to vomit take place, 
which are denominated retching. Occasionally the nausea continues long, and 
is very distressing, without the occurrence of either vomiting or retching; and, 
in rare instances, vomiting appears to come on suddenly and unexpectedly, 
without any preceding nausea, or at least with a degree of it so slight as not 
to attract notice. During the act of vomiting, the return of the blood from 
the head is impeded by the contraction of the muscles, and there is conse- 
quently flushing of the face, with swelling of the external parts of the head, 
and a feeling of fulness and distension in the temples, which is sometimes 
painful. Apoplexy has resulted from the pressure maderon the brain in the 
act of vomiting. The pulse becomes slower and fuller, probably in conse- 
quence of this pressure. The stomach sometimes contracts so violently as to 
produce a painful feeling of spasm, though it would appear from the experi- 
ments of Magendie, that its contraction is not absolutely necessary to the act 
of vomiting. When the vomiting subsides, the patient is generally left in a 
state of universal relaxation, with a soft pulse, a moist skin, and a disposition 
to sleep. 532 
LOCAL DISEASES. 
[PART II. 
Explanation.-In the production of the above phenomena, the first impres- 
sion is probably, in most cases, upon the stomach, whence it is transmitted 
to the brain, giving rise to the sensation of nausea, which is referred to the 
epigastric region. After the impression upon the brain has reached a certain 
degree of intensity, an influence is sent down to the various parts concerned 
in vomiting, by which these parts are brought into simultaneous action. It 
is thus seen that the intervention of the brain is essential to the result. But 
it is not necessary that the original impression should be made upon the sto- 
mach. Other organs are susceptible of modifications in their condition, capable 
of inducing the same state of the brain, and consequently the same results of 
nausea and vomiting, as when the stomach is the incipient point of the move- 
ment. It may be said that, in these cases, the morbid impression is sent first 
sympathetically to the stomach from the organ primarily affected, and thence 
transmitted to the brain. This may be true in those instances in which the 
organ is connected with the stomach by means of the sympathetic nerve. But, 
in other instances, the stomach is probably brought into the circle of morbid 
movement solely through the brain. That this is possible, is proved by an 
experiment of Magendie, who removed entirely the stomach of a dog, and, 
having substituted for it an inert bag filled with liquid, succeeded in bringing 
on vomiting by injecting tartar emetic into the veins. Again, the original 
movement is often in the brain itself. Nothing is more common than nausea 
and vomiting dependent upon derangements of that organ. Mental associa- 
tions alone are sufficient to produce the result; as must be evident to those in 
whom the sight or smell of an object, which has already produced sickness of 
stomach, occasions a return of the affection. It appears, therefore, that nothing 
more is requisite to occasion nausea and vomiting than the production, in any 
mode whatever, of that condition of brain which precedes these conditions, 
when the stomach itself is the seat of the first morbid impression. This is 
an important practical fact; as a knowledge of it will serve to direct the atten- 
tion of the physician, in many instances, to the true seat of the disease, which 
might otherwise be referred exclusively to the stomach. 
Causes.-The most common immediate cause of vomiting is inflammation 
or irritation of the stomach. The result equally takes place, whatever may 
be the cause of the inflammation or irritation, whether offending matter in 
the stomach, vicissitudes of temperature, congestion of the portal veins, rheu- 
matic or gouty disorder, translated cutaneous affections, spinal irritation, or 
direct sympathy with other organs in a state of inflammation. Evidence is 
very often afforded, as to the precise cause, by the nature of the substances 
vomited. If these be excessively sour, very acrid, or very bitter, the vomit- 
ing may in general be inferred to proceed from acid, bile, or other offending 
matter in the stomach; if they consist of mucus, or of substances swallowed 
not in themselves irritating, it may for the most part be ascribed to the morbid 
state of the stomach itself; and whether this be inflammation or irritation, 
direct or sympathetic, must be decided by the symptoms. But the ejection 
of bile must not always be considered as a certain evidence of its presence in 
the stomach, previously to the commencement of vomiting; for the pressure 
on the gall-bladder during vomiting, and the probable increase of the hepatic 
secretion during nausea, may cause an increased flow into the duodenum, the 
action of which viscus as well as that of the stomach is often inverted in 
emesis. Disease of the abdominal viscera, and of the uterus is very apt to 
occasion vomiting. In these cases, it may result from an extension of irrita- 
tion to the stomach through the ganglionic or spinal centres, or from an im- 
pression made by these organs intermediately upon the brain. There seems 
to be a state of the nervous system, resulting from various causes, which dis- CLASS III.] 
IRRITATION OF STOMACH.-NAUSEA AND VOMITING. 
533 
poses to that cerebral action essential to vomiting. Such a state results from 
violent spasm of internal organs, as of the biliary ducts, the ureters, and the 
bowels; from severe injuries produced by external violence, as by blows, falls, 
and sometimes even by surgical operations; from the loss of blood, the use of 
the warm bath, and other causes which induce faintness; from the depression 
attending the cold stage of idiopathic fevers; and from certain peculiar influ- 
ences disturbing to the nervous system, such as occur in exanthematous fevers, 
pregnancy, and unaccustomed motions of the body, as in sailing, swinging, 
riding backwards in a carriage, &c. Disorders of the brain itself very fre- 
quently produce nausea and vomiting. Obstinate vomiting is one of the most 
characteristic features of hydrocephalus. Concussion and inflammation of 
the brain are frequently attended with it, as are also various functional de- 
rangements of that organ, producing giddiness or swimming of the head, 
cephalalgia, &c. ' 
It would appear, from what has been said, that vomiting cannot always be 
considered as arising from gastric irritation; but that, on the contrary, it is 
not an unfrequent attendant upon great depression of the system. Even direct 
depression of the stomach itself would seem to be capable of producing it. 
Thus, draughts of tepid water often occasion nausea and vomiting, probably 
by their relaxing or depressing influence; for the same quantity, either hot, 
or cold, does not produce the same effect, proving that it is not by the stimulus 
of distension; and the temperature, being about the same as that of the sto- 
mach, cannot be the exciting cause. When the liquid is taken either hot or 
cold, the direct stimulus of the heat in the one case, and the indirect stimulus 
of the cold in the other, obviates the depressing influence of the liquid. The 
loss by the stomach of its ordinary mechanical support may give rise to nausea 
and vomiting. Hence, these effects have resulted from relaxation of the ab- 
dominal parietes, and have been relieved by a bandage. 
Treatment.-It is obvious that, in the treatment of vomiting, regard must 
be had to the pathological condition upon which it depends, and remedies 
employed accordingly. Gastric inflammation or irritation must be relieved 
by the means pointed out under these heads. When the spine is in fault, 
the remedies must be addressed to that part. When the vomiting proceeds 
from the retrocession of external diseases, attempts should be made to recall 
the irritation to the surface or extremities by rubefacient, pustulating, or 
blistering applications. When it is a purely sympathetic affection, the real 
disease should be attacked in its proper seat. But there are certain modes 
of treatment, applicable to sick stomach under most circumstances, which it 
is proper to mention here, in order to avoid frequent repetitions. 
Whenever there is reason to suspect that the vomiting is sustained by 
offending matters in the stomach, as for example when small quantities of 
bilious matter are thrown up at each effort, the stomach should be well cleared 
out by the free use of warm water, warm chamomile tea, chicken water, or 
other mild liquid, assisted, if necessary, by a moderate dose of ipecacuanha. 
In cases wholly free from inflammation, this treatment will often prove effec- 
tual, even though the vomiting may not depend upon the presence of an 
irritant. A tumbler full of warm water sometimes immediately settles a 
disturbed stomach, without being vomited. 
After the stomach has been thus cleansed, if such cleansing should be 
necessary, the most efficient remedy, beyond all comparison, is opium. This 
may be given in the form of pill, of tincture, of camphorated tincture, of 
black drop, or of one of the salts of morphia. Dr. Chapman recommends a 
pill which has become hard by keeping. The camphorated tincture is pecu- 
liarly applicable to cases in which there is no vascular excitement of stomach, 534 
LOCAL DISEASES. 
[part II. 
the black drop or sulphate or acetate of morphia to others. The dose may 
be from the sixth of a grain to a grain of opium, or an equivalent quantity of 
its preparations, and may be repeated every hour or two if required. Should 
the remedy be rejected by the stomach, it may be given very advantageously 
by enema. An anodyne injection of from thirty to sixty drops of laudanum, 
with two fluidounces of thin starch or some mucilaginous liquid, is a most 
excellent remedy in vomiting. Should this be resisted, half a grain of finely 
powdered acetate or sulphate of morphia may be sprinkled upon a small blis- 
tered surface upon the epigastrium. In cases of great emergency, a denuded 
surface for the purpose may be obtained very speedily by the strong solution 
of ammonia, or by the careful application of nitric acid. 
Next to the influence of opium in efficiency, is probably revulsion to the 
epigastrium by means of rubefacients or blisters. An elegant cataplasm for 
the purpose may be made with equal parts of powdered cinnamon, cloves, 
ginger, and pepper, incorporated by means of warm spirit, and some adhesive 
substance, as honey or molasses. Flannels moistened with a decoction of 
Cayenne pepper in spirit, or with the oil of horsemint or of turpentine, may 
also be used, although the unpleasant smell of the latter oil is an -objection 
to it. But the most effectual of the rubefacients is a sinapism made with 
pure mustard and water, which should be kept on from half an hour to an 
hour. When a strong and lasting impression is required a blister should be 
resorted to. 
Lime-water and fresh milk, in the dose of a tablespoonful of each every 
half hour, hour, or two hours, is very useful in cases where there is not too 
much excitement, where some nutriment is required, and especially where the 
stomach rapidly creates acid. 
Carbonic acid water, either alone or sweetened with ginger syrup, is an 
excellent as well as agreeable remedy. It should be given occasionally as the 
patient wishes drink, in doses of one or two fluidounces, and each dose should 
be in a separate phial. When there is vascular irritation of stomach, it is 
best given without syrup, and very cold. A dose of the effervescing draught, 
made with carbonate of potassa and lemon juice (see U. S. Dispensatory), 
given every hour or two, is especially useful in febrile cases. The Seidlitz 
powder, in one-sixth or a quarter of the ordinary dose, may be given under 
similar circumstances, and at similar intervals. 
Different saline substances, besides those just mentioned, have been found 
useful by some practitioners in very small doses. Among them, common 
salt and sulphate of magnesia have been recommended. They may possibly 
sometimes prove useful by meeting some idiosyncrasy of the stomach, or by 
sustaining a slight peristaltic movement, and thus causing irritating secretions 
to pass downward. 
In the absence of vascular excitement, and especially in cases of debilitated 
or depressed stomach, the various aromatics are often useful. That one should 
be selected which is usually most acceptable to the patient. Cinnamon, cloves, 
and nutmeg, are upon the whole best suited to this purpose. They should be 
given in infusion, or in the form of volatile oil, which may be administered in 
sweetened water, or preferably dissolved in water with the intervention of 
magnesia, as directed by the Pharmacopoeia. Certain aromatic spirits or 
tinctures may also be used, in the dose of a fluidrachm. Such are the com- 
pound spirit of lavender, and the compound tinctures of cardamom and of 
cinnamon. I have found the aromatic spirit of ammonia, in the dose of fif- 
teen or twenty-drops, highly efficient in similar cases. It is an elegant addi- 
tion to antacid mixtures, in eases of acidity connected with nausea and vomit- 
ing. Small quantities of brandy and water, spiced brandy, spiced wine, the CLASS III.] 
IRRITATION OF STOMACH.-SEA-SICKNESS. 
535 
sparkling wines, sulphuric ether, and Hoffmann's anodyne, have also been 
advantageously used in depressed states of the stomach. 
Among the remedies which have been highly recommended for vomiting, 
when a mere functional disorder, is creasote in the dose of a drop, repeated 
occasionally. Injections of iced water into the rectum are asserted to have 
been very useful in vomiting connected with hysteria. It is sometimes neces- 
sary to obey the intimations of the stomach itself, which is occasionally quiet- 
ed in this way when all ordinary measures fail. I have seen, for example, a 
patient at once cured of vomiting by roasted onions, which had been urgently 
and perseveringly called for, when the stomach rejected everything else that 
could be given, even a little cool water. (See page 199.) 
Great thirst often attends vomiting, and the patient is constantly calling 
for drink; but he should be allowed to take only a very small quantity at 
one time. 
Sea-Sickness.-This is a variety of vomiting so peculiar .as to merit a 
separate notice. It may be considered aS identical with the sickness produced 
on land by various unusual motions, such as riding backward in a carriage, 
swinging, rocking, or turning rapidly round as in waltzing. Sea-sickness 
differs only in its greater intensity and duration, which are attributable to the 
continued and unavoidable operation of its cause. 
This affection is very often preceded by vertigo, and sometimes by head- 
ache. In some individuals there is a feeling of uneasiness, sinking, and great 
distress at the epigastrium, which is described as worse than vomiting, and 
which occasionally lasts for a long time. Sickness of stomach and vomiting, 
however, in general soon come on. The vomiting is frequent and exceedingly 
distressing, with convulsive heaving of the stomach which extorts groans from 
the patient. Along with this is a general feeling of wretchedness and pros- 
tration, which in bad cases is sometimes so great as to render the patient 
utterly inattentive to everything around him, and almost indifferent to life. 
The affection is usually harmless in its results, but has been known to prove 
fatal by inducing hemorrhage from the stomach, or wearing the patient out 
through protracted suffering. The probability is, that, in such cases, there 
was previous disorder, or morbid tendencies, which were merely aggravated, 
or called into action by the sea-sickness. 
Individuals vary exceedingly in their susceptibility to this affection. Some 
are never attacked by it, others only in their first voyage, and others again 
in every voyage which they undertake. With some it continues hut for a few 
hours or a few days, with others so long as they are at sea. Some persons, 
even long accustomed to the sea, are attacked with it whenever the waves are 
more than usually agitated. In most individuals, however, it occurs but 
once, and continues only for a period varying from one or two days to a week. 
It is said that infants and very old people are rarely attacked, and that women 
are more susceptible than men. It almost always ceases immediately after 
landing. 
The cause of sea-sickness is undoubtedly the motion of the ship; and the 
pitching of a vessel, or the alternate elevation and depression of the bow and 
stern is said to be most productive of it. The affection is most apt to occur 
when the ship is sailing against a head sea, or tossing in a calm, before the 
waves excited by the previous storm have subsided. It is least experienced 
in large ships, and in those heavily laden. 
Various explanations have been given of the operation of the cause. The 
sickness has been ascribed to the movements of the abdominal viscera rubbing 
against each other. But this explanation would not apply to the similar 
affection occurring on land, and it is very doubtful whether, in most cases, 536 
LOCAL DISEASES. 
[part II. 
any such friction occurs. Dr. Wollaston gave a purely physical explanation 
of the phenomena, which he supposed to proceed from the tendency of the 
blood to rise, and its consequent pressure upon the brain during the sinking 
of the ship, as the mercurial column in the barometer .rises under the same 
circumstances. But this would not explain the occurrence of the affection in 
the horizontal position at sea, or from riding backward in a carriage. Dr. 
Darwin ascribed it to a disturbance of brain consequent upon the unusual 
impression produced upon the vision by the motions of the vessel; and Dr. E. 
Miller, of New York, united with this opinion, extending the explanation so 
as to embrace the sense of touch as well as that of sight. This is probably a 
correct view. The brain is thrown into a disturbed condition by the associa- 
tion of its'present impressions, received through the senses, with the very dif- 
ferent impressions previously received from similar objects; and this disturb- 
ance is exactly that which gives rise to the sensation of nausea and the act of 
vomiting. In support of this view, the facts may be adduced, that the disorder 
gradually ceases as the brain becomes habituated to the new impressions; that 
it is experienced in a less degree in the horizontal position, with the eyes 
closed, or in the dark, than under opposite circumstances; that it is diminished 
or obviated by intense engagement or pre-occupation of the mind; and, finally, 
that a somewhat similar effect is produced by certain deceptions of the senses, 
as when the eyes are directed to some fluctuating object, and the impression 
is conveyed that the body itself is moving. 
Treatment.-From the foregojng statements it results, that a person may 
diminish or obviate sea-sickness by assuming the horizontal position, especially 
in a hammock, and as nearly in the centre of the ship's movements as possible, 
and keeping his eyes closed. This is. a desirable measure for very susceptible 
persons, on very short voyages; but would be too irksome under ordinary 
circumstances. It is better, as a general rule, to submit to the present tran- 
sient evil, and thus gain immunity for the future. To alleviate the distress, 
it is recommended to fix the attention upon something calculated to interest 
it, and to assist, if admissible, in the active duties of the ship. Much may be 
done towards overcoming the tendency to sickness, by a determination not to 
give way to it, by keeping about instead of lying by, and by being as much 
as possible in the open air. Seamen advise the compression of the abdomen 
by means of a tight girdle. The patient may advantageously use acidulated 
drinks and liquids impregnated with carbonic acid. In severe cases, resort 
may be- had to the various remedial measures mentioned under vomiting. 
Washing out the stomach, keeping the bowels regularly open, and the use of 
opiates, or diffusible stimulants, in small doses, have been especially recom- 
mended. The food should be easily digestible, and moderately taken. 
Sick-lieadache.-This is very often essentially a gastric affection, and 
therefore may be considered in this place. 
Symptoms.-The pain in the head sometimes comes on abruptly, but is 
usually preceded by certain premonitory symptoms, such as confusion of 
head, vertigo, dullness, depression of spirits, irritability of temper, and perver- 
sion of hearing or sight, especially of the latter. There is often a glimmering 
before the eyes, or muscae volitantes, or dimness; in some cases, objects are 
bordered with a halo of prismatic colours, in others are only half seen, and in 
others again appear double. Not unfrequently the patient complains of numb- 
ness or formication in the extremities, generally upon one side, and this numb- 
ness sometimes continues after the headache comes on. Coldness of the feet 
and hands, irregular pains in the back and loins, and deficient urinary secre- 
tion are also among the occasional premonitory symptoms. Sometimes the 
appetite is impaired; sometimes the patient eats a hearty meal immediately CLASS III.] 
IRRITATION OF STOMACH.-SICK-HEADACHE. 
537 
before the attack. The pain in the head is usually slight at first, and gra- 
dually increases until it becomes intense; but sometimes is violent from the 
outset. In the great majority of cases, it is felt in the forehead, over the 
brow, or in the eye, sometimes only on one side, but generally on both; and 
not unfrequently the eyeballs are sore to the touch. In some instances, the 
pain extends over the whole head, or is felt more especially in the back of the 
head or neck. It is often attended with chilliness, flushes of heat, and other 
deranged sensations; but the pulse is almost always natural or nearly so in 
frequency, and thus at once serves to distinguish the case from an attack of 
fever. The tongue is in some instances slightly furred. After the pain has 
continued for some time, nausea occurs, by which it is somewhat relieved; 
and there is often an alternation of severe headache and nausea for a con- 
siderable time, the latter gradually increasing, until at length vomiting takes 
place. The matters discharged are usually sour or bitter, but sometimes 
tasteless, especially if some antacid medicine has been taken. After vomiting 
freely, the patient usually falls asleep, and, having rested for several hours, 
awakes free.from pain or nearly so. Should a dull pain in the head remain, 
it generally disappears after a meal, or upon exercise in the open air. The 
disease thus, in most instances, runs its course within a period of twenty-four 
hours.' Sometimes, however, it is protracted with little abatement of violence 
for two or three days ; the patient frequently vomiting during that period. 
In such cases, there is reason to think that the liver or head is involved, other- 
wise than merely by sympathy with the stomach. Some persons suffer much 
less than others, having but a slight headache, which is very soon relieved by 
vomiting. Occasionally the attack subsides without vomiting, in consequence 
of the passage of the contents of the. stomach downward. This is apt to 
happen if the patient fall asleep before vomiting. The paroxysm is occasion- 
ally interrupted by causes making a strong impression, whether on the mind 
or body. The attacks in some persons are rare, in others very frequent, occur- 
ring sometimes as often as once a week, with scarcely a complete freedom 
from pain in the intervals. 
Causes.-In persons predisposed to sick-headache, slight causes are suffi- 
cient to induce an attack. It is brought on by the use of indigestible or 
acescent food, excess in eating or drinking, great bodily fatigue, loss of rest, 
extraordinary mental inquietude or exertion, exposure to cold when warm and 
perspiring, and by whatever else is capable of producing a morbid accumula- 
tion of acid in the stomach, or an excessive secretion of bile. The predispo- 
sition for the most part consists in debility of stomach, and a peculiar state of 
the nervous system, which renders the brain especially sensible to gastric 
irritation. Hence, all the causes of dyspepsia are predisposing causes of sick- 
headache. (See Dyspepsia.} It may be proper to mention here, as among 
the most prominent, the habitual use of coffee and tea, especially of the former. 
These nervous stimulants, when long and freely employed, have the indirect 
effect of diminishing the energy both of the stomach and brain, by the state 
of excitement which they produce in these organs; and their operation often 
escapes notice, because their immediate effect is not unfrequently to relieve, 
for a time, the affection resulting from their habitual use. 
The pathological condition of the stomach, during the paroxysm, is irrita- 
tion -of the mucous membrane, induced either by an excess of acid, by un- 
digested food by regurgitated bile, or by venous congestion resulting from a 
sluggish State of the liver. In the last case, neither acid nor bile, nor any 
other irritating matter, is necessarily vomited, and the hepatic secretion is 
proved to be deficient by the want of colour in the stools. Under all these 
circumstances, the affection of the brain is secondary. There is reason, how- 538 
LOCAL DISEASES. 
[part II. 
ever, to believe that this organ is sometimes the first recipient of the morbid 
impression, and that the stomach is secondarily involved. 
Treatment.-This must be considered in relation first to the paroxysm, and 
secondly to the interval. The attack may often be prevented by proper mea- 
sures, applied upon the first appearance of the premonitory symptoms. The 
previous experience of the patient will generally serve as an index to the 
nature of the offending cause. If this be acid in the stomach, as happens in 
the majority of cases, from half a drachm to a drachm of magnesia will be 
found among the most effectual preventives. A drachm or more of the bicar- 
bonate of soda may be substituted, when a laxative effect is not desired. These 
antacids may be elegantly administered in carbonic acid water, combined with 
a little ginger syrup, and a fluidrachm of some aromatic or tonic tincture, as 
the compound, tincture of cinnamon, the compound tincture of cardamom, or 
the compound tincture of gentian. Twenty or thirty minims of aromatic 
spirit of ammonia will form a useful addition, when the stomach is considerably 
debilitated. If bile be the offending cause, some quick and gentle cathartic 
will be best adapted to the case; as half an ounce or an ounce of sulphate of 
magnesia, one or two Seidlitz powders, or a little infusion of senna. When 
the cause appears to be deficient hepatic action, a dose of calomel, with or 
without another cathartic, will be most efficient. Certain nervous stimulants 
also will frequently set aside the paroxysm, by obviating the sympathetic 
impression upon the brain; and they are especially serviceable when the affec- 
tion is primarily cerebral. The most efficient of these is perhaps strong' tea. 
Coffee answers with some, but more frequently fails. A teaspoonful of Hoff- 
mann's anodyne may be given for the same purpose. 
These same remedies may also be employed during the paroxysm in its 
earlier stages, and will sometimes set it aside even when fully formed. But, 
when nausea has commenced, it is generally advisable to promote the evacua- 
tion of the stomach by copious draughts of warm water, or warm chamomile 
tea, or a moderate dose of ipecacuanha. Free dilution with warm water some- 
times settles the stomach, and favours a solution of the paroxysm. When the 
headache is severe, the patient should retire to bed, in a dark room, and keep 
as quiet as possible. He will thus sometimes fall asleep, and awake much 
relieved, without vomiting. Bathing the temples and forehead with some 
aromatic spirit, as spirit of lavender, or Cologne water, sometimes affords relief; 
as also does the application of sulphuric ether, confined by the hand so as to 
prevent its too rapid volatilization. Many persons, when they feel the paroxysm 
approach, prefer submitting quietly, and allowing it to have its course. Should 
the head not be relieved after the stomach has been fully evacuated, and the 
patient be unable to sleep, a dose of laudanum or sulphate of morphia may 
often be given with advantage, and afterwards a cathartic. If, however, any 
evidence of cerebral congestion exist, the opiate should be withheld. In such 
a case, bleeding or leeching to the temples may be necessary. 
In relation to the treatment in the intervals little need be said here. All 
those measures are indicated, which are calculated to strengthen at once the 
stomach and the nervous system. These will be fully treated of under dys- 
pepsia. Among them none is more important than the removal of the pre- 
disposing causes. It has been stated that the habitual use of coffee and tea, 
especially the former, is one of the most influential of these causes. I have 
repeatedly known cures of sick-headache to be effected by an entire abstinence 
from coffee, where other means had failed; and pne striking instance occurs 
to me in which an individual, after suffering long and severely with the dis- 
ease, obtained an entire exemption by refraining from the use of black tea, 
which was his only indulgence. We cannot, therefore, too strongly urge an CLASS III.] 
IRRITATION OF STOMACH.-MORBID APPETITE. 
539 
abstinence first from coffee, and, if this should prove insufficient, from tea also, 
even from black tea. These beverages, as has been stated, often operate 
advantageously as remedies in the paroxysm; but it is inconsequence of those 
very properties which render their habitual use poisonous to some persons. 
Tobacco and alcoholic drinks, if habitually indulged in, should also be given 
UP- . ; 
Various remedies have been extolled as peculiarly useful in this complaint. 
Thus, cider was recommended by Dr. Dwight, of Connecticut. (JV. York Med. 
Repository, vol. 2.) This may prove useful in cases of idiosyncrasy, but is 
not generally applicable. Dr. Otto, of Philadelphia, cured a very obstinate 
case by the long continued use of the solution of arsenite of potassa,' in doses 
of about three drops three times a day. (Mease on Sick Headache.') In cases 
where the paroxysm returns at regular intervals, as sometimes happens, sul- 
phate of quinia will often effect at least a temporary cure. Should the biliary 
secretion be habitually deficient, a mercurial pill, or a grain of calomel, should 
be given every night, or every other night, followed by a laxative next morn- 
ing, and continued till the evil is corrected. 
Morbid Appetite.-There are two forms of morbid appetite, one in 
which the desire for food is abnormally increased, the other in which it is 
directed towards unusual objects. In the former case, it is said to be vora- 
cious, in the latter, perverted or depraved. 
1. Voracious Appetite.- Voracity.- Canine Appetite.-Boulimia.-There 
are various degrees of this affection, from a slight increase beyond the point 
of health, to a constant and insatiable craving for food. Cases are on record 
in which the patient when awake was never content unless eating, and in 
which an almost incredible amount of food was consumed. Dr. Mortimer, in 
the 43d volume of the London Philosophical Transactions, relates the case of 
a boy of about twelve years, who,*in six successive days, took a quantity of 
different kinds of food weighing three hundred and eighty-four pounds eight 
ounces, equal to about sixty-four pounds a day. In such cases, when food is 
withheld, there is a feeling of uneasiness, inquietude, or even faintness, with 
an indescribable vacuity or sinking of stomach, a sort of craving void, which 
impels the patient to seize voraciously upon everything in the shape of food, 
however unsuitable or ordinarily repulsive, and even to gnaw his own flesh if 
not indulged. Individuals with this propensity are usually thin and even 
emaciated; although, in some instances, the food serves the purpose of an 
increased nutrition, and enormous obesity is the consequence. In cases of 
the former kind, the food is sometimes vomited, and sometimes passes quickly 
through the bowels, without undergoing digestion. Occasionally it is rapidly 
digested, and is converted into chyle and blood, but merely serves to supply 
materials for hemorrhage, or some extensive excretion, as that of perspiration 
or urine. > 
If it be considered that hunger is a sensation, which, though always re- 
ferred to the stomach, and often originating in that organ, may be equally 
produced by impressions sent to the brain from the nutritive vessels all over 
the body, when in want of supplies for their proper function, it will be easily 
understood, that voracious appetite may depend either upon a disordered con- 
dition of the stomach, or upon the state of the nutritive function in general. 
Hence, we find it as a consequence sometimes of a kind of gastric irritation, 
proceeding from stimulating secretions in the stomach, sometimes of a defi- 
ciency of nourishing matter in the blood-vessels, or of an unusual energy in 
the nutritive process. Hence the voracity of persons who have long fasted, 
and of those convalescing from diseases in which there has been great loss 
of flesh. Hence, too, the occasional morbidly increased appetite of anemic 540 
LOCAL DISEASES. 
[PART II. 
patients; and of those affected with a tendency to excessive obesity, and with 
wasting diseases and profuse evacuations, as consumption and diabetes. 
The affection sometimes also arises from disordered innervation of the sto- 
mach, produced by causes disturbing the nervous system in general, as in 
hysteria and the early stages of pregnancy. To the same head may also be 
referred the effect ascribed to worms in the bowels, especially to the tape 
worm, of producing a voracious appetite. In some of the worst cases, the 
disease depends upon original or accidental irregularities in the structure of 
the stomach. Thus, it has been attributed to a preternatural capacity of the 
stomach, and to an enlargement of the pyloric orifice, allowing the food to 
pass undigested. Of the same character are cases in which the stomach 
communicates directly with the colon. The habit of indulging the appetite 
to excess leads no doubt frequently to a morbid craving, as the desire for 
stimulant drinks increases with their use. Lastly, voracious appetite may be 
a cerebral affection-a species of insanity, in which the condition of brain 
necessary to the sensation of hunger, originates in that organ itself, exactly 
as in the case of nausea, which frequently arises directly from disorder of the 
brain. 
Little need be said upon the treatment of this affection. In cases arising 
from malformation of stomach a cure is not to be expected. As a palliative, 
compression of the abdomen by a tight band has been recommended. When 
the complaint depends upon any morbid state of the system, or an organ, 
our remedies must be addressed to the primary disease. Direct irritation of 
the stomach must be combatted in the inodes already detailed. Perhaps, in 
some cases, advantage may be derived from sustaining nausea for a considera- 
ble time by means of emetic medicines in small doses. In the excessive 
appetite which follows long fasting, and attends convalescence, it is often 
highly important to restrain the propensity; as much danger sometimes 
results from over-indulgence. In the gluttony of habit, on the contrary, 
'there is danger from too sudden a withdrawal of food. The system some- 
times sinks rapidly and unexpectedly in such cases, as from the sudden with- 
drawal of stimulating drinks. Hence gluttons, like drunkards, are in pecu- 
liar danger from diseases which take away the appetite, and thus cut oft' the 
usual supply. The practical inference from this fact is, that any attempt to 
cure an established habit of over-eating should be gradual. 
Depraved Appetite.-Pica.-In this affection there is a desire, often irre- 
sistible, for strange articles of food, for substances wholly unfit for food, and 
sometimes for 'things offensive or even disgusting. These whims of the appe- 
tite are exceedingly diversified, and there is scarcely any object in nature' to 
which they may not be directed. Thus, instances are on record of persons 
having a propensity for spiders, toads, serpents, candles, paper, human excre- 
ment, earthy matters of various kinds, as clay, chalk, and magnesia, and even 
hard, wounding bodies, as stones, pieces of glass, pins, needles, and blades of 
knives. Such vagaries are often temporary, and of little importance; but 
they are sometimes durable, and cease only with the life of the individual, 
who falls a victim either to the disease of which the depraved appetite is 
merely a symptom, or to the chronic gastritis, and general disorder of health, 
which its indulgence produces. 
Like voracity, this affection may depend upon some form of gastric irrita- 
tion, upon inscrutable changes in the innervation of the stomach, upon cere- 
bral disorder amounting to a species of insanity, or upon mere habit. The 
form of depraved appetite, which seeks indulgence in the eating of clay, 
chalk, &c., is probably often connected with acid in the stomach, which is 
neutralized by the substance swallowed. It is possible that, in some of those CLASS III.] 
INDIGESTION. 
541 
cases in which hard, rough, or pointed bodies are swallowed, the propensity 
depends upon that insupportable feeling of vacuity in the stomach, which is 
relieved by the pain or excitement these bodies may produce. Depraved 
appetite occurs most frequently in children, and in chlorotic, hysterical, or 
pregnant females. The whimsical fancies of pregnancy are universally 
known. 
The general observations upon the treatment of voracious appetite are appli- 
cable here. To obviate, as far as possible, every observable disorder of func- 
tion is the chief indication. In cases strictly and exclusively stomachic, an 
emetic followed by cathartic, antacid, and tonic medicines, with wholesome 
digestible food, and the various other measures calculated to invigorate the 
stomach, are the remedies from which most advantage may be anticipated. 
(See Dyspepsia.} 
Article IV. 
INDIGESTION, or DYSPEPSIA. 
Under this name have often been confounded various morbid states of the 
stomach, such as chronic gastritis, irritations of all kinds whether vascular 
or nervous, and different forms of gastric depression or debility. A conse- 
quence of this confusion has been serious error in practice; a set of rules 
applicable to a particular condition, having been too frequently extended, 
without discrimination, to others wholly different. The name is unfortunate; 
as, instead of expressing a particular pathological state, it merely refers to a 
result which may flow from different and even opposite conditions of the sto- 
mach; and it is not improbable, that much of the confusion alluded to has 
arisen from this cause. It has been questioned, whether there is any distinct 
gastric disorder, not included under other recognized titles, to which the name 
of dyspepsia properly belongs. Broussais and his disciples referred all those 
affections usually called dyspeptic to gastric irritation or inflammation. But 
this view has not generally prevailed. Cases frequently occur, in which it 
would be impossible to trace all the phenomena to this origin. It can 
scarcely be doubted, that a depression of the actions of the stomach, or a 
diminution of its power, constitutes, in many instances, the basis of a dis- 
tinct pathological state, entitled to rank as a disease. It is to this state that 
I propose to restrict the name of dyspepsia. With the depression or debility 
are undoubtedly very frequently associated different forms of irritation, and 
even inflammation; but these are mere incidental complications, and, when 
removed by appropriate measures, still leave the original disease. As dys- 
pepsia actually occurs, the phenomena are consequently of a mixed character, 
though an accurate observation will usually discriminate those which belong 
to the proper disease, from those which are the result of the associated affec- 
tions. 
Symptoms, Course, &c.-Dyspepsia does not in general come under the 
notice of the physician, until it has existed for a considerable time. The 
symptoms which it then presents are very different in different cases. One 
of the most prominent is a feeling of vague uneasiness in the epigastrium, 
which is not pain, and is often worse than pain, so that the patient sometimes 
strikes' himself over the stomach, or upon the side, in order to obtain relief 
by changing the sensation. This feeling is usually diffused over the epigas- 
tric region, and often extends to the hypochondria, to the chest, especially on 542 
LOCAL DISEASES. 
[part II. 
the left side, and even to the shoulder, and down the arms. The uneasiness 
is greatest when the stomach is empty, and is often replaced, after eating, by 
a sense of fulness, distension, or weight. Besides the peculiar feeling referred 
to, there is not unfrequently a sensation of heat, a burning or gnawing pain, 
arising from vascular irritation of the stomach, and sometimes spasmodic and 
gastralgic pains, and a sense of distension from flatulence or other causes. 
Frequently, along with the debility of stomach, is an increase of sensibility 
from deranged innervation, in which case substances swallowed may occasion 
acute pain, and the epigastrium evinces considerable tenderness on pressure. 
The appetite is usually more or less impaired, and is sometimes wanting, 
constituting anorexia. In other cases, again, it is craving, or perverted. (See 
Morbid Appetite.) There is seldom a healthy feeling of hunger, but, in place 
of this, the patient very commonly experiences a sensation of hollowness or 
sinking at the epigastrium, when the stomach is empty, which leads him to 
wish for food. Thirst is not unfrequent. 
Eructations of wind, and regurgitation into the mouth of food or chyme, or 
of a sour, bitter, acrid, oily, or offensive liquid, are common symptoms. Some 
patients are affected with water-brash (see Pyrosis), and some with occasional 
or habitual vomiting. 
The phenomena hitherto mentioned belong more especially to the stomach. 
There are also very numerous symptoms, having their seat elsewhere, which 
depend on derangements either consequent upon those of the stomach, or pro- 
duced by an extended operation of the same cause. Among these are various 
disordered sensations, such as headache, giddiness, and heaviness of the head; 
muscae volitantes, and other results of perverted vision; tinnitus aurium, and 
other unreal sounds (see Sick-headache); irregular pains between the shoul- 
ders, in the back, and various other parts of the body; a feeling of coldness 
between the shoulders; stricture, or uneasiness about the throat; and irrita- 
tion in the larynx and fauces, leading to frequent attempts to clear the throat, 
which at length become habitual. There is often also general uneasiness or 
malaise, a tendency to low spirits, a feeling of indifference or of anxiety and 
apprehensiveness, an indisposition to exertion, irritability of temper, fretful- 
ness, &c. The patient is apt to imagine himself affected with consumption, 
organic disease of the heart, or some other incurable malady. Palpitations of 
the heart, coming on at uncertain intervals, dyspnoea, and a short dry cough, 
are not unfrequent symptoms, and tend to confirm these melancholy impres- 
sions. The patient in general sleeps badly, is disturbed by unpleasant dreams, 
sometimes by nightmare, and awakes unrefreshed, and much depressed in 
mind. In some instances, however, the sleep is sound, and affords almost the 
only interval of ease; apd in others, again, there is even a morbid tendency 
to drowsiness. The tongue is usually somewhat furred, especially in the 
mornings, and there is often an unpleasant taste in the mouth, as if the saliva 
were sour. In some cases, there is frequent hawking, with a discharge of 
frothy mucus from the fauces. 
The bowels are almost always constipated, unless in cases complicated with 
chronic enteritis, or excessive secretion of bile. The hepatic function is also 
frequently deranged. The secretion of bile is very often diminished, giving 
rise to light clay-coloured, whitish, or hard and scanty stools. Sometimes it 
is perverted, giving a dark or black colour to the passages, and more rarely 
is too abundant, producing vomiting of bile, or bilious diarrhoea. 
The surface is usually dry, and of irregular temperature. The feet and 
hands are often obstinately cold, but sometimes hot and even burning, espe- 
cially at night. In debilitated cases, instead of dryness of skin, there is 
sometimes copious sweating. The urine is variously affected, sometimes CLASS III.] 
INDIGESTION. 
543 
scanty and high coloured, depositing a lateritious or whitish precipitate, some- 
times copious, limpid, and almost colourless. The pulse is in some cases quite 
natural, in others more or less disordered, being either too slow or too fre- 
quent, or altogether irregular. In some patients it is very irritable; being 
slow and regular under ordinary circumstances, but thrown into great disor- 
der by slight causes of excitement, whether bodily or mental. In such per- 
sons, it is apt to be rendered very frequent by exertion in the morning. 
The symptoms above enumerated are by no means all present in every case. 
They are combined in almost infinite diversity; and there, are scarcely two 
cases in which striking differences might not be observed; At first, the dis- 
ease usually exhibits itself in slight paroxysms, with intervals of almost entire 
exemption. These attacks are little noticed, and gradually increase in dura- 
tion and frequency, until at length the patient is seldom without some evi- 
dences of disorder. 
The patient usually loses flesh, and sometimes becomes much emaciated, 
with flabby muscles, a sunken abdomen, a pale sallow skin, and an anxious 
expression of countenance. The disease, however, seldom proves directly 
fatal. In the vast majority of cases, the patient either recovers entirely, or 
so far as to be liable only to occasional returns, upon a renewed application 
of the cause. In others, the disorder, which was at first purely functional, 
becomes organic; chronic gastritis is established; and the patient sometimes 
sinks under the combined influence of debility and irritation. The chief dan- 
ger from dyspepsia, however, is, that the reduced strength of the system may 
disable it from surmounting other diseases by which it may be assailed. It 
is possible that, as maintained by Wilson Philip, functional sympathetic affec- 
tions of the liver, lungs, &c., having their origin in dyspepsia, may become 
organic diseases, and constitute the chief'source of inconvenience and danger; 
but my observation would lead me to the conclusion that such cases are very 
rare. The predisposition to phthisis may be favoured by the debility attend- 
ant on dyspepsia, as it is by the same condition from any other cause; but 
the former disease is probably seldom or never the direct result of the latter. 
It is important to distinguish chronic gastritis from dyspepsia, and to be 
able to recognize inflammation when it takes place in the course of the latter 
affection. In chronic gastritis, the pain is on the whole more severe, the 
epigastric tenderness greater and more constant, vomiting much more frequent, 
and the pulse more tense, and, as a general rule, more accelerated. In this 
complaint, the tongue is frequently red, with prominent papillae, or altered 
surface, which is seldom the case in pure dyspepsia. Hot and stimulating 
drinks increase uneasiness in the inflamed stomach, while they often afford 
relief to the dyspeptic; and food is in general more acceptable to the latter 
than to the former. When the matter vomited is mucus, or blood, or like 
coffee-grounds, the existence of chronic gastritis may be inferred. Febrile 
action, and diarrhoea, are also much more common in that complaint than in 
dyspepsia. When, therefore, in a case of indigestion, the various symptoms 
mentioned increase or become developed, there is good reason to believe that 
gastritis has supervened. 
Causes.-The most prolific source of dyspepsia is probably the combined 
influence of sedentary habits and errors of diet. A certain amount of exer- 
cise is necessary to support every part of the body in due. vigour; and the 
stomach consequently participates in that debility which results from tlie want 
of it. If the quantity and quality of the food were in proper relation with 
this reduced energy, the whole system might remain enfeebled, but the sto- 
mach would not especially suffer. The fact, however, is, that while the gas- 
tric energies are impaired by sedentary habits, the diet is scarcely modified, 544 
LOCAL DISEASES. 
[part it. 
and the quantity of the food taken, and its quality are those adapted to undi- 
minished powers of digestion. The consequence is, that the weakened stomach 
is stimulated to. undue exertion in ordei' to effect the process of chymification, 
and falls subsequently into a proportionate degree of languor; and this alter- 
nation, being continued with a steadily diminishing energy of stomach, and a 
steadily increasing disproportion between its power and the task it has to 
accomplish, ends at length in the production of a permanently morbid gastric 
depression, below the general standard of action for the rest of the system, 
thus constituting dyspepsia. 
The habitual use of food, peculiarly difficult of digestion, has the same 
effect in a healthy stomach, producing an indirect debility, consequent upon 
excessive excitement. Larger quantities of food than the stomach can well 
manage operate injuriously, upon the same principle, and, additionally, by 
weakening the muscular coat through over-distension. Food insufficiently 
masticated operates in like manner as indigestible food, by affording a mecha- 
nical impediment to the action of the gastric juice. The habit of rapid eating 
conduces to the same end, partly through imperfect mastication, but still more 
by overloading the stomach, which is unable to appreciate the quantity of 
food received, in consequence of the rapidity with which it is swallowed, and 
does not, therefore, communicate to the palate the feeling of satiety, at the 
proper point of time. In speaking of indigestible food, it must be borne in 
mind that the term is relative, and always has reference to the energy of 
stomach; those articles often being easily digested by a person accustomed to 
unusual bodily exertion, which are difficult of digestion by ordinary persons, 
and are almost indigestible by a weak stomach. 
The excessive use of alcoholic liquors, opium, or other cerebral or nervous 
stimulants, especially strong coffee and tea, produces dyspepsia, in the same 
manner as indigestible food, by calling the stomach into excessive action, and 
thus occasioning secondary depression, and ultimate loss of power, by the 
exhaustion of the excitability. The spices used largely as condiments have 
a similar effect, though less in degree, because they operate less upon the 
nervous functions. 
Whatever calls off nervous energy from the stomach, by concentrating it 
strongly elsewhere, depresses the gastric actions, and favours the production 
of dyspepsia. Intense and protracted study, or other absorbing mental occu- 
pation, has this effect; and young students, therefore, who are usually at the 
same time sedentary, and indulgent to their appetites, are peculiarly liable to 
the disease. Excessive and exhausting exercise, by directing excitement to 
the muscles, has the same effect. 
Among the causes of dyspepsia must also be enumerated those which have 
an immediate depressing action upon the stomach. Such are the sedative 
narcotics, as tobacco; large quantities of cold drinks, when the stomach has 
little power of reaction; large draughts of lukewarm water; and especially 
the depressing emotions, as grief, anxiety, and fear. 
Pathology.- From what has been said, it will appear that pure dyspepsia 
consists essentially either in depression of stomach, arising from the with- 
drawal of its ordinary supply of nervous influence, or from some immediate 
sedative influence upon it, or in positive debility, from the loss of excitability, 
consequent upon excessive stimulation. In either case, the stomach performs 
less efficiently its appropriate function. In the process of chymification, it 
exercises two offices, first, the secretion of gastric juice for the solution of the 
food, and secondly, the admixture of the food with the juice, by its peristaltic 
movements. In its state of comparative inaction, there is less of the solvent 
secreted, and less of the muscular movement to favour solution. When, CLASS III.] 
INDIGESTION. 
545 
therefore, nutriment is introduced, especially such as is difficult of digestion, 
it remains longer than usual undissolved, and sometimes is not dissolved at 
all. It thus comes within the influence of its own chemical affinities, decom- 
position takes place, and new substances are formed, among which acid and 
gaseous matters are predominant. Hence, in part, the flatulent eructations, 
and the regurgitation of acid, so common in dyspepsia. But a diminution of 
the gastric secretion is not the only result, in relation to that fluid. It is 
also altered in quality, in consequence of the deficient energy of stomach. 
Thus, from being a comparatively bland liquid, it becomes acrid and irritating. 
This altered secretion, the undigested food remaining as a foreign body in the 
stomach, and the acid, &c., resulting from its fermentation, all co-operate in 
producing vascular irritation of the mucous membrane, and often also a sym- 
pathetic nervous irritation of the muscular coat. Hence the heartburn, the 
occasional gastralgia and spasm, and frequently the headache and vomiting of 
dyspepsia. The peculiar epigastric uneasiness, characteristic of the disease, 
arises probably from defective innervation, like the exceedingly disagreeable 
feeling often experienced in a partially palsied limb. The weight, oppression, 
&c., after eating, is the obvious result of undigested food, acting upon a sur- 
face too feeble to respond in the usual manner by an increased secretion of 
gastric juice, and the removal, through its means, of the offending cause. 
Sometimes the food occasions suffering in consequence of the increased sensi- 
bility to painful impressions, which not unfrcquently attends upon the debili- 
tated state of an organ. 
Along with the gastric depression or debility, a similar condition is often 
produced either by the action of the same causes, or by sympathy with the 
stomach, in the bowels, the liver, and perhaps the pancreas. Hence the 
diminished or vitiated secretion of bile, and the constipation of bowels. Hence, 
too, in all probability, the portal congestion which sometimes complicates 
dyspepsia. The diversified nervous disorders, which attend the disease, are 
ascribable partly' to the simultaneous operation of its causes upon other parts 
of the system, as well as upon the stomach, but chiefly to the extended and 
intimate sympathies of this organ. Should the disease not give way, the 
repeated vascular irritation, from the causes already enumerated, at length 
ends in inflammation, which is so much the more difficult of cure, as the de- 
bility both of stomach and system forbids the energetic employment of the 
most effective antiphlogistic measures. 
Treatment.-In the treatment of dyspepsia, the first and by far the most 
important indication is the removal of the causes. The measures requisite for 
this end, embrace the regulation of the diet, the exercise, and the general 
habits of the patient, moral as well as physical. 
Diet.-The most obvious rule, in relation to diet, is to avoid the use of all 
substances of difficult digestion. To be practically useful, however, the direc- 
tion must be more precise, and embrace an enumeration of the particular 
substances to be forbidden or allowed. The following specification is only 
correct in general; for the peculiarities of individual stomachs are so nume- 
r ms, that an article easily digestible by one will often prove almost indigestible 
by another, and vice versa. 
The patient, as a general rule, should avoid all culinary vegetables, with the 
exceptions hereafter to be mentioned; all fruits, whether fresh, preserved, or 
pickled ; all fat, salted, and smoked meats, and those which are tough, from 
whatever source derived. Of the particular kinds of animal food, pork, pig, 
veal, and domestic ducks and geese, are peculiarly difficult of digestion. The 
flesh of very young, or of very old animals, is usually less digestible than that 
of the same animals in the intermediate stages of life. Fish is generally 546 
LOCAL DISEASES. 
[part II. 
deemed of difficult digestion; and most shell-fish, especially clams and lob- 
sters, should be avoided by the dyspeptic. Of substances prepared by the 
culinary art, pastry; fresh, hot, and heavy bread; puddings; cakes made with 
butter or fat; fried meats; hard-boiled eggs; jellies; soups; gravy; and all 
sorts of dressings with butter, sugar, wine, &c., should be forbidden. What- 
ever is pasty, doughy, or disposed to form a tenacious mass with water, resists 
digestion, because impenetrable by the gastric juice. Sausages, and cheese of 
all kinds, are of difficult digestion. Butter, lard, and other fats, when altered 
by heat, are very injurious to the dyspeptic stomach. Brown sugar, molasses, 
and honey, are apt to induce acidity. Vegetable acids have been found to 
be generally injurious; and the fruits which contain them largely should be 
especially avoided. 
The list of allowable substances is not scanty. Among those of vegetable 
origin are wheaten bread, which should always be light, stale, and perfectly 
free from acid; crackers, made without shortening of any kind; well-boiled 
rice; and Irish potatoes, either roasted or boiled so as to be dry and mealy. 
Some object to the last mentioned vegetable, and the small, waxen or watery 
potatoes which are often met with are certainly of difficult digestion; but, 
when of good quality, they agree well with most dyspeptic stomachs. The 
sweet potato, when dry and mealy, though sometimes flatulent, is often very 
acceptable, and may always be tried, when the patient desires it. Tomatoes, 
well prepared, without butter, are found to agree with many individuals, and 
prove useful by their laxative property. The same may be said of perfectly 
ripe, and sweet free-stone peaches, and perfectly ripe blackberries or dewber- 
ries. But all these fruits may, as a general rule, be placed in the category 
of doubtful substances. 
Good fresh milk, boiled or unboiled, is usually easily digested, and forms 
an excellent diet for dyspeptics, especially when stronger animal food may be 
thought hazardous, in consequence of existing or suspected chronic gastritis. 
It forms a good dessert when loosely coagulated by means of rennet, and 
mixed with refined sugar, nutmeg, and a little sound wine. Small quantities 
of sweet cream may be taken with propriety, and even agree with some sto- 
machs which most other food offends. The same may be said of pure ice- 
cream, flavoured with vanilla. This forms a very good dessert for dyspeptics; 
but should always be eaten very slowly, and allowed to dissolve perfectly in 
the mouth, before being swallowed. Good fresh butter, though condemned 
by some writers, has, within my observation, when eaten moderately with 
bread, rice, potatoes, &c., proved in general perfectly innocent. But there is 
a vast difference in this product, and, when badly prepared, or in the slightest 
degree rancid or musty, it is as offensive to the stomach, as it is to the delicate 
palate. It should never be used in dyspepsia after having been subjected to 
any culinary process; as heat has a very injurious effect upon it. 
Among the meats, tender mutton or beef, and among poultry, the common 
fowl or turkey is to be preferred. The flesh of wild animals is in general 
more easily digested than that of the tame. Good venison is perhaps the 
lightest and most digestible of meats. The American pheasant and partridge, 
and the canvass-back duck, with many of the smaller birds, are admissible 
articles. But in eating all sorts of fowl, care should be taken to avoid the 
skin and fat, especially when they are roasted; and the fat of all the meats 
which have been mentioned should be rejected. Both meats and poultry should 
be kept for some time after being killed, before cooking, so as to lessen the 
tenacity of the muscular fibre; but they should never be allowed to be in the 
least tainted. They should be either boiled, roasted, or broiled. When there CLASS III.] 
INDIGESTION. 
547 
are symptoms of even slight gastric inflammation, if flesh is used at all, it 
should be preferred boiled. 
There are various other articles of animal food, well adapted to dyspeptic 
patients; such as oysters, raw or slightly roasted; sweet-bread; the liver of 
calves; terrapins, cooked well without butter; and soft boiled eggs. It is 
highly necessary that eggs should not be overdone. They should be so pre- 
pared that the albumen may be coagulated, while the yolk remains liquid. 
This is accomplished by placing them in boiling water, and keeping them in 
it for three minutes. The yolk of eggs may also be prepared by beating it 
up raw with water, sugar, and a little ginger. This mixture is well adapted 
for those whose stomachs will not allow them to pass the whole interval 
between the regular meals, without food. Although, as before mentioned, 
salted and smoked meats are usually injurious as articles of diet, very small 
quantities of chipped very tender dried beef or venison, or boiled ham, or a 
little smoked herring may be employed with impunity for relish. 
Condiments, such as salt, mustard, black and Cayenne pepper, horse-radish, 
&c., should always be used with moderation. They occasionally prove bene- 
ficial by assisting digestion; and, as their stimulant effects are chiefly local, 
they are less dangerous than alcohol; but, like all other stimulants, if 
abused, they diminish the excitability, and thus increase the already exist- 
ing debility. 
In relation to drinks, the best, upon the whole, is cool water. The vinous 
and spirituous liquors, though they often afford temporary relief, are positively 
injurious if constantly used, and always place the patient in the danger of 
acquiring intemperate habits. Should any one of them be employed, it 
should only be at dinner; and sherry or madeira among the wines, and brandy 
among the spirits should be preferred. Some stomachs bear sound ale or 
porter pretty well, in moderate quantities. For the morning and evening 
meals, an infusion of the chocolate nut, with a little sugar and milk, or a 
cup or two of not very strong black tea, may be used; though water alone, or 
a mixture of milk, sugar, and hot water, would perhaps be preferable. Coffee 
should never be taken, unless occasionally, in small quantity, as a pleasant 
nervous stimulant, immediately after dinner. 
It must be remembered, however, in regulating the diet of dyspeptic patients, 
that the stomach is singularly capricious, and sometimes takes fancies, which, 
however contrary to preconceived opinion, it may be proper to indulge. Such 
fancies, when they persist for a considerable time, are usually signs by which 
nature indicates her wants. Numerous instances have been noticed, in which 
patients have been benefitted if not cured by the use of articles of food, which, 
under ordinary circumstances, are highly indigestible. Experience, moreover, 
will often be a better guide, in any particular case, than general precepts. 
Care, however, must be taken, that the judgment of the patient be not biased 
by his inclinations or prejudices. (See Pointings of Nature, p. 199.) 
Almost as much depends upon the proper mode of taking food as upon 
the selection of the substances to be used. The patient should, as a general 
rule, eat at regular intervals, and three meals a day are usually sufficient. 
The stomach should be allowed some rest; and the habit of eating little and 
often through the day, as well as at bed-time, so that the stomach may be as 
seldom as possible quite empty, is not advisable. In some cases, when the 
interval between breakfast and dinner is long, and the patient suffers much 
from an empty stomach, a few oysters, a little egg prepared in the manner 
above mentioned, or some other light food, may be taken about two hours 
before the latter meal. Large suppers are very injurious, as they overtask the 
digestive organs at a time when their energy is least. Great care should at 548 
LOCAL DISEASES. 
[PART II. 
all times be taken not to overload the stomach. On this account the patient 
should eat slowly; as the stomach will be more likely to give the signal of 
satiety at the proper time, when permitted to feel the full influence of the food 
as it is swallowed. Besides, it is of great importance that the food should be 
thoroughly masticated, so as to favour its solution; and this is prevented by 
rapid eating. A meal should never be taken immediately after fatiguing 
exercise; as the stomach participates in the general languor. The patient 
should not drink largely, especially at meals. Besides the injurious effects 
of distension, the solvent power of the gastric juice is diminished by too great 
dilution. 
Exercise.-The great object of exercise is to equalize excitement, so that 
each organ may have its due Supply of blood and of nervous influence. This 
is accomplished by a combination of passive and active exercise. By the 
former the viscera are especially acted on, by the latter the whole of the 
voluntary muscles, and the structures associated with them in function, while 
both affect the nervous system. Of the different kinds of passive exercise, the 
best, as a general rule, for the dyspeptic, is riding on horseback; the next best, 
riding in a somewhat .rough vehicle, or over a rough road, as in one of our 
stage-coaches over a stone turnpike. These, however, will be found too 
severe for some very delicate persons, especially those in whom there is a 
nervous tenderness of stomach. For such persons, driving in an ordinary 
carriage, or travelling on rail-roads, or sailing may be substituted. Of the 
modes of active exercise, walking is best for persons somewhat advanced 
in life; running, leaping, &c., may be practised by the young. Gymnastic 
exercises are also useful; but care is necessary to avoid the temptation of 
carrying them to extremes. In bad weather, and for persons who cannot 
conveniently leave their homes, exercise of various kinds within doors should 
be contrived. The ordinary household duties afford abundant opportunities 
for active exercise to females. When the patient cannot command the means 
or opportunities for riding, he may substitute the plan recommended by Hal- 
sted, or some analogous one, for giving passive exercise to the stomach. This 
consists in bending the body forward, and so relaxing the abdominal muscles 
as to allow the hands to be pressed with their palms upward beneath the sto- 
mach ; and then, by gentle and repeated impulses with the fingers, keeping up 
a regular movement in that organ. It should not, however, be practised when 
the process is painful, or there is any reason to suspect inflammation of the 
stomach. It often affords relief in flatulence. 
Exercise should be as regular as possible, and promptly timed in relation 
to the periods of eating. Violent exercise should never be taken immediately 
before or immediately after a full meal. I am disposed, however, to believe, 
with Dr. Beaumont, that gentle exercise after eating, especially of the passive 
kind, rather promotes than interferes with digestion. (Exp. and OLs. on the 
Gastric Juice, &C.} In taking exercise, the dyspeptic should always stop 
short of great fatigue. It is important that this remedial measure should not 
become irksome to the patient, and, therefore, that some other immediate 
object should if possible be associated with it, besides the mere promotion of 
health. It is always desirable to connect it with the pursuit of interest or 
enjoyment. Hence one of the advantages of travelling. 
General habits.-1The patient should observe regularity and moderation in 
all his habits. Excesses of all kinds are injurious to the debilitated stomach. 
He should retire early to bed and rise early, allowing from six to eight hours 
for sleep, and never permitting either pleasure, business, or study, to encroach 
upon his period of rest. The sleeping apartment should be well ventilated, 
and mattrasses used in summer instead of feather beds. Nevertheless, it CLASS III.] 
INDIGESTION. 
549 
would he injurious to sleep so lightly covered as to suffer in the least from 
cold. It is- a mistake in dyspeptic individuals to suppose that they Can harden 
themselves in this way. Personal cleanliness should be rigorously observed; 
but the too frequent or long continued use of baths, especially of warm baths, 
is injurious by their sedative or relaxing influence. The cold bath, or shower 
bath, is to be preferred when a vigorous reaction follows. This, indeed, is an 
excellent remedial measure in dyspepsia. But, when the system is too feeble 
to react thoroughly, the tepid bath must be used; and the patient should 
remain in it no longer than is necessary for cleanliness. When the skin is 
in a cold, languid state, the warm salt-bath will often be found useful; and 
friction to the surface, by means of a flesh-brush, or coarse towel, should be 
employed daily. Friction over the abdomen is highly advantageous. The 
patient, moreover, in employing this measure, has the additional benefit of 
wholesome exercise. 
Relaxation from severe study, and from the cares and anxieties of harass- 
ing business, of whatever kind, is essential to the cure of dyspepsia. Yet the 
mind must not be left without occupation; as in no disease is it more apt to 
prey upon itself, when surrendered wholly to its own caprices. Innocent 
amusements, cheerful society, light reading, and moderate professional occu- 
pation, exercise a very healthful influence. Sources of mental depression 
should always, as far as possible, be removed or counteracted. All these 
objects can be accomplished in no other way so effectually as by travelling, 
which unites the advantages of exercise, pure air, relaxation from care, and 
agreeable excitement of the mind; and, if directed to some suitable watering- 
place, affords the additional advantage of an efficient medicinal agent. To 
render a journey permanently useful, it must be a long one; and hence a 
voyage to Europe or some foreign country, and an absence of six months, a 
year, or more, are among the most effectual means -of curing dyspepsia. It 
is probable that the effect produced on the stomach by the sea-sickness, and 
consequent abstinence is advantageous in many cases. 
Medicinal Treatment.-Two principal indications are presented in dyspep- 
sia for the use of medicines; first, to keep the bowels regularly open, and 
secondly, to make a moderate, but durable stimulant impression upon the 
stomach. The former is to be accomplished by laxatives or enemata, the 
latter by tonics. It has been recommended to commence the treatment with 
an emetic of ipecacuanha. This, however, is called for only in certain inci- 
dental conditions; as when serious inconvenience is experienced from offend- 
ing matters in the stomach, or where it is desirable to arouse the languid 
portal circulation, and thus remove congestion. If emetics should be em- 
ployed merely for stimulating the stomach, little permanent effect could be 
expected from them, unless occasionally repeated; and the danger of irritation 
might, in this case, be greater than the chance of benefit. In general, there- 
fore, it is safest to dispense with them. 
It would be desirable to maintain regular alvine evacuations by means of 
diet alone; but unfortunately the articles of food best calculated for this effect, 
such as the fruits and fresh vegetables, are inadmissible from their difficulty 
of digestion, and aptness to occasion acidity and flatulence. Bran bread, or 
bread made from unbolted flour, is not liable to this objection, and consti- 
tutes, on account of its laxative quality, an excellent article of diet for dys- 
peptics. It does not, however, suit all stomachs, and frequently fails in pro- 
ducing the effect desired. When medicines are employed, those should be 
selected, as a general rule, which have no tendency to weaken the stomach, 
but on the contrary unite some tonic or stimulant with their laxative power. 
Rhubarb and aloes are the most suitable. They may be given separately or 550 
LOCAL DISEASES. 
[part II. 
combined; and the most convenient period for administering them is gene- 
rally at bedtime, so that they may act in the morning. Rhubarb may be 
used in all cases; aloes in all, when there is no tendency to piles or uterine 
irritation. Combination with soap is thought to render them milder, without 
impairing their efficacy. They are usually given in pill; but many persons 
are in the habit of chewing rhubarb, or of taking it reduced to powder by 
grating. In the latter case, it may be advantageously associated with grated 
nutmeg. When these medicines lose their effect by repetition, they may be 
mixed with a minute proportion of croton oil. One-sixth of a drop will often 
be sufficient to communicate to them the requisite activity. I have found a 
small teaspoonful of Cheltenham salt, taken half an hour or an hour before 
breakfast, in half a tumblerful of water, to be an admirable laxative in some 
cases of dyspepsia. A draught of Saratoga water, taken at the same time, 
also answers a good purpose. A drachm of sulphur once or twice a day, is 
especially useful in cases complicated with rheumatism. White mustard seeds 
unbruised, in the dose of a tablespoonful, repeated as often, have been found 
to answer well in cases requiring a somewhat stimulant impression. Magnesia 
should be employed in cases of acidity of stomach. Mild laxative enemata or 
suppositories, applied daily, are sometimes usefully substituted for cathartics 
by the mouth. In general, however, they do not sufficiently affect the upper 
bowels. 
Tonics must be used with caution. If largely employed, and long and 
steadily persevered in, there is danger that they may wear out- the excitability 
of the stomach, and thus indirectly increase the debility they were given to 
relieve; while, at the same time, they may increase the danger of chronic 
inflammation. They should never be used as substitutes for the course of 
treatment above recommended, but only as adjuvants; for, if administered 
while the causes of the disease continue to act, they can only afford present 
relief at the risk of future mischief. When tire stomach is placed under cir- 
cumstances in which, upon being excited to the proper point by artificial 
means, it can execute its function duly without further aid, tonics may be 
advantageously employed; but they should be omitted as soon as they are 
found no longer necessary. The best for the purpose are, on the whole, the 
purer bitters, such as columbo, gentian, and quassia. Chamomile is well 
adapted to mild cases. Wild cherry bark may be used when an irritable cir- 
culation, indicated by the occurrence of palpitations or very frequent pidse 
under slight excitements, is associated with the gastric depression. Serpenta- 
ria is applicable to cases of unusual debility; and valerian may be advan- 
tageously combined with the bitters, when the patient is affected with symp- 
toms of hysteria, or other nervous functional disorder. The officinal infusions 
of these medicines may be given in the dose of a wineglassful, three or four 
times daily. Gentian and quassia may also be conveniently administered, in 
the form of extract. The tinctures should be employed cautiously, and only 
as adjuvants of the other preparations, when the stomach is very feeble. Of 
the mineral tonics, the chalybeates are to be preferred. Of these, the best 
are the pills of carbonate of iron of the U. S. Pharmacopoeia. Sulphate of 
iron combined with twice its weight of carbonate of soda or carbonate of po- 
tassa, and incorporated, either in liquid mixture or pill, with honey or syrup, 
affords a good substitute for this preparation, when it does not happen to be 
at hand. Subcarbonate of iron, tincture of chloride of iron, and solution of 
iodide of iron, are also good preparations. The chalybeate mineral waters, 
which usually contain the carbonate of iron dissolved by means of carbonic 
acid, are among the best tonics in dyspepsia. Besides the substances men- 
tioned, sulphuric, nitric, and muriatic acids, subnitrate of bismuth, sulphate CLASS III.] 
INDIGESTION. 
551 
of zinc, and nitrate of silver, are sometimes used. Carbonic acid water is also 
an excellent tonic in dyspepsia, and usually very acceptable to the stomach, 
but like all others is liable to be abused. Creasote has also been recom- 
mended; but I have not employed it. A current of electricity or galvanism, 
made to pass through the stomach, is sometimes useful when that organ is 
peculiarly torpid. 
Advantage will often accrue from the combination of medicines, to meet 
different indications. Thus, the bitter tonics may be associated with the aro- 
matics, and, when a laxative effect is desired, with the cathartics. An infu- 
sion of columbo, ginger, and senna is an excellent preparation, from which I 
have derived great advantage in dyspepsia.* Rhubarb among the cathartics, 
and orange peel, cloves, cardamom, fennelseed, &c., among the aromatics, may 
in like manner be connected with the bitters; and, when there is excess of 
acid in the stomach, one of the alkaline carbonates may be added to the infu- 
sion. The extracts of gentian and of quassia may be combined, in pills, with 
rhubarb or aloes, and one of the chalybeates; and, when a carminative effect 
is desired, with an aromatic volatile oil. When the bilious secretion is defi- 
cient, a little of the mercurial pill or calomel may be added to the other 
ingredients. 
It is always proper to attend to the state of the skin. To invite excitement 
to the surface, and restore the function of perspiration, are prominent indica- 
tions. The use of the cold or shower bath, of the warm salt-bath, and of 
frictions has been already mentioned. Flannel should be worn next the skin 
at all seasons, unless in the very hottest weather of summer, when they who 
perspire very freely may substitute some soft and warm fabric of cotton or 
silk. Occasional small doses of opium and ipecacuanha combined are recom- 
mended by Dr. Wilson Philip. The coldness of feet so common in this com- 
plaint should be obviated by stimulating applications, and suitable covering. 
The occasional use of mustard pediluvia, the wearing of socks sprinkled with 
Cayenne pepper, and the application of a plaster of Burgundy pitch, or of the 
resin plaster, to the soles of the feet, have all been recommended. Perhaps 
the most effectual method is to bathe the feet every morning, for a short time, 
in very cold water, and then rub them thoroughly dry. This, however, should 
not be practised, unless reaction take place readily. 
The hepatic secretion also demands a vigilant attention. If diminished or 
deranged, it is best corrected by alterative doses of the mercurial pill or calo- 
mel, either alone, or combined with the tonic and purgative medicines. The 
decoction or extract of dandelion may be used as an adjuvant; and nitro- 
muriatic acid comes in very well in such cases, as a substitute for the mer- 
curial. 
Various incidental affections, occurring in the course of dyspepsia, require 
a treatment more or less independent of the general plan. For an account of 
these the reader is referred to the different heads under Gastric Irritation, 
where he will find a detail of the treatment appropriate to gastralgia, pyrosis, 
spasm of the stomach, nausea and vomiting, and sick-head ache, all of which 
are occasional attendants on this complaint. I shall have occasion hereafter 
to treat of flatulence. Some more precise remarks upon the remedies for 
acid in the stomach, than will be found in other parts of the work, may be 
appropriate here. The best palliatives for this are the antacids. Of these 
magnesia is the most effective as a neutralizing agent, and should be preferred 
when the quantity of acid is large, and there is a coincident indication for a 
R.-Colomb. contus., Zingiber, contus., aa ^ss; Sennas gij; Aq. bullient. Oj. Fiat 
infusum, & A- wineglassful twice or three times daily, before meals. 552 
LOCAL DISEASES. 
[part II. 
cathartic effect. The carbonate of magnesia is Hss disagreeable to the taste, 
and may be substituted in twice the dose, when the carbonic acid which it 
evolves may not constitute an objection. Being in lump, it is habitually 
chewed by some persons, in minute quantities, when they suffer with heart- 
burn. When the quantity of acid is small, the solution of magnesia in car- 
bonic acid water, by which the bicarbonate is probably formed, may be used 
by those who prefer it. In cases which do not require a laxative, the bicar- 
bonate of soda is preferable to the magnesian preparations, as more acceptable 
to the stomach. When vomiting is connected with acidity, lime-water is 
often given with advantage. (See Vomiting.} If diarrhoea exist, and a laxa- 
tive effect is to be avoided, the prepared chalk or prepared oystershell should 
be preferred. In cases of great stomachic torpor or coldness, the preparations 
of ammonia are most appropriate. The carbonate, aqueous solution, spirit, or 
aromatic spirit of ammonia, may either of them be given. The last is the 
most elegant, though rather feeble, and may be usefully added to the other 
antacids, which it renders less offensive to a very weak stomach. None of 
these antacids should be employed unless, acid is actually present, as they 
have no power to prevent its generation. Their beneficial operation is chiefly 
confined to the removal of a present evil, and, if too largely given, most of 
them have a tendency to debilitate the stomach. A proper regulation of the 
diet, and the application of all the means above detailed as remedies for dys- 
pepsia, must be looked to for permanent relief. 
When chronic gastritis has supervened upon dyspepsia, the patient must 
be treated for the former affection, reference being always had to the debility 
of stomach, and general debility which attend the latter. (See Chronic 
Gastritis.) 
SUBSECTION IE. 
DISEASES OF THE BOWELS. 
Article I. 
INFLAMMATION OF THE BOWELS. 
The intestinal tube is seldom if ever inflamed throughout its whole extent. 
Nor are the phenomena which different portions of it present, or the treat- 
ment they demand, in a state of inflammation, quite identical. It is, there- 
fore, convenient, to divide the intestines into distinct sections, and to consider 
the affection in each of these separately. It is nevertheless true, that inflam- 
mation in any one section often spreads, to a greater or less extent, into that 
which adjoins it; and, in some instances, it would be impossible to decide 
which of the two is most prominently affected. I shall treat separately of 
inflammation of the upper portion or duodenum, of the middle portion, em- 
bracing chiefly the jejunum and ileum, and of the lower portion or large 
intestines. 
1. INFLAMMATION OF THE DUODENUM, or DUODENITIS. 
The duodenum is liable to the same modes of derangement as the stomach, 
and very frequently participates in its diseases. Thus, the various forms CLASS III.] 
INFLAMMATION OF THE DUODENUM. 
553 
already described of gastric inflammation and irritation, cancer of the stomach, 
and even that condition of the organ denominated dyspepsia, extend in many 
instances to this portion of the bowels. Indeed, the duodenum itself is very 
seldom independently affected. The modifications produced either in the 
symptoms or treatment of stomachic disease by this complication are very 
few; and, even where the duodenum may be supposed to be the exclusive 
seat of disorder, the phenomena and indications of cure are so similar to those 
presented by the analogous condition of the stomach, that it would be useless 
repetition to enter into minute detail, in relation to the morbid affections of 
the former structure. I shall, therefore, content myself with referring merely 
to the diagnostic symptoms-, and to those points in the treatment which are 
in any degree peculiar. The circumstance, in diseases of the duodenum, 
which most deserves notice, is their peculiar tendency to produce functional 
disorder of the liver. Diseases exclusively gastric have the same tendency, 
but in an inferior degree. Broussais appears to have been the first to call 
attention decidedly to this fact. Among the phenomena of hepatic or bilious 
disorder, accompanying affections of the duodenum, the most striking is a 
jaundiced state of the skin. The mode in which this is produced has been 
variously explained. It has been ascribed to a closure of the common duct 
of the liver, either by mucus, or a thickening of its coats consequent upon 
duodenal inflammation, and to the absorption of the bile thus impeded in its 
passage to the bowels. This explanation may possibly apply to some cases; 
but it is probably not true in general, and certainly not universally; for cases 
of duodenitis with jaundice occur, in which bile freely enters the bowels; and, 
in fatal cases, the duct has been repeatedly found upon dissection entirely 
unobstructed. A more probable explanation is founded upon the observation 
of Bichat, that between a secreting gland and the surface upon which its ex- 
cretory duct opens, there is a sympathy by which a stimulus applied to the 
latter causes an increased action in the former. Thus, the stimulus of food 
in the mouth causes an increased secretion of saliva. In like manner, the 
presence of the chyme in the duodenum stimulates the liver and pancreas, so 
that an increased supply of bile and pancreatic fluid, which are useful in the 
process of digestion, may be received where they are wanted. Irritation or 
inflammation of the duodenum should, therefore, produce irritation of the 
liver, which, according to its degree, may be attended either with an increase 
or diminution of the secretion of bile. In the former case, absorption takes 
place from the abundance thrown into the biliary passages and bowels, in the 
latter the materials out of which the bile is formed accumulate in the blood; 
and, in both cases, the yellow colouring matter is eliminated upon the surface 
and elsewhere. Again, in the dyspeptic or depressed state of the duodenum, 
it is incapable of receiving the ordinary impression from the chyme, and the 
ordinary stimulus is consequently not supplied to the hepatic secretory func- 
tion. In this way also the secretion of bile is diminished, its materials accu- 
mulate in the blood, and jaundice results. But, notwithstanding the occa- 
sional dependence of bilious affections upon disease of the duodenum, I believe 
that some authors have pushed this view much too far, and given to that 
viscus a pathological importance which it does not merit. Jaundice and 
other bilious symptoms may sometimes ■ result from duodenal inflammation; 
but much more frequently they proceed originally from the liver, and the 
duodenum, if at all involved, is so either secondarily, or simultaneously from 
its exposure to the influence of the same causes. 
Diagnosis.-Duodenitis, when it occurs, is almost always associated with 
inflammation of the stomach or of the bowels. Its. existence may be suspected 
when, in addition to the ordinary symptoms of gastritis, there is- deep-seated 554 
LOCAL DISEASES. 
[part II. 
pain in the vicinity of the pylorus, extending below the stomach toward the 
left hypochondrium, or pain in the back about the first or second lumbar ver- 
tebra; when there is tenderness upon strong pressure in the space which lies 
immediately to the left of the right hypochondrium, without any evidence of 
enlarged or inflamed liver; and when the skin is more or less yellow, and the 
urine bilious, as in jaundice. If these symptoms should occur, without vomit- 
ing, great thirst, or pain and tenderness in the region of the stomach, indi- 
cating gastritis; without diarrhoea, pain in the lower bowels, or tympanites 
indicating enteritis; and without enlargement or tenderness of the liver indi- 
cating hepatitis, it may be inferred that the inflammation is confined chiefly, 
if not exclusively, to the duodenum. In acute duodenitis there is occasionally, 
along with the fever, a degree of coma dependent probably upon the hepatic 
derangement. In the chronic form of the complaint, a diagnostic symptom 
is the occurrence of pain two or three hours after a meal, arising from the 
passage of a portion of the contents of the stomach into the duodenum. The 
bowels in duodenitis are generally slow, but readily acted on by cathartics. 
The appearances after death are so similar to those in gastritis as not to 
require particular notice, except in relation to the mucous follicles, or, as they 
are often called, the glands of Brunner, which are very numerous in the duo- 
denum, especially near the pylorus, and, in inflammation of this viscus, are 
apt to be enlarged, exhibiting sometimes elevated, irregular, almost continuous 
patches, of considerable extent. 
The causes of duodenitis are essentially the same as those of inflammation 
of the stomach. Such of them, however, as act through the liver are probably 
more influential in producing the former than the latter affection. 
Treatment.-The treatment also is that adapted to gastritis If there be 
any difference, it is chiefly in the freer use of mild cathartic medicines, such 
as the neutral salts, bitartrate of potassa, castor oil, senna, &c., and in a more 
frequent employment of mercury, which in the acute form may be pushed to 
salivation, but in the chronic should in general be restricted to an alterative 
action on the functions of the liver. 
2. INFLAMMATION OF THE SMALL INTESTINES, 
or ENTERITIS. 
Syn.-M uco-enteritis.--Ileitis.-Ileo-colitis. 
The name enteritis is, strictly speaking, applicable to inflammation of any 
portion of the bowels; yet, as this affection, in the upper and lower extremi- 
ties of the intestinal tube, has received the designations of duodenitis and 
dysentery, and as the symptoms of these two complaints are in certain points 
strikingly peculiar, it becomes convenient to give a distinct name to inflam- 
mation of the intervening portion, and enteritis may perhaps, without impro- 
priety, receive this more restricted meaning. It should be understood that 
inflammation of the peritoneal coat of the bowels, as a distinct affection, though 
hitherto frequently denominated enteritis, is not here included under that 
term, as it clearly belongs to peritonitis. Enteritis, then, as employed in this 
work, signifies inflammation of the mucous membrane of the jejunum and 
ileum, extending frequently to a greater or less distance into the colon, and 
occasionally involving the other coats as a secondary result. The force of the 
disease is usually spent upon the ileum, the jejunum being less liable to in- 
flammation than any other portion of the alimentary canal. The greater 
liability of the ileum to be affected depends, probably, on that arrangement 
by which the fluids, in their passage through the bowels, are somewhat im- CLASS III.] 
IMFLAMMATION OF THE SMALL INTESTINES. 
555 
peded at the ileo-caecal valve, and commencement of the ascending colon, and 
thus have the opportunity of exercising a more protracted irritant influence 
on this than upon the upper portion of the tube. As the inflammation may 
extend indefinitely into the colon, it is obvious that the phenomena of dysen- 
tery must often be mingled with those of the complaint under consideration; 
and cases occur, in which it would be impossible to decide to which affection 
they should be referred; yet, for the most part, the symptoms are sufficiently 
distinctive. Attempts have been made to divide enteritis into the common 
diffused inflammation of the membrane, the follicular or that affecting espe- 
cially the mucous follicles, and the pseudo-membranous or that attended with 
the formation of false membrane. But, though there are cases in which each 
of these forms severally predominates, yet they are frequently intermingled; 
they offer no symptoms during life by which they can be sufficiently distin- 
guished when occurring as original affections, and, even could they be distin- 
guished, no great practical good would accrue. The follicular enteritis of 
enteric fever is treated of in connexion with that disease. 
Acute Enteritis.-The complaint commonly begins with uneasiness in 
the bowels, followed after a time by occasional slight griping pains, which 
gradually become more frequent and severe. In some cases, however, the 
symptoms are violent from the commencement, and in others, again, very 
little pain is felt throughout. There is generally more or less tenderness 
upon pressure. The seat ,of the pain and tenderness is usually about the 
umbilicus, though it varies with the part inflamed, and is not unfrequently 
found more especially in the right iliac region. 
Diarrhoea is a very frequent symptom. Discharges from the bowels are 
apt to follow attacks of griping pain, which they often mitigate; and several 
of these discharges may occur in the course of a day. The lower in the bowels 
is the seat of inflammation, the more liable is it to be attended with diarrhoea, 
and the more frequent, as a general rule, are the evacuations. In cases where 
the bowels are not loose, they are for the most part readily and frequently 
moved by very small doses of mild cathartics. Sometimes the diarrhoea is 
suspended and again recurs, and this may happen several times during the 
course of the complaint. The stools are usually liquid, consisting of the 
increased serous exhalation of the intestines, mixed with fecal matter, bile, 
mucus, and undigested food, and sometimes tinged with blood. Occasionally, 
they are dark or green from the changed bile, or clay-coloured from the absence 
of that fluid. There is occasionally some flatulent distension of the bowels; 
but this rarely amounts to tympanites, unless in children. When the inflam- 
mation depends upon obstruction in the bowels, or affects to any considerable 
extent the muscular and peritoneal coats, constipation instead of diarrhoea is 
experienced. Sometimes, indeed, the constipation, in inflammation involving 
the whole thickness of the bowel, is extremely obstinate, giving rise to vomit- 
ing and tympanitic distension, so as to resemble cases of obstruction, and 
sometimes to have been mistaken for them, with unfortunate therapeutical 
consequences.* 
Febrile symptoms sometimes precede those of a local character, the sympa- 
thies and sensibility of the intestinal mucous membrane being such, that its 
inflammation may be felt by the system at large before making itself known 
by pain or increased secretion. In such cases, there is general uneasiness, 
languor, and diminished appetite, with alternate chilliness and flushes of heat 
for some days before the occurrence of pain. The fever when established is 
* See an interesting paper by P. M. Kollock, M.D., of Savannah, Georgia, in the Im. 
Journ. of Med. Sci., N. S., vii. 348. 556 
LOCAL DISEASES. 
[PART II. 
often remittent in character. The pulse is more or less excited and usually 
well developed, the skin dry, the urine scanty, and the tongue moist, and 
somewhat furred. There is usually little or no headache or delirium. 
The disease is often very mild, running its course in a few days, with little 
fever or pain, and but a slight diarrhoea. Even the severer cases, when pro- 
perly treated, and not injuriously complicated, or subjected to the continued 
action of the cause, generally begin to decline in about a week. The result, 
however, is not always so favourable. The pains, instead of diminishing, are 
aggravated; the flatulent distension increases; the discharges become very 
offensive; inflammation ascends to the stomach, and vomiting occurs, with 
burning thirst, and epigastric tenderness; the liver sometimes becomes in- 
volved, and jaundice is added to the other symptoms; delirium sets in; the 
tongue becomes red and dry, and the pulse frequent and feeble; great ema- 
ciation takes place; and the patient either sinks at last, or recovers after a 
tedious and uncertain convalescence. In other cases, the peritoneal coat be- 
comes inflamed, in consequence either of a direct extension of the disease from 
the mucous coat, or of an ulcerative perforation of the intestine, and the escape 
of its contents into the abdominal cavity. This event is marked by the 
occurrence of symptoms characteristic of peritonitis, and is too apt to prog- 
nosticate a fatal issue. Acute enteritis also frequently terminates in the 
chronic form. 
Some writers make a distinct disease of inflammation of the caecum, but 
without sufficient grounds, as there is nothing peculiar in its causes or symp- 
toms. Pain and tenderness in the right iliac region, attended, if there be not 
complete obstruction, with a muco-feculent diarrhoea, and occasionally with an 
aching sensation in the lumbar region, are the characteristic phenomena. The 
cause is most frequently accumulation of feculent matter, undigested food, or 
insoluble bodies taken into the stomach, as the stones of fruit, &c. Like other 
portions of the bowels, the caecum is liable to ulcerative perforation, which 
may occasion diffused or circumscribed peritonitis, or, if the perforation be in 
the posterior part of the bowel, where it is attached without peritoneal cover- 
ing to the iliac fascia, may occasion the formation of abscesses, opening after 
a longer or shorter period of suffering, hectic, &c., in the lumbar region. The 
append^da vermiformis is also, in some instances, the seat of inflammation, 
which may end in ulceration, perforation, and peritonitis. This is especially 
apt to result from the presence of insoluble bodies, such as calculous concre- 
tions, and the stones or seeds of fruits. 
Anatomical Characters.-The same changes of colour, consistence, and 
thickness in the mucous membrane are found in this disease as in gastritis. 
(See Acute Gastritis.) The follicles, however, are. more frequently seen 
enlarged, forming small eminences, sometimes ulcerated upon their summits, 
and surrounded by an areola of inflammation. Occasionally two or more of 
these ulcers coalesce, presenting a more extended surface, and an irregular 
outline. Ulceration is also observed in intervening portions of the membrane. 
The process sometimes extends deeply into the parietes of the bowel, pene- 
trating the submucous and the muscular tissues, and leaving only the perito- 
neal coat at the bottom of the ulcer. Under such circumstances, a moderate 
force is sufficient to produce a rupture, and consequent effusion into the 
abdominal cavity. This, however, very seldom happens, unless in typhoid 
fever or tuberculous affections. Portions of false membrane are occasionally, 
though rarely, observed adhering to the surface of the mucous membrane. 
Gangrenous sloughs are rare, probably because death ensues before those 
changes can occur which are consequent upon mortification. In some in- 
stances, however, portions of the bowels have been found dark and gangren- CLASS III.] 
INFLAMMATION OF THE SMALL INTESTINES. 
557 
ous, especially in cases of obstruction; and, in such cases, the whole thickness 
of the intestine sometimes sloughs, allowing the escape of its contents. 
Causes.-Among the causes of enteritis may be mentioned exposure to cold, 
especially when in a state of perspiration, retrocession of gout, rheumatism, 
and cutaneous eruptions, and the suppression of accustomed discharges. It 
is produced, also, by the direct contact of irritating substances, as by articles 
of food which have passed undigested through the stomach, acrid medicines, 
especially drastic purges, poisons, hard insoluble bodies which have been swal- 
lowed, acrid secretions from the stomach, liver, pancreas and bowels them- 
selves, worms, and by various causes which more or less completely obstruct 
the bowels, such as feculent or other solid accumulations, tumours, intussus- 
ceptio, strangulation, &c. Enteritis is a frequent attendant upon other 
diseases, especially typhoid fever, the exanthemata, and consumption, is one 
of the consequences of extensive burns, and may arise from the propagation 
downward of inflammation of the stomach. It attacks indiscriminately per- 
sons of both sexes and all ages, but is probably most common in children. 
Diagnosis.-This complaint is distinguished from peritonitis by the want 
of that intense pain and tenderness, that excessive vomiting, that obstinate 
constipation and tympanites, and that contracted, frequent pulse, so common 
in the latter affection. When these symptoms occur during the progress of 
enteritis, there is reason to believe that the inflammation has attacked the 
peritoneal coat, and, if they come on suddenly, that the bowel has been per- 
forated. Colic is distinguished by the greater severity of the pain and its 
more decided spasmodic character, by the relief afforded by pressure, by the 
constipation which attends it, and by the frequent entire absence of fever. 
Another affection with which enteritis might be confounded is rheumatism of 
the abdominal parietes. But in this the pain and tenderness are more super- 
ficial, the patient suffers extremely from any attempt to move his body, there 
is no diarrhoea, and, if any febrile action exist, it is much less than would 
attend an equal amount of local suffering from enteritis. 
General Treatment.-Bleeding from the arm may be resorted to when the 
pulse is strong and excited, and may sometimes be repeated once and again 
with advantage in vigorous constitutions; but, in the great majority of cases, 
it should be moderately employed, and, in many of a mild character, or in 
feeble constitutions, should be wholly dispensed with. If the disease is 
attended with constipation, and especially if there is reason to believe that 
the liver is somewhat torpid, a cathartic dose of calomel should be given, fol- 
lowed, if it do not operate, by castor oil. Even when there is diarrhoea, laxa- 
tives are indicated in order to remove irritating secretions or accumulations. 
For this purpose castor oil often answers admirably well, combined with fifteen 
or twenty drops of laudanum, which relieves pain without preventing the 
action of the medicine. Magnesia is preferable when there is much acid in 
the bowels, which may often be known by the odour and colour of the stools. 
A mixture of magnesia and manna with fennelseed tea forms a very good 
combination, in such cases. Throughout the complaint, the bowels should be 
kept open, if necessary, by these laxatives, or by the neutral salts, so that 
there may be two or three stools daily. Emollient encmata may be substi- 
tuted, if cathartics are found too irritating, and, in any case, may be used as 
adjuvants. The drastic purgatives should never be employed; and much 
smaller doses of the medicines mentioned will answer than under ordinary 
circumstances. It is also desirable to direct action towards the surface. When 
the skin is hot and dry, and the febrile action considerable, the neutral mix- 
ture or effervescing draught may be employed, combined, if it irritate the 
bowels, with a small portion of laudanum; in other cases, the powder of opium 558 
LOCAL DISEASES. 
[PART II. 
and ipecacuanha is preferable. This should be given at night, so as to pro- 
cure rest. Calomel or the blue mass should be added, in small doses, when 
there is deficiency or derangement of the hepatic function. The warm bath 
is also very useful, especially in the cases of children. Should the disease 
not yield, one of the mercurials may be given in connexion with opium and 
ipecacuanha, in small doses, repeated at short intervals, and continued until 
the mouth is slightly affected.* Either of the mercurials already mentioned 
will answer; but, when there is considerable diarrhoea, the blue mass, or mer- 
cury with chalk, is perhaps preferable to calomel. In the advanced stages, 
after the subsidence of fever, and when the indication to check diarrhoea 
exists, cretaceous or testaceous mixtures, containing the blue mass and lau- 
danum, and given in small and frequently repeated doses, will be found highly 
useful, particularly in children.f Under similar circumstances, I have also 
derived advantage from a mixture of nitro-muriatic acid and laudanum.J 
Great care is requisite in relation to the diet. In very severe cases, with 
much fever, a solution of gum arabie will be sufficient. When something 
more nutritious is required, the farinaceous drinks, such as barley-water, rice- 
water, bread-water, and solutions of arrowroot, sago, and tapioca may be given. 
A little black tea and dry or toasted bread may be allowed to patients who 
crave them. In the declining stages, weak chicken or mutton broth, without 
fat or vegetables, will sometimes be found useful. 
Local Treatmen t.-The most efficient local measure is leeching immediately 
over the seat of tenderness. Three or four dozen American leeches will gene- 
rally be sufficient, though more may often be applied with advantage. When 
these cannot be obtained, cups may be substituted. Many cases, however, 
require neither. Warm fomentations or emollient cataplasms should be kept 
constantly applied for days together; with these laudanum or hops may be 
conjoined as anodynes; and advantage will sometimes ensue from the addition 
of a little mustard, or other rubefacient. I have found much benefit from 
bruised garlic mixed with emollient cataplasms, especially in infantile cases 
with tympanitic abdomen. When the disease is obstinate, a blister should 
be applied over the abdomen, and, if a mercurial impression is desired, the 
vesicated surface may be dressed with mercurial ointment. 
When the stomach, liver, or brain, becomes involved, treatment adapted to 
the affections of these organs respectively must be resorted to. Should the 
disease reach the peritoneal coat, more active depletion, both general and 
local, will be required. But if the peritoneal inflammation arise from per- 
foration of the bowel, and the escape of its contents, large and frequent doses 
of opium, as recommended by Graves and Stokes, are the only means from 
which much good can be expected. (See Peritonitis.') In convalescence, it is 
highly important to regulate the diet so as to avoid relapses, which probably 
proceed from errors in this respect more commonly than from any other cause. 
The patient should resist his frequently strong inclination to eat to excess. 
The lightest and most digestible articles of animal food should first be em- 
ployed, along with easily digestible farinaceous substances, and a gradual 
advance made to more substantial aliment. Most of the fresh vegetables and 
fruits should be avoided until health is re-established. 
* R.-Opii pulv., Ipecac, pulv. aa gr. i]; Pil. Hydrarg. gr. xij; Acacia; pulv., Syrup, 
aa q. s. Misce et fiant pil. no. xij. S. One every two hours. 
f R.-Cretas Ppt., vel Testte Ppt. gij; Pil. Hydrarg. gr. viij; Tinct. Opii gtt. xxx; 
Acaciae pulv., Sacch., aa ^iss; Aquae Cinnam. f^j; Aq. fluvial, f^iij. Misce. S. A 
tablespoonful for an adult every two, three, or four hours; to be diminished for children. 
J R.-Acid Nitromuriatic, git xl; Tinct. Opii gtt. xl; Aquae fluv. f^ viij. Misce. S. 
A fluidounce to be taken six times a day, diluted with water, in a glass vessel. CLASS III.] 
INFLAMMATION OF THE SMALL INTESTINES. 
559 
Occasionally, after the complete disappearance of all evidences of inflamma- 
tion, a diarrhoea is left, dependent probably upon a relaxation of the secretory 
vessels or orifices, consequent on the previous excitement. In such cases, 
tonics and astringents become useful. (See Diarrhoea.') 
Chronic Enteritis.-This may follow the acute disease, or may be the 
direct result of the same causes, operating with less force, or upon a less sus- 
ceptibility. Diarrhoea is even more characteristic of chronic than of acute 
enteritis. Most cases of very obstinate diarrhoea are, in fact, nothing more 
than chronic inflammation of the bowels. The frequency, quantity, and 
quality of the stools vary exceedingly. Sometimes the number does not 
exceed two or three in twenty-four hours, sometimes the patient enjoys no 
rest from their recurrence; and this diversity is often found at different periods 
of the same case. The amount discharged is in some instances trifling, in 
others exceedingly abundant. In character the evacuations are not unlike 
those of acute enteritis. Occasionally portions of false membrane are dis- 
charged, and, in some rare instances, tubes of considerable length, obviously 
the result of a plastic inflammation, throwing out coagulable lymph upon the 
surface of the mucous membrane. Such cases are apt to be somewhat tedious, 
but may nevertheless do well in the end. In the advanced stages of the 
complaint, the evacuations are sometimes mingled with pus, which is an un- 
favourable sign. There is generally more or less pain; and strong pressure, 
or any sudden jar, as in coughing or jumping, occasions uneasiness. Some- 
times the pain is severe, and, though relieved after each evacuation, returns 
so frequently as to keep the patient in almost constant distress. In many 
cases, it comes on at a certain period after eating, indicating the time at 
which the ingesta reach the spot affected. The abdomen is sometimes very 
flat, sometimes much distended, and even tympanitic. The appetite is often 
craving, and seldom wholly wanting, unless when the stomach participates in 
the disease. Occasionally the system scarcely evinces any other signs of sen- 
sibility to the local affection, than a diminution of strength, and a more or 
less rapid emaciation. Generally, however, the pulse is somewhat increased 
in frequency, the tongue slightly furred, and the skin dry and harsh. In bad 
and protracted cases, the tongue is sometimes red, smooth, and dry, or aph- 
thous, and the pulse very frequent. The spirits are usually depressed, some- 
times greatly so, the patient being gloomy, morose, or irritable, dwelling on 
nothing but his own suffering, and seeing no hope before him. The mental 
disturbance amounts, in some instances, to insanity; and incurable cases of 
this disease have had their origin in chronic enteritis. The stomach not un- 
frequently participates in the inflammation, and then all the symptoms of 
chronic gastritis are superadded. The duration of the disease is exceedingly 
variable. It may be cured within a week or two from the commencement of 
treatment, or may run on for years. When of long duration, it generally 
undergoes numerous vicissitudes, the patient being at one time much relieved 
or nearly well, and then again relapsing, upon some new exposure, or even 
without obvious cause. Towards the close of fatal cases, hectic fever usually 
takes plaee, and the patient becomes much emaciated. 
Desides the usual marks of inflammation in the mucous membrane, the 
surface, upon dissection, often appears strewed over with enlarged or ulcer- 
ated follicles. Ulcers are even more common in this than in the acute form 
of the disease. The mesenteric glands are sometimes found enlarged, and 
even suppurating. 
The causes are the same as those of acute enteritis. A tuberculous dia- 
thesis strongly predisposes to the complaint; and, in very obstinate cases,, 
which cannot be traced to cancerous disease of the bowels, or other obvious 560 
LOCAL DISEASES. 
[PART II. 
cause, there is great reason to apprehend that tubercles may have been de- 
veloped in the mucous membrane. Chronic enteritis is„a very common 
attendant upon the advanced stages of phthisis. 
Treatment.-The most important part of the treatment is probably the 
regulation of the diet. As the appetite is often unimpaired, and sometimes 
craving, the patient is constantly tempted to transgress, both in the quantity 
and quality of his food; and this is one of the chief causes of the occasional 
obstinacy of the complaint. The dietetic rules applicable here are so nearly 
the same with those already given under chronic gastritis, that it is unneces- 
sary to repeat them. The particular kind of food which, on the whole, is most 
suitable, is milk; and patients will frequently get well without medicine, if 
confined to that article exclusively. But, as it would thus be very irksome, 
it may be taken with stale bread or water-crackers, or boiled and thickened 
with wheat or rice flour, arrowroot, carrageen moss, &c. A decoction of Ice- 
land moss with milk is sometimes useful, as well by its tonic as its nutritive 
properties. When the debility is considerable, it is necessary to have recourse 
to animal broths, &c. (See Chronic Gastritis.} 
General bleeding is seldom admissible in chronic enteritis; but occasional 
leeching may be resorted to with great advantage. Laxatives are required 
only when the bowels are slow, as sometimes though rarely happens, or when 
an accession of irritation arises from acrid accumulations. Opiates are 
almost always indicated. They prove useful by relieving pain, moderating 
secretion, and quieting that excessive action of the bowels which is itself 
injurious to the complaint. Opium may be used in the manner recom- 
mended for acute enteritis, or in small doses combined with the various reme- 
dies which may be given to meet other indications. I have found the cam- 
phorated tincture of opium an excellent preparation in this complaint. A 
fluidrachm of it given three or four times a day, is, in many cases, the only 
medicine which will be required, in connexion with a properly regulated 
diet. Acid in the bowels may be corrected by cretaceous preparations, as 
in the acute form. The astringents, as kino, catechu, rhatany, logwood, 
alum, acetate of lead, &c., sometimes answer a good purpose, when the in- 
flammation is very moderate, and its consequences, rather than the affec- 
tion itself, are to be combatted. (See Diarrhoea.} They should be com- 
bined with an opiate, and often form a good addition to cretaceous mixtures. 
But not unfrequently they either fail to arrest the discharge, or, by arrest- 
ing it, aggravate the inflammation, producing an increase of pain, abdominal 
distension, fever, &c. When such results occur, the astringents should be 
immediately omitted; and, on the whole, they should be used with much 
caution. There is, however, a set of mineral substances, which, inde- 
pendently of their astringent properties, exercise an alterative influence 
over inflamed and ulcerative surfaces, which renders them highly useful 
in some cases. Of these sulphate of copper is one of the best. In the dose 
of one-sixth or one-quarter of a grain, combined with from a sixth to a 
twelfth of a grain of opium, and given every three or four hours through 
the day, I have seen it do great apparent good in obstinate cases of chronic 
enteritis. The nitrate and oxide of silver with opium have also been highly 
recommended, and the sulphate of zinc may be similarly employed. Oil 
of turpentine and copaiba sometimes prove useful through their alterative 
influence over the mucous membranes. They should be given in emulsion, 
and, like the other remedies, combined with an opiate. Tar-water is also 
sometimes useful. In some feeble cases, the simple bitters, sulphate of qui- 
nia, and the chalybeates are serviceable by imparting a degree of tone to the CLASS III.] 
DYSENTERY. 
561 
ulcerated and relaxed mucous surface, which is necessary to the curative 
process. 
In conjunction with the above measures, the warm or hot bath is highly 
important, the former being preferred when the temperature of the skin is 
above, the latter when it is at or below the healthy standard. In the latter 
case, the warm salt-bath is an admirable remedy. It should be given daily, 
and may sometimes be advantageously repeated twice a day. Frictions to 
the surface are also useful. When the symptoms are somewhat acute, a 
large blister may be usefully applied over the whole abdomen; and a small 
blister, near the affected part, frequently repeated, or kept open by stimu- 
lant dressings, will often be found beneficial in ordinary cases. Postula- 
tion with tartar emetic or croton oil may be tried, when the complaint is 
obstinate. The patient should always wear flannel next the skin; and a 
broad flannel roller passed frequently round the abdomen is sometimes of 
service. 
Should other means fail, recourse should be had to a mercurial impression, 
which should not be carried beyond a very slight effect upon the gums, and 
should be sustained for a considerable time. Obstinate cases often yield 
speedily to this remedy. In cases attended with the discharge of false mem- 
brane in considerable quantity, an alterative course of mercury should be im- 
mediately instituted. 
Moderate passive exercise, mental recreation, relaxation from business, sea- 
bathing, a journey into the country, a sea-voyage, and a residence abroad may 
be resorted to, as recommended in chronic gastritis, when the condition of the 
disease, or the circumstances of the patient, do not forbid them. 
3. DYSENTERY. 
Syn.-Inflammation of the large Intestines.-Colitis.-Colo-rectitis.-Bloody Flux. 
Dysentery is inflammation of the mucous membrane of the colon and rec- 
tum, characterized by small mucous or bloody evacuations, griping pains in 
the abdomen, straining at stool, and tenesmus. Inflammation in the colon, 
without these phenomena, would rank under enteritis. Dysentery may be 
acute or chronic. 
1. Acute Dysentery.-The disease may occur with or without pre- 
monitory symptoms. In the former case, it is preceded by general uneasiness, 
lassitude, impaired appetite, dull or transient pains in the abdomen, costive- 
ness or diarrhoea, and other evidences of moderate intestinal irritation. Some- 
times the local symptoms make their appearance before those of a general 
character; and, in very mild cases, of moderate extent, the disease may run 
its course without fever. Sometimes the local and febrile phenomena com- 
mence simultaneously, the patient being attacked with a chill almost at the 
moment that he begins to complain of pain and tenesmus. Again, the fever 
often precedes, and occasionally for a considerable period, any evidence of 
disorder in the bowels. In such cases, however, the dysentery is usually a 
mere attendant upon some other disease. 
We are presented, in different cases of dysentery, with a regular gradation 
in severity, from a very slight affection, occupying but a small extent of the. 
rectum and colon, unattended with fever, and passing off in two or three days, 
up to one of the most violent and dangerous forms of disease fo which the 
bn man frame is liable. This diversity is dependent partly on differences in 
the activity of the cause, and the susceptibility of the patient; but it is im- 
portant to recollect, that it may also depend upon the degree in which the 562 
LOCAL DISEASES. 
[part Hi 
disease is simple or complicated. Generally speaking, mere mucous inflam- 
mation of the large intestines is a mild affection; but it is very frequently 
associated, at the outset, with disease in some other organ or organs, or with 
some morbid state of the system at large, which, in various degrees, compli- 
cates the symptoms, and increases the danger. I shall first describe simple 
dysentery, and then allude to its more frequent combinations. 
In the beginning of a case of simple dysentery, there are usually griping 
pains in the abdomen, technically called torm ina, irregular in their position 
and periods of recurrence, and attended with discharges from the bowels, by 
which they are partially relieved. After a very short time, a sense of weight, 
burning, or other uneasiness is experienced in the rectum, with a painful and 
frequently returning inclination to go to stool, without the ability to evacuate 
anything more than a little bloody mucus. This feeling of tenesmus increases, 
and at length becomes the most striking feature of the case; the abdominal 
pains appearing to concentrate themselves in some measure about the rectum. 
The calls to stool are very frequent, in some cases almost incessant; are 
attended with much straining, so much so as sometimes to produce prolapsus 
ani, especially in children; and are followed by only partial relief. The dis- 
charges often occasion a burning or cutting pain in the anus, which leads the 
patient to dread their return, and to resist the disposition so long as possible. 
The passages are seldom less than a dozen in twenty-four hours, are often 
double or triple that number, and sometimes, in very bad cases, have been 
known to amount to one hundred and even two hundred. After the first few 
evacuations, which are often more or less fecal, the stools are very small, and 
consist of transparent or whitish mucus, or of mucus mixed with blood, and 
sometimes of almost pure blood. With these, as the complaint advances, a 
little vitiated bile, and shreds of false membrane, or small masses of coagu- 
lated matter, are occasionally intermingled; and, in some instances, small 
hardened lumps of feces called seyhala are discharged, though these are less 
common than might be inferred from many published accounts of dysentery. 
Feculent evacuations are almost always followed by considerable relief. At 
first the discharges have little smell; but after a time they acquire a disa- 
greeable odour, almost peculiar to dysentery, and quite distinct from the 
feculent. The bladder and urethra sometimes sympathize with the rectum, 
and along with the tenesmus there is frequent and difficult micturition. In 
females, the vagina participates in the same irritation. There is generally 
more or less tenderness in the abdomen; and the extent of the inflammation 
upwards, along the colon, can sometimes be traced by ascertaining in what 
parts pain is produced on pressure. When the tenderness is observed across 
the epigastrium, and along the right side, there is reason to believe that the 
inflammation has reached the transverse and ascending colon, and that the 
whole of the large intestines are involved. 
There is always fever, except in cases of very small extent. The pulse is 
accelerated, and usually somewhat full and forcible, the skin warm and dry, 
the urine scanty, the tongue moist and covered with a whitish fur. The 
secretion of bile is generally diminished. Occasionally, in cases of some 
severity, the vital forces sink-temporarily under the violence of the impression 
made on the nervous system. The patient experiences an indescribably pain- 
ful feeling of hollowness or sinking in the abdomen, attended with a cold 
damp skin, a feeble and almost threadlike pulse, and sometimes nausea and 
vomiting. This condition, however, soon passes over, as the acrid secretions 
descend. In the simple form of the disease above described, vomiting is not 
frequent; and the symptoms of cerebral affection are still less so. 
In..the vast majority of cases, the disease takes a favourable turn between CLASS III.] 
DYSENTERY. 
563 
the sixth and tenth day, and the patient recovers. Sometimes, however, from 
the extent and violence of the inflammation, symptoms of depression appear 
at the outset, and the system never fairly reacts. Here the same condition 
appears to exist continuously, which has been above described as occurring 
occasionally in milder cases. The nervous system yields to the violence of 
the first shock, and is unable to react under the continued violence of the dis- 
ease. The patient has, throughout, a very small feeble and frequent pulse, a 
pale, cool, and clammy skin, anxious and sunken features, and a somewhat 
livid or purplish appearance under the eyes, about the lips, and at the roots 
of the nails; while, at the same time, there is extraordinary violence in the 
local symptoms, with much tormina and tenesmus, incessant discharges, tense 
and tumid abdomen, and great teiiderness on pressure. Such cases prove 
fatal in a few days. They are happily very rare, and I have seen them only 
during epidemics. 
Danger much more commonly accrues from a continuance of the disease, in 
ordinary cases, beyond a week or ten days. Should the symptoms not give 
way by that time, they are all apt to become aggravated. The tormina and 
tenesmus increase; the abdomen becomes swollen and more tender; the dis- 
charges, more frequent; the pulse, weaker and more rapid; the tongue as- 
sumes a dryish and brownish appearance, or throws off its fur and becomes 
red, smooth, and sometimes gashed; the patient is weak, exhausted, and very 
restless; the stools are more copious and offensive, and, instead of consisting 
chiefly or exclusively of mucus or blood, are mixed with puruloid matter, 
sanies, or vitiated secretions from the upper bowels, and arc sometimes nothing 
more than a kind of bloody serum (lotura carnium). Even after the worst 
of these symptoms, however, the patient may recover, though the convale- 
scence is usually tedious, and the case not unfrequently runs on into the 
chronic form. Should the event prove unfavourable, a set of symptoms 
usually supervene, which will be mentioned under the head of prognosis. 
Bilious Dysentery.-In almost all cases of dysentery the bilious secretion 
is somewhat diminished; but, in the simple form of the disease, this may be 
considered as nothing more than a result of the colitis, in like manner as the 
dry skin and scanty urine. But occasionally disorder of the liver and sto- 
mach attends the disease from the commencement, being the result of causes 
either identical or coexistent with those which produce the intestinal affection. 
The complaint, under these circumstances, is sometimes called bilious dysentery. 
It is characterized by a feeling of oppression in the epigastric region; more 
frequent vomiting; occasional yellowness, in various degrees, of the tongue, 
conjunctiva, skin, and urine; a higher degree of fever; a greater tendency to 
delirium; and either an entire absence, morbid increase, or depraved condi- 
tion of the biliary secretion. It is this complication which adds so much to 
the violence and danger of dysentery, occurring in tropical climates. 
Adynamic Dysentery.-Another form of the disease is that which occurs in 
individuals previously exposed to the action of various depressing causes, as 
in ships, prisons, besieged towns, camps, and marching armies, in which ex- 
posure to wet and cold, unwholesome or insufficient food, fatigue, and wretch- 
edness of every kind, combine with a contaminated atmosphere to prostrate 
the vital powers, and vitiate the blood. The same influence is sometimes 
exerted by certain epidemic constitutions of the air. Under these circum- 
stances, along with the symptoms of ordinary dysentery in an aggravated 
degree, are those of malignant, typhoid, or scorbutic disease; such as nausea 
and vomiting; great thirst; a frequent, feeble, irregular pulse; a foul, brown 
or black, dry tongue, with sordes about the teeth; a dusky skin, sometimes 
hot, sometimes cold, and occasionally marked with petechia), dark livid spots, 564 
LOCAL DISEASES. 
[part II. 
gangrenous vesications, &c.; reddish, brown, or black stools, more copious 
than in the simple disease, and excessively fetid, or large hemorrhagic dis- 
charges, consisting often of altered uncoagulable blood; great prostration of 
strength even from the beginning; and finally, various evidences of nervous 
disorder, as anxiety, depression of spirits, headache, low delirium, subsultus 
tendinum, and stupor. All these symptoms are not found in every case, but 
are variously mingled, and in various degrees; sufficient generally existing 
to indicate pretty clearly the character of the affection. In the worst cases, 
the patient appears to be struck with death from the very beginning, and the 
disease proves fatal in a few days. In all cases, the danger arising from the 
mere colitis is very much increased by the complication. When the causes 
producing this form of dysentery unite with those which produce the bilious 
variety, we have occasionally a combination of symptoms unsurpassed in 
malignancy by those of any other disease. 
Intermittent and Remittent Dysentery.-Dysentery is not unfrequently 
associated with other diseases. It is very common in miasmatic countries, 
and during the prevalence of epidemic intermittent and remittent fevers, 
sometimes apparently occurring as a distinct disease more or less modified by 
the prevailing atmospheric influence, sometimes in connexion with the proper 
miasmatic fever. In the latter case, the colitis may come on as a mere acces- 
sory of the fever, after it has continued a greater or less length of time, or it 
may first occur, and the miasmatic fever afterwards set in. When a decided 
fever, preceded by chill, has existed for one, two, or three days before the 
dysentery begins, there can be little doubt as to the nature of the case. 
Greater difficulty is presented when the two occur simultaneously, or when 
the fever is the last to make its appearance. Generally speaking, however, 
such cases may be distinguished from uncomplicated dysentery, by their 
paroxysmal tendency. The fever is aggravated at a certain time every day 
or every other day, and in the interval either relaxes or entirely intermits; 
the dysenteric symptoms undergoing, to a certain extent, the same change. 
There is, moreover, during the paroxysm, more flushing of the face, pain in 
the head, tendency to delirium, general arterial excitement, and nervous dis- 
order, than usually attend an attack of pure colitis; and the occurrence of 
perspiration at the subsidence of each paroxysm is an almost certain diagnos- 
tic symptom. A correct diagnosis in these cases is important, because essen- 
tial to the proper course of treatment. 
Typhous Dysentery.-Dysentery is also sometimes associated with proper 
typhus fever. I have already treated of that form of the disease, in which 
symptoms resembling those of typhus attend it, in consequence of a previous 
adynamic state of system. In that case, however, the fever is the result of 
the colitis, and the peculiar phenomena flow from the diminished energy of 
the solids, or the vitiated state of the liquids. But I now allude to the coin- 
cidence of dysentery with a distinct febrile disease, the result probably of a 
peculiar poison, which exists altogether independently of the bowel affection 
associated with it. Such cases occur during the prevalence of typhous epi- 
demics. It is not so important, in a therapeutical point of view, to make an 
accurate diagnosis here as in the former variety; because the practice must 
be regulated by the obvious condition of the system. But these cases are 
interesting in reference to the question of the propagation of dysentery by 
contagion. 
Authors speak also of rheumatic dysentery ; but this is not distinguishable 
from the disease arising from ordinary causes, except sometimes in the mode 
of its attack, when the irritation is suddenly translated from some other seat 
to the large intestines. Besides the complications which have been men- CLASS III.J 
DYSENTERY. 
565 
tioned, colitis may co-exist with gastritis, with enteritis, and with various 
other diseases local or general; in which case, the symptoms will of course 
be modified by combination with those of the associated affection. 
Prognosis.-When dysentery is about to terminate favourably, the pains 
gradually become less frequent and severe, the tenesmus diminishes, the stools 
become more copious and less frequent, and assume a fecal or bilious character, 
and at length nothing but a slight diarrhoea remains which soon ceases. On 
the contrary, a sudden cessation of the tormina and tenesmus, the occurrence 
of tympanites, coldness of the extremities, or a cool clammy state of the skin 
in general, a livid or purplish hue about the nails, a very feeble, frequent, and 
irregular pulse, hiccough, involuntary stools, delirium, subsultus tendinum, 
and stupor, are symptoms of the most unfavourable kind, and together por- 
tend a speedy and fatal termination. Death may result in dysentery from a 
failure of the powers of life under the intensity of the irritation, from general 
debility, from gangrene, or from the continued wearing and exhausting effect 
of the combined inflammation and discharge. The longer the disease con- 
tinues without amendment, the greater is the danger; and a persistence beyond 
the fourteenth day may itself be looked upon as a ground for great solicitude. 
The danger is also proportionate to the extent of the colon involved, and, if 
tenderness be discoverable upon pressure along its whole track, indicating a 
similar extent of the inflammation, the prognostication is unfavourable. Ordi- 
nary sporadic cases of dysentery, in temperate climates, are seldom fatal. It 
is when prevailing epidemically, or among great masses, as in armies and 
garrisons, or in the miasmatic districts of tropical countries, that it is most 
malignant; and, under these circumstances, it sometimes commits terrible 
ravages. 
Anatomical Characters.-The mucous membrane of the rectum and lower 
portion of the colon always evinces signs of inflammation, in cases of death 
from dysentery. It is much reddened and thickened, and not unfrequently 
ulcerated. Ulcers, in fact, exist in this disease much more frequently than 
in any other acute inflammation of the alimentary canal, unless in the folli- 
cular enteritis of typhoid fever and small-pox. They are either small and 
roundish, or large and irregular from the confluence of the smaller, have usu- 
ally an abrupt edge, and are often covered with a concrete exudation having 
the appearance of a slough. In some cases, almost the whole of the mem- 
brane is covered with a coating of coagulated lymph, upon the removal of 
which it appears red and swollen, but without loss of continuity. Occasion- 
ally real gangrenous sloughs are found; and cases are mentioned in which 
very large portions of the mucous membrane have been removed, probably by 
a combination of mortification and ulceration. In many cases, the redness, 
thickening, and ulceration extend beyond the mucous membrane, and some- 
times involve the whole of the parietes of the bowel, unless, it may be, the 
peritoneal coat. Penetration of the latter coat is exceedingly rare in dysen- 
tery. In protracted cases, the mesenteric glands are enlarged and softened, 
though seldom or never in a state of suppuration. In some instances, evi- 
dences of inflammation have been found extending throughout the colon, into 
the small intestines, and, it is said, even to the stomach. The liver is fre- 
quently diseased, especially in the dysentery of tropical latitudes. Out of 
twenty-five fatal cases examined by Dr. Parkes in India, seven were affected 
with hepatic abscess; and about the same proportion has been found by others. 
