c 
 
 LIBERTY TEES BLOCK, 
 
 m: a y, 1 e 6 1 . 
 
 H 
 
THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 PRESENTED BY 
 
 PROF. CHARLES A. KOFOID AND 
 
 MRS. PRUDENCE W. KOFOID 
 
LETTERS 
 
 A YOUNG PHYSICIAN 
 
 JUST ENTERING UPON PRACTICE. 
 
 PROFESSOR EMERITUS OF THE THEORY AND PRACTICE OP PHYSIO IN THE UNI 
 
 VKR3ITY AT CAMBRIDGE J LATE PHYSICIAN IN THE MASSACHUSETTS GENERAL 
 
 HOSPITAL ; HONORARY MEMBER OF THE MEDICO-CHIRURGICAL 
 
 SOCIETY OF LONDON ; CORRESPONDING MEMBER OF 
 
 THE ACADEMY OF MEDICINE AT PARIS, 
 
 &c. &c. &0 ■ 
 
 jrrnt) mtsiuon. 
 
 BOSTON: 
 TICKNOR AND FIELDS.. 
 1861. 
 
 <ivvX 
 
Entered according to Act 9f Congress, in the year 1856, by 
 
 JAMES JACKSON, 
 
 In the Clerk's Office of the District Coiu-t for the District of Massachusetts. 
 
 Bt«teoc;ped by 
 
 HOBABT « R0BBIN8, 
 
 r England Type and Stereotype Fonndery 
 
 B08T0X. 
 

 CONTENTS. 
 
 Pagb 
 
 Dedication, 3 
 
 Letter 
 
 I. — Inteoductoet, 7 
 
 H. — On Conduct in the Sick-room, 25 
 
 in. — On the Neevous System and on Headache, ... 42 
 
 IV. — On Epilepsy and the Convulsion-fits of Young 
 
 Children, 61 
 
 V. — On Apoplexy and Palsy, 74 
 
 VI. — On Choeea, Neuealgia and Pain, 85 
 
 Vn. — On Somnambulism, Animal Magnetism and Insanity, 92 
 Vm. — On Dentition and the Peeiod of Weaning, . . . 107 
 
 IX. — On Choleea Infantum, the Second Dentition, 
 
 AND Ulcusoula Oeis, 129 
 
 X. — On Abscess in the Tonsils, Elongated Uvula, 
 
 Beonchitis and Pneumonitis, Rheumatism, 
 
 AND Gout, 154 
 
 ^I. — On Phthisis and HiEMOPTYSis, .......... 173 
 
 XIL— On Dyspepsy, 208 
 
IV CONTENTS. 
 
 Xni. — On Some Diseases op the Intestines, particu- 
 larly OF THE CCECUM AND COLON, 232 
 
 XIV. — On Constipation of the Bowels, ....... 271 
 
 XV. — On Bilious Diseases, Biliary and Urinary 
 
 Calculi, and Irritable Bladder, 297 
 
 XVI. — On Boils, 306 
 
 XVII — On the Treatment of Typhoid Fever, 326 
 
to 
 
 JOHN C. WARREN, M. D., 
 
 PROFESSOR EMERITUS OF ANATOMY IN THE UNIVERSITY AT CAJt 
 BRIDGE ; LATE SURGEON IN THE MASSACHUSETTS GENERAL 
 hospital; I'RESIDENT OF THE BOSTON SOCIETY OF NATU- 
 RAL history; HONORARY MEMBER OP THE MEDICO- 
 CHIRURGICAL SOCIETY OF LONDON ; CORRE- 
 SPONDING MEMBER OF THE ACADEMY OF 
 
 medicine at paris, etc., etc., etc. 
 
 My dear Friend, — 
 
 I have been writing some letters to a young physician, 
 and am about to publish them, I beg leave to introduce 
 them to the public by a letter of dedication to you. To 
 whom can I so properly dedicate them as to my oldest 
 medical friend, one with whom I have lived in close inti- 
 macy for more than half a century ? Is it not a great 
 satisfaction to look back to the many objects we have 
 pursued, and labors we have performed, together, during 
 this period ? 
 
 It is not my intention to eulogize you, or to attempt to 
 extend a reputation which has long since spread further 
 than my voice can reach. We have tried an experiment, 
 and I am inclined to state to the young men of our pro- 
 fession what it was, and what have been its results. 
 There will be a little boasting in it ; but the young must 
 indulge their seniors in boasting; when they are getting 
 past service, it may be all that is left for them. Allow 
 I 
 
Z PREFATORY AND DEDICATORY. 
 
 me, then, in this public letter to give an account of our 
 experiment. 
 
 You and I began our active lives in this city nearly at 
 the same time. It was when Boston had about one sixth 
 of its present population, and I suppose much less than a 
 sixth of its present wealth. We were so circumstanced 
 as to be peculiarly rivals. Our business led us across 
 each other's paths every day for a long series of years. 
 What one gained, the other seemed to lose. It would 
 have been very easy for us to have got up a pretty quar- 
 rel at any moment ; and having once begun, we might each 
 have got partisans, and all the usual entanglements to 
 such cases appertaining might have followed. Happily, 
 we pursued a diflferent course. We met together with the 
 feelings we had had as fellow-students. We took much 
 delight in consultation and discussion on professional sub- 
 jects, and were ever ready to help each other. We have, 
 indeed, maintained a strong personal interest in each 
 other's welfare, and promoted each other's happiness. 
 We do not resemble each other in temperament, and can- 
 not see all things alike. From this cause, and not always 
 looking at objects from the same point of view, we often 
 diflfered in opinion. But we have always agreed to dijffer. 
 We have not often disputed, and never have quarrelled 
 on account of this difference of opinion, nor on any other 
 account. In our intercourse with the sick, each has given 
 the other credit for what was good in him, instead of 
 studying and publishing the other's faults. In every 
 work for the promotion of medical science, or for elevating 
 the profession, we have cooperated heartily, neither of us 
 trying to push the other aside. And thus it is, that being 
 now, as regards age, in the front rank in our profession, 
 
PREFATORY AND DEDICATORY. 3 
 
 we have continued to this day on terms of intimacy and 
 friendship. This is something to rejoice in, and something 
 for which we may properly thank God ; and I know you 
 will join me in giving thanks reverently. 
 
 As we are near the end of our journey, I hope I may 
 be excused for stating this experiment and its results. I 
 would show to young men how grateful these results are. 
 I can say to them that our interests have been promoted 
 by our friendly treatment of each other ; that each of us 
 has gained by it much more than either of us could have 
 done by the sharpest quarrels. If they believe me, any 
 two of them, placed side by side, as we were, may be 
 induced to try the plan of a peaceful competition. 
 
 Enough, as regards ourselves. As regards the breth- 
 ren, who have multiplied about us since we began our 
 course, we have much cause for rejoicing. We were 
 pioneers in a country not new, but not much cleared. We 
 were not fully aware of it then, but when we commenced 
 our career, our country had just begun to be assured of 
 prosperity after the hard and exhausting revolution it 
 had undergone. I will not indulge myself in relating to 
 the young all the changes which have taken place since I 
 began business in 1800. I will not point out how much, 
 necessary to elevate the profession, was yet to be done. I 
 cannot be supposed to intimate any deficiency in our 
 predecessors. The community was not rich enough to 
 encourage or aid in works for the public welfare. But 
 the time was coming. We happened to be so situated as 
 to be called to work. Jumores ad lahores was, not in 
 words, but in effect, the motto, under which we were 
 brought into service ; and our arms, such as they were, 
 with implements quite inferior to such as the present 
 
i PKEFATORY AND DEDICATORY. 
 
 day can furnish, were occupied in felling the trees. We 
 worked to get up some log houses, useful for a time, but 
 which we pulled down when no longer wanted. We have 
 since then aided in getting up edifices more costly, and 
 "destined, I trust, to be permanently useful. 
 
 It has been my delight for many years past, as I be- 
 lieve it has been yours, to point out to others what a 
 respectable body of junior practitioners has been rising 
 up around us. Compare the power of distinguishing dis- 
 eases, and the discretion in treating them, shown in young 
 men of the present day, with the like characteristics of 
 our medical men forty years ago, and you will find the 
 advance to be very honorable. Medical science has been 
 increasing in Europe and in this country. Our younger 
 men have had great masters. Not to mention our own 
 countrymen, they have had Laennec and Louis, and many 
 ©thers among the French ; in Great Britain and Ireland 
 too many to be named ; and a host of surgeons, of whom 
 you could best give the list. It may be said that it 
 would have been shameful if they had not acquired much. 
 But no such reproach falls on them ; on the contrary, it is 
 due to them to say, that they have ftilly availed them- 
 selves of their opportunities. For my own part, in look- 
 ing at one, and now another, who have succeeded me in 
 office, I think it enough to boast of that I aided in teach- 
 ing them how to learn. I should be sorry to believe that 
 they had not gone ahead of their predecessor. I only 
 beg that thSy will allow him to be a sort of honorary 
 member in the corps of i/outk/ physic. 
 
 Let me put an end to this rambling, lest some oner 
 smile at the garrulity of old age. I designed this letter 
 not only as a dedication^ with reminiscences attached to 
 
PREFATORY AND DEDICATORY. 5 
 
 it, but also as an introduction, or preface, to the letters 
 which are to follow it. You might guess that I was 
 stirred up to write a book by the success with which my 
 fellow ex-professors had been doing the like. If I could 
 succeed as well as the rest of you, it would be inducement 
 enough. But, in truth, the project has been in my mind 
 a long while. The physical objections to much confine- 
 ment in my study have kept me back. But early in this 
 year I decided to undertake the task, and from that time 
 have given to it all the labor I was capable of. In this 
 undertaking I flattered myself I could be of some service 
 to young physicians just coming into practice. I did not 
 propose a systematic work; but I thought it possible, 
 availing myself of the form and license of letters, to give 
 whatever useful thing my experience could furnish. Had 
 I kept notes of cases in private practice, I might have 
 been able to give information in a more precise form 
 But this I have »not done, finding that it drew ofi" my 
 attention too much from the case itself. I have, however, 
 always endeavored to keep the results of experience in 
 my mind, so as to have them ready for use at the bed- 
 side. Now I have run my eyes over the list of diseases 
 strictly medical, and whenever I have recalled anything 
 worthy to be brought forward, I have stated it, more or 
 less fully, as the case seemed to require. I have not 
 given cases in support of my statements. When I have 
 furnished cases, it has, generally, been by way of illus- 
 tration, not as proofs. I have described diseases, so far 
 as necessary for my purpose, but without attempting to 
 give full delineations of them. I should except from 
 this remark some morbid affections, which I think have 
 1* 
 
6 PREFATORY AND DEDIGATORT. 
 
 been imperfectly understood, or not at all described by 
 others. An instance of this jou will find in Letter XIII. 
 
 It may be said that I have gone into theoretical ques- 
 tions, and certainly into the discussion of first principles, 
 such as do not belong to a plain, practical work. There 
 is an instance of this in the letter on nervous diseases. 
 My reply is, that, for practical purposes, I think a disease 
 should be first viewed in its simplest form and in the 
 clearest light ; free from extraneous circumstances. This 
 is what I have attempted to bring about in the discussion 
 above referred to, and on some other occasions. 
 
 Let me hope that the work may be worthy of youi 
 approbation, and that it may be useful to the class of per- 
 sons for whom it is designed. 
 
 With the best wishes for your health and happiness, 
 I remain, as always, 
 
 sincerely your friend, 
 
 JAMES JACKSON 
 
 Hamiliox Place, August, 185S. 
 
LETTER I. 
 
 INTRODUCTORY. 
 
 I CONGRATULATE you, my joung friendj on having 
 arrived at the period on which your eyes have long 
 been fixed: the period at which your education is 
 terminated, and at which you are to enter upon the 
 serious business of your profession. Your education, 
 I say, is terminated. You are told, indeed, that you 
 must continue to educate yourself through life. With- 
 out quarrelling about words, I think this does not 
 present the subject in its true point of view. I agree 
 that you are bound to study and to increase your 
 knowledge as long as you continue to be engaged in 
 your profession. But you are now educated; you 
 are brought out. You are now placed on the course 
 where you are to run your race. You look at the 
 objects before you from a new point. You have put 
 on your working-dress, and you are to go to business. 
 
8 INTRODUCTORY. 
 
 From this day jou. must realize, more and more, the 
 diiFerence between the study of the sciences and the 
 application of them to the business of life, — to the 
 practice of your art. You may, before this, have 
 tried your hand at practice; but it has been as an 
 apprentice, and not with the feelings of responsibility 
 belonojinor to the master- workman. 
 
 In some respects I should call on you for instruc- 
 tion, rather than offer instruction to you. For 
 instance, knowing how you have applied yourself, I 
 should regard you as an authority in microscopic 
 anatomy, or on nice points of organic chemistry. 
 But I have been working, in my fashion, for more 
 than half a century. I have been travelling through 
 the country upon which you are entering. Its high- 
 roads and its by-paths are somewhat familiar to me. 
 You have studied them in the books and on the 
 maps, and I doubt not you have studied them well. 
 Yet I may be able to communicate to you some useful 
 knowledge respecting them, although it relates to small 
 matters only. However, that I may not seem to dis- 
 parage myself, I will acknowledge a hope that there 
 may be some few points of real importance on which I 
 can enlighten you. 
 
 It is my object in these letters to point out to you 
 m a familiar manner whatever occurs to me as likely 
 
INTEODUCTORY. 9 
 
 to aid you, and which the books do not say much 
 about. I shall not be perfectly methodical, yet I 
 shall endeavor to hold to some plan. This may be 
 regarded as an introductory letter, in which I may 
 treat of matters and things in general. 
 
 Ours is said to be a liberal profession. This is often 
 said, with some vague notions of its dignity, by those 
 who are not aware why it has been called so. It has 
 been customary, you know, for those, who designed to 
 acquire a knowledge of any mechanic art, to be bound 
 as apprentices to some master-workman. . Now, an 
 apprentice is a servant, though he may not be a menial 
 servant. He works for his master's benefit, and at 
 his master's bidding. It was the case formerly, and 
 I believe it is so at the present day, in our father- 
 land, and in Europe generally, that common surgeons 
 and apothecaries learned their arts in the same way. 
 But it was never so as to physicians. They did not 
 pursue their studies under bonds, but like clergymen 
 and lawyers, as freemen. Hence the professions of 
 these three descriptions of men have been called lib- 
 eral. At present, you know, physicians and surgeons 
 take the same rank, or nearly so, in England, and 
 altogether so in this country. Indeed, with very 
 rare exceptions, the two professions are not distinct 
 
10 INTRODUCTORY. 
 
 I have been led into these remarks because I think 
 that some members of our profession have called it 
 liberal, with false notions on the subject. Thej have 
 thought not onlj that thej differed from artisans, but 
 they have seemed almost to believe that they were not 
 practising an art. They have seemed to regard them- 
 selves as professors of a science, by which they could 
 explain all the causes of diseases, and the true modes 
 of treating them. I rejoice to say that, in some 
 instances, this is true; and it is among the most 
 delightful' parts of our business when we can instruct 
 an enlightened man in the principles w^hich should 
 guide him in the attainment of health. It is not 
 often, however, that we can have this pleasure, for two 
 reasons : First, because many principles, on which we 
 act, are not established on certain ground ; and there- 
 fore they must be followed with great caution and 
 constant watchfulness. Second, because there are 
 few principles which are universal in their applica- 
 tion. In its application every principle is subject to 
 the limitation of other- principles. We are not, then, 
 acting on so grand a scale, always guided by well- 
 settled principles of science ; we are often glad of the 
 most limited empirical knowledge, and often obliged 
 to choose our course under much doubt. These diffi- 
 culties are great j but they are not greater than those 
 
INTRODUCTORY. 11 
 
 attending the application of principles to practice m 
 many common affairs of life, where the circumstances 
 are complicated. There is a marked resemblance, in 
 certain fundamental points, between our art and the 
 arts of agriculture and navigation. In the practice of 
 each of these arts we avail ourselves of the laws of 
 nature to produce certain results. The seaman places 
 his machine — his ship — upon the waters, and avails 
 himself of the winds to propel it. These winds are 
 uncertain ; thej are not, in any way, subject to his 
 control, so that he cannot be sure as to the duration, 
 the comfort, nor even the safety of his voyage. He 
 cannot furnish a pupil with positive rules, by which 
 to conduct his bark across the Atlantic. The captain 
 must have first a knowledge of the principles of navi- 
 gation ; but this is not enough. In applying them he 
 must have regard to the qualities of his ship, to the 
 strength of his crew, and to the constantly varying 
 circumstances of the weather. The complexity here 
 is much less than that attending the treatment of a 
 disease ; for in this we have to do with a living being. 
 It is not strange, then, that the physician cannot 
 always foretell the length or the amount of suffering 
 of a disease, or the ultimate issue of it. All this is 
 consistent with the wisest management on the part of 
 the navigator, or that of the physician. It is much 
 
12 INTRODUCTORY. 
 
 the same with the agriculturist. He may prepare his 
 ground with the most appropriate manures, and give 
 to it the nicest tilth; he may sow his seed at the 
 proper season ; and yet his expectations as to the har- 
 vest may be entirely disappointed. Not only may the 
 weather be unpropitious, but, at the moment when the 
 skies and the winds are favorable, and when success 
 seems certain, some insect army may suddenly invade 
 his fields and destroy his crop. Thus there is an 
 uncertainty in dealing with the powers of nature 
 which are most constant ; for there is a good degree 
 of constancy in the results of agriculture — so much 
 that we are rarely disappointed in relying on it for 
 the sustenance of man and beast. Yet, from year to 
 year, there is a variation in its results ; and, some- 
 times, the crops fail, in particular regions, almost 
 entirely. Is it, then, surprising that there is much 
 uncertainty in the success of the medical art ; an art 
 which has to do with a diseased body, and whose end 
 is to bring back this body to the healthy functions 
 which belong to it ? More especially, can this uncer- 
 tainty be surprising, when this diseased body has been 
 previously damaged, or enfeebled by a long course of 
 errors or misfortunes ? While, then, we acknowledge 
 the imperfection of our art, we must deny that this 
 is a proper subject of reproach. It is so, indeed, as 
 
INTRODUCTORY. 13 
 
 applied to those who profess to have a system, by 
 which thej can explain everything and effect every- 
 thing you may desire. But it certainly is not so 
 when applied to those who pursue an expectant, or an 
 active treatment, as circumstances may make proper ; 
 and who exercise modesty and discretion, as well as 
 decision, in the practice of their art. 
 
 I am very desirous to place this matter in what 
 appears to me its proper light. Those, who are dis- 
 posed to think ill of our profession, may ask how we 
 justify the use of powerful and dangerous drugs, while 
 we acknowledge the uncertainty of their effects. The 
 evils, they say, are certain ; the benefits, uncertain. 
 This is true ; and the question implies a grave objec- 
 tion to the careless use of such drugs. The objection, 
 however, is to the abuse of them. They should not 
 be used without grave consideration. But the physi- 
 cian, who knows all the risks attending the use of 
 powerful remedies, may also know within what limits 
 they are safe ; and likewise may know that the danger 
 attending his patient's case is much greater, than that 
 of the remedy. Now, I contend that this is true in 
 regard to men well educated, instructed in good prin- 
 ciples, and endowed with sound discretion. 
 
 It is my own practice to avoid drugs as much as 
 possible; and I more frequently find it difficult to 
 2 
 
14 INTRO DTJCTORY. 
 
 persuade people to abstain from using them, than lo 
 induce them to take them. But I hope that jou will 
 not believe me to be distrustful of the power of drugs 
 to do real service to the sick, under proper circum- 
 stances. I am far otherwise. And, in reference to 
 this point, I wish to tell you that your success in the 
 use of medicines may depend somewhat on the temper 
 with which you give them. You must be hopeful and 
 feel an interest in them. Do not, like a cold step- 
 father, leave them to make their own way in the world ; 
 but watch them in their course. You cannot make a 
 fire burn well if you put the wood on the andirons 
 with a feeling of indiflference. You must study to 
 know the power of the drug you prescribe, the proper 
 doscj and the tests of a sufficient dose, the mode of 
 preparation of the medicine, and then of the patient 
 for the medicine, and all the management requisite for 
 a good result. Do not be in a hurry to give credit to 
 your prescription, as soon as the patient shows any sign 
 of amendment, nor be discouraged if relief do not fol- 
 low as soon as you had anticipated. In this last case 
 see if there has not been some error in the manage- 
 ment of the affair, or if some counteracting cause has 
 not interfered. Do not despair because the medicine 
 has failed on your first trial of it. Try it again, 
 before you condemn what has been recommended as 
 
INTRODUCTORY. 15 
 
 beneficial hj one well qualified to form a judgment on 
 it. I have wandered from mj point. 
 
 It is a very narrow and unjust view of the practice 
 of medicine, to suppose it to consist altogether in the 
 use of powerful drugs, or of drugs of any kind. Far 
 from it. , It is true that the common question addressed 
 to the physician by the patient is. What shall I take ? 
 That question implies that there is a drug adapted to 
 every disease. But the enlightened physician first 
 considers whether the patient shall take anything. 
 He considers what other modes of relief there are 
 besides pills and draughts. He looks to diet and 
 regimen. To these points I shall have frequent occa- 
 sion to refer. 
 
 Let it be remembered, — and we may address this 
 particularly to the scofier, — that the true physician 
 takes care of his patient without claiming to control 
 the disease in all cases. He does not regard himself 
 as making an exhibition before a company to show his 
 skill ; he makes no boast of what he can do. I wish 
 I could say that this is never done by any of our pro- 
 fession. There are those who, directly or indirectly, 
 trumpet forth their skill and their success, attributing 
 the recovery of their patients to the remedies they 
 have prescribed, and never to the spontaneous efibrts 
 of nature. These, whatever titles may be appended 
 
16 INTRODUCTOBY. 
 
 to their names, are true quacks. They quack ! quack / 
 that they may attract the attention of the passers-by ; 
 and, while they extol their remedies for the sick- and 
 the suffering, they are seeking only their own profit 
 and their own glory. The true physician, on the 
 other hand, cannot fail to be modest in his pretensions ; 
 for he is aware how his knowledge and power are 
 limited, while he feels the magnitude of his task. Is 
 it his business to cure all his patients ? It is so, if 
 he can do it, even in the sense now attached to the 
 word cure. But, in the original sense of it, he should 
 cure all ; for in that sense to cure meant to take care. 
 The priest had the parish for his cure, the physician 
 the sick for his. In this sense the sick were under 
 his cure till they got well or died, if they were willing 
 to remain so. The physician may do very much for 
 the welfare of the sick, more than others can do, 
 although he does not, even in the major part of cases, 
 undertake to control and overcome the disease by art. 
 It was with these views that I never reported any 
 patients cured at our hospital. Those who recovered 
 their health before they left the house Avere reported 
 as toell^ not implying that they were made so by the 
 active treatment they had received there. But it was 
 to be understood that all patients received in that 
 house were to be cured, that is, taken care of. 
 
INTRODUCTORY. 17 
 
 I have sometimes had patients say I was not doing 
 anything for them, because I had not ordered any 
 medicine to be taken. It may be that the patient in 
 Euch a case thinks that no medicine will remove the 
 disease, and is right in his opinion ; yet, something is 
 to be done, but not by medicine. By diet and regimen 
 much may be done to mitigate suffering and prolong 
 life. In all cases, in the worst, there is one course 
 more prudent than another. If the ship is running 
 on to the shore, or is even breaking up on the rocks, 
 there may be one course better than another in the 
 management of affairs. In the worst peril, when you 
 must leave the bark to which you had trusted yourself, 
 in whose guidance would you place most confidence ? 
 Would you leave yourself to the mercy of the waves ? 
 Would you trust an ordinary sailor because he bawled 
 the loudest ? Or would you follow the advice of the 
 experienced ship-master ? 
 
 Ours, I said, is a liberal profession. While studying 
 tlie sciences, which qualify you to practise the art of 
 medicine, while deciding what rules of art you will 
 adopt, you have not been bound to follow any man as 
 a guide ; you have not promised fealty to any intellect- 
 ual master. If you have been as wise as I think you 
 have, you have weighed the characters of your teach- 
 ers, dead and living, and judged for yourself, in regard 
 2^ 
 
18 INTRODUCTORY. 
 
 to each of them, how far you might rely on him for 
 accuracy and honesty in stating facts and observations, 
 and for philosophical accuracy in the inferences to be 
 drawn from them. You are bound as by an oath, 
 though you have never held up your hand before man, 
 to use your best judgment in the treatment of those 
 who are committed to your care. You are bound to 
 consult the best teachers, but not to follow the orders 
 of any individual among them. 
 
 Ours is a liberal profession, and you may rejoice in 
 being received into it. There are to be found in our 
 ancestry father^ of whom we may be proud. First, 
 Hippocrates, whose title to father was not only be- 
 cause he was the first in time who left any writings 
 worthy to be preserved, but also because he pursued 
 his inquiries in the truest spirit, and in the best mode. 
 Like all scientific writers, he employed the language 
 of the day, and that involved the received doctrines 
 and hypotheses of the day. But he was a true 
 observer of diseases ; he noted the circumstances under 
 which they arose, and he stated the treatment he 
 employed. This was a communication of knowledge. 
 If error was mixed with it, the wonder is that so much 
 of it was true and substantial knowledge. I will not 
 give you a list of the worthy successors of Hippoc- 
 rates. It would be a long list, though I should select 
 
INTRODUCTORY. 19 
 
 those only whose claims would not be disputed. I 
 might find some such in our own land, who ha^^e 
 finished their career in the present century. I will 
 indulge myself in naming one only ; one w^hom I had 
 the happiness to know intimately. He was my first 
 teacher, and I have been accustomed, with, some others 
 of his pupils, to call him old master. I refer to the 
 late Edward Augustus Holyoke, M. D., of Salem. 
 He, like Hippocrates, lived more than a hundred 
 years, retaining his faculties, mental and bodily, to 
 the end of his century, in unusual perfection. But it 
 IS not for his longevity that I mention him as entitled 
 to a high rank in the profession. He was little more 
 than fifty years of age when our Massachusetts Medi- 
 cal Society received its charter, and in that Dr. 
 Holyoke' s name stands first on the list of those incor- 
 porated. Upon the organization of the society he was 
 elected its first president. Thus it appears that his 
 high claims were acknowledged by his brethren at 
 a time when there must have been very many in the 
 state older than he was. It was on account of his 
 professional merit that he was thus honored ; but all 
 the more that his whole character was most worthy 
 of respect. He had the delicacy of taste, as shown in 
 his manners and general bearing, which grows out of 
 a fine organization and of a cultivated mind. This 
 
20 INTRODUCTORY. 
 
 was accompanied hj true piety ; that piety, which not 
 only elevates the heart and promotes all holy affec- 
 tions, but also clears the atmosphere in which the in- 
 tellect dwells; for, it is certainly true that, when 
 all the lower appetites and passions are kept under 
 control, and divine things are made real to the mind, 
 then truth will be discerned most clearly. This is 
 peculiarly obvious as regards moral subjects, but it is 
 not limited to them. 
 
