A 
TREATISE 
ON THE 
PRACTICE 0E MEDICINE, 
BY 
GEORGE B. WOOD, M.D., 
PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF 
PENNSYLVANIA; 
PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; 
ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL; 
ONE OF THE AUTHORS OF THE DISPENSATORY OF THE UNITED STATES OF AMERICA; 
ETC. ETC. 
FOURTH EDITION. 
IN TWO VOLUMES. 
VOL. I. 
PHILADELPHIA: 
LIPPINCOTT, GRAMBO, AND CO. 
No. 20 NORTH FOURTH STREET. 
1855. Entered, according to the Act of Congress, in the year' 1855, 
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. TO 
I 
N. CHAPMAN, M.B., 
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. 
Philadelphia, January 1847. PREFACE 
TO THE 
FIRST EDITION. 
In adding another to the many 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 impulses 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 reme- 
dies, 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, he 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 
exclusive originality. The sources of our knowledge are so various, 
we learn so much from books, and hear so much from others, in addi- 
tion 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 wherevei' 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 fol- 
lowing 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, 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 
FOURTH EDITION. 
From the original preface it may be gathered that the design of the author, 
in preparing this work, was to present, along with the results of his own per- 
sonal observation, experience, and reflection, in reference to the Practice of 
Medicine, such a view of this important department of medical science, as 
fairly to represent its general condition at the time. He wished, and spared 
no pains, to make the Treatise a safe and useful guide to the student and 
young practitioner; and was not without the hope, that the old and expe- 
rienced might find something in it to aid them in the clearer understanding 
and treatment of disease. From the speedy exhaustion of three successive 
editions, all of them large, he feels justified in concluding that the work has, 
in some degree, met the wants of the profession; and the favour with which 
it has been received has served as a strong stimulus to him, in the several 
revisions it has undergone, to make it still more worthy of approval by in- 
creasing its practical usefulness. Since its first publication in 1847, there 
has been great activity almost everywhere of the medical mind; and a flood 
of new facts, observations, and speculations has been poured forth in the 
journals, in monographs, and in treatises more or less general, from which 
the author has faithfully endeavoured to gather whatever appeared to him 
true, and likely to be useful. In every revision, numerous alterations and 
additions have been made; and if, at present, the work is not better calculated 
than at any former time to fulfil the purposes for which it was written, the 
fault must be ascribed to the want of ability, and not to that of earnest en- 
deavour, on the part of the author. One object with him has always been 
to increase its bulk as little as possible consistently with its more important 
qualities. This object he has sought to accomplish by studying brevity 
of expression; and it is surprising how much may be gained by sacrificing 
words, useless if not weakening to the sense, which, nevertheless, constantly 
present themselves to the writer, and are apt to escape a careless attention. 
As the reader will readily perceive, the same end has been promoted by con- 
sulting economy of space ; so that few original works, it is presumed, will be 
found, which, with the same size of type, contain more printed matter within 
given limits than this. The author, therefore, ventures to hope that any 
increase in the value of the Treatise will be estimated, rather by the improved 
quality and greater amount of its matter, than by the number of its pages; 
though it has been found necessary also to swell the volumes considerably. 
With these prefatory remarks, he offers the work for the fourth time to the 
medical public, quite confident, from previous experience, that the profession 
will be disposed to judge favourably of his efforts, and to give them all the 
countenance they may be found to merit. 
Philadelphia, January, 1855. TABLE OP 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 II. Inflammation. 
Article III. Depression. 
Article IV. Congestion. 
Article V. Fever. 
Article VI. Disease with Peculiar Products. 
1. Tuberculosis. - 2. Melanosis. - 3. Organized Non-malignant Pro- 
ducts.-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. 
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. Smallpox, or Variola. 
Article VIII. Vaccine Disease. 
Article IX. Chickenpox, or Varicella. 
Article X. Measles, or Rubeola. • 
Article XI. Scarlet Fever, or Scarlatina. 
Article XII. Erysipelas. 
Article XIII. Glanders. 
Article XIV. Dengue. 
CLASS IL 
CONSTITUTIONAL DISEASES. 
Article I. Rheumatism. 
Article II. Gout. TABLE OF CONTENTS. 
XI 
CLASS ILL 
LOCAL DISEASES. . 
Section I. 
DISEASES OF THE DIGESTIVE SYSTEM. 
Subsection I. 
DISEASES OF THE MOUTH. 
Article I. Inflammation of the Mouth, or Stomatitis. 
1. Common diffused inflammation. -2. Diffused Inflammation with Curdy 
Exudation, or Thrush. - 8. Follicular Inflammation.-4. Eruptive 
or Vesicular Inflammation. - 5. Ulcerative Inflammation, or Can- 
ker.- 6. Sore-mouth of Nursing Women. - 7. Gangrenous Inflam- 
mation.- 8. Mercurial Inflammation. 
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 CESOPHAGUS. 
Article I. Inflammation of the Fauces, or Angina. 
1. Common Inflammation of the Fauces, or Simple Angina.-2. Pseudo- 
membranous Inflammation.-3. Ulcerative Inflammation. 
Article II. Inflammation of the Tonsils, or Tonsillitis. 
Article III. Inflammation of the Pharynx, or Pharyngitis. 
Article IV. Inflammation of the CEsophagus, or GEsophagitis. 
Article V. Stricture of the Oesophagus. 
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 In- 
testines, or Enteritis.-3. Dysentery. 
Article II. Cancer of the Bowels. 
Article III. Irritation of the Bowels. 
1. Diarrhoea.-2. Colic, including Simple Spasmodic Colic, Bilious Colic, 
Colic from Obstruction, Rheumatic Colic, and Neuralgic Colic.- 
3. Lead Colic. XII 
TABLE OF CONTENTS. 
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. Fissures of the Anus. 
Article X. Prolapsus Ani. 
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 Inflam- 
mation of the Nostrils, or Ozrnna. 
Article II. Inflammation of the Larynx, or Laryngitis. 
1. Acute Laryngitis, including Mucous Laryngitis, Submucous Laryn- 
gitis, and Pseudo-membranous Laryngitis.-2. Chronic Laryngitis. 
Article III. Inflammation of the Bronchia, or Bronchitis. 
1. Acute Bronchitis.-2. Chronic Bronchitis. - 3. Catarrh.-4. Influ- 
enza.- 5. Croup, including Catarrhal Croup, and Pseudo-mem- 
branous 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.-4. Laryngeal and Tra- 
cheal Pains. 
Article II. Hooping-cough, or Pertussis. 
Article III. Nervous Cough. 
Article IV. Asthma. TABLE OF CONTENTS. 
XIII 
Subsection III. 
ORGANIC DISEASES 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. 
Subsection IV. 
FUNCTIONAL DISEASE OF THE PULMONARY TISSUE. 
Article I. Loss of Breath, Apnoea, or Asphyxia. 
Section IV. 
DISEASES OF THE CIRCULATORY SYSTEM. 
Subsection I. 
DISEASES OF THE HEART. 
Article I. Inflammation of the Pericardium, or Pericarditis. 
Article II. 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. 
1. Atrophy.-2. Softening. - 3. Degeneration and Abnormal Products, 
including Eatty Degeneration, Tubercles, &c.-4. Rupture.-5. 
Polypous Concretions. - 6. Malformation with Cyanosis. 
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, or Purulent Infection.- 
3. Chronic Phlebitis. 
Article II. Varicose Veins. XIV 
TABLE OF CONTENTS. 
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 in general. 
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 VII. Hemorrhage from the Rectum, or Bleeding Piles. 
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. 
DISEASES OF THE ORGANS OF SECRETION. 
Subsection I. 
DISEASES OF THE SEROUS AND CELLULAR TISSUES. 
Article I. Dropsy in general. 
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. Acne.-4. Rosacea. - 5: Sycosis. 
Article V. Scaly Diseases. 
1. Psoriasis.-2. Lepra, or Leprosy. - 3. Pityriasis.-4. Ichthyosis. TABLE OF CONTENTS. 
XV 
Article VI. Tuberculated Diseases. 
1. Elephantiasis of the Greeks.-2. Lupus.-3. Molluscum.-4. Yaws, 
or Framboesia.-5. Keloid. 
Article VII. Discolorations, or Maculae. 
1. .Lentigo, or Freckles.-2. Ephelis. - 3. Naevus. - 4. Albinism.- 
5. Vitiligo. 
Article VIII. Cryptogamous affections. 
1. Porrigo, or Favus.-2. Trichosis. 
Article IX. Unclassified Skin Diseases. 
1. Elephantiasis of the Arabians.-2. Pellagra. 
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. 
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 
Hydatids.-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 Blad- 
der, and Strangury. - 2. Disorders of Secretion and Excretion. 
Article VII. Diuresis. XVI 
TABLE OF CONTENTS. 
Article VIII Diabetes. 
Article IX. Suppression of Urine. 
Article X. Lithiasis. 
1. Uric Acid Lithiasis, or Lithic Gravel.-2. Phosphatic Lithiasis.- 
3. Oxalic 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. 
Article IV. Functional Disease of the Brain. 
1. Nervous Irritation.-2. Vascular Irritation, or Active Congestion.- 
3. Depression.-4. Mechanical, or Passive Congestion. ■-5. Head- 
ache, or Cephalalgia. - 6. Stupor and Wakefulness. - 7. Ecstasy. 
- 8. Somnambulism. - 9. Artificial Somnambulism. -10. Con- 
vulsions. -11. Catalepsy. 
Article V. Insanity. 
Article VI. Delirium Tremens. 
Article VII. Epilepsy. 
Article VIII. Chorea. 
Subsection IL 
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 is also 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 preventing 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 
numerous hypotheses which have risen and disappeared, in rapid succession, 
in this as in other departments of medicine. 
1 2 
general pathology. 
[part I. 
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 subordi- 
nate 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 probable termination-a branch of general pathology which 
may be designated as symptomatology; and fourthly, of the general prin- 
ciples 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 great 
apparent diversity is produced. These constituent morbid states bear to 
diseases, in their ordinary forms, the same relation that the proximate prin- 
ciples 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 containing 
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 nature 
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 associations of morbid 
states or actions usually called diseases. It may be admitted, as a self- 
evident proposition, that disease has its seat in the fluids or solids of the 
body, or in both. CHAP. I.] 
DISEASE OF THE FLUIDS. 
3 
SECTION I. 
DISEASE OF THE FLUIDS. 
In relation to the fluids of the body, our pathological knowledge, though 
greatly advanced within a few years, is still very deficient. There can be no 
doubt that all of them are occasionally unhealthy in their condition; and 
there can be as little doubt that, in this unhealthy condition, many of them 
may become the sources of serious disease. 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 pre- 
valence of the Humoral Pathology, it was customary to ascribe most oom- 
plaints 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 prevails; 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 con- 
sist 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^uthe blood from which they are derived, or of the 
organs by which they ye elaborated; if they become deranged after their 
fornJjk^sspmetim® happens with the bile, urine, and some others, it 
mu^JProwmg to theism due detention, or an undue influence of surround- 
ing parts upon them.j®either of which cases the solids are in fault. 
1. There can be i^Bioubt that the blood is very frequently the source of 
diseases, by serving aW 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. The body itself affords sources of a similar deleterious impregna- 
tion. Thus, the fetid contents of the bowels, if long retained, .are often 
partially taken up by the veins or absorbents; and, in cases of mortification, 
the putrid results of that process may follow the same course into the circula- 
tion. Various morbid products, the results of deranged secretion, such as 
pus and the sanies of unhealthy ulcers, occasionally find an entrance into the 
blood-vessels; and 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. In all these instances, there can be no doubt that the noxious 
matters prove injurious to health by coming into contact everywhere with the 
tissues, and deranging their condition or function. How far they may act 
also directly on the blood, is a point for subsequent consideration. 
2. Another source of vitiation in the blood is the accumulation of certain 
principles, which, normally existing in that fluid in very small proportion, 
are usually thrown off by The excretory functions, and, when retained, are 
capable of exercising a highly injurious influence. This accumulation may 4 
GENERAL PATHOLOGY. 
[part I. 
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 economy in a healthy 
state, but is thrown off by the kidneys so as not to be readily discovered in 
the blood. In persons who live chiefly on animal food, and take little exer- 
cise, the quantity of this acid is sometimes very much increased, so that it is 
not only secreted in unusual abundance by the kidneys, constituting gravel, 
but is also deposited in other parts of the body, especially in the joints and 
fibrous tissues. It is not improbable that its accumulation 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 yith 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. Bernard has proVed that 
glucose or grape sugar is generated as a normal product in the liver, and 
thence carried to the lungs where it is consumed. If too largely generated 
in the former organ, or insufficiently consumed in the latter, it enters the 
general circulation, and, being thrown off by the kidneys, gives rise to dia- 
betic urine. There is reason to believe that other principles, elaborated by 
the digestive and absorbent processes, or resulting from the partial disinte- 
gration which the blood itself, as well as all other constituents of the body, 
are perpetually undergoing in their normal operations, exist in the circula- 
tion, and prove innocent in health only because they are rapidly eliminated 
with the urinary, cutaneous, pulmonary, or intestinal secretion. Hence, 
probably, one of the sources of the numerous evils which result from the sup- 
pression of these secretions. In certain febrile conditions',Ahe sour breath 
and sour perspiration evince the existence of an acid in the blood, which pro- 
bably aids other causes in sustaining the disease, ancHlhe elimination of which 
may be one of the advantages of diaphoretic medicines in thgs^cmJ^^its. 
3. Hitherto, we have considered the blood as Satiated ii^con^|^nce 
either of some foreign principle being admitted int^k or of the accumula- 
tion of some principle which, though naturally ent^ME the circulation, is, 
in the healthy state, thrown out as fast as it enters.^But it must also be 
regarded as in a morbid state, when any one of its ordinary and essential 
constituents 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 ma- 
terials, 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. Healthy blood contains 
in 1000 parts from 110 to 140 parts of the red corpuscles, from 2'5 to 3'5 
parts of fibrin, and from 65 to 70 parts of pure albumen. Any considerable 
excess or deficiency of either or all of these ingredients, in reference to the 
numbers mentioned respectively, must be regarded as morbid.* 
* It may be useful to present to the student a slight sketch of the constitution of 
the blood, as now generally admitted. This most important constituent of the system 
consists of a liquid denominated liquor sanguinis, in which float certain minute organ- 
ized bodies, denominated corpuscles, which only the microscope can render distinctly 
visible. The liquor sanguinis consists of water, holding in solution or intimate ad- 
mixture fibrin, albumen, extractive and fatty matters, and various salts. The corpuscles 
are of two kinds, one denominated red corpuscles, to which the blood owes its colour, CHAP. I.] 
DISEASE OF THE FLUIDS. 
5 
Sometimes, under the influence of a rich diet and vigorous digestion, with 
a comparative deficiency in the nutritive process, the solid organic principles 
and the other, in comparatively very small proportion, called white or colourless cor- 
puscles. Besides these ingredients, there is held in solution more or less gaseous 
matter, which is chiefly oxygen and carbonic acid, the former existing in the arterial, 
the latter in the venous blood; and a volatile principle which, when the blood is drawn, 
is exhaled with a peculiar and characteristic odour. These may be considered as 
proper constituents. But the blood also contains minute quantities of urea, bilious 
colouring matter, and probably various other substances, the results of its own disin- 
tegration, or that of the solid tissues, which are present in it merely in order that they 
may escape from the system, and in fact, in the healthy state, are eliminated as fast 
as they originate in or enter it. 
MM. Guillot and Leblanc believe that they have detected casein as a normal con- 
stituent of the blood. The proportion has not been ascertained; but it appears to be 
inconstant, though the principle is always present in health. It is peculiarly abundant 
in the female during lactation. (Archives Generales, 4e ser. xxiv. 364.) 
When removed from the body the blood undergoes a new arrangement of its con- 
stituents. The fibrin, before held in solution, now spontaneously coagulates, involving 
the corpuscles, and forming the clot, which at first holds the liquid part mechanically 
entangled in its meshes, but gradually separates from it by a firmer contraction. The 
liquid thus deprived of the fibrin is called the serum, and contains the albumen, salts, 
and extractive and fatty matters of the liquor sanguinis. 
The red corpuscles, which are cells containing a red liquid, are not chemically 
homogeneous, but consist of various substances, most of which are identical or analo- 
gous with the constituents of the liquor sanguinis, but one at least, denominated 
hematosin, is quite distinct, being the principle to which the red corpuscles and conse- 
quently the blood owe their colour, and having this striking peculiarity, that it con- 
tains a definite proportion of iron as one of its elements. M. Le Canu gives the 
following as the result of his latest researches into the chemical composition of the 
red corpuscles: 1. hematosin or red colouring principle; 2. albumen, and extractive, fatty, 
and saline matters, differing in nothing from those of the serum; 3. globulin, an albu- 
minous substance, but distinguishable from ordinary albumen by its solubility in hot 
diluted alcohol, and by forming with cold water a solution, which is not troubled by 
the subacetate of lead; and 4. a fibrinous substance constituting the envelope or cell- 
wall of the red corpuscles, and differing from ordinary fibrin in being insoluble, even 
at a boiling temperature, in a solution of potassa containing one-tenth of the alkali. 
(Journ. de Pharm. et de Chim. 3e ser. xxii. 339.) 
Of the chemical nature of the white corpuscles little is definitively known. They 
are believed to be identical with the lymph corpuscles, and to enter the circulation 
with the fluid of the thoracic duct. It has been rendered highly probable that they 
constitute a stage in the development of the red corpuscles. No method has yet been 
discovered of ascertaining their exact relative amount in the blood, but, compared with 
the red corpuscles, they are in very small proportion in health. 
For a more particular account of the properties of the constituents of the blood 
above mentioned, the reader is referred to the recent anatomical and physiological 
works. It will be sufficient here to call his attention to some of the latest observa- 
tions, which may not yet have found their way into systematic treatises. 
From the researches of Doctors Leconte and de Goumoens it appears that albumen, 
fibrin, and globulin, as well as other albuminoid substances, are always composed of 
two distinct chemical constituents, one soluble and the other insoluble in crystallizable 
acetic acid. In fibrin, the first of these constituents has when isolated the form of 
granules, the second retains that of fibres. As obtained from albumen or globulin, 
they cannot be distinguished by the microscope, but still have precisely the same che- 
mical characters as those of fibrin. These are interesting facts, having a strong bear- 
ing on the physiological properties of albuminoid substances, and tending to show a 
higher grade of fibrin than of the others, in reference to organization. (Archives 
Generates, Juin 1853, p. 681.) 
The fact is stated by M. Verdeil, that hematosin has strong analogies with chloro- 
phylle, or the green colouring matter of plants, when freed from a fatty impurity asso- 
ciated with it as ordinarily obtained. {Chern. Gaz. Feb. 16, 1852, p. 74; from Comptes 
Rendus, Dec. 1851.) In reference to hematosin, another interesting statement, which 
at present must be looked on rather as a probable conjecture than as a fact, is that 
the colouring principles of the urine and the bile, are merely altered conditions of that 6 
GENERAL PATHOLOGY, 
[PART I. 
of the blood increase so much as to constitute a state of disease. The blood 
is intensely red, and, when 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 local 
inflammation or hemorrhage. 
Again, owing to a meager diet, feeble digestion and sanguification, and 
various exhausting agencies, separate or combined, a condition of the blood 
often 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 digestive process, so that the defi- 
ciency must be supplied by the absorption of watery fluid. I have had under 
my care a case, in 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 a variety of the disease called anaemia, 
wJiich will be fully described hereafter. 
principle, resulting from the normal disintegration of the red corpuscles after the 
period of their active life is past. 
As useful to the reader for reference in the perusal of this work, the following tables 
of the composition of the blood are given, offering the average of the results obtained 
by numerous experimentalists. They are taken from the last edition of Kirkes and 
Paget's Manual of Physiology. 
P. Chief constituents in 1000 parts of the blood. 
Water 784.00 
Red corpuscles . . . . 131.00 
Albumen of the liquor sanguinis 70.00 
Fibrin . . . . . .2.20 
Extractive and fatty matters, &c. . 6.77 
Saline matters .... 6.03 
Water . . . . . "784.00 
Albumen . . . . .70.00 
Fibrin ..... 2.20 
2. All the constituents in 1000 parts. 
Chloride of sodium . 3.60 
Chloride of potassium 0.36 
Tribasic phosphate of 
soda . . . 0.20 
Carbonate of soda . 0.84 
Sulphate of soda . 0.28 
Phosphate of lime and 
magnesia . .0.25 
Oxide and phosphate of 
iron . . .0.50 
Globulin . . . 123.50 
Hematin . . . 7.50 
Red Cor- 
puscles. 
(Jholestenn . . 0.08 
Cerebrin . . . 0.40 
Serolin . . . 0.02 
Oleic and margaric 
acids, volatile and 
odorous fatty acid 
Fat containing phos- 
phorus 
Inorganic 
Salts. 
Fatty 
Matters. 
0.80 
Extractive matter, with salivary 
matter, urea, biliary colouring 
matter, gases, and accidental 
substances .... 5.47 
The fibrin must be considered as including the white corpuscles, which chemists 
have yet been unable to examine separately. The proportion of fibrin given in the 
above table is below the average generally admitted, which is about 3 in 1000 parts. 
It should be stated that arterial blood differs in the proportion of its constituents 
from venous; containing, according to Dr. J. B4clard, more of the red corpuscles and 
somewhat less of the fibrin. From the experiments of the same physiologist it would 
appear that, while the arterial blood is identical in all parts of the system, the venous 
differs in different situations. Thus, the blood returning from the spleen contains 
less of the red corpuscles and more of the albumen and fibrin than the venous blood 
of the general system; while that of the mesenteric veins varies according to the 
period of digestion, having a considerable increase of albumen with diminution of the 
red corpuscles in the early stage of digestive absorption, and precisely the reverse 
condition after the absorption has been completed. (Archives Generales, 4c ser. xviii. 
442.) It has been stated in the text that, according to the observations of Bernard, 
glucose or grape sugar is found as a normal constituent in the blood of the liver, and 
in the route of the circulation thence to the lungs, but in no other part. CHAP. I.] 
7 
DISEASE OF THE FLUIDS. 
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 serum, 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 dimi- 
nished 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, the loss of blood, and various ex- 
hausting diseases; and it is a singular 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. 
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 other animalized constituents. 
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 buffy 
coat. It probably predisposes to hemorrhages, and diseases of a low charac- 
ter; 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 circum- 
stances which contribute especially to its excess do not appear to have been 
well ascertained. That a superabundance of it is often connected with the 
inflammatory condition, either as cause or effect, would appear to be esta- 
blished by the experiments of Dr. Traill and M. G-endrin, who found nearly 8 
[part I. 
GENERAL PATHOLOGY. 
twice as much albumen in the serum of the blood in that condition as in 
health. {AndraVs Precis, &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. {Simon1 s Chemistry, i., 252.) It has 
been stated that the fibrin of the blood increases during inflammation. It 
is very probable that this increase takes place at the expense of the albu- 
men. If this be the case, we can readily understand the different results 
obtained by experimenters. The albumen may be excessive in the blood 
before and at the commencement of the inflammation, but may become defi- 
cient 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 predominance 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 conse- 
quence 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. 
A morbid state of the blood has recently attracted attention, in which the 
white or colourless corpuscles are in great excess. The name of leucocythe- 
mia has been proposed for it by Professor Bennet of Edinburgh, by whom a 
detailed account of it was first presented to the profession. It is unneces- 
sary to say more of it in this place, as it will be fully treated of among the 
special diseases of the blood. 
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 
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 thirst equal to that which attends the highest state of fever. 
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 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, how- 
ever, may be attributed also in part to a concentration of the colouring mat- 
ter, 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. 
Eatty matter, which has 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 CHAP. I.] 
DISEASE OF THE FLUIDS. 
9 
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 prin- 
ciple which proves noxious when in excess, or to the want of that oxygena- 
tion which it is generally believed that the blood undergoes in the lungs, is 
a point which yet remains undecided. 
4. Lastly, the blood may become diseased by changes in the character, 
as well as in the relative quantity of its constituents. Such changes may 
happen in various ways, independently of the entrance into the circulation of 
any foreign principle. There are not wanting facts to show that they may 
result from disordered nervous influence. If, under such influence, the pro- 
ducts of secretion performed in the capillaries may become unhealthy, as is 
generally believed, there can be no difficulty in admitting 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 che- 
mical agency without it; viz., heat, light, and electricity. The effect of 
lightning in altering the condition of the blood is well known. In the capil- 
lary circulation, moreover, where the particles of the blood come into exceed- 
ingly close relation with those of the solids, where, probably through cell- 
action, 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, when perverted, of 
producing a complete revolution in the state whether of the blood or of the 
fixed tissues. Again, the kind of food out of which the blood is made by 
the assimilative processes, may affect the character 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 abstinence from fresh vegetable food, 
with other co-operating causes. Finally, as blood probably possesses in some 
degree a self-developing power, converting its unorganized ingredients, such 
as albumen, oil, &c., into living germ-containing matter, and elevating its 
lower into its higher forms, as the white probably into the red corpuscles, it 
follows that changes in its state of healthy power may lead to irregularities 
in its physical constitution, and consequently in the proportion and character 
of its several constituents. 
But probably the most frequent cause of morbid alteration in the character 
of the blood is the influence of various deleterious agents which are ab- 
sorbed into or otherwise enter the circulation either from without, or from 
sources within the body itself. That the blood is materially changed in this 
way no longer admits of a doubt.' The injection of putrid substances into 
the veins is followed by a loss of coagulability in the blood, and a tendency 
to more speedy decomposition; and the same effects have resulted from the 
influence of certain poisons. It is highly probable that the various delete- 
rious substances before referred to as finding an entrance into the circulation 
(see page 3), change the blood by a direct influence upon it, independently 
of any derangement they may produce in the blood-supplying functions. 
Foreign substances in the circulation may alter the blood in three different 
methods. In the first place they may produce the effect by chemical reac- 
tion with one or more of the constituents of that fluid. In the second place, 
they may by their mere presence set on foot chemical changes, or a series 
of changes in the blood, upon the principle of a ferment. Thirdly, they 10 
[part I. 
GENERAL PATHOLOGY. 
may act upon the vital properties or susceptibilities of the living and organ- 
ized constituents of the blood, modifying their condition and powers, pre- 
cisely as they derange the living solids through a similar influence. 
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 red corpuscles are often changed is to be infer- 
red from the greatly altered colour of the blood in certain diseases, as in bad 
cases of scurvy and in malignant fevers, in which it is sometimes almost black, 
and also from the fact that the corpuscles themselves are occasionally, in 
morbid states of the blood, found dissolved in the serum. The coagulability 
of the fibrin is sometimes so much augmented, that it 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 
examined in the vessels after death, is found to coagulate but feebly, and 
sometimes to be incapable of coagulation altogether. We find this condi- 
tion in some cases of purpura, not to speak of malignant fevers, and certain 
poisonous affections, in which the cause of this change in the blood is wholly 
or in part derived from without. It is highly probable that the fibrin under- 
goes, through the direct agency of deleterious substances absorbed, especially 
the sanies from unhealthy ulcers, abscesses, &c., another modification, ap- 
preciable only in its results, by which its vital force is impaired, and it is 
rendered incapable, when thrown out of the blood-vessels, of becoming duly 
organized, so that it is degraded into pus, or other morbid product. Cases 
are on record in which air has been evolved from the diseased blood in 
such quantities as to cause death. If it be admitted that the blood may 
thus become deranged through influences operating directly upon itself, the 
inference cannot be avoided that diseases may have their essential seat in 
that fluid, even though the symptoms may also indicate great derangement 
of the solids; for the blood is so essential both as an excitant and nutritive 
agent to all the functions and tissues, that they must all feel its deficiencies, 
and express that feeling in various morbid phenomena. Purpura and scurvy 
are now generally believed to have their seat primarily and essentially in 
the blood; and the present tendency of medical opinion is to include in 
the same category all febrile affections dependent on an absorbed poison, 
whether malarial or contagious, as typhus fever, yellow fever, small-pox, 
measles, scarlet fever, erysipelas, &c. But there is some danger that, in 
the reaction from the old exclusive solidism, we may go too far, and with our 
attention engrossed by the diseased state of the blood, may overlook the 
obvious fact, that the very agents which are thus changing the blood, have 
probably also an equal power to act deleteriously on'all the tissues with 
which they may be brought into contact, and that the circulating fluid, 
instead of being the special seat of the disease, merely participates in the 
universal derangement. 
The blood, and the solids through which it circulates, are so intimately 
related, their mutual reactions are so constant and essential, that any dis- 
order 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, performed with the blood of a healthy animal, is usually 
followed by no serious results; thus proving that the blood participates in CHAP. I.] 
DISEASE OF THE SOLIDS. 
11 
the disease of the solids. It is probable that, in many cases, morbid im- 
pressions are simultaneously made upon both. In many others, it is impos- 
sible 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 thirdly, the typhoid condi- 
tion; and whether the fluids or the solids be considered 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 investigated 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 patho- 
logy 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 exclu- 
sively 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. 
DISEASE FROM MECHANICAL OR CHEMICAL CAUSES. 
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 
derangements to which they give rise, that they cannot be separately con- 
sidered with advantage. Little more, therefore, need here be done than to 
arrange them under heads corresponding with their causes, so that the 
student may have a general view of the whole in a regular order. 12 
[PART I. 
GENERAL PATHOLOGY. 
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 
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 will 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 exces- 
sive 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 in- 
fluence, 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 
counteract any degree of this influence to which the system is ordinarily 
exposed. But, when excessive, it is capable of producing local derange- 
ments 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 circumstances, a tendency to subside into the lower ex- 
tremities, where it accumulates 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 people. 
The forces which move the blood are too feeble to overcome the influence 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 CHAP. I.]» 
DISEASE OF THE SOLIDS. 
13 
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 
capillaries, the functions of 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, the artery 
be obstructed, the part in which it ramifies languishes from the want of 
blood, and may perish from the same cause, if the caliber of the vessels be 
quite obliterated, and the blood be unable to find its way through the anas- 
tomosing 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 de- 
ficient absorption. The obstructing cause is often such as to affect more 
than one of these sets of vessels, and the results are modified accordingly. 
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 indurated glands, aneurisms, the impregnated uterus, diseased contrac- 
tions 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 organ with 
the usual rapidity, the portal vein 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 in- 
tended for the escape of secreted fluids, give rise to a series of morbid phe- 
nomena, 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 dis- 
tension, 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 neighbouring 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 pres- 
sure 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 necessarily accumulates behind the point of closure, 
and there is danger of rupture of the ducts or of the gall bladder, and of 14 
GENERAL PATHOLOGY. 
t [PART I. 
fatal effusion into the abdominal cavity. The colouring matter and probably 
other principles of the bile may be absorbed; and, as the secretory action 
of the liver is restrained by the pressure of the fluid accumulated in the 
ducts, the bilious matter ceases to be eliminated as 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 kidneys, giving rise to jaundice. A similar train of conse- 
quences follows an obstruction of the ureters. 
The causes of such obstruction may be external tt) 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 of obstruction in the respiratory pas- 
sages 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 similar cases, the me- 
chanical results are so intermingled with vital derangements, or so imme- 
diately followed by them, and the latter are so much the more important, 
that the cases are most advantageously treated of in connexion with these 
derangements. 
SUBSECTION IL 
DISEASE FROM INFLUENCES UPON THE VITAL PROPERTIES. 
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 
influence of -certain agents either internal or external. The excitation thus 
produced is essential to the preservation of life, and is susceptible of con- 
siderable variation in degree or extent, without exceeding or falling short of 
the limits of health. 
But, under the influence of certain causes, this excitation may be in- 
creased 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 impres- 
sions, 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 con- 
stitute disease. It is, indeed, impossible to say where precisely, in the 
advance or retrocession of excitation, health ends and disease commences. 
The morbid excitation 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 impos- 
sible 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 CHAP. I.] 
DISEASE AFFECTING THE VITAL PROPERTIES. 
15 
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 affections. As we cannot draw the line precisely between 
health and disease, neither can we determine always where functional dis- 
order ends and organic begins. The latter is usually preceded by the for- 
mer; and, as a general rule, functional disorder long continued, ends in 
structural lesion.* 
But all disorder is by no means the consequence of augmented action. 
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 withdrawal of the ordinary healthy excitants, or indirectly in conse- 
quence of certain physiological laws, to be explained in another place. It 
may be 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 excitation 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 demon- 
strated 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 deposition of a cheesy matter, with slow suppuration and very linger- 
ing recovery, as scrofula; a fourth, in characteristic degeneration of structure, 
utterly different 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 admit- 
ting its validity, in opposition to the evidences of the senses. 
There are, moreover, diseased conditions, which are not in themselves 
necessarily connected with an elevation or depression of the vital actions, 
but exhibit a complete change or perversion 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 
• The author does not deny that every act of every part of the living body is accom- 
panied, as essential to its performance, ■with some molecular change, though this is 
not positively proven, and is perhaps insusceptible of proof; yet such change may 
certainly take place without any alteration of the organization. If one molecule, or 
granule, or cell disappears, and is replaced by another exactly similar, the state of 
the organ remains the same; there has been performance of function without change 
of structure. Now it is easy to conceive that this alternate destruction and repair 
may go on more rapidly than is consistent with a healthy state of the function; the 
structure of the part remaining unaffected, and the same at the end as at the beginning 
of the morbid process. For the sake of convenience, we may consider organic de- 
rangement as commencing when the changes of structure are such as to be discover- 
able by the senses, and whatever falls short of this to be functional. [Note to the third 
edition.) 16 
GENERAL PATHOLOGY. 
[part I. 
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 continual 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-excitation in which tbe functions are morbidly 
deranged, without obvious organic change, is called irritation. When the 
excitation 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 
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 excitation, 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 precise 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 excitation. 
That morbid condition in which the vital actions are reduced below the 
healthy standard is called depression. It differs from debility, which implies 
a loss or diminution of vital power; while, in the case of depression, this 
power may be undiminished, though temporarily restrained. It may consist 
in a simple reduction of the vital actions, or may be accompanied by pecu- 
liarities 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 are 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 the constituent forms of disease, with the exception of certain morbid 
changes in the state of the system independent of deranged action, such as 
excess of the sthenic condition, debility, and excess or deficiency of excita- 
bility, which, however, may be incidentally considered in connexion with 
their attendant disorder of function. CHAP. I.] 
IRRITATION. 
17 
Article L 
IRRITATION. 
Causes, Propagation, Transfer, &c., of Irritation.-Any morbid excite- 
ment of the vital actions not amounting to inflammation is denominated 
irritation. 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 
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 miasmata, 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 system appears to possess a certain amount of excitability. If this 
be called 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 restrained, 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 duration, indirectly pro- 
duce irritation by the reaction which results. This is probably true of the 
whole system, though the fact is denied by some pathologists. It is cer- 
tainly 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 warm apartment. A degree of heat 
which was before only sufficient to sustain the natural condition of the part, 
now that the excitability has accumulated through the sedative agency of 
the cold, becomes capable of producing an unhealthy excess of action. This 
principle is very important, and of very frequent applicability in the explana- 
tion 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; in 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, which 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 18 
[PART I. 
GENERAL PATHOLOGY. 
time, an increase of the excitability and of the exciting agent in the same 
portion of the body, and irritation necessarily 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 
existence 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 portion, without 
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 affection. 
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 tissues 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, 
or of the urinary bladder, consequent upon irritation of the mucous mem- 
brane ? 
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 or 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 CHAP. I.] 
IRRITATION. 
19 
irritation, while the general diathesis in which it may have originated remains, 
and which now throws iLjfprce upon some other part, as in the case of gout 
in the stomach succecdnB^ removal from the feet by cold applications; 
and, secondly, of the estaOT^ment 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 
sympathetic 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 
distributed 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. 
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 phenomena. 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 20 
GENERAL PATHOLOGY. 
{part I. 
exhibit itself in various harassing nervous disordersj/^dyspepsia, spasm of 
the stomach and bowels, asthma, palpitation of thdineart, vertigo, and neu- 
ralgia. Hence, the system when enfeebled is c^^Waid to be in an irritable 
state, because it is easily excited into disordef^md 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- 
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. It has been objected 
to this view that, as there is only a fixed amount of blood, and as an increased 
supply of blood is a necessary attendant upon exaltation of function, a uni- 
versal irritation is impossible, because in such cases the blood must be held 
everywhere in equilibrium, and there could be no accumulation in any one 
part. But, though this is true as to the amount of blood in any part at any 
given instant of time; yet all the effects of irritation are obtained by an in- 
creased rapidity of circulation, which may be universal. Nor is the evidence 
of facts against the opinion here advocated. It has not been and cannot be 
proved that no case of universal irritation has existed. But such a case 
cannot be of long duration. The excitability must soon be exhausted, and 
the system sink into a state of indirect depression. Nor, admitting the pos- 
sible existence of such cases, can they be allowed to be common. It seldom 
happens that a stimulant 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 excited to morbidly increased action. Even when the agent 
is a universal stimulant, 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 circum- 
stances, not only insusceptible to the stimulant impression, but in a certain CHAP. I.] 
21 
IRRITATION. 
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 ma- 
jority of diseases, therefore, there is a mixture of these two opposite condi- 
tions ; 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 influ- 
ence, 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 convulsive affections, and innumerable derangements in the secretory 
functions, 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 far 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 
* As in the morbid state induced in persons of 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 al®w him to entertain a 
doubt upon the subject. He does not, however, wish to be understood as ascribing 
any other influence to these operations than one of an exclusively mental character*. 22 
[part I. 
GENERAL PATHOLOGY. 
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 
inculcated in this section is incalculable. 
Phenomena, Effects, &c., of Irritation.-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. 
In most parts of the system there is a combination of capillaries, nerves, 
and ultimate cells or molecules, fhe last of which are the proper agents of 
the function, while the two former supply material and requisite influence. 
Now it is possible that the relation between the irritant cause and these 
several parts may be such, that the irritation may be primarily seated in one, 
to the exclusion of the others, or all may be affected simultaneously. But 
on whichever the first impression is made, though there may be a predomi- 
nance throughout of its morbid action, yet the others will soon more or less 
participate in the derangement. The nerVe tissue is certainly more sus- 
ceptible of an independent irritation than the blood-vessels; and the various 
functions of the nervous system or its parts may be increased, deranged, or 
suppressed, without a direct original participation of the capillaries. Thus, 
the sensations may be sharpened or perverted, the emotions and intellectual 
operations elevated or deranged, and muscular movement invigorated, dis- 
ordered, or suppressed, without any discoverable evidence of antecedent vas- 
cular change. It may, indeed, be said that the capillaries of the neurilemma, 
or of the nervous substance itself, either in the nervous centres, or the con- 
ducting cords, may be the seat of the irritation which thus interferes with 
the functions; and this is undoubtedly the case in many instances, as dis- 
section has proved; but, in many other instances, neither examination 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 nervous irritation, the 
capillaries and elementary cells are apt to become secondarily involved; and 
perhaps in no case can the latter be the seat of irritation, without a speedy 
participation of the nervous structure; so that in most instances all partake 
of the disorder, and contribute to the results. 
A phenomenon always present in local irritation not exclusively nervous, 
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 inflam- 
mation. 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 accomplishment of those changes. Independently of the 
results which flow from the vital influence of the blood thus accumulated, it 
frequently proves injurious mechanically by pressing upon and cramping the 
organ, and thus interfering with the due performance of its functions; as in 
the vertigo, or even apoplexy, which sometimes results from general conges- 
tion of the brain without 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 CHAP. I.] 
IRRITATION. 
23 
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 
contraction 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- 
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 elimination is not counterbalanced by a cor- 
responding 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 nutritive, 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 Jatter. It is highly probable that the kind of absorption which 
results from the mere physical imbibition of fluids, or endosmosis, is the only 
one in which irritation appears directly to diminish the process; while that 
effected through cell-action, which is the true vital absorption, is obedient to 
the general law. 
The influence of irritation upon the function of secretion is of great prac- 24 
GENERAL PATHOLOGY. 
[PART I. 
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 moderate flow of healthy bile, while that which results 
from large doses is not unfrequently dark-coloured and exceedingly acrid. 
There are many diseases which consist essentially in increased secretion, con- 
sequent upon irritation of the secreting organs. Such frequently are diarrhoea, 
cholera morbus, and various forms of dropsy; and whether the character of 
the fluid secreted shall be the same as in health, or in a greater or less degree 
modified, depends often upon the degree of the existing irritation. 
In many instances, the secreting organ, under high irritation, throws out 
blood little if at all altered, either by rupture of the distended capillaries, 
or through pathological openings in their walls large enough to admit the 
passage of the red corpuscles, of the possible occurrence of which there 
will be occasion to speak hereafter. Hemorrhages frequently have their 
origin in this cause. 
When the irritation exceeds a certain point, the secretory process is dimi- 
nished 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 cha- 
racter. That condition of a part denominated hypertrophy, or excessive 
growth, appears to be the result of a mere augmentation of the nutritive pro- 
cess, consequent upon a moderate irritation in the part, directed probably 
with special force to its cellular or molecular constituent. The disorder may 
affect the whole of an organ, or only one or more of its component parts. 
Thus, the liver is sometimes enlarged, without any other apparent deviation 
from the healthy state. lu 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 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 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 the 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 ourselves of this principle so as to relieve existing irritations, by esta- 
blishing 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 CHAP. I.] 
INFLAMMATION. 
25 
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, gives 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 fron* 
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 close, 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 require a special consideration. In relation tq their origin, propagation, 
and effects, they are for the most part obedient to the general laws already 
stated. Their peculiarity is dependent upon some peculiar diathesis or pre- 
disposition 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 irri- 
tation of hooping-cough is developed, in the ordinary state of system, by a 
peculiar contagious principle. All contagious diseases, so far 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. 
Jlrticle 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. The absence, however, of one or more of the symptoms 
mentioned is not incompatible with the existence of inflammation. Thus, 26 
GENERAL PATHOLOGY. 
[part I. 
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 pro- 
cesses are so allied, intermingled, or overlapped, that scarcely any one is 
susceptible of being entirely isolated, even for the purpose of description. 
In this work, the term inflammation is considered as embracing all that series 
of local changes which commences when irritation ceases, and ends only with 
the loss of life, or the restoration of the part to health. 
Inflammation is beyond all comparison the most important of diseased 
conditions; as it either attends, or forms an essential part of the great ma- 
jority of serious diseases, and in very many instances constitutes the chief 
source of danger. 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 varieties which may deserve to be considered as specific. 
1. Phenomena, Progress, and Results of Inflammation. 
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 of 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 fingers, and returns upon the 
removal of the pressure; the rapidity with which it returns measuring the 
activity of the circulation in the part. Sometimes, however, it cannot be 
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 vessels, which thus admit a greater 
volume of blood, and to the crowding of the red corpuscles, which exist in 
much larger relative proportion in the vessels of the inflamed part than in 
the circulation generally. It also sometimes depends in part upon the effu- 
sion of blood, or the extravasation of the red fluid of the corpuscles. The 
intense redness exhibited in certain cases may be ascribed, as suggested by 
Hunter, and subsequently proved by microscopic examination, to the passage 
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 ren- 
dered evident by the thermometer; 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 increase of temperature is less than, under similar circumstances, in the 
extremities, 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 lower extremi- 
ties, 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 CHAP. I.] 
INFLAMMATION. 
27 
in health. Thus, Hunter found that the ear of a rabbit, inflamed in conse- 
quence 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 evolu- 
tion 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 inflammation, particularly when this occupies a distant portion 
of one of the extremities; so that the temperature of the inflamed part can- 
not 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 lan- 
cinating, at othei' 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, more- 
over, 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 in- 
flamed. 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 inflammation 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 
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 
inflammatory process, the senses are sometimes rendered more acute; and 
the same result takes place, 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 exter- 
nal 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 28 
GENERAL PATHOLOGY. 
[part i. 
in part or wholly the sense of touch, by which a judgment may 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 
organization 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 copious- 
ness relieving, in some measure, the violence of the inflammation. Hence 
the mucous discharge in dysentery and catarrh, the serous effusion under 
the cuticle in erysipelas, and the similar effusion which takes place in 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 acrid, irritating and excoriating the parts 
with which they come in contact. They are more or less albuminous, 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. They are, moreover, generally mingled with coagulable 
lymph, and often, in the progress of the disorder, with pus; two charac- 
teristic attendants of inflammation, which require particular notice. 
Coagulable lymph is a name applied by English writers to a substance 
exuded from the vessels of an inflamed part, which, though it escapes in the 
liquid form, coagulates after exudation, 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 sometimes extravasated with little if any of the other constitu- 
ents 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 por- 
tion of the blood, deprived of the red corpuscles, and possibly somewhat 
altered in the process of exudation. Of this fluid, the fibrinous part con- 
cretes, while the albuminous portion, remaining combined with water and 
saline matters in the form of serum, fills and distends the cavities and inter- 
stitial spaces into which it may have been effused, or escapes in the form of 
flux from exposed surfaces, or those having a natural outlet. 
All that is absolutely essential to the organization of the exuded fibrin is 
that it should be in contact with living tissue. As it first escapes it is a ho- 
mogeneous, formless, transparent fluid; but very soon afterwards, if examined 
by the microscope, it is found to contain multitudes of fibrils, great num- 
bers of minute granules of different sizes, and another set of minute bodies, CHAP. I.] 
INFLAMMATION. 
29 
which are often covered by a cellular envelope, and constitute what are called 
exudation corpuscles. Coagulation appears to depend upon the multiplica- 
tion and interlacing of the fibrils referred to. After coagulation, the rudi- 
ments of blood-vessels speedily appear. Numerous red points are first seen; 
these lengthen into lines, which quickly inosculate so as to form a continu- 
ous network; a communication is formed between this and the capillaries of 
the contiguous tissue; and, in a wonderfully short space of time, a new struc- 
ture is produced, possessing a more or less perfect organization. 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. 
Coagulable lymph is often exuded immediately after inflammation has been 
established. It forms solid flocculi swimming in the serous effusion, or or- 
dinary secretion of the part; coagulates upon inflamed surfaces in patches or 
extensive layers, constituting what has been denominated false membrane ; 
fills and consolidates the cells of the areolar and adipose tissues; and is even 
extravasated into the substance of membranes, rendering them rough and 
opaque, when they were before smooth and transparent. To this, much of 
the tumefaction and hardness often attendant upon inflammation is ascrib- 
able. 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 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 
mischief into the neighbouring parts, as in the case of abscesses, and in that 
of irritating effusions into the serous cavities; or by surrounding foreign or 
noxious bodies with a coating by which they are isolated and rendered harm- 
less. By its organization, the opposite surfaces of inflamed membranes are 
often permanently 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 often reunited, and spaces produced by a violent 
solution of continuity in any portion of the body are filled up by a new 
growth. Tn each of these latter cases, the inflammation by which the effu- 
sion of coagulable lymph is produced is named by Mr. Hunter adhesive in- 
flammation ; 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 an 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 areolar 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 gra- 
dually 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 30 
GENERAL PATHOLOGY. 
PART I. 
wrong, therefore, to say of suppuration that it is one of the terminations of 
inflammation, or to use the name suppurative inflammation as expressive of 
a distinct character of this morbid state. The period at which pus first ap- 
pears varies from a few hours to many days. There is no vascular tissue of 
the body in which it may not be produced. It is liable to considerable 
diversity of character; but that produced in ordinary inflammation, 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 properties. 
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 readily 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, fatty matter, soda, chloride of sodium, phosphate of lime, and nume- 
rous other salts. The fatty matter is peculiarly abundant, constituting from 
9 to 24 per cent. Under the microscope, pus appears to consist of small, 
round, and occasionally oval corpuscles, floating in a thin transparent liquid. 
The pus globules are larger than the red corpuscles of the blood, and than 
the greater number of the exudation corpuscles. The liquid in which they 
float is albuminous, and bears a considerable resemblance in chemical com- 
position 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 materially in properties, even where no difference is observable 
by the senses or chemical examination. The pus of syphilis, or of small- 
pox, cannot be distinguished 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. 
At one time it was believed to be the product of a secretory process; but it 
has been satisfactorily shown, by means of the microscope, that no orifices 
exist in the coats of the capillaries through which its corpuscles could pos- 
sibly escape; and it is now admitted to be produced from the exuded lymph, 
probably in consequence of failure in the attempt at organization, the exuda- 
tion corpuscles degenerating into those characteristic of pus. It - is not 
impossible that the fibrin of effused blood may undergo a similar change. 
It is a doubtful 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 other 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. 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 continuance has been removed. But they are CHAP. I.] 
INFLAMMATION. 
31 
also said to be presented in some rare instances, in which no inflammatory 
source of pus, existing at the time, or within a short period previously, could 
be discovered. In the former case, the collections of pus have been ascribed 
to the previous absorption of that liquid from the suppurative source, and 
its subsequent deposition in distant parts. But, with our present knowledge 
of the constitution of pus, and the structure of blood-vessels and absorbents, 
it can scarcely be allowed that the corpuscles of the former can find either 
entrance or exit through the coats of the latter; and, if pus has occasionally 
been found in veins and absorbents proceeding from the neighbourhood of 
purulent collections, its presence is to be ascribed rather to its production 
within these vessels than to its entrance into them from without. It is not 
impossible, however, that pus may sometimes enter blood-vessels or absorb- 
ents through ulceration or other pathological openings made through their 
walls. Some ascribe the deposits of pus above mentioned to inflammation 
in the lining membrane of the veins, or blood-vessels in general, terminating 
in suppuration; but we are here again met by the difficulty of accounting 
for the passage of the pus corpuscles through the continuous and unbroken 
coats of the capillaries, in the act of deposition. The probability appears to 
be that, under the influence of various matters absorbed into the veins, or 
otherwise entering the circulation, the fibrin or organizable constituent of the 
blood may undergo such a degradation in character, as to provoke its elimi- 
nation, and, when it is eliminated, to cause its conversion into pus, as when 
thrown out in certain stages of inflammation. Where the affection proceeds 
from any suppurative focus previously existing, the pus, degraded into an 
absorbable sanies, and then entering the veins or absorbents, may act as a 
ferment in inducing the change referred to in the fibrin. 
When suppuration is established, the violence of the inflammation abates; 
and hence its occurrence has been erroneously considered as one of the ter- 
minations of inflammation. The pus may appear upon the free surface of 
membranes, or diffused in the interstices of the tissues, or collected together 
within the substance of the different structures, forming abscesses. 
6. Modification of Nutrition, 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 
finger 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 down, and is either removed by the absorbents, or 
dissolved in the pus, with which it seems to become identified. 
Induration.-It rarely happens that a part is hardened in a state of acute 
inflammation. 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 may tend to indent, 
rupture, or divide it. It is torn or cut with greater difficulty, is often sono- 32 
GENERAL PATHOLOGY. 
[part I. 
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 left behind when 
the inflammation ceases. In these cases, it arises from an organization of 
the coagulable lymph effused into the interstices of the tissue affected, and a 
consequent consolidation of that tissue, by the union of its surfaces. 
Ulceration.-Though, during the existence of acute inflammation, the 
absorption of foreign bodies from the part affected is much less 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 ab- 
sorption, or ulceration. It may also happen in the interior of the tissues, 
preparing a receptacle for the pus, and making a way for the resulting ab- 
scess to the surface. In the latter case, Mr. Hunter denominated it pro- 
gressive absorption. There seems to be little difference in the character of 
the process in these two cases. Another opinion as to the nature of ulceration 
is at present entertained by some pathologists. Denying the action of the 
absorbents in the case altogether, they maintain that the loss of substance 
is owing to the disintegration and liquefaction of the tissue, which thus 
separates from its attachment, and is either thrown off from surfaces, or 
collected along with the pus in the interior of the structure. 
If we admit ulceration to be the result of an absorbent action, its probable 
cause is, in most cases, such a diminution of vitality, under the inflammatory 
process, as to lessen the resistance to that action, which is always going 
on even in health, but is then properly balanced by a due condition of the 
other functions. When a part dies, if the neighbouring parts are not too 
much debilitated, the absorbents immediately begin to remove it. When a 
part approaches death, the same operation commences in the more vigorous, 
or less exhausted structure, in contact with it. Certain specific inflamma- 
tions are peculiarly disposed to ulceration; and it is more apt to occur, 
other things being equal, in a debilitated or depraved than in 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 
cannot 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. Occa- 
sionally, it is very slow and of very small extent, and again is exceedingly 
rapid and destructive. In the latter case, it is commonly denominated pha- 
gedenic. 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 is 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. CHAP. I.] 
33 
INFLAMMATION. 
Abscesses.-It has been stated that pus may be collected in cavities, in the 
interior of the different structures, and that these collections are called abscesses. 
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, either 
by the absorption of the softened tissue, or by the breaking down and decom- 
position of the tissue, and its solution in the pus, or by the two agencies com- 
bined. 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 ©r 
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 fre- 
quently discharged portions of solid matter, sometimes resembling membrane, 
though unorganized, and consisting probably in chief of coagulated fibrin. 
Where a dense tendinous or fibrous fascia, which is of very difficult absorp- 
tion, 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 mischief in its 
course, by occasioning the absorption of 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 inflammation 
excited in the parts with which the pus comes in contact. Sometimes, also, the 
barrier of coagulable lymph, which usually confines it, is defective or altogether 
wanting; and the pus, escaping into the cellular tissue, travels to a considerable 
distance, destroying, and, as it were, dissecting 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 pre- 
sents 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 structure 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 gangrene 
or sphacelus. Many writers, however, following Galen, make a distinction 
between gangrene and sphacelus, applying the former term to the state which 
immediately 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 34 
GENERAL PATHOLOGY. 
[PART I. 
dead; though the epithet gangrenous may sometimes be employed as expres- 
sive of a state allied or approaching to gangrene. 
The immediate cause of gangrene, in inflammation, is probably a dispropor- 
tion between the excitement of a part and its powers of vitality, the latter 
being entirely exhausted by a great 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 excitation 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 weakest. There are certain states of system, and certain diseases, which 
are characterized by a universal reduction of vital power, and in which inflam- 
mation is very apt to run into mortification; and there appear to exist certain 
specific inflammations, which are much more liable to this result than inflam- 
mation 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 of material, and that healthy stimulus, which are requisite to 
vigorous health. Gangrene, moreover, may occur from obstruction to the cir- 
culation 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 
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 have their interstices 
filled and often distended with fetid gases, and with brownish, turbid, and 
offensive liquids. But putrefaction must not be confounded with mortification. 
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 mortifi- 
cation has not occurred. Still, as spontaneous decomposition begins sooner or 
later, and as parts which have entirely lost the ordinary signs of life some- 
times 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. Oh 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 excitation 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 CHAP. I.] 
35 
INFLAMMATION. 
communicating externally, is thrown off in the form 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 an- 
other head. 
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 exudation of 
coagulable 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. According to Macartney, however, though granulations may 
sometimes be formed out of exuded coagulable lymph, they are usually the 
product of deposition and organization, going on simultaneously, as in ordinary 
growth. The process is generally, if not always, accompanied with the forma- 
tion of pus, which covers, and in some measure protects, the new and tender 
growth. It is a step in the progress of inflammation, which is now directed 
towards health. That the action is essentially inflammatory is proved by the 
elevation of the temperature above that of surrounding parts, by the increased 
vascularity of the surface upon which the granulations form, and by the pro- 
duction 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 
adhesive inflammation, or first intention. But this subject belongs exclusively 
to surgery. 
Granulations have a strong tendency to unite. Hence, when developed, 
they coalesce, producing a constantly increasing contraction of the granulating 
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 coalesce 
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 cor- 
rectly 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. This is not the place to consider the question whether the edges 
of wounds, as has been maintained, 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 
may be inferred, in relation to the former, from the sensibility of granulating 
surfaces, and, in relation to the latter, from 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 36 
[PART I. 
GENERAL PATHOLOGY. 
coating somewhat analogous to that which had originally existed. By English 
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 the new skin is called cicatrization, 
and the new skin itself a cicatrix. Some of the French writers extend the 
signification of these terms much further, 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 extension as to em- 
brace 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 desig- 
nated. But the term cicatrization is here restricted to' the process first 
alluded to. 
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 liquid 
part of the blood or liquor sanguinis is effused, with more or less of the 
colouring matter, and frequently blood itself little if at all altered. More 
or less of the coagulable lymph or fibrin of the effused liquor sanguinis coagu- 
lates, while the serous portion, or that remaining liquid, is diffused in the 
interstices of the tissue, the former being most abundant in the central portion 
of the inflammation, and the latter in its borders. In this condition, the 
coagulated fibrin becomes the seat of organic action, resulting in the formation 
of new blood-vessels connected with the previously existing capillaries, se 
that a sort of growth takes place 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 solidified fibrin. The 
inflammation is then said to terminate 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 exuded coagulable lymph 
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 ter- 
minate in effusion, in the latter, in adhesion. It is obvious, however, that the 
effusion and adhesion arc mere effects of the inflammatory action, and should 
not be considered as its terminations. 
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, coagu- 
lable 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. Some- 
times a portion of the affected tissue or tissues undergoes mortification, or, in chap, i.] 
37 
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, which in the first two persists dur- 
ing 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 process, which cannot legitimately be 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 unfre- 
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 the habitual use of stimulating drinks, or to the 
existence of some peculiar diathesis, as the scrofulous, which predisposes to a 
slow march of the inflammation. The nature of the part also has some influ- 
ence, 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 of 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 
evidences by which its existence in the interior parts of the body is usually 
detected, such as pain, disordered function, and constitutional disturbance. 
Under these circumstances, it is said to be latent, and often escapes attention 
until serious 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 fed than in those of luxurious habits; and is not uncommon in conva- 
lescents from acute diseases. Sometimes, however, the absence of pain and 
other obvious symptoms is ascribable to the simultaneous existence of some 
INFLAMMATION. 38 
[part I. 
GENERAL PATHOLOGY. 
other disease which blunts 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 
necessarily 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; 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, independently 
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 modified 
during inflammation. The most striking result of the change is that peculiar 
appearance called the huffy coat. This is a whitish, or yellowish-white, and 
sometimes greenish stratum, formed upon the upper surface of the blood during 
coagulation. Soft and viscid at the commencement of the coagulation, it is 
fully formed when the clot begins to contract 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 a cupped appearance. Sometimes 
the coating remains soft and gelatinous, like size; and hence the blood which 
exhibits it is occasionally called sizy blood. 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 evi- 
dence of inflammation. Out of eighteen hundred cases in which the blood was 
examined by Andral, it never had the buffy coat except in inflammation or 
anaemia. The cause of the buffy coat was conjecturally referred by Hunter 
to a slower coagulation of inflammatory blood, allowing the red corpuscles to 
subside in some measure before the clot was formed; and he inferred from an 
experiment that the red corpuscles themselves are heavier in inflammatory 
than healthy blood. Gendrin, however, asserts that in the blood of inflamma- 
tion 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 buffy coat. Yet, from numerous experiments of 
this author, it may be inferred that whatever causes a more rapid coagulation 
of inflammatory blood interferes with the formation of the buffy coat, and that, 
when it coagulates very speedily, this coat is not exhibited, because the red CHAP. I.] 
39 
INFLAMMATION. 
corpuscles 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 ves- 
sels, 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 appearance 
upon the surface, it is usually less bulky and firmer than in health, owing pro- 
bably to the greater contractility of the fibrin. 
It has been satisfactorily shown, by the experiments of Andral and Gavarret, 
that the proportion of fibrin in the blood is very generally if not always aug- 
mented 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 cases 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 the 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.) 
But another cause of the buffy coat, co-operating with excess of fibrin, is 
probably a tendency of the red corpuscles in the blood of inflammation, first 
clearly noticed by Wharton Jones, to cohere by their flat surfaces, and thus 
arrange themselves in columns. By this tendency they are at the same time 
separated from the fibrin, and rendered more compact so as to sink more 
readily; and consequently present the very condition requisite for the pro- 
duction of the phenomenon in question.* 
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 presents this phenomenon 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 
* The production of the buffy coat through excess of the fibrin may be hypothetically 
explained. We may suppose a certain affinity to exist between the fibrin and red cor- 
puscles, which, in their ordinary proportion, retains them in connexion, but, when the 
fibrin is in excess, is insufficient to prevent the corpuscles, which are specifically heavier, 
from sinking to the bottom along with the normal proportion of fibrin, and leaving 
the excess of the latter floating alone upon the surface. This explanation is appli- 
cable to all the cases in which the buffy coat is observed. The cohesive tendency of 
the red corpuscles among themselves, is not sufficient to explain all the phenomena 
connected with the case; as anemic blood exhibits the same tendency to the buffy coat 
as the inflammatory.-Note to the tenth edition. 40 
GENERAL PATHOLOGY. 
[PART I. 
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 
lattar, the serum is coloured by a blackish matter which subsides to the bot- 
tom 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 huffy coat, are inci- 
dent to inflammation in all parts of the body, they are most striking in acute 
articular rheumatism and pneumonia. 
In examining the appearances of inflammation in the web of a frog's foot, 
some microscopists observed a remarkable excess of the colourless or white 
corpuscles of the blood, easily distinguishable in cold-blooded animals by their 
spherical shape from the red corpuscles, which in these animals are oval. It 
was hence inferred that one of the changes produced in the blood by inflam- 
mation is to augment the number of the white corpuscles; and, as these are 
believed to be rudimental blood-cells, it was naturally thought that this change 
was an important feature of the process, and available in the explanation of 
many of its phenomena. But the conclusions were premature. From the 
observations of Wharton Jones and Professor Bennet of Edinburgh, it appears 
that this excess of white corpuscles is not an ordinary attendant upon inflam- 
mation, being seen only in young animals or those of feeble health or badly 
nourished, in which they are abundant in the circulation generally, altogether 
independently of the inflammatory process; and Mr. Paget states that he has 
often examined the blood of inflamed parts in warm-blooded animals, without 
ever having observed a greater proportion of the white corpuscles than in 
other parts of the same animals. In the present state of the inquiry, there- 
fore, an excessive production of the white corpuscles in inflammation cannot 
be admitted as an established fact, at least of general application. 
According to Simon of Berlin, and MM. Becquerel and Rodier, the propor- 
tion of the fatty matters of the blood is notably increased in inflammation. 
Effects upon particular Organs.-It has already been stated that the inter- 
ruption or disturbance of function in any one organ, occasioned by inflamma- 
tion, necessarily produces derangement in other associated or dependent func- 
tions. Another source of disturbance, in organs not immediately the seat 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 derangement in an- 
other, independently of any peculiar relation between their functions. This 
is not the place to speak of such effects; as they may be more advantageously 
treated of under the heads of the phlegmasiae of the several organs or struc- 
tures 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 identical and continuous structures, as from one point 
in the skin to the surrounding parts of the skin, from a particular spot in a 
membrane to the surrounding 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 con- 
nected 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 themselves. Contiguous parts are, moreover, CHAP. I.] 
41 
INFLAMMATION. 
very liable to this direct communication 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 portion 
of membrane connecting these surfaces. When distant parts are sympa- 
thetically affected, the secondary disorder most frequently stops short at the 
point of irritation. 
Constitutional Effects.-Symptomatic Fever.-When inflammation has at- 
tained a certain degree of intensity or extent, it brings the whole system into 
derangement, causing that general condition which has been denominated 
fever, and which, occurring under these circumstances, is distinguished 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 inflammation. 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 inflam- 
mation is sufficient to produce fever, and disappears when the fever ceases. 
(Android) But there is probably some further, and yet unexplained mode 
of action, by which fever is produced as a consequence of local inflammation. 
The character of the fever varies exceedingly with the grade and stage of the 
inflammation, the nature of the cause producing it, and the predispositions 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 inter- 
mittent, remittent, or continued; in relation to the state of the constitutional 
forces, it may be sthenic, asthenic, or of any intermediate condition; 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 Feverd) It is 
sufficient here to say, in addition, that when the inflammation is severe and 
sudden in its onset, the constitutional symptoms generally make their appear- 
ance very speedily, and are often, so far as can be observed, simultaneous in 
their commencement with the inflammation. In subacute and chronic inflam- 
mation, the fever is much less than in the acute, and is sometimes quite 
wanting; and the same is the case in those instances in which the inflamma- 
tion is said to be latent. If the onset of fever should precede that of inflam- 
mation, as sometimes happens, the former cannot properly be considered as 
symptomatic of the latter. In this case, either the inflammation is the con- 
sequence of the fever, or both have the same cause. 
Hectic Fever.-The advanced stages of inflammation are frequently at- 
tended with a peculiar morbid condition of system, which must be noticed 
here; as no other opportunity will be offered of giving it a distinct consider- 
ation. I allude to the affection denominated hectic fever (from ixrtxos, 
habitual). It is not usually met with until after suppuration has taken place, 
and is much more common in the chronic than in the acute form of the dis- 
ease. 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 and brain are often unaffected; and 
the only derangements essential to it are those, primarily, of the circulation 
and calorification, 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, occurring generally towards evening, and subsiding 
before the beginning of the next day. The heat is especially felt in the 
hands and feet. After some time, tbe excitement of pulse continues, in a 42 
GENERAL PATHOLOGY. 
[PART I. 
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. Generally, there is only a remission of excitement between the 
paroxysms; but sometimes, a perfect intermission. The paroxysms usually 
occur daily, sometimes in the morning after breakfast, but more frequently in 
the evening, when they are commonly 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 when 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 not unfrequently 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 conjunc- 
tiva, 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 usually 
most abundant during sleep. It shows 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 to be smooth, especially in the last stage, when there is not 
unfrequently a tendency of the whole mucous membrane of the mouth and 
fauces to throw out a thrush-like 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 edema- 
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 
consequence, 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 cases 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, CHAP. I.] 
INFLAMMATION. 
43 
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 enter- 
tained, not without some show of reason, that the absorption of pus constitutes 
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 cases of disease affecting the interior 
structure of organs, but may result also from chronic inflammation with sup- 
puration of surfaces, as of the bronchia, bowels, urinary passages, and skin. 
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 
prevent 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. 8. When of great violence or extent, it 
may so concentrate the blood and vital forces in the part affected, as completely 
to prostrate the nervous and circulating functions, 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 feebleness, and the 
skin is cold almost from the commencement of the disease. 4. It may elabo- 
rate products, which, being absorbed or in some other way entering the cir- 
culation, 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 carried into the general mass of the blood. 5. Death 
frequently results from the debility induced by long-continued or extensive 
suppuration, or by gangrene in the inflamed part. 6. We can readily con- 
ceive, moreover, that the constitutional excitement of inflammation, when very 
violent, or in a feeble constitution, may be succeeded by fatal collapse. 
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 inflamma- 
tion may prove fatal without leaving the ordinary traces; 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 re- 
sembling inflammation, so far as relates to congestion of the capillaries, 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 in- 
flammatory origin. 
2. Nature of Inflammation. 
An outline having been given of the ordinary phenomena and course of 
inflammation, it comes next in order to treat of its nature, and to explain the 
various steps of the complex process. That this may be done understandingly, 
it is necessary to be acquainted with the results of microscopic observation; 
as the changes going on in the inflamed tissue are quite beyond the reach of 
accurate examination by the unassisted eye. 
Microscopic Observations.-Among the many who have investigated this 
subject microscopically, may be mentioned Wilson Philip, Thomson, Hastings, 
Gendrin, Kaltenbrunner, and more recently Gerber, Muller, Lebert, Gulliver, 
Addison, C. J. B. Williams, Wharton Jones, Hughes Bennet, and Paget, as 
the authorities mainly depended on in the statements which follow. The 44 
[part I. 
GENERAL PATHOLOGY. 
experiments were generally made on the web of a frog's foot, which readily 
admits the passage of light; but, lest it should be objected to the phenomena 
thus observed that, being exhibited in a cold-blooded animal, they are not 
applicable to the explanation of the process as it occurs in animals with warm 
blood, it may be mentioned that they correspond in all essential particulars 
with the appearances presented by the wing of the bat, which belongs to the 
latter class. 
When a part is irritated, either mechanically or by a stimulant substance, 
the minute vessels, whether arteries, veins, or capillaries, are variously affected 
in relation to their diameter, being sometimes diminished in size, sometimes 
immediately expanded, and sometimes little if at all altered for a time. 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 presented. This expansion is sometimes very consider- 
able, amounting to twice or even thrice the ordinary diameter of the vessel. 
At the same time that the observable capillaries are thus dilated, others before 
unseen become visible, probably by the entrance of the red corpuscles into 
vessels before too small to receive them. The motion of the blood is much 
affected, along with these changes in the capacity of the vessels. At first, the 
current occasionally slackens, or even retrogrades for an instant; and not un- 
frequently oscillatory movements may be noticed; but, when the dilatation has 
been effected, the blood flows more rapidly, and a much greater quantity passes 
during a given time than in the unexcited state of the part. After a time, 
however, the current becomes slower, without any diminution, or even with 
an increase of its size; and this retardation gradually increases 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, especially in the outskirts of 
the inflammation, may go on with a greater velocity than in health. The blood 
thus stagnating is not disposed to coagulate, remaining liquid for a long time, 
and sometimes resuming its onward movement when circumstances favourably 
modify the inflammatory condition. During the slackened or stagnant state of 
the blood, another very interesting change takes place. In the healthy state, 
the red corpuscles occupy only the middle of the current, leaving a colourless 
space between them and the walls of the vessels, in which a white corpuscle 
may be seen now and then floating along. In inflammation, the red corpus- 
cles increase in proportionate amount in the part affected, till at length they 
fill the whole capacity of the dilated vessels, becoming also much more 
crowded. It is obvious that they are detained, while the liquor sanguinis 
flows onward. When the blood has become quite stagnant, the outlines of 
the corpuscles can sometimes be no longer seen, and the vessel presents an 
almost uniform bright carmine hue. Another phenomenon is one before 
alluded to, the appearance, namely, of an increased number of white corpuscles, 
which seem to have an affinity for one another, and for the inner surface 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 physical vis- 
cidity, has not been ascertained. In some instances, they accumulate 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. But 
this occurrence, to which attention was called by Drs. Williams and Addison, 
is stated by Mr. Paget not to take place in warm-blooded animals, and there- 
fore cannot be received in explanation of the phenomena of inflammation. 
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 contrac- CHAP. I.] 
45 
INFLAMMATION. 
tion, atid a more rapid current, to be again followed by dilatation. In such 
a case, the original action of the irritant, hi stead of producing immediate red- 
ness, causes the part to be eVen paler than before; but the subsequent dilata- 
tion is accompanied by redness, which disappears when contraction is again 
produced, to return once more when the vessels expand. The walls of the 
vascular tubes are perfectly continuous, without exhibiting the slightest natu- 
ral orifice, even when most largely dilated. The liquor sanguinis exudes 
through invisible pores, and, being quite transparent, cannot be seen at first, 
unless coloured, as sometimes happens, with the red liquid of the corpuscles, 
which, escaping from the cellular envelopes, exudes along with it. Occasion- 
ally, the corpuscles themselves are effused into the tissue through ruptured 
orifices in the capillaries. In a very short time, the fibrin of the exuded 
liquor becomes visible through coagulation, and then exhibits numerous 
granules, organized spherical bodies, called exudation corpuscles, and a vast 
multitude of interlacing fibrils, which give firmness and tenacity to the coagu- 
lated mass. The corpuscles at first bear a close resemblance to those found 
in the chyle of the thoracic duct, and to the white corpuscles of the blood.* 
They undergo various changes, being converted into fibro-plastic cells, fila- 
ments, and possibly blood-vessels, when the coagulated fibrin undergoes 
organization, and degenerating into pus corpuscles, compound granular cor- 
puscles, granules, &c., when it is to become quite degraded, and to be surren- 
dered ultimately to chemical laws. Sometimes these corpuscles are alone 
developed in the exuded liquid, which then does not coagulate, and is wholly 
incapable of organization.f After a short time, when the coagulated lymph 
becomes organized, red lines are seen penetrating it in various directions, inos- 
culating with one another, and finally forming a network of blood-vessels, 
which have a vascular connexion with those of the neighbouring tissue. 
In parts softened by inflammation, as in softening of the brain, for example, 
the microscope renders visible numerous granules, and compound granular 
corpuscles, which are often very large, spherical, and consist of numerous 
cohering granules, sometimes though not generally surrounded by a vesicular 
envelope. Not unfrequently these corpuscles may be seen apparently in the 
process of disintegration, breaking up more or less completely into irregularly 
clustered and isolated granules. Another singular phenomenon sometimes 
* Mr. Paget gives the following account of the formation of these corpuscles: "The 
first discernible organic form, the form of what might with propriety be called the 
primordial cytoblast, is that of a minute mass of soft, colourless, or pale grayish-white 
substance, round or oval, pellucid, but appearing, as if through irregularities of its 
surface, dimly nebulous or wrinkled. It does not look granular, nor is it formed by 
an aggregation of granules; nor, in its earliest state, can any cell-wall be clearly de- 
monstrated, or any nucleus. But, as the development of this cell-germ or cytoblast 
proceeds, a pellucid membrane appears to form a cell-wall over its whole surface; and 
now, when water is added, it appears to penetrate this membrane, raising up part of it 
like a clear vesicle, while upon the other part the mass retreats, or subsides, and appears 
more nebulous or grumous than before. In yet another state, which appears to be a 
later state of development, the action of water not only raises up the cell-wall, but breaks 
up and disperses the outer part of the contents of the cell, i. e., of the enclosed mass of 
the primordial Cytoblast, and exposes in its interior a nucleus, which is commonly round, 
clearly defined, pellucid, and attached to the cell-wall." 
f The discovery noticed already (see note, page 5) of the existence of two chemical 
substances in fibrin, separable from each other by chemical means, one exhibiting minute 
fibrils, the other granules under the microscope, is happily illustrative of the fact stated 
in the text. The one may give rise to the fibrils, the other to the granules and exuda- 
tion corpuscles of coagulating fibrin; and, as one or the other is most abundant, will 
be the predominance of its .particular form. Probably both are necessary to perfect 
organization; and hence, perhaps, the observed fact that, when the corpuscles alone 
occur in a liquid, no organization ip effected. 46 
GENERAL PATHOLOGY. 
[part I. 
presented, when hemorrhage accompanies the inflammation, is the presence of 
very large corpuscles, consisting of a transparent envelope enclosing several 
of the blood corpuscles, which appear to' be undergoing various degradation. 
Several microscopic observers have noticed an irregular dilatation, or, as it 
were, aneurismal pouching of the capillaries and of the small arteries and veins 
of an inflamed part, probably owing to a weakening of the coats, occurring in 
the progress of the inflammation. 
The general aspect of pus has been already described, and the fact men- 
tioned, that it consists essentially of a serous fluid, and of peculiar corpuscles 
floating in that fluid. There are also other bodies usually present; and, as it 
is sometimes important to distinguish pus from different products somewhat 
resembling it to the eye, its microscopic characters merit a further notice. 
Pus corpuscles are globular, and have a mean diameter of somewhat more than 
2 0V0 an inch, being about twice that of the blood corpuscle. They have a 
finely granular surface, and are somewhat diaphanous. On the addition of 
water they swell considerably, lose the granular appearance, and become more 
transparent. Acetic acid also increases their transparency,,and renders visible 
an interior body, consisting of one or more nuclei. The number of the nuclei 
is usually two or three, but sometimes amounts to five. Occasionally, these 
corpuscles are observed to have a distinct vesicular envelope, forming cells of 
about of an inch in diameter, which vary in shape according to the pres- 
sure to which they are exposed. Water and acetic acid dissolve this cell-wall, 
and set the contained corpuscle free. (Hughes Bennet.) Pus corpuscles, in 
undergoing degradation, are resolved into granules and molecules, which ulti- 
mately become fluid. Along with these bodies are often seen in pus red blood- 
corpuscles, unchanged exudation corpuscles, compound granular corpuscles, 
numerous isolated granules, fatty matter in molecules or globules, rhomboidal 
plates of cholesterin, and the debris of the tissues from which the pus pro- 
ceeds, as cellular fibres, and epithelial or epidermic scales. 
Theory of Inflammation.-Numerous theories have been formed to explain 
the phenomena of inflammation. The following views are those which appear 
to me to accord best with observation and reason. An irritant cause acts on 
a part of the body either immediately from without, or through the blood, or 
by the instrumentality of the nerves. Morbidly increased action or irritation 
is excited in the part, embracing probably all its vital constituents, as well 
the ultimate molecular or cell structure, as the blood-vessels, and nerves. 
According to the nature of the cause, or its precise mode of application, the 
irritation may commence in either of the constituents mentioned; but, when it 
has attained the grade of inflammation, the whole of them are always involved. 
The first observable change is in the capillaries and minute arteries and veins. 
Whether these contract at first or not, they soon increase in diameter, as the 
direct result of the irritant influence, and probably through an active, vital, 
expansive power of their own. Consequent upon this enlargement is the 
entrance into them of an increased quantity of blood; and the backward flow, 
or oscillating movement, which has been observed in them at this point of 
time, may be ascribed to the influence of atmospheric pressure, which tends to 
force the blood into the dilated portion of the vessels from both directions; 
but, when the enlargement is completed, the regular forces which move the 
blood onward gain the ascendency; and it then flows in its regular course with 
an accelerated movement, consequent upon the increased operation of these 
forces under the stimulant cause. Hitherto the action may not have exceeded 
the grade of irritation. But, probably through the same excitant influence of 
the cause, the constituents of the blood itself are stimulated to an increased 
exertion of their vital forces. Hence arises an augmented proportion of fibrin, CHAP. I.] 
INFLAMMATION. 
47 
and a disposition of the corpuscles somewhat to cohere through their vital 
attraction. The blood is thus rendered more viscid, and the red corpuscles 
accumulate in the expanded vessels, much beyond their normal proportion; 
so that the whole increased capacity of the tubes is crowded with them. Their 
forward movement is consequently impeded, not by any inactivity of the im- 
pelling forces, but by the mechanical obstacle opposed by these results of the 
higher vital action of the blood. At this stage, inflammation is fully esta- 
blished ; and it will be observed that, according to the views here taken, it is 
thus far purely an excessive exercise of the vital powers of the parts concerned. 
This retardation of the blood at length ends in absolute stagnation in some of 
the vessels; but in others it is still flowing with increased rapidity, so that 
much more passes through the inflamed part in a given time than in health, as 
proved by the conclusive experiment of Mr. Lawrence.* Through the walls 
of the distended capillaries the liquor sanguinis exudes more or less altered 
in quality, and distends the areolar tissue, or escapes upon free surfaces. Of 
this fluid a portion greater or less consists of fibrin, which, though quite liquid 
and formless when exuded, nevertheless contains the germs of a vital growth. 
The exuded fibrin sometimes retains its liquid form for a considerable time, in 
other cases coagulates immediately; but always sooner or later undergoes this 
process when it is to become organized. Frequently, the inflammation pro- 
ceeds no further than the point of effusion; when it abates, absorption of 
the effused liquids takes place, and the part returns unchanged to health. 
But if it continue, the fibrin coagulates and undergoes a series of organizing 
changes, all of them the result of vital action, and indicative, it appears to 
me, of an increased exertion of vital power. The invisible germs assume the 
shape of molecules, which unite in rows to form fibrils,f or around a common 
centre to form granules, the latter of which are ultimately developed into the 
exudation corpuscles. The fibrils rapidly interlace so as to create a tissue of 
greater or less firmness, while the corpuscles, which when fully formed are 
complete nucleated cells, appear to be capable of undergoing various changes 
according to the wants of the diseased structure. Sometimes they elongate 
at each extremity, and, joining end to end, form filaments, which serve as the 
basis of a new fibrous tissue.' It is not impossible that they are also the origin 
of the new blood-vessels, which rapidly form in the exuded and coagulated 
fibrin, and thus advance its organization. Different opinions, however, have 
been entertained upon this point. John Hunter believed that the coagulable 
lymph generates its own blood-vessels, which afterwards form a connexion 
with the previously existing vessels; and Rokitansky and many other eminent 
physiologists have entertained the same conviction. One strong argument 
in favour of this view is the fact, that blood-vessels and the contained blood 
are formed, in the embryo of the chick, out of cells, without the preexistence 
of other vessels. In this instance, the cell-wall shoots out in various points, 
forming tubes, which unite with similar elongations of other cells, so as to 
produce a network of capillaries; while the contents of the cells are converted 
into blood. Now such a change does not seem improbable in the exudation 
corpuscles of the recently coagulated fibrin. They are supposed by many to 
be identical in character with the proper chyle and lymph corpuscles. These 
are believed, in the ordinary process of sanguification, to be converted into 
blood corpuscles, probably by the developement of their contained nucleus, 
while their other parts may contribute to other portions of the blood. It 
* In a patient with inflammation of one of his hands, Mr. Lawrence made similar 
openings in the veins of both arms, and found that three times as much blood flowed in 
a given time from that of the side affected, as from the other. 
j- See observations of M. Mouueret in the Archives Generales, 4e ser., xxx. 112. 48 
GENERAL PATHOLOGY. 
[part I. 
would seem reasonable to conclude that the exudation corpuscles, arrayed 
side by side, might by means of their cell-wall form continuous capillary tubes, 
while their nucleus should be matured into the blood corpuscle, and their other 
contents into the liquor sanguinis. But it must be acknowledged that this 
is pure speculation, as microscopists have not been able to detect the steps of 
such a process. Hence, many maintain that the new tissue is supplied with 
blood by offshoots from the neighbouring vessels. Lebert and Paget are among 
those who take this view. But their opinions equally want the support of 
observation ; for such offshoots have never been demonstrated; and the aneu- 
rismal pouching of the vessels, occasionally noticed in irritated parts under the 
microscope, instead of affording strength to the opinion, are in fact rather op- 
posed to it; as, if the supposed offshoots really existed, they might be as readily 
detected as these partial dilatations themselves. It seems to me, therefore, 
that the fibrin is capable of self-organization, even to the production of its own 
blood and vessels, when duly supplied with vital influence from the surround- 
ing tissue, which is on all hands admitted to be essential. That lymphatics 
exist in newly-formed parts has been proved by Schroder Van der Kolk 
(Ranking's Abstract, xii. 267), and Virschow has also detected nerves in 
them (Land. Med. Gaz., Aug. 1851, p. 331); but the exact source of these 
structures has not been proved. The inflammatory condition is here con- 
sidered as lasting throughout the organizing process, and as essential to it; 
being in fact only such a moderate elevation of the vital actions as is necessary 
to carry on this excess of growth. But, if immoderate, it lessens or destroys 
the powers of the part by an excitation beyond its vital capacity; and, under 
such circumstances, instead of new organization, we have degradation or 
destruction. 
It sometimes happens, from the quantity of coagulable lymph thrown out, 
from its defective quality, or from its position in relation to living tissues, that, 
instead of becoming the seat of a series of vital changes, it merely dries up, 
assuming a firm, hard, sometimes almost horny consistence, without any ap- 
pearance of organization or vitality. But much more generally, when the 
vital influences are insufficient to carry through the changes in the lymph 
requisite for its conversion into organized structure, the result is the produc- 
tion of pus, or the process of suppuration. This may ensue from a defective 
quality of the lymph exuded, depending on a depraved state of the blood; from 
the exhaustion of the vital forces of the affected tissue, consequent on excess 
or long continuance of the inflammatory excitement of the part affected, and 
possibly of the blood itself; from such a position of the exuded lymph that it 
is excluded from the influence of neighbouring living tissues; or from whatever 
else has the effect of lowering the vital powers concerned in the process of 
organization. From such causes, the exudation corpuscles, unable to advance, 
lose their vitality, and pass into the condition of pus corpuscles, which are 
capable of no other change than one of degradation. At the same time, the 
other ingredients of the exuded matter, if coagulated, are liquefied, and con- 
verted either into the serous constituent or isolated granules of pus, or pos- 
sibly into the compound granular corpuscles sometimes found in that product; 
though it is most probable that these latter bodies, as well as the distinct 
granules, proceed directly from the disintegration of exudation corpuscles. 
Should the pus not escape from the body, it may undergo further degradation; 
the corpuscles being resolved into granules, and these ultimately assuming the 
liquid form, so as to admit of being absorbed; and thus nature provides for the 
elimination of this product, which is a necessary result of her efforts at repair, 
when foiled in the organization of the exuded lymph. The tendency of the 
exuded matter of inflammation to pass into pus, is directly proportionate to CHAP. I.] 
49 
INFLAMMATION-. 
the quantity of exudation corpuscles contained in it, and inversely to that of 
the fibrillating material; so that, when most disposed to coagulation it is least 
to suppuration, and vice versa. 
Another mode of degradation, dependent on the same deficiency of vital 
force, is the softening and destruction of tissue in the processes of suppuration 
and ulceration, and in those other cases in which legitimate pus is not among 
the products. This appears to be effected, in part at least, by the resolution 
of the decaying tissues into compound granular corpuscles or isolated granules, 
and the ultimate liquefaction of these products, so that they may be absorbed 
when not eliminated with the pus. 
Still another mode of degradation is the change of the exuded lymph, and 
perhaps in some measure of the debilitated tissues, into fatty matter, of which 
more will be said under the head of depression, as it is a not unfrequent 
result of that pathological condition, altogether independently of any preced- 
ing inflammation. Instead of fat, calcareous matter sometimes takes the place 
of the normal constituents of the degenerating exudation corpuscles; and not 
unfrequently the two are mixed together; and we have coincident fatty and 
calcareous degeneration. In other instances pigment granules are produced in 
greater or less abundance in the corpuscles. 
The death of portions more or less extensive of the exhausted tissues is the 
lowest point of their degradation. 
In all these cases, if life continue, an effort of repair is made in those parts 
of the structure which have vital energy enough remaining for the purpose; 
and this effort consists in a continuance of inflammation, or its establishment 
in new parts. Thus, when an abscess has been formed by the destruction of 
portions of the inflamed tissue, or when an ulcer has resulted from the same 
cause, the parts around take on such a moderate degree of inflammation as is 
necessary for the exudation of organizable lymph. The same is the case where 
an ulcer has arisen from the sloughing of a mortified part. The exuded 
fibrinous matter closes the blood-vessels, and consolidates the areolar tissue, 
so as to prevent hemorrhage, and the diffusion of the pus and other degene- 
rated products. It does more. It forms granulations by its organization, and 
thus fills up the cavities. These granulations are found, when examined by 
the microscope, to consist of a network of vessels, in the interstices of which 
are fibrils and exudation corpuscles. The same process is, in fact, going on in 
them as in the coagulable lymph undergoing organization in other situations. 
The outer layer of corpuscles, not having the vital influence of the tissues 
exerted sufficiently upon them, degenerate, and are converted into pus cor- 
puscles; and hence granulating surfaces are usually covered with pus. After 
the cavity of the abscess or ulcer has been filled to the level of the surface, the 
granulations cease to grow, and become covered with an epidermis on the outer 
surface, and an epithelium on the mucous surfaces, in consequence probably 
of the conversion of the exudation corpuscles into epidermic or epithelial cells. 
Whether this process of organization takes place in lymph exuded into the 
interstices of tissues, or in that extravasated in the course of granulation, in 
either case, after the growth has ceased, absorption of the liquids present, 
and of portions of the solid tissue formed takes place, which goes on till the 
structure is brought to the condition in which it is ultimately to remain; and 
this absorption is accompanied with considerable contraction. 
The newly formed parts sometimes bear a more or less close resemblance 
to those of the vicinity, being fibrous, ligamentous, adipose, bony, or epider- 
mic, according as they are intended to supply the place of one or the other of 
these tissues. Whether this result is owing to something peculiar in the 
character of the coagulable lymph exuded in each vicinity, or whether .to 50 
GENERAL PATHOLOGY. 
[part I. 
some influence exerted on it by the neighbouring tissue after exudation, has 
not been determined. But there are some structures which are never exactly 
replaced, as the skin, muscle, &c. Dr. Addison gives a beautiful explanation 
of this result. No tissue can be produced except from peculiar germs. The 
blood or its fibrin is furnished with the germs of its own substance as well 
as of its containing tissue, and of analogous structures. The fibrin may be 
developed into areolar, fibrous, ligamentous, and vascular structure, and even 
into blood, because it contains the germs of these, everywhere so essential. 
But the more elaborate tissues have germs of their own, which are merely 
developed by the blood serving as a nutriment to them, and not made out of 
the blood. Hence, they cannot be produced from fibrin alone. (Lond. Med. 
Gaz., Aug. and Sept. 1850, pp. 193,316, 488.) The new formed parts, like 
the old, are liable to irritation, inflammation, and various morbid degeneration 
or deposition, as the fatty, calcareous, melanotic, tuberculous, cancerous, &c. 
The views above given of the inflammatory process are those entertained 
by the author. In relation to the increased action of the blood-vessels, and 
the excessive exercise of the vital properties generally of the part affected, 
they are in accordance with the opinion suggested by Van Helmont and Stahl, 
adopted by Haller, Cullen, Hunter, and Bichat, and still maintained by 
many distinguished pathologists. But an opposite theory, which maintains 
that the vessels are in a state of debility, and traces most of the phenomena of 
inflammation to this source, was put forth by Vacca at Florence so early as 
1765, and was afterwards advocated by several pathologists, especially by Mr. 
Allen of Edinburgh, in his lectures; though it did not attract general atten- 
tion till adopted and supported by Wilson Philip, whose microscopic observa- 
tions appeared to give it countenance. 
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 inflamma- 
tion. According to Wilson Philip, at the same time that the capillaries are 
debilitated, the arteries by which they are supplied are stimulated to increased 
action, so that the disproportion between the resistance and power is still 
further augmented. The blood necessarily moves more slowly through the 
distended vessels; and thus the retardation of the current in the capillaries, 
visible 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 
to 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; and 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 actually exhibited under the microscope, upon the 
application of certain stimulants. The expansion of the vessels which follows, 
and which is the first step of inflammation, results from the debility or re- 
laxation consequent upon the exhaustion of their excitability by the previous 
stimulation. When dilatation of the vessels immediately follows the appli- 
cation of the cause, it is to be ascribed to the immediately debilitating influ- 
ence of the cause; for the existence of a vital expansive property is altogether 
denied by the advocates of this hypothesis. CHAP. I.] 
INFLAMMATION. 
51 
It appears to the author that this theory of inflammation, however inge- 
nious, fails altogether to account for the retrogression of the blood which is ob- 
served, with the aid of the microscope, in parts irritated and reddened. Were 
the expansion merely an effect of the 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 paleness and a diminished supply of blood, which with difficulty pene- 
trates the vessels. Such, for example, is the result of a violent blow paralyzing 
for the moment the vessels of the part. It is true that reaction may subse- 
quently come on, and symptoms of inflammation make their appearance; but, 
in this case, the vital powers arise 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 Gendrin. Why one irritant should produce direct debility of the 
vessel, while another produces the same state indirectly, through the medium 
of a previous excitation, the theory does not satisfactorily explain. 
It has been stated 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 adduced 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 independent 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 
physiology, to which the reader is referred. (See also Thompson on Inflam- 
mation.') 
The nature of the causes from which inflammation results would appear to 
indicate its active character. These are almost always such as, if applied in 
a moderate degree, produce merely a healthy excitation of the part, or an 
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 excitation, 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 excitation 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, and, 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- 
pended, yet the whole quantity of blood entering and leaving the inflamed part 
in a given time is increased. The ordinary phenomena presented in the early 
stages of inflammation are those which would be expected from an increased 
exertion of the vital power. Thus, we have increased heat, which can hardly 52 
[PART I. 
GENERAL PATHOLOGY. 
be ascribed exclusively to the blood accumulated in the part in consequence 
of the expansion of the vessels; as there is reason to believe that the tempera- 
ture exceeds that of the blood before its arrival, especially in parts distant 
from the centre of circulation. It must, therefore, result from a more ener- 
getic exercise of that vital function which generates or evolves animal heat. 
The increased secretion which attends the earliest stage of inflammation, the 
new products which are copiously eliminated in the more advanced stage, the 
exalted sensibility of the part affected, and the rapid generation of new struc- 
ture, 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, the preparations of lead, and warm 
water, in relieving inflammation, affords further evidence to the same effect. 
The sudden expansion of the capillaries in inflammation has been considered 
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 that they 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 wrhich one is followed imme- 
diately by contraction, the other by dilatation of the capillaries. 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 contraction as the result exclu- 
sively of muscular action. The existence of a muscular 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 modification of nervous influ- 
ence, the succession of particles which may be considered 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 contraction 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 dilata- 
tion as well as that of contraction, the phenomena 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- 
gical, which cannot otherwise be well accounted for. Blushing; determination 
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 lacta- 
tion ; 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 CHAP. I.] 
inflammation; 
53 
phenomena, in which an accumulation of blood in the capillaries is exhibited, 
at the same time that these vessels are stimulated to a more energetic perform- 
ance of their proper office, would seem 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 pheno- 
mena mentioned. The operation 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 a moment 
towards the centre of irritation, and the seat of expansion, as observed by aid 
of the microscope. Hence, consequently, the congestion 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 fey 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 inflamma- 
tion, the expansibility is called into action. The reader who may wish to pro- 
secute this inquiry further, will find the arguments in support of the doctrine 
of an active dilatability of the capillaries, very fully stated in a paper by Dr. 
H. L. Hodge, in the IV Am. Med. and Surg. Journ., vol. vi. p. 1. The chief 
difficulty in the way of the theory of capillary excitement is the fact 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 researches. The rapid increase of fibrin, rendering the blood more 
viscid, and the acquired disposition of the red corpuscles to crowd together, 
both of them probably the effect of an increased exertion of vital power, will 
account for the retardation and even stagnation of the blood. Of the same 
tendency is the discovery of the fact, that the white corpuscles also crowd 
together, and adhere to the sides of the vessel and to each other; but, as this 
phenomenon has not been noticed in hot-blooded animals, it cannot be used 
as an argument in the present case. The increased production of fibrin, how- 
ever, is one of the strongest proofs 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 inade- 
quate to the development of the requisite amount of vitalized fibrin for exuda- 
tion, the want of this preservative principle leads to the most destructive 
results. Pus, or other wholly disorganized matters, take the place of coagu- 
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. 
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 54 
GENERAL PATHOLOGY. 
[PART I. 
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 artificial 
inflammation is simply a mechanical result, arising from obstruction of the 
capillaries, and consequent distension of the neighbouring vessels. In the 
present state of our knowledge, however, no explanation is likely to be gene- 
rally received which leaves out of view^e vital properties of the part affected. 
Authors who admit the existence of amnncreased action in the inflamed part, 
differ in relation to the precise nature of that action. Cullen imagined the 
existence of spasm in the extreme arteries, supporting an increased 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 advo- 
cated in this work. He believed that there was an increased action in the 
vessels, and at the same time an increased distention. According 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 pre- 
dicated of inflammation in general, which is often itself the direct result of 
the morbid cause, without any violence to the part, and without any discover- 
able intermediate disease. Dr. Allison 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 are 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, only greater in degree, or longer con- 
tinued. 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 necessarily give rise to inflammation ; since this is a process essential CHAP. I.] 
55 
INFLAMMATION. 
to the restoration 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 or depositions within the organs, 
which require the intervention of the inflammatory process for their elimina- 
tion, 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 disorder. Richness of the blood, 
or superabundance of the red corpuscles, of albumen, and of fibrin, no doubt 
has this effect, and is probably capable itself of producing inflammation, 
without the co-operation of other causes. The febrile movement operates 
powerfully in favouring the same result, and often, indeed, acts not only as 
a predisposing, but as a direct cause. 
4. Modifications of Inflammation hy 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 struc- 
tures, 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 disturb- 
ance 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. Areolar or Cellular, and Adipose Tissues.-These tissues are considered 
under one head, as their only observable difference is in the circumstance 
that the latter secretes a fatty matter, which is deposited in its cells. Inflam- 
mation 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 disease, 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 erysipelas 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 the areolar tissue is not 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 56 
GENERAL PATHOLOGY. 
[PART I. 
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 
tissues, 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 phlegmonodes, than to 
phlegmon itself, which, when it gives rise to fever, is generally attended with 
sufficiently vigorous action. 
2. Serous Tissue.-Next to the skin and mucous membranes, this is per- 
haps most frequently inflamed. The areolar 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 tissues, or may also extend into the contiguous structure, 
especially when it is of a somewhat analogous nature, as in the case of pleurisy 
extending into the lungs. 
An inflamed serous 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 
subjacent 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 often increases and accumulates in the cavity of the 
membrane; but, when the inflammation is fully established, the surface 
usually becomes dry in the part specially affected, though from other portions 
which are merely irritated the exhalation may continue. The serous fluid is 
often reddened with blood, and sometimes unaltered blood is effused. Very 
frequently, after a short time, the inflamed membrane exudes a glutinous sub- 
stance, which is sometimes disposed in layers, sometimes in distinct granules, 
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 sub- 
stance consists of fibrin, with a mixture of albuminous liquid. It gradually 
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 sur- 
face. The latter is now penetrated with blood, becomes vascular and organ- 
ized, and is converted into that morbid structure denominated false membrane. 
This process sometimes begins so early as twenty-four hours after the appear- 
ance of the exudation, sometimes much later, and sometimes does not occur 
for months. 
When the inflammation is so violent as to prove speedily fatal, no false 
membrane is found, but a bright redness, with small ecchymoses, 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 
inflammation 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 CHAP. I.] 
INFLAMMATION. 
57 
takes on the appearance and character of cellular tissue. Permanent adhe- 
sions are thus frequently formed between opposite serous substances, espe- 
cially 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 conse- 
quence partly of changes in the subserous 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 surface 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 the membrane, 
never encysted, and never softened. (Gendrin.') The fluid in the cavity is 
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 with a 
sort of cellular tissue resulting from organized false membrane, which is 
infiltrated with pus, and occasionally itself forms cavities, in which pus is col- 
lected and confined. When a cure takes place, the liquor is absorbed, the 
cavity contracts, and the new tissues become firm, and sometimes of a fibrous 
consistence. Often, however, the false membrane is entirely absent, especially 
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, pre- 
sented in the thickened and altered tissue. The serous membrane and sub- 
jacent 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 this tissue from that of the 
parenchymatous or mucous tissue in its neighbourhood. Sometimes, how- 
ever, 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 
sympathy; and occasionally it is 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 lymph, and consequent adhesions. When adhe- 
sion takes place in joints, it arises, for the most part, from ulceration and 
granulation. 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, 58 
[PART I. 
GENERAL PATHOLOGY. 
it is often very painful and severe, involving the safety of the patient, and 
requiring active treatment. 
3. Fibrous, Fibro- Cartilaginous, and Cartilaginous Tissues.-The fibrous 
tissue, including the periosteum, dura mater, aponeuroses, capsular ligaments, 
tendons, &c., is sometimes affected with inflammation, though much more 
frequently with the rheumatic and gouty than the ordinary form of that 
affection. The changes which it undergoes are those described under the 
general head. It becomes red and swollen, 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 inflamma- 
tion 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 suppuration. When very long inflamed, it often loses entirely 
its original character, and becomes cartilaginous or bony. Sometimes ossifi- 
cation 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 fibro-cartilages, a structure intermediate between the fibrous and pro- 
per cartilaginous tissues, of which we have examples in the intervertebral and 
interarticular cartilages, the annular ligament of the radius, and the cornea, 
are occasionally affected with inflammation, being much softened, reddened, 
and infiltrated with a turbid reddish fluid, which becomes sero-purulent, and 
is sometimes collected in small abscesses in its substance. Inflammation of 
this tissue, however, is little known, and is not often original. 
Cartilages are but little exposed to inflammation, and, being without blood- 
vessels, are insusceptible of the process as ordinarily observed. Yet, when 
wounded, they may heal by the formation of tissue out of their intercellular 
substance or the nuclei of their cells, and are affected sometimes by a kind of 
ulceration, consisting in a degradation of their structure, and its absorption 
or elimination. (Redfern, Month. Journ. of Med. Sci., Sept., 1851.) Hence, 
the cartilages which form the articulating surfaces in movable joints some- 
times disappear during long-continued inflammation of the neighbouring bony 
structure. Others, such as those of the larynx, trachea, and ribs, throw off 
portions from their surface, or exfoliate when the perichondrium is inflamed. 
According to Gendrin, these are occasionally affected with a chronic inflam- 
mation, which begins in the perichondrium, and gradually modifies the car- 
tilaginous structure, so as to make it approach to the fibrous. They are thus 
apt to ulcerate, and sometimes assume a bony character. They occasion little 
pain or constitutional disturbance; and that which does occur, is probably 
ascribable more to the accompanying inflammation of the neighbouring parts 
than to that of the cartilages themselves. 
4. Cutaneous Tissue.-From the complex nature of this tissue, its numerous 
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 particular 
portion of the structure which they occupy, in their greater or less degree 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 
extending beyond the reticular layer beneath the cuticle. Under these CHAP. I.] 
59 
INFLAMMATION. 
circumstances, there is generally a slight swelling, with a redness which dis- 
appears upon pressure, and returns upon its removal. If the inflammation be 
very slight, or subside speedily, the cuticle usually separates either in furfu- 
raceous 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 duration, 
a serous fluid is secreted, appearing under the cuticle in small separate collec- 
tions, 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 inflamma- 
tion persist, becomes at first reddish, then turbid, and ultimately purulent. 
It abounds with exudation corpuscles, and is therefore specially disposed to 
the formation of pus. It appears to me probable that these so-called exuda- 
tion corpuscles are nothing but young undeveloped epidermic cells, which 
become degraded into pus corpuscles because deprived of those conditions 
essential to their complete developement. Occasionally, when the inflam- 
mation 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 deprived of its cuticle, and irritated by some 
stimulating substance, as savine or mezereon. Small quantities of exudation 
on the surface, whether of lymph or puriform, often dry up and form scabs. 
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 
separates sooner than in the inflamed parts, upon the commencement of 
decomposition. In severe cases, even though lasting not more than a day, 
the corium appears injected, and somewhat thicker than in health; and the 
affected part putrefies more readily than the rest of the skin. 
Inflammation may extend from the surface of the true skin, through its 
substance, 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. (Gendrind) 
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 it may be the areolar. 
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 erysipe- 
latous. Common inflammation does not usually extend so rapidly in the skin 
as in some other tissues, particularly the serous membranes and absorbents. 
Witness the effects of blisters and sinapisms, which are generally confined to 
the limits of the original application on the skin; while the inflammation 
often rapidly runs up the absorbents to the nearest gland. 
The pain is apt to be burning, and, in the milder cases, is often of an 
itching, 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 
of 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- 60 
GENERAL PATHOLOGY. 
[PART I. 
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 causes, 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; 
but, sometimes, especially in 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 mamillated. It may be easily separated from the parts beneath, 
in consequence of the loss 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 thickei' membranes, the same effusion takes place in the mucous tissue 
itself. In the advanced stages of the inflammation, the place of the serum is 
occupied by a purulent infiltration. In some cases, there is a very strong 
tendency to serous effusion, so as to produce an edematous condition, which, 
in certain positions, as in the neighbourhood of the glottis, is productive of 
no inconsiderable danger. This is particularly apt to happen in patients 
with dropsical tendencies. In such cases, there is less redness than is ordi- 
narily 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, limpid, 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 reestablished, and at this 
time is frequently 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 
infiltration of the membrane itself. When examined by the microscope, the 
discharge is found to consist of an amorphous fluid, which is the proper 
mucous secretion, and of epithelial scales, granules, and corpuscles of various 
size and character, with which are not unfrequently mixed proper blood-cells 
and shreds of fibrillated lymph. The corpuscles are chiefly young epithelial 
cells in different stages of developement, or pus corpuscles, which are some- 
times very abundant. The former are frequently called mucous corpuscles. CHAP. I.] 
INFLAMMATION. 
61 
In the earlier stage of inflammation, the mucous fluid is thrown off more 
copiously ; at first transparent and thin, but gradually becoming thicker, 
whitish, and opaque, from the admixture of increasing quantities of the effete 
epithelial cells, and of the yet incompletely developed cells, which the excess 
of action causes to be separated before maturity, and perhaps to be generated 
more abundantly than in health out of the lymph exuded through the base- 
ment membrane. When the vital powers begin to be exhausted, these cor- 
puscles degenerate into those of pus, probably in part through the formation 
of oil; and it is by the accumulation of the latter bodies that the secretion 
assumes gradually more and more of the yellow purulent character, until it 
sometimes at length becomes almost pure pus. Not unfrequently black pig- 
ment granules are found in considerable quantities in the degenerated mucous 
corpuscles, especially in affections of the bronchial mucous membrane. By 
the character of the epithelial scales mixed with the mucous secretion in in- 
flammation, the exact seat of the affection may sometimes be determined; as 
the form of these cells varies in different parts of the membrane. 
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.-Inflammation of the mucous 
membranes is sometimes attended with a secretion of albumino-fibrinous mat- 
ter, 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 ap- 
pears 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 has been supposed by some to be 
capable of becoming organized; but Gendrin has never seen traces of vessels 
in the false membranes which it forms, and Andral considers the apparent 
vessels, which have 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 gradu- 
ally thinned till they become like a delicate epidermis; sometimes they are 
softened and converted into a kind of thick mucus, or puriform matter; and 
sometimes they are separated from the mucous tissue by a layer of mucus or 
of pus beneath them, and are rejected either whole or in fragments. Occa- 
sionally, other parts of the same membrane upon which they are formed 
afford an abundant mucous or muco-purulent secretion. 
Follicular Inflammation.-Inflammation of a mucous membrane may affect 
chiefly or exclusively the glandular follicles, producing small, rounded, promi- 
nent, more or less pointed tumours, when the distinct follicles are inflamed; 
or flattish and somewhat depressed tumours, consisting of aggregated follicles, 
with which, in the alimentary canal, the inflamed villi are also mingled, form- 
ing patches of some extent. But, without attention, a healthy erection of 
these mucous glands may be mistaken for inflammation. In the state of 62 
GENERAL PATHOLOGY. 
[part I. 
normal excitement, they are diaphanous, with a little depression marking the 
orifice of the duct; in inflammation, opaque and reddish, with a phlogosed 
condition of the adjacent portions of membrane; and, as the inflammation 
advances, they lose entirely the follicular character, becoming merely small 
phlegmons, and often ulcerating. 
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, somewhat harder to the touch than in 
health, thicker, denser, 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 consider- 
able, there is often also much serous exhalation. 
In very slight and old cases, there is only left a thickening of the mem- 
brane, with a slight vascular injection, and follicles more voluminous than in 
health. Such cases are known, during life, only by increased mucous or 
muco-purulent secretion, and are not always easily recognized 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, pre- 
senting 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 
membrane loses its tenacity, becomes friable, or softened, and, in the case of 
the alimentary mucous membrane, is sometimes quite disorganized, and re- 
duced to a pulpy or semi-liquid state. Sometimes, instead of this change, 
small red excrescences form in the membrane, which at length become gray, 
dense, and hardened, and remain after the inflammation has ceased. (Gendrin.') 
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 
inflammation 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 acute inflammation, but much 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 may be 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, indi- 
cate chronic inflammation. If the tissue around and at the bottom of the 
ulcer is softened, puffed up, and bleeding, there is reason to believe that acute CHAP. I.] 
INFLAMMATION. 
63 
has supervened upon chronic inflammation. Ulcers 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 pene- 
trate 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 effusion. Mucous 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 felt, unless on motion or pressure. 
Not unfrequently it is altogether wanting. In acute inflammation, there is 
generally a considerable feeling of heat, which is often also experienced in the 
chronic form. 
Inflammation of the mucous tissues is often attended with sympathetic dis- 
turbance. When it occupies a portion of the membrane in which some excre- 
tory 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 ending in inflammation of the gland. Hence 
the disordered hepatic function, so common in inflammation of the duodenum. 
Every grade of fever accompanies mucous inflammation, from the most vigor- 
ous to the lowest and most malignant. As a general rule, in ordinary states 
of the constitution, and where the disease has not originated from a peculiar 
cause, the fever may be considered, in relation to the grade of action, as inter- 
mediate between that of serous and that of cutaneous inflammation, support- 
ing and requiring more depletion than the latter, and less 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 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 injections. In cases of intense inflammation, 
the whole texture of the gland, both the strictly glandular and the interlobu- 
lar, 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 it may still be maintained by 
other portions of the gland. 
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, 64 
GENERAL PATHOLOGY. 
[part I. 
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 ex- 
cretory ducts of which are opened by the disorganizing process. Sometimes 
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, however, 
if the patient is not first exhausted, it makes its way by means of the com- 
bined 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- 
vessels, 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. (Gendrin.') 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 in- 
fluence 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 general 
observations are requisite, as inflammation of each of these tissues constitutes 
one or a few special diseases, in treating of which, anything of a general na- 
ture that could be said here would be necessarily repeated. 
5. Specific Inflammation. 
There are numerous 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 modification 
impressed upon it by another coexistent 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 inflammation 
chiefly by the presence of tuberculous matter, or a curdy, cheese-like secre- 
tion, 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 65 
CHAP. I. 
DEPRESSION. 
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 mor- 
bid 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 be 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 
scrofula, rheumatism, gout, &c., or in the character of the exciting cause, as 
in syphilis, smallpox, 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. The most prominent of them are the 
scrofulous, the erysipelatous, the rheumatic, the gouty, the various exanthema- 
tous inflammations, as those of smallpox, measles, scarlatina, &c., the syphi- 
litic and gonorrhoeal, and all other inflammatory effects of peculiar poisons, 
whether of animal, vegetable, or mineral origin. 
Article III. 
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 dis- 
tinct, 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 depres- 
sion, 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, which is here denominated excitability, are different conditions or 
qualities of the system, and may each be reduced without a necessary reduc- 
tion 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 coexist; but a few remarks will show 
that they are distinct, and may exist separately. Thus, depression or dimi- 
nished action may result from a temporary abstraction of some wonted stimu- 
lus, 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 necessarily diminished, is often increased by causes producing temporary 
depression; as is proved by the reaction which immediately follows the with- 
drawal of the depressing cause, and which is ascribable only to an augmented 
susceptibility, by which the ordinary healthy excitants produce more than 
their usual effect. 66 
GENERAL PATHOLOGY. 
[PART I. 
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 
would have scarcely discomposed these functions, in the ordinary state of the 
system ! How often, under similar circumstances, do the slightest causes pro- 
duce 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 
may be 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 in- 
crease 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 debilitated, but 
with excessive action of some important organ, dependent upon increased ex- 
citability, are no less injuriously depleted with a view to the reduction 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 
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, in fatty degeneration, and in 
gangrene. 
As irritation may be either 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, the CHAP. I.] 
DEPRESSION. 
67 
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 ope- 
ration of certain excitants upon the susceptibilities of the system, it follows 
that, upon the diminution or removal of these excitants, the action must be 
diminished or cease. Among the most common and efficient causes 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 blood.-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 stimulating, 
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 deficiency in the 
quantity or quality of the food, or insufficiency in the processes 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 in- 
troduced into the system may, by a chemical 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 undergo great deterioration, either from 
the direct action of the poison introduced, or from derangement of the organs, 
and thus becomes wholly unfit to support the healthy actions, which are con- 
sequently greatly depressed. In all these cases, there may not only be de- 
pression 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 diminution 
of its stimulant properties, without any positively noxious deterioration, though 
it may cause debility, does not necessarily diminish excitability. On the con- 
trary, 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 increase of excitant agency, the heart very often 
acts with greatly increased frequency. This phenomenon, however, may be 
explained. The nutrition, muscular contraction, digestion, and other functions 68 
[part I. 
GENERAL PATHOLOGY. 
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 increased 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 in- 
sufficient 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 ac- 
tivity 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. 
It has already been observed that the nervous system acquires the same in- 
creased 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. As the nervous centres are the 
media through which the wants of the functions make themselves felt, and 
through which the requisite influence is sent to the sympathizing organ, it is 
easily understood why they are themselves disturbed in cases in which the 
functions are insufficiently supported. 
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 ge- 
nerally promoted, and various other functions occasionally much excited; 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 in the same ratio. 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 ordi- 
nary 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 may 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 CHAP. I.] 
DEPRESSION. 
69 
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 sup- 
plies exclusively from the absorption of the materials composing the body, is 
probably more irritating 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 irritants; 
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 excitation, varying according to the precise nature 
of the cause. 
Cold, or abstraction of heat.-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 condi- 
tion 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 increase and diminution of tem- 
perature, and, in part, from the loss or diminution of that function in the capil- 
laries, 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 active 
dilatation. All the immediate effects, then, of cold, are those of depression. 
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, and 
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 original 
cause; and this reaction, unlike that which often follows the application of 
excitants in real debility, is of a healthy and invigorating character, unless, 
indeed, it amount, as often happens, when the primary depression was con- 
siderable, to inflammation. Cold, therefore, though an immediately depressing 
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 depressing, 
and indirectly tonic or excitant. Strictly speaking, however, it is not possible 70 
[part I. 
GENERAL PATHOLOGY. 
for a moderate degree of cold to act directly upon the whole system; as, before 
it can reach the interior portions of the body, it excites a reaction, which ob- 
viates 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 part. In either case, 
the whole of the vital actions gradually diminish until they cease altogether. 
It has been stated that, under 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 ; 
the nutritive function, upon which the support of due strength depends, being 
thus impaired. This is especially the case when the cold is united with an 
impoverished diet. 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 accompanies 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 persons 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 apt to end in the production of low forms of 
fever, or to induce the typhous state in diseases having another origin. 
b. Direct positive Causes.-The causes hitherto mentioned have been of a 
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, amount- 
ing sometimes to fainting, which results from the use of the warm bath. Si- 
milar 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 ex- 
plained 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. Hence 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 distension. 
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 greater tendency to low forms of disease, or in greater susceptibility to CHAP. I.] 
DEPRESSION. 
71 
any prevailing epidemic. Some of the excitant passions also occasionally pro- 
duce 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 con- 
centration of action in the brain, withdrawing it from other parts, on the prin- 
ciple 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. 
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, therefore, 
a necessary result. In cases of violent excitement, the subsequent depression 
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 consequent depression 
greater. By a continued repetition of this course, great prostration is occa- 
sionally 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 pa- 
ralysis. 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 neces- 
sary to the sustenance of these actions. It is obvious, however, 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 sys- 
tem, so powerful as to suspend or materially interfere with its functions. Such 
is the prostration sometimes produced by concussion of the brain, by sudden 
and startling intelligence, by very severe surgical operations, &c. 
It is highly probable that the sympathy between our different organs is ex- 
tended, as well to states of depression, as to those of excitement or irritation. 72 
[PART I. 
GENERAL PATHOLOGY. 
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 sympa- 
thetic impression is necessarily the result of action in the impressing organ. 
But this is not essential. Sympathy between separate parts is such a con- 
nexion as enables one part to share in any impression made upon another, of 
whatever nature the impression may be; and it is as easy to conceive that a 
depressing agency may propagate its influence in this way, as one of excite- 
ment. We know that cold, applied externally, often arrests internal hemor- 
rhages; 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 participate in the 
depressing effect of the cold upon the cutaneous capillaries. It is not difficult 
to explain theoretically the sympathetic propagation of depression. The de- 
ficiency of action in a part may, through the afferent nerves, cause a partial 
vacuum in the nervous centre, which through the efferent nerves may occasion 
a similar deficiency in the sympathizing organ; the nervous power obeying the 
same law as that which governs analogous electrical movements. 
3. Phenomena, Effects, &c., of Depression.-In every case of depres- 
sion, there is a diminutipn of activity in the function of the part, organ, or 
system affected. If the whole system is affected, all the functions are de- 
pressed. 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 
symptoms of depression, so far as they are obviously a mere diminution of the 
phenomena of health. To say that sensation, muscular motion, and intel- 
lectual action are impaired, that digestion is less vigorous in all its depart- 
ments, 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 depression, and yet so closely resemble those of super-excitation 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 distinguish; 
and, in reference to them, I shall survey the several functions, touching upon 
such points, in each, as may seem to deserve notice in a general treatise. 
Depression in the nervous Centres, 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 nervous 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 nervous 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 centre, 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 re- 
sult would follow a similar disturbance in the natural equilibrium of the fibre 
by the transmission of an excessive supply, in consequence of nervous irrita- CHAP. I.] 
73 
DEPRESSION. 
tion, 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 con- 
tradiction in the ascription 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 remedies, when the morbid affection 
is itself 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 concerned. 
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 vascular coats. 
Respiration is sometimes, by a direct reduction of the function, thrown into 
great disorder, which, without attention, might easily be ascribed to an 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 strug- 
gle, 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 unfrequently met with in infants, when debilitated by disease 
or depletory treatment, especially in cases in which the lungs or bronchial 
membrane, having been previously inflamed, are left in a weakened condition 
upon the disappearance of the inflammation. In the latter case, the occur- 
rence of this condition has probably often been ascribed to an increase of the 
inflammation, and fatally regarded as a signal for further depletion. 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 pul- 
monary arteries to the pulmonary veins, and thus sustain the circulation. If 
the action of these vessels be depressed, there is to a certain extent a stagna- 
tion 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. Besides, in a depressed con- 
dition of the proper respiratory function, the change from venous to arterial 
blood 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 sym- 
pathies which have been established, through the nervous centres, 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, that the muscles concerned in the office should 
be stimulated to increased action, in order that an increased supply of air should 74 
PART I. 
GENERAL PATHOLOGY. 
be furnished to the lungs. It is the same feeling that leads to hurried respi- 
ration 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 
supply of air that is wanted, but increased activity of the proper respiratory 
process; 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 
different from those to which recourse is had in an over-excited condition of 
the lungs. Happily, the present modes of exploring 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 vessels, 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 cavae, 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 treat- 
ment of the congestive condition of the organs, with the effect of calling it 
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 inter- 
nal 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 thera- 
peutical efforts should be directed mainly to the state of the circulation, or 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 occurs in certain stages or varieties of inflammation. This resem- 
blance is still further increased by the circumstance, that the caliber of the 
relaxed vessels is sometimes augmented, probably from a loss of equilibrium 
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 red and swollen; and the same thing occurs upon other membranes, 
and upon the skin. It is an entirely different condition from that of inflam- 
mation; 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 inflamma- CHAP. I.] 
DEPRESSION. 
75 
tion, 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 vesselsis insufficient to resist the force of gravity. 
From the same cause, in cases of great debility, it may be observed as the 
mere 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 in the interior organs 
after death, as in the raucous membrane of the stomach and bowels, has often 
been mistaken for the immediate effect of inflammation. When this condition 
occurs externally, slight pressure 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 condition 
in which they are after death, and in which it is well known that blood often 
percolates through them into the dependent parts of the body. This hemor- 
rhage 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 purpura 
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- 
mon in the skin, constituting the petechiae 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. Atrophy, 
however, is not always necessarily the result of depressed nutrition. It may 
originate also from an excessive activity of absorption, the nutritive deposi- 
tion not being diminished in quantity. This is probably the case in those 
instances of universal emaciation which are accompanied 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 sub- 
stance, 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. Nutrition requires not only an elimina- 
tion of the organizable material, but also a process of organization; and it is 
only when this process is efficiently conducted, and in due relation with the 
excess of matter acted upon, that the function can be asserted to be in a state 
of positive exaltation. 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 ex- 
ample of this we have in fungous granulations, arising from debility of the granu- 
lating surface. It is not uncommon for this sort of morbid growth to be 
produced in wounds or ulcers by local or depressing applications. Emollient 
poultices, which, in consequence of their moisture, are positively depressing, 
often produce this effect when too long continued. The weakened vessels 76 
GENERAL PATHOLOGY. 
