' 9 . COL. GEORGE WASHINGTON FLOWERS V^IORIAL COLLECTION TRINITY COLLEGE LIBRARY DURHAM, N.C. The Gift of Date_ 37 , / J / ■ M 1 A PBACTICAL TEEATISE ON THE MOST COMMON DISEASES OE THE SOUTH: EXHIBITING THEIR PECULIAR NATURE, AND THE CORRESPONDING ADAPTATION OF TREATMENT. TO WHICH IS ADDED AN APPENDIX, CONTAINING SOME MISCELLANEOUS MATTER. ALSO A GLOSSARY, EXPLAINING THE MEANING OF THE TECHNICALITIES, OR MEDICAL PHRASES, USED IN THIS WORK. BY THOMPSON McGOWN, M.D., GRADUATE OF TRANSYLVANIA UNIVERSITY, MEMBER OF THE LEXINGTON MEDICAL SOCIETY, AND A .PRACTITIONER OF THE SOUTH. l; Is Ihere no balm in Gilead ? is there no physician there ?” Why, then, may not all be healed, or profiled? PHILADELPHIA: GRIGG, ELLIOT AND CO., 14 NORTH FOURTH STREET. 1849 . Entered according to the Act of Congress, in the year 1849, by THOMPSON Me GOWN, in the Clerk's Office of the District Court for the Eastern District of Pennsylvania. PHILADELPHIA : T. K. AND P. G. COLLINS, PRINTERS. (d I ( o M ) PREFACE. From the desire that has very frequently been ex- pressed by many of the best southern practitioners, and also from my own practical experience and ob- servation. I have, for some time, been convinced of the great necessity that existed for a medical w'ork that should serve as a book of reference and instruc- tion in relation to the peculiarities and proper treat- ment of Southern Diseases. Our medical books having been written almost entirely by European and northern authors — how- ever useful they may have generally been — are not adapted, as experience has amply proved, to the dis- eases of the South.* Impelled by these considera- tions, I have in this work endeavored to supply, in part, this desideratum. The book has not, however, been prepared with that care and leisure that I could have desired ; but, nevertheless, I have endeavored to express myself concisely and intelligibly ; although, in some instances, I have intentionally avoided brevity, in order to be the better understood by the general reader ; though, by this course, I may have violated * Dr. Cartwright, of Natchez, Mississippi, says, the best works extant on Diseases of the South, are those of Hippocrates, the father of medicine. IV PREFACE. some of the established rules of composition. Some errors may also have crept into the work. In connection with my own practical experience and observation, I have availed myself of the expe- rience of some of the most erudite southern practi- tioners, most of whose names will be found in the work. Reference is also occasionally made to foreign or northern authors, in instances where such refer- ence is pertinent. The author feels confident that this work will be of great value to students of medicine, young, and even old practitioners, and those who have recently emigrated to the south or southwest, and the southern and southwestern people generally. I believe that the medical as well as the legal pro- fession is in error in using technicalities , especially where they can be conveniently avoided, and more particularly in practical works, in which, as far as possible, they should be supplanted by plain English words, in order that all persons who are disposed to inform themselves, to some extent, on the subject of medicine, may do it with comparative ease ; though it should be recollected that technicalities cannot be entirely dispensed with, at least at present. My experience is, that nothing human is more certain than that the more the public are instructed in eclec- tic or philosophic medicine, the better are they pre- pared to appreciate it; they thus learn the import- ance of obtaining the services of a qualified physician, in case they or their families or friends should be so unfortunate as to be afflicted to a degree which their PREFACE. V own knowledge is not competent to control ; and they are also thus rendered more competent to judge of the qualifications of a practitioner, and not so easily im- posed on by mountebanks, or by every new or fool- ish notion that is gotten up to gull the public for a time, from mere pecuniary considerations. It ap- pears, on the one hand, that the human mind has a great proclivity to deal in that in which it can see some reason or plausibility, or which it pretty well comprehends; or, on the other, that, in relation to which it is totally ignorant, and for which it can perceive no reason, but which, nevertheless, com- mands its superstitious credulity. Hence, from re- mote ages to the present day, charms and ceremonies — which common sense teaches us can have no in- fluence, except on or through the mind — have been used for the cure of diseases. In the onward and upward march of the human mind, as intelligence becomes more general, we may hope, at least in a great measure, to see these superstitious notions ban- ished from the world. In order, then, that the regu- lar practice^ that eclectic or philosophic medicine — the principal foundation of which appears to have been laid between twenty-two and twenty-three hundred years ago, by Hippocrates, who is commonly called “ The Father of Medicine” — should be properly ap- preciated or confided in by the public, every disci- ple of Esculapius, every member of the regular pro- fession, should take an interest in attracting the public more to the subject of rational medicine, and communicate information as opportunity may offer. VI PREFACE. The author has, therefore, in order that the public may be benefited, as well as his professional brethren, endeavored to adapt his composition to the general reader. Having been compelled, however, to use some technicalities, a glossary is added to explain their meaning. There is one objection to instruct- ing some non-professional persons on the subject of medicine, and this is, that they become bigoted, and profess to know as much as physicians, and are there- by emboldened to practice, at the risk of the patient’s life, when a physician should be called in. It is somewhat remarkable that so little attention is paid in our common schools and academies to the outlines of anatomy, physiology, and the general prin- ciples of medicine. It is not expected that all per- sons will be learned in medicine, but surely these subjects are of such importance to every one, that they should not be so ignorant of them. Of late years, I believe, there seems to be more interest felt in this matter, and, ere long, we may hope to see it more extensively introduced into the schools of gene- ral literature. I had thought of writing an introductory chapter to this work, on the General Principles of Medicine, having some original peculiar views, which I consi- der founded in the laws of truth, and which, when understood, enable us to reconcile apparent incon- sistencies, and various opinions of eminent medical men, and are also well calculated, to a considerable extent, to prevent physicians from being led into error by the sophistry of their imaginations, and PREFACE. vii which also greatly simplify the subject of medicine, so that an intelligent public may, in a great measure, comprehend it, and perceive its rationality. But as a proper delineation of this subject wmuld require a volume (which I have not had time to prepare), I have omitted it, having endeavored to teach prin- ciples as well as practice in this work ; and if it is sufficiently patronized and the author encouraged, he may, in the future, provided opportunity permits, prepare a work on the general principles of medicine, and perhaps, also, a more comprehensive edition of this w r ork. In the following pages, I have endeavored to be guided by the light of truth ; and though I may have freely alluded to the errors of some of my profession- al brethren, it is not because I love them less, but that I love truth and humanity more : and, as has been said by some writer, though I should cast mis- siles at the spots on the sun, it is no evidence that I despise the brightness of its disc. Hoping and believing that my professional bre- thren, and the public, may be amply rewarded by carefully consulting this work, it is most respectfully submitted to them. THOMPSON Me GOWN, M.D. August, 1849. TESTIMONIALS. Philadelphia, Penn., July, 1849. Whilst this work was passing through the press, I received a letter from a friend in the South, who advised me to have testimonials, in order that those with whom I am not acquainted may he assured of the merits of this book, and therefore seek an early opportunity to obtain it. This I had not thought of doing, expecting it to make its way on its own merits, if it has any ; it is clear, however, that these cannot be appreciated till the work is perused. And, therefore, not having prepared myself with testimonials for this purpose, and it now being too late — as the work will soon be out of press — in deference to the suggestion of my friend, I will here insert some communications (which I happen to have in my trunk) that were handed to me on other occasions and for other purposes ; and I hope the gentlemen whose names appear below will excuse me for this liberty. The following were kindly handed to me, when I was about leaving Mis- sissippi to locate in North Alabama. Hillsboro’, Scott County, Mississippi, July 19 th, 1848. To all whom it may concern. The undersigned having learned that their highly respected friend, T. McGown, 51. D., is going to leave this place, and as he may locate where he is not known, we voluntarily take great pleasure in recommending him as a gentleman of moral habits, probity, mild and courteous, worthy of the confidence and esteem of all those who respect morality, virtue, and honesty, lie located here in 1844, and has proven himself to be a talented and skill- ful physician; he has practiced in all our families, and we have been highly pleased with his success. He is a pleasant and agreeable friend, and we very much regret his leaving here, and hope that, wherever he may locate, his merits may be duly appreciated. * * * * ■J. 51. Chambers, Minister of the Gospel in the Baptist Church. J. J. Smith, Esq. J. -J. Chambers, Ex-clerk, Circuit Court of Scott County, Miss. X TESTIMONIALS. From Rev. J. I). Abney. Carthage, Miss., May 2 9th, 1848. Elder J. M. Chambers, Hillsboro’, Miss. Dear brother in the Lord: I am now on my way home from my appoint- ment in Madison County. * * * * * * I did intend to call at Hillsboro’, in order to spend some time with our friend Dr. McGown pre- vious to his leaving, but my business presses me on home by the shortest route. Give the doctor my best wishes ********* My acquaintance with the doctor has been truly intimate and of the most pleasant character, and I hope you will have the goodness to hand him this; and I hope that his modesty will not prevent him from using it on any proper occasion ; for I can, with the greatest pleasure, say to the afflicted, that he is a man who stands pre-eminently high as a knowing and attentive physician ; and to the good citizens of any community, I can, with plea- sure say, that he is, as his deportment fully shows him to be, a faithful friend and gentleman ; and I earnestly hope that he may find a situation that will be able to appreciate his high attainments, and his moral worth. I am yours in love, J. D. Abney. Hillsboro’, Mississippi, July 20 th, 1848. Gentlemen: — This will introduce you to Dr. Thompson McGown. ***** I have enjoyed the pleasure of an intimate acquaintance with Dr. McGown for near three years, and I take pleasure in saying, that his exemplary conduct as a gentleman, and his success as a practitioner, have made him more friends, wrought a confidence in his abilities, and gained him a repu- tation that is seldom the fortune of one of his age to attain. I risk nothing in saying, that you only have to become acquainted with Dr. McGown, to admire him as a gentleman, and appreciate his abilities as a physician. Respectfully, I). R. -Jones, Sheriff of Scott County, Miss. Hillsboro’, Miss., July 14 th, 1848. To all whom it may concern. Some four years since, I became acquainted with Thompson McGown. M. D., at this place; during the past three years it has been my pleasure to cultivate with him an intimate and sociable intercourse, both in private and professional life ; occasionally requiring his professional attention as a pdiysician. TESTIMONIALS. XI In my intercourse with him, which has been of the most intimate cha- racter, I have found him to possess those rare qualities so necessary to the character of a gentleman. ****** His professional ability in this vicinity has been thoroughly tested in numerous cases, nearly all of whom now live to award him the just meed of praise, which well-directed skill, timely administered, claims from the hands of a grateful circle of friends. E. Rush Bucknor, Attorney at Late, Hillsboro’, Miss. The three following brief extracts are from the undersigned, to gentlemen whose names appear, the letters never yet having been handed to them. Neshoba County, Miss., April 15th, 1849. •J. B. Kirtland, Esq., Memphis, Tennessee. Dear Sir: — Please permit me to introduce to your acquaintance my friend Dr. McGown, who visits your town for the purpose of locating * . * * The Dr. has for some time past been engaged in preparing a medical work for publication. I take great pleasure in saying to you, that the Dr. is a gen- tleman of high standing, both as a citizen and a practitioner of medicine, *•■***■* Yours Respectfully, H. M. Walsh. The other two extracts I thought of making, are in substance as the above ; one of them addressed to Dr. Lard of Tippah County, Miss., and the other to Messrs. Wisdom & Walsh, Purdy, Tenn. Erasmus S. Broyles, M. D., of Aberdeen, Miss., in a letter to me under date of April 19th, 1849, after learning that I was about to publish this work, says: “It will afford me pleasure to patronize your work when it makes its advent to this place." The Editor of the Southern Patriot, a newspaper published at Athens, Alabama, after examining a portion of the manuscript of the work, gave it a highly complimentary notice in his paper. In conclusion, I will remark, that a number of physicians, and others, have already subscribed or spoken for a copy of the work in advance, in anticipation of its publication. ' ; TABLE OF CONTENTS. Malarious Diseases PAGE CHAPTER I. 9 CHAPTER II. Intermittent Fever — Chills and Fever . . . . .30 Cachexia CHAPTER III. 80 CHAPTER IV. Tuberculous Cachexia — Consumption, &c. . . . .94 Scrofula — Rickets Chronic Rheumatism CHAPTER V. .139 . 140 Tabes Mesenterica CHAPTER VI. 143 Chronic Bronchitis CHAPTER VII. ib. CHAPTER VIII. Haemoptysis, or Spitting of Blood ..... 147 Hydro-polyaemia, or Serous Polyaemia — Treatment . . . 150 Dropsy — Treatment of . CHAPTER IX. ib. CHAPTER X. Enlargement of the Spleen and Splenic Cachexia . . . 152 XIV CONTENTS. PAGE CHAPTER XI. Liver — Chronic Enlargement and Induration of 155 , CHAPTER XII. Nervous Diseases — Epilepsy — Puerperal Convulsions . . 156 CHAPTER XIII. Atonic Dyspepsia CHAPTER XIV. . 162 Leucorrhcea, or Whites . . . . . 165 Chronic Metritis CHAPTER XV. . 171 Bysmenorrhoea. or Painful Menstruation CHAPTER XVI. . 173 Additional articles for the cure of Intermittent Fever CHAPTER XVII. . 176 Congestive Fever, or Cong estive Chills CHAPTER XVIII. . 180 Remittent Fever . . 224 Jaundice CHAPTER XIX. . 293 Fellow Fever CHAPTER XX. . 294 Acute Rheumatism CHAPTER XXI. . 306 Typhoid Pneumonia CHAPTER XXII . 308 Diarrhoea and Dysentery CHAPTER XXIII. * . 326 Asiatic Cholera . CHAPTER XXIV. . 353 Croup (cynanche trachealis), . '383 CONTENTS. XV APPENDIX. PAGE I. Clap, or Gonorrhoea ...... 399 II. Miscellaneous ........ 407 Concussion, Jar, or Fall ...... 407 III. Incised wounds ........ 408 Lacerated and contused wounds ..... 409 Gun Cotton ........ 410 Collodion 410, 412 IY. Worms in the Alimentary Canal . . . . . 413 Y. Catarrh, or cold . . . . . . . . 416 VI. Ephemeral Fever ....... 418 VII. Itch (scabies), ........ 420 GLOSSARY .421 INDEX 439 A PRACTICAL TREATISE ON DISEASES OF THE SOUTH. CHAPTER I. MALARIOUS* DISEASES. The almost universal malarious influence in the southern and western portions of the United States, as well as many other portions of the globe, undoubtedly renders this subject one of the most interesting which pertains to the practice of medicine. This is a subject which does not only interest physicians, but all those who reside in those portions of the world where this malarious influence is felt. A committee (Prof. Bartlett being one of the number) appointed by the Lexington Medical Society in 1847, re- marked: “ Extensively as malarious fever has been written about, there are many points of its natural history wdiich need further elucidation. Amongst these may be men- tioned, particularly, the following : the comparative liability of the sexes, of the black and white races, and of different periods of life, to the several forms of the disease ; the influence of race upon its severity and dan- ger ; the relative proportions, in different years and locali- * I use this term for the sake of convenience, and to he understood, with- out assuming to prove or disprove the existence of such a thing as malaria , or miasm , according to what is generally understood by these terms. 2 10 MALARIOUS DISEASES. ties, of the three principal forms — intermittent, remittent, and congestive ; the most common type of the pure in- termittent form ; and the variations in the general cha- racter of the disease, in different seasons.” A southern and malarious region having been the place of my nativity, and having had considerable practical experience in the various forms of disease produced or modified by malarious influence ; and, moreover, having taken pains to acquire what information I could on the subject, from southern practitioners and others, and from books and medical journals, I am induced to believe that the condensation of this summary may convey to those who feel interested enough to read this work, some information that may not be without interest and profit, especially to those who expect to practice in the South or West; and I am the more inclined to prepare it, from not only observing the improper and deleterious practice of many physicians who have been educated at the North, but from the common observation of many of my professional brethren of the South, and also by many of the non-professional. Indeed, it is remarked by many of the older practitioners of this country, who came here from the North, that they, and others who had been educated at the North, and subsequently located in the South, had to learn to treat the diseases of this country after they came here. I feel assured that very few, if any, of the northern teachers and writers sufficiently appreciate the peculiarities of not only the malarious fevers, but of many other forms of disease which are modified by this climate and locality, and requiring a corresponding adaptation of treatment. It gives me pleasure, however, to observe that some of the teachers at the North are not so fully obnoxious to these remarks at present, as heretofore. It appears that some of them, at least, are taking more pains than formerly, to make themselves acquainted with the MALARIOUS DISEASES. 11 diseases of the South; and I am the more gratified at this increased manifestation of interest, because I believe the abuses in practice in the South will be but tardily ameliorated till the northern professors and writers are prepared to give students from the South the requisite and proper instructions in these respects; — as from other advantages, the competency of northern teachers in other respects, and the reputation of northern schools, a great many students in the South will perhaps continue to go to the North to acquire medical information. A large number of southern physicians are still too much inclined to look at the diseases of this country through northern spectacles. I would that the observation of the late Dr. Eberle was more universally true, that “ The American practitioner, free from the trammels of systems, and the dogmas of the schools, pays no further regard to the verba magistri than is sanctioned by his own experience and observations. He inquires, observes, and reflects for himself, and adopts the mode of treatment which he finds, from varied experience, most successful. A prac- tice, which has received the approbation of a numerous portion of the profession, may be confidently regarded as founded on individual experience and observation, and not adopted on mere authority, and entitled, therefore, to full confidence.” As regards southern diseases, these remarks apply appropriately to many southern practi- tioners, especially the better informed ones, on the subject of southern diseases. Ere long, I hope to see northern teachers, as well as southern ones, and medical writers generally, pay more attention to this subject ; as I feel well assured that the profession would be amply rewarded for such attention, bj? additional trophies in the healing art, as well by removing some of the opprobria from an honorable and useful profession, and one which is essen- tially necessary, not only in relieving the sufferings and 12 MALARIOUS DISEASES. diseases of the human family, but as a guardian, in point- ing out the principles of hygiene, and those means of prophylaxis which are best calculated to secure health and comfort, and immunity from disease. But as it is human nature to be tenacious of preconceived opinions, time will be required to eradicate error, and bring about a great desideratum, a correct and general knowledge of the diseases of the South, and the principles of treatment theij demand. I have not the presumption to suppose that I can remove the veil, and at once appreciate the nature of all these diseases, but, being willing to contri- bute according to my experience and ability, I hope to receive the approbation of my professional brethren, especially of the South, in this humble, — but I trust, laudable undertaking. It is not my intention to enter into an analytical ex- amination of the different opinions as to the existence or non-existence of what is termed “ miasm f “ marsh poison ,” “ malaria ,” etc. The Italian term malaria, which merely means “ had air,” is not that signification which is commonly attached to the word. Those who believe in the existence of such a poison, are of the opinion that it is sui generis, and produces its peculiar influence on the system, which differs from everything else. There are others who do not acknowledge the existence of this hypothetical poison, but believe that the morbid influences attributed to it are produced by varia- tions of temperature, heat and moisture, etc. etc. A retrospective view of the history and prevalence of the different forms of malarious disease in different locali- ties, would be a task impossible, and if possible almost ad infinitum, and without equivalent profit arising from such a prolix historical detail. Yet it may not be with- out interest to notice briefly some of the times and places of its prevalence in our own country. Dr. Cartwright, MALARIOUS DISEASES. 13 of Natchez, Mississippi, is of opinion that the different forms of malarious disease were better known bj Hippo- crates, than any of the medical profession of the present day. I may premise that its prevalence in any year or place, seems to be induced by occult causes — which, as yet, we have been unable to appreciate. In some places, where it is endemic, a certain season may be wet and healthy, or dry and healthy. The late Hr. Eberle ob- served : “ It would seem that either the generation of miasmata, or their power of producing intermitting and remitting fevers, is greatly controlled by certain occult conditions, wholly unconnected with any appreciable circumstances, with regard to atmospheric temperature, or any of the other known requisites for the production of this poison and further, correctly remarks : “ In cer- tain districts of the temperate latitudes, malarious fevers will sometimes disappear, or become extremely rare for a number of successive years, and then gradually become more and more common, until, in the course of a few seasons, they assume the prevalence of an epidemic: and yet no material difference will be obvious between these periods of exemption from, and prevalence of disease, in relation to what are deemed the necessary concomitants for the production of miasmata.” Professor Dunglison says : “ It is proper to remark, that such a change occa- sionally occurs in a malarious region, as to render it entirely healthy, and this without our being able to assign any plausible conjecture for the alteration. At times, too, after having left one of its former haunts, the malaria may return, after the lapse of a longer or shorter period.” The correctness of these remarks is corroborated by the observation of all those who have for many years noticed its prevalence. Professor Dunglison further observes : “Not many years ago, the villas on the banks of the Delaware were almost uninhabitable in the latter part of 14 MALARIOUS DISEASES. summer, and in the autumnal months, but they are now healthy, whilst those on the verdant and sylvan banks of the Schuylkill suffer from malarious emanations;” and further remarks, that “ It is met with in all climates, but less perniciously, perhaps,* in the colder regions of the globe, than in the torrid or the temperate. In the same region, too, it prevails more virulently in some districts than in others the cause of it “ sometimes exhibiting itself in the high grounds, whilst the low are exempt; and occasionally visiting tracts of country where it had previously been unknown ; whilst, on the other hand, it may leave localities where it had been before an annual visitor.” Dr. Boling, of Montgomery, Alabama, says : “ The exact combination of circumstances under which that mysterious agent of disease, malaria, is generated, remains yet to be satisfactorily explained, as well as the chemical and physical properties belonging to it. We find at times all the circumstances in existence, so far as we are capable of understanding or appreciating them, which on a previous occasion had been supposed to cause its development, without the presence of malarious dis- ease ; and again, we find such diseases prevailing to a considerable extent, when of the generally recognized causes of malaria, but few are present, or, if all, their existence in but a feeble degree.” In certain portions or localities in the southern and western States, where it is more or less common every year in the latter part of the summer, and during autumn, and not unfrequently to a less extent during the entire year, it appears as an endemico-epidemic in the latter * Prof. D. might properly have' left out the word “perhaps,” and also re- marked that it does not prevail equally iu all regions of the globe. W hile it is almost unknown or uncommon in the New England States (according to Prof. Bartlett), where typhoid fever mostly prevails, it is the most com- mon form of disease in the south-western portion of this Union. MALARIOUS DISEASES. 15 part of summer and in autumn, at which times it is apt to be more severe ; sometimes assuming what has been termed the pernicious remittent type, and at others the form of congestive chill. It is said that in 1822, a bad form of bilious remittent fever prevailed at Louisville. I believe it was about the year 1824 or ’5, when a very fatal form of fever prevailed about Huntsville, Ala. The usual mode of treatment was of so little avail, that Dr. Thomas Fearn was induced to try large doses of quinine, which proved successful ; and it appears that he is the first who used large doses of this article, a practice which has since become very popular in the southern and western States, amongst the most enlightened and suc- cessful practitioners. Malarious disease prevailed in some portions of North Alabama, in the summer and autumn of 1827 and ’8; especially in the region about Decatur, Moulton, Courtland, and Tuscumbia. Dr. Hogg gives an account of the epidemic fevers of Natchez, Miss., in 1837, ’8, and ’9 ; and takes brief notice of the malignant double tertian. Dr. T. D. Bell gives an account of an epidemic congestive fever, attended with dysentery, which prevailed in the flat, low, marshy country near the junction of the Black Warrior and Tombigbee rivers, in Alabama, in the summer of 1829. Malarious fever also prevailed in many places in the South, in 1839 and ’40, and with a good deal of intensity or severity. In the latter part of summer and in autumn, in 1840, it appeared as an epidemic in ibhe counties of Franklin. Coffee, Warren, and others in Middle Tennessee; the severer forms being very common ; and prevailed to a considerable extent in the same region, and elsewhere, in 1842. In the same season of the year, in 1844, it pre- vailed in the southern part of Alabama and Mississippi, manifesting its severer forms in those endemic localities where it had formerly more virulently prevailed, the 16 MALARIOUS DISEASES. healthier localities mostly furnishing the milder forms, with perhaps some exceptions. Dr. Charles McCormick, Assistant Surgeon, U. S. Army, made a report at Fort Gamble, Florida, Sept. 1841, of 167 cases of fever; 119 being of the quotidian type, 32 of the tertian, and 16 of the remittent form. Two or three cases assumed the congestive form, and he remarks: “I think the strongest peculiarity of character these cases have presented, this season, has been the strong tendency they have had to run into and assume the remittent type. In fact, in many of the cases, it has been extremely difficult to draw a distinct and plain line of demarkation, to say where the one ended and the other commenced.” Dr. Lewis, of Mobile, Ala., observes, when speaking of what he calls the third epoch in the Medical History of Alabama: “But in 1834, we find its approach (i. e. fever) was insidious and unobserved, giving no serious warning of its proximity, until the unconscious victim was secure in its grasp. The patient first complained of depression, heat and burning , when to the touch the sur- face was icy cold. That cold, that first stage, is now the stage of disease and peril; and that reaction, which in past days was looked to with fear and trembling, would now be hailed as the messenger of returning health and vigor.” Malarious fever appeared as an epidemic in the region of country about Nashville, Tennessee, in 1845. A writer to the editor of the New Orleans Medical Journal, under date of Nov. 6th, 1845, says : “ Since I wrote you last, we have been dreadfully scourged with disease. Although our town has been healthful as usual, the surrounding counties of Middle Tennessee, and the ad- jacent counties of Kentucky, have suffered more from sickness than the ‘ oldest citizen’ can remember at any former period. The disease has been principally fever, MALARIOUS FEVERS— PREVALENCE. 17 and of the ordinary remittent and intermittent types, re- quiring, as far as I have observed and inquired, no important modification in the treatment. The disease commenced about the middle of September, and con- tinued with unabated violence until about the 25th of October, when it ceased with the approach of cool wea- ther, and very suddenly. I have not been able to ascer- tain that one locality has been more liable to its ra- vages than another ; the high, hilly, and even mountain- ous districts, as well as the flat, rich country, have been alike sufferers. And during its severest form, the country was perfectly dry, not having had rain for many months.” The summer season at Woodville, Miss., 1846, was w T et, and fevers were mostly of the tertian type. Ther- mometer from 73° to 93°. The congestive fever appeared as an epidemic at Pensacola, in 1844, for the first time, and again in the summer and autumn of 1846. Dr. T. A. Cooke, of Opelousas, Louisiana, says, according to his experience, which is confirmed by others who have enjoyed a better opportunity than himself for observation, that congestive fever does not bear to our autumnal bilious fevers a ratio greater than two per cent. During eleven years’ practice in Opelousas and the adjacent country, he had not observed on an average more than twelve cases a year. At Montgomery, Ala., in 1845, it was dry and very healthy ; in 1846, wet and healthy. The sickly season at Columbus, Miss., is mostly confined to August, September, and October ; but in 1846, marked cases of bilious fever commenced early in July; and though this sickly season was long, the diseases were mostly mild, and of the remittent and intermittent form, till about the middle of September they became more obstinate ; and there were a few cases of congestive fever. The summer was very wet. In the latter part of Sep- tember, the worm or caterpillar committed great depre- 18 MALARIOUS FEVERS— PREVALENCE. dations on the cotton, every leaf in the largest farms was eaten up ; and the effluvia from the cotton field was sick- ening, and almost intolerable. Dr. J. B. Wilkinson, of Louisiana (New Orleans Medical Journal , July 1845), says : “ In the last three years, during the spring, sum- mer, and autumn, I have treated successfully between six and seven hundred cases of intermittent fever, embracing every variety of form, from the simplest grade to those cases where complete stupor and insensibility were co-ex- istent, and succeeded to the cold stage, and those cases in which the paroxysm was ushered in by symptoms and appearances so similar to those indicative of cholera mor- bus, that, unless acquainted with the history of the case, an observer wmuld have declared them cases of the latter disease.” These cases, perhaps, should more properly be considered as the dysenteric variety of congestive fever. John Dawson, M. D., of Jamestown, Ohio, in 1846, says : “ The summer and autumnal diseases were more prevalent, so far as my own experience was concerned, than last season, although that was generally regarded as being a sickly season compared with several of the pre- ceding. All parts of the State, if I have been correctly informed, have not been equally affected. Our towns, as a general rule, have been comparatively healthy, while certain country situations have suffered beyond any former precedent. Nor have I been able to trace any connection between the occurrence of certain of our autumnal diseases and particular districts of country. Along the courses of the larger streams of water, the dis- eases considered peculiar to such localities have not been more frequent, or more severe, than in the vicinity of small streams, or even in the interior.” He further re- marks : “ Bilious remittent and intermittent have had an almost unexampled prevalence.” The bilious form pre- vailed some in August, more in September, and he thinks MALARIOUS FEVERS— PREVALENCE. 