(Brit. and For. Med. Rev., Am. ed., Jan. 1847, p. 149.) In the adynamic 
or malignant variety, gangrene is much more frequently observed than in ordi- 
nary dysentery, and the mucous membrane, when not mortified, exhibits a 
dark purple or livid appearance. 566 
LOCAL DISEASES. 
[part II. 
Causes.-A predisposition to dysentery is produced by the continued influ- 
ence of heat, augmenting the excitability of the alimentary mucous membrane, 
disordering the hepatic function, and relaxing the surface of the - body so as 
to render it more susceptible to the influence of cold. Under these circum- 
stances, causes will often produce an attack of the disease, which, under 
others, are wholly inoperative. One of the most common of the exciting 
causes is cold, especially when combined with moisture. Hence the frequency 
of dysentery among persons exposed to the cold dampness of night, after 
having been much heated during the day. The perspiration is checked, and 
excitement thus directed inward; while the hepatic secretion is at the same 
time arrested, and congestion of the portal circle, and consequently of the 
mucous membrane of the bowels results. Substances directly irritant in their 
action on the bowels are often exciting causes. Among these may be men- 
tioned unripe and acid fruits, ripe fruits in large quantities, vegetables of dif- 
ficult solution in the stomach, and unwholesome and indigestible food of all 
kinds; acid and imperfectly fermented alcoholic drinks, such as cider, weak 
wines, malt liquors, &c.; putrid water; drastic purges; worms; and feculent 
and other accumulations in the large intestines. Formerly much importance 
was attached to collections of hardened feces as the cause of dysentery, and 
undoubtedly they occasionally produce or aggravate the complaint; but they 
are much less influential than was supposed. Exhalations from putrid animal 
substances, and vegetable miasmata are also among the causes. 
Dysentery is not unfrequently epidemic, prevailing in some instances over 
considerable extents of country, but more commonly confined within small, 
and sometimes very accurately defined limits. In the latter mode, it often 
occurs in different parts of the United States. It is especially apt to prevail 
in miasmatic districts, preceding or accompanying intermittent and remittent 
fevers; but sometimes it cannot be traced to any local cause whatever. It is 
a frequent accompaniment also of typhous epidemics. 
The question has been much agitated whether dysentery is a contagious 
disease. The profession is now almost universally agreed that it is not so in 
its ordinary form. The circumstances under which individuals are succes- 
sively affected in epidemics have led to the opinion, with some, that most 
diseases assuming this character are propagated by contagion. When no 
obvious cause appears, and one person after another is affected in the same 
neighbourhood, or in the same family, it has always been a favourite conclu- 
sion with many that the complaint is communicated from individual to indi- 
vidual. But a closer examination has, in most cases, detected the error of 
this conclusion. There is little doubt that it is a mistake in relation to epi- 
demic dysentery. In certain confined Situations, where many dysenteric 
patients are crowded together, without due attention to cleanliness and venti- 
lation, the disease appears to be communicated to others who maybe exposed; 
but the result is probably owing to the influence rather of putrid exhalations, 
which are acknowledged to be capable of producing dysentery, than of any 
really contagious effluvium. Nevertheless, it must be admitted that the evi- 
dence is in favour of the occasional propagation of this complaint by contagion. 
The result may, perhaps, be best explained by the supposition, that, in cases 
of this kind, the dysentery is associated with the proper typhus fever, now 
generally admitted to be contagious, and that it is this disease which is actu- 
ally communicated, the inflammation of the bowels being dependent upon 
some peculiar atmospheric or other incidental influence, as we occasionally 
see the same fever prevailing in certain districts, very generally attended with 
pneumonia. 
Dysentery attacks indiscriminately persons of both sexes and all ages, and, CLASS III.] 
DYSENTERY. 
567 
if one class of individuals is affected more frequently than another, it is pro- 
bably owing to their greater exposure to the causes of the disease. It is much 
more prevalent in summer and autumn than in winter, and in hot than in 
temperate climates. Miasmatic countries are more subject to it than others; 
and strangers are more apt to be attacked in these countries than natives. In 
all ages, armies and garrisons have been peculiarly liable to suffer from it; 
and the records of campaigns and military marches are full of accounts of its 
devastating ravages. 
Treatment.-A great variety of remedies have been employed in dysentery, 
and very different plans have been found successful under different circum- 
stances. To be rational, the treatment must vary with the degree of violence 
in the disease, the existing state of system, and the diversities arising from 
associated affections. In Ordinary uncomplicated colitis, the indications are 
simply those presented by inflammations in general; though some are more 
than usually prominent; as the relief of pain and distress, and the removal 
of causes of irritation whether applied directly to the affected part, or consist- 
ing in a congested state of the portal circulation. The modifications of treat- 
ment required by the state of system, and by the co-existence of other diseases, 
will be presented after an account of the remedies for simple dysentery. These 
are so numerous, as recommended by different practical writers, that it will 
be most convenient to consider the value of each remedy and its modes of 
employment, before describing the general course of treatment; as this would 
otherwise be constantly interrupted by the necessary remarks upon individual 
measures. 
Bleeding is not necessary in all cases of dysentery, and, in the adynamic 
form of the disease, may be injurious. It should, however, always be resorted 
to when there is much pain and tenderness of the abdomen, with febrile action, 
and a vigorous pulse. As the disease generally occurs in temperate latitudes, 
and when not epidemic, one moderate bleeding will usually be sufficient; but, 
if the pulse remain firm, and the local symptoms unabated, it may be repeated 
again and again. In violent inflammatory cases, threatening immediate danger 
if not relieved, and especially in persons of vigorous constitution or plethoric 
habit of body, it may be necessary to bleed largely at once. In such cases, 
the remedy should be promptly resorted to, and the blood allowed to flow, 
until a decided impression is made on the pulse. If postponed, it may be- 
come useless or even worse than useless; as the powers of life are rapidly 
exhausted under the violence of the disease. It is seldom advisable to bleed 
in the advanced stages of dysentery, whatever may have been its previous 
character. 
Emetics have been highly recommended by numerous authors, and are 
undoubtedly often serviceable at the commencement of the disease. Given 
at its very outset, they will sometimes effect an immediate cure. They 
Were formerly, however, much more used than at present. The physician 
is generally called too late for their most efficient application; they are to 
most patients a very disagreeable remedy; and sometimes, when the stomach 
participates in the inflammation, or great abdominal tenderness exists, they 
may do positive harm. They are clearly indicated when the stomach is 
loaded with acrid accumulations of any kind, as shown by epigastric oppres- 
sion, nausea, eructation of bile or other irritating matter, and frequent but 
ineffectual efforts to vomit, without the pain and tenderness of gastric in- 
flammation. If employed with any other view, it should only be at the very 
commencement. Some have used the antimonial preparations; Chisholm 
recommended sulphate of zinc, but ipecacuanha is now almost universally 
preferred, and, from its mildness as well as efficiency, deserves the preference. 568 
LOCAL DISEASES. 
[part II. 
Cathartics are among the most efficient remedies. One of the most promi- 
nent indications in dysentery is to free the bowels from irritating secretions 
and accumulations; a second is to diminish congestion in the portal circula- 
tion; and both are best answered by this class of medicines. But it is 
necessary to use discrimination both in the selection of the articles, and in the 
circumstances of their application. Drastic .purges produce more harm by 
irritating the inflamed membrane, than they can do good by their evacuating 
effect. Laxatives, therefore, or the milder purgatives should always be pre- 
ferred. Nor is it in all cases advisable to persevere with them until feculent 
discharges, and especially consistent feculent discharges, are obtained. Occa- 
sionally, the dysentery has been preceded by a diarrhoea, which has cleansed 
the bowels; and in such cases solid feces are not to be looked for in the 
stools. Wheii the disease has commenced abruptly, without antecedent diar- 
rhoea, it is generally proper to obtain at first a pretty brisk cathartic effect, 
and then to be satisfied with sustaining a gentle peristaltic movement, so as 
to keep the bowels free from irritating accumulations. It is better to run 
the risk of allowing some scybala to remain in the colon than to persevere 
with active purgation, when the great probability is, that there is nothing in 
the bowels which can require it. But another important object, in the use 
of purgatives, is to unload the portal veins. The capillary circulation in the 
liver is often sluggish, and in many instances the secretion of bile appears to 
be suspended. Blood, therefore, accumulates in the veins proceeding from 
the abdominal viscera, and must press injuriously upon the capillaries of the 
bowels. By stimulating the hepatic circulation and secretion we remove this 
evil. Hence one great advantage of calomel. This is indeed one of the most 
useful cathartics in dysentery, having the advantage of mildness in its action 
on the mucous membrane, while it excites the liver. But, as it is not quick 
in its operation, and in moderate doses is sometimes uncertain, it should be 
assisted by other medicines. In ordinary cases, from five to fifteen grains of 
calomel should be given at the commencement, and followed in from four to 
six hours by the adjuvant. In severe bilious cases, it may be given in a 
larger dose at first, and subsequently repeated in the same quantity once or 
oftener; but, as we generally meet with the disease, if the medicine be re- 
peated, it should be in small doses of from one to three grains, so as to sustain 
a moderate secretion of bile, which should be carried off by other cathartics. 
Of these, castor oil is on the whole probably the best. Should it offend the 
stomach in its ordinary form, it may be administered in emulsion with gum 
arabic, sugar, and some aromatic water. In the advanced stages of dysentery, 
this oleaginous mixture may often be advantageously combined with a little 
laudanum, and given in small divided doses at short intervals. Thus admin- 
istered, it often produces a soothing effect on the bowels, while it operates as 
a laxative. Some prefer the neutral salts, as sulphate of magnesia, sulphate 
of soda, tartrate of potassa and soda, &c. These are especially applicable 
when there is much fever, with a hot dry skin. In such cases, they are some- 
times associated with tartar emetic in solution, and given in divided doses, so 
as at once to relax the skin and operate on the bowels. Hufeland recom- 
mends a mixture of manna, tamarinds, Glauber's salt, and tartar emetic. 
When the stomach is irritable, the Seidlitz powder may be used. Bitartrate of 
potassa has been highly recommended as possessing peculiar powers. Dr. 
Cheyne found it in doses of half an ounce, repeated at intervals of four or six 
hours, to cure cases of dysentery which, in his opinion, would have sunk under 
any ordinary treatment. Some practitioners employ the compound powder 
of jalap. It is desirable that, by means of the cathartics mentioned, one or 
two evacuations, if mot spontaneously produced, should, be obtained daily CLASS III.] 
DYSENTERY. 
569 
or every qther day, of such a character as to evince that they have come from 
the upper bowels. In the advanced stages of the disease, cathartics must be 
employed more sparingly than at the commencement; though even here, so 
long as the affection remains strictly dysenteric, they are often useful. When 
the strength fails, or the symptoms assume a chronic form, rhubarb or one of 
its preparations may be substituted for the other cathartics. Under the same 
circumstances, melted butter, prepared by introducing solid butter into hot- 
water, agitating, and then skimming the oil from the surface, has been given 
advantageously, in the dose of a tablespoonful every two hours, until it pro- 
duced some effect upon the bowels. Great benefit will often accrue from com- 
bining an opiate with the cathartic. So far from uniformly counteracting the 
operation of the latter, it will not unfrequently promote it by resolving 
spasmodic constriction of the bowels, while it is also useful by relieving pain. 
Diaphoretics are useful by giving an external direction to the circulating 
fluids, and by depleting from the blood-vessels; but, in consequence of the 
exposure of the surface from frequent rising, they are sometimes hazardous 
when the temperature of the apartment is much below that in which the 
patient is kept in bed. When the skin is hot and dry, small doses of tartar 
emetic, or of the neutral mixture, may be given separately or combined, at 
intervals of an hour or two. The effervescing draught is preferable when 
there is nausea or vomiting. Dr. Eberle speaks favourably of a combination 
of fifteen or twenty grains of asclepias tuberosa with half a grain of ipecacu- 
anha, and a quarter of a grain of opium, every two or three hours. After 
the general excitement has been subdued by depletion, or has subsided in the 
course of the disease, and early in cases of feeble general action, the powder 
of opium and ipecacuanha is preferable to the refrigerant diaphoretics. Great 
advantage sometimes accrues from the warm bath, which is liable, however, 
to the same objection as diaphoretics internally administered. It is peculiarly 
useful in cases of children, because in these it can be managed with less 
exposure of the person to cold. The vapour bath may be substituted in the 
advanced stages. In all cases, the caution cannot be too carefully observed, 
not to allow the patient to be exposed to cold when the skin is moist. At 
the same time, he should never be kept oppressively hot by the bedclothes in 
order to promote perspiration. 
Opium is an invaluable remedy in dysentery. Recommended by Syden- 
ham, and afterwards neglected upon theoretical grounds, it came again into 
repute, and is now almost universally employed. Besides relieving the suf- 
ferings of the patient, and procuring sleep, which is necessarily much inter- 
rupted in this disease, it does good by diminishing the morbid sensibility of 
the bowels to the irritating matters they contain, by relieving spasmodic 
constriction and thereby facilitating the action of cathartics, and, when com- 
bined with ipecacuanha or tartar emetic, by directing action to the surface of 
the body. When there is much fever, it is best to postpone its administration 
until the force of the circulation has been reduced by the lancet; but in 
general the use of it may commence very early. It may be given along with 
cathartics, or combined with ipecacuanha, which somewhat diminishes its 
stimulant properties, and causes it to act as a diaphoretic. In the early 
stages, it is best administered in full doses, and generally at bedtime, so as 
to procure rest and sleep at night. In the advanced stages, it may often be 
usefully given in smaller doses, at stated intervals, so as to sustain a constant 
impression. 
Mercury.-Not only is calomel useful in the commencement as a purgative, 
but afterwards also, in smaller doses, so as to stimulate the hepatic secretory 
function, and sustain a flow of bile into the bowels. For this purpose it is 570 
LOCAL DISEASES. 
[part II. 
conveniently combined with the opium and ipecacuanha given at night. Two 
grains of opium, from two to four of ipecacuanha, and from two to four of 
calomel, may be made into four pills, two of which may be given at once, and 
one every hour or two afterwards till rest is procured. The ipecacuanha may 
be omitted if it should sicken the stomach, and the blue mass substituted for 
the calomel, if the latter should inconveniently irritate the bowels. If the 
disease should not begin to yield in six or seven days, the mercurial may be 
more freely administered, so as to affect the mouth. In severe hepatic or 
bilious cases, and in those of a typhoid character, unconnected with a scor- 
butic state of the blood, it may be carried to salivation at an earlier period. 
When this indication is to be fulfilled, the mercurial, instead of being admin- 
istered only at night, should be given in small doses at intervals of two, four, 
or six hours, still in combination with opium and ipecacuanha. The quantity 
of each ingredient must vary with the peculiar susceptibilities of the patient, 
and the urgency of the symptoms. No remedial influence is more effectual 
in dysentery than that of mercury. The chief cautions to be observed are to 
stop short of profuse salivation, and to avoid the remedy altogether in those 
malignant cases in which the blood is dark, and either feebly or not at all 
coagulable. 
Numerous alterative remedies^NQ enjoyed more or less credit in the treat- 
ment of dysentery. Ipecacuanha has been thought to exercise a peculiarly 
favourable influence, and some practitioners have confided the cure chiefly to 
that remedy, I have spoken of its use as an emetic and diaphoretic. It has 
been highly recommended in doses of from half a drachm to two drachms, 
with from thirty to sixty drops of laudanum; and it has been asserted that, 
if the patient be kept quiet on his back, it will in this quantity effect cures 
without producing nausea or vomiting. Mr. Twining, of Calcutta, found it 
very useful in doses of five or six grains, given night and morning, with 
compound powder of jalap in the interval. He administered it in pill with 
extract of gentian, and rarely observed it to occasion sickness of stomach. 
Acetate of lead has been employed in all stages of the disease. The atten- 
tion of the profession in this country was especially called to it by the late 
Dr. Harlan, of Philadelphia, who employed it successfully in acute cases 
(Med. Record, v.); and several writers have since attested its efficacy. It 
is not, however, generally employed in the earlier stages. After sufficient 
depletion, and a thorough evacuation of the bowels, should the symptoms not 
yield, this salt may be given with some hope of advantage; but it is best 
adapted to chronic cases, and to those of an acute character which are attended 
with considerable hemorrhage. No remedy is perhaps so effectual in the 
hemorrhage of typhoid or malignant cases. It may be given in doses of from 
one to three grains every two hours, and should generally be combined with 
opium. 
Sulphate of copper and sulphate of zinc have also been recommended. 
These are applicable to the advanced stages, and to chronic cases, when 
ulceration may be supposed to have taken place. They should be given in 
the ordinary doses, combined with opium, at intervals of two, three, or four 
hours. 
Acids have sometimes been found beneficial. Much notice has been 
attracted by Hope's mixture, consisting of a fluidrachm of nitrous acid, forty 
drops of laudanum, and eight fluidounces of camphor water, of which one- 
fourth was given every three or four hours. The proportion of acid is too 
great, if of the officinal strength or near it; though perhaps not so, as the 
acid is usually found in the shops. Nitric acid is equally effectual; as the 
common impure preparation called nitrous acid is converted into the former by CLASS III.] 
DYSENTERY. 
571 
dilution. I have found this preparation useful in the advanced stages, and in 
chronic cases, but should not be disposed to employ it when the inflammation 
is acute, and attended with fever. Nitro-muriatic acid with laudanum may 
be employed under similar circumstances. The vegetable acids have also 
been recommended; and cures have been referred to the free use of lemon- 
juice, vinegar, and pyroligneous acid. Dr. Young of Chester, Pennsylvania, 
has employed buttermilk with success, as the exclusive remedy in numerous 
instances. (Am. Journ. of Med. Sei., N. S., iii. 260.) Cheyne's treatment 
by cream of tartar has already been referred to. There appears occasionally 
to be in dysentery a predominance of alkali in the secretions, indicating the 
use of this set of remedies. 
Among the alterative remedies may also be mentioned copaiba and oil of 
turpentine. Given in emulsion with laudanum, in small and frequently re- 
peated doses, these are certainly useful in some cases of advanced or chronic 
dysentery, and are probably more especially applicable to such as are attended 
with ulceration. In typhoid cases, a combination of oil of turpentine with 
castor oil in emulsion is sometimes an excellent remedy. 
Peruvian bark has been recommended; but is applicable only to parox- 
ysmal cases, or those requiring tonic and stimulating treatment. 
Nux vomica has been much employed by the German physicians. It 
should never be used in the acute febrile stage. Hufeland states that in 
obstinate cases it is very effective. The powder, extract, or active principle 
strychnia, may be given in the ordinary dose three or four times a-day. 
Dr. J. W. Sterling has employed powdered guaiac with great success in 
acute dysentery. He gave about two scruples in a wineglassful of sweetened 
mucilage three times a-day. (N. Y. Journ. of Med., N. S., i. 370.) 
Sidphur, cerated glass of antimony, chloride of lime, nitrate of soda in 
the quantity of from half an ounce to an ounce in twenty-four hours, and 
wax both animal and vegetable, and in various modes of combination, have 
been recommended. Dysentery has also been treated by affusion of cold 
water ; and Tissot asserts that he cured many cases by means of tvarm water 
alone, given in the quantity of a cup full every quarter of an hour. In rela- 
tion to many of the above remedies it is difficult to say, whether the cure took 
place merely with them, or through them, or in spite of them. 
Local Remedies.-As auxiliary to general bleeding, and in the place of it, 
when not required or forbidden, cups or leeches are of great importance. They 
should be used when there is much pain and tenderness; and should be ap- 
plied along the course of the colon, where the tenderness is greatest. Leeches 
about the anus are peculiarly useful; and are especially adapted to cases in 
which there is severe tenesmus. The operation may often be advantageously 
repeated. 
Fomentations and emollient cataplasms to the abdomen are also very use- 
ful, and are rendered still more so by anodyne additions, such as camphor, 
laudanum, and decoction of poppy capsules. Warm hop poultices often afford 
relief. Dr. O'Beirne, of Dublin, recommends fomentations with infusion of 
tobacco. Blane found great relief to be afforded by fomentations of chamo- 
mile with a little laudanum to the anus. The warm hip-bath is useful upon 
similar principles. 
Rubefacient and anodyne embrocations, consisting of solution of ammonia, 
oil of turpentine,- oil of monarda, &c., with laudanum or camphor, variously 
combined and diluted, may be employed, though they are less beneficial than 
the applications just mentioned. A broad flannel roller passed repeatedly 
around the body, so as completely to cover the abdomen, has been strongly 
recommended; but this is applicable rather to chronic than to acute dysen- 572 
LOCAL DISEASES. 
[PART II. 
tery. Blisters over the abdomen come in appropriately when these measures 
have failed; but they should never be applied until after sufficient depletion 
both local and general. Great relief may sometimes be obtained by sprink- 
ling morphia on the blistered surface. 
Large emollient enemata have been strongly recommended. They act as 
adjuvants to the cathartics, and are supposed to soothe irritation, and operate 
as poultices to the bowels. They undoubtedly afford occasional relief by 
diluting the acrid fluids, and, when composed of demulcent materials, in some 
measure protect the inflamed surface. But they sometimes also cause pain 
by distension; and the irritation about the lower rectum is increased by the 
mechanical disturbance. When found to yield comfort to the patient, they 
may be repeated daily or more frequently. In the early stages, warm water, 
solution of starch, and infusion of flaxseed, marshmallow, or'bran, and, in 
the advanced stages with debility, veal-water, and mutton-water, are the pro- 
per materials. Melted butter has also been used with asserted advantage. 
Opiate enemata, or suppositories, are sometimes very useful in allaying the 
local distress. Dr. O'Beirne recommends injections of infusion of tobacco ; 
but this remedy must be used with caution. According to Dr. Kent, very 
cold water thrown up the bowels every half hour, speedily alleviates all the 
distressing symptoms. (Phil. Journ. of Med. and Phys. Sci., x. 411); but 
it is necessary to take care that the system be not too far depressed by the 
remedy. 
Injections of acetate of lead or sulphate of zinc are most valuable adju- 
vants to the general treatment, after febrile action has been moderated, and 
especially when the disease is confined chiefly to the rectum and lower 
colon. I have seen the happiest effects from these remedies; the disease 
being often almost immediately arrested by them after a long continuance. 
Acetate of lead is preferable when the affection retains its acute character; 
sulphate of zinc, when it verges towards the chronic state. Of either of 
them six or eight grains may be given in three or four fluidounces of water, 
with twenty or thirty drops of laudanum, and repeated once, twice, or three 
times daily. 
Summary of the Course of Treatment.-In very mild cases without fever, 
it is often sufficient to give a single dose of castor oil, with or without twenty 
drops of laudanum. If the case be of a somewhat higher grade, a dose of 
calomel may be given at the commencement, and followed in a few hours 
by castor oil or sulphate of magnesia. If there should be evidences of a 
loaded stomach, and the physician be called early, he. may add an emetic 
dose of ipecacuanha to the calomel. Should the symptoms increase, and 
fever with a strong pulse be superadded to the abdominal pains, the patient 
ought to be bled moderately from the arm; and, if this condition exist from 
the beginning, the bleeding should precede the other remedies. In violent 
inflammatory cases, it may be necessary to bleed very copiously. After the 
bowels have been thoroughly evacuated, and the patient bled if necessary, 
he may be allowed to rest for a short time upon cooling drinks and some one 
of the refrigerant diaphoretics, if the skin be hot and dry. Should the 
strength of the pulse and the local symptoms continue unabated, it may be 
proper to bleed again moderately, though this repetition of the remedy is 
seldom required, as the disease ordinarily occurs. If the degree of general 
excitement be not sufficient to call for the lancet, and considerable pain and 
tenderness exist, cups or leeches' should then be employed, and warm foment- 
ations or emollient cataplasms applied over the abdomen. The combination 
of opium, ipecacuanha, and calomel or blue mass, before alluded to, may be 
given at bed-time, and afterwards repeated daily at the same hour, being CLASS III.] 
DYSENTERY. 
573 
followed in the morning by a laxative. While this plan is in operation, the 
fomentations or cataplasms should be continued, the leeches or cups repeated 
if called for by pain and tenderness, mild refrigerants administered internally, 
the warm or vapour bath applied if circumstances should be favourable, and 
one or more of the various local measures before enumerated for the relief 
of tenesmus, resorted to. Should the disease not seem disposed to yield to 
this treatment by the sixth or seventh day, the mercurial plan, for which the 
foundation hag been already laid, should be carried to a slight salivation; 
and, at the same time, if the local symptoms are violent, a large blister 
should be applied over the abdomen. The mercurial impression is in gene- 
ral most conveniently brought about by small doses of opium, ipecacuanha, 
and calomel or mercurial pill, repeated every two, four, or six hours, so that 
from two to three grains of opium, four to six grains of ipecacuanha, and 
four to six grains of calomel, or three times the weight of mercurial pill, 
may be given in twenty-four hours. If the system resist salivation, and 
the symptoms are urgent, the blistered surface over the abdomen may be 
dressed with mercurial ointment, and frictions with the ointment applied to 
the inside of the thighs. The disease seldom fails to yield to this treat- 
ment, unless considerable ulceration of the bowel exists. But the prejudices 
of the patient, the peculiarities of his constitution, or some other circum- 
stance may forbid the employment of mercury. In this case, or in the event 
of a failure of the mercurial plan, some of the various alterative measures 
already enumerated (see page 570), may be resorted to, the choice being 
directed by the peculiar circumstances of the case. I would, however, invite 
an especial attention to the injections of acetate of lead and sulphate of zinc. 
(See page 572.) 
The course of treatment above indicated applies to dysentery as it ordina- 
rily appears. The bilious variety requires a more energetic employment of 
mercurial remedies. In the severer cases of this kind, calomel may be given 
in doses of fifteen or twenty grains daily, or of five grains three or four times 
a-day, until some impression is made on the disease or upon the mouth. . Upon 
the occurrence of salivation, the symptoms are almost always ameliorated. 
Opium may often be advantageously combined with the calomel; nor should 
the other measures, above detailed, especially general and local bleeding, 
emollient applications, and the means for relieving tenesmus, be neglected. 
In dysentery associated with intermittent or remittent fever, the same course 
of treatment should be pursued as in the common form, so far as regards the 
bowel affection; but it is highly important also to bear in nlind the indica- 
tions presented by the general disease. The most striking of these is for the 
use of measures calculated to prevent the return of the paroxysms, and no 
remedy is so effectual for this purpose as Peruvian bark, or sulphate of quinia. 
It may be questioned whether this remedy should be employed before the cure 
of the dysentery; as the tonic properties of the bark might aggravate the 
inflammation. But the fact is, that the dysentery is a mere attendant upon 
the fever in this case, and is sustained by it; and whatever may cure the latter 
will be very likely to cure the former also. Whenever, .therefore, an inter- 
mission is obtained, or a regular remission, with only so much general action 
in the interval as may be supposed to be sustained by the local disease, the 
sulphate of quinia may be safely given, after a thorough preliminary evacua- 
tion of the bowels, and the loss of blood, if that be deemed necessary. The 
quantity taken and th^ mode of administration should be regulated as in 
intermittent fever. Severe and obstinate dysenteries are sometimes rapidly 
cured in this way; the colitis ce'asing almost immediately when the prop which 
supports it is removed. The prompt and free use of quinia is especially 574 
LOCAL DISEASES. 
[part II. 
necessary, when, as sometimes happens in epidemics, the fever has a typhoid 
or malignant tendency. It is probably owing to the association of miasmatic 
fevers with the disease of the bowels, that some practitioners have met with 
extraordinary success in certain epidemic dysenteries by the use of bark, 
which is quite useless if not injurious in the ordinary form of the complaint. 
In the adynamic or typhoid form of dysentery, whether complicated with 
the proper typhus fever or not, general bleeding and active purgation are not 
admissible; at least in such cases as exhibit this character at their commence- 
ment. An emetic of ipecacuanha is sometimes serviceable at the very begin- 
ning, and a moderate cathartic dose of calomel may be given if the patient is 
seen early. If it be afterwards deemed advisable, as often happens, to keep 
the bowels clear of irritating or depressing matter, this should be effected by 
medicines calculated rather to support than to weaken, such as infusion or 
tincture of rhubarb, or castor oil with oil of turpentine in small doses. In 
cases where the depression is not great, leeches may sometimes be useful. But 
the remedial measure on which reliance should be chiefly placed, is the mer- 
curial impression, which should be effected by combinations of opium and 
calomel or blue mass, or of these with ipecacuanha, given in small and fre- 
quently repeated doses. This plan should be put in operation immediately 
after the patient is first seen, unless it may be considered proper to precede it 
by an evacuation of the priinse vise. The only cases to which it would be 
inapplicable are those of excessive debility, or great malignancy, or of a scor- 
butic character. It is often necessary, in adynamic dysentery, to support the 
strength of the patient by stimulants, and nutritive drinks, such as carbonate 
of ammonia, wine-whey, wine and water, brandy and water, opium, infusion 
or decoction of bark or sulphate of quinia, oil of turpentine, egg and wine, 
animal jellies, chicken broth, &c., to which some writers add valerian, arnica, 
and the more stimulating aromatics. These remedies should always be used 
with caution, and proportioned carefully to the degree of prostration. The 
mineral acids are also occasionally useful. In cases of hemorrhage from the 
bowels, acetate of lead combined with opium and kino, is perhaps the most 
effectual remedy. Rubefacient embrocations over the abdomen are peculiarly 
useful in this form of dysentery; and a blister may be resorted to much 
earlier than in the disease as it ordinarily occurs. 
Diet.-In very light cases, without fever, solid farinaceous substances, such 
as boiled rice, stale bread, crackers, &c., may beiallowed; but in febrile cases, 
at least in the early stage, the diet should consist exclusively of mucilaginous 
or farinaceous drinks, which may be rendered more palatable by sugar and 
lemon-juice, if the patient desire it. Suitable preparations are solutions of 
gum arabic and arrow-root, thin gruels, infusions of flaxseed, slippery elm, 
and sassafras pith, and decoctions of barley, rice, sago, tapioca, and Irish moss. 
After the general excitement has somewhat subsided, rennet-whey may be 
given; and, in cases of great debility, animal jellies and broths. Sir G. Baker 
recommends mutton suet mixed with warm milk. In convalescence, the 
patient should, as a general rule, be confined to milk, butter, and farinaceous 
substances, until recovery is confirmed. Relapses are very apt to follow im- 
proper indulgence. Great care should be taken to keep the person of the 
patient and the bed-clothes clean, to remove all excrementitious matters, to 
ventilate the apartment, and preserve the air sweet and pure, and, as far as 
possible, to remove the patient from the influence of causes which may have 
contributed to produce the disease. 
2. Chronic Dysentery.-Chronic dysentery is often associated with 
chronic enteritis; and it is not always easy to determine how far the two por- 
tions of .the bowels are severally involved in the inflammation. Nor is the CLASS III.] 
DYSENTERY. 
575 
decision a matter of much importance, as the treatment of the two affections 
is essentially the same, at least in those cases in which the symptoms are 
commingled. Chronic dysentery, when not thus combined, is readily known 
by the frequency and comparatively small quantity of the evacuations, their 
character, and the tenesmus with which they are attended. The greater 
number of the stools consist chiefly of mucus, sometimes mixed with a pus- 
like secretion or blood. Occasionally, however, feculent or bilious matter is 
mixed with the proper dysenteric discharge. When the disease occupies the 
rectum and lower portion of the colon, the feculent matter is often consistent, 
and, instead of being uniformly mixed with the mucus, is either irregularly 
pervaded by it in layers or streaks, or enveloped in a thick coating of it, de- 
rived from the surface of the bowel with which the feces lay in contact. 
There is usually more or less tormina, and tenderness on pressure; though 
the latter is by no means present in all cases. The pulse, skin, tongue, appe- 
tite, &c., are affected as in chronic enteritis; but the symptoms of general 
derangement are, upon the whole, less. When the disease is confined to the 
lower extremity of the bowels, the constitution often sympathizes but little. 
In such cases, the complaint sometimes continues for months or years, with- 
out making very serious inroads on the general health. But, for the most 
part, in chronic dysentery, if a favourable change is not effected by treatment, 
the patient gradually emaciates, the. countenance becomes pale, sallow, and 
shrunken, the appetite fails, the general strength gives way, and ultimately 
the disease closes with hectic fever or anasarca. 
Anatomical Characters.-Besides thq usual signs of chronic inflammation 
in the mucous membranes, ulceration is very generally found in cases of death 
from chronic dysentery. An interesting fact is, that some of the ulcers are 
not unfrequently observed in a state of cicatrization, and others completely 
cicatrized, rendering it probable that patients may recover in this disease, even 
after extensive ulceration of the mucous coat. Abscesses of the liver are not 
unfrequently observed in chronic dysenteric cases; but whether they are to 
be considered in the light of cause or of effect, it is not easy to determine. 
Chronic dysentery is seldom an original disease, but, when it occurs, is 
almost always the consequence of an acute attack. Slight cases of it, affect- 
ing only the rectum and lower extremity of the colon, may sometimes per- 
haps arise from an extension of inflammation from hemorrhoidal tumours. 
Treatment.-The regulation of the diet is among the most important points 
in the treatment of this disease; and the same rules are applicable here as in 
the cases of chronic inflammation of the stomach and small intestines. Gene- 
ral bleeding is scarcely ever admissible; but leeches may sometimes be applied 
when the pain and tenderness arc considerable. When the disease is connect- 
ed with chronic inflammation of the small intestines, cathartics are seldom 
required; as the bowels are sufficiently opened spontaneously. Indeed, in 
this ease, the treatment is altogether so closely analogous to that directed for 
chronic enteritis, that it is sufficient to refer the reader to the account of that 
disease. In pure dysentery, especially when seated in the lower colon and 
rectum, it is often advisable to employ mild laxatives, in order to prevent 
morbid accumulation in the bowels, above the part affected. This indication 
is presented, when no fecal matter is passed in the course of the day. Small 
doses of castor oil, confection of senna, rhubarb, manna, or some other very 
mild laxative should be employed. When the pain is considerable, and the 
discharges frequent, opium and ipecacuanha should be given at bed-time, and 
with these calomel or the mercurial pill should be associated, when hepatic 
action is deficient. Indeed, great powers over the complaint have been 
ascribed to the alterative action of the mercurial pill, independently of any 
disorder of the liver. Dr. J. K. Mitchell states, as the result of his observa- 576 
LOCAL DISEASES. 
[PART II. 
tion, that most cases of chronic dysentery may be cured by the exclusive use 
of pure mucilage as a diet, and of the blue pill given once every day or every 
other day, in doses of from three to five grains. (Am. Journ. Med. Sei., ii. 
323.) Pushed to moderate salivation, it will undoubtedly often effect cures; 
and this measure should always be resorted to if others fail. The various 
alterative medicines before mentioned as sometimes useful in the advanced 
stages of acute dysentery, are still more applicable to the chronic form of the 
disease. Such are sulphate of copper, sulphate of zinc, nitrate of silver, nitric 
acid, nitro-muriatic acid, Hope's mixture, a mixture of alum and sulphate of 
zinc as recommended by Moseley, copaiba, and the turpentines or their vola- 
tile oil. Moderate doses of these medicines should be given three or four 
times a-day, and may often be usefully combined with from the eighth to the 
quarter of a grain of opium. Copaiba and turpentine are best administered 
in emulsion. I have seen the happiest effects from oil of turpentine, given in 
the dose of ten drops every two hours, in chronic dysentery, especially when 
attended with a perfectly dry and smooth tongue. The root of arnica is used 
by the Germans, in the dose of a scruple every two or three hours. The vege- 
table astringents, formerly so much employed in chronic dysentery, though 
sometimes beneficial when the complaint borders on the character of diarrhoea, 
are generally, in the unmixed cases, worse than useless. Dr. Blackburn recom- 
mends strongly the wild strawberry leaves, which he employs in strong Spiritu- 
ous decoction, made by boiling a pound of the fresh leaves in two pints of brandy 
to a pint, and given in the dose of a tablespoonful every three hours. (Bost. 
Med. and Surg. Journ., xxxvii., 342-, from South. Med. and Surg. Journd) 
The warm or hot salt-bath, given every day, is one of the most beneficial 
adjuvants to internal remedies. Swathing the body with flannel, as recom- 
mended by Dewar, may also be resorted to. " Four or five folds of fine 
flannel, or a large piece of thick fleecy hosiery, ought to be laid over the ab- 
domen, and, over this, a flannel bandage should be bound, rather tight, and 
in a uniform manner, from the groin nearly to the arm-pits and back again." 
(Dewar on Diarrhoea and Dysentery, p. 111.) 
When the disease is confined chiefly or exclusively to the lowest portion of 
the bowels, I have found no remedy comparable in efficiency to injections of 
sulphate of zinc, given in solution along with a little laudanum, and repeated 
twice a day. page 572.) It is perhaps worthy of consideration, whether 
the remedy might not be advantageously employed by injection through a 
tube, in cases where the more remote portions of the nolon are affected. 
There can be little doubt that it operates by a direct alterative influence on 
the surface which it touches, exactly as in ulcerations of the mouth. 
In relation to clothing, exercise, &c., the same observations apply here as 
in the case of chronic enteritis. 
Article IL 
CANCER OF THE BOWELS. 
This is a rare disease. All portions of the intestinal canal are not equally 
liable to it. The parts most frequently affected are the duodenum, caecum, 
rectum, and sigmoid flexure of the colon. There are in general no means by 
which the disease can be certainly distinguished in its earlier stages. It is 
often for a long time latent, or attended only with occasional pain or uneasi- 
ness, which is usually referred to some other cause. No decided symptoms 
appear until the tumefaction has become so considerable as materially to CLASS III.] 
CANCER OF THE BOWELS. 
577 
interfere with the passage of the contents of the bowels, or until ulceration 
has taken place so as to occasion great pain in their passage, or until the dis- 
ease has begun to involve other structures. Obstinate vomiting and constipa- 
tion are symptoms which usually mark its encroachment upon the cavity of the 
bowel. Along with these are paroxysms of severe lancinating or spasmodic 
pain, extending from a particular spot over the abdomen. The pain usually 
comes on at a certain time after eating, longer or shorter, according to the 
distance of the disease from the stomach. When the complaint is seated in 
the caecum or below, there is usually great and distressing abdominal disten- 
sion from feculent accumulation and flatus, and the patient is much troubled 
with eructation of air. Stercoraceous vomiting sometimes occurs, when the. 
obstruction is very great. In some cases, however, a sufficient passage remains 
open from the beginning, and the patient suffers comparatively little from 
vomiting, constipation, and abdominal distension. In others, the passage is 
enlarged by ulceration, or a new one is created, and temporary relief is ob- 
tained from these alarming symptoms. Sometimes diarrhoea occurs, with 
bloody, glairy, gelatinous, sanious, or otherwise disordered evacuations; and, 
in the latter stages, the passages are often very offensive. The extension of 
the disease to neighbouring organs, as the liver, pancreas, kidneys, &c., gives 
rise to various complications of the symptoms. The patient emaciates rapidly; 
the countenance assumes the peculiar cancerous pallor; the pulse becomes 
frequent; edematous effusion takes place; and the patient dies, worn out with 
pain, loss of blood, and general irritation. In some cases, death occurs more 
suddenly, as the result either of complete obstruction of the bowel, or of peri- 
toneal inflammation consequent upon ulcerative perforation. The diagnosis 
between cancer and other organic affections of the bowels is not always easy. 
It is, however, very much assisted, when, as often happens, a tumour can be 
felt through the abdominal parietes, corresponding with the seat of suffering. 
The phenomena presented by cancer in different parts of the bowels arc not 
exactly the same. When it affects the duodenum, there must obviously be 
less of the distressing distension of the bowels, while the patient is in a still 
greater degree troubled with vomiting, which, as well as the greatest severity 
of pain, comes on generally from two to four hours after eating, when the 
chyme passes out of the stomach. When the caecum is the seat of the disease, 
the obstruction is often very great, in consequence of the valve becoming in 
a greater or less degree affected; although a case has been recorded by Dr. T. 
E. Beesley, in which the passage was even larger than is usual in health, not- 
withstanding a great thickening of the parietes. (Phil. Journ. Med. and 
Phys. Sei., vi. 350.) In cancer of the rectum, there is less disposition to 
vomit than when the upper part of the canal is affected, and less general dis- 
turbance of health until the complaint has made great advances. The tenesmus 
and great but often ineffectual straining, the discharges of feces in a flattened 
tape-like form, or in slender cylinders not thicker than a quill, or in other 
distorted shapes, and the acute lancinating pains in the region of the sacrum, 
extending down the limbs even to the feet, will be sufficient to indicate the 
necessity of an examination of the rectum, in which the finger will encounter 
a stricture, more or less completely surrounded by an almost cartilaginous 
hardness. When to these symptoms are added an ichorous fetid discharge, 
and an extension of irritation to the vagina in females, and to the bladder in 
males, there can be little doubt as to the nature of the disease. 
In all these cases, dissection shows the same morbid structure as in cancer 
of the stomach. Sometimes the whole parietes of the bowel are thickened, 
and the passage contracted to the size of a crow's quill; sometimes irregular 
indurated tumours, or others of a medullary character are found projecting 578 
LOCAL DISEASES. 
[part II. 
into the cavity of the intestine. Ulceration of various extent is discovered, 
not unfrequently penetrating into neighbouring parts, which have become 
agglutinated with the bowel in a mass of cancerous disease. Contiguous con- 
volutions of the intestines have been found thus agglutinated; and a passage, 
made by ulceration through their coats, is one of the means by which that 
sudden relief from the most imminent danger, which occasionally marks the 
progress of a case of intestinal cancer, is produced. 
Treatment.-Only palliative measures can be employed. Tf there be some 
doubt whether the case may not be simply chronic inflammation of the bowels, 
the treatment for this affection should be employed, and the more especially, 
as, though it cannot cure, it may somewhat alleviate the complaint if really 
cancerous. The chief indications in cancer of the bowels are to facilitate the 
passage of the intestinal contents, and to allay pain. The former is answered 
by the use of a laxative diet, and of laxative medicines, the latter by opium, 
conium, or hyoscyamus; care being taken to counteract the constipating effect 
of the first of these narcotics. Opiates may be used by the mouth, or rectum, 
or by the endermic method. When the disease is in the rectum or lower 
colon, relief may be obtained by the use of demulcent enemata, which pene- 
trate the stricture, and, by diluting the feculent accumulation above, facilitate 
its passage. These may sometimes be advantageottsly thrown up by means 
of a gum elastic tube previously passed through the stricture. A bougie may 
be occasionally employed to obtain present relief from distressing flatulence, 
&c., but not with the view of effecting permanent dilatation. The diet should 
be light, digestible, and nutritious, without being stimulant; and substances 
should be preferred which yield but a small proportion of excrementitious 
residuum. Farinaceous substances, animal broths, milk, cream, and the most 
digestible of the laxative fruits, whether fresh or dried, may be allowed. Milk 
is peculiarly suitable. 
Article III. 
IRRITATION OF THE BOWELS. 
This, as in the case of the stomach, may be vascular, affecting especially 
the mucous membrane, or nervous, affecting the muscular coat, or both at 
once. Diarrhoea, the different forms of colic, flatulence, spasm of the rectum, 
and hemorrhoids may come under this head, though all occasionally associated 
with a debilitated condition of the bowels. 
1. DIARRHCEA. 
Those cases are denominated diarrhoea in which the alvine evacuations are 
more liquid, frequent, and copious than in health, without being hemorrhagic 
oi' dysenteric in their character. 
The affection is rather a consequence of certain pathological conditions than 
itself a disease. These conditions are various and sometimes even opposite; 
as is rendered obvious by a consideration of the different agencies which may 
produce increased evacuation from the bowels. A simple increase of the pe- 
ristaltic action may have this effect, without the co-operation of any other 
cause. It may also result from an elevated excitability of the bowels, causing 
them to receive a stronger impression from their usual contents than in health, CLASS III.] 
DIARRHOEA. 
579 
or from an increase in the quantity or stimulating quality of the ingesta acting 
upon the ordinary excitability, or from a condition of the digestive organs, 
allowing bland materials introduced into the stomach to undergo changes 
which may render them irritant. Again, irritation or inflammation of the 
intestinal mucous membrane may produce secretions, which, from their quan- 
tity or quality, shall prove purgative; and, in one portion of the alimentary 
canal, matters may be generated, which shall operate in this way upon ano- 
ther portion further down. The biliary and pancreatic secretions, moreover, 
may be so altered as to excite the bowels to increased action, though the latter 
may be in perfect health. Finally, debility of the mucous membrane may 
allow the elimination of fluids, which, by mere distension of the bowel, shall 
cause^the muscular coat to contract more rapidly. These are very different 
conditions, yet all attended with diarrhoea. The only common circumstance 
is increased peristaltic action. 
With this diversity in the sources of diarrhoea, there is an equal diversity 
in the attendant symptoms; and there is scarcely any phenomenon common 
to all the varieties except those mentioned in the definition. The evacuations 
may be very few, not exceeding two or three daily, or so frequent that the 
patient scarcely satisfies one call before he experiences another. Their quan- 
tity, which is sometimes but little greatei- than in health, has been known to 
amount to forty pounds in a day. (Dalmas, Diet, de Med., 2e ed., x. 271.) 
There is generally more or less pain before the evacuations, which are almost 
always followed by relief; but in some cases no pain whatever is experienced 
throughout. Along with the discharge i§ occasionally a very disagreeable 
sinking sensation in the abdomen, with a general feeling of exhaustion or 
faintness, a cool skin, and a feeble irregular pulse. This condition, however, 
is almost always temporary. Diarrhoea, is sometimes attended with fever, 
which is generally an indication of inflammation, or very high and extensive 
irritation of the mucous coat. But in the great majority of cases there is no 
fever. The skin is usually dry, and the urine scanty. Every possible diversity 
exists in the degree, duration, and danger of the complaint. It may be quite 
trivial, getting well in a day or two without aid, or may run on for months 
and even years, resisting every variety of treatment. In some rare cases, 
death occurs suddenly from great exhaustion, even while the patient is on the 
stool. But more commonly, a fatal termination is preceded by a slow ema- 
ciation and gradual failure of strength. Very protracted and fatal cases are 
generally connected with tuberculous or cancerous lesions of the bowels, or- 
ganic disease of the liver, or a scorbutic state of system. In simple diarrhoea, 
whether acute or chronic, without organic lesion, the prognosis is almost 
always favourable, provided proper treatment can be applied. 
In reference to the pathological condition of the bowels, three varieties of 
diarrhoea may be recognized:-1. that in which the increased peristaltic move- 
ment results from causes acting directly on the muscular fibre, with a per- 
fectly healthy state of the mucous membrane; 2. that in which it is brought 
about through irritation or inflammation of the membrane; and 3: that in 
which it proceeds indirectly from debility of the membrane. 
1. Diarrhoea from Increased Peristaltic Action alone.-Of this kind is pro- 
bably the looseness of bowels induced by terror or other sudden and strong 
emotion, which appears at the same time to relax the sphincter and excite the 
peristaltic action. The same result is sometimes seen in hysterical or other 
nervous affections; and to this head, moreover, we may refer the crapulous 
diarrhoea of great eaters, in which the exciting cause of the increased peris- 
taltic movement is probably distension of the bowels, which is felt as a direct 
stimulus by the muscular coat. In these cases, the stools are always fecal, 580 
LOCAL DISEASES. 
[PART II. 
and usually semiliquid, and of a healthy colour. The affection is very slight 
and yields without difficulty. 
2. Diarrhoea from Inflammation or Irritation of the Mucous Membrane.-• 
This is beyond all comparison the most frequent of the three varieties referred 
to. Inflammation of the membrane has been already sufficiently considered 
under the head of enteritis. The remarks which follow, therefore, have refer- 
ence to irritation of the bowels; although it is often very difficult to decide 
between the two Conditions; as they run into each other by insensible shades. 
Diarrhoea of irritation may exist independently of any concurrent disorder in 
other parts of the system, or may originate and be sustained by such disorder. 
Upon this difference of origin two sub-varieties may be founded. In both 
there is often a morbid predisposition in the alimentary mucous membrane, 
rendering it susceptible to impressions which it would not feel under ordinary 
circumstances. This predisposition consists in an increased excitability, which 
is little else than the first step towards positive irritation. Such a condition 
is induced by continued exposure to heat, and is often left behind by idiopa- 
thic fevers and other acute diseases. Hence in part it is, that diarrhoeas are 
most prevalent in summer, and are so apt to occur during cofivalescence. The 
same predisposition may also arise from any of the ordinary causes of irrita- 
tion, acting in a degree insufficient to bring on obvious disease. Thus, under 
the continued influence of fatigue and an improper diet, exposure to cold will 
occasion an attack of diarrhoea, which neither the former nor the latter cause 
alone might have been sufficient to produce. Here a slight and latent irrita- 
tion is provoked by a new cause into open violence. 
a. From irritation of bowels independent of disease elsewhere.-1This may 
be produced by causes acting either directly upon the mucous membrane, or 
intermediately through the system. Of the causes acting directly, the most 
prominent are insufficiently masticated or indigestible food; acidulous and 
saccharine fruits, such as cherries, plums, melons, &c., particularly when un- 
ripe or used in excess; spoiled meats, and mouldy or corrupted provisions of 
all kinds, such as are often used in armies and on shipboard; newly and 
imperfectly fermented or spoiled liquors, as new cider, table beer, sour ale or 
porter, spruce and ginger beer, &c.; certain natural waters, especially lime- 
stone water in persons unused to it; sour milk or the milk of unhealthy 
nurses; cold water in excess; acid or other irritating matters resulting from 
spontaneous changes in the food, after introduction into the stomach; worms 
and collections of feculent matter in the bowels; and the abuse of irritating, 
stimulant, or purgative medicines. Particular kinds of food always induce 
diarrhoea in certain individuals, in consequence of idiosyncrasy. Of the ex- 
citing causes acting through the system cold is by far the most common. 
This, howrever, alone is seldom sufficient to produce diarrhoea. It is after 
previous exposure to heat, and especially when the body is perspiring, that it 
acts so energetically. The diarrhoea induced in this way is denominated by 
some writers catarrhal, probably because attended with increased serous" or 
mucous secretion; by others rheumatic, from the similarity of its cause with 
that producing rheumatism, though any other irritation or inflammation 
resulting from cold might with just as much propriety receive the same 
designation. Nevertheless, a rheumatic or gouty predisposition is sometimes 
called into activity in the form of diarrhoea; ^md this complaint not unfre- 
quently results from the translation of rheumatism or gout from some other 
part of the body to the bowels. Sometimes very sudden and alarming dis- 
charges from the bowels are brought on in this way. In like manner, the 
retrocession of cutaneous eruptions, and the cessation of some habitual dis- 
charge either natural or artificial, occasionally produce diarrhoea. Fetid ex- CLASS III.] 
DIARRHCEA. 
581 
halations, and the continued influence of anxiety or other mental disturbance, 
are also capable of calling into action this form of intestinal irritation. It is 
probable that vegetable miasmata have the same effect. Diarrhoea is very apt 
to accompany epidemic cholera and dysentery, sometimes acting as a forerun- 
ner to them, and often, during the continuance of the epidemic, preceding 
individual attacks of those diseases, so that the practitioner frequently has it 
in his power, by a proper management of the diarrhoea, to prevent a much 
more serious affection. In these cases, however, the diarrhoea is frequently 
associated with hepatic derangement, and might fall under the following 
variety. 
In diarrhoea of irritation, proceeding from the above mentioned causes, the 
stools are more or legs fecal, often of the healthy colour, though sometimes 
green from the action of acid upon the healthy bile, and occasionally somewhat 
bloody, when the irritation is very severe, or a hemorrhagic tendency exists. 
In some instances, they are copious and watery, constituting the serous diar- 
rhoea of authors; in others, chiefly composed of mucus, in which case the 
disease is sometimes denominated mucous diarrhoea. Not unfrequently por- 
tions of the food undigested are found in the stools, and in some instances this 
constitutes the chief feature of the affection. Such cases are always connected 
with a feeble digestion. They were formerly designated by the name of 
lientery. In the diarrhoea of infants nothing is more common than to find 
undigested coagula of milk in the passages. 
b. Dependent on hepatic derangement.-Of this variety of diarrhoea there 
are three distinct forms, characterized respectively by an increased, perverted, 
and diminished secretion of bile. 1. The first form, or that connected with 
an increased secretion of bile, is commonly called bilious diarrhoea. The 
stools are liquid, of a bright yellow colour, sometimes green, from the action 
of acid in the bowels, generally rather frequent, and attended with considera- 
ble tormina, and a burning or otherwise painful sensation in the rectum during 
the discharge. Some excitement of the circulation is not unfrequent. The 
bile is, in these cases, the direct cause of the intestinal irritation, by coming 
in greater quantity than usual into contact with the mucous membrane. An 
aggravation of the affection, attended with vomiting, constitutes cholera mor- 
bus. 2. The second form differs from the first only in the circumstance that 
the bile is secreted not only in greater abundance, but of an unhealthy or per- 
verted character. The stools are brown, or black, or otherwise deranged in 
colour, and not unfrequently of a tarry consistence. In bad cases, they are 
sometimes very profuse, and exquisite pain attends the passage of the bile 
through the bowels. It is important to distinguish the passages, in these 
cases,, from those black discharges which -depend on intestinal secretion or 
hemorrhage, as the treatment required is different. In the bilious cases, how- 
ever black the stools may appear in mass, they always exhibit a yellowish 
tinge, if viewed in very thin layers. This perverted secretion, though per- 
haps in most cases dependent on mere functional derangement of the liver, is 
often also connected with serious organic disease of that organ. 3. The third 
form is wholly different in character from the two preceding. In this, the 
biliary secretion is much diminished or entirely suspended. The evacuations 
are consequently light coloured, and often of a dirty white, being more or less 
colourless as they are more or less' deprived of bile. They are usually opaque, 
and sometimes almost milky in appearance. Hence, they have been supposed 
to consist of chyle; but they are in many instances too copious to allow of 
the truth of this supposition. When very abundant, they resemble somewhat 
the rice-water evacuations of cholera. In most instances, the diarrhoea appears 
to depend upon the suspension of the hepatic secretion, and very soon ceases 582 
LOCAL DISEASES. 
[part II. 
upon its restoration. Congestion probably takes place in the intestinal mu- 
cous membrane, in consequence of a torpid capillary circulation in the liver, 
and relieves itself by secretion from the distended vessels. Occasionally it is 
possible that the case may be reversed, and a profuse secretion from the bowels, 
consequent upon intense irritation, may diminish that supply of blood to the 
liver which is necessary for the formation of bile. The former, however, is 
a much more frequent occurrence. It is highly probable that the two patholo- 
gical conditions occasionally coexist in the same case. This form of diarrhoea, 
though '-attended with less acute pain than the two preceding, is often very 
distressing from a feeling of indescribable uneasiness in the abdomen with 
depression of spirits, is obstinate unless properly treated, and sometimes pro- 
duces a fatal exhaustion. As it ordinarily occurs, it may almost always be 
speedily arrested by suitable remedies, and hence the importance of an early 
inspection of the evacuations in this complaint. 
It is obvious that the various forms of diarrhoea above described may be 
more or less mingled one with another, and that from such an admixture 
an almost infinite variety of appearance may be given to the evacuations. 
c. Occurring sympathetically in various diseases.- Diarrhoea is a very 
common attendant upon teething, in which, when not severe, it sometimes 
forms a useful outlet for irritation, and should not be too hastily arrested. In 
such cases attention should be directed especially to the gums. (See Morbid 
Dentition.') It frequently supervenes in the course of febrile affections, espe- 
cially the exanthemata. Thus, it is common in scarlatina and small-pox. 
It has already been spoken of as attendant upon the thrush or sore-mouth of 
children. But in these cases, as well as in typhoid fever and phthisis, the 
diarrhoea depends rather upon inflammation of the bowels than mere irritation. 
In the course of dropsy, and at the close of febrile complaints, attacks of diar- 
rhoea sometimes come on, which appear to be an effort of nature to relieve 
the morbid condition of system. Thus, a paroxysm of fever sometimes goes 
off with increased secretion from the bowels instead of perspiration. In 
such cases, the diarrhoea has been called critical, and should not be too hastily 
interfered with. 
3. Diarrhoea of Debility.-Diarrhoea may depend upon debility of the mu- 
cous nlembrane of the bowels, with or without antecedent inflammation. The 
most numerous cases of this kind are undoubtedly those which, originating in 
inflammation, continue after all inflammatory action has subsided. The capil- 
lary vessels and secreting orifices, enlarged during the inflammation, are left 
by the subsidence of the excitement too feeble to contract vigorously, and the 
more fluid parts of the blood escape, with more or less modification, according 
to the greater or less amount of remaining energy in the vessels. Of this 
character may even be considered the diarrhoea attended with chronic ulcers 
of the bowels, which are too feeble or indolent to take on the healing process. 
But occasionally we meet with this disease, without any previous intestinal 
inflammation or irritation which can be recognized. Thq secreting orifices 
appear too feeble to resist the force with which the blood is moved, and the 
serous and even fibrinous parts of the blood escape, attended sometimes with 
more or less of the red globules; An increased degree of the same affection 
constitutes passive hemorrhage. It is not unfrequently associated with a 
watery condition of the blood, which becomes incapable of sustaining a due 
energy in the extreme vessels. An example of this kind is afforded in the 
colliquative diarrhoea of phthisis, which, though generally associated with 
ulceration of the mucous membrane, sometimes occurs without any evidence 
of organic disease in this structure, alternating with the colliquative sweats CLASS III.] 
DIARRHOEA. 
583 
which depend upon the same cause. Diarrhoea of debility is generally with- 
out pain or tenderness of the bowels, and without febrile excitement. Never- 
theless, in the mucous membrane of the bowels as in other parts, debility and 
inflammation may co-exist, in which case the symptoms would be modified. 
Treatment.'-This must vary according to the character of the disease. In 
relation to the treatment of diarrhoea, the propriety of inspecting the evacua- 
tions cannot be too strongly urged. When the complaint depends simply 
upon increased peristaltic movement, it usually subsides with the cessation of 
the cause. Should it require treatment, from five to ten drops of laudanum^ 
or a fluidrachm of the camphorated tincture of opium may be given, and re- 
peated if necessary. In the crapulous form, the loaded bowels may be re- 
lieved by a dose of castor oil or other mild cathartic, and the diet afterwards 
reduced in quantity, and made to consist of materials which yield a compara- 
tively small proportion of excrement, as meats, milk, and farinaceous sub- 
stances. 
The treatment for inflammatory diarrhoea has already been detailed. (See 
Enteritis.') In diarrhoea- of irritation, respect must be had to the cause. If 
slight, without discoloration of the passages, without febrile excitement, and 
with little or no griping, the case will in general require scarcely anything 
more than a regulation of the diet. If the presence of irritant substances in 
the bowels is suspected, a dose of castor oil should be given with or without 
laudanum, according as the pain is considerable or otherwise. When the 
stools are green or of a sour smell, or other evidence of acid in the primae vise 
is presented, magnesia, or a mixture of this with rhubarb, should be substi- 
tuted for the oil. Purging, however, has been abused in this complaint. It 
should not be carried further than is necessary to evacuate irritant substances. 
In some rare cases, collections of feculent or foreign matters in the bowels, 
somewhat difficult to dislodge, sustain a vexatious diarrhoea, which can be 
removed only by a removal of the cause. In such cases, the cathartics already 
mentioned may be repeated, or others more active resorted to. When worms 
are the offending cause, calomel is the most efficient cathartic, and should be 
given in connexion with vermifuge medicines. These cases, however, are 
rare; and, in general, a single dose of the cathartic is sufficient. In cases 
not requiring laxatives, and in others, after the proper use of these medicines, 
opiates are the most efficient remedies. If the irritation be moderate, and 
wholly unattended with arterial excitement, from five to ten drops of lauda- 
num, with or without a little camphor water, or a fluidrachm of camphorated 
tincture of opium, repeated two or three times a-day, will generally arrest the 
disease. If the symptoms of irritation are high, and the case borders on in- 
flammation, it may be proper to bleed moderately. In such cases, and even 
in those of a milder character, the opium may be advantageously combined 
with ipecacuanha, when the patient is confined. This combination is pecu- 
liarly suitable at bed-time. When acid continues to be generated, prepared 
chalk or prepared oyster-shell should be added to the anodyne, or, if these do 
not suit the stomach, and especially if there should be a slight febrile action, 
carbonate or bicarbonate of soda or potassa should be substituted. If by 
these means the discharge is not arrested, and the patient complains of little 
or no pain, one of the vegetable astringents may be added, such as logwood, 
kino, catechu, rhatany, geranium, or pure tannic acid. The more bitter 
astringents should be avoided at this stage. These various remedies may 
often be conveniently combined in mixtures, of which the precise form must 
differ with the circumstances of the case. A suitable vehicle for them is 
diluted cinnamon water, and insoluble substances should be suspended by 584 
LOCAL DISEASES. 
[PART II. 
means of gum arabic and sugar.* It is best, as a general rule, to give the 
mixtures in small doses frequently repeated. If the astringents are found to 
increase the pain, they should be omitted. 
In bilious diarrhoea with bright yellow or green passages, a gentle cathartic 
may first be administered with or without laudanum, and then small doses of 
calomel and opium, about the sixth of a grain of the former to the twelfth 
of a grain of the latter, for example, every hour or two. The sixth of a 
grain of ipecacuanha may be added to each dose, if there is no nausea. Not 
more than two grains of the mercurial should, in general, be given in this 
mode during the day. Should there be fever and much pain, a little blood 
should be taken from the arm, and the refrigerant diaphoretics administered, 
the patient being confined to his bed. In cases attended with black or very 
dark bilious evacuations, the alterative mercurial plan should in general be 
commenced immediately, and continued until the colour is changed. When 
the discharges are riot copious, and the pain not severe, the calomel may be 
given without opium. Advantage is sometimes derived, in these cases, from 
alternating the mercurial with the syrup or infusion of rhubarb. 
In the form of diarrhoea attended with white passages, it is often highly 
important to stimulate the liver as speedily as possible. When the stools are 
small, and the patient not materially weakened, from five to ten grains of 
calomel may be given at once. In children two or three years old, one or 
two grains of calomel may be given every two hours until it produces some 
effect on the bowels, care being taken not to exceed four or six grains. The 
happiest effects sometimes immediately result. But, if the passages are 
somewhat copious, or the patient feeble, the calomel should be given with 
opium, or the compound powder of ipecacuanha, and followed by some prepa- 
ration of rhubarb, or a little castor oil, if the bowels should be confined. 
The alterative plan may afterwards be followed, by giving smaller doses of 
the mercurial with opium or Dover's powder. When the evacuations are 
alarmingly copious and exhausting, I have found great advantage from small 
and frequent doses of calomel, opium, and acetate of lead.']' In infants, 
affected with this or any other form of bilious diarrhoea, which in them is 
very generally attended with acidity, I can from experience recommend the 
formula below.t If the alterative mercurial plan fail in these cases, or cir- 
cumstances prohibit its employment, the nitromuriatic acid, with or without 
laudanum, may be substituted, and will sometimes operate most happily on 
the hepatic function. Should the diarrhoea continue after the secretion of 
the liver has been corrected, it should be treated as cases of simple irritation. 
In diarrhoea of debility, in which may be included most cases of chronic 
diarrhoea not attended with pain or fever, after correcting the biliary secretion 
if deranged, we may resort to astringents and tonics, of which a vast variety 
* The chalk mixture of the Pharmacopoeia is a convenient formula for the adminis- 
tration of chalk, and the same will answer for oyster-shell. The dose is a tablespoonful 
repeated several times a-day. Opiates being generally indicated at the same time, from 
five to ten drops of laudanum, or from f^ss to fgj of camphorated tincture of opium, 
maybe added'for every fluidounce of the mixture. If the vegetable astringents are 
employed, from ten to twenty grains of kino, catechu, extract of logwood, or extract of 
rhatany, or from two to four grains of tannic acid, should be added to the same quantity. 
Logwood, rhatany, and geranium may also be conveniently used in decoction or infusion, 
and these preparations may be used as the vehicle of the chalk, and of the laudanum or 
paregoric. 
f R.--Hydrarg. Chlorid. Mit. gr. ij; Opii gr. j; Plumbi Acetat. gr. vj. Misce, et fiant 
pil. no. xii. S. One to be taken every half hour. 
J R.-Testae Praparat. ^ss; Tinct. Opii gtt. vj; Pil.PIydrarg.gr. iij ; Acaciae pulv., 
Saech., aa gss; Aquae Cinnam. f^ss; Aq. fluvial, f^j. Misce. S. A teaspoonful to be 
given at intervals of two, four, or six hours, or less frequently. CLASS III.] 
DIARRHOEA. 
585 
have been recommended. Among the vegetable astringents, may be enumer- 
ated, besides those already mentioned, galls, oak bark, blackberry and dew- 
berry root, black alder, alum root, pomegranate, &c.; among the tonics, 
columbo, gentian, quassia, simaruba, angustura, cascarilla, &c. These may 
be tried, separate or variously combined, in decoction or infusion, flavoured 
with cinnamon or orange peel, and with some hope of advantage. But, on 
the whole, more good may be expected from the mineral substances belonging 
to the same classes, especially alum, acetate of lead, sulphate of copper, sul- 
phate of zinc, nitrate of silver, and the various chalybeates. With all these 
remedies it is usually proper to combine opium. Ergot was used successfully 
by Dr. Stout, of Bethlehem, Pennsylvania, in the dose of six grains three 
times a-day, in a case which had long obstinately resisted tonic and astringent 
treatment. (Phil. Journ. of Med. and Phys. Sci.,yi. 118.) M. Bayer em- 
ploys subnitrate of bismuth, with great advantage, in the diarrhoea of phthisis, 
that of typhus fever, and in the cases of children. (Am. Journ. of Med. Sei., 
N. 8., xiv. 219.) When stimulation is requisite, good port wine should be 
preferred. For the treatment especially applicable to the diarrhoea of chronic 
enteritis, the reader is referred to that disease. 
There are various accessory measures which may be resorted to, in any of 
the forms of diarrhoea. Of these the warm bath, in acute cases, when the 
skin is warm and dry, the hot bath, and especially the warm salt-bath, in 
chronic cases when it is cool and pale, are perhaps the most efficient. They 
may be used with great advantage in the cases of children. A bath of 
decoction of oak bark has been recommended in similar cases. Much benefit 
may also be expected from a flannel roller about the body, Frictions to the 
surface are decidedly useful, when the cutaneous circulation is languid, and 
rubefacients or blisters to the abdomen may be tried in obstinate cases. 
Anodyne enemata are sometimes highly serviceable in allaying the intestinal 
irritation. Warm clothing, with flannel next the skin, is important. This 
precaution is too often neglected in children, whose feet, legs, and arms, are 
apt to be exposed unprotected to the changes of temperature, which they are 
less able to bear than adults. Regular exercise should not be neglected in 
chronic cases, when the patient is in a situation to take it. 
Diet.-Attention to diet is indispensable. In many cases, indeed, no other 
remedial measure is necessary, especially- when the disease has originated 
from improper food. In infantile diarrhoea, it is important to ascertain 
whether the milk of the1 nurse is healthy, and, if there is reason to suspect 
that it is otherwise, to substitute another nurse, or to remove the child from 
the breast altogether. The farinaceous substances, such as stale or toasted 
bread, water crackers, and boiled rice, constitute a suitable diet in the early 
stages of diarrhoea of irritation. Milk is admissible in mild cases. Farina- 
ceous drinks may be employed when the irritation is considerable, and 
especially when the stomach participates in it. Fresh vegetables and fruits 
should, as a general rule, be avoided. Whatever is eaten should be thoroughly 
masticated. For infants, fresh milk, diluted with water, and thickened with 
arrowroot or pulverized water crackers, constitutes a good diet; but, when 
there is fever or evidence of inflammation, the food should consist exclusively 
of mucilaginous or farinaceous liquids. In the more advanced stages, milk, 
broths, and boiled meats, with fresh butter and cream may be allowed; and, 
in diarrhoea of debility, this kind of food should be given from the commence- 
ment. In many chronic cases, an exclusive milk diet will often alone effect 
cures. The dietetic rules applicable to dyspepsia should be observed during 
convalescence. (See Dyspepsia.') 586 
LOCAL DISEASES. 
[part ii. 
2. COLIC. 
Colic (from xwXov, colon, or xoiXta, the belly') is characterized by pain in 
the bowels, usually more or less paroxysmal in its character, associated with 
constipation, and occurring independently of inflammation either of the 
mucous or peritoneal coat. Pathological conditions essentially different are 
included in the above definition; but there is a convenience in considering 
them together; as their most prominent symptoms are the same, and their 
treatment similar. I shall first give the symptoms of colic in general, and 
then treat of the varieties of the disease, so far as they are peculiar. 
Symptoms.-The pain of colic occurs usually in frequently returning 
paroxysms, with irregular remissions or intermissions; but, in some instances, 
is continued and almost uniform, for considerable periods. During the exa- 
cerbation, it is often exceedingly severe, so as to cause even persons of forti- 
tude to groan or cry out. It occurs most commonly about the umbilicus, 
though not unfrequently in other parts, and. sometimes over the whole abdo- 
men. It is described as twisting, rending, pinching, &c., and is often attended 
with a feeling of spasmodic constriction. The patient is for the most part 
extremely restless, frequently changing his position, turning from one side to 
the other, sitting up in bed, or rising and walking about the room with his 
body bent, and his hands frequently pressed against the abdomen. The 
muscles of the abdomen are sometimes spasmodically contracted, either in 
knots, or so as to produce a general rigidity of the anterior parietes. The 
violence of the pain occasionally depresses temporarily all the vital actions, 
producing paleness of the skin, cold sweats, a shrunken countenance, and a 
feeble pulse. When very sudden in its attack, it may produce faintness, and 
even temporary insensibility, and in infants frequently occasions general con- 
vulsions. It is often relieved by pressure on the abdomen, but not uniformly 
so. When the violent pain has ceased, a feeling of soreness is generally left 
behind. 
The pain, in true colic, is always accompanied with constipation either as 
cause oi' effect; and, when this is overcotne by medicines, not unfrequently 
ceases. In certain cases, however, it continues without abatement, notwith- 
standing the operation of cathartics. 
Along with the pain and constipation there is often vomiting, but this is 
by no means constantly present. The stomach occasionally participates with 
the bowels in the spasmodic pain. The pulse is generally either healthy, or 
somewhat depressed. Occasionally, however, the disease- is originally asso- 
ciated with inflammation, or this condition ensues in the course of it, or there 
is high irritation in some neighbouring organ. Under these circumstances, a 
febrile condition may be developed. 
Colic, in the great majority of cases, yields readily to suitable treatment. 
In some instances, however, the constipation persists and the disease assumes 
the most alarming character, in spite of all that can be done. The vomiting 
is now frequent, everything taken into the stomach is rejected, the action of 
the bowels themselves is inverted, and even feculent matter is discharged from 
the mouth. Along with these symptoms, are a swollen, tense, and tympanitic 
abdomen, hiccough, great anxiety, cold sweats, a feeble pulse, and a general 
expression of the last degree of prostration. This condition is denominated 
ileus or the iliac passion, and is frequently, though upon insufficient grounds, 
treated of as a distinct disease. It is the closing stage of the severest forms 
of colic, and is often connected with some irremovable mechanical obstruction. 
It may occur, in fact, in any case in which, no matter from what cause, whe- CLASS III.] 
COLIC. 
587 
ther spasm, or partial paralysis of the bowel, or obstruction, the alvine con- 
tents cannot find their way downward. Even ileus, however, is not always 
certainly fatal. Patients have, in numerous instances, recovered under appa- 
rently desperate circumstances; and hope and consequent efforts sliould never 
be abandoned, unless when some insuperable obstacle, such as scirrhous occlu- 
sion of the bowel, is known to exist. 
Colic has no fixed duration, sometimes terminating in a few hours, and 
sometimes running on for two or three weeks. 
Diagnosis.-The Complaint with which colic is most likely to be confounded 
is strangulated hernia. In fact, the only difference between this and some 
forms of colic depending on mechanical obstruction is; that the former pre- 
sents certain external characters by which it can be recognized, and may be 
relieved by the timely application of surgical means. But this distinction is 
of the highest importance, and the possible existence of strangulated hernia 
should be borne in mind, in every case of severe or obstinate colic, and a close 
examination instituted. Many lives have been lost from want of attention to 
this caution. From mucous enteritis colic may be distinguished by the con- 
stipation which attends, it; from both this and peritonitis, by the more 
paroxysmal character of the pain, by the relief frequently derived from 
pressure, by the absence of fever, and by the restless movements of the 
patient. 
Simple Spasmodic Colic.-The essential character of this variety is 
spasm of the bowel, unattended with any other necessary pathological con- 
dition. Constipation is here the result, and not the cause of the spdsm. 
Attacks are most' commonly brought on by indigestible food, especially flatu- 
lent vegetables, and are peculiarly apt to occur in dyspeptic persons. Under 
these circumstances, the disease is sometimes called dyspeptic colic. The pre- 
sence of the undigested matters in the bowels occasions frequently a copious 
extrication of flatus, which increases the spasm by the stimulus of distension. 
Gases evolved from other causes sometimes produce attacks, without any irri- 
tant substance in the bowels. In either case, the disease is often called flatu- 
lent colic. The patient is affected with borborygmi, distension of the abdomen, 
and eructations of flatus, which are sometimes exceedingly copious, and usually 
afford more or less relief. When the attack is induced by indigestible food, 
or other irritant taken into the stomach, this organ is apt to participate in the 
spasm, and occasionally the symptoms are of the most violent character. The 
presence of irritant secretions in the bowels, or the retention of portions of 
hardened feces insufficient to obstruct the passage, may sometimes act as an 
exciting cause; but the irritation from these sources is more apt to fall upon 
the mucous Coat than upon the muscular, and to produce diarrhoea or dysen- 
tery, than colic. This variety of colic is also frequently induced by cold, 
especially by cold feet, and sometimes results from rheumatic or gouty irrita- 
tion acting upon the nervous tissue of the bowel, from suppressed discharges, 
repelled cutaneous eruptions, mental disturbance, and an hysterical state of 
the nervous system. In the last case it has been called hysterical colic. To 
the same variety belongs also the intestinal spasm induced by worms, denomi- 
nated by some verminose colic. 
Simple spasmodic colic is very rarely fatal. Sometimes, however, it is so; 
and then large portions of the bowel are usually found, upon dissection, in a 
contracted state, while the portion above the stricture is distended, and marked 
more or less with appearances of inflammation, though not enough to account 
for the fatal issue. Death probably results from the spasmodic closure of the 
bowel, operating as an obstacle to the passage of the intestinal contents. It 
is probable that the great distension of the bowel, above the contracted por- 588 
LOCAL DISEASES. 
[part II. 
tion, may in some measure paralyze the muscular coat, and thus act as an 
additional cause of the constipation. 
Bilious Colic.-The peculiarity in this form of colic, is the coincidence 
of derangement of the biliary organs with the intestinal spasm; the former 
being probably the source of that irritation which evinces itself in the latter. 
An attack of bilious colic is frequently preceded by loss of appetite, nausea, a 
feeling of lassitude or weariness, and other symptoms of disordered hepatic 
action. The paroxysms of pain are generally attended with much irritation 
of stomach, and vomiting of yellow or green bile, the discharge of which 
affords temporary relief. There is at the same time usually some sallowness 
of the skin, or a yellow tinge of the conjunctiva; the urine is often deep- 
coloured, and yellowish; and there is a yellowish-white fur on the tongue. 
Not unfrequently some tenderness will be found upon pressure in the epigas- 
trium or right hypogastrium; and the pulse, though usually calm at first, is 
sometimes febrile from the beginning, and often becomes so, if the disease 
continues. There is also occasionally incomplete paralysis of some portion of 
the upper or lower extremities, with convulsive movements in different parts 
of the body. When stools are obtained, they are sometimes bilious, some- 
times light coloured, indicating a want or deficiency of bile. The immediate 
cause of the spasm is probably an irritation of the muscular coat of the bowels, 
induced either by sympathy with irritation of the liver, or by a Congested 
state of the portal veins, or by both. The vomiting of bile does not neces- 
sarily indicate an increase of hepatic secretion; for the bilious matter may 
proceed from the gall-bladder, discharging its contents in consequence of the 
pressure upon it in the act of vomiting. Either an increase or diminution of 
bile may be a consequence of irritation of the liver, and an attendant upon 
portal congestion, and either may therefore occur in bilious colic. The original 
causes are probably the same as those which give rise to cholera morbus and 
bilious diarrhoea. Perhaps the most common is exposure to cold, after pre- 
vious lengthened exposure to heat. Hence the disease occurs most frequently 
in hot weather, especially when the nights are cool; and is peculiarly preva- 
lent in those regions where this alternation of temperature between the day 
and night is a usual event. It is probable also that miasmata are capable of 
producing colic, by their influence upon the biliary organs. 
Colic from Obstruction.-In this variety, the spasm of the bowel is 
the result of its accumulated contents, consequent upon a stoppage more or 
less complete of the passage. The constipation is here the cause, instead of 
being, as in the preceding cases, the effect of the spasm. The obstruction 
may depend upon accumulated and compacted feces, upon insoluble sub- 
stances taken largely or repeatedly by the mouth and arrested in the bowels, 
upon invagination of the intestine, tumours, &c. Of these various causes, 
as well as of the diagnosis of obstruction in general, and of its varieties, I 
shall treat at large under the head of obstruction of the bowels; as it is this 
which constitutes the real disease, of which the colic is merely a symptom. 
It is sufficient here to say that, unless the impediment to the passage of the 
alimentary matters be removed, the complaint ends in death, preceded by all 
the symptoms of ileus. 
Inflammatory or Rheumatic Colic.-Inflammation of the mucous 
or the peritoneal coat of the bowels, though almost always attended with 
spasmodic pain, is characterized by symptoms which strikingly distinguish 
it from colic. This, however, is not the case with inflammation of the mus- 
cular coat exclusively. It is true that this coat is seldom or never inflamed 
without more or less participation of one of the others, unless in cases of 
rheumatism or gout attacking the bowels. Hence, this variety of colic CLASS III.] 
COLIC. 
589 
might emphatically be styled rheumatic or gouty, although these two affec- 
tions may also be exhibited in the bowels in a merely neuralgic form, or in 
that of mucous inflammation or irritation. Rheumatism of the muscular 
tissue of the bowels is not very uncommon. It may be either original or 
translated. It may frequently be recognized by coming on immediately 
after the retrocession of rheumatism from some external part. A portion 
more or less extensive of the muscular coat becomes tender and painful, and 
either refuses altogether to contract under the stimulus of the alimentary 
or feculent matter, like an external muscle similarly affected, or is thrown 
into the most exquisitely painful, and at the same time inefficient efforts at 
contraction. The pain, in these cases, is more steady and uniform than in 
spasmodic colic; and, when paroxysms occur, they appear to depend upon 
the effort of the bowel to carry forward its contents by the ordinary peri- 
staltic movement. Hence, purgatives produce occasionally severe pain dur- 
ing their operation. The constipation is a consequence of the insufficiency 
of the peristaltic action, and does not depend necessarily upon spasm; al- 
though a portion of the bowel, not affected to the point of inflammation, may 
sometimes be thrown into spasmodic contraction. There is often tenderness 
upon pressure, and sometimes fever. The pain is in general more circum- 
scribed than in spasmodic colic, and purgatives do not afford the same 
relief. Within my observation, the ascending and descending colon have 
been the portions of bowel most commonly affected. Though exceedingly 
painful, and sometimes apparently threatening, this form of colic is very sel- 
dom fatal. 
Neuralgic Colic.-Neuralgia of the Bowels.-The bowels, like most 
other parts of the body, are subject to attacks of severe pain, without inflam- 
mation, or necessary vascular excitement. Such attack^, when complicated 
with spasm, belong to simple spasmodic colic. When not thus complicated 
they cannot be better designated than by the title at the head of this section. 
The pain, though somewhat paroxysmal, is usually more steady during a 
certain length of time than spasmodic colic. There is not the same frequent 
alternation of severe pain and comparative ease. As in the preceding va- 
riety, paroxysms are sometimes induced by the passage of alimentary matters 
and purgative medicines; and constipation is owing to the indisposition of the 
muscular coat to contract, in consequence of the pain which contraction in- 
duces; but there is less difficulty in procuring evacuations from the bowels 
than in most other forms of colic. The pain, during the exacerbation, is not 
increased by pressure, although the bowel is afterwards left tender. The 
pulse is either at the standard of health, or beneath it. Sometimes the dis- 
ease is distinctly intermittent, occurring at the same time every day or every 
other day, and after having continued for some hours, leaving the patient quite 
easy in the interval. The causes of neuralgia of the bowels are not less ob- 
scure than those of the same affection elsewhere. Sometimes it depends on 
disorder in the spine, or in the ganglia of the sympathetic nerve, and some- 
times appears to have its origin in general debility, or in a rheumatic or gouty 
diathesis. 
Lead Colic, or Painters1 Colic, is so peculiar both in its origin and charac- 
ter as to merit the rank of a distinct disease; and will therefore be treated of 
under a separate head. 
Besides the varieties of colic above referred to, several others have been 
enumerated by authors. Spasm of the bowel sometimes occurs from sym- 
pathy with irritation or inflammation in various neighbouring parts, as during 
the passage of biliary and urinary calculi, in painful menstruation, and in 
hemorrhoids. Hence the designations of hepatic, nephritic, uterine or men- 590 
LOCAL DISEASES. 
[part II. 
strual, and hemorrhoidal colic. In all these cases, so far as the intestinal 
spasm is concerned, the complaint would come under the variety of simple 
spasmodic colic above described. The designation of metallic colic is used, 
by soine medical writers, for painful bowel affections among persons who work 
in different kinds-of metal. It is only the lead or painter's colic, however, 
which deserves this name. The intestinal affection which sometimes attacks 
workers in copper, and other irritant metals, is properly enteritis. The dis- 
ease which has occasionally appeared endemically or epidemically in certain 
localities, and has been named from these localities Madrid colic, Devonshire 
colic, Poitou colic, &c., and by some French writers vegetable colic, appears 
from the descriptions of authors to have been, in some instances, identical 
with lead colic, and in others with bilious colic. It not unfrequently happens 
that different causes of colic operate at the same time, and thus produce mixed 
cases, in which the peculiar symptoms of two or more of the several varieties 
may be observed. 
Treatment.-The general indications in the treatment of colic are to 
relieve pain, and evacuate the bowels. Different modes of effecting these 
objects are required, under different circumstances, and in different forms of 
the disease; and the indications themselves are more or Iqss modified in cer- 
tain cases. I shall first consider the plan applicable to simple spasmodic 
colic, and afterwards the modifications demanded in the other varieties seve- 
rally. . . 
In simple spasmodic colic, when the pains are moderate, and dependent 
upon flatulence or mere exposure to cold, without the presence of irritating 
solid or fluid matter in the primm vim, relief may often be quickly obtained 
by the exhibition of moderate stimulants, especially of those which are rather 
local than general in their action, such as the aromatic oils, infusions, and- 
tinctures. A cupful of hot infusion of ginger, cloves, or calamus; from fifteen 
to thirty drops of the essence of peppermint or spearmint, dropped on sugar, 
or diffused in sweetened water; or from one to four fluidrachms of the com- 
pound spirit of lavender, or compound tincture of cardamom, sufficiently 
diluted with hot water, may be employed. One or two teaspoonfuls of the 
camphorated tincture of opium will usually ^e found still more efficient. When 
the complaint has originated in exposure to cold, the feet may be soaked in 
hot water, or held before a hot fire; and this simple remedy will often give 
relief without other means. 
In severe cases of the same kind, or in such as have resisted the above 
treatment, a full dose of opium or some one of its preparations should be 
given, and repeated at intervals of one, two, three, or four hours, according to 
the urgency of the symptoms, until the pain is moderated, or decided narcotic 
effects are experienced. The above mentioned aromatics, or even more.power- 
ful stimulants, may be advantageously associated with the opiate, .especially 
when the system sinks under the severity of the pain. Under these circum- 
stances, laudanum may be given with tincture of camphor, oil of turpentine, 
oil of juniper, aromatic spirit of ammonia, sulphuric ether, or even musk when 
the stomach is the seat of the spasm. In cases complicated with hysteria, infu- 
sion of valerian, mixture or tincture of assafetida, or the anodyne liquor of 
Hoffmann, may be substituted for the stimulants mentioned. 
The anodyne and stimulating remedies should be accompanied, or soon 
followed, by some quick cathartic, especially castor oil, which is beyond all 
others adapted to these cases. A fluidounce of the oil with twenty-five or 
thirty drops of laudanum, given in peppermint water, will very often effect- 
ively meet all the indications. 
At the same time, external means should not be neglected. Strong friction CLASS III.] 
COLIC. 
591 
over the abdomen sometimes proves very serviceable by aiding in the expul- 
sion of flatus. Warm fomentations, anodyne and emollient cataplasms, and, 
in urgent cases, hot oil of turpentine applied by means of a folded flannel 
moistened with it, and even a large sinapism over the abdomen, may also be 
employed. ; \ : i ■ ' ' i. 
When the pain arises from irritating matter in the stomach, which may be 
inferred to be the case if the attack commence soon after eating, or if the 
patient be affected with nausea or retching in the intervals of the spasm, full 
vomiting should be promptly induced, either by copious draughts of warm 
water of warm chamomile tea, or by an emetic dose of ipecacuanha. The 
most violent and threatening cases sometimes yield immediately to this simple 
remedy, after powerful anodynes and stimulants have been employed without 
effect. The attention of the young practitioner cannot be too strongly directed 
to this fact. , . j ' ,1 • 
If there be reason to suppose that undigested food, acrid secretions, fecu- 
lent accumulations, or any other irritating substance in the bowels, are the 
cause of the spasm, the indication for alvine evacuations is still stronger than 
in other cases^ and this, should be kept prominently in view. Should castor 
oil not act speedily, or be rejected from the stomach, recourse: may be had to 
sulphate of magnesia; to infusion of senna with Epsom salt, manna, and fen- 
nelseed, cardamom, or ginger; or, in very obstinate cases, to croton oil, of 
which from half a drop to two drops may be given, and repeated at short 
intervals until it operates, or produces some obvious inconvenience. When 
the stomach is very irritable, calomel i^ often preferable to other cathartics, 
being retained when alpiost everything else is rejected. Five grains may be 
given, every two, three, or four hours until it operates, or the whole quantity 
amounts to twenty grains. The occurrence of salivation will, under such cir- 
cumstances, in persons of ordinary constitution, be of no disadvantage. The 
most obstinate cases sometimes yield immediately after the mouth has become 
sore. If the irritating matter in the stomach or bowels be acid, magnesia 
should either be substituted for the other cathartics, or given in conjunction 
with them; and it has been observed that mild laxatives of this character 
sometimes operate, when more powerful purgatives serve merely to increase 
the spasmodic constriction, and to provoke vomiting. A good laxative mix- 
ture for the purpose consists of magnesia and manna, mixed with strong fen- 
nelseed tea. •. t J • 
To hasten the action of the cathartics, or to supply their place when they 
are rejected from the Stomach, or from other cause fail to operate, purgative 
enemata are of the utmost importance. Indeed, in some very bad cases, they 
constitute our chief reliance. The milder should be first employed, and after- 
wards, if necessary, the more powerful, their strength being increased at each 
successive repetition. After failure with the common injection, consisting of 
olive oil or lard, common salt,, and molasses, of each a tablespoonful, mixed 
with a pint of warm water, the operator may resort successively to castor oil, 
infusion of senna, jalap, extract of colocynth, &c., each in three or four times 
the quantity usually given by the mouth, and diluted with water so as to mea- 
sure a pint or more. Oil of turpentine, in the quantity of from half a fluid- 
ounce to two fluidounces, mixed with half a pint or a pint of water by the 
intervention of the yolk of eggs, forms an excellent enema in severe cases. 
When the spasm is dependent on flatulence, or connected with hysterical disor- 
der, the greatest advantage may be expected from a drachm of assafetida rubbed 
up with water. In cases of ileus, where danger is imminent, the tobacco 
enema should be employed. In this country, we usually infuse a drachm of 
the narcotic in a pint of hot water, and give half the quantity, repeating the 592 
LOCAL DISEASES. 
[part II. 
operation with the other half at the end of half an hour or an hour, if the first 
should fail. Dr. Abercrombie recommends fifteen or twenty grains infused in 
six fluidounces of water, to be repeated, if necessary, every hour, until slight 
faintness or giddiness is felt. The smoke of tobacco has also been forced into 
the rectum, with asserted advantage. Sometimes very cold water, injected 
into the bowels, produces relaxation of the spasm, when other measures have 
failed; and very large quantities of pure warm water, thrown up by means of 
a self-injecting apparatus, until the patient can no longer support the disten- 
sion without suffering, have been found very efficient in alarming cases. There 
may be some hope that intussusceptio, obstruction from twisting of the bowel, 
or even concealed strangulation may be relieved by this latter measure. The 
introduction of a long gum-elastic rectum tube, so as to pass the sigmoid 
flexure high up into the colon, will afford the means of applying the injected 
matter more efficiently. 
Other means may be employed as auxiliary to the above course of treat- 
ment. Occasionally a stream of cold water, poured from a pitcher at a' con- 
siderable height upon the naked abdomen of the patient, placed on his back 
upon the floor, has been followed almost immediately by an al vine evacuation, 
and consequent relief. Bleeding is very useful by relaxing the spasm, ancl 
obviating the danger of inflammation. In obstinate cases, when not contra- 
indicated by the state of the pulse, or the general condition of the patient, it 
should never be neglected. The warm bath too is often very efficient, and in 
cases of children is not inconvenient. Irritability of stomach, if not checked 
by some of the various means employed for the1 relief of the pain and spasm, 
may sometimes be happily allayed by an anodyne enema, so as to admit of 
medicines being administered by the mouth. Sometimes a state of debility 
comes on, which requires the support of wine-whey, or other form of alcoholic 
stimulus. The hope of a favourable issue should never be surrendered, but 
these various means perseveringly repeated^ and variously alternated to the 
end. Patients have often been rescued under the most unpromising circum- 
stances, and sometimes from apparently inevitable death. 
•After the bowels have been freely ^evacuated, care should be- taken to keep 
them open by mild means; and, if much tenderness of the abdomen or any 
part of it, with or without fever, should lead to the apprehension of danger 
from inflammation, this should be combatted by bleeding, cupping, or leech- 
ing, fomentations, blisters, &c., as the case may seem to require. The diet 
of the patient should for some time be cautiously regulated; light and easily 
digested food being employed; and everything likely to occasion flatulence, or 
excess of acid, avoided. 
In bilious colic, as the pulse is usually more active, and evidence of existing 
congestion or even inflammation of the liver not uncommon, bleeding should, 
as a general rule, be resorted to more freely, and at an earlier period, than in 
the preceding variety; and cupping over the region of the liver and duodenum 
will often be advantageous. In the commencement, an emetic of ipecacuanha 
or tartarized antimony may sometimes be advantageously exhibited; and at 
any time, if the stomach should be irritable, and small quantities of bilious 
matter occasionally vomited, this organ should be well washed out, by means 
of warm water, or infusion of chamomile. But, in the great majority of cases 
of bilious colic, the most appropriate treatment, at the commencement, is to 
exhibit a combination of opium and calomel, in repeated doses, until the pain 
is relieved or rendered tolerable, and then to carry off the mercurial by means 
of quicker purgatives, such as castor oil, sulphate of magnesia, infusion of 
senna with salts, &c. I usually direct four grains of opium, with from eight 
to twelve grains of calomel, to be made into four pills, two of which are to be CLASS III.] 
COLIC. 
593 
taken immediately, and the others at intervals of an hour, if required. The 
operation of the cathartics should be assisted by enemata; and recourse should 
be had to the various measures already enumerated, as calculated to facilitate 
the opening of the bowels. The remarks before made in relation to external 
remedies, such as warm fomentations, sinapisms, blisters, the warm bath, &c., 
are equally applicable here; and the necessity is still greater for guarding 
against, or correcting inflammation, by general and local depletion. Calomel 
is much more strongly indicated than in the simple spasmodic colic; and if 
the quantity at first exhibited, as above directed, should fail to effect a cure, 
the medicine may be administered with tolerable freedom throughout the 
complaint. Indeed, in obstinate cases, it is almost always desirable to push 
the mercurial to a moderate salivation, for which purpose a grain or two may 
be given at regular intervals, varying according to the urgency of the symp- 
toms. The same cautions are requisite here as already given, in relation to 
the maintenance of a free state of the bowels, and the proper regulation of 
the diet, during convalescence. Especial care should be taken to avoid 
exposure to changes of temperature, until convalescence is firmly established. 
Should the fecal discharges remain clay-coloured, an alterative course of mer- 
cury, or nitromuriatic acid may be employed, and the various means resorted 
to, calculated to restore the function of the liver to its healthy state. (See 
Jaundiced) 
Rheumatic or inflammatory colic usually presents stronger' indications for 
general and local bleeding than either of the other forms of the disease. In 
almost all cases, where the constitution of the patient is tolerably robust, the 
lancet may be advantageously employed with great freedom. Cups or leeches 
may also be liberally applied along the course of the affected bowel, which is 
generally marked by exhibiting more or less tenderness upon pressure. It is 
desirable to evacuate the bowels at first freely; but this should be accom- 
plished if possible by the milder cathartics, such as castor oil or Epsom salt, 
aided if necessary by enemata, rather than by those of a very active or drastic 
character; as the portion of the bowel affected becomes exceedingly painful, 
under the stimulus of active purgation. After the bowels have been well 
opened, and the pulse sufficiently reduced by the loss of blood, objects which 
in general may be very soon effected, the patient should be put under the 
influence of opium, which may be very advantageously combined with ipeca- 
cuanha and calomel. One or two grains of opium, with an equal quantity of 
ipecacuanha, and from two to four grains of calomel, may be given at bed- 
time, and the combination may be repeated, if necessary, at intervals of four, 
six, or eight hours, so as to keep the patient in tolerable ease, and to sustain 
a steady perspiration; the plan of treatment being occasionally intermitted, in 
the day, for the administration of a mild cathartic; Should the mouth exhibit 
the slightest evidence of a general mercurial influence, the calomel should be 
suspended. Upon the commencement of such an influence, the symptoms of 
the disease very generally give way. Should the stomach be irritable, as 
sometimes happens, the calomel and opium may be given without the ipeca- 
cuanha; or the whole may be suspended until the irritability has yielded to 
anodyne enemata, and to external applications calculated to relieve it. (See 
Vomiting, page 533.) When it is desirable, upon any account, to avoid the 
possibility of salivation, the calomel must be omitted, and either the opium 
and ipecacuanha employed alone, or their place supplied by a mixture of an 
opiate with some preparation of colchicum. I have been in the habit of using 
the officinal solution of sulphate of morphia, in the dose of one or two 
fluidrachms, with from twenty to forty drops of the wine of colchicum root, 
repeated every four, six, or eight hours. It has appeared to me, that this 594 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
combination is especially applicable to cases in which the irritation is of a 
somewhat fugitive and unsettled character, and liable to ready translation to 
other, and perhaps still more delicate organs. The remarks already made, in 
relation to local external remedies, and the use of the warm or hot bath, in 
simple spasmodic colic, are equally applicable to this variety. Bevulsion to 
the extremities is also indicated, and hot and stimulating pediluvia, with 
sinapisms to the feet and ankles, may be employed. Occasionally cases occur 
in which the general actions are so feeble as not to admit of depletion. If, 
along with this debility, there should be a disposition to sweat during sleep, 
sulphate of quinia will be likely not only to support the strength of the patient, 
but also to cure the disease. 
In neuralgia of the bowels, the same indications exist as in the other forms 
of colic, for relieving pain, and procuring alvine evacuations. The former 
indication requires the use of opiates, the latter of mild cathartics, which are 
usually sufficient for the end. But the same relief is not obtained after the 
cathartic action, as in ordinary colic. Other remedies must be employed for 
the cure of the affection. Of these .the preparations of colchicum, given as 
largely and as frequently as can be well borne by the stomach, are perhaps 
the most effectual. Good may also, be expected from the narcotic extracts, as 
those of belladonna, stramonium, conium, and hyoscyamus, which may be 
given alone or in combination, and pushed so far as to produce their peculiar 
impression upon the brain. It is possible that the chalybeates, and other 
mineral tonics, may also prove serviceable, although I have little experience 
with them in this form of neuralgia. Should the affection assume the regular 
intermittent form, it will be almost certainly cured by the free employment 
of sulphate of quinia; and this medicine may be used, with some hope of 
advantage, in the remittent and even continued cases. The same external 
remedies may be applied as in ordinary colic, with the addition of frictions 
with strong tincture of aconite, or ointment of veratria. Should tenderness 
upon pressure be observed in any portion of the spinal column, cups or leeches, 
with subsequent rubefaction, vesication, or pustulation of the part affected, 
will be required. Bleeding seldom does good, but on the contrary often 
much injury in this affection. The diet should be digestible and nutritious 
without being stimulant. 
3. LEAD COLIC. 
Syn.-Painters' Colic.-Colica Pictonum. 
This disease has been called saturnine colic and metallic colic, from its 
cause, painters' colic from a class of persons very subject to it, and Devon- 
shire colic and colica Pictonum, the former from the county of Devonshire, in 
England, the latter from the province of Poitou, in France, in both of which 
districts of country it has prevailed. 
It usually commences with symptoms not unlike those of dyspepsia, as 
diminution or loss of appetite, epigastric uneasiness, slight and fugitive ab- 
dominal pains, a disposition to costiveness, with general languor and depres- 
sion of spirits. These' symptoms continue for several days, gradually aug- 
menting, until the patient is at length generally compelled by the severity of 
his pains to abandon his customary avocations, and betake himself to his bed. 
In some instances, however, the attack is sudden, and without premonition. 
The pain is felt more especially about the umbilicus, or in the spinal 
region, but usually extends also in a greater or less degree over the abdomen, 
and sometimes shoots up into the chest and downwards into the pelvis. It is CLASS III.] 
LEAD COLIC. 
595 
excessively severe, being described as tearing, rending, boring, &c., and is 
attended, moreover, with a feeling of indescribable wretchedness, which is 
forcibly expressed upon the countenance., Though paroxysmal, it is seldom 
entirely absent, unless momentarily after vomiting, which sometimes appears 
to afford relief. In the remission, however, there is rather a feeling of con- 
striction and vague uneasiness than of acute pain. The patient finds it im- 
possible to remain long in one position; sometimes rising, and walking about 
the chamber, and again resuming his bed; now turning upon one side, then 
on the other, getting upon his knees, or lying upon his face, and assuming 
the most grotesque postures, often with his' body bent almost double, and his 
hands pressing together upon his abdomen. The suffering is so exquisite as 
to extort groans from individuals of the greatest fortitude, and I have known 
a strong man to cry like a child. To an experienced eye, the expression of 
extreme wretchedness upon the countenance, in connexion with the whimsical 
movements of the patient, is sometimes alone sufficient to mark the complaint. 
The paroxysms are often worse during the night, and the patient is unable to 
sleep. Moderate pressure upon the abdomen does not in general aggravate 
the pain, but, on the contrary, often yields partial relief. Some uneasiness, 
however, is occasionally felt, in particular spots, when they are strongly 
pressed. The belly is in most cases somewhat retracted, especially at the 
umbilicus, and the abdominal muscles are hard, and often gathered into knots. 
The testicles are apt to be drawn up during the paroxysm; and a severe irri- 
tation is sometimes extended to the urinary passage's and rectum, producing 
strangury and tenesmus. 
Obstinate constipation, sometimes resisting the most active cathartics, and 
often attended with a desire to go to stool, and a feeling as if an evacuation 
would afford ease, is one of the mosf characteristic features of the disease. 
When evacuations are obtained, the feculent matter first discharged is usually 
in small, hard, dark-coloured, knotty lumps, sometimes covered with mucus. 
It is said that the sphincter ani is in some instances so violently constricted 
as to resist the introduction of a pipe. 
Nausea and vomiting are very frequent, and the matter discharged is gene- 
rally bilious. Indeed, irritability of stomach is one of the most distressing 
circumstances of the disease, and sometimes interferes greatly with the effi- 
cacy of the medicines administered. Occasionally, it is among the first signs 
of the action of the poison. 
The tongue is flabby, pale, and often tremulous when protruded; the breath 
sometimes fetid; the urine scanty; the pulse usually slow and hard, but occa- 
sionally frequent; the face of a pale, dingy, or sallow aspect; the hand tremu- 
lous, with great weakness at the joint of the wrist; the lower extremities 
affected with painful cramps; and the muscles of the chest sometimes spas- 
modically contracted, with pains like those of angina pectoris, and palpitation 
of the heart. According to Dr. Burton, the gums present, especially at their 
margin, a pale, bluish-gray colour, characteristic of the action of lead upon 
the system. 
The complaint is sometimes attended with evidences of inflammation in the 
abdominal viscera; such as tenderness upon pressure, a hot dry skin, frequent 
pulse, and a general febrile condition. Delirium, convulsions, and paralysis 
are also among its occasional complications. The palsy may affect only the 
muscles, or it may extend also to the sensorial functions, involving the senses 
of touch, sight, and hearing. It is, however, more frequently a consequence 
than an accompaniment of the colic. 
The symptoms usually continue unabated for several days, and then gradu- 
ally subside; and this result will take place, in the great majority of cases, 596 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
though little or no treatment be employed. The severity of the complaint, 
however, may be diminished, its duration abridged, and its very unpleasant 
sequelae in great measure prevented by appropriate remedies; and there can 
be no doubt that cures may be effected in cases which would prove fatal, if 
left without aid. Under proper treatment, the proportion of deaths is very 
small. Of 3569 cases treated by different physicians in Paris, 95 died, or 
about 2-7 per cent.; and, according to Andral, of more than 500 persons 
treated during eight years in the hospital la Charite by M. Lerminier, only 
5 died, or less than 1 pel' cent. {Diet, de Med., viii. 388.) The disease usu- 
ally yields to appropriate remedies in less than a week; and, when it proves 
fatal, does so as a general rule in consequence of some unfortunate complica- 
tion, arising from the peculiar susceptibility of the patient, or the intense 
action of the cause. The cases attended with epileptic convulsions, almost all 
end unfavourably. Sometimes headache, delirium, and coma supervene, and 
the patient dies apoplectic. In other cases, a general failure of the nervous 
power takes place, the violent pains cease, dyspnoea occurs, the skin becomes 
cold and pale, the pulse feeble, the countenance shrunk, sight and hearing 
impaired, and a fatal asphyxia closes the scene. In some rare instances, death 
appears to result directly from the morbid state of the abdomen, and the 
symptoms preceding the fatal issue indicate mortification of the bowels, or 
intense inflammation. 
Patients before a perfect cure are liable to relapse, and, after one attack, 
are much more susceptible to the disease than before, so that a slight exposure 
to the cause frequently induces a return. By repeated exposure, or by the 
long continued but slight action of the cause, a state of chronic disease at 
length ensues, which is often difficult to manage, and sometimes bids defiance 
to medicines, either terminating fatally in a few weeks or months, or produc- 
ing a train of complicated evils, which run through long years of suffering. 
Among the characters of this morbid condition are palsy of the extremities, 
especially of the forearms, and occasionally also of the voluntary muscles of 
other parts; defective nutrition and consequent general emaciation; enfeebled 
capillary circulation, with a pale, sallow, or dingy skin; oedema of the extremi- 
ties gradually extending upwards; abdominal dropsy, and effusion in the 
pleura or pericardium; and general failurb of the sensorial functions, indi- 
cated. by defective touch, impaired hearing and vision, epilepsy, mania, and 
mental imbecility. 
The diagnosis of lead colic is not difficult. It can scarcely be confounded 
with any other disease than one of the varieties of colic already described, 
from all of which it differs in the peculiar aspect, grotesque motions, and 
excessive restlessness of the patient, the incomplete remission of the pain, the 
retracted abdomen with its hard and knotty parietes, the spasmodic pains in 
the extremities, and the occasional paralytic complications. 
On examination after death, constriction of portions of the bowels, particu- 
larly of the colon, has been observed, so great in some places as scarcely to 
admit the passage of a crow's quill. It is asserted that, in some instances, 
the stomach and intestines have been found in a state of preternatural con- 
traction throughout their whole extent. Marks of inflammation, and even 
disorganization, of portions of the alimentary mucous membrane have also 
been noticed. In the United States army report of 1827, a case is given in 
which the arch of the colon was mortified "all around" to the extent of "five 
fingers' breadth," and six lines below was a stricture of the intestine. (Re- 
marks, &c., by S. Forry, M. D.-Am. Journ. of Med. Sd., N. S. iii. 321.) 
But these appear to have been accidental complications, and not essential 
results or attendants of the disease; for of eight cases reported by Andral in CLASS III.] 
LEAD COLIC. 
597 
his Clinique Medicale (3e ed., tom. ii. p. HO), only one presented constric- 
tion of the intestines, and, though slight marks of inflammation were observed 
in several, the intestinal canal was entirely sound in others; and in none 
were lesions discovered sufficient to explain the symptoms. In a case reported 
by Louis, the alimentary canal exhibited no mark of disease whatever. (Re- 
cherch. Anat. Patholog., &c., p. 483.) Several others have obtained similar 
results from their post-mortem examinations. (Diet, de Aled., viii. 389.) In 
cases of death from epilepsy supervening upon colica pictonum, hypertrophy 
of the brain has been found in some instances, softening of the brain or spinal 
marrow in others, while in others again no discoverable lesion existed in any 
of the nervous centres. (Ibid., p. 385.) The inference to be drawn from 
these facts is, that the morbid cause acts directly upon the nervous system, 
and that any organic derangement, which may be detected after death, is 
merely an incidental occurrence, not constituting an essential part of the 
disease. 
Cause.-Lead, admitted into the system, is probably the sole cause of colica 
pictonum. Hence, painters, glaziers, plumbers, potters, lead-miners,' and 
manufacturers of white-lead and red-lead, are frequent subjects of the disease. 
Any preparation of the metal capable of finding an entrance into the circula- 
tion may produce the effect; but the vapours of melted lead, and the carbonate 
of its protoxide are the most frequent agents, probably because the greatest 
number of persons are exposed to their action. No matter by what avenue 
the poison enters the system, the effect is the same. Proof is not wanting, 
that lead colic has resulted from the external u^e of the solution of subacetate 
of lead, especially when applied to the skin with an imperfect state of the 
cuticle. (Trans, of Land. Col. of Phys.fm. 435.) Innumerable observations 
have shown, that various preparations of the metal produce the effect when 
taken into the stomach. Acetate of lead given as a medicine; water which 
has long stood in leaden reservoirs; cider and wines which have either been 
introduced into leaden vats, or been impregnated with the metal by means of 
litharge employed to sweeten them; carbonic acid, water drawn from the foun- 
tain through leaden pipes, in which it had been permitted .to stand; acidulous 
food kept in vessels glazed with lead; these, and various other forms in which 
the poison enters the stomach with medicine, food, or drink, have been abund- 
ant sources of the disease. The prevalence of colica pictonum among painters 
and manufacturers of white-lead, is ascribed by some to the uncleanly habits 
of the workmen, in consequence of which the carbonate, adhering to their 
hands and clothing, finds access to the stomach along with their food; and it 
is asserted that the disease has been rendered less prevalent among these in- 
dividuals, by increased attention to cleanliness' in their persons and dress. 
But even the most guarded care in this respect is not sufficient to ward off 
the disease; as the poison enters the system even more readily by another 
avenue. It is now generally believed, that the lungs afford an easier entrance 
than either the skin or stomach. Hence thia great liability to the disease of 
those who work in the melted metal. It is stated that, in white-lead facto- 
ries, where the practice of grinding the paint under water has been adopted, 
and the escape of the dry carbonate into the air thus prevented, the disease 
has become much less frequent. Painters are said to be most liable to be 
affected when shut up in close apartments, or in those heated in order more 
rapidly to dry the paint; and, according to Gendrin, they who use only fixed 
oil as the vehicle of the white lead almost always escape, while others who 
employ the oil of turpentine for the same purpose very frequently suffer. 
The complaint has been ascribed to other causes. Thus, it has been some- 
times considered epidemic, from its great prevalence in certain districts; but 598 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
a local cause has generally been discovered, as in Devonshire and Poitou, in 
the use of wine or cider kept in leaden vessels, or purposely impregnated with 
litharge. Besides, it is highly probable that the bilious colic, which some- 
times resembles it closely, has been mistaken for it. Another cause has been 
found by some in the use of acidulous drinks and food, and crude articles of 
diet; but the strong probability is, that, when the disease resulting from this 
cause has really been the one under consideration, and not simple spasmodic 
colic, it has arisen from some unsuspected impregnation of the article used 
with a salt of lead. When a disease having the characters of colica pictonum 
occurs, attention should always be directed to the discovery of some possible 
source of this poison. In a garrison of U. S. soldiers, at Fort Delaware, 
numerous violent cases of the disease occurred, which were found to be owing 
to the use of water collected in cisterns from a large painted roof. (Am. Journ. 
Med. Sci., N. S., iii. 319.) The constitutional susceptibility to the poisonous 
action of lead is exceedingly different in different individuals; some persons 
escaping under precisely the same circumstances as those under which others 
suffer; and one individual being attacked only once or twice in his life, while 
another is subject to the disease upon every fresh exposure. Women are 
attacked much less frequently than men; but this is probably owing exclu- 
sively to the circumstance, that they are much less exposed to the cause. 
The greater prevalence of the disease at certain seasons, which has been ob- 
served by some, is ascribable to the greater activity, during these seasons, of 
those occupations which give occasion for its attack. Inferior animals in 
the vicinity of white-lead factories, are said to suffer in a similar manner 
with man. / 
It is probable that lead operates as a poison by an immediate influence 
upon the nervous matter, wherever it may meet with it, diminishing and 
ultimately destroying the motor power, as well as the property of receiving 
and conveying impressions, and that it does not produce its local effects, at 
least primarily, through an influence upon the nervous centres. On the con- 
trary, the cerebral derangement is often the last in the succession of its effects. 
Its action upon the external muscles appears to be identical with that which 
it exerts upon the muscular coat of the bowels, which may be considered, in 
the lead colic, as in a state of partial paralysis. The violent neuralgic pains 
afford one out of numerous examples of this kind of derangement, attendant 
upon a depressed condition of the nervous power. The disorganization which 
is occasionally observed, in Altai cases, may, without violence, be referred to 
some incidental cause, or be considered as a mere result of the pre-existing 
nervous disorder. Some of the phenomena attendant upon the action of lead, 
such as the dryness of the alimentary mucous membrane, and the general 
deficiency of secretion, are ascribable to a^timulant influence upon the organic 
contractility, in other words an astringency, which is associated with the seda- 
tive power of its preparations, and is perhaps the most prominent of their 
therapeutical properties. 
Treatment.-1This is one of the complaints which, in the great majority of 
cases, get well spontaneously, and in which various modes of practice have 
acquired some repute, from • the mere circumstance that they have been em- 
ployed without proving an obstacle to the favourable course of nature. Never- 
theless, there are remedies which are capable of producing a positive impres- 
sion upon the complaint, of relieving it sooner and more effectually than 
nature would do unaided, and of counteracting its tendency to leave paralysis, 
and other serious derangements of health behind it. 
The plan of treatment which has been generally adopted in this country, 
and which in my hands has almost invariably proved successful, consists of CLASS III.] 
LEAD COLIC. 
599 
a combination of opiates and purgatives, and a resort to the constitutional 
impression of mercury in rebellious cases. Mercury appears to exercise a 
specific controlling influence over the poison of lead; but. as its operation if 
pushed too far is very inconvenient, and as in so severe a disease it cannot 
always be used with that caution which would secure- only a slight impression 
on the mouth, it is best in ordinary cases to attempt the cure without a sali- 
vation, and to resort to this measure only under urgent and threatening cir- 
cumstances. 
Two grains of opium may be given at once with from five to fifteen grains 
of calomel, to be followed in a few hours by castor oil, sulphate of magnesia, 
infusion of senna, croton oil, or some other active cathartic which the stomach 
may be best able to support; and cathartics should be repeated daily until 
the bowels are evacuated. The auxiliary employment of injections, as de- 
scribed under colic (page 591), may also be resorted to; and some advantage 
may be expected from fomentations, anodyne and emollient cataplasms, and 
rubefacients to the abdomen, and from the warm bath, though these remedies 
arc less efficacious than in ordinary colic. The opiate should in general be 
repeated every night, in such quantities' as may be necessary to alleviate the 
sufferings of the patient, and procure some sleep; being combined or not 
combined with calomel, according as the object may be to produce or not to 
produce the mercurial action. An anodyne enema containing a fluidrachm 
of laudanum may be substituted for opium by the mouth, when the stomach 
is very irritable; or the sulphate or acetate of morphia, in the quantity of a 
grain, may be sprinkled upon a small blistered surface in the epigastrium, 
under the same circumstances. This latter mode of relieving pain, and quiet- 
ing irritability of stomach, may also be advantageously employed during the 
day, while efforts are made to evacuate the bowels by cathartics. Indeed, 
the internal use of opium is not incompatible with that of cathartic medicines, 
but sometimes rather favours their action by relaxing the spasm which resists 
it; and the two remedies may therefore be employed conjointly throughout 
the complaint. 
When the symptoms are unusually urgent, or the case unusually obstinate, 
calomel and opium should be given together, in the quantity of two grains of 
the former and half a grain of the latter every two hours, or in equivalent 
doses at longer intervals, and steadily persevered in, until the gums become 
somewhat sore. Upon the occurrence of this event, the symptoms are in 
general greatly relieved, and cathartics which may have before failed will 
readily operate. 
If the pulse should be accelerated, febrile symptoms developed, and the 
belly painful on pressure, indicating the probable existence of inflammation, 
blood should be taken freely from the arm, and cups or leeches, followed by 
an emollient poultice or a blister, should be applied to the abdomen. It is 
said that, when points of tenderness have been discovered under strong pres- 
sure, leeches applied directly to these points have afforded much relief. Should 
delirium or convulsions occur, it will be advisable to employ general bleeding, 
sinapisms or blisters to the extremities, and cups or leeches with cold to the 
head, while we are going on with the use of purgatives. But, in the ordinary 
cases of colica pictonum, the loss of blood is not required. 
When paralytic symptoms remain after the cure of the colic, if the patient 
has not been already salivated, he should now be put under a moderate mer- 
curial impression, as the most effectual remedy for this disorder. The daily 
use of the warm bath, with blisters to the part affected or to the spine, will 
be found useful auxiliaries. Nux vomica,, and the nitrate of silver in the 
dose of half a grain three times a day, united with a little opium and gra- 600 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
dually increased, have also been recommended. Care should be taken to keep 
the bowels regularly open, and sulphur if necessary may be employed for this 
purpose. 