[part I. 
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 possessed 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 they, together 
with the cells which are thought often to be the agents of secretion, lose that 
vital power of election and elaboration by which peculiar secretory products 
may be 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 
frequent 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 ex- 
amples of this kind. So are, in many instances, diuresis, 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, dependent 
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 proper healthy energy of the 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, be- 
cause 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 ad- 
ministration 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 circulating 
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 increase 
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 continued 
restraint, loses at length its susceptibility and its power of action, and becomes 
as it were paralyzed. This result is probably connected with the want or defect 
of nutrition under such circumstances. Again, if the restraint be continued 
remittingly, 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 ex- 
haustion is produced. The excitability is either worn out by undue exercise, 
or, the parts affected being thrown into irregular reaction beyond their depressed 
powers, organic mischief results. When the depressing agent is intermittingly CHAP. I.] 
DEPRESSION. 
77 
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 pro- 
duced by rousing the sleeping energies into action. Thus, the occasional ap- 
plication of cold to the body, alternating, as in civilized life, with a comfortable 
temperature, often produces a healthy excitement by the reaction which it calls 
forth; but, if long continued, with little or no remission, it either directly de- 
stroys life, or gives 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 sup- 
ported by the powers of the part, as in the case of frostbite 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 occasionally be pro- 
duced 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 examina- 
tion 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. Even the granular corpuscles, so common an attendant 
on inflammatory softening, are not detected in this variety; at least, Dr. Hughes 
Bennet could not discover them in non-inflam matory softening of the brain. 
The colour of the part is unchanged, there is no injection of the blood-vessels, 
and none of those peculiar products are observable which invariably attend 
inflammation when severe and lasting. The result is 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 softening does not proceed from the absolute 
loss of vitality, and the entrance of the part within the domain of chemical 
laws, is evinced by 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 molecules 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 body, as for example to a paralytic limb; 
or still more narrowly to some 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 condition 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 78 
GENERAL PATHOLOGY. 
[part I. 
solid parts with fluids, from the solvent action of the gastric juice, or from in- 
cipient putrefaction. 
Fatty Degeneration.-Another organic result of depression is fatty degene- 
ration. It has long been known that flesh, under certain circumstances of 
exclusion from atmospheric air, is converted into a fatty matter called adipocire. 
This fact suggested to Dr. C. J. B. Williams that the fatty degeneration occur- 
ring during life might be equally a result of chemical action. Dr. Quain found 
that, by immersing muscle in dilute acid, so as to prevent the putrefactive pro- 
cess, the pathological fatty degeneration of that tissue might be closely imitated. 
The inference from these facts is, that, when the organic tissues are so far 
withdrawn from vital influences as to allow the predominance of chemical 
affinities, without being completely surrendered to them as in putrefaction, the 
tendency of these tissues is to yield fatty matter as one of the results of their 
decomposition. If, therefore, any part is greatly depressed, whether from the 
want of due vital influence, or from an insufficient supply of material for its 
nourishment, chemical reactions may take place, by which the tissues of the part 
may to a greater or less extent be converted into fat, the other products of the 
decomposition being carried off by the absorbents, or in some other way elimi- 
nated. There is reason to believe that this result very frequently takes place. 
It is of no consequence whether the depression is indirect, as in the advanced 
stages of inflammation, or direct, as when a due supply of blood is withheld. 
The formation of pus, one of the first results of depression in inflammation, 
is always attended with the production of fat, and the degeneration of the pus 
corpuscle into the granule-cell has been shown to be mainly an oleaginous 
transformation. It is probable that the pus corpuscle differs from the fully 
formed exudation corpuscle in which it originates, simply in the loss of vitality 
in the latter, and the consequent generation of oil within it. In fatty degene- 
ration of the heart, liver, and kidney, from depression of the nutritive func- 
tion, oil may be seen, upon microscopic examination, occupying the place of 
the proper muscular structure within the sheaths of the fibrils, and of the 
proper contents of the secreting cells in the glandular parenchyma. This 
sort of fatty degeneration is wholly different from the excessive secretion of 
fat which results from an overabundance of the material of nutrition, or an 
overaction of the nutritive function, constituting morbid obesity. In the latter 
case, fatty matter is deposited in addition to the normal structure, and, if it 
interfere with it, does so by producing absorption through pressure. In the 
former case, the normal structure itself undergoes degradation. 
Calcareous Degeneration.-This is still another organic result of depression. 
In this affection molecules of earthy matter, generally with a calcareous base, 
take the place of the normal tissue, and often to such an extent as to give an 
almost bony hardness to the part. It is very apt to occur in the coats of the 
blood-vessels; but may take place in any of the tissues, and, indeed, is fre- 
quently found in abnormal structures or deposits, as in the false membrane of 
inflammation, in tubercle, and in cancer. Whether it is the result of the 
disintegration of the tissue leaving its earthy components behind, or a direct 
deposition from the blood, supplying the place of the absorbed structure, has 
not been determined; but the probability is that it proceeds from both these 
sources. It is very analogous to the fatty degeneration, occurring under the 
same circumstances, and not unfrequently along with it. Both are very com- 
mon in the old, in whom they seem to be regular consequences of the failing 
powers and actions of life, rather than morbid changes; capable it is true, like 
other normal processes, of producing injury by excess or malposition, but on 
the whole forming one of the physiological series of vital processes beginning 
with the impregnated germ, and ending with the last breath of expiring old CHAP. I.] 
79 
DEPRESSION'. 
age. The arcus senilis, or grayish-white circle often observable in elderly 
persons near the edge of the cornea, has been ascertained to be a fatty degene- 
ration, generally coincident with a similar change in various internal parts of 
the body; and the ossification of the arteries, so common in the same class, is 
an example of the calcareous degeneration. 
Gangrene.-This has already been defined to be the death of a part, without 
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 necessarily 
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 poi- 
sons or depraved states of health with inflammation, such as occur 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 cer- 
tain diseases of the heart, which disable it from transmitting to the extremities 
the necessary quantity of blood for the support of their vital actions. Such 
also is the case with the gangrene produced by certain positively depressing 
agents, as excessive cold, large quantities of ergot, and local violence so great 
as to destroy the life of the part without reaction. 
There is in gangrene a total absence of all the phenomena of life in the part. 
There is no sensibility, no circulation, no active movement whatever, no gene- 
ration of animal heat. But these are not unequivocal signs of the loss of vi- 
tality. They may all exist, and yet the part may be living, and, 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 inter- 
ruption to the circulation. It is of the greatest practical importance that, in 
such cases, the apparent should not be mistaken for real death, to the neglect 
of proper measures of restoration. The only certain sign that mortification 
has really occurred is the commencement of putrefaction. This, under ordi- 
nary circumstances, always takes place sooner or later after the death of the 
part. But, though it is indispensable as a sign, gangrene may occur and 
continue to exist for a considerable time without it, as when resulting from 
cold, or in parts destitute of fluids or secluded from the air. Sometimes 
putrefaction is concurrent with the mortification, especially when the latter is 
the consequence of inflammation, and the part is exposed to the conjoined 
influence of air, moisture, and warmth. Besides loss of sensation, vital move- 
ment, and animal heat, there is generally, even in cases where putrefaction has 
not taken place, a change of colour and consistence, dependent partly upon 
alterations antecedent to the loss of vitality, partly upon 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. In some instances, however, as in 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. 80 
[PART I. 
GENERAL PATHOLOGY. 
In the state which precedes gangrene, in that which is presented by the 
living parts in the vicinity of the dead, in the progress of the affection, and in 
the earlier or later occurrence of putrefaction, there are sources of such diver- 
sified and complicated phenomena that it would be wholly out of place, in a 
general treatise, to attempt to describe all their possible combinations. When 
the gangrene has originated in inflammation, the phenomena 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 sometimes experienced, as in the 
gangrene which attacks the extremities of old persons. In such cases, it is 
possible that the nerves may preserve, for a time, their vitality in the midst 
of the mortified structure, and thus be exposed to irritation from the contact 
of what has now become foreign matter. Sometimes the mortification ad- 
vances gradually without any apparent disposition to set limits to its exten- 
sion, 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, inflammation occurs in the living parts in contact 
with the dead, and the latter are separated by ulcerative absorption, as already 
described under the head of inflammation. Occasionally, when the consti- 
tutional tendency to gangrene is strong, mortification recommences, after having 
been temporarily arrested; and this alternation may occur several times, 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 circum- 
stances, as in persons of good constitution and previously vigorous health, 
and in soft highly vital parts, the separation is effected in eight or ten (fays; 
but, under 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 considerable 
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 recovered. A previously feeble state of health, or the coexistence 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 depressing products which result from putrefaction. Other 
sources of danger, in cases of extensive gangrene, are hemorrhage from the 
sloughing of large arteries, and the exhaustion consequent upon excessive sup- 
puration, during or after the separation of the slough. Gangrene has some- 
times proved curative by attacking exclusively some morbid structure, as the 
cancerous, for example, which, if not thus destroyed, would have gone onward 
to a fatal issue. As gangrene presents phenomena somewhat different accord- 
ing to the tissue which it occupies, it will be proper to trace it, at least briefly, 
through the different tissues. 
In the areolar or cellular tissue, gangrene is very apt to occur as a conse- 
quence 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, mitscles, tendons, 
blood-vessels, and nerves. When it affects the subcutaneous cellular or adi- 
pose membrane, the skin over the part affected often assumes a gangrenous CHAP. I.] 
DEPRESSION. 
81 
appearance, and portions of it slough away, or numerous orifices are made by 
ulceration, 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 bowels 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 membrane 
exists, it sometimes participates in the affection, presenting the same pheno- 
mena 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, or 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 separating than most other parts. 
The skin is more liable to gangrene than any other tissue, unless it may be 
the areolar. The appearances which it presents, immediately before the death 
of the part, have been already described. (Seepage 34.) After mortification 
has taken place, the surface, if moist, is of a grayish or ash colour; if dry, is 
darker and even 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 mortification has occurred during suppu- 
ration, it is still softer; and, if the subcutaneous 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 inflammation, the neigh- 
bouring 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, pre- 
sents the ordinary appearances which characterize the affection. In the blood- 
vessels, it is exceedingly rare as 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 mortification. 
Muscles, in a state of gangrene, are usually of a dark livid colour, though some- 
times, when not exposed to the air, they are yellowish or grayish, and are 
black in dry gangrene. Gendrin 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 gangrenous part is 82 
GENERAL PATHOLOGY. 
[part I. 
gray or blackish, very soft, and very fetid. But fetor and softening are not 
certain signs of mortification; for the latter is often produced 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 admission to the part. In bones, 
gangrene is not unfrequent, and is perhaps produced more readily by an equal 
amount of cause than in any other tissue. The mortification of bones is 
attended with phenomena somewhat peculiar, which have given it a distinct 
name, and have led to especial attention. It is usually denominated necrosis. 
Of this affection, however, as it is considered 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 in- 
ternal, 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 disordered; 
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 inflam- 
mation, and especially when attended with a sudden cessation 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 mortifica- 
tion ; and that, in others, though death may have occurred in the part, yet 
general death has so speedily followed, that no time has been allowed for the 
commencement of putrefaction, which, as before observed, is the only unequi- 
vocal sign of gangrene. 
Article IV. 
CONGESTION. 
This 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 ramifi- 
cations, 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-ex- 
isting 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 
complex phenomena presented by the part congested. There is probably no CHAP. I.] 
83 
CONGESTION. 
form of congestion which may not be traced to some one of the morbid affec- 
tions 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 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 over- 
excitement, and is hence called active congestion; 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; for, although the affection 
is in many instances confined chiefly to the veins, it is not necessarily so in 
all. I shall treat of congestion under two distinct heads, corresponding with 
these two conditions. 
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 
excitation, 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 
excitation 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 symp- 
toms of inflammation have not yet made their appearance. Congestion, 
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 substance. 
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 ves- 
sels, though it may cause, cannot itself constitute congestion. This is con- 
sequently not the proper morbid action. The disease is, in fact, some pecu- 
liar modification, not well understood, of the solid tissues, of which a change 
in the innervation 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 the important circumstance of the nervous derangement. 
Even within the limits of healthy excitation, 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 again to their usual state in a short 
time, without having suffered injury or inconvenience. The process is en- 
tirely healthy. If, however, the excitation increase or persist so as to induce 
a derangement of function, it then amounts to irritation, and the attendant 84 
GENERAL PATHOLOGY. 
[part I. 
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 phenomena and 
morbid effects. The latter, however, may be summed up in a few words. 
There are distension, increased redness and heat, and usually some unplea- 
sant or deranged sensation, as a feeling of fulness, weight, or oppression ; 
but no positive pain, unless the disease amount to inflammation. The func- 
tions of the part are always modified, being often increased, when the affec- 
tion is moderate, and deranged, diminished, or altogether suspended, when 
it is severe. Hemorrhage from the distended vessels is not uncommon. It is 
now generally thought by microscopists to proceed from rupture of the ves- 
sels, the possibility of the passage of the unbroken blood corpuscles through 
their coats being denied. 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, dis- 
ordered sensation generally, and paralytic affections, are often consequent upon 
congestion of the brain. Active congestion may even terminate in disorgani- 
zation of the part, the result being ascribable, when not produced by inflam- 
mation, to a depression consequent upon a preceding excess of excitement. 
But I wish again to urge the consideration, that all these effects do not pro- 
ceed 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 
disease itself. Still, it is highly important to consider the particular character 
of the irritation in which they originate, as this will very much modify the 
extent, and, indeed, the nature of the treatment. 
2. Passive Congestion.-1This 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 ac- 
cumulates 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 malignant 
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, CHAP. I.] 
85 
CONGESTION. 
the pale and shrunken skin, and the frequently suspended or impaired intel- 
lectual functions, 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 debility, 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 
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 ramifica- 
tions, but in the vessels and their radicles, which convey the venous blood 
from the abdominal viscera to the vena portae. Hence arise congestions of the 
stomach, bowels, spleen, and liver. Depression in the capillaries of a secret- 
ing organ may also promote congestion by diminishing secretion. That part 
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 tergo, in greater quantities than in the healthy state, and. thus occasions 
congestion. In this case, the congestion is entirely passive, and to be re- 
moved 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 health, by a too long continuance in one posture. But, in 
cases of debility, in which the vital actions are less capable of countervailing 
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, or in its passage through the heart, is capable of producing passive 
accumulations in parts behind the point of obstruction. (See page 13.) 86 
GENERAL PATHOLOGY. 
[part I. 
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 
operation of the depressing cause. It is, in any event, however, very obvious 
that the remedies must be addressed, not to 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 conges- 
tion 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 unfrequently 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 capillaries, 
where the blood is retained, and presents, upon post-mortem examination, 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 con- 
gestion, 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 influence of gravity, this fluid seeks the vessels of the most depend- 
ent 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 lower- 
most 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. 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 serum and red globules 
that are thus extravasated, the fibrin remaining in the vessels. CHAP. I.] 
FEVER. 
87 
Article V. 
FEVER. 
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- 
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 o'f intermittent fever, typhus fever, yellow fever, ; 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 re- 
spects 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 called 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 they 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 ob- 
stacle 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 each one of these complaints is a fever, 
it is said, nothing can be an essential constituent of fever in general which is 
entirely absent in any part of its progress, and still less, if absent throughout 
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 can- 
not 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 in- 
fluence of severe cold, is in a state of inflammation, because inflammation 88 
[PART I. 
GENERAL PATHOLOGY. 
takes place when reaction ensues. The general depression which often ushers 
in fever, bears to it a relation analogous to that which the local depression 
bears to the subsequent 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 
definition, the essence of the affection is universal derangement of the func- 
tions. The phenomena specially 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 
occasionally 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 de- 
rangement 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 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. 
1. Phenomena of Fever. 
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 cha- 
racter of their derangement; while the various associations of the functional 
disorder, not to mention the complications to which fever is liable, increase 
the diversities which it offers almost beyond calculation. We must content 
ourselves 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 febrile diseases, until these 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; CHAP. I.] 
89 
FEVER. 
sometimes pain in the head or giddiness, diminished appetite, and even nau- 
sea. The patient is apt to be affected with disturbed sleep, mental confusion 
or debility, and depression of spirits; but not unfrequently complains of 
nothing but a vague uneasiness, or feeling of discomfort, which he is unable 
to refer to any particular part, or to any particular cause. These symptoms 
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 are, for the most part, 
such as indicate derangement in the nervous functions. 
2. Cold stage, 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 coid 
to others, particularly in the extreme parts, as the hands, the feet, the ears, 
and the tip of the nose. 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 smallpox, 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 peculiar 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, 90 
GENERAL PATHOLOGY. 
[part I. 
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 sometimes 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 
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 drowsiness, 
which may increase to stupor, and end in a true apoplectic state, dependent 
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 shrunk; 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 reaction 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 surface 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, when 
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. CHAP. I.] 
91 
FEVER. 
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 160. 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 
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, lightness, 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. 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, all of which 
are frequently present in fever, and some in a very distressing degree. 
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 exude 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 constipation 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 vio- 
lence has so far remitted as to permit the secretory organs to resume their 
functions, the quantity secreted is often in excess. Hence the copious per- 
spiration, the serous and bilious diarrhoeas, and the profuse discharge of urine, 
which occur under the circumstances mentioned. The character as well as 92 
GENERAL PATHOLOGY. 
[part I. 
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 fe- 
brile affections, and are often complicated with others not essentially belong- 
ing to fever itself; as with those resulting from the incidental inflammation 
of different organs, from peculiar changes induced in the vital energies and 
the condition of the blood by the nature of the cause, and from certain or- 
ganic derangements also referrible to peculiarity of cause, such as the erup- 
tion in the exanthematous fevers, and the disease of the intestinal mucous 
follicles in enteric or typhoid fever. An account, however, of these compli- 
cations 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 w-hat 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 continues for days, weeks, or months. The diversities in its course 
will engage our attention directly; at present, it is best to complete 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 reason 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 evacu- 
ations were the means by which nature effected the cure of the complaint; 
and the idea at one time extensively prevailed, that, through their instrumen- 
tality, offensive 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 CHAP. I.] 
FEVER. 
93 
removal. By far the most frequent of the evacuations which attend the de- 
cline 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 make 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- 
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 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, 
and the patient gradually recovers his appetite, which often becomes inconve- 
niently 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 derangement of the blood, or disorgani- 
zation of some vital organ or organs, consequent upon inflammations which 
have arisen during the course of the disease. Sometimes, however, the pa- 
tient sinks from debility, resulting either from the direct influence of the 
original cause, from some profuse discharge by hemorrhage or secretion, or 
from the collapse which follows excessive excitement. 
2. Duration and Course of Fever. 
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 94 
GENERAL PATHOLOGY. 
[part i. 
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 
cold or other causes, 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 very 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 complicated, 
in a certain number of days, as the smallpox, measles, &c. 
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, reaction, and decline, in less than a single day, per- 
haps in a few hours, and then ceasing altogether. In such cases, the disease 
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 indefinitely. In this 
case, it is said to be intermittent or periodical; the period occupied by the 
febrile movement is called the paroxysm, and the intervening space, in which 
there is a total absence of fever, the intermission or apyrexia; 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 different designations of intermittent fever, 
as the quotidian, tertian, &c., according to its length. (See Intermittent Fever.) 
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 pecu- 
liarities of form or character. All febrile diseases are not susceptible of the 
intermittent character; nor are fevers the only intermittent diseases. Per- 
haps all merely functional disease is capable of becoming intermittent. The 
cause of periodicity, I shall endeavour to explain in another place. This 
quality of disease 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 intermittent. Thus, irritation in the urethra has pro- 
duced an attack of intermittent 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. CHAP. I.] 
FEVER. 
95 
Fever often exhibits a tendency to the paroxysmal form, without being 
intermittent. The febrile action, after being fully established, subsides for 
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 dimi- 
nished excitement, the remission; and the fever is said to be remittent. 
Sometimes, the exacerbations and remissions are strongly marked; the for- 
mer, 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 Remittent 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-mentioned 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 
or 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 intervals, 
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 propriety 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 sus- 
ceptibilities and energies of the system are unimpaired, or even perhaps ele- 
vated 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 de- 
veloped; 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 circum- 
stances, 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 Cul- 
len, it is sometimes called synocha ; but it should be understood that this is 
not a distinct disease, or variety of fever, but merely a particular state which 96 
[PART I. 
GENERAL PATHOLOGY. 
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 fevei' 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 sometimes, 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 pros- 
tration 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 condition 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 smallpox and scarlatina, 
and in symptomatic fevers, as pneumonia and dysentery. 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 com- 
plaint, 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. It is possi- 
ble also for fever to be attended with great debility and even prostration, 
without the peculiar phenomena which are considered characteristics of the 
typhous state; as stupor, low delirium, dry tongue, sordes about the teeth, a 
dark hue of the surface, &c. It is probable that the difference depends on 
the state of the blood, a special derangement of which, there is every reason 
to believe, gives rise to the proper typhous symptoms. 
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 in- 
flammatory condition of fever; whatever diminishes these powers, to the 
adynamic. Thus, vigorous exercise, pure air, a cheerful mind, a good appe- 
tite, and a full diet, place the system in a condition, partly through their 
invigorating 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. On the contrary, con- CHAP. I.] 
97 
FEVER. 
finement, impure air, mental dejection, bad living, and the depressing influ- 
ence of long-continued cold, of sulphuretted hydrogen, and of other sedative 
agents, produce a general deterioration of health, a languor in all the vital 
functions, and an impoverished or depraved condition of the blood, which 
very generally give to fever, by whatever cause induced, the low, asthenic, oi' 
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 pro- 
ducing the tendency to prostration, by destroying the healthy character of 
the blood. At least, it is certain that the blood is often very much de- 
praved 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 example, 
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 
1. 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 consti- 
* Thus, it happened to the author to attend, on one occasion, in a large establish- 
ment (the Institution for the Deaf and 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 them. Inflamma- 
tion of the lungs was at the time prevalent in the city, and not less than thirty mem- 
bers of the family w'ere attacked with a fever, exhibiting evidences of bronchial or 
pneumonic inflammation. The fact which is particularly interesting at present is, that 
a large proportion of these exhibited typhous symptoms; and in very few, if any, was 
copious depletion well borne. This result was ascribed to the depressing influence of 
the exhalations, •which predisposed the system to the low form of fever, even when 
attacked by inflammatory disease. 98 
GENERAL PATHOLOGY. 
[part I. 
tution of the blood, which is often highly stimulating; and in the increased 
rapidity of the circulation; not to mention the irregular distribution 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 cir- 
cumstances, for the excitement in particular parts to pass the boundary which 
separates mere irritation from inflammatory action! It is.not, therefore, sur- 
prising that fevers, of any considerable duration, should be almost always 
attended with inflammation of one or more organs, though, in the commence- 
ment, 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 phlegmasise, 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 results from the immediate 
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 require 
no comment in this place. The fever attending wounds, and all the phleg- 
masiae 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 inflam- 
mations, 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 dif- 
ferent 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 sym- 
pathies, 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, CHAP. I.] 
99 
FEVER. 
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 derange- 
ment 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 
its action. It follows, from what has 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 inflammation, 
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 inflammation 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 provo- 
cative of fever than the functional disorder of the same part, in a state of irri- 
tation, 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, there- 
fore, 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; some- 
times 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 recrementitious substances in the blood may give to that 
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, how- 
ever, one well-ascertained condition, which frequently serves as the predispo- 
sition 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 ^accustomed 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 in- 
direct, 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 
cause has ceased to act. In some instances, it is possible that a fever, pro- 
duced and long sustained by irritation, may continue a certain length of time, 100 
GENERAL PATHOLOGY. 
[part I. 
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, subsides very quickly, 
unless sustained by inflammation simultaneously produced; and the constitu- 
tional symptoms in pleurisy, pneumonia, gastritis, &c., disappear 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 tran- 
sitory 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 into 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 eliminated 
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, conta- 
gion, 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 particularly, in the 
chapter upon the general causes of disease, it is unnecessary to dwell upon 
them here. 
6. Theories of Fever. 
Upon a subject so important as fever, which has occupied so much of the 
attention of writers on medicine, in all ages, it is deemed 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 dis- 
tinguishing the phlegmasiae 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 ancients, that the commo- 
tion in the system had the object of expelling the superabundant 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 learn- CHAP. I.] 
101 
FEVER. 
ing, 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 the exclusive, source of mischief. 
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 impurities 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 Sydenham, "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 substance 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 expelled 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 fermentation, were prominent among the almost 
infinite multitude of speculations. The idea of the necessity of a certain con- 
coction, 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 smallpox 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 con- 
tamination 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 autocrateia, 
anima medica, and vis medicatrix naturse, which, in this as in all other dis- 
eases, 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 practice, which con- 
tented 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 profes- 
sional opinion which has scarcely yet disappeared. 
Nervous Theories.-All the opinions hitherto mentioned were upon the 
basis of the humoral pathology. This 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 102 
[part I. 
GENERAL PATHOLOGY. 
fever, to be spasm of the capillaries; and the heat of skin and arterial excite- 
ment which follow, he considered as the mere reaction of the system, neces- 
sary to overcome this spasm. It was Cullen, however, who gave consistence 
and popularity to the new opinions, and completely overturned the old doc- 
trines 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 in- 
strumentality 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 irri- 
tation 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 evidences 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 seda- 
tive 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 medicatrix 
naturae, there is no proof whatever of the existence of spasm of the extreme 
vessels. On the contrary, in the cold stage, they are in a state of collapse 
from their inability to receive and circulate the blood, and in the hot stage, 
though the secretory pores 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 antecedent of all that follows. Fever some- 
times 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 CHAP. I.] 
103 
FEVER. 
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 
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 va- 
rious 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 simultaneously. Now, 
if, in addition to the above principles, we admit the positively depressing in- 
fluence of certain morbid agents, and the reactions which follow their appli- 
cation, which is but an extension of the second principle above mentioned, 
we shall have the means of explaining a great many of the phenomena of 
febrile diseases; though it must be confessed that there are many difliculties 
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 11 Inquiry into the Seat and Nature of Fever," 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, oi' inflam- 
mation of the brain. Dr. Clutterbuck'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 104 
[PART I. 
GENERAL PATHOLOGY. 
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, are gastritis 
or gastro-enteritis. Indeed, he appears to have considered every case of disease 
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 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. Inflammation 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 suffi- 
ciently violent to produce fever, it is a grade of inflammation. But, when 
inflammation is sufficiently intense to produce excitement 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 alimentary 
canal, and cerebro-spinal system, with an altered condition of the blood, &c. 
Others again, 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 gradually faded; and there are at 
present few pathologists who consider fever in all cases symptomatic of in- 
flammation. Since his time, there has been no doctrine of fever which can 
be said to have had a general prevalence. Each individual has the grounds 
before him, and judges for himself; and probably most persons, seeing a little 
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 or that viscus, and frequently even in 
a diffuse phlogosis of the entire sanguiferous system." (Medico-Chirurg. Rev., N. S., vi. 
273.)-Note to the second edition. CHAP. I.] 
FEVER. 
105 
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. Among the 
views recently put forth, 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 nerv- 
ous or sensorial functions, secondly, of those of the circulation, and thirdly, 
of those of secretion and excretion; and that, though inflammation is some- 
thing quite distinct from fever, it is nevertheless an almost constant attendant, 
constituting, in fact, that state of vascular excitement which marks the re- 
action of all febrile diseases. Dr. Smith admits of only two possible excep- 
tions 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 inflammation by dissection, and the symptoms are not such 
as to prove it without this aid; the second, in those very severe cases in which 
death takes place in the earliest stage, before inflammation could be developed. 
A disposition to return to the fluids, as the main source of at least idio- 
pathic fever, has of late been strongly evinced. Many now believe that the 
miasmatic, epidemic, and contagious causes of fever act mainly upon the blood, 
and that the morbid phenomena are due to the unhealthy influence upon the 
system of that fluid in its altered state. There can be no doubt that the blood 
is often greatly altered in fevers arising from the causes mentioned; and it is 
possible that, in many instances, this alteration is primary and the direct 
cause of other changes; but, in the present state of our knowledge on this 
point, the assumption that all fevers, or even the particular fevers referred to, 
are dependent exclusively on the morbid state of the blood, is not, I think, 
warrantable. Very often, when examined in the early stages of fever, that 
fluid presents no appreciable change; and, even when its alteration has pre- 
ceded 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 function, 
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, some- 
times 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, 
to be more or less disordered. We are justified, therefore, in considering 
fever as a disease of the whole system. 106 
GENERAL PATHOLOGY. 
PART I. 
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 and 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 combating 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 mayor may not be 
the case. The probability is, that some causes act locally on one organ exclu- 
sively, 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 abso- 
lutely 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 course. 
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 very frequently induce it, if sufficiently protracted and 
severe to destroy life. Indeed, fever proves fatal, in very many cases, through 
the instrumentality of the inflammation which it excites. So far, therefore, 
are these appearances from proving the fever to have been produced by 
the inflammation, that it would be surprising were they absent in pro- 
tracted and fatal cases of this disease, though free from inflammation at the 
commencement. The onset of the inflammation, when it takes place, is ge- 
nerally sufficiently striking to engage the attention of the physician. 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,-there- 
fore, of proofs of inflammation, we have no right to assume its essential ex- 
istence; 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 
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 CHAP. I.] 
FEVER. 
107 
fevers, if they are to be considered as phlegmasiae. 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 in- 
dicate 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 fevex- 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 develope- 
ment, 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 existence; 
and yet, never till the present century did it occur to the most observing phy- 
sicians that inflammation is an invariable attendant upon this disease. If 
inflammation be thecause 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 mis- 
taken who conjecture the existence of internal inflammation in intermittents; 
and if it be not the cause of this form of fever, there is reason to suppose that 
there has been an equal mistake 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 Broussais' theory regards fever as gastritis, or gastro- 
enteritis ; 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 ra- 
mifications, is not unfrequently presented by stomachs perfectly healthy, in 
persons, for example, who have died by violence. The late Dr. Parrish found 108 
[PART I. 
GENERAL PATHOLOGY. 
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 inflammation 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, exudation, softening, or other 
organic change, discoverable by close inspection. Even in the skin, unless 
exceedingly slight or transient, it produces some derangement of structure evi- 
dent after death. Those 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 fre- 
quently indicates a particular condition of the blood, which calls for dilution. 
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 inflammation. Other indi- 
cations of inflammation 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 invariable 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 in- 
fluence; and are quite compatible with true debility of the organ. The red 
and furred tongue has very generally been considered 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 stomach proves that they are exposed to 
the same influence, not that the disorder of one is dependent upon that of 
the other. Hence, 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, CHAP. I.] 
FEVER. 
109 
are speedily followed by improvement in the appearance of the tongue. 
This is often true, and the fair inference 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 experienced. Leeching to the 
temples would have a similar influence if cerebral 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 main- 
tained is, that this connexion is not sufficiently close to justify the inference, 
that, because the tongue is red in fever, the stomach 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, which is a 
powerful gastric irritant, is perhaps, next to quinia or bark, the most effectual 
remedy. Intermittents 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 disposi- 
tion ; 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 de- 
nominated symptomatic. Undoubtedly fever may arise from inflammation of 
the stomach and bowels; but it then takes rank with the other phlegmasiae. 
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 when they encounter it. There must, therefore, be something in the 
different febrile diseases common to the whole of them, and*to this tbe 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 these, when they do occur, are 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 peculiar in the irritation and depression. But if such peculiarity 110 
GENERAL PATHOLOGY. 
[PART I. 
exist, we cannot point out its nature. Together with disorder of the solids, 
there is very frequently an altered state of the blood ; but the question has 
not yet been settled, whether this is an essential part of the disease, and im- 
portant in the chain of causation, or a mere incidental effect. We are thus 
in a condition of uncertainty upon almost all points. 
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 may be entirely different in 
different 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 prin- 
ciple. 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 seems to be of a depressing nature. The phe- 
nomena immediately 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 occasionally 
for a time almost deadening its energies. Something analogous to this we 
have in the effects of a severe surgical 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 dimi- 
nution of all those functions dependent upon it. We may thus partially ex- 
plain 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 esta- 
blished. But there is here also something more than mere reaction. There 
is the continued action of the cause, a diversified 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 reciprocal 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 opera- 
tion, to enable us to advance far beyond conjecture. We know that the 
heart, arteries, and capillaries are in a state of super-excitement, and the 
blood often disordered ; that, under the combined influence of the nerves and 
blood-vessels, calorification is increased; that all the secreting surfaces, in- 
cluding that of the stomach, and all the secreting glands, and the whole pro- 
cess of nutrition, are deranged; sometimes probably being irritated, some- 
times depressed, and sometimes peculiarly affected, under the influence of 
peculiar causes. 
But in many instances of fever, even the imperfect concatenation above 
described is not evinced. Not unfrequently, 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. Eithei* the 
cause enters the circulation, and reaches all the organs so as to act on all 
simultaneously, while at the same time it may be acting on the blood, or it 
affects some one part primarily, from which an influence is conveyed sympa- CHAP. I.] 
TUBERCULOSIS. 
111 
thetically over the system. The latter was the opinion of the late Professor 
Chapman, who traced most fevers to an original morbid impression made 
upon the stomach. His opinion was promulgated in lectures before the an- 
nunciation of Broussais' hypothesis. But in ascribing fever to a gastric ori- 
gin, Dr. Chapman did not consider the affection of the stomach as necessarily 
inflammation, nor did he consider the original impression upon this organ 
necessary for the continuance of the fever which it has set in motion. 
•Article VI. 
DISEASE WITH PECULIAR 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 rather 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. 
The most important of the affections belonging to this category is beyond 
all comparison, tuberculous or scrofulous disease; and melanosis may be 
ranked under the same head. These are constitutional diseases, exhibiting 
themselves by their peculiar deposits in various parts of 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 con- 
sidered as constituting distinct diseases, and will be treated of as such. In 
this place, we are concerned with the general affections, independent of 
locality. 
I. DISEASE WITH UNORGANIZED OR FEEBLY ORGANIZED PRODUCTS. 
TUBERCULOSIS. 
Syn. Tuberculous or Scrofulous Disease.-Strumous Disease.-Scrofulosis. 
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 development of scro- 
fulous tumours, and which is denominated scrofulous or strumous diathesis. 
In this work, they are considered as one affection. When this state of sys- 
tem becomes decidedly and obviously morbid, it is sometimes called tubercu- 
lous, 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 yellow, opaque, and rather soft. According to Laennec and Louis, 
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. 112 
GENERAL PATHOLOGY. 
[PART I. 
The minute, isolated bodies are called miliary tubercles, or tuberculous 
granulations. When gray, semi-transparent, and hard, they are sometimes 
distinguished by the name of gray semi-transparent granulations ; when yel- 
low, and of a caseous consistence, they are denominated yellow miliary tuber- 
cles. 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. When they are at first 
of the gray semi-transparent variety, a yellow spot soon makes its appearance 
within them, which enlarges 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 pro- 
cess 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 unaltered. Not unfrequently, numbers of the miliary 
tubercles are aggregated together, forming a considerable mass; in which 
case, several points of alteration 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 ulcer- 
ation 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, sometimes consist only of the consoli- 
dated 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 destruction generally 
goes on more rapidly than that of reparation, and the result is fatal. Some- 
times, instead of the series of changes above described, the tubercle under- 
goes 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 re- 
garded 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 
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 exist 
in many parts at the same time. They are most frequent in the 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 membranes of the brain, the brain itself, and CHAP. I.] 
TUBERCULOSIS. 
113 
the bones; and, lastly, the pericardium, stomach, kidneys, pancreas, &c.* In 
their various positions, 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 pieurge, chronic pleuritis; in the peritoneum, chronic perito- 
nitis and abdominal dropsy; in the mesenteric glands, tabes mesenterica; 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 
frequent. After the age of puberty, there is some exemption; but the liabi- 
lity 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 evident. 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 called attention 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 peculiarly indi- 
cative 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, 
and a swarthy complexion are affected, as of those with opposite physical 
characters. Negroes are, in this climate, more disposed to the disease than 
the whites. 
But more confidence may be placed in the signs which indicate a com- 
mencing developement of disease, and which often long precede the deposition 
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; 
* From a personal observation of thirteen or fourteen thousand cases, Rokitansky 
gives the following as the order of parts, in reference 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 and pleura, 6. pia 
mater, 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. In children, the lymphatic glands and spleen are most frequently af- 
fected, and after these, the lungs, bronchial mucous membrane, brain, serous membranes, 
&c. This order, it will have been perceived, differs somewhat from that given by 
Louis. It relates, however, only to the comparative frequency in which the tubercles 
are found in the several organs after death. The order of frequency in reference to 
the primary attack is very different. Here the lungs and lymphatic glands maintain 
the precedence; while the intestines, larynx and trachea, serous membranes, spleen, 
and liver are so low on the list as to indicate that they are scarcely susceptible of a 
primary attack. (Note to the second and third editions.) 114 
[part I. 
GENERAL PATHOLOGY. 
occasional purulent discharges from the nostrils or ears; a tendency to sore- 
ness of the eyes, and especially to a vesicular eruption upon the conjunctiva; 
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 con- 
dition of the bones; a weak but excitable pulse; flabby muscles; a rapid in- 
crease in height, without corresponding lateral developement; and general 
weakness, indicated by fatigue after moderate exertion. It is not to be sup- 
posed that all these symptoms are present in every case; but enough of them 
frequently are so to justify solicitude, and to lead the prudent practitioner to 
the adoption of preventive measures. Not unfrequently, a slight febrile move- 
ment, rather occasional than persistent, is observed in addition to the other 
phenomena; and, indeed, such a movement is sometimes the immediate fore- 
runner or attendant of 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 pro- 
cess occurs from other causes, it often assumes the peculiar scrofulous character, 
even though no tubercles may be present. 
After the formation of tubercles, and during their maturation and discharge, 
the system often sympathizes strongly, and there is almost always, at first, a 
simple irritative fever, and afterwards, when suppuration has become established, 
more or less hectic fever, which, in severe cases, rapidly exhausts the remain- 
ing 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, independent 
of the red corpuscles, as if these had undergone a partial disintegration. {Diet, 
de Med., xxviii. 221.) The blood is, therefore, watery and impoverished, and 
incapable of supplying the nutritive function sufficiently. But it should be 
stated that Lebert, in the examination of many cases, never observed the red- 
dened serum noticed by M. Dubois. {Traite Pratique des Malad. Scrof. et 
Tuberc., p. 33.) 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 Gavarret, the proportion of the red corpuscles diminishes, and that 
of the fibrin increases with the advance of the disease. That of the red cor- 
puscles is almost always below the healthy standard ; that of fibrin often above 
it. But the increase of the fibrin is a result of the inflammation occasioned 
by the tubercles; and we have no proof that it is in excess under other circum- 
stances. From the observations of Nicholson it may, indeed, be inferred that 
the fibrin is, in many instances, diminished. 
What is the nature of this affection, denominated tuberculous disease, but 
of which the tubercle is a mere incident, though a very general, characteristic, CHAP. I.] 
115 
TUBERCULOSIS. 
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 wre 
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, generally 
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 in- 
duce 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 in- 
herited peculiarity of organization. 
It has been supposed by many that tubercle is a product of inflammation, 
and diffefs 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 
colourless blood, are especially affected. But a sufficient refutation of this 
opinion is, that, in a vast number of cases, tubercles exist without any in- 
flammation whatever, evinced either by the symptoms, or by anatomical 
examination. No fact in pathology is better established than this. Un- 
doubtedly, inflammation is often found in connexion with them. But it is 
generally a result, and not a cause. It comes on after the tubercles have 
been formed, and not before them. There is, however, reason to believe 
that the occurrence of inflammation, in an individual predisposed to tubercles, 
favours their production. It causes exudation, and, if the material out of 
which tubercles are formed is present, this will probably be deposited along 
with other exuded matters. 
The nature of tubercle has been a subject of some inquiry. Very different 
analytical results have been obtained by different chemists. An analysis 
by Dr. Glover gave 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 oLchlorides, 0.58 of earthy salts (phosphates), 
0.50 of alkaline salts, 21.72 orprotein 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 che- 
mists profess 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 116 
[PART I. 
GENERAL PATHOLOGY. 
found what he considered to be albumen and pyin, but never succeeded in 
obtaining casein. 
The microscopic constitution of tubercle has been definitively ascertained 
by M. Lebert, whose statements have been essentially confirmed by subse- 
quent observers. The constituents, before the softening of the tubercle, are 
1. a hyaline, formless substance, 2. molecules or molecular granules in great 
numbers, and 3. peculiar and characteristic corpuscles; the two latter being 
held together by the translucent material first mentioned. The corpuscles 
are quite distinct from all others. They are seldom perfectly round, but are 
irregularly polyhedral with rounded angles, approaching sometimes the sphe- 
rical, and sometimes the oval form. Their diameter varies from about 
VoVo to °f an inch. Within the transparent envelope is a somewhat 
translucent matter, probably of a solid consistence, in which are embedded 
from three to ten or more granules. Water does not change them. Acetic 
acid renders them more transparent, and enables us to determine positively 
that they contain no nucleus; by which circumstance, as well as by their 
shape, and their much smaller size, they are readily distinguishable from pus 
corpuscles. In only one instance did Lebert ever detect a nucleus. These 
peculiar corpuscles are found in all varieties of tubercle. They are numerous 
and closely compacted together, and to this circumstance probably owe their 
irregular form. 
When the tubercle softens, the cementing hyaline substance liquefies, and 
the corpuscles thus set free imbibe apparently a portion of the liquid, become 
somewhat larger, and assume a spherical shape. In the progress of the 
change, the cell-wall ultimately dissolves, and the included granules are libe- 
rated, thus increasing this constituent of the tuberculous mass. In this con- 
dition, the matter bears to the unassisted eye a considerable resemblance to 
pus, from which, however, when examined by the microscope, it is found to 
differ essentially, as it never contains the pus corpuscle; and, whenever this 
body exists in tuberculous matter, it is always derived from the neighbouring 
tissues. When pus from some external source, as frequently happens, be- 
comes mingled with the softening tubercle, it hastens its dissolution and con- 
version into a granular fluid. In some instances, after being thoroughly 
liquefied, the tuberculous matter is absorbed, leaving only saline or calcareous 
matter, which, appearing first in points, gradually increases, and at length 
forms an aggregate chalk-like body. 
The above observations apply to the yellow tubercle. The gray or semi- 
transparent granulations contain fibres, the hyaline constituent sometimes 
finely granular, and the peculiar corpuscles, which, from their great compact- 
ness, are less easily distinguishable than in the other variety. According to 
Lebert, the fibres are derived from the tissues in the midst of which the 
tuberculous matter is deposited, and give transparency to the mass by sepa- 
rating the corpuscles. In the conversion of the gray into the yellow tubercle, 
the fibres are first destroyed, and the corpuscles being set free congregate in 
the centre, and, together with the granules which are formed, give yellowness 
and opacity to the mass. In the yellow miliary tubercle there is little or no 
fibre unless at the very earliest stage of its formation, and the hyaline sub- 
stance is more granular. The gray granulations are most frequent in the 
subserous areolar tissue of the pleura and pemoneum, and among the fibres 
of the areolar tissue of the lungs. 
Besides the elements proper to the tubercle itself, others are often inci- 
dentally present; as the black matter of melanosis, fatty matter, and the incor- 
porated fibres already referred to, all of which may exist in the tubercle before 
its disintegration; while afterwards are often added to it, from the neighbour- CHAP. I.] 
117 
MELANOSIS. 
ing parts, blood corpuscles, the epithelial scales and other detritus of adjoining 
tissues, crystals of salts, and all the products of inflammation. (Lebert, 
Physiologie Pathologique..') 
The readiest explanation of the phenomena successively presented by 
tubercles is, that a formless matter is first extravasated, having a low and 
feeble vitality, that, as the result of an imperfect attempt at organization, 
granules and peculiar corpuscles are generated, and that the tubercle thus 
formed grows like cartilage by imbibition, and then, as a result of the law 
of its constitution, undergoes a series of changes ending in its complete dis- 
integration. 
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 semifluid; and these different conditions may all exist in the' 
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 
observed 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 enclosed in what ap- 
pears to be a cyst, but which is probably nothing more than the condensed 
areolar structure around them. Under the microscope, they appear to be 
made up of unorganized granules, among which are sometimes seen cells 
from the neighbouring tissues enclosing the same dark matter. 
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 ex- 
ample, with the indurated fibrinous products of chronic inflammation, with 
tubercle, with scirrhus, or with medullary fungus. In these affections, the 
melanotic matter may be interspersed in granules among the proper consti- 
tuents of the morbid structure, or may form a portion of the interior of its 
peculiar cells. 
Occasionally, it has been observed in small patches, upon the free surface 
of the serous membranes, especially of the peritoneum. Some believe that 118 
GENERAL PATHOLOGY. 
[part I. 
they have also detected it on the mucous surfaces; and persons are not want- 
ing who consider the black discharges of mclacna and black vomit, as owing 
their colour to an identical product. It has certainly been found in the 
liquid form in cavities, cither natural, as that of the abdomen, or formed by 
disease in one of the organs. 
After deposition, the matter increases by further extravasation from the 
surrounding 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 investi- 
gation 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, sup- 
puration, and ulceration. But the melanotic bodies, in these cases, act me- 
chanically. They are usually very slow in their progress. In those cases 
in which melanosis has been supposed to pursue an active course, and to pre-< 
sent the characters of tubercle or cancer, it has been the structure in which 
the black matter was deposited that has been the subject of the morbid pro- 
cess, 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 pig- 
ment of the eye and hair, and of the skip 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 me- 
tastatic 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 
change, at the moment of extravasation. But in the present state of our 
knowledge, all explanations are purely hypothetical. The affection is evi- 
dently connected 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 de- 
pends immediately 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 any part 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. CHAP. I.] 
CYSTS. 
119 
tions, except when the affection exists in the form of one or more character- 
istic tumours upon the skin. In such cases, any existing internal disorder 
of apparent organic origin, may, with some degree of confidence, be ascribed 
in part or wholly to melanosis. 
II. DISEASE WITH ORGANIZED PRODUCTS.-MORBID GROWTHS. 
Morbid growths may be arranged in three subdivisions. The first embraces 
those in which the organized product has a close resemblance to some healthy 
tissue, without an independent power of nutrition or reproduction, and with- 
out malignant tendency. To this section belong cysts, and non-malignant 
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 repetition or 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 nutrition. These are the parasitic animals, or entozoa, which, 
under the names 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 
occasion the formation of a false membrane, which envelopes, and in some 
measure isolates them. Again, certain natural cavities are sometimes irri- 
tated into unhealthy action, and, by the consequent excess of their secretion, 
expand their walls, and sometimes acquire a great magnitude. Some 
of these are naturally closed, as the ovarian vesicles, the bursae of the 
tendons, &c.; others are open in health, but are either unable to discharge 
the excess of their secretion, as the sebaceous follicles of the skin, or become 
closed by an inflammatory adhesion, as the cells of the areolar 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, hard- 
ening of mucus, compression from without, &c., the healthy secretions accu- 
mulate behind the point of obstruction, and produce sometimes large tumours 
of an apparently encysted character. Such, for example, is the tumour under 
the tongue denominated ranula, and dependent on obstruction in the salivary 
duct. None of these, however, belong to the class of morbid affections that 
we are now considering. 
The cysts to which allusion is here made are closed membranous bags, simi- 
lar 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, sanguineous, 
oleaginous, mucoid, or puruloid matter. Names have been given to them in 
accordance with the character of these contents. Thus, when the enclosed 120 
GENERAL PATHOLOGY. 
[part I. 
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, pultaceous 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. In general each cyst is simple, or complete in itself; but there are 
also compound cysts, first accurately described by Dr. Hodgkin, which are 
characterized by the outgrowth of smaller cysts from the inner surface of the 
original bag, similar to it in structure, and sometimes quite filling its cavity. 
The cystic walls occasionally become much thickened, and are liable to undergo 
various degeneration, in consequence of the deposit or formation in their sub- 
stance of cartilaginous, calcareous, or bony matter. They are sometimes, like 
the healthy tissues, attacked with inflammation, in consequence of which, 
blood, lymph, pus, &c., may be mingled with the previous contents of their 
cavities. They occur in all parts of the body, except the cartilages, and per- 
haps the bones. In the abdomen, they occasionally give rise to that form of 
abdominal 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, espe- 
cially the areolar, or the serous. Though capable themselves, in consequence 
of the accumulation of the secreted matter in their cavities, of an almost in- 
definite expansion, and often attaining a very great magnitude, they have no 
power of converting the neighbouring tissues into structure analogous to their 
own; nor have they any essential tendency to degeneration. They prove in- 
jurious, as a general rule, only by their physical properties, such as their con- 
sistence 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, or osseous degeneration. They not 
unfrequently obstruct, in greater or less degree, the outlets of secretory glands, 
the alimentary passages, the blood-vessels, and absorbents, and thereby pro- 
duce serious and sometimes fatal effects. They occasionally 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 results, 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 de- 
scribed, such as the effusion of coagulable lymph from inflammation, or simple CHAP. I.] 
CARCINOMA, OR CANCER. 
121 
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 formation. They 
are sometimes enclosed in a cyst, which may have been the origin of the mor- 
bid growth within it. Their structure is various, and they are named accord- 
ingly. Dr. Paget describes the following varieties; 1. the fatty, resembling 
the normal adipose tissue; 2. thefibro-cellular, resembling the ordinary fibro- 
cellular or areolar tissue; 3. the fibrous, imitating the normal fibrous or ten- 
dinous tissue; 4. the recurring fibroid, similar to the preceding in external 
appearance, but differing in their tendency to return after extirpation, and 
exhibiting under the microscope elongated caudate and spindle-shaped cor- 
puscles, as if developing into fibres; 5. the cartilaginous, closely resembling 
foetal cartilage in appearance and structure, but characterized by great diver- 
sity in the form and arrangement of their constituent cells, nuclei, and fibres, 
being in this respect analogous to carcinoma; 6. the bony, resembling bone, 
and often developed from the preceding; 7. the myeloid, or fibro-plastic tumours 
of Lebert, similar to the fibrous in appearance, but having a peculiar micro- 
scopic structure, which, though it may be somewhat fibrous and vascular, con- 
sists essentially of elongated caudate spindle-shaped cells, nuclei, and certain 
characteristic cells, large, dimly granular, and containing from two to ten or 
more nucleolated nuclei, all embedded in a dimly granular substance; 8. the 
glandular, imitating glandular structure, as that of the mamma; and 9. the 
elastic or vascular, consisting of blood-vessels, or of a tissue similar to the 
erectile. For a more particular account of these morbid growths, which it is 
not consistent with the objects of this work to describe minutely, the reader 
is referred to Mr. Paget's excellent work on surgical pathology. 
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-germs, which retain their power of extension, under the ordinary 
nutritive 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. Like them, too, 
they may undergo inflammation, the results of which may prove irritant to 
surrounding parts. Unfortunately, as they are without the circle of the 
ordinary systemic actions and susceptibilities, they are scarcely in any degree 
influenced by medical treatment. Sometimes they become the seat of malig- 
nant action, and then belong to the following section. 
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 destruc- 
tion of life. They may be dormant for a considerable time, even for years; 122 
[part I. 
GENERAL PATHOLOGY. 
and an individual may go to his grave, at a good old age, of another disease, 
after 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 reparative 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 terms, espe- 
cially 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 ana- 
logous character 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 varie- 
ties of the same disease, which is almost certain. In support of this opinion, 
the considerations may be adduced that all of them, in their- earliest stage, 
often present certain common features, however unlike they may afterwards 
become; 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 different 
stages; that, in the progress of the disease, the secondary affection sometimes 
belongs to a variety different from that of the primary; and, lastly, that, after 
the extirpation of one variety by the knife, another may occur in the same, 
or another part of the body. They all, moreover, contain, in greater or less 
number, a peculiar cell, which may be considered as characteristic of cancer. 
Anatomical and Microscopic Characters.-Only a single tumour may ex- 
ist in the body, or there may be many, occupying the same or different organs. 
They may be a mere speck in size, or as large as the head of a man, and of 
any intervening magnitude. In shape, they may be irregularly globular, 
when surrounded by a structure of equable density; pear-shaped, fungiform, 
or like a cauliflower, when projecting from a free surface; in layers or patches, 
when in membranous tissues; and ramified, when the carcinomatous matter 
occupies the veins or absorbents. They generally have an irregular, as it 
were tuberculated surface; but this is by no means always the case. Their 
consistence may be very hard and almost stony, as in scirrhus; soft, like that 
of the brain, as in the medullary form of the disease; gelatinous, as in the 
colloid or gelatinous cancer; or liquid, like cream. The colour is generally 
white or whitish, sometimes inclining to yellow, brown, or red, according as 
oil, bile, blood, or other adventitious matter is present. When melanosis co- 
incides with carcinoma, the latter is brown or blackish. 
When a cancerous tumour is subjected to pressure, or scraped, a cream-like 
or gruel-like liquid is generally obtained, in smaller or larger quantity, charac- 
teristic of this kind of growth, and called "the cancerous juice." This liquid 
has the property of forming with water a uniform emulsion. It is usually of 
a pale, yellowish-white colour, but sometimes yellow, red, or black from the 
admixture of fat, blood, or melanotic matter. Colloid cancer is the only va- 
riety which does not yield it, the juice of this being gelatinous, and not unit- 
ing with water to form an emulsion. 
When examined with the aid of a microscope, cancerous tumours are found 
to consist of three chief ingredients; 1. a fibrous tissue, 2. a viscous liquid or 
solid homogeneous blastema, contained within the meshes of that tissue, and 
3. peculiar cells in different stages of developement. The proportion of these CHAP. I.] 
123 
CARCINOMA, OR CANCER. 
constituents is very different in the different forms of carcinoma; the fibrous 
being most abundant in the hard varieties, the liquid in the gelatinous, and 
the cells in the medullary. Dr. Bennet considers the coexistence of these 
elements as essential to cancer. According to Lebert, though fibres are gene- 
rally present, they are not always so, being sometimes absent in very soft 
medullary cancer (Traite Pratique des Malad. Cancereuses, p. 204); and Dr. 
Redfern has published an account of a cancer df the brain, in which they 
appeared to be wanting. (Month. Journ. of Med. Sei., N. S. ii. 510.) Lebert 
considers the cells as the only constant and essential element; and he is pro- 
bably correct. Blood-vessels are found in all the varieties of cancer, being 
abundant in some, in others scanty, and in others again distributed in clusters. 
Lebert states that he has never detected nerves or absorbents; but Schroder 
Van der Kolk twice succeeded in injecting lymphatics in the very substance 
of medullary cancer. 
The cancer cells may be best seen by examining the expressed liquid with 
a microscope. They are of great diversity of form, being spherical, oval, 
irregularly quadrangular with rounded angles, triangular, spindle-shaped, caud- 
ate, bifurcated, heart-shaped, &c., all in the same drop of juice. They differ 
much in size, but are for the most part large, having a mean diameter of about 
T 2W or To'oo °f an inch. Their nucleus is also large, not only in proportion 
to other nuclei, but to the size of the cell, of which it often occupies from 
one-half to two-thirds. It is usually excentrically placed, is round, or oval, and 
encloses from one to three large nucleoli. Besides the cells containing one or 
two nuclei, there are others called mother-cells, very large, sometimes exceed- 
ing an inch in diameter, and enclosing from three to fifteen nuclei, 
which are by some considered as small cells, and occasionally present the pro- 
per cellular character. Still another cell is that called by Lebert, the concen- 
tric, in which a complete cell is surrounded by a distinct envelope, and some- 
times by several envelopes concentrically arranged. The extra-nucleolar 
contents of the cell have a dull, finely-granular appearance, which, however, 
in no degree obscures the nucleus. Naked nuclei fully formed, and others 
in the course of developement, exist in great numbers intermingled with the 
cells; and molecules and granules are also dispersed through the cancerous 
juice. The cells are rendered more transparent by acetic acid, which has no 
decided effect on the nuclei. 
The elements above enumerated are generally met with in cancerous struc- 
tures, and may be considered as their proper constituents, though not all 
essential. According to Lebert, not more than two or three per cent, of can- 
cers are destitute of the characteristic cells above described. Their absence in 
these cases he ascribes either to incomplete developement, as in some rapidly 
formed very soft medullary tumours, or to the degradation of pre-existing cells. 
Besides the proper ingredients of cancer, others, purely accidental, are not 
unfrequently met with, such as fatty matter, melanotic matter, crystals, the 
different results of inflammation, the constituents of the blood in various 
states of degeneracy, and the elements of neighbouring tissues. 
In degenerating carcinoma, the cells are variously changed. In some, the 
walls are much thickened and the nuclei converted into transparent vesicles; 
others are altered by imbibition, having their cell-wall distended and lami- 
nated, and their interior diffused; a third set exhibit a granular and fatty 
infiltration, giving them the appearance of compound granular corpuscles; a 
fourth shrink up and become dried by the exosmosis of their liquid contents ; 
and a fifth are converted more or less completely into a mass of molecular 
granules, which appears to be their lowest stage of degradation. (Lebert.') But 
in almost all instances where these forms are observed, they occupy but a 
part of the tumour, while unchanged cells are found in other parts. 124 
GENERAL PATHOLOGY. 
[part I. 
Chemical investigation has furnished no very satisfactory result in reference 
to cancer. Water, albumen, fibrin, gelatin, different kinds of fatty matter, iron, 
and various salts have been detected; but it is impossible to determine which 
of these, and what proportion of them, belong to the essential cancerous struc- 
ture; as the coats of the blood-vessels and the contained blood necessarily modify 
the results. 
Origin and Progress.-The disease first appears in a small spot, and gradually 
extends, or in several nearly contiguous spots, which coalesce. In either case 
it spreads by degrees, destroying the neighbouring structures, and forming a 
tumour, which varies in shape, size, and consistence, according to the circum- 
stances under which it is produced. It appears to maintain a vascular con- 
nexion with the surrounding parts; but the veins are often filled with can- 
cerous matter or coagulated blood, so that it is impossible to inject them. 
Hence the varicose condition of the superficial veins, so often observed in 
scirrhous tumours. 
The constant tendency of carcinoma, when in action, is to extend itself by 
encroaching upon the neighbouring tissues. But the rapidity 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 in 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 
owing either to a sympathetic irritation, acting upon a cancerous predisposition, 
or, what appears more probable, to a transplantation of the cancerous germs 
through the medium of the absorbents. The disease very frequently also ex- 
tends 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 
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 most cases, if not sooner fatal by its influence upon 
the system, or entirely destroyed by gangrene, ends in ulceration. The 
resulting ulcer is of an aggravated character, with ragged and inverted or 
everted edges, often deep excavations, a sanious and extremely offensive dis- 
charge, and a frequent disposition to bleed and to slough. Gangrene is a 
natural result of the interruption of the circulation, consequent upon the 
formation of the carcinomatous matter in the blood-vessels. In the soft va- 
rieties, especially, enormous sloughs sometimes separate; and instances have 
occurred, in which the whole diseased structure has thus been destroyed and 
thrown off, with the effect, it is said, of saving the life of the patient. It is 
generally admitted that cancer is liable to inflammation and suppuration; but 
these results are rare in the genuine carcinomatous structure; and, when ob- 
served in connexion with the disease, are probably most frequently situated in CHAP. I.] 
CARCINOMA, OR CANCER. 
125 
the surrounding or invaded normal tissue. Some believe that carcinomatous 
structure occasionally undergoes a calcareous transformation, and thus loses its 
malignant character. Dr. Bennet has met with cases which he considers 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; and, according to Lebert, allowing that a 
cancerous tumour may perish, or be destroyed, the disease always exists, and 
will sooner or later give rise to new tumours, unless prevented by the death 
of the patient from some other cause. 
Seat.-Every organ, and almost every tissue of the body, are liable to 
become 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 seizes on the proper fibrous tissues, or cartilages. Though the veins are 
readily attacked, the arteries appear to resist it considerably. It is sometimes 
confined 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 
Le Conte, it would appear that carcinomatous affections become relatively 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 period 
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 car- 
cinoma 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 
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 very often commences in the midst 
of apparent health. When the disease has advanced so far as to involve the 
system, the patient generally has a peculiar wan, sallow paleness of complexion, 
which, with an expression of sadness, is almost characteristic of carcinoma. 
Disordered digestion, general weakness, and emaciation are also common 126 
GENERAL PATHOLOGY. 
[part I. 
attendants upon the cancerous cachexia; hut, in some cases, a considerable 
fulness of habit is maintained, even to the close of the complaint. In the ad- 
vanced stages, the pulse is generally quickened, and febrile symptoms appear. 
In the regular course of carcinoma, the patient may sink under the exhaus- 
tion 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, as of 
the oesophagus, pylorus, intestines, &c. By compression or obliteration of the 
blood-vessels, it sometimes occasions venous congestion, and consequent dropsy. 
Thus, carcinoma in the liver gives rise to ascites, by impeding the portal cir- 
culation ; 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. It has a strong tendency to occasion coagulation of the blood in the 
neighbouring veins, and sometimes gives rise to a kind of phlebitis, which has 
the same effect. When the veins which carry the blood from the exterior parts 
of the body are thus affected, oedema of these parts is apt to occur, and some- 
times also a tense elastic swelling of the areolar tissue, bearing considerable 
resemblance to that of the milk-leg in women. I have seen two cases of this 
kind of tumefaction, in one of which the lower extremities were much swollen, 
tense, and elastic, in consequence of phlebitis of the iliac veins and vena cava 
connected with cancer of the liver; in the other, the neck, anterior and poste- 
rior part of the chest and the right arm were similarly affected from an extensive 
medullary cancer in the anterior mediastinum. Lebert thinks that death in 
cancer usually results, not from these secondary effects, but from a direct de- 
pravation of the blood, rendering it unfit for the support of the vital functions. 
The blood contains a diminished proportion of red corpuscles, and in the 
advanced stages is found, after death, either liquid, or in soft coagula, very 
different from those observed in health. The heart and muscular tisgue ge- 
nerally are soft and fragile, as are also the bones; and the viscera are, for the 
most part, remarkably bloodless. Evidences of pneumonia are not unfrequently 
noticed in post-mortem examinations. (Lebert.') 
The duration of the disease is extremely variable. While in some very rare 
cases it runs its whole course in two or three months, it continues in others 
for ten or even twenty years. The mean duration is different in different 
organs. Cancer of the viscera is more speedily fatal than that of external 
parts. Thus, cancer of the stomach and bowels runs its course, on the 
average, in from thirteen to eighteen months, while that of the mamma has 
a mean duration of about forty-two months. The character of the tumor also 
has great influence over its course. The soft cancers are usually much more 
speedily fatal than the hard. 
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 practitioner, how- 
ever, 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 ca- 
chectic appearance of the complexion, to which allusion has been already made. CHAP. I.] 
CARCINOMA, OR CANCER. 
127 
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. When 
the opportunity is offered of examining portions of the cancerous tissue by the 
microscope, a correct conclusion can generally be formed as to its nature. Dr. 
Bennet lays much stress on the coexistence of a fibrous tissue and the cell-struc- 
ture already described, as a means of diagnosis. He does not consider the cells 
alone as sufficiently distinctive. It is true that a satisfactory conclusion can- 
not be drawn from a single isolated cell; but, in the aggregate, they are quite 
characteristic. Theii' great size, particularly that of the mother-cells; the unu- 
sual relative magnitude of their nuclei and nucleoli, and the extreme diversity 
of their form, give to them in mass an appearance which is presented in no 
other structure than the carcinomatous. A variety of cancerous formation is 
sometimes met with, bearing so close a resemblance to the yellow tuberculous 
masses that the unaided eye is unable to distinguish them. By the aid of the 
microscope, however, the cancerous cells are seen, and at once determine the 
nature of the tumour. This peculiar aspect is attributable to the production 
of yellow fatty matter. 
Other morbid formations, very analogous to carcinoma, not only in the 
appearance of the tumours after death, but to a certain extent in their course 
and results in the living subject, are those denominated cancroid. These are 
tumours of the skin and mucous membranes, consisting of an excessive pro- 
duction of epidermis or epithelium, having, like cancer, a tendency to extend 
into neighbouring tissues, and to ulcerate; and, like it also, capable of destroy- 
ing life. But they are not attended with, and do not produce any infection 
of the system; if extirpated or destroyed, do not necessarily return in other 
parts of the body, and are therefore curable. Under the microscope, they 
exhibit no cancerous cells, but appear to be made up mainly of papillae and 
epidermic, or epithelial cells, according to their position.* The hard fibrous 
* Cancroid, Lebert.-Epithelial Cancer, Paget. Mr. Paget considers this variety of 
tumour as having all the malignant qualities of carcinoma, though in a less degree. It 
has a similar disposition to invade the neighbouring parts, is prone to ulceration, is apt 
to return after removal, is repeated or propagated in other parts, is attended with a 
vitiated condition of the system at large, and, after being once established, generally 
goes on to a fatal issue. He does not hesitate, therefore, to rank it with the can- 
cerous affections. It is usually simple, and seated in or immediately beneath the skin or 
mucous membranes, but in some rare instances is deeper seated, and appears to have 
no connexion with these tissues. Its most common position is in the lower lip. The 
essential character of the tumour is that it consists chiefly of cells resembling those of 
the epithelium or epidermis, infiltrated into the proper tissue of the part affected. The 
papillae, being included and enlarged, often give it a condylomatous or warty appearance. 
It has no distinct basis-structure of its own; the peculiar cells being supported by the 
original tissue. The outline of the flattened cells is much diversified, sometimes fantas- 
tically so. Their diameter varies from to of an inch. The nucleus is usually 
single, central, and small; and the surrounding contents of the cell, clear or slightly 
nebulous, with a few minute granules interspersed. Some of the cells, probably the 
younger, are smaller, rounder, and more regular; others exhibit various appearances 
of degeneration. Besides these characteristic cells, there are 1. free nuclei, 2. endo- 
genous cells containing one or more nuclei, appearing as if developing into cells; and 3. 
very large laminated capsules, oval or roundish, from to of an inch in diameter, 
very thin, closely compacted, and containing granular matter, and nuclei or cells ob- 
scurely visible. The ordinary cancer-cells are not found in these tumours. They have 
been ascribed to an excessive production of epithelial or epidermic cells; but Mr. Paget 
thinks that they are a peculiar growth, and that their characteristic cells are merely 
Imitations of those of normal epithelium. This form of cancer, however, beginning 
later in life than the other forms, advances more slowly, is less apt to multiply, and 128 
[part I. 
GENERAL PATHOLOGY. 
structures resulting from chronic inflammation have sometimes been mistaken 
for scirrhus, and have, by some pathologists, been thought capable of taking 
on the cancerous character. But they are rather elastic than of the stony 
hardness of scirrhus; are usually smooth, instead of knotty on the surface ; do 
not extend themselves into neighbouring organs; never contaminate the system, 
and never exhibit cancerous cells. When indurations, supposed to be inflam- 
matory in their origin, have afterwards exhibited the carcinomatous character, 
they have, in all probability, had this character from thebeginning. Several 
of the organized non-malignant tumours enumerated in page 121, might be 
confounded with the cancerous upon a superficial examination, but differ from 
them essentially not only in their microscopic characters, but in their com- 
paratively innocent nature. Thus, though some of these tumours are apt to 
return after removal, yet for the most part it is in the cicatrix of the old, 
leaving room for the supposition that the extraction had been incomplete. 
Again, it is not very uncommon to find several tumours of a particular kind 
in the same or different parts of the body; but this arises from special 
tendencies of the system or diatheses, leading to special products, and not 
from the propagation of disease from one original point, and is not accom- 
panied with the carcinomatous depravation of health. It must be acknow- 
ledged, however, that tumours are occasionally met with, having a precise 
resemblance to those considered innocent, both in external and microscopic 
characters, and in which no cancerous cells can be discovered, which neverthe- 
less run in all respects the course of carcinoma, and with no less malignancy. 
The pathology of cancer, therefore, though it has of late years been greatly 
advanced, cannot be considered as definitively settled. 
Nature and Mode of Dev elopement.-The minutest speck of carcinomatous 
growth, at the earliest stage in which it is susceptible of examination, has 
all the microscopic elements which are detected at a later period. Yet it 
cannot be admitted as possible, that the large cancer cells should have passed 
from the blood through the walls of the capillaries, in which no opening, 
however minute, can be seen. It is inferrible, therefore, that the carcino- 
matous matter must originally exude from the capillaries in the state of a 
uniform liquid, a minute particle of which, being deposited in the midst or 
on the surface of a living tissue, immediately takes on, through its own vital 
force, the characteristic organization of cancer. New exudation around the 
little tumour undergoes a similar organization, and thus the disease gradually 
spreads, incorporating the original tissue, or causing it to disappear through 
absorption, occasioned probably by pressure. At this stage of our investiga- 
tion we are met by the questions, whence is derived the tendency to this 
abnormal organization of the exuded matter ? and through what agency is the 
tumour increased, whether by the inherent quality of the exudation, or by 
some influence exerted upon it by the morbid structure already formed ? The 
answers to these questions, in the present state of our knowledge, must be 
somewhat speculative. 
First, in relation to the tendency to abnormal organization in the exuda- 
tion, it may be said that invisible cancerous germs exist in the blood, which, 
being thrown out with the fibrin, undergo developement into cells and fibres. 
The idea has been entertained that the cancerous matter is formed in the 
blood, and Dr. Carswell maintains that it is often seen in the veins, either 
less frequently affects the interior organs. Besides, it in a less degree impairs the gene- 
ral health; and cases have occurred in which a permanent recovery has followed extir- 
pation. For more precise details upon this subject, the reader is referred to Mr. Paget's 
Lectures on Surgical Pathology, in which the whole subject of tumours is treated in a 
masterly manner.-Note to the tenth edition. CHAP. I.] 
CARCINOMA, OR CANCER. 
129 
loosely connected with their inner coat, or quite free from attachment, 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. 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. Cars- 
well; and Lebert states that cancer cells are never found loosely floating in 
the blood, being either connected with excrescences formed on the inner sur- 
face of the veins by exudation, as elsewhere, or, when they have entered the 
veins by erosion, being prevented by the coagulation of the blood from tra- 
velling beyond a certain distance in the vessels. The notion, therefore, of 
proper cancerous structure existing in visible forms in the blood, must be 
given up. It can only be in the state of invisible germs that that fluid can 
contain the carcinomatous matter. But whence these germs? Have they 
proceeded from the parent; have they been derived from external sources and 
found entrance into the circulation along with the results of digestion; or 
have they been elaborated in the processes which contribute to sanguification ? 
These questions cannot be answered in the present state of our knowledge. 
Indeed, there is no certainty that any such germs do pre-exist in the blood. 
In favour of this idea is the fact, that cancer often originates at numerous 
points often far separated; but against it is the other fact, still more frequently 
observed, that the tumour may be quite solitary. It may be that, in the 
cancerous constitution, certain tissues have the power to elaborate cancerous 
structure out of healthy exudation; and, in favour of the idea that some 
influence of this kind is exerted by tissue, is the well-known predilection of 
the disease for certain localities, such as the* mamma and uterus. Upon all 
these points we must wait for further light from observation. 
In relation to the second question, as to the agency through which the 
tumour, when once originated, is subsequently propagated, there is also room 
for difference of opinion. Some believe that the cancer cell, being once 
formed, has the power of self-propagation, requiring only nutriment from the 
blood. But this opinion is opposed by the result of experiment, which has 
never succeeded in producing cancerous tumours by transplantation. Dr. 
•Joseph Leidy, of Philadelphia, observed a vascular connexion to take place 
between a portion of cancerous tissue, inserted beneath the skin of a frog, and 
the neighbouring parts, proving the existence of an independent vitality in 
the former; but, on examining the tumour subsequently, instead of finding 
an increase of cancerous cells, he observed that those pre-existing in the 
inserted structure had disappeared, and that fibrous tissue only remained. 
(Proceed, of Apad. of Nat. Sci., May, 1851, p. 201.) The inference would 
appear to be, as maintained by Lebert, that each increase of developement 
takes place in the newly exuded matter through its own inherent powers. 
Nevertheless, that the tumour already formed exercises some influence in 
contributing to the additions made to it, and in the further extension of the 
disease, would seem to be proved by the much greater tendency to the for- 
mation of cancer about a carcinomatous centre already existing, than else- 
where, and by the well-known disposition of the affection to extend from one 
VOL. I. 9 130 
GENERAL PATHOLOGY. 
[part I. 
of these centres through the absorbents to lymphatic glands at considerable 
distances, which is best explained upon the supposition of the conveyance of 
germs from the part first affected. The ultimate infection of the whole 
system, if it be referred to existing tumours, and not to an increase of the 
morbid state of system which originally led to the formation of these tumours, 
can be explained only by a similar conveyance of germs from the diseased 
centre into the blood. 
Some difference of opinion has existed in reference to the origin of the 
fibres in cancerous tumours. As these are found most abundantly in tumours 
occupying tissues normally fibrous, some pathologists have been disposed to 
consider them as the result of simple hypertrophy of the natural fibrous 
structure. Dr. Paget is convinced that the fibrous ingredient of carcinoma- 
tous tumours of the mamma, in the great majority of instances, is only that 
which belongs properly to the breast. (Leet, on Sure/. Pathol., ii. 304.) But 
fibres sometimes also exist abundantly in tumours occupying tissues destitute 
of this structure, or but scantily supplied with it; and the probability is, 
that they are for the most part formed out of the same exudation or blastema 
as the cells, and by the same inherent formative force. 
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; and other cases 
of a similar kind have been since reported. (See Lond. Med. Times and Gaz., 
Jan. 1854, p. 71.) 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 con- 
tagion. Such a result, however, would be in accordance with the notion of 
the origination of the disease in peculiar germs. Such germs transplanted 
to another body, might be supposed readily to adapt themselves to their new 
position, and there to grow and propagate. It has been already stated that 
such a transplantation may, possibly occur 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. Of its causes and essential nature, we are 
quite ignorant. 
Cancer has by some been supposed to be a parasitic animal; but strongly 
in opposition to this notion is the well-established fact, that many of the 
lower animals are liable to the same disease; whereas parasites are generally 
peculiar to the species of animal in which they are found. 
Varieties of Carcinoma.-The varieties of carcinomatous disease may be 
arranged into three groups, characterized severally by certain distinctive qua- 
lities of consistence, growth, &c. These are 1. scirrhus, 2. medullary carci- 
noma, 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 often 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 CHAP. I.] 
131 
CARCINOMA, OR CANCER. 
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. In its perfect form 
it yields very little cancerous juice on pressure; and it is best prepared for 
microscopic examination by being scraped with a knife, so as to be reduced 
to a pulpy state. It is more frequently than the other varieties attended 
with the peculiar lancinating pain of carcinoma. 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 struc- 
tures, 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 of scirrhus. When softened, it is converted, according to 
Walshe, into a yellowish-brown, semi-transparent, jelly-like matter. Scir- 
rhus 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 
following variety to attack different parts of the body. Hemorrhage within 
its structure, or from its ulcerated surface, is less frequent than in the soft 
carcinoma. Scirrhus seldom occurs before puberty, and is most common in 
advanced life. 
2. Medullary Carcinoma.-Medullary Sarcoma (Abernethy).-Encepha- 
loid Disease.- Cerehriform Disease.-Fungus Haematodes (Hey).-Soft 
Cancer.-This consists of a dull-white, opaque, softish matter, bearing a con- 
siderable resemblance to brain, with a tabulated arrangement. Hence the 
names of encephaloid and cerebriform disease employed by French writers. 
It owes its consistence to the predominance of the proper carcinomatous 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 haematodes. In some rare instances in which the arteries are very 
numerous, and the tumour is seated in or upon bone, and bound down by 
fibrous tissue, a full soft pulsation may be felt in it. (Paget.} Sometimes 
the tissue has greater firmness, resembling considerably 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 cha- 
racter, it must be ranked with this variety of carcinoma. Other names have 
been given to varieties of the tumour, from certain supposed resemblances to 
objects in nature, as the solanoid, from its resemblance 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 sometimes 
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 132 
GENERAL PATHOLOGY. 
[part I. 
it has not been found. It is 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, sometimes grayish, 
brownish, or reddish, which, when separated from the tissue, is soft, but, as 
found in the tumour, has considerable firmness. It is contained in a vast 
number of loculi or cysts of various size. This variety of cancer may exist 
alone, or as a part of other cancerous tumours. It seldom occurs in more 
than one organ at the same time; and hitherto has been observed chiefly 
at the pyloric orifice of the stomach, in the omentum, and the intestines; 
though it has also been seen in the bones, testis, and mamma. It is very 
rare in youth. Lebert states that gelatinous tumours resembling the carci- 
nomatous in appearance sometimes occur, which do not exhibit any of the 
true cancer cells, and are therefore not entitled to be considered as carcino- 
matous. 
Cause of Carcinoma.-Of the cause of cancer we know nothing, except 
that it sometimes appears to be hereditary, and occasionally makes its appear- 
ance at such a period after local injuries, as to justify the inference that the 
injury has served to call a pre-existing tendency to the disease into action. 
Treatment of Carcinoma.-1The treatment of external cancer belongs to 
surgery. That of the internal disease is simply palliative. Three indications 
are presented: 1. to relieve pain, 2. to support the failing strength, and 3. to 
obviate as far as possible the effects of the tumours upon neighbouring organs, 
and on the function of those they occupy. The first indication is to be met 
by narcotics, of which opium is by far the most efficacious; but others, as 
conium, hyoscyamus, stramonium, belladonna, &c., may be occasionally sub- 
stituted with advantage; the great principle being to husband the suscepti- 
bility of the system to the operation of these anodynes, so that they may not 
too soon lose their effect. Hence they should at different times be applied 
in different modes, as by the stomach, rectum, or skin; and one should now 
and then be substituted for another. The second indication is usually bet- 
ter fulfilled by the use of a nutritious, easily digestible diet in the advanced 
stages, than by stimulation. It is said that cod-liver oil, alternated with chaly - 
beates, has been found useful in anemic cases. As to the measures calcu- 
lated to obviate the effects of the tumours, these will be most conveniently 
treated of under the heads of diseases of the several parts respectively in 
which the cancer may be situated. 
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 dwell- 
ing of one or more of them; and it has been observed, that certain species CHAP. I.] 
133 
PARASITIC ANIMALS. 
have a peculiar predilection for certain organs, which they sometimes exclu- 
sively inhabit. 
In relation to their mode of origin, pathologists have longbeen divided 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 inapplicability 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 their 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 re- 
mained concealed in the same individual and his predecessors, possibly for many 
generations, without 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 observation 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, animals 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 cha- 
racters 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 germs much smaller than that corpuscle have within them 
the powers requisite for organization. Microscopic germs may enter our sys- 
tems through the lungs or stomach, and circulate everywhere with the blood, 
and even pass along with nutriment into the foetus, though larger in proportion 
to the resulting animals than an acorn to the oak. A positive argument 
in favour of the opinion here advocated 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 134 
GENERAL PATHOLOGY. 
[PART I. 
¥ 
chiefly to certain parts of Europe, where the other is comparatively little known. 
(See Intestinal Worms.} 
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 hap- 
pens especially in the alimentary canal. Wherever they may be situated, acting 
as foreign bodies, they are liable to produce injury by their bulk, exciting irri- 
tation, 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 mischief 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, moreover, in which 
they are very numerous, or of great size, they divert from the system a por- 
tion of the nutriment essential to its support. 
In some situations, especially in the brain, they are productive of great mis- 
chief 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 alimentary canal with 
other parts of the body. Sometimes they produce great destruction 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 par- 
ticular 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 membrane, 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 observable effects. Thus the 
Trichina spiralis, which is almost microscopic, sometimes inhabits the muscles 
in great number, 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 para- 
sites. 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 CHAP. I.] 
135 
PARASITIC ANIMALS. 
probable that a certain condition of system is generally favourable, or neces- 
sary to their developement; as their occurrence is comparatively rare, while 
there is no reason to suppose that all may not be exposed to the 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 in Tweedie's System of Practical Medicine. 
Class 1. Hydatids.-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 Acephalocystis, 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 
Acephalocystis there are two species, distinguished from each other by the 
reproduction occurring, in the one, upon the inner, and in the other, upon 
the outer surface. The former, named Acephalocystis endogena, is the com- 
mon 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. 
Acephalocystis 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 tissue 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 occa- 
sionally 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, 136 
[part I. 
GENERAL PATHOLOGY. 
and with different contents of the abdomen, they sometimes occasion encysted 
dropsies of enormous magnitude; at least, dissection, in 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, 
around 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 follow- 
ing 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 seed, 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 tegumentary system. They 
have but one opening to the alimentary canal, and the sexes are placed upon 
the same individual." (Farre.} 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, and 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.-The 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 duct 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.-1These 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 CHAP. I.] 
137 
PARASITIC ANIMALS. 
of generation on separate individuals. The genera belonging to this class, 
deemed worthy of notice, are Trichina, Filaria, Tricocephalus, Strongylus, 
and Ascaris. Two others, Spiroptera and Dactylius, are described by Dr. 
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 "thickly sprinkled with the 
eggs of some small insect." This appearance has 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, resembling minute white ovate grains, which cannot be 
distinctly examined without the aid of the microscope. The cyst is about 
or 4'0- of an inch long, and a third or half as broad, and consists 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, 4116 reader is referred to Dr. Farre's essay in Tweedie's System of Prac- 
tical 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 the fibres. They abound more in the superficial than in the 
deep seated muscles, but in persons affected with them, are generally present, 
in fewer or greater numbers, in almost all the muscles of the body, excepting 
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 produced 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 oculi, 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 138 
GENERAL PATHOLOGY. 
[part I. 
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 of matter, or merely a 
quality, condition, or action, is entitled to be ranked among the causes of 
disease. These, therefore, are exceedingly numerous, and may, indeed, be 
considered 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 
mechanical or chemical and physiological, the positive and negative, the prox- 
imate and remote, the predisposing and exciting or occasional, &c.; and sub- 
divisions 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 CHAP. II.] 
CAUSES OF DISEASE. 
139 
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 re- 
mote; 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 con- 
sidered as the disease, the inflammation of bowel in which it may have origi- 
nated was called the proximate cause, and the cold which may have occasioned 
that inflammation, 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 nomenclature, 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 be 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, ex- 
hausted and perspiring after fatigue, is exposed to cold, and attacked with 
pleurisy. The state of exhaustion and perspiration constitutes the predispo- 
sition; the fatiguing exercise, the predisposing cause; and the cold, the ex- 
citing 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 cause; or, by its long- 
continued influence, may occasion a depression, highly favourable to the de- 
velopement of some other disease, thus operating as .a predisposing cause. 
Most of the morbid conditions of which the frame is susceptible, may consti- 
tute predispositions 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 predisposition, 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 to- 
wards 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 either 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 appro- 
priately 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 140 
GENERAL PATHOLOGY. 
[part I. 
task. I shall endeavour first to take a general view of them, and afterward 
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. ex- 
cess or deficiency of the actions or processes, in any degree under the control 
of the will; 3. noxious matters within the body, yet not forming a part of 
it; 4. derangement 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 covering 
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 endless as are 
the objects of our affections, wishes, aversions, fears, pursuit, avoidance, or 
interest of any kind. 
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 or- 
ganization, we have intestinal worms, and other parasitic animals, acid and 
aeriform products of fermentation in the primm vim, acrid or otherwise un- CHAP. II.] 
141 
CAUSES OF DISEASE. 
healthy secretions, retained excrementitous matter, and intestinal, biliary, and 
urinary concretions. 
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 
derangements which are peculiarly prominent in the list of morbid causes, 
and which may be properly alluded to here. Such are mechanical impedi- 
ments arising from stricture, compression, or obstruction of narrow passages, 
as of the alimentary canal, ureter, urethra, and biliary ducts; compression or 
displacement of vital organs, as the lungs, heart, brain, and abdominal vis- 
cera, by tumours or fluid collections; the suppression of habitual discharges, 
whether 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 irri- 
tation ; 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 subdivisions, some act apparently 
merely by stimulant or sedative properties, as opium, belladonna, digitalis, 
tobacco, hydrocyanic acid, sulphuretted hydrogen, &c.; others produce pecu- 
liar 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 mucous 
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, running 
upwards, through a greater or less number of links, to the first, from which 
they all depend. Thus, apoplexy may sometimes be traced backwards, through 
hypertrophy of the left ventricle of the heart, obstruction or deficiency 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, pul- 
monary obstruction, and chronic bronchitis, to the habitual inhalation of irri- 
tant 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- 142 
[part I. 
perienced. Thus, a dense population is sometimes exposed to the prostrating 
influence of meagre and unwholesome diet, impure air, contagious effluvia, and 
the depressing emotions, and are consequently swept off in vast numbers by 
typhus fever. 
In relation to the character and 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 appropriately considered. 
These it will be most convenient to treat of in the present place. They may 
be ranked under the several heads of heat, cold, water in the liquid and aeri- 
form states, electricity, light, atmospheric impurities, miasmata, epidemic in- 
fluence, and contagion. 
GENERAL PATHOLOGY. 
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 disturbing 
them by over-excitement. By its general influence, it is capable of producing 
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 certain organs more 
than others, and especially the skin, liver, and alimentary mucous membrane. 
Irritation and inflammation of these structures are sometimes the direct result 
of heat. Nature, however, has provided the means of relief, to a considerable 
extent, by the increase of secretion. Heat is peculiarly 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 also 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 prevent attacks of hepa- 
titis, gastritis, or enteritis. Occasionally, heat also acts with great energy 
upon the brain, but rather in consequence of a direct application, than through 
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; and cooks are subject to 
all the consequences of general vascular fulness of the head, from the neces- 
sary exposure of that part of the body to the fife. Along with the effects 
mentioned, certain 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 oxidation of carbon less necessary, and consequently tends to 
reduce the activity of the pulmonary function. The lungs, therefore, are less CHAP. II.] 
CAUSES OF DISEASE.-HEAT. 
143 
excited than other organs, and hence their comparative freedom from disease 
in hot countries. Though the sensations and emotions, which may be deemed 
passive functions of the nervous system, do not seem to be impaired or di- 
minished by a moderate 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 aug- 
mented; as a muscle, for example, refuses to contract when affected by rheu- 
matic irritation. 
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 for several min- 
utes, with perfect impunity, in ovens or apartments heated over the tempera- 
ture 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 
beefsteaks 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 excitation at length wears out the excitability of the 
organs, which consequently become, in some degree, insensible to the ordi- 
nary 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 necessarily 
sedative or depressing. Under the local influence of cold, the tissues shrink, 
the capillaries circulate the blood less vigorously, secretion is checked, sensi- 
bility is impaired, and the part becomes pale from the want of blood, or purp- 
lish from its stagnation. Should the application continue with intensity, a 144 
GENERAL PATHOLOGY. 
[part I. 
deadly whiteness ensues, circulation ceases entirely, sensibility is lost, and, 
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 
general, the whole surface undergoes the change above described; while the 
interior functions exhibit a similar depression. The heart acts by degrees 
more and more feebly, a general torpor steals over the senses, the movements 
become tottering from muscular weakness, and the benumbing influence ex- 
tends at last to the brain, giving rise to wandering of the thoughts, drowsi- 
ness, 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 sys- 
tem, 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 dimi- 
nished 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 attention of the individual to his condition, so that he might seek 
timely means of relief; while the sympathetic connexion of the sentient sur- 
faces 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 in- 
fluence 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 
Depression.') This reaction is often healthful, and the cold then proves in- 
directly 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 diges- 
tion, &c., amounting often to fever. Now, it is not only the part to which 
the cold is directly applied that undergoes depression, and subsequent reac- 
tion ; 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 conveyed by sympathy, or, to speak more precisely, to which it is trans- 
mitted 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 
intensely, 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. CHAP. II.] 
CAUSES OF DISEASE.-COLD. 
145 
Another method in which cold may become a source of disease, is by the 
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 sur- 
face ; 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 eventuate in disease. 
Still another, and probably one of the most important morbid effects of cold, 
is the suppression of perspiration, resulting from its sedative influence 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 excitation is necessarily directed to some one of the 
interior organs, and proves the cause of inflammation. Very probably, also, 
the suppression may sometimes be injurious by preventing the escape of nox- 
ious 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 
disease, 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 seda- 
tive 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 stand- 
ard, even though perspiring, cold is generally innoxious; while it is much 
otherwise 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 pre- 
servative, in a considerable degree, against the morbid effects of cold. In its 
sympathetic operation, and, to a considerable degree, in its immediate opera- 
tion, this agent acts through the nervous system; and, if that system is under 
powerful impressions 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 im- 
mersion 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 fre- 
quently 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 reaction 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 reaction of cold 
VOL. I. 10 146 
PART I. 
GENERAL PATHOLOGY. 
before this has subsided, and thus render morbid what might otherwise have 
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 air 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 
reaction, 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 reaction 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 reaction 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 ex- 
amples of this principle of action we have in the phlegmasiae of the brain, and CHAP. II.] 
CAUSES OF DISEASE.-WATER. 
147 
of the thoracic and abdominal viscera, the active hemorrhages, diarrhoea, cho- 
lera, dropsy, rheumatism, and gout. 
Cold, as a morbific 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. 
Water. 
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 reaction. Operating probably by penetrat- 
ing the 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 circulation, 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 148 
GENERAL PATHOLOGY. 
[part I. 
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. 
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, because 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 breath 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 conse- 
quence of absorbing all the liquids of the body to which it can have access. 
The fatal winds of the African desert are said to owe their deleterious influ- 
■ence 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 CHAP. II.] 
CAUSES OF DISEASE.-ATMOSPHERIC IMPURITY. 
149 
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 
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 man- 
ner 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 
observed 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 impossible to determine how much of the result is ascribable to the want of 
light, and how much to other causes. 
Electricity. 
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 
understood, 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 electricity upon our systems, and of the dependence of our 
health upon a proper equilibrium of that principle. It must be confessed, 
however, that our knowledge of the pathological agency of electricity is ex- 
ceedingly 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 reci- 
pient of its current, in the same destructive manner as upon inorganic bodies; 
namely, by a mechanical rupture of parts, and by the destructive evolution 
of caloric. 
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, 
hydrosulphuric acid, and sulphurous acid, are almost all that proceed from 
natural sources, or ordinary artificial processes, in quantities likely to prove in- 
jurious 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 animal exhalation, by sponta- 150 
GENERAL PATHOLOGY. 
[part I. 
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 
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 in- 
fluence upon the whole or any part of the system. A few remarks in rela- 
tion 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 pro- 
cess ceases, from the want of action in the pulmonary capillaries. The symp- 
toms, therefore, are those of asphyxia and cerebral oppression combined. 
(See Asphyxia.) 
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 
nature. 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 posi- 
tion 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, drow- 
siness 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, ac- 
* It lias been rendered probable by Schdnbein, that the peculiar atmospheric ingre- 
dient or condition which he names Ozone, has the property of decomposing most of the 
deleterious effluvia which are constantly escaping into the air by deoxidizing them, and 
that the preservation of the purity of the atmosphere is the important function, in the 
economy of nature, for which this extraordinary agent was destined.-Note to the fourth 
edition. CHAP. II.] 
CAUSES OF DISEASE.-ATMOSPHERIC IMPURITY. 
151 
count for the asserted fact, that the gaseous products of burning charcoal are 
more dangerous 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. 
Hydrosulphuric acid, or sulphuretted hydrogen, is undoubtedly a most violent 
poison. It is capable of destroying life, no matter by what avenue it may enter 
the system, whether by the lungs, the stomach, the rectum, or the skin. Ac- 
cording to Chaussier, a horse was killed by breathing atmospheric air containing 
a 290th part of this gas. Nine quarts of it, injected into the bowels 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. (JJhristison on Poi- 
sons.) Symptoms of great nervous derangement, with immense 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 especially 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 proportion, of inducing 
a typhoid state of fever, or at least of strongly predisposing 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 deleteriously 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 pre- 
disposing 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 152 
[PART I. 
GENERAL PATHOLOGY. 
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 gene- 
rating 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- 
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 more frequently does 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 
cleanliness and ventilation, such decomposition is productive of no evil; for 
experience has abundantly shown, that the resulting products are only inju- 
rious when in a certain degree of concentration. Even when most copiously 
evolved, and under the most unfavourable circumstances, they are quickly 
diluted beyond 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 
surface of the body. 
The nature of these effluvia is unknown. It is highly probable that sul- 
phuretted hydrogen is one of their ingredients. They generally have a dis- 
agreeable odour, which often strongly recalls that of malignant typhus. They 
are generated usually in the hovels and cellars of the poor, in which many per- 
sons often dwell in the same small room, and where no attention is paid to per- 
sonal cleanliness, or to proper ventilation. But they may be developed in any 
situation in which numbers are crowded together, as in prisons, infirmaries, 
besieged fortresses, camps, and ships, when due regard to the health and com- 
fort 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 necessary for the 
decomposition is produced, and the resulting effluvia are accumulated 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 sufficiently concentrated, 
are not unfrequently of themselves competent to the production of typhus 
fever. Among the effluvia just alluded to, are not included those which result 
from the putrefaction of the dead bodies of animals, or portions of them. Ex- 
perience has shown that these are not apt to produce 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, CHAP. II.] 
CAUSES OF DISEASE.-MIASMATA. 
153 
or malaria, and those distemperatures of the atmosphere which occasion epi- 
demics. These I shall proceed to consider. 
Miasma ta.-Mala r ia.-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 
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 im- 
purity. (See Animal effluvia, page 152.) 
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, mias- 
matic diseases seldom 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 malarious fevers com- 
mence. 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 de- 
structive when grounds covered with a luxuriant vegetation are overflowed, so 
as to destroy the plants, and occasion their putrefaction. Hence, miasmatic 154 
GENERAL PATHOLOGY. 
[part I. 
diseases are apt to follow the submerging of meadows in order to increase their 
fertility, the forming of mill-ponds, and the damming of streams for the pur- 
poses of navigation. Neighbourhoods, before remarkably exempt from disease, 
have thus become very unhealthy, and have not ceased to be so until the ve- 
getable matter, thus deprived of its life, has undergone complete decomposition. 
The draining of lakes, ponds, &c., is often followed by disease; because the 
organic matters, previously lying quiescent in their beds, are brought into a 
renewed movement of chemical reaction by exposure to the sun's heat. Hence, 
too, the increase of disease which often follows the commencement of cultiva- 
tion, in a newly settled country, in consequence of 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 summer, and in autumn, may be as- 
cribed in part to the circumstance, that vegetable life has now very frequently 
run its course, and plants are consequently exposed to decay. A long con- 
tinuance 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 influence 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 sponta- 
neous 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 dissolv- 
ing 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 con- 
tinued rains lessen the miasmatic influence. They wash the atmosphere 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 favouring the 
decomposition of the dead plants upon the surface of the earth. Upon the 
principle of this affinity, may also be explained the influence 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 unnecessary 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 permit 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 CHAP. II.] 
CAUSES OF DISEASE.-MIASMATA. 
155 
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 been attacked, 
while those upon the upper have escaped. Fogs, in which the poisonous ex- 
halation is probably dissolved, are well known to affect especially 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 physician 
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 efflu- 
vium appears to rise by the heat of the sun, and to be so dispersed as to be- 
come 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 season 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 exhalations. 
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 car- 
rying miasmata, either enveloped in clouds and fogs or otherwise, a very con- 
siderable 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 protect the regions be- 
yond 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 to a dwelling or even a whole neighbourhood. The 156 
GENERAL PATHOLOGY. 
PART I. 
late Dr. Joseph Parrish, of Philadelphia, used to speak, in his practical lec- 
tures, 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 con- 
sequence 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 high grounds, serving 
as a sort of funnel, in which the miasmata are concentrated 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 dangerous, 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 miasmatie 
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 
appropiiate 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 exhalations, 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 a short time, by the prevalence 
of miasmatic disease. In hot climates, however, where the temperature, even 
in the shade, is abundantly sufficient for the copious developement of these 
effluvia, forests are thought to do harm by the material they supply for de- 
composition, the dampness which they promote, and the impediment they 
offei- 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 mias- 
mata developed in the soil beneath. It is, therefore, never advisable to remove 
this scum; and it is not impossible that a violent rain may sometimes do harm 
by breaking it up. Dr. Cartwright, of Natchez, ascribes extraordinary anti- 
miasmatic properties to the Jussieua. grand iflora, an aquatic plant growing 
abundantly in the stagnant waters of the southern sections of Louisiana. He 
founds his belief on the facts, that the waters which it frequents 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 else- 
where to be most conducive to those affections. The plant derives its sustenance 
not from the soil, but from the water, and thus consumes all the soluble pro- 
ducts 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. Whether, 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 va- 157 
CHAP. II. 
CAUSES OF DISEASE.-MIASMATA. 
riable 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 mias- 
mata, which must not be overlooked. These effluvia are neutralized, decom- 
posed, 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 out- 
skirts 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 
Borne; and we have seen it abundantly confirmed in the larger towns of the 
United States, in the neighbourhood of which these diseases have prevailed. 
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 districts 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 nothing 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 occurred 
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 positive; for, 
even though none may be visible to the observer, yet chemical examination 
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 there should 
be no source of miasmatic exhalation 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 mi- 
croscope 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 contamination inconsistent with 
health. In the few instances, therefore, in which miasmatic fevers have pre- 
vailed, 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 Laucisi, 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 diseases. But, even 158 
GENERAL PATHOLOGY. 
[part r. 
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- 
pendent on gaseous exhalation; but chemists have never succeeded in satis- 
factorily 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 sir., 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 micro- 
scopic fungi, which are supposed to find, in vegetable putrefaction, circum- 
stances 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, and can never be established until the existence 
of such organic beings shall be demonstrated, and experiment 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. {Dublin Med. Press, Nov. 
27, 1844.) But the simple consideration, that such a disturbance is con- 
stantly 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 cha- 
racter it may be, whether gaseous or imponderable, 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, and 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 may enter with the saliva. A full meal, and the stimulant 
influence of ardent spirit, are supposed to afford some protection against them. CHAP. II. 
159 
CAUSES OF DISEASE. EPIDEMIC INFLUENCE. 
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. 
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 miasmata, and how 
far of the febrile diseases which are the acknowledged results of this morbid 
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. 
(McCulloch.') 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 diseases 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.* 
Occasionally, diseases prevail temporarily throughout a mbre or less exten- 
sive range of country, strikingly different either in their character, or in their 
inodes 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 upon, and people) from some extraneous source; while 
the ordinary complaints are called endemic (sv in or among, and S^o$), be- 
cause dependent on causes originating among the inhabitants, or within the 
country itself. The distinction is not very precise; and, frequently, it might 
Epidemic Influence. 
* A peculiar condition of the tongue has been noticed by Dr. Thomas C. Osborne, of 
Erie, Alabama, which he considers indicative of malarious influence on the system, and 
which he believes to precede the more obvious effects of the poison. The following is 
his description of this condition, which he denominates the malarial margin. " It is 
an essential departure from the normal aspect of the edge, constituting a distinct lateral 
boundary of the tongue, occupying more or less surface according to the charge of infec- 
tion in the system. Ordinarily, the colour amounts only to a very faint bluish tinge, 
which is liable to be lost or merged in the various tints imparted to the tongue by various 
diseases. The most fixed condition of this symptom is an appearance of indentation 
transversely, which is apparently continued to the subjacent tissue, while the superficial 
tegument is moist, smooth, and transparent. In a word, it appears to be an encroach- 
ment of the inferior surface upon the superior and lateral borders of the tongue, greater 
as we approach the root of that organ." (Am. Journ. of Med. Sci., N. S., xxii. 555, from 
West. Journ. of Med. and Surg., Aug. 1851.)-Note to the third edition. 160 
[part I. 
GENERAL PATHOLOGY. 
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 influence 
of insufficient and unwholesome food, depressing emotions, and the noxious 
exhalations of crowded dwellings. 
Tn 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 
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 migration 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 animalcular 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 sup- 
posed to be the result of animal impulses and caprices, in migrating swarms 
of insects; for 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 pathc- 
logists; how, for instance, with strong evidence of their non-contagious na- 
ture, they should sometimes appear to be spread by the movements of men, 
individually or in bodies, from infected neighbourhoods to others before un- 
touched. The living germs, carried in clothing or merchandise, 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 ana- 
logies are offered in the receding of the visitation, often as rapid as its ap- 
proach, the occasional lingering of deserted fragments of the moving host in 
isolated neighbourhoods, and the subsequent temporary and relatively feeble 
revival of the pestilence, sometimes observed, as though organic germs had 
been left behind to struggle into a short course of activity and propagation, 
under unfavourable circumstances. They who desire to prosecute this inquiry 
may advantageously consult the " Medical Notes and Reflections" of Dr. 
Holland, who has fully considered, and seems disposed to adopt the animal- 
cular 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 unknown influences, atmo- CHAP. II.] 
CAUSES OF DISEASE.-EPIDEMIC INFLUENCE. 
161 
spheric, 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. 
The recent discovery of a peculiar atmospheric condition, ascribed by some to 
the presence of a principle called ozone, has given origin to various conjectures 
as to its morbific agency; but as yet they are nothing but conjectures. It is, 
indeed, vain to speculate upon this subject. All that we can say, with cer- 
tainty, 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 opera- 
tions. The following are some of the laws alluded to. It would not be amiss 
to consider as epidemics only the diseases which originate in, or are affected 
by, the influence alluded to; and the observations which follow may be re- 
ceived 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 cholera, 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 particular 
diseases, under circumstances differing from those in which they are ordinarily 
produced, and to an extent not attainable without its aid. Thus, smallpox, 
scarlatina, and other contagious eruptive affections, sometimes become epidemic. 
Whether the epidemic influence is alone sufficient to produce 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 specific cause, yet many are now attacked who 
may have been frequently exposed to the contagion on former occasions with- 
out effect; and the complaint often assumes a more violent character than be- 
longs to it in ordinary years. Sometimes the epidemic influence predisposes 
to some one especially of the exanthemata, as to smallpox 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 
* A remarkable exemplification of this statement is offered in the furunculoid epidemic 
which has recently prevailed both in Europe and this country, beginning probably 
so early as 1849, reaching its greatest height in 1852, and still continuing, though 
in a greatly diminished degree. Every practitioner must have been struck with the 
extraordinary prevalence in 1852 of boils or furuncles, carbuncles, whitlows, and other 
pustular affections of the outer surface of the body.-Note to the fourth edition. 162 
GENERAL PATHOLOGY. 
[part I. 
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 predisposition 
to them is greatly increased by some unknown cause; so that an amount of 
miasmatic exhalation, more or less of which may be always floating in the 
air in warm weather, may now produce its peculiar effects, which, in ordinary 
seasons, would be wholly unfelt. Hence, probably, the late prevalence of in- 
termittent and remittent fevers, during the summer and autumn, in portions 
of the Middle and Eastern States, in which these diseases were formerly almost 
unknown; while the circumstances of these regions, in relation to the produc- 
tion of miasmata, remained, so far as could be discovered, the same as in pre- 
ceding 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 management. 
3. One of the established laws of epidemics is, that they give more or less 
of their own charactei* to all other diseases.- Thus, when cholera prevails, 
looseness of the bowels is very apt to be superadded to other affections; when 
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, modifies 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 
it pervades a large portion of the earth, it is never present everywhere at the 
same time, but attacks different parts successively; in some instances advanc- 
ing regularly, and sweeping all before it, in others, irregular and discursive 
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 is 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 CHAP. II.] 
CAUSES OF DISEASE.-EPIDEMIC INFLUENCE. 
163 
appear subsequently. This, perhaps, may be owing to the greater suscepti- 
bility 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 pre- 
valence, 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 visits the same 
place a second time, in the next or some subsequent year; and in India, after 
its epidemic prevalence, appears to have taken up a fixed residence, and almost 
to have become endemic. The miasmatic epidemic which made its appear- 
ance in the year 1820, in the neighbourhood of Philadelphia, and recurred 
annually for many years, left traces behind it which have scarcely yet ceased 
to be 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 Jurn 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 
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 inter- 
val of comparative exemption; but the miasmatic fevers recurred, and have 
since continued in a greater or less degree-, though, during the year 1851 and 
subsequently, they appear to have given way considerably to the typhoid fever, 
which has been prevalent in this district of country, as in other parts of the 
Union. 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 intro- 
duction of vaccination, the smallpox 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 has seldom been en- 
tirely absent from among us. From the experience of the past, we may look 
forward with confidence to a period of renewed exemption, when vaccination 
will again assert its complete supremacy. 
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. 164 
GENERAL PATHOLOGY. 
[part I. 
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 cases 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 fevei' 
or smallpox, 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 the terms 
infection and infectious altogether, especially as we can express all that is 
essential 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 atmosphere 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 
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 
operates through absorption, so far as constitutional effects are concerned. 
In certain instances, however, it appears to be confined to the surface af- 
fected, 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 smallpox, chickenpox, 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 body, as in smallpox, scarlatina, measles, and typhus. It has no sen- 
sible properties by which its poisonous character might be indicated, nor does 
it yield any evidence of its nature to chemical investigation. In some dis- 
eases, as in smallpox and typhus fever, it is often attended with a disagree- 
able odour; but it is by no means certain that it is the matter of contagion 
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 CHAP. IlJ 
CAUSES OF DISEASE.-CONTAGION. 
165 
to it, as in scarlatina; in others, very active, allowing few that are unpro- 
tected to eseape, as in smallpox. Contagion does not usually act at a great 
distance 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, merchandise, &c., and may thus be conveyed to great distances. It very 
rarely happens, however, that the mere entrance into the sick room is sufficient 
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 smallpox, 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 cotton, 
are especially liable to act as fomites; 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 destroyed 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. 
The matter of contagion is said to be rendered inert by a heat of 120° F., 
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 numerous 
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 direct operation is rather 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 
endemic; but spreads from individual to individual, or from house to house; 
and, w'hen new cases occur at a distance from the original one, they can often 166 
GENERAL PATHOLOGY. 
[part I. 
be traced to it by the intervention of persons or fomites. Instead of originally 
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 run 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 
subsided. Such is the case with measles and smallpox. Occasionally, how- 
ever, we see two of these complaints apparently existing together, and modi- 
fying 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 
whether 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. 
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 two circumstances 
which serve to distinguish them from other morbific agents, and which especi- 
ally merit notice. These are their power of reproduction in the human system, 
and the immunity which one attack generally gives against their future in- 
fluence. 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 simi- CHAP. II.] 
CAUSES OF DISEASE.-CONTAGION. 
167 
lar contagious matter; as the fermentation of beer developes an additional 
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 exist, as consequences of the organic processes of growth, 
peculiar matters, each one of which, through the fermentation excited by the 
contagious cause, is itself converted into contagion, and eliminated; so that, 
on any future occasion, though the poison may be absorbed, it will find no 
material to act on, and will therefore be harmless. An explanation so purely 
hypothetical scarcely requires criticism. The objection naturally suggests 
itself, that there should be so many distinct unnecessary 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. A more 
plausible explanation of the future exemption is that given by Mr. Paget. 
Each organized structure has the property of assimilating to its own nature, 
the material presented to it in the nutritive process. Thus the bony tissue 
converts the organizable material into bone, muscle into muscle, &c. The 
blood itself is in the same category, being capable of assimilating nutriment 
to its own nature. Should a structure become diseased, it assimilates the 
material, not to its original, but to its altered condition. Tumours, upon this 
principle, retain their character as they increase in size. In like manner the 
blood, which, under the influence of absorbed contagious matter, undergoes 
some modification which renders it no longer susceptible to the influence of 
the contagion, maintains its new condition and of course a continued insus- 
ceptibility by the principle of assimilation. (Leet, on Surg. Pathol., i. 51.) 
The second theory considers contagion as the influence of certain invisible 
organic agents, either animal or vegetable, which, fully developed, or 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 cuta- 
neous 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, the disease is conveyed by animalcules of a peculiar cha- 
racter, which propagate in the skin. But the fact that, in these affections, no 
future exemption is secured, shows that they are essentially 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 expla- 
nation of the immunity, secured by one attack of these latter complaints.* 
* Zymotic Diseases.-The term zymotic, applied to a class of diseases, and sometimes 
to their cause or causes, has come so extensively into use as to require some explana- 
tion in a general treatise like the present. It is derived from the Greek word Qf*", 
ferment, and is applied to a certain set of diseases, in which it is supposed that a mor- 
bific agent, entering the blood, operates upon it as a ferment, as yeast for example 
operates upon saccharine juices. A minute quantity of the poison sets on foot an ac- 
tion in the blood, by which the whole mass is changed; and the resulting phenomena 
proceed from the altered state of the blood, and not from the direct agency of the fo- 
reign matter admitted into the circulation. Upon this principle it is thought that all 
those causes operate which are included, in the text, under the names of animal effluvia, 
miasmata, epidemic influence, and contagion. They would be called, under this theory, 
zymotic agents; while the diseases produced by them are called zymotic diseases. Of 
course, under the latter title, are included all miasmatic or malarious fevers, all epidemics, 
and all contagious diseases resulting from an absorbed poison. The reader will notice 
that this view of the operation of certain causes of disease is purely hypothetical, being 
founded altogether on certain analogies which in themselves are not complete, and un- 
supported by chemical or microscopic observation. The hypothesis is plausible, and 168 
[PART I. 
GENERAL PATHOLOGY. 
Pr edispositions. 
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 
terms, of the distinction between predisposing and exciting causes; and have 
considered somewhat fully 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 as- 
saults of disease. These may be arranged in three divisions. The first in- 
cludes 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 denomi- 
nated diatheses; that is, tendencies to some one special and peculiar disease, 
which is apt to appear whenever the body is excited or disturbed, no matter by 
what cause, and will occasionally break forth without any apparent cause what- 
ever. 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, idiosyn- 
to a certain extent may be true, but has not been proved, and should not, therefore, 
I think, be made the basis of a new classification or new nomenclature of diseases. 
The effect of such classification and nomenclature, if generally adopted, is to lead the 
student to receive as admitted fact, what is yet simply conjecture. 
In the text, allusion is made to a mode of explaining the peculiarities of contagious 
diseases upon the principle here referred to. Liebig teaches that fermention is owing 
to a movement of decomposition excited in one body by the mere presence of another 
body undergoing decomposition. Yeast is a nitrogenous substance in this condition. 
Introduced into a pure saccharine solution, it sets on foot a process of decomposition 
which results in the formation of alcohol and carbonic acid out of the sugar, without 
further change; but, if along with the sugar and water there be a nitrogenous body, 
as in the infusion of malt, this body undergoes, through the same agency, chemical 
changes which convert it into a substance having all the properties of the yeast origin- 
ally employed. So in contagious diseases, a little of the zymotic agent, itself in a state 
of chemical change, entering into the blood, and finding there some material susceptible 
of its influence, sets on foot a process of decomposition in that material which ends in 
its conversion into a similar zymotic agent, to be thrown out of the system. 
Dr. Carpenter has ingeniously extended this theory to the explanation of the predis- 
positions to the epidemic or zymotic diseases, which, as is well known, are apt to attack 
only a certain number of the individuals exposed to their influence, while many escape. 
In reference to cholera, for example, it is those who have lived miserably, in confined 
places, and in a contaminated atmosphere, who are most apt to suffer. He supposes 
that in these persons the blood has become contaminated with absorbed or generated 
nitrogenous matters, in a state ready to enter into decomposition with great facility 
upon the application of the ferment. In these, therefore, the absorbed poison excites 
the movement of decomposition which gives rise to the morbid phenomena; while pure 
blood, offering no such material for the action of the poison, undergoes no change, and 
the individual escapes. The reader who is disposed to push this inquiry farther is re- 
ferred to an article on the predisposing causes of epidemics in the British and Foreign Me- 
dico- Chirurgical Review, for January, 1858. All these speculations, however, should be 
looked on as suggestive merely, prompting to positive experimental research, and 
should not be received as truths until established by the results of such research.-■ 
Note to the fourth edition. CHAP. II.] 
CAUSES OF DISEASE.-PREDISPOSITIONS. 
169 
crasies, sex, and age; among the predispositions, 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 pecu- 
liarity 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 dis- 
ease, is, that a predominance either of developement or function, in any struc- 
ture, organ, or system of the body, is apt to lead to disease of that part. Thus, 
the sanguine temperament, in which the circulatory system predominates, pre- 
disposes to acute inflammations, hemorrhages, and fevers of a sthenic charac- 
ter ; 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 indicates 
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 morbid 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, certain 
kinds of food, usually very wholesome, may produce violent urticaria. Exha- 
lations, which are quite harmless to the great mass, excite, in certain indivi- 
duals, excessive irritation of the nostrils, fauces, or respiratory passages. Some 
very susceptible persons faint at the perception of odours, usually agreeable in 
their effects. So frequent are these peculiarities, and sometimes so important, 
especially in relation to the operation of medicines, that the physician should 
make himself acquainted with the constitution of every new patient, as far as 
practicable, before 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 func- 
tions. But, independently of these, women, in consequence of the greater 
excitability of their nervous system, are especially predisposed to 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 forms 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 im- 
press on the general system predispositions, not immediately or necessarily 
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 to its accidents, is probably on the whole favourable to health, by super- 
seding constitutional morbid tendencies. But, when menstruation has perma- 
nently ceased, these tendencies are apt to display themselves; and this, con- 
sequently, is the most dangerous period in the life of woman. It is now, 170 
[part I. 
GENERAL PATHOLOGY. 
especially, that cancerous affections occur. But if she escape the dangers of 
this period, she may reasonably hope to enjoy along exemption from disease, 
and to live on to a good old age. Much of the peculiarity, ordinarily observ- 
able in the female predispositions, is owing rather to their habits than to 
any natural cause. Hence, probably, in part, their tendencies to spinal de- 
formity, pulmonary consumption, anemic complaints, and dyspepsia. 
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, after- 
wards makes these also a centre of morbid action. The process of dentition 
keeps up, during its continuance, a constant irritation, which, through the 
fresh and unimpaired sympathies, extends to the various functions, especially 
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 unremitted 
excitement of the nervous system, either directly from the source of irritation, 
or 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 completion of the second 
dentition. In the inflammatory affections of children, at this age, there is a 
strong tendency to the exudation of coagulable lymph, and the consequent 
formation of false membrane, even upon the mucous surfaces. 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 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 affec- 
tion than epistaxis. They are, 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 unfre- 
quently 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 hemor- 
rhages, pulmonary consumption, and dyspeptic affections. The quantity of 
blood furnished by the digestive process has not yet become exactly accom- 
modated 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, CHAP. II.] 
CAUSES OF DISEASE. -PREDISPOSITIONS. 
171 
therefore, is especially liable to derangement. But, when the period of de- 
cline has arrived, the balance is again disturbed, one organ fails too rapidly, 
another retains a disproportionate 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; and 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 pro- 
perties of the ultimate cells are sometimes perverted or lost; new laws regu- 
late the nutritive process; and thus morbid growths are apt to be developed, 
such as scirrhus or cancer, which, though not exclusively, is especially a dis- 
ease 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 constitution, 
which serve as predispositions to disease. We are not born with the scrofula, 
gout, rheumatism, &c., of our parents, but only with that condition of system 
which favours the developement of these affections, when other causes operate. 
The 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 can 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. 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 children are greatly diminished. Hence 
the danger of constant intermarriages between near connexions, who may be 
supposed to have the same defects of constitution. The morbid tendencies 
thus go on accumulating, from generation 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 explanation. It is only the tendency 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 developement. The tendency is, nevertheless, 
handed down to the next generation, which may be less fortunate in relation 
to the influences that bear upon it. Occasionally, we observe, family predis- 
positions to disease, which have no prototype 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 sys- 
tem, 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 172 
[part I. 
GENERAL PATHOLOGY. 
infancy, are gradually accustomed to the noxious influence, and appear not to 
suffer. Occasionally, however, habit constitutes a predisposition to disease. 
Thus, when the system has adapted itself to certain influences, ordinarily in- 
jurious, 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 is 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 consequently 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 comparatively 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 proportionably less duty to 
perform. Under these circumstances, hepatic affections 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 conse- 
quence of the frequent vicissitudes of weather, and the consequent varying 
conditions of the organs, there is a greater general tendency to inflammatory 
affections. The vicissitudes are felt more strongly when the climate is damp 
as well as variable, and the morbid tendency is also consequently stronger. 
Rheumatism and catarrhal affections are the most frequent 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. 
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 disease 
already enumerated, and ascertaining their bearing in each particular case. 
A few remarks on the subject 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 blood, 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 tile body, and predisposes to scurvy 
and low forms of fever. Stimulating drinks and condiments favour directly the CHAP. III.] 
SYMPTOMS OF DISEASE. 
173 
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 resulting 
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, including 
the pursuit of pleasure, are concerned, there are two prominent considerations 
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 in- 
flammation from other causes; and, 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 conse- 
quences of a failure of their functions, as well as, generally, to the influence 
of morbific causes through the resulting debility. 
CHAPTER III. 
SYMPTOMATOLOGY, OR SEMEIOLOGY. 
Symptoms are those effects of disease which are either sensible to the pa- 
tient, or perceptible by the observer. Signs are the evidences by which dis- 
ease 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 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, 
therefore, be signs; but they cannot be considered as symptoms. 
Symptomatology, or Semeiology, is the science which treats of the symptoms 
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 diagnosis 
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, therefore, its diag- 
nosis, 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 terminations of dis- 
ease; 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 
variously denominated general, rational, and vital symptoms; the latter, 
physical ^gns. 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 174 
[part I. 
GENERAL PATHOLOGY. 
of the pulse are felt; and convulsive movements are seen. On the other 
hand, many of the sigps called physical are 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 dis- 
eases, it will be most convenient, in many instances, to separate from the 
ordinary symptoms those signs which are elicited by certain processes of com- 
paratively recent origin, as percussion and auscultation, and which have been 
distinguished by the designation of physical signs. Such a discrimination 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 de- 
partment of special pathology. Our attention here must be directed more 
especially to those phenomena, which, being common to numerous diseases, 
require a general description in order to be fully understood, and of which a 
description now will spare the necessity of much repetition hereafter. It 
will be necessary, moreover, to explain the nature of certain symptoms, 
which, not entering into the category of diseases, might otherwise not receive 
the special 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 cor- 
rect conclusion upon this point; and it is only necessary that the attention 
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 wrell 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 
digestive 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 CHAP. III.] 
SYMPTOMS OF DISEASE.-THE TONGUE. 
175 
contraction, when not the mere effect of dryness, is usually the result of a 
diminished 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 inference 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 arterial- 
ized state of the mass of the blood is indicated; in the latter, either over- 
excitement 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 
irritation. 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 aera- 
tion 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- 
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 to 
perfect aridity. It depends on a deficiency of saliva, or of mucus, or both, 
and indicates a general tendency to diminished secretion. It not unfre- 
quently occurs, as a sympathetic affection, in ulcerative inflammation of the 
small intestine. It affords sometimes the most important therapeutical indi- 
cations, 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 coolness 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. 176 
GENERAL PATHOLOGY. 
[PART I. 