 Dr. Holyoke ranked among our first men in his 
 general scientific attainments. But the great object 
 of his life, industriously and faithfully pursued, was 
 the practice of medicine in its various branches. He 
 observed, closely and critically, the phenomena of 
 disease and the methods of treating it. His concep- 
 tions were clear, and his memory strong ; though, like 
 other old men, he lamented its decay, in the latter 
 part of his life. He had not lost it, however, as was 
 shown on the day which completed his hundred years, 
 and when he began on a new century. On that day 
 a case was presented to him of an unusual character, 
 on which, after examining it, he remarked that he did 
 not recall any like it, unless that of a patient whom 
 he named. This patient was one whom he had seen^ 
 once only, forty years before. He had, then, a great 
 store-house of cases in his mind ; and of the materials 
 
INTRODUCTORY. 21 
 
 in this store-house he constantly availed himself. He 
 told me that his habit was, in a difficult case, first to 
 look to experience for a guide ; and only when this 
 was deficient, to allow himself to act on hypothetical 
 principles. After considering a case, he would decide 
 upon the treatment which he thought best adapted, 
 and would pursue this with firmness ; watching, how- 
 ever, for whatever would correct his opinions. He 
 was too modest to believe that he had become a perfect 
 master of his art, and too wise to adventure rashly 
 where human life was at risk. He had great dignity 
 of character, such that it seemed to prevent the exhi- 
 bition of any bad passions in his presence ; but it was 
 combined with the greatest modesty. This will be 
 understood, when I add that this dignity was founded 
 on purity of heart. His reputation was unspotted. I 
 never heard any one hint even at any moral error in 
 his life. 
 
 Dr. Holyoke was in his seventieth year when I 
 went into his study. He had had a very extensive 
 practice, but he had then contracted it so that he 
 attended to his business on foot. After a short time 
 he allowed me to walk with him and see his patients ; 
 a privilege for which I have ever felt most thankful. 
 My intercourse with him was highly instructive ; it 
 was also most agreeable. He was extremely afiable, 
 
22 INTRODUCTORY. 
 
 and had the simplicity of manner which belongs to the 
 true gentleman. Withal he had a playful humor and 
 a most hearty laugh ; but he never wounded any 
 man's reputation. Erom my very imperfect delinea- 
 tion of his character you may judge how much I 
 must have venerated and loved him ; and I hope that 
 this delineation may not seem to you to have occupied 
 too much space. 
 
 "We belong, then, to a profession in which there 
 have been in every age men whom we may be proud 
 to call our fathers. But a man whose father was 
 ennobled on account of his high character and great 
 services to the cause of humanity, does not necessarily 
 derive advantage from the title which descends to 
 him. He does so only when he imitates the virtues 
 of his parent, and labors for the common good. A 
 desire for profit and reputation might be enough to 
 prompt him to do all this ; it would also be good pol- 
 icy. But he will not do it with a full certainty of 
 success if he be not influenced by still higher motives ; 
 by a true love of science and humanity. 
 
 You must not mistake me. We are not called 
 upon to forget ourselves in our regard for others. 
 We do not engage in practice merely from philan- 
 thropy. We are justified in looking for both profit 
 and honor, if we give our best services to our patients ; 
 
INTRODUCTORY. 2B 
 
 only we must hot be thinking of these when at the 
 bed-side. There the welfare of the sick must occupy 
 us entirely. The sea-captain, in a storm, must not be 
 thinking of the rich merchandise with which his ship 
 is freighted. His mind must then be engrossed by a 
 regard to the lives committed to his charge. Our 
 profession has attached to it great labors and great 
 responsibility. It is for the public good that it should 
 hold out due rewards, so as to attract to it young men 
 of talents and sound learning. Such men, with minds 
 liberalized by scientific studies, and especially by the 
 study of sciences most interesting to humanity, may 
 be expected to act from motives of the highest order. 
 My excellent friend, M. Louis, of Paris, in a letter to 
 me, says that he looks upon a physician ''as holding 
 a sacred office, which demands greater sacrifices than 
 are to be made in any other profession." No one 
 is better entitled by his own character than this 
 distinguished pathologist to utter this noble senti- 
 ment. 
 
 Before concluding this letter I have a remark to 
 make in reference to the acknowledged imperfection 
 of our art. Are there any in our ranks who cease to 
 study it diligently on this account ? This, surely, is 
 altogether unjustifiable ; for, if it is imperfect, they 
 should study to improve it. Besides, there is abun- 
 
24 INTRODUCTORY. 
 
 dant reason and encouragement for every one to con- 
 tinue his studies as long as he lives. Imperfect as the 
 healing art is, be assured of this, no one man knows 
 all that is knowfi respecting it. 
 
LETTER II. 
 
 ON CONDUCT IN THE SICK-KOOM, 
 
 In this letter I mean to treat of the deportment of 
 the physician in the sick-room, and of the investiga- 
 tion of the cases presented to him. 
 
 The physician should enter the sick-room with the 
 feeling that he has a serious duty to perform. He 
 must remember that his countenance, and words, and 
 actions are closely watched by the patient and by his 
 friends in all cases of severe sickness ; and, indeed, 
 where, though the disease is slight, the apprehension 
 of evil is great. 
 
 First of all, his deportment should be calm ; he 
 should be sober without solemnity, and civil without 
 formality. He should abstain from all levity. He 
 should, indeed, be cheerful, and, under proper circum- 
 stances, he may indulge in vivacity and in humor, if 
 he has any. But all this should be done with refer- 
 ence to the actual state of feeling of the patient and 
 of his friends. He should avoid mannerism ; and 
 8 
 
26 ON CONDUCT IN THE SICK-ROOM. 
 
 rather cultivate the feelings which will lead him 
 aright, than be thinking in detail of the particular 
 steps which he should take. The physician should 
 never exact attention to himself The patient is the 
 central object in the sick-room, or should be so. The 
 physician should recognize this, and, if possible, put 
 his patient at his ease, so as to facilitate his inter- 
 course with him. As far as possible, he should seek 
 information from the patient himself If the sick one 
 be an infant, or in any way incapable of speaking for 
 himself, the inquiries must be addressed to the mother, 
 or to the nurse. Yet the conversation should relate 
 to the patient only. In the same spirit, paying no 
 more attention to others than decency requires, he 
 should proceed at once to business. In this way, he 
 acquires the confidence of his patient, and will be 
 most likely to get at the truth in respect to his case. 
 Now that is a very hard matter, this getting at the 
 truth. I have often stated to pupils in the hospital, 
 after a hard struggle to get at the truth in some case, 
 this anecdote, which, whether true or not, has served 
 my purpose. It has been said that when Sir Waltei 
 Raleigh was a prisoner in the Tower of London, he 
 saw in the yard a rencontre between two men, who 
 were strangers to him. He thought he saw the whole 
 transaction, and that he knew which was the aggressor. 
 
ON CONDUCT IN THE SICK-EOOM. 27 
 
 He was much incensed at the conduct of this man ; 
 and when his keeper visited him he expressed his feel- 
 ings in regard to the afiair. His keeper then related 
 the whole story, and showed Sir Walter that he was 
 quite in the wrong ; that the man whom he called the 
 aggressor was, in truth, the innocent and injured 
 party. Sir Walter then turned round, and, taking up 
 some papers, threw them into the fire, saying, that he 
 had been attempting to write a history, but, if he had 
 been so much deceived in what had passed before his 
 own eyes, he could not expect to tell the truth as to 
 events of distant regions and past times. 
 
 I would not inculcate by this anecdote that we can- 
 not arrive at the truth, but that we are very liable to 
 be deceived, and to adopt wrong conclusions even as to 
 occurrences almost under our own eyes. It is a great 
 part of our business to get at, and examine the evi- 
 dence respecting the cases which are under our care. 
 I hold that a physician must be quite as acute as a 
 lawyer in examining witnesses. The lawyer, when 
 questioning a witness, acts as an advocate, seeking 
 only for what will support his side of the case. Un- 
 happily, the physician sometimes exhibits the same 
 spirit, by seeking for what shall support his own doc- 
 trines. But his duty is to examine the testimony 
 presented to him in the spirit of a judge, seeking for 
 
28 ON CONDUCT IN THE SICK-ROOM. 
 
 truth only ; being careful not to reject that which is 
 well substantiated, because he cannot understand it, or 
 because it contradicts his preconceived notions. It is 
 for facts that we are to seek, — for the actual phe- 
 nomena, — and we must be careful not to accept opinions 
 in lieu of them. Hence, our scrutiny must sometimes 
 be very close. We must insist on exact answers, 
 though not in a violent manner ; for we must always 
 take care not to agitate the sick man. 
 
 In the investigation of a case, it is best to have a 
 method. It is not necessary that we should pursue 
 this formally, but we should have it in mind, and, in 
 difficult cases of long standing, it may be necessary to 
 pursue it in a somewhat precise manner. The method 
 should be such that we may be sure not to neglect 
 any point. Chiefly, it should be such as to lead 
 us to an examination of all the functions and all 
 the organs ; and of the relation to each other of the 
 different affections of the various parts. My own 
 plan has been this : first, to examine the organic func- 
 tions, then the animal functions, and then those 
 relating to reproduction : following, thus far, the plan 
 of Bichat. Under the head of organic functions 1 
 consider those of assimilation, formation and excretion. 
 The functions of assimilation are those, by which the 
 foreign substance is taken into the organs of digestion. 
 
ON CONDUCT IN THE SICK-ROOM. 29 
 
 and all which follow until the nutriment is conrerted 
 into blood. The functions of formation are those by 
 which the solid organs are moulded and maintained, 
 and by which those secretions take place, which are 
 employed for the various purposes of the body. The 
 functions of excretion are those, by which the parts of 
 the food, not employed for nutrition, are carried off, 
 and those by which the blood is depurated of the ma- 
 terials gathered up from the various parts of the 
 body, where they are no longer useful. The animal 
 functions are, first, those of sensation ; second, those of 
 the voluntary muscles, and of the organs of speech ; 
 and, third, between these, all the mental functions ; 
 including under this head the emotions and passions, as 
 well as the operations of the intellect. I need not 
 treat in detail of the functions of reproduction. Ordi- 
 narily, they may seem not to require special attention ; 
 but it is not so as regards females ; for it is very often, 
 if not always, necessary to advert, with them, to the 
 subject of menstruation ; likewise, in married women, 
 we must know when one is in a state of pregnancy, 
 or of lactation. In some cases, of course, the principal 
 or primary disease is found in the organs of repro- 
 duction. 
 
 Having obtained a methodical history of the func- 
 tions, we must avail ourselves of the physical signs, 
 3* 
 
50 ON CONDUCT IN THE SICK-KOaM. 
 
 as well as of the sensations of the patient, and any 
 other testimony, in order to ascertain the state of the 
 various organs of the body. In regard to all symp- 
 toms, we must learn whether they are constant, or 
 occasional ; and if occasional, whether they recur at 
 regular periods ; also whether two or more occur in 
 any order relative to each other. In these inquiries, 
 it is sometimes necessary to guard against suggesting 
 symptoms, when the patient is full of imaginations. 
 Hence, not only should the physician avoid a rigid 
 fornfality, but he should exercise due discretion in 
 the mode of inquiry. By having a method in the 
 mind we can more readily decide, when our examina- 
 tion is finished, although we do not adhere to the 
 method in every examination. 
 
 The symptoms may be divided, in the language of 
 the day, into the objective and subjective. The 
 objective are those which we discover by our own 
 observation and examination of the patient. Such are 
 the phenomena of the countenance, the respiration, 
 pulse, &c., &c. The subjective symptoms are those 
 which we must learn from the patient himself, con- 
 sisting ill his own sensation, or derived from his own 
 consciousness. It is obvious that the objective symp- 
 toms are most worthy of reliance, because we can 
 measure them for ourselves, and have one standard 
 
ON CONDUCT IN THE SICK-ROOM. 61 
 
 for all patients. Far otherwise with the subjective 
 symptoms ; since patients, equally anxious to tell us 
 the truth, will describe their sensations in very differ- 
 ent terms, when we have reason to believe that they 
 are the same, or nearly the same. This difference 
 relates, in the first place, to the degree of violence, or 
 severity, if it be pain which the patient speaks of. 
 But there is a greater difficulty in regard to the kind, 
 or quality of the sensations. We employ names for 
 objects which are well known, such as animals, plants, 
 or machines ; but there are many sensations which are 
 sufficiently definite in themselves, and well known to 
 those who have experienced them, but which are so 
 rare as not to have acquired distinct names. These 
 are described by each patient by such comparisons as 
 occur to his mind. But to two different men, having 
 the same feelings, different comparisons will occur. 
 The two patients will at first seem to speak of different 
 things ; and, though the experienced physician will 
 generally discover what is meant, he cannot always do 
 it ; and probably, in some instances, he is entirely mis- 
 led. There are cases, in which we find no objective 
 symptoms, or none of much importance, and must 
 therefore rely on the patient alone. In such, this 
 absence of objective symptoms should be noted, as part 
 of their history. It is one of the great accomplish^ 
 
32 ON CONDUCT IN THE SICK-EOOM. 
 
 merits of modern physicians that thej learn so much 
 more, by their own observations on the patient, than 
 their predecessors did. This is instanced particularly 
 in the exploration of the thorax by auscultation and 
 percussion. But I think it is quite as difficult an art 
 to collect and duly estimate the subjective symptoms. 
 For this purpose one must have a good knowledge of 
 human nature, be in the habit of intercourse with 
 men, and be able to estimate aright the scale on 
 which language is employed by different persons. 
 Besides this difference, which arises from the more or 
 less acute feelings of different persons, there are others 
 which come from the different degrees of precision 
 with which men express their ideas, or from the more 
 or less extensive vocabulary which they employ. 
 Thus, the lawyer, the farmer, and the seaman, would 
 describe their sufferings in very different terms, 
 although one might not be more acute than the other 
 in his feelings. 
 
 In first examining a new case, it is not well to ask 
 what is the disease, for that leads the patient to give 
 his opinion, on which it is not well that he should be 
 committed ; or else, he replies, it is that which he 
 wants you to tell. It is better to ask in what way he 
 is incommoded, for that is what he does know. Often- 
 times it is best to let the patient tell his story in his 
 
ON CONDUCT IN THE SICK-ROOM. 33 
 
 own way, without bringing into view your method 
 of examination. When he has finished, you may 
 cross-question him ; afterwards you may consider 
 how many of the questions, which you would have 
 asked, he has answered, and then address to him such 
 new ones as will fill up the methodical examination of 
 his case. In grave cases, however, especidly when 
 of long standing and obscure, it is best to insist upon 
 a methodical examination. It is the shortest way. 
 This examination will, of course, include the past his- 
 tory, and the present state. In many instances, one 
 interview, or even two, will not suffice for this investi.< 
 gation. 
 
 In subsequent attendance on the case it is important 
 to watch the changes in the past symptoms, as well as 
 to note all new ones. Not unfrequently we must 
 make inquiries of the friends of the patient to obtain a 
 full account of the case. I state this in order to give 
 a caution. Without any bad intentions, the friend will 
 sometimes mislead us, owing to his undue anxiety and 
 apprehension, or because he has adopted an hypothesis, 
 and, like an advocate, enlarges upon the evidence in 
 support of that. It does happen, though rarely, that 
 some sinister motive causes the supposed friend to 
 misrepresent the case. I would not inspire jealousy 
 on this subject, but only caution. In getting the his- 
 
34 ^ ON CONDUCT IN THE SICK-EOOM. 
 
 tory of the case it is always right, and sometimes 
 quite essential, to get dates ; if possible, with accuracy. 
 Ascertain not only the date of the beginning of the 
 disease, but also that of each prominent symptom, and 
 of every change which has occurred, good or bad. In 
 every important case the previous history of the 
 patient should be ascertained, in respect to his own 
 health, and even that of his family; likewise, his 
 habits as to diet, business, pleasures, etc., his temper- 
 ament and disposition, should be ascertained. If the 
 attack be acute, and, especially, if of a nervous char- 
 acter, we should ascertain whether the patient has 
 been subject to the same. 
 
 It is thought quite essential, you know, that the 
 physician should feel the pulse, and look at the 
 tongue ; and the objective signs, which we thus dis- 
 cover, are often quite important. I believe Celsus 
 advises that we should not be in a hurry to feel 
 the pulse. But I have found it better to make this 
 examination early in the visit, before the patient has 
 become fatigued or excited ; and, if there seems to be 
 any emotion at that time, the examination may be 
 repeated when the patient has become calm. To see 
 the tongue fairly, you should sit between the patient 
 and the light. I make this minute remark because 
 this position will enable you to make other obser 
 
ON CONDUCT IN THE SICK-KOOM. 35 
 
 fations with advantage, such as relate to the counte- 
 nance, eyes, complexion, attitude, motions of the 
 chest, and of other parts ; and these things may be 
 watched without embarrassing the patient, without his 
 being aware of your object, if you are so placed as to 
 see him distinctly. Let me add to this long detail as 
 to the examination of the patient, that, in difficult 
 cases, it is necessary to review, consider, and digest 
 the evidence, and to repeat your examination until 
 you have arrived at all the satisfaction which the cir- 
 cumstances permit. 
 
 A young physician, fearful that he may be thought 
 ignorant, is tempted to answer too readily the inquiries 
 of the patient, or his friends, as to the diagnosis, prog- 
 nosis, and the treatment. He will, however, ulti- 
 mately, gain by not yielding to this temptation. 
 Sensible men, and sensible women too, will give him 
 credit if he takes time to think before he speaks. I 
 would not counsel any affectation ; do not say that the 
 case is uncertain, with a wiseacre shake of the head. 
 This will not ultimately advance your reputation. Be 
 cautious, but, at the same time, frank ; and, when you 
 have made up an opinion, state it plainly. Be slow 
 to give an alarm as to the result, especially to the 
 patient ; for to judicious friends it is best to state all 
 your apprehensions. It is sometimes quite essential, 
 
36 ON CONDUCT IN THE SICK-ROOM. 
 
 though not so often as you might suppose, to hide 
 your fears entirely from the patient, and from anxious 
 friends who surround him. This is justified only 
 where it is evidently for the welfare of the sick, to 
 whom, certainly, you ought not to make your knowl- 
 edge work an injury. Every one will admit the pro- 
 priety of this where the mental powers are- impaired. 
 But also with young persons, whose minds are imma- 
 ture, and with persons who are morbidly apprehensive, 
 it is often dangerous to acknowledge your fears. When 
 conscious that you are influenced only by benevolent 
 motives, and that you 'must deceive the patient, do it 
 thoroughly ; do not try to save yourself by equivocal 
 expressions. If a patient of sane mind and of adult 
 age demands your honest opinion, give it to him dis- 
 tinctly ; even then do not couch it in the coarsest 
 terms, but use the mildest words which will answer 
 your purpose. 
 
 A common inquiry on the part of the patient and 
 his friends is as to the cause of disease. To this 
 inquiry they are sometimes answered by the physician 
 in blind terms, which they cannot understand. It is 
 unworthy of a scientific man to make a reply to such 
 queries in terms which are designedly unintelligible ; 
 and yet it is often impossible to do it in terms which 
 will be properly understood. If a professor at a clini- 
 
ON CONDUCT IN THE SICK-ROOM. 37 
 
 cal lecture were stating to his pupils his views in such 
 a case, he might, perhaps, occupy an hour in so doing ; 
 and this to pupils so far advanced as to understand the 
 scientific terms he would employ. How, then, can he 
 make a brief, and at the same time an intelligible 
 reply to a common patient ? But there is another 
 difficulty which I will not disguise. This is, that in 
 many cases we do not know the causes. Thus, in 
 diseases of the skin, it is often impossible to assign 
 the true cause ; that is, the true efficient cause. From 
 these considerations I have thought it better to avoid 
 the discussion of causes as much as possible, never 
 hesitating to avow that physicians are much more 
 ignorant on these points than they are supposed to be ; 
 or, at least, that this was true in my own case. 
 
 I have known one physician who could hardly be 
 made to answer any question, during his visits, on 
 points not relating to his patient. He was, perhaps, 
 too dry, too stiff. But his course was admirable com- 
 pared with that of the gossiping doctors, who talk over 
 all the affairs of the village, almost forgetting the 
 patient immediately before them. I need not point 
 out the numerous evils of this course. 
 
 Of many cases, and even of all, it may be desirable 
 to keep notes ; but there are some evils attending this. 
 If the notes are taken during the visit, they must be 
 4 
 
38 ON CONDUCT IN THE SICK-IIOOM. 
 
 brief, often hurried, and then not worthy of reliance. 
 If taken afterwards, at home, many circumstance& 
 may be forgotten. Taken during the visit, they dis- 
 tract the attention, and the physician puts his knowl- 
 edge on paper without fixing it in his mind. We 
 would desire that the physician should give himself to 
 the examination of his case, until it should become 
 daguerreotyped upon his mind. This is not so likely 
 to be done, if he is occupied Avith his pencil and his 
 note-book. However, men differ in their capacities ; 
 and some are able to get the benefit of notes, without 
 the evils which I have suggested. If you do take 
 notes, use them ; put them in a form to be useful. 
 Set down carefully all the plienomena — what you do 
 not understand, as as well as what you do. Then 
 transfer the whole in a systematic manner to your 
 large case-book, at home. Review your notes from 
 time to time while the case is going on, and, when it 
 is finished, subjoin to your notes such reflections as 
 they may give rise to. 
 
 Your directions as to medicines, diet and general 
 management, should be given with great care. Make 
 them clear and exact, and state whether they are to 
 be followed literally, at all events, or whether anything 
 is to be trusted to the discretion of the attendants. 
 In grave cases, or where the drugs are potent, it is best 
 
ON CONDUCT IN THE SICK-ROOM. 39 
 
 to put the directions in writing. If possible, deal 
 \Yith the real nurse, whether she be the mother or a 
 nurserv-maid ; for directions, which pass from one per- 
 son to another, are very likely to be misstated. When 
 you make your prescription, settle in your own mind 
 what direct effects are to be expected from the med- 
 icine, and in what way it is to benefit the patient. 
 Afterwards note whether the results are such as you 
 had anticipated, or in what way they have been differ- 
 ent from your expectations. It is in this way you 
 can make your experience beneficial. It is a grateful 
 thing to see your patient get well in any way ; but it 
 is important, for those who are to follow him, that you 
 should know how far your treatment had helped him, 
 or hurt him. 
 
 I said that you should enter the room of a sick 
 man in a calm manner, and with a sober air, showing 
 your desire to learn the state of your patient. I 
 will now add, that, if possible, you should leave the 
 room with an air of cheerfulness ; such as should give 
 all the hope, which the case will justify, for the com- 
 fort of the patient and his friends. 
 
 It is your interest, as well as your duty, to render 
 all the service you can to those who call for your pro- 
 fessional aid. And, first, you should attend to the 
 sails which are made on you with the least possible 
 
40 ON CONDUCT IN THE SICK-ROOM. 
 
 delay ; not, however, breaking an old engagement for 
 a new one. Next, be punctual in your attendance. 
 If possible, make your visit when it is expected, and 
 let it be known when you should be expected. Entire 
 precision in this respect is not possible ; but it should 
 be approximated. It is proper to decide in your own 
 mind, during one visit, when you will make the next ; 
 for you will then think of all the circumstances which 
 should decide you, which you might forget the next 
 morning. If it is a matter of indifference, let it be 
 known that the time is uncertain, so that the patient 
 may be saved from anxiety, or other inconvenience. 
 To a man in full practice these arrangements are 
 attended with difficulty. But one who realizes that 
 they are important to the comfort, and sometimes to 
 the essential welfare of the patient, will be able to 
 conform to them more easily than might be antici- 
 pated. 
 
 It is proper for a physician, as it is for other men, 
 to take care of his reputation. His success in life 
 depends on it. He should, however, be more ready 
 to meet any charge against him on the score of fidelity 
 and honorable conduct, than on account of skill. He 
 will sometimes suffer from the ignorance of those about 
 him. A stupid and tattling nurse, or a silly fine 
 lady, may do him real injury ; and this is the more 
 
ON CONDUCT IN THE SICK-ROOM. 41 
 
 vexatious and mortifying because he cannot meet them 
 on fair grounds. If his skill is called in question, he 
 cannot condescend to defend himself against such 
 assailants. If they circulate falsehoods, it may be 
 necessary to expose them. But, if the charges are not 
 grave, it is better to disregard them. Above all, he 
 should not court such persons as I refer to, with a 
 view to prevent injury from them. Foolish friends 
 may do him great harm. They may desert him ; but^ 
 what is worse, they may give him injudicious praise. 
 If he can help it, he should never let any one cry him 
 up ; not even the wise and -good. It must be his wish 
 that such persons should think well of him, but not 
 that they should give him extravagant praise. On 
 the whole, one need not fear that he shall not get suf- 
 ficient credit. I have often remarked that, though a 
 physician is sometimes blamed very unjustly, it is 
 quite as common for him to get more credit than he is 
 fairly entitled to ; so that he has not, on the whole, 
 any right to complain. 
 4* 
 
LETTER III. 
 
 ON THE NERVOUS SYSTEM AND ON HEADACHE. 
 
 Let us now begin at the head, and go downwards. 
 I shall not notice all the diseases in the various parts, 
 but only those on which I have something to say. 
 
 In the head the most important part is the brain, 
 and I must connect my observations on diseases of 
 this organ with those, which relate to the whole 
 nervous system. As introductory to particular dis- 
 eases of this system, I wish to oifer some general 
 remarks and explanations in respect to its physiology 
 and pathology. 
 
 To give you my thoughts on the diseases of the 
 nervous system, I must point out wherein it is affected 
 by or through the organic system, and where it acts 
 independently. To make my views clear, I must 
 begin with the simplest living beings, but I will not 
 carry you minutely through the whole series of vege- 
 tables and animals. 
 
 The polypus is one simple organ ; a bag, of which 
 
ON THE NERVOUS SYSTEM AND HEADACHE. 43 
 
 the outside is as good as the inside, and vice versa ; 
 and of which one portion is as good as any other ; so 
 that you may cut it in pieces, and each piece may live 
 and model itself into a perfect polypus. The cellular 
 vegetables, such as the algae, are as simple in organi- 
 zation as the polypus, or even more so. They may 
 be regarded as consisting of simple cells, aggregated 
 together, but each capable of an independent life. As 
 you ascend, you find in animals and vegetables distinct 
 parts, or organs, destined for special purposes. Thus, 
 in vegetables, you find a coating like a skin, or a 
 bark, and you find leaves for respiration. You also 
 find distinct parts for the perpetuation of the species, — 
 the flowers, — many of them among the most beautiful 
 objects in creation. Yet, all that belongs to these 
 vegetables is for the maintenance of individual life, 
 and for the perpetuation of the species. 
 