19 obtained its greatest prevalence in October. The cases in August and September were generally of short du- ration, and easily controlled with purgatives and qui- nine. I believe the severer forms of malarious fever prevailed as an endemico-epidemic in some portions of North Mississippi, in the summer and autumn of 1842, and again in 1843; and I believe in the same seasons, and with considerable malignity, in the south-western portion of Alabama. It is said there is more sickness at Tuscumbia, Ala., this season — autumn of 1848 — than has been for many years. The different forms of malarious disease, as is usual in this valley, were the forms of disease that prevailed ; some of fatal congestive form. I may here remark, that in the Tennessee river valley, and more particularly on the south side, from Gunter’s Landing in North Alabama, to Tuscumbia, including Decatur and Courtland, there is more or less of the three principal forms of malarious fever every summer and autumn ; and, indeed, some have ague and fever all winter. Previous to the 10th of Sep- tember, the quotidian is, perhaps, the most common form ; after this, it is apt to assume more or less the tertian, double tertian, irregular, remittent, or what some call the continued form, — perhaps improperly, — and an occa- sional case of the congestive form. Perhaps I have already been more tedious than neces- sary in noticing the prevalence of malarious fever in dif- ferent localities, and at different times. This part of the subject might be extended to almost an indefinite length, as before remarked, without corresponding practical ad- vantage. I will close this part of the subject, therefore, by a few tabular statements and remarks. Fever Statistics, showing the relative proportion of the different forms of malarious and other fevers admitted into the New Orleans Charity Hospital, during a period 20 MALARIOUS FEVERS— PREVALENCE of seven years, from 1st January, 1841, to 1st January, 1848, inclusive ; monthly and annually. Reported by E. D. Fenner, M. D. Dr. F. says: “This institution is probably the most extensive fever hospital in the world, and affords the greatest facilities for investigating the disease in all its forms and varieties.” 1841. FEVERS. >— 5 Feb’y. March. April. May. June. July. | August. Q. O Vj | October. | Nov. Dec. r3 © Intermittent, - - 3 27 45 39 28 65 187 151 18 66 93 72 794 Typhoid, 1 5 6 12 Congestive, 4 3 i 7 3 3 1 2 24 Remittent, - 3 2 2 9 6 31 31 5 1 7 2 39 Malignant Intermittent 3 3 6 Yellow, ... 174 642 252 37 8 1113 Bilious, | 3 11 32 46 41 37 71 22S 362 665 322 143 93 1991 Total admissionof all diseases, 4380. 1842. FEVERS. January. Feb’y. March. April. May. June. | July. j August. | Sept j October. | Nov. Dec. Total. Intermittent, 45 29 35 39 45 124 160 169 144 140 110 61 1092 Remittent, 4 1 3 4 8 12 34 41 35 11 3 155 Typhoid, - 9 2 4 2 2 2 1 22 Bilious, - 2 3 9 3 1 o o 1 23 Congestive, 1 3 3 2 10 5 4 9 2 1 40 Gastric, 1 2 6 1 1 11 Catarrhal, ... 1 1 1 3 Yellow, 47 247 93 23 410 Nervous, - - i ' - 1 1 Adynamic, 1 1 59 31 39 47 52 142 197 259 439 2S4 150 79 175S Total admissions of all diseases, 4404. 1843. FEVERS. January. Feb’y. March. April. >-> § June. | August. © cz> October. | Nov. Dec. Total. Intermittent, 31 30 35 31 19 40 70 9S 12S 136 149 76 843 Typhoid, 2 2 4 Remittent, 1 1 9 40 75 49 12 8 10 205 Catarrhal, 1 1 2 Bilious, - 1 1 15 3 37 5 2 2 3 2 71 Typhus, 3 6 9 Congestive, 3 17 4 24 Gastric, 1 1 1 4 7 Continued, 1 1 Yellow, 23 1SS 365 351 111 15 1053 Cephalic, 3 36 30 35 33 34 60 194 372 544 501 273 107 2222 Total admissions of all diseases, 5013. MALARIOUS FEVERS — PREVALENCE, 21 1844. FEVERS. January. Feb’y. March. April. May. June. =3 | August. | Sept. | October. > o £ | Dec. Total. Intermittent, 66 49 41 32 44 75 176 258 255 261 216 116 1589 Remittent, 2 4 2 1 4 24 30 47 67 55 5 3 244 Yellow, ... 2 2 1 1 1 68 52 25 152 Typhoid, 6 1 3 3 10 12 11 8 6 20 80 Simple, - 3 6 3 12 Gastric, - 1 2 1 5 2 11 Typhus, ... 4 4 Bilious, - 2 4 2 1 3 1 13 Inflammatory, - 1 2 2 2 2 2 11 Congestive, - 1 7 11 17 14 13 15 3 81 Adynamic, 2 2 4 Continued, 2 3 5 Eruptive, - 1 i 21 84 63 62 106 151 201 151 339 241 206 148 2207 Total admissions of all diseases, 6136. 1845. FEVERS. January. Feb’y. March. April. May. June. | August. G. O £ Dec. Total. Intermittent, 7 75 57 44 79 112 145 96 279 196 189 124 1403 Typhoid, 7 6 5 2 10 8 11 14 IS 20 15 23 139 Remittent, 2 1 1 11 17 00 00 34 33 17 154 Congestive, - 3 1 1 2 1 4 5 4 21 Inflammatory, - 2 1 1 4 Yellow, 1 1 Continued, 1 2 1 1 5 Nervous, 1 1 1 * 3 Bilious, . - 1 2 6 1 1 1 14 Simple, - 1 4 1 1 1 2 9 Pernicious, 2 2 1 4 Ephemeral, - 1 1 Adynamic, 1 1 2 Scarlet, 2 2 Catarrhal, - 1 i 21 84 63 52 106 151 201 151 339 241 206 148J1763 Total admissions of all diseases, 6136. 1846. FEVERS. January. Feb’y. March. April. May. June. July. | August. Q, O October. Nov. Dec. Total. Intermittent, 79 58 75 76 85 138 214 227 359 376 310 SI 2078 Typhoid, 30 13 7 5 10 12 14 17 5 7 23 52 195 Typhus, - Remittent, 3 3 5 7 6 2 9 22 36 7 3 103 Congestive, 1 1 2 4 2 5 9 2 5 31 Yellow, 29 83 32 4 148 Bilious, ... 1 1 2 4 Pernicious Intermittent, 6 4 1 11 Adynamic, Scarlet, ... 2 o 1 2 1 8 Catarrhal, 1 1 Nervous, 1 1 1 3 Malignant, 2 2 Larvata, 2 2 1 1 6 Pernicious, 2 9 11 Gastro-Hepatic, 1 1 Ataxic, - 1 1 117 75 90 83 104 161 246 255 433 522 380 147 2603 Total admissions of all diseases, S044. 22 MALARIOUS FEVERS— PREVALENCE. 1847. FEVERS. January. Feb’y. March. April. May. June. July. August. Sept. October. Nov. Dec. Total. Intermittent, 144 117 98 153 140 211 223 74 53 00 380 341 2192 Typhoid, 40 21 50 73 66 20 7 2 1 6 60 111 457 Typhus, - 2 4 107 165 369 57 1 4 100 236 1045 Remittent, 4 1 4 9 17 38 69 64 25 12 18 8 269 Congestive, 1 1 1 2 3 12 10 1 1 2 2 36 Yellow, 5 148 1611 777 219 49 2 2811 Bilious, 2 2 4 7 2 1 9 7 8 42 Pern. Intermittent, 1 2 1 1 5 Adynamic, 1 1 Ephemeral, - 3 2 1 6 12 Catarrhal, 1 4 18 23 Inflammatory, 1 5 Continued, 1 2 3 193 142 157 346 396 661 521 1756 ' 857 512 622 834 6901 Total admissions of all diseases, 11,890. In justice to Dr. Fenner, it should be observed, that he has given the names of fevers as he found them on the books of the hospital, without attempting to rectify the “ very faulty nomenclature applied to fevers,” parti- cularly in the city of New Orleans. From the above “ tables, it appears there were admit- ted, of all kinds of fever, 19,445 cases — of which 999 L were marked 1 Intermittent' Add to which 26 marked £ Pernicious'' and 1 Malignant Intermittent ,’ and 257 mark- ed ‘ Congestive 1 (which is only the American cognomen for the same form of Intermittent fever), and you will have 10,274 Intermittents, or more than one-half of the whole amount , by 1103. “ Is it not curious to note the gradual increase and decline of intermittent fever at this hospital ? And also the remarkable fact that this form of fever is never en- tirely absent, not even at the zenith of the worst epidemics of the yellow fever? In August, 1847, when there were admitted 1611 cases of yellow fever, there were also ad- mitted 74 cases of intermittent. But examine the statis- tics carefully, and you will discover other curious facts, which I shall not take the time to point out. “ The following table will show the relative preva- MALARIOUS FEVERS— PREVALENCE. 23 lence of what is marked ‘ Intermittent fever ’ at the differ- ent seasons of the same seven years : — Spring. Summer. Autumn. 'Winter. 1841 112 403 177 92 1842 119 453 394 135 1843 85 208 413 137 1844 117 469 732 231 1845 180 353 664 206 1846 236 569 1045 218 1847 391 508 691 602 Totals. 1240 2963 4116 1621 “Two interesting questions may here be examined, viz., What proportion of all this intermittent fever really originated in New Orleans , and in what part of the city did most of it occur ? “ The city of New Orleans is certainly a great tho- roughfare, and has a larger transient or floating popula- tion, perhaps, than any other to be found. It is accessible by ships, steamboats, and land carriage. It is surrounded by a low, level, and very fertile country, having a large number of free white laborers. This class in the country is engaged principally in draining wet land, and, to some extent, in the mechanic arts; about the city, it is also extensively engaged in draining the suburbs; but, per- haps, to a greater extent in street labor, such as paving, draying, and loading and unloading ships and steamboats on the levee. Their residences are chiefly in the newer and more retired parts of the city, where rents are cheapest; but they are generally interspersed among those of the wealthier class. “ Now, the Charity Hospital is opened gratuitously to all indigent persons, male and female, white or colored, who may wish to enter, and there is no obstacle to ad- mission. This charity is only offered to the indigent, but pay wards are provided for those who are able to afford a moderate compensation. 24 MALARIOUS FEVERS— PREVALENCE. “ I believe it has been established, that the poorer classes suffer more than any others from all kinds of fevers. Such is certainly the fact here, where the usual exciting causes , such as intemperance in eating and drinking, and exposure to the hot sun, etc., are very potent. The records of the Charity Hospital do not afford any precise information as to the length of resi- dence in New Orleans. The question is asked, and the time stated ; but the clerk informed me that he made no distinction between a residence in the city proper and the neighboring country. The house surgeon, and one of the clerks, both gave the opinion that most of the cases of intermittent fever occurred amongst the laborers in the suburbs and vicinity of the city. But the truth is, the laborers on the levee, streets, and canals, furnish the greatest number of cases of all kinds of fever at this place. My own opinion is, that those localities, within the pre- cincts of the city, which afford the greatest amount of intermittent fever, also afford the greatest amount of re- mittent, bilious, and yellow fevers; moreover, that they are all dosehj allied affections. “ If I w r ere asked what sort of index these hospital statistics afford as to the prevalent fevers among the better classes of society in this city, I might be at a loss for a satisfactory reply. I think that the people in good cir- cumstances, who live w r ell (as they generally do), and are not imprudent, suffer but little from fever in this city. Those who have but recently settled here, are apt to take yellow fever, when it prevails; but, as they generally have prompt attendance, the mortality amongst them is small, and many escape it entirely. They appear to suffer more from the eruptive fevers than any others. No one, aware of the stupid imprudence and negligence of the laboring classes, can be surprised at the mortality amongst them. MALARIOUS FEVERS— PREVALENCE. 25 They receive high wages for their labor, and, having no idea of economy, it too often causes their ruin. “ One more reference to the statistics, and. I have done. It appears that the total admissions of all diseases into the main building of the Charity Hospital, during the above-stated period of seven years, was 45,713, of which 19,445 were for fevers, and of these last, 10,274 were for the different forms of intermittent fever .” From 9th August to 10th October, 1847, the following cases are reported at Montgomery, Ala.: Fever, Inter- mittent, Simple, 319; Remittent, Simple, 141 ; Remit- tent, Pernicious, 10; Remittent, Infantile, 11; Ty- phoid, 2. At Woodvilie, Miss., occurring in the practice of three physicians, from 15th August to 14th October, 1847 : Fever, Intermittent, 38 ; Remittent, 45 ; Remittent, In- fantile, 25 — One fatal ; Continued Bilious, 6 ; Congestive, 9 — one fatal. I have been informed by a respectable citizen (Mr. Davis) of Decatur, Ala., that, in 1840, there were 57 families in towm, and in the sicklv season there w T as sick- ness in 52 of them, in 12 of which all w r ere sick, both black and white. It was also very sickly at this place, and in the surrounding country, in the summer and autumn of 1836, with considerable fatality; one work- man made 74 coffins. At this place, in the autumn of 1848, 1 noted 39 cases of Quotidian Intermittent ; 8 Ter- tian; 8 Double Tertian; 2 Quartan; 13 Irregular, mostly inclined to the Quotidian type ; and a few cases of the Remittent and Congestive forms. This summary has, perhaps, been already sufficiently extended. From this review it appears that the inter- mittent is by far the most common form of malarious fever. From extensive inquiries, and from my own ob- servation, the quotidian is the most common type of in- 3 26 MALARIOUS FEVERS— COMPARATIVE LIABILITY. termittent fever. In some unhealthy localities, some believe the tertian to be the most common type. The tertian generally being a severer and more obstinate form, and, therefore, more frequently requiring medical aid, may explain the reason why authors have been led to suppose it is the most common. M. Nepple has endeavored to determine under what circumstances intermittent fevers may manifest a quoti- dian, tertian, or quartan type. It would appear that the relative frequency of these types varies with the latitude. Out of 3,114 cases of fever treated at Bona and Algiers, and out of 954 cases treated in the canton of Marthiel (Ain), the types were as follows : — All medical writers, who have written on fever as it exists in northern climates, agree in regarding the tertian as the most common type, while the above facts prove that the quotidian is more frequent in warmer latitudes. The quotidian type, according to M. Nepple, occurs most frequently in warm years, w T hile the tertian form is, on the other hand, most frequent in cold years ; the quoti- dian type also appearing to be less dependent on marsh miasmata than on accessory circumstances.* Comparative Liability, &c. — In addition to my own observation and experience, I have made considerable inquiries in relation to the “ comparative liability of the sexes, of the black and white races, and of different periods of life, to the several forms of the disease ; the influence of race upon its severity and danger.” 1st. As to the liability of the sexes, perhaps males Bona and Algiers. Ain, France. 443 420 91 Quotidian fevers Tertian Quartan - 2,181 901 32 * See London Med. Gaz., Sept. 1846, or Med. News, Dec. 1846. MALARIOUS FEVERS— COMPARATIVE LIABILITY. 27 are somewhat more frequently the subjects of the several forms of malarious disease, than females ; but it appears that the difference is very little ; and under the same cir- cumstances there is perhaps no difference, one being just as liable to it as the other. 2d. As regards the comparative liability of the black and wlrite races to the several forms of the disease, I be- lieve I can confidently state, that when both are placed under the same circumstances, there is no difference ; nor does there appear, under the same circumstances, any difference as to its severity or danger. Those who have resided for some time in a malarious district, appear to be less liable to it, and its severity less with them, than those who have recently arrived from a healthy re- gion of country; hence, the citizens of Charleston, South Carolina, on visiting their rice plantations in the coun- try, are more obnoxious to it than the work hands who remain on the plantations. It is also disposed to be much more virulent under these circumstances. Dr. Dickson, formerly of Charleston, now of New York, says: “In the bills of mortality for the city of Charleston, you will find every year a certain number of cases distinguished by the appellation of ‘country fever.’ The phrase is employed to denote the febrile attack, which follows within a short time, and with appalling certainty, an ex- posure to the concentrated malaria of the low country in our immediate vicinity. To sleep a single night upon his plantation, involves the southern agriculturist in the most serious danger; nay, he is not safe if he indulge himself in frequent visits, even by day, to his rice fields, or inhale too often, under any circumstances, the pesti- lential air of our swamps and marshes.” It is proper to remark that the slaves which reside on these plantations are by no means exempt from malarious disease, but the law above referred to appears to hold good here, as else- 28 MALARIOUS FEVERS— COMPARATIVE LIABILITY. where, viz. : that those who have resided for some time in a malarious district are less liable to it, and its seve- rity less with them, than those who have recently arrived from a healthy region of country. I have been informed that the negroes use “ bitters' 1 '' pretty freely, on these rice plantations, as a prophylaxis. The planters in Alabama. Tennessee, Mississippi, Louisiana, Arkansas, and else- where, who reside on their plantations, together with their families, appear to be no more liable to the several forms of malarious disease than the negroes ; but, in some seasons and localities, the negroes appear to suffer most (perhaps on account of their greater exposure), especially from what is termed typhoid pneumonia , in the southern and western States, which seems to be caused and modi- fied by malaria , cold and humidity, and exposure. This form of disease appears to be more common and fatal amongst the black population than the white, especially where the latter are not exposed in out-door business ; and I believe it is rather more common among the black males than the black females, where the latter remain mostly within doors, while the former are exposed to the vicis- situdes of weather, especially wet weather, in the latter part of the winter, and during the spring months; for it is at these times that this form of disease mostly prevails. I would not wish to be understood that the white popu- lation are exempt from it ; nay, in certain unhealthy loca- lities it sometimes prevails with great malignity amongst them. A great many, both black and white, suffered, and many died of it, in Decatur, Ala., and vicinity, in the latter part of the winter and spring in 1846 ; and again during the same season in 1847. I believe it is generally more malignant early in the spring than at any other time ; — but I will defer the further considera- tion of this subject till I come specially to treat of it. 3d. As to the comparative liability of the different pe- MALARIOUS FEVERS— COMPARATIVE LIABILITY. 29 riods of life to the several forms of malarious disease, it appears that those between the ages of two years and fifty or sixty, are most liable to intermittent fever. I be- lieve that those who are over sixty years of age are some- what less liable to it than those under two years. The susceptibility of those under two years appears to in- crease with increase of age. And here I will take occa- sion to remark that young children are more frequently the subjects of intermittent fever, than is supposed by many. I have frequently known them laboring under this form of disease when it was not suspected by their parents, who supposed their child was very sick with some other malady, or they did not conjecture what was the matter. I have also known practitioners to overlook or mistake its character. Of this I shall have more to say when I come to speak particularly of intermittent fever. Children under five years of age are less liable to re- mittent fever than those who have passed this age. Those between two and five years of age appear to be more liable to it than those under two years, but it does not appear to occur very frequently in the former. Those under two years of age, so far as I am aware, are seldom the subjects of remittent fever, though they are not entirely exempt from it. Professor Geddings, of Charleston, in 1822, speaks of an infant that died of autumnal fever, which Professor Dunglison notices under the head of Malignant Remittent Fever. It appears that a very large majority of the cases of congestive fever occur among adults, or those who have arrived at the age of puberty ; though it is not exclusively confined to them; as children of three years, or five years and upwards, are sometimes the subjects of it. In the autumn of 1848, I saw a case in an infant about two and a half months old. Poverty and destitution, want of sufficient and whole- 30 INTERMITTENT FEVER— CAUSES' OF. some nourishment, exposure and intemperance, undoubt- edly largely contribute to render all ages, sexes, or races, much more obnoxious to the several forms of malarious disease. CHAPTER II. INTERMITTENT FEVER— CHILLS AND FEVER. Causes. — I will first offer what I have to say of the causes of intermittent fever (the “ fever and ague ,” or “ fever and agerf of many of the country people) ; then proceed to give a description of the several forms, patho- logy, complications, sequelae, treatment, etc. As my object is a fair and impartial statement of facts, designing to be plain and practical, I will not enter into metaphysical disquisitions in relation to what a majority of authors of the present day consider as the essential cause of this affection — viz., malaria. What are termed malarious diseases are generally considered to be pecu- liar to themselves, and acknowledge the same cause or causes, more or less modified. They are endemic in many parts of the southern and western States, as well as in many other parts of the world, especially in low, marshy, and swampy regions ; and on nearly all the principal, and many of the smaller water courses in the southern and western States ; but they are not always confined to these, sometimes making their way into hilly and mountainous regions; indeed, in some elevated hilly places they are endemic. They are, however, most ge- nerally disposed to penetrate into hilly and mountainous regions when they appear as an epidemic or endemico- epidemic. Nor do they prevail as an endemic in all swampy regions of country. Professor Dunglison says: “ Districts, indeed, similar to those which in certain re- INTERMITTENT FEVER— CAUSES OF. 31 gions are known to disengage the marshy miasm in great abundance, may, in other regions, be perfectly salu- brious. It is not every marsh that exhales the fitful pest. In the eastern parts of this country, many marshes exist, where agues are unknown ; and, again, malarious dis- eases prevail in fearful intensity, in the most pernicious form, where there is no such thing as a marsh within many miles.” Dr. Cartwright, of Natchez, Mississippi, asserts, that the Jussieua grandifolia, or floating plant of the bayous and lakes of Lower Louisiana, has the power of preventing the development of malaria in regions particularly adapted to its generation; and, moreover, affirms that it purifies all stagnant water in which it grows ; that of the lakes and bayous inhabited by it being as pure to the sight, taste, and smell, as if it had just fallen from the clouds. He ascribes to the presence of, and the peculiar hygienic, or health-preserving proper- ties of this plant, the remarkable exemption of the inha- bitants of Lower Louisiana from malarious or miasmatic diseases. He says, the fact, that the region of country in which this aquatic plant abounds, is exceedingly healthy, can be established beyond cavil or dispute, but nevertheless contains more stagnant water and swamps than any other inhabited district, of the same extent, in the United States. This family of diseases have had assigned as their cause, besides miasm or malaria, heat and moisture, warm days followed by cool, humid nights; carbonic acid, and sulphuretted hydrogen gas; animalcules ; aerial, tellurical, or geological disturbances or modifications in electricity; by local irritation, etc., etc. But in the present state of our knowledge, of the qualities, proper- ties, or nature of the commonly assigned cause, we may confess our ignorance. If there is any such thing as miasm, perhaps, in the march of mental improvement, 32 INTERMITTENT FEVER— CAUSES OF. future generations may be enabled to appreciate its pro- perties or its nature. Some writers, with plausibility too, deny the existence of such a thing. There are, however, what we may term exciting or secondary causes (if there is such a poison as miasm, as the chief or pri- mary cause), which we can better appreciate or compre- hend. Of these we may mention, exposure to sudden vicissitudes of weather, as high atmospheric temperature during the day, followed by cool, humid nights; intempe- rance ; want of proper and sufficient nourishment ; lying, during the night especially, in low, damp situations ; and everything which has a tendency to produce relaxation and debility. Exposure to the rays of the sun, especially when the weather begins to get a little cool in autumn ; and eating muscadines or watermelons late in the season, are noticed as causes by the non-professional. Some authors state that inter mittents have been brought on by various crude ingesta, and by local irritation, without being exposed to marsh effluvia. A case of remittent fever, produced by a one grain weight in the intestines of a child eighteen months old, is noticed in the October number of the Western Lancet , for 1848. This case is reported by Richard Payne Cotton. It escaped from the rectum after a period of six weeks, appearing to have lost nothing in its transit, retaining its usual brightness. Professor Dunglison says : “ The health of a locality is, likewise, often connected with the winds that prevail during the latter part of summer and autumn. In this country, they are chiefly from the southward, or have, what the sailors term, southing in them. These winds are warm, and, when from the east, are moist at the same time. Inhabitants of the northern shores of our rivers, that exhale malaria, or to the northward of any malarious locality, may, therefore, be expected to suffer more than those to the south of those localities ; and such is, cceteris INTERMITTENT FEVER— CAUSES OF. 33 paribus , the fact.” The reverse of this holds good, generally, in the south-western States, at least, so far as the author’s observations extend. In this region of country, a constant cool wind from the north, in aguish districts, is almost sure to bring about intermittents, and other malarious diseases. This is particularly noticed, not only by physicians, but the people generally. It has also been observed that the inhabitants on the north side of a river suffer more from malarious diseases when the wind is from the south, and that both sides of a river, which runs westwardly or eastwardly, are seldom or never equally sickly at the same time. These remarks apply particularly to the Tennessee River Valley in North Alabama. I have heard it suggested that the more malignant or congestive forms of malarious fever, were not known in this country till since the epidemic or Asiatic cholera visited this continent. Though conges- tive fever appears to have been much more common since this time, and more particularly noticed by that name, yet it was observed in this country prior to the visitation of the cholera. As a means of prophylaxis, many southern planters are in the habit of leaving a woodland surrounding their residences, or especially between their dwellings and any swamp that may be near, which is suspected to generate the marsh poison or miasm. Though this does not secure immunity, it perhaps renders them somewhat less liable. It would seem that the ancients entertained similar views as to the protective influence of forests, and, therefore, it has been supposed that the woods in the vicinity of Rome were consecrated to Neptune, to secure them from the axe. If the Jussieua grandifolia has the powers ascribed to it by Dr. Cartwright, would not its propagation in all our swampy, malarious districts, be one of the greatest blessings to the inhabitants of these regions ? and almost 34 INTERMITTENT FEVER— CAUSES OF. induce them to suppose, if they were believers in ancient mythology, that most of the Fates, which escaped from Pandora's box, were destroyed by this aquatic plant ; as the less informed Irishman believes that St. Patrick destroyed all the frogs and serpents in Ireland, and ren- dered that island uninhabitable by these animals? I have sometimes been led to notice, that a removal from a malarious district to a healthy one, during what may be supposed to have been the latent period, ap- parently has a tendency to develop some form of mala- rious disease. If this be true, it is a curious fact. Professor Dickson’s observations appear to corroborate this idea. He says, “ It has been a long received opinion that a return to our comparatively healthy city (Charles- ton) atmosphere, the ordinary summer residence of so many planters, during the latent period which ensues after efficient exposure, as above described, endows the coming attack, in some obscure manner, with a peculiar violence and malignity,” and that the type “ is apt to be irregular, confused, and complicated and further, “a similar aggravation of violence and danger is affirmed to occur everywhere, when a subject efficiently exposed to the influence of febrific miasmata, has removed during the latent period to a pure and salubrious atmosphere. This is true, as Flint tells us, of the upland prairies of the far West, and as I have more than once had occasion to note, in our own lofty mountain regions.” Some who have had an attack of intermittent fever one summer or autumn, appear, under favorable circum- stances for its development, to have acquired a proclivity or obnoxiousness to it the next succeeding summer or fall, and hence some authors have made an annual va- riety of intermittent fever. Before noticing the different stages of a paroxysm of intermittent fever, I will notice what may be considered INTERMITTENT FEVER— PRODROMIC FORM OR TYPE. 35 the prodromic form or type of malarious disease. This is indicated by a slight feeling of malaise , or restlessness, feverishness, headache ; slight, rather obtuse pains or aching in the loins, and sometimes elsewhere ; nervous- ness, sometimes alternated with, or followed by flushes of heat, dryness and moisture of the skin. If these disturbances t^ke place about meal time, the appetite is noticed to be not good, much less food than usual suffi- cing for the repast. The fingers and toes, during these irregular nervous disturbances, are apt to be a little cool, and, perhaps, generally moist, especially the feet, and sometimes other portions of the body ; but probably most frequently not noticed by the patient, unless the attention be particularly pointed to them by interrogatories. A feeling of drowsiness, or slight languor, or headache may ensue. These slight disturbances, sometimes so slight as scarcely to attract attention, may recur about the same time every day, every other day, or at irregular periods, for several days, a week or more, and sometimes pass off; but frequently, if not attended to, is soon developed into a distinct paroxysm of intermittent, remittent, or conges- tive fever. R. S. Holmes, M. D., Med. Staff, U. S. A., in his Re- marks on the use of quinine in Florida, and on malaria and its influence in that State, says : “ I believe there is scarcely a person even in good health in a miasmatic re- gion, who is not subjected in some degree to the effects of the unseen agent around him. His rest will be broken at night; his appetite will not be so good as formerly; he will not enjoy that feeling of full health he has been accustomed to; his system will be attacked from time to time by the offshoots of the diseases preying on others around him, though he will not be sick, and may escape with a like freedom from disease during all his sojourn in the country : but the whole constitution seems in some 36 INTERMITTENT FEVER— PRODROMIC FORM OR TYPE. degree to labor under the influence of malaria. Slight wounds, that would heal elsewhere in a few days’ time, must here undergo the slow process of suppuration and granulation, and even this does not come on easily, the wound remaining for several days without any visible advance towards a cure. You cannot persuade a slight incision of the skin to heal by adhesive inflammation ; and I have repeatedly seen wounds in habits that were to all intents healthy, assume a deep, burrowing suppu- ration. I was in the habit at first of discharging patients when the wound had closed by granulations, if not on an important part of the body, and not interfering with com- mon duties ; but on the slightest exercise or excitpment, inflammation would set in afresh, in surrounding parts; the granulations would assume an unhealthy appear- ance; suppuration, if advanced, would be slow in pro- gress, and of an unhealthy form : perfect rest, good diet, occasionally tonics ; and poultices or stimulants to the part, were necessary for a cure. Many of these wounds, especially about the fingers, ran rapidly into deep-seated inflammations. A miasmatic constitution of the atmos- phere is particularly favorable to the formation of whit- lows. I treated these by deep incisions, and generally, some hours after, sprinkled the part over with calomel ; but the first incisions scarcely ever proved sufficient; the suppuration would extend beyond them. The pain of these whitlows will take on regular remissions.” This prodromic form or type of malarious derangement may be easily cured by quinine or other tonics, it some- times being necessary to take an aperient. Some phy- sicians, when busily engaged in practice, if they feel some of the manifestations of this prodromic form or type, are in the habit of immediately taking a dose of quinine. I have thought it proper to consider this condition first, and separately, because those thus affected are not INTERMITTENT FEVER— SYMPTOMS— COLD STAGE. 37 prevented from attending to their ordinary business, and it frequently attracts so little attention, unless its milder manifestations are increased to greater disturbances, that its treatment is often neglected, which, if it had been at- tended to, might have averted an attack of intermittent, remittent, or congestive fever. Before a paroxysm of any of the types of intermittent fever occurs, it is generally, if not always, preceded by 'precursory symptoms ; as, aching in the loins, with ner- vous sensations running up and down the same ; which some have likened, for want of a better simile, to cold water trickling down the loins ; yawning, stretching ; being a little cool, with a disposition to draw near the tire, etc. Sometimes pains in the limbs or joints, slight headache, indisposition, lassitude, the fingers and toes become cool, and the features are generally somewhat pallid. To these soon succeeds, 1. The Cold Stage, Chill, or Rigor, sometimes merely attended with an uncomfortable sensation of cold- ness, especially of the hands and feet, and a feeling of uncomfortableness and oppression ; at others stretching, gaping, and drawing near the fire, with an involuntary shivering or shaking of the whole body, more or less in- tense, at times causing chattering of the teeth. The aching and trickling sensations of the back, noticed during the premonitory stage, are augmented. There is generally a disposition to draw the knees and chin near each other, as though the patient wished to get into as small a compass as possible ; the skin is pale, and generally of a rather purplish or muddy hue, though in other cases slightly tinged with a yellowish hue. These are more distinct on some parts than others ; as the lips, about the face and neck, fingers, particularly blueness of the nails, &c. The cutaneous surface also becomes con- 38 INTERMITTENT FEVER— SYMPTOMS. tracted, wrinkled, more or less rough; which condition has been called cutis anserina , or goose skin. The cold, chilly, benumbed sensations of the patient, are not always in accordance with the actual reduction of the tempera- ture of the surface. The sensations of the patient may incline him to believe that he is very cold, when to the hand of any of his attendants there appears to be little or no alteration of the temperature of the surface; or the pa- tient may correctly appreciate the degree of coldness; or he may feel cool, when to the touch of another he is warmer than natural, especially about the chest; or he may feel hot when he is cool. The sensible perspiration is suspended ; the pulse is small, weak, contracted ; but in the sanguine temperament may be rather firm, and is generally increased in frequency. Respiration is embar- rassed, irregular, and increased in frequency, with a full inspiration or deep sigh occasionally, in some cases at- tended with a short, dry cough ; a sensation of oppres- sion ; enfeebled and tremulous voice. In some cases, a sensation of weight or heaviness, pain and distressing nausea of the stomach, at times, in some cases, attended with vomiting of a ropy, glairy mucus; and, if the vo- miting continues for some time, succeeded by yellowish bile, and sometimes even blood; a wild stare of the eyes; great desire for cold drinks; the mouth and fauces rather dry and clammy ; cramps of the stomach and abdomen, and upper and lower extremities. Urine usually co- pious and clear. Though some or all of the above symptoms usually characterize the cold stage, yet others sometimes occur, which are commonly regarded as anomalies , and which we will notice presently. The duration of the cold stage is very various, in some cases lasting only a few minutes, in others one, two, three, four, or five hours, or longer. I believe those cases INTERMITTENT FEVER— SYMPTOMS. 