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 
and the mucus of the mouth • 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 epithelium. It is almost always confined to the upper surface, where 
the structure of the membrane 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 num- 
ber 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, toleraibly 
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, 
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. 
WTheu 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, CHAP. III.] 
SYMPTOMS OF DISEASE. 
177 
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 remains 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, however, 
is an aphthous state of the tongue, which is apt to come on in the advanced 
stages of chronic diseases, and is generally to be received, under these circum- 
stances, 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 
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 exceed- 
ingly unfavourable, indicating either great prostration, or dangerous cerebral 
disease. Of similar unfavourable prognostication, under the same circum- 
stances, is the occurrence of a difficult and hesitating utterance, like stam- 
mering. 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 the nervous power, from paraly- 
sis, or from inflammation of the muscles themselves or 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 ad- 
mitting the food or drink to enter that aperture upon every attempt to swal- 
low, as when the epiglottis is ulcerated, or swollen and stiffened by inflamma- 
tion. From this view of the causes of difficult deglutition, it is obvious that 
the symptom is of considerable 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 mentioned, it often affords just ground for great solici- 
tude. 178 
GENERAL PATHOLOGY. 
[part I. 
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 bo 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, with- 
out any disease whatever elsewhere. Excess of appetite, or boulimia, 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 
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.-These, 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 viscus, and without spinal tenderness, there is CHAP. III.] 
SYMPTOMS OF DISEASE.-DYSPNCEA. 
179 
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 theii' 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 stools, 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 
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 see. 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 trans- 
mitted 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 180 
GENERAL PATHOLOGY. 
[part I. 
centre itself. In its higher grades, it constitutes or rather occasions, the sen- 
sation of want of breath; 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 dys- 
pnoea 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 pulmonary air-cells and bronchia, there goes up, through the affe- 
rent 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 la- 
boriously, he is compelled to maintain the erect position, he cannot bear the 
windows or doors shut even in cold weathet, 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 unea- 
siness at all; and the only apparent morbid result is an increase in the fre- 
quency of respiration, of which the patient himself may not be sensible. 
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- 
bility under the influence of badly aerated blood, as not unfrequently happens, 
there may be neither sensation nor increased movement; and asphyxia, or a 
state approaching to it, is produced. It may happen, moreover, that irrita- 
tion may exist in the nervous centre, independently of any deficiency in the 
aeration 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 disease, 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 respi- 
ration languishes or ceases, instead of being excited. Another condition is 
that in which the blood, from various causes, becomes congested in the pul- 
monary capillaries, so as to impede the entrance of air into the cells, and at 
the same time retard the pulmonary circulation. A third condition is afford- 
ed by different diseases of the lungs, which produce consolidation, compres- 
sion, 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 pericardium, tumours 
of all kinds within the chest, pulmonary consumption, &c., operate, in ex- 
cluding the air from portions of the lungs, in one of the modes just men- 
tioned. The portion to which the air has access is insufficient 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 constricting of the air CHAP. III.] 
181 
SYMPTOMS OF DISEASE.-COUGH. 
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 respiration, either paralytic, 
rheumatic, or inflammatory, in which they become 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 circumstances. 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 important 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 unimpaired. 
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 
received by the nervous centre, producing a sensation of tickling, pressure, 
fulness, 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 
obviously the removal of matters in the air-tubes, which might interfere with 
respiration. 
The source of the impression made upon the sensprium 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 coldness 
and dampness, which operate by reaction, or upon substances extravasated 
into the passages, as mucus, pus, blood, &c. Inflammation, from whatever 
cause, acts as 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 espe- 
cially sensitive, with the purpose, no doubt, of guarding the entrance of the 
tube against injurious agents. Another source of the sensorial 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 stomach, the 
liver, the bowels, the peritoneum, &c. It is probably through branches of 
the par vagum, directly or indirectly, that impressions from these sources 
are conveyed to the medulla oblongata, and the brain. A third source of 
the impression is some inappreciable change in the nervous centre, or the res- 
piratory 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 182 
GENERAL PATHOLOGY. 
[part I. 
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 to proceed, or the cause producing it. 
Pxpectoratioii.-Expectoration is the act of discharging the secretions or 
fluids of the air-passages. This is usually effected by coughing. Sometimes, 
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 vomit- 
ing, and it is sometimes difficult to determine whether the substances dis- 
charged have proceeded from the lungs, or from the stomach. Chomel calls 
it pectoral vomiting. It is in this manner that blood is sometimes expectorated 
in violent attacks of haemoptysis. A third mode of expectoration 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. 
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 falla- 
cies, and much caution is often necessary to avoid wrong inferences. The 
pulse, in the ordinary acceptation of the term, is the beating of the arteries. 
In each pulsation, the vessel is slightly expanded, and sometimes laterally dis- 
placed, and then returns to its original size and position, after which there is 
an interval of rest. The influences concerned in its production and peculiari- 
ties, 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 pulsations, and the regu- 
larity or irregularity of their succession, must depend upon the heart. The 
pulse at the wrist, when it can be felt, always corresponds with the systole of 
the ventricles, allowance being made for the very 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 characters 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 im- 
pulse 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 CHAP. III.] 
183 
SYMPTOMS OF DISEASE.-THE PULSE. 
be strong, while the former is comparative!}7 weak. Again, an excessive ten- 
sion 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 absolute. The pulse may be small, even in a plethoric state of the 
system, if some obstruction to the pulmonary circulation exist, causing con- 
gestion in the lungs and venous system, and preventing a due supply to the 
left ventricle. 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 
frequency in health, at different ages; viz. from 130 to 140 in a minute soon 
after birth, 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 the 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. Journ. 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, how- 
ever, that very many exceptions will be found; for there are few points in 
which men differ more, physiologically, than in the frequency 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 constitutional 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 ave- 
rage, to be ten beats in the minute more frequent than in men. There is cer- 
tainly some difference; but this, I think, is beyond the reality. Temperament 
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 increase 
it, and in some persons greatly. The effect of posture referred to may be resolved 
into that of muscular exertion. Dr. B. B. Todd has observed that, in some 
instances of great debility of the heart, the rule of increased frequency in the 184 
[PART I. 
GENERAL PATHOLOGY. 
erect position does not hold, and may even be reversed. (Lond. Med. Gaz., 
March, 1851, p. 397.) In the inverted posture of the body, the frequency is 
diminished, probably from pressure on the brain. During sleep, the pulse is 
usually considerably slower than in the waking state. In health, whatever 
exercise of function 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 com- 
pensate 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 exhausting 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 excitation exists in the system. Even with such a source, it will 
sometimes occur when the susceptibility of the heart has become exhausted; 
as towards the close of a fatal affection, and when the nervous centres, which 
are the medium through which stimulation reaches the heart, become insensi- 
ble by disease, as in cerebritis and 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 slow- 
ness of the pulse, unconnected with its other qualities. It may, however, be 
admitted as generally true, that extreme frequency indicates irritation com- 
bined 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 indi- 
cates irritation with little strength. The heart makes a quick, short, angry 
contraction, differing much from the somewhat prolonged and forcible con- 
traction 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 an abrupt cessation, as if the direction of the 
current had suddenly changed. Dr. Hope considers this pulse as evincing 
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 intermission 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 may be so feeble, that the impulse CHAP. III.] 
SYMPTOMS OF DISEASE.-THE PULSE. 
185 
does not reach the extremities. Hence, intermissions of the pulse are some- 
times observed, when the pulsations are regular over the heart. But very fre- 
quently, along with intermissions of the pulse, there is irregularity in other 
respects. Several beats may occur rapidly in succession, and then be followed 
by others at longer intervals; and these 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 suf- 
ficient to justify suspicion of something worse, and should lead to a close ex- 
amination. Irregularity of pulse is sometimes observed in perfectly healthy 
individuals, who live to old age without any resulting inconvenience. This is 
especially the case with mere intermission, which is not uncommon in persons 
advanced in life. Habitual intermissions of the pulse, in elderly people, some- 
times 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 be full, or it may be less than usual, when it is said to be small or contracted. 
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 pulsa- 
tion. In the latter case, the pulse readily yields to the finger, and, in its ex- 
treme of debility, is sometimes called a gaseous pulse. It is not unfrequent 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 sometimes said to be thread-like. It may be associated, like fulness, with 
firmness 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 synony- 
mous 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 pulse 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 186 
GENERAL PATHOLOGY. 
[part I. 
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. Force or momentum is, in the body as well as out of it, the product of 
velocity a'nd 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 bloody or 
very slow action of the heart, or great relaxation of the arteries, or of all 
these conditions combined, there may be 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, and the pulse will be necessarily feeble. A mistake, 
in such a case, might be fatal. Inflammation, even of a vigorous character, 
in the nervous centres which more immediately influence 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, pros- 
trate the circulatory forces, and produce the same phenomena; as in severe 
inflammation of the stomach or peritoneum. These are examples of depression 
of certain vital actions, but not of debility; depletion maybe demanded instead 
of stimulation; and it is highly important 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 ansemia. 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 CHAP. III.] 
187 
SYMPTOMS OF DISEASE.-THE PULSE. 
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 examined. 
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 position 
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, 
under 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 
very advantageously engage his patient in conversation, so as to divert the 
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 
conclusions he may have formed from the first. When the pulsations are 
excessively 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 ad- 
vancing 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. By examining the pulse while the arm is much 
elevated, some inference may be drawn as to the strength of the heart's con- 
tractions, which must be very great to overcome the effect of gravitation, and 
sustain a full strong pulse at the wrist. 
State of the Capillaries.-1The state of the capillary circulation cannot always 
be correctly inferred from that of the circulation generally, and sometimes re- 
quires a distinct examination. By pressing the finger upon the skin, and ob- 
serving 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 188 
[PART I. 
GENERAL PATHOLOGY. 
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 debility. 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 some- 
times 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 jugular. 
State of the Blood.-This should always be examined when blood is drawn. 
From 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 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 ordi- 
nary circumstances. The symptoms presented by the blood must be observed 
incidentally; for it can seldom 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 defi- 
ciency of all the secretions, as in certain cases of fever; but a general increase 
is scarcely possible. Much more frequently, the deficiency, as well as the in- 
crease, 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 perversion 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 reagents 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 CHAP. III.] 
SYMPTOMS OF DISEASE.-CALORIFIC FUNCTION. 
189 
the kidneys, when the liver ceases to secrete. The individual secretions 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 deep-yellow, or clay-coloured, or dark, according 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 altera- 
tion 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 
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 di- 
rection 96J°, 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 bystander, 
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 
interior, 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 
hear.d 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 190 
GENERAL PATHOLOGY. 
[part I. 
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 mor di cans), 
&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 ex- 
ceedingly numerous. They embrace all derangements, not only of general and 
special sensation, as these terms are usually understood, but also of those feel- 
ings 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 con- 
sidered hereafter, in connexion with the derangements of which they are the 
expressions. Our attention will at present be confined to the symptoms af- 
forded by derangements of general sensation, and of the several special senses 
of sight, bearing, &c. General sensation is deranged in two ways. Either it 
is, in the first place, defective or altogether wanting, or, secondly, it is dis- 
agreeably altered, constituting various kinds of uneasiness, which, for con- 
venience sake, may all be classed together under the head of pain. It is only 
the latter that requires any general remarks. 
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 our 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 obvious 
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 modifica- 
tion of the nerves, in which their sensibility is exalted, independently 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 unfrequent, 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 positive 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, there- 
fore, a great error to consider pain as always an evidence of inflammation. It 
is, indeed, in very many instances, most effectually relieved by means calcu- 
lated most strongly to aggravate 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, in- CIIAP. III.] 
191 
SYMPTOMS OF DISEASE.-PAIN. 
tense, excruciating, or agonizing. In character, it is dull or obtuse, sharp or 
acute, aching, smarting, &c.; and, in its different varieties, has received pecu- 
liar names from certain real or supposed analogies, as lancinating, cutting, sting- 
ing, pungent, boring, tearing or rending, gnawing, &c. When attended with 
a beating sensation, consequent upon the heart's action, it is called pulsating 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 considered so in their 
slighter degrees. Sueh 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 inflammation. 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 injurious loss of blood. Under 
pain, finally, we may rank those general and indefinite sensations which are 
vaguely designated by the terms general uneasiness, 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 adiagnostic symptom. Thus, 
it may be doubted whether a pain in the side is symptomatic of pleuritis 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 disease 
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 different 
degrees of acuteness. Some persons are little sensitive to painful impressions 
of any kind, others suffer really and greatly from slight causes. External 
cancer, which, in most individuals, is a source of extreme suffering, appears 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, 192 
general pathology. 
[part I. 
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 volitant.es, and the tinnitus aurium, which so frequently accom- 
pany derangement of stomach. But the symptoms connected with the senses, 
will be most advantageously treated of with the diseases of the organs 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, and 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 may 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 others 
evince an equally strong tendency to mental dejection and despondency, es- 
pecially 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 there 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 de- 
lirium tremens; of the languor which follows excessive excitement, as in the 
advanced stage of active delirium; or of the direct action of a sedative agent, 
as the poison of typhus fever, or the depraved blood of that disease 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, it tends rather to impair power and function together. 
Delirium may, therefore, be active or passive. The active differs greatly CHAP. III.] 
SYMPTOMS OF DISEASE.-FACIAL EXPRESSION. 
193 
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. Heis 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 per- 
ceptions 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, 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 le 
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 descrip- 
tion. 
There are, however, certain changes in the face of a more tangible charac- 
ter, 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 in- 
dications. 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 bead; in the latter, it is unduly 
carbonaceous, 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 fea- 
tures 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, exhaustion, 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 con- 194 
GENERAL PATHOLOGY. 
[PART I. 
traction 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 relaxed, 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 existence of a degree of prostration requiring support, when we might be 
embarrassed without that sign. Certain positions or movements of the fea- 
tures are sometimes also highly expressive. Thus, alternate contraction and 
expansion of the alae nasi frequently indicate dyspnoea; irregular motions of 
the eyes, with contracted or expanded pupil, disease of the brain; and a fall- 
ing 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 
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, will be most advantageously studied in connexion with the 
several diseases in which they are found. Our limits do not permit of am- 
pler 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 ter- 
mination, the symptoms show no disposition to abate, or when they regularly 
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 commonly, 
the symptoms, after a shorter or longer continuance, abate considerably, with- 
out, 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 abate- 
ment is called the remission, and that of excitement the exacerbation. Fre- 
quently, 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 smallpox, 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- CHAP. III.] 
195 
COURSE AND DURATION OF DISEASE. 
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 excitement be continued. During 
this state of comparative rest or diminished excitement, the system acquires 
additional excitability, which renders it again susceptible to the influence of 
the stimulating agent; and the temporary reduction is, therefore, followed 
by a renewed elevation 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, in cases of disease, though it may 
occasionally vary in the 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 dispo- 
sition 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 mo- 
dification 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, or exposure of the patient, are disposed to pursue a cer- 
tain course, and in a given time to end in recovery, unless fatal disorganiza- 
tion 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 196 
GENERAL PATHOLOGY. 
[PART I. 
themselves, and sometimes in defiance of all treatment, go on gradually in- 
creasing in intensity till they ultimately destroy the patient. Examples of 
the first class are presented in rheumatic inflammation and neuralgia, of the 
second in smallpox 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 disease; 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 alle- 
viate the sufferings and protract the life of the patient. It is particularly 
important that the practitioner 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 mean time, 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 vain at- 
tempts 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. 
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 attached 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 
removing 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 existing, and superseding or increasing them, as the case may 
be, as when an attack of bleeding piles, occasioned by straining at stool, re- 
lieves an existing attack of splenitis or hepatitis. 
Hippocrates believed that disease, in general, was more disposed to change 
at certains 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 mentioned are very nearly a week; and Hippocrates considered the 
crisis as falling on the last day of each septenary period. He carried the 
doctrine further, and supposed that there were certain intermediate days, in 
which, though the tendency to change was not so strong as in those men- CHAP. III. 
TERMINATION OF DISEASE. 
197 
tioned, 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 disease 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 observation, that miasmatic fevers, when they re- 
turn after being checked, are apt to do so in one, two, or three weeks, or 
some other septenary period, most frequently perhaps at the end of the 
second week. This tendency is, in the present 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. 
Convalescence is sometimes sudden. There is an immediate transition from 
disease to health. This is most apt to happen in nervous affections. But 
much more frequently the change is gradual. Among the first symptoms of 
convalescence from acute disease are generally a commencement of the clean- 
ing of the tongue, and a diminution in the frequency of the pulse. The skin, 
if before dry, is apt to become moist, the other secretions are gradually re- 
stored to their normal condition, and all the functions are in the end re-esta- 
blished. Emaciation, however, is usually more striking in convalescence 
than in the previous illness. This may possibly be in part merely apparent, 
and the result 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 disturbed by unpleasant symptoms, and interrupted by drawbacks, 
consequent upon the irregular action of the debilitated or perverted func- 
tions. Copious night sweats are frequent; the appetite is sometimes feeble, 
and requires stimulation; the bowels are apt to be constipated; the pulse 
often remains frequent; and the patient is troubled with various nervous 
symptoms, such as restlessness, wakefulness, and extraordinary dejection of 
spirits, or fanciful and hypochondriacal notions. These, however, gradually 
disappear, spontaneously, or under appropriate treatment; all the functions 
become active; and the oscillation not unfrequently extends even beyond the 
original standard of health. The appetite becomes voracious, nutrition ab- 
normally active, and the body swells considerably beyond its previous dimen- 
sions. 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 be- 
comes 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 aftei' severe illness, and sometimes does not return, especially in 
advanced life; but generally its place is supplied by a new and equally luxu- 
riant 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 
depend on a specific poison, run a certain course, and are usually taken but once, 
as smallpox, 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- 198 
GENERAL PATHOLOGY. 
[part I. 
masise generally. In relapses, the patient suffers under the disadvantage of 
the debility and unrepaired mischief of the first attack, and, therefore, not 
unfrequently 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 
disease 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 vigour of the vital func- 
tions is permanently impaired, and dropsy, anaemia, or other cachectic condi- 
tion 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 
to say that any one part or function suffers prominently, and becomes the im- 
mediate 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 
it may be more appropriately denominated, apnoea. The brain presides, as 
the centre of the nervous actions, and the great link which binds the functions 
together, over all the vital processes; and none can go on without its continued 
influence. If the brain become powerless, respiration must cease, the circu- 
lation must cease, and life of course along with them. Death may now be said 
to occur by coma. 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. 
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 less 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 CHAP. III.] 
199 
DIAGNOSIS. 
agony, though very improperly; for in most cases it is without a struggle, 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 disease it is with which 
the patient may be affected; in the other, it distinguishes diseases one from 
another 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, 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 search will be fruitless, and we shall be compelled 
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 par- 
ticular attention to all the modifying circumstances; such as the peculiar in- 
fluence 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 neces- 
sary 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 must take into view all controlling influences, as age, sex, tem- 
perament, constitutional peculiarities whether original or acquired, habits of 
life, pursuits of pleasure or business, climate, residence, &c. Accidental cir- 
cumstances 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, &c., 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 exposed. In cases, however, which are 
not doubtful, a too 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 200 
GENERAL PATHOLOGY. 
[PART I. 
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 pathogno- 
monic symptom of smallpox. But such symptoms are unfortunately very rare. 
In the strictest sense of the term, 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 certainty. Thus, 
in the case above alluded to, the red spots would have no force, unless accom- 
panied with the circumstances mentioned. 
Certain rules ought to be observed in conducting a diagnostic examination. 
The physician should guard against a too purely scientific or professional feeling. 
He should not regard his patient as a mere subject for medical analysis; 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 im- 
mediate object, by securing the hearty co-operation of the patient, and the 
favourable effects of confidence in his medical adviser. 
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, information can 
be obtained from the mother or attendants, it is infinitely better to procure it 
thus, at second hand, than to extort it by a sort of violence from the subject. 
In examining young children, great care must be taken to avoid exciting 
theha. Perfectly correct inferences can seldom be drawn from the examination 
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 exami- 
nation, which, in its devious course, must often return upon itself. In general, 
when the organ or function affected is obvious, this should first engage atten- 
tion. Afterwards, or originally in cases of any degree of obscurity, it is CHAP. III.] 
201 
DIAGNOSIS.-EXPLORATORY PROCESSES. 
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 ac- 
count 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, sue- 
cussion, percussion, measurement, and auscultation. 
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 
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, we 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 pro- 
truded, 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. By 
this means, the state of the uterus can often be very advantageously ascer- 
tained ; 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 
hand 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 
sometimes 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 202 
[part I. 
GENERAL PATHOLOGY. 
nail of the finger should always be cut short, in order to avoid wounding 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 flaccidity, elasticity, and fluctuation. 
It occasions crepitation when 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 
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 to 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 contained in the same general 
cavity with gases, a peculiar tone is often given to the drum-like sound. The 
nature of the surface 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 CHAP. III.] 
DIAGNOSIS.-EXPLORATORY PROCESSES. 
203 
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 edu- 
cate his ear in reference to this process, by frequent practice both upon the 
healthy and diseased subject. To Avenbrugger, who published his observa- 
tions 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 percussion, and /usrpor, measure), to the intervening body. 
In immediate percussion, the ends of the four fingers, with the nails pared, 
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 flat 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 cir- 
cular 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 its 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 should 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 im- 
pulse. Some substitute for the fingers a very light hammer, the head of which 
may be made of wood or ivory, with its percussing surface protected by a soft- 
ish, 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. 
(M. Poirson, of Paris, recommends that percussion should be performed by 
means of a common sewing thimble, placed on the middle or fore-finger, so as 204 
GENERAL PATHOLOGY. 
[PART I. 
to include a small portion of air between the end of the finger and that of the 
thimble. The intensity of the sound elicited is said to be thus greatly increased. 
{Land. Med. Gaz., Jan. 1850, p. 163.) 
The surface to be percussed should be naked, or slightly covered. The posi- 
tion of the body must be influenced by circumstances; and it is very often de- 
sirable 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. 
A new mode of percussion has been proposed by M. Martin Solon, consist- 
ing in the application of the palm of the hand to the part to be percussed, and 
striking upon the back of it with the closed fist of the other hand. Pain is 
thus produced in a diseased organ which is not sensible to mere pressure; and 
occasionally, through the contre coup, an organ on the opposite side of the body 
to that upon which the blow is given affords evidence of disease by pain, which 
is not elicited by direct percussion. Thus, painful sensations in the liver 
sometimes follow a blow over the region of the spleen, which an equal force 
applied directly to the hepatic region fails to produce. (Journ. de Med. et 
Ghirurg. Practiques, June, 1849.) 
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 dimin- 
ished, 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 degree interfering with the health. Perhaps 
the most useful application of 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. Another 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 between 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 mea- 
suring the lengths of the lower limbs, reference should always be had to the 
obliquity of the pelvis. 
Auscultation.-This term, in its technical sense, signifies the act of listening 
to the sounds developed in the interior of the body, and made sensible upon 
tbe 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 century, to extend 
the boundaries of medical knowledge, and to give precision to what was before 
vaguely known. chap, in.] 
DIAGNOSIS.-EXPLORATORY PROCESSES. 
205 
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. Laennec 
preferred the use of the stethoscope; but his arguments in its favour have not 
been considered conclusive; and immediate auscultation is now generally pre- 
ferred, 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 movement upon the ear, 
and the operator is spared the trouble of keeping it properly fixed at both ex- 
tremities. 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 preferable. In the cases of fe- 
males, 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 exists beneath the clavicle. 
The stethoscope is a hollow cylinder of soft light wood, or of gutta percha, 
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 extre- 
mity 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 nipple-shaped projection for insertion into the ear. When the instrument 
is 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 termi- 
nation for application to the chest. The advantage of this instrument in car- 
diac 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. Sometimes 
the sounds are so decided that they can be heard through a considerable thick- 
ness 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 206 
GENERAL PATHOLOGY. 
[part I. 
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 con- 
traction, to a sound which is audible 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 sitting, or kneeling by the bed- 
side. 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 auscultation, as well as their indications, will be subjects of detail 
under the particular 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, 
1S40.) 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 different 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 percus- 
sion alone. 
Chemical and Microscopical examinations may sometimes be employed by 
the practitioner with advantage in diagnosis. Chemical tests are indispensa- 
ble 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 appre- 
ciation of the condition of the blood. The microscope is useful, in numerous 
instances, in detecting diseased conditions of the blood and the secretions, and 
in distinguishing 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 knowledge of 
the course which the same disease has ordinarily pursued, together with the 
peculiar circumstances which may modify the case under consideration. In 
most instances, only probable opinionscan be formed of precise results, though 
it very often happens that the main result may be predicted, with great con- 
fidence, in general terms. Thus, certain diseases almost always end in recovery, 
others with a more than equal universality have a fatal termination. But we 
cannot determine, with precision, the period of these changes. Some com- 
plaints 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 correct prognosis. But, 
even in cases of this kind, so many accidents occur to change the accustomed 
* See Laennec on Mediate Auscultation, in the third article of chap, iv., on Pneu- 
mothorax. CHAP. III.] 
PROGNOSIS. 
207 
course, so many inappreciable influences are at work of which the effects can- 
not be calculated, that predictions should almost always be made with caution. 
A pihysician 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. 
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 pro- 
priety of withholding information, which may be essential to higher interests 
even than those of life. Under these circumstances, it appears to me that 
no exclusive course can be pursued with propriety. As a general rule, it is 
probably best that the patient should not be informed of his danger; but, 
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 with- 
held. 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, 
making 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 
unfrequently happens that certain diseases are peculiarly dangerous, under 
certain 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 dis- 
tress, exhaustion from sensual excesses, and debility from previous disease, 
impoverished diet, or impure air, usually augment the gravity of the disease, 
and consequently 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 cir- 
cumstances, and a cheerful temperament, exercise a favourable influence on 
disease, 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. 197.) 208 
GENERAL THERAPEUTICS. 
[part I. 
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 employ- 
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 CHAP. IV.] 
209 
GENERAL INDICATIONS. 
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 modes of action. 
In doubtful cases, when both reason and experience fail us, the best rule is 
to adopt the expectant pl&n; that is, to do little or nothing which can strongly 
impress the system, and await further developements, trusting in the mean time 
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 therapeu- 
tical indications. In many cases, the disease is sustained solely by its con- 
tinuance, and yields immediately when it ceases to operate. Thus, nervous 
headaches often depend upon the habitual use of coffee, dyspepsia upon indi- 
gestible 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 imme- 
diately after the cause has ceased, it is greatly aggravated by its continuance, 
and often cannot be cured until after its removal. Thus, cholera 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 in- 
stances, only by residence in cold or temperate latitudes. Here, attention 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 smallpox, measles, scarlatina, 
&c., or ceases immediately after it has produced its effect, as often in inflam- 
matory diseases resulting from cold. In such instances, attention to the cause 
is important, in a therapeutical point of view, only so far as a knowledge of it 
may lead to a more correct estimate of the nature of the disease. In search- 
ing 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 wuthin 
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 appa- 
rently relieved for a time, quickly relapsing into their previous condition, 
which have yielded, immediately and permanently, to measures calculated to 
restore the healthy condition of the blood. Of these measures, attention 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, anaemia, 
scurvy, and purpura. 
3. In relation to diseases affecting the solids, which include the vast majority 210 
GENERAL THERAPEUTICS. 
[PART I. 
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 
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 
physician. Whenever complaint is 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 employ- 
ment of the remedies denominated anti-periodic or anti-intermittent. These 
remedies will be 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 appropriate 
measures. Thus, the paroxysm of a remittent fever may sometimes be en- 
tirely 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 practitioner 
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. CHAP. IV.] 
211 
GENERAL INDICATIONS. 
A third set of diseases, though not incurable, have a tendency to a fatal 
termination, unless interrupted. These must be checked at all events, mild 
measures being employed if sufficient, but the most energetic if necessary. 
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, 
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 aggrava- 
tion 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 disease 
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 habitu- 
ally 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, there- 
fore, 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 212 
GENERAL THERAPEUTICS. 
[PART I. 
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 may cause 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 care 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, especially 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 patient as 
to any peculiar susceptibilities which lie 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 susceptibility 
of the patient to the mercurial impression. Remedies which usually produce 
no unpleasant effect whatever, act with great violence in some individuals. 
I know a lady, in whom the smallest quantity of a decoction of pipsissewa 
(Chimaphila umbellata) produces excessive irritation of the mucous mem- 
brane 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 account in 
prescribing. In persons accustomed to excessive eating and drinking, it should 
be recollected that vast and fatal depression often follows the abstinence con- 
sequent upon attacks of illness, against which it is necessary that the practi- 
tioner 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 bleeding may be ren- 
dered necessary by an acute and dangerous attack of inflammation. 
Previous disease generally leaves a debility vthich renders the patient less 
able to bear depleting or depressing measures. But there is another point of 
view, in which this influence is to be considered. Peculiar diatheses, such as 
the rheumatic, the gouty, the tuberculous, &c., often have a wonderfully modi- 
fying 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. CHAP. IV.] 
213 
GENERAL INDICATIONS. 
8. Coincident influences often greatly modify the morbid results of parti- 
cular causes. Of these, perhaps, the most important are the miasmatic in- 
fluence, 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 dis- 
eases 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 phlegmasiae, occurring in the autumn and win- 
ter, exhibit generally the remittent aspect of the proper 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 some- 
times the epidemic influence conduces to a sthenic or vigorous state of sys- 
tem, sometimes to an asthenic, feeble, or typhoid condition. In the former 
case, diseases ordinarily of a feeble character assume a degree of energy and 
elevation 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, dur- 
ing the prevalence 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, in the progress of a disease, the patient expresses a wish for some arti- 
cle of food or drink, some medicine, or some change in other respects in his 
management, 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, 
however, 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 result 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 though 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 secre- 
tions, as urinary and biliary calculi. These, however, as they constitute 
special diseases, and offer special indications, do not call for particular Consi- 
deration in this place. 214 
GENERAL THERAPEUTICS. 
[PART I. 
SECTION II. 
GENERAL THERAPEUTIC PROCESSES. 
These may he included under the heads of 1. depletion ; 2. repletion; 3. 
dilution; 4. stimulation; 5. sedation; 6. revulsion; 7. supersession; 8. 
alteration; 9. elimination; 10. chemical action; and 11. 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 
circulatory system. It diminishes also digestion, respiration, nutrition, secre- 
tion, calorification, and the functions of animal life. This last effect is ren- 
dered obvious, when depletion is carried to any considerable extent. Lan- 
guor, impaired sensation, deficient emotional and intellectual energy, muscular 
weakness, 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 ali- 
mentary 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 se- 
cretion, and other derangements of function, so far as these disorders are 
results of irritation, are to be combatted by means of it. In the treatment of 
inflammation 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 pages 66 and 67), the read- 
er 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 CHAP. IV.] 
THERAPEUTIC PROCESSES.-BLEEDING. 
215 
especially those of the heart and nervous system. The functions of the sys- 
tem generally, feeling the want of their wonted support, make this want sen- 
sible 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 impover- 
ished condition of the blood. 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 tak- 
ing 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- 
sary even then. Venesection is almost universally preferred. This is usu- 
ally performed in the arm, at the bend of the elbow; and, where a vein suffi- 
ciently 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 di- 
gestion 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 stimu- 
lating 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 always produce 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. 
The nature also of the tissue inflamed has some influence 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 mem- 
branes, 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 216 
[PART I. 
GENERAL THERAPEUTICS. 
inflammation has taken place, 8 to 10; and in chlorosis 8. But these arc 
mere approximations; 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 quantity 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 particular 
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 approaching syncope 
appear. But, in ordinary cases of vascular irritation or inflammation, this is 
seldom necessary. It is usually sufficient, in these cases, to produce a sensi- 
ble 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 previous parts of this 
work, the repose of all the organs, during the state of fainting, increases their 
excitability; and, when action is restored, it is very apt to 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 time 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, 
hut 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 appear. 
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 de- 
pletion. Leeches are preferable when the part is tender, when the surface is 
irregular or of very loose texture, and when it is desirable to concentrate the 
application within a very small space. They should always be used, prefer- 
ably, 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 tho 
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 indication 
for the loss of blood is offered by the existence of inflammation, the general CHAP. IV.] 
217 
THERAPEUTIC PROCESSES.-DEPLETION. 
strength may be inadequate to support bleeding from the arm. But, most fre- 
quently, 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 capilla- 
ries are, in such cases, rapidly refilled through the vis a tergo, and little impres- 
sion is made on the disease. But, after excitement has been sufficiently 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 purposes 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 
advantage, in cases of internal inflammation, to the outer surface directly over 
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 immediately 
from the inflamed vessels. But the remedy proves scarcely less beneficial in 
the affections of organs which have no such direct connexion, as in mucous 
gastritis and in bronchitis. Its mode of operating, under these circumstances, 
is not so easily explained. Some have ascribed the result to derivation; 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 surface, by which an impres- 
sion 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. 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 increased secretion than by bleeding, and conse- 
quently 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 218 
[PART I. 
GENERAL THERAPEUTICS. 
this principle, are cathartics, diuretics, and diaphoretics. But all that increase 
secretion are occasionally useful, including expectorant^, 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 inflammatory 
affections. In the application of these various remedies, there is much room 
for discrimination; some being better adapted to one condition, others to an- 
other, 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 expectorants. 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, 
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.-This 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 ali- 
mentary 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 de- 
pletion, cannot be better 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 no- 
thing from the alimentary canal, they draw upon the whole system for a sup- 
ply, and the detritus of the tissues, conveyed into the circulation by the 
lymphatics, becomes a substitute for food. The blood is thus recruited by the 
most highly animalized products, and, instead of acquiring antiphlogistic pro- 
perties, passes into the state most calculated to excite inflammation. It is 
always, therefore, safest, where the stomach will receive nutriment, 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 sub- 
stances employed as diet in inflammatory febrile affections; one that they should 
be feebly nutritive, the second that they should not be irritant by their insolu- 
bility 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 re- 
laxation is admissible as the stomach becomes less irritable; but, so long 
as a depletory course is called for, the third condition should be rigidly ad- 
hered 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 CHAP. IV.] 
THERAPEUTIC PROCESSES.-LOW DIET. 
219 
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 blandness, 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, ta- 
pioca, barley-water, rice-water, refined sugar, and uncrystallizable 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 considered, in a dietetic 
point of view, as identical with gum. These substances should be adminis- 
tered in the state of solution, which may be more or less concentrated, accord- 
ing to the degree of nutrition required, but so that they may be conveniently 
used for drink. They may be given separately or combined, 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 em- 
ployed in the form of the expressed juice, or infusion 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 re- 
mains, requiring an antiphlogistic regimen. They are never used in an isolated 
state, but as they exist in nature, associated with the principles constituting 
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, whic 220 
[PART I. 
GENERAL THERAPEUTICS. 
are all supposed to be modifications of one peculiar nitrogenous principle, de- 
nominated 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 cooking 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 identical with the similar prin- 
ciples of plants, the animal albumen with the vegetable, animal fibrin with 
vegetable gluten, and the casein of milk with a peculiar 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 varieties of food containing the 
animal principles alluded to, different effects upon the system from those pro- 
duced 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 certainly 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 vegetable and a full animal diet, and are adapted to cases 
in which some reduction of diet, but the least possible, is required. Milk has 
been mentioned as one of the varieties bf 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. 
Thoroughly 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 op- 
posite of those requiring depletion; viz., general debility, a too scanty blood, 
and a condition of that fluid in which, though its bulk may be sufficient, 
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 sanguification, 
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 of 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 emunctories. CHAP. IV.] 
THERAPEUTIC PROCESSES.-STIMULATION. 
221 
The therapeutical effect is to relieve irritation or inflammation of the surfaces 
with which the diluted fluid may be in contact, as the mucous membrane of 
the stomach, and that of the urinary passages, and to moderate general excite- 
ment 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 develope- 
mcnt, 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, throughout the body, the latter confined 
originally to a particular part or organ. A property common to all stimula- 
tion, 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 propor- 
tion to the previous excitement. There may be conditions of temporary pros- 
tration, in which stimulation may put the system in the power of resuming its 
ordinary grade of action, without subsequent depression; but these do not 
come within the general rule. The depression is consequent upon the tem- 
porary diminution of excitability, resulting from excessive action. If the 
stimulant 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 ex- 
citants, and morbid and often fatal debility results. This is an evil against 
which it is necessary to be ever on our guard, in the use of stimulant measures. 
Another, scarcely less important, is the production of inflammation by the 
excessive or repeated excitation to which the stimulated organ or system is 
exposed. These two cautions are applicable to every kind of stimulation. 
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 belonging to all parts of the frame is exalted, as 
contractility, or nutrition; or when one of the systems which pervade 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. Therapeutically, 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, 222 
GENERAL THERAPEUTICS. 
[part I. 
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 is 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 power to the blood by a direct 
action upon that fluid. Such are the chalybeates. There are other important 
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 who 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, more- 
over, 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 cir- 
culation, and augment animal temperature, without any peculiar or direct 
influence on the brain or nerves, may be called arterial stimulants. They 
are adapted to cases of considerable debility, in which active stimulation is 
indicated; and are peculiarly applicable when, in such cases, there may exist 
any strong tendency to cerebral congestion or inflammation, as in the great 
prostration which sometimes precedes febrile disease, or threatens death in 
concussion of the brain. 
Stimulants which act chiefly upon the nervous system, may diffuse an ap- 
parently 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 to 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. CHAP. IV.] 
THERAPEUTIC PROCESSES.-STIMULATION. 
223 
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 con- 
traindicated. Among medicines of this class, I rank alcohol, ether, opium, 
and camphor. In the use of all these stimulants, it must be remembered that 
the system sometimes puts on the appearance of debility, when in 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. In- 
stead of stimulation, depletion is often strongly indicated. Such are the cases 
in which the circulation fails in consequence of overpowering active congestion 
or inflammation of the brain, heart, or lungs; these organs being incapacitated 
from performing their functions, and the dependent functions ceasing of course. 
The excessive nausea which sometimes attends acute mucous gastritis, may 
have the same apparent effect by prostrating the circulation. 
Heat may often be very advantageously resorted to 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 temperature of which may vary from 98° to 110°, accord- 
ing to the effect to be produced. In the use, however, of this agent, the tend- 
ency 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 sys- 
tem, 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 produced 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 144.) Ammoniacal remedies, applied to the nostrils, act in the same way. 
Sometimes the excitement of strong emotion, when consciousness remains, pro- 
duces a similar effect. Electro-m agnetism is also a most powerful agent, under 
these circumstances. 
Certain general stimulants h ave 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 especially 
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 nu- 
tritious substances are vegetable and animal products containing albumen, 
gluten, or fibrin, and casiein, to which oil may be added. These may no doubt 
prove stimulant, if in e xcess, by enriching and augmenting the blood; but, if 
oil be excepted, 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 stimu- 224 
[part i. 
GENERAL THERAPEUTICS. 
lant impression 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 character. Such probably is osmazome, or animal extractive. Such, more- 
over, may be gelatin, though its claim to be considered stimulating might be 
contested. Every one is familiar with the fact, that roasted or broiled meats 
arc more stimulating than the boiled. This may be partly owing to some 
change which the proximate principles undergo, through the greater heat to 
which the former are exposed; but it is probably ascribable, in chief, to the 
more stimulant character of the principles extracted by boiling. This is strongly 
exemplified 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 bot- 
tle 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 constitutes 
the preparation in question. It is a concentrated solution of the soluble princi- 
ples of the meat, is powerfully stimulant, and, in the quantity of from a tea- 
spoonful 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 
excellent diet for those who labour severely, and appear to require a strong 
impression upon their digestive organs, and a very rich bloqd. 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, broiled, 
or fried pork, beef, and mutton, and, among poultry, goose, duck, and 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 surface 
is concerned, are the rubefacients, epispastics, and escharotics. Occasionally, 
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 stimu- 
lation sometimes answers an excellent purpose in removing the evil. 
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 imperfect 
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 weakened func- 
tions are medicines and other remedies having a special influence over the func- 
tions 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; CHAP. IV.] 
THERAPEUTIC PROCESSES.-SEDATION. 
225 
cathartics; diuretics; expectorants; emmenagogues; and cholagogues 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. 
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 tempera- 
ture along with vascular action. They are indicated in excited states of the 
circulation, and morbidly increased temperature, especially when the condition 
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 nitre and citrate 
of potassa, and the vegetable acids, as the citric and tartaric, have in some 
degree the same effect. Cold internally and externally is also powerfully 
sedative. It is usually employed in connexion with water or ice. But its 
strong tendency to be followed by reaction should nevei' be forgotten in these 
cases. Water alone is also powerfully sedative. It has this effect whether 
taken internally or applied to the surface. In order 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 produce 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 de- 
pressing influence upon the whole nervous system, and, secondly, by so affecting 
the .nervous centres as to render them incapable of duly receiving and trans- 
mitting impressions. Those which act in the first mode are directly and essen- 
tially 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 performance 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 reme- 
dies 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 preparations 
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 
* The 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. 226 
GENERAL THERAPEUTICS. 
[PART I. 
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 inflam- 
mations, when made to cover the external surface corresponding to the part 
affected. As in the case of leeches, some authors ascribe the antiphlogistic 
operation of cataplasms, under these circumstances, to revulsion or derivation. 
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 
sedatives, in inflammation of the skin and subcutaneous cellular tissue. They 
are best employed in solution, and, by reducing the temperature of the solution, 
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 em- 
ployed 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 pro- 
ducing 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 pro- 
duction 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 
excitement, 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 
inflammation, any of the forms of vascular irritation, or mere nervous disorder, 
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 of 
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 
relieve spasmodic affections of the air-passages, in consequence of the relaxa- 
tion they produce, they are probably also useful by a revulsive influence to- 
wards the stomach. Cathartics act very powerfully upon this principle in 
the relief of inflammations and congestions, though they may be employed 
chiefly in reference to their depleting power. There is no 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 reference to this principle of action, are external irritants, such as 
hot water, rubefacients, epispastics, and caustics. Derivation may often be 
advantageously effected by exercise, calling off undue excitement from inter- 
nal organs to the exterior, or from one part of the body to another, and thus 
producing an equilibrium 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 frequently 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 sina- CHAP. IV.] 
THERAPEUTIC PROCESSES.-SUPERSESSION. 
227 
pisms 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 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 peritonitis 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 
retrocedent eruption, 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 com- 
mencing inflammation, before any febrile action has been excited, and in the 
declining stages, when the fever has in some measure yielded to depletion, or 
subsided spontaneously. But, during the existence of high constitutional 
excitement, the revulsive agent is not sufficient to unseat the inflammation, 
and, if of itself very irritant, as in the instances of the more powerful rube- 
facients and of blisters, may add to the existing excitement, by the sympathy 
of the system with the superficial inflammation they produce. But, when the 
revulsive impression is conjoined with copious depletion, as in the case of the 
saline hydragogue 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 a degree of 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 inflammation 
is severe, to sustain a more moderate impression for a longer time. Hence, 
the more active rubefacients, such as mustard and ammonia, are applicable in 
the former case, and epispastics in the latter. 
VII. Supersession.'}"-By this process is meant the displacing or pre- 
vention 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 portion 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 subside spontaneously without injury, we cure our 
patient. The operation of numerous remedial agents is explained in this way. 
* Of course, in the cases here referred to, it is taken for granted that there is no 
inflammation or undue excitement in the alimentary canal itself; as, under such cir- 
cumstances, any counter-irritant or revulsive impression made upon the stomach and 
bowels would be contraindicated. 
f 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. 228 
[part I. 
GENERAL THERAPEUTICS. 
It is thus, for instance, that mercury is supposed to cure syphilis. But we 
have better examples in the powerful influence of certain anti-periodic reme- 
dies, 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 occupied at the moment when the disease was to re- 
turn, is incapable of admitting 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 attendant on 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 ali- 
mentary canal and urinary passages, yield, upon this principle of supersession, 
to certain applications made to them directly, or, in the case of urinary dis- 
eases, through the route of the circulation. 
VIII. Alteration.-This name may be given to that operation of me- 
dicines 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 un- 
known, or at best conjectural. It will be perceived that the employment of 
the term is merely a convenient mode of classifying certain unintelligible re- 
sults, which depend altogether for their acceptance upon the evidence of ob- 
servation. In certain states of disease, we administer certain remedies with- 
out 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 medicines 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. Elimination.-It is now generally if not universally admitted that 
noxious substances sometimes exist in the blood, or in the tissues, or both, 
which cause, sustain, or aggravate disease. To separate these from the sys- 
tem is an important indication; and the process of elimination by which this 
end is effected must rank among the methods of treatment. The agents of CHAP. IV.] 
229 
THERAPEUTIC PROCESSES.-CHEMICAL INFLUENCE. 
this process are either such as, by stimulating the secretions, cause the sepa- 
ration from the blood of the offending matter, or such as exert an influence 
on noxious substances deposited in or incorporated with the tissues, so far 
changing their condition as to enable them to be carried into the blood and 
thrown off by the different emunctories. The former agents have already 
been considered under the head of depletion. They are the cathartics, dia- 
phoretics, diuretics, &c. The latter are included among those which operate 
chemically, and therefore belong to the next division. It is only necessary 
here to call attentio* to this, as a distinct principle of therapeutics.' 
X. Chemical Influence.-Substances may be employed therapeu- 
tically, in reference to their chemical influence, for three 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; and, 
thirdly, for the production of such a change in noxious bodies existing in the 
tissues, and not removable by the ordinary powers of the system, as will enable 
them to be unseated, and discharged, as when iodide of potassium causes the 
elimination of lead and possibly of mercury from the system. It is not im- 
possible that certain substances, taken internally, may produce curative effects 
through chemical reactions with the vital constituents of the blood, or of the 
tissues; but too little is known of the subject to justify any positive state- 
ments. It is well known that nitrate of silver has a powerful influence in 
subduing 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. 
XI. 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 de- 
pendent 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, 230 
GENERAL THERAPEUTICS. 
[PART I. 
however, be carried so far as to produce paralysis of the muscular fibre, and 
thus prevent 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 useful agent in rousing and supporting the system in 
low disease, and in exciting the part itself when enfeebled; but it is more 
frequently and beneficially employed for its effect in producing revulsion from 
within outwardly. 
The covering of surfaces, so as to protect them against irritating sub- 
stances, and the contact of the air, is another useful mechanical process. 
Thus, demulcents protect inflamed mucous surfaces; and collodion, cata- 
plasms, plasters, and cerates are applied for the same purpose to the skin. 
It is not improbable that a part of the effect of nitrate of silver and iodine, 
in subverting superficial inflammations, may be owing to a chemical change 
in the epidermis, rendering it less pervious to the air. 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 may 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 effu- 
sion, in other words, from a mere effect of the proper pathological condition, 
from which the secretion or effusion proceeds. Some may object to the pro- 
priety 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 patho- 
logical 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 diseases, and 
names expressive of them will always hold their place in the common language. 
To 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 suf- 
ficiently 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 proposed 
to adopt. 232 
SPECIAL PATHOLOGY. 
[part II. 
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 phlegmasise, 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 fever; and synochous 
or mixed fever, beginning as synocha and ending as typhous. To these, con- 
gestive fever has been recently added. But these diversities have reference 
merely to difference of form, grade, or 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 differ- 
ent circumstances, either intermittent, remittent, or continued, inflammatory, 
typhous, synochous, or congestive. Again, many distinct fevers have been 
made out of accidental complications; such as gastric, gastro-enteric, hepatic, 
and cerebral fevers, so called in consequence of the predominance of disease 
in the several organs which gave origin to the names. 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 dis- 
tinguished, whereas they may be absolutely the same disease, merely diversi- 
fied by the occurrence of inflammation or irritation in one organ rather than 
in another. But, in very many instances, the diseases named as above have 
been nothing more than cases of phlegmasise, and would have been more CLASS I.] 
233 
GENERAL DISEASES. 
properly entitled gastritis, gastro-enteritis, hepatitis, and encephalitis. 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 inca- 
pable of being converted into one another. 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 indi- 
viduals are produced by one cause, others by another, others again by a third, 
and so on through almost the whole list; and we find, further, that those 
produced by one of these causes cannot be produced by another, each set re- 
quiring its own particular cause. Here, then, is an excellent, and, as it 
appears to me, quite unobjectionable ground of association. The cases pro- 
duced 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 iden- 
tify it in its phenomena, course, circumstances of occurrence, and anatomical 
characters, that we can scarcely deny its claims to individuality, though its 
cause is hidden, or at best obscure. The disease alluded to is that denomi- 
nated variously, continued fever, nervous fever, slow or protracted remittent, 
typhoid fever, typhus mitior, dothinenteritis, &c., and which I propose to de- 
nominate enteric fever. 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. Smallpox, or variola, 
8. Vaccine disease, or vaccina, 
9. Chickenpox, or varicella, 
10. Measles, or rubeola, 
11. Scarlet fever, or scarlatina, 
12. Erysipelas, 
13. Glanders, or equinia, and 
14. Dengue. 
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 in vogue, inflammatory or congestive. 
Of the fevers above mentioned some have circumstances in common which 
might serve to associate them in distinct subdivisions. Thus, some are propa- 
gated by contagion, and are hence called contagious fevers', some have the 
property, in common, that they are attended with an eruptive affection, and 
are denominated eruptive or exanthematous fevers. Now it happens that these 
are 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. 234 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 cause may or may not be 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 phlegmasise, 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 dis- 
position 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 
reaction, as described under the head of fever in general. Sometimes jt begins 
abruptly with the chill, without the usual premonitory symptoms; and some- 
times even the chill is dispensed with, though this event is comparatively rare. 
The degree of febrile reaction 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 numbers 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 lattei- 
is most apt to be the case when the frequency is greatest. The blood, when 
drawn, is usually florid, coagulates rather speedily, and exhibits no appearance of 
the inflammatory crust. This is a point in which the affection differs strikingly 
from the phlegmasim, in which the buffy coat is generally found. There is 
occasionally slight inflammation associated with the fever, most frequently in 
the fauces, or some portion of the alimentary 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 fever, which had every appearance of a long 
continuance, and, upon repeating my visit in the morning, have found them CLASS I.] 
IRRITATIVE FEVER. 
235 
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 sustains 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 car- 
ried off by a diarrhoea. 
The grade of the disease is generally inflammatory; and the fever may 
often be considered as an example of the synocha, or pure inflammatory fever 
of Cullen. But occasionally the general actions of the system, though ex- 
cited, 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 conditions 
requisite for the production of an intermittent fever. The disease, however, 
in this form, does not materially differ, in its symptoms or therapeutic indica- 
tions, from the miasmatic intermittent, to which, therefore, the reader is re- 
ferred. It will be sufficient to state, in this place, that the irritative inter- 
mittent is less apt to be complicated with bilious disorder than the miasmatic, 
and, as might be anticipated from the nature of the cause, is more apt to ter- 
minate spontaneously after a few paroxysms. 
The infantile remittent of authors, so far 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, tuberculous 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 lat- 
ter, and to continue on for several days in the remittent form. In this case, 
it exhibits usually more or less of the following character. 236 
GENERAL DISEASES.-FEVERS. 
[part II. 
Children from two to eight 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. When first visited, the child has a hot 
skin, a frequent pulse, sometimes amounting to 140 or even 160 in a minute, 
a furred and dryish tongue, quickened breathing, thirst, aversion for food, 
sometimes nausea and vomiting, and generally constipation of the bowels. 
There is also obvious disorder of the nervous system. If able to express him- 
self, the child often complains of pain in the head; but otherwise, is restless 
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 the following morning, the child is found 
with a cooler skin, a less frequent pulse, a moister mouth, less nervous disturb- 
ance, and a brighter and more lively expression. As the day advances, the 
fever again rises with similar symptoms as at first; and thus the disease con- 
tinues, with daily remissions and exacerbations, till its close. In some cases, 
however, the remission is much less decided than in others; and occasionally 
it might be difficult to determine at what period in the twenty-four hours the 
febrile symptoms were most violent. Throughout the complaint, the tend- 
ency 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 odour, characteristic of febrile disease in children. 
Delirium is not unfrequcnt; 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 bedclothes, or at whatever other object is near him, even at 
imaginary objects in the air; but this phenomenon is not confined to this form 
of fever, nor to children, though much more common, and a much less dan- 
gerous sign in them than in adults. 
The disease runs on variously from five to ten days, or even two weeks; 
but, in the protracted cases, there is always reason to apprehend the existence 
of positive inflammation, 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 re- 
turn ; and health is gradually re-established. 
It is not always easy to distinguish the true infantile remittent from the 
phlegmasim of the bowels. The occurrence of diarrhoea or uf 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- 
nent diagnostic symptoms of the latter affections. Some authors have at- 
tempted to distinguish between this and the worm fever. I believe that they CLASS I.] 
237 
IRRITATIVE FEVER. 
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 lat- 
ter 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 dose 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 
vomiting, in the earlier stages, and the ordinary circumstances that the stupor 
increases 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. General 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 corpuscles, 
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 
much pain is felt in the head, or other signs of active cerebral congestion 
appear, it will be proper to take from twelve to sixteen ounces of blood from 
an adult; but this remedy is seldom necessary. Generally, an efficient ca- 
thartic, followed by refrigerant diaphoretics, will be sufficient, with a proper 238 
GENERAL DISEASES.-FEVERS. 
[part ii. 
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 fe- 
brile excitement, with or without a little redness of the fauces, he should 
prescribe sulphate of magnesia, or a combination of this with infusion 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 want of colour in the evacuations from 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 and 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 occasionally happens, is associated with the fever, ten grains of the pow- 
der 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 
exclusively 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 disease yield 
immediately to a full dose of calomel, after having been ineffectually treated 
with magnesia, castor oil, salts, &c. For more than 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 unloading 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 administer 
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 cas'es 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 
bowels have been freely opened, should the fever continue, it may be treated CLASS I.] 
IRRITATIVE FEVER. 
239 
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, when there is much starting or twitching of the tendons. 
The warm bath is useful under similar circumstances. This treatment is 
especially applicable to 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 recommended, poultices made 
with bruised garlic and flaxseed meal or 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 means necessary in all cases. The practitioner must be 
influenced by the degree of arterial action, and the evidences of sanguineous 
determination 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, espe- 
cially 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. Mag- 
nesia, 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, not 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 calomel, though in smaller doses than at first. It would be especially 
indicated by whiteness or blackness of the stools. Under the same circum- 
stances, if the alimentary canal should be delicate, blue mass may be substi- 
tuted for the calomel. 
When the breath is sour, small doses of bicarbonate 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, teaspoonful doses of lime-water and milk, 
mixed in equal quantities, and given every hour, are often very serviceable. 
In the same cases, aromatic poultices, or weak sinapisms should be applied 
over the stomach; and it may become necessary to give 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. In the early stages, very little food is re- 
quired, 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, hav- 
ing 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, when something rather more nutritious is required; and ren- 
net whey is a good article of diet under similar circumstances. Milk and 
water, together with farinaceous substances, may be employed in small quan- 240 
[part II. 
GENERAL DISEASES.-FEVERS. 
tities 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 nothing that can irritate the stomach or bowels. Cold water 
should be given frequently throughout the fever, and nothing is more grate- 
ful 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 IL 
MIASMATIC FEVER. 
Under this name are included all the forms of fever resulting from the influ- 
ence 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 effects 
are experienced, and the manner in which it operates, the reader is referred to 
the dissertation on the causes of disease in general. (See page 153.) 
Of the different cases of fever which originate in this cause, some are inter- 
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 frequently 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 coexisting morbid influence. They are in fact as much one disease 
as are the different varieties of smallpox, 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 
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 CLASS I.] 
MIASMATIC FEVER. 
241 
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 
tendency may be supposed to have lurked in the system, derived from ex- 
posure 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 
sufficiently protracted, to cause the evolution of miasmata in a dilute, and com- 
paratively inefficient form. 
INTERMITTENT FEVER. 
Syn.-Fever and Ague. 
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 men- 
tioned by authors; such as the quintan, sextan, septan, and oct an, the last 
occurring at intervals of a week; but they are all very rare; and there are 
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 are going on at 
the same time, but at different periods of the twenty-four hours. Sometimes 
there are two paroxysms in one day, and none in the next. This variety is dis- 
tinguished by the name of duplicated or doubled tertian. The triple tertian 
_ -in 242 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 respec- 
tively 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 refinements, of no practical value, and exceed- 
ingly 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 distin- 
guished by the title of erratic intermittents. 
Symptoms.-Each paroxysm of an intermittent, when quite regular and 
fully formed, consists of three stages; viz., the cold, the hot, and the sweating 
stage, which usually succeed each other in the order mentioned. Very often, 
the paroxysm is preceded by the ordinary preliminary symptoms of fever, 
such as feelings of languor or weariness, general uneasiness, stretching, yawn- 
ing, &c. (see page 87); 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 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 paroxysm seizes 
the patient in the midst of apparently good health, and without warning. 
Cold Stage.-After some yawning, stretching, &c., the patient experiences 
sensations of chilliness, especially in the limbs. These increase, and gradually 
spread over the whole body, becoming often severe and distressing. Not un- 
frequently, the chilliness seems to run in longitudinal lines, as if little stream- 
lets 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 experi- 
ences 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 sebaceous 
and capillary follicles, while the proper tissue of the skin shrinks. From the 
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, orz 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 CLASS I.] 
243 
INTERMITTENT FEVER. 
bilious matter, are experienced. The breathing is irregular, and often hur- 
ried ; and the patient has a feeling of oppression or weight in the epigastrium 
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 gene- 
rally scanty; but the urine is usually 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 in- 
stances 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 rather 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 complains 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 uncom- 
mon 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 
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 pa- 
tient frequently falls into a calm sleep, from which he awakes free from fever. 244 
[part II. 
GENERAL DISEASES.--FEVERS. 
The kidneys now resume their function, and the urine which is discharged, 
very often deposits a lateritious sediment upon cooling. 
It has been 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 sometimes oc- 
curring without any preceding chill whatever. The probability is, that, 
while the depression of 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, in 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, and in the 
quartan at five or six. But the 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, or a copious flow of urine. The idea has 
been advanced, and it 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 
considered as masked cases of the disease (febris intermittens larvatai). 
Among these may be enumerated neuralgia, rheumatism, epilepsy, hysteria, 
hiccough, petechial eruptions, diarrhoea, and dysentery, all of which occasion- 
ally appear in the intermittent form, occurring daily or every other day at 
the same hour, with intervals of apparent 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 CLASS I.] 
INTERMITTENT FEVER. 
245 
fever. If they could be shown to be uniformly the result of miasmatic influ- 
ence, 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 possibility have been the cause. 
Intermission, or Apyrexia.-After the paroxysm has subsided, the patient, 
though without fever, is not usually quite free from signs of disease. General 
languor, facility of fatigue, pains in the back and loins, uneasy sensations in 
the head and epigastrium, with some fur upon the tongue, and a feeble appe- 
tite, 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 pa- 
roxysms. Sometimes they are very slight, sometimes so considerable as, in 
connexion with some heat of skin and frequency of pulse, to render the inter- 
mission imperfect. They generally diminish with the continuance of the 
disease; and at length the patient becomes apparently quite well in the in- 
tervals of his attacks; having, not unfrequently, the appetite, the digestion, 
and the general vigour, though not perhaps fully the aspect of health. To the 
above rule, however, there are exceptions. Cases occur in which the patient, 
even at the commencement, is as free from all signs of disease during the in- 
termission, as in his most perfect 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 an- 
ticipating 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 even- 
ing ; and it is worthy of observation that, in the anticipating and retarding 
cases, when the receding or advancing paroxysm reaches the period of dark- 
ness, 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 afterwards 
successively at the hours of ten, eight, and six, will, after attaining 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.') 
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 appear. Thus, 246 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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 observa- 
tion is, that the longer the duration of the disease, 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 conversion 
sometimes takes place abruptly. The most common is from a type with fre- 
quent paroxysms, to another in which they are less frequent. Hence, a quoti- 
dian 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 
Salpdtribre of Paris, in the autumn of the sixth year of the Republic, termi- 
nated 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 Fordyce, quotidians 
usually end spontaneously in about ten weeks, tertians in about four months, 
and quartans in six, seven, or eight months. But occasionally, these dis- 
eases 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 
intermittent is very frequently succeeded by another, at the opening of the 
warm weather, in the subsequent spring. The liability to the recurrence of 
the disease 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 
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 to be inflammatory; for the 
condition may exist altogether independently of inflammation. In the second 
form, it may be called simply feeble, 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 depravation of the circulating 
fluid; and malignant, pernicious, or congestive, when the powers of the sys- 
tem are so much prostrated as to endanger a very speedy and fatal issue. CLASS I.] 
INTERMITTENT FEVER. 
247 
These differences 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 charac- 
ters of this grade have been sufficiently detailed in the general description of 
fever. The merely feeble cases are known by a general deficiency of energy 
in the reaction, 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 compara- 
tively small and feeble pulse, the more than ordinary dryness of the mouth, 
the brown colour of the tongue, the tendency 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 
sustenance, fresh air, 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 over- 
looked or disregarded. The distinguishing general character of these com- 
plicated cases is the appearance of the buffy coat of the blood upon coagula- 
tion. 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 peculiar 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 
part of its surface, and diarrhoea, or dysenteric symptoms. The liver may 
be considered as the seat of inflammation, when there are pain and tender- 
ness in the right hypochondrium, difficulty of lying on the left side, pain in 
the right shoulder, nausea and vomiting, discoloured evacuations from the 
bowels, yellowness of the skin, conjunctivae, 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, accord- 
ing as the bronchial membrane, the parenchyma of the lungs, or the pleura, 
is affected. In the first case, the ordinary catarrhal symptoms are presented; 248 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 complication is most frequent in winter and spring. Inflamma- 
tion of the encephalon may be suspected, when the pain in the head is severe, 
the patient is painfully sensitive to light or sound, the pupil is contracted, 
and delirium or convulsions are conjoined with the other symptoms. All 
these inflammatory complications are most 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- 
mation is not of a grade or extent to sustain a symptomatic fever, the inter- 
mission 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 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 inter mitten ts, and cerebral intermit- 
tents; but there is no foundation for such distinctions. It is true that the 
stomach and brain are severally much more irritated in some cases than in 
others; but the same may be said of any one of the organs; and thus we 
should have subdivisions of the disease as numerous as the functions. The 
cases, denominated as above, generally owe whatever peculiarity they may 
evince to complications of the intermittent fever with gastro-hepatic inflam- 
mation, in the one case, and with some form of encephalitis 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 ex- 
posure 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 
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 viscera, and 
especially in the spleen, which is probably intended as a diverticulum, to pre- 
vent injury from such irregularities of the circulation to more important or- 
gans. 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 extending 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 com- 
monly called ague cake, and is a well-known affection in miasmatic districts. CLASS I.] 
INTERMITTENT FEVER. 
249 
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, sometimes 
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 substi- 
tution of a serous discharge for the perspiration to which the system was 
accustomed, and to which the process of sanguification had become accommo- 
dated; and a return of the paroxysms is sometimes followed by a disappear- 
ance of the dropsy. (^Nordamerik. Moratsbericht, &c., i. 27.) I have often 
found the urine to be albuminous, and sometimes highly so. Yet the dropsy 
is generally curable. Hence it may be doubted whether the kidneys are, as 
has been supposed, organically diseased. Sometimes the urine is albuminous 
in intermittent fever, without any dropsical symptoms. (Archives G6n£rales, 
4e ser., xv 509.) The probability is, that the watery condition of the blood 
so often an attendant or result of intermittents, is the main source of the effu- 
sion in these cases. Another source of dropsy in intermittents, is organic 
disease of the liver and spleen. The veins of the abdominal 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 inter- 
mittents, it is much less hopeless than when springing from independent 
disease of the viscera; 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 in- 
jurious 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 
diseases, and removing morbid tendencies which had before resisted treatment. 
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 exclu- 
sively, 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 in- 
termittent fever, and the tendency to pulmonary consumption has been 250 
[part II. 
GENERAL DISEASES.-FEVERS. 
thought, though probably on insufficient grounds, to be materially counteracted 
by it.* 
Anatomical Characters.-The proper anatomical character of intermit- 
tent fever has scarcely been ascertained. The lesions which have generally 
proved fatal, and which are those observed upon dissection, are not essentially 
parts of the fever, being sometimes purely incidental, and sometimes effects» 
which might have been absent without affecting the integrity of the disease. 
Inflammation of the brain and of its membranes, cerebral congestion and effu- 
sion, gastritis, gastro-enteritis, pulmonary inflammation and congestion, and 
various diseases 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. Enlargement 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 en- 
larged, and altered in texture, sometimes broken down and softened, so as even 
to resemble coagulated blood enveloped in a membranous covering. Occasion- 
ally it has been ruptured, and dark or grumous blood has been met with in the 
cavity of the peritoneum. Suppuration of the viscus has also been noticed. 
Causes.-Of the intermittent fever here treated of, miasmata are th^ssen- 
tial cause. Some have supposed that all cases of intermittent fever hWe 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 mias- 
mata. 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 probably rare; and the presumption, 
when we meet with a case of ague and fever, is that it is miasmatic. 
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 essential, 
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 
* 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 
disease, 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 to the second edition. CLASS I.] 
INTERMITTENT FEVER. 
251 
itself. Under these circumstances, any exciting cause may call the fever into 
action; and sometimes an attack iA produced, which might otherwise have 
been avoided. Exposure to the heat of the sun, a cold bath, excessive exer- 
tion, mental excitement, even a dose of purgdlive medicine, may thus give 
rise to a paroxysm. The contrast between the cold of the mornings and 
evenings and the heat of the middle of the day, favours the developement of 
the disease in the latter part of summer, and the beginning of autumn. Per- 
sons 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 al- 
most 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, where it is scarcely known. In Europe its northern limit is stated to 
be the 60th or 61st degree of north latitude. (Arch. Gen., Mai, 1853, p. 516.) 
It occurs occasionally in the vicinity of Stockholm. 
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 are 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 prolonged 
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-pf 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. 
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 
apoplexy may be induced in the paroxysm, either from the venous congestion 
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 these cases, however, the prognosis is more favourable than 252 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 also nasi. Relapses usually yield 
more readily than the original disease; and the vernal eases than the autumnal. 
Of the different types, as a general 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 
existed in the system which the paroxysms tended to eliminate; that the 
dise'ase acted favourably in preventing or removing other diseases, when per- 
mitted 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 longer the disease has continued, the more 
liable does the system become to it, and the more difficult is it to be eradicated. 
Besides, so long as it lasts, there is constant danger of those secondary dis- 
eases, 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 tie 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 
drinks 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 sand 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. Should the stomach be irritable, the anodyne may be given by the 
rectum. In this case, fifty or sixty drops of laudanum should be adminis- 
tered 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 
stimulate 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, CLASS I.] 
INTERMITTENT FEVER. 
253 
when reaction shall have taken place. Nevertheless, it may become neces- 
sary 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 accompanied with heat. Cayenne pepper heated in brandy, and 
hot oil of turpentine, 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 comatose cases, reliance must be placed chiefly upon revulsion by ex- 
ternal stimulants; but, should the symptoms be apoplectic; should there be 
stertor, for example, with a suffused face, and a slow laboured pulse, it 'may 
become 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 cases, 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 
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 practi- 
tioners 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 expe- 254 
GENERAL DISEASES.-FEVERS. 
[part II. 
rienced 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 would 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 
sudden 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 the 
materials for the preparation of the effervescing draught not be at command, 
twenty grains of the citrate of potassa, dissolved in water or carbonic acid 
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 CLASS I.] 
INTERMITTENT FEVER. 
255 
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 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 determination 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 cold carbonic acid water. Should these fail, recourse can be had to the 
measures recommended for the same symptom in the cold 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 combined 
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. 
When the apyrexia is very short, so as not to allow time for the action of a 
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, the 
most valuable is sulphate of quinia. Formerly, the bark in substance was 
much used; but, in consequence of its bulk, and of the nauseating property 256 
[PART II. 
GENERAL DISEASES.-FEVERS. 
of some of its ingredients, it was found impossible, in many instances, to ad- 
minister 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 antiperiodic property in a very high de- 
greerif not completely; and maybe 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 introduced into use; and, 
except in two instances, have never failed in arresting the paroxysm in regu- 
lar 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 evacuating the bowels, and getting down 
a sufficient quantity of the medicine. If it fail with the first, it will gene- 
rally 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 parox- 
ysms return after its use, they are generally milder, and often postponed. All 
that we can say of its 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 principle, 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 a complicated intermittent, 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 
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 ordinary 
manner. There is a simple rule which, I think, will serve the practitioner as 
a sufficient guide in relation to this disputed point. Whenever the intermis- 
sion 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 ex- CLASS I.] 
INTERMITTENT FEVER. 
257 
isting 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 originate 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 wifh typhoid symptoms, or a 
low state of system, as not unfrequently happens in the southern and western 
portions of this country, especially in the winter, when typhoid pneumonia 
supervenes upon, or becomes 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 physi- 
cians, 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 in certain malignant cases, but seldom or never in the dis- 
ease as it ordinarily occurs. I do not remember ever to have found more 
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 cases 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. 258 
GENERAL DISEASES.-FEVERS. 
[part II. 
Upon the whole, I prefer the plan of administering the medicine in small 
doses frequently repeated, and of distributing it equally 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 are 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 paqpx- 
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 prevent 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 give^ 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 som^ 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 tertian 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 of 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. It should, however, 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- 
haps rely with more certainty on the solution than the pill. The solution is 
made by acidulating the water employed. For this purpose, the aromatic 
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.* 
* R.-Quinise sulphat. gr. xvi; Acid, sulphuric, aromat. f^ss; Aquas fluvial., vd 
Aq. menth. pip., vd Aq. camphorae, f 2ij. A teaspoonful every hour or two. Liquorice 
may be added in the proportion of Qij, in order to cover the taste, when the medicine 
is intended for children. CLASS I.] 
INTERMITTENT EEVER. 
259 
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 cases 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 hours. 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 pre- 
viously denuded of the cuticle by means of a blister. It is said to have acted 
efficiently 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 power, 
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, Article Piper.) 
Various cheaper preparations of bark have sometimes been substituted for 
sulphate of quinia. Sulphate of cinchonia is probably equally effectual in 
somewhat larger doses, and has recently been much employed with the best 
effects. It may be given in doses about one-quarter or one-third larger 
than those of the salts of quinia. The same remarks are applicable also to 
the sulphate of quinidia. An impure preparation, consisting of the sulphates 
of quinia and cinchonia, regular or amorphous, with some colouring matter, 
and often a portion of sulphate of quinidia, being the residue procured by 
evaporating the mother liquor left in the preparation of the officinal sulphate, 
has frequently been sold under the name of extract of bark, impure sulphate 
of quinia, &c. In double the dose, it has the same effect as the sulphate; 
but no reliance can be placed upon its purity. The alkaline matter, obtained 
by precipitating the mother-water above referred to by means of an alkaline 
carbonate, has also been much used under the names of quinoidine, amorphous 
quinia, and precipitated extract of bark. When pure, it is equally effectual 
with unaltered quinia, but is liable to the objection that, from its uncrystal- 
lizable character, it is more exposed to adulteration. (See U. 8. Dispensatory, 
10th ed., p. 1171.) 
If quinia should happen to fail in interrupting the paroxysms, recourse 
may be had to Peruvian bark in substance. The officinal yellow (Calisaya), 
or the best red bark should be preferred. From one to two ounces should 260 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 wineglassfuls of 
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 may be added 
to the mixture, for every dose that it contains. Sometimes opium is a very 
useful addition; and, in debilitated cases, port wine may constitute a portion 
or the whole of the vehicle. (See U. 8. Dispensatory.^ The preparations 
of iron are often very advantageously associated with sulphate of quinia, 
especially in obstinate cases of the disease, connected with an anemic state of 
the circulation, and much disposed to relapse. I prefer for this purpose the 
pill of carbonate of iron of the U. S. Pharmacopoeia. 
An 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 be added to this preparation, or to the sulphate of quinia, 
in cases of great debility, or in those of drunkards; from fjj to f§ss being 
given with each dose. The use of bark in the form of jackets, cataplasms, 
and baths, has been entirely superseded by sulphate of quinia. 
Various obvious inducements have led to an industrious search, at different 
times, for substitutes for Peruvian bark, or its active principles, in the treat- 
ment of this disease. Many of these have been introduced to the notice of 
the profession, with the highest commendation; 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 super- 
sede 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 inter- 
mittents, it must be recollected that this disease not unfrequently ceases 
spontaneously, and that it may very often be interrupted by anything calcu- 
lated 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 patient believe that the time for his chill has 
passed, is said to have sometimes had the effect of preventing its occurrence. 
Certain individuals are supposed by the vulgar to possess a supernatural in- 
fluence over the ague, which disappears at their command. I have known of 
two individuals 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 legiti- 
mately 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 antiperiodic 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 effi- 
cacy is probably arsenic. In the form of solution of arsenite of potassa or 
Fowler'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 CLASS I.] 
261 
INTERMITTENT FEVER. 
present, we may sometimes perhaps advantageously recur to it in infantile 
cases, when the solution of sulphate 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. Some think that the disease is less apt to return, after 
being arrested by arsenic, than after the use of the preparations of bark. The 
doSe of Fowler's solution is ten drops three times a day. It may be continued 
until the disease is arrested, or until some oedema of the face, oppression of 
stomach, general tremours, or feelings of muscular weakness, evince the action 
of the medicine. It must then be suspended, lest the poisonous effects of the 
arsenic should be produced. I have known a case of universal anasarca appa- 
rently arise from its use in a child. It 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 antipe- 
riodic 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 blue, has been much 
praised. It was introduced into practice by Dr. Zollickoffer, of Maryland, 
who considered it even superior to Peruvian bark. Dr. Samuel Jackson, for- 
merly 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 parox- 
ysm 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 a day; Dr. Jackson one or two drachms during the in- 
terval. (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 aban- 
doned it. The persesquinitrate of iron has been used successfully by Mr. William 
Kerr, in West Canada. (Month. Journ. - of Med. Sci., Oct. 1851, p. 336.) 
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 favourable opinion of it; and Dr. Dickson, of Charleston, con- 
siders it a most valuable remedy in various intermittent diseases, and especially 
applicable to intermittent 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. Sci., N. S., xiv. 223.) Sal ammoniac has long been 
occasionally used; and Dr. Aran found it successful, in the whole of thirteen 
cases in which he tried it, in the quantity of two drachms taken in two doses, 
with the interval of half an hour, in the apyrexia. (Archives Gen., 4e s£r., 
xxvii. 351.) Dr. Montdezert, of France, has recently called attention to com- 
mon salt as a powerful antiperiodic ; and its efficacy has been attested by M. 
Piorry, and by Drs. Lattimore and Hutchison in this country. By the last men- 
tioned practitioner it is considered inferior only to quinia. Among its asserted 
* R.-Cupri sulphat. gr. j ; Opii pulv. gr. j ; Quinise sulphat. gr. viij ; Acacias pulv., 
Syrup, aa q. s. Misce et fiant pil. no. iv. S. One four times a day. 262 
GENERAL DISEASES.-FEVERS. 
[PART II. 
effects, besides a solution of the paroxysm, is a remarkable diminution in the 
bulk of the spleen. The dose is about a drachm, given at intervals so as to 
amount to half an ounce or an ounce in the apyrexia, dissolved in coffee, in- 
fusion of slippery elm, or other convenient vehicle. (See Archives Gen., 4e 
ser., xxviii. 343; Am. Journ. of Aled. Sci., N. S., xxiv. 101; N. Y. Journ. 
of Aled., N. S., xii. 159.) 
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 dif- 
ferent species of willow, of the horsechestnut, of the oaks, of the mahogany 
and its congener Swietenia febrifuga ; all the simple bitters, as quassia, gen- 
tian, &c ; wormwood, chamomile, and eupatorium or boneset; the leaves of 
the olive tree; kino with nutmeg; pepper or piper in, sage, coffee, and a host 
of others of the same classes, have been enumerated among antiperiodic reme- 
dies. 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 overpraised. Nux vomicaYvA formerly some reputation as a 
febrifuge, and the use of it has been revived in the form of strychnia. Sul- 
phate 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 brought into notice by Dr. O'Shaughnessy, of Calcutta; 
and numerous cases have been adduced in proof of its efficacy. He gave it 
in the dose of three grains three times a day, in connexion 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. Spider's 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 considerable reputation. Chloroform has 
recently been proposed as a remedy. All the above substances have been em- 
ployed in reference 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 preoccupy the ground, and thus preclude 
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 boneset {Eu- 
patorium perfoliatum), taken warm in the quantity of a small bowlfull, 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 treatment is 
admirably adapted to cases in which there is a slight fever throughout the in- 
terval. I have repeatedly employed emetics, under these circumstances, 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 CLASS I.] 
263 
INTERMITTENT FEVER. 
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 appli- 
cable rather to remittents than to intermittents. Powerful rubefacients, such 
as mustard, ammonia, or oil of turpentine applied to the spine, may be occa- 
sionally 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. 
Nitromuriatic acid is an excellent remedy under these circumstances; but 
it should not be used in connexion with the mercurial. In anemic cases the 
chalybeates should be given. 
It has been stated that relapses are frequent in this disease. They are 
indeed among the circumstances which give the practitioner most trouble. I 
have found, however, by ascertaining the period at which the disease is dis- 
posed to return, which is generally remarkably regular in each case, 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 expected 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 eradi- 
cated; as exciting causes may afterwards induce a recurrence of the disease. 
This, when it takes place, should immediately 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 sulphate of quinia 
daily for two or three months. I have found also the infusion of wild cherry 
bark, in the dose of a wineglassful foui* 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 tincture or infusion, and given twice 
or three times a day. The preparations of iron and of manganese may be 
usefully employed,where the tendency to relapse is connected with anaemia. 
In some instances, however, this tendency is so adhesive as to resist everything 
in the shape of medicine that can be employed. It may be corrected for a 
time, but is apt to show itself when the patient is 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 com- 264 
[PART II. 
GENERAL DISEASES.-FEVERS. 
pletely 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, during the continuance of the disease, should be light, digestible, 
nutritious, and unstimulating. For the first day or two, the patient 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 sub- 
stances and easily digested vegetables. Stimulating drinks should not be used. 
He should 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 intermission is complete, it is 
not necessary that the patient should confine himself to the house; though he 
should avoid fatigue. In some old cases, violent exercise on horseback between 
the paroxysms has proved 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 necessarily 
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 excess should 
be. scrupulously shunned. Individuals should be careful not to expose them- 
selves to cold when heated, and never to remain long in wet clothes. Great 
alternations of temperature are very apt to induce the disease. The use of a 
fine gauze veil, or something equivalent to it, has been recommended, under 
the impression that it might exclude the miasmata. A much more effectual 
measure is to keep the system steadily under the moderate influence of quinia 
or Peruvian bark. This plan was recommended by Dr. Lind, in his treatise 
on the Preservation of the Health of Seamen (2d ed. p. 58), and has been since 
frequently put in practice with great success. 
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 Mazanderan, 
a low, wooded, very moist, and very sickly district upon the borders of the 
Caspian, the inhabitants are in the habit of eating garlic freely, asserting that 
it protects them against the complaints of the climate. 
REMITTENT FEVER. 
Syn.-Bilious Fever.-Bilious Remittent Fever. 
Besides the disease last treated of, two distinct fevers are endemic in the 
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, 
dothinenteritis, &c., which occurs most frequently during cold weather. So 
peculiarly 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 CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
265 
characters. This is the more necessary, 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 Lakesand 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 com- 
mon 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 there 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 prevalent are the 
valleys of streams, the borders of lakes or ponds, the neighbourhood 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 por- 
tions 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 Miasmata, p. 153.) 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 Mediterra- 
nean, and South America, we have heard so much ; which has depopulated the 
Campagna of Rome, and rendered intertropical Africa uninhabitable by whites. 
It was probably this fever that was best known to the Greek and Roman phy- 
sicians, and upon which the descriptions of ancient medical writers were chiefly 
founded. It must not be confounded with the yellow fever, which is quite a 
distinct affection. 
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 decided remission. It is often bilious; 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 therefore im- 
properly 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 con- 
sidered 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 intermit- 
tents there is often some degree of morbid action between the paroxysms, and 
in remittents often very little; and it is not always possible to determine, 266 
[part II. 
GENERAL DISEASES.-FEVERS. 
whether the morbid action that exists does or does not amount to fever. If it 
be pronounced not to be fever, the disease must be considered intermittent; 
if fever, remittent. In the latter affection there 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 sweating 
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 the commencement, 
there may be two or more regular paroxysms as in the intermittent; afterwards 
the paroxysms may recur regularly without the chill or the perspiration; 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 frequent 
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 tertian, 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 oc- 
currence. Thus, the paroxysm may occur one day in the morning, 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 con- 
sidered of the double tertian type, when, having an exacerbation every day, it 
is yet much worse on alternate days. Sometimes two exacerbations 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 irregularly, and when least 
expected. 
Some difference exists among writers as to the time of day at which the pa- 
roxysms 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; sometimes 
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 com- 
mencement 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 
fhn nrnmnf.oct. onf t.n nrAfiArvA lifp an fl nrrninsf. whiph nil tnft rPSOnTPP.S CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
267 
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 previous disease, intemperance, or other de- 
bilitating cause. In these two conditions, the resulting febrile action partakes 
of the character of the vital functions; 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 in- 
flammatory, 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 incompatible 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 elevated above, nor prostrated below, the medium 
standard of health. The 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 general 
discomfort, weariness, or languor, a sense of weight, fulness, or indescribable 
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 parox- 
ysms. During this preliminary period, the patient is going about, and en- 
gaged, though languidly, in his ordinary avocations. In many cases, no such 
premonitory symptoms are observable, and the patient is attacked 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 duration 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 sensa- 
tion, 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 gene- 
rally somewhat reddened and expanded, the respiration hurried, and the pulse 
increased in frequency and fulness, and often also in force. At this stage of 268 
GENERAL DISEASES.-FEVERS. 
[part II. 
the complaint, however, the pulse is in ordinary cases not very frequent; 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 appe- 
tite, amounting even to a feeling of loathing for food; sometimes with, some- 
times 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, ten- 
sive, 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 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, usu- 
ally from six to eighteen hours, after which they begin to relax, with the ap- 
pearance 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 become 
almost natural; the skin is cool and soft; the tongue often shows a disposi- 
tion to clean ; and food is sometimes received, if not with relish, at least with- 
out 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 
not 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. An- 
other paroxysm of fever then takes place, sometimes, like the first, beginning 
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 in- 
stances 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 morning than in 
the evening. In this stage, the following symptoms are presented; and it 
may not be improper to repeat, that, in some cases, the disease starts into ex- 
istence in this comparatively continuous form, and presents the symptoms 
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 inflamma- 
tion 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 be- 
comes 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 occasionally disposed to be dry in the parox- 
ysm, 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 con- CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
269 
sequence 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 .uncom- 
fortable 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 exces- 
sive, 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 irri- 
table, sometimes an excessively irritable state of the stomach. Nausea and 
vomiting are very frequent attendants upon bilious fever. Though occasion- 
ally 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 yellow- 
ish, 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 either medicine or 
drink. The nausea is often so great as to produce some temporary weakness 
of pulse, and damp relaxation of the skin; and, when it is severe, the head- 
ache 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 con- 
centrated in the brain, the stomach apparently escapes. The bowels are usu- 
ally constipated, especially in the early stages; and it is said that purgatives 
sometimes act with great difficulty. This, however, does not correspond 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-colored and offensive, some- 
times 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 symp- 
toms sometimes make their appearance. In some instances, looseness of the 
bowels exists 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 discharged. 
The urine is scanty, and 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 
thrown off 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 270 
GENERAL DISEASES.-FEVERS. 
[part II. 
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. Very 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 deter- 
mination to the brain, if not positive meningitis. The throbbing headache 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 mode- 
rate, or cease. Delirium, though not very frequent at the commencement as 
the disease ordinarily appears, is now apt to set in; generally, however, 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. Some- 
times there is drowsiness or stupor, sometimes apoplectic or paralytic symp- 
toms, 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 unfrequent disorder 
of the nervous system is obstinate wakefulness, with restlessness and jactita- 
tion ; 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 case; 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 
termination 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 cooler 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 
convalescence which is apt to be permanent. When the disease goes off with CLASS I.] 
271 
REMITTENT, OR BILIOUS FEVER. 
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 sometimes 
occur towards the close of severe bilious fever, and are considered as a favour- 
able 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 fre- 
quently ensues in bad, and badly managed cases of the disease. Instead of 
the favourable 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 appearance; the extremities are covered with a clammy sweat; 
the tongue is dark-brown, clammy or dry, and sometimes chapped; hiccough 
not unfrequently occurs, sometimes with eructation of dark matter from the 
stomach; the abdomen is often tympanitic; black liquid matters, or dark 
blood, or a reddish serum like the washings of flesh, are discharged, often 
involuntarily, from the bowels; the urine is dark-brown, fetid, and scanty, or 
quite suppressed; 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 
fourteenth 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 
discharges, 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 272 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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 
papillary structure. Under these circumstances, convalescence may be ex- 
pected, though it is always rather slow. In other cases, the tongue cleans in 
the ordinary manner, and then we 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.-The above description applies to bilious fever in its ordi- 
nary 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 
of them there are evident, in some of the cases, certain signs, either full blown, 
or as it were in the bud, which mark the disease as miasmatic or bilious fever; 
more especially gastric irritation, yellowness of the skin, and a tendency 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 enor- 
mous vomiting of bilious matter, by which the head is somewhat relieved, 
unquenchable thirst, and quickly supervening yellowness of the skin and 
eyes; the pulse being either frequent or slow, and the skin hot or cool, with- 
out materially 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. Sea- 
men on board ship endeavour to jump overboard, though this may possibly 
be less from a disposition to self-destruction, than from an instinctive ten- 
dency to seek relief in the water. Sometimes the delirium is followed and 
relieved by the occurrence of the gastric symptoms already mentioned. After 
an uncertain 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 
apoplectic 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 the CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
273 
brain. Sometimes a collapse takes place, with symptoms such as those 
already 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 
follow that it necessarily must return in this manner; but it is always safest 
thus to regard it. 
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, tvith- 
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 pressure. 
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 considerably 
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 fre- 
quently the membranes are affected; and then we have severe headache, 
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 ty- 
phoid 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 commencem9nt. 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 274 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 alvine 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 petechiae 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 ab- 
sence, 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 stomach is especially in- 
volved, 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. 
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 in- 
stances are comparatively rare. Under appropriate treatment, it is often 
much shortened. 
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 pheno- 
mena of the disease. 
The mucous membrane of the bowels is also often inflamed. I)r. Steward- 
son observed that the mucous glands of Brunner, in the duodenum, were de- 
veloped in an extraordinary degree; but this is not a uniform lesion. Ulcera- 
tion 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 CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
275 
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 forma- 
tion 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 enteric fever 
has sometimes been mistaken for bilious or remittent fever, and legions be- 
longing 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 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 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 observ- 
able, or at least is much diminished. This alteration of colour was first dis- 
tinctly described by Dr. Stewardson, of Philadelphia, in a paper published in 
the American Journal of Medical Sciences, for April, 1841 (N. S., i. 289) ; 
and has since been noticed by other observers, among whom may be particu- 
larly 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 characteristics of the disease. 
It may possibly depend, as suggested by Dr. Stille {Ibid., p. 323), upon a dis- 
tension 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 pro- 
portion of cases, so far as he was able to judge, "the organ was entirely healthy;" 
and, when otherwise, it was only the concave surface that had changed colour, 
this being of a 11 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. Some- 
times its colour is black, sometimes reddish, like the lees of red wine. 
The blood in bilious fever, as drawn near the commencement of the disease, 
generally coagulates without presenting the buffy coat. At a more advanced 
stage, however, it often becomes buffy, and even cupped, probably in conse- 
quence of the developement of inflammation. Dr. Frick, of Baltimore, 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. 276 
GENERAL DISEASES.-FEVERS. 
[PART II. 
Sci., N. S., xv. 30.) Meli discovered, in the blood of bilious fever, a con- 
siderable quantity of the colouring and fatty principles of the bile. (Diet, de 
Med., xv. 284.) In violent cases, it has been found partially disorganized, 
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 bilious 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 com- 
bined with moisture. If this were the case, why should we not see it origi- 
nating in the midst of our cities, where the heat is intense, and moisture often 
abundant ? Why does it not occur constantly among seamen, navigating equa- 
torial 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 phlegmasiae; but they escape bilious fever. 
Let them, however, approach a miasmatic coast, and it often happens that 
almost the whole crew are seized with the disease. They are also often af- 
fected 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 record, in 
which the disease is asserted to have raged fearfully in barren islands, with 
little vegetation upon their surface, and offering no obvious 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 dis- 
eased 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 excessive heat, 
if unattended with vegetable decomposition, and so seldom escape it entirely, 
when the latter cause is to any great extent conjoined with the former, that 
the few instances which have been adduced in contravention of the rule cannot 
but be looked upon with some suspicion; at least the inference is justifiable, 
* Cases of this kind occuri'edin 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 or sixth day. Along with the chill 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 malignant bilious 
fever. See an account of the epidemic by Dr. G. Emerson, in the Philad. Jown. of the 
Med. and Phys. Sciences, iii. 193. CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
277 
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, intermittents are more common, rela- 
tively, in the cooler latitudes, at the commencement or 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 
act, and among individuals least protected by habit against their influence. 
(See Miasmata, page 153.) 
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- 
tain seasons appear to favour the developement of miasmata; and a strong 
proof that, even in apparent epidemics, 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. 
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 pro- 
duce the disease, when without such aid they might have failed; but, in all 
cases, the miasmatic influence is necessary. In relation to these co-operating 
causes, it is unnecessary to add anything to what has been already said 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 mias- 
matic 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 incident- 
ally visit them; and, after complete recovery from one attack of remittent 
fever, the visitor acquires, in a certain degree, the same comparative insus- 
ceptibility, 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 one 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 wit- 
nessed such cases among the students of medicine, who attend the Philadel- 
phia schools in the winter. 
Nature.-The opinion which referred all the phenomena of bilious fever to 
gastritis scarcely requires to be combated, now that it no longer meets with 278 
GENERAL DISEASES.-FEVERS. 
[part II. 
supporters. Another and more plausible view is that which considers the 
disease as the superaddition, 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 phlegmasiae. But that remittents 
generally are not of this character is evinced by the fact, that in many 
instances 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. 
Remittent fever has been considered by some as identical with the enteric 
or typhoid fever; but it is difficult to conceive how this opinion can be enter- 
tained by persons 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 distinguishable 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 dis- 
eases sometimes coexist. The causes of both, operating at the same time, 
may be readily supposed 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 mem- 
brane, 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. It 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 CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
279 
emunctories, not the liver only, but the skin, kidneys, and possibly also the 
mucous membranes. There is reason to believe that the yellow colouring 
matter at least results from a change effected by this agency in the red cor- 
puscles ; and hence the striking deficiency of that ingredient of the blood in 
protracted cases of miasmatic fever. Still, this excess of bilious matter in 
the circulation is only one of the peculiarities of the disease. It cannot be 
the only one; for such an excess frequently exists without producing remit- 
tent fever. Can its elimination from the blood have anything to do with the 
cure or prevention of the disease ? Can it be in this 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 spontaneous attack of cholera morbus at this period, or the somewhat 
similar operation of a full dose of calomel, occasionally prevents the develope- 
ment 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 re- 
mains 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 wak- 
ing ; 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 phlegmasiae 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 
paroxysmal 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 
production, 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 circum- 
stances, 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 to three weeks after the patient 
has been obviously 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 mismanaged, and the severest often yield 280 
GENERAL DISEASES.-FEVERS. 
[PART II. 
to prompt and suitable treatment. There is, perhaps, no disease, 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 very often be conducted by proper treatment to a favourable 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 in 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 irri- 
tation. The opposites of these signs are of course unfavourable, but do not by 
any means uniformly 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 with eructation of black matter, hemorrhage from the bowels, invo- 
luntary 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 reme- 
dies 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 tai emetic; and some 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 
* I would especially call the attention of the reader to the fact, that these remarks 
apply to the early stage of the disease. CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
281 
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 pres- 
sure, and the discharge merely of drinks that may be swallowed, an emetic 
could do nothing but harm. In the great majority of cases, it may be safely, 
and perhaps advantageously dispensed with. 
Au 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 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 pro- 
motes, and thereby unloads the portal circle, while it also tends to free the 
blood from the biliary matter which may have become 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 
or eight hours, by half an ounce or an ounce 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 ope- 
rates.* Sometimes, when the bowels are extraordinarily obstinate, or the sto- 
mach very irritable, it becomes necessary to have recourse to purgative ene- 
mata. (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 in 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, sulphate 
of soda, tartrate of potassa and soda, or other saline purgative, four fluidounces 
of solution of citrate of magnesia, a Seidlitz 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 enemata. 
Another remedy, sometimes 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 
* R.-Sennas ^ss; Mannae opt., Magnesite sulphat. aa§j ; Cardamomi, vel Foeniculi, 
contus. gij ; Aquae bullient. Qj. Fiat infusum. 282 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 persons debili- 
tated by previous disease, or by intemperance, and in whom a typhous influ- 
ence 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 fre- 
quently the immediate cause of death, it is of great importance to be able 
to control them; and bleeding is among our most efficient means for this pur- 
pose. Hence, the indication for this remedy is the existence of inflamma- 
tion, or of some active sanguineous 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, 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 may exhaust the little remaining strength, and thus disable the 
system from supporting the course of morbid actions, requisite to the restora- 
tion of health. There must, therefore, be not only inflammation, or threaten- 
ing active congestion, or a reasonable fear of them; but also sufficient strength 
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 symp- 
toms, 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 symp- 
toms 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, suggest 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 
unfrequently 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 CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
283 
remedy was indicated. In doubtful cases, it may be proper to bleed cautiously, 
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 aban- 
don the measure altogether; but, under opposite circumstances, to resume it, 
and continue till the requisite quantity has been lost. 
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 
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, it 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. 
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 with, whether in the first or in subsequent paroxysms, 
along with the condition of the pulse referred to, then it is that bleeding 
should be employed; but it must be remembered that, in the advanced stages, 
the system has often become so exhausted that even the existence of inflam- 
mation 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, 284 
[part II. 
GENERAL DISEASES.-FEVERS. 
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 tartar emetic may be given every hour or two, caution being observed so 
to proportion the dose as not to occasion excessive nausea. The antimonial 
or James's powder has enjoyed much reputation, and the precipitated sulphuret 
has 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 frequently irritant 
effect upon the stomach. 
The effervescing draught is, beyond all comparison, the best diaphoretic in 
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, and 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 quinia. I feel very confident that no practitioner, who 
has ever been in the habit of using the effervescing draught, properly pre- 
pared, in the treatment of bilious fever, will be disposed to abandon it. To 
the patient it is almost always, when given 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 maybe 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 Potassae 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 CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
285 
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 bath 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 
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 on 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 quinia, 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 es- 
tablished; and the inference is, that, were proper attempts made to establish 
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 286 
GENERAL DISEASES.-FEVERS. 
[PART II. 
from this cause. It is true that, from idiosyncrasies, patients are sometimes 
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 deprived 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 
influence rests upon experience. I will only adduce a single fact, out of 
thousands which might be advanced in its favour. In the year 1804, 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 disease 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, and generally with the effect of inducing ptyalism. Out of 
one hundred and fifty cases not one was lost. {Diet, de Med., n. 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 
outset, and does not soon show a disposition to yield to the remedies em- 
ployed, 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 deple- 
tion, 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 re- 
source. The large quantities in which it has been sometimes employed are 
altogether unnecessary. Only a certain amount of it 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 symptoms, and the known susceptibility of the patient. Let not persons 
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 persevered in, will often have a more decided 
constitutional effect, than fifty times the quantity. The influence of these 
small doses, in calming bilious vomiting, is often most delightful. 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 CLASS I.] 
287 
REMITTENT, OR BILIOUS FEVER. 
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 ipe- 
cacuanha, if these be not contraindicated, the former by the state of the brain, 
and the latter by irritation of stomach. The refreshing effects of sleep are 
thus obtained, and the patient frequently awakens in a fine perspiration in 
the morning. 
Calomel has been 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 
either be diminished or suspended, unless in cases of an almost desperate 
character. 
Sulphate of quinia 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 decided, so as to approach an intermission. 
Should no signs of cerebral or gastric inflammation be present, and the acti- 
vity of the circulation have subsided or been subdued, this medicine may be 
ventured upon whenever the remission has the character above mentioned. 
From twelve to eighteen grains, given in divided doses during the remission, 
will often be sufficient to prevent the paroxysm; and if not, a repetition 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 preju- 
dice probably derived from the unpleasant effects produced by the powdered 
bark when given during the existence of fever, yet I am not prepared 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 circumstances 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 
came 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 occasion- 
ally diminish the frequency of the pulse in febrile cases, is 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 employing, in inflammatory or active congestive tendencies of the 
brain; and for the same reason, we should avoid quinia under similar circum- 
stances, unless there were some danger to be averted by the use of it, greater 
than that of the apprehended cerebral disease. 288 
GENERAL DISEASES.-FEVERS. 
[part ii. 
But there are circumstances in bilious remittent fever which render quinia 
of the utmost value. When a paroxysm of great violence 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 remission, 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 confident 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 remission, 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. The doses must be regulated by the length of the remis- 
sion. If this be short, they must be very large, and if of a few hours' dura- 
tion 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 led 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 remark- 
able 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 im- 
possible 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 administration of the quinia.* 
Nor shordd 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 
* 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 reference to remission or exacerbation. Indeed, I cannot refuse credence to 
the many statements 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, produces evil effects by fixing, if not determining some inflam- 
matory 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 generally supposed to contraindicate its employ- 
ment ; and a similar influence may be exerted by epidemic constitutions within par- 
ticular 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 
the second edition.) CLASS I.] 
REMITTENT, OR BILIOUS FEVER. 
289 
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 calo- 
mel. 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. 1 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 purpose, 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, (fee page 271.) In such cases, 
the tongue being dry, the skin dry, and the secretions generally deficient, it 
is advisable, if the patient has not already been salivated, to give the mercurial 
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 fojm 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 mer- 
curial 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 tiiucous 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 sulphate of quinia should that still be indicated. Nitrate 
of silver may be used as an alterative under the same circumstances. Should 
pressure upon the abdomen detect a tender spot, a few leeches may sometimes 
be employed 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 sus- 
tain 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. 290 
[PART II. 
GENERAL DISEASES.-FEVERS. 
Gastric Disorder.-When there is frequent retching, with discharge occa- 
sionally of a mouthful of bile or other acrid liquor, indicating that there is 
offending matter in the stomach, effectual relief will often be afforded by 
copious draughts of warm water or chamomile tea, or even, in some instances, 
by a very mild emetic of ipecacuanha. Irritation existing in the coats of the 
stomach itself, and independently of its contents, should be treated by cata- 
plasms 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 in- 
ternally, 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 efferves- 
cing 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, limewater and milk, mixed in equal proportions, may be given in the 
dose of half a wineglassful, every half hour or hour, with very great advan- 
tage ; not only allaying the gastric irritation, but yielding nutriment to the 
system in the most suitable form. Dr. Condie has repeatedly seen vomiting 
promptly relieved by a grain of acetate of lead every hour or two. {Am. ed. 
of Watson'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 
of that column, will arrest the vomiting, when measures directed more im- 
mediately 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, not 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, re- 
vulsion 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. Cups 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. CLASS I.] 
291 
REMITTENT, OR BILIOUS FEVER. 
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 when opiates are contraindicated; as when the brain is over- 
excited, while the extremities are cool. Should opium not be contraindi- 
cated, it is on the whole the most effectual means for obviating morbid watch- 
fulness. Sometimes, hyoscyamus, or lactucarium may produce the desired 
effect, when opium disagrees with the patient. Great advantage is often ob- 
tained from varying the preparations of opium, one answering a good purpose 
where another acts unkindly, and vice versa. Thus, a salt of morphia will 
occasionally put to sleep when opium will not; and the changes may be rung 
upon solid opium, Dover's powder, extract of opium, 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, chloroform, &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 employed. 
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, apple- 
water, tamarind-water, or water flavoured with currant-jelly, blackberry-jelly, 
molasses, or freshly toasted bread. I have often found very acceptable to 
patients, in fever, a beverage consisting of weak molasses and water, with a 
little lemon-juice, and a piece of toast, and kept cool by ice. 
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 pro- 
portion 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 fari- 
naceous drink. The patient may also suck the juice of oranges, or swallow 
that of sweet grapes, discarding 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 292 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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 (see page 224), 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 
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 somewhat languid, I have found that it is often suffi- 
ciently stimulated by a little crisp broiled lean of ham, or frizzled driedcbeef. 
When it is excessive, as often happens, the greatest caution should be ob- 
served 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 excrementitious 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 medi- 
cal 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 mean time, it may be proper occasionally to admin- 
ister one of the nervous stimulants. Opium or hyoscyamus, or their prepara- 
tions, may sometimes be necessary to procure sleep, care being taken to with- 
draw them gradually, when no longer required. Hops, in the form of infusion 
or tincture, sometimes answer a good purpose under these circumstances. 
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 ex- 
cess of acid in the stomach, rhubarb, a little castor oil, a Seidlitz powder, &c. CLASS I. 
PERNICIOUS FEVER. 
293 
Active purging must be carefully avoided, as it endangers a relapse. Diar- 
rhoea sometimes requires the use of gentle astringents. If the stools are clay- 
coloured, or in any other way indicate hepatic disorder, a mercurial pill, or a 
grain of calomel, may be given every night, or every other night, till the symp- 
tom 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 patient must be guarded against a 
too early exposure to fatigue. Some are anxious to regain strength by exer- 
cise 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 fever. I will merely add that many attacks of bilious fever 
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, if properly timed, of preventing the first paroxysm. 
PERNICIOUS FEVER. 
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 conventionally 
received as designative of a particular morbid state of great danger, to the ex- 
clusion 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 ex- 
ample, 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 dis- 
ease. It might be inferred, from the use of this epithet, that the congestion 
which certainly exists in this affection constitutes tbe 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 ordinary 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 
Syn.-Congestive Fever.-Pernicious Intermittent.-Pernicious Remittent. 294 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 character and im- 
portance, which may be best given by treating of it distinctly-; while the 
danger of false pathological views may be readily guarded against by due ex- 
planation. 
This modification of miasmatic fever may be intermittent, remittent, or con- 
tinued. 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 fre- 
quently, 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, accord- 
ing 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 prominently in the 
brain. There are differences also in the disease, as it is evinced most strik- 
ingly 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 at once, with its own peculiar characters. More commonly, however, 
the first symptoms are those of ordinary miasmatic fever, or at most equivocal. 
Thus, the patient may have been seized with a paroxysm, differing 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 alternat- 
ing with slight perspirations, &c., as if a remittent were endeavouring 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 several days, without show- 
ing 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 strikingly 
peculiar in the appearance of the patient. The face, hands, and feet are of 
a livid paleness; the features shrunk and impassive, or singularly expressive 
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 contracted, and 
the fingers shrivelled as if long soaked, like those of a washerwoman, in soap 
and water; the extremities and sometimes even the trunk chillingly cold, 
though not sensibly so to the patient; the surface either partially 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. CLASS I.] 
PERNICIOUS FEVER. 
295 
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. "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- 
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 either dark-coloured and uncoagula- 
ble, 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 
vomiting 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 
pernicious 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 fre- 
quent, amounting to 120, and sometimes to 160 in the minute. Not unfre- 
quently, 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 tumultuous." (Am. Journ. of Med. Sei., 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, page 
184) contracting very frequently, has appeared to me to be feeble, rather 
than energetic in its action. 
Along with the symptoms above enumerated, there are often great rest- 
lessness, general uneasiness, and jactitation. The patient, not aware of his 
extreme danger, and sometimes wondering at the anxiety exhibited by his 296 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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, in- 
cluding 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, 
perhaps, with unsuccessful attempts at reaction, for a period varying from one 
to three days; when, unless relieved by remedial measures, they terminate 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 be- 
comes 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 appears 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 same measures are necessary in either case. Perhaps the 
chance of a favourable issue may be greater, in proportion to the complete- 
ness 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 CLASS I.] 
PERNICIOUS FEVER. 
297 
milder; and at length nothing hut an ordinary intermittent is left. In other 
instances, the disease runs on with remissions, and either 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 al vine evacuations of. a dark tar-like 
liquid take place from the bowels; as they indicate a restoration of the sus- 
pended 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, 
cold sweats, &c.; but without nausea:, vomiting, purging, or abdominal dis- 
tress of any kind. In this, as in the other forms, there may be one or two 
remissions 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 
alternates 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 
pernicious 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 another; and often stammers. This dulness gradually increases 
into deep coma, from which the patient cannot be roused. The respiration 
is somewhat noisy, and stertorous as in apoplexy. The pulse is full, and, 
though generally somewhat accelerated, it is much less so than in other cases, 
and occasionally is even slower than in health. It often, too, has considera- 
ble 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 per- 
spiration takes place, sensation gradually returns, and the patient may have 
no symptom of the disease remaining; though, more frequently, he continues 298 
[PART II. 
GENERAL DISEASES.-FEVERS. 
. omewhat soporose in the interval. The next paroxysm usually proves fatal, 
like an apoplectic attack, unless arrested. In some cases, the comatose symp- 
toms 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 at an earlier period. The result was generally unfavourable. (A Or- 
leans 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 
nu 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 
commencement 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 
sense of chilliness, or a feeling of heat, while the extremities are really cold, 
and a want of uniform heat after reaction; a disposition to copious or fre- 
quent 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 dis- 
position to faintness; considerable delirium or drowsiness; a prolongation of 
the cold stage, and a less degree of febrile excitement than might have been 
anticipated; and the continuance in the apyrexia of some mental confusion, 
sleepiness, faintness, or unusual anxiety and uneasiness; any of the above 
symptoms should be a sufficient warning to the practitioner, not to 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 CLASS I.] 
PERNICIOUS FEVER. 
299 
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, 
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 sus- 
ceptibility to its influence. Dr. Parry tells us that in Indiana, while ordinary 
bilious fever occupies the table lands, the pernicious form has been observed 
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 have seldom seen the 
complaint in Philadelphia or the neighbourhood, except in the hospital among 
sailors recently from the southern coast, or among medical students from the 
Southern and Southwestern States. Latitude, moreover, appears to have 
some influence upon the character of the disease; for, while in the countries 
north of the Ohio it generally assumes the intermittent form, in the State of 
Mississippi, according to Dr. Wharton, this disposition is much less obvious. 
The weakness of old age, or previous disease, does not appear to constitute a 
predisposition; for, according to Dr. Parry, the greater number of fatal cases 
is between 25 and 35, and among the plethoric and robust (Am. J. of Med. 
Sei., 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 debi- 
litated by chronic disease, are apt to take on the pernicious character, and to 
prove exceedingly fatal. (Archives Gen., 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 con- 
ceive of an acute and fatal inflammation of the mucous membrane of the sto- 
mach, with considerable appetite, or of the brain, with a perfectly sound intel- 300 
[PART II. 
GENERAL DISEASES.-FEVERS. 
lect, and without headache or other cephalic uneasiness? Inflammation, in a 
certain degree, may eo-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 menin- 
gitis, 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, 
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 rup- 
ture 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 surface, 
owing to the stagnation of the blood. From 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 coldness obviously arises from the languid circulation, and deficient change 
of blood. This condition of the capillaries may coexist with considerable power 
in the heart; for the want of innervation is not necessarily equal in the whole 
circulation. Nay, the heart may be excited to tumultuous action by the calls 
upon it of the empty capillaries through the nervous centres. But sometimes 
the deficiency is experienced first and specially by the heart. In such cases, 
syncope or a tendency 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 
* 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. CLASS I.] 
PERNICIOUS FEVER. 
301 
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 remarkably 
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 con- 
tinues 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, &c., of the 
mucous membrane, as evidence of inflammation or congestion. I am not dis- 
posed to deny the occasional existence of some degree of inflammation, 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 extensive in- 
flammation. 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 not 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 178.) The heat 
can be referred only to morbid nervous influence. That there is no real in- 
crease of temperature within, is inferred from the coolness of the tongue. Be- 
sides, 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 pheno- 
mena of the organic functions. The congestion necessarily follows the pros- 
tration 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 compara- 
tively 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 determination 
than to stagnation in the capillaries. The colour of the cortical portion is de- 
scribed 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 can- 
not here be followed by paleness as upon the surface. The vessels must always 
be full, or the vacuity must be compensated by effusion. Bedness, therefore, 
and serum in the ventricles are not necessarily signs of over-excitement. But 
I am not disposed to maintain that the cerebral affection, in these cases, is cer- 302 
[part II. 
GENERAL DISEASES.-FEVERS. 
tainly the result of diminished sensorial action. It may be so; or it may pro- 
ceed 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 de- 
pends. 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, oneway 
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 nervous, 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 of the cases 
without treatment, or with the usual treatment for bilious fevers, end fatally. 
Under proper management the result 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 con- 
tinued 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-pathol. des fibres 
intermit. Append., p. 10.) Dr. Parry gives the general result of special treat- 
ment at 1 death in 8 cases. (Am. J. of Med. Sci., 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 practi- 
tioners. Experience, however, has proved the frequent inefficiency and even 
danger of this practice; and the profession have, I believe, generally abandoned 
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 depres- 
sion, 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 principles, 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 surfaces of the body. 
One of the most obvious remedies is artificial heat. Heated bricks, bottles 
filled with hot water, heated flat-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 105° Fahr. Sinapisms may be applied to the extremities, CLASS I.] 
PERNICIOUS FEVER. 
303 
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 re- 
commend very strongly, as the most efficacious external remedy, especially 
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 mea- 
sures 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. (AC Orleans Med. and Sury. Journ., 
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 
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 substituted 
in an equivalent dose. The only circumstance which would strongly contra- 
indicate 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 peculiarly 
adapted to the case, and may be given, with great propriety, when the evacua- 
tions 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 stimu- 
lus, 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 em- 
ployed, even in the paroxysm, before reaction. It is indicated 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 de- 
mands interference, and, when the case approaches the continued form, it is 
of great importance to establish the mercurial influence. The proper com- 
bination of these remedies, and the regulation of their dose and time of ad- 
ministration, are scarcely less important than the remedies themselves. 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, ac- 
cording 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 dose may be increased; when there is more time to 
spare, the interval may be lengthened. Of course the proportions must vary 
to suit circumstances. So also must the articles employed. If the Cayenne 
pepper should not agree with the stomach, or appear insufficiently 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 304 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 esta- 
blished, should be cautiously omitted. At this point the patient maybe con- 
sidered comparatively safe. 
It would be wrong not to mention that, other means of producing reaction 
have been highly recommended. Some practitioners in the 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 consuming him, in a 
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 de- 
lightfully, 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 mea- 
sure had proved effectual in several apparently desperate cases. Dr. Barbour, 
of St. Louis, Missouri, esteems the affusion of cold water, above all other means 
in the treatment of this disease. (OLserv. on Int., Remit., and Congest. Fever, 
St. Louis, 1847, p. 26.) The remedy is certainly one not to be hastily re- 
jected. 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 irra- 
tional. The nervous system is chiefly in fault in these cases. A strong im- 
pression is made on that system by the sudden application of cold to 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 sensation, 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 may 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. 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 employed in the protracted 
chill of ordinary intermittents, as one mode of exciting reaction, though now 
generally superseded by less disagreeable remedies. Dr. Geo. G. Banks, of 
Clinton, Mississippi, uses for this purpose powdered mustard, of which he 
gives a tablespoonful in a pint of warm water, and repeats the dose in a short 
time if the first does not operate; and I have been informed that the practice 
is very successful. He follows the emetic with morphia. 
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 CLASS I.] 
PERNICIOUS FEVER. 
305 
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 by Dr. Wharton. Its operation may sometimes be much facilitated, 
according to the same authority, by a hot bath. Dr. Wharton does not con- 
sider his patient 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 administration of this remedy. 
Even excessive irritability of stomach is no sufficient contraindication. 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 por- 
tion 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 with a little acid so as to dissolve the sul- 
phate, 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 absorption. 
It has even been proposed to inject it into the veins; but it is only in other- 
wise desperate cases that this method of administration would be justifiable, 
in the present state of our knowledge; and, should it be resorted to, care 
must be taken that the salt be thoroughly dissolved. 
The paroxysm is 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 con- 
sideration of its effects upon the head, until the period for the second paroxysm 306 
GENERAL DISEASES.-FEVERS. 
[part II. 
is passed. The disease is then subdued; or at least all of it which belongs 
to the pernicious fever. The remaining treatment, if any is requisite, must 
be conducted as in ordinary cases. 
•Miele 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; 
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 shows itself, as a prevailing disease, in 
a scattered population, or at a distance from navigable rivers. 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 and 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. 
Yellow 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 symptoms and 
course with ordinary bilious fever. The effluvia generated among the filth 
of congregated masses of people, may be readily supposed to have occasion- 
ally 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 CLASS I.] 
307 
YELLOW FEVER. 
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 inten- 
sity of the cause, there is every grade of violence, from a mildness in no way 
alarming, to the most fatal malignancy. Curious and inexplicable anomalies 
also not unf^equently 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 paye 88), 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 
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 occasion- 
ally sore, so as to render deglutition difficult. Nausea or other uneasiness of 
the stomach, with or without vomiting, not unfrequently attends the disease 
from the commencement; but, in the majority of cases, the gastric symptoms 
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 or 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 reject- 
ing 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 occasionally a troublesome symptom. The desire for cold drinks is usu- 
ally extreme; and ice, held in the mouth and slowly swallowed, is very grate- 
ful, in consequence of the intense gastric heat. The bowels are 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 sometimes insupportably se- 
vere, extorting groans and even screams from the patient. The mind is 
usually much disturbed 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 various 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 greater tend- 
ency to remission. Having run its course, the fever subsides, and a great 
apparent amelioration of the disease is experienced. The skin becomes cooler 308 
GENERAL DISEASES.-FEVERS. 
[part ii. 
and softer, the pulse nearly or quite natural, the respiration calm, and the 
stomach comparatively quiet. The headache, and the excruciating 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 strug- 
gle is yet to come. This apparent amelioration is not, in any respect, com- 
parable 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 an 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 
existence of undiminished danger. Upon pressure in the epigastrium, the 
tenderness, instead of being diminished, is often 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 
prostration. In severe cases the weakness is extreme. The pulse is quick, 
irregular, and feeble; the skin is yellow, orange, or of a bronzed aspect; 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 slowy; 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 re- 
sumes all its former irritability; everything swallowed is thrown up again; 
and a new matter is ejected, consisting of brown or blackish flakes or parti- 
cles 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 condition of system above described may come on even so early as the 
first day; and occasionally, the extreme capillary prostration, with the pur- 
plish 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, re- 
tained. 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 sometimes also vomited, or discharged by stool, or with the 
urine; and petechiae and vibices, arising from its extravasation, appear upon 
the skin. The irritability and extreme distress of the febrile stage are now 
replaced by an extraordinary apathy; and the countenance expresses a quiet CLASS I.] 
YELLOW FEVER. 
309 
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 convul- 
sions. 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 system very 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 vari- 
able length of time; sometimes speedily terminating in health, with the ordi- 
nary signs of convalescence, sometimes ending in fatal exhaustion, and occa- 
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 pri- 
mary 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 sub- 
sidence 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 subjected. 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. In some rare instances, in which the disease 
runs into a protracted typhoid form, it may be considerably postponed. 
It has been already stated that the disease is liable to great diversity. 
Most frequently the action in 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 the whole capil- 
lary system. In the fashionable language of the day, these cases are denomi- 
nated 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 occasionally almost wanting 
at the wrist, while the heart and carotids may be throbbing tumultuously; 
the face pale or purplish, with an expression of countenance 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 310 
GENERAL DISEASES.-FEVERS. 
[part II. 
cases. Occasionally the system evinces a disposition to rally, and signs of 
febrile action are exhibited; but these for the most part quickly give way, 
and complete collapse ensues. Copious black vomit, occasional hemorrhage 
and petechias, a dark mahogany 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 respi- 
ration, 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 expres- 
sion of countenance. Upon his pulse being examined, it is found to be ex- 
ceedingly 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 against 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. 
In some epidemics, an eruptive affection, of the character of a rash or 
papulus, has been noticed, during the first stage, upon the face, neck, and 
upper part of the body. Dr. C. H. Stone, in his account of the yellow fever 
which prevailed at Natchez in 1848, states that the breath was generally 
offensive. (A^ Orleans Med. and Surg. Journ., v. 560.) 
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 cases 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 unfre- 
quently nearly or quite natural. In the last stage, it again increases in fre- 
quency, but is almost always rather feeble, and, in the prostrate condition, is 
small, extremely weak, often irregular, and sometimes nearly or quite absent 
for some time before death. In the asthenic cases, where there is little or no 
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 CLASS I.] 
YELLOW FEVER. 
311 
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 pur- 
ple. 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 pre- 
sent. 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 
yellowness to the bile. It often affects the cellular and adipose tissue, as well 
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. (2V Orleans Med. and Surg. Journ., iv. 691.) 
The Hack 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. 
Black vomit is either nearly tasteless, or sour; and to chemical tests is in 
general decidedly acid. Formerly, it was thought to be black bile. Dr. Phy- 
sick suggested that it might be a secretion from the stomach, and supposed 
that it was thrown out in order to relieve the inflamed vessels. At present, 
it is believed to be blood somewhat altered, either by a feeble secretory action 
of the membrane, or by the acid which exists in the stomach. I am inclined 
to the opinion, that the blood undergoes some modification either in the 312 
GENERAL DISEASES.-FEVERS. 
[PART II. 
capillary vessels, or in its exit from them through the epithelium. Were the 
character of the black vomit dependent on the reaction of gastric acids, as is 
supposed by some, it should be changed for that of unaltered blood upon the 
free exhibition of magnesia, instead of remaining unaffected, as it actually 
does. Black vomit, though apparently homogeneous when discharged, sepa- 
rates 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 solid 
and coagulable matter of the blood, the clear liquid its serum. Dr. Rhees, 
of Philadelphia, 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, or 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 
remittent fevers, but no similar appearances were discovered." (S. Jackson, 
Phil. Journ. of Med. and Phys. Sciences, ii. 23.) In a communication 
to the London Lancet (see Am. ed., Feb. 1853, p. 192), Dr. Manly states 
that he has repeatedly noticed animalcules in black vomit, belonging to the 
genus Acarus, but of unknown species; but other observers have failed to 
find the appearances noticed by Dr. Rhees; and the presence of animalcules 
certainly cannot be considered as in any degree characteristic. Black vomit 
has recently been submitted to careful microscopic examination by several 
observers, among whom may be mentioned Dr. J. L. Riddell of New Orleans, 
Dr. M. Michel of Charleston, S. C., Prof. A. Clark of New York, Dr. Hassall 
of London, and Dr. Leidy of Philadelphia, with results confirmatory of the 
views above given as to the nature of this morbid product.* Besides the 
different epithelial cells of the mucous membrane, which are found in different 
stages of developement and disintegration, the most prominent constituents 
are blood corpuscles variously altered, and a black granular or amorphous 
matter, probably resulting from the breaking up of the solid ingredients of 
the blood. Microscopic fungi have also been noticed; but they were not 
uniformly present, and were probably developed by changes in the black 
vomit after its production. Specimens examined chemically by Prof. R. E. 
