i . 1 j ! , . iiiPliiiiiiiliiliiliiiliilli 
 
HE SPARKS 
 
 LIBRARY. 
 
 [MISCELLANY.] 
 Collected by 
 
 JARED SPARKS, LL. D., 
 
 President of Harvard College. 
 
 Purchased by the Cornell University, 
 
 1872. 
 
Cornell University Library 
 
 arV17136 
 
 Another letter to a young physician: 
 
 3 1924 031 268 935 
 
 oiin,anx 
 
a Cornell University 
 S Library 
 
 The original of this book is in 
 the Cornell University Library. 
 
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ANOTHER LETTER 
 
 TO A 
 
 YOUNG PHYSICIAN 
 
 TO WHICH ABE APPENDED 
 
 SOME OTHEB MEDICAL PAPEES. 
 
 BY 
 
 JAMES JACKSON, M. D., 
 
 FROFESSOU EUfiRITUS OF THE THEORY AND PRACTICE OP MEDICINE 
 
 IN Harvard University. 
 
 BOSTON: 
 
 TICKNOR A.NT> FIELDS. 
 
 1861. 
 ® 
 
Entered according' to Act of Congress, in the year 1861, 
 
 By JAMES JACKSON, 
 
 In the Clerk'a Office of the District Court of the Uistrict of Massachusetts. 
 
 cakebaidoe: 
 
 MILES & DILLINGHAM, 
 
 Printers and Stereotypers . 
 
CONTENTS. 
 
 Faqi 
 
 Lettee XVIII., \ 
 
 NoTBs, 95 
 
 Note I. John Loweli, .... 101 
 
 " II. EXTSACT FEOM LeTTEB TO Ds. 
 
 FOKBES, Ill 
 
 " III. Rebecca Tatlok, . . . 118 
 " IV. Mk. Pbescott, .... 130 
 Memoib on the Sickness and Death op 
 
 Genebal Washington, . 157 
 
PREFACE. 
 
 A FEW years since I published a book 
 entitled " Letters to a Young Physician." 
 I did this with some hesitation, fearing 
 that I was too old to- venture on any work 
 for the public. Nevertheless, I have now 
 taken courage to prepare one more letter. 
 Probably I should not have done this, if 
 that book had not been very kindly re- 
 ceived. Emboldened by that reception, I 
 have more than once had it in my mind 
 to write one or more letters on subjects, 
 which, from time to time, have engaged my 
 attention. But on reflection I have thought 
 it wiser to leave the work to younger and 
 abler men. Within the last year a grave 
 question has been agitated among us, on 
 which one, whose experience has extended 
 
 a* [y] 
 
VI PREFACE. 
 
 through more than half a century, may be 
 thought qualified to form an opinion. 
 
 The question is whether there is any 
 good to be derived from the practice of 
 medicine. Our public in this little Com- 
 monwealth of Massachusetts was led to 
 this question by the discourse delivered 
 before our Medical Society at their annual 
 meeting in May, 1860, by Oliver Wendell 
 Holmes, M. D. Whatever is said, or written 
 by that gentleman, will always produce an 
 impression among us, and probably in 
 other parts of the world. 
 
 Dr. Holmes did not present the question 
 as I have stated it ; but the matter has 
 been treated as if he had done so. At 
 least, some of our brethren have regarded 
 him, as denying the utility of our art, and 
 it was so understood by many persons not 
 of the medical profession. It is because 
 this question has been before the public 
 that I have prepared the following letter. 
 It may be admitted as some apology for 
 
PREFACE. Vn 
 
 offering my thoughts upon this subject, 
 that a large proportion of the present fathers 
 and leading practitioners of medicine in 
 our Commonwealth were pupils in our 
 principal Medical School, while I was a 
 professor there. 
 
 In regard to Dr. Holmes, it has seemed 
 to me that he was misunderstood by those, 
 who suppose that he maintained the nega- 
 tive upon the question above stated. His 
 great object was to inculcate caution in the 
 practice of medicine. He placed in a strong 
 light the evils, which may be occasioned 
 by the action of potent drugs upon a living 
 body. He urged us to put a reliance on 
 nature and to pursue what has been called 
 the expectant plan of treating the sick in 
 all cases, where the evidences in favor of 
 some active practice are not clearly shown 
 by experience. 
 
 Without discussing precisely the opinions 
 advanced by my learned friend, I have met 
 the question, which has in fact been en- 
 
Vlll PREFACE. 
 
 tertained among us since the delivery of 
 his discourse. And in regard to this ques- 
 tion I have not taken a side for, or against, 
 the utility of medicine, in the style of a 
 partizan. The stand I take is somewhat 
 that of a witness, called upon in the char- 
 acter of an expert. 
 
 I trust it will be found that I have 
 given my testimony fairly, with a regard 
 to the oath that a witness is supposed to 
 take. So far as it goes, I believe that this 
 testimony will afford some support to the 
 claims of medicine to be a useful art. I 
 do not deny, but affirm that our art is im- 
 perfect. Taking the cases of disease as 
 they are brought to us, it is not often that 
 we are justified in employing heroic prac- 
 tice. But much may be done without 
 adopting this practice. "When a surgeon 
 is called to 'a man with a broken leg, he 
 places the limb of his patient, and in some 
 measure his whole body, in a fixed position, 
 using splints and bandages; and then he 
 
PREFACE. IX 
 
 watches him from day to day. He does 
 not pretend that the processes of healing in 
 the fractured bone are brought into opera- 
 tion by the splints and bandages, nor by 
 his watching. But he has placed the in- 
 jured parts under the circumstances most 
 favorable for healing ; and he watches that 
 he may guard against everything, which 
 can interfere with the salutary operations 
 of nature, as well as that he may give to 
 her any support, which he may think that 
 she needs. Just so, the physician, in the 
 larger number of cases under his care, makes 
 it his business to dispose of everything re- 
 lating to his patients in such a manner, as 
 to give the best chance for the salutary 
 operation of the natural powers. A good 
 nurse, it may be said, may do the same. 
 But the qualifications of a well-educated 
 physician must enable him to take the care 
 with much greater advantage. 
 
 I have not followed any strict method 
 in this letter. After some introductory re- 
 
PREFACE. 
 
 marks I have named several of the most 
 powerful articles of the materia medica, 
 which are in use among us, and some minor 
 articles analogous to each of them respec- 
 tively, and have stated in regard to each 
 what value I attach to them. In doing 
 this I have necessarily mentioned the dis- 
 eases, in which I have found them bene- 
 ficial. Next, turning to the most prominent 
 of the diseases we meet with, the acute 
 diseases particularly, I have stated in which 
 of these, and under what circumstances, I 
 have found benefit from the employment 
 of powerful remedies. While expressing 
 my opinions on these topics I have allowed 
 myself to go into details, whenever I deemed 
 this might be useful. Indeed, when stating 
 that benefit may be expected from the use 
 of a medicine in a particular disease, it is 
 often quite necessary to say in what way 
 the drug must be prepared, and under what 
 conditions it should be given. 
 
 In writing, I have had in view princi- 
 
PREFACE. XI 
 
 pally my brethren in New England, and 
 especially the Fellows of the Massachusetts 
 Medical Society. Indeed, I have felt almost 
 as if preparing a circular letter to these 
 Fellows. 
 
 To this eighteenth letter some articles 
 are added which will, I hope, be read with 
 interest by medical men, and not be without 
 some attraction for general readers in the 
 region about Boston. 
 
 The critic may note in this book the 
 garrulous tendency common in old age. If 
 he cannot, I can. I claim the apology, 
 which the aged may always offer in such 
 a case. When a traveller returns home, he 
 has a right to suppose that his friends and 
 neighbors will like to hear what he can 
 tell of foreign parts. Just so, old men and 
 old women are justified in the belief that 
 the young will be glad to hear anecdotes 
 of old times and notices of the people who 
 were cotemporaries of their grandfathers. 
 The travellers through the bygone years 
 
XU PREFACE. 
 
 and in the foreign countries, are both right. 
 The care should be not to spin out their 
 stories to too great a length. 
 
 Boston, March 29, 1861. 
 
LETTER XVIII. 
 
 ON THE UTILITY OF MEDICINE. 
 
 In my former letters I discussed questions of 
 practice, referring to first principles occasionally, 
 as far as seemed necessary to explain my views 
 on practical matters. Now I turn to first prin- 
 ciples — fundamental principles. Do not be sur- 
 prised, however, if I seem to forget what I had 
 set about, so as to run off continually to the 
 consideration and statement of little details as to 
 practice. I know my own tendency in this par- 
 ticular. The truth is that I consider it very 
 dangerous to lay down first principles in any art, 
 without a nice regard to the limitations of those 
 principles, when applied to the art concerned. 
 Listen a minute to an anecdote which I heard 
 long ago, and which made a very strong impres- 
 sion on my mind. Roger Sherman of Connecticut, 
 one of the Committee who drew up the Declaration 
 of Independence in 1776, was not a graduate of 
 1 
 
Z ON THE UTILITY OF MEDICINE. 
 
 any college. He began life as a shoemaker ; but 
 he had a mind fitted by nature for deep thought. 
 About the year 1793, when he was a member of 
 the Senate of the United States, on some occasion, 
 not one of the greatest importance, he addressed 
 the highly respected members of that grave body, 
 proposing to them some measure which he moved 
 them to undertake. In doing it, he was extremely 
 exact and cautious in describing the limitations to 
 be regarded in bringing his principles into practice. 
 He carried his caution so far as to amuse one of 
 his friends and fellow Senators, who told the story 
 to me, and who afterwards asked him why he 
 was so careful in this instance. His reply was 
 to this effect, — the laying down general princi- 
 ples is hke building a stage, on which you are 
 to take your stand. You must be cautious in 
 building it ; for if you make it too large, or 
 without proper limitations, your opponents will 
 have a chance to get upon it, and drive you 
 oflF. 
 
 The question I am about to consider is, how 
 far the sick are benefited by the care and pre- 
 scriptions of the physician ; — or, limiting the 
 inquiry to the use of medicinal drugs, — whether 
 the sick are more helped than hurt by them. 
 
ON THE UTILITY OF MEDICINE. K 
 
 Scepticism in the art of medicine is not new. 
 Probably it has existed from the days of Hip- 
 pocrates ; at any rate, I know that it has existed 
 as long as I have been engaged in professional 
 life; which means for a term of sixty years. 
 Sometimes the wits have laughed at the doctors ; 
 sometimes the philosophers have called them into 
 the court of science, there to show cause why 
 tiiey should not abandon the use of powerful 
 drugs altogether; urging that such drugs mani- 
 festly do harm ; and that they were bound to 
 show that the benefit from them was greater than 
 the evil. In tnith, it has not been very uncom- 
 mon, for an old practitioner of medicine himself, 
 to avow his doubts as to the real benefits to be 
 derived from the treatment of diseases by heroic 
 remedies. 
 
 If the question were as to the soundness of any 
 system of medicine, old or new, I should always 
 take my place among the sceptics. It is quite 
 certain that more is required to make a system of 
 medicine satisfactory, than can be furnished from 
 our present stock of knowledge ; although it is 
 certainly true that we are better prepared than 
 any of our predecessors. Before we can make a 
 system of rational medicine, our stock of knowl- 
 
4 ON THE UTILITY OF MEDICINE. 
 
 edge must be increased in all and each of the 
 various departments of our science. First, our 
 physiology must be perfected in all its details ; in 
 regard to the elements of the human body, its 
 structure, the powers belonging to its various 
 parts, the functions performed by each of these 
 parts, &c. Secondly, we must understand how, 
 or in what mode foreign agents act on the living 
 body ; in what way they do good, and in what 
 way they do harm. We should be able to ascer- 
 tain when such agents modify the functions only, 
 and when they lead to, or induce changes in the 
 structure of the part they act on. We must be 
 able to ascertain whether there are any natural 
 processes, by which disease is removed ; and, if 
 so, in what cases this happens, and in what it 
 does not; and when there are not any such 
 natural processes, we should be able to point out 
 modes of obviating the evils of the disease, the 
 remedies which nature has fiimished for this pur- 
 pose, and their modus operandi. Such is a brief 
 and imperfect sketch of what is required to make 
 up a system of medical science. In all ages efforts 
 to attain this purpose have been made ; and ac- 
 cordingly systems more or less elaborate have 
 been devised and published. Some of them have 
 
ON THE UTILITY OF MEDICINE. 6 
 
 been adopted by the learned, and been the sub- 
 jects of temporary admiration and confidence. 
 But no one of them, up to this time, has stood its 
 ground after a full and thorough trial of it. The 
 wisest and soundest practitioners have never 
 placed their reliance on these systems, or not 
 long. In all ages, such practitioners have looked 
 to experience, and been guided by this in the 
 treatment of the sick. And let me ask if there 
 be any, among the useful arts, in which the same 
 is not true. But the knowledge derived from 
 this source comes slowly and with difficulty. It 
 certainly has not yet led us to modes of practice, 
 which are entirely satisfactory in all instances ; 
 and the bold and the enterprising, in attempting 
 to gain the requisite knowledge more rapidly, 
 have too often inflicted as many evils as they 
 have removed. 
 
 Many men, in and out of our profession, believe, 
 or seem to believe, that disease must always be 
 removed by medicines, ignoring in a good measure 
 the spontaneous efforts, by which disease is brought 
 to a happy termination in a large proportion of 
 cases. These remarks are not new ; but I think it 
 may be said that, at this time, there is a tendency 
 on this side of the Atlantic and on the other, to 
 
8 ON THE UTILITY OF MEDICINE. 
 
 more rational opinions on this subject. At the 
 last annual meeting of the Massachusetts Medical 
 Society, Dr. Holmes, the distinguished Professor 
 of Anatomy and Physiology in our medical school, 
 delivered a discourse, in which the evils of over 
 medication were portrayed in strong colors. I 
 shall keep this discourse in view, while I oifer 
 the results of my own observations and experience 
 on the utility of medicinal drugs in the treatment 
 of the sick. I wish to draw your attention to 
 the limits, which, in the present state of our 
 knowledge, should be put to the use of these 
 drugs. This is a large subject ; and I do not 
 dream of treating it fully and accurately. But 
 I hope at least to offer some usefiil hints ; and 
 while thus engaged, I shall avail myself of any 
 fit opportunity for practical remarks on the treat- 
 ment of the sick. 
 
 An impression has been received, in and out 
 of our profession, that Dr. Holmes meant to rep- 
 resent the medical art as useless, and even as 
 productive of evil, at least so far as the adminis- 
 tration of medicine is concerned. Somewhat simi- 
 lar opinions have been formed, by some persons, 
 in respect to the faith of my learned friend. Dr. 
 Jacob Bigelow, in the utility of our art. I do 
 
ON THE UTILITY OF MEDICINE. ( 
 
 not understand that either of these gentlemen is 
 thus sceptical. They may, or may not place less 
 confidence in the utility of the practice of medicine 
 than I do. One hardly finds two men, who agree 
 exactly on any practical question, though it be 
 one with which both are conversant. I am happy 
 to say that I accord generally with the opinions 
 expressed in the writings of my two friends. I 
 go with them in what may be called their con- 
 servative opinions. I have held the same for 
 many years. Nearly twenty years ago Sir John 
 Forbes published a review on the subject of 
 homoeopathy, in which he reprobated excessive 
 medication. Immediately upon reading this re- 
 view I wrote him a letter, designed to be private 
 only, expressing thoroughly and clearly my agree- 
 ment with him. Some extracts from this letter 
 he published in the next number of his review, 
 where it remains to testify to my opinions at that 
 time. But my objections then, as now, were to 
 the abuses of medicine. That I have faith in the 
 usefulness of our profession and in the benefits 
 to be derived from medicinal drugs, I have shown 
 in the preceding letters published in 1854. I 
 am not aware of anything in those letters which 
 I wish now to retract. It is the errors and abuses 
 
8 ON THE UTILITY OF MEDICINE. 
 
 in medical practice, against which the three gen- 
 tlemen, above named, have made war. The errors 
 and abuses consist in the -constancy, with which 
 medicine is administered in all diseases and in all 
 stages of disease, in the undue strength and doses of 
 the drugs employed, and above all in the disregard 
 of the spontaneous efforts for relief by natural pro- 
 cesses, and the neglect of hygienic principles in 
 the treatment of the sick. It is said, on the other 
 side, that the sick are often unhappy, if medicinal 
 remedies are not ordered for them. It is true, 
 in many instances, when medicine is not pre- 
 scribed for a sick man, even one who is intelligent, 
 that he complains that the physician does not 
 order anything for the removal of the principal 
 pain, or trouble for which his aid had been in- 
 voked. But, in the great majority of cases, 
 though not in all, I have found that a plain state- 
 ment of the truth would satisfy the complainant ; 
 would satisfy him, I mean, that the physician 
 was taking the best course. In connection with 
 the foregoing I wish to state, emphatically, two 
 principles, which I should be very glad to engrave 
 on the memory of every medical man, and of all 
 men, who may wish to derive benefit from the 
 care of medical men. The first is that it is at 
 
ON THE UTILITY OF MEDICINE. 9 
 
 the veiy commencement of a disease that there is 
 the best chance of arresting, or mitigating it by 
 treatment. Patients have sometimes said to me 
 that they had not sent for me a day, or a week 
 sooner, because they did not know what was the 
 matter with them, or how the disease was brought 
 about. To this I have rephed by asking if your 
 house were on fire, would you delay calling for the 
 firemen, till you found out how and where the 
 fire originated? In truth the ignorance on the 
 part of the patient, as to the nature of the disease 
 and its cause, should be regarded as the best 
 reason for asking a physician's advice without 
 delay. The other principle is that when medicinal 
 drugs cannot' be employed with benefit, medical 
 treatment may nevertheless be very useful. It 
 is by hygienic treatment that the sick may be 
 relieved, in many instances, especially when em- 
 ployed in the first stage of disease. In truth the 
 wisest course for a sick man, who can have re- 
 course to a physician, in whom he has confidence, 
 is to call for professional aid as soon as he finds 
 himself sick ; — and this, all the more, if he does 
 not understand his own case. Having called his 
 physician, the patient should submit himself to 
 his control entirely, allowing him to delay any 
 
10 ON THE UTILITT OF MEDICINE. 
 
 active treatment, in order to watch the course 
 of the disease, as long as he pleases ; or, on the 
 other hand, to resort at once to the use of such 
 active and powerful measures, as he may think 
 proper. If the patient cannot trust the phy- 
 sician so much as this, he had better not employ 
 him. 
 
 Let us now return to Dr. Holmes' discourse. 
 The great principle which he endeavors to im- 
 press on the minds of his brethren is this ; — that 
 medicinal drugs, generally, are articles which have 
 some noxious influence on the person, to whom 
 they are administered. He does not deny that 
 they may be serviceable, but maintains that it is 
 the duty of the physician, when administering 
 them, to compare the possible evil, which may 
 be produced, with the benefits which he is 
 justified in expecting from it. So far nothing 
 new is offered to the mind of the physician ; but 
 this necessary caution may be more deeply im- 
 pressed upon his mind by this forcible inculcation 
 of it.* 
 
 * Let me here refer the reader to my introductory letter in 
 the " Letters to a Young Physician." See there, at page 13, a 
 paragraph beginning on the eighth line, and also the paragraph 
 following that which terminates on the 15th page. 
 
ON THE UTILITY OF MEDICINE. 11 
 
 "We are questioned daily, especially by timid or 
 cautious patients, whether the taste of the medicine 
 proposed will not be offensive, whether it will not 
 give cause for pain or distress, and whether it will 
 not be productive of weakness, or of other evils. 
 On these points the physician answers, as the case 
 may be, that indeed such and such evils may be 
 produced, but he states that in his opinion^ the 
 benefits will be greater than the evil consequences, 
 else he would not make the prescription. Though 
 a conversation like this does not occur in every 
 instance, yet it is presumed that the prudent phy- 
 sician does always have these questions in his 
 mind, and that he would not make his prescrip- 
 tion, if he did not think the chance of evil much 
 less than that of good. But Dr. H. wishes his 
 medical friends to look at this subject with peculiar 
 care, and he fears that there are some among us at 
 least, who, being accustomed to the use of power- 
 ful medicines, become forgetful of the grave and 
 injurious consequences to "which they tend, or 
 which at least they may produce. He brings be- 
 fore us a statement of the evils in a numerical 
 form. Supposing the vital power to be represent- 
 ed by 100, he estimates, by way of example, the 
 evil occasioned by the medicine employed at five 
 
12 ON THE UTILITY OF MEDICINE. 
 
 per cent. ; and then it follows that twenty such 
 doses would take away all the vital power ; that 
 is, it would destroy the life of the patient. This 
 must follow on the supposition ; but we may ask 
 Dr. H. if he has not made a very violent supposi- 
 tion. It is by the way of example he states the 
 risk at five per cent. ; but, when one makes such a 
 statement, it is presumed he will take an instance 
 within ordinary limits. It is undoubtedly true 
 that ignorant and rash men may often subject 
 their patients to such a risk. It is true that a 
 wise and prudent physician will sometimes do the 
 same, when he thinks the risk of death from the 
 disease is very great. Surgeons perform opera- 
 tions every day, from which the risk to life is very 
 much more than five per cent. ; but it is because 
 the risk from the disease is forty, sixty, or ninety 
 per cent. But it is very rare that the risk to Hfe 
 from a single dose of medicine amounts to one per 
 cent. The risk, however, from a continued use of 
 a powerftJ drug for weeks, or months, may be as 
 much and a great deal more than five per cent. 
 This risk is, I fear, sometimes incurred without 
 sufficient consideration. We can all see that in 
 the common practice of the last age such a risk 
 was incurred too frequently. It can do us no 
 
ON THE UTILITT OF MEDICINE. 13 
 
 hann to have our attention strongly directed to 
 the subject, so as to lead each one of us to inquire 
 whether we, at the present day, are sufficiently 
 cautious. 
 
 When Dr. H. spoke of sinking all the drugs in 
 the sea, he did not mean to be very literal. If we 
 contemplate the act proposed, we must see that he 
 must be more of an autocrat than Peter the 
 Great, Emperor of all the Russias, before he could 
 put his proposal into execution. If he could take 
 up all the mineral medicines in the market, he 
 could not take away the demand for them ; and 
 the demand would bring the supply, even though 
 that supply must be sought for in the deepest 
 mines. And as to the vegetable and animal 
 articles of the Materia Medica, if he should empty 
 the shops of the druggists from San Francisco to 
 New York, it would only insure us a clean stock 
 the next year. Our friend was not understood to 
 mean hterally that he would fill up the Bay of 
 Massachusetts by pouring into it all the drugs in 
 these United States. But I do understand him to 
 say that he thinks that medicinal drugs, as used 
 in this country and in Europe, do on the whole 
 cause more harm than good. Is this opinion 
 strictly correct ? It is not agreeable to make such 
 
14 ON THE UTILITY OF MEDICINE. 
 
 a statement, but I must acknowledge that I 
 have been in the habit, for many years, of giv- 
 ing advice which corresponds with this opinion 
 in some measure. To friends about to travel 
 whether on this side of the Atlantic or on the 
 other, I have said, " Do not employ any physician 
 unless you can ascertain, on good authority, that 
 he is regularly bred and likewise has the character 
 of being prudent and discreet." I agree fully 
 with Dr. Holmes that there is a very great risk 
 of evil from active practice, conducted by persons 
 imperfectly qualified. 
 
 The chance of evil resulting from an indulgence 
 in the use of alcoholic beverages is analogous to 
 that of the indiscreet use of powerful medicines. 
 These beverages, used with discretion, are in my 
 opinion blessings, for which we should be thankful ; 
 but it would be difficult to state, though we should 
 employ the strongest language, how great are the 
 evils, direct and indirect, produced by alcohol as 
 actually employed. It has often been a question in 
 my own mind, whether the benefits from this arti- 
 cle could be as great, as the evils connected with it. 
 I have- not decided, however, that discreet men 
 should abandon it on that account ; — for it is my 
 belief that those evils could not be prevented, if 
 
ON THE UTILITY OF MEDICINE. 15 
 
 every discreet man on the earth should abstain 
 from using it. I would say of medicinal drugs, as 
 I do of alcohol, that prudent men need not 4iesitate 
 to employ them, because other men make an im- 
 proper use of them. These are opinions to which, 
 I believe, my friend, Dr. Holmes, would give his 
 assent. I wish, therefore, to be understood as 
 being of the conservative party in respect to the 
 use of medicine, though I am not prepared to give 
 it up altogether. 
 
 Let me now examine these powerful medicinal 
 drugs in some detail, and give my opinions respect- 
 ing their value. When I began my professional 
 studies, my old master, pointing to the numerous 
 drawers and to the bottles arranged on the shelves 
 in his shop, said to me, " I seem to have here a 
 great number and variety of medicines, but I may 
 name four, which are of more importance than all 
 the rest put together ; viz. Mercury, Antimony, 
 Opium, and Peruvian bark." It is more than 
 sixty years since this statement was made to me by 
 my respected teacher. From that time to this, 
 scarcely a day has passed, in which I have not 
 seen one, or more of these articles in use among 
 the sick. What is my experience as to their 
 value ? I proceed to state it with as much 
 
16 0« THE UTILITY OF MBDICIHX. 
 
 fidelity and accuracy as I am capable of. Let me 
 treat of each of the four articles above named, in 
 its tumi, referring at the same time to others having 
 the same, or similar properties, with each of them 
 respectively- 
 
 To the first two, Mercury and Antimony, as 
 well as to some other metallic articles, there are 
 certainly grave objections. They are capable of 
 doing great mischief. They should not be put 
 into the hands of children, nor into those of any 
 ignorant, or unprincipled men, any more than 
 gunpowder or bowie-knives. But I should be 
 very sorry to be entirely deprived of either of 
 them. I have directed the use of them for my 
 friends, and have employed them on myself, when 
 occasion called for them ; for it has always been 
 my rule to administer to my patients those articles 
 only, which I would employ for myself under like 
 circumstances. Following this rule, I should wish 
 to keep on the Hst of my Materia Medica — Mer- 
 cury — Antimony — Arsenic — and some other 
 potent metallic medicines. 
 