39 in which the cold stage is several hours long, are apt to be attended with great distress of the stomach, nausea and vomiting, but this is not always so. In many cases the mental functions are increased, ideas passing through the mind with unusual rapidity, with concomitant restlessness, confusion and irritability of mind, and sometimes slight delirium : this is more likely to occur in those of a sanguine or excitable tem- perament ; while it is common for those of a leuco-phleg- matic temperament, especially after they have had ague for a long time, to be dull, careless, manifesting a taciturn moroseness ; and this stage in them is frequently charac- terized only by cold extremities and dulness. In those of full habit, stupor or coma is sometimes induced, but this is more apt to be the case on the approach of, or during the next stage, the stage of excitement. During the cold stage, the whole body is diminished in volume ; rings on the fingers, which were previously tight, become loose, and tumors near the surface are re- duced in size. But it must not be supposed that all the above symp- toms or phenomena are to be met with in every case. In some cases there are only slight sensations of chilli- ness creeping along the loins, with cool hands and feet, with some degree of restlessness or languor ; and even these are sometimes scarcely noticed. The degree of excitement cannot be anticipated by the intensity or se- verity of the cold stage, chill, or rigor. Sometimes the reaction will be as great when the feet and hands have merely been observed to be a little cool, with perhaps some creeping, nervous sensations in the back, slight nervous agitation, or feeling of uncomfortableness, as when the rigor is very severe. And here I wish to re- mark, and desire that especial attention be paid to it, that infants, and young children generally, merely have 40 INTERMITTENT FEVER— SYMPTOMS. cool hands and feet , sometimes attended with restlessness , respiration somewhat embarrassed , and quickness or ir- regularity of the pulse , during the cold stage of intermit- tents : and as the coolness of the extremities is fre- quently overlooked, or not noticed by the parent or attendant physician, they are puzzled to properly appre- ciate the nature of the affection ; and, in consequence thereof, an improper course of treatment may be, and not unfrequently is, adopted. It is also said that, in young children, a paroxysm is sometimes ushered in by con- vulsions, but this is more apt to occur at the commence- ment of the hot stage. In some cases the febrile condition precedes the chilly sensations. This was the case with the writer in the latter part of August, 1848. About twilight one evening some slight, chilly sensations came on, which were fol- lowed by fever ; the second evening afterwards a febrile condition came on ; and some twenty-five or thirty minutes afterwards, chilly sensations, with the peculiar sensations in the loins were felt, w’hile the febrile excitement con- tinued. Indeed, it is not unfrequently the case, that the chilly feeling and febrile condition are concomitant in their inception, the former passing off after an indefinite length of time. This form is perhaps analogous if not identical with the epialos of the ancient Greeks. It would be impossible to describe all the various modi- fications and phenomena which at times manifest their appearance in the cold stage of intermittents. In order to fully appreciate them, it is necessary that one should practice a sufficient length of time in a malarious region of country, and observe closely and carefully for himself ; and he may be much assisted by frequent conversations and communications with his brother practitioners. Most commonly, as the chilly feelings begin to abate, transient flushes of heat make their appearance. INTERMITTENT FEVER— HOT STAGE. 41 which become more and more permanent ; the heat of the body is first augmented, and then extends, pari passu , to the head and extremities ; the reverse of this having taken place during the cold stage. It has been remarked that the nausea and vomiting are commonly most apt to be severe at this time. 2. The Hot Stage, or Stage of Expansion, as it has been termed, which succeeds the cold stage, is charac- terized by a full and flushed countenance, quickness of the mental functions, pain in the forehead, and headache, most commonly; restlessness, mobility, and in some cases slight delirium ; or a disposition to coma and lethargy; aching in the loins, and sometimes in the ex- tremities and joints. The respiration is still embarrassed, hurried, and oppressed, but in a less degree than in the preceding stage. The pulse becomes more full and de- veloped, still being increased somewhat in rapidity; in some cases the carotids are seen to beat with augmented force and frequency, especially in those of a sanguine temperament, or those who have recently arrived from a more healthy region of country. In these, it is more apt to assume what has been called the inflammatory variety of intermittent fever. In many of those whose systems have become debilitated and relaxed from a long residence in a warm and malarious country, the pulse is not usually so full and hard as might be expected by those who prac- tice in more northern and healthy regions. The skin is dry , hot, and accompanied with embonpoint, or fulness; the mouth dry and clammy, and the breath warmer than natural. The sensation of heat is variable, sometimes considerably augmented,* at others but little more than natural. At this time, in most cases, there is more * Fordyce observed the temperature of the surface as high as 105° Fahr. 4 42 INTERMITTENT FEVER— HOT STAGE. or less restlessness, and a disposition to throw off the bed- clothes, in order that the body may he exposed to a cool atmosphere ; but in some there is an indifference, dul- ness, and stupidity, more especially in those who have had the disease a long time, and have become cachectic, with concomitant visceral disease. In some cases the fever is so mild that the patient is able to walk about, feeliim nervous and feeble. O The gastric disturbance at the commencement of this stage usually gradually subsides, and is succeeded by cephalalgia, or pain in the head, which, in the robust and sanguine temperament, is sometimes very intense. The urine is scanty and high colored, depositing little or no sediment, and of a sort of pungent, rancid odor. The duration of the hot stage is very various, but generally longer than the cold stage. Not unfrequently it passes off in two or three hours, and the individual gets up and walks about, or attends to some light work or business; frequently it lasts for four, six, or eight hours, or more, which is usually succeeded by a greater degree of weakness and languor. Sometimes this stage becomes more and more protracted at each paroxysm, till this form of fever is merged into the remittent form. The above may be considered the usual manifestations or attendant phenomena of the cold and hot stages of in- termittent fever, but they are not always uniformly so; some of them may be wanting, and other anomalous phe- nomena, more or less common, manifest themselves; as cramp and intense pain of the stomach, and palpitations of the heart, connected with cold hands and feet; griping pains in the bowels; intense pain in some part of the body, which may be more or less migratory, coming on by spells, with intervals of partial or entire relief. Indeed, almost every form of neuralgia may be indicative of the malarious influence ; frontal neuralgia, or headache , which returns every day, or every other day, at about the same INTERMITTENT FEVER— ANOMALOUS VARIETIES. 43 time of day, is not unfrequently observed. Sometimes we observe dor so-inter costal neuralgia , hepatalgia , hemi- crania , toothache, some form of rheumatism, hiccough, mania, etc. etc.; and these are observed to recur at par- ticular times, with as much regularity as a well-marked case of quotidian or tertian intermittent, and yield to the same remedies as these latter. These are the mashed agues, febres intermittentes larvatce, of authors, or dumb ague, of the non-professional ; but I believe a goodly num- ber of the unprofessional, call a case the “ dumb ague,” when the cold stage is scarcely perceived, attended with languor. Diarrhoea and dysentery not unfrequently attend some of the manifestations of malarious influence ; and cholera is also mentioned by some authors. Dr. Eberle says: “In some instances, anomalies of a remarkable character occur, both in relation to the phe- nomena and the succession of the stages of the disease. I have known a case, in which the first two paroxysms occurred in a perfectly regular manner ; but after em- ploying arsenic, unsuccessfully, during the second and third intermissions, the paroxysms returned without a cold stage, the patient experiencing, instead of it, a pecu- liar feeling of numbness on the top of the head, with great dulness of hearing, for about forty or fifty minutes before the supervention of the hot stage. There are in- stances on record, of the inversion of the natural order of the cold, hot, and sweating stages; several distinct in- stances of which occurred under my observation in the fall of 1828. Cases have been noticed, in which the perspiration, in the third stage, was substituted by diar- rhoea ; and Cleghorn states that he saw tertians, which terminated by an increased flow of urine, with scarcely any sweat.” But I will return from this digression, and notice what is commonly considered the last stage of the paroxysm, namely — 44 INTERMITTENT FEVER— ANOMALOUS VARIETIES. 3. The Sweating Stage, which usually commences with moisture of the forehead and temples, neck, axilla, chest, inner part of the thighs, soon becoming general ; sometimes being very copious, and not only soaking the body linen, but even the bed-clothes ; in other cases, there is but a gentle perspiration, or there may only be mois- ture on some parts of the body. When it is copious, it has a sort of flat, funky smell; when scanty, or slight, less so, and more pungent. The patient gets better soon after the commencement of this stage ; the hot skin of the former stage now as- sumes its normal temperature, or may even feel a little cooler to another person ; the pains and oppression gra- dually disappear ; the respiration becomes free and easy ; the pulse full and soft, and but little, if any more frequent than natural. In fact, the patient is every way relieved. The urine is now more or less high colored, and deposits a lateritious or pale red sediment ; the odor above no- ticed may also be perceived, somewhat modified perhaps. “ This gradual melioration of the febrile symptoms con- tinues under the free flow of the perspiration, until the paroxysm terminates in a state of perfect convalescence, or apyrexia .” ( Eberle .) Dr. Billing does not consider this stage entitled to the appellation, or says there is no third stage, the sweat being “ nothing but an indication of renewed secretion by the capillaries ; which, after having lost their tone, and been consequently in a relaxed, disturbed, non-se- creting state, renew their secretion on being restored to a normal condition.” The above-mentioned three stages are said to consti- tute a 'paroxysm , or Jit. The paroxysm being over, the patient may feel en- tirely well during the apyrexia, though usually rather INTERMITTENT FEVER— TYPES. 45 weak, languid, lazy, or averse to bodily exertion ; with, in some cases, hebetude of the sensorial or mental powers ; looks pale and sickly ; is very susceptible to the influence of cold; is easily fatigued by exertion or labor; the appe- tite is generally impaired, but in some protracted or chro- nic cases it is very voracious. The duration of the period of apyrexia is modified by the length of the paroxysm, the type of the intermittent, and the means that may be used to avert the next paroxysm. Types. — Intermittent^ having a disposition to recur at certain times, has given rise to distinctive appellations which indicate the type ; as, the quotidian , which returns every day, or every twenty-four hours ; the tertian , every other day; the quartan , every third day. The double quotidian has two paroxysms every day ; the first one corresponding with the first one, and the second the second one, the day previous. The double tertian has a paroxysm every day, the paroxysms of every other day corresponding. These are the principal types, though others are noticed, especially irregular ones, which ob- serve no particular time in their recurrence, but are apt to simulate, in some degree, some of the other types, at least for a time, and then there may be an interval of several days. Double quartans, triple quotidians , triple and quadruple tertians occur but seldom. Authors men- tion the quintan, sextan , hebdomadal , octan, nonan , men - sual, bimensual, tnmensual , annual, etc. If the paroxysm recurs after an interval of more than three days, I am inclined to believe that they should generally be regarded as relapses, or a return of the disease ; and this is more apt to take place if the preceding attack has induced some local visceral disease and debility ; or the indivi- dual is still exposed to the causes of intermittents. Not unfrequently one type changes to another ; and this 46 INTERMITTENT FEVER— TYPES. reciprocity or interchanging is most common among the different varieties of quotidians and tertians ; and these are also more liable to run into the remittent or conges- tive fever ; and these latter, by treatment, may be made to assume some of the intermittent types. Remittent fever, especially in some instances when it appears as an epidemic, is sometimes easily changed to the intermittent form, by a venesection. Intermittent fever is also apt to ensue after a remittent has been cured, especially if the case occur in a highly malarious district, and proper at- tention is neglected. One paroxysm may follow another in a short time, by exposure and fatigue; indeed, these may bring on a second chill before the paroxysm is over. An individual may have three, four, five, or more chills in one day ; again he may have a chill one day, and not another for several days afterwards; and then he may have several in pretty close succession; and then they may again disap- pear for an indefinite length of time, or entirely. Many respectable medical writers speak of the strong proclivity of intermittents to relapse at certain intervals, as the seventh, fourteenth, or twenty-first days; and also re- mark that they are more easily and permanently cured by the exhibition of the proper remedies at these pe- riods. In this, there appears at least some inconsistency, some fixing one period and some another. As I have known intermittents to recur or return at so many and various periods, I am inclined to consider these notions as relics of ancient superstition. A believer in these cri- tical days, having his mind more particularly directed to them, may observe the recurrence of a paroxysm on those days, while many others may escape his attention. When the paroxysm comes on earlier in the day than the preceding paroxysm, it is said to be anticipating; when later, postponing. If one begins before the prece- INTERMITTENT FEVER— PATHOLOGY. 47 ding one terminates, the fever is said to be subintrant. Those of this nature are, perhaps, closely allied, if not identical with the amphemerina of the Greeks. As to complicated intermittents, it would seem that the malarious influence may attach itself to almost every form of organic or constitutional disease, and as this is of very frequent occurrence, I consider it of much im- portance to those who have recently commenced practice in a malarious region, in order that they may appreciate this twofold condition, and combine their remedies so as to fulfil this double indication. Visceral affections, dysen- tery, jaundice, paralysis, apoplexy,*' epilepsy, and the various neuralgias may bbSregarded as complications. The various forms of malarious neuralgia, if I may be allowed the expression, Which strictly observe a periodi- cal recurrence (perhaps a majority of them observe the quotidian type), are generally preceded by some of the mildest premonitory symptoms of ague ; as, a feeling of nervousness, or slight chilliness ; the feet are apt to get cool and moist, perhaps the fingers also, and moist skin, etc. etc. ; and after the paroxysm is over, the urine is apt to be turbid ; during the paroxysm clear, and sometimes copious, especially in nervous females. Pathology. — If intermittent fever and other malarious affections are caused by any material substance, as miasm, malaria, poisonous gas of any kind, animalculae, or any- thing floating in the atmosphere, it appears most rea- sonable to suppose that it is inhaled into the lungs with the air in inspiration, there absorbed, admitted into the circulating fluid, the blood, on which it probably in- * This malarious influence, in reference to the pathological condition of the brain, should, perhaps, be, regarded as a sort of nervous apoplexy (if it is entitled to the appellation of “ apoplexy ” at all), entirely distinct from true apoplexy. 48 INTERMITTENT FEVER— PATHOLOGY. duces some morbid change, or is carried by it to the nervous centres , where it apparently first manifests its morbid influence; or this derangement of the nervous centres may be the result of pathological changes that have taken place in the blood : indeed, the position that the poison is inhaled into the lungs, and there admitted into the circulation, appears tacitly to acknowledge, that, during the latent period, some morbid change may be going on in the blood. If malarious affections are caused by the sensible or appreciable conditions of the atmo- sphere, as heat and cold, and humidity, or by electrical, tellurical, or geological disturbances, it would seem that the primary morbid influence is exerted an the nervous centres, and thence on the nervous system generally ; and then, as a matter of course, the whole system partici- pates to a greater or less extent in the derangement. In the present state of our knowledge, as to the precise nature of these morbid impressions, we can only draw inferences from the effects, and these may be correct or otherwise. Whatever is the primary impression, it ap- pears that the nervous centres are so affected as to pre- vent them from generating regularly the normal amount of nervous fluid, or that which gives nervous power (call it by whatever name you may); hence, there is a want of equilibrium in the nervous functions, or func- tions of the different parts of the nervous system, and this is soon succeeded (and probably attended from the beginning at the nervous centres) by manifest distur- bances of the circulation, as is evinced by the phenomena of a rigor most unequivocally. This being the case, we need not be surprised that those organs situated inter- nally, of a soft or spongy nature, and freely supplied by large blood-vessels, their nervous power considerably les- sened, should suffer from congestion or hypersemia, and consequent enlargement, as is most commonly observed INTERMITTENT FEVER— PERIODICITY. 49 of the spleen. The liver, lungs, kidneys, brain, heart, etc. etc., and even the larger vessels themselves, may suffer from congestion. Hence we observe that the in- tensity and seriousness of visceral diseases, as complica- tions, are in the ratio of the intensity and frequency or repetition of the paroxysms. In this general derange- ment of the nervous and circulatory systems, the capilla- ries become affected, and the different secretory functions are disturbed. Periodicity of Malarious Diseases. — As to the cause, or the laws that govern the periodical recurrence of intermit flents, and affections of a kindred nature, though plausible conjectures may be offered, nothing en- tirely and wholly satisfactory is known. Professor Dun- glison makes the following remarks, which in part, I believe, were expressed by Sydenham. “ We know no- thing of the causes of that periodicity, which is observed in the action of various organs in health, any more than of those which constitute the essence of various periodi- cal diseases. There is probably a periodical movement within us at different periods of the day, which corre- sponds with the same period in other days, and gives rise to the exacerbations that we notice in hectic and other fevers.” M. Rostan was of the opinion that the cause of the intermittence “is primarily seated in the fluids, in the blood ; and that from thence it influences, in a special manner, the nervous system.” Post-mortem examinations have heretofore thrown little or no light on the essence of intermittent fever, and other malarious affections, and perhaps never will ; unless, in the process of time, the improvements and discoveries in animal chemistry may enable us to detect some altered or modified condition of the blood and nervous matter ; 50 INTERMITTENT FEVER— PATHOLOGY. and the physiologist is better prepared to appreciate, in connection therewith, the peculiarities and properties of the functions of the different parts of the nervous sys- tem, both in health and disease. Some believe that malarious diseases are caused by lesion or disease of the cerebrospinal axis , or spinal mar- row, which they also consider to be the cause of the aching in the back and limbs, cold sensations, and shiver- ing. In confirmation of this opinion, they refer to ten- derness or pain produced by pressure on some portion of the dorsal or cervical region. Dr. Malone, of Florida, in 1834, appears to have been one of the first whose atten- tion was drawn to this cause or complication of inter- mittent s, and he believed that if they were not actually produced by spinal irritation , they were kept up by it, secondarily induced. He refers to a case (a female) in which he found the lower part of the neck and upper half of the dorsal column tender in several places ; which he cured by the application of a mustard cataplasm be- tween the shoulders, just before the coming on of the chill, and by the use of chamomile infusion. Dr. Kremer refers entirely to the first dorsal vertebra, and says, if in- termittent fever is considerable, or old, or masked, pres- sure on it, by giving pain, will suffice to evince its ( spi- nal irritation) existence. Dr. Grosheim found the pain to be most in the middle portion of the dorsal region, es- pecially in quotidians — and in five cases, by the applica- tion of leeches, cured four of them without any other remedy. Dr. B. Rush Mitchell, of St. Louis, Missouri, considers what is called “ congestive fever ” toxical apo- plexy of the cerebrospinal system” and says : We regret that we have not been able to substantiate our position by dissections which have been made, but the registers of which we have lost.” Of late years, southern practition- ers have paid more attention to the spinal column in in- INTERMITTENT FEVER— PATHOLOGY. 51 termittents, and some of them are in the habit of cupping or applying locaL applications to the spine, as adju- vantia, in their treatment. I have examined the spinal column in a great many cases of ague and fever; and though I have seen many cases, especially recent ones, in which 1 could discover no tenderness on pressure, or in some so slight as scarcely to be perceived, yet, in a large majority of the chronic cases, I have been able to discover one or more tender spots , principally, or indeed nearly always, in the upper half of the dorsal region ; and, occasionally, in some of these cases, in the lower portion of the cervical region. This tenderness of a por- tion of the dorsal region may extend up and down the spine to the extent of one, two, three, or more inches ; and, in some cases, after passing the fingers over a few inches where no tenderness is perceived, another tender spot may be found. I believe, so far as I can rely on my own observation, that it is somewhat more common, and most prominently manifests itself in females of a nervous temperament, in whom it is sometimes so tender, that they will shrink, and indeed scream out, when firm pressure ikinade. This condition is frequently observed for some time after the intermittent has been cured or disappeared ; indeed, in many cases, this spinal affection (as indicated by the sensitiveness of the upper portion of the dorsal region particularly) seems to become much more promi- nent after the disappearance of the fever and ague ; or the individual may be subject to occasional relapses. I may also remark, that this affection of the dorsal region, and in comparatively few cases the lower portion of the cervical region, is quite common among nervous females, and not uncommon amongst males, in the South, uncon- nected with intermittent fever. This morbid condition of the spinal marrow sometimes extends its influence around the sides of the chest, as is indicated by pain {dor so- 52 INTERMITTENT FEVER— TERMINATIONS. intercostal neuralgia ) extending sometimes to the liver (, hepatalgia ) and mammae. I believe, in nervous females, it more frequently affects the lower portion of the left mammse than the right, often exciting in them needless fears that it is the incipient stage of cancer, especially if some of the mammary glands should be rather sensitive or sore on pressure. These pains about the chest, to- gether with a more or less pallid appearance, also often induce them to believe that they are taking phthisis pul- monalis (consumption); or, if it extends to the liver (hepatalgia) and shoulder, it is too frequently regarded, even by physicians, as disease of the liver, and the patient is kept under the influence of calomel and blue mass for months, and even years, till his or her health becomes more and more imperfect ; and if this mercurial practice (which I regret is too often practiced, to the destruction of many valuable lives) is persisted in, organic diseases are induced, and the unfortunate sufferer is doomed to lead a more or less protracted existence, till consumption, dropsy, or some other form of disease, closes his earthly career. Perhaps females are somewhat more frequently sufferers in these respects than males, but it is not of very uncommon occurrence among the latter. I will defer the further consideration of this subject till I come to speak of it specially. Terminations of Intermittent Fever. — Perhaps or- dinary intermittents very rarely, if ever, primarily produce death; they may, however, assume the remittent or con- gestive form, and produce this result. Dr. Eberle says he has seen death occur in two cases of simple and mild intermittent ; but this is not easy to reconcile; for if they produced symptoms of apoplexy and death in the cold stage , I should think they were not very 11 simple and mild” but were perhaps what is now termed “ congestive INTERMITTENT FEVER— TERMINATIONS. 53 fever .'' 1 He says : “ The violent internal congestions which occur during the cold stage, are well calculated to produce cerebral oppression and apoplexy.” I have never known a case of pure uncomplicated intermittent fever to terminate fatally. This form of disease often produces enlargements of the spleen and other visceral affections, but these usually yield to the remedies for the primary disease, or get w 7 ell of themselves after the primary affection has been cured, especially if it has only been of short duration; but if more protracted, there are frequent exceptions, especially with regard to the spleen. This viscus may continue enlarged for a long time after the original disease has been cured ; indeed, it is often neglected till it becomes per- manently enlarged or hypertrophied, and in some cases indurated or serni-ossified ; cachexia (a pale tallowish appearance), nervous sympathies, or nervous disorders are produced, especially on the left side of the thorax and corresponding portion of the spine, left shoulder, neck, and head. Sympathies also exist between it (spleen) and the stomach, loins, and womb ; and the liver and kidneys may be implicated. These morbid conditions gradually steal upon the health of the individual, ' till debility, prostration, dropsy, and, in females, derangement of the menstrual functions, and, finally, if relief is not obtained, death closes the scene. Besides the morbid conditions of the spleen above noticed, if intermittent fever is suf- fered to continue for a long time, it is apt to produce other visceral diseases and conditions which may be re- garded as sequelae ; as, enlargement, induration, &c., of the liver ; diseases of the heart, stomach ; cachexia, ane- mia, or chlorosis, and derangements of the catamenial functions; anasarca, hydrothorax, ascites, hydrocele, chronic bronchitis, phthisis, etc. etc., and various neu- ralgic affections. 54 INTERMITTENT FEVER— DISLOCATION OF SPLEEN, ETC. Dr. Walter Teller, Medical Superintendent of the Temporary Provincial Lunatic Asylum, at Toronto (Canada West), in his report from April 1st, 1846, to March 31st, 1847, says : “ I would here refer to the case of three patients, who, previously to their becoming insane, had been laboring under intermittent fever ; after becoming insane, and during the early part of their resi- dence in the asylum, no symptom of that disease ap- peared. But suspecting, from their previous history, that this disease might still be connected with their insanity, as the latent cause, they were put under the proper treatment for intermittent fever. The insanity began to decline, and, with its gradual disappearance, the original disease again manifested itself in the usual symptoms. Ultimately, complete restoration to health of both body and mind was effected.” Dislocation of the Spleen. — So far as I am aware, dislocation of the spleen has entirely escaped the atten- tion of almost all medical writers, — and from this fact, it would seem reasonable to suppose that it is of very rare occurrence; indeed, I believe that there are but few physicians and authors who are aware that such a thing is possible. Several years ago, a case of enlargement and dislocation of the spleen, in a young lady, came under my professional care. She had dysmenorrhoea, and the en- largement and dislocation were principally induced by the perturbations of the system and congestion during very extremely painful catamenial epochs. By protracted treatment the dysmenorrhoea was relieved, the spleen reduced nearly to its natural size, appearing to assume almost its natural position, and seemed to have become attached, apparently by subacute inflammation, to the surrounding parts. Her health was now good ; but in the latter part of November, 1847, from exposure, and INTERMITTENT FEVER— DISLOCATION OF SPLEEN, ETC. 55 riding in the country on a limping horse, during the catamenial period, inflammation of the caecum or perityph- litis, was induced, and ccecal abscess ensued ; the latter ob- tained egress via the vagina ; and in consequence of the most violent and oft repeated paroxysms of suffering and. congestions, the spleen became again enlarged and dislo- cated, and she has suffered a great deal ever since; till recently (now December, 184S) her spleen is improving, and her general health getting better again. She suffered much from nervous pains in the spleen, left side of the thorax, extending to the left mammae; spine, shoulder, neck, head, heart, stomach, matrix, kidneys ; the ccecal abscess induced pains in the right lower limb, on the lower and right side of the loins, and upper portion of sacral region, in the matrix, right side, etc. She was also much troubled with eructations and singultus. The spleen was so much enlarged (being larger sometimes than at others) as to almost fill one side of the abdomen, sometimes oc- cupying the right side, at others pressing on the brim of the pelvis and fundus of the matrix, but it was most commonly kept on the left side by pressure, and, when in bed, by lying on the left side, with the hips elevated.* About the last of December, 1848, the abscess healed. Since writing the above (now May, 1849,) I am grati- fied to learn that the dislocated spleen is again nearly reduced to its natural size, and has almost assumed its normal position, being lower than natural ; and that the dysmenorrhoea is almost entirely well — the result of pro- tracted, and, as the result has proved, proper treatment. In the latter part of September last, another case of dislocation of the spleen, with induration of this viscus, * In a conversation Iliad with H. H. Parker, M. Di_(May 31st, 1849), of Brandon, Mississippi, he informed me that lie had seen two cases of dislo- cated spleen, both being enlarged, and one indurated. The subjects were females. 