Rogers, of Philadelphia, at the request of Dr. La Roche, were found to contain, 
besides free muriatic acid, many of the constituents of the blood, especially 
albumen and iron. (Am. Journ. of Med. Sci., N. S., xxvii. 308.) There can 
be little doubt, therefore, that the proper black vomit of yellow fever is essen- 
tially disintegrated blood. 
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 buffy coat, when it occurs, is often of a gelati- 
nous consistence. It has been thought that, in malignant cases, the blood 
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 
* See, for the results of Dr. Riddell's observations, the TV. 0. Med. and Surg. Journ. 
(ix. 420); for those of Dr. Michel, the Charleston Med. Journ. and Rev. (viii. 333); for 
those of Prof. Clark, the N. Y. Med. Times (ii. 230); for those of Dr. Hassall, the Lon- 
don Lancet for February, 1853; and for those of Dr. Leidy, the Am. Journ. of Med. Sci., 
N. S. (xxvii. 312). The reader is also referred to an elaborate and excellent paper by 
Dr. R. La Roche on the black vomit of yellow fever, contained in the last mentioned 
journal (vol. xxvii. pp. 13 and 295). CLASS I.] 
TELLOW FEVER. 
313 
portal system; but Dr. Hewson found that this blood, when removed from 
the body, coagulated upon standing ten or fifteen minutes. (Phil. Journ. of 
Aled. and 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 on the alimentary 
canal, especially on the stomach. The oesophagus is sometimes found in- 
flamed, and deprived of 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. Sometimes it 
is distended with this fluid. Occasionally it contains blood in different stages 
of alteration. According to Gillkrest, there is sometimes to be seen, adhering 
in large quantities to the mucous coat, a deep-black homogeneous substance, 
of a gelatinous consistence. The muscular and peritoneal coats are usually 
sound ; but the mucous coat is in general partially or universally reddened, 
sometimes thickened and softened, and sometimes, though rarely, eroded. The 
cardiac portion is usually more affected than the pyloric. Sometimes the mem- 
brane is wholly free from any signs of inflammation, or other appreciable lesion. 
(Harrison, A7". 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 inflamma- 
tion here and there in patches. The glands of Peyer are seldom materially 
altered. The veins of the omentum and mesentery 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 observed 
by Dr. Stewardson, of Philadelphia, in a case examined by him in the Penn- 
sylvania Hospital. (Am. J. of Med. Sci., Jan. 1842.) It was supposed that 
this state of the liver might be characteristic of the disease. But examina- 
tions, made both previously and subsequently to those of M. Louis, prove that 
the lesion is by no means universal. Thus, Dr. S. Jackson, of Philadelphia, 
found the liver sometimes gorged with blood, sometimes quite anemic. {Phil. 
J. of Aled, and Phys. Sci., ii. 21.) The same observation was made by Dr. 
Harrison, of New Orleans, who ascribes the pale yellow colour sometimes 
observed chiefly to the loss of blood. (M. Orleans Aled, 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 profuse hemorrhagic dis- 
charges. (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 fherap., i. 357.) Dr. Nott found the 
yellow anemic condition present in only about one-third of the cases. (Am. 314 
[PART II. 
GENERAL DISEASES.-FEVERS. 
Journ. of Med. Sei., April, 1845.) Recent microscopic observations by Prof. 
Clark, of New York, and Drs. T. H. Bache, Rhoads, Darrach, and Green, 
resident physicians of the Pennsylvania Hospital in Philadelphia, have shown 
that a great excess of oil generally exists in the liver, both free and within 
the proper hepatic cells, in which they frequently replace the nucleus; so that 
fatty degeneration of that organ may be considered as one of the characteristic 
lesions in fatal cases of yellow fever.* 
In various parts of the body extravasation of blood has been observed, espe- 
cially 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 smallpox or scarlatina. But great diver- 
sities of opinion have existed upon this subject. Some of these it will be pro- 
per 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 diseases. But 
these arguments will not bear examination. 
It is true that the two fevers prevail in 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 prevalent, and 
quite as violent, in the interior of miasmatic countries as near the sea ; yellow 
fever seldom 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 cities 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 miasmata. 
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. 
* See Prof. Clark's paper in the N. Y. Med. Times (ii. 234), and a paper by Dr. T. H. 
Bache in the Am. Journ. of Med. Sei., N. S. (xxviii. 124). The latter communication is 
peculiarly interesting, giving the results of the microscopic examination of the liver in 
fourteen cases which proved fatal in the summer of 1853 in the Penn. Hospital, in all 
of which, as well as in several others in which the liver was sent to the Hospital for ex- 
amination, this fatty degeneration was uniformly noticed. CLASS I.] 
YELLOW FEVER. 
315 
It is not true that the symptoms of the two diseases are the same, at least 
in their well developed forms. They are, on the contrary, strikingly differ- 
ent. 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 smallpox or measles, for one, two, or three days, and then ceases; while 
bilious fever has a tendency to remission 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 diminished. Though it is possible that the 
turbid conjunctiva, and purplish flush of the upper part of the face, so com- 
mon in yellow fever, may occur in some cases of the bilious, they are uncom- 
mon 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 termi- 
nation 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 dif- 
ference 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 rarely 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 smallpox; 
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 
* It must be recollected that second attacks of smallpox, in a modified form, are not 
very uncommon during epidemic visitations of that disease. 316 
[PART IL 
GENERAL DISEASES.-FEVERS. 
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 disease 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. 
But these arguments are met by powerfully opposing facts. Thus, in hos- 
pitals situated in healthy districts, though crowded with yellow fever patients, 
the disease is never imparted to the nurses and other attendants. From ves- 
sels arriving in healthy ports yellow fever patients are often landed, some- 
times in considerable numbers, without propagating the disease.* 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 con- 
sequence 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 the country; and yet the instances are exceedingly rare, in which it 
is even pretended that the disease is thus communicated. Attempts have 
been made to propagate the disease by inoculation with the blood and secre- 
tions of those affected, but without success; 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 de- 
serving of no weight unless supported by positive facts. 
For these and perhaps other reasons, the great majority of physicians who 
have had any opportunity of seeing yellow fever, altogether deny its conta- 
gious nature. This fact is rendered incontestable by the industry of the late 
I)r. Chervin, who personally collected the written opinions of almost all the 
practitioners 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 
disease 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 close. It seems to 
me that the doctrine of the contagiousness of yellow fever, in the ordinary 
meaning 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 
* See letters of Dr. Geo. A. Smith and Dr. W. J. Tuck, of Memphis, Tenn., in the 
N. 0. Med. and Surg. Journ. (x. 662.) It is here stated that in the year 1853, when 
yellow fever prevailed epidemically with great violence in New Orleans, and various 
other towns on the Mississippi river below Memphis, it did not reach the last mentioned 
town, nor any point above it, in the epidemic form. It happened, however, that sixty- 
two cases of the disease were landed at Memphis from the towns below, and carried 
through the streets of the city in open vehicles for a mile to the hospital; yet in no 
instance, either within the hospital where they were distributed indiscriminately 
among the patients, or in the city at large, was the disease communicated. CLASS I.] 
YELLOW FEVER. 
317 
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 
energetic 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 
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- 
mate, 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 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 the air proceeding from her thoroughly dissipated? 
Two theories have been advanced, either of which will explain these apparent 
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 gene- 
rated 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 gene- 
rated during the vinous fermentation which yeast has set in motion. The other 
theory supposes the cause to be a living, organized, microscopic being, either 
animal or vegetable, which, produced out of pre-existing germs, under favour- 
able circumstances, is capable of propagating itself indefinitely 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 indi- 
viduals, from one spot to another; and, if it find the proper material to act 
upon, or the proper food to support it, with the temperature essential to its 
activity, may spread itself indefinitely, and, though perhaps 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 ne- 
cessity 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 con- 
veyance of the poison in the clothing of an individual 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 original only in a comparatively small 318 
GENERAL DISEASES.-FEVERS. 
[PART II. 
portion of those regions of the world, where all the exterior circumstances 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 latitudes 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 production, 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 some- 
times 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 ex- 
tensive regions. Thus, from the year 1762, when the yellow 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 ap- 
peared in most of our large cities upon the Atlantic coast, from Charleston to 
Boston; and in 1853 again made its appearance in Philadelphia, which had 
in the meantime been nearly exempt. This epidemic constitution only gives 
efiiciency to the specific cause, and therefore never produces the disease when 
that cause does not exist. Perhaps a long continued elevation of temperature 
may contribute 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 
frequently, 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 ex- 
posed 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 susceptibility 
to its influence, without having ever absolutely produced the disease. 
Various circumstances operate as exciting causes, calling into action the effi- 
cient and specific cause, which may have been lurking in the system. Any- 
thing 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, 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 complaint. 
But the symptoms and course of the disease clearly show that it is a mere at- CLASS I.] 
YELLOW FEVER. 
319 
tendant. 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 generally, is not univer- 
sally 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 morbific cause. 
Diagnosis.-The initial stage of most fevers has so many symptoms in com- 
mon, 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 
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 suffu- 
sion of the upper portion of the face, are such symptoms. At a more advanced 
period, the excessive irritability of stomach and extreme epigastric tenderness; 
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, whether the con- 
ditions 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 violence, 
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 mild, 
and few comparatively die. When it occurs epidemically, the first cases are 
generally the most severe, and sometimes almost all end fatally. Afterwards, 
the disease becomes milder, and, towards the close of the epidemic, it some- 
times happens that almost all recover. Even within the same city, the violence 
of the disease may vary greatly in different spots. Thus, in Philadelphia, in 
1820, out of twelve reported cases in one vicinity, there was only a single re- 
covery, of seventy in another thirty recovered, and of four in a third three re- 
covered. Perhaps the general average of deaths from yellow fever, prevailing 
epidemically, may be stated at one-third. Dr. Fenner 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. 
Journ., v. 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 work on Pathology and Therapeutics. "The attack is apt to be violent, 
and its progress hasty, in the sanguineous and plethoric. For the intemperate 
there is almost no hope. National habits and modes of life have a decided in- 
fluence. The Irish, Germans, and Scotch afford us the worst cases; Spaniards, 
Italians, and Frenchmen, are very apt to recover. Midway stand the English- 
man, the northerner, and the mountaineer, or inhabitant of our interior country. 
Generally speaking, the more recently a stranger has come here [Charleston, 
S. C.], 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 320 
GENERAL DISEASES.-EEVERS. 
[part II. 
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 
appearance. Dr. Fenner estimates the chances of recovery at about one in a 
hundred cases. (Hist. of the Yellow Fever at New Orleans in 1853, p. 53.) 
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 production of strangury by blisters, and of salivation by 
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 fever in which treatment can 
be of no avail. The patient has received his death blow at the beginning. 
There are others, again, so mild that they get well spontaneously, under any 
kind of management, unless positively destructive. Hence the great uncer- 
tainty, 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 influence 
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 assum- 
ing 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 warm water or warm chamomile tea. 
The question must be decided, at an early period, whether it will be requi- CLASS I.] 
YELLOW FEVER. 
321 
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 of the second stage. It should be resorted 
to only when the pulse is tense and strong. When this is very frequent, 
or readily compressible, the lancet should not be employed. The enormous 
bleedings which have been recommended by some 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 stomach 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 are adapted to 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. Mercury 
seems incapable of taking hold of the more violent cases, however energetic- 
ally 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, certainly, that the 
instances in which salivation occurs would end in recovery, under other mea- 
sures. The circumstance, that, when the influence of mercury is experienced, 
the patient gets well, proves, at least, that the remedy can do no great harm. 
If, therefore, it is indicated upon general therapeutical principles, if it is not 
injurious, and if its influence when experienced is always followed by favoura- 
ble results, whether as mere consequences, or as effects, there can be no im- 
propriety, 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 322 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 interruption, 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 quantity in largei' doses, and at 
longer intervals. Calomel is usually well borne by the stomach. It may 
even compose irritation of that organ. Should it too much disturb the bowels, 
it may be combined with opium. Recourse may be had also, if necessary, 
to mercurial frictions and mercurial dressings to blistered surfaces,-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 application may be re- 
peated, 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. S. 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 irri- 
tation. 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 appro- 
priate 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- CLASS I.] 
323 
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 mentioned; 
viz., the effervescing draught, cold carbonic acid water, or small portions of 
ice. Small doses of one of the salts pf morphia are sometimes useful, 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. Ir- 
vine, 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 the flaky 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. 
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. Advantage may sometimes 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 stimulants, with a nutritious diet. Sulphate of quinia or the 
compound infusion of Peruvian bark, the mineral acids, capsicum, oil of tur- 
pentine, wine-whey, carbonate of ammonia, 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 de- 
gree 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 ter- 
minate. It is possible that the capsicum and oil of turpentine may be useful 
as alteratives to the mucous membrane of the stomach. Should any one of 
YELLOW FEVER. 324 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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 turpentine with laudanum, or one of the salts of morphia, is a 
combination sometimes especially useful. Of the oil from twenty drops to 
half a fluidrachm may be given at once, suspended in water by means of 
gum arabic, and repeated every hoqr. 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 im- 
mediately into convalescence; but, in other instances, though the primary 
fever may be apparently cut short, and the secondary fever prevented, yet the 
disease marches steadily onward to black vomit and a fatal issue, as in violent 
cases treated in the ordinary mode. (Ar. 0. Med. & Surg. Journ., n. 208.) 
In the comparatively mild epidemic of 1847, the quinia practice was found so 
satisfactory as to have been very extensively adopted in New Orleans; but in 
the very severe one of 1853 it was less successful; and the late Dr. Hester, 
editor of the N. 0. Med. & Surg. Journ., stated in the last number of that 
journal put forth under his supervision (vol. x. p. 404), that it had not proved 
satisfactory to those who employed it in the latter epidemic. In the preceding 
number (x. 279), he made the following statement. "In the commencement 
of the present epidemic, the advocates of large doses of quinia soon found 
that this article when given in sedative doses, failed to accomplish a cure, 
although the febrile symptoms gradually gave way to its use." 
Dr. H. R. Frost, of Charleston, S. C., has found the chlorate of potassa an 
excellent remedy in the febrile stage of the disease. After having freely 
evacuated the bowels, he gives the chlorate in the quantity of three or four 
drachms in divided doses during the twenty-four hours, employing at the 
the same time, when necessary, leeches to the temples, and iced-water to the 
head. (^Charleston Med. Journ. and Rev., viii. 182.) 
Throughout the treatment, especial attention should be paid to the tho- 
rough ventilation of the apartment, and to the preservation of personal clean- CLASS I.] 
325 
ENTERIC, OR TYPHOID FEVER. 
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 
bleeding when the excitement is great, a little magnesia now and then, foment- 
ations 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; 
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 exposure 
to the cause, it will be sufficient to remove and exclude strangers and children 
from the infected districts. 
Article IV. 
ENTERIC FEVER. 
Syn.-Typhoid Fever.-Typhus mitior.-Nervous Fever.-Abdominal Typhus.-Com- 
mon Continued Fever.-Entero-mesenteric Fever.-Dothinenteritis.-Follicular En- 
teritis. 
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 proba- 
bility is that it belongs to the whole human family, and is to be found in all 326 
GENERAL DISEASES.-FEVERS. 
[PART II. 
inhabited regions. Though long known in its different forms, its identity in 
these forms was not clearly perceived until after the researches of Louis, 
which, by determining its anatomical, in connexion with its exterior charac- 
ter, 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 
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 phlegmasiae 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 Sofhuv, 
pustule, and evtepov, 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 smallpox. 
Symptoms, Course, &c.-1The 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- CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
327 
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 inchoa- 
tive 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 minute, 
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 or more. 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 
experience's pains in the 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 in- 
stances, the occurrence of bleeding at the nose, which, however, is generally 
slight, and no otherwise important than as a sign. In very many cases, 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 pun- 
gent; 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 appear- 
ing red at the tip and borders; the stomach, though often retentive, is some- 
times irritable; diarrhoea is not unfrequent; transient pains are often felt in 
the abdomen, increased by pressure, especially in the right iliac region; and 
a slight degree of tympanitic distension in the bowels is discovered upon per- 
cussion, with a gurgling sound upon pressure by the hand. A cough fre- 
quently sets in, either dry, or accompanied with a slight mucous expectora- 
tion; 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. Deglutition' 
is sometimes painful or difficult. The abdomen is obviously distended, so as fre- 
quently 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 tympa- 328 
GENERAL DISEASES.-FEVERS. 
[PART II. 
nitic. 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 wfill 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 become more decided. Delirium or stupor often takes the place of 
the headache with wrhich the patient had been tormented. Ringing or buz- 
zing in the ears is followed by hardness of hearing, amounting sometimes to 
deafness. The eyes are often injected. The tongue is protruded with diffi- 
culty, and is occasionally observed to tremble in the effort. 
If the disease continue, a completely typhous condition is at length developed. 
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 either universally 
hot and dry, or hot in some parts wdiile it is cool in others ; and a peculiar 
unpleasant odour often exhales from the body ; subsultus tendinum, twitching 
of the facial muscles, and even epileptiform spasms sometimes make their ap- 
pearance. The patient is very feeble, lying on his back, and often slipping 
involuntarily down in the bed. He picks at the bedclothes, or at imagin- 
ary 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 occasional symptoms are in- 
voluntary fecal evacuations, retention of urine, hemorrhage 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 pro- 
duced 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 becomes 
either excessively frequent and fluttering, or slow and scarcely perceptible; 
the extremities become cool and clammy, or the whole surface is bathed in a 
clammy sweat; the abdomen is often enormously distended; hiccough some- 
times 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 abdominal 
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 severe 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 pendulum and half arches 
will, if examined, be found covered with an exudation, which they are begin- 
ning to part with. This is usually a sign of an approaching amelioration of CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
329 
the symptoms. If the tongue, when thus cleaned, remain moist, convalescence 
may be pretty confidently expected, though it is always tedious. In some in- 
stances, the tongue coats itself over again, and again becomes clean; and this 
change may take place more than once. Occasionally, too, a thrush-like exu- 
dation appears upon its surface. But still, if the moisture continue, the prog- 
nosis 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 promi- 
nent feature in the complaint, and have found it to yield most happily to treat- 
ment 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 de- 
gree of mischief to the organization which time only can repair. Sometimes 
months elapse before the patient recovers his usual health. The pulse remains 
long frequent, a febrile paroxysm somewhat resembling hectic occasionally ap- 
pears every day, there are copious and debilitating sweats at night, the appe- 
tite is feeble, and the bowels are disturbed by slight causes. Troublesome 
nervous symptoms also frequently occur ; such as wakefulness, depression of 
spirits, weakened memory, childish fretfulness, and sometimes a kind of im- 
perfect delirium or insanity, though this is rare. The lower extremities some- 
times become painful and edematous. Troublesome and tedious abscesses oc- 
casionally break out, especially near the parotid; and boils appear in various 
parts of the body. At length, these symptoms gradually disappear, the appe- 
tite 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 fatjil 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 
may take place on the sixth or seventh day; but so early a termination is 
very rare. 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 conva- 
lescence 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 con- 
valescent before the end of the third or fourth week; and not unfrequently 330 
GENERAL DISEASES.-FEVERS. 
[PART It. 
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, ag 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 
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 dis- 
ease. The diarrhoea sometimes precedes the fever; but more frequently com- 
mences during the first twenty-four hours after the attack, and is occasionally 
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 yellowish 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 de- 
pends upon the inflammation or irritation of the mucous membrane; but has 
not been found to bear any fixed relation to the characteristic disease of the 
aggregated intestinal glands. It is generally attended with pains in the- ab- 
domen, 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 have very seldom witnessed a case without some degree 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 
may be a slight increase of tension in the abdominal parietes; but percussion 
is necessary to the certain detection of the symptom. It increases as the dis- 
ease 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 dis- 
tension 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 larger, often slightly prominent, and dis- 
appearing 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, CLASS I.] 
331 
ENTERIC, OR TYPHOID FEVER. 
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 men- 
tioned 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. As the disease has occurred to my own observation, they are very 
seldom absent; and I have no doubt that, from their small number, faint- 
ness, and fugitive character in many cases, they are often only overlooked 
where they are supposed to be wanting. 
These spots must not be confounded with petechiae, which also appear in 
this disease, but are not peculiar to it. The latter can scarcely be considered 
strictly as an eruption; consisting merely of blood extravaJsated in the skin. 
They are distinguishable usually by their more livid colour, by never project- 
ing above the surface, and by not disappearing upon pressure. They occur 
much less frequently than the rose-coloured eruption, and are more common 
in genuine typhus fever than in the enteric. Sometimes the hemorrhagic 
effusion is more extensive, consisting of patches or vibices. 
Sudamina are minute vesicles, generally about the size of a small pin's 
head, but sometimes larger, either circular or oval, and, in consequence of 
their minuteness and transparency,-often requiring to be viewed obliquely in 
order to be seen. They may frequently be detected by the touch. They 
occur 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 affec- 
tions 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 332 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 not an 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, 
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 petechias 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 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 CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
333 
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 sometimes 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 unfrequently 
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 
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 
defective sensibility, urine accumulates in the bladder so as to produce con- 
siderable distension before the want of micturition is felt; and then the mus- 
cular 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. Enor- 
mous 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 
coexistence of tympanites, the distension of the bladder may be usually de- 
tected 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 oc- 
casionally albuminous, especially in severe cases, in which this character of 
the secretion must be considered as an unfavourable sign. {Archives Generales, 
4e ser., xv. 545.) Dr. J. W. Begbie, of Edinburgh, has found it frequently 
albuminous in the advanced stages, and has noticed that in the fatal cases this 
impregnation continues until death, while, in those which recover, it sometimes 
disappears when convalescence is completed, and sometimes persists for an 
indefinite period afterwards. {Ed. Month. Journ. of Med. Sci., Oct. 1852, p. 
384.) Mr. G. W. Edwards has found the urine in the early stages invariably 334 
[part II. 
GENERAL DISEASES.-FEVERS. 
destitute of albumen, but heavier than in health in consequence of the excess 
of urates. He thinks that albumen appears only when the crisis is past. 
(Ibid., Sept. 1853, p. 236.) 
Varieties and Complications.-Though the description above given is ap- 
plicable 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 nervous disorder, 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 less 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 disorder, 
little heat of skin, no great prostration, and no typhous phenomena. The 
disease may thus run on for several weeks, exciting little solicitude, except by 
its obstinacy. I have been repeatedly called in consultation, in such cases, 
and have been able to detect their true nature by an examination of the ab- 
domen, 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, 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 enteric fever, we have 
much nausea and vomiting, often of bilious matter, tenderness of the epigas- 
trium, and not unfrequently yellowness of the conjunctiva or the skin. These 
cases may be readily 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 ordi- 
nary dry or mucous cough and bronchial rales, with little or no oppression, 
we have a tenacious or bloody expectoration, shortness or difficulty of breath- 
ing, sometimes pain in the chest, and the physical signs of crepitation and 
dulness, indicating the supervention of pneumonia. 
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 CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
335 
consequence of deficient action in the brain, dependent either on a direct loss 
of power, or an altered state of the blood. When occurring in the earlier stages, 
without the signs of general prostration, 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. Now and then cases occur in which the cerebral 
symptoms are precisely those of meningitis, but in which after death no me- 
ningeal inflammation is detected, but much intestinal disease. The probability 
is that, in such cases, the cerebral disorder is caused by the irritation of the 
enteric affection transmitted to the nervous centres in the brain. 
There is still another set of cases, in which the typhous element seems to 
predominate. Fronrthe beginning, there is an obvious deficiency of general 
power. The feeble, though perhaps frequent pulse, the obvious sensorial de- 
bility, the tendency to black sordes upon the tongue and teeth, the petechial 
and hemorrhagic disposition, the dark stools, the peculiar typhous odour, and 
the speedy and great prostration of strength, are evidences of this condition 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 
kidneys 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 characteristic symp- 
toms are entirely wanting, and nothing calls attention to their true nature, 
until, perhaps, perforation of the bowels takes place, or death from some other 
cause reveals the existence of the peculiar intestinal affection. 
Dr. J. H. T. Beau has described a species of acute paralysis, characterized 
by intense subsultus tendinum or muscular trembling, with difficult articula- 
tion, fever, and low delirium soon terminating in coma, which he has noticed 
as occurring during convalescence from enteric fever. The affection always 
ends fatally in a period varying from three to six days. The most constant of 
the lesions found after death is softening of the cortical substance of the brain, 
attended sometimes with cerebral congestion, and injection of the vessels of 
the pia-mater. The same affection sometimes occurs in the course of the fever, 
and has been noticed in the convalescence from other diseases, but never as 
an original affection. He proposes to call it general acute palsy. (Archives 
Centrales, 4e ser., xxviii. 5.) 
Anatomical Characters.-There 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 affec- 
tion of the elliptical patches of those peculiar minute bodies 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 smallpox. It has, in 
fact, come to be regarded almost as a necessary post-mortem test of the exist- 
ence of the disease. The affection had been observed by various pathologists, 
as by Stark, Petit, and Bretonneau; but it is to Louis that the credit is espe- 
cially due of fixing its precise relation fee this form of fever. The facts ascer- 
tained by the last mentioned pathologist, in relation to the enteric fever of 
Europe, have been amply proved to be equally applicable to the disease, as 
it prevails in the United States. 336 
GENERAL DISEASES.-FEVERS. 
[PART II. 
The opportunity is seldom offered of ascertaining the condition of the glands 
of Peyer in the earliest period of the disease. They have been examined, how- 
ever, at all stages after the sixth day. At first the patches are qbserved 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 more than 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 inflammatory 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 mammillated, with innu- 
merable small orifices, which give it a reticulated appearance ; a condition 
which is ascribed by Louis to an enlargement of the several follicles. This 
character is lost in the progress of the affection; the surface becoming uniform, 
smooth, and still softer. Sometimes 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 num- 
ber from one up to thirty, averaging perhaps ten or twelve. They appear upon 
the surface of the intestine opposite to the mesentery. They do not all origi- 
nate at once, but in general come successively, those near the ileo-caecal 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 
developement, the oldest being most advanced. Those highest in the intestine 
are sometimes but just visible, while the lowest are in a state of ulceration. 
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 
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 cae- 
cum. The perforation is produced either by the progress of ulceration, by 
mortification 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 ele- 
vated 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. Rilliet and Barthez state, as the result of their observation, that, in CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
337 
the cases of children, the diseased patches are almost always of the soft variety, 
that the submucous 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 minute solitary closed glands of the ileum, frequently though erroneously 
denominated the glands of Brunner, from which they differ anatomically as 
well as in position, the true glands of Brunner being provided with excretory 
ducts, and 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 bodies 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 qp grayish colour, though 
more generally reddened. 
The mesenteric glands are as constantly diseased as those of the mucous 
membrane. Those corresponding with the morbid patches are most affected, 
but not exclusively 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.* 
* Certain German pathologists, among whom are Rokitanski and Engle, have put 
forth an opinion, that there is a morbid condition of the blood in typhus fever, dis- 
posing 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. The 
deposit may take place in various organs, as the spleen, lungs, intestinal mucous mem- 
brane, mesenteric glands, &c. It is of a yellowish, reddish, or brownish colour, at 
first of a rather firm consistence, but ultimately softening, and in the end either ab- 
sorbed, or discharged by ulceration, &c. This opinion appears to be applicable to 
enteric or typhoid fever, between which and phthisis some analogy has long since been 
noticed, allowance being made for the acute character of the former, and the chronic 
character of the latter. As the typhus of the continent of Europe is in fact the enteric 
fever, or typhoid of Louis, it is to this affection, and not to the proper or British typhus, 
that the remarks of Rokitanski must be considered a£ applicable. Prof. Bennet, of 
Edinburgh, noticed the deposit referred to in the fever which prevailed in that city in 
1846-7. Out of 63 cases examined by him, 10 presented the deposit in the spleen, 
15 something analogous to it in the lungs, and 19 the disease of the glands of Peyer, as 
described by Louis, &c. (Ed. Monthly Journ. of Med. Sci., Oct. 1847.) There can scarcely 
be a doubt that these were cases of enteric or typhoid fever. Dr. Wm. Jenner has noticed 
in this disease a deposit similar to that of Peyer's patches, and of the mesenteric glands, 
in the spleen, the walls of the gall-bladder, the lungs, and the kidneys. (Lond. Med. 
Times and Gaz., vi. 287.) The substance thus deposited appears to be an exudation 
possessed of feeble powers of organization, in consequence of which it soon loses its 
vitality, and passes under the influence of chemical laws, being thereby softened, and 
partially at least converted into a puruloid liquid, such as is sometimes seen in the 
diseased mesenteric glands of enteric fever. Dr. Jenner suggests that the change may 
be a process of fatty degeneration, which is very probable. In the intestines, this 
softened matter is thrown off by ulceration; in the mesenteric glands and spleen it is 
probably absorbed. The idea has been advanced that the typhoid matter, like the 
tuberculous and cancerous, might have peculiar characteristic cells; but none such, I 
believe, have been observed under the microscope. (Note to the second and fourth editions.) 338 
[part JI. 
GENERAL DISEASES.-FEVERS. 
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, ulcer- 
ated, coated with false membrane, or infiltrated with pus. The oesophagus 
was ulcerated about as frequently, the ulcers being generally small, and some- 
times numerous. The gastric mucous membrane was more frequently quite 
natural than in subjects who had died of any other acute disease ; but it was 
nevertheless often morbid, being softened, reddened, thinned, mammillated, 
ulcerated, &c. The softening, which is the most frequent lesion, though some- 
times 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 enormously so. Oc- 
casionally isolated closed glands 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 membrane 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 conditioq.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 often reddened; 
and signs of congestion, inflammation, or apoplectic sanguineous effusion, are 
sometimes 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 satisfac- 
tory connexion has been traced between these lesions and the symptoms of 
cerebral disorder 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 in- CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
339 
sufficient 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 resi- 
dent 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 
with it. This has been observed in Paris. I have often noticed it in Phila- 
delphia. 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. Journ. of Med. Sci., 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 imparted to others. 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 very seldom in- 
deed 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. I have attended a female patient who died of the disease in 
her fifty-fifth year. From the above statement it would appear not to occur 
in children below puberty. But the cases referred to were in hospitals, where 
I presume children are not admitted. The fact, at any rate, is, that the dis- 
ease 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. 340 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 predisposi- 
tion 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 
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 de- 
composing animal excretions, the contagious miasm of typhus itself, epidemic 
influence, and even marsh miasmata, may act as exciting causes of the disease 
in the predisposed. Admitting this to be the case, we are furnished 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 predisposition into action, may 
produce that sort of complication, which we occasionally witness, of the re- 
mittent or bilious and enteric fevers. Even the occasional apparent contagious- 
ness 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 bring into action other 
disorders to which the system may be predisposed from inherent causes, or 
from external, such as epidemic influence. Hence, perhaps, the seeming con- 
tagiousness, 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 pheno- 
mena resulting from this affection, just as the fever 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 glands is a sort of 
internal eruption, like that of smallpox upon the skin, and, like it, merely a 
characteristic attendant upon the complaint. It is not, indeed, certain that 
this glandular 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 CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
341 
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 
to the general loss of power incident to the Jong continuance of the fever, and 
especially to the depravation of the blood, arising from disease of the struc- 
tures 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 hue 
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 vomit- 
ing 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, epis- 
taxis, 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 considerable 
resemblance, 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. 
The different forms of acute tuberculosis, especially in children, are 
sometimes difficult to diagnosticate from enteric fever, which they often very 
closely resemble in their symptoms and course. Whether the tuberculization 342 
GENERAL DISEASES.-FEVERS. 
[part II. 
affects the membranes of the brain, the lungs, or the peritoneum, there are 
often many points of resemblance; but, with attention directed to the subject, 
and a recollection of the more characteristic symptoms of enteric fever-the 
epistaxis, the dulness of countenance, the diarrhoea with the generally healthy 
looking stools, the tympanites, and especially the rose-coloured spots, there 
can in general be no great uncertainty in the diagnosis after a due period of 
observation. Dr. Wm. Jenner deserves credit for calling attention to this 
subject. (See Land. Med. Times & Gaz., May, 1853, p. 464.) 
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 
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 ^o 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 pro- 
bably 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 
* Out of twenty-one cases of the fever, treated by myself in the Pennsylvania Hos- 
pital during the term of my attendance in the winter of 1850-51, but one proved fatal. 
The same proportion of deaths occurred in the following winter. In the winter of 
1852-8, the number of cases was thirteen, and of deaths two, or one to six and a half. 
In the winter of 1853-4, the number of cases treated was thirty-one, and of deaths one. 
The general average of deaths for the four years, was, therefore, one out of seventeen 
cases. The cases admitted into the Hospital were of all grades of severity from the 
mildest to the most severe, and in all stages from the very commencement to near the 
close. The treatment employed was that recommended in this work. (Note to the 
fourth edition.) CLASS I.] 
ENTERIC, OR TYPHOID FEVER. 
343 
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 com- 
plete delirium, a notion on the part of the patient that nothing is the matter 
with him, profound coma, stertorous respiration, excessive subsultus or epi- 
leptic spasms, rigidity of the limbs and eyelids, abundant diarrhoea, hemor- 
rhage from the bowels, involuntary discharges, great prostration, extreme 
feebleness and frequency of pulse amounting to 130 or upwards, coldness 
and clamminess 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 tongue to become 
moist and clean. The younger the patient, and the better his previous state 
of health, the more favourable is the prognosis. 
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 active 
purging. 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 very 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 
advisable, when there is pain at the same time with diarrhoea, to administer 
castor oil with fifteen or twenty drops of laudanum. Afterwards, throughout 
the complaint, the state of the bowels should be attended to. If the evacua- 
tions 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 
laxatives, and those in small doses, will be sufficient. A fluidrachm or two 
of castor oil, a single Seidlitz powder, one or two drachms of Epsom salt, or 
half a drachm of magnesia may be given for a dose, and repeated if neces- 
sary. The magnesia should be preferred, when sourness of the breath indi- 
cates the presence of acid in the circulation. Rhubarb or one of its prepa- 
rations 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 be 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 this 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 344 
[part II. 
GENERAL DISEASES.-FEVERS. 
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 seldom be proper to employ 
it after the first four or five days; though local bleeding may be resorted to 
at almost any stage, when called for by inflammation or active congestion of 
particular organs, even though there may be great debility, care being taken 
to proportion the amount of blood abstracted to the strength. I have known 
much advantage to accrue from the loss of an ounce or two of blood, in the 
most advanced stages, from the neighbourhood of a congested or inflamed 
organ. Leeches or cups to the temples or back of the neck, in cases of cere- 
bral fulness or excitement, to the chest in cases of oppressed respiration, 
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 dis- 
posed to irritate the bowels, and, when freely employed, have too sedative an 
influence except in the earliest stages. I prefer the citrate of potassa, in the 
form of neutral mixture, or effervescing draught. (See U. S. 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 
symptoms 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 use- 
fully 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 the 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 exist- 
ence of stupor does not contraindicate the remedy, a dose of Dover's powder, 
or an equivalent quantity of opium and ipecacuanha in pill, or some other 
preparation 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 application may be extended to 
the whole surface. In cases attended with much debility, diluted spirit may 
be substituted. The patient should also be allowed cold drinks, and, if he 
wish it, a little ice in his mouth, when not greatly prostrate.' 
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 
tender 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 acetate of lead, kino, extract of rhatany, or pure tannic acid may CLASS I.] 
345 
ENTERIC, OR TYPHOID FEVER. 
be added, if necessary. Nervous symptoms, such as restlessness, general 
uneasiness, jactitation, wakefulness, and slight subsultus, may often be quieted 
by sweet spirit of nitre, Hoffmann's anodyne, or camphor water; and opiates 
may be 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 
dryish, the skin dry, and the urine scanty. The pulse, though perhaps more 
frequent, is neither so full nor so strong as at first. Some degree of delirium, 
or an increase of stupor often supervenes, and the abdomen becomes tympa- 
nitic. Without any diminution in the violence of the disease, a close ex- 
amination 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 in- 
dicated as an antiphlogistic remedy. One of the great dangers is now dis- 
organization from inflammation of some important organ. After direct deple- 
tion, nothing is so efficient in arresting this process as mercury. At the 
present stage of enteric fever, general 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 mercury 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 impression 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 irri- 
table, this may with great propriety be associated with small doses of ipeca- 
cuanha, which tends to soften the skin and promote bronchial secretion; and 
opium is frequently also an excellent addition. In cases admitting this com- 
bination, 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 connexion with it, ac- 
cording to the condition of the skin, and the state of the pulse, being always 
indicated when the surface is hot and dry, and the circulation accelerated, but 
not much enfeebled. The mercurial should be continued until the gums 
are slightly touched, and then either diminished gradually, or omitted. Un- 
der 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 avoided. 
But, should the symptoms not yield; especially, should the tongue become 
very dry, and the abdominal distension remain undiminished, the oil of tur- 
pentine will prove an excellent remedy. I cannot too strongly impress upon 
the profession 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. But there is a particular condition, and that a not uncommon and 
sometimes a very dangerous condition, in which I have very often employed 
it, and hitherto have very seldom known it to fail. In the description of the 
* R.-Mass. pil. hydrar^ gr. xij; Ipecacuanhas pulv. gr. ij ; Opii pulv. gr. ij; Aquss, 
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. 346 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 calculated on. But it not infre- 
quently 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 certainly 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- 
csecal 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 employ it in similar cases. I did 
so, and, as before stated, have seldom found it to fail, under the circumstances 
mentioned, though I have very frequently employed it, both in private and pub- 
lic 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 emulsion with gum arabic, loaf sugar, and water; 
a little laudanum being occasionally added, if it disturb either the stomach 
or the bowels. My usual dose is ten drops every two hours. In the course 
of twenty-four, or at most forty-eight hours, some amelioration of/the symp- 
toms may be observed. The tongue becomes gradually moister, and covers 
itself with a whitish fur; the tympanitic distension ceases to augment, and 
after a 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 
* At the time of the publication of the second edition of this work, I had met with 
no unsuccessful case, where the oil of turpentine was used in the particular condition 
referred to in the text, however unpromising the symptoms might have appeared. 
Since that period, I have had two fatal Cases in the Pennsylvania Hospital, which, 
however, upon post-mortem examination, exhibited pathological conditions which 
amply accounted for the failure. 
In one of these cases, an enormous amount of disease was found in the ileum; the 
patches exceeding, in number, size, and elevation, any that I remember to have seen be- 
fore, and obviously beyond the reach of remedies. 
In the second case, the patient was apparently doing well under the oil of turpentine. 
The tongue had become moist, the abdominal distension was diminishing, and the case 
was exhibited to the attending class as in a fair progress towards convalescence. Sud- 
denly, thh symptoms of violent peritonitis came on, and death occurred in six or seven 
hours. Examination showed the ulcerated glands of Peyer in a healing state; but, on 
slitting up the ileum, about two feet from the caecum, the orifice of a pouch presented 
itself, from half to three-quarters of an inch in diameter, which descended between the 
laminae of the mesentery for about an inch and a half, and at the bottom exhibited a 
small ulcer, probably in one of the isolated glands, which had perforated the coats of 
the bowel, and allowed the escape of its contents. The oil of turpentine had not been 
able to reach this ulcey at the bottom of the cul-de-sac, filled as it was with mucus, and 
consequently had not exercised the same curative influence upon it, as had been produced 
in the accessible ulcerations of the general surface. The specimen is now in my pos- 
session. (Note to the. third edition.) CLASS I.] 
ENTERITIC, OR TYPHOID FEVER. 
347 
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 seen them yield immediately to this remedy. I will repeat, that 
the oil of turpentine may be used, with great hope of benefit, in any case of 
enteric fever, in the advanced stage, with a dry tongue; but, in the cases 
above referred to, with confidence of success, so far as an experience of more 
than thirty years may be admitted as a ground of confidence.* I have also 
seen it strikingly useful in the advanced stages of lingering cases in which, 
though the tongue may be whitish and moist, there seems to be some impedi- 
ment to recovery, probably connected with an indisposition of the ulcerated 
surfaces to heal. Such cases, under the use of the oil, often enter imme- 
diately into convalescence. 
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 debili- 
tating 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 in- 
crusted with dark sondes, 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 oftener 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 con- 
trary, 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. Upon the whole, the most suit- 
able stimulant is probably wine-whey, of which from a tablespoonful to a wine- 
glassful may be given every two hours. When the strength is beginning to 
decline, without any abatement of the ^brile heat, it maybe alternated, in the 
smallest dose mentioned, with the neutral mixture. Afterwards, it may be given 
in conjunction with the mercurial, or with the oil of turpentine. As the 
strength becomes reduced, it is often advisable to superadd carlaonate of am- 
monia; and it may be necessary to have recourse to the more powerful in- 
fluence of pure wine or brandy.f In cases of sudden and great prostration, 
* See a paper by the author on the use of oil of turpentine in Fevers, in the 2V. Am. 
Med. and Surg. Journ., i. 272, April, 1826. 
In a letter to the author, dated Feb. 5th, 1850, Dr. T. S. Jarmon, of Tennessee, states 
that he has found a mixture of copaiba with the oil of turpentine, in equal proportions, 
to succeed better than the oil alone. 
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 
may be used. R. Ammonite carbonat. ^ij; Acacise pulv., Sacch. alb. aa gij ; Aq. menth. 
p., vel Aq. fluv. f^vj. Misce. From a teaspoonful to a tablespoonful 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, Brandy 
is often advantageously administered in the form of milk-punch, made with one part of 348 
GENERAL DISEASES.-FEVERS. 
[PART II. 
sulphuric ether may be employed. 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 perspiration. 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 stimu- 
lant ; in the dose, for example, of half a grain or a grain every four, six, or 
eight hours. Tonics may often be advantageously combined with the more 
diffusible stimulants; and, in some cases in which the debility is not great, 
may be substituted for them. 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 re- 
mittent or proper typhus. Either the compound infusion (U. S. Ph.), or sul- 
phate 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 moderate 
doses frequently repeated, and omitted if found materially to disturb the 
stomach, or to increase the fever. The large doses of quinia, sometimes re- 
commended, 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, and at present use it less than 
formerly. When coldness of the skin is connected with debility, powerful 
rubefacients should be used in connexion with the internal stimulants. 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 tbighs or to the trunk, care being taken 
not to leave them on longer than is necessary merely to produce 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, assafetida, and camphor. Some- 
times 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 ordinary remedies fail, recourse must be had to plug- 
ging 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 the pulmonary congestion which is occasionally an alarming 
feature of the advanced stages, much good will accrue from the extensive ap- 
bi'andy and two parts of milk, and given in doses of one, two, or three tablespoonfuls 
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.] 
ENTERITIC, OR TYPHOID FEVER. 
349 
plication of dry cups over the chest. 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 formation 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. 
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. MitchelJ, Professor of the Practice of Medicine 
in the Jefferson College of Philadelphia, has had great success with the in- 
ternal 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 exceedingly 
effectual.f Alum and chloride of soda have also been severally recommended 
as having specific virtues. The mercurial treatment has recently been recom- 
* A case came a few years since under the notice of the author, in which, during ap- 
parent convalescence from an attack of the fever, when the pulse had become natural in 
frequency, and all the symptoms were favourable, the patient was suddenjy attacked 
with violent pain in the right iliac region, extending over the right side of the abdomen, 
with great distension, exquisite tenderness on pressure, and extreme frequency of the 
pulse. It was the opinion of Dr. Gerhard, who was the attending physician, and my- 
self, that perforation had taken place. We put the patient under the powerful influence 
of morphia, applied a blister over the abdomen, and had the satisfaction to see our 
patient ultimately recover. (Note to the third edition.) 
A similar case has since occurred to the author in the Pennsylvania Hospital with 
the same favourable result, for the particulars of which the reader is referred to the 
Transactions of the College of Physicians of Philadelphia (N. S. i. 418.) It must be con- 
fessed, however, that the value of such observations is diminished by the publication of 
certain cases by Dr. Thirial, which go to prove that violent and fatal peritonitis, which 
might readily be mistaken for peritonitis from perforation, occasionally occurs in enteric 
fever without any discoverable opening in the bowel. (See Philad. Ned. Examiner, N. S. 
x. 120.) 
f 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 on the 
subject, dated' Lancaster, Nov. 4th, 1848. " 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 symptoms 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 combating 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 the 
second edition. 350 
GENERAL DISEASES.-FEVERS. 
[part II. 
mended as a novelty in France, having been introduced into notice by M. 
Serres, who employs the black sulphuret of mercury internally, and frictions 
over the abdomen with mercurial ointment; and M. Becquerel claims great 
success for this treatment. I havq, been in the habit of employing mercury 
carefully in bad cases of the disease for more than twenty years, and have 
recommended it in this work since its first publication. 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 pro- 
portioned to the urgency of the symptoms. 
Large doses of sulphate of quinia have been recommended in the early 
stages as an abortive to the fever; but I have already stated my belief, founded 
both on experience and my views of the nature of the disease, that this treat- 
ment must fail in enteric fever. Small and frequently repeated doses of 
morphia have been recommended as an exclusive treatment by Dr. H. N. 
Bennett, of Connecticut (W Y. Journ. of Med., N. S., viii. 357); and Dr. W. 
C. Norwood, of S. Carolina, speaks favourably of the American hellebore or 
Veratrum viride, which, however, if used at all, should be employed with 
great caution. 
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 Iridian meal, molasses and water, vegetable jellies 
mixed with water, and other similar preparations may be successively, or 
interchangeably employed; and the patient maybe allowed, if he desire it, to 
swallow tiie 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 wine- 
glassful to be given every two or three hours, or less frequently, according 
to the apparent strength of the patient. A cup of tea may also be allowed, 
with dry 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. It 
may be added also to the farinaceous preparations already referred to. In 
the last, or prostrate stage, it is proper that the diet should be not only nu- 
tritious, 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. (Seepage 224.) 
Throughout the whole case, the greatest attention should be paid to clean- 
liness and ventilation ; and, when the atmosphere cannot be sufficiently puri- 
fied 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 CLASS I.] 
TYPHUS FEVER. 
351 
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 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 parox- 
ysm occurs every afternoon, and the patient sweats copiously at night. Under 
these circumstances, I have foun^l 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 
convalescence, 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 probably 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 or typhoid condition of bilious fever, yellow fever, smallpox, measles, 
pneumonia, dysentery, &c.; or, with greater brevity, of typhous pneumonia, 
typhous dysentery, &c.; by the latter phraseology, however, generally imply- 
ing a more thorough incorporation of the typhous constituent with the prin- 
cipal 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 non-identity 
with the disease styled in this work enteric fever, but more generally known 
as typhoid fever. Many consider the two as constituting varieties of the 
same disease, differing only in the superaddition of a certain intestinal affec- 
tion, in the case of enteric fever. A greater number probably 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. 352 
GENERAL DISEASES.-FEVERS. 
[part II. 
Differences between the two diseases sufficiently fundamental, in his estima- 
tion, to justify this opinion, will be pointed out under the heading of diag- 
nosis. It is sufficient here to say that, from the time of Huxham downwards, 
authors have observed such obvious and important differences in the symp- 
toms 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 oppor- 
tunities of seeing the proper typhus fever, which prevailed epidemically in 
different parts of the United States, beginning in New England so early as 
1807, reaching our own neighbourhood in the winter of 1812-13, and con- 
tinuing to lurk in the lanes and alleys, among the crowded poor of Philadel- 
phia, until the year 1820-1821, 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 extinguished. During 
the eight or nine subsequent years, though prescribing in the Pennsylvania 
Hospital during one-third of each year, 1 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 in- 
flammatory in the beginning and becoming typhoid in its progress, which 
was formerly designated among us as nervous fever, slow remittent, &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 
obvious 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 conse- 
quence 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 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 
confounded with that disease; though post-mortem examination will almost 
always detect the difference, even here.* t 
* Since the above account was written, we have had ample opportunities of witness- 
ing typhus fever in the Pennsylvania Hospital, occurring among the emigrants from 
Ireland during the year 1847 and subsequently. My views have not been altered by 
these cases. Among the emigrants there have been some with enteric fever, as there 
always had been, at the periods when none came with typhus. But the greater num- 
ber, originating on shipboard, were of the latter affection. In general, there has been 
little difficulty in making a diagnosis between the two classes of cases, during the pro- 
gress of the disease; and, in every fatal case that has occurred, the correctness of the 
diagnosis has been established by the result of post-mortem examination. In accordance, 
however, with what has been stated in the text, there have been a few obscure cases, 
which may have been mixtures of the two diseases, but the precise pathological cha- 
racter of which we had no means of determining with certainty, as they recovered.- 
Note to the fourth edition. CLASS I.] 
353 
TYPHUS FEVER. 
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 some- 
times exceedingly 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 occui- 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 alternation 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. In general the 
bowels are costive, and stools are not 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- 
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. 354 
GENERAL DISEASES.-FEVERS. 
[part II. 
A characteristic eruption now generally makes its appearance, which gives 
the disease a claim 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 cases. 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. Though usually very nume- 
rous, they are sometimes 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, 
which sometimes also appear 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 has been especially 
the case with the disease as it has appeared among the emigrants from Europe. 
The abdomen is sometimes quite flat, sometimes moderately swollen and tym- 
panitic. The urine is usually scanty. The colour of the face deepens, some- 
times 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 
rooms, in which numbers of persons, diseased or otherwise, have been long 
crowded together, and no attention paid to ventilation or cleanliness. 
According to the observations of Mr. G. W. Edwards, the urine is gene- 
rally pale, of a rather low specific gravity, and in the early period of the dis- 
ease uniformly contains albumen. (Ed. Month. J. of Med. Sci., xvii. 235.) 
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 CLASS I.] 
355 
TYPHUS FEVER. 
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. 
Sometimes 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 restless- 
ness and jactitation occur, with 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 sup- 
port him, and no power of his own to check his descent. This has been de- 
scribed to me, after recovery, as a most horrible feeling, worse even than 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 some- 
times 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, amoiAiting 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 i» 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 
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 
preceded by convulsions. When it takes place at an earlier period of the dis- 
ease, 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 [part II. 
356 
GENERAL DISEASES.-FEVERS. 
symptoms generally, and a return of consciousness. Not unfrequently con- 
valescence is ushered in by some incident which may be considered as forming 
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 imperceptible 
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 in- 
convenience 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, 
and is perhaps most frequent from the ninth to the»twelfth day. It may also 
occur at a much later period. 
Varieties.-These are such as arise from differences in degree, and from 
complications. Sometimes the disease is very mild, exhibiting only the ordi- 
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 frequently called congestive. Their danger probably de- 
pends 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 attending 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 
* 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 intestinal 
glands. (See Bost. Med. and Surg. Journ., xxxvii. 16, 34, &c.) CLASS I.] 
357 
TYPHUS FEVER. 
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 not more than 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 
mechanical congestion of the blood in the posterior portion of the lungs may 
give a peculiar tendency. For an account of the diagnostic symptoms of this 
affection 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 mur- 
mur, the existence of a crepitant or subcrepitant rale, and dulness on percus- 
sion 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, diarrhoea or dysentery sometimes occurs, in consequence of in- 
flammation 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 occa- 
sionally complicated with erysipelas. It is highly important that the prac- 
titioner 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 unfrequeutly 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 con- 
sidered 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, some- 
times dark-coloured coagulum, without the buffy coat. In consequence of 
the developement 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 globules. 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 generally below, and the red corpuscles above their normal propor- 
tion. (Am. Journ. of Med. Sei., N. S., xv. 31.) MM. De Mussy and 
Rodier found the blood lighter than in health, the red corpuscles sometimes 
in normal proportion, sometimes considerably diminished, the fibrin either 
normal in quantity or diminished, and the serum remarkably diminished in 
density. (See N. K Journ. of Med., N. S., xiii. 124.) 
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, 358 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 
without the granular appearance of hepatization. 
The gastric mucous membrane is often reddened, much softened, and some- 
times mammillated; that of the intestinal canal is frequently free from disease, 
though sometimes found inflamed, and even ulcerated, in cases complicated 
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. The blad- 
der not unfrequently presents evidences of inflammation. (Macgreggor, Lond. 
Med. Gaz., March, 1851, p. 411.)f 
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 crowded within confined and ill-ven- 
tilated places, in which the filth from the excretions is also allowed to accu- 
mulate. Hence, the disease has often made its appearance in camps, prisons, 
ships, hospitals, garrisoned cities, &c.; and hence, too, it is usually most pre- 
valent 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 
* 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. 
(Note to the second edition.') 
f There is reason to believe that the deposition in various organs of a peculiar matter 
supposed to be characteristic of typhus fever, and therefore denominated typhous matter, 
belongs not to the fever now under consideration, the proper typhus, but to the enteric 
or typhoid fever, under which head the reader will find it referred to. (Sw page 337.) CLASS I.] 
TYPHUS FEVER. 
359 
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 whatever 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 §ick, and 
that produced, in some inexplicable manner, during epidemics. If we sup- 
pose 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, 
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 exer- 
cise 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 ad- 
vanced 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 cer- 
tain 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 con- 
fined 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 latitudes, per- 
haps because dwellings are so much more open to 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 360 
[part II. 
GENERAL DISEASES.-FEVERS. 
powers of the nervous system, and vitiates the blood. All the local conges- 
tions, and the low imperfect inflammations which attend the disease, are 
obviously 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 sordes 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 I)r. Gerhard, of Philadelphia, for the means of 
an accurate diagnosis. It was in the results obtained by the careful post- 
mortem examinations, made in the Philadelphia Hospital by that distin- 
guished pathologist, in conjunction with Dr. Pennock, and their no less care- 
ful investigation of the symptoms during life, that we first obtained positive 
proof of an essential distinction between the two diseases, which Louis himself 
had previously been disposed to consider identical. Numerous and very care- 
ful observations subsequently made by Dr. W. Jenner, in the London Fever 
Hospital, fully coincide in their results with those of our own countrymen. 
The following 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 diar- 
rhoea, or extraordinary susceptibility to the action of purgatives, which almost 
uniformly attends the latter disease, it is frequently accompanied with con- 
stipation; and, when fecal discharges are obtained, they are usually darker 
and more offensive. But hemorrhage from the bowels, which is not unfre- 
quent 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 con- 
junctiva, and much greater debility. The eruption in typhus also differs from 
that of 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; doesnot appear in successive crops; and, instead of 
being confined chiefly to the abdomen and chest, is found equally upon the 
extremities, probably still more on the back, and is often diffused over almost 
the whole body. There is sometimes, however, in typhus, an 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. Sar- 
gent," Am. J. of Med. Sci., N. S., xiv. 532.) In typhus fever the abdomen 
is often flat, and perfectly free from tympanites, which is almost 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 inflammation in the latter. Enteric fever is of considerably 
longer duration than typhus. Dr. Jenner found the average duration of fatal 
cases of the former twenty-two days, of the latter fourteen. The urine, which, 
according to Mr. G. W. Edwards, is uniformly albuminous in the early stages 
of typhus, is so in the enteric only towards the close. 
The anatomical characters of the two diseases are very different. The 
peculiar disease of the glands of Peyer, and of the mesenteric glands, so con- 
stantly 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. CLASS I.] 
TYPHUS FEVER. 
361 
Dr. Jenner states that the spots which appear in typhus during life remain 
after death, while no traces of those of enteric fever are visible. 
There are points of difference also 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 
affections 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.* 
* RELAPSING FEVER.-This is another peculiar disease, which, with the enteric 
and typhus fevers, has generally been classed in Great Britain, under continued fever. 
Though we have no certain proof of its existence in America, it will be proper to de- 
scribe it briefly; as, if not here at present, it may readily be imported, and take root 
among our customary diseases. 
The first known reference to it is contained in Rutty's History of the Diseases of Dub- 
lin, in which place it appears to have prevailed epidemically in 1739, and in several 
subsequent years. In 1817-18, it occurred at Edinburgh, and was described by Drs. 
Welsh and Christison. In the years 1842 and 1843, it again made its appearance in 
the same city; and it was through the published descriptions given of it, on this occa- 
sion, by Drs. Mackenzie, Cormack, Craigie, and others, that it came to be generally re- 
garded as a distinct affection. In 1847, it appeared at London, where it was carefully 
examined by Dr. William Jenner, whose investigations have confirmed the conclusions 
of the Edinburgh physicians. There can be little doubt that it occurs also on the conti- 
nent, as it has been recognized in the descriptions of various German writers. The 
probability is, that it is a not uncommon disease in Europe, but has escaped general 
notice from being confounded with other fevers. (For references to various authorities 
in relation to it, see the British and Foreign Medico-Chirurgical Review for July, 1851.) 
The name of relapsing fever, by which it will probably be known hereafter, was derived 
from one of its most striking peculiarities. It has also been called five-day fever, seven- 
day fever, bilious remittent fever, mild yellow fever, &c. 
Symptoms, Course, ^c.-Though sometimes preceded by the ordinary premonitory symp- 
toms of fever, it more frequently begins abruptly, with coldness or rigors, headache, 
pains in the body and limbs, nausea and vomiting, and feelings of great weakness. Af- 
ter these come the usual phenomena of febrile reaction; a hot skin, thirst, frequent 
pulse, furred tongue, anorexia, &c.; attended with headache and severe pains in the 
muscles and joints, resembling those of rheumatism. Excessive nausea, retching, and 
vomiting are not unfrequent. Delirium is occasionally noticed, but is not an ordinary 
symptom. The patient is apt to be restless and wakeful. Epistaxis sometimes occurs. 
The abdomen -is generally more or less tympanitic, and there is often tenderness on 
pressure over the liver, stomach, spleen, and bladder. The bowels are not usually dis- 
ordered ; but dysenteric symptoms occasionally appear towards the close. The patient, 
in some instances, complains of pain in passing his urine. Perspiration now and then 
occurs in the course of the disease, with some relaxation of the febrile phenomena. In 
many of the cases, particularly those of a grave character, the countenance has a pecu- 
liar light-bronze hue, which, on the third or fourth day, is followed by yellowness of va- 
rious intensity, spreading over most of the surface. Though not always present, this 
is one of the characteristic features of the disease. The jaundice does not depend on 362 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 in 
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 
bstruction of the gall ducts, which are quite free. It is often attended with vomiting 
i bile, hypochondriac or epigastric tenderness, deep-brown urine, and enlargement of 
the liver and spleen. In very bad cases, there is hemorrhage from the mucous mem- 
branes, black stools like those of melmna, and vomiting of a matter like the black 
vomit of yellow fever. At the height of the disease, convulsions sometimes occur; and 
pregnant women are very apt to miscarry. 
When the symptoms have attained their greatest violence, and appear to threaten the 
most serious consequences, they often suddenly yield to a profuse perspiration, of an 
acid smell, which continues for several hours, sometimes even for a day or more, and 
leaves the patient almost free from disease, though, in bad cases, extremely weak. 
This event occurs sometimes so early as the third or fourth day, more frequently on the 
fifth, sixth, or seventh, and very rarely so late as the ninth. It is usually denominated 
the crisis. The patient now seems convalescent, and, in a few cases, the recovery is 
complete and permanent. But, in the great majority, at the end of about a week from 
the first appearance of amendment, or about two weeks from the commencement of the 
disease, a relapse takes place, in all respects similar to the first attack, sometimes being 
more severe, sometimes milder, and lasting usually four or five days. The pains are 
probably on the whole more distressing in this than in the first fever; and, if jaundice 
did not then appear, it is apt to appear now. Dr. Mackenzie states that the proportion 
of cases in which this relapse takes place is not less than nineteen out of twenty. Very 
generally, upon the subsidence of the second attack, the patient remains permanently 
well; but occasionally a third and even a fourth takes place, with similar intervals. In- 
stead of going off with perspiration, the disease sometimes subsides without any striking 
phenomenon, or with an increased discharge from other emunctories. As a general 
rule, its duration may be stated at about three weeks. 
Troublesome sequelm sometimes occur, such as articular pains, muscular weakness, 
oedema of the feet, enlarged lymphatic glands, boils, inflammation of the eyes with 
amaurotic symptoms, and general chronic debility. 
Upon dissection, redness of the mucous membrane of the bowels has been observed, 
but no special disease of the glands of Peyer. The spleen is very frequently enlarged. 
Cause.-The cause is generally believed by British medical writers to be a peculiar 
contagion, which Dr. Jenner has shown not to be the contagion of the proper typhus 
fever. (Medico-Chirurg. Trans., xxxiii. 23.) The disease, however, appears to occur 
epidemically, and is said to affect preferably persons living miserably, in crowded, 
filthy, and ill-ventilated situations. 
Prognosis.-This is very favourable. Of persons previously in vigorous health, almost 
all recover. In different places, and by different writers, the average mortality has 
been variously stated at from two to nearly nine per cent. According to Dr. Mac- 
kenzie, scarcely any one died in the Edinburgh epidemic of 1842-3, except infants, the 
aged, and persons of broken constitutions. 
Diagnosis.-The course and association of symptoms in this disease are different from 
those of any other known fever. It approaches the yellow fever most nearly, but dif- 
fers prominently in its extreme actual mildness, compared with its apparent severity, 
and in the much longer duration both of the first fever and the intermission. With the 
enteric or typhus it could scarcely be confounded, if carefully watched throughout its 
whole course. It has neither the rose-coloured spots of the former, nor the measle- 
like eruption of the latter. Sometimes red spots, like fleabites, not removable upon 
compression, have been observed on different parts of the body, and sometimes also 
petechise. But neither of these is common. It differs entirely from both the above 
fevers in its course. The tendency to relapse, so characteristic of this, is wholly 
wanting in typhus; and in the enteric fever, if febrile symptoms recur sometimes dur- 
ing convalescence, they are obviously not a proper relapse, but the mere consequence 
of some local irritation, as of the bowels from over eating, or of the lungs from exposure 
to cold. Dr. Cormack gives, as the diagnostic symptoms of the disease, its sudden in- 
vasion, the darkening of the face before and after seizure, the almost uniform occurrence of one 
or more relapses, the yellowness of the skin and occasional black vomit and hemorrhage, the 
brevity and mode of termination of the pyrexia, the severe muscular and articular pains, and 
the absence of the peculiar eruption of typhoid and typhus fevers. CLASS I.] 
TYPHUS FEVER. 
363 
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. Pre- 
vious debility, from whatever cause, whether disease, intemperance, excess of 
any kind, or old age, increases the danger. 
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 erup- 
tion, and involuntary evacuations; among the second, abundant and dark- 
coloured petechias, copious hemorrhages, a very turbid conjunctiva, fetid breath, 
and a purple appearance of the extremities ; among the third, violent delirium 
or profound coma, with a greatly expanded or greatly contracted pupil and 
stertorous 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 increase 
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 func- 
tions by its sedative power; and there is danger that they may be reduced be- 
low the point of reaction. External stimulants are the safest. The most 
powerful rubefacients, such as mustard, solution of ammonia, Cayenne 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 pediluvia, or, what 
Treatment.-This is very simple. The bowels should be kept open with mild cathar- 
tics, as castor oil; febrile heat should be allayed by the usual refrigerating methods ; 
the irritation of stomach should be quieted by eifervescing draughts, leeches, or revul- 
sives to the epigastrium ; or, upon the failure of these, by opiates administered either 
by the mouth or the rectum; and the headache should be counteracted by cold appli- 
cations, and local bleeding if necessary. In the jaundiced cases, especially if attended 
with hepatic tenderness, the blue mass may be given, and suitable applications made 
to the right hypochondrium. Dysenteric symptoms are to be met by castor oil and 
laudanum. The Dover's powder may be given to control the general pains, when it 
can be retained by the stomach. Terebinthinate injections may be administered in the 
tympanitic cases. Debility is to be counteracted by wine, opium, sulphate of quinia, 
and nourishment. Attempts have been made to prevent the relapses by sulphate of 
quinia; but with doubtful success. (Note to the third edition.) 364 
GENERAL DISEASES.-FEVERS. 
[part II. 
would probably be most effectual, the hot batb. If internal stimulation should 
become necessary, carbonate of ammonia, or oil of turpentine, would be pre- 
ferable 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. Through- 
out the whole course of the disease, the bowels, if there be a tendency to con- 
stipation, should be kept open by cathartics. These are indicated by the neces- 
sity 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 ob- 
viate 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 ex- 
ists here 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^tinctures of rhubarb may be employed, with great propriety, in the latest 
stage, when stimulation becomes necessary. Sometimes, it is advisable 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 great- 
est importance; by others it has been condemned as almost always injurious, 
and scarcely ever necessary. Probably the advocacy of it may have been 
partly owing to the confounding of this disease with enteric fever, which is 
known often 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 neighbourhood, not 
being understood by the physicians, and frequently presenting the complica- 
tion 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 disease 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 not understood, and was treated as an inflammatory affection, with almost 
uniformly fatal results. 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 CLASS I.] 
365 
TYPHUS FEVER. 
skilful physician, which has never been exceeded in our city. So fatal was 
copious bleeding in that epidemic, that popular and to a great extent profes- 
sional opinion received a set against it; and it was some time after the disap- 
pearance of all tendency to the disease, before the fear of the remedy so far 
subsided as to permit its judicious use, under circumstances 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 ad- 
vantage. 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 resorted 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 prostration from the loss of large quantities. Six or eight ounces 
are often sufficient, and more than twelve should seldom be abstracted at one 
operation. In the great majority of cases, venesection is altogether unneces- 
sary. In those which are at all doubtful, it is best 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 external 
use of cold water. This may be dashed upon the patient, as recommended by 
Dr. Currie, 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 pneumonia. In 
doubtful cases, sponging with warm water should be preferred. Sometimes 
spirit, or spirit diluted with water, may be advantageously substituted. The 
effect of these remedies is to relieve the distressing heat, relax the skin, pro- 
duce 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. British practitioners frequently employ the antimonials. Dover's 
powder is often very useful by producing diaphoresis, quieting restlessness, 
and promoting sleep. It should, of course, not be employed 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. Sometimes 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 neces- 
sary 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 prostration. 366 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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 accept- 
able 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 produced. 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 quantities, and at 
such intervals, as to maintain a regular excitement, without stupefaction. 
From 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. From 
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-whey and carbonate of am- 
monia, alternately, each every second hour; increasing 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, combining 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 moder- 
ate 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 produces extreme exhaustion. 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., camphor 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 important 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 red- 
den without vesicating; and by frictions with Cayenne pepper and hot brandy, 
oil of turpentine, liniment of turpentine, &c. In the lowest and most insen- 
sible 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 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 the 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, when the cold appli- 
cations fail. CLASS I.] 
367 
TYPHUS FEVER. 
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 
threatening cases of diarrhoea, from injections of a solution of nitrate of 
silver, containing a drachm of the nitrate in a pint of water. {New York 
Joum. of Med., ix. 270.) 
The remarks made in reference to diet, under enteric fever, are applicable 
also here. It is even more necessary in typhus to throw a due amount of 
nutriment into the system; and, though for the first few days, it may be pro- 
per to confine the patient to farinaceous liquids, yet, as the disease advances, 
animal broths become necessary, and in very feeble states we must have 
recourse to the animal essences, egg-nog, milk punch, &c. 
Though Peruvian bark, in various forms of preparation, has long been used 
in the treatment of typhus fever, it has generally been given in moderate 
doses, and with reference to its tonic or supporting effect. But, in the form 
of sulphate of quinia, it has recently been very highly recommended by Dr. 
Robert Dundas, of Liverpool, in large doses, in the early stages of the dis- 
ease, with reference to an immediate curative effect; and, from his own state- 
ments, as well as those of several others who have adopted the practice, there 
is reason to believe that it often very much shortens the duration of the 
complaint. According to Mr. J. 0. Fletcher, who has employed this treat- 
ment very largely, and has found it very successful, it is applicable only to 
the pure cases of typhus, and not to those complicated with ulcerated bowels, 
pneumonia, or cerebral congestion. The sulphate is given in doses of from 
three to ten grains every two or three hours. It may be given at any stage, 
unless there should be great prostration. Milk and soup are to be given 
freely, and wine or brandy in the advanced stages, or in cases of drunkards. 
{Lond. Med. Times and Gaz., vi. 422.) 
Prevention.-There are few diseases in which more can be effected in the 
way of prevention than this. Thorough ventilation; perfect cleanliness in 
clothing, person, and apartments; a wholesome and nutritious diet; and 
sufficient protection against cold, will go far towards securing impunity to 
individuals necessarily exposed in some degree to the cause of the disease. 
Persons not called upon by duty to attend the sick should avoid their pre- 
sence. 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 
hands and face, 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. 368 
GENERAL DISEASES.-FEVERS. 
[part II. 
Article VI. 
PLAGUE. 
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 1720, when 
Marseilles lost with it nearly one-half of her population. It is now limited 
chiefly to Egypt, Syria, Anatolia, Greece, and European Turkey; occasion- 
ally extending northward into Russia, and westward as far as Malta. 
Symptoms, Course, &c.-The 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. 
Darting pains are felt in the groins, arm-pits, or other 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 
symptoms more or less alarming are rapidly developed. The tongue, at first 
somewhat 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 lips. There is often extreme 
thirst, and a sensation of burning heat internally. Severe pain is felt 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 
comatose; 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 
Syn.-Pestis. CLASS I.] 
PLAGUE. 
369 
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 re- 
garded as favourable. From that time the exacerbations return with dimi- 
nished violence, and there is a gradual amendment, though the disease may 
continue for a week or two longer before convalescence is established. In the 
mean time, 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. Tn 
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 
end in death in less than twenty-four hours, without the developement of buboes 
or carbuncles, and without any signs of reaction. Occasionally a partial reac- 
tion takes place, with symptoms of fever; but the malignant phenomena, 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 car- 
buncles may be formed; but the former do not advance to suppuration, nor 
the latter to the separation of the slough. Petechiae and vibices are not un- 
common. Death takes places 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 preliminary appreciable dis- 
order. A few words upon buboes, carbuncles, and petechiae, 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 gland, or may extend 
to several. The first sign of the affection is usually a shooting pain in the 
part, which precedes the tumefaction. In the beginning there is no discolora- 
tion of the skin. The tumour is sometimes movable, but frequently adheres 
to the tissues beneath, especially in the more serious cases. In favourable 370 
[part II. 
GENERAL DISEASES.-FEVERS. 
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. Tumours resembling 
buboes occasionally form in the subcutaneous tissue; and secondary buboes 
may result from the propagation of irritation from a carbuncle along the ab- 
sorbents 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 reddish 
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 favourable 
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. 
Petechias 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 vibices; and cases occur in which the whole sur- 
face 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. (Bulard.'') It 
is usually denser than in health, of a dark colour not brightening on expo- 
sure, and sometimes of a peculiar odour. The inflammatory crust does not 
appear when it coagulates. After death, black coagula are found in the ven- 
tricles, aorta, and vena cava. 
Upon dissection, black spots of extravasation are observed through the 
viscera, as the heart, lungs, stomach and bowels, liver, &c., and even in the 
neurilema of the nerves. The parenchyma of the solid viscera is generally 
engorged 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 in- 
flammation 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 oc- 
curs only occasionally, and at longer or shorter intervals, the inhabitants being 
perfectly 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 CLASS I.] 
PLAGUE. 
371 
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 ex- 
posed to the cause of the disease, in a sickly district, have removed to a distant 
and healthy place, and have there died of the plague; and shortly afterwards, 
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 predestinarians, and use no precau- 
tion. 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 circum- 
stances; 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 considerable extent with measles, both of which 
are contagious. It is generally supposed that the contagion may not only be 
imparted from individual to individual; but that it may be conveyed by means 
of clothing or articles of merchandise from place to place; though some, who 
even admit personal contagion, deny the latter mode of communication. Dif- 
ference 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 be exhaled in the aeriform state from the body, and, 
like that of other contagious fevers, act through the medium of the atmo- 
sphere. 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 excre- 
tions of a crowded and 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 formerly 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 suggest 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 population 372 
GENERAL DISEASES.-FEVERS. 
PART II. 
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 inten- 
sity. Nor is the disease usually confined to one city. A number of different 
places within certain limits are often affected simultaneously, without any com- 
munication, 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 ani- 
mals 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 tem- 
perature is above 80° F., or a little below 60°. Hence, when it prevails dur- 
ing 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 318.) 
Nature.-1This 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 phe- 
nomena, it can be decided with certainty that any given case is plague, only 
by its occurrence at the commencement, or in the midst of an epidemic pre- 
valence 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 in- 
habitants are thought to have perished. 
In individual cases, the unfavourable symptoms are great general depression 
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 petechise, and all the symptoms which generally 
characterize great malignancy, such as a drunken expression of countenance, 
muddiness of the conjunctiva, coma or low delirium, stammering, excessive 
oppression of breath, severe precordial pains and vomiting, hemorrhages of 
dark blood, hiccough, black tongue, fetid breath, &c. Favourable signs are 
the occurrence of buboes without fever, the early appearance and regular pro- 
gress 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 enume- 
rated 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 prin- 
ciples. There is no specific for the plague. Emetics are recommended at 
the commencement of the disease by many practitioners. There is also a 
very common consent in the propriety of employing a brisk cathartic, to be CLASS I.] 
SMALLPOX, OR VARIOLA. 
373 
followed 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 ad- 
vised 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 constitutional 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 re- 
sort to tonics and diffusible stimulants. The local treatment is confined, by 
the best practitioners, 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. Cauteri- 
zation 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 add water, perfect cleanliness in clothing, 
moderation in eating, drinking, and the pursuit of pleasure, ventilation, and 
the avoidance of crowded and filthy places, are important measures. Venti- 
lation 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 VIL 
SMALLPOX, 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 dif- 
ferent stages of pimple, vesicle, and pustule, and arrives at maturity in about 
eight days. 
There is no proof that smallpox 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 s^id to have first shown itself in Arabia about the time of the birth of 
Mohammed, and to have invaded Syria, Egypt, and Southern Europe, with 
the armies of his successors. 374 
[part it. 
GENERAL DISEASES.-EEVERS. 
Two prominent varieties of the disease have been recognized by most writers 
upon the subject; the distinct and the confiuent; 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 smallpox 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 smallpox; 
but they are too slight, and too frequently quite wanting, to be considered 
as an essential part of the complaint. 
Symptoms, Course, &c. 
1. Distinct Smallpox.-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 uneasi- 
ness, 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 smallpox, to distinguish it with certainty 
from other febrile affections. If there is anything peculiar, it is in the vio- 
lence of the pains in the small of the back, and the frequent occurrence of 
obstinate vomiting, which cannot be referred to gastric inflammation or cere- 
bral disease, and which often resists all the remedies that can be applied. 
There are various other occasional symptoms. A tendency to perspiration is 
sometimes observable. 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 oppression in breathing, and occasionally with severe pains 
in the chest. In children, 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 con- 
tinues 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 subsidence of the fever is often rapid and even 
abrupt. At one visit, the patient is seen with headache, a hot skin, a fre- 
quent pulse, and perhaps vomiting; and at the next is found cool and com- 
fortable, with a natural pulse and. a retentive stomach, and, except for the 
eruption, which has shown itself in the mean time, 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 CLASS I.] 
375 
SMALLPOX, OR VARIOLA. 
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 depression, giv- 
ing 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 sometimes still longer, 
before those upon the feet have attained maturity. The process by which the 
vesicles are changed into pustules is called their maturation. 
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 tender. 
An eruption also takes place upon the mucous membrane of the mouth, fauces, 
eyelids, prepuce, and female labia*which may be distincly seen two or three 
days after the first appearance of that upon the skin, in the form of small cir- 
cular 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, painful deglu- 
tition, and salivation, are apt to come on, which are among the most disagree- 
able 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 
external 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. 376 
GENERAL DISEASES.-FEVERS. 
[part II. 
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, without 
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 smallpox. 
The scabs fall off entirely between the fourteenth and twenty-first days. 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 the pustules is considerably hastened, so that the pocks on the 
inflamed spot commonly run through all their 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 dis- 
appear. 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 Smallpox.-This is only a more aggravated form of the 
same disease, and there is every grade between the extremes of the two varie- 
ties. In the more fully confluent forms, the initial fever is more violent, 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 in- 
flammatory or malignant complication. The delirium is occasionally violent 
and uncontrollable, and, though sometimes associated with signs of inflamma- 
tory congestion of the brain, is, in other cases, apparently dependent on ex- 
cessive 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 eruption appears CLASS I.] 
377 
SMALLPOX, OR VARIOLA. 
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 trpnk, 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 a nearly 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 ex- 
tends 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 burrowing 
in the parts beneath it. 
The eruption in the mouth, fauces, &c., is more copious than in the dis- 
tinct, the consequent swelling and pain in these parts greater, and the saliva- 
tion more abundant and distressing. Not unfreq uently 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 smallpox, causing death by suffo- 
cation, in some instances through the closure of the rima glotidis, in others 
by the clogging of the bronchial tubes with their viscid secretion. Conse- 
quent upon this condition in its advanced stages, and arising from a want of 
arterialization of the blood, are a dark discoloration of the skin, a livid or 
purplish hue of the eruption, feebleness of the pulse, coolness of the surface, 
and universal prostration. The deglutition, which is painful from the inflamed 
state of the fauces, becomes in some of these cases still more difficulty in con- 
sequence 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 cuti- 
cular 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 378 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 smallpox. 
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 func- 
tions through the severity of local disease. 
Should he survive the period of maturation, and pass into that of the de- 
cline of the eruption, he has still great dangers to encounter. It is now that 
disorganizing inflammations are most apt to occur, in various parts of the 
body. Pseudo-membranous or edematous inflammation of the fauces, and 
larynx, pneumonia, pleurisy, diarrhoea or dysentery, and occasionally inflam- 
mation of the brain, complicate the proper variolous symptoms, and often with 
fatal effect. It is now 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. Sometimes the whole eye is converted into an abscess. 
In milder cases, an opacity of the cornea is produced, which either remains 
permanent, or gradually disappears after several months. Obstinate abscesses 
of the ear are also occasionally formed. Erysipelas sometimes appears upon 
the face or elsewhere. In hospitals, this affection is one of the most common 
attendants on the disease, occurring not only in the period of decline, but also 
in that of maturation. 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. (Rayer.'') Even when other dangers have been escaped, an extra- 
ordinary 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. Gan- 
grene, also, sometimes attacks the surface, and portions of the skin slough. 
Should the disease not prove fatal from some of the above causes, the pa- 
tient 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. Occa- 
sionally 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. 
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 smallpox which run a more kindly course; and 
which, after surmounting the dangers of maturation, go 'on without interrup- 
tion 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, CLASS I.] 
379 
SMALLPOX, OR VARIOLA. 
founded upon the amount or arrangement of the eruption; as the semi-confluent, 
when the degree of confluence is moderate, and the coherent or corymbose, 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 smallpox, 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 smallpox, 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, induc- 
ing ineflicient reaction, with coma, delirium, or excessive restlessness and. 
anxiety, and sometimes an imperfect developement of the eruption, or a sudden 
retrocession of it when formed, or, secondly, by those symptoms which charac- 
terize a depraved condition of the blood, such as petechias 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 
gangrene, oppressed breathing, an anxious countenance, and great feebleness 
of the circulation. Sometimes the signs of malignancy do not exhibit them- 
selves 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 smallpox {varioles nigres') has been sometimes applied. 
3. Varioloid, or Modified Smallpox.-Different writers on smallpox 
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 variolis) •, 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 tubercules, 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 smallpox, 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 smallpox the same relation as varicella or chickenpox. 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 smallpox, and is itself capable of 
producing smallpox 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- 380 
GENERAL DISEASES.-FEVERS. 
[PART II. 
scribe minutely all the shapes which it assumes. There is, in fact, every shade 
between the slightest symptoms, scarcely recognizable as having affinity with 
smallpox, 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 individuals 
who want but little of being perfectly protected, without any eruption what- 
ever. 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 observed it in 
persons who had been previously vaccinated or affected with smallpox. 
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 occasionally 
scarcely sufficient to attract notice. Judging from my own observation, I 
should say that, in the greater proportion of cases, it is very regular, bearing 
a much nearer resemblance to the fever of unmodified smallpox, than the sub- 
sequent eruption does to the eruption of the genuine disease. Indeed, one of 
the most striking circumstances, in connexion with varioloid, is the frequently 
slight proportion which the amount of eruption bears to the severity 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 papulae, as in the confluent smallpox, is preceded 
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, 
oi' undergoes but a partial and imperfect suppuration, and begins to dry on 
the fourth or fifth day of the eruption, forming a small hard tubercule, 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 smallpox, becoming pustular, and even convex at top, but 
stopping ope or two days sooner, on the sixth or seventh day of the eruption, 
for example, instead of the eighth or ninth. I have thought that this differ- 
ence has sometimes been 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. CLASS I.] 
SMALLPOX, OR VARIOLA. 
381 
These two signa, 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 smallpox. 
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 smallpox, 
with an equal amount of eruption, to leave pits behind. 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 smallpox, 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 smallpox, it will be proper to notice 
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 smallpox 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. 
An atomical 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 smallpox 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 gelatinous. 
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 Bayer, " the size, colour, and umbilicated depression of the pustules 
depend on the pseudo-membranous disk, secreted by the papillary body, in- 382 
[part II. 
GENERAL DISEASES.-FEVERS. 
flamed and elevated in the form of a zone." (Dis. of Skin, Am. ed., p. 154.) 
The most probable explanation of the central depression is, that it depends 
on a connexion existing at this point between the epidermis and the true 
skin, which at first resists the expansive force of the effused fluids, but at 
length gives way to an increase of this force, or to some organic change 
which may take place, in the progress of suppuration, in the connecting me- 
dium. 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 erup- 
tion, 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 pustule 
never exists in the stomach and bowels. It is true that signs of inflamma- 
tion 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 with diarrhoea or dysentery; but these 
eminences are said to be nothing more than inflamed and enlarged mucous 
glands. A case, however, is recorded by Dr. George Patterson, in the 
Monthly Journal of Medical Sciences (Feb. 1849, p. 549), in which pustules 
were observed on the mucous membrane of the colon, which were pronounced 
by Dr. Gardiner to be identical with the pustules on the skin. 
Cause. 
The cause of smallpox is universally admitted to be 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 frequent 
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 herself was 
either partially or wholly protected.* The idea has been advanced, that some 
of those persons who seem exempt from the disease, may owe their 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 contents 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 has 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- 
* See the report of a case by Dr. Wm. T. Taylor, illustrative of the fact that the 
foetus may be attacked with genuine smallpox through the mother when partially pro- 
tected. {Am. Journ. of Med. Sci., N. S., xxvi. 127.) Dr. Mead relates a casein which 
a pregnant woman, wholly protected by a previous attack of smallpox, attended upon 
a case of the disease, and soon afterwards was delivered of a dead child covered over 
with pustules; the mother escaping. CLASS I.] 
SMALLPOX, OR VARIOLA. 
383 
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; accord- 
ing to Mr. Hawkins, for a period of at least ten or twelve days, even without 
contact. Some have supposed that the odour is connected with the con- 
tagious 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 contagious principle attaches itself to clothing, which retains it some- 
times 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 necessarily futile; for the distance must vary greatly with the de- 
gree of concentration of the poison; and its activity is probably much greater 
in certain conditions 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 gene- 
rally modifies the recurrent affection, so as to render it harmless. It cannot, 
however, be denied that fatal cases of secondary smallpox 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 extraordi- 
nary susceptibility to the variolous contagion, so that individuals belonging 
to them are much more liable tpf returns of the disease than others, and 
generally also have it more severely. 
It is an interesting question, whether any other cause is capable of produc- 
ing smallpox 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 irre- 
gular but comparatively short intervals; until at length the epidemic influ- 
ence seems to be exhausted, and a long and almost entire exemption is again 
enjoyed, interrupted only occasionally by cases arising from obvious conta- 
gion. It is especially during these visitations that individuals supposed to 
be protected by inoculation, vaccination, or any other cause, and who may 
have before freely exposed themselves to the contagion with impunity, are 
apt to suffer. Yet it is doubtful whether the epidemic influence has the 
power of originating the disease. In the face of the testimony which has 
been given upon this point, it would be going too far to assert that it never 
does so.* But the probability is, that in general it operates simply by in- 
creasing, 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 smallpox, there is often also an extra- 
* For cases in which it'would be difficult to admit the possibility of a contagious 
cause, the reader is referred to a paper by Dr. William D. Purple, in the New York 
Journ. of Med. &c. (N. S. vii. 183), and to another by Dr. E. C. Banks, in the Medical 
Examiner (N. S. v. 518.) 384 
GENERAL DISEASES.-FEVERS. 
[PART II. 
ordinary tendency to certain other cutaneous diseases, or to eruptive affec- 
tions in general. Dr. Gregory states that smallpox has never yet been seen 
in Australia and Van Dieman's Land. {Lecture on the Eruptive Fevers, Am. 
ed., p. 79.) This has been advanced as a strong fact against the sponta- 
neous origin of the disease; yet no one supposes that yellow fever does not 
occur spontaneously in America, because it is unknown in Asia. 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 approach 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 versd. 
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. 
Diagnosis. 
When regular smallpox 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 smallpox; 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 vario- 
lous 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 
much shorter duration. A day or two, however, must remove all difficulty 
by the further developement of the eruption. 
Varioloid, or modified smallpox, 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 erup- 
tion does not advance beyond the papular state; though the duration of the 
fever, and its complete subsidence at the appearance of the eruption, in con- 
nexion 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 
complaints 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. CLASS I.] 
385 
SMALLPOX, OR VARIOLA, 
Prognosis. 
Unmodified smallpox 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 cases of varioloid are comparatively very few; and, in the vast ma- 
jority of instances, the affection is quite trifling, except from the considera- 
tion that it may be the source of danger to the unprotected. 
It may be considered a favourable sign when the disease pursues its regu- 
lar course towards desquamation, without any serious inflammatory compli- 
cation, 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 abund- 
ance 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; petecbiae 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 intempe- 
rate 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 
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 32, 
in the third 21, and in the fourth or later 16. (Tweedie's Sy st. of Pract. 
Medf But it should be observed that these were cases in a London hospi- 
tal, in which there was no doubt a much greater malignancy, and conse- 
quently 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 eigh- 
teenth days. 386 
GENERAL DISEASES.-FEVERS. 
[part II. 
Treatment. 
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 
smallpox 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 smallpox 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 smallpox. 
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 
occasional 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- 
table stomach. After the bowels have been well evacuated, saline diaphoretics 
should be given, especially citrate of potassa, in the form of neutral mixture 
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 potassa, solu- 
tion 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 extensively; 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 in- CLASS I.] 
387 
SMALLPOX, OR VARIOLA. 
flammations. Sponging with warm water may be more freely employed, 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 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 has- 
tening 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 bleeding should be employed only to avert 
threatened danger from some important organ. It is necessary not to be mis- 
guided by the pains which so commonly attend severe smallpox 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 con- 
nexion 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 carbonic 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 con- 
gestion, 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 extremities by hot or stimulating 
pediluvia, mustard to the legs, &c. Should symptoms of laryngeal or pecto- 
ral inflammation appear, local depletion and emollient cataplasms are indicated. 
The drinks should be such as have 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 exclu- 
sively 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 erup- 
tion with threatening constitutional symptom^, to have recourse to an emetic, 
the warm or vapour bath, diaphoretics, such as acetate of ammonia 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 388 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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. The diet, however, should be strictly antiphlogistic. 
Upon the occurrence of secondary fever, the original diaphoretic and refri- 
gerant plan should be resumed, in a degree corresponding to the excitement, 
and the apparent strength of th'e patient; and a still more guarded attention 
is necessary to the supervention of inflammations. For 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 re- 
mainder of the disease, unless contraindicated by decided symptoms of cerebral 
inflammation. They calm the nervous disturbance, and render the system 
much less susceptible to the excessive annoyance of the local affection. Com- 
bined 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 due 
action, recourse should be had to tonics and stimulants, and to a nutritious 
diet, proportionate to the apparent wants of the system. The particular reme- 
dies 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 excellent addition to 
the other remedies in cases attended with nervous disturbance. 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 addition to the sub- 
stances before employed. 
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 externally, and the 
careful use of mercury with opiates internally. The diarrhoea which occasion- 
ally attends the complaint must be treated on general principles. (See Diar- 
rhoea.) Convulsions, when they occur in the early stage, and are attended 
with an active pulse, require the treatment appropriate to active cerebral con- CLASS I.] 
SMALLPOX, OR VARIOLA. 
389 
gestion. 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 with that caustic in substance. 
In consequence of the repulsive deformity of face which frequently follows 
smallpox, 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 Payer 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, or 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 of without leaving pits. 
To succeed, however, the operation must be performed .as early as the second, 
or at furthest the third day. When the solution has been applied uniformly 
over 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 the vesicular stage, of causing them to dry up into tubercules, or at 
least preventing 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 Hy dr argyri') is asserted to be 
more effectual than the mercurial ointment. I have employed the latter, how- 
ever, 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 irritation. 
The only hazard from this remedy is a mercurial salivation, which, however, 390 
[part II. 
GENERAL DISEASES.-FEVERS. 
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; and a similar in- 
fluence is claimed by Professor Bennet, of Edinburgh, for calamine mixed 
with olive oil, which forms a coherent crust, and thus excludes the air. (Ed. 
Month. Journ. of Med. Sci., April, 1854, p. 301.) Dr. Samuel Jackson, of 
Philadelphia, formerly of Northumberland, employed the tincture of iodine 
for the same purpose with apparent advantage. He applied the tincture 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 applica- 
tion 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 confluent cases. 
(Med. Examiner, N. S., ii. 465.) It appears, however, from a communication 
in the British American Medical Journal, for Nov. 1846, that the credit of 
having first employed tincture of iodine for this purpose belongs to Dr. Craw- 
ford, of Montreal, who applied it in a case so early as the year 1844. (Ran- 
king's Abstract, No. 5, p. 66.) 
The idea has been advanced, that the influence of the atmospheric air is 
essential to the developement of the pustules, and consequently that they may 
be rendered abortive by anything which will exclude this influence. M. Serres 
has found that their progress is arrested by covering them with little cups of 
darkened glass, or involving them in honey or fatty matter (Am. Journ. of 
Med. Sci., N. S. xvii. 183, from L' Union Aled., Oct. 1848). Collodion has been 
employed for the same purpose, with asserted success, by several practitioners; 
but Dr. Christen, who tried its effects in the Prague Hospital, found it in- 
effective to the end proposed, and otherwise injurious. (Ibid. xxv. 487.) 
Dr. Graves, of Dublin, recommends a saturated solution of gutta percha in 
chloroform, but states that it should not be applied until after the pustules 
have fully maturated, or even begun to decline, as before this period it is 
mischievous. (Dublin Quart. Journ. of Aled. Sci. xiv. 7 and 224.) 
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 smallpox. 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 smallpox by the 
* A preparation employed in the Children's Hospital in Paris, and which succeeds 
" marvellously 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 effica- 
cious. (Journ. de Pharm. Be ser., viii. 282.) M. Briquet recommends mercurial oint- 
ment simply thickened with powdered starch. (Am. Journ. of Med. Sci., N. S., xiii. 
438.) As the ointment sometimes salivates, it should be diluted with an equal proportion 
of lard, and then stiffened with the starch. CLASS I.] 
SMALLPOX, OR VARIOLA. 
391 
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 
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 is 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 it sappearance 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 mean time, the original pus- 
tule 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 smallpox 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 after- 
wards, the proportion of deaths was very small, not exceeding, according to 
Gregory, 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 dis- 
ease in the community. Hence, society has deemed it necessary, in some 
places, to protect itself against mischief by forbidding the practice of inocu- 
lation under a heavy penalty. 392 
GENERAL DISEASES.-FEVERS. 
[part II. 
Article VIII. 
Syn.-Cowpox.-Kinepock.-Vaccina.-Vaccinia. 
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 rendering 
the system, in a greater or less degree, insusceptible to the contagion of 
smallpox. 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 smallpox, 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 con- 
ceive or to practice the artificial communication of the vaccine disease, that 
celebrated 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 inocu- 
lation 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 smallpox. 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 " Inquiry 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. CLASS I. 
VACCINE DISEASE. 
393 
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 hands 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 sup- 
posed 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 smallpox received from man, and modified in the 
system of the inferior animal. Dr. Jenner believed that smallpox and cow- 
pox were merely different forms of the same disease. Mr. Ceeley, 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 in- 
dividual, with all the phenomena and effects of cowpox. 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 Kassan, in Russia, 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 cowpox, even omitting its incommunicability through 
the air, are so different from those of smallpox 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 
* It was an easy inference from the modifying influence of the system of the cow on. 
the variolous contagion, that a similar effect might be produced by the milk of the cow 
on smallpox matter; and M. Theile, of Kassan, and M. Robert, of Marseilles, proposed 
the use of' such a mixture in vaccination. M. Bracket, of Lyons, in the year 1832, 
made some experiments with satisfactory results; and these have been recently re- 
peated on a much larger scale at La Charite, in Lyons, by M. Bouchocourt. Equal 
parts of cold milk and, variolous matter taken from the pock in the vesicular stage 
were mixed, and three children inoculated with the mixture. Others were inoculated 
from matter proceeding from the vesicles thus produced, and others again from these 
secondary cases. Of 21 cases, 18 presented solitary vesicles confined to the place of 
puncture, having all the characters of genuine vaccine disease, and the three others 
but a few additional pocks. The inoculation thus performed proved protective. (See 
London Med. Times and Gaz., April, 1854, p. 412.) 394 
[part II. 
GENERAL DISEASES.-FEVERS. 
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 
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 
_ardens, 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 appears 
often to sympathize with the local affection, and a moderate febrile move- 
ment takes place. The glands in the axilla are often also swollen and pain- 
ful. 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 
different 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 in- 
flamed, 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 separate pocks, the areolae of which coalesce. 
There is great difference also in the relative duration of the different stages, 
and in the whole duration of the complaint. The period of incubation, or 
that which intervenes between the insertion of the matter and the first ap- 
pearance of the pock, is sometimes greatly lengthened; extending to one, two, 
or three weeks, or even more, instead of two or three days. Occasionally 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 in- CLASS I.] 
395 
VACCINE DISEASE. 
stances, 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 such cases, and, upon subsequently 
testing them, have found the system equally protected as by the disease in its 
ordinary form. Occasionally the vesicle is broken by accident, and a sup- 
purating sore produced; and the experiment has been tried of destroying 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 
smallpox or revaccination, sometimes appears about the eighth day after vac- 
cination, without any vesicle whatever; though such a case has never occurred 
to me. Occasionally cases are said to occur in which other vesicles arise at 
points where no matter was inserted; and an instance is recorded by Dr. R. 
0. Clark, in which there was no appearance of a pock at the point of insertion, 
but one regular in all its characters showed itself in the other arm, and proved 
quite protective. (Land. Med. Gaz., Nov. 1850, p. 788.) 
In all the above varieties, the disease may be considered as genuine. But 
sometimes a spurious affection results from vaccination, which affords no pro- 
tection against smallpox. This generally arises from the use of bad matter; 
but it not improbably also results, in some instances, from peculiarities in the 
constitution of the patient. There is little difficulty in distinguishing these 
cases. The inflammation almost always commences earlier than the genuine, 
sometimes almost immediately after the operation. The vesicle or pustule is 
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 cowpox, or smallpox, also gives rise to anomalies, which will be no- 
ticed 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 por- 
tion 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 uni- 
formly 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-membranous 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 ren- 
dered inert by extreme cold. On the tenth day of vaccination, the liquid is 396 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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 contained 
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 character, and 
until it begins to decline; and the pus that may be present is probably not 
the result of a change in the original lymph, but of a distinct action, and does 
not appear to have the property of communicating the disease. 
Susceptibility to the Disease.-1This 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 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 period, will, upon being repeated 
at an interval of some weeks or months, readily succeed. Failures are often 
owing to defect in the virus, or imperfect insertion; but, making all due allow- 
ance 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, imme- 
diately after birth, are less susceptible of the disease than wThen at the age of 
a month or six weeks. Rayer states that the operation fails twice out of three 
times, in infants three or four days old. It has been supposed 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 vac- 
cinated 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 consti- 
tution; that it was very slow of developement in advanced tuberculous affec- 
tions, 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, urticaria, and pemphigus, the vaccine com- 
plaint was always retarded when the operation was performed in their initia- 
tory stage, and, if either of these diseases supervened upon vaccination, was 
suspended until that disease had run its course, and then resumed its march. 
(^Dict. de Med., xxx. 406.) 
Protective Power.-1The vaccine disease owes all its importance to the pro- 
tection which it yields against the attack of smallpox. 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 
* Similar cases have occurred resisting the influence of the smallpox virus. In rela- 
tion to some of them at least, it is highly probable that the child owes its insusceptibility 
to having been affected with smallpox or vaccine disease received from the mother be- 
fore delivery. Dr. S. F. Parker records a case in which such protection appeared to be 
afforded by smallpox in the mother (Bost. Med. and Surg. Journ. xliv. 441); and Dr. 
W. T. Taylor another in which the same protection seemed to result from a previous 
vaccination of the mother. (Am. J. of Med. Sei., N. S., xxvi. 129.) CLASS I.] 
VACCINE DISEASE. 
397 
too far; for it is impossible to say that smallpox is not frequently springing up 
anew, independently of contagion; and it is not possible to secure every in- 
habitant 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 pre- 
vious attack of smallpox; 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 smallpox; 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 vari- 
olous 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 epidemics 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 vaccinated suffered more or 
less, tended very much to shake the confidence of the profession; and there 
were many who abandoned their faith in the protective virtues of cowpox al- 
together. It cannot now be denied that a single vaccination does not afford 
the permanent security it was supposed to do. Probably, nearly one-half of 
those vaccinated successfully are liable to more or less effect from the variolous 
contagion; though it is asserted that, when the operation is performed with 
four or more insertions instead of one, the proportion of the protected is much 
greater. (Medico-Chirurg. Trans., xxxvi. 388.) 
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 smallpox, 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 smallpox, occur- 
ring 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 vacci- 
nation, reported by Dr. Thomson, of Edinburgh, only one proved fatal; while 
of 71 of secondary smallpox three died. Of 248 cases of natural and modi- 
fied smallpox noticed by Drs. Bell and Mitchell, of Philadelphia, 64 were 
after vaccination with but one death, and 16 were after inoculated or natural 
smallpox 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, con- 
sequent on the peculiar state of the patient's constitution at the time. Thus, 
it appears 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 398 
GENERAL DISEASES.-FEVERS. 
[part II. 
fails entirely; very often produces a modified cowpox, 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, he would 
have been more or less affected by the contagion of smallpox, had he been 
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 interesting. 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 
11 regular pustules" were produced, and in about one-fifth more " irregular 
pustules;" while in the remainder there was no effect whatever. If, by the 
regular pustule, is here meant the vaccine vesicle in its legitimate form and 
course, as before described, these results are very extraordinary, and far be- 
yond 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 between the proportion of 
persons subject to the vaccinoid disease, and of those supposed to be liable 
to the varioloid, which has already been stated at about one-half of the vacci- 
nated. 
The question may be reasonably asked, how it happens that the protection 
afforded by vaccination against smallpox 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 
children under eight years are seldom attacked. It is inferred that the pre- 
servative influence lasts about seven years. But the conclusion is not justi- 
fied 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 num- 
bers 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 vac- 
cine protective 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 undis- 
tinguishable from the smallpox. Such is not the case. On the contrary, the 
susceptibility 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 
smallpox than at other times, 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 smallpox, occurring in seasons when no 
epidemic influence exists, may be effectual under similar circumstances, but 
may fail during an epidemic, when other forces are added to that of the con- 
tagious cause. Hence the occurrence of varioloid abundantly in Philadelphia CLASS I.] 
399 
VACCINE DISEASE. 
in 1823, though it had been previously unknown, when no epidemic influ- 
ence 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 variolous 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 one vaccination 
fails to afford security against a modified form of smallpox 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 revacci- 
nation. 
It is an important question, how far vaccination, performed after exposure 
to the cause of smallpox, 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 oc- 
curred, the smallpox 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 
variolous eruption, was vaccinated before any appearance of the smallpox 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 student 
of medicine, who had been exposed to variolous contagion, was vaccinated 
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 smallpox has not already commenced. 
It has even been asserted that, if vaccine virus be freely introduced 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 erup- 
tions. It is said to have cured various chronic inflammations, such as oph- 
thalmia, otitis, and bronchitis. In hooping-cough, it was at one time supposed 
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 in- 
flammation produced by the insertion of the virus; and my preceptor, the late 
Dr. Joseph 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- 
* In the report by Dr. F. W. Sargent of cases attended in the Philadelphia City Hos- 
pital, in 1845-6, it is stated that of the cases of varioloid or smallpox after one vaccina- 
tion, amounting to 136, more than twice as many occurred in the ten years from 19 to 
29 inclusive, as in either of the ten years preceding or following those ages. (Am. J. of 
Med. Sci., N. S., xvii. 372.) 400 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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. 
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 he vaccinated.-As new-born infants are comparatively insus- 
ceptible of the disease, in consequence possibly 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 
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 not 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 decom- 
posed by heat. When it is important to preserve it long, the scab should be 
thoroughly dried, then wrapped closely in tinfoil, and well coated with wax. 
A coating of collodion has also been recommended, in order to protect it from 
the air. It should be umbilicated, of a reddish-brown or garnet colour, trans- 
lucent, 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 scab, which is certainly the most con- 
venient form in which the matter can be kept, and has been found to answer 
every desirable purpose. In the few cases in which it fails, recourse may be 
had to lymph from the vesicle. 
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 
Vaccination. CLASS I.] 
VACCINATION. 
401 
kept in closed 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 coexisting disease. The following is given as 
the result of the experience of M. Taupin, who has had extraordinary oppor- 
tunities for ascertaining the truth. " The matter taken from children affected 
with acute or chronic diseases, with essential fevers, typhoid affections, erupt- 
ive fevers, thoracic, abdominal, and cerebral inflammations, the neuroses, such 
as chorea, hysteria, epilepsy, &c., was as energetic as if drawn from healthy 
children, gave rise to as copious and regular a vaccine disease, was as effica- 
cious against smallpox, and transmitted no disease whatever, 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 vaccinated. (Ibid.) 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 influence 
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 vaccination, for more 
than thirty years; and, within my remembrance, there has certainly been no 
material change in the appearance of the local affection, as we ordinarily per- 
ceive 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 combated, 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, some matter was brought from Europe to this country, said 
to be extraordinarily efficacious. It produced, however, such violent inflam- 
mation and extensive sores, that physicians became alarmed, and I believe 
generally abandoned it. There is 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 em- 
ploying 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 vac- 
cination 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 ren- 
dered 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.) 
3. 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 402 
[PART II. 
GENERAL DISEASES.-FEVERS. 
vaccinate on the outer part of the arm, near the insertion of the deltoid; the 
object being to avoid an unsightly sear, 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 some- 
what 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 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 vaccination is performed 
after 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 smallpox contagion, during an epidemic prevalence of the dis- 
ease. 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 smallpox on exposure; and, though the attack will probably be mode- 
rate, 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. Abun- 
dant 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 about thirty years; 
and, during that time, have seen no decided case of varioloid in any one that CLASS I.] 
REVACCINATION. 
403 
I have revaccinated, unless the patient had been exposed to the contagion of 
smallpox, 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 a secondary smallpox, 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 smallpox. 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 institution for 
the deaf and dumb in this city, amounting to about seventy, were revaccinated; 
and, though an epidemic smallpox 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 smallpox in a boarding-house, containing about thirty in- 
mates. 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 revac- 
cinated in 1841, in Prussia, only eight were attacked with varioloid. " Before 
the order for revaccination was issued, the different barracks used to be a prey 
to varioloid disease; it has now, however, disappeared." (See Am. Journ. of 
Med. Sci., vi. 248.) What possible reason then can there be for not employ- 
ing revaccination universally? It can do no harm, and may secure from a 
loathsome, if not dangerous disease.f That in some very rare instances the 
smallpox, or some modification of it, has followed revaccination, is no argu- 
ment against it. The susceptibility in some individuals is so great that no 
means of prevention appears sufficient to extinguish it, and cases have hap- 
pened in which smallpox itself has recurred even a third time. Some caution 
should be exercised in relation to the revaccination of pregnant women; and, 
during the prevalence of epidemic erysipelas, the operation should be post- 
poned unless imperiously-called for, as it has been occasionally followed by an 
attack of that disease, under such circumstances. 
Other cautions also may be useful. As an increased susceptibility seems 
to be acquired after the eighth year of life, and especially about and subse- 
quent to the age of puberty, it will be proper not to revaccinate, unless to 
ward off immediate danger, until the fourteenth or fifteenth year. Consider- 
ing, moreover, that the varioloid is much more apt to occur during variolous 
epidemics than at other times, it will always be advisable to seize those occa- 
sions for revaccination. The efficacy of the resulting vaccinoid disease will 
* Dr. F. W. Sargent states that, of 287 cases of variolous disease admitted into the 
Philadelphia City Hospital in 1845-6, in not one had the patient been revaccinated. 
(Am. Journ. of Med. Sci., N. S., xvii. 369 and 372.) 
f Two cases of death after revaccination are noticed in the New York Journal of Me- 
dicine, 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 vaccina- 
tion, 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 revaccination. (Note to the second 
edition.) 404 
[PART II. 
GENERAL DISEASES.-FEVERS. 
very probably be greater, when the influence of the epidemic thus co-operates 
with that of contagion. It seems rational to suppose that vaccination also, 
at these seasons, would yield a more complete protection than when not aided 
by this additional influence. This, however, is a point for experience to 
determine. 
It may be asked, whether vaccination should be employed in persons pre- 
viously affected with smallpox. I should unhesitatingly answer this question 
in the affirmative. It has been before stated that, though fewer persons are 
attacked with varioloid after inoculation or natural smallpox, than after vacci- 
nation, yet a greater number perish. The same protection that a second 
vaccination extends in one case, will probably be extended by vaccination in 
the other, and is even more needed, at least so far as life is concerned. In 
a family under my professional care, of which all the younger members were 
revaccinated, and thus secured, the mother, believing herself safe, in conse- 
quence of having had a smart attack of inoculated smallpox in infancy, de- 
clined the operation. She was afterwards attacked pretty severely with 
varioloid, while all the rest of the family escaped. It is generally stated in 
the books that vaccination after smallpox produces little or no effect. My 
own observation has been exactly the reverse. I have very often noticed that 
the local affection closely resembled genuine cowpox, 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. Some years since I 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 red 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 rela- 
tion to them, there is always some uncertainty whether the matter has been 
properly introduced, or was sufficiently active; and I should not so confi- 
dently 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 in- 
stances, a local impression is produced, but the resulting pock is quite spu- 
rious. On the day of the operation, or the following day, the patient feels 
an itching at the puncture, and a little irregular tumor 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 ap- 
proach to the genuine disease; the vesicle being umbilicated, surrounded by 
an irregular and sometimes greatly swollen and painful areola, and often 
running 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 vaccine 
disease in those not previously vaccinated, showing a strong analogy to the 
varioloid, the contagion of which causes smallpox 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 smallpox, and of ultimately eradicating it, if not from the globe, at least 
from extensive communities. CLASS I.] 
405 
CHICKENPOX, OR VARICELLA. 
Article IX. 
CHICKENPOX, or VARICELLA. 
This is a contagious eruptive disease, in which a slight fever, of short dura- 
tion, 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 vomit- 
ing. Not unfrequently 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 
smallpox. 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 unfrequently attended with itching or tingling, 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 gene- 
rally from the eighth to the sixth of an inch in diameter, occasionally some- 
what larger, rounded at top, transparent, colourless or slightly yellow, and 
very delicate, so that they are easily ruptured. Sometimes they occur in suc- 
cessive crops for two or three days, and consequently appear in different stages 
of advancement. As they mature, they become a little yellowish and some- 
what 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 discoloured, but not depressed. 
The last crop is sometimes a day or two later than the first in reaching ma- 
turity, and separating. If much irritated, as by scratching or rubbing, the 
vesicles sometimes become pustular, and then occasionally leave pits. In cer- 
tain rare cases of what seems to be varicella, umbilicated 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 smallpox existed to which they could be 
traced. The conoidal and globular varieties, of Bateman's synopsis, are pro- 
bably examples of varioloid. 
Cause.-The only known cause of chickenpox 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 propagate 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 chickenpox. One attack protects the system against a second. The dis- 
ease sometimes occurs epidemically; but whether independently of contagion 
is unknown. It is confined almost exclusively to children, though not en- 
tirely 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 
Syn.-Crystalli. 406 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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. Chickenpox often occurs in neighbourhoods where there 
is no smallpox; and epidemics of the former disease sometimes occur, without 
a case of the latter. It does not give rise to smallpox in the unprotected, 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 
uuvaccinated, in those who have had and those who have not had smallpox; 
nor does it afford the least protection against smallpox 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 superficial vesicle, situated 
between the true 'skin and epidermis, without any pseudo-membranous pro- 
duct, and without any deep-seated disease of the corium. 
Diagnosis.-The 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 smallpox, in relation to which it was impossible to 
decide, with certainty, whether they were variolous or varicellous. But gene- 
rally the distinction between modified smallpox and chickenpox is sufficiently 
obvious. In the former, the fever is more severe and longer continued. 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.-1The 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 re- 
quired. 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. 
Article X. 
MEASLES, or RUBEOLA. 
Syn.-Morbilli. 
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 dis- 
appearance of the fever. There is no certainty that it was known to the an- 
cients. The first accurate accounts of it are contained in the Arabian writers. 
Rhazes described it under a distinct name in the ninth century. It was, how- 
ever, long and strangely confounded with smallpox by the earlier modern 
physicians. 
Symptoms, Course, &c.-1The disease often commences with feelings of lassi- 
tude, 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 sore- 
ness 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 CLASS I.] 
MEASLES. 
407 
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 in severity for two or three days, then oc- 
casionally 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 commencement. 
The rash occurs at first in minute, red, distinct spots, very slightly elevated, 
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; ar- 
ranging itself in irregular clusters, which are occasionally 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 elsewhere, probably on account of its great Vascularity. In some 
cases, a more prominent or papular eruption mingles with the rash, in others, 
minute vesicles 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 a generally diffused redness which is observable in others. 
Occasionally, 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 appeared. When at its height, which is usually upon the 
second or third day of the eruption, it is frequently attended with a trouble- 
some itching and heat of skin. In the fauces, the original punctuated red- 
ness now often clusters in irregular patches as on the skin; and red points 
are often seen projecting above the fur on the tongue. 
Neither the catarrhal symptoms, nor the fever, decline on the appearance 
of the erilption. 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 abdo- 
minal 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. Dr. Gre- 
gory states that the catarrhal symptoms, in perfectly regular measles, begin 
to abate on the appearance of the erupti'on; and he has seen the "cough 
cease instantly as if by magic." (Leet, on Eruptive Dis., Am. ed., p. 125.) 
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 yel- 408 
[part II. 
GENERAL DISEASES.-FEVERS. 
lowish hue; and the cuticle separates in fine furfuraceous scales. But the 
desquamation is not uniform, being sometimes visible on the face or breast 
exclusively, 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, &c., 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 
alluded to, must not be confounded with that early and altogether favourable 
disappearance of the rash, which sometimes occurs in slight cases. 
A return or exacerbation of the eruption has been noticed, in a few cases, 
after the period of its normal decline. 
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. CLASS I.] 
409 
MEASLES. 
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 imperfect 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 
petechias, 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 
disease 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 un- 
frequent. Ophthalmia is common and sometimes .severe. Perhaps the most 
dangerous complication, when it occurs, is pseudo-membranous inflammation 
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. Rube- 
ola 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 fatal case of that 
kind has occurred to me. It is said sometimes to exist in connexion with 
smallpox; 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, in- 
flammation and suppuration of the ear, swelling 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- 410 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 stand- 
ard. This proves the existence of a febrile, rather than an inflammatory cha- 
racter 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, therefore, 
contagious. Some difference of opinion exists as to the possibility of com- 
municating 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, and even the tears and saliva. Though the circumstance that these ex- 
periments have generally been made during epidemics, when all not protected 
are liable to the disease, may throw some doubt upon the subject; yet the 
cases of asserted success are so numerous and varied, as to make the affirma- 
tive of the question greatly preponderate in the balance of probabilities. 
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 Rayer 
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 per- 
sonal 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 
be. The difficulty would be removed one step by admitting the vital organic 
character of contagions. (See Contagion, page 164.) 
Cold weather appears favourable to the production of the disease ; as epi- 
demics 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, measles are capable of being taken but once, in- 
stances have undoubtedly occurred, as in all other contagious diseases, in 
which the same individual has been affected a second time. 
The period which intervenes between exposure to the cause, and the occur- 
rence of the disease, is generally thought to be about a week, though it is 
said to be 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.* 
* From an account by Dr. P. L. Panum of the measles which, in the year 1846, af- 
fected more than 6000 of the 7782 inhabitants of the Feroe Islands, and in which unu- 
sual opportunities were offered for estimating the -operation of the contagious cause, it CLASS I.] 
MEASLES. 
411 
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 appears; and cases in which no 
eruption occurs must necessarily be doubtful, especially when the influenza 
is at the time prevalent, or the changes of weather favour catarrhal affec- 
tions. The only diseases liable to be confounded with measles, after the 
occurrence of the eruption, are smallpox, scarlatina, and roseola. In distinct 
smallpox, 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 rubeolous eruption, while the variolous is rapidly becoming 
vesicular and umbilicated. The diagnosis between measles and scarlet fever 
will be given under the latter disease. From roseola measles are distin- 
guished 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 in- 
flammation, and the danger is probably greater after the disease has begun 
to decline than during its progress. The occurrence of pseudo-membranous 
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 
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 smallpox. 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, 
nor 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 
appears that the period of incubation was almost always thirteen or fourteen days. The 
same writer concluded, from his observations, that it is probably only after the occur- 
rence of the eruption that the disease is contagious. (Arch. Gen. 4 s6r., xxv. 451, 
from Arch. Physiol. Heilkundes, t. 11.) Note to the third edition. 412 
[PART II. 
GENERAL DISEASES.-FEVERS. 
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 expecto- 
rants just mentioned. 
The eyelids, when inflamed, should be frequently moistened with demulcent 
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. 
The retrocession of the eruption, and its retardation, occasionally recpire 
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 gastro-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 accom- 
pany the retrocession, it may be necessary to take blood from the arm. In 
certain cases, not attended with nausea, an emetic has sometimes answered CLASS I.] 
413 
MEASLES. 
an excellent purpose. Should the fault lie in a debilitated state of the sys- 
tem, from excessive loss of blood, a typhous tendency, or other cause, it may 
be necessary to administer warm wine-whey, and the preparations of ether or 
ammonia internally, while sinapisms, stimulating frictions, and artificial heat 
are diligently applied externally. When irritation exists in one of the inte- 
rior organs, a sinapism or blister 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 cases 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 assafetida, 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. 
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 
desquamation has been for several days entirely completed, and the catarrhal 
symptoms have disappeared. 
Friction with fat bacon over the whole surface of the body, as recommended 
by Dr. Schneeman in the treatment of scarlet fever, has been employed also 
in measles, with much supposed advantage, by Dr. John Evans. (/St. Louis 
Med. and Surg. Journ., ix. 276, from Charleston Med. JournC) 
Attempts have been made to prevent measles by inducing a mild form of 
the 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. 414 
[part II. 
GENERAL DISEASES.-FEVERS. 
Article XL 
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 symptoms 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 
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 instances, 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- CLASS I.] 
415 
SCARLET FEVER. 
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. The 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 ob- 
servable. The colour has been compared to that of a boiled lobster; but it 
is usually, I think, of a darker hue. It disappears under pressure, and re- 
turns when the pressure is removed. Whatever increases the general excite- 
ment 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 pa- 
pillae. The skin itself is often slightly swollen, especially in the face, hands, 
and feet; and the hands are rendered somewhat stiff in their movements. 
Along with the characteristic rash, may not unfrequently be observed, upon 
the neck, in the armpit, 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- 
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 416 
[part II. 
GENERAL DISEASES.-FEVERS. 
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. In many cases of scarlatina, albumen may be detected 
in the urine a few days after the commencement of desquamation; and, when 
examined with the microscope, it is found in these cases to be attended inva- 
riably, according to Dr. Begbie, with a considerable amount of epithelium of 
the uriniferous tubules, or other portions of the urinary passages. Of twenty- 
one cases examined by Dr. Begbie, albumen was detected in all. The quan- 
tity was small, and it continued to appear but a few days. {Ed. Month. Journ. 
of Med. Sci., Jan. 1849, p. 443, and Oct. 1852, p. 323.) 
But the course of the complaint is often much less favourable. From 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 rash. 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 
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 CLASS I.] 
SCARLET FEVER. 
417 
prominent. Stiffness of the jaws, soreness of throat, and pain in swallowing 
are often experienced at the commencement of the attack. The eruption 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 confined 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 in- 
tense 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 ordi- 
narily 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 gut- 
tural voice; and hemorrhage sometimes occurs from the nostrils. Upon ex- 
amination 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, resem- 
bling 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 portions 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, which may even be gangrenous. Occa- 
sionally they extend into the larynx, producing the symptoms of pseudo-mem- 
branous 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 glands; 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 neighbouring 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 per- 
mit 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 unfrequently the mucous 
membrane of the nostrils partakes of the disease; the nasal passages are closed 
by the consequent swelling, and the crusts which 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 exceed- 
ingly offensive liquid is occasionally discharged from the nostrils, which is 
sometimes very acrid, and excoriates the orifices. A similar secretion from 
the fauces is swallowed, and probably conduces to the production of the irri- 
tation of stomach and diarrhoea, which are occasional features of the disease 
towards its close. The discharges from the bowels are also sometimes acrid, 418 
[part II. 
GENERAL DISEASES.-FEVERS. 
so as to excoriate the anus. Occasionally the inflammation travels back through 
the eustachian tube into the cavity of the tympanum. The tongue is apt to 
lose its fur at an early period, becoming deep-red, smooth and glossy, or some- 
what 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 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 dis- 
ease, 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, fre- 
quent, and irregular; the surface either cool, or hot in one part and cold in 
another; the respiration preternaturally slow, or hurried and irregular; the face 
pale or livid; and the muscles almost powerless. Feeble attempts may be made 
at reaction; febrile heat may be partially developed to disappear again; and 
even some violet specks may appear as if they were endeavouring 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 established, with 
delirium, stupor, or mental inertness, a feeble circulation, a livid, purplish, or 
dark-red eruption, petechiae or vibices, passive hemorrhage, involuntary alvine 
discharges, and, unless a favourable change is effected, death in a few days. 
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, 
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 de- 
cidedly typhous or malignant character. The pulse becomes feeble, and the 
skin less regularly heated; the eruption disappears, or turns of a livid or pur- 
plish colour; petechise and ecchymoscs occasionally appear; the pseudo-mem- 
branous exudation in the fauces is of a more dirty or darker hue, and is some- 
times almost black; the whole throat is of a deep-red, approaching to a ma- 
hogany colour; true gangrenous eschars and deep ulceration often form, with CLASS I.] 