 Among these articles, no one is more commonly 
 viewed with abhorrence than Mercury. It is well 
 that it should be so. It has been used within the 
 last himdred years with too much liberality, and 
 
ON THE UTILITY OF MEDICINE, 17 
 
 often to the great injury of the sick. Yet, when 
 employed discreetly, it may be given even to 
 children, during early infancy, during the period 
 of the first dentition. For them, calomel in a 
 single dose, may often be employed with great 
 relief, and with more advantage than any other 
 drug. They are specially subject to disorders in 
 the first passages, and by it these may be cleared 
 out more efficiently, and generally with less incon- 
 venience than by any other article. But the use 
 of it should not be continued. If one dose seem 
 to have removed half the disease, we must not 
 expect to remove the other half by a second dose. 
 If a derangement in the digestive organs has 
 brought about a necessity for the administration 
 of it, we must subsequently insist upon such care 
 as to diet, . air, exercise, &c., as will perfect the 
 cure, and will prevent the recurrence, certainly 
 will prevent the firequent recurrence of the same 
 derangement, for which the medicine had been 
 administered. For though the benefit fi-om one 
 dose may be much greater than the evil produced 
 by it, yet it may be too much to incur the risk of 
 this evil anew every few days. Calomel should 
 not be made familiar in the nursery, as a con- 
 venient brush or broom, by which to clean up that 
 2 
 
18 ON THE UTILITY OF MEDICINE. 
 
 apartment as often as the children have got it dirty, 
 I give this caution, for this reason. Though many- 
 mothers have a fear of the use of calomel for their 
 children, there are others who do not hesitate to 
 keep it on hand, and to administer it at their own 
 discretion. For adults, also, this article, as well 
 as the blue-pill, may be given in a single dose with 
 undoubted advantage. By a certain class of per- 
 sons it is regarded with great favor ; by those, I 
 mean, who indulge their appetites too freely. But 
 by them even, although they may generally be in 
 vigorous health, it must be used with discretion. 
 It is not well for them to make free with it. The 
 patient who begs for it, will be greatly vexed if it 
 treat him roughly. Early in life, my old- and 
 much respected friend, the late Dr. James Lloyd, 
 told me the story of a case, similar to what may 
 have occurred within the experience of many of 
 our brethren. A hundred years ago, Capt. A. B. 
 having a severe colic, sought relief from Dr. 
 Clarke. He begged the doctor not to be sparing 
 in his remedies, to give him the most powerful, and 
 those in the fullest doses. He demanded heroic 
 practice. He asked for calomel especially, from a 
 vague, though erroneous notion, that it was the 
 most power M of cathartics. Dr. C. yielded to his 
 
ON THE UTILITY OF MEDICINE. 19 
 
 solicitations, and after due time obtained relief for 
 his patient ; but, within two days, the patient 
 began to have a sore mouth, and ultimately the 
 affection of his mouth was so severe, that for sev- 
 eral days he could neither eat, nor speak, without 
 great distress. The captain now became more 
 impatient under the new disease, than he had been 
 under the colic. In this speechless state he sat at 
 his table, and gave vent to his feelings by writing 
 every few minutes, — " Damn Dr. Clarke." This 
 poor patient realized how true it is that a medicine 
 may do a certain amount of harm, which is to be 
 taken into the calculation when the physician 
 attempts to do good with it. In passing, let me 
 here remark that I tliink calomel should never be 
 employed in a case of great constipation ; for in 
 such a case, if it be not effectual at once, being 
 retained in the body, it is very likely to produce 
 its peculiar effects on the mouth. Besides this, 
 calomel is not the best medicine for removing a 
 great constipation. Its peculiar excellence is that 
 it acts on the stomach, and the upper part of the 
 intesthies. It is not so certain as some other arti- 
 cles, to induce a speedy evacuation of the whole 
 canal. But I will not go on to mention the 
 occasions proper for using this article ; several of 
 
20 ON THE UTILITY OF METIICJXE.- 
 
 these have been noticed in the preceding letters. 
 Of course, every medical man knows that there 
 are occasions, which justify the use of mercurial 
 preparations, until the mouth is made sore. 
 
 I mention Antimony next to Mercury. In a 
 report, made more than twenty years ago, upon 
 Typhoid Fever, founded on cases in the Massachu- 
 setts General Hospital, I showed what benefits 
 had been derived from the use of this article, as 
 an emetic, when administered on the first day, or 
 even within the first three days of that fever. I 
 brought up this subject anew in the 17th of these 
 letters. It is because I think it for the common 
 good tliat physicians should be duly impressed 
 with the value of this remedy in typhoid fever, 
 that I now bring the subject before them again. 
 That they may avail themselves of it, there is 
 one point to be studied, which I fear is not 
 always studied with sufficient care and exact- 
 ness. The point I refer to is the diagnosis of 
 typhoid fever on its first days ; on its first day, 
 if possible. I will begin by acknowledging that 
 on the first day of this disease, even if the patient 
 be brought distinctly under the physician's eye, 
 the symptoms of it are often so shght and shad- 
 owy, that it is with difficulty the disease can then 
 
ON THE UTILITY OF MEDICINE. 21 
 
 be recognized. It is almost impossible, by verbal 
 instruction, to prepare any man to detect the 
 disease thus early, in every instance. As in the 
 cases of many animals and plants, with wliich you 
 would make your pupils acquainted, you must 
 take them to the objects, in order to make them 
 familiar with their characteristics. You must 
 show them the specimens. How then shall the 
 pupil, or the young physician get this knowledge, 
 by which to recognize typhoid fever at its very 
 onset ? Let him avail himself of the opportuni- 
 ties afforded every few years, in New England at 
 least, when this disease is prevalent. Then he 
 can make himself familiar, by daily observation, 
 with the phenomena of the disease in its various 
 stages and under its various forms and shapes. 
 In fact, during a season, when the public are 
 under an alarm from the epidemic, patients are 
 oftener induced to call for advice on the first ap- 
 pearances of disease than in ordinary seasons ; 
 and in two years of such an epidemic, if not in 
 one, the medical man may, with diligence, acquire 
 such a knowledge of the disease as will subse- 
 quently save him from doubt, at least with rare 
 exceptions. But he must first study it with the 
 specimens in his hands, or before his eyes. 
 
22 ON THE UTILITY OF MEDICINE. 
 
 Let it be granted that we cannot arrive at abso- 
 lute certainty on the first day of typhoid fever, 
 yet, at least where it is epidemic, we may be 
 sufficiently certain for practical purposes ; and, 
 when it is not epidemic, the careful observer may 
 be sure enough, ordinarily. It is true that an 
 antlmonial emetic has a powerful influence on the 
 system, and should not be given from trifling con- 
 siderations. Yet when one is as well assured, as 
 I am, of the great benefits which this remedy 
 afibrds in the very commencement of this disease, 
 he will feel justified in taking some risk. Con- 
 sider for a moment the amount of evil to be ward- 
 ed off. In typhoid fever, left to itself, one must 
 ordinarily pass tlirough two weeks of severe sick- 
 ness, two to three more weeks of confinement to 
 the house ; and again, from two to five more 
 weeks, before he is truly fit to return to his 
 usual occupations. During most of this time 
 there are the evils of prostration and debflity ; 
 during a portion of it those of pain, — often great 
 pain and distress ; most commonly for some days 
 there is delirium, and often great delirium, and to 
 all these must be added the risk of life. This is 
 a great risk. I cannot put the proportion of 
 patients, to whom the disease proves fatal, whert 
 
ON THE UTILITY OF MEDICINE. 23 
 
 not arrested by treatment, at anything less than 
 one in seven. In some seasons it is much less 
 fatal than this, but in some it is much more so. 
 Viewing the antimonial emetic, administered on 
 the first day, as creating almost a certainty of a 
 speedy and safe termination of the disease, I think 
 I may say that the remedy ought to be employed 
 in every case, where there is an even chance that 
 this disease has begun its course. For myself, in 
 such a case, I should not liesitate. But why do I 
 express myself thus ? 1 have been placed precisely 
 under these circumstances, and I did avail myself 
 of the remedy promptly. This was in 1814, when 
 the disease was very prevalent among us. I was 
 attacked in the evening, and I took the emetic 
 about midnight. I acknowledge that a physician 
 is very liable to err in regard to himself ; I should 
 not therefore mention this case, as one in which 
 it was certain that the disease had taken hold of 
 the patient, though I have no doubt on the sub- 
 ject. But I mention it, as showing the strength 
 of my conviction of the advantages of the remedy, 
 and to show that I employ for myself what I 
 prescribe for others. Let it not be forgotten that, 
 when the remedy has been employed at the very 
 commencement of the disease, the patient should 
 
2i ON THE UTILITY OF MEDICINE. 
 
 not think that he is now safe ; he should be re- 
 garded as a sick man for several succeeding days, 
 even though he should appear to be entirely re- 
 lieved of all disease. If he will not do this, he 
 will be very likely to bring on the disease anew. 
 
 I have not stated the evils of this disease sufB- 
 ciently. Of those who recover from it, not a few 
 continue unfit for the common duties of life from 
 three to six months, during which time secondary 
 affections often make their appearance. And it 
 is not uncommon to meet with persons, ten and 
 twenty years after they have undergone this fever, 
 who refer to the period of it as a marked era in 
 their lives, since which they have never enjoyed 
 perfect health. 
 
 The greatest benefit, which can be derived 
 from antimony, is that to which I have here 
 referred ; but there is sufficient evidence that it 
 is useful in typhoid fever, when running its 
 course ; — useful in mitigating its severity, and 
 perhaps in shortening its duration. It has similar 
 good .effects in some other affections, when em- 
 ployed in such doses as do not ordinarily prove 
 operative. It has had a reputation for producing 
 favorable effects in febrile affections, and in certain 
 inflammatory diseases for several ages. It can 
 
ON THE UTILITY OF MEDICINE. 25 
 
 hardly happen that it should have retained this 
 reputation among physicians, maintaining very 
 diverse theories on pathological and therapeutical 
 points, if it had not in some measure deserved it. 
 That it has often been used, when there was not 
 a sufficient occasion for it, and that it has been 
 employed rashly and too freely, and that it may 
 have been productive of much injury, I do not 
 doubt. But we should not discard it on these 
 considerations ; M'e should only study, with in- 
 creased care, when and how it ought to be pre- 
 scribed. For its use in typhoid fever, after the 
 earliest days, I will refer to my Report on that 
 disease already mentioned. I might refer, no 
 doubt, to better and higher authorities ; but I 
 mention that as containing the results, at which 
 my mind had arrived. I think this medicine 
 may be used in pneumonitis and inflammation in 
 the internal viscera generally ; also in cases of 
 inflammation of the mucous membrane, even when 
 this is not sufficient to induce strong febrile symp- 
 toms. To this general remark an exception must 
 be made, — as to cases of inflammation of the 
 mucous membrane of the stomach. In acute 
 gastritis there is scarcely any medicinal article, 
 which will not offend the stomach ; and we may 
 
26 ON THE UTILITY OF MEDICINE. 
 
 say nearly as much of even the mildest articles 
 of diet. The same may be found true in acute 
 inflammation of the duodenum. But when the 
 inflammation is seated in the lower part of the 
 small intestines, and yet more, if in the large in- 
 testines, I think that antimony may be employed, 
 though ipecacuanha is usually preferable. It is, 
 however, especially in the affections of the mucous 
 membrane of the fauces, of the larynx, the trachea 
 and the bronchi, that I am in the habit of using 
 antimonials in small doses. In such cases, I most 
 frequently add opium to it. In affections of the 
 windpipe and bronchi, where cough and expec- 
 toration are produced, we may for a time arrest 
 the cough by opiates alone ; but an easy expec- 
 toration is more certain to follow when antimony 
 is added to the opiate. If these articles, in com- 
 bination, be administered at bed-time, for a few 
 successive nights, the durktion of the disease will 
 generally be shortened. To be successful, we 
 must study to give the right doses, so as to obtain 
 the greatest good with the least inconvenience. 
 A reasonable regard to diet and some other things 
 is necessary to secure the most favorable result. 
 When a bronchitis is severe at the beginning, in 
 a person who can endure the use of medicine 
 
ON THE UTILITY OF MEDICIJME. 27 
 
 without much trouble, it may be well to employ 
 these two medicines from the commencement of 
 the disease. In such a case and wherever the 
 opiate is to be employed, for several days in suc- 
 cession, it will generally be found necessary to 
 combine with these two articles some laxative 
 medicine. I prefer, however, to abstain from the 
 use of opium except where the cough is protracted, 
 or where the patient is particularly liable to pro- 
 tracted coughs. On the other hand, in some 
 instances, where the bronchitis appears to extend 
 very widely through the lungs, and to continue 
 obstinately, we may add to antimony and opium 
 another powerful drug ; — powerful for harm 
 when employed indiscreetly, but certainly often 
 very powerful for good. The article I refer to is 
 calomel. For an ordinary adult we may add 
 from one to two grains of calomel to each of the 
 evening doses of opium and antimony. Such a 
 dose, in an urgent case, may be taken on two suc- 
 cessive nights ; but ordinarily it should not be 
 repeated on two successive nights. The antimony 
 and the opium may be continued every night, 
 but the calomel only on every second, or every 
 third night. It is very seldom proper to repeat 
 the calomel more than three times after the first 
 
28 ON THE UTILITY OF MEDICINE. 
 
 dose. Indeed, there will rarely be a want of it, 
 if the affection is bronchial only. It very seldom 
 happens that we need to employ the antimony, 
 or the calomel, for young children in cases of 
 bronchitis. Yet we may sometimes do it with 
 unequivocal advantage, even for them. In child- 
 ren, as early as the fourth year, we occasionally 
 meet with protracted bronchitis causing a frequent 
 and very annoying cough through the day and 
 much more in the night. In such instances I 
 have long been in the habit of employing what I 
 have called my " puerile pill," and usually with 
 most marked success. When the disease has been 
 bronchitis only, not combined with any other 
 disease, the pills, I have used under this name, 
 have contained the following articles, viz : 
 
 Of Tartarized Antimony, One grain. 
 Of Opium, . . . One grain. 
 Of Calomel, . . , Ten grains. 
 
 And these articles, mixed with mucilage of Gum- 
 Arabic, have been divided into eight, ten, twelve 
 or fourteen pills, according to the age and con- 
 stitution of the patient. I have given one of 
 these at night, and most commonly a second on 
 the first or second night afterwards. I have very 
 
ON THE UTILITY OF MEDICINE. 29 
 
 rarely used any more ; for though the disease 
 has not been entirely removed, yet it has been so 
 decidedly relieved by two pills, and often by one, 
 that there was no inducement to give more. I 
 ought to say that the first dose will most com- 
 monly occasion some vomiting, and will almost 
 always prove cathartic, sometimes violently so. 
 But the evil from these effects is usually very 
 transient, and this is fully compensated by the 
 marked relief. To my friends, who are fearful of 
 the use of strong medicines, I will say that a few 
 trials in cases worthy of the remedies, would, I 
 believe, remove their apprehensions. To those 
 on the other hand, who believe that when one 
 dose proves to be very useful, a second and a 
 third will be equally so, I may quote here, as well 
 as on many other occasions, an old saying, That 
 two and two do not always make four. To the use 
 of antimony, combined with other medicines, as 
 above described, I have given close attention for 
 very many years, during my pupilage, and ever 
 since, and I beheve that my commendations of the 
 same are expressed in very moderate language.. 
 It will not be supposed that I claim to myself any 
 originality as to this mode of using antimony and 
 so forth. I mean only to add my testimony to 
 
80 ON THE UTILITY OF MEDICIKE. 
 
 that of others. I will not waste time in discussing 
 the ^^ modus operandi " of these medicines. On all 
 practical questions, if others will agree with me 
 as to the results produced by any given mode of 
 treatment, I am satisfied without any such dis- 
 cussion. 
 
 A few remarks will be added on Ipecacuanha, a 
 vegetable article similar in many respects to anti- 
 mony. Where the object is merely to unload the 
 stomach, this is preferable as an emetic to anti- 
 mony. Though more offensive to the taste, it is 
 more mild in its operations. For young children, 
 especially, and for all tender subjects, it is the most 
 appropriate. It is not only as an emetic that this 
 medicine is a substitute for antimony. Though 
 more feeble than this last, it supplies its place in 
 some measure as an anti-febrile medicine, and still 
 more in combination with opium in bronchitis, 
 dysentery, and some similar diseases. I will not 
 omit to say it produces asthma in some few indi- 
 viduals, even from handling it. To such persons 
 it should not be given. 
 
 The Squill is another article sometimes employed 
 as a substitute for antimony, or more commonly 
 combined with it, as an expectorant. It is very 
 valuable for this purpose. But I have mentioned 
 
ON THE UTILITY OF MEDICINE. 31 
 
 the squill principally to comment on one good 
 property, which it is known to possess, but for 
 which it is not sufficiently valued ; I mean that of 
 a diuretic. From my own experience I venture 
 to say that the reason why it is not sufficient!)' 
 valued in this respect, is that it is not usually put 
 to the test, in such doses, as are requisite for the 
 purpose. 
 
 It is well known that dropsy is ordinarily an 
 effect of some organic disease, such as is seldom 
 removed. Nevertheless the dropsy is often relieved 
 temporarily, — for weeks or months, or occasionally 
 for years. This takes place spontaneously some- 
 times, but much more often by the use of medicine 
 and especially of diuretics. In such cases the 
 squill always deserves a trial before resorting to 
 more powerful articles, except in very urgent and 
 distressing cases. It succeeds in most instances, 
 and though it may occasion some nausea, this is 
 seldom severe, or long continued. I think that 
 the tincture is the preparation of squills the most 
 convenient for this purpose, because its dose is 
 readily graduated to each individual case. It 
 should be given in such quantity as the stomach 
 will bear without nausea, three times a day. It is 
 best to begin with twenty-five drops for a dose, and 
 
32 ON THE UTILITY OF MEDICINE. 
 
 to increase it gradually. Ordinarily an adult can 
 bear thirty-five drops, but some bear more and 
 some less. 
 
 Some other medicines might be mentioned, more 
 or less similar to the antimony, &c., but this is not 
 necessary to my purpose. 
 
 As the third among Dr. Holyoke's four great 
 articles, comes Opium. It relieves pain ; this is its 
 great power. Where immediate relief is required, 
 and such as shall not be transient only, it certainly 
 takes the first place among' ansesthetics. There is 
 not any substitute for it in such a case. Sul- 
 phuric Ether and Chloroform will operate more 
 immediately ; but the relief they afibrd is very 
 transient, unless the remedy be constantly re- 
 peated. There are other vegetable narcotics, 
 besides opium, to which we may sometimes be glad 
 to resort, where the efiects of opium are particular- 
 ly annoying. Conium and Hyoscyamus are very 
 feeble compared with opium, yet we succeed with 
 them in some instances. It is necessary to begin 
 with the use of these in moderate doses, although 
 these medicines rarely produce decided effects 
 until large doses are administered. Stramonium is 
 much more powerful, and hence must be used with 
 great caution. It may produce more or less of 
 
ON THE UTILITY OF MEDICINE. 33 
 
 blindness, even in moderate doses ; and life itself is 
 endangered by it in large ones. Aconite is so hazr 
 ardous, -when used internally, that it should never 
 be resorted to, except on very extraordinary 
 occasions. Employed externally, in a saturated 
 tincture, it is not hazardous, and sometimes gives 
 relief to severe pain. I should be unwilling to 
 banish either of these articles ; and without opium, 
 I should hardly be willing to practice medicine. 
 At the same time, I resort to this invaluable drug 
 with reluctance, and especially to a continued use 
 of it, even for a few successive days, and with still 
 greater reluctance for longer periods. In regard 
 to this drug especially, I may say that it should 
 never be prescribed without bearing in mind the 
 eAdls it may produce. Some persons can take it 
 without any, or with only very little inconvenience ; 
 but there are a few in whom its effects are very 
 distressing. There are persons in whom they are 
 so much so, as to forbid the use of it entirely. It 
 takes away the appetite, and impairs, — often 
 destroys, — the power of digesting food. It con- 
 stipates the bowels, and checks all the secretions 
 and excretions, except cutaneous perspiration. 
 And, very frequently, it prevents perfect sleep. 
 I say this notwithstanding it is regarded as the 
 
34 ON THE UTILITY OF MEDICINE. 
 
 first of soporifics. After long continued distress, 
 or pain, it sometimes produces calm and refresh- 
 ing sleep. When sleep has been prevented by 
 a cough, it may often be obtained by an opiate 
 in a very moderate dose. But, in a large pro- 
 portion of cases, the sleep produced by opium is 
 imperfect. Especially the mind gets no re«t. It 
 is disturbed by dreams, and often by such, as 
 are very distressing ; and it is not productive 
 of any refreshment. Such are the effects on 
 many subjects. Some persons, more fortunate, 
 are always soothed and tranquilized by opium, 
 and think of it only as a comforter. For such 
 persons, if the occasion require, we may be more 
 wLUing to protract the use of it. But when long 
 continued, I believe that it always undermines the 
 constitution. 
 
 The last and fourth of the articles mentioned 
 by my old master, is Cinchona, — the bark of the 
 cinchona, — which in my youth was famiharly 
 called The Bark. It is regarded as a specific 
 remedy for the Fever and Ague. It used to be 
 thought that, if the physician would " put down 
 the Bark " in fiiU doses, it would certainly arrest 
 an intermittent fever without any other medicine. 
 But I believe that those who have tried it much 
 
ON THE UTILITY OF MEDICINE. 35 
 
 in malarious districts, have found it best to pre- 
 pare the patient, and especially to attend to the 
 stomach, into which it was to be introduced, before 
 administering this potent drug. As it was often 
 necessary to administer this bark in large quanti- 
 ties, the task of taking it was a severe one. At the 
 present day we employ the Alkaloid derived from 
 the cinchona, known as Quinia, or Quinine, of 
 which the doses are so small in bulk, as to remove 
 the terrors of it. This medicine is employed not 
 only in regular intermittent fever, but also in the 
 irregular intermittents and remittents, such as are 
 often epidemic and pestilential in hot climates. 
 
 There are other diseases, which have intermis- 
 sions more or less regular, in which the cinchona, 
 or its alkaloid, may be employed with great ad- 
 vantage. The most distinctly marked of these 
 is the intermittent Hemicrania. It has appear- 
 ed to me, as I have stated elsewhere, that the 
 effect of this medicine is to take away the dispo- 
 sition to, or the susceptibility of, certain diseases, 
 some of them not intermittent. When exhibited 
 in ftill doses, it will often put a stop to those 
 painful affections, which occur independently of 
 inflammation and of any organic disease, and 
 appear to' be ftmctional disorders in the nervous 
 
36 ON THE XJTILITY OF MEDICINE. 
 
 system. In these cases it is not necessary to the 
 beneficial use of the medicine, that the pain 
 should have any regular periods, such as we see 
 in the intermittent hemicrania. 
 
 I may repeat here what I have said in the 16th 
 Letter of this series, 320th page. In that letter 
 I mentioned its good influence in arresting certain 
 cutaneous diseases, of which the fiirunculi (boils) 
 famish the most remarkable instance. In all these 
 cases, where the intention is to overcome the sus- 
 ceptibility to a disease, I consider it requisite to 
 begin the use of the medicine in large doses. A 
 little of it will not do a little good ; it even does 
 harm. Beginning with small doses, and gi-adually 
 increasing them, it seems to me that the system 
 becomes accustomed to the medicine, so that even 
 large doses afterwards fail to do good. The 
 evils produced by this medicine are — a sense of 
 stricture in the head, noises in the ears, not 
 usually very distinct, and a slight deafiiess, or a 
 diminution in the power of hearing. To avoid 
 these evils, when they are great, and sometimes 
 because the patient is under some other disease, 
 which is thought to forbid the use of the quinia, 
 we substitute arsenic. The name often excites 
 some terror. It may be used so as to destroy life ; 
 
ON THE UTILITY OF MEDICINE. o7 
 
 and so may opium, and so may a lancet, or a 
 scalpel, if placed in improper hands. But as 
 arsenic has a bad character with many, I feel 
 bound to testify that it as mild and gentle in its 
 effects on the human body, as almost any efficient 
 medicine ever employed by us. If the physician 
 watch its effects from day to day, his patient will 
 seldom experience as much trouble fi-om it, as is 
 often brought about by quinia. General experi- 
 ence bears witness to the good effects of arsenic 
 in intermittent fevers, and in various chronic cu- 
 taneous diseases. I am aware, that in these last, 
 the good effects of this medicine are attributed 'to 
 some salutary operation upon the blood. It is so 
 regarded, when, in the language of the day, the 
 disease is called a blood-disease. It may be that 
 this is correct. I do not profess to have pene- 
 trated with any success, the arcana of blood dis- 
 eases. But, to my mind, the explanation above 
 suggested, in regard to the good effects of the 
 cinchona and arsenic in intermittent diseases, and 
 on those which are frequently recurring in the 
 same subject, though not at regular periods, is 
 much the most satisfactory. I know that we may 
 be told that both these remedies are tonics ; but I 
 have not found them acting as such in these cases. 
 
38 ON THE UTILITY OF MEDICINE. 
 
 In regard to quinia especially, I can say, that, 
 when exhibited in full doses, it does not manifest 
 any effects, showing that it acts as a tonic. If 
 I wish in a debilitated subject to increase the 
 appetite, or to fortify the stomach in any way, I 
 may give the sulphate of quinia, in doses of one 
 or two grains, twice or thrice in a day, and often 
 with good effect. I agree that its effects are tonic 
 in those instances. But when I give from fifteen 
 to twenty-five grains in a day, I usually find the 
 appetite is diminished, and that the power to 
 digest the food is diminished also. Yet it is in 
 the large doses that it arrests an intermittent 
 fever, and prevents the recurrence of neuralgia. 
 Therefore it is that I say, it is not by its tonic 
 effects it stops the intermittent fever. If we at- 
 tribute to this medicine, when given in large 
 doses, the power to arrest the disposition to cer- 
 tain diseases, we can explain its effects in diseases 
 apparently quite diverse from each other. Similar 
 remarks may be justly applied to arsenic. 
 