56 INTERMITTENT FEVER— DISLOCATION OF SPLEEN, ETC. came under my professional attention. The subject of it is a lady, who suffered some four years ago with inter- mittent fever, and also occasionally since. The spleen feels almost as hard as bone, is increased in length, some- what in breadth, and very little, if any, in thickness. Its notched edges can be as distinctly felt, when its position is favorable, as the cartilages of the ribs on either side of the epigastrium. It rolls about in the abdomen, either on the left or right side;, sometimes resting on the brim of the pelvis and pressing on the fundus of the womb. When I first saw her she w T as very low in health, subject to occasional attacks of ague and fever, of a pale, leuco- phlegmatic appearance, very much enfeebled and pros- trated, suffering very much from nervous pains in the spleen, left side of the thorax, extending to left mammae, spine, shoulder, neck, head, heart (occasionally palpita- tions), stomach, loins, womb. The liver was somewhat enlarged and indurated, and painful on pressure. Cata- menia irregular and scanty ; leucorrhqea present. I spoke guardedly encouraging to her, that she must have pa- tience to persevere in a protracted treatment, but gave an unfavorable prognosis to her husband. Up to this time (December 16th) she has, under treatment, improved much beyond my expectations; yet, assuredly, perfect health cannot be expected so long as the dislocated spleen remains in this situation. An interesting question might here arise as to the propriety of extirpating this viscus, which is not essential to life. The danger of producing peritoneal inflammation, appears to be the principal ob- jection. In reply to a letter which I recently wrote to Professor Dunglison on this subject, he says (Philadel- phia, Oct. 28th, 1848): * * * “In regard to the general question, as to the propriety of removing the spleen, I should have little hesitation in stating my opinion in the affirmative;” then, after referring to its INTERMITTENT FEVER— DISLOCATION OF SPLEEN, ETC. 57 performance on animals, which we will presently notice, says: “And they confirm the idea so ably urged by an old friend of mine, Dr. Blundell, of London, that there is not as much danger from peritoneal inflammation in operations implicating that membrane as has generally been imagined. The history of ovariotomy has confirmed his position. Still, splenotomy on man must be a serious and most dangerous operation, and cases must be rare where it is indispensable, and, therefore, justifiable.” In his work on Physiology, after noticing the various opinions as regards the functions or uses of the spleen, he remarks, that “ It is hard to say which of these specu- lations is the most ingenious. None can satisfy the ju- dicious physiologist, especially when he considers the comparative impunity consequent on extirpation of the organ. This was an operation performed at an early period. Pliny affirms that it was practiced on runners, to render them more swift. From animals the spleen has been repeatedly removed, and although many of these have died in consequence of the operation, several have recovered. Adelon refers to the case of a man who was wounded by a knife under the last false rib of the left side. Surgical attendance was not had until twelve hours afterwards, and as the spleen had issued at the wound, and was much altered, it was considered neces- sary to extirpate it. The vessels were tied ; the man got well in less than two months, and has ever since enjoyed good health. Sir Charles Bell asserts, that an old pupil had given him an account of his having cut off the spleen in a native of South America. The spleen had escaped through a wound, and had become gangrenous. Fie could observe no effect to result from the extirpation. T. Chapman, Esq., of Pumeah, in India, has related a case of excision of a portion of the spleen, by Dr. Mac- donald, of that station. A native, about thirty years of 5 58 INTERMITTENT FEVER— DISLOCATION OF SPLEEN, ETC. age, was gored in the abdomen by a buffalo, and through the wound, which was about three inches in length, a portion of the spleen protruded. Six days afterwards, the man sought advice from Dr. Macdonald, who removed the spleen with the knife, and the patient rapidly re- covered. “Dr. O’Brien, in an inaugural dissertation, published at Edinburgh, in 1818 , refers to a case which fell under his own management. The man was a native of Mexico ; the spleen lay out, owing to a wound of the abdomen, for two days before the surgeon was applied to. The bleed- ing was profuse ; the vessels and other connections were secured by ligature, and the spleen separated completely on the twentieth day of the wound. On the forty-fifth day, the man was discharged from the hospital, cured ; and he remarked to some one, about this time, that ‘ he felt as well as ever he did in his life.’ “ Dupuytren extirpated the spleen of forty dogs on the same day, without tying any vessel, but merely stitching up the wound of the abdomen ; yet no herporrhage su- pervened. In the first eight days, half the dogs operated on, died of inflammation of the abdominal viscera induced by the operation, as was proved by dissection. The other twenty got well without any accident, at the end of three weeks at the farthest. At first, they manifested a vora- cious appetite, but it soon resumed its natural standard. “ The experiments which have been made on animals by removing the spleen, have led to discordant results. Malpighi says, that the operation was followed by in- creased secretion of urine ; Dumas, that the animals had afterwards a voracious appetite ; Mead and Mayer, that digestion was impaired, that the evacuations were more liquid, and the bile more watery ; Tiedemann and Gme- lin, that the chyle appeared more transparent and devoid of clot; Professor Coleman, that the dogs, the subjects of INTERMITTENT FEVER— DISLOCATION OF SPLEEN, ETC. 59 the experiment, were fat and indolent. A dog - , whose spleen was removed by Mr. Mayo, became, on recovering from the wound, fatter than before ; in a year’s time it had returned to its former condition, and no difference was observed in its appearance or habits from those of other dogs. Similar results followed the experiments of Dr. Blundell, Mr. Dobson, and Mr. Eagle; and the last gentleman states, that an offer had been made him of a ‘ smart sum of money,’ by a dealer in Leadenhall Market, if he would tell him his method of fattening animals.” As before remarked, it is manifestly not essential to life. Dulaurens, Keiohring, Baillie, and others, refer to cases in which the spleen has been absent in man, without any apparent derangement of the functions. Dr. R. Lebby records, in the Southern Journal of Medicine and Phar- macy (Sept. 1846), a case of entire absence of the spleen. Another case is recorded by Dr. Meinhard, of St. Peters- burg!], in a German Journal. In concluding this part of the subject, I will notice two other cases of dislocation of the spleen. Professor Dunglison records a case, which occurred in a lady, in his Practice of Medicine , Vol. I., pages 554-5. He ob- serves : “On examining the right side of the abdomen, in which pain had been experienced, especially on change of posture, a large tumor was found extending from the hypochondriac region as far as the pelvis. The umbilical margin of this tumor could be felt distinctly lobated, as if it were shaped like the cactus. The tumor was per- ceptible in some positions of the patient more than in others, evidently changing its seat in the abdomen.” It appears that this case was brought on by suffering from malarious disease in the State of Virginia, and was mis- taken by the professor for enlargement or tumor of the right kidney. But he says : “ On opening the abdomen, the tumor of the right side was found to be an enlarged o o 60 INTERMITTENT FEVER— DISLOCATION OF SPLEEN, ETC. spleen, which had broken away from its attachments, and was resting with its convex surface on the brim of the pelvis, the lower extremity of the organ being turned up so as to reach the lumbar region. It was suspended by its peritoneal and vascular attachments, and could be moved freely in any direction.” She was pregnant, and her confinement was somewhat premature ; after delivery, she gradually sunk, until the period of her dissolution. Some years previously, in a fall from a horse, she had injured the right lumbar region. For further particulars in relation to this case I refer to his work, as there were other complications of a serious nature. M. Bozzi, in the Gaz. Med. de Milan, reports a case of descent of the spleen into the pelvis, with symptoms of sub- acute peritonitis and of intestinal strangulation. The subject of it was a female, 27 years of age, with curved spine, in the third or fourth month of pregnancy. From the commencement of utero-gestation, she had been daily affected with vomiting, and, at the period mentioned, symptoms of subacute peritonitis and intestinal strangu- lation manifested themselves, under which, in three days, she succumbed. On post-mortem examination, the spleen was found above the right iliac region, greatly enlarged, weighing six pounds, of a black color, and resting in part on the uterus and in part on the lower portion of the ilium and the ccecum, which were very much injected. The cord of splenic vessels was twice twisted on itself, by which the return of blood by the veins was impeded, and which was the cause of the great size acquired by this viscus. The peritoneum was injected principal^ at the points at which the spleen pressed. Nothing was ob- served abnormal in the interior of the intestines. (See Amer. Journ., 1847.) I am inclined to believe that dislocation of the spleen occurs more frequently than is generally imagined ; as INTERMITTENT FEVER— PROGNOSIS. 61 practitioners generally may not be careful enough in their examinations to ascertain its existence, and as the greater portion of the works on the practice of medicine do not speak of it, perhaps there are but few physicians who are aware that such a thing is possible. The second case, which I noticed above, for the greater portion of the last four years was under the care of several physicians, either alternately or conjointly, and, so far as I am aware, they had never detected it. Prognosis in Intermittent Fever. — Intermittent fever is one of the mildest and most manageable forms of disease with which we are acquainted ; yet, when neglected and suffered to run on, it may, and often does, more especially in the poorer classes, produce visceral and other affections, which have already been noticed, which may be protracted and difficult to cure ; or these secondary affections, especially if not properly attended to in time, may become more severe, the general health more and more impaired, till ultimately death results. Professor Dickson, formerly of Charleston, now of New York, says : — “The general prognosis in intermittent fevers is favor- ably, with some allowance for their tendency in all sea- sons and climates to obstinate protraction, and in hot and moist climates to malignant violence. Vernal intermit- ten ts are everywhere more curable than the autumnal : they are for the most part easily manageable, yet not without some risk both of immediate and ultimate ill effects.” Vernal intermittents are generally so mild as to have given rise to the old saying, that — “ An ague in the Spring, Is physic for a king.” “ It was supposed to act as ‘ physic’ by expelling mor- bific matters, which, without its intervention, might have 62 INTERMITTENT FEVER— POST-MORTEM APPEARANCES. been the source of more serious mischief.” ( Dunglison ■ ) It is needless to say this opinion was erroneous. Inter- mittents should always be avoided if possible. “ Particular 'prognosis. — The favorable symptoms are. ready solution of a paroxysm by sweating, and complete- ness of the apyrexia ; entire freedom from local ailment during the interval; postponement of the period of ac- cess ; and diminution of the violence of the invasion. On the other hand, an imperfect apyrexia ; the pertina- city of some of the local pains brought on by the pa- roxysm ; anticipation of the time of approach ; intensity of cold stage, and other symptoms of congestion ; violence of determination to important organs, in the hot stage, as to the head and stomach, are unfavorable signs.” (Dickson.) Post-mortem Appearances. — Dr. John P. Harrison, in the 'Transyloania Journal of Medicine , Yol. II., pages 424-5, reports the following case, which occurred in the Louisville Hospital. “ Matthew Revel, native of Ireland, aged 22 years, came under my care April 11th, 1827. He has been sick seven weeks with ague and fever. There is ascites, with anasarca of the face and feet ; he cannot lie on the left side ; spleen much enlarged ; has diarrhoea, with loss of appetite ; pulse moderately full and strong. He was purged with cream of tartar and jalap ; had calomel given as an alterant. After he had been in the hospital several days, discovered, in examining his thorax, some distinct evidences of hydrothorax ; has now some cough. He was purged, blistered, took calomel, digitalis, squills, and cream of tartar, alternately, but no visible amendment resulted from the treatment. On the 4th day of May he died. Upon examination, a few hours after death, the following appearances of disease were seen. The abdominal cavity contained a quart of water, INTERMITTENT FEVER— PATHOLOGY— BLOOD. 63 and more than a pint of thick, gelatinous substance, of the consistence of paste, or starch as prepared for starch- ing linen : the peritoneum was thickened generally ; the colon and stomach were adherent; a firm and gelatinous adhesion existed between the heart and pericardium ; the lungs were adherent to the pleura costalis of both cavi- ties; the right lung was partially hepatized, and was im- mersed in a pint of serous fluid.” The Blood. — Perhaps I may remark, without submit- ting myself to the charge of humorism , that a sufficient knowledge of the pathological condition of the blood, in intermittent fever, as well as other diseases, compared with its normal or healthy condition ; together with a proper knowledge of the properties and functions of the nervous system , both in health and disease, and the rela- tions these sustain respectively to each other , might en- able us to form a more rational therapeutics. But this desideratum, so difficult to obtain, being abstruse and surrounded with difficulties, which will require a great deal of patient research and minute investigations by the most devoted and ablest chemists, pathologists, and phy- siologists, will perhaps be retarded in its progress by some of the most prominent men in the medical world throw- ing the weight of their influence against them, — prefer- ring a shorter (empirical) way of treating diseases. It may be said that this department of medicine is just be- ginning to dawn ; and though some are now and then.led astray, as might be expected in the infancy of this de- partment, yet, it is to be hoped, that, step by step, facts, and additional facts, will be appreciated and combined ; analysis lead to synthesis, and, ultimately, that a well- understood, rational therapeutics will be established. Of course, in connection with this subject, the properties and modus operandi of the different articles of the ma - 64 INTERMITTENT FEVER— PATHOLOGY— BLOOD. ieria medica , in relation to each condition respectively, are to be considered. May unfading laurels crown the brows of those who devote themselves indefeasibly, assi- duously, and indefatigably, to these investigations ! The appearance of the blood in intermittent fever, when drawn, differs in different cases, owing to the tem- perament of the patient, the inflammatory nature, com- plications, acute or chronic form of the disease, etc. etc. It is generally of a dark color, and more consistent than natural. In those of a sanguine temperament, and in the acute stage of the inflammatory variety, it will pre- sent a buffy appearance and firm clot. In the chronic form of ague and fever, I believe the blood is usually of a paler appearance, with a predominance of serum ; and in some cases the surface presenting a greenish hue. In splenic cachexia, Dr. Twining says, the blood varies much in appearance; “sometimes it coagulates imperfectly, and no serum is separated ; in others, the cruor is black and soft, and, after being exposed to the air, its surface does not generally assume that more florid color which we observe on the top of a coagulum of blood drawn from the vein of a healthy person ; and it seldom exhibits a buffy coat, except when ardent pyrexia is present, or where the disease is attended with acute pain in the side. The serum, when heated, coagulates as firmly as that of a healthy person, but the coagulum is more friable and less tough, and it frequently has a slightly yellowish ap- pearance ; sometimes it has a greenish color.” Drs. Leonard and Foley, it appears, examined the blood in sixty-seven cases of intermittent fever, and “ con- stantly found that, in the incipient stages of the disorder, the fibrin of the blood was undiminished, but that its quantity fell under the influence of long duration or re- lapses of the malady. The red corpuscles, on the con- trary, are almost invariably lowered in quantity, and the INTERMITTENT FEVER— PATHOLOGY— BLOOD. 65 albumen of the serum, in particular, undergoes a marked diminution.” In concluding this part of the subject, I will refer to the analysis of Charles Frick, M. D., of Baltimore, in relation to the relative proportioiis of the different organic and inorganic elements of the blood, in “ Remittent and Intermittent Fever. — In the following table, the first five cases are of remittent, and the re- mainder of intermittent fever. Two are of the congestive form, one. remittent, No. 1, and the other intermittent, No. 7. In studying the proportion of fibrin in these cases, it will be found that, in four of those classed as remittent fever, this element is above the average stand- ard, the exception occurring in a patient, the duration of whose disease had been three weeks, and in whom all the elements of the blood, except the chlorides and the phosphates, were below their natural standard; while in five of the cases of intermittent fever out of the seven, it is below the average quantity; No. 10, one of the excep- tions, being complicated with ascites, and oedema of the lower extremities, coming on as an acute affection, and being preceded by a chill ; and the other being compli- cated with a pneumonia at the summit of the lung. It has been suggested, that the difference between these two fevers consists in the first having an acute gastro-duode- nites superadded to the second, thereby producing the gastric symptoms so common to the one, and wholly wanting* in the other, and also accounting for the attend- ant fever, being of a continued type. The increase of the fibrin in these cases seems, in a measure, to substan- tiate this idea. The globules in the remittent form, in all except the one above alluded to, are increased, as is * By referring to the symptoms of intermittent fever, it will he seen that Dr. F. is in error in stating that gastric symptoms are wholly absent. 66 INTERMITTENT FEVER— PROPHYLAXIS. the case generally with all the pyrexia. The changes of quantity in the chlorides and phosphates are found to be nearly dependent upon the particular month in which the examination is made ; and instead of being- dimin- ished, as Stephens has asserted, are, in reality, somewhat above the average in a majority of the cases, viz., nine out of twelve.” < V m Ti <*- o c c W C TO TO o i 1 £ S O -O — — TO O *— O o £ .2 % 2 .2 Q Solids 1000 g « to ■s ° s ..o o 5 gg TO c dogwood (Cornus cericea ), either the bark or the leaves, may be used as the above. The hark of the wild cherry (primus Virginiana), or the hark of the common poplar (Liriodendron tulipi- fera ), may be combined with either of the above. This list might be made much more extensive; but we will briefly mention the following: Boneset (eupato- rium per foliatum), extract or infusion; common yarrow, or milfoil (achillea millefolium) ; gentian; sulphate of iron; Prussian blue, in doses of from three grains to five, or more, three or four times a day; dose for a child, one grain ; sulphur ; horehound (marubium vulgar e)\ a decoc- tion of the leaves (fodder) of maize, or common corn, has been used in some places; stimulants; etc. etc. etc. 180 CONGESTIVE FEVER. CHAPTER XVII. CONGESTIVE FEVER ; OR, CONGESTIVE CHILLS. Some authors object to the term “ congestive fever” as they regard it an improper name for the disease we are about to consider : others think it the most proper designation that could be given it. As the disease is generally known by this appellation, I will not enter into a discussion as to its propriety or impropriety, wishing rather to be practically useful than theoretical. Notwith- standing a correct and uniform nomenclature is desira- ble, I consider it a matter of no very great importance, if the morbid condition is correctly appreciated, and the proper treatment adopted. Other names have been ap- plied to this disease, as “ malignant intermittent ,” “ per- nicious intermittent ” “ intermittent ataxic fever” and “ cold plague” Unquestionably, the best definition of congestive fever, as of all other diseases, consists in a description of its several forms and modifications. In the language of Dr. Harden, “Disease, abstractly considered, is not an entity or substantive thing, possessed of distinct qualities or properties, by which it may be distinguished and ar- ranged like the objects of natural history, but rather a mere mode or condition of the living organism, consist- ing in a certain change or series of changes in the solids and fluids ; the external manifestations of which are the phenomena, whether vital, physical, mechanical, or che- mical, presented during its continuance, or after the death of the individual subject of it. The difficulty, under wdiich the nosologist labors, therefore, may be CONGESTIVE FEVER. 181 appreciated by reflecting that the classification of diseases is but a classification of modes or conditions of the living system, or more properly, perhaps, the varying 'phe- nomena connected with those conditions In ctlmost all cases of congestive fever, premonitory symptoms, analogous or identical to those of intermittent fever precede the attack; although, in rare cases, the attack is sudden, and the shock as powerful and over- whelming as though the system had received a very severe concussion or wound, or was being overpowered with some_vioient poison. Sometimes, though very rarely, an individual may be walking about apparently well, and fall down suddenly, as from a fit of apoplexy. This occurs in hot, relaxing climates, in which intermit- tent, congestive, and remittent fevers are endemic, as in Bengal, Batavia, India, Italy, the more southern portions of our own country, and elsewhere. Dr. Bell says whan he was at Whampoa, below Canton, he saw a sailor fall down on the deck, within a few feet of him, senseless and motionless, as if apoplectic. He recovered. On board of another vessel, he “ was requested to visit incidentally a man, the steward, supposed to be under the influence of poison; he was in a state of insensibility, comatose, with occasional slight convulsions, and unable to swallow. He had been in this state since the preced- ing evening. It was then ten o’clock in the morning. External stimulants, and an enema of turpentine, had no effect. He died before noon.” Dr. R. S. Holmes, Sur- geon in the United States Army, in Florida, saw two cases, in which the attack was sudden and powerful, and which terminated fatally in less than twenty-four hours. In these sudden attacks, the individual may either be very much prostrated, dull, stupid, and disinclined to move, or he may be restless, rolling to and fro in the bed, perhaps jumping up and walking about over the house, in 182 CONGESTIVE FEVER. some cases becoming giddy ; then staggers, and probably falls on the floor. Such cases are apt to terminate fa- tally, unless prompt relief is afforded. Occasional attacks of intermittent fever, especially after the system has be- come much debilitated, now and then suddenly assumes a very severe form of congestive chill, and the patient may die in a few hours. Fortunately, the species of cases noticed above are of very rare occurrence, and it is said that after death there may be no lesion of any vital organ to account for this result. In one of those violent, restless cases reported bv Dr. R. S. Holmes, and which terminated fatally in less than twenty-four hours from the time of attack, the pa- tient being a stout, vigorous, dragoon soldier, the post- mortem appearances revealed the following : The con- gestion was in the thoracic viscera. “ The viscera of the abdomen were in apparently a sound and healthy condi- tion ; the contents of the cranium were in a healthy state ; the skin around the whole circumference of the chest was discolored by extravasated blood ; the vessels of the heart were deeply engorged with blood ; the auri- cles and right ventricle were filled ; and the lungs bled as if sponge had been cut that was soaked in blood ; the whole blood of the body seemed to have found a common reservoir in the thorax.” In nearly all cases of congestive fever, the attack is precisely like that of intermittent fever, with this differ- ence ; in the former it is more intense : indeed, conges- tive fever is only a more severe form of intermittent fever; the nervous system being more profoundly im- plicated, the determination to, or congestion of the lungs, heart, spleen, liver, etc., is so great that the systein is unable, or barely able, to react without assistance. There will be more or less languor and debility, oppression and restlessness, most commonly chilliness, shivering, and CONGESTIVE FEVER. 183 shaking; the feet and hands, arms and legs, nose, ears, and face, and the surface, become cold and benumbed ; with exceptions as to the surface surrounding the thorax, which in some cases is of the natural temperature, or of a morbid heat, which in some instances may also be the case with the head. The cheeks are usually blanched and more or less purplish, the lips pale or bluish, the features contracted and haggard, eyes perhaps suffused, with a wild or vacant stare ; skin pale, with more or less mixture of purple, purplish and motley, with ecchy- moses sometimes in dependent parts, and shrivelled. The sensibility of the benumbed extremities is impair- ed, and the general surface so in a less degree; in some cases the patient desires his benumbed extremities rubbed, in order “to keep up the circulation in them.” The mouth is usually cool and clammy, and the tongue more or less pointed, pale, or of a leaden hue. Impressions made on the skin by mechanical means, as by the finger, remain for some seconds after the pressure is removed. In most cases, the patient complains of being cold, though in others no coldness is complained of ; this latter is com- monly the case in the algide form, in which the surface of the patient feels of an icy coldness to another person. Most patients complain of great internal heat, are thirsty, desire cold drinks, and their room freely ventilated. Some desire to have their breast and face fanned, and perhaps sprinkled or sponged with cold water. In some cases, there is a cold perspiration about the forehead and tem- ples, which, in some of these, extends over the greater portion of the body. In other cases, where there is great restlessness, a copious sweat occasionally makes its ap- pearance, and suddenly or soon disappears. The pulse at the wrist is feeble, very compressible, yielding under very gentle pressure, generally increased in frequency (in the worst cases, Dr. Holmes has not seen it exceed 184 CONGESTIVE FEVER. 85 or 90; Dr. Lavender has seen it as high as 120 and 150), more or less irregular, and in some cases intermitting. Respiration is increased in frequency, is irregular, with an occasional deep inspiration, or sigh. In some very severe cases, sometimes convulsions, singultus, or hic- cough, a feeling of suffocation, heaving of the chest and laborious breathing occur. In some cases, especially in the algide form, the patient may not complain of any pain at all ; or there may be an aching, dull pain in the back, head, and limbs ; griping pains in the stomach and intes- tines, cramps in the extremities, etc. In many cases, there is nausea, irritability of the stomach and vomiting, in which it is often a very difficult matte! for the stomach to retain anything; even cold water, which the patient drinks with avidity, is frequently soon thrown up. Some cases of congestive fever are attended with coma and costiveness ; others with copious watery evacuations from the bowels, and great prostration. I will condense the notes of a couple of cases recorded in my case-book, to illustrate each of these. Comatose, somnolent, or lethargic variety of congestive fever , attended with obstinate costiveness. — Mr. , aged about fifty-five, farmer, was taken with this variety of congestive fever in the early part of November 1S44. Before I saw him, he had had a paroxysm which lasted ten or twelve hours, during which time he was somnolent and insensible to all surrounding objects, nor could he be aroused. When I first saw him, this paroxysm had passed off, and he conversed some, intelligibly, though it was manifest that his mental faculties were dull. I gave him a dose of medicine composed of quinine, calomel, and rhubarb; but it was but a short time after this till another congestive chill came on, with concomitant som- nolency, coma, or lethargy, from which he could not be CONGESTIVE FEVER. 185 aroused; occasional stertorous breathing; eyes nearly closed ; deglutition most of the time could not be per- formed ; subsultus tendinum; cold extremities, &c. A small blister having been made on the nape of the neck, quinine and sulphate of morphine were mixed with a little thin paste made of flour and water, and applied to it. Stimulating injections were repeatedly used. This paroxysm lasted about as long as the previous one; after it passed off, quinine and other adjuvantia were promptly and repeatedly given, which averted another paroxysm, and the patient recovered. Case of congestive chill., with copious watery discharges from the bowels . — Mrs. , aged about twenty years, mother of two children, youngest about ten months old, was taken with a chill and diarrhoea on the 24th (even- ing) of March 1846. On the morning of the 25th she w\as able to ride a few miles to visit some relatives, and while on her visit, in the evening, was taken with a con- gestive chill, attended with copious and very frequent watery discharges from the bowels ; having walked out to stool, in returning, ere she reached the door she fainted, and fell prostrate in the yard. I saw her about sun- set, faint, very weak, and prostrated ; almost incessantly getting up to stool; great anxiety and oppression, pulse very weak, increased in frequency, extremities cold, &c. Gave her quinine, laudanum, and paregoric; repeating the quinine every four hours, and the laudanum and paregoric as occasion required. 26th . — The quinine affected her head in the course of the night. Ordered it to be given in smaller doses, with longer intervals; and the laudanum and paregoric to be given as occasion required. Recovery without another chill; the bowel affection also arrested and cured. I might have added, that this case was also attended wdth 13 186 CONGESTIVE FEVER— DIFFERENT FORMS. griping pains in the bowels, aching in the loins, cramps in the lower limbs, &c. This form, or type, appears to be analogous, or identical, to that described by Hippo- crates, under the title of Asodes. Dr. T. D. Bell (see page 15) speaks of this form of congestive fever, which prevailed in the low, flat, marshy country, near the junc- tion of the Black Warrior and Tombigbee rivers, in Alabama, in the summer of 1829. Dr. J. B. Wilkinson, of Louisiana, in a communication to the New Orleans Medical Journal, in the July No., 1845, speaks of such cases occurring in his practice. (See page 18.) In many cases, attended with very great restlessness and oppression, the patient almost incessantly rolling to and fro in bed ; the bowels are obstinately costive, seem- ing to be almost insensible to the influence of cathartics. In the algide variety, the skin is as cold as marble, wet with the morning dew; the action of the heart is feeble, pulse scarcely perceptible ; there may be no thirst: vomiting easily excited ; mouth and tongue pale, cold, moist, and even the breath is cold ; mental faculties com- posed ; the patient complains of no pain ; if dysentery is conjoined, the eyes sink further in the sockets, look hol- low, glassy, and are surrounded by a purplish hue. Some authors uselessly make many varieties of con- gestive fever, which depend on the predominant symp- toms or complications; as the delirious ; gastralgic ; choleric ; syncopal; carditic ; hcemoptoic ; pleuritic ; pneu- monic ; &c. But there is one form of the disease, of which I have seen no account, by any author. I have seen but one or two strongly marked cases of it myself, but have heard of others. My esteemed friend, Dr. Murphy, of Decatur, Alabama, first attracted my atten- tion particularly to this form of congestive fever. He informed me, that he and his copartner, Dr. Dancy, saw eight or ten cases of it in the summer and autumn of CONGESTIVE FEVER— DIFFERENT FORMS. 187 1848, all the subjects being adult males. This variety is characterized by a copious perspiration, which is cooler than natural; embonpoint natural, features, body, and limbs, are as full as in health ; no shriveling of the skin, the extremities cold, and the general surface cool; great restlessness and oppression, rolling or turning from side to side; usually some pain in the head; in many cases intense gastric distress, and perhaps vomiting of a quan- tity of ropy, glairy mucus, in some cases mixed with bile, or streaked with blood, or both. Dr. Murphy says, the pulse is usually about fifty, though he has observed it as low as forty-five.* Prostration is considerable, and commonly the patient imagines death almost inevitable, requiring the encouragement of the attendants, and the assurance of an almost certain recovery. Cases of this kind may, or may not be attended with dysentery. As, so far as I am aware, they are not described by authors, an abbreviation of the notes of a case, recorded in my case-book, may further profitably instruct the reader. Sept. 22d, 1848. — Mrs. , aged 39, of full habit and lax fibre ; enceinte, and, according to her statement, about seven w'eeks till the full term of utero-gestation ; was usually confined at about eight and a half months; was the mother of eight or ten children. In the tw T o last pregnancies previous to this, abortion took place about the seventh month. When called to-day, I learned that she had had quotidian intermittent, for several days, the chill coming on about four o’clock every evening. I found her with the chill on, attended with copious and frequent watery discharges from the bow r els, griping pains in the lower part of the abdomen, great gastric distress, * Since -writing the above, I have seen a case, white male, aged forty-eight, in which the pulse varied from forty-eight to fifty-eight. 