SCARLET FEVER. 
419 
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; gangrenous eschars form 
on the sacrum, hips, &c.; and at length collapse takes place, with sunken fea- 
tures, ghastly expression, a cold clammy skin, a fluttering pulse, and involun- 
tary 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 shattered system, has not unfre- 
quently to struggle with exhausting abscesses, ulcers, and alvine discharges, 
which too frequently carry him off, though he may survive even these, and 
ultimately be restored to health. It needs 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 occa- 
sionally 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 trou- 
blesome and dangerous gastro-enteritis. 
In females, inflammation of the vagina, with muco-purulent discharge, is an 
occasional attendant and sequela of the disease. 
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 com- 
mon after scarlatina than measles, though it occasionally happens. 
Pain and swelling of the large joints, closely resembling rheumatism, cramp- 
like pains in the lower extremities, and stiff-neck, are other sequela). 420 
[PART II. 
GENERAL DISEASES.-FEVERS. 
But, perhaps, 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 colfl 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 sometimes 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 affected. The dropsy is generally accompanied with scanty and 
albuminous urine, and is believed to be dependent on an active congestion or 
inflammation of the kidneys. It may always be apprehended when, during 
the desquamative stage of scarlatina, the urine is highly albuminous and much 
diminished in quantity. A moderate albuminous impregnation, with undi- 
minished secretion, is not to be considered as evincing a disposition to the 
complaint. The anemic condition of system, which occasionally follows 
scarlatina, may also occasion dropsical symptoms, in which case the urine may 
or may not be albuminous. For other remarks on this sequela of scarlatina, 
the reader is referred to the article on dropsy. 
It is said that, in certain epidemics of scarlet fever, dropsy has resulted from 
exposure to the contagion, without being preceded by the usual symptoms of 
the disease, owing possibly to the absorption of the poison, and its direct 
action upon the kidneys. Dr. Copland considers this a peculiar form of the 
disease, and proposes to call it scarlatina la.tens. The name might, with equal 
propriety, be applied to those cases of sore-throat and swelling of the salivary 
glands which occasionally result from exposure to the contagion, without the 
other symptoms of the disease. 
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 
glandules 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. The kidneys are frequently found 
congested or inflamed. 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 CLASS I.] 
SCARLET FEVER. 
421 
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 pre- 
serve generally about the mean of fibrin, while the red corpuscles are in- 
creased ; 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 decided proof that it had communicated itself in any one instance." 
The circumstance that one member of a family is usually first attacked, and 
afterwards others, at an interval of several days, is a strong fact in favour of 
contagion. The cause generally operates through the medium of the atmo- 
sphere. Whether the disease can be imparted by inoculation may be con- 
sidered doubtful, 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 is probably true; 
for cases occur which cannot be traced to communication with the sick, and in 
which, indeed, such communication could scarcely have happened; as when 
the disease first appears 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 or sthenic, in others an 
asthenic or typhous character; and occasionally causing a particular direction 
of the irritation, 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 ; and in another great numbers perish. 
In one, bleeding is well borne; in another it is very hazardous, and the pa- 
tients 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' wholly insus- 
ceptible to its cause. I presume that, in this country, there is scarcely a com- 
munity in which by far the larger proportion of the population does not escape 
altogether. It not unfrequently happens that only a single individual in a 
family is affected. 
No age is entirely exempt from scarlatina, but children are much more 
liable to it than adults. Indeed, the susceptibility seems to diminish from 
the age of ten upwards. (See Lond. Med. Times and Gaz., vi. 334.) Of the 
adults exposed to the cause few comparatively are attacked; and the in- 
stances 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 epi- 
demics 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 instance in which 422 
[part II. 
GENERAL DISEASES.-FEVERS. 
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 afterwards, and that contagion may lurk in fomites for 
months or years; but these opinions are at best doubtful. 
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 ap- 
pearance of redness in the fauces. After the eruption, one of the complaints 
with which it may be most easily confounded is measles. From this, how- 
ever, 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 charac- 
teristic 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 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, conversely, cases appa- 
rently the most desperate sometimes end favourably. Besides, after the case 
has reached convalescence, even under highly favourable circumstances, there 
is a liability to 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 closely related. 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 occa- 
sions, though the disease, prevailing at the time, may have no particular malig- 
nancy. In such families, the prognosis is always more unfavourable than in 
others; and special 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 nearly one- 
half of them have terminated unfavourably. Of course, the instances of mere 
febrile sore-throat, from exposure to the cause of the 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 circum- 
stances ; when otherwise, we should be more guarded. 
Among the unfavourable signs are a late appearance, considerable deficiency, 
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 
petechias, ecchymoses, or hemorrhage; a livid appearance of the fauces, with CLASS I.] 
423 
SCARLET FEVER. 
gangrenous sloughs or ulcers; extension of the pseudo-membranous 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. 
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 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. Ipeca- 
cuanha 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 affirm- 
ative 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 cause is probably in general depressing in its nature, 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 writh 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 424 
GENERAL DISEASES.-FEVERS. 
[part II. 
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 malig- 
nancy be the predominant character, it should scarcely be used at all. I have 
seldom found it advisable to bleed in any case; and do not remember the 
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 Sy st. 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 sensation 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 
* Dr. Samuel Jackson, of Philadelphia, formerly of Northumberland, has given to 
the public highly interesting statements of his success, in the treatment of anginose 
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, inclosed in a gauze bag. When the fever is very 
high, small quantities 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 main- 
tained 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 gangre- 
nous. These simple remedies were found exceedingly efficient by Dr. Jackson, and by 
several other practitioners who had been induced to employ them upon his recom- 
mendation. 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 circumstances seemed to call for them; but tne ice appears to 
have been the one most relied on in the anginose cases. (See Am. Journ. of Med. Sci., 
xii. 261 and 550; and xxii. 45; also Eberle's Practice of Medicine, edited by Dr. George 
MClellan, i. 478.) CLASS I.] 
425 
SCARLET FEVER. 
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. 
When the urine is very scanty, and especially if a tendency to delirium or 
coma should be observed, mild diuretics may be resorted to with hope of 
benefit, such as sweet spirit of nitre, acetate of potassa, bitartrate of potassa, 
wine of colchicum root, &c. 
But the practitioner should always be on the watch for symptoms of de- 
bility, 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 stronger stimulants, 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. When nervous symptoms are superadded, musk, assafetida, camphor, 
or valbrian 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 not 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 tfluidrachm 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 an excellent 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 sooth- 
ing to the throat, even though burning to the mouth, in which the same con- 
dition 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, 426 
[part II. 
GENERAL DISEASES.-FEVERS. 
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, con- 
taining fifteen or twenty grains in a fluidounce of water, as an application to 
the patches; and the nitrate of silver is also an excellent remedy, especially 
when the patches threaten to invade the larynx. Applied in solution, vary- 
ing in strength from a scruple to a drachm to the fluidounce of water, and 
repeated daily or twice a day, the latter preparation is now much employed, 
and by some practitioners is thought very favourably to modify the course of 
the disease when early resorted to. Dr. Eberle speaks 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 lime, or by diluted pyroligneous acid, which 
act also favourably upon the diseased surface. 
Leeches may sometimes, as already stated, be used externally when there 
is considerable strength of pulse; and some also recommended blisters. I 
have employed these frequently, but not with much apparent advantage. In 
the asthenic cases the blistered surface is liable to slough. Rubefacient 
applications to the throat, such as the liniment of ammonia, tincture of cap- 
sicum, or oil of turpentine diluted with olive oil, may be used. Among the 
best external applications is a large emollient poultice. 
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 sequelee 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. Red oxide of 
mercury mixed with almond oil has been recommended in the otirrhoea which 
is apt to follow the disease. 
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 
influence 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. 
Other modes of treating scarlatina have been employed, with great asserted 
success. Dr. John Gardner has treated thirty cases, some of which were of 
alarming violence, by means of belladonna, without the loss of a patient. 
He gives from half a grain to a grain of the extract, every three, four, or 
six hours, according to its effects, with no other, medicine except an occa- 
sional dose of castor oil. (^Braithwaite's Retrospect, xxiii. 28.) Inunction of 
the surface is highly recommended by Dr. Schneeman, of Hanover, and the 
practice has been successfully repeated by others. The whole surface of the 
body, with the exception of the face and scalp, is rubbed with a piece of fat 
bacon every morning and evening. (See Am. Journ. of Med. Sci., N. S., xx. 
503.) Among the new modes of treatment is also the external application 
of hot water, recommended by Dr. Bully, of the Berkshire Hospital. For 
the mode of employing it, the reader is referred to Braithwaite's Retrospect 
(xx. 30), and to the Medical Times (August 29, 1849). In malignant cases, CLASS I.] 
427 
ERYSIPELAS. 
brewers' yeast has proved highly useful in the hands of Dr. G. B. Smith, of 
Baltimore. He gives the yeast mixed with an equal bulk of water, and 
sweetened with brown sugar, in the dose of a tablespoonful every two hours. 
(Boston Med. & Surg. Journ., xlvi. 9.) Dr. II. L. Byrd, of Savannah, Geo., 
has recently met with great success from the use of the tincture of chloride 
of iron, given in a moderate dose every four hours or less frequently. 
(Charleston Med. Journ. c& Rev., ix. 165.) 
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. The weight of testimony is, I think, decidedly against its possession 
of any prophylactic virtues. 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 con- 
sists, 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 M^dC) Dr. John Webster, of London, strongly recommends, as a means, 
conjointly with isolation, of preventing the spread of scarlatina, the frequent 
sponging of the patient with warm vinegar. He believes, as the result of 
much observation, that with this precaution the disease will very seldom be 
communicated. (Ed. Month. Journ. of Med. Sci., Dec. 1849, p. 1295.) I 
have had no experience with either of the above prophylactics. 
Article XIL 
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 or 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 nfiusea and vomiting, headache, restlessness, muscular weakness, 
and not unfrequently soreness of throat, 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 428 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 
extends over the scalp, this is usually much swollen and puffy, and the whole 
head sometimes enormously 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 cu- 
ticle is elevated by a serous liquid, which appears sometimes in the form of 
minute eczematous or miliary vesicles, sometimes in that of 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 rupture. 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, CLASS I.] 
429 
ERYSIPELAS. 
though sometimes shorter, especially in the young and healthy, and some- 
times, from various causes, considerably protracted. Even after desquama- 
tion, it is sometimes long before the skin acquires its natural appearance and 
flexibility. Dr. J. W. Begbie has found the urine often moderately albumi- 
nous in the early convalescence of severe cases of the disease. (Ed. Month. 
Journ. of Med. Sci., Oct. 1852, p. 329.) 
The course of erysipelas often varies more or less from that above described. 
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 suc- 
cessively ; 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 tissues, 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 cases, 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 
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 remains 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. 
Sometimes it passes from the skin into the mouth, travels into the respiratory 
and alimentary passages, and produces characteristic effects in these several 430 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 vomit- 
ing, 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 admission 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 ap- 
pearance till some time in the course of the complaint. It is scarcely neces- 
sary to repeat the sympto'ms, which are those of the typhous state in fevers 
generally. 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 as- 
thenic character. Diarrhoea, with black fetid stools, not unfrequently comes 
on before the close; and, if the patient do not sink under the immediate 
disease, 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 ex- 
ternal 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 dis- 
appearance 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 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 hardness. 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 Hos- 
pital. The erysipelas, which was facial, suddenly disappeared, and the patient 
became delirious, with an exceedingly feeble pulse, cold skin, and other evi- 
dences of profound debility. He was stimulated actively with milk punch, 
&c.; the vital actions were restored, and with them the erysipelas, which after- 
wards terminated happily. 
But, notwithstanding these occasional protracted or dangerous cases, ery- 
sipelas, 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. CLASS I.] 
431 
ERYSIPELAS. 
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 
greatly 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 gangrenous. 
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 superficial portion, 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 cedematodes.-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- 
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- 432 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 interior organs or surfaces. Under 
such circumstances, the disease may be denominated erysipelatous fever. Oc- 
casionally 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 ery- 
sipelas. Its peculiarities depend either upon a torpid state of the liver, or on an 
excessive production of bilious matter in the blood. The name of malignant 
erysipelas is given to those terrible forms of the disease, generally 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 their 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 upon some part of the abdomen, and 
spreads rapidly over the trunk, to the genitals, the nates, and lower extremities. 
It may also begin upon the face or limbs. It is 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 affects more especially children born 
in crowded hospitals, than under ordinary circumstances. 
Anatomical Characters.-The blood drawn during life has the buffy 
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 true 
skin, and subcutaneous cellular tissue exhibit marks of inflammation. 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 uni- 
formly the case. Pus is often found in small abscesses, or diffused extensively 
in the cellular tissue and among the muscles. Sometimes small collections 
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 dis- 
tended; but sometimes, also, no morbid appearances are observed in the 
encephalon. Of course, the incidental inflammations which not unfrequently 
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 CLASS I.] 
433 
ERYSIPELAS. 
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 pre- 
viously diseased. 
But none of these causes 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; something 
which predisposes the individual to this particular form of disease rather than 
to others. Such a predisposition appears to be possessed by some persons consti- 
tutionally. 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 unfre- 
quently, 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 depressor debilitate the system, 
even without producing open disease, have the same effect. Hence, partly, 
the prevalence of erysipelas in hospitals. But there is also some unknown 
condition of the atmosphere, which greatly favours the production of the dis- 
ease; so that, when it exists, the slightest causes will give rise to this form 
of inflammation, though, on other occasions, they may have no such effect. It 
is felt especially in large infirmaries; but is nevertheless independent of the 
ordinary circumstances of those institutions; for no observable difference can 
be recognized between these circumstances, during the existence of this influ- 
ence, and at other times. It is occasionally so strong that the slightest irrita- 
tion of the surface induces an attack of erysipelas; and, when it prevails, it 
is hazardous to bleed, leech, or apply a blister, not to mention serious surgical 
operations, which are altogether unjustifiable. Wounds about the head are 
peculiarly liable to this unpleasant complication. It has been noticed that 
the predisposition to erysipelas exists in the ordinary wards of hospitals, 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. It is, indeed, a not uncommon 
opinion, especially in Europe, that puerperal fever and erysipelas, occurring 
epidemically, are interchangeable diseases, the one being able to produce the 
other by personal communication.* But neither in public nor private practice, 
have I ever seen a case of erysipelas in which there appeared to be any proof 
of a contagious origin; nor do I believe that, as it ordinarily occurs, it is in 
the least degree contagious. When, however, 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 
* See for cases apparently confirmatory of this view, the American Journal of Medical 
Sciences (N. S., xx. 250), quoting from the Edinburgh Monthly Journal of Medical Sciences 
for March, 1850; also the London Medical Gazette for October, 1851, p. 722. 434 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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.-Black Tongue.-The newspapers, 
a few years since, teemed 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 black tongue. 
Several accounts of the disease have been published in the medical journals, 
to which I am indebted for the facts contained in the following summary, as 
I have very seldom had the opportunity of witnessing the disease.* It pre- 
vailed in several of the New England States, in those of the West and North- 
west, in the interior of Pennsylvania, and in several of the Southwestern States, 
during the years 1842, 1843, and 1844; and I have heard accounts of it in 
isolated neighbourhoods in some of the Southern Atlantic States. The dis- 
ease 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 affection 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 com- 
mon and characteristic symptom. It is a very interesting fact, recorded both 
by Dr. Sutton and by Drs. Hall and Dexter, that puerperal 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 examina- 
tion of a female who had died of puerperal fever, became the starting-point of 
an extensive and severe erysipelatous inflammation. 
The disease very often began with difficulty of swallowing from inflammation 
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, extremi- 
ties, head, &c., nausea and retching, a frequent and depressed pulse, a fetid 
breath, cold and contracted skin, shrunken features, anxiety of countenance, 
and rigors more or less severe and protracted. The pains were often exceed- 
ingly 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 subse- 
quent inflammation. After a variable continuance of some or all of the above 
symptoms, occasionally extending to twenty-four hours or longer, febrile reac- 
tion came on, with a hot skin, frequent pulse, great restlessness and anxiety, 
delirium, furred tongue, &c. In the erysipelatous cases, the cutaneous inflam- 
mation appeared generally on the third or fourth day, though sometimes not 
earlier than the seventh. It was no uncommon event for the eruption to dis- 
* 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. George 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. See also an article by Dr. Montgomery in the St. Louis 
Med. andSurg. Journ., vii. 490, and another by Dr. H. N. Bennett, of Bridgeport, Con- 
necticut, in the N. Y. Journ. of Med., N. S., xi. 9. CLASS I.] 
435 
ERYSIPELAS. 
appear suddenly ; and this was generally an unfavourable sign. The inflam- 
mation 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 pene- 
trated 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. Hemorrhage was not un- 
common in the latter stages. In some cases, the nervous symptoms were pre- 
dominant, and occasionally the disease commenced with coma, from which the 
patient was never roused. When the erysipelatous affection did not appear, 
and sometimes along with it, there was violent 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 
downwards into the air-passages of the lungs, the stomach, and even the bowels, 
or upwards into the nasal passages and the brain. 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 occurred in two or three days, but more fre- 
quently about the eighth or tenth day, and occasionally much later. Conval- 
escence frequently took place in about a week or ten days, as in ordinary ery- 
sipelas, 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 secre- 
tions of the living body, as occasionally happens to the accoucheur. An 
inflamtnation generally runs up the absorbents of the arm, and not unfre- 
quently spreads out into an erysipelatous affection not only of the arm, but 
also of the chest and neck, with the formation occasionally of immense ab- 
scesses, 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 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 de- 
rives 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 436 
[part II. 
GENERAL DISEASES.-FEVERS. 
constitutional 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 Mid., 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 va- 
riety 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 
hastened. 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 tem- 
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 CLASS I.] 
437 
ERYSIPELAS. 
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 some- 
times be found useful to counteract acidity, and castor oil in states of intesti- 
nal irritation. 
Should the pulse be strong and full, and the inflammation severe and threat- 
ening, bleeding may be employed advantageously in the early stages, and in 
the young and vigorous with considerable freedom. It may sometimes 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 positively forbidden by the existing 
debility. It should be recollected that bleeding will not cure the erysipelatous 
inflammation, unless by inducing such a degree of depression as almost to pre- 
vent the blood from circulating in the capillaries ; and this is always dangerous. 
The remedy, therefore, should not be employed for this purpose. It is indi- 
cated when danger of suppuration 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, solu- 
tion 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 decidedly sthenic, 
small quantities of tartar emetic. 
When the general action is feeble, whether at the commencement, or becom- 
ing so in the course of the disease, and especially when nervous symptoms are 
exhibited, such as restlessness, wakefulness, and slight delirium, the combina- 
tion 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, however, 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. For the doses 438 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 per- 
haps a gangrenous tendency in the local affection, it becomes necessary to sup- 
port 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. Chlorate of potassa has been 
usefully employed in the malignant epidemic erysipelas, or black tongue, by 
Dr. R. L. Scruggs, of Tennessee. (Med. Exam., N. S., v. 227.) 
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. 
Mr. C. Hamilton Bell, of Edinburgh, treats erysipelas with the tincture of 
the chloride of iron, of which he gives from fifteen to twenty-five drops, every 
two hours, night and day, throughout the disease, without reference to the 
degree of fever, or the delirium. The only other treatment he employs is at 
first freely to act on the bowels, and afterwards to keep them properly open. 
His local applications are hair-powder and cotton wadding. He has used this 
method for more than twenty-five years with invariable success. (Ed. Monthly 
Joxtrn. of Med. Sci., June, 1851, p. 498.) Since the publication of Dr. Bell's 
paper, the remedy has been tested by many practitioners, and the reports have 
generally been in its favour. 
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 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 re- 
pelled by applications, the irritation may retreat with fatal effect to some in- 
terior 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 CLASS I.] 
439 
ERYSIPELAS. 
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 
impregnation 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 silver, 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 generally desquamates. Blisters may be employed in 
the same way, and they generally succeed, though more inconvenient than 
the iodine. Nitrate of silver is also very efficient, 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 em- 
ploys the stick itself, or a strong solution, made with eight scruples of the 
nitrate and twelve drops of nitric acid in a fluidounce 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 often 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 
danger, 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 inflamma- 
tion, is there not some danger that the bites themselves may become new foci 
of the disease? The only circumstance which calls strongly for this remedy 
is, I think, the existence of some threatening internal inflammation or irrita- 
tion, 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- 440 
GENERAL DISEASES.-FEVERS. 
[PART II. 
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 
liable to the inconvenience of forming hard crusts upon the surface. Whether 
it has any influence in reducing the inflammation is doubtful. Once, how- 
ever, 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 ascriba- 
ble 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 erysipe- 
las 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 
unguents was applied to one side, while the other was left untouched; and 
he never perceived that the disease was influenced by any of these proceed- 
ings. (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 applica- 
tion of cloths wet with ice-water has also had its advocates, and may be a 
useful measure in phlegmonoid erysipelas of the extremities. Dr. Trevor, of 
Illinois, has employed collodion as an external remedy with advantage. (AC IE 
Med. and Surg. Journ., Jan. 1850.) The same substance mixed with one- 
fifteenth of castor-oil has been highly recommended. 
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. (AC Am. Med. 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 Med. 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 fasciae, 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 advisa- 
ble 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 pro- 
duced, in consequence of the separation of the cuticle, and seems indisposed 
to heal, it may be advantageously dressed with Goulard's cerate. 
The progress of gangrene may sometimes, possibly, be arrested by a blister 
ap^ied 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. CLASS I.] 
GLANDERS. 
441 
Article XIII. 
GLANDERS. 
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 
satisfactory account of it was given by Dr. Elliotson, in the latter of these 
years, in a paper published in the London Medico-Chirurgical Transactions. 
Subsequently, various contributions on the subject have been made to the 
journals; 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, in- 
tended to express its derivation from the horse; as that of vaccinia was be- 
fore given to cowpox. 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 glandulosa upon the glanders. The 
former is a trivial eruption of phlyzacious pustules, similar to those of ecthy- 
ma, 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 ultimately disappears, leaving small well-defined scars. 
It occasions little inconvenience 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 entitle it to the same designation, however qualified 
by epithets. The general adoption of one generic name for the two com- 
plaints might lead to the injurious 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 
commingled; 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. 
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 
Syn.-Equinia (Elliotson).-Morve (French'). 442 
GENERAL DISEASES.-FEVERS. 
[part II. 
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, 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 phlyzacious pustules takes place, most abund- 
ant on the face and limbs, about the size of the vaccine vesicle, having fre- 
quently a small red areola, sometimes umbilicated, and presenting occasionally 
a dark purple hue. They occur in successive crops, and appear, therefore, in 
different stages of progress at the same period of the disease. Dr. H. Graves, 
of Dublin, observed a white zone about the pustules in two cases, and con- 
siders this as characteristic of the disease. Along with these pustules are gan- 
grenous bullae, especially on the face and scalp; prominent ecchymoses filled 
with a reddish sanies, and having sometimes a gangrenous base; and tumours 
frqm one to three inches or more in diameter, which are at first hard and 
painful, but soon suppurate, and form abscesses extending into the subcuta- 
neous 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 
obstructed 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 cer- 
tain 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 
participates 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- 
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 CLASS I.] 
GLANDERS. 
443 
and sometimes stertorous; the pulse frequent, small, and feeble. There is 
often extreme thirst. Diarrhoea is an almost constant symptom, with fre- 
quent, offensive discharges. The body exhales a fetid odour. The mind 
wanders, and delirium alternates with coma. At length involuntary dis- 
charges and extreme prostration indicate the immediate approach of death. 
The duration of the disease varies in general from two to three weeks. Some- 
times 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 almost invariably the same. The patients 
nearly all die. In only a few cases, and those either very mild or of doubtful 
nature, is recovery reported to have taken place.* 
Symptoms of Chronic Glanders.-The cases which have been recorded as 
belonging to this variety of the affection are comparatively few, and its his- 
tory 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 an offensive discharge issues, sometimes glutinous, sometimes purulent 
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 super- 
vene, and the patient speedily perishes. Instead of being at first restricted 
to the nostrils, the complaint may show 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 
glanders, 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 mu- 
cus, 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 de- 
nudation and caries of the bone, and sometimes an opening through the sep- 
tum ; 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 
frequently 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 glan- 
* See Archives Gen., 4e s6r., xiv. 89 ; xviii. 222; and xxvii. 419. For cases described 
by Dr. F. W. Mackenzie, see the Land. Journ. of Aled, for Sept. 1851, p/789, and the 
Lond. Med. Times and Gaz. for July, 1852, p. 7. Neither of these cases can, I think, be 
considered as undoubted examples of the disease ; and still less a third case, in which 
a cure took place, described in the last mentioned Journal for March, 1854, p. 303. 444 
GENERAL DISEASES.-FEVERS. 
[part II. 
ders. The disease is imparted either by contact of the poisonous secretion 
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 animal; or 
through the medium of the atmosphere, though this last mode of communica- 
tion is somewhat doubtful. Persons have been affected with it who have 
lodged in the same stable, or been otherwise in close communication 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 indi- 
viduals 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 constitutions otherwise de- 
bilitated. 
Treatment.-In relation to the acute disease, the methods of treatment 
hitherto employed having proved almost invariably 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 a 
case of supposed glanders recorded by Dr. Mackenzie, which ended favourably, 
the treatment consisted in an emetic dose of ipecacuanha, followed by five 
grains of the carbonate of ammonia every two hours, the use of wine or porter, 
an opiate at night, nourishing food, a small quantity of the blue pill, and a 
gargle of solution of chloride of lime. 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. 
Article XIV. 
Syn.- Breakbone Fever.-Dandy Fever.-Dunga. 
DENGUE. 
By the above names has been designated a peculiar febrile disease, cha- 
racterized by the presence conjointly or separately of rheumatic symptoms 
and cutaneous eruption, and always, so far as has been observed, occurring 
epidemically. The first notice of it is contained in an account by Dr. Rush 
of an epidemic which prevailed in Philadelphia, in the summer and autumn 
of 1780, and which he described under the name of "bilious remitting fever/' 
stating, at the same time, that it was commonly called " breakbone fever," 
in consequence of the violence of its attendant pains. (Medical Inquiries and 
Observations, 3d ed., ii. 385.) In 1824, the disease prevailed at Calcutta, 
and was described by Dr. James Meilis, in the Transactions of the Medical 
and Physical Society of that city. (Am. Journ. of Med. Sci., iv. 495.) To- 
wards the close of 1827, an epidemic broke out in the West Indies, whence 
it proceeded to the continent, reaching New Orleans in the Spring, and 
Charleston and Savannah in the summer and autumn of the following year. 
It was to this that the name dengue was first applied, the origin of which is 
somewhat uncertain, though it is supposed to be a Spanish corruption of the 
word dandy; the name of dandy fever having been jocosely conferred on the CLASS I.] 
DENGUE. 
445 
disease by the negroes of St. Thomas, where it first appeared, from the stiff 
carriage of those affected with it. Various accounts were given of this epi- 
demic, of which the most satisfactory are probably those of Dr. S. H. Dick- 
son, who described it as it appeared in Charleston (see Bell's Library for 
1839), and Dr. Wm. R. Waring, whose communication in relation to it ap- 
peared in the North American Medical and Surgical. Journal (ix. 374). Ac- 
cording to Dr. Waring, the disease first appeared in Savannah in the autumn 
of 1826, and prevailed to a certain degree in the following year; but the 
Spanish name dengue was not applied to it until the attack of the epidemic 
in the autumn of 1828. For a long time after this period nothing was heard 
of it; but in the summer of 1850 it again visited the South, and Charleston 
suffered from it with special severity. A history of the epidemic, as it pre- 
vailed the second time in that city, was communicated to the Charleston Medi- 
cal Journal for November of the same year, by Dr. S. H. Dickson; and it is 
from the published accounts of that author, and of Dr. Waring, that the fol- 
lowing summary has been chiefly drawn. I have had no opportunity of seeing 
the disease. 
Symptoms, Course, &c.-In many cases, the complaint comes on gradually; 
but in the greater number its commencement is somewhat abrupt, though 
there is seldom a regular, well-formed chill. The first symptoms are usually 
headache with intolerance- of light, general uneasiness, restlessness, sometimes 
more or less chilliness, a sense of great debility, and violent pains in the back, 
limbs, and joints, attended often with some degree of tumefaction, and with 
soreness and. stiffness of the muscles, very much resembling rheumatism. The 
small as well as the large joints are affected, and sometimes the pain is first 
felt in the thumb or fingers. It is occasionally confined to one part, but sel- 
dom; and when it attacks several parts, may seize upon them all at once, or 
successively. In some cases it affects the stomach and bowels. The skin soon 
becomes hot and dry, the pulse increased in frequency, the face flushed, and 
the eyes red and watery. The tongue, however, though red, is usually clean 
at this stage. Sometimes a rash or papular eruption appears, but not gene- 
rally at this early period of the disease. Not unfrequently the patient exhibits 
drowsiness, which may continue in greater or less degree throughout the com- 
plaint. Children are sometimes attacked with convulsions, and pregnant wo- 
men are apt to miscarry. Painful swellings of the lymphatic glands in the 
neck, axilla, and groin, and of the testicles, occur in some cases, and continue 
after the subsidence of the other symptoms. The initial fever lasts from twelve 
hours to three or four days, perhaps, on the average, about a day and a half; 
after which it subsides, leaving the patient much more comfortable, but often 
very feeble. Then follows an interval of two, three, or four days, during 
which the patient is without fever, and suffers less from the pains, though he 
still complains somewhat of rheumatic sensations, and of general weakness. 
On the fourth or fifth day, there is often a return of the fever and pains, and 
the tongue now becomes thickly coated. In some instances, however, there 
is no febrile heat or frequency of pulse, but severe pain in the head. Nau- 
sea and epigastric uneasiness are prominent symptoms, but the patient 
seldom vomits. On the fifth, sixth, or seventh day, an eruption usually ap- 
pears, more especially upon the upper portion of the body, and gives relief to 
the symptoms of internal irritation. This eruption is extremely variable in 
character, being sometimes smooth, red, and continuous, as in scarlatina; some- 
times in patches, rough, and of a darker hue, as in measles; and occasionally, 
also, either papular, vesicular, pustular, or furunculous; and often there is a 
mixture of two or more of these forms. Cutaneous affections like urticaria 
and erysipelas are also occasionally observed; and even carbuncles occur. In 446 
[PART II. 
GENERAL DISEASES.-FEVERS. 
some few instances, the eruption assumes the petechial character; the gums 
are red, spongy, and bleeding; and soreness of the mouth, with ulcers, com- 
plicates the case. The cutaneous affection is attended usually with heat and 
itching. Upon subsiding, it is sometimes followed by a furfuraceous or scaly 
desquamation. The complaint gradually subsides, leaving the patient for the 
most part with some rheumatic stiffness or soreness for a longer or shorter 
period, and with feelings of weakness, and occasionally of mental depression. 
Sometimes the debility is very considerable, and even alarming, with a slow, 
weak pulse, cold sweats, and a purplish or livid appearance of the eruption. 
The duration of the affection varies with the length of the remission, but on 
the average, is about eight days. Sometimes the cases are much milder; and, 
as in other epidemics, there is every grade, from a scarcely observable disorder 
to the greatest intensity of which the disease is susceptible. 
The course of symptoms above detailed bears a considerable resemblance 
to that of.yellow fever; and the two affectionshave sometimes been confounded. 
The persevering rheumatic symptoms, and the cutaneous eruptions are, how- 
ever, sufficiently diagnostic of the dengue. It is not improbable that the causes 
of the two affections may sometimes prevail at the same time: in which case, 
the yellow fever may take on some of the characters of this peculiar epidemic, 
and the diagnosis be rendered more difficult. Another striking distinction 
between the two diseases is the great difference in their results. The yellow 
fever is very often fatal, the dengue almost never. 
Cause.-No other cause of this affection is known than epidemic influence. 
It has been ascribed to contagion; but the proofs of this are insufficient. Conta- 
gious affections do not so rapidly disappear without leaving traces behind them. 
Besides, it is stated that, when families are attacked, it is not a single member 
of the family that is first affected, and afterwards at a certain period several 
others; but almost all are seized at once, or in rapid succession, so that there 
are not enough well to attend on the sick. This epidemic differs from almost 
all others in the numbers affected in proportion to the population. The great 
majority of the people usually suffer. The epidemic which in this respect 
most nearly resembles it, is the influenza. It attacks indiscriminately persons 
of both sexes, of all colours, and of all ages from earliest infancy to extreme 
old age. The period of incubation is extremely variable, being in some in- 
stances, as asserted, so short as twenty-four hours, and extending in others to 
ten days. 
Prognosis.-This is almost always favourable. Perhaps no disease with so 
much severity of symptoms is so seldom fatal. When death occurs, it is 
almost always in consequence of some incidental complication, or of the great 
previous weakness of the patient, as in very advanced life. 
Treatment.-Where all the patients recover, treatment is to be employed 
simply to palliate and alleviate. An emetic, administered at the very earliest 
period, is said sometimes to have arrested its progress; but so disagreeable a 
remedy will probably not be generally resorted to in an affection attended 
with so little danger. Some gentle aperient may be given early in the attack, 
and subsequently if the bowels should be confined. When the skin is hot 
and dry, the neutral mixture or other refrigerant diaphoretic may be adminis- 
tered. In very violent cases of headache, a small bleeding has been recom- 
mended as affording relief. But the most important remedies are anodynes, 
to relieve the exquisite pains. Of these opium is the most efficient. It may 
be given in any quantity requisite to produce the desired effect, so that it do 
not occasion stupefaction. When there is no nausea, it is probably best 
given in the form of Dover's powder. In light cases, the camphorated tinc- 
ture of opium is sufficient. The warm bath might be expected to afford CLASS II.] 
447 
CONSTITUTIONAL DISEASES.-RHEUMATISM. 
relief. It is often advisable to counteract the depressed state of the system 
by stimulants, as by wine, the malt liquors, or even brandy; and nutritious 
food should be given at the same time. Some practitioners treated their 
patients on the expectant plan; prescribing rest, a recumbent position, cold 
to the head, hot pediluvia, and a regulated diet. 
CLASS II. 
CONSTITUTIONAL DISEASES. 
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 [page 232), the second class embraces constitutional 
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 one organ to another 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 affec- 
tions 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 advantageously 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- 
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, when it occurs, is 
probably in general secondary, and dependent on the local affection. 
Article I. 
RHEUMATISM. 
Syn.-Rheumatismus. 
Rheumatism (from psi^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 448 
[part II. 
CONSTITUTIONAL DISEASES. 
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, (l 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 following pages. 
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 follow- 
ing varieties may be recognized:-1. the acute, in which violent local inflam- 
mation 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. 
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 
the trunk, jointly or successively; and occasionally it involves almost the 
whole exterior of the body. It lias 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 sub- 
side with the pain, but usually becomes softer, and, instead of being firm and 
elastic, will often pit somewhat upon pressure. Not unfrequently, a joint CLASS II.] 
449 
RHEUMATISM. 
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 confined 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 ex- 
tremely 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 con- 
sequence 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 super- 
ficial 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 slight- 
est 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 asthenic 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 hun- 
dred and ten, and probably, in the greater number of cases, not exceeding a 
hundred. 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 relieving 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 
secretions 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 symp- 
tom, 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 peculiar 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 ordi- 
nary symptoms 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 450 
CONSTITUTIONAL DISEASES. 
[part II. 
symptoms of rheumatic inflammation of the heart were unequivocal in twenty- 
one, of which five were pericarditis. (Tweedies Syst. of Pr act. 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 dis- 
ease comes on varies from the eighth to the twenty-seventh day; and, though 
it is stated by Dr. Fuller that it occurs at all stages, and sometimes even pre- 
cedes the inflammation of the joints, yet there can be no doubt of its greater 
frequency at a somewhat advanced stage of the disease.* With us, acute rheu- 
matism often terminates within the limits stated by Dr. Budd, 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. Pericarditis is more immediately dangerous, endocarditis leaves the 
most unpleasant effects behind it. In the former, the two surfaces of the 
pericardium often coalesce in case of recovery, and no disagreeable conse- 
quences 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 ulti- 
mately 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 pecu- 
liar expression of countenance, supervene, disease of the heart may always 
be suspected; and a close examination should-be made, by means of auscul- 
tation 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 atten- 
tion of the practitioner, unless sought for by the means alluded to. It should, 
however, be stated here that some caution is to be observed not to draw too 
hasty a conclusion, as to the existence of endocarditis, from the circumstance 
that cardiac murmurs are heard in auscultation; for it is probable that they 
sometimes arise from the deposition of fibrin from the highly fibrinated 
blood, independently of inflammation of the endocardium; and it is well 
known that they are frequent attendants on an anemic state of the blood, 
which is not uncommon in acute rheumatism, especially in its advanced stage. 
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 me, in which a 
retrocession of the inflammation from one of the lower extremities was fol- 
lowed by disease of the heart, which proved fatal in a few days. Either 
there was metastasis here, or the concentration of a powerful excitement in 
the central organ called off the disease from the limb upon the principle 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 inflammatory rheu- 
matism, are much more liable to this complication than adults; and in 
relation to the latter, the liability appears to diminish with the age. Women 
are said also to be more frequently affected than men. 
* See Treatise on Rheumatism, &c., by Dr. Henry William Fuller, Am. ed., 1854, p. 
165. CLASS II.] 
451 
RHEUMATISM. 
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. 
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 pf 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 
ten days 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 partsy each run- 
ning 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 disease is 
indicated, first by the diminution or disappearance of the pain, then by a 
softening of the part, so that, instead of being tense and elastic as at first, 
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 452 
CONSTITUTIONAL DISEASES. 
[part II. 
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 buffy coat when drawn during life, and allowed to coagulate. 
Indeed, with the exception of pneumonia, there is no one of the phlegmasiae 
in which these characters exist so strongly as in acute articular rheumatism. 
In one instance, Andral and Gravarret 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. Gaz., Feb. 1848); and, since this statement was 
originally made, it has been repeated after the examination of a great number 
of cases. (Ibid., July, 1854.) 
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 internal inflammations attendant on 
the disease leave the same effects behind 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 power- 
fully during perspiration from previous exercise or exposure to heat. Sleep- 
ing 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 au- 
tumn and in spring. 
But solhething 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 
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; CLASS II.] 
453 
RHEUMATISM. 
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 pre- 
disposition to the disease is often inherited. It is very apt to exist in mem- 
bers of the same family, whether inherited or not. Debility appears to favor 
the predisposition ; 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 complaint 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 rheuma- 
tism is concerned, have been greatly exaggerated in some recent practical 
treatises. 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 ten- 
dency to give rise to a condition of the heart, ending in fatal hypertrophy and 
dilatation. 
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, &c.-Two or more joints may be inflamed; but, in 
probably the greater number of instances, the disease is confined to one at 
a time; as, with the grade of action often present in these cases, an extension 
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, how- 
ever, 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. 
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 contracts. In 
others, the patient first becomes sensible of the complaint by a very severe 
2. Subacute Rheumatism. 454 
[PART II. 
CONSTITUTIONAL DISEASES. 
sharp lancinating pain, which seizes the muscle upon some occasion when it 
is suddenly called into action, as upon attempting to rise from the sitting pos- 
ture, to turn in bed, or to lift a burthen. The pain is sometimes excruciating, 
so that the patient is unwilling 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 con- 
siderable, and is often wanting. The pulse is sometimes excited, and the 
general heat increased; but the constitutional 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 at- 
tacked 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 them- 
selves, which is felt in pain and spasm of the parts to which they are distri- 
buted. Many of the severe and complicated nervous disorders both of exter- 
nal and internal parts, connected with tenderness of the spinal column when 
the spinous processes are pressed, are probably owing to subacute rheumatism 
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 indisposed to change. In the subacute, the constitutional tendency 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 be- 
tween the highly 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 head- 
ache, often quite severe, soreness of the scalp on pressure, pain on the move- 
ment of the occipito-frontalis muscle, and the presence of rheumatism pre- 
viously, 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 headache, 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 
of the disease, the ball is painful to pressure, and a dull redness may some- 
times be seen through the conjunctiva; but it is often very difficult to distin- 
guish the affection from ordinary inflammation, except by taking into consi- 
deration 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 CLASS II.] 
RHEUMATISM. 
455 
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 re- 
main at rest, the patient is easy, or feels only a dull aching; but every move- 
ment is exquisitely painful. 
In the Parietes of the Chest.-Pleurodynia.-This complaint is not unfre- 
quent. It is a rheumatic affection of the intercostal muscles, and is charac- 
terized by severe, acute, and generally shifting pain in the side upon taking 
a full breath or coughing, by soreness of the intercostal spaces upon pressure, 
and by the general absence of fever. It resembles 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 uncer- 
tain that it can be made out only by attending 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 contraction of the intercos- 
tals, there is little expansion of the affected side of the chest, so that the re- 
spiratory 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 pos- 
ture, or to raise a burthen. When very severe, it confines the patiett 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 
partially 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 pressure, 
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 testicles, the irritation of 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 occa- 
sions 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 the Hip.-Sciatica.-The parts about the hip are often attacked with 456 
CONSTITUTIONAL DISEASES. 
[part II. 
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 be- 
lieve, 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 corre- 
sponding 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.-1The 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 ex- 
ternal attacks of rheumatism, too moderate or limited to be considered as be- 
longing 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, produc- 
ing, according to its severity, immediate death, or severe pains, palpitations, 
oppression, &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 heart, or the original occurrence in the heart, 
of a rheumatic irritation so severe as wholly to disable the organ, or the part 
of it affected, from contracting. 
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 rheumatism, 
not sufficiently noticed, I think, by authors generally, is the muscular coat of 
the hotels. The patient complains of a constant aching in some portion 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 by purgative medicine. Some- 
times 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 recog- 
nized from occurring upon the retrocession of an external attack, or in in- 
dividuals known to be subject to rheumatism. It differs from colic in being 
less decidedly spasmodic, and from ordinary inflammation of the whole thick- 
ness of the bowel, in the much less violence of the constitutional disturbance. 
Rheumatism sometimes also attacks the mucous coat of the howels, 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 tjie 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, CLASS II.] 
RHEUMATISM. 
457 
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 
swallowing of food produces acute pain at the point where the oesophagus 
penetrates 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 melsena. 
In the nephritic affection, there is pain in the back, extending to the abdo- 
men, and shooting towards the groin, and sometimes retraction of the testi- 
cle, but not, so far as I have observed, the copious deposition of urates which 
characterizes gout, nor so urgent a disposition to frequent micturition as in 
ordinary nephritis. The complaint, whether in the liver or kidney, is at- 
tended, 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 rea- 
son 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 
inflammation 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 pricking or darting pain of 
a neuralgic character, occurring at irregular intervals, and excited sometimes 
by the touch. (Archives G^n., 3e ser., xii. 120.) 
The duration of subacute rheumatism is exceedingly uncertain, and de- 
pends greatly upon the treatment. It is often relieved in two or three days, 
and sometimes runs on for weeks or months if neglected, degenerating, in 
the latter case, into the chronic form. Though much more readily subdued 
than the acute, it is much more liable to return quickly. 
Causes.-The causes are the same as those of the acute variety. The 
complaint 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 may sometimes do so when 
a strong predisposition to it exists; but more frequently, when supposed to 
be the cause, they merely serve to make known to the patient the existence 
of the disease. When the constitutional tendency is very strong, it is pro- 
bable that anything excitant 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 rheumatism. 
* 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. 458 
CONSTITUTIONAL DISEASES. 
[part II. 
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 joints, arising from contraction, thickening, and rigidity of the ligaments, 
from firm contraction or shortening of the muscles and tendons, and some- 
times from changes in the cartilaginous and bony structure, which undergo 
degeneration or absorption under the long continued irritation. 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 
paralyzed. 
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, CLASS II.] 
459 
RHEUMATISM. 
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 the diagnosis. 
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 discover- 
able 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, 
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 signs 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 
4. Nervous Rheumatism. 460 
[PART II. 
CONSTITUTIONAL DISEASES. 
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. There is 
one form of nervous disorder supposed to be not unfrequently of rheumatic 
origin, which does not equally occur in gout, probably in consequence of the 
age at which it generally makes its attack; I allude to chorea. 
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 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 sensatiAi, and perverted function in the liver, kidneys, and genitals. 
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 
affection, 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, not a few pathologists are disposed to ascribe 
its peculiarities to the abnormal presence of an acid in the circulation, which, 
according to Dr. Prout, is the lactic, according to others, the uric acid. But 
there is so utter a want of proof as to the uniform existence of any such offend- 
ing cause in rheumatism, that, in the present state of our knowledge, the 
opinion must be looked on as purely-speculative.* 
* Dr. Garrod found in the blood, in acute rheumatism, only that proportion of uric 
acid which exists in health; but Dr. Maclagan, of Edinburgh, in a few cases which he 
examined, discovered an excess both of uric acid and urea, and is disposed to believe that 
such an excess is general. (Ed. Month. Journ. of Med. Sci., N. S., v. 21.) But before 
this humoral opinion of the nature of rheumatism can be admitted as established, it is 
necessary to demonstrate not only the presence of the offending matter in so large a 
number of instances as to leave no room for reasonable doubt that it is universal in 
this disease, but also its absence in other febrile and inflammatory affections. Now CLASS II.] 
RHEUMATISM. 
461 
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 mor- 
bid 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 proportionate 
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 cir- 
culation. The pulse, and the obvious amount of local disease, as exhibited 
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 operation 
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. Generally, from 
twelve to twenty-four ounces may be taken from a robust individual, 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 irrita- 
tion 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 
intensity. Sudden death has resulted from an apparent transfer of rheumatic 
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 doubt- 
ful 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. 
acid in the breath, perspiration, and urine is so common in complaints having none of 
the characteristics of rheumatism, that even if it should be shown to be always present 
in this affection, which it has not been, we should be justified simply in considering it as 
a result of morbid processes common to rheumatism and other diseases, and not as the 
essential characteristic and essence of the former. (Note to the fourth edition.') 462 
[PART II. 
CONSTITUTIONAL DISEASES. 
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 
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 deple- 
tion.* 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 obviated by the 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 intervals 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 per- 
spiration, as to sustain a moderate sedative impression 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 abandoned as generally 
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 sufficient to give half 
the quantity. Should it be doubtful whether excitement has been sufficiently 
reduced for the remedy, as just recommended, the proportion of ipecacuanha 
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 one or at furthest two weeks, or 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 
* The following formula may be used. R.-Magnesias Sulphat. ^ss; Magnesias ^ss; 
Vin. Colch. Rad. fjss; Aquae fluv., vel Aq. Acid. Carbonic, q. s. Fiat haustus. 
f The following is a convenient formula. R.-Opii pulv., Ipecac, pulv., aa gr. vj ; 
Potassas Nitrat. gj: Guaiaci Resinas pulv. giss. 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. 
463 
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 
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 frequently 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. Should the case be in a some- 
what advanced state when it first comes under the notice of the practitioner, 
the calomel and opium treatment may be commenced immediately. There 
is generally a speedy abatement of the symptoms on the occurrence of sore- 
ness of the gums. 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 re- 
lieving if not curing the disease. A grain may be 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 
occasionally happens without the least alleviation of the pains, swelling, &c., 
and is probably the mere result of debility, with some irritation of the circu- 
lation. 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 alarming, 
a blister over the whole head. Along with these means, calomel should be 
given promptly and freely, so as to induce 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 rubefacient, 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 in the early stage, and recourse be had to quinia 
as soon as an intermission, or a decided remission shall have been obtained. 464 
[part II. 
CONSTITUTIONAL DISEASES. 
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, 
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 io 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 Phila- 
delphia, has spoken highly to the author of the, efficiency of the tobacco 
cataplasm. 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 condition. 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 in- 
dispose 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 applica- 
tions 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 dura- 
tion of rheumatism in his hands is only one or two weeks, instead of six or 
eight; and, up to the publication of his treatise, there had been no death, 
even in cases complicated with disease of the heart. 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 morn- 
ing, 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 CLASS II.] 
RHEUMATISM. 
465 
three times a day. The calomel was omitted when the swelling and pain 
greatly abated, or the gums became in the least tender. According 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. A few 
years since 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 was given daily, in divided portions. As might 
have been anticipated, though the external inflammation was suppressed 
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. The practice is likely to fall again into 
neglect. The risk of injury to the stomach from the large amount, as well 
of the liquid as of the salt, will probably 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. Dr. Golding Bird 
has employed the acetate of potassa, and considers it preferable to the nitrate. 
(Lond, Lancet, Feb. 15, 1851, p. 177.) 
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 plight 
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 vary- 
ing 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 rheu- 
matism. (Am. J. of Med. Sci., N. 8., xi. 108.) Dr. Samuel Edwards, of 
Bath, England, 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 466 
CONSTITUTIONAL DISEASES. 
[part II. 
remedies, and found them extraordinarily effectual. He prefers soda to the 
other alkalies, giving the bicarbonate internally, and applying the carbonate 
externally in baths. (Med. Times, June 5, 1847.) Others prefer potassa; 
and the officinal solution, or liquor potassae, is sometimes employed. Besides 
the correction of acidity, another effect expected from the alkalies is to render 
the fibrin more soluble in the blood, and thus to prevent or correct the 
fibrinous deposits in the heart, which sometimes so seriously complicate 
the disease. 
A directly opposite plan has recently been proposed by Dr. Owen Rees, 
of London, who has found lemon-juice, in. the dose of one or two fluidounces 
from four to six times a day, very efficient in acute rheumatism, rapidly 
reducing the pulse and relieving the pains, and effecting the cures in a shorter 
average period than the plans ordinarily followed. It is only the sthenic 
cases to which the remedy is applicable. The method has been followed by 
other practitioners with similar results. Dr. Wm. Pepper, of Philadelphia, 
has reported a number of cases, successfully treated by him with this remedy 
in the Pennsylvania Hospital. Great relief was generally obtained in about 
a week, and in some in a shorter time, and most of the patients were dis- 
charged cured in less than two weeks. (Trans, of Col. of Phys, of Philadel- 
phia, N. S., i. 124.) Dr. Babington, of London, has found the juice very 
successful, and believes that no other remedy is equally efficient. But he 
employs it in larger doses than above mentioned, giving as much as six 
ounces three times a day. (Lancet, Nov. 8, 1851, p. 431.) Others have 
not been equally successful; but it must be recollected that it is only in 
acute rheumatism that much is expected from it. In two cases in the Penn- 
sylvania Hospital, both acute, and closely resembling each other, I employed 
in one the lemon-juice, and in the other the plan of treatment recommended 
in this work. At the end of about a week the latter was convalescing, and 
no apparent effect had been produced in the former. I then abandoned the 
lemon-juice, and adopted the same treatment as in the other case, under which 
the patient speedily recovered. This is the amount of my experience with 
the remedy. 
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. S., xiv. 263.) 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, sulphur, 
and aconite, which have been lauded in acute rheumatism, are better adapted 
to the other varieties. The leaves of the common European ash, in substance 
or infusion, have been recently recommended on the continent of Europe. 
(See Lond. Med. Times and Gaz., v. 650.) • 
MM. Piedaguel and Trousseau cure acute rheumatism generally in seven 
or eight days by veratria, in the dose of about one-thirteenth of a grain; one 
dose being given on the first day, two on the second, three on the third, and 
thus with a like increase up to the sixth or seventh, if the symptoms do not 
previously abate. When this happens, the number of doses arrived at is 
continued for two or three days, then diminished daily with the decrease of 
the disease. (See Am. J. of Med. Sci., N. S., xxvi. 496.) American helle- 
bore has been employed in this country. (See U. S. Dispensatory.} 
Great success has been claimed for an expectant plan, pursued by M. Gouzee 
in the military hospital at Antwerp. A comfortable and uniform tempera- 
ture, pure air, the free use of diluent drinks, prolonged local tepid baths 
once or twice daily, cataplasms in the intervals, confinement to bed for a few class II.] 
467 
RHEUMATISM. 
days during convalescence, and the use of simple bitters or quinia at this pe- 
riod, constitute the sum of the treatment. The disease naturally, it is stated, 
tends to recovery in a week or two, and the patient gets well as speedily as 
when actively treated, if not more so. {Ranking1 s Abstract, xviii. 234.) 
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 sub- 
acute 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 nau- 
seated. It may often be advantageously combined with the solution of sul- 
phate of morphia, so as to keep the patient under a moderate narcotic impres- 
sion; 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 exhibit 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, may be 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 are 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. 
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 ten- 
der 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 468 
CONSTITUTIONAL DISEASES. 
[part II. 
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, chloroform, plasters made with 
the extract of belladonna, or of aconite, &c. Ointment of iodide of potassium 
has been used with asserted benefit. Cyanuret of potassium has been em- 
ployed, either in solution in the proportion of one part to seventy-five parts 
of water, or in the form of ointment made with three grains of the cyanuret 
and an ounce of lard; the remedy being applied three times a day. (Valleixl) 
Cold water has been recommended; but this I should consider very hazard- 
ous. It is in this form of rheumatism, and in the neuralgic, that acupunctu- 
ration has been most efficient. In some cases, as in stiff neck, heat may be 
advantageously 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 depiction, 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 ounce 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 of 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 
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 CLASS II.] 
469 
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. The following remedies and plans of treatment appear to me to merit 
attention, the general being first mentioned, and afterwards the local. 
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 neutral 
salts alone may be used, as in the former varieties. Sulphur is also frequently 
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 pre- 
ceded 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 rheuma- 
tism by a supposed alterative action. As the precise mode in which these 
remedies do good is not known, they need not be employed with any great 
discrimination. Those which the experience of the practitioner may suggest 
as likely to be most effective may be first tried, and others resorted to succes- 
sively 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, wlchicum 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, is often very useful. 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, relieving, in the course of a few days, 
rheumatic pains which have lasted for months. It may be resorted to in all 
cases of vague pains in different parts of the body, with little or no swelling, 
particularly when there is reason to suppose that they are seated in the peri- 
osteum or the bones; and in cases of this kind it often operates admirably 
well, even when there can be no suspicion of syphilitic taint. 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 omitted, or moderated, 
if it irritate the stomach, or produce any other unpleasant effect. Nitrate of 
potassa has been used in chronic as well as in acute rheumatism. Of 100 
cases treated by Dr. John Carghill with nitre, 61 were cured in an average 
period of about 14 days; while of 43 treated with colchicum, only 14 were 
cured after a treatment of about 15 days. He gave from two scruples to two 
drachms in barley water three times a day. (Lond. Med. Gaz., xiii. 639.) 
Dr. Fuller, in his treatise on rheumatism {page 29, Am. ed.), speaks of mu- 
RHEUMATISM. 470 
[part II. 
CONSTITUTIONAL DISEASES. 
riate of ammonia as a remedy 11 of singular efficacy." 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 tinc- 
ture ; but its stimulating properties should always be borne in mind. The 
other alterative diaphoretics are occasionally employed, most frequently in the 
form of compound decoction or compound syrup of sarsaparilla, which is fre- 
quently associated with a mercurial course. Turpentine, or its volatile oil, 
and copaiba, are occasionally used with advantage, and are especially recom- 
mended in chronic lumbago and sciatica. Dr. Chapman speaks in strong 
terms of the efficacy of savine, which he introduced into the treatment of this 
disease. Some have found great advantage from capsicum very freely used. 
Arsenic has occasionally proved very efficacious, and is thought to be spe- 
cially 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 
which the reader is referred to the dispensatories. Cod-liver oil is very highly 
praised by the German practitioners. It is particularly applicable to cases in 
which the rheumatism is complicated with a scrofulous taint. I have seen 
obstinate cases of what was originally supposed to be rheumatism of the knee 
or of the ankle, with an anemic state of the circulation, a frequent pulse, and 
tendency to night-sweats, get well under perfect rest of the joint, and the use 
of cod-liver oil, after the ordinary anti-rheumatic remedies had been exhausted 
without effect. Purging flax has recently been brought into notice, or rather 
its old reputation has been revived, by Dr. Butterlane, as a remedy in chronic 
rheumatism. He gives it in extract or infusion, and in such doses as to purge 
moderately, and act as a diuretic. (Med. Times, July, 1850.) 
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 remedies 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 
useful, conjoined with the drinking of sulphurous waters. To obtain the 
advantages 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 Ken- 
tucky, 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 system. Care should be taken, whenever cold bathing is 
employed, that reaction should subsequently take place, and be sustained by 
friction and exercise. Vapour baths are also arqong 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. Baths of the vapour of turpentine, at a temperature of from 140° 
to near 160° Fahr., have been found safe and effectual by M. Chevandier, of 
Die, in France. (See Archives G^n., 4e ser., xxviii. 80.) CLASS II.] 
471 
RHEUMATISM. 
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 proyes an effectual remedy. 
The patient should always wear flannel next his skin, unless 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 blis- 
tering. 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 affected part, at various points, in quick succession.* In mild cases, rube- 
facient and anodyne liniments may be used with 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. Poultices contain- 
ing carbonate of soda are said to have proved beneficial. Friction with castor 
oil has been recommended. The tincture of iodine has been applied advan- 
tageously to the surface of the inflamed part, and has been particularly recom- 
mended in disease of the joints. 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 ; com- 
pression 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 of gout, that I shall content myself 
with referring the reader to that disease. 
* 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 fiat. The disk of iron is to be heated in a spi- 
rit-lamp, until the finger, placed on the wire half an inch above it, becomes uncomfort- 
ably 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 has 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.) 472 
[part II. 
CONSTITUTIONAL DISEASES. 
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 por- 
tion 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, 
according to the accompanying strength of system, and energy of local action; 
acute or chronic, according to its duration and violence; misplaced 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 acute, chronic, and 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 varie- 
ties 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 ball 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 tearing, 
rending, boring, piercing, &c., as if the joint were torn by pincers, or pene- 
trated by a gimlet or a nail, or were under the action of a saw. At first, there 
1. Acute Gout. CLASS II.] 
GOUT. 
473 
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 ex- 
quisite 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 fol- 
lowed by acceleration of pulse, increased heat of skin especially of the 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 
sometimes an unpleasant odour exhales from the surface. The febrile symp- 
toms 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 attacks of the complaint, 
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 usu- 
ally 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. Sometimes, 
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 dis- 
posed to ascribe to a sprain, or other accident. In other instances, 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 unfrequent. 
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 474 
[PART II. 
CONSTITUTIONAL DISEASES. 
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, defi- 
cient or deranged biliary secretion, a tendency to constipation or looseness, 
nephritic disorder, occasional palpitations and dyspnoea, giddiness, buzzing 
or roaring in the ears, dimness or other disorder of vision, and emotional irre- 
gularities, as depression of spirits, hypochondriacal notions and unusual irasci- 
bility of temper. Dr. 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, alterna- 
ting 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 subsidence of the inflammation, 
if it has been severe and of the usual duration, 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 parox- 
ysm does not occur for three or four years, or even longer; but usually it 
makes its appearance in a year; and the returns afterwards continue to be 
annual, and, with remarkable uniformity, at about the same season, even in 
the same month. As the disease advances, the length of the paroxysms in- 
creases, while the intervals shorten. Intead 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 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 migrating 
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 com- CLASS II.] 
GOUT. 
475 
pletely recover its natural healthy power as at first; but is apt to remain 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 irri- 
tation in the stomach, bowels, kidneys, liver, lungs, heart, and brain, are more 
apt to occur, whether originally, or in consequence of the retrocession 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- 
quently, 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 result 
from anything which tends to put an end to rhe external inflammation, with- 
out, 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 the disposition of the disease to fix itself, 
in a 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 cold, 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 ap- 
plied to the stomach. 
In the nervous or functional affection, there is either violent spasm, or op- 
pression, distress, nausea, and vomiting, according as the muscular or mucous 
coat is the seat of irritation. But the burning pain is wanting, the tender- 
ness 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 op- 
pression, dyspnoea, sharp pains, and syncope more or less complete, may be 
produced. 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 476 
[PART II. 
CONSTITUTIONAL DISEASES. 
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 re- 
trocedent gout occasionally seizes upon these glands. 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 
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 displays itself in the skin, producing the 
phenomena of urticaria, erythema, or other exanthematous eruption. 
The brain is sometimes attacked by acute gout, with the production of 
stupor, and occasionally of complete apoplexy or palsy. The eye also may 
suffer. One of the most obstinate instances of ophthalmia that have fallen 
under my notice, was in a gouty patient. The eye appeared to have become 
the point in 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 inflammatory process, is entirely 
exempt. The organs most frequently and prominently affected are probably 
the stomach and kidneys. It is often difficult, 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 good effect. 
When the gouty diathesis exists in a person of otherwise feeble health, or 
debilitated system, though it may still show itself in the form of external in- 
flammation, yet this will be of a lower grade than in more vigorous individu- 
als, more disposed to change its position, and more apt consequently to fix 
upon the internal organs. In these cases, the internal affections 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 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 CLASS II.] 
GOUT. 
477 
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 danger 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, 
or kidneys. In this condition, however, the affection may be considered as 
having assumed the chronic form. 
Symptoms, Course, &c.-Chronic gout is generally the result of a long 
continuance 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 neigh- 
bouring bursae, are so much increased as to produce a considerable appearance 
of tumefaction, and to fluctuate obviously under pressure. This is particu- 
larly 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 subsided; 
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 movable, 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 the 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 permanently 
altered, so as to bend with difficulty, and sometimes to be nearly or quite use- 
less. 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 depo- 
sition is more especially apt to occur in the joints of the fingers. The earthy 
matter is first extravasated in a liquid, or semi-liquid state, and afterwards 
2. Chronic Gout. 478 
CONSTITUTIONAL DISEASES. 
[PART II. 
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 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 some- 
times 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. Sub- 
sequently, 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 discharged, and art 
can do little to hasten the process. At length, however, the whole of the 
offending cause is eliminated; and the ulcers heal; or cicatrization 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. It is an interesting fact, ascertained by Dr. A. B. Garrod, of London, 
that in cases attended with this deposition about the joints, there is a deficiency 
of uric acid in the urine, and an excess of it in the blood. 
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 parts of the body. Unless cut otf 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 interarticular cartilages, exhibit evidences 
of inflammation; the cartilages covering th.e articulating ends of the bones 
are sometimes partially absorbed; and the bones themselves near the joints are 
injected with blood, softened, and occasionally eroded. The external ligaments, 
though less affected, are sometimes injected aud 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 areolar tissue, in the muscles, fasciae, ligaments, and periosteum. 
In cases of death from internal inflammation, the ordinary signs of that affec- 
tion 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. CLASS II.] 
GOUT. 
479 
3. Nervous Gout. 
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 temperament, 
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 members 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 only gout or rheumatism in the nervous form. 
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 fre- 
quent intermixture or alternation with slight attacks, or abortive efforts at 
external inflammatory gout, raises the suspicion pretty nearly to certainty. 
An individual has an attack of regular gout, which relieves him from various 
functional 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 
derangement, and in whom the pain suddenly disappeared upon the occur- 
rence of an attack of insanity, to return again when the insanity ceased. 
That the affection 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, how- 
ever, 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 pre- 
cordial region extending to the left arm, the right side of the chest, and the 
scalp, are not unfrequent seats of it. Ilemicrania 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 genera- 
tive organs, the anus, and any one of the viscera. Not unfrequently, they 
attack the muscles, which thus become painful on contraction. 
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 480 
CONSTITUTIONAL DISEASES. 
[PART II. 
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. 
Let us now turn our attention to the several functions. The digestive f unc- 
tion is among those most frequently deranged. All the varieties of disordered 
sensation which usually attend dyspepsia are experienced in this affection. 
Vague uneasiness in the epigastrium, a feeling of weight or oppression, irre- 
gular appetite, cardialgia, sour or acrid eructations, flatulence, sometimes 
nausea and vomiting, sometimes severe spasm, are among the prominent 
symptoms. The bowels are generally costive, occasionally loose, with fre- 
quent 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. 
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 care. 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 abdomen, 
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 melama; or there maybe derange- 
ment of the secretion with little local uneasiness, though the affection is 
almost always attended with depression 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. Sometimes even coma and convulsions are expe- 
rienced. 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 roar- 
ing 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 affections 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, weari- 
ness, soreness, &c., which they only can fully appreciate who have felt them. CLASS II.] 
GOUT. 
481 
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 pe- 
riod 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 
completely to arrest its 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. ( 
Causes of Gout. 
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 0. Scudamore collected information, 322, or 
nearly two-thirds could trace the disease to a parent, grandparent, uncle, or aunt. 
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 
forefathers, and introduced into modes of life which dispose to the complaint, 
are frequently attacked with it. It is generally believed that the most effi- 
cient causes in generating the gouty diathesis, and consequently in promot- 
ing it when inherited, are the use of animal food in undue proportion, espe- 
cially 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 functions. 
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 deve- 
lopement 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 482 
[PART II. 
CONSTITUTIONAL DISEASES. 
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 
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 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 ale or 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 drunk- 
ards. 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 half a century ago. But, though inflammatory gout has greatly 
diminished, I believe that the nervous form of it has increased; because tem- 
* A fact strongly illustrative of this statement is mentioned by Dr. William Budd, 
in his Essay on Gout, in Tweedie's System of Practical Medicine. A body of workmen 
is employed on the Thames, in a peculiarly fatiguing duty, requirtng frequent exposure 
to inclement weather, and labour both by night and day. In consideration of this 
exposure 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. CLASS II.] , 
GOUT. 
483 
perance, 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 veTy 
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-fifth or fortieth. It 
is exceedingly rare before the age of puberty; though Dr. Chapman has known 
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 de- 
scendants 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 exciting 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. This is a fact worthy of recol- 
lection; as it will often enable the practitioner to explain unusually obstinate 
pains attending slight local injuries, and immediately to apply the proper 
remedy. 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. 
Nature of 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, 
is again gaining ground, and ranks at present among its advocates men of high 
name in the profession, of whom not the least conspicuous is Dr. Holland. 
(See Medical Notes and Reflections.) The fact which lends the strongest sup- 484 
CONSTITUTIONAL DISEASES. 
[PART II. 
port 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. Garrod has proved 
by chemical examination that the blood in gout contains urate of soda, which 
can readily be separated from it in a crystalline state. He has also shown that, 
before the occurrence of the gouty paroxysm, there is, along with this excess 
of urate of soda in the blood, a deficiency of uric acid and its salts in the urine. 
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 complaint. But 
these arguments, as well as others drawn from the movable character of the 
local disease, as if it depended upon an offending matter carried 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 
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-arthritis 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 fact, 
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 forma- 
tion 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 another, 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 diag- 
nosis is difficult, if not impossible; and it is not at all improbable that the two CLASS II.] 
GOUT. 
485 
complaints sometimes co-exist, fused, as it were, into one. In such instances, 
it is common to denominate the affection rheumatic gout. 
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 child- 
ren under puberty, the latter does so not unfrequently, though it must be con- 
fessed 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, moreover, 
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 evi- 
dence 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; 
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 retrocede, 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 rheu- 
matism, 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 paroxysm, 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 inter- 
ference 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 considered favourable to an external direction of the disease, all deple- 
tory measures were especially apprehended. It was, indeed, no uncommon 
Treatment. 
* The following is the mode in which Dr. Garrod tests the presence of uric acid in 
the blood. About a fluidrachm of the clear serum is placed in a deep watch-glass with 
six minims of strong acetic acid ; a very fine fibre of hemp is then introduced; and the 
glass, being covered with a piece of paper to protect it from the dust, is allowed to 
remain at re^ for about forty-eight hours, when it will probably have become nearly 
dry. Should uric acid be present in the blood, it will be found to have crystallized on 
the fibre in the form of rhombs, which may readily be detected with the aid of the mi- 
croscope. (Note to the third edition.) 486 
[PART II. 
CONSTITUTIONAL DISEASES. 
practice of gouty patients to indulge freely in wine, even during the con- 
tinuance 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 unnecessarily increased, and life probably not unfrequently short- 
ened. 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 paroxysm 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 endeavouring to render the patient as comfortable 
as possible. But we may do more than this. We may endeavour to super- 
sede 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 principles of treatment in the parox- 
ysm of acute gout. 
But what are the remedies calculated to modify the constitutional affec- 
tion? 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 treat- 
ment. Bleeding has been proposed. But this remedy has been found to 
exercise no 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 un- 
touched, while, if incautiously employed, it impairs the vigour of the consti- 
tution, 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 external, and no vital organ appears to be threatened by the latter, 
it is, as a general 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, not 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 primae vise, 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- CLASS II.] 
GOUT. 
487 
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 ensued; 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 secretions 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. That it is not by a mere increase of 
these functions that it acts is proved by the fact, that other and more active 
diaphoretics and diuretics have not been found equally beneficial; and col- 
chicum is believed to be useful even when it exercises no sensible influence 
over the secretions. It has no decided narcotic property, and, therefore, can- 
not act as an anodyne. Experiments seem to have shown that the quantity 
of uric acid and urea in the urine is increased under the action of colchicum; 
and, with those who consider uric acid in the blood as the offending agent 
through which the phenomena of gout are produced, this fact affords a suffi- 
cient explanation of the therapeutic action of the medicine; but it does not 
explain how the disposition to the overproduction of this offending agent is 
obviated, which, even upon the humoral hypothesis, is the real pathological 
condition. It is by modifying the morbid state which gives rise to the over- 
production of uric acid along with the other phenomena, that colchicum cures 
gout. We may say that it acts as an alterative; which is the same as to 
confess that we do not understand its mode of action. The general convic- 
tion of its usefulness rests upon experience. 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 in- 
fusion. When the medicine is desired in the form of pill, the acetic extract 
may be used. After the bowels have been well evacuated, 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 prepa- 
ration be properly made, will often produce excessive nausea, or much intes- 
tinal 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 abbreviates the paroxysm; 
and, as it does so rather by acting upon the real disease, than merely on the 488 
CONSTITUTIONAL DISEASES. 
[PART II. 
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 purga- 
tive which may from time to time be given to the patient; the wine being 
preferred, 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. Sometimes 
spirit of nitric ether may be advantageously added to the draught, especially 
when the patient is restless, or otherwise affected with nervous disorder. 
Much comfort sometimes accrues from a full dose of Dover's powder at 
bed-time. It should not, however, be given until the inflammatory and fe- 
brile symptoms, if considerable, have abated. 
In relation to the local affection directly, the less that is done, as a gene- 
ral 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 
preventing retrocession to the stomach or other internal organ; and this was 
certainly preferable to the repellent plan which some have advised. It pro- 
bably, however, sometimes occasioned an unnecessary amount of inflamma- 
ticn, 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 evapo- 
rating lotions, with the view of moderately reducing the heat, and relieving 
the pain; and, when these are excessive, such applications may not be im- 
proper, 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 
camphorse, U. S.) and one of alcohol, by means of linen compresses com- 
posed of six or eight folds, or of bread poultices saturated with the liquid. 
When this was removed, the 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, 
* I am in the habit of using the following formula:-R.-Magnesias gss; Magnes. 
Salphat. gss; Vin. Colchic. Rad. n^xx; Aquae fluv., vel. Aq. Acid. Carbon. f§ij. Fiat 
haustus. CLASS II.] 
GOUT. 
489 
&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 disease 
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 em- 
ploying it in this way. In the morning he was found dead in his bed. 
Should the joint remain swollen and edematous after convalescence, ad- 
vantage 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 cases, 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 apparently 
those of great depression; the skin being pale and cool, the pulse small and 
feeble, and the strength greatly prostrated. This depression may be conse- 
quent 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 relief. It should, however, be used with caution. 
The physician should himself superintend the operation, should keep his 
fingers on the pulse while the blood is flowing, and close the orifice if he find 
the circulation becoming feebler. 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 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 mustard 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 internal 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 some other liquid preparation 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 necessary. If the 
stomach reject these medicines they may be administered by enema. A large 
sinapism should be immediately applied to the epigastrium. 490 
[part ii. 
CONSTITUTIONAL DISEASES. 
In the treatment of the gouty paroxysm, reference must be had to the con- 
stitution and habits of the patient. The remedies which may be employed 
safely and efficiently in individuals of strong constitutions, and temperate 
habits, may prove too powerful for the feeble and intemperate. In the latter, 
purgative tinctures, as the tincture of rhubarb, or the tincture of rhubarb and 
senna (Warner's gout cordial), may be substituted for, or added to the cathar- 
tics ordinarily used. They may in general be appropriately conjoined with 
magnesia. Colchicum must be employed with more reserve ; and greater care 
should be taken not to cause 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 abstraction may pro- 
duce prostration. It should, however, be diminished 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 medicinal agents. Various attempts 
have been made to cure gout by medicines; but they have all proved to be 
failures. The famous Portland powder, employed, in variously modified forms, 
from the time of Galen to that of Cullen, has fallen entirely into disuse, in 
consequence of its fatal effects. Consisting chiefly of tonic or stimulating in- 
gredients, and continued for a great length of time, it probably made the 
stomach a centre of afflux to the gouty irritation, and thus obviated the exter- 
nal 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 their 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 its causes. If this plan is begun soon after the first 
developement 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 favourably modified, and dis- 
armed in great measure of its violence and danger. Temperance in eating, a 
rigid abstinence from 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 CLASS II.] 
GOUT. 
491 
character. (See Dyspepsia.) Care must be taken also to keep the bowels in 
a regular state, to correct any derangement of the hepatic or nephritic func- 
tion, to obviate any temporary excess of acid in the primae vise or in the cir- 
culation, 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 rhu- 
barb, magnesia water, Saratoga water, &c., of the antacids, as the bicarbonates 
of potassa 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 moderat- 
ing the force of the disease ; though a cure is not to be expected. In elderly 
persons, who have long been in the habit of indulging in wines, it is scarcely 
desirable to attempt the breaking up of the habit. There may be some dan- 
ger 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 esta- 
blished 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 de- 
bilitate, as rhubarb, aloes, sulphur, or magnesia, which may be given sepa- 
rately, 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 and restlessness may be quieted by opiates with or without ipecacuanha, 
or, if these disagree with the patient, by hyoscyamus, stramonium, or belladonna. 
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 492 
CONSTITUTIONAL DISEASES. 
[part II. 
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 recom- 
mends benzoate of ammonia or of potassa, in cases in which there is a tend- 
ency to the deposition of urate of soda in and about the smaller joints, and 
thinks he has found deposits of this kind, already in existence, to diminish 
under its use. {Med. Gaz., May 14, 1847.) Dr. Owen Rees has found 
lemon juice very useful in similar cases. He employs it in the quantity of 
one or two fluidounces four or five times a day, combined with small doses of 
the tincture of chloride of iron; and, in several instances, has thus succeeded 
in removing deposits which had resisted all other treatment. {London Lancet, 
Dec. 14, 1850, p. 561.) Mr. T. Spencer Wells regards iodide of potassium 
as the most efficient solvent of urate of soda, and gives it habitually in refer- 
ence to this property in all varieties of gout except the acute. (See Am. J. 
of Med. Sei., N. S., xxviii. 178.) In chronic gout, with contractions of the 
limbs or paralysis, the internal and external use of savine has been advan- 
tageously resorted to by practitioners in Germany. (See J. de Pharm., 3e 
sfir., xxii. 58.) 
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, are very hazardous for patients with chronic gout. Moderate 
exercise, in a pure atmosphere, is highly useful. Excessive mental exertion 
should be avoided with as much care as all 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- 
order of digestion, especially with a tendency to constipation, those of Sara- 
toga 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 
beneficial. A residence during the winter in a warm climate is very desira- 
ble 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 advisable to repeat the blister several times. But when the disease CLASS II.] 
GOUT. 
493 
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 ano- 
dyne cataplasms, mild camphorated lotions, &c. Some have recommended 
a covering of oiled silk, or thin layers of caoutchouc, so as to confine the 
perspiration of the part, and thus make a kind of vapour bath about it. 
Poultices with carbonate of soda are said often to prove beneficial. 
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 fascise will often yield to 
steady external counter-irritation, by means of the galbanum or ammoniac 
plaster, one of the turpentines, the ointment of iodine, 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 obtaining a longer or shorter respite from suffering; and sometimes pos- 
sibly the patient may surmount the disease; but, though life may be pro- 
longed not unfrequently to old age, it is rare that an individual, constitu- 
tionally 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 follow- 
ing observations 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. 
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 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 between 494 
CONSTITUTIONAL DISEASES. 
[part II. 
the paroxysms, or even more, if required to bring on the peculiar cerebral 
phenomena which characterize the action of the medicine. 
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 mor- 
phia, 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 belladonna, stramonium, and conium, are often very efficient, 
especially the first. Chloroform may also be usefully employed in some 
instances. 
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 tempo- 
rary 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 combi- 
nation, 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 fre- 
quently 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 resem- 
bles that proceeding from other causes, and requires the same treatment. 
Thus, when it attacks the stomach in the form of dyspepsia, or of gastro- 
dynia, it must be treated exactly as those affections are usually treated. (See 
Diseases of the Stomach.') The same maybe 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 now and then 
prove useful, and may be alternated with the other remedies. Constipation 
of the bowels should be obviated by laxatives, as rhubarb, sulphur, magnesia, 
Cheltenham 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 excesssive, 
by narcotics and astringents, or by terebipthinate remedies. Palpitations, 
and precordial oppression, will often yield to the aromatic spirit of ammonia, 
Hoffmann's anodyne, oil of valerian, assafetida, or musk; and dyspnoea,when 
purely spasmodic, may be treated in the same way. CLASS IL] 
GOUT. 
495 
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-outy or rheumatic headache often yields 
very happily to a few leeches or cups to the temples, or nape of the neck. 
But bleeding must 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 dis- 
ease. Another important fact to be borne in mind is, that, in many of these 
cases of disordered function and neuralgic pains, the real cause is an attack 
of the disease in the ligaments or internal membranes of the spinal column, 
producing irritation in the spinal marrow, and consequently derangement 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 
aconite, veratria, and colchicum, in ointment, or strong spirituous solution; 
plasters of belladonna and stramonium; morphia sprinkled on the skin de- 
nuded of the cuticle; chloroform in poultices, or applied by means of linen 
moistened with it, and protected from evaporation by a covering of oiled silk; 
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 pecu- 
liar 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 dissipate the pain en- 
tirely for a time; and nothing is more common than for the same effect to 
follow any strong mental movement, whether emotional or intellectual. 
In this variety of gout, it is especially necessary to invigorate the consti- 
tution; 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 luxuries, indolence, and self-indulgences of wealth, to the necessity of daily 
exertion for a livelihood. Hence, probably, also, in part, the advantage which 
has frequently accrued, in such cases, from the famous water-cure. 496 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
CLASS III. 
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 
phlegmasiae, 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 disorder, from which it 
may have sprung, is often concealed and unknown. Such are the local tuber- 
culous 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 at the same time in the chest, 
abdomen, and external areolar tissue. In the order of the functions, I begin 
W'ith that which nature has placed first and lowest in the scale, and follow her 
course through the remainder. Pursuant to this plan, the diseases connected 
with the digestive system come first in order; then those of the absorbent 
system; and afterwards successively those of the respiratory, circulatory, 
secretory, and nervous. Diseases of the reproductive system, so far as they 
peculiarly belong to it, come generally under the care of the surgeon or ob- 
stetrician. 
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 standards 
of comparison for the more obscure functional affections. 
LOCAL DISEASES. 
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.] 
497 
INFLAMMATION OF THE MOUTH. 
Article I. 
INFLAMMATION OF THE MOUTH, or STOMATITIS. 
The term stomatitis (from stopa, mouth) 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, or a pseudo-membranous 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 pecu- 
liar 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 become 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. The 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. There is a mild variety of stomatitis, which 
may be denominated catarrhal, attended with a copious secretion of mucus 
and saliva, with a furred tongue, and deficient taste, but with little redness, 
swelling, or pain. This is sometimes mistaken for disease of the stomach, 
especially when it becomes chronic; but may be distinguished by the undi- 
minished powers of digestion, and the absence of direct gastric symptoms. 
Upon careful observation, it will be found that the discharged liquid pro- 498 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
ceeds from the mouth, and does not rise from the stomach either by eructa- 
tion or vomiting. A mistake of this affection for gastrorrhoea would be very 
inconvenient in practice. 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 edges or spicula 
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 pro- 
ceeds from the propagation of inflammation from the fauces, and is a fre- 
quent consequence of gastric irritation, produced by sour or acrid matter in 
the stomach. Drunkards seem peculiarly predisposed to it. Of the consti- 
tutional causes none are so frequent as the state of fever, which, whatever 
may be its particular character, is very apt to affect the mouth, and not un- 
frequently occasions 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 indis- 
posed to heal, their surface may be touched with a strong solution of sul- 
phate of zinc, sulphate of copper, or nitrate of silver, care being taken that 
the application do not extend beyond the limits of the ulcer. In the chronic 
catarrhal variety of stomatitis, Dr. Pfeifer recommends a mouth-wash con- 
sisting of a grain or two of corrosive sublimate dissolved in a pint of water. 
In cases accompanied with gangrene, washes of chloride of soda, chloride of 
lime, or aqueous solution of creasote may be used. Should the inflamma- 
tion depend upon the condition of the teeth, whether upon sharp edges or 
points wounding the adjacent parts, or upon acrid secretions, or the deposi- 
tion 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.-Muguet, of the French writers.-As this affection, thbugh 
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, form- 
ing 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 pharynx. The exudation is 
sometimes thick and covers the whole surface, but is more commonly in irreg- 
ularly scattered patches and points. It occasionally assumes a yellowish or CLASS III.] 
499 
INFLAMMATION OF THE MOUTH. 
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 sometimes 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 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 children of bad habit 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, sometimes 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 appearances 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. In the matter thrown out upon the inflamed surface, Dr. Gruby, of 
Vienna, and Dr. Berg, of Stockholm, discovered, by means of the microscope, 
a cryptogamic growth analogous in structure to the lower order of fungi, to 
which the disease has been ascribed. It is true that, under the microscope, 
the curdy matter of thrush is seen to consist mainly of thickened epithelial 
cells, mingled with great numbers of minute cryptogamic sporules or seeds, 
from the midst of clusters of which long thread-like, jointed, and branching 
plants arise, intertwining among one another; but the question is not deter- 
mined whether the vegetation is the origin of the complaint, or whether this 
consists of an inflammatory exudation, which simply affords a nidus for the 
growth and propagation of the fungus. I confess that I am inclined to the 
latter opinion. 
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 secondarily involved. 
It is not uncommon in the last stage of phthisis; and, whenever 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 constitution. 
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 intestinal disorder, dis- 
poses to its occurrence. Yet it often comes on, under apparently the most 500 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 vicissitudes of tem- 
perature. It seems occasionally to assume something like an epidemic cha- 
racter, being more than usually prevalent in certain families, or certain neigh- 
bourhoods, 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 diar- 
rhoea occur, with green stools, magnesia may be given alone or combined with 
rhubarb; or, if the child be too weak for purgatives, prepared chalk or oyster- 
shell may be substituted; or the two may be alternated. 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 enemata, and poultices over the abdomen, may be 
employed to relieve the intestinal irritation. Dr. Dewees recommends a flui- 
drachm 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 gas- 
tric 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, solu- 
tion 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 often be found 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 carefully, from four to eight times 
* R.-Magnesiae gss; Rhei pulv. gr. xv. Misce et divid. in chart, no. vj. S. One 
for a dose. R.-Magnesias gij; Acacise pulv., Sacch. alb. aa gj; Aq. Menth. P., 
Aq. fluv. aa fgj. Misce. S. A teaspoonful, every two or three hours till it operates. 
R.-Cretae ppt. vel Testae ppt. jj ; Tinct. Opii rr^iv; Acaciae pulv., Sacch. alb. aa ; 
Aq. Cinnam. f^ss; Aq. fluv. fgiss. Misce. S. A teaspoonful every three or four hours, 
in diarrhoea. 
f R.-Acid. Sulphuric. Dilut., vel Acid. Muriat. ; Syrup, vel Meilis fgj; Aq. Rosae 
f^ij. Misce. R.-Alumin. gr. x; Meilis fgss; Aq. Rosae fgiss. Misce. R.-Liq. Sodas 501 
CLASS III. 
INFLAMMATION of the mouth. 
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. Dr. W. 
Jenner finds the application of a solution of sulphite of soda, in the proportion 
of a drachm to an ounce of water, to effect a speedy cure of the disease. He 
ascribes its beneficial effect to the destructive influence of the sulphurous acid, 
liberated by the acids of the secretions of the mouth, upon the parasitic fungus 
on which he supposes the disease to depend. (Land. Med. Times & Gaz., 
vii. 181.) 
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 
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 inflam- 
mation should not subside, the little tumours soften in the centre and ulcer- 
ate, and the surface 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 abdo- 
minal 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 affec- 
tions 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 confounding with this affection the thrush of early infancy, which, in gene- 
ral, 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 sore-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 
probably the vesicular eruption, which constitutes the subject of this section. 
The vesicle is small, oval or roundish, white or pearl-coloured, and consists 
Chlorinat. f^iss; Aquas 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 fiuidounce of distilled water; but such a solu- 
tion should not be applied oftener than once or twice a day. 502 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
rpART II. 
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 de- 
cayed teeth. The confluent variety is much more severe and obstinate. This 
frequently 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 
attack preferably women in childbed. It may continue for several weeks, 
and sometimes proves 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 stage, 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 fluidounce of water, which he applies by means of a camel's hair pencil 
exclusively 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.- Ulcerative Stomatitis.- Cancrum Oris. 
- Canker.-Any inflammation of the mouth may be attended with ulcera- 
tion ; but the complaint here referred to is essentially ulcerative, appearing in 
this form at the commencement, 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. INFLAMMATION OF THE MOUTH. 
503 
CLASS III.] 
It is true that the ulcers, usually called canker, may, in constitutions predis- 
posed 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 its 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 neigh- 
bouring parts are also inflamed and swollen, and,, when the ulcer is in the 
cheek or lips, the tumefaction is observed externally, the cheek 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. 
Patches of pseudo-membranous inflammation now and 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 or separation of the pseudo- 
membranous matter, or by a destruction of a portion of the mucous tissue, when 
an ulcer results. 
The causes of cancrum 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. 
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 advisable to have re- 
course to the mineral acids, and to infusion of bark or sulphate of quinia. Iodide 
of potassium often operates very favourably. 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-washes 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 
proportion 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 504 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
continued 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. 
Nitrate of copper and the diluted nitric acid of the pharmacopoeia have also 
been found useful. The pseudo-membranous patches above described may be 
treated in the same manner. 
Dr. T. H. Babington, of Coleraine, Ireland, has employed chlorate of potassa, 
internally, in this complaint, in thirty cases, with speedy and uniform success. 
After administering an aperient of rhubarb and magnesia, he gives four grains 
of the chlorate, dissolved in sweetened water, every four hours; frequently 
washing the mouth in a warm weak solution of chloride of soda. (Dub. Quart. 
Journ. of Med. Sei., xv. 236.) 
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, while 
others appear upon the tongue and inside of the cheeks, and the inflammation 
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 unat- 
tended 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 irritated; diar- 
rhoea often takes place; and the patient falls into a state of great debility and 
emaciation, which sometimes terminates in death. Dr. W. H. Byford treats 
of three varieties of the disease; 1. a diffused superficial inflammation of the 
buccal mucous membrane; 2. a vesicular eruption which may be superadded 
to the first variety; and 3. an ulcerative affection similar to that above de- 
scribed. (Am. Journ. of Med. Sci., N. S., xxv. 393.) The cause is some 
influence exerted on the system by nursing, or by the advanced state of preg- 
nancy ; as persons are not affected under other circumstances, and the disease 
always gives way upon the weaning of the child. What is the nature, how- 
ever, of this influence is unknown. It does not seem to be connected with 
any pre-existing condition of health, or character of constitution. The com- 
plaint 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 ap- 
pears 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. Dr. 
Byford recommends cod-liver oil. The diet should be of milk and farina- 
ceous substances. As local applications, mild astringent infusions, or a solu- CLASS III.] 
INFLAMMATION OF THE MOUTH. 
505 
tion 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-iveed {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. Journ. of Med. Sci., N. S., xvi. 248.) Dr. J. Y. Ware, of 
Massachusetts, has found the compound mixture of iron (U. S. Ph.), given 
internally in doses of a tablespoonful three times a-day, and a solution of 
nitrate of silver containing two grains to the fluidounce, used as a gargle, to 
be infallible. (Ibid., xviii. 290.) Dr. M. L. Knapp, formerly professor of 
Materia Medica in the University of Iowa, considers this disease as essen- 
tially scorbutic; and has treated cases on this principle successfully which 
have come under his notice; but the affection, as described by Drs. Hale and 
Backus, has not the peculiar features of scurvy, and differs probably from 
that noticed by Dr. Knapp. (See New York Journ. of Med., N. S.,vii. 206.) 
7. G-angrenous Inflammation.- Gangrsena Oris.-Sloughing Phage- 
daena 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 
whatever 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 gangreena 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- 
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 inflamma- 
tory redness and swelling. When on the inside of the cheek, it is usually 
accompanied 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 po- 
lished, 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 func- 
tions are apparently regular, and the usual avocations or amusements are not 
interrupted. There are seldom any signs of fever. As the complaint ad- 
vances, the slough spreads, the saliva flows copiously, and the breath becomes 
excessively fetid. The disease penetrates to the bony structure, necrosis of 506 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 exter- 
nally, 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 inflammation of the mouth and throat, resulting from 
the sloughs and the acrid discharges, and, in part, by the putrid matter 
swallowed by the patient. The pulse is frequent and feeble, and the child 
very restless and morbidly wakeful. There is often, in the advanced stages, 
an almost total inability to take food, which tends to increase the debility. 
An exhausting diarrhoea, moreover, supervenes towards the close of the dis- 
order. Death is preceded by cold extremities, and the other customary evi- 
dences 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 habit- 
ual exposure to a vitiated air, and the use of unwholesome or insufficient 
food. Hence, it is most prevalent in miasmatic districts, and in public 
establishments 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 sometimes have degenerated into this complaint, in persons pre- 
disposed to it. The opinion is highly probable, which ascribes the constitu- 
tional predisposition to the disease to a depraved condition of the blood. It 
is not unfrequently complicated with pneumonia, which greatly increases the 
danger. Of twenty-one fatal cases, Rilliet and Barthez found this complica- 
tion in nineteen. (^TraiU 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 
calculated to support the strength of the patient. Sulphate of quinia, or 
infusion of Peruvian bark, the mineral acids, and a nutritious diet, are 
usually advisable. Chlorate of potassa, in the dose of five or six grains for 
a child from six to eight years old, repeated three or four times a day, may 
be employed with hope of advantage. Chalybeates will sometimes prove 
useful, especially in cases originating in miasmatic diseases. 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 given throughout 
the complaint to relieve restlessness and paip. 
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. H. 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. Journ., vol. ii. p. 20.) Solid 
nitrate of silver, or a strong solution of the salt if sloughs are already formed, CLASS III.] 
507 
INFLAMMATION OF THE MOUTH. 
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 
effectual 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 general 
diseases, shch as the scorbutic and syphilitic ulcers, and the variolous erup- 
tion; but these are more properly treated of under the heads of the diseases 
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, and some increase of the saliva. 
At the same time, a close examination will detect a slight redness and swell- 
ing of the gums, particularly about the necks of the lower incisors, while 
somewhat below their edge, a broad white line may often be observed, de- 
pending 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 extends, 
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 absorbent 
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, wrhich, from the beginning, and sometimes even before the appear- 
ance of any one of the symptoms mentioned, has a peculiar disagreeable odour, 
now becomes extremely offensive, and in bad cases almost intolerable. Ulcer- 
ation often occurs, especially about the necks of the teeth, which are conse- 
quently 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 
501.) The whole mouth with its appendages is sometimes so much 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 his food, and sometimes can scarcely swallow. A case was related 
by Dr. Physick, in his lectures, in which an obstinate dislocation of the jaw 
resulted from the enormous tumefaction of the tongue. Hemorrhage is not 
an uufrequent attendant upon these bad cases, and is sometimes 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 cases, more or less 508 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
PART II. 
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 numerous instances; 
but the patient generally recovers from the worst forms of the 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 th§ 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, when the inflammation 
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 infernal use of chlorate of potassa 
has also been recommended as highly useful, though requiring caution. (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 505.) 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 reliev- 
ing pain. 
Ar Iide II. 
INFLAMMATION OF THE TONGUE, or GLOSSITIS. 
The term Glossitis (from yXuooa, 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 CLASS III.] 
509 
INFLAMMATION OF THE TONGUE. 
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 ob- 
viously 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 articulate. 
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 
unfrequently the neighbouring parts participate in the inflammation. 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 pulse loses its strength, and cold sweats occur. The inflam- 
mation may terminate in resolution; but, if not interrupted by remedial treat- 
ment, 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 subsidence 
of the inflammation. Less destruction is produced by gangrene than might 
be imagined from the large sloughs thrown off by the tongue; for, when the 
organ shrinks to its original size, the loss is often found inconsiderable. 
Causes.-Glossitis may result from the usual causes of inflammation. Per- 
haps the most frequent cause is 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 enemata, 
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 
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 yielded to the free use of leeches externally, beneath the floor of the 
mouth, after suitable general depletion. After the leeching, emollient poul- 
tices may be employed; or recourse may be had to blisters. But, should 510 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 incision, 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 HL 
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, 
&e., 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 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 roots also occasion distress, during their developement, by incommoding CLASS III.] 
MORBID DENTITION. 
511 
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 eruption 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 con- 
sidered as a salutary effort to relieve or prevent more dangerous affections, 
especially 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. 
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 laxa- 
tive 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 diapho- 
retics 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 danger- [part II. 
512 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
ously upon the brain. The disorder behind the ears is apt to be unsightly 
and troublesome; and mothers are often anxious for its cure; but it should 
rather be encouraged than removed; and the late Dr. Joseph Parrish, of Phila- 
delphia, used to insist upon the importance, not only of not interfering with 
this salutary process 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 sub- 
stance, 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 with- 
out hesitation down to the teeth, so as to divide both the gum and the in- 
vesting membrane. These may be made by a gum-lancet, or a sharp pen- 
knife, 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 ap- 
pears, and thus leaves a scar more difficult to penetrate than the original 
gum, is altogether without foundation. 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 forma- 
tion of that structure; and G-uersent 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 inflam- 
mation 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 repeated, or kept open by 
stimulating dressings. 
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 CLASS III.] 
513 
TOOTHACHE. 
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, 
sometimes mild in the beginning, gradually increasing in intensity, and as 
gradually declining; but usually very irregular, at one time moderate, at an- 
other 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 ex- 
cited by certain harsh sounds, such as that produced in the filing of saw teeth, 
by mental inquietude, 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 paroxysmal 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 alternates 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 exist- 
ing predisposition, it is sometimes invited by caries, but very frequently oc- 
curs 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. 
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 
emmenagogue in amenorrhcea ; and not unfrequently the co-existence of two 
or more of these affections calls for the simultaneous use of the appropriate 
remedies. 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 re- 514 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
gular intermittent cases, and often useful in others. Mercury is sometimes 
effectual, when the disease has resisted all other treatment. In fact, what- 
ever alters materially the distribution of nervous influence, and changes the 
condition 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 fumigations, 
irritant and anodyne masticatories, errhines, electricity or galvanism, and all 
other topical means employed in the treatment of neuralgia. (See Neuralgia.') 
Chloroform, locally applied, will probably be found the most efficient anodyne. 
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. Be- 
fore 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 sepa- 
rated, and its place supplied by new structure, takes place. Thos. Bell, how- 
ever, 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- 
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. (Good's Study of Med.) 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 CLASS III.] 
TOOTHACHE. 
515 
cavity of the tooth, the pulp becomes sensible to heat, 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 gradu- 
ally destroyed by ulceration or gangrene. The body of the tooth, deprived of 
the nourishment 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 advances 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 sym- 
pathetically in other parts; and painful affections of the head, ears, and 
eyes, have ceased upon the extraction of a decayed tooth, which had never 
ached. I have seen violent and obstinate headache yield to the extraction of 
a tooth which had not been painful; and Dr. I. Hays, of Philadelphia, has 
described several cases of excessive photophobia which depended on the 
same cause, and yielded to the same remedy. In these cases, though the 
tooth may not ache, it will be found painful when pressed upon or struck 
smartly. (Trans. of Col. of Phys, of Philadelphia, ii. 411.) 
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 dis- 
ease 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 sur- 
faces of the teeth, and all kinds of mechanical violence. Of the latter, the 
principal are heat and cold suddenly applied, and especially in quick alterna- 
tion. 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 
frequent 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 
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 
toothache 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 metallic 
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. 516 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 continued. 
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 producing 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 neuralgic 
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 con- 
tinue 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 jaw, 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 the palate, it is generally of 
slower progress, and sometimes continues for weeks or months without open- 
ing; 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 are artificially removed. 
Suppuration also takes place in the pulp or dental cord. If an opening 
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 
inflammation 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- CLASS III.] 
517 
TOOTHACHE. 
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 dis- 
covered 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. Closing 
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 
eruptions, the suppression of accustomed discharges, the translation of rheu- 
matic or gouty inflammation from other parts, the pressure of osseous con- 
cretions in the cavity of the tooth, and from direct violence. 
Treatment.-Little general treatment is 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 
are sedative, anodyne, and revulsive applications, and depletory measures, 
either within the mouth or externally. Among these remedies are brandy, or 
tincture of camphor, held 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 rendered anodyne by the admixture of lauda- 
num, hops, &c.; anodyne lotions, as tincture of camphor with laudanum; rube- 
facient 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 vapours of hot water; scarification of the gums; and, finally, 
leeches outside of the face or to the gums, when the inflammation is consider- 
able, and it is deemed highly desirable to bring about resolution. In most 
cases, the milder of these means are sufficient; as the disease is generally 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, if it 
occupy the substance of the cheek, care should be taken to 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; all of which should be introduced on cotton. 
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 chloroform has been strongly recommended. The 
chloroform relieves the pain, and the copal, by its adhesiveness, retains the 518 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part ii. 
cotton in the cavity, and protects it from the air. (Journ. de Pharm. et de 
Chim., xiv. 125.) Collodion has been applied to the interior of the cavity, 
■with the view of protecting the part from the air and from irritating sub- 
stances, with great asserted advantage. Strong astringents, such as galls and 
catechu, are sometimes used; but they answer better as preventives than 
cures, and are not unfrequently employed to prepare the carious tooth for 
plugging. If opium is used, care should be taken that the quantity be not 
so great as to do serious injury if swallowed. Attempts are sometimes made 
to effect a permanent cure of toothache by destroying 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 there is reason to believe that the pulp is inflamed, in con- 
sequence of caries or from other cause, the practice, suggested by Dr. Hullihen, 
of Wheeling, has been adopted by several American dentists, with great asserted 
benefit, of drilling a hole into the cavity of the pulp; thus allowing any pus 
which may have been produced to escape, and aiding the recuperative efforts 
of the pulp by removing pressure from it. (See a paper by Dr. John Trevor, 
in the New York Med. Gaz., iv. 104.) 
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 
fistulae, 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 propriety of 
extraction, it should always be borne in mind that, when the permanent 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 often useful in mastication, in the intervals of pain. Another consideration 
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. 
As a means of preserving the teeth, they should be thoroughly cleansed, 
and not only in the morning, but after each meal. Dr. Bowditch, of Boston, 
has found that, in healthy states of the mouth, animal and vegetable parasites 
rapidly form between the teeth, and at their roots, probably from the presence 
of impurities; and it is not improbable that they may contribute to produce 
disease in these parts. (Am. Journ. of Med. Sei., N. S-, xix. 364.) 
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 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 perios- 
teum about the root, or the lining of the alveolar cavity, or on the external 
surface of the jaw, rather than in the pulp, or in the dental cord. In addition 
to the local measures enumerated, the constitutional treatment applicable to 
other forms of rheumatism or gout may be employed; and efforts may be made 
by stimulating pediluvia to invite the disease to the lower extremities. 
4. Toothache from Exostosis.-As a consequence of inflammation, or CLASS III.] 
FALLING OF THE TEETH. 
519 
from some other cause, the periosteum about the root of the teeth sometimes 
becomes 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 severe in the advanced stage, in consequence of pres- 
sure upon the sensitive parts. There are no means of distinguishing this, 
with certainty, from other forms of toothache; but it may be suspected when 
the pain is constant, and 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 extraction. According to Dr. 
Good, it may be cured in the early stage by leeches and mercurial ointment; 
though it must be confessed that the 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 Dictionnaire de Medecine. 
Article V. 
FALLING OF THE TEETH. 
The absorption of the socket, and consequent loss of the teeth, which are 
apt to occur in advanced life, are 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 canker and gan- 
grene of the mouth, and occasionally as a consequence of mercurial inflam- 
mation of the gums. In carious teeth, after the loss of the body by the 
advance of the disease, the roots are sometimes cast off through the ulcera- 
tion 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 elevation 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 
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, 520 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 oozing 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 
colour, 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 or 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 presence 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 tuberculous 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 ap- 
plication 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 mode 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. Might not cod-liver oil prove useful in these cases, if employed 
in the earliest stage ? CLASS III.] 
521 
INFLAMMATION of the fauces. 
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, smallpox, 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. 
1. 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 522 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
ordinary; and the flushed appearance of the face and neck marks a still closer 
analogy with scarlet fever. 
Dr. R. B. Todd, of London, describes a variety of angina, which he con- 
siders erysipelatous. Its chief characters are a dusky appearance of the in- 
flamed surface, an almost total inability to swallow, not from swelling or mere 
pain, but from a seeming paralysis of the muscles of deglutition, great con- 
stitutional disturbance, and a tendency to rapid prostration, so that the case 
terminates fatally in two or three days if not arrested. (Lond. Med. Times 
and Gaz., iv. 557.) 
The inflammation, in ordinary cases, runs on for several days, and then gradu- 
ally declines, terminating almost always in resolution. In some rare cases, sup- 
puration takes place in the substance of the uvula or soft palate, and gangrene 
may occur in persons of debilitated and unhealthy constitution. The tonsils 
sometimes 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. Not unfrequently the Eustachian tube participates in the inflam- 
mation, and partial deafness results from its closure. This may be ascertained 
by causing the patient to close firmly the mouth and nostrils, and then endea- 
vour to expire forcibly, or, as suggested by Mr. Toynbee, simply to perform 
the act of deglutition. If the tube is open, the air will readily enter the tym- 
panum, otherwise not at all, or with difficulty. Another method, suggested 
by Prof. Richter, is to auscult over the ear with the cartilaginous portion 
pressed down so as to cover the external meatus. If the tube is open, the 
sound of the breath and voice is heard, otherwise not. (See Am. Journ. of 
Med. Sci., N. S., xxv. 223.) 
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 
numerous in the pharynx as to give its surface a mamillated appearance, 
and occasionally are associated in long prominences, or ridges, 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 fSuces, or deeper 
seated, penetrating through the membrane, and even into the structure be- 
neath 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 de- 
lusive. A dry laryngeal cough 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 
inconvenient by its disposition to extend into the throat or chest. Sometimes CLASS III.] 
INFLAMMATION OF THE FAUCES. 
523 
it extends into the Eustabhian tube, as in the acute form, causing hardness 
of hearing. 
One 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 it produces about the root of the tongue and the glottis. Long 
continued and serious coughs have arisen from this cause, or been sustained 
by it. The irritation may even extend to the cerebral centres ; and M. West, 
of Belgium, has recorded a case of long continued and harassing nightmare, 
•which was completely relieved by the amputation of a much elongated uvula. 
(See Am. Journ. of Med. Sei., N. S., xxi. 222.) 
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 sufficient 
to produce it. There is reason to believe that it may arise from the re- 
action which follows the direct effect of very cold air upon the fauces. Irri- 
tating or corrosive substances swallowed, and acrid eructations from the sto- 
mach, 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 tuberculous or scrofulous diathesis 
sometimes probably contributes to give obstinacy to the disease. The acute 
disease occurs at all periods of life, but is most frequent with the young. 
Treatment.-If 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 recom- 
mended ; but, though occasionally beneficial, they are unnecessarily violent, 
and are not often used. The diet should be strictly vegetable; and liquids or 
soft substances, as mush, 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 depletory treatment should 
be very moderately employed, or altogether avoided; and it might even become 
necessary to resort to stimulation. When the disease 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 com- 
plicated 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. 524 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 may prove use- 
ful by facilitating the discharge of the viscid mucus, and even diminishing 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 strong solution of nitrate of 
silver, and powdered alum applied directly to the part by blowing through a 
tube, will often effect speedy cures; but they are seldom necessary. 
It is advisable that the patient should speak little, should resist the dispo- 
sition to frequent hawking and swallowing, and should keep the head as much 
as he conveniently can in an erect position. 
In the rapid and violent cases described by Dr. Todd, all depletion should 
be avoided, nitrate of silver should be applied to the fauces, and the strength 
of the patient supported by the use of sulphate of quinia, wine, and rich soups, 
or, if deglutition is quite impossible, by the injection of the same remedies 
into the rectum. By this method Dr. Todd thinks that the cases can gene- 
rally be saved, if taken in time. 
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 
into the stomach, or lodges in the throat. The mineral acids, more or less 
diluted, have been recommended for the same purpose. Dr. A. P. Merrill, 
of Memphis, employs with great advantage a liquid consisting of a drachm 
of iodide of potassium, half a drachm of iodine, half an ounce of syrup, and 
an ounce of water, which he applies by means of a large camel's-hair pencil. 
(W 0. Med. and Surg. Journ., ix. 151.) This direct method of local applica- 
tion must be used in all cases when the pharynx is affected. 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 reme- 
dies addressed to the system. Disorder of the stomach should be corrected 
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 mer- 
curial 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 from 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 reason- 
able hope of benefit. In scrofulous cases, recourse may be had to cod-liver 
oil, or the preparations of iodine. 
In the relaxed and edematous condition of the uvula which follows acute CLASS III.] 
INFLAMMATION OF THE FAUCES. 
525 
inflammation, or attends the chronic form of it, the astringent gargles above 
mentioned may be used, or 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 of the Fauces.-Membranous 
Angina.-Angina' membranacea.-Diphtheritis.-This is characterized by 
the exudation of fibrinous and albuminous matter, in the form of 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 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 
concrete exudation similar to false membrane, and that the surface of the 
membrane beneath them has not necessarily undergone any loss of substance. 
In some instances, they are translucent. Their consistence is various, occa- 
sionally 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 submax- 
illary 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 whole fauces, but more frequently advancing rather slowly, and leaving 
portions of the membrane uncovered. There is commonly more of the exuda- 
tion 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 nostrils, indicating the extension of the disease to the nasal 
passages. The odour of the discharges in these cases has tended to confirm 
the erroneous idea, that the disease is 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, 526 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
which obstructs respiration, and often 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.') A distinguishing character of this diphtheritic affection, showing 
that it is connected with the state of the system at large, or of the blood, is 
that it is disposed to appear on .all other surfaces which may be excoriated or 
suppurating. (Arch. G^n., 4e ser., xxii. 281.) 
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 ak 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 good constitutiops, 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 exu- 
dation 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. Occa- 
sionally, obstinate 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 condi- 
tions here presented there are various grades, in which their characteristic 
symptoms are more or less mingled or modified. In the malignant cases, 
the system is probably under some poisonous influence superadded to that of 
the local affection. Such cases are happily rare. 
The diphtheritic exudation differs decidedly from that of thrush, and in 
t ome points also from that which accompanies scarlet fever. In the thrush, 
the white coating appears first in separate points which afterwards coalesce; is 
formed upon the surface of the epidermis, or at least not beneath it; may be 
readily removed without affecting the integrity of the mucous membrane, or 
causing the least hemorrhage, and, when examined under the microscope, is 
found to contain abundantly a peculiar fungous plant. The diphtheritic exu- 
dation forms in patches, beneath the epidermis ; adheres strongly to the mem- 
brane, so that it can rarely be detached without causing the extravasation of 
some blood; and under the microscope exhibits the ordinary constituents of 
false membrane; namely, interlacing fibrils, molecules or granules, and exu- 
dation or pus corpuscles. The exudation in scarlatina occurs generally first 
in points like the thrush, is much less cohesive than the diphtheritic, less 
adherent to the mucous membrane, much less disposed to spread into the 
larynx, and also less disposed to make its appearance upon surfaces else- 
where that may be excoriated. (Empis, Arch. Gen., 4e ser., xxii. 284.) 
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 predisposi- 
tion, however, is not known, although it is probably ascribable to some peculiar CLASS III.] 
INFLAMMATION OF THE FAUCE^. 
527 
state of 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 contagion; 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 Foth- 
ergill, Huxham, and others, with which 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 produced by the same cause, in those cases in which 
they have an epidemic or contagious character. 
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.-Besides thrush and the sore-throat of scarlatina, the only com- 
plaints with which this can be confounded are common angina, ulcerated and 
gangrenous or malignant sore-throat, and pseudo-membranous croup. From 
the first of these 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 exudation extends into the larynx, that 
this complaint can be confounded with proper pseudo-membranous croup. 
The latter affection, however, differs by commencing in the larynx, and in sel- 
dom 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 mo- 
derate fever, the cathartic may be repeated, and antimonials and the neutral 
mixture administered at short intervals. When the pulse is full and strong, 
blood should be taken freely from the arm, especially in adults; but venesec- 
tion does not exercise the same controlling influence over 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 gene- 
ral 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 528 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
the peculiar character of the affection; and are only sometimes useful, in the 
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 maybe 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 
fiuidounce, applied daily or twice a day to the pseudo-membranous patches, will 
be found sufficient. When a stronger impression is required, caustic sub- 
stances 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 cases 
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 ap- 
plication. 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 flui- 
drachm 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 Bretonneau; but its chief advan- 
tages are probably derived from the portion of it which may be swallowed. 
For the local treatment of those cases in which the disease has entered the 
larynx, the reader is referred to pseudo-membranous croup and chronic 
laryngitis. 
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, smallpox, syphilis, and the mercurial action. 
But they sometimes also occur as an original disease, at least they are present 
when the case first comes 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 case 
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- CLASS III.] 
INFLAMMATION OF THE TONSILS. 
529 
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, 
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. Should the 
ulcers become chronic, iodide of potassium may be employed internally. By 
far the most efficient remedies are local; and the best of these are solutions 
of sulphate of zinc, sulphate of copper, and 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. q 
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, co-existing with it, as in the 
typhoid forms of fever. In malignant cases of pseudo-membranous angina, the 
surface beneath the exudation is sometimes covered with a slough, the result 
of mortification. Thrush and aphthae occurring in the fauces occasionally 
become gangrenous; and the infantile affection called gangrene of the mouth 
may have its seat in the same part. Indeed, whenever intense inflammation 
of the fauces occurs in persons whose health has been depraved by insufficient 
or unwholesome nourishment, or who are affected by some malignant or ty- 
phoid 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 
children. The malignant sore-throat described by Fothergill and Huxham, 
and by Dr. Cullen under the name of Cynanche maligna, is now generally 
admitted to be a modification of scarlatina; the local and constitutional symp- 
toms being precisely the same as those which attend the worst forms of that 
complaint, except that, in some instances, comparatively few, the scarlet erup- 
tion is absent. In relation, therefore, to the causes and treatment of this 
affection, it is unnecessary to say anything in this place; the subject having 
been sufficiently considered under scarlet fever. 
Article IL 
INFLAMMATION OF THE TONSILS, or TONSILLITIS. 
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- 
Syn.-Cynanche tonsillaris.-Angina tonsillaris.-Amygdalitis.-Quinsy. 530 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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, 
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 proba- 
bly 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 exhibit at first redness, with some projection of one or both 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 or diffused, the result of morbid secretion, apparently from 
the mucous follicles. The uvula is usually much swollen and elongated, and 
the soft palate inflamed. There is also almost always external inflammation, 
with swelling of the cervical glands and the cellular tissue, and so much stiff- 
ness of the jaws, that, when the disease is at its height, the mouth can some- 
times 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 exquisite. 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 
asleep, 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 swollen and indurated; and this is especially apt to be the case in persons 
of a scrofulous habit, and in those frequently attacked. Sometimes the tume- 
faction becomes at length so great as to be seriously inconvenient, producing CLASS III.] 
531 
INFLAMMATION OF THE TONSILS. 
difficulty of deglutition, and an alteration of the voice. The tonsils, more- 
over, may come into this hypertrophied condition 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 very rare, unless the larynx becomes involved. I have never 
witnessed a fatal case. One, however, is recorded in the Am. Journ. of Med. 
Sei. (N. S., xxiv. 96), which was caused by the pressing downward of the 
epiglottis, so as completely to close the orifice of the larynx. 
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 smallpox, 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 subject to it in youth 
and adult age, generally cease to be so 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 may be 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 by refrigerant 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 restlessness 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 is usually 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- 532 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[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 pith, or slippery elm bark, vine- 
gar 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 has been recommended, as also 
has bleeding from the ranine vein. There are two remedies which, applied 
in the early stage of the disease, will often arrest it; namely, powdered alum 
and nitrate of silver. The alum may be brought into contact with the sur- 
face of the tonsils, either by means of the index finger moistened and then 
touched to the powder, or by blowing it into the fauces through a quill or 
other tube into which it may have been introduced. The nitrate of silver 
may be applied in substance, by touching the surface with a stick of it, or in 
strong solution by means of a camel's-hair pencil. When suppuration has 
commenced, 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 ad- 
vance 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 invisi- 
ble portion is much less common. Its diagnostic symptoms are pain in swal- 
lowing opposite to the top of the larynx, and tenderness 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 pharynx, 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. 
J.6scess 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- CLASS III.] 
INFLAMMATION OF THE (ESOPHAGUS. 
533 
rynx, between it and the cervical vertebrae. It is not a frequent, but is 
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, which 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 arises 
partly from inanition, but chiefly from pressure upon the larynx, producing 
suffocation. Several fatal cases are on record; and it is probable that 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 sometimes cephalic symptoms, which tend 
to direct attention away from the real danger. The abscess is more danger- 
ous in the lower than the upper part of the pharynx. 
This affection may attend the advanced stage of certain fevers, or may re- 
sult simply from inflammation of the pharynx. It may also be produced by 
disease of the cervical vertebrae. As hitherto observed, it has been most com- 
mon in children under four years; but it may occur at any age. 
The treatment consists simply in opening the abscess; and the chief cautions 
requisite are to avoid making too deep an incision, and to strike as nearly as 
may be 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 IK 
INFLAMMATION OF THE (ESOPHAGUS, or (ESOPHAGITIS. 
This is a very 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 cardiac 
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 ex- 
perienced, if the disease is seated in the upper part of the oesophagus. Deglu- 
tition is usually more or less difficult, and sometimes impossible. The com- 
plaint 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 
* For an elaborate account of this affection, the reader is referred to an article by 
Dr. Charles M. Allin, in the New York Journal of Medicine (N. S., vii. 307). 534 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
it is usually propagated from the fauces or larynx, though it does occasionally 
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 suspi- 
cion 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 propagated 
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 patient 
by nourishing liquids injected into the bowels. 
Article V. 
STRICTURE OF THE (ESOPHAGUS. 
1. Organic Stricture.-The consideration of this subject belongs proper- 
ly 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 diffi- 
culty 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 cancer, from cartilaginous or osseous degeneration of the tube, or from 
the pressure of exterior tumours. Among its effects is a dilatation of the 
oesophagus 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 ai)d 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 
is either rejected immediately and with force, or is retained for a time, and CLASS III.] 
STRICTURE OF THE (ESOPHAGUS. 
535 
then rises by regurgitation. The former event is apt to occur when the stric- 
ture is near the upper extremity, the latter when it is near the lower. Occa- 
sionally, 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, produc- 
ing much embarrassment of respiration, with a feeling of impending suffoca- 
tion. 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 hysteri- 
cus 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 exacerba- 
tions 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 con- 
founded, 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 frequently 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 affec- 
tions 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 a debilitated and anemic 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 inflamma- 
tion 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 surface, to rubefacients, epispastics, pustulating substances, or a 
seton applied to the back of the neck, and to the internal use of antispasmo- 
dics and narcotics, such as assafetida, valerian, Hoffmann's anodyne, cam- 
phor, 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 
air, a nutritious diet, the avoidance of coffee, tea, and tobacco as habitual 
luxuries, and attention to the bowels and the various secretions. Strychnia 536 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
has been employed successfully in one severe case by M. Mathieu. A com- 
plete cure was effected in six weeks. (Journ. de Pharm., Be ser., xxii. 390.) 
In the regularly intermittent form of the complaint, sulphate of quinia will 
prove effectual. 
SUBSECTION III. 
DISEASES OF THE STOMACH. 
Article I. 
INFLAMMATION OF THE STOMACH, or GASTRITIS. 
The inflammation in this disease is usually seated in the mucous mem- 
brane, and the submucous cellular tissue; though it sometimes extends to' 
the other coats, and may even involve the whole stomach. The peritoneal 
coat is seldom exclusively affected, unless in cases of general peritonitis, to 
which disease, 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 distinction in any peculiarity of character, or precise degree of violence. 
Acute Gastritis.-This is not common as an independent affection, 
though frequently associated with other diseases, of which it may 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 sto- 
mach, 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 influences from without, would be constantly suffer- 
ing, and causing the system to suffer, if readily excited into inflammation by 
such influences; while, if undisturbed by inflammation, or morbid excitement 
in other organs, it would continue to furnish, through the function of di- 
gestion, 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 dis- 
tension 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 coat- 
ing; but sometimes it is red, smooth, dryish, and without fur, from the com- 
mencement. The bowels are almost always constipated, unless they partici- 
pate in the inflammation, in which case they are looser than in health. The 
patient lies on his back, is apt to be low spirited, is restless and wakeful, and 
has a feeling of great debility, with an expression of face indicating anxiety 
and distress. The pulse is frequent and sometimes full, but usually small 
and corded; the respiration often short and hurried; the skin hot and dry; CLASS III.] 
537 
and the urine high coloured. A hard, dry cough, occasionally paroxysmal, 
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 
cheek, 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; hiccough ha- 
rasses the patient; active vomiting is succeeded by mere regurgitation ; 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, pre- 
ceded 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 ex- 
treme 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 commencement 
by the violence of the cause, as when one of the concentrated mineral acids 
has been swallowed, great prostration comes on 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 constriction; 
instead of obstinate and incessant vomiting, merely a slight nausea, or a dis- 
position to vomit ingesta. The pulse, too, in such cases, is usually more full 
and developed. Epigastric tenderness is seldom absent. Occasionally, 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 afforded by dissection. 
This is sometimes attributable to the fact, that secondary or sympathetic affec- 
tions, such as severe headache or delirium, pains in the back or limbs, or irri- 
tation of some portion of the pulmonary apparatus, become so prominent as 
to act revulsively in relation to the gastric sensibilities, and thus to mask the 
real disease. When gastritis attends other diseases, it is peculiarly liable to 
be thus concealed, as in the delirium of drunkards which immediately follows 
an occasional debauch, and in which it is highly important that it should be 
recognized. (Stokes.) 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 sub- 
sides into chronic gastritis of indefinite duration. Milder cases 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, some- 
times 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, 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 
INFLAMMATION OF THE STOMACH. 538 
[PART II. 