 Iron is a medicine similar in some respects to 
 cinchona, and it is among the medicines which no 
 one would be willing to dispense with. In dis- 
 eases, in which there is a deficiency of the red 
 globules of the blood, benefit may often be ob- 
 
ON THE UTILITY OF MEDICINE. 39 
 
 tained from the use of iron internally. For this 
 purpose it need not be given in large doses. 
 Whether acting as a nutriment, or as a tonic, in 
 some way, certainly, it often operates to restore 
 the strength of debilitated subjects, especially 
 where there is not any organic disease present. 
 There are many preparations of it in use, some of 
 which are effectual in small doses, and cannot be 
 borne in large ones ; while others, as the carbon- 
 ate and phosphate, may be given in very large 
 doses. It does not appear to be more useful as a 
 tonic, when employed in large doses, nor does it 
 always produce any increase of tone. But when 
 employed in large doses, it does appear sometimes 
 to have an effect on the nervous system. From 
 my own experience, however, I judge that it can- 
 not be rehed on, so much as quinia, for the relief 
 of chronic pains, or of neuralgia. 
 
 There are many sub-tonics, as they are some- 
 times called, which might be brought into notice 
 in connection with these remarks on cinchona, 
 and which I think no experienced physician 
 would be willing to dispense with. Among the 
 principal of these I place Bismuth, Cascarilla, and 
 Quassia. There is one other article, in much use 
 at the present day — I mean Cod Liver Oil — 
 
40 ON THE UTILITY OF MEDICINE. 
 
 which deserves to be noticed as a restorative, if 
 not a tonic. It is certain, that persons, who are 
 much emaciated and much debihtated, often un- 
 dergo a great change while using this medicine. 
 Its effect in giving to the patient a coating of fat 
 might lead one to ask, if it does not operate as a 
 nutriment ; but I beheve it has been found that 
 the addition to the weight of the body, when it 
 has been used three or four weeks, is actually 
 greater than the weight of the oil which has been 
 taken. While the patient becomes more corpu- 
 lent, from the use of this oil, he is generally 
 stronger after it. Thus we may be authorized to 
 suppose, that, if it acts as a nutriment, it also acts 
 as a tonic. We still wait for further experience 
 to decide us as to its true influence. 
 
 I have thtis been treating of various medicines, 
 more or less similar to the four great articles 
 pointed out by Dr. Holyoke. I have mentioned 
 those only, which have occurred to me as best 
 estabhshed in their character without professing 
 to have looked carefully through the hst of the 
 Materia Medica. I wiU now bring into view 
 some other drugs, or medicines not allied to those 
 four articles. And first, of the tribe called 
 Cathartics. Of these we have a great variety ; 
 
ON THE UTILITY OF MEDICINE. 41 
 
 the harsh and powerfiil, the Hght and gentle. 
 Some of these we employ when we w .nt only to 
 empty the bowels of their ordinary contents : 
 some can do more ; they promote the watery 
 secretions. These are called drastic cathartics. 
 There is not any tribe, or class of medicines so 
 much used as this. It would seem that we could 
 hardly live without the use of cathartics. They 
 are necessary. But the abuses in their use are 
 enormous. For the great mass of mankind, who 
 labor in the open air, and who are provided with 
 food tolerably well adapted to the powers of the 
 digestive organs, these medicines, like other medi- 
 cines, are very rarely needed. ■ But in civiUzed 
 communities, in cities most especially, there must 
 always be a large proportion of men and women 
 who pass most of their time, in houses or offices, 
 and without sufficient exercise, or without that 
 which is of the best kind. Among these persons 
 cathartics are much used, — too much. Yet, un- 
 der the actual circumstances of mankind, they 
 cannot be entirely dispensed with by such persons. 
 The rich and luxurious are very prone to hve in- 
 active lives ; or, if they go abroad, their exercise 
 is often passive only. Preaching to such pei-sons 
 is sometimes very useful : but, too often, I have 
 
42 ON THE UTILITY OF MEDICINE. 
 
 fonnd it useless, as much better preaching often is. 
 1 believe tbat some patients say to themselves, if 
 not to us, what are doctors good for, if they can- 
 not prescribe some remedies in these cases, less 
 troublesome than diet and exercise ? Alas ! 
 neither Emperors, nor Empresses can command 
 any other remedy, that is consistent with health. 
 There is a large proportion of the employments, 
 by which the inhabitants of cities, and of manu- 
 facturing districts gain their livehhood, which are 
 necessarily sedentary and within doors. Among 
 all the persons thus described, we find more or less 
 failure in the functions of the digestive organs. 
 This failure is increased when the food best adapt- 
 ed to such persons cannot be obtained. Persons 
 thus circumstanced are compelled to seek aid from 
 the physician. It is first of all proper for him to 
 make them acquainted with the causes of their ill 
 health. He should point out to them the necessity 
 of exercise in the open air, and the changes in 
 diet, which, in each case, respectively, are neces- 
 sary for their relief But, after his best efforts, he 
 will find many, who either will not, or cannot obey 
 the hygienic rules, which he points out to them. 
 Thus, at last, he is driven every day to allow, or 
 direct some of them to use medicine for relief. It 
 
ON THE UTILITY OF MEDICINE. 43 
 
 is an evil to which the feeble, especially if poor, 
 must submit. Shall we reproach a widow, who 
 supports herself and two children by her needle, 
 and in doing it often sits up half the night, — 
 shall we reproach her, because she does not follow 
 our prescriptions as to diet and exercise ? 
 
 In addition to the call for cathartics for the 
 causes above stated, there is very frequently a 
 propriety in employing the same for temporary 
 and transient disorders. In the commencement 
 of acute febrile diseases, even although they be self- 
 limited, so that we cannot hope to remove them 
 by any treatment, cathartics may usually be ad- 
 ministered with more or less benefit ; at least, so I 
 think. Some of the wisest among my brethren 
 think otherwise. I believe that experience jus- 
 tifies my opinion. It seems to me that it is easy 
 to explain in what way this depletion, under such 
 circumstances, is ordinarily, though not always, 
 beneficial. The intestines are almost never empty. 
 On the other hand, they ordinarily contain, in 
 health, a certain amount of fecal matter, and that 
 sufficient to make up several such discharges, as are 
 usually produced by a cathartic. Such a quantity 
 is commonly found on hand, when a man is attacked 
 with an acute disease. If he had remained well. 
 
44 ON THE UTILITY OF MEmCINE. 
 
 a due portion of it would probably have been 
 discharged on the day of his attack, or on the 
 following day. From the influence of the acute 
 disease the intestines become incapacitated, in some 
 measure, for performing their functions with their 
 usual vigor. Meanwhile, by the undue retention 
 of their contents, the whole system is embarrassed. 
 Left to themselves, the intestines may labor on, 
 for several successive days, before they can be 
 fiilly reheved, and from this cause the general 
 disease is augmented. Precisely this state of 
 things, I have very often witnessed. If, under 
 the use of some moderate laxative, the desired 
 relief can be hastened, the patient may go through 
 his disease with less discomfort, and ultimately 
 with less reduction of strength. Such, I beUeve 
 to be the true explanation of the good effects, 
 which are usually experienced from cathartics in 
 the commencement of acute diseases. I believe 
 that the same benefits ensue, upon the same treat- 
 ment, in surgical cases where patients are suddenly 
 brought to the bed, and become afifected with 
 symptomatic fever. On the other hand, if the 
 patient, to whom such a prescription has been 
 found distinctly useful, is treated with a repetition 
 of the dose every day or two, great evil ensues. 
 
ON THK UTILITY OF MEDICINE. 45 
 
 This is one of the abuses of medicine, which is 
 rare among us at the present time, but of which 
 however we sometimes continue to see instances. 
 
 I might go on to show other occasions, on 
 which cathartic medicines may be properly or- 
 dered, but I beheve it will be enough to refer to 
 my letter on Constipation, and to passages in 
 other letters of the preceding series for statements 
 on these points. My main object at present is to 
 bring into view the medicinal drugs which I 
 should not be willing to discard ; yet, while doing 
 this, I endeavor to intersperse such practical re- 
 marks as I think may be found useful. 
 
 I have not forgotten that Dr. Holmes advises 
 us to think more of the expectant treatment of 
 diseases, then we usually do. I go with him to 
 
 certain extent, perhaps as far as he does. There 
 are some acute diseases, in which it is best to do 
 so from the first ; — and it more frequently be- 
 comes proper, when the early days have been 
 passed over before medical aid is called for. In 
 many chronic diseases, from which recovery can- 
 not be expected, much may be done to render 
 the patient more comfortable. But in such it is 
 ofiener by hygienic measures, than by drugs, that 
 we do the most good. 
 
46 ON THE UTILITY OF MEDICINE. 
 
 There have been many abuses of medicine 
 among the regular practitioners beyond doubt. 
 But I am wilhng to believe that this is much 
 less common now, than in some past times. 
 If our profession has furnished many heroic 
 practitioners, many who have distrusted nature 
 altogether, or who are not willing to wait for 
 her tardy steps, it has also no doubt in all ages 
 furnished those, who have not published their 
 opinions, but who have calmly and quietly watched 
 the course of diseases under their care, and by 
 gentle means, and only when the powers of nature 
 seemed much embarrassed, have ventured to em- 
 ploy any potent drugs. There is perhaps always 
 a tendency among physicians to pursue this course, 
 as they advance to old age. Unquestionably this 
 is often the right course. But, far advanced as 
 I am in age, I am not yet ready to adopt this 
 course entirely. I am fully convinced that, in the 
 early stage of diseases, powerful remedies may be 
 employed with great benefit. Indeed, it is scarcely 
 necessary for me to say this, since in this letter, 
 as well as in others which have preceded it, I 
 have named many diseases, in which I have 
 advised very active treatment under these con- 
 ditions. 
 
ON THE UTILITY OF MEDICINE. 47 
 
 There is a tribe of diseases which must be per- 
 mitted to have their ovm way, if I may use the 
 expression. For instance, when the measles, or 
 the small-pox has begun its course, it cannot, if 
 life continue in the subject of it, be prevented 
 from going through its regular steps. But even 
 in these cases, when from any cause the disease 
 is peculiarly violent, aggravated by untoward 
 circumstances, we may often do something to 
 diminish these accidental evils. Indeed, more 
 may be said, if Sydenham and many of his follow- 
 ers have not misled us ; merely by the free ex- 
 posure of a patient under the small-pox to cool 
 fresh air, we may always lessen both the suffering 
 and the risk attending that disease. If it is said 
 that no drug is used in this case, I reply that a 
 powerftil remedy is used, and one which was at 
 first thought to be attended with great danger. 
 Diseases hke these, which, when they have be- 
 gun, must pass through certain stages, and which 
 sometimes terminate fatally, have, as you know, 
 been denominated by Dr. Bigelow, self-limited. 
 Although the view, which he took of this subject, 
 was not altogether new, yet he brought it much 
 more clearly into the light than had been done 
 previously, and pointed out the uselessness and 
 
48 ON THE UTILITY OF MEDICINE. 
 
 the frequent evils of an attempt to arrest dis- 
 eases of this tribe. I think no reasonable man 
 will now hesitate to admit the justice of his 
 opinions and the importance of regarding them 
 in practice. 
 
 There is however a point yet to be settled. 
 What are the diseases which are included in this 
 natural tribe ? Dr. Bigelow has mentioned many, 
 without professing to exhaust the subject. I agree 
 as to most of those enumerated by him, but not 
 as to all of them. I have gome doubts as to 
 erysipelas. I have much more as to typhoid 
 fever, as I have stated in my seventeenth letter. 
 Generally, it may be true, as to some diseases, 
 that they are self-limited, when they have ar- 
 rived at a certain period ; when, for instance, 
 they have passed the second or third day, 
 but not before. Dr. Bigelow has also placed 
 epilepsy among the self-limited diseases. How 
 far this is correct, is to be tested by experience. 
 I am fully convinced that all active interference, 
 during the fit, is useless and may be injurious. 
 But, viewing the disease as a whole, regarding 
 the patient as having at all times a liability to 
 the epileptic paroxysm, the question is, can this 
 liability be removed ? My reply to this has been 
 
ON THE UTILITY OF MEDICINE. 
 
 40 
 
 given in the second of these letters. This rejily 
 is substantially as follows : — First, so far as I 
 know, there is not any medicine, which can be 
 relied on to overcome this hability. So dreadful 
 is the disease, so hard to be endured both by the 
 patient and his friends, that I suppose men will 
 never cease to try medicinal articles for this pur- 
 pose. I would warn them to be careful in their 
 experiments ; but I would certainly hope and pray 
 that their efforts may ultimately be crowned with 
 success. Secondly, there is a large proportion of 
 cases, in which I suppose no mode of treatment, 
 now known, will effect the desired object. I 
 cannot find out any marks, by which these in- 
 tractable cases may be distinguished with cer- 
 tainty. I will say, however, that the older the 
 patient, and the longer time the disease has ex- 
 isted, the less will be the chance of recoveiy. 
 Thirdly, I am happy to say that there are some 
 epileptics, though not the larger portion of these 
 unfortunate invalids, who may be relieved per- 
 manently by care in diet and regimen ; particu- 
 larly by abstinence from animal food. I am happy 
 .that it is not the use of a powerful drug, which 
 I urge upon my brethren for this dreadful disease ; 
 but I will say that for a disease so distressing to 
 5 
 
60 ON THE UTILITY OF MEDICINE. 
 
 the patient and to his friends, a drug could scarcely 
 be named, which I would not administer, if it 
 could be done with a reasonable chance of success. 
 It is perfectly consistent with this to add that the 
 random employment of strong medicines, dreadfiil 
 as the disease is, is entirely unjustifiable. 
 
 I have stated my belief that typhoid fever may 
 sometimes be arrested at once within the first 
 three days ; or, if not arrested, that it may be 
 shortened by treatment at that early period. After 
 that, it may be regarded as a self-limited disease ; 
 and, for the most part, the physician is not called 
 to the cure of the disease until after that period. 
 Now I am inclined to say the same things in 
 regard to pleurisy, pneumony, and the similar 
 affections. At the very commencement of these 
 diseases I believe that they may be diminished in 
 violence, and in duration, sometimes perhaps may 
 be arrested, jugulated, by blood-letting, aided by 
 appropriate antiphlogistic remedies. 
 
 The value of blood-letting in the treatment of 
 diseases, has been variously estimated in different 
 ages and in different places. Within the life- 
 time of some of our brethren now living, this 
 practice was carried to a great excess, by a very 
 distinguished medical teacher in our own country. 
 
ON THE UTILITY OF MEDICINE. 01 
 
 I refer to Dr. Rush, whose influence during the 
 latter part of the last century, and the earlier 
 part of this, was greater and more extensive than 
 that of any other physician in the United States. 
 It was not in New England that his influence was 
 thus great ; but it was, I believe, in every State 
 out of New England. Yet, here, blood-letting was 
 resorted to in pleurisy and lung fever, if not in 
 other inflammatory diseases. It has also been 
 used in this vicinity in various affections of preg- 
 nant women, and with great benefit. My old 
 master told me during my pupilage, that women 
 bear bleeding during pregnancy much better than 
 men, or than women in other circumstances. The 
 justice of this statement was ftilly confirmed by 
 my own experience in the early part of my life ; 
 for I gave up all obstetric practice when I had 
 been in business eighteen years. 
 
 In this city, during the life of Dr. Rush, there 
 was one practitioner, regarded by many as the 
 most scientific man among us, who abstained fi-om 
 blood-letting entirely, or nearly so. This was 
 Dr. Samuel Danforth, a man with a strong mind 
 and a strong will, but wedded to a theory. It is 
 singular that, while there was a great similarity in 
 the doctrine of these two gentlemen, there was 
 
62 ON THE UTILITY OF MEDICINE. 
 
 none in their practice. Like the old methodics, 
 and the late John Brown of Edinburgh, both of 
 them regarded disease as differing from health in 
 more or less of something. If health was thought 
 to be maintained by a certain amount of tension 
 in the living fibres of the body, then it was 
 thought that disease consisted in more or less 
 tension, more or less excitement, than appertained 
 to health. This description is sufficient in a gen- 
 eral view of the systems of these various medical 
 philosophers. Some of them. Rush especially, 
 regarded disease as a unit. But between Rush 
 and Danforth there was this difference. Rush 
 believed, that, in almost all instances, disease con- 
 sisted in too much excitement. Danforth, on the 
 contrary, maintained that it consisted almost al- 
 ways in too little. Hence, Rush almost con- 
 stantly prescribed blood-letting, that he might 
 diminish the amount of the most general stimu- 
 lant, one which pervades, or at least has an influ- 
 ence on, every fibre of the body. In a very large 
 proportion of febrile diseases there is experienced 
 after bleeding some relief, for the moment at least, 
 as to pain and distress. There may be, at the 
 same time, a feeling of exhaustion, and not un- 
 commonly syncope ensues. But then this is 
 
ON THE UTILITY OF MEDICINE. 53 
 
 treated as a temporary inconvenience, making 
 ultimate relief more certain. Hence the sick 
 were led to submit to this treatment, and to re- 
 gard the evacuation as useful. The other gentle- 
 man. Dr. Danforth, looking at debility as the 
 great source of disease, administered diffusible 
 stimulants, with an idea that, if they do not give 
 permanent strength, they bring on the normal 
 actions, by which the strength may be renovated. 
 He also looked ultimately to nutrition as fumish- 
 iuCT the substantial means of restoration. With 
 this view, he took care to relieve the alimentary 
 canal from any undue burden, and from any 
 offensive materials, which he supposed it might 
 contain. When thus prepared, he believed that 
 the patient might be brought back to a normal 
 condition, sooner or later, by furnishing him with 
 proper nutriment, and adding to it direct stimu- 
 lants, by which all the organs, but the digestive 
 organs especially, might be driven to the perform- 
 ance of their proper functions. At the same time, 
 he paid great attention to some other hygienix; 
 laws, thereby favoring the influence of good diet. 
 In a large proportion of chronic diseases, the 
 patient derived, at least, temporary comfort from 
 this treatment ; and when pursued with judg- 
 
54 ON THE UTILITY OF MEDICINE. 
 
 ment, and where no organic disease embarrassed 
 the case, he often obtained from it permanent rehef. 
 In acute diseases relief followed, in a greater or 
 less degree, from the early evacuations of the 
 alimentary canal, which he thought a necessary 
 preparation for his other treatment. But the 
 plan of supplying nutriment, and of using diffu- 
 sible stimulants in acute diseases, sometimes occa- 
 sioned much trouble and distress. However, Dr. 
 Danforth was ordinarily too sagacious to press 
 this treatment very strongly, when the patient's 
 feelings forbade ; then he waited and watched his 
 chance. In this wav he often succeeded. 
 
 While these two gentlemen pursued courses so 
 opposite to each other, the majority of medical 
 men in this vicinity, less wedded to system, 
 adapted their treatment more carefully to the 
 actual condition of their patients. This, at least, 
 was their plan ; they meant to do so. It must 
 however be confessed that when I entered upon 
 practice, polypharmacy was the crying sin among 
 our medical men. 
 
 Recurring now to blood-letting, I will add, that, 
 while Danforth and some others abstained from it 
 entirely, those practitioners who were regarded as 
 most judicious, employed the lancet in the com- 
 
ON THE UTILITY OF MEDICINE. 55 
 
 mencement of what they called inflammatory- 
 diseases. For local affections they directed local 
 bleeding. None of them, however, bled so freely 
 as Dr. Rush and his disciples did. At the present 
 day, a change has come over us. I can hardly 
 say just when it began. For the last twenty 
 years, at least, venesection has almost gone out of 
 use among us, in medical, if not in surgical prac- 
 tice. The use of leeches and cupping also has very 
 much diminished ; so that I doubt whether there 
 is a quarter part, and it may be that the number 
 of leeches directed now is not more than a tenth 
 part of the number directed thirty years ago. 
 Now I rejoice that blood is not taken away, as a 
 matter of routine, in every case of inflammatory 
 disease, without regard to its period. I rejoice 
 that our physicians do not direct blood-letting, be- 
 cause the pulse is thought to be unhealthy. It 
 was on such false grounds that Rush was in the 
 habit of prescribing this evacuation. The benefit 
 derived from bleeding, to a reasonable extent, 
 bears no proportion to the evils produced when this 
 practice is carried to excess. Nevertheless, I feel 
 persuaded, from my own observation and expe- 
 rience, that the use of the lancet should not be al- 
 together abandoned. It is true, as to pleurisy. 
 
50 ON THE UTILITY OF MEDICINE. 
 
 and pneumony, which are the diseases, for which 
 it has heen considered most appropriate, that, 
 when confined to one side, and where no other 
 morbid aifection exists at the same time, in an 
 adult of a healthy constitution, these diseases 
 rarely prove fatal. I cannot say the same with 
 regard to young children. In them, simple and 
 pure pleurisy will sometimes destroy life, and still 
 oftener, pneumonitis will do this, and even severe 
 and extensive bronchitis. But, in the adult, 
 bleeding on the first or second day of the disease, 
 or perhaps even on the third day, will somewhat 
 shorten the disease, and will more certainly dimin- 
 ish its violence. In young subjects I am entirely 
 convinced that the bleeding diminishes the risk of 
 life. I am aware that I am repeating here some 
 things which may be found in my tenth letter. 
 I do it to show that I have not met with anything 
 since that letter was written to alter my opinion. 
 Let me here note, that with young children, it is 
 not easy to take blood from the arm, because the 
 veins are commonly hidden in the subcutaneous 
 fat of children, particularly of very A'oung chil- 
 dren. But any one, who will take the trouble to 
 study the mode of performing it, may effect his 
 object in these subjects by opening the external 
 
ON THE UTILITY OF MEDICINE. 57 
 
 jugular vein, around which he will not find any 
 impediment firom adipose matter. At the present 
 day as I have already said, bleeding is veiy much 
 out of fashion amongst us ; and I am aware that 
 it may excite some surprise that I, who mean to 
 co-operate with my friends, Dr. Bigelow and Dr. 
 Holmes, in discouraging the frequent use of violent 
 remedies, and in trusting to the efforts of nature 
 in very many cases, should give so much commen- 
 dation to a mode of treatment generally regarded 
 as the most violent, and therefore as the most 
 objectionable. But, in the first place, these gen- 
 tlemen do not decry active treatment on all 
 occasions, nor do I know that either of them has 
 actually proscribed blood-letting. I know, indeed, 
 that they would oppose themselves to Sangrado if 
 he were to reappear on the earth, and either of 
 them would be capable of putting him out of 
 countenance by ridicule, as well as of putting 
 him down by sound argument. But though 
 Sangrado and his follower, Rush, should be 
 opposed by all sound minded men, it does not 
 follow that this unfashionable practice can never 
 be employed with advantage. Looking at it as 
 a violent remedy, let me say, that powerfiil 
 emetics and drastic cathartics, especially if fre- 
 
58 ON THE UTILITY OF MEDICINE. 
 
 quently repeated, may prove more permanently 
 depressing and injurious to the constitution than 
 one full blood-letting ; that is, taking from an 
 adult of ordinary vigor a pint of blood. In my 
 opinion, as much as this, and sometimes more, 
 shoidd be taken at once. If the design is to give 
 the remedy a fair trial, it is better to do at once 
 all that is requisite. It is scarcely ever wise to 
 repeat the evacuation. The practice of repeated 
 small bleedings, averaging eight or ten ounces, 
 which obtained, I beheve, in former times on the 
 continent of Europe, much more than in Great 
 Britain, or in this country, I regard as very in- 
 jurious. By this practice, the evils of blood- 
 letting are produced without its benefits. For, 
 usually, more blood is abstracted ultimately when 
 this mode of treatment is adopted, while there is 
 not a sufficient impression made at any one time 
 to check the disease effectually. 
 
 I cannot refrain from referring again to what I 
 have said as to bleeding in young children. On 
 this point I ground my opinions entirely on my 
 own experience. When I began practice, I was 
 not disposed to employ bleeding in any cases, 
 especially in those of children. But, finding that 
 in them acute inflammations within the thorax 
 
OJJ THE UTILITY OF MEDICINE. 59 
 
 were often fatal, I felt myself bound to make a 
 trial of this remedy, -which had been approved by 
 many men of sound minds. I then tried bleeding 
 in subjects of all ages, and the opinions above 
 given resulted from these trials. 
 
 Further, with regard to bleeding, we sometimes 
 have inflammatory affections within the thorax, or 
 elsewhere, which are epidemic and of a character 
 differing from that of ordinary inflammation. In 
 such epidemics, blood-letting is not so useful as 
 in common inflammations ; and often, indeed, it 
 appears to be hurtfiil. The most remarkable epi- 
 demic of this sort, which I have ever witnessed, 
 occurred in New England, in the years 1812, 13, 
 and 14. This epidemic followed that of the spotted, 
 or petechial fever. This affection of the thoracic 
 viscera received various names, according to the 
 theories adopted by those who applied them. It 
 was called peri-pneumonia notha, typhoid pneu- 
 monia, biKous pneumonia, &c., &c. From fost- 
 morlem examinations, as well as from the symptoms 
 during life, it was found that the inflammation was 
 seated sometimes in the pleura, sometimes in the 
 substance of the lungs, sometimes in the heart, on 
 its inner, or its outward coat, or in two or more of 
 these parts at the same time. Further, it was 
 
60 ON THE UTILITY OF MEDICINE. 
 
 found that the disease ran its course more rapidly, 
 often much more rapidly, than common inflam- 
 mation in the same parts. Likewise, from the 
 commencement of the disease, in many of the 
 cases, the prostration of strength was exceedingly 
 great. The general belief among medical men 
 was that patients under this epidemic disease could 
 not bear blood-letting, as they might do in ordi- 
 nary inflammations of the lungs, &c. The disease 
 was vastly more fatal than those of the same name, 
 in other seasons. So far as my limited experience 
 permitted me to judge, for this epidemic prevailed 
 much less in this city than in many other places 
 within New England, a vigorous man might be 
 bled within the first few hours of the disease, not 
 only with safety but with advantage. But at the 
 end of ten or twelve hours, the time for the remedy 
 had passed by. A great majority of physicians 
 who saw this epidemic, decried blood-letting alto- 
 gether ; but I suspected that they did so without 
 testing the remedy at the very onset of the disease. 
 I was not alone in the opinion I have stated 
 above. 
 