188 CONGESTIVE FEVER— TREATMENT OF. puking of a glairy, ropy mucus, which formed a con- siderable bulk, as it adhered together; and, after the vo- miting continued some time, the mucus was mixed with yellowish bile, and tinged with blood. Administered laudanum and quinine, which soon gave relief. Sept. 23 d . — Griping pains in lower part of abdomen ; abortion suspected, or anticipated. Ordered injection of laudanum in a little starch gruel, which gave relief. Also ordered three or four grain doses of quinine, four times a day, and laudanum, if necessary. Sept. 25th . — Night visit; found her with congestive chill; extremities cold; the general surface cool, and covered with a copious, slightly clammy perspiration, which was not very cold, but cooler than natural ; pulse scarcely perceptible, and about 55 beats in a minute; great gastric distress; vomiting and purging; eyes wild- looking, and expressive of distress ; great oppression ; oc- casionally a deep sigh, and a disposition to change her position in bed frequently. She seemed to think that death was almost inevitable ; prostration considerable. Treatment. — Gave fifty drops of laudanum, with ten grains of quinine, and shortly afterwards, one teaspoon- ful of sulphuric ether, which gave relief, and brought about reaction. Left two doses of quinine for her to take during the night, and ordered three or four grain doses of quinine four times a day, and laudanum, &c., as occasion required. Sept. 27th . — Early this morning, was informed by her husband that a small quantity of blood had come from the genital organs, attended with pain in the loins, heavi- ness, and bearing-down sensations in the region of the womb. Abortion feared. Ordered sugar of lead and laudanum internally, and opiate injections. P. M. — Soon after supper was called to deliver her — female child CONGESTIVE FEVER. 189 — dead — its face of a leaden hue, as though it had been dead some time ; the mother said she felt it move early in the morning. Tonic treatment was adopted, and she soon recovered. Dr. S. R. Beatty, of Clear Spring, Washington Co., Maryland, gives an account of what he calls “ congestive bilious fever," which occurred in his practice on the Po- tomac river for four or five years previous to 1823, or 1829, inclusive. Notwithstanding he has given it a wrong name, he has pretty well described the symptoms of congestive fever. I will quote some of his remarks, from the circumstance that, so far as the writer is aware, he is one of the first American writers who well de- scribes this disease separately — we can scarcely say separately, as he considers it only a modification of bilious fever ; yet it does not matter about the name, so the symptoms are well portrayed. I also make the ex- tract from the fact that he recognizes its relation to the typhoid pneumonia of this country (to which a chapter- will be devoted in the latter part of this work), and which it appears a large number of the medical world, even at the present day, do not. But to the extract. “The congestive bilious fever, from the coldness of the surface which attends it, and its fatality, has received the vulgar appellation of cold plague ; and in the winter and spring, being accompanied with pneumonic symptoms, is called typhoid pneumonia ; * * * * * the malaria, and the exciting causes producing the congestive form, are of a grade so overwhelming and deadly, as to pros- trate at once the action of the heart and other constitu- tional powers, to such a degree that reaction either does not take place at all, or, if it does, it is only partial or transient. If not early arrested by proper treatment it soon runs on to the stage of collapse, without an inter- vening one of excitement; * * * the surface is as cold 190 CONGESTIVE FEVER. as marble, particularly on the extremities, and often be- dewed with a clammy sweat; the patient, at the same time, complaining of great heat internally ; in some cases, so intolerable as to cause him to cry out that he feels as if a furnace was burning within him, and constantly to be calling for cold water to relieve the intense thirst and internal heat ; while, at the same time, the pulse is fre- quent, weak, struggling, and unresisting. The attack often comes on suddenly; at other times more gradually, the patient first complaining of lassitude, as in other fevers; the extremities then become cold ; the stomach is so irritable as to reject everything it receives ; if a glass of cold water, so grateful to the patient, be taken, it is immediately thrown up ; if medicine, the same thing occurs. There is great anxiety at the praecordia ; pain in the head, and anxious and difficult respiration. The tongue is often thickly coated, and the bowels torpid ; all the secretions being either totally arrested, diminished in quantity, or of a vitiated quality.” Dr. Beatty men- tions, that some cases occurred in the country situations on the Potomac, in the fall of 1823, with yellowness of the skin and white of the eyes, and such violent symp- toms “ as would have ranked them amongst the worst cases of yellow fever, in those cities where the disease mostly prevails.” In further describing congestive fever, Dr. Beatty remarks, “ In all the cases of congestion which I have met with, a symptom occurred which I have never seen noticed by any author — a numbness and deadly feeling, commencing in the extremity of the fin- gers and toes, and proceeding gradually up the arms and legs ; * * '* the patients pointed out this symptom, and were never satisfied unless some person was constantly rubbing each limb, as they themselves said, ‘ to keep the blood circulating.’ ” u Sometimes partial reaction comes on, some part of CONGESTIVE FEVER— TERMINATIONS. 191 tne body or the head becoming preternaturally hot. If it be the latter, the carotid arteries pulsate strongly. A general excitement may emerge, particularly after the action of proper remedies, and the disease then runs its course under the simple or inflammatory form, and must be treated as such.”* A very large majority of the cases of congestive chills are preceded, for a few days or longer, by common chills and fever, or ague and fever; to which latter, either on account of neglect or maltreatment, in highly malarious districts, congestive fever ensues. Some years ago, when calomel was used so freely in the southern portion of the United States, congestive fever was of very fre- quent occurrence in many places ; and is unquestionably much more frequent at present in those regions of the southern country where calomel is more freely used, and the old antiphlogistic treatment adopted. In many places in the South, congestive fever has almost entirely disap- peared, in consequence of the improved mode of prac- tice; and from the fact that the people in the country have learned, not only the proper means to cure com- mon chills and fever, but also the importance of arresting these before they are merged into the congestive form. About Courtland, Alabama, is known to be a highly ma- larious region of country; yet, in consequence of the applicability of the above remarks, Dr. Sykes, of that place, not long since informed me, that congestive fever was now of rare occurrence there. But rather than be too tedious, I will let these few remarks suffice. Terminations. — Very few cases of congestive fever terminate in death, if the proper treatment is resorted to * See second volume Transylvania -Journ. of Med. for 1829. 192 CONGESTIVE FEVER. in time. Though it is a dangerous malady, if left to it- self, it usually readily yields to early and proper treat- ment. I have seen a severe case treated promptly and efficiently, and the patient get up and walk out and at- tend to some light business on the same day. A remark- able case of this kind came under my observation in the fall of 1848; and as the notice of particular cases is more impressive and instructive than general remarks, I will, for the benefit of the reader, take some notes of this one, recorded in my case-book, and enter them here. This case may be classed with that variety which we have al- ready noticed, and which we considered as analogous or identical to that described by the father of medicine, under the title of Asodes* The symptoms of these cases are very analogous, if not identical, to those of Asiatic cholera. But to the case. Mr. IT, aged about twenty-two, was taken early in the morning, on the 10th of November 1848, with diarrhoea, which, in two or three hours, was followed or accompa- nied by a congestive chill. The general surface was of a pale leaden, or bluish hue ; extremities of an icy coldness, and the general surface cool and dry ; features contracted and anxious; shivering, and complained of being cold — requested a hot rock placed to his feet; great anxiety and restlessness ; would, occasionally, lie in one position for a few minutes, with now and then a disposition to doze ; pain in the head and back, with pain and cramp in the stomach and bowels severe, and cramp in the legs; puked freely and repeatedly — water, mucus, and blood thrown up, which, after a time, was tinged with yellowish bile; purging more copious and watery. Respiration increased in frequency, irregular, louder than natural, labored, with an occasional deep sigh. Pulse feeble, somewhat irregu- * A Greek word, said to mean “ anxiety,” “ disgust,” etc. CONGESTIVE FEVER. 193 lar, about ninety per minute; very thirsty, desiring cold water every few minutes. Treatment commenced at about half-past nine o’clock, the chill having been on near two hours. I gave him about eight grains of quinine and forty-five drops of laudanum, which were thrown up in about ten minutes, and then the dose was repeated; which, after retching, or efforts at vomiting, relieved the severe pain of the stomach, and otherwise gave relief. After I discovered that reaction was gra- dually taking place, I left; having given directions to repeat the quinine and laudanum again, if that I had given should be thrown up. Also ordered quinine and paregoric to be taken at night, and the ensuing morning ; and quinine in smaller doses three times a day for seve- ral days, and opiates, as occasion required, to control the bowel affection, -&c. Nov. llth. Saw my patient walking about town to-day. He informed me he was up walking about, about an hour after I left him yesterday, which would make it about noon. He said he had very little fever. Notwithstanding the severity and danger of congestive fever, if left to itself, the treatment of this case shows how promptly and certainly it yields to early and proper treat- ment. And the analogy between this form of congestive fever and Asiatic cholera, inclines me to believe that the same mode of treatment adapted to the former, if early resorted to, would be equally successful in the latter. If a case of congestive fever proceeds on to a fatal ter- mination, in the language of Charles E. Lavender, M.D., of Selma, Alabama, “he lies still, it may be for a minute, without breathing, then gasps for breath, makes short and hurried respiration, cries that he shall die for want of breath; rises, advances hurriedly to the window, stag- gers, throws himself on another bed, or falls on the floor; the pulse has ceased to flutter at the wrist; a moment’s 194 CONGESTIVE FEVER. unusual anguish, a gasp or two for breath, the heart ceases to beat, and death closes the scene in six or emht hours from the access, the sufferer retaining his senses to the last. At other times, death approaches under cover of a deep, comatose sleep, of several hours’ duration. Sometimes, though rarely, the paroxysm closes in con- vulsions. “ The fatal moment is sometimes delayed a few hours by the free use of diffusible stimulants, in which case the patient usually dies comatose. At other times, partial reaction takes place; the skin becomes w T arm, or even hot; extremities remaining cold; pulse may again be counted; from 150, it falls to 120 ; it may be the patient sleeps for some hours, or dozes on in painful and inter- rupted slumbers, to be followed the next twenty-four hours by another paroxysm, terminating in fatal collapse.” The coldness of the extremities becomes more and more permanent, and gradually encroaches upon the body ; the feet, legs, hands, and forearms, first being of a deathlike coldness ; then the thighs, arms, head, face, and so on to the body, till life becomes extinct. In some cases, for some time prior to dissolution, the sur- face is covered with a copious, cold, clammy perspira- tion. If the paroxysm is less severe, it may be followed by complete reaction, and rapid convalescence may ensue; or, if the reaction is less complete, a severer paroxysm may come on in the next, twenty-four hours, and termi- nate in death; or, it may be less intense, followed by more perfect reaction, and the patient may soon be re- stored to health; or it may run into the remittent or in- termittent form of fever. If it proceeds on to the third chill or paroxysm, it is said generally to terminate fatally ; though this is not always the case; yet, the third chill is very much dreaded by practitioners, and the people. CONGESTIVE F-EVER— TERMINATIONS. 195 In their recurrence, the paroxysms^ I believe, usually obey the quotidian type — sometimes the tertian. Dr. R. S. Holmes remarks, that the congestion in congestive fever, is. not “brought on purely by the time of the pa- roxysm ; any quick, exciting cause, be it ever so trivial, the entrance of a stranger, the firing of a gun, some one bursting suddenly into the room, even the visit of the physician, will throw the blood from the extremities, or more properly, perhaps, prevent its due propulsion into them; the lips will become livid, the tip of the nose and ears cold, the feet and legs cold, the cheeks blanched ; and yet the patient, strange to say, will be unconscious, generally, that a change has come over him ; all this, too, independent of the regular periodic time, when the true paroxysm comes on.” Dr. Lavender says : “ Of all the local congestions that attend upon this form of disease, that of the brain is most alarming, least manageable, and most fatal. It is marked by deep coma, low, muttering delirium, rolling the head on the pillow, a drawing of the head backwards, dilata- tion of pupils, optic illusions ; and, if partial reaction takes place, raging delirium may come on.” Engorge- ments, and consequent enlargements of the spleen, etc. etc., are well known to be of common occurrence in con- gestive fever, but these will be noticed when we come to treat of its pathology, and refer to post-mortem examina- tions. In the intervals, or between the paroxysms, Dr. Holmes observes: “He will be torpid, morose; his mind dull, slow in gathering up his thoughts, his pulse laboring, and full and slow, Jus bowels sluggish, or, if irritation has set in upon them, frequently purged ; the secretions from his liver, kidneys, and skin, improperly carried on, or almost checked ; if the congestion is on the brain, he will complain of dull pain in the head, if on the thorax, 196 CONGESTIVE FEVER— PATHOLOGY. his breathing will be hastened, if on the abdomen, in- flammation of the intestines will probably soon set in, if the disease is not speedily checked.” As to the causes of congestive fever, the reader is re- ferred to the first part of this volume, and also to a few remarks made on page 191. Pathology. — It appears that the primary morbid impression is perfectly identical with that of intermit- tent fever, with the difference that, in congestive fever, it is much more intense. As remarked when treating of the former, for aught we know, previous to the chill, there may be a link in the chain of morbid action, con- sisting in a modified, altered, or, in other words, morbid condition of the blood ; yet, apparently, the first great or primary morbid impression is made on the nervous sys- tem. The precise nature of this impression is not known, though it would appear to be a sedative or debilitating one, which prevents the great nervous centres from se- creting or generating a sufficiency of nervous fluid, or that which gives nervous power, or power to the nervous system ; hence, the heart, lungs, etc., not receiving that amount of nervous influence which will enable them to carry on or perform their functions normally ; or, more properly, on account of nervous debility, their functions are impaired, and they become congested, engorged with the circulating fluid, the blood. So far as we are capable of judging from symptoms, it appears that the morbid impressions made on the three great nervous centres do not always bear the same relation to each other in diffe- rent cases; as, for instance, the undisturbed condition of the intellectual faculties in the algide form, and even a repose which is said to be agreeable to the patient, which may be regarded as an evidence that the brain is less affected than the spinal and ganglionic systems of CONGESTIVE FEVER — PATHOLOG V. 197 nerves, though the absence of pain in the former does not necessarily imply that it is not.affected at all ; yet, while the brain maintains its functions, this is an evidence that it is but slightly, if at all, morbidly affected : however, even t®§ feeling of repose may be an evidence of morbid impression. Other cases are attended with, coma or le- thargy, or raging delirium, which unmistakably inform us of the serious implication of the brain. In others, again, we observe that the spleen, stomach, and bowels, heart, etc., are most prominently affected, an evidence of the greater implication of the ganglionic or organic sys- tem of nerves ; but as all parts of the nervous system are so intimately connected with each other, and so mutually dependent on one another, when one is much affected, the others will participate in a greater or less degree. Post-mortem examinations also go to justify such conclu- sions as these; pathological lesions in some cases being most prominent in the head, in others in the thorax, and in others in the abdomen. In the case we have hereto- fore noticed (examined by Dr. R. S. Holmes, when he was army surgeon in Florida), the viscera of the abdo- men and contents of the cranium were in an apparently healthy condition, the heart and lungs being deeply en- gorged with -blood. The pathological lesions observed by M. Bailly, who visited Rome for the purpose of endea- voring to ascertain the nature and seat of this disease, go also to prove that they are not uniform. In 36 necrosco- pies, as given by Bell, the records are as follows : arach- nitis, 25 ; gastro-enteritis, 19 ; splenitis, 18 ; rupture of the spleen, 3 ; diffluent spleen, 2 ; cephalitis, 13 ; gastri- tis, 7 ; enteritis, 7 ; alterations of the liver, 5 — of which one w T as by inflammation, two by congestion, and two by putrilaginous softening ; pneumonitis, 3 ; pericarditis, 3 ; peritonitis, 2 ; parotiditis, 1 ; oesophagitis, 1 ; cystitis (biliary), 1. 198 CONGESTIVE FEVER— PATHOLOGY. Some writers consider the phenomena of congestive fever to be induced by irritation of the cerehro-spinai axis ; others, that the ganglionic system suffers most severely ; so far, then, as opinions are -worth anything, they go to prove the remarks already made. Unfortunately, heretofore, the minds of physicians have been too much directed to the circulation of the blood, and pathologists have been too exclusively hunting after some local or organic disease, to the neglect of the nervous system, and its functions. The folio-wing re- marks of Dr. S. R. Beatty, will serve pretty well to give an idea of the disturbances of the circulation; but, un- fortunately, his mind is too exclusively directed to this, an effect, without looking to the cause of it, the morbid condition of the nervous system. He says, the cause or causes “ are so deadly and overwhelming, as almost com- pletely to prostrate the action of the heart ; a more exten- sive congestion takes place about its right side, than in the other two varieties [simple and: inflammatory fevers], and its muscular parietes are so much distended by this un- natural engorgement as to be almost paralyzed ; for the same reason that the contractile muscles of the hand or mouth, or any other part, when they are stretched to their utmost extent, have not near so powerful a contract- ing force, as wdien they are only moderately extended. , “ The heart, therefore, in this fever, has not the power of producing a general excitement, as in the two former ; but efforts towards it are sometimes made, the tempera- ture of the chest or abdomen being raised considerably above the natural standard ; while the other part of the body remains of a deathlike coldness, bedewed with a clammy sweat, and the pulse at the wrist scarcely per- ceptible, the powers of the heart being still too weak to extend its influence so far from the centre of circulation. This attempt at reaction generally vanishes in a short CONGESTIVE FEVER— PATHOLOGY. 199 time, the heart being too much oppressed by the internal engorgement to accomplish it, and the disease passes on to the stage of collapse, and terminates in violent cases as soon as the third day ; in others, it lasts nine or ten days, or even longer. The congestion, commencing in the right side of the heart, extends up the descending cava into the sinuses and veins of the brain, producing the sense of fullness of that organ, coma, delirium, &c. In the thorax, the blood returning from the vena azygos, and through it from the bronchial veins, being obstructed by the accumulation in the descending cava, and the congestion of the right ventricle extending into the pul- monary arteries, oppress the lungs, and thereby cause that anxious respiration and sense of suffocation which invariably attend this disease. “ It is now plain, that in the congestive state, too large a proportion of blood is accumulated in the veins and right side of the heart, and, of consequence, too small a quantity remains in the left side and arteries. This state explains the cause of the extreme feebleness of pulse and general coldness of the surface, the characteristic symp- toms of congestion.” This country has for many years past, and is still, but to a less extent, cursed with an ingenious, false, delusive, and fatal theory, in referring all our fevers to disease of the liver, and, consequently — as the advocates of this theory contend — demand the liberal use of calomel! ! I am sorry to see that there are, even yet, not only men who stand high in the medical profession, but even profes- sors and teachers in medical schools, under the influ- ence of this delusion ; and it is but reasonable to sup- pose, that hundreds and thousands of medical students will thus be led astray, till they learn, from actual prac- tice at the bedside, this error of their teachers. There are not a few practitioners, who have learned, from expe- 200 CONGESTIVE FEVER— PATHOLOGY. rience and common sense, the nature and proper treat- ment of our autumnal fevers; and who, though they admire the learning and talents of their former teachers, lament the errors into which they have been led, and in which some of .them still remain. But after this short digression, I will quote the following very appropriate remarks, by Charles E. Lavender, M. D., of Selma, Alabama : — “ It sometimes happens that the patient dies in the first paroxysm, without any febris at all. At other times, there is a chill, or cold stage, followed by a state of com- parative repose, but little or no reaction, to be succeeded by another and fatal cold stage. Venous congestion also doubtless exists in other forms of fever. This congestion, however, so far from being the seat, or proximate cause of the disease in question, is but an effect of the action of the poison upon the brain and nervous centres. A simi- lar pathological condition may be superinduced by con- cussion, or other injury done to the brain. It is but a symptom of congestive fever. And could we, with equal clearness, see the workings of the cerebro-spinal and nervous systems, the motions and uses of their fluids, the degree of their intensity, the momentum with which they circulate, and the obstructions which they encounter, we would then advance another, and more satisfactory step, in the investigation of this, as well as other forms of dis- ease. These more obscure, yet vastly more important, vital and pathological phenomena have, unfortunately, been overlooked by many able pathologists, in their re- searches on the liver and venous congestion. Too much importance has doubtless been attached to the circula- tion of the blood, to the neglect of the nervous functions. The symptom has been elaborately investigated, while the cause has received comparatively little attention. “ A case that has assumed, and for some paroxysms CONGESTIVE FEVER— PATHOLOGY. 201 maintained, the character of remittent or intermittent, may suddenly put on a congestive type. An attack, which at first assumed a congestive form, may, after a successful effort at reaction, wear the face of remittent or intermittent, of a mild character. “ Many cases, in their onset and progress, wear the livery of all three of these types ; and might, at different stages, be set down under each of these heads. And. sometimes, it would be no easy matter to decide upon the class to which a case properly belongs. “ There is scarcely an important organ which may not, during the progress of the disease, become the seat of local congestion. The spleen may become engorged to such an extent, in a few hours, as to be found double its natural size. The same, to a less extent, may be said of the liver. Congestion of the lungs is an alarming occur- rence, which, doubtless, always exists, to a greater or less extent, in this form of fever. The great oppression, la- borious breathing, heaving of the chest, and sense of suf- focation and sinking down, denote such a state * * * “ Unfortunately for young practitioners at the South, their knowledge of this formidable disease is chiefly drawn from the well-studied lectures of professors who never met with it in practice, or from the ponderous vo- lumes of writers on general therapeutics, to whom con- gestive fever is a matter of history. The most unwel- come, and perhaps the most useful lesson that such a practitioner ever learns, is taught him by the first well- marked cases of this type with which he meets.” It is said, that blood drawn from a patient who has congestive fever is much darker and thicker than natu- ral. Charles Frick, M. D., of Baltimore, gives us the result of the chemical analyses of the blood of two cases, one of which he terms the remittent congestive form 14 202 CONGESTIVE FEVER— DURATION. (see No. 1 ) ; and the other, the intermittent congestive form (see No. 7). (See pages 65 and 66, and table; or, the American Journal of the Medical Sciences, January No., 1848; pp. 29, 30.) The writer’s observations corroborate the following re- marks of Dr. R. S. Holmes : “ One circumstance has often attracted my attention, in cases of diseases from miasmatic origin in this country ; that is, the abnormal actions of the heart; its beats, if the patient has been weakened by disease, are so tumultuous and diversified, but afford withal so little sign of organic lesion, that, if not acquainted with the former condition, your prognosis will be most unfavorable. I have seen, however, but few permanently bad results from this cause. If you strengthen the patient by tonics, and remove him to a more healthy spot, even in Florida, he will recover. I look upon this as a deranged, miasmatic, nervous action in that organ, for which change of place and tonics afford the best cure.” According to my experience, these ner- vous palpitations or abnormal actions of the heart are most apt to be troublesome at night, just after the indi- vidual has gone to bed. Disturbances in the actions of the heart may also be brought about by violent and sud- den exertions. The duration of congestive fever is very various. In some cases, if the proper treatment be early resorted to, the paroxysm may last only a few hours, and the patient may get up and walk about, feeling almost well, though somewhat enfeebled, and dull. In more severe cases, it may last several days; and in others, especially those which are of the remitterft form, and in which the sensibility of the nervous system is greatly im- paired or benumbed ; characterized by languor, dull- CONGESTIVE FEVER— PROGNOSIS. 203 ness, little or no restlessness, or pain, it may last ten or fifteen days, or even longer. Nearly all cases which last over three days, are of the remittent congestive form. If congestive fever does not result fatally in two or three days from its inception, it is apt to terminate in conva- lescence, intermittent, or remittent fever. Prognosis. — Though congestive fever is a malignant and fatal form of disease, when neglected, or improperly treated, yet, under timely and proper treatment, the prognosis is nearly always favorable. Thus far, I have been successful in every case that has come un- der my professional care. In conversations with prac- titioners, I learn, as the result of their experience, that death is extremely rare, as the result of congestive fever, except in those cases which have been neglected too long, or have been improperly treated. Dr. R. S. Holmes remarks, that he has “ known, in Chester county, Penn- sylvania, in a small district, one-fourth the number of patients die, who were seized with a pure miasmatic, congestive fever, differing from that of Florida only in its lighter grade; yet the disease, as treated by army surgeons in Florida, with quinine, was one of the least mortal, probably not more than one in forty cases proving fatal.” Then, after stating that he has not seen a patient die, who survived after twenty-four hours from the time of attack, remarks, that “ The fatal cases are those, in which the quinine has not been given in a proper quan- tity, or where it has not been thrown into the constitution for a sufficient length of time to reach the disease.” These remarks, will, perhaps, not only be rather sur- prising, but probably scarcely credited, by many who have heretofore witnessed the great mortality of this dis- ease, under improper treatment; indeed, in many places, the term “congestive fever” has had an appalling signi- 204 CONGESTIVE FEVER— PROGNOSIS. fication, almost synonymous with death. Coupled, or followed by some sensible remarks, I w T as very much surprised to see so frightful an estimate of the mortality of congestive fever, in a southern Medical Journal, wffiich fell into my hands some time last year (1848), made by Stephen N. Harris, M. D., of Savannah, Georgia; and which tempted me to imagine that the physicians in that region of country have not yet learned how T to treat it properly; that they are, perhaps, still under the erroneous teachings of Dr. Dickson, with regard to the too liberal and improper use of calomel. The following is the sub- stance of his remarks. As they are not before me, I will not vouch that they are verbatim. “The prognosis, as might be anticipated, is exceedingly unfavorable in most cases, and uncertain in all. I am'unable to give an exact proportion of recoveries, but the probable ratio is two in five (! !<■). Much depends upon the youth and previous vigor of the subject, as well as upon the concentrativeness of the congestion ; but I am inclined to think that much more depends upon the complexion of the diseases preva- lent at the time ; if these have a tendency to typhus or ataxia, there is probably a diminution of chances for in- ducing reaction, and the disease proceeds to a fatal termi- nation ; but if, on the other hand, the character of the season disposes to activity of the vital manifestations, the chances of recovery are increased. There is another influence, and a most important one, affecting the com- plexion of all diseases, in a greater or less degree, but especially the class under consideration ; it is the influ- ence of locality.” In those cases which observe the intermittent type, the chill may only last a few hours, and, if property treated, rapid convalescence is most likely to ensue ; or, if the treatment should not be entirety efficient, a second chill rnay come on in a day or two, which will probably be CONGESTIVE FEVER— TREATMENT. 205 much lighter than the previous one, and the patientsoon recover, under a tonic treatment ; but if the proper treat- ment be neglected, if he escape death in the first pa- roxysm, a second or a third may be more severe, under which the individual may succumb. Those cases in which the paroxysm lasts for a long time — from eight to twelve or twenty-four hours, or longer, or those which partake of the remittent form, are to be dreaded, and imperatively demand prompt and assiduous attention. Cases of this kind are more likely than others to be protracted, or run into the remittent form of fever. E. F. Bouchelle, M.D., of Columbus, Mississippi, says : so long as he “ pursued the plan of correcting the secretions , and stimulating by brandy , camphor, camphor and quinine , ammonia, pepper, &c. &c., I lost pa- tients. But when, on the other hand, after much reflec- tion, I had changed my pathology of the disease, and adopted the cold ivater and anodyne practice,* my labors were crowned with success, and have been ever since. In truth, the most violent forms of congestive fever will as certainty yield to the anodyne treatment, as will a local inflammation yield under depletion.” Dr. Bouchelle considers “ that all of the leading phenomena of the dis- ease are referable to derangement of the organic system of nerves more particularly ; the excitement of conges- tive fever is irritable excitement, and in most cases so excessive that it soon sinks the system into collapse, un- less moderated.” Treatment. — The prompt relief, which we are almost always enabled to give to those who are suffering with all the agonies and distress of a congestive chill, which * By the “ cold water and anodyne practice,” Dr. Bouchelle means the cold dash to the general surface, and opiates internally. 206 CONGESTIVE FEVER— TREATMENT. seem so ominous of ill, is enough to excite within us feelings of gratitude to the Author of our Being, that he has placed such potent and effectual means within our power, that he has given us minds capable of appreciat- ing their virtues, and that we are therefore instrumental, not only in relieving the sufferings of our fellow-beings, but snatching them, as it were, from an untimely or pre- mature grave, by neutralizing or rendering ineffectual one of the powerful instruments of death. It is pleasant to reflect, that notwithstanding the severity and danger of congestive fever, it is one of the most corrigible diseases in the whole catalogue of nosology, if it receives timely and proper attention. The treatment, though plain, and easy of comprehension, may be regarded as one of the trophies of the present day in the healing art. The different forms or modifications of congestive fever require, as one would naturally suppose, some modifications of treatment, so as to adapt it to these respectively. The two great and principal remedies are quinine and opium ; with the exhibition of sulphuric ether in some cases, and in some the cold dash to the general surface, &c. &c. If called to one of those vio- lent attacks in which there are great distress and restless- ness, and the vital manifestations seem to be rapidly yielding, as though the vital spark would soon be smothered out, give, immediately, from 8 to 20 grains of quinine, from 50 to 100 drops of laudanum, and one or two teaspoonfuls of sulphuric ether. First, mix the laudanum and quinine together, and give them; then, after waiting a few minutes, mix the ether in half a glass of sweetened water, stir briskly for a moment, and let the patient swallow it down quickly. If the patient is shivering, and manifests much anxiety, a few teaspoonfuls of ether poured upon a handkerchief, and held to the mouth and nose, so that he may inhale it, usually gives CONGESTIVE FEVER— TREATMENT. 