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 arbor- 
escent 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 different form in another. The darker shades of colour, the brown and 
black, for example, are, according to Andral, very seldom found in acute gas- 
tritis, and only in cases of great intensity and brief duration, such as result 
from the corrosive poisons. Ecchymosis is not unfrequent, usually in patches, 
sometimes in isolated spots in the submucous tissue, producing small pro- 
minences on the surface. The mucous follicles often exhibit evidence of in- 
creased developement 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 disor- 
ganization, and the consequent vital process of separation, in various states of 
advancement. Ulcers ate 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 in- 
flamed. Yellowly, however, by experiments made in 1813, satisfactorily 
proved that stomachs, previously in a healthy state, often appeared much red- 
dened 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 cer- 
tain proof of inflammation. All the varieties of shade, and all the diversities 
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 obstructing 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 membrane 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 material change of con- 
sistence. 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 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 tem- 
LOCAL DISEASES.-DIGESTIVE SYSTEM. CLASS III.] 
INFLAMMATION OF THE STOMACH. 
539 
perature which are so often the cause of other inflammations. It most fre- 
quently results from caustic or irritant substances taken into the stomach. 
The corrosive 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, tha' 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 
phlegmasise. 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 system is 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 de- 
pressing 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 
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. 540 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
PART II. 
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 sub- 
stances, even small quantities of cold water, are rejected. Besides, it ope- 
rates 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 cathartic, may be administered with advantage; but, if found to 
disturb the stomach, they should not be persevered in. The effervescing 
draught will often operate 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 inflammation has subsided. A full dose may be administered at bed- 
time, and repeated in an hour or two if it should not procure rest. Calomel 
may often be usefully 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, re- 
peated every four, six, or eight hours, will generally be suflicient 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 com- 
plaint, stimulating pediluvia, or other measures for exciting action in the 
lower extremities, should be employed when these are pale and cold. In the 
last and most prostrate stage, when the symptoms indicate threatened or ex- 
isting gangrene, the most efficient remedy is oil of turpentine with laudanum 
or a salt of morphia, given frequently in small doses. I have seen one ap- 
parently 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 carbonic 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 advanced 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 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 ob- 
served 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 CLASS III.] 
CHRONIC INFLAMMATION OF THE STOMACH. 
541 
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 
leeching operates with so much advantage is not obvious. Some refer it to 
revulsion, and the direction of the current of blood from the stomach to the 
surface. 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 leeching, warm 
fomentations, or light emollient cataplasms should be applied over the region 
of the stomach, unless found very oppressive by their weight. Care, how- 
ever, 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 
experience. 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 sul- 
phate 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 occasional 
headache, and vague pains or soreness in the limbs as if from fatigue. Some- 
times nausea and vomiting occur at the commencement. The symptoms gra- 
dually increase in intensity and diversity; and the disease puts on a great 
variety of aspects, dependent on the degree, extent, stage, cause, and charac- 
ter of the inflammation, the tissue or part affected, the constitution and habits 
of the patient, and the almost infinite diversity of sympathetic 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, 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 heartburn. 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 inva- 542 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
riably, 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. Fre- 
quently also pain is felt in other places, as in various parts of the chest, in 
the shoulder and arm, and in the back immediately behind the region of the 
stomach. The sensation is seldom constant; but has exacerbations and re- 
missions, or entirely intermits, and is generally worse immediately after eat- 
ing, 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 confined to a comparatively small portion of the sto- 
mach. 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 sen- 
sation 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 headache 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 ip some instances inodorous, in others 
fetid and irritating. Eructations of sour and acrid liquids are not uncom- 
mon. Vomiting is also a frequent attendant. It occurs seldom at the com- 
mencement 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 appa- 
rently all their food. Portions, however, must remain and be digested. 
The matters vomited are food, bile, mucus, sour and acrid liquors 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. Some- 
times, 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 evacuations. This is blood somewhat modified either in 
its passage through the epithelium, or by the chemical action of the gastric 
liquids. The discharge of these various substances often affords so much re- 
lief to the patient, that he acquires the injurious habit of throwing them up 
voluntarily. In some cases, large quantities of a glairy fluid like the unco- 
agulated white of eggs, or of the ordinary mucus of the stomach, or of a taste- 
less colourless liquid like saliva, are discharged, often rather by a species of 
eructation than by vomiting. 
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 reddened CLASS III.] 
CHRONIC INFLAMMATION OF THE STOMACH. 
543 
papillae projecting, or is red and smooth, or has the papillae enlarged and red- 
dened 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 aphthae, or a thrush-like exuda- 
tion. This is supposed to indicate piceration 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, however, 
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 lattter 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 per- 
sons 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 commence- 
ment 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 nume- 
rous 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 favour- 
able circumstances of position, constitution, and treatment, the disease very 
generally terminates favourably, unless complicated; and the patient some- 
times 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, into the cavity of the abdomen. The ulcer having destroyed 
nearly the whole thickness of the coats, the remaining slender portion is rup- 
tured 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 may con- 
tract adhesions with that of an adjacent viscus, the body of which thus forms 
a floor for the ulcer. The liver, spleen, or pancreas may serve this useful 
purpose. Sometimes the stomach and colon become united, and communi- 
cate so that the contents of the former escape through the latter. These results, 
however, are more common in cancer of the stomach than in ordinary ulceration. 
It has been mentioned that numerous varieties of chronic gastritis exist. 544 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 alarm- 
ing intensity almost from the outset. In a few instances, the complaint runs 
on in its mi'ldest form for a long time, and then suddenly breaks out into fatal 
violence. Under such circumstances, there is reason to suppose that the in- 
flammation may have been confined to a small portion of the stomach, 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. Perfora- 
tion 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 pheno- 
mena of peritonitis. Dissection reveals an ulcerated opening in the stomach. 
It is desirable, in reference to treatment, to be able to diagnosticate those cases 
of deep solitary ulcers, which are most apt to end in perforation. Such a con- 
dition may be suspected when a patient, with little constitutional disturbance, 
complains of almost constant pain in a particular point of the stomach, in- 
creased after eating, with sour eructations, occasional vomiting, and perhaps 
the discharge of blood, though these latter symptoms are not essential. An- 
other variety of the disease is so peculiar as to merit a separate paragraph. 
Under the name of gastrorrhoea, 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 circumstance 
is, that the matter is often thrown off after eating, without a simultaneous 
discharge of the food. The vomiting is usually very easy, sometimes in fact 
little more than a species of regurgitation. The disease may be considered 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 mucous follicles 
continue their disordered mode of action. 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, ar- 
ranged in the different modes mentioned under acute gastritis. The colour is 
sometimes, though rarely, red. In some instances innumerable minute black 
points are seen, so close together as to give the whole surface of the mem- 
brane 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, sometimes to 
a considerable extent, sometimes only in small spots. The increased develope- 
ment is occasionally confined to the mucous follicles, which form numerous 
granules either disseminated through the membrane, or collected in clusters, CLASS III.] 
CHRONIC INFLAMMATION OF THE STOMACH. 
545 
and are sometimes so large as to give to the surface a mammillated 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 common than in inflam- 
mation of the ileum and colon. The mucous membrane exhibits either slight 
superficial erosions, or small isolated ulcers from inflammation of the follicles, 
or a larger and deeper ulcer, which sometimes penetrates 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. These solitary ulcers are round or oval, 
an inch more or less in diameter, with abrupt edges often thickened and 
indurated in old cases, and appear as though they might have been formed 
by punching out a portion of the membrane. The ulcer is usually-'situated in 
the lesser curvature. Though generally solitary, there are in some rare in- 
stances, two or more. These ulcers are seldom or never found in persons 
under sixteen.* 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, induration 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 in- 
corporated with the membrane, as in gastritis. John Hunter long ago ascer- 
tained 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 after- 
wards 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, certain, that 
softening may result from other morbid 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 
irritation arising from disease in other organs, especially in the liver and 
* See a good paper on ulcers of the stomach by Dr. Geo. Budd, in the Lond. Med. 
Times and Gaz., June, 1853, n. 617, and July, p. 27. 546 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
spleen, may also give rise to the complaint. It is a frequent attendant upon 
phthisis, especially in the latter stages; and the tuberculous diathesis com- 
municates to it an extraordinary obstinacy when it arises from other causes. 
But no disease probably is so productive of chronic gastritis as dyspepsia; 
and the two affections are so frequently associated, that by some authors they 
are considered identical. This subject will be discussed under dyspepsia. It 
is sufficient here to say that the chronic inflammation, which so often accom- 
panies 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 stomachic 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, 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 
without fever on the one hand, or debility on the other, a more nutritious 
diet may be employed, consisting of stale bread, crackers, boiled rice, mush, 
and gruels; care being always taken that the solid substances should be 
thoroughly masticated. In cases of general debility, the diet may be im- 
proved by the addition 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 circumstances, 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 exceedingly unpleasant form of chronic gastritis, as the ex- CLASS III.] 
CHRONIC INFLAMMATION OF THE STOMACH. 
547 
elusive 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 experienced 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 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 indications; 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, excepj. 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 against any premature relaxation of the dietetic plan. A single de- 
bauch, or indulgence for a short time in forbidden food, may undo the work 
of months. When there is reason to suspect the existence of the deep, soli- 
tary ulcer, it is of the utmost importance to adhere rigidly and for a long 
time to these rules of diet; and the food especially adapted to these cases is 
milk, with farinaceous substances finely comminuted, or in the liquid state. 
In some obstinate cases, attended with incessant vomiting, a system of entire 
abstinence from food by the stomach, the strength being supported by nutri- 
tious enemata of soups, with or without an opiate addition, has sometimes 
proved successful. I have known at least one case rescued from immediately 
impending death by this plan, conjoined with the use of nitrate of silver in- 
ternally. The return to food must be very cautiously regulated. 
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 pustu- 
late, 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 548 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
stomach is injurious; but «enemata are of themselves scarcely sufficient to 
meet the indication to evacuate the upper as well as the lower bowels. The 
gentlest laxatives 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 irri- 
tate the stomach. 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 perspinftion, as well as by 
enabling the patient to sleep. When there is great local suffering with gene- 
ral 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 habit, which the patient may have difficulty in 
breaking. Hydrocyanic acid has been recommended under the same circum- 
stances. The feet should be kept warm, if necessary, by rubefacient applica- 
tions. Congestion of the portal circle, visceral disease, whether functional or 
organic, and, in the female, 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 alterative 
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 within a few years 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 repeat- 
edly 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 ex- 
press 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 mercurial 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 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 tissue, relaxed by the previous inflammation, sufficient energy to take on 
a healthy action, and resume its 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 combated 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- CLASS III.] 
CANCER OF THE STOMACH. 
549 
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 secretion. 
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 use- 
fully combined with opiates. The diet should in general be nutritious and 
digestible, consisting chiefly of farinaceous substances and anipial 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 importance 
of regular though not violent exercise, of relaxation from the cares and anxie- 
ties 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 movement is not contra- 
indicated, in bringing about a cure, or confirming convalescence. 
Article IL 
CANCER OF THE STOMACH. 
Carcinoma attacks the stomach in all its different forms, whether of scirrhus, 
medullary cancer, or colloid cancer. The notion, at one time entertained by 
certain pathologists, that these tumours were simply the result of inflamma- 
tion, has been entirely exploded. There is little doubt that mere effects of 
chronic inflammation, neglected or abused, have sometimes been mistaken for 
cancer; and there are also instances in which it would be difficult or impossi- 
ble to determine, upon a mere inspection of the diseased parts, especially in 
scirrhous cases, to which of these complaints they should be referred. But 
the microscope has removed the difficulty, so far as post-mortem examination 
is concerned, and has satisfactorily shown, in many of the cases otherwise 
doubtful, that the disease is true scirrhus, by the detection of the proper 
cancer cells. 
Symptoms and Diagnosis.-The symptoms of cancer in the stomach are so 
nearly those of chronic inflammation, that it is often impossible to distinguish 
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 at- 
tached 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. Lancina- 
ting 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 present 
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, 550 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 ex- 
cessive nausea and the discharge of a glairy mucus, there is reason to sup- 
pose 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 occupied by a cancerous tumour, and resists 
the passage of the chyme. When, after frequent vomiting, the patient ceases 
to be troubled in this way, but is seized with a severe and exhausting diar- 
rhoea, it may be inferred that the mucous membrane at the pylorus has been 
destroyed by ulceration, and thus opened a wider passage. Generally speak- 
ing, 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 perceiv- 
able 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 scir- 
rhus. 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 con- 
tinues 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, and with the character of the cancerous 
affection. In scirrhus, if ulceration has not taken place, 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 CLASS III.] 
CANCER OF THE STOMACH. 
551 
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 mu- 
cous membrane, into the stomach. Instead of being indurated and white, the 
tumour is sometimes of a soft or brain-like consistence, constituting medullary 
cancer, and sometimes red, as if injected with blood, resembling fungus hae- 
matodes. In another form of the disease, the parietes of the stomach are 
thickened, and, instead of their usual structure, present numerous cells sepa- 
rated by fibrous partitions, and filled with a gelatinous deposit. This is 
colloid cancer. 
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 progtess, 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 has often contracted 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 abdomen, which ex- 
hibits 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 or 
diathesis; but of the origin of this we know nothing. It is highly probable 
that whatever irritates or inflames the stomach may call the predisposition 
into action. It is certain that the disease is at least aggravated by such in- 
fluences. The abuse of alcoholic liquors, excesses in eating, and the employ- 
ment 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 prematurely into ex- 
istence. 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 
unfrequent 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 
important 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 either by its quality or quantity. It may con- 
sist 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 b^ the bicarbon- 
ate of soda or of potassa, or by lime-water with milk as food. A few leeches 
occasionally applied to the epigastrium, and revulsion towards the same place 
by means of rubefacients or epispastics, will sometimes prove useful by dimi- 552 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part ir. 
nishing inflammation. To relieve the pain or local distress, to quiet irrita- 
tion, and promote sleep, it is necessary to resort to anodynes; and the prepa- 
rations 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 sub- 
stitutes. 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. 
Article III. 
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 danger- 
ous, irritation of stomach is in many of its forms very distressing to the 
patient, and, if not arrested, 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 organic functions especially, 
sometimes the nervous exclusively, and both at the same time. Though often 
merely the antecedent of inflammation of the stomach, or frequently a second- 
ary or attendant affection of other diseases, it yet has in numerous instances 
an independent existence, and therefore requires an independent considera- 
tion. 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 some 
repetition, but is necessary to a satisfactory view of the subject. 
Irritation from Congestion of the Portal Veins.-From a 
sluggish 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 is 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 
amounting to pain. The appetite is somewhat impaired, the tongue often 
slightly furred near the root, the stools scanty, or light coloured from defi- 
ciency of bile, the complexion sometimes sallow, and the mind irritable or 
depressed, and disposed to view everything in a gloomy light. The condi- 
tion 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, jaun- 
dice, and vomiting 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 
other 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 mer- 
curial pill, or a grain of calomel may be given at night, and followed by a 
mild laxative in the morning; and this plan should be continued every day, 
or every other day, until the passages indicate that the liver is acting freely. 
1. In Relation to its Causes. CLASS III.] 
IRRITATION OF STOMACH. 
553 
Very frequently this alterative treatment will be sufficient, without the ante- 
cedent 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 
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 stupor or 
coma. In children and delicate females, the nervous disorder amounts some- 
times to convulsions. When the sympathetic affection is considerable, the 
gastric symptoms are usually masked, and wrong inferences 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 irritation has been con- 
siderable 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, inflamma- 
tion 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 secretions 
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 sub- 
stances 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 has been 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- 554 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 diluting the 
acrid contents of the stomach, in part by promoting the peristaltic motion 
downward by means of the distension they occasion. After the 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. Powdered charcoal has been recommended, and is probably some- 
times useful by absorbing the irritating matters. 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 revul- 
sives 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 epigastrium, 
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 conse- 
quent 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 elsewhere. 
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 pro- 
duces 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 or 
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 re- 
tentive or otherwise. When the affection is purely spasmodic, nervous stimu- 
lants may be conjoined with the anodyne. Emollient and anodyne applica- 
tions 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.-Gastric 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 affection, 
especially in females, and is often very injuriously confounded with dyspepsia. 
It is attended, in different cases, by almost every variety of symptom by which 
the stomach is capable of expressing its suffering. All kinds of pain men- 
tioned 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 intolerable than acute 
pain, and is occasionally attended with great restlessness, mental dejection, 
and even with convulsions. In some cases the most prominent symptom is CLASS III.] 
555 
IRRITATION OF STOMACH.-CARDIALGIA. 
vomiting, which is incessant and excessive, so that the patient can retain 
scarcely anything upon the stomach. The tongue is generally 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 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 im- 
portant, in doubtful gastric affections, to make pressure on the spinous pro- 
cesses 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 relief may 
be obtained from anodynes, especially, according to M. Barbier, from the pre- 
parations of codeia, when the solar plexus is the source of irritation; but the 
symptoms return with undiminished force upon the suspension of the medi- 
cine. 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, necessary to repeat 
the local bleeding, and, in some cases, several times before a cure is accom- 
plished. 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 cha- 
racter, 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 digestible kinds of 
animal food may be employed. The bowels must be kept regularly 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 seated. Thus, it is one of the first organs to 
participate in that general movement denominated fever, no matter what may 
be its origin. 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- 
2. In Relation to the Phenomena. 556 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
tralgia, and, from its origin (xagSia and axyoj), 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 re- 
strict 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 vas- 
cular irritation of the stomach, in contradistinction to mere nervous irritation. 
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 
aaute 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.-Gastralgia 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 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 capri- 
cious, 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 epi- 
gastrium. In the former affection, the appetite, though variable, is often 
undiminished, vomiting 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 un- 
frequently 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, CLASS III.] 
557 
IRRITATION OF STOMACH.-GASTRALGIA. 
palpitation, restlessness, morbid vigilance, &c.; but wants the extreme ema- 
ciation and hectic symptoms which mark the advanced stage of the inflam- 
mation. The spirits in both are usually depressed, but in gastralgia are more 
variable, being excessively low during the paroxysms, and again bright and 
cheerful when the pain remits or retires. Ilot and stimulating drinks gene- 
rally aggravate chronic gastritis, while they often relieve gastralgia. In both, 
constipation is an almost constant attendant, unless the case is complicated 
with chronic enteritis, which is much more likely to happen in the inflamma- 
tory than in the nervous affection. Not unfrequently the two affections are 
combined in the same case, and the diagnosis is thus obscured. In doubtful 
cases, it is safest to treat the disease as chronic inflammation, and, if the mea- 
sures employed fail, then to address our remedies to the neuralgic condition. 
Treatment.-1The 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 
applications. Opium, or some one of its preparations, is the most efficient 
anodyne; but other narcotics, as hyoscyamus, stramonium, belladonna, extract 
of hemp, lactucarium, and chloroform, separate or combined, may often be 
advantageously resorted to, especially when it is necessary to sustain a con- 
stant impression for a considerable time. Hydrocyanic acid has also been 
highly recommended; and it is probable that the smoking of tobacco might 
sometimes prove beneficial. Great relief is asserted to have followed the use 
of powdered charcoal; but the pain, in these instances, has probably pro- 
ceeded from irritant matters in the stomach. According to Dr. Belloc, the 
best form of charcoal is that prepared from the wood of the poplar. It may 
be taken in the form of an electuary, in the dose of a teaspoonful several 
times a day. 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. 
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 diseases, 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 intermittent. 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 reme- 
dies may be advantageously 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. (See page 
555.) If it be of rheumatic or gouty origin, in addition to other measures, 
stimulant applications should be made to the extremities. To meet this same 
indication, all those means should be employed which are requisite for con- 
firming 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 [part II. 
558 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
accrue from visits to the watering-places, a sea-voyage, or a protracted jour- 
ney or residence abroad. Sea-bathing, or the occasional use of the shower- 
bath, may be added to the other measures. 
In order to avoid sources of irritation, the diet should be carefully regu- 
lated. The rules which will be given hereafter, undei' the head of dyspepsia, 
are applicable in the present case. Advantage is sometimes experienced 
from stimulating drinks, as a little brandy and water during meals; but the 
moral hazard is, on the whole, greater than any probable benefit. 
Pyrosis. - Waterbrash.-The term pyrosis has been differently em- 
ployed, sometimes to signify merely a burning pain in the epigastric region, 
sometimes as the title of a peculiar affection usually called waterbrash. I 
follow 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 sup- 
ported 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 th.ey 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 whiskey freely. Linnaeus mentions that it is pre- 
valent in Lapland; and, according to Ur. Magnus Huss, of Stockholm, it is 
very common throughout Sweden, so as to be a real national scourge, from 
which few of the lower classes escape. The author ascribes it to the abuse 
of spirits, and the habitual use of indigestible food. (Archives Giu., 5e ser., 
i. 519.) But it is confined to no class, nor to any particular mode of lifp. 
It seldom, however, occurs before the age of puberty, or in old people, and is 
more common in women than men. According to Cullen, its attacks may 
be brought on by cold applied to the lower extremities, or by any considera- 
ble emotion of the mind, but for the most part occur without any known 
exciting cause. Any cause calculated to disturb the stomach, independently 
of diet, may occasionally induce an attack, as pregnancy, mental anxiety, &c. 
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 
mucous membrane, occurring paroxysmally, and relieved at each attack by a 
copious elimination of fluid from the exhalant vessels of the stomach. The 
pain does not appear to be produced by the presence of the fluid, which is CLASS III.] 
IRRITATION OF STOMACS. 
559 
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.-1The pain may be relieved by opiates or other narcotics, as in 
gastralgia, conjoined if necessary with revulsive applications to the epigastrium. 
If the liquid discharges be sour, magnesia, bicarbonate of soda or potassa, or 
aromatic spirit of ammonia may be united with the anodyne. But this treat- 
ment 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 modes of life, appli- 
cable 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 gastralgia. Nitrate of silver may 
also be employed with prospect of advantage. Oxide and sulphate of zinc, 
and the vegetable astringents, have been recommended. Linnaeus speaks 
favourably of nux vomica. This maybe given in the dose of five grains three 
times a-day, or its active principle strychnia, in the dose of from the twelfth to 
the 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 ^ny 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 con- 
traction, 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 stomach. 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 560 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 fugitive 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 of spasm of the 
stomach, unless when the latter depends upon some offending matter in the 
viscus. In such cases, the nausea is experienced between the paroxysms, be- 
ing replaced during their continuance by the more violent sensation. In the 
act of vomiting, the stomach often contracts spasmodically, and occasions ex- 
cruciating pain. 
Causes.-Whatever irritates the mucous coat may throw the muscular sym- 
pathetically 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 disagree with the sto- 
mach in consequence of idiosyncrasy; and by irritating matters in the stomach, 
whether the result of alteration in the food 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 occa- 
sional 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 oc- 
casioned also by congestion of the portal system of veins, by irritation of the 
spinal marrow or sympathetic nerve, by gout or rheumatism, by cold exter- 
nally 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 continu- 
ance of depressing emotions, or certain chronic disorders affecting particularly 
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 character, even mental 
association without emotion, may serve as an exciting cause. I have heard of 
a woman, 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 neces- 
sary 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 affec- CLASS III.] 
IRRITATION OF STOMACH.-NAUSEA AND VOMITING. 
561 
tion 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, recourse 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 either of these may be considered necessary. In the absence of all in- 
flammation, or high vascular excitement of the stomach, certain stimulants, 
especially the nervous, such as Hoffmann's anodyne, ether, musk, and the pre- 
parations 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 turpentine, &c. 
External applications, such as have been mentioned under gastralgia, should 
never be neglected. The most efficient, on the whole, is a sinapism 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 super- 
added, 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 555.) In gouty and rheumatic 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 contrac- 
tion 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 mus- 
cular 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 dia- 
phragm 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 move- 
ments are simultaneous. In some instances the oesophagus appears to relax 
only partially, or not at all; and then those ineffectual efforts to vomit take 562 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 so little as not 
to attract notice. During the act of vomiting, the return of the blood from 
the head is impeded, and there is consequently flushing of the face, with 
swelling of the external parts of the head, and a feeling of fulness and dis- 
tension in the temples, which is sometimes painful. Apoplexy has resulted 
from the pressure made on the brain in the act of vomiting. The pulse be- 
comes slower and fuller, probably in consequence of this pressure. The sto- 
mach sometimes contracts so violently as to produce a painful feeling of 
spasm, though it would appear, from the experiments 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 relaxa- 
tion, with a soft pulse, a moist skin, and a disposition to sleep. 
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 epi- 
gastric 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, capa- 
ble 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 
movement. 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, suc- 
ceeded 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 associations 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 state 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 attention 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 CLASS III.] 
563 
IRRITATION OF STOMACH.-NAUSEA AND VOMITING. 
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 in- 
crease 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. So much is this the case that, in 
obstinate vomiting, the origin of which cannot be traced to disease of the 
stomach itself, attention should be directed to the liver, spleen, kidneys, &c., 
in order to ascertain the condition of these organs. In cases of this kind, it 
may result from an extension of irritation to the stomach through the gan- 
glionic or spinal centres, or from an impression made by the diseased organs 
intermediately upon the brain. There seems to be a state of the nervous 
system, resulting from various causes, which disposes 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 in- 
juries 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 influences disturb- 
ing to the nervous system, such as occur in exanthematous fevers, pregnancy, 
and unaccustomed motions of the body, as in sailing, swinging, riding back- 
wards in a carriage, &c. Disorders of the brain itself very frequently pro- 
duce nausea and vomiting. Obstinate vomiting is one of the most character- 
istic features of hydrocephalus. Concussion and inflammation of the brain 
are frequently attended with it, as are also various functional derangements 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, obviate the depressing influence of the liquid. The 
loss by the stomach of its ordinary mechanical support may give rise to nau- 
sea and vomiting. Hence, these effects have resulted from relaxation of the 
abdominal 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 564 
[part ii. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
"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 extract, of tincture, of camphorated tinc- 
ture, of black drop, or of one of the salts of morphia. Dr. Chapman recom- 
mends a pill which has become hard by keeping. The camphorated tincture is 
peculiarly applicable to cases in which there is no vascular excitement of sto- 
mach, 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 lasting impression is required a blister may be resorted to. 
Lime-water and fresh milk, in the dose of a tablespoonful of each every 
half hour, hour, or two hours, are 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 fiuidounces, 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 CLASS III.] 
IRRITATION OF STOMACH.-NAUSEA AND VOMITING. 
565 
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 tinc- 
tures may also be used, in the dose of a fluidrachm. Such are the compound 
spirit of lavender, and the compound tinctures of cardamom and of cinnamon. 
I have found the aromatic spirit of ammonia, in the dose of fifteen or twenty 
drops, highly efficient in similar cases. It is an elegant addition to antacid 
mixtures, in cases of acidity connected with nausea and vomiting. Small quan- 
tities of brandy and water, spiced brandy, spiced wine, the 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. Some have found chloroform, given in doses of five drops, shaken 
in water, highly successful; and the same remedy applied to the epigastrium 
has been recommended. Injections of iced water into the rectum are asserted 
to have been very useful in vomiting connected with hysteria. Small doses 
of the tincture of nux vomica have been successfully used, especially in the 
vomiting of pregnant women; and frictions with extract of belladonna over the 
hypogastrium are recommended under the same circumstances by Bretonneau. 
It is sometimes necessary to obey the intimations of the stomach itself, which 
is occasionally quieted 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 213.) 
Yeasty Vomiting.-There is a kind of vomiting, in which large quanti- 
ties of a brown liquid are thrown up, generally very sour, which on standing 
soon begins to ferment, and covers itself with a thick coating of froth, closely 
resembling that of fermenting beer; the bulk of the vomited matter being 
thereby very greatly increased. On examination by the microscope, this mat- 
ter has been found to contain the ordinary yeast plant, and, besides this, vast 
numbers of another microscopic fungus, named by Goodsir sarcina ventriculi, 
from its resemblance to a pack of wool. Dr. Todd, of London, has rendered 
it extremely probable that this kind of vomiting is dependent on and pathog- 
nomonic of enlargement of the stomach, with obstruction of the pylorus, 
whereby the food and other matters swallowed are retained, undergoing more 
or less chemical change, until, accumulating to an amount which the stomach 
can no longer tolerate, they are rejected. The pyloric affection may be car- 
cinomatous, but probably is more frequently a cicafrix, or an existing ulcer 
with thickened submucous tissue. (Land. Med. Times and Gaz., July, 1854, 
p. 1.) Sulphite of soda was employed by Dr. Jenner as a remedy for this 
affection, upon a suggestion of Professor Graham, that sulphurous acid might 
be useful in the destruction of parasitic fungi. The free acid of the ferment- 
ing liquid decomposes the sulphite; and the sulphurous acid, being liberated, 
fulfils the requisite condition. The remedy has been found in many instances 566 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
to produce the expected effect of destroying the sarcina, and partial relief has 
been afforded; but, as the presence of the fungus is a result of the condition 
which gives rise to the vomiting, and not the cause of the affection, the disease 
in general is not materially abated. The sarcina has, indeed, been found under 
other conditions, as in the stomach of diabetic patients without yeasty vomit- 
ing, in the bowels, the ventricles of the brain, the lungs, the bladder, and even 
the nostrils; but nowhere so abundantly as under the circumstances above re- 
ferred to. The sulphite of soda may be given in the dose of a drachm three 
times a day, or oftener. But it is obvious that the cure must be effected, if 
at all, by measures addressed to the pathological condition of the stomach. 
I have had under my care a similar case in the Pennsylvania Hospital, which 
was discharged apparently well, after a treatment of several months with 
nitrate of silver. 
Obstinate vomiting, after long resisting all other treatment, has been per- 
manently removed by the occurrence of sea-sickness during a voyage. 
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 headache. 
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, how- 
ever, 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 
has been previous disorder or morbid tendency, which was 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 but 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 
in the voyage, 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 im- 
mediately 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 most apt to produce 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 CLASS III.] 
IRRITATION OF STOMACH.-SEA-SICKNESS. 
567 
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, 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 circum- 
stances. 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, coincided in this opinion, extending the explanation so as to em- 
brace 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 association of 
its present impressions, received through the senses, with the very different 
impressions previously received from similar objects; and this disturbance is 
exactly that which gives rise to the sensation of nausea and the act of vomit- 
ing. 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 ob- 
viated 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 foregoing statements it results that a person may 
diminish or obviate sea-sickness by assuming the horizontal position, espe- 
cially 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 transient 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 de- 
termination 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 compres- 
sion of the abdomen by means of a tight girdle. The patient may advantage- 
ously 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 recommended. The food should be easily digestible, and 
moderately taken. I have found nothing, under such circumstances, so ac- 
ceptable to the stomach as raw salt oysters. 
Sick-headache.-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, dulness, depression of spirits, irritability of temper, and perversion 
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 568 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
numbness or formication in the extremities, generally upon one side, and this 
numbness sometimes continues after the headache comes on. Coldness of the 
feet and hands, irregular pains in the back and loins, and deficient urinary 
secretion are also among the occasional premonitory symptoms. Sometimes 
the appetite is impaired; sometimes the patient eats a hearty meal immediately 
before the attack. The pain in the head is usually slight at first, and gradu- 
ally increases until it becomes intense; but sometimes is violent from the 
outset. In the great majority of eases, 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 vomit- 
ing 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 in- 
volved otherwise 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 vomit- 
ing, in consequence of the passage o.f the contents of the stomach downward. 
This is apt to happen if the patient fall asleep before vomiting. The paroxysm 
is occasionally interrupted by causes making a strong impression, whether on 
the mind or body. The attacks in some persons are rare, in others very fre- 
quent, occurring 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 accu- 
mulation of acid in the stomach, or an excessive secretion of bile. The pre- 
disposition 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 unfre- 
quently 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- CLASS III.] 
IRRITATION OF STOMACH.-SICK-HEADACHE. 
569 
digested food, by acrid gastric secretions, 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, however, to believe that this organ is sometimes the first re- 
cipient 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 bi- 
carbonate of soda may be substituted, when a laxative effect is not desired. 
These antacids may be elegantly administered in carbonic acid water, com- 
bined with a little ginger syrup, and a fluidrachm of some aromatic or tonic 
tincture, as the compound tincture of cinnamon, of cardamom, or of gentian. 
Twenty or thirty minims of aromatic spirit of ammonia will form a useful ad- 
dition, 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 pow- 
ders, 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 affection is primarily cerebral. The best 
of these is perhaps strong tea. Coffee answers with some, but more frequently 
fails. Citrate of caffein, in the dose of a grain every hour has been recom- 
mended. A teaspoonful of Hoffmann's anodyne may be given for the same 
purpose. I have repeatedly known attacks of sick-headache to be averted by 
a fluidrachm of the solution of sulphate of morphia, in connexion with two or 
three drachms of sulphate of magnesia. 
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 
spirit of lavender, Cologne water, or other aromatic spirit, sometimes affords 
relief; as also does the application of chloroform, or of sulphuric ether con- 
fined by the hand so as to prevent its rapid volatilization. Many, 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 be given, 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- 570 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 one 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 
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 in consequence 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. (A5 K 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 Sickdieadached) 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 faint- 
ness, 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. Occasion- 
ally 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 refer- 
red to the stomach, and often originating in that organ, may be equally pro- 
duced by impressions sent to the brain from the capillary vessels all over the 
body, when in want of supplies for the nutritive function, it will be easily 
understood that voracious appetite may depend either upon a disordered con- CLASS III.] 
IRRITATION OF STOMACH.-MORBID APPETITE. 
571 
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 
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 stomach, 
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 de- 
pends upon original or accidental irregularities in the structure of the sto- 
mach. Thus, it has been attributed to a preternatural capacity of that organ, 
and to an enlargement of the pyloric orifice, allowing the food to pass undi- 
gested. 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. Lastly, boulimia may be a cerebral 
affection; a species of insanity, in which the sensation of hunger originates in 
the brain itself, exactly as in the case of nausea, which frequently arises 
directly from cerebral disorder. 
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 modes already detailed. Perhaps, in 
some cases, advantage may be derived from sustaining nausea for a consider- 
able 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 sometimes sinks 
rapidly and unexpectedly in such cases, as from the sudden withdrawal of 
stimulating drinks. Hence gluttons, like drunkards, are in peculiar danger 
from diseases which take away the appetite, and thus cut off the usual supply. 
The practical inference from this fact is, that any attempt to cure an esta- 
blished 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, as clay, chalk, and magnesia, and even hard, wounding 
bodies, as stones, pieces of glass, pins, needles, and blades*bf knives. Such 
vagaries are often temporary, and of little importance; but they are sometimes 
durable, and cease only with life; the patient falling a victim either to the 
disease of which the depraved appetite is merely a symptom, or to the chronic 
gastritis, and general disorder produced by its indulgence. 
Like voracity, this affection may depend upon some form of gastric irrita- 
tion, upon inscrutable changes in the innervation of the stomach, upon cere- 572 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 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 gastric, 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 IF. 
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 distinct patho- 
logical 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 un- 
doubtedly very frequently associated different forms of irritation, and even 
inflammation; but these are incidental complications, and, when removed by 
appropriate measures, still leave the original disease. As dyspepsia 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 produced by the associated affections. 
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 epigastric CLASS III.] 
573 
INDIGESTION. 
region, and often extends to the hypochondria, to the chest, especially on 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 numerous symptoms, having their seat elsewhere, which de- 
pend 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; 
muscaa 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 other parts of the body ; a feeling of coldness between 
the shoulders; stricture, or uneasiness about the throat; and irritation 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 apprehen- 
siveness, an indisposition to exertion, irritability of temper, fretfulness, &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 impressions. 
The patient in general sleeps badly, is disturbed by unpleasant dreams, some- 
times by nightmare, and awakes unrefreshed, and depressed in mind. In 
some instances, however, the sleep is sound, and affords almost the only in- 
terval of ease; and in others again, there is even a morbid tendency to drowsi- 
ness. 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 some- 574 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
times copious sweating. The urine is variously affected, sometimes scanty 
and high coloured, depositing a lateritious or whitish precipitate, sometimes 
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 have only 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 danger 
from dyspepsia, however, is, that the reduced strength of the system may 
disable it from surmounting other intercurrent diseases. It is possible that, 
as maintained by Wilson Philip, functional sympathetic affections of the liver, 
the lungs, &c., having their origin in dyspepsia, may become organic diseases, 
and constitute the chief source of inconvenience and danger; but my observa- 
tion would lead me to the conclusion that such cases are very rare. The 
predisposition to phthisis may be favoured by the debility attendant on dys- 
pepsia, 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 epi- 
gastric 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 aflbrd 
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 the 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 gastric CLASS III.] 
INDIGESTION. 
575 
energies are impaired by sedentary habits, the diet is scarcely modified, and 
the quantity of the food taken, and its quality are those adapted to undimi- 
nished powers of digestion. Hence it results that the weakened stomach is 
stimulated to undue exertion in order 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 eat- 
ing 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 576 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
secreted, and less of the muscular movement to favour solution. When, 
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 regurgitations 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 irri- 
tating. 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 sympathetic nervous irritation of the muscular coat. Hence the heart- 
burn, 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 surface too feeble to respond in the usual manner by an in- 
creased secretion of gastric juice, and the removal, through its means, of the 
offending cause. Sometimes the food occasions suffering in consequence of 
the increased sensibility to painful impressions, which not unfrequently at- 
tends upon the debilitated 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 compli- 
cates dyspepsia. The diversified nervous disorders attendant upon 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 numer- 
ous, 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 Jess digestible CLASS III.] 
INDIGESTION. 
577 
than that of the same animals in the intermediate stages of life. Fish is 
generally deemed of difficult digestion; and most shell-fish, especially clams 
and lobsters, 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 for- 
bidden. Whatever is pasty, doughy, or disposed to form a tenacious mass 
with water, resists digestion, because impenetrable by the gastric juice. Sau- 
sages, 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 dew- 
berries. 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 deli- 
cate palate. It should never be used in dyspepsia after having been sub- 
jected 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 578 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
there 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 existing 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 pa- 
tients, 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 benefited if not cured by the use of articles of 
food, which, under ordinary circumstances, are highly indigestible. Experi- 
ence, 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. 213.) 
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 bedtime, 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 CLASS III.] 
INDIGESTION. 
579 
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 important that the food should be tho- 
roughly 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 injury from distension, the 
solvent power of the gastric juice is diminished by too great dilution. 
Exercise.-1The 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 volun- 
tary 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 railroads, 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 Halsted, 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 stomach ; 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 Obs. 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.-The 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 would 
be injurious to sleep so lightly covered as to suffer in the least from cold. It 580 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
is a mistake in dyspeptic individuals to suppose that they can harden them- 
selves 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, more- 
over, 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, have 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 excite- 
ment 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.-1Two principal indications are presented in dyspepsia 
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 ipe- 
cacuanha. This, however, is called for only in certain incidental conditions; 
as when serious inconvenience is experienced from offending matters in the 
stomach, or where it is desirable to arouse the languid portal circulation, and 
thus remove congestion. If emetics should be employed merely for stimu- 
lating 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, therefore, it is safest to dis- 
pense 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 constitutes, 
on account of its laxative quality, an excellent article of diet for dyspeptics. 
It does not, however, suit all stomachs, and frequently fails in producing 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 con- 
trary unite a tonic or stimulant with their laxative power. Rhubarb and aloes 
are the most suitable. They may be given separately or combined; and the 
most convenient period for administering them is generally at bedtime, so 
that they may act in the morning. Rhubarb may be used in all cases; aloes CLASS III.] 
581 
INDIGESTION. 
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 compli- 
cated with rheumatism. White mustard seeds unbruised, in the dose of a 
tablespoonful, repeated as often, have been found to answer well in cases re- 
quiring a somewhat stimulant impression. Magnesia should be employed 
when there is 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 affond'prcsent 
relief at the risk of future mischief. When the stomach is placed under cir- 
cumstances in which, upon being excited to the proper poin^ 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 quassia, gentian, and columbo. Chamomile is well 
adapted to mild cases. Wild cherry bark may be used whe4 an irritable cir- 
culation, indicated by the occurrence of palpitations or very frequent- pulse 
under slight excitements, is associated with the gastric depression^ ,'^i-pen- 
taria is applicable to cases of unusual debility; and valerian may *e/advan- 
tageously combined with the bitters, when the patient is affected witU symp- 
toms of hysteria, or other nervous functional disorder. The officinal infusions 
of these medicines m^y 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 e?mployed 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. PharnJhcopoeia. 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, muriatic, and nitromuriatic acids, subnitrate of bis- 
muth, sulphate of zinc, and nitrate of silver, are sometimes used. I have 
found the nitromuriatic acid especially useful in cases in which the gastric 
symptoms were associated with a foul breath, indicating an impure state of 582 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
the blood. 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 recommended ; 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 infusion 
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, an alkaline carbonate may be added to the infusion. 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 deficient, a little 
of the mercurial pill or calomel may be added. 
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 demands a vigilant attention. If diminished or de- 
ranged, it is best corrected by alterative doses of mercurial pill or calomel, 
either alone, or combined with the tonic and purgative medicines. The de- 
coction or extract of dandelion may be used as an adjuvant; and nitromuriatic 
acid may sometimes be advantageously substituted for the mercurial. 
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 Irritation of the 
Stomach, where he will find a detail of the treatment appropriate to gastralgia, 
pyrosis, spasm of the stomach, nausea and vomiting, and sick-headache, all of 
which are occasional attendants on this complaint. I shall have occasion here- 
after 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 
cathartic effect. The carbonate of magnesia is less 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 
* R.-Golomb, contus., Zingiber, contus., aa §ss; Sennse gij ; Aq. bullient. Oj. Fiat 
infusum. S. A wineglassful twice or three times daily, before meals. CLASS III.] 
INFLAMMATION OF THE BOWELS. 
583 
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, 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. Recently prepared charcoal, 
finely powdered, is sometimes useful by absorbing the acids, and other offen- 
sive liquids and solids in the alimentary canal. It may be given in the dose 
of a teaspoonful or more three or four times a day; but care should be taken 
not to allow it to accumulate in the bowels. 
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. 
SUBSECTION IV. 
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 in- 
flammation of the upper portion or duodenum, of the middle portion, embracing 
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 
already described of gastric inflammation and irritation, cancer of the stomach, 584 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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. Dis- 
eases 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 ex- 
planation 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 secret- 
ing gland and the surface upon which its excretory 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 duo- 
denum 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 re- 
ceived where they are wanted. Irritation or inflammation of the duodenum 
should, therefore, produce irritation of the liver, which, according to its de- 
gree, may be attended either with an increase or diminution of the secretion 
of bile. In the former case, absorption may take 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 receiv- 
ing the ordinary impression from the chyme, and the ordinary stimulus is 
•consequently not supplied to the hepatic secretory function. In this way also 
the secretion of bile is diminished, its materials accumulate in the blood, and 
jaundice results. But, notwithstanding the occasional 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 viseus a pathological im- 
portance 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 CLASS III.] 
INFLAMMATION OF THE SMALL INTESTINES. 
585 
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 
vertebra; 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 
vomiting, great thirst, or pain and tenderness in the region of the stomach, 
indicating 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 
duodenum, especially near the pylorus, and, in inflammation of this viscus, 
are apt to be enlarged, exhibiting sometimes elevated, irregular, almost con- 
tinuous 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.-1The treatment also is that adapted to gastritis. If there is 
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.-Muco-enteritis.-Ileitis.-Heo-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 inflamma- 
tion of the intervening portion, and enteritis may perhaps, without impropriety, 
receive this more restricted meaning. It should be understood that inflamma- 
tion 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, ex- 
tending 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 inflammation 
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 impeded at the ileo- 586 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 indefi- 
nitely into the colon, it is obvious that the phenomena of dysentery 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 inflam- 
mation of the membrane, the follicular or that affecting especially 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 distinguished when 
occurring as original affections, and, even could they be distinguished, no 
great practical good would accrue. The peculiar intestinal affection 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 pres- 
sure. 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. Tn 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 bqwels; 
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 
Am. Journ. of Med. Sci., N. S., vii. 348. CLASS III.] 
INFLAMMATION OF THE SMALL INTESTINES. 
587 
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 very generally 
the forerunner of a fatal issue. Acute enteritis also frequently terminates in 
the chronic form. 
Typhlitis.-Some writers make a distinct disease of inflammation of the 
ceecwm and its appendages, under the name of typhlitis caecum), or 
perityphlitis, when it extends to the neighbouring cellular tissue. Pain and 
tenderness in the right iliac region, attended sometimes with obstinate con- 
stipation, and even the symptoms of obstruction, sometimes with a muco- 
feculent diarrhoea, and occasionally with an aching sensation in the lumbar 
region, are the characteristic phenomena. Not unfrequently a tumefaction, 
with more or less hardness, can be perceived upon external examination, 
which may be well defined when confined to the intestine alone, but is some- 
what diffused when there is conjoined inflammation of the external areolar 
tissue. In the former case, the tumour will generally yield a dull sound on 
percussion, indicating that the caecum is filled with solid matter. The cause 
is most frequently accumulation of feculent matter, undigested food, or inso- 
luble 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 
appendicula 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. Sometimes the inflammation in the 
cellular tissue around the bowel ends in suppuration and the formation of an 
abscess, which opens externally, without any reason to suppose that the bowel 
had been perforated. 
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 mem- 588 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
brane. The process sometimes extends deeply into the parietes of the bowel, 
penetrating the submucous and the muscular tissues, and leaving only the 
peritoneal 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- 
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, rheuma- 
tism, 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 dis- 
eases, 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, lax- 
atives are indicated in order to remove irritating secretions or accumulations. 
For this purpose castor oil often answers admirably well, combined with fif- 
teen 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 CLASS III.] 
INFLAMMATION OF THE SMALL INTESTINES. 
589 
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 enemata 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 and ipecacuanha is preferable. This should be given at night, so as to 
procure 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 lauda- 
num, 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 arabic 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 Treatment.-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 perforation 
* R.-Opii pulv., Ipecac, pulv., aa.gr. ij; Pil. Ilydrarg. gr. xij; Acacise pulv., 
Syrup, aa. q. s. Misce et fiant pil. no. xij. S. One every two hours. 
f R.-Cretae Ppt., vel Testae Ppt. gij ; Pil. Hydrarg. gr. viij ; Tinct. Opii gtt. xxx; 
Acacias pulv., Sacch., aa giss; Aquae Cinnam. f gj; Aq. fluvial, fgiij. Misce. S. A 
tablespoonful for an adult every two, three, or four hours; to be diminished for children. 
j R.-Acid Nitromuriatic, gtt. xl; Tinct. Opii gtt. xl; Aquae fluv. fjjviij. Misce. 
S. A fluidounce to be taken six times a day, diluted with water, in a glass vessel. 590 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 im- 
portant 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 employed, 
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. 
Occasionally, after the complete disappearance of all evidences of inflam- 
mation, 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 exceed- 
ingly abundant. In character, the evacuations are not unlike those of acute 
enteritis. Occasionally portions of false membrane are discharged, 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 unfavourable 
* A variety of chronic pseudomembranous inflammation of the bowels has been de- 
scribed by Dr. W. Cumming, of Edinburgh, having peculiar characters, and demanding 
a peculiar treatment. When in Edinburgh, in the summer of 1848, I had my attention 
called by Professor Simpson to a peculiar intestinal affection which he said was not un- 
common in that city, and in which, considering it to be a kind of eruptive disease of 
the bowels, he was using the arsenical solution as a remedy. I presume that it was the 
same complaint as that described by Dr. Cumming. The characteristic symptoms, 
according to this author, are a feeling of emptiness or faintness at the epigastrium; a 
more or less fixed pain in the left hypochondriac or iliac region, or both ; an appetite 
and digestion not materially impaired, but pain in the route of the colon an hour or two 
after eating; the bowels sometimes loose, sometimes constipated; and the discharge of 
a peculiar fibrinous matter, which is in some instance stringy or tape-like, in others in 
small masses, and in others again diffluent or gelatinous. The appearance of this 
fibrinous matter in the stools is the pathognomonic symptom. There is, besides, great 
nervous disorder, producing sleeplessness, unpleasant dreams, mental depression or 
hallucination, &c. The remedy which, after the failure of all ordinary measures, has 
been found successful in these cases by Dr. Cumming, is electro-galvanism, which he 
believes competent of itself to the cure of almost every case, and, aided by the internal 
use of tar, which was suggested by Dr. Simpson, will cure the disease both certainly 
and promptly. Dr. Cumming used the instrument of Kemp, of Edinburgh, which sup- 
plies a continuous stream of any required intensity without a "jerk or shock." He 
connects pieces of sponge to the extremities of the two conducting wires, applies one to 
the spine in the lumbar region, and carries the other from point to point on the abdo- 
men over the track of the colon. One of the peculiarities of its action is to develope 
pain, or extreme tenderness, in the affected parts of the bowel. It has the effect of 
keeping the bowels duly open. The remedy should be applied for fifteen minutes daily, 
and used perseveringly. The tar is to be given in pill or capsule three times a day. 
(Medical Gazette, Decemb. 1849, p. 969.) CLASS III.] 
INFLAMMATION OF THE SMALL INTESTINES. 
591 
sign. There is generally more or less pain ; and strong pressure, or any sud- 
den jar, as in coughing or jumping, occasions uneasiness. Sometimes 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 dis- 
tended, and even tympanitic. The appetite is often craving, and seldom 
wholly wanting, unless when the stomach participates in the disease. Occa- 
sionally, the system scarcely evinces any other signs of sensibility to the 
local affection than a diminution of strength, and a more or less rapid emacia- 
tion. 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 aphthous, and the 
pulse very frequent. The spirits are usually depressed, sometimes 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, which may be very obstinate. The 
stomach not unfrequently participates in the inflammation, and then all the 
symptoms of chronic gastritis are superadded. The duration of the disease 
is exceedingly variable. It maybe cured within a week or two from, the 
-commencement of treatment, or may run on for years. When of long dura- 
tion, 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 place, and the patient becomes much emaciated. 
Besides 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 
cause, there is great reason to apprehend that tubercles may have been de- 
veloped in the mucous membrane. Chronic enteritis is a very common at- 
tendant upon the advanced stages of phthisis. 
Treatment -One of the most important parts of the treatment is the regu- 
lation 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 unnecessary 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 Iceland 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 592 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 recommended for acute 
enteritis, or in small doses combined with the various remedies which may 
be given to meet other indications. I have found the camphorated tincture 
of opium an excellent preparation in this complaint. Afluidrachm 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 inflammation is very moderate, 
and its consequences, rather than the affection itself, are to be combatted. (See 
Diarrhoea.') They should be combined with an opiate, and often form a good 
addition to cretaceous mixtures. But not unfrequently they either fail to 
arrest the discharge, or, by arresting 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, independently of their astringent properties, exercise an alterative in- 
fluence over inflamed and ulcerative surfaces, which renders them highly use- 
ful 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 en- 
teritis. To be effectual, it must be continued for a considerable time. 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. I have found the oil especially useful in those cases in 
which the tongue is destitute of fur, smooth, and perfectly dry. 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 quinia, and the chalybeates are serviceable by imparting a degree 
of tone to the 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 im- 
portant; 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 stimulant dressings, will 
often be found beneficial in ordinary cases. Pustulation 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 
immediately instituted. 
Moderate passive exercise, mental recreation, relaxation from business, sea- CLASS III.] 
593 
DYSENTERY. 
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 to which the 
human 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 
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 tormina, 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 as 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 594 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 or patches of false membrane, or small masses 
of coagulated matter, are occasionally intermingled; and, in some instances, 
small hardened lumps of feces called scybala are discharged, though these are 
less common than might be inferred from many published accounts of dysen- 
tery. Feculent evacuations are almost always followed by considerable relief. 
At first the discharges have little smell; but after a time they acquire a 
disagreeable 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 may participate 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 impres- 
sion made on the nervous system. The patient experiences an indescribably 
painful 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 
the sixth and tenth days, and the patient recovers. Sometimes, however, from 
the extent and severity 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 tenderness 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 CLASS III.] 
595 
DYSENTERY. 
chiefly or exclusively of mucus or blood, are mixed with puruloid matter, 
sanies, or vitiated secretions from the upper bowels, and are sometimes nothing 
more than a kind of bloody serum (Jotura carmuni). Even after the worst 
of these symptoms, however, the patient may recover, though the convales- 
cence is usually tedious, and the case not unfrequently runs on into the chronic 
form. ' Should the event prove unfavourable, a set of symptoms usually super- 
vene, 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 beginning, 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 petechise, dark livid spots, 
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 596 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 par- 
oxysmal 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 disorder, 
than usually attend an attack of pure colitis; and the appearance of perspira- 
tion at the subsidence of each paroxysm is an almost certain diagnostic symp- 
tom. I have known dysentery to be intermittent, occurring paroxysmally and 
violently every other day, with very little disease of any kind in the inter- 
vening day. 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 
or coexisting 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 coincidence 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 epidemics. 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 mentioned, 
colitis may coexist with gastritis, enteritis, enteric fever, and various other 
diseases, local or general; in which case, the symptoms will of course be 
modified by combination with those of the associated affection. 
Epidemic dysentery is frequently spoken of as if it were a peculiar form of 
the disease. But this is not the case. Every variety of the affection above 
referred to may occur epidemically, according to the peculiar influences which 
may be conjoined with the special cause of the colitis. Thus the disease may 
be quite uncomplicated; or it may be associated with results of miasmatic in- 
fluence, as frequently happens in our own country ; or it may exhibit the con- 
joined action of the typhous poison, as in the epidemics of Ireland. There 
is, however, in general one important characteristic of epidemics of dysentery; 
namely, that they are apt to be attended with evidences of malignancy, and 
that, on the whole, the disease is much more violent than when it occurs spo- 
radically, or as the result of ordinary causes. 
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 CLASS III.] 
597 
DYSENTERY. 
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 garri- 
sons, or in the miasmatic districts of tropical countries, that it is most malign 
nant; 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. The inflammation is sometimes diffuse, affecting the whole 
membrane equally, in other cases is seated especially in the solitary glands, 
or in the mucous follicles, as evinced by the greater prominence of these 
structures. The membrane is much reddened and thickened, and not unfre- 
quently ulcerated. Ulcers, in fact, exist in this disease much more frequently 
than in any other acute inflammation of the alimentary canal, unless in the 
enteric affection of typhoid fever and smallpox. 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. Perforation 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. 
In the adynamic or malignant variety, gangrene is much more frequently ob- 
served than in ordinary dysentery, and the mucous membrane, when not 
mortified, exhibits a dark-purple or livid appearance. 
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 dysen- 
tery among persons exposed to the cold dampness of night, after having been 598 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 mentioned unripe and acid 
fruits, ripe fruits in large quantities, vegetables of difficult solution in the 
stomach, and unwholesome and indigestible food of all kinds ; acid and im- 
perfectly fermented alcoholic drinks, such as cider, weak wines, malt liquors, 
&c.; putrid water ; drastic purges ; worms ; and feculent and other accumula- 
tions in the large intestines. Formerly much importance was attached to col- 
lections of hardened feces as the cause of dysentery, and undoubtedly they 
occasionally produce or aggravate the complaint; but they are much less in- 
fluential 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 w'hether 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 dis- 
eases assuming this character are propagated by contagion. When no obvious 
cause appears, and one person after another is affected in the same neighbour- 
hood, or in the same family, it has always been a favourite conclusion with 
many that the complaint is communicated from individual to individual. 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 epidemic dysentery. 
In certain confined situations, where many dysenteric patients are crowded 
together, without due attention to cleanliness and ventilation, the disease ap- 
pears to be communicated to others who may be exposed; but the result is 
probably owing to the influence rather of putrid exhalations, which are ac- 
knowledged to be capable of producing dysentery, than of any really contagious 
effluvium. Nevertheless, it must be admitted that the evidence 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 actually communicated; 
the inflammation of the bowels being dependent upon some peculiar atmo- 
spheric 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 
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, CLASS III.] 
DYSENTERY. 
599 
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 consisting 
in a congested state of the portal circulation. The modifications of treatment 
required by the state of system, and by the coexistence 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 employ- 
ment, 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, maybe 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 ^t-e^i domic, one moderate bleeding will usually be sufficient; but, 
if the pulse regain* firm, and the local symptoms unabated, it may be repeated 
again and again. In violent inflammatory cases, threatening immediate danger 
if not relieve|l, and especially in persons of vigorous constitution or plethoric 
habit of body, it may be necessary*'io .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 ex- 
hausted 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 un- 
doubtedly 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 gene- 
rally called too late for their most efficient application; they are to most 
patients a very disagreeable remedy; and sometimes, when the stomach parti- 
cipates 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 oppression, 
nausea, eructation of bile or other irritating matter, and frequent but inef- 
fectual efforts to vomit, without the pain and tenderness of gastric inflam- 
mation. If employed with any other view, it should only be at the very 
commencement. Some have used the antimonial preparations; Chisholm re- 
commended sulphate of zinc; but ipecacuanha is now generally preferred, and, 
from its mildness as well as efficiency, deserves the preference. 
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 circulation; 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. Laxa- 
tives, therefore, or the milder purgatives should always be preferred. Nor is 
it in all cases advisable to persevere with them until feculent discharges, and 
especially consistent feculent discharges, are obtained. Occasionally, the 
dysentery has been preceded by a diarrhoea, which has cleansed the bowels; 600 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
and in such cases solid feces are not to be looked for in the stools. When the 
disease has commenced abruptly, without antecedent diarrhoea, 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, there- 
fore, accumulates in the veins proceeding from the abdominal viscera, and 
must distend injuriously 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 mem- 
brane, 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 me- 
dicines. In ordinary cases, from five to fifteen grains of calomel should be 
given at the commencement, and followed in from four to six hotirs 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 oftenes; but, as we 
generally meet with the disease, if the medicine be repeated, 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 ordi- 
nary 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 administered, 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 sometimes 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 recommends 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 treat- 
ment. Some practitioners employ the compound powder of jalap. It is 
desirable that, by means of the cathartics mentioned, one or two evacuations, 
if not spontaneously produced, should be obtained daily or every other 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 affec- 
tion remains strictly dysenteric, they are often useful. When the strength 
fails, or the symptoms assume a chronic form, rhubarb or one of its prepara- 
tions may be substituted for the other cathartics. Under the same circum- 
stances, melted butter, prepared by introducing solid butter into hot water, 
agitating, and then skimming the oil from the surface, has been given advan- 
tageously in the dose of a tablespoonful every two hours, until it produced some 
effect upon the bowels. Great benefit will often accrue from combining an 
opiate with the cathartic. So far from uniformly counteracting the operation CLASS III.] 
601 
DYSENTERY. 
of the latter, it will not unfrequently promote it by resolving spasmodic con- 
striction 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 hath, which is liable, however, 
to the same objection as diaphoretics internally administered. , It.is pecu- 
liarly useful in cases of children, because in these it can be managed with less 
exposure of the person to cold. The vapour hath 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 con- 
striction and thereby facilitating the action of cathartics, and, when combined 
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 impres- 
sion. Some rely mainly on large doses of opium after due depletion, in the 
treatment of the disease. 
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 
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. 602 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
When this indication is to be fulfilled, the mercurial, instead of being admi- 
nistered 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 malig- 
nant cases in which the blood is dark, and either feebly or not at all coagulable. 
Numerous alterative remedies have 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 com- 
pound 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; 
and several writers have since attested its efficacy. It is not, however, gene- 
rally 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 he- 
morrhage. 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 
has 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 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 in- 
flammation 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, Penn- 
sylvania, has employed buttermilk with success, as the exclusive remedy in 
numerous instances. (Am. Journ. of Med. Sci., 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- CLASS III.] 
603 
DYSENTERY. 
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 Grerman physicians. It 
should never be used in the acute febrile stage of the ordinary sthenic form 
of the disease. In epidemic dysentery it is asserted to halve proved very 
effective. (Cornell, N. Y. Journ. of Med., N. 8., iii. 122, from the Charleston 
Med. Journ.) Hufeland states that in obstinate cases it is very useful. 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. 8., i. 370.) 
Dr. Frick, of Baltimore, has found a mixture of naphtha and charcoal very 
useful in certain cases of the disease, in its epidemic form. (Am. J. of Med. 
Sci., N. 8., xxii. 310.) 
Aconite has recently been recommended in the dysentery of hot climates. 
(Marbot, Archives Generates, 4" s6r., xxi. 214.) 
The use of yeast has been suggested in the sloughing stage of the adynamic 
or malignant forms of the disease. 
Sulphur, 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 warm 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- 
tery. Blisters over the abdomen come in appropriately when these measures 
have failed; but they should never be applied until after sufficient depletion 604 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 great 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. 
Nitrate of silver is said to have been employed in the same way very advan- 
tageously. From two to ten grains to a fluidounce of water have been used; 
and from three to six fluidounces thrown up at one time. Iodine has also 
been employed by injection, with great asserted advantage, even in recent 
cases. It is especially recommended by Dr. Eimer, of Germany, who admi- 
nisters, from twice to four times a day, an enema consisting of from five to 
ten grains of iodine, the same quantity of iodide of potassium, and two or 
three ounces of water, with ten or fifteen drops of laudanum, when the rectum 
is too irritable to retain the solution otherwise. (Brit, and For. Med.-Chir. 
Rev., Am. ed., April, 1852, p. 424.) 
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 begin- 
ning, the bleeding should precede the other remedies. In violent inflamma- 
tory 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 CLASS III.] 
605 
DYSENTERY. 
bleed again moderately, though this repetition of the remedy is seldom re- 
quired, 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 fomentations or 
emollient cataplasms applied over the abdomen. The combination of opium, 
ipecacuanha, and calomel or blue mass, before alluded to, may be given at 
bedtime, and afterwards repeated daily at the same hour, being 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 
has 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 general most conveniently 
brought about by small doses of opium, ipecacuanha, and calomel or mercu- 
rial 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 of the abdomen may be dressed with mercurial ointment, 
and frictions with the ointment applied to the inside of the thighs. The dis- 
ease seldom fails to yield to this treatment, unless considerable ulceration of 
the bowel exists. But the prejudices of the patient, the peculiarities of his 
constitution, or some other circumstance may forbid the employment of mer- 
cury. In this case, or in the event of a failure of the mercurial plan, some 
of the various alterative measures already enumerated (see page 602) 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 ace- 
tate of lead and sulphate of zinc. (See page 604.) 
The course of treatment above indicated applies to dysentery as it ordinarily 
appears. The bilious variety requires a more energetic employment of mercu- 
rial 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, emol- 
lient 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 mind the indications 
presented by the general disease. The most striking of these is for the use 
of measures calculated to prevent the return of the paroxysm, 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 in- 
flammation. 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 606 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
PART II. 
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 the mode of administration should be regulated as in in- 
termittent fever. Severe and obstinate dysenteries are sometimes rapidly 
cured in this way; the colitis ceasing almost immediately when the prop which 
supports it is removed. The prompt and free use of quinia is especially ne- 
cessary, 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, which, it will be remem- 
bered, is apt to occur when the disease prevails epidemically, general bleeding 
and active purgation are not admissible; at least in such cases as exhibit this 
character at their commencement. An emetic of ipecacuanha is sometimes 
serviceable at the very beginning, and a moderate cathartic dose of calomel 
may be given if the patient is seen early. If it be afterwards deemed advisa- 
ble, 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 mercurial impression, which should be effected 
by combinations of opium and calomel or blue mass, or of these with ipecacu- 
anha, given in small and frequently repeated doses. This plan should be put 
in operation immediately after the patient is first seen, unless it may be con- 
sidered proper to precede it by an evacuation of the primae vise. The only 
cases to which it would be inapplicable are those of excessive debility, or 
great malignancy, or of a scorbutic character. It is often necessary, in ady- 
namic 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 be used with caution, and proportioned carefully to the degree 
of prostration. The mineral acids are also occasionally useful. In hemor- 
rhage from the bowels, acetate of lead combined with opium and kino, is per- 
haps the most effectual remedy. Rubefacient embrocations over the abdo- 
men 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 be allowed; 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 bedclothes clean, to remove all excrementitious matters, to CLASS III.] 
DYSENTERY. 
607 
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 
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 num- 
ber of the stools consist chiefly of mucus, sometimes mixed with a pus-like 
matter 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 discharge is often consistent, and, 
instead of being uniformly mixed with the mucus, is^either irregularly per- 
vaded by it in layers or streaks, or enveloped in a thick coating of it, derived 
from the surface of the bowel with which the feces lay in contact. There is 
usually more or less tormina, ahd tenderness on pressure; though the latter is 
by no means present in all cases. The pulse, skin, tongue, appetite, &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, without 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 gradu- 
ally emaciates, the countenance becomes pale, sallow, and shrunken, the appe- 
tite fails, the general strength gives way, and ultimately the disease closes with 
hectic fever, anasarca, or some other form of dropsy. The association of chronic 
dysentery with a tuberculous constitution gives great obstinacy to the disease; 
and, in some cases, the inflammation of the mucous membrane of the colon is 
owing to tubercles diffused in the membrane, which finally soften and ulcerate. 
Occasionally the inflammation extends from the bowels to the venous trunks, 
especially the internal iliacs, and thence descending into the lower extremi- 
ties, gives rise to the phenomena, in a greater or less degree, of phlegmasia 
dolens. (Mayne, Dublin Quart. Journ. of Med. Sci., x. 375.) 
Anatomical Characters.-Besides the 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 certain 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 are considerable. When the disease is connected 608 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
with chronic inflammation of the small intestines, cathartics are seldom re- 
quired; as the bowels are sufficiently opened spontaneously. Indeed, in this 
case, 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 bedtime, 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- 
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. of Med. Sci., 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. Cases have repeat- 
edly recovered under this remedy, which had long resisted others. One case 
of recovery I remember, in which the disease was considered quite desperate 
when the oil was first administered. I cannot too strongly press this remedy 
on the attention of the reader under the circumstances referred to. In two 
or three days, or sooner, the tongue begins to become moist, and to be 
covered with a delicate white fur, and there is a corresponding improvement 
in the intestinal symptoms. The oil should be given in emulsion, and asso- 
ciated with a little laudanum. The root of arnica is used by the Germans 
in the dose of a scruple every two or three hours. The vegetable astrin- 
gents, 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 
spirituous 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. Journ.} 
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. Ill.) CLASS III.] 
CANCER OF THE BOWELS. 
609 
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. (See page 604.) 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 colon are affected. There 
can be little doubt that it operates by a direct alterative influence on the sur- 
face 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 inter- 
fere 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 disease 
has begun to involve other structures. Obstinate vomiting and constipation 
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 re- 
mains 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 fre- 
quent; 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 are 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 610 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 ceecum 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, 
notwithstanding 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 tenes- 
mus 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 indi- 
cate the necessity of an examination of the rectum, in which the finger will 
encounter a stricture, more or less completely surrounded by an almost carti- 
laginous 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 
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. If 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 advantageously 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. CLASS III.J 
611 
DIARRHCEA. 
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 asso- 
ciated 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 
or 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 
peristaltic 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, 
or from an increase in the quantity or stimulating quality of the ingesta act- 
ing 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 
quantity or quality, shall prove purgative; and, in one portion of the ali- 
mentary canal, matters may be generated which shall operate in this way 
upon another 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 mem- 
brane 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 greater 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 is 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 612 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 peri- 
staltic 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, 
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 convalescence. 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 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 irri- 
tation is provoked by a new cause into open violence. 
a. From irritation of bowels independent of disease elsewhere.-This 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- CLASS III.] 
613 
DIARRHCEA. 
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 im- 
perfectly 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 
diarrhcea in certain individuals, in consequence of idiosyncrasy. Of the ex- 
citing causes acting through the system cold is by far the most common. 
This, however, 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 desig- 
nation. Nevertheless; a rheumatic or gouty predisposition is sometimes called 
into activity in the form of diarrhoea; and this complaint not unfrequently 
results from the translation of rheumatism or gout from some other part of 
the body to the bowels. Sometimes very sudden and alarming discharges 
from the bowels are brought on in this way. In like manner, the retrocession 
of cutaneous eruptions, and the cessation of some habitual discharge either 
natural or artificial, occasionally produce diarrhoea. Fetid exhalations, and 
the continued influence of anxiety or other mental disturbance, are also.capa- 
ble 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 forerunner to them, 
and often, during the continuance of the epidemic, preceding individual at- 
tacks 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 less fecal, often of the healthy colour, though sometimes 
green from the action of acid upon the healthy bile, and occasionally some- 
what bloody, when the irritation is very severe, or a hemorrhagic tendency 
exists. In some instances they are copious and watery, constituting the 
serous diarrhoea of authors; in others, chiefly composed of mucus, in which 
case the disease is sometimes denominated mucous diarrhoea. Not unfre- 
quently portions 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 diarrhcea of infants nothing is more common 
than to find undigested coagula of milk in the passages. 
6. Dependent on hepatic derangement.-Of this variety of diarrhoea there 
are three distinct forms, characterized respectively by an increased, perverted, 
* Dr. Vogel has found, upon microscopic examination, in the milk of nurses which 
has proved unwholesome to children, even when quite fresh, infusoria such as are ob- 
served in incrustations upon the teeth; little rod-shaped bodies, dark in the middle, 
without head or tail, but with numerous feet, and often swimming actively in the liquid. 
Children fed on this milk are attacked with diarrhoea, which ceases on substituting 
good cows' milk. (See Am. J. of Med. Sci, N. S., xxvii. 204.) 614 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 mem- 
brane. An aggravation of the affection, attended with vomiting, constitutes 
cholera morbus. 2. The second form differs from the first only in the cir- 
cumstance that the bile is secreted not only in abnormal amount, but of an 
unhealthy or perverted character. The stools are brown, or black, or other- 
wise 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 intes- 
tinal secretion or hemorrhage, as the treatment required is different. In the 
bilious cases, however black the stools may appear in mass, they always ex- 
hibit a yellowish tinge, if viewed in very thin layers. This perverted secre- 
tion, though perhaps 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 upon its restoration. Congestion probably takes place 
in the intestinal mucous membrane, in consequence of a torpid capillary cir- 
culation 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 secre- 
tion 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 pathological conditions occasionally coexist. This form of diar- 
rhoea, 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 
produces fatal exhaustion. As it ordinarily occurs, it may almost al>5ig^ 
be speedily arrested by suitable remedies, and hence the importance of Ti 
early inspection of the evacuations. / 
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 passages. 
c. Occurring sympathetically in various diseases.-Diarrhoea is a very com- 
mon 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 Den- 
tition.') It frequently supervenes in the course of febrile affections, especially 
the exanthemata. Thus, it is common in scarlatina and smallpox. It has 
already been spoken of as attendant upon the thrush or sore-mouth of chil- CLASS III.] 
615 
DIARRHCEA. 
dren. But in these cases, as well as in typhoid fever and phthisis, the diar- 
rhoea depends rather upon inflammation of the boWels than mere irritation. In 
the course of dropsy, and at the close of febrile complaints, attacks of diarrhoea 
sometimes come on, which appear to be an effort of nature to relieve the mor- 
bid 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 
mucous membrane of the bowels, with or without antecedent inflammation. 
The most numerous cases of this kind are undoubtedly those which, originat- 
ing in inflammation, continue after all inflammatory action has subsided. 
The capillary 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. The eliminating 
tissue appears too feeble to resist the force with which the blood is moved; 
and the serous and even fibrinous parts of the blood escape, attended some- 
times with more or less of the red colouring matter. 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 with- 
out any evidence of organic disease in this structure, alternating with the 
colliquative sweats which depend upon the same cause. Diarrhoea of debility 
is generally without pain or tenderness of the bowels, and without febrile ex- 
citement. Nevertheless, in the mucous membrane of the bowels as in other 
parts, debility and inflammation may coexist, in which case the symptoms 
would be modified. 
Treatment.-This must vary with the character of the disease. In relation 
to the treatment of diarrhoea, the propriety of inspecting the evacuations can- 
not be too strongly urged. When the complaint depends simply upon in- 
creased 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 camphorated tincture of opium may be given, and repeated if necessary. 
In the crapulous form, the loaded bowels may be relieved by castor oil or 
other mild cathartic, and the diet afterwards reduced in quantity, and made 
to consist of materials which yield a comparatively small proportion of excre- 
ment, as meats, milk, and farinaceous substances. 
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 primm vim 
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. 616 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part n. 
In some rare cases, collections of feculent or foreign matters in the bowels, 
somewhat difficult to dislodge, maintain 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 bedtime. When acid continues to.be generated, prepared 
chalk or prepared oystershell 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 
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 not 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 
* The chalk mixture of the Pharmacopoeia is a convenient formula for the adminis- 
tration of chalk, and the same will answer for oystershell. 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 f^j of camphorated tincture of opium, 
may be 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. CLASS III.] 
DIARRH(EA. 
617 
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 pre- 
paration 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.f If the alterative mercurial plan fail in these cases, or circum- 
stances prohibit its employment, nitromuriatic acid, with or without lauda- 
num 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. 
Sulphuric acid, which has long been occasionally used in diarrhoea, has 
recently attracted much attention in England as a remedy in this disease, and, 
according to the statements in the journals, has proved successful in a most 
extraordinary degree. From twenty to thirty minims of the officinal diluted 
acid (acidum sulphuricum dilutum) are given every hour, two, or three hours, 
in about two fluidounces of water or other vehicle; and, in very urgent cases, 
the dose is still more frequently repeated. It seems to be especially applicable 
to diarrhoea of irritation.J 
Creosote has also been very highly commended. Mr. Kesteven, who em- 
ployed it upon the recommendation of Mr. Spinks, of Warrington, speaks of 
it as being signally beneficial in every case, generally checking the disease at 
the first dose, and very seldom requiring to be repeated more than once. He 
gives from one to five minims, mixed with aromatic spirit of ammonia in about 
a wineglass-full of water. (Land. Med. Gaz., N. S., xii. 235.) Dr. J. R. 
Cormack states that, if two or three drops can be taken twice, at the interval 
of an hour or two, it scarcely ever fails (Association Med. Journ., Nov. 11, 
1853); and Dr. Woodson, of Sumner Co., Tennessee, found it more successful 
than any other remedy which he had ever used. (Am. Journ. of Aled. Sci., 
N. S., xxiv. 237.) 
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 
have been recommended. Among the vegetable astringents may be enume- 
rated, besides those already mentioned, galls, oak bark, blackberry and dew- 
berryroot, black alder, alum root, pomegranate, &c.; among the tonics, columbo, 
gentian, quassia, simaruba, angustura, cascarilla, &c. These may be tried, se- 
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. 
f R.-Teste Prajparat. gss; Tinct. Opii gtt. vj ; Pil. Hydrarg. gr. iij ; Acaciae pulv., 
Sacch., aa gss; Aquae Cinnam. fgss; Aq. fluvial, f^j. Misce. 8. A teaspoonful to be 
given at intervals of two, four, or six hours, or less frequently. 
J See a communication by Dr. II. W. Fuller, in the Land. Med. Times and Gaz. (Jan. 
1852, p. 31), and various other communications in the same journal, and the London 
Lancet, in the years 1851 and 1852. 618 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
parate or variously combined, in decoction or infusion, flavoured with cinnamon 
or orange peel, and with some hope of advantage. Nux vomica has been re- 
commended as having peculiar efficacy. 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, sulphate of zinc, nitrate 
of silver, and the various chalybeates. With all these remedies it is usually 
proper to combine opium. When there is reason to suspect ulceration of the 
bowels, sulphate of copper in the dose of one-quarter of a grain, with the sixth 
of a grain or more of opium, given four times a day, I have found a most 
effectual remedy. Of the chalybeates, the solution of nitrate of iron (U. S. 
Ph.) has of late years acquired considerable reputation; but, in my own expe- 
rience, it has not proved superior to the other preparations of the same metal. 
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., vi. 118.) M. Rayei' employs subnitrate of bismuth, with great ad- 
vantage, in the diarrhoea of phthisis, that of typhus fever, and in the cases of 
children. (See Am. Journ. of Med. Sci., N. S., xiv. 219.) M. Monneret uses 
the same remedy, with great asserted success, in the atonic diarrhoea of chil- 
dren, in the quantity of two drachms gradually increased to twelve drachms 
daily. {Ibid., xviii. 462.) He considers the remedy innocent in these large 
doses;, but, never having employed them, I cannot speak of them from my 
own experience. When stimulation is requisite, good port wine should be pre- 
ferred. 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. 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 the nurse is healthy, and, if there is reason to suspect that it is other- 
wise, to substitute another nurse, or to remove the child from the breast alto- 
gether. The farinaceous substances, such as stale or toasted bread, water 
crackers, and boiled rice, constitute a suitable diet in the early stages of diar- 
rhoea of irritation. Milk is admissible in mild cases. Farinaceous 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 pul- 
verized water-crackers, constitutes a good diet; but, when there is fever or 
evidence of acute inflammation, the food should consist exclusively of muci- CLASS III.] 
COLIC. 
619 
laginous or farinaceous liquids. In the more advanced stages, milk, broths, 
and boiled meats, With fresh butter and cream, may be allowed; and, in diar- 
rhoea of debility, this kind of food should be given from the commencement. 
In many chronic cases, an exclusive milk diet will often alone effect cures. 
The dietetic rules applicable to dyspepsia should be observed during convales- 
cence. (See Dyspepsia.} 
2. COLIC. 
Colic (from xuXov, colon, or xotxca, the- belly) is characterized by pain in the 
bowels, usually more or less paroxysmal in its character, associated with con- 
stipation, 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 to- 
gether; 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 pa- 
roxysms, with irregular remissions or intermissions ; but, in some instances, is 
continued and almost uniform for considerable periods. During the exacer- 
bation, it is often exceedingly severe, so as to cause even persons of fortitude 
to groan or cry out. It occurs most commonly about the umbilicus, though 
not unfrequently in other parts, and sometimes over the whole abdomen. 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 insensi- 
bility, and in infants frequently occasions general convulsions. 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 or effect; and, when this is overcome 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 some- 
what depressed. Occasionally, however, the disease is originally associated 
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 620 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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, whether 
spasm, or partial paralysis of the bowel, or obstruction, the alvine contents 
cannot find their way downward. Even ileus, however, is not always certainly 
fatal. Patients have, in numerous instances, recovered under apparently des- 
perate circumstances; and hope and consequent efforts should never be aban- 
doned, unless when some insuperable obstacle, such as scirrhous occlusion 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 parox- 
ysmal 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 spasm. 
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, denominated 
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 CLASS III.] 
COLIC. 
621 
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- 
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 hypochondrium ; 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, and 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 alteration 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 ali- 
mentary matters be removed, the complaint ends in death, preceded by all 
the symptoms of ileus. 
Rheumatic or Inflammatory 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 622 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
from colic. This, however, is not the case with inflammation of the muscular 
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 might emphatically 
be styled rheumatic or gouty, although these two affections may also be ex- 
hibited in the bowels in a merely neuralgic form, or in that of mucous inflam- 
mation or irritation. Rheumatism of the muscular tissue of the bowels is 
not very uncommon. It may be either original or translated. It may fre- 
quently 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 pain- 
ful, 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 parox- 
ysms occur, they appear to depend upon the effort of the bowel to carry for- 
ward its contents by the ordinary peristaltic movement. Hence, purgatives 
produce occasionally severe pain during their operation. The constipation is 
a consequence of the insufficiency of the peristaltic action, and does not de- 
pend necessarily upon spasm; although a portion of the bowel, not affected 
to the point of inflammation, may sometimes be thrown into spasmodic con- 
traction. There is often tenderness upon pressure, and sometimes fever. 
The pain is in general more circumscribed than in spasmodic colic, and 
purgatives do not afford the same relief. Within my observation, the ascend- 
ing and descending colon have been the portions of bowel most commonly 
affected. Though exceedingly painful, and sometimes apparently threaten- 
ing, this form of colic is very seldom fatal. 
Neuralgic Colic.-Neuralgia of the Bowels.-Nervous Colic.-The 
bowels, like most other parts of the body, are subject to attacks of severe pain, 
without inflammation, or necessary vascular excitement. Such attacks, when 
complicated with spasm, belong to simple spasmodic colic. When not thus com- 
plicated 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 variety, 
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 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 disease 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. A form of colic closely resembling colica pictonum has 
been described under the name of nervous colic; J)ut I believe that, in such 
cases, a very close scrutiny will generally detect the operation of some prepa- 
ration of lead. 
Lead Colic, Painters' Colic, or Colica Pictonum, is so peculiar both in its 
origin and character as to merit the rank of a distinct disease; and will there- 
fore be treated of under a separate head. CLASS III.] 
COLIC. 
623 
Besides the varieties of colic above referred to, several others have been 
enumerated by authors. Spasm of the bowel sometimes occurs from sympa- 
thy 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- 
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 some medical writers, for painful bowel affections among persons who work 
in different kinds of metal. It is only the lead or painters' 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 less modified in certain 
cases. I shall first consider the plan applicable to simple spasmodic colic, 
and afterwards the modifications demanded in the other varieties severally. 
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 primae 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 be 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, 
infusion 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 624 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 
over the abdomen sometimes proves serviceable by the expulsion 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, 
or a large sinapism over the abdomen, may also be employed. 
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 or warm chamomile tea, or by a dose of ipecacuanha. The most violent 
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. 
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 in- 
tervals until it operates, or produces some obvious inconvenience. When the 
stomach is very irritable, calomel is often preferable to other cathartics, being 
retained when almost 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 circumstances, 
in persons of ordinary constitution, be of no disadvantage. The most obsti- 
nate 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 spas- 
modic constriction, and to provoke vomiting. A good laxative mixture for 
the purpose consists of magnesia and manna, mixed with strong fennelseed tea. 
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 dis- 
order, the greatest advantage may be expected from a drachm of assafetida 
rubbed up with water. In cases of ileus, where danger is imminent, the CLASS III.] 
COLIC. 
625 
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, repeat- 
ing the 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 distension without suffering, have been found very efficient in 
alarming cakes. 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 alvine evacuation, 
and consequent relief. Bleeding is very useful by relaxing the spasm, and. 
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 the 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, ah emetic of ipecacu- 
anha or tartarized antimony may sometimes be usefully 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 626 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PAET II. 
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 taken 
immediately, and the others at intervals of an hour, if required. The opera- 
tion 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 re- 
medies, 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 ex- 
posure 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 
Jaundice.') 
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 maybe 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 accomplished 
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 charac- 
ter, 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 ipecacuanha 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 bedtime, 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 per- 
spiration ; 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 sus- 
pended. Upon the commencement of such an influence, the symptoms of the 
disease very generally give way. Should the stomach be irritable, as some- 
times happens, the calomel and opium may be given without the ipecacuanha; 
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 561.) When it is desirable, upon any account, to avoid the possibility 
of salivation, the calomel must be omitted, and either the opium and ipecacu- 
anha 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 CLASS III.] 
LEAD COLIC. 
627 
from twenty to forty drops of the wine of colchicuni root, repeated every four, 
six, or eight hours. It has appeared to me that this 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 appli- 
cable to this variety. Revulsion to the extremities is also indicated; and hot 
and stimulating pediluvia, with sinapisms to the feet and ankles, may be em- 
ployed. 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 colchicuni, given as 
largely and as frequently as can be wTell 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. Alum has been found very useful in 
certain cases of nervous colic, closely simulating, if not identical with colica 
pictonum. 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 postulation 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. 
Syn.-Painters' Colic.-Colica Pictonum. 
3. LEAD COLIC. 
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 628 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 
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 bis 
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 passages 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 most 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 occasionally frequent; the face of a pale, dingy, or sallow aspect; the 
hand tremulous, with great weakness at the joint of the wrist; the lower 
extremities affected with painful cramps; and the muscles of the chest some- 
times spasmodically contracted, with pains like those of angina pectoris, and 
palpitation of the heart. As first noticed by 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. CLASS III.] 
629 
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, 
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 3509 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 per cent. (Diet. de Med., viii. 388.) The disease 
usually 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 
complication, 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 ex- 
posure 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 dis- 
ease 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 producing 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 extremities gradually extending upwards; abdominal dropsy, and effusion 
in the pleura or pericardium; and general failure of the sensorial functions, 
indicated 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 reven 
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. (Forry, 
Am. Journ. of Med. Sei., N. S., iii. 321.) But these appear to have been 
LEAD COLIC. 630 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
accidental complications, and not essential results or. attendants of the disease; 
for of eight cases reported by Andral in his Cliniqrte Medicale (3e ed., ii. 110), 
only one presented constriction 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 symp- 
toms. In a case reported by Louis, the alimentary canal exhibited no mark 
of disease whatever. (Recherch. Anat. Patholog., &c., p. 483.) Several others 
have obtained similar results from their post-mortem examinations. (Diet, de 
Med., viii. 389.) In cases of death from epilepsy supervening upon colica 
pictonum, hypertrophy of the brain has been found in some instances, soften- 
ing of the brain or spinal marrow in others, while in others again no discover- 
able 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 carbon- 
ate 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 use of the solution of subace- 
tate of lead, especially when applied to the skin with an imperfect state of the 
cuticle. (Trans, of Land. Col. of Phys., iii. 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 
fountain through leaden pipes, in which it had been permitted to stand ; acidu- 
lous 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 
abundant 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 individuals, 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 by the lungs even more 
readily than by the skin or stomach. Hence the great liability to the disease 
of those who work in the melted metal. It is stated that, in white-lead fac- 
tories, 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 CLASS III.] 
631 
LEAD COLIC. 
a local cause has generally been discovered, as in Devonshire and Poitou, in 
the use of cider or wine 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 apparently resulting 
from such causes 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 pic- 
tonum 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 Dela- 
ware, 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 
escaping under precisely the same circumstances as those under which others 
suffer; and one being attacked only once or twice in his life, while another is 
subject to the disease upon every fresh exposure. Women are much less fre- 
quently affected than men, probably owing to the circumstance, that they are 
much less exposed to the cause. The greater prevalence of the disease at 
certain seasons, which has been observed 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 fatal 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 stimulant 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.-This 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 pursued in this country, 
and which in my hands has almost invariably proved successful, consists of 
a combination of opiates and purgatives, and a resort to the constitutional 632 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 
circumstances. 
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 described 
under colic (page 624), may also be resorted to; and some advantage may be 
expected from fomentations, anodyne and emollient cataplasms, and rubefa- 
cients to the abdomen, and from the warm bath, though these remedies are 
less efficacious than in ordinary colic. The opiate should in general be re- 
peated 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, w7hile 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 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 may 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 writh 
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 may now be put under a moderate mercu- 
rial impression, as one of the most effectual remedies 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 
gradually increased, have also been recommended; and alum, or iodide of CLASS III.] 
633 
potassium, if not previously used, may now be tried as a substitute for the 
mercury, or in conjunction with it. Care should be taken to keep the bowels 
regularly open, and sulphur if necessary may be employed for this purpose. 
Before dismissing the subject of the treatment of colica pictonum, it will be 
proper to give a brief account of other plans or remedies which have attracted 
attention. The great success of the treatment known in France as that of the 
Hdpital de la Charite, claims for it a particular notice. According to this 
plan, the patient is put upon a certain course of treatment, each day of the 
disease having its appropriate combination 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 principles with that already detailed, viz., the con- 
current use of anodynes and purgatives.* 
Some have treated the dise^e 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 was considered as gastro-enteritis, 
and treated with bleeding, repeated leeching, warm fomentations, baths, emol- 
lient injections, and diluent drinks. Great success was claimed for this 
mode of management; but general opinion has not decided in its favour. 
Alum has been very highly praised 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. Gin. de Med., xviii. 370); and M. Gendrin 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 mer- 
curial treatment, with the effect of producing a prompt cure. Dr. Eberle 
obtained the happiest effects from a combination of alum and opium, given in 
LEAD COLIC. 
* 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 glasses of a laxative and sudorific drink, consisting of a " de- 
coction 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 infusion of senna, one ounce of the 
electuary diaphoenix (an officinal of the French codex, containing demulcents and aro- 
matics 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. Everyday, 
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 about seventy ingredients, and con- 
taining 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 considered complete when all pain has ceased, and con- 
stipation has not returned foi' five or six days after the disuse of purgatives. During 
the treatment a strict diet is observed; but the patient is afterwards allowed tn 
eat freely. 634 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
the dose of twenty grains of the former and one grain of the latter every 
three hours, after calomel with opium pushed to salivation, and active pur- 
gation had been employed in vain. M. Brachet, of Lyons, author of a prize 
essay on lead colic, and experienced in the treatment of the disease, though 
he employs purgatives and opiates, considers alum as the most valuable re- 
medy. The quantity administered should generally not exceed two or three 
drachms in twenty-four hours; as beyond this amount it would be very liable 
to irritate the stomach. With my present experience in relation to this medi- 
cine, I should be disposed to employ it preferably to mercury, at least in all 
chronic cases, and only to have recourse to the latter remedy, when the alum 
had failed. 
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. 
Iodide of potassium has been introduced to the notice of the profession by 
M. Meisens as a remedy in lead poisoning; and others have since employed 
it with very encouraging success. Its use was suggested on the ground of 
its probable chemical agency in eliminating the poison from the system. As 
iodide of potassium has the property of dissolving the salts of lead, it was 
supposed that it might render soluble in the blood any compound of lead de- 
posited iu the tissues, and thus enable it to be discharged by some one of the 
emunctories. Recent observations have tended to confirm this view of its 
action; as, in several cases of saturnine poisoning, in which no lead could 
be detected in the urine before the employment of the iodide, it was found in 
that secretion after the system had been placed for a short time under the use 
of the medicine.* It may be given in the dose of from five to twenty grains 
three times a day, and should be long persevered with in obstinate cases. 
M. Malherbe employs belladonna in the treatment of this disease, and gene- 
rally relieves his patients on or before the third day. (See Braithwaite's 
Retrospect, Am. ed., xxiv. 116.) Dr. Swett, of New York, states that strych- 
nia, in the dose of one-sixteenth of a grain three times a day, usually gives 
relief in forty-eight hours. (W York Med. Times, ii. 352.) Dr. Graves re- 
commends tobacco fomentations to the abdomen, continued until the peculiar 
effects of the narcotic are experienced, and then followed by cathartics. {Dub- 
lin Hospital Reports, vol. iv.) Dr. Aran employs chloroform, both internally 
and externally, with great advantage in relieving pain and relaxing spasm. 
(See Am. J. of Med. Sei., N. S., xxi. 484.) Dr. Odier, of Geneva, com- 
bines valerian and cold baths with purgatives. {Diet. de Med., viii. 396.) Dr. 
Wilson, physician to the Middlesex (London) Hospital, has employed with 
success enemata and the hot bath simultaneously, the former being admi- 
* See upon this subject a paper by Dr. F. A. Parkes, of London, in the British and 
Foreign Medico-Chirurg. Rev. for April, 1853 (Am. ed., p. 410); and another by Dr. H. 
S. Swift, of New York, in the New York Med. Times (iii. 145), where several inte- 
resting cases are detailed in which the iodide of potassium was employed with complete 
success. CLASS III.] 
635 
CONSTIPATION. 
nistered while the patient is in the latter. (Med. Exam., iv. 488, from the 
London Lancet.) Vinegar diluted with water, and taken as a drink, is said 
to have effected a speedy cure after the failure of other means. (Phil. Journ. 
of Med. and Phys. Sci., xii. 172.) MM. Chevallier and Bayer gave hydro- 
sulphuric acid in several cases with supposed advantage. (Bullet, des Sci. 
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. 
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 particu- 
lar case, it is necessary to take into consideration the interval at which the 
alvine 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, suffi- 
cient 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 quantity. 
It not unfrequently happens that a portion of the feculent matter which ought 636 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 pain- 
ful 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 deficiency 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 funda- 
ment, a frequent but ineffectual disposition to go to stool, flatulence, colicky 
pains, distension of the abdomen, and nausea with or without vomiting. At- 
tention 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 mat- 
ter, 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. Some- 
times the discharges are bloody or dysenteric in character. 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. There is in some instances 
difficulty in passing urine. If a case be attended by more or less of the above 
symptoms, constipation should be suspected, and a close examination insti- 
tuted. If the feculent mass be lodged in the rectum, it will at once be de- 
tected 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, when 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 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 rec- 
tum, 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 constipation is enor- 
mous. 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 de- 
jections, is astonishing. From one to two weeks is no uncommon 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, 
60 as to prevent a fatal distension. Generally speaking, should the constipa- 
tion 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 muscular 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 CLASS III.] 
CONSTIPATION. 
637 
or more of the conditions mentioned. The causes must be such as are capable 
of inducing these conditions. 
- 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 organized tumours 
upon their caliber; and strangulation of the intestines, as in hernia, intussus- 
ceptio, and twisting of some portion of the tube. These will be more parti- 
cularly considered under obstruction of the bowels. 
The causes which impair the contractility or susceptibility of the bowels, 
or both, are of more importance in relation to our present subject. These 
operate more especially upon the colon, thorfgh 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 power 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 dyspepsia; 
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 con- 
sequently 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 extent, with a power of regu- 
lating 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 stimulation, 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 uniform 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 ascribes 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. 638 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part it. 
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 excrementitious 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, amenorrhcea, menorrhagia, leucorrhcea, 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, how 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 
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 
treatment 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 adds 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 insuffi- 
cient. 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, gamboge, 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 of the liver. It not unfrequently hap- 
pens that, after the gums have been touched by the use of mercurials, other 
cathartics will act with facility which had failed before. Dr. Daniel, of Sa- CLASS III.] 
CONSTIPATION. 
639 
vannah, recommended charcoal very highly as superior to all other remedies 
in obstinate constipation. He gave 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., n. 119.) The remedy, 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 irrita- 
bility of stomach which precludes the use of most cathartics by the mouth. 
The reader is referred to the article on colic (page 624) for an account of 
the substances which may be used in this forsa. 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-injecting 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 assist- 
ance of the finger, a scoop, spoon-handle, or some similar instrument, intro- 
duced 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, either 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 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 ipecacuanha 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 occasioned. (Philad; Journ. of 
Med. and Phys. Sci., iv. 337.) The use of metallic mercury, in large quan- 
tities, 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 re- 
straining the peristaltic motions of the part. In such cases, persistence in the 
use of violent cathartics can do only harm. Bleeding, general and local, calo- 
mel 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 scene, all have a favourable effect by contributing 
to the restoration of tone to the bowels. Frictions over the whole surface of 640 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 complaint 
depends on torpor of the intestines. 
The regulation of the diet is highly important, and this alone will frequently 
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 properties; 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 em- 
ployed with great advantage in this case. Dr. John C. Warren, of Boston, 
recommends highly a preparation made by grinding wheat coarsely in a coffee- 
mill, adding a little salt, and then boiling for three or four hours, adding 
water from time to time, so as to bring it to the consistence of hominy. (Am. 
Journ. of Med. Sci., N. S., xvii. 296.) When the stomach is not dyspeptic, 
fresh and dried fruits are highly useful. Indeed, it is not uncommon for 
persons, disposed to costiveness, to be entirely free from this condition at those 
times of the 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 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 butter- 
milk. Broths are sometimes preferable, under similar circumstances, to solid 
food. Burne recommends the use of bacon at breakfast. An exclusive diet 
of milk has sometimes appeared to produce very obstinate constipation; 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 re- 
sorted 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 drachm or two of sulphate of magnesia, 
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 irritable, 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 dose of a tablespoonful daily or twice a day, are often 
advantageous under similar circumstances. Infusion of senna, with columbo 
and ginger or other aromatic, is also well adapted to constipation complicated 
with feeble digestion. The torpid bowels of old people require the more CLASS III.] 
641 
CONSTIPATION. 
stimulating cathartics. Besides aloes and rhubarb, the drastic purgatives may- 
be used in small doses and combined together, as in the 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 laxa- 
tives, especially with aloes and rhubarb, with the happiest effect. The quarter 
or sixth of a drop, for adults, will be found to add considerably to the activity 
of the dose, and generally without irritating the stomach. 
When the stomach is not very feeble, the salin€ 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 applicable to 
cases attended with deficient intestinal secretion. A very small quantity 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 com- 
binations of salts existing in mineral waters are often more effectual 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 in- 
gredients, has answered admirably in my 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 bedtime, in the dose of a drachm, it usually 
causes a soft feculent evacuation in the morning, without irritation, or other 
inconvenience. It is peculiarly suited to constipation with piles. Powdered 
senna, mixed in very small proportion with stewed dried peaches or prunes, 
operates in a similar manner. A drink made from cream of tartar, in imita- 
tion of lemonade, may be used in similar cases, and is often grateful in sum- 
mer. 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 as 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 in- 
troduction in the solid form. But both are liable to the objection, that they 642 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 bedtime, without previous 
supper, are the proper periods. Given at bedtime, they will often not act 
until morning, and the patient will experience little or no inconvenience dur- 
ing the night; while he thus escapes the annoyance of their operation during 
the day. This, therefore, upon the whole, is the most appropriate time. 
In cases dependent on deficiency of contractile power in the muscular coat, 
nux vomica or its active principle, strychnia, has been employed with great 
success; and, as it is not always possible to distinguish these cases, the re- 
medy may be tried in any case of habitual constipation, where this cause may 
be supposed on probable grounds to exist. 
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. Electro-galvanism has also been found useful, a current being 
directed through the bowels, by applying the end of a wire from one pole to 
the sacrum, and from the other to various points along the course of the colon 
upon the front of the abdomen. 
Article V. 
OBSTRUCTION OF THE BOWELS. 
This term, as here employed, implies the existence of some mechanical im- 
pediment to the passage of the contents of the bowels. The obstruction some- 
times 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 un- 
expected. It often happens that, for a few days after the cessation of dis- 
charges, no great inconvenience is felt; but sooner 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 down efforts, 
which are either quite ineffectual, or produce only slight, bloody, mucous, or 
feculent passages, without affording relief. Cathartics are taken without effect, 
and enemata, 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 care should be taken that they do not 
lead to false inferences as to the nature of the affection. Distension of the CLASS III.] 
OBSTRUCTION OF THE BOWELS. 
643 
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 inflammation, 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 unfrequently 
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 counte- 
nance haggard; and the patient sinks, completely worn out and exhausted, 
death being frequently preceded by delirium. This, however, is not the uni- 
form result. The vomiting of feces sometimes affords temporary relief; the 
worst symptoms disappear, to occur again when the bowels become again 
loaded; or the obstruction may be partially removed by an effort of nature, 
and again return; and a course of suffering and exhaustion, alternating with 
partial relief and reaction, may continue for months, or even years, ending at 
last in death, or in a complete removal of the obstruction, and recovery. It 
is singular how, in some cases, the system accommodates itself to defecation 
by the stomach, 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 was reported by Dr. Franklin Bache, in the N. American Med. 
and Surg. 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 ulti- 
mately 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 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 ob- 
struction; water introduced into the rectum having been thrown out from 
the mouth. The ileo-caecal valve offers an impediment to the upward passage 
of the contents of the colon; but, if it be admitted that the pressure of the 
fluids above and below the valve is about equal, the valve may be flaccid, and 
an intermixture of the fluid matters on each side of it in some degree take 
place. (Roper, Lond. Med. Gaz., Oct. 1849, p. 623.) 
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 pheno- 
mena 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 inflamma- 
tion are frequently observed, and sometimes those of gangrene. According 
to Burne, when the obstruction depends upon a purely mechanical cause, and 
not upon feculent accumulation arising from functional derangement of the 644 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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. 
Causes.-One of the most frequent causes of obstruction is an accumula- 
tion of impacted feces. This, though the result of a pre-existing functional 
derangement of the bowels, becomes itself, when so considerable as to close 
the passage, and to resist the peristaltic movement, the chief source of mis- 
chief ; 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 bowels 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 sus- 
pected 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 636.) 
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 caecum; 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 are occasionally found to have as a nucleus 
some insoluble substance accidentally swallowed. They are not generally 
numerous, seldom exceeding two or three; 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 concre- 
tions 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 ob- 
struction, 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 thicken- 
ing 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 
depend also upon a simple inflammatory hypertrophy of the submucous cel- 
lular tissue, or on the cicatrices following large ulcers; and Dr. Symonds has 
pointed out another cause in a fatty deposition beneath the peritoneal coat. 
The stricture is most frequent in the rectum, but it is also found in various CLASS III.] 
645 
OBSTRUCTION OF THE BOWELS. 
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 ob- 
struction has come on by degrees, and the feces have been discharged for a 
long time previously in gradually diminishing cords or ribbons. In many 
instances, however, it cannot be ascertained until after death. 
Tumours, cancerous or non-cancerous, projecting into the cavity of the 
bowel, are another cause. 
Organized Lands across 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. (Burne on 
Habitual Constipation.) They are very rare. 
Adhesions of the peritoneal coat of the intestines, arising from inflamma- 
tion, 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 appendicula 
vermiformis encircling the bowel, and bound in its abnormal position by in- 
flammatory adhesion; and also of those accidental processes denominated diver- 
ticula, 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 the lower, but not invariably so; 
the inversion sometimes taking place from below upward. The extent of the 
invagination varies from a few lines to a foot or more. Sometimes it is enor- 
mous. I attended, with Dr. Ashmead of this city, an infant with fatal intus- 
susceptio, in which, during life, a hard tumour could be felt extending from 
the pubes along the left side to the middle of the arch of the colon; and, 
after death, it was found that the right half of the arch, the whole of the 
ascending colon, the caecum, and a large portion of the ileum, had entered the 
lower half of the large intestine, and that most of the duodenum with a por- 
tion of the jejunum had been drawn, for a short distance, into the same 
opening. Intussusceptio occurs not unfrequently in more than one part of 
the bowels in the same case, and probably arises from a spasmodic constric- 
tion of the entering portion of the intestine. There is reason to believe that 
it frequently takes place during colic, and other spasmodic intestinal affec- 
tions, without producing serious effects, being relieved by the spontaneous 
movement of the bowels. Almost any portion of the bowels may become the 
seat of the affection; but it is said to occur most frequently either at the 
union of the small with the large intestines, the former being in this case 
received into the latter, or at the arch of the colon. 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, greatly aggravates 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 shock of the obstruction, inflammation, and 
gangrene, and the long subsequent exhausting processes of sloughing and 646 
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, without previous disorder, or as 
the consequence of an attack of colic, or the administration of a dose of active 
purgative medicine, and when at the same time a tumour, not previously ex- 
isting, 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, proving 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 
5th, 1843), may even make two complete revolutions, thus entirely prevent- 
ing 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 
irremediable; but it is probable that slight turns of the kind are susceptible 
of being untwisted by movements of the bowels, either spontaneous or ex- 
cited by medicines. There are no means of ascertaining its existence during 
life; but it may be conjectured to have occurred, when the obstruction is 
sudden, and unattended with any discoverable tumour. 
Still another cause of obstruction is strangulation by the passage of the 
bowel through some abnormal opening, as, for example, through a rent in the 
mesentery or mesocolon. 
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 
possible, to ascertain the cause; so that the treatment may be modified ac- 
cordingly. But, when this is obscure, or altogether uncertain, as often hap- 
pens, 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 
to 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 dan- 
gers from inflammation are obviated. Purgatives should be immediately 
resorted to, as recommended for occasional constipation (see page 640); and 
these should be aided by suitable enemata. For the composition of the ene- 
mata, the reader is referred to the article upon simple spasmodic colic. (See 
page 624.) But, in relation to the use of purgatives, some caution is requi- 
site. When the vomiting is very obstinate, and especially when it has be- 
come stercoraceous, 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 cathartics would probably be to increase the existing irritation or 
inflammation, 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 treatment, active purges may be employed; but, when found unsuccess- 
ful, they should not be urged under the circumstances mentioned. Effer- 
vescing aperient medicines, or the saline cathartics, given in small doses in 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. CLASS III.] 
647 
OBSTRUCTION OF THE BOWELS. 
carbonic acid water, 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 un- 
promising circumstances. According to Burne, 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. Indeed, where there is reason*to think that further at- 
tempts at purgation can be of no avail, but may even prove injurious, opium 
is the remedy which is to be mainly relied on, so far as the stomach is con- 
cerned. 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 639), is one of the most efficient remedies. If the ob- 
struction consists 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 op- 
posite 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 efficient 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 ordinary manner. 
There is often great difficulty in passing a tube through the sigmoid flexure; 
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 matter 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 reservoir 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 rectum; an accident which has happened 
from the incautious use of bougies. (Aew Views of Defecation, &c.) Others 
consider the difficulty as resulting from the projection of the sacrum, or the 
oblique direction of the bowel, and recommend the employment 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. (See page 625.) Dr. Alexander 
succeeded, in an obstinate case, by introducing a long tube into the rectum, 
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 648 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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. Dr. R. H. Townsend, of Philadelphia, succeeded in overcoming an 
obstruction which threatened speedy death, by first throwing a quart of ice- 
cold water into the rectum, then suspending the patient by his feet to the ceil- 
ing of the chamber, and kneading the abdomen with considerable force. The 
signs of obstruction immediately ceased, and in fifteen minutes the patient 
evacuated the injected water with feculent matter. (Am. Journ. of Med. Sci., 
N. 8., xviii. 547.) 
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., prefer- 
ably to other forms of cathartic medicine. In those cases which run on for 
months, it will be necessary to watch their progress carefully, 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 639.) 
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 
circumstances, 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 pro- 
priety 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; and another 
is recorded in the Edinburgh Monthly Retrospect of the Medical Sciences (May, 
1849, p. 121). Many cases of obstruction from disease of the sigmoid flexure 
and rectum are on record, in which the descending colon was successfully opened 
by an incision through the loins or in the groin. Of these cases, some terminated 
unfavourably immediately after the operation, and others in the course of a 
few weeks; but, in a considerable proportion, the patients survived a long 
time, with only the inconvenience of an artificial anus. In most of these fa- CLASS III.] 
vourable cases, however, death ultimately occurred, either from a closure of 
the artificial opening, or from the progress of the disease in which the obstruc- 
tion originated. In almost all, the life of the patient was prolonged more or 
less by the operation.* 
WORMS IN THE ALIMENTARY CANAL. 
649 
Article VL 
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 sym- 
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.-This worm has frequently been 
called lumbricus, or in the plural lumbrici, 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 in- 
dividuals. 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 ex- 
ternal genitals of the male are at the caudal extremity. 
2. Ascaris vermicularis.- Oapuris vermicularis. Bremser.-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, which are but faintly 
marked, 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 A. lumbricoides. 
3. Tricocephalus dispar.-Long thread-worm.-1This 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 
* See a statement by C. H. Hawkins, Esq., in the Land. Med. Times and Gaz., March, 
1852, p. 302. 650 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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. Taenia solium,.--Common tape-worm.-hong 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 
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 Taenia cucurbitina, or gourdworm. The 
head is small and flattish, having a projecting papilla in the centre, furnished 
with a double circle of hooks, which, however, are sometimes wanting, and 
surrounded by four equidistant circular somewhat raised disks, depressed in 
the centre, which have been supposed to be mouths, but in fact appear to be 
suckers, by which the animal is enabled to attach itself to the surface of the 
bowel. From these run two parallel canals, one on each side, near the mar- 
gin of the segments, from one end of the animal to the other, being con- 
nected by numerous transverse vessels. These canals are not distinct from 
the body, but merely passages excavated, as it were, in the parenchymatous 
tissue of the animal, and therefore differ materially in character from the 
digestive tube of the three species before described. Each joint has a mar- 
ginal foramen in the centre of a prominent papilla; and the foramina occur 
alternately on the opposite sides of the animal. These lateral pores are con- 
nected 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.- Tsenia lata.-Broad tape-worm.-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, 
which is small, elongated, without the hooks and the four circular disks or 
suckers of taenia, and divided into two lobes by a longitudinal fossa on each 
side (whence Bothriocephalus from /SoSpiov, a fossa or ditch, and head); 
and by having for mouth 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 segments alternately as in the taenia, but in a single row, each 
segment having one pore in its centre. The digestive tube is arranged as in 
the preceding species, being a mere excavation in the parenchymatous sub- 
stance 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, with some modifications, from' those 
by Dr. Farre, 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 CLASS III.] 
651 
WORMS IN THE ALIMENTARY CANAL. 
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, PhaJeena 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 treatment. 
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. 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 cause. In addition to these affections, may be mentioned obsti- 
nate cough, spasm of the glottis, dyspnoea, palpitations, hysteria, menorrhagia, 
and a general cachectic state of system, marked by a languid circulation, a 
pale or sallow skin, sunken eyes, a livid circle about the eyelids, and general 
emaciation, 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 that 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 
General Observations. " 652 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 coexist without any neces- 
sary connexion as cause and effect. Persons in apparently perfect health are 
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 the influence of the 
disease itself; and it is no uncommon event to 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 per- 
sons 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 derangement of health, whether as cause or effect, 
they should always engage attention, and be removed if possible; as their re- 
moval, under such circumstances, is often followed by the best 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 ali- 
mentary 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 ob- 
served 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 ulcera- 
tive and suppurative processes had some other origin than the irritation of 
the worms. The tricocephalus, however, appears to have the power of insert- 
ing 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 worms of this genus. 
(Brooks, quoted by Farre, in Tweedie's System of Pract. Medf 
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 
of 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 133.) 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 653 
CLASS III. 
WORMS IN THE ALIMENTARY CANAL. 
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 favoured by certain morbid conditions 
of the stomach and bowels, and particularly by a feeble or disordered state of 
digestion. Hence, persons of sedentary habits, of scrofulous tendency, and 
of general depraved health, are apt to be affected with them. It is supposed 
that an excess of food over the powers of digestion is favourable to their 
growth. Excessive indulgence of the appetite has, therefore, the same effect 
as defective digestion. The use of certain articles of 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 might trace their 
origin to some impropriety of diet affecting great numbers of individuals ; and 
the same remark is perhaps applicable to the well-ascertained fact, that some 
regions of country are much more subject to worms than others. Neverthe- 
less, 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 abun- 
dant in moist countries, and during a long prevalence of warm damp weather. 
Children, after weaning, and up to about the age of puberty, are more fre- 
quently affected with worms than either very young infants or adults, proba- 
bly owing to the nature of their diet, which is often ill adapted to their yet 
immature powers of digestion. 
Treatment.-1Two 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 increasing the peristaltic movement, or by anthelmintic medicines, which 
favour their expulsion through the ordinary contraction 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 diminishing their pow- 
ers 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 mechan- 
ically bruising or wounding it. Among those which operate in the former 
method may be mentioned pink-root, azedarach, the Lark of Andira inermis, 
male fern, the bark of pomegranate root, koosso, walnut-rind, common salt, 
camphor, various bitters, and numerous substances characterized by contain- 
ing a strongly odorous or highly stimulating volatile oil, as turpentine, copaiba, 
savine, chenopodium or American wormseed, semen santonicae or European 
wormseed, tansy, rue, wormwood, garlic, and assafetida. Several of the vola- 
tile oils themselves are still more efficacious, especially the oil of turpentine 
and that of chenopodium. Electricity passed through the bowels, in suc- 
cessive and somewhat violent shocks, has been supposed to injure or kill the 
worms, and favour their expulsion by cathartics. The mechanical anthelmin- 
tics are chiefly cowhage, which wounds and sometimes destroys the worms by 
the sharp bristles of its pods, and the powder of tin, or of zinc which bruises 654 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 act as anthelmintics by 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 
acrid property of the b'ile 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 colocynth. 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 Lark 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 on the 
muscular coat of the bowels. Senna, jalap, scammony, aloes, black hellebore, 
cevadilla, colocynth, gamboge, croton oil, and elaterium have been used, va- 
riously combined, and in various modes of preparation; but, except in very 
obstinate cases, it is better to trust to the proper anthelmintics, with the less 
violent of these cathartics, than to endanger inflammation of the bowels, 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 necessary 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 lumbricoides.-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 
numbers; and two hundred have been known to pass from one patient in a 
week. The worm is supposed to feed upon the intestinal mucus, which is 
usually copious where these parasites exist. It occurs most frequently in 
children, occasionally in adults, and seldom in old persons. Of all the differ- 
ent worms that infest the bowels, this is usually considered as by far the 
most common, and certainly is so with the exception of the tricocephalus. CLASS III.] 
655 
WORMS IN THE ALIMENTARY CANAL. 
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 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, 
or even a longer period, if necessary, and it do not too much debilitate the 
patient.* A little savine may sometimes be advantageously added to the 
infusion, in obstinate cases. Another good preparation is the officinal fluid, 
extract of spigelia and senna, of which a teaspoonful may be given to a child 
two or three years old, and repeated as above. 
If evidences of deranged biliary secretion are presented, or the bowels are too 
irritable 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 bedtime, 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, scammony, or compound 
extract of colocynth. 
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 the 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 Philadel- 
phia. In our Southern States, where the pride of China (Melia Azedarach} 
* R.-Sennae, Spigeliae, aa §ss; Magnesite Sulphat. gij ; Mannse ; Fceniculi gij ; 
Aquas 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 f^iij or f^iv. 656 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 ex- 
crescence 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 some- 
times succeeding when another has failed. 
In nervous cases, advantage may result from combining assafetida, garlic, or 
valerian with the more decided anthelmintics. When the digestion is feeble, 
the vegetable bitters, or chalybeate preparations should be employed in a 
similar connexion, and, in cases of the existence of an excess of acid in the 
stomach or bowels, antacids should also be added. These different remedies 
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 654. 
2. Thread-Worm.-Ascarides.-Maw-worm.-Ascarisvermicularis.-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 to 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 multiply very rapidly. 
Persons of all ages are liable to them; but they are most frequent in children. 
Their characteristic symptom is an itching 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 case all that are exhibited; but the general derange- 
ments 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 convul- 
sions. 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 during the night, and may 
be seen upon the sheets in the morning; and are sometimes discharged in con- 
siderable 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, however 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 produc- 
tive 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. (Heberden, 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 enemata, then to procure their expulsion by cathar- CLASS III.] 
657 
WORMS IN THE ALIMENTARY CANAL. 
tics taken in the ordinary way, or thrown into the bowels. The substances 
most advantageously employed in enemata, are oil of turpentine, aloes, com- 
mon salt, decoction of rue or wormwood, infusion of tobacco, sulphuretted 
waters, the alkaline sulphurets, tincture of chloride of iron, chloride 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 Hopitaux, Sept. 1846.) Some one of these, or some combination 
of them, should be injected daily, with a sufficient quantity of 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 intro- 
duction 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 exter- 
nal application of creasote incorporated with some unctuous matter, have been 
recommended as palliative measures. The frequent local use of cold water 
also allays the itching. It is advised to avoid exposure 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 unfavour- 
able to the existence of these worms, which often cease to appear after that period. 
3. Long Thread-worm.- Tricocephalus 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 in- 
serted 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 evidence of its existence 
during life. The tricocephalus was first noticed as a distinct worm in Ger- 
many, 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 
minuteness, or been confounded with the ascaris vermicularis. It is stated 
in the London Medico-Chirurgical Transactions (vol. xxii. p. 285), 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 disease. 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 pre- 
sent, the remedies adapted to the round worm may be employed. 
4. Common Tape-worm.- Tsenia, solum.-Broad Tape-worm.-Both- 
riocephalus latus.-Tsenia 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 tsenia, 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 658 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
are much more common in some countries than in others, and are compara- 
tively rare in the United States, at least within the limits of my observation. 
Perhaps 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 perform- 
ance of the intestinal functions. 
It is affirmed that the taenia and bothriocephalus cannot propagate in the 
human intestines through their eggs, and require to be transplanted to an- 
other animal in order to become reproductive; so that, if the worm can be 
wholly expelled, there is no danger of an increase from its eggs deposited in 
the bowels. (See Archives Gen., 4e ser., xxix. 206.) 
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 pain, and are often attended with great de- 
pression of spirits oi' 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; dulness 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 vomiting of thin mucus in the mornings; itch- 
ing 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 Oesterrich. Med. Jahrbuch, 1841, No. 2.) 
Sometimes the nervous disturbance amounts to convulsive movements, of an 
epileptiform or hysterical character, and when these occur in a man, with 
signs of abdominal disorder, the possible existence of the worm should be 
suspected, and an investigation of the evacuations made. 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 years to harass the patient, who 
passes from time to time separated joints, or even large portions of the 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 CLASS III.] 
659 
WORMS IN THE ALIMENTARY CANAL. 
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 advised to precede the anthelmintic, for four or five days, 
by a spare diet, consisting 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 an- 
thelmintics, 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 
constitutional disturbance or irritation of the kidneys; because, acting as a 
cathartic, it is less apt to be absorbed. The only inconveniences usually ex- 
perienced 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 insure 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 it 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 ob- 
viate 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, coSee, 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. He found that a drachm or two of the oil, given with a 
little water, morning and evening, for three days successively, was generally 
sufficient to destroy the worm, even in the most obstinate cases, and to cause 
its discharge from the bowels without the aid of purgatives; though the 
administration of a little castor oil, each day about noon, was deemed ad- 
visable. (See N. American Med. and Surg. Journ., ii. 116.) The success 
said to have attended upon the use of small and repeated doses of Venice 
turpentine, which depends for its virtues upon the volatile oil, is confirmatory 
of the statement of Dr. Knox. (Ilufeland's Journal, June, 18'26.) 
A preparation known by the name of Chabert's empyreuniatic oil, which 
obtained great reputation on the continent of Europe in the cure of taenia, 
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 empyreuniatic 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- 660 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 dis- 
coverable in the evacuations, though the cessation of the symptoms proves 
the efficacy of the medicine. The oil is very nauseous, and aromatic addi- 
tions should be made to cover its flavour. 
Much published testimony exists in favour of the bark of pomegranate 
root. The fact that a living tape-worm, 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 recommended to diet the patient strictly, and 
give a dose of castor oil on the preceding 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 repu- 
tation in the treatment of tape-worm. The reports in its favour are too 
numerous 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 conse- 
quence 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. 
An Abyssinian product called koosso has recently attracted much atten- 
tion as a remedy for tape-worm; and, from the numerous reports in its favour, 
there can be no doubt of its great efficacy. It consists of the flowers of a tree, 
and is administered in the form of powder, of which half an ounce is mixed 
with half a pint of warm water, and given in two or three draughts at short 
intervals, in the morning, on an empty stomach. Should the medicine not 
operate in three or four hours, it should be followed by a brisk cathartic. 
For further particulars in relation to it, the reader is referred to the U. S. 
Dispensatory. 
Dr. Kiichenmeister has performed some interesting experiments to ascertain 
the relative poisonous power over the two kinds of tape-worm, out of the body, 
of the different anthelmintics above mentioned, with the following result. A 
decoction of the koosso in milk destroyed the worm in half an hour; oil of 
turpentine mixed with the white of eggs in an hour and a half; root of the 
pomegranate in three hours and a half; and the ethereal extract of the 
male fern in four hours. {Arch. G6n.} 4e ser., xxix. 205.) CLASS III.] 
STRICTURE OF THE RECTUM. 
661 
Tin and Zinc, granulated or in filings, have been occasionally employed 
with success. In order that the worms may be exposed unprotected to their 
mechanical action, they should be preceded by a cathartic. The dose is some- 
what 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. 
Many cases have recently been reported in the journals in which pumpkin 
seeds have been used successfully. The dose is about two ounces, which 
should be taken in the morning, fasting, and followed in an hour or two by a 
dose of castor oil. They may be taken beaten into a paste, or in the form of 
emulsion. 
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 tape-worm {Taenia solium) thirty feet long, which had been dis- 
charged 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. Mr. Whittel has found oxide 
of silver, in the dose of a grain, repeated occasionally, effectual in two cases. 