( Having stated the course of treatment I would recommend in colica pictonum, 
it will be proper to give a brief account of other plans or remedies, which 
have respectable testimony in their favour. The great success of the treat- 
ment known in France as that of the Hopital de la Charite., claims for it a 
particular attention. According to this plan, the patient is put upon a cer- 
tain course of treatment, each day of the disease having its appropriate com- 
bination of medicines, without reference to the peculiarities of the case. The 
plan essentially is' to vomit in the early stage, to purge daily afterwards, and 
to administer at night an opiate by the mouth, and wine by enema. ' With 
the exception of the emetic, the treatment is founded upon the same princi- 
ples with that already detailed, viz., the concurrent use of anodynes and pur- 
gatives.* > 
Some have treated the disease with purgatives chiefly or exclusively, and 
croton oil has been especially recommended, others with opiates; but, though 
the patients have generally recovered, the cure is neither so speedy nor satis-, 
factory as when the two are combined. 
By the school of Broussais the complaint has been considered as gastro- 
enteritis, arid been treated with bleeding, repeated leeching, warm fomenta- 
tions, baths, emollient injections, and diluent drinks. Great success has been 
claimed for this mode of management; but general opinion has not decided in 
its favour. 
Alum has been very highly lauded as a remedy for colica pictonum, and is 
asserted to have procured relief where all the usual remedies have failed. It 
has long been employed by various German and French practitioners. M. 
Montanceix asserts that, given in the quantity of three or four drachms in the 
twenty-four hours, it uniformly cures the disease in the course of six or seven 
days (Arch. Geri, de Med., xviii. 370)-; and M. G-endrin has seen it employed 
in fifty-eight well marked cases without a single failure. (Trans. Med., vii. 62.) 
I have employed it in two cases which had resisted mercurial treatment, with 
the effect of producing a prompt cure. Dr. Eberle obtained the happiest 
* The following sketch of this rather empirical plan is taken from the Dictionnaire 
de Medecine.-First day, a pint of infusion of cassia fistula (^j to Oj), with three grains 
of tartar emetic, and from four to eight drachms of Epsom salt.-Second day, six grains 
of tartar emetic in eight ounces of water, at two doses, with an interval of ten minutes.-• 
Third day, two or three glassbs of a laxative and sudorific drink, consisting of a " decoc- 
tion of the. four sudorific woods" (guaiacum wood, sarsaparilla, china root, and sassafras 
root), in which from four to six drachms of senna have been infused.-Fourth, day, a 
purgative potion consisting of six ounces of infusipn of senna, one ounce of the electuary 
diaphanix (an Officinal of the French codex containing-demulcents and aromatics with 
scammony), from a scruple to a drachm of jalap in powder, and an ounce of syrup of 
buckthorn.-Fifth day, as the third.-Sixth day, as the fourth. Every day, during the 
treatment, a pint of " decoction of the four sudorific woods'' is to be taken for ordinary 
drink; and every evening an injection is to be administered,containing twelve ounces of 
red wine and four ounces of the oil of walnuts, to be followed by half a drachm of 
theriac (a French officinal consisting of abqut seventy ingredients, and containing about 
a grain of opium, which is the chief ingredient, in a drachm), with one or two grains of 
opium. At noon every day, or upon those days when no purgative is taken, a cathartic 
enema is to be administered, composed like the purgative potion above mentioned, except 
that it contains a pound instead of six ounces of the infusion of senna. If the pains still 
remain at the end of six days,.the treatment is continued by giving on alternate days the 
laxative sudorific drink, and the purgative potion above mentioned. The cure is con- 
sidered complete when all pain has ceased, arid constipation has not returned for five 
or six days after the disuse of purgatives. During the treatment, a strict diet is observed; 
but the patient is afterwards allowed to eat freely.. CLASS III.] 
LEAD COLIC. 
601 
effects from a combination of alum and opium, given in the dose of twenty 
grains of the former and one grain of the latter every three hours, after calo- 
mel with opium pushed to salivation, and active purgation had been employed 
in vain. The quantity administered should generally not exceed two or three 
drachms in twenty-four hours; ^.s beyond this amount it would be very liable 
to irritate the stomach. 
Ascribing the influence of alum, in the cure of colica pictonum, to its che- 
mical action in converting the poisonous compound of lead which may have 
entered the system into the insoluble and probably inert sulphate of that 
metal, M. Gendrin was induced to try the effects of sulphuric acid alone, and 
found this remedy not less successful. He states that he has employed the 
acid in more than three hundred cases, and uniformly with success. From -a 
drachm to a drachm and a half of sulphuric acid, mixed with three or four 
pints of water, was given daily. (Diet. de Med., viii. 395.) Whatever may 
be thought of the Results, the explanation is, I think, more than doubtful. 
If alum and sulphuric acid are capable of curing painters' colic, it is by some 
other' mode of action than by following the salt- of lead in its course through 
the system, and changing-it wherever overtaken into the sulphate. 
Other remedies also have .been employed. Dr. Graves recommends tobacco 
fomentations to the abdomen, continued until the peculiar effects of the nar- 
cotic are experienced, and then followed by cathartics. (Dublin Hospital Re- 
ports, vol. iv.) Dr. Odier, of Geneva, combines valerian and cold baths with 
purgatives. (Diet, de Med., viii. 396.) Dr. Wilson, physician to the Middle- 
sex (London) Hospital, has employed with success enemata and the hot bath 
simultaneously, the former being administered while the patient is in the 
latter. (Med. Exam., iv. 488, from the Londbn Lancetd) Vinegar diluted 
with water, and taken as a drink, is said to have effected a speedy cure 
after the failure of other means. (Phil. Jcurn. of Med. and Phys. Sei., xii. 
172.) MM. Chevallier and Rayer gave hydro-sulphuric acid in several cases 
with supposed advantage. (Bullet, des Sei. Med., Dec. 1827.) 
The diet, throughout the treatment, should be light and easily digested, 
consisting of farinaceous substances with weak animal broths, when these 
are not contraindicated by the existence of inflammation. Care should be 
taken, even after recovery, to avoid flatulent, acescent, and indigestible food, 
until the stomach and bowels have entirely recovered their powers. Exposure 
to a cold damp atmosphere should also be avoided, and flannel should be worn 
next the skin. When an individual has shown himself, by successive attacks, 
to be peculiarly susceptible to the poisonous influence of lead, nothing remains 
for him but to abandon the business which has exposed him to this influence. 
Prophylactic measures are of some importance in guarding against.the poison 
of lead. Frequent washing of the hands and of the whole person, and a 
change of clothes upon leaving off work; care not to apply the hands when 
soiled with white lead to the mouth; sleeping at a distance from the works; 
free ventilation of the apartments; and the grinding of the white lead under 
water, are all measures calculated to diminish the chances of an attack. M. 
Gendrin recommends the internal and external use of sulphuric acid, largely 
diluted with water; and it is possible that this may have some effect so far as 
regards the poison introduced into the stomach, or applied to the skin; but it 
is difficult to perceive how it could prevent the action of lead inhaled into the 
lungs. Besides, the continued use of so active a substance might itself lead 
to serious derangements of health. Not much more, probably, can with justice 
be said of the prophylactic virtues of fats and fixed oils, as articles of diet; 
though the use of two ounces of olive oil, every morning, is said to have 
proved efficacious in warding off' the disease. 602 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
Article IV. 
CONSTIPATION. 
By this term is indicated a condition of the bowels in which the stools are 
less frequent or less in quantity than in health. Cases in which the intes- 
tines are entirely closed against the passage of feces, in consequence of some 
mechanical impediment, are treated of under the head of obstruction. 
Symptoms.-In deciding as to the existence of constipation in any par- 
ticular case, it is necessary to take into consideration the interval at which 
the al vine evacuations habitually occur, in the healthy state of the individual. 
Most persons have one passage in each period of twenty-four hours; but some 
have two or more daily, others only one every third or fourth day; and in- 
stances are occasionally met with, in which the interval is extended to one or 
even two weeks, without apparent disadvantage. It is probable, however, 
that, in these latter cases, a close examination would discover derangements 
sufficient to prove, that the long suspension of the evacuations was anything 
but a healthy state of the function. In general, constipation may be said to 
exist when the passages occur less frequently than once a day. But a person 
may be very seriously constipated, notwithstanding that his evacuations are 
quite regular in the period of their recurrence, if they be of insufficient quan- 
tity. It not unfrequently happens that a portion of the feculent matter 
which ought to be discharged at each stool is retained, and an accumulation 
thus insensibly takes place, which at length becomes manifest by the great 
inconvenience it occasions. 
The feces in constipation are usually harder and dryer than in health, and 
not unfrequently come away in knotty lumps, with much straining, and a 
painful distension of the anus. These lumps are occasionally covered with 
a white or bloody mucus, and are of different colour, sometimes natural, 
sometimes blackish, and sometimes light or clay-coloured, indicating a de- 
ficiency or total absence of bile. When not pointed out by the diminished 
number or apparent condition of the stools, the affection may be suspected 
to exist, if the patient complain of a sense of weight or oppression in the 
abdomen or at the fundament, a frequent but ineffectual disposition to go to 
stool, flatulence, colicky pains, distension of the abdomen, and nausea with 
or without vomiting. Attention to these points is the more important, as 
in some cases of great fecal accumulation, whether in the rectum or higher 
up in the colon, the irritation of the bowel gives rise to occasional mucous 
discharges, tinged with fecal matter, and having a very offensive fecal 
odour; or small quantities of the liquid contents of the bowels are forced 
around the mass, or through an opening existing in it, and discharged per 
anum, so as to simulate diarrhoea. Such a condition is peculiarly apt to 
occur in old people, and has not unfrequently been treated as diarrhoea, to 
the great detriment of the patient. If attended by the above symptoms, or 
some of them, constipation should be suspected, and a close examination 
instituted. If the feculent mass be lodged in the rectum, it will at once be 
detected by introducing the finger through the anus; if in the colon, it will 
often be obvious in the form of a hard tumour or tumours in the left iliac 
fossa, or in the course of the descending, transverse, or ascending colon; and, 
where the solid mass cannot be felt through the abdominal parietes, it may 
often be- detected by the flat sound which it will yield on percussion. There CLASS III.] 
CONSTIPATION. 
603 
is reason to believe that such masses have not unfrequently been mistaken 
for organized tumours. The impossibility of introducing an injecting pipe 
far into the rectum, or the great resistance made to the entrance of liquids 
through the instrument, often leads to the detection of these accumulations. 
The quantity of feculent matter which has sometimes accumulated in con- 
stipation is enormous. A case is recorded in the Archives Generales (iv. 
410), in which thirteen and a half pounds were found in the intestines. 
The length of time also, during which patients sometimes sustain a complete 
want of alvine dejections, is astonishing. From one to two weeks is no un- 
common period, in the experience of most practitioners; and cases are on 
record in which the patient has survived months of suffering from this cause. 
But, in most of these cases, the dejection per anum has been replaced by a 
vomiting of feces, so as to prevent a fatal distension. Generally speaking, 
should the constipation not yield to appropriate treatment, symptoms of an 
alarming character come' on in the course of a few days, and the case ends 
fatally, after a longer or shorter period of much and various suffering, with 
occasional remissions and exacerbations, as temporary relief is obtained from 
vomiting, the use of remedial measures, or other causes. (See 'Obstruction of 
the Bowels.") 
Causes.-Constipation is either occasional, arising from some temporary 
cause, or protracted and habitual. In both cases, its pathological condition 
must consist in either 1. a mechanical impediment to the passage of the 
alvine contents along the bowels, 2. a diminished contractility of the mus- 
cular coat, or a diminished susceptibility of the intestines to the influence 
of the usual alvine stimuli, 3. a deficient supply of these stimuli, or 4. a 
combination of two or more of the conditions mentioned.. The causes of 
the affection must, therefore, be such as are capable of inducing these con- 
ditions. 
Among those which occasion mechanical impediment are solid masses 
formed out of the ingesta, or by precipitation from the intestinal liquids; 
spasmodic or permanent stricture of the bowels; the encroachment of va- 
riously organized tumours upon their caliber; and strangulation of the' in- 
testines, as in hernia, intussusceptio, and twisting of some portion of the 
tube. These will be more particularly considered under obstruction of the 
bowels. - 
The causes which impair the contractility or susceptibility of the bow'els, 
or .both, are of more importance in relation to our present subject. These 
operate more especially upon the colon, though their influence is also felt 
throughout the intestinal tube. Torpor of the colon is one of the most com- 
mon conditions in habitual constipation. Unable to contract sufficiently on 
the feculent matter, or unduly insensible to its presence, the bowel becomes 
distended by the accumulation which takes place, and, under the distension, 
suffers a still further diminution of its powrer and sensibility. The causes 
of this condition are numerous. They' are, for the most' part, the same as 
those which produce the analogous condition of the stomach existing in dys- 
pepsia; as sedentary habits, excessive mental occupation, sensual indulgences 
of all kinds, morbid diversion of the blood and nervous energy to other 
organs, the use of narcotics and especially of opium, diseased conditions of 
the brain and spinal marrow, and, in fine, whatever debilitates the system 
generally, and consequently involves the bowels. (See Dyspepsia.) Old age 
is attended with a diminished susceptibility of the alimentary canal, and is 
therefore very subject to constipation. Habit also has a powerful influence, 
and is indeed one of the most frequent causes of the complaint. By means 
of our control over the sphincter ani, we are endowed, to a considerable ex- 604 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
tent, with the power of regulating the alvine discharges, and of resisting the 
solicitations of nature at inconvenient seasons. This power is too apt to be 
frequently exercised, and especially by females. The bowel is thus habituated 
to the presence of the feculent matter, feels less and less its wholesome stimu- 
lation, and at length ceases to be excited into action. Habitual constipation 
is a necessary result. The preparations of lead have a directly paralyzing 
effect upon the bowels; and obstinate costiveness is therefore an almost uni- 
form attendant on colica pictonum. 
Of the causes which impair the stimulant properties of the intestinal liquids, 
the most common is perhaps a diminished or suspended secretion of bile, or 
anything which impedes its access to the bowels; the bile being one of the 
most energetic alvine stimulants provided by nature. Hence the frequent 
deficiency of the bilious colour in the evacuations. The same may possibly 
be true to a certain extent of the pancreatic liquor, and is certainly so of the 
intestinal mucous and serous secretions. Hence the influence of excessive 
discharges from other organs, as from the skin and kidneys, in producing 
costiveness. Hence, too, the action of astringents, which diminish or arrest 
the intestinal secretion. Dr. Dick ascribe^ the costiveness of the young, in 
some instances, to a too rapid absorption of the intestinal liquids. (Braith- 
waite's Retrospect, xvii. 152.) 
Many of the causes above enumerated operate doubly, impairing the con- 
tractility and sensibility of the bowel, while they diminish the amount of 
healthy stimulus by checking secretion. Such especially are those which act 
through the medium of the brain and spinal marrow. Excessive exercise 
often produces this effect by directing the energies of the system to other 
parts. A disposition to constipation is a very common attendant upon a long 
and fatiguing journey. 
Effects.-Constipation gives rise, especially when habitual, to a great diver- 
sity of local and constitutional derangements. Besides its effects upon the 
bowels, consisting in irritation, inflammation, distension, ulceration, gangrene, 
&c., it deranges the neighbouring organs by the pressure of the accumulated 
feces; impedes from the same cause the abdominal circulation, and thus occa- 
sions various congestions; extends a sympathetic irritation to the viscera of 
the abdomen and pelvis, as well as to the brain, heart, and other distant 
parts; and finally gives rise to contamination of the blood, both by checking 
the secretion of cxcrementitious matter, and by causing,/a reabsorption of that 
already eliminated from the blood-vessels, and of various products of chemical 
change in the retained contents of the bowels. 
It is often attended, even in its occasional attacks, with dulness, depression 
of spirits, drowsiness, irritability of temper, vertigo, headache, flushing of the 
face, pains in the loins and limbs, palpitation, dyspnoea, furred tongue, gastric 
derangement, and various disorder in the biliary, urinary, and generative 
organs. When habitual, it produces the same effects in an aggravated degree, 
and others even more unpleasant. Bleeding from the rectum, hemorrhoidal 
tumours, fissures and prolapsus of the anus, fistula in ano, strangury, catarrh 
of the bladder, dysmenorrhoea, amenorrheea, menorrhagia, leucorrhoea, colic, 
diarrhoea, dysentery, hepatic congestion and inflammation, dyspepsia, sick- 
headache, foul breath, epistaxis, apoplexy, epilepsy, paralysis, hysteria, melan- 
choly, hypochondriasis, and insanity, are among the disorders which have 
been traced to constipation as their source. 
It is not always easy to say, flow much of the disease which is found asso- 
ciated with constipation is properly its effect. Derangements of the same 
kind as those which it induces arise often also from other causes, and may 
bring on this condition of the bowels if not previously existing. But, even CLASS III.] 
CONSTIPATION. 
605 
in this case, it often aggravates the original disorder; and thus, whether 
viewed as cause or effect, is still a source of mischief. Not unfrequently, 
the complaints which originate in constipation take on an independent exist- 
ence, and continue though the cause may cease. From all these considera- 
tions it follows, that the disorder in question, whether original or induced, 
requires a close attention, and should be immediately made an object of treat- 
ment whenever it occurs. 
Treatment.-Occasional attacks of constipation must be met by cathartics, 
proportionate in their activity to the difficulties of the case; the milder being 
first employed, under ordinary circumstances, and the more energetic resorted 
to, after these have failed. Castor oil is, from its combination of mildness 
with quickness and efficiency, one of those best adapted to ordinary cases. 
Sulphate of magnesia and the other saline cathartics may also be used, and 
are especially applicable to solid fecal accumulations, in consequence of the 
copious serous secretion they induce, which penetrates and breaks down the 
impacted mass. Senna tea combined with the salt addh to its-.efficiency, by 
the energetic influence which this cathartic exercises upon the muscular 
coat. Croton oil should be employed, when those mentioned have proved, 
insufficient. It is preferable to most other drastic cathartics by its quicker 
action and greater energy, while less disposed to produce inflammation of the 
bowel. Cases, however, may occur in which, from great insensibility of the 
intestines, the irritant properties of jalap resin, scammony, colocynth, gam- 
boge, or even elaterium, given separately or in combination, may render them 
preferable. Calomel should always be employed, in full doses, When the 
constipation is dependent on torpidity or congestion Lof the liver. It not un- 
frequently happens that, after the gums have been touched by the use of 
mercurials, other cathartics will act with facility which had failed beforb. 
Dr. Daniel, of Savannah, recommended charcoal very highly as superior to 
all other remedies in obstinate constipation. lie employed it in the quantity 
of from one to three tablespoonfuls every half hour or hour, and found it 
successful in numerous instances. (Philad. Journ. of the Med. and Phys. 
Sci., v. 119.) The remddy, however, has not succeeded so well in other 
hands, and is liable to accumulate in the bowels, so as itself to become a 
source of obstruction. 
Should the purgative not operate in due time, it should be aided by ene- 
mata, which sometimes become indispensable, in consequence of an irritability 
of stomach which precludes the use of most cathartics by the mouth. The 
reader is referred to the article on colic {page 591) for an account of the sub- 
stances which may be used in this form. Perhaps, upon the whole, the most 
safe and at the same time efficient, in cases of great obstinacy, is simple warm 
water thrown up the bowel, in very large quantities, by means of a self-inject- 
ing apparatus, and repeated so as gradually to soften and wash away the 
feculent matter. Any desirable quantity of water may thus be introduced 
into the bowels, if care be taken, by twisting a towel round the pipe and 
pressing it against the fundament, to aid the contractile power of the sphincter. 
Advantage may occasionally result from introducing the water directly into 
the colon, through a long gum-elastic tube, passed high up into that bowel. 
When the feces are impacted in the rectum, the assistance of the finger, a 
scoop, spoon-handle, Or some similar instrument, introduced per anum, becomes 
necessary to break up and discharge the solid mass. Other measures may be 
employed in aid of those mentioned, as friction over the abdomen, warm 
vapour to the fundament, and the application of cold externally, cither by ice 
to the palms of the hands and soles of the feet, or by a stream of cold water 
allowed to fall upon the abdomen. Spasmodic stricture of the bowels has 606 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
sometimes given way under this latter measure, after resisting purgatives and 
enemata. The application of cloths wet with ice-water to the abdomen, and 
the free use of ice-water internally, persevered in for days if necessary, is an 
old remedy, which is said to have proved very effectual in ileus. (See Boston 
Med. and Surg. Journ., xxxvii. p. 229.) The late Dr. Hosack, of New 
York, was in the habit of employing emetics of tartarized antimony and ipe- 
cacuanha in obstinate constipation, and ascribed their beneficial influence 
partly to the increased action of the liver, and partly to the relaxation of 
spasm which they occasion. (JPhilad. Journ. of Med. and Phys. Sei., iv. 337.) 
The use of metallic mercury, in large quantities, is asserted to have sometimes 
overcome constipation under almost desperate circumstances. (See Obstruction 
of the Bowels.} 
It is highly important that the practitioner should bear in mind the occa- 
sional dependence of obstinate constipation upon local inflammation of the 
intestine, affecting either the muscular or peritoneal coat, and entirely restrain- 
ing the peristaltic motions of the part. In such cases, persistence in the use 
of violent cathartics can do only harm. Bleeding, general and local, calomel 
and opium internally, occasional enemata, with emollient applications and 
blisters, are the chief remedies; and they will often succeed most happily, 
after failure with active purgatives. 
In habitual constipation, a somewhat different course must be pursued. 
Attention must here be especially paid to the removal of the cause. Efforts 
should be made by the patient to establish the habit of regular evacuations 
by daily attendance at the privy, though it is important that he should avoid 
severe straining, which often gives rise to hemorrhoids, or prolapsus ani. 
Moderate exercise, regular habits of life, relaxation from intense mental occu- 
pation, change of air and of scene, all have a favourable effect by contributing 
to the restoration of tone to the bowel. Frictions over the whole • surface of 
the body, and the occasional use of the cold or shower-bath contribute to the 
same end; and, whenever the excess of any function may be found to divert 
the due supply of vital energy from the colon, this excess should if possible 
be corrected. The use of all narcotic substances, including green tea and 
coffee, should be abandoned, when there is reason to believe that the com- 
plaint depends on torpor of the intestines. 
The regulation of the diet is highly important, and this alone will fre- 
quently be sufficient to restore the proper action of the bowels. The food 
should in general be easily digestible, and such as is not calculated to yield a 
large amount of feculent residue. (See Dyspepsia.} An exception to this 
rule may sometimes be made in favour of substances having laxative proper- 
ties; but discrimination is necessary. Laxative articles of diet are apt to be 
of difficult solubility in the stomach, and are not all adapted to a dyspeptic 
state of that organ. Such as are of this character should therefore be avoided, 
or used cautiously, in constipation associated with dyspepsia. Bran bread, 
however, or some other preparation of wheat flour containing bran, may often 
be employed with great advantage in this case. When the stomach is not 
dyspeptic, fresh and dried fruits are highly usefid. Indeed, it is not uncom- 
mon for persons, disposed to costiveness, to be entirely free from this condi- 
tion at those times of year when fruits are in season. The different edible 
berries, peaches, pears, apples, melons, &c., may be taken as freely as the 
stomach will admit without inconvenience^ and tomatoes, used as a vegetable 
at dinner, have been found highly beneficial, even by dyspeptic persons. In 
the winter, the imported fresh fruits, such as grapes and oranges; and the 
dried fruits, such as dried peaches, prunes, figs, &c., may be substituted. 
Other laxative articles of diet applicable to cases in which the digestion is CLASS III.] 
CONSTIPATION. 
607 
vigorous are brown sugar, molasses from the plantations, honey, olive oil, rye 
and Indian meal in the form of mush or bread, oat-meal gruel, rennet-whey, 
and buttermilk. Broths are sometimes preferable, under similar circum- 
stances, to solid food. Burne recommends the use of bacon at breakfast. An 
exclusive diet of milk has sometimes appeared to produce very obstinate con- 
stipation; and this fact should be attended to in the treatment of children. 
When constipation is found to be connected with deficient secretion of bile, 
an alterative mercurial course, or the use of nitro-muriatic acid should be 
resorted to. A calomel purge may be given at first, and afterwards half a 
grain or a grain of the same mercurial, or three grains of the blue mass every 
night or every other night, followed by a drachmor two of sulphate of mag- 
nesia, or other mild laxative in the morning. 
Laxative medicines are often indispensable. In the choice of these, refer- 
ence must be had to the peculiar condition of the stomach and bowels. When 
the former is weak, and the latter inirritable, as in dyspepsia, atonic gout, &c., 
the warm tonic laxatives should be selected, and may often be advantageously 
combined with bitter extracts, chalybeates, or other tonics. Aloes and rhu- 
barb, separate or combined, are most employed, and are often mixed with 
extract of gentian or quassia, and pill of carbonate of iron. But aloes should 
not be used in cases attended with hemorrhoids or irritated uterus. White 
mustard seed, in the quantity of a tablespoonful daily or twice a day, are often 
very advantageous under similar circumstances. Infusion of senna, with co- 
lumbo and ginger or other aromatic, is also well adapted to constipation com- 
plicated with feeble digestion. The very torpid bowels of old people require 
the more stimulating cathartics. Besides aloes and rhubarb, the drastic purga- 
tives may be used in small doses and combined together, as in the form of 
compound extract of colocynth, or the compound cathartic pill of the U. S. 
Pharmacopoeia; and with the cathartics, Cayenne or black pepper, assafetida, 
myrrh, ammoniac, &c., may be advantageously associated. Not only in these 
cases, but in all others where the bowels are very torpid, even in the cases of 
infants, I have been in the habit of combining minute quantities of croton oil 
with other laxatives, especially with aloes and rhubarb, with the happiest 
effect. The quarter or sixth of a drop, for adults, will be found to add con- 
siderably to the activity of the dose, and generally without irritating the 
stomach. 
When the stomach is not very feeble, the saline laxatives may often be 
used with propriety. They have this advantage, that they are less apt than 
some others to leave the bowels in a costive state; and are peculiarly appli- 
cable to cases attended with deficient intestinal secretion. A very small quan- 
tity of one of these salts, a drachm or two of Epsom or Rochelle salt, for 
example, taken on an empty stomach, early in the morning, will often act 
sufficiently. The Seidlitz powder suits some stomachs admirably well. The 
natural combinations of salts existing in mineral waters are often more effect- 
ual than the salts separately. The different waters of the Saratoga Springs 
are deservedly in high repute. The Cheltenham salt made in imitation of the 
Cheltenham water in England, and containing a chalybeate associated with 
the saline ingredients, has answered admirably in ray experience. But the 
alkaline salts have the disadvantage in general, that, when long continued, 
they debilitate the stomach and impair digestion. 
When the digestion is good, the confection of senna or lenitive electuary 
is an excellent laxative. Given at bed-time, in the dose of a drachm, it usu- 
ally causes a soft feculent evacuation in the morning, without irritation, or 
other inconvenience. It is peculiarly suited to constipation with piles. -Pow- 
dered senna, mixed in very small.proportion with stewed dried peaches or 608 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
prunes, operates in like manner, though upon the whole less agreeably. A 
drink made from cream of tartar, in imitation of lemonade, may be used in 
similar cases, and is often grateful in summer. Flake manna, carried in the 
pocket, and eaten occasionally, is also adapted to costiveness with unimpaired 
digestion. 
Some persons are able to take castor oil without disgust, and find it useful 
in habitual costiveness; but in general the stomach cannot be reconciled to 
its very frequent use. With others, olive oil answers the same purpose, though 
it requires to be given in larger doses. 
Sulphur is adapted.to cases as well of feeble as of vigorous digestion, and, 
as it produces unirritating passages, may be usefully employed in piles. In 
consequence of its alterative properties, it is an excellent laxative in the cos- 
tiveness of rheumatic and gouty individuals. It is often associated with mag- 
nesia in dyspeptic cases, and with cream of tartar in inflammatory piles. Its 
disadvantages are that it is apt to occasion griping, and in time imparts odour 
to the breath and secretions. 
Magnesia and its carbonate are peculiarly useful in cases attended with 
excess of acid in the stomach. It should not, however, be used largely and 
habitually, unless in association with other laxatives to insure its action; as 
it has sometimes accumulated in the bowels, and formed masses interfering 
with their due movement. 
Some have employed enemata or suppositories as substitutes for cathartics 
by the mouth, administering them daily, or every other day, for a long time 
together. The mildest substances should be selected; as flaxseed tea or other 
mucilaginous liquid for injection, and hard soap or solidified molasses for 
introduction in the solid form. But both are liable to the objection, that 
they concentrate in one part of the bowels the irritation which the laxative 
medicine spreads, in a comparatively diluted state, over their whole track; 
while they do not so effectually evacuate the upper portions of the canal. 
But laxatives either by the mouth or rectum should be employed only as 
adjuvants to a properly regulated regimen, and should be suspended the 
moment that they are no longer necessary. Care should also be taken to 
administer them in doses no larger than is essential to the end desired. 
They should always be given on an empty stomach, as they thus operate 
more speedily and with less uneasiness. Half an hour or an hour before 
breakfast, an hour or two before dinner, and at bed-time without previous 
supper, are the proper periods. Given at bed-time, they will often not act 
until morning, and the patient will experience little or no inconvenience 
during the night; while he thus escapes-the annoyance and inconvenience of 
their operation during the day. This, therefore, upon the whole, is the most 
appropriate time. 
Various other measures have been employed in habitual costiveness. The 
introduction of a bougie high up into the rectum is favourably spoken of by 
Burne, who recommends it especially in cases attended with great rigidity of 
the sphincter ani. The smoking of tobacco has in some persons been found 
to obviate constipation, though in others it occasions it, when used in excess, 
by impairing the sensibility of the digestive tube. Friction to the abdomen 
with rubefacients, coarse flannel, or the flesh-brush; tepid or cold affusion 
upon the loins; and leeches or cups to the spine, when the constipation may 
be supposed to have its origin in disorder of the medulla spinalis, have been 
recommended. CLASS III.] 
OBSTRUCTION OF THE BOWELS. 
609 
Article V. 
OBSTRUCTION OF THE BOWELS. 
This term, as here employed, implies the existence of some mechanical 
impediment to the passage of the contents of the bowels. The obstruction 
sometimes comes on slowly, .with the ordinary symptoms of constipation, the' 
patient experiencing gradually increasing difficulty in obtaining evacuations 
until they cease. In many instances, however, the attack is sudden, and 
altogether unexpected. It often happens that, for a few days after the cessa- 
tion of discharges, no great inconvenience is felt;.but sooper or later, and 
sometimes immediately, the patient.begins to complain of uneasiness in the 
abdomen, attended frequently with a desire to go to stool, and bearing do^n 
efforts, which are either quite ineffectual, or produce only slight, bloody, 
mucous or feculent passages, without affording relief. Cathartics are taken 
without effect, and endmata, after Evacuating occasionally small quantities of 
fecal matter, come away aS administered. The discharges which thus occur 
spontaneously, or are obtained artificially, consist only of matters contained in 
the bowels below the point of obstruction; and care1 should be taken that they 
do not leacl to false inferences as to the nature of the affection. Distension 
of the abdomen now comes on, with flatulent eructation,'severe, spasmodic 
pain, great restlessness and, anxiety, and at length nausea and vomiting, so 
that substances taken into the stomach are instantly rejected, and medicines 
cannot be retained. Symptoms of inflaipmatjon, as tenderness upon pressure, 
a quick pulse, and furred tongue, are often mingled with those of obstruction. 
Should relief not be obtained, troublesome hiccough occurs; the vomiting not 
^infrequently assumes a stercoraceous or bloody character; dysury, with deep- 
red urine 'is added to the other symptoms; the belly becomes enormously 
distended and tympanitic, the respiration oppressed, the face bathed in sweat, 
the skin pale and clammy, the extremities cold, the pulse exceedingly feeble, 
and the countenance haggard; and the patient sinks, completely worn out and 
exhausted, death being frequently preceded by delirium. This, however, is 
not the uniform result. The vomiting of feces sometimes affords temporary 
relief; the worst symptoms disappear, to occnr again when thb bowels become 
again loaded; or the obstruction maybe partially removed by an effort of 
nature, and again return; and a course of suffering and exhaustion, alternating 
with partial relief apd reaction, may continue for months, or even years, end- 
ing at last in death, or in a' complete removal of the obstruction, and recovery. 
It is singular how, in some oases, the system accommodates itself to defecation 
by the sfomacli, so as to dispense for a long time with the. ordinary alvine 
evacuations. Dr. Crampton relates, in the Dublin Hospital Reports (vol. iv.), 
the case of a young woman, living at the time, who for seven years had 
laboured under stercoraceous vomiting, with obstinate constipation, having 
had stools at distant intervals, only two or three during the year preceding 
the report, and none at all during'the last eight months. Another case of a 
young female is reported by Dr. Bache, in the N. American Med. and Burg. 
Journal (vol. vi. p. 262), which continued for a period of ten months, during 
which there was several times an absence of stools for more than twenty days, 
and once for eighty-seven days, and yet the patient ultimately recovered. In 
both these cases, the stercoraceous matter vomited had occasionally a strong 
urinous smell, and there was, during longer or shorter periods, suppression or 610 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
retention of urine. These latter phenomena are not uncommon attendants 
upon obstinate constipation. 
The names of Ileus and Volvulus have been given to cases of stercoraceous 
vomiting, with pain in the bowels, and constipation. There is nothing, how- 
ever, in this association of symptoms, which entitles it to be considered as a 
distinct disease. This kind of vomiting may occur in violent colic, from a 
spasmodic closure of the bowel; and it is asserted to have sometimes arisen 
from a mere morbid inversion of the peristaltic movement, without any 
obstruction; water introduced into the rectum having been thrown out from 
the mouth. 
In cases presenting the above symptoms, a close examination of the abdo- 
men should be made, in order to ascertain whether the cause of the phenomena 
may not be strangulated hernia. There is reason to think that death has 
frequently occurred from a neglect of this precaution. 
Dissection after death exhibits the intestine very much distended, in some 
instances, enormously so, above the place of obstruction. Marks of inflam- 
mation are frequently observed, and sometimes those of gangrene. Accord- 
ing to Burne, when the obstruction depends upon a purely mechanical cause, 
and not upon feculent accumulation arising from functional derangement of 
the bowel, the feces are always found soft; a provision of nature which tends 
to prolong life, by enabling the bowels to relieve themselves until the passage 
becomes absolutely closed. A 
Causes.-One of the most frequent causes of obstruction is an acczcmulation 
of impacted feces. This, though the result of a pre-existing functional de- 
rangement of the bowels, becomes itself, when so considerable as to close the 
passage, and to resist the peristaltic movement, the chief source of mischief; 
and the obstruction, therefore, may be strictly said to be mechanical. This 
is the form of the complaint which is least dangerous, and most ^easily relieved 
by proper measures. A case is mentioned, by O'Beirne, in which the patient 
had been without an evacuation from the howels for nearly six months, in 
consequence of a mass of solid excrement in the sigmoid flexure, and yet was 
relieved by a stimulant injection thrown high up into the rectum. (New 
Views of the Process of Defecation.') Such accumulation may be supposed to 
exist, when the symptoms of obstruction have been long preceded by those of 
habitual constipation, without any evidence, from the appearance of the stools, 
of the existence of stricture. The means of detecting it have been already 
detailed. (See page 602.) 
Another not uncommon cause, of obstruction is the formation of solid con- 
cretions in the bowels._ These have their seat most commonly, for obvious 
reasons, in the rectum, sigmoid flexure, or csecum; though they may exist in 
other parts of the colon, and even in the small intestines. They originate in 
various sources. Insoluble substances taken largely and frequently as medi- 
cines sometimes concrete in the bowels, held together by a cement of animal 
matter or calcareous salt, and frequently mixed with indigestible portions of 
substances used as food. Cases are on record of serious obstruction proceed- 
ing from the daily and continued use of chalk, sulphur, magnesia, and sub- 
carbonate of iron. The stones of various fruits, especially of cherries and 
plums, swallowed along with the pulpy matter, under the impression that 
they assist digestion, frequently form concretions in the bowels, which have^ 
in some instances, given rise to fatal obstruction. Sometimes solid masses 
are formed out of the secretions poured into the intestines, especially from 
the bile; and these concretions, upon examination, have been occasionally 
found to have as a nucleus some insoluble substance accidentally swallowed. 
They are not generally numerous, seldom exceeding two or three in number; CLASS III.] 
OBSTRUCTION OF THE BOWELS. 
611 
but, in some instances, many have been found, and of various sizes, from a 
few lines to two inches or more in diameter. When there are several, they 
can sometimes be felt rubbing against each other. When obstruction has 
arisen from any of the concretions above referred to, a probable inference as 
to the cause may be drawn from the previous habits of the patient, which 
should always be inquired into. Their nature may occasionally be detected 
by examination per anum; and, when beyond the reach of the finger, they 
may often be felt through the parietes of the abdomen, especially in the right 
and left iliac fossae; and will always occasion undue flatness on percussion 
When tenesmus attends obstruction, an examination of the rectum should 
never be omitted. 
Permanent stricture of the bowels is a third source of obstruction. This 
appears sometimes to originate in a spasmodic stricture becoming permanent 
by inflammatory adhesion; but, in most instances, it depends on a thickening 
of the parietes of the bowel, and a consequent diminution of its caliber. 
Cancer is probably one of the most frequent causes of this thickening. It 
may also depend upon a simple inflammatory hypertrophy of the submucous 
cellular tissue, and Dr. Symonds has pointed out another cause in a fatty de- 
position beneath the peritoneal coat. The stricture is most frequent in the 
rectum, but it is also found in various parts of the upper bowels. When in 
the former situation, it may be detected by the finger or a bougie; and its 
existence may be suspected when the obstruction has come on by degrees, and 
the feces have been discharged for a long time previously in gradually dimin- 
ishing cords or ribbons. In many instances, however, it cannot be ascertain- 
ed until after death. 
Organized bands dicross the bowel sometimes produce obstruction. These 
probably originate in an inflammatory adhesion of the surfaces of the mucous 
membrane, in consequence of the effusion of coagulable lymph, and a subse- 
quent separation of these surfaces, before the lymph has become quite con- 
solidated, so that it is drawn out in apparently interlacing cords. These 
bands are said to be most common in the rectum, though a fatal case is given 
by Burne, in which the seat of the obstruction was in the caecum. (Burn® 
on Habitual Constipation.') They are very rare. 
Adhesions of the peritoneal coat of the intestines, arising from inflammation, 
sometimes produce bands, which, in certain positions of the bowels, act as a 
cause of external stricture, and produce fatal obstruction. Under this head 
may perhaps be included the strangulating operation of the appendiaida ver- 
miformis encircling the bowel, and bound in its abnormal position by inflam- 
matory adhesion; and also of those accidental processes denominated diverti- 
cula, which have been known to bridle the intestine in a similar manner. 
Intussusceptio, or invagination of the bowel, is a frequent and fatal cause 
of obstruction. This consists of the introduction of one portion of the intes- 
tine, by inversion, into the portion immediately above or immediately below 
it, thus producing, in many instances, a complete closure of the cavity. The 
upper portion is generally received into that below it, but not invariably so; 
the inversion sometimes taking place from below upward. The extent of the 
invagination varies from a few lines to a Toot or more. It occurs not unfre- 
quently in more than one part of the bowels in the same case, and probably 
arises from a spasmodic constriction of the entering portion of the intestine 
There is reason to believe that it frequently takes place during colic, and other 
spasmodic intestinal affections, without producing serious effects, being re- 
lieved by the spontaneous movement of the bowels. Almost any portion of 
the bowels may become the seat of intussusceptio; but it is said to occur most 
frequently either at the union of the small with the large intestines, the for- 612 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
mer being in this case received into the latter, or at the arch of the qolon. 
It is not uncommon in the small intestines, and I have seen it involving the 
sigmoid flexure and upper part of the rectum. Inflammation not unfrequently 
takes place, and, by causing tumefaction and adhesions, very greatly aggra- 
vates the danger, Even in this case, however, the affection, though generally 
fatal, is not necessarily so. The invaginated portion of bowel mortifies and 
sloughs, while adhesion is established between the peritoneal surfaces of the 
upper and lower portion at their place of junction; and, if the constitution 
of the patient is sufficiently vigorous or pliant to support the first shock of 
the obstruction, inflammation, and gangrene, and the long subsequent ex- 
hausting process^of sloughing and reparation, an effectual recovery eventually 
takes place. The diagnosis of intussusceptio is at first always uncertain. It 
may be suspected when the symptoms of obstruction come on suddenly, with- 
out previous disorder, or as the consequence of an attack of colic, or the ad- 
ministration of a dose of active purgative medicine, and when at the same 
time a tumour, not previously existing, can be felt in any part of the colon. 
In those cases which continue long, portions of the bowel that have sloughed 
away are sometimes found in the stools, after the restoration of the alvine 
evacuations, giving strong evidence of the nature of the obstructing cause. 
Twisting of the bowel is still another cause of obstruction. A fold or loop 
of the intestines sometimes turns round upon itself, and, as in the case of Mr. 
Legare, reported by Dr. Bigelow (Boston Med. and Surg. Journ., July 5 th, 
1843), niay even make two complete revolutions, thus entirely preventing the 
passage of the feces. This rotation appears sometimes to occur in consequence 
of external violence, as in a case of Sir A. Cooper's, described in Burne's 
work on habitual constipation; but more frequently without any known 
cause. It is most apt to take place in the convolutions of the small intestines, 
or at the sigmoid flexure of the colon. In its severer forms, it is irremedia- 
ble; but it is probable that slight turns of the kind are susceptible of being 
untwisted by movements of the bowels, either spontaneous or .excited by 
medicines.- There are no means of ascertaining its existence during life; but 
it may be conjectured to exist, when the obstruction is sudden, and unattended 
with any discoverable tumour. 
Organic tumours, formed exterior to the bowel, may sometimes so diminish 
its caliber as to produce obstruction; but this result is rare; the impediment 
being seldom so great as altogether to prevent the passage of feces. 
Treatment.-The first object in any particular case of obstruction is, if pos- 
sible, to ascertain the cause; so that the treatment may be modified accord- 
ingly. But, when this is very obscure, or altogether uncertain, as very often 
happens, that plan should be adopted which is most likely to be useful in 
curable forms of the complaint. As a general rule, the following course of 
treatment is recommended. 
If the pulse and constitution admit, and especially if symptoms of inflam- 
mation exist, blood should be taken freely from the arm, and leeches applied 
tq the abdomen or the anus. Spasm of the bowel, which, if not the cause of 
the difficulty, may greatly aggravate it, may thus be relaxed, while the dangers 
from inflammation are obviated. Purgatives should be immediately resorted 
to, as recommended for occasional constipation (see page 605); and these 
should be aided by suitable enemata. For the composition of the encmata, 
the reader is referred to the article upon simple spasmodic colic. (See page 
591.) But, in relation to the use of purgatives, some caution is requisite. 
When the vomiting is very obstinate, and especially when it has become ster- 
coraceous, there is strong evidence that the peristaltic movement of the bowels 
is exerted to its utmost limits; and the only effect of powerful and drastic CLASS III.] 
OBSTRUCTION OF THE BOWELS. 
613 
cathartics would probably be to increase the existing irritation or inflamma- 
tion, and still further to aggravate the vomiting. The reparatory processes 
which nature might be disposed to institute may thus possibly be interfered 
with, and a curable case rendered incurable. At the beginning of the treat- 
ment, active purges may be employed; byit, when found unsuccessful, they 
should not be urged under the circumstances mentioned. Efl'ervescing ape- 
rient medicines, or the saline cathartics, given in small doses in carbonic acid 
water,7 should be preferred., as more acceptable to the stomach, and calculated 
to direct downward the already excited peristaltic action. Calomel may also 
be given in moderate and repeated doses; as it is often well retained by the 
stomach, and if it do not purge, may produce a general mercurial impression, 
which has often proved highly salutary under very unpromising circumstances. 
According to Borne, the addition of a drop of creasote to. the purgative dose, 
when the stomach is very irritable, will often enable it to be retained, when 
it would otherwise be rejected. 
During the above treatment, opiates should be freely used to allay pain and 
relax spasm; and warm fomentations and the warm bath will be found useful 
auxiliaries. The repeated injection of large quantities of warm water into the 
bowels, by means of a forcing pump, as recommended in obstinate cases of 
constipation {see page 605), is one of the most efficient remedies. If the ob- 
struction consist in fecal masses or other concretions, it may thus be loosened, 
broken down, and gradually brought away; if in intussusceptio or twisting of 
the bowel, there may be some hope-, in the one case, of pushing up the inva- 
ginated' intestine by the force of the stream, provided adhesions have not been 
formed, and in the other of untwisting the rotation by an impulse opposite to 
that which produced it. To insure its full effect, however, the fluid should 
be introduced by means of a tube passed as high as possible into the bowel. 
Even the ordinary purgative and stimulant injections prove much more effi- 
cient, when introduced in this way. Dr. O'Beirne succeeded in causing, by 
a single stimulating injection thrown through a tube passed nine or ten 
inches up the rectum, the breaking up and discharge of a great fecal mass, 
which had been lodged for six months in the sigmoid flexure, and during that 
period,had resisted purgatives, and numerous enemata exhibited in the ordi- 
nary manlier. ■ 
There is often great difficulty in passing a tube through the sigmoid flex- 
ure, some obstacle to its passage being offered' about eight or ten inches above 
the anus, so that the tube often curves upon itself, and forms a coil in the 
rectum. This difficulty is ascribed by O'Beirne to a contraction which 
he supposes always to exist in the upper part of the rectum, in the ordinary 
state of the bowel, and to relax only when the accumulation of feculent mat- 
ter in the colon is such as to require evacuation; the rectum being, in his 
opinion, merely an instrument for the expulsion of the feces, and not a reser- 
voir for its reception. To overcome this constriction, he recommends that the 
instrument be pressed steadily against it with considerable force, though not 
sufficient to endanger the penetration of the coats of the reettmi; an accident 
which has happened from the incautious use of bougies.' {New Views of Defe- 
cation, &c.) Others consider the difficulty as resulting from the projection of 
the sacrum, or the oblique direction of the bowel, and recommend the em- 
ployment of a bent director, or the injection of some water through the tube 
when it reaches the curved part, so as to distend the intestine, and keep the 
tube in the middle of the stream. 
Tobacco enemata have sometimes been found effectual in very threatening 
cases, but must be used very cautiously. {Seepage 591.) Dr. Alexander 
succeeded in an obstinate case, by introducing a long tube into the rectum, 614 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
throwing up through this, by means of a syringe fitted to it, more than a pint 
of warm water, and then withdrawing the piston of the syringe, so as to bring 
atmospheric pressure to bear upon the bowel. ^Lond. Med. and Phys. Journ., 
Dec. 1827.) Metallic mercury has by its great weight forced obstructions 
which have resisted other means. It is recommended in the quantity of a 
pound or more, given in doses of four ounces at intervals of a few hours; but 
it should be employed only as a dernier resort. Cold water thrown upon 
the lower extremities and abdomen has occasionally proved effectual in obstinate 
cases. ■ 8 
Efforts for the relief of the patient should never be abandoned so long as 
life continues. If one measure fail, another should be tried, and nothing 
which affords any reasonable prospect of advantage should be neglected; for 
success has often rewarded the efforts of the practitioner, in these cases, when 
there scarcely seemed to be ground for hope. When the strength of the 
patient begins to fail, it should be supported by stimulants and nutritious 
food. Wine-whey, carbonate of ammonia, egg beat up with wine, milk-punch, 
animal broths, &c>, may be employed. Lime water and milk in small and 
frequently repeated doses, will sometimes lie upon the stomach, when other 
nutriment is rejected. Opiates should be administered throughout the case, 
if required to give ease or produce sleep. In low states of the system, it may 
be proper to employ the purgative tinctures, as those of rhubarb, aloes, senna 
and jalap, &c., preferably to other forms of cathartic medicine. In those cases 
which run on foi' months, it will be necessary to watch their progress care- 
fully, in order to meet*., any offered indication, and favour the recuperative 
efforts of nature. 
A few remarks may be made in reference to particular cases of obstruction. 
Should the complaint depend upon feces or concretions lodged in the rectum, 
the aid of the finger or of instruments should be resorted to. (See page 605.) 
The latter, if cautiously used, may be even applied to similar obstructions at 
the lower extremity of the sigmoid flexure. If there be reason to suppose 
that magnesia has concreted in the bowels, acidulous liquids should be given 
with the purgative. When the obstruction depends on stricture of the rec- 
tum, resort should be had to the bougie, unless in cases of scirrhus or cancer, 
in which this instrument can do no good, and may prove injurious by tearing 
the easily lacerated structure. In permanent impediments of this kind, the 
best plan is to administer frequently small doses of the saline cathartics, so as 
to keep the passages in a liquid state, and thus prevent irritation. The use 
of laxative mineral waters has been found very beneficial, under such circum- 
stances, in alleviating the pains and protracting the life of the patient. If 
there is strong reason to believe in the existence of intussusceptio, twisting of 
the bowel, or other form of internal strangulation, there may possibly, under 
peculiar circumstances, and in cases otherwise desperate, be some propriety in 
opening the abdomen and removing the mechanical impediment; at least the 
question of an operation may be entertained. A successful case of the kind 
is referred to in Dr. Eberle's Practice of Medicine (2d ed., vol. ii. p. 341), 
quoted from Hufeland's Journal for February, 1826.- CLASS III.] 
WORMS IN THE ALIMENTARY CANAL. 
615 
Article VI. 
WORMS IN THE ALIMENTARY CANAL. 
Five different species of worms inhabit the alimentary canal. I shall first 
briefly describe these parasites, then give some observations upon the symp- 
toms, causes, and management of intestinal worms in general, and lastly treat 
of what is peculiar, in these respects, to each species. 
1. Ascaris lumbricoides.--Round worm.-AAas worm has frequently been 
called lumbricus or in the plural lumbfici, from a supposed identity with the 
common earth-worm, from which, however, it is wholly distinct. It has a 
cylindrical body, tapering towards the extremities, generally from six to twelve 
inches long by two or three lines in thickness, smooth, of a whitish, yellowish, 
or pale reddish colour, and somewhat transparent when first voided. The 
head is at the slenderest extremity, and is distinguished by three tubercles 
surrounding the mouth. The alimentary canal is distinct from the general 
parietes, and runs from the mouth near one end of the worm, to the anus 
near the other. The surface exhibits numerous circular fibres, and four lon- 
gitudinal equidistant lines, the former indicating the course of the muscles, 
the latter of the nerves and blood-vessels. The two sexes are in different 
individuals. The male is smaller and much less abundant than the female, 
and has its tail shortly curved, while that of the female is straighter and 
thicker. The latter is also distinguished by a constriction, which is the seat 
of the vulva, at about one-third of the distance from the head to the tail. 
The external genitals of the male are at the caudal extremity. 
2. Ascaris vermicularis.--Thread-worm.- Seat-worm. - Maw-worm.-- 
This worm is most commonly designated by the- plural term ascarides. It is 
the smallest of the intestinal worms, the male not exceeding two lines, and 
the female being about five lines in length. It is very slender, and of a 
white .colour, and bears considerable resemblance to a small piece' of thread, 
whence one of its names was derived. The head, as in the former species, is 
furnished with three tubercles, and the body gradually diminishes towards 
the tail, which, in the female, is slender and pointed, in the male, somewhat 
thicker, obtuse, and "spirally inflected." The interior structure resembles 
that of the A. lumbricoides. 
3. Tricocephalus dispar.-Long thread-worm.-This worm is an inch or 
two in length, and consists of two distinct portions, of which the anterior, 
constituting about two-thirds of the whole length of the animal, is scarcely 
thicker than a horse-hair, and suddenly swells out into the much thicker but 
shorter posterior portion. Hence the names tricocephalus (from hair,< and 
head), and dispar, unequal. Like the two preceding worms, this 
also has a distinct alimentary canal, and the different sexes in different indi- 
viduals. The digestive tube, commencing in a small orbicular mouth, at the 
anterior extremity, runs longitudinally through the animal to the anus at the 
opposite extremity, being straight in the capillary portion, and sacculated in 
the larger. The male, which is generally found convoluted, is smaller than 
the female. The former has at the posterior extremity a projecting sheathed 
spiculum, the latter a foramen which serves both for anus and vulva. 
4. Tsenia solium.-Common tape-worm.-Long tape-worm.--The taenia 
varies much in length, being, as generally found, from five to ten feet long, 
but sometimes reaching sixty, and, according to some writers, upwards of one 616 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
hundred feet. It is flat, and where largest, three or four lines broad, but 
tapers gradually towards the anterior extremity, which is slender, and thread- 
like. The body consists of numerous segments, which are most distinct at a 
distance from the head, and, in the lower part of the worm, are longer than 
they are broad, resembling, when separated, the seeds of a gourd, whence the 
animal has sometimes been called Trenia cucurbitina, or gourd-worm,. The 
head is small and flatfish, having a projecting papilla in the centre, furnished 
with a double circle of hooks, and surrounded by four equidistant apertures, 
which appear to be the mouths of the apimal. From these run two parallel 
canals, one on eaqh side, near the margin of the segments, from one end of 
the animal to the other, being connected by numerous transverse vessels. 
These canals ate not distinct from the body, but merely passages excavated, 
as it were, in the parenchyiiiatous tissue of the animal, and therefore differ 
materially in character from the digestive tube of the three species before de- 
scribed. Each joint has a marginal foramen in the centre of a prominent 
papilla; and the foramina occur alternately on the opposite sides of the ani- 
mal. These lateral pores are connected by a duct with an ovarium, occupying 
the centre of each segment; and the ova, as they escape, are supposed to be 
fertilized by a fluid derived from a vesicle, the duct of which opens at the 
same point as that from the ovary; so that in this worm the organs of the two 
sexes are contained in the. same individual. 
5. Bothriocephalus latus.-Taenia lata.--Broad tape-worn®.-The body of 
this worm is also long and flat, but is broader than that of the taenia, being 
from four to ten lines in breadth. It is distinguished also by the shape of 
the segments, which are broader than they are long; by the form of the head, 
which1 is small, elongated, without spines, and divided into two lobes by a 
longitudinal fossa on each side (whence Bothriocephalus from fiodpiov, a fossa 
or ditch, and head); and by having, instead of the four mouths of the 
taenia, a single minute pore in the centre between the fossae, or else two pores, 
one at the extremity of each lobe. The foramina supposed to be the outlets 
for the escape of the ova, are situated not on the opposite margins of the seg- 
ments alternately as in the taenia, but in a single row, each segment having 
one pore in its centre. The arrangement of the digestive tube is the same as 
in the preceding species, and is in like manner a mere excavation in the 
parenchymatous substance of the animal, without a distinct coating. The 
bothriocephalus is said to be somewhat less opaque than the taenia, and, when 
kept in alcohol, has a somewhat opaline appearance. 
The above descriptions, are condensed chiefly from those by Dr. Arthur 
Farre, contained in Tweedie's System of Practical Medicine. Other animals 
besides those described are sometimes found in the human intestines, but none 
peculiar to this situation. The eggs, larvae, or young of various insects, 
worms, lizards, and serpents, have been taken in with the food or drink, or 
have crept into the mouth or anus during sleep, and, having undergone a 
greater or less degree of developement in the alimentary canal, have produced 
derangements of health, sometimes long continued, and of the most serious 
character. Numerous cases of this kind are recorded in medical journals, 
or other periodicals; and, much allowance being made for exaggeration, 
enough remains to justify the above statement. Among the animals particu- 
larly enumerated are Gordius aquaticus, or horse-hair worm, different species 
of Hirudo, or leech, different species of Musca, or fly, Phalaena pinguinalis, 
Triton -palustris, and Lacerta aquatica. (Good, Study of Medicine.) But 
none of these produce symptoms by which they could be respectively charac- 
terized. Their effects are essentially the same as those of the proper parasites 
of the bowels, and for the most part they are amenable to the same treatments CLASS III.] 
617 
WORMS IN THE ALIMENTARY CANAL. 
General Observations. 
Symptoms.-In consequence of their movements, the interruption they 
offer to the progress of the contents- of the bowels, and probably other modes 
of irritation, worms very generally occasion uneasiness or pain in the abdo- 
men, sometimes spasmodic; sometimes described as gnawing or biting, and 
not unfrequently of a vague indescribable-character, and yet very distressing. 
Sympathetic with this, is a sensation of itching at the anus and at the nos- 
trils, producing a disposition to Scratch the fundament, and to pick the nose, 
which is highly characteristic of the verminous affection. The bowels are 
often disordered, being sometimes constipated and sometimes relaxed, with 
occasional tenesmus, and mucous or bloody discharges as in dysentery. The 
mucus is sometimes in shreds or flakes, which are not unfrequently mistaken 
for fragments of the partially digested worms. It is not uncommon for por- 
tions of undigested food to pass with the feces.J The appetite is exceedingly 
variable, in some cases natural, in others deficient, craving, or depraved; one 
condition not unfrequently alternating with another. The belly is often 
swollen, hard, and tympanitic, the breath heavy or fetid, and the tongue 
furred, with a disagreeable taste and a copious flow of saliva. Swellings, of 
the upper lip, bleeding from the nostrils, and a disposition to grind the teeth 
during sleep, are other characteristic symptoms. 
But the effects often extend beyond the alimentary canal, and various de- 
rangements of health are-experienced in consequence either of the direct irri- 
tation of the worms, or of the disordered digestion which they occasion. Among 
the most common of these are nervous affections; such as fretfulness, irrita- 
bility of temper, wakefulness or somnolence, disturbed sleep, sudden starting 
out of sleep as if from fright, vertigo, headache, spasmodic movements of the 
eyelids, dilated pupils, perverted vision, temporary blindness, tinnitus aurium, 
and partial deafness. General convulsions are not unfrequent in children, 
and symptoms strongly resembling those of hydrocephalus-have been ascribed 
to worms, and have ceased on their expulsion. Cases of chorea, melancholy, 
hypochondriasis, and even insanity have been referred with apparent reason 
to the same causes Besides these affections, may be mentioned obstinate 
cough, spasm of the glottis, dyspnoea, palpitations, hysteria, menorrhagia, and 
a general cachectic stafe of system, marked by a languid circulation, a pale or 
sallow skin, sunken eyes, a livid circle about the eyelids, and general ema- 
ciation, or oedema. A febrile condition occasionally accompanies worms, with 
daily exacerbations and remissions, a tumid abdomen, offensive breath, and 
frequently symptoms of cerebral oppression. The name of worm fever by 
which it has been called indicates the prevalent opinion as to its origin, There 
can be little doubt th'at worms are capable of producing it; but any other 
cause which induces protracted intestinal irritation, with disordered digestion, 
may have the same effect; and there is no such necessary connexion between 
the fever and the worms as might be inferred from its name. 
As to many of the above disordered conditions, it is often impossible to say 
whether they bear to the worms the relation of cause or effect, and sometimes 
whether the connexion may not be a mere coincidence. That worms are 
sometimes the cause, may be inferred from the frequently observed fact, that 
all the phenomena vanish when they are removed. Again, it is well known 
that disordered digestion and general debility favour the production of worms; 
and the same causes which give rise to the developement of these parasites are 
quite sufficient to produce various derangements by their direct action, wholly 
independent of the worms; so that the two may co-exist without any neces- 
sary connexion as cause and effect. Persons in apparently perfect health are 618 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
occasionally affected with worms, which give no signs of their existence until 
they are observed in the ordinary passages, or are expelled during some acute 
attack of disease, either by the medicines employed, or by the action of the 
disease itself; and it is no uncommon event' tp find worms, in the bowels of 
individuals after death, who have evinced no signs of them during life. Hence 
some have inferred that they are generally if not always harmless, and persons 
have even gone so far as to maintain that .they perform a useful office, being 
intended as scavengers to clear off the noxious matters contained in the bowels. 
But these opinions are opposed to general experience; and, though it may not 
be proper to disturb the system of a perfectly healthy individual, supposed to 
be affected with worms, by active measures for their', expulsion; yet, when 
associated with a deranged state of health, whether as cause or effect, they 
should always engage attention, and be removed if possible; as their removal, 
under such circumstances, is often followed by the happiest results.. 
Appearances after death.-Worms are very rarely fatal; but opportunities 
are often afforded, in cases of death from other causes, to observe the patho- 
logical changes they produce in the -stomach and bowels^ These are very 
slight, consisting chiefly of an excess of mucus, with occasionally an increased 
vascularity of the mucous membrane.. It has been supposed that worms, are 
capable of piercing the intestine, and escaping through its parietes; as they 
have sometimes been found engaged in small openings in the coats of the 
alimentary canal, and even loose in the abdominal cavity. But there is every 
reason to believe that the openings were the result of previous ulceration, or 
of changes after death, as in an instance in which great numbers were observed 
to have escaped through holes in the stomach, which may have been produced 
by a post-mortem action of the gastric juice. Worms have also been discharged 
with pus from external abscesses connected with the bowels; but it is most 
probable that the inflammation which gave rise to the ulcerative and suppu- 
rative processes had some other origin than the irritation of the worms. The 
tricocephalus, however, appears to have the power of inserting its capillary 
head into the substance of the mucous membrane; and a case is on record, 
in which the caecum was found perforated as if with a number of pin holes, 
and the lining membrane much eroded by worifts of this genus. (Brooks, 
quoted by Farre, in Tweedie's System of Pratt. Med.) 
Causes.-The origin of intestinal worms has been a subject of much con- 
troversy. The difficulty of otherwise accounting for their presence in the 
alimentary canal has led .some to the notion of spontaneous or equivocal 
generation; but, before a mode of production so contrary to the general course 
jof nature can be admitted, it must be clearly shown that their origin from a 
parent animal is quite impossible. This subject has been already,sufficiently 
discussed, in the first part of this work, to which the- reader is referred. (See 
page 120.) The conclusion there come to is, that these parasites obey the 
general laws of animal nature, as well in the mode of their generation, as in 
that of their developement and growth. 
It is probable that the ova, received into the alimentary canal, are capable 
of developement in a healthy state of this structure, as worms are sometimes 
found in individuals who are apparently quite free, from disease; but, never- 
theless, it is certain that their growth is very much favoured by certain mor- 
bid conditions of the stomach and bowels, and particularly by a feeble or dis- 
ordered state of digestion. Hence, persons of sedentary habits, of scrofulous 
tendencies, and of generally depraved health, are apt to be affected with them. 
It is supposed that an excess of food over the powers of digestion is very 
favourable to their growth. Excessive indulgence of the appetite has, there- 
fore, the same effect as defective digestion. The use of certain articles of CLASS III.] 
WORMS IN THE ALIMENTARY CANAL. 
619 
food also predisposes to worms, such as crude vegetables, unripe fruits, and 
indigestible substances in general. Bad bread, spoiled cheese and meats, the 
flesh of diseased animals, and the use of bad water as drink, are fruitful 
sources of verminous affections. It is said that they seem sometimes to occur 
epidemically; but the probability is, that, under these circumstances, a close 
examination would generally trace their origin to some impropriety of diet 
affecting great numbers of individuals; and the same remark is perhaps ap- 
plicable to the well ascertained fact, that certain regions of country are much 
more subject to worms than others. Nevertheless, it is not impossible that 
certain conditions of the atmosphere may favour the production of worms; 
and it has been observed that they are most abundant in moist countries, and 
during a long prevalence of warm damp weather. Children, after the period 
of suckling, and up to about the age of puberty, are more frequently affected 
with worms than either very young infants' or adults, probably owing to the 
nature of their diet, which is often ill adapted to their yet immature powers 
of, digestion. 
Treatment.-Two indications are presented, first, to expel the worms from 
the bowels, and, secondly, to prevent their reproduction. . - 
The first indication may be fulfilled by active purgatives, which expel them 
by the increased activity they give to the peristaltic movement, or by anthel- 
mintic medicines, which favour their expulsion through the ordinary contrac- 
tion of the bowels, by rendering them less able or less disposed to resist this 
contraction. But a more effectual plan is to combine these two modes, thus 
at the same time bringing a greater force to bear upon the worms, and dimin- 
ishing their powers of resistance. The purgatives and anthelmintics may be 
given conjointly; or the latter may be administered night and morning for a 
few days, and then followed by the former. 
Anthelmintics are medicines which prove disagreeable to the worms, and 
thereby dispose them to leave the bowels, or so debilitate them as to disable 
them from maintaining their position, or destroy their life, and thus expose 
them to the expulsive powers of the intestines, or the digestive powers of the 
stomach. They may produce these effects by acting on the susceptibilities of 
the worm, as medicines and poisons act on the human system, or by mechani- 
cally bruising or wounding it. Among those which operate in the former 
method may be mentioned pink-root, azedarach, the bark of Andira inermis, 
male fern, the bark of pomegranate root, walnut-rind, common salt, camphor, 
various bitters, and numerous substances characterized by containing a strongly 
odorous or highly stimulating volatile oil, as turpentine, copaiba, savine, che- 
nopodium or American wormseed, semen santonicae or European wormseed, 
tansy, rue, wormwood, garlic, and assafetida. Several of the volatile oils 
themselves are still more efficacious, especially the oil of turpentine and that 
of chenopodium. Electricity passed through the bowels, in successive and 
somewhat violent shocks, has been supposed to injure or kill the worms, and 
favotir their expulsion by cathartics. The mechanical anthelmintics are chiefly 
cowhage, which wounds and sometimes destroys the worms by the. sharp bris- 
tles of its pods, and the powderpf tin or of zinc, which bruises or scratches 
them by its angular particles. Metallic mercury, which has been recommended 
in worms, undoubtedly operates by its great weight. The fixed oils are thought 
by some to operate as anthelmintics xby covering the surface of the worm, and 
thus closing its respiratory pores against, the entrance of air. 
In the choice of purgatives, attention should be paid to their anthelmintic 
properties. Thus, calomel is a powerful vermifuge, much more so than can 
be satisfactorily explained by a reference to its mere cathartic power. The 
probability is, that it proves disagreeable or injurious to the worm by the 620 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
acrid property of the bile which it causes to be secreted. Aloes is also thought 
to possess vermifuge properties, independently of its purgative action, owing 
to its intense bitterness-; this property being considered by some as extremely 
offensive to worms. The same may be said of colocyntli. If there is truth in 
the supposition before alluded to, of the suffocating action of fixed oils on the 
worms, which, however, is by no means certain, at least in reference to the 
operation of these oils when taken into the stomach, castor oil and olive oil 
ought to be efficacious anthelmintics. The oil of turpentine in very large 
doses, and the bark of pomegranate root, unite purgative and anthelmintic 
powers. Considered independently of anthelmintic properties, those cathar- 
tics are the most powerfully vermifuge which act with greatest energy W the 
muscular coat of the bowels. Senna, jalap, scammony, aloes, black hellebore, 
cevadilla, colocyntli, gamboge, croton oil, and elaterium have been used, vari- 
ously combined, and in various modes of preparation; but, except in very 
obstinate cases of worms, it is better to trust to the propter anthelmintic^ with 
the less violent of these cathartics, than to endanger inflammation of the bow- 
els, or exhaustion of the patient, by a resort to the most energetic. 
To meet the second indication, that, namely, of preventing the reproduction 
of the worms when once destroyed or evacuated, it is npcessary to attend to 
the food and drink of the patient, and, if the digestion is feeble, to promote 
that function by tonic medicines; exercise, and other suitable measures. Ex- 
cess in eating, indigestible substances, unwholesome food of all kinds, and 
unwholesome drinks should be avoided. Of the tonics, the different prepara- 
tions of iron are probably, the most efficacious; though they may be advan- 
tageously combined with the simple bitters, as.gentian; quassia, and columbo. 
The bitters in which the tonic principle is associated with an anthelmintic 
volatile oil, as wormwood, tansy, and rue, were formerly much used, and are 
probably not without a peculiar efficacy. When there is acid in the stomach 
or bowels, lime-water, or one of the alkaline carbonates may be usefully asso- 
ciated with the bitters. The rules applicable to the treatment of dyspepsia 
may be considered as in force in the present case. Very often, however, 
after the expulsion of the worms, all unpleasant symptoms cease, and no 
further treatment is necessary. 
1. Round Worm.-Ascaris lumbncoidesi-The round worm generally 
inhabits the small intestines; but not unfrequently makes its way upward 
into the stomach, or downward into the rectum; and sometimes escapes from 
the alimentary canal by the mouth, or by the anus. : It occasionally enters 
other passages which communicate with that canal; having been found in the 
posterior nares, the trachea, the pancreatic and biliary ducts, and. the gall- 
bladder. It is sometimes solitary; but more generally in considerable num- 
bers ; and two hundred have been known to. pqss from one patient in the 
course of a week. The worm is supposed to feed upon the intestinal mucus, 
which is usually copious where these parasites exist. It occurs most fre- 
quently in children, occasionally in adults, and seldom in old persons. Of all 
the different worms that infest the bowels, this is by far the most common. - 
The symptoms are those already enumerated as resulting from intestinal 
worms in general. The most characteristic signs are perhaps a tumid abdo- 
men, irregularity of the bowels, depraved appetite, picking of the nose, and 
grinding of the teeth in sleep. When these worms exist in the stomach, they 
occasion peculiar deranged sensations in the epigastrium, with nausea, and 
frequent retching, and motions on the part of the patient as if he were choking 
from something in the throat,, produced probably by attempts of the worm to 
enter the oesophagus, or by its actual presence in that tube. When these 
motions occur in an infant, the round worm may be suspected to exist in the CLASS III.] 
WORMS IN THE ALIMENTARY CANAL. 
621 
stomach. But the only certain proof that a patient is, or has been, labouring 
under this worm, is the sight of it after it has passed from the bowels, or been 
discharged from the stomach. It sometimes comes away spontaneously from 
the anus, and is not unfrequently evacuated with the feces, thus affording the 
requisite evidence of its existence. 
The general course, of treatment for worms already described is applicable 
to this species. A good remedy at the commencement, and one which will 
alone, in a great majority of cases, produce an evacuation of the worms, is an 
infusion of senna and pink-root, with sulphate of magnesia to correct the 
griping property of the-cathartic, manna to cover the taste, and fennel-seed 
or other aromatic to correct the flavour, and to render the whole more accept- 
able to the stomach. This infusion may be given in a small dose once or 
twice a day, so as to produce two or three evacuations in the twenty-four 
hours; and may be continued daily, or every other day, for one or two weeks, 
of even a longer period, if necessary, and it do not too much debilitate the 
patient.-* A little savine, or other vegetable anthelmintic, may sometimes be 
advantageously added to the infusion, in obstinate cases. 
If evidences of deranged biliary secretion exist, or the bowels be too irrita- 
ble for. the use of the above infusion, or if the infusion has failed, or any 
difficulty exists in the way of its exhibition, calomel may often be advantage- 
ously resorted to. This, is, indeed, one of the most efficacious anthelmintics, 
and has the great advantage, in the cases of children, of easy administration. 
It is best given in connexion with powdered spigelia, and followed, at a proper 
interval by castor oil. To a child, four grains of calomel and sixteen of 
spigelia may be given at bed-time, and followed by a dose of castor oil in the 
morning; and the remedy may be repeated once and again, if required, at 
intervals of three or four days. In adults, the calomel .and pink-root may be 
associated with some quicker cathartic,- as jalap, segmmony, or the compound 
extract of colocynth. r . 
v Another plan is to administer, morning and evening,'for several successive 
days, a dose of some anthelmintic, and afterwards a purgative dose of calomel 
or other cathartic, to expel the debilitated or dead worms. For this purpose, 
in the case of a child, half a fluidounce or a fluidounce of the officinal infusion 
of pink-root, or from ten to twenty grains of the powder; from twenty to 
forty grains, of powdered wormseed (chenopodium), or from five to ten drops 
of the volatile oil; from five to twenty drops of tile oil of turpentine ; or a 
drachm of an electuary made by incorporating the bristles of cowhage with 
syrup or molasses, may be employed. The oil of turpentine is peculiarly 
efficacious in stomachic worms, as pointed out by the late Dr. Joseph Klapp, 
of Philadelphia. In our southern states, where the pride of China (Melia 
Azedarach) grows, the bark of the root of that tree (Azedarach, U. S.) is 
much employed. Four ounces of the fresh bark are boiled with two pints of 
water down to one, and a tablespoonful is given to a child for a dose. The 
cedar apple, an excrescence upon the branches of the Juniperus Virginiana, 
or common red cedar, has been highly recommended, in the dose of from ten 
to twenty grains of- the powder, repeated as. above mentioned, and will often 
prove effectual. The above anthelmintics may be employed successively, one 
of them sometimes succeeding when another has foiled. 
In nervous cases, advantage may result from combining assafetida, garlic, 
or valerian with the more decided anthelmintics. When the digestion is 
* R.-Sennse, Spigeliw, aa §ss; Magnesias Sulphat. gij; Mannae §j; Fcenjculi ^ij; 
Aquae fervent Oj To be macerated for two hours in a covered vessel. Dose for a 
child two years old, about f^ss; for an adult or f^iv. 622 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
feeble, the vegetable bitters, or chalybeate preparations should be employed 
in a similar connexion, and, in case of the existence of an excess of acid in 
the stomach or bowels, antacids should also be added. These different reme- 
dies may be combined in the liquid form, in that of powder, electuary, or pill, 
to suit the views of the practitioner, or'the convenience of the patient. Care 
must be taken, after the expulsion of the worms, to provide against their 
reproduction, as directed in page 620. 
2. Thread-worm. -Ascarides. - Maw-worm. - Ascaris vermicularis.- 
The peculiar seat of ascarides is the rectum, but they sometimes also inhabit 
the colon, and are said to have been occasionally seen in the stomach, and to 
have derived from this circumstance their name of maw-worm, though Dr. 
Good ascribes the origin of this name rather to the disagreeable sensations 
they produce in the stomach, from sympathy with , the rectum, than from their 
actual presence in the former viscus. In the female they sometimes enter 
the vagina, giving rise to severe irritation and intense itching, and even to 
symptoms of nymphomania. They are usually in great numbers, and mul- 
tiply very rapidly. Persons of all ages are liable to them; but they are most 
frequent in children. 
Their characteristic symptom is an itchiiag sensation at the anus, which is 
often distressing and almost insupportable, especially in the evening, and 
after the patient has become warm in bed. Tenesmus; mucous or bloody 
discharges, and small tumours about the anus are also among their effects. 
These- local symptoms are in some cases all that are exhibited; but the 
general derangements which have before been described as produced by 
worms, may proceed also from this species. Disorder of the nervous system 
is especially apt to occur, from the intense local irritation occasioned by the 
movements of the worms; and this disorder amounts sometimes in children 
to general convulsions. But this irritation of the anus may proceed from 
other causes, and the only certain evidence of the existence of ascarides in 
the rectum is afforded by their occasional appearance upon the bed-clothes, or 
in the stools^ They not unfrequently make their way out of the rectum dur- 
ing the night, and may be sCen upon the sheets in the morning; and are 
sometime^ discharged in considerable numbers, either mixed with the feces, 
or enveloped in mucus, or clustered together in the form of a ball. It is 
extremely difficult completely to dislodge them from the bowels; for, how- 
ever great the numbers evacuated, or the temporary relief obtained, a few 
generally remain, and, by the rapidity of their propagation, reproduce all the 
original symptoms. Though productive of great inconvenience, and even 
suffering, they may exist for many years without serious injury to the health, 
and have been known to continue through almost the whole of a long life, 
without reason to suppose that they had in any degree shortened it. (Heber- 
den, Trans, of the Col. of Phys., Lond., i. 54.) ' 
Treatment.-Medicines taken by the mouth are usually less efficacious in 
this than the other species of worms. The most successful plan is to address 
the remedies immediately to the rectum,' and, having weakened or destroyed 
the worms by anthelmintic cnemata, then to procure their expulsion by 
cathartics taken in the ordinary way, or thrown into the bowels. The sub- 
stances most advantageously employed in enemata, are oil of turpentine, 
aloes, common salt, decoction of rue or wormwood, infusion of tobacco, sul- 
phuretted waters, the alkaline sulphurcts, tincture of chloride of iron, chlo- 
ride of soda, and vinegar. Great advantage is said to have resulted from an 
infusion of quassia made in the proportion of two drachms to four fluidounces 
of water. (Gaz. des Ilopitauf Sept. 1846.) Some one of these, or some 
combination of them, should be injected daily, with a sufficient quantity of class in.] 
WORMS IN THE ALIMENTARY CANAL. 
623 
water, and after several days should be followed by a dose of calomel or aloes, 
or other brisk cathartic. A dose of sulphur, taken every morning before 
breakfast, has been found very useful. Advantage has also been derived 
from the introduction into the rectum of a bougie smeared with mercurial 
ointment, or of a candle or piece of fat pork tied to a string, which, after 
having been allowed to remain for some time, is withdrawn with the worms 
adhering to it. In adults, much relief may sometimes be obtained by the 
greased finger employed in like manner. Injections of olive oil or other mild 
fixed oil, and the external application of creaspte incorporated with some unc- 
tuous matter, have been recommended as palliative measures. The frequent 
local use of cold water also allays the itching. It is advised to avoid expo- 
sure to heat, or the use of stimulating articles of food. When the worms 
have found their way into the vagina, injections of cold water with vinegar 
are recommended by Bremser. The general health should be attended to as 
in the other kinds of worms. It is asserted that the change of system which 
takes place at puberty is unfavourable to the existence of these worms, which 
often cease to appear after that period. 
3. Long Thread-worm.- Tricoceplialus dispar.-This worm is found most 
frequently in the caecum or other part of the colon, but sometimes also in the 
small intestines, either loose, or with its anterior capillary portion inserted 
into the mucous membrane. It is often observed, in great numbers, in the 
bodies of individuals who have died suddenly, by accident or from some acute 
disease, and. who have exhibited no evidences of its existence during life. 
The tricoceplialus was first noticed as a distinct worm in Germany, in the 
year 1760, and has since generally been considered as very rare. The fact, 
however, appears to be, that it is very common, perhaps the most so of all 
the intestinal parasites; but has escaped notice in consequence of its minute- 
ness, or been Confounded with the ascaris vermicularis. It is stated in the 
London Medico-Cliirurgical Transactions (vol. xxii. p. 2;85), that, in the 
London Hospital, during one winter, this worm was found in almost all the 
bodies carefully examined, whether of persons destroyed by injuries, or of 
those who had died of acute or chronic diseases. It does not appear that 
there are any peculiar symptoms which indicate its, existence, or that any 
special course of treatment is to be pursued. Should the ordinary signs of 
worms be present, the remedies adapted to the ascaris lumbricoides may be 
employed. 
4. Common Tape-worm.-Taenia solium.-Broad Tape-worm.-Both- 
riocephalus latus.- Taenia lata.-Between these two worms there seems to 
be no such difference in their habits, residence, symptoms, or treatment, as to 
require a distinct practical consideration. The following observations may, 
therefore, be considered as applicable to both kinds. The bothriocephalus, or 
broad tape-worm, is said to be found only among the inhabitants of Switzer- 
land, Poland, and Russia, or in individuals who have been in those regions; 
the taenia, or common tape-worm, is met with everywhere. 
They inhabit chiefly the small intestines; and are often solitary, but some- 
times also in numbers, though less numerous than the other intestinal worms. 
They occur during childhood, but more frequently after puberty, and are very 
rare in old age. Females are more subject to them than males. They are 
much more common in some countries than in others, and are comparatively 
rare in the United States, at least within the limits of my observation. Per- 
haps this result may be ascribed to the abundance of wholesome food within 
reach of everybody in this country. Tape-worms often exist in large and 
tangled bunches, So as to interfere mechanically with the proper performance 
of the intestinal functions. 624 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
Symptoms.-In some instances, the tape-worm has long existed in the 
bowels without producing any very prominent symptoms; but it generally 
occasions great discomfort, and sometimes materially deranges the health. 
There is not often perhaps very acute pain; but the sensations experienced 
are scarcely less distressing than paiiq and are often attended with great de- 
pression of spirits or irritability of temper. These sensations are referred to 
the movements of the worm. Professor Wawruch, of Vienna, who during a 
period of twenty years had witnessed 206 cases of tape-worm, gives the fol- 
lowing summary of the symptoms:-Dull pain in the forehead; giddiness; 
buzzing in the ears; dullness of the eyes, which are surrounded by a dark 
circle; edematous eyelids; dilated pupils; frequent and spasmodic movements 
of the eyes; alternate paleness and flushing of the face; paleness of the lips; 
peculiar movements of the nose and mouth; emaciation; alternate loss and 
excess of appetite; cravings for particular articles of food; offensive breath; 
furred tongue; spitting and vomitingjOf thin mucus in the mornings; itching 
at the nose, anus, and vulva; grinding of the teeth, especially during sleep; 
constriction of the throat; swelling of the.belly; gurgling, shooting pains, and 
a sense of pinching about the umbilicus; a feeling in the morning as of a 
foreign body moving in the bowels; amelioration of all the symptoms under 
the use of farinaceous food, hot bread, and coffee; finally, depression of spirits, 
and a train of nervous derangements in protracted cases. (Archives Generates, 
4e ser., i. 208, from Oesterreich. Med. Jahrbuch, 1841, No. 2.) But. the 
most certain sign is the discharge of joints of the worm, which are either 
passed alone or with the stools. These joints usually exhibit signs of life 
when they first appear, and have been supposed to possess the power of 
independent existence, and even of propagation; but this is denied by the 
best authorities. 
Treatment.- Tape-worms have the power of retaining their place very tena- 
ciously in the bowels, possibly in consequence of holding on to the mucous 
coat by means of suction. They often continue for year's to harass the patient, 
who passes from time to time separated joints, or even a whole worm, without 
getting entirely rid of the troublesome parasite. The duration of the affection, 
according to the observation of Wawruch, varies from a few months to thirty- 
five years. It is considered important that the head of the worm should be 
expelled; as, until this happens, there is no certainty that the evil has ceased. 
Many different plans of treatment have been employed with asserted success; 
most of them including active purgation, and the use of substances calculated 
to injure or destroy the worm. Whatever method .of cure is followed, much 
pain is often experienced by the patient just before the expulsion of the worm, 
which is ascribed to the violent movements of the animal, under the influence 
of the medicine. It is deemed best to prepare the patient by a somewhat 
restricted diet upon the day preceding the use of the medicine, which should 
be given in the morning upon an empty stomach. By some it is even ad- 
vised to precede the anthelmintic, for four or five days, by a spare diet, con- 
sisting chiefly of liquids, and by the use of saline or other laxatives, so as to 
leave the worm with as little protection as possible from the alvine contents, 
against the influence.of the active purgatives, or the anthelmintics, which may 
be given for its expulsion. The following remedies are those which have 
attracted most notice. 
The medicine at present probably most relied on is the oil of turpentine. 
This is given in large doses, and very often with the speediest and happiest 
effects. The quantity administered at once varies from half a fluidounce to 
two fluidounces, and much exceeds the dose of the medicine for ordinary pur- 
poses. But, in this large dose, the oil is thought to be less apt to produce CLASS III.] 
WORMS IN THE ALIMENTARY CANAL. 
625 
constitutional disturbance dr irritation of the kidneys; because, acting as a 
cathartic, it is less apt to be absorbed. The only inconveniences usually 
experienced are heat of stomach, some 'general febrile excitement, and a Sense 
of fulness in the head; but sometimes it causes headache, vertigo, a kind of 
intoxication or delirium, drowsiness, &c.; and these effects will occasionally 
continue for several days. They are most apt to follow when the medicine 
fails to act as a cathartic. The oil usually operates quickly upon the bowels, 
and brings the worm or portions of it away dead along with it. The caution, 
however, should always be observed, if it do not purge in the course of two 
or three hours, to administer a full dose of castor oil, and to aid the action of 
the medicine, if necessary, by enemata., A good plan, in order to ensure the 
cathartic action, is to give the two oils conjointly, half a fluidounce of the oil 
of turpentine being mixed with an ounce of castor oil, and the dose repeated 
in a few hours if it should fail to operate. Olive oil has been recommended 
as a substitute for castor oil, in double the dose; but is not to be relied on. 
Croton oil has sometimes been given after the oil of turpentine; but, though 
powerful, it adds unnecessarily to the intestinal irritation. In order to obviate 
such irritation, it is recommended that the patient drink freely of broths or 
mucilaginous liquids during the use of the oil. This may be administered in 
milk, coffee, or some one of the aromatic waters. 
From the ■ statement of Dr. Knox, who had the opportunity of treating 
numerous cases of tape-worm among the British troops at the Cape of Good 
Hope, it appears that the large doses of oil of turpentine above mentioned are 
not essential, tie found that .a drachm or two of the oil, given with a little 
water, morning and evening, for three days successively, was generally suffi- 
cient to destroy the worm, even in the most obstinate cases, and to cause its 
discharge from the bowels without the aid of purgatives; though tile adminis- 
tration of a little castor oil, each day about noon, was deemed advisable. 
(A^ American Med. and Surg. Jourm, ii. 116, from Edin. Aled, and Surg. 
Journ.^ The success said to have attended upon the use of small and re- 
peated doses of Venice turpentine, which depends for its virtues upon the 
volatile oil, is confirmatory of the Statement of Dr. Knox. [Hufeland's 
Journal, June, 1826.) 
A preparation known by the name of Chabert's empyreumatic oil, which 
obtained great reputation on the continent of Europe in the cure of tsenia, 
owes its efficacy, in all probability, chiefly to the oil of turpentine which it 
contains. It is prepared by mixing together three parts of oil of turpentine 
and one of the empyreumatic oil of hartshorn, allowing the mixture to stand 
for four days, and then distilling off three-quarters of it by means of a sand- 
bath. The liquid should be kept in small and well-stopped bottles; as it is 
injured by exposure. Bremser found it a most efficacious remedy in tape- 
worm, having effected cures with it in more than five hundred cases. His 
treatment consisted in first evacuating the bowels by means of a purgative 
electuary, afterwards administering two teaspoonfuls ' of the oil in a little 
water, morning and evening, for several days, until about three ounces had 
been used, then interposing a purgative, and finally resuming the oil as at 
first until the cure was completed. From four to six ounces altogether are 
required for this purpose. Under the action of this remedy, the worm is 
thought by Bremser to be destroyed, and to undergo' partial digestion, so' that 
it does not come away whole from the bowels, and sometimes is not discover- 
able in the evacuations, though the cessation of the symptoms proves the effi- 
cacy of the medicine. The oil is very nauseous, and aromatic additions 
should be made to cover its flavour. 
Perhaps next in value to the oil of turpentine is the bark of pomegranate 626 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
root. Much published testimony exists in its favour. The fact that a living 
tapeworm, introduced into a decoction of the bark, immediately evinces great 
suffering by its writhings and contortions, and dies in the course of five 
minutes, while it is capable of living several hours in pure water, is a proof 
that the bark is poisonous to the animal. The remedy may be administered 
in powder or decoction; but the latter form is usually preferred. Two ounces 
of the bruised bark are macerated in a quart of water for twenty-four hours, 
and the mixture then boiled down to a pint. A wineglassful is to be given 
every half-hour, hour, or two hours, until the whole is taken, or a powerful 
action is produced. The remedy often occasions nausea and vomiting, and 
generally purges, and the worm comes away with the stools. ' It is recom- 
mended to diet the patient strictly, and give a dose of castor oil on the pre- 
ceding day, and, if the decoction should not purge, to follow it with castor 
oil or an enema. Should the worm not be discharged at the first trial, it is 
recommended to repeat the remedy daily for three or four days, or until the 
desired effect is obtained. 
The root of the male- fern is also a remedy which has enjoyed great reputa- 
tion in the treatment of tapeworm. The reports in its favour are too nume- 
rous to admit of a reasonable doubt of its efficacy; but the dried root as found 
in our shops is probably in general nearly or quite inert, in consequence of 
long keeping; and the remedy, therefore, has obtained little credit in this 
country as a vermifuge'. It is given in powder, or in the form of ethereal 
extract, sometimes called oil of fern. The dose of the former is from one to 
three drachms, of the latter from twenty to thirty grains, to be given in the 
form of electuary, and repeated morning and evening for a day or two. It is 
customary to follow the root by some brisk cathartic. 
Tin and Zinc, granulated or in the form of filings, have been occasionally 
employed with success. In order that the worms may be exposed unprotected 
to their mechanical action, their use should be preceded by the exhibition of 
a cathartic. The dose is somewhat indefinite. Dr. Alston, beginning with 
an ounce in the morning on an empty stomach, administered half an ounce 
on each of the two succeeding days, and closed with an active purgative. 
Various other remedies have been recommended. Schmucker employed 
powdered cevadilla in the dose of half a drachm daily, or half the quantity 
twice a day, interposing an occasional purge. Mare's milk is asserted to have 
been used with great advantage in Germany. Hufeland associated a decoction 
of garlic in milk with castor oil and tin filings. Wawruch used salicin in 
doses of from two to six grains every two hours, with advantage in some cases. 
Dr. S. Jackson, late of Northumberland, showed the author a portion of 
tapeworm (Taenia solium) thirty feet long, which had been discharged by a 
female patient of his, upon taking a dose of castor oil, after having been, for 
two months, upon the use of half a fluidounce of olive oil, night and morning, 
to obviate constipation. Sometimes a portion of an unbroken worm passes' 
out through the anus, while the remainder continues within the bowels. 
Caution is here requisite not to break the worm in attempting to extract it. 
Brera recommends that it should be tied with a piece of silk. When thus 
treated, though the worm may draw itself within the bowel, it begins to de- 
scend again not long afterwards. Dr. Cagnola proposed to touch the extruded 
portion with hydrocyanic acid, in the expectation that this poison would de- 
stroy the worm; and the experiment was successfully tried by Dr. Garleke. 
Caution, however, would be requisite not to incur the risk of injuring the 
patient. Dr. Frank, of St. Petersburg, succeeded in withdrawing the taenia 
whole, by passing the part without the bowel through a canula, and intro- 
ducing this into the rectum, so as to overcome the resistance of the sphincter 
ani. (Al Am. Med. and Surg. Journ., ii. 118.) CLASS III.] 
STRICTURE OF THE RECTUM. 
627 
Article VIL 
STRICTURE OF THE RECTUM. 
The existence of stricture of the rectum may be suspected when there is 
difficulty in the evacuation of the bowels, with straining, and the discharge 
of the feces in portions of diminished size and altered shape, either flattened 
like ribbons, or in worm-like cylinders, straight or spirally twisted, or in 
small distinct lumps. If an examination be now made, and resistance offered 
to the passage of the finger, or a large bougie up the rectum, the suspicion 
will be confirmed. The stricture may depend on a thickening or other or- 
ganic derangement of the coats of the bowels, or upon spasmodic muscular 
contraction. These two conditions require a separate consideration. 
1. Organic Stricture.-In this form, which is the most frequent, the diffi- 
culty of expelling the feces comes on almost imperceptibly, and increases 
gradually, until it becomes a source of great inconvenience. When the affec- 
tion is considerably advanced, there is usually obstinate constipation, ■with 
severe and painful efforts to procure evacuations, and often nothing for some 
time but bloody or mucous passages; though occasionally, from the irritation 
produced by purgatives, or by the accumulated fecal matter, a looseness sets 
in which yields temporary relief. All the morbid effects enumerated under 
the head of constipation are experienced in this affection. The stricture may 
remain for an indefinite time in this condition, or it may go on increasing 
until the passage is nearly or quite closed, and positive obstruction ensues. 
(See Obstruction of the Bozcels^ Reath is now inevitable unless from the 
interference of art, or unless nature, as sometimes happens, creates a new 
opening; for the escape of the feces by means of ulceration. 
The organic derangement which constitutes the stricture may be of a car- 
cinomatous character, or it may be entirely destitute of malignancy; and it is 
important that the two states should be properly distinguished; as the means 
which may be found useful in the one, are generally useless if not injurious 
in the other,. 
In the carcinomatous or cancerous stricture, there is severe lancinating 
pain, which usually extends down the thighs; and the part affected, if still in 
the scirrhous state, is usually unequal to the-touch, and of an almost cartila- 
ginous hardness. In the advanced stages, after ulceration has commenced, 
there is an ichorous discharge of an offensive and peculiar odour, charac- 
teristic of cancer wherever met with, and occasional exhausting hemor- 
rhages. To the finger the diseased structure now offers ulcerated surfaces, 
with hard inverted or everted edges, and prominent friable granulations. 
The patient has also in general a peculiar cachectic aspect, with a pale waxen 
or leaden skin, oedema of the extremities, and a very painful and wan 
expression of countenance, consequent upon his protracted sufferings.- 
When the complaint is beyond the reach of the finger, it may, for the most 
part, be recognized by the odour of the sanious stools, the lancinating and 
persevering pains, and the cachectic appearance just alluded to. The dis- 
ease sometimes affects a small portion of the bowel, occupying either one side 
or the whole circumference, or more rarely projecting in the form of a tumour 
into the cavity. In other instances, it extends over a large portion or the 
whole of the rectum, which is unequally thickened and hardened, with a 
small winding passage through it, and offering to the finger nothing but hard 628 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
tubercles, or bleeding friable ulcers. Cancer of the rectum is not uniformly- 
attended with obstinate constipation; and the degree of this affection varies 
with the extent and position of the induration, being greater when the whole 
circumference of the bowel is affected, than when the disease occupies only- 
one side of it. In the ulcerative stage, instead of constipation there is often 
an exhausting diarrhoea. In the carcinomatous stricture art can afford little 
relief. Bougies and caustics have sometimes been employed to open or 
enlarge the passage; but they are justifiable only when the danger of death 
from obstruction is imminent. The same may be said of the attempts to 
break or tear away portions of the diseased mass, which have been re- 
sorted to for a similar purpose. The only chance of cure is afforded by the 
extirpation of the diseased structure, which is very rarely possible, without 
great danger. Scirrhus occupying only the anal extremity has sometimes 
been successfully removed by the knife, and tumours supposed to be scirrhous 
have been separated by a ligature. ■, 
The ordinary, non-malignant, organic stricture is distinguished by the 
absence of the symptoms above, described as characteristic of the cancerous. 
It usually depends upon a thickening of the submucous cellular tissue, conse- 
quent probably upon inflammation. This may occupy a considerable extent 
of the bowel, and its whole circumference, or may be confined to a small part 
of it, and to one side. Sometimes it consists in a sort of crescentic cord, pro- 
jecting from the side of the rectum, sometimes of a partition extending in a 
greater or less degree across it, and again of a transverse-net-work of fila- 
ments. It may be seated in any part of the bowel, but is most commonly 
found about two or three inches above the anus. Instances have occurred in 
which the feces, accumulated above the stricture, have by their pressure pro- 
duced ulceration, and thus made their way outward by a new passage. Such 
a passage has been made around the stricture into the portion of bowel beneath 
it, into the bladder, and into the vagina; the feces escaping in the first case 
per anum, in the second with the urine, and in the third from the vulva. In 
such instances, the relief obtained is usually but temporary; the patient being 
at length worn out by the continued irritation and discharge. 
Anything may operate as a cause of this stricture, which is capable of 
producing chronic inflammation in the coats of the bowel. It is occasionally, 
perhaps, ascribable to venereal infection. Polypus of the rectum may pro- 
duce the symptoms of stricture; but the affection is so purely surgical that I 
shall not treat of it here. 
Stricture is in general amenable to treatment. The passages should be 
kept soft and un irritating by a proper attention to diet, and by the use of 
laxatives, especially those of a saline character. But the chief means of 
cure consists in the use of the bougie, which should be introduced daily, 
and gradually increased in size as the passage becomes enlarged. In some 
instances, the bistoury may be advantageously resorted to, especially when 
the stricture consists of a thin partition, and the symptoms of obstruction are 
threatening. In cases where there is no alternative between death, and the 
formation of an artificial anus, it is recommended by Amussat to make an 
opening into the colon, on the left side posteriorly, where it is not covered by 
the peritoneum; and the operation has been performed with success.. (Diet, 
de Med., xxvii. 303.) 
2. Spasmodic Stricture of the Rectum.-In this form of stricture there is 
the same difficulty in evacuating the bowels, and the same lessened dimen- 
sions, and altered shape of the fecal cylinder; but these symptoms are not 
constant ; and the feces will occasionally be found of the natural size. One 
of the characteristic signs is a feeling of constriction before or at the time of CLASS III.] 
STRICTURE OF THE RECTUM. 
629 
going to stool, and an occasional severe spasmodic pain, especially upon the 
application of any irritant. The introduction of a bougie will be resisted at 
one time, while at another, the instrument may pass with little or no difficulty. 
The stricture sometimes exists at the anal extremity of the rectum, depending 
on a spasmodic contraction of the internal or external sphincter, or both. It 
is then characterized by great difficulty in introducing the finger or an instru- 
ment through the anus, while, above the internal sphincter, the bowel may 
be quite relaxed. There is the same difficulty in passing the feces as in the 
other cases; and, after' the evacuation, the patient experiences considerable 
pain for some time. From the great straining, the affection is apt to be 
attended with hemorrhoidal tumour?. Spasmodic stricture is more apt to 
attack the-young than the old, and is not commonly attended with that cachec- 
tic aspect, or general failure of health, which frequently marks the perma- 
nent organic affection. 
This form of stricture may result from a peculiar irritability of the rectum; 
from disorder in the spinal marrow, or neighbouring pelvic visceta which may 
radiate irritation to this bowel; or from a morbid excitability of the nervous 
system in general, such as occurs in hysterical or hypochondriacal individuals. 
The exciting cause may be anything capable of directly irritating the rectum, 
as hardened feces, vitiated bile, or acid in the bowels; or, in cases dependent 
upon the state of the general health, anything calculated to produce disorder 
in the nervous functions. ' C ' 
The indications in the treatment are, 1. t,o remove or prevent sources of 
direct irritation to the rectum, 2. to produce relaxation of the spasm, 3. to 
diminish the morbid irritability of the bowel, 4. to remove any existing spinal 
disorder, and 5. to correct the morbid condition of the nervous system when 
this is in fault. To meet the first indication, the feces should be kept in a 
soft state by the use of a mild laxative diet, aided, if necessary, by the most 
unirritating laxative medicines, such as sulphur and the salin6 aperients; 
the biliary secretion, if deranged, should be corrected, and acid in the bowels 
neutralized; and all acrid or drastic cathartics, and especially aloes, should be 
carefully avoided. To produce relaxation of the spasm, recourse may be had 
to enemata of opium, belladonna, camphor, assafetida, and cold water, and to 
the use of the warm bath or semicupium. The bougie, frequently introduced, 
will sometimes be found useful by diminishing the irritability of the rectum; 
but, if this condition be connected with inflammation, leeches to the anus will 
be, a more appropriate remedy. Spinal disorder should be encountered by 
leeches, and rubefacient, vesicatory, or pustulating applications. Finally, the 
morbid state of the nervous system is to be corrected by tonics, exercise, a 
regulated diet, proper mental occupation, and the occasional use of the nerv- 
ous stimulants, as valerian and assafetida. In females, attention should be 
paid to the condition of the uterus, as disorder of this organ may operate 
injuriously upon the affection, not only by deranging the condition of the 
nervous system generally, but by transmitting a sympathetic irritation directly 
to the rectum; and the same remark is applicable to diseases of the genital 
organs in men, and of the urinary apparatus in both sexes. 630 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
Article VIII 
HEMORRHOIDS, or PILES. 
This term has been applied both to hemorrhages from the rectum, and to 
certain tumours which form in and about the anus. In the former case, 
whether the hemorrhage is or is not accompanied with tumours, the affection 
is called bleeding piles ; in the latter, when unconnected with any discharge, 
blind piles. The tumours are also distinguished into internal piles, which 
are within the sphincter ani, and external piles, which are without the sphinc- 
ter. I shall pay little attention to these distinctions in the following remarks. 
Simple bleeding from the rectum, independent of tumours, though it may 
proceed from the same pathological condition as that which gives rise to the 
tumours, falls properly among the hemorrhages, and will be considered with 
them. I shall here speak of the hemorrhage only ds an attendant or result 
of the tumours. , ' 
Two distinct ingredients often enter into the composition of the hemor- 
rhoidal disease; 1. a peculiar constitutional disturbance which determines 
irritation and congestion of the rectum, and 2. tumours at the extremity of 
the bowel. The two may exist separately-the former occasionally running 
its course without resulting in tumours, the latter often originating in purely 
local causes; but they are very generally more or less associated. I distin- 
guish the one by the name of the hemorrhoidal effort, the latter by that of 
hemorrhoidal tumours, or simply hemorrhoids. 
The hemorrhoidal effort is frequently marked by certain symptoms of con- 
stitutional disorder, preceding or attending those of irritation or congestion of 
the rectum. Of the former are general uneasiness, mental dejection or irrita- 
bility, languor, uncomfortable sensations in the head, pain in the loins, dys- 
peptic feelings, constipation, and colicky pains; of the latter, a feeling of 
weight or tension in the region of the sacrum, heat about the anus, sometimes 
pains in these parts extending to the neighbouring pelvic viscera and to the 
lower extremities, a sensation of fulness in the lower portion of the rectum, 
and a disposition to go to stool, with little or no evacuation. This condition 
continues for three or four days, and then subsides spontaneously, or under 
treatment, to return under various excitements, and sometimes periodically, 
without any known cause, at intervals of weeks, months, or years. It is some- 
times relieved by hemorrhage, sometimes passes off without either this, or the 
production of hemorrhoidal swellings, but most frequently either accompanies 
or produces tumours, and, if these have existed previously, provokes them 
into irritation or inflammation. 
Hemorrhoidal tumours are not entirely identical in character. The follow- 
ing varieties may be distinguished. 1. The simplest form is that of varicose 
hemorrhoidal veins, consisting in a mere distension of the coats of the vessel, 
as in varicose veins of the leg. The same vessels are affected in the external 
and the internal piles, the veins above and below the sphincter being continu- 
ous, and not suffering dilatation in general at the sphincter, because com- 
pressed by that muscle. In their simplest state, these tumours are full of 
liquid blood, and may be readily evacuated by pressure, to be filled again 
immediately upon the removal of the uressure. After death they frequently 
disappear entirely, but may be rendered ^evident by injecting the inferior 
mesenteric vein. 2. The varicose tumours, in consequence of inflammation, CLASS III.] 
HEMORRHOIDS. 
631 
or from rupture and resulting effusion of blood, undergo various changes. 
By inflammation their coats are thickened, coagulable lymph is effused into 
the neighbouring tissue, with which adhesions are contracted, the communi- 
cation between the varix and the venous trunk is closed, and the blood within 
coagulates. By rupture, the blood escapes, and, being diffused in the cellular 
tissue, or forming a distinct cavity for itself either in the substance of the 
tissue, or between it and the mucous membrane, coagulates, and excites in- 
flammation and consequent effusion of lymph in the contiguous parts. In 
either of these'cases, a solid, vascular, hard, or more or less spongy tumour 
results, which, upon being opened, often discloses a clot of blood in its centre, 
thus showing its mode of production. 3. Instead of being varicose, the 
tumours sometimes consist of a sort of erectile tissue, which may be supposed 
to be. formed by the opening of communications between contiguous venous 
and perhaps arterial radicals, and between both and the cellular tissue, which 
assumes a denser and firmer character, exhibiting numerous interlacing fibres. 
4. Fleshy tumours may originate from the altered varices described above, by 
the organization of the coagulated blood in their centre, or its absorption and 
the deposition of organizable lymph. Or they may be produced, as Burne 
suggests, by a circumscribed thickening of the submucous cellular tissue, 
which, thus projecting somewhat into the cavity of the rectum, is carried 
down during defecation, and, being arrested by the contraction of the sphinc- 
ter, becomes inflamed and enlarged, so as not to admit of return. 5. Tumours 
formed in any of the above modes may, by the influence of adhesive inflam- 
mation and subsequent absorption, be converted into dry, hard, indolent, wart- 
like projections in or near the anus; and, even though originating under the 
mucous membrane, may be covered with skin, in consequence of a not unfre- 
quent transformation of that membrane, when prolapsed and exposed long to 
the air. Another sequela of the proper hemorrhoids consists in folds of the 
mucous membrane or skin in or near the anus, resulting from the absorption of 
the contents of previous tumours. 
Symptoms and Course of Hemorrhoids.-The patient experiences a feeling 
of heat, fulness, and dull pain about the sacrum and anus, radiating more or less 
to surrounding parts. This continues for a few days, disappears, and again 
returns; and the event may occur several times without attracting much atten- 
tion. At length the patient becomes conscious of a swelling, or a sensation 
as if a foreign body were in the anus or above it, and, applying his finger after 
an evacuation, discovers a small tumour of the size of a pea or larger, which 
either remains perceptible or retires, according as it originated without or 
within the sphincter. In other instances, the tumour appears to be formed 
suddenly in consequence of severe straining at stool. It is covered by the 
mucous, membrane of the rectum, or, if external, partly by this and partly by 
the neighbouring skin, which is generally movable over it. The little tumour 
gradually increases; others form around it, occasionally clustering like a bunch 
of grapes; and a mass at length results, often as large as a pigeon's egg, and 
sometimes much larger. The progress, however, of the tumour is not uni- 
form. During the periods of hemorrhoidal congestion, it increases most 
rapidly, acquiring an augmented volume at each successive period, though 
diminishing and sometimes almost disappearing in the intervals. In its ordi- 
nary uninflamed state, the tumour has little sensibility, but, when inflamed 
or strangulated by the sphincter, it becomes the seat of burning, stinging, and 
otherwise very painful sensations, is often exquisitely tender to the touch, and 
renders defecation difficult, and sometimes exceedingly painful. Shooting 
pains extend from it to the back, down the thighs, and to the viscera of the 
pelvis; irritation is sometimes radiated to the prostate gland, bladder, and 632 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
uterus; and difficult micturition is not unfrequently produced. Sometimes 
the patient can neither stand, walk, nor sit with comfort, and finds the hori- 
zontal position the only one tolerable. 
The phenomena of piles are somewhat different, according as they are 
external or internal. In the external piles, a tumour is observed on the verge 
of the anus, of greater dr less extent, sometimes on one side only of the aper- 
ture, sometimes completely surrounding, it, and in the latter case usually 
presenting an unequal outline, as if consisting of several tumours separated 
by shallow furrows. The consistence and coldur of the tumour vary according 
to its charapter. If varicose, it is of a violet colour, soft, arid more or less 
removable by pressure; if fleshy, it is of a red colour, solid, firm, and elastic. 
It has usually a broad base; and the fleshy tumour is often elongated from 
before backward, in consequence of being pressed on each side by the ,buttocks. 
When inflamed, these piles are peculiarly inconvenient by interfering with 
exercise in almost every way, and even with sitting. The internal piles are 
attended with a sense of distension which provokes a constant disposition to 
go to stool, and are peculiarly painful during the act of defecation. At first, 
though they are .apt to descend at each evacuation, they usually return spon- 
taneously when the straining ceases; but, after haying acquired a certain 
magnitude, they can be restored to their position within the sphincter, after 
protrusion, only by the aid of the finger of the patient. When without the 
sphincter, they are rendered very painful by its' contraction, but become com- 
paratively easy/when returned. After a time they descend when the patient 
walks or stands, especially if the rectum is full, and great inconvenience is 
experienced from the irritation and excoriation to which they are subjected. 
When thus extruded, they<are sometimes strangulated by the sphincter, and 
become in consequence so much inflamed and swollen, that the patient cannot 
himself restore them, and even the surgeon finds considerable difficulty. Oc- 
casionally, in this condition, they burst, and by the discharge of blood are so 
much diminished in size, and relieved, as to admit of easy reduction. In 
other cases, they swell enormously, become gangrenous,' and, after having 
occasioned vast suffering and inconvenience to the patient, slough off, and 
terminate finally in a radical pure. There are the same differences in colour 
and consistence in the internal as in the external piles. The fleshy tumours 
are sometimes narrow at the base, and bear no inconsiderable resemblance to 
polypi of the rectum. 
Both the internal and external piles occasionally suppurate, forming ab- 
scesses or ulcers, which are often very troublesome, ending sometimes in the 
establishment of fistulae, though in other eases they eventuate more favourably, 
and even lead to a permanent cure. 
More or less hemorrhage often attends defecation, the blood proceeding 
either from the abraded mucous coat, or from a rupture of the tumour, or 
from an oozing over its whole surface in an inflamed state. In general the 
bleeding is very slight, not more than sufficient to tinge the feces. But it is 
sometimes copious, and, in a few comparatively rare cases, very much so, 
producing by its frequent returns, and the quantity discharged at each time, 
an alarming arid dangerous anemic condition of the patient. Some individuals 
are liable to periodical attacks of this hemorrhage, corresponding probably 
with the periodical returns of the hemorrhoidal congestion; and it is not 
always easy to decide, whether the bleeding is or is not connected with the 
tumours. The blood sometimes collects in large quantities in the rectum 
before being discharged. It is in some instances venous, in others arterial; 
being of the former character probably when proceeding from a ruptured 
tumour, and of the latter when from other sources. CLASS III.] 
HEMORRHOIDS. 
633 
During the discharge of the feces, fissures are sometimes produced in the 
mucous coat around the anus, which afterwards bleed at each evacuation, and 
become occasionally so tender as to render the act of defecation almost insup- 
portable. / 
In consequence of a chronic inflammation of the hemorrhoidal tumours, 
and the neighbouring mucous membrane, a discharge of whitish mucus some- 
times occurs, which was formerly distinguished by the name of white piles, or 
anal leucorrhoea. 
Among the local consequences of piles is also sometimes a thickening of 
the inferior part of the rectum, resulting from repeated inflammation, which 
forms a sort of stricture, and very much interferes with the discharge of the 
feces. 
The general health often suffers very severely, from long continued and 
aggravated piles. Preventing exercise, and rendering necessary an almost 
constant use of medicines which interfere more or less with digestion, they 
lead to. the production of dyspepsia with all its train of evils, and, besides, 
call numerous. organs into a direct sympathy, which cannot but impair their 
functions. Paleness, emaciation, and rhental irritability or dejection, or at 
least .a very uncertain condition of the feelings, are among their frequent 
concomitants. ' • 
Diagnosis.-The complaints with which piles are most likely to be con- 
founded,1 are polypus of the rectum, and prolapsus ani. It is, however, only 
the solid and firm hemorrhoidal tumours that resemble polypus. They may 
be distinguished by the firmer consistence of polypus, and by its gradual and 
steady developement, without the periodical congestions, and alternate increase 
and diminution which characterize piles. The latter, moreover, generally 
have a broad base, while the polypus is joined to the mucous membrane by a 
sort of peduncle; but this is not a certain criterion; as the two conditions 
are sometimes reversed. Piles are usually distinguishable from prolapsus by 
their colour, their distension and compressibility, and their greater or less 
irregularity, even when forming a ring about the anus. Syphilitic tumours 
may sometimes be confounded with fleshy piles; but they differ in the cir- 
cumstances of their origin, and in their uninterrupted progress. 
Causes.-1These are such as either produce congestion in the rectum, or 
act with an immediate mechanical violence upon its lower extremity. The 
former may be constitutional or local. Among- the constitutional, the most 
common is probably a plethoric state of the blood-vessels, induced by a rich, 
nutritious, and stimulating diet, or simple excess in eating, conjoined with 
sedentary habits. Gouty and rheumatic irritation sometimes finds expression 
in a congested state of the hemorrhoidal vessels. The suppression of habitual 
discharges, such as that of the menses, sometimes leads to the same result. 
Hereditary predisposition has also been considered as one of the remote causes 
of piles, and there can be little doubt that a peculiarity of constitution favour- 
able to this disease occasionally descends from the parent to the offspring. 
Of the local causes, those are most efficient which by any means tend to check 
the return of blood from the hemorrhoidal veins. Torpidity and congestion 
of the liver often occasion piles, by impeding the return of the blood of the 
portal circulation through the capillaries of that organ; and hepatic induration 
or enlargement may have the same effect, either in the same way, or by 
narrowing the ascending vena cava. Pregnancy, and a long continuance in the 
erect position, the former by mechanical pressure upon the returning veins, the 
latter by the effect of gravitation, often cause a distension of the hemorrhoidal 
vessels that results in piles. To the above list may be added all causes of irrita- 
tion of the rectum, whether direct or indirect, such as acrid purgatives and espe- 634 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
cially aloes, irritating injections, the frequent use of suppositories, acrid alvine 
evacuations, ascarides, violent jolting on horseback, dysentery, inflammation of 
the prostate or of any of the pelvic viscera, and venereal excesses. The causes 
which act by mechanical violence are long and severe straining at stool, and the 
difficult passage of hard fecal matter through the anus. But piles probably have 
their origin more frequently in constipation of the bowels than in any other 
source. This operates in various ways in producing them, but chiefly by the 
pressure of the accumulated and hardened feces upon the returning veins, and 
by the straining, violent compression, irritation, and even laceration they occa- 
sion during their evacuation. 
Piles' are very rare in children before the .age of puberty, and are most 
common between the thirtieth and fiftieth year. Males are more subject to 
them than females, if we leave out of consideration ^pregnant women, in whom 
they are very frequent. 
Treatment.-In relation to the treatment of piles, it is proper first to con- 
sider what effect their cure may have upon the general health, and how far 
we may venture upon their removal with safety. They have been considered 
as an outlet through which various morbid tendencies are allowed to expend 
themselves, and the premature closure of which might bring these tend- 
encies into injurious action elsewhere. There can be little doubt that this 
opinion is in some degree true. The hemorrhoidal effort depends on a 
general disordered condition, which, if not directed to the rectum, would 
find some other point upon which to expend its force. This is the case 
whether the piles are, or are not attended with a discharge of blood. But, 
when bleeding -from the hemorrhoidal tumours has been frequent, long 
continued, and considerable, there is the additional consideration, that the 
system has in some measure accommodated itself to these discharges, and, 
in order to supply the loss, has acquired the habit of elaborating blood 
more rapidly, so that the danger of plethora from their arrest would be 
superadded to that of the morbid tendency in which the piles originated. 
The complaints which are most to be feared from the cure of piles are 
apoplexy and pulmonary hemorrhage; and, when a predisposition to these 
affections is known to exist, it should always be allowed to have some 
weight in the decision of the practical question. But as piles themselves, 
when severe, sometimes materially interfere with the general health, it is 
necessary to weigh carefully the opposing considerations, and to strike the 
balance between them. Should .the danger of the very serious complaints, 
above alluded to, seem to outweigh the inconvenience of the hemorrhoidal 
affection, and its direct injurious influence on the ■ health, it will be better 
to confine our efforts, to the alleviation of the symptoms than to attempt a 
radical cure; and, in cases in which the latter course is pursued, the pro- 
priety is obvious of counteracting the morbid tendencies by a proper regu- 
lation of the diet, and the use of suitable depletory or revulsive means, as 
bleeding, saline purgatives, and blisters or issues. In all instances, how- 
ever, where the hemorrhoids are purely a local affection, they cannot be 
treated too promptly; and the number of cases is comparatively few, in 
which, though connected with some constitutional derangement, they may 
not be removed with safety, if care be taken to obviate the possible evil by 
suitable precautionary measures. So far as the treatment is directed to the 
removal of the causes, it may be carried into effect without the least hesi- 
tation. 