207 relief in a very short time. These means will almost invariably give speedy relief, especially if resorted to soon after the attack. If the above articles should be puked up, on account of the irritability of the stomach, they should be repeated. If they should be thrown up a second time, quinine and laudanum, in double doses, should be mixed with an ounce or two of starch or flour gruel, and given by injection into the rectum ; or quinine and morphine may be applied to a blistered surface, first mixing them with a little thin paste, or gruel, made of flour or starch; twenty or thirty grains of quinine, with one grain of sulphate of morphine, will be a sufficient amount for this purpose. The blister should be prefera- bly made on the nape of the neck, between the shoulders, or over the region of the stomach. In order to make a blister quick, so as not to lose important time, it may be done almost immediately, by dipping a piece of cloth in concentrated acetic acid, solution of ammonia, &c., or the application of hot water. In such cases as the one above instanced, some practitioners speak very highly of the cold dash. If the stomach should have retained the remedies (rendering it unnecessary to give them by injection, or their application to a blistered sur- face), it may be necessary to repeat the laudanum and ether, though in smaller quantities, say from 30 to 50 drops of each ; if the former is slow in producing any effect, in the course of half an hour, or an hour or two, according to the severity of the case, and the distress and anxiety of the patient. I commonly repeat the dose of quinine in three or four hours. This plan of treatment is almost sure soon to give relief and repose, bring about moderate reaction, and a rapid convalescence. The pa- tient should, however, to insure recovery, and prevent relapse, take from three to five grain doses of quinine four or five times a day ; and, if dysentery attend, in ad- 208 CONGESTIVE FEVER— TREATMENT. dition to the quinine, from 25 to 40 or 50 drops of lauda- num, or one or two teaspoonfuls of paregoric, should be given once, twice, or thrice a day, or as occasion requires ; to which may sometimes be added with advantage, if it prove obstinate, some astringent, as krameria, catechu, tannin, a strong decoction of oak bark, if the stomach will bear it, tincture of cinnamon, or sugar of lead, which latter may be given with the opiates, but should not be given with the quinine, or for an hour or two after a dose of quinine has been taken, as these two articles are in- compatible with each other. In those cases attended with great restlessness and op- pression, the patient tossing to and fro in bed, the extre- mities and general surface of an icy coldness, with exceptions, in some cases, of the region about the chest and head, which may be of a natural or morbid heat; and more particularly, also, if the general surface is not covered with perspiration, in addition to the use of qui- nine and laudanum, some practitioners have great confi- dence in the cold clash, to bring about reaction and composure : indeed, I believe a few practitioners rely almost exclusively on the cold dash to bring about reac- tion. The patient, stripped of his clothing, is laid on a blanket on the floor, several buckets of cold water are then dashed all over him ; he is then wiped dry, perhaps some hasty friction is used ; he is then put in bed, and covered with two or three blankets, to assist in bringing about reaction. However useful the cold dash may be, we should not rely on it, to the exclusion of quinine and laudanum, and ether, if necessary. As before remarked, some practitioners have great confidence in the cold dash, but I may observe that there are others who do not seem to think favorably of it. It would seem from this, that we might infer that there are some cases to which it is adapted, and some to which it is not. So far as I am CONGESTIVE FEVER— TREATMENT. 209 aware, the cases to which it is applicable are not yet well settled. I have taken some pains to try to acquire infor- mation on this subject, and it appears that it is most adapted to such cases as the last one instanced above ; and that in the following conditions it is not applicable, or does little or no good — as in those cases which come on slowly and insidiously, torpidity of the system and dullness ; no restlessness, but great prostration ; weak pulse, cold extremities, etc. I might refer to the expe- rience of reputable practitioners to prove the potency of the cold dash in the treatment of congestive fever. We have already incidentally referred to the confidence Dr. Bouchelle, of Columbus, Miss., reposes in it. So far as I have been able to learn, our own countryman, Dr. Thomas Fearn, of Huntsville, Alabama, was the first to resort to the cold dash in congestive fever. Dr. Fearn was also the first who used quinine in large doses; which he did but a few years after this article was discovered by Pelletier and Caventeau, in 1820. The success attending its exhi- bition in what once would have been regarded as very large doses, and even yet at the North, might have rea- sonably induced one to fear that it would be injudiciously used by many, and thus be productive of mischief ; and such has been the case. Considering, however, its po- tency for good, its evil effects are comparatively small. Dr. Perrine, of Mississippi, was one of the next after Dr. Fearn, to appreciate the value of quinine in larger doses than had formerly been used. Dr. R. S. Holmes says, “It cannot be thought strange that the practice at the North of giving quinine in divided doses for bilious, remittent, and congestive fevers, should prove so unsuccessful. Though the fevers there do not require such large doses of this article as at the South, they require very different ones from those that are now given. 210 CONGESTIVE FEVER— TREATMENT. “ The experience of physicians in the south of France, in Italy, and in the southern States of the Union, shows that a much larger dose of quinine is necessary to check a fever in those countries, than in latitudes and regions where malarious influence is not so powerful. “ On my arrival in Florida, knowing nothing of south- ern diseases from practice, and being stationed alone at a distant and unhealthy post, I learned the rules by expe- rience alone, guided by which I have since successfully administered quinine. I practiced on northern precepts, annoying the patient without arresting the disease, by a continued succession of two grain pills ; occasionally, at long intervals, checking the disease by these means, but much more frequently vexed for weeks by the continued sickness of the soldier.-* I rose finally to ten grains, and continued to give this quantity at once. I more fre- quently succeed by this practice, but not yet to my satis- faction. * * Finally, convinced that large doses of quinine are necessary in the South, I increased my minimum dose, for intermittent fever, to fifteen grains given at once.” Dr. Holmes was in the habit of giving thirty, forty, or more grains of quinine at once, in congestive fever. He says the largest amount of quinine he has ever given at a single dose, has been eighty grains ; this is the extreme dose; the average quantity is about twenty grains. Quinine has even been given in larger doses than this ; but I do not approve of this practice, as I consider these doses unnecessarily large, and they sometimes produce bad effects. The late Judge "Willis, of Mississippi, informed me, some years ago, that he knew a case or two of insanity produced by excessively * See Amcr. Journ. Med. Sci., Oct. 1846. Does not this show the folly of sending northern physicians with our soldiers to the South? CONGESTIVE FEVER— TREATMENT. 211 large doses of quinine. Moreover, I believe that ten, fif- teen, or twenty grain doses, with a dose of laudanum, will have a better effect, and consequently do more good, than thirty or eighty grains of the quinine given alone. In ad- dition to this, if the patient is thirsty, he should he allowed moderate quantities of cold or iced water, fre- quently repeated. In cases attended with coma or lethargy , and in which deglutition cannot be performed, the quinine and lauda- num should be given in double doses by injection, or a double dose of quinine (twenty-five or thirty grains), and one grain of sulphate of morphine may be applied to a blistered surface, as before directed. Dry frictions to the extremities, and along the spinal column, or with pepper, mustard, or spirits of turpentine, maybe of some service as adjuvantia ; as also heat, applied to them by means of hot rocks, bricks-, bottles filled with hot water, or, if the skin is dry, a dozen ears of corn, just taken out of hot water, is preferable. If costiveness attends cases of this kind, ten grains of calomel and fifteen grains of rhubarb should be given with the quinine and laudanum at the commencement of the treatment, or as soon as deglutition can be performed. It may be necessary to repeat the calomel and rhubarb once or twice, with in- tervals of twenty-four or forty-eight hours. If nothing can be given by the mouth, resort to injections of spirit of turpentine and castor oil, in order to relieve the cos- tiveness, when necessary. These remarks will apply to all cases of this disease attended with costiveness. Some cases are attended with languor, dullness, tor- pidity, and costiveness, and require the same treat- ment as just given above, with the exception that in these cases the medicines can be given by the mouth. Some cases are attended with great restlessness, op- pression, rolling to and fro in the led , &c., and very ob- 212 CONGESTIVE FEVER— TREATMENT. stinate costiveness, and require the same treatment. If the skin is dry, the cold dash may here also be of service. In some of these cases, the bowels appear to be almost insensible to the influence of cathartics, and, therefore, it will be necessary to give some of the more active ones ; as spirits of turpentine and castor oil — and these may be also given by injection. If the patient cannot swallow anything, a drop of croton oil may be applied to the tongue. We should guard against too active and violent catharsis, though under these circumstances it is not likely to occur. Purging, as a general rule in this malady, should be avoided. If the disease is disposed to assume the remittent form, with cotemporary costiveness, the calomel and rhubarb, as above directed, should be given every twenty-four, thirty-six, or forty-eight hours, till two or three doses have been exhibited. If the bowels do not respond to the ape- rient influence of these articles, some other should be * When tartar emetic is given to young children, it will he advisable to add some paregoric to the solution, to prevent too much griping and irri- tation of the stomach and bowels. CROUP— TREATMENT. 391 After the second or third vomiting, if necessary to resort to it again, it will generally be advisable to use ipecac. In twelve or twenty -four hours, if the disease is not almost entirely removed, it may be well to repeat the dose of calomel. If the medicine should purge too severely, it should be moderated with a little paregoric, from five to fifteen drops, according to the age of the patient, if under six years of age. As to local applications, I do not place much reliance upon them; a piece of flannel dipped in spirits turpentine, and applied to the throat till it pro- duces a burning sensation; or a snuff plaster, applied to the same place ; or, the application of a garlic or onion poultice may afford some relief. As the disease subsides, from five to twelve drops of Coxe’s hive syrup, four or six times a day, or if this is not at hand, small doses (from half a grain to a grain) of ipecac., or the decoc- tion or infusion of boneset, may be given in such quan- tities as to produce slight nausea, and a gentle or slight moisture of the skin, to insure recovery, and prevent a return of the disease. Two or three free evacuations from the bowels should be procured at the onset of the disease, during the period of febrile excitement; after which, one or two operations daily are usually sufficient ; as active purging at this time would do harm, by ex- hausting the system. After the febrile excitement has been reduced by vo- miting, and the other means that may have been thought proper, and a remission brought about, I have found quinine in free doses (from two to five grains, according to the age of the patient), repeated three or four times a day, superior to anything else in putting a check to the further progress of the disease; not neglecting, however, the use of such other articles as the symptoms may re- quire. My experience with quinine, in croup, has not been extensive enough to ascertain to what extent it 392 CROUP— TREATMENT. may be profitably given, as I have generally pursued the treatment recommended by authors; but from the known influence of quinine, when given in free doses, in arresting inflammation in its incipient stages, in other organs, attended with febrile excitement, and from analogy, I am inclined to believe that if, soon after free vomiting was induced, a good-sized dose of quinine was given, with the dose of calomel that is above recom- mended, at this time, it would have a powerful influence in putting a stop to the disease. Opiates at this time are often of much service, and are, perhaps, too seldom exhibited. “ In the advanced periods of the disease, there exists often so much torpor or insensibility of the system, in consequence of the imperfect decarbonization of the blood and vascular congestion in the brain, that great difficulty is experienced in procuring the operation of emetics. To obviate this gastric insensibility, and procure emesis, we must endeavor to diminish the sanguineous congestion in the head; and this may, in general, be readily accom- plished,” except when near the fatal termination, “ by putting the patient’s feet in warm water, and applying a napkin, wet with very cold w’ater, to the head. The abstraction of blood, too, w r hile the patient is supported in a sitting or erect posture, will rarely fail to insure the operation of an emetic under the circumstances in ques- tion.” ( Eberle .) In the early stages of the disease, when the skin is hot and dry, the warm or tepid bath is recommended by some authors, and it may be of benefit, under these circumstances, but I do not think that much reliance should be placed in it. Never having tried it, I would not here recommend the cold or shower bath, or the pouring cold water over the body, as is particularly enjoined in the inflammatory or second variety of re- CROUP— TREATMENT. 393 mittent fever; but in the early stage of highly inflam- matory croup, when the skin is hot and dry, the face flushed, and the pulse full and hard, I am inclined to be- lieve that the application of cold water, in the manner above mentioned, so as to control the febrile excitement, and probably also tend to relieve the local inflammation, would be of much service. I think these suggestions are worthy of being tested by the profession. In this form, tartar emetic is probably superior to any other article. The system should be kept under its emetic and nauseating influence till the excitement is subdued, and used to a less extent subsequently. In the latter stage of the disease, or after it has lost its acute inflammatory character, if viscid accumulations clog the upper portion of the windpipe, and an emetic is necessary to remove them, some of the followdng arti- cles should be selected ; viz., ipecacuanha, boneset, syrup of squills, solution of common salt (in warm water), mus- tard, alum, white vitriol ( sulph . zinc), blue stone ( sulph . copper). Some authors speak favorably of the seneka snake-root {poly gala senega). The late Dr. Eberle says, “ After the complaint has been, in some degree, subdued, or lost its acute inflammatory character, its influence is often conspicuously beneficial. For the removal of the dry and hoarse cough, and slight oppression of the res- piration, which, in some instances, remain after the in- flammation has been subdued, we possess no remedy equal in usefulness to the polygala. It is, moreover, a decidedly useful remedy in all instances of chronic croupy affections, and in the catarrhal and pectoral affec- tions which remain as the sequela of this and other acute affections of the respiratory organs. It is best given in decoction. An ounce of the root to a pint of boiling water, suffered to simmer for fifteen or twenty minutes, 26 394 CROUP-TREATMENT. and afterwards sweetened with honey. The dose of this is about an ounce (two tablespoonfuls) every hour or two, according to the urgency of the symptoms.” In this latter stage, perhaps, puccoon or blood-root would be equally or more efficacious, and rendered more so, by the addition of a little sulphate of zinc and paregoric. To an infusion or tincture of the puccoon, an equal por- tion, or one-third of paregoric, may be added, and ten or fifteen drops given in a little milk, every two or three hours, till sufficient relief is obtained ; after which a dose, three or four times a day, or less frequently, as the disease subsides, may suffice. If the zinc be added, a dose of the solution should contain about one-twelfth of a grain of this article. After , the mixture is made, it may be sweetened with honey or sugar. Some authors, within the last few years, maintaining that the inflammation generally commences about the tonsils or fauces, and extends to the larynx and wind- pipe, and, in some cases, into the bronchia, insist on the importance of the early application of a strong solution of lunar caustic (from twelve to twrnnty grains to the ounce of water) to the inflamed surface of the tonsils, palate, uvula, .&c., so as to arrest the disease in its in- cipient stages, before the inflammation extends into the larynx and windpipe. There are but few, however, except physicians, who have sufficient knowledge to apply this properly. It may be done with a fine camel's hair pencil, or a small piece of sponge, tied to a stick or whalebone. In those cases in which a false membrane has formed, lining the windpipe, but little hopes are usually enter- tained of a favorable result. In rare instances, emetics may cause its expulsion. Tracheotomy, laryngotomy, or cutting into the windpipe or larynx, so as to be able CROUP— TREATMENT. 395 to extract the false membrane, and allow the child to breathe, is an operation that has been performed as a dernier resort, but generally without success, and there- fore considered of doubtful propriety. If my recollection serves me correctly, I heard Professor J. M. Bush, M.D., of Transylvania University, say that one of his children was attacked with croup, in which the membranous for- mation took place. He called in Professor B. W. Dudley, w-ho opened the child’s mouth, and, perceiving the upper portion of the deciduous membrane, immediately caught hold of and extracted it, and the child soon recovered. Dr. Charles D. Meigs reports a case of croup, in which the false membrane had formed. After other in- effectual means were resorted to, as a dernier resort, in the advanced stage of the disease, tracheotomy was per- formed by Dr. Pancoast, and the child recovered. “ After laying bare the trachea, he divided the second, third, and fourth cartilaginous rings ; immediately upon opening the trachea, a discharge took place of mucus, mixed with blood and portions of plastic lymph. In forty seconds, the child breathed with great freedom. The next day the child was up and running about.” An elliptical portion of cartilage was cut from the trachea, so as to keep an opening through i|, and the edges of the soft parts were kept apart by a leaden wire — with hooked ends — which passed around the neck. For further particulars in rela- tion to this case, see the American Journal of the Medical Sciences , Oct. 1848. Nervous or spasmodic croup is the most common form in the South, and perhaps also elsewhere. It is usually very easily controlled by the exhibition of an emetic, of which lobelia is probably the best, given alone, or combined with ipecac. Any of the other emetics may be used, the tartar emetic, however, being unnecessarily violent, in most cases, unless' paregoric be added to the 396 CROUP-TREATMENT. solution, and perhaps even then. Shortly after the ope- ration of an emetic, the exhibition of two grains of calo- mel, in many instances, may be of service unless the attack be very slight, in which case it may be dispensed with. A recurrence of the attack may be prevented by quinine, in doses of one, two, or three grains, two or three times a day, for a few days. This is the form of croup in which the old women procure relief by the ex- hibition of onion juice, and similar articles. The syrup of puccoon, zinc, and paregoric, above mentioned, three times a day, would also probably answer well to avert a return of it. If this variety is caused by worms or other irritating matters in the stomach or bowels, these should be removed by emetics, mild cathartics, or anthelmintics in the case of worms. In this latter condition, give first two or three grains of calomel, after the operation of an emetic, as above advised ; and, after it operates on the bowels, Jerusalem oak, pinkroot, china root, spirit of turpentine, or other worm medicines should be given. In addition to what has already been said in relation to the application of lunar caustic to the larynx in croup, I find the following in the January No. of the American Journal of the Medical Sciences , for 1848. “ Croup cur edhy cauterizing the larynx with a solution of the nitrate of silver. — Dr. Latour was sent for to a child of four years old, ill of sore-throat, accompanied with a hoarse cough, fever, anxiety, and other severe symptoms, the uvula and right tonsil being covered with very adherent false membranes. Nitrate of silver in the solid form was immediately applied to all the afflicted parts within reach, and a vomit was given, by which some fragments of false membrane were brought away. Next day, the false membrane had not covered the left tonsil, but appeared to have extended downwards, and the larynx seemed to be involved in the disease, as there CROUP— TREATMENT. 397 was a suppressed hissing cough, and a loss of voice. Ob- jecting, as insufficient, to the usual method of applying the nitrate of silver in such cases, namely, by introduc- ing into the back part of the throat a sponge dipped in the solution of the salt, Dr. L. determined to use a stronger solution, between seven and eight grains to the ounce of water, and to adopt a method of applying it which he had already published in the ‘ Clinique des Hopitauz des Enfans This consists in saturating a strong ball of lint in the solution, and conveying it to the opening of the larynx by means of a long, curved, pair of forceps, and then squeezing out the solution by compressing the ball between the blades. In this man- ner, the solution was applied in the case referred to every eight hours, for four days, with complete success ; the voice was first restored, and then the convalescence soon became complete.”* * From Gazette Medicate de Paris, August 21, 1847. APPENDIX. 4 GLAP. (GONORRHOEA.) My object is briefly to notice the subject of Clap , from the fact of its being so often improperly treated, which renders it difficult to cure, sometimes producing stricture, enlarged prostate, affecting the bladder, &c., and also exercising a deleterious influence on the general system. The clap usually manifests itself in three or four days after an impure connection, but in some cases it makes its appearance much sooner, and in others, again, several days later. “At first, a disagreeable itching or prickling sensation is felt in the point of the urethra, passing a short distance up from the orifice, which, on examination, will be found slightly reddened and somewhat tender. After this sensation has continued for ten or twelve hours, the mouth of the urethra becomes sensibly inflamed and swollen, and a limpid or yellowish matter begins to ooze from it. The stinging and itching increase, and the emission of urine occasions a severe smarting and burning: pain in the anterior portion of the urethra. The pain, now, extends more or less speedily inwards along the urethra; the glans penis become swollen, dark red, and tender to the touch, and the discharge acquires a yellow- greenish color, resembling diluted pus. Frequent and 400 APPENDIX. very painful erections harass the patient, more especially after he has been some time in bed ; and on passing water the stream is forked, and the pain, in some instances, is exceedingly smarting.” — ( Eberle .) At this stage of the disease, when the erections, or chordee , are painful and troublesome, a small quantity of blood is occasion- ally mixed with the discharge from the urethra, '‘and the prepuce sometimes becomes much inflamed, tumid, and slightly excoriated at the edges, and in spots on its internal surface. Many patients experience a constant aching pain in the glands and body of the penis, and oc- casionally one or both testicles become tender, inflamed, and much swollen, attended with pain along the whole course of the spermatic cord. Considerable symptomatic fever always attends, when the inflammation becomes thus extended from the urethra to the neighboring' struc- tures. Not unfrequently the whole track of the urethra becomes inflamed, giving rise to harassing sensations of burning and titillation in the neck of the bladder and anus, and very severe cutting pains in the perineum on making water. The patient, under these circumstances, feels a continual urgency to make water, but from the great tenderness of the neck of the bladder and urethra, only a few scalding drops are voided at a time. When the testicles become inflamed, the gonorrhoeal discharge 7 O £5 is always sensibly diminished, and in many cases entirely suppressed. Sometimes some of the engorged capillaries of the mucous membrane burst, and more or less pure blood passes off. After an uncertain period, these in- flammatory symptoms begin to subside. The scalding pain in making water gradually ceases, the erections be- come less frequent and painful, and the gonorrhoeal mat- ter acquires a greater consistence, and becomes white and ropy. “ The specific inflammation of gonorrhoea is primarily APPENDIX. 401 seated in the mucous membrane of the urethra, a short distance above its orifice in the fossa naoacularis , and chiefly affects the lacuna mucosa of Morgagni, and their excretory ducts. From this point, however, it often ex- tends higher up the urethra, to the membranous portion, the veru montanum, and neck of the bladder. “ Sometimes the gonorrhoeal matter, in the first in- stance, does not penetrate the urethra during impure ve- nereal connection, but, being applied to the glans penis, it gives rise to irritation and a discharge of thin, purulent matter from the sebaceous glands situated around the corona glandis.” — {Eberle.) In women , gonorrhoea, in many instances, produces but little irritation, pain, uneasiness, or excitement. — Eberle says, that “ Women, affected with gonorrhoea, generally experience a disagreeable itching and titillation, about the orifice of the vagina, and at the raphe. In se- vere cases, the labia, nymphae, and clitoris, become swol- len and extremely tender; and there is, generally, a severe burning and stinging pain felt in voiding the urine. In violent instances of the disease, there is a constant aching pain, experienced in the bladder, womb, groins, and back; and the upper and inner surface of the thighs often becomes inflamed, excoriated, or covered with an inflamed pustular eruption, from the irritation occasioned by the gonorrhoeal discharge.” What is called the inflammatory stage of clap, usually lasts six or eight days, or even longer, in some cases. After this period, the discharges from the urethra may become even more copious than previously, and are of the appearance of cream, to which, sometimes, there is a greenish tinge. Now, the discharges are commonly at- tended with little or no pain, perhaps a slight burning sensation at the time of voiding urine, and for a short 402 APPENDIX. time afterwards; and the disease, in many instances, as- sumes a chronic character, usually called gleet. Treatment. — During the inflammatory stage, the treatment should be antiphlogistic ; therefore, as soon as one is attacked with clap, if be is of a full, sanguine tem- perament, young and vigorous, he should be immediately bled to a moderate extent ; but, whether or not bleeding is now resorted to, he should be freely purged, and his sto- mach kept nauseated. For these purposes, he may com- mence by taking ten grains of calomel with ten grains of jalap, or twenty grains of rhubarb, with the addition of a quarter of a grain of tartar emetic, or a teaspoonful of the tincture of lobelia, or two or three grains of ipecacuanha. These latter articles, for the purpose of producing nausea, should be repeated every two or three hours, and the dose increased or diminished, according to their effect; indeed, if the nausea w T ere carried to the extent of causing vomiting once a day, the disease would be more promptly controlled. Twenty-four hours after taking the first dose of calomel, as above noticed, the bowels having been freely purged, a second dose of six or eight grains should be given; after which, they may be kept loose by the use of the nauseants above mentioned ; and, if necessary, the additional use of cream of tartar. This may be dissolved in a mucilaginous solution, as of gum Arabic, flaxseed, slippery elm, benne, &c., and drunk occasionally or frequently through the day, so as to keep the bowels open; or a dose of two or three tea- spoonfuls or more may be taken at once, dissolved, as above mentioned; or it may be dissolved in warm water, and, if desired, sweetened. Other cathartics may be se- lected and used instead of this. This treatment should be persevered in till the inflammatory stage of the dis- ease has subsided. APPENDIX. 403 As to local treatment, in the mean time, Professor B. W. Dudley, M. D., recommends the frequent application of warm water, which may be done by sitting in or over the vessel containing it, and frequently throwing the water upon the genitals. For the relief of the painful erections at night, the wrnrm w 7 ater may occasionally be applied ; or a soft opiate poultice may procure some re- lief; as of Jimpson-weed leaves, nightshade, opium; or an ointment of morphine, or camphor and mercurial ointment. The parts should be kept clean, by washing them three or four times a day in weak tepid soap-suds. A clean piece of cotton cloth should be worn over the genitals, which ought to be changed for another twice or thrice a day, or as often as it becomes soiled with the go- norrhoeal discharges. During the first six or eight days, or the inflammatory stage, the affected individual should live very abste- miously, as upon small quantities of gruel, weak soup, panada, rice soup, and the like. Stimulants of all kinds should be eschewed. The individual should also avoid exercise, keep quiet, and remain mostly in a horizontal position, as upon a bed, sofa, &c. Unfortunately during this stage it is too common, both amongst those afflicted with the disease and physicians, to give balsam copaiva and other stimulating diuretics, and also to throw stimulating astringent injections into the urethra, often thus making the disease worse — more painful, distressing, protracted, difficult to cure — and also sometimes producing swelling of one or both testicles, stricture, &c. After the acute or inflammatory stage has passed off, balsam copaiva, cubebs or turpentine, should be freely given three times a day in mucilaginous solution, or mixed with sugar. The following formula will answer a good purpose at this time : — • 404 APPENDIX. R . Balsam copaiva two flmdounces ; Sulphate of zinc half a drachm ; Gum Arabic, pulverized, a tahlespoonful ; W ater four fluidounces. Dissolve the zinc in the water, add the gum Arabic, and then the balsam copaiva, and shake it well just before using it. Dose, from a dessertspoonful to a tablespoon ful three times a day. If it should operate too much on the bowels, half an ounce of laudanum should be added to the mixture. It may be taken alone or mixed with sugar ; or, if it is not convenient to prepare the above, from forty to sixty drops, or near a teaspoonful of the balsam copaiva, may be mixed with sugar, and thus taken. Dr. Eberle says the following is an excellent formula for administering this article: — R. Balsam copaiva one ounce ; Sweet spirit of nitre half an ounce ; Laudanum, and spirit of camphor, of each, one drachm. Mix. Of this, a teaspoonful should be taken four times daily. When the disease assumes a chronic or gleety cha- racter, spirit of turpentine, or cubebs, should be mixed with the balsam copaiva, in the proportion of equal quantities of the former, or tincture of cubebs, and the balsam ; or, the first two may be mixed together in equal quantities, and given in teaspoonful doses, three or four times a day, mixed with a little sugar. In cases of this kind, I am inclined to think favorably of the addition of tincture of puccoon root and a solu- tion of sulphate of zinc to the mixture of balsam and turpentine. The use of the above means should be continued till the discharge ceases ; after which, the doses should be gradually diminished for six, eight, or ten days; when, if there is no appearance of the gonorrhoeal discharge, the individual may consider himself cured, though he APPENDIX. 