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 descend again not long afterwards. Dr. 
Cagnola proposed to touch the extruded portion with hydrocyanic acid, in the 
expectation that this poison would destroy 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 introducing this into the rectum, so as to over- 
come the resistance of the sphincter ani. 
Article VII. 
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 dis- 
tinct 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 thickening or other organic derange- 
ment 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 662 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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. AU 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, Bowels.} Death is now inevitable unless from the in- 
terference of art, or unless nature, as sometimes happens, creates a new open- 
ing 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 in the scir- 
rhous state, is usually unequal to the touch, and of an almost cartilaginous 
hardness. In the advanced stages, after ulceration has commenced, there is 
an ichorous discharge of an offensive and peculiar odour, characteristic of can- 
cer wherever met with, and occasional exhausting hemorrhages. 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, con- 
sequent 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 disease 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 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 resorted to for a similar purpose. The only chance of cure is 
afforded by the extirpation of the diseased structure, which is very rarely pos- 
sible, 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 of a sort of crescentic cord, pro- CLASS III.] 
663 
STRICTURE OF THE RECTUM. 
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 network of filaments. 
It may be seated in any part of the bowel, but is most commonly found about 
two or three inches above the anu*. Instances have occurred in which the 
feces, accumulated above the stricture, have by their pressure produced ulcer- 
ation, and thus made their way outward by a new passage. Such a passage 
has been made around the stricture into the portion of the 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 produce 
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 unirritating 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 in- 
creased in size as the passage becomes enlarged. In some instances, the bis- 
toury may be advantageously resorted to, especially when the stricture consists 
of a thin partition, and the symptoms of obstruction are threatening. In the 
circular stricture, which is usually seated about One-quarter or one-third of an 
inch above the anus, M. Robert prefers the use of the Vienna caustic (potassa 
with lime), which may be applied by means of a speculum. (See Am. Journ. 
of Med. Sei., N. S., xix. 512.) 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 Mid.., 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 
going to stool, and an occasional severe spasmodic pain, especially upon the 
application of an 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 tumours. Spasmodic stricture is more apt to at- 
tack the young than the old, and is not commonly attended with that cachectic 
aspect, or general failure of health, which frequently marks the permanent 
organic affection. 
This form of stricture may result from a peculiar irritability of the rectum; 
from disorder in the spinal marrow, or neighbouring pelvic viscera 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. 664 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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. 
The indications in the treatment are, 1. to remove or prevent sources of 
direct irritation to the rectum; 2. to produce a relaxation of the spasm; 3. to 
diminish the morbid irritability of the bowel; 4. to remove any existing spi- 
nal 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 saline 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 en- 
countered 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 nervous stimulants, as valerian and assafetida. In women, 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. 
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 as 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. CLASS III.] 
HEMORRHOIDS. 
665 
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 
irritability, languor, uncomfortable sensations in the head, pain in the loins, 
dyspeptic 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 
sometimes relieved by hemorrhage, sometimes passes off without either this, 
or the production of hemorrhoidal swellings, but most frequently either ac- 
companies or produces tumours, and, if these have existed previously, pro- 
vokes 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 contin- 
uous, 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 pressure. 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, 
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 cellu- 
lar 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 cen- 
tre, 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 tis- 
sue, 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 
unfrequent transformation of that membrane, when prolapsed and exposed 666 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 
attention. At length the patient becomes conscious of a swelling, or a sensa- 
tion 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 uniform. 
During the periods of hemorrhoidal congestion, it increases most rapidly, ac- 
quiring an augmented volume at each successive period, though diminishing 
and sometimes almost disappearing in the intervals. In its ordinary unin- 
flamed state, the tumour has little sensibility, but, when inflamed or strangu- 
lated 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 distressing. Shooting pains ex- 
tend 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 uterus ; 
and difficult micturition is not unfrequently produced. Sometimes the patient 
can neither stand, walk, nor sit with comfort, and finds the horizontal 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 or less extent, sometimes on one side only of the aperture, 
sometimes completely surrounding it, and in the latter case usually presenting 
an unequal outline, as if consisting of several tumours separated hy shallow 
furrows. The consistence and colour of the tumour vary according to its 
character. If varicose, it is of a violet ■'Colour, soft, and more or less remov- 
able 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 spontaneously when 
the straining ceases ; but, after having 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 comparatively easy when 
returned. After a time they descend when the patient walks or stands, espe- 
cially 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 themj CLASS III.] 
HEMORRHOIDS. 
667 
and even the surgeon finds considerable difficulty. Occasionally, in this con- 
dition, 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 
cure. 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 cases 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 and 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 piot 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. * 
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 
insupportable. 
In consequence of chronic inflammation of the hemorrhoidal tumours, and 
of 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 sometimes a thickening of the 
lower 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 much 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 pro- 
duction of dyspepsia with its train of evils, and, besides, call various organs 
into a direct sympathy, which cannot but impair their functions. Paleness, 
emaciation, and mental irritability or dejection, or at least a very uncertain 
condition of the feelings, are among theii' frequent concomitants; and dropsy 
sometimes results from the anemic state of the blood. 
Diagnosis.-The complaints with which piles are most likely to be con- 
founded, 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 in- 
crease and diminution which characterize piles. The latter, moreover, gene- 
rally 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 condi- 
tions are sometimes reversed. Piles are usually distinguishable from pro- 668 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
lapsus 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 circumstances of their origin, and in their uninterrupted progress. 
Causes.-These 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. Grouty and rheumatic irritation, sometimes shows itself 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 
favourable to this disease occasionally descends from the parent to the off- 
spring. 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 dis- 
tension of the hemorrhoidal vessels that results in piles. To the above list 
may be'added all causes of irritation of the rectum, whether direct or indi- 
rect, such a$ acrid purgatives and especially aloes, irritating injections, the 
frequent use of suppositories, acrid alvine evacuations, ascarides, violent jolt- 
ing 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 occasion 
during their evacuation. 
Piles are very rare before the age of puberty, and are most common be- 
tween the thirtieth and fiftieth year. Males are more subject to them than 
females, if we except 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 tendencies 
into injurious action elsewffiere. There can be little doubt that this opinion is 
in some degree true. The hemorrhoidal effort depends on a general disor- 
dered 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 con- 
siderable, 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 mor- CLASS III.] 
HEMORRHOIDS. 
669 
bid 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 ques- 
tion. But, as piles themselves, when severe, sometimes materially interfere 
with the general health, it is necessary to weigh carefully the opposing con- 
siderations, and to strike the balance between them. Should the danger of 
the very serious complaints, above alluded to, seem to outweigh the inconve- 
nience 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 symp- 
toms than to attempt a radical cure; and, in cases in which the latter course 
is pursued, the propriety is obvious of counteracting the morbid tendencies 
by a proper regulation of the diet, and the use of suitable depletory or revul- 
sive means, as bleeding, saline purgatives, and blisters or issues. In all 
instances, however, 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 hesitation. 
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 
cause, should be corrected by saline cathartics, and an antiphlogistic regimen. 
t)ne or two doses of sulphate of magnesia, and a diet exclusively of vegetable 
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 is its removal 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 bedtime so as to ope- 
rate gently in the morning, or, as suggested by Burne, a short time before 
dinner so as to operate before bedtime, and thus allow 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 often 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 670 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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. Acrid secretions should be 
removed by castor oil, and acid in the bowels by magnesia. Irritations in 
the bowels or neighbouring pelvic viscera should be corrected if possible, and 
practices carefully shunned which tend to produce such irritations. 
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 laxatives if required, cures have been 
effected even in very unpromising cases. Care should be taken not to irri- 
tate the rectum by an unskilful introduction of the pipe. Sponging 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 
cute by obviating the tenesmus and straining, which tend so strongly to sus- 
tain and aggravate the complaint. But caution is necessary, in their appli- 
cation, 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 useful. The application of the 
leeches directly to the tumour is not advisable; as the inflammation from the 
bite may be 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 inflammation. When the inflammation is not acute, benefit may sometimes 
be obtained from astringent applications. Ointment of galls with opium may 
be used when the tumours are external; decoction of galls or oak bark, or 
infusion of catechu or kino, when they are internal. If the internal piles 
have protruded, and do not return of themselves, and cannot be returned by 
the patient, the practitioner must endeavour to reduce them by placing the 
patient on his hands and knees, anointing tire 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 tumour within the 
sphincter. Should he not succeed by these means, he may apply cold water 
to the part in order to produce contraction, or 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 CLASS III.] 
671 
HEMORRHOIDS. 
a drachm daily in divided doses. The oil of turpentine has been especially 
praised in obstinate cases of hemorrhoidal flux. Aloes has been highly re- 
commended, and may prove useful, in some cases of passive hemorrhage, by 
stimulating the rectum. 
Copious mucous, or muco-purulent discharges may be treated, if acute, 
simply 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. Linseed oil, given in the dose 
of two fluidounces every morning and evening, is said to have very rapidly 
effected cures. (See Am. Journ. of Pharm., xxiii. 87.) The confection of 
black pepper 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 rectum, as it passes out with the feces, and should not be given during 
acute inflammation of the parts. Sir Everard Home found it very effica- 
cious, 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 use- 
ful, 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 pro- 
bably acts both by its laxative and stimulant properties. Another remedy, 
which appears to operate in the same manner, is black pitch. Dr. Wardle- 
worth 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 hemor- 
rhoids, will prove useful, by its irritant and laxative action, in some cases of 
piles dependent upon relaxation of the hemorrhoidal vessels. A tincture of 
aloes and anise, given in such quantities as to produce several soft stools 
daily, was found highly efficacious by Drs. Pindell and Crockett, of Lexing- 
ton, Kentucky. (W. Am. Med. and Surg. Journ., iii. 193.) Burne recom- 
mends 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. (^Dict. de Med., xv. 211.) Dr. Symonds has known great benefit 
to result from the assiduous use of citrine ointment properly diluted. (Twee- 
dies Syst. of Prad. Medd) 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. Bougies are extolled by different authors; and radical cures 
are asserted to have been frequently obtained by their means. They are par- 
ticularly 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 circumstances 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 caustics 
or the actual cautery, are modes of cure which have had their advocates. But 672 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
this branch of the subject belongs properly to the surgeon. Nitric acid, ap- 
plied with a view to its caustic effect, has recently been highly recommended. 
(See Lond. Med. Times and Gaz., April, 1853, p. 343, and Aug. 1854, p. 184.) 
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 treatment. 
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 mu- 
cous membrane at the anus, and probably owes its exceeding severity and 
obstinacy to the circumstance that it is embraced by the sphincter muscles, 
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 four 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 distressing; 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, whenever the patient 
goes to stool, a violent burning or rending pain, which sometimes amounts to 
insupportable agony, giving rise even to syncope or convulsions. This con- 
tinues for some time after defecation; but at length subsides, leaving only sore- 
ness, 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 possible, though he 
thereby increases the difficulty when the time for an evacuation arrives. Most 
pain is experienced when the feces are hard, but is by no means entirely avoided 
by keeping them in the liquid state. In some eases, 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 CLASS III.] 
FISSURES OF THE ANUS. 
673 
uneasiness. The introduction of the finger or an instrument into the anus 
occasions exquisite pain; and there is almost always great difficulty in intro- 
ducing the finger, in consequence of a spasmodic contraction of the sphincters, 
which is considered by some an essential part of the complaint. 
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, or for cancer; 
but a careful examination of the parts will reveal its nature. The ulcer gene- 
rally 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 or never 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 above 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 con- 
traction of the sphincters constitutes the chief source of difficulty. Unless 
arrested, the disease at length affects the general health, dyspepsia and ema- 
ciation occur, and the patient is worn out by complicated derangements. 
Causes.-1The 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 disturbance. 
Treatment.-1The 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 ob- 
viating mechanical injury in their passage, 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 rec- 
tum. (Diet. de Medd) 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 
accomplished in two or three weeks. (Med. Exam., iii. 552.) Dr. W. P. 
Johnston, of Philadelphia, has employed the same remedy with success. (Ibid., 
iv. 293.) It is probable that kino, catechu, or other astringent extracts, 674 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 in- 
jected. (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. For 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 probably 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 operation, therefore, should be resorted to only after other measures have 
failed. Mr. Richard Quain, Surgeon of the University Hospital, London, 
considers the division of the sphincter unnecessary, having found the affection 
to yield to a longitudinal incision of the mucous membrane through the ulcer. 
The tension of the membrane is thus removed, and the ulcer heals. Mr. 
Quain, though the operation was original with him, ascribes the priority to 
Mr. Copeland. (Lond. Med. Times and Gaz., July, 1852, p. 83.) 
Article X. 
PROLAPSUS ANI. 
Prolapsus ani is a descent of a portion of the rectum or its lining mem- 
brane 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 
intussusceptio, 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 
portion of bowel was two feet. But such incidents as those above men- 
tioned are rare. The affection commonly called prolapsus ani consists of a 
protrusion 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 some other cause, and be- 
comes so swollen and painful as to render reduction impossible, until after 
the inflammation 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 mem- 
brane, have occurred. This result, however, is more to be apprehended in CLASS III.] 
675 
PROLAPSUS ANI. 
cases of eversion of the whole thickness of the bowel, than where the mucous 
membrane only protrudes. The prolapsus sometimes continues long unre- 
duced without serious results; as the parts affected have a wonderful facility 
of accommodating themselves to their new position, and the mucous mem- 
brane takes on the characters of the skin. 
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 
much more efficient, when a relaxation or atonic condition of the sphincters 
coexists. When these muscles are 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, pro- 
ducing 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. 
Treatment.-1The 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 easily accom- 
plished; 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 mem- 
brane 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, warm poultices or injections containing laudanum, and 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 offered; 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 ad- 
hesion between it and the parts with which it is in contact. The first indi- 
cation 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 position, so as to pre- 
vent much straining. To answer the second indication, that is, to obviate re- 
laxation 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 oint- 
ments 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 vegetable astringents, as 
kino, catechu, rhatany, galls, and oak bark, or solutions of the mineral astrin- 
gents, 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. Journ. of Med. Sci.^. S., xv. 546.) In children, 
almost all cases will yield to this simple treatment, with attention to the state 676 
[part it. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
of the bowels as above directed. But in old cases, in which the fibres con- 
necting 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 carefully 
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 adhesion; 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. 
Dr. S. M. Baer, of Baltimore, has invented a chair, which, by supporting the 
parts about the anus during evacuation, is said to prevent the prolapsus, and 
thus ultimately to effect a cure. {Am. Journ. of Med. Sci., N. 8., xxv. 552.) 
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 information on these various points requiring manual inter- 
ference, the reader is referred to treatises upon surgery. 
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 specially to either section of the aliment- 
ary 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 inflam- 
mation often attacks both parts conjointly, constituting gastro-enteritis. This 
is true ; but these affections may be restricted to one portion of the canal, and 
generally have their primary seat in one portion; the other parts being second- 
arily involved. They may, therefore, be considered as especially belonging 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 pathological 
conditions in which this affection originates, are very apt to involve both divi- 
sions of the canal. I place peritonitis in the same category ; as, when gene- 
ral, 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 CLASS III.] 
677 
CHOLERA MORBUS. 
cholera, and cholera infantum. The present article is devoted specially to the 
first of these affections. It is the variety so common as an endemic disease 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 begin- 
ning 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 sometimes 
excruciating, but is relieved after each discharge. In the intervals between 
the paroxysms of vomiting, the patient, though comparatively easy, often ex- 
periences distressing nausea, or a burning sensation in the epigastrium, and 
complains of general languor and exhaustion. The discharges generally con- 
sist at first merely of the ordinary contents of the stomach and lower bowels; 
the matter vomited being either food recently taken, or colourless and often 
sour or acrid liquid, and the dejections fecal. But these are, in the vast ma- 
jority 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 extrem- 
ities, especially of the legs. These irregular muscular movements amount 
sometimes to general convulsions. In favourable cases, the more violent symp- 
toms subside after a few hours, or readily give way to treatment, leaving only 
temporary debility. But occasionally the complaint, either from original vio- 
lence 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 suffer- 
ings 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, irregular, 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 pa- 
tient, if not rescued by remedial measures, sinks in a state of complete ex- 
haustion, retaining his mental faculties not unfrequently to the last. Death 
may occur within twenty-four hours, though more frequently the complaint 
runs on for two or three days, before terminating 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 678 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
rises by the aid of a suitable regimen. Sometimes, however, the debility is 
considerable and protracted, and requires medical interference. Occasionally 
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 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 morbus 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, lob- 
sters, crabs, sour and incompletely fermented liquors, putrid water, &c.; 
excesses at the table, independently of the character of the food; the use 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 ac- 
tion 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 du- 
ring 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 re- 
ferred 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 con- 
tents. 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, CLASS III.] 
CHOLERA MORBUS. 
679 
gastroenteritis, 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 considera- 
tion 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 
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 given 
every half hour, or every hour, according to the urgency of the symptoms. 
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 farinaceous fluids, 
such as solution of gum arabic, 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 administered 
moderately merely to relieve the thirst of the patient. For this purpose, 
also, as well as to quiet irritation of stomach, carbonic acid water, in small 
draughts of about two fluidounces, frequently 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 tolerable. In 
severe cases, or in the advanced stages, when the prostration is great, it is 
often necessary to administer opium more freely than above directed. From 
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 the least 
quantity of opium that will answer the purpose is the best; as, though it is 
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 the 
mercurial 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 less liable to irritate 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, maybe 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 car- 
bonic acid water, commonly called liquid magnesia; and the eifervescing draught 
and cooling drinks should be administered at short intervals. Symptoms of 
gastric inflammation may be counteracted by leeches to the epigastrium, fol- 
lowed by warm fomentations or emollient cataplasms. Intestinal 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 
relied chiefly upon bleeding, leeching, and demulcents. But this is hazardous 
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 fa- 
vour the recommendation of Dr. C. D. Meigs, of Philadelphia, as well as that 
of its original proposer. (TV Am. Med. and Surg. Journ., ii. 419.) Dr. D. 
J. Cain has found great advantage from the use of creasote. (^Charleston 
Med. Journ. and Rev., vii. 145.) 
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 IL 
EPIDEMIC CHOLERA. 
Syn.-Spasmodic Cholera.-India Cholera.-Asiatic Cholera.-Malignant Cholera - 
Cholera Asphyxia. 
This disease appears to have been long known in India; but it 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 Granges, 
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, appeared in the 
Mauritius and the Isle of Bourbon. At the same time, it was slowly advancing 
towards the east and southeast; invaded the Burman dominions; attacked 
Siam, the peninsula of Malacca, and the island of Sumatra; and, in 1820, 
had reached Canton and the Philippine Islands. It was subsequently 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 paused 
for a while before leaving its native soil; and it was not till the year 1821, CLASS III.] 
681 
EPIDEMIC CHOLERA. 
that it appeared 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. Here it again paused; and several years elapsed be- 
fore 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, Dantzic, Berlin, and Hamburg, and showed 
itself in Sunderland, on the northeastern 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 Atlantic, appears to have struck the shores 
of the United States at New York, where the disease broke out on the 24th of 
June. Thence it spread northwardly up the Hudson, and southwardly to the 
Delaware and Chesapeake Bay, reaching Albany on the 3d or 4th, and Phila- 
delphia 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 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 northwestern borders of Asia, was spreading consternation through- 
out 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 disappeared 
entirely in somewhat more than two years from its first visitation. 
In India, however, the disease continued as an endemic, and, at the date 
of the first publication of this work, in the early part of 1847, we had re- 
ceived accounts of its having commenced a new march of desolation in the 
East. Before the close of that year it again entered Europe, and afterwards 
advanced regularly westward, pursuing a course singularly corresponding 
with that of its first invasion, both as to the succession of regions visited, 
and the period of its approach and departure. Setting out from India as 
before, it passed destructively through the cities of Persia, skirted the shores 
of the Caspian, and reached Astracan in July 1847, and Moscow before the 
close of the year. Here its progress was suspended during the winter; but 
in the spring of 1848 it again advanced westward, in June arrived at St. 
Petersburg, in August at Berlin, in September at Hamburg, and crossing 
thence to Great Britain, attacked Edinburgh in October, and London soon 
afterwards. On the ninth of November, a ship with emigrants sailed from 
Havre for New York. At the time of her departure there was no cholera 
either in that port or at Paris, and the crew and passengers were all healthy. 
The vessel had been sixteen days at sea when the disease appeared on board, 
and she arrived with it at the quarantine ground at Staten Island, on the first 
of December. The passengers were landed, and very soon afterwards the 
disease broke out in the neighbourhood. It did not, however, extend beyond 682 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
the quarantine enclosure, and ceased entirely about the beginning of the new 
year. Three deaths occurred from it in the city of New York. Another 
ship, which had left Havre on the second or third of November, without 
cholera on board, was attacked with the disease twenty-six days after leaving 
port, and brought it with her to New Orleans, where she arrived on the 
eleventh of December. Cases of cholera soon afterwards occurred in the city, 
and rapidly multiplied, the weather being at the time very hot, and of course 
favourable to the spread of the disease. From New Orleans it extended to 
Texas, and up the Mississippi, reaching the city of Memphis so early as the 
twenty-second of December, and sweeping over the valley of that great 
stream with unheard of rapidity. It did not, however, surmount the Alle- 
ghanies; and, with the exception of the slight demonstration made in the 
harbour of New York, the Atlantic States remained free from the disease 
during the winter. The epidemic cause, however, was in the mean time pur- 
suing its regular course across, the Atlantic; and, as on the previous odcasion, 
reached our shores in the season following that of its appearance in western 
Europe, though somewhat earlier than in the year 1832. It broke out in 
New York about the beginning, and in Philadelphia about the close of May, 
1849; and while, commencing at the Atlantic coast, it visited many parts of 
our country on this side of the mountains, it seemed to take a fresh start 
from New Orleans, and again spread along the tributaries of the Mississippi 
with fearful violence. In its further progress, it invaded the West Indies 
and Mexico, and, crossing the whole breadth of the continent, reached the 
shores of the Pacific, producing as it went great havoc among the emigrants 
on their way, like itself, to California. It attacked the cities of St. Fransisco 
and Sacramento in October, 1850. In the summer of 1850, and in every 
year since that time, it has occurred to a greater or less extent in various 
parts of the valley of the Mississippi, in which there is reason to fear that it 
has become naturalized; but the section of our country, east of the Allegha- 
nies, with some slight exceptions, remained exempt, from the period of its 
visitation in 1849, until the summer of the present year (1854), when it 
again made its appearance in the epidemic form, having pursued the same 
course as on former occasions, from the Eastern parts of Europe, through the 
north of that continent, to Great Britain, and thence across the Atlantic to 
the United States. 
From the above brief account of the progress of cholera, it will be seen 
that its march is extremely irregular, in relation both to time and direction. 
Sometimes it advances with great rapidity, sometimes slowly, and sometimes 
pauses for a longer or shorter period, giving hopes to the yet unvisited coun- 
tries, that they may escape its ravages. In general, its progress is arrested 
during the winter, to be resumed in the spring; though this is not invariably 
the case; for at Moscow it prevailed through most of the winter of 1830-31; 
and the cold weather did not prevent its spreading along the Mississippi in 
the winter of 1848-49. Though preferably following the course of streams, 
affecting low and damp places, and attacking the filthy and crowded portions 
of populous cities, it is yet absolutely confined to no particular character of 
locality, but shows itself occasionally upon lofty mountains, in the midst of 
sandy deserts, and among the scattered inhabitants of thinly peopled agricul- 
tural districts. No barriers are sufficient to obstruct its progress. It crosses 
mountains, deserts, and oceans. Opposing winds do not check it. All 
classes of persons, male and female, young and old, the robust and the feeble, 
are exposed to its assault; and even those whom it has once visited are not 
always subsequently exempt; yet, as a general rule, it selects its victims 
preferably from among those already pressed down by the various miseries CLASS III.] 
EPIDEMIC CHOLERA. 
683 
of life, and leaves the rich and prosperous to their sunshine and their fears. 
It is exceedingly capricious in the choice of its localities, not unfrequently 
leaving towns and districts in its line of march untouched, and deviating 
apparently from its course to seize upon others, in no important respect dif- 
ferently circumstanced. The period of its duration, in any one spot, is gene- 
rally from one to two or three months; though this is much influenced by 
the season, being shorter for the most part when winter is near. When it 
prevails in the same place more than once, it usually affects fewer persons, 
and is 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, is usually felt in the more or less 
general prevalence of moderate disorders of the stomach and bowels, which 
precede for a short time the appearance of the disease, and continue in 
various degrees to affect a large portion of the population, after it has become 
established. Sometimes there is only a slight derangement of digestion, or 
a simple diarrhoea, or mild dysentery; but very frequently, the premonitory 
affection takes on a more decided character, and, without amounting abso- 
lutely to cholera, approaches it more or less nearly. From this circumstance 
it has received the name of cholerine, adopted from the French writers. 
Cholerine, in fact, often constitutes the first stage of cholera, and in other 
cases is undoubtedly produced by the same cause, operating either more mildly, 
or upon less susceptible subjects. It is 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 is attended with 
febrile symptoms. The alvine discharges are sometimes bilious, sometimes of 
a dirty-white colour and turbid, very much resembling oatmeal gruel. Occa- 
sionally the force of the cause seems to expend itself upon the nervous system, 
and the patient is affected with severe neuralgic pains, and distressing spasms, 
amounting sometimes to convulsions, with little or no evacuation from the 
stomach or bowels. The affection often subsides spontaneously, or yields 
readily to proper treatment; but it is very apt, upon exposure to any exciting 
cause, and even, if neglected, without such cause, to be aggravated into cholera. 
When the epidemic influence has attained an intensity adequate to the pro- 
duction of the full-formed disease, a few cases are first observed, usually among 
the lowest orders of the community. These are soon followed by others; and 
the numbers gradually increase until the pestilence reaches its acme ; when 
it speedily subsides, and ultimately disappears, leaving behind it, for a short 
time, that same tendency to bowel complaints which had heralded its approach. 
The attack often occurs 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 comes 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 is seized with 
vomiting and purging, which are 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, consist of the 
ordinary contents of the stomach and bowels ; but the dejections which follow 684 
[part II. 
are of a whitish colour, thin, and watery, resembling rennet whey, thin gruel, 
or rice water, and, when allowed to stand, separate into a colourless fluid, and 
a white, flocculent, insoluble matter, which subsides. In mild cases, or after 
the subsidence of the severer symptoms, they are sometimes tinged with bile, 
and a little blood is occasionally discharged. In some instances they are 
brown, or of a deep chocolate colour. The matter vomited is generally similar 
to the stools, but is sometimes white and glairy, as if consisting of mucus, and 
has an acid reaction. The evacuations are usually forcibly ejected, but with- 
out apparent straining, or much voluntary effort, and are often very copious. 
The cramps usually begin in the extremities, affecting especially the calves 
of the legs, but subsequently extend to the muscles of the trunk and abdomen. 
They are excruciatingly painful, and almost incessant, the muscles gathering 
into hard board-like knots, one contracting as another relaxes, and often dis- 
torting the fingers and toes in various directions, according to the particular 
muscle or muscles affected. 
At the same time the pulse sinks rapidly; the extremities become cold ; 
the features shrink ; the patient is restless, and complains of intense thirst; 
the whole .surface is bathed with sweat; the urine is scanty; and the skin be- 
gins to assume a bluish, leaden, or violet colour, which extends more or less 
over the body, but is peculiarly striking in the face, hands, and feet. If the 
complaint is not arrested, the evacuations become still more copious and watery; 
the thirst insatiable, with a burning heat at the epigastrium; the pulse fre- 
quent, feeble, and sometimes scarcely perceptible; the breath cool; the tongue 
cool and pale, though still moist; the skin unusually cold, shrunken, and in- 
elastic, so that when pinched into folds it does 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 are 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 respiration short, hur- 
ried, and oppressed; and every symptom indicative of extreme prostration. 
The patient is often exceedingly restless, and calls incessantly for cold water 
or ice, and for fresh air. With all these changes, the external sensibility often 
remains acute, so that mustard plasters and other irritants produce severe pain; 
and, though cold to the touch, the patient frequently complains of a distress- 
ing heat over the whole surface. The intellect is generally sound, but more 
or less obtuse; and, in all his moral relations, the patient evinces an extraordi- 
nary apathy, being insensible alike to his own danger and prospects, and to 
the feelings of those connected with him. 
The case is now on the borders of complete collapse. But a step further, 
and the pulse becomes quite imperceptible; a feeble oscillatory movement only 
of the heart is discoverable upon auscultation; the blood stagnates in the capil- 
laries; a wound of the surface yields no blood, and little or none follows the 
opening of a vein; the features and whole body are so shrunken that the pa- 
tient can scarcely be recognized by his friends; the bluish or purplish colour 
often pervades the whole surface; the voice is 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 countenance calm or 
quite inexpressive ; and the whole aspect of the patient that of utter helpless- 
ness. The reduction of temperature is such that the thermometer, with its 
bulb placed under the tongue, sinks often to 90°, and sometimes as low as 80°, 
or even 77° F. The body has the appearance of death except the eyes, which 
sometimes retain an expression of intelligence, and seem as if they were look- 
ing out of a corpse. But even these are often half closed, glazed, and inani- 
LOCAL DISEASES.-DIGESTIVE SYSTEM. CLASS III.] 
EPIDEMIC CHOLERA. 
685 
mate. In some instances, considerable muscular strength remains, and the 
patient suddenly rises up from bed with an expiring effort, and falls lifeless. 
There is a total suspension of the urinary secretion. The evacuations some- 
times continue till the close, and are at last involuntary. Sometimes, how- 
ever, they cease entirely for a considerable time before death. The same 
difference is observable in relation to the cramps, which, in some cases, do not 
end even with life, the muscles remaining stiff and contracted in the dead body. 
Intelligence is sometimes retained till within a few moments of the close. In 
other cases, a period of stupor precedes death. The fatal issue sometimes occurs 
in four or five hours from the commencement of the attack, though more 
frequently life is protracted for one, two, or three days. The mean duration 
of fatal cases, according to the report of the Registrar-general of England for 
the year 1848-9, was about 49 or 50 hours. 
The complaint is susceptible of a favourable change, either spontaneously 
or under treatment, at any stage, even in that of collapse. If it is arrested 
early, the patient sometimes enters into a speedy convalescence, without any 
subsequent embarrassing symptoms, though not unfrequently diarrhoea and 
other evidences of gastro-intestinal irritation continue for a longer or shorter 
period. But, if collapse has begun before the turn of the disorder, the pa- 
tient has still great dangers to encounter, and the progress of recovery, when 
it takes place, is often very tedious, and liable to frequent interruptions. One 
of the most favourable symptoms, in any stage of cholera, is the appearance 
of bile in the evacuations. In the cases of collapse, after the system has 
begun to react, a gradual restoration of the suspended functions is observed; 
the pulse returns, the skin becomes warm, the pallor or blueness of face yields 
to a red flush, the secretion of urine and bile recommences, the vomiting 
diminishes; but the oscillation extends frequently into a febrile excitement; 
severe headache is experienced; the abdominal pains, thirst, loathing of 
food, and diarrhoea continue; and convalescence, even in favourable cases, 
does not set fairly in until after several days of doubt and discomfort. 
Sometimes a relapse follows the temporary excitement, and the patient 
sinks with all his former symptoms. Much more frequently, the febrile 
state continues, 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 assumes the remittent type, and ultimately becomes 
intermittent. Eruptive affections, resembling those of scarlatina, rubeola, 
erythema, &c., occasionally diversify the stage of reaction. They are some- 
times accompanied with wheals, like those of urticaria, but without the itch- 
ing. Pneumonia, bronchitis, and pleurisy also not unfrequently occur, but 
so masked by the low state of the system, and the gastro-intestinal irritation, 
as often to escape the notice of the practitioner, unless upon his guard. But 
the most dangerous affection, in this stage of cholera, is perhaps that of the 
brain, characterized by headache, drowsiness, low delirium, stupor, coma, 
subsultus tendinum, and sometimes convulsions or paralysis. In its severe 
forms, it is almost always fatal. The convalescence from these secondary 
disorders is often protracted for months, and sometimes even for a year or more. 
The course of the symptoms in cholera is not always uniform, nor exactly 
as above described. Sometimes the spasms are comparatively trifling or 
altogether absent; sometimes they constitute the chief feature of the case, to 
the exclusion of the ordinary evacuations. In occasional instances, the com- 
plaint is ushered in by universal and violent convulsions. Cases have been 
frequently observed, in which fatal collapse supervened without vomiting; 
and others are on record, in which there was neither vomiting nor diarrhoea, 686 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 occurs with little or no diarrhoea. Though 
in general there is 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 are not unfrequent, in 
■which the patient passes almost immediately into that state, and dies appa- 
rently under the first blow. The bluish aspect of the surface, so characteristic 
of cholera, is not present in all cases, not even in all those which end fatally. 
Instead of the sinking pulse, so common even in the onset of the disease, the 
circulation is sometimes little affected for a considerable time; and, in some 
cases, febrile symptoms, with a strong and excited pulse, appear in the first 
stage. The intellect, usually correct, though obtuse, is in some cases clouded 
almost from the commencement; and instances have occurred in which de- 
termination of blood to the head, and 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 exhibits four distinct stages, the observance of which is important in a 
practical point of view. The first is the forming stage, consisting of a simple 
diarrhoea, or of more or less of those derangements described under the head 
of cholerine. The second is that in which the symptoms of cholera are de- 
cided, but the system has not yet sunk into complete prostration, and the 
circulation is distinctly observable, both in the larger vessels and capillaries. 
The third is the stage of collapse, already sufficiently described. The fourth 
is that of reaction, in which the characteristic symptoms of cholera have given 
way to local inflammations or irritations, and to general fever. All these 
stages do not by any means occur in all cases. The disease is often arrested 
in the first or second, or proves fatal in the third, without ever reaching the 
fourth; and sometimes the second or even third stage comes on, without the 
known existence of those ordinarily preceding it. 
The Evacuations.-It has been stated that the peculiar choleric evacua- 
tions, whether from the stomach or bowels, consist of a colourless liquid, 
holding.in suspension a white flocculent matter, which subsides on standing. 
This insoluble matter, formerly supposed to be coagulated albumen or fibrin, 
was found by Dr. Boehm, of Berlin, to consist mainly of epithelial cells, in 
their various stages of developement, separated or adhering together; and his 
statements have been confirmed by subsequent microscopic observers. The 
clear liquid is water holding a very small proportion of saline and organic 
substances in solution. Of the salts, chloride of sodium is by far the most 
abundant. There is also in the dejections, according to Dr. Guterbock, a 
little carbonate of soda, with salts of lime and magnesia, but none of potassa. 
A little albumen may usually be detected by the agency of heat and nitric 
acid; but the quantity is insignificant. According to Mialhe, there is a con- 
siderable proportion of a principle which he calls albuminose, analogous to 
albumen, but differing from it in being uncoagulable by heat or the acids, 
while it is precipitated by alcohol, corrosive sublimate, tannic acid, &c. (See 
Am. Journ. of Med. Sci., N. 8., xviii. 257.) The stools of cholera are said 
always to have an alkaline reaction. The evacuations from the stomach differ 
from them mainly in being slightly acid, and in containing a smaller propor- 
tion of solid matters. Guterbock states that the former contain somewhat 
over 98 per cent, of water, the latter 99 per cent. {Ibid., xxi. 198.) 
The urine appears, from the observations of Dr. J. W. Begbie, to be of 
diminished density, and to contain in general albumen and bilious colouring CLASS III.] 
EPIDEMIC CHOLERA. 
687 
matter, with the ordinary salts, but little or no urea. When examined with 
the microscope, it uniformly exhibits the presence of epithelium, of different 
forms, from all parts of the urinary passages, and even from the tubali urini- 
feri of the kidneys. It presents these characters when it begins to reappear, 
after its almost total suppression in the prostrate state. If the case go on 
favourably, its normal condition returns in a day or two. (Ed. Month. Journ. 
of MM. Sci., Nov. 1849, p. 1207.) 
The air expired in the state of collapse contains much less carbonic acid 
than in health. This in some degree explains the great coldness so charac- 
teristic of the collapse of cholera. 
The Blood.-The character of the blood varies with the stage of the dis- 
ease. At an early period, nothing abnormal has been observed; in the stage 
of reaction, it often contains an excess of fibrin, consequent on the develope- 
ment of inflammation. It is during the collapse, or in the state approaching 
it, that its composition has been most carefully investigated. In relation to 
this composition very discrepant statements have been made. The results 
here given are those obtained by the most accurate observers, among whom 
may be particularly mentioned, M. Becquerel, and Drs. R. D. Thompson, 
Gairdner, Garrod, and Wm. Robertson. According to the last-mentioned 
reporter, the blood was found in the early stage to be defective in red cor- 
puscles and somewhat lighter than in health, though the proportion of albu- 
men was somewhat above the healthy medium. This fact would tend to 
show that anemic persons are most liable to be attacked. (Ed. Month. Journ. 
of Med. Sci., Sept. 1853, p. 247.) The blood in the collapse of cholera, 
whether from the veins or arteries, is darker, more viscid, denser, and less 
coagulable than in health. It does, however, usually coagulate upon stand- 
ing, and separates into serum and crassamentum; but the latter has little 
firmness, and the former is in smaller proportion, considerably heavier, and 
much more deeply coloured than ordinary. As might be inferred from the 
character of the alvine evacuations already referred to, the quantity of water 
in the blood is much diminished, while that of the solids is of course propor- 
tionably increased. The red corpuscles are increased in larger proportion 
than the other constituents. From 140 parts in 1000, its highest normal 
proportion, it rises, according to Dr. Garrod, to 166 or 171. The proportion 
of fbrin cannot be accurately ascertained in consequence of its altered cha- 
racter, and imperfect coagulability. The albumen is augmented in relation 
to the water of the serum, as might be inferred from the fact, that the watery 
evacuations contain but very little of this principle. The salts, contrary to 
what was formerly believed, are also increased relatively to the whole bulk 
of the blood; but the soluble are less so than the insoluble, as must neces- 
sarily happen from the amount excreted with the gastric and intestinal dis- 
charges. Urea was found in the blood by Dr. O'Shaughnessy; but, from 
the experiments of Dr. Garrod, it appears to be in much smaller proportion 
in the collapse than early in the stage of reaction. At the time that the 
secretion of urine is suspended, and the urea of course ceases to be thrown 
off, it ceases also to be produced, in consequence of the failure of the organic 
processes which generate it in health; but, when reaction takes place, its pro- 
duction recommences before the kidneys are able fully to resume their func- 
tion, and it now consequently accumulates in the blood. Hence, possibly, 
in some degree, the coma often presented at this period of the disease, and 
the general tendency to inflammations. Becquerel found a very greatly in- 
creased proportion of the extractive and fatty matters. (Arch. Gen., 4e ser., 
Dec., xxi. 199.) The blood, which in the healthy state has an alkaline reac- 
tion, is said to be sometimes acid in cholera. 688 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
An indisposition has been noticed in the black blood of cholera to become 
reddened on exposure to the air. This has been ascribed to a deficiency of 
the saline constituents of the blood, which, according to Dr. Stevens, are 
necessary to its conversion from venous to arterial; but some doubt is thrown 
upon this explanation, as also upon the correctness of the therapeutical deduc- 
tion that saline substances should be used in the treatment of the disease, 
by the ascertained fact, that the proportion of salts in the blood is increased 
instead of being diminished. 
Anatomical Characters.-After respiration and the action of the heart have 
ceased, spasmodic movements of the muscles are still sometimes observable; 
and it is a remarkable fact, asserted by many observers, that when death 
occurs suddenly in the cold stage, the temperature of the body not unfre- 
quently rises after all signs of life have ceased, and the warmth continues 
until cadaveric rigidity begins. The appearances upon dissection vary, ac- 
cording as death has taken place in the stage of collapse, or in that of reaction. 
When it is very speedy, it is said that sometimes no morbid changes whatever 
are observable. The following phenomena are ordinarily presented after 
death in the collapse. 
The whole arterial system is emptied of blood, with the exception of a few 
clots in the aorta and left side of the heart. The venous system, on the con- 
trary, is distended, especially the large veins and right side of the heart, 
which is 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, 
exhibit signs of venous injection; and large ecchymoses are frequently found 
in all the parenchymatous glands. The vessels of the lungs, however, gene- 
rally contain little blood; and the spleen is sometimes remarkably small and 
dry. When the abdomen is opened, the peritoneum is observed to be dry, as 
in fact are the serous membranes generally; and the small intestines have a 
rose or violet colour, owing to the venous injection of the inner coat. Some- 
times, however, the serous surface of the bowel is covered with a very'delicate 
layer of viscid matter, rendering it somewhat adhesive; and the same condi- 
tion is occasionally noticed in the pleura, and more rarely in the pericardium. 
The mucous membrane, throughout nearly its whole extent, is usually more 
or less reddened, and the parietes of the bowels are somewhat thickened, in 
consequence of this venous injection. Patches of ecchymosis are also fre- 
quent in their coats. Enlargement of the intestinal follicles, and eleva- 
tion of the elliptical patches are very commonly met with; but in some cases 
the mucous membrane is throughout of the natural colour, and there is no 
abnormal developement of the mucous glands. In many cases, an eruption of 
minute semi-transparent vesicles has been noticed, disappearing upon punc- 
ture, very closely arranged, and extending from the duodenum to the ileo-cmcal 
valve, and even into the colon. These have been considered as morbidly devel- 
oped follicles; but, according to Dr. Horner, they are altogether distinct from 
that structure, and are formed by a mere elevation by a serous fluid of the 
epithelium of the mucous membrane. (Am. Journ. of Med. Sei., xvi. 289.) 
The intestinal mucous membrane is frequently coated, to a greater or less 
extent, with a layer of a whitish or grayish matter, apparently identical with 
the flocculent substance deposited by the evacuations when allowed to stand. 
A similar coating is sometimes found in the stomach. The whole alimentary 
canal is distended with the same whitish liquid of which the evacuations con- 
sist, often mixed with a dark-reddish or chocolate-coloured liquid, which 
probably owes its colour to effused blood. A glairy mucus sometimes exists 
in the stomach, more or less adherent to the mucous coat. The texture of CLASS III.] 
689 
EPIDEMIC CHOLERA. 
the membrane is seldom materially altered in this stage. The brain, spinal 
marrow, and nervous ganglia are little changed. The lungs are healthy in 
appearance, except that they are sometimes edematous, and contain a frothy 
liquid in the bronchial tubes; and the parenchyma of the liver and kidneys 
exhibits no other irregularity than an occasional venous engorgement. The 
gall-bladder is usually filled with a viscid, not unhealthy bile. The bladder 
is often very much contracted, and contains little or no urine. The mucous 
membrane of the pelvis of the kidneys, ureters, and bladder often exhibits 
the same consistent coating that was found in the bowels. 
Microscopic investigations have thrown much light on the pathology of 
cholera. It has been already stated that the white flocculent deposit in the 
evacuations from the stomach and bowels, has been ascertained to consist 
mainly of the disintegrated epithelium of the alimentary mucous membrane. 
The same observer to whom we were originally indebted for this fact, Dr. 
Boehm, of Berlin, ascertained that the whitish layer which is often found 
covering the surface of the membrane, and to which reference has been made 
above, is of the same character. It is, indeed, nothing more than the epi- 
thelium, detached to a greater or less extent from the basement membrane, 
and adhering loosely to the bowel. This observation has been confirmed by 
a committee of the College of Physicians of Philadelphia, appointed to inves- 
tigate the condition of the mucous membrane of those dying of cholera. 
They found the epithelium of the membrane, in all cases, either entirely de- 
tached, or adhering loosely as a pulpy layer, mixed with mucus or an albu- 
minoid substance. The white matter contained in the prominent solitary 
glands, is probably the same epithelial tissue detached from the surface of 
the follicles. The villi are also denuded of epithelium.* But this derange- 
ment of the mucous epithelium is not confined to the lining membrane of the 
bowels. By an examination of the character of the cells in the discharges, 
it has been found to affect, more or less, the whole of the alimentary canal, 
from the fauces to the rectum. (Burnett, Am. Journ. of Med. Sei., N. S., 
xviii. 283.) In the account of the urine and of the urinary mucous mem- 
brane in cholera, it was stated that the former contained epithelium from all 
parts of the urinary passages, and that the latter, whether of the kidneys, 
ureters, or bladder, exhibited the same consistent coating which is found in the 
bowels. This has, in like manner, been ascertained to consist of detached epi- 
thelium ; and even the tubuli uriniferi are found gorged with imperfectly de- 
veloped epithelial cells. Professor Walther, of Kieff, in Russia, has extended 
these investigations to the bronchial mucous membrane, and discovered in the 
frothy fluid found after death in the air passages, large quantities both of the 
flat epithelial cells of the pulmonary air vesicles, and of the cylindrical cells of 
the bronchial tubes; proving that the epithelial lining of these tubes, as well as 
that of the air vesicles, is very much disturbed. (Arch. G^n., 4e ser., xxiv. 167.) 
After death in the stage of reaction, the phenomena are entirely different 
from those of the collapse, but vary with the length of time which has 
elapsed from the commencement of that stage. The bladder has now re- 
sumed its dimensions, the viscid condition of the peritoneum, if previously 
existing, has disappeared, the venous injection has partially or wholly given 
way, the blood has lost some of its blackness and viscidity, though still not 
restored to its healthy state, and the rice-water contents of the bowels have 
* See the Report of the Committee in the Summary of the Transactions of the College 
of Physicians of Philadelphia, vol. iii. p. 85. The committee consisted of Drs. Samuel 
Jackson, John Neill, Henry H. Smith, and Wm. Pepper. Dr. Neill made the requisite 
anatomical injections and preparations. 690 
ROCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
given place to bilious and bloody fluids. Instead of the dark shade of ve- 
nous congestion, there is now the vivid redness of unequivocal inflammation 
in the alimentary mucous membrane, which is also sometimes softened or 
otherwise changed; and the mucous follicles exhibit marks of incipient 
ulceration. Lesions in the various nervous centres and their investing mem- 
branes, such as might be expected from the symptoms during life, and not 
unfrequently evidences of inflammation of the lungs, are observed. 
Causes.-The essential and specific cause of this form of cholera is un- 
doubtedly a peculiar epidemic influence. Various circumstances increase the 
susceptibility of the system to this influence; and many others hasten the 
attack, or call into operation a tendency originating in the specific cause, 
which without them might remain quiescent, and ultimately pass away. 
The former may be considered as predisposing, the latter, as exciting causes ; 
but neither the one set nor the other, nor both combined, are alone adequate 
to the production of the disease; while the epidemic influence is 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, the 
presence of ozone in the air, and peculiar electrical states of the atmosphere; 
but no facts exist to prove anything more than a mere accidental connexion 
between these circumstances and the appearance of cholera, and nothing cer- 
tainly to authorize the suspicion, that they stand 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 appears in ships at sea, in sandy deserts, and in the depths 
of a Russian winter. Chemical analysis, and the closest examination by the 
senses, have been 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 exhibits from every general rule of government-would 
seem to have some analogy with the uncertainty of will, which often charac- 
terizes animal migrations. In opposition to this hypothesis, the fact has been 
advanced, that the cause of cholera, whatever it may be, withstood the seve- 
rity of the winter at Moscow; but this has less force when we consider the 
uniform heat maintained by the Russians in their vast houses, so that the 
supposed animalcules might be conceived not only to live, but even to pro- 
pagate within the walls of a large city. The spread of the cause of cholera 
in opposition to winds, may also be thought to imply some inherent power 
of movement in the cause, such as belongs to animals. Another interesting 
fact, in its bearing on this point, is the influence of elevation on the operation 
of the cholera cause; the mortality from this disease being inversely as the 
height of the region affected.* The cause, if animalcular, would be apt pre- 
ferably to occupy the lower elevations for two reasons, first that less effort is 
requisite to maintain the position, and secondly that the organic ingredients of 
* In the Registrar-general's Report on cholera in England, for the year 1848-9, it 
is stated that the mortality, in the 19 highest districts, was 0.33 per cent, of the popu- 
lation, while in the 19 lowest it was 1 per cent., or three times greater; and, notwith- 
standing various disturbing influences, this inverse ratio was observed with remarkable 
exactness, even with differences of elevation not exceeding 20 feet. (See Brit, and For. 
Med.-Chir. Rev., July, 1852.) CLASS III.] 
EPIDEMIC CHOLERA. 
691 
the atmosphere which may be supposed necessary to support insect life are 
here most abundant. Still, it must be confessed that the opinion is entirely 
without proof; as these animalcules have never been detected. Equally with- 
out proof, though not without some plausibility, is the doctrine put forth and 
supported by Dr. Cowdell, that the disease has its origin in invisible atmo- 
spheric fungi. The reader need scarcely be told, that much interest was some 
time since excited by the asserted discovery of the choleric fungus in the air 
and the water of the vicinities where the disease prevailed, and in the evacu- 
ations of cholera patients; nor that this supposed discovery has been since 
entirely exploded by more accurate investigations. This epidemic influence 
is more analogous, in its movements, to that which produces the epidemic 
catarrh or influenza than to any other known cause of disease; but it differs 
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, how- 
ever 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 travels 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 exceeds the possible rapidity of 
human progression; 3. that its occurrence often succeeds the arrival of an 
infected ship, caravan, or corps of marching soldiers; and 4. that its attack 
is not general in the beginning, but, whether in a city or particular family, 
one or a few are seized at first, and then others successively, as if the cause 
had passed from individual to individual. But it will be perceived that these 
are not proofs of contagion, but only evidences, so far as they go, of the pos- 
sibility, 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 
prefer the course of streams, this may well be in consequence of the known 
affinity of its cause for low, damp, and marshy situations; if it is observed 
especially along the routes of inland trade, this may be owing to the circum- 
stance, that the largest and most conspicuous towns, which it is apt to select, 
are upon these routes, while remote spots which it also visits are less open 
to observation; if it pass from an infected port to other transmarine ports 
between which there is commercial intercourse, the fact could scarcely be 
otherwise if it travel at all, so intimately are all parts of the world associated 
in the meshes of a universal traffic; if its arrival is often preceded by that 
of a ship or of travellers from an infected place, this may well be the result 
of accident, and very often no such connexion can be traced, while inter- 
course of the kind is constantly carried on, without the conveyance of the 
disease; and, finally, if it sometimes attack 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 is not always true of cholera, 
which occasionally prostrates multitudes at one blow. The case made out 
by the contagionists, therefore, fails of adequate proof. There are circum- 
stances, moreover, in the course of cholera, which cannot be explained upon 
their hypothesis. If propagated by contagion, why should the disease at one 
time march with an awful rapidity, and at another halt for years upon the 
confines of countries, open to a constant intercourse with the infected terri- 
tory? Why should it suddenly seize upon a certain district, rage fiercely for 
one or two months, and then leave it altogether? Why should it attack large 
cities, and often let the surrounding and closely associated rural villages go 
free? How, in fine, does it happen that a distinct line is sometimes drawn 692 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
between the infected and uninfected neighbourhoods; that a low damp spot is 
desolated, while a neighbouring height is in safety; that even the upper and 
lower stories of the same house should be in opposite conditions in this respect; 
while in all these cases there is 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 differ- 
ent products in every way into the system, altogether without success. The 
sucking infant has failed to receive the disease from its mother. Physicians 
and other attendants upon the sick are 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 escape 
altogether. Individuals affected with the cholera do not become centres of a 
new infection, when removed to healthy situations. Some few instances have 
been adduced in opposition to this statement; but their force is entirely lost 
in the overwhelming numbers of those which might be advanced in support 
of it; and the very incidents so much relied on are, in fact, either misinter- 
preted, or offer only such coincidences as happen in all epidemics, and have 
led to the belief, at one time or another, in the contagiousness of every epi- 
demic disease, even of influenza. When the disease invades cities, it very 
generally attacks individuals in quick succession, at distant points, and without 
any previous communication. Thus it acted in Londonf in 1848, in Phila- 
delphiaj in 1849, and in Memphis§ on the Mississippi in December, 1848. 
The facts above given are, I think, sufficient to prove that the disease is in 
no degree contagious. 
Perhaps it may be thought, on first view, that the occurrence of cholera at 
New York and New Orleans, in December, 1848, affords proof of its propa- 
gation by contagion. I think that exactly the reverse is the case. The reader 
is requested to revert to the short history of those two invasions of the disease 
already given. A ship sails from Havre for New York; the people of the for- 
mer town, and her own crew and passengers being quite free from the disease. 
When sixteen days at sea, she is attacked with cholera. Assuredly, the dis- 
ease could not have arisen, in this instance, from contagion. Even the six- 
teen days, without claiming a longer exemption from any possible exposure, 
are too long a period of incubation to admit of this idea. She arrives at the 
quarantine ground and lands her passengers. A few persons are attacked with 
cholera in the vicinity. But, according to the report of the attending physi- 
* In the summer of 1850,1 was in Stockholm; and at that time there was not a case 
of cholera in that city, or, so far as was known, in all Sweden. It had, however, 
reached the opposite coast of Finland in its westward march from Russia. The most 
rigid quarantine regulations were inflexibly enforced to prevent communication with 
the places where cholera prevailed, sufficient to exclude any contagious disease, even 
smallpox. I had occasion to leave Sweden, and was absent for a month in Russia, 
and other parts where cholera more or less prevailed. On my return, though the 
steamboat in which I was a passenger had no case of cholera on board, and had never 
had any, yet, as she came from a port supposed to be infected, she was placed in 
quarantine in the bay more than twenty miles from Stockholm, and none of the passen- 
gers were allowed to go beyond the limits of a small uninhabited island, which consti- 
tuted the quarantine ground. Here I remained till the boat returned to Prussia. Yet 
at that very time the cholera had broken out in Stockholm, and soon raged with great 
violence. It had passed over the gulf directly from Finland, wholly regardless of the 
legal obstacles. (Note to the fourth edition.) 
f Parkes, Lond. Med. Gaz., July, 1849, p. 157. 
+ Condie, Am. Journ. of Med. Sci., N. S., xix. 457. g Shanks, Ibid., xviii. 13. CLASS III.] 
EPIDEMIC CHOLERA. 
693 
cian, it was not the individuals most exposed to the sick who were especially 
attacked.* Nor did the disease spread in Staten Island beyond the boundaries 
of the quarantine, though more than one hundred of the passengers scaled the 
walls, and were distributed in the villages around. Three cases only occurred 
in the city of New York, one of which was in a crowded and filthy house con- 
taining two hundred inmates, among whom the disease did not spread.f In 
a short time, the disease disappeared both from Staten Island and the city. 
These facts appear to me to be incompatible with the idea of contagion. Cer- 
tainly, there is no other contagious disease which would have pursued the 
same course. It may be said that the contagion is inoperative in cold weather. 
If so, it is the only known and admitted contagion that is so. Again, it may- 
be said that the contagion is effective only in certain favourable conditions of 
the atmosphere. The same reply may be made, that the fact is true of no 
other. At the utmost, all that the advocates for contagion can claim from the 
above incidents is, that the disease has an extremely feeble power of propaga- 
tion, which can operate only under circumstances peculiarly propitious to it. 
But what of the vessel which sailed from the same French port to New Or- 
leans ? In this, the passengers were not attacked until they had been at sea 
twenty-six days. It is utterly impossible that they should have brought the 
disease with them from Europe. On their arrival at New Orleans, the cholera 
broke out in a very few days, and with a fearful rapidity spread not only through 
that city, but through the valley of the Mississippi. Never did contagion pro- 
pagate itself so rapidly as this. If this was the cause of the spread of cholera 
on that occasion, it must be infinitely the most contagious disease that was ever 
before known, immeasurably more so than smallpox, itself perhaps the most 
contagious of all diseases, flow can this idea be reconciled with the incidents 
at New York? To believe that cholera was propagated by contagion in these 
two instances, is to believe that it is at once the most and the least contagious 
of all known maladies. How then, it may be asked, can the occurrences on 
these two occasions be explained ? Simply, thus. The cause of cholera, 
whether organic or inorganic, is self-propagating. In favourable states of the 
air, it has the property of producing its like, and that with the rapidity of 
animalcular reproduction. The two vessels, departing from a healthy port in 
Europe, entered at a certain period of their passage the cholera atmosphere, 
which, in the regular progress of the epidemic, was making its way westward 
over the Atlantic. With this atmosphere, impregnated with the germs of the 
cholera cause, the whole capacity of the two vessels was thoroughly imbued. 
They outsailed the advancing column of aerial poison, and carried the germs 
of it with them to the places of their destination. At Staten Island, these 
germs propagated in the air; but the reproduction soon ceased, either through 
the influence of cold, or from the want of a due medium for the process. At 
New Orleans, on the contrary, finding favouring influences in the hot weather, 
and probably in the state of the atmosphere, the cause multiplied with vast 
rapidity, and, being carried by the steamboats up the river, diffused itself in 
the towns which stud the banks of that river and its tributaries. It did not 
cross the Alleghanies, because there were no boats to convey its aerial germs 
over the hills. Individuals, in numerous instances, brought the disease with 
them to the villages on this side of the mountains, and died with it; but they 
did not propagate it, because it is not capable of being propagated by contagion. 
It is not impossible that individuals, fresh from a highly charged cholera atmo- 
sphere, may carry the germs with them, in their clothing, for a short distance, 
* See a communication by Dr. Sterling, in the New YorkJourn. of Med., N. S., iii. 25. 
f New York Journ. of Med., N. S., ii. 97. 694 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
and thus be the means, in some rare instances, of spreading the disease; but 
this is not contagion. The effect would ensue as well from a healthy as from 
a diseased person. It will be remembered that, in the spring of 1849, the epi- 
demic attacked the Atlantic sea-board, and thence spread into the interior. This 
was in the regular course of its progress. The column of morbific influence 
through which the ships had passed, and which they had outsailed, had now 
reached our continent. I have dwelt longer on this subject, because of its 
importance. A belief in the contagiousness of cholera has done vast mischief 
by bringing our fears into conflict with our duties to the sick; and it is, beyond 
all calculation, important to the interests of humanity, that this dread of con- 
tagion, if really unfounded, should be believed to be so. 
The predisposing causes are very numerous. Whatever is calculated to 
diminish the vital energies, or to reduce the vital actions below the standard 
of health, may be ranked among these causes. Not only are debilitated in- 
dividuals in greater danger when labouring under the disease; they are 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 predispose to cholera. 
Nor are the exciting causes less numerous. Indeed, the two sets of causes 
often act interchangeably, those which in some cases excite the disease, pro- 
ducing a predisposition to it in others, and vice versa. Whatever makes a 
sudden and powerful impression on the system, and whatever irritates the 
stomach, may convert a tendency to cholera into its reality. One of the most 
common exciting causes is a sudden exposure to cold when the body is warm 
and perspiring. Hence, in part, the injurious effects of the night air and of 
damp places. Sudden and strong emotions often bring on an attack. Indi- 
gestible food, such as unripe fruit and crude vegetables; excessive eating 
even of wholesome food; unwholesome drinks, including impure water, cider, 
poor wines, and imperfectly fermented liquors of all kinds; very cold drinks 
and ices, taken too freely, especially when the body is heated; purgative 
medicines, particularly those of a drastic character; these, and many other 
causes, operating in a similar manner, are capable of exciting the disease in 
persons previously exposed to the specific influence. 
From a combination of these causes it is, that the ravages 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 
almshouses, the inhabitants of crowded and filthy suburbs, or of miasmatic 
districts, soldiers fatigued by long marches, 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 has almost always 
been the lowest, dampest, most crowded, and most filthy sections that have 
suffered first and most. In general, the well provided classes of society have 
suffered little in any country, though there have almost everywhere been 
occasional exceptions to this rule. The ravages in different countries or sec- 
tions of the globe have borne, in general, an inverse proportion to their well- 
being. Thus, Asia has suffered more than Europe, and Europe more than 
North America. CLASS III.] 
695 
EPIDEMIC CHOLERA. 
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, 
ascribing the phenomena to the combination of a sedative action of the spe- 
cific cause upon the functions pf organic life, with an irritant action upon 
those of animal life. (Hodge, Am. J. of Med. Sci., xii. 386.) 
That an irritation of the stomach and bowels exists in cholera can scarcely 
be doubted. How else can we explain the great abdominal uneasiness, the 
frequent burning pain in the epigastrium, the antecedent diarrhoea, nausea, 
and vomiting, and the unequivocal evidences of positive inflammation which 
are 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? Is it not by producing or augment- 
ing irritation, that indigestible food, and active cathartics so often induce an 
attack of the disease? But that the affection is 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 
phenomena of malignant cholera? Every candid practitioner will, I think, 
admit 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 some- 
thing new to his experience. Examination of the bodies of those who die in 
the cold stage reveals no uniform and unequivocal evidences of inflammation. 
The injection of the mucous membrane is venous. The same injection is 
found, though in a less degree, in the skin, the bronchial tubes, and the 
parenchyma of various organs. The apparent deposit upon the surface of 
the membrane is not fibrin, but mainly the epithelium, separated by the 
gushing forth of the watery liquid from the blood-vessels. The vesicular 
appearance noticed by Dr. Horner is probably owing to the same cause. 
The enlargement of the intestinal follicles may depend in part on conges- 
tion, in part on the separation of epithelium. Besides, in some cases of 
speedy death, no signs whatever of organic change are observed, to which the 
symptoms could be ascribed. Inflammation takes place after reaction, and 
sometimes proves fatal; but the proofs are wanted of its existence, in any 
considerable degree, during the first stage, or that of collapse; and the pro- 
babilities are wholly against'it. If there is so violent an inflammation as to 
produce death in a few hours, how does it happen that the simple measures 
employed often so readily arrest it, upon the borders of collapse ? Do we 
see inflammation of such intense severity give way so easily under, other cir- 
cumstances? If these considerations are of much weight, the inference is, 
that in cholera there is an irritation, sometimes possibly a moderate or par- 
tial inflammation of the gastro-intestinal mucous membrane; but not that 
intense degree of inflammation 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. 696 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
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 is not confined to 
the alimentary canal. The perspiration is in some instances scarcely less 
profuse; yet no one could suppose the existence of cutaneous inflammation. 
A whitish coating, similar to that of the alimentary mucous membrane, is 
often found also in the urinary passages; but these are not supposed to be 
irritated or inflamed. There is some cause, therefore, disposing to this ex- 
cessive elimination of watery liquid, and especially to this exfoliation of the 
mucous epithelium, other than a mere excess of excitement. What this 
cause is, or how it operates, is not so easily determined. The probability is, 
that a poison is taken into the system, capable of producing a profound im- 
pression on all its parts; and that, among its effects, is either such a relaxa- 
tion of the exhaling orifices as to admit the ready passage of the more fluid 
parts of the blood, and sometimes of the red corpuscles themselves, or such a 
modification of the circulating fluid as to cause it to pass through the struc- 
tures which ordinarily retain it, or else a combination of these two conditions. 
It is also highly probable that other phenomena in the disease are due to the 
same unknown cause. It is true that the immense loss of fluid from the ali- 
mentary canal and skin will account for most of the symptoms of the collapse. 
The blood is thus rendered black, thick, and viscid, and circulates with diffi- 
culty through the vessels. It loses its capacity of absorbing oxygen, and, 
no longer changing from venous to arterial, ceases to support the temperature 
of the body, or to stimulate the heart to contraction. Hence the failing cir- 
culation, the stagnation in the capillaries, the blue skin, the feeble and hurried 
respiration, and the universal coldness. The more elaborate secretions, as 
those of the bile, urine, and tears, cease because the serous part of the blood 
finds an easier outlet through the exhaling surfaces. The whole body shrinks 
from the exhaustion of its fluids; and the same cause gives rise to the intense 
thirst, which is 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 depend upon the condition of the alimentary 
canal, as they are often worst when that structure is least obviously affected. 
Nor is it certain that the symptoms of collapse are always dependent on the 
alvine discharges. It is not improbable that the exfoliated condition of the 
epithelium in the pulmonary air vesicles may contribute to it, by preventing 
the due circulation and change of blood in the lungs, and thus producing a 
true asphyxia. Cases have frequently been 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 is capa- 
ble of producing all the characteristic phenomena of cholera by its direct 
action. What is 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 sedative to the system at large, especially to the functions under 
the control of the organic nervous centres, but irritant to the alimentary 
mucous membrane, and perhaps to the mucous membranes generally. This 
is similar to the poisonous action of tartar emetic, which depresses the circu- 
lation, while it irritates the lining membrane of the stomach and bowels; 
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 CLASS III.] 
EPIDEMIC CHOLERA. 
697 
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 grada- 
tions 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 shrinking 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, and the persons 
they attack, the situations they respectively affect, their cause, course, and termi- 
nation, are other reasons for considering them as essentially distinct affections. 
Prognosis.-Treated in the forming stage, while yet in the state of diarrhoea 
or cholerine, the disease can almost always be arrested. Even when com- 
pletely formed, if not advanced to the stage of collapse, it terminates favour- 
ably, under appropriate management, in the vast majority of cases. But in 
the collapsed state, with the fluttering or absent pulse, the cold and leaden sur- 
face, the suspended capillary circulation, the sunken and inexpressive features, 
and complete mental apathy, the patient is already in the grasp of death, and 
medicine can be of little avail. Very few rise out of this condition, when 
completely formed; and the danger is in proportion to the degree in which it 
is approached. From the rapidity of the disease, and the destitute state of 
many of those most exposed to it, the patient is very often reduced to this 
condition of collapse before medical aid can be obtained. Hence the great 
mortality of this fearful epidemic. The published reports of cholera often 
have reference to the disease as witnessed in hospitals, or other public insti- 
tutions, where the worst cases are crowded together, and not unfrequently in 
the last stage. The inmates of these institutions are, moreover, very fre- 
quently of the classes least able to resist the complaint; such, namely, as are 
already debilitated by age, disease, want, excessive fatigue, or intemperance. 
Among these, cholera has always made terrible havoc. It is not surprising, 
therefore, that the published records give a fearful proportion of fatal cases. 
In some instances, almost all seized with the disease have perished. Out of 
1,387 patients at Dantzic, during the first epidemic, only 377 recovered. Of 
those attacked in the Polish army more than one-half died. The same was the 
case in the hospitals of Paris. About one-half of the reported cases died in 
London. In New York, the ratio of deaths was one-half, in Philadelphia, one 
out of two and a half. (Am. Journ. of Med. Sci., 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 698 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 commence- 
ment 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. The rate of mortality in subsequent epidemics has been, 
on the whole, very nearly as in the first. 
In forming an estimate of the probable result, in any particular case, all 
these circumstances are to be considered. In the early stages, before the 
symptoms of collapse have come on, in a young or middle aged, previously 
healthy and robust individual, and especially if the case occur in the decline 
or towards the close of the epidemic, a favourable termination may be rea- 
sonably expected. If, during the collapse, the pulse begin to rise, the skin 
to become warm, and the secretion of bile and urine to return, there is hope 
for the patient; though, in giving an opinion, it is necessary to bear in mind 
the great dangers of the stage of reaction. When the attack is violent, and 
hastening into collapse, or this condition has already occurred, and when the 
seizure has taken place at the commencement of the epidemic, in an individ- 
ual more than fifty years old, or previously much debilitated from any cause 
whatever, the roost serious consequences are 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, are 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, 
oi' 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, however, 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 disor- 
der 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- CLASS III.] 
699 
EPIDEMIC CHOLERA. 
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 opi- 
um 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 tannic acid, kino, catechu, or the extract of rhatany. 
Very large doses of opium are considered, and probably are injurious, by ob- 
tunding the nervous 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 moderate 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 gentle, 
general, diffusive excitement. Minute and frequently repeated doses of calo- 
mel 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 equivalent doses. Acetate of lead acts by the combination of 
astringency with a directly sedative influence upon the mucous membrane; 
tannic acid, 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 ace- 
tate of lead should be added; and 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. The first dose or two of opium may be larger, say from half a 
grain to a grain or more in threatening cases, in order to produce a prompt 
impression, which may be afterwards sustained, if necessary, with the smaller 
doses. 
* The following are convenient formulae. R.-Opii pulv. gr. j; Hydrarg. Chlorid. 
Mit. gr. ij ; Acacias 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; Acaciae pulv., Syrup., aa q. s. Fiant pilules 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. gj; Acaciae pulv., Syrup., aa q. s. Fiant pil. no. xxiv. S. Two every 
half hour, or every hour. It should be recollected, as stated in the text, that, in urgent 
cases, a larger dose than any above indicated must 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 or two 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 calo- 
mel in three times the quantity; but it is generally less efficient. [PART II. 
700 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
During the administration of the above remedies, the patient may be al- 
lowed 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 ad- 
ministered should be cold, as heat increases the thirst, and already intolerable 
burning of the stomach. Lime-water and milk are sometimes useful in allay- 
ing 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 the 
effects of opiates given by the mouth should be aided by enemata of from forty 
to sixy drops of laudanum, with mucilage or thin starch. I wish particularly 
to impress on the young practitioner the importance of an early resort to the 
sinapism and anodyne enema, as here advised. 
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 effect- 
ing 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 con- 
nexion 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 ointment, 
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- 
vulsive symptoms, blood should be taken from the arm. Leeching to the 
epigastrium is indicated in the earlier stages, when there is tenderness with 
burning 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, 
or to its earliest stage. The cramps may sometimes be relieved by steady and 
firm extension of the affected muscle. 
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 diarrhoea 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 CLASS III.] 
EPIDEMIC CHOLERA. 
701 
or is not deficient. It is, however, of the utmost importance to arrest the dis- 
ease in this stage, and the simple measures necessary for this purpose become 
highly valuable remedies. When the stools retain the natural colour, a tea- 
spoonful of the camphorated tincture of opium three or four times a day, 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 regi- 
men, 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. Should the stomach 
be loaded with undigested 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 foi' the purpose. 
In the stage of collapse, the same indications are presented as in the previous 
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 ex- 
perience 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 remain- 
ing excitability of the system. It cannot possibly restore the lost epithelium 
of the bowels, and may possibly sometimes aggravate the inflammation which 
must necessarily ensue. The stimulants, however, already mentioned, 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. Sinapisms may be applied to 
the abdomen and extremities, and Cayenne pepper and brandy, oil of turpen- 
tine, tincture of camphor, liniment of ammonia, &c., over the surface of the 
body. Hot baths, rendered stimulating by common salt, mustard, capsicum, &c., 
have been recommended. To close the cutaneous exhalant orifices, astringent 
solutions maybe employed, as of alum with brandy; and for the same pur- 
pose, as well as indirectly to excite the skin, frictions with ice or iced-water 
have been strongly recommended, and are often very grateful to the patient. 
Under the reaction from the cold application, the blueness of the surface gives 
way to a glowing redness, the temperature is elevated, and the pulse, which 
may have been quite wanting in the wrist, sometimes returns; but the im- 
provement is too often only temporary. To repair, as far as possible, the loss 
of water and soluble salts by the blood, the patient should be allowed to drink 
frequently of carbonic acid water with bicarbonate of soda in solution, weak 
animal broths with salt, iced-water, iced brandy and water, gum-water, barley- 
water, &c.; and injections of salt water with laudanum may be occasionally 
thrown up the bowels. With the same object, saline baths have been em- 
ployed by some. 
When reaction has begun, the stimulants should be moderated or withdrawn, 
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 irrita- 
tions 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 702 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
in mind, that the inflammations which are apt to occur cannot, in consequence 
of the previous exhaustion, be treated with the same activity of depletion 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, or 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 such 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 vege- 
table and animal food, avoiding indigestible, flatulent, acid, and irritating sub- 
stances, but admitting the more digestible fruits, when not forbidden by an 
already debilitated or irritated condition of stomach. They are useful by ob- 
viating 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 equable state of 
mind should be preserved as far as possible; and excessive fatigue, sensual 
indulgences, exposure to sudden changes of temperature, and especially 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, or warm brine; and even purgatives have found their 
advocates. Nitrate of silver in solution, by the mouth and the rectum, is said 
to have proved highly beneficial in some cases. It has been given in tbe dose 
of one, two, or even three grains, dissolved in one or two fluidounces of water, 
in cases of approaching collapse, with the apparent effect of arresting the dis- 
ease. Great success bas been claimed for the officinal diluted sulphuric acid, 
of which twenty minims may be given with a little aromatic addition, in a 
wineglassful of water, and repeated after each act of vomiting, or each copious 
stool, or at intervals of four hours. A mixture of sulphuric and nitric acids 
has been used, under the name of the Austrian specific. Strychnia, admin- 
istered in the collapse, is stated to have great power of producing reac- CLASS III.] 
703 
CHOLERA INFANTUM. 
tion ; and, though most of the patients die subsequently, yet a more than 
usual proportion of recoveries from that condition takes place. Thus, out 
of 22 cases to which this medicine was administered, 19 reacted, and of these 
only 9 died. {Archives G^n., Aug. 1854, p. 234.) In the East Indies, and 
subsequently in some parts of the United States, calomel in large doses, with 
or without opium, has been a favourite remedy; and the quantities adminis- 
tered with impunity, in certain cases, would seem scarcely credible, were they 
not well authenticated. Frequent draughts of hot water have been highly 
lauded, as constituting the most effectual treatment, by one practitioner; while 
another has spoken, with equal confidence, of the almost exclusive use of cold 
drinks and cold water, or ice applied externally. Some have 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 treat- 
ment, in which the prominent measure was the application of irritants over 
the spinal column; ammonia, oil of turpentine, or a heated flat-iron, being em- 
ployed for the purpose. The doctrine of Stevens, that the salts of the blood 
are essential agents of its arterialization, taken in connexion with the supposed 
loss of these salts by the evacuations which occur in cholera, has led to the 
use by some of the non-purgative salts, such as bicarbonate of soda, chloride 
of sodium, chlorate of potassa, &c., as the main remedial measure. From 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 solu- 
tion, in the proportion in which these salts are found in the serum of the 
blood. The happiest effects seemed for a time to result from this remedy; 
the pulse returning, the surface assuming its natural colour and fulness, and 
the patient reviving into the appearance of convalescence ; but the evacuations 
recurred, and collapse generally ensued, followed by speedy death. The gene- 
ral result of experience as to this plan of treatment has been, that, though in 
a very few instances recovery has taken place under it, from a state of col- 
lapse, yet these instances have scarcely exceeded the proportion in which 
nature unaided has effected cures under similar apparently desperate circum- 
stances. Besides the above plans of management, particular articles of the 
Materia Medica have acquired a more or less diffusive credit with the profes- 
sion or the public. Among these may be mentioned, chloroform, used by 
inhalation, Persian naphtha, wood naphtha or pyroxylic spirit, terchloride of 
carbon, solution of chlorine, tincture of camphor, charcoal, sulphate of quinia 
in very large doses, strychnia, gallic acid, and galvanism. But, as 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. The author has already given his views as to the course of treat- 
ment which these principles appear to him to suggest; and his own experi- 
ence, so far as it has gone, is in its favour. 
Article III. 
CHOLERA INFANTUM. 
This affection, though not unknown in Europe, is comparatively so rare 
as to have escaped the special notice of most of the writers of that continent, 
and, when it occurs, is merely ranked among the cases of gastro-enteric irri- 
Syn.-Summer Complaint of Children. 704 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
tation 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 merit- 
ing a distinct designation. 
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 season, 
commencing with the 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.-1The attack of cholera is often preceded, for a longer or shorter 
time, by diarrhoea; but sometimes the vomiting and purging commence simul- 
taneously. In fatal cases, of short duration, the vomiting usually continues 
to the end; but, when the disease terminates favourably, or is much pro- 
tracted, 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 rejects 
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. 
Much more frequently, however, the attack is attended with febrile symp- 
toms, and the case protracted to one, two, 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 tem- 
perature, while the extremities are cool. Writers in general describe the 
fever as remittent, and state tffat the exacerbation occurs in the evening. It 
is sometimes attended with delirium or stupor. 
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 symptoms already mentioned; but more fre- 
quently it diminishes or ceases, leaving a diarrhoea, which runs on for several 
weeks, and gradually wears out the patient. In the progress of the com- 
plaint, the child emaciates rapidly; the flesh becomes soft and flabby; the 
skin hangs loosely about the neck; the features shrink greatly; the eyes are 
sunken; and the whole surface becomes 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 assumes a dull dirty hue, and the conjunctiva appears blood-shot; 
the emaciation 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 convul- 
sions, or apparently hydrocephalic symptoms. 
Throughout the complaint, 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, sometimes rapa- 
cious, and again seeking the most unusual articles of food. The discharges CLASS III.] 
CHOLERA INFANTUM. 
705 
are in a high degree various in character. At first, they consist of the pre- 
vious contents 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 stomach. After the discharge of the ingesta and feculent mat- 
ter, the evacuations are for the most part thin and copious, sometimes colour- 
less, but usually more or less tinged green, yellow, or brown, and not unfre- 
quently deep-green. Along with the more liquid parts, the stools often con- 
tain 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 wash- 
ings of putrefying flesh. Throughout the complaint, they are either inodo- 
rous, or sour, putrid, or otherwise offensive, but seldom if ever have the 
healthy fecal smell. When the disease has degenerated into a lingering diar- 
rhoea, it very commonly happens 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. Per- 
haps 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 live- 
liness 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. Sci., 
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 ex- 
hibiting more or less redness in points and patches, and an increased develope- 
ment 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. The gastric mucous membrane is some- 
times very soft, so as to be readily scraped off by the nail. Livid or purple 706 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part II. 
spots have been observed upon the exterior surface of the stomach and duo- 
denum. The bowels usually contain green, yellowish, or colourless mucus. 
Dr. Horner noticed pus in considerable quantities in the colon in one case; 
and retained feculent matter is sometimes found in the large intestines. The 
liver is usually enlarged and congested; and the gall-bladder contains a liquid, 
which is sometimes dark-green, and sometimes pale or nearly colourless. The 
brain has also been occasionally found congested; and serous effusion in the 
ventricles or upon the surface, and thickening and opacity of the arachnoid 
Aave 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 Med Sci., xxiv. 306.) 
Causes.-The main cause of cholera infantum 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. 
Condie, 3576 children died of it in Philadelphia during a period of 20 years; 
and Dr. Lindsly states that, of 201 deaths in Washington, during the three 
summer and first two autumnal months of the year 1838, fifty-five, or about 
one quarter, were of cholera infantum. 
But there are other causes which 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 probably not alone 
capable of producing it, very much favours its production, and greatly aggra- 
vates the danger. Most of the fatal cases occur during this process, and 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 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 CLASS III.] 
CHOLERA INFANTUM. 
707 
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 
child will almost always recover, even without medicine, or with such 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 sent 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. Cases often oc- 
cur, 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 impracti- 
cable, the patient should be carried daily into the country, or into one of the 
open 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 teeth, 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 fluids. 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 permitted 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 worn next the skin, and the feet and legs should be pro- 
tected by light woollen stockings. 708 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 or some other mercurial; to divert excitement externally by diaphoretics, 
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 stages, 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 effect- 
ual 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. Ab the same time, very small and re- 
peated draughts of fresh and cold carbonic acid water; or teaspoonful 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 teaspoonful 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. {Phys, and Med. Treat, of 
Children, 4th ed., p. 420.) Dr. Condie speaks favourably of the oil of tur- 
pentine, 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, p. 223.) When the vomiting is excessive, and other means fail 
in arresting it, an anodyne injection maybe 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 re- 
peated 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 often made in infantile cases. 
When the stomach becomes retentive, medicines should be given to evacuate 
the bowels. Combinations of rhubarb and magnesia usually answer well. They 
may be given in powder; but the syrup of rhubarb, and the solution of car- 
bonate of magnesia in carbonic acid water, are perhaps preferable. A'tea- 
spoonful of the syrup, with twice that quantity of the solution, may be given 
every two hours until they operate. The operation 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 aro- 
matic vehicle. When the discharges are small, mucous, and attended with 
pain, castor oil should be substituted. But probably, upon the whole, the 
most 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 CLASS III.] 
CHOLERA INFANTUM. 
709 
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 
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 sup- 
pressed or greatly deficient. The calomel may be administered mixed with a 
little powdered gum arabic, in syrup or on the surface of a teaspoonful 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 laxa- 
tive 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 continued until 
the discharges assume a more natural appearance, unless there may be reason 
to think that it aggravates the complaint, or that no benefit accrues 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, with- 
out preventing the cathartic action. It may thus be combined with syrup of 
rhubarb or 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, if the 
intestinal irritation approach 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 indication 
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 below.* 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 occasionally 
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 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 logwood, 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 blackberry root or dewberry 
root. Some of the mineral astringents are perhaps still more efficient, espe- 
cially acetate of lead, which has been highly recommended, and is certainly 
very useful in many cases of the diarrhoea following cholera infantum. Dr. 
* R.-Pil. Hydrarg. gr. vj; Pulv. Ipecac, et Opii gr. ij ; Cretae, vel Testae Ppt. gi; 
Acacia; pulv. 3j; Sacchari 3j; Aquae Menth. P. f^ij. S. A teaspoonful every two 
hours, or pro re nata. 710 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
Chapman, in his lectures, spoke favourably of alum. These remedies pro- 
bably operate as much by an alterative impression on the mucous membrane, 
as by their astringency. They may in general be usefully combined with an 
opiate, and sometimes with ipecacuanha. Dr. Lindsly speaks, in strong terms, 
of the efficacy of a combination of acetate of lead and Dover's powder. The 
mineral acids sometimes prove useful as alteratives and tonics. These also 
should be combined with an opiate. The nitromuriatic acid is perhaps to be 
preferred. I have employed nitric acid, in the form of Hope's mixture (see 
page 602), with decided benefit. Nitrate of silver was employed by Dr. Skin- 
ner, of N. Carolina, in one almost desperate case, with the happiest result. The 
salts of iron may be resorted to in cases of obstinate diarrhoea connected with 
anaemia. Other substances sometimes used as alteratives are oil of turpen- 
tine, copaiba, and creasote. In 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 circum- 
stances. When heat is deficient in the extremities, the equilibrium should 
be restored by frictions, and by rubefacients applied to the legs and 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 given in relation to 
country air, ventilation, dentition, diet, dress, and exposure to sudden changes 
of temperature, are applicable here. The late Dr. Joseph Parrish used 
strongly to urge the propriety, when the predisposition is very strong, of for- 
tifying 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 
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 
Syn.-Eructation.-Crepitus.-Borborygmus.-Tympanites.-Meteorism. CLASS III.] 
FLATULENCE. 
711 
liquid and solid contents. It is only when they are produced so abundantly, 
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 disorder. 
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 
eructation, 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 
abdominal muscles and diaphragm; but sometimes they are quite involuntary, 
and depend solely on the contraction of the muscular coat of the alimentary 
canal, or the elastic 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 sensation of distension or pressure, provoking and re- 
lieved by the discharges, the patient is often affected with pains, which are 
in some cases moderate and fugitive, in others distressing and almost con- 
stant, 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. Perhaps the term meteorism may be appropriately applied 
to the slighter degrees of distension, and tympanites to that condition in which 
the abdomen is very much swollen, so as to be quite tense and sonorous. Some- 
times the swelling is local, so as even to have given rise to the suspicion of 
the existence of solid tumours; sometimes it is equable over the abdomen. 
In its higher grades it is often very injurious. 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 constipa- 
tion 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 respiration 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 resulted from a 
cessation of respiration* consequent upon an enormous tympanitic distension 
of the bowels. (Transact, of Col. of Phys, of Philad.,3&n.. 4,1842.) Another 
fatal accident* sometimes proceeding from the same cause, is the rupture of the 
stomach or intestines by the expansive force of the confined air. In some 712 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
rare (Jases of tympanites, 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 great length of time. In the form of meteorism, or tympanites, 
it often lasts for years with little abatement or alteration. In some cases, it 
disappears spontaneously, in consequence apparently of the absorption 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 dis- 
tensions of the abdomen may be distinguished from liquid accumulations by 
the absence of the feeling of fluctuation produced by the latter, when the palm 
of the hand is placed on one side of the abdomen, and a gentle blow given to 
the other; from solid tumours, by the flat sound emitted by these upon per- 
cussion, instead of the clear resonance characteristic of confined air. 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 on auscultation indicates a mixture of liquid and air. 
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 
unfrequently 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, how- 
ever, 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 chemical 
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 primse vise, and, on this account, are called flatulent. Such 
are cabbage, unripe fruits, melons, tough or fibrous roots, and fermenting or 
fermentable liquids. These will often evolve gas copiously in a healthy sto- 
mach. 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 they are 
confined too long in the intestines; and constipation thus becomes a cause of 
the disorder. When these secretions are unhealthy, in consequence of disease 
of the secreting organs, they are often highly flatulent. It is, moreover, pro- CLASS III.] 
FLATULENCE. 
713 
bable that the chemical changes, which take place when the heterogeneous 
contents of the small intestines are converted into chyle, are often attended 
with the production of aeriform substances, even when the processes of diges- 
tion 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. Por- 
tions 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 mem- 
brane which leads to this result is not known. It seems to be in some measure 
connected with defective or deranged innervation; for flatulent accumulations 
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 spasmodic con- 
strictions 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 con- 
dition, analogous to certain mental perversions ranked under hypochondriasis 
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. 
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 714 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part it. 
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 mdvement. 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, 
cinnamon, cloves, allspice, black pepper, ginger, and calamus. Twenty 
drops of the tincture of oil of peppermint, or oil of spearmint (essence of pep- 
permint or spearmint}, dropped on sugar, will often afford prompt relief. 
Compound spirit of lavender, and compound tincture of cardamom, are agree- 
able preparations, and may be given in the dose of a fluidrachm. Hot ginger 
tea will be found especially useful when there are colicky pains. Fennel- 
seed tea, given both by the mouth and by injection, is well adapted to in- 
fants. Recourse 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 occasionally 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 ner- 
vous disorder. Prompt relief is often procured, when severe stomachic pain 
depends on flatulence, from a fluidrachm of camphorated tincture of opium. 
When the bowels are affected with flatulence, the aromatics may often be 
advantageously combined 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 ab- 
dominal muscles, jumping, jolting in a rough vehicle, or a ride on horseback, 
will aid much in the expulsion of the confined air. Compression by a flannel 
roller or otherwise, stimulating embrocations, and galvanism, 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 rec,turn, 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, or other 
part of the intestinal tube. In cases of excessive tympanites with irremova- 
ble obstruction of the bowels, the operation has been occasionally performed, 
with the effect of affording relief; though the cases afterwards terminated 
fatally, in consequence of the obstructing disease. (See Am. Journ. of Med. 
Sci., N. S., xxiv/543.) . 
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 CLASS III.] 
PERITONEAL INFLAMMATION. 
715 
the head of dyspepsia. Constipation should be obviated by a proper regula- 
tion of the diet, and if necessary by laxatives; but, in the choice of means 
for this 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 in 
connexion with these, when acid exists in excess in the primae vise. Un- 
healthy secretions into the bowels 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 vomica has 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 depen- 
dent upon other diseases, care should be taken, in all instances, to discover 
its source, and apply remedies to this, instead of wasting time in a direct 
combat with the flatulence itself. Particular attention should be paid to ner- 
vous derangements, which frequently 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 lauda- 
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 oil. 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 isj per- 
haps, its most important function; and its diseases may, therefore, be very ap- 
propriately associated with those of the digestive organs. Inflammation of the 
peritoneum is susceptive of 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 occa- 
sionally the occurrence of the two phenomena is simultaneous. The pain is 
sharp and very severe, and usually commences in the lower part of the abdo- 
men, in the hypogastric or one of the iliac regions, whence it gradually ex- 
tends over the whole cavity. Sometimes it is changeable, occurring now in 
* R.-Quiniae Sulphat. gr. ij; Assafoeticte gr. iv; Acacise pulv., Sacchar., aa, gss; 
Aq. Cinnamom. f^j. Misce. 8. A teaspoonful for a child one year old, four times a day. 716 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 slight- 
est pressure by the hand occasions exquisite pain, and whatever gives rise to 
contraction of the abdominal muscles has the same effect. Hence, the patient 
suffers much from vomiting, the act of defecation, the discharge of urine, 
and straining of all kinds. A deep inspiration is often very painful. Move- 
ments 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 
motionless upon his back, with his knees drawn up, so as at once to relax the 
abdominal muscles, and take off the weight of the covering. Another ob- 
ject 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 description 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 con- 
tact with the abdomen. Most frequently the tenderness is general, but in 
some instances is greatest in particular spots, and in others is confined alto- 
gether to one spot; indicating, in the latter case, the local position of the 
inflammation. From near the commencement, there is generally a feeling of 
hardness, tension, and elasticity in the abdominal parietes; and verf 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 
the hand the sensation of a tumour or tumours 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, especially in the depending parts. After the com- 
plaint has lasted a short time, the abdomen frequently offers, under ausculta- 
tion, 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 symp- 
tom, and sometimes gives way to diarrhoea. The face is pale, contracted, and 
marked by an expression of deep distress and anxiei^, 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 some- 
times nearly natural. The patient is very often wakeful. The chill with 
which the attack commences, or which follows the occurrence of pain, is usu- 
ally 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 march of peritonitis is in general rapid. In fatal cases, death sometimes 
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 CLASS III.] 
PERITONEAL INFLAMMATION. 
717 
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. Oc- 
casionally 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 ten- 
derness 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 stomach, intes- 
tines, 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, 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 in- 
flammation 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 movable organ is affected. Any part of the abdo- 
men, 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 consti- 
tutional, 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 modified by the posi- 
tion 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 
unfrequently 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 constipation, with 
a lower seat of pain, that of the bowels; painful irritation with tenderness in 
the hypogastric region, and great pain in micturition, that of the bladder. 
The omentum may be separately inflamed, in which case the pain extends over 
the front of the abdomen, and effusion into the folds of the membrane may 
occasion circumscribed swellings, perceptible to the touch, and liable to be 718 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
mistaken for enlarged spleen, or ovaries, or scirrhous tumours of different por- 
tions of the bowels. Andral mentions, as characteristic of pelvic peritonitis, 
pain above and behind the pubes, and extending backwards 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 with 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 inflam- 
mation 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 
tumefaction over the head of the colon, and by obstinate constipation, and 
frequently 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, intussusceptio, or other cause. In these cases, the symp- 
toms 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 
gtercoraceous 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 disease, 
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, occa- 
sionally producing, in its passage, much destruction of the organs with which 
it may come in contact. 
I have known sudden swelling of the scrotum, with great pain and tender- 
ness, to come on in the course of peritonitis, consequent upon the extension 
of the inflammation to the tunica vaginalis of the cord, and that altogether 
independent of the existence of hernia. 
Though for the most part an exceedingly painful disease, peritonitis some- 
times comes on 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 coun- 
tenance and pulse of peritonitis, even without abdominal pain, a close exami- 
nation 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. Severe rigors, followed by some febrile reaction, with 
nausea and vomiting, and distressing sensations of sinking at the epigastrium, 
which can be traced to no other cause, should lead to the suspicion of perito- 
nitis. In all doubtful cases, the observation of the friction sound in auscul- 
tation would very much aid the diagnosis. 
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. Headache, active CLASS III.] 
PERITONEAL INFLAMMATION. 
719 
delirium, subsultus, convulsions, sudden alternations in the violence of the 
ordinary symptoms, restlessness, wakefulness, and great general distress, are 
among the characters of this form of the disease. Andral states that he has 
known the disease to recur regularly for some time with the paroxysms of an 
intermittent, disappearing entirely in the intervals, until at length it became 
permanently established and continuous. (Clinique Medicale, 3e ed., 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 hollow 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 sudden 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 of peritonitis is generally fatal. But occasionally, 
when the perforating orifice is small, and in a neighbourhood where the in- 
testine is not movable, 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 preced- 
ing 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- 
* It is sometimes impossible to decide with certainty, before an external communica- 
tion has been 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 him. I found him 
with fever, diarrhoea, tympanites, and a dry tongue; and should have been disposed to 
consider the case as one of enteric 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, pos- 
sibly, 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 cel- 
lular 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-csecal 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, in 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 ju this instance.-(Note to the second edition.) 720 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
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 
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 as 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 paye 56.) They will not, therefore, require a very par- 
ticular notice in this place. If death has occurred very early, the membrane 
may offer no other morbid appearance than redness. In cases of longer dura- 
tion, there is almost always more or less of a fibrinous exudation upon the 
surface of the membrane, and of free liquid in the cavity. At first it is often 
in the form of a thin, viscid, almost colourless layer; but it soon becomes 
more copious, and is then 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 intestines, 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 
thickness, 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 fibrinous 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 CLASS III.] 
721 
PERITONEAL INFLAMMATION. 
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 mortification. 
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 character 
of the liquid in the cavity varies with the organ perforated, and sometimes 
serves to designate the organ. Thus, portions of undigested or partially 
digested 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 or rheumatism. It is, however, 
more frequently the result of local violence, as of blows, falls, and bruises qf 
all sorts, and of wounds penetrating the peritoneal cavity, including various 
surgical operations, among which may be mentioned that for strangulated 
hernia and for tapping, and the Cesarian section. * 
Sometimes it is secondary to other diseases, especially to inflammation of 
the organs which receive a complete or partial covering from the peritoneum. 
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. A frequent 
cause 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 ulceration, by mortification and the 
separation of sloughs, or by mechanical rupture depending upon an extraordi- 
narydistending 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 opening 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 which affections ulceration of the 
mucous membrane of the bowels is not uncommon. It is also not unfrequently 
produced by foreign bodies lodged in some portion of the canal, especially in 
the caecum and appendix, where they occasion inflammation, ulceration, and 722 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[PART II. 
ultimately perforation of the coats of the bowel. Peritonitis sometimes comes 
on in the course of other diseases, particularly those of a febrile character, 
without any assignable cause, imitating, in this respect, the inflammation of 
various other parts or organs. 
Of the variety of peritonitis denominated puerperal, the cause is probably 
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 partici- 
pation 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 originating, assumes not unfre- 
quently 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 epidemically. 
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 affection 
in its earlier stages, its excessively obstinate constipation, and the fecal vomit- 
ing 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 mem- 
brane is inflamed, the acute pain, tenderness, abdominal tension, position, pain 
upon movement, &c., serve to indicate the fact; from rheumatism of the ab- 
dominal muscles, which bears to it the closest local resemblance, by the vomit- 
ing, the febrile symptoms, the peculiar expression of face, and the difference 
in the pain which attends motion in the two cases, the pain in rheumatism 
being much severer from voluntary movements, which call the muscles 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 diagnosis is 
of less consequence, as the treatment required by the peritoneal inflammation 
would in general involve that required by the inflamed organ, and, when the 
symptoms are violent and the diagnosis doubtful, the measures required 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 dis- 
turbed ; the urine, instead of being scanty, is usually copious and pellucid; CLASS III.] 
723 
PERITONEAL INFLAMMATION. 
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 dis- 
ease, 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. 
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 action by the violence of the local affec- 
tion ; and the pulse, though often corded, is generally small and very fre- 
quent, 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. Nei- 
ther 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 second and 
third operation should not generally be so great as at first. It may some- 
times be necessary to repeat the bleeding within twenty-four, and even twelve 
hours. Faintness, 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 irrita- 
tion 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 immovable 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 enemata. 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 724 
[PART II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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, 
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 the 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. 
Opium may be used very early in this inflammation. After free bleed- 
ing 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. Calo- 
mel should generally be added to it in small quantities. This is useful by 
preparing for the easier evacuation of the bowels on the following day, but 
still further, by facilitating the mercurial impression, should this be after- 
wards 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 anodyne influence. A direction to the surface of the body may be 
very usefully 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 sim- 
ply warm water, or, if necessary, a small dose of ipecacuanha, which serve to 
wash out the stomach, and to remove any offending matter that may be pre- 
sent in it. Anodyne enemata may also be resorted to. In order to favour 
diaphoresis, the warm bath may sometimes be used with advantage, espe- 
cially 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 com- 
mand 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 to 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 to the mercurial 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; CLASS III.] 
725 
PERITONEAL INFLAMMATION. 
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 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, car- 
bonate 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 as 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 constitutions 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 depletion 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 reliance is 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 treatment. Depletion may be pushed as 
far as the strength of the patient will admit; but, as this has generally 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, 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 maintain the system 
completely and constantly under its influence. The opium, while it thus 
puts the bowels, as it were, in splints, answers another excellent purpose, 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 forbidden, 
or at least admitted only in such quantities as may insure them against pass- 
ing 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 considered as almost despe- 
rate ; but the one described affords some little chance of a favourable issue. 
One case was successfully treated by Dr. Stokes, of Dublin, upon the opiate 
plan; and another, probably of this character, already referred to as occurring 
in convalescence from enteric fever, ended in recovery under the care of 
Dr. Gerhard and myself. (See note, page 349.) 726 
[part II. 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
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 particularize the remedies, which are absolutely identical 
with those already mentioned. Attention should be additionally plaid to the 
state of the uterine discharges. The lochia, if suppressed, should be pro- 
moted by fomentations or emollient applications to the external genitals; and 
acrid discharges, 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 byresorting 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 
blooddetting; for the diagnosis is sometimes difficult, and the effects of 
bleeding, and the quality of the blood drawn, are among the most charac- 
teristic marks of the affection. Should the pulse 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 use- 
fully 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. Stimulants and a nutritious diet are also often neces- 
sary. 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 experience are, I think, adverse to its employment in 
the cases of ordinary open inflammation of the peritoneum, whether occurring 
in puerperal women or others. 
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 tubercles disseminated in the mem- 
brane, and serving as a constant source of irritation. I shall first describe 
the former, and then point out those additional symptoms which may be sup- 
posed 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 excitement is experienced towards even- 
ing, the patient loses flesh and strength, and the disease becomes fully 
developed. 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 after- CLASS III.] 
PERITONEAL INFLAMMATION. 
727 
wards 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 
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 
eases, 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, and more 
or less chapped. The pulse is frequent; the urine scanty; the skin usually 
dry, unless in the latter stages when 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 and 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 protracted 
and very obstinate, resisting the curative measures employed, and when its 
origin cannot be traced to a preceding acute attack, to local injury of the ab- 
domen, 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 exam- 
ination of the abdomen will often detect small tumours consequent upon 
enlargement of the mesenteric glands; and the external lymphatic glands, 
especially in the groin, are also occasionally enlarged. The simultaneous ex- 
istence of tubercles in the lungs, or an obstinate diarrhoea, indicating tuber- 
culous 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- 728 
LOCAL DISEASES.-DIGESTIVE SYSTEM. 
[part it. 
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 may- 
yield to remedies. 
Anatomical Characters.-Not uncommonly there is almost universal ad- 
hesion of the peritoneal membrane, 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 situ- 
ated 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 gray- 
ish, reddish, or dark colour, often rough, and of an areolar appearance upon 
the surface, and sometimes of an almost cartilaginous hardness. Sometimes 
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 outline 
of the abdomen. The liquid effusion is variable in quantity, position, and 
appearance; being in some cases very scanty, in others more or less abund- 
ant ; sometimes anterior to the bowels, which are compressed into the back 
part of the abdomen, and sometimes, as before mentioned, partially collected 
in sacs; occasionally nearly colourless and limpid, with fibrinous flakes, occa- 
sionally more or less opaque, and of a yellowish, brownish, blackish, or reddish 
colour, from admixture of pus or of blood. In some instances, it consists 
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 developement. 
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 convo- 
lutions, has produced ulceration in both, and thus formed a communication 
between them. 
l^eatment.-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 applica- 
tions 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 ne- 
cessity of counteracting the tendency of general debility to produce tubercu- 
lous deposition, may render a resort to bitters, chalybeates, cod-liver oil, and CLASS III.] 
ABSORBENT SYSTEM. 
729 
moderate exercise of a passive character, desirable. Should abscesses form 
with an apparent external direction, their tendency to the surface should be 
favoured by emollient poultices. 
SECTION II. 
DISEASES OF THE ABSORBENT SYSTEM. 
The absorbent system, besides'sharing in the general susceptibility of the 
body to 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 also the alimentary product of the digestive process, 
and, possibly, numerous bodies from without, of every degree and variety of 
noxious power, it must, in many 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 thus 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 struc- 
ture ; so that an irritation existing at their origin is very apt to be transmit- 
ted for a considerable distance along their course. A slight general sketch 
of the derangements of which they are susceptible, will be a proper introduc- 
tion 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 fun- 
gus, of melanosis, and of other less strictly defined and understood degenera- 
tions. They may become enlarged or varicose, and diminished in their caliber 
or strictured. Their channel may be entirely closed, giving rise to accumu- 
lations behind the strictured point, and consequent rupture of the vessel. 
Their coats are sometimes 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 particular instance, hypothetical, or at best merely 
conjectural. Others again are completely lost in the ravages which the dis- 
ease produces in parts more immediately vital. Of the various complaints, 730 
[PART II. 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
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. 
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 
inflame'd 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 without redness, is deep-seated and shooting, and gradually extends 
along the course of the vessels. Slight pressure on the surface has little 
effect, 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 first 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 sometimes 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 CLASS III.] 
731 
INFLAMMATION OF THE ABSORBENTS. 
small abscesses, occupying the seats of previous hardness; but sometimes it 
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 neighbouring cellular tissue is in some parts healthy, 
in others hardened, and in others again destroyed by purulent infiltration. 
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 inflammation 
produced in the toe by the pressure of the nail, is apt to extend up the lym- 
phatics 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 occa- 
sionally give rise to the disease. In the last case, the irritation of a poisonous 
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 con- 
sequence of an examination per vaginam with a slightly wounded finger. The 
effect of dissection, whether of a putrefying or sound body, in producing the 732 
[PART II. 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
disease, is well known. Ulcers, and various eruptive affections of the skin 
also frequently induce it. Thus, impetiginous ulcers of the head and face, and 
the sores so common behind the ears in children, often give rise to inflamma- 
tion of the lymphatic glands of the neck, and the intervening absorbents. 
The deep-seated absorbents may become inflamed in consequence of a contu- 
sion, fracture, or deep penetrating wound, and from communicating with col- 
lections of various acrid secretions. It has been observed, however, that the 
latter result rarely takes place, unless the matter has undergone 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 vessels are affected either 
by a propagation of the inflammation from the original point, through what 
has been called continuous sympathy, or by the absorption 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 infer- 
ence 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 likely 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 diffused character of ery- 
sipelas. 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 irri- 
tation from the wounded or inflamed point, and to correct the inflammation 
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 patient vigorous, and the local disease 
considerable, blood should be taken from the arm; but caution is 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 becomes, under such circumstances, 
important to husband the strength. Bleeding 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 inflammation, 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; and, if it affect the mouth, will 
♦ CLASS III.] INFLAMMATION OF THE ABSORBENT GLANDS. 
733 
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 escape; 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 gra- 
duated pressure, by means of bandages and compresses, is often highly useful 
in diminishing the cavities, promoting the healing process, and causing the 
absorption of the edematous 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. 
Syn.-Lymphadenitis. 
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 -1The 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 movable. The inflammation, in most cases, soon extends to the 
neighbouring cellular tissue, thus greatly increasing the tumefaction, which 
is now less precisely bounded, while the gland becomes fixed. Not unfre- 734 
[PART II. 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
quently several glands are inflamed at the same time, thus producing irregu- 
larity 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, sup- 
puration commences; 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 contained sometimes in one, sometimes in several distinct cavities. 
Occasionally it is confined to the gland, in which case the tumour is circum- 
scribed and somewhat movable; occasionally to the surrounding parts, when 
the boundary of the swelling is quite indefinite; and not unfrequently occu- 
pies both situations. The skin at length ulcerates; and the abscess or ab- 
scesses open, discharging a homogeneous healthy pus, sometimes in small 
quantities, sometimes copiously; and then gradually heal, leaving almost 
always more or less swelling and hardness, which last for a long time, but 
ultimately in general disappear. 
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, con- 
tinuing circumscribed and movable, 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 sub- 
stance 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 scrofulous 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, in the external glands, is almost always 
favourable. When treatment is applied early, before any appearance of sup- 
puration, resolution is very often 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 infil- 
trated 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 
disease, the usual evidences of inflammation in that tissue. (See page 36.) 
Causes.-1The causes of inflammation of the lymphatic glands are so exactly 
those of inflammation of the lymphatic vessels, that it is unnecessary to re- 
peat them here. (See page 731.) If there is any difference, it is, perhaps, 
that the glands are more liable than the vessels to the influence of the ordi- 
nary 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. CLASS III.] 
EXTERNAL SCROFULA. 
735 
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, ex- 
tensive 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 ordinary 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 oval, pretty well 
defined, and more or less movable, especially when near the skin. When seve- 
ral 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 indolent, and remaining 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 736 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[part II. 
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 movable in consequence of adhesion 
to the neighbouring cellular tissue, and to the skin, which is warm, tender to 
the touch, and often reddened. Fluctuation is now evident, and is felt equably 
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 very generally appears 
when the substance of the gland suppurates. Occasionally the cellular 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, con- 
tinuing 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 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 dull-red or purplish. The bottom is uneven, light-red or grayish, with 
soft indistinct granulations, giving rise to a copious serous discharge, with 
curd-like flakes. The ulcer is often 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 inappreciable 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. (See pa<je 113.) The incubative stage, 
or that which precedes the tumefaction, if open enough to be observed, is 
marked by a greater or 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, whicli discharges a thin excoriating fluid, and 
is attended with swelling about the nasal orifices, so as to impede the entrance 
of air. The upper lip is often swollen and chapped in the middle. In some CLASS III.] 
737 
EXTERNAL SCROFULA. 
cases, the conjunctiva is irritated or inflamed, and the edges of the eyelids be- 
come 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 symptom which attracts attention. When constitutional 
symptoms precede them, they generally become ameliorated after the glands 
have begun to enlarge. But, as the disease advances, especially when severe, 
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 exhausting and irritating influence of large 
abscesses or ulcers, hectic symptoms often occur, with various nervous de- 
rangements, and, in the adult female, with disorder of the uterine functions. 
In very mild cases, however, the disease may run its whole course, with little 
if any observable disturbance 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; 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 tuber- 
culous 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 
lungs, 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 treat- 
ment, and runs on for many months, and even for years. Generally, how- 
ever, it sooner or later terminates favourably, unless complicated with or re- 
placed by disease of the bones or joints, phthisis, tabes mesenterica, or some 
other internal tuberculous affection. 
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.-In the first stage, there is merely an enlargement 
of the gland, without any striking alteration of the tissue, unless that it may 738 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[PART II. 
be somewhat redder and firmer than in health. As the tumour advances, it 
becomes still harder, exhibiting a granular structure, and a grayish colour. 
Tuberculous matter is then deposited either in the form of distinct granula- 
tions, 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 maybe created in individuals, pre- 
viously free from any peculiar morbid tendency, by the operation of certain 
causes which lower the grade of the vital forces, and vitiate or impoverish the 
blood. Such causes are a meagre and unwholesome diet; confined and con- 
taminated air, especially that of crowded apartments; sedentary occupations; 
long exposure to cold, especially after a previous habitual exposure to heat, as 
in those who remove from a warm to a cold climate; a damp atmosphere; ex- 
cessive and exhausting indulgences; continued mental depression; and finally, 
the influence of various diseases, as smallpox, 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 mentioned 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 affection has a strong tendency to develope scrofu- 
lous disease, where the predisposition exists. The complaints above alluded 
to as sometimes co-operating, by the debility they induce, in establishing a 
predisposition, oftener operate as exciting causes. Upon the whole, the most 
frequent sources of external scrofula are probably inheritance, and the com- 
bined influence of a cold, damp, and variable atmosphere, with depressing 
habits of life. The disease is most common in temperate latitudes, where the 
vicissitudes of weather are most experienced, and sufficiently 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 
population in this country enjoy more abundant means of physical comfort. 
Nature.-The nature of scrofula has been discussed under another head. 
(See page 115.) 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 con- 
stitutes 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 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 tuberculous deposition, which forms the peculiar 
feature of the complaint; and that the existence of the predisposition which 
leads to this deposition, is capable of impressing a peculiar character upon in- 
flammation arising from any ordinary cause. But it would be altogether 
premature to state that a low grade of inflammation necessarily precedes the CLASS III.] 
EXTERNAL SCROFULA. 
739 
tuberculous deposit. There is, on the contrary, reason to believe that this 
matter is often eliminated, whether in consequence of a species of vascular irri- 
tation, 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 capable also, without the 
deposit, of giving a somewhat peculiar character to the inflammatory process. 
But, whatever may be the origin of the tuberculous matter, there can be no 
doubt that, when once secreted, it serves, like a foreign body, as the cause of 
the subsequent inflammation, suppuration, ulceration, &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 form- 
ing his judgment, by the hereditary or family influences, which may have 
served to create a peculiar predisposition in the patient. When, upon the 
occurrence of suppuration, the curdy matter above referred to is discharged, 
there can be no doubt as to the scrofulous nature of the case. 
Treatment.-The point that should be first aimed at is the correction of 
the peculiar state of system in which the tuberculous 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 be invigorated, and the vital actions moderately supported; but care 
should be taken not t(^itimulate 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 tbe 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 wards 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 740 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
- [part II. 
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 ani- 
mal food become advisable, and sometimes necessary. The clothing should 
be such as to preserve the temperature of the surface as nearly equable as 
possible; 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 cli- 
mate during winter. Where long journeys are impracticable, excursions, 
within the means of the patient, to watering-places, or to the seashore, 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 effi- 
cacious in scrofulous affections, where the lungs are not involved or suspected, 
and especially in the cases of children, than sea-bathing and a residence by 
the sea-side. Experience has shown that such an exposure is peculiarly unfa- 
vourable 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 the 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 
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 
febrile excitement that may attend the developement of the tumours. 
The state of the blood should be attended to, and, if a deficiency of red 
corpuscles 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 affec- 
tions. 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. CLASS III.] 
EXTERNAL SCROFULA. 
741 
The pills of carbonate of iron of the Pharmacopoeia, the powder of iron, the 
subcarbonate, 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 de- 
bility, which call for the use of astringents and tonics. One of the most 
agreeable and useful of these is pipsissewa (chimaphila, U. S.), which com- 
bines 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 had reason to be satisfied with its effects. The 
decoction should be given to the amount of half a pint or a pint daily to an 
adult, and proportionably to children. In many cases, I have found no other 
medicine 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 walnut leaves, which have recently been introduced into use, in 
Europe, as a remedy in scrofula, and are highly lauded by some French prac- 
titioners. (See U. 8. 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 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. Nitro- 
muriatic acid is thought, in addition to its tonic effects, to exercise a beneficial 
alterative influence; and it has appeared to me to be more effectual than the 
other acids, in the condition referred to. Phosphoric acid has also been 
highly recommended. The diluted acid of the London Pharmacopoeia may 
be given in the dose of twenty or thirty drops three or four times a day. 
Cod-liver oil has been found by experience among the most efficient, if not 
the most efficient corrective of the scrofulous diathesis. It probably acts by 
improving the character of the blood, and favourably modifying the nutritive 
process. It may be given in the dose of a tablespoonful three times a day, 
and should be persevered in for months, or intermittingly even for years, if 
the patient continue to improve, and such a perseverance seem necessary to 
eradicate the morbid tendency. 
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 antispasmodics, espe- 
cially conium, hyoscyamus, belladonna, and stramonium. The extracts of 
these medicines may often be advantageously combined with the laxatives, 
chalybeates, and other tonics employed. The preparations of hops, from 
their combination of narcotic and tonic properties, are useful 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 well 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 same 
time tonic to the digestive and nutritive functions, and, through its hydro- 
cyanic acid, sedative to the nervous and circulatory systems. 742 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
[PART II. 
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 act- 
ing-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. Among 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 may be 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 maybe 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. For the modes of exhibiting iodine, 
the reader is referred to the U. S. Dispensatory. Bromine and its prepara- 
tions 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- 
ment of 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. Sea- 
water, taken internally, has been thought useful, through the chlorides which 
it contains. 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 inter- 
fere with the healthy processes of the system, and thus to favour the scrofu- 
lous diathesis; so that, though the glandular affection might be relieved, 
there wrould 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 asso- 
ciated 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 chloride of mercury, with the prepara- 
tions of sarsaparilla, have been much used, in cases of combined scrofula 
and syphilis. 
Phosphate of lime has been recommended by Dr. Beneke, a G-erman phy- 
sician, in ulcerous and rickety affections, of a scrofulous character, upon the CLASS III.J 
EXTERNAL SCROFULA. 
743 
ground that, as it is essential in the formation of cells, it is likely to prove 
useful where there is deficiency in cell-growth. The remedy is an old one in 
rickets, and had been generally abandoned as inert, until brought forward 
under these new auspices. Since the publication of Dr. Beneke's observa- 
tions, it has acquired a certain popularity, especially in connexion with other 
phosphates, as those of iron, soda, and potassa; but, when it is considered that 
there is an abundance of these salts in our food, and that much of them is con- 
stantly thrown off from the system, even in scrofulous affections, as the result 
of the disintegration of the tissues, the inference seems fair that it is not so 
much the phosphates that are wanting, as the due power to make use of them. 
Very advantageous impressions may often be made in scrofula by different 
kinds of bathing. When there is a depressed state of the system, and yet 
vigour enough to insure 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 impreg- 
nated with these salts artificially. When, instead of requiring a tonic impres- 
sion, the system is in a febrile state in consequence of the local inflammation, 
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. Sul- 
phur-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 Kentucky, and the 
Avon and Sharon springs in New York. Dr. Simpson, of Edinburgh, having 
observed that persons working in wool-factories are seldom affected with scrofula 
and phthisis, and ascribing the exemption to the oil with which their skin 
comes incessantly into contact, proposes the external use of oil as a remedy 
and prophylactic in these affections. 
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 of 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 has become much ex- 
hausted, that the more actively tonic and stimulant plan of treatment is adapted. 
Cod-liver oil and 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 744 
[part II. 
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, 
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 fistulous 
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 with mild dressings. If indisposed to heal, they may be 
stimulated by resin cerate, the ointment of red oxide or subnitrate of mercury 
more or less diluted, that of 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 gangre- 
nous, 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. The 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 ex- 
tended to the period of lactation. If the mother positively labour under the 
disease, she should relinquish to a healthy and vigorous wet nurse the nourish- 
ment 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 relin- 
quished. Attention should be paid to the clothing of the child, who should 
be kept perfectly clean, exposed freely to the fresh air, and early accustomed 
to active exercise. The mental precocity, which is a not unfrequent attendant 
of the scrofulous diathesis, should rather be repressed than encouraged. The 
physical rather than the mental education should engage the solicitude of the 
parent; and, when the time comes for the choice of an occupation, the atten- 
tion 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 CLASS III.] 
DISEASE OF THE BRONCHIAL GLANDS. 
745 
assume a black colour, which is not to be considered an evidence of disease. 
The absorbents of the lungs pass through them; and the change in their 
colour corresponds 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 cancerous growths. But their diseases generally 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 embar- 
rassment of respiration. Even when pressing upon the air-passages, they do 
not always occasion difficulty of breathing, probably in consequence of the 
gradual manner in which their encroachments take place. Another circum- 
stance which prevents an accurate diagnosis is the very frequent coexistence 
of other diseases, the symptoms of which completely mask those of the glan- 
dular affection. Sometimes, however, these tumours do produce dyspnoea by 
compressing the windpipe or bronchia, and, according to Dr. Carswell, even 
give rise to symptoms of obstructed circulation, by diminishing 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 compression of one of the 
principal bronchia by a mass of tuberculated glands. (Clinique M&dicale, iv. 
250.) Dr. Williams states that he has seen tumours of these glands " push- 
ing 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 f 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 enlargement, 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 subject of inflammation and 
tuberculous disease of the glands; as other affections are so uncertain, that 
nothing could be profitably said in relation to them. 
Inflammation of the Bronchial Glands. 
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 the 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 original, advancing even to 
suppuration, with discharge of pus into the trachea or one of the bronchia, 
without any evidence 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 746 
[PART II. 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
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 pecu- 
liar 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 moderate 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 antiphlo- 
gistic treatment, there would be grounds for believing that inflammation had 
existed, and terminated in resolution. 
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 duration, 
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 instances of inflamed bronchial glands. 
The treatment of this disease, when supposed to exist, should be conducted 
on the general principles applicable to inflammation wherever seated. Deple- 
tion, 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 Glands. 
In phthisis, the bronchial glands are often inflamed and enlarged, but not 
necessarily tuberculated. The bronchial and pulmonary inflammation asso- 
ciated with tubercles gives rise to a sympathetic inflammation 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, whatever 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 ac- 
companied with common inflammation of the absorbent glands with which 
these parts respectively communicate, it not unfrequently happens that, in 
infants predisposed to scrofula, common enteric or bronchial inflammation 
gives rise to a tuberculous affection of the same structures. Hence, the com- 
plaint 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 
cover and conceal those of the glandular affection, that it can seldom be re- 
cognized until after death. Occasionally, however, it occurs without any 
preceding or simultaneous developement 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 observed, with little or no pain in the part, with occasional fever, 
cough, and dyspnoea, which have come on gradually and persisted for a con- 
siderable time; when along with these symptoms are marks of a scrofulous 
constitution, 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 CLASS III.] 
747 
DISEASE OF THE MESENTERIC GLANDS. 
of the disease in question. The diagnosis, however, is always 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, adhesion, 
and ultimate absorption of their parietes, thus opening a way for the dis- 
charge 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 middle 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 frequently 
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. 
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 colouf, softened, and sometimes charged with small collections of 
pus. Those were most diseased which corresponded with the most diseased 748 
[part II. 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
portion of bowel. {Clin. Med., i. 600.) Louis found them more or less al- 
tered 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 retained only 
by a thin sac, and must have been effused into the abdominal cavity, had 
death been postponed for a few days. {Recherches sur la gastro-enterite.') 
Even the enteric inflammation and ulceration which attend phthisis, not un- 
frequently give rise to common inflammation of the mesenteric glands. Thus, 
Louis states that, when the glands were not found tuberculated in these cases, 
they were often increased in size, and more or less reddened. {Recherches 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. (Guersent, 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 frequently 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 apprehended 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 adhesion 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 Mesen- 
terica.-Scrofula Mesenterica.-Atrophia Mesenterica. 
This 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 occur between the ages of one 
and ten years. The complaint is not common in this country, at least as a 
distinct affection. It is more frequent in Europe. Guersent states that, in 
the Hopital des Enfans 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 CLASS III.] 
749 
DISEASE OF THE MESENTERIC GLANDS. 
of the tuberculous diathesis, which are often much more serious than itself, 
and not unfrequently completely mask its symptoms, so that it is first dis- 
covered upon dissection. Louis found the mesenteric glands more or less 
tuberculated in twenty-three, out of one hundred and two cases of pulmonary 
consumption. ^Recherches sur la phthisic.) Chronic inflammation and ulcera- 
tion of the bowels, so common in the advanced stages of this complaint, are 
very frequent complications of the mesenteric affection; and it is occasionally 
associated 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 
scrofulous diathesis appears to expend itself chiefly if not exclusively upon 
the mesenteric glands, in which case the disease may be distinct and pro- 
minent. 