In the medical treatment of piles, the first object is to remove the causes. 
Attention should, therefore, be paid to the condition of the system, and any 
existing plethora or general excitement, which may act as a predisposing CLASS III.] 
HEMORRHOIDS. 
635 
cause, should be corrected by saline cathartics, and an antiphlogistic regimen. 
One or two doses of sulphate of magnesia, and a diet exclusively of vegeta- 
ble food, will often be sufficient to relieve that hemorrhoidal effort of system, 
and consequent congestion of the rectum, which lead to a paroxysm of piles; 
In some cases, it may be proper also to take blood from the arm, but this 
necessity very rarely occurs. 
As constipation is the most productive cause of piles, so its removal is the 
most important indication; and-the complaint may often be effectually cured 
by keeping the bowels regularly open, and the feculent discharges in a soft 
unirritating condition. This, is best done by a proper regulation of the diet, 
and by the use of mild laxatives. (See Constipation.^ Among the best of 
these, are confection of senna, and sulphur, which may be given separately or 
together, and may be usefully combined with bitartrate of potassa when the 
tumours are inflamed. The laxative may be given at bed-time so as to ope- 
rate-gently in the morning, or, as suggested by Burne, a short time before 
dinner so as to operate before bed-time, and thus leave the parts irritated by 
the evacuation to become quieted during the night. As a general rule, how- 
ever, I prefer the former course; as the weight and pressure of the feces 
upon the rectum through the day, which is the result of the evening evacua- 
tion, are dften more inconvenient than the mere irritation produced by the 
act of defecation, provided the feces be kept in a perfectly soft, almost semi- 
liquid state by the laxatives employed. It will sometimes be preferable to 
administer a quick saline cathartic, in small doses about an hour before break- 
fast. The laxative mineral waters, and the Cheltenham salt, may thus be 
advantageously given, and will generally operate very mildly a short time after 
breakfast. ' - . ; / 
In connexion with the use of laxatives, attention should be paid to the 
correction of those habits of the patient which tend to- produce and maintain 
the disease. High seasoned food, alcoholic drinks, and strong coffee should 
be avoided; moderate exercise should be taken both on foot and on horseback; 
the patient should not sit habitually on soft cushions, nor sleep too warmly 
in feather beds; the use of acrid purgatives, especially those containing aloes, 
of warm emollient or stimulating enemata, and of the warm hip-bath, should 
be discouraged; and care should be taken to correct torpor or congestion of 
the liver, if this be one of the complications of the case. Acrid secretions 
should be removed by castor oil, and acid in the bowels by magnesia. Irri- 
tations in the bowels or neighbouring pelvic viscera should be corrected as 
far as possible, and those practices carefully shunned which tend to produce 
such irritations. X 
While removing the causes of piles, we may* also advantageously direct 
our remedies immediately to the seat of disease. One of the most efficacious 
means Of cure is the injection daily, after the bowels have been evacuated, 
of half a pint or more of cold water into the rectum; and, by a perseverance 
in this plan for several months, with the use of laxatives if required, cures 
have been effected even in very unpromising cases. Care should be taken 
not to irritate the rectum by an unskilful introduction of the pipe. Spong- 
ing the anus with cold water every morning and evening will also be found 
useful. 
Should the tumours be inflamed, rest in a horizontal posture, with lotions 
of cold water, or lead-water; and, when the pain is very severe, liniments, 
ointments, or cataplasms containing opium, hyoscyamus, belladonna, or stra- 
monium, or decoctions of poppy heads or hops, should be employed. These 
anodyne applications are not only useful by allaying pain, but contribute to a 
cure by obviating the tenesmus and straining, which tend so strongly to sus- 636 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
tain and aggravate the complaint. But caution is necessary, in their applica- 
tion, not to allow them too powerfully to affect the system. When the tumours 
are highly inflamed, and severe pains shoot to the neighbouring parts, leeches, 
or cups to the sacrum are often very useful. The application of the leeches 
directly to the tumour is not advisable; as the inflammation from the bite is 
often more injurious than the depletion is beneficial. In the proper varicose 
tumours, punctures with the lancet so as to evacuate the blood they contain, 
have been recommended; but the use of needles is preferable, as they answer 
the purpose of relieving the distended varices, without the risk of inflamma- 
tion. When the inflammation is not acute, benefit may sometimes be ob- 
tained from astringent applications. Ointment of galls with opium may be 
used when the tumours are external; decoction of galls or oak bark, 'or infu- 
sion of catechu or kino, when they are internal. If the internal piles have 
protruded, and do not return of themselves, and carinot be returned by the 
patient, the practitioner must endeavour to reduce them'by placing the patient 
on his hands and knees, anointing the parts well with unctuous matter, then 
making gentle and uniform pressure so as to force out the blood, and lastly, 
introducing by his hands the diminished tumotir within the. sphincter. Should 
he not succeed by these means, he may apply cold water to the part in order 
to produce contraction, oi* let out the blood by means of needles or a lancet, 
and then restore the piles. In cases where strangulation and gangrene have 
taken place, poultices with laudanum should be applied locally, and the patient 
kept under the influence of opiates, with wine,- quinia, and a nutritious diet, 
if necessary to support his strength. 
When the hemorrhage is so copious as to require treatment, if it be acute, 
the patient should lie on his back, cold water should be injected into the rec- 
tum, and applied externally, and nitre with antimonials, or the acetate of lead 
given by the mouth. If these measures fail, a solution of alum or a strong 
vegetable astringent infusion, or the two combined, may be used in the form 
of enema. In more. chronic cases, the same astringents- may be employed, 
and recourse may at the same time be had to the internal use of oil of tur- 
pentine, in the dose of from fifteen to thirty drops three or four times a day, 
or of copaiba in the same dose, or of ergot to the amount of two scruples or a 
drachm daily in divided doses. The oil of turpentine has been especially 
praised in obstinate cases of hemorrhoidal flux. Aloes has been highly recom- 
mended, and may prove useful, in some cases of passive hemorrhage, by stimu- 
lating the rectum. 
Copious mucous, or muco-purulent discharges may be treated, if acute, sim- 
ply as inflammation, if chronic, by injections of acetate of lead, sulphate of 
zinc, or astringent infusions or decoctions. 
Numerous remedies, besides those already mentioned, have obtained more 
or less credit in the treatment of habitual piles. The con fection of black pep- 
per of the British Pharmacopoeias, made in imitation of Ward's paste, which 
formerly had a very great reputation as a remedy in piles, is very highly 
recommended by Brodie and others. It is given in the dose of a drachm 
twice or three times a day, and should be continued for two, three, or four 
months. It probably acts by stimulating the mucous membrane of the rec- 
tum, as it passes out with the feces, and should not be given during acute 
inflammation of the parts. Sir Everard Home found it very efficacious, when 
introduced directly into the rectum. Its employment should be accompanied 
with the use of laxatives. Powdered cubebs taken internally, in the dose of 
a scruple or half a drachm three times a day, has proved useful, probably in 
the same way. Copaiba, in the quantity of from twenty to forty drops, once 
or twice a day, was recommended by Dr. Cullen. It probably acts both by CLASS HI.] 
FISSURES OF THE ANUS. 
637 
its laxative and stimulant properties. Another remedy, which appears to 
operate in the same manner, is black pitch. Dr. Wardleworth found it highly 
efficacious in numerous cases, in the quantity of six grains given in two pills 
every night. (Lond. Lancet, Aug. 27,1842.) Even aloes, the abuse of which 
is thought to be a common cause of hemorrhoids, will prove useful, by its irri- 
tant and laxative action, in some cases of piles dependent upon relaxation of 
the hemorrhoidal vessels. A tincture of aloes and anise, given in such quan- 
tities as to produce several soft stools daily, was found highly efficacious- by 
Drs. Pindell and. Crockett, of Lexington, Kentucky. (A Am. Med. and Surg. 
Journ., iii. 193.) Burne recommends an ointment made with a drachm of 
black hellebore and an ounce of lard, applied, morning and evening to the 
parts affected. The pain is much increased at first, but in the course of half 
an hour is greatly diminished or disappears. (Diet. de Med., xv. 211.) Dr. 
Symonds has known great benefit to result from the assiduous use of citrine 
ointment properly diluted. (Tweedie's Syst. of Bract. Med.') Dr. Good states 
that the tumours, when not very sore, will often yield to a layer of gypsum, 
or fuller's earth, rubbed into a soft paste. (Study of Med.) Bougies are highly 
extolled by different authors; and radical cures are asserted to have been fre- 
quently obtained by their means. They- are particularly useful in cases 
attended with rigid contraction of the sphincter ani. They should be very 
smooth, and of different sizes, so as to be accommodated to the different cir- 
cumstances of the case. In some instances, where there is a great tendency 
to prolapsus of internal piles, advantage may be obtained from the support of 
a spring pad, connected behind with an elastic belt, or from a compress and 
bandage. 
When other means fail, and the health of the patient suffers, or the incon- 
venience of the tumours is very great, recourse may be had to their extirpa- 
tion either by the knife or ligature, or by both'united. The evacuation of 
the tumours by incision, or by the removal of a portion of their summit by 
the bistoury or a pair of bent scissors, and their destruction by different caus- 
tics or the actual cautery, are modes of cure which have had their advocates. 
But this branch of the subject belongs properly to the surgeon. 
Should the cure of piles be found to have occasioned any serious injury to 
the health,, endeavours should be made to restore the hemorrhoidal disease by 
aloetic purgatives, irritating injections, and the use of the warm hip-bath. . 
Article IX. 
FISSURES OF THE ANUS. 
Ulcers in and near the. anus occur from various causes, as from the abrasion 
or tearing of the parts during difficult defecation in hemorrhoids, stricture, 
obstinate constipation, &c., from violence proceeding from some external cause, 
from venereal infection, and from inflammation; and these ulcers are some- 
times very inconvenient from their discharge, and the pain they occasion at 
the time of going to stool; but they generally yield without much difficulty 
to suitable remedies, and are a subject rather for surgical than medical treat- 
ment. But there is a particular form of ulceration, to which the name of 
fissure of the anus has been applied, which requires a brief notice. 
The ulcer, in these cases, is situated between the folds of the skin or 
mucous membrane at the anus, and probably owes its exceeding severity and 
obstinacy to the circumstance that it is embraced by the sphincter muscles, 638 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
and is therefore liable to constant injury from their movements. It runs in 
the direction of the rectum, is narrow and elongated, being a line or two in 
breadth and from foui* to ten lines in length, and is generally of a lively red 
colour, without much swelling and induration, not unlike the crevices which 
sometimes occur in the lower lip of those much exposed to the cold in winter. 
It may occupy any part of the circumference of the anus, and is somewhat 
differently placed in relation to its length, being sometimes so low as scarcely 
to reach the mucous membrane at its upper extremity, and sometimes so high 
as not to reach the skin at its lower. A slight oozing of liquid takes place 
from its surface, and the feces, when discharged, are occasionally streaked 
with blood; but neither of these phenomena is constant. 
■ At the commencement, the symptoms are not usually very severe. A 
sense of itching, tingling, heat, and sometimes pain, is experienced during 
and after a stool, which gradually increases, and at length becomes very dis- 
tressing; but months or even years may pass before the complaint reaches its 
greatest height. In some instances, however, the painful symptoms occur at 
the beginning. When the disease is completely formed, there is felt, when- 
ever the patient goes to stool, a violent burning or rending pain, which some- 
times amounts to insupportable agony, giving rise even to syncope or convul- 
sions. This continues for some time after defecation; but at length subsides, 
leaving only soreness, or occasional lancinating pains, which are quite tolerable. 
So great is the suffering of the patient during the passage of the feces, that 
he dreads the recurrence of the act, and is apt to postpone it as long as possi- 
ble, though he thereby increases the difficulty when the time for an evacuation 
arrives. Most pain is experienced when the feces are hard, but it is by no 
means entirely avoided by keeping them in the liquid state. In some cases, 
the suffering at length continues in the intervals of defecation, so that the 
patient is compelled to keep his bed; severe pains shooting from the anus to 
other parts of the pelvis, and the tenderness of the parts being so great that 
the least effort which causes pressure on the bowels, as the act of coughing or 
even spitting, produces great uneasiness. The introduction of the finger or 
an instrument into the anus occasions exquisite pain; and there is almost 
always great difficulty in introducing the finger, in consequence of a spasmo- 
dic contraction of the sphincters, which is considered by some an essential part 
of the complaint, and no doubt contributes to its great obstinacy. 
Fissure of the anus is apt to be mistaken by the patient and his attendant 
for piles, prolapsus, stricture, disease of the bladder or; prostate, pr for cancer; 
but a careful examination of the parts will reveal its nature. The ulcer 
generally becomes visible between the folds of skin at the anus by separating 
them; -but if not, the patient should be induced to protrude the anus as in 
the act of defecation, so as to bring it within view. If too high up to be 
seen, the finger?introduced into the anus will detect it by the exquisite pain 
produced by pressure upon a particular part, and by a different sensation 
communicated to the finger by that part, though any considerable induration 
or thickening is seldom if ever present. 
The disease has no tendency to spontaneous cure, and in general goes on 
indefinitely unless arrested by proper treatment. It has been asserted, how- 
ever, that, when abovp or below the sphincters, the ulcers heal readily upon 
suitable applications, like other sores; and that peculiar obstinacy is expe- 
rienced only when they are embraced by those muscles. This statement, 
though not perhaps sufficiently supported by facts, is highly probable; and 
the mode of cure found most effectual tends to confirm the view, that the 
contraction of the sphincters constitutes the chief source of difficulty. Unless 
arrested, the disease at length affects the general health, dyspepsia and ema- CLASS III.] 
FISSURES OF THE ANUS. 
639 
ciation occur, and the patient is worn out by complicated derangements of his 
system. 
Causes.-The idea has been entertained that this affection is of a peculiar 
character, and owes its origin to some peculiar and unknown cause. The 
probability, however, is that it may arise from any cause capable of irritating 
or mechanically injuring the part affected; and that it is peculiar only from 
its situation within the limits of the sphincter muscles, which render the 
ulcers irritable and indisposed to heal, in consequence of incessant disturb- 
ance. - ■ , I , - 
Treatment.-The measures ordinarily found useful in ulcerative affections, 
generally produce in fissures of the anus no other advantage than some alle- 
viation of the symptoms. Gentle saline purgatives, with a mild laxative diet, 
prove beneficial partly by keeping the feces in a liquid state, and thus 
obviating mechanical injury in their passoge, and partly by obviating any 
irritant effect from over-excitement. Anodyne and emollient enemata also 
sometimes afford relief. Boyer employed a mixture consisting of equal 
parts of lard, juice of houseleek, juice of black nightshade, and almond oil, 
injected in the quantity of a few tablespoonfuls two or three times a day into 
the rectum. (Diet. de Med.} But this can act only as a soothing application. 
Dupuytren found great advantage from the extracts of belladonna and stra- 
monium. ' He employed an ointment made by rubbing together a drachm of 
extract of belladonna, a drachm of acetate of lead, and six drachms of lard, 
a portion being applied several times a day, spread upon a tent, which was 
small at first, and gradually increased to the size of the index finger. (Am. 
Cyc. of Pract. Med. and Surg., ii. 121.) M. Bretonneau, of Tours, has used 
with great success injections of extract and tincture of rhatany. His plan is 
to administer every day an injection of cold water, and, after this has come 
away, another composed of a drachm and a half of extract of rhatany, half 
a drachm of the tincture, and five fluidounces of water. Improvement is 
generally experienced at the end of a week or sooner, and a cure often accom- 
plished in two or three weeks. (Med. Exam., iii. 552.) Dr. W. P. Johnstofi, 
of Philadelphia, has employed the same remedy with success. (Ibid., iv. 293.) 
It is probable that kino, catechu,, or other astringent extracts, would answer 
the same purpose. M. Deday recommends tannic acid, mixed with fifteen 
parts of lard, to be applied by the finger to the part, or, when the fissures are 
situated high up, a solution of the same substance to be injected. (Ann. de 
Therap., A. D. 1847, p. 170.) Beclard applied nitrate of silver to the ulcers 
with almost uniform success; but others who have tried the remedy have 
been less fortunate. (Diet, de Med., iii. 300.) Dilatation by means of 
tents is strongly recommended by Velpeau. Foi' this purpose, plugs of lint 
may be used, covered with some mild ointment, and gradually increased in 
size till the resistance of the sphincter is overcome. Advantage would pro- 
bably accrue from combining dilatation with the application of lunar caustic 
to the ulcers. Boyer, by whom the disease was first clearly described and 
designated, was in the habit of treating it by dividing the sphincters. This 
practice was eminently successful, but has sometimes failed, and two instances 
are on record in which it proved fatal. (Diet, de Med., iii. 303.) The opera- 
tion, therefore, should be resorted to only after other measures have failed. 640 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
Article X. 
PROLAPSUS ANI. 
Prolapsus ani is a descent of a portion of the rectum or its lining, membrane 
below the sphincters, forming a tumour at the anus. In some instances, the 
upper portion of the rectum descends through the lower, exactly as in intus- 
susceptio, and protrudes externally. The same thing has happened to the 
colon, and even the caecum has been known to be thus everted, and to be 
forced through the anus. The extent of this kind of prolapsus is sometimes 
very great; and a case is on record in which the length of the protruded por- 
tion of bowel was. two feet. But such incidents as those above mentioned 
are rare. The affection commonly called prolapsus ani consists of a protru- 
sion of the lower portion of the mucous membrane only of the rectum, the 
outer coats being too firmly connected with the neighbouring parts to admit 
of eversion, under any ordinary circumstances. 
Symptoms.-Occasionally a. considerable protrusion takes place at once, 
under some peculiarly strong force applied to the part; but in general there 
is only a small tumour, in the form of a regular ring about the anus, appear- 
ing when the patient strains at stool, and either retroceding spontaneously, or 
disappearing under slight pressure when the straining ceases. If the affection 
be not arrested in this stage, the prolapsus recurs at each stool, and gradually 
increases, forming at last a considerable tumour, an inch or more in length, 
which is sometimes difficult of reduction, and always very .inconvenient to the 
patient. Sometimes the protruded membrane takes on inflammation, either 
from the constriction of the sphincters or from other cause, and becomes so 
swollen and painful as to render reduction impossible, until after the inflam- 
mation has been subdued. Instances have occurred in which the protruded 
part has been strangulated by spasmodic stricture of the sphincters, and 
symptoms resembling those of hernia, with mortification of the membrane, 
have occurred. This result, however, is more to be apprehended in cases 
of eversion of the whole thickness of the bowel, than where the mucous mem- 
brane only protrudes. The prolapsus sometimes continues long unreduced 
without serious results; as the parts affected have a wonderful facility of 
accommodating themselves to their new position, and the mucous membrane 
takes on the characters of the skin. 
K Causes.-Whatever irritates the rectum, and occasions severe straining at 
stool, may give rise to prolapsus ani. Hence, the affection is common in 
dysentery. Aloetic medicines, frequent irritating enemata, ascarides, costive- 
ness, piles, other tumours or thickening of the rectum, and complaints of the 
prostate, bladder, and urethra act in the same manner. Strong contraction 
of the abdominal muscles without tenesmus, as in the crying of infants, and 
in protracted parturition, may also produce prolapsus. But these causes are 
all much more efficient, when a relaxation or atonic condition of the sphinc- 
ters co-exists. When these muscles are very much relaxed, the prolapsus 
sometimes takes place under the ordinary degree of force to which the rectum 
is exposed in defecation. It is said to have occurred as the result of sudden 
fright, producing relaxation of the sphincters. ' In most cases, however, the 
straining and relaxation of the sphincters co-operate. 
The affection is very common in children, and more so in old age ,than in 
middle life. CLASS III.] 
PROLAPSUS ANT. 
641 
Treatment.-Tlie objects in the treatment are first to return the. prolapsed 
bowel, if it remain without the anus, and then to adopt such measures as may 
prevent subsequent protrusion. The former object is in general very easily 
accomplished; nothing more being necessary than to press regularly and 
gently with the oiled palm of the hand upon the tumour, or to push up the 
membrane with the oiled index finger inserted into the anus. If constriction 
of the sphincter oppose the reduction, it should be relaxed by means of the 
warm hip-bath, of warm poultices or injections containing laudanum, and of 
bleeding if necessary. Sometimes the sudden application of cold produces the 
same effect. If the protruded parts be inflamed and swollen, they should be 
treated with depletion, an antiphlogistic diet, cold applications, and a proper 
posture. ? 
In the prevention of prolapsus three indications are presented; one, to 
obviate irritation of the rectum, the second, to obviate relaxation of the 
sphincter, and the third to produce contraction of the' membrane liable to 
protrusion, and adhesion between it and the parts with which it is in contact. 
The first indication is met by keeping the bowels regularly open, and the feces 
soft, by means of a mild laxative diet and laxative medicines, by avoiding all 
causes of direct irritation to the rectum, and removing those which can be 
Ascertained to exist, and by the use of anodyne enemata. Dr. Physick was 
in the habit of prescribing for children with this affection a diet of rye-mush 
and molasses, and the performance of the act of defecation in the erect posi- 
tion, so as to prevent much straining. To answer the second indication, that 
is, to obviate relaxation of the sphincter muscles, when it exists, cold water 
should be applied either by a sponge, or by directing a continued stream 
against the anus; astringent injections should be thrown into the rectum, or 
astringent ointments introduced by means of a pledget of lint within the 
sphincters; and, when the case is wholly unattended with irritation of the 
rectum, substances calculated to stimulate the sphincters may be given by the 
mouth, as copaiba, cubebs, or oil of turpentine. To consolidate and fix the 
membrane, which is the third indication, infusions or decoctions of the vege- 
table astringents, as kino, catechu, rhatany, galls, and oak bark, or solutions 
of the mineral astringents, especially alum, should be injected, with a little 
laudanum, after each protrusion. Mr. Vincent recommends strongly the 
injection of a solution of sulphate of iron. (See Am. Joum. of Med. Sci., N. S., 
xv. 546.) In children, almost all cases will yield to this simple treatment, 
with attention to the state of the bowels as above directed. But in old cases, 
in which the fibres connecting the protruded membrane with the other coats 
are much elongated, it becomes necessary to establish new adhesions with the 
neighbouring structure; and this may often be accomplished by slipping off 
longitudinally, with a pair of scissors, small portions of the membrane, or by 
applying caustic cai'efully over small longitudinal strips of its surface. Great 
advantage is also said to have accrued from passing a ligature through the 
membrane, and allowing it to remain so as to excite inflammation and adhe- 
sion; and the plan has even been adopted by some surgeons of amputating 
the dependent flap. These latter methods, however, should be resorted to 
only in extreme cases, after the milder have failed. 
When a permanent cure cannot be obtained, and the intestine is disposed 
to protrude even in the intervals of the evacuations, the patient may be made 
more comfortable by substances in the form of pessaries.introduced into the 
rectum, or, which is perhaps preferable, by constant pressure upon the anus 
made by means of a spring pad, or a suitable bandage and compress. For 
more particular reference to these various points requiring manual interference, 
the reader is referred to treatises upon surgery. 642 
[PART h. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
SUBSECTION V. 
DISEASES OF THE STOMACH AND BOWELS CONJOINTLY. 
There are certain diseases so equally shared by the stomach and bowels, 
that it is impossible to attach them especially to either section of the ali- 
mentary canal. Such are the different forms of cholera. It may be said 
that in dyspepsia the stomach and bowels are both diseased, and that mucous 
inflammation often attacks both parts conjointly, constituting gastro-enteritis. 
This is true; but these affections maybe restricted to one portion of the canal, 
and generally have their primary seat in one portion; the other parts being 
secondarily involved. They may, therefore, be considered as especially be- 
longing to a particular section. But this is not the case with cholera. It 
would not be cholera, unless both stomach and bowels were involved. It was, 
therefore, necessary to form this subsection; and, as it has been formed, it 
was most convenient to consider flatulence in connexion with it; as the patho- 
logical conditions in which this affection originates, are very apt to involve 
both divisions of the canal. I place peritonitis in the same category; as, 
when general, it necessarily involves both the stomach and bowels, and could 
not be with so much propriety associated with any other set of diseases. 
Article I. 
CHOLERA MORBUS. 
The name of cholera is given to any complaint in which the prominent 
characters are simultaneous and repeated vomiting and purging, with painful 
spasm of the stomach and bowels, and occasional cramps of the external mus- 
cles. Three varieties of the disease have been observed, so different in the 
circumstances of their occurrence, as well as in their symptoms, progress, and 
results, as to merit distinct consideration. These are cholera morbus, epidemic 
cholera, and cholera infantum. The present article is devoted especially to 
the first of these affections. It is the variety so common as an endemic dis- 
ease in various parts of the United States during the summer season, and no 
doubt the same as that noticed by the ancient authors, and described by 
Sydenham as occurring epidemically in England, towards the close of summer 
and beginning of autumn. By recent European writers, it is distinguished 
from the epidemic variety by the name of common or sporadic cholera. 
Symptoms.-Cholera morbus is generally characterized by the vomiting and 
purging of bilious matter. It often comes on suddenly, especially when the 
immediate result of some irritant influence on the stomach and bowels; but, 
not unfrequently, it is preceded for some hours or even days by a feeling of 
weight or other uneasiness in the epigastrium, colicky pains, more or less 
headache, and sometimes by furred tongue, chilliness, and a slight febrile 
excitement. The vomiting and purging are usually preceded by a good deal 
of nausea, and attended by spasmodic pain in the stomach, which is some- 
times excruciating? but is relieved after each discharge. In the intervals 
between the paroxysms of vomiting, the patient, though comparatively easy, 
often experiences distressing nausea, or a burning sensation in the epigas- 
trium, and complains of general languor and exhaustion. The discharges 
generally consist at first merely of the ordinary contents of the stomach and CLASS III.] 
CHOLERA MORBUS. 
643 
lower bowels; the matter vomited being either food recently taken, or colour- 
less and often sour oi' acrid liquid, and the dejections fecal. But these are, 
in the vast majority of cases, soon followed by bilious matter of a green or 
yellow colour, and very often extremely bitter, and more or less acrid. The 
pulse is usually feeble, the countenance pale and shrunk, the skin cool and 
damp, the urine scanty or suppressed; and, in severe cases, the patient is not 
unfrequently affected with very painful cramps of the muscles of the abdomen 
and extremities, especially of the legs. These irregular muscular movements 
amount sometimes to general convulsion. In favourable cases, the more vio- 
lent -symptoms subside after a few hours, or readily give way to treatment, 
leaving only temporary debility. But occasionally the complaint, either from 
original violence or neglect, assumes an alarming character. The vomiting 
and purging are almost incessant; everything taken into the stomach is 
promptly rejected, the discharges being often brown or blackish, acid, or even 
bloody; the sufferings from nausea, anxiety, heartburn, and spasmodic pains, 
both internal and external, are intense; the patient complains of extreme 
thirst, and is clamorous for cold drinks; the pulse is small, frequent, irregu- 
lar, and extremely feeble, the respiration short and frequent, the extremities 
cold, the eyes sunken and surrounded with a dark areola, the skin bathed in 
cold sweat; hiccough and abdominal distension come on, with a cessation of 
the vomiting; and the patient, if not rescued by remedial measures, sinks in 
a state of complete exhaustion, retaining his mental faculties not unfrequently 
unimpaired to the last. Death may occur within twenty-four hours, though 
more frequently the complaint runs on for two or three days, before termi- 
nating fatally. 
In some instances, moderate febrile symptoms attend the disorder, as if an 
attempt had been made to establish bilious fever, which had been prevented 
from entire success by the occurrence of the cholera; and, in ordinary cases, 
a sudden suppression of the discharges by opium sometimes gives rise to a 
similar state of system. Instead of being bilious, the evacuations are, in some 
very rare instances, colourless or whitish, somewhat as in epidemic cholera. 
In such cases, the attendant symptoms are of an aggravated character, though 
by no means necessarily fatal. 
Cholera morbus generally subsides under- remedies without unpleasant con- 
sequences, leaving only a moderate debility, from which the patient speedily 
rises by the aid of a suitable regimen. > Sometimes, however, the debility is 
considerable and protracted, and requires medical interference. Occasionally, 
too, the patient is left with a troublesome diarrhoea, or with other evidences 
of a continued irritation of the stomach and bowels. In intemperate persons, 
the checking of the cholera is very apt to induce delirium tremens. 
In persons of good constitution-, the disease is very rarely fatal. It is most 
apt to prove so in the very old, the feeble, and the intemperate. 
Causes.-Hot weather, long continued, strongly predisposes the system to 
cholera morbus, and may of itself occasion the disease, without any other 
cause. The same may probably be said of marsh miasmata; for cholera mor- 
bus very often precedes the breaking out of miasmatic fevers, as if resulting 
from the operation of the same cause' in a less degree. Most commonly, 
however, the immediate attack is brought on by some exciting cause, capable, 
either directly or through the nervous centres, of irritating the stomach and 
bowels. Among such causes may be mentioned, exposure to cold when the 
body is heated and perspiring; the use of certain indigestible and irritating 
articles of food or drink, as cabbage, cucumbers* melons, various unripe fruits, 
fat pork, lobsters, crabs, sour and incompletely fermented liquors, putrid water, 
&c.; excesses at the table, independently of the character of the food; the use 644 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
of ice, or very cold drinks in excess; strong mental emotions, as fear or anger; 
and various movements which produce sickness of stomach through their action 
on the brain, as riding backward, turning rapidly in a circle, and sailing upon 
a rough sea. The disease prevails especially in hot countries, and during the 
hot season in temperate latitudes. Sometimes it is so prevalent as to put on 
the appearance of an epidemic, though probably dependent on the heat of the 
weather, or the local miasmata, in the same manner as our endemic remittent 
fever. In this country, it is most common in the months of July and August. 
It chiefly attacks adults. 
Nature.-This must be inferred from the symptoms and causes; as dissec- 
tion reveals nothing which can lead to any accurate conclusion. Sometimes 
redness or other evidence of inflammation is discovered in the stomach, or 
some portion of the bowels; but often no such phenomena are presented, and 
neither the alimentary mucous membrane, nor any other structure exhibits 
appearances which could explain the symptoms. The probability is, that the 
disease consists essentially in congestion of the portal system, produced by 
the continued action of a high temperature, by miasmata, or both, and in- 
ducing an irritation both in the liver and lining membrane of the stomach 
and bowels, which exhibits itself in an increased and altered secretion. Should 
the congestion from these causes be alone inadequate to the result, a super- 
added irritation, from the various exciting causes above enumerated, may be 
required for the production of the phenomena of the disease. The painful 
gastric and intestinal symptoms may result either from the general state of 
sanguineous congestion in the whole canal, or from the irritating quality of 
the morbid bile and intestinal secretions, or from both. That the liquids 
referred to are the source of much of the pain and spasm, is evident from the 
temporary relief which follows their discharge. The prostration is owing 
partly to the profuse evacuations, partly'to the depressing influence of the 
nausea. The extreme thirst, instead of being an evidence of inflammation of 
the stomach, is the mere expression, in the throat and neighbouring parts, of 
the wants of the blood-vessels, deprived of a large portion of their more fluid 
contents. The spasms of the extremities are probably one of the consequences 
of the gastric and intestinal irritations, acting through the nervous centres. 
Diagnosis.-Vomiting and purging, with more or less bile in the evacua- 
tions, are not unfrequent attendants upon other diseases, as bilious fever, 
gastro-enteritis, and inflammation of the liver. From the first of these, how- 
ever, cholera morbus may be distinguished by the absence of a hot skin, a 
strong pulse, and headache, and by its much shorter course; from the two 
latter by the same absence of decided febrile symptoms, and the less degree 
of tenderness. There may be greater difficulty in distinguishing it from the 
effects of certain mineral poisons. I have seen the operation of calomel in 
some instances so exactly like cholera morbus, that the most experienced eye 
could scarcely have detected the difference. But, in poisoning by corrosive 
substances, the vomiting generally precedes the purging by a considerable 
interval, the discharges are seldom so highly bilious, and the poison may often 
be detected in the evacuations. The circumstances attending the origin of 
the complaint, and the season of the year, may also be taken into consideration 
in forming the diagnosis. Bilious diarrhoea is sometimes attended with 
moderate vomiting; but this affection may be considered as only an inferior 
grade of cholera. The vomiting and purging produced by indigestible food, 
in a system not predisposed to cholera morbus, are scarcely entitled to rank 
with that disease. 
Treatment.-The following mode of treatment will very generally be found 
promptly effectual, in ordinary cases of cholera morbus. It is founded on the CLASS III.] 
CHOLERA MORBUS. 
645 
indications, 1. of removing the irritating causes by clearing out the stomach, 
2. of checking the irritation directly by the moderate action of opium, and 
indirectly by powerful revulsion to the surface, and 3. of changing the morbid 
action of the liver by the alterative influence of calomel. Mild diluent drinks 
are to be administered freely; a sinapism of pure mustard mixed with water, 
to be applied over the epigastrium; and a pill containing the sixth of a grain 
of calomel and from the sixth to the twelfth of a grain of opium, to be admin- 
istered every half hour, or every hour, according to the urgency of the symp- 
toms. The drinks should consist of chicken tea made by boiling, for a very 
short time, a portion of chicken deprived of skin, in a large quantity of water, 
so as merely to impart a slight taste to the liquid; of mucilaginous or farina- 
ceous fluids, such as gum-arabic water, mucilage of sassafras pith or flaxseed, 
toast-water, barley-water, &c.; of mild herbaceous infusions, as balm or mint 
tea; or finally of lukewarm water. They should be given freely at first, so 
as to facilitate the evacuation of the acrid bile, and then suspended, or admin- 
istered moderately merely to relieve the thirst of the patient. For this pur- 
pose, also, as well as to quiet irritation of stomach, carbonic acid water, in 
small draughts of about two fluidounces, frequemly repeated, answers admirably 
well. The mustard cataplasm should be left on for half or three quarters of 
an hour, or until it reddens the skin intensely, and becomes no longer tolera- 
ble. In severe cases, or if the physician is called in the advanced stages, 
when the prostration is great, it is often necessary to administer opium more 
freely than above directed. Fr.om half a grain to a grain of opium in pill, 
or, what is generally preferable, from twelve to twenty-five drops of laudanum, 
or an equivalent quantity of the solution of sulphate of morphia, may be given, 
and repeated, at longer or shorter intervals, until the violence of the symptoms 
abates. But, as a general rule, the least quantity of opium that will answer 
the purpose is the best; as, though it is absolutely necessary to allay the 
pain, and check the discharge, yet a complete and sudden suspension of the 
secretion is not desirable. There is danger, if the congestion be not allowed 
to relieve itself, that fever or inflammation may ensue. Hence one of the 
advantages of uniting calomel with the opium. Large doses of this medicine 
are not required; as experience has shown that, in the minute doses before 
mentioned, frequently repeated, it acts effectually on the liver, while it is 
much less liable to produce irritation of the stomach and bowels. 
If the disease should resist the above measures, recourse may be had to a 
blister over the epigastrium, and powdered acetate of morphia may be sprinkled 
on the blistered surface deprived of its cuticle. Injections of laudanum, with 
thin starch or mucilage, may also be given. In cases of great prostration, 
rubefacients may be applied externally, and blisters to the insides of the arms 
or legs; and tincture of camphor, aromatic spirit of ammonia, wine-whey, and 
even ether, may be given internally, in conjunction with the opiate. 
Should diarrhoea continue after the vomiting has ceased, it should be 
treated as directed under the head of that disease. Should fever follow a 
suspension of the discharges, the bowels should be kept open by small doses 
of some mild cathartic, as the Seidlitz powder, or a solution of carbonate of 
magnesia in carbonic acid water, commonly called liquid magnesia; and the 
effervescing draught and cooling drinks should be administered at short inter- 
vals. Symptoms of gastric inflammation may be counteracted by leeches to 
the epigastrium, followed by warm fomentations or emollient cataplasms. In- 
testinal irritation may be treated by emollient enemata, and mild laxatives, as 
castor oil with a little laudanum. 
Various other modes of treating cholera morbus have been recommended. 
Some practitioners, considering it essentially gastritis or gastro-enteritis, have 646 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
relied chiefly upon bleeding, leeching, and demulcents. But this is a hazard- 
ous practice. Ipecacuanha, in emetic doses, has had its advocates. Nitric 
acid has been lauded as a specific. Hope's mixture, consisting of a drachm 
of nitrous acid, forty drops of laudanum, and eight fluidounces of camphor 
water, and taken in doses of two fluidounces every three or four hours, has in 
its favour the recommendation of Dr. C. D. Meigs, of Philadelphia, as well as 
that of its original proposer. {N. Am. Aled, and Surg. Journ., ii. 419.) 
During convalescence, the greatest caution should be observed in relation 
to the diet, which should consist of mild and easily digested aliment, such as 
farinaceous substances, milk, cream, broths without fat, and the lighter forms 
of solid animal food. 
Article II. 
Syn.-Spasmodic Cholera.-India Cholera-Asiatic Cholera.-Malignant Cholera.- 
Cholera Asphyxia. 
EPIDEMIC CHOLERA. 
This disease appears to have been long known in India; but first began to 
attract the attention of the medical profession generally in the year 1817, 
when it broke out as an epidemic with great violence in Bengal, and from 
that province, as a centre, commenced the fearful march, which did not cease 
until it had encircled the globe. In its progress westward, it ascended the 
Ganges, pervaded Central India, and, crossing the mountainous range of the 
Ghauts, established itself, in the year 1818, upon the western coast of the 
peninsula. During the same year, it made its way southward to Madras; in 
1819, crossed the sea to Ceylon; and, before the close of the latter year, ap- 
peared in the Mauritius and the Isle of Bourbon. At the same time, it was 
slowly advancing towards the east and southeast; invaded the Burman domi- 
nions; attacked Siam, the peninsula of Malacca, and the island of Sumatra; 
and, in 1820, had reached Canton and the Philippine Islands. It was sub- 
sequently heard of as extending its ravages into the northern parts of China, 
and into Tartary. After arriving at the western coast of the peninsula of 
Hindostan, it appeared to pause for a while before leaving its native soil; and 
it was not till the year 1821, that it made its appearance on the shores of the 
Persian Gulf. From this position it ascended the Tigris and Euphrates; in 
1822, passed over the desert into Syria; and, in 1823, having made its way 
northward through Persia, reached the shores of the Caspian Sea, and seized 
upon the Russian city of Astracan. It had now traversed the whole length 
of Asia, and was pressing upon the confines of Africa and Europe. 1 Here it 
again paused; and several years elapsed before it crossed the boundaries, and 
commenced a new career of invasion in these hitherto undisturbed regions. 
In 1828, it appeared at Ohrenburgh, on the borders of European Russia; but 
it did not fairly enter Europe until 1830, when it advanced as far as Moscow. 
In 1831, it took a westward course, attacked St. Petersburg, Warsaw, Dant- 
zic, Berlin, and Hamburgh, and showed itself in Sunderland, on the north- 
eastern coast of England. In 1832, it reached Paris and London; and, in 
the same year, overleaping the barrier of the Atlantic, appeared in Quebec on 
the 8th of June, and at Montreal on the 10th; and thence pursued a rapid 
course along the St. Lawrence, and the Lakes, to the valley of the Mississippi 
River. A detachment from the main line of invasion, as it crossed the CLASS III.] 
EPIDEMIC CHOLERA. 
647 
Atlantic, appears to have struck the shore of the United States at New York, 
where the disease broke out on the 24th of June. Thence it spread north- 
wardly up the Hudson, and southwardly to the Delaware and Chesapeake 
Bay, reaching Albany on the 3d or 4th, and Philadelphia on the 5th of July, 
and Baltimore in the course of the same month. About the beginning of 
November, it appeared in an island off Charleston; in February, 1833, at the 
Havana, in Cuba, where it committed great ravages; and, before the end of 
that year, in Mexico. At the same time that the epidemic, leaving the north- 
western borders of Asia, was spreading consternation throughout the north of 
Europe, it took also a southward course from Syria, penetrated the deserts of 
Arabia, and invaded Egypt, appearing in Mecca, in May, and in Alexandria, 
in August, 1831. It was very late in attaining the extreme north, and the 
extreme south of Europe. Thus, Sweden was not visited until one or two 
years, nor Sicily until four years after the epidemic had reached New Orleans. 
In this country, there were partial returns of the disease subsequently to its 
original appearance, and it prevailed to a considerable extent in the year 
1834; but both in North America, and the greater part of Europe, it dis- 
appeared entirely in somewhat more than two years from its first visitation. 
In India, however, it continued as an endemic disease; and, at the date 
of the first publication of this work, in the early part of 1847, we had received 
accounts of its having commenced a new march of desolation in Persia, and 
other parts of the East. Since that time it has again entered Europe, and, 
having followed its former track through the northern parts of that continent, 
has reached once more the eastern coast of Great Britain. While these sheets 
are going to the press, November 1841^ we have information of its prevalence 
to a greater or less extent, in Hull, Edinburgh, London, and other towns near 
the coast; and are looking forward, with fearful expectation, to a visitation 
from it, in our own country, in the approaching spring or summer. 
From the above brief account of the progress of cholera, it will be seen 
that its march was extremely irregular, in relation both to time and direction. 
Sometimes it advanced with great rapidity, sometimes slowly, and sometimes 
paused for a longer or shorter period, giving hopes to the yet unvisited coun- 
tries, that they might escape its ravages. In general, its progress was ar- 
rested during the winter, to be resumed in the spring; though this was not 
invariably the case; for at Moscow it prevailed through most of the winter of 
1830-31. Though preferably following the course of streams, affecting low and 
damp places, and attacking the filthy and crowded portions of populous cities, 
it was yet absolutely confined to no particular character of locality, but showed 
itself occasionally upon lofty mountains, in the midst of sandy deserts, and 
among the scattered inhabitants of thinly peopled agricultural districts. No 
barriers were sufficient to obstruct its progress. It crossed mountains, deserts, 
and oceans. Opposing winds did not check it. All classes of persons, male 
and female, young and old, the robust and the feeble, were exposed to its 
assault; and even those whom it had once visited were not always subse- 
quently exempt; yet, as a general rule, it selected its victims preferably from 
among those already pressed down by the various miseries of life, and left 
the rich and prosperous to their sunshine and their fears. It was exceedingly 
capricious in the choice of its localities, not unfrcquently leaving towns and 
districts in its line of march untouched, and deviating apparently from its 
course to seize upon others, in no important respect differently circumstanced. 
The period of its duration, in any one spot, was generally from one to two or 
three months; though this was much influenced by the season, being shorter 
for the most part when winter was near. When it prevailed in the same 648 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
place more than once, it usually affected fewer persons, and was of a milder 
character, in the second attack than in the first. 
Course, Symptoms, &c.-The first approach of the epidemic influence, in 
places about to become the seat of cholera, was usually felt in the more or 
less general prevalence of moderate disorders of the stomach and bowels, 
which preceded for a short time the appearance of the disease, and continued 
in various degrees to affect a large portion of the population, after it had 
become established. Sometimes there was only a slight derangement of 
digestion, or a simple diarrhoea, or mild dysentery; but very frequently, the 
premonitory affection took on a more decided character, and, without amount- 
ing absolutely to cholera, approached it more or less nearly, and from this 
circumstance received the name of cholerine, adopted from the French 
writers. 
Cholerine, in fact, often constituted the first stage of cholera, and in other 
cases was undoubtedly produced by the same cause, operating either more 
mildly, or upon less susceptible subjects. It was marked by a furred tongue, 
irregular appetite, thirst, impaired digestion, uneasiness in the stomach and 
bowels with a feeling of weight or distension, colicky pains, hiccough, diarrhoea 
sometimes disappearing and again recurring, nausea, sometimes vomiting, a 
feeling of general weakness and languor, a disposition to perspire, occasional 
neuralgic pains, and cramps in the extremities. In some instances, it was 
attended with febrile symptoms. The alyine discharges were sometimes 
bilious, sometimes of a dirty-white colour and turbid, very much resembling 
oatmeal gruel. Occasionally the force of the cause seemed to expend itself 
upon the nervoqs system, and the patient was affected with severe neuralgic 
pains, and distressing spasms, amouating sometimes to convulsions, with little 
or no evacuation from the stomach or bowels. The affection often subsided 
spontaneously, or yielded readily to proper treatment; but was very apt, upon 
exposure to any exciting cause, and even, if neglected, without such cause, to 
be aggravated into cholera. 
When the epidemic influence had attained an intensity adequate to the 
production of the full-formed disease, a few cases were first observed, usually 
among the lowest orders of the community. These were soon followed by 
others; and the numbers gradually increased, until the pestilence reached its 
acme; when it speedily subsided, and ultimately disappeared, leaving behind 
it, for a short time, that same tendency to bowel complaints which had he- 
ralded its approach. 
The attack often occurred after some imprudence in diet or exposure; but 
often also without any obvious exciting cause; and, according to some writers, 
most frequently in the night. It occasionally came on with loss of appetite, 
pain in the back and abdomen, vertigo, noise in the ears, disordered vision, 
feebleness of the pulse, paleness of the face, copious sweats, a feeling of gene- 
ral weakness, and sometimes rigors. In the midst of these or similar symp- 
toms, in most cases after a longer or shorter duration of diarrhoea or cholerine, 
but sometimes without any premonition whatever, the patient was seized with 
vomiting and purging, which were frequently repeated, and attended with 
severe pain in the abdomen, neuralgic pains in different parts of the body, 
and cramps of the voluntary muscles, especially those of the lower extremities. 
The first evacuations, in cases not originating in diarrhoea or cholerine, con- 
sisted of the ordinary contents of the stomach and bowels; but the dejections 
which followed were of a whitish colour, thin, and watery, resembling rennet 
whey, thin gruel, or rice water, and, when allowed to stand, separated into a 
colourless fluid, and a white, flocculent, insoluble matter, which subsided. In 
mild cases, or after the subsidence of the severer symptoms, they were some- CLASS III.] 
EPIDEMIC CHOLERA. 
649 
times tinged with bile, and a little blood was occasionally discharged. In 
some instances', they are described as having been brown, or of a deep choco- 
late colour. The matter vomited was generally similar to the stools. but was 
sometimes white and glairy, as if consisting of mucus, and had an acid reac- 
tion. The evacuations were usually forcibly ejected, but without apparent 
straining, or much voluntary effort, and were often very copious. . 
The cramps usually began in the extremities, affecting especially the calves 
of the legs, but subsequently extended to the muscles of the trunk and abdo- 
men. They were excruciatingly painful, and almost incessant, the muscles 
gathering into hard board-like knots, one contracting as another relaxed, and 
often distorting the fingers and toes in various directions, according to the 
particular muscle or muscles affected. 
At the same time the pulse sank rapidly; the extremities became cold; the 
features shrunk; the patient was restless, and complained of intense thirst; 
the whole surface was bathed with sweat; the urine was scanty; and the skin 
began to assume a bluish, leaden, or violet colour, which extended more or 
less over the body, but was peculiarly striking in the face, hands, and feet. 
If the.complaint was not arrested, the evacuations became Stillmore copious 
and watery; the thirst insatiable, with a burning heat at the epigastrium; 
the pulse frequent, feeble, and sometimes scarcely perceptible; the breath 
cool; the tongue cool and pale, though still moist; the skin unusually cold, 
shrunken, and inelastic, so that when pinched into folds it could not resume 
its former state; the hands and feet shrivelled and wrinkled, as if long soaked 
in water, and of a dark, purplish or livid colour, especially at the nails, which 
were sometimes almost black; the eyes, deeply sunk in their sockets, and 
surrounded with a livid circle; the conjunctiva dry, and of a dirty whiteness; 
the nose and lips blue; the secretion of urine and tears 'suppressed; the re- 
spiration short, hurried and oppressed; and every symptom indicative of ex- 
treme prostration. The patient was often exceedingly restless, and called 
incessantly for cold water or ice, and for fresh air. With all these changes, 
the external sensibility often remained acute, so that mustard plasters and 
other irritants produced severe pain; and, though cold to the touch, the pa- 
tient frequently complained' of a distressing heat over the whole surface. The 
intellect was generally sound, but more or less obtuse; and, in all his moral 
relations, the patient evinced an extraordinary apathy, being insepsible alike 
to his own danger and future prospects, and to the feelings of those connected 
with him. * 
The case was now on the borders of complete collapse.. But a step further, 
and the.pulse became quite imperceptible; a feeble oscillatory movement only 
of the heart was discoverable upon auscultation; the blood stagnated in the 
capillaries; a wound of the surface yielded no blood, and little or none fol- 
lowed the opening of a vein; the features and whole body were so shrunken 
that the patient could scarcely be recognized by his friends; the bluish or 
purplish colour often pervaded the whole surface; the voice was feeble, or 
quite extinct; the breath almost as cold as the external air; the respiration 
either hurried and feeble, or very slow and scarcely perceptible; the counte- 
nance calm or quite inexpressive; and the whole aspect of the patient that of 
utter helplessness. The reduction of temperature was such, that the ther- 
mometer, with its bulb placed under the tongue, sank often to 90°, and some- 
times as low as 80°, or even 77° F. The body had the appearance of death 
except the eyes, which sometimes retained an expression of intelligence, arid 
seemed as if they were looking out of a corpse. But even these were often 
half closed, glazed, and inanimate. In some instances, considerable muscular 
strength remained, and the patient suddenly rose up from bed with an expiring 650 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
effort, and fell lifeless. The evacuations sometimes continued till the close, 
and were at last involuntary. Sometimes, however, they ceased entirely for 
a considerable time before death. The same, difference was observable in 
relation to the cramps, which, in some cases, did not end even with life, the 
muscles remaining stiff and contracted in the dead body. Intelligence was 
sometimes - retained till within a few moments of the close. In other cases, 
a period of stupor preceded death. The fatal issue sometimes occurred in 
four or five hours from the commencement of the attack, though more fre- 
quently life was protracted for one, two, or three days. 
The complaint was susceptible of a favourable change, either spontaneously 
or by the aid of treatment, at any stage of its progress, even in that of col- 
lapse. If it was arrested early, the patient sometimes entered into a speedy 
convalescence, without any subsequent embarrassing symptoms, though not 
unfrequently diarrhoea and other evidences of gastro-intestinal irritation con- 
tinued for a longer or shorter period. But, if collapse had begun before the 
turn of the disorder, the patient had still great dangers to encounter, and the 
progress of recovery, when it took place, was often very tedious, and liable to 
frequent interruptions. One of the most favourable symptoms, in any stage 
of cholera, was the appearance of bile in the evacuations. In the cases of 
collapse, after the system had begun to react, a gradual restoration of the 
suspended functions was observed; the pulse returned, the skin became warm, 
the pallor or blueness of face yielded to a red flush, the secretion of urine and 
bile recommenced, the vomiting diminished; but the oscillation extended fre- 
quently into a febrile excitement; severe headache was experienced; the 
abdominal pains, thirst, loathing of food, and diarrhoea continued; and con- 
valescence, even in favourable cases, did not set fairly in until after several 
days of doubt and discomfort. 
Sometimes a relapse followed the temporary excitement, and the patient 
sank with all his former symptoms. Much more frequently,, however, the 
febrile state continued, generally assuming a low form, with most of the 
characters of idiopathic nervous or typhoid fever, and unequivocal evidences 
of gastric or intestinal inflammation, and either ending in death, or in a very 
slow recovery.. In some cases the fever assumed the remittent type, and 
ultimately became intermittent. Various eruptive affections, resembling 
those of scarlatina, rubeola, erysipelas, &c., occasionally diversified the stage 
of reaction. Pneumonia, bronchitis, and pleurisy also not. unfrequently oc- 
curred, but so masked by the low state of the' system, and the continued 
gastro-intestinal irritation, as often to escape the notice" of the practitioner, 
unless carefully upon his guard. But the most dangerous affection, in this 
stage of cholera, was perhaps that of the brain, characterized by severe head- 
ache, drowsiness, low delirium, stupor, coma, subsultus tendinum, and some- 
times, by convulsions or paralysis: In its severe forms, it was almost always 
fatal. The convalescence from these various secondary disorders was often 
protracted for months, and sometimes even for a year or more. 
The course of the symptoms in cholera was not always uniform, nor exactly 
as above described. Sometimes the spasms were comparatively trifling or 
altogether absent, sometimes they constituted the chief feature of the case, 
to the exclusion of the ordinary evacuations. In occasional instances, the com- 
plaint was ushered in by universal and violent convulsions. Cases were fre- 
quently observed, in which fatal collapse supervened without'vomiting; and 
others are on record, in which there was neither vomiting nor diarrhoea, 
though, in such instances, the bowels, upon, examination after death, were 
found loaded with the same whitish liquid of which the discharges consisted. 
In some rare instances, vomiting occurred with little or no diarrhoea. Though CLASS III.] 
EPIDEMIC CHOLERA. 
651 
in general there was an interval of some hours, and sometimes of a day or 
more between the attack and the occurrence of collapse, so as to allow time 
for the intervention of efficacious treatment, yet instances were not unfrequent, 
in which the patient passed almost immediately into that state, and died ap- 
parently under the first blow. The bluish aspect of the surface, so character- 
istic of cholera, was not present in all cases, not even in all those which ter- 
minated fatally. Instead of the sinking pulse, so common even in the onset 
of the disease, the circulation was sometimes little affected for a considerable 
time; and, in some cases, febrile symptoms, with a strong and excited pulse, 
showed themselves in the first stage. The intellect, usually correct, though 
obtuse, was in some cases clouded almost from the commencement; and in- 
stances occurred in which determination of blood to the head, with drowsiness, 
stupor, and numbness of the extremities were the prominent symptoms. 
From an examination of the symptoms above detailed, it will be perceived 
that a fully developed case of cholera, running through a regular course, 
often exhibited four distinct stages, the observance of which was important in 
a practical point of view. The first was the forming stage, consisting of a 
simple diarrhoea, or of more or less of those derangements described under 
the head of cholerine. The second was that in which the symptoms of 
cholera were decided, but the system had not yet sunk into complete prostra- 
tion, and the circulation was distinctly observable, both in the larger vessels 
and capillaries. The third was the stage of collapse, already sufficiently de- 
scribed. The fourth was that of reaction, in which the characteristic symp- 
toms of cholera had given way to local inflammations or irritations, and to 
general fever. All th^se stages did not by any means occur in all cases. 
The disease was often arrested in the first or second, or proved fatal in the 
third, without ever reaching the fourth; and sometimes the second or even 
third stage came on, without the known existence of those ordinarily pre- 
ceding it. 
The Blood and Evacuations.-The blood, in the advanced stage, or that of 
collapse, was black, thick, and viscid, even when drawn from the arteries; 
and did not become red on exposure to the air. It usually coagulated upon 
standing, and separated into serum and crassamentum; but the latter had 
little firmness, and the former was in smaller proportion, considerably heavier, 
and much more deeply coloured than ordinary. It appears from the experi- 
ments of Drs. Clanny, Thomson, and O'Shaughnessey, that the blood of ad- 
vanced cholera contained less water, albumen, fibrin, and saline matter, and 
much more of the red corpuscles, than an equal weight of healthy blood. The 
carbonate of soda was'1 altogether wanting, and the other salts of the blood 
greatly diminished. The fluid portion of the alvine evacuations, which were 
often enormous in quantity, consisted chiefly of water holding carbonate of 
soda and other salts, with a little uncoagulated albumen in solution; while 
the solid portion was eithei' fibrin or coagulated albumen; so that the princi- 
ples contained in them were precisely those lost by the blood. The inference 
is clear, that the rice-water discharges were merely a portion of the blood 
itself, little changed by secretion; and the deficiency of serum in the cholera 
blood, and the greater density and viscidity of the blood, are thus explained. 
It must not be concealed that Dr. Bohn, of Berlin, inferred from microscopic 
examination, that the solid portion of the evacuations consisted of fragments 
of the epithelium of the mucous membrane (^Dublin Jdurn., No. 44); and 
this fact corresponds with the statement of Dr. W. E. Horner, of Philadelphia, 
who found, from his post-mortem examinations, that the epithelium, as well 
as a layer of venous capillaries which he discovered, immediately beneath it, 652 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
was exfoliated to a greater or less extent in the progress of the complaint. (Am. 
Journ. of Med. Sci., xvi. 59.) 
Dr. Stevens has shown that the salts of healthy blood favour, if they be 
not essential to, its conversion from venous to arterial; and the loss of them 
is probably one cause at least of the blackness, and disposition to be red- 
dened on exposure to the air, so characteristic of that fluid in cases of cho- 
lera. The air expired during^the collapse of cholera was not only cold, but 
contained a smaller proportion of carbonic acid than that expired in health. 
This resulted no doubt from the circumstance, that the blood underwent little 
or no change in the lungs; and the general coldness of the body might be 
considered as dependent upon the same cause. Another peculiarity of the 
cholera blood was, that it contained a notable portion of urea; 3-66 parts pf 
this principle having been found by Dr. O'Shaughnessey in 1000 parts of 
blood, drawn from a patient who died of cholera. This fact is of some patho- 
logical importance, and is readily accounted for by the almost total suppres- 
sion of urine, the secretion of which in health carries the urea out of the 
Circulation as fast as it is generated. 
Anatomical Characters.-After respiration and the action of the heart had 
ceased, spasmodic movements of the muscles were still sometimes observable; 
and it is a remarkable fact, asserted by many observers, that when death 
occurred suddenlyJn the cold stage, the temperature of the body not unfre- 
quently rose after all signs of life had ceased, and the warmth continued until 
cadaveric rigidity began. The appearances upon dissection varied, according 
as death had taken place in the stage of collapse, or in that of reaction. If 
it was very speedy, it sometimes happened that no morbid changes whatever 
were observed. The following phenomena were ordinarily presented after 
death in the collapse. 
The whole arterial system was emptied of blood, with the exception of a 
few clots in the aorta and left side of the heart. The venous system, oil the 
contrary, was distended, especially the large veins and right side of the 
heart, which were gorged with a black, viscid, imperfectly coagulated blood. 
Almost all parts of the body, the brain, and spinal marrow, the substance of 
the heart, the abdominal viscera, the limbs, even the spongy substance of the 
bones, exhibited signs of venous injection. The vessels of the lungs, how- 
ever, generally contained little blood; and the spleen was sometimes remark- 
ably small and dry. When the abdomen was opened, the peritoneum was 
observed to be dry, as in fact were the serous membranes generally; and the 
small intestines had a rose or violet colour, owing to the venous injection of 
the inner coat. Sometimes, however, the serous surface of the bowel was 
covered with a very delicate layer of viscid matter, rendering it somewhat 
adhesive; and the same condition was occasionally noticed in the pleura, and 
more rarely in the'pericardium. The mucous membrane, throughout nearly 
its whole extent, was more or less reddened, and the parietes of the bowels 
were somewhat thickened, in consequence of this venous injection.. There 
was also sometimes a slight infiltration of the coats. In many cases, there 
was an eruption of minute semi-transparent vesicles, disappearing upon punc- 
ture, very closely arranged, and extending from the duodenum to the ileo^ 
caecal valve, and even into the colon. These have been considered as morbidly 
developed follicles; but, according to Dr. Horner, they were altogether dis- 
tinct from that structure, and were formed by a mere elevation by a serous 
fluid of the epithelium of the mucous membrane. (Am. Journ. of Med. Sci., 
xvi., 289.) In other cases, instead of these vesicles, which were so. transparent 
as to be. sect! with difficulty, there were numerous minute white prominences, 
having a depressed blackish point in the centre, which were by some con- CLASS III.] 
EPIDEMIC CHOLERA. 
653 
sidered as a second stage of the former eruption; but were very probably 
distinct. They did not disappear entirely when cut into or compressed; and 
could not be distinguished from enlarged glands of Brunner, observed in other 
affections. The glands of Peyer were also morbidly developed. The intes- 
tinal mucous membrane was frequently coated, to a greater or less- extent, 
with a layer of a whitish or grayish matter, probably identical with the floc- 
culent substance deposited by the evacuations when allowed to stand. A 
similar coating was sometimes found in the stomach. The whole alimentary 
canal was1 distended with the same whitish liquid of which the evacuations 
consisted, often mixed with a dark reddish or chocolate coloured liquid, which 
probably owed its colour to effused blood. A glairy mucus sometimes existed 
in the stomach, more or less adherent to the mucous coat. The texture of 
the membrane was seldom materially altered in this stage; nor were there in 
any other organs appreciable lesions, which would assist in explaining the 
symptoms of the disease. The brain, spinal marrow, and nervous ganglia 
were not materially altered. The lungs were healthy, and the parenchyma 
of the liver and kidneys exhibited no other irregularity than an occasional 
venous engorgement. The gall-bladder was usually filled with a viscid, not 
unhealthy bile. The bladder was often very much contracted, and contained 
little or no urine. The mucous membrane of the pelvis of the kidneys, 
ureters, and bladder, often exhibited the same consistent coating that was 
found in the bowels. 
After death, in the stage of reaction, the phenomena were entirely different, 
but varied with the length of time which had elapsed from the commencement 
of that stage. The bladder had now resumed its dimensions, the viscid con- 
dition of the peritoneum, if previously existing, had disappeared, the venous 
injection had partially or wholly given way, the blood had lost some of its 
blackness and viscidity, though still not restored to its healthy state, and the 
rice-water contents of the bowels had given place to bilious and bloody fluids. 
Instead of the dark shade of venous congestion, there was now the vivid red- 
ness of unequivocal inflammation in the alimentary mucous membrane, which 
was also sometimes softened or otherwise changed; and the mucous follicles 
exhibited marks of incipient ulceration. Lesions in the various nervous 
centres and their investing membranes, such as might be expected from the 
symptoms during life, and not unfrequently decided evidences of inflammation 
of the lungs, were observed. r 
Causes.-The essential and specific cause of this form of cholera was un- 
doubtedly a peculiar epidemic influence. Various circumstances increased 
the susceptibility of the system to this influence; and many others hastened 
the attack, or called into operation a tendency originating in the specific cause, 
which without them might have remained quiescent, and ultimately passed 
away. The former may be considered as predipjosiny, the latter, as exciting 
causes; but neither the one set nor the other, nor both combined, were alone 
adequate to the production of the disease; while the epidemic influence ap- 
peared to be capable of producing it altogether unaided. 
The nature of the specific cause is unknown. In the minds of the specu- 
lative it has been-vaguely associated with astral influence, the approach of 
comets, the conjunctions of the planets, various meteoric phenomena, and 
peculiar electrical states of the atmosphere; but no facts exist to prove any- 
thing more than a mere accidental connexion between these circumstances and 
the appearance of cholera, and nothing certainly to authorize the suspicion, 
that they stood towards each other in the relation of cause and effect. That 
terrestrial exhalations of the nature of miasmata cannot have been the epidemic 
agent, is inferrible from the fact, that the disease appeared in ships at sea, in 654 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
sandy deserts, and in the depths of a Russian winter. Chemical analysis, and 
the closest examination by the senses, were able to detect no new ingredient 
in the cholera air, nor any deviation in the proportion of its ingredients from 
the ordinary standard. Some have been disposed to refer the results to 
invisible animalcules; and the apparently whimsical march of cholera-its 
rapid advances, long pauses, and sudden resumption of movement, its distant 
excursions from the regular line of march, its frequently capricious choice of 
localities, and the occasional deviation which it exhibited from every general 
rule of government-would seem to have some analogy with the uncertainty 
of will, which often characterizes animal migrations. But in the way of this 
hypothesis is its utter want of proof, and then the fact, that the cause of 
cholera, whatever it may have been, withstood the severity of the winter at 
Moscow, which, one would suppose, must be fatal to unprotected animal life. 
Equally without proof, though not without some plausibility, is the doctrine 
recently put forth and supported by Pr. Cowdell, that the disease had its 
origin in invisible atmospheric fungi. This epidemic influence was more 
analogous, in its movements, to that which produces the epidemic catarrh or 
influenza than to any other known cause of disease; but it differed also from 
that in its somewhat less rapid and much less sweeping march; the> cause of 
cholera seizing only upon certain localities in its course, and leaving many 
others untouched, while that' of influenza scarcely passes a spot, however 
secluded, without giving some evidences of its visitation. 
The hypothesis that cholera is propagated by contagion has not been with- 
out numerous advocates. In favour of this the facts have been adduced; 
1. that it travelled along the lines of commercial intercourse, as in the course 
of large streams, in the track of caravans, and from port to'port across seas 
or oceans; 2. that its rate of advance never exceeded the possible rapidity of 
human progression; 3. that its occurrence often succeeded the arrival of an 
infected ship, caravan, or corps of marching soldiers; and 4. that its attack 
was not general in the beginning, but, whether in a city or particular family, 
one or a few were seized at first, and then others successively, as if the cause 
had passed from individual to individual. But it will be perceived that these 
were not proofs of contagion, but only evidences, so far as they went, of the 
possibility, or at best of the probability of its existence; and it is not difficult 
to explain them without recourse to such an hypothesis. Thus, if the disease 
preferred the course of streams, it might have been in consequence of the 
known affinity of its cause for low, damp, and marshy situations; if it was 
observed especially along the routes of inland trade, this might have been 
owing to the circumstance, that the largest and most conspicuous towns, which 
it was apt to select, are upon these routes, while remote spots which it also 
visited are less open to observation; if it passed from an infected port to other 
transmarine ports between which there was commercial intercourse, the'fact 
could scarcely have been otherwise if it travelled at all, so intimately are all 
parts of the world associated in the meshes of a universal traffic; if its arrival 
was often preceded by that of a ship or of travellers from an infected place, 
this might well have been the result of accident, and very often no such con- 
nexion could be traced, while intercourse of the kind was constantly carried 
on, without the conveyance of the disease; and finally, if it sometimes attacked 
one person after another, instead of all simultaneously, this is nothing more 
than often occurs in the operation of morbid causes confessedly non-contagious, 
and was not always true of cholera, which occasionally prostrated multitudes 
at one blow. The case stated by Dr. Dickson, of Charleston, South Carolina, 
is one of the strongest that I have seen in^upport of the notion of contagion. 
The crew of a vessel which sailed from New York were seized with cholera CLASS III.] 
EPIDEMIC CHOLERA. 
655 
when six days from port, and afterwards wrecked on a sandy island twenty 
miles from Charleston, far out seaward. Of the wreckers, attendants, and 
guards who went down from the city to the island, and of the negroes residing 
upon the island, four only in number, many were seized with the disease, and 
not a few died, while no case existed in Charleston itself, except among those 
who had visited the infected spot. But this event. may be readily explained 
upon the supposition, that the ship had struck a vein of the cholera atmo- 
sphere, which involved the island without reaching the main land. The fact, 
also mentioned by Dr. Dickson, that an individual from the island was seized 
with cholera, in the city, without communicating the disease to any one, is 
not so easily reconciled with the idea of contagion. (Am. Journ. of Med. Sei., 
xiii. 359.) The case made out by the contagiohists, therefore, fails of ade- 
quate proof. There were circumstances, moreover, in the course of cholera, 
which could not be explained upon their hypothesis. If propagated by con- 
tagion, why should the disease at one time have marched with an awful 
rapidity, and at another halted for years upon the confines of countries, open 
to a constant intercourse with the infected territory? Why should it have 
suddenly seized upon a certain district, raged fiercely for one or two months, 
and then left it altogether? Why should it have attacked large cities, and 
let the surrounding and closely associated rural villages go free ? How, in 
fine, did it happen that a distinct line was sometimes drawn between the 
infected and uninfected neighbourhoods; that a low damp spot was desolated, 
while a neighbouring height was in safety; that even the upper and lower 
stories of the same house should have been in opposite conditions in this 
respect; while in all these cases there was no suspension of intercourse? The 
strictest quarantine regulations have often signally failed. The disease has 
laughed at walls, guards, and legal penalties. It may be said that, like scarlet 
fever, it might have been the result of an epidemic cause, and yet capable of 
propagating itself by contagion after it had been produced. But attempts 
of the most varied kind have been made to impart it by inoculation, and 
by introducing its different products in every way into the system, alto- 
gether without success. The sucking infant has failed to receive the disease 
from its mother. Physicians and other attendants upon th.e sick were not 
attacked in larger proportion than the rest of the population of the same class, 
similarly exposed in other respects. In hospitals situated in uninfected 
neighbourhoods, the attendants escaped altogether. Individuals affected with 
the cholera did not become centres of a new infection, when removed to 
healthy situations. These facts are sufficient, I think, to prove that the 
disease, was in no degree contagious. 
The predisposing causes were very numerous. Whatever was calculated to 
diminish the vital energies, or to reduce, the vital actions below tlm standard 
of health, may be ranked among these causes. Not only were debilitated 
individuals in greater danger when labouring under the disease; they were 
also much more liable to its attack. Previous disease, old age, intemperance, 
vicious indulgences of all kinds calculated to impair the health, deficient ali- 
mentation, an exclusive vegetable diet, confined air, especially in low and 
damp places, the effluvia of crowded residences, continued grief, fear,, anxiety, 
and other depressing emotions; all these predisposed to, cholera. 
Nor were the exciting causes less numerous. Indeed, the two sets of causes 
often acted interchangeably, those which in some cases excited the disease, 
producing a predisposition to it in others, and vice versa. Whatever could 
make a sudden and powerful impression on the system, and whatever could 
irritate the stomach, was capable of converting a tendency to cholera into its 
reality. One of the most common exciting causes was a sudden exposure to 656 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
col(l; "when the body was warm and perspiring. Hence, in part, the injurious 
effects of the night air and of damp places. Sudden and strong emotions often 
brought bn an attack. Indigestible food, such as unripe fruit and crude vege- 
tables ; excessive eating even of wholesome food; unwholesbihe drinks, includ- 
ing impure water, cider, poor wines, and imperfectly fermented liquors of all 
kinds; very cold drinks and ices taken too freely, especially when the body 
was heated; purgative medicines, particularly those of a drastic character; 
these, and many other causes, operating in a similar manner, were capable of 
exciting the disease in persons previously exposed to the specific influence; 
From a combination of these causes it is, that the ravaged of cholera have 
been experienced especially by the poorest and most wretched of the popula- 
tion, in every country; by the intemperate, the debauched, the ill-fed and ill- 
clothed, the badly lodged, the over-worked, the tenants of prisons and alms- 
houses, the inhabitants of crowded and filthy suburbs, or of miasmatic districts, 
soldiers fatigued by long inarches, sailors shut up in the holds of ships, and 
garrisons crowded in damp and badly provided camps or fortresses. In India, 
the natives, who live chiefly on vegetable food, suffered much more than the 
Europeans. In Havana, the proportion of deaths to the population was, 
among the coloured people in general, more than twice as great, and among 
the free African negroes, who are probably the worst provided, about four 
times as great as among the whites. In cities, it was almost always the lowest, 
dampest, most crowded, and most filthy sections that suffered first and most. 
In general, the well provided classes of society suffered little in any country, 
though there were almost everywhere occasional exceptions to this rule. The 
ravages in different countries or sections of the globe bore, in general, an 
inverse proportion to their well-being. Thus, Asia suffered more than Europe, 
and Europe more than North America. 
The time requisite for the production of cholera, after exposure to the epi- 
demic cause, is indefinite, but often very short. Instances are on record, in 
which persons, arriving in perfect health in an infected neighbourhood, have 
been attacked within two or three days, and even within a single day from 
the time of their arrival. 
Nature.-The most opposite opinions have been entertained as to the nature 
of the disease. While some have maintained that it was essentially irritation 
or inflammation of the alimentary mucous membrane, and that all the phe- 
nomena have their root in this primary affection; others have associated with 
this pathological condition, as the direct result of the same cause, a deranged 
state of the nervous functions, and especially those of the ganglionic system; 
and others again have rejected altogether the notion of gastro-enteritis, ascrib- 
ing the phenomena to the combination of a sedative action of the specific 
cause upon the functions of organic life, with an irritant action of the same 
cause upon those of animal life. [N^dge, Ain. J. of Med. Sei., xii. 386.) 
That an irritation of the stpmach and bowels existed in cholera can scarcely 
be doubted. How else can we explain the great abdominal uneasiness, the 
frequent5burning pain in the epigastrium, the antecedent diarrhoea, nausea, 
and vomiting, and the unequivocal evidences of positive inflammation which 
were presented after reaction, both by the symptoms and upon dissection. 
How else, moreover, explain the action of the various exciting causes, most of 
them of a directly irritant character? Was it not by producing or augment- 
ing irritation, that indigestible food, and acrid cathartics so often induced an 
attack of the disease? But that the affection was, a pure gastro-enteritis, ap- 
pears to be contradicted by all the results of previous observation. We have 
long been familiar with every shade and variety of inflammation of the ali- 
mentary mucous membrane; but when had we ever before met with the phe- CLASS III.] 
EPIDEMIC CHOLERA. 
657 
nomena of malignant cholera? Every candid practitioner will, I think, adtait 
that, though he may have seen instances of disease bearing some analogy with 
this, it struck him, on the whole, when he first saw it, as something new to 
his experience. Examination of the bodies of those who died in the cold 
stage revealed no uniform and unequivocal evidences of inflammation. The 
injection of the mucous membrane was venous. The same injection was 
found, though in a less degree, in the skin, the bronchial tubes, and the 
parenchyma of various organs. The deposit upon the surface of the mem- 
brane was merely the albuminous or fibrinous portion of the cholera discharge, 
which appeared to escape from the blood-vessels through the patulous exhalant 
orifices, almost as through the nieshes of a sieve. Even the eruption occa- 
sionally seen upon the membrane may have been nothing more than the 
result of a similar exhalation, retained by the less permeable epithelium, or 
distending the mucous follicles. Besides, in some cases of speedy death, no 
signs whatever of organic change were observed, to which the symptoms could 
be ascribed. Inflammation took place after reaction, and sometimes proved 
fatal; but the proofs are wanted of its existence, in any considerable degree, 
during the first stage, or that of collapse, and the probabilities are wholly 
against it. If there was so violent an inflammation as to produce death in a 
few hours, how did it happen that the simple measures employed often so 
readily arrested it, upon the borders of collapse? Do we see inflammation of 
such intense severity give way so easily under other circumstances ? If these 
considerations are of much weight, the inference is, that in cholera there was 
an irritation, sometimes possibly a moderate or •partial inflammation of the 
gastro-intestinal mucous membrane; but not that intense degree of inflamma- 
tion, which would be implied by the notion that it was the essential basis of 
the disease. But, admitting the existence of irritation, we shall not find this 
sufficient to account for the phenomena. Even supposing it to be directed 
especially to the secretory function, still, it is contrary to all our experience 
of this affection, that it should produce and sustain a secretion so immense 
in amount, continuing too, even when the pulse has almost ceased to beat, 
without the co-operation of some other morbid derangement. Besides, the 
excess of secretion was not confined to the alimentary canal. The perspira- 
tion was in some instances scarcely less profuse; yet no one could suppose the 
existence of cutaneous inflammation. The whitish coating of the alimentary 
mucous membrane was often found also on that of the urinary passages; but 
these were not supposed to be irritated or inflamed. There was some cause, 
therefore, disposing to this excessive elimination of serous and albuminous 
matter, other than a mere excess of excitement. What this cause was, or 
how it operated, is not so easily determined. The probability is, that a poison 
was taken into the system, capable of producing a profound impression on all 
its parts; and that, among its effects, was either such a relaxation of the ex- 
haling orifices as to admit the ready passage of the more fluid parts of the 
blood, and sometimes of the red globules themselves, or such a modification 
of the circulating fluid as to cause it to pass through the structures which 
ordinarily retain it, or else a combination of these two conditions. It is also 
highly probable that other phenomena in the disease were due to the same 
unknown cause. It is true that the immense loss of fluid from the alimentary 
canal and skin will account for most of the symptoms of the collapse. The 
blood was thus rendered black, thick, and viscid, and circulated with difficulty 
through the vessels. It lost its capacity of absorbing oxygen, and, no longer 
changing from venous to arterial, ceased to support the temperature of the 
body, or to stimulate the heart to contraction. Hence the failing circulation, 
the stagnation in the capillaries, the blue skin, the feeble and hurried respi- 658 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
ration, and the universal coldness. The more elaborate secretions, as those 
of the bile, urine, and tears, ceased, because the serous part of. the blood found 
an easier outlet through the exhaling surfaces. The whole body shrunk from 
the exhaustion of its fluids, and the same cause gave rise to the intense thirst, 
which was only the want of the whole system expressing itself through the 
fauces. But the nervous phenomena do not admit of the same solution. It 
is quite doubtful whether they depended upon the condition of the alimentary 
canal, as they were often worst when that structure was least obviously 
affected. Nor is it certain that the symptoms of collapse were always de- 
pendent on the alvine discharges. Cases were frequently noticed, in which 
fatal collapse occurred with little or no evacuation from the stomach and 
bowels; and, though, in these cases, the same peculiar fluid was found in the 
bowels after death, yet the quantity was scarcely sufficient to account for the 
symptoms. We are driven, therefore, to the supposition, that the poisonous 
cause was capable of producing all the characteristic phenomena of cholera by 
its direct action. What was the precise nature of this action cannot be said; 
but the nearest approach to a rational explanation appears to me to be that 
which considers it generally sedative to the system, especially to the circula- 
tion, but irritant to the alimentary mucous membrane. This is precisely the 
poisonous action of tartar emetic; and the case of disease, which, within my 
observation, has approached nearest to the collapse of cholera, and which 
resembled it so closely as to have been mistaken for it at first by a practitioner 
who had much experience in the complaint, occurred in a female who had 
taken a poisonous dose of that antimonial. 
By many the epidemic cholera is believed to differ from ordinary cholera 
only in its violence. There is undoubtedly considerable resemblance between 
the two affections; but I nevertheless believe them to be distinct. In cholera 
morbus the evacuations are generally bilious, in epidemic cholera they are 
rarely so. This difference has been ascribed to the greater severity of the 
latter complaint; and it is stated, in support of this view, that bile often ap- 
pears in the discharges of epidemic cholera, when it begins to moderate. But 
the distinctive sero-albuminous character of the dejections in this affection is 
observed even in very mild cases, which yield readily to treatment, and which 
are certainly less violent than the higher grades of cholera morbus. Were 
the two affections identical, there ought to be a point, in their respective gra- 
dations of severity, in which they should exactly coincide. Though I have 
seen much of cholera morbus, both in public and private practice, I have not 
met with a case exhibiting exactly the rice-water evacuations of the epidemic 
disease. There is often great and sometimes fatal prostration in the former 
affection; but the blue skin, the shrivelled extremities, the universal shrink- 
ing away of the flesh, and the peculiar mental apathy, are generally, if not 
always wanting; and the neuralgic and spasmodic symptoms, if present, are 
so in a much less degree. The differences in the seasons at which they occur, 
the persons they attack, the situations they respectively affect, their cause, 
course, and termination, are other reasons for considering them as essentially 
distinct affections. 
Prognosis.*-Treated in the forming stage, while yet in the state of diar- 
rhoea or cholerine, the disease could almost always be arrested. Even when 
completely formed, if not advanced to the stage of collapse, it terminated 
favourably, under appropriate management, in the vast majority of cases. But 
in the collapsed state, with the fluttering or absent pulse, the cold and leaden 
surface, the suspended capillary circulation, the sunken and inexpressive fea- 
tures, and complete mental apathy, the patient was already in the grasp of 
death, and medicine could be of little avail. Very few rose,out of this con- CLASS III.] 
EPIDEMIC CHOLERA. 
659 
dition, when completely formed; and the danger was in proportion to the 
degree in which it was approached. From the rapidity of the disease, and 
the destitute state of many of those most exposed to it, the patient was very 
often reduced to this condition of collapse before medical aid could be obtained. 
Hence the great mortality of this fearful epidemic. The published reports of 
cholera generally have reference to the disease as witnessed in hospitals, or 
other public institutions, where the worst cases were crowded together, and 
often in the last stage. The inmates of these institutions were, moreover, 
very frequently of the classes least able to resist the disease; such, namely, 
as were already debilitated by age, disease, want, excessive fatigue, or intem- 
perance. Among these, cholera has always made terrible havoc. It is mot 
surprising, therefore, that the published records give a fearful proportion of 
fatal cases. In some instances, almost all seized with the disease perished. 
Out of 1,387 patients at Dantzic, only 377 recovered. Of those attacked in 
the Polish army more than one-half died. The same was the case in the hos- 
pitals of Paris. About one-half of the reported cases died in London. In 
New York, the ratio of death? was one-half, in Philadelphia, one out of two 
and a half. (Am. Journ. of Med. Sei., xi. 292.) But this gives an unfair 
view of the mortality, at least as the disease prevailed in the United States; 
for a great number of moderate cases which recovered were not reported. 
From my own observation, and the published statements of others in relation 
to their private practice, I should infer that the proportion of recoveries, even 
from well-marked cases of the disease, was vastly greater than that above 
given. In almost all instances, the amount of fatality was greatest at the 
commencement of the epidemic, and gradually declined with its continuance. 
It was no uncommon circumstance for almost every individual to perish of 
those who were first attacked. i 
In forming an estimate of the probable result, in any particular cask, all 
these circumstances were to be considered. In the early stages, before the 
symptoms of collapse had come on, in a young or middle-aged, previously 
healthy, and robust individual, and especially if the case occurred in the decline 
or towards the close of the epidemic, a favourable termination might be rea- 
sonably expected. If, during the collapse, the pulse began to rise, the skin 
to become warm, and the secretion of bile and urine to return, there was hope 
for the patient; though, in giving an opinion, it was necessary to bear in mind 
the great dangers of the stage of reaction. When the attack was violent, 
and hastening into collapse, or this condition had already occurred, and when 
the seizure took place at the commencement of the epidemic, in an individual 
more than fifty years old, or previously much debilitated from any cause what- 
ever, the most serious consequences were to be apprehended. Dryness of the 
cornea, ecchymosis of the conjunctiva, and a perfect stasis of blood in the 
capillaries, as indicated by the want of any change of colour in the gums or 
inner surface of the lips upon pressure with the finger, were certain signs of 
approaching death. 
Treatment.-The plans of treatment which have been employed in epidemic 
cholera are almost as numerous as the combinations of which remedies are 
susceptible; and, judging from the reports upon a great scale, there seems to 
have been little difference in the results; for the proportion of deaths has 
generally varied from one-half to one-third, no matter what was the locality, 
or what the means of cure resorted to. This apparent uniformity has no 
doubt arisen in part from the circumstances, that, of the cases reported, a 
very large proportion was utterly beyond the reach of remedies, and that, in 
any particular place, the favourable and unfavourable results of the different 
modes of treatment pretty nearly counterbalanced each other. When, how- 660 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
ever, a discriminating view is taken of the whole ground, and the published 
results of individual practitioners or individual institutions, in connexion with 
the treatment employed, are compared, we still find insuperable difficulties in 
coming to a just conclusion as to the most effective plan; great success being 
often claimed for the most different, and even opposite remedies, by their 
respective advocates. In deciding, therefore, for himself, the physician is 
necessarily thrown off of the ground of general experience upon that of prin- 
ciple, and his own individual observation. I shall first give a sketch of the 
plan of treatment suggested by a judgment formed upon this basis, and after- 
wards a detail of various other plans, recommended by their apparent merits, 
or the testimony in their favour. 
In the absence of any certain pathology of the disease, the efforts of the 
practitioner should be directed to the correction or removal of obvious disturb- 
ances of the functions, and thus to put the system as nearly as possible into 
its normal condition. The indications of treatment, in the first and second 
stages of the disease, deducible from the obvious phenomena are, to arrest the 
evacuations from the stomach and bowels; to relieve irritation of the.gastro- 
intestinal mucous membrane; to restore the suspended secretions, especially 
that of the liver; to equalize the circulation; to relieve the nervous disturb- 
ance; and to support, when necessary, the general strength. Of these the 
most important is to arrest the alvine evacuations; for it is by their continu- 
ance and increase, that the fatal, condition of collapse is generally induced. 
But the measures best calculated to answer this indication are such as, will 
meet, to a certain extent, most of the others also; as the evacuations, if not 
the result of the irritation, are probably promoted by the sanguineous con- 
gestion which it induces; and the restoration of the suspended secretions, and 
the equalization of the circulation, must have a tendency to diminish this 
congestion. 
Among the remedies best calculated to meet the above indications are opium 
and calomel, in small and frequently repeated doses, combined, when the 
discharges are copious, with acetate of lead, and, in addition, if this should 
prove insufficient, with kino, catechu, or the extract of rhatany. Large doses 
of opium are considered, and probably are injurious, by obtunding the nerv- 
ous system below the point of necessary impressibility, and thus inducing 
torpor and even coma, and favouring congestions of the brain and other great 
internal organs. In small doses, on the contrary, it proves highly useful by 
checking exhalation into the bowels, determining to the surface, relieving 
pain and allaying irritation, and sustaining a moderate, general, diffusive 
excitement. Minute and frequently repeated doses of calomel have the 
effect of stimulating the hepatic secretion, without irritating the stomach. It 
is indeed highly probable, that they have a tendency directly to allay gastric 
irritation; and, if the general mercurial influence is induced, it may prove 
useful not only by changing the existing morbid action, but also by obviating, 
in some degree, the danger of inflammation in the fourth or last stage. The 
mercurial pill may often be advantageously substituted for calomel, in equiva- 
lent doses. Acetate of lead acts by the combination of astringency with a 
directly sedative influence upon the mucous membrane; kino, catechu, and 
extract of rhatany, by their astringency alone. The mutual reaction of these 
substances, though resulting in the formation of new compounds, does not by 
any means necessarily imply a therapeutical incompatibility. In relation to 
the combination and exact dose of the above remedies, the practitioner must 
be guided by the degree of severity, and the peculiar circumstances of each 
particular case. In the mildest cases, opium and calomel may be employed 
alone; in those of a higher grade, the acetate of lead should be added; and CLASS III.] 
EPIDEMIC CHOLERA. 
661 
in the most obstinate, all should be given simultaneously. The dose should 
be such as to admit of repetition every half hour or hour, during the height 
of the disease; after which the interval may be gradually lengthened.* From 
one-twelfth to one-half of a grain of opium, from one-sixth of a grain to one 
grain of calomel, from one-third of a grain to two grains of acetate of lead, and 
from two to five grains of kino or extract of rhatany are suitable quantities; 
and they are best given in the pilular form. 
During the administration of the above remedies, the patient may be 
allowed to swallow frequently very small quantities of cold carbonic acid 
water, which tends at the same time to relieve the burning thirst, and allay 
the vomiting. If this cannot be had, small doses of the effervescing draught 
may be substituted. A little very cold water every now and then, or small 
pieces of ice, will be found very grateful to the patient. Whatever liquids 
are administered should be cold, as heat increases the thirst, and already in- 
tolerable burning of the stomach. Lime-water and milk are sometimes useful 
in allaying the gastric irritation; and some of the aromatic waters may be 
employed for the same purpose. In cases requiring stimulation, the aromatic 
spirit of ammonia will often admirably answer both indications. At the same 
time, a sinapism of pure mustard should be applied over the epigastrium; and, 
when opiates given by the mouth are rejected, enemata of thirty drops of lau- 
danum, with mucilage or thin starch, should be substituted. 
To equalize the circulation and nervous excitement, efforts should be made 
to bring about action upon the surface of the body. For this purpose, dry 
heat, and moist heat by means of the warm bath or vapour bath, have been 
recommended. These may sometimes be advantageous in the earlier stages; 
but, at a more advanced period of the disease, when they would seem to be 
yet more strongly indicated, experience has not pronounced in their favour. 
Though the surface may be cold, the patient has not unfrequently an opposite 
feeling, and suffers greatly from hot applications. These, moreover, are apt 
to increase the perspiration, already in many instances exceedingly abundant, 
and thus to aid the alvine evacuations in the exhaustion of the serous portion 
of the blood, and consequently to hasten the collapse. Hot pediluvia, ren- 
dered stimulating with mustard, Cayenne pepper, or common salt, may be 
used in all Cases in which the extremities merely are cold. The best mode of 
effecting a centrifugal excitement is by moderate frictions over the surface, 
either by the hand alone, or with flannel, coarse towels, or a flesh-brush, or in 
connexion with rubefacients. Care must be taken to avoid injury to the skin 
by the violence of the friction. This remedy often affords great relief to the 
cramps. Frictions over the whole surface of the body with mercurial oint- 
ment, mixed with half its weight of camphor, and one-quarter of its weight 
of Cayenne pepper, urged to salivation, were employed with the happiest 
results by Dr. Lee, of New York. (Am. Journ. of Med. Sci., x. 544.) 
Peculiar circumstances may require additional remedies. In those rare 
cases in which the pulse is full and strong, especially if connected with con- 
* The following are convenient formulae. R.-Opii pulv. gr. j; Hydrarg. Chlorid. 
Mit. gr. ij ; Acacise pulv., Syrup., aa q. s. Fiant pil. no. xii. S. One every half hour, or 
every hour. R.-Opii pulv., gr. j; Hydrarg. Chlorid. Mit. gr. ij; Plumb. Acetat. gr. xij; 
Acaci;® pulv., Syrup., aa q. s'. Fiant pil. no. xij. S. One every half hour, or every hour. 
R.-Opii pulv. gr. j; Hydrarg. Chlorid, Mit. gr. ij; Plumb. Acetat. gr. xij; Kino pulv. 
5j; Acacias pulv., Syrup., aa q. s. Fiant pil. no. xxiv. S. Two every half hour, or every 
hour. In urgent cases, a larger dose than any above indicated may be given at first, so 
as to produce a prompt impression, which is afterwards to be maintained by the smaller 
doses. Thus, the first dose may consist of half a grain or a grain of opium, with two 
grains of calomel. The blue mass may, in either of the formulae, be substituted for the 
calomel in three times the quantity; but it is generally less efficient. 662 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
vulsive symptoms, blood should be taken from the arm. Leeching to the epi- 
gastrium is indicated in the earlier stages, when there is tenderness with burn- 
ing pain in the stomach. Prostration must be obviated by the diffusible 
stimulants, especially in intemperate persons, though little good can be ex- 
pected from these remedies in the state of collapse. Tincture of camphor, 
aromatic spirit of ammonia, and the ethereal preparations are among the best. 
Sound port wine or brandy diluted with cold water, and impregnated with 
mint or other aromatic, may also be used, though with caution. The cam- 
phorated tincture of opium is admirably adapted to mild cases of the disease, 
oi' to its earliest stage. 
The above remedies must of course be graduated to the .severity of the 
case; and,.in the forming stage, while the disease is yet in the state of diar- 
rhoea or cholerine, it may not be necessary to resort to any other remedy than 
an opiate, with or without calomel or the blue mass, according as the .hepatic 
secretion is or is not deficiciit. It is, however, of the utmost importance to 
arrest the disease in this stage, and the simple means necessary for this pur- 
pose become highly valuable remedies. When the stools retain the natural 
colour, a teaspoonful of the camphorated tincture of opium three or four times 
a dpy, or from five to ten drops of laudanum with a few drops of tincture of 
camphor, repeated as often, will very frequently be sufficient, along with a 
proper regimen, to check .the preliminary diarrhoea, and thus ward off an 
attack of the cholera. Should the stools be white, or very light-coloured, the 
mercurial should be conjoined with the opiate in alterative doses, and the 
addition of a small proportion of ipecacuanha to each dose, insufficient to nau- 
seate, will be found advantageous. Should the stomach be loaded with undi- 
gested food during the forming stage, the treatment may very properly be 
commenced with a gentle emetic of ipecacuanha. Should costiveness follow 
the use of the means requisite for checking the disease, it should be corrected 
by the mildest possible measures; and rhubarb is perhaps the best laxative 
for the purpose. 
In the stage of collapse, the same indications are presented as in the previ- 
ous stages, with two additional; namely, to check the. excessive sweats, and 
to supply the loss of watery fluid and salts which has been sustained by the 
blood. There would seem to be even a stronger call for active stimulation; 
but .experience has shown that this measure should be employed with some 
reserve. In the existing state of the circulating fluid, it can be of little avail, 
and, when carried too far, it has the effect of still further aggravating the 
danger, by increasing the already excessive sweats, and exhausting the little 
remaining excitability of the system. The stimulants, however, already men- 
tioned, may be used in small and frequently repeated doses, and continued if 
found productive of no ill effects. The efforts to restrain the evacuations 
from the stomach and bowels, if these continue, should not be abandoned; 
and, though external heat has been found productive of little good, attempts 
should still be made to excite the surface by frictions and rubefacients. Sina- 
pisms may be applied to the abdomen and extremities, and Cayenne pepper 
and brandy, oil of turpentine, tincture of camphor, liniment of ammonia, &c., 
over the surface of the body. To close the cutaneous exhalant orifices, astrin- 
gent solutions may be employed, such as a saturated solution of alum in 
brandy; and for the same purpose, as well as indirectly to excite the skin, 
frictions with ipe or iced-water have been strongly recommended, and are said 
to be often very grateful to the patient. To repair, as far as possible, the loss 
of water and salts by the blood, the patient should be allowed to drink fre- 
quently of carbonic acid water with bicarbonate of soda in solution, weak ani- 
mal broths with salt, iced-water, iced brandy and water, gum-water, barley- CLASS III.] 
EPIDEMIC CHOLERA. 
663 
water, &c.; and injections of salt water with, laudanum may be occasionally 
thrown up the bowels. 
When reaction has begun, the stimulants should be moderated or with- 
drawn, and attention confined chiefly to the correction of the quality of the 
blood by the continued use of suitable drinks, and to the obviating of any 
local irritations which may appear. 
When reaction is established, the treatment must be made to conform to 
the variable morbid conditions presented, and must be guided by the general 
principles applicable to other affections., One fact, however, must be borne 
in mind, that the inflammations which are apt to occur cannot, in conse- 
quence of the previous exhaustion, be treated with the same activity of deple- 
tion as-under ordinary circumstances. Blood, must be cautiously abstracted, 
and cupping or leeching is in general preferable to the lancet. Reliance must 
be placed chiefly upon fomentations, blisters, the mercurial impression, and a 
properly regulated regimen. If a typhoid state of disease appear, it may be 
necessary to have recourse to tonics and stimulants, as sulphate of quinia, 
serpentaria, carbonate of ammonia, wine-whey, oil of turpentine, &c., as em- 
ployed in the ordinary typhoid fever. 
Attention to the diet is very important. In the preliminary diarrhoea, 
while the appetite continues in a greater or less degree, the food should be 
of the least irritating and most digestible kind. Stale bread, crackers, boiled 
rice, milk, cream, light broths,, and boiled meats of easy digestion (see Dys- 
pepsia), may be employed. When the disease is established, the diet should 
consist of mucilaginous and farinaceous liquids, or very weak chicken or mut- 
ton water. Milk, in very small quantities, with lime water, sometimes proves 
useful both as food and medicine. During convalescence, the utmost caution 
should be observed to avoid indigestible, flatulent, of irritating substances. 
The farinaceous preparations, and the lighter kinds of animal food, should be 
preferred. The, dietetic rules given in dyspepsia and chronic gastritis are 
applicable here. ■ 
Much may be done by proper prophylactic measures to avoid the disease, 
or render it milder. The diet should be of such a character as to preserve 
the digestive organs, and the general system, in the soundest possible state, 
so that they may be neither over-stimulated nor depressed. It should consist 
of a mixture of vegetable and animal food, avoiding indigestible, flatulent, 
acid, and irritating substances, but admitting the more digestible fruits, when 
not forbidden by an already debilitated or irritated condition of stomach. 
They are useful by obviating costiveness, and the consequent necessity for the 
use of cathartic medicines. All those drinks should be shunned, which have 
been mentioned as exciting causes of the disease. Habits of temperance both 
in eating and drinking are all-important; but, for an individual accustomed to 
the use of stimulating drinks or food, there might be some danger in a sudden 
change. A moderate elevation of the vital functions is preferable to their 
depression; and hence, the use of gentle stimulants, such as ginger, mustard, 
black and Cayenne pepper, in moderation, may prove serviceable. An equa- 
ble state of mind should be preserved as far as possible; and excessive fatigue, 
sensual indulgences, exposure to sudden changes of temperature, and espe- 
cially to the damp night air, should be avoided. 
In relation to the various plans of treatment, not included in the above 
statement, a very general sketch must suffice. Bleeding in all stages of the 
disease, even in that of collapse, has been the remedy chiefly depended upon 
by some practitioners. Others have placed great reliance upon emetics of 
ipecacuanha, mustard, dr warm brine; and even purgatives have found their 
advocates. In the East Indies, and subsequently in some parts of the United 664 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
States, calomel in large doses, with or without opium, was a favourite remedy; 
and the quantities administered with impunity, in certain cases, would seem 
scarcely credible, were they not well authenticated. Frequent draughts of hot 
water were highly lauded, as constituting the most effectual treatment, by one 
practitioner; while another spoke with equal confidence of the almost exclu- 
sive use of cold drinks and cold water, or ice applied externally. Some relied 
upon opium, brandy, and other stimulants; the school of Broussais, on the 
contrary, upon cool and demulcent drinks, leeches'to the epigastrium, and the 
external use of fomentations and rubefacients. Great success has been claimed 
for a treatment, in which the prominent measure was the application of irri- 
tants over the spinal column; ammonia, oil of turpentine, and a heated flat- 
iron, being employed for the purpose. The doctrine of Stevens, that the salts 
of the blood are essential agents of its aj-terialization, and the well ascertained 
loss of these salts by the evacuations which take place in cholera, led to the 
use of the non-purgative salts, such as bicarbonate of soda, chloride of sodium, 
chlorate of potassa, &c., as the main remedial measure. Irom the same idea 
of restoring to the blood the constituents lost during the disease, originated 
the practice of injecting into the veins, during the collapse, large quantities of 
warm water, holding common salt and carbonate of soda in solution, in the 
proportion in wdiich these salts are found in the serum of the .blood. The 
happiest effects seemed for a time to result from this remedy; the pulse re- 
turning, the surface assuming its natural colour and fulness, and the patient 
reviving into the appearance of convalescence: but the evacuations' returned, 
and collapse generally ensued, followed by speedy death. Nevertheless, the 
remedy is worthy of attention, as it affords some prospect of benefit in cases 
otherwise almost hopeless; and instances have occurred, in which, by the 
simultaneous use of internal remedies calculated to restrain evacuations, a 
return of collapse has been prevented, and the patient restored to health. 
Besides the above plans of management, particular articles of the Materia 
Medica acquired a more or less diffusive credit with the profession or the pub- 
lic. Among theise may be mentioned tincture of camphor, charcoal, sulphate 
of quinia in very large doses, and galvanism. Accounts have recently been 
received (November, 184$) of extraordinary success, in some Eastern coun- 
tries, from the use of the native naphtha, which is given in the dose of from 
ten to twenty drops. Butbas before observed, experience has not pronounced 
so favourably in relation to any of these remedial means, as . to obviate the 
necessity of a recourse to general principles; and the author has already given 
his views, as to the course of treatment which these principles appear to him 
to suggest. 
Miele III. 
CHOLERA INFANTUM. 
Syn.-Summer Complaint of Children. 
This affection, though probably not altogether unknown in Europe, is so 
rare as to have escaped the particular notice of most of the writers of that 
continent, and, when it occurs, is merely ranked among the cases of gastro- 
enteric irritation or inflammation to which infancy is subject. Its frequency 
and great fatality in this country make it an object of strong interest, and, both 
among the profession and the people at large, it is universally considered as 
meriting a distinct designation. CLASS III.] 
CHOLERA INFANTUM. 
665 
The complaint usually affects children between the ages of three months 
and two years, though instances sometimes occur before the first, and after 
the last of these two periods. It is exclusively a disease of the warm Reason, 
commencing with tlm first heats of summer, and ceasing upon the occurrence 
of cool weather in autumn. It is confined, moreover, almost entirely to cities, 
and prevails most in those of largest size, and most densely peopled. 
Symptoms.-The attack of cholera is often preceded, for a longer or shorter 
time, by diarrhoea; but sometimes ,the vomiting and purging commence 
simultaneously. In fatal cases, of short duration, the vomiting usually con- 
tinues to the end; but, when the disease terminates favourably, or is much 
protracted, it very often subsides considerably, or ceases altogether, leaving 
only the diarrhoea behind. Occasionally, the disease is exceedingly violent 
and rapid; the vomiting and purging are almost incessant; the stomach re- 
jects everything swallowed, even cold water; the intervals are marked by 
great languor and distress, with more or less spasmodic pain of the stomach 
and bowels; and, if relief is not afforded, prostration comes on, with a cool 
and clammy skin, pallid and shrunken features, half-closed eyes, insensibility 
amounting at length to coma, and death in three or four days, or sometimes 
even within twenty-four hours. 
Muth more frequently, however, the attack is attended with febrile symp- 
toms, and the case protracted to one, twd, or three weeks, or more. In such 
instances, the pulse is frequent, small, and weak or corded, the mouth is hot, 
the tongue somewhat furred, and the surface of the body irregularly heated; 
the head and trunk being often above the healthy standard of temperature; 
while the extremities are cool. Writers in general describe the fever as re- 
mittent, and state that the exacerbation occurs in the evening. It is some- 
times attended with delirium or stupor, indicating a morbid state of the- brain. 
The abdomen, though usually flat or sunken, is sometimes swollen and 
painful on pressure. In fatal cases, the vomiting occasionally continues un- 
abated to the close, with the symptoins already mentioned; but more frequently 
it diminishes or ceases, leaving a diarrhoea, which runs on for several weeks, 
and gradually wears out the patient. In the progress of the complaint, the 
child emaciates rapidly; the flesh becomes soft and flabby; the skin hangs 
loosely about the neck; the features shrink greatly; the eyes become sunken; 
and the whole surface, pale, and either cool and clammy, or harsh and dry. 
In the more advanced stages, various morbid phenomena are presented. The 
abdomen is tumid or much sunken; the mouth is moist and aphthous, or 
brownish-red and dry; petechias occasionally appear upon the surface of the 
body, and a small vesicular eruption on the breast; the skin sometimes as- 
sumes a dull dirty hue, and the conjunctiva appears blood-shot; the emacia- 
tion is extreme; the circulation is in the lowest state of languor; the child is 
often exceedingly restless, rolling the head from side to side and tossing the 
body in various directions, with moans and plaintive cries; at length coma 
sets in, and the scene is closed not unfrequently with convulsions, or in the 
midst of apparent hydrocephalic symptoms. 
Throughout the coinplaint, the child generally sleeps with the eyes more or 
less open; there is almost always thirst, which is sometimes insatiable; the 
appetite is variable and capricious, sometimes wanting, sometime^ rapacious, 
and again seeking tlie most unusual articles of food. The discharges are in a 
high degree various in character. At first they consist of the previous con- 
tents of the stomach and bowels; and the matter vomited is always liable to 
be modified by substances swallowed, being frequently mingled with milk, 
either liquid or in various states of coagulation. The discharge of curdled 
milk is popularly viewed as an unfavourable sign, but is in fact the reverse, 
as it indicates the continued possession of a degree of digestive power by the 666 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
stomach. After the discharge of the ingesta and feculent matter, the evacua- 
tions are for the most part thin and copious, sometimes colourless, but usually 
more or less tinged green, yellow or brown, and not unfrequently deep-green. 
Along with the more liquid parts, the stools often contain concrete or semi- 
concrete matter, yellow, green, white, or translucent, or of these different 
characters variously combined, and not unfrequently tinged with blood. 
Sometimes they consist chiefly of slime. At an advanced period, they are 
often copious, and dark-coloured or reddish, like the washings of putrefying 
flesh. Throughout the complaint, they are either inodorous, or sour, putrid/ 
or otherwise offensive, but seldom if ever have the healthy fecal smell. When 
the disease has degenerated into a lingering diarrhoea, it very commonly hap- 
pens that more or less appetite remains, without the power of digestion; and 
the ingesta pass from the bowels little if at all changed. Worms either dead 
or alive are not unfrequently discharged by stool, or even from the stomach. 
Dr. Dewees considered the passage of live worms as a very unfavourable sign. 
The duration of the disease varies from a few hours to weeks, or even 
months. When terminating in a diarrhoea, it often runs on for a long time, 
sometimes improving under treatment, or with the diminished temperature of 
the air, and then again relapsing when the favourable circumstances change, 
until at length the system is worn out, or the permanent return of cool 
weather turns the scale in favour of health. The struggle is. often one of 
time; the aim of the physician being to keep the enemy at bay, until he can 
receive the aid of the advancing autumnal season. There is scarcely any 
condition of the disease so desperate as to forbid all hope; recoveries having 
occasionally taken place under the most unpromising circumstances. Perhaps 
the most alarming symptoms are those of hydrocephalus occurring in the 
advanced stages. A general subsidence of the morbid phenomena affords, of 
course, ground for a favourable prognosis; but one of the most cheering signs 
is a return of the discharges to the healthy condition. Increased liveliness 
on the part of the child, a regular appetite, and diminished frequency of the 
evacuations, are also very favourable signs. 
Anatomical Characters.-According to Dr. Condie, if death take place 
early, an unusual paleness of the mucous coat, and more or less hepatic con- 
gestion, are often the only morbid appearances discoverable. (Diseases of 
Children, p. 219.) Dr. Hallowell states that there is " undue developement 
of the follicles, both of the stomach and intestines, or of one of those organs, 
without inflammation of the mucous membrane." (Am. Journ. of Med. Sei., 
N. S., xiv. 42.) At a more advanced stage, there is generally some indica- 
tion of inflammation; the mucous membrane of the stomach and bowels 
exhibiting more or less redness in points and patches, and an increased de- 
velopement of the glandular follicles. Dr. W. E. Horner found the mucous 
follicles in great numbers enlarged, and even ulcerated, both in the small and 
large intestines; and in one case he observed small ulcerations of the surface 
of the membrane in the jejunum. (Am. Journ. of Med. Sci., iii. 253.) The 
large intestine was in some degree inflamed and softened in almost all the 
cases examined by Dr. Hallowell. (Ibid., N. S., xiv. 48.) The gastric 
mucous membrane is sometimes very soft, so as to be readily scraped off 
by the nail. Dark livid or purple spots have been observed upon the ex- 
terior surface of the stomach and duodenum. The bowels usually contain 
green, yellowish, or colourless mucus. Dr. Horner observed pus in consider- 
able quantities in the colon in one case; and retained feculent matter is some- 
times found in the large intestines. The liver is usually enlarged and con- 
gested; and the gall-bladder contains a liquid, which is sometimes dark-green, 
and sometimes pale or nearly colourless. The brain has also been occasion- 
ally found in a congested state; and serous effusion in the ventricles or upon CLASS III.] 
CHOLERA INFANTUM. 
667 
the surface, and thickening, and opacity of the arachnoid have been observed. 
In cases which have exhibited hydrocephalic symptoms before death, the brain 
is either generally or partially softened. Dr. Lindsly found the bladder in 
several cases quite empty and much contracted. (Am. Journ. of Aled. Sei., 
xxiv. 806.) 
Causes.-.-The main cause of cholera infantutn is undoubtedly a combina- 
tion of heat of weather and the impure air of cities. Neither of these causes 
is alone sufficient; for the disease does not occur at an equal or even greater 
elevation of temperature in country places; nor in cities during cold weather. 
The peculiar condition of the air generated in a crowded population appears 
to be essential; as even miasmatic districts in the country are exempt. It is 
true, that miasmata have been supposed to favour the disease; but this is 
contrary to the personal observation of the author; and it is a well known 
fact, that our autumnal fevers, which are universally believed to be of mias? 
matic origin, scarcely ever penetrate the densely built portions of our cities, 
where cholera infantum is most rife. It is a fact of constant observation, 
that this disease is most frequent and most virulent in crowded lanes, courts, 
and alleys, where population is thickest, and ventilation most imperfect. It 
is, indeed, one of the greatest scourges of our large cities. According to Dr. 
Dondie, 3576 children died of it in Philadelphia during a period of 20 years 
(Diseases of Children, p. 220); and-Dr. Lindsly states that, of 201 deaths 
in Washington, during the three summer and first two autumnal months of 
the year 1888, fifty-five, or about one-quarter, were of cholera infantum. 
(Am. Journ. of Aled. Sei., xxiv. 302.) 
But there are other causes which occasionally produce a predisposition to 
the disease, or call an already existing predisposition into action. (, Among 
these may be mentioned the process of dentition, unwholesome food, worms, 
and exposure to cold in a relaxed state of the skin. Dentition, though pro- 
bably not alone capable of producing it, very much favours its production, 
and greatly aggravates the danger. Most of the fatal cases occur during this 
process, and very few after its completion. _ Hence, children are universally 
considered as having passed the period of greatest danger, when the second 
summer is over. That diet has much influence upon the origin and severity 
of the complaint is proved by the fact, that children fed by the bottle, or the 
spoon, are more frequently and more dangerously affected than those nourished 
at the breast. 
Nature.-From the symptoms of the disease, and the appearances upon 
dissection, it may be safely inferred to consist essentially in an irritation or 
inflammation of the alimentary mucous membrane, directed especially to the 
mucous follicles, and associated, with a congested and torpid state of the liver, 
probably depending upon the same cause. The morbid phenomena connected 
with other organs are probably secondary or accidental. 
Treatment.-The first indication in the treatment of cholera infantum is 
obviously to remove the causes. While these continue to act, the most judi- 
cious efforts of the practitioner will, for the most part be either quite nugatory, 
or but partially successful. The patient may be relieved, may even be appa- 
rently cured; but the disease will often return under less favourable circum- 
stances of constitution than at first; and, though a partial restoration may be 
again effected, and this alternation of relief and relapse may occur several 
times, yet there is great danger that the powers of vital resistance may be 
quite broken down, before the morbid cause shall cease with the hot season. 
The child, therefore, should be promptly removed into the pure air of the 
country. In general, the happiest change in the disease speedily follows this 
change of atmosphere. With a proper attention to diet and clothing, the 668 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
child will almost always recover, even without medicine, or with sttch only as 
may be entrusted, by the medical adviser, to the judgment of the mother or 
nurse. The author has always been in the habit of pursuing this course, and, 
during the whole period of his practice, recollects only one fatal case, where 
the child has been rsent into the country in the early stage of the disease. 
When the. complaint is of longer standing, and the irritation of the bowels 
has had time to deepen into inflammation, the Success of the measure is less 
striking, though even then it will be found the most effectual, especially when 
judicious medical advice can at the same time be obtained. Oases often 
occur, in which, under apparently the most desperate circumstances, the child, 
upon leaving the city, almost immediately begins to revive, and advances 
rapidly to convalescence. Should circumstances render a removal imprac- 
ticable, the patient should be carried daily into the country, or into' one of 
the opfen and moSt airy spots- of the city, and kept there as long as possible; 
and great care should be taken to have the apartments at home well ventilated, 
and perfectly clean and dry. 
It is also highly important to examine the mouth of the infant at once, 
and, if the gums are swollen and painful, to lance them freely. Should the 
inflammation of the gums be extensive, from the pressure of several tefeth, it 
may be advantageous, in addition to the lancing, to apply a few leeches to the 
cheeks, and a pair of blisters behind the ears. 
Under the same head may be considered the diet and dress of the patient; 
as errors in these respects are among the common exciting causes of the dis- 
ease.' The food of the infant should be the mother's milk, or, if she be dis- 
eased, that of a healthy wet nurse; and the child should not be weaned during 
the existence of the complaint. The best substitute for this diet is perfectly 
fresh cow's milk, diluted with water. The farinaceous liquids prepared from 
barley, rice, sago, tapioca, arrowroot, wheat bread, water-crackers, &c., may 
also be used; but care must be taken that these substances are entirely free 
from mustiness. When there is much fever, solution of gum arabic, infusion 
of benne leaves, or other mucilaginous fluid may be substituted. The caution 
should always be observed, whatever nutritive drink may be used, to give it 
in small quantities, so as not to irritate the stomach; and the disposition 
which the child often evinces, in consequence of its thirst, to suck freely 
should be restrained. To quiet the excessive thirst, very cold water, or cold 
solution of gum arabic, given frequently in small quantities, is preferable to 
more nutritious fluid?. Pounded ice, confined in linen or gauze, so as to 
prevent it from being swallowed undissolved, will often be found useful. In 
the advanced stages of the disease, when the system is much enfeebled, it 
will be proper to allow a portion of animal food, such as weak chicken or 
mutton broth; and the child may be allowed to suck a piece of ham, dried 
salt beef, salt fish, &c., if these upon trial should be found grateful. It occa- 
sionally happens that the little sufferer exhibits a peculiar longing for some 
article of diet, which may not be thought suitable. Should this disposition 
be permanent, it should be attended to, as the voice of nature; and the desired 
article should be allowed, with such caution, however, at first, as to insure 
against serious evil. The clothing should be such as to preserve an equable 
temperature of the surface, without oppressing the child. Very thin flannel 
should generally be w*orn next the skin, and the feet and legs should be pro- 
tected by light woollen stockings. 
In relation to the medical treatment, the indications appear to be, to remove 
sources of irritation from the alimentary canal by laxatives and antacids; to 
promote the hepatic secretion, and thereby remove portal congestion, by calo- 
mel oi' some other mercurial; to divert excitement externally by diaphoretics, CLASS III.] 
CHOLERA INFANTUM. 
669 
and by measures addressed to the surface; to relieve irritation by anodynes, 
and inflammation, when of a decided character, by direct depletion; to check 
excessive evacuations, in the advanced stag6s, by astringents; to modify the 
morbid state of the affected membrane by alteratives; and, finally, to support 
the patient by suitable stimulants when greatly debilitated. 
In the early stage, attention should be first directed to the means for allay- 
ing the excessive vomiting. For this purpose, rubefacients should be applied 
to the epigastrium, so as to excite a very decided irritation upon the surface. 
Mustard, diluted with an equal quantity of rye-meal, is perhaps the most 
effectual application; but bruised mint steeped in brandy, or cataplasms made 
of the different spices, such as powdered black pepper, ginger, cinnamon, 
cloves, &c.) separate or mixed, may be employed. At the same time, very 
small and repeated draughts of fresh and cold carbonic acid water; or tea- 
spoonful doses, repeated every quarter or half hour, of lime water and fresh 
milk, mixed in equal proportions; or some one of the aromatic waters or 
infusions, such as mint-water, and fennelseed tea; or camphorated tincture of 
opium, in the dose of five or ten drops sufficiently diluted, may be given 
internally, one of them being preferred to another according to the particular 
circumstances of the case, as, for instance, the degree of vascular action, the 
presence or absence of acid, &c. Dr. Dewees recommends, for the same 
purpose, a teaspoonful of strong coffee without sugar or milk, every fifteen 
minutes, and an injection of a gill of warm water holding a teaspcionful of 
common salt in solution, which may be repeated when the vomiting is severe. 