 Here, then, we see, in the simplest of living beings, 
 a capacity for forming such organs as are needed for 
 their humble and limited purposes. It is easy to 
 conceive that beings, coming under the same general 
 character, may be able to form other organs, for dis- 
 tinct purposes, not essential to their own life, nor for 
 the maintenance of their race. Thus, the coral forms? 
 a matrix for itself and its progeny, and this answers like- 
 wise for its tomb. In this its remains, with those of 
 
44 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 its contemporaries and its progeny, continue bedded 
 for ages, and by their accumulation build up rocks in 
 the ocean, and give a foundation for islands. But the 
 most simple instance, and one most to my purpose, is 
 the thorn formed on plants. This seems to me the 
 simplest of outgrowths. It is formed by the organic 
 system for its use ; but it does not perform any func- 
 tion necessary for the life of the plant, nor for that of 
 its progeny. The naturalist might point out to you an 
 abundance of like instances, and go gradually from 
 the thorn, through the more complicated structures, 
 to the nervous system in man. Among animals, low 
 in the scale of beings, you find nerves. Rising in this 
 scale you find a ring, or some larger centre, where 
 the various nerves meet, or from which they are falsely 
 said "to issue ; and you arrive through the ganglia to 
 the brain, a compound ganglion, with the medulla 
 spinalis attached to it. All these are outgrowths from 
 the organic system; they are maintained in life by 
 that system, and are subject to the diseases which be- 
 long to it, such as inflammation, tuberculosis, &c. It 
 is perfectly true that the brain and nerves repay the 
 obligation to the organic system. Man is not planted 
 in the earth whence he may derive his nourishment. 
 Thougli he gets one essential of his life from the 
 atmosphere that surrounds him, his skin is not encom- 
 
ON THE .NERVOUS SYSTEM AND HEADACHE. 45 
 
 passed by a material, from which his nutriment can be 
 absorbed. He must seek and gather his food ; and, 
 to secure enough of it, he finds it best to cultivate the 
 earth which is to produce it. Thus the animal system 
 repays the organic system, by which it was built up, 
 and by which it is maintained. 
 
 Now, how are all these functions, organic and 
 animal, performed ? As to the organic, we can obtain 
 some notions, though in them there is a mystery we 
 cannot solve. We get so far behind the curtain as to 
 discover the cells, and can trace their subdivision and 
 multiplication ; we can see how some are combined to 
 build up the solid organs ; and we find the secretions 
 are gathered from other cells, which open and pour 
 them out. Here is something to gratify our wish to 
 comprehend the operations in a living body, though 
 we cannot discover, from the examination of any cell, 
 by itself, for. what purpose it is fitted — whether to 
 make a bone or a muscle, saliva or bile. An 
 acquaintance with the normal operations in the organic 
 system enables us to comprehend something as to its 
 abnormal, or pathological operations. We find in in- 
 flammation a modification of the formative or nutri- 
 tive processes; and in some more grave, happily 
 more rare, morbid aifections, the organic system appears 
 to form something like new organs, Or structures. 
 
46 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 These do not conform to anything in the healthy state, 
 and they cause a waste and decay of the whole body. 
 Now, these, and other changes which are wrought by 
 the organic system in its own organs, may, some of 
 them at least, be wrought in the organs belonging to 
 the animal system. Every day we are seeing inflam- 
 mation and tubercles in, or about the nervous organs. 
 So far we can get at some understanding of the diseases 
 of the nervous system. This system has its functions 
 impaired, or arrested in its various organs by pressure 
 on them, especially when suddenly made. This is one 
 of the effects of inflammation. There may also be 
 destructive diseases in the brain, or other nervous 
 organs ; such as softening — a consequence, as some 
 think, of inflammation. In these instances, if we can 
 examine the parts affected, before or after death, we 
 see the changes of structure which have been wrought, 
 While some of the diseases of the brain and its 
 nervous appendages are eiplained, as has been stated, 
 there are others not to be explained in the same way. 
 On inspection of the organs concerned, there cannot 
 be discovered any addition to, nor change of, structure. 
 Here we have diseases, of which we know nothing 
 more than clinical examination discloses. We know 
 only the abnormal phenomena. By studying the 
 symptoms, their course, and the order of their occur- 
 
ON THE NERVOUS SYSTEM AND HEADACHE. 47 
 
 rencGj we satisfy ourselves in what part of the nervous 
 system the morbid affection originated ; but that is all 
 we can do. And now I wish you to see where the 
 difficulty lies. 
 
 We know what are the normal functions of the ner- 
 vous system, and we know much of the relation of its 
 various parts, or organs. We know that, connected 
 with the nervous centres, there are many nerves lead- 
 ing to every part of the body. We know that these 
 nerves are not all adapted to the same office ; but that 
 they perform various offices, quite distinct in their 
 nature. We have nerves of sense, nerves subservient 
 to volition, those through which an irritation in one 
 part causes motion in another, &;c. How do the op- 
 erations take place in these nerves, and how do they 
 differ from each other ? How is the image formed on 
 the retina communicated through the optic nerve to 
 the brain ? Or, how is the fine aroma of a rose con- 
 veyed through the olfactory nerve ? No answer can 
 be given to these questions in the present state of our 
 knowledge. They say, men have, each and all, a 
 right to their opinions, and some one may choose to 
 believe that vibrations are carried through the nerves 
 of sense to the brain. Let him have his opinion, and 
 then beg him to explain why visual objects cannot be 
 discovered through the ear, or sounds through the nose. 
 
48 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 It must be allowed, I think, that there is a specific 
 difference in the action of the nerves connecting the 
 different organs of sense and the brain ; and a further 
 examination of the subject would show that there must 
 also be a difference between nerves of sense and those 
 sent to the muscles, each having specific powers and 
 modes of action, or operation. But we cannot point 
 out what their actions, or operations are in any one of 
 the cases of nervous influence. We do not know how 
 any of the natural, normal, or healthy operations in 
 the nervous system take place. 
 
 If I have succeeded, you are prepared for my corol- 
 lary, which is this : the nervous system may undergo 
 important changes in its functions, the effects of which 
 are perfectly and abundantly manifested, while we 
 cannot ascertain in what those changes consist. If we 
 cannot show the difference in the operations of the 
 olfactory and optic nerves, we cannot expect to dis- 
 cover the difference in the healthy and the morbid 
 operations which occur in the brain and its appendages. 
 You will understand that I refer here to cases where 
 no change of structure is to be discovered in the part 
 affected, and where there is not any morbid change in 
 any other part of the body acting on the diseased brain 
 and nerves. ; 
 
 I am aware of a resource for the explanation of 
 
ON THE NERVOUS SYSTEM AND HEADACHE. 49 
 
 nervous affections among those, who cannot endure to 
 be ignorant of anything, or who will not avow their 
 ignorance. They will resort to the more or less. 
 They will tell you there is too much tone, or strength, 
 in the part, or too little ; or those who would be more 
 definite, will compare the nervous power, calling it a 
 fluid, to the electric power or fluid. These persons 
 will tell you that there is an accumulation of nervous 
 fluid in a particular part in one case, and a deficiency 
 of the same fluid in another. I will not spend words 
 in sifting this and similar explanations, but will say, 
 dogmatically, they come to nothing. 
 
 I arrive at the conclusion that many morbid affec- 
 tions of the nervous system do not admit any explana- 
 tion in the present state of our knowledge ; and that 
 our treatment of the same is, and must be, founded 
 entirely on experience ; I may say, perhaps, a blind 
 experience. 
 
 Let us now proceed to the diseases of the head. 
 Among these we may first consider Headache. 
 This occurs as one of the symptoms in many diseases, 
 where the whole system is involved, such as fevers. 
 But headache, independent of these, is of several kinds. 
 Among these is one commonly known as the Sick- 
 Headache. This affection is various in its degree, 
 and in the frequency of its occurrence. To some 
 5 
 
60 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 persons it is a very sore evil, not onlj from the suffer- 
 ings which belong to it, but because it occupies so 
 large a portion of their time. As it may occur at any 
 moment, such persons are scarcely able to make any 
 engagements without bargaining that they shall be 
 excused if they have the headache. I think I have 
 known some, who have suffered from this disease from 
 one quarter to one third of the time, for several years 
 in succession. I believe that this disease occurs even 
 in early childhood ; more commonly it is not noticed 
 until after the age of puberty. Having once occurred, 
 it often increases in severity and in frequency, to the 
 age of forty or even later. It usually diminishes at, 
 or before, fifty, and ceases before sixty. This disease 
 seems to me to be one of the affections of the brain 
 proper. The prominent symptoms are pain in the 
 head and nausea, to which vomiting is often added ; 
 and the first impression is that it is produced by in- 
 digestion, or what is called a disordered stomach. It 
 very certainly is provoked, in many instances, by 
 errors of diet ; but it is provoked also by other causes, 
 such as the air of a close room, over-labor, or any 
 derangement of the body or mind. The duration of 
 its fits is various. In many persons, coming on in the 
 day, it is relieved by a night's sleep ; but in some it 
 continues two, and even three or four days. It varies as 
 
ON THE NERVOUS SYSTEM AND HEADACHE. 51 
 
 to its intensity : some persons continue their attention 
 to business ; while to others this is almost impossible. 
 Some even must resort to the bed, and remain in dark- 
 ness and silence till the fit is over. It is hardly 
 necessary to describe the paroxysm minutely. In 
 some persons it begins with a blind turn, scotoma. 
 Most usually anorexia^ as well as nausea, attends it. 
 In others, however, the appetite is not entirely de- 
 stroyed ; and these can take a little food, not only 
 without injury, but even with advantage. 
 
 Under so much suffering, the patient calls for relief. 
 Occasionally some advantage is gained at the begin- 
 ning by draughts of warm water, or of weak chamo- 
 mile tea, so as to promote vomiting. Where the 
 nausea is urgent these may be tried ; but ipecacuanha 
 and other emetic drugs should be avoided. Even 
 when they give temporary relief, they are ultimately 
 injurious to the stomach. This is not manifest in a 
 single instance, but becomes very much so when the 
 emetic is frequently repeated. In those persons in 
 whom the paroxysm is usually long, if constipation of 
 the bowels exists, some laxative may be employed with 
 advantage. Aloes is among the best articles for this 
 purpose, unless forbidden by the existence of haemor- 
 rhoids, or by other reasons Sometimes strong coffeo 
 will afford relief. Some persons employ opium ; and, 
 
52 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 as they think, with benefit. But, when the paroxysms 
 are frequent, much evil may be produced by this article. 
 In these later days ether by inhalation has been tried 
 with occasional relief; but I have not had opportuni- 
 ties for testing this fully. 
 
 In a large proportion of cases active treatment may 
 be omitted, as the disease soon subsides of itself; but 
 in all cases the means of prevention must be studied. 
 To this end, we must endeavor to discover the exciting 
 causes of the paroxysm. These may be sought first in 
 the food which is taken. The gross errors of diet are 
 readily discovered ; but in some persons the headache 
 is occasioned by articles which may commonly be 
 taken with impunity. A peculiar instance of this 
 sort came under my notice many years since. A 
 gentleman of a philosophical mind, and who was 
 moderate in all things, sufiered much from sick-head- 
 ache. He kept notes of its occurrence, and for some 
 time before the period to which I am to refer, he was 
 attacked by it about once in a fortnight. Being called 
 away from home, he made his dinner at a country 
 tavern on bread and cheese. This was followed by a 
 Y6ry severe headache. He now suspected the cheese 
 to have caused the disease, though previously he had 
 felt confident that this article always agreed with him, 
 and he used it often. He abstained from cheese, and 
 
ON THE NERVOUS SYSTEM AND HEADACHE, 53 
 
 had no recurrence of the headache for eighteen 
 months, when it took place after eating a mince pie. 
 I state this instance as showing that every article of 
 diet should be suspected in turn ; and, by experiment, 
 we should ascertain what articles are in fault. But 
 though errors in diet are a very common cause of the 
 paroxysm, they are not the essential cause ; at least, I 
 believe so. In some persons, willing to make the 
 trials, I have varied the diet in every way, as to quan- 
 tity and quality, and yet the disease has continued. 
 
 In the largest number of cases this disease begins to 
 grow more mild, and the paroxysms less frequent, 
 before the age of fifty. If it continues to a later 
 period, without any alleviation, there is ground to 
 anticipate some more grave disease of the brain. In 
 one instance of this sort there took place an affection 
 of the brain, which terminated in death, in which I 
 thought there was reason to suspect hypertrophy of 
 the brain. The truth of this opinion was not tested 
 after death, as the patient was at a distance from me. 
 In another case hemiplegia occurred. In both in- 
 stances the patients were females, between sixty and 
 seventy years of age. One was married, and had had 
 a large family ; the other was single, and had led a 
 regular life. Both were well formed and naturally 
 vigorous. Of course, I do not pretend to draw a 
 5* 
 
54 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 positive inference from two cases. These are the two 
 strongest cases I have known, but I have seen others, 
 where slighter evidence favored the same conclusion. 
 
 I referred to care of the diet as one mode of pre- 
 vention. But all the hygienic rules should be care- 
 fully regarded by those, who are afflicted with this 
 troublesome disease. What those rules are I may 
 take some other occasion to state. 
 
 There is another headache, affecting only one side, 
 and occurring in paroxysms of a few hours daily, 
 which is called Intermittent Hemicrania. This is 
 the only regular intermittent disease, which is com- 
 mon in this vicinity. In some instances tlie parox- 
 ysms are more severe on the alternate days. It is 
 usually connected with catarrh in the head, and is 
 more frequent when the influenza prevails than at any 
 other time. In a few instances the pain is on both 
 sides of the head, but the great and severe pain is still 
 limited to one side. It has seemed to me, when the 
 pain was on both sides, that it is a general headache, 
 accompanying the intermittent headache, as it might 
 any other disease ; and, in accordance with this, when 
 the violence of the disease abates, the general headache 
 goes off, leaving the hemicrania. I have made this 
 statem.ent, because this pain on both sides may leave 
 a doubt as to the diagnosis. The pain is about the 
 
ON THE NERVOUS SYSTEM AND HEADACHE. 55 
 
 temple, or around the eje, or both ; sometimes ex- 
 tending towards the top of the head. In one instance 
 onlj I have found the pain in the back part of the 
 head, still limited to one side. The paroxysm usually 
 begins before noon, and not unfrequently early in the 
 morning ; but rarely if ever before sunrise. Its dura- 
 tion varies from three hours, to ten and even twelve. 
 The severity of the pain also varies, but in most 
 instances it is very intense, a part of the time at least, 
 so as to entirely interrupt an attention to business ; 
 and it very often drives the patient to his bed, in a 
 dark room. The stoutest and boldest men give up 
 to it. 
 
 The duration of the whole disease is as much as 
 three weeks in all cases, and sometimes much more. 
 I once saw a case which had lasted three months, and 
 which was entirely relieved by treatment in five or 
 six days. I speak less certainly about the ordinary 
 duration, because the cases I have seen have uniformly 
 been treated by medicine, and have terminated in less 
 than three weeks ; even in one week when attended 
 to from the first. 
 
 There are some few persons, in whom I have known 
 this disease to occur repeatedly. These have been 
 persons of strumous or tuberculous constitutions. 
 
 This is one of the very few diseases in which I can 
 
56 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 venture to say that it may certainly be removed by 
 medicine. The treatment is the same as for intermit- 
 tent fever. I have employed the cinchona in the 
 earlier part of my life, and subsequently the sulphate 
 of quinia ; likewise, both formerly and latterly, I have 
 employed the solution of the arsenite of potash. This 
 last I found much more convenient, at least, than any 
 preparation of cinchona, before the introduction of 
 quinia ; and I may say that, were it not for a reluct- 
 ance to use metallic articles, and especially one which 
 has so bad a name, I should employ it in most instances 
 at the present day. Whichever article is employed, 
 it should be given in as large a dose as the patient 
 can conveniently bear. In giving the quinia, I ad- 
 minister it only during the intermission. For an 
 adult, I first order twelve to sixteen grains during 
 this period, and in the next intermission increase the 
 quantity to a scruple, and go on to increase it until 
 the buzzing of the ears, or sense of tension in the head, 
 shows that the dose is sufficient. Subsequently, I 
 keep at as large a dose as can be borne without much 
 inconvenience, until the patient has passed the periods 
 of two paroxysms without any return of the pain. 
 The sulphate is given in divided doses, but as the 
 intermission usually includes the night, and sometimes 
 the night only, it is most convenient to make each 
 
ON THE NERVOUS SYSTEM AND HEADACHE. 57 
 
 dose large. In using the arsenic, I have not found it 
 necessary to regard the period of intermission, but 
 have exhibited it morning and evening, and in very 
 severe cases, if the patient is not delicate, I have given 
 it at noon likewise. Prom five to seven drops of the 
 solution may be given at first, and each dose may be 
 augmented by one drop, until some nausea is pro- 
 duced. Then the dose may be diminished by two 
 drops, and, if this does not occasion nausea, the same 
 may be continued until the patient has been well two 
 days. Each dose of the solution should be diluted by 
 at least one tablespoonful of soft or pure water. 
 
 I have been thus minute as regards the administra- 
 tion of these articles, because I have found that relief 
 has not been obtained by those of my brethren, who 
 have not regarded the rules which I have mentioned. 
 
 There is another headache, which we often meet 
 with, called the Chronic Headache. Probably all 
 the cases which pass under this name are not strictly 
 the same in kind ; but if they would admit of any 
 classification, it is not known to me. The pain in 
 chronic headache is sometimes limited to the forehead, 
 but, I believe, it more frequently extends over the 
 whole or nearly the whole of the head. This pain 
 appears, in some cases, to be constant ; in others, it is 
 seldom absent during a whole day. It may continue 
 
58 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 many weeks, many months, and even many years. 
 It would appear to be very severe in some cases ; yet 
 it does not, ordinarily, oblige the patient to relinquish 
 his employments. This headache is not necessarily 
 attended by any other derangement in the body, nor in 
 the mind. Sometimes it takes away the cheerfulness, 
 or, at least, prevents all gayety ; but this is far from 
 being true in all instances. I have had one patient, 
 who was among our most active business men, who 
 suffered under this complaint for many years, not less, 
 certainly, than twenty. During this time, he em- 
 ployed the remedies, which I directed, both medicinal 
 and hygienic, without benefit. He went abroad, and 
 obtained the best medical aid he could find in London ; 
 and he consulted likewise more than one medical man 
 among ourselves. By the advice of one English 
 physician, he kept a seton in his neck for several 
 months ; but neither this nor any other treatment 
 afforded him any relief In this instance, as in 
 many others, attended by obscurity, each physician 
 was ready to suspect the existence of his own pet 
 *nalady. Accordingly, one thought he was bilious, 
 another that he was simply dyspeptic, another that he 
 needed tonics, and anotlier that there was some low 
 inflammation within the cranium, or at least a deter- 
 mination of blood to the head. Ought not a case of 
 
ON THE NERVOUS SYSTEM AND HEADACHE. 69 
 
 this sort to be considered as an affection purelj 
 nervous, according to the principles suggested in the 
 beginning of this letter ? 
 
 In every case of chronic headache it is certainly 
 proper to examine closely and repeatedly all the func- 
 tions of the body, and the state of mind, to ascertain 
 if there is any cause on which the pain depends ; and, 
 if so, whether this cause can be removed. There is 
 one set of cases, in which the pain in the head obvi- 
 ously depends on an affection of another part of the 
 system. I refer to the cases, not very rare, where it 
 occurs in children, during the period of their second 
 dentition. Of this more hereafter. I believe that some 
 derangements of the uterus, or ovaries, may give rise 
 to this headache in females. It is among the concom- 
 itants of pregnancy in rare instances. I had one 
 patient who recognized this affection as the evidence 
 of pregnancy, just as most women do the occurrence 
 of nausea and vomiting in the morning. 
 
 In regard to the treatment, I have very little to 
 say. If the disease can be traced up to an affection 
 of the digestive organs, or of any other part of the 
 system, the appropriate remedies will suggest them- 
 selves. Otherwise, I can advise nothing better than 
 a tranquil, though not an idle life ; simple but nutri- 
 tious food, exercise in the open air, as freely as it can 
 
60 ON THE NERVOUS SYSTEM AND HEADACHE. 
 
 be bornGj and a due regard to all the other hygienic 
 rules. 
 
 There are other headaches, besides those I have 
 enumerated, but none on which I have any special 
 remark to offer 
 
LETTER IV. 
 
 ON EPILEPSY AND THE CONVULSION-FITS OF YOUNG 
 CHILDREN. 
 
 Next among the diseases which we refer to the 
 head, I have something to oiSer upon epilepsy. This, 
 you know, is a disease which occurs in fits, or parox- 
 ysms ; and these take place after very short warnings, 
 or without any, so that often the patient falls down 
 suddenly. Hence these are CQWed falling Jits. The 
 essential symptoms are loss of consciousness, and 
 spasms more or less severe and extensive. Most fre- 
 quently, if not always, the head is drawn to one side 
 with a twitching motion ; a circumstance on which Dr. 
 Marshall Hall lays great stress. Biting the tongue, 
 and frothing at the mouth, often colored with blood, 
 are common attendants. The duration of the parox- 
 ysm varies, from a few mmutes to several hours. It 
 does not, however, often exceed half an hour, except 
 in the variety called apoplectic. When the spasms 
 cease, and the consciousness is restored, the patient 
 6 
 
62 ON EPILEPSY AND CONVULSION-FITS. 
 
 does not at once recover the full use of his mind, but 
 commonly falls into a heavy sleep, from which he 
 awakes with a stupid headache. Then, in a few 
 hours, or at most after a day, jou will find him quite 
 restored to his ordinary state. In bad cases the intel- 
 lectual powers are gradually lost, and especially the 
 memory. Sometimes a child, affected, for instance, 
 at six years of age, continues to grow in body, and 
 becomes a man in appearance, while his mind has 
 made scarcely any advance. The loss of memory 
 
 was most remarkable in Mr. P , who belonged to 
 
 a family distinguished for their intellectual powers. 
 He had this disease for many years without any 
 marked change in his mind, except only as to mem- 
 ory. About the time when the first Napoleon became 
 Emperor of France, some reference was made to him ; 
 
 upon which Mr. P inquired who he was. His 
 
 friend stated to him briefly the history of Bonaparte, 
 in such language as most men would have used at 
 that day respecting one who seemed to aim at uni- 
 versal empire. Mr. P then said he jsould not 
 
 believe that story ; that no man could be so bad. At 
 this time Mr. P must have been hearing of Bona- 
 parte every day for several years. 
 
 Besides the paroxysms which I have briefly de- 
 scribed, many persons, subject to this disease, have 
 
ON EPILEPSY AND CONVULSION-FITS. 63 
 
 very slight affections, which are called faint turnSj 
 or by other names. In some of them you see very 
 little, if any, change of the countenance. In others, 
 the face turns pale, and then becomes very red, and 
 the whole is over in a minute or less. The shortness 
 of the duration of these turns ^ in some persons, is 
 very remarkable. I had one patient, who experienced 
 them very often, when walking, or when engaged in 
 conversation, while those around him discovered no 
 change in his appearance. The patient described them 
 as consisting of a stoppage of all action of the mind, 
 analogous to stoppage of light to the eye by bringing 
 a dense body momentarily before it. 
 
 I believe that no patient has recovered from the 
 epilepsy, in whom I have seen it associated with these 
 slight turns. 
 
 A more grave affection connected with epileptic 
 paroxysms is insanity. In asylums for the msane 
 you will usually find instances of this kind. 
 
 I referred to apoplectic epilepsy^ which has been 
 described by Dr. Marshall Hall. It resembles apo- 
 plexy in its general characters, though the fit is accom- 
 panied by more spasms than usually attend apoplexy. 
 But this last is ordinarily, if not always, attended or 
 followed by some paralytic affection. This is not true 
 of apoplectic epilepsy. Besides, this affection returns 
 
64 ON EPILEPSY AND CONVULSION-FITS. 
 
 again and again, though much less frequently than 
 the common epilepsy. I had noticed this kind of 
 epilepsy before reading Dr. Hall's work, and have a 
 recollection of four well-marked instances of it. In 
 three of them I believe every paroxysm was of the 
 apoplectic character. In one, the first paroxysm was 
 of this character, and the last ; but, between these, 
 epilepsy appeared in its common form. In each of 
 these instances the patient died apoplectic, but not till 
 after several years from the first attack. There was 
 not in either case a post-friortem examination. 
 
 Since I have been engaged in writing these letters, 
 I have seen, in consultation, a patient, who has been 
 subject a year or more to the apoplectic epilepsy. I 
 mention his case because I find that he is occasionally 
 afiected by the slighter attacks, which I have described 
 under the name of faint turns. It is the only in- 
 stance in which I have known these to occur in con- 
 nection with the apoplectic epilepsy. 
 
 Epilepsy is spoken of as if it often terminated 
 fatally. It undoubtedly shortens life in most, if not 
 in all instances ; but I have rarely seen life terminated 
 directly by this disease. Epileptic patients will have 
 many successive paroxysms, and die shortly after- 
 wards ; that is, within a few days, or a week or two. 
 But, I believe, in these cases, there is some other dis- 
 
ON EPILEPSY AND CONVULSION-FITS. 65 
 
 ease, which is ushered in by the epileptic attacks. 
 Here the epileptic paroxysms take the place of chills, 
 which are the common precursors of acute diseases. 
 The symptoms of the acute diseases in such cases are 
 usually masked by epilepsy. I wish not to speak too 
 confidently on this point ; but this is the opinion to 
 which my own experience has led me. 
 
 The proximate cause of epilepsy certainly exists in 
 the nervous system, the brain and medulla spinalis. 
 The nature of this affection of the nervous system is 
 unknown, and not such as necessarily to leave any 
 organic changes manifest after death. I must refer 
 here to my remarks on diseases of the nervous system, 
 in the last letter. Organic changes have been found 
 in the brain after epilepsy; but they have been 
 various in their seat, if not in their nature, and must, 
 I think, be regarded as coincidents, and not as proxi- 
 mate causes of the disease. I do not mean, however, 
 .that they have had no connection with the peculiar 
 affection belonging to epilepsy, in the instances in 
 which they have occurred. I am aware that at the 
 present day pathologists are disposed to believe that 
 some morbid state of the blood may be regarded as an 
 irritant, operating on the nervous system, to produce 
 this disease. I would not neglect inquiries connected 
 with this view, but we must be very cautious not to 
 6* 
 
66 ON EPILEPSY AND CONVULSION-FITS. 
 
 follow the practice of the old humoralists in imagining 
 a change of this nature as the cause of every obscure 
 disease. 
 
 The exciting causes of epilepsy are better known 
 than the proximate cause ; yet we cannot, in every 
 instance, satisfy ourselves as to those. It would seem 
 that any cause, disturbing the body or the mind, in 
 an epileptic subject, may give rise to a paroxysm. 
 Errors of diet are among the causes most commonly 
 noted ; great fatigue is also among the causes. In a 
 young girl, in whom, perhaps, the disease partook of 
 the hysteric character, paroxysms followed the occur- 
 rences which I will mention. When she was at a 
 party with her little friends, where her spirits were 
 much excited, and at the same time her food was less 
 simple than common, the paroxysm was apt to occur. 
 General Jackson, when president, made a visit to 
 this part of the country, and she went, with others, to 
 see the procession, as he passed through her town ; a 
 paroxysm followed. So did another upon seeing the 
 '• Conflagration of Moscow," an exhibition well known 
 at the period of her youth. Again, she had a parox- 
 ysm on going into a crowd in a church, where an 
 ordination was taking place. These were among the 
 occasions which I call to mind ; and from them you 
 see the variety in the exciting causes of this disease. 
 