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 frequent 
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, may 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 
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 gene- 
ral depend mainly on the first-mentioned cause. The emaciation, paleness, 
hectic, &c., are abundantly accounted for by the extent of tuberculous dis- 
ease, scattered over various parts of the system. The whole series of symp- 
toms may exist without disease of the mesenteric glands. 750 
[PART II. 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
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 Bbker, 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 coexistence of tuberculous disease 
in various organs, and the exhausting irritation of system which this occa- 
sions. In those instances of tabes mesenterica in which no symptoms are 
exhibited during life, the result is to be ascribed to the absence of inflamma- 
tion 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 considerable extent, it probably sooner or later 
becomes active, from the necessity of inflammation and ulceration to the 
escape of the foreign matter. 
• In many cases, inflammation 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 com- 
plications 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 enteric, 
peritoneal, or pectorgl 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 even- 
ing, loss of colour and flesh, and various sympathetic derangements of the 
neighbouring organs, such as constipation or diarrhoea, nausea and vomiting, 
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 compress- 
ing 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 CLASS III.] 
DISEASE OF THE MESENTERIC GLANDS. 
751 
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, especially at 
an advanced period of the complaint, as to be readily felt upon a careful ex- 
amination. When this evidence is joined to that of the symptoms above 
enumerated, and at the same time the patient exhibits signs of a scrofulous 
constitution, there can be no doubt as to the nature of the case. Hardened 
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 accumulations of 
this kind are confined to the large intestines, and must 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, 
red, swollen, and somewhat hardened; but sometimes they are entirely free 
from marks of inflammation, and even paler 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 peritoneal 
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 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 
deposits 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 dis- 
eases before the period of complete maturation. Occasionally, glands are 
found filled with 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- 752 
[PART II. 
LOCAL DISEASES.-ABSORBENT SYSTEM. 
dened, especially about the caecal extremity of the ileum, and is frequently 
ulcerated; the ulcers being small or large, superficial or deep, and in various 
stages of progress. Not unfrequently the omenta are found inflamed and 
tuberculated, 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 738.) 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 very apt to prevail in large hospitals 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 identi- 
cal, so far as regards constitutional measures, with that already detailed under 
the head of external scrofula. Any modifications that may be deemed neces- 
sary 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 influential 
in awakening the scrofulous predisposition in the mesenteric glands than in- 
testinal irritation or inflammation, and a torpid condition of the liver giving 
rise to congestion of the whole portal circle. Hence the great importance 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, magnesia, 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 ant- 
acids maybe conjoined with the tonics and cathartics; that one being pre- 
ferred 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, propor- 
tioned to the strength of the system, and to the violence of the local affection. 
General bleeding, however, will seldom be admissible. 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 CLASS III.] 
AUSCULTATION. 
753 
inflammation of the glands, which accelerates the march of the tuberculous 
affection, 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 purely chronic states of inflammation, gentle and long 
continued friction over 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. This remedy is preferable to mercury, from the circumstance, that, 
while iodine acts as a general tonic, and rather tends to support the vital ac- 
tions than otherwise, this remedy, though it may correct existing inflamma- 
tion 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 739.) 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 mea- 
sures 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 suppu- 
ration; 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 diag- 
nosis, which, being applicable to many of the affections in common, cannot 
be appropriately treated of in connexion with any one of theni exclusively. 
These may be included under the heads of auscultation, percussion, inspec- 
tion, manual application, and measurement, which are here mentioned in the 
order of their importance. 
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 sur- 
face, either directly, or through the intervention of an instrument denomi- 
nated the stethoscope. The proper methods of practising auscultation are 
sufficiently explained elsewhere. (See page. 204.) It is here to be considered 
only in its application to respiratory complaints. 
It may be proper to observe, preliminarily, that the sounds heard in aus- 754 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
cultation, or developed in percussion, vary in quality, intensity, and pitch, 
independently of those differences which depend on duration and succession. 
By the quality of sound is meant its peculiar character, that by which it may be 
distinguished from all other sounds, however similar they may be in the 
other properties referred to. Intensity has reference to the degree of strength, 
pitch to that of elevation. Differences in these respects often have important 
significance in diagnosis. 
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 compare each individual 
with himself; in other words, to examine the chest at different periods, and 
especially 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, are, first, those directly resulting from inspiration ana 
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. 
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 re- 
sults 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. Be- 
tween 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 con- 
tinuous. In relation to the character of the sound, it is a soft, diffused mur- 
mur, 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 
corresponding 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 by whatever increases the rapidity and force of respiration, and is CLASS III.] 
755 
AUSCULTATION. 
prolonged by a full breath. Thus, when naturally feeble, so as to be per- 
ceived with difficulty, it may be 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 persons, 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 re- 
spiration is said to be puerile, wherever met with, when the vesicular murmur 
is very loud. In old age, the sound becomes much weaker, while its dura- 
tion, which is diminished during inspiration, is increased in expiration. 
Hence, breathing of this kind is called senile. But sometimes, also, even 
when all circumstances 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 situ- 
ation it is sometimes called tracheal; but this differs only in degree from the 
sound yielded by the bronchia, 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, and between the scapulae posteriorly. It is more dis- 
tinct, both before and behind, on the right side than on the left, owing to the 
greater caliber of the tube proceeding to the right lung. That it cannot 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 strik- 
ingly 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 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. 756 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
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 like!y 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 mor- 
bid increase in the frequency and force of respiration, will give greater inten- 
sity, 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 ob- 
struction 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 or 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 a 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 cases 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 to some impediment in the bronchial tubes interfering with the 
ready exit of the air, or possibly, in some instances, as has been supposed, 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 circumstances, 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 vesicular sounds are both heard in the healthy state, the two become 
mingled, forming what has been called the rough or rude respiration. This CLASS III.] 
757 
AUSCULTATION. 
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 cither be feeble or increased, according as the cells are more or 
less affected. It is in expiration that this change is more especially observa- 
ble; 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 signs of incipient tubercle, pneu- 
monia, or pleurisy. 
The bronchial sound also is liable to morbid irregularities. Very fre- 
quently, in consequence of disease, it is heard without the accompaniment of 
the respiratory murmur, in parts of the chest where it is usually quite inau- 
dible. 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 bronchial respiration may depend 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, or 
into the pulmonary vesicles. It is in consequence of the greater solidity of 
the intermediate structure, that the sound is conveyed to the surface. Some- 
times the blowing sound is even louder than over the trachea, probably owing 
to the greatly increased surface of contact with the air, consequent upon the 
multiplication of the tubes; and also to the fact, that, in addition to the 
sound made by the movement of the air in the smaller tubes, that also of the 
larger tubes is brought to the ear, being conveyed downward through the 
ramifications, and thence to,the surface through the solidified lung. 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 dila- 
tation of the tubes, existing jointly with consolidation of the tissue. In vio- 
lent dyspnoea, the bronchial respiration may sometimes be heard over the 
whole chest without any change of structure. 
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. These sounds often pass into each 
other by such insensible gradations that no accurate line can be drawn be- 
tween them; and the cavernous respiration is denied by Skoda to be in any 758 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
degree distinct from the bronchial. It is certain that there are none of these 
sounds, except the amphoric, which may not be produced without a cavity in 
cases of consolidation of the pulmonary tissue; yet it is no less certain that, 
as a general rule, excavations in the lungs do give a somewhat modified cha- 
racter to the bronchial sound, which, though it cannot be relied on as sure 
evidence of a cavity, may, in conjunction with other not more certain signs, 
render its existence extremely probable. There does not, therefore, seem to 
be sufficient reason for abandoning, at least in the present state of our know- 
ledge, the nomenclature of Laennec in this respect. 
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 
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 the 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 mucoxis 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 
consequence of the sudden removal by coughing or otherwise of the obstruct- 
ing 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 yielding 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 CLASS III.] 
759 
AUSCULTATION. 
mucus, pus, or blood, of considerable, but unequal size. It accompanies both 
inspiration and expiration. When prevalent over a considerable portion of 
the lungs, it may often be heard at some distance from the chest. It is fa- 
miliar to most practitioners, as the sound which attends bronchitis after secre- 
tion 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 ex- 
ample 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 the name of cavernous rale. This is usually more circumscribed, and 
confined to narrower limits than the mucous rale, though, when owing to en- 
larged 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 resembles very closely that made by rubbing 
a lock of hair between the thumb and fingers, near the ear. It has been 
compared also to the crackling of salt, and to that produced by the burning 
of a very small train of moist gunpowder. It is confined exclusively to the 
minutest bronchial tubes, and to the air-cells, and may depend on the suc- 
cessive 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. Sci., 
N. S., 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 regu- 
lar 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 gen- 
erated. 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 760 
[part it. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
patient examination are necessary, to enable the practitioner to distinguish 
them satisfactorily. 
It must be recollected that, in consolidation of the pulmonary tissue, the 
various rales above referred to may be heard, in like manner with the bron- 
chial respiration, in parts of the lungs distant from their point of production, 
being conveyed through the bronchial tubes into the consolidated lung, and 
through that to the ear. 
Metallic tinkling is another morbid sound requiring notice. It is quick 
and sharp, and resembles that produced by striking a pin, or other small me- 
tallic body, gently against a glass vessel. Different opinions have been held 
as to its cause. The only necessary condition of parts, universally admitted, 
is the existence of a cavity of considerable size, with firm walls, containing 
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, to the bursting of the bubble on the surface 
of the liquid, and to the falling of a drop of fluid matter from the walls of 
the cavity, through the air, into the liquid. But Dr. Williams is probably 
correct in considering it as resulting from any sudden vibration of the air in 
the cavity, which is reflected from side to side of the walls. Hence, not only 
may any one of the above causes occasion it, but the voice, the respiratory 
act, and the different rales, may have the same effect; 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 communication, by the mere 
concussion of the voice and cough carried through condensed pulmonary tis- 
sue. (^Tweedie s Sy st. of Pract. Med., art. Pneumothorax.} In pulmonary 
cavities, having an external communication, it frequently attends and alter- 
nates with amphoric respiration, which owes its existence to a similar condi- 
tion 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; and an analogous sound is produced by placing the palm of the hand 
over the ear, and then giving the back of it a sharp tap with the end of the 
finger. 
Friction sound is a name given to the noise produced by the rubbing to- 
gether, during respiration, of the pulmonary and costal pleura, roughened by 
an irregular deposition of coagulable lymph upon the surface. It is of course 
entirely morbid, never being produced in a healthy state of the membrane. 
It consists usually of a succession of quick, jerking sounds, not very nume- 
rous, 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 vi- 
brations of the walls of the chest, perceptible to the hand, and even felt by 
the patient himself. Sometimes the friction sound, when not occasioned by 
ordinary breathing, may be developed by a deep inspiration, or by coughing. 
In its slighter varieties, it sometimes closely resembles the subcrepitant rale, 
from which it may be distinguished, according to Dr. Gerhard, by less regu- 
larity in the component sounds, and by not following so closely the passage 
of the air. Though usually most observable during inspiration, it is gene- 
rally 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 CLASS III.] 
761 
AUSCULTATION. 
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. 
Under the same name may be included the creaking sound made by the 
movement, during respiration or the pulsations of the heart, of the consoli- 
dated layer of coagulated lymph, after adhesion between the opposite surfaces 
has taken place. It is obvious that the proper interrupted friction sound may 
pass by degrees into the more continuous creaking sound, as the surfaces gra- 
dually coalesce. 
The friction sound is attended with vibrations of the thoracic walls, which 
may generally be perceived by the hand ; and sometimes are sensible to the 
patient himself. 
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 then* 
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 scapulae 
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 
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 intervenes 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 pene- 
trates 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, 
in 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 particular 
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 badly conducting 
medium, as of a large quantity of liquid in the pleural cavity. It is, how- 
ever, much more frequently increased, often becoming, in diseased lungs, 762 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
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 perceived 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 usually 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 
air-cells, the interlobular tissue, or to a certain extent into the pleural cavity. 
It may also depend upon morbid enlargement of the bronchial tubes, with 
thickening and consolidation of their walls. 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, therefore, 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 resonance at the top 
of the right than of the left lung, the presumption will be strong of the exist- 
ence of disease.* 
./Egophony is a name given to a modification of bronchophony, supposed to 
be 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, com- 
pared to the bleating of a goat, from which this variety of bronchophony 
derived itg name. When the lung is at the same time consolidated, the reso- 
nance is louder than when dependent solely on the presence of effused liquid. 
But the same sound is sometimes produced without liquid in the pleural 
cavity, and Skoda asserts that it is occasionally heard in the healthy lung, in 
the interscapular space. It cannot, therefore, depend solely on the movement 
of the liquid, as supposed by Laennec. Skoda ascribes it to the impact of one 
solid body against another, or of a solid against a liquid or aeriform body. 
Pectoriloquy is another variety of morbid vocal resonance, in which not 
* Skoda, the celebrated professor of Vienna, denies that the bronchial sound is con- 
veyed more readily through consolidated pulmonary tissue than through the same tissue 
in a healthy state. He ascribes the sound heard under such circumstances to conso- 
nance, by which the vibrations produced by the voice in the larynx, and conveyed through 
the air of the bronchial tubes, are repeated by the walls of those tubes in the consoli- 
dated lung, and thence reach the ear; the only effect of the consolidation being to give 
increased firmness to the walls of the bronchia, and thus enable them to vibrate more 
freely. He extends the same views to the respiratory bronchial sound, which he believes 
to be formed not in the tubes of the solidified lung, which scarcely expand or contract in 
respiration, and into which, therefore, air does not enter, or enters only in small quan- 
tity, but in the larger bronchia above, from which it is conveyed downward through the 
contained air. Skoda is no doubt correct in ascribing both bronchophony and morbid 
bronchial respiration to a conveyance of the sound from above into the tubes of the 
diseased lung; but he has not proved that the walls of the tubes do not transmit the 
vibrations as well as the contained air, nor that these vibrations do not reach the sur- 
face more readily through the solidified lung than they would do through the healthy 
sponge-like tissue. It is an established law in physics that solids transmit vibrations 
more readily than air, as in the well known example of a rail, in which a slight scratch 
of a pin at one end is distinctly heard at the other. Is it probable that a piece of loose 
sponge would transmit vibrations producing sounds so readily as the same sponge 
infiltrated with wax ? A similar relation the healthy pulmonary tissue bears to the 
same tissue uniformly consolidated by plastic exudation.-(Note to the fourth edition.) CLASS III.] 
AUSCULTATION. 
763 
only the sounds 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. But it may 
also be produced in the bronchial tubes of solidified lung tissue without a 
cavity, of which, therefore, though it may in general indicate the existence, it 
cannot be considered as a pathognomonic sign. 
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 circum- 
stances which produce bronchophony, cavernous under those which produce 
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, ca- 
vernous 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.* 
As a general rule, all the sounds given forth in morbid states of the respi- 
ratory organs are heard in those parts of the walls of the chest which corre- 
spond most nearly with the part affected; but it is necessary to bear in mind, 
in order to avoid false inferences, that they are sometimes conveyed to a con- 
siderable distance from their true seat, by the intervention of abnormal solid 
or liquid matters, which have a greater conducting power than the healthy 
pulmonary tissue. Thus, gurgling from a cavity in the upper part of the 
lung may sometimes be heard low down in the organ when solidified; and 
cardiac murmurs, usually most distinct at points nearest the valves producing 
them, are, under similar circumstances, sometimes audible over large portions 
of the chest. 
* 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 com- 
pressed, 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 " heautophonics" had been pro- 
posed by Dr. R. G. Latham, for this mode of diagnosis; and some attemptshave been made 
by Mr. G. Corfe, of the Middlesex Hospital, to apply it to the study of particular pec- 
toral affections. It is scarcely probable, however, that sufficient precision can be given 
to rules upon the subject, to render it anything more than a subordinate aid to ordinary 
auscultation. (See Braithwaite's Retrospect, xvii. 65; from Med. Times for January and 
March, 1848.)-Note to the second edition. 764 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
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 202.) 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 
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 
strikingly different from the dull flat sound, yielded by a perfectly solid 
structure as the thigh. This clearness, however, is much less than that of a 
large cavity containing air alone, or air and liquid, as, for example, the sto- 
mach 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 moderately tense, but without contracting the muscles in the 
part percussed. 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 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 per- 
•ssion, moreover, should be performed under similar circumstances in refer- 
ence 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 corre- 
sponding places on the opposite sides shall have been percussed; or, at any CLASS III.] 
PERCUSSION. 
765 
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 structure on the opposite sides; that it should not, for example, be 
in the intercostal 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 
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 not 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 heartland 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 tympanitic 
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 men- 
tioned is not abrupt. In consequence of the convexity of the diaphragm, 
the abdominal viscera project further into the thorax towards the middle than 
at the edges of the cavity, where they are to a considerable extent 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 di- 
rection 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 uncovered part of that 
organ. It follows that the clearness of the pulmonary sound gradually 
diminishes from the outer limits of the heart, liver, 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 dul- 
ness if full. On the right side, the sound begins to become 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 cer- 
tain extent, towards the epigastrium, by the stomachic sound. Behind the 
middle of the sternum, and on the left side behind 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. Behind 
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 consequence 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 cla- 
vicle percussion is less resonant than below; and the sound on the right side 766 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
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 per- 
sons. In women it is affected in front by the mammae, which render it dull, 
unless under pretty strong percussion. 
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 pulmonary 
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 
the degree of clearness in those parts of the chest where the lungs overlap the 
heart, liver, &c., depends in some measure on the force of percussion; a slight 
impulse evolving only the sound proper to the superficial parts, and conse- 
quently 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 pulmonary sound, though a very feeble per- 
cussion 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. It will be sufficient here to 
state that percussion is said to be tympanitic when it produces a drum-like 
sound, as over a cavity containing air with moderately tense walls; tubular 
when made over the trachea or one of the larger bronchia with solid or liquid 
intervening between it and the wall of the chest; and amphoric when attended 
with a certain musical intonation similar to that of amphoric resonance and 
respiration, and usually indicative of a large cavity with firm and thin walls, 
and lying near the surface. Consolidation or hepatization of portions of the 
lungs, oedema of these organs, compression by fluids in the pleural cavities, 
solid tumours, encroachments of the neighbouring organs, as the heart, liver, 
stomach, and spleen, emphysematous distension of the air-cells, and the pre- 
sence 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 CLASS III.] 
767 
INSPECTION. 
highly important, however, by calling attention to the existence of disease 
within the chest, and, in connexion with other* methods of diagnosis, often 
serves to give a certainty scarcely attainable otherwise. In relation to the 
existence of fluid in the pleural cavity, it is often of itself sufficiently diag- 
nostic. 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. An important fact, ascertained by Skoda, is, that great 
tension of the walls of a cavity containing air, contrary to what was formerly 
believed, causes dulness on percussion. This is probably owing to a degree 
of immovability of the particles, which prevents the ready transmission of 
vibrations to or from the air beneath; so that it is only the sound of the 
surface percussed, and not that of the air which is heard. 
Independently of the diversities of sound evolved by percussion, this method 
also affords useful indications by the impression made upon the sense of touch. 
When percussion is made with the finger, a certain sense of resistance is per- 
ceived, the degrees of which serve as a measure, in some degree, of the con- 
dition, in relation to elasticity, of the parts percussed; and inferencescan thus 
be drawn as to the condition of the lungs, which may serve to confirm or cor- 
rect, in some instances, those deducible from the sound. 
This is nothing more than an examination by the eye of the shape, size, 
and movements of the chest; and the object is to ascertain the existence of 
any 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 de- 
pression or flatness may often be observed surrounding the chest, immediately 
above the bulging produced by the abdominal viscera, during inspiration. 
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. Derange- 
ments, either congential or acquired, are very common, without any want of 
health in the contents of the thorax. This must always be taken into con- 
sideration 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 considerable deviation 
Inspection. 768 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
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 walls of the abdomen also 
expand regularly with every inspiration, in consequence of the descent of the 
diaphragm. The number of respirations in health is from sixteen to twenty 
in a minute. Between inspiration and expiration there is scarcely any appre- 
ciable 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 inequality in the size of the two sides ; by changes in the rela- 
tive 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. Irregularities in the movements of the abdomen 
connected with respiration are also observable upon inspection. The indica- 
tions 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 expan- 
sion of the lung itself, or of other organs in its immediate vicinity, as the 
heart, liver, stomach, or spleen, and tumours of various character, either in 
the lungs or their neighbourhood, 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 upon the right than the left side. In disease, the tremor 
is increased by whatever consolidates the lung without obliterating the bron- 
chial tubes, because the pulmonary structure thus becomes a better conductor 
of sonorous vibrations. The impression produced upon the hand in this way 
is sometimes very strong, when there is a considerable extent of consolida- 
tion. The intervention of liquid or air between the sides of the chest and 
the lungs, or an emphysematous expansion of the air-cells, has, on the con- 
trary, the effect of checking or intercepting the vibrations, so that the tremors 
will not be felt. The thrill imparted to the chest by the friction of the op- CLASS III.] 
769 
MEASUREMENT. 
posite surfaces of the inflamed pleura may sometimes be perceived by the 
hand, as may also the vibrations which attend a sonorous rale of great inten- 
sity. In the same way, fluctuation in the pleura or lungs may occasionally 
be detected; the fluctuating movement being produced either by strong agita- 
tion of the chest in certain morbid states of respiration, or artificially by 
shaking the patient, or by a sharp tap with the fingers upon one of the inter- 
costal spaces in the neighbourhood. The act of respiration also gives rise to 
it, in cases of large pulmonary cavities partly filled with liquid. In examin- 
ing the chest in reference 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 or 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 movements 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 detected, may become under some circumstances a valuable 
sign. 
The beating of the heart, after full expiration, is felt between the cartilages 
of the third and fifth 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. 
The inodes of effecting measurement have been elsewhere described. (See 
page 204.) The object of the process is to detect differences in the dimen- 
sions of the two sides, or in those of the whole chest 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, though the liver may also have some effect in 
causing 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 left- 
handed persons it is said that the two sides are equal, or that the left is some- 
what 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. Among other points ascertained by measure- 
ment, is the increase or diminution of fluids in the cavity of the pleura. 
Under this head may also be considered the measurement of the respiratory 
movements, and of the quantity of air respired. It is often desirable to know 
how, and to what extent, the motions of the thorax and abdomen are inter- 
fered with by disease; and diagnosis is aided, in several important points, by 
the decision of this question. In order, however, to have some standard of 
comparison, it is necessary to determine the mean amount of movement in 
health. In ordinary respiration in men, the walls of the chest are but 
slightly expanded; inspiration being mainly effected by the descent of the 
diaphragm. The forward movement of the chest, therefore, is very slight, 
while that of the abdominal parietes is considerable, and readily observable 
by the eye. In women, it is different; the thoracic movement being much 
more distinctly observable, and that of the abdomen less so. According to 
Dr. Sibson, the forward movement of the sternum, above the seventh rib, in 
a robust man, in ordinary healthy respiration, is from the fifteenth to the 
fourteenth of an inch, that of the abdomen about one quarter of an inch. 
In forced respiration, these dimensions are greatly altered. An extreme in- 
vol. i. 49 
Measurement. 770 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
spiration will advance the sternum from one to two inches; while the greatest 
movement of the abdomen is from half an inch to an inch and a half. In the 
fullest possible inspiration the abdomen projects very little, because the ex- 
pansion is now effected mainly by the ribs, and comparatively little by the 
descent of the diaphragm. The expansion of the chest, as indicated by its 
circumference, in a healthy male adult, at the level of the sixth cartilage, in 
an ordinary inspiration during calm breathing, is on the average about one 
quarter of an inch. In a forced inspiration it amounts to from one and a half 
to three inches, being somewhat greater on the right than the left side. The 
difference between the extremes of a forced inspiration and a forced expira- 
tion, varies from two and a half to five inches. In the abdomen, in the 
greatest possible inspiration, the increase is only about one quarter of an inch, 
being less than that which occurs in ordinary breathing; though, by a volun- 
tary effort of the individual, directing the inspiratory movement rather to the 
diaphragm than the ribs, the result may be very different. Any considera- 
ble deviation from the above measurements may be looked upon as suspicious, 
and should lead to further investigation. Two instruments have been invented, 
which greatly facilitate the mensuration of the chest while in motion. One 
of these is the " chest measurer," of I)r. Sibson, the other the " stethometer," 
of Dr. Quain, the former of which indicates the change of diameter, the latter 
that of circumference.* In relation to the measurement of the quantity of 
air respired, it is extremely difficult to arrive at any satisfactory results; and 
the reports of different experimenters have been so various and conflicting, 
that little reliance can be placed on them for practical purposes. An instru- 
ment, however, invented by Mr. Hutchinson, affords a very convenient method 
of measuring the amount of expired air; and some conclusions have been 
attained.by means of it, which are not without practical value. An account 
of this instrument, which is called the "spirometer," and of its application, is 
given in a note below.f 
* The " chest measurer," of Dr. Sibson, consists of a small round case -with two dial- 
plates supported at the end of a rod, which at the other end is connected, in a manner 
to admit of free movement upward and circularly, with a second rod rising perpendicu- 
larly from a long narrow plate, upon which the body rests when examined. From the 
interior of the case projects a short movable rack, which, as it rises or falls, causes the 
index hand on the face of the dial to revolve in a circle, each revolution representing 
an inch of movement in the rack, and each subdivision the hundredth of an inch. When 
applied, the end of the rack is brought into contact with the surface of the chest or 
abdomen, the elevation or depression of which, at the point of application, is exactly 
measured by the movement of the rack, and, of course, by the change of the index on 
the dial. For a particular account of the instrument and its uses, the readei' is referred 
to Dr. Sibson's paper, in the London Medico-Chirurgical Transactions (xxxi. 355). 
The stethometer of Dr. Quain is a simpler instrument. Upon the surface of a case 
resembling a watch, is a graduated dial with an index, moved by means of a silk cord a 
foot oi' more in length, that enters the side of the case. The instrument being applied 
by the fingers of one hand to any given point of the chest, the cord is carried over that 
part of the surface the movements of which are to be measured, or, if deemed advisa- 
ble, quite round the thorax, and, being fixed by the other hand, acts with each expan- 
sion or elevation of the thoracic wall upon the index, a complete revolution of which 
indicates an extension of the cord, and consequently an increase in that part of the cir- 
cumference measured, equal to one-fourth of an inch. The instrument and its uses 
are particularly described in the London Medical Gazette for January, 1851 (page 127), 
and in Braithwaite's Retrospect (Am. ed., xxii. 157). Note to the third edition. 
| Mr. Hutchinson's spirometer, as modified by Dr. Pereira, consists essentially of a 
reservoir of water, in which is suspended an inverted glass receiver, so arranged that, 
by breathing through a tube entering into the receiver from below, this is made to rise 
in proportion to the amount of air admitted, which is measured by a graduated scale 
affixed to the upper end of the receiver. As each degree of the scale represents a cubic CLASS III.] 
INFLAMMATION OF THE RESPIRATORY PASSAGES. 
771 
SUBSECTION I. 
INFLAMMATION OF THE RESPIRATORY PASSAGES. 
Inflammation may occupy distinct portions of these passages, terminating 
in the same part in which it began, 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 
inch, it follows that the number of degrees through which the receiver rises indicate 
the number of cubic inches of air expired. 
From the various circumstances which modify respiration, it is almost impossible to 
measure with accuracy the results of that process as ordinarily performed. But the 
greatest amount of air that an individual can possibly expire, after the fullest possible 
inspiration, gives a certain measure of capacity which can be ascertained, and, being 
compared as found in the same individual under different circumstances, or in different 
individuals as nearly as may be under the same circumstances, may lead to inferences 
of some practical value. To this quantity Mr. Hutchinson gives the name of "vital 
capacity." Now, from the examination of a vast number of individuals, Mr. Hutchinson 
seems to have established the curious law, that the vital capacity is proportionate in 
health directly to the height of the body, without reference to the depth or breadth of 
the chest, or to its absolute capacity when at rest. It is, however, somewhat affected 
by the weight and the age of the individual, and allowance must be made for these 
modifying influences in forming any practical conclusions. Other influences also are 
not without effect; but they maybe left out of the calculation with little inconvenience. 
The mean vital capacity for a man from five feet to five feet two inches, at a temper- 
ature of 60°, was found to be 175 to 176 cubic inches. For convenience of calculation 
it may be stated at 174 cubic inches for the stature of five feet. For every inch of 
increased height, eight cubic inches are to be added to the vital capacity. 
In reference to the effect of weight, it has been ascertained that the vital capacity in 
healthy men is not materially altered below the mean weight; but is diminished in a 
certain ratio with any increase amounting to more than 7 per cent, above the mean. 
The mean weight of a man in England, from five feet to five feet one inch in height, is 
said to be about 115 pounds. For every additional inch of height, the mean increase 
of weight may be stated roughly at 5J pounds. From these data the mean weight for 
any height above five feet may be readily ascertained. Add to this weight 7 per cent.; 
and then, for every additional pound, one cubic inch is to be deducted from the vital 
capacity. These are only approximations to the numbers which have resulted from 
positive experiments as presented by Mr. Hutchinson; but they are sufficiently near 
for practical purposes, and are useful on the score of simplicity of calculation. 
The effect of age is next to be considered. Up to 85 years, the vital capacity, accord- 
ing to the table of Mr. Hutchinson, is somewhat augmented with age, but not sufficiently 
so to render the increase an object of consideration. From 85 years to 65 there is a de- 
crease of 45 cubic inches, or exactly 1J cubic inches for every year. In estimating the 
vital capacity, therefore, this number must be deducted for every year above 85. 
With these data, the normal vital capacity of any individual may be readily estimated; 
and, if this considerably exceed the result given by the instrument, the inference drawn 
would be unfavourable as to the healthy condition of his respiratory function. General 
debility, muscular fatigue, rheumatism or other disease of the respiratory muscles, and 
various abdominal affections, as well as disease of the lungs, have the effect of lowering 
this capacity ; and the decision as to the precise cause must be left to other modes of 
investigation. It is obvious that the spirometer affords an admirable means of estimating 
any change in the capacity of the lungs of the same individual whether for better or for 
worse. 
To illustrate the operation of the above rules let a case be imagined, and the result 
deduced in accordance with them. What is the healthy vital capacity of a man five 
feet ten inches high, weighing 160 pounds, and 45 years of age? Starting from 174 
cubic inches, which is the vital capacity for the height of five feet one inch, and adding 
8 cubic inches for each inch of stature, we shall have 246 cubic inches as the vital ca- 
pacity in reference to the stature alone. The mean weight at five feet one inch is 115 
pounds, to which 5J pounds being added for every inch, gives the mean weight at 164J 
pounds, or less than 7 per cent, beyond the supposed weight. No allowance, therefore, 772 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
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, as those 
of the superior maxillary and frontal bones, all of which are lined by con- 
tinuations of the same mucous membrane, and all are liable to become 
inflamed, though the whole surface is probably seldom affected at once. 
1. ACUTE INFLAMMATION OF THE NOSTRILS, or CORYZA. 
Syn.-Cold in the Head.-Gravedo. 
Symptoms.-The first sensations are usually those of dryness, fulness, and 
tickling or other irritation in the nostrils, with sneezing. These are in gene- 
ral soon followed by a copious discharge of a thin, colourless, acrid fluid, which 
still further irritates the membrane, while it often inflames and even exco- 
riates 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 tume- 
faction 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 thS 
disease to the frontal sinuses produces pain in the forehead. The maxillary 
sinuses are sometimes involved, with consequent pains in the face; and hard- 
ness of hearing in a greater or less degree is not uncommon, from swelling 
and closure of the Eustachian tubes. Even the external parts occasionally 
participate in the inflammation, and the nose and cheeks are swollen and 
tender. The sense 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 
is to be made on this score. The age being 10 years beyond the standard of 35, and 
1J cubic inches being the mean diminution for each year, 15 altogether are to be de- 
ducted from the 246 cubic inches, which represent the vital capacity in reference to 
height alone. There -will then remain 231 cubic inches as the healthy vital capacity 
under the circumstances referred to, and as that which the spirometer should indicate. 
(See, for Mr. Hutchinson's paper, London Medico-Chirurgical Transactions, xxix. 137.) 
In using the spirometer, with the view of ascertaining the vital capacity, the individual 
should loosen his dress, stand erect, and then, having inspired to the utmost extent of 
his power, apply his mouth to the tube, and empty his chest as completely as possible 
into the receiver. (Note to the third edition.') CLASS III.] 
CORYZA. 
773 
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 head- 
ache. 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 less acrid; and sometimes assumes a yellowish, or greenish-yellow, puru- 
loid appearance; the fever gradually subsides; and the recovery is usually 
complete in from five to seven days, unless the disease is kept up by improper 
management, or renewed by a repetition of the cause. In this case, it some- 
times becomes chronic, and may then run on for weeks, months, or years. In 
a few instances, it retains a sort of acute character, with a thin acrid dis- 
charge, for a considerable time, probably in consequence of fresh attacks 
before the old have ceased. This watery secretion, so characteristic of the 
disease, and which has given it the name of coryza, is not invariably present; 
the inflammation being sometimes dry at the commencement, and remaining 
so until thick mucus, 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 th$ 
nostrils, and immediately adjoining parts. Sometimes it affects one part only, 
being confined to one side of the nostrils, 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 sometimes 
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 mem- 
brane, which forms solid layers upon the surface, as in diphtheritic inflam- 
mation of the fauces, which this affection sometimes accompanies. Such cases 
are always serious, and not unfreq uently 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 coughing or sneezing, 
of portions of the false membrane, and the appearance of the exudation either 
near the anterior nasal orifices, or in the fauces. 
Causes.-The most frequent exciting cause of coryza, beyond all comparison, 
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 exertion. 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 774 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
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 habit of ex- 
posure; hut 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, and are 
scarcely entirely free from the complaint until warm weather returns. Coryza 
is also frequently epidemic, being a very general attendant upon the influ- 
enza. It is very common at the beginning of measles, and sometimes accom- 
panies other exanthemata in their earlier stages, especially smallpox, and 
scarlet fever. Occasionally it is produced by the direct application of acrid 
vapours, or irritating powders, to the nostrils. 
Treatment.-Most cases of this disease are so mild as not to require medi- 
cal treatment, and scarcely to interrupt the avocations 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 am- 
monia, nitre, and tartar-emetic, variously combined to suit the circumstances 
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 addi- 
tional 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 
sinuses, 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. S., iv. 
295.) A lump of camphor held near the nostrils sometimes affords relief. I 
knew an individual who derived prompt relief from snuffing up powdered 
cloves. Powdered cubebs have been recommended in the same way. Steam- 
ing with the vapour of hot water, snuffing powdered gum arabic up the nose, 
■the injection of oleaginous liquids with some narcotic ingredient, and the 
direct application of the vapour of acetic acid, are also among the measures 
occasionally resorted to. M. Deschamps has found a solution of extract of 
opium, made in the proportion of about a grain to a fluidounce of water, and 
drawn into the nostrils by inspiration, 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 enter the fauces, when it is to be allowed to flow out again. 
The application may be made every two hours if necessary; but seldom re- 
quires to be more than once repeated. (Journ. de Pharm. et de Chim., xi. 
370.) Dr. J. II. Douglas, of New Orleans, cures the severest coryzas by 
causing the patient to snuff a little laudanum up the nostrils, taking care 
that none is swallowed, and following this measure by a brisk cathartic. 
(V. 0. Med. and Surg. Journ., ix. 604.) Dr. John A. Lockwood has CLASS III.] 
775 
CORYZA. 
found the application of a solution of nitrate of silver, containing eight or 
ten grains in the fluidounce, applied by means of a camel's-hair pencil, to the 
mucous membrane of the nostrils, at the beginning of the attack, a sovereign 
remedy. (Am. Journ. of Med. Sei., N. S., xviii. 21.) Injections of a solution 
of sulphate of zinc, of the strength of two or three grains to the fluidounce, 
have also been used. 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 comple- 
tion 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 antimonial. 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 contri- 
butes to the cure. The food should not be heating or saline so as to excite 
thirst, and the solid matters used may be moistened with liquids. Though 
" total abstinence from liquids is most effectual, yet taking about a teaspoon- 
ful 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 discomfort." As, according to Dr. Williams, the plan pro- 
duces no injurious effects, the patient may well be allowed to choose between 
its discomfort, and that of the disease under ordinary treatment. 
When, after the subsidence of the acute symptoms, the complaint continues 
obstinate, with a copious mucous or muco-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. Dr. C. D. Meigs recommends strongly, as a very effectual 
remedy, to cover the head with a closely fitting flannel cap. (Trans. of Col. 
of Phys, of Phil., iii. 63.) In severe cases, when the head is threatened, it 
will be proper to apply leeches, 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, or to blow powdered alum up the nostrils. 
When an individual is subject to the complaint in 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. More than thirty years ago, the author heard this plan 
suggested by the late Dr. Chapman, of the University of Pennsylvania, in his 
lectures, and he has had frequent opportunities of verifying the statements of 
Dr. 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 bedtime; and the 776 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
patient will often awake in the morning free from the disease. An aperient 
may sometimes be advisable to correct the constipating effects of the opium. 
Another mode of obtaining the same end is to produce a copious diaphoresis 
by soaking the feet in hot water, and administering copious draughts of some 
hot herb-tea, as of balm, sage, horehound, &c., at bedtime. The plan will 
be still more 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 pre- 
caution. Sometimes a rich supper, with a due accompaniment of stimulants, 
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 cause, 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 cold shower-bath is also recommended. 
2, CHRONIC INFLAMMATION OF THE NOSTRILS, or OZ^ENA. 
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. 
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 ozaena, 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 
sometimes occurs without any violation of the integrity of the mucous mem- 
brane ; but more frequently it is associated with ulceration, and sometimes 
with caries of the bones, or necrosis. In the latter case, pieces of bone some- 
times escape with the pus or sanies. Large solid flakes of excessively offen- 
sive 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 is almost always much impaired, if not lost. 
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 ozaena, 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. CLASS III.] 
777 
OZ^NA. 
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 in the nos- 
trils, 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 inflammation 
of t?he fauces. Iu the form of ozaana, when not ulcerous, it may depend upon 
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 accidental retention of the secretions 
In ay 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 supposition of peculiar morbid- constitu- 
tional tendencies. When associated with ulcers, it is most frequently de- 
pendent on a syphilitic, scrofulous, or scorbutic taint. 
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 prefer- 
red 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 rehch 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 chlo- 
ride 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 injections 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 
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 de- 
coction or syrup of sarsaparilla. Tonics, and, in general, measures calculated 778 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
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 in 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 danger- 
ous, 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 propriety might 
we restrict the name of bronchitis or pneumonia to the very highest grades 
of these complaints, and then proclaim them as eminently dangerous. 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 submucous tissue, it be- 
comes very alarming and even fatal. Its great danger, under these circum- 
stances, 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. 
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 sub-mucous cel- 
lular tissue, involving that and the mucous membrane at the same time, thus 
greatly increasing1 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. sid)-mucous laryn- 
gitis, in which the sub-mucous tissue is also involved, and sometimes chiefly 
so, as in the proper edematous variety; and, 3. pseudo-membranous 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 to- 
gether, or differ only by almost insensible shades, so that they cannot be dis- 
tinguished by'the symptoms. 
1. Mucous Laryngitis.-In its mildest form, this is marked by a slight 
hoarseness, without pain or difficulty of respiration, and often with little or no CLASS III.] 
779 
ACUTE LARYNGITIS. 
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, to- 
gether with tightness or stricture, a dry husky cough, and often a slight diffi- 
culty of inspiration. If the fauces are examined, they will frequently be found 
in a greater or less degree reddened. Under proper treatment, these symp- 
toms speedily subside. 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 laryngitis. 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 mode- 
rate, increased by speaking and coughing, and occasionally by external pres- 
sure. The patient often has the sensation as of a foreign body in the larynx. 
Inspiration is difficult, and often stridulous or tightly sounding, while the 
patient feels a distressing constriction of the throat, and exhibits some anx- 
iety or apprehension about his ability to get breath. The cough is hoarse or 
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 convulsive. Thbre is often some diffi- 
culty of swallowing, arising from coexisting 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 experienced, arising from spasm of the 
muscles of the glottis, such as occurs in croup. There is generally some de- 
gree of fever, which may have come on simultaneously with the local symp- 
toms, or not until they had existed for some time. It cannot be doubted that 
there is in these cases considerable swelling of the mucous membrane; and it 
is riot 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 foui- 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 bronchitis is apt to ensue. 
2. Sub-mucous Laryngitis.-Edematous Laryngitis.- Cynanche Laryngea. 
-This differs from the preceding rather in degree than in character. It may 
be considered as the highest grade of acute laryngitis, extending to the sub- 
jacent areolar 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 have been the first recorded in detail. According to Cheyne, the dis- 
ease 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 chil- 
liness 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 inspira- 780 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
tion is prolonged, wheezing, whistling, or otherwise sonorous, and requires a 
considerable 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 
sometimes 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 ex- 
ternal parts about the larynx are also often much swollen, though not invaria- 
bly 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 
substances swallowed to enter the larynx, where they excite intense irritation, 
and give rise to vehement paroxysms of coughing, with the most distress- 
ing dyspnoea. Dr. Watson relates a case in which, after laryngotomy, a por- 
tion of anything swallowed appeared immediately at the wound. {Leet, on 
Princip. and Pract. of Med.} 
Should the case continue to advance, all the symptoms are aggravated. 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 accomplished 
only after violent efforts, with great distress and anxiety, and a feeling as of 
impending suffocation. The patient is in general extremely restless, some- 
times starting up suddenly in bed, walking about the chamber, putting his 
hands to his throat, showing the greatest eagerness for fresh air, and express- 
ing in his countenance an almost fearful anxiety, apprehension, and distress. 
He is unable to sleep longer than a few minutes at a time, being roused by 
the necessity for voluntary effort to get breath. The blood now begins to ex- 
hibit 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 quickly 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. 
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 is unable to recover from the depressing influence of the black 
blood. Death may, therefore, occur either suddenly, from complete closure 
of the passage; or gradually from a partial and insufficient supply of air, 
causing a change of blood, the effects of which a subsequent return of respira- 
tion cannot always obviate. 
The disease is very rapid; generally, when fatal, ending in from three to 
five days, and sometimes much sooner. 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 tumefac- 
tion in the larynx, though it is probable that life is sometimes suddenly termi- 
nated by the supervention of spasm of the glottis. I have seen a case, in CLASS III.] 
781 
ACUTE LARYNGITIS. 
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 entered 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 de- 
pends 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, or 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, and 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 inflammation; 
and the peculiar result is probably owing in general to peculiarity of the con- 
stitution or of the blood, predisposing to serous effusion under inflammatory 
action. Dr. Stokes says that this variety of laryngitis is sometimes conse- 
quent 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 
symptoms. 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 
difference between the facility of inspiration and expiration, and the results 
of local inspection, point beyond all doubt to the true seat of disease. Some 
of the French practical writers speak of the introduction of the finger into 
the posterior fauces, and the perception of a cushion formed by the tumefac- 
tion of the border of the glottis (Valleix, Guide Med. Prat., 2e ed., i. 240); 
but this mode of examination must be difficult, and might possibly aggravate 
the inflammation. 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 a mistake impossible. 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 
ofcroup, laryngitis bears a close analogy; but, in the former, spasmodic con- 
traction of the muscles of the glottis, in the latter, swelling of the lining 
membrane or the parts beneath it, is the prominent and characteristic phe- 
nomenon. More will be said upon this subject under croup. With mere spasm 
of the rima glottidis, unconnected 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. 782 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
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 ob- 
servation, 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 gene- 
rally 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 chances 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 positive 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 may 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. Pseudo-membranous 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 exten- 
sive 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 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 
smallpox 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 dis- 
tinguished during life. After death, pus has been found bathing the carti- 
laginous surfaces. 
Appearances after Death.-The mucous membrane lining the larynx is 
gorged with blood, softened, and thickened, while the subjacent cellular tissue 
is distended with bloody serum or a sero-purulent fluid. This tumefaction 
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 mem- 
brane, but great swelling, in consequence of the effusion of serum beneath it. 
Causes.-The 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 
perspiration from heat or exercise. There is in some individuals a peculiar 
predisposition to be affected by this disease; so that when any general cause CLASS III.] 
ACUTE LARYNGITIS. 
783 
of inflammation acts, it is almost certain to affect the larynx. Persons simi- 
larly predisposed to tonsillitis, are said to be also peculiarly susceptible to 
laryngitis; the force of the morbid influence falling sometimes on one part, and 
sometimes on the other. A continued, frequent, and powerful exertion 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 scald- 
ing water or corrosive liquids, which an individual may accidentally attempt 
to swallow; flame or hot air inhaled during exposure to fires; corrosive irri- 
tating 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 mu- 
cous 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 relative position in the other. 
Hence, when tonsillitis is propagated to the larynx, the disease sometimes as- 
sumes the worst forms of sub-mucous laryngitis. Mercurial stomatitis, accord- 
ing to Cheyne, sometimes extends into the larynx. Erysipelas, and the sore- 
throat of scarlet-fever, sometimes prove fatal by reaching that structure, and 
giving rise to sub-mucous or pseudo-membranous inflammation. Measles, 
catarrh, and smallpox also occasionally give rise to some form of laryngitis. 
The affection occurs as an accompaniment or consequence of typhoid fever. 
Aneurism of the aorta may produce it, by the propagation upward of the bron- 
chial inflammation which it causes. Cheyne considers intemperance as a pre- 
disposing 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- 
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 insure 
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, 784 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
and the system afterwards be kept moderately under its influence, in con- 
junction 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 
prostrating influence from this powerful sedative. I have witnessed the hap- 
piest 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 hyoscyamus 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 reme- 
dies. If the disease still remain unsubdued, recourse should be had to the 
mercurial influence, which will seldom fail, in cases of ordinary inflammation, 
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 forbid- 
den 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 bleed- 
ing, and the operation repeated once or oftener if necessary. The loss of 
blood should stop short of syncope. The obstruction to the respiration con- 
sists in an internal tumefaction of the larynx, which is not at once removed 
by the bleeding. A certain amount of muscular force is necessary to over- 
come the resistance in the glottis; and, if the patient be bled to fainting, 
there might be some reason to fear that his returning powers would be insuf- 
ficient 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 moderate degree of inflammation, and little or no fever. 
It might prostrate the patient below the point of reaction. Moderate vene- 
section, however, is both tolerated and required. In the highly inflamma- 
tory 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 diffi- 
culty, in consequence of the superficial inflammation they excite producing 
subcutaneous extravasation. But the danger 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 
leeches 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 substituted, 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 hours, 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 CLASS III.] 
785 
ACUTE LARYNGITIS. 
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 antimonials in this affec- 
tion. 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 would be very apt to enter the glottis, and provoke the 
most vehement and distressing paroxysms of cough and dyspnoea. 
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 rather 
than in the front, where it would be in the way of laryngotomy. The strong 
solution of ammonia would, in some cases, be preferable to cantharides, in 
consequence of the rapidity of its action. 
In the asthenic cases, which will not bear bleeding, reliance must 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 of the disease with chronic tuberculous or scrofulous 
laryngitis. 
When bleeding and mercury fail, the only remedy upon which much reli- 
ance can be placed is the opening 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 condi- 
tion which positively forbids it is the existence of extensive pulmonary disease, 
which would render death certain at all events. It is highly important 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 instrumentality, 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 patient, ex- 
hausted by wakefulness, suffering, and the labour of respiration, sinks into a 
calm slumber almost immediately after the opening has been effected. Respi- 
ration 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 secretion, more or less 
copious, of muco-purulent matter. The performance of the operation be- 
longs to surgery. Laryngotomy is generally recommended; and the opening 
should be made between the cricoid and thyroid cartilages. Some advise the 
upper part of the trachea as the seat of the operation. If not liable to 
surgical objections, the latter position would appear to be preferable, on ac- 
count of the danger of augmenting the laryngeal inflammation, by the intro- 
duction of the tube necessary to keep the opening pervious. The inner 786 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
extremity of the tube should be prevented from projecting into the cavity, 
beyond the level of the mucous surface. Sir 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 operation. 
As much mucus is often discharged, it is advisable that the patient should 
facilitate the coughing necessary for its expulsion by 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, too, 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 pas- 
sage, 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 employed, the cure was ascribed chiefly 
to this measure. (A7 K Journ. of Med., x. 72.) This remedy is especially 
indicated in the pseudo-membranous variety. 
2. CHRONIC LARYNGITIS. 
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 as the 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 
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 the 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 
Syn.-Laryngeal Phthisis. 
* For various information and views on the subject of "bronchotomy in edematous 
laryngitis," see a paper by Dr. Felix Sestier, in the Archives Generales, 4e ser., xxiii. 
385, and xxiv. 35, 297, and 441. CLASS III.] 
787 
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 progress. There appear, how- 
ever, to be cases in which the mucous follicles become the seat of ordinary 
inflammation, and in which ulceration may take place, without complication 
either with the scrofulous diathesis or syphilitic disorder. 
The disease, when not consequent upon an 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 for months, and ulti- 
mately disappear, especially upon the occurrence of warm weather. Fre- 
quently, however, the symptoms are less mild. Various morbid sensations 
are felt in 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 occasion- 
ally by pressure. But, in a large portion 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, some- 
times stridulous or squeaking, and sometimes whispering. 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 com- 
plaint 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 inflammation, 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 exist- 
ence, and not unfrequently occur before they are even suspected. But, gene- 
rally speaking, the ulcerative stage is marked by some of the following pheno- 
mena. In cases attended with follicular inflammation of the fauces, the follicles 
within view exhibit signs of ulceration. There is often a pricking 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. Trousseau 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 portions of the cartilages, sometimes ossified, and 
calcareous concretions, are found among the matter discharged. The respira- 
tion is often difficult, though occasionally somewhat relieved after free suppu- 
ration, in consequence probably of the removal by ulceration of tumefactions, 788 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
which may have narrowed the passage. It may be wheezing, hissing, or other- 
wise noisy, and is sometimes merely tight, as if the air were drawn through 
a narrowed passage. The difficulty is sometimes continuous, but is more fre- 
quently 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 of 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 laryn- 
gitis. 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 reason 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 discharged 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 
epiglottis can be seen ulcerated or deformed, if these or some of these symp- 
toms 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 
character. Should evidence of tubercles in the lungs be afforded, or the pa- 
tient 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-exist- 
ence 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 fatal; that the syphilitic 
variety may generally be cured in its earlier stages, and is seldom quite despe- 
rate; and that, when neither of these complications exist, and no other serious 
depravation of the general health can be discovered, we may entertain a reason- 
able hope of making a favourable impression oh the complaint. 
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 liga- 
ments and epiglottis, sometimes superficial, sometimes deep, penetrating 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. The cartilages themselves 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 ulcera- 
tion, and bathed in a fetid pus. The epiglottis is sometimes irregularly con- 
tracted, ulcerated, and partially or wholly destroyed; as are also the vocal 
ligaments. The sub-mucous tissue is infiltrated with serum or pus, or thick- CLASS III.] 
789 
CHRONIC LARYNGITIS. 
ened and indurated; and the ventricles are sometimes obliterated from this 
cause. The muscles of the larynx are wasted, hardened, or otherwise degene- 
rate, and the ligaments contracted and distorted. Excrescences of various kinds 
appear on the surface of the mucous membrane, especially in syphilitic cases. 
It is stated that, in syphilis, ulcers are apt to form on the anterior surface of 
the epiglottis, while in scrofulous cases they occupy the posterior surface. 
Louis states that he has not found tuberculous granulations 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 subjects. 
Among these the most common are cold, an excessive use of the voice in 
speaking or singing, irritating substances inhaled, propagation of inflamma- 
tion 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 occasionally con- 
nected sympathetically with chronic gastritis. It is often the result of inflam- 
mation 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 consti- 
tutes 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, hyoscyamus, lactucarium, extract of hemp, or some other 
narcotic. It has been recommended to rub unctuous preparations of hyoscya- 
mus, belladonna, &c., over the larynx; and plasters of opium and of bella- 
donna 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 inhalation 
of irritating substances, should be protected against them, by means of a fine 
gauze veil, or 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 some- 
times 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 prepara- 
tions of iodine, especially the iodide of potassium; and iodine ointment may 
be rubbed upon the throat. Means should also be employed to 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 ulceration and suppuration. Cod-liver oil is 
a most valuable remedy in this form of the disease. 
Local applications 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 790 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
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 subnitrate 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 whole the most manageable and 
efficacious. It was commonly employed by M. Trousseau dissolved in distilled 
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 fluidounee. 
Nitrate of silver has the great advantage of combining superficially with the 
tissues, and thus affecting only the surface, so that little danger need be appre- 
hended of extensive mischief, if the application be properly made. Various 
plans have been proposed by M. Trousseau 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 di- 
rected to make the motion of swallowing, so as to raise the larynx. Another 
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 sipall 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 
together, 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 ap- 
plied, the solution occasions a violent paroxysm of coughing, and sometimes 
even vomiting, which, however, subside in a short time without serious conse- 
quences. To decompose the portion of nitrate which may not unite immedi- 
ately 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 tb inspire forcibly. 
Dr. Horace Green, of New York, applies a strong solution of nitrate of 
silver directly to the laryngeal mucous membrane, and with the best results. 
He employs a solution of the crystallized nitrate, of the strength of frojn 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 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. 566.) CLASS III.] 
ACUTE BRONCHITIS. 
791 
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 aperture. 
A momentary spasm of the glottis takes place, by which the sponge is com- 
pressed, 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 repeated 
two or three times a week, until a cure is effected. (Treatise on Dis. of the 
Air Passages, &c., N. Y., p. 199, &c.) 
Dr. Cotton, of London, employs a pair of curved forceps, with flattened 
blades, to the end of one of which a small piece of sponge is firmly attached. 
This being saturated with the solution, the instrument is introduced into the 
fauces, and the blades are closed, so as to compress the sponge, and cause the 
liquid to fall directly into the larynx. (Lond. Med. Times and Gaz., June, 
1852, p. 579.) 
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 im- 
mediate 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 tra- 
cheitis to croup, is founded on 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 fea- 
tures 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 
man 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, in the last 
mentioned position, unless modified by treatment, the grade of severity which 
characterized it at the outset. 792 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
In its mildest form, acute bronchitis is a very slight disorder, commonly 
called a cold, or a cold in the hr east. It usually comes on with a little 
hoarseness, 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 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, 
followed by febrile reaction, it soon exhibits the characteristic signs of bron- 
chial 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 se- 
vere cases, these sensations are distressing, and attended with feelings of 
oppressed breathing, and occasionally with some difficulty of inspiration. 
Cough is usually among the first, and soon becomes one of the most promi- 
nent symptoms. It is at the commencement short and dry, or accompanied 
with but a slight expectoration; and is often very painful, producing sensa- 
tions 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 temporary relief. At 
this stage, the patient is usually affected wjth 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 symp- 
toms 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 bronchial 
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 expectorated matter gradually increases in quantity, and at 
the same time in consistence, 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 secre- 
tion is mixed with the thinner transparent matter, at others is exclusive. 
Along with the change in the mucous secretion, there is usually an ameliora- 
tion 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 transpa- 
rent, and the symptoms generally undergo a corresponding change for the 
worse, indicating a temporary increase of the inflammation. At length, how- 
ever, 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. The 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 character to hectic, 
with frequent pulse, copious purulent expectoration, night sweats, emaciation, CLASS III.] 
ACUTE BRONCHITIS. 
793 
and debility. The system is too feeble to recover from the blow which it 
has received, and, unless supported by appropriate treatment, sinks into a 
dangerous or even fatal exhaustion. The 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 asthenic, in consequence 
of the peculiar state of the constitution, or peculiar influences of a depressing 
character to which the patient may be subjected. 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 secre- 
tion, which, therefore, overwhelms the lungs, and literally drowns the patient. 
But cases of a much severer and more dangerous character are not unfre- 
quently met with. In those already treated of, the inflammation is compara- 
tively moderate in degree, and confined chiefly to the larger tubes. In those 
now alluded to, the inflammation is more intense, sinks more deeply into the 
bronchial membrane, perhaps even to the sub-mucous tissue, or penetrates 
further into the tubes, so as even sometimes to reach their ultimate ramifica- 
tions. 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 diffi- 
culty through the thickened or contracted tubes, producing a blowing sound 
audible at a considerable distance; and the patient suffers with feelings of im- 
pending suffocation. When the cause of difficulty arises from the extent of the 
inflammation, respiration is hurried, the dyspnoea extreme, the pulse exceed- 
ingly frequent, and the general strength speedily exhausted. This condition 
of the disease is most common in infants, and is sometimes quickly fatal. 
Occasionally, in these severer forms of bronchitis, the attacks of dyspnoea are 
exceedingly sudden and violent, destroying life in the paroxysm unless relieved. 
The expectoration is sometimes thick and glutinous, even at the beginning, 
more like the adhesive secretion of pneumonia than the mucus of ordinary 
catarrh. It is also occasionally fibrinous, and small quantities of false mem- 
brane 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 aeration of the blood. Bark blood, 
therefore, flows 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 dys- 
pnoea 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 con- 
siderable portion of the lung, that occasions sudden death. Besides, the 
bronchitis not unfrequently becomes complicated with pneumonia, 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 
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 of the disease above described. 794 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
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 con- 
sequent 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 or 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 situa- 
tions is essentially the same. Pneumonia may always be suspected in bron- 
chitis, 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 sometimes been confounded; such, for example, as congestion or apoplexy 
of the lungs, pneumonia supervening upon old catarrhs, and proper 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 respiration. The patient 
* The microscopic appearance of the expectorated matter varies with the degree, 
seat, and stage of the inflammation. In the earlier stage, and in mild cases, it differs 
little from that of healthy mucus, showing effete epithelial cells with their cilia, mucous 
corpuscles which are epithelial cells in different stages of developement, patches of ad- 
hering cells, and others of basement membrane with attached nuclei, all of which are 
contained in a transparent liquid. In severer cases, when the whole thickness of the 
mucous membrane may be supposed to be affected, there are in addition irregular masses 
of fibrinous exudation, with fibrils and exudation corpuscles in different stages, and, if 
the small tubes have been affected, minute cylindrical casts of fibrin. At a later stage,' 
pus corpuscles are intermingled with the other ingredients, and increase until they be- 
come the prominent constituent. These are probably the result of the degradation of 
the mucous and exudation corpuscles. Besides these, crystals of uric acid and oxalate 
of lime have been noticed, with urate of ammonia, and amorphous sulphate of lime. 
(C. Black, Ed. Month, down, of Med. Sei., vii. 294, 297, &c.) The first transparent 
mucus of bronchitis would appear to be the result of a more rapid formation of epi- 
thelial cells with their liquid product; the white opacity which follows may be ascribed 
to the abundance of undeveloped cells or mucous corpuscles, which are produced and 
thrown off under the excitement of the inflammation ; the greater tenacity and dusky hue 
frequently noticed evince the presence of fibrinous exudation, resulting from a higher 
grade or deeper seat of the inflammation; while the gradually increasing yellowness of 
the sputa, as the affection advances, is owing to the formation of pus, consequent on the 
failing vital forces of the tissue. (Note to the fourth edition.} CLASS III.] 
795 
ACUTE BRONCHITIS. 
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 
sometimes also tinged with blood. An almost universal mucous rale may be 
heard over the chest, while percussion is occasionally dull in some parts, in 
consequence of the accumulation of mucus, or the existence of pulmonary con- 
gestion or collapse. Febrile symptoms sometimes appear at the commence- 
ment ; but they do not usually continue long. Those consequent 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 pre- 
vious 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 perform its duty, in conse- 
quence either of congestion, mucous accumulation, or 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 unfrequently the dis- 
ease 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 dur- 
ing the whole period of inspiration and expiration; for in the small tubes the 
air is not so long in its passages in the larger; but, generally 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 in general the 
extent of the inflammation; but 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; and, if any 
*part of the lungs is consolidated by pneumonia, all the rales, whether dry or 
moist, may be conducted to the ear from a considerable distance. 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 the dry sounds that deter- 796 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
mines the stage of the disease. Not unfrequently, the mucous rale ceases for 
a time after expectoration. At length, when the stage of.secretion is fully 
established, 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- 
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 sono- 
rous and sibilant rales; which, however, under such 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 among 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 
cause. But percussion relieves the apprehension by proving that the 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 
coughing, which displaces the obstruction, and allows the air again free 
admission and exit. Dr. Gairdner has shown that, as a consequence of ob- 
struction in the bronchial tubes in bronchitis, a collapse of that portion of 
the lung supplied by the tube affected is not unfrequent; giving rise of 
course, when extensive, to more or less dulness on percussion, as well as to 
absence of respiration. 
Anatomical Characters.-The bronchial mucous membrane is reddened, 
thickened, 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. Under 
the microscope, the surface of the membrane may sometimes be seen deprived 
of its epithelium, and the fibrous layer covered with a fibrinous exudation in 
place of it. The tubes contain mucus in various states, sometimes blood, 
and not unfrequently pus. In cases which appear to have proved fatal from 
the abundance of the undischarged secretion, the lungs refuse to collapse upon 
the admission of air into the pleural cavities. The bronchia are sometimes 
dilated. 
Dr. Gairdner, of Edinburgh, has demonstrated that, in certain cases of 
local condensation of lung in the adult, previously ascribed to limited inflam- 
mation of the pulmonary tissue, the result is in fact owing to collapse of the 797 
CLASS III.] 
ACUTE BRONCHITIS. 
air-cells, consequent on the obstruction of the bronchial tubes leading to the 
parts affected, and that the phenomenon is one not of lobular pneumonia, but 
of bronchitis. The same observation had been previously made by MM. 
Bailly and Legendre in relation to the supposed lobular pneumonia of infants. 
The state of the lung is similar to that imperfect expansion of the lungs of 
newborn infants, denominated atelectasis. This seems to be proved by the 
fact that, in cases of such condensation, before the parts have become altered 
in structure by length of time, the portion of lung affected can frequently be 
restored nearly to its natural condition by forcible inflation. Dr. Gairdner 
describes two conditions of this collapse, one diffused, and the other of the 
lobular form. In both, the colour is usually of a dark violet on the surface, 
and brownish-red within; the crepitation is diminished or quite lost; and, 
when the collapse is complete, portions are found to sink readily in water. 
The cut surface is nearly smooth, having somewhat the appearance of muscu- 
lar flesh, and without any trace of the granular aspect characteristic of the 
hepatization of pneumonia. In the diffused variety, the state of collapse may 
affect considerable portions of one or both lungs, especially the posterior part, 
and gradually passes into the healthy structure ; in the lobular, the condensed 
part has an abrupt boundary, being accurately limited by the interlobular septa. 
These collapsed portions may have been affected with bronchial inflammation, 
in which case small abscesses may sometimes be observed in them, from the 
size of a hemp-seed to twice or three times the volume, bearing when incised 
no inconsiderable resemblance to softening tubercle. These are lined with 
false membrane, and communicate with the bronchial tubes. Dr. Gairdner 
considers them as strictly bronchial, but they probably arise from disten- 
sion of the air-vesicles with pus. They sometimes occur in adults; but are 
more frequent in infants, being a common attendant on acute infantile bron- 
chitis of a severe character. (See Ed. Monthly Journ. of Med. Sei., Aug. 
& Sept. 1850.) Dr. Gairdner ascribes this local collapse of the lung in 
bronchitis, partly to an excess of the expiratory over the inspiratory power, 
which causes the air to be expelled with greater force than it can enter 
through the impediment in the bronchia, partly also to the mechanical action 
of the plug of mucus, which with the inspiration is forced into a constantly 
diminishing passage, and with the expiration into one constantly enlarging, 
so that air necessarily passes outward more readily than inwards. The latter 
is probably the true cause. The collapse, if permanent, is followed by atrophy 
of the part, which leaves in the place of pulmonary structure, nothing but a 
little fibrous tissue with specks of carbonaceous matter. 
Causes.-Cold is beyond 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 neck, feet, &c., or to the body 
previously heated by exercise, and in a state of perspiration ; and it is always 
most injurious when combined with moisture. The disease appears sometimes 
to result from reaction in the bronchial mucous membrane, upon entering a 
heated apartment after having breathed an intensely cold air. It is most fre- 
quent 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 798 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
11 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, 
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 be learned was never exposed at that season to the 
influence of any peculiar cause. He died ultimately of phthisis at an advanced 
age, and had probably for thirty years been subject to occasional attacks of 
haemoptysis. Two other persons, of gouty families, have occasionally con- 
sulted me for a similar affection, occurring about the same time every summer. 
I think it not improbable, that such cases are often gout affecting the respi- 
ratory 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, 
smallpox, scarlet fever, hooping-cough, asthma, enteric or 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. 
Treatment.-In the very commencement of one of these bronchial affections, 
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 perspira- 
tion induced by hot teas or strenuous bodily exertion, or even by a full sup- 
per of stimulating food and drink. But it is only in cases where previous 
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 774.) 
In a mild case of bronchitis, with little or no fever, nothing more is required 
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 magnesia, to 
drink daily, in small portions at a time, a pint of flaxseed tea with two fluid- 
drachms 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 decoc- 
tions 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. CLASS III.] 
ACUTE BRONCHITIS. 
799 
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- 
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 call 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 hour 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 
this stage of bronchitis, at least as a general rule, in consequence of its ordi- 
nary effect of restraining mucous secretion, and therefore of shutting up the 
inflammation in the membrane. Recourse, then, may sometimes be had, 
where the cough is peculiarly violent, to the preparations of hyoscyamus, 
conium, or hydrocyanic acid. Either of these medicines may be advanta- 
geously given in liquid mixtures, along with some demulcent substance, as 
liquorice, gum arabic, or sugar. Every practitioner can make a cough mix- 
ture out of these materials to suit his own views, and the circumstances of the 
case. It is generally preferable to employ the liquid preparations of the medi- 
cines recommended, as the syrup of squill or seneka, the wine or syrup of 
ipecacuanha, and the tincture of sanguinaria. Tartar emetic may be used in 
aqueous or vinous solution; 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.* 
* A mixture may contain in each dose, for an adult, from rr^x to f^ss of Antimonial 
or Ipecacuanha Wine or Tincture of Sanguinaria, or from f^ss to f^j of Syrup of Ipeca- 
cuanha ; combined with from tr^xx to n^xl of Syrup of Squill, or trLx to TT^xx of Vinegar 
or Tincture of Squill, or from f^ss to fgj of Syrup of Seneka; and with from f^ss to fgj 
of Tinct. of Hyoscyamus or Conium, or npj to BUV Officinal Hydrocyanic Acid, la 
cases suitable for opiates, for the above narcotic tinctures may be substituted, in each 
dose, from Up] to n^iv of Laudanum, nLxvto fgss of Solution of Sulphate of Morphia, 
or fgss to f^j 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 ^ij of Sugar or 
Liquorice, in such quantities that a tablespoonful of the mixture shall contain the doses 
above mentioned. 800 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
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, 
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 night, the opium is 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 
symptoms be of an urgent character, there should be no delay in resorting to 
mercury, 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 contraindicate 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, espe- 
cially 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 considerable 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 at a certain stage. 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 action 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 
sometimes preferable to blisters. Towards the period of convalescence, plas- 
ters of Burgundy or Canada pitch, or the warming plaster, may hasten perfect 
recovery, 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 cases complicated with spasm of the bronchia, than to pure acute 
inflammation. CLASS III.] 
801 
ACUTE BRONCHITIS. 
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 aud perhaps puruloid appearance ; 
but the cough continues severe and harassing, the pulse is often frequent, 
and the patient suffers greatly from feelings of debility and general uneasi- 
ness. Every experienced practitioner must have seen 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 resort- 
ing 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 
be 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 cases 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 calomel, too, frequently produce in children the happiest effects. 
In the advanced stage of the disease, when the strength 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 some- 
times accrues from applying garlic poultices to the feet, and bathing the chest 
with a tincture of the same substance made extemporaneously by heating it 
in brandy. 
When the disease is seated in the smaller bronchia, and occupies a large 
portion of the chest, the treatment should be especially active. General aud 
local bleeding pushed as far as the strength will permit, free and early blis- 
tering, and the use of mercury, are the chief remedies. 
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 the variety of bronchitis called in Great Britain the hay 
asthma, independently of the measures ordinarily employed in catarrhal 
affections, Mr. Gordon, who appears to have paid particular attention to the 
subject, 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, on Princip. and Pract. 
of Physic.} Dr. Elliotson has obtained signal relief, 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. (^Twee- 
die's Sy st. of Pract. Med.} The tincture of nux vomica, in the dose of ten 
drops, gradually increased to twenty, three times a day, has produced the 
best effects in the hands of Mr. Gream. At the same time he applies to the 
nasal membrane, as high up as possible, an ointment made by mixing a 
drachm and a half of solution of subacetate of lead with two ounces of sper- 
maceti cerate, aud a few drops of oil of bergamot. (London Lancet, June 8, 802 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
1850.) Dr. F. W. Mackenzie, of London, has found arsenic peculiarly use- 
ful, and gives the Fowler's solution in doses of from one-to five minims. 
(Lond. Journ. of Med., July, 1851.) In the catarrhal cases which occur 
regularly in the same individual, at the same time every year, I should expect 
benefit from colchicum. 
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 
and feeble, who are much more 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 bron- 
chial secretion is too abundant, and the muscular powers of the patient too 
feeble for its expectoration. In intermediate cases, the two kinds of expec- 
torants 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 unfre- 
quently 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, some- 
times easy and copious, of a thick, somewhat tenacious, opaque mucus, 
whitish, yellowish, or greenish, sometimes streaked with blood, and fre- 
quently 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 An- 
dral, 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 expectoration most abundant in the morning. It is occa- 
sionally 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 hur- 
ried 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 may be observed to form every day. The complaint may CLASS III.] 
CHRONIC BRONCHITIS. 
803 
run on for a very long time with little modification, except, perhaps, a dimi- 
nution 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 of a 
milder chronic form of the disease, the symptoms sometimes exhibit a formi- 
dable character. There is copious purulent expectoration, with occasionally 
a little blood, shortness of breath much increased by exercise, debility, ema- 
ciation, a frequent pulse, sweats at night, and, in fact, all the obvious 
symptoms of phthisis; so that the complaint was formerly, and is still occa- 
sionally denominated catarrhal consumption. Such cases not unfrequently 
terminate 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 some instances, however, such ^cute 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 dis- 
charge, cannot accommodate itself to the new condition consequent upon its 
cessation; and serious or fatal congestion or inflammation is apt to occur in 
some one of the vital organs. 
Frequently, in the course of chronic bronchitis, there is a mixture of acute 
with the chronic symptoms, in consequence either of the supervention of fresh 
inflammation in the parts before inflamed chronically, or of new parts becom- 
ing affected; and this possible complication should always be borne in mind 
in the treatment. A test of the occurrence of acute symptoms, suggested by 
Andral, 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 dyspnoea 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 exceedingly 
variable in their duration, are seldom accompanied with fever, and sometimes 
begin with coryza. Upon auscultation, the dry morbid sounds are first heard, 
which are very soon followed by the mucous rale, showing that the attacks 
commence with a congestion and consequent tumefaction of the mucous mem- 
brane, which is afterwards relieved by secretion. The chronic disease consists 
in a peculiar condition of the bronchia, which renders them liable to conges- 
tive attacks from slight irritation; while the tissue does 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 the stomach, 
liver, and especially of the heart. It sometimes also attends the develope- 
ment 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 discharge. 
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 become dropsical, 
and dies at length from exhaustion or suffocation. The excessive secretion 
sometimes relieves complaints of the heart by removing congestion. 804 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
Laennec describes, under the name of dry catarrh, a variety of chronic 
bronchitis, with a very troublesome cough, sense of oppression in the chest, 
and either no expectoration, or only of small, semi-transparent, pearl-gray pel- 
lets, of the consistence of pitch. A sibilant rale is heard. The disease is apt 
to attack the gouty and hypochondriac, the inhabitants of the sea-coast, per- 
sons 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 physical signs that the chronic catarrh can be 
distinguished from phthisis. The diagnostic symptoms of the former are equa- 
ble resonance upon percussion, the absence of the signs of consolidation in any 
portion of the lung, as bronchial resonance and respiration, and of the signs 
indicating a cavity, as amphoric resonance or respiration, and pectoriloquy. 
When these signs are absent, and at the same time there is copious purulent 
expectoration, the evidence is almost conclusive that the disease is bronchial. 
But, when the bronchia are themselves much enlarged, and contain pus, it is 
sometimes difficult to make an accurate diagnosis. The signs, however, of 
preceding consolidation of the lungs, characteristic of ordinary tuberculous 
deposits, are wanting in this case. (See Phthisis.') 
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 in- 
directly, by so far debilitating the system, and deteriorating the lungs, as to 
cause the patient to sink under the supervention of acute inflammation whether 
of the bronchia 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 bron- 
chitis. 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 coexistence of much enlargement of the bronchia 
with chronic inflammation is an unfavourable sign. The supervention 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 Characters.-1The mucous membrane is thickened, sometimes 
partially indurated, sometimes, though rarely, softened or ulcerated, in some 
.cases of a deep-red, violet, or 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 pul- 
monary 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, sometimes throughout the whole extent of a branch and its 
ramifications, 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 im- 
pulse 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, CLASS III.] 
805 
CHRONIC BRONCHITIS. 
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 individu- 
als to chronic bronchitis; and such a peculiarity often exists in persons of a 
rheumatic or gouty habit of system, and those subject to cutaneous eruptions. 
The disease is a frequent accompaniment of other pectoral complaints, espe- 
cially phthisis, in which, when fully developed, it is never absent. Disease of 
the heart frequently causes it, in consequence of the irregular distribution of 
blood in the lungs which it produces, and, when not the cause, tends to aggra- 
vate the complaint, and to render it much more obstinate. It frequently fol- 
lows measles and hooping-cough; and 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 con- 
siderable extent. In some cases, when the symptoms, under temporary influ- 
ences, 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 the 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 so 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 and liquorice root, with 
tartar emetic, described under acute bronchitis. (See paye 800.) It has 
happened to me to see many very obstinate cases of cough yield to this reme- 
dy. 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 ammoniac, is 
an excellent combination. Recourse may also be had to the balsams of Tolu 
and Peru, the compound tincture of benzoin, and to copaiba. The last- 
mentioned medicine often proves serviceable in chronic catarrhs. The expec- 
torants 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, hyoscyamus, conium, stramonium, belladonna, or hydro- 
cyanic acid should be preferred to opium ; and camphor, in the form of tinc- 
ture, or of camphor water, may sometimes be usefully added to the other 
ingredients. Under other circumstances, one of the opiates should be pre- 
ferred, as more effectual than the medicines mentioned in allaying cough. 
The salts of morphia are probably the best preparations of opium for use in 806 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
bronchial disease. The camphorated tincture of opium is a very agreeable 
preparation, well adapted to cases without any vestige of acute inflammation. 
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. G-um arabic, liquorice, and sugar, are useful 
demulcent additions to the expectorants. 
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, pustulation 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 may be sufficient for 
the patient to wear a plastei' of Burgundy or Canada pitch, or a warming 
plaster. Frictions to the chest are also useful, and especially with rubefacient 
liniments, composed of some of the stimulating volatile oils, as of turpentine, 
rosemary, origanum, or monarda, sufficiently diluted with olive oil. When 
the disease is connected with a repelled eruption, it is important to endeavour 
to restore the cutaneous affection by irritation to the part in which it had 
previously 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 decom- 
posed by heat have been employed with advantage. An ethereal solution of 
balsam of tolu has been recommended. Other substances, occasionally admi- 
nistered 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 expec- 
toration, night sweats, &c., it is in many instances highly important, in addi- 
tion to the treatment above detailed, to employ measures calculated to invi- 
gorate 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 advantageously 
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 accompanied with chills 
and hectic paroxysms. Porter and other stimulant drinks must be called in 
requisition when the debility is great. Dr. Alison, of Edinburgh, has found CLASS III.] 
CATARRH. 
807 
great advantage from tannic acid, in doses of from one to three grains, two 
or three times a day. It diminishes the secretion and the cough, and in- 
creases the general strength. Should gastric or hepatic disease exist, the 
treatment must be modified accordingly, and, in cases of vomiting with gas- 
tritis, the stimulant plan 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 resident of cold and aus- 
tere 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 bene- 
ficial, and, if long enough, will not unfrequently effect a cure. A change of 
residence, even without any considerable obvious change of climate, is some- 
times beneficial. A resort to the Sulphur Springs may be 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. Ordinarily, it should be 
nutritious without being stimulant, consisting, for example, of milk, the 
lighter meats in moderation, fish, farinaceous preparations, and vegetables. 
When there is any degree of acuteness in the symptoms, meats should be 
forbidden, and the patient confined to milk and vegetables, 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- 
rhoca, or humoral asthma, the treatment should vary according as it is applied 
to the paroxysm or the interval. At the accession of the attacks, hot pedilu- 
via, 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 may be 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 useful. The functions 
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 808 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
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 dis- 
ease. For this, in its full extent, we have no other name than catarrh. Some 
writers consider catarrhal inflammations 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 cha- 
racter. 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 
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 downwards; 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. 
The grade of inflammation is apt to be nearly the same throughout this 
course, unless modified by treatment. If the coryza or angina be light, the 
chalices are that the bronchitis will be light also ; and vice versa. Some of 
the worst cases of bronchitis begin as intense inflammation 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 with the 
part or parts affected, and have been sufficiently described under the preceding 
heads. When severe, the complaint is almost always attended with fever, 
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 important to arrest 
the disease, or diminish its violence, in its earliest seat, so that it may either 
not 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 were to be confined within these limits. Attention 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 bedtime, and the production of a copious 
and continued flow of perspiration. For the modes of carrying these mea- 
sures into effect, and the cautions necessary, the reader is referred to the 
article on coryza. CLASS III.] 
INFLUENZA. 
809 
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- 
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 
towards 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 southeast, 
and entering France and Spain from Italy, has thence proceeded to England, 
and swept round the north of Europe. In this country, it has sometimes pro- 
ceeded 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 consider- 
able 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 cause 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 animals appear to suffer as well as man. Many instances are on record, 
in which horses, dogs, sheep, and even birds have been seized 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 
or less degree affected. 
The disease exhibits, on the whole, a remarkable uniformity of character, 
though it has occasionally differed much in its 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 epi- 
demic of 1850, nine thousand persons are said to have died of the disease in 
Rome. It is probable that other epidemic influences may occasionally com- 
bine with and modify it in certain situations. It may, for example, be con- 810 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
ceived that, if it should appear in a neighbourhood already tainted with a 
typhoid influence, this 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 
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 chest, 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. Disorders of stomach, 
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 num- 
ber of instances, it is described as having been feeble; and in some, the de- 
bility 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 upon attempting 
to sit up. Another striking circumstance is, that the debility often continued 
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 extremely 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 effects of this epidemic influence do not necessarily appear in the 
shape of catarrh. In some instances, its force has been spent upon the brain; 
and violent headache, flushed face, delirium, and fever have been the promi- 
nent 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 complications of the 
catarrhal affection, especially towards its close. Inflammations of the lungs, 811 
CLASS HI.] 
INFLUENZA. 
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 per- 
sons predisposed to it. Authors speak also of inflammation 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 
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, in most cases, goes 
off 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. (^Boston Med. and Surg. 
Journ., xxxviii. 149.) 
Epidemic catarrh cannot be considered as 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 cardiac affections. It occasionally also proves 
fatal in infants. But, though thus mild in its character, it affects so large 
a number of individuals, and 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 consequence 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 explained. 
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 its 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 refuta- 
tion. Nor does the idea of contagion, though entertained by so high an au- 
thority as Cullen, appear to deserve a much more serious notice. It is alto- 
gether 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 812 
[part II. 
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 be purely accidental. 
At present very few believe that 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 is organic, consisting of innumerable animalcules or vegetable micro- 
scopic 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 movements of the epidemic, and ac- 
counts 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 as- 
sertion 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 cause 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 can obtain new light. 
Treatment.-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 symp- 
toms of inflammation are decided, it is best to avoid venesection altogether, and 
to trust chiefly to the diaphoretic plan. Even active purgation is scarcely ad- 
missible. Eupatorium, or boneset, has long been recommended in this disease. 
Dr. Peebles (Am. Journ. of the Med. Sci., 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 properties, when adminis- 
tered early in the complaint, in the form of warm infusion; and by its tonic 
powers, when given in cold infusion in the advanced stage. When diarrhoea 
occurs in the latter stages, it maybe arrested by means of opium and ipecacuanha. 
When the debility is considerable, it is often necessary to support the system by 
tonics, aromatics, and even more powerful stimulants. Should the disease 
assume a regular periodical character, sulphate of quinia would be indicated. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. CLASS III.] 
CROUP. 
813 
5. CROUP. 
Syn.-Cynanche trachealis.-Angina trachealis. -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 tra- 
chealis, and the more modern tracheitis arc objectionable designations; as they 
lead to false notions 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 bron- 
chial tubes. It may, therefore, occupy one or several divisions of the respi- 
ratory 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 inflam- 
mation or high vascular irritation of the laryngeal, or laryngo-tracheal mucous 
membrane. But that inflammation alone does not constitute the disease is 
proved by the fact, that it often exists without the peculiar croupal pheno- 
mena, as in measles, catarrh, smallpox, &c. The additional circumstance, not 
less essential than inflammation, is spasm of the interioi- muscles of the larynx. 
It is this which distinguishes the croup of children from the similar inflam- 
matory affections of adults, occupying precisely the same structure. 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 phenomena are different 
from those of croup, and belong to a different pathological condition. 
Definition.-Croup, therefore, may be defined to be a disease, in which in- 
flammation 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, when the treatment is better understood, is not 
less than one half. The two forms of the disease differ essentially in the 
product 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 814 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
PART II. 
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-membran- 
ous; in other words, that a case beginning with the symptoms of the 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 portion of the 
membrane shall secrete mucus, and another exude fibrin; and the relative 
amount of the secretion and exudation would determine the position of the 
case in one or the other division. From these facts the 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 employed 
and properly guarded, they can do little serious injury; while the neglect of 
them may possibly lead to the most deplorable consequences. 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 time 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 the 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 interven- 
ing 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- CLASS III.] 
CATARRHAL CROUP. 
815 
dated 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 tension to the sides of the rima glottidis. Im- 
mediately succeeding the cough there is often a shrill, stridulous sound, pro- 
duced 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 dys- 
pnoea, which is often severe and very distressing; the respiration being dry, 
wheezing, and often sonorous, as if the air entered through a narrowed 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 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 coun- 
tenance an alarmed, anxious, and affectingly beseeching expression. Some- 
times, when able to speak, he complains of tightness or pain in his throat; but 
his voice, and 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, especially when it is very severe, the effects of the impeded 
respiration begin to be experienced in the state of the blood, which is insuf- 
ficiently afirated. 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 re- 
laxes, and the 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 re- 
lieved. In some extraordinary cases, complete and fatal asphyxia may take 
place before the spontaneous subsidence of the paroxysm; but this is exceed- 
ingly rare, and never, perhaps, under suitable treatment. 
Very generally the symptoms are much more moderate than as above de- 
scribed. 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 dys- 
pnoea; and the child may be 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 816 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
remissions, and with a more or less threatening aspect, according to the de- 
gree 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 rare; 
and the greater violence of the disease depends simply on the greater severity 
or extent of ordinary inflammation of the air-passages. This frequently 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, indicated by the cry- 
ing 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 breath- 
ing, 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, though hoarse, is not suppressed; and the cough is sonorous. In 
connexion with these symptoms, which are constant, the paroxysms of dyspnoea 
return with greater frequency and violence than in milder cases. The slightest 
cause, such as crying, attempts at speaking, drinking, mental emotion, &c., 
brings on the most distressing difficulty of breathing, with a suffocative cough, 
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 
vanishing 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 
to two weeks from the commencement. Sometimes, however, an excess of 
secretion beyond the ability of the patient, already greatly weakened, to throw 
off from the lungs, added to the embarrassment of the respiration from the 
laryngeal and tracheal disease, brings on a fatal defect of haamatosis. Not 
unfrequently, 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 disease, by supervening or accompanying bronchitis or pneumonia. 
Throughout the complaint, the stomach is usually remarkably insensible to 
emetic impressions, 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 CLASS III.] 
PSEUDO-MEMBRANOUS CROUP. 
817 
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; but, if the pa- 
tient be examined after the subsidence of a paroxysm, or during the relaxa- 
tion 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 
result. In some rare instances, no signs of disease are discovered in the 
mucous membrance, 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. Indeed, it is often treated successfully in domes- 
tic practice; and very numerous cases occur to w'hich 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 Croup. - Pseudo-membranous pharyngo- 
iaryngitis, or true croup. (Guersent.) - Pseudo-membranous laryngitis. 
(Rilliet and BarthezJ-Laryngeal diphtheritis.-This variety of croup is, 
compared 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. 
Possibly, the disease may present a somewhat different aspect in Great Bri- 
tain 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 re- 
cognize the distinction clearly, and treat of Our common disease under a dis- 
tinct designation. Guersent calls it false croup. 
Symptoms, Course, &c.-This affection begins variously. In some in- 
stances, it has the pseudo-membranous form from the very commencement; 
the occurrence of the inflammation and of the exudation being, so far as can 
be observed, 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 feeble, and sometimes, in the beginning, scarcely sufficient to in- 
duce fever. It is, as before observed, to the peculiar character of the inflam- 
mation, 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 apart- 
ment 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 818 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
its fatal progress. The disease may be suspected, in such cases, 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 especially 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 
it is this peculiar plasticity of the secretion that constitutes the very essence 
of the affection ; and the vast importance of the consequences certainly justi- 
fies us in ascribing to it the rank of at least a distinct variety of the 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 mem- 
brane is forming. 
Often, 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 
grave 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 cough altogether loses whatever sonorousness it may have pos- 
sessed, 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 inspi- 
ration. 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 the air were forced 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, jactitation, and feelings as of impending suffo- 
cation. These symptoms, though never absent, relax for a time, to return 
with equal or increased violence from the slightest cause, and often without 
apparent cause. 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 dis- 
ease marches directly onward 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 expecto- 
rate, some viscid mucus is coughed up, either transparent or opaque, and 
occasionally mixed with flakes or patches, or even tubes of concrete fibrinous CLASS III.] 
PSEUDO-MEMBRANOUS CROUP. 
819 
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 appear in 
scarcely one-third of the cases. (Rilliet and Barthez.') 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 gra- 
dual, or even sudden 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 all their former violence; the false membrane is re- 
newed, or penetrates more deeply into the respiratory passages, and the little 
sufferer 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, mean- 
while, 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 drow- 
siness or stupor. The brain and heart, no longer stimulated by arterial 
blood, cease to act, and the patient sinks gradually and quietly away; or the 
nervous system 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 recovery 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 820 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
the occurrence of these, the developement proceeds as above described. Bre- 
tonneau 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 malignant sore-throat., which probably depend upon the same 
cause as scarlet fever, frequently at least, and like that, end in pseudo-mem- 
branous 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 unfrequently with a fetid breath, and sometimes with 
strongly malignant symptoms. Their cause is usually either epidemic in- 
fluence or contagion, neither of which produces ordinary croup, unless per- 
haps when it attends influenza.. 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. Aftei- all that has 
been said, however, 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 symp- 
toms 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 vi- 
bratory 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 some 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 speak 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 bronchia 
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 
Guersent, it is never entirely absent in the larynx. It is sometimes confined CLASS III. 
PSEUDO-MEMBRANOUS CROUP. 
821 
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 inconsider- 
able resemblance, as suggested by Dr. Cheyne, to macaroni boiled in milk. 
More frequently, however, it is in patches, or long narrow ribbons, and occa- 
sionally, 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 frequently loosened by intervening mucus or muco-puru- 
lent 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, in 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 certain red points and lines upon its adhering sur- 
face, which cannot be washed off, have been thought, though probably on 
insufficient grounds, to be the commencement of vascularity. 
In the cases associated with other diseases, as smallpox, 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 membrane 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 lobu- 
lar pneumonia, and an emphysematous condition of the pulmonary air-cells, 
are not unfrequent. 
Causes of Croup.-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 occa- 
sionally 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 usually 822 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
occurs at an earlier age 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 be- 
tween the second and sixth year. It is probable that the change of diet, after 
weaning, may contribute to render the blood more favourable to the plastic 
exudation. The structure of the larynx in children probably disposes to the 
spasmodic 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 influence, at least as relates to pseudo- 
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 of 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 of 
croup. The influenza and measles are often attended with the catarrhal 
variety; scarlatina and smallpox 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 admin- 
istered 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. Tartar 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 CLASS III.] 
CATARRHAL CROUP. 
823 
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 on 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.) 
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 necessary. 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 improved, 
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 more 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 antimonial or ipeca- 
cuanha 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 too long continued, it may produce 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 practitioner after a paroxysm 
of croup, without any reference to the time or circumstances 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 left to omit the antimonial if it purge, or other- 
wise 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 824 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
be again resorted to. Should this fail, an 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 
severe cases of laryngeal spasm. But it is necessary to be cautious, 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 re- 
medy is one which should never be employed in domestic practice, and should 
generally be applied under the immediate superintendence of the physician. 
It should never be placed upon a blistered surface. The internal use of lobelia 
is here also highly serviceable; and, when a powerfully relaxing effect is re- 
quired, it may be combined, in powder or tincture, with one of the emetics 
already mentioned. 
The above treatment is adapted to the paroxysm. It scarcely ever happens 
that this does not give way, however violent, if the case be not pseudo-mem- 
branous, to some one of the remedies mentioned, or some combination of them. 
After the spasmodic paroxysm has been subdued, or has subsided, the treat- 
ment must be guided altogether by circumstances. If the croupy phenomena 
have disappeared, and only a cough with moderate catarrhal symptoms re- 
mains, the treatment before mentioned as proper after the subsidence of the 
paroxysm may be adopted. But it often happens that, though the violent 
spasmodic symptoms give way, there are yet considerable inflammation 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 influence 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 or sibilant sound during inspi- 
ration, or evidences of pain in the throat or chest, leeches are an admirable 
remedy. It is always best to make use of oui' 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 applica- 
tion, 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 maybe applied, so as to take 
from two to four ounces of blood. After leeching, an emollient cataplasm 
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 CLASS III.] 
PSEUDO-MEMBRANOUS CROUP. 
825 
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 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. 
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 fol- 
low successively; and, in case of severe spasm, tobacco externally, and lobelia 
with decoction or syrup of seneka internally, may be superadded. 
After the employment of 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 of 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 car- 
bonaceous 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 threat- 
ened every moment. Now it is that the nervous stimulants, and stimulating 
expectorants are to be employed, while our antiphlogistic efforts must be con- 
fined to external revulsive measures. Decoction of seneka, assafetida 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 advantageously 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 sulphate of copper, will 
best answer this indication. Externally, garlic and brandy may be applied 
warm to the breast and spine; and liniments or cataplasms of oil of turpen- 
tine, mustard, Cayenne pepper, ammonia, &c., may be resorted to, if necessary, 
to aid in the support of the system, until the offending cause is removed, or 
reaction established. 
Dr. Fithian, of Woodbury, New Jersey, treats croup successfully by cold 
water, applied by means of towels to the throat and upper part of the chest. 826 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
The symptoms of the paroxysm are relieved, and, if they return, again give 
way upon a repetition of the application. (Report, &c., by Dr. J. G. Garrison, 
M. J. Med. Reporter, iii. 249.) The external application of tincture of iodine 
has been strongly recommended. (See Am. Journ. of Med. Sei., N. S., xvii. 
496.) Dr. Tracy, of Worcester, Mass., has found great advantage from keep- 
ing the patient in a warm dry atmosphere, from 80° to 90° F., and thinks he 
has successfully treated many cases in which false membrane had formed 
mainly by this remedy, though he conjoined the use of emetics and rubefacient 
liniments. (Bost. Med. and Surg. Journ., xlv. 374.) 
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 recommended by Bre- 
tonneau. (See Pseudo-membranous Inflammation of the Fauces, p. 527.) The 
nitrate of silver is generally preferred, and a solution may be employed, vary- 
ing 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 
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 cauteriza- 
tion ; but experience seems to have shown that this cavity may be penetrated, 
without serious inconvenience, even in the infant; and cures have been 
effected apparently by this measure 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 inflam- 
mation, but upon its peculiarity, or that of the blood, and this peculiarity is 
not modified by bleeding. This remedy has no effect in removing the false 
membrane already formed. The utmost that can be effected by it is to mo- 
derate 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 prostration. 
The rule for the use of bleeding, in pseudo-membranous croup, is to propor- 
tion it as exactly as possible to 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 mat- 
ter 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. 
* See communications by Dr. Wm. N. Blakeman, in the N. Y. Journ. of Med., viii. 
209; by Dr. Charles E. Ware, in the Boston Med. andSurg. Journ., xxxvii. 417; and by 
Dr. James Bryan, in the Medical Examiner, N. S., iv. 342. See also cases in the Am. 
Journ. of Med. Sei., N. S., xvii. 26,by Dr. Clark; and in the same, xxii. 85, by Dr. S. D. 
Townsend. Successful cases have since been recorded by Dr. Chapman, of Brooklyn, 
N. Y. (2V. Y. Journ. of Med. Sei:, N. S., xii. 214), and by Dr. Kemp, of Baltimore (Am. 
Journ. of Med. Set., N. S , xxiv. 281). CLASS III.] 
827 
PSEUDO-MEMBRANOUS CROUP. 
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 expected 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, absorp- 
tion, or separation of that already formed; 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 character 
of the secretion, which, from being plastic, becomes mucous or puruloid and 
diffluent. This plan of treating croup originated with American practitioners. 
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 me- 
dicine, 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 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 of 
green stools by it, further purgative effect should be avoided; and, should it 
then disturb the bowels, it should be combined with minute doses of the pow- 
der of opium and ipecacuanha. Its operation may be aided by mercurial fric- 
tions. Should any effect upon the mouth or salivary organs be observed, the 
remedy should be suspended. In young children, however, it very seldom 
salivates. It 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 caution 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 posi- 
tive 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 secre- 
tion, 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-mem- 
branous croup get well, without the expectoration of false membrane; and dis- 
section sometimes shows that portions of the exudation have been removed. 
We can sometimes even see the process going on, in the diphtheritic disease 
of the fauces. 
Along with the mercurial, expectorant medicines should be given freely, to 
promote the loosening of the false membrane. Of these, tartar emetic and 828 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
seneka are the most efficient; and they should be pushed as far as the patient's 
strength will admit. 
To meet the same indications, the alkalies have been strongly recommended 
by some writers. They have been thought to dispose, like mercury, 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 sulphuret of potassium, pro- 
posed by the author of a prize essay upon croup in France, had at one time 
the reputation almost of a specific; but has fallen into neglect. Cures, how- 
ever, 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 carbonate or bicarbonate of potassa, soda, or 
ammonia would be preferable. I cannot speak of the effects of these medicines 
in croup from my own observation. 
Dr. J. D. Griscom, of Philadelphia, relates a case in which the iodide of 
potassium, given in the dose of five grains every two hours, to a child be- 
tween two and three years old, and continued for several days, had the apparent 
effect of modifying the plastic exudation, so that a gradual amendment took 
place, and the child ultimately recovered, (Trans. of Col. of Phys, of Phil., 
N. S. ii. 164.) Mr. E. F. Sankey, of Sussex, England, relates azcase in which 
similar advantage was supposed to be derived from chlorate of potassa. (Lond. 
Med. Times and Gaz., July, 1852, p. 99.) Dr. Wm. Budd, of London, has 
obtained very encouraging success by keeping the child constantly immersed 
in warm vapour of from 75° to 80° F., and at the same time using emetics. 
(Ibid., June, 1852, p. 614.) 
To favour the expulsion of the membrane, which is the last indication, eme- 
tics are the most efficient remedies. Of these, ipecacuanha, tartar emetic, 
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 mineral, 
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 membrane. 
The dose as an emetic, for a child two or three years old, is half a 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 proposed 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 tea- 
spoonful 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 Dis- 
eases of Children, by J. Forsyth Meigs, p. 46.) In relation 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. (Rilliet and Barthezf 
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 the affusion of cold water upon the whole posterior 829 
CLASS III. 
PSEUDO-MEMBRANOUS CROUP. 
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 so- 
lution 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 stage, when the strength has become exhausted, our hopes must 
rest upon stimulants. The only chance for medical treatment is now to sup- 
port the strength, in the hope that the false membrane may be spontaneously 
loosened and discharged. The remedies to be used are carbonate of ammonia, 
wine-whey, weak milk-punch or egg beat with wine, and spirituous fomenta- 
tions 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 anodyne remedies, 
such as assafetida and opium, which may be conveniently given by injection. 
This practice was successfully resorted to by Dr. Isaac Parish, in a case re- 
corded 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. 
It is especially applicable to cases in which there is good reason to think that 
the false membrane does not extend into the bronchial tubes. This operation 
has been frequently performed by Bretonneau, Trousseau, and other French 
practitioners, and not without considerable success. Of twenty cases, Breton- 
neau 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 treatment. It is, there- 
fore, very difficult to determine upon the real value of the operation. If post- 
poned until the case is otherwise quite desperate, it offers comparatively slen- 
der 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 or greater 
proportion by other means. Besides, in order to obtain its most favourable 
results, a degree of skill in operating is required, not to be found in practi- 
tioners generally. M. Trousseau finds necessary to success the application 
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.xRilliet 
and Barthez, on the diseases of infants (i. 367). In two out of three cases re- 
corded by Dr. J. F. Meigs, in which the operation was performed by Dr. Jos. 
Pancoast, of Philadelphia, it was successful. In one of these, it afforded the 
only chance of safety. Instead of making a slit in the trachea and introduc- 
ing a tube, Dr. Pancoast removed a small piece of the trachea itself, thereby 
superseding the necessity for the canula, and avoiding the danger of irritation 
from that source. (2m. Journ. of Med. Sei., N. S., xvii. 307.) 
General Points of Treatment.-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 830 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
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 to fashion or 
to vanity. In children predisposed to the disease, the plan may be 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 II. 
NERVOUS OR FUNCTIONAL DISEASES OF THE RESPIRATORY PASSAGES. 
Article I. 
LARYNGEAL NERVOUS DISEASE. 
1. Infantile Spasm of the Glottis. - 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 inflam- 
mation of the larynx. There is much unfortunate confusion in its nomen- 
clature. 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 dis- 
ease is not croup at all. Asthma, however qualified by epithets, is equally 
inappropriate; as that is the name for a pectoral affection, while this com- 
plaint resides in the larynx. Inward fits is a vulgar title of the disease. 
The affection is usually characterized by a shrill sound in inspiration, some- 
what like the crowing of a cock, which has given origin to the name of crow- 
ing disease. The sound is supposed 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 frequently 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 pur- 
plish, or of a pale cadaverous hue, with an expression of extreme anxiety CLASS III.] 
831 
SPASM OF THE GLOTTIS. 
and distress. 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 
stridulous sound during inspiration is not absolutely essential; for it some- 
times happens that the spasm, instead of yielding partially, relaxes at once 
and completely, so as to allow 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, increas- 
ing 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 said by some writers to be frequent, 
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, 
such as impure and confined air, and unwholesome food. Attacks may be 
brought on by sources of irritation in the intestines, including undigested 
food, acidity, acrid secretions, and worms. Disorder in the alimentary canal 
is, indeed, believed by some to be its most frequent cause; and hence it is 
apt to occur in infants fed by the hand. In some instances, the disease is 
associated with, and probably dependent on, affection of the brain, and has 
been considered 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 832 
[PART II. 
LOCAL DISEASES. RESPIRATORY SYSTEM. 
of unusual magnitude in some fatal eases. Some authors consider the latter 
as among the chief causes of the complaint, which has therefore been named 
thymic asthma. 
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, gently slapping the back, breast, or nates, blowing into the face or 
ear, or exposure to a current of cool air at an open window. When the spasm 
recurs frequently, it may often be prevented by the warm bath, nauseating 
medicines, and antispasmodics injected into the rectum. Should the symp- 
toms 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 ene- 
ma, prepared with five grains of the tobacco and a fluidounce of hot water. 
Dr. F. Collins, of Wanstead, England, has employed the inhalation of chlo- 
roform, in several cases, with unfailing success. (Land. Med. Times and Gaz., 
April, 1853, p. 380.) But the practitioner must bear in mind the hazardous 
character of this remedy. 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. Artificial respiration is recommended 
by Dr. Reid. 
The general nervous excitability in which the complaint sometimes origi- 
nates, 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 the sensibility to exciting causes. 
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. 
Inhalation of the vapour of ether was 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. Jouyn., June 2, 1847.) 
Attention should always be paid to 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, magne- 
sia, 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 mode- 
ration afterward. The child should be clothed warmly, and made to 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. CLASS III.] 
APHONIA. 
833 
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 open but still contracted 
passage, and occasionally a croupy cough. The spasm may be excited, and 
sometimes fatally, by a foreign body in the larynx or pharynx. Choking is 
in such cases not mechanical; but arises from involuntary contraction of the 
laryngeal muscles, 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 pro- 
tean 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 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 mus- 
cles 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 ap- 
pears 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 aneur- 
isms 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 
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. Nux vomica or strychnia may be employed, when there is reason to 
suspect a paralytic state of the muscles of the glottis, without sufficient active 
congestion or inflammation of the nervous centres to contraindicate its use. 834 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
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 produce 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 circum- 
stances, we may employ gargles of alum and other astringents whether vege- 
table 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 benzoin has been found effectual. Dr. Pancoast, of Philadelphia, has 
related two cases in which the voice was restored by inhalation of chlorine. 
[Trans. of Am. Med. Association, iii. 13G.) The vapour of ether with balsam 
of Tolu has been recommended. 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 evi- 
dence 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 considera- 
ble 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 general debility, or irri- 
tation 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 gene- 
rally. Those especially applicable in this case would be the inhalation of 
warm aqueous vapour, 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 II 
HOOPING-COUGH, or PERTUSSIS. 
Syn.-Chin-cough.-Convulsive Cough of Children.--Tussis convulsiva, spasmodica, 
strangulans, &c. 
This is a contagious disease, characterized by frequent paroxysms of cough- 
ing, in which the expiration is broken into numerous short, rapid, and spas- 
modic movements, and the inspiration is long, and frequently sonorous. It 
most frequently affects young children. Medical writers usually divide it 
into three stages f 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 CLASS III.] 
HOOPING-COUGH. 
835 
instance of the disease. Something like them, however, is very generally 
observable; and the division enables the symptoms 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 period, 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 most cases, for one or two weeks, before decided spasmodic symptoms ap- 
pear. Sometimes, however, its duration is shorter, and sometimes longer. 
Instances, indeed, now and then occur, in which the characteristic symptoms 
of the disease appear at the outset; and it is occasionally observed, during the 
prevalence of hooping-cough, that catarrhal affections run a corresponding 
course, as if dependent upon the same cause, though destitute of the peculiar 
spasmodic phenomena. 
But, in most cases, at the end of eight or ten days, the cough 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 mucus, and not unfrequently in vomiting, which appears to relax 
the spasm, and thus proves serviceable in the complaint. Occasionally, how- 
ever, 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 appears feeble and perhaps trembling, with hurried pulse and 
breathing; but he soon recovers from these symptoms, and seems as if no- 
thing had happened, 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 836 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
in croup, and the crowing disease of children. The expectoration is probably 
produced, not by 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 man- 
ner as prolonged fits of laughter. The vomiting arises from the disturbed 
movements 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 it 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 par- 
oxysm; and the child appears to dread its approach, and to repress the dis- 
position 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 or three weeks, after 
which it begins to decline, and the third stage commences. The spells of 
coughing now gradually become less 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 whooping 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 having 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 al- 
lowed 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 CLASS III.] 
837 
HOOPING-COUGH. 
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 parox- 
ysm. A case of death is recorded from emphysema of the neck and medias- 
tinum, consequent upon a violent paroxysm of coughing. (London Lancet, 
Aug. 1849.) In protracted cases, great emaciation and debility sometimes 
ensue, and the patient may die of exhaustion. But these results are compa- 
ratively rare. The simple form of the disease almost always terminates 
favourably. It is, however, liable to complications, which are very often 
dangerous, and not unfrequently 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 same 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 also 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 neces- 
sarily 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 re- 
garded as a disease calculated to excite solicitude, and a careful watchfulness. 
Great numbers die of it in every epidemic. It is most fatal in children under 
two years, probably because then combined with dentition. By comparing 838 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
results stated by Dr. Condie, it appears that the average deaths from hooping- 
cough, in our Atlantic cities, are 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, 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 mucus 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 say 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 appears 
probable, when we consider that the chief force exerted is in expiration. It 
is, I think, more justly attributed by Guersent and others to an increased nu- 
trition under the stimulus of irritation. 
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 occasion- 
ally associated with the influenza in certain localities. It is altogether irregu- 
lar 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 per- 
haps 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 summer in- 
stead of the winter. Occasionally the complaint is sporadic. Different opinions 
have been entertained of its contagious nature; but the great majority of 
writers are united in believing that it is propagated from individual to indi- 
vidual; 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. Excep- 
tions occasionally happen 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- CLASS III.] 
HOOPING-COUGH. 
839 
tory or nervous. The cause appears to he 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. Some have 
ascribed the complaint to inflammation 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 dis- 
sections. 
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, treat- 
ment is often highly useful in alleviating the symptoms, and, in complicated 
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, or 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 be preserved 
to bear the patient through. He will, therefore, take less blood than in cases 
of original inflammation having the same seat, and the same grade. 
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 centres, 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 inflammation shall have been re- 
moved. When these symptoms linger in connexion with the spasmodic, it 
will be preferable to precede the antispasmodics and narcotics by occasional 
emetic doses of ipecacuanha, in violent cases everyday or every other day, with 
smaller doses every two or three hours in the interval, so as to sustain a very 840 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
slight degree of nausea. Should the bronchitis be considerable, 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 propriety. The daffodil 
(Narcissus pseudo-narcissus), which has been recommended 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 antispasmodics; and, if there be any doubt 
upon the point, the use of these may be combined 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 one 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 are unnecessary, when it is supported well by the stomach. 
Garlic may be employed as a substitute for assafetida, when this is not at hand, 
or may from any cause be forbidden. Strong coffee is said to have proved 
very serviceable. Other antispasmodics, which have had more or less repu- 
tation in the complaint, are music, artificial musk, castor, valerian, camphor, 
ammonia, oil of amber, Dippel's animal oil, and cochineal. 
Of the narcotics, belladonna has the highest reputation. It appears, in- 
deed, from much highly respectable testimony, both of European and Ame- 
rican 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, 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 suc- 
cessful, 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 peculiar effects. The uncertainty and occa- 
sional 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 
dulcamara. Opium is undoubtedly the most efficient in allaying cough; but 
is liable to the objection of being apt to check mucous secretion, and conse- 
* See a paper by Dr. Hiram Corson, of Montgomery Co., Pennsylvania, in which 
this remedy is asserted to be extremely efficacious in shortening the disease, and nu- 
merous cases are adduced in proof of the fact. (Am. Journ. of Med. Sci., N. 8., xxiv. 
353.) CLASS III.] 
841 
HOOPING-COUGH. 
quently to prevent expectoration. Still, it may be occasionally used with 
advantage in connexion with ipecacuanha or tartar-emetic, and other expecto- 
rants. It has been recommended, in the form of one of the salts of morphia, 
as an endermic application to the throat. Hydrocyanic acid has been very 
highly praised. 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 over- 
doses, that it is scarcely an advisable remedy, especially when we have so many 
others much safer, and not less effectual. Cherry-laurel wrater, the properties 
of which are identical with those of hydrocyanic acid, has been used in Europe, 
both by the mouth and by inhalation. 
The tonics, which often prove efficient remedies in the purely nervous af- 
fections, have enjoyed some reputation in the treatment of this, especially at 
a somewhat advanced period, when the system has begun to be exhausted by 
the continuance of the disease. The mineral tonics have usually been pre- 
ferred. 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, subcarbon- 
ate 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. Nitric acid, recommended by Dr. Arnoldi, is affirmed by Dr. 
G. D. Gibbs, in his treatise on hooping-cough, to "shorten the disease almost 
as effectually as quinia does intermittent fever." (See Lond. Med. Times 
and. Gaz., July, 1854, p. 118.) Among the substances which have enjoyed 
more or less reputation, sulphate of guinia has also been considerably em- 
ployed, and probably quite as effectually as the mineral tonics. 
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 symptoms linger, 
the emetics may be combined with the antispasmodics and narcotics; in the 
latter stages, when debility has supervened, tonics may take the place of 
emetics; and in all stages, should the bowels be confined, and the medicines 
employed to meet other indications not have the effect of opening them, lax- 
atives 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, nitric 
acid, or one of the cbalybeates, 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 mixtures 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 spasmodic 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 men- 
tioned, solution of arsenite of potassa, iodide of potassium, acetate and sub- 842 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
acetate of lead, alum* sulphur, and 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 ; arid 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 
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 water, added 
in the quantity of a fluidrachm to the warm water employed, camphor, tar, 
benzoin, galbanum, nitrous acid vapours, &c. Ether and chloroform have 
recently been recommended, and the latter is stated to have been used with 
great advantage; but it requires much caution, and, in consequence of the 
occasional fatal results of its inhalation, should not be resorted to unless to 
save life, which can seldom be necessary in this complaint. Dr. E. Watson, 
of Glasgow, recommends the application of a strong solution of nitrate of 
silver to the interior of the larynx, as in cases of chronic laryngitis ; having 
cured the complaint, in several instances, by this remedy. (Ed. Month. Journ. 
and Retrosp., Dec. 1849, p. 1290.) Vaccination appears 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. 
Dr. R. L. Madison, of Petersburg, Va., believing the disease to originate in 
irritation of the spinal cord near the orifices of the pneumogastric and phre- 
nic nerves, treats the disease with a blister to the back of the neck, and 
finds this remedy to prove speedily and permanently effectual. In most cases, 
a single application is sufficient to effect a cure. (W. J. Med. Reporter, v. 124, 
from, the Western Lancet.) 
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 hyoscyamus, 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 convulsions 
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 Meninyitisf Severe bronchitis or 
pneumonia must be encountered by the remedies demanded by these affections 
occurring originally; except that bleeding should be less freely employed. 
* Drs. J. F. Meigs and D. F. Condie, in tbeir respective wopks on the diseases of 
children, speak very decidedly of the efficacy of alum. Dr. Meigs has found alum 
more efficacious in moderating the violence of the disease than any other remedy that 
he has used. (Note to the fourth edition.') CLASS III.] 
NERVOUS COUGH. 
843 
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 primae viae, leeches to the 
abdomen, emollient cataplasms, refrigerant diaphoretics, warm baths, demul- 
cent drinks, mild aperients, as rhubarb and magnesia, and sometimes small 
doses of calomel, are suitable remedies. 
Throughout the complaint, there are various points of regimen and man- 
agement 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 carefully at- 
tended to. If swollen, they should be lan'ced 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 vege- 
table substances with or without milk; at a more advanced period, of the 
same materials with milk freely, and a little of the lightest kind of meat, as 
the boiled breast of fowl, soft boiled egg, &c.; 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 flan- 
nel 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, or 
those with a tedious convalescence, the cure is much promoted by a 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. 
•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 pecu- 
liar 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. 844 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
The cough is almost always dry, unless in instances in which, after a vio- 
lent 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 varia- 
tions. It is sometimes single, short, and at uncertain and distant intervals. 
Sometimes 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 inter- 
vals 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 hy 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 interrupt- 
ing sleep. Not unfrequently 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 reme- 
dies to which it 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 
it associated with tenderness of the spine between the scapulae. 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 exist- 
ing, must be corrected by the usual means. CLASS III.] 
845 
ASTHMA. 
Article IK 
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 
auscultation and percussion, to refer difficulty of breathing, not truly asth- 
matic, to its proper source, and thus to give greater precision to our concep- 
tions of this disease. 
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 affebtion, 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. Those cases, therefore, even of spasmodic and paroxysmal dys- 
pnoea, in which bronchial inflammatioi) is the most important constituent, 
are not, in this work, treated of as examples of asthma, but are referred to 
bronchitis. (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 bronchial 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 merely subordinate. 
Symptoms, Course, &c.-1The asthmatic paroxysm is often preceded, for a 
Syn.-Spasmodic Asthma. 846 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part it. 
longer or shorter time, varying from a few hours to several days, by certain 
premonitory symptoms, which 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. In some instances, however, the attack is sudden and without warn- 
ing. 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 chest. A peculiar wheezing noise is made in breathing, 
which can be heard at a considerable distance. Yet, notwithstanding 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. Expiration is much 
less difficult and painful than inspiration. Under a sense of impending suffo- 
cation, the patient is irresistibly impelled to seek for cool and fresh air, and 
the least semblance of restriction in this respect is insupportable. 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 surprising 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 nervous excitement. 
The countenance of the patient, and his general movements express an inde- 
scribable 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 impeded respiration. Speak- 
ing is equally imperfect and difficult. The pulse is often small, feeble, irre- 
gular, 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 alternately; the eyes are promi- 
nent; 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 begin- 
ning of the attack. After two, three, or 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 humoral asthma; though the latter name is more frequently applied to a 
variety of chronic bronchitis already described. (See Bronchorrhoea, p. 803.)' 
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 CLASS III.] 
847 
ASTHMA. 
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 even 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, notwithstand- 
ing the violent efforts at inspiration, the ear applied to the thorax is sensible 
of little sound from the entering air; only a faint respiratory murmur, 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 apparently 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. Ac- 
cording 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 stopping, and 
then quietly to commence breathing again, the spasm appears to be in a man- 
ner 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.) According to Williams, the same diminution of respiratory 
sound is found in the intervals as during the paroxysm, though in a less 
marked degree; and a similar relaxation, upon holding the breath, shows that 
the affection is still spasmodic. (Tweedie's iSyst. of Pract. Med.) 
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 dis- 
eases, 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 lessens the 848 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
general bulk of the lungs, and impedes the entrance of air from without, 
causes that contained in the vesicles to expand, and thus to produce their 
dilatation. 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 affec- 
tions which must be regarded as direct causes of the asthmatic symptoms, are 
lesions of the brain, spinal marrow, or par vagum, either original or conse- 
quent 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 inapprecia- 
ble modification of the nervous constituents of the bronchial tubes, or of the 
par vagum, or of one or more 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 
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 indulg- 
ence of any of the stronger passions, profuse evacuations, protracted illness, 
and the different forms of dyspepsia. It is said that persons much exposed 
to irritating inhalations, whether in the form of gas, vapours, or dust, 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 bron- 
chitis, attended with more or less bronchial spasm, than true asthma. Another 
predisposing cause is said to exist in those professions which require in their 
exercise violent and continued respiratory efforts; but, with the same excep- 
tions 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 may have in 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- CLASS III.] 
ASTHMA. 
849 
dom originates in advanced life. It is more frequent in men than women, 
except in old age, when it is said to prevail about equally in both. 
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 
peculiarly 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 
different, 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 contami- 
nated 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, 
whether aeriform or solid, may excite the paroxysms when inhaled. In pecu- 
liar idiosyncrasies, certain odours, as that of ipecacuanha, and of new-mown 
hay, produce violent attacks of dyspnoea, which are sometimes of the asthma- 
tic character. Anything capable of irritating the bronchial mucous membrane 
may excite a paroxysm. The suppression of hemorrhages 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. 
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 susceptibili- 
ties. 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 
asthmatic paroxysm. When the two complaints, therefore, are associated, if 
there be any relation of cause and effect between them, the probabilities are 
altogether in favor 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. 
It is impossible not to be struck with a strong analogy, in certain respects, 
between asthma and gout. The apparently constitutional nature of the com- 
plaints, this disposition of the attacks to recur at distant but gradually dimin- 
ishing intervals, the division of each attack into nightly paroxysms with 850 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
marked remission in the day, the duration of the early spells for several days 
or a week, and the general incurability of the affection, are circumstances 
calculated to induce the suspicion that the two diseases are often identical; 
in other words, that asthma, as before stated, may often be nothing more 
than gout in' the nervous form. 
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 much 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 instances 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. Colcbicum 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 inflammation. 
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 
especially 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. 
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. 
Stramonium 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 CLASS III.] 
ASTHMA. 
851 
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 re- 
lief. Chloroform, administered by means of inhalation, sometimes completely 
resolves the paroxysm; but care is required to prevent a too powerfully de- 
pressing effect. It would probably be safer to administer it in connexion with 
ether; and these same remedies may be given in combination by the stomach. 
Opiates are very useful in the purely spasmodic cases, without tendency 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 some- 
times afford relief; but there is danger that some of the more volatile sub- 
stances 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 burn- 
ing 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, or in the form of a 
cigar. M. Collidoni cures the disease by causing the patient to smoke sarsa- 
parilla, by means of a pipe, in the same manner as tobacco. (Journ. de 
Pharm., Be s^r., xviii., from Bidletin Gen., Aug. 1850.) M. Rayer 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 Annales de Therapeutique.) 
Dr. A. M. Johnson, of Illinois, has administered sulphate of quinia in a single 
dose of twelve grains in the paroxysm, with success in several cases. (See 
Wood's Quart. Retrosp., ii. 2.) Dr. J. P. Root, of New Hartford, Connec- 
ticut, has obtained extraordinary effects from sulphate of lime. (Boston Med. 
and Surg. Journ., 1. 33.) In cases attended with spinal tenderness, cups or 
leeches should be applied over the tender vertebrae, 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 move- 
ments of the chest should be removed, as few assistants as will answer the 
purposes of attendance should remain in the room, and smoke and other ex- 
halations should be carefully avoided. 
In the interval, our efforts should be directed to the removal of the mor- 
bid tendency; and, for this purpose, every discoverable deviation from 
health should be corrected as far as practicable. It is impossible to particu- 
larize all the remedies that may be employed. The attention should be 
directed particularly to the state of the stomach and bowels. Dyspeptic 
symptoms may require antacids, carminatives, and tonics; constipation, laxa- 
tives; deranged hepatic secretion, the mercurial alteratives. In the female, 
the menstrual function should be kept in order. In gouty cases, moderate 
doses of colchicum may be found beneficial. Anemia and general debility 852 
LOCAL DISEASES.-RESPIRATORY SYSTEM. [PART II. 
must be counteracted by tonics and a suitable regimen. Dr. T. S. Hopkins, 
of Bethel, Georgia, has found special advantage from nitric acid. (Am. Journ. 
of Med. Sci., N. S., xx. 549.) If chronic bronchial inflammation exist, it 
should be treated with local depletion, blistering, the stimulating and nau- 
seating 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. Dr. Huss, of Sweden, has found the dis- 
ease to yield promptly to chloride of platinum, given in the dose of half a 
grain, three or four times daily. When the paroxysms occur at precisely 
regular intervals, with complete intermission, there is some chance of inter- 
rupting them by sulphate of quinia. Strong moral or physical impressions 
of any kind will sometimes avert them. Dr. Lefevre, a French physician, 
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. 
( Valleix, 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 favour- 
able. Travelling is sometimes highly advantageous. In this as in other 
habitual nervous affections, it is useful to surround the patient with entirely 
new circumstances, so that a new set of impressions may be made on his ner- 
vous system. A long voyage, or a protracted journey abroad, would offer 
some hope of a permanent cure, should no organic disease exist.