The latter he considers as the most prompt and certain remedy that can be 
employed. (Treat. on Phys, and Med: Treat, of Children, 4th ed., p. 420.) 
Dr. Condie speaks very favourably of the oil of turpentine, and of a solution 
of camphor in sulphuric ether, and, when everything else, has failed, generally 
succeeds with a solution of acetate of . lead, in doses containing about one-sixth 
of a grain, repeated every hour or two. (Diseases of Children,y. 223.) When 
the vomiting is excessive, and other means fail in arresting it, an anodyne 
injection may be resorted to, containing from three to six drops of laudanum 
in a little thin starch. Indeed, opiate enemata will be found highly useful 
throughout the complaint, when the irritation of stomach is considerable, and 
no symptoms of cerebral disease exist. They may be repeated in suitable 
cases every day, and, if given at night, will be. found very useful by enabling 
the child to rest. Care, however, must be taken not to employ too large a 
dose; a mistake which is often made in infantile cases. 
When the stomach becomes retentive, medicines should be given to eva- 
cuate the bowels. Combinations of rhubarb and magnesia are usually well 
adapted for this purpose. They may be given in powder; but the syrup of 
rhubarb, and the solution of carbonate of magnesia in carbonic acid water, 
are perhaps preferable. A teaspoonful of the syrup, with twice that quantity 
of the solution, may be given every two hours until they operate. The ope- 
ration of the rhubarb may be known by its colour in the stools. The 
magnesia is peculiarly suitable, when a sour smell and green colour of the 
evacuations indicate acid in the bowels. Advantage will often arise from 
administering these medicines in some aromatic vehicle. When the dis- 
charges are small, mucous, and attended with pain, castor oil should be sub- 
stituted for the rhubarb and magnesia. But probably, upon the whole, the 
mo^t effective cathartic in these cases is calomel. In children two years old 
or upward, I have seen it act most happily in numerous cases, in doses of two 
grains repeated at intervals of two, four, or six hours, until evidences of its 
operation were presented in the passages. Employed in this way, it often 
puts an almost immediate end to the disease, if given early. Another mode 670 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
of exhibiting calomel, which is much employed, and is adapted to any age, is 
in doses of from one-sixteenth to one-quarter of a grain, repeated so that from 
one to two grains may be given in the course of twenty-four hours. This 
plan is peculiarly useful when the stomach is irritable, and the secretion of 
bile suppressed, or greatly deficient. The calomel may be administered mixed 
with a little powdered gum arabic, in syrup or upon the surface of a tea- 
spoonful of milk, or simply introduced into the mouth of the infant with a 
little sugar. A good plan is to give the mercurial one day, and the syrup of 
rhubarb or other laxative on the next, and thus alternate them until the stools 
become bilious; or the two may be alternated upon the same day, or even 
given conjointly, at the discretion of the practitioner. The laxative plan 
should be persevered in until the discharges assume a more natural appear- 
ance, unless there maybe reason to think that it aggravates the complaint, or 
that no benefit continues to accrue from it. Occasionally, from half a drop 
to a drop or two of laudanum may be usefully added to the laxative. It 
quiets pain, and relieves spasm of the bowels, without preventing the cathar- 
tic action. It may thus be combined especially with the syrup of rhubarb 
and castor oil. This latter cathartic, given in the form of oleaginous mixture, 
made with gum arabic, loaf sugar, mint or cinnamon water, and laudanum, 
may^be used with peculiar advantage in the advanced stage of the complaint, 
when the intestinal irritation approaches the dysenteric form.. 
When the complaint has the character of diarrhoea from the beginning, or 
assumes that character in its progress, and there is little or no irritability of 
stomach, but still deficiency of biliary secretion, the minute doses of calomel 
may be very happily associated with the powder of opium and ipecacuanha, 
which quiets irritation of bowels, and gives a direction to the skin. Under 
these circumstances, also, the cretaceous preparations should be substituted 
for magnesia, especially if fever is absent', and the debility considerable. 
They are like it antacid, but rather astringent than purgative; and the indi- 
cation is less to promote than to check the alvine evacuations. The mercurial 
pill, or mercury with chalk, may be substituted for calomel. These remedies 
may often be advantageously given in combination, as in the formula beldw.* 
If ipecacuanha should be objectionable, laudanum may be substituted for the 
Dover's powder in equivalent proportion. Mixtures made in the same way 
with carbonate of soda, or carbonate of potassa, as an antacid, are also occa- 
sionally used, but are less efficient. Cinnamon water may be substituted for 
that of peppermint; but, if the officinal preparation be used, it should be 
diluted with from two to four parts of water. This plan of management 
should be continued until the stools assume a healthy colour. 
In a still more advanced stage, when the continuance of the evacuations 
threatens to exhaust the patient, it becomes necessary to attempt to arrest 
them by astringents. For this purpose, kino, catechu, or extract of krameria 
may be added to the cretaceous mixture above directed, from which the mer- 
curial may be omitted, if no longer requisite. The decoction of log-wood, or 
of cranes-bill (^geranium, U. S. Ph.) may also be used; and, if a combined 
tonic and astringent effect is desired, that of the black-berry .root or dew- 
berry root. Some of the mineral astringents are perhaps still more efficient, 
especially acetate of lead, which has been highly recommended, and is cer- 
tainly very useful in many cases of the diarrhoea following cholera infantum. 
Dr. Chapman, in his lectures, speaks favourably of alum. These remedies 
probably operate as much by an alterative impression on the mucous mem- 
* R--Pil. Hydrarg. gr. vj; Pulv. Ipecac, et Opii gr. ij; Cretse, vel Testae Ppt. ^i; 
Acaciae pulv. gj; Saccbari gj; Aquas Mentli. P. f^ij. S. A teaspoonful every two hours, 
or pro re nata. CLASS III.] 
FLATULENCE. 
671 
brane, as by their astringency. They may in general be usefhlly combined 
with an opiate, and sometimes with ipecacuanha. Dr. Lindsly speaks, in the 
strongest terms, of the efficacy of a combination of acetate of lead and Dover's 
powder. (Am. Journ. of Med. Sci.^ xxiv. 311.) The mineral acids some- 
times prove useful as alteratives and tonics. These also should be combined 
with an opiate. The nitro-muriatic acid, or nitric acid is perhaps to be pre- 
ferred. The author has employed the latter in the form of Hope's mixture 
(see page 570),'with decided benefit. Nitrate of silver was employed by Dr. 
Skinner, of N. Carolina, in one almost desperate case, with the happiest result. 
The salts of iron may be resorted to in cases of anaemia, connected with 
obstinate diarrhoea. Other substances sometimes used as alteratives are the 
oil of turpentine and copaiba. In cases of great debility it may be necessary 
to resort to wine-whey and the ammoniacal preparations; and the vegetable 
tonics will often prove useful in hastening a protracted convalescence. 
When, in the course of the complaint, there is much tenderness of the 
abdomen, and the patient is not greatly exhausted, leeches, followed by warm 
fomentations or emollient cataplasms, should be employed; and, if these do 
not relieve the inflammation, they should be succeeded by a blister. In some 
rare cases, in which there is tension of pulse connected with gastric, intes- 
tinal, or cerebral inflammation, recourse may be had to the lancet. Should 
symptoms of meningeal inflammation occur early in the disease, they must be 
counteracted by local and general depletion, carried as far as circumstances 
will warrant, by cold applications to the head, and by blisters. 
Throughout the complaint, remedies should be employed in reference to a 
direct impression upon the surface. In the early stages, the simple warm- 
bath, and, in the more advanced, the warm salt or mustard bath, may be 
tried, and if found beneficial may be repeated every day. Great advantage 
may be expected from the salt-bath, especially when the disease has termi- 
nated in diarrhoea. Baths of oak bark may also be tried under similar cir- 
cumstances. When heat is deficient in the extremities, the equilibrium should 
be restored by frictions, and by rubefacients applied to the legs ahd arms. 
Oil of turpentine, liniment of ammonia, or warm tincture of Cayenne pepper, 
may be employed. Blisters to the extremities, under these circumstances, 
are also clearly indicated. Rubefacient applications to the abdomen should 
be occasionally used, and the •■effects of a flannel bandage in the advanced 
stages have been much praised. 
Prophylactic measures should always be resorted to in cases in which a 
predisposition to this disease exists. The rules already giveii in relation to 
country air, ventilation, dentition, diet, dress, and exposure to sudden changes 
of temperature, are -applicable here. The late Dr. Parrish used strongly to 
urge the propriety, when the predisposition is very strong, of fortifying the 
stomach and bowels by a digestible animal diet, and the use of aromatics, 
particularly the infusion of ginger, during the period of danger. 
Article IV. 
FLATULENCE. 
Syn.-Eructation.-Crepitus.-Borborygmus.-Tympanites.'-Meteorism. 
Gases of different kinds are always found in the stomach and bowels, where 
their presence appears to be a provision of nature to sustain an equable dis- 
tension of the abdominal cavity, under the constantly varying quantity of its 
liquid and solid contents. It is only when they are produced so abundantly, 672 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
or accumulate so much as to become a source of decided inconvenience, that 
they can be considered in the light of morbid phenomena. In most instances, 
flatulence is a mere result of other morbid affections, and is to be regarded 
rather as a symptom than as a disease. But it is sometimes an original affec- 
tion, without any appreciable. organic or functional derangement, other than 
that which its existence necessarily implies, and, like dropsy, deserves to rank 
as a distinct order. ' , , i ( 
Symptoms, Course, Diagnosis, &c.-The symptoms of flatulence are such 
as depend either upon a too copious evolution of gas in the alimentary pas- 
sages, or upon its undue detention in these passages, or upon these two con- 
ditions united. A sense of distension, Or of other uneasiness, is experienced 
in the stomach or some portion of the bowels, which is soon followed by the 
expulsion of air either upward through the mouth, producing belching or eruc- 
tation, or downward through the anus, not unfrequently with a loud report, 
which, however, the patient has it generally in his power to suppress. These 
discharges are often brought about by the voluntary contraction of the ab- 
dominal muscles and diaphragm; but sometimes-they are finite involuntary, 
and depend solely on the contraction of the muscular coat of the alimentary 
canal, or the clastic force of the confined gases. .They are sometimes exceed- 
ingly copious, the air rushing from the stomach ~or bowels, or from both 
together, in an almost continuous torrent, and constituting a very annoying 
affection, which has been called by some writers the dry cholera. Flatulence 
is often also attended with a disagreeable rumbling or gurgling sound in the 
bowels, called borborygmus, which is produced by the passage of the air from 
one part to another, and its intermixture with the intestinal fluids as it passes. 
Besides the sensations of distension or pressure, provoking and relieved by 
the discharges, the patient is often affected with pains, which are in some 
cases moderate and fugitive, in others distressing and almost constant, and in 
others again severe and spasmodic, amounting even to the most violent colic. 
Occasionally also acute pain is felt in various other parts, sympathetically 
connected with the stomach and bowels. Thus, it is not very uncommon for 
the spasmodic pain of gastric flatulence to shoot upward into the breast and 
throat, and even to ascend to the head. 
Meteorism, or tympanites is another distressing affection connected with 
flatulence. This consists in a distension of the bowels so considerable as to 
become visible to the eye. Perhaps the term meteorism may be appropriately 
applied to the slighter degrees of this distension, and tympanites to that con- 
dition in which the abdomen is very much swollen, so as to be quite tense 
and sonorous. Sometimes the swelling is local, so as even to have given .rise 
to the suspicion of the existence,of solid tumours; sometimes it appears to 
extend equally over the abdomen. In its higher grades it is often very inju- 
rious. The muscular coat of the bowels, when greatly distended, loses its 
power of contraction; and thus, not only is the collection of gas allowed to 
go on increasing, but the passage of the liquid and solid contents of the canal 
is impeded, and obstinate constipation results. Sometimes, however, diarrhoea 
attends tympanites. Another injurious result is the derangement of function 
in the neighbouring parts, pressed upon by the expanded bowels. The respi- 
ration especially suffers in this way, in consequence of the upward pressure of 
the diaphragm. A case is recorded by Dr. Ashmead, of Philadelphia, in 
which death obviously resulted from a cessation of respiration, consequent 
upon an enormous tympanitic distension of the bowels. ( Transact, of Col. of 
Phys, of Philad., Jan. 4th, 1842.) Another fatal accident, sometimes pro- 
ceeding from the same cause, is the rupture of the stomach or intestines by 
the expansive force of the confined air. In some rare cases of tympanites, CLASS III.] 
FLATULENCE. 
673 
the air is accumulated in the cavity of the peritoneal sac, instead of in the 
alimentary canal. 
There is nothing determinate in the course of flatulence. It may come on 
suddenly and as suddenly disappear, or it may continue, with various fluctua- 
tions, for a very great length of time. In the form of meteorism, of tympa- 
nites, it often lasts for years with little (abatement or alteration. In some 
cases, it disappears spontaneously, in consequence apparently of the absorp- 
tion of the gas; in others, it yields with greater or less facility to remedial 
measures; and,, in others, again, it obstinately resists all the means employed, 
and ceases only with life. / 
The part of the alimentary canal in which the evolution of gas takes place, 
may sometimes be inferred from the point whence the ascending or descend- 
ing current of flatulence seems to the patient to proceed, from the period 
intervening between the introduction of some flatulent substance into the sto- 
mach and the- first appearance of the symptoms, and, in the case of meteorism' 
or tympanites, from the particular position of the tumefaction. Flatulent 
distensions of the abdomen may be distinguished from liquid accumulations 
by the absence of that feeling of fluctuation produced by the latten, when the 
flat of the hand is placed on one side of the abdomen, and a gentle blow given 
to the other; from solid tumours, by the dull flat sound emitted by these upon 
percussion, instead of the clear resonance characteristic of confined air. A 
peculiar sound is given by percussion when the air is mixed with liquid 
matter. It is not always possible to determine, whether the gas occupies 
the bowels or the peritoneal cavity. The former position, however, may be 
inferred, when the distension was, in its forming stage, or continues to be 
unequal, and when a gurgling sound upon auscultation, or the peculiar reso- 
nance upon percussion, just alluded to, indicates a mixture of liquid and 
gaseous matter. 
The air evolved or confined, in flatulence, is generally a mixture of different 
gases, among which oxygen, nitrogen, and carbonic acid are the chief. Not 
unfrcqucntly inflammable air escapes, consisting probably of hydrogen, or its 
gaseous compounds. Sometimes the flatulent discharges are without odour 
and perfectly bland, sometimes they are loaded with offensive exhalations 
from the alvine contents, and sometimes they are acrid and burning. Little, 
however, is precisely known upon this subject. 
Causes.-Flatulence has its origin either in the character of the ingesta, or 
the condition of the alimentary canal, or in the two sources combined. Food 
not digested, or but imperfectly digested in the stomach, is liable to a chemi- 
cal decomposition, resulting in the evolution of gaseous fluids; and the quantity 
thus evolved from a very small portion of solid or liquid matter is sometimes 
enormous. This result may take place in a perfectly healthy condition of 
the digestive organs, if food be employed of a nature not adapted to the modes 
of living, or peculiar constitution of the individual, and consequently to his 
strength of digestion. Certain kinds of food and drink are peculiarly apt to 
evolve gases in the primae vim, and, on this account, are called flatulent. 
Such are cabbage, unripe fruits, melons, tough or fibrous roots, and ferment- 
ing or fermentable liquids. These will often evolve gas copiously in a healthy 
stomach. But, when the powers of digestion are morbidly enfeebled, the 
effect takes place in a much greater degree, and substances become flatulent, 
which, under ordinary circumstances, are easily dissolved in the gastric liquor. 
Any cause, therefore, which is capable of debilitating digestion, may act as a 
cause of flatulence. (See Dyspepsia.) The ordinary contents of the healthy 
bowels, consisting of the residuary alimentary matter and various secretions, 
are also liable to chemical reactions, which extricate gases, especially when 674 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
they are confined too long in the intestines; and constipation thus becomes a 
cause of the disorder. When these secretions are of an unhealthy character, 
in consequence of disease of the-secreting organs, they are often very highly 
flattdent. It is, moreover, very probable that the chemical changes, which 
take place when the heterogeneous contents of the small intestines are con- 
verted into homogeneous chyle, are often attended with the production of 
aeriform substances, even when the processses of digestion and of secretion 
are perfectly healthy. 
There is reason to believe that a direct exhalation of gas often takes place 
from the mucous membrane. We know that such an exhalation occurs into 
the cellular tissue, constituting emphysema; and into the various closed serous 
cavities; and the alternation which has sometimes been observed between 
emphysema, and flatulence of the bowels, leads to the inference, that the 
latter may be produced in the same manner. (Diet. de Med., xxi.' 132.) 
The occasional sudden substitution of tympanites for diarrhoea is another 
evidence of a similar character. But positive proof of the fact is not wanting. 
Portions of intestine entirely emptied of their contents, and inclosed between 
two ligatures, have been observed to become distended with gas,, especially 
when inflamed by some stimulant application. (See Am. Journ. of Med. Sei., 
N. S'., iv. 403.) What is the particular pathological condition of the mucous 
membrane -which leads to this result is not known. It seems to be in some 
measure' connected with defective or deranged innervation; for flatulent accu- 
mulations in- the stomach and bowels, not attributable to any other known 
cause, are frequent in nervous affections, such as hysteria, hypochondriasis, 
and strong mental emotion. Some have supposed the globus hystericus to 
be a sudden distension -of portions of the oesophagus by. air, confined by spas- 
modic constrictions' above and below it. Cold drinks taken too freely, during 
a heated state of the body, sometimes produce sudden attacks of flatulence, 
originating probably in exhalation or secretion. Another cause of flatulence 
is the habit which some acquire of swallowing air, and which may become a 
morbid condition, analogous to certain mental perversions ranked under hypo- 
chondriasis or monomania. 
The form of flatulence denominated meteorism or tympanites, is produced 
by some cause preventing the discharge of the air contained in the bowels. 
This cause, whatever it may be, is itself sufficient to occasion the affection, 
without any unhealthy production or evolution of gas; for the air taken in 
with the food, and that which, as before stated, is always extricated to some 
extent in perfect health, must become, morbidly accumulated, if any accidental 
excess of it be prevented from finding an exit. The effect, however, is much 
greater, when the causes of production or evolution, above enumerated, co- 
operate with those of detention. Among the latter are debility or atony of 
the muscular coat, impairing its contractile power; rigidity of the sphincter 
muscles of the oesophagus, pylorus, and rectum; spasmodic closures of the 
intestinal tube at other points; fecal accumulations; and mechanical obstruc- 
tions of all kinds, as by. tumours, permanent strictures, and foreign bodies. 
Tympanites is most commonly an attendant upon other diseases, especially 
enteric or typhoid fever, peritonitis, malignant dysentery, and the different 
forms of colic and obstruction of the bowels. In its chronic forms, it is often 
associated with hypochondriacal, hysterical, and uterine disorder. When 
dependent upon accumulation of air in the peritoneal cavity, it usually pro- 
ceeds from perforation of the stomach or bowels, perforation of the diaphragm 
(Arch. Gen., 4e ser., i. 471), or decomposition of the peritoneal membrane. 
It may, however, in this, as in other serous cavities, and in the cellular tissue, 
be the result of a secretory or exhaling process. 
Flatulence is most common in infants and young children. CLASS III.] 
FLATULENCE. 
675 
Treatment.-The indications are to cause the removal of the air already 
accumulated, and to prevent its evolution and accumulation in future. The 
first indication often requires prompt and energetic treatment, in consequence 
of the sufferings of the patient. The object may frequently be effected by 
the use of stimulants calculated, to act directly on the alimentary mucous 
membrane, and thus indirectly to excite the muscular movement. Such are 
the medicines denominated carminatives. To this set belong most of the 
aromatics. These may be variously employed, in substance, hot infusion, or 
tincture; or the volatile oil of the aromatic may be substituted for the medi- 
cine; and they may'be given separately, or differently combined, to suit the 
taste of the patient, or the views of the practitioner. , Among those most 
employed are peppermint and spearmint, fennelseed, cardamom, caraway, cin- 
namon, cloves, allspice, black pepper, ginger, and calamus. Twenty drops of 
the tincture of oil of peppermint, or oil of spearmint, (essence of peppermint 
or spearmint,) dropped on sugar, will often afford-prompt relief. Compound 
spirit of lavender, ami cojnpound tincture of cardamom, are very agreeable 
preparations, and may be given in the dose of a fluidrachm. Hot ginger tea 
will be found especially useful when there are colicky pains. Fennelseed tea, 
given both by the mouth and injection, is well adapted to infants. Becourse 
may also be had to various stimulants, which do not belong to the aromatics. 
The oil of turpentine is a powerful carminative. Cayenne pepper, oil of 
juniper, assafetida, camphor, ammonia, and ethereal oil, may also be occa- 
sionally used with advantage. Aromatic spirit of ammonia is an excellent 
preparation, when there is a depressed Condition of the system. Assafetida 
and compound, spirit of sulphuric ether (Hoffmann's anodyne) are peculiarly 
useful, when flatulence is complicated with hysteric or other nervous disorder. 
Prompt relief is often procured, when severe stomachic pain depends on flatu- 
lence, from a fluidrachm of camphorated tincture of opium. When the bowels 
are affected with flatulence, the aromatics may often be advantageously com- 
bined with mild cathartics. The free use of lime-water does good in some 
cases; probably, in part at least, by combining with and neutralizing carbonic 
acid. Friction over .the abdomen, agitation of the bowels by the hand with 
the body in a bent position so as to relax the abdominal muscles, jumping, 
jolting in a rough vehicle, or a ride on horseback, will aid much in the expul- 
sion of the confined air. Compression by a flannel roller or otherwise, stimu- 
lating embrocations, and gal vanism, have also been recommended. In meteorism 
or tympanites, injections of oil of turpentine or assafetida should be given, in 
connexion with other means; and, if the symptoms are severe, attempts should 
be made to draw off the air by the introduction of a long gum-elastic tube, 
through the rectum, far into the colon. -Life has probably been saved in that 
way. When the danger is very imminent from the vast distension of the 
abdomen, and relief Cannot be obtained by the ordinary measures, it may 
become a question, whether it would not be the-duty of the practitioner to 
puncture the caecum. . - ' - 
To prevent the morbid collection or evolution of air, it is necessary to 
remove or obviate the cause. Flatulent food and drink should be avoided, 
and the diet should be made to conform as nearly as possible to the digestive 
powers of the patient. Should, however, flatulent substances enter into the 
diet, their effects may be somewhat corrected by associating them with stimu- 
lating condiments, as Cayenne and black pepper and mustard. If the com- 
plaint originate in, or be associated with, debility of stomach and bowels, this 
should be? corrected by tonic medicines, and other means indicated under the 
head of dyspepsia. Constipation should be obviated by a proper regulation 
of the diet, and if necessary by laxatives; but, in the choice of means for this 676 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
purpose, care should be taken to shun those disposed to occasion flatulence. 
Among the most appropriate are bran bread, as an article of diet, and 
rhubarb or aloes as a cathartic. Magnesia may be -employed with advantage 
in connexion with these, when acid exists in excess in the primasAim. Un- 
healthy secretions into the-bowrels should be corrected, and the blue pill will 
often be useful to this effect, by its alterative action on the liver. 
When there is reason to believe that the gas proceeds from a secretory or 
exhaling act of the mucous membrane, tonics and astringents are indicated. 
An infusion of galls with fennelseed has seemed very useful in my hands, 
under these circumstances; and I have repeatedly known the affection to yield 
to the free use of sulphate of quinia. Strychnia or nux voinica lia's also been 
recommended. Dr. Graves strongly advocates the use of acetate of lead in 
tympanites; and Dr. Baddeley, of Chelmsford, has employed, both this salt 
and sulphate of zinc, in conjunction with an opiate, with success in very bad 
cases. (London Lancet, Jan. 8,1848, p. 44.) As flatulence is often dependent 
upon other diseases, care should be taken, in all instances, to discover its 
source, and apply remedies to this, instead of wasting tiirie in a -direct combat 
with the flatulence itself. Particular attention should be paid to nervous 
derangements, which appear frequently to occasion or aggravate it. 
Great advantage will often be derived from combining, in the same pre- 
scription, medicines calculated to meet different indications. Thus sulphate 
of quinia, as a tonic, may be united in mixture with assafetida and one of the 
aromatic volatile oils, as carminatives; and such a mixture is often highly 
useful in the cases of infants subject to flatulence.*' Magnesia may be asso- 
ciated, in mixture, with the aromatic oils, camphor water, and a little laudar- 
num when there is pain. Rhubarb or aloes may be given in pill, with quinia 
or a bitter extract, and with assafetida, black pepper, or a volatile' oib Such 
combinations may be multiplied indefinitely, and often with great: advantage, 
by a practitioner who possesses an adequate knowledge of medicines, *and the 
modes of preparing them. 
Article V. 
PERITONEAL INFLAMMATION, or PERITONITIS. 
The protection which the peritoneum gives to the alimentary canal is, per- 
haps, its most important function; and its diseases may, therefore, be very 
appropriately associated with those of the digestive organs. Inflammation of 
the peritoneum is susceptible of a division into several varieties; but may 
be most conveniently considered under the two heads of the acute and the 
chronic. 
1. ACUTE PERITONITIS. 
Symptoms, Course, &c.-A chill is sometimes the first symptom of peri- 
tonitis; but perhaps more frequently the disease begins with pain; and 
occasionally the occurrence of the two phenomena is simultaneous. The pain 
is sharp and very severe, and usually commences in the lower part of the 
* R. Quiniae Sulphat. gr. ij; Assafetida; gr. iv; Acacioe pulv., Sacchar. aa gss; Aq.. 
Cinnamom. f^j. Misce. S. A teaspoonful for a child one year old, four times a-day. CLASS III.] 
PERITONEAL INFLAMMATION. 
677 
abdomen, in the hypogastric or one of the iliac regions, whence it gradually 
extends over the whole cavity. Sometimes it is changeable,' occurring now 
in one spot and then in another; and not unfrequently is attended with a 
sense of heat or burning. The abdomen is always tender to the touch. The 
slightest pressure by the hand occasions exquisite pain, and whatever gives 
rise to contraction of the abdominal muscles has the same effect. Hence, the 
patient buffers much from vomiting, the act of defecation, the discharge of 
urine, and straining of all kinds. A deep inspiration is often very painful. 
Movements of the body in or out of bed are also painful; and even the weight 
of the bedclothes is often insupportable. Hence the patient usually lies mo- 
tionless upon his back, with his knees drawn up, so as at once to relax the 
abdominal muscles, and take off the weight of. the coverings. Another object 
of the supine position appears to be, to obviate in some degree the pressure 
of the bowels upon the parietal peritoneum. But this posture is not so 
universal as might be inferred from the descriptions of most medical writers. 
The author recollects that, in one of the worst cases of peritoneal inflammation 
he ever witnessed, the favourite position of the patient was upon his left side, 
with the knees so much drawn up as to be almost in contact with the abdo- 
men. Most frequently the tenderness is general, but in some instances is 
greatest in particular spots, and in others is confined altogether to one spot; 
indicating, in the latter case, the local existence of the inflammation. From 
near the commencement, there is generally a feeling of hardness, tension, and 
elasticity in the abdominal parietes; and very soon a tumefaction begins, 
which increases with the progress of the complaint, and towards the close 
assumes the character of tympanites. In some cases, however, there is little 
swelling; and in others, none at all;, the abdomen being sometimes even 
drawn in by the constriction of the muscles. The' swelling is for the most 
part uniform, but is sometimes irregular, giving to thb hand the sensation of 
a tumour or tumpurs in the abdomen, which may be either permanent or 
changeable. Percussion evinces at first a resonance healthy, or greater than 
that of health; but, as the disease advances, the sound becomes dull, espe- 
cially in the depending parts. After the complaint has. lasted a short time, 
the abdomen frequently offers, under auscultation, a friction sound, like that 
observed, in pleurisy, and like it arising.from the rubbing together, during 
respiration, of the. opposing surfaces of the serous membrane, roughened by 
the effused coagulable lymph. 
Besides the above phenomena, there are many others, either sympathetic, 
or depending on a direct propagation of the irritation to contiguous parts. 
Nausea and vomiting, thirst, constipation, and scanty or suppressed urine are 
very frequent symptoms. The vomiting is sometimes exceedingly distressing. 
The constipation is obstinate, in those cases in which the muscular coat of 
the bowels becomes involved in the inflammation; but it is not a constant 
symptom, and sometimes gives way to diarrhoea. The face is pale, contracted, 
and marked by an expression of deep distress and anxiety,' characteristic of 
the disease. The respiration is short. The pulse is usually very frequent, 
from 110 to 130 or more in a minute, small, and tense; though in some rare 
cases it is full, and but little accelerated. The tongue is usually moist, and 
covered with a whitish or yellowish fur; but sometimes it is red and dry, and 
sometimes nearly natural. The patient is very often wakeful. The chill 
with which the attack commences, or which follows the occurrence of pain, is 
usually succeeded by febrile heat of surface, which, however, soon subsides; 
and, during the greatest severity of the complaint, the skin is often but little 
warmer than in health. 
The inarch of peritonitis is usually rapid. In fatal cases, death sometimes 678 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
occurs within twenty-four hours, and generally in about a week; but occa- 
sionally the disease runs on for three or even four weeks. An aggravation 
of the pain, tenderness, and other symptoms marks its advance;' but, when 
the fatal termination approaches, the pain often suddenly subsides, or ceases 
altogether; and this may be considered as one of the most unfavourable signs, 
when not attended with a marked amelioration of the disease in other respects. 
At this stage, the pulse is extremely frequent and feeble; the extremities are 
cold, and sometimes purplish or livid; the countenance is sunken and ghastly; 
the abdomen is either tympanitic, or soft and flaccid; a troublesome hiccough 
often occurs; and a green-or blackish matter'is thrown up from the stomach, 
rather by regurgitation than vomiting, and sometimes flows from the mouth 
of the patient without his consciousness. Occasionally the bowels give way, 
and a similar dark matter is discharged per anum. Coma, or convulsions, or 
both, sometimes precede the fatal issue. 
A favourable termination is indicated by a gradual subsidence of the pain, 
tenderness, and. tension of the abdomen, a cessation of the vomiting, a dimin- 
ished frequency of pulse, and a less anxious expression of countenance. 
Occasionally a copious discharge from the skin, bowels, or kidneys, attends 
the solution of the disease. In some cases, the symptoms entirely disappear, 
and the recovery is perfect. In others,- a greater or less degree of pain and 
tenderness in the abdomen and frequency of pulse continues long after the 
danger is over; and sometimes a hard tumour in some part of the cavity 
remains for a considerable time. Again, the acute may subside into the 
chronic form of the disease; and the result thus be long postponed, and quite 
uncertain. In a few cases, the pus poured out by the inflamed membrane, 
and confined within sacs formed by the organized coagulable lymph, makes 
its way by ulceration either into some one of the hollow viscera, as the sto- 
mach, intestines, or bladder, or to the surface of the body, and is discharged. 
In some of these cases, recovery takes place, especially when the pus has 
found an outlet through the skin. 
Various modifications of peritonitis as above described occasionally take 
place,1 and require notice.' Thus, it is sometimes entirely local, affecting some 
one portion of the peritoneum only; and this is apt to be the case when the 
disease proceeds from a local cause, such as mechanical violence, or the inflam- 
mation of an invested organ. In such cases, it frequently happens that, 
though the inflammation is not propagated to any great extent continuously, 
it affects the portion of membrane opposed to, and in contact with that 
inflamed. The inflammation is thus more likely to be confined to one spot, 
when a fixed than when a moveable organ is affected. Any part of the 
abdomen, where there is peritoneum, may be the seat of the affection. It is 
scarcely necessary to say that, in these- cases, all the symptoms, both local 
and constitutional, are less violent than in general peritonitis. The local 
character of the affection is marked by the limited extent of the pain and 
tenderness, though it must be confessed, that, in some instances, it would be 
very difficult to establish -a certain diagnosis. The symptoms are much mo- 
dified by the position of the inflamed membrane, and by the organ which it 
may invest. Thus, when the inflammation occupies the peritoneal covering of 
the liver, it not nnfrequently happens that the skin, eyes, and tongue, are more 
or less yellow, in consequence of an extension of irritation into the substance 
of the organ. Great epigastric pain and tenderness, with severe constitutional 
symptoms, mark the peritoneal inflammation of the stomach; obstinate con- 
stipation, with a lower seat of pain, that of the bowels; painful irritation with 
tenderness in the hypogastric region, that of the bladder. The omentum may 
be separately inflamed, in which case, the pain extends over the front of the CLASS III.] 
PERITONEAL INFLAMMATION. 
679 
abdomen, and effusion into the folds of the membrane may occasion; circum- 
scribed swellings^ perceptible to the touch, and liable to be mistaken for 
enlarged spleen, or ovaries, or scirrhous tumours of different portions of the 
bowels. Andral mentions, as characteristic of pelvic peritonitis, pain above 
and behind the pitbcs, and extending backward towards the loins, tenderness 
in the hypogastrium, slight fever, sweats, and the . formation of tumours in 
the cavity, which press on the neighbouring organs, as the rectum, vagina, 
and bladder, materially interfering ^ith their functions. Another frequent 
seat of partial peritonitis is the right iliac region. ' This, however, is almost 
always secondary, depending either upon the propagation of inflammation 
from the exterior cellular tissue, or from the caecum or appendix, or upon the 
direct irritation of matters which have escaped from these portions of the 
alimentary canal by ulceration. It is marked by great tenderness and tume- 
faction over the head of the colon, and by obstinate constipation, and fre- 
quently terminates in an abscess, which makes its way to the surface, either 
anteriorly, or in the lumbar region. Other instances of local peritonitis are 
those in which the inflammation depends upon strangulation of the bowel, 
whether from hernia, intussusc.eptio, or other cause. In these cases, the 
symptoms of inflammation are always preceded by those of obstruction in its 
earlier stages, and subsequently associated with those of the same affection in 
its advanced stages, such as almost insuperable constipation, and vomiting of 
stercoraceous matter. (See Obstruction of the Bowels.) Partial inflammation 
sometimes becomes general, and may thus, prove very dangerous; but, when 
confined to its original seat, it generally yields to proper treatment, unless 
complicated with some other more serious affection. As in the general dis- 
ease, it occasionally gives rise to collections of pus, which is retained by 
adhesions between opposite surfaces of the membrane, and makes its way by 
ulceration either to the surface of the body, or into some one of the hollow 
viscera, occasionally producing, in its passage, much destruction of the organs 
with which it may come in contact. 
Though for the most part an exceedingly painful disease, peritonitis some- 
times conies gn very insidiously, with little pain, and no great degree of. ten- 
derness, and runs its whole course, even to a fatal termination, without being 
suspected. This form of the disease is most apt to occur in persons of feeble 
health, and as a complication of other acute diseases, which serve to mask it. 
Affections of the brain, which diminish the ordinary sensibility, are perhaps 
most liable to this dangerous complication. In all these cases, when a sudden 
and unaccountable increase of disease takes place, with the peculiar counte- 
nance and pulse of peritonitis, even without abdominal pain, a close examina- 
tion should be instituted; and, if tenderness is found to exist generally through 
the abdomen, or in some one part of it, the existence of .this disease may be 
suspected. 
Peritonitis, like all other inflammations, is sometimes connected from the 
commencement with a typhoid' state of system, marked by feebleness of the 
circulation, general prostration, a dry and. dark tongue with sordes about the 
teeth, a tendency to hemorrhage from the mucous surfaces, and various ner- 
vous symptoms, as delirium, subsultus tendinum, coma, &c. Sometimes 
nervous symptoms attend it without evidences of typhoid disorder. Head- 
ache, active delirium, subsultus, convulsions, sudden alternations in the vio- 
lence of the ordinary symptoms, restlessness, wakefulness, and great general 
distress, are among the characters of this form of the disease. Andralstates 
that he has known the disease to recur regularly for some time with the pa- 
roxysms of an intermittent, disappearing entirely in the intervals, until at 
length it became permanently established and continuous. [Clinique Medi- 680 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
calc, ed. Be, ii. 639.) Not unfrequently the symptoms alternately diminish 
and increase, in the manner of a remittent disease. 
Another modification of peritonitis is that resulting from the perforation of 
a liolloiv viscus or cavity, and the escape of its contents into the peritoneal 
sac. The inflammation is in-this case most frequently general, though it may 
also be local.. It is usually preceded by symptoms of some other disease of 
longer or shorter duration. The commencement of the peritonitis is marked 
by the suddem occurrence of severe pain, without preceding chill, usually in 
some one point, from which it rapidly spreads over the abdomen. In a very 
short time, all the symptoms of the disease in its most violent form are de- 
veloped, and death ensues, generally in two or three days, and sometimes' even 
in a few hours. This form Qf peritonitis is almost certainly fatal. But occa- 
sionally, when the perforating orifice is small, and in a neighbourhood where 
the intestine is not moveable, the inflammation is limited to a small extent, 
the effused matter becomes isolated through the agency of adhesion, and the 
affection ends in an "abscess, which pursues the same course with those alluded 
to in preceding sections, and with the same result.* 
Puerperal peritonitis is still another variety of this affection. It attacks 
women in child-bed, usually within three or four days after delivery, and 
sometimes within twenty-four hours. The pain sometimes comes on gradually, 
and almost insensibly, sometimes suddenly and with severity, and in many 
cases is subject to exacerbations, resembling after-pains, with which it has 
often been confounded. It almost always commences in the hypogastric and 
lumbar regions, and, after the whole abdomen has become involved, is apt to 
be felt most severely in those parts. The tenderness on pressure is also at 
first confined to the region of the uterus. The lochia are diminished or sup- 
pressed; the mammae become flaccid; and the secretion of milk either is not 
established, or is .suspended, if it had commenced. The abdomen is soft and 
flaccid at first, and, though it ultimately swells and becomes tympanitic, the 
parietes have none of that elastic tension, which is found in ordinary peri- 
tonitis, probably owing to their great distension in advanced pregnancy. The 
* It is sometimes impossible to decide with certainty, before an external communica- 
tion has beep effected, as to the existence of perforation of the bowel, in those cases in 
which, adhesion, having taken place between the intestinal and parietal peritoneum, the 
alvine matter seeks an outlet by means of ulceration. The following sketch of a case 
which occurred to me, in the Pennsylvania Hospital, in the autumn of 1847, may prove 
useful, by putting the young practitioner upon the proper track in similar cases. The 
patient, who was a(man short of the middle age, complained at first of pain in the left 
lumbar region, which had been treated as rheumatism before I saw hirn. ' I found him 
with fever, diarrhoea, tympanites, and a dry tongue; and should have been disposed to 
consider the case as one of Ont'erie or typhoid fever, but for the absence of the rose- 
coloured eruption, and of the characteristic countenance of that affection. At length a 
tumour was perceived in the back, which gradually increased, and, after a considerable 
time, presented an obscure fluctuation, with a diffused erysipelatous redness, and swell- 
ing of the subcutaneous areolar tissue for a great extent. Thinking that it might possibly 
have some connexion with the bowel, I directed it to be opened. An offensive sanious 
fluid escaped, with a decided feculent odour. But extensive gangrene of the cellular tissue 
came on, under which the patient sank. Examination after death disclosed the existence of 
an ulcer of the colon, near the sigmoid flexure, communicating with the exterior abscess. 
Except at this one spot, the. colon'appeared healthy; but there was inflammation of the 
mucous membrane of the ileum for the extent of more than a foot from the ileo-cascal 
valve, though without ulceration, and without special disease of the glands of Peyer, 
With the light which dissection thus afforded, I should, in a similar case, be disposed to 
make an early and deep incision into the tumour, iii the hope that the intestinal contents 
might thus find an,easy escape, and the patient be.spared.the gangrenous destruction of 
the cellular tissue,, which was the probable cause of death in this instance.-(Ahte t® 
second edition.) CLASS III.] 
PERITONEAL INFLAMMATION. 
681 
effused liquid is often copious, so that fluctuation in the abdomen is readily 
perceived. It is unnecessary to repeat an account of the general symptoms, 
which .are essentially the same as those of ordinary peritonitis, though usually 
more severe. The pulse is more, frequent, the respiration more hurried, the 
countenance more deeply affected, the prostration of strength greater, and the 
march of the disease more rapid and fatal. Severe pain in the head, vertigo, 
and delirium are more frequent, and cough is a common attendant of the 
puerperal affection.. Death, which in the severe cases occurs in the course of 
a few days, and sometimes in less than twenty-four hours, is preceded by 
symptoms of great prostration; an extremely rapid and feeble pulse, cold 
skin, a brown and dry tongue, sordes about the teeth, tympanitic abdomen, 
and discharges of black or dark*-green matter by vomiting and, stool. There 
is reason to believe that puerperal peritonitis is sometimes a secondary affec- 
tion, in the same manner a.s erysipelas, being dependent upon or at least aSso+ 
ciated with a malignant febrile state of system, of which one Of the characters 
is a depraved condition of the blood. In such cases, the general actions are 
feeble almost from the commencement, and the state of system is similar to 
that which occurs in malignant typhus. This form of the disease, the only 
one to which the name of puerperal fever can be attached with propriety, is 
most apt to result from epidemic influence. 
Peritonitis is always a dangerous disease; but, when it occurs in a person 
of good constitution, and without complication, generally yields to early and 
efficient treatment. That form of it which depends on perforation is the most 
fatal.' Next, perhaps, in degree of danger is the puerperal peritonitis. The 
inflammation is least dangerous when it is partial, and, as a general rule, 
when it results from external injury. 
Anatomical Characters.-These are Such as inflamed serous surfaces gene- 
rally present. (See page 49.) They will not, therefore, require a very par- 
ticular notice in this place. If death has occurred very early, the membrane 
may offer no othei- morbid appearance than redness. In cases of longer dura- 
tion, there is almost always more or less of an albuminous or fibrinous exuda- 
tion upon the surface of the membrane, and of free liquid in the cavity. The 
solid matter is soft, of a dull white, yellowish, or greenish-yellow colour, and 
generally more or less organized, forming false membrane, which connects 
together the opposite peritoneal surfaces,, agglutinating the folds of the intes- 
tines, and causing the different viscera to adhere to one another, or to the 
sides of the cavity. This layer is, in advanced cases, several lines in thick- 
ness, and has an irregular surface) which gives rise to the friction sound 
observed in auscultation during life. The degree to which it is organized 
depends on the character of the inflammation, and the stage of the disease. 
In some cases, little tendency to organization is shown at any stage; in 
others, it appears to have commenced a few hours after exudation. The 
liquid is found in the interstices of the intestinal convolutions, and more 
largely in the pelvis and iliac fossae. It is sometimes colourless and limpid 
or whey-like, with albuminous flakes floating in it; sometimes yellowish and 
turbid; sometimes milky, sero-purulent, or bloody; and sometimes composed 
of nearly pure pus, or of blood. In consequence of the adhesions formed by 
the false membrane, it is often contained in sacs, which appear like so many 
abscesses, and now and then occasion irregularities, observable upon the sur- 
face of the abdomen during life. In some instances, pus is formed without 
the peritoneum. Gangrene is very seldom observed in the membrane, except 
in cases in which the bowel has been strangulated. The dark spots occasion- 
ally noticed, resulting from effused blood in the submucous tissue, have pro- 
bably been mistaken for mottification. 682 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
If the disease has depended upon the perforation of the alimentary canal, 
gas generally escapes upon the opening of the peritoneum, and is more or 
less fetid as the perforation has been lower down in the canal. The charac- 
ter of the liquid in.'the cavity varies with the organ perforated, and sometimes 
serves to designate the organ. Thus, portions of undigested or partially di- 
gested food have probably come from the stomach; a yellowish or brownish 
fetid liquid from the bowels; solid fecal matter from the colon; a yellowish- 
brown, or green inodorous liquid from the gall-bladder or biliary ducts; and 
liquid of a urinous smell from the bladder. Stones- of fruit, calculi, and 
biliary concretions are sometimes found. By taking the upper portion of the 
bowel between the fingers, and compressing it steadily towards the lower 
extremity, the.escape of gas. or liquid will sometimes indicate the point of 
perforation, which might otherwise escape attention. 
In the typhoid cases of peritonitis, especially the puerperal, little or no 
fibrinous - exudation is found, the, effusion consisting of a serous, milky, or 
bloody fluid,, with only a few flakes .of coagulable lymph here and there ad- 
hering to the membrane. 
Though vomiting is so frequent a symptom of peritonitis, the mucous mem- 
brane of the stomach is only in exceptional cases found to have been the seat 
of any considerable inflammation. 
Causes.-Peritonitis may arise from the ordinary causes of inflammation, 
such as vicissitudes of temperature, excessive use ,of stimulating food or drink, 
suppression of habitual discharges whether healthy or morbid, retrocession of 
cutaneous eruptions, and translation of gout and rheumatism. It is, how- 
ever, more, frequently the result of local violence, as of blows, falls, and 
bruises of all sorts, and oT wounds penetrating the peritoneal cavity, including 
various surgical operations, among which may be mentioned that for strangu- 
lated hernia and for tapping, and the Caesarian section. 
Sometimes it occurs secondarily to other diseases, especially to inflamma- 
tion of the organs which receive a complete or partial covering from the peri- 
toneum. Inflammation of the womb, whether occurring from violence to 
that organ, or injury received in the process of parturition, is said frequently 
to extend to the peritoneal membrane. The disease is an ordinary result of 
strangulation of the bowel, both internal and external, when not relieved. 
Among the most frequent causes of it is perforation of the different hollow 
viscera of the abdomen, or of morbid cavities, allowing the escape of their 
contents into the peritoneal sac. This perforation may be produced by ulcer- 
ation, by mortification,, and the separation of sloughs, or by mechanical rup- 
ture depending upon an extraordinary distending force within the cavities, 
or weakening of their parietes. Thus, perforation of the stomach, bowels, 
gall-bladder, biliary ducts, urinary bladder, kidneys, and ureters; the open- 
ing of abscesses in the substance of the organs, or in the cellular tissue 
without the peritoneum; the discharge of tubercles; the rupture of distended 
cysts or of aneurisms^ may all occasion peritonitis. The perforation of the 
alimentary canal is. most frequent in the course of typhoid fever and of 
phthisis, in both of wfliich affections ulceration of the mucous membrane of 
the bowels is very common. It is also not unfrequently produced by foreign 
bodies lodged in some portion of the canal, especially in the caecum and ap- 
pendix, where they occasion inflammation, ulceration, and ultimately perfora- 
tion of the coats of the bowel. Peritonitis sometimes comes on in the course 
of other diseases, particularly those of a febrile character, without any assign- 
able cause, imitating, in this respect, the inflammation of various other parts 
or organs. 
Of the variety of peritonitis denominated puerperal, the cause is probably CLASS III.] 
PERITONEAL INFLAMMATION. 
683 
in many instances a propagation of inflammation of the substance of the 
uterus, or of its veins or absorbents, to the peritoneal covering, or the direct 
participation of that covering in violence done to the organ. The disease 
may also ■ arise from irregularities of diet, vicissitudes of the weather, &c., 
as any other) inflammation. But very'often also it arises from a peculiar 
epidemic influence, or, as some believe, from contagion; and thus originat- 
ing, assumes not unfrequently its most malignant form. Of this character 
is the puerperal peritonitis of hospitals and lying-in establishments, which 
has often proved so fatal, and so little under the''control of remedies. It has 
been asserted that peritonitis in the male has sometimes also occurred epi- 
demically. ' 
Diagnosis.-When the disease is well developed, and attended with the 
usual symptoms, without complication, 'there can ,be little difficulty in its 
diagnosis. From colic of all kinds it may be distinguished by the great ten- 
derness upon pressure, the more persistent and less paroxysmal pain, and the 
almost constant-supine position of the patient; from mucous gastritis and 
enteritis by the sharper pain and greater tenderness, the elastic tension of the 
abdomen, the supine position, the greater tendency to-constipation, the small 
and very frequent pulse, the sunken and anxious countenance, and generally 
the deeper impression upon the constitution; from inflammation of the mus- 
cular coat of the bowels, by the more decided colicky symptoms of this affec- 
tion in its earlier stages, its excessively obstinate constipation, and the fecal 
vomiting which attends its close; from inflammation of the liver, bladder, 
and other parts more or less invested by the peritoneum,• by the absence, in 
these affections, of the .symptoms which characterize peritonitis, while, if the 
membrane is inflamed, the acute pain, tenderness, abdominal tension, position, 
pain upon movement, &c., serve to indicate the fact; from rheumatism of the 
abdominal muscles, which bears to it the closest local resemblance, by the 
vomiting, the febrile symptoms, the peculiar expression of face, and the dif- 
ference in the pain which attends motion in the twd cases, the. pain in rheu- 
matism being much severer from voluntary movements, which call the mus- 
cles into contraction, than from passive movement while both occasion severe 
suffering in peritonitis. The distinction between the inflammation of the 
peritoneal investment of an organ, and the substance of. the organ itself, is 
often rendered difficult by the fact, that the functions of the organ are almost 
always more or less deranged, when the investing membrane only is inflamed; 
and, in fact, the two affections are often Simultaneous; but, an accurate diag- 
nosis is of less consequence, as the treatment required by the-peritoneal in- 
flammation would in general involve that required by the inflamed organ, and, 
when the symptoms are violent and the diagnosis doubtful, the measures re- 
quired by the more dangerous affection should be adopted. 
There is sometimes danger of confounding with peritonitis a peculiar nerv- 
ous affection of the contents of the abdomen and pelvis, occurring especially in 
females. This is often attended with severe pain, tenderness, tumefaction, 
vomiting, and frequent pulse. But the pain is less constant; and, though 
aggravated by slight pressure, is sometimes alleviated when the pressure is 
strong. It is, moreover, often quite paroxysmal. The patient is liable to 
various nervous derangements of an hysterical character; and is able and dis- 
posed to change position in bed. The pulse and countenance are less disturbed; 
the urine, instead of being scanty, is usually copious and pellucid; and not 
unfrequently pressure upon the spine, by the suffering it occasions, at once 
discloses the nature of the disorder. In all cases of abdominal disease, the 
friction sound under auscultation may be considered, when it occurs, as a 
certain sign of peritonitis; though it does not always attend this disease. 684 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
Treatment.-In ordinary peritonitis, prompt and copious bleeding is the 
most important remedy. The pulse cannot be relied on as a guide. The 
heart appears to be cramped in its actidn by the violence of the local affec- 
tion; and the pulse, though often corded, is generally small and very frequent, 
and well calculated to mislead an inexperienced practitioner. Indeed, it often 
becomes more developed under the loss of blood, and this result may always 
be considered as a proof that the remedy was properly applied. Neither 
should, paleness of face, and absence of febrile heat upon the surface, deter 
from venesection, when the evidences of inflammation are unequivocal, and 
the patient is seen early in the attack. The quantity of blood withdrawn 
must be regulated by the apparent constitution of the patient, the stage of 
the disease, and the effects produced by its loss. In a tolerably vigorous 
individual, soon after the attack, from fifteen to thirty fluidounces may gene- 
rally be taken with propriety; and the bleeding may be repeated once and 
again, if the symptoms -should remain unabated, and no decided evidences of 
exhaustion be observable, though the amount abstracted at the sebond and 
third operation should not generally be so great as at first. It may sometimes 
be necessary to repeat the bleeding within twenty-four, and even twelve hours. 
Faintpess^, or decided sinking of the pulse, occurring during the flow of blood, 
should be received as an evidence that sufficient had been taken for the time.. 
After the first bleeding, from five to fifteen grains of calomel should be 
given, followed ,in six or eight hours by castor oil, or sulphate of magnesia, 
or infusion of senna with salts, whichever may be most easily retained by the 
stomach, so as to produce a thorough evacuation of the bowels. The irritation 
of accumulated feces, and the injurious but vain efforts at movement in the 
muscular coat of the bowels which they tend to sustain, are thus avoided, 
and at the same time a wholesome revulsion effected towards the inner intes- 
tinal surface, and congestion of the portal system in some measure relieved 
by secretion from the liver and mucous membrane. Calomel is peculiarly 
appropriate, because better retained than most other cathartics, and for the 
reason, moreover, that it serves as an early basis for mercurial treatment, 
should this be ultimately advisable. But, after the first thorough evacuation 
of the bowels, it is not desirable to push purgative medicines actively'. I am 
convinced that any benefit, they might produce would, as a general rule, be 
more than counteracted by the disadvantage of the continued friction of the 
inflamed serous surface of the intestinal convolutions. It is considered of the 
utmost importance to keep the opposite surfaces of an inflamed synovial mem- 
brane at rest. Why not also those of the inflamed peritoneum ? It is true 
that this objection is of less force when the inflammation is confined to the 
abdominal parietes, or to the, investment of an immoveable viscus; and, in 
such cases, when the diagnosis can be clearly made out, it may be proper to 
keep up an active purgation; In general, however, it will be quite sufficient 
to procure one or at most two soft evacuations daily, by the use of the mildest 
laxatives, aided by encmata. In the selection of the laxative, regard should 
be had to the irritable state of the stomach. Small doses of the effervescing 
Seidlitz powder, or of Rochelle or Epsom salt dissolved in carbonic acid 
water, or of infusion of tamarinds with cream of tartar, may be employed 
early in the day, and rendered effective by a laxative enema in the evening. 
These often allay vomiting, and also act usefully as refrigerants. Castor oil 
may sometimes be given in very small quantities, when acceptable to the 
stomach; and some authors speak highly of a combination of this with oil of 
turpentine. Should these laxatives prove irritating to the stomach, they 
should be suspended, and reliance placed upon enemata alone. 
After one or two large bleedings, and a full evacuation of the bowels, CLASS III.] 
PERITONEAL INFLAMMATION. 
685 
recourse should be had immediately to leeches, which should be very freely 
applied, especially over those points of the abdomen where the pain and ten- 
derness are greatest. From fifty to one hundred and fifty American leeches 
should be applied at once; and the application may be subsequently repeated, 
if required by a persistence of 7the symptoms. The leeches should be followed 
by warm fomentations, or, what is better, if the patient can support their 
weight, by light emollient cataplasms, as of mush, oatmeal, flaxseed-meal, 
&c., large enough to cover the whole surface of the abdomen. These cata- 
plasms should be kept on steadily for several days. Laudanum may some- 
times be advantageously added to them. Instead of warm emollient applica- 
tions, some recommend cold water, or even ice to the abdomen; but I have 
not tried this remedy, and confess that I am afraid of it. 
s Opium may be used very early in this inflammation. After free bleeding 
and leeching, and the full evacuation of the bowels, there is no occasion for 
further delay. At first, the best plan is to give the narcotic at night, so as 
to secure rest to the patient, and quiet to the inflamed membrane. Calomel 
.should generally be added to it in small quantities. This is useful by pre- 
paring for the easier evacuation of the bowels on the following day, but still 
further, by facilitating the mercurial impression, should this be afterwards 
determined on. One or two .grains of opium, with from two to four grains of 
calomel, may be given in one dose; or two grains of the narcotic and four of 
the mercurial may be made into four pills, two of which may be administered 
at once, and one every hour or two afterwards until the patient feels the 
ailodyne influence. A direction to the surface of the body may be very use- 
fully given by the addition of a grain or two of ipecacuanha to the mixture, 
should it not prove offensive to the stomach. 
In the same stage, advantage will often be found from the use of the effer- 
vescing draught, every two hours through the day. It acts favourably by 
quieting the stomach, and producing diaphoresis; two effects which are strongly 
indicated. Other anti-emetics that may be employed are small draughts of 
cold carbonic acid water, and creasote when there is no reason to suspect 
mucous gastritis. If the vomiting should be obstinate, it may.sometimes be 
relieved by copious draughts of warm chamomile tea, or simply warm water, 
or, if necessary, a small dose of ipecacuanha, which serve to wash out the sto- 
mach, and to remove any offending matter that may be present in it. Ano- 
dyne cnemata may also be resorted to. In order to favour diaphoresis, the 
warm bath may sometimes be used with advantage, especially in the cases of 
children; but in adults, on account of the difficulty and pain of motion, it 
would be better dispensed with, unless means are at command to apply the 
remedy, without disturbing the relative position of the different parts of the 
body. 
As the disease advances, the fomentations or cataplasms may be superseded 
by rubefacient applications, especially hot oil of turpentine, or by blisters, 
which, in general peritonitis, should be made sufficiently large tQ cover nearly 
the whole anterior surface of the abdomen. 
Should the complaint not exhibit evident signs of yielding in the course 
of three or four days, recourse should be had, without hesitation, to the mer- 
curial impression. For this purpose, from two to four grains of calomel may 
be given every four or six hours, combined with from a quarter of a grain to 
a grain of opium; and, in very urgent cases, the doses may be increased, or 
the interval between them diminished. ' If the system do not quickly respond 
to the calomel thus employed, mercurial ointment may be applied by friction 
to the inside of the limbs, and as a dressing to the blistered abdomen. The 686 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part ii. 
patient almost always recovers from ordinary peritonitis when ptyalism is 
induced. 
In the advanced stages, it sometimes becomes necessary to counteract de- 
bility by tonic or stimulant remedies. For this purpose, wine-whey, carbon- 
ate of ammonia, and nutritious liquids may be used; but perhaps the best 
remedy is a combination of oil of turpentine with laudanum or one of the 
salts of morphia. Sometimes it may. be necessary to have recourse to milk 
punch, or eggs beat up with sugar, and with wine or brandy and water. 
During the activity of the inflammation, the diet should consist exclusively 
of liquids, and these should be taken in small quantities at a time. Lemon- 
ade, orangeade, infusion of tamarinds, solutions of the various syrups made 
from fresh fruits, orgeat and water, gum-water, barley-water, and the like, 
while they serve ate drink, afford sufficient nutriment to the patient. Ice- 
water and cold carbonic acid water may also be taken to quench thirst'. Ren- 
net-whey may be used, when it is considered desirable to make the diet some- 
what more nutritious. Animal broths may become proper before the close of 
the complaint. 
The patient should be kept perfectly quiet in bed* and not allowed to rise 
for the purpose of evacuating either bowels or bladder. 'The. bed-clothes 
should be prevented from pressing on the abdomen by crossed segments of 
hoops, or other contrivance. 
Cases of partial peritonitis are to be treated upon the same plan precisely, 
though with less energy. It is not necessary to take so much blood from the 
arm, and calomel should, as a general rule, be more sparingly, employed. 
If the complaint occur in constitutidns previously enfeebled by other -dis- 
eases, or if it be complicated with an adynamic or typhous state of system, it 
will not admit of the same active depletion, and, in some very low cases, will 
scarcely admit of depiction at all. Where any doubt exists upon the point, it 
will be best to employ leeches, to the exclusion of the lancet. The remedy 
upon which relianceris chiefly to be placed is mercury combined with opiates. 
Stimulants may sometimes become necessary. 
Peritonitis dependent upon perforation of the alimentary canal or other 
cavity, requires a somewhat peculiar plan of treatment. Depletion may bo 
pushed as far as the strength of the patient will admit; but, as this has gene- 
rally been much impaired by preceding disease, the remedy must be used with 
caution. The great indication to be fulfilled is to keep the bowels perfectly 
at rest, in order that the effused matter may be prevented from travelling far, 
and that the formation of adhesions may serve to limit the disease. This is 
to be effected by the use of opium in large and repeated doses, so. as to main- 
tain the system completely and constantly under its influence. The opium, 
while it thus puts the bowels, as it were, in splints, answers another excellent 
purposp, by rendering the system at large less sensible to the shock of the 
disease. The body of the patient should be kept absolutely at rest, and drinks 
positively forbidden, or at least admitted only in such quantities as would 
insure them against passing through the pylorus. Thirst may be allayed by 
washing the mouth out with cold liquids, and allowing-small pieces of ice to 
lie upon the tongue. Under any plan of treatment, the case must be consi- 
dered as almost desperate; but the one described affords some little chance of 
a favourable issue. One case was successfully treated by Dr. Stokes of Dub- 
lin, upon the opiate plan. 
Puerperal peritonitis is to be treated upon the same plan as the ordinary 
form of the disease; but being, as a general rule, more rapid and violent, it 
requires, in a proportionate degree, more prompt and energetic interference. 
It is unnecessary to repeat the remedies, which are absolutely identical with CLASS III.] 
PERITONEAL INFLAMMATION. 
687 
those already mentioned. Attention should be additionally paid to the state 
of the uterine discharges. The lochia, if suppressed, should be1 promoted by 
fomentations or emollient applications to the external genitals; and acrid dis- 
charges, if any such exist, should be removed as they appear, while the vagina 
is carefully washed out by emollient injections. It is also advised, by some 
writers, to favour the flow of milk by similar applications to the breast, and 
by resorting to the efforts of the infant, or of some young sucking animal, as 
the puppy. In the adynamic form of this disease, bleeding is not well borne; 
the loss of a few ounces sometimes producing great faintness, from which the 
patient scarcely rises/. Still, it is generally proper to try blood-letting; for 
the diagnosis is sometimes, difficult, and the effects of bleeding, apd the cha- 
racter of the blood drawn, are among the most characteristic marks of the 
affection. Should the pul^e become very feeble, and the patient very faint 
from the loss of a little blood, while the blood which has been drawn is dark, 
and yields a loose and easily broken coagulum, the inference is, that the case 
is one of a malignant adynamic character, and- the plan of direct depletion 
should be abandoned. Leeches may often be usefully- substituted for the 
lancet.- Calomel, however, combined with opium, and pushed, if possible, to 
salivation, is the most valuable remedy in this form of -the disease. Stimu- 
lants and a nutritious diet are also often necessary. It is probably to cases 
of this nature, that oil of turpentine, so highly recommended by Dr. Brenan, 
of Dublin, is especially applicable. Both sound medical reasoning and expe- 
rience are, I think, adverse to its employment in the cases of ordinary open 
inflammation of the peritoneum, whether occurring in puerperal women or 
others. ■ A . 
2. CHRONIC PERITONITIS. 
There are two varieties of chronic peritonitis-, differing entirely in their 
origin, and much in their degree of fatality, which are nevertheless so similar 
in their symptoms, that it is not always easy to distinguish them. In one, 
the inflammation is of the ordinary character, and originates in the ordinary 
causes; in the other, it depends upon tubeicleS disseminated in the membrane, 
and serving as a constant source of irritation. I shall first describe the 
former, and then point out those additional symptoms which may be supposed 
to indicate the existence of the latter. 
Symptoms.-The disease is sometimes original, but, when the inflammation 
is of the ordinary character, is more frequently a mere sequel of an ill-cured 
acute attack. In the former case, its commencement is often very obscure, a 
little pain being sometimes felt in the abdomen, with derangement of diges- 
tion, and alternations of constipation and looseness of bowels, which exist for 
a considerable time without attracting much attention. At length the gene- 
ral health is affected, a little febrile exciteihent is experienced towards even- 
ing, the patient loses flesh and strength, and the disease becomes fully de- 
veloped. When the result of a preceding acute attack, it exhibits the 
characteristic phenomena immediately after the subsidence of the primary 
symptoms. In some instances, it would be difficult to decide whether the 
disease began in its acute or chronic form; for, even in cases which might be 
considered as belonging to the latter, the pain is severe at first and afterwards 
diminishes; and' the truth appears to be, that there is no distinct line of 
division between the two varieties. 
When the complaint is fully formed, there is usually slight pain in the 
abdomen, which in many instances is scarcely felt unless under direct pres- 
sure, or on the occasion of some shock or jar, such as that produced by a false 688 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
step, or the motion of a carriage, or some effort on the part of the patient, 
such as coughing, straining, &c., which causes a sudden concussion or com- 
pression of the abdominal viscera. Sometimes the pain and tenderness are 
confined to one spot, sometimes are diffused or variable. There is occasion- 
ally a sense of heat in the epigastrium. The abdomen is sometimes swollen 
in consequence of effusion into the cavity; but, where this is not the case, it 
may be even flatter than in health, in consequence of the- tension of the 
muscles. In the former case, there is dulness on percussion, often more or 
less fluctuation, and sometimes an edematous condition' of the feet and legs. 
In the latter, the abdomen is firm and elastic to the touch, and often more or 
less unequal, from the irregular formation of adhesions., and the developement 
of tumours or of sacs within the folds of the peritoneum. Occasionally the 
abdominal effusion is so great as. closely to imitate ascites, if not to constitute 
a variety of that disease. 
The appetite is feeble or irregular, and the digestion impaired. In most 
cases, there is nausea with occasional vomiting, and the bowels are irregular, 
being either constipated or affected with diarrhoea.. Food produces a feeling 
of weight in the stomach, and, in some instances, causes pain in a particular 
portion of the abdomen, occurring at a certain interval after eating. The 
stools are often light-yellow or clay-coloured. The state of the tongue is 
variable; .but generally it is either slightly furred, or smooth, red, ahd more 
or less chapped. The pulse is frequent; the urine scanty; the skin usually 
dry, unless in the latter stageswhen hectic fever has been developed; and the 
face pale and expressive of anxiety. The progress of the disease is usually 
very slow. Strength gradually fails; and the patient, worn out by the con- 
stant irritation, as well as by the failure of digestion and nutrition, sinks into 
a state of extreme debility find emaciation, which terminates at length in 
death. The fatal issue is sometimes accelerated by the supervention of an 
acute attack of inflammation. The disease is sometimes complicated in its 
course by functional disorders of various organs, the action of which is in- 
terfered with by adhesions,' or tumours formed in the peritoneal cavity. 
Thus, jaundice may result from pressure upon the gall ducts, and obstinate 
constipation from pressure on the bowels. Sometimes the disease is quite 
latent until near its close. 
It is not always easy to determine, during life, whether the disease is or 
is not connected with tubercles of the peritoneum. Whenever it is pro- 
tracted and very obstinate, resisting all the curative measures employed, and 
when its origin cannot be traced to a preceding acute attack, to local injury 
of the abdomen, or to chronic affections of the abdominal viscera, there is 
strong reason for believing it to be tuberculous. In this form of the disease, 
a close examination of the abdomen will often detect small tumours conse- 
quent upon enlargement of the mesenteric glands; and the external lym- 
phatic glands, especially in the groin, are also occasionally enlarged. The 
simultaneous existence of tubercles in the lungs, or an obstinate diarrhoea, 
indicating the existence of tuberculous ulceration of the bowels, would be 
further-evidence of the nature of the affection. Some aid in the diagnosis 
may also be drawn from the general habit of the patient, and his hereditary 
tendencies. 
The disease is always one of danger, but, in the tuberculous form, may be 
considered as quite incurable. When partial, or dependent on a curable dis- 
ease of neighbouring organs, or consequent upon an acute attack, and espe- 
cially when not connected with tubercles, there is reason to hope that it will 
yield to remedies. CLASS III.] 
PERITONEAL INFLAMMATION. 
689 
' Anatomical Characters.-Not uncommonly there is almost universal ad- 
hesion of the peritoneal ?nembrane, in consequence of the effusion and organ- 
ization of coagulable lymph. Occasionally, small spots of lymph, are observed 
thickly strewed over the surface of the peritoneum, which at first sight might 
be mistaken for tubercles, but are distinguishable by their less regular form, 
and by being easily scraped from the membrane, while tubercles, being 
situated in the subserous tissue, are not thus removable. In those cases in 
which the false membrane covers the peritoneum, it is usually very thick, of 
a grayish, reddish, or dark colour, often rough, and of an areolar appearance 
upon the surface, and sometimes of an almost cartilaginous hardness. Some- 
times the intestines are so agglutinated as to form'tumours sensible externally, 
and now and then, in consequence , of partial adhesions of the peritoneum, sacs 
are formed, which are filled with liquid, and give an irregularity to the out- 
line of the abdomen. The liquid effusion is-variable in quantity, position, 
and appearance; being in some cases very scanty, in others more or less 
abundant; sometimes anterior to the bowels, which are compressed into the 
back part of the abdomen, and sometimes, as before mentioned, partially"col- 
lected in sacs; occasionally nearly colourless and limpid, with albuminous flakes, 
occasionally more or less opaque, and of a yellowish, brownish, blackish, or 
reddish colour, from admixture of pus or of blood. In some instances, it con- 
sists exclusively of pus. 
In cases' complicated with tuberculous deposition, this is found either in 
small distinct granulations, or in masses formed by their aggregation, more 
or less extensively diffused over the peritoneum, and generally attended with 
false membrane and adhesions. The tubercles-exist in all stages of develope- 
ment. They are usually solid, but are sometimes met with in the softened 
state, and even opening into the peritoneal cavity. Instances have occurred 
in which tuberculous matter, deposited in the adhering coats of two intestinal 
Convolutions, has produced ulceration in both, and thus formed a communica- 
tion between them; \ } \ 
Treatment.-The remedies to be chiefly relied on are rest, occasional 
leeching, fomentations or emollient cataplasms, warm bathing, blisters, and 
the constitutional impression of mercury and of iodine. Rubefacient appli- 
cations to the abdomen, pustulation by tartar emetic, and setons or issues on 
the inside of the thighs, have also been recommended. Mercury may be used 
both internally, and externally;. - the ointment being applied by friction over 
the abdomen, or as a dressing to the blistered surface. Iodine may be used 
in the same way. Attention should be paid to the state of the bowels, con- 
stipation being obviated by laxatives, and diarrhoea by opiates combined with 
cretaceous preparations. Dover's powder, or the extract of hyoscyamus, may 
often be usefully given at night, especially in connexion with the mercurial 
preparations. Diuretics may be employed to promote the absorption of the 
effused fluid. The diet should be regulated by the circumstances of the case. 
In the more active stages, it should consist exclusively of vegetable matter; 
when the strength fails under this rigid course, milk may be added; and cir- 
cumstances of debility and exhaustion may occur, requiring the use of animal 
food. In the tuberculous cases, the diet, as a general rule, should be more 
nutritious than in those of uncomplicated inflammation. In these cases, 
moreover, a preference should be given to iodine over mercury; and the neces- 
sity of counteracting the tendency of general debility to-produce tuberculous 
deposition, may render a resort to bitters, chalybeates, and moderate exercise 
of a passive character, desirable. Should abscesses form with an apparent 
external direction, their tendency to the surface should be favoured by emol- 
lient poultices. 690 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
SECTION II. 
DISEASES OF THE ABSORBENT SYSTEM. 
The absorbent system, besides sharing in the general susceptibility of the 
body t'o morbid influences, is, from the nature of its office, peculiarly exposed 
to certain causes of disease. Receiving not only the effete matters of the 
general organism, but all the alimentary product of the digestive process, and, 
besides, innumerable bodies from without, of every degree and variety of 
noxious power, it must, in numerous instances, experience the first evil effects 
of morbid agents; and not unfrequently, it is probable, experiences such 
effects'exclusively; as there is reason to suppose that the glands, and perhaps 
the vessels themselves, have a modifying influence over the substances absorbed, 
which often brings them into harmony with the susceptibilities of the system, 
and ^hus prevents their injurious influence beyond the structure, into which 
they have penetrated in their unaltered state. The absorbents, moreover, 
seem, beyond all other vessels, to be possessed of that continuous sympathy, 
which transmits an impression from one part to another of the same structure; 
so that an irritation existing at their origin is very apt to be transmitted for 
a considerable distance along their course. A slight general sketch of the 
derangements of which they are susceptible, will be a proper introduction to 
the more detailed account of those few of their diseases which appear to merit 
a separate description. The absorbents, as the result of irritation, may act 
more energetically than is compatible with health, and may thus produce 
general emaciation, or the wasting of particular parts or organs. They may 
fall into the opposite state of depression or debility, and, failing to execute 
their legitimate function, may give rise to morbid accumulation of fluids, 
constituting dropsy, or of solids, constituting obesity, and various local excesses 
of growth. As a consequence, also, of deficient action, they may fail in their 
office of assimilation, and thus allow noxious matters to enter the blood, which 
might otherwise be rendered innocent, or at any rate be very favourably 
modified. They are subject to inflammation in all its grades and stages. To 
the scrofulous or tuberculous degeneration they are peculiarly liable, and are 
among the most frequent seats of that affection. Involved, as they almost 
always are, at their origin, in every specific local disease to which the frame 
is subject, they generally serve as channels by which the affection spreads to 
neighbouring or distant parts, or pervades the system, and consequently are 
themselves the, first to suffer. Hence, the absorbents or absorbent glands 
become, the seat of syphilis, of scirrhus, of medullary fungus, of melanosis, 
and of other less strictly defined and understood degenerations. They may 
become enlarged or varicose, and diminished in their caliber or strictured. 
Their channel may be entirely closed, giving rise to accumulations behind the 
strictured point, and consequent rupture of the vessel. Their coats are some- 
times ossified, and like other parts are liable to excessive and deficient growth. 
But most of these affections are very obscure, and scarcely discoverable during 
life. Some of them must, from the very nature of the case, be, in any par- 
ticular instance, hypothetical, or at best merely conjectural. Others again 
are completely lost in the ravages which the disease produces in parts more 
immediately vital. Of the various complaints, therefore, to which this system 
is incident, a few only merit a separate notice. Those here treated of are 
inflammation of the absorbent vessels, inflammation of the absorbent glands, 
and scrofulous or tuberculous disease of the glands. CLASS III.] 
INFLAMMATION OF THE ABSORBENTS. 
691 
Article I 
INFLAMMATION OF THE ABSORBENTS. 
Syn.-Angeioleucitis.'--Lymphangeitis. 
Of inflammation of the lacteals, as distinct from that of the glands which 
they permeate, and of the lymphatics of the- viscera, whether of the chest or 
abdomen, little can be known during life. Though probably of no very un- 
frequent occurrence, and sometimes possibly very serious in its results, there 
are no symptoms by which it can be distinguished from other inflammations, 
with an approach to accuracy; and the practitioner must content himself with 
treating the affection according to the visible indications. But inflammation 
of the external lymphatics is in general sufficiently obvious. 
Symptoms, Course, &c.-If the superficial layer of absorbents only is 
affected, as usually happens when the disease originates in a wound, ulcer, or 
inflamed point of the surface, pain, increased by pressure, is usually felt along 
the course of the lymphatics, and simultaneously, or soon afterward, one or 
more reddish streaks may be observed, commencing at the originating point of 
disease, or at a greater or less distance from it, and running towards the centre 
of circulation. These streaks are sometimes straight and sometimes crooked, 
often interlace with each other, so as to form irregular meshes, and, when 
examined by the fingers, feel like hard cords. The redness often extends to 
some distance on each side of the cord, being gradually shaded off into the 
natural colour of the skin. It is generally of a rather bright tint; but is 
sometimes dark. Not unfrequently,distinct patches of redness occur, irregular 
and obscurely defined, but usually connected by the lines alluded to. The 
inflammation travels rapidly until it reaches the lymphatic glands, which 
become enlarged and painful; and often extends beyond these, spreading as 
it advances, and giving rise, in some instances, to a diffused erysipelatous 
redness. The cellular tissue also becomes inflamed, and the whole neigh- 
bouring parts swollen and hardened. The hardness, however, occurs rather 
in nodules than diffusively. The patient now suffers greatly with soreness 
and burning pain. 
When the more deeply-seated lymphatics are exclusively affected, the pain 
is at first unattended with redness, is deep-seated and shooting, and gradually 
extends along the eourse of the vessels. Slight pressure on the surface has 
little effect upon it, but strong pressure increases it considerably. There is 
much swelling, and deep-seated irregular hardness may be felt upon a close 
examination. The surface at firsi retains its natural colour; but at length 
becomes reddened; the redness occurring not in lines, but irregularly in 
patches, and having a pinkish or roseate hue. Both sets of vessels are some- 
times simultaneously inflamed; and then, the symptoms of the two are 
united. 
Most frequently the symptoms are much less severe than those enumerated; 
and often only a few red lines are observable, which are sore to the touch; 
and give rather a feeling of stiffness than of acute pain. Occasionally the 
inflammation of the vessels is so slight, that it could scarcely be recognized, 
but for the swelling and soreness of the glands towards which they run. 
The mild cases generally terminate in resolution, under suitable treatment. 
The severer often run on to suppuration. The pus is generally in separate 
small abscesses, occupying the seats of previous hardness; but sometimes it 692 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
is diffused through the cellular tissue, or forms large collections, from which 
the matter flows copiously when the cavity is opened. Mortification rarely 
occurs, unless in the very old, or in persons of worn out constitution. Occa- 
sionally, however, the cellular tissue sloughs as in erysipelas. In some rare 
instances, the inflammation appears to assume a chronic form. 
The constitutional symptoms vary with the severity of the local disorder. 
When this is very slight, the system at large is not affected; when intense, 
the general disturbance is sufficient to involve life in danger.. The pheno- 
mena are usually those of ordinary symptomatic fever; at first rigors, followed 
by heat of surface, a frequent and full pulse, furred tongue, thirst, loss of 
appetite,, restlessness, and want of sleep; then, after suppuration, a relaxed 
skin, often sweats at night, diminution of the strength but not the frequency 
of the pulse, with a continuance of other symptoms. Sometimes there is 
nausea or vomiting, and sometimes slight delirium. In bad cases, especially 
those which result from wounds in dissection, the fever assumes in its pro- 
gress a typhoid character, with a very frequent and feeble pulse, a dry or 
gashed tongue, great restlessness and anxiety, subsultus, delirium, &c. Death 
seldom occurs, unless in constitutions enfeebled by intemperance, or previous 
disease, or in cases dependent upon the absorption of some poisonous agent. 
Most parts of the body are liable to this affection, but it is more frequent 
in the extremities than elsewhere, especially in the upper, because these are 
most exposed to the accidents in which it is apt to originate. When it occu- 
pies the arm, it runs up, on the inside, to the glands of the axilla, and often 
spreads to the chest before, behind, and below the arm-pit; producing, in bad 
cases, extensive erysipelatous inflammation, and subsequent suppuration in 
these parts. It sometimes occurs, usually in a mild form, in the neck; and 
has been found by dissection to have existed in the lungs, abdominal viscera, 
uterus, and thoracic duct, though no symptoms during life can reveal it with 
certainty in these parts. 
Anatomical Characters.-The coats of the lymphatics are thickened, the 
cellular tissue about them infiltrated and tender, the internal coat sometimes 
softened though not reddened, and the cavity often filled with pus. Some- 
times the caliber is distended with pus, so as to offer the appearance of an 
abscess; and AmusSat details the examination of a chronic case, in which a 
large abscess in each groin, communicating with the abdomen through the 
crural arch, proved to be nothing more than distended lymphatics. In this 
case, the thoracic duct, and the lymphatics of the abdomen, were also found 
loaded with pus. The cellular tissue of the parts affected is in some parts 
healthy, in others hardened, and in Others again destroyed by purulent infil- 
tration. 
Causes.-The cause of this affection is, in the great majority of cases, either 
inflammation in a particular spot, with or<without solution of continuity, or 
the introduction of some acrid or poisonous matter through a wound, ulcer, 
or abrasion of the skin, or a combination of the two. Thus, the inflamma- 
tion produced in the-toe. by the pressure of the nail, is apt to extend up the 
lymphatics of the limb. Very small wounds, particularly punctured wounds, 
even the pricking of a thorn or briar, and the bites and stings of insects, will 
occasionally give rise to the disease. In the last case, the irritation of a poi- 
sonous matter is superadded to that of the wound. Among the most common 
causes is the exposure of a finger or hand, in which there has been some 
slight wound or abrasion, to the action of irritant animal matter, either in the 
dead or living body. The author recollects attending an accoucheur affected 
with this disease, in consequence of an examination per vaginam with a slightly 
wounded finger. The effect of dissection, whether of a putrefying or sound CLASS III.] 
INFLAMMATION OF THE ABSORBENTS. 
693 
body, in producing the disease, is well known. Ulcers, and various eruptive 
affections of the skin also frequently induce it. Thus, porriginous ulcers of 
the head and face, and the sores so common behind the ears in children, often 
give rise to inflammation of the lymphatic glands of the neck, and the inter- 
vening absorbents. The deep-seated absorbents may become inflamed in con- 
sequence of a contusion, fracture, or deep penetrating wound, Mid from com- 
municating with collections of various acrid secretions. It has been observed, 
however, that the latter result rarely takes place, unless the matter, has under- 
gone decomposition, and acquired irritating properties by exposure to the air. 
Similar causes may produce inflammation of the visceral absorbents, and those 
of the intestines are peculiarly exposed to it, from the frequent existence of 
inflamed points and ulcerations on their inner surface. In all cases, the ves- 
sels are affected either by a propagation of the inflammation from the original 
point, through what has been called continuous sympathy, or by the absorp- 
tion of acrid matter which comes in direct contact with their inner surface. 
But these causes often exist without inducing inflammation of the lymphatics; 
and the inference is admissible, that there must be at the same - time some 
peculiar condition of system, acting as a predisposition to the disease. This 
condition is seldom appreciable; but it is highly probable that bad living, 
sedentary habits, and other agencies calculated to deteriorate the character of 
the blood, may have some effect in producing it. 
Diagnosis.-The only disease which is very liable to be confounded with 
inflammation of the external lymphatics, is phlebitis or inflammation of the 
veins. But in this the inflamed cords are larger, of a darker redness, and 
less disposed to inosculate; the lymphatic glands do not participate in the 
inflammation; and the redness upon the surface is less apt to have the dif- 
fused character of erysipelas. The progress of the disease, too, is more rapid; 
suppuration occurs more speedily; and the constitution is in general more 
profoundly affected, in consequence of the passage of pus into the circulation. 
Treatment.-The first indication is obviously to remove the cause, if it 
continue to act. Hence, it is necessary to remove any existing source of 
irritation from the wounded or inflamed point, and to correct the inflamma- 
tion by cooling applications, or emollient poultices. In poisoned wounds, as, 
for example, those which happen in dissection, the application of nitrate of 
silver is often useful. Might not the tincture of iodine, or a strong watery 
solution of chlorine, prove advantageous, by chemically decomposing any 
organic poison existing in the wound ? 
If the pulse is full and strong, the constitution of the patient vigorous, and 
the local disease considerable, blood should be taken from the arm; but cau- 
tion is highly necessary; as the nature of the cause, and the constitution of 
the patient, sometimes give a tendency to a low form of disease, and it be- 
comes, under such circumstances, important to husband the strength. Bleed- 
ing can scarcely ever be proper after suppuration has begun. Leeching along 
the course of the absorbents is a very valuable remedy. Solution of acetate 
of lead in the proportion of two drachms to the pint, or the officinal diluted 
solution of the subacetate, should be applied by means of linen' cloths to the 
inflamed surface. Laudanum or acetate of morphia may be added to either 
solution. Blisters may sometimes be useful; but they seldom remove the 
disease. I have employed them chiefly to prevent the spread of the cutaneous 
and subcutaneous inflammation, by applying them at the outer limits of the 
erysipelatous surface, partly on the inflamed and partly on the sound skin. 
For the same purpose, as well as for the removal of the erysipelatous inflam- 
mation, recourse may be had to the local application of tincture of iodine, or 
a strong solution of nitrate of silver. Mercurial ointment may also be used, 694 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
and, if it affect the mouth, it will prove so much the more efficacious. When 
suppuration has begun, it should be favoured by emollient poultices. Blisters 
sometimes hasten it. When pus has accumulated, free openings should be 
made for its discharge; and care should be taken to assist the-discharge, if 
necessary, by pressure with the hand or otherwise, once or twice a day. If 
this precaution be neglected, the pus may spread through the cellular tissue, 
and extend the mischief. Properly graduated pressure, by means of bandages 
and compresses, is often highly useful in diminishing the cavities, and pro- 
moting the healing process, and also by causing the absorption of the edema- 
tous effusion. 
Internally, the saline cathartics and refrigerant diaphoretics should be given 
in the early stages. The neutral mixture or effervescing draught, and the 
antimonials, when there is no nausea, may be selected. Spirit of nitric ether 
should be added, when the fever is attended with nervous symptoms. After 
due depletion, opium and ipecacuanha should be given, especially at bedtime; 
and, if the disease is obstinate, they may be very usefully combined with 
calomel. When suppuration has taken place, it may become necessary to 
support the system by quinia, the mineral acids, wine-whey, ale or porter, 
&c. Nervous symptoms, occurring in this stage, may be counteracted by 
infusion of serpentaria and valerian, camphor, and compound spirit of sul- 
'phuric ether;. and opiates, should be continued. If the tongue is dry, very 
small doses of mercurial pill, combined or not with opium and ipecacuanha, 
may be given at short intervals until the mouth is slightly affected. The oil 
of turpentine is also sometimes useful under these circumstances. If the case 
should be typhous or adynamic from the commencement, it may be necessary 
to begin early with the tonic and stimulant plan; but such cases have not 
come under my notice. , ' / 
The diet should consist, in the early stages, chiefly of farinaceous or muci- 
laginous liquids, to which, in the more advanced stages, it may be necessary 
to add rennet-whey, milk, and animal broths and jellies, according to the 
degree of support required. When there is no fever, and the appetite is not 
affected, it is sufficient to confine the patient to a vegetable diet. 
Article IL 
INFLAMMATION OF THE ABSORBENT GLANDS. 
This affection may occur wherever there are absorbent glands, whether 
superficial, deep-seated, or within the great cavities; but, as it comes under 
observation, it chiefly affects the external glands, especially those of the neck, 
groin, and axilla. The bronchial glands may be occasionally attacked by 
common inflammation, and we know that those of the mesentery very often 
become more or less inflamed in consequence of ulceration or inflammation 
in the mucous membrane of the small intestines; but we have no means of 
ascertaining this point certainly during life; and, so far as the treatment is 
concerned, we must be guided by general principles. The following descrip- 
tion has reference to the external glands. 
Symptoms, Course, &c.-The affected gland becomes at first swollen, hard, 
painful, and tender to the touch. If near the surface, it forms an obvious 
tumour, which is usually oval, with a rather definite outline, and generally 
somewhat moveable. The inflammation, in most jases, soon extends to the 
Syn.-Lymphadenitis. CLASS III.] 
INFLAMMATION OF THE ABSORBENT GLANDS. 
695 
neighbouring cellular tissue, thus greatly increasing the tumefaction, which is 
now less precisely bounded, while the gland becomes fixed. Not unfrequently 
several glands are inflamed at the same time, thus producing irregularity in 
the surface of the tumour, perceptible especially by the touch. If the disease 
is not arrested, in a period varying from one to two weeks, suppuration com- 
mences; the skin becomes thinner under the distension, and assumes a dark 
reddish or somewhat livid hue; and one or more prominent points in the 
tumour are observable, where fluctuation may be -perceived. The pus is con- 
tained sometimes in one, sometimes, in several distinct cavities. Occasionally 
it is confined to the gland, in which case the tumour is circumscribed and 
somewhat moveable; occasionally to the surrounding parts, when the boundary 
of the swelling is quite indefinite; and not unfrequently occupies both situa- 
tions. The skin at length ulcerates; and the abscess or abscesses open, dis- 
charging a homogeneous healthy pus, sometimes in small quantities, sometimes 
copiously; .and then gradually heal, leaving almost always more or less swell- 
ing and liardness, which last for a long time, but ultimately in general dis- 
appear. 
Sometimes the tumour, before suppuration has commenced, or has made any 
considerable progress, ceases to increase, becomes less painful and tender, but 
at the same time harder and more circumscribed, and continues thus for a 
long time in a state of chronic inflammation, with a slight feeling of heat and 
soreness. The inflammation sometimes takes on at the beginning the chronic 
form. In this case, the gland slowly enlarges and hardens, continuing cir- 
cumscribed and moveable, with a deep, dull pain; and thus remains, until 
either some accidental cause induces an acute inflammation which hastens the 
result, or the tumour, after a long time, passes gradually into the state of 
resolution or suppuration. When the latter event occurs, the substance of 
the gland is ultimately destroyed, and its place occupied by the pus, which is 
confined within its exterior envelope, forming a single cavity. The pus, both 
in the acute and chronic forms, is destitute of that tuberculous or cheesy 
matter which characterizes s,c^pfulous disease of the glands. 
Acute inflammation of the glands is generally accompanied with more or 
less febrile disturbance, which differs in nothing from ordinary symptomatic 
fever. Chronic inflammation, on the contrary,, scarcely ever brings the system 
into sympathy. 
The prognosis of this disease, occupying the external glands, is almost 
always favourable. When treatment is applied early, before any appearance 
of suppuration, resolution can very often be effected. But, when the skin 
has begun to assume a reddish or purplish hue, or the slightest fluctuation 
can be perceived, it is generally futile to attempt to backen the disease, and 
the practitioner should confine his efforts to the hastening of the suppuration. 
Anatomical Characters.-In the early stage of the inflammation, the tissue 
of the gland is firm, dense, and homogeneous, and presents upon the cut sur- 
faces, numerous dark reddish points, which mark the orifices of the divided 
vessels. In the more advanced stage, it is dark-red, easily torn, and infiltrated 
more or less with .effused blood. When suppurating, it is softened, and 
exhibits at first minute cavities containing a viscid serous fluid, which are 
gradually enlarged, and at length filled with a yellowish uniform-pus. The 
cellular structure about the gland exhibits, when it has partaken in the dis- 
ease, the usual evidences of inflammation in that tissue, flee page 34.) 
Causes.-The causes of inflammation of the lymphatic glands are so exactly 
those of inflammation of the lymphatic vessels, that it is unnecessary to repeat 
them here, flee page 692.) If there is any difference, it is, perhaps, that 
the glands are more liable than the vessels to the influence of the ordinary 696 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
causes of inflammation in other parts. It not unfrequently happens that the 
gland is inflamed, in consequence of an irritation or irritant carried to it by 
the vessels, while the latter exhibit no signs of being themselves affected. 
Treatment.-General bleeding may be employed when the disease is vio- 
lent, the constitution of the patient vigorous, and the inflammation at a stage 
which admits of resolution. Leeching is often very useful, and may be 
repeated once or oftener, if it be considered very desirable to arrest the pro- 
gress of the disease, and prevent suppuration. The cold poultice, made with 
crumb of bread and lead-water, may afterwards be applied with a similar 
object. Saline cathartics should be given in the early stages, and the patient 
confined to a vegetable diet. Should suppuration have commenced, or appear 
inevitable from the prominence of the tumour and discoloration of the skin, 
all these measures should be abandoned, and the new process promoted by 
emollient poultices. After an abscess has clearly formed, and fluctuation 
become distinct, a free opening should be made by the lancet. By allowing 
the abscess to open itself, the practitioner endangers, in some instances, exten- 
sive injury of the cellular structure, and such a thinning of the skin, as to 
cause great destruction of this tissue, and consequently a large ulcer, and 
ultimately, a deforming cicatrix. If pus appears to exist in distinct cavities, 
each one of them should be freely opened. 
In cases disposed to assume the chronic form, or in those originally of that 
form, after due depletion by leeches, repeated blisters will often be found use- 
ful. Various other discutient applications may also be resorted to, such as 
the compound galbanum plaster, the ammoniac plaster, the mercurial plaster, 
the mercurial ointment, and various unctuous preparations of iodine, as the 
simple or compound ointment of iodine, the ointment of iodide of potassium, 
and that of iodide of mercury. The most effectual applications are those of 
mercury and iodine. 
Article III. 
SCROFULOUS INFLAMMATION OF THE ABSORBENT 
GLANDS, or EXTERNAL SCROFULA. 
Syn.-Scrofulous Adenitis. 
All the absorbent glands, whether external or internal, are liable to scro- 
fulous inflammation. But there is so much difference, both in the course and 
progress of the disease, according as it occupies the glands within or those 
without the great cavities, that it requires a distinct consideration in these 
two positions. I shall treat of it, under the present head, as it occurs in the 
external glands, constituting the most ordinary form of external scrofula. 
Symptoms, Course, &c.-The first symptom which usually calls attention 
to the existence of the disease is an enlargement of one or more of the glands, 
which has come on almost imperceptibly, and increases for the most part very 
slowly. The tumour is hard, somewhat elastic, usually of an oval shape, 
pretty well defined, and more or less moveable, especially when near the skin. 
When several neighbouring glands are affected, though isolated at first, they 
often become aggregated as the disease advances, forming a large, irregular 
mass, with an uneven, slightly lobulated surface. In the early stage, they 
are in general nearly or quite free from pain, and from the other marks of 
inflammation, with the single exception of tumefaction. Sometimes, without 
any obvious cause, they cease to advance, becoming quite indolent, and re- CLASS III.] 
EXTERNAL SCROFULA. 
697 
maining in this state for months or even years, and then again resume their 
activity. - ) 
Not unfrequently, under proper treatment, the tumour or tumours gradu- 
ally disappear, leaving, in some instances, no traces, but, in the greater num- 
ber, perhaps slight glandular enlargements, which continue during life. When 
allowed to pursue their own course, they generally proceed to suppuration; 
and this often happens even under the best treatment. A higher grade of 
inflammation now supervenes, extending frequently to the neighbouring cel- 
lular tissue, and sometimes producing considerable pain, heat, and even febrile 
symptoms. The tumour becomes less moveable in consequence of adhesion 
to the neighbouring cellulai' tissue,, and to the skin, which is warm, tender to 
the tpuch, and often reddened. Fluctuation is now evident, and is felt equally 
over the tumour, or in distinct points, according as the pus is contained in 
one, or several cavities. At length,one or more Openings are produced, and 
a liquid is discharged, which is sometimes true pus, sometimes a puruloid 
serum mixed with a curdy matter, considered identical with the tuberculous 
deposit. Frequently, pus first escapes, and afterwards a mixture of viscid 
serum and the curd-like matter alluded to. The latter always appears when 
the substance- of the gland suppurates; otherwise the affection could scarcely 
be considered scrofulous. Occasionally, the cellulai' tissue is the exclusive 
seat of suppuration; in which case, the liquid may consist of genuine pus 
alone. The resulting abscess is usually very slow to heal, continuing for a 
long time to discharge its characteristic matter, and sometimes forming an 
obstinate fistulous sore, with the skin about its orifice, 'smooth, shining, and 
of a purplish or violet hue. 
It often happens that the thin skin over the-abscess ulcerates, leaving an open 
sore, of an unhealthy, characteristic aspect. - The edges are irregular, often 
undermined, sometimes hard, swollen and obtuse', sometimes thin and flabby, 
and of a dull-red or purplish colour. The bottom is uneven, light-red or 
grayish, with soft indistinct granulations, giving rise to a copious serous dis- 
charge, with curd-like flakes. The ulcer is offen very obstinate, and frequently 
changes its form, in consequence of partial cicatrization, or the extension of 
ulceration, or of both these processes going on at the same time in different 
parts. It is very uncertain in its progress, sometimes appearing as if about 
to heal, and then again breaking out, in consequence frequently of inappre- 
ciable changes in the state of the system. It is seldom attended with much 
pain. Upon healing, it is apt to leave an irregular, rugged, and unsightly 
cicatrix. 
The superficial glands of the neck are most frequently affected, and next, 
those of the axilla, groin, and mammae, The disease sometimes also attacks 
the more deeply seated glands. It is apt to run from gland to gland, along 
the course of the absorbents in which it originates. In the neck, there is 
sometimes a chain of diseased glands extending from the ear to the clavicle, 
and even within the chest. Sometimes both sides are affected, sometimes 
only one. In the former case, the tumours are apt to be larger on one side 
than the other. The diseased superficial glands are distinguishable from the 
deep seated by their greater prominence and mobility. 
The constitutional symptoms vary with the stage. Even before the appear- 
ance of the tumours, a certain disordered condition of the system is often 
obvious to a close inspection, especially in very severe cases; and peculiar 
physical characters, even in the healthy state, are thought to mark a predis- 
position to the disease. These have been detailed sufficiently under the head 
of tuberculous or scrofulous disease. (Seepage 106.) The incubative stage, 
or that which precedes the tumefaction, if open enough to be observed, is 698 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
marked by a greater oi' less degree of languor and dejection, defective or irre- 
gular appetite, loss of colour and of flesh, occasional erratic pains in the bones 
and joints, and slight febrile paroxysms. Certain local symptoms are some- 
times also observable. The mucous membranes are apt to become inflamed, 
especially that of the nostrils, which discharges a thin acrid excoriating fluid, 
and is attended with swelling of the parts about the nasal orifices, so as to 
impede the entrance of air. The upper lip is often swollen and chopped in 
the. middle. In some cases, the conjunctiva is irritated or inflamed, and the 
edges of the eyelids become affected in such a manner that the eyelashes' drop 
out. The last joints of the fingers are occasionally swollen, and a disposition 
in the nails to curve forward at their extremities has often been noticed. In 
many cases, however, the tumours occur in the midst of apparent health, and, 
as before observed, are generally the first symptoms which attract attention. 
When constitutional symptoms precede them, they generally become amelio- 
rated after the glands have begun to enlarge. But, as the disease advances, 
especially when of a severe grade, the system sympathizes with the local 
affection, more or less fever is often experienced, and the appetite and strength, 
which had improved for a time, again begin to fail. In the last stage, when 
suppuration has been established, and the patient labours under the exhaust- 
ing and irritating influence of large abscesses or ulcers, hectic symptoms often 
opeur, attended with various nervous derangements, and, in the adult female, 
with disorder of the uterine functions. In very mild cases, however, the 
disease may run its whole course, with very little if any observable disturb- 
ance of the constitution. 
When the scrofulous tendency is strong, the local developement is not 
always confined to the glands. Indolent swellings occur in the subcutaneous 
cellular tissue, in various parts of the body, which ultimately become abscesses, 
or ulcers, with pus similar to that found in the glandular tumours. Abscesses 
also sometimes form under the fasciae, or in the cellular tissue between the 
muscles. The skin occasionally ulcerates in consequence of a morbid condi- 
tion of its own tissue, forming open sores of a very intractable character. 
Certain obstinate cutaneous eruptions, which sometimes attend the complaint 
in its progress, are supposed to have their origin in the scrofulous taint. 
Chronic inflammation of the conjunctiva and eyelids is not unfrequent; and 
the mucous membranes generally, are more or less subject to the same vitia- 
tion. Disease of the joints, periosteum, or bones, may complicate the gland- 
ular affection j though more frequently, when the morbid tendency finds a 
vent through these avenues, it leaves the glands untouched. External scro- 
fula is also- sometimes associated with a similar condition of the internal 
glands, and with those fatal derangements which result from the deposition 
of tuberculous matter in the vital-organs, or the serous tissues investing them. 
It occasionally happens that the internal alternates with the external disease; 
and, though the two are, as before stated, sometimes associated, it may be 
considered true, as a general rule, that, in -cases of a strong tuberculous or 
scrofulous diathesis, a direction to the external glands serves as a safeguard, 
in some measure at least, against the much more dangerous affections of the 
lung's, brain, peritoneum, and mesenteric glands. 
The duration of external scrofula varies exceedingly. Sometimes, in slight 
cases, it begins to retrocede almost immediately, under proper treatment, and 
finishes its course in a few weeks; while, in other instances, it resists all 
treatment, and runs on for many months, and even for years. Generally, 
however, it sooner or later terminates favourably, unless complicated with or 
replaced by disease of the bones or joints, phthisis, tabes mesenterica, or some 
other internal tuberculous affection. CLASS III.] 
EXTERNAL SCROFULA. 
699 
The disease is most frequent in children, from the close of the first denti- 
tion to the period of puberty. It is said to be more frequent in females than 
males; and the negro, or person of mixed blood between the negro and white, 
is much more subject to it than the pure white. The attack usually com- 
mences in the winter or spring, and the symptoms are often ameliorated 
during summer, to resume their original violence upon the return of cold 
weather. 
Anatomical Characters.-Tn the first stage, there is merely an enlargement 
of the gland, without any striking alteration of the tissue, unless that it may 
be somewhat redder and firmer than in health. As the tumour advances, it 
becomes still harder, exhibiting a granular structure, and a grayish colour. 
Tubercular matter is then deposited either in the form of distinct granulations, 
or of irregular infiltration, or of roundish masses, isolated or agglutinated. 
The proper tissue of the gland is now more or less absorbed, and sometimes 
wholly disappears. In the advanced stage, abscesses are observed, sometimes 
only one or two, sometimes several, containing pus, or tuberculous matter in 
various states of softness. * 
Causes.-There can be no doubt that a peculiar state of system often exists, 
either inherited from the parent, or derived from the circumstances of early 
infancy, which constitutes a predisposition to this complaint. There\ is, I 
think, as little doubt, that a similar predisposition may be created in indi- 
viduals, previously quite free from any peculiar morbid tendency, by the ope- 
ration Of certain causes which tend to lower the grade of the vital forces, and 
to vitiate or impoverish the blood. Such causes are a meagre and unwhole- 
some diet; confined and contaminated air, especially that of crowded apart- 
ments; sedentary occupations; long exposure to cold, especially after a pre- 
vious habitual exposure to heat, as in. those who remove from a warm to a 
cold climate; a damp.atmosphere; excessive and exhausting indulgences; 
continued mental depression; and, finally, the influence of various diseases, 
as small-pox, scarlet fever, measles, syphilis, &c. The state of system which 
may be considered, in some cases, as merely predisposing to the disease, often 
becomes absolutely morbid by an excess of the influence which produced it, 
and thus passes directly into the disease itself. The agencies above men- 
tioned as predisposing, thus become immediate causes. In other instances, 
the predisposition is called into action by exciting causes, among which the 
most prominent are those which give rise to inflammation. It is very certain, 
that this morbid state has a powerful tendency to develope scrofulous disease, 
where the predisposition already exists. The complaints above alluded to as 
sometimes co-operating^ by the debility they induce, in establishing a predis- 
position, oftener operate as exciting causes. Upon the whole, the most fre- 
quent sources of external scrofula, are probably inheritance, and the combined 
influence of a cold, damp, and variable atmosphere,, with depressing habits of 
life. The disease is most common in temperate latitudes, where the vicissi- 
tudes of weather are most experienced, and equally effective measures are not 
resorted to, as in the extreme north, in guarding against the cold. It is less 
frequent in the United States than in Europe, because the mass of the popu- 
lation in this country enjoy more abundant means of physical comfort. 
Nature.-The nature of scrofula has been discussed under another head. 
(See page 107.) It will be sufficient here to observe that a question has been 
made, whether the original local affection is a peculiar inflammation leading 
to the deposit of tuberculous matter, or whether the deposit of this matter 
constitutes essentially the first step of the disease; the inflammation resulting 
from its presence, as from that of any other foreign substance. In answer to 
this, it may be stated that dissection often shows the existence of a low grade 700 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[PART II. 
of inflammation before any tuberculous matter has been secreted; while, in 
some cases of scrofula, inflammation of the same slow and obstinate character 
as that of the tuberculated glands sometimes occurs, in one part or another of 
the body, without the obvious secretion of the characteristic cheesy or curdy 
substance. The inference is, that, in a system predisposed to scrofula, the 
occurrence of inflammation often leads to the albuminpus secretion, which 
forms the peculiar feature of the complaint; and that the existence of the 
predisposition which leads to this secretion, is capable of impressing a pecu- 
liar character upon inflammation arising from any ordinary cause. But it 
would be altogether premature to stale that a. low grade of inflammation ne- 
cessarily precedes the tuberculous deposit. There is, on the ..contrary, reason 
to believe that this matter is often secreted, whether in consequence of a spe- 
cies of vascular irritation, whether from the state of the blood, immediately 
from the blood-vessels, without the slightest preceding inflammation; and the 
truth probably is, that the state of' system which leads to this deposit, is capa- 
ble, also, without the deposit, of impressing a somewhat peculiar character on 
the inflammatory process. But, whatever may be' the origin of the tubercu- 
lous matter, there can be no doubt thdt, when once secreted, it serves, like a 
foreign body, aS the cause of the subsequent inflammation, suppuration, ulcer- 
ation, &c., which are necessary for its discharge; and that, as it is the chief 
source of the obstinacy and danger of the case, it must also be the chief object 
of solicitude. 
Diagnosis.-Scrofulous inflammation of the glands is distinguished from 
ordinary chronic inflammation of the same parts by the greater hardness of 
the tumours, their less degree of tenderness upon pressure, their longer con- 
tinuance and greater indisposition to yield to treatment, their frequent com- 
plication with other scrofulous affections, and by the state of system which 
precedes or attends them. The practitioner will also be influenced, in forming 
his judgment, by the hereditary or family influences, which may have served 
to create a peculiar predisposition in the patient. 
Treatment.-1The point that should be first aimed at is the correction of 
the peculiar state of system in which the tubercular deposit, and the other 
characteristic morbid phenomena of scrofula, originate. While this condition 
remains, our efforts to correct the local disease will at best be useless, and 
may be very injurious. Either the tumours will resist our remedies, or, if 
they yield and disappear, the diathesis will exhibit itself in disease of some 
other and more dangerous part. It is no uncommon event for the recession 
of scrofulous swellings upon the neck, or in other external situation, to be 
followed by pulmonary consumption. Instances of this kind have come under 
the notice of the author. The late Dr. Parrish, of Philadelphia, whose expe- 
rience in this form of disease was ample, had so much dread of such transla- 
tions, that he always employed measures calculated immediately to discuss 
scrofulous tumours with great caution, and generally preferred leaving them 
entirely alone, addressing his remedies solely to the system. That the swol- 
len glands are sometimes relieved exclusively by local means, and with im- 
punity, only proves that, in mild cases, the morbid tendency may exhaust 
itself by the first demonstration, and cannot be admitted as a justification for 
a similar course, in cases where the tendency may be much stronger and more 
permanent. 
In order to correct the state of system, it is of the utmost importance to 
remove the causes which may have produced, and. may still be sustaining it. 
The patient should be surrounded with circumstances most favourable to the 
production of sound health, without undue excitement. The vital forces 
should bo invigorated, and the vital actions moderately supported; but care CLASS III.'] 
EXTERNAL SCROFULA. 
701 
should- be taken not to stimulate the latter beyond the healthy standard. A 
fresh, pure 'air at all times, and exercise within the limits of fatigue, are 
among the most- efficient remedial measures. If the patient be compelled to 
labour for a livelihood, he should, if possible, select an avocation in which the 
muscles generally might be called into action, and which would not require 
confinement to close, and especially to crowded apartments. Among the 
worst situations for a scrofulous patient are the crowded walls of an ill-con- 
ducted, and over-peopled hospital. The diet should in general be simple, 
digestible, and nutritious, but not stimulating. Farinaceous substances, the 
more easily digested fruits and vegetables, milk, meats in moderation, and 
especially boiled meats, may be employed. Should the patient find himself 
over-stimulated by animal food, he should diminish the quantity, or abandon 
it for a time. But, in relation to diet, reference must be had to the stage of 
the disease, and the state of the system. Should the local inflammation be 
considerable, or any febrile excitement exist, as sometimes happens in the 
earlier stages, it would be proper to confine the patient to vegetable food. In 
the stages of debility, on the contrary, the more stimulating kinds of animal 
food become advisable, and sometimes necessary. The clothing should be 
such as to preserve the temperature of the surface as nearly equable as possi- 
ble; and for this purpose garments of wool should be worn next the skin. 
The mind should be kept in a state of moderate and agreeable occupation, 
neither overworked on the one hand, nor allowed to prey upon itself by utter 
idleness on the other; and efforts should be made to produce and sustain a 
cheerful flow of - spirits, or at least a feeling of placidity and contentment. 
The injurious influences of climate should be obviated, as. far as possible, 
without sacrificing the all important requisite of exercise in the open air. 
Many of these conditions may be. fulfilled by a sea-voyage, or by travelling 
on land, especially if the course of the patient be directed towards a warm 
climate during winter. Where long journeys are impracticable, excursions, 
within the means of the patient, to watering places, or to the sea-shore, should 
be recommended; and great advantage will sometimes accrue, in the case of 
adults, from their performance on horseback. The waters of many of the 
springs, employed both internally and externally, will be .found to add to the 
various, other advantages of these excursions; and few remedies are more 
efficacious in scrofulous affections, where the lungs are not involved or sus- 
pected, and especially in the cases of children, than sea-bathing and' a resi- 
dence by the sea-side. Experience has shown that such an exposure is pecu- 
liarly unfavourable to persons consumptively disposed, and to such persons, 
even though affected with external scrofula, the sea-shore should not be 
recommended. 
In addition to the measures above advised, care should be taken to keep all 
the functions as nearly as possible in their healthy state. If any one of the 
secretions be deranged, deficient, or excessive, it should be corrected by the 
appropriate remedies. Constipation should be obviated by means calculated 
not to injure the tone of the bowels, or depress the general strength. Excess 
of acid in th^ stomach, or elsewhere, should be neutralized by lime-water, or 
one of the alkaline carbonates. Excitement should be equalized by supply- 
ing its deficiency in particular parts by artificial measures. Thus, if the feet 
and hands are habitually cold, and the surface of the body habitually pallid, 
frictions, champooing, gentle slapping upon the skin, rubefacient liniments, 
and warm stimulating pediluvia or baths, as of common salt, mustard, nitro- 
muriatic acid, &c., should be resorted to. Internal inflammations should be 
counteracted, as far as may be, without exhausting the resources of the sys- 
tem. Hence, local depletion, counter-irritation, the antimonials and other 702 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
refrigerant diaphoretics, and the saline cathartics, should be preferred to free 
depletion by the lancet. The same rule is applicable to the treatment of 
any general excitement or fever that may attend the developement of the 
tumours. L ' , 5 
The state of the blood should be attended to, and, if a deficiency of red 
corpuscles should be observed, as may not unfrequently happen, it should be 
supplied by means of animal food, and the use of the chalybeates. The 
preparations of iron are, indeed, among the most efficacious remedies in 
scrofulous affections. They act directly by their tonic power, and indirectly 
by increasing the richness of the blood. Those should be preferred which 
are at the same time least irritating to the stomach, and most readily enter 
the circulation. The' sub-carbonate, the pills of carbonate of iron of the 
Pharmacopoeia, the tincture of the chloride, and the solution of the iodide, 
may be employed. Some recommend also highly the wine of iron, 'which 
owes its chalybeate virtues to the tartrate of iron and potassa. 
There are very frequently, in scrofula, a laxity of tissue and general debility, 
which call for the use of astringents and- tonics. One of the most agreeable 
and useful of these is pipsissewa (chimaphikj U. S.), which combines a mild 
astringent and tonic power, and may be given very freely and for a long time 
with impunity. I have been in the habit of using this remedy largely, and 
have almpst always found it effectual in private practice. The decoction 
should be given to the amount of half a pint or a pint daily to an adult, and 
proportionably to children. Tn very many cases, I have found no other me- 
dicine necessary than this, in connexion with a saline cathartic twice or three 
times a week, during the increase of the tumours. The same indication is 
met by the walnut loaves, which have recently been introduced into use, in 
Europe, as a remedy in scrofula, and arc highly lauded by some French prac- 
titioners, (See U. S. Dispensatory.) Some of the products of the oak have 
long been used for a similar purpose. In Germany, coffee made from roasted 
acorns is a favourite remedy; and baths of a decoction of oak bark are likely 
to be useful, particularly in the cases of children. The simple bitters, such 
as gentian, quassia,, and columbo, may be given in cases of general debility 
with enfeebled digestion; and, in the latter stages of the complaint, when a 
more powerful tonic impression is required, to support the patient under the 
exhaustion of the puruloid discharges and colliquative sweats, sulphate of 
quinia, or some other preparation of Peruvian bark, may be advantageously 
substituted, in connexion with wine or the malt liquors. The mineral acids, 
too, are highly useful under these circumstances, being peculiarly adapted to 
cases, in which night sweats are associated with want of appetite and weak 
digestion. Nitromuriatic acid is thought, iii addition to its tonic effects, to 
exercise a beneficial alterative influence. 
Still another indication, frequently presented in external scrofula, is to 
relieve the nervous irritation, the pains, restlessness, want of sleep, and va- 
rious vague uneasinesses, which attend the advanced stages of the disease. 
This is to be accomplished-by means of narcotics and anti-spasmodics, espe- 
cially conium, hyoscyamus, belladonna, and stramonium. The extracts of 
these medicines may often be very appropriately combined with the laxatives, 
chalybeates, and other tonics employed. The preparations of hops, fr6m their 
combination of narcotic and tonic properties, are often beneficial under the 
same circumstances. Opiates, in consequence of their constipating property, 
should be employed only when the other narcotics fail, or when they may be 
indicated for the suppression of diarrhoea. A remedy admirably adapted to 
the debilitated and irritated condition of system, incident to the advanced 
stages of the disease, is the cold infusion of wild-cherry bark, which is at the CLASS III.] 
EXTERNAL SCROFULA. 
703 
same time tonic to the digestive and nutritive functions, and, in consequence 
of its hydrocyanic acid, sedative to the nervous and circulatory systems. 
Various remedies have been introduced into the treatment of external 
scrofula, with a view to their alterative effect. Some of these, probably, owe 
their reputation to the circumstance, that the disease frequently runs a certain 
course, and, in the end, subsides spontaneously, without the employment of 
remedies. Now, in cases having this disposition-and the category probably 
includes all those in'which the causes of the disease are not incessantly acting 
-the medicine last employed, before the spontaneous amendment, gets the 
credit of the* cure. It can scarcely, however, be doubted that some of these 
alteratives are highly efficient in the cure of the disease. Amorig them, the 
most important, beyond all comparison, is iodine. The efficacy of this medi- 
cine has been too variously and abundantly tested to admit of reasonable 
question. It maybe employed in all forms and stages of the complaint, 
unless, perhaps, when it is attended with febrile excitement.. The prepara- 
tions which may be most advantageously employed,- as a general rule, are the 
compound solution of iodine, the compound tincture, and iodide of potassium. 
One of these may be preferred to another, according as. it is found, upon trial, 
to agree best with the patient. Upon the whole, iodide-of potassium may be 
considered the safest to commence with. If chalybeates are at the same time 
indicated, the iodide of iron may be preferred; if mercury, the iodide of that 
metal. Whichever preparation is given, it should be employed at first in 
moderate doses, and persevered in steadily for a long time, unless some local 
or general irritation, should appear to. be occasioned by its use, when it should 
be suspended. When it cannot well be administered internally, resort may 
be had to ointments, lotions, or baths; and this mode of application is often 
usefully combined with the internal; as the system may be affected by either, 
and consequently more speedily by both together. For the modes of exhi- 
biting iodine, the reader is referred to the U. S. Dispensatory. Bromine and 
its preparations have properties closely allied to those of iodine, and may, 
perhaps, be substituted for it occasionally without disadvantage. 