 Let it now be borne in mind that, in a large 
 proportion of the occasions, on which I recom- 
 mend the employment of the heroic medicines, 
 
ON THE UTILITY OF MEDICINE. 01 
 
 it must be on the first day, or at a very early 
 period of the disease that is to be treated. If, 
 according to the popular opinion, every disease 
 has its remedy, by which it may be removed at 
 any part of its career, the case would be vastly 
 different ; but, if you^have to do with a disease, 
 the natural duration of which would be three, or 
 four, or five weeks, and if your remedy were one, 
 which would be effectual only when employed 
 within the first two days of the disease, you would 
 meet with success in a very small proportion of all 
 the cases of that disease, which would come under 
 your care. Ordinarily, a man who is attacked by 
 an acute disease, which is destined to become very 
 severe, is not aware of the evil which threatens 
 him. Hence, he neglects to call for medical aid 
 until he has lost the precious days or hours, in 
 which rehef may be obtained. The patient is 
 unwilhng to be sick. He loves to deceive himself, 
 perhaps. Ofi;entimes, such a one will deny the 
 existence of what we call the subjective symptoms 
 of disease ; that is, of those symptoms, which the 
 patient knows by his own sensations, and which 
 cannot be discovered except by his statements. 
 Likewise, when the first symptoms of a disease are 
 not very severe, the cautious physician, one who is 
 
62 ON THE UTILITY OF MEDICINE. 
 
 unwilling to come to an unwelcome decision, will, 
 as well as the patient, hope for the best, and let 
 the same precious hours pass by, — often the only- 
 hours in which medicine can be employed with 
 great advantage. When, from any cause, the 
 opportunity for active treatment has been lost, 
 the wise course is to pursue the expectant 
 method. It is when it becomes evident to the 
 physician, that the fever must run its course, 
 as the popular phrase is, that the patient and his 
 friends become anxious, and in some cases clamo- 
 rous for active and powerful treatment. This is 
 the time, at which the physician must take a 
 decided stand. Hence it is, because he has not 
 had an opportunity in the early days of the dis- 
 ease, or has neglected it, that the largest pro- 
 portion of patients under acute diseases, whether 
 severe or mild, muet be treated on the expectant 
 plan. Indeed, this is commonly more necessary 
 in diseases, which are severe and attended by 
 danger, than in those of a milder character. For 
 instance, in a severe pneumonitis one cannot em- 
 ploy active remedies with safety after the second 
 or third day, because it is then too late to arrest 
 the disease ; and though we might still lessen it 
 by active remedies, there is the danger that we 
 
ON THE UTILITY OF MEDICINE. 63 
 
 may so impair the powers of the sick man that he 
 cannot hold out through the whole course of his 
 malady. But in a bronchitis, which is less danger- 
 ous than a pneumonitis, there is no such risk, and 
 we need not therefore have the same fear of active 
 remedies after the first days. 
 
 There is one inflammatory disease, not yet 
 mentioned, in which it was formerly somewhat 
 common to take blood, but in which it is very 
 rarely, if ever done now. I refer to a general 
 acute rheumatism, or rheumatic fever. In that 
 disease there may, no doubt, be some temporary 
 relief from bleeding, though even that is not cer- 
 tain ; but, ultimately, the evil is much greater 
 than the good. Such is the result of my expe- 
 rience. In acute rheumatism a patient is most 
 commonly relieved spontaneously within a fort- 
 night; so much relieved, that he thinks himself 
 nearly well, and the inexperienced physician will 
 think so too. This is one of the cases, where a 
 confidence in a speedy recovery prevents the re- 
 covery from being speedy. For, after a respite 
 of a week, more or less, a new attack of the dis- 
 ease takes place, and, as in the first instance, the 
 disease shows itself in succession in various joints 
 of the body, large or small ; sometimes in the eyes. 
 
64 ON THE UTILITY Oi' MEDICINE. 
 
 there attacking their different tissues successively ; 
 and not unfrequently it reaches the heart, aiFect- 
 ing the external or the internal membranes of 
 that organ, or, more rarely, its muscular substance. 
 A third attack of the disease may follow, after 
 this last one has subsided, and this may not be so 
 rapid in its course ; instead of passing quickly 
 from one articulation to another, it may become 
 permanent in one or more of them for many 
 weeks or months. Thus, if we regard rheumatism 
 as an inflammation, it differs from other grave 
 inflammations, in the early part of the disease 
 especially, in that it does not remain long in any 
 one part. Also, it differs because it does not 
 terminate in suppuration, and so far as any mate- 
 rial is thrown out upon the diseased tissues, the 
 same will usually be removed spontaneously within 
 a short time. But while individual parts recover, 
 something remains in the system which causes 
 successive attacks in different parts. 
 
 Now, though bleeding employed at the begin- 
 ning may hasten the recovery in the elbow, knee, 
 or other part which is first affected, the evacuation 
 does not prevent the disease from showing itself 
 in new parts. The question might be asked, by 
 some Sangrado at least, if larger bleedings, or if 
 
ON THE UTILITY OF MEDICINE. 65 
 
 a frequent repetition of the bleeding would not be 
 more successful. It would not be easy, I believe, 
 for any one, except Sangrado himself, to try this 
 method often. But, owing to accident, I knew of 
 one instance where it was tried to a large extent. 
 In this case, the part first affected was the tunica 
 conjunctiva, and the inflammation was of extreme 
 violence. The other tissues of the eye were af- 
 fected in rapid succession. The patient was a 
 vigorous young man, previously in good health. 
 There was no reason at that moment to think of 
 anything else than a common inflammation, com- 
 mon in kind, though not in degree. Of course, 
 the eye seemed to be threatened with destruction. 
 The most vigorous measures were called for ; the 
 more, as the sight of the other eye had been 
 destroyed some years previously by a blow upon 
 the organ. Seven pounds of blood were taken 
 away within the first five days of the disease. 
 Then, the true character of the disease was shown 
 by a rheumatic attack on one of the knees, upon 
 which the eye rapidly mended. From this period 
 the disease pursued the usual course of acute 
 rheumatism with great violence, and within a few 
 weeks the eye took its turn twice more. The 
 patient was not able to go abroad with any free- 
 6 
 
66 ON THE UTILITY OF MEDICINE. ' 
 
 dom for three months, and then with a painful 
 and swollen ankle. So far as one case can go, 
 this one shows that very copious bleeding in the 
 early part of the disease does not arrest acute 
 rheumatism, but rather makes it worse.* 
 
 Those, who hold the favorite opinion of the 
 present day, that acute rheumatism has its origin 
 in a morbid state of the blood, will readily explain 
 the failure of relief from- bleeding. But questions 
 regarding the proximate cause of disease, I am 
 not fond of discussing. For me, the experience 
 gained from carefdl and honest observation, is 
 more satisfactory than any the most plausible and 
 most ingenious hypothesis. 
 
 Although bleeding is not to be recommended 
 in acute rheumatism, it does not follow that the 
 disease may not be relieved by any other treat- 
 ment. So far as I know, there is not any other 
 which can be recommended with entire confi- 
 dence. Yet, in a good proportion of cases, if the 
 treatment is begun at the very commencement of 
 the disease, experience justifies some hope of ad- 
 vantage from it ; that is, that there is a chance of 
 diminishing the violence of the disease, and its 
 
 * See, in Appendix, the case of Mr. Prescott. 
 
ON THE UTILITY OF MEDICINE. 67 
 
 length. Various remedies are thought to do good, 
 but that on which my experience leads me to rely 
 is colchicum. Other active cathartics are found 
 beneficial, but none so much so as this. To be 
 effectual, it should be repeated once in four to six 
 hours, until it brings on copious discharges ; and 
 if it occasion some vomiting, the chance of success 
 is the better. Under its use, profuse perspiration 
 •will commonly occur, and the heat of the surface 
 is diminished at the same time, while the pain is 
 relieved without any extension of the disease to 
 new parts. In consequence of all this, the patient 
 often has a great sense of weakness and exhaus- 
 tion ; but if the use of the medicine is stopped, as 
 soon as the powerfiil effects occur, he will usually 
 be restored to some comfort within twenty-four 
 hours. Under these circumstances, it will ordi- 
 narily be found that the disease has a lull, and if 
 we can be assured that it would not return, no one 
 would deny that the benefit would be an abund- 
 ant compensation for the evil of the remedy. The 
 object then is to prevent such a return. For this 
 purpose it is necessary, in the first place, that the 
 patient should remain on his bed, and be kept 
 fi-ee from all disturbance of body and of mind. 
 Secondly, his food should be of the mildest kind. 
 
68 ON THE UTILITY OF MEDICINE. 
 
 and moderate in quantity, for one or two days at 
 least. After that, he may be allowed milk and 
 bread, or some other equivalent vegetable article. 
 Thirdly, sulphate of quinia should be administered 
 with a view to prevent a recurrence of the disease. 
 I will not say that this always succeeds, yet I have 
 never perceived any inconvenience from the trial 
 of it. It is not a new remedy in this case. It 
 was recommended, I think, by Dr. George Foiv 
 dyce, in the last century ; but it was more dis- 
 tinctly recommended in the early part of this 
 century by Dr. Haygarth, of Bath ; or, to speak 
 more correctly, the Peruvian bark was recom- 
 mended by these distinguished physicians ; for in 
 their time the quinia was not known. That this 
 medicine may have a fair chance, it should be 
 exhibited at first in very fiill doses, as it is ia 
 intermittent fever. In the first twenty-four hours, 
 sixteen or twenty grains of the sulphate should be 
 given. The whole quantity for the day may be 
 divided into four doses, the interval between the 
 doses being four or five hours. 
 
 Most persons prefer to take tliis medicine in the 
 form of pills, although some prefer a solution, in 
 water. If the patient complain of dulness in 
 hearing, or of unusual sounds, or of a sense of 
 
ON THE UTILITY OF MEDICINE. 69 
 
 tension in the ears, the dose should not be increas- 
 ed; otherwise, four grains may be added to the 
 previous quantity on the second day. The dose 
 may be increased again on the third day, if no in- 
 convenience is experienced from it. Whenever 
 any very decided inconvenience is produced, the 
 quantity should be diminished, until the inconven- 
 ience has nearly disappeared. But it is best that 
 the medicine should be continued in such quantity, 
 as that the patient may be sensible of its effects for 
 four or five days. After this, the dose may be 
 gradually diminished for six or eight days, when 
 the medicine may be given up. If, however, the 
 disease should return in any considerable force, 
 under the use of the medicine, this should be with- 
 drawn. If then the disease appear nearly of the 
 same force as during the first attack, the attempt 
 to arrest it should be abandoned. But if it be 
 evident that the disease is lessened in violence, the 
 colchicum may be used again in such doses as to 
 operate moderately, and on the subsidence of the 
 rheumatic affection the use of the quinia should 
 be resumed. During the use of the quinia, care 
 should be taken to keep the bowels soluble, and 
 the diet should remain moderate in quantity, 
 and mild in quality. All animal food and stim- 
 
70 ON THE UTILITY OF MEDICINE. 
 
 ulating liquors should be withheld during tWs 
 period. 
 
 1£ the treatment fail to be useful, or if the 
 patient should not be brought under care within 
 the fixst few days of the disease, he should be left 
 free from active treatment ; in other words, the 
 expectant course should be pursued. As the dis- 
 ease is often extremely painful and prevents sleep, 
 opium may be employed as a solace. By many 
 physicians, this is the only drug employed in acute 
 rheumatism, and it is given in such quantities as to 
 keep the patient free from severe pain. It has 
 seemed to me, however, that, when this medicine 
 is used constantly and freely, the evils are greater 
 than the benefit. It does not shorten the period 
 of the disease, though it lessen the sufferings that 
 belong to it. But it lessens the appetite for food, 
 it lessens very much, and often destroys, the power 
 of digesting food, and it induces great consti- 
 pation. Thence, in the end, it occasions much 
 greater debihty, more true exhaustion, than is pro- 
 duced by the operation of colchicum in the early 
 period of the disease. The power of recovery 
 seems to be lost. The patient may, at last, he still 
 in his bed without any distinct pain, but he cannot 
 turn from side to side, he can scarcely raise his 
 
ON THE UTILITY OF MEDICINE. 71 
 
 hand, and often he becomes quite incapable of 
 raising his head. You may offer him food under 
 these circumstances, and stimulants with food, but 
 he cannot take them with pleasure, and for a long 
 while they will not be retained, or if retained, 
 they will produce distress. True, it is not always 
 so. There are people who can bear opium with- 
 out these inconveniences, but they are the happy 
 exceptions. 
 
 Various other remedies are recommended in 
 acute rheumatism. Of late years both acids and 
 alkalies have been employed. I cannot say that I 
 have witnessed much benefit from these, or from 
 any other medicines, with the exception of those I 
 have already mentioned. In cases where the 
 disease, though acute, has been local, and though 
 severe, has not been attended by febrile, or consti- 
 tutional affections, I have very commonly seen 
 relief from the internal use of the resin of guaia- 
 cum. I think this should be given in a powder, 
 and not in the form of tincture. One drachm 
 may be taken at bed-time, and the same, or half 
 the dose may be given in the morning, if the 
 disease be severe. It should be given until it pro- 
 duces some active operation. In a bad case some 
 colchicum may be added. If the disease do not 
 
72' ON THE UTILITY OF MEDICINE. 
 
 yield in three days, a blister should be drawn 
 by cantharides as near as may be to the part 
 affected. 
 
 In ordinary cases of local rheumatism, such 
 active treatment causes more trouble than the 
 relief is worth. Here, mild measures will suffice. 
 Cover the diseased part with substantial new 
 flannel, and two thicknesses of it, as soon as the 
 pain is distinctly recognized. By so doing, in a 
 large majority of cases, the pain will be over- 
 come within twelve or twenty-four hours. The 
 flannel should not, however, be removed in less 
 than three days, and it is well then to remove 
 only half of it at a time. If one means to 
 follow this direction, let him attend to every 
 word of it. 
 
 There is a disease which has been called, though 
 it is not the only disease which has been so called, 
 the opprobium medici ; I mean the gout. It has 
 been said that the doctor could not remove it. 
 Now, if this be said in respect to a fit of the gout, 
 it is no longer true. The remedy is colchicum. I 
 should be supported by a very large proportion 
 of the medical men, who have tried this drug 
 at the commencement of a fit of the gout, in 
 saying that it can give relief. No doubt, it may 
 
ON THE UTILITY OF MEDICINE. 73 
 
 sometimes fail ; but it is most rare for it to do 
 so, when properly employed. The dose requisite 
 is different with different men, and in a new case, 
 the medicine must be tried for awhile to ascertain 
 this dose. When it is ascertained, let the medi- 
 cine be employed as soon as the attack is fairly re- 
 cognized, and let it be repeated once in six or eight 
 hours, until the pain has fairly given way, or 
 nausea is produced. The experienced patient 
 does not often require a second dose, and very 
 rarely a third dose. I have been told by gouty 
 patients, and by their physicians, that they have 
 tried this remedy without success, and perhaps 
 they have thought that injury has been produced 
 by it , but a fair and careful trial has at once 
 brought about a change of opinion. In England, 
 where this aristocratic disease prevails much more 
 than with us, I believe that almost all physicians 
 of experience agree in testifying to the efficacy of 
 colchicum in gout. By many it is thought a 
 specific. 
 
 I have spoken of the treatment of the paroxysm 
 of the gout, but it is much more important to 
 prevent the recurrence of the paroxysm. This is 
 attended with difficulty, and I fear there is not 
 any method, by which we can with certainty 
 
74 ON THE UTILITY OF MEDICINE. 
 
 effect this object. This, we are told, is the disease 
 of high Hvers. This is not said without some 
 foundation, but it does not require great excess 
 to produce it. You do not meet with it, or very 
 rarely, among men who work with their hands ; 
 not among common laborers, nor among mechan- 
 ics. You do not commonly find it among men 
 who use spirituous liquors without wine, whether 
 they use them in moderation, or in excess. You 
 find it among men who drink wine, or other fer- 
 mented liquors. I mention the fermented liquors 
 because in one instance, at least, I have seen it in 
 a gentleman who had not used wine habitually, 
 but had used cider freely. But the occurrence of 
 gout is not any evidence that the subject of it has 
 used wine to excess. This malady is much more 
 common in Great Britain and Ireland than in this 
 country. I was ready to say, that it occurs among 
 men distinguished above their fellows. I may 
 say, at least, that among men much distinguished 
 it is extremely common. You find this in reading 
 the biographies of bishops and priests, of judges 
 and counsellors-at-law, and of eminent physicians ; 
 likewise, and perhaps I should say, more particu- 
 larly, amongst distinguished statesmen. I ha,ve 
 Englishmen in my mind while I make these state- 
 
ON THE UTILITY OF MEDICINE. 75 
 
 merits. Among them I believe it is not rare to 
 find soldiers and sailors subject to gout ; not those 
 in the ranks, and not the mariners, but the major- 
 generals and the admirals. But it is by no means 
 so common in these two classes, as among the great 
 men in civil hfe. You see, then, that this disease 
 occurs among men v\fho use their minds on im- 
 portant subjects, among those eminent in their 
 respective branches, vi^hose mental labors are often 
 excessive, and especially if these labors are attend- 
 ed by great responsibiHties, and give rise to great 
 anxiety. The influence of wine in producing 
 this disease has been much dwelt upon, and 
 very properly. 
 
 I have said, that it comes to those who do not 
 use wine to excess ; and I have an impression, 
 though I am not sure about it, that it rarely, if 
 ever, occurs among those, who are in habits of intox- 
 ication from wine. Under this view of the matter, 
 one's first thought would be to advise the subject 
 of gout to abstain from wine altogether. The only 
 ground of hesitation on this point is, that there 
 may be something in the constitution, or circum- 
 stances of the patient, which would make one fear 
 to withhold this accustomed stimulus. But can 
 abstinence in this respect be relied on with entire 
 
76 ON THE UTILITY OF MEDICINE. 
 
 confidence to prevent the recurrence of the dis- 
 ease ? It cannot. Ordinarily, decided benefit will 
 ensue from this abstinence ; but not always. The 
 subjects of gout are, very many of them, persons 
 of sedentary habits. But, also, this disease is hered- 
 itary, and hence comes upon men, who are very 
 active. The son suffers, I will not say for the 
 sins, but for the unhealthy habits of his father. 
 Hence you find families subject to it. I once 
 knew a gentleman, finely made, tall and stout, 
 of excellent habits, but who belonged to a gouty 
 family. He began to have the disease very early 
 in life. He was a man of firm mind, of great 
 resolution, and he determined to avoid such suffer- 
 ings, as he had seen among his family and friends. 
 With this view, he avoided fermented and dis- 
 tilled liquors entirely. He abstained from animal 
 food, and he led an active life. He persisted in 
 this course for a series of years, more than twenty 
 years, I believe ; perhaps thirty. Probably, he 
 did better than if he had not been thus abstinent 
 as to diet, and thus active in his habits. Never- 
 theless^ he suffered severely from the gout, and he 
 did not reach the period of old age. I state this 
 cose only to show that the disease is not main- 
 tained merely by the use of wine. I should, 
 
ON THE UTILITY OF MEDICINE. 77 
 
 however, advise abstinence from this liquor in 
 every case where there were no obvious objec- 
 tions ; but I should advise other things also. The 
 first in importance among these other things is 
 exercise in the open air, active and habitual ex- 
 ercise, without over-caution as to the weather. 
 Next, I should advise moderation and regularity 
 as to food. In certain cases, probably, vegetable 
 food with milk would be the most beneficial diet. 
 In all cases the regular excretions should be pro- 
 moted. Not merely the alvine excretions, but 
 also those from the kidneys, the skin, and the lungs. 
 Regularity as to sleep also should be enjoined. 
 But this sleep should be in the night, and should 
 Le begun in such good season as to permit early 
 rising. Something gratefully stimulating should be 
 permitted to one, who abjures the indulgences of 
 the table. Now there is one stimulant, which is 
 not commonly enjoyed among men in elevated 
 stations, although it seems to be at the command 
 of all mankind ; I refer to the morning air. I 
 should insist that a man who seeks to gain the 
 vigor by which he can resist disease, should get the 
 benefit of air and exercise daily, before he has yet 
 engaged in any close application of his mind to 
 business. To all this I would add, what perhaps it 
 
78 ON THE UTILITY OF MEDICINE. 
 
 is impossible for some men to regard, that is, avoid 
 over-work and avoid anxiety. But how can the 
 statesman, how even can the man engaged on -the 
 bench, or at the bar in a court of justice, and I 
 may say, perhaps, how can a physician engaged 
 in extensive practice in a large city, how can any 
 of these limit his labors at all times and avoid the 
 anxieties, which seem almost inevitably to attach 
 themselves to great trusts ? Undoubtedly, for 
 many men, this is impossible. The soldier takes 
 the risk of life. Other men must occasionally 
 do the same. Much depends on one's tempera- 
 ment and constitution and early training. But 
 ■with firmness and discretion, something can be 
 done. 
 
 The soldier, who exposes his hfe in battle, may 
 feel that it is quite as proper to put his health and 
 his life at risk under the continued labors, and the 
 heavy anxieties which appertain to his position. 
 Let it be so. Temporarily he may perform his 
 duty, and disregard the hazards ; but it rarely 
 happens tnat the soldier is called to pass his whole 
 life, or many years in succession, under these un- 
 favorable circumstances. Wars do not commonly 
 continue for many successive years. For a states- 
 man the difficulty is much greater. William Pitt, 
 
ON THE UTILITY OF MEDICINE. 79 
 
 living in a turbulent age, not having a hun- 
 dred eyes, could hardly find time enough to watch 
 over the events of the world, the great events, eacli 
 one of which it was necessary for him to know 
 and to estimate correctly, and at the same time 
 to make such arrangements as to obtain the 
 best results from the favorable events, and to 
 guard against the evils threatened by those of 
 an opposite character, — William Pitt, I say, 
 striving to control the affairs of the world amidst 
 storms and tempests, could not turn away from his 
 official engagements, or his public duties, and pay 
 attention to his own health. This is very true. 
 But very few men have Uved in the world, who 
 for a series of years have been situated as Pitt 
 was. He was not an emperor ; not an autocrat ; 
 he was the servant of his king, responsible to him 
 and to the great nation under him. Napoleon, 
 with all his mighty labors, did not act under any 
 master, was not forced to consult any peers, any 
 fellows, but thought and acted for himself as a 
 man does in his private affairs. Perhaps to Pitt 
 the trial of his constitution was harder than that 
 of Napoleon. But both of them were bound to 
 incur all risks of personal evils, while in the 
 service of their country. They might well dis- 
 
80 ON THE UTILITY OF MEDICINE. 
 
 regard the advice of a physician. But they are 
 exceptions. 
 
 Let us leave this fine discussion and remember 
 that, if one would avoid a fit of the gout, he must 
 endeavor to lead a calm life, and rather give up 
 the pleasures of society, than to incur the evils 
 resulting from its indulgencies, its cares and 
 anxieties. 
 
 It has been shown that in some acute diseases 
 from the beginning, and in others after the earliest 
 days, we must abstain from heroic remedies. But 
 it must not be understood that in pursuing the 
 expectant course, we necessarily avoid the use of 
 all medicines ; still less, that we leave the patient 
 without any directions as to the treatment in other 
 respects. By leaving a case to nature, it is not 
 meant, that we must leave it to chance. There 
 are many points, on which directions may be 
 necessary. Accidental aggravations may require 
 to be removed, or relieved; and, for this reason, 
 medicine may be called for. But mostly what is 
 called the hygienic treatment must be cared for. 
 Here, it may be asked, do we mean by the hygi- 
 enic treatment anything but good nursing? It may 
 be said in reply, that this treatment is, in good part, 
 that which it is the business of the nurse to look 
 
ON THE UTILITY OF MEDICINE. 81 
 
 after ; just as it is the business of the apothecarv to 
 put up the medicines which are ordered. But, in 
 both cases, it is the business of the physician to 
 prescribe what is to be done. He must not only 
 point out the general principles, on which the 
 treatment is to be founded, but should show in 
 each case how these principles are to be applied, 
 and should descend to particulars so far as each 
 case may require. Let me specify a few of the 
 points to be regarded as such, when the treatment 
 is conducted on the expectant, as when on the 
 active plan. Where shall the patient be ? Shall 
 he go abroad, or stay in the house ? Shall he sit 
 up, or lie on the bed ? What shall be the tem- 
 perature of his room, and how shall ventilation be 
 managed ? What nourishment shall he have, and 
 how often may it be given, and in what quantities ? 
 Although we abstain from the use of strong medi- 
 cines to produce, or to check evacuation, yet by 
 mild remedies or by the dietetic treatment we may 
 favor, or we may restrain them. On these points, 
 and on many others analogous to them, the admi- 
 rable Miss Nightingale gives us many excellent 
 directions. She professes to be instructing the 
 nurses. She tells them in what way they should 
 manage as to the points referred to. But I believe 
 
82 ON THE UTILITY OF MEDICINE. 
 
 that Miss Nightingale would, in reality, look to 
 the physicians, for the care of these things. She 
 is too modest, or too polite to offer her advice 
 directly to the doctors. But she may be said to 
 talk to the nurses within their hearing, and as I 
 presume, with the hope that they will take the 
 hints which she throws out. Until she has estab- 
 lished a school for nurses, she will hardly be 
 willing to entrust them with the regulation of 
 these important points. I will acknowledge that 
 she may find too many instances, in which the 
 doctors fail to give proper directions on hygienic 
 points ; but if she were to speak her mind, she 
 would say to them that this was their business. 
 It is nevertheless tme that the physician should 
 not always be peremptory in his orders ; he may 
 allow to the nurses some latitude. As far as possi- 
 ble he should consult the taste and feelings of his 
 patient. For one, who is suiFering under disease, 
 that should be done, which is most agreeable, so 
 far as it is consistent with safety. I know that it 
 is too common for those about the sick to hesitate 
 as to an indulgence of the feelings and taste of a 
 sick man ; they rather presume that such indul- 
 gence would lead to injuiy. On the other hand, 
 I have long been persuaded that the taste and 
 
ON THE UTILITY OF MEDICINE. 83 
 
 inclination of the patient should be indulged, 
 unless there should appear some obvious and de- 
 cided objection. The burden of proof, that indul- 
 gence would be wrong, must be thrown on those, 
 who raise the objection. But it is by the physi- 
 cian, and not by the patient, that the final decision 
 should be made ; as on the physician the respon- 
 sibility should rest. 
 