405 should live temperately, avoiding too much exercise or excessive venereal indulgence, for fear that the disease might again be developed ; and this is the more imper- ative, if the individual has had it before. If the clap is disposed to yield to the above means, no injections into the urethra, of any kind, should be used ; but, if it is rather obstinate, a silver bougie should be smeared with balsam copaiva, and introduced three times a day ; or, in obstinate cases, twenty grains of lunar caustic, pulverized finely, and rubbed up, or in- timately mixed with half an ounce of lard, or citrine ointment, smeared on the bougie, may be used in the same manner. Weak solutions of sulphate of zinc, lunar caustic, sugar of lead, oil of vitriol, or sulphate of cop- per, may be injected into the urethra, instead of the above; but care is requisite that they be of the proper strength, and carefully injected, so that the solution may come in contact with the diseased surface, and that the end of the syringe do not touch the diseased urethra so as to excite increased irritation and inflammation. The following is the proportion in which these articles may be added to an ounce of water, using the weaker solutions first; as the disease becomes more protracted, or chronic, the strength should be increased ; sulphate of zinc , from a grain and a half to eight grains ; lunar caustic, from one to six grains ; sugar of lead, from three to eight grains; oil of vitriol, a drop to a drop and a half; sul- phate of copper, from one to four grains. Dr. Eberle very correctly observes “that, where there is much irritability or active inflammation of the urethra present, all astringent or irritating injections are highly improper. When used under circumstances of this kind, they are apt to give rise to various distressing affections, particularly to obstinate chordee, inflammation of the body of the penis, of the neck of the bladder, and of the 406 APPENDIX. testes, and to strictures in the urethra.” It should also be borne in mind that these secondary results may take place in cases in which no injections have been used, if the proper treatment has been neglected. The bowels should be kept gently open by aperients, of which blue mass or calomel should constitute a part, if any of the secondary conditions above mentioned exist. Minute doses of corrosive sublimate, with ex- tract of cicuta, are favorably spoken of by some authors. When one or both testicles are swelled and painful, an emetic should be given, and the testes enveloped in a piaster made of mercurial ointment and camphor. In cases of enlarged prostate, iodine and mercurial ointments should alternately be rubbed over it twice a day. The general treatment recommended above is also ap- plicable to females, though in them it usually need not be quite so active. During the inflammatory stage, the parts should be frequently bathed or sponged with tepid water, and also kept clean by injecting weak soap-suds into the vagina three or four times a day, after which a weak solution of sugar of lead may be thrown into it. After the acute stage has passed by, any of the afore- mentioned injections recommended for the male are pro- per, and should be repeated three or four times a day. If the disease extends into the urethra, a silver bougie should be smeared with balsam copaiva, or some of the articles mentioned heretofore, and introduced into it twice or thrice a day. In chronic cases, muriated tincture of iron, or iodine, is sometimes of much service. The diet should be light, in the early stages of this form, but, subsequently, it may be more nourishing, especially if there is much debility; in w hich case tonics may be necessary. APPENDIX. 407 II. MISCELLANEOUS. It has been, and still is too common an error with many, so soon as an individual receives a severe concus- sion or jar — as by a fall from a height, or other severe injury, to bleed him immediately , while the pulse is very small or scarcely perceptible ; the face pale, and perhaps the extremities cold. In cases of this kind, and during this condition, stimu- lants should be given, if necessary ; spirits of camphor, hartshorn, or ether, held to the nose ; cold water sprinkled on the face frequently, and the extremities assiduously rubbed with the hands. After reaction is fully established, the pulse being hard and full ; the general surface and extremities warm and dry, or even hot; perhaps pain in the head; it may then be necessary to take away a moderate quantity of blood, administer a mild cathartic, and, if there is much pain in the head, it should be kept cool by the applica- tion of cold water. If the reaction is moderate, bleeding will be unnecessary ; but the bowels should be operated on by a cathartic, as castor oil, Epsom salts, cream of tartar, extract of butternut, calomel and jalap, &c. If the person thus injured should again relapse, stimu- lants should again be given; and, if the case should be protracted, quinine and other tonics may be necessary. If any degree of febrile reaction attends, the occasional use of the above cathartics, with the use also of lemon- ade, will probably be demanded. 408 APPENDIX. III. INCISED WOUNDS. Incised Wounds are those made by sharp-edged in- struments; such, for instance, as an axe, drawing-knife, pocket-knife, cutlass, &c. It is so common an error amongst the people generally to treat injuries of this kind by filling the wound with ashes, sugar, soot, or other improper materials, that I wish to call their atten- tion to the proper treatment of wounds of this sort. As soon as possible after the occurrence of an incised wound, its edges should be drawn together and held in this position, in order that the parts may soon unite again, by what is commonly called “ healing by the first intention ,” and mithout suppurating or mattering. Before drawing the edges of the wound together, how T - ever, if there is any dirt, clotted blood, or other foreign matter in it, it should be removed. The edges may be held in apposition by adhesive plaster spread on linen, by an ethereal solution of gun-cotton, or by stitching them together; or, on certain parts, the appli- cation of a bandage may suffice for this purpose. If the plaster, or linen saturated with an ethereal solution of gun-cotton be used, the width of the strips should depend on the size of the wound, as from a quarter of an inch to an inch wide, and sufficiently long to extend some distance beyond the wound, so that it may have enough surface of skin to adhere firmly to. If the wound is in very fleshy or soft parts, and so large that its edges cannot be held in apposition by these means, APPENDIX. 409 the suture should be resorted to ; and, in the spaces be- tween- the stitches, the adhesive strips (either of the plaster or solution of gun cotton), should be applied. After the wound has been treated as above, if it is dis- posed to bleed too much, some clean wool, dipped in a mixture of flour and water, should be applied to it. If it is on any of the limbs where a bandage can be pro- perly applied, the bleeding may be arrested by it, taking care to commence wrapping the limb at its extremity, and firmly and smoothly encircling it to a few inches above the wound. The bandage should be two or three inches wide; and it may be profitably applied to wounds which do not bleed too much, especially those inflicted on the limbs or about the head, or anywhere else where it can be used so as to compress and firmly hold the edges of them together. After a wound has been dressed as above, usually but little else is necessary than to cover the parts with a soft piece of folded cloth. No ashes or sugar should be thrown into it to prevent it from healing, or force it to fill up by granulation, which would, probably, require weeks or months. Let some blood remain on its edges, which serves to assist in holding the parts together, and to heal it. If the wound is large, and the parts become consider- ably inflamed, hot, and painful, they should be frequently sponged with tepid or cold water, or water and vinegar ; or a cool poultice, as of slippery elm, should be applied over the inflamed parts, and renewed as soon as it be- comes dry. Lacerated , or contused wounds should be treated like the above ; in the latter, as the parts are not separated or torn asunder, the application of the bandage, and some opodeldoc, will, perhaps, be sufficient. If much inflam- 27 410 APPENDIX. mation should ensue, attended with considerable heat and pain, a cool poultice of slippery elm, or the frequent application of tepid water, or of cool water and vinegar, if it is found to afford more relief, should be used. As the recent discovery of “ gun cotton ,” and its adhe- sive properties when dissolved in sulphuric ether — the solution being called “ Collodion 1 ’ — have attracted much attention, formulas for making these articles, and the uses of the latter, may be of interest to the reader. Receipt for making Gun Cotton. Take about equal quantities of pure sulphuric and nitric acids, put them into a glass vessel (a glass tumbler, for instance), and put in as much clean cotton or cotton rags as the acids will completely saturate ; let it thus re- main for from three to four hours, then wash the cotton well with water, and dry it in the sun. Gun cotton is possessed of great explosive properties, and may be used, as a substitute for gunpowder. “ Collodion ,” or Ethereal Solution of Gun Cotton , or prepared Cotton. R. Gun cotton ten to twelve grains ; Commercial sulphuric ether one ounce. Mix. Mr. S. Hutchings, of Montgomery, Alabama, has pre- pared an ethereal solution of prepared cotton , which he considers superior to the Boston preparation. His for- mula is as follows : — R. Sulphuric acid (commercial) four ounces; Nitric acid (Farr’s chemically pure) two ounces : Gotton three drachms. Mix the acids. Saturate the cotton in the mixture for six minutes; then gently press off the acids. Allow the APPENDIX. 411 cotton to remain for an hour in the fumes, in a covered vessel; then wash repeatedly in water, so as to remove the slightest taste of acid, and dry thoroughly in the sun. Then, To make Collodion , Take of the prepared cotton ten to twelve grains ; Commercial sulphuric ether one ounce. Mix. The cotton should be dissolved in the ether as soon as it is perfectly dry ; if kept for any length of time (for instance, a week) it loses to some extent its solubility, which may be owing to its absorption of moisture from the atmosphere. The above is a most excellent application to all in- cised, or lacerated wounds. It adheres with great te- nacity, holds their edges together, and gives them an opportunity to heal by the first intention. In the lan- guage of J. Marion Sims, M. D., of Montgomery, Ala- bama, “ In the application of the solution to common incised mounds , nothing more is necessary than to bring their edges into apposition, and smear the wound over with it, by means of a camel’s hair pencil. But in wounds of greater magnitude, requiring sutures or straps, it will be necessary to use strips of linen or cotton fabric, of the requisite length and breadth, well moistened with the liquid. For this purpose, let one end of the strip be stuffed into the vial containing the preparation. When thoroughly saturated, let it be applied, and wait patiently' till it becomes perfectly dry, which will be in from a half minute to three, four, or five, according to circumstances. The other end of the strip may now be wet and applied in like manner. In some wounds, as, for instance, after amputation, the whole strip may be saturated at once and applied over the parts. Be sure of one thing, not to feel afraid of wasting the article; and of another, not to be 412 APPENDIX. in a hurry; for a failure sometimes arises from using the solution too sparingly, and again, from not waiting till it gets thoroughly dry.”* M. Mialhe makes collodion in the following manner R. Finely powdered nitrate of potash forty parts by weight ; Concentrated or common sulphuric acid sixty “ “ “ Carded cotton two “ “ “ “ Mix the nitre with the sulphuric acid in a porcelain vessel, then add the cotton, and agitate the mass for three minutes by the aid of tw T o glass rods.” If the sulphuric acid is weak, a longer immersion of the cotton is neces- sary. “Wash the cotton, without first pressing it, in a large quantity of water, and, when all acidity is removed (indicated by litmus paper), press it firmly in a cloth. Pull it out into a loose mass, and dry it in a stove at a moderate heat. “ The compound thus obtained is not pure fulminating cotton ; it always retains a small quantity of sulphuric acid, is less inflammable than gun cotton, and it leaves a carbonaceous residue after explosion. It has, however, in a remarkable degree, the property of solubility in ether, especially when mixed with a little alcohol, and it forms therewith a very adhesive solution.” R . Prepared cotton eight parts by weight ; Rectified sulphuric ether one hundred and twenty-fire do. Rectified alcohol eight do. “ Put the cotton with the ether into a w r ell-stopped bottle, and shake the mixture for some minutes. Then add the alcohol by degrees, and continue to shake until the wdiole of the liquid acquires a syrupy consistency. It may be then passed through a cloth, the residue strongly pressed, and the liquid kept in a well-secured bottle.” — [Med. News, Dec. 1848.) *New Orleans Medical and Surgical Journal, Sept, 1S48, APPENDIX. 413 IV. WORMS IN THE ALIMENTARY CANAL. The most common symptoms of worms are generally pretty well understood; as a pallid or sallow complexion, with usually a fullness or protuberance of the abdomen, swelling of the upper lip, scratching of the nose and anus, grinding of the teeth, and sometimes sudden jumps or starts when the child is asleep, sometimes disagreeable or gnawing sensations in the belly, irregularity of the bowels, indigestion, fetid breath, more or less debility, and commonly anaemia; in some cases fever is produced {worm fever), or convulsions or other nervous affections occur; the appetite is generally variable. Worms are most common in children between the periods of weaning and puberty. A debilitated condition of the system favors their production, either in children or adults. Treatment.— -At the commencement, if there should be attendant fever, or a somewhat full, florid appear- ance, one or two doses of calomel (from two to six or eight grains, according to the age and condition of the patient) should be given, with an interval of twelve or twenty-four hours, if more than one dose is taken. After this, some of the other anthelmintics should be administered ; or, if the conditions mentioned above should not be present at first, calomel need not be given, and these at once commenced with. The most common worm medicines are spt. turpentine , norm-seed , or Jerusalem oak, pinkroot, the bark of the root of the China-tree , the hark of the pomegranate root, male fern , 414 APPENDIX. walnut rind , wormwood , garlic , tansy , rue, cowage , pow- der of tin or zinc, copperas , common salt, bitters, &c. The size of a dose of any of these articles will, of course, depend on the age and condition of the patient, and should usually be repeated two or three times a day. For a child some five or seven years of age, the follow- ing answers very well R . Spt. turpentine three teaspoonfuls ; Sweet oil or castor oil three tablespoonfuls. Mix, and shake well just before using; dose, a teaspoon- ful, taken alone, or mixed wdth sugar or mucilage of some kind, two or three times a day. When the subject is older or younger, the dose should be increased or di- minished accordingly. The addition of some twenty grains of calomel to this mixture may add to its anthel- mintic virtues; when the calomel is added, its use should not be continued longer than two or three days; but, if necessary, it may be resumed at a subsequent period. Usually, after giving some of the anthelmintics which do not purge for a day or two, it will be advisable, if worms are not discharged, to give a cathartic. The ve- getable anthelmintics noticed above (except the cowage, which should be taken in syrup), may be given in de- coction or infusion, or otherwise. The seeds of the Je- rusalem oak are frequently given in sweet milk. When children are wormy, a very convenient way to remove these parasites is to incorporate the seeds of the Jerusa- lem oak with candy. This may be easily done, when candy is made of molasses or sugar, in the usual way ; just before the syrup becomes cool and hard, freely stir in the seeds ; and when the candy is prepared, the chil- dren should be allowed to use it somewhat freely, which they will probably most commonly willingly and cheer- APPENDIX. 415 fully do. The other anthelmintics may be finely pul- verized, and given in the same way. The thread-worm ( ascarides ) commonly inhabits the rectum ; and for their removal, besides the means men- tioned above, injections should be resorted to daily, of solutions of common salt, or spirit of turpentine and sweet oil or castor oil, or some bitter decoction; as of wormwood, aloes, rue, &c., sufficiently diluted with water. In cases of tape-worm, occurring in adults, large doses of spirit of turpentine are highly spoken of by authors. It may be given in doses of from one to two or three teaspoonfuls, with a tablespoonful of castor oil, and some sugar or thick solution of gum Arabic, slippery elm, flour, or the like, and taken once or twice a day. For further particulars, see works which treat more at length on this subject. As there is generally greater or less debility after the worms have been removed, or even during their removal, tonics are necessary ; and as, in a large majority of cases, there is a greater or less degree of anemia — the subject presenting a pallid appearance, some of the preparations of iron are indicated, which also act well as tonics. For this purpose, for children some five or six years of age (and for younger or older in proportion), a grain of cop- peras, or three or four grains of carbonate of iron, should be given in syrup or molasses, two or three times a day, till the health of the patient is restored. Some of the vegetable bitters may also be used; as dogwood, poplar, gentian, quassia, &c. Generous diet, fresh air, and other hygienic measures should be attended to. The worms that are generally met with in the ali- mentary canal, are the round-worm ( Ascaris lumbri- coides ), thread-worm ( Ascaris vermicularis ), long thread- worm ( Tricocephalus dispar ), long tape-worm ( Tcenia solium ), broad tape-worm [Tcenia lata). 416 APPENDIX. y. CATARRH, OR A COLD: COMMONLY CALLED “A BAD COLD.” As the real nature of this affection is so little under- stood bj most persons, though it is of common occur- rence, and as it is often so variously and improperly treated by them, a brief notice of it here may not be without profit to many. It should be borne in mind that, though it is produced in cold and wet or variable weather, or by sudden exposure to a cool current of air, after being in a crowded ball-room or other warm place, the pathological condition is a superficial inflam- mation of a greater or less portion of the mucous mem- brane, or mucous follicles of the air passages, more particularly of the windpipe, bronchi, and nasal cavi- ties, with, in some cases, a febrile condition of the system. The symptoms are cough and sneezing, with increased secretion of mucus from the air passages; a feeling of lassitude or dullness; probably watery eyes, a greater or less degree of fever and thirst, and commonly a fullness of the head, which is said by the patient to be “ stopped up.” In some severe attacks, that are neglected or impro- perly treated, it becomes chronic and troublesome; and, it has been said, may run into consumption. Treatment. — Bad colds are often so slight as to get well without the exhibition of medicines. At the onset, in violent attacks in young plethoric persons, in which APPENDIX. 417 the febrile excitement is considerable, with pain in the head, a moderate quantity of blood may be taken from the arm, though this is very rarely if ever necessary, in the South. An emetic and cathartic, or a few doses of some cathartic, are usually sufficient. I have generally found a moderate dose of Epsom salts (three or four tea- spoonsful) taken at bed-time, for several nights in suc- cession, suffice to cure a cold. Bathing the feet and legs in hot water for about twenty minutes, just before going to bed, and immediately wiping them dry, may be of service; so also may drinking a little warm sage tea, after getting in bed, so as to favor slight perspiration. If the cough is troublesome, the following mixture O 1 O may be of much service : — Or, EL. Syrup of squills Tartar emetic C Ipecacuanha, or, \ Tincture of lobelia Sulphate of morphine Water two fluidounees; six grains ; two scruples ; one fluidounee ; five grains ; one fluidounee. Dissolve the tartar emetic and morphine in the water (if the water is used instead of the tincture of lobelia; if the latter is used, dissolve these ingredients in it), then mix it with the syrup of squills, and shake well before using : dose, a teaspoonful, three or four times a day, so as scarcely to nauseate the stomach. If the cough is troublesome at night, a dose should be taken to allay it; or if there is little or no febrile excitement, a teaspoonful or two of paregoric, or thirty or forty drops of laudanum, or a quarter or third of a grain of morphine, may be used for the same purpose. Five grains of morphine dissolved in an ounce of tincture of lobelia, and this added to two fluidounees of Coxe’s hive syrup, and the mixture shaken and taken in doses of a teaspoonful three or four times a day, may be used instead of the above formula or mix- 418 APPENDIX. ture. In cases that are somewhat protracted, the ad- dition of either of the above mixtures to an equal quan- tity of sweet spirit of nitre, and taken in doses of from one to two teaspoonfuls, three times a day, has appeared to be of much service. Other articles, w T hich common sense may suggest, guided by the nature of the disease, may also be of use. If there is febrile excitement, the diet should be light and cooling ; otherwise, little or no alteration from the usual mode of living is necessary. If the affection becomes chronic , the treatment for chronic bronchitis will be proper ; to which the reader is referred. VI. EPHEMERAL FEVER. On account of the susceptibility of young children to be morbidly affected by slight causes, which mayor may ‘not be appreciable, a febrile condition is sometimes in- duced in them, which may last for several hours and then pass off, and it may or may not return the next ensuing day, in mild cases. In severe cases, the fever will pro- bably last a much longer time, perhaps for ten or twelve hours or more. In many of these the brain becomes con- siderably affected, even to coma or convulsions, or jerking of the limbs. The pulse is greatly increased in frequency, and to some extent in fullness and hardness. The fever is most likely to be at its acme in the afternoon ; and will probably subside during the night, especially if the proper remedies have been given ; and it may return again the ensuing day. The fever is generally, if not always, APPENDIX. 419 preceded by coldness of the extremities, which may even present a purplish or bluish appearance, as in the cold stage of an intermittent. When the fever is at its highest the skin is hot and dry, and it is at this time that the brain is most affected. This disease is usually most severe, according to my observation, in florid, healthy looking children. Treatment. — A solution of tartar emetic, lobelia, or ipecac, should be given, so as to nauseate the stomach for a time, and then produce free vomiting. In florid, san- guine looking children, tartar emetic is superior to either of the other articles. After free puking has been induced, the system should be kept under its slightly nauseating influence till the fever is subdued. Abput an hour after the vomiting, two or three grains of calomel should be given, and in severe cases it ought to be repeated once or twice, with intervals of twelve hours. The bowels should be moved rather freely at the commencement, which the tartar emetic and calomel are almost sure to do. During the period of high febrile excitement, the child’s head should especially be kept cool, with cold water, in cases in which the brain is likely to suffer, and, indeed, the whole body may be sponged with cool water, provided it can be done without fretting the child much. After the fever has been subdued, to prevent a return of it, two or three grains of quinine should be given every four or five hours. The diet should be light for a day or two. 420 APPENDIX. VII. FOR THE ITCH. (SCABIES.) Many articles have been used for the cure of the itch, but perhaps a mixture of pulverized sulphur, lard, and soap, is about as good as any. This mixture should be rubbed on at night, on going to bed, and persevered in till a cure is effected. Red precipitate ointment , made by mixing the red precipitate with mutton suet, is also a good remedy, but the sulphur ointment is preferable. GLOSSARY A. Abnormal. Morbid, or a deviation from health. Acupuncture. To puncture parts with a fine needle. Ad Infinitum. A Latin phrase, which means — »to infinity, or without limit. Adjuvant. A medicine which assists another. Albumen. The white of an egg consists almost entirely of albumen. It is also one of the ingredients of animal and vegetable substances— “is found in the serum of the blood, chyle, &c. Albuminuria. A morbid condition of the system, in many cases attended with disease of the kidneys, characterized by the presence of albumen in the urine. Algide. Icy coldness ; applied to one form of congestive chill. Alvine. Pertaining to the bowels or abdomen ; alvine discharges, means the discharges from the bowels, as from the operation of a cathartic, or in diarrhoea. Amenorrhcea. Absence of the menses or catamenia, in females who have arrived at the age of puberty, and previous to the proper time for their cessation in advanced life. Anasarca. Dropsy of the cellular membrane, or general dropsy. Anemia. Privation of blood ; the opposite of plethora, or hyperaemia. Anemic persons are pale and enfeebled ; and there is a greater or less diminution in the ratio of the red corpuscles of the blood. Anemic. Pertaining to anemia. Animalcule. An extremely small animal, which may be seen by means of the microscope. Antiphlogistic. Opposed to inflammation; generally applied to lowering treatment; as bleeding, purging, very light diet, &c. — the opposite of a stimulatihg or tonic treatment. Anus. The fundament; the circular opening at the lower extremity of the rectum, through which the excrements escape. Aplastic. That which is not disposed to, or is incapable of becoming organized or vitalized. Apyrexia. Absence of fever, commonly applied to the period between the paroxysms of intermittent fever. 422 GLOSSARY. Arachnitis. Inflammation of the arachnoid membrane. Synonymous with phrensy, or brain fever. Arachnoid Membrane. A thin, serous membrane, resembling a spider-web ; situate between the pia mater and dura mater ; these latter mem- branes are situated in the interior of the scull ; the dura mater lining its internal cavity, the pia mater enveloping the brain, and both extending into the spinal canal, enveloping the spinal marrow. Articulo mortis. Dying. Ascites. Dropsy of the belly. Assimilation. To render similar. The act by which living bodies appro- priate and transform into their own substance matters with which they may be placed in contact. In man, assimilation is a function of nutrition. ( Dunglison .) Asodes. Disgust, nausea. A variety of fever attended with anxiety, nau- sea, &c. Ataxia or Ataxic. Applied to the prostrated condition of the system in cases of protracted fever, in which the patient is very feeble and nervous. Auscultation. The act of listening. Used as a means of diagnosis in diseases of the lungs, heart, &c., by appreciating the different ab- normal sounds, or their variation from natural or healthy ones. B. Biliary. Pertaining to bile. Bilious. Pertaining to bile, or that which is produced by, or contains bile. A term made use of by some, applied to slight derangement of health which they suppose to depend on torpidity of the liver, a deficiency of bile, or a superabundance of secretion of bile, or biliary derange- ment ; also applied in the same way to diseases, and to certain con- stitutions in which there is supposed to be a superabundance of the biliary secretion ; as in the bilious temperament. Blaud’s Ferruginous Pills. Take of Gum Tragaeantli , in powder, six grains; water, one drachm. Macerate in a glass or porcelain mortar, until a thick mucilage is formed ; and if it be desired to prevent the formation of peroxide of iron, and to make the pills similar to those of Yallet, substitute a drachm of powdered sugar for the mucilage. Add afterwards of sulphate of iron, in powder, half an ounce. Beat well until the mixture is homogeneous, and add subcarbonate of potass, half an ounce. Beat until the mass becomes of a deep green color, and of a soft consistence. Divide into 48 pills. Dose, one a day ; gradually increasing to two, and afterwards to three. ( Dunglison .) Blood, Composition of in health. In 1000 parts, fibrin, 3 ; red corpuscles or globules, 127 ; water, about 790; solid matter of the serum, 80. According to M. Lecanu, the blood is composed in 1000 parts of water, 785.590; albumen, 69.415; fibrin, 3.565; coloring matter, GLOSSARY. 423 119.626; crystallizable fatty matter, 4.300; oily matter, 2.270; ex- tractive matter soluble in alcohol and -water, 1.920; albumen com- bined with soda, 2.010 ; chlorides of sodium and potassium, alkaline phosphates, sulphates, and subcarbonates, 7.304; subcarbonate of lime and magnesia, phosphate of lime, magnesia and iron, peroxide of iron, 1.414 ; loss, 2.586. Blood-Globules. Globules of the blood, Blood-corpuscles, Blood-disks or Blood-vesicles, are small, circular bodies, which constitute a portion of the blood of all animals. “ The globules of blood are circular in the mammalia, and elliptical in birds and cold-blooded animals. They are, also, flat in all animals, and composed of a central nucleus enclosed in a membranous sac.” ( Dunglison .) Borboryghus. A dull or rumbling noise in the bowels, produced by an accumulation of gas or wind. Bougie. A round, flexible instrument, of different sizes, made of metal, gum elastic, &c. Bronchia. The two tubes, with their branches or ramifications, which commence at the lower portion or bifurcation of the windpipe. Bronchial-Respiration or Respiratory Murmur. The noise heard during inspiration and expiration, especially the former. It is produced by the passage of the air through the bronchial tubes, and into the air cells. It has also been called murmur of the expansion of the lungs ; and, when distinctly vesicular, respiration of the cells, or vesicular respiration. Vesicular respiration is, of course, absent when the cells of the lungs have been obliterated from any cause. At times, it is rude during inspiration or expiration, or both — the Respiration rude, or R. rcipense of the French. At others, there is a blowing sound (French, Souffle, Respiration soufflante), as if some one were blowing into the auscultator’s ear through a tube. This is heard in the healthy state over the larynx, trachea, and about the bifurcation of the bronchia ; but when it proceeds from the lungs it denotes disease. The respiration perceived over the trachea and bronchia in health, is called tracheal or bronchial, or tubal, according to the situation in which it is heard. ( Dunglison .) Bronchitis. Inflammation of the lining membrane of the bronchia. Bronchophony, or Resonance. A thrilling of the voice more loud than natural ; or its existence in a part where it is not heard in health, as detected by auscultation. A thickened and hardened state of the lungs, caused either by a mass of crude tubercles, or by inflamma- tion, is generally considered to produce this phenomenon, by render- ing the lung a better conductor of the murmur of the voice in the bronchi. — Ibid. Bruit, Sound. A French term, applied to various sounds heard on per- cussion and auscultation. 424 GLOSSARY. Bruit de Diable. Noise resembling that made by the diable, or humming- top. Venous hum. A high degree of bruit de soufflet, heard on aus- cultating the arteries. It denotes an impoverished state of the blood. ( Dunglison .) Bruit de Scie, or “ saw sound." Bruit de Soufflet. Bruit de Souffle, “bellows sound," “blowing sound." A sound like that of a bellows, heard occasionally by the ear applied to the chest during the contraction of the ventricles, auricles, or large arteries. It co-exists with affections of the heart ; but is heard, also, without any disease in that organ, whenever, indeed, an artery is compressed. — lb. C. Cachectic. Pertaining to, or one who has cachexia. Cachexia. A bad habit or condition of the system, in which it is depraved, debilitated, and in which the red corpuscles are more or less below the natural standard, 127 ; as in chlorosis, anemia, hydropolycemia, dropsy, scrofula, consumption, &c., which see. Cachectic persons present a pale, tallo.wish, or exsanguious appearance. Cacoplastic. “ I form bad." That which is scarcely, or only in a low degree, susceptible of organization. Ceteris Paribus. All other things being equal. Capillary. Prom capillus. A “ hair." Small, like a hair. Capillary Vessels. The extremely small vessels at the ends of the arte- ries and veins, which connect, or form a medium of communica- tion between these latter, through which the blood passes from the former to the latter. In the capillary system, secretion and nutri- tion are performed ; it is also the seat of inflammatory and other diseases. Capsicum. Cayenne pepper. Caput-CvECCm, or Caecum Caput coli. The blind gut; that portion of the bowels situated between the lower end of the ileum, or small gut, and the commencement of the colon, or large gut. Its length is about three or four inches. It is situated in the right iliac fossa, between the lower central portion of the abdomen and the right hip. The appendix vermiformis cocci is attached to it. Cardiac. Appertaining to the heart, or upper orifice of the stomach. Carditis. Inflammation of the fleshy substance of the heart. Carotids. The large arteries or blood-vessels of the neck, which convey blood to the head ; their pulsations may be felt on the right and left of the windpipe, or larynx. Catamenia. The menses, monthly flow of females. Catamenial. Pertaining to the menses. Catarrhus Vesicle. Cystorrhoea, Cystirrhcea. An affection of the lining membrane of the bladder, which gives rise to a discharge of mucus GLOSSARY. 