ON EPILEPSY AND CONVULSION-FITS. 67 
 
 A fright has been repeatedly noticed as occasioning a 
 paroxysm. I remember one instance, of a ladj, past 
 middle life, whose health had been good until a sudden 
 fright occurred, which was followed by epilepsy. 
 From this time the disease continued. I saw her 
 many years afterwards, and then the powers of the 
 mind were much impaired, although not lost. 
 
 I believe that, in a certain proportion of the cases 
 of epilepsy, the disease is susceptible of relief, so as 
 not to return without the operation of some powerful 
 cause. This relief is not to be attained by any medi- 
 cine with which I am acquainted, but by diet. The 
 diet, which I have directed with success, has been 
 almost purely vegetable. I have directed an entire 
 abstinence from flesh and fish, but have allowed the 
 use of milk and butter, and occasionally of eggs. I 
 have thought it necessary to use these last watchfully; 
 that is, in moderate quantity, mixed with farinaceous 
 substances, as in puddings, and at those times only 
 when the health was at the best. I was led into the 
 use of this diet gradually; I hardly remember by 
 what steps. Under the use of it I have seen many 
 recoveries ; yet, in the larger proportion of cases, it 
 I'las failed. But to this I must add, that I have not 
 known an instance where the patient has ultimately 
 recovered after trying this diet without success. Now, 
 
68 ON EPILEPSY AND CONVULSION-FITS. 
 
 cf the cases in which it has failed, probably every one 
 employed various remedies, not only under my direc- 
 tion, but under that of others, and those, skilful physi- 
 cians. Every medical man knows that in this dreadful 
 disease, when long continued, the patient or his friends 
 resort to every one who holds out a prospect of relief, 
 whether he be a regular or an irre'gular practitioner. 
 
 It is proper to add that, when directing this diet, 
 I have also directed that every possible precaution 
 should be taken to guard against fright. Or agitation of 
 mind, of any kind ; against over-fatigue, excessive in- 
 dulgence in food, and all other exciting causes. I will 
 give one instance, in reference to this point, among 
 several which I have known. A gentleman brought 
 me his son, a boy of about twelve years of age, whose 
 health was good in other points^ but in whom epilepsy 
 occurred under its most certain characters. This was 
 in February. The gentleman lived in the country, 
 and I did not see him till the next September. He 
 then told me that his son had had only one attack ; and 
 that in August, after an excessive indulgence in green 
 apples. The apples w^ere subsequently thrown off. 
 This was nearly twenty years ago, and the patient has 
 never had another attack. 
 
 In cases of apoplectic epilepsy I have not had an 
 opportunity of trying the diet above described. In 
 
ON EPILEPSY AND CONVULSION-FITS. 69 
 
 one I believe it was tried, but I am not sure how 
 fully. 1 should think it worthy a trial in such cases, 
 but I should not direct it with much confidence of suc- 
 cess. In suchj as in all the other cases, a careful 
 attention to hygienic rules would probably be of some 
 benefit. 
 
 The convulsive Jits of children bear a great analogy 
 to those of epilepsy. I cannot point out any certain 
 signs by which they may be distinguished from epi- 
 lepsy, yet they do not seem to be quite the same. In 
 most instances they are not repeated ; yet in some 
 cases they are repeated often. They do not ordinarily 
 continue after seven years of age. If they should so 
 continue, I think the fits would be called epileptic. 
 As in epilepsy, the main symptoms are spasms and a 
 loss of consciousness. These fits are hereditary in 
 some instances. They begin in the early periods of 
 infancy. As in epilepsy, a paroxysm may be induced 
 by various exciting causes. The fits occur during the 
 period of dentition, and are sometimes evidently connected 
 with a tooth pressing on the gums. Errors of diet are 
 a common cause, and, when the powers of digestion are 
 impaired, very slight errors are sufiicient. These fits 
 occur like chills, as the heralds of acute disease. 
 Thus, in a boy who had been affected during dentition, 
 subsequently, a fit ushered in a pneumonia. After 
 
70 ON EPILEPSY AND CONVULSION-FITS. 
 
 this, I vaccinated the child, and then said to the 
 mother, that it would not surprise me if a fit should 
 occur at the time of the constitutional affection from 
 the vaccination. On the eighth day from the vaccina- 
 tion the fit did occur. In one family, now living, three 
 children have been the subjects of these fits. They 
 have occurred under the variety of circumstances above 
 described. In one winter each in succession had 
 bronchitis, and, a few weeks afterwards, each had 
 scarlatina. At the commencement of each of these 
 diseases the fits occurred in every one. I one day 
 said to the mother, I suspect that you or your husband 
 may have had this disease in your childhood. She 
 replied, " We both had it." 
 
 These fits cause great alarm to the parents and 
 attendants, and violent remedies are expected. It is 
 important to understand that they are not always 
 needed. If the stomach be full when they occur, or 
 if any extra food has been taken, or if there be nausea 
 and retching, it is well to administer an emetic. If 
 there is costiveness, an injection into the bowels may 
 be the first remedy. A warm bath should be used 
 early, as it is a safe remedy, and often beneficial. If 
 the fit is violent, or is frequently repeated, and the 
 emetic is not specially indicated, an active cathartic 
 may be given. I think this will commonly be found 
 
ON EPILEPSY AND CONVULSION-EITS. 7l 
 
 useful ; for, even if the alimentary canal be in good 
 order, and some acute disease is to ensue, this remedy 
 will probably be beneficial. Where the fits continue 
 in a vigorous child, where the pulse is firm, more 
 especially if the face be flushed, and the head hot, one 
 or two leeches may be used with advantage. In 
 obstinate cases, chloroform is said to have been useful. 
 This I have never tried, and I should be slow to do 
 so. If employed at all, it should be with extreme 
 caution. A few drops may be sprinkled on a hand- 
 kerchief, and this may be held near the nose. 
 
 It is quite important that the parents of children 
 subject to this affection should be apprised that violent 
 remedies are not always to be employed. It is not 
 wonderful that the parents are alarmed in such cases ; 
 but the real hazard is very slight. It is true that 
 death sometimes follows these fits, and even speedily ; 
 but I presume that this always happens, not from the 
 fits, any more than it would from chills, but from the 
 disease on which the fits are attendants. In such 
 cases the real disease is masked. 
 
 Children subject to these fits should be guarded 
 against all the exciting causes. But for this purpose 
 they should not be kept in a nursery, but should be 
 invigorated by exercise in the open air, and be inured, 
 as far as possible, to the irritations necessarily attend- 
 
72 ON EPILEPSY AND CONVULSION-FITS. 
 
 ant on life, though protected from all extraordinary 
 causes of excitement. Simplicity and regularity in 
 diet should be rigorously enforced. The hours for 
 sleep should be regular, and they should go to their 
 sleep in a calm state, so far as it is possible to 
 eflfect it. 
 
 Convulsion-fits often occur in the disease commonly 
 known under the name of acute Hydrocephalus. 
 Hence, when these fits occur and continue with 
 severity, that disease is apprehended. I believe, how- 
 ever, that when the fits occur in one previously in 
 apparent health, and prove severe, the hydrocephalus 
 rarely follows. 
 
 I wish also to say, in this connection, that hydroceph- 
 alus is supposed to be present in some cases where the 
 real disease is typhoid fever; for this fever is not 
 readily distinguished in children, especially when 
 there is great stupor. Yet a careful examination of 
 the whole history will usually remove all doubt. In 
 such instances, when a child recovers, undue credit is 
 given to the remedies employed. The evil of this 
 error is that the same remedies are inflicted upon other 
 children without benefit. I relieve my conscience in 
 stating this. Early in life I thought I had saved some 
 children under hydrocephalus by shaving the head and 
 keeping it blistered. In one instance I kept the blister 
 
ON EPILEPSY AND CONVULSION-FITS. 73 
 
 Open for many days, and rejoiced in the final success 
 of the remedy. More enlarged experience satisfied 
 me that in this, and other such cases, the real disease 
 was typhoid fever. Further than this I have not any 
 remark to make on this hydrocephalus, the real nature 
 of which is' much betl«ir uadtjrirtood now than in the 
 early part of this century. 
 7 
 
LETTEB. V. 
 
 ON APOPLEXY AND PALSY. 
 
 I HAVE a little to say about apoplexy, into the 
 description of which I shall not enter. It is to the 
 treatment I wish especially to call your attention. 
 This disease is very commonly spoken of as belonging 
 to old age, and as occurring mostly in persons of full 
 habit, with large heads and short necks. But it is 
 also seen, and not very rarely, in middle age, or even 
 earlier ; also it occurs in persons of a spare habit, 
 without the large head and short neck. When apo- 
 plexy does not prove fatal, it is usually, if not always, 
 followed by palsy. Palsy occurs, indeed, without 
 being preceded by apoplexy. In many instances 
 there is a very slight shock, in which the patient loses 
 his consciousness momentarily, or in which he may be 
 said to be confounded for a moment ; and then there 
 will follow a numbness, or loss of sensibility, and 
 more or less diminution of the power of voluntary 
 motion. These last are the si§;ns of palsy, and they 
 
OF APOPLEXY AND PALSY. 75 
 
 may be increased to any degree, rapidly or slowly, 
 until, perhaps, there is an entire loss of sensibility, 
 and of the command over the voluntary muscles. 
 Palsy following apoplexy is almost invariably limited 
 to one side of the body. It is common to find persons 
 in middle life, sometimes under forty, sometimes past 
 fifty, in whom one of the slight shocks, which have 
 been described, is followed by slight palsy, and that 
 not very lasting, sometimes not continuing more than 
 one or two days. The patient suddenly falls down, 
 perhaps, and it is thought he may be faint only. He 
 soon rises, and does not, on the first attack, always 
 show any palsy. More frequently, one of the extrem- 
 ities is affected, or the muscles of the face, or the 
 organs of speech. These attacks may occur at various 
 intervals, of from a few months to two or three years, 
 and at last prove fatal ; the palsy having become more 
 severe, perhaps, after each apoplectic attack. I call 
 these slight attacks apoplectic, because there is usually 
 a momentary abolition of sense, if not of motion : and 
 principally because I have reason to believe that they 
 have for theii* immediate cause an effusion of blood, 
 though a very small one, within the cranium. 
 
 I have given this brief description of a certain class 
 of cases, because I consider them more susceptible of 
 relief than other cases of apoplexy and palsy. If 
 
76 ON APOPLEXY AND PALSY. 
 
 the subject of these attacks is of a constitution to bear 
 it, and especially if the symptoms be rather more 
 severe than I have described, or if they should not be 
 lessening within twenty-four hours, venesection is 
 proper. But, in these cases, there is not so much risk 
 at the moment, as there is of their recurrence at sub- 
 sequent periods. Hence, the great object in the 
 treatment is the prevention of subsequent attacks* 
 I should have made my remarks on apoplexy and 
 palsy before those on epilepsy, had I not wished to 
 state first the results of my experience of a vegetable 
 diet in this latter disease. Influenced by my experi- 
 ence in this, I have been led to the same treatment in 
 cases such as I have described above. Besides advising 
 moderation in all things, I have directed the diet just 
 mentioned to be continued indefinitely. If one says 
 to a man in middle life that he should never eat meat 
 any more, he may rebel. He will think that this rule 
 calls for more self-denial than it really does. It is 
 enough to suggest abstinence for the present, and at 
 the end of several months, or pretty certainly in a 
 year, most men become more indifferent on this subject 
 than they had anticipated. So far from losing muscu- 
 lar power, a man under this treatment may get to 
 endure long-continued labor, and to make as great 
 exertions as prudence would permit. The exercise m 
 
ON APOPLEXY AND PALSY. 77 
 
 important, and should be a part of his treatment ; but 
 he should never permit himself to make violent 
 efforts. He should also be enjoined, as far as possible, 
 to abstain from anger and anxiety. And, further, when 
 I advise abstinence from animal food for an indefinite 
 period, I do not mean to say that this abstinence 
 should continue for life. I know not what length 
 should be fixed upon ; but this appears to me reason- 
 able, that the patient should not return to the use of 
 animal food so long as he has very good health without 
 it. Whenever it appears that he suffers for want of 
 such food, let him cautiously resume the use of it. 
 
 Take a brief statement of two cases, in which this 
 treatment was adopted; in both of which there had 
 been more than one attack within twelve or eighteen 
 months before a strict compliance with the diet pro- 
 posed. One gentleman had two attacks, so slight 
 that their nature was not certainly known. In twelve 
 or eighteen months from the first he had a third. In 
 this the paralytic symptoms were unequivocal, and 
 continued so for a few days. The right hand and the 
 speech were principally affected. He did not entirely 
 recover the use of his hand ; and the failure in speech, 
 though very slight, continued for a long time, perhaps 
 to the present day. The last attack occurred more 
 than five years since ; but, under the treatment above 
 7* 
 
78 ON APOPLEXY AND PALSY. 
 
 described, there has been no recurrence of the disease 
 if we except once only, when there was a ver^ 
 transient feeling, reminding him of the former attacks. 
 The other instance was that of a medical friend 
 whom I valued very highly. His first attack occurred 
 in April, 1845, after a period of intense professional 
 labor, and the day after making a difficult and tiresome 
 dissection. The left side was paralyzed, not very 
 strongly ; his intellect was not afiected in any way. 
 He was bled at this time, and at my suggestion he 
 adopted the diet which I have mentioned. At the end 
 of three months he felt perfectly well, and relinquished 
 the diet. In March of the following year he had a 
 second attack of paralysis, in which the right side 
 and also the muscles of speech and deglutition were 
 afiected. He was very soon well enough in this, as 
 in the jjreceding year, to return to his business ; but 
 the recovery was not so complete. His speech was 
 very slightly embarrassed, and the motions of his right 
 hand were not quite perfect for two or three years. 
 Immediately after this attack he began the vegetable 
 diet anew, and continued it until his death. This 
 took place from accident in the year 1853. The 
 recovery progressed regularly soon after the second 
 attack, and during the last four years of his life hia 
 health and vigor were as good as they had ever been. 
 
ON APOPLEXY AND PALSY. 79 
 
 * 
 
 I hope that you will not understand me tc say that 
 ihis treatment will always be successful. But I feel 
 assured, first, that it is safe. Therein it differs from 
 any active medical treatment; and I say, moreover, 
 that it offers a better chance for permanent relief and 
 a restoration to useful health, than any other mode of 
 treatment with which I am acquainted. 
 
 I must make a few remarks on the facial paralysis , 
 the full history and explanation of which would be 
 enough to immortalize Sir Charles Bell, if he had 
 done nothing more. You are aware that this disease is 
 traced to an interruption of the nervous influence in the 
 facial nerve. First, I will remark that it is often pre- 
 ceded or accompanied by a pain in the ear ; and once I 
 saw it preceded by hemicrania for two or three days. In 
 such cases, as soon as the paralysis shows itself with 
 its peculiar character, the nature of the disease must 
 be obvious. When there is pain in the ear, it is 
 advisable to commence the treatment with a good 
 leeching, or cupping. I say this pointedly, because 
 in such cases there is hazard that the whole auditory 
 nerve may be involved in an inflammation. Should 
 this happen, deafness may follow, as well as a paraly- 
 sis of the face. But in most cases of the disease, 1 
 believe a recovery would be spontaneous, without 
 treatment. Yet, if the patient is in good vigor, it 
 
80 ON APOPLEXY AND PALSY. 
 
 will be well to use leeches and a blister behind the 
 ear. 
 
 I have mentioned this disease mostly to introduce 
 two cases. A physician once called on me with a 
 facial paralysis. He was of a full habit, and his face 
 was always very red, though a tee-totaller. His 
 father had died of apoplexy, and he had had a brother 
 and a sister affected with hemiplegia. It is not 
 strange that this patient believed himself to be threat- 
 ened with this family disease. In truth, he was not 
 acquainted with the characteristics of this variety 
 of palsy. He was desponding. I could not deny 
 that, in his case, any symptom of paralysis was a 
 proper cause for alarm ; but, on the strictest exami- 
 nation, I could not discover any affection of the 
 mind, nor diminution of the sensibility in any part of 
 the body ; and the palsy on one side of the face showed 
 itself only when the muscles of the face were called 
 into action, and in the inability to close the eyelids. 
 This in some measure was a test case ; a test as to the 
 confidence with which the diagnosis and prognosis 
 might be declared. I ventured to assure the patient 
 of his safety, and that he would probably recover in a 
 short time. He could hardly place faith in me, but 
 the result was entirely favorable ; and now, at the end 
 of twenty years, he is in good health. This case 
 
ON APOPLEXY AND PALSY. 81 
 
 shows that we may place great reliance on the peculiar 
 symptoms of this kind of palsy ; and that it is quite a 
 different affection, as regards its seat, from the palsy 
 following apoplexy. 
 
 I shall state another case, to show that it is not 
 always safe to promise a recovery from this disease. 
 I have seen more than once instance in which the 
 disease proved lasting. In the one I refer to, the 
 disease had existed for many months before I saw it. 
 The palsy had diminished, but had not disappeared. 
 There was frequent pain in the head, and occasionally 
 this became severe. Yet in most respects the health 
 was very good. It appeared that, at some time not 
 long preceding the paralysis, the patient had received 
 a violent blow on the forehead. Under these cir- 
 cumstances, I apprehended some organic change 
 within the cranium. The patient was benefited by a 
 vegetable diet. While he pursued this, and restrained 
 himself to a very moderate quantity of food, every- 
 thing did well, except only the remnant of the paraly- 
 sis. He was convinced of the benefit of this course, 
 but he declared to me that his hunger was so great 
 that he could not endure the abstinence. At length, 
 after a new indulgence, stupor came on, and under 
 this he died in three or four days. On examination, 
 there was found a tumor in the anterior lobe of th© 
 
82 ON APOPLEXY AND PALSY. 
 
 cerebrum, on the side aifected. Here there was a 
 complication, manifested by the severe pain in the 
 head, at intervals, and by the undue prolongation of 
 the palsy. 
 
 There is a palsy produced by lead. In some cases 
 I have found it is sufficient that the patient should 
 no longer use the water, or meddle with any other 
 material, in which lead was contained. I deem it 
 important to state this, as showing that active and 
 powerful treatment need not be adopted in mild cases. 
 But, in cases where the paralytic symptoms are 
 strong, I feel no doubt of the advantages which may 
 be obtained from the use of strychnine. On this sub- 
 ject I will refer you to a report drawn up by my 
 friend. Dr. Horatio Adams, of Waltham, and pub- 
 lished in the fifth volume of the Transactions of the 
 American Medical Association. I will here add, in 
 respect to all cases of disease produced by lead, that I 
 believe the hydriodate of potass may be used with 
 decided benefit. See, on this subject, the British and 
 Foreign Medico-Chirurgical Review, Nos. 21 and 22, 
 for January and April, 1853. 
 
 Before leaving this subject of palsy, I wish to refer 
 to an affection, which, I think, may be called mimotica, 
 or mimicking palsy. Patients now and then present 
 themselves having symptoms resembling those of 
 
ON APOPLEXY AND PALSY. 83 
 
 paralysis, and exciting their apprehensions therefore. 
 Such persons do not, ordinarily, manifest any agita* 
 tion of mind ; on the contrary, they preserve a calm 
 demeanor. At first view, one must partake of these 
 apprehensions, which, however, will commonly be re- 
 moved in a few days, if not on the first examination. 
 First of all, the symptoms are what are called sub- 
 jective, and not objective. There is a numbness in 
 various parts, shifting from place to place, and seen 
 manifesting itself in many parts at the same time. 
 This is attended with a feeling of stiffness in the 
 fingers, or elsewhere. The patient will move his 
 fingers very well, so far as you see ; but he feels a 
 difficulty in doing it. Sometimes there is also a pain 
 in the course of the spine, or some unusual feeling 
 about the head. These symptoms do not come on 
 suddenly, as from a stroke on the head ; on the con- 
 trary, they crawl on gradually, and the patient cannot 
 well tell when they began. There is likewise a want 
 of steadiness in the symptoms ; they consist in the 
 feelings of the patient, and those feelings are shadowy. 
 The patient speaks on the subject with calmness ; but 
 usually there may be discovered a dejection of spirits, 
 and an anxiety. If these can be removed, the symp- 
 toms are alleviated. Yet it is not to be understood 
 that the feelings are imaginary; they really exist. 
 
84 ON APOPLEXY AND PALSY. 
 
 The important thing in the case is that the physician 
 should feel assured as to his diagnosis. To do this, he ^ 
 must make a careful inquiry, and it is better that he 
 should not hurry to a decision. Then, if he does de- 
 cide that the case comes under the above description, 
 the patient will place confidence in his decision, and 
 be encouraged by it. I once had a case where the 
 father of the patient had had apoplexy, followed by 
 hemiplegia. Of course, I felt some doubt in this 
 instance ; but, after examining the patient twice with 
 great care, I became decided in my opinion ; and, by 
 communicating my confidence to the patient, his mind 
 was soon relieved. This occurred several years since, 
 and the patient is now in very good health. In this 
 instance the patient had been exhausted by labor and 
 anxiety ; labor of mind,, and not of body, and without 
 due exercise abroad. The same is true in most in- 
 stances ; or, if not just so, there has been some cause 
 operating to exhaust the powers, and usually such as 
 to waste the flesh before the attack. Relief is to be 
 found by rest from mental labor, relief from anxiety, 
 amusement, change of place, as in travelling, tonics 
 and stimulants. It is one of the affections of the 
 nervous system in which wine affords great relief. 
 It is only necessary that the use of it should be regu- 
 lated with discretion. 
 
LETTER YI. • 
 
 ON CHOREA, NEURALGIA AND PAIN. 
 
 Chorea is one of the nervous diseases. I shall not 
 describe it ; but I have something to offer upon its 
 treatment. In a nosological system this would have 
 been brought into connection with epilepsy. This dis- 
 ease usually occurs in young persons ; and, with rare 
 exceptions, terminates spontaneously in from two to 
 four months. . It often occurs during the period of the 
 second dentition, and sometimes shows itself the second 
 or third time, at about the same season of the year. 
 It is said to be chronic in some instances, and I have 
 seen cases which were so regarded. But I feel as- 
 sured that they were different in their nature. In the 
 treatment of it various tonics are employed with suc- 
 cess. Iron, especially the carbonate of iron, in large 
 doses, also the shower-bath, have removed the disease 
 in a very short time. I have seen the valerianate of 
 zinc useful, where other remedies failed, and w^here 
 the patient could not take the oil of turpentine. This, 
 8 
 
86 ON CHOREA, NEURALGIA AND PAIN. 
 
 "was in a young lady past eighteen. But the great 
 remedy is the oil of turpentine. As it is not an 
 agreeable one, if the case be mild, other remedies may 
 be tried first. In a severe case, however, or where 
 other remedies fail, this should be used. -The oil 
 should be given in such doses as the patient can bear. 
 In a very young child you may begin with five drops 
 three times a day ; but the dose should be increased 
 steadily until relief is obtained, if no objection occurs 
 The objections are, first, nausea; but this is not com- 
 mon ; second, too great an operation on the bowels ; 
 and third, and chiefly, irritation of the urinary organs. 
 If employed too freely, it will produce bloody urine 
 and great distress. If the attendants are aware of 
 these difficulties, and watch for them, no serious incon- 
 venience need ensue. A child of eight or ten years 
 of age will sometimes bear a teaspoonful for a dose. 
 This remedy is successful, whether given early or late 
 in the disease. 
 
 I will only add, that I never saw an instance in 
 which chorea proved fatal, except once. The patient 
 was, I think, twenty years of. age, and in full health 
 previous to the occurrence of the disease. The spas- 
 modic afiection was very severe and very constant. I 
 saw her only a day or two before her death, under the 
 care of a judicious and learned physician, in whose 
 
NEURALGIA AND PAIN. 87 
 
 treatment of the case I saw no fault. Unfortunately, 
 no autopsy was permitted. 
 
 At the present day we hear much of a disease 
 called Neuralgia. This name is applied to any case 
 of severe pain which cannot be traced to inflammation, 
 nor to any organic affection. I have sometimes ven- 
 tured to laugh on this subject, saying that the patient 
 informs the physician that she is frequently troubled 
 with a severe pain, without any other symptom of dis- 
 ease ; and she asks what is its nature, and what is its 
 cause. She says it is pain, in plain English, and he 
 answers her in Greek, that it is a neuralgia. It is, no 
 doubt, a satisfaction to her to know that her disease 
 has a distinct name. I rather prefer, however, to 
 reply that it is a pain, and that that is all we know 
 about it. I say this the more because there is an 
 affection properly named neuralgia. Sauvages, the 
 father of nosology, admitted in his system an order 
 named Dolores. That was not plain English, but it 
 was plain Latin, and gave a name to the diseases 
 which consist in pain only ; or in pain only, so far as 
 we know. Now we know that, when pain exists any- 
 where, as we know with regard to every sensation, 
 it is transmitted through the nerves to the brain 
 and to the mind ; but we do not say that the nerve 
 is diseased, or that the disease is situated in the nerve 
 
88 
 
 m every, case where pain occurs. But there is a dis- 
 ease where the pain appertains to the nerves them- 
 selves^ and this is shown by its limitation to the 
 ramifications of some one nerve, or branch of a nerve. 
 Thus, when there is a pain passing from directly 
 below the eye, and spreading over the cheek, no other 
 symptom coexisting, we perceive that this belongs to 
 the infra-orbital branch of the fifth pair of nerves. Or, 
 when a pain is passing in the neighborhood of the 
 great trochanter, following the course of the great 
 sciatic nerve, and dividing as that nerve branches upon 
 the leg, we consider it a disease of that nerve. It is 
 a painful affection, appertaining to the nerve itself; 
 being a disease in the nerve. If we have a pain 
 seated in the epigastrium, limited to a small space, it 
 may, perhaps, be an affection of a nerve in that situa- 
 tion ; but we have no evidence that it is so, and it is 
 an assumption to call it a neuralgia. We do not find 
 it following the ramifications of any large nerve. I 
 do not here wish to quarrel about words, but it ap- 
 pears to me that there is a real distinction between 
 the things themselves, and therefore they should be 
 called by different names. When this is not done, the 
 physician, who has been able to give relief to a severe 
 pain in any part, urges the trial of his remedy in 
 oases of proper neuralgia; but the patient, who 
 
89 
 
 employs the twenty successful remedies recommended 
 by as many different physicians, is wearied, and, per- 
 haps, injured, and the profession is discredited. 
 