 I avail myself of this opportunity to make a few- 
 remarks on the diet of the sick. By one class of 
 people, those in and those out of the medical pro- 
 fession, the fear is that the sick man will be allowed 
 too much to eat and drink, or such as he cannot 
 digest, or such as from its quantity will aggravate 
 his disease. By another class it is feared that he 
 will not be supplied with food sufficiently nutri- 
 tious, or will be too much limited in quantity. 
 Now, I take it, that in an acute disease, at the 
 commencement of it, the stimulus of food may 
 increase the disease ; so that from the first to the 
 sixth or eighth day, according to the character of 
 the disease, it is best that the food be small in 
 quantity, mostly liquid in form, and mild in quality. 
 Besides, at this period, the stomach will not act 
 well on solid food, while, if the food be liquid, it 
 may be passed through the canal with comparative 
 
84 ON THE UTILITY OF MEDICIXE. 
 
 ease. But, after the early period, the case i; to 
 be regarded in a new light. Then food should not 
 be withheld from the fear of aggravating the disease 
 by its stimulating property ; though it should be, 
 if appetite is entirely wanting ; and that only 
 should be furnished which is agreeable to the 
 taste. Under these conditions, it may be given, 
 but with caution ; for the stomach will not always 
 digest food, even when the patient craves it, and 
 when it proves grateful to his taste. At first then 
 it should be given in small quantities once, or at 
 most twice in a day. In proportion as the patient 
 bears it well, the quantity may be slowly in- 
 creased ; and so may the frequency of the meals. 
 If the food be solid, it should never be given 
 oftener than once in four hours ; and then not 
 in the night hours, unless the quantity is very 
 limited. Under similar circumstances, when fer- 
 mented and spirituous hquors are craved, they 
 may be given, such as are most gratefiil ; at first 
 in small quantities. The extent, to which these 
 liquors may be used with advantage, is very vari- 
 ous ; the limits depend partly on the previous 
 habits of the patient in the use of them. There 
 are instances, now and then, in which good wine 
 is not only borne well by a convalescent, but in 
 
ON THE UTILITY OF MEDICINK. 85 
 
 which it seems essential ; — in which he is so 
 evidently benefitted by it, that he may be allowed 
 a bottle, and even more than that, in the twenty- 
 four hours, for many days in succession. In this I 
 have reference to good Sherry, Madeira or Port 
 wine. But it is not wise to lead the patient to 
 such large potations, unless he is obviously more 
 comfortable for the indulgence. It is not merely 
 those who are accustomed to drinking wine, who 
 can bear this iree use of it. I have in a few 
 instances seen teething children, much wasted 
 and much exhausted by cholera infantum., take 
 wine to the amount of a pint a day for many 
 successive days, with unquestionable benefit. 
 
 I have not exhausted my subject. Far from it. 
 There are many more medicinal drugs, too good 
 to be expunged from the Hst of the materia medica, 
 which I might mention. Among the more power- 
 ful of these are Elaterium, Digitalis, Diluted Hy- 
 drocyanic Acid and Iodine ; to which I may add 
 Sulphuric Ether taken by inhalation. All of 
 these may be occasionally employed by discreet 
 men ; men who are willing to study the mode of 
 using them, the effects to be expected from them, 
 and the extent to which they may be given. 
 Among milder drugs may be mentioned the Spirit 
 
86 ON THE UTILITY OK MEDICINE. 
 
 of Nitric Ether, the compound Spirit of Ether, the 
 Solution of Acetate of Ammonia, Valerian, and 
 Assafetida, as old friends, whom I would not like 
 to part with. The same may be said of Mustard, 
 the Water of Ammonia, Croton Oil, Chloroform 
 and Cantharides, for external use. Nor should 
 water, pure or medicated, cold or hot, employed 
 as a partial, or general bath, be omitted in the list 
 of remedies not to be dispensed with. Many other 
 articles, without great pretensions, are often ad- 
 ministered to the great satisfaction of the sick. 
 
 I may also bring to view other morbid affections, 
 besides those mentioned in this letter, or in the 
 series of letters formerly addressed to you, from 
 which the subjects of them may be relieved wholly, 
 or in pajrt, by the proper administration of articles 
 contained in our apothecaries' shops. For instance, 
 there is the whole tribe of cutaneous diseases, for 
 which the Specialists would show you that much 
 benefit may be afforded by remedies, some of them 
 external, some internal. If, now and then, it be 
 true that those, who offer instruction in regard to 
 diseases of this tribe, are too confident in pointing 
 out the remote causes of these diseases, or in the 
 means directed for the cure of them, — it is cer- 
 tainly true that, in many instances, the evidence of 
 
ON THE UTILITY OF MEDICINE. 87 
 
 the benefit produced is more obvious, than in most 
 diseases of other descriptions. This success is 
 easily explained, when we consider that the dis- 
 eased parts are exposed to examination much more 
 perfectly, than the internal parts of the body. 
 Hence the diagnosis is comparatively easy, and 
 the diagnosis of the different stages of a disease, — 
 a circumstance which it is always very important 
 in regard to the treatment, — may be much 
 more certainly ascertained than in other diseases. 
 So likewise the effect of remedies can be more 
 satisfactorily demonstrated, in treating diseases 
 of the skin, than in treating those of the in- 
 ternal organs. 
 
 Remarks, somewhat the same, may be made in 
 respect to the treatment of other local diseases, 
 called at the present day Specialities, such as dis- 
 eases of the eyes and of the ears. 
 
 I am aware that it is objected to the Specialists 
 that they are apt to make greater pretensions to 
 skill, than are justified by the result of their treat- 
 ment. No doubt this sometimes happens. This 
 happens partly because they are honestly deceived, 
 as men are always liable to be, when their attention 
 is confined to a very limited sphere. But, it must 
 be confessed that it sometimes happens from less 
 
00 ON THE UTILITY OF MEDICINE. 
 
 creditable causes. A man with a good address, a 
 due share of low cunning, or a due share of bold 
 impudence, does not find it difficult to deceive 
 persons suffering under disease. Yet, from all 
 that I have learned from the Specialists, I have 
 been led to the conclusion that they can show us 
 many cases, in which medicine can be employed 
 with unequivocal benefit. 
 
 To what conclusions have we arrived ? First. 
 
 1 have admitted the abuses of medicine. It is, 
 though much less than formerly, given too much 
 as a matter of course to all, who .apply to the phy- 
 sician for aid ; and powerful drugs are adminis- 
 tered too often, without bearing in mind that they 
 will certainly do some harm. This certain evil 
 should be compared with the uncertain benefit, 
 which we are justified in expecting from them. It 
 becomes every medical man to keep these consid- 
 erations fairly before his mind, when making his 
 prescriptions. I have flattered myself that we are 
 not peculiarly subject to reproach on this head, in 
 this region of the civilized world. But I know 
 how readily all men take to their hearts such sweet 
 flatteries as this. 
 
 Secondly. I have endeavored to point out the 
 importance of resorting to what I have called the 
 
ON THE UTILITY OF MKDICINE. 89 
 
 hygienic treatment, in all cases admitting the use 
 of it. This I have recommended especially in 
 chronic diseases, maintaining that, in very many 
 cases, the best chance for relief may be found in . 
 the promotion of the general vigor. By this the 
 system may be enabled to overcome the disease ; 
 or, where this cannot be done, to delay as long 
 as possible its fatal termination. 
 
 Thirdly. I have expressed my conviction that 
 by medical treatment, often by the efficient 
 use of powerful drugs, sometimes by blood-letting, 
 we may frequently succeed in diminishing the 
 violence, in lessening the suffering, and in short- 
 ening the duration of diseases. But I have dis- 
 tinctly stated, and as forcibly as I could, that it 
 was only at the commencement of a disease that 
 the treatment, above described, could be employed 
 with any just hope of success. In doing this, I 
 hope that I have been clearly understood as re- 
 ferring to the first days of the actual disease, not 
 to the first days of the physician's attendance 
 on it. 
 
 Fourthly. I have brought into view the self- 
 limited diseases, of which Dr. Bigelow has treated, 
 in which certain processes must be gone through, 
 
 and which medicine cannot arrest. I have stated, 
 8 
 
90 ON THE UTILITY OF MEDICINE. 
 
 however, that we can sometimes diminish the 
 sufferings, and perhaps also the danger attending 
 these diseases, when these are passing beyond 
 certain bomidaries. Otherwise, these diseases are 
 to be left to their own course, only guarding 
 against such things as would aggravate, or pro- 
 long them. 
 
 Fifthly. When diseases are brought under the 
 treatment of a physician, after the period during 
 which active measures are found useful, or when 
 such treatment has done all that it is capable 
 of, the expectant mode of cure should be relied 
 upon. 
 
 To show the claims of medicine to the character 
 of a useful art, I have given an account of the 
 uses, which may be made of some of the most 
 powerful drugs employed among us at the present 
 day. Subsequently, I pointed out some of the 
 most common diseases, in which ' I have thought 
 medicinal drugs, as well as other treatment, may 
 be used with benefit. I have given the results 
 at which my own mind has arrived. I have not 
 pretended to demonstrate the justness of my con- 
 clusions. Nor have I brought forward any system 
 of medical science. I am not capable of so doing. 
 I think I may say more ; — viz : that our knowl- 
 
ON THE UTILITY OF MEDICINE. 91 
 
 edge at the present day does not justify the 
 attempt to bring forward any such system. I do 
 not deny that we have much valuable knowledge 
 in the various branches of medicine. I maintain 
 the contrary opinion. But, as I stated in the 
 first part of this letter, our acquaintance with 
 physiology and pathology is limited and imper- 
 fect ; and these are the fiindamental branches. 
 Of course the same must be true in regard to 
 therapeutics. We do not know enough, as to 
 either of these branches, to enable any one to offer 
 a satisfactory system of rational medicine. In 
 many instances, certainly, our practice is founded 
 on experience alone. In the good sense of the 
 word, our practice is empirical. Happily this is 
 often sufficient. If we know that cinchona will 
 arrest an intermittent fever, have we not good 
 cause to be satisfied, although we cannot answer 
 all the questions, which may be put, in regard 
 to the etiology and the pathology of that dis- 
 ease, or in regard to the modus operandi of the 
 cinchona. 
 
 There is one acknowledgment, which has, I 
 think, been implied in what I have already writ- 
 ten ; but I choose to make it in distinct terms. 
 This is, that in very many instances, in which the 
 
92 ON THK UTILITY OF MEDiriJfE. 
 
 aid of a physician is invoked, it is certain that he 
 cannot remove the disease. In some instances 
 this is because he is called too late ; unhappily in 
 very many it is because the disease will very rare- 
 ly, perhaps never, yield to medical skill. Yet, 
 even in these forlorn cases, the art of medicine is 
 not useless. On many points there is a choice as 
 to the course to be pursued. Life may be pro- 
 longed by wise care, however hopeless the case. 
 What is more important, by art the sufferings 
 may be mitigated, and the patient be comforted, 
 though the disease cannot be arrested. To many 
 persons, who know they have a disease, which is 
 without a remedy, it affords much consolation to 
 have one to watch over them, who understands 
 their sufferings, and wire is daily studying to 
 soothe them. The faithfiil care of nurses, and 
 the kind sympathy of friends, are often still more 
 important ; but, in some sad cases, all are not too 
 much to uphold the strength, or to soften the 
 anguish of a beloved one in the last da,js and 
 hours of life. 
 
 In conclusion, may I hope that you will agree 
 with me that there does exist much valuable 
 knowledge in regard to the treatment of the sick. 
 Let us not throw this aside, because it is imper- 
 
0\ THE UTIMTY OF MEDICINK. 93 
 
 feet; bwausc it will not satisfy those, who ire 
 critically scientific in their requirements. There 
 are results of personal experience, of which each 
 medical man, or, at least, many medical men can 
 furnish a part ; there is much of this sort which 
 has been accumulating through ages. What I 
 have stated in respect to diseases and their treat- 
 ment, is grounded on this sort of experience. It 
 would be too absurd were I to pretend that I have 
 gathered, or discovered, all which I have stated. 
 With me, as with my brethren, most of what I 
 know has been derived from others. But then I 
 have also been told by others much, which I have 
 not found to be true. In general terms I may 
 say that the statements, I have made, have been 
 confirmed by my own observation, or experience. 
 I have not offered proofs ; I offer only opinions. 
 I claim to have formed these opinions after much 
 and careful observation. I claim to have been 
 diligent and carefiil ; but there is no doubt that I 
 have made mistakes, and I will thank any one, 
 who will point them out to me. I never suspected 
 that I was possessed of any extraordinary powers, 
 or talents. But I do claim an honest' devotion to 
 the pursuits of my calling, and a sincere love of 
 truth. I hke to compare myself to an old gar- 
 
94 ON THE UTILITY OF MEDICINE. 
 
 dener, who has sedulously devoted himself to rais- 
 ing the flowers and the finiits, and still more the 
 kitchen vegetables of the plat of ground under 
 his charge ; who has listened to the suggestions of 
 the scientific, and has been willing to follow them 
 in making his experiments, exercising due caution 
 when those experiments appeared to be attended 
 with risk of evil, or likely to involve too much 
 expense ; and who, at last, points out to those 
 engaged in the same pursuit the best opinions and 
 practices he has been able to arrive at. 
 
 IHE END. 
 
NOTES. 
 
NOTES. 
 
 I TRUST that the foUowhig papers will be 
 found interesting on account of the subjects of 
 them. With the exception of the article in 
 respect to Washington, they all have reference 
 to the preceding letter ; but I have thought 
 it best to leave them to be read after the letter, 
 and therefore did not place on its pages any 
 notice of them. 
 
 In the letter, I have frequently mentioned the 
 hygienic treatment of the sick. By that I meant 
 a treatment as to diet, regimen, &c., founded on 
 the principles of that branch of medical science 
 called hygiene. By this mode of treatment we 
 often aid the spontaneous efforts of nature in over- 
 coming disease. The two first notes are given 
 partly to show that I have always paid great 
 regard to the hygienic treatment. I have not 
 become tired of administering medicine ; I am not 
 incredulous as to its utility, although I do not use 
 it so freely as I did in my early years. 
 
 9 [97] 
 
98 NOTES. 
 
 The first note contains an account of the first 
 important case, which came under my care, and 
 it will be seen that I then paid great regard to 
 the treatment just mentioned. I would not how- 
 ever have given this case for that purpose only. 
 My fellow citizens in Boston will see other reasons 
 for publishing it. 
 
 The second note is given to show that, when I 
 had been in practice forty-six years, I continued 
 to hold the same regard for the hygienic treat- 
 ment. It is copied from the British and Foreign 
 Medical Review, No. XLIII. published in July, 
 1846. In the number of that Review for Janu- 
 ary, 1846, the Editor, Sir Jolin (then Dr. John) 
 Forbes, had published his celebrated article on 
 the subject of Homoeopathy. I had previously 
 had some correspondence with Dr. Forbes, and 
 immediately after reading that article I wrote to 
 him expressing the great satisfaction it had given 
 me. My letter was not designed for pubhcation, 
 as he saw ; but he replied to it at once and asked 
 my consent to his printing some extracts from it 
 in his Journal. This explains the appearance, in 
 that excellent periodical, of the paragi-aph, which 
 makes up the second note given in these pages. 
 
 The third note contains some remarks on the 
 
NOTES. 99 
 
 care necessarj' in getting reports regarding pa- 
 tients under treatment, and on nurses. These 
 remarks I wished to offer for their own sake ; 
 but I confess that my main object was to bring 
 into view the character of one, whom I have 
 long considered a model nurse. 
 
 The fourth note contains an account of the 
 ailments and death of the late William H. Pres- 
 cott, Esq., the celebrated historian. It is his case, 
 which was referred to in the preceding letter, as 
 an instance of acute rheumatism treated at its 
 commencement by very copious blood-letting. 
 
 Soon after Mr. Prescott's decease my friend 
 George Ticknor, Esq., requested me to furnish 
 him with a medical account of Mr. P. 's case. 
 Mr. Ticknor wanted this to aid him in preparing 
 a biography of our lamented friend. I gave to 
 him my statement in the form of a letter, which is 
 copied below. I found that Mr. Ticknor's work 
 would not be published for some time, and as I 
 wished to bring Mr. Prescott's case before my 
 professional readers, I begged the favor of him to 
 allow me to use it in this way. He very kindly 
 consented to my wish, with the proviso that he 
 should still use the whole, or any part of my 
 letter, as he should think proper. 
 
100 NOTES. 
 
 There is a fifth article which is not a note to 
 tlie letter. It is a distinct affair. It contains an 
 account of the last sickness and death of General 
 Washington. This was written by me about a 
 year ago, at the request of the Hon. Edward 
 Everett, to be used by him in his Life of Washing- 
 ton. It is referred to by Mr. E. in that work, 
 and is printed in an appendix to it. Copies of it 
 have been sent by me to various friends, in a 
 pamphlet form. These were printed for me in a 
 larger type than in the Memoir^ expressly for 
 private use, by Mr. Everett. 
 
 For this unexpected favor I could not but feel 
 very grateful to my respected and learned friend ; 
 but, as often happens, emboldened by one favor I 
 asked for another. After I had obtained Mr. 
 Ticknor's leave to make use of my letter to him, 
 it occurred to me to ask Mr. Everett's permission 
 to add to this volume the paper on Washington's 
 case. I could not say that it had any reference to 
 my new letter to a young physician ; but I thought 
 that it might reach some medical men, who would 
 not otherwise see it. The subject is one, in which 
 I have a right to suppose that every man, but 
 especially every medical man, must feel a strong 
 interest. 
 
NOTE I. 
 
 I am induced to give the history of the case 
 which follows from several considerations. It was 
 and is interesting to me on personal accounts ; it 
 was the first important case which came under my 
 care when I entered on the duties of my pro- 
 fession, and it relates to one whose memory will 
 always be held in regard in our city. I will add 
 that it is one of the instances, of which I have 
 since seen very many, which teach us not to 
 despair, although the appearances of danger may 
 seem very great. We meet with some diseases, 
 which scarcely permit any hope, such as tubercles, 
 malignant diseases of various sorts, hydrophobia, 
 tetanus, &c. In such cases, the best encourage- 
 ment may be founded on a hope that we have 
 erred in our diagnosis. But, when dealing with 
 diseases, which are not so uniformly fatal, it will 
 be found that more than three out of four of the 
 instances of sickness, which are regarded by the 
 friends of the patient as very dangerous, ultimately 
 terminate in recovery. Hence in bad cases, we 
 
 [101] 
 
102 NOTES. 
 
 are justified in being hopeful ; and it is right for 
 the physician to encourage hope in the patient and 
 his friends. He need not deny that there is 
 danger, but he is justified in looking at the bright 
 side, and it gives to the patient a better chance of 
 recovery. I know that some of my brethren are 
 fearful of pursuing this course, as it may subject 
 them to censure, if the result is unfavorable ; 
 whereas, if the patient recovers after he has been 
 despaired of, he and his friends are repaid for all 
 their anxiety. But there is no fear that recovery 
 from a severe sickness will not bring pleasure 
 enough to the parties concerned, and I regard it 
 as the duty of the physician to rim a little risk 
 of reproach now and then, rather than keep the 
 parties more anxious than they need to be for 
 several successive weeks, or days, or even hours. 
 
 One reason for writing this note is that the 
 treatment was, in very great part, conducted on 
 hygienic principles. I wish to show that my 
 regard for these principles has not arisen in my 
 old age, from a distrust of the benefits of medicinal 
 treatment ; but that I began life with feelings of 
 great confidence in them. That confidence has 
 never left me, while experience has made those 
 principles more fiilly and more distinctly known 
 to me. 
 
NOTES. 103 
 
 I went to London in October, 1799, to pursue 
 professional studies there. I returned home, and 
 commenced the practice of medicine about the 
 first of October, 1800. When I went away my 
 father had one grandcldld only, a boy about 
 five months old, then bright and healthy, though 
 small. He was, of course, an object of great 
 interest in my father's family. On my return 
 home, I found him wofuUy altered. His appear- 
 ance shocked me. He was very pale, much 
 emaciated and exhausted. His skin was flabby, 
 and seemed to hang in folds around his bones. 
 His appetite was capricious, his food was very 
 imperfectly digested, not always retained in his 
 stomach, and did not nourish him. His dejections 
 were fi-equent, loose, changing in character from 
 hour to hour, made up of undigested food, of 
 mucus and watery fluid, varying in color, mostly 
 green, and never healthy in consistence, color, or 
 odor. His bright blue eyes had not lost all their 
 spirit, but otherwise his countenance exhibited 
 marks of great wretchedness. By turns he was 
 languid and fretful. His nights were wakeful, 
 and the sleep he got was uneasy and unrefresh- 
 ing. It was a bad case of cholera infantum. 
 Such was his appearance, that, dear as he was to 
 
104 NOTES. 
 
 me, the son of a sister near my own age, and my 
 earliest playfellow, I felt, on first looking at him, 
 as if it would be a happiness to see him die. The 
 case seemed to be desperate. I had acquired some 
 familiarity with the subjects of the disease during 
 my pupilage, before I went abroad, and I thought 
 I had never seen one so sick as he was, who re- 
 covered. Thus, at the first, I was in despair. 
 But, on the second day, when I had reviewed the 
 case, my feelings changed. I began to have hope, 
 and happily my hopes became stronger from day 
 to day, or at least, from week to week, and in a 
 month or less, I regarded his ultimate recovery as 
 almost certain. When I entered on a considera- 
 tion of the case, with a view to treatment, I put on 
 paper the opinions I had adopted as to the actual 
 pathological state of the patient, the changes which 
 I should strive to produce by the treatment, and 
 the means best adapted to bring about these 
 changes. From the relation of the patient to 
 myself, my strong interest in him, and the great 
 responsibility I felt to the parents, who ventured 
 to intrust their only child to the care of a strip- 
 ling like myself, the circumstances have remained 
 in my mind to this period, more than sixty 
 years, since they occurred. I shall not, however. 
 
NOTES. 105 
 
 give all the details of the case, though I shall 
 relate so much as to make it intelligible. 
 
 I must go back to show how this child had been 
 brought to the dismal state, in which I found him. 
 He was small at his birth, which was premature 
 by more than two months. Under the care of an 
 experienced nurse, he got on very well during the 
 summer and autumn of 1799. Unhappily, his 
 mother's strength and health failed her, so that he 
 was weaned in the spring of 1800. From that 
 time till the next October, when I saw him, he 
 was at the height of his teething. During this 
 period, he should have been fed partly, if not 
 wholly, on the human milk. . Ohalera infantum was 
 brought about, and became severe from the den- 
 tition, the dogday-weather, and the unpropitious 
 diet. 
 
 I will not here go into an explanation of the 
 pathological state in Oholera infantum, which I 
 have endeavored to describe in the ninth of these 
 letters. At the time, when I took charge of this 
 child, I had not as definite opinions on the subject 
 as I acquired subsequently. I then, however, 
 saw, how all the evils were aggravated by the foul 
 and acrid contents of the alimentary canal, and 
 from time to time procured relief by a small dose 
 
106 NOTES. 
 
 of calomel, sometimes, though rarely, followed by 
 castor oil, or some like article. I believe that 
 distinct relief, for the time at least, followed every 
 dose of calomel. But, from the first, my great 
 object was to prevent the recurrence of this foul 
 state of the canal, by limiting the quantity of food 
 and drink, and by administering such as could be 
 best digested, or such as, if not digested, would 
 be the least likely to cause morbid irritation by 
 becoming acid, or acrid. I directed a bath, pleas- 
 antly tepid, at night, to soothe the whole system, 
 to equalize the temperature, and thus to promote 
 sleep. In the morning, the cold sponge bath, to 
 which the child had been accustomed from his 
 birth, and which seemed grateful to him, was con- 
 tinued. He was too feeble to walk, but he was 
 carried abroad every day, when the weather was 
 not positively foul. He enjoyed this excursion, 
 and it was continued through the winter, as the 
 best thing next to food, to restore his health. 
 
 His food was boiled milk, to which was added 
 lime water, when the dejections were loose and 
 frequent, the cold water cracker soaked in water, 
 when he wished it, and tender beef or mutton, 
 broiled or roasted, twice a day if he liked them, 
 with poultry occasionally, by way of variety ; for 
 
NOTES. 107 
 
 regard was had to his taste, so far as consistent 
 with the principles, on which his food was selected. 
 These principles were to avoid acid and acescent 
 articles, and, as far as could he, consistently with 
 his taste, to avoid food in a liquid form, I doubt 
 not that some tonics and cordials, such as wine, 
 were administered with this food ; hut my memory 
 does not serve me on that point. It is the at^ 
 tention I gave, when commencing practice, to 
 hygienic principles, which it is my special object 
 to state. I may say that, from that day to this, I 
 have studied those principles, and endeavored to 
 guide my patients by them. I will remark that 
 this is not always easy. With some patients there 
 are prejudices to be overcome ; some are not 
 willing to submit to the self-denial as to various 
 indulgences, especially as to the quantity and 
 quality of food ; and some are unwilling to make 
 the efforts required. In the case I have related, 
 I had friends willing to pursue the treatment I 
 directed in the most thorough manner. 
 