425 from it, which passes out with the urine ; commonly producing dysuria, pain, with a sensation of heat in some part of the urethra, and difficulty in passing the urine. Cava, Vena. The two great veins of the body, which meet at the right auricle of the heart. The inferior one arises from the union of the two primary iliacs, opposite and in front of the fourth or fifth lumbar vertebra, ascends along in front of the spine, in its course receiving several veins, and opens, as above stated, at the posterior and infe- rior part of the right auricle of the heart. The superior one is formed by the union of the subclavian veins, and, like the inferior, after re- ceiving several other smaller veins, terminates at the upper part of the right auricle of the heart. Cavernous Respiration. When a cavity exists in the lungs, and one or more ramifications of the bronchia terminate in it, a loud tubal noise is emitted, provided the cavity be not filled with fluid, which is called cavernous respiration. In this condition, the cough is cavernous like- wise. When the capacity of the cavern is very great, the sound of respiration is like that produced by blowing into a decanter, with the mouth at a little distance from the neck. This kind of cavernous respiration has been called amphoric, from amphora, “ a flask.” ( Dunglison .) Cephalalgia. Headache, or pain in the head. Cephalitis. Phrenitis, inflammation of the brain or its membranes, the latter being sometimes called Meningitis. Cerebral. Appertaining to, or similar to the brain. Cerebro-spinal Axis, includes the brain and spinal marrow. The au- thor has occasionally used it to signify the medulla oblongata, or base of the brain, and upper portion of the spinal marrow ; as when treating of typhoid pneumonia, or spasmodic croup. Chlorosis. A disease characterized by a pale appearance, debility, &c., which affects young females; and which prevents, or otherwise dis- turbs the regular and healthful appearance of the menses. (See Anemia.') Choleric. Pertaining to cholera morbus, or to the bile. Cholesterine. An insipid, inodorous substance found in the bile. Clavicle. The collar-bone, one end of which is in contact with the upper end of the sternum, or breast bone ; the other with the acromion pro- cess of the scapula, or shoulder-blade. Collapse. Great prostration of strength, which is more likely to occur in the latter stage of severe or malignant diseases, as in the severer forms of remittent fever ; but in some other diseases the stage of collapse may come on early, as in the cold stage of a severe conges- tive chill, or cholera. Colliquative. An adjective applied to copious discharges which produce great exhaustion or debility, as copious liquid evacuations from the bowels, or copious sweating, &c. 28 426 GLOSSARY. Colon. The large bowel, which extends from the caecum to the rectum. Coma. A profound or deep sleep, from which it is more or less difficult to rouse the patient ; but less so than in lethargy. Corrigent. A medicine given to prevent any unpleasant or unfavorable effect of the principal medicinal agent, as compound tincture of car- damoms, cinnamon, paregoric, or the like, given with some cathar- tics to prevent them from griping. Costalis. Pertaining to the ribs. Crepitant. Crepitating. Crackling. Crepitant Kale. Crepitant Rattle, 'JaGurd during respiration, in severe pneumonia, and in oedema of the lung ; so termed on account of the analogy between the sound and that occasioned by pressing a healthy lung between the fingers. (Dunglison.) Crassamentum. The clot of the blood. Cruor. The clot of the blood, or crassamentum. Cystitis. Inflammation of the bladder. Biliary cystitis is inflammation of the gall-bladder. D. Decarbonization. Hcematosis, Arterialization of the blood, Atmospherization of the blood. Venous blood contains an amount of carbonic acid, &c., which, if it did not escape from the system, would soon accumulate to such an extent as to be deleterious or poisonous ; hence, when it reaches the lungs, this superabundance escapes by means of respi- ration ; oxygen, from the air breathed, combines with the venous blood — with which lymph and chyle are mixed in the lungs — ren- dering it more florid, and better suited to nourish the system, in which condition it is called arterial blood. Decubitus. Dying down in a horizontal posture. Diapedesis. Exudation of blood through a membrane, or the skin. Diaphoresis. Perspiration. Diathesis. This word is applied to certain conditions or affections of the system, which dispose it to become affected with certain diseases rather than others. Hence, we say the scrofulous diathesis, anemic or chlorotic diathesis, gouty diathesis, cancerous diathesis, & c. Dorsal. Relating to the back, or one of its parts. The dorsal vertebrce are the twelve bones of the back between the lower portion of the neek and the lumbar vertebra, the latter consisting of five bones. Dorso-intercostal. Relating to the dorsal region and between the ribs. Douche. Dashing or pouring water on the body, or any part of it. Duodenum. A name given to about twelve fingers’ breadth of the intestine, extending from the lower orifice of the stomach to that portion of small intestine called the jejunum. Dyspncea. Difficult breathing. Dysmenorrhcea. Painful menstruation. Dysuria. Difficulty of passing the urine. GLOSSARY. 427 E. Elliptical Plates. Payer’s glands , Agminated glands. Small glands or follicles, situate beneath, the villous coat of the intestines. They are clustered together, having a honeycomb appearance, and are ex- tremely numerous. They occur most numerously in the lower por- tion of the ileum. ( Dunglison .) Embonpoint. “ In good point, or habit.” The state or condition of the body when it presents a, fleshy, plump, or fat appearance. Emesis. Vomiting, puking. Emphysema. Wind-dropsy. Applied to the condition of a part in which air has escaped into the cellular substance. Emphysema op the Lungs. An infiltration of air into the cellular texture of the lungs ( interlobular emphysema), or an excessive dilatation of the air cells ( vesicular emphysema ). Emollients. Substances or preparations which are applied to relax and soothe parts that are inflamed, or too tense. They consist of cata- plasms or poultices, oils, fomentations, &c. Emulsion. A milky-white, opaque preparation, made by mixing oil, muci- lage, and water. Encephaloid. A name given to certain cancerous or scirrhous tumors, in which their substance resembles, in appearance, the brain. Endermic. The application or method of applying medicines to the skin, especially after the cuticle has been removed. Endemico-Epidemic. A compound word, applied to endemic diseases when they manifest an epidemic character. Enceinte. One with child. Pregnant. Enteritis. Inflammation of the intestines. Entomology. The science or natural history and description of insects. Epialos. A name given by the ancients to fever, when the hot stage was mingled with irregular chills. Also, the cold stage of fever. ( Dun- glison .) Epigastric Region, Scrobiculus cordis. The pit of the stomach, the su- perior central region of the belly. Epigastrium. The epigastric region. Prcecordia. Epistaxis. Bleeding at the nose. Epithelial. Pertaining to the epithelium, a thin layer of epidermis, skin or membrane, which covers the interior or florid portion of the lips, the nipple, mucous membranes, &c. Exacerbation. An increase in the violence of a disease; the hot stage of a fever. A paroxysm. F. F.ecal, Fecal. Relating to the faeces. FiECEs, Feces. The excrements, the evacuations from the bowels. 428 GLOSSARY. Femoral. Pertaining to the thigh. Fetor. A had smell. Stench. Fibrin. An immediate, solid, white, inodorous, insipid principle, which constitutes a portion of the blood and chyle, and forms the chief part of the flesh of red-blooded animals. Follicle, Crypta. A crypt or follicle is a small, roundish, hollow body, situate in the substance of the skin or mucous membranes, and con- stantly pouring the fluid which it secretes on their surfaces. Fomites. A word applied to substances which are supposed to retain and convey the poison which propagates contagious diseases ; as woollen or cotton goods, &c. Fundus. The base of any organ which ends in a neck, or has an external aperture ; as the fundus or upper part of the womb or bladder. Fungus, plural, Fungi. A term applied by botanists to a large natural order of plants of a peculiar organization and manner of growth, compre- hending mushrooms, toadstools, the microscopic plants which form mold, mildew, smut, &c. The word is also applied to excrescences on plants. Also proud flesh. Any morbid excrescence, whether in wounds, or arising spontaneously. G. Gastric. Pertaining to the stomach. Gastritis. Inflammation of the stomach. Gastro-enteritis. Inflammation of the stomach and small intestine, or of the stomach and bowels. Glands of Brunner, Solitary Glands, Solitary Follicles. Muciparous fol- licles of a small size, seated between the mucous and muscular coats of the stomach, along the two curvatures of that organ, and in the small intestines, especially the duodenum. The solitary intestinal follicles are usually known at the present day, as the glands of Brunner, although Brunner restricted the latter term to the glands of the duodenum. ( Dunglison .) H. H/Ematemesis. Vomiting of blood. Hematosis. (See Decarbonization. ) Hemicrania. Pain confined to one-half of the head. Hemoptysis. Spitting of blood (which see, in the work). Hemorrhage. Bleeding. Any discharge of blood from vessels destined to carry it, with or without rupture of their coats ; as bleeding from the nose, lungs, &c. Hepatalgia. Nervous pain of the liver ; neuralgia of the liver. Hepatic. Pertaining to, or resembling the liver. Hepatization. Conversion into a liver-like substance. The lungs are GLOSSARY. 429 said to be hepatized when they are engorged with effused blood, &c., are impervious to air, and present the appearance of the liver, as sometimes occurs in pneumonia. Humorism, Humeral Pathology . An ancient theory which referred all dis- eases to the morbid condition of the humors or jluid parts of the body, as the blood, lymph, &c. Hydrocele. Dropsy of the testicle, or scrotum. Hydropericarditis, llydropericardium. Dropsy of the pericardium, a membranous sac which envelops the heart. IIydrothorax. Dropsy of the chest. Hygiene. Health . Pertaining to the preservation of health. IIyferjemia. Preternatural fullness of blood in a part, or preternatural accumulation of blood in the capillary vessels. Hypertrophy. Morbid enlargement of a part with increased substance, as enlargement of the heart, &c. Hypochondriac Regions are two in number, situated to the right and left of the pit of the stomach, beneath the lateral and front parts of the chest. I Ileon, Ileum, Ilium. The longest portion of the small intestine, which ex- tends from the jejunum to the caecum. Iliac. Pertaining to, or connected with, the flanks. Iliac Fossae. The hollow, or cavity, formed by the depression on the in- ternal surface of the hip-bone (ilium). This term is also applied to a depression on the external surface of this bone. Ilium, Ilion, Ilium, Ileum. The hip or haunch bone. Ingesta. Substances taken into the stomach, as food, &e. Innervation. The nervous influence, or functions of the nervous system, which are necessary for the maintenance of life and the functions of the various organs. Interscapular. Between the scapula, or shoulder-blades. Isomeric. An epithet applied to different bodies, which agree in compo- sition, but differ in properties. This condition is termed Isomerism. ( DungUson .) Isomorphous. An epithet applied to different bodies, which have the same crystalline form. The condition is called Isomorphism.— Ibid. Isopatiiia. Parallelism of diseases. The disposition of diseases to anas- tomose with each other, or to wear each other’s livery. J. Jactitation, Jactation. Tossing about. Extreme anxiety ; excessive rest- lessness. Jejunum. That portion of the small intestine between the duodenum and ileon. 430 GLOSSARY. L. Laryngitis. Inflammation of the larynx. Laryngotomy. A surgical operation, which consists in cutting an opening into the cavity of the larynx, for the purpose of extracting some fo- reign body, or to remedy an obstruction of the glottis. Tracheotomy. Larynx. A cartilaginous cavity, situated at the upper and front part of the neck, at the upper end of the windpipe, with which it communi- cates. It modulates the voice in speaking and singing. Lateritious. Having the appearance of brick-dust. Leucophlegmatic. Relating to a pale, anemic, or dropsical habit. Leucorrhcea, Whites. A disease in females, attended with a more or less abundant discharge of a white, yellowish, or greenish mucus, from the membrane lining the genital organs ; as that of the vagina and womb. M. - Malaria. Miasm. Malaise. An indescribable feeling of being unwell ; a feeling of indispo- sition. Mamma. The female breast. Mammelonation, Nammillated. Small mammiform projections. Mastoid. Having the form of a nipple. The mastoid process is situated behind and below the ear, at the inferior and posterior part of the temporal bone. Materia Medica. That part of medical science which treats of the articles or substances used in the practice of medicine, their action on the animal economy, and mode of administration. Also, the materials of medicine. Medulla Oblongata. The medullary, or nervous substance, that lies with- in the cranium, on the basilar process of the occipital bone, being at the base of the brain, and connecting it with the spinal marrow. Melanosis. Black tubercle, Black cancer. An organic affection, in which the tissue of the parts is converted into black, hard, homogeneous substance, near which ulcers or cavities form — owing to the soften- ing, either of this substance itself, or of some other morbid tissue — of tubercles, especially. Menorrhagia. Profuse menstruation. Too great a flow of the menses. Sometimes used synonymously with uterine hemorrhage or metror- rhagia. Mesenteric Glands are the lymphatic ganglions of the mesentery. Through them the chyliferous vessels pass to the thoracic duct. When they are diseased, nutrition is interfered with, and marasmus, or a wasting away of the body, is produced. Mesentery. A membrane in the cavity of the abdomen, attached to the GLOSSARY.' 431 lumbar vertebras posteriorly, and to the intestines anteriorly. It is formed of a duplicature of the peritoneum, and contains adipose matter, lacteals, mesenteric glands, lymphatics, and mesenteric arte- ries, veins, and nerves. Its use is to retain the intestines and their appendages in a proper position. [Hooper.) Metastasis. A mutation, translation, or removal of a disease or morbid action from one part to another. Meteorism, Tympanites. A swelling of the abdomen, caused by accumu- lation of air in the intestinal tube, or in the peritoneum (cavity of the abdomen). Metritis. Inflammation of the womb. Miasm. A hypothetical poison, which is supposed to be generated in marshy districts, and considered to be the cause of what are called malarious diseases. This term is also applied to poisonous emana- tions from the bodies of the sick, or from animal and vegetable sub- stances, or from the earth. Miasmata. (See Miasm.) Miasmatic. Pertaining to miasm. Moxa. A substance that is used for burning the skin; a powerful means of counter-irritation. Mucous Membranes are the lining membranes of the cavities which have an external outlet, as of the bowels, air-passages, &c. Murmur, Respiratory. (See Bronchial Respiration.) N. Narcosis, Narcotism, Stupor, Sleep. The condition of the system when under the stupefying influence of opium or other narcotics. Necroscopy. Dissection, Sectio-cadaveris, Post-mortem examination. Atten- tive examination of the body after death. Nervous. Pertaining to the nerves or nervous system. Also weak, irri- table. Neuralgia, Nervous pain. Applied to nervous diseases. The neuroses. Nosology. A name given to that part of medicine whose object is the clas- sification of diseases. Also, Pathology. ( Dunglison .) Nucha. The nape of the neck. O . Omentum, Epiploon. The caul. Organ. Part of an organized being, destined to exercise some particular function ; as, for instance, the stomach, liver, kidneys, lungs, &c. Organic Nervous System, Ganglionic Nervous System. That part of the nervous system which presides over nutrition and secretion. It is, however, very intimately connected with the spinal and cerebral divisions of the nervous system. 432 GLOSSARY. Orthopn(ea. Impracticability of breathing, except in the erect posture. Any difficulty of breathing. Ovariotomy. The operation of cutting out an ovary, the testicle or pride of the female. P. Papular. Relating to papula, pimples ; an eruption on the skin, consist- ing of small, acuminated elevations of the cuticle, with an inflamed base; very seldom containing a fluid, or suppurating, and commonly terminating in scurf. Parenchyma. The texture of glandular and other organs, composed of agglomerated globules united by cellular tissue, and tearing with more or less facility. Such is the texture of the liver, kidneys, &c. ( Dunglison .) Parietes, Plural of Paries, a wall. A name given to parts which form the enclosures — the limits of the different cavities of the body. Ibid. Pari passu. With equal pace, or progress. Step by step. Pathognomonic. A symptom, or symptoms, characteristic of a disease ; the symptoms by which a disease is known with certainty. Pathology. The morbid condition which constitutes disease. A discourse or treatise on a disease, or diseases in general. Pectoriloquy, Pedoriloquism, Cavernous voice. Speech or voice coming from the chest. Laennec has designated, by this name, the phe- nomenon often presented by consumptive individuals, when their chests are examined with the stethoscope. The voice seems to issue directly from the chest, and to pass through the central canal of the cylinder — a phenomenon owing to the voice resounding in the an- fractuous cavities, produced in the lungs by the suppuration or breaking down of tubercles, which constitute abscesses or ulcers of the lungs. ( Dunglison .) Per anum. By way of, or through the anus. Percussion. The act of striking the external walls of the chest, or other parts, so as to elicit or produce sound, which indicates the diseased or healthy condition of the parts beneath ; as percussing or striking the external walls of the chest, in order to ascertain the healthy or diseased condition of the lungs, heart, &c. Pericardial Sac. The pericardium. Pericarditis. Inflammation of the pericardium. Pericardium. A membranous sac which envelops the heart. Peritoneum. The serous membrane which lines the cavity of the abdomen, and is reflected over the bowels, &c. Peritonitis. Inflammation of the peritoneum. Perityphlitis. Inflammation of the cellular substance surrounding the caecum. Petechia. Small spots on the skin, resembling flea-bites. GLOSSARY. 433 Pharynx, Fauces. A symmetrical canal, on the median line, irregularly funnel-shaped, situate between the base of the cranium and the oeso- phagus, in front of the cervical portion of the spinal column. It is very narrow above ; but dilates in the middle, and again contracts below, at its junction with the oesophagus. Into the anterior walls of the pharynx open, successively, from above to below, the posterior orifices of the nasal fossae: the Eustachian tubes; the posterior aper- ture of the mouth, and the top of the larynx. The pharynx gives passage to the air during respiration, and to the food at the time of deglutition. Physical Signs. (See page 109.) Pia Mater. A thin, delicate membrane, which covers or envelops the brain and spinal marrow immediately. Pleura. A serous membrane, one of which lines each side or cavity of the chest. That portion of the pleura which is reflected over the lungs is called Pleura Pulmonalis; and that which lines the parietes or internal walls of the chest, Pleura Costalis. Pneumonia, Pneumonitis. Inflammation of the lungs ; vulgarly called lung fever. Pneumothorax. An accumulation of air in the cavity of the chest, in the cavity formed by the pleura. Post-mortem, after death. A post-mortem examination of a body, is one made after the death of an individual. Precordia or Precordial Region. The epigastrium or epigastric region ; the pit of the stomach. Also, used by some writers for the region of the heart. Prodromic. Prodromic symptoms are the first symptoms of a disease ; the precursory or premonitory symptoms. Profluvia. Morbid discharges or fluxes ; as diarrhoea or dysentery. Prognosis. The judgment or prediction formed in relation to the future progress and termination of a disease. Prophylactic. That which prevents disease. Prophylaxis. The means of preventing or averting disease. Pro re nata. As circumstances or occasion requires. Pubis or Pubic Region. Pubes. The region above the external organs of generation, in front of the os pubis, at the lower part of the abdomen, and which is covered with hair in both sexes at the age of puberty. Pylorus. The orifice at the lower portion of the stomach, through which food passes into the bowels. Pyrexia. Fever. Q- Quartan. A type of ague, the paroxysm of which recurs every third day, or with intermissions of seventy-two hours. 434 GLOSSARY. Quininism. The aggregate effects produced on the brain and nervous sys- tem by too much, or the improper exhibition, of quinine. Quintan. An intermittent fever, the paroxysms of which return every fifth day ; with three intervening days without fever. Quotidian. A type of ague and fever, the paroxysm of which returns every day, or every twenty-four hours. It. Rale. Rattle. Rattle. Bhonchus. A term that has been given to different sounds during respiration, caused by the air passing through fluid contained in the bronchi, or areolae of the pulmonary tissue ; which are perceived by auscultation. Also, noise produced by the air in passing through mucus, of which the lungs are unable to free themselves. This condition is chiefly observed at the approach of death, and is commonly called, “ The Battles.” ( Dunglison .) Rhonchus, Mucous. Mucous rattle. Subcrepitant rhonchus. The sound produced by the passage of air through mucus accumulated in the bronchi or trachea, or through softened tubercular matter. This rale occurs in catarrh, and in softened tubercle. When carried to a very high degree, it constitutes gurgling. ( lb .) Rhonchus, Sibilant. Sibilant rattle, Bale sibilant. A slight, though pro- longed whistling sound ; occurring either at the commencement of inspiration, or of expiration ; owing to the presence of mucus, thin and viscid, but not abundant ; which obstructs, more or less com- pletely, the smaller bronchial ramifications. It is seated in the small tubes, and occurs in the first stage of bronchitis. (16.) Rhonchus, Sonorous. Sonorous rattle. A sound resembling, at times, the snoring of a person asleep ; at others, the sound of the bass string of an instrument when rubbed with the finger, and not unfrequentlv the cooing of a dove. It seems to be caused by a contraction of the bronchial tubes, and is characteristic of chronic catarrh. (16.) Recipe. R. Take. Placed at the top or commencement of a formula or prescription. Rectum. That portion of the large bowel situated immediately above the anus, and below the sigmoid flexure of the colon. It is vulgarly called “ The Arse-gut.” S. Sacrum, Os sacrum. The bone at the back part of the pelvis, below the loins, and on the upper part of which the lower lumbar vertebra rests. Sanguinaria Canadensis. Puccoon, or blood-root. Sanious, Ichorous. Relating to ichor or sanies, a thin, acrid, irritating dis- GLOSSARY. 435 charge, -which comes from the surface of foul ulcers, or those which are not inclined to heal readily. Sarcocele. A fleshy tumor of the testicle. Scapula. The shoulder-blade. Scirrhus. A hard or indurated tumor, commonly attended by shooting pains, and considered to be of a cancerous nature. Scrofula. A species of anemia, in which indolent glandular tumors occur, principally about the neck, and in the mesentery, affecting the mesen- teric glands, in which latter case it is called Tabes mesenterica. The glandular swellings frequently result in ulceration, which heals with difficulty. Scrofula may also terminate in consumption. Scrofulosis, Scrofula, Scrophula. Scrofulous. Relating to, or suffering from scrofula. Sectio Cadaveris. (See Post-mortem.) Serous Poly.emia, Hydro-poly cemia. Too much water in the blood. Like the other species of anemia, it is attended with a diminution in the amount of the blood-globules. Sextan. Applied to an ague which returns every sixth day. Sigmoid Flexure of the Colon. A crooked portion of the colon, resem- bling the letter S, which is situated in the left lower portion of the abdomen, and communicates with the rectum. Sinapism. A cataplasm, of which mustard is the basis ; commonly made by mixing mustard, flour, and vinegar or water, together. Singultus. Hiccough. Sinus. This word is applied to certain cavities, as in the bones of the face and head, in which the interior is more expanded than the entrance. It is also applied to certain venous canals into which a number of vessels empty. Solitary Glands. (See Glands of Brunner.) Speculum. A hollow instrument, used for the purpose of dilating a cavity, so that the condition of the parts within may be seen ; as its intro- duction into the vagina, to observe a diseased condition of the neck or mouth of the womb. Sphacelus. The disorganized or dead portion of an ulcer, which separates or sloughs off from the living tissue by means of mortification or gangrene. Also gangrene, mortification, or slough. Sphincter Ani. A muscle which surrounds and closes the anus, the open- ing through its centre constituting the latter. Spinal. Pertaining to the spine ; as, Spinal Irritation. An affection of the spinal marrow or nerves; which see described in the work. Splenitis. Inflammation of the spleen. Splenotomy. The operation of cutting out the spleen. Sporadic. Diseases are said to be sporadic which occur at any time, and are not epidemic, endemic, or contagious. Sporule, Spore. “I sow.” The reproductive body in cryptogamous plants, 436 GLOSSARY. which is analogous to the seed of phanerogamous plants. ( Dun - glison.) Sputa. Plural of Sputum, Spit. Sternal. Relating or pertaining to the Sternum. The breast-bone. Stomachic. Stomachal. A corroborant or medicine which strengthens or gives tone to the stomach. Styptic. A medicine possessed of constringent properties, and which is applied locally, to arrest bleeding or too copious discharges. Also, used synonymously with astringent. Subsultus Tendinum. Twitching of the tendons, caused by the involuntary and instantaneous contractions of the muscular fibres, most com- monly observed at the wrist, but occurring also elsewhere. Sui generis. This term is applied to anything that is peculiar to itself. Syphilis. Lues venerea, Pox, French Pox. T. Tabes Mesenterica. Scrofula mesenterica, Mesenteric Disease. (See Scrofula.) Tannin. Tannic acid is an astringent principle contained in oak bark and other vegetable astringents, from which it may be extracted. It is called Tannin, from its being the principal agent in the process of tanning. Taraxacum. Dandelion. Temperament. This term is used to designate the peculiar constitutions of different persons, in consequence of the variety of relations and pro- portions between the constituent parts of the body ; hence, when an individual appears stout, and presents a florid appearance, we say he is of a Sanguine Temperament ; if he is somewhat pallid and plump, possessing a good degree of embonpoint, his temperament is said to be lymphatic ; if he is still more pallid, we say he, or she, as the case may be, is of a Phlegmatic or Leucophlegmatic appearance or tem- perament, in which there is a greater or less degree of anemia. The Bilious Temperament is applied to those who present a rather dark, lean appearance, and who have dark hair. Those who possess a Nervous Temperament are commonly excitable, nervous, quick, and usually have a slender form. In most persons, however, there is a mixture of temperaments ; hence, we say sanguineo-nervous, lympha- tico-nervous, bilio-sanguineous temperament, & c. Tenesmus. Frequent and painful desires to go to stool, attended with very little or no discharges. Tertian. Tertian ague. An ague whose paroxysms return every other day, or every 48 hours. Thoracic. Appertaining to the thorax, or chest. GLOSSARY. 437 Thorax. Chest, Breast. The lungs and heart are situated within the thorax. Tinnitus Aurium. Ringing of the ears. Tormina. Griping pains in the bowels, as in dysentery. Trachea. The windpipe. Tracheal. Trachealis. An epithet applied to the respiration as heard through the stethoscope, opposite the trachea, larynx, and root of the bronchia ; the air appearing as if sucked in from the cylinder during inspiration, and expelled during expiration. (Dunglison.) Tracheitis. Inflammation of the lining membrane of the trachea. Cy- nanche trachealis. (See Croup.) Tracheotomy. (See Laryngotomy.) Tubercle. (See page 102.) Tuberculosis. Tubercular cachexia, as consumption, &c. Tuberculous. Tubercular. Relating to tubercular disease. Tympanites. (See Meteorism.) Typhlitis. Inflammation of the caecum. Typhus Grayior. A severe form of typhus fever. U. Utero-gestation. Pregnancy. V. Yagina. “ A sheath.” The vulvo-uterine canal, which is cylindrical and four or six inches long in the adult; situated between the rectum and blad- der, communicating at its external end with the os externum or ex- ternal organs of generation, in the female, and at the other, at the uterus, the neck of which it embraces. The male organ enters this cavity in copulation ; and through it the secretions and contents of the womb are permitted to escape externally. Vallet’s Ferruginous Pills. Pills of Carbonate of Iron. These pills are made as follows : Take of sulphate of iron, four ounces; carbonate of soda, five ounces ; clarified honey, two ounces and a half; syrup, boiling water, each, a sufficient quantity. Dissolve the sulphate of iron and carbonate of soda, each, in a pint of the water, and to each so- lution add a fluidounce of syrup ; then mix the two solutions in a bottle just large enough to contain them, close it accurately with a stopper, and set it by that the carbonate of iron may subside. Pour off the supernatant liquid, and, having washed the precipitate with warm water, sweetened with syrup in the proportion of a fluidounce of the latter to a pint of the former, until the washings no longer have a saline taste, place it upon a flannel cloth, and express as much of the water as possible ; then immediately mix it with the 438 GLOSSARY. honey. Lastly, heat the mixture, by means of a water-bath, until it attains a pilular consistence. U. S. Disp. When the above is made into pills, each one should weigh from three to five grains, one of which may be taken three or four times a day. Dr. Bache says, “ There can be but little doubt that, in cases in which the alterative effects of iron are called for, Tallet’s preparation is superior to any other derived from that metal." Vena Azygos. Azygos vein. This vein forms a communication between the Vena cava inferior and Vena cava superior, permitting the blood to pass freely between the two. Vena Cava. (See Cava Vena.) Venous. Pertaining to a vein. Ventricle. A “ Little Belly.'” A name given to several parts ; as, Ventricles of the Heart. Two cavities in the anterior part of the heart, one on each side, into which the venous blood passes from the auri- cles or ears of the heart, and from thence into the arteries, the right ventricle communicating with the pulmonary artery ; and the left ventricle with the aorta, the largest artery or blood-vessel of the body, which distributes blood to nearly all of it. Verba magistri. Merely the words of a tutor or teacher. Vertebrae. The bones which, by their union, form the vertebral or spinal column, vulgarly called the back-bone. The vertebrae are twenty-four in number; namely, seven in the neck, called the cervical vertebrae; the next twelve below are called the dorsal vertebrae; and the five lower ones the lumbar vertebrae. Villous Membranes or Coats, are such as are covered with soft papillae, or villi, constituted of blood-vessels, nerves, and absorbents. Chaus- sier gives the name simple villous membranes to the serous mem- branes ; and that of complicated or follicular villous membranes to the mucous membranes. ( Dunglison .) Viscera. Plural of Viscus. The organs contained within the three great cavities of the body — the abdomen, chest, and head ; as the entrails, liver, lungs, heart, brain, &c. Visceral. Pertaining to the viscera. Viscus. (See Viscera.) In preparing the above Glossary, I frequently referred to Dunglison’s Medical Dictionary, sometimes adopting his definitions, in part. 9 , INDEX. A Achillea millefolium, 179 Ague and fever, 30 Appendix, 399 Atonic dyspepsia, 162 B Bad cold, 416 Bark, Peruvian, 178 willow, 178 Bilious fever, 224 Blood in consumption, 96 — 98 Blood globules in cachexia, 87 Boneset, 179 Bronchitis, chronic, 143 treatment, 144 C Cachexia, 80 anemia, 80 blood-globules in, 87 chlorosis, 86 — 88 treatment, 121 consumption, &c., 94 pathology, 114 blood in, 96 — 98 treatment, 125 diet in, 137 dyspepsia, atonic, 162 hydropolysemia, 80 — 83 rickets, 139 scrofula, 139 scrofulous matter, 106 serous polysemia, 80 — 83 splenic, 152 tabes mesenterica, 143 treatment, 121 tuberculous, &c., 94 causes, 98 Cachexia, tuberculous pathology, 114 white swelling, 95 tubercle, 102 microscopic appearances, 102 composition, 105 Catarrh, or cold, 416 Cherry-tree bark, 179 Chills and fever, 30 Chiniodine, 177 Cholera, Asiatic, 353 causes, 359 history, 354 means of prevention, 371 pathology, 364 remarks, 380 symptoms, 365 treatment, 375 of cholerine, 373 Clap, 399 Cold, 416 Collodion, 410—412 Congestive chills, 180 fever, 180 Concussion, or fall, 407 Contused wounds, 409 Convulsions, puerperal, 160 Cornus cericea, 179 Cornus Florida, 179 Cotton, gun, 410 Croup, 383 Cynanche trachealis,.383 D Diarrhoea and dysentery, 326 causes, 327 — 331 pathology, 333 treatment, 340 chronic, treatment, 345, 352 diet in, 352 440 INDEX, Diseases, malarious, periodicity of, 49 Dislocation of the spleen, 54 Dogwood, 179 'swamp, 179 Dropsy, treatment, 150 Dysentery and Diarrhoea, 326 Dysmenorrhcea, 172 Dyspepsia, 162 E Enlargement of the spleen, 152 liver, 155 Ephemeral fever, 418 Epilepsy, 160 Eupatorium perfoliatum, 179 F Falling down of the womb, 170 Ferrocyanate of quinia, 176 Fever, bilious, 224 congestive, 180 algide variety, 186 choleric variety, 15, 18, 185 with coma and costiveness, 184 embonpoint, 187 duration, 202 pathology, 196 prognosis, 203 terminations, 191 treatment, 205 intermittent, 30 and ague, 30 anomalous varieties, 42, 43 causes, 30 chills and, 30 cold stage, 37 hot stage, 41 sweating stage, 44 pathology, 47 prodromic form, 35 treatment, 36 post-mortem, 62 blood in, 63 prognosis, 61 prophylaxis, 66 terminations, 52 types of, 45 treatment, 67 premonitory stage, 67 cold stage, 68 hot stage, 70 sweating stage, 71 Fever, chills and, treatment of chronic form, 74 ephemeral, 418 remittent, 224 causes, 225 forms of 1. Mild form, 228 2. Causus, 230 3. Comatose, or nervous, 234 4. Typhoid, 236 pathology, 242 prognosis, 240 treatment, 259 1. Mild form, 259 2. Causus, 261 3. Comatose, 281 4. Typhoid, 285 diet in, 288 convalescence, 289 yellow, 294 treatment, 299 Fevers, malarious, 9 periodicity, 49 Fits, 160 G Gentian, 179 Glossary, 421 Gonorrhoea, 399 Green sickness, 86 — 88 treatment, 121 Gun cotton, 410 II Haemoptysis, 147 Holly, 179 Horehound, 179 Ilydropolyaemia, 80, 88 treatment, 150 I Incised wounds, 408 Intermittent fever, 30 Inflammation, chronic, of womb, 170 Itch, 420 J Janders, yellow, 293 Jaundice, 293 L Lacerated wounds, 409 INDEX. 441 Leucorrhcea, 165 treatment, 167 Sulphate of iron (copperas), 179 Sulphur, 179 M. T Malarious fevers, 9 Marubium vulgare, 179 Menstruation, painful, 172 Metritis, chronic, 170 Miscellaneous, 407 Tabes mesenterica, 143 Thoracic vibration, 112 Tubercle, 102 composition of, 105 microscopic appearance of, 102 Tuberculous cachexia, 94 N Tuberculosis, pathology of, 114 Typhoid pneumonia, 308 description, 311 1st form of attack, 311 Nervous diseases, 156 treatment, 157 2d form of attack, 312 duration, 314 causes, 314 P pathology, 315 physical signs, 316 treatment, 316 Peruvian bark, 178 Physical signs, 109 Poplar bark, 179 Prolapsus uteri, 170 Prussian blue, 179 Puerperal convulsions, 160 U Uterus, prolapsus of, 170 chronic inflammation, 170 falling of, 170 Q V Quinia, ferrocyanate of, 176 Quinine, endermic use of, 176 Vibration, thoracic, 112 R W Remittent fever, 224 Rheumatism, acute, 306 chronic, 140 Rickets, 95, 139 Whites, 165 White swelling, 95 Willow bark, 178 Womb (see Uterus), 170 Worms, 413 S Wounds, contused, 409 incised, 408 Salicin, 179 Scabies, 420 Scrofula, 139 Serous polysemia, 80 — 83 treatment, 150 Spleen, dislocation of, 54 Splenic cachexia, 152 Spitting of blood, 147 Strychnine, 178 lacerated, 409 Y Yarrow, 179 Yellow fever, 294 treatment, 299 Yellow janders, 293 THE END. 29 Date Due OOH % ■ Dec. 13 *3' ,:ai4 5 3..> , w- t Oct20’346 rAD RF | N 1 »k£ 1 8 : 18 Library Bureau Cat no. 1 ! 37 . $'7 ' / /; ! 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