Other substances, which have enjoyed considerable reputation in the treat- 
menbof scrofula, are the chlorides of barium and calcium, and various vege- 
table alteratives, as sarsaparilla, guaiacum, and mezereon. The compound 
syrup and compound decoction of sarsaparilla are still occasionally used, and 
probably with advantage, in cases in which it is desirable to sustain a gentle 
excitement of the various secretions, and particularly that of the skin. The 
two chlorides mentioned, though probably not wholly destitute of efficacy, 
have been almost entirely superseded by the preparations of iodine. Neulk 
> water, taken internally, has been thought useful, through the chlorides which 
it contains. Cod-live?' oil has long been used, with great asserted advantage, 
by German practitioners; and has recently come into extensive employment 
both in Great Britain and the United States. By some it is looked upon as 
the most efficacious known remedy in scrofula. I have had little experience 
with it; but have seen cases of the most unpromising character, in the Penn- 
sylvania Hospital, under the charge of my colleague Dr. George Fox, which 
have recovered or been greatly benefitted by its use, after a long and fruitless 
trial of other remedies. It should be taken in the dose of a tablespoonful three 
or four times a-day, and continued for three or four months before being 
abandoned. Mercury has been highly recommended; and, so far as concerns 
the removal of the tumours, will probably often prove effectual, especially in 
the early stages. But at .present its use is generally considered hazardous, 
and has been abandoned by the most prudent practitioners, at least in refer- 
ence to its sialagogue action. It is thought, when pushed thus far, to act 704 
LOCA*L DISEASES.-ABSORBENT SYSTEM. 
[part II. 
unfavourably by interfering with the healthy processes of the system, and 
thus favouring the scrofulous diathesis; so that, though the glandular affec- 
tion might be relieved, there would be danger of tuberculous deposition in 
other and more vital parts. There may, however, be complications, which 
would justify the moderate use of mercury in external scrofula; as, for 
example, when this disease is associated'with chronic hepatitis, or secondary 
syphilis. In such cases, it should be used with caution, and the iodide of 
mercury would be a convenient form for exhibition. Small doses of the chlo- 
ride of mercury, with the preparations of sarsaparilla, have been much used, 
in cases of combined scrofula and syphilis. 
Very advantageous impressions may often be made in scrofula by different 
kinds of bathing. When ther6 is a depressed state of the system, and yet 
vigour enough to ensure reaction, the cold bath, employed daily or less fre- 
quently, will often prove an excellent tonic. Hence, in part, the virtue of 
sea-bathing already alluded to; but it is probable that the saline-contents of 
the water of the ocean, such as the chlorides and iodides, are additionally 
advantageous, both by a stimulant action on the skin,-and an alterative action 
on the system. Sea-bathing may be imitated by the use of cold baths im- 
pregnated with these salts artificially. When, instead of requiring a tonic 
impression, the system is in a febrile state in consequence of the local inflam- 
mation, the warm bath, as one of the mildest and at the', same time most 
efficacious sedatives that can be employed, should be substituted for the cold- 
bath. Sulphur-baths have been useful as an alterative in external scrofula, 
and especially when consisting of the natural sulphurous waters, such as those 
of the springs in the mountains of Virginia, of the Blue-lick springs in Ken- 
tucky, and the Avon and Sharon springs in New-York. 
In the treatment of external scrofula, reference must always be had to the 
stage of the disease, and the state of the system. In the early period, when 
tonic medicines are indicated, those of the mildest character should in general 
be selected. If, as often happens, there should be some excitement o¥ the 
pulse, gentle purgation with sulphate of magnesia or other saline cathartic, 
given twice or three times a week, is not only well borne, but often proves 
highly advantageous by diminishing the excitement, and at the same time 
sustaining a moderate and safe revulsion from the seat of the disease to the 
long course of the bowels. Should the excitement be considerable, and the 
general vigour of the system little impaired, a combination of jalap and bitar- 
trate of potassa may be substituted for the less active cathartic. Under this 
treatment, especially when combined with the use of the decoction of pipsis- 
sewa, the patient often gains instead of losing flesh. In the more advanced 
stages of the disease, or at any period, if the debility is considerable, rhubarb, 
aloes, or some mild laxative which is without the property of materially in- 
creasing the intestinal exhalation, such, for example, as sulphur, should be 
preferred. It is to the last' stages, when the system lias become much 
exhausted, that the more actively tonic and stimulant plan of treatment is 
adapted. The preparations of iodine may be employed at any stage, unless 
the system be in a state of inflammatory excitement. 
Local Remedies.-For reasons already given, local measures'should always 
be employed with caution. When inflammation is considerable in the gland, 
and especially when it extends to the surrounding cellular tissue, leeches and 
the saturnine applications may be resorted to. In the more indolent states 
of the tumour, if its dispersion be considered advisable, lotions or ointments 
of iodine, or the iodide of potassium or of lead; mercurial ointment; common 
salt, applied in solution or in the form of cold poultice; ammoniacal liniments; 
and plasters of the stimulating gum-resins, as of ammoniac and galbanum, CLASS III.] 
DISEASE OE THE BRONCHIAL GLANDS. 
705 
may be used with some effect, especially if applied in the earlier stages, before 
the deposition of tuberculous matter. When suppuration appears inevitable, 
it should be favoured by emollient poultices; and the abscess, when formed, 
should be opened by the lancet. Should the abscess degenerate into a fistu- 
lous sore, the sinuses should be excited by stimulating injections, or distended 
by sponge-tent, or laid open by the knife. When ulcers are formed, they 
should at first be treated by mild dressings. If indisposed to heal, they may 
be stimulated by resin cerate, the ointment of red oxide or subnitrate of mer- 
cury more or less diluted, that of the iodide or biniodide of mercury, weak 
nitric acid, and other similar applications. The ointment of iodide of lead 
has also been very strongly recommended. When the ulcer is flabby, and 
disposed to form fungous granulations, chalk, dried alum, nitrate of silver, the 
vegetable astringents, Peruvian bark, &c., may be resorted to. If fetid and 
gangrenous, the chloride of soda or lime, creasote, and the fermenting poultice 
are suitable applications. Should acute inflammation supervene, it should be 
corrected by emollient poultices. To obviate the danger arising from the cure 
of the local affection, it has been recommended to establish a steady external 
revulsion, by means of setons or issues in the arms or legs. 
Prophylactic Treatment.-In persons known or strongly suspected to have 
the scrofulous predisposition, it is of great importance to prevent the develope- 
ment of the disease by suitable prophylactic treatment. T-he measures to be 
employed are identical with those already mentioned, as calculated to obviate 
the causes of the disease, and need not be again enumerated. But the care 
of the physician should extend even beyond these. When a scrofulous female 
is likely to become a mother, or even when the defect lies upon the side of 
the male parent, the utmost care should be employed, during pregnancy, to 
keep her in a sound state of health; and the same care should afterwards be 
extended to the period of lactation. If the .mother positively labours under 
the disease, she should relinquish to a healthy and vigorous wet nurse the 
nourishment of the infant. The child should be weaned at the end of a year, 
and then fed with milk, farinaceous substances, and a portion of light animal 
food; and these should be commenced with, even before the breast has been 
relinquished. Attention should be paid to the clothing of the child, who 
should be kept perfectly clean, exposed freely to the fresh air, and early ac- 
customed to active exercise. The mental precocity, which is a not unfrequent 
attendant of the scrofulous diathesis, should rather be repressed than encou- 
raged. The physical rather than the mental education should engage the 
solicitude of the parent; and, when the time comes for the choice of an occu- 
pation, the attention should be directed to one, which would .lead necessarily 
to frequent or habitual exercise in the open air. 
Article IV. 
DISEASE OF THE BRONCHIAL GLANDS. 
These glands, from ten to twenty in number, are seated about the bifurca- 
tion of the trachea,, and its bronchial ramifications, which they accompany for 
some distance into the pulmonary tissue. It should be recollected that, though 
reddish in early life, and afterwards grayish, they ultimately often assume a 
black colour, which is not to be considered an evidence of disease. The ab- 
sorbents of the lungs pass through them; and the change in their colour cor- 706 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
responds with a similar change that takes place, to a certain extent, in the 
lungs themselves. 
The bronchial glands are liable to all the diseases which affect the same 
structure in other parts of the body. They may be affected with inflamma- 
tion, acute or chronic, may become scrofulous or tuberculated, and may be 
the seat of encephaloid or cancerous degeneration. But, generally, their dis- 
eases offer no signs by which they can be certainly recognized during life; 
and are often first revealed by dissection. The glands may be considerably 
swollen, and indeed sometimes attain a great magnitude, without producing 
any material embarrassment of respiration. Even when pressing upon the 
air-passages, they do not always occasion difficulty of breathing, probably in 
consecpience of the gradual manner in which their encroachments take place. 
Another circumstance which prevents an accurate diagnosis is the very fre- 
quent co-existence of other diseases, the symptoms of which completely mask 
those of the glandular affection. Sometimes, however, these tumours do pro- 
duce dyspnoea by compressing the windpipe or bronchia, and, according to 
Dr. Carswell, even give rise to symptoms of obstructed circulation, by dimin- 
ishing the caliber of the great blood-vessels. Andral relates a case in which 
he ascribed great feebleness of respiration, observed upon one side of the 
chest, without the loss of sonorousness on percussion, to the probable com- 
pression of one of the principal bronchia by a mass of tuberculous glands. 
(■Clinique Medicale, iv. 250.) Dr. Williams states that he has seen tumours 
of these glands 11 pushing out the sternum or the ribs on one side, and causing 
dulness at those parts, and symptoms of displacement of the lung further 
down." (Leet, on the Physiol, and Dis. of the Chest.') When there is cough 
and more or less dyspnoea, together with dulness upon percussion in the 
interclavicular space, or over the upper dorsal vertebrae; when the upper part 
of the sternum and the neighbouring ribs are unnaturally prominent; and 
when, along with these symptoms, is an absence of the signs of aneurism, or 
other known organic disease of the chest, the existence of enlargement of the 
bronchial glands may be reasonably suspected, especially if the patient be 
very young. But, even should there be conclusive evidence of such enlarge- 
ment, which is scarcely possible, it would still be difficult to determine the 
character of the affection; and any inference upon this point must be more or 
less conjectural. The few remarks which follow will be confined to the sub- 
ject of inflammation and tuberculous degeneration of the glands; as other 
affections are so uncertain, that nothing could be profitably said in relation 
to them. x. 
Inflammation of the Bronchial (Hands. 
This may be acute or chronic, and is probably, in the greater number of 
cases, the result of inflammation of the bronchial mucous membrane. At 
least, in those post-mortem examinations in which tjie glands were found in- 
flamed, Andral states that he generally observed redness of that membrane. 
Indeed, such a result is in accordance with the general fact, that irritation 
is apt to be propagated to the absorbent glands which lie in the course of 
the lymphatics running from the part affected. But the disease does not 
always arise from this cause. It is sometimes an original affection, advancing 
even to suppuration, and the discharge of pus into the trachea or one of the 
bronchia, without any evidence being afforded of preceding or attending 
bronchitis. 
Should a case occur, presenting pain beneath the upper part of the ster- 
num, or deep in the chest towards the corresponding portion of the spine, 
together with the symptoms before mentioned as indicative of enlargement CLASS III.] 
DISEASE OF THE BRONCHIAL GLANDS. 
707 
of the glands; should there also be fever, cough, and expectoration of puru- 
lent matter, followed by a disappearance of the symptoms, without the evi- 
dences of inflammation in any other part of the chest, and without the peculiar 
signs of a strumous state of system, there would be reason to suppose that the 
disease had consisted in acute inflammation of the bronchial glands. A mode- 
rate degree and longer duration of these symptoms, with the same termination 
in suppuration and recovery, would mark a chronic affection of the same kind. 
Should the same symptoms be presented, with the exception of the purulent 
discharge, and should they yield to the ordinary antiphlogistic treatment, 
there would be grounds for believing that inflammation had existed, and ter- 
minated in resolution. V. .• ' , \ • 
The affection is more common in children than in adults; and it is not 
impossible that some of those cases, not very unfrequent in infants, in 
which pain and oppression of chest, with fever of longer or shorter dura- 
tion, have been followed by a sudden expectoration of pus with consequent 
relief, and which have been considered as abscesses in the tissue of the 
lungs, may have in fact been nothing more than instances of inflamed bron- 
chial glands. • '■ j . , . 
The treatment of this disease, when supposed to exist, should be con- 
ducted on the general principles applicable to inflammation wherever seated. 
Depletion, general and local, refrigerant cathartics and diaphoretics, revulsion 
by means of blisters or rubefacients, the antiphlogistic',regimen, anodynes to 
allay cough, and ultimately, should other means fail, mercury, or, in chronic 
cases, the preparations of iodine internally and externally, would be the pro- 
per remedies; care being taken to adapt them in degree to the severity of the 
local disease, and the general condition of the- system. 
Scrofulous or Tuberculous Bronchial G-lands. 
In phthisis^ the bronchial glands are very often somewhat inflamed and 
enlarged, but not necessarily tuberculated. The bronchial and pulmonary 
inflammation associated with tubercles gives rise to a sympathetic inflamma- 
tion in these glands, which may or may not be attended with a deposition 
of tuberculous matter. The former result is much more apt to take place 
in children than in adults. In infants of a strumous constitution, what- 
ever provokes inflammation of the absorbent glands is apt to awaken in 
them the scrofulous action. Thus, while , in adults, tuberculous ulceration 
of the bowels, or of the lungs, may be accompanied with common inflamma- 
tion of the absorbent glands with which these parts respectively communi- 
cate, it not unfrequently happens that, in infants predisposed to scrofula, 
common enteritic or bronchial inflammation will give rise to a tuberculous 
affection of the glands. Hence, the complaint of which we are now treating 
is incomparably more frequent in young children than in persons of mature 
age. . . • . ' . . 
The disease is so frequently associated with phthisis* the symptoms of 
which completely cover and conceal those of the glandular affection, that it 
can seldom be recognized until made known by dissection after death. Oc- 
casionally, however, it occurs without any preceding or simultaneous deve- 
lopement of tubercles in- the lungs; and, even when these exist, they are 
sometimes much smaller in amount than the tuberculous deposit in the 
glands, and cannot be considered as the source of the latter affection. 
When the physical signs indicative of enlarged bronchial glands are ob- 
served, with little or no pain in the part, with occasional fever, cough, and 
dyspnoea, which have come on gradually and persisted for a considerable time; 
when along with these symptoms are marks of a scrofulous constitution, 708 
LOCAL DISEASES.-ABSORBENT SYSTEMS 
[part II. 
such as swellings of the cervical glands, occasional epistaxis or spitting of 
blood, tumefaction of the abdomen, &c.; and especially when the patient is 
under the age of puberty; it is reasonable to suspect the existence of the 
disease in question. The diagnosis, however, must always be more or less 
uncertain. 
The disease is various in its progress, being sometimes rather rapid, but 
generally slow, and occasionally quite stationary for a considerable time. 
The tumours now and then attain a very great magnitude, filling the whole 
posterior mediastinum, or protruding, in young subjects, the bones of the 
thorax. Pressing upon the air-passages, they occasion inflammation, adhe- 
sion, and ultimate absorption of their parietes, thus opening a way for the 
discharge of the softened tuberculous matter they contain into the trachea or 
its branches. In this way, there is reason to believe that the diseased glands 
are sometimes ultimately restored to health. Occasionally also the tubercu- 
lous matter deposited in them appears to be absorbed, and, in some instances, 
its place to be supplied by chalky matter, as happens in certain cases of pul- 
monary tubercles. But unfortunately the affection is so often complicated 
with pulmonary consumption, tabes mesenterica, or other fatal tuberculous 
disorder, that its favourable termination can seldom have any considerable 
effect upon the general issue. 
The complaint has been found on dissection in every stage of developement, 
including mere tumefaction of the glands, solid tuberculous deposit in their 
substance, softening of this tuberculous matter, absorption in various degrees 
of the structure of the air-passages, openings into these passages, and cavities 
resulting from the evacuation of the softened matter. The glands, moreover, 
have been observed shrunken, hardened, and chalky or even bony. Andral 
states that he never met with perforation of the trachea or bronchia from 
this cause in adults; while the chalky deposition was most frequent in mid- 
dle and advanced life. He had generally observed redness or other marks of 
existing or former inflammation of the bronchial mucous membrane, but not 
always. • , 
The treatment of this disease, when ascertained, is to be conducted upon 
the same principles as that of external scrofula. The most important point 
is to obviate the tuberculous tendency of the system by measures calculated 
to support the general health and strength, without producing undue excite- 
ment; for the danger is much greater from an extension of the disease to the 
lungs, than from that already existing in the glands themselves. 
Article V. 
DISEASE OF THE MESENTERIC GLANDS. 
Of the absorbent glands of the abdomen, the mesenteric are most fre- 
quently diseased, after these, probably, the mesocolic, and next, the lumbar; 
but all are liable, in a greater or less degree, to the various morbid affections 
to which the lymphatic ganglia are incident in other parts of the body. The 
remarks which follow, though directed especially to the mesenteric glands, 
are, in great measure, applicable also to the others. They are confined to the 
simple inflammation, and the scrofulous or tuberculous degeneration of the 
glands. CLASS III.] 
DISEASE OF THE MESENTERIC GLANDS. 
709 
Inflammation of the- Mesenteric Glands. 
This is a very frequent attendant upon inflammation and ulceration of 
the mucous membrane of the small intestines, and especially of the ileum. 
Andral states that, whenever he had found the intestines exanthematous or 
ulcerated, the mesenteric glands were seriously affected, being enlarged, of a 
reddish or brownish colour, softened, and sometimes charged with small 
collections ,of pus. Those were most diseased which corresponded with the 
-most diseased portion of bowel. (Clin. Med., i. 600.) Louis found them 
more or less altered in size, colour, and consistence, in all instances of typhoid 
fever, in which their condition was examined after death. Those were affected 
which corresponded with the inflamed or ulcerated elliptical patches of the 
ileum; and the changes observed were the same as those above mentioned. 
In one instance, a gland was completely converted into pus, which was re- 
tained only by a thin sac, and must have been effused into the abdominal 
cavity, had death been postponed for a few days. (Redierdicssur la.gastro- 
enterited) Even, the enteritic inflammation and ulceration which attend 
phthisis, not unfrequently give rise to common inflammation of the mesenteric 
glands. Thus, Louis states that, when the glands were not found tubercu- 
lated in these cases, they were often increased in size, and more or less red- 
dened. (Recherckes sur la phthisic.} 
That they are also subject to ordinary chronic inflammation may be inferred 
from the fact, that, in cases of tabes mesenterica, they are sometimes observed, 
upon dissection, to be enlarged, compact, and hardened, though less indurated 
than in scirrhus, and without tuberculous deposit. (Guerstent, Diet, de Med., 
vi. 439.) It appears that any inflammation existing in the bowels is liable 
to be propagated to these glands, through the lacteals by which the two parts 
are connected. It is possible, also, that they may be originally inflamed; but 
little seems to be known upon the subject. Either the affection is very rare, 
or so mild as seldom to lead to serious results. 
The diagnosis of ordinary inflammation of the mesenteric glands is very 
uncertain. The disease may be inferred to exist, should a patient, without 
any scrofulous symptoms, complain of pain, increased by strong pressure, in 
the central parts of the abdomen,-or towards the right iliac region, and at the 
same time one or more roundish tumours be felt in the same part, by means 
of a very careful examination. In consequence, however, of the depth of the 
mesentery, the want of considerable magnitude in the tumours, and the fre- 
quently swollen state of the abdomen, this could very seldom happen. The 
tendency of the disease appears to be towards resolution, or, if suppuration 
commences, the pus is generally absorbed. The only danger to be appre- 
hended is, that an abscess may form, and open into the peritoneal cavity. 
There is reason to believe that this event has sometimes occurred. But, more 
frequently, the pus would probably find a safer outlet into the bowel by means 
of adhesive and ulcerative absorption. Where the diagnosis is so vague, little 
need be said of the treatment. Fortunately, the measures calculated to relieve 
the enteritis in which the affection generally originates, will be all that will 
be required. 
Scrofulous or Tuberculous Disease of the Mesenteric Glands.- Tabes 
Mesenterica.-Scrofula Mesenterica.-Atrophia Mesenterica. 
The disease is confined to no period of life, having been observed in the 
foetus of six or seven months, and in old age; but it is most common in child- 
hood. By far the largest proportion of cases occurs between the ages of one 
and ten years. The complaint is not common in this country, at least as a 710 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
distinct affection. It is more frequent in Europe. Guersent states that, in 
the liopital des Enfants at Paris, where no one is admitted' under one year, 
or over sixteen, the proportion of tuberculous mesenteric cases to the whole 
number of deaths., may be for boys five or six, for girls from six to eight per 
cent. (Diet. de Med., vi. 436.) But this was under circumstances, both as 
regards age and situation, most favourable to the disease. Bayle gives the 
general proportion at scarcely four in the hundred. (Ibid.) 
The disease is associated, in the great majority of cases, with other results 
of the tuberculous diathesis, which are often much more serious than itself, 
and not unfrequently completely mask its symptoms, so that it is first disco- 
vered upon dissection. Louis found the mesenteric glands more or less tuber- 
culated in twenty-three, out of one hundred and two cases of pulmonary con- 
sumption. (Recherahes su-r la phthisied) Chronic inflammation and ulceration 
of the bowels, so common in the advanced stages of this complaint, are very 
frequent complications of the mesenteric affection; and it is occasionally asso- 
ciated also with tuberculous peritonitis, * chronic hydrocephalus, scrofulous 
disease of the'spine, rickets, tuberculated bronchial glands, and various other 
forms of scrofula. In most of these cases, it is either altogether secondary, 
or at most of little comparative importance. Occasionally, however, the scro- 
fulous diathesis appears to expend itself chiefly if not exclusively upon the 
mesenteric glands, in which case the disease may be distinct and prominent. 
Symptoms;--The symptoms which ordinarily attend a case of tabes mesen- 
terica are very ambiguous. As a general rule, the greater number belong to 
the associated diseases, and comparatively few to the proper affection of the 
mesenteric glands. Nevertheless, as they actually occur in this association, 
it is important that they should be presented in one view. The following 
are those usually enumerated. The appetite is irregular, sometimes feeble, 
and sometimes voracious or perverted. Occasionally there is vomiting of 
glairy matter. The bowels are either costive, or affected with, diarrhoea; and 
the discharges are usually unhealthy, being mucous, bloody, or otherwise dis- 
coloured, and sometimes of a clayey or chalky appearance. There is fre- 
quent abdominal pain, which is sometimes acute and colicky, sometimes dull 
and continuous, and is usually increased by pressure. But. perhaps the most 
prominent symptom, and the one generally regarded as most characteristic, is 
tumefaction and hardness of the abdomen, with general emaciation, evinced 
especially in the extremities. The features are also shrunken, the surface 
pale, and the strength greatly depressed. A livid appearance may sometimes 
be observed beneath or around the eyes. The secretions are often perverted ; 
the breath being offensive, the exhalations from the surface sour or otherwise 
disagreeable, and the urine scanty and of a whitish or milky colour. The 
child is usually dull and indisposed to exertion. The pulse is almost always 
more or less accelerated, especially towards- evening, when there is often an 
accession of febrile symptoms, which are followed by perspiration early in the 
morning. Cough is a frequent symptom. At length hectic fever sets in, the 
emaciation becomes extreme, effusion begins to appear in the extremities, and 
sometimes in the abdomen, and the patient dies exhausted, or is cut off by the 
supervention of some acute inflammation. 
But none of the symptoms above enumerated are absolutely characteristic 
of the mesenteric disease, and there are none which may not proceed from 
other causes. The deranged appetite, vomiting, irregular alvine evacuations, 
and abdominal pains, niay be the result of chronic enteritis or intestinal 
ulceration, which are often present. The chalky stools, instead of consisting, 
as has been conjectured, of the chyle which is evacuated because unable to 
pass through the lacteals of the mesentery, are probably in general ascribable CLASS III.] 
DISEASE OF THE MESENTERIC GLANDS. 
711 
to a suspension or perversion of the hepatic secretion, and the milky urine to 
an excess of earthy phosphates. The swelling of the abdomen may depend 
on derangement of bowels, or chronic peritonitis, and probably does in general 
depend mainly on the first mentioned cause. The emaciation, paleness, hectic, 
&c., are abundantly accounted for by the extent of tuberculous disease, scat- 
tered over various parts of th^e system. The whole series of symptoms may 
exist without disease of the mesenteric glands. 
Nor is this complaint, when it does occur, necessarily attended with any of 
the enumerated symptoms. The mesenteric glands occasionally become tuber- 
culated, swell largely, and advance even to the stage of maturation, without 
perceptibly deranging the health; and the existence of the disease is first 
revealed by dissection, after death from some other cause. Striking cases of 
this kind are recorded by Bayle and Morgagni. In one of these cases, the 
patient is represented as having been very fat, showing that the chyle finds 
access into the circulation, notwithstanding the disease of the mesenteric 
glands. The emaciation has been usually ascribed to the non-absorption of 
the chyle, in consequence of obstruction of the lacteals; but the existence of 
Cases such as the one just mentioned, and the fact that Boker, a German 
anatomist, was always able to inject the diseased glands with mercury, their 
absorbents being quite permeable (Cyc. of Pract. Med., Lond. 1835, iv. 149), 
throw some doubt upon this explanation. There is, in most cases, abundant 
cause for the loss of flesh in the co-existence of tuberculous disease in various 
organs, and the exhausting irritation of system which this occasions. In those 
instances of tabes mesenterica in which no symptoms are exhibited during 
life, the result is to be ascribed to the absence of inflammation of the substance 
of the glands, or of neighbouring parts, which, in active cases, always attends 
the tuberculous deposit. There is reason to believe that, in some of these 
instances, the disease may run its whole course to health again, undiscovered; 
the tuberculous matter being absorbed after maturation. But, when of con- 
siderable extent, it probably sooner or later becomes active, from the neces- 
sity of inflammation and ulceration to the escape of the accumulated foreign 
matter. - - 1 
In many cases, inflainmation of the glands attends the disease from its very 
commencement, either preceding the tubercles or excited by them, and not 
unfrequently involving also the corresponding portion of the bowel or perito- 
neum. There may, at the same time, or may not be more or less of the 
complications before alluded to; and the symptoms will vary with the amount 
and nature of the associated affections. The whole train of phenomena above 
enumerated may be presented, or those only which indicate either enteritic, 
peritoneal, or pectoral disease, besides the mesenteric, according as one or 
another of these complications may exist. 
But what are the symptoms which characterize the affection of the mesen- 
tery itself, and which may serve to point it out, whether isolated or connected 
with others ? These cannot be stated with certainty, because dissection very 
seldom affords the means of verifying the inferences drawn during life; fatal 
cases being almost always greatly complicated. Conjecturally, however, the 
following may be stated as characteristic symptoms; viz., a steady dull pain 
in the centre of the abdomen, extending to the back, and inclining towards 
the right iliac region; tenderness upon strong pressure either backward from 
the neighbourhood of the umbilicus or forward from the lumbar region; the 
increase of the pain by sudden jars of the frame, as by coughing, sneezing, 
jumping, &c.; and, finally, its perseverance for months or even years, with 
remission in summer and exacerbation in the autumn and winter. Besides 
these, a general acceleration of pulse, occasional fever, especially towards 712 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
evening, loss of colour and flesh, and various sympathetic derangements of 
the neighbouring organs, such as constipation or diarrhoea, nausea and vomit- 
ing, disordered hepatic secretion, &c., might be reasonably expected. The 
pressure of the enlarged glands, moreover, sometimes occasions derangement 
in the functions of the contiguous viscera. Thus, according to Andral, by 
compressing the pylorus, they have simulated scirrhus of this passage, and, 
by operating in a like manner upon the biliary ducts, have induced jaundice. 
But the only unequivocal sign of the disease is the actual discovery, by the 
touch, of hard, roundish, or knobbed tumours in the region of the mesentery. 
It not unfrequently happens that the glands become so much enlarged, espe- 
cially at an advanced period of the complaint, as to be readily felt upon a 
careful examination. When this evidence is joined to that of the symptoms 
above enumerated, and at the. same time the patient exhibits signs of a scrofu- 
lous constitution, there can be no doubt as to the nature of the case. Hard- 
ened feces may possibly be mistaken for enlarged glands; but there can be 
little danger of such an error, if it be borne in mind that feculent accumula- 
tions of this kind are confined to the- course of the large intestines, and must 
therefore occupy a seat different from that of the mesenteric glands. 
The progress of tabes mesenterica is very generally slow, often lasting for 
years. There is reason to believe that it not unfrequently terminates favour- 
ably, when not complicated with other incurable affections. In fact, in almost 
all fatal cases, death is owing much less to the disease of the mesentery, than 
to pulmonary consumption, chronic peritonitis, tuberculous hydrocephalus, 
intestinal ulceration, or spinal disease, acting' severally or in a greater or less 
degree conjointly. When death results directly from the diseased glands, it 
must generally be in consequence of the discharge of their contents into the 
peritoneal cavity. But this is not a necessary consequence of the opening of 
the tumours, and the escape of their tuberculous and puruloid matter. Cases 
have occurred in which adhesion to the abdominal parietes was established, 
and the matter discharged externally by means of ulceration; and there can 
be little doubt that, by the same process, it sometimes escapes into the cavity 
of the intestines, and is evacuated per anum. In either of these events, 
recovery may take place. 
Anatomical Characters.-In most cases, the glands are, in the early stages, 
rod, swollen, and somewhat hardened; but sometimes they are entirely free 
from marks of inflammation, and even palei* than in health. The tuberculous 
matter exists in roundish or irregular granules, which are often more or less 
aggregated, or in, small flat plates or layers; and may be deposited either in 
the substance of the gland, or immediately exterior to it, beneath its perito- 
neal covering. It is especially apt to be found in the latter position in those 
cases which are unattended with inflammation. The substance of the gland, 
pressed upon by the increasing tubercles, is either absorbed, or forced within 
smaller limits, and sometimes quite, disappears; the glands being transformed 
into masses of tuberculous matter. These are isolated or connected, and vary 
in size from that of a pea to that of a hen's egg, or, according to Portal, even 
the head of an infant. Sometimes the tuberculous matter is deposited in 
layers between the laminae of the mesentery. This matter is generally from 
the very first dull white or yellowish, and is very seldom of that gray colour 
and transparency, which often characterize the commencement of pulmonary 
tubercles. It undergoes the various stages of softening to which similar depo- 
sits are liable elsewhere, and is at length converted into a sero-puruloid liquid, 
with curdy flakes intermingled. But this condition of the glands is not often 
observed upon dissection; as death generally occurs from other diseases before 
the period of complete maturation. Occasionally glands are found filled with CLASS III.] 
DISEASE OF THE MESENTERIC GLANDS. 
713 
a calcareous or gypseous matter, which, has probably taken the place of the 
tuberculous; and, in some instances, this matter has been observed surrounded 
by a bony shell. ' " _ > : 
In relation to contiguous structures, the peritoneum is sometimes perfectly 
sound, sometimes inflamed to a greater or less extent, with small tubercles 
between it and the subjacent cellular tissue. The mucous membrane of the 
bowels may also be either sound, or variously diseased. Sometimes it is red- 
dened, especially about the caecal extremity of the ileum, and is frequently 
ulcerated; the ulcers being small or large, superficial or deep, and in varibus 
stages of progress. Not unfrequently the omenta are found inflamed and tuber- 
culated, and the liver to a greater or less extent similarly affected. 
Causes.-The causes of this disease are essentially the same as those of 
external scrofula. The strumous diathesis necessary to its developement may 
be inherited, or may be the result of various agencies calculated, to impair the 
vigour of the system and impoverish the blood. (See page 699.) The milk 
of mothers or nurses, themselves scrofulous in fact, or in their constitutional 
tendencies, is said to predispose to the disease. As in many other affections, 
the causes which give rise to the predisposition are of themselves sufficient, 
by their long continued action, to bring on the complaint; but it is, perhaps, 
more frequently hastened by exciting causes, and especially by such as irritate 
or inflame the intestinal mucous membrane. The exanthematous fevers, and 
repelled cutaneous eruptions are among these causes. In the same light may 
be considered the cure of External scrofula by local measures, which do not 
modify the general tendencies of the system. From the character of the 
causes, it would be inferred that the disease must be- most frequent among 
the poor, and that it would be very apt to prevail abundantly in large hospi- 
tals crowded with.children; and such is really the case. It is comparatively 
rare in private families, in affluent or comfortable circumstances.' 
Treatment.-Of the treatment very little need be said; as it is almost 
identical, so far as regards constitutional measures, with that already detailed 
under the head of external scrofula. Any modifications which maybe deemed 
necessary, would have reference generally to the state of the bowels and the 
liver, which are more frequently disordered in this form of scrofula, than in 
that which attacks the external glands. Few causes are probably more influ- 
ential in awakening the-scrofulous predisposition in the mesenteric glands 
than intestinal irritation or inflammation, and a torpid condition of the liver 
giving rise to congestion of the whole portal circle. Hence the great import- 
ance of attending to the condition of these parts. Constipation should be 
obviated, acid or other irritating contents of the bowels should be neutralized 
or removed, vitiated secretion should be corrected, and the liver if torpid 
stimulated to increased action. These various indications may be met by the 
use of small doses of calomel, daily, every other day, or at longer intervals; 
combined or alternated with mild cathartics, such as rhubarb, castor oil, mag- 
nesia, or one of the purgative salts; and aided by mild tonics and aromatics, 
when called for by debility of the stomach or bowels. To correct acidity, one 
of the antacids may be conjoined with the tonics and cathartics; that one 
being preferred which may seem best adapted to the circumstances; as, for' 
example, magnesia or its carbonate, when a laxative effect is indicated, chalk 
or other form of carbonate of lime in an opposite state of the bowels, and the 
alkaline carbonates or bicarbonates, when neither laxatives nor astringents 
are wanted. It need scarcely be added that, should positive signs of intestinal 
or peritoneal inflammation exist, recourse should be had to antiphlogistic 
measures, proportioned to the strength of the system, and to the violence of 
the local affection. General bleeding, however, will seldom be admissible. 714 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
The warm bath, used frequently, will, under these circumstances, be found 
an excellent adjuvant to the other measures. 
Another point of treatment in which this affection differs somewhat from 
external scrofula, is the greater attention which the local disease requires. 
In tabes mesenterica, it is of the utmost importance to prevent, if possible, 
the maturation of the tumours, and to favour the absorption of the tubercu- 
lous matter. Especial care should, therefore, be taken to correct any acute 
inflammation of the glands,, which accelerates the march of the tuberculous 
affectio'n, if it do not call it into action. When signs of such a condition 
exist, leeches or cups should be applied to the abdomen, if the strength of the 
patient permit, and these should be aided by fomentations, emollient cata- 
plasms and blisters. In mere chronic states of inflammation, gentle and long 
continued friction oyei' the abdomen, rubefacient liniments,' stimulating plas- 
ters, or pustulation by tartar emetic or. croton oil, will be preferable. To 
promote absorption of the tumours, nothing will be found so efficient as the 
free application of ointment of iodine to the belly, persevered in for a con- 
siderable time. Great advantage may also ensue from the use of iodide of 
potassium internally, in doses as large as the system of the patient will sup- 
port. Perhaps, upon the whole, more is to be expected from the external 
and internal use of this remedy, in tabes mesenterica, than from any other. 
It is greatly preferable to mercury, from the circumstance, that, while iodine 
acts as a general tonic, and rather tends to support the vital actions than 
otherwise, this remedy, though it may correct existing inflammation of the 
glands, if pushed to salivation, leaves a condition of debility behind it highly 
favourable to the increase of the scrofulous diathesis, and consequently to the 
deposition of tuberculous matter. The use of mercury should be restricted 
to its purgative action, and its alterative influence on the functions, especially 
that of the liver/' < ' 
For whatever else is requisite in the curative, palliative, or prophylactic 
treatment of this complaint, the reader is referred to the article upon external 
scrofula, (See page 700.) In its earlier stages, much may be expected from 
appropriate treatment; and, even when the glands have become so much en- 
larged as to be felt through the parietes of the abdomen, there is no reason 
to despair. One cause, probably, of the frequent failures is, that the circum- 
stances of those affected are often such as prevent the employment of measures 
best calculated to obviate the diathesis, such as exercise, fresh air, wholesome 
and nutritious food, and whatever tends to cheer the mind, and invigorate the 
bodily functions. When the disease has advanced to suppuration; and hectic 
fever, with emaciation, night sweats, and colliquative diarrhoea, has set in, 
little else can be expected from remedies than simple palliation. 
SECTION III. 
DISEASES OF THE RESPIRATORY ORGANS. 
Previously to entering upon the consideration of the individual diseases of 
these organs, it will be necessary to call attention to certain means of diagno- 
sis, which, being applicable to many of the affections in common, cannot be 
appropriately treated of in connexion with any one of them exclusively. These 
may be included under the heads of auscultation, percussion, inspection, 
manual application, and measurement, which are here mentioned in the order 
of their importance. CLASS III.] 
715 
AUSCULTATION. 
Auscultation. 
By this term, in its technical sense, is meant the act of listening to the 
sounds of the interior of the body, by means of the ear applied to the surface, 
either directly, or through the intervention of an instrument denominated the 
stethoscope. The proper methods of practising auscultation arc sufficiently 
explained elsewhere. (Seepage 190.) It is here to be considered only in its 
application to respiratory complaints. 
In employing this method of diagnosis, it is often advisable to examine the 
chest in different stages, and states of respiration; because the sounds are 
materially modified in these, varying conditions; and occasionally a Sound is 
evolved in one condition which might not be heard in another, or might be 
heard so imperfectly as to lead to incorrect inferences. Thus, the patient 
should be first examined while breathing in the ordinary manner, and should 
afterwards be directed to breathe quickly or forcibly, to take a long'breath, or 
to exhaust his lungs more or less completely, to hold his breath for a 
time after inspiration or expiration, or in fine to make any other modification 
of the respiratory act, which may be thought capable of furnishing more pre- 
cise materials for judgment. As the,sounds produced even in perfect health 
vary greatly in different individuals^ so that what would be morbid in one 
might be quite normal in another, it is proper to compate each individual with 
himself; in other words, to examine'the chest at different periods,.and espe- 
cially to examine the two sides of the chest at corresponding points, so as to 
detect any difference that may exist between them. Should one side yield 
results decidedly different from the other, allowance being made for the very 
few natural, diversities, the existence of disease, may be considered as highly 
probable. 
The sounds connected with the function of respiration, which are the sub- 
jects of this process, axe,'first, those directly resulting from inspiration and 
expiration, and secondly, those of the voice, including coughing. 
1. In the healthy state of the lungs, two distinct sounds are sensible in 
auscultation; one called the vesicular, because supposed to depend upon the 
passage of air from the ultimate ramifications of the bronchia into the air-cells; 
the other bronchial or tubal, because generated in the bronchial tubes, and 
probably caused by the air impinging upon their sides in its movement through 
them. r-. i • 
The vesicular sound, sometimes designated as the respiratory murmur, is 
heard over those parts of the chest where the proper structure of the lungs 
comes into contact with its walls. It is produced during inspiration, and 
results probably in part from the vibrations occasioned in the minute tubes 
and cells by the impulse of the air, and in part from the .dilatation of the 
cells themselves. During expiration, though of the same character, the sound 
is very faint, and sometimes scarcely if at all perceptible, owing probably to 
the circumstance, that the motion of the air now commences in the cells, and 
is at first too feeble to give rise to other than very feeble vibrations. Between 
the murmur of inspiration and that of expiration, the interval is almost too 
short to be appreciated, and the two may practically be considered as continu- 
ous. In relation to the character of the sound, it is a soft, diffused murmur, 
which has been compared to the sighing of a gentle breeze among green leaves, 
but is best appreciated by applying the ear to those portions of the chest, 
where it exists in greatest purity. It does not appreciably differ in corre- 
sponding points upon opposite sides of the thorax. It is purest in the lateral 
and lower portions, where the bronchial tubes are finest. The sound varies 
considerably within the limits of perfect health. It is increased in intensity 716 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
by whatever increases the rapidity and force of respiration/ and is prolonged 
by a full breath. Thus, when naturally feeble, so -as to be perceived with 
difficulty, it maybe rendered sensible by directing'the patient to breathe 
rapidly, or to cough; the inspiration which follows the latter act being usually 
quick and' forcible. Its intensity varies much in different individuals. It is 
proportionate, in some degree, to the amplitude of the chest, and the thinness 
of its walls. Hence, the sound is usually more distinct in thin and lank per- 
sons, than in those who are fat or muscular. It is above the general average 
in hysterical women, and men of excitable nervous constitution, in consequence 
of their rapid breathing. In women the sound is usually louder than in men, 
and in children much more so than in adults. Hence the'respiration is said 
to be puerile, whereyer met with, when the vesicular murmur is very loud. 
In old age, the sound becomes much weaker, while its duration, which is 
diminished during inspiration, is increased in expiration. Hence, breathing 
of this kind. is called senile. But sometimes, also, even when all circum- 
stances are apparently similar, the respiratory murmur may vary greatly in 
different individuals, being loud in some and very feeble in others, without 
any appreciable cause. When, in the same person, the sound is much 
weaker on one side than at the corresponding part of the opposite side, or 
when two points on the same side materially differ in this respect, there is 
good reason to suspect the existence of disease. 
The bronchial or tubal sound has a blowing character, such as may be 
produced, out of the body, by causing air to pass quickly through a tube. 
It is harsher than the vesicular, and quite distinct from it. The part at 
which it may be heard in its greatest intensity is over the trachea, and in that 
situation it is sometimes called tracheal; but this differs only in degree from 
the sound yielded by the bropchia, and therefore scarcely merits a distinct 
name. It is perceived, in a somewhat lower degree, over the bronchia where 
they enter the root of the lungs, and, from that point, gradually diminishes, 
as the tubes ramify and penetrate more deeply into the pulmonary structure, 
until it is at length entirely lost. It is heard characteristically at the upper 
portion of the sternum, and may be distinguished for some distance upon each 
side, under the clavicle- anteriorly, between the scapulae posteriorly, and some- 
times in the axilla. As 'first observed by Dr. Gerhard, it is more distinct, 
both before and behind, on the right side than on the left, owing to the greater 
caliber of the bronchia proceeding to the right lung. That it carinot be heard 
over the whole chest, is owing to the intervention of the soft spongy structure 
of the lungs, which deadens the sound, so that it is inaudible unless the tube 
is large, or very near the surface. The bronchial sound differs Strikingly from 
the vesicular in the circumstances, that it is nearly as loud and long continued 
in expiration as in inspiration, and that instead of being nearly continuous in 
these two acts, it suffers a distinct interruption between them. The reason of 
these differences is obvious. In any given space from which the bronchial 
sound can reach the ear, the entering and returning currents, being of about 
equal velocity, and acting through an equal extent of tube, produce about an 
equal amount of vibratory movement and consequently of sound, both as 
regards intensity and duration; while, as the entering column is arrested before 
the returning movement commences in the cells, it is obvious, that a certain 
time must elapse, after the cessation of the sound of inspiration, before the 
impulse which produces that of expiration can reach the part. Both of 
these circumstances are wanting at the point at which the current of air 
begins to return, or, in other words, at the place in which the vesicular 
sound is generated. In parts of the chest in which the vesicular structure 
of the lungs exists, while the bronchial respiration is still audible, the two CLASS III.] 
AUSCULTATION. 
717 
sounds are sometimes so commingled as to be with difficulty distinguished, 
and the kind of respiration is produced which has been called rough, harsh, 
or rude. 
The sounds of the chest hitherto treated of are those of healthy respiration. 
They should be well studied on the living subject, in order to serve as points 
of comparison with the same sounds modified by disease, or with new ones 
which may arise from morbid states of the chest. 
The vesicular sound is liable to various changes. In the first place, it may 
become morbidly loud and prolonged, the latter alteration taking place more 
especially during expiration. Whatever has a tendency, by impairing, sus- 
pending, or destroying the respiratory function in one part of the lungs, to 
throw an increased duty upon the remainder, will be likely to render the 
sound in the latter portion more intense. Hence, tight bandages around the 
lower part of the chest occasion a louder vesicular murmur in the upper. The 
same effect is produced by obstructions in the bronchial tubes, excluding the 
air from a portion of the lungs; by consolidation of the pulmonary structure; 
by compression from tumours, effused liquid in the pleural cavity, or from 
other causes;. and even by dilatation of the air-cells, so considerable as to 
interfere with the performance of their duty. Whatever, too, produces a 
general morbid increase in the frequency and force of respiration) will give 
greater intensity, other things being equal, to the vesicular murmur, which 
thus becomes a pathological sign. On the other hand, the sound may be 
morbidly weakened or altogether suppressed, in any particular part of the 
chest, by a partial or' complete obstruction to the entrance of air into the cells, 
whether this obstruction exists in the tubes conveying the air, or arises from 
a filling up, compression, or want of expansibility of the cells themselves. 
Nor is a mere increase or1 diminution of intensity the only change to which 
this murmur is liable. It is occasionally deranged in various ways, in refer- 
ence to its duration and continuity. Sometimes it is not audible at the com- 
mencement of a respiratory movement, but becomes so before its close; and 
again, though audible at the beginning, it ceases before the inspiration is 
completed. The former irregularity may be ascribed to an impediment which 
is capable of resisting for a time the entrance of air into a portion of the 
lungs, but is overcome by a continuance of the inspiratory movement, as in 
bronchitis partially closing the bronchial tubes, and in pleuritic effusion press- 
ing with certain but not irresistible force upon the lungs; the latter, to 
some obstacle which, though it admits a certain amount of air to pass, resists 
a full inspiration, as in spasmodic asthma, and certain c^ses of fixed compres- 
sion of the air-cells short of obliteration. Sometimes the murmur, instead of 
being thus abbreviated at the commencement or close, is interrupted or jerk- 
ing, coming to the ear in successive irregular fragments, owing to some cause, 
such as pleurisy or pleurodynia, which renders inspiration painful, and breaks 
its continuity. Still another irregularity, is the occurrence of a decided and 
readily appreciable interval between the sounds of inspiration and expiration, 
attributable in some instances to permanent distension of the air-cells, as in 
emphysema. It may be proper also to state, in this place; that agitation of 
the patient, at the commencement of an examination, sometimes induces 
temporarily a condition of the respiratory passages, in which, though the 
muscles of respiration may act, air does not enter the cells freely, and the 
vesicular murmur is not heard. To avoid false inferences, under such cir- 
cumstances, it is always proper to make another examination after the agitation 
alluded to has subsided. 
The character of the vesicular sound is sometimes morbidly altered. It has 
before been stated that, in certain parts of the chest where the bronchial and 718 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
vesicular sounds are both heard in the healthy state, the two become mingled, 
forming what has been called the rough, or rude respiration. This frequently 
occurs, as a result of disease, in other parts of the chest. It usually depends 
on a certain degree of condensation in the pulmonary tissue, which renders 
it a better conductor of sound, without an obliteration of the air-cells. The 
bronchial respiration thus becomes audible and modifies the vesicular, which 
may either be feeble or increased, according as the cells are more or less 
affected. It is in expiration that this change is more especially observable; 
the expiratory murmur being increased in intensity and duration, and having 
more of the harsh blowing character of the proper bronchial sound than the 
murmur of inspiration. This modification of the pulmonary sound is often 
of considerable value, as one of the sighs of incipient tubercle, pneumonia, or 
pleurisy. 
The bronchial sound also is liable to morbid irregularities. Very frequently, 
in consequence of disease, it is heard, without the accompaniment of the 
respiratory murmur, in parts of the chest where it is usually quite inaudible. 
Under these circumstances, the respiration is said to be bronchial. The sound 
does not materially differ from that which is heard in health, near the root of 
the lungs. The sounds of inspiration and expiration, however, are for an 
obvious reason less distinct from each other and more continuous. The bron- 
chial respiration depends upon a consolidation of the pulmonary tissue, and 
an obliteration, temporary or permanent, of the air-cells. The air is admitted 
into the larger tubes, but not into the minute ramifications, oi* into the pul- 
monary vesicles. It is in consequence of the greater solidity of the inter- 
mediate structure, that the sound is conveyed to the surface. Sometimes the 
blowing sound is even louder than over the trachea, probably owing to the 
greatly increased surface of contact with the air, owing to the multiplication 
of the tubes. The blowing character of respiration may also be induced by 
dilatation of the tubes, without condensation of the pulmonary tissue; but in 
this case the vesicular murmur is mixed with it. The strongest effect is 
produced by dilatation of the tubes, existing jointly with consolidation of the 
tissue. 
Bronchial respiration-may be diffused equably over a considerable extent 
of lung, and proceed apparently from a great number of smaller tubes; or it 
may be limited, as if proceeding from the larger tubes only, the smaller rami- 
fications being filled or consolidated along with the air-cells. In the latter 
case, the medium, being denser, is a better conductor of the sound, which is 
therefore more distinct, louder, and of a metallic character, as if produced in 
a brass pipe. In this state, the respiration may be called tubal or tubular. 
Another modification is the cavernous respiration, produced by the passage of 
air into a cavity of moderate size. The sound is hollow, blowing, metallic, 
circumscribed, and less rapid than in the other varieties. When the cavity 
is very large, with dense and firm walls, the sound is still more metallic, and 
resembles that produced by blowing into an empty glass bottle. The respi- 
ration is in this case denominated amphoric. It is heard both in inspiration 
and expiration, unless the opening into the bronchia be very small, in which 
case the expiration is not distinctly audible. It is probably in this condition, 
that the amphoric sound may become sensible through strong inspiration, 
when not heard in ordinary breathing. 
The morbid sounds hitherto treated of are modifications of those of health. 
But others of a distinct character are generated by disease, and are highly 
important as signs. These are called rales by the French, ronchi by English 
authors. I prefer the former word, as susceptible of being adopted into our 
language; while ronchus, with its plural ronchi, must always remain foreign CLASS III.] 
AUSCULTATION. 
719 
to it. These rales may entirely supersede the healthy sounds of the chest, or 
may more or less mingle with and mask them. They result from the passage 
of air through altered tubes, or through liquid or semi-liquid matters con- 
tained in them) or from the friction of contiguous surfaces in th,e respiratory 
act. They have been divided into the dry and the moist. The dry rales are 
formed by the passage of the air, with more than the ordinary rapidity, through 
portions of the bronchial tubes, narrowed either by inflammatory thickening, 
adherent secretions, spasmodic contraction, or exterior pressure. The chief 
varieties of this sound are the sibilant and the sonorous rales. The moist 
rales are produced by the passage of air through a fluid in the bronchia of 
greater or less tenacity, causing the formation of a succession of bubbles, the 
bursting of which occasions the sound. They include the mucous rale and 
its varieties, the crepitant, and the subcrepitant. Each of these requires a 
brief description. 
1. The sibilant rale is a low whistling sound, heard both in inspiration and 
expiration, or in either exclusively, sometimes short and sharp, ceasing almost 
immediately, sometimes prolonged and of a lower tone, and produced usually 
in the smaller bronchia, though it may occur in the larger when their caliber 
is very much diminished. 
2. The sonorous rale is a Musical sound, of a deep or grave tone, and has 
been compared, in its different varieties, to the snoring of a man, the hum- 
ming of a gnat, the plaintive cooing of the wood-pigeon, and the bass notes 
of a violin. It varies greatly in intensity, being in one extreme so low as to 
be just audible, and in the other so loud that it may be heard at some dis- 
tance from the chest, without the aid of an instrument. It may occur during 
either inspiration or expiration, or may accompany both these movements, but 
is more common in the latter. It is sometimes of short duration, in conse- 
quence of the sudden removal by coughing or otherwise of the obstructing 
cause, sometimes persistent, though generally occurring interruptedly, and 
seldom with every successive respiratory movement. It arises in the larger 
bronchial tubes, which alone are capable of producing the grave tone by 
which it is characterized. It is occasionally associated with the sibilant and 
mucous rales. A modification of this sound, sometimes called the dry mucous 
rale, is produced by a portion of tough mucus obstructing a tube, and yield- 
ing to the air, during each inspiration, at short, successive intervals, so as to 
occasion a ticking or crackling noise, which, during very rapid and forcible 
breathing, becomes continuous, and passes into the proper sonorous rale. 
3. The mucous rale is heard in bronchial tubes of the size of a crow's quill 
or larger, and is formed by the bursting of bubbles of liquid, whether mucus, 
pus, or blood, of considerable, but unequal size. It accompanies both inspi- 
ration and expiration. When prevalent over a considerable portion of the 
lungs, it may often be heard at some distance from the chest. It is familiar 
to most practitioners, as the sound which attends bronchitis after secretion 
has become established; and, in the stage of transition from the dry to the 
secretory state of the membrane, is often mixed with the sibilant and sonorous 
rales, forming a singular combination of sounds, which have been compared 
to the various notes of different birds, singing or chirping together. In the 
smaller tubes, in which the bubbles are necessarily more minute, and the 
sound weaker, it is sometimes designated as the submucous rale, an example 
of which is afforded in the early stage of pulmonary tubercles, which keep up 
a slight inflammation in the small tubes in their vicinity. When the air 
passes into a pulmonary cavity, or into morbidly enlarged bronchial tubes 
containing liquid, the sound is still looser and coarser than■ the mucous rale, 
assuming a gurgling and sometimes hollow character, which has entitled it to 720 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
the name of cavernous rale. This is usually more circumscribed, and confined 
to narrower limits than the mucous rale, though, when owing to enlarged 
bronchia, it may . extend over a considerable portion of the chest. 
4. The crepitant rale is a very fine, regular, crackling sound, with minute, 
sharp, equal crepitations, and is said to resemble very closely that made by 
rubbing a lock of hair between the thumb and fingers, near the ear. It has 
also been compared to the crackling of salt, and'that produced by the burning 
of a very small train of moist gunpowder. It is confined exclusively to the 
minutest brQnchial tubes, and to the air-cells, and may depend on the succes- 
sive bursting of very minute bubbles of the tenacious secretion which occurs 
in pneumonia, of which affection this sound is characteristic, or, as suggested 
by Dr. Carr, of Canandaigua, New York, upon the separation of the walls of 
the cells, agglutinated by the plastic exudation. (Am. Journ. of Med. &cit, 
N. 8., iv. 360.) One of its peculiarities is, that it is heard only during in- 
spiration, and this fact corresponds with the explanation of Dr. Carr, as it is 
only during the expansion of the air-cell that the necessary condition for its 
production exists. Or the peculiarity may be owing to the passage, which 
has been opened by the entering air, , remaining open for a time, in conse- 
quence of the stiffness of the secretion, and permitting the returning air to 
escape without resistance, and consequently without sound. When this rale 
is once perceived, it remains for a considerable time, and is not removable, 
like the mucous rale, by coughing, and thus clearing out the bronchia. Two 
varieties of the crepitant rale may be distinguished, one fine as above, the 
other coarser, .more irregular, and often heard in expiration. The latter ap- 
proaches to the subcrepitant. 
5. The subcrepitant rale is intermediate between the two preceding. The 
sound is bubbling, but the bubbles are finer, more crackling, and more regular 
than the mucous. It has been compared to the sound of a liquid in moderate 
effervescence. It is heard both in inspiration and expiration. 
Variations in the force and fulness of respiration materially affect the sounds 
above described. Some that are heard in ordinary breathing, cease when the 
lungs are fully expanded, because the passage for the air is now free. On 
the contrary, when the bronchial fluids are so abundant as to- close the smaller 
tubes, and thus entirely to prevent the passage of air, a forcible and deep 
inspiration will open them, and thus enable the respiratory sounds to be 
generated. Sometimes the different sounds are audible at the same time in 
different parts of the lungs, and two or more occasionally in the same part. 
Not unfrequently also the rales are combined in greater .or less proportion 
with the healthy respiratory sounds; and very often much experience and a 
patient examination are necessary, to enable the practitioner to distinguish 
them satisfactorily. 
Metallic tinkling is another morbid sound requiring notice. It is quick 
and sharp, and resembles that produced by striking a pin, or other small 
metallic body, gently against a glass vessel. Different opinions have been 
held as to its cause. The only necessary condition of parts universally ad- 
mitted, is the existence of a cavity of considerable size, with firm walls, con- 
taining air. Laennec supposed the simultaneous presence of air and a liquid 
in the cavity essential to its production. It has been ascribed to the passage 
of a bubble of air through the liquid, and to the falling of a drop of fluid 
matter from the walls of the cavity, through the air, into the liquid. Accord- 
ing to Dr. Bigelow, it is owing to the bursting of a bubble of air on the sur- 
face of the liquid. M. Guerard thinks, that the sound is produced at the 
orifice of the fistulous communication, in consequence of its stoppage by viscid 
matter, or the shreds of diseased structure, being suddenly overcome by the CLASS III.] 
AUSCULTATION. 
721 
pressure of the air into the cavity, under expansion of the chest, or out of it, 
under the opposite condition of contraction. (Diet. de Med., xxv. 244.) But 
Dr. Williams, with greater appearance of probability, considers it as resulting 
from any sudden vibration of the air in the cavity, which is reflected from 
side to side of the walls. Hence any one of the above cause's may occasion 
it; nor is the conjoined presence of air and liquid absolutely necessary, as it 
has been produced in cavities filled only by air, and having no external com- 
munication, by the mere concussion of the voice and cough carried through 
condensed pulmonary tissue, f Tweedie's Sy st. of Pract. Med., art. Pnewmo- 
thoradd) It is, however, seldom heard in closed cavities; and is by far most 
frequent when the cavity contains bo,th air and a liquid, and has an external 
communication. Under such circumstances, it frequently attends and alter- 
nates with amphoric respiration, which owes its existence to a similar con- 
dition of parts. A sufficiently correct idea of the sound may be obtained 
by ausculting over the stomach, when it contains a certain amount of air and 
liquid. '■•. a . - 
Friction sound is a name given- to the noise produced by the rubbing 
together, during respiration, of the pulmonary and ^costal pleurae, roughened 
by an irregular deposition of coagulable lymph upon their surface. It is of 
course' entirely morbid, never being produced in a healthy state of the mem- 
brane. It consists usually of a succession of quick, jerking sounds, not very 
numerous, superficial in position, developed over an uncertain but limited 
extent of surface,, and exceedingly Variable in intensity, being' sometimes 
scarcely audible, sometimes very loud, and, in the latter case, often attended 
with vibrations of the walls of the chest, perceptible to the hand, and even 
felt by the patient, himself. Sometimes the friction sound, when not occa- 
sioned by ordinary breathing, may be developed by a deep inspiration, or by 
coughing. In its slighter varieties, it sometimes closely resembles the sub- 
crepitant-rale, from which it may be distinguished, according to Dr. Gerhard, 
by less regularity in the component sounds, and by not following so closely 
the passage of the air. Though usually most observable during inspiration, 
it is. generally heard during both movements, but rarely, if ever, according to 
Walshe, in expiration alone. ' ■ ,' 
The friction sound is not confined to the pleura during respiration; but is 
produced by whatever causes two contiguous surfaces of a'serous membrane 
to move upon each other, when roughened by the "exudation of coagulable 
lymph. It sometimes arises from the movements in the inflamed pleura, 
occasioned by the contraction and dilatation of the heart; and may be clearly 
perceived over the abdomen, in cases of peritoneal inflammation with plastic 
effusion, when the walls are made to move upon one of the solid viscera, or 
upon an abnormal tumour, as during a deep inspiration, or by a change of 
position. 
The vocal resonance is also a subject of auscultation. This obviously in- 
cludes cough; for all sound formed in the larynx, above that of the breath, is 
voice, whether articulated or not. It will be most convenient, as in the respi- 
ratory sounds, to treat first of the healthy sounds, and afterwards of their 
modification by disease. If the'stethoscope be applied over the trachea, in 
front of the neck, or at the top of the sternum, the voice will be heard loudly, 
and words will reach the ear through the tube with tolerable distinctness. 
This sound is sometimes called tracheophony. For a short distance on each 
side of the upper part of the sternum, below the clavicle, between the scapulas 
behind, and in the axilla, the voice is still heard, but less loud and distinct, 
and with a very imperfect and confused articulation. The sound is, in these 
situations, called bronchophony. It does not extend below the third rib in 722 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
front. Over the remainder of the lungs, the voice is either not heard, or 
produces only an obscure, confused, thrilling sound, which may be distin- 
guished by the name of pectoral resonance, and is often accompanied with a 
slight vibration of the walls of the chest, sensible to the hand laid flatly 
against them. The cause of this difference is, that, in .the former case, little 
besides the walls of the chest intervene between the bronchia and the ear, 
while, in the. latter, the tubes are enveloped in a mass of spongy pulmonary 
tissue, that intercepts the sound, which, moreover, is weakened by its ramifi- 
cation with the air-passages. The bronchial sound is a little stronger on the 
right side than on the left, below the clavicle, and in the space between the 
spines of the scapulae behind. In other parts, allowance being made for the 
heart, the two sides of the chest have a pretty accurate correspondence. The 
general vocal resonance is stronger in the upper than in the lower portions of 
the chest, and in front than behind, except in the interscapular space. It 
differs greatly in different individuals. A thin chest transmits the sound 
better than one which is fat, or very muscular; and a voice with a high key 
penetrates more deeply into the lungs than a low or bass one, in consequence 
of the more ready entrance of its small vibrations into the smaller tubes. But, 
as the bass voice is usually the strongest, it is more apt to produce a general 
vibration of the chest. Hence, the pectoral resonance and sensible tremor of 
the walls of the thorax are more marked in men; while articulate .sounds 
extend further in women and children. The difference between individuals, 
|n relation to the degree and extent of these sounds, is so great, that patho- 
logical inferences are deduced, less from their general character in any par- 
ticular case, than from their want of correspondence on opposite sides of the 
chest. \ 
The vocal resonance may be morbidly diminished or suppressed, in conse- 
quence of collapse of the lung, or the intervention of a non-conducting medium, 
as air in the distended air-cells, or pleural cavity. It is, however, much more 
frequently increased, often becoming, in diseased lungs, much louder and 
more extensive than in health; so that, in parts of the chest where naturally 
only a feeble sound is heard, it may approach or equal that ordinarily per- 
ceived over the larger bronchia or the trachea. 
When bronchophony is perceptible in other parts of the chest, besides 
those above pointed out as the seat of it in health, it is in general a sign of 
disease. It results from the intervention of a denser medium than the nor- 
mal structure of the lungs between the bronchia and the ear, and may indicate 
either consolidation or compression of the lungs, or effusion of liquid into the 
tur-cclls, the interlobular tissue, or the pleural cavity. It may also depend 
upon morbid enlargement of the bronchial tubes. It is a valuable sign in 
diagnosis; but the fact before referred to must be borne in mind, that persons 
differ much in the degree to which it naturally prevails, and that it may be 
audible in one individual without deviation from health, in parts in which it 
would in others be unquestionably morbid. To obtain correct inferences, there- 
fore, it is proper to examine both sides of the chest; and, if the sound be 
louder on one side than at the corresponding spot on the other, or if it be 
heard only on one side, allowance being made for the naturally greater reso- 
nance at the top of the right than of the left lung, the presumption will be 
strong of the existence of disease. 
Atyophony is a name given to a modification. of bronchophony, produced 
by the intervention of a moderate layer of liquid between the side of the chest 
and the lung. The voice, transmitted through the compressed lung to the 
liquid, imparts to this a vibratory movement, which causes the sound as it 
passes to the ear to assume a tremulous irregular character, compared to the CLASS III.] 
AUSCULTATION.-PERCUSSION. 
723 
bleating of a goat, from which this variety of bronchophony derived its name. 
When the lung is at the same time consolidated, the resonance is louder than 
when dependent solely on the presence pf effused liquid. 
Pectoriloquy is another variety of morbid vocql resonance, in which not only 
the sound of the voice, but the articulated words seem to proceed from the 
walls of the chest directly into the ear, resembling tracheophony almost exactly. 
It differs from bronchophony in the distinctness of the articulation, and in the 
circumstance that the resonance is usually more circumscribed, and limited in 
its extent. It is produced by the voice entering a cavity which communicates 
freely with the bronchial tubes. When the cavity is near the walls of the 
chest, the voice is still louder and more distinct. 
Amphoric Resonance is the sound produced by the voice in a large cavity, 
communicating with the bronchia by a small aperture. In this case, the 
voice is not articulated as in pectoriloquy^ and does not seem to enter the ear 
as in bronchophony, but reverberates through the cavity, and has a ringing 
metallic sound, similar to that produced by speaking into a hollow broad- 
mouthed vessel. , . . , < 
The cough, which in health yields to auscultation a short, dull, indistinct 
sound, undergoes, in morbid states of the lungs, modifications analogous to 
those produced upon the ordinary voice. It is called bronchial under cir- 
cumstances which produce bronchophony, cavernous under those which pro- 
duce pectoriloquy, and amphoric in large cavities with firm walls and narrow 
outlets. '' 
The signs of respiration and vocal resonance generally correspond, as they 
result from the same physical modifications of structure. Thus rough respi- 
ration and increased resonance, bronchial respiration and bronchophony, cavern- 
ous respiration and pectoriloquy, and finally amphoric respiration and amphoric 
resonance usually go together, and lend to each other a mutual support, as 
means of diagnosis.* 1 • ' ' ■ '< v 
Percussion. 
>For the methods of performing this operation, and for the principles of the 
process, the reader is referred to the general observations on the modes of 
exploring disease. (See page 188.) It is only its application to diseases of 
the respiratory organs that is to be considered in this place. Mediate percus- 
sion, or that performed by tapping with the ends of the fingers upon a small 
solid body applied closely to the chest, such as a piece of caoutchouc, ivory, 
or wood, or, what is still more convenient, one or more fingers of the left 
hand, is exclusively referred to in the following remarks. 
The sound produced by percussion over the chest in health, wherever the 
* The voice of the operator, in auscultation, may be used as a means of diagnosis. 
When a person, with his ear applied to the chest, speaks aloud, the tone of voice varies 
according to the condition of the parts beneath, being lower or more bass with greater 
resonance when the lung is solidified, as by tubercles or by inflammation, than when in 
the healthy state; higher or shriller, and also more resonant, when there is a large cavity 
filled with air; and quite flat, and without resonance, when the lung is compressed, as by 
pleuritic, or dropsical effusion. Now it >must be obvious that a person, who has rendered 
himself familiar With the effects of these and other conditions of the chest upon his own 
voice, will be able to detect them with some certainty by simply speaking aloud in the 
act of auscultation. The name of aheautophoni.es'' has been proposed by Dr. R. G. Latham 
for this mode of diagnosis ; and some attempts have been made by Mr. G. Corfe, of the 
Middlesex Hospital, to apply it to the study of particular pectoral affections. It is scarcely 
probable, however, that sufficient precision can be given to rules upon the subject, to ren- 
der it anything more than a subordinate aid to ordinary auscultation. (See Braithwaite's 
Retrospect, xvii. G5; from Med. Times for Jan. and March, 1848.) Note to second edition. 724 
LOCAL DISEASES:-RESPIRATORY SYSTEM, 
[part it. 
proper structure of the lungs comes into contact with its walls, has a certain 
degree of depth and clearness, indicating the presence of air within, and strik- 
ingly different from the dull flat sound, yielded by a perfectly solid structure, 
as the thigh. This clearness, however, is much dess than that of a large 
cavity containing air alone, or air and liquid, as, for example, the stomach 
and intestines when empty of solid food. The peculiarity of the sound is 
owing to the spongy structure of the lungs, in which air is distributed into 
an immense number of minute cells, around which are solids and liquids 
intimately intermingled. Its precise character can be appreciated only by 
making frequent percussion upon the healthy chest, and familiarizing the ear 
with the sounds thus produced. 
The sound varies considerably in certain parts of the lungs, with the force 
of percussion. When this is 'slight, the vibrations reach only the superficial 
structure, which, therefore, gives character to the sound; when it is strong, 
they penetrate more deeply, and evolve the sonorous peculiarities of the parts 
there situated. Thus, over the lower part of the right side, where the liver 
projects into the thorax, but with a thin layer of lung between it and the 
outer wall, a slight percussion yields the clear sound of the pulmonary tissue, 
a. strong one, the dull sound of the hepatic.' The sound is even affected by 
the material upon which the patient may lie, being deadened by a feather bed 
more than by a hard mattrass. But it is best that the examination should 
be made in the erect or sitting posture. The state of the thoracic parietes 
also affects the character of the sound, which is resonant in proportion to their 
thinness and elasticity. Hence, during the examination, the patient should 
keep his chest tense, but without contracting the muscles in the part per- 
cussed. If examined in front, he should have his head erect; his shoulders 
thrown backward, and his arms either hanging loosely by his side, or thrown 
over the back of the chair; if upon the side, he should place his hand upon 
the top of his head; if upon the back, he should bend a little forward, and 
fold his arms 'tightly over the breast. 
Both sides of the chest should always be examined, so that the sounds 
yielded by their corresponding parts may be compared. The natural sound 
is different in different individuals, and what is morbid in one may be per- 
fectly healthy in another. But the opposite sides yield the same sounds, with 
some few exceptions; and any difference in them, allowance being made for 
these exceptions, may be considered as indicative of disease. The percussion, 
moreover, should be performed under similar circumstances in reference to 
respiration; as the sound after full inspiration is considerably more resonant 
than after full expiration, especially in certain parts of the chest. Hence, it 
is important, in making a comparison of the two sides, not to examine one in 
one stage of respiration and the other in another. The patient should be 
directed, if possible, to hold his breath until the corresponding places on the 
opposite sides shall have been percussed; or, at any rate, the practitioner 
should seize the same point in successive inspirations or expirations, for his 
trials. Care should also be taken that the finger, or other object employed, 
as the pleximeter, should be in the same direction, and upon the same struc- 
ture on the opposite sides; that it should not, for example, be in the inter- 
costal space upon one side, and on the rib upon the other, or in«a perpendicular 
direction on one, and a horizontal on the other. 
In order to appreciate the morbid changes of the pectoral sounds, it is 
necessary to be acquainted with their modifications in the healthy chest. 
The results of percussion vary considerably in different individuals, in con- 
sequence of difference in the relative size of the lungs, and the relative mag- 
nitude and position of the neighbouring viscera. The following probably CLASS III.] 
PERCUSSION. 
725 
approaches, as nearly as may be, to the general average. In the whole upper 
portion of the chest, anteriorly and laterally, the sound has- the ordinary pul- 
monary character, and does riot differ materially on the two sides. As we 
descend, the sound' is modified by the presence of the liver upon the right 
side and in front, by the heart and stomach in front and on the left side; and 
by the spleen further to the left. Over the liver, heart, and spleen, the 
sound becomes duller, shorter, and flatter; over the stomach either very flat, 
when that organ is full of food, or very resonant, and of a peculiar tympan- 
itic character, when it contains only air and a portion of liquid. But the 
change of the sound from the pulmonary character to that of the organs 
above mentioned is not abrupt. In consequence of the convexity of the dia- 
phragm, the abdominal viscera project further into the thorax towards the 
middle than at the edges 'of- the cavity, where they are to a considerable.ex- 
tent overlapped by the lungs; and the thickness of the pulmonary layer, 
intervening between them and the walls of the chest, diminishes gradually in 
the downward direction until the lung ceases, and the viscera press directly 
against the ribs. , In like manner, the lung overlaps the greater portion of 
the heart, with a gradually diminishing thickness as it approaches the unco- 
vered part of that organ.. It follows, that the clearness of the pulmoriary 
sound gradually diminishes from the outer limits of the heart, liyer, and 
spleen,- up to the line where the lung ceases, when it yields entirely to the 
flat sound afforded by these organs; while, in the transition to the stomach, 
it changes into the strikingly different resonance of that organ if flatulent, or 
into its perfect dulness if full. On the right side, the 'sound begins to be- 
come somewhat duller below the fourth rib in front, and the sixth rib in the side, 
and gradually increases in dulness; as far as the sixth rib in front, and the eighth 
in the side, below which the pulmonary is superseded by the hepatic, and, to 
a certain extent, towards the epigastrium, by the stomachic sound. Below 
the middle of the sternum, and on the left side, below the third rib in front, a 
very slight diminution of clearness may be - observed, in consequence of the 
presence of the heart, which. is here, however, covered by the lung. Below 
the intercostal space between the fourth' and fifth ribs, for an extent of one 
or two square inches,' bounded by the middle of the sternum on the right, 
and stretching towards the nipple on the left, which, however, it does not 
reach, there is dulness in consequetice of the contact of the heart with the 
chest. With this exception, the left lung reaches to the seventh rib in front, 
and to the eighth on the side, where the pulmonary gives place to the sto- 
machic, and perhaps slightly in front to the hepatic'sound, and further towards 
the left to the splenic. Besides these variations anteriorly, there are others 
in the upper part of the chest. The sternal extremity of the clavicle gives a 
very clear sound, which becomes somewhat duller towards the middle of the 
bone, and is much duller at the humeral extremity. Above the clavicle 
percussion is leSs resonant than below; and the sound on the right side 
under the clavicle is said by Dr. Gerhard to be in a slight degree less clear 
than on the left. In the back- of the chest, the sound is much affected by 
the masses of muscle, and the presence of' the scapula. It is very dull above 
the spine of the scapula, somewhat less so upon that bone beneath the spine, 
and still less so upon the spinous processes of the vertebrae. In the space 
between the scapula and spinal column it is rather clear, but is clearest below 
the scapula, until we reach the region of the liver on the right side, and that 
of the stomach or colon and spleen on the left, which is somewhat lower than 
the same line anteriorly. This infra-scapular region is peculiarly clear in 
children. The sound is remarkably clear in the lateral portions of the chest 
in consequence of the absence of muscle. The pulmonary sound generally 
is clearer in children than in adults, and in these than in old persons. In 726 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
women it is affected in front by the mammm, which render it dull, unless 
under pretty strong percussion. The mammary region in women is, indeed, 
not a proper seat for this mode of exploration. 
But the limits above designated are much affected by a full inspiration, 
which causes the lung to descend about one rib lower, and almost entirely 
to cover the surface of the heart; so that the boundary of the proper pul- 
monary sound is thus much extended, while the sound itself becomes 
clearer. A full Expiration, on the contrary, somewhat narrows its limits, 
and extends those of dulness, at the same time diminishing somewhat the 
general clearness of the sound. But it has been observed by Williams that 
either a full expiration or inspiration, by giving greater firmness to the walls 
of the chest, quickens their vibrations, and renders the key higher. It must 
be recollected, too, that tbe degree bf clearness'in those parts of the chest 
where the lungs overlap the heart, liverp&c., depends in some measure on 
the force of percussion; a slight impulse evolving only the sound proper to 
the superficial parts, and consequently a clear one, while a strong impulse 
brings the hepatic and cardiac dulness to the surface. The limits between 
the lungs and stomach cannot be- so easily detected, in consequence of the 
hollow resonance of the latter organ, which swallows up the slighter pulmo- 
nary sound, though a very feeble percussion may sometimes elicit the latter, 
without the former. 
The morbid states revealed by percussion are those in which the pulmonary 
sound becomes flatter, or is altogether superseded, and those in which it 
acquires additional clearness and sonorousness.. The former effect is produced 
by whatever increases the density of the pulmonary tissue, or substitutes, a 
denser substance in its place; the latter, by whatever increases the relative 
amount of air, whether in the air-cells, in morbid cavities, in the cavity of 
the pleura, or in the external cellular tissue. The special changes of the 
sound will be more conveniently treated of under the several affections upon 
which they depend, and which they serve to indicate. Consolidation or 
hepatization of portions of the lungs, oedema of these organs, compression by 
fluids in the pleural cavities, solid tumours, encroachments of the neighbour- 
ing organs, as the heart, liver, stomach, and spleen, emphysematous distension 
of the air-cells, and the presence of air within the pleura, are among the 
pathological ^conditions which percussion may assist in pointing out. But it 
is inadequate to the detection of very slight changes, especially if deeply 
seated, and it seldom happens that it is alone sufficient precisely to define the 
character of the complaint. It is highly important, however, by calling atten- 
tion to the existence of disease within the chest, and, in connexion with other 
methods of diagnosis, often serve's to give a certainty scarcely attainable 
otherwise. In relation to the existence of fluid in the pleural cavity, it is 
often of itself sufficiently diagnostic. If dulness upon percussion is observed 
in the lower, part of the chest, and if this dulness materially varies with the 
position of the patient, being absent or present according as the operation of 
gravity ought, in the change of position, to bring the level of the surface of 
a fluid in the pleura below or above the point of examination, the evidence is 
conclusive that such a fluid exists in the cavity. A very skilful examiner 
will sometimes detect a state of things of the kind calculated to produce dul- 
ness, when so slight as to escape the notice of the ear, simply by the feeling 
in the finger struck, of a want of due elasticity in the parts beneath. 
Inspection. 
This is nothing more than an examination by the eye of the shape and 
movements of the chest; and the object is to ascertain the existence of any CLASS III.] 
INSPECTION. 
727 
deviations from health, in either of these respects. The patient should be 
viewed in front, behind, in the direction of his length, and from side to side. 
During'the inspection, the chest should be naked, or, as in females, covered 
with a thin closely fitting garment; and the position of the body should be in 
one uniform plane, whether lying,, sitting, or standing. In order that a good 
longitudinal view may be obtained, the patient may lie evenly on his back, 
while the practitioner stations himself at the foot of the bed, and directs his 
eye along the surface of the chest; or, what is perhaps better, the patient may 
sit, and the practitioner, standing behind him, may bend over his shoulder 
and look from above downward. 
In a perfectly well formed chest, the sides are symmetrical. The general 
shape of the chest is that of an irregular cone, truncated at top, larger below 
than above and from side to side than from front to. back, somewhat depressed 
above the clavicle, rather less so immediately below it, and gently convex 
from the second rib downward, as far as the base of the lungs, where a slight 
depression or flatness may often be observed surrounding the chest, imme- 
diately above the bulging produced by the abdominal viscera, during inspira- 
tion. Attention has been called by Dr. Edward Harrison to this line of 
depression, as the boundary between the lungs above and the liver, stomach, 
-and spleen below. The chest is often slightly prominent over the heart. 
Behind, it is somewhat convex from above downward, and there is a sulcus 
on each side of the spine. The ribs, except in fat persons, are somewhat 
more prominent than the intercostal spaces. But a perfectly formed chest is 
rare. Derangements, either congenital or acquired, are very common, without 
any want of health in the contents of.the thorax. This must'always be taken 
into consideration in forming a judgment; and it will seldom be proper to 
depend on the shape of the chest, without confirmatory evidence from other 
signs. But this is valuable as an aid in diagnosis; and,, when any considera- 
ble deviation from the normal shape, and especially when any striking want 
of conformity in the opposite sides is visible, it should lead to the suspicion 
of disease, and to other modes of examination. 
In inspiration, the chest is at the same time expanded and elevated; in 
expiration contracted and depressed; the intercostal spaces being somewhat 
widened in the former, and diminished in the latter. The ribs rise upward, 
and project outward, at their central portions during inspiration, and fall 
during expiration, having at the same time a somewhat rotatory motion. In 
health these movements are all regular, and those of the ribs correspond in 
all parts with those of the chest in general. The jaumber of respirations in 
health is from sixteen to twenty in a minute.. Between inspiration and ex- 
piration there is scarcely any appreciable interval, and their duration is nearly 
equal. 
The chest may exhibit derangement to the eye by a general morbid expan- 
sion, or local bulging; by the contrary state of general contraction, or local 
depression ; by changes in the relative position of its parts in reference to their 
elevation; by lateral curvatures; by an increased or diminished frequency, or 
irregularity of respiration; by changes in the relative duration of inspiration 
and expiration; and by an increase, diminution, or entire cessation of visible 
expansion in the act of breathing, whether in the whole chest, or only a part 
of it. Sometimes fluctuation is visible when there is liquid in the pleura, 
and the intercostal spaces are much bulged. The indications of these various 
abnormal phenomena will be given under the individual diseases in which they 
are observed. It will be sufficient to mention here, that collections of liquid 
or air in the pleura or pericardium, enlargement or expansion of the lung 
itself, or of other organs in its immediate vicinity, as the heart, liver, stomach, 728 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
or spleen, and tumours of various character, either in the lungs or their neigh- 
bourhood, may occasion projections, general, or partial, in the walls of the 
chest, which may be obvious to the eye, and which are much more frequent 
and extensive in the lower than the upper part of the thorax. Contraction or 
depression may result from permanent compression of the lung,, produced by 
fluid in the pleura, which is afterwards absorbed, and from whatever destroys 
the substance of the lung, or produces' shrinking in its tissue. 
Application of the Hand. 
By applying, the palm of the hand to the chest, in a healthy state, during 
the act of speaking, we are sensible of a very slight tremor, which is most 
observable in persons with a strong bass voice, and diminishes in proportion 
as the voice is feeble or high-toned. Thus, it is scarcely ever felt in children, 
and is often wanting in women. It is more perceptible in thin, chests than in 
those covered with fat, in the horizontal than in the erect position, in front 
than behind, and, according to Dr. Stokes, upon the right than the left side. 
In disease, the tremor is increased by whatever consolidates the lung without 
obliterating the bronchial tubes, because the pulmonary structure thus be- 
comes a better conductor of sonorous vibrations^ The impression produced 
upon the hand in this way is sometimes very strong, when there is a considera- 
ble extent of consolidation. The intervention of liquid or air between the 
sides of the chest and the lungs, or an emphysematous expansion of the air- 
qells, has, on the contrary, the effect of checking or intercepting the vibra- 
tions, so that the tremors will not be felt. The thrill imparted to the chest 
by the friction of the- opposite surfaces of the inflamed pleura may sometimes 
be perceived by the hand, as may also the vibrations which attend, a sonorous 
rale of great intensity. In the same way, fluctuation in the plpura or lungs 
may occasionally be detected; the fluctuating movement being-produced either 
by strong agitation of the chest in certain morbid states of respiration, or arti- 
ficially by shaking the patient, or by a sharp tap with the fingers upon one of 
the intercostal spaces in the neighbourhood. In examining the chest in refer- 
ence to these parietal vibrations, it is generally proper to apply the two hands 
to corresponding portions of the opposite sides, so that the effect produced-may 
be compared. If found less pr greater upon one side than the other, it gives 
ground for reasonable suspicion of disease. The application of the hand 
sometimes aids in the detection of a want of correspondence in the move- 
ments of the opposite sides of the chest, and even of different parts of the 
same side. The immobility of a portion of the walls of the chest, thus de- 
tected, may become under some circumstances a valuable sign. 
The beating of the heart, after full expiration, is felt about the cartilages of 
the third and fourth ribs,-and at the neighbouring part of the sternum. After 
full inspiration, it is either quite lost, or felt as low as the sixth rib. When 
the lungs are extensively consolidated, even though the heart itself may be 
healthy, the impulse is sometimes felt to a considerable distance. 
Measurement. 
The modes of effecting measurement have been elsewhere described. (See 
page 189.) The object of the process is to detect differences in the dimen- 
sions of the two sides, or in those of the whole cliest at different times. It 
should be recollected that the right side of the chest is usually rather larger 
than the left, owing probably to the greater developement produced in the 
whole of that side by exercise, thotigh the liver may also have some effect in 
producing the difference. The amount of difference varies with the degree 
in which the causes operate. On the average it is about half an inch.. In CLASS III.] 
CORYZA. 
729 
left-handed persons it is said that the two sides are equal, or that the left is 
somewhat larger. Care must be taken, in making comparative measurements, 
that the lungs should be in the same condition in reference to the respiratory 
movement; and, therefore, it may be best that the patient should hold his 
breath during the examination. This mode of diagnosis is of no great prac- 
tical importance. The eye will generally detect changes of dimension so 
considerable as to constitute a valuable sign. Measurement may sometimes 
prove useful by indicating the daily increase or diminution of fluids in the 
pleura. 
SUBSECTION I. 
INFLAMMATION OF THE RESPIRATORY PASSAGES. 
Inflammation may occupy distinct portions of these passages, terminating 
in the same part in which it - begad, or it may affect several portions succes- 
sively or simultaneously, forming one continuous disease. Thus, we have 
inflammation of the nostrils, of the larynx, of the trachea, and of the bronchial 
tubes, constituting severally coryza, laryngitis, tracheitis, and bronchitis, and 
inflammation of all these' parts successively or conjointly, as in catarrh. It 
will be most convenient to consider the first set of these complaints in the 
first place; and, after the more local affections have been described, then to 
treat of such as embrace various parts of the structure, either at once or 
during their course. 
Article I. 
INFLAMMATION OF THE NOSTRILS. 
In the nostrils we consider as included the neighbouring sinuses, such as 
those of the superior maxillary, and frontal bones, all of which are lined by 
continuations of the same mucous membrane, and all are liable to become in- 
flamed, though the whole surface is probably seldom affected at the same. time. 
1. ACUTE INFLAMMATION OF THE NOSTRILS, or CORYZA. 
Symptoms.-The first sensations are usually those of dryness, fulness, and 
tickling, or other irritation in the nostrils, with sneezing. These are usually 
soon followed by a copious discharge of a thin, colourless, acrid fluid, which 
still further irritates the membrane, while it often inflames-and even excoriates 
the skin about the nasal orifices, and on the upper lip. The nostrils are at 
this time not unfrequently either partially or wholly closed by the tumefac- 
tion of the inflamed membrane; which causes the voice'to assume a nasal 
tone. There is often a considerable degree of dull pain or aching, with burn- 
ing heat in the nasal passages; and now and then severe stinging sensations 
are experienced from the irritation of the acrid fluid. The eyes become red 
and watery, either from sympathy, or by the continuous extension of irritation 
along the lachrymal passages; and sometimes these passages appear to be 
closed, so as to occasion an overflow of the tears. A similar extension of 
the disease to the frontal sinuses produces pain in the forehead. The maxil- 
Syn.-Cold in the Head.-Gravedo. 730 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
lary sinuses are sometimes involved, with consequent pains in the face; and 
hardness of hearing in a greater or less degree is not uncommon, from swell- 
ing and closure of the Eustachian tubes. Even the external parts occasion- 
ally participate in the inflammation^ and the nose and cheeks are swollen and 
tender. The sehse of smell, and in a less degree that of taste, are almost 
always blunted or lost. 
In many instances, the constitution does not seem to sympathize with the 
local affection; the pulse and skin remaining in their ordinary state) and the 
appetite unimpaired. Very frequently, however, febrile symptoms make 
their appearance^ especially when the inflammation is of a high grade, and 
affects the whole of the nasal passages. Chilliness and pains in the limbs 
are followed by a hot skin, excited pulse, furred tongue, loss of appetite, and 
severe headache. The fever sometimes shows a tendency to exacerbations 
and remissions. 
The complaint usually attains its height in three or four days, after which 
the symptoms begin to subside. The uneasiness in the nostrils and adjoining 
parts diminishes; the secretion becomes less copious, thicker, more opaque, 
and much less acrid; and sometimes assumes a yellowish, or greenish-yellow, 
puruloid appearance; the fever gradually subsides; and the recovery is usually 
complete in from five to seven days, unless the disease is kept up by im- 
proper management, or renewed by a repetition of the cause. In this case, 
it sometimes becomes chronic, and may then run on for weeks, months, or 
even years. In a few instances, it retains a sort of acute character, with a 
thin acrid discharge, for a considerable time, probably in consequence of fresh 
attacks before the old have ceased. This watery secretion, so characteristic 
of most cases of the disease, and which has given it the name of coryza, is 
not invariably present; the inflammation being dry at the commencement, 
and remaining so until thick mucous, or muco-purulent secretion takes place. 
Very frequently ■ the inflammation travels downward into the bronchial 
tubes, constituting catarrh; but frequently also it does not extend beyond the 
nostrils, and immediately adjoining parts. Sometimes it affects one part only,, 
being confined to one side of the nostril s, or to one of the sinuses. When it 
affects the frontal sinus, the symptoms are heaviness and pain in the middle 
of the forehead, extending frequently to the superciliary ridges and the eyes, 
with a disposition to more copious discharge from the nostrils when the patient 
rises, after having for some time maintained the horizontal posture. It is 
more especially to this condition of the complaint that the name of gravedo 
has been attached. In the maxillary sinus, the disease is usually indicated 
by pain and tenderness, with some swelling of the corresponding cheek, a 
similar condition of the gums on the affected side, and soreness of the teeth. 
A copious discharge from the nostrils when the patient turns upon his side 
is another characteristic symptom. Sometimes, however, the orifice into the 
nostrils is closed by inflammation, which, if not relieved, may end in abscess 
of the antrum, requiring the aid of the surgeon. Coryza is sometimes regu- 
larly intermittent. In new-born or very young infants, this disease is attended 
with some peculiar effects which require notice. In consequence of the stop- 
page of the nostrils, they have great difficulty in sucking, and may-suffer from 
the want of nourishment. On attempting' to take the breast, they some- 
times become black in the face from suspended respiration, and are said 
occasionally to be thrown into convulsions by the same cause. In its severest 
forms, the complaint is asserted to have sometimes proved fatal. Another 
peculiarity in children is the tendency to exudation of coagulable lymph from 
the membrane, which forms solid layers upon the surface, as in diphtheritic 
inflammation of the fauces, which this affection . sometimes accompanies. CLASS III.] 
CORYZA. 
731 
Such cases are always serious, and not unfrequently fatal, from the extension 
of the same kind of inflammation to the larynx or lungs. They may be 
known by the fetid odour of the discharge; the occasional ejection, in cough- 
ing or sneezing, of portions of the false membrane; and the appearance of 
the exudation either near the anterior nasal orifices, or in the fauces. 
> Cduses.-The most frequent exciting cause of coryza, beyond all compari- 
son, is the partial application of cold, as to the back of the head or neck, to 
the feet, &c.; and the effect is especially apt to be produced after perspiration 
from heat or exbrtion. Hence, the complaint is most common in winter. In 
some instances, it is probably induced by the breathing of a warm air after 
previous exposure to cold, in the same manner as chilblains. Some persons 
are much more liable to be affected in this way by cold than others. This 
greater susceptibility is frequently ascribable to a want of the habikof ex- 
posure; but it is often also constitutional, and inexplicable. Individuals are 
occasionally met with, who are liable to attacks of the complaint periodically, 
at a certain date, once a year, without reference to the state of the weather at 
the time. Others are attacked at the commencement of winter, ancf are 
scarcely entirely free from the complaint until warm weather returns. Coryza 
is also frequently epidemic, being A very general attendant upon the influenza. 
It is very common at the beginning of measles^ and sometimes accompanies 
other exanthemata in their earlier stages, especially small-pox and scarlet 
fever. Occasionally it is produced by the direct application of acrid vapours, 
or irritating powders, to the nostrils. One of the most prominent men of 
science of this country is subject to such attacks from metallic powders or 
exhalations; and has once or oftener suffered severely, merely from opening 
a package of platinum. , ' 
Treatment.-Most cases of this disease are so mild as not to requjre medi- 
cals treatment, and scarcely to' interrupt the avocation's or pleasures of the 
patient. Even in those in which the physician is consulted, the gentlest 
measures only are in general required. ' When there is no fever, it is usually 
sufficient to direct a dose of sulphate of magnesia, abstinence from animal 
food, and the avoidance of exposure to cold or wet. Should the patient be 
under the necessity of leaving his house, he should clothe himself warmly, 
take care especially to keep his feet dry, and protect his nostrils by a hand- 
kerchief against the cold. Should the symptoms be more severe, and fever 
present, the treatment, in addition to the above measures,- may consist of hot 
pediluvia, made more stimulating by the addition of common salt or mustard, 
and the use of refrigerant diaphoretics, as citrate of potassa, acetate of 
ammonia, nitre, and tartar-emetic, variously combined to suit the circum- 
stances of the case. The patient should be confined to bed, and should lie 
with his head raised by pillows. When there is much headache, with a full 
strong pulse, and the symptoms have not yielded to the above treatment, with 
additional purgation by one of the neutral salts, a little blood may be taken 
by the lancet from the arm, or, in case of inflammation of the frontal or 
maxillary sinus, by leeches from the. forehead or cheek, or from within the 
nostrils. 
Various measures have been recommended to relieve the local symptoms, 
which are often very distressing. Dr. Physick was in the habit of advising 
the frequent inhalation, through the nostrils, of the vapour from a mixture of 
laudanum .and Hoffmann's anodyne. Mr. Harrington, a dentist of Philadel- 
phia, has found the affection, in several instances, to disappear at once and 
completely under the inhalation of chloroform. (Med. Examiner, N. 8., iv. 
295.) A lump of camphor held near'the nostrils sometimes affords relief. I 
know an individual who derives prompt relief from snuffing up powdered 732 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
cloves. Steaming with the vapour of hot water, snuffing powdered gum ara- 
bic up the nose, and the injection of oleaginous liquids with some narcotic 
ingredient, are also among the measures occasionally resorted to. M. Des- 
champs has found a solution of extract of opium, made in the proportion of 
about a grain to d fluidounce of water, and drawn into the nostrils by inspi- 
ration, promptly effectual. One nostril is to be closed with the finger, and 
the liquid drawn in through the other, until felt to be about to elater the fau- 
ces, when it is to be allowed to flow out again. The application may be made 
every two hours if necessary; but -seldom requires to be more than once 
repeated. (Jburn. de Pharm. et de Chim., xi. 370.) The patient will derive 
comfort from applying some stiff, mild, fatty matter, as suet or spermaceti 
cerate, to the upper lip and nasal orifices, in order to protect them against the 
irritating secretion. He should employ a soft linen handkerchief. 
Dr. Williams strongly recommends an almost total abstinence from liquids, 
as an effectual cure for coryza.- The secretion is arrested by the deficiency of 
the watery portion of the blood, and the inflammation speedily subsides, when 
no longer aggravated by the discharge. The coryza begins to disappear at 
the end of a' day, and in the course of thirty-six or forty-eight hours the cure 
is generally completed, so that, after that time, the patient may resume .the 
moderate use of drinks. After, the commencement, and before the completion 
of the cure, a single copious draught may bring back all the symptoms.- When 
there is fever, Dr. Williams precedes his dry plan by an aperient and an anti- 
monial. If care be taken to keep the surface warm, exercise in the open air 
is rather beneficial -than otherwise by promoting secretion from the skin; and 
any other dry method of favouring the healthy secretions contributes to the 
cure. The food should not be heating of saline so as to excite thirst, and the 
solid matters used may be moistened with liquids. Though (i total abstinence 
from liquids is most effectual, yet taking about a teaspoonful of tea or milk 
with breakfast and the evening meal, and a wineglassful of water on going to 
bed, does not prevent the success of the plan, whilst it diminishes its discom- 
fort." As, according to Dr. Williams, the plan produces no injurious effects, 
the patient may well be, allowed to choose between its discomfort, and that of 
the disease mider ordinary treatment. 
When, after the subsidence of the acute symptoms, the complaint continues 
obstinate, with a copious 'mucous or mueo-purulent discharge, a speedy cure 
may sometimes be effected'by a return to nourishing food, and free exercise 
in the open air. Sometimes violent exercise will of itself throw off an attack, 
in its earlier stages, by promoting perspiration. 
If the complaint have the intermittent form, it may be readily cured by 
sulphate of quinia. 
In infantile-' cases, it is necessary to feed the child by means of a spoon. 
Relief may sometimes be afforded by holding a sponge wet with warm water 
upon the nose. In severe cases, when the head is threatened, it will be pro- 
per to apply leeched, to administer a calomel purge, and to blister behind the 
ear, or at the back of the neck. In pseudo-membranous cases, it may become 
necessary to apply a solution of nitrate of silver by means of a camel's hair 
pencil to the parts, oi' to blow powdered; alum up the nostrils. 
When an individual is subject to the complaint jn its severer forms, and 
especially when previous experience suggests that it is likely to be the pre- 
cursor of a protracted disease of the chest, it is important to be able to set 
the attack aside at its very commencement. This may often be done by a 
full dose of opium. So long as thirty years ago, the author heard this plan 
suggested by Dr. Chapman, of the University of Pennsylvania, in his lectures, 
and he has had frequent opportunities of verifying the statements of Dr. CLASS III.] 
0Z2ENA. 
733 
Chapman as to its efficacy. From one to two grains of opium, or from ten 
to twenty grains of Dover's powder may be given at bed-time; and the patient 
will often awake in the morning free from the disease. An aperient may 
soyietimes be advisable to correct the constipating effects of the opium. An- 
other mode of obtaining the same end is to produce a copiqus diaphoresis by 
soaking the feet in hot water, and administering copious draughts of some 
hot herb-tea, as of balm, sqge, horehound, &c., at bed-time. The plan will 
be still m'ore efficacious, if some nauseating diaphoretic be added, as ipecacu- 
anha or tartar emetic. A hot infusion of eupatorium combines these advan- 
tages. If it operate as an emetic, the success will be still more certain. Care, 
however, must be taken by the patient not to expose himself to the cold air 
next day. I have known severe pneumonia result from a neglect of this 
precaution. Sometimes a rich supper, with a.due accompaniment of stimu- 
lants, will set aside a commencing coryza; but the plan is hazardous; as, if 
not successful, it may cause a great aggravation of the symptoms, and render 
serious what would otherwise have been a trivial disease. 
It is very desirable to be in possession of a prophylactic against this trou- 
blesome affection. I know of none so effectual as the daily habit of washing 
the head and back of the neck in very cold water; or, where wet feet are the 
ordinary pause, to dip them in ice-cold water every morning. It is best to 
begin with this plan in warm weather, and persevere through the winter. 
The csld shower-bath is also recommended. 
2. CHRONIC INFLAMMATION OF THE NOSTRILS, or OZJENA. 
Chronic inflammation of the nostrils is sometimes dry, being attended with 
little if any increase, or even with a deficiency of the usual amount of secre- 
tion, There is a feeling of uneasiness,, heat, and stiffness in the nostrils, 
which are often closed, on one or both sides, from the thickening of the mem- 
brane, so as to .impede the passage of air;, and this is generally the greatest 
inconvenience experienced. When it affects the posterior nares, there is a 
frequent disposition to clear them out by sudden- and forcible inspirations of 
air through the nostrils. , . 
In other cases, there is a copious secretion of a whitish somewhat opaque 
mucus, or of a yellowish muco-purulent matter, with little uneasiness or dis- 
comfort other than that which arises from the constant necessity of blowing 
the nose. - ' . , a 
Again, the discharge is occasionally quite purulent, and of a yellowish or 
greenish colour, or it is sanious and frequently tinged with blood; and, in 
both cases, has an odour generally more or less disagreeable, and sometimes 
intolerably offensive. In this form, the disease is called ozsena, and is one 
of the most obstinate and disagreeable affections which the physician has to 
encounter. In some instances, the breath of the patient is so revoltingly 
offensive as almost to isolate him from society, and to render him an object 
of disgust even to himself. There is reason to believe that this affection some- 
times occurs, without any violation of the integrity of the mucous membrane; 
but more frequently it is associated with ulceration, and sometimes with caries 
of the bones, or necrosis. In the latter case, pieces of bone are sometimes 
discharged along with the pus or sanies. Large solid flakes of excessively 
offensive matter are occasionally discharged along with blood. These are 
probably plastic exudation, or hardened mucus, from 'the surface of the ulcers. 
The sense of smell in these cases is almost always much impaired, if not 
entirely lost. J . i ; 734 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
Whatever may be the form of chronic inflammation of the nostrils, it often 
runs on for months or years, sometimes even for many years, and, in the 
form of ozama, is, in certain old cases, quite incurable. Billard relates the 
case of an infant, of seventeen months, who died of the disease after a year's 
illness; the immediate cause of death being suffocation. 
Causes.-In many instances, the chronic disease results from a continuation 
or frequent repetition of the acute. It is often also original. The cause is 
generally obscure. In some cases, it depends on foreign bodies lodged in the 
nostrils, and acting as nuclei for the deposition of solid matters from the 
secretion. In others, it appears to be associated with a scrofulous or gouty 
diathesis, with a tendency to scaly cutaneous eruptions, or with that disordered 
state of the digestive organs which so often gives obstinacy to chronic inflam- 
mation of the fauces. In the form of ozsena, when- not ulcerous, it may 
depend upon the existence of some impediment to the free discharge of mucus 
from the nostrils or sinuses, which, consequently accumulating, becomes 
putrid and excites inflammation. In ordinary chronic inflammation, the ac- 
cidental retention of the secretions may thus superadd the putrid character 
of ozaena. The offensiveness of the discharge, however; in some cases, cannot 
be traced to this cause, and is quite inexplicable, except upon the vague sup- 
position of peculiar morbid constitutional tendencies. When associated with 
ulcers, it is most frequently dependent on a syphilitic, scrofulous, or scorbutic 
taint. r । • 
Treatment.-In simple chronic inflammation, cures may very often be 
effected by the injection into the nostrils of solutions of acetate of lead, sul- 
phate of zinc, sulphate of copper, or nitrate of silver. I have usually pre- 
ferred sulphate of zinc, beginning with two grains to the fluidounce of water, 
and rapidly increasing, as the nostrils are found to bear the impression, to ten, 
fifteen, or even twenty grains to the. fluidounce. The injection should be 
repeated daily or twice a day, and continued perseveringly for months if 
necessary. It is important that, by a proper direction of the instrument, and 
position of the head, the fluid should be made to reach the seat of disease, 
whether this occupy the whole of the membrane, or, what is much more fre- 
quent, some comparatively small portion of it, in the nasal passages or the 
sinuses. Sometimes the part -can be reached by a camel's hair pencil, in 
which case, this is the best means of applying the solution, as the sound por- 
tions of the nostrils may thus be avoided, and a stronger solution may be 
employed. When the discharge is offensive, solutions of creasote, or of chloride 
of soda; potassa, or lime, will do much towards correcting the fetor, and may 
prove useful as alteratives to the mucous surface. Dr. Jackson, formerly of 
Northumberland, informed the author that, in a case of this complaint, he had 
found an injection of Fowler's solution, much diluted, completely to remove the 
fetor, and much to diminish the discharge. Caution, of course, is necessary not 
to allow the solution to be swallowed. Sometimes advantage will result from 
the mere washing out of the retained mucus, two or three times daily, by injec- 
tions of warm water. When an ulcer exists, and is within reach, it may be 
treated by the direct application of solid nitrate of silver, or by a saturated 
solution applied by means of a camel's hair pencil. Inhalations through the 
nostrils of diluted chlorine, and of the vapours of creasote, tar, and vinegar, 
have been recommended. Blisters often repeated behind the ears, or at the 
nape of the neck, or on the arm, and issues or setons between the shoulders, 
may sometimes prove useful, especially in cases which may have followed the 
disappearance of a cutaneous eruption. 
Remedies should also be addressed to the constitution. Their character 
must depend upon the peculiar diathesis, or general morbid condition which CLASS III.] 
LARYNGITIS. 
735 
may exist. Syphilis, scrofula, and scurvy have their appropriate treatment, 
which should of course be applied, when these constitutional affections exhibit 
themselves in this form. Even when the complaint can be traced to no par- 
ticular morbid predisposition, still good may occasionally be expected from 
alteratives, such as mercury, iodide of potassium, arsenic, and compound 
decoction or syrup of sarsaparilla. Tonics, and, in general, measures calcu- 
lated to give vigour to the system, will be likely to prove useful. Among 
these may be mentioned, a wholesome nutritious diet, exercise, fresh country 
air, sea-bathing, long journeys, and a sea-voyage. 
Article IL 
INFLAMMATION OF THE LARYNX, or LARYNGITIS. 
The larynx, though most commonly involved with inflammation of other 
parts of' the respiratory passages, is sometimes exclusively, and often chiefly 
affected. By some English writers laryngitis is considered as among the 
most dangerous, perhaps the most dangerous, of inflammatory diseases. But 
they restrict the term to a highly aggravated form of laryngeal inflammation, 
excluding altogether the milder forms of that affection. With as much pro- 
priety might we restrict the name of bronchitis or pneumonia to the very 
highest grades of these complaints, and then proclaim them as eminently dan- 
gerous. The truth is, that inflammation of the larynx is not uncommon, and 
is in general very manageable; though, in a few instances, when very intense, 
or attended with an unusual degree of serous effusion into the sub-mucous 
tissue, it becomes very alarming and even fatal. Its great danger, under 
these circumstances, is owing to the narrowness of the passage through the 
chink of the glottis, which is closed by the swollen state of its walls, aided 
probably by spasm of the muscles, against the admission of air; so that the 
patient dies of true asphyxia. There is no other portion of the respiratory 
passages, in which an equal extent of inflammation is capable of producing 
the same fatal results. As in most other inflammations,, the disease may be 
acute or chronic. J. 
1. ACUTE LARYNGITIS. 
Of the acute form, several modifications exist, according to the grade of 
action, the part attacked, or the character of the extravasated matter. Some- 
times it is very superficial, affecting only the mucous tissue, and perhaps only 
the surface of the membrane. Sometimes it extends to the submucous cel- 
lular tissue, involving that and the mucous membrane at the same time, thus 
greatly increasing the tumefaction, and consequently the danger. Again, the 
inflammation, which is usually attended with mucous secretion, occasionally 
gives rise to an exudation of coagulable lymph, which lines the larynx with 
false membrane. Finally, the sub-mucous tissue may be swollen simply as 
in ordinary acute inflammation, or may be distended with serum in a degree 
greatly disproportionate to the grade of inflammatory action, presenting indeed 
an edematous condition. These varieties may be conveniently considered 
under the three divisions of 1. mucous laryngitis, affecting the mucous mem- 
brane especially^and attended with mucous secretion; 2. sub-mucous laryn- 
gitis, in which the sub-mucous tissue is also involved, and sometimes chiefly 736 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
SO, as in the proper edematous variety; and, 3. pseudo-meribranous laryngitis, 
which is characterized by the formation of false membrane. These are dan- 
gerous in the order in which they have been mentioned. But it must not be 
supposed that they are always distinct. On the contrary, they often run 
together, or differ only by almost insensible shades, so that they cannot be 
distinguished by the symptoms. 
1. Mucous Laryngitis.--In its mildest form, this is marked by a slight 
hoarseness of, the voice, without pain or difficulty of respiration, and often 
with little or no cough, unless complicated with catarrh. It passes off in a 
few days, frequently without medical interference. When of a Somewhat 
higher grade, in addition to the hoarseness, there is a feeling of soreness in 
some part of the larynx, together with tightness or stricture, a dry husky 
cough, and often a slight difficulty of inspiration. If the fauces are examined, 
they will frequently be found in a greatdr or less degree reddened. Under 
proper treatment, these symptoms speedily ;s]ibside. Not unfrequently the 
inflammation descends into, the bronchia^ with relief of the laryngeal affection. 
But, if neglected, it may take on the character of a still higher grade of laryn- 
gitis. In this, the .voice is from the beginning very hoarse or stridulous, and, 
in the progress of the disease^ is almost or quite suppressed, so that the patient 
cannot' speak above a whisper. There is almost always pain, sometimes 
severe, sometimes moderate, increased by speaking and coughing, and occa- 
sionally by external pressure. The patient often has the sensation as of a 
foreign body in the larynx; and Valleix attaches much importance to this as 
a diagnostic symptom. Inspiration is difficult, and often stridulous or tightly 
sounding, while the patient feels a distressing constriction of the throat, and 
exhibits some anxiety or apprehension about his ability to get breath. The 
cough is hoarse muffled, and of a peculiar character, commencing as it were 
in the larynx, and obviously intended to remove some obstruction at that 
point. It is- either dry, or attended with the discharge of a little tough 
mucus. In some instances, it comes on paroxysmally, and is almost convul- 
sive. There is often some difficulty, of swallowing, arising from co-existing 
inflammation of the fauces, from the pressure of the alimentary bolus upon 
the tender larynx, or simply from the motion of this structure in deglutition. 
Paroxysmal attacks of great oppression and dyspnoea are sometimes experi- 
enced,. arising from spasm of the muscles of the glottis, such as occurs in 
croup: There is generally some degree of fever, which may have come on 
simultaneously with the'local symptoms, or not until they have existed for 
some time. It cannot be doubted that there is in these cases considerable 
swelling of the mucous membrane; and it is not improbable that the sub- 
mucous tissue is often in some degree involved. Redness of the epiglottis 
may generally be seen by strongly depressing the base of the tongue, and 
inducing the patient to cough, or make 'the motion of swallowing. The attack 
gradually subsides under proper treatment, and goes off in from four to six 
days, sometimes by mere resolution, but more frequently with a secretion of 
mucus, which is at first transparent, but gradually becomes thick and opaque, 
if not purulent. Should the inflammation travel into the lungs, severe bron- 
chitis is apt to ensue. 
2. Sub-mmcous Laryngitis.-Edematous Laryngitis.- Cynanche Laryn- 
gea.-This differs from the preceding rather in degree than in character. It 
may be considered as the highest grade of acute laryngitis. It is true that 
there is very generally sub-mucous inflammation; but it is not certain that 
this is, always the case. A mere swelling of the membrane may close the 
rima glottidis, as that of the Schneiderian membrane does the nostrils. Still, 
a degree of inflammation sufficient to produce this effect would almost always CLASS III.] 
ACUTE LARYNGITIS. 
737 
penetrate to the subjacent tissue. It is not many years since this was first 
noticed as a distinct disease. Washington is supposed to have died of it; and 
his case is said to be the first recorded in detail. According to Cheyne, the 
disease was not generally understood until after the publication of a paper by 
Dr. Farre, in the third volume, of the Medico-Chirurgical Transactions. 
When originating in the larynx, and not the result of some direct violence, 
this form of laryngitis usually commences with a distinct chill, or with chilli- 
ness alternating with flashes of heat, which is followed by fever, with a full 
strong pulse, a hot skin, and flushed face. At the same time, some soreness 
of the throat is felt, the voice is hoarse, and a sense of tightness, stricture, 
or pressure, is experienced, as if there were some- mechanical impediment in 
the larynx. To remove this the patient coughs, but brings up nothing, or 
only a little clear viscid mucus. The cough is painful, and its sound is harsh 
and stridulous. Great difficulty of breathing soon comes on. The inspiration 
is prolonged, wheezing, whistling, or otherwise sonorous, and requires a con- 
siderable effort on the part of the patient. The expiration is performed more 
easily and silently; as the swollen membrane of the glottis acts like a closing 
valve against the entrance of the air, but opens readily for its exit. Upon 
examining the fauces in the manner described above, the epiglottis may some- 
times be seen of a bright or deep red colour, erect, and much swollen, so as 
to be unable to descend, and close the glottis during deglutition. The external 
parts about the larynx are also often much swollen, though not invariably so. 
Deglutition is difficult, partly from inflammation of the fauces, but chiefly in 
consequence of the swollen state of the epiglottis, which prevents it from 
closing, accurately over the orifice of the windpipe, and thus allows the sub- 
stances swallowed to enter the larynx, where they excite intense irritation, 
and give rise to vehement paroxysms of coughing, with the most distressing 
dyspnoea. Dr. Watson relates a case in which, after laryngotomy, a portion 
of anything swallowed appeared immediately at the wound. (Leet. on Princip. 
and Pract. of Med.) 
Should the case now continue to advance, all the symptoms are aggra- 
vated. The voice becomes wheezing or whispering, or is quite extinguished; 
the cough, of which the sound is scarcely above the breath, is agitating, often 
convulsive, and very painful; inspiration is exceedingly difficult, and is accom- 
plished only after violent efforts, with great distress and anxiety, and a feeling 
as of impending suffocation. The patient is in general extremely restless, 
sometimes starting up suddenly in bed, walking about the chamber, put- 
ting his hands to his throat, showing the greatest eagerness for fresh air, and 
expressing in his countenance an almost fearful anxiety, apprehension, and 
distress. He is unable to sleep longer than a few minutes at a time, being 
constantly roused by the necessity for voluntary effort to get breath. The 
blood now begins to exhibit signs of deficient aeration, which rapidly increase 
in intensity. The lips have a bluish or purplish colour; the face becomes of 
a livid paleness; and a dark circle forms about the eyes, which are sometimes 
protruded and watery. The surface is cool, and the pulse frequent, irregular, 
threadlike, and very feeble. In the midst, however, of this exhaustion, the 
patient makes the most violent efforts; his shoulders rise; his whole chest 
heaves; his countenance assumes a staring and ghastly expression; his skin 
is bathed in a cold sweat; and he sinks at last into a drowsy or comatose state, 
often preceded by delirium, and speedily followed by death. 
The fatal effects depend upon the want of air to support respiration, and 
the consequently carbonated and poisonous state of the blood, which no longer 
affords the due stimulus to the vital functions. Sometimes this condition of 
the blood is sufficient to cause death, even though respiration should be restored. 738 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
Thus, patients not unfrequently die in the intervals of violent dyspnoea, when 
air is no longer excluded from the lungs, and sometimes even after the opera- 
tion of tracheotomy,, though the lungs themselves are-not embarrassed. The 
nervous system i$ unable, tp recover from the' depressing influence of the black 
blood. Death may, therefore, occur either suddenly, from complete closure 
of the passage, as in strangulation; or gradually from a partial and insuffi- 
cient supply of air, producing a fatal change of blood, the effects of which a 
subsequent return of respiration cannot always obviate. 
The disease is very rapid; generally, when fatal, ending in from three to 
five days, and sometimes in a much shorter time. Death has been known to 
occur in seven hours. Sometimes, however, the complaint is protracted for 
several weeks. Its duration depends in general upon the degree of internal 
tumefaction in the larynx, though there is reason to believe that occasionally 
life is suddenly terminated by the supervention of spasm of the glottis. I 
have seen a case, in which spasm of this kind recurred frequently at short 
intervals, each time attended with complete suspension of respiration, and 
partial insensibility from asphyxia, during ' the relaxation of which, air again 
found admission into the.chest, and thus prevented immediate death. This 
case ultimately recovered under copious depletion, and tobacco cataplasms. 
Occasionally the attack is very sudden; the dyspnoea and all the other bad 
symptoms occurring in the course of a few hours. In other cases, it is gradual. 
The disease varies also much in the grade of inflammation. Sometimes this 
is very violent; sometimes it is comparatively moderate, and the danger 
depends rather upon-a copious serous effusion into the submucous tissue than 
ordinary inflammatory tumefaction. Cases of the latter kind are distinguished 
by the name of edematous laryngitis. In these, there is little pain in the 
throat, and tenderness upon pressure, and little or no febrile disturbance. If 
the epiglottis can be seen, it is observed to be much swollen, but rather pale 
or livid than of a bright red colour. The symptoms, however, arising from 
closure of the rima glottidis, are not less urgent, arid the disease is perhaps 
even more fatal, because it does not so well tolerate. antiphlogistic treatment. 
Cases are said to have occurred, in which this oedema of the larynx was strictly 
dropsical; but such cases are, to say the least, exceedingly rare. In most 
instances, the effusion undoubtedly depends upon a low grade of inflamma- 
tion; and the peculiar result'is probably owing in general to peculiarity of the 
constitution m; of the blood, predisposing to serous effusion under inflamma- 
tory action. Dr. Stokes says that this variety of laryngitis is sometimes 
consequent upon the inflammatory swelling in the vicinity of the parotid, 
which occasionally follows continued fever. 
In all its varieties, the disease may'exist either alone, or in connexion with 
inflammation of the fauces' and tonsils, of the trachea, or of the bronchial 
tubes. 
The diagnosis is sometimes a point of much importance. It is very neces- 
sary that the complaint should not be confounded with diseases of the chest, 
which are sometimes attended with severe dyspnoea, and similar constitutional 
effects. But, in the latter, either the disease is chronic, or is accompanied with 
such obvious symptoms of pectoral disorder that there can scarcely be room 
for mistake, if due examination be made. Besides, in affections of the larynx, 
the change of the voice, the feeling as of a foreign body in the throat, the 
laryngeal cough, the seat of pain, tenderness, and constriction, the great dif- 
ference between the facility of inspiration and expiration, and the results of 
local inspection, point beyond-all doubt to the true seat of disease. Aneurism 
of the aorta, by pressing on the windpipe, has given rise to symptoms which 
have been taken for those of laryngitis; but auscultation would render such CLASS III.] 