 I have said that, when I first looked on my 
 nephew under his disease, he seemed so exhausted, 
 and so wretchedly feeble, that I felt as if he could 
 never live to have comfortable health, and that 
 he could never become useftil to himself or others. 
 
108 NOTES. 
 
 A fortnight later, when he had hecome convales- 
 cent, I ventured to give an encouraging prognosis. 
 Some wise old people thought me wrong, and one 
 of them, who felt a very strong interest in my 
 professional success, very kindly took me aside to 
 give me some cautions. He told me that he had 
 heard of the hopes I had given to the friends in 
 regard to this child, and that I had done likewise 
 in respect to a young lady of his acquaintance. 
 "Now," said he, "everybody says that both of 
 them will die, and if you are so bold in your 
 opinions, your reputation will be injured." My 
 reply probably was, such as I have often made 
 since, if I did not then ; — that I thought it no 
 more than fair to impart to the friends the hopes 
 which I felt authorized to entertain myself. Sure- 
 ly I would not promise a recovery in a doubtful 
 case, but I would not allow loving friends to suffer 
 more than was needful. Happily, the young lady 
 above referred to recovered, and is now living, 
 having given and received much pleasure during 
 the sixty years which have since passed away. 
 My little nephew also recovered, and, at the end 
 of two or three years, he became tolerably vigo]> 
 ous. Ultimately he became a tall and healthy 
 man. 
 
NOTES. 109 
 
 It is not for us to judge what a miserable sickly- 
 infant may become, if he can be carried over a 
 few weeks. This feeble boy was John Lowell, 
 the founder of the Lowell lectures. He lived 
 to be father of two children, both of whom died 
 within three weeks of each other of scarlet fever, 
 which prevailed at the time under one of its most 
 pestilential forms. Their mother had gone before 
 them. Mr. Lowell was then left, a little more 
 than thirty years of age, a widower and childless. 
 At the end of two years he followed an inqlination 
 he had felt in early life, and engaged in travels in 
 foreign countries. After a visit in Europe, where 
 he had been once before, he went to Egypt, and 
 there passed some time, during which he con- 
 tracted a disease of the climate. He did not give 
 up his projects, but, passing over the desert-, went 
 to the Gulf of Persia, and thence to Bombay. 
 He reached that place in miserable health, and 
 within a few weeks his life was terminated, in 
 the thirty-seventh year of his age. 
 
 Mr. Lowell died possessed of a large fortune. 
 One half of this property he gave by his will to 
 establish the Lowell Institute. The custom of 
 having popular lectures had begun not long before 
 his departure from his native shores. He saw 
 
110 NOTES. 
 
 that much good might be done by such lectures, 
 if conducted discreetly on a liberal plan, such as 
 would bring forward men of the best talents. It 
 was principally for such lectures, and entirely for 
 giving popular instruction, that this Institute was 
 established. The inhabitants of Boston well know 
 how much pleasure and profit have been derived 
 directly from these Lowell Lectures for the last 
 twenty years, and as yet we may say they have 
 only made a beginning. We may hope that this 
 blessing to our community may continue for many 
 ages. But this is not all. One good thing leads 
 to another. Distinguished men have been brought 
 from Europe to give courses of lectures in this 
 Institute. It is in this way Mr. Agassiz was in- 
 duced to visit our country. How much this most 
 distinguished naturalist has already done, and how 
 much directly or indirectly he will do for us, I 
 will not undertake to tell. If our wealthy men 
 do not become less mindfiil of the interests of 
 science than they have hitherto been, our Uni- 
 versity at Cambridge may have a School for 
 Comparative Zoology such as the world has 
 liitherto never possessed. 
 
NOTE II. 
 
 " (America), January 30th, 1846. 
 
 " I THANK you much for having written the 
 article. The fulness of time has come in which 
 all this matter should be exposed fully and clearly. 
 You have not said a thing, which I have not 
 thought of and agreed to beforehand. I know 
 how presumptuous this may seem ; but you know 
 that it is one thing to entertain correct thoughts 
 on a subject, and quite another thing to bring 
 them out clearly and in proper order, so as to 
 claim the assent of all good judges. This last is 
 what you have done most satisfactorily. 
 
 " Some of the opinions you have expressed I 
 have entertained for many long years ; others I 
 have arrived at more lately. I first longed for a 
 good natural history of diseases, to decide how far 
 remedies had an effect. As connected with this I 
 early learned the primary importance of diagnosis, 
 and this in reference to the different stages of 
 diseases, as well as in reference to diseases them- 
 
 ULl] 
 
112 NOTES. 
 
 selves. It is many years since I was satisfied, in 
 respect to acute diseases, that it was only on the 
 first days (principally the first three days) that 
 medicine (drugs) could be of much service. At 
 this period I am still satisfied that acute diseases 
 can, ordinarily, be much mitigated and somewhat 
 shortened. But an exception must be made in 
 regard to such as we call malignant (yellow fever, 
 Asiatic cholera); and, as to shortening, in re- 
 ference to the exanthemata. I have been getting 
 more and more of the opinion, that in most 
 chronic diseases, diet and regimen will often have a 
 great influence, — drugs rarely have any very de- 
 cisive good effect, and often an injurious effect 
 only. I have long deprecated the idea (and this I 
 have done in communication with my intelligent 
 patients) that medicines (drugs) are necessary in 
 the treatment of all diseases. I have urged that 
 it was the business of the physician to take care of 
 the sick, pointing out that cure and care were the 
 same word originally, — and that in taking care, 
 it was much more important that he should 
 endeavor to control the influence of the common 
 agents, than that of the occasional ones, called 
 medicines ; — that he should attend to the non- 
 naturals, — those things which nature does not 
 
NOTES. 113 
 
 decide, but leaves to our choice, — that he, the 
 physician, should do it, and not leave it to the 
 uurse or the grandmother. In consonance with 
 these views, I have been unwilling to say that my 
 patients, who recovered, were cured by me ; for I 
 endeavored to cure all of them, and claimed to have 
 done it, even when they died. In our hospital, 
 opened twenty odd years ago, I would not allow 
 the record books to say that so many patients had 
 been cured, as is a common practice ; but that so 
 many were discharged well, so many improved in 
 health, &c. I have often urged upon my brethren 
 tliat we should never get the better of quackery, 
 so l9ng as we attributed the recovery of our 
 patients to medicine, on the propter hoc principle, 
 — that is, propter hoe because post hoc. Our 
 proper ground is, that, having studied the subject 
 and had personal experience, we know better than 
 others how to direct the cure of the sick ; and 
 that in doing so we may use drugs, or may not, as 
 the case may require. These drugs may some- 
 times be directed against the principal disease ; 
 but oftener, they may be used to counteract or 
 guard against the accidents, which would aggra- 
 vate that disease. 
 
 " I have found no difficulty in all this. In some 
 10 
 
114 NOTES. 
 
 respects I have, perhaps, had advantages which 
 you do not yet enjoy. . . Though we have good 
 apothecaries, by whom alone medicines are or- 
 dinarily put up, — they are strictly men of the 
 shop. They never visit the sick, and do not 
 pretend to practice. They make their charges 
 for medicines alone, and are paid as grocers or 
 other tradespeople are. The physicians (and 
 practitioners generally) charge for their services, 
 whether they order medicine or not. Thus, there 
 are none of the inducements to employ drugs, 
 which exist among a large class of practitioners " 
 with you. In our country towns the physicians 
 supply the drugs ; still the influence of city 
 customs prevents their resting their emoluments 
 on these ; they charge distinctly and mamly for 
 their visits, &c. Again, among the regular 
 practitioners we have not any distinction of 
 classes ; though age, &c. give to some men a 
 certain rank, it is very different firom what exists 
 with you. We all of us have therefore a chance 
 
 to get patients at the onset of disease 
 
 " I have said that I have found no difficulty in 
 satisfying patients without medicines. I began 
 life with a good confidence in certain articles, and 
 more especially in the alterative powers of mer- 
 
NOTES. 115' 
 
 curials. The doctrine now prevalent with you as 
 to the power of calomel in acute diseases, especial- 
 ly in inflammation, was familiar to me, and fully 
 believed, when I attended St. Thomas's, in 1799- 
 1800. I used to say to my young friends there, 
 with the true juvenile conviction of superiority, 
 that it was singular Dr. Saunders (William) could 
 be so blind ; in his book, and in his lectures, he 
 advised the use of mercury in acute, as well as in 
 chronic hepatitis ; yet did not see that it ought to 
 be equally useful in other acute inflammations, as 
 I knew that it was. It was some years later that 
 one of your Dr. Hamiltons (in England, not 
 Scotland) first brought forward the general 
 doctrine ; at least, so far as I know. At the 
 present day, I find it maintained by Dr. Watson 
 in his delightful lectures. Now, I am not ready 
 to say that the practice is all wrong. There is 
 perhaps some good in it in some cases ; but when 
 pursued heroically it does a wonderful deal of 
 mischief. Whether it often causes a fatal result I 
 will not say ; I think not often ; but it often adds 
 much to the suffering of the patient and to the 
 duration of his siehness, if not of his disease. I 
 began to perceive this early in my career, but not 
 in its whole extent for more than twenty-five 
 
116 NOTES. 
 
 years. In acute rheumatism I gave up the 
 mercurials within six or eight years after I began ; 
 though it would seem to be the disease, to which it 
 should be most applicable. And, as early as, this 
 I became very careful not to produce a bad sore 
 mouth in any case of disease. But I was a pio- 
 neer here ; and I can boast (for I may seem to be 
 boasting) much more of what has been done by 
 younger men — whose modes of philosophizing in 
 medicine I have influenced in some measure — 
 
 than of my own doings 
 
 " I must finish by saying, that I am often con- 
 sulted by people from the country, as well as from 
 the city, in chronic diseases, though I have ceased 
 to be a busy practitioner ; and that I find no 
 difiiculty in satisfying a patient, after an hour's 
 lecture upon his mode of life and conversation, 
 without any prescription for medicine. In epilepsy 
 and in phthisis, except so far as symptoms may 
 require to be alleviated, I always tell the patient 
 at once not to employ any drug to remove his 
 disease. But in epilepsy, not evidently from 
 organic disease, and in phthisis at an early period, 
 I venture to say that much alleviation and benefit 
 may be derived from care as to diet, exercise 
 abroad, &c. Do not understand that there is a 
 
NOTES. 117 
 
 precise formula, which I follow in these cases. I 
 try to communicate principles rather than rules, 
 and I find a large proportion of patients can un- 
 derstand me." 
 
NOTE III. 
 
 Among the sciences, the principles of which it is 
 necessary for the physician to understand, is that 
 of human nature ; or, otherwise described, the 
 principles of the philosophy of the human mind 
 and heart. This, strictly and properly, is a branch 
 of human physiology. It is not, however, a branch 
 which is ordinarily brought into view, if it is 
 ever thought of, by our teachers of physiology. 
 The mind has so much to do with the health of 
 the body, the two mutually acting on each other, 
 that an intimate acquaintance with the one is 
 necessary to a full comprehension of the other. 
 A person who is familiar with the characteristics 
 of the mind and heart, is prepared to see how 
 the bodily health is injured and how it is benefited 
 through the medium of the mind. These obvious 
 truths are familiar to medical and non-medical 
 men, whether they are adverted to as much as 
 they should be, or not. But I wish now to bring 
 into view the importance of a knowledge of the 
 
 11181 
 
NOTES. 119 
 
 human mind and heart with reference to one 
 branch of the details of a physician's daily duties, 
 which is not perhaps sufficiently regarded. It is 
 a daily business of a physician, an hourly duty, to 
 ascertain, through human testimony, what has oc- 
 curred to his patients. As far as possible, let the 
 physician get a knowledge of the case before him 
 by the objective signs. Some of our brethren 
 rely on these alone, and scarcely ask a question as 
 to the history of a case presented to them, though 
 they may listen to the story told by the patient 
 or his friends. Now I hold that it is wise to get 
 all the information we can, by our own senses, — 
 to learn in that way all the objective signs of 
 health or disease. For we may be able to get 
 an absolute assurance about these, while there is 
 some difficulty in gaining a certain knowledge of 
 the subjective signs. Yet, ordinarily, it is highly 
 important that we should gain this knowledge, and 
 most of us always seek it. Remember that we 
 must depend upon the patient for an account of 
 these signs, and there Are various modes, in which 
 we may be deceived about them. In some in- 
 stances, strange to say, the patient deceives us 
 designedly, influenced by various motives. But 
 more frequently he misleads us undesignedly. This 
 
120 NOTES. 
 
 happens from an imperfect observation of himself, 
 from forgetfulness, or carelessness in his answers 
 to questions, or very often from a want of 
 accuracy in the use of language. Thus you may 
 ask your patient if he suffers any pain, and he 
 may answer, no, none at all ; yet a few minutes 
 afterwards you may gather from him that he 
 often has a headache, or that in the night he is 
 frequently annoyed by cramps in his lower ex- 
 tremities, or that when he coughs he feels a pain 
 in his breast, or side, — or that some pain is in- 
 duced when he lies down in bed. Even thought- 
 ful and careful people will sometimes assert a 
 universal negative, without being aware of its 
 force. We must then cross-question our patients, 
 and their friends, who assist them in reporting 
 their histories. It is the proper duty of a 
 nurse — (the person who takes care of the sick 
 is to be called the nurse, whether a friend, or a 
 hireling) — it is the proper duty of the nurse to 
 report to the physician, at every one of his visits, 
 whatever has occurred during his absence, in the 
 order of the occurrences. A woman who can 
 take very good care of the sick man, may be 
 quite unable to make a good report from a want 
 of the habit of close observation, or from a want 
 
NOTES. 121 
 
 of the knowledge of language. But, besides, 
 when a nurse is closely questioned, she often 
 answers wrong by design. She may think that 
 she ought to be able to give an answer, when, in 
 reality, she is not ; and then she will give some 
 answer, relying on a guess to hide her ignorance. 
 Or, she may fear that an evil, which has occurred, 
 such as a chill, may be attributed to her negli- 
 gence, and for that reason she will try to keep it 
 from the knowledge of the Doctor ; or she may 
 have committed an error in the food, or the 
 medicine, and be afraid to acknowledge it. It 
 requires some address to ascertain the truth, and 
 guard against error from these sources. It be- 
 hoves the physician always to pursue his in- 
 quiries calmly, not using words or tones which 
 will agitate the patient, or the nurse, from appre- 
 hension that he will find fault. And, generally, 
 it is unwise in him to reproach the nurse when 
 she has made a mistake. If he do this, she may 
 be unwilling to teU him the truth another time. 
 If the nurse is too negligent, or grossly deficient 
 in her duty, he may take measures to have her 
 discharged. But, however it may seem to show 
 his spirit, it does not belong to him to find fault 
 with her. Let him point out the faults to her 
 11 
 
122 NOTES. 
 
 employers when they are too great. For the 
 sake of the patient, it is important to avoid un- 
 pleasant discussions in the sick room. 
 
 I hope these remarks will not be thought too 
 trivial. 
 
 I am tempted to take this occasion to put in 
 print a statement of the merits of a nurse in the 
 Massachusetts General Hospital, who began her 
 career there a few years after it was opened, and 
 after a service of thirty-four years, left that ex- 
 cellent institution a few months since. Trustees 
 and medical men, who have been familiar with 
 the Hospital, will understand at once that I have 
 reference to Miss Rebecca Taylor. I believe that 
 there is not any person living, who has been 
 connected with the hospital for so many years, — 
 perhaps I may say for half as many years, as she 
 was. If any person is to be excepted, it is my- 
 self. From the day on which the house was 
 opened to this day, about forty years, I have 
 been nominally connected with it ; and, so far as 
 a strong interest in it is concerned, I have been 
 connected with it from the first conception of its 
 estabhshment. But my active service in it ex- 
 tended only through its first fifteen years. Since 
 then, for about twenty-five years, I have been 
 
NOTES. 123 
 
 only a consulting physician. But my excellent 
 firiend, Miss Taylor, gave her personal services, 
 with occasional visits to the country for health's 
 sake, for the whole period of thirty-four years ; 
 and this in the ofBce of head nurse, doing all its 
 duties till a few of the last years of her service. 
 It is certain that she would not have been re- 
 tained in office so long, if she had not merited 
 some distinction. All, who have known her, 
 will remember the great modesty of her deport- 
 ment. She never obtruded herself on the notice 
 of any one, and never claimed any distinction. 
 It has long been my remark that physicians and 
 nurses might be divided into two classes ; viz : 
 those who keep in view their own glory, and 
 those who look only to the welfare of the patients 
 under their care. Miss Taylor was of the last 
 class. With most of us there is experienced a 
 regard to both the considerations above mentioned. 
 With her I never saw that she thought at all of 
 her own glory. She was uniformly devoted to the 
 sick in her wards, in the most quiet manner, and 
 most tenderly too ; but she never substituted 
 terms of endearment for faithful and punctual 
 attendance. I remember that she committed mis- 
 takes in administering medicines twice. Both 
 
124 NOTES. 
 
 times, when I inquired into the circumstances, 
 she told me at once, in a distinct voice, " It was 
 my fault, sir." She would have been unhappy, 
 if she could not have made the avowal of her 
 errors. I do not doubt that she might have 
 explained them away, but she would not attempt 
 to do it. There were two instances, under my 
 observation, in which she had reason to think 
 ill of the characters of patients in her wards. 
 She did her duty towards them ; but it was with 
 a coldness, which she seemed unable to repress. 
 In proportion as her patients were helpless, her 
 attentions to them were more assiduous. I must 
 indulge myself in giving one instance ; the reader 
 may pass it over, if he pleases. 
 
 Many years ago there was placed in Miss Tay- 
 lor's ward a very respectable Dutch woman, who 
 had recently arrived in this country, and could 
 not speak a word of English. She was past fifty 
 years of age, with a smooth and fair countenance, 
 and one expressive of kindness and gentleness. 
 Her good looks might have influenced anybody, 
 and no doubt might have had some effect on our 
 good nurse. As none of us could speak in the 
 Dutch tongue, we obtained help from two learned 
 Germans ; but, after four or five days, we were 
 
NOTES. 125 
 
 able to relieve them from further attendance. At 
 that time, Miss Taylor had established a language 
 of signs with the patient, and watched her so 
 closely, that she was able to give us a very satis- 
 factory account of the case from day to day, and 
 with her intervention the management of the case 
 was so successful, that the patient was dismissed 
 well after a week or two. Meanwhile our Dutch 
 woman learned to speak two words of imperfect 
 English, which she repeated daily, pointing to our 
 Miss Taylor. These words were " too goot, — 
 too goot." 
 
 I will add, that I reminded Miss Taylor of this 
 case lately, when I called to see her before she 
 left the hospital. She remembered it, and told 
 me that in other instances she had not found it 
 difficult to maintain a satisfactory intercourse with 
 patients, who could not speak our language. It is 
 obvious that this could not happen without the 
 most devoted attention on the part of the nurse. 
 
 There is not any comparison to be made be- 
 tween our good nurse and Miss Nightingale. The 
 latter is a lady of education, and in a different 
 rank in life. She sees how important is the office 
 of a nurse. She has studied the duties, I may 
 say the high duties of a nurse for the sick. She 
 
126 NOTES. 
 
 has brouo-lit science to her aid, and she has the 
 energy to teach the operatives the way to do their 
 work, and the care and fidelity requisite to do it 
 effectually. I have no doubt she has set examples 
 to her pupils in the hospitals, in which she has 
 taken the oversight of the patients. It is evident 
 from her writings that she has not been a mere 
 looker-on. My fiiend is one of much humbler 
 pretensions. She has been a hired nurse. She 
 sought an employment for her living. Ha^dng 
 gained an appointment, she gave herself to her 
 duties. Filled with a sense of duty, she brought 
 all her faculties into exercise, without bustle, and 
 without parade. She did not think of reputation, 
 of gaining a character. She must have had system 
 and industry, for I always found her work was 
 done in proper season. Her fidehty, her tendemess- 
 her patience, were proved by the uniform satis- 
 faction shown by the sick under her care. One, 
 who saw her casually, might think her cold. Her 
 manners were always calm. She was never in a 
 hurry ; rarely, if ever, agitated. But the strength 
 and warmth of her feelings were shown by the 
 constancy and tenderness, with which she per- 
 formed the trying duties of her office ; hence 
 the confidence which was placed in her by her 
 patients. 
 
NOTES. 127 
 
 Miss Taylor is a small woman, but well propor- 
 tioned. She is not slender, and never showed 
 weakness, though not fitted for hard and heavy 
 labor. She is well formed ; but the contour is de- 
 rived entirely from the muscles, while there is 
 none of the rotundity caused by adipose matter 
 near the surface. Her face is thin, the features 
 well defined, her nose and chin distinctly promi- 
 nent, her eyes blue, decidedly handsome, and, 
 with her mouth, full of expression. Every- 
 thing about her shows calmness and composure of 
 mind. She uses few words, but they are apposite, 
 very definite, and are uttered distinctly. Though 
 she never shows any violence in her manners, she 
 manifests, at all times, so much firmness that, as I 
 suspect, she has rarely met with any resistance 
 from those under her control. I never heard that 
 any one complained of her. She seldom found 
 fault with others. I think if any unhappy and 
 captious individual in her ward had found fault 
 with her, all the other inmates of it would, at 
 once, have risen up in her defence. At one time 
 a very excellent and intelligent woman, whom I 
 had recommended for some years as a private, or 
 family nurse, became very sick, and was brought 
 to our hospital in a dreadful and helpless state. 
 
128 NOTES. 
 
 She was palsied, and had extensive bedsores at 
 the time of her admission, so as to be very offen- 
 sive. She retained her mental faculties, and was 
 well qualified to criticize a nurse. " Oh, sir," 
 she would exclaim to me, "you don't know, — 
 nobody knows, — what an excellent nurse and 
 what an excellent woman Becky Taylor is ! " 
 
 But I will stop. I have always known how 
 difficult the duty of a nurse is ; how much it re- 
 quires to make a good one. It has been my prac- 
 tice to praise and encourage every one, whom I 
 found capable of doing well. I have known many 
 good ones in private families. It is harder to per- 
 form well and faithfully the nursing in a hospital. 
 I have been describing one the most uniformly 
 faithful, fulfilling all her duties in the most fault- 
 less manner. I have loved many others, but I 
 have loved her the most. I avail myself gladly 
 of an opportunity to leave behind me this testi- 
 mony to her merits. Her best rewai'd is in her 
 own breast. She must know that she tried to do 
 her whole duty. It is for others to say how well 
 she succeeded. It may gratify her, in her retire- 
 ment, to read what I have written. I am happy 
 to know that she reciprocates my friendship. But 
 it is not to gratify her that I have done this. It 
 
NOTES. 129 
 
 is a pleasure to bear testimony in favor of one so 
 good. I cannot help hoping that it will be usefiil 
 to hold up such an example for imitation. And, 
 I will add, that, so far as my influence can go, I 
 wish to point out how high are the duties of a 
 nurse ; and how justly they entitle one, who per- 
 forms them skilfully and faithfully and kindly, to 
 the love and respect of mankind. 
 
NOTE IV. 
 
 mir. i>re!scott's ca.sk. 
 
 My Dear Mr. Ticknob, 
 
 You ask for a statement in respect to the 
 diseases, which affected our late friend, Mr. Pres- 
 cott. It would not be interesting to relate all the 
 ailments of his life, of which there was the usual 
 variety. His eyes suffered from accident at one 
 time, and, from disease at another ; and the injury 
 as to his sight had a great influence on his Hfe. 
 His days were ended by an affection of the 
 brain. 
 
 First, at an early age his eyesight was impaired 
 in such a degree, that one might have supposed 
 that he would at once have abandoned books. 
 Instead of this, he spent his days among them, 
 and became a distinguished scholar, and a distin- 
 guished writer. 
 
 In his boyhood Prescott was healthy and vigo- 
 rous. While a sophomore in our University at 
 Cambridge, there occurred a very pecuHar acci- 
 dent, by which he lost the sight of his left eye. 
 
 [180] 
 
NOTES. 131 
 
 There was a frolic among the undergraduates, in 
 tlie Commons-liall, after dinner, in which among 
 other things, they used crusts of bread as missiles. 
 One of these, thrown at random, but undoubtedly 
 with great force, struck Prescott upon the globe 
 of the open eye. If the person who threw it had 
 stood in front of him, his eyes would have taken 
 the alarm as the crust approached them, the lids 
 would have closed instantaneously, and then per- 
 haps the injury would have been less severe. But 
 it was not so. He was going out of the hall, but, 
 for some cause turned round suddenly with his 
 eyes open, and the crust, already on its way, met 
 his eye at the moment when he turned. From 
 careful inquiry on the day of the accident, I satis- 
 fied myself, that this was the mode of the occur- 
 rence, and that, with all the marvellous guards by 
 which the eyes are surrounded, one of his was left 
 exposed to a severe blow on its unprotected and 
 tense surface. The immediate effects were very 
 remarkable. They were such as attend a concus- 
 sion of the brain. His strength was immediately 
 prostrated, and vomiting took place. As soon as 
 could be, he was brought to his father's house in 
 town, where I saw him within two or three hours 
 of the accident. He was on the bed, not feeling 
 
132 NOTES. 
 
 able to sit up ; his face was pale and shrunk, and 
 his skin cool ; but his mind was calm and clear, so 
 that he gave a distinct account of the unfortunate 
 affair. Though the eye was not insensible to 
 light, its power of vision was lost. It did not 
 exhibit any external mark of severe injury, but it 
 seemed that the retina had been paralyzed by the 
 shock. There was, I think, pain in the eye and 
 in the whole head. His pulse was feeble, and his 
 temperature rather below than above that of health. 
 The case did not admit of any active treatment. 
 He was kept quiet, and every precaution taken 
 against irritation, or disturbance. Within a few 
 days, the system recovered from the shock, but the 
 eye never underwent any material change during 
 his subsequent life. He had one good eye left, 
 and all who knew him, know that it was bright 
 enough to give great animation to his expressive 
 countenance. 
 