 The true neuralgia is very irregular, ceasing for a 
 long while, and then recurring; or at other periods 
 felt every day, and almost every hour ; but the disease 
 is very rarely permanently overcome by remedies. 
 This is not true in regard to other cases of severe pain, 
 where it is pain alone. The disease in these cases is 
 often very obstinate, and resists the influence of power- 
 ful remedies ; but, most commonly, temporary relief 
 can be obtained from narcotics and anaesthetics ; and 
 often permanent relief from quinia and iron. Among 
 the narcotics, opium is, perhaps, the most certain; 
 but its subsequent effects make the use of it very 
 inconvenient, and often very deleterious. If other 
 narcotics can answer the purpose, even less perfectly, 
 they are to be preferred. Of these, the most power- 
 ful which I have employed internally is stramonium. 
 We have a guide in the use of this in its effects upon 
 the vision. When this is impaired the dose must not 
 be increased, nor the medicine repeated, until the 
 blindness has subsided. 
 
 For permanent relief I believe that quinia may be 
 relied upon more than iron. To be effectual the qui- 
 nia should be given in as large doses as the patient 
 8* 
 
90 ON CHOREAj NEURALGIA AND PAIN. 
 
 can bear, as is done when it is given for intermittent 
 fever. It does not appear that the benefit depends 
 upon the tonic power of the quinia. The good effect 
 of this article in arresting the progress of intermittent 
 fever is not in proportion to any tonic effect. It would 
 seem rather to depend on a power to lessen or remove 
 the susceptibility to disease. Now, I have thought 
 that the quinia acts in the same way in other diseases, 
 even when not intermittent. I shall have occasion, in 
 subsequent letters, to point out instances in which this 
 power is manifested. Probably arsenic operates in the 
 same way. 
 
 Narcotics applied externally have often a good effect 
 in cases of simple pain. Among these I give a pref- 
 erence to aconite. I use the saturated tincture, which 
 is a cheap article compared with any of the alkaloids. 
 Some care is necessary in the use of this article. It 
 should be rubbed on the part in pain, or as near to it 
 as may be. If the nurse who applies it gets any upon 
 her finger, and then touches her eye, great pain ensues, 
 and sometimes the eye becomes inflamed. It is, there- 
 fore, proper to direct that a basin of water be placed 
 close at hand before beginning the application; by 
 this the nurse will be reminded to wash her hand as 
 soon as the rubbing is finished. The trial of this 
 article is most satisfactory when some stinging or 
 
NEURALGIA AND PAIN. 91 
 
 smarting is experienced during the rubbing. Usu- 
 ally some numbness in the part follows the appli- 
 cation, and occasionally this numbness continues a 
 long time. 
 
LETTER VII. 
 
 ON SOMNAMBULISM, ANIMAL MAGNETISM, AND IN- 
 SANITY. 
 
 As I have formerly said, there are diseases of the 
 nervous system which cannot be explained; for we 
 cannot explain the mode, in which the common, or nor- 
 mal operations of this system take place. At the 
 present day no one would undertake to show what is 
 the difference, as to the state of the brain and nerves, 
 in sleeping and watching ; but thus much, I believe, 
 may be safely asserted, that the whole of the nervous 
 system is not uniformly affected in an equal degree 
 during sleep. Sometimes the senses, the mind, and 
 the muscles of locomotion, all equally sleep ; this is 
 sound and perfect sleep. But, more commonly, sleep 
 does not take place equally in all those parts ; and, 
 especially, the mind is often in an active state while 
 the senses and the muscles sleep. This is called 
 dreaming. Then a man keeps quietly in his bed; 
 and, as dreaming is a common occurrence, it excites 
 
ON SOMNAMBULISM, ETC. 93 
 
 no wonder. But, as it is less common, it excites more 
 attention when you hear of one who frequently rises 
 from his bed in the night and walks about. Such a; 
 person is called a sleep-walker, or somnambulist. 
 Some somnambulists engage in the business and labors 
 which belong to their waking hours. A woman sets 
 her breakfast-table ; a man goes into the field and 
 hoes his corn; and sometimes the student occupies 
 himself in writing. Here it seems difficult, at first 
 view, to distinguish between sleeping and waking. 
 Yet, ordinarily, there is something in the conduct of 
 these persons, by which it is obvious that they are not 
 in the natural waking state. In general, they do not 
 talk, and do not seem to hear one speaking to them in 
 common tones. If roused by violence, they show sur- 
 prise and confusion of mind. If left to themselves, 
 these persons usually return to their beds, and the 
 next day are not at all aware of what has occurred 
 during the night. I say during the night, for I do not 
 recollect any instance of a person, falling asleep during 
 the day, having been afiected by ordinary somnambu- 
 lism. 
 
 I have made rather a long preface to an interesting 
 case, which I wish to relate to you. I will not say 
 that it is one of any great practical value, but it may 
 throw some light upon phenomena, which fall under 
 
94: 
 
 common oDservatioiij and may prevent too much 
 apprehension, if a similar case should ever come 
 under your own care. 
 
 The case I refer to was that of Miss S , about 
 
 eighteen "years of age, who was under my care more 
 than forty years ago. She was a visitor in the town, 
 at the house of an aunt, and, though her family was 
 well known to me, I was not then acquainted with 
 their constitutions. I will say now, what I learned 
 subsequently, that they were all very liable to nervous 
 diseases, and especially to affections of the brain. 
 This young lady, very soon after I saw her, and I be- 
 lieve on the first day, was singularly affected in the 
 early part of the evening. It was said that she had 
 fallen asleep and then roused to the state in which I 
 saw her. In her ordinary state she was extremely 
 modest and bashful. Now, I found her with her eyes 
 widely opened, instead of being downcast, and with 
 an air of boldness. She appeared to be in some dis- 
 tress, and referred to the epigastrium as the seat of 
 her trouble. At some moments she appeared to have 
 extreme pain there. She was not tranquil at any 
 time, but occasionally the muscles of her limbs and 
 those of the abdomen became rigid. Those of the 
 face were affected in like manner, and, being accom- 
 panied by staring, she had an expression of sternness. 
 
95 
 
 But these tonic spasms were transient, and most of 
 the time she was at rest. She talked freelj, as if 
 awake, but in a manner totally different from her 
 own when in a waking state. She had a certain set of 
 notions, and all which she said conformed to them ; 
 but these notions, as well as her manner, were totally 
 different from anything shown in her normal state. 
 With all this there was not any remarkable change in 
 the organic system. She had nothing which you could 
 call fever. She did not take much nourishment, but 
 she took enough to support her. The paroxysm under 
 which I saw her subsided after a few hours, when 
 she had a natural sleep ; and the next morning she 
 appeared very well, although enfeebled. A paroxysm 
 of the same general character occurred every evening 
 for about three weeks. In these paroxysms she remem- 
 bered very well what had passed in the preceding 
 ones; but in her normal state she could not recall 
 anything, which had taken place in the morbid state 
 In the morbid state she addressed those about her as 
 knowing them, but to three or four persons whom she 
 saw the most, she gave false names, and uniformly 
 recognized them under the same names; but they 
 were the names of real persons. To her aunt she 
 gave the name of an old nurse whom she had known ; 
 and she called me by the name, of one of her brothers, 
 
96 ON SOMNAMBULISM, ETC. 
 
 considering me as being her brother. She objected to 
 my leaving her, and made me promise to see her early 
 the next evening. The next evening, if I did not 
 enter until the paroxysm had commenced, she would 
 reproach me for being tardy. I saw her several even- 
 ings before the paroxysm, and noted the manner of its 
 occurrence. While lying quietly on her bed she 
 would undergo a sudden change. She would start, 
 and her countenance would become distorted. Her 
 eyes would be opened widely, and she would strike 
 her hand upon the epigastrium, appearing to be in 
 great agony. With this, or shortly after, some spasms 
 would take place, more or less extensive. For a time 
 her jaws would be set, and she would utter no articu- 
 late sound, though her groans would indicate suffering. 
 It soothed her if I removed her hands, and pressed 
 my own on the epigastrium ; and the more, if I did so 
 with all the strength I possessed. In a longer or 
 shorter time she would become calm, and then I would 
 commonly have a very pleasant conversation with her. 
 She never lost her own identity, but I believe she did 
 not know where she was, and showed no curiosity with 
 respect to her situation. On some occasions she mani- 
 fested violent emotions, and on one evening particu- 
 larly, jumping from her bed, she climbed up the bed- 
 post like a kitten, and afterwards made an attempt to 
 
97 
 
 jump out of the window. In this she was quite in 
 earnest, and it required one person in addition to 
 myself to prevent her from accomplishing her pur- 
 pose. The most remarkable thing was the double 
 consciousness ; for, though she never considered her- 
 self as a diiferent person in the morbid state, yet she 
 was of a totally different character ; and in that state 
 she could not be made to remember what had occurred 
 in the preceding day, as in the sound state she did not 
 remember the occurrences of the night. Yet, in each 
 state she recalled all which had taken place in the 
 same state, during the period of her sickness. Her 
 memory seemed to have two distinct store-houses ; 
 one for the normal and one for the morbid state. 
 
 The disease was a new one to me, as it was also to 
 the older practitioners who were called to consult with 
 me. Remedies were tried, corresponding to the differ- 
 ent notions suggested as to the nature of the difficulty, 
 but without any benefit. I very soon became satisfied 
 that medicine was not of any use to her, and aimed 
 only to avoid everything which should aggravate the 
 trouble. The disease subsided gradually, but left her 
 much enfeebled. 
 
 I learned that several months before I saw her, she 
 had undergone a similar course of disease, in another 
 town, not at her own home. At that time, the sick- 
 9 
 
98 
 
 ness had been shorter, and I believe not quite so reg- 
 ular in its course. She lived many years after the 
 disease which I have described, and always exhibited 
 marks of a nervous temperament ; but she never again 
 was aJBfected with double consciousness. She was mar- 
 ried, and then lived in this city. After several years 
 she became pregnant. She had not quite reached her 
 term when labor took place, and she gave birth to a 
 dead child. Severe convulsions ensued, under which 
 she died. It happened at a time when I was absent 
 from the city, so that I am not able to state the par- 
 ticulars minutely. I ought to say, respecting this 
 patient, that she was an amiable and intelligent 
 woman ; not at all whimsical, nor irregular as to her 
 conduct ; on the contrary, quite discreet. 
 
 A knowledge of this case, and of others similar 
 which the books furnish us, has helped me in form- 
 ing opinions on the subject of animal magnetism. It 
 shows that the human mind can pass from a natural 
 to a morbid or unnatural state very suddenly ; and 
 that, under its change, it may temporarily view sub- 
 jects in a new light, and be affected in a manner quite 
 different from that which is common to it. When I 
 first saw persons in the magnetized state, as it is 
 termed, I was struck with the resemblance of their 
 cases to that of my interesting patient. I examined 
 
ETC. 99 
 
 several persons in this magnetic state. All, whom I 
 saw, were females, and I believe all fairly ranked in 
 the class of nervous people. 
 
 The doctrine commonly received is this : that one 
 person is capable of throwing another into the mag- 
 netic state by some influence, which he exercises over 
 the subject. But it is notorious that the magnetizer 
 cannot succeed with all persons ; and, indeed, only on 
 a small proportion of persons. Now, I believe the 
 true doctrine is this : that there are some persons who 
 can go into the magnetized or somnambular state, and, 
 yielding themselves up to the operator, they fall into 
 this state. It is not that the magnetizer possesses any 
 peculiar power ; but that the magnetizee^ if I may 
 coin a word for the occasion, is liable to be affected in 
 a peculiar way, and becomes so affected, whenever so- 
 licited by one professing to possess a peculiar power 
 or faculty. There is not any trick about this. The 
 magnetizee is really brought into a state different from 
 the normal state. This state is exceedingly like, if it 
 is not identically the same, as regards its essential 
 characters, as that of my patient under double con- 
 sciousness. We had had no experience of this animal 
 
 magnetism when I attended Miss S , whose case I 
 
 cave described ; but, at that time, I began to think 
 Uiat I had some influence in producing the nightly 
 
100 ON SOMNAMBULISM, ETC. 
 
 return of the morbid state ; because this usually took 
 place soon after my entrance into the patient's room i 
 so thatj at last, I ceased my regular attendance in the 
 evening, and, as I suspected, with benefit to the 
 patient, although the change was not effected imme- 
 diately. At the time that Miss Brackett was distin- 
 guished as a magnetizee in Providence, and when 
 there were two other young ladies there distinguished 
 in the same way, I visited that place for the purpose 
 of seeing them. Having these notions in my mind, I 
 asked Miss Brackett if she had ever been subject to 
 somnambulism. She answered that she had not been, 
 but that she had a brother who had been a very re- 
 markable somnambulist. He had hoed his corn in the 
 ndght, aiwi done various other things, such as are not 
 often met with. This corresponded with my opinion^ 
 previously entertained, that th^re was a tendency in 
 the constitution of the subject to somnambulism. In 
 this connection it should be remembered that the first 
 change cardinarily produced in this process c£ animal 
 magnetism, so called, is to put the subject asleep. 
 There she remains unless the magnetizer uses his 
 influence to produce a partial wakening. This waken- 
 ing is an exhibition of the double consciousness. In 
 Miss Brackett' s case I found that, when in this abnor- 
 mal state, she remembered what had befallen he? 
 
ON SOMNAMBULISM, ETC. 101 
 
 when in the same state at a previous time. During 
 the magnetic sleep the subject continues to feel a 
 dependence on the magnetizer, so as to awake when- 
 ever he makes known to her his wish that she should 
 wake. It has been said, indeed, that the magnetizer 
 can exercise an influence to make the subject sleep, or 
 wake, without making his wishes known to her by any 
 sign. This I doubt. I have witnessed efforts of this 
 kind ; but, upon close watching, it was plain that no 
 effect was produced until the subject was apprized of 
 the design of the magnetizer. And in cases related to 
 me by others, I never found one where it was proved 
 that the magnetizee was influenced without any sign 
 from the magnetizer. 
 
 There was one remarkable instance, which fell under 
 my own observation, and which I will relate. A num- 
 ber of gentlemen, principally clergymen and physi- 
 cians, were collected to see an exhibition of animal 
 magnetism by one of the first professors of the art 
 among us. After various experiments, the magnetizer 
 informed us that he should now act upon the magnet- 
 izee without her knowing his design ; and he asked us 
 to keep her engaged in conversation so that she might 
 not notice his movements. Accordingly, several gen- 
 tlemen surrounded the lady, while the magnetizer 
 
 seated himself at a distance, but kept his eyes fixed 
 9* 
 
102 
 
 on the spot where she sat. I took my station with 
 apparent carelessness, but at a spot where I could 
 watch both the parties. For a long while he kept his 
 gaze upon her, while he was designedly screened from 
 her by the gentlemen around her. At length there 
 was a break in the circle for a moment, so that she 
 could see her friend, the magnetizer, and become 
 aware of his fixed look. Instantaneously her eyelids 
 began to droop, as they had done in each of the pre- 
 vious instances, in which he had operated on her ; and 
 within a minute she was in the magnetic sleep. It 
 was perfectly clear that she was not influenced until 
 his object was manifested to her. 
 
 The pretensions of magnetizers have gone further. 
 They tell you that their subjects, under the influence 
 of animal magnetism, possess the power of clairvoy- 
 ance. That is, they maintain that these subjects can 
 see what is passing in another room, or in another 
 house, and even in another city from that in which 
 they are placed. Thus, they are supposed to see 
 through opaque substances, and even at distances at 
 which vision is impossible ; and they profess an ability 
 to tell what is doing in foreign countries. This power 
 being admitted, those who have faith must be pre- 
 pared to believe that these magnetized persons can 
 look through the solid walls of the human body and 
 
ON SOMNAMBULISM, ETC. 103 
 
 point out the seat and the character of internal dis- 
 eases. To all this I have to say, that I patiently 
 examined into the evidence of such a power, and 
 became entirely satisfied that it had not any existence. 
 
 Miss Brackett being left under my influence by the 
 gentleman who had magnetized her, I requested her 
 to travel with me in the spirit to my own residence. 
 To this she assented. I then designated the road by 
 which we should go, and from time to time asked her 
 to stop and tell me what she saw. She replied to 
 me with great cheerfulness and readiness. But, in 
 every instance, her answers were such as were sug- 
 gested by my remarks, or else they consisted of vague 
 generalities. In this way I led her sometimes to give 
 answers consistent with the truth ; but oftener her 
 answers were ridiculously inconsistent with it. I sat- 
 isfied myself that she was a very honest girl, and 
 failed because she attempted an impossibility. 
 
 It is well settled among those who have studied the 
 human mind, that it has two modes of getting knowl- 
 edge. One is by sensation, through the eye, the ear. 
 etc. The other is by consciousness, by which any one 
 may be apprized of what happens in his own mind. 
 Now, this doctrine of clairvoyance is that there is 
 some other way, or avenue, by which knowledge may 
 ciome into the mind. I say, simply, that all such pre- 
 
104 ON SOMNAMBULISM, ETC. 
 
 tensions are set aside, as soon as they are calmly and 
 thoroughly examined. They have been brought for- 
 ward in all ages ; and I presume that there cannot 
 be found any nation, in which they have not been 
 professed by some one at every period. But when 
 called upon for such proof, as the case will admit, the 
 pretension has always been shown to be groundless. 
 This has held true in our New England from the time 
 Oi the witches to that of the spirit-rappers of the 
 present day. The same pretensions will, probably, 
 continue to be held up in dilBferent modes till all man- 
 kind become enlightened. 
 
 I know not when I shall find a proper place for a 
 few words respecting the treatment of insanity, or 
 diseases of the mind, if I do not avail myself of this 
 letter. Though insanity differs in respect to its nature, 
 as well as in respect to its degree, and is no more one 
 and the same thing, than disease of the lungs is one 
 and the same thing, yet there is one remark, as to its 
 treatment, which applies in almost all cases. This 
 remark is that the patient can be treated with very 
 much greater advantage in a public institution, an 
 asylum, or hospital, than in a private house. The 
 patient's own house is, with very rare exceptions, just 
 the worst place for him. The sufficient reason is that 
 the patient is, usually, much more uncomfortable in 
 
105 
 
 his own house than in an asylum. Even in the slight 
 cases, where the patient is said to be only ?ie?'vous, in 
 common parlance, if he will not engage in his accus- 
 tomed employments, especially if he is dissatisfied 
 with those around him, he is made more comfort- 
 able at the asylum. The same is true in regard to 
 the octogenarian, whose mind seems worn out, and 
 who has become jealous of his family and friends, and 
 in turn of every attendant. All are ready to agree 
 that the violent and outrageous are best guarded in a 
 hospital. Of the truth of these statements I could 
 bring abundant evidence. The explanation is this. 
 The patient, in his own dwelling, is accustomed to 
 exercise certain rights and enjoy certain privileges. 
 This is true, whether it be father or son, mother or 
 daughter. But, when deranged in mind, the patient 
 is subjected to some restraints, or, at least, he thinks 
 he is ; and these restraints come from those, whom he 
 regarded as his friends. He then believes that his 
 friends have changed, not that he has ; and therefore 
 he resents what he considers as injuries, or insults. 
 There are other cases, where the spirits are depressed, 
 and gloomy apprehensions engross the mind. In 
 these cases the sight of near friends adds to the trouble. 
 Remove the patient to an asylum, and new trains of 
 thought and of feeling are produced. Perhaps the 
 
106 
 
 real pain of a separation from home-friends may 
 counteract the disposition to dwell on imaginary causes 
 of trouble. At any rate, I find that the patient gets 
 relief at the hospital. 
 
 / 
 
LETTER VIII. 
 
 ON DENTITION AND THE PERIOD OF WEANING. 
 
 Children usually begin to have their first teeth 
 about the seventh month, and continue to be teething^ 
 as it is termed, for about two years. I have known 
 the dentition to be terminated at the age of twenty-one 
 months ; and in another case, or more than one, it has 
 not terminated until the age of forty-two months, the 
 subjects being equally healthy. It is well known 
 that, while the teeth are coming through the gums, 
 children are liable to diseases of various kinds, more 
 or less severe. Men who reason without observing, 
 are very liable to fall into errors. Such an one may 
 discredit my statement, and ask why disease should 
 attend dentition, since this consists only in the forma- 
 tion and growth of certain parts of the body. It is 
 not true that we suffer during the whole process of 
 forming the teeth.- The germs are formed in the 
 foetus, and there is no period in which teeth are not 
 forming, from birth, until we arrive at the age of 
 
108 DENTITION AND PERIOD OF WEANING. 
 
 twenty or thirty. It is only when the germs are 
 swelling, and are ready to burst ; or, speaking liter- 
 ally, when the teeth are undergoing the last rapid 
 enlargement, and are to be brought through the gums, 
 that the liability to disease is manifestly connected 
 with dentition. Whatever a reasoner might anticipate, 
 we know that the system sympathizes with, or is 
 affected by, any new or uncommon local change ; or, 
 at least, that it may be so affected. This is more 
 readily understood when the new process is a morbid 
 one; as when, instead of the common nutritive pro- 
 cesses, an inflammation is set up in any part. But in 
 various normal processes, besides dentition, the same 
 thing is seen. We see it attending the changes 
 belonging to the age of puberty, and again in preg- 
 nancy. Purturition often commences with a chill, 
 just as a symptomatic fever does ; and lactation almost 
 always, at least the first time, commences with a chill, 
 followed by heat, by headache, and other phenomena 
 of symptomatic fever. Even the catamenia sometimes 
 commence with a chill, and, in a large proportion of 
 cases, with constitutional symptoms more or less 
 severe. These considerations may lead the incredulous 
 more readily to admit that the diseases of infancy are 
 sometimes caused by dentition alone ; and in many 
 cases, if I may so say, favored by dentition, when not 
 
DENTITION AND PERIOD OF WEANING. 109 
 
 entirely caused by it. I shall take occasion to state 
 that it is not only in the first dentition, but also 
 during the growth of the permanent teeth, that dis- 
 ease shows itself frequently ; and that sometimes the 
 whole constitution undergoes a change, more or less 
 marked, at this period. 
 
 Until the age when the teeth show themselves, and 
 in some cases for three or four months after this period 
 has commenced, you see infants expanding in every 
 part; those, at least, who are properly nourished. 
 The bones, the muscles, the internal viscera, are all 
 enlarging ; and with this abundant health you see fat 
 constantly accumulating under the integuments. 
 Hence comes the rotundity, at every point, character- 
 istic of infancy. The whole business of the little one 
 seems to be to eat, laugh, and grow fat ; leaving the 
 cares and pains of life to its parents. But, if not with 
 the first tooth, before many show themselves, the 
 child begins to experience the hardships of life. If 
 the general growth be not diminished, the fat is 
 absorbed somewhat, and thus the aspect is altered. 
 The digestive organs fail to perform their functions as 
 perfectly as before, as is shown in various ways. 
 Even without any error of diet, but particularly if 
 there has been any error, the food is vomited, more or 
 less digested, or sometimes unchanged. This may 
 10 
 
110 DENTITION AND PERIOD OF WEANING. 
 
 occur a single time, and pass off without further 
 trouble. Next, diarrhoea is a common occurrence. 
 This too may be temporary, produced apparently by 
 some article difficult of digestion, and ceasing when 
 the cause is removed. But as the powers of the 
 stomach are impaired by continued irritation, trace- 
 able to the teeth, the diarrhoea becomes more frequent, 
 and perhaps constant. This is seen especially in 
 August and September. The diarrhoea may be in all 
 degrees, and may or may not be attended by pain. 
 These are among the most common phenomena of 
 teething, and consist, as you see, in a failure of the 
 digestive organs and of the processes of nutrition. 
 But the animal system likewise manifests the effects 
 of the local irritation. The sleep is no longer so calm 
 as it had been ; and the temper is not so sweet. The 
 child gets restless, and it becomes a labor to amuse 
 him. Occasionally, even, convulsions are produced, 
 accompanied by loss of consciousness apparently, and 
 followed by stupor. The respiratory system and the 
 heart partake of the general trouble, and so does the 
 urinary apparatus. Occasionally, after two or three 
 days of disturbance, without any obvious cause, a red 
 sand is deposited from the urine; and, in a day or 
 two, the child is well again. This may happen at any 
 
DENTITION AND PERIOD OF WEANING. Ill 
 
 period of life, but sometimes it appears in infants to 
 arise only from the dentition. 
 
 I have spoken, mostly at least, of diseases which 
 may be called functional. But inflammation arises in 
 various parts in consequence of dentition. This shows 
 itself in the gums and cheeks in the form of little 
 ulcers, commonly called canker, but by my master, 
 Dr. Holyoke, denominated ulcuscula oris. Of this I 
 will give a more full account hereafter. Inflammation 
 likewise occurs in the mucous membrane of the stomach 
 and intestines, and is often recognized by nurses under 
 the name of canker in the stomach or bowels. This 
 inflammation is sometimes in patches of some extent ; 
 but more commonly it is limited to small spots, prob- 
 ably either the solitary or the agminated glands of the 
 alimentary canal. There is not one uniform course 
 in these inflammatory afiections of the mucous mem- 
 brane, and I have often thought that both in the 
 alimentary canal and in the bronchi there might be 
 affections corresponding to what we call eruptions on 
 the skin, and these varying in kind and extent. While 
 engaged on these letters I have learned that the tal- 
 ented Dr. Simpson, of Edinburgh, has entertained a 
 similar opinion. I trust that he will prosecute this 
 subject with the zeal, industry and sagacity, which are 
 characteristic of him, 
 
112 DENTITION AND PERIOD OF WEANING. 
 
 Anorexia, vomiting, purging, pain, with or without 
 heat, and accelerated pulse, and all these in various 
 degrees, attend the gastritis and enteritis above men- 
 tioned. The symptoms resulting from these affections 
 are modified by errors of diet, or by any contravention 
 of the laws of hygiene. The continuance of these 
 affections causes debility, and often increases the irri- 
 tability which belongs to the infantile age. The errors 
 of diet are the most noted, as in truth they are the 
 most frequent. This happens because the regulation 
 of the food does not belong to nature, but depends on 
 human discretion. Let me take this occasion to point 
 out the use of a term which is not always understood. 
 Eating, sleeping, etc., are called non-naturals. This 
 certainly does not mean that they are unnatural. It 
 means that Nature does not determine when we should 
 eat, nor what, nor how much, nor when we should 
 sleep, nor how long. I have made these remarks the 
 more distinctly, because I wish to treat, at some 
 length, of the diet of infancy, particularly during den- 
 tition. If I should not take this up by itself, I should 
 be interrupted afterwards by the necessity of referring 
 to it parenthetically, as it were. 
 
 It would seem, at first sight, useless to say much 
 upon the diet of infancy, as that is the only period for 
 which nature has made absolute provision, Parturi- 
 
DENTITION AND PERIOD OF WEANING. 113 
 
 tioii is followed by lactation. Nature furnishes tlie 
 proper food in the mother's breast; and to that breast 
 the mother delights to apply her child, and there the 
 child's instinct enables it to obtain the needed supply. 
 Yet we find the discretion of the child's guardian is 
 often required, notwithstanding all this admirable pro- 
 vision. In civilized society mothers are not always 
 vigorous, and cannot furnish all that is requisite for 
 their offspring, nor hold out so long as is needed. 
 Besides, nature does not decide up to what age a child 
 must be kept at the mother's breast. It is then left 
 to human discretion to say with what, besides the 
 mother's milk, an infant shall be fed ; with hoAV much 
 it shall be fed, and how often in the day ; and, lastly, 
 at what period it shall be weaned. On these points I 
 shall proceed to make such remarks, as my experience 
 seems to me to authorize. But do not imagine that I 
 can give precise rules, for the same will not suffice 
 for every case. Principles only can be furnished, and 
 a sound discretion is requisite in applying them. 
 Success, sufficient at least to satisfy the parties con- 
 cerned, follows various modes of proceeding ; yet all 
 are not equally good. 
 