ACUTE LARYNGITIS. 
739 
a mistake impossibly. Abscesses near the larynx may sometimes simulate 
laryngitis so far as to lead, upon superficial examination, to an erroneous 
diagnosis; but a close inspection of the parts would correct the error, and it 
is only necessary that the attention of the practitioner should be awake to its 
possible occurrence. To one of the forms of crOup laryngitis.bears a close 
analogy; but, in the former, spasmodic contraction of the muscles of the 
glottis, in the latter, swelling of the lining membrane or the parts beneath it, 
is the prominent and .characteristic phenomenon. More will be said upon 
this subject under croup. With mere spasm of the rima glottidis, uncon- 
nected with inflammation, it is scarcely possible to confound it, even leaving 
out of consideration the fact, that this affection is rare in adults, and confined 
chiefly to hysterical women. a . 
This form of laryngitis is considered by many writers as exceedingly fatal. 
By far the larger proportion of persons attacked with it are thought to' perish. 
But it is very certain that individuals, attacked with symptoms in all appear- 
ance identical with those of sub-mucous laryngitis, often recover. It is true, 
that they cannot be positively proved to have had effusion in the sub-mucous 
tissue, as the evidence of dissection is wanting. Judging from my own obser- 
vation, I should say that, when the disease makes its attack in the form of 
open and decided inflammation, in a person of tolerably vigorous constitution, 
and not previously labouring under chronic disease of the larynx, it may 
generally be cured, if attacked in its,early stages,,before the powers' of the 
system have begun to give way under the depressing influence of the black 
blood. After this deterioration has commenced, the cha,nces of saving the 
patient are very much diminished. Of the cases published a large proportion 
have proved fatal; because, in consequence of the difficulty of adducing posi- 
tive proof of the character of .the affection, from the symptoms alone, it is 
chiefly the fatal cases that have been brought before the public. When the 
disease supervenes upon chronic laryngitis, as not unfrequently happens, it 
jnay be considered as almost incurable; as too little vigour of system remains 
to-support the requisite measures. For the same reason, it is more than 
ordinarily dangerous in its edematous variety, which is most likely to occur 
in persons of feeble health. 
3. Pseitdo-jnembranous Laryngitis.-This is exceedingly rare in adults. 
In severe cases of inflammation of the larynx, patches of coagulable lymph 
may. sometimes be found upon the surface of the mucous membrane after 
death; but these are not sufficiently extensive to be of themselves a serious 
source of danger. Sometimes'an extension to the larynx of a pseudo-mem- 
branous condition of the fauces has taken place in adults, with fatal results; 
but even such cases very seldom occur, so that many practitioners in extensive 
business have probably never seen an instance. In children the disease is 
not uncommon, and in them it constitutes a variety of croup. To the article 
upon that disease the reader is referred for all that it is deemed requisite to 
be said upon this form of laryngitis. (See Croup.) 
Besides the forms of acute laryngitis above described, another has been 
noticed in which the perichondrium appears to be the seat of the inflamma- 
tion. It is very rare, but has been known occasionally to attend or follow 
small-pox and typhoid fever; and to occur originally from direct injury, and 
exposure to cold. I know of no symptoms by which it could be certainly 
distinguished during life. After death, pus has been found bathing the car- 
tilaginous surfaces. 
Appearances after Death.-1The mucous membrane lining the larynx is 
gorged with blood, softened, and thickcneff, while the subjacent cellular tissue 
is distended with bloody serum or a sero-purulcnt fluid. This tumefaction 740 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
affects especially the epiglottis, and the upper part of the larynx, extending 
often no further than the ventricles. It seldom reaches the trachea, of which, 
however, the lining. membrane often shows an increased vascularity. The 
thickening is so great about the glottis, that the chink is almost closed, so 
that when held up to the light, only a few rays can penetrate through it. 
The surface of the membrane is usually covered with mucus, and sometimes 
exhibits patches of coagulable lymph, which is also occasionally found effused 
in the sub-mucous tissue. In the edematous variety, there is little injection 
of the mucous membrane, but great swelling, in consequence of the effusion 
of serum beneath it. 
Gauses.-1The most frequent cause of laryngitis, in all its forms, is probably 
partial exposure to cold, or to cold and wet, especially when in a state of per- 
spiration from heat or exercise. There is in some individuals a peculiar pre- 
disposition to be affected by this disease; so that when any general cause of 
inflammation acts, it is almost certain to affect the larynx. Persons similarly- 
predisposed to. tonsillitis, are said to be also peculiarly susceptible to laryn- 
gitis; the force of the morbid influence falling sometimes on one part, and 
sometimes on the other. A continued, frequent, and usually powerful exer- 
tion of the voice sometimes produces the complaint, and often predisposes to 
it. Other causes are such as produce direct injury to the larynx. Among 
these are scalding water or corrosive liquids, which an individual may acci- 
dentally attempt to swallow; flame or hot air inhaled during exposure to 
fires; corrosive irritating gases, vapours, or powders, taken in with the inspired 
air, and arrested in some measure at the glottis; the unskilful insertion of 
instruments; and external violence. The author has witnessed a very severe 
case resulting in a child from smelling at a bottle of chlorine. Another 
source of the disease is the propagation of inflammation from neighbouring 
parts. Inflammation of the fauces is very apt to extend to the larynx, and 
to retain in the latter the' character which it had in its original seat. Thus, 
if confined to the mucous membrane in the fauces, it is apt to be similarly 
limited in the larynx; if pseudo-membranous in the former, it is also pseudo- 
membranous in the latter; if sub-mucous in the one, it retains the same rela- 
tive position irf the-other. Hence, when tonsillitis is propagated to the larynx, 
the disease sometimes assumes the worst forms of sub-mucous laryngitis. 
Mercurial stomatitis, according to Cheyne, sometimes extends into the larynx. 
Erysipelas, and the sore-throat of scarlet-fever, sometimes prove fatal by reach- 
ing that structure, and giving rise to sub-mucous or pseudo-membranous in- 
flammation. Measles, catarrh, and small-pox are other diseases which occa- 
sionally give rise to some form of laryngitis. The affection also occurs as an 
accompaniment or consequence of typhoid fever. Aneurism of the aorta may 
produce it,, by the propagation upward of the bronchial inflammation to which 
it gives rise. Cheyne considers intemperance as a predisposing cause of the 
complaint.. It is said that the disease is most common in middle and advanced 
life, and very rare in infancy. This is true of the sub-mucous variety. The 
other forms of laryngitis are not uncommon in the young; but in these they 
are apt to assume the form of croup. 
Treatment.-In slight cases, a dose of sulphate of magnesia, a vegetable 
diet, and, if the weather be cold or damp, confinement to the house for one, 
two, or three days, are the only remedies required. Should the fauces, upon 
examination, be found reddened, a solution of alum may be employed twice 
a day as a gargle. These simple measures will often avert a serious increase 
of the inflammation, or its propagation to the bronchia. 
When the disease is more severe, with febrile action and a strong pulse, 
blood should be taken from the arm once or oftener, in quantities proportion - CLASS III.] 
ACUTE LARYNGITIS. 
741 
ate to the violence of the symptoms, and the apparent vigour of the patient. 
After the first bleeding, from five to fifteen grains of calomel should be admi- 
nistered, either in connexion with or followed by another cathartic, to ensure 
its action on the bowels. These should afterwards be kept freely open, 
throughout the complaint, by saline aperients if required. If the disease do 
not yield, the purgative should be followed by tartar emetic or ipecacuanha, 
in diaphoretic or nauseating doses, given at short intervals, together with the 
neutral mixture or effervescing draught, if the skin be hot and dry. With 
these measures may also be combined hot and stimulating pediluvia. From 
the beginning, the throat may be enveloped in an emollient poultice, contain- 
ing a. very small proportion of mustard, sufficient merely to produce a feeling 
of warmth upon the skin. When bleeding from the arm seems to be no 
longer called for, leeches may be applied freely over the larynx, and will 
often be found at once'to cut short the disease.. Should spasm of the glottis 
accompany the inflammation, the antimonial may be given in an emetic dose, 
and the System afterwards be kept moderately under its influence, in conjunc- 
tion with tincture of lobelia, which exercises a powerful influence over this 
affection. In case of failure by these means, a cataplasm of tobacco should 
be applied to the throat, due caution being exercised to prevent a too pros- 
trating effect from this powerful sedative. I have witnessed the happiest 
effects from this remedy in very alarming cases. Should the skin be denuded, 
from any cause, in front of the neck, the cataplasm may be applied to the 
back of the neck or between the shoulders. In the more advanced stages, 
syrup of seneka and syrup of squill, or the same medicines in other forms, 
are often, of advantage in conjunction with antimonial or ipecacuanha wine; 
and, at this period, small doses of opium or hyoscyamiis will often be found 
useful by allaying cough, without the objection to which the former remedy 
especially is liable in the early stage, in consequence of checking secretion. 
A blister to the neck Will also chime in happily with these remedies. If the 
disease still remain unsubdued, recourse should be had to the mercurial influ- 
ence upon the system, which will seldom fail, .in cases of ordinary inflamma- 
tion, at this stage. During the whole treatment, the patient should avoid 
using his voice altogether, or speak only in a whisper, and should suppress 
the cough as much as possible. Rest and low diet are also requisite. 
In the violent cases described under the title of sub-mucous laryngitis, it is 
of the utmost importance to employ active remedies promptly. If postponed 
until the purple lips and livid paleness of the face indicate an insufficiently 
aerated blood, they will be of little avail. In the early stage, if not forbidden 
by the debility of the patient, blood should be taken'very freely. In a robust 
adult, from twenty to thirty ounces may be drawn at the first bleeding, and 
the operation repeated once or oftener if necessary. The loss of blood should 
stop short of syncope. The obstruction to the respiration consists in an inter- 
nal tumefaction of the larynx, which is not at once removed by the bleeding. 
A certain amount of muscular force is necessary to overcome the resistance in 
the glottis; and, if the patient be bled to fainting, there might be some rea- 
son to fear that his ,returning powers would be insufficient for that purpose, 
and consequently that the syncope might be fatally prolonged. Nor is this 
copious bleeding applicable to the edematous cases, attended with but a mode- 
rate degree of inflammation, and little or no fever. It might prostrate the 
patient below the point of reaction. Moderate venesection, however, is both 
tolerated and required. In the highly inflammatory cases, the lancet should 
be aided by the very free use of leeches to the throat. From fifty to one 
hundred American leeches may be applied in robust cases. Apprehension has 
been expressed, lest they might increase the difficulty, in consequence of the 
superficial inflammation they excite, producing subcutaneous extravasation. 742 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
But the clanger is from effusion within and not without the larynx, and if the 
latter should result from the leeches, it might act usefully by revulsion. It 
could scarcely be injurious. Nor should the le'eches be delayed in these cases. 
Take blood once from the arm, and as soon afterwards as the patient's strength 
will permit, apply them. Should they not be attainable, cups may be substi- 
tuted, to the side or back of the neck, or between the shoulders. 
Next to the loss of blood, calomel is the most important remedy. It. should 
be given in the. full dose at once, and afterwards in smaller doses, at ■ stated 
intervals, until the system is brought under its influence'. For this purpose, 
two grains may be given every two or three hpurs, either alone, or combined 
with opium and ipecacuanha, should these not be contraindicated. 'Mercurial 
frictions to the inside of the extremities may also be employed to hasten the 
effect on the system. As soon as any soreness of the gums is perceived, the 
mercurial should be moderated or suspended; as there might be some danger 
from its excessive action. Small doses of Dover's powder are a useful addi- 
tion to the calomel, when given with a view to its general effects, by pre- 
venting it from running off by the bowels. They are also useful in mode- 
rating the cough, which is itself a source of mischief by still further irritating 
the inflamed parts. The opiate, however, should not be carried to the stupe- 
fying point; and, if the disease should be complicated with bronchitis, ought 
not to be used in the early stage. 
Some practitioners place great reliance upon the antimpnials in thikaffection. 
Dr. Stokes considers them even more important than calomel. They may be 
used as auxiliaries, but care should be taken to avoid vomiting; as the matter 
discharged from the stomach would be very apt to enter the glottis, and pro- 
voke the most vehement and distressing paroxysm of cough and dy&pncea. 
The measures recommended for the milder forms of laryngitis may also be 
employed, as occasion may seem to call for them; but the chief dependence 
must be placed upon the heroic remedies above mentioned. Should a blister 
be employed, it should be placed upon the sides or back of the neck rathqr 
than in the front, wherq it wohld be in, the way of laryngotomy. The strong 
solution of ammonia would, in some cases, be preferable to cantharid.es, in 
consequence of-the rapidity of its action. 
In the asthenic cases, which will not hear bleeding, reliance mhst be placed 
upon leeching, blistering, and the prompt and efficient use of mercury. The 
only circumstance, under which the last mentioned remedy is contraindicated, 
is the complication pf the disease with chronic tuberculous or scrofulous 
laryngitis. 
When bleeding and mercury fail, the only remedy upon which much 
reliance can be placed is the ppening of the -larynx or trachea. As soon as 
the system begins to exhibit a depravation of the blood, and a disposition to 
sink, this remedy should be at once resorted to. It may even be employed 
in the earlier stages when the danger of suffocation is imminent. The only 
condition which positively forbids it is the existence of extensive pulmonary 
disease, which would render death certain at all events. It is highly im- 
portant that it be not postponed too long; for, in the advanced stages, death 
sometimes takes place in consequence of the state of the blood, even though 
air be freely admitted into the lungs. Nevertheless, the remedy should not 
be omitted. Recoveries have sometimes taken place, through its instrument- 
ality, under apparently desperate circumstances. Well authenticated cases 
are on record, in which patients have been restored after respiration had 
ceased, and the pulse could no longer be felt at the wrist. In such instances, 
it might be proper to resort to artificial respiration, after the opening has 
been made. The effect of the operation is to admit air into the lungs, and it 
is surprising how speedy and complete is the relief sometimes afforded. The CLASS III.] 
CHRONIC LARYNGITIS. 
743 
patient, exhausted by wakefulness, suffering, and the labour of respiration, 
sinks into a calm slumber almost immediately after the. opening has been 
effected. Respiration is afterwards maintained for some time through the 
artificial passage. The laryngeal inflammation may now be cured at leisure 
by proper remedies. It will indeed generally subside of itself, with a secre- 
tion, more or less copious, of muco-purulent mat,ter. The performance of the 
operation belongs to surgery. Laryngotomy is generally recommended ; and 
the opening should be made between the cricoid and thyroid cartilage^. 
Some advise the upper part of the trachea as the seat of the operation. If 
ndt liable to surgical, objections, the latter position Would appear to be pre- 
ferable, on account of the danger of augmenting the laryngeal inflammation, 
by the introduction of the tube necessary to keep' the opening pervious. The 
inner extremity of,the, tube should be prevented from projecting into the 
cavity, beyond the level of the mucous surface. Sii^ Charles Bell sometimes 
keeps the wound open by blunt hooks,, inserted in each side, and fastened 
behind the neck. Some attention to the opening is necessary after the ope- 
ration. As much mucus' is often discharged, it is advisable that the patient 
should facilitate the coughing necessary for its expulsion by1 placing his finger, 
after inspiration, on the orifice of the tube, and retaining it there until the 
effort' of expiration has acquired force enough to drive the air vigorously 
through the'opening-. , Care,, toq, should be taken that the patient be properly 
watched during sleep, and the mucus which accumulates, and might possibly 
suffocate him, be removed. After the subsidence of the inflammation, the 
glottis again opens; and,, the patient, being now able to breathe by the natural 
passage, the tube should be removed, and: the opening allowed to close. The 
Voice', which is lost for a time after the> operation, returns with a restoration 
of the larynx to its healthy state.' 
Dr. Gordon Buck, of New York, found decided benefit from incisions in 
the edges of the glottis, and in the epiglottis, by means of a guarded bistoury, 
in a case of oedema of the glottis.' (Annalist, July 15, 1837.) Dr. T. R. 
Varick, of New York, applied a solution of nitrate of silver, of the strength 
of two scruples to the fluidounce, by means of a sponge affixed to a curved 
bougie, to the inner surface of the larynx, in an apparently almost desperate 
case of acute laryngitis,'' from which the patient afterwards recovered; and, 
though other active treatment was einployed, the cure was ascribed chiefly to 
this measure. (7Y K Jdurn. of Mecl., x. 72.) 
2. CHRONIC LARYNGITIS. 
Syn.-Laryngeal Phthisis. 
Like the acute inflammation of the larynx, this differs much in degree and 
in danger, being in its mildest and simplest form nothing more than a chronic 
hoarseness, which is scarcely inconvenient and not at all dangerous; while, 
in its higher grades and with certain complications, it is one of the most 
serious diseases to which the human frame is liable. In the earlier stages, 
however, it is often impossible to discriminate between cases of the most 
opposite tendencies; as the most fatal frequently commence with the same 
symptoms aslhe most trivial; so that the affection, even in its mildest form, 
always merits attention. So long as the mucous membrane, though inflamed, 
maintains its integrity, there is comparatively little inconvenience. It is only 
when ulceration takes place, that the case begins to present a very alarming 
aspect. Now, in ordinary inflammation, without any peculiar morbid consti- 
tutional tendency, neither the mucous membrane nor any other constituent of 
the larynx has a disposition to ulcerate; and the disease, after a longer or 744 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
shorter duration, almost always gets well under appropriate treatment. Upon 
the occurrence of ulceration, there is generally reason to suppose that some 
morbid complication exists, calculated to render the disease in the highest 
degree obstinate' and dangerous. This complication is almost always either a 
tuberculous tendency of system, or syphilis. In some very rare instances, it 
may be cancer, or other malignant local disorder. In by far the greater 
number of cases, it is the first mentioned cause that renders chronic laryngitis 
dangerous. In fact, this complaint, in ,its severer forms, is very generally 
associated with tubercles of the lungs. It is a very common incident in the 
course of phthisis, and, when it occurs originally, is generally attended with 
the formation of pulmonary tubercles, and complicated, before its close, with 
the symptoms arising from their ordinary progless. There appear, however, 
to be cases in which the mucous follicles become the seat of ordinary inflam- 
mation, and in which ulceration may take place, without complication either 
with the scrofulous diathesis or syphilitic disorder. 
The disease, when not consequent upon ah acute attack, generally begins 
with hoarseness, a little uneasiness in the throat, and a slight laryngeal 
cough, which is often rather a clearing up of the throat or hawking than a 
proper cough, such as occurs in pulmonary affections. In this condition, with 
occasional aggravations and remissions, it may continue Tor several months, 
and ultimately disappear, especially upon the occurrence of warm weather. 
Frequently, however, the symptoms are less mild. Various morbid sensations 
are felt in some part of the larynx, such as heat, dryness, .constriction^ itching 
or tickling'sensations which provoke cough, and sometimes dull, smarting, or 
even acute pain, increased by coughing or any strong exertion of the voice, 
and occasionally by pressure. But, in a large proportion of cases, even those 
of a fatal kind, there is little or no pain through the whole course of the 
complaint. The voice is always in some degree altered, being generally 
hoarse or husky, sometimes stridulous or squeaking, and sometimes whisper- 
ing. The change of voice is more perceptible when the patient attempts to 
speak loudly or to sing. The cough is at first usually short and dry, but 
becomes loose as the-complaint advances, and is attended with a mucous or 
muco-purulent discharge. It is apt to be excited by speaking loud, or by the 
inhalation of cold air or irritating substances. If the fauces be examined, 
they will sometimes be found to exhibit the appearances of chronic inflam- 
mation, and, among others, enlargement of the mucous follicles, as described 
under Pharyngitis^ . ' ; 
All the symptoms above enumerated may occur without ulceration, though 
not inconsistent with it; for ulcers do not always give evidence of their 
existence, and not unfrequently occur before they are even suspected. But, 
generally speaking, the ulcerative stage is marked by some of the following 
phenomena. In cases attended with follicular inflammation of the fauces, 
the follicles within view exhibit signs of ulceration. There is, often a prick- 
ing sensation in the larynx, as if from a sharp or pointed body, especially 
when the patient speaks. Deglutition is not unfrequently painful, and 
sometimes, in consequence of ulceration of the epiglottis,'occasions violent 
paroxysms of coughing, with sensations as . of suffocation, and a return by the 
nostrils of what the patient attempts to swallow. In some instances, however, 
there is no difficulty of swallowing from the beginning to the end of the case. 
The voice is still more altered than in the earlier stage, and is very variously 
affected, being hoarse, or whistling, or hollow, or quite lost, in the last case 
indicating ulceration of the rima glottidis, and partial destruction of the vocal 
ligaments. The cough undergoes analogous changes, being hoarse, croupy, 
stridulous, or altogether without sound above the breath. Sometimes, in the 
last stage, it has a peculiar loose continuous character, ascribed by M. Trous- CLASS III.] 
CHRONIC LARYNGITIS. 
745 
seau to inability to close the glottis. The discharge is now purulent, and 
occasionally bloody and fetid. Sometimes patches of coagulable lymph are 
detached from the. membrane and thrown up, with at least ■ temporary relief 
to the symptoms. Instances too are mentioned, in which portibns of the 
cartilages, sometimes ossified, and calcareous concretions, are found among the 
matter discharged. The respiration is often difficult, though occasionally 
somewhat relieved after free suppuration, in consequence probably of the 
removal by ulceration of tumefactions, which may have narrowed the passage. 
It may be wheezing, hissing, or otherwise noisy, and is sometimes merely 
tight, as if the air were drawn through a narrowed passage. The difficulty 
is sometimes continuous, but is more frequently in some measure paroxysmal, 
being brought on by attempts to swallow,.by bodily exertion, or by irritations 
of any kind provoking spasm of the glottis. Sometimes the patient dies in 
one pf these paroxysms. In other cases, he is carried off by the supervention 
of sub-mucous effusion, as in acute laryngitis. Still more frequently the 
general health gives way. Debility, emaciation, night sweats, frequency of 
pulse, oedema of the extremities, loss of appetite, occasional nausea and 
-vomiting, and obstinate diarrhoea, mark the approaching close; and the 
patient dies in a state of -hectic exhaustion. 
It is not always easy to distinguish the different varieties of chronic laryngitis. 
If the symptoms indicating- the existence of ulcers are wanting, if the chest is 
perfectly sound, and the general health of the patient unimpaired, there is rea- 
son to suppose that the inflammation may be of the ordinary kind, and to hope 
that it may yield to treatment. But if the disease has continued long and 
gradually increased, if a pricking pain is felt in the larynx, if the matter dis- 
charged is purulent, bloody, sanious, or fetid, if deglutition provokes paroxysms 
of cough and dyspnoea, if the voice has become broken or extinct, and the 
cough nearly aphonic, if the larynx crepitates under pressure, and the epi- 
glottis can be seen ulcerated or deformed, if these or some of these symptoms 
are present, and at the same time the general health appears impaired, the 
probabilities are that the laryngeal disease is of a scrofulous, or syphilitic cha- 
racter, Should evidence of tubercles in the lungs be afforded, or the patient 
in other respects show any signs of a scrofulous or tuberculous habit of body, 
the complaint may be considered as of the former kind. The ' pre-existence 
of syphilis in other forms, and the absence, of the ordinary local signs of 
phthisis, would determine in favour of the latter. It is said that laryngeal 
phthisis has sometimes occurred, and proved fatal, without tubercles in the 
lungs or elsewhere, and without the suspicion of syphilis. This may possibly 
be the case; but the instances are very rare. In such cases, we may ascribe 
the obstinacy of the local disease, at our pleasure, to the peculiar circumstances 
of the structure in which it is situated, or to a scrofulous or other concealed 
vice of constitution. We have no means of deciding the question. 
In relation to the prognosis in these several cases of ulcerative laryngitis, 
it may be stated that, when the disease is connected with pulmonary con- 
sumption, the two together are almost necessarily sooner or later fatal; that 
the syphilitic variety may generally be cured in its earlier stages, and is sel- 
dom quite desperate; and that, when neither of these complications exists, and 
no other serious depravation of the general health can be discovered, we may 
entertain a reasonable hope of making a favourable impression on the com- 
plaint. . < , 
Appearances after Death.-If the patient happens to be carried off in the 
earlier stage, the mucous membrane is found red, thickened, softened or indu- 
rated, and often rough from the enlarged follicles. At a more advanced 
period, ulcers are found in various situations, most frequently between the 
vocal ligaments and epiglottis, sometimes superficial, sometimes deep, pene- 746 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part n. 
trating through the mucous membrane to the cartilages, and occasionally even 
through these. Dissecting abscesses ■ meander among the different structures, 
and sometimes result in external fistulous openings. Tire cartilages them- 
selves are changed, being sometimes ossified or encased in bony matter, and 
sometimes partially in a state of caries, or of necrosis, with the- dead portions 
surrounded by ulceration, and bathed in a fetid pus. The epiglottis is some- 
times irregularly contracted, ulcerated, and partially or wholly destroyed; as 
are also the vocal ligaments. The sub-mucous tissue is infiltrated with serum 
or pus, or thickened and indurated; and the ventricles are sometimes.oblite- 
rated from this cause. The muscles of the larynx are wasted, hardened, or 
otherwise-degenerate, and the ligaments contracted and: distorted. Excres- 
cences of various kinds appear on the surface .of the mucous membrane, espe- 
cially in syphilitic' cases. It is staled that, in syphilis, ulcers are apt to form 
to the anterior surface of the epiglottis, while in scrofulous cases they occupy 
the posterior surface. Louis states that he has not found tuberculous granum 
lations upon the surface, or in the substance, of the epiglottis or larynx. 
Causes.-The ordinary causes of acute laryngitis may produce also the 
chronic form, when operating with less force, or upon less ■ susceptible sub- 
jects. Among these the most Common are cold, an excessive use of the voice 
in .speaking or singing, irritating substances inhaled, propagation of inflam- 
mation from the fauces above and the bronchia below, foreign bodies in the 
larynx, mechanical violence, the retrocession of cutaneous eruptions, and 
sometimes probably gout and rheumatism. The disease appears to be occa- 
sionally connected sympathetically with chronic gastritis. It is often the 
result of inflammation propagated from the fauces to the larynx. The abuse of 
sensual pleasures is thought to predispose to the complaint, which is said to 
be very common among drunkards and prostitutes. The scrofulous diathesis 
constitutes a predisposition to it. Polypous excrescences, warts, and other 
tumours in the larynx-or its vicinity, may -also be counted among the causes. 
The chronic disease occasionally succeeds the acute. It is said to be rare in 
infancy and old age, and most common between the., thirtieth and fortieth 
year. Men are more frequently affected than women. 
Treatment-In the early stages, moderate depletion, rest as complete as 
possible to the organ, and revulsion by means of a steadily sustained external 
irritation, are the chief remedies. It may sometimes be proper, during an 
access of excitement, to take a little blood from the arm; but this is seldom 
required. Leeching is safer and more effectual. Cups may also be applied 
to the side or back of the neck. In order to rest the larynx, the patient 
should abstain from speaking aloud, and from singing; and cough should be 
allayed by opium, hybscyamus, lactucarium, extract of hemp, or some other 
narcotic. It has been recommended to rub unctuous preparations of hyos- 
cyamus, belladonna, &c., over the larynx; and plasters of opium and of bel- 
ladonna have been used, with the same view. For revulsion, a perpetual 
blister, pustulation by croton oil or tartar emetic long sustained, or a seton to 
the back of the neck, may be employed. The patient, if exposed to the inha- 
lation of irritating substances, should be protected against them, by means of 
a fine gauze veil, or a respirator. The diet should be nutritious but not 
stimulating, and should consist chiefly of vegetables, farinaceous preparations, 
and milk, with little or no meat. In the somewhat advanced stages, seneka 
may sometimes be found useful; but the most effectual remedy, when other 
means fail, is mercury pushed to a very moderate ptyalism. This will often 
cure chronic inflammation, of the ordinary, or the syphilitic character. It is 
not adapted to scrofulous cases. In these, more reliance should be placed on 
the preparations of iodine, especially the iodide of potassium; and iodine oint- 
ment may be rubbed upon the throat. Means should also be employed to CLASS III.] 
CHRONIC LARYNGITIS. 
747 
support the general health,'such as wild-cherry bark, and the chalybeates; 
and, in these cases, the diet may contain a larger proportion, of animal food, 
especially when the disease is far advanced into ulperation and suppuration. 
Local application's to the diseased surface are'very important. The smoking 
of stramonium leaves, belladonna, hyoScyamus, and tobacco, has been recom- 
mended; as have also inhalations of the vapour of heated water impregnated 
with chlorine, iodine, camphor, turpentine, tar, creasote, or ether with extract 
of hemlock. Liquids and powders have also been applied to the larynx, and 
sometimes with great asserted advantage. For this purpose, solutions of cor- 
rosive sublimate, nitrate of mercury, sulphate of copper, and nitrate of silver, 
and powders of subnftrate of bismuth, red oxide of mercury, calomel, sulphate 
of zinc, sulphate of copper, alum, acetate of lead, and nitrate of silver, all 
variously diluted with sugar, have been employed by M. Trousseau.* Of 
these substances, nitrate of silver is upon the ■vyhole the most maiiageable' and 
efficacious. It was commonly employed by M. Trousseau dissolved in dis- 
tilled water, in the proportion of one part of the nitrate to two or four parts 
of the menstruum, forming a strong caustic solution. Others have used a 
much weaker solution, containing only fifteen or twenty grains in the fluid- 
ounce. • ' 7 
Nitrate of silver has .the great advantage of combining superficially with 
the tissues, and thus affecting only the surface, Sb that little danger need be 
apprehended of extensive mischief, if the application be properly made. Va- 
rious plans diave been proposed by M. Tfoussfeau and others. One of the 
simplest is to introduce a drop of the solution into the glottis, by means of a 
slender roll of stiff paper, bent downward-at the extremity; the base of the 
tongue being strongly depressed and somewhat drawn forward, and the patient 
directed to make the motion of swallowing, so as to raise the larynx. Ano- 
ther mode is to apply quickly to the same part, similarly brought within 
reach, a small piece of sponge, firmly secured to the end of a piece of bent 
whalebone, and saturated with the solution. A third method of Trousseau's 
was to inject into the glottis the solution mingled with air, by means of a 
small silver syringe, like that of Anel, with a long tube bent at the end, and 
having an orifice at least one-quarter of a line in diameter. The syringe was 
to contain three-quarters of air and one-quarter of the solution, and the two, 
mingled together4, were to be forced by a quick descent of the piston into the 
glottis, in the form of a fine shower. A convenient plan, proposed by Mr. 
Cusack, of Dublin, is to sew .a small piece of lint to the end of the finger of a 
glove, and, having fixed this upon the right fore-finger, to moisten the lint 
with the solution, and bring it into contact with the glottis. In whatever 
mode applied, the solution occasions a violent paroxysm of coughing, and 
sometimes even vomiting, which, however, subside in a short time without 
serious consequences. To decompose the portion of nitrate which may not 
unite immediately with the tissues, it is recommended to rinse the mouth and 
throat with a solution of common salt, of which the patient may also swallow 
a portion. The powders above mentioned may be applied by means of a 
tube, into which they have been introduced, and through which, placed deeply 
in the mouth with one end projecting, the patient should be directed to inspire 
forcibly. Several cures effected by these means have been recorded by Trous- 
seau. 
Dr. Horace Green, of New York, applies a strong solution of nitrate of 
* The proportions employed by Trousseau were subnitrate of bismuth undiluted; 
calomel with twelve parts of sugar; red precipitate, sulphate of zinc, and sulphate of 
copper, with thirty-six parts; alum with two parts.; acetate of lead with seven parts; 
and nitrate of silver variously with twenty-two, thirty six. and twenty-four parts. (Diet. 
de Med., xvii. 5G6.) 748 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
silver directly to the laryngeal mucous membrane, and with the best results. 
He employs a solution of the crystallized nitrate, of the strength of from two 
to four scruples of the salt to a fluidounce of distilled water, and makes the 
application by means of a piece of curved whalebone, with a sponge attached 
to the end of it, as recommended by M. Trousseau. Before attempting to 
penetrate the glottis, he accustoms the membrane to the irritant impression 
by applying the solution daily, for several days, to the parts immediately 
about the opening.' When the sensibility of the lips of the glottis is thus 
somewhat blunted, he passes the sponge, saturated with the solution, through 
the rima glottidis into the cavity of the larynx. He recommends that the 
patient, upon opening his mouth, " should take a full inspiration, and then 
breathe gently out, at the moment in which the sponge is introduced." This 
is carried over the top of the epiglottis, along the posterior surface of this car- 
tilage, and then suddenly pressed' downward and forward through the aper- 
ture. A momentary spasm of the glottis takes place, by which the sponge is 
compressed, and the fluid forced out of it. The application should generally 
be made every other day for the first two weeks, after which it may be re- 
peated two or three times a week, until a cure is effected. (Treatise on Dis. 
of the Air Passages, &c., N. Y., p. 199, &c,) ' 
In the closing period of the disease, it sometimes becomes necessary, in 
consequence of the difficulty and danger of swallowing, to support the patient 
by the introduction of food through a stomach tube; and Occasionally it may 
be necessary to perform the operation of tracheotomy, in order to avert imme- 
diate death. 
Article III. 
INFLAMMATION OF THE BRONCHIA, or BRONCHITIS. 
In a pathological^ account of the several portions of the air-passages, it 
might be thought that the trachea should receive a separate consideration; 
but it is very seldom exclusively affected, offers no symptoms when inflamed 
which are not observed in other localities, and requires absolutely nothing 
peculiar in the treatment. The nomenclature which gives the title of tracheitis 
to croup, is founded oh a false assumption in relation to the especial seat of 
that complaint. It is true that the trachea is generally affected in croup; but 
it is almost never exclusively affected; nor are the peculiar features of the 
disease essentially connected with that part of the respiratory passages. (See 
Croup.) The symptoms and treatment of tracheitis are almost always merged 
in those of laryngitis and bronchitis. 
The term bronchitis is applicable to any case of inflammation of the bron- 
chial tubes, whatever may be its grade, character, or precise locality. It will 
be here considered under the two heads of acute and chronic bronchitis. 
1. ACUTE BRONCHITIS. 
This designation has been restricted by some writers, without any very 
obvious propriety, to the higher grades of inflammation of the bronchia. The 
author considers it applicable to every case of short duration. In this sense 
of the term, acute bronchitis is one of the most common diseases to which the 
human frame is liable. It varies very greatly in degree, and somewhat in 
character. The inflammation begins very frequently in the nostrils, fauces, 
or larynx, and thence descends into the bronchia; and is very apt to retain, CLASS III.] 
ACUTE BRONCHITIS. 
749 
in the last mentioned position, unless modified by treatment, the grade of 
severity which characterized it at the outset. .x 
In its mildest form, acute bronchitis is a very slight disorder, commonly 
called a cold., or a cold in the breast. It usually coines on with a little hoarse- 
ness, followed by a moderate cough, and slight feelings of heat or soreness in 
the-.chest. The cough is at first dry, but is soon attended with expectoration, 
and then gradually subsides, causing little inconvenience to the patient, and 
seldom requiring the interference of the physician. Between this form of the 
disease, and the higher grade next to be described, there is every shade of 
difference. "a 5 
A common form of bronchitis is one formerly known as catarrh fever, and 
still frequently so called- Beginning with coryza, sore-throat, or hoarseness, 
and sensations of lassitude, weariness, aching in the limbs, and chilliness, fol- 
lowed by febrile reaction, it soon exhibits the characteristic signs of bronchial 
inflammation. There is a feeling of diffused heat and uneasiness in the 
upper and anterior part of the chest, and often of tightness, stricture, weight,- 
or soreness, but without acute pain, unless, sometimes in coughing. In severe 
cases, these sensations are distressing, and attended with feelings of oppressed 
breathings and occasionally with some difficulty of inspiration. Cough is 
usually among the first, and soon becomes one of the most prominent symp- 
toms. It is at the commencement short and dry, or accompanied with but a 
slight expectoration j and is often very painful, producing sepsations as of 
scraping, tearing, or rending, behind the sternum. It has some tendency to 
occur in paroxysms, especially in the morning' after waking, when a little 
viscid mucus is occasionally discharged with some temporary relief. At this 
stage, the patient is usually affected with frequency of pulse, heat and dryness 
of skin, flushed face, headache, furred tongue, scanty and high-coloured urine, 
sometimes nausea or vomiting; in short, with all the symptoms of fever. There 
is generally a remission of fever in the morning, and an exacerbation in the 
evening. In some rare instances, the symptoms above enumerated gradually 
subside, without any material increase of the bronchiab secretion; but, in the 
great majority of cases, after a duration of from some hours to two or three 
days, the patient begins to expectorate a transparent, ropy, and often frothy 
mucus, of a saline taste, and sometimes streaked with blood, which is thrown 
up with painful, and occasionally almost convulsive coughing. This expecto- 
rated matter gradually increases in quantity, and at the same time in con- 
sistence, and, instead of being colourless and transparent as at first, becomes 
opaque and white, and ultimately yellowish or greenish, and at the same time 
quite bland to the taste. Sometimes this altered secretion is mixed with the 
thinner transparent matter, at others is exclusive. Along with the change in the 
mucous secretion, there is usually an amelioration of the other symptoms. The 
cough is easier, the soreness and tension are diminished, and the fever abates. 
In some instances, after such an amendment, the mucous discharge again 
becomes thinner and more transparent, and the symptoms generally undergo a 
corresponding change for the worse, indicating a temporary increase of the 
inflammation. At length, however, the disease gives way; the expectoration 
becomes free, and easy, with an opaque, often puruloid discharge; the skin 
becomes moist; the urine is increased in quantity; the fever subsides; and 
the patient returns gradually to health, but often with a slight cough, which 
remains for a considerable time. Thq attack varies in duration generally from 
four to ten days, though it sometimes runs on for two or three weeks, and 
sometimes assumes the chronic form. When the patient recovers, with a 
cough remaining, he is liable to relapse from slight causes. Occasionally, 
after the subsidence of the acute symptoms, a condition is left approaching in 750 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
character to hectic, with frequent pulse, copious purulent expectoration, night 
sweats, emaciation, and debility. The system is too feeble to recover from 
the blow which it has received, and, unless supported by appropriate treat- 
ment, sinks into a dangerous or even fatal exhaustion. The general grade of 
action throughout the complaint varies much. Generally it is sthenic, with 
a strong, full pulse, and bears depletion well. Occasionally it is low or as- 
thenic, in consequence of the peculiar state of the constitution, or peculiar 
influences of a depressing character to which the patient may.be subjected, 
such, for example,.as give rise to typhoid diseases. This distinction is occa- 
sionally important in practice. 
In the grades of bronchitis above described, the disease is very seldom fatal, 
unless in old persons, or in those debilitated by chronic complaints, in whom 
there is insufficient strength to throw off the copious bronchial secretion, 
which, therefore, overwhelms the lungs, and literally drowns the patient. But 
cases of a much severer and more dangerous character are not unfrequently 
met with. In those already treated of, the inflammation is comparatively 
moderate in degree, and confined chiefly to the larger tubes. In those now 
alluded to, the inflammation is more intense, or penetrates more deeply into 
the bronchia, .so as even sometimes to reach their ultimate ramifications. In 
these cases, without a materially greater amount of pain or soreness, there is 
much greater oppression and difficulty of respiration. When these arise from 
mere intensity of inflammation, the air sometimes enters with difficulty 
through the thickened or contracted tubes, producing a blowing sound audible 
at a considerable distance; and the patient suffers with feelings of impending 
suffocation. When the. cause of difficulty arises from the extent of the in- 
flammation, respiration is hurried, the dyspnoea extreme, the pulse exceedingly 
frequent, and the general strength speedily exhausted. This condition of the 
disease is most ..common in infants, and is sometimes quickly fatal. Occa- 
sionally, in these severer forms of bronchitis, the attacks of dyspnoea are 
exceedingly sudden and violent, destroying life in the paroxysm unless re- 
lieved. The expectoration is sometimes thick and glutinous, even at the 
beginning, more like the adhesive secretion of pnfeumonia than the mucus 
of ordinary catarrh. It is also occasionally fibrinous, and small quantities of 
false membrane are coughed up with the mucous secretion. The danger may 
arise partly from the shock of the inflammation upon the nervous system; 
but much more commonly it proceeds from the interference of the disease 
with the access of air to the cells, and consequently with the due oxidation 
and decarbonization of the blood. Dark blood consequently flbws through 
the arteries, and produces its depressing effects upon the brain and all the 
dependent functions. The face becomes pale, or somewhat livid or purplish, 
the surface cool, the pulse frequent and very feeble, the dyspnoea excessive, 
and the countenance expressive of great anxiety. The vital powers give 
way, the skin is cold and clammy, the patient complains of intense thirst, and 
death soon takes place, preceded by coma, delirium, or convulsions. Those 
who most frequently perish of this disease are the very young, and the old 
and debilitated. The swelling of the tubes, and the secretion into those of 
smaller dimensions, cause an obstruction to the entrance of air, which the 
feeble muscular power of the patient is unable to overcome. Sometimes it 
is the blocking up suddenly of one of the larger bronchia which supplies a 
considerable portion of the lung, that occasions sudden death. Besides, the 
bronchitis not unfrequently becomes complicated with pneumonia, or other 
form of pectoral inflammation, which greatly increases its danger. 
An occasional variety of bronchitis is one in which the inflammation is 
obviously accompanied with spasm of the bronchial tubes. Paroxysms like CLASS III.] 
ACUTE BRONCHITIS. 
751 
those of spasmodic asthma come on at irregular periods, and threaten the 
patient with immediate suffocation. In other respects, the Cases do not differ 
from the forms pf the disease above described. 
There is another variety, in which, instead of mucus, or in connexion with 
it, coagulable lymph is secreted upon the inner surface of the bronchia, form- 
ing tubes of false membrane, which greatly obstruct the passage of air. This 
happens chiefly in infants, constituting a feature in the worst forms of croup. 
(See Croup.') It is exceedingly rare in adults, perhaps almost never occurring 
in them to any great extent. Occasionally, in persons of full age, a small 
portion.of one of the bronchia becomes thus affected, and fibrinous tubes are 
expectorated with complete relief to the symptoms. There is not necessarily, 
in these cases, any considerable amount of constitutional disturbance. Indeed, 
the disease is sometimes.of so limited an extent as not even to occasion fever. 
The patient is harassed with an obstinate cough, perhaps spits up blood conse- 
quent upon a partial separation, of the false membrane, and some time later, 
after severe efforts, expectorates the offending cause. 
Bronchitis is sometimes complicated with bilious and gastric symptoms, 
such as a yellow tinge of the eyes and skin, a loaded tongue, nausea or vomit- 
ing, and tenderness in the epigastrium and right hypochondrium. These 
may arise from portal congestion, gastric dr hepatic inflammation, or from the 
influence of miasmata, adding remittent fever to the bronchial disease. 
When bronchitis invades the smaller tubes> it has a strong tendency to pass 
into the air-cells, especially in infants, and thus to constitute pneumonia. It 
is not always easy to determine the limits between the two affections; nor is 
it a point of much practical importance; as.their treatment in these situations, 
is essentially the same. Pneumonia may always be, suspected in bronchitis, 
when, along with the loose fluid secretion of the latter complaint, the tough, 
rusty-coloured, yellowish, or greenish, adhesive matter, characteristic of the 
former, is thrown up. 
Under the names of peripneumonia notha, suffocative catarrh, and catar- 
rhus senilis, affections have been described by practical writers which have 
not always been sufficiently defined; and it is probable'that very different 
diseases have spmetimes' been confounded; such, for example, as congestion 
or apoplexy of the lungs, pneumonia supervening upon old catarrhs, and pro- 
per bronchitis. There is a condition of the last mentioned disease, which 
may be considered perhaps as representing the greater number of these cases. 
It is characterized by the sudden occurrence of dyspnoea, often in paroxysms, 
with a copious and early secretion of mucus, and consequent wheezing respi- 
ration. The patient speaks with difficulty, is often unable to lie down, gasps 
for breath, and coughs violently and incessantly to free the lungs from the 
matter which threatens to overwhelm them. The expectoration, if not free 
at the onset of the disease, soon becomes abundant, and is frothy from the 
violence, of the cough. It is sometiriies also tinged with blood. An almost 
universal mucous rale may be heard over the chest, while percussion is occa- 
sionally dull in some parts, in consequence of the accumulation of mucus, or 
the existence of pulmonary congestion. Febrile symptoms sometimes appear 
at the commencement; but they do not usually continue long. Those con- 
sequent upon deficient aeration of the blood soon occur, and are very striking. 
The face is pale or livid, the lips are purple, the extremities cool, and the 
circulation very feeble. The disease is very dangerous, the more so as it has 
a tendency to run into pneumonia. But its fatality is owing chiefly to the 
circumstance of the previous bad health of the patient, who, long balanced 
between life and death, is precipitated by comparatively slight causes to the 
fatal issue. The sudden inability of even a small portion of the lungs to per- 752 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
form its duty, in consequence either of congestion, mucous accumulation, 
or, as sometimes though rarely happens, from the obstruction of one of the 
larger bronchial branches by a clog of concrete matter, is thus sufficient to 
endanger or destroy life. 
Physical Signs.-The characteristic signs of bronchial inflammation are 
clearness upon percussion in all parts of the chest, sometimes diminishing a 
little as the disease advances; the dry or sonorous and sibilant rales in the 
earliest stage; afterwards the moist or mucous rales more or less mingled 
with the dry; and the respiratory murmur still audible, though frequently 
weakened, especially when the disease is seated in the smaller tubes. It is 
not in every case of bronchitis that the dry rales are heard; for not unfre- 
quently the disease is so mild, as not to produce sufficient narrowing of the 
tubes to give the requisite physical condition for these sounds.. Nor are the 
two sounds heard always under the same circumstances. Both arise from the 
diminished caliber of the bronchia, consequent upon inflammatory thickening 
or exudation, or spasmodic constriction. But the sonorous rale is heard in 
the larger, and the sibilant in the smaller tubes. It sometimes happens that 
the caliber of one of the larger bronchia is so much contracted as to occasion 
the hissing or whistling sound; and this may be known by the persistence of 
the sound during the whole period of inspiration and expiration; for in the 
small tubes the air is not so long in its passage as in the larger: but, gene- 
rally speaking, when the sibilant rale is heard, and especially when it extends 
over a large surface, the evidence is strong that inflammation exists in the 
small tubes. According to the extent of the chest over which these sounds 
prevail, is the extent of the inflammation; though it must be borne in mind 
that the sonorous rale, from its loudness, may often be heard at a considerable 
distance from its actual seat, sometimes even over the whole of one side of the 
thorax. There is always great reason for apprehension, when the hissing 
sound, as sometimes happens in infants, is audible 'over a great portion of the 
chest. ' ■ » ' ' " 
The dry rales are seldom entirely pure, even when first distinguishable by 
the ear ; as secretion generally begins before the membrane has become so 
thickened as to cause them. Occasionally, however, they are so; and it is 
asserted that they have continued two or three days without admixture of the 
mucous rales, and that they have even subsided altogether without the occur- 
rence of the latter sounds, or of expectoration. In the great majority of cases, 
there is, almost from the beginning, more or less of the mucous bubbling or 
crepitation; and it is only the predominance of tbe dry sounds that determines 
the stage of the disease. Not unfrequently, the mucous rale ceases for a time 
after expectoration. At length, as the stage of secretion is fully formed, the 
moist sounds predominate, though the dry are still frequently heard. All of 
them are variable, often shifting about from one part of the chest to another, 
with the varying condition of the tubes and the secretion. 
The moist sounds themselves vary according to the size of the tubes, and 
consequently of the bubbles formed in them. The mucous rale is perceived 
in the larger, the subcrepitant in the smaller. When, therefore, the fine 
crepitation of the latter is observed, and especially if in connexion with it is 
the sibilant rale, the evidence is conclusive that the disease is seated in the 
smaller bronchial ramifications; and, should the respiratory murmur be super- 
seded by these sounds, it would be inferred that the disease is very extensive. 
Under such circumstances it might be difficult to distinguish bronchitis from 
pneumonia, especially if some congestion of the lung, producing a degree of 
dulness on percussion, were connected with the former; but the absence of 
the crepitant rale, of the rusty sputa, of bronchial respiration, and of bron- CLASS III.] 
ACUTE BRONCHITIS. 
753 
chophony, and the temporary duration of the dulness, would be sufficient to 
prove the- absence of pneumonic inflammation. Sometimes the mucus is so 
thick and tenacious, in the advanced stages of bronchitis, as to narrow the 
passage by adhering to the. sides of the tubes, and thus to occasion the sonorous 
and'sibilant rales; which, however,, under sucji circumstances, cease after 
coughing. Such a condition of the mucus occasions also a sort of ticking 
sound, in consequence of the greater tenacity and consequent less frequent 
rupture of the bubbles. 
An important point amopg the physical signs of bronchitis is, that the 
respiratory murmur, though usually heard over the whole lung, yet some- 
times ceases to be audible in one or more parts, thus leading to the suspicion 
that consolidation of the lung has taken place from inflammation or other 
capse. But percussion relieves the apprehension, by proving that tlie part 
affected continues sonorous, and consequently contains air. The phenomenon 
is owing ^to .the obstruction of one of the bronchial tubes by a. plug of mucus, or 
by inflammatory thickening. In the former case, it is often removed by cough- 
ing, which displaces the obstruction, and allows the air again free admission 
apd ekit. 
Anatomical Characters.-The bronchial mucous membrane is reddened, 
thiqkened, sometimes softened, occasionally rough and destitute of its natural 
polish, and, in. some very rare cases, ulcerated or gangrenous. The redness 
is sometimes diffused, but more frequently in patches, points, streaks, or 
arborizations. In slight cases, the redness is often confined to the larger 
bronchia; in the severer, it extends into the smaller ramifications. The tubes 
contain mucus in various stales, sometimes blood, and not unfrequently pus. 
In cases which appear to have proved fatal from the abundance of the Undis- 
charged secretion, the lungs refuse to'collapse upon the admission of air into 
the pleural cavities. The bronchia are Sometimes dilated. 
Causes.-Cold is beybnd all comparison the most frequent cause of bron- 
chitis. It is most apt to produce the disease when applied partially to some 
one portion' of the frame, as to the back of the heck, feet, &c., or to the body 
previously heated-by exercise, and in a state of perspiration; and it is always 
most injurious when coihbined with moisture.^ The disease appears some- 
times to result from reaction in the bronchial mucous membrane, upon enter- 
ing a heated apartment after having breathed an intensely cold air. It is 
most frequent in the latter part of autumn, in winter, and spring, when the 
atmospheric changes are frequent and great, and the air is often loaded with 
condensed moisture. But it occurs from the same cause in summer, and 
sometimes, when protracted, ceases upon the occurrence .of the clear cold 
weather of winter. 
Other causes are heated air, acrid gases or vapours, and irritating powders 
inhaled into the lungs. In some persons, the disease is produced by peculiar 
exhalations which do not affect men in general. Thus; the powder of ipeca- 
cuanha occasionally excites violent bronchial inflammation when" inhaled. 
English writers speak of a peculiar catarrhal affection, called in Great Britain 
a the hay asthma," which occurs in' some susceptible individuals about the 
period of mowing in May and June, and is ascribed to the exhalation from a 
certain kind of grass when cut. The complaint is often very severe, involv- 
ing the whole of the air passages, and requiring removal from the sphere of 
the supposed cause in those exposed to its attacks. Only a few comparatively 
are liable to it. 
Bronchitis occurs periodically in some individuals once a year, and at the 
same time of the year, without any assignable cause.' Among my patients, 754 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
for a long time, was an elderly gentleman, who was attacked with the disease 
regularly at a certain time in August.' He resided in the city of Philadel- 
phia, and, so far as could he- learned, was never exposed at that season to the 
influence of any peculiar cause. He died ultimately of phthisis at an ad- 
vanced age, and had probably for thirty years been subject to occasional 
attacks of haemoptysis. Another gentleman, of a gouty family, has occasion- 
ally consulted me for a similar affection, occurring about the same time every 
summer. .1 think it not improbable, that such cases are often gout affecting 
the respiratory passages. - , ' 
Epidemic influence, is a powerful and not unfrequent cause of bronchitis. 
(See Influenza.') 
The disease is a frequent attendant upon many other complaints, as 
measles, small-pox, scarlet fever, hooping-cough, asthma, typhoid fever, and 
acute inflammation /of the lungs, pleura, pericardium, and liver. It also 
affords us one of the, first intimations of the deposition of tuberculous matter 
in phthisis. ' ■ ' . ' - t 
Treatment.-In the very commencement of one of these bronchial affec- 
tions, while there is yet but a slight coryza, soreness of throat, or hoarseness, 
-and the irritation is but just beginning' to show itself in the chest, the disease 
may often be entirely subverted by a dose of opium at bedtime, a copious 
perspiration induced by hot teas or strenuous bodily exertion, or even by a 
full supper of stimulating food and drink. But it is only in cases where pre- 
vious experience justifies the apprehension of a severe attack from these slight 
beginnings, that such treatment would be desirable; and the stimulating plan 
is altogether too hazardous for ordinary use, as, if it fail, it will be liable 
greatly to aggravate the subsequent symptoms. For further particulars the 
reader is referred to the subject of coryza. (See page 731.) 
In a mild case of bronchitis, with little or no fever, nothing more is re- 
quired than a saline cathartic, confinement to the house, a vegetable diet, 
demulcent drinks, and small doses of one of the antimonials. I usually direct 
an adult patient, after having been purged by an ounce of sulphate of mag- 
nesia, to drink daily, in small portions at a time, a pint of flaxseed tea with 
two fluidrachms of antimonial wine. Other demulcents may be employed if 
preferred by the patient; as solution of gum arabic in the proportion of an 
ounce to the pint, infusion of slippery elm, decoction of marsh-mallow, and 
decoctions of the dried fruits, sweetened and flavoured with lemon or orange- 
juice. To allay the cough, demulcent substances may be held in the mouth, 
and swallowed as they slowly dissolve. Such are gum arabic, liquorice, jujube 
paste, solidified molasses, and gum pectoral, consisting of a mixture of gum 
and sugar dissolved together and evaporated. 
Should considerable fever exist along with the pectoral symptoms, the 
patient ought to soak his feet in hot water, go to bed, and take every two or 
three hours -a dose of the neutral mixture, effervescing draught, solution of 
acetate of ammonia, or nitre, with a small proportion of tartar emetic, or one 
of the liquid preparations of ipecacuanha. In infantile cases, in which the 
nervous system is often disordered, spirit of nitric ether may be added to the 
diaphoretic medicines. The air of the room should be kept warm, and the 
patient should use his voice as little as possible. 
When there are headache, oppressed breathing, and considerable pain or 
soreness in the chest, or any one of these symptoms, in a high degree, along 
with a strong and excited pulse, blood should be taken from the arm, to the 
amount, in robust persons, of sixteen ounces; but generally less bleeding is 
required than in the serous inflammations, and the great majority of cases do 
very well without it. Occasionally, but not often, the bleeding may be re- CLASS III.] 
ACUTE BRONCHITIS. 
755 
peated. In relation to the loss of blood, it is highly important to have refer- 
ence to the constitution of the patient; and the discharge should always be 
stopped, however little, may have been lost, when the pulse begins to fail. In 
feeble patients, it is of the utmost importance to reserve sufficient strength 
for the expectoration of the pulmonary secretion. When bleeding is of doubt- 
ful propriety, should the local inflammation seem to ball for depletion, leeches 
or cups should be applied to the breast or between the shoulders, or wherever 
the sibilant rale may be most heard; and, in all cases, these are admirable 
adjuvants to the lancet. Sometimes, when there is considerable debility, dry 
cups may be applied with benefit. 
In severe cases, a full purgative dose of calomel should be given at first, 
and followed by depletion and diaphoretics as above. Some advise, as an 
adjuvant to the lancet, or as a substitute for it in cases in which' it may be of 
doubtful propriety, tartar emetic in doses as large as can'well be tolerated by 
the stomach without emesis, as one-quarter, one-third, or one-half of a grain, 
every ho.ur or two. 
When the first violence of the ' inflammation is over, remedies should be 
given calculated to favour the expectoration. Squill or seneka in connexion 
with tartar emetic, ipecacuanha, or sanguinaria, are now suitable remedies. 
Some strongly recommend also "the alkaline carbonates, as having the property 
of thinning and rendering of easier expectoration the viscid bronchial secre- 
tion. I have little confidence, however, in the latter remedies. It is more 
desirable to associate with the expectorants, substances calculated to allay the 
cough and quiet restlessness. Opium, however, which, under favourable cir- 
cumstances, is best adapted to these ends, cannot be used with propriety in 
thi^ stage of bronchitis, at least as a general rule, in consequence of its ordinary 
effect of restraining.mucous secretion,and therefore of shutting up the inflam- 
mation in the membrane. Recourse, then, may sometimes be had, where the 
cough is peculiarly violent, to the preparations of hyoscyamus, conium, or 
hydrocyanic acid. All these medicines may be advantageously given in liquid 
mixtures, along with some demulcent substance, as liquorice, gum arabic, or 
sugar. Every practitioner can make a cough mixture out of these materials 
to suit his own views, and the circumstances of the case. It is generally pre- 
ferable to employ the liquid preparations of the medicines recommenced, as 
the syrup of squill or seneka, the wine or syrup of ipecacuanha, and the tinc- 
ture of sanguinaria. Tartar emetic may be used in aqueous or vinous solu- 
tion^ and the. narcotics in the form of tincture or extract. The proportions 
should be so arranged that a dose may be given every two, four, or six hours, 
according to the urgency and acuteness of the symptoms.* 
After expectoration has been fairly established, opiates come in with great 
propriety, and not only add vastly to the comfort of the patient, but tend to 
promote a cure. The salts of morphia are probably preferable to any other 
preparations of opium in cough mixtures, from the circumstance that they 
tend less to restrain the secretions. The camphorated tincture, or paregoric, 
* A mixture may contain, in each dose, for an adult, from ITLx to fjss of Antimonial 
or Ipecacuanha Wine or Tincture of Sanguinaria, or from f^ss to f^j of Syrup of Ipecacu- 
anha; combined with from IT^xx t° VLX1 °f Syrup of Squill, or rr^x to h^xx of Vinegar 
or Tincture of Squill, or from fgss to f^j of Syrup of Seneka; and with from fjss to fgj 
of Tinct. of Hyoscyamus or Conium, or t0 hL'v °f Officinal Hydrocyanic Acid. In 
cases suitable for opiates, for the above narcotic tinctures, may be substituted, in each 
dose, from ttpij to hUv °f laudanum, 1TLXV t0 ^ss Solution of Sulphate of Morphia, or 
f^ss to fgj of Camphorated Tincture of Opium. It will be convenient to prescribe these 
medicines in a mixture of f^vj, with gij of Gum Arabic, and gij of Sugar or Liquorice, 
in such quantities that a tablespoonful of the mixture shall contain the doses above men- 
tioned. 756 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
which is much employed both popularly and by physicians, is less, suitable to 
acute than to chronic cases, in consequence of its stimulating properties. The 
opiate may in general be most conveniently administered, in small doses, in 
connexion with the expectorant mixtures. Sometimes, when the cough is very 
troublesome and productive of wakefulness at nights, the opium may be best 
given in full doses at bedtime, conjoined with an equal or double weight of 
ipecacuanha. .. > 
Should bronchitis be indisposed to yield to suitable depletion, and the symp- 
toms be of an urgent character, there should be no delaj^ in resorting to mer- 
cury, with a view to its peculiar influence on the-system. It may also be 
used, with great' advantage, in some dangerous; cases, in which the debility of 
the patient may contra-indicate the lancet. 
In the advanced stage of the disease, when it appears to be verging to a 
chronic form, I have found nothing so effectual, with the exception of mer- 
cury, as a decoction of seneka with tartar emetic. An ounce of the bruised 
root, and the same quantity of liquorice root, may be boiled in a pint and a 
half of water to a pint, and one grain of tartar emetic, and an ounce or two 
of sugar, added to the decoction. The dose is a tablespoonful every two hours, 
or a wineglassful, if the patient's stomach will bear it, twice or three times a 
day. I prefer the former mode of exhibition. The compound pills'of squill, 
consisting chiefly of squill and ammoniac, are also an excellent remedy. 
Assafetida is capable of doing great service in certain cases, especially in 
infants, in whom the nervous actions are often irregular, and the system needs 
support, under the exhausting action of the disease. When there is considera- 
ble debility, with difficulty of expectorating the bronchial secretions, carbonate 
of ammonia, in doses of three or five grains every-hour or two, often answers 
an admirable purpose. 
Local measures are also important. After the-application of cups or leeches, 
in severe cases, large emollient poultices are often useful, kept steadily applied 
for days together. After due depletion, sinapisms and blisters are highly 
beneficial. The latter are, indeed, among the most effectual means that can 
be employed in certain stages. Very early in the disease, they often fail to 
arrest the inflammation, while they aggravate the fever. It is after the vio- 
lence of the diseased abtion has begun to subside, that they are most usefully 
employed. In this condition of the disease, they sometimes' put an immediate 
end to it. Occasionally, in very threatening cases, when a very speedy action 
is required, the strong solution of ammonia may be employed as a rubefacient 
and vesicatory. In mild cases, especially in children, rubefacient liniments, 
made of solution of ammonia or of oil of turpentine, mixed in various propor- 
tions with olive oil, with the occasional addition of tincture of camphor, and 
certain aromatic oils, as those of rosemary, origanum, and horsemint, are some- 
times preferable to blisters. Towards the period of convalescence,.plasters 
of Burgundy or Canada pitch, or the warm plaster, may hasten perfect reco- 
very, and guard, against relapse. Inhalation of the vapour of hot water, is 
recommended by some writers as a kind of emollient application to the 
inflamed surface; but I believe that it will be found to aggravate, quite as 
frequently as to alleviate the discomfort of the patient. It is probably better 
applicable to eases complicated with spasm of the bronchia., than to pure acute 
inflammation. 
There is a point in the progress of some cases of acute bronchitis, when 
it becomes highly important to abandon all depletory methods, and resort to 
a supporting treatment. The pectoral stricture and pains have ceased, expec- 
toration has been fully established, the skin has become soft or moist, and 
the matter discharged has assumed an opaque and perhaps puruloid appear- CLASS III.] 
ACUTE BRONCHITIS. 
757 
ance; but the cough continues severe and harassing, the pulse is often fre- 
quent, and the patient suffers greatly from feelings'of debility and general 
uneasiness. Every experienced practitioner must have witnessed such cases 
.recover rapidly, as if by a charm, under a nutritious diet, a little malt liquor 
or wine, and exercise in the open air. When purulent expectoration, night 
sweats,, and a. hectic circulation are observed, there should be no hesitation in 
resorting to tonics, among which sulphate of quinia is the most efficient. 
Should this produce constriction of the chest, the infusion of wild-cherry bark 
should he-substituted, with the addition of one of the mineral, acids. 
Throughout the case, the patient should avoid speaking long or loudly, 
should wear flannel next the skin, and should not expose himself to vicissi- 
tudes of temperature. 
Certain special c^ses require, in some degree, special modes of treatment. 
In infants, leeching is often in the highest degree efficient, emetics are some- 
times beneficial, and the warm bath proves a useful adjuvant. Full purga- 
tive doses of caloinel, too, frequently produce in children the happiest effects. 
In the advanced stage of the disease, when the strength of system begins to 
fail, the respiration to become hurried, and the nose and cheeks to feel cool 
to the hand, assafetida produces immediate amendment, and sometimes speedily 
rescues the little patient from great apparent danger. The syrup of onions, 
and the syrup of garlic, have the same effect in a less degree;, and advantage 
sometimes accrues from applying garlic poultices to the feet, and bathing the 
chest with a tincture of the same substance made extemporaneously by heat- 
ing it in brandy. c S ■ 
When the disease'is seated in the smaller bronchia, and occupies a large 
portion of. the chest, the treatment should be especially active. General and 
local bleeding pushed as far as the strength will permit, free and early blister- 
ing, and the use of mercury, are the chief remedies. v 
When the inflammation is complicated with spasmodic paroxysms of an 
asthmatic character, emetics of ipecacuanha during the paroxysms, and the 
steady use of tincture of lobelia, in such doses-as slightly to nauseate without 
vomiting the patient, will be found highly useful additions to the ordinary 
antiphlogistic measures. Tincture of lobelia and syrup of seneka answer well 
together in such (cases. 
In relation to the1 variety of bronchitis'called in, Great Britain the hay 
asthma', independently of the measures-ordinarily employed in catarrhal affec- 
tions, Mr. Gordon, who appears to have paid particular attention to the sub- 
ject, states that he has found lobelia the most speedy and effectual remedy, 
and the cold shower-bath and a combination Of the sulphates of quinia and 
iron the most effectual preventives. ( Watson's Leet, an Princip. and Pract. 
of Phy sic.) Dr. Elliotson has obtained signal relief,1 in three out of four 
cases, by diffusing chlorine in the patient's apartment; by means of the chlo- 
ride of lime or of soda, placed in saucers or other convenient vessel. ( Tweedie's 
Sy st. of Pract. Med.) In the catarrhal cases which occur regularly in the 
same individual, at the same time every year, I should expect benefit from 
colchicum. i 
When bronchitis is associated with hepatic disease, calomel should be early 
given as a purge, and the system brought quickly under the mercurial influ- 
ence. If associated with miasmatic fever, especially in its intermittent form, 
it will generally yield to quinia, after due depletion. 
The treatment adapted to the variety of the disease denominated peripneu- 
monia notha, depends very much upon the strength of the patient. In vigor- 
ous individuals, and in cases not complicated with chronic disease, active 
depletion by the lancet and by local means should be employed. In the old 758 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
and feeble, who are much mpre frequently the subjects of attack, blood must 
be taken cautiously; and more reliance should be placed upon cups or leeches, 
blisters, and expectorants than on general bleeding. The choice of expecto- 
rants will also be influenced by the symptoms; the antimonials and ipecacu- 
anha being adapted to the more open inflammatory cases; squill, seneka, 
ammoniac, assafetida, and carbonate of ammonia, to those in which the 
bronchial secretion is too abundant, and the muscular powers of the patient 
too. feeble for its expectoration. In intermediate cases, the two kinds of 
expectorants may be very properly combined. 
2. CHRONIC BRONCHITIS. 
Of chronic Inflammation of the bronchia there are, perhaps, as many grades 
and varieties as of the acute. It often occurs in a very mild form, with no 
other observable symptoms than a slight cough and moderate expectoration, 
which, after lasting a considerable time, either gradually cease, or become 
aggravated so as to excite -the solicitude of the patient. Such coughs are apt 
to diminish or disappear during the summer, and, when the predisposition is 
strong, to return again in the winter; and in' this way they not unfrequently 
continue for many years, especially in elderly people. 
Severer cases are not uncommon, in which there is a troublesome cough, 
usually attended with expectoration, sometimes scanty and difficult, sometimes 
easy and copious,, of a thickrsomewhat tenacious, opaque mucus, whitish, yel- 
lowish, or greenish, sometimes streaked with blood, and frequently mixed 
with larger quantities of a thinner and more transparent, ropy liquid, probably 
the result of more recent inflammation, either supervening upon the old, or 
occupying a different part of the lungs. In some instances, small, whitish, 
opaque, solid particles are mixed with the sputa, which have by some been 
considered as tuberculous matter, but which, according to Andral, are nothing 
more than the concrete Secretion of mucous follicles in the fauces. In certain 
rare cases, the expectoration has a very offensive odour, referrible possibly to 
the condition of the blood. The cough is usually most severe, and the expec- 
toration most abundant in the morning. It is occasionally attended -with pain, 
soreness, heat, and some degree of tightness in the chest; but these symptoms 
are not common, unless as consequences of new accessions of inflammation. 
Sometimes the patient is affected with hurried respiration or dyspnoea, and 
these are much more apt than in health to occur after muscular exertion. In 
general there is no fever; but it is not uncommon to find the pulse somewhat 
quickened; and sometimes a slight febrile paroxysm maybe observed to form 
every day. The complaint may run on for a very long time with little modifi- 
cation, except, perhaps,' a diminution in warm weather, which, indeed, not 
unfrequently co-operates with proper remedial measures in putting an end to 
it. Unless relieved, it is apt in time to take on the following more aggravated 
form. 
Either as a consequence of an acute attack, or from the increase pf a milder 
chronic form of the disease, the symptoms sometimes exhibit a formidable 
character. There is copious purulent expectoration, with occasionally a little 
blood, shortness of breath much increased by exercise, debility, emaciation, a 
frequent pulse, sweats at night, and, in fact, all the obvious symptoms of 
phthisis; so that the complaint was formerly, and is still occasionally denomi- 
nated catarrhal consumption. Such cases not unfrequently teminate fatally, 
either by gradually wearing out the patient, or by the supervention of acute 
inflammation of the bronchia or other portion of the respiratory organs. In CLASS III.] 
CHRONIC BRONCHITIS. 
759 
some instances, however, such acute attacks appear to supersede the chronic, 
and, if they do not carry off the patient, leave him better than they found 
him. When chronic bronchitis of this or the milder form has lasted for many 
years, it is sometimes dangerous to. suppress it, especially in very old people. 
The system, so long accustomed to the discharge, cannot accommodate itself 
to the new condition consequent upon its cessation; and serious or fatal con- 
gestion or inflammation is apt to occur in some one of the vital organs. 
Very frequently, in the course' of chronic bronchitis, there is a mixture 
of acute • with the chronic symptoms, in consequence either of the super- 
vention,of fresh inflammation in the parts before inflamed chronically, or of 
new parts becoming affected; and this complication should always be borne 
in mind in the treatment. A test of the occurrence of acute symptoms, 
suggested by Andrei, is the appearance of transparent, amidst, or in the 
place of previously opaque sputa. The sign is generally, but not universally 
true. 
A variety of chronic bronchitis ■ called by Laennec pituitous catarrh, by 
Williams bronchorrhoea, and by the older writers humoral asthma, is charac- 
terized by paroxysms of. severe dyspnefea and coughing, followed by the copious 
expectoration of a ropy, glairy, transparent, and more or less frothy mucus, 
which has been compared to the white of egg beat with water, and allowed to 
stand. Several pints are sometimes discharged in twenty-four, hours. The 
paroxysms occur daily, and, in some cases, several times a-day, are exceed- 
ingly .variable in their duration, are seldom, accompanied with fever, and some- 
times begin with coryza. Upon auscultation, the dry morbid sounds are first 
heard, which are very soon ..followed by the mucous Vale, showing that the 
attacks commence with a congestion and consequent tumefaction of the mu- 
cous membrane, which is afterwards relieved by secretion. The chronic dis- 
ease consists in a peculiar condition of the bronchia, which renders them 
liable to congestive attacks from slight irritation; while the vessels do not 
possess energy enough to take on acute inflammation. The complaint is apt 
to occur in old gouty individuals, and those labouring under chronic disease 
of -thp stomach, liver, and especially of the heart. It. sometimes also attends 
the developement of miliary tubercles throughout the lungs; The paroxysms 
are induced by cold, irritating vapours or powders, and by other causes which 
ordinarily produce catarrh. 
The disease is sometimes speedily fatal in old persons, who die in one of 
the paroxysms, suffocated by the excessive secretion which they cannot dis- 
charge. Generally, however, it continues for a long time, in some instances 
for many years, wearing out the strength of the patient, who is apt to be- 
come dropsical, and dies at length from exhaustion or suffocation. The ex- 
cessive secretion sometimes relieves complaints of the heart by removing con- 
gestion. 
Laennec describes, under the name of dry catarrh, a variety of chronic 
bronchitis, with a! very troublesome cough, feelings of oppression in the chest, 
and either no expectoration, or only of small, semi-transparent, pearl-gray 
pellets, of the consistence of pitch. A sibilant rale is heard in the chest. 
The disease is apt. to attack the gouty and hypochondriac, the inhabitants of 
the sea-coast, persons subject to cutaneous diseases, and those enfeebled by 
excesses. 
Physical Signs.-These are the mucous rales, occasionally mixed with the 
sonorous and sibilant, occurring in various parts of the chest, and often shift- 
ing. It is sometimes only by the physical ^igns that the chronic catarrh can 
be distinguished from phthisis. The diagnostic symptoms of the former are 
equable resonance upon percussion, the absence of the signs of consolidation 760 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
in any portion of the lung, as bronchial resonance and respiration, apd of the 
signs indicating a cavity, as cavernous resonance or respiration, and pecto- 
riloquy. When these signs tire wanting; and at the same' time there is co- 
pious purulent expectoration, the evidence is almost conclusive that the dis- 
ease, is exclusively bronchial. 'But, when the bronchia are themselves mpch 
enlarged, and contain pus, it is sometimes very difficult to make an accurate 
diagnosis. The signs, however, of preceding consolidation of the lungs,, cha- 
racteristic of ordinary tuberculous deposits, are wanting in this. case. (See 
Phthisis.') A s . 
Prognosis.-In its worst forms, chronic bronchitis is a dangerous affection, 
though it often continues for many years, and is occasionally prolonged from 
middle life into an "advanced old age. It is not so often directly fatal, as 
indirectly, by so far debilitating the system, and deteriorating the lungs, as to 
cause the patient to sink under the supervention of acute inflammation, whe- 
ther of the bponchia or other part of the respiratory apparatus. One of the 
first effects of these acute attacks is to produce a suspension or diminution of 
the discharge from the bronchia, which is, therefore, a bad sign in chronic 
bronchitis. Patients with this disease also frequently die of complaints of 
the heart, which are sometimes the cause, and sometimes, probably the result 
of the bronchial affection. The co-existence of much enlargement of the 
bronchia with chronic inflammation is an unfavourable sign. The superven- 
tion of an attack of spasmodic asthma upon an old catarrh occasionally adds 
greatly to its danger. In determining as to the degree of danger from chronic 
bronchitis, it is very important to ascertain whether it may not be dependent 
upon some more serious disease. 
Anatomical ClbCLracters.^-TAc mucous membrane is thickened, sometimes 
partially indurated, sometimes, though rarely, softened or ulcerated, in some 
cases of a deep-red, violet, dr brownish hue, in others grayish, whitish, or 
only of a slightly reddish tinge, and generally lined with puruloid mucus or 
well-formed pus. The extreme tubes are not unfrequently distended with the 
pulmonary secretion; and the. bronchial glands enlarged and softened. In 
the dry catarrh of Laennec, the minute bronchial ramifications are reddened, 
and so much thickened as often to obstruct the passage, and, when this is not 
the case, are. apt to be blocked up by a thick tenacious matter, in globules of 
the size of millet seeds. The tubes are occasionally found dilated, either singly 
or in numbers, soinetimes throughout the ^vhole extent of a branch and its rami- 
fications, sometimes in isolated portions of the tube. In the former case, the 
parietes are generally thickened, and the result is probably owing to a kind 
of inflammatory hypertrophy; in the latter, they are thinned, sometimes very 
much so, owing, undoubtedly, to distension from the extraordinary impulse 
given to the air in coughing and respiration. Constriction of the tubes is 
sometimes observed, in such a degree as completely to close them, arising from 
thickening of the mucous membrane, or of the entire wall of the tube. In 
some cases in which all the signs of chronic bronchitis exist during life, the 
tubes are found to all appearance perfectly healthy after death. (Andral, 
Bayle, &c.) 
Causes.-The greater number of cases of chronic catarrh are the conse- 
quences of acute attacks. But not unfrequently they come on gradually 
from the slight and continued or frequent application of causes of irritation, 
such as ordinarily produce the acute disease, when more intense, or acting on 
more susceptible subjects. Irritating powders are apt to produce this effect 
when inhaled; and hence, stone-cutters, workers in metal, and those employed 
to cleanse feathers, hair, &c., by beating them, are liable to the disease. 
There is a peculiarity, moreover, of constitution, which predisposes certain CLASS III.] 
CHRONIC BRONCHITIS. 
761 
individuals to chronic bronchitis; and such a peculiarity often exists in per- 
sons of a rheumatic or gouty habit of system, and those subject to cutaneous 
eruptions. The disease is a frequent 'accompaniment of other pectoral, cpm- 
plaints,' especially phthisis, in which, when fully developed, it is never absent. 
Disease of the heart frequently causes it, in consequence of the irregular dis- 
tribution of blood in the lungs which it produces, and, when not the cause, 
. tends to aggravate the complaint, and to render it much more obstinate. It 
frequently follows measles-and hooping-cough; arid appears sometimes to 
depend upon the suppression of habitual discharges, especially the menstrual 
and hemorrhoidal. < . . ; 
Treatment.-General bleeding is seldom required or admissible, to any 
considerable extent. In some cases, when the symptoms, under temporary 
influences, assume a more acute character, a few ounces of blood may be taken 
with advantage from the arm; but it should always be done with caution. 
Local bleeding, by cups or leeches, is both safer and more efficacious. -It may 
be resorted to occasionally, and in moderation, when there is some pain or 
stricture in the chest, with sufficient strength of pulse. • 
The expectorants are, upon thb whole, the medicines' best adapted to this 
complaint. In the choice of them, the practitioner must .be guided by the 
symptoms. Should some excitement of the circulation exist,-, with deficient 
expectoration, and some degree of constriction, the least stimulating articles 
of the class should be used, such as tartar emetic in aqueous or vinous solu- 
tion, ipecacuanha wine or syrup, tincture of sanguinaria and of lobelia,/and 
wine of colchicum; of which a dose should.be given four or six times a-day, 
and $o regulated as to be kept just within the nauseating point. If, as com- 
monly happens, there is little or no evidence of general excitement, or active 
inflammation, one or more of the above mentioned expectorants may be con- 
joined with syrup or tincture of squill or syrup of seneka. I have found no 
combination so efficacious as the decoction of, seneka arid liquorice root, with 
tartar emetic, described under acute bronchitis. (See 756.) It has 
happened to me to see many very obstinate castes of cough yield to this 
remedy. The seneka appears to exercise an alterative influence over the 
bronchial mucous membrane, independent of its expectorant power. The 
compound squill pill of the Pharmacopoeia, containing chiefly squill and am- 
moriiac, is an excellent combination. Recourse may also be had to the bal- 
sams of Tolu and Peru, the compound tincture of benzoin, and to copaiba. 
The last mentioned medicine often proves serviceable in chronic catarrhs. 
The expectorants should generally be given in mixture, with small doses of 
one of the narcotics to allay cough. When there is tightness of the chest, 
and want of bronchial secretion, hyoscyainus, conium, stramonium, bella- 
donna, or hydrocyanic acid should be preferred to opium; and camphor, in 
the form of tincture, or of camphor water, may sometimes be usefully added 
to the other ingredients. Under other circumstances, one of. the opiates should 
be preferred, as more effectual than the medicines mentioned in allaying 
cough. The salts of morphia are probably the best preparations of opium 
for use in bronchial disease. The camphorated tincture of opium is a very 
agreeable preparation, well adapted to cases without any vestige of acute in- 
flammation. Black snake-root, or cimicifuga, sometimes exerts a happy 
influence in the relief of chronic coughs. Sulphur, in the dose of half a 
drachm, or a drachm, two or three times a-day, is also said to be useful. 
Cough mixtures of almost infinite diversity may be prepared from the above 
materials, in the choice and association of which the practitioner has ample 
opportunity for the exercise of a discriminating judgment. Gum Arabic, 
liquorice, and sugar, are useful demulcent additions to the expectorants. 762 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
If the expectorant treatment fail, aided by local measures, such as will be 
detailed immediately, and should the case exhibit no peculiar tendency to 
tuberculous disease, recourse should be had to a mercurial impression, which 
should be maintained moderately for weeks, if not sooner effectual. For this 
purpose calomel or the mercurial pill should be employed, and advantage will 
often accrue from the addition of a narcotic, such as extract of hyoscyamus 
or/conium, or opium with ipecacuanha when not contraindicated. 
Should febrile action supervene upon chronic bronchitis, it may usually be 
relieved by a saline aperient, the neutral mixture, and tartar emetic in small 
doses. ' - ' „ • • 
External irritation should be sustained by blisters to the chest frequently 
repeated, postulation by tartar emetic or croton oil, and setons or issues be- 
tween the shoulders. To do permanent good, these must be long persevered 
in. The irritant should be applied as near as possible to the seat of inflam- 
mation, as indicated by auscultation. In mild cases, it unay be sufficient for 
the patient to wear a plaster of Burgundy, or Canada pitch, or a warm plas- 
ter. Frictions to the chest are also useful, and especially with rubefacient 
liniments, composed of some of the stimulating volatile ojls,. as of turpentine, 
rosemary, origanum, or monarda, sufficiently diluted with olive oil. When 
the disease is connected with a repelled eruption, it is iinportantdo endeavour 
to restore the cutaneous affection by irritation to the part in which it had pre- 
viously existed; and croton oil is an excellent irritant for this purpose. 
Inhalations are also very useful in some cases of chronic bronchitis. The 
vapours of tar are especially beneficial. The air of pine forests is thought 
to be peculiarly wholesome in this complaint. The fumes of common resin 
decomposed by heat have been, employed with advantage. Other substances, 
occasionally administered in this way, are chlorine and the vapour of iodine. 
The former may be breathed with the air in apartments, in which solutions of 
chloride of lime, potassa,- or. soda are placed; the latter is most conveniently 
applied by means of an inhaler, along with the vapour of water, and that of 
tincture of conium, hyoscyamus, opium, ether, or Hoffmann's anodyne.. 
In old or prostrate cases of chronic bronchitis, with copious purulent ex- 
pectoration, night sweats, &c., it is in many instances highly important, in 
addition to the treatment above detailed, to employ measures calculated to 
invigorate the system. The chalybeates, combined with the bitter tonics, 
may be used, the former to improve the character of the blood, the latter to 
promote digestion. The infusion of wild-cherry bark, long and freely used, 
is an excellent remedy under these circumstances;• and may often be advan- 
tageously associated with one of the mineral acids, especially the aromatic 
sulphuric acid, or the nitro-muriatic. Decoction of Iceland moss has been 
much used, and it is said sometimes very efficaciously, as tonic, demulcent, 
and nutritive. Sulphate of quinia may be given when the disease is accom- 
panied with chills and hectic paroxysms. Porter and other stimulant drinks 
must be called in requisition, when the debility is great. Should gastric or 
hepatic disease exist, the treatment must be modified accordingly, and, in cases 
of vomiting with gastritis, the stimulant plati should be suspended if possible. 
Exercise should be taken freely in warm dry weather; but exposure to cold 
and wet should be avoided. Hence the importance, if the patient be a resi- 
dent of cold and austere climates, that he should remove during the winter 
to warm and equable latitudes. The interior of one of our most southern 
states, or one of the West India islands, may be recommended. A sea-voyage 
is itself often beneficial, and, if long enough, will not unfrequently effect a 
cure. A change of residence, even without any considerable obvious change 
of climate, is sometimes beneficial. A resort to the Sulphur Springs may be CLASS III.] 
CATARRH. 
763 
advised) in the hope of good from their waters. Warm clothing, and flannel 
next the skin are important. Advantage will often accrue, during the severe 
cold of our /winters, from wearing wadded cotton or lamb's wool over the 
breast or shoulders. General frictions to the surface are sometimes useful. 
The diet should vary with the circumstances of the case. Under ordinary 
circumstances, it should be nutritious without being stimulant, consisting, for 
example, of milk, the lighter meats in moderation, fish, farinaceous prepara- 
tions, 'and vegetables. When there is any degree of acuteness in the symp- 
toms, meats should be forbidden, and the patient confined to milk and vege- 
tables, or the latter alone. Stimulating drinks should not be allowed unless 
in cases of considerable debility. 
In the form of bronchial disease denominated pituitous catarrh, hronchor- 
rhoea, nr Immoral asthma, the treatment should vary according as it is applied 
tmthe paroxysm or the interval. At the accession of the attacks, hotjpedi- 
luvia, hot baths, sinapisms over the epigastrium, and, if the strength permit, 
an emetic of ipecacuanha, may be employed, followed by small doses of the 
same medicine or of tincture of lobelia, every hour or two, so as to sustain a 
slight nausea. During the excessive expectoration, stimulants sometimes 
become necessary to support the strength, and aid the patient in the discharge 
of the. mucus. For this purpose, carbonate of ammonia, Hoffmann's anodyne, 
or .sulphuric ether maybe employed. Strong coffee has also been recom- 
mended. In the intervals, efforts should be directed towards obviating the 
tendency to bronchial congestion. The indication, therefore, is to sustain the 
tone of the bronchial vessels, and to maintain a moderate secretion from them. 
For this purpose, the stimulant expectorants already enumerated as remedies 
in- chronic catarrh should be employed, and should be given with small doses 
of one of the preparations of antimony or ipecacuanha, or some other nau- 
seating expectorant. Blisters to the chest are also sometimes useful. The 
functions of the system should all be carefully attended to, and corrected if 
deranged. Disease of the liver and stomach, if existing, should be removed, 
the bowels should be kept regular, and gouty tendencies obviated by suitable 
remedies. In relation to diet, exercise, fresh air, an equable temperature, 
and warm clothing, the same remarks are applicable as to chronic bronchitis 
in general. - ■ . * 
3. CATARRH. 
This name was formerly applied to diseases of the mucous membranes 
generally, attended with increased secretion*. At present, however, when 
not connected with some epithet fixing its locality elsewhere, it is confined to 
inflammation of the respiratory passages. Each portion of these passages 
gives a distinct name to the inflammation with which it. may be affected. 
Hence we have coryza, angina, laryngitis, and bronchitis. But it often hap- 
pens that, in the same attack, all these parts are successively or simultaneously, 
the seat of inflammation, which, therefore, may be said to constitute one disease. 
Eor this, in its full extent, we have no other name than catarrh. Some 
writers consider catarrhal inflammation as peculiar or specific, "characterized 
by slightly increased vascularity, afflux of the circulating fluids, and augmented 
secretion." I have never been able to discover anything specific in its 
character. The inflammation, which begins with increased secretion in the 
nostrils, very often becomes dry when it reaches the throat or bronchial tubes; 
and yet it can hardly have changed its nature. There is a certain grade or 
stage of inflammation in the mucous membranes, in which they are disposed 764 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
to copious serous or thin mucous secretion; and what these writers designate 
as catarrh differs from other examples of inflammation only in this respect. 
The disease usually begins in the nostrils with coryza, then invades succes- 
sively the fauces, larynx, trachea, and bronchia, and finally loses itself in the 
ramifications of the last mentioned tubes. Sometimes, especially in children, 
it penetrates to the vesicular structure of the lungs, and constitutes pneumo- 
nia. Not unfrequently also the inflammation commences in the fauces or 
larynx, and runs downward; and, in some instances, making its first appear- 
ance in the bronchial tubes, it extends upwards as far as the nostrils, giving 
rise to coryza. 1 . " - 
The grade of inflammation is apt to be nearly the same throughout this 
course, unless modified by treatment. If the coryza or inflammation of the 
fauces be light, the chances are that the bronchitis will be light also; and 
vice versa. Some of the worst cases of bronchitis begin ds intense inflamma- 
tion of the fauces, extending to the submucous tissue. When the disease 
reaches the chest, and is attended with febrile symptoms^ it is called catarrh 
fever. ■ . ■ ■ , - " 
It is unnecessary to treat of the symptoms of catarrh. They vary wifh the 
part or parts affected, and have been sufficiently described under the preced- 
ing heads. When severe, the complaint is almost always attended with fevter, 
and, even though slight, is not unfrequently thus attended, if it occupy simul- 
taneously a great extent of the respiratory passages. 
The treatment has been already -fully detailed. Thus, when the disease 
occupies the nostrils, it must be treated as coryza, when the fauces, as 
angina, when the larynx, as laryngitis, and, finally, when the bronchia, as 
bronchitis. It is only necessary to state here, that it is often highly import- 
ant to arrest the disease, or diminish its violence,'in its earliest seat, so that 
it may either pot reach the bronchia at all,, or reach them in a milder form. 
Hence the propriety of attacking inflammation of the nostrils and fauces more 
efficiently than if the complaint vyere to be confined within these limits. At- 
tention to this suggestion may often prevent a long continued, if not serious 
attack of pectoral disease. 
In the cases of individuals subject to frequent and .severe attacks of catarrh, 
it is sometimes very desirable to meet the disease upon the threshold, and turn 
it aside if possible. This is true in whatever portion of the air-passages it 
may make its first appearance. The means calculated for this purpose/are, 
chiefly, a large dose of opium at- bed-time, and the production of a copious and 
continued flow of perspiration. For the modes of'carrying these measures 
into effect, and the cautions necessary, the reader is referred to the article on 
coryza. 
4. INFLUENZA. 
Syn.-Epidemic Catarrh.'-Grippe (Fr.). 
The name influenza, adopted from the Italian, has been applied exclusively, 
though with no great propriety,'to an epidemic disease which usually takes on 
the character of catarrh. The first epidemic of this kind, of which we have 
any distinct medical record, occurred in the year 1510. There can be little 
doubt, however, that it. has occasionally visited mankind from the earliest 
ages. Since the year mentioned, we have numerous records of its occurrence, 
at irregular intervals, down to our own times. 
The epidemic appears to have been altogether irregular in the period of its 
recurrence. Sometimes returning in two or three years after its disappear- CLASS III.] 
INFLUENZA. 
765 
ance, it has, in other instances, postponed its return for seven, ten, or even 
twenty years. Nor does it appear to have observed any certain course in its 
progress'. In general, however, its tendency is to proceed from the East 
towyards the West, and it probably marches more frequently from the south 
northward, than in the contrary direction. On the old continent, it has 
sometimes commenced in Russia, advanced westward through Poland and 
Germany, then crossed into Britain, and afterwards visited successively 
France, Spain, and Italy. On other occasions, it has begun in the south- 
east, and entering France and Spain from Italy, has thence proceeded to 
England, and swept round the north of Europe. In this country, i,t has 
sometimes proceeded from the northern states towards the southern, on other 
occasions, has commenced in the latter, and marched towards the north. Its 
spread is usually so rapid, that it not unfrequently appears throughout vast 
extents of territory almost simultaneously. Oceans seem to oppose no 
obstacle to its Course. It has leaped over from Europe to North America, 
has been observed in solitary islands in the midst of the ocean, and has 
attacked the crews of ships far out of reach of any communication from the 
land. It appears sometimes to have made the .circuit of the whole globe. 
There is a considerable resemblance in its course to that of epidemic cholera, 
the march of which it has both immediately preceded and followed. 
- At the moment of invasion,-it-seizes almost simultaneously on great num- 
bers, and before its departure-sometimes involves almost the-, whole popula- 
tion. Its average duration, in each neighbourhood, is about six weeks; 
though the pause appears to linger after all the susceptible material for its 
action has been exhausted'; for strangers arriving in the affected region, after 
the disease has' apparently ceased, are not unfrequently attacked. The in- 
ferior animal's appear to suffer as well as man. Many instances are on record, 
in which horses, dogs, sheep, and even birds have been attacked by the epi- 
demic. Some persons are much less susceptible to the morbid influence than 
others, and some appear to be altogether insusceptible. No obvious cause 
.exists for this discrepancy. All ages, both sexes, and every variety of tem- 
perament and occupation, are equally liable to attack. It has been estimated 
that from one-half to three-quarters of. the whole community are in a greater 
oi' less degree affected. 
The disease exhibits, on the whole, a remarkable uniformity of character, 
though it has occasionally differed much in it's grade of severity, in different 
times and places. In general it is very mild; but, on some'occasions, and in 
certain localities, it has proved extremely fatal. Thus, during the epidemic 
of 1580, nine thousand persons are said to have died of the disease in Rome. 
It is probable that other epidemic influences may occasionally combine with 
and modify it in certain situations. It may, for example, be readily con- 
ceived that, if it should make its appearance in a neighbourhood already 
tainted with a typhoid influence, it might fearfully increase the mortality. 
In many of the epidemics, authors have recorded unusual changes in the 
temperature, moisture, and weight of the atmosphere; but the same state of 
the weather has not been observed in different places attacked; and not un- 
frequently there has been nothing uncommon noticed. It appears that the 
disease has prevailed in all climates, at all seasons, and in every possible 
thermometrical, hygrometrical, and barometrical variation. It has sometimes 
occurred in summer, though more frequently in the colder seasons. 
Symptoms.-Influenza usually appears with the ordinary symptoms of 
catarrh, upon the whole, in a rather aggravated form. In many instances, 
however, it is very light, without fever, and scarcely regarded by the patient. 
It usually begins with coryza or sore-throat, and the common preliminary 766 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
symptoms of fever, as feelings of lassitude and weariness, pains in the limbs, 
chilliness, rigors, &c., which are followed first by. heat of skin, headache, and 
excited pulse, and -soon afterwards by cough, uneasiness - in the chesty and 
other signs of pectoral disease. But the symptoms of nervous derangement 
are in general much more prominent than in ordinary catarrh, and there is 
greater muscular debility. Disorders of sight and hearing, giddiness, pains 
in the back and limbs, general uneasiness, and depression of spirits are not 
uncommon in this disease. The headache is often severe, sometimes affecting 
equally the whole head, but more frequently concentrated in the forehead, 
and especially in the region of the frontal sinuses. Not unfrequently the 
pains extend to the back of the neck, in the form- of rheumatism, and to the 
cheeks and temples, which are very sore and painful. Disorder of sto- 
mach, such as nausea and vomiting, are more common than in ordinary 
catarrh. But the most distinguishing feature of the disease is the debility 
which attends it; Almost all writers are agreed upon this point. In some 
of the epidemic attacks, it seems to have been less striking than in others, 
and in a few instances the pulse is said to have been strong, and to have not 
only borne, but imperiously demanded depletion. But, in the much greater 
number of instances, it is described as having been feeble ; and in some, the 
debility was extraordinary, so that the disease would not at all bear the loss 
of blood, and death was in numerous cases ascribed to bleeding. So great 
was the prostration of strength, that the patient fainted merely tipon attempt- 
ing to sit up. Another striking circumstance is, that the debility often con- 
tinued for a considerable time after the cessation of all other symptoms. I 
cannot say that I have observed this extraordinary debility in the epidemics 
which it has been my lot to witness; but the testimony to the fact is too 
strong and united, to admit of denial. As in ordinary catarrhal fever, there 
is generally a remission of the febrile' symptoms in the morning, and an 
exacerbation towards night. The degree of intensity in the nasal, throat, and 
pectoral symptoms is 'exceeding variable. Sometimes the affection of the 
mucous membrane scarcely exceeds the point of irritation or congestion; and, 
even when the cough is considerable, auscultation does not always detect the 
signs of bronchial inflammation. 
But the morbid effects of this epidemic influence do ndt necessarily appear 
in the shape of catarrh. In some instances, the force of the disease has been 
spent upon the brain; and violent headache, flushed face, delirium, and fever 
have been the prominent symptoms. Sometimes the digestive.organs have 
been affected, and the disease has been evinced chiefly by epigastric pain and 
tenderness, nausea, vomiting, &c. Occasionally it has appeared in the form 
of colic, diarrhoea, or dysentery, which have either existed alone, or as com- 
plications of the catarrhal affection, especially towards its close. Inflamma- 
tions of the lungs, pleura, and pericardium have always been frequent during 
the prevalence of influenza, and have undoubtedly been dependent upon the 
same cause as that of the respiratory passages. Sometimes inflammation has 
appeared in these situations as an original affection, and sometimes as an 
attendant upon the bronchial disease. Abscesses of the frontal sinuses were 
noticed by Rush among the forms of influenza. Haemoptysis not unfrequently 
occurs in persons predisposed to that complaint. Authors speak also of in- 
flammation of the urinary organs among the effects of the epidemic cause. 
Epidemic catarrh has usually the same course and duration as the disease 
from ordinary causes. It generally terminates favourably by perspiration, 
copious mucous secretion from the bronchia, or increased discharge of urine, 
which deposits a sediment on standing. Pustular eruptions, erysipelas, and 
scarlet rashes, are enumerated among the phenomena which occasionally occur CLASS III.] 
INFLUENZA. 
767 
at the close of the complaint. The duration of the disease varies from two 
or three days to one or two weeks; and a cough is frequently left after the 
other symptoms have disappeared. The fever probably, ip most c^ses, goes 
oft' about the fifth day, with copious sweating or expectoration. 
A. catarrhal epidemic, in which the disease assumed, in frequent instances, 
a regular intermittent character, with paroxysms occurring- daily at a particu- 
lar hour, and which yielded to the sulphate of quinia, is described by Dr. 
Samuel Webber, of Charlestown, N. Hampshire, in the Boston Medical and 
Surgical Journal of March 22d, 1848 (vol. xxxviii. p. 149). 
Epidemic catarrh is seldom a dangerous disease. It is scarcely ever fatal, 
unless complicated with inflammation of the brain, lungs, or heart,.or in persons 
debilitated by old age, or previous maladies, such as chronic catarrh, phthisis, 
and organic affections of the heart. It occasionally also proves fatal in 
infants- But, though thus mild in its character, it affects so large a number 
of individuals, pnd so many persons in every community are just tottering on 
the brink of the grave, that it proves the immediate cause of numerous deaths 
whenever it prevails,. Thus,, in some places, it is asserted'to have, proved 
more fatal in reference to the community at large than even cholera, in con- 
sequence of the vastly greater number of persons affected. It has been 
estimated that, of those attacked by the influenza in its different forms, about 
two out of every hundred perish. 
■ Causes.-The.peculiar nature of this epidemic influence has been a subject 
of much conjecture and discussion, but has not yet been satisfactorily ex- 
plained. Some have supposed that it might consist in those atmospheric 
vicissitudes which have often been observed to accompany the epidemic; but 
this notion is contradicted by the fact, that the disease has occurred under all 
possible varieties of appreciable atmospheric condition, at all seasons, in all 
weathers, and at the same moment in distant places, differing wholly in 
climate, and the state of the. atmosphere at the time. The ascription of the 
disease to a peculiar electrical state of the air is equally unsatisfactory; for 
no such state has been shown to exist in connexion with it. That the cause 
cannot be an exhalation from the earth is proved by jts rapid passage from 
one country to another, from the immense extent of its prevalence, and from 
the fact, that it acts in the midst of the ocean, which no such exhalation 
would be apt to reach. The notion of some uncertain telluric influence is 
too vague to require refutation. Nor does the idea of contagion, though 
entertained by so high an authority as Cullen, appear to deserve a much more 
serious notice.1 It is altogether beyond modern credulity, that a disease 
which sweeps like a tempest over nations, and prostrates whole communities 
almost-at the same moment, should be propagated by communication from 
individual to individual. That, though occurring epidemically, it may still 
have contagious properties, like measles and scarlatina, is another matter, and 
not so obviously absurd. But there is no good reason even for this modified 
belief. A contagious disease usually attacks some one individual in a family, 
and after a certain interval extends to others. The influenza commonly seizes 
at once upon the whole family. The vicinity of the sick has not been shown 
in any degree to favour the occurrence of the disease. Contagious affections 
communicated through the atmosphere usually occur but once. An attack 
of influenza is no security against subsequent attacks. Contagion lingers 
long after the epidemic has passed. Influenza leaves few or no straggling 
cases behind it; unless those of individuals who may suffer relapses from cold 
or other cause. It is said that the disease has been observed to commence in 
certain places after the arrival of strangers from infected neighbourhoods, and 
to spread from the point of arrival. This might happen fifty times, and yet 768 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
be purely accidental. At present very few believe thtit the disease is in any 
degree contagious. The last notion which has been advanced as to the nature 
of the epidemic 'cause, is that'it is1 organic, consisting of innumerable animal- 
cules, or vegetable microscopic fungi, which have .the power of propagating 
rapidly in the atmosphere, but run a brief course of existence. There .is 
some plausibility in this idea. It explains many of the extraordinary move- 
ments of the epidemic, and accounts for the asserted fact of individuals from 
infected districts becoming the centre of' a new prevalence elsewhere. They 
may bring about their persons, or in their baggage, organic germs, which may 
soon fill the atmosphere with their progeny. But this hypothesis is wholly 
destitute- of proof; for the assertion that immense swarms of visible insects 
sometimes appear during the catarrhal epidemic, even if its truth be admitted, 
goes but a very little way towards proving that the epidemic caus(e consists in 
insects that are invisible. It is best then at once to confess our ignorance on 
this point, and to wait patiently until we cap obtain new light. 
Treatrhent.-In relation to the treatment it is necessary to say but little. 
The disease must be managed in the same way essentially as common catarrh. 
(See coryza, laryngitis, and bronchitis?) There is- one prominent difference, 
however, which requires notice. Almost all writers agree that the influenza 
does not so well tolerate depletion. Bleeding is not borne well, or if borne, 
is said to be less effective. In abstracting blood, therefore, it is proper to be 
cautious, and always carefully to examine the pulse. If this begin to falter, 
the bleeding should be immediately checked. As a-general rule, unless the 
symptoms of inflammation are decided, it is best to avfiid venesection' alto- 
gether, and to trust chiefly to the diaphoretic plan. Even active purgation 
is scarcely admissible. Eupatorium, or boneset has long been recommended 
in this disease. Dr. Peebles (Am. Journ. of the Med. ^ci., N.'S., vii. 365) 
speaks in the highest terms of its utility. He employed it in many cases 
exclusively, and found it useful by its sudorific, laxative, and emetic proper- 
ties, when administered early in the complaint, id the form of warm infusion; 
and by its tonic powers when given in chid infusion, in the advanced stage. 
When diarrhoea occurs in the latter stages, it may be arrested by means of 
opium and ipecacuanha. When the debility is considerable, it is often neces- 
sary to support the system by tonics, aromatics, and even more powerful 
stimulants. Should the disease assume a regular periodical character, sul- 
phate of quinia would be indicated. 
5. CROUP. 
Syn.-Cynanche traehealis.-Angina tracliealis.-Tracheitis.-Hives. 
This is a disease almost peculiar to infancy and childhood. The name of 
croup, by which it is usually designated, is of Scottish origin, and is said to 
be derived from roup, a word used in some parts of Scotland for the sound 
made by a chicken with the pip. No correct scientific name has yet been 
adopted, embracing all the varieties of the disease. Cullen's cynanche 
trachealis, and the more modern tracheitis are objectionable designations; as 
they lead to false notioiis of the pathology of the affection. Croup is not 
essentially inflammation of the trachea. It may exist without disease of that 
portion of the respiratory passages; and inflammation of the trachea often 
takes place in infants, as in their catarrhal affections, without producing the 
symptoms of croup. The complaint may be confined to the larynx; though 
it generally embraces also the trachea, and not unfrequently extends deeply 
into the bronchial tubes. It may, therefore, occupy one or several divisions CLASS III.] 
CROUP. 
769 
of the respiratory passages. If any one part is necessarily affected, it is the 
larynx; for a. case would scarcely come under the designation of croup, in 
which this organ should not be disordered, at least in its functions. 
To constitute croup two circumstances are essential/ One of these is in- 
flammation or high vascular irritation of the laryngeal, or laryngo-tracheal 
mucous membrane. But that inflammation alone does not constitute the 'dis- 
ease, is proved by the fact, that it often exists without the peculiar croupal 
phenomena, as in measles, catarrh, small-pox, &c. The additional circum- 
stance, not less essential than inflammation, is spasm of the interior muscles 
of the larynx. It is this which distinguishes the croup of children from the 
similar- inflammatory affections of adults, occupying precisely the same struc- 
ture. Some have supposed that a variety of croup exists which is purely 
spasmodic. It is certain that the muscles of the glottis sometimes contract 
spasmodically, without inflammation or vascular excitement; but the pheno- 
mena are different from those of croup, and belong to a different pathological 
condition. 
Definition.-Croup, therefore, may be defined to be a disease, in whidh 
inflammation or high vascular irritation of the laryngeal, or laryngo-tracheal 
mucous membrane, is combined with spasm of the interior muscles of the 
larynx, giving rise to peculiar modifications of voice, cough, and respiration. 
Varieties.-Under the name of croup are usually confounded two forms of 
disease, materially different in their character, and greatly so in their results. 
This will scarcely admit of contradiction, when we consider that, of the cases 
commonly called croup, both popularly and professionally, in this country, a 
vast majority are very manageable, yielding with great facility and with con- 
siderable certainty to the early application of remedies; while the disease, as 
described by most European writers, is stated, under precisely the same treat- 
ment, to be exceedingly fatal, even when attacked in the early stage, and 
almost necessarily so in the advanced- stage. Without having the support of 
statistics, I do not think I shall greatly err in stating, that not one in fifty 
patients dies of ordinary croup in this country, when properly treated; while 
European writers inform us, that formerly the proportion of deaths was four 
out of five, and at present, wheti the treatment is better understood, is not 
less than one-half. ■ The two forms of the disease differ essentially in the pro- 
duct of the inflammatory action. In the more curable variety, the mucous 
membrane, if it secrete at all, yields mucus, pus, or a muco-purulent fluid, 
according to the degree and stage of the inflammation. In the more danger- 
ous form of the disease, an albuminous or fibrinous exudation takes place 
upon the inner surface of the air-passages, giving rise to the formation of false 
membrane. In the former, the inflammation is exactly analogous to that 
which takes place in catarrh, and, as in that affection, may be of every grade, 
from the slightest and most trivial, to the severest and most dangerous. The 
disease differs from catarrh only in consequence of the addition of spasmodic 
symptoms. In the other form of croup there is something peculiar, either in 
the character of the diseased action, or the state of the blood, which induces 
the peculiar effusion. The nature of the exudation, in this case, has nothing 
to do with the violence of the inflammation; for the false membrane is often 
produced when the inflammatory action is only moderate, as proved both by 
the phenomena during life, and the results of dissection. The milder form of 
the disease will be distinguished in this treatise by the name of catarrhal 
croup, the more dangerous, by that of pseudo-membranous croup. 
But, while making this distinction in the general character of the two 
varieties, I admit that the catarrhal form may run into the pseudo-mem- 
branous; in other words, that a case beginning with the symptoms of the 770 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
former may terminate with those of the latter. Indeed, in the earliest stage, 
before secretion has commenced, it would be impossible to determine, with 
certainty, which form the disease was about to assume. Again, there may be 
cases in which the two forms shall be combined; that is, in which one por- 
tion of the membrane shall secrete mucus, and another exude fibrin; and the 
relative amount of the secretion would determine the position of the case in 
one or the other division. From these facts the highly important practical 
inference is deducible, that, in every case in which the symptoms of croup 
appear, efficient remedies should be promptly applied; for, if carefully em- 
ployed and properly guarded, they can do little serious or lasting injury; 
while the neglect of them may possibly lead to the most deplorable conse- 
quences. No rule in medicine is more certain, than that every case of croup, 
whatever may be its apparent character, should be treated promptly and 
efficiently. 
1. Catarrhal Croup.-False croup.-Stridulous laryngitis.-Stridu- 
lous angina.-Spasmodic laryngitis.-This is sometimes called spasmodic 
croup; but the name is improper, as both forms of the complaint are more or 
less spasmodic. In giving it the name of catarrhal croup, I wish to be under- 
stood merely as indicating that the inflammation is of the same.general nature 
as that which occurs in catarrh. 
Symptoms, Course, &c.-The disease commences variously. Not unfre- 
quently the child is affected for some tiihe with the symptoms of common 
catarrh, such as coryza, sore throat, bronchial irritation, cough of an ordinary 
character, and perhaps fever, before those peculiar to croup are developed. 
Very often a croupy cough and some hoarseness precede the attack for some 
hours or even days; and this state of things, though always suspicious, some- 
times passes away spontaneously, without the occurrence of the fully formed 
disease. Either after ythe prevalence, for a shorter or longer time, of the 
symptoms just referred to, or altogether without premonition of any kind, the 
child is attacked with a paroxysm of coughing and dyspnoea, having certain 
peculiar and highly characteristic features. In the majority of instances, this 
occurs in the night, and more frequently in the early part of it than towards 
morning. The paroxysm differs greatly in severity in different cases, being 
sometimes very slight, sometimes violent and alarming, and of every inter- 
vening grade between these two extremes. The following description applies 
to one of a very decided character. 
The child usually starts out of sleep with a peculiar dry, sonorous, ringing 
cough, sounding, according to Cheyne, as though it came through a brazen 
trumpet, but in fact comparable to nothing else in nature, and to be appre- 
ciated only by being heard. When once heard, it will always afterwards be 
easily recognized. So characteristic is it of this disease, that, when met with 
in other affections, as sometimes happens, it is called the croupy cough. It 
is occasioned, in all probability, by a certain spasmodic rigidity of the vocal 
cords, giving an almost metallic tensibn to the sides of the rima glottidis. 
Immediately succeeding the cough there is often a shrill, stridulous sound, 
produced during inspiration; and the two sounds together, that of the cough 
and of the inspiration, have been compared to the barking of a small dog, or 
the crowing of a young cock, though the resemblance is not very obvious. 
Along with the cough, which is frequently repeated, the child is affected with 
dyspnoea, which is frequently severe and very distressing; the respiration 
being dry, wheezing, and often sonorous', as if the air entered through a nar- 
rowed passage, with firm vibrating walls. If the child attempt to speak, the 
voice is usually more or less rough and hoarse, though very rarely quite 
extinct or whispering, and scarcely ever more than temporarily so. This is CLASS III.] 
CATARRHAL CROUP. 
771 
an important point in the diagnosis of the two varieties of croup. So long as 
■ the voice is sonorous, even though occasionally suppressed during a paroxysm 
of laryngeal spasm, there is good reason to hope that the case may not prove 
to be pseudo-membranous. The distress of the little sufferer during the 
paroxysm is often very great. He sits up or tosses himself about in bed, 
supports himself on his hands and knees, or lies- on his back with his head 
extended, so as to give as great a permeability as possible to the trachea; 
puts his hands to his ■ throat as if to remove some difficulty there, or holds 
them out imploringly for aid from his attendants; and/as if conscious of 
threatened suffocation, has upon his countenance an alarmed, anxious, and 
affectingly beseeching expression. Sometimes, when able to speak, he com- 
plains of tightness or pain in his throat; but his voice, as well as his piteous 
attempts to. cry, are often stifled by the cough, and increase the violence of 
the paroxysm. At first the countenance is usually flushed, the skin warm, 
and the pulse frequent and febrile; but, unless the paroxysm subside, espe- 
cially when it is- very severe, the effects of the impeded respiration begin to 
be experienced in the state of the blood, which is insufficiently aerated. The 
lips assume a purplish or livid hue; the face becomes pale, the extremities 
cool, the pulse very frequent, feeble, and irregular; and a condition takes 
place approaching to asphyxia, during which the spasm relaxes, and tile air is 
allowed again to enter the lungs more freely. The violent symptoms are now 
moderated, and the paroxysm gradually subsides, so that the child falls to 
sleep, and upon awaking is found to have been greatly relieved. In some 
extraordinary cases, complete and fatal asphyxia may take place before the 
spontaneous subsidence of the paroxysm; but this is exceedingly rare, and 
never, perhaps, under suitable treatment. 
Very generally the symptoms are much more moderate than as above 
described. They are said to be less severe when the attack occurs in the day- 
time. The duration of the paroxysm varies from a few minutes to several 
hours. In the morning, the patient often appears nearly well, except that an 
occasional cough may be heard, the croupy sound of which gives warning that 
the disease is not yet gone. There may also be some hoarseness of the voice, 
and, .if the fauces are examined, they may be found somewhat reddened. 
Should proper treatment be adopted, there may be no return of the paroxysm 
of dyspnoea; and the-child maybe restored to health. This result sometimes 
takes place even without treatment. But in general the cough and dyspnoea 
return, occasionally during the day, but more frequently in the following 
night, and often with symptoms more violent than at first. A similar course 
is run, though perhaps with a less complete subsidence of the symptoms; and 
for two, three, or four days, the disease continues, with occasional exacerbations 
and remissions, and with a more or less threatening aspect, according to' the 
degree of the accompanying inflammation. If this is moderate, it gradually 
yields, and along with it the spasmodic paroxysms, which become milder and 
milder, and at length cease to recur; the child being left with nothing but a 
catarrhal cough, which is of little consequence, and soon disappears. 
But often, especially when not properly cared for in the beginning, the 
course of the disease is less favourable. Sometimes the symptoms of pseudo- 
membranous croup supervene, indicated by a huskiness of the voice, gradually 
increasing until no sound can be uttered above a whisper. But this is very 
rare; and the greater violence of the disease depends simply on the greater 
severity or extent of ordinary inflammation of the air-passages. This fre- 
quently affects the bronchia; and then, along with the peculiar phenomena 
of croup, are those of catarrhal fever, such as a hot skin, an accelerated pulse, 
rapid respiration, frequent cough, and often pain or soreness of the chest, 772 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part ii. 
indicated by the crying of the infant after every paroxysm of coughing. 
When the- laryngeal or tracheal inflammation is severe, there are pain and 
soreness upon pressure, with occasional'swelling of the external parts, and 
constant difficulty of breathing, with sonorous or even sibilant inspiration, 
dependent partly upon swelling of the mucous membrane, and partly upon 
spasm of the muscular fibres. But the voice,, th ougff hoarse, is not suppressed; 
and the cough is sonorous. In .connexion with these symptoms, which are 
cdnstant, the. paroxysms of dyspnoea return with greater frequency and vio- 
lence than in milder cases. The Slightest cause, such as crying, attempts at 
speaking, drinking, mental emotion, &c., brings on the most distressing diffi- 
culty of breathing, with suffocative paroxysms' of Coughing, occasionally 
attended with vomiting, probably in consequence of the irritating movements 
of the fauces. If not .relieved, the patient may go off suddenly in one of 
these spasmodic exacerbations; or, after suffering inexpressible agony, may 
perish of a slower suffocation, with a-cold skin, clammy sweats, a feeble van- 
ishing pulse, and ultimate coma. 
If he survive, a new train of symptoms commences, which may be con- 
sidered as the second stage of the disease, and usually makes its appearance 
at the end of two or three days. It is the stage of secretion. The cough 
now sounds loose and more broken, especially towards the end of a paroxysm; 
and a portion of mucus is often thrown up, clear or tinged- with blood. • Should 
the attack be disposed to terminate favourably, the-paroxysms of coughing 
become .shorter and less severe, the inspiratory sounds acquire a mucous 
character, the cough loses its harsh ringing tone, and becomes quite loose, and, 
if the child be old enough to/expectorate, mucus is discharged freely, at first 
clear, then whitish and opaque, and ultimately purulent, exactly as in catarrh. 