 In due time, he returned to Cambridge, and 
 there pursued his studies through the usual course. 
 So far as I can recollect, he did not experience 
 any trouble in his right eye while at College, nor 
 subsequently, though his whole occupation was 
 over his books, until the period of which I have 
 next to speak. His general health during this 
 time was very good. 
 
NOTES. 133 
 
 On the 15th of January, 1815, he called on me 
 with an inflammation of his right eye. The in- 
 flammation was seated on the surface (the tunica 
 conjunctiva). He spoke of some pain in moving 
 the eye, which seemed more than is commonly 
 noticed in simple ophthalmia. I directed a satur- 
 nine lotion, and some leeches on the temple. 
 These remedies were employed that evening. 
 They seemed sufiicient for a recent attack, not 
 showing extreme violence at the time when I saw 
 it ; but during the night the pain in the eye be- 
 came very violent, and the next morning I found 
 the inflammation very seriously increased. The 
 tunica conjunctiva was very red, and greatly 
 swollen, so as to exhibit a chemom, the most 
 strongly marked which I ever witnessed before, 
 or since. The cornea had become opaque, and 
 the power of vision was entirely lost. His state 
 gave rise to the most serious apprehensions. To 
 himself, and even to his calm and philosophic 
 father, it seemed that every risk, except that of 
 life itself, must be incurred, to save him from per- 
 manent blindness. Such were my own feelings. 
 I retain at this distant day the most vivid recol- 
 lections of my apprehensions and solicitude in 
 regard to this young man, whom I had known 
 
134 NOTES. 
 
 from his childhood, and for whom I entertained 
 the highest regard. 
 
 I should have noted that on the morning of 
 January 16th, his pulse was hard and accelerated, 
 and his skin was very hot. On that day, I hied 
 him freely from the arm twice, purged him and 
 vesicated his neck. At evening, the pain had 
 ceased, but it returned with great severity during 
 the night. I called in consultation my friend Dr. 
 John C. Warren, on that day. For five days the 
 inflammation continued with great ftuy ; and dur- 
 ing this time he lost by general and local bleeding 
 more than seven pounds of blood, was purged 
 abundantly, was blistered freely, was kept in the 
 dark, and on the lowest diet ; also the vessels of 
 the conjunctiva were divided twice, with a view 
 to arrest the disease in the cornea. This part 
 mended during these five days, but the aqueous 
 humor became turbid. On the sixth day the 
 disease was yielding in all parts, and on the 
 seventh it had greatly subsided. The cornea and 
 aqueous humor were very soon restored to their 
 usual transparency ; but the powers of vision were 
 scarcely mended, owing as we presumed, to an 
 affection of the retina. 
 
 Thus far, nothing had appeared except an in- 
 
NOTES. 135 
 
 flammation in the eye, changing rapidly from one 
 tissue to another ; this inflammation being ex- 
 tremely violent, notwithstanding the most vigorous 
 treatment. An inflammation so violent, was, of 
 course, attended by strong constitutional symp- 
 toms. I ought to note that the iris escaped the 
 disease, so far as we could judge in a dark room 
 and with an opaque cornea. On the sixth day 
 of the disease our apprehensions were greatly 
 abated ; the eye was in every respect better except 
 as to the vision, and we promised ourselves an 
 amendment in this respect also. On the morning 
 of the seventh day, also, everything seemed favor- 
 able ; but before night. Judge Prescott called on 
 me to announce a new trouble. He said that a 
 pain had come in the right knee, which was on 
 the increase, and was attended by some redness 
 and swelhng. To Mr. Prescott's surprise, I in- 
 stantly replied, that I was very happy to hear it. 
 Thus far, we had not had any occasion to regard 
 the disease as diflerent, in its nature, from common 
 inflammation ; but now it flashed on me that the 
 inflammation was rheumatic. 
 
 I must take the liberty to state the grounds, on 
 which I came to this sudden conclusion. It had 
 long been known that in some cases of acute 
 
136 NOTES. 
 
 rheumatism, (or rhemnatic fever, as it was most 
 commonly called,) the disease was not limited 
 entirely to the various tissues about the joints and 
 muscles, but that it likewise affected the different 
 tissues of the heart and the lungs. But it was 
 not known to me that any one had ever believed 
 that it affected also the tissues of the eyes, unless 
 perhaps the muscles appertaining to them. I had, 
 however, been satisfied that such an affection of 
 the eyes sometimes took place. I had seen some 
 cases, of which one was very clearly marked, in 
 which the ophthalmia was rheumatic in its charac- 
 ter. In acute rheumatism we find the different 
 joints, or different muscles, affected in succession, 
 sometimes two or more parts at once. Now in 
 cases, which had occurred before that of our friend, 
 I had seen the same change of the inflammation 
 fi'om the joints to one, or both eyes ; and again 
 fi:om the eyes to some joint. I had also known 
 the eyes to be attacked more than once during 
 the same case, just as an elbow, or a knee may be 
 affected more than once. I had not therefore any 
 doubt that the eye, as well as the heart, was 
 subject to rheumatic inflammation. I had not, 
 however, been able to find in the books any record 
 of similar observations. Let it here be noted that 
 
NOTES. 137 
 
 I refer to acute rheumatism. An affection of the 
 eye in chronic rheumatism, especially of the tunica 
 sale: utiva, had been observed by different persons. 
 The observations on this affection were scattered, 
 and were not, I believe, at all familiar to prac- 
 titioners at the time I refer to, viz : in 1815. At 
 the present day, the chronic disease has been 
 mentioned by many writers ; though I doubt 
 whether it is now very well known. I find also 
 the bare recognition of an affection of the eye in 
 acute rheumatism in Le Dictionnaire des Sciences 
 Medicales, 48th volume, page 648. This volume 
 was published in Paris in the year 1820. In 
 1816, when I published my paper, from which I 
 shall give a quotation, I had looked in vain among 
 all the medical works within my reach for any 
 recognition of such a case. In the volume above 
 mentioned of the French Dictionary, the affection 
 of the eye in chronic rheumatism is fully discus- 
 sed, while its occurrence in the acute disease is 
 mentioned in two lines only. It is certainly very 
 remarkable, that, when I stated my opinion on 
 Mr. Prescott's case to my friend Warren, he at 
 once confirmed it fi-om his own experience. He 
 related the instances, in which he had seen the 
 same thing, giving the names of the parties, as I 
 12 
 
138 NOTES. 
 
 did to him those of my patients. In the New 
 England Journal of Medicine and Surgery for 
 April, 1816, both of us Subsequently published 
 observations on this point. 
 
 You may now understand why I was rejoiced 
 to hear from Judge Prescott that his son's knee 
 had become affected with acute rheumatism. This 
 was not because I regarded rheumatic inflamma- 
 tion of the eyes as a slight disease, but because I 
 thought it less likely to be destructive than com- 
 mon inflammation of so severe a character, as we 
 had witnessed in this instance. 
 
 " From this period the disease manifested the 
 common symptoms of acute rheumatism, affecting 
 the large joints of the lower extremities for the 
 most pai't, and occasionally the neck and loins. 
 It continued to renew its attacks with severity for 
 three months, although there was in this time one 
 interval of a month, in which the disease appeared 
 to be subsiding. The eye had two attacks during 
 these three months, the disease leaving the limbs 
 and returning to them again as the eye recovered. 
 The second attack was short but severe, though 
 less so than the first. The third was less severe, 
 but longer. In each of them the blindness was 
 perfect ; and in each the disease affected first the 
 
NOTES. 139 
 
 tunica conjunctiva, then the cornea, then the 
 aqueous humor. In one instance the crystalline 
 humor was opaque for a day or two. The changes 
 of structure took place suddenly and subsided sud- 
 denly, as happens in respect to the swelling of the 
 joints in this disease. 
 
 " When the eye was attacked the second time, 
 blood was drawn from the arm, and in each attack 
 leeches were applied liberally." Vesication was 
 employed almost constantly about the head and 
 on the hmbs. Antimonials were given very freely 
 both before and after the real nature of the disease 
 was manifested , — opium was exhibited p. r. n. — 
 and in the course of the disease cinchona was 
 tried very fully. The strength of the patient was 
 less reduced than might be expected from the 
 evacuations made, and he was never so much pros- 
 trated as is common in acute rheumatism. Great 
 care was taken in the use of both food and medi- 
 cine not to get the stomach into the irritable state 
 so common in this disease; and although the appe- 
 tite was lost in the early stage, that organ never 
 lost its tone, and nothing like dyspepsia took place 
 at any period. 
 
 " The joints of the upper extremities were al- 
 most exempted from disease ; but those of the 
 
140 NOTES. 
 
 lower extremities (the knees and ankles) were so 
 severely affected, that the patient was unable to 
 walk a step from the first attack until about the 
 1st of May. During perhaps the largest part of 
 this time he had very little pain when at rest. 
 
 " The power of vision in the rheumatic eye was 
 never restored perfectly ; but the precise state of 
 it was not ascertained until April, when for the 
 first time the light was admitted freely into the 
 patient's apartment. He then found that there 
 was frequently occurring an appearance of some- 
 thing like the body of a spider, with two wings, 
 passing over his eye at the upper part of the pupil. 
 As there was not any mark of injury in the cor- 
 nea, nor of change in the humors, this appearance 
 was attributed to an affection of the retina. This 
 opinion was confirmed by the consideration that 
 the power of vision was restored very slowly after 
 each attack, although the opacities had subsided 
 suddenly and rapidly; and by the statement of 
 the patient that he had frequently noticed this 
 appearance before he mentioned it, and while the 
 room was darkened, but that he thought it was 
 owing to the defect of fight in the room. 
 
 " In the latter part of April and in May electri- 
 cal shocks were appfied to the head three times a 
 
NOTES. 141 
 
 day. Also mercurials were used moderately — 
 one grain of Calomel every night. The eye re- 
 covered partially, hut not entirely. 
 
 " Mr. P.'s mother has heen very often, and at 
 times severely, affected with rheumatism. Two 
 gentlemen, cousins of hers, have been nearly crip- 
 pled for many years with the same disease, and 
 their eyes have been so much affected, as to have 
 rendered them nearly blind. This affection of the 
 eyes has evidently been connected with the dis- 
 ease in the limbs." 
 
 The foregoing account is derived mostly from 
 the article referred to above in the New England 
 Journal of Medicine and Surgery, Vol. 5th, p. 
 140, the latter part being a literal copy from that 
 article. I will close the history as brieiiy as I 
 can. In the summer of 1815, Mr. Prescott went 
 to England, and afterwards travelled on the Con- 
 tinent through France, &c. One of his objects 
 was to consult experienced oculists abroad re- 
 specting his eyes, with the hope of doing some- 
 thing to help his vision. At that time. Sir Wm. 
 Adams was in great repute in London as an 
 ocuhst, in consequence of having been very suc- 
 cessful in the treatment of purulent ophthalmia. 
 I presume that he was so, but I believe that he 
 
142 NOTES. 
 
 was not so well prepared to meet all the diseases 
 of the eye, as some of his cotemporaries in the 
 English metropolis. Mr. Prescott placed himself 
 under the care of this gentleman. So far as I 
 could discover, he seemed never to have entered 
 into the question of the rheumatic character of 
 the disease in the right eye. He probably thought 
 that this was founded on a mere hypothesis ; 
 although the history of the case, fairly viewed, 
 scarcely admitted any other explanation. Before 
 Mr. P. left this coimtry, I felt assured that his 
 case was not to be influenced by any active, or 
 heroic treatment. Unfortunately, I think, Sir 
 William took a different view of it, and kept his 
 patient for a long time under the use of blue-pill, 
 and saline cathartics in large doses. These were 
 employed not only while Mr. P. remained in 
 London, but subsequently on the continent ; that 
 is, for several months. I rather think that this 
 treatment was sanctioned by some surgeon in 
 Paris. However sanctioned, I consider it certain 
 that the eye was not made better by this active 
 treatment, and that the intestinal canal was 
 materially injured by it ; so much so that his 
 health, through his whole subsequent life, was 
 permanently aifected in consequence of it. 
 
NOTES. 143 
 
 I should not have written these lines of censure, 
 if this case, principally on account of the celebrity 
 of its subject, though partly because it is an un- 
 common one,, had not engaged the attention of 
 many medical men. I am the more ready to go 
 so far, because it opens the way to some remarks 
 on the treatment I myself pursued at the com- 
 mencement of the attack on the right eye. Those 
 who agree with me in my objections to Sir Wil- 
 liam's treatment, may say that mine, at the time 
 referred to, was equally worthy of censure. Let 
 me then recall the circumstances. When the 
 disease began, I had not any reason to suspect 
 that the inflammation was rheumatic. It is true 
 that I had learned that the eye was susceptible 
 of rheumatic inflammation, but this was to be 
 known only when it occurred in connection with 
 rheumatism in its common seats, in the trunk, or 
 limbs. I had never known the disease to make 
 its JJrst attack upon the eye. I may add that I 
 have not known such an instance in the forty- 
 four years which have passed since that period ; 
 nor have I heard of any such having been seen 
 by others. At a later period I heard that, when 
 young men, two cousins of Mr. P. *s mother 
 had had rheumatic inflammation of the eyes, and 
 
Hi NOTES. 
 
 that one of them had gradually become nearly 
 blind. But of these I had not heard when Mr. 
 P. was sick ; nor, as I believe, were the cases 
 understood at the time when they occurred. I 
 gathered the histories afterwards, and then made 
 the inference as to their true character. 
 
 It is then to be remembered that the profiise 
 bleeding was practised on a young and healthy 
 man, who had a most violent inflammation of his 
 only good eye, such as threatened destruction to 
 the delicate tissues of that organ. This evil did 
 not occur, although the eye was permanently in- 
 jured. I am now fully satisfied that the treat> 
 ment I adopted was not beneficial. Possibly it 
 prevented still farther mischief to the eye ; but I 
 think it did not, because it did not check the 
 disease of the whole system. The result was 
 certainly unfavorable to the treatment of acute 
 rheumatism by bleeding, a treatment of which I 
 had not thought favorably before. I suspect that 
 there never was a case, in which so much blood 
 was abstracted in the first five days of that dis- 
 ease, as in this. And what was the result ? The 
 disease was greater in its violence, and in its 
 duration, than it is in the average of cases. 
 
 I will close the history of the disease in the 
 
NOTES. 145 
 
 right eye by saying that it had diminished so 
 much that he could make some use of it before 
 he went to Europe in 1815 ; although as a matter 
 of precaution he abstained from any great use of 
 it in reading, or writing. There was not any 
 opacity, and undoubtedly the permanent difficulty 
 was mainly, if not entirely, in the retina. In 
 subsequent years he regained the power to use it 
 in some measure, but it always remained greatly 
 impaired. He studied very thoroughly and sys- 
 tematically the influence of everything operating 
 on the organ of vision and was veiy ingenious in 
 contrivances as to the best mode of using light, 
 and of doing without it. You will probably be 
 led to mention some of these in your history of 
 his life. 
 
 From the time of Mr. Prescott's return from 
 his travels abroad, his pursuits were altogether 
 literary, and of course most of his time was passed 
 in his library. He never engaged in active busi- 
 ness of any kind. He was however very uniform 
 in taking exercise in the open air, mostly in walk- 
 ing, but at some periods on horseback. Though 
 diligent in his studies, he did not abstain from 
 social intercourse. His disposition would have 
 forbidden this, and his company was so much 
 13 
 
146 NOTES. 
 
 coveted, that it would have been veiy diiBcult for 
 him to have done so. He never passed his sum- 
 mers in the city. He valued good health, and 
 he succeeded in maintaining it in a certain degree. 
 The transient observer might have considered him 
 as very healthy, so bright was his countenance, 
 and so cheery was his temper. He was however 
 hable to dyspeptic troubles, more or less, and the 
 functions of the colon were performed very slug- 
 gishly, from causes I have referred to. But, so 
 far as I can recollect, he never had any serious 
 disease, by which he was confined to the house, 
 until the occurrence of the disease in his head. 
 This was on the fourth of February, 1858. For 
 a year, or more, he had been annoyed by head- 
 ache more frequently than usual, and this had 
 sometimes been quite severe. He had likewise 
 had frequent flushings of the face, sometimes 
 amounting to an unusual redness, through a great 
 part of the day. He mentioned these things to 
 me, and on two or three occasions called mv 
 attention to them in an especial manner. But 
 they rarely inteiTupted his habitual labors, and 
 did not materially interfere with the common 
 bodily functions. I did not regard the complaints 
 as trivial, yet they did not seem to demand the aid 
 
NOTES. 147 
 
 of medicine, and I advised only the precautions 
 as to diet and regimen, which would naturally 
 suggest themselves. On the fourth of Feb. 1858, 
 I was summoned to him in haste, when I found 
 him on his couch, and heard the following story. 
 
 He had not appeared well the evening of the 
 preceding day. He then complained of head- 
 ache, and of numbness in his right leg. He was 
 heavy and sleepy. His wife read to him some- 
 thing sufficiently agreeable, but he did not take an 
 interest in it ; he was so sleepy that she stopped 
 reading. He attempted to write a note, not on 
 any complicated affair, but gave it up, because he 
 became confused. The next morning he said that 
 he was sensible of something unusual the preced- 
 ing evening, that his mind was in some way over- 
 come, and especially that he could not remember 
 names. None of these things arrested great atten- 
 tion at the time, as he was able to rouse himself, 
 and then seemed well enough. On referring to 
 these things in the morning he seemed depressed 
 in his spirits. But after a while he became bright 
 and cheerful, and pursued his usual course. At 
 the accustomed hour he went to walk, but on his 
 return he showed some uneasiness at not finding 
 Mrs. Prescott at home. The maid-servant noted 
 
148 
 
 NOTES. 
 
 that he did not appear well, and was led to render 
 him unusual attentions. He went up stairs, and 
 ordering some articles to be brought to him as a 
 lunch. He subsequently said, that before reaching 
 his library, he felt some failure in his legs, es- 
 pecially in mounting the last few stairs. When 
 the maid entered his room, soon afterwards, she 
 found him looking uncomfortably, and he ex- 
 pressed to her a feeling of uneasiness, and begged 
 her to go for Mrs. Prescott, who was in a neigh- 
 boring house. On her arrival Mrs. Prescott was 
 satisfied that he had some real malady, and feared 
 it was a paralysis. She got him on a couch and 
 sent for me. This was about 2, p. M. On my 
 arrival, he was on the couch, but not quite pros- 
 trate ; his head was raised up, and he was looking 
 round with an unnatural expression of counte- 
 nance, and seeming to be bewildered ; yet he evi- 
 dently knew those about him. He attempted to- 
 speak, but was unable to command words, and his 
 utterance was very imperfect and indistinct. He 
 seemed, however, to understand in some measure 
 what was said to him, and complied, as to his 
 movements, with our requests. He was able to 
 move all his limbs, but the command of his right 
 hand and arm was evidently not so perfect, as that 
 
NOTES. 149 
 
 of the other limbs. He had some retching and 
 nausea. He had complained that he was weary, 
 and had had some twitching of the limbs. He 
 was not flushed ; his respiration was not labored, 
 though it had the irregularity attending emotion 
 of the mind, and his pulse was nearly normal. I 
 had him placed on a bed, after removing his su- 
 perfluous dress, and after a little deliberation I 
 decided not to bleed him, but to administer Ipecac 
 as an emetic. He took three doses of the powder, 
 a scruple each, and after a long interval he vomited 
 rather copiously. He did not throw off" any food, 
 but only the liquids of the stomach, with some 
 bile. The strong excitement of the stomach 
 seemed evidently to be salutary. Almost imme- 
 diately after it he got a better use of the organs 
 of speech, and his mind became more clear. He 
 mended during the evening, and his night was 
 tranquil. 
 
 The next morning I found him in a state com- 
 paratively comfortable, up and dressed. Generally 
 his senses and intelligence were satisfactory, but 
 his eyesight was more than usually imperfect. 
 In attempting to read, he said the words became 
 confused, and especially he noted that some one or 
 more of the words would drop down from one line 
 
150 NOTES. 
 
 to a lower one. This difficulty continued for 
 many weeks, but gradually diminished. By de- 
 grees, he seemed capable of bringing up the word 
 which had fallen out of its place, and sometimes 
 instead of a whole word, one letter only would 
 fall down. On the same day, or soon after, he 
 noticed some peculiar spectra, and these continued 
 to return for many days. They would appear 
 while he was wide awake, in full day-hght, and 
 with his friends about him. Principally he noted 
 that certain gentlemen, neatly dressed in black, 
 would march round the room in regular order, 
 and gradually slide out of sight. He would say, 
 " There go my gentlemen," or words to that 
 efFect. 
 
 To the common musece volitantes he had been 
 accustomed from the period of his rheumatic fever, 
 under some varieties of form. These continued 
 and increased somewhat. On the 5th of Feb- 
 ruary, the morning after his attack, he inquired 
 into and discussed the history and nature of his 
 disease, telling us all that he could recollect of it. 
 He was never satisfied, when at all unwell, with- 
 out the most full explanation of his symptoms. I 
 did not attempt to hide from him the true char- 
 acter of his present disease ; on the contrary, I 
 
NOTES. 151 
 
 wished him to be sensible of it, that he might 
 know how strong were the inducements to comply 
 with my prescriptions. I told him that his disease 
 was apoplexy, though very slight in degree, and 
 that a repetition of it was to be feared. I ex- 
 plained to him the advantage of placing his reli- 
 ance on diet and regimen, rather than on drugs 
 and medical treatment. Especially, I stated the 
 benefit from an entire abstinence from animal 
 food. I also advised an abstinence from vinous 
 and spirituous liquors. He entered into my plan 
 with great readiness and adhered to it very stead- 
 ily. He also, at my suggestion, gave up his 
 books and his pen, and avoided all intellectual 
 efforts and all moral excitements. 
 
 He very soon got abroad, and he returned grad- 
 ually to his accustomed walks, and cautiously 
 resumed a pleasant intercourse with his friends. 
 Such, however, were his habits of industry that 
 the time hung heavily on his hands, so that in 
 three months after his attack, I advised him to 
 resume his studies, provided that this should be 
 done in a very moderate and gradual manner. 
 Subsequently, he had the little variations in his 
 feehngs common to all men, whose vigor is in any 
 measure impaired. But on the whole, his health 
 
152 NOTES. 
 
 was getting more perfect, through the succeeding 
 summer and autumn. When he returned from 
 the country in November, his appearance was very- 
 satisfactory. The flushing of his face had disap- 
 peared, and his headaches had very much dimin- 
 ished, from the period of his sickness in February. 
 His muscular strength was very good, though not 
 quite so great as in the preceding years. His 
 walks amounted to four or five miles a day. He 
 had gone through much literary labor, and in 
 December he brought out the third volume of 
 Philip the Second. We were greatly encouraged. 
 He was not free from headache, and occasionally 
 spoke of some unfavorable symptoms ; but he was 
 on the watch for such, though he maintained a 
 cheerful spirit. He never recovered fully the 
 hilarity, for which he had been so much distin- 
 guished during his life, and perhaps his mind was 
 less rapid in its operations than formerly. But, 
 if not hurried, his intellect was equal to its accus- 
 tomed tasks, and I believe that the most exact 
 critic would not discover in the printed sheets any 
 evidence that its author was incapable of what he 
 had imdertaken. He distrusted himself at times, 
 btu he could not show that he had made any real 
 false step. 
 
NOTES. 153 
 
 After the publication of his last volume, Mr. 
 Prescott allowed himself a little vacation before 
 entering on a new task. During this time he 
 learnt with how much pleasure and delight the 
 new volume had been received and criticized by 
 those, who were most competent to estimate its 
 merits. But, after a few weeks, he began to look 
 with feelings of pleasure to the renewal of his 
 studies, and on the morning of the 28th of Jan- 
 uary last, he stated to his wife that it was time 
 for him to begin, and that he felt prepared. On 
 that very day, about noon, the great change oc- 
 curred. He was for the moment alone, in a 
 closet, when his faithful secretary heard an un- 
 usual sound there. He went to him immediately, 
 and found him in a state of complete apoplexy. 
 He was entirely insensible, he performed no vol- 
 untary motion, and his respiration soon, if not at 
 first, became stertorous. His whole face was 
 changed ; his features were altered ; all influence 
 of the mind upon them had ceased. He continued 
 in this state between two or three hours, and then 
 expired, surrounded by those he most loved. With 
 what feelings the result was witnessed by them, 
 and what impression it made on the community 
 as the news was spread abroad, how every one 
 
154 NOTES. 
 
 felt the great void that was left, it belongs to you, 
 my dear sir, to tell. Allow me a few remarks on 
 the case as viewed medically. 
 
 It would perhaps have been sufficient, my dear 
 Mr. Ticknor, if I had confined mj'-self to a brief 
 and plain statement of the morbid affections which 
 occurred in our lamented friend ; — of the imper- 
 fect vision, apparently an obstacle to all literary 
 pursuits, but which did not prevent the most ex- 
 tensive researches, and the most minute scrutiny 
 in the fields of learning ; — and of the lesion of 
 the brain, ultimately of the fatal affection of that 
 organ, by which in an instant a mind so enlarged, 
 so powerful, so comprehensive, so splendid in its 
 manifestations, so adorned by moral beauty, — by 
 which, in one instant this mind, — not one last 
 look allowed even for those most tenderly beloved, 
 — was at once separated from all that is earthly. 
 But let me not seem to lament the mode of his 
 death, by which it would almost seem as if a kind 
 Providence had granted his repeated prayer; by 
 which he was saved the pangs of a separation he 
 dreaded to meet. 
 