 When the mother has milk enough, it is safe to 
 leave the child to that alone, in the early months of 
 its life. Nevertheless, there is a convenience in feed- 
 10* 
 
114 DENTITION AND PERIOD OF WEANING. 
 
 ing it with something else, once a day. The mother 
 may sometimes be sick, and sometimes unavoidably 
 separated from the infant ; then some food other than 
 her milk must be given ; but if the child is not accus- 
 tomed to the spoon, or the bottle, great difficulty is 
 apt to arise. It is, therefore, expedient to accustom 
 it, from the beginning, to the use of the spoon. For 
 the purpose now in view a small quantity will suffice ; 
 say from one to four table- spoonfuls. This little meal 
 should be given early in the day ; for if any uneasi- 
 ness follows in the day-time, it is of much less impor- 
 tance than it would be in the night. Every precaution 
 should be taken to keep the child quiet in the night, 
 for its own sake, and for its mother's also. At first, 
 cow's milk, diluted with three times its quantity of 
 water, is, perhaps, the best article. The more fresh 
 from the cow, the better the milk is for this purpose. 
 If it has been standing two or three hours I would pre- 
 fer to use the top of it, as I hold that the cream, or 
 buttery part, is better than the coagulable or cheesy 
 part of the milk. Other articles may be used with 
 safety, and now and then seem even to be preferable ; 
 and, if the mother has not food enough for the child, 
 larger and more frequent meals must be given. If 
 goat's milk can be procured easily, it should be given 
 in preference to cow's milk ; and, for a child with a 
 
DENTITION AND PERIOD OF WEANING. 115 
 
 very delicate or feeble stomacli, it should be sought 
 for, when a woman's milk cannot be had in sufficient 
 quantity. Water-gruel, made from oatmeal or Indian 
 meal, is often used for young children. This gruel 
 depends for its quality on the mode in which it is 
 prepared. If made in a summary way, with a short 
 boiling, it is given with the coarser parts, the hull of 
 the grain, in a pulverized state. This portion of the 
 grain is indigestible, and from that very circumstance 
 is a laxative. This sometimes makes it useful ; that 
 is, useful for a child habitually costive. But, like all 
 laxative food, and this more than some other articles, 
 it often causes flatulence and pain in the bowels. For 
 young infants it is not proper, on this account, for in 
 them these evils are most readily produced ; but for 
 those, more than three or four months old, this prepa- 
 ration may be tried, if called for by costiveness. In 
 Buch cases the good or bad effects cannot be well 
 decided under a trial of less than three or four days. 
 When employed in this way, the article may be given 
 once or more in a day, as may be found necessary, 
 with reference to its effects on the bowels. 
 
 The other mode of preparing a gruel from meal is 
 to boil it from two to four hours. Then the hull will 
 be thoroughly separated from the nutritious, or farina- 
 ceous matter. In this state the gruel should be 
 
116 DENTITION AND PERIOD OF WEANING. 
 
 allowed to stand until the coarse part has subsided. 
 The supernatant liquor will be an emulsion-like arti- 
 cle ; in fact, a decoction of the farinaceous grain. 
 This is to many persons more pleasant than the solu- 
 tion of arrow-root, and is quite as mild. Arrow- 
 root is a very good article, and the advantage of it is 
 that it may be prepared much more easily and more 
 quickly. With either of these substances a little milk 
 or cream may be mixed. When the child cannot easily 
 be made to take such food as I have described, and it 
 is important that it should be fed, because the mother 
 cannot fully supply its wants, some sugar may be 
 added. When, however, the child will take the food 
 without the sugar, it should not be employed. True, it 
 is often, and perhaps commonly, given with impunity ; 
 but, when the stomach gets feeble and delicate, the 
 sweetened food is apt to become sour ; then the child 
 cannot be induced to take the food without the sugar, 
 and, often, great inconvenience follows. 
 
 It is well, then, to feed the infant once a day, for 
 the benefit of haying it accustomed to take its food in 
 this way ; and it may be necessary to feed it much 
 more when the mother has not a sufficient quantity 
 of nourishment for it. In either case the food must 
 De liquid and very simple in its character. Various 
 other substances may be used. Sago is among those 
 
DENTITION AND PERIOD OF WEANING. 117 
 
 which are easily procured. If the child must depend 
 largely on feeding , as it is termed by the nurses, 
 it is best to get it more and more accustomed to the 
 cow's milk, until this becomes the larger part, and at 
 last the whole of the article administered. The great- 
 est inconvenience of this milk is that it is apt to occa- 
 sion costiveness. If it does so, oatmeal may be used 
 with it, in such a manner as to include its coarse 
 parts. Adding water to milk is thought to weaken it, 
 as water operates when added to wine or alcohol. I 
 apprehend that milk is not in any sense weakened by 
 a mixture of water. In the stomach the milk goes 
 for the same thing, the quantity being the same, 
 whether water is added or not. Yet there is usually 
 an advantage in adding water for a child ; the cow's 
 milk is stronger, contains more nourishment than a 
 woman's milk. If a child is eager for quantity, 
 whether from thirst or what not, it would take more 
 cow's milk at a time, than it could well bear. The 
 evil is obviated by adding water, as thus the quantity 
 is increased without giving too much nutritious matter 
 at once. 
 
 I suggested a measure for the meal of a very young 
 infant ; but if it needs more food than the Jiother can 
 furnish, the quantity at a meal must be increased, and 
 the frequency of its meals also, in proportion to the 
 
118 DENTITION AND PERIOD OF WEANINO. 
 
 case. Here watchfulness and discretion are requisite; 
 for children, as well as adults, require very different 
 quantities of food. A very young infant, taking lit- 
 tle at a time, may require to have a meal once in two 
 hours, whether from the breast or the bottle. But, 
 as soon as possible, the interval between its meals 
 should be increased to three hours ; and I think it 
 best to make the interval four hours at six months 
 after birth. It is impossible, however, in most in- 
 stances, to make mothers adhere to exact rules in this 
 matter. When a child feeds much, the rules should 
 be more rigidly enforced, than when it is nursing 
 only, or principally. 
 
 It is important to direct that liquid food should 
 be administered to infants just tepid, as near to the 
 warmth of the mother's milk as may be. The use 
 of hot liquids to new-born infants is especially inju- 
 rious, often causing an aphthous mouth. 
 
 The time comes sooner or later for children to use 
 solid food, as a part of their nourishment. Nature 
 has not marked out any exact period for this, unless 
 we consider the coming of the teeth as a sufficient 
 guide. To a certain extent it is so. As long as a 
 child is strong, and grows well, and shows the beauti- 
 ful rotundity of infancy, one need not be anxious to 
 make any change in his food. Yet, in a view of all 
 
DENTITION AND PERIOD OF WEANING. 119 
 
 his coming wants, and of the possible failure of the 
 supply from his mother, I think it well to begin grad- 
 ually to give him bread, in very small quantities, in 
 the fifth or six month. He should be watched, as in 
 every change of diet, to see how it agrees with him. 
 If he is always uneasy after it, or if his alvine dis- 
 charges show any evil, the bread must be given up 
 for a time. Commonly, good white bread is easily 
 digested at the age mentioned, if the quantity is 
 small. As the child grows older the quantity may 
 be increased, until the bread constitutes an important 
 article of its food. Other vegetable substances may 
 be gradually introduced, such as rice and potatoes well 
 cooked. But these are not necessary, where the bread 
 is well borne. If the child be habitually costive, 
 bread made from coarse wheat flour (wheat meal) 
 may be given ; or plain molasses gingerbread, or 
 fruit. The hard fruits, apples especially, should be 
 cooked, — roasted or baked. In summer the various 
 berries are often useful. 
 
 There comes a time when a child should have some 
 gratification to his carnivorous propensity. There is 
 not any precise time at which this is requisite. Chil- 
 dren, who are vigorous and grow well, can afford to 
 defer it. The pale, thin and feeble child should have 
 an early opportunity to show whether he loves flesh or 
 
120 DENTITION AND PERIOD OF WEANING. 
 
 fishj and whether he can digest the same and thrive 
 upon it. Any one who has teeth may begin with a 
 chicken-bone, and, if he is pleased with the indul- 
 gence, may have a little tender meat, very finely 
 minced, once in a few days. According to the effects, 
 the indulgence may be gradually increased. It is 
 well that a child should get the habit of taking a lit- 
 tle meat daily, or frequently, before he has completed 
 his first year. 
 
 I have said something of the frequency of meals ; 
 but there is one remark, connected with that matter, 
 which I have reserved that I might make it emphati- 
 cally. This is that, if possible, the infant should be 
 made to pass six or eight hours in the night without 
 food. In the mother's phrase, the child should not 
 nurse in the night. This is mutually beneficial to 
 mother and child. The proper rest, which the mother 
 gets in this case, enables her to support the strain 
 which is made upon her, and thus indirectly is bene- 
 ficial to the child. This is a sufficient reason for the 
 practice ; for among us there are few mothers who do 
 not shrink under the fatigue of nursing their children. 
 But it is directly beneficial to the child, also, whose 
 stomach is the better for this full rest once in twenty- 
 four hours. Children thus treated are, usually, more 
 happy in the day, than those who nurse much in the 
 
DENTITION AND PERIOD OF WEANING. 121 
 
 night, and increase quite as fast in flesh and strength. 
 That there are restless children, who cannot be trained 
 up in this way, I admit ; but they are comparatively 
 very few. Nothing is lost by the trial ; and, if this 
 be made in good earnest, success often follows, even 
 in cases which seem desperate. The best chance for 
 success is found in beginning the practice from the 
 very first night. 
 
 One other direction I should not omit. I have 
 mentioned feeding during the period of nursing. I 
 have had reference in ail this to a child in health. 
 When attacked by any acute disease, whether in the 
 digestive organs or elsewhere, the child should be 
 kept to the breast alone, if enough for its support can 
 be found there. As the food should be diminished in 
 quantity, in such a case, this is not very difficult. It 
 is the less so, because the child commonly falls off in 
 appetite in such a case. It is true that he may want 
 to nurse because he is thirsty. The difficulty in 
 this respect may be obviated by small draughts of 
 water, either warm or cold, as may seem most grate- 
 ful to him. 
 
 We come now to the great change in the infant's 
 
 diet, weaning ; weaning from the breast. This is a 
 
 change, to which the young mother looks forward with 
 
 great anxiety. It is right that she should do so. It 
 
 11 
 
122 DENTITION AND PEKIOD OF WEANING. 
 
 is worthy a careful consideration. At the risk of 
 seeming to exalt this matter unduly, I will say that 
 it is one of the great events in life. The child's sub- 
 sequent health and vigor of constitution may depend 
 upon the proper timing of this great change. 
 
 Undoubtedly it is best that the weaning should 
 take place gradually — very gradually. But circum- 
 stances often make it necessary to be somewhat abrupt 
 in making the change. However made, in a very 
 few days after it has taken place the child loses the 
 faculty of drawing the breast, and likewise the mother 
 ceases to form milk. Thus the separation of child 
 from mother, in this particular, once made, is made 
 forever. Especial care, then, should be taken not to 
 do it before the child is sufficiently advanced in age, 
 and not at a time when it is peculiarly liable to 
 
 The months of July, August, September and Octo- 
 ber, are those in which infants are most liable to sick- 
 ness. It is in August and September that this is 
 most especially true. The child, who has kept well 
 till October, will commonly escape the autumnal dis- 
 eases in that month ; more especially after the first 
 week in it. But these remarks apply to children who 
 are teething. Those who have not begun to have 
 teeth at the season described, will pass through it as 
 
DENTITION AND PERIOD OF WEANING. 123 
 
 well as children who have got all their first, or milk 
 teeth. These take their turn in the second summer 
 of their lives, in which the process of dentition will 
 be going on rapidlj. All this is to be kept in view 
 when fixing upon the period for weaning. 
 
 When I commenced practice, I was unable to get at 
 any rules on this subject. The first question was, at 
 what age children should be weaned. Neither the 
 books to which I had access then or since, nor the 
 medical fathers around me. gave any reliable informa- 
 tion on the point. Circumstances, which I will not 
 detail, caused it to arrest my attention. Then I was 
 soon led to suspect that the age was not the only 
 thing to be considered, but the season also. It would 
 have required years to have obtained sufficient knowl- 
 edge on this subject by my own observation. Then I 
 began to draw from all the mothers I met with, not 
 their opinions, but their experience. If I asked for 
 opinions, the mothers and experienced nurses told me 
 that I must look to the almanac, and be decided by the 
 particular phase of the moon in deciding upon the time 
 of weaning. My method of inquiry was this : I asked 
 the matron how many children she had had ; and, in 
 regard to each one, in what month it was born ; then 
 at what age it was weaned ; and then what was its 
 health subsequently, and especially in the summer 
 
124 DENTITION AND PERIOD OF WEANING. 
 
 months after its weaning. Comparing what I learned 
 in this waj with what passed under my own obser- 
 vation, I came to these conclusions, which I published 
 more than forty years ago in the "New England 
 Journal of Medicine and Surgery." I will give you 
 an extract from a paper you will find in that Jour- 
 nal, entitled Remarks on the Morbid Effects of 
 Dentition. 
 
 " Children are benefited by living principally on 
 the breast for twelve months; their vigor is evi- 
 dently impaired, in almost all cases, when they are 
 nursed less than nine months. The safest period of 
 the year for weaning is from the middle of October to 
 the middle of March ; provided they be not weaned 
 under ten months after December, under eleven after 
 January, nor under twelve after February. Children 
 who are weaned at the age of twelve months in March 
 are ordinarily safe ; those who are weaned at this age 
 in April are less so — one half of them, perhaps, suf- 
 fering severely in the subsequent summer or autumn. 
 In May the danger increases ; and in the four sub- 
 sequent months, if a child of any age be weaned, it 
 will in most cases be very sick before the middle of 
 the October ensuing. The disease does not imme- 
 diately follow the weaning ; though in many cases the 
 diarrhoea of teething children ensues at once. But 
 
DENTITION AND PERIOD OF WEANING. 125 
 
 the instances, in which children, who are weaned 
 between May and October, escape severe cholera 
 infantum, are extremely rare indeed. It must, how- 
 ever, be noted that in some years the seasons are much 
 more favorable to the health of teething children than 
 in others. It must also be noted that the limits, which 
 have been mentioned, must be varied by particular 
 circumstances. First, the seasons vary two or three 
 weeks in different years. Second, something will 
 depend on the constitution of the child. But we must 
 beware not to place too much reliance on this circum- 
 stance, especially on the general appearance, on the 
 fatness, etc. Those children who love meat and rel- 
 ishing food, who digest their food well, who are in 
 perfectly regular habits as to their alvine evacuations, 
 and who sleep well, are the best qualified to bear a 
 deviation from the rules suggested above." 
 
 In giving the precise remarks contained in the fore- 
 going extract, it was not meant that nature is limited 
 by exact, straight lines. There is a difference in the 
 constitutions of children, and the seasons are constantly 
 varying from year to year. In remarks, such as are 
 given above, we make approximations to the truth. 
 Tliey are founded on averages, and are not supported 
 by each individual instance. However, I may sa;^ 
 that the rules deduced from them are the most safe at 
 11* 
 
126 DENTITION AND PEHIOD OF WEANING. 
 
 W^hich I was able to arrive in 1812 ; and I may repeat 
 the same as to the present year, 1855. I have been 
 obliged to discuss the subject in every intervening 
 year between these two dates; and many a mother 
 has shown me a healthy child whom she has reared 
 while disregarding the rules I have given. More than 
 this, I have seen whole families of children reared in 
 safety without any aid from a woman's milk. I be- 
 lieve, however, it is only two or three such families I 
 have seen. But the question is not to be decided by 
 a few selected instances. I know that many men are 
 holding up their heads, and are sound in mind and 
 limb, who have been repeatedly exposed in hot battles. 
 Yet no one pretends that a man is not in great danger 
 in such battles. Many are killed, and many maimed. 
 I should add that my experience has been limited 
 mainly, though not entirely, to this city of Boston. I 
 know very well that people living in the open country, 
 not in crowded villages, if they avail themselves of 
 their advantages, and keep their children much in the 
 open air, find it comparatively easy to rear infants. 
 Yet, in their proportion, the same troubles arise among 
 t;hem as in the cities. They have the best chances, 
 yet they experience some evils which we escape in 
 cities. I am quite convinced that our city children 
 get vigor by passing the summer and autumnal 
 
DENTITION AND PERIOD OF WEANING. 127 
 
 months in the country ; but they more frequently get 
 sick there; that is, they are oftener attacked with 
 acute diseases, than when in the city. This remark 
 has reference more to children after, than during the 
 period of dentition. If asked for an explanation of 
 this difference, I reply that I suspect it to be owing to 
 more frequent exposure to evening air in the country. 
 I am, however, more sure of the difference above 
 stated, than of the cause. 
 
 It sometimes happens that, when a child is weaned 
 from the breast, it immediately becomes very sick. It 
 rejects whatever is taken into the stomach, manifests 
 a deadly nausea, has incessant thirst, but no appetite 
 for the food which is offered to it, is extremely pros- 
 trated, and sometimes within twenty-four hours, often 
 within three or four days, gets the cadaverous aspect 
 of a victim to the Asiatic cholera. In these cases, 
 when so extreme, death often follows within a few 
 days ; but some recover after the worst symptoms. If, 
 under these circumstances, you restore the child to 
 the breast, it revives within twenty-four hours, and is 
 soon well again. Sometimes such a child will not 
 take the breast of a stranger, and its mother, or its 
 foster-mother, cannot be had. In that case, if you can 
 find a woman who can milk out the nutritious fluid, 
 and you give that to the child warm from the breas^ 
 
128 DENTITION AND PERIOD OF WEANING. 
 
 the whole purpose is answered. When a child is made 
 sick, as I have described, if you give it just such food 
 as it had taken and borne well on the preceding days 
 or weeks, and in the same quantities, it cannot bear it. 
 But, after restoring it to the use of the human milk, 
 it soon bears the same food very well ; and even a very 
 little human milk is sufficient to keep the infant's 
 stomach in such a state as to bear the other food. 
 Under these circumstances, I have been in the habit 
 of saying that the human milk kept the stomach in 
 good humor. 
 
LETTER IX. 
 
 OK CHOLERA INFANTUM, THE SECOND DENTITION, 
 AND ULCUSCULA ORIS. 
 
 In the last letter I took notice of diarrhoea in 
 teething children. In the simplest form, this comes 
 from the use of an indigestible substance as it may 
 at any age. , But at the period of dentition, every 
 disorder attracts more attention than at a later period 
 of life, and very justly. By observing such an occur- 
 rence, in connection with the diet employed, we learn 
 what articles to avoid in an individual case. But the 
 same article, and in the same quantity, is not always 
 followed by the same effects ; and even without any 
 error as to the quality of the food, the diarrhoea takes 
 place. If there is no error as to quality or quantity, 
 we must infer that the organs of digestion are wanting 
 in power. This may happen temporarily from vari- 
 ous disturbing causes. It is brought on gradually 
 during dentition, from the wasting of strength incident 
 to that period. Undue quantity may have this effect 
 
130 
 
 and is particularly apt so to do, when the digestive 
 organs have become weakened. The remedy for the 
 evils I have now stated consists chiefly in correcting 
 the errors of diet, where we are able to understand 
 them. When the natural efforts do not appear to 
 effect a removal of the offending matters, some castor 
 oil or other cathartic should be given. After this the 
 chalk mixture should be used, until the discharges are 
 less frequent and more natural ; and if this remedy 
 should not cause an amendment in twenty-four hours, 
 some opiate may be added to it. The tincture of 
 opium may be given in the dose of one or two drops to 
 a teething child, and repeated to the extent of four 
 times a day. In obstinate cases the quantity may be 
 increased, but always with great watchfulness at this 
 tender age. 
 
 Diarrhoea, arising from too great a quantity of food, 
 may occur in a healthy infant at any time. I am 
 tempted to leave the period of dentition for a moment, 
 m order to point out the circumstances, under which 
 a diarrhoea occurs, before that 'period. I refer to a 
 case, which is not uncommon to infants in the first 
 few months after birth, which is not, I think, well 
 understood ; and for which too severe a treatment by 
 medicine is often tried, and tried fruitlessly. This 
 infantile diarrhoea is not of serious importance. The 
 
131 
 
 discnarges are frequent, loose, though not watery, and 
 oftentimes green. Thej are sometimes attended with 
 pain, but this is not serious. Meanwhile, no weak- 
 ness nor emaciation takes place ; on the contrary, the 
 child grows apace. While the mother is speaking of 
 his alarming disease, the infant by its smiles brings 
 her smiles also, and she becomes puzzled as to the 
 conclusion to be arrived at. It is on these circum- 
 stances — that the nutrition goes on well, and that the 
 general health is maintained — that you may place 
 your reliance. The cause is principally the undue 
 quantity of milk which the child takes from its mother. 
 I will not say this is the only cause ; for I have some- 
 times suspected some fault in the milk. Ordinarily, 
 however, if you can persuade the mother to nurse the 
 child less frequently, the diarrhoea ceases, and the 
 child continues to flourish. I would not have you 
 understand that I learned all this at once. Usually, 
 before a case of this sort came into my hands, the 
 mother or the nurse had administered various cathar- 
 tics, most especially magnesia and castor oil. These 
 brought away the green matter, and then, perhaps, 
 more healthy dejections followed. But the amend- 
 ment would seldom continue more than one, or two 
 days. In my early years I would try rhubarb, and 
 afterwards chalk-mixture, but without any permanent 
 
132 ON CHOLERA INFANTUM, ETC. 
 
 benefit. At length, I became satisfied that medicine 
 was worse than the disease ; and that, if not arrested, 
 the diarrhoea was not seriously injurious. In sucn 
 cases, I have always taken care to explain the case to 
 the mother, that she might not think it equally safe 
 to neglect a diarrhoea in a teething child. 
 
 To return from this digression. I will now state 
 that, in the sickly months, children are often affected 
 with a more grave disease than diarrhoea, and which 
 is commonly known as the Cholera Lifantum, 
 Under this name, however, you do not always find 
 what appears to be one simple disease. The term 
 cholera, you know, was originally applied to diseases 
 in which bile made its appearance ; and this bile was 
 supposed to be the proximate cause. To this day, 
 persons out of the profession, and very many in it, 
 think of bile as a cause of disease, and do not look 
 behind it for any cause more within their control. 
 You know that, if you get a mote in the eye, the 
 lachrymal gland pours out tears, which are well calcu- 
 lated to wash it away. If any inflammation occurs on 
 the conjunctiva, the same flow of tears takes place. 
 So any acrid substance in the mouth, or an inflamma- 
 tion in its mucous membrane, may cause a flow of 
 liquid from the salivary glands. Precisely so, as I 
 apprehend, acrid substances in the stomach, or duo- 
 
ON CHOLERA INFANTUM, ETC. 138 
 
 denum, or inflammation of the mucous membrane of 
 these organs, will cause a great flow of bile into them. 
 An occasional vomiting of bile, therefore, or a bilious 
 diarrhoea, may arise from a transient cause, of which 
 you have instances in the efiects of antimonial and 
 other medicines. But, when this vomiting or purging 
 of bile continues after all irritating causes are removed, 
 you may infer that it is not an acrid substance, but 
 an inflammation of the parts above mentioned, which 
 gives occasion to the flow. It is proper to add that 
 various circumstances are to be taken into considera- 
 tion before this conclusion is admitted as certain. 
 Thus, for instance, an irritation in some distant organs, 
 as in the kidneys, or the uterus, may cause a vomiting 
 of bile. But I need not go further upon this point. 
 
 I will now state that when gastritis, or enteritis 
 occurs, you will find produced the phenomena of 
 cholera infantum. It is more especially when the 
 inflammation is limited, as above stated, to the stomach 
 and duodenum,' that this takes place. But, in the 
 progress of the disease, inflammation sometimes occurs 
 in the other intestines, and, of course, the symptoms 
 are modified. Vomiting and purging are the leading 
 symptoms of cholera ; but, alone, they do not consti- 
 tute the formidable disease, and not even if anorexia 
 be added to them. The great distinction arises from 
 12 
 
184 
 
 the constitutional symptoms, added to those which are 
 local ; and among these constitutional symptoms, the 
 prostration of strength and shrinking of the whole 
 body are the most important. It is not, then, the color 
 of the discharges, nor the frequency of them, which 
 makes the distinction between cholera infantum and 
 iiarrhcea. The difference, pathologically, consists, as 
 £ believe, in the existence of an inflammation in the 
 mucous membrane of the stomach and duodenum in the 
 cholera ; while, in the diarrhoea, it is probably lower 
 down in the canal, if anywhere, that inflammation 
 exists. It is not requisite that the inflammation be 
 very severe to produce the effects pointed out. The 
 difference as to symptoms is that in the cholera there 
 is an altered countenance, a shrinking of the features, 
 prostration of strength and spirits, and at times dis- 
 tress, or stupor, or these two alternating. Pain 
 accompanies diarrhoea as well as cholera ; but in the 
 latter it is often very extreme, and the sufferer 
 rejects all aid and comfort, seeming to believe that no 
 one can help him. This, however, is occasional, and 
 does not occur in every case. Common febrile symp- 
 toms also are frequent attendants on this disease. 
 
 As the actual disease varies in its extent and 
 severity, and as the constitution varies in its readiness 
 to sympathize with the local affection^ so must the 
 
ON CHOLERA INFANTUM, ETC. 135 
 
 symptoms vary. In some instances, mostly in July 
 or August, the disease is quite acute. The child is 
 taken down at once, and overpowered, and the disease 
 may prove fatal in a few days ; but this is rare. 
 More commonly, the patient rallies from an acute 
 attack, or the disease commences more gently, and in 
 either case it continues, varying in severity. Thus, 
 it may continue, fresh attacks occurring from time to 
 time, through xlugust, September, and later. It may 
 prove fatal at different periods, or cease altogether, 
 but leaving the patient greatly reduced. When con- 
 tinuing for a length of time, the patient loses, after 
 each new attack, both flesh and strength. 
 
 This disease is seldom fatal to a nursing child. 
 When not nursing, from the want of the appropriate 
 food, the child does not get up well from the first or 
 subsequent attacks, and the disease becomes compli- 
 cated with dyspepsia. Then there is a great need of 
 food, and often a great craving for it, and yet, perhaps, 
 nothing but the human milk can be digested. You 
 will see such a child reduced to a skeleton, tended on 
 a pillow, the skin so loose that it may be wrapped 
 over the subjacent parts, life being doubtful from day 
 to day, supported only by wine, or even by ardent 
 spirits, and yet ultimately recover. 
 