The fever subsides, the croupy Symptoms quite disappear, and the child 
recovers completely, in a length of time varying from three or four days tp 
two weeks from the commencement. Sometimes, however, an excess of secre- 
tion beyond the ability of the patient, already greatly weakened, to throw off 
from the lungs, added to the embarrassment of the respiration from the laryn- 
geal and tracheal disease, brings "on a fatal defect of hmmatosis-. Not Unfre- 
quently, too, the bronchial symptoms become mingled with those of pneumonia, 
which adds greatly to the danger. Indeed, though the child occasionally 
perishes in a spasmodic paroxysm, death is generally occasioned, in this dis- 
ease, by supervening or accompanying bronchitis or pneumonia. Throughout 
the complaint, the stomach is usually remarkably insensible to emetic im- 
pressions, and the bowels are rather torpid than otherwise. After recovery, 
relapses are remarkably frequent. 
The physical signs are not very distinct. The stridulous respiration, accord- 
ing to Williams, may be detected by the stethoscope or ear applied directly to 
the throat, before it becomes sensible in the ordinary manner. • The sounds of 
the chest are obscured by the louder sounds of the larynx and trachea; but, 
if the patient be examined after the subsidence of a paroxysm, or during 
the relaxation which follows the operation of an emetic, the peculiar signs 
of bronchitis or pneumonia may generally be detected, if existing in a marked 
degree. 
Dissection exhibits redness of the mucous membrane of the larynx, trachea, 
and bronchia, either in patches or continuous, with occasional swelling of the 
submucous tissue from inflammatory infiltration, and more or less mucus in 
the air passages, which, if death has taken place early, is scanty, viscid, and 
adherent to the sides of the tubes, if in the more advanced stages, is more 
abundant, and often purulent. Occasionally patches of adhering false mem- 
brane may be detected, but insufficient to have had any agency in the fatal CLASS III.] 
PSEUDO-MEMBRANOUS CROUP. 
773 
result. In some rare instances, no signs of diseasp are discovered in the 
mucous membrane, and the patient has probably died of spasm, consequent 
upon high vascular irritation or congestion, the marks of which disappear 
with life. 
The prognosis in this variety of croup is almost always favourable, if treat- 
ment has been' commenced early, and no complications exist. In the vast 
majority of cases, -the disease may' be quickly arrested by proper curative 
measures in the first stages. Indeedjxit is often treated successfully in domes- 
tic practice; and very numerous cases occur to which the physician is never 
called. But, if the patient is neglected' until the inflammation has penetrated 
into the ultimate ramifications of the bronchia, or into the pulmonary tissue, 
or if the disease assume the pseudo-membranous form, the issue is much more 
uncertain, and not unfrequently fatal. 
2. Pseudo-membranous Group. - Pseudo-membranous pharyngo- 
laryngitis, or True croup. (Guersent.) Pseudo-membranous laryngitis. 
(Rillie'tet Barthez.) Laryngeal diphtheritisi--This variety of croup is, com- 
pared with the former, in this country at least, a very rare disease. It is, 
however, the form usually described by European writers under the name of 
croup; and it is important to bear this fact in mind in estimating the value 
of their statements. That such is really the case, will be inferred from the 
exceedingly fatal character which they assign to the disease. That by some 
of the best English authors, the two affections have been more or less con- 
founded in description, is true; but they must have had their eye fixed on the 
more dangerous variety, if we are to judge from their prognosis alone. Pos- 
sibly, the disease may present a somewhat different aspect in Great Britain 
from that which it offers with us, and may in all cases have a tendency to the 
more dangerous form. Some, recent French and German writers recognize 
the distinction clearly, and treat of our common disease under a distinct de- 
signation. Guersent calls false croup. 
Symptoms, Course, &c.-This affection begins variously. In some instances, 
it has the pseudo-membranous form from the very commencement; the occur- 
rence of the inflammation and of the exudation being, so far as can be ob- 
served, quite simultaneous. This is. not owing to any peculiar violence in 
the inflammatory act; for the grade of inflammation in these cases is, in fact, 
often very feeble, and sometimes, in the beginning, scarcely sufficient to induce 
fever. It is, as before observed, to the peculiar character of the inflamma- 
tion, or of the blood-, that the result is to be ascribed. I once attended the 
case of a little girl, who,, when first visited, was running about the apartment 
with no other apparent disease than a whispering voice, and perhaps some 
little difficulty of respiration; yet she was, at that moment, almost as surely 
condemned to death as' though she had been in the last stage of the disease; 
for the membrane was already formed, and no efforts could prevent its fatal 
progress. The disease may always be suspected, under such circumstances, 
when the voice cannot be raised above a whisper, when the cough is as it 
were muffled, when some wheezing in inspiration can be detected, and espe- 
cially when an examination of the fauces reveals patches, or a continuous 
coating of fibrinous exudation on the soft palate, half arches, or pharynx. 
But very frequently inflammation exists, and makes itself evident, before 
any considerable amount of plastic exudation has taken place. Indeed, the 
symptoms are sometimes at first exactly those of the catarrhal croup, and the 
difference is not detected until the voice begins to become whispering, and the 
cough to exchange its peculiar ringing or sonorous character for a husky 
sound. It may be said that, in these cases, the disease is the same, with the 
single exception, that a plastic instead of diffluent exudation takes place. But 774 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
it is this peculiar plasticity of the secretion that constitutes the very essence 
of the complaint; and the vast importance of the consequences certainly jus- 
tifies us in ascribing to the affection the rank of at least a distinct variety of 
disease. The occurrence of the changes above mentioned in the voice and 
the cough, though not certain signs, should always lead to the suspicion that 
false membrane is forming. 
In many cases, instead of being either fully formed at-the outset, , or of 
beginning like ordinary catarrhal croup, the complaint has an intermediate 
character. There is more or less cough, which is rough and hoarse, or 
hollow and of a grhve tone, but not peculiarly sonorous. It may even differ 
in no respect from a. common cough, when the disease does not happen to 
begin in the larynx. The voice, too, is hoarse; as in a common cold in an 
adult. But the symptoms soon become more characteristic. The voice 
gradually sinks into a whisper, above which it can scarcely be elevated by 
any efforts of the patient. The cbugh altogether loses whatever sonorous- 
ness it may have possessed, .and becomes husky, and as- it were stifled in 
the throat. Each effort of coughing (is often followed by a short, whistling 
or sibilant sound in inspiration. The cough sometimes occurs in spells or 
paroxysms, and,- though often frequent, is sometimes rare and at distant 
intervals. At length the breathing becomes difficult; every inspiration has 
more or less of the sibilant character, or sounds as if passing with difficulty 
through a narrowed and rigid passage. The voice is now whispering or 
quite extinct, and the effort to speak often' excites paroxysms of a muffled 
cough, attended with pain in the throat and upper part of the chest, with 
great dyspnoea, swollen and darkened features, anxiety, restlessness, jacti- 
tation, and feelings as of impending suffocation. These symptoms, though 
nevei- absent, relax for a time, to return with equal or increased violence 
from the slightest cause, and often without apparent causm . The child is 
afraid to speak lest he 'may thereby induce a paroxysm. Sooner or later, 
there is always some febrile action, and, when the inflammation is severe or 
extensive, it is very high. In all cases, the pulse is frequent, and towards 
the close excessively' so. The respiration is also quickened, sometimes to 
between forty and fifty in a minute. In the intervals of the paroxysms, the 
patient is disposed to sleep. ' Cases now and then occur, in which the 
spasmodic character is nearly wanting, and the disease marches directly on- 
ward to suffocation, almost without paroxysms. 
Should the case now take a favourable turn, the cough, instead of being 
perfectly dry and tight, sounds loose or broken, as if from the presence of 
liquid in the bronchia. Sometimes it produces on the ear an impression as if 
there were a concrete substance with one end loose, moving backward and 
forward with the motion of the air. If the child is old enough to expectorate, 
some viscid mucus is coughed up, either transparent or opaque, and occasion- 
ally mixed with flakes or patches, or even tubes of concrete fibrinous matter. 
It is not always, however, that this membranous substance is thrown up, even 
when it exists in the tubes. It is probably sometimes dissolved by the mucus 
or muco-purulent matter, and sometimes gradually absorbed, as we see the 
similar matter disappear, which is now and then thrown out upon the surface 
of the fauces. This sort of expectoration is said to occur in scarcely one-third 
of the cases. (JRilliet and Barthezd) It occurs especially after the action of 
powerful emetics. Sometimes the discharge of the false membrane gives 
great relief; and the patient goes on recovering with a gradual, or even sud- 
den amelioration of all the symptoms, though suppression of the voice, more 
or less complete, for a considerable time after recovery, is not uncommon. In 
other cases, however, after a partial amendment, the symptoms return with CLASS III.] 
PSEUDO-MEMBRANOUS CROUP. 
775 
all their former violence; the false membrane is renewed, and the little suf- 
ferer passes into the last and fatal stage of the disease. I have seen a relapse 
of . this kind, after the discharge of a tube about two inches long. 
The symptoms of the last stage, occasionally come on very early, even 
within twenty-four hours from the commencement of the attack. More fre- 
quently, however, they are postponed for three or four days, and sometimes 
considerably longer. This stage is characterized by the excessive difficulty of 
respiration. Along with complete suppression of the voice, and a perfectly 
tight and dry, though now comparatively infrequent cough, the inspiration is 
wheezing and sonorous, so that it may be heard at a considerable distance. 
The child uses his utmost efforts to expand the chest, and the respiratory 
muscles, are thrown into almost convulsive action. The shoulders rise, the 
breast heaves, the nostrils, expand and contract, the head is thrown backward, 
and the intercostal spaces may be observed to be pressed inward by the weight 
of the air, which finds, the ordinary entrance almost closed against it. The 
force of the respiratory effort is sometimes so great as to rupture the air-cells 
of the lungs, and even to make a rent between the rings of the wind-pipe. 
The child appears in an agony of distress. He throws himself about in bed, 
or jumps up and runs to the window for air, his face bearing, meanwhile, a 
most anxious, alarmed, and imploring expression. At length the powers of 
the system fail. The pulse becomes exceedingly quick and feeble, the skin 
cool and bathed in sweat, the cheeks pale and cold, the lips livid; and the 
former agitation at first alternates with, and then gives way to drowsiness or 
stupor. The brain and heart, no longer stimulated by arterial blood, cease 
to act, and the patient sinks gradually and quietly ayay; or the nervous sys- 
tem rouses itself for a last struggle, and death, takes place in the midst of 
convulsions. Not unfrequently, however, the patient is cut off, at an earlier 
stage, by suffocation in one of the paroxysms of dyspnoea. Instances of re- 
covery from the last stage are very rare. The duration of the disease varies 
from less than a day to one or two weeks. 
The symptoms vary at the outset with the portion of the air-passages first 
affected. When the larynx and trachea are first seized upon, the phenomena 
of the disease are as above described. But sometimes it begins in the bron- 
chia, and travels upward; so that the symptoms of bronchitis precede those 
peculiar to the croup. In other instances, the starting point appears to be in 
the fauces, or posterior nares, as we frequently see in ordinary catarrh. In 
such cases, there is sore-throat and some pain in swallowing, for a longer or 
shorter time antecedent to the laryngeal symptoms; and, if the fauces be 
inspected, a white or yellowish membranous exudation may be seen, diffused 
or in patches, upon the soft palate, half arches, and pharynx. Sometimes the 
whole fauces are thus covered. The first sign of the disease having reached 
the larynx is usually hoarseness of the voice and cough; and, after the occur- 
rence of these, the developement proceeds as above described. Bretonneau 
and Guersent believe that the disease begins in this way in the great majority 
of cases. It may be so in France; but is not so in this country, so far as 
my observation has extended; and does not appear to be so in Great Britain 
from the accounts of British writers. We have occasionally severe cases of 
croup, occurring during epidemics of scarlet fever; and now and then cases of 
diphtheritic sore-throat, such as have commonly been called ulcerated or ma- 
lignant sore-throat, which probably depend upon the same cause as scarlet 
fever, frequently at least, and like that, end in pseudo-membranous croup. 
But these affections differ from ordinary croup, whether catarrhal or pseudo- 
membranous, both in their origin and in some of their symptoms. They are 
generally attended with a low, typhoid, or adynamic state of system, not un- 776 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
frequently with a fetid breath, and sometimes with strongly malignant symp- 
toms. Their cause is usually either epidemic influence or contagion, neither 
of which is a cause of ordinary croup, unless perhaps when it attends influ- 
enza. In fact, their only resemblance to this affection is the presence of a 
pseudo-membranous exudation in the larynx. They come under the head of 
what some European writers call secondary croup, though, as appears to me, 
not very appropriately; for ordinary pseudo-membranous croup often follows 
an attack of catarrh, and might, under such circumstances, with equal propriety 
be,called secondary. After all that has been said,Jiowever, there is no doubt 
that ordinary croup of this variety occasionally begins by pseudo-membranous 
inflammation in the fauces; ,but such cases are the exceptions, and not the rule. 
Diagnosis.-The loss of voice and the. extinction of the sound in coughing, 
the appearance of albuminous or fibrinous exudation in the fauces, and the 
expectoration of patches or tubes of false membrane, are diagnostic symptoms 
of this variety of croup. The only certain one, however, is the • last. The 
suppression of the voice is sometimes met with in catarrhal croup, and false 
membrane in the fauces is, often absent in the disease, at least as it occurs-in 
this country; nevertheless, when the former symptom occurs at a somewhat 
early stage, and afterwards perseveres, with a steady march of the disease 
towards a state of extreme danger, there is little reason to doubt its pseudo- 
membranous character.. Barth and Roger state that a trembling vibratory 
sound may often be, heard in auscultation, during the ingress and egress of 
the air through the larynx and trachea, denoting the presence of floating false 
membrane. (Traite Pratique d'Auscultation.) This sign may be of some1 
value in the diagnosis. . . < 
It has been stated as essential to the constitution of croup, that the larynx 
should be more or less involved; Pseudo-membranous inflammation some- 
times attacks the- trachea, without in any degree-involving.the larynx. This 
is tracheitis, but not croup. There are fever, cough, pain, and soreness in 
the trachea, and gradually increasing difficulty of respiration; but, although 
the patient may ^peak low from pain, there is no extinction of the voice, nor 
croupy sound of the cough, nor whistling sound of inspiration such as follows 
the cough in genuine croup. The patient may expectorate a portion of false 
membrane and recover, or the disease may descend deeply into the bronchia, 
and bring on fatal suffocation. Sometimes the disease attacks the brorichia 
exclusively. The symptoms are then those of severe bronchitis, with more 
of stricture and suffocative sensation than in ordinary cases, and with the oc- 
casional discharge of pseudo-membranous matter after violent fits of coughing. 
Anatomical Characters.-False membrane is always found somewhere upon 
the free surface of the mucous membrane of the air-passages. According to 
Gruersent, it is never entirely absent in the larynx. It is sometimes confined 
to the glottis, sometimes lines the whole interior of the larynx, including the 
ventricles, and not unfrequently extends throughout the trachea, and for a 
greater or less distance into the bronchial tubes. I have seen a case in which it 
lined the upper portion of the bronchia, the whole trachea and larynx, and the 
pharynx as low down as the oesophagus. It occasionally reaches even the 
remote ramifications of the bronchial tubes. Sometimes the deposit forms 
perfect tubes, which, when removed, bear no inconsiderable resemblance, as 
suggested by Dr. Cheyne, to macaroni boiled in milk. More frequently, 
however, it is in patches, or long narrow ribbons, and occasionally, especially 
in the earlier stages, has a granular aspect, with the red mucous membrane 
appearing in the intervals of the imperfectly connected grains. In some 
instances, it adheres firmly, especially in the upper part of the tube; but it is CLASS III.] 
PSEUDO-MEMBRANOUS group. 
777 
frequently loosened by intervening mucus or muco-purulent secretion, in 
which the lower extremity sometimes floats loosely. 
The false membrane is sometimes thin and .delicate, more frequently thick, 
opaque, white or yellowish-white, and smooth on both surfaces. It varies 
much in consistence, being in general tough and almost leathery, id .some 
instances soft, and in some nearly diffluent towards the lower extremity. In 
the larynx, it is said to be less firm than in the trachea. In chemical nature, 
it is closely analogous to the fibrin of the blood, and to the exudation which 
takes place upon inflamed serous surfaces. It is dissolved by alkaline solu- 
tions and strong acetic acid. The question is not yet settled, whether this 
matter is susceptible of organization. Generally the false, membrane shows 
no sign of such a condition. It is said to'have been found partially organized 
in some rare cases; and Some .persbns consider certain red points and lines 
upon its adhering surface, which cannot be washed off, to be the commence- 
ment of vascularity. 
In the cases associated with other diseases, as small-pox, scarlet fever, &c., 
the false membrane is usually yellowish; less firm than in the original cases, 
less adherent, and often associated with considerable mucus or pus. It sel- 
dom extends, unless in small quantity, below the larynx. 
When the deposit is removed, the mucous menibrane beneath it, though 
sometimes quite healthy in appearance,, and seldom exhibiting the marks of 
severe inflammation, is commonly reddened either partially or generally; and 
the red points and streaks correspond with those upon the separated surface 
of the false membrane. Sometimes, though rarely, the mucous membrane is 
softened, and still more rarely'thickened. The bronchial tubes are usually 
more-or less extensively reddened, and contain an opaque whitish, greenish, 
or yellowish puriform mucus, sometimes in large quantities. Signs of lobular 
pneumonia, and an emphysematous condition of the pulmonary air-cells, are 
not unfrequenti 
Causes of Croups-The 'most common cause of this disease in all its forms, 
certainly in its ordinary catarrhal form, is cold, or cold combined with damp- 
ness. 'The disease is said to prevail most in moist places. It is frequently 
brought on by the sudden passage from hot to cold air, and in infants is pro- 
bably often occasioned by sleeping in very cold chambers, after having been 
all day in hot rooms. Irritating substances inhaled into the lungs have 
sometimes caused it. Foreign bodies lodged in the larynx give rise occasion- 
ally to closely analogous symptoms. 
Among the predisposing causes, age appears to have the greatest influence. 
The disease is not positively confined to any period of life; but it is exceed- 
ingly rare in adults, and is seldom seen in very early infancy. From one to 
seven years is the age at which it is most prevalent; though cases are not very 
uncommon at any period before puberty. The catarrhal variety probably 
occurs at an earlierage than the pseudo-membranous; and the cases in infants 
less than a year old are generally of the former kind. The pseudo-membranous 
cases which have come under my observation have almost always been between 
the third and sixth year. It is probable that the change of diet, after wean- 
ing, may contribute to render the blood more favourable to the plastic exuda- 
tion. The structure of the larynx in children probably disposes to the spas- 
modic phenomena; but we are to look for the main cause of these rather in 
the more excitable condition of the nervous system generally at that age, than 
in any local cause. When persons in advanced life are attacked with croup, 
it is generally of that variety which attends the diphtheritic disease of the 
fauces, and is produced by epidemic influence. 
Sex appears to have some causative powers, at least as relates to pseudo- 778 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
membranous croup; for this has been observed to be much more common in 
males than females. The disease sometimes, appears to run in families. All 
the children of certain parents are peculiarly predisposed to it, while those of 
others escape. Vigorous and fleshy children, with rosy complexions, are said 
to be most frequently affected. • 
The disease. has also been ascribed by some writers to epidemic and con- 
tagious influence. But, if we except the cases which are apt to occur during 
the prevalence pf epidemic catarrh, it is/Only to the diphtheritic disease of 
Bretonneau that this remark is;applicable. Original, uncomplicated croup is 
probably never either epidemic or contagious. 
Certain febrile -diseases strongly predispose to one or the other form pf 
croup. The influenza and measles are often attended with the catarrhal 
variety; scarlatina'and small-pOx with the pseudo-membranous. 
Treatment of Catarrhal ■ Croup.-The treatment in this disease should 
always be prompt and decided. It is impossible, from the first symptoms of 
croup, to determine', in any case, that it will be harmless. Should it be mild 
in its tendencies, it will probably yield at once • to the moderate measures 
which are first employed in all cases, and no injury can result. Should a 
disposition to pseudo-membranous effusion exist, a prompt interference affords, 
in many instances, the only chance of safety. 
So soon as croupy cough and dyspnoea occur, an emetic should be adminis- 
tered without hesitation. In this disease it is often difficult to vomit, and 
larger doses are usually required than under ordinary circumstances. The 
choice of the emetic should depend on the degree of violence in the symptoms. 
When these are mild, with little or no fever, ipecacuanha should be given; 
when they are severe or decidedly febrile, tartar emetic is preferable. One 
of these will generally answer the purpose. To a child two years old, from 
four to six grains of ipecacuanha, or from one-quarter to one-third of a grain 
of tartar emetic, may be given diffused or dissolved in water, every fifteen, 
twenty, or thirty minutes, until vomiting is produced. Tartai' emetic is the 
more efficient of the' two, because more nauseating and consequently relaxing, 
more sedative, and more powerfully revulsive. It should always be preferred 
in doubtful cases, or at least should be combined with the ipecacuanha. Should 
the emetic not be at hand in substance, one of its .officinal preparations may 
be resorted to; as the wine or syrup of ipecacuanha, in the dose of a fluidrachm 
of the former and two fluidrachms of the latter, or antimonial wine in the 
dose of a fluidrachm. I have seldom had occasion to employ any other emetic 
than these in the early stages. Others, however, are occasionally used. Dr. 
Archer, of Maryland, recommended seneka, urged to the point of emesis. 
There is no doubt that this medicine exercises a powerful alterative influence 
over the respiratory mucous membrane, and is, therefore, capable of doing 
good independently of its merely emetic property; but, in reference to this 
alterative power, I have always considered it more applicable to the advanced 
than to the earliest stages. Nevertheless, this remedy combined with squill 
and tartar-emetic, in the form of the officinal compound syrup of squill, more 
commonly named, after its original inventor, Coxe's hive syrup, is much 
and advantageously employed, both in regular and domestic practice, in all 
stages of croup. Thirty or forty minims may be given to a child two years 
old, and repeated at short intervals till it vomits. Dr. Hubbard, of Hallowell, 
in Maine, strongly recommends turpeth mineral, which, while scarcely less 
efficient than the antimonial, he considers safer, as less prostrating, and less 
disposed to act bn the bowels. He gives two or three grains to a child of 
two years, and repeats the dose every fifteen minutes till it operates. (Trans, 
of Phil. Col. of Phys., A. D. 1845, p. 332.) CLASS III.] 
CATARRHAL CROUP. 
779 
Should the emetic not be disposed to act, it. will be much aided by a warm 
bath, in which the whole body should be immersed,.the water being warm 
enough to relax, but not so hot as, to stimulate. About 98° or 100° will be 
a suitable temperature. The immersion should continue fifteen or twenty 
minutes, or even half an hour if necess'ary. Great care must be taken that 
the skin of the child be not exposed to cold air during the process. When 
removed from the bath, he • should be wrapped for a time in a warm blanket, 
and wiped dry with a heated towel. Even after emesis, if the symptoms 
should not have given way, the bath may be resorted, to;■ and in all stages of 
the disease, except the last, it constitutes one of the legitimate means for 
overcoming spasm in the paroxysms. 
After vomiting, the child is often greatly .relieved. The spasm relaxes, 
the breathing becomes easy and quiet, the voice loses much of its hoarseness, 
and the patient falls into a gentle sleep, from which he awakes much im- 
proved, if not well. In mild cases, the cure is now frequently accomplished. 
From my own observation, I should say that the great majority of cases will 
yield to this simple treatment; nothing inore being subsequently necessary 
than to open the bowels, if not already loose', by a dose of castor oil, and to 
sustain a slightly nauseating, or expectorant effect by small doses of antimo- 
nial or ipecacuanha wine, or the compound syrup of squill, given at intervals 
of two, three, or four hours, and continued till the croupy cough ceases, and 
the danger of another paroxysm is passed. But a caution is necessary to 
inexperienced practitioners, in relation to the use of tartar emetic, under 
these circumstances. If too largely given, or tooMong continued, it may pro- 
duce great and even fatal prostration. I have,witnessed a case of death in an 
infant, resulting from repeated doses of < antimonial wine, directed by a prac- 
titioner after-a paroxysm of 'croup, without any reference to the time or cir- 
cumstances of its omission. The parents continued to repeat the dose until 
the child was prostrated beyond recovery. The stools were in this instance 
white, as in malignant cholera. Directions should always be Ibft to omit the 
antimonial if it purge, or otherwise prostrate much, and whether or not, 
provided the croupy symptoms quite disappear. 
But, in many instances, the spasmodic symptoms resist the action of an 
emetic, or return after a shorter or longer interval of comparative relief. This 
is very apt to be the case when there is considerable inflammation. In such 
instances, if the pulse is full and vigorous, it is proper to bleed from the arm. 
The quantity of blood taken should be regulated by the effects produced. It 
is desirable that the pulse should be reduced, but not to the point of syncope. 
From two to five ounces may be taken from a child two years old, and some- 
what less than an ounce be added for each year. Dr. Cheyne recommends 
bleeding from the jugular vein, in very young children. Should the bleeding 
not afford the requisite relief, the emetic with or without the warm bath may 
be again resorted to. Should this fail, a very efficient remedy remains in 
tobacco, which may be applied, in the form of fomentation or cataplasm made 
from the leaves, upon the front of the throat. I have seen this of great use 
in very severe cases of laryngeal spasm. But it is necessary to be guarded 
in its use, especially in children, and to remove it as soon as its relaxing 
effects have been obtained. Dangerous prostration may result from a neglect 
of this precaution. The remedy is one which should never be employed in 
domestic practice, and should generally be applied under the immediate super- 
intendence of the physician. It should never be placed upon a blistered sur- 
face. The internal use of lobelia is here also highly serviceable; and, when 
a powerfully relaxing effect is required, it may be combined, in powder or 
tincture, with one of the emetics already mentioned. 780 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
The above treatment is adapted to the paroxysm. It scarcely ever happens 
that this does not give way, however violent it may be, if the case be not 
pseudo-membranous, to some one of the remedies mentioned, or some com- 
bination of them. After the spasmodic paroxysm has been subdued, or has 
subsided, the treatment must be guided altogether by circumstances. If the 
croupy symptoms have disappeared, and only a cough, with moderate catarrhal 
symptoms remain, the treatment before mentioned as proper after the sub- 
sidence of the paroxysm may be adopted. But it often happens that, though 
the violent spasmodic symptoms give way, there are yet considerable inflam- 
mation and fever, with some cough and dyspnoea, threatening- a return of the 
paroxysms. Under these circumstances, it will be proper to administer a full 
purgative dose of calomel, which should be followed in a few hours by castor 
oil. Three or four grains of the mercurial may be given to a child two years 
old. Few remedies are more efficient in the relief of infantile, catarrh than 
this. The patient'may at the same time be kept moderately under the influ- 
ence of antimony,, ipecacuanha, or seneka, or combinations of them; and 
advantage will occasionally accrue from warm poultices to the feet, .made of 
bruised garlic, mixed with the bread and milk or flaxseed meal cataplasm. 
If, in connexion with the cough and febrile symptoms, there should be 
considerable difficulty of respiration, a hoarse dr sibilant sound during in- 
spiration, or evidences of pain in the throat or chest, leeches are an admirable 
remedy. It is. always best to make use of our native leeches, as there is with 
them less subsequent bleeding, and we are better able to regulate the quantity 
of blood lost. Dangerous and even fatal prostration has sometimes resulted 
from the difficulty of arresting the hemorrhage, consequent upon the bite of 
the European leech, in very young children. The leeches should be applied 
upon the throat, or upper part of the chest, according to the apparent seat of 
the severest inflammation. Great care should be taken, during their appli- 
cation, that the skin of the child be not chilled by wet and exposure. In 
young infants, leeches may be employed as a substitute for the lancet. In a 
child of two years, from twelve to twenty-four leeches may be applied, so as 
to take from two to four ounces of bldod. After leeching, an emollient cata- 
plasm should be applied to the chest or throat, or to both. This is often 
highly useful in inflammation of the air passages. 
Should paroxysms recur with the original or increased violence, it will be 
necessary to go through the same routine of remedies as at first; viz., an 
emetic, the warm-bath, bleeding once more if the pulse will permit, and the 
tobacco cataplasm; recourse being had to the latter remedies only when the 
former fail. Bleeding in this stage must be used with more caution than at 
first. It is scarcely probable that the bronchial inflammation can be resolved 
without a great increase of secretion; and there may be danger that the 
strength may be reduced so far as to disable the- child from coughing up the 
mucus, which would thus overwhelm the lungs, and produce suffocation. 
After the subsidence of the more violent inflammatory symptoms, counter- 
irritation to the throat and chest, by means of blisters or active rubefacients, 
will often be very useful in removing the remains of the inflammation, and 
the tendency to a recurrence of the spasm. Rubefaction may be produced 
by mixtures of the oil of turpentine or solution of ammonia, or both, with 
olive oil, spirit of rosemary, camphor, &c., or by means of a cataplasm con- 
taining a proportion of mustard or garlic. If flies are used for blistering, 
they should not be allowed to remain in contact with the skin longer than 
three or four hours, and should then be followed by a poultice. If a power- 
ful and very speedy impression is desired, it may be made with the strong 
solution of ammonia, which, however, should be used with great caution. CLASS III.J 
PSEUDO-MEMBRANOUS CROUP. 
781 
If the physician should not be called until the disease has entered into its 
advanced stage, and the peculiar symptoms should then be more or less con- 
tinuous, such as dyspnoea,, the croupy cough and voice, high fever, and signs 
of considerable or extensive inflammation in the respiratory passages, he 
should at once take blood as freely as the pulse and general strength may 
allow,-and, if doubtful about bleeding, should substitute leeching, with the 
same caution. Emetics^ the warm bath, calomel as a purge, and the steady 
use of antimonials in moderate doses, repeated at short intervals, should 
follow successively; and, in case of severe spasm, tobacco externally, and 
lobelia with decoction of syrup of seneka internally, may be superadded. 
After the employment 'uf the above remedies unsuccessfully, an attempt 
should be made without hesitation _to bring the system under the influence of 
mercury; and, for this purpose, one grain pf calomel may be given every two 
hours, united, if it purge, with a little Dover's powder-; and mercurial fric- 
tions may also be made to the inside of the upper and lower extremities. 
It very seldom happens that a patient with catarrhal croup may not be 
rescued by some of the above remedies, if timely applied. But it may hap- 
pen that no medical aid is obtained Until the disease is already in its last 
stage; or the means may have been inefficiently employed; or finally, in 
some few instances, the tenacity of the. complaint may have been such as to 
resist the best directed measures. The system is now too much enfeebled 
by the carbonaceous state of the blood, and the. exhausting influence of the 
disease; to admit of depletion^ The lungs are overwhelmed with the mucous 
or purulent secretion, which the sufferer is unable to discharge, and suffocation 
is threatened every moment. Now it is that the neiwous stimulants, and 
stimulating expectorants are to be employed, while our antiphlogistic efforts 
must be confined to external revulsive measures. Decoction of seneka, assa- 
fetida by the mouth and rectum, carbonate of ammonia, valerian, musk, oil 
of amber, wine-whey, animal broths, and sometimes a little weak milk-punch, 
may be employed; the activity of the remedies being graduated according to 
the debility of the patient. An emetic may sometimes be employed advan- 
tageously even in this stage. It proves useful by aiding in the expectoration 
of the pulmonary secretion. But some substance should be selected which 
operates without producing prostration. Mustard, sulphate of zinc, or sul- 
phate of copper, will best answer this indication. Externally, garlic and 
brandy may be applied warm to the breast and spine; and liniments or cata- 
plasms of oil of turpentine, mustard, Cayenne pepper, ammonia, &c., may be 
resorted to, if necessary, to aid in the support of the system, until the offend- 
ing cause is removed, or reaction established. 
Treatment of Pseudo-membranous Croup.-In the forming stage of the 
disease, when it is still doubtful what may be the nature of the secretion, the 
treatment differs in no respect from that above detailed as applicable to the 
catarrhal variety. It is here only necessary to treat of the measures to be 
employed, after it has become obvious that the case is truly pseudo-mem- 
branous. In the first place, if, upon the occurrence of hoarseness and other 
symptoms of commencing croup, the fauces should be found covered with a 
coating of false membrane, recourse should be had immediately to cauterization 
by nitrate of silver, powdered alum, or muriatic acid, as recom'mcnded by Bre- 
tonneau. (See Pseudo-membranous Inflammation of the Fauces,]). 498.) The 
nitrate of silver is generally preferred, and a solution may be employed, varying 
in strength from two scruples to two drachms to the fluidounce of distilled 
water. The weaker solutions must be used several times a-day, the stronger 
require to be applied once daily. The application should be extended to the 
borders of the glottis, which may be effected by means of a small piece of 782 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
sponge fixed to a slender stick of whalebone, somewhat curved near the end. 
There may be some hope of arresting, in this way, the inflammation as it 
passes downward. It was formerly thought that, after the exudation had 
formed in the larynx, it would be useless to attempt the cure by cauterization; 
but experience seems to have shown that this cavity maybe penetrated, with- 
out serious inconvenience, even in the infant; and cures have been effected 
apparently by this measute in several instances.* 
Depletion, in this variety of croup, is ' much less efficient than in the 
Catarrhal. The nature of the exudation does not depend upon the violence 
of the inflammation, but upon its peculiarity -or that of The blood, and this 
peculiarity is not modified by bleeding. This remedy has no effect in remov- 
ing the false membrane already formed. The utmost that can be effected by 
it is to moderate the severity of the inflammation, and thus possibly diminish 
the amount of effusion. But there are many cases in which it is borne very 
badly. Such are those associated with scarlet fever, and epidemic diphtheritis 
or pseudo-membranous angina. The inflammation is here decidedly peculiar, 
and is scarcely diminished by bleeding, which, besides, endangers fatal pros- 
tration. The rule for the use of bleeding, in pseudo-membranous croup, is 
to proportion it as exactly as possible fo the violence of the inflammation, and 
the vigour of the patient; regard being always had to the preservation of 
sufficient strength for those efforts, which will be necessary for the discharge 
of the offending matter from the air-passages, without which recovery can 
seldom take place. It should never be employed in low cases, nor in the last 
stage of the disease. Leeching is generally preferable to bleeding; as an 
equal amount of blood taken in this way has a greater influence on the' local 
affection. I have seen bleeding pushed far in this variety of croup; but 
never, after the membrane had been clearly formed, with any obvious effect 
in ameliorating the symptoms. If it is to do good, it must be resorted to 
before the exudation has become extensive. Nor can much benefit be ex- 
pected from blisters,'except sometimes to the chest, in order to moderate 
bronchitis and prevent pneumonia. In the diphtheritic variety, the blistered 
surface is much disposed to slough. 
The indications in the treatment of pseudo-membranous croup are, to pre- 
vent the further formation of false membrane; to effect the dissolution, ab- 
sorption, or separation of that already fdrmed; and to favour its expulsion. 
The most effectual method of meeting the first indication, after any violence 
of inflammatory excitement that may exist has been moderated by bleeding, 
is, beyond all comparison, to bring the system as speedily as possible under 
the mercurial influence. This, more than any other known means, modifies 
the peculiar nature of the inflammatory process, and consequently the charac- 
ter of the secretion, which, from being plastic, becomes mucous or puruloid 
and diffluent. This plan of treating croup originated with American prac- 
titioners. Dr. Rush recommends the use of calomel freely in his Medical 
Inquiries. It has subsequently been pushed to an enormous extent in some 
parts of Europe. Three hundred grains are said to have been given in 
twenty-four hours. But this heroic practice is quite unnecessary. Only a 
certain amount of the medicine, after entering the stomach, can find access 
into the general system; and the remainder lies inert, or nearly so, in the 
bowels. It will be sufficient to administer to a child from two to four years 
old, first a purgative dose of four or six grains, and afterwards to follow this 
* See communications by Dr. Wm. N. Blakeman, in the N. Y. Journ of Med., viii. 209; 
by Dr. Charles E. Ware, in the Eoston Med. and Surg. Journ., xxxvii. 417; and by Dr. 
James Bryan in the Medical Examiner, N. S., iv. 342. CLASS III.] 
PSEUDO-MEMBRANOUS CROUP. 
783 
by from one to three grains every hour or two. I am not certain that the 
end would not be better accomplished, after effectual purgation by the first 
dose or doses, by giving a fraction of a grain, say one^quarter, or one-half of 
a grain, every half hour. It would thus be less apt to purge, and more apt 
to be' absorbed. After the production pf green stools by it, further purga- 
tive effect should be avoided; and, should it then disturb the bowels, it should 
be combined with minute doses of the powder of opium and ipecacuanha. 
Its operation may be aided by mercurial frictions. Should any effect upon 
the mouth or salivary organs be observed, the remedy should be suspended. 
In young children, however, it very seldom salivates. Jt is said, in some 
cases, to. have produced gangrenous, ulcers in the -mouth, and necrosis of the 
jaw-bones. I have not witnessed these effects; but, in cases of the desperate 
character of pseudo-membranous croup, a remedy must not be rejected on 
account of some hazard from its use. It should be employed with great cau- 
tion in children of very feeble health, or of a scrofulous habit. Theory as to 
its mode of action is useless, in the present state of positive knowledge on 
the subject. It not only so modifies-the secretory process as to prevent the 
production of false membrane, but by causing a liquid secretion, favours the 
separation and possibly the solution of that already existing, and thus meets 
the second indication. It may even promote the absorption of the adhering 
exudation. There is every reason to believe that this process occasionally 
takes place; for cases having all the characters of pseudo-membranous croup 
get well, without tire expectoration of false membrane; and dissection some- 
times shows that portions of the exudation have been removed. We can 
sometimes even see the process going Qn, in the diphtheritic disease of the 
fauces. 
To meet the same indications, the alkalies have been strongly recom- 
mended by some writers. They have been thought to dispose, -like mer- 
cury, to mucous rather than to fibrinous secretion, and even to dissolve the 
secreted membrane, as they are known to do out of - the body. The sulphu- 
ret of potassium, proposed by the author of a prize essay upon croup in 
France, had at one time the reputation almost of a specific; but has since 
fallen into' neglect. Some cures, however, asserted to have been effected by 
it are on record. It may be given in doses of from one to four grains every 
three or four hours. In overdoses it purges and vomits, and may produce 
dangerous effects. In reference merely to their alkaline properties, the car- 
bonate or bicarbonate of potassa, soda, or ammonia would be preferable. I 
cannot speak of the effects of these medicines in croup from my own obser- 
vation. 
Along with the mercurial, expectorant medicines should be given freely, to 
promote the loosening of the false membrane. Of these, tartar emetic and 
seneka are the most efficient; and they should be pushed as far as the pa- 
tient's strength will admit. 
To favour the expulsion of the membrane, which is the last indication, 
emetics are the most efficient remedies. Of these, ipecacuanha, tartar eme- 
tic, sulphate of zinc, and sulphate of copper, have been proposed. When the 
strength is considerable, the action decidedly sthenic, and the inflammation 
of a high grade, tartar emetic is the best; but, in the advanced stage, when 
the strength has begun to fail, sulphate of copper, or perhaps turpeth mine- 
ral, as proposed by Dr. Hubbard, would be preferable. Sulphate of copper' 
has been highly applauded by some German practitioners, both as an emetic 
and alterative. It was introduced into use in croup by Hoffmann. I have 
seen it apparently very effectual in promoting the discharge of the false mem- 
brane. The dose as an emetic, for a child two Qr three years old, is half a 784 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
grain or a grain, repeated every fifteen minutes till it operates, after which 
one-quarter of a grain may be given every two hours. Alum, originally pro- 
posed by Dr. C. D. Meigs as an emetic in croup, is strongly recommended 
by his son Dr. J. Forsyth Meigs, upon the faith of frequent and advantageous 
trial. A teaspoonful of the salt, in powder, is to be given in honey or syrup, 
every ten or fifteen minutes till it operates. It is rarely necessary to give 
the second dose. One prominent advantage is that the emetic effect may be 
obtained several times a-day, without exhausting the patient. (Practical 
Treatise on the Diseases of Children, by J. Forsyth Meigs, _p. 46.) In rela- 
tion to the general* results of the emetic treatment in pseudo-membranous 
croup, it is stated by M. Valleix that of fifty-three cases treated upon this 
plan, fifteen were cured; whilst of twenty-two cases in which emetics were 
omitted, or parsimoniously used, only one recovered. Of thirty-one treated 
by energetic emetics, twenty-six discharged false membrane through the effort 
of vomiting, and fifteen were cured. (RilUet and Barthezh) 
Sternutatories have been proposed in order to favour the expulsion of the 
false membrane, and may be tried. The same end is asserted to have been 
successfully attained by fthe affusion of cold water upon the. whole posterior 
surface of the trunk. The remedy was proposed by Harder, and has been 
recommended by other German practitioners. It operates by the shock pro- 
ducing a powerful reaction. It is, however, applicable only to desperate cases. 
The water should be of the temperature of 53° to 55° F. 
Reference has already been made to the cauterization of the larynx by solu- 
tion of nitrate of silver. After an unsuccessful employment of other means, 
the practitioner would certainly be justified in resorting to this measure. 
In the last stages, when the strength has become exhausted, our hopes must 
rest upon stimulants. The only chance from medical treatment is now to 
support the strength, in the hope that the false membrane may be sponta- 
neously loosened and discharged. The remedies to be used are carbonate of 
ammonia, wine-whey, weak milk-punch or egg beat with wine, and spirituous 
fomentations externally. To quiet the extreme agitation of the patient, and 
give the other means employed opportunity to act more efficiently, it will 
be proper to place the system under the influence of antispasmodic and ano- 
dyne remedies, such as assafetida and opium, which may be .conveniently 
given by injection. This practice was successfully resorted to by Dr. Isaac 
Parrish, in a case recorded in the Transactions of the College of Physicians 
of Philadelphia (vol. ii. p. 277). 
As a last resort, in cases otherwise desperate, tracheotomy may be employed. 
This operation has been frequently performed by Bretonneau, Trousseau, and 
other French practitioners, and not without considerable success. Of twenty 
cases, Bretonneau saved six; and out of one hundred and twelve operations 
performed by Trousseau, twenty-seven were successful. In a memoir by 
Trousseau it is stated that, out of one hundred and fifty operations performed 
by different practitioners, thirty-nine ended favourably. But M. Trousseau 
recommends that the operation be performed so soon as it is satisfactorily 
established that the false membrane has formed in the larynx; and, in such 
cases, many cures might be cited which have been effected by medical treat- 
ment. It is, therefore, very difficult to determine upon the real value of the 
operation. If postponed until the case is otherwise quite desperate, it offers 
very slender chances of success; if performed at an earlier period, it saves 
life, but possibly may do no more than can be accomplished in an equal 
proportion by other means. Besides, in order to obtain its most favourable 
results, a degree of skill in operating is required, which is not to be found in 
practitioners generally. M,. Trousseau finds necessary to success, the appli- CLASS III.] 
SPASM OF THE GLOTTIS. 
785 
cation of topical remedies, such as the solution of nitrate of silver to the 
trachea, through the opening made into it, and moreover employs mechanical 
means to aid in removing, through the opening, the membranous matter which 
may exist in the windpipe. For detailed, information on all points relating 
to tracheotomy in croup, the reader is referred to Memoirs by M. Trousseau 
in the Dictionnaire de Medecine (ix. 381), and in the treatise of MM. Rilliet 
and Barthez, on the diseases of infants (i; 367). The operation of tracheotomy 
has recently been successfully performed in an apparently desperate case by 
Dr. Jos. Pancoast, of Philadelphia. (See Transact, of Col. of Phys. of Phi- 
lad., vol. ii. p. 276.) 
General Point's of Treatmenf-^The, patient with croup should be confined 
to bed, should have flannel next his skin, and should be kept in the same 
temperature day and night. Great caution should be exercised, in the use of 
fomentations, cataplasms, leeches, and the warm bath, not to expose the skin 
while moist to .the air. The diet should be' farinaceous ,and mucilaginous, in 
the stage of highest excitement; when strength is wanted, milk may be em- 
ployed; and, in the lowest cases, animal broths, jellies, &c. To prevent 
relapses, the.clothing should be warm, and the child should not be transferred 
from a warm room in the day to a cold one at night. The custom of leaving 
the arms and breasts of infants uncovered is too great a sacrifice tQ fashion or 
to vanity. In children predisposed to the disease, the plan maybe tried of 
gradually accustoming the skin to the impression of cold, by washing the 
shoulders and breast with water of the temperature of the air, beginning in 
the warm season, and continuing into winter, and taking care to avert any 
present unpleasant,effect by wiping the part dry with a towel, and bringing 
about reaction if necessary by friction. When families are thus predisposed, 
especially to the more fatal form of croup, it may be advisable to remove to 
a mild and dry climate. 
SUBSECTION IL 
NERVOUS OR FUNCTIONAL DISEASES OF THE RESPIRATORY PASSAGES. 
Article I. 
LARYNGEAL NERVOUS DISEASE. 
1. Infantile Spasm of the G-lottis.-Laryngismus Stridulus (Good). 
- Crowing Disease.-Inward Fits.-Spasmodic Croup.-Thymic Asthma. 
-Millar s Asthma.-This disease, though similar to catarrhal croup in some 
of its symptoms, is essentially distinct in the circumstance, that it is purely 
nervous, and altogether independent of vascular irritation or inflammation of 
the larynx. There is much unfortunate confusion in its nomenclature. The 
description by Dr. Good of his laryngismus stridulus, though the name has 
been adopted by several writers for the disease in question, obviously also 
embraces catarrhal croup in some of its less inflammatory forms. The name 
of spasmodic croup is altogether inapplicable, as the disease is not croup at 
all. Asthma, however qualified by epithets, is equally inappropriate; as that 
is the name for a pectoral affection, while this complaint resides in the larynx. 
Inward fits is a vulgar title of the disease. The affection is usually charac- 
terized by a shrill sound in inspiration, somewhat like the crowing of a cock, 
which has given origin to the name of crowing disease. The sound is supposed 786 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
to be owing to a spasmodic contraction of the chink of the glottis; and the 
complaint is confined to infancy and very early childhood, occurring at any 
time from a few days after birth to the end of the third year, but most fre- 
quently during the first dentition. Hence the name at the head of this article. 
Symptoms.-The attack is sudden, and may occur at any time, though it 
is most frequent during sleep, from which the child awakes with a start, and 
in great apparent alarm. He is seized with inability to inhale the air; and 
the first symptoms are those of a struggle for breath, with the head thrown 
back, the breast elevated, the nostrils expanded, the mouth open, and all the 
muscles of inspiration in* almost convulsive action. The veins of the neck 
and head are distended; and the countenance is flushed, swollen, and purplish, 
or of a pale cadaverous hue, with an expression of extreme anxiety and dis- 
tress. At length, but occasionally not until symptoms of asphyxia appear, 
the spasm of the glottis somewhat relaxes, and the air rushes in, with a shrill, 
whooping sound. The child then usually begins to cry, and, after a short 
period of hurried breathing, returns to his previous health. But the stridu- 
loUs sound during inspiration is not absolutely essential; for it sometimes 
happens, that the spasm, instead of yielding partially, relaxes at once and 
completely, so as to alldw the air to enter quietly. Not unfrequently, along 
with the difficulty of inspiration, there is a spasmodic contraction of the fingers 
and toes; and the paroxysm is sometimes followed by general convulsions. 
When the attack is over, the child is free'from all symptoms of disease of the 
throat. Occasionally only a single paroxysm occurs at first, and the disease 
does not return for weeks. But the interval is often much shorter; and, in 
bad cases, the attacks take place several times a-day, increasing in duration 
and frequency, until they occupy a quarter or half an hour at a time, and 
sometimes scarcely have an appreciable intermission between them. 
The complaint is usually unattended with cough, fever, bronchial disease, 
or any appreciable inflammation of the larynx or trachea. By the absence of 
these affections it may be readily distinguished from croup. 
Though often a trifling disease, it is sometimes far otherwise. In some 
instances, the child perishes with asphyxia from the persistence of the spasm. 
The interruption of respiration, when the fits are frequent, gives rise to a 
degree of cerebral congestion, which sometimes produces convulsions, or other 
serious morbid phenomena. But in general, the complaint, when alarming, 
is so merely as a sign of serious disorder elsewhere. It is often rather a 
symptom than itself a disease. Though considered by some writers as of 
frequent occurrence, it has been rare within the observation of the author. 
M. Herard, who saw much of the disease in the Children's Hospital at 
Paris, asserts that no characteristic morbid condition can be discovered after 
death. The emphysema, which he uniformly noticed, is an effect and not a 
cause. By this writer, spasm Of the diaphragm is considered as sometimes 
forming an essential part of the affection, being the cause, in all cases, of the 
peculiar sonorous inspiration by which the disease is characterized, and which 
he states to be occasionally present without the spasm of the glottis. (Med. 
Times, Nov. 6, 1847.) 
Causes.-The disease appears sometimes to depend upon a general morbid 
excitability of the nervous system, directed especially to the muscles of the 
glottis, which contract spasmodically from slight causes, such as the sudden 
contact of cold air, any quick unexpected movement, or vivid mental emotion, 
especially fright. Hence infants are sometimes attacked with it, when tossed 
playfully in the air. The act of swallowing occasionally brings on an attack. 
This morbid nervous irritability is most frequently owing to dentition; but it 
may also be produced by other causes which deteriorate the general health, CLASS III.] 
SPASM OF THE GLOTTIS. 
787 
such as impure and confined ajr, and unwholesome food. Attacks may be 
brought on by sources of irritation in the intestines, including undigested food, 
acidity, acrid secretions, and worms. In some instances, the disease is asso- 
ciated with, and probably dependent on, affections of the brain, and is con- 
sidered by some as one of the earliest signs of hydrocephalus. It has also 
been ascribed to inflammation of the cervical portion of the spinal marrow, 
and to tumours pressing on the par vagum, or the recurrent nerve, which 
regulates the movements of the glottis. Thus, it has appeared to arise from 
enlarged,absorbent glands in the neck; and the thymus gland has been found 
of unusual , magnitude in some fatal cases.. Some authors consider the latter 
as among.the chief causes of the complaint, which has therefore been named 
thymic asthma. ■ ; ' . z ■ 
Treatment.-It is sometimes highly important to relax the spasm of the 
glottis, at the commencement of the paroxysm, so as to prevent asphyxia. 
This may generally be accomplished by dashing cold water upon the face or 
shoulders, gently1 slapping the back, or blowing into the ear. When the 
spasm recurs frequently, it may often be prevented by the warm bath, nau- 
seating medicines, and antispasmodics injeOted into the rectum. Should the 
symptoms be alarming, tobacco should be applied'to the throat in the form of 
a cataplasm. It is said also to have proved very effectual in the form of 
enema, prepared with five grains of the tobacco and a fluidounce of hot water. 
Should the danger of death from asphyxia appear imminent, and no other 
remedy have proved : availing, recourse should be had to tracheotomy, which 
could scarcely fail to rescue the patient for the time. But it must be very 
rarely requisite. 
The general nervous excitability in which the complaint sometimes ori- 
ginates, should be controlled by the nervous- stimulants, which have the pro- 
perty of equalizing the excitement. For this purpose, assafetida or valerian 
may be given internally, and garlic; applied in the form of cataplasms to the 
feet, or with hot brandy to the spine. Narcotics may also prove useful, when 
the brain is not diseased, by diminishing sensibility to exciting causey. Tonics 
and the cold bath, when the latter does not induce the spasm by the alarm 
it produces,, are also useful by giving strength to the nervous system. Inha- 
lation of the vapour of ether has recently been effectual in a very bad case, 
recorded by, Mr. Image, of the Suffolk Hospital, England. It was applied 
by means of a sponge held to the mouth and nostrils, at the commencement 
of each recurring paroxysm, which was thus instantly set aside; and at length 
the disposition to a return of the paroxysms ceased entirely. (Prov. Med. and 
Surg. Journ.^ June 2, 1847.) 
Attention should always be paid to the state of the gums, which should 
be lanced if swollen and painful. When the dentition is peculiarly difficult 
and painful, blisters may be applied behind the ears, or at the nape of the 
neck. 
The bowels should also be scrupulously attended to. If the stools are 
white, or otherwise disordered from deranged biliary secretion, minute doses 
of the mercurial pill or calomel should be given, or mercury with chalk if 
there is diarrhoea. Acidity must be corrected by . the usual remedies. Should 
a tendency to constipation exist, it must be counteracted by rhubarb, mag- 
nesia, castor oil, or other mild cathartic, so as to obtain one or two stools 
daily. The diet should be very carefully regulated, and all indigestible or 
acescent food forbidden. The mother's milk is usually the best food under 
the year, and cow's milk with arrowroot, ground rice, &c., and animal broths 
in moderation afterward. The child should be clothed warmly, and made to 788 
LOCAL DISEASES.--RESPIRATORY SYSTEM. 
[part n. 
breathe a free and pure air. Especial care should be taken to avoid all 
frights, and other sudden or violent emotions. 
Should there be reason to suspect disease of the brain, or tumours pressing 
upon the par vagum or its recurrent branch, as the cause of the complaint, 
the remedies should-be addressed to these affections. 
2. Spasm of the Glottis in Adults,-Occasionally the glottis is 
spasmodically affected in adults, independently of inflammation. The same 
phenomena to a certain extent occur as in children. There is first difficulty 
with laborious effort in inspiration, then the shrill whooping sound arising 
from the entrance of air through the somewhat opened but still contracted 
passage, and occasionally a croupy cough. The spasm may be excited, and 
sometimes fatally, by a foreign body in the larynx of pharynx. Choking is 
in such cases not mechanical; but arises from involuntary contraction of the 
laryngeal musqles, consequent upon irritation of parts supplied with branches 
of the same nerves. The affection results most frequently from an unstable 
and excitable condition of the nervous system, and is merely one of the protean 
forms in which hysteria exhibits itself. Sometimes it appears to have its 
origin in spinal, sometimes in cerebral irritation. It may also be produced 
by tumours pressing upon the recurrent nerve, as aneurism of the. aorta and 
its primary branches. It is much more common in women than in men. 
The treatment must be directed to the cause, and is for the most part such 
as is adapted to cases of hysteria. Antispasmodics, narcotics, tonics, the cold 
or shower-bath, a proper regulation of the intestinal and uterine functions, 
counter-irritation to the spine, an appropriate diet, and exercise in the open 
air, are the chief remedies. ■ 
3. Suppression of the Voice, or Aphonia.-Allusion is here made 
only to the affections of the voice of a nervous character, independently of 
inflammation or organic alteration of the larynx. Changes of the voice of 
this kind are not uncommon. Sometimes it becomes acute, or of a higher 
key, though feeble. The voice of a man is thus rendered feminine, or puerile. 
Sometimes the alteration is of an opposite character, the voice becoming low, 
or hoarse, or croaking, so that a child or a woman will speak like a man. In 
many instances, it is entirely suppressed. No sound is formed above that of 
the breath, and speech is in whispers. The attack may be sudden or gradual, 
and brief or of - long and indefinite duration. 
Causes.-These are numerous. Among the most frequent is the irregular 
distribution of nervous influence consequent upon general debility, as after long 
continued or exhausting diseases. The affection is often nothing but a form 
of hysteria. Sometimes it depends upon debility of the laryngeal muscles 
alone; as where these have been overstrained by-protracted and excessive 
efforts in speaking or singing. Occasionally an attack is brought on by a 
sudden and strong mental emotion, as of joy, anger, or fright. Quick changes 
from a warm to a very cold air have induced it. In some instances, it appears 
to depend on sympathy with intestinal irritation, or disease of the sexual 
organs, whether in man or woman. It has attended the poisonous action of 
lead, and has been brought on by powerful narcotics, as belladonna and stra- 
monium. Another frequent source of it is disease affecting the par vagum or 
recurrent nerve, or one of the nervous centres. Hence it may attend aneurisms 
in the upper part of the chest, and, in the form of partial or complete palsy 
of the larynx, may depend upon congestion or effusion in the brain, or other 
organic cerebral disease. 
Treatment.-When the disease depends on general debility, the obvious 
plan of cure is to restore strength by tonics, the cold bath, nourishing food, 
and exercise. When a mere form of hysteria, it is to be treated like spasm CLASS III.] 
HOOPING-COUGH. 
789 
of the glottis from the same cause. If the brain is in fault, our remedies 
must be addressed to that organ, and must vary with the nature of the affec- 
tion. Aphonia arising from temporary causes often disappears spontaneously. 
When produced by cold, it is cured by hot teas, or warm stimulating drinks, 
given so as to induce perspiration. If the result of lead poison, it may be 
treated by mercury, and by measures calculated to stimulate the organ. Such 
measures are also obviously proper in all cases, where the modification of the 
voice depends on debility of the laryngeal muscles. Under such circumstances, 
we may employ gargles of alum and other astringents whether vegetable or 
mineral, stimulating inhalations, electricity or galvanism, external irritation 
by means of sinapisms, blisters, croton oil, or a seton, and strychnia applied 
to a blistered surface, or taken internally. Inhalation of the vapours of ben- 
zoin has been found effectual. Solution of nitrate of<silver has been applied 
directly to the internal surface of the larynx, with success in several cases, by 
M. Trousseau; but the operation requires dexterity, and should be tried only 
by a skilful hand, and after a fruitless employment of other remedies. _ 
4. Laryngeal and Tracheal Pains.-Neuralgia of the Larynx and 
Trachea.-Severe pain sometimes attacks these parts, without any evidence 
whatever of .inflammation. It is felt along the anterior part of the throat, and 
beneath the upper part of the sternum. Like other forms of neuralgia, it 
may occur in paroxysms, or may be continuous for a considerable time, and 
varies greatly' in degree. It may '■or may not be accompanied with spasm 
of the muscular fibres. The most frequent cause of it is probably rheumatic 
or gouty irritation, in constitutions of a nervous character. It may arise also 
from other causes of neuralgia elsewhere, as debility, or irritation existing in 
the nervous centres, or in the course of the nerves supplying the parts. In 
persons predisposed to the affection, it is sometimes excited'by breathing cold 
air. The remedies are the same as for neuralgia generally. Those especially 
applicable in this case would be the inhalation of warm aqueous vapour1, either 
unmixed or impregnated with the vapours of narcotic and anodyne substances, 
such As. opium, camphor, and conium; the smoking of tobacco or stramonium; 
and the ■ application of a blister Over the seat of pain, and the sprinkling 
of morphia upon the blistered surface. When apt to be induced by cold air, 
it may probably be best prevented by the habitual use of the cold shower- 
bath, or the frequent application of cold water to the neck and breast. An 
attack may sometimes be averted by holding a silk handkerchief to the mouth 
and nostrils, upon entering the open air. 
Article IL 
HOOPING-COUGH, or PERTUSSIS. 
Syn.-Chin-cough.-Convulsive Cough of Children.-Tussis convulsiva, spasmodica, 
strangulans, &c. 
This is a contagious disease, characterised by frequent paroxysms of cough- 
ing, in which the expiration is broken into numerous short, rapid, and 
spasmodic movements, and the inspiration is long, and frequently sonorous. 
It most frequently affects young children. Medical writers usually divide it 
into three stages; 1. the catarrhal or forming stage, 2. the spasmodic stage, 
or that of progress and maturity, and 3. the declining stage. The limits of 
these several stages are not always well defined, nor do they all exist in every 
instance of the disease. Something like them, however, is very generally 790 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
observable; and the division enables the symptom's to be more conveniently 
grouped in description, than they could be without this or some similar 
arrangement. 
Symptoms, Course, &c.-The disease generally begins, like a common cold, 
with coryza, red and watery eyes, sneezing, irritation of throat, a dry cough, 
and sometimes febrile symptoms; and it is often impossible to distinguish it, 
with certainty, at this p'eriod, from catarrh. The cough, however, has usually 
more of a paroxysmal character; and this circumstance, in connexion with the 
fact that the disease is prevalent at the time, is sufficient to fix suspicion upon 
the case, and put the practitioner upon his guard., This stage continues, in mosf 
cases, for one or two weeks, before decided spasmodic symptoms appear. Some- 
times, however, its duration is shorter, and sometimes longer. Instances, 
indeed, now and then occur, in which dhe characteristic symptoms of the dis- 
ease appear at the-outset; and it is occasionally observed, during the preva- 
lence of hooping-cough, that catarrhal affections run a corresponding course, 
as if dependent upon the same cause, though destitute of the peculiar spasmo- 
dic phenomena. . * ; 
But, in most cases, at the end of eight or ten days, the cotigh begins to 
change, gradually assuming the proper character of pertussis; and the disease 
passes into the second stage. This, when fully formed, presents the follow- 
ing symptoms. At irregular intervals through the day and night, the child 
is seized with an irresistible disposition to cough. But the sound, instead of 
occupying continuously the whole time of expiration, as in ordinary com- 
plaints of the chest, is broken into a number of short coughs, which succeed 
each other with an almost convulsive force and rapidity; and the inspiration 
that immediately follows is long, difficult, and often attended with a shrill or 
whooping sound, which has given its common name to the complaint. This 
succession of spasmodic cough and shrill inspiration is repeated again and 
again, thus constituting a paroxysm, which lasts variously from thirty seconds 
to fifteen minutes, or even longer. During the paroxysm, the face is flushed, 
swollen, and sometimes purplish or livid, the veins of the neck and temples 
distended, the eyes prominent, and the countenance expressive of much dis- 
tress. The child, if lying, starts up into the sitting posture, and, if standing, 
seizes some person or object near him for support. In violent cases, the blood 
sometimes escapes from the nose, mouth, or ears, or is extravasated into the 
tissue of the conjunctiva; and the urine and feces are discharged involuntarily. 
The paroxysm usually terminates with the expectoration of transparent mucuSj 
and not unfrequently in vomiting, which appears to relax the spasm, and thus 
proves serviceable in the complaint. Occasionally, however, no discharge 
takes place from the lungs or stomach, and the paroxysm ceases with the 
exhaustion of the patient. For a short time after it is over, the child ap- 
pears feeble and perhaps trembling, with hurried pulse and breathing; but 
he soon recovers from these symptoms, and seems as if nothing had hap- 
pened, resuming his play or occupations with his ordinary cheerfulness, and 
often showing an eager desire for food, especially after vomiting. If asleep 
when seized with a cough, he lies down when it is passed, and is soon asleep 
again. 
The successive broken coughs, so characteristic of the disease, are obviously 
the result of short and quick spasms of the muscles of expiration. This 
symptom not unfrequently occurs long before the whooping sound, which, in 
some few instances, is very seldom or never heard throughout the complaint. 
The sonorous inspiration, or whooping, is owing to the difficult passage of the 
air through the contracted and rigid chink of the glottis, as happens also in 
croup, and the crowing disease of children. The expectoration js probably CLASS III.] 
HOOPING-COUGH. 
791 
produced, not by any inflammation of the bronchial mucous membrane, but 
in consequence of the violent agitation of the lungs, which induces an increased 
afflux of blood and consequent increased secretion, exactly in the same manner 
as prolonged fits of laughter. The vomiting arises from the disturbed move- 
ments of the fauces, and seems to be a provision of nature for a solution of 
the paroxysm. There is no previous or subsequent sickness of the stomach. 
The paroxysms recur quite irregularly, sometimes without apparent cause, 
sometimes from slight causes, such as exposure to cold air, sudden or rapid 
movements, crying? attempts at swallowing, fits of passion, irritating inhala- 
tions, and even the sight of others labouring under an attack. The period 
of their recurrence is very different in different cases. In some, there is only 
an interval of. a few minutes between them, in others, they occur not oftener 
than eight or ten times in twenty-four hours; and there is every intervening 
degree of frequency. Authors do not agree upon the point, whether they 
occur oftener during the day or night; from which it may be inferred that 
there is no great difference in this respect. The patient is often sensible, for 
some time previously to the seizure, that i£ is about to take place. A tickling 
sensation in the larynx and upper part of the trachea, pains in the breast, and 
increased frequency of the pulse and respiration, often precede.the paroxysm; 
and the child appears to dread its approach, and to repress , the disposition to 
cough as long as possible. 
The paroxysms increase in frequency and violence until the complaint is at 
its height, which is usually in four or five weeks from the commencement of 
the attack, though the time may be considerably shorter or longer. The dis- 
ease then appears, to remain stationary for about two of three weeks, after 
which it begins to decline;, and the third rstage commences. The spells of 
coughing now gradually become le,ss frequent and severe,-and more catarrhal, 
being attended with the expectoration of opaque whitish or yellowish matter, 
and losing much of the spasmodic or convulsive character. At length the 
broken expiration and the whoopifig sound cease entirely; and the patient is 
either well, or affected with a slight ordinary cough, which in its turn ceases. 
But not unfrequently the termination is much less regular. Sometimes the 
symptoms^ after haying ceased, reappear for a time. Frequently, after resto- 
ration to health, if the patient acquires a. cough from any cause, it is apt to 
exhibit more or less of the characteristics of pertussis. Occasionally the dis- 
ease seems to assume a chronic form, and is indefinitely protracted. Its dura- 
tion is quite uncertain. Sometimes it .has disappeared in a month or six 
weeks, while, in other cases, it is asserted to have run on for two years. It 
will probably be no great deviation from the truth to state, that, in its ordi- 
nary course, the disease occupies about three months; six weeks being allowed 
for its formation and progress, two or three for its highest elevation, and three 
or four for its decline. 
As above described, hooping-cough is in its simple uncomplicated form. 
Except the catarrhal symptoms at the commencement, it does not necessarily 
show any signs of bronchial inflammation. The patient runs about, often 
with a good appetite, and, except during the paroxysm, suffers little. There 
is no fever,, or only an occasional slight accession, dependent probably on some 
temporary irritation of the bronchial or alimentary mucous membrane. Aus- 
cultation may sometimes detect the dry or mucous rales; but very often, as 
asserted by Blache from personal observation, it discovers no morbid sounds 
whatever in the chest. (Diet. de Med., ix. 27.) It is a curious fact, that, 
during the paroxysm, the respiratory murmur cannot be heard. The air does 
not enter the air-cells, either in consequence of the deficient quantity that is 792 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
allowed to pass the glottis, or, what is very probable, from spasmodic closure 
of the small tubes. Immediately after the paroxysm, the ordinary sound of 
respiration is heard distinctly. , • - 
The force of the disease varies much even in its simple form. In some 
instances, it is so slight that it can scarcely be determined, after recovery, 
whether the child has had hooping-cough or not. In others again it is very 
severe, with frequent and violent paroxysms, which seem to threaten suffoca- 
tion. By the pressure upon the brain, fatal convulsions are sometimes,brought 
on; and death may also take place from asphyxia during the paroxysm. In 
protracted cases, great emaciation and debility sometimes ensue, and the pa- 
tient may die of exhaustion. But these results are comparatively,rare. The 
simple, form of the disease almost always terminates favourably. It is, how- 
ever, liable to complications, which are very often dangerous, and not unfre- 
quently fatal. 
Of these complications, the most frequent are probably bronchitis and pneu- 
monia. When the child becomes steadily febrile, one of these affections may 
be suspected. It is not uncommon for the peculiar symptoms of pertussis to 
be diminished during their continuance, and to reappear upon their decline. 
A certain degree of bronchial inflammation is not unusual in the early stage, 
and for some time even after the spasmodic symptoms have appeared. But 
this is not often serious. That from which danger is most to be apprehended 
occurs at an advanced period of the disease. It may affect the larger, tubes 
exclusively, or may penetrate into their minute ramifications. The symptoms 
and physical signs are' the sariie as in bronchitis from other causes. Pneu- 
monia very seldom occurs early in the complaint. Rilliet and Barthez state 
that they have not observed it in children, who have perished before the 
twenty-seventh day. ^Malad. des Enfants, ii. 216.) It is usually lobular, 
though it occasionally also1 affects large portions of the lung continuously. 
Convulsions are another frequent complication of hooping-cough. They 
are most apt to occur during the period of dentition. They may be owing 
simply to an excessively excitable condition of the nervous system, induced- 
by the two affections jointly. In this case, they are not necessarily very dan- 
gerous. A more serious form of them is that which 'Occurs in consequence of 
congestion or effusion within the cranium, indicated by a rolling of the head, 
contracted or dilated pupil, squinting, paralysis of some portion of the body, 
and comatose symptoms. Occasionally they are the mere expression of a 
hydrocephalic condition of the brain; in which case they are almost necessa- 
rily fatal. (See Tuberculous Meningitis and Hydrocephalus.') 
Croup sometimes complicates pertussis, and, if of the pseudo-membranous 
character, is greatly to be dreaded. 
Still another complication is inflammation of some portion of the alimentary 
canal, indicated by fever of the remittent character, furred tongue, tenderness 
and sometimes swelling of the abdomen, diarrhoea, &c. The hepatic secretion 
is not unfrequently deranged. 
When any predisposition to tubercles exists, these are very apt to be deve- 
loped. Dropsical effusion sometimes attends pertussis. Various other dis- 
eases have been enumerated as occasional accompaniments, but their presence 
is in general merely accidental. 
Taking into consideration all the complications of pertussis, it must be 
regarded as a disease calculated to excite solicitude, and a careful watchful- 
ness. Great numbers die of it in every epidemic. It is said to be most fatal 
in children under two years, probably because then combined with dentition. 
By comparing results stated by Dr. Condie, it appears that the average num- 
ber of deaths from hooping-cough, in the cities upon our Atlantic coast, is CLASS III.] 
HOOPING-COUGH. 
793 
about one in seventy of the whole number of deaths from all diseases; while, 
in various countries of Northern Europe mentioned, it is nearly one in thirty- 
four. (Diseases of Children, by D. F. Cond'ie, p. 325.) 
Anatomical Characters.---After death, in uncomplicated cases, no other 
morbid appearance is observed than some signs of congestion of the brain, 
and a viscid mucus1 in the .bronchia. But, as death very rarely occurs in such 
cases, there is seldom an opportunity of ascertaining their anatomical charac- 
ters. It is scarcely necessary to shy that the several additional affections of 
which patients may die leave their peculiar marks behind them, which are 
enumerated under the proper heads. One organic lesion it is proper to notice 
here, as a common attendant upon the advanced stages of fatal cases. The 
lesion alluded to is a dilatation of the bronchial tubes. This has been ascribed 
by some to pressure from violent coughing; but the explanation hardly ap- 
pears probable when we consider, that the chief force exerted is in expiration. 
It is, I think, more justly attributed by Gruersent and others to an altered 
organic process; to an increased nutrition, for example,vunder the stimulus of 
irritation. ' 3 ; • .'W p- 
Causes.-One of the most common causes of pertussis is certainly epidemic 
influence. But this is not so sweeping in its range,,nor so rapid in its pro- 
gress, as the cause of influenza. Epidemic hooping-cough is more commonly 
somewhat partial in its prevalence, like measles and scarlatina, affecting only 
certain districts or cities, or even parts only of these, to the exclusion of other 
parts. Sometimes the disease attends an epidemic of measles; and is occa- 
sionally associated with the influenza in certain localities. It is altogether 
irregular in the periods of its recurrence. Its fatality is said to be much 
greater in some epidemics than in others. It is not confined to any season, 
though perhaps more frequent in cold than in warm weather. The disease is 
more favourable in spring than in autumn, because its latter stages, in which 
there is. greatest danger of pectoral inflammation; are brought into the sum- 
mer instead of the winter. Occasionally the complaint is sporadic. Different 
opinions have been entertained of its contagious nature; but the great ma- 
jority of writers are united in believing that it is propagated from individual 
to individual; and it does not appear to the author possible to resist the 
weight of evidence in favour of this view. It is probably most contagious at 
the period of its highest developement. 
As a general rule, the disease occurs only once in the same person. Ex- 
ceptions occasionally occur to this rule, as in'all other contagious diseases. It 
is confined to no age, sex, or condition of life. Persons advanced in life are 
sometimes attacked, and Dr. Watson mentions a case in which a child was 
born with it. For a very obvious reason, however, it is confined chiefly to 
early childhood. Being frequently prevalent and highly contagious, it attacks 
most persons-early in life; and adults escape because they have once had the 
disease. It is said to affect infants less frequently before than after the com- 
mencement of dentition. But may not this be owing to the fact, that, upon 
the whole, very young infants are less exposed to the cause ? 
Nature.-Very different opinions have been advanced as to the nature of 
hooping-cough. Some consider it as essentially a variety of bronchitis; but 
this opinion is not tenable; because the best evidence exists, both from the 
physical signs during life and examination after death, that the bronchia are 
often wholly free from inflammation. Others again ascribe the phenomena 
to cerebral disorder, considering this to be the essential feature of the disease. 
But this opinion wants the support of facts. No proof whatever is afforded 
by the symptoms, that the brain is chiefly disordered. It seems to the author 
very clear that the complaint is not wholly and exclusively either inflamma- 794 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
tory or nervous. The cause appears to be capable of giving rise to inflamma- 
tion of the air-passages directly; for this is often the first observable effect; 
and, when not sufficient immediately to induce inflammation, it strongly pre- 
disposes to that condition, as proved by the frequency of bronchitis and pneu- 
monia in the latter stages.- But it is not less certain that the same cause 
gives rise immediately to nervous disorder of ,the respiratory passages; for 
this not unfrequently exists without any inflammation whatever in the second 
stage of the disease, and, in a few instances, is the first effect produced. Usu- 
ally the catarrhal and spasmodic, in other words the inflammatory and the 
nervous effects, exist in the same case, and not unfrequently conjointly; but 
the cause may operate exclusively in either of these directions; for cases some- 
times occur in which the peculiar spasmodic phenomena are quite uncompli- 
cated, while others have been observed, in all probability ascribable to the 
same epidemic cause, which have been catarrhal throughout. There seems to 
be no necessity for extending the seat of the morbid action beyond the parts 
in which it obviously exists. Some have ascribed the phenomena to inflam- 
mation of the pneumogastric nerve, and have even found that nerve inflamed 
after death; but other close observers have searched in vain for this condition 
of things,/ through a long series of dissections. 
Treatment.-In simple cases of hooping-cough, without violent symptoms, 
little treatment is requisite. It is probable that, in the majority of cases, the 
disease runs its course to a favourable termination, with very little, if any, 
interference on the part of the physician. In its severer forms, however, 
treatment is often highly useful in alleviating the symptoms, and, in compli- 
cated cases, is frequently indispensable to safety. 
In the early stage, if the catarrhal symptoms- are moderate, it will be suffi- 
cient to give a mild cathartic, as castor oil, magnesia, of the sulphate of mag- 
nesia, and afterwards small doses of ipecacuanha or antimonial wine, at short 
intervals. But, should fever be present, with signs of bronchial inflamma- 
tion, it will be proper to administer a full purgative dose of calomel; > three 
or four grains, for example, to a child two or three years old, to be followed 
by castor oil,, if it should not operate freely. This cathartic may be repeated 
in a few days, if the febrile symptoms do. not abate. When the bronchitis is 
very decided, with some pain in coughing, difficulty of breathing, and the 
sonorous or sibilant rale under auscultation, blood should be taken from the 
arm, or locally from the breast by leeches, or from both, according to the 
severity of the symptoms, and the age of the patient. But the practitioner 
should always remember, while depleting in this disease, that the loss of 
blood cannot check its course, and that sufficient strength should b'e ■ pre- 
served to bear the .patient through. Ue will therefore take less blood than 
in cases of original inflammation, having the same seat, and the same grade 
of activity. 
When the spasmodic symptoms appear, different remedies are required. 
They may be either such as by stimulating the nervous system tend to 
equalize its actions, and thus obviate the irregular distribution of influence 
which causes spasm, or such as diminish the sensibility of the nervous cen- 
tres, and render them less susceptible to the exciting or irritating cause. 
Hence, the nervous stimulants or antispasmodics, and the narcotics, have 
been found useful. The former are perhaps upon the whole preferable, as 
less likely to promote any pre-existing disposition to cerebral disease; but the 
two may often be happily conjoined. The use of these should not, as a 
general rule, be commenced with, until any existing fever or bronchial inflam- 
mation shall have been removed. When these symptoms linger in connexion 
with the spasmodic, it will be preferable to precede the antispasmodics and CLASS III.] 
HOOPING-COUGH. 
795 
narcotic by occasional emetic doses of ipecacuanha, in violent cases every day 
or every other day, with smaller doses every two or three hours in the interval, 
so as to sustain a very slight degree of nausea. Should the bronchitis be con- 
siderable, and especially if croup should coexist, or be threatened, tartar-emetic 
may be preferred to ipecacuanha, in reference both to its. emetic and nauseant 
action. Lobelia, too, may be employed, in the latter case, with great pro- 
priety. The daffodil (Narcissus pseudo-narcissus), which has-been recom- 
mended in hooping-cough, probably acts in the same way. Emetic medicines 
are useful by relaxing the-spasm, depressing general arterial excitement, and 
promoting expectoration. They may be aided by the frequent use of hot 
pediluvia, or the warm bath. When fever has disappeared, and the proper 
paroxysms of hooping-cough only remain, recourse may be had to the anti- 
spasmodics ; and, if there be any doubt in the mind of the practitioner, he 
can combine the use of these with that of the emetic medicines. 
By far the best of the nervous stimulants that I have employed is assa- 
fetida. It should be given in emulsion, in' the dose of on.e or two grains to 
a child 'two years old, repeated three or four times a-day, or, in severe cases, 
as often as every two or three hours. Though disagreeable at first, it soon 
ceases to be so; and it is not at all uncommon to see the little patient anxious 
for the repetition of his dose. It has been recommended also by injection, 
and, in the form of tincture, as an application to the spine; but these modes 
of administration vare unnecessary, when it is supported well by the stomach. 
Garlic may often be very happily employed as a substitute for assafetida, 
when this may not be at hand, or may from any cause be forbidden.. Other 
antispasmodics, which have had more or less reputation in the complaint, are 
musk, artificial musk, castor, valerian, camphor, ammonia, oil of amber, 
Dippel's animal oil, and cochineal. . 
Of the narcotics, belladonna has beyond all comparison the highest repu- 
tation. It appears, indeed, from much highly respectable testimony, both of 
European and American practitioners, to exercise a very powerful influence 
over the disease. Little good, however, can be expected from it until it has 
given some obvious sign of its action upon the system, as dryness of the 
fauces, vertigo, or dimness of vision; and it should therefore be pushed to this 
point. Dr. Samuel Jackson, late of Northumberland, in Pennsylvania, now 
of Philadelphia, who was one of the first physicians to employ the remedy in 
this country, and has found it very successful, insists upon the necessity of 
giving it so as. to dilate the pupiL The dose for a child two years old is from 
the twelfth to the sixth of a grain of the extract, twice or- three times a-day 
to begin with, and gradually increased, if necessary, until it produces its pecu- 
liar effects. The uncertainty and occasional great strength of the extract 
render it advisable to begin with a very small dose. The same effects may 
be obtained from the external, as from the internal use of the medicine. The 
most convenient mode of applying it is in the form of a plaster between the 
shoulders. I have seen a plaster of this kind act like a charm in relieving 
the symptoms of pertussis; but alarming convulsions came on; and, though 
these ultimately yielded, and the patient recovered, I have since been very 
cautious in the employment of the remedy. The connexion, however, in this 
case, may have been merely accidental. Various other narcotics have been 
employed in hooping-cough. Among them are opium, hyoscyamus, conium, 
extract of Lactuca virosa or lactucarium, and didcamara. Opium is un- 
doubtedly the most efficient in allaying cough; but is peculiarly liable to the 
objection of being apt to check mucous secretion, and consequently to prevent 
expectoration. Still, it may be occasionally used with advantage in connexion 
with ipecacuanha or tartar emetic, and other expectorants. It has been 796 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part ir. 
recommended, in the form of one of the salts of morphia, as an endermic 
application to the throat. Hydrocyanic acid is another narcotic which has 
been very highly lauded. It does, in fact, appear to exercise a favourable 
influence in the disease; but its strength is so-uncertain, and it is so dangerous 
in overdoses, that it is scarcely an advisable remedy, especially when we have 
so many others much safer, and not less effectual. Cherry-laurel water, the 
properties of which are identical with those of hydrocyanic acid, has been 
used in Europe,, both by the mouth, and in the way of inhalation. 
The tonics, which often prove efficient remedies in the purely nervous affec- 
tions, have enjoyed some reputation in the treatment of this, especially at a 
somewhat advanced period, when the system has begun to be worn or ex- 
hausted by the ^continuance of the disease. The mineral tonics have usually 
been preferred. Of these, oxide of zinc, in the dose, for a child two years 
old, of from half a grain to two or three grains every three or four hours, 
subcarbonate of iron in the quantity of from ten to fifteen grains in twenty- 
four hours, iodide of silver in the dose of one-quarter of a grain three times 
a-day, and nitrate of silver in that of one-fifth of a grain daily, have been 
especially commended. Sulphate of quinia- has' also been considerably em- 
ployed, and probably quite as effectually as the metallic preparations. 
We should perhaps be no great losers, were we to confine ourselves, in the 
treatment of the first two stages of hooping-cough^ to the remedies already 
enumerated. The practitioner will select from among them those which he 
may deem most efficient, and variously combine them to answer different in- 
dications. Thus, in the earlier stages, when the catarrhal symptohls linger, 
the emetics may be combined with the antispasmodics and narcotics; in the 
latter stages, when debility has supervened, tonics may take place of the 
emetics; and in all stages, should the bowels be confined, and the Inedicines 
employed to meet other indications not have the effect of opening them, laxa- 
tives should be added to the other remedies. On the whole, of the emetics I 
should prefer ipecacuanha, of the antispasmodics assafetida; of the narcotics 
hyoscyamus, belladonna, or opium, of the tonics sulphate of quinia or one of 
the chalybeates, and of the laxatives, castor oil, rhubarb, or magnesia. In 
connexion with this course of medicines, occasional recourse may be had with 
advantage to the antacids, when the stomach or bowels are disordered; and 
hence the preference given to magnesia as a laxative. But, when laxatives 
are not required, the carbonates or bicarbonates of soda and of potassa should 
be used. These have had much reputation in hooping-cough, independently 
of their antacid properties, and have been considerably used in liquid mix- 
tures with cochineal. If to the above measures we add the use of the warm- 
bath, for half an hour, an hour, or even two hours at a time, in bad spas- 
modic cases, when the paroxysms are very frequent and distressing, we shall 
have completed the round of desirable remedies. 
Nevertheless, it will be proper to allude to others which have been strongly 
commended; as some of them may undoubtedly be occasionally useful, and 
the practitioner may know where to resort, when he has ineffectually ex- 
hausted the usual remedies. Among those of mineral origin may be 
mentioned, solution of arsenite of potassa, iodide of potassium, acetate and 
subacetate of lead, alum, sulphur, sulphuret of potassium; among the 
vegetable, tannic acid, the misletoe of the oak, in the dose of ten or twelve 
grains to a child, and mix vomica; and of the animal, tincture of cantharides. 
Local irritation by blisters, tartar emetic, &c., has had strenuous advocates, 
though in general it is in little favour, unless in cases of obvious inflamma- 
tion, whether pectoral, encephalic, or abdominal. Pustulation by tartar 
emetic is hazardous, and a case of death from this cause, consequent upon CLASS III.] 
HOOPING-COUGH. 
797 
sloughing and ulceration, is recorded. (Diet. de Med., ix. 41.) Inhalations 
have also been resorted to, and promise some temporary benefit- The sub- 
stances used in this way, among others, have been cherry-laurel ivater, added 
in the quantity of a fluidrachm to the warm water employed, camphor, tar, 
benzoin, galbanum, nitrous acid vapours, &c. Vaccination appears, in some 
instances, to have exercised a decided influence in modifying or arresting the 
disease; and may therefore be resorted to, in cases in which the child has not 
yet undergone this process. 
In the declining stage of the disease, the same remedies may be employed 
as previously, in gradually diminishing quantities, as the peculiar symptoms 
decline. Should a troublesome cough remain, in this stage, it may be treated 
with the stimulant expectorants, combined with opium or hyoscyamu's, as in 
chronic bronchitis., Debility must be counteracted by the moderate use of 
tonics. But what is chiefly required is-care to avoid causes of inflammatory 
attacks, to which the child is now very liable. 
Should convulsions occur in the course of the complaint, without fever, 
heat of head, or other signs of dangerous cerebral disease, assafetida should 
be given by injection, garlic poultices applied to the feet, frictions with garlic 
and, brandy made along the spine, and the body immersed if necessary in a 
warm bath. Should, they, be simply threatened, the same use may be made 
of garlic, while assafetida or Hoffmann's anodyne, with or without a little 
laudanum or paregoric elixir, may> be given by the mouth. If the con- 
vulsions are connected with symptoms of cerebral congestion, it will be 
necessary , to apply leeches to the temples,- cold to the head, a blister to- the 
back of the neck, and stimulating applications to the feet. In such cases, 
narcotics must be avoided. A bolder practice would be indicated, should the 
symptoms threaten an attack of meningitis. (See Meningitis.') Severe bron- 
chitis or pneumonia must be encountered by the remedies demanded by these 
affections occurring originally) except that bleeding should be less freely 
employed. The most efficient remedy, under these circumstances, next to a 
due. amount of depletion, is calomel given in purgative doses, daily, every 
other day, or twice a week, according to the severity of the symptoms. In 
cases of fever, connected with irritation or inflammation of the primm vim, 
leeches to the abdomen, emollient cataplasms, refrigerant diaphoretics, warm 
baths, demulcent drinks, mild aperients, as rhubarb and magnesia, and some- 
times small doses of calomel, are suitable remedies. 
Throughout the complaint, there are various points of regimen and manage- 
ment which require attention, independently of the use of medicines. One 
important rule is, that, when very young, the patient should be sedulously 
watched; as there might be danger of strangulation in the paroxysm. The 
infant, as soon as the cough begins, should be raised to the upright position; 
and, at the close of the paroxysm, the nurse should remove by her finger the 
mucus which is thrown up into the fauces. The violence of the paroxysm 
may sometimes be abated by inducing the child to drink a little cold water, 
or some cool demulcent beverage; and, when suffocation is threatened by the 
violence of the spasm, this may often be relaxed by dashing a little cold 
water into the face, or, according to Williams, by blowing into the ear. The 
bowels should be carefully regulated, and the biliary secretion, if deranged, 
corrected by appropriate means. During dentition, the gums should be care- 
fully attended to. If swollen, they should be lanced freely; and, if they still 
remain inflamed and painful, a few leeches may be applied near the angle of 
the jaws, and blisters behind the ears. The diet should vary with the stage 
and the degree of excitement. It should consist in the early stage chiefly of 
vegetable substances, with or without milk; at a more advanced period, of 798 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
the same materials, with milk freely, and a little of the lightest kind of meat, 
as the boiled breast of fowl, soft boiled egg, &e.; and, in the end, when the 
patient is debilitated, of the most nutritious food. Whatever is taken should 
be of easy digestion. Should inflammation at any time supervene, the diet 
should be strictly vegetable. The child should always be clothed with flannel 
next the skin. In the catarrhal stage, he should be confined to a uniform 
temperature; but, when the disease has become purely spasmodic, frequent 
exposure to fresh dry air, even in winter, is not only allowable, but often 
highly useful. Damp should always be avoided. In protracted cases, nr 
those with a tedious convalescence, the cure is much promoted by change of 
residence, as' from town to the country, or from one part of a town to another; 
and, in the winter season, great good may be expected from removal to a 
Warm climate. -v < ' 
Article III. 
NERVOUS COUGH. 
Now and then we meet, both in children and adults, with a cough which 
cannot be referred to any recognized disease. It is not attended essentially 
with any of the symptoms of catarrh. There is no evidence whatever of 
inflammation,-or even vascular irritation in any part of the respiratory pas- 
sages. None of the morbid sounds, whether of the dry or moist character, 
are necessarily detected in the chest. It is obviously a purely nervous affec- 
tion; but it does not run the course, and is seldom attended with the peculiar 
symptoms of hooping-cough. It is the characteristic, and sometimes only 
observable sign of a peculiar morbid condition of the respiratory nerves, or 
their centres, and deserves to be ranked among diseases. 
The cough is almost always dry, unless in instances in which, after a 
violent paroxysm, some mucus is thrown up, consequent upon the excitement 
of the respiratory organs, in the same , way as expectoration results from a 
paroxysm of laughter. In other respects, it is liable to all possible variations. 
It is sometimes single, short, and at uncertain and distant intervals. Some- 
times it is almost incessant, leaving the patient scarcely any rest for days and 
weeks together, except when interrupted by sleep. I have known a young 
lady affected with it in this form for months, with occasional intervals of 
brief duration. In this case, it had a uniform character, continued evenly 
onward, sometimes almost as regularly as the breathing, and had a peculiar 
loud, hollow sound, which could often be heard in the adjoining house. In 
such cases, it is occasionally interrupted by any cause which strongly engages 
the attention, or excites the feelings. It is even checked for a time by eating. 
In other instances, the cough assumes a paroxysmal character, sometimes 
approaching to hooping-cough, and occasionally scarcely distinguishable from 
that affection. When of this form, it is apt to occur in the night, and I have 
known it to prove extremely troublesome by interrupting sleep. Not unfre- 
quently it bears so close a resemblance to the cough of the earlier stages of 
catarrh, as to be distinguished only by the absence of the other characteristic 
symptoms of that affection, and by resisting the remedies to which that very 
generally yields. 
The cause is not always evident. The disease is most common in women 
and children, though it may occur also in adult males. It is often, no doubt, 
the result of an hysterical condition of the nervous system, and I have seen CLASS III.] 
ASTHMA. 
799 
it associated with tenderness of the spine between .the scapulse. I have seen 
it also apparently the result of gouty and rheumatic irritation. Very fre- 
quently such a cough proceeds from gastric or other abdominal disorders, 
probably in consequence of the nervous connexions of the abdominal viscera 
with the larynx, through the 'medium of the par vagum and sympathetic. 
Sometimes it probably depends upon primary or secondary organic disease of 
the par vagum or recurrent nerve. But there are many cases in which the 
cause of it cannot be traced. 
When not associated with any other disease, it almost always either sub- 
sides spontaneously in the end, or yields readily to remedies. In the uncom- 
plicated affection, I have found nothing so effectual as assafetida. To this 
remedy it will often give way immediately, after having long resisted all the 
treatment usually applied to catarrhal affections. The other antispasmodics 
are also more or less efficient; and musk, so powerful as a remedy in hiccough, 
may be expected to be very useful here. Garlic, externally and internally, 
may be used advantageously, especially in the cases of young children. The 
narcotics may also, be appealed to, and the warm bath will be found beneficial 
in cases of a spasmodic nature. Leeches or cups to the spine, followed by 
the tartar-emetic' plaster, are most to be depended upon in hysterical cases; 
and wine of colchicum with morphia, in. those of a rheumatic or gouty origin. 
When the cough is a mere attendant upon dyspeptic or other abdominal dis- 
ease, it yields with the cause which produced it. General debility, if existing, 
must be corrected by the usual means. 
Article IV. 
ASTHMA. 
Asthma, as the term is here employed, is a disease characterized by great 
difficulty of breathing, occurring in paroxysms, and depending on spasmodic 
constriction of the bronchial tubes, without the necessary accompaniment of 
fever, or organic disease of the lungs or -heart. 
The name has been very indefinitely applied. It would seem often to 
have been used synonymously with dyspnoea; but this use of it is clearly 
incorrect. Dyspnoea is not a disease.; but a mere symptom, which may occur 
in various diseases; and, indeed, is occasioned by whatever interferes, in any 
way, with the due arterialization of the blood in the lungs. Compression of 
the air-cells, as in pleuritic and pericardial effusion; solidification of the pul- 
monary tissue, as in pneumonia; excess of liquid secretion in the bronchial 
tubes, as in bronchitis; loss of the substance of the lungs, as in phthisis; 
mere congestion of the lungs, as in cardiac diseases; and even deficient in- 
nervation, as in various malignant affections, may all produce it. Frequency 
of the pulse is as much a disease as difficulty of breathing. The latter, there- 
fore, is not asthma. Formerly, in consequence of deficiency in the means of 
diagnosis, many cases of dyspnoea could not be traced to their real origin in 
organic diseases of the chest; and were thrown together into the same cate- 
gory with true asthma, because it was not known where else to place them. 
This difficulty is now removed; and we are enabled, by the methods of aus- 
cultation and percussion, to refer difficulty of breathing, not properly asthmatic, 
to its proper source, and thus to give greater precision to our conceptions of 
this disease. 
Syn.--Spasmodic Asthma. 800 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
The pathological condition proper to asthma, is that constriction of the 
bronchial tubes which sometimes occurs independently of inflammation or 
other organic lesion, and even of congestion, and which, though not positively 
demonstrated to depend upon muscular contraction,,is generally believed to 
do so, and is therefore considered as spasmodic. But every case of constriction 
of this kind is not included in asthma. Bronchial spasm is a frequent and 
subordinate attendant upon other diseases of a much more serious character, 
as in cases of severe bronchitis. The inflammation is here the prominent 
affection; the one from which danger is apprehended, and to which treatment 
is directed. It would be as inappropriate to rank such cases with asthma, as 
to give the name of colic to every painful spasm of the bowels, attendant 
upon enteritis. It is only when the spasm, whether in the respiratory or 
alimentary passages, is the predominant affection, that it is entitled to rank 
as a disease, and take the name, in the one case, of asthma, and in the other, 
of colic. All those cases, therefore, even of spasmodic and paroxysmal dys- 
pnoea, in which bronchial inflammation is the most important constituent, 
are not, in this work, treated of as examples of asthma, but are referred to bron- 
chitis. (See Bronchitis.} In some instances, there is reason to believe that 
asthma is purely nervous or functional, and quite independent of any other 
disease; but it is probably more frequently associated with some degree of bron- 
chial inflammation or other organic affection, which serves to call it into action. 
In the latter case, it does not lose its claim to be considered as the disease, so 
long as the exciting cause is mierely subordinate. 
Symptoms, Course, &c.-The asthmatic paroxysm is often preceded, for a 
longer or shorter time, varying from a few hours to several days, by certain 
premonitory symptoms, whiph warn the experienced patient of its approach. 
Among these symptoms are languor, heaviness of the head, drowsiness or 
headache, flatulent distension of the stomach, loss of appetite, stricture , across 
the lower part of the chest, and sometimes the copious discharge of limpid 
urine. (Forbes.} In some instances, however, the attack is sudden and 
without warning. It occurs generally in the night, most frequently between 
bedtime and two or three in the morning. The patient starts out of sleep 
into an erect posture, with a feeling of tightness or compression of the chest, 
and great difficulty in breathing. The air seems as if excluded from the 
lungs, and violent and even convulsive efforts of the muscles of inspiration 
are made in order,to expand the uhest. A peculiar wheezing noise is made 
in breathing, which can be heard at, a considerable distance. Yet, notwith- 
standing the expansive efforts of the muscles, the chest sometimes appears 
contracted in consequence of the shrinking of the lungs, and a hollow in the 
epigastrium is produced by the unusual elevation of the diaphragm. Expira- 
tion is much less difficult and painful than inspiration. Under a sense of 
impending suffocation, the patient is irresistibly impelled to seek for cool and 
fresh air, and the least semblance of restriction in this respect is insupport- 
able. He insists that every avenue for the entrance of air should be opened, 
and often rushes to the door or window, and even leans over the window sill 
with his head and trunk projecting, in the vain search of breath. It is sur- 
prising how long the body is sometimes thus exposed, very imperfectly covered, 
to the cold air of winter, without any injurious consequence. But a similar 
impunity is well known to attend exposure, under other forms of great .ner- 
vous excitement. The countenance of the patient, and his general move- 
ments express an indescribable anxiety and distress. It seems to him as 
though he could not possibly live. A common and characteristic position is 
with the elbows upon the knees, and the head between the hands. There is 
occasionally an attempt to cough, but it is imperfect, in consequence of the CLASS III.] 
ASTHMA. 
801 
impeded respiration. Speaking is equally imperfect and difficult. The pulse 
is often small, feeble, irregular, and frequent, with palpitations of the heart; 
but occasionally both the pulse and the actions of the heart are nearly or 
quite healthy. The face is either pale or flushed, or one and the other alter- 
nately; the eyes are prominent; the extremities often cool; and the head 
and breast covered with a cold sweat. The urine, during the paroxysm, is 
pale and abundant, but at its close, becomes scanty and high-coloured, and 
sometimes deposits a copious sediment. The bowels are, in some instances, 
suddenly relaxed at the beginning of the attack. After continuing for two, 
three, dr four hours, the symptoms gradually subside, usually with a copious 
expectoration of mucus, though sometimes without this accompaniment. In 
the latter case, the disease is sometimes called dry asthma, in the former, 
when the expectoration is abundant, humid or humor al asthma; though the 
latter name is more frequently applied to a species of chronic bronchitis 
already described. (See Pituitous Catarrh, or Bronchorrhoea, p. 759.) 
After the subsidence of the paroxysm, the patient usually falls into sleep, 
and, upon awaking in the morning, feels himself comparatively well. 
But. the symptoms do not wholly disappear. Soreness of the muscles, and 
occasionally neuralgic pains are experienced. Some feeling of constriction, 
and perhaps a little wheezing, continue through the day; and the dyspnoea is 
greatly increased by muscular exertion, and by the horizontal posture". The 
patient often complains of weight and distension of the stomach after eating, 
and of other dyspeptic symptoms. In the following night another paroxysm 
occurs with the same symptoms as the first, and with the same declension 
towards morning. This alternation of exacerbation at night and remission 
in the day, is repeated for several days, usually less than a week; when the 
paroxysms, which have been gradually abating in violence, cease altogether, 
and leave the patient in his ordinary health. There is still, however, some 
occasional dyspnoea; or at least this condition is brought on by causes which 
have no such effect upon other persons, showing the existence of a morbid 
predisposition. 
Early in the course of asthma, there is often no return of the phenomena 
above described for a long time. A year, or eyen several years may elapse, 
before the patient experiences another succession^of paroxysms; but more 
frequently they return at the end of six, four, or two months, and sometimes 
recur monthly, though the interval is seldom regular. In general, they in- 
crease in frequency with the duration of the complaint; till at length, in some 
instances, they are brought on by the slightest causes, and the patient is never 
free from the danger of an attack. 
In relation to the physical signs, percussion is usually clear throughout the 
chest, during the paroxysm, when there is no complication; but, notwith- 
standing the violent efforts at inspiration, the ear applied to the thorax is 
sensible of little sound from the entering air; only a faint respiratory mur- 
mur, and occasionally a degree of sibilant or wheezing sound being heard. 
Towards the end of the paroxysm, a temporary relaxation of the constriction 
appears now and then to take place, during which the respiratory murmur is 
heard as in health, but it soon becomes faint again. My young friend, Dr. 
Fitzwilliam Sargent, informs me, that, in several cases of asthma, he has 
observed that, towards the close of inspiration, or even after this has appa- 
rently ceased, sibilant and sonorous rales begin to be heard, and soon spread 
all over the lung, denoting that the spasm of the smaller tubes has yielded to 
the pressure of the air; and the same sounds are continued through the 
expiration. According to Laennec, if a patient be induced to hold his breath 
for a short time, or to count aloud as many numbers as possible without stop- 802 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
ping, and then quietly to commence breathing again, the spasm appears to be 
in a manner surprised into relaxation, and the air can be heard entering all 
parts of the lungs for the next breath or two, after which the ordinary state 
of things returns. This phenomenon may be considered as characteristic of 
spasmodic constriction of the bronchia. Forbes states that, during expiration, 
sound is perceptible over the whole chest, even in the extreme points of the 
lungs; not the sound of healthy respiration, but a loud sibilant or dry sonorous 
rale, corresponding with the wheezing noise usually heard in the paroxysm. 
(Cyclop. of Pract. Med., art. Asthma.') According to Williams, the same 
diminution of respiratory sound is found in the intervals as during the parox- 
ysm, though in a less marked degree; and a similar relaxation, upon holding 
the breath, shows that the affection is still spasmodic. (Tweedie's Sy st. of 
Pract. Med., art. Spasmodic Asthma.) 
When asthma is uncomplicated, it often continues for a great length of 
time without materially impairing the health in other respects; and patients 
sometimes carry the disease into extreme old age. It has, indeed, been 
thought by some to contribute to longevity by warding off other affections; 
but this may well be doubted. Very often it is associated with organic 
diseases, either accidental, or standing towards the asthma in the relation of 
cause or effect. The most frequent of these are diseases of the heart, and 
emphysema of the lungs. It is easy to understand, how either of these may 
be the result of asthma. The pulmonary circulation being impeded by the 
constricted state of the bronchia, the blood accumulates in the right cavities 
of the heart, which may thus suffer dilatation and hypertrophy. As to 
emphysema, the expansion of the chest, under the convulsive action of the 
muscles of inspiration, while the constriction of the bronchia impedes the 
entrance of air from without, causes that contained within the cells to expand, 
and thus to produce dilatation of these minute expansible cavities. When, 
in asthma, near the commencement of the disease, the intervals between the 
paroxysms are free from dyspnoea, should emphysema come on, it may be 
safely considered as a result of the spasmodic affection. 
Appearances after death.-It is asserted that, in many instances, no lesions 
have been found after' death in asthmatic patients, which could account for 
the disease. But, as the uncomplicated cases scarcely ever prove directly 
fatal, there is little opportunity for making the requisite examination, unless 
in instances in which the patient is carried off by some other accidental malady. 
Hence it happens that, in persons reported to have died of asthma, a great 
variety of lesions have been observed, of which it is often impossible to say 
whether they had any essential connexion with the disease, or if so, whether 
the connexion was that of cause or of effect. The only organic affections 
which must be regarded as direct causes of the asthmatic symptoms, are lesions 
of the brain, spinal marrow, or par vagum, either original or consequent upon 
neighbouring tumours. All these are occasionally observed. 
Causes.-A peculiar predisposition is generally necessary to the production 
of asthma by the ordinary exciting causes. These causes may operate in 
equal degree upon great numbers of individuals, and yet occasion asthma in 
but a very few. What is the nature of this predisposition, it is not easy to 
determine. The most that can be said is, that it consists in some inappre- 
ciable modification of the nervous constituents of the bronchial tubes, or of 
the par vagum, or of one of the nervous centres, the influence of which is 
extended to the respiratory apparatus. 
The predisposition is sometimes hereditary. The congenital shape of the 
chest, or of the glottis, has been supposed to have some influence in its pro- 
duction. I believe that it is often connected or identical with the gouty or CLASS III.] 
ASTHMA. 
803 
rheumatic diathesis; and that the paroxysm is nothing more than an attack 
of nervous gout or rheumatism, affecting the respiratory organs. A certain 
general mobility or excitability of the nervous system, such, for example, as 
occurs in hysteria, may be supposed to be favourable to the production of an 
asthmatic predisposition. Indeed, asthma is sometimes probably nothing 
more than hysteria in the lungs. It may occasionally be traced pretty clearly 
to spinal irritation, indicated by tenderness upon pressure of one or more of 
the spinous processes. A similar condition of the nervous system may possi- 
bly be induced by causes of an exhausting or debilitating nature, such as 
excessive venery or masturbation, habitual mental depression, habitual indul- 
gence of any of the stronger passions, profuse evacuations, protracted illness, 
arid the different forms of dyspepsia. It is said that persons much exposed 
to irritating inhalations, whether in the form of gas, vapours, or dnst, are 
peculiarly liable to asthma. I suspect that, except in cases in which the 
predisposition has existed, the result of these causes has rather been bronchitis, 
attended with more or less bronchial spasm, than true asthma. Another pre- 
disposing cause is said to exist in those professions which require in their 
exercise violent and continued respiratory efforts; but, with the same excep- 
tion as above stated, it is highly probable that the dyspnoea is in these cases 
ascribable to emphysema of the. lungs. It is difficult to determine, how much 
influence climate mayrhave ia the production of the asthmatic predisposition. 
The disease would seem to prevail most in moderately cold and moist regions; 
though it is said to be frequent also in very cold and very hot climates. But 
the accounts of writers are somewhat contradictory on this point. 
All ages are liable to the disease; but it is most common in middle age, 
rarely attacks young children, and, though occasionally found in the old, sel- 
dom originates in advanced life. It is more frequent in men than in women, 
except in old age, when it is said to prevail about equally in the two sexes. 
Of the exciting causes, the most frequent is probably cold. Hence, the 
paroxysms are most frequent in winter. Exposure to a very hot air, and the 
hot bath sometimes induce them. It is said that asthmatic patients are pecu- 
liarly apt to suffer from dyspnoea immediately before a thunder-gust, when 
the atmosphere is highly charged with electricity. Patients are sometimes 
affected by what appear to be whimsical causes. Thus, the change from light 
to darkness, the removal from one apartment to another not obviously differ- 
ent, an alteration in the direction of a journey, the shutting of a door, the 
very alarm of an expected paroxysm, are said to have induced attacks. With 
one patient a cold dry air agrees best, with another a damp air; some can 
breathe only a pure atmosphere, others prefer the smoky and contaminated 
air of cities. There can be no doubt that the imagination has much to do in 
directing the agency of various reputed causes. Irritating substances, whe- 
ther aeriform or solid, may excite the paroxysms when inhaled. In peculiar 
idiosyncrasies, certain odours, as that of ipecacuanha, and of new mown hay, 
produce violent attacks of dyspnoea, which are sometimes of the asthmatic 
character. Anything which is capable of irritating the bronchial mucous 
membrane may excite a paroxysm of asthma. The suppression of hemor- 
rhages or other habitual discharges, the sudden disappearance of cutaneous 
eruptions, the retrocession of gout or rheumatism, and various derangements 
of stomach consequent upon dyspepsia, especially flatulence, are enumerated 
among the causes. 
True asthma is occasionally found associated with organic diseases of the 
thoracic viscera. More frequently these induce ordinary dyspnoea, with or 
without some spasm of the respiratory passages. In order that they may 
cause asthma proper, they must act on a predisposition to that complaint. 804 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
Perhaps not one case in one hundred of the difficulty of breathing consequent 
upon pulmonary diseases deserves to be called asthma. In producing this 
disease, they must act either by a direct irritation to the bronchial mucous 
membrane or the nerves which supply it, or by producing congestion in the 
membrane, and thus secondarily acting upon its peculiar nervous suscepti- 
bilities. Tubercles and other tumours in the lungs may operate in the former 
mode, diseases of the heart in the latter. It has been already explained, how 
emphysema of the lungs, which is a frequent accompaniment of asthma, may 
be the result of that affection. We may easily conceive how it may occasion 
dyspnoea; but it is not so easy to understand how it can give rise to the asth- 
matic paroxysm. When the two complaints, therefore, are associated, if there 
be any relation of cause and effect between them, the probabilities are alto- 
gether in favour of asthma as the cause. Bronchitis is another complaint 
very often connected with asthma; and is perhaps the most frequent accom- 
paniment. The same cause which excites the one, will be very apt also to 
excite the other; .and their coincidence is, therefore, not remarkable. It is 
not at all unlikely that the inflammation, once established, may have a tend- 
ency to sustain' the spasmodic constriction of the bronchia, and thus far act 
as a cause of asthma in the predisposed. Should the inflammation be very 
violent, it would constitute the main disease; should the spasmodic symptoms 
preponderate, they would class the case under asthma; and there are occa- 
sional instances in which the two are so nearly balanced, that it would be 
impossible to decide in which category the particular case should be placed. 
Prognosis.-Asthma is occasionally cured, and more frequently relieved; 
but, in the great majority of cases, after being once established, it continues 
with more or less frequent recurrence of the paroxysms until the close of life. 
When uncomplicated, it is almost never fatal, notwithstanding its apparent 
violence; but it is not unfrequently associated with fatal diseases; and there 
is reason to believe that it sometimes produces them, and is thus the remote 
cause of death. A judgment, therefore, as to its results, in any particular 
case, must be founded on the character of the attendant diseases. 
Treatment.-There are two prominent indications in the treatment of 
asthma; one to relax the spasm, the other to correct the predisposition. The 
former is presented in the paroxysm, the latter in the interval. . 
The symptoms of the asthmatic paroxysm so strongly suggest the idea of 
congestion and inflammation of the lungs, that blood-letting is apt to present 
itself to the mind as a necessary remedy. Should the disease be associated 
with considerable bronchitis, and a strong excited pulse, this remedy may be 
employed with propriety; but, in the absence of inflammation, or of decided 
congestion, and when the pulse is at the same time rather feeble than strong, 
it should be avoided as rather injurious than beneficial. One of the most 
effectual means of producing relaxation is the use of emetic substances. These 
may be given so as to vomit, or merely to sustain a considerable degree of 
nausea. Ipecacuanha is perhaps most employed. It may be given in the 
full emetic dose, and afterwards, if deemed necessary, in small doses, so as to 
nauseate. Lobelia, too, has great reputation, and is certainly in some in- 
stances very effectual, though it fails, as every remedy is liable to do, in 
others. I think I have derived more advantage from it than from any other 
single remedy. Tartar emetic and squill have also been employed. Colchi- 
cum administered so as to produce moderate nausea, is especially applicable 
to gouty cases. The emetic and nauseating treatment generally is best 
adapted to the disease, when associated with a degree of bronchial inflam- 
mation. CLASS III.] 
ASTHMA. 
805 
Antispasmodics are often very useful in the purely spasmodic cases. Sul- 
phuric ether, assafetida, and musk, are among the most effectual; and they 
are often usefully associated with one of the salts of morphia. They are espe- 
cially beneficial in hysterical cases. Strong coffee is also much employed, and 
is often serviceable. It should be saturated, and a cup full-taken every twenty 
or thirty minutes. As it loses its effects somewhat upon repetition, it is a 
good plan to abstain from its habitual use at meals. Inhalation of the vapour 
of chloroform has been resorted to with success. 
Certain narcotics have been much and beneficially employed. . Some cau- 
tion, however, is requisite in their use. When the asthma is associated with 
hypertrophy of the heart, and a tendency to cerebral congestion, or when the 
affection has resulted from translated gout, especially in persons of an apo- 
plectic habit, they may prove dangerous by making the brain the centre of 
irritation, and consequently of an afflux of blood. The death of asthmatic 
patients has been ascribed, in repeated instances, to the use of narcotics. Stra- 
monium is the one which enjoys the highest reputation. It is employed 
almost exclusively by smoking the dried leaves or stems, like tobacco. The 
relief which it affords is sometimes great and immediate. It is most efficient 
when used at the commencement of the paroxysm. But it not unfrequently 
fails, and has sometimes proved highly dangerous and even fatal in its effects, 
by inducing coma. It should; therefore, always be used with due reference 
to the cautions above given, and should be omitted as soon as it produces 
vertigo or nausea. The smoking of tobacco also occasionally affords great 
relief. Opiates are very useful in the purely spasmodic cases, without tend- 
ency to cerebral disease. The salts of morphia are perhaps preferable to the 
other preparations. They may often be usefully associated with the other 
medicines employed, as with sulphuric ether and colchicum. Hydrocyanic 
acid has been recommended; but, to produce a decided impression, it must 
be employed in quantities which may readily become hazardous. 
Besides the three classes of medicines above mentioned, many other reme- 
dies have been used with greater or less advantage in the paroxysm. The 
application of electricity or electro-galvanism has occasionally arrested it. 
The same may be said of cold water, dashed in the quantity of a pail-full 
over the shoulders. The simultaneous use of cold drinks and hot pediluvia 
has been recommended. Sinapisms or other powerful rubefacients to the 
chest sometimes afford relief; but there is danger that some of the more 
volatile substances of the class may increase, by their vapours, the sense of 
suffocation. Insufflation of the lungs by a pair of bellows is among the means 
which are said to have been used with advantage. The inhalation of the 
fumes of burning paper, previously impregnated with a saturated solution of 
nitre and dried, is asserted to be sometimes very effective. It is best that 
the paper should have been dipped a second time into the solution and dried. 
It may be either burned in the chamber, or smoked by means of a pipe. M. 
Bayer applies solution of ammonia, by means of a roll of lint moistened with 
it, to the velum pendulum palati, for a few seconds, and with almost uniform 
advantage. The patient is at first seized with a feeling of suffocation, which 
is followed by coughing and copious expectoration, and soon afterwards with 
great relief. (Am. Journ. of Med. Sci., N. S., xiii. 165, from Annaies de 
Therapeutiqued) In cases attended with spinal tenderness, cups or leeches 
should be applied over the tender vertebras, and followed in due time, by strong 
ammonia, a fly blister, or tartar emetic ointment. The apartment should be 
well aired, all articles of dress that in any degree restrain the movements of 
the chest should be removed, as few assistants as will answer the purposes of 806 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
attendance should remain in the room, and smoke and other exhalations should 
be carefully avoided. 
In the interval, our efforts should be directed to the removal of the morbid 
tendency; and, for this purpose, every discoverable deviation from health 
should be corrected as far as practicable. It is impossible to particularize all 
the remedies that may be employed. The attention should be directed parti- 
cularly to the state of the stomach and bowels. Dyspeptic symptoms may 
require antacids, carminatives, and tonics; constipation, laxatives; deranged 
hepatic secretion, the mercurial alteratives. In the female, the menstrual 
function should be kept in order. In gouty cases, moderate doses of colchi- 
cum may be found beneficial. Anemia and general debility must be counter- 
acted by tonics and a suitable regimen. If chronic bronchial inflammation 
exist, it should be treated with local depletion, blistering, the stimulating and 
nauseating expectorants, &c. Any remains of the spasm, connected with the 
inflammation, may be advantageously treated with tincture of lobelia, asso- 
ciated with ipecacuanha wine or syrup, the tincture or syrup of squill, or the 
syrup of seneka. In some cases, the metallic tonics which prove useful in 
nervous affections, as chorea, epilepsy, hysteria, and neuralgia, have the effect 
of interrupting or postponing the paroxysms. For this purpose may be 
employed, subnitrate of bismuth, oxide and sulphate of zinc, ammoniated 
copper, nitrate of silver, and' the chalybeates, which may sometimes be con- 
joined with small doses of opium. When the paroxysms occur at precisely 
regular intervals, with complete intermission, there will be some chance of 
interrupting them by sulphate of quinia. Strong moral or physical impres- 
sions of any kind will sometimes avert them. Dr. Lefevre, a French physi- 
cian, who published a paper on asthma, used frequently to set aside a paroxysm, 
in his own case, by having his bed heated, or heating himself before a fire. 
( VaUeix, ii. 564.) 
The diet should be easy of digestion and nutritious, yet not stimulating. 
Caution should be particularly observed not to overload or distend the sto- 
mach. Alcoholic drinks, as well as the habitual use of tea and coffee, should 
be forbidden. Advantage will sometimes accrue from the daily use of the 
shower-bath, or sponging the chest with cold water or salt and water; but 
these means should not be employed unless followed by immediate reaction. 
Exercise is highly useful, especially on horseback. The place of abode should 
be chosen in reference to the particular experience of the patient, that being 
preferred which is found to suit him best. As a general rule, a mild equable 
climate, neither very moist nor very dry, is the most favourable. Travelling 
is sometimes highly advantageous. In this as in other habitual nervous affec- 
tions, it may be found useful to surround the patient with entirely new circum- 
stances, so that a new set of impressions may be made on his nervous system. 
A long voyage, or a protracted journey abroad, would offer some hope of a 
permanent cure, when no organic disease existed.