 I have allowed myself to go out of my path. 
 I meant only to apologize for the length and mi- 
 nuteness of detail, in which I have indulged 
 
NOTES. 155 
 
 myself, and of the discussion even of the propriety 
 of the treatment adopted in Mr. Prescott's case. 
 I .know it is more than most readers will care for. 
 1 hope, therefore, that you will put this letter into 
 an appendix, where it may be found by those, who 
 desire to see it. I could not write it without 
 realizing that medical men, as well as others, 
 would be interested in the life of Mr. Prescott, 
 and I wished to give them satisfaction as regards 
 the details of his case, viewed professionally. It 
 is, in reahty, very interesting as a medical case. 
 And now, for them, I wish to add a few more 
 words ; such, I mean, as relate to the treatment 
 after the first apoplectic attack. 
 
 I have elsewhere* given to professional readers 
 my views on the importance of diet in warding 
 off a second attack of paralysis ; such attacks as 
 are very commonly due to sudden hemorrhages 
 within the cranium. These hemorrhages cause 
 perfect apoplexy when they arrive at a certain 
 amount, but when more slight, they cause paraly- 
 sis only. My experience has led me gradually to 
 the belief that the risk of a recurrence of the 
 hemorrhage may be much diminished by entire 
 
 * Letters to a Young Physician. 
 
156 NOTES. 
 
 abstinence from animal food. I do not, in every 
 case, regard an entire abstinence from diffusible 
 stimulants so essential, as the abstinence from the 
 food in which nitrogen most abounds. In various 
 instances I have adopted this practice with favor- 
 able results, and among them were men very near 
 and dear to me. 1 did indulge a strong hope in 
 the case of our friend, that I should be gratified 
 with a like result, though I never supposed that 
 the same could happen in every instance. I was 
 able to inftise into his mind much of the same 
 hope. I have suffered a most grievous disappoint- 
 ment. But I trust one failure, though in a very 
 memorable case, will not deter my brethren from 
 a trial of the same mode of treatment. More ex- 
 perience is required to decide its merits. But, let 
 it be noted, it is not attended by the hazards of a 
 powerful drug. 
 
 I am, my dear Sir, 
 
 Very sincerely, your friend, 
 
 James Jackson. 
 Oeoboe Ticesor, Esq. 
 
 Hamilton Place, June 1st, 1859. 
 
MEMOIR 
 
 ON THE 
 
 LAST SICKNESS OF 
 
 GENERAL WASHINGTON 
 
 AND ITS 
 
 TREATMENT BY THE ATTENDANT PHYSICIANS. 
 
MEMOIR. 
 
 The death of General Washington took place 
 unexpectedly after an illness of less than forty- 
 eight hours. He was in his sixty-eighth year, 
 but had not begun to show much of the infirmi- 
 ties of age. Under the exposures of the active 
 period of his life, and again shortly after he had 
 engaged in the heavy cares and responsibilities of 
 office in 1789, he had undergone severe acute 
 diseases ; but it does not appear that he had been 
 suffering under any wearing or wasting chronic 
 malady. His faithful biographer, Mr. Sparks, 
 says of him, that " Since his retirement fi-om the 
 presidency, his health had been remarkably good ; 
 and although age had not come without its infir- 
 mities, yet he was able to endure fatigue, and 
 make exertions of body and mind with scarcely 
 less ease and activity than he had done in the 
 prime of his strength." * Such being the case, 
 the circumstances of his short disease, its character 
 
 ♦ Sparks's Life of Washington, p. 528. 
 
 [159] 
 
160 MEMOIR ON THE LAST SICKNESS 
 
 "viewed scientifically, and the treatment adopted 
 by his physicians, have all been ascertained and 
 discussed ; and the remedies employed have been 
 spoken of by some persons in terms of strong ap- 
 probation. 
 
 We derive the only original account of his 
 disease from a statement made out by Colonel 
 Lear within twenty-four hours after his decease, 
 with an attestation to the correctness of this 
 account made at the time, " so far as he could 
 recollect," by his excellent friend and physician, 
 Dr. Craik. This account has the appearance of 
 accuracy and fidelity. It is consistent with itself, 
 and accords with what is now known to belong 
 to the disease, which cut short the days of this 
 great man. 
 
 On the 12th of December, 1799, he was abroad 
 on his farms, on horseback, from 10 o'clock, a. m. 
 to 3, p. M. ; and " soon after he went out the 
 weather became very bad ; rain, hail, and snow 
 falhng alternately, with a cold wind." To the 
 watchful eyes of his family there were no appear- 
 ances of disease, though they looked for them, 
 until the next day. He then complained of a 
 sore throat, and it became evident that he had 
 taken cold ; " he had a hoarseness, which in- 
 
OF GENERAL WASHINGTON. 161 
 
 creased in the evening ; but he made light of it." 
 So far from feeling anything like serious illness 
 on this 13th of December, he seems to have been 
 kept from " riding out, as usual," only by a snow- 
 storm. In the afternoon he went out of the house 
 to look after some work, which was not of an 
 urgent character. He passed his evening as usual, 
 and did not seem to be aware that his cold was 
 uncommonly severe. When Colonel Lear pro- 
 posed at bedtime that he should take " something 
 to remove his cold," he answered, " No, you know 
 I never take anything for a cold ; let it go as 
 it came." 
 
 It was in this night that his sickness arrested 
 his attention. He was taken with an ague, and, 
 between two and three o'clock on Saturday morn- 
 ing, (the 14th,) he awoke Mrs. Washington and 
 told her that he was very unwell. He then had 
 great difficulty in breathing,.speaking and swallow- 
 ing. These are the symptoms which are charac- 
 teristics, the essential characteristics, of his disease. 
 They continued till his death, which took place 
 between 10 and 11 o'clock in the following night. 
 There seem to have been some hours during which 
 he did not swallow anything, in consequence of 
 the distress attending any effort to do it. It was 
 U 
 
162 MEMOIR ON THE LAST SICKNESS 
 
 also SO difficult to speak, that he did that only 
 when he thought it important, and as briefly as 
 was consistent with his habitual care to be distinct 
 and definite in his expressions. It was the breath- 
 ing, however, which caused him most distress. In 
 regard to that the patient cannot choose, as he 
 can in respect to speaking and swallowing. The 
 efibrts, which he was compelled to make in breath- 
 ing, were extremely distressing, and occasioned 
 great restlessness ; — the more because his strong- 
 est efforts were insufficient to supply his lungs 
 with as much air as his system had need of. It 
 was from the inability to do this that death en- 
 sued. He was in fact strangulated by the closure 
 of the windpipe, as much as if a tight cord had 
 been twisted around his neck. His intellect re- 
 mained unclouded, and it is needless to say that 
 he showed to the last those strong and great 
 characteristics of mind and heart, by which his 
 whole life had been marked. 
 
 What was this disease which cut down a strong 
 man in so short a time ? It was such as has cut 
 down very many, no doubt, in times past ; but 
 it is a rare disease. It had not, at the time of 
 Washington's death, been clearly described, so as 
 to be distinguished from other diseases about the 
 
OF GENERAL WASHINGTON. 163 
 
 throat. It is now well known under the name of 
 acute laryngitis ; — inflammation of the larynx, — 
 the upper part of the windpipe. It was about 
 1810 that this morbid affection was first brought 
 into notice and distinctly described by Dr. Mat- 
 thew Baillie, of London, confessedly, while he 
 lived, at the head of his profession in that great 
 city. He published two cases seen by himself, 
 both of them within a short period, both in medi- 
 cal men, and one of these a very dear friend of 
 his. To these cases he added a third reported to 
 him by a practitioner in London, which was evi- 
 dently like the other two. He ascertained the 
 morbid changes, by which these persons had been 
 suddenly deprived of hfe, by examinations after 
 death. It was ascertained by these examinations, 
 as it has been by many made since in similar 
 cases, that the disease consists in an inflammation 
 in the mucous membrane of the whole larynx, in- 
 cluding the epiglottis ; but that this inflanunation 
 is not limited to the mucous membrane. It ex- 
 tends to the cellular membrane subjacent to the 
 other, indeed to all the soft parts, including the 
 muscles ; and perhaps, in some degree, to the 
 cartilages. From these morbid changes the epi- 
 glottis is disabled from the free and ready motion 
 
164 MEMOIR ON THE LAST SICKNESS 
 
 essential to its office, which is that of guarding 
 the windpipe from the admission of substances 
 passing through the phaiynx. Hence one of the 
 difficulties in swallowing ; probably the greatest. 
 In such a state the attempt to swallow any sub- 
 stance, liquid or soUd, would be attended by an 
 instinctive effort of the epiglottis to shut up the 
 larynx, as it always does in health during the act 
 of swallowing. But this instinctive effort must 
 cost great pain ; and it is an effort which could 
 not succeed in the most severe state of the disease. 
 Thus the principal difficulty in swallowing is ex- 
 plained. Another difficulty in swallowing arises 
 from the state of the pharynx. The inflammation 
 of the larynx passing over its posterior part, in some 
 if not all cases, spreads to the pharynx, and dis- 
 ables that part from performing its office in carry- 
 ing down the liquids or solids brought to it. 
 
 Just below the entrance to the laiynx we find 
 the delicate structures belonging to the organ of 
 the voice, and here is the narrowest part of the 
 air tube. In these parts, a common acute inflam- 
 mation of their mucous membrane will cause sore- 
 ness and hoarseness ; but when the disease extends 
 to the subjacent cellular membrane, so that all 
 these parts are thickened by the distension of 
 
OF GENERAL WASHINGTON. 165 
 
 the small bloodvessels, and the more if there 
 take place an effusion of any fluid into this cellu- 
 lar membrane, it is seen at once how these soft 
 parts must be swollen. Now this swelling occa- 
 sions a difficulty, if not an impossibility, of motion 
 in the delicate parts belonging to the organ of 
 the voice, and accounts for the difficulty and at 
 length the impossibihty of speaking. At the same 
 time we see how the passage of the air is im- 
 peded, and at last entirely obstructed, producing 
 the difficulty of breathing and at length the stran- 
 gulation. 
 
 Thus this disease, so suddenly destructive of 
 life, is among the most simple in its nature. One 
 readily understands that his fingers may be in- 
 flamed, that is, become red, swollen, indurated 
 in all the soft parts, and painful, to such a degree 
 as to make motion in them very difficult and at 
 length impossible. But all this may take place 
 without interfering with functions important to 
 life. But let the organs by which the voice 
 is formed and through which the air must be 
 passed for the supply of the lungs, — the organs 
 through which the breath of life must have an 
 open road, — let these organs be swollen and 
 rigid so as to block up this passage, and we 
 
166 MEMOIK ON THE LAST SICKNESS 
 
 readily comprehend that life may be arrested 
 in young or old, in the strong as well as in the 
 feeble, in a very short space of time. It follows 
 that the only question in a disease of this kind, 
 as it occurs in adults, is whether we can prevent 
 or remove the fatal obstruction, which has been 
 described as characteristic of this disease. 
 
 There are, however, some further remarks to 
 be made on the disease, before discussing the 
 treatment of it. Any one conversant with the 
 subject will see at once how much acute laryngi- 
 tis resembles the common affection, which we all 
 know as a sore throat from a cold. Though 
 the words a cold are employed with reference 
 to any disease, which is thought to arise from 
 an exposure to a change of temperature, or to 
 cold and damp weather, they are most commonly 
 used in reference to an attack in the nose, or in 
 the windpipe. These are called colds in the head, 
 or colds in the throat. The cold in the throat 
 is marked by a sense of slight soreness in that 
 part, especially felt in deglutition and in cough- 
 ing, and by hoarseness in the voice. Some cough 
 soon follows and presently an expectoration of 
 matter, at first watery and afterwards thick and 
 glutinous, and more or less opaque. In these 
 
OF GENERAL WASHINGTON. 167 
 
 cases there is an inflammation of the mucous 
 membrane of the larynx. The disease may begin 
 in the nasal passages, when it is commonly called 
 a cold in the head, or a nasal catarrh ; and this 
 does most frequently take place first ; but which- 
 ever part is affected first, the inflammation may 
 extend firom this to the other. Further, when 
 the larynx is affected, the inflammation may also 
 pass downward to the bronchi, which are the 
 ramifications of the windpipe in the lungs. Then 
 the disease gets the name of pulmonaiy catan-h, 
 or bronchitis. 
 
 To one who understands the above statement, 
 it will be plain that the cold in the throat, when 
 there take place soreness in the throat, hoarse- 
 ness, a slight difficulty in deglutition, and more 
 or less cough, — in other words, a hoarse sore 
 throat, is the same thing as the acute laryngitis. 
 It is assuredly the same thing, except in degree. 
 In the disease first described, the laryngitis, the 
 inflammation is more severe, and it is not con- 
 fined to the mucous membrane, but extends to tlie 
 other tissues. The mucous membrane may be 
 called an internal skin ; and like the skin it is 
 connected with other parts by a cellular mem- 
 brane. Now if the skin be inflamed in its ex- 
 
168 MEMOIR ON THE LAST SICKNESS 
 
 temal surface only, in one man, and in another 
 an inflammation of the skin should pass through 
 it into the subjacent cellular membrane, the swell- 
 ing would be much more in this last case than 
 in the first. The greater swelling in the second 
 case would be attended with more general' affec- 
 tion of the system than would occur in the first 
 one. So &r the difference between the common 
 affection of the larynx, in ordinaiy colds, and 
 that in the severe disease under consideration, 
 is illustrated by the supposed inflammation in 
 the skin in the two men. But there is one great 
 difference. The swelling of the skin is not pro- 
 ductive of any serious inconvenience ; not so in 
 the larynx. That is the tube through which the 
 air passes to the lungs in respiration, and in one 
 part the passage is very narrow. In this part 
 the swelling must occupy the calibre of the tube ; 
 in fatal cases it fiUs up the air passage ; and the 
 effect of this is the same as if a cord were tied 
 very tightly around the neck. As the passage 
 is filling up, the air passes with more and more 
 difiiculty, and at last it cannot pass at all. Even 
 this, however, does not state quite the whole. 
 In the last hours of life, the lungs do not get 
 air enough to produce the requisite change in 
 
OF GENERAL WASHINGTON. 169 
 
 the blood ; and likewise the carbonic acid gas, 
 which is an excretion from the blood, and is 
 usually discharged at once from the lungs, is 
 retained in some measure and acts as a poison. 
 From this imperfect renewal of the blood, if we 
 may use the expression, arises the livid counte- 
 nance in the last hours ; and, under this state of 
 the blood, every part of the body is constantly 
 losing its vigor. Thus, before the larynx is abso- 
 lutely blocked up, the muscles of respiration be- 
 come incapable of the effort requisite to expand 
 the thorax, and death ensues, although there may 
 be a very small passage still left open at the last 
 moment of life. 
 
 We are prepared now to consider the treatment 
 proper in acute laryngitis, in connection with that 
 adopted in the case under consideration. It has 
 been thought by many persons, medical and non- 
 medical, that General Washington was not treated 
 judiciously ; and some, perhaps, believe that by a 
 different treatment his life might have been pre- 
 served. Sixty years have passed since his decease, 
 and the disease, which was fatal to him, is under- 
 stood now much more perfectly than it was in 
 1799. To what result have we arrived? Has 
 any treatment proved to be moi-e successful than 
 16 
 
170 MEMOIR ON THE LAST SICKNESS 
 
 that adopted in his case ? He was hied, he was 
 blistered, and calomel and antimony were admin- 
 istered internally. Whether these remedies were 
 employed early enough^ and whether to too great 
 an extent, or not sufficiently, are questions to 
 which we will return presently. 
 
 What was the treatment adopted by Dr. BaiUie 
 in the cases of his medical friends ? He directed 
 bleeding, both general and local, and his patients 
 not only agreed with him, but, being medical 
 men, directed it for themselves in his absence. 
 This happened at a period comparatively near to 
 that of Washington's case. 
 
 What do the best teachers say at the present 
 day ? To answer this question fully and accu- 
 rately would require great research. One need 
 not, however, hesitate to say, generally, that they 
 recommend bleeding and blistering. In addition, 
 the EngUsh teachers advise the use of mercurials 
 carried to the point of salivation, and our own 
 did the same until very lately. Some of them, 
 perhaps, do it now. Some, if not many, would 
 add antimony and opium to the calomel, or other 
 preparations of mercury. 
 
 We believe that the lectures by Dr. Watson of 
 London are received as good authority, by as 
 
OF GENEKAJL WASHINGTON. 171 
 
 many persons who speak the EngHsh language, 
 as the work of any writer of our time on the 
 theory and practice of medicine. In the last 
 edition of his lectures he advises bleeding freely 
 at an early period of acute laryngitis, with the 
 qualifications which every discreet and experi- 
 enced practitioner would assent to. So far, then, 
 it would seem that the treatment adopted by Dr. 
 Craik and his medical coadjutors is the same 
 which has been, and is now, directed by physicians 
 of the first standing. 
 
 Let us look into this matter somewhat, and see 
 whether blood-letting in acute laryngitis appears 
 to be a rational practice. To what cause is the 
 danger to life to be attributed in this disease ? 
 The answer has already been given. The danger 
 arises from the filKng up of a part of the wind- 
 pipe. In what way, or by what material is the 
 windpipe filled up ? By an extra quantity of 
 blood in the small vessels of the part, similar to 
 what most persons may have seen in a violent 
 inflammation of the external surface of the eye. 
 By this blood in the first instance, and in part, is 
 the tube filled up; but fiirther, by the eifiision 
 under the mucous membrane of the larynx of a 
 watery liquid, called serum, or serous fluid. When 
 
172 MEMOIR ON THE LAST SICKNESS 
 
 a man is bled largely, he usually becomes pale. 
 This happens because the small vessels of the ex- 
 ternal surface contract under the loss of blood, 
 and the skin is seen to be white, or sallow, accord- 
 ing to the complexion of the individual. If, in 
 the disease under consideration, the small blood- 
 vessels in the morbid part will contract as those 
 of the skin do, after the abstraction of blood,, we 
 may hope for relief, as long as that contraction is 
 maintained. Not only so ; it will be found that 
 if this contraction takes place in the diseased 
 part, the effusion of serous fluid is more readUy 
 absorbed than it would otherwise be. 
 
 It must be confessed that the effect, here de- 
 scribed, on the small blood-vessels in the morbid 
 part, is not certain to take place in consequence 
 of the loss of blood. The success of the measure 
 depends mainly on the period of disease, at which 
 the bleeding takes place. The chance of success 
 is great in the very beginning of the inflammatory 
 process ; but it is less, the later the period at 
 which the remedy is employed. There is not, 
 however, any other measure by which effectual 
 relief is so likely to be produced as by blood- 
 letting. If anything else can be equally effectual, 
 in so short a space of time, it must be some local 
 
OF GENERAL WASHINGTON. 173 
 
 applications to the part aiFected. There are cases 
 of disease in the larynx, where nitrate of silver 
 and other articles may perhaps be ajiplie'd to the 
 parts affected, with great benefit. But in the 
 irritable state of the part in question, in this acute 
 disease, such applications must be attended with 
 very great difficulty, and apparently with great 
 hazard. The success of this treatment in cases 
 of ulceration in the mucous membrane of the 
 larynx, in a chronic disease, does not prove what 
 would happen in the acute disease under consid- 
 eration. 
 
 But there is a difficulty which ordinarily attends 
 the bleeding in this disease, to which may be at- 
 tributed the failure in the largest proportion of 
 cases, in which it has been tried. It is that the 
 disease usually commences under the familiar form 
 of a common cold in the throat, so that at first no 
 alarm is felt. Nor ought there to be an alarm in 
 such a case. It has been shown above that such 
 an inflammation as occurs in a common hoarse 
 cold, may suddenly increase in importance by ex- 
 tending irom the mucous membrane or tissue, to 
 the surrounding tissues, especially to the subjacent 
 cellular membrane. Thence comes the tumefac- 
 tion, which, acting mechanically, blocks up the 
 
m MEMOIR ON THE LAST SICKNESS 
 
 passage of the air into the lungs. It is in tliis 
 first stage, before the fatal extension of the inflam- 
 mation has occurred, that the disease might be 
 the most easily arrested. But who would advise 
 the active treatment req^uisite for this purpose in 
 every case of a hoarse cold, which is the first 
 stage ? In every such case the severe disease 
 may ensue. But what is the chance that it will 
 ensue ? A very large proportion of persons, prob- 
 ably three quarters of the community among us, 
 have such a cold once a year, and not a few have 
 such an attack twice or three times in a year ; but 
 the change into the severe disease, called acute 
 laryngitis, is among the most rare occurrences. 
 It does not take place in one case out of a mil- 
 lion. But if it happened in one case in a hundred, 
 it would not be justifiable to resort to a severe 
 treatment in each one of a hundred cases, in order 
 to save one of them fi-om the fatal change. There 
 is no doubt that every discreet man would choose 
 to incur the slight hazard of the severe disease, 
 rather than to resort to a copious bleeding every 
 rime he had a hoarse sore throat. Washington 
 was evidently familiar with a cold in his throat in 
 his sixty-eighth year, as other men are. He prob- 
 ably had never suspected the possible issue of 
 
OF GENERAL WASHINGTON. 175 
 
 such a cold. But if he had been told that the 
 chance of such an issue was one in a million, 
 or even one in a hundred, would he have con- 
 sented to a copious bleeding? We think not. 
 
 Here we see the real difficulty. At the time 
 when the danger is manifested, the disease is not 
 strictly new ; it has not just commenced. In 
 looking over the histories of cases of acute laryn- 
 gitis, we find that the disease, under the form of a 
 hoarse cold, has existed from a few hours to a few 
 days, before it arrives at the state when danger to 
 life is suspected. It cannot be said that the bleed- 
 ing, at that stage of the disease, can be relied on, 
 as it might have been in the very commencement. 
 Yet this remedy, even then, affords a chance of 
 relief, and the more when the disease has not re- 
 mained long in the first stage. In Washington's 
 case the first stage was of short duration. Bleed- 
 ing was resorted to early, by his own direction. 
 But that bleeding was nominal. His wife objected 
 to it, because the patient was old, and the bleed- 
 ing had not been directed by a physician. We 
 must give her the credit of exercising a wise 
 caution. Of course she did not understand the 
 nature of the disease ; she did not suspect how 
 rapidly it was pressing forward to a fatal ter- 
 
176 MEMOIR ON THE LAST SICKNESS 
 
 mination. Even the delay of the three or four 
 hours which had abeady passed away since he 
 waked her in the night, was a most serious loss. 
 When Dr. Craik reached him, some hours after- 
 wards, he prescribed a new venesection. He was 
 right; it is in such circumstances that the anceps 
 remedium is justifiable. What would medical 
 critics, what would posterity have said, if this 
 good doctor, when such a patient was in his 
 hands, in imminent danger from an affection 
 which was manifestly due to an inflammation, had 
 folded his arms, and said, " There is no possibility 
 of giving relief; but you may let him inhale the 
 vapor from some herb tea ? " 
 
 Although bloodletting is the great remedy, 
 there are other modes of treatment which may 
 be employed in aid of it, or without it. Calo- 
 mel and antimony, • usually with the addition of 
 opium, are thought by many physicians to be 
 proper articles for the reUef of this laryngitis. 
 Colonel Lear says that calomel and antimony 
 were given to General Washington, but he does 
 not say in what doses, nor whether more than 
 once. There is not any reason to beheve that 
 they were given in large doses ; though I think 
 Dr. Craik and his coadjutors have been re- 
 
OF GENERAL WASHINGTON. 177 
 
 preached on this score. In 1799 the use of 
 mercurials in inflammatory diseases was very rare, 
 I believe, in Great Britain, though it was very 
 common in this country. At the present day 
 the reverse is true. At least in New England 
 the practice is now relied on much less than in 
 old England. Fashions change, it must be ac- 
 knowledged, in medicine as in other things. 
 Probably the result, at the end of another fifty 
 years, will be that mercurials will not be ad- 
 ministered in either country as freely, as they 
 have been heretofore ; but that they will not 
 be abandoned altogether. 
 
 It would not be well to go further into the 
 subject on this occasion. We have considered 
 the bloodletting more fully perhaps than was 
 quite necessary, but it has been to defend the 
 reputation of Dr. Craik and his medical friends, 
 who we think did as well, at least, as any of their 
 critics would have done. We must acknowl- 
 edge an unwillingness not to think well of Dr. 
 Craik, who was the personal friend of Washing- 
 ton through his life. 
 
 Passing by some other modes of treatment for 
 acute laryngitis, we should not omit to notice 
 one, on which much reliance is placed at the 
 
178 MEMOIK ON THK LAST SICKNESS 
 
 present day, when it becomes obvious that all 
 other remedies are ineffectual. This consists in 
 an opening into the trachea, below the diseased 
 part. In this way life may be prolonged while 
 a chance is afforded for the subsidence of the 
 disease by a natural process, after which the 
 wound may be allowed to heal up. This prac- 
 tice has been resorted to with success in various 
 instances of obstructions in the windpipe, and 
 especially of late in croup. In this disease of 
 children and in the acute laryngitis of adults, it 
 is important that the surgical operation should . 
 be performed, before the vital powers have been 
 too much exhausted, by the painful and wearing 
 struggles for life. 
 
 But it is time to bring this memoir to a close. 
 On some points the writer has gone into a minute 
 statement of particulars, and into a discussion of 
 principles, as to the pathology and as to the 
 therapeutics. But this has been done only so 
 far as seemed to him necessary to make the sub- 
 ject understood by non-professional men ; not 
 with any pretence to bring into view all that 
 relates to the disease or its treatment. If he 
 seem to have lingered on the subject too long, 
 it will be remembered that the interest which 
 
OF GENERAL WASHINGTON. 179 
 
 is inspired by every circumstance in the life of 
 Washington, attaches, with melancholy intensity, 
 to the disease by which that life was suddenly 
 brought to a close. 
 
 Boston, March, 1860. 
 
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by TiCKNOR AND FlELDS. 11 
 
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by TiCKNOR AND FlELDS. 13 
 
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by TiCKNOR AND FlELDS. 1^ 
 
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I I 
 
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