 While other symptoms vary, the diarrhoea never, or 
 
136 ON CHOLERA INFANTUM, ETC. 
 
 very rarely, ceases. This is kept up from the imperfect 
 digestion (and there the stomach is in fault), and from 
 the irritable state of the bowels, dependent sometimes 
 on inflammation, or slight ulceration. Consider, then, 
 that the dejections vary from the kind of food received, 
 the more or less perfect digestion of this food, the 
 mixture of the secretions, which are poured into the 
 bowels, healthy or morbid, and, lastly, from the greater 
 or less embarrassment attending the passage of these 
 materials through the canal. And remember that 
 this difficulty, as to the passage of the materials, 
 operates more especially in holding back the proper 
 faeces derived from the food; for the secretions, not 
 being solid, are more easily transmitted. Now, if you 
 would understand such a case, you must, day by day, 
 ascertain the following facts : first, the ai'ticles taken, 
 how much of each, and at what periods, including the 
 liquids ; second, how far any discomfort has followed 
 a meal, whether this be pain or uneasiness only ; also, 
 whether there has been heat, heaviness, or restlessness ; 
 and, third, the dejections, their number and character. 
 These dejections must be carefully analyzed ; I do not 
 mean by chemical means, but by an estimate of the 
 proximate elements which compose them. Each dis- 
 charge should be kept by itself, and they should be 
 placed in the order in which they take place, aftd you 
 
ETC. 137 
 
 should take note of the periods at which they occurred. 
 You should then observe, in respect to each, whether 
 it contains any faeces, and how much ; and whether 
 the material is in its crude state, or partially digested ; 
 and, then, how much there is of mucus, watery fluid 
 and bile ; to which I may add blood, as this is some- 
 times added to the morbid materials. Now, that dis- 
 charge is the best in which there are the most faeces ; 
 more especially if these are truly faeces, and not an 
 undigested matter. This is best, at least for this rea- 
 son, that it shows the organs to be in a condition so 
 healthy and so vigorous as to transmit the faeces; for 
 one of the worst things in this, as in other diseases of 
 the bowels, is, that the lame intestines cannot perform 
 their duty. Let me impress this by saying that you 
 should always insist upon learning from the nurse, 
 when you do not see the discharges, what the quantity 
 is ; for, even a good nurse is apt to think it is enough 
 if she tells you the color, adding, perhaps, that the 
 stool was loose, or was not so. Next, the mucus is 
 more or less, first, according to the inflammation of 
 any patches in the intestines, which at a certain period 
 become covered with extra mucus ; and, second, it is 
 mcreased by the irritating materials which are passed 
 over these surfaces. Indeed, very irritating matters 
 will provoke the formation of mucus in parts iwt 
 12* 
 
138 
 
 inflamed. A watery fluid, diluting the alvine dis- 
 charges, may be poured out, like mucus from the 
 surface of the mucous membrane, consequent upon 
 either irritation or inflammation. Generally, this fluid 
 denotes the presence of peculiar irritants, such as 
 neutral salts ; and this may be seen in common diar- 
 rhoea ; or it is poured out from surfaces at an early 
 stage of inflammation, just as you often see in the 
 nasal catarrh, in its early stages, before a more viscid 
 secretion takes place. Bile is another of the fluids 
 found in the discharges ; and this should be found in 
 every alvine discharge, and intimately mixed with its 
 other elements. This should be found, I say, in a 
 state of health. An undue proportion of bile is found 
 in various cases, but in this disease, mostly from irri- 
 tation of the mucous membrane of the stomach, or of 
 the duodenum. This matter has been before adverted 
 to. But there is a stage of inflammation in which the 
 parts are left dry for a while, or comparatively so, the 
 neighboring secretions not having come to their relief. 
 In this way, I believe, the efiusion of bile into the 
 canal is sometimes suspended, and is, therefore, want- 
 ing in the dejections. There is still another cause for 
 the absence of bile, the same as for the absence of 
 faecal matter ; that a portion of the intestine cannot 
 transmit the materials brought to it, so that the dis- 
 
ON CHOLERA INFANTUM, ETC. 139 
 
 charges consist of those matters only which come from 
 the parts below the obstruction. This is what is con- 
 stantly happening in dysentery ; and which happens 
 likewise in cholera infantum, where a portion of the 
 large intestine has become the seat of disease. Blood, 
 also, is sometimes found in these dejections, and is to 
 be regarded. A little blood is not, however, a serious 
 matter; nor even is an ounce or two, for a single 
 time, a cause for alarm. It is bad when most, or all, 
 the stools are colored by blood, and the remaining part 
 consists only of mucus, or of slimy matter, derived 
 from a diseased surface, while the faeces are kept 
 back. In other words, it is bad when the cholera 
 passes into dysentery. I will add that pus, which 
 you often see in dysentery, may also occur in the 
 dejections of dysenteric cholera. 
 
 It has long been remarked that those alvine dis- 
 charges are bad, which are pure or sincere^ as they 
 have been called. By pure, in this case, it is meant 
 that the discharge consists of one material alone ; such 
 as bile, or mucus, or watery fluid, or blood. A dis- 
 charge, which consists of two distinct portions, one 
 part of bile or mucus alone, and another part of im- 
 perfect faeces, is worse than when the constituents are 
 duly mixed together. I mentioned above that it was 
 proper to regard the order of the discharges. Under 
 
140 
 
 this head I will remark, it is favorable if, after a quiet 
 night, the patient has one or two copious discharges in 
 the morning, although these be followed by frequent 
 small dejections of a bad character. Observe that in 
 this case the bowels have performed their office ; they 
 have carried through the faecal mass, with more or 
 less of morbid matter. By this they are relieved, at 
 the same time that they have shown vigor. If, after 
 this effort, they be irritated, it is of much less impor- 
 tance, than when they labor and cannot carry forward 
 their contents. I do not wish to speak now of the 
 treatment ; but, to avoid describing this state of things 
 again, I will say that this is the best moment, after 
 the large evacuations, for the use of opium ; then the 
 opium is best borne, and, while it gives rest to the 
 organs, it does not aggravate the evil by retaining the 
 faeces. Let me add here, that it is favorable when 
 the discharges are less frequent, or cease entirely in 
 the night-time, corresponding to the course of things 
 in health. 
 
 It is a bad case when the discharges run away in- 
 voluntarily, the child looking as if unaware of the 
 occurrence, and with a sunken countenance. If, with 
 this, the appetite is quite gone ; if there is disgust for 
 food, and even for drink ; if the skin be dry, and the 
 tongue also, the abdomen distended by flatus, the 
 
ON CHOLERA INFANTUM, ETC. 141 
 
 pulse and the respiration showing great weakness, the 
 patient rousing only occasionally with a shriek, or 
 perhaps rolling the head from one side to the other 
 very frequently, or tossing it rather than rolling it ; 
 under these distressing circumstances you can scarcely 
 hope for a recovery. But do not despair entirely. 
 In this disease, though these and other bad symptoms 
 have accumulated, recovery may take place. With a 
 mother who cannot give up while life continues, or a 
 faithful nurse, to watch the patient, you may see it 
 rise again from the very brink of the grave. 
 
 I hope I have said enough to aid you in understand- 
 ing this disease. I think that you must encounter it 
 at times, though I believe that it is vastly less common 
 now than formerly, when I had most to do with young 
 children. In this city, the errors which lead to 
 cholera infantum are now much better understood, and 
 are avoided. There is more care as to diet, and very 
 many children are carried to the country in the dog- 
 days. I will not enlarge on various points, which are 
 less essential, but will proceed to speak briefly of the 
 treatment. ^ 
 
 In the acute attacks of cholera infantum, the first 
 object is the dislodgment of ofiending materials from 
 the alimentary canal. In most cases the spontaneous 
 efforts suffice to clear the stomach. But, occasionally, 
 
142 ON CHOLERA INFANTUM, ETC. 
 
 it is evident that these efforts fail to remove a load, 
 which the patient has, imprudently, been permitted to 
 take into the stomach. Then small doses of ipecacuanha 
 may be given with benefit, till the burden is thrown 
 off. Two to four grains for a dose will usually suffice. 
 Much more frequently the efforts of the bowels are 
 not successful in carrying off their contents, and the 
 stomach is, at the same time, so irritable as not easily 
 to retain medicine. Then calomel is the great rem- 
 edy. Whatever objections theoretical men may make 
 to the use of so potent a drug for a tender infant, few 
 practical men, after having tried it, are willing to 
 treat this disease without this article. It is not offen- 
 sive to the taste ; it can be retained when scarce any 
 other medicine can be ; and, if vomiting follows a dose 
 of it, the stomach becomes less irritable, so that a 
 way is open for other medicines, or for nourishment. 
 By its operation the bowels are disburdened of their 
 load with benefit. But it is a medicine which is slow 
 in its operation, and castor oil may be used after it 
 with advantage ; or a few grains of jalap may bo 
 given, if the oil is offensive to the stomach. When 
 the bowels are unburdened, if the diarrhoea does not 
 subside, it may be arrested by opiates. Erom three 
 to five drops of the tincture of opium may be given, 
 and the dose may be repeated in eight or twelve 
 
ON CHOLERA INFANTUM, ETC. 148 
 
 hours. Larger doses are often requisite ; but this 
 article should be used very watchfully in a new sub- 
 ject, until its ability to bear it is ascertained. There 
 are instances — very rare ones — in which young chil- 
 dren are overcome by a very small quantity of opium. 
 I believe, upon the testimony of others, that a child, 
 a year old, has been killed by eight drops of the tinc- 
 ture of opium. I have known an instance of one, two 
 years old, killed by a dose of this tincture, given by a 
 nurse, under the belief that it was elixir asthmatic^ 
 in the dose of thirteen drops. Such instances should 
 teach caution ; but in many cases much larger doses 
 are required ; and such may be given when cautious 
 trials have shown that smaller ones are unavailing. 
 
 In the acute and violent attacks, after the evacua- 
 tions, and the administration of opiates sufficient to 
 arrest the discharges, our reliance must be on caution 
 in the use of food. The human milk is the best ; but 
 even that must be given in very small quantities, till 
 the stomach gets well quieted. From time to time 
 opiates may be needed on account of the diarrhoea. If 
 possible, however, these must be reserved for the 
 nigtit, and in the day-time the bowels should be al- 
 lowed a chance to clear themselves. Among children, 
 as among adults, we find some on whom opiates do 
 not act kindly ; not producing quiet rest, and leaving 
 
144 ON CHOLERA INFANTUM, ETC. 
 
 nausea and prostration, as consequences, after ten or 
 twelve hours. In such cases we are sometimes obliged 
 to give up this excellent medicine, for which we have 
 not any good substitute. 
 
 In all cases, as soon as possible, we must omit med- 
 icines, and endeavor, bj great care in diet and regimen, 
 to prevent a recurrence of the disease. If the gums 
 are irritated by an advancing tooth, they must be 
 carefully divided down to the tooth. The good effect 
 of this practice is doubted by those only who do not 
 try it. The requisite diet has been sufficiently dis- 
 cussed already. When the vigor of the patient will 
 at all permit, he should be carried freely into the 
 open air. If it is in a city, advise that he shall be 
 taken into the country. So great is the effect of 
 change of place, that even a child well situated in the 
 country, when in a very bad way, should be removed, 
 if it be only a mile, to a new place, and one of a 
 different character. Experience justifies us in relying 
 on so small a change for some benefit. Tonics may 
 be employed with benefit in the dyspeptic state, to 
 which teething children are reduced by diarrhoea, or 
 cholera infantum. Wine, and even spirit, may be 
 given to a large amount to those who are very much 
 reduced, and who cannot bear nourishment enough to 
 sustain life. I am hardly willing to state what quan- 
 
ON CHOLERA INFANTUM, ETC. 145 
 
 titles I have sometimes given, from the fear that the 
 same might be done when unnecessary. In every 
 instance we must decide, after careful watching of the 
 patient before us, to what extent the stimulants, or, I 
 would rather say, cordials, should be carried. But 
 the bad cases are almost entirely among children who 
 are weaned. In such, when possible, a woman should 
 be found who can press out the milk from her breast, 
 and the child should be supplied with this best of food 
 and of cordials. I feel vastly more sure that I have 
 saved life in many instances by resorting to this expe- 
 dient, than that I have ever saved it by the use of 
 medicine. 
 
 The occurrence of diseases during the first period 
 of dentition is familiarly known, and attributed to the 
 irritation of the coming teeth. It is not so well known 
 that the appearance of the permanent teeth, also, is 
 attended by diseases of various kinds. I feel satisfied, 
 however, that this is the case. I cannot quote any 
 authority in support of this opinion ; but for many 
 years I have pointed it out to my brethren, and some 
 of these have confirmed my observations by their own. 
 
 During the second dentition, then, a liability to 
 
 disease may be remarked as well as during the first j 
 
 though not so great. Besides this general liability, 
 
 there are certain morbid afiections which are in a good 
 
 13 
 
146 ON CHOLERA INFANTUM, ETC. 
 
 measure peculiar to the period. But you will not 
 understand me that these are showing themselves 
 during the whole period of the second dentition ; far 
 from it. There are instances where disease is pro- 
 duced during the first years of this period, and some 
 also in the very latest period of it. I have seen per- 
 sons between twenty and thirty much afi*ected by a 
 wisdom tooth not yet protruded, and distinctly re- 
 lieved by cutting the gum. But I think the most 
 common period of suffering from the second dentition 
 is from the tenth to the thirteenth year. The most 
 characteristic affections are wasting of flesh and nerv- 
 ous diseases. The boy loses his comeliness, and his 
 complexion is less clear, while emaciation takes place 
 in every part, though mostly, perhaps, in the face. 
 The nervous symptoms are various ; but the most 
 common are a change in the temper, and a loss of 
 spirits. With these there is some loss of strength. 
 The patient is unwilling to engage in play, and soon 
 becomes tired when he does do it. Among the distinct 
 symptoms which are not uncommon, I may mention 
 pain in the head and in the eyes. The headache is 
 not commonly severe, but it is such as inclines the 
 patient to keep still. The eyes are not only painful, 
 but are often affected with the morbid sensibility, to 
 which those organs are subject. I have known boys, 
 
ON CHOLERA INFANTUM, ETC. 147 
 
 truly anxious to pursue their studies, obliged to give 
 them up on this account ; and these, not having the 
 disposition to plaj, will of choice pass the day with 
 their mothers, and increase their troubles by the want 
 of air and exercise. Nervous affections of a more 
 severe character are sometimes manifested. Chorea 
 is noticed very often at this period of life ; and, in 
 some instances, I have known this disease to appear in 
 the spring season for two or three years in succession. 
 Some children at this same period become very notional 
 and whimsical, so that they may be regarded as insane. 
 In one instance, a boy about twelve years of age, would 
 loiter in the house, keeping his slippers on, careless in 
 his attire, and almost refusing to go abroad, even into 
 a garden. All this was entirely different from his 
 usual course of life, which was very orderly. After 
 some months, he was placed under the care of a 
 medical gentleman, who received nervous and insane 
 patients into his house, and under his treatment was 
 very shortly restored to a sound state. 
 
 The remedies, which I have found most useful, are 
 as follows. First, a relief from study, or from regular 
 tasks ; yet using books so far as they afford agreeable 
 occupation or amusement. Second, exercise in the 
 open air, preferring the mode most agreeable to the 
 patient ; and, in more grave cases, the removal from 
 
148 ON CHOLERA INFANTUM, ETC. 
 
 town to country. The lad above-mentioned, in whom 
 the disease had amounted almost to insanity, was very 
 skilfully managed in this way. The physician first 
 took him to ride with him as an indulgence ; and it 
 was felt to be so by the boy. Then he let him drive 
 the horse occasionally, and, finding he was interested 
 in the horse, he allowed him to harness him. In 
 short, by means of the horse, he restored him to habits 
 of activity, while his mind and feelings were engaged ; 
 when soon, instead of moping, he became cheerful, and 
 his flesh was restored. In all cases, the stomach and 
 bowels are to be attended to, but the trouble with 
 them is nothing compared with that during the first 
 dentition. Sometimes iron may be employed with 
 advantage, but, generally, medicines are not required. 
 Those, who get much enfeebled during s.ummer, may 
 employ sea-^bathing with benefit. 
 
 When I tell you that the affections appertaining to 
 this period of childhood and youth have not been 
 understood to be connected with dentition, you may 
 ask what has been thought of them ? My reply is, 
 that in a large proportion of cases, where troublesome 
 symptoms have occurred, the patients have been 
 thought to have worms in the intestines. Since I 
 have become acquainted with the affections above- 
 deacribed, I have almost ceased to use pink-root, and 
 
149 
 
 rarious other remedies regarded as vermifuges. I 
 will here remark, that, though worms in the intestines 
 do sometimes give occasion to grave symptoms, yet 
 instances of this sort are extremely rare. In some of 
 the worst cases produced by the second dentition, 
 disease of the brain has been suspected, and, I fear, 
 suffering has been sometimes inflicted upon patients by 
 this error in diagnosis. A low diet prescribed under 
 this misapprehension must be very injurious. 
 
 I know very well that many sagacious practitioners 
 are satisfied as to frequent and serious evils from worms 
 in the intestines. I am constrained to differ from them. 
 It is very common to find worms discharged by chil- 
 dren and adults, who have previously been in good 
 health. This will happen sometimes without obvious 
 cause ; but more commonly in consequence of any 
 fever, under which the patient ceases to take the usual 
 nourishment. I remember a case of pneumonia, as 
 distinctly marked as possible, in which lumbrici 
 were discharged. The attendant physician called the 
 disease a worm fever. I have seen a man confined in 
 consequence of a fracture of the tibia, in whom the 
 same evidence of a worm fever showed itself A 
 medical gentleman, forty years ago, invited me to 
 attend an autopsy of a boy who had died of worm 
 fever. I accepted the invitation, and en laying open 
 13* 
 
150 ON CHOLERA INFANTUM, ETC. 
 
 the abdomen found the cayitj filled with pus, and all 
 the other marks of peritonitis. I would not be under- 
 stood to say that we do not ever see inconveniences from 
 worms. The ascarides often occasion much uneasi- 
 ness, accompanied by itching about the anus. Other 
 worms also give trouble at times, but not often any- 
 great trouble. Excuse this digression. 
 
 While treating of cholera infantum I made mention 
 of the disease known under the popular name of canker 
 in the mouth. This is a different affection from 
 aphthcB of the mouth, and I know of no other distinct 
 name, w^hich has been given to it, except that of 
 ulcuscula oris. This name I got from my master, 
 Dr. Holyoke. 
 
 Ulcuscula oris are little ulcers within the mouth, 
 on the cheeks, gums, and tongue ; and more rarely on 
 the fauces. They may occur at any period of life, 
 and some persons suffer from them throughout their 
 lives, occasionally. This is among the hereditary 
 diseases. At least, I know one family, in which it 
 showed itself in three successive generations. But 
 this, perhaps, is not just the same disease as that 
 which occurs in childhood. I cannot point out the 
 difference as to symptoms, but I know that it does not 
 yield, in these cases, to the same treatment which is 
 employed successfully in children. Also, in children, 
 
ON CHOLERA INFANTUM, ETC. 151 
 
 Ihe disease often assumes a violent and acute form, 
 and it is even sometimes epidemic under this form. 
 The local affection, as jou commonly see it, consists 
 in small, superficial, circular ulcerations. On looking 
 into the mouth, you see a circular white spot, sur- 
 rounded by a red line. If, however, you catch the 
 disease at its commencement, you will find that it is a 
 vesicle, but the skin or pellicle is extremely thin, and 
 is very soon broken, leaving the circular ulcer. In 
 severe cases, you find the gums generally, and some- 
 times portions of the cheeks swollen, and very red. 
 The tenderness of the ulcuscula is great, especially 
 when the surrounding parts are inflamed ; but the 
 degree of tenderness varies more than the appearance 
 to the eye ; so that some patients will take food into 
 the mouth, and manage it very well, while others, the 
 disease not looking worse, will admit only the most 
 bland liquids. In some instances I have seen children 
 refuse all nourishment except once, or at most twice, 
 in the twenty-four hours ; when, driven by desperation, 
 they would seize and swallow down a cup of milk. I 
 had once a memorable case, in which the disease was 
 protracted for some days in its severe form, and 
 where various articles were offered in hopes to save 
 the child from starvation. Among these articles was 
 some broiled meat. The child seized this, tore it to 
 
152 
 
 pieces with his little hands, like a wild beast, and then 
 pressed it to his nose, snuffing at it with an obvious 
 gratification, and seeming almost to derive nourishment 
 from the scent. This was done for three or four days, 
 more than once a day, until he was so far restored aa 
 to be able to take food into his mouth. 
 
 When the ulcuscula occur in an acute form they 
 are attended by febrile symptoms, which are especially 
 violent in the night. In one season both this disease 
 and measles were epidemic, and many children had 
 both of them in the course of the spring. Among 
 these there were several instances, in which the fever 
 attending the sore mouth was more severe, than that 
 of the measles in the same subject. This sore mouth 
 terminates favorably when not complicated with 
 cholera infantum. But its violence may be abated, 
 and I believe its duration may be shortened, by treat- 
 ment, if this be employed early. Calomel should be 
 given in doses of three to five grains with the same 
 quantity of jalap, and the dose may be repeated after 
 two days. Meanwhile, an astringent gargle, or 
 mouth-wash should be used every two hours during 
 the day-time. I prefer a solution of sulphate of 
 zinc to any other article for this purpose. I direct 
 ten or twelve grains of the sulphate to be dissolved in 
 four ounces of rose-water. There is often a difficulty 
 
153 
 
 In \ising any mouth-wash for children. I have been 
 in the habit of doing it in this manner : take a tea- 
 spoon and fill it nearly full ; then watch a chance for 
 introducing this into the mouth, and throw it on one 
 side. If the liquid is placed on the tongue, the child 
 can easily spit it out, or swallow it, not allowing the 
 liquid to extend over the mouth. If it be thrown on 
 one side of the mouth, or under the tongue when this 
 is Hfted up, the child will make an effort to bring it 
 on the tongue in order to spit it out. In doing this 
 he will spread it over the mouth, so that it will reach 
 all the parts affected. 
 
LETTER X. 
 
 ON ABSCESS IN THE TONSILS, ELONGATED UVULA, 
 BRONCHITIS AND PNEUMONITIS, RHEU- 
 MATISM AND GOUT. 
 
 Before passing to the organs of respiration, there 
 are two diseases about the fauces, on each of which 
 I have a word to saj. The first is Abscess in the 
 Tonsils, This disease you will meet with not unfre- 
 quently ; and you will find that most persons, who 
 have it once, will have it again and again. At first 
 the patient feels a soreness about the throat, attended 
 with a difficulty in deglutition. So far, it may be 
 some other afiection of the fauces : but some of those, 
 who are subject to it, think they can distinguish it by 
 a peculiar sensation, a stinging, or something else, 
 from any other disease. If examined at this period, 
 there will be found an enlargement of one of the ton- 
 sils, such as to press forward the anterior pillar of the 
 palate. In two or three days this tonsil is found to 
 be tense and enlarged, with a shining surface. The 
 
ABSCESS IN THE TONSILS, ETC. 155 
 
 pain increases from day to day, as does the difficulty 
 of swallowing, so that at last the patient will avoid 
 swallowing as much as possible. Accompanying these 
 symptoms is a peculiar difficulty of speech. The voice 
 sounds as if the patient had a mouthful of pudding just 
 stopped in the fauces. At this time speaking is pain- 
 ful, as well as swallowing. This disease is often dis- 
 tressing, causing the patient to sit up a great part of 
 the time, and preventing quiet sleep. The respiration 
 is impeded, but not seriously; though apprehensions 
 are sometimes excited on this score. At length th-e 
 abscess opens, sometimes discharging freely, and giv- 
 ing sensible relief at once ; but not uncommonly the 
 orifice is small, and the relief comes on gradually. 
 An abscess in the tonsils is sometimes spoken of as 
 dangerous, and patients are, not unnaturally, filled 
 with fears ; but the danger is very slight, if there be 
 any. I have seen it very many times, and have never 
 seen a fatal case. When you see the disease at an 
 early period, you may very naturally think of the 
 remedies proper for inducing resolution, such as 
 leeches and vesication. Now I wish to express to 
 you my conviction that in these cases suppuration 
 cannot be prevented by any treatment. I have noticed 
 the disease only to state this as the result of my ex- 
 perience. If you believe me, it may save trouble to 
 
156 ABSCESS IN THE TONSILS, ETC. 
 
 your patients. Leeches and blisters only add to the 
 affliction, and so do gargles. These cannot be prop- 
 erly used. The parts are too lame to permit it. The 
 only relief, which art can give, is by opening the ab- 
 scess ; and, if this be attempted too early, it is una- 
 vailing. Where the abscess points, as it sometimes 
 does, posteriorly, it is not easy to reach the pus with 
 the lancet. 
 
 I will mention next the elongation of the uvula^ a 
 morbid change which may be seen very frequently ; 
 oftener in the old than the young. In some instances 
 the uvula is very much thickened and enlarged, as well 
 as elongated ; sometimes it is long and pointed ; but 
 this is rare. When most diseased, it will not be re- 
 tracted upon stretching the fauces open, as it is in a 
 sound state. The part itself does not appear to suffer ; 
 it is not painful, nor sore. It is, however, very an- 
 noying to the surrounding parts ; especially to the 
 root of the tongue, and to the epiglottis. In some 
 few instances it causes nausea. But the common evil 
 from it is a cough, or a hawking, or both. The cough 
 is ineffectual, and is therefore repeated very often ; 
 hence the surrounding parts become irritated more or 
 less extensively, especially the larynx. In some per- 
 sons the muscles of the thorax are fatigued, and are 
 made lame and sore by the coughing. In a few 
 
ABSCESS IN THE TONSILS, ETC. 157 
 
 instances you will find the voice affected; there is 
 hoarseness, and some difiicultj in speaking. The 
 trouble from this affection is much aggravated when 
 bronchitis occurs ; for then the cough is much more 
 frequent and distressing than would arise from the 
 bronchitis alone. This disease often continues for 
 years without being suspected, and is always to be 
 looked for in old men, who have winter coughs. The 
 plain remedy is the amputation of the uvula. This 
 gives relief ; sometimes strongly marked, at once ; 
 but the surrounding parts, which have been long sub- 
 ject to irritation from the vain coughing, may require 
 time for their recovery ; so that, in most cases, the 
 full relief is not immediate. If bronchitis exists 
 at the time, the relief must necessarily be partial, 
 though ultimately the bronchitis is terminated in a 
 shorter time than it would otherwise be. 
 
 Though I am not a surgeon, I have a word to say 
 upon this operation. The uvula should not be cut off 
 at its root. It is sufficient to remove from one half to 
 two thirds of it, according to its length. In all cases, 
 the wounded parts are sore for a few days, so as to be 
 irritated by a hot liquid, by an acid, or by pepper. 
 But when the uvula is cut off at its root, the subse- 
 quent evil is much greater ; for, in this case, when- 
 ever the soft palate is brought into play, the wound is 
 14 
 
158 ABSCESS IN THE TONSILS, ETC. 
 
 stretched J the raw surface is irritated, and thus the 
 healing is protracted. But the wound of the uvula, 
 when cut midwaj, does not suffer in this manner, and, 
 like other wounds within or about the mouth, will 
 commonly heal in a short time. 
 
 I now proceed to diseases in the organs of respi- 
 ration ; but I shall not treat of all of them ; and not 
 fully nor exactly of any ; for, as in the preceding let- 
 ters, my only object in describing diseases is to make 
 it sure that you shall know what I am dealing with. 
 
 First, of catarrh, or bronchitis ; terms, which, at 
 the present day, are nearly synonymous. The patient 
 with catarrh tells you he has a cold, and he thinks 
 that is all you need to know. In calling the disease 
 a cold, he refers to its remote cause, or what he con- 
 siders so. But he would also tell you he had taken 
 cold in various other cases ; if, for instance, he is 
 aifected with ophthalmia, or rheumatism; and, per- 
 haps, if he has a diarrhoea. Even on the first days 
 of typhoid fever the patient will talk of his cold. 
 Likewise, patients affected with chronic diseases very 
 frequently speak of an aggravation of their symp- 
 toms, in consequence of a cold. When, therefore, a 
 patient says he has taken a cold, it is necessary to 
 ascertain the symptoms and the order of their occur- 
 rence. In going through this scrutiny, I think it is 
 
159 
 
 of no small use to make the patient perceive just how 
 the evil from cold, as a cause, has been brought about. 
 From not attending to this point, patients and their 
 friends are led to believe that an exposure to cold 
 water and to cold air is always attended with some 
 danger, and then they are led into habits of precau- 
 tion, under which the liability to disease is greatly 
 increased. One who has been in active exercise, and 
 especially if much fatigued, and then stands still in a 
 cold atmosphere, or goes into a cold cellar, or lies 
 down on the damp grass, or sits in a draught of wind, 
 or leaves off an accustomed garment, is very apt to 
 have a catarrh, or some other disease, which may be 
 fairly attributed to "taking cold." This comes from 
 the sudden reduction of temperature on the surface. I 
 I shall not stop to inquire how this affection of the 
 surface operates in bringing on a catarrh, or a rheu- 
 matism. And I need not say that there are other 
 ways, besides those enumerated, in which you may 
 take cold. A mere exposure to a cold atmosphere 
 does not necessarily make one take cold, even when 
 exposed after being heated. The evil effects depend 
 very much on the ordinary habits of the subject as to 
 exposure. If you pass your time mostly in the house, 
 and never move abroad without a great abundance of 
 warm clothing, and keep yourself over-heated much 
 
160 
 
 of the time, the slightest exposure to a change of tem- 
 perature will give you a cold. If such be your case, 
 you should take measures to harden yourself, as it is 
 termed. To this end you may be directed to use a 
 cold bath every day. This is good advice. But, if 
 you do no more, the gain will be very moderate. 
 This remedy, operating only a few minutes in a day, 
 will have very little influence unless your habits be 
 changed in other respects. The most important change, 
 in such a case, is to go abroad daily and get exercise 
 in the open air, whatever the weather may be. This 
 cannot be done fully at once ; the change must be grad- 
 ual. At the same time, the habit of heavy clothing 
 must be gradually abandoned. As near as may be, 
 the clothing should be such as you can move under 
 with ease, and without inducing great heat. This is 
 the advice to be given to one who is apt to suffer from 
 exposure to cold weather. There are some persons 
 who seem incapable of being hardened to the weather 
 in any way ; but they are very rare exceptions. 
 
 A catarrh consists in an inflammation of the mucous 
 membrane of the nose, fauces, windpipe, and its subdi- 
 visions, the bronchi. It may commence in any one 
 part, and be limited to that ; but it very commonly 
 spreads from the part first affected. Usually, in 
 spreading, it leaves this part in a state of recovery 
 
ABSCESS IN THE TONSILS, ETC. 161 
 
 while it extends to the adjoining parts, in the same 
 manner as erysipelas spreads on the skin. Most com- 
 monly the disease begins in the nose, and travels down 
 to the larynx, where it causes a hoarseness, and thence 
 it goes to the bronchi on one side, or occasionally to 
 both. In the lungs its extent may be greater or less. 
 When it reaches the extreme air-vessels, especially if 
 it affects many of them at the same time, it becomes 
 a somewhat grave disease. A catarrh is sometimes 
 very slight and limited ; at others severe and exten- 
 sive. The constitutional affection bears a relation to 
 its severity and to its extent. When the disease is in 
 the bronchi, it is at the present day called bronchitis j 
 though this word is used loosely, and is employed by 
 many when the disease is in the larynx. 
 
 A severe bronchitis often receives the name of in- 
 fluenza in our community. But influenza, though it 
 commonly includes bronchitis, is a different disease. 
 It is ushered in by constitutional symptoms, chills, 
 pains in the head, back and limbs, as happens in more 
 grave febrile diseases. It is also an epidemic, and an 
 extensive epidemic, spreading over a continent in the 
 course of a few months, or even of a few weeks. It 
 is doubtful if this disease is ever sporadic. When the 
 great and learned have a severe bronchitis, there often 
 fs, among all concerned, a disposition to magnify the 
 14* 
 
162 
 
 disease, and then it is called an influenza. Now, 1 
 could tell the reverend or the honorable gentleman, 
 that when he has the influenza, the chance is that the 
 domestics in his kitchen will have it too. I should 
 not make this remark if I did not believe that the 
 patient, who has his malady thus exalted by a great 
 name, is often led into some unnecessary evils by the 
 misnomer. 
 
 When a catarrh, or bronchitis is not severe, a per- 
 son, whose usual health is good, may pursue his com- 
 mon course of life. But if severe, or if the patient 
 has not a very sound constitution, some precautions 
 should be taken. For two or three days, at the com- 
 mencement, the food should be diminished, and that 
 which is most stimulant should be avoided. If there 
 be chilliness, well marked, a slender person should 
 keep the house for one or two days. But this should 
 not be done for a slight cause, as if it was the safer 
 course at any rate.- There is danger in keeping close 
 upon every slight occasion, for thereby the system is 
 made more susceptible ; and then slight exposure will 
 aggravate the disease, or induce disease anew. 
 
 Medicinal remedies are not often advisable, even in 
 bronchitis, except when a cough becomes troublesome, 
 preventing sleep, or causing soreness or lameness in 
 the breast. Then opium, combined with ipecac, or 
 
163 
 
 some preparation of antimony, is useful. This should 
 be taKen at night ; and as the opium will commonly 
 occasion costiveness. it is well to counteract this by 
 adding some cathartic in a small dose. For this pur- 
 pose two or three grains of comjwund extract of 
 colocynth^ or as much aloes ^ will often suffice. A 
 si^th of a grain of tartarized antimony, and double 
 that quantity of opium, is usually sufficient, as the 
 night dose for an adult. Two or three grains of 
 squills may be advantageously added to this dose, 
 when the expectoration is scanty and difficult. In 
 bad cases it is useful to give one to three grains of 
 calomel, instead of the colocynth, for one or two 
 nights. 
 
 For an adult, previously healthy, who is affected 
 with bronchitis and is anxious to throw off the disease 
 at once, even with some inconvenience, a more active 
 practice may be used. If not always successful, it 
 will commonly be found so, when employed in the first 
 week of a bronchitis. The following is the dose which 
 I have employed for this purpose; in some cases 
 giving half of it only. It should be taken at bed-time. 
 
 R. Antimon. tartar g^- j- 
 
 Pulv. opii g^- j- 
 
 Hydr. submur gi*- x. 
 
 Mucilag. gum acac. qs. m. f. pil. No. iij. 
 
164 ABSCESS IN THE TONSILS, ETC. 
 
 Such a dose should never be given to a scrofulous 
 or tubercular subject, nor to one approaching old age. 
 nor to any one in tender health. Usually much 
 milder articles serve to mitigate the symptoms of 
 bronchitis. When there are no strong inflammatory 
 symptoms, the tincture of tolu is very useful ; that 
 may be sweetened by the syrups of tolu and of squills. 
 Half a drachm of each may be given three or four 
 times a day, and double the dose at bed-time. A little 
 opiate should be added when the cough is very urgent. 
 In chronic bronchitis the same is valuable among the 
 mild remedies. For young children, under a trouble- 
 some bronchitis, I employ the following: Take of 
 either almond or olive oil, of syrup of squills, of any 
 agreeable syrup, and of mucilage of gum acacia, equal 
 parts, and mix them. Of this mixture a teaspoonful 
 may be given to a child at two years of age ; a little 
 less if younger, and increased if older, so as to double 
 the dose to one in the sixth year. This may be given 
 from three to six times in the twenty-four hours. 
 Sometimes a little opiate must be added at night to 
 appease an urgent cough. The diet at first should be 
 simple in kind and moderate in quantity ; but, when 
 the first violence of the disease has subsided, the usual 
 diet may be allowed. 
 
 I have very little to say on pneumonitis. I be- 
 
ABSCESS IN THE TONSILS, ETC. 165 
 
 lieve that this disease is very rarely fatal to healthy 
 adults, except during an epidemic of a peculiarly bad 
 character, or unless it affects both lungs. If the pa- 
 tient have tubercles in the lungs, or a cancer, or other 
 malignant affection, or if worn down by any other dis- 
 ease, or by intemperance, the danger is very consider- 
 able. The same remarks may be made in regard to 
 pleuritis and pericarditis, when not complicated. 
 
 In young children the disease is attended with more 
 danger, than in adults. The same is true, in some 
 measure, as to persons past seventy years of age. Yet 
 in these, and even in those past eighty, if the consti- 
 tution be not very slender, and if the habits of life 
 have been good, almost all recover, provided one lung 
 only be affected. 
 
 The common practice has been to take blood from 
 the arm in pneumonitis. I am satisfied that this is 
 wise, if the patient is vigorous and not very old, pro- 
 vided it be done on the first or second day of the 
 disease. Even on the third day, in a strong man, it 
 is a good practice ; but later than this I believe it is 
 useless at least, and that it is sometimes injurious. 
 
 M. Louis, of Paris, has shown that the disease is 
 not arrested, nor materially shortened, by bleeding, 
 as he has seen it practised ; but I believe that all the 
 cases lie has brought forward had arrived at, or passed 
 
166 
 
 the third day of the disease before the bleeding had 
 taken place. An examination of the cases at the 
 Massachusetts General Hospital confirmed the opinion 
 advanced by M. Louis. 
 
 I have said that this disease is attended with more 
 danger in young children than in adults. In such 
 young subjects, when vigorous, I have thought bleed- 
 ing, within the first forty-eight hours, decidedly bene- 
 ficial ; lightening the disease, if not shortening it. In 
 young children it is not easy to find any good vein for 
 the operation, except the external jugular. It is not 
 difficult to open this vein. I have done it many times 
 for this and other diseases. I never lamented that I 
 had done it ; I have lamented very much in some 
 instances that I had not done it. 
 
 Whether bleeding has, or has not been employed, I 
 believe that the free use of antimonials in the first week 
 of pneumonia is beneficial. They diminish the violence 
 of the disease at least. But there a,re many delicate 
 subjects who do not bear this article well. In regard 
 to mercurials I have not so favorable an opinion. I 
 have seen them tried fully. They were very univer- 
 sally employed in this vicinity when I was a pupil 
 and many years afterwards. They were not at all 
 used in England when I was there, in 1799 and 1800. 
 They were first introduced in inflammatory complaints 
 
167 
 
 at a later period, and have been in great favor there 
 for twenty or thirty years. I think that they will not 
 remain in favor fifty years hence, there or elsewhere, 
 for the relief of simple inflammation. 
 
 In mild cases of pneumonitis, and in very feeble 
 subjects, it seems to me most safe to avoid all active 
 treatment. In all cases opiates are sometimes useful 
 to prevent urgent coughing ; but they should be used 
 very moderately, and not in the early stage of the dis- 
 ease. When the disease continues, without much 
 abatement, towards the end of the second week diar- 
 rhoea sometimes occurs. This should not be checked 
 suddenly, for it affords relief I think I never saw 
 this except when the disease was in the right side ; 
 and I have supposed that the liver was first congested 
 and then a great secretion of bile was induced. 
 
 As this letter is not very long, I will add a few 
 words in respect to rheumatism and gout, and only a 
 few. 
 
 Rheumatism is a very large box, and contains quite 
 a variety of things ; and these- things do not all agree, 
 either as to their material, or their form. This is con- 
 ceded at once as to the acute and chronic. The acute 
 disease, known as rheumatic fever ^ has a pretty dis- 
 tinct character ; its form and pressure are such that a 
 man, who has once endured them, does not easily forget 
 
168 
 
 them. If any good is to be done in this disease, it 
 must be at the very beginning ; just as I have endeav-. 
 ored to show about all diseases, especially such as 
 are acute. The chance in this disease is not so good 
 as in some others. Free evacuations and low diet 
 from the first are, I think, certainly useful, though 
 they do not jugulate the disease. But there is a 
 natural relief in two or three weeks, and then patient 
 and doctor are too apt to think the disease is going 
 away. Not so ; if ever, very rarely. At this stage 
 medicine will not do much, if anything ; but care may 
 do much. Not the care which keeps a man smothered 
 up, such as to increase the excessive perspiration 
 which belongs to the disease. Let the patient be as 
 lightly covered as is consistent with his present com- 
 fort ; that will be enough. But the care must be in 
 avoiding any great effort of body or mind, in maintain- 
 ing calmness and tranquillity, and in moderate diet. 
 Give enough milk and bread, or some other vegetable 
 article, to support the patient; but withhold animal food. 
 If the disease is not checked at the beginning, avoid all 
 strong medicines, except opium for severe pain. Keep 
 the bowels open, and be watchful as to diet. If any- 
 thing has been useful in my hands after the first few 
 days of the disease^ it is the sulphate of quinia. 
 This article, taken as freely as it is for intermittent 
 
ABSCESS IN THE TONSILS, ETC. 169 
 
 fever, appears sometimes to arrest the disease. It is 
 not, however, as certain as was believed by Dr. Hay- 
 garth in respect to the cinchona itself. 
 
 Next, — the local rheumatism^ from which a large 
 part of mankind suffer more or less frequently, about 
 the shoulders, or loins, or elsewhere, may, I believe, 
 be stopped in all cases, — at the heginning ; and this 
 by the old remedy, flannel, red, blue, or white. Two 
 things are important ; first, that the flannel be applied 
 at once, when the pain comes ; not by and by. It 
 should be applied within the first six hours ; and it is 
 better to apply it the first hour. On the second day 
 it does very little good. Second, the flannel should 
 be new and thick, or doubled, and there should be 
 enough of it to extend much beyond the region 
 affected. It should be kept on until the pain has been 
 quite gone for twenty-four hours. Meanwhile, one 
 who is accustomed to cold bathing may continue this, 
 taking care to use extra friction after it. In some 
 instances of lumbago particularly, I have seen decided 
 benefit from applying a solid lump of ice to the part, 
 and holding it there as long as the patient can make 
 up his mind to bear it. But this should not be done 
 except to a man in good health and of good vigor 
 
 Last, there is an affection, called rheumatism, 
 which begins hi the small joints^ in the hands and 
 15 
 
170 ABSCESS IN THE TONSILS, ETC. 
 
 feet ; first in the hands most commonly.^ It differs 
 from goutj inasmuch as it begins slightly, and increases 
 gradually, extending from part to part. Probably the 
 patient does not apply for medical aid until he has had 
 it long enough for two or three fits of the gout. By 
 degrees the disease spreads to the large joints ; but 
 whereas acute rheumatism is getting well in one part, 
 while it is increasing in another, this disease seldom 
 leaves a part entirely on which it has once fixed itself 
 It is a chronic disease, not affecting the system very 
 sensibly at first, but gradually bringing on a cachexy. 
 I do not know that any writer has noticed this disease, 
 distinguished by the slow beginning in the small joints 
 and gradually extending ; but men of experience 
 cannot have failed to see it, though it is not an every- 
 day malady. 
 
 There is a very bad part of this story ; bad for me. 
 I do not know of any remedy for it. The patients 
 live under it twenty and thirty years, and of course 
 they try all sorts of remedies, but they do not recover. 
 Such, at least, is my experience. It is to guard 
 against inflicting useless suffering on the patients that 
 I have made this statement. I beg my brethren to be 
 tender with such persons. The humoralists of the 
 present day have turned their attention to rheumatism. 
 I hope that they will continue to study it. The dis 
 
ABSCESS IN THE TONSILS, ETC. 171 
 
 ease I have just referred to, obviously different from 
 any other thing called rheumatism, is most especially 
 worthy the study of men truly scientific, and willing 
 to he patient in their investigations. 
 
 Now of gout. I shall not say a word respecting 
 the disease; I wish only to consider the treatment. 
 And my only wish on that score is to add my testi- 
 mony to that of many of the highest authority, in 
 respect to colchicum. That remarkable article is 
 sometimes found useful at any period of gout ; but it 
 is comparatively of little use except in the very outset. 
 The great point to be ascertained, in regard to each 
 individual patient, is the dose he requires. This should 
 be enough to act on the bowels quite freely, without 
 being so much as to cause nausea. For most persons 
 such a dose may be found. If some, having irritable 
 stomachs, cannot bear without nausea sufficient for the 
 purpose, then give what the stomach will bear with 
 ease, and repeat the same in six or eight hours. It 
 may sometimes be necessary to use some cathartic in 
 addition. In most instances the fit dose for any indi- 
 vidual may be found ; that settled, let him take his 
 dose as soon as he feels the gout. Let him not, on 
 any account, wait longer than six hours, after the first 
 sign of gout, before he takes his dose. Then, in all 
 probability, his disease will vanish within twenty-four 
 
172 
 
 ETC. 
 
 hours. He may take a dose unnecessarily once in ten 
 times. This is a small loss for the benefits he will 
 obtain on the whole. Gout is not so common among 
 US as to permit me to speak from a large experience, 
 but I believe this statement to be substantially correct. 
 I should feel less confidence in it, if it did not accord 
 with the opinions of the best physicians in England, 
 the country where the gout prevails most extensively. 
 
LETTER XI. 
 
 ON PHTHISIS AND HEMOPTYSIS. 
 
 I SHALL now treat of Phthisis Pulmonalis. This 
 is a disease which carries off a very large proportion 
 of mankind in all climates ; more, I presume, than 
 one sixth. I confine the name to cases which are 
 founded on tubercles, as most medical men do at the 
 present day. Though almost uniformly fatal, the 
 disease differs much in the rapidity of its course. In 
 general terms, it is more rapid in the young than in 
 those much advanced in life. It occurs in young 
 children, though not frequently. From eighteen to 
 thirty-six years of age, men and women are very sub- 
 ject to it ; and its course is comparatively rapid, rarely 
 lasting much more than two years. Some melt away 
 at once ; and this happens even to those who, at first, 
 are florid and full of flesh. Some persons endure it 
 for ten and twenty years, and perhaps longer. This 
 happens mostly in those who are thirty-five or forty 
 years old, before the disease commences. Some, who 
 are not very vigorous in appearance, will fight every 
 15* 
 
174 ON PHTHISIS AND HEMOPTYSIS. 
 
 inch of ground, even under great sufiering. It is not 
 to the slender and feeble only that it comes, but occa- 
 sionally to large men, showing all the usual marks 
 of vigor. It is a satisfaction to be able to say that 
 phthisis is not always fatal ; we do see instances of 
 recovery from it. 
 
 I shall not enter into the history of the disease, but 
 shall point out what I consider the great principles, by 
 which to be guided in the treatment of it. These 
 have regard not only to the part affected, but to the 
 system at large. We must endeavor to prevent the 
 cachexy, if that has not appeared, or to overcome it 
 when it has. To effect this purpose we must not 
 rely on medicinal drugs. We must pursue a course 
 calculated to increase the general vigor of the system, 
 trusting to the natural efforts to overcome the disease, 
 if that be possible; and we may do this with the more 
 confidence, as such a course may, at least, prolong 
 life, if we cannot save it. To this end we should 
 direct a nutritious diet ; but we must not leave the 
 patient to judge what articles are comprehended in 
 such a diet. For nutrition, we must direct animal 
 food, millc, and the farinaceous articles. These are 
 sufficient for that purpose ; but if they should be used 
 alone, the functions of the bowels would not be well 
 performed. In that case, costiveness would lead to 
 
ON PHTHISIS AND HEMOPTYSIS. 175 
 
 djspepsj, to dryness of the mouth, to heat of the skin, 
 and, perhaps, to trouble about the head, with uneasy 
 sleep. So far, tljerefore, as the bowels require it, 
 there should be added fruit and other articles of a 
 laxative character. Next to the diet, and of all things 
 most important, is exercise in the open air. This 
 should be carried as far as the vigor of the patient 
 will permit. It should not be done rashly, but 
 boldly. If possible, the patient should be made to 
 have faith in it ; for, without this, he is not likely to 
 pursue it as far as he can^ and then he will not derive 
 from it all the benefit which it can afford. An in- 
 stance occurred to me, nearly fifty years ago, which I 
 have often related since, as well calculated to produce 
 a proper faith. It confirmed my previous convictions 
 on the subject. A man presented himself, in the 
 month of May, who lived in a retired part of Maine, 
 below Penobscot river. He had come from his home, 
 with great inconvenience, to seek for medical aid. I 
 found that he had the usual symptoms of phthisis; 
 he had been confined to his house in January, at 
 which time he sweat profusely in the night, was much 
 reduced in strength, and wretchedly sick. He saw, 
 however, that he and his family must starve, if he 
 could not engage in his usual winter employment of 
 cutting wood. After much reflection he went forth, on 
 
176 ON PHTHISIS AND HEMOPTYSIS. 
 
 the first of February, with his axe on his shoulder. 
 He labored for half an hour, when he was so exhausted 
 that he was forced to lie down upon the snow. Thus 
 ended his first day's trial. He persevered, however, 
 and by degrees gathered strength, so that at the end 
 of the season he could do a moderate day's work. 
 This story he told me with many details, which I 
 need not repeat. They were such as to show conclu- 
 sively that his was a case of phthisis. Auscultation 
 was then unknown. I told him that his story was a 
 very interesting one, and very instructive ; that he 
 had done more for himself than any drugs could do ; 
 and that, if his health could be restored, it would be 
 by continuing the course, on which he had so happily 
 entered. 
 
 The mode of exercise should be such as the strength 
 and circumstances of the patient permit. One would 
 not have proposed such a course as was pursued 
 by the man from Maine ; and I presume that no 
 man could have gone through that course, who was 
 not urged by necessity. In general, exercise on horse- 
 back is to be commended. It does not embarrass the 
 organs of respiration, which walking does in some 
 instances ; and it does bring the muscles into play 
 which driving^ or riding on wheels, does not. Work 
 ing in a garden would suit some persons. Any exer- 
 
ON PHTHISIS AND HEMOPTYSIS. 177 
 
 cise is better than a life of rest. I once had a patient 
 who got his living by white-washing. That is, he 
 passed his time in washing the inside walls and ceil- 
 ings of houses ; thus surrounded by moisture, and in 
 rooms where it was necessary to keep open windows, 
 and consequently steady drafts of air about him. He 
 was satisfied that he did better, when he kept at hia 
 work, than when he staid at home. 
 
 Besides the attention to diet and exercise, it is 
 proper to enjoin care as to clothing. The skin should 
 be protected against sudden vicissitudes of the weather, 
 by woollen garments. Especial care should be di- 
 rected, during passive exercise, against the chilling 
 effects of the atmosphere at certain seasons. Yet it is 
 proper that the patient should abstain from such a 
 weight of clothing as would be oppressive. Regular 
 habits as to sleep should be enjoined ; and exposure 
 abroad during the evening should be forbidden. But, 
 in the day-time, the patient should not be kept within 
 doors by clouded skies, nor by east winds, nor by 
 slight falls of rain, or of snow. Even in tempestuous 
 weather the more hardy ones may drive out some- 
 what. It is well for the patient to feel that the risk 
 is in staying in the house, and not in going out of 
 it. In all this, I have had reference to tubercular 
 subjects in the earlier periods of disease. But a 
 
178 ON PHTHISIS AND HEMOPTYSIS. 
 
 patient, with the right spirit, may go abroad somewhat 
 till the last week, and even to the last day of life. If 
 any one object to dragging out a patient, when greatly 
 reduced in strength and flesh, I agree with him ; I 
 would not drag him out. But some persons find the 
 open air so necessary to their comfort, that they are 
 anxious to go abroad, though they know that death is 
 near at hand. I think it right that such should do 
 so ; they may suffer somewhat in doing it, but they 
 suffer in the opposite course. Contrast with such a 
 case a patient, who passes the last two or three months 
 of life in the bed, sitting up, at most, an hour or two 
 in the day. In such a one, the misery of muscular 
 weakness, added to the necessary evils of the disease, 
 is extremely great. One great evil from a confine- 
 ment in bed consists in the bed sores, which, for weeks 
 before death, do not permit the patient to find any 
 position, in w^hich he can rest without great pain. It 
 is true that inevitable circumstances may prevent the 
 patient from the exercise, by which these evils may be 
 averted. But, for the most part, we may guard 
 against them, by keeping in mind one physiological 
 principle. In a wasting disease, like phthisis, the 
 muscular strength, once lost, can seldom be regained, 
 and never in the later stage of disease ; while the 
 muscles, if kept in daily use, will retain their power, 
 
ON PHTHISIS AND HAEMOPTYSIS. 179 
 
 though not unimpaired, almost to the last moment 
 of life. 
 
 I wish not to say anything of medicine in this dis- 
 ease, although much may be done, in its advanced 
 stages, to mitigate troublesome and distressing symp- 
 toms. For instance, to patients who can bear it well 
 opium is invaluable. Tonics, too, are occasionally use- 
 ful. But each case must be studied by itself, and the 
 juvantia and laedentia must be sought out, without 
 following any universal rules. 
 
 There is one affection connected with phthisis which 
 I will treat of separately. This is haemoptysis, or 
 spitting of blood. This is the first symptom, which 
 occurs in a large proportion of consumptive cases. 
 Quite independently of a knowledge of this fact, spit- 
 ting of blood always creates alarm in the patient. 
 The stoutest hearts quail under it. Some persons are 
 made faint by the sight of one drop of blood which 
 they believe to come from the lungs. It is thought 
 that there is much present danger from this hemor- 
 rhage ; but it is not so. Patients, who are taken with 
 spitting of blood, sometimes die at once, or within a 
 few days ; but these are in an advanced stage of 
 phthisis. These, I take it, are cases in which an 
 urtery of some magnitude is laid open in a tuberculous 
 cavity. The blood-vessels in the parietes of such a 
 
180 ON PHTHISIS AND HEMOPTYSIS. 
 
 cavity are secured bj a natural process, as the j are in 
 the parietes of an abscess. But, in rare instances 
 some vessel so secured and plugged up is opened by 
 an ulceration, with which the adhesive process within 
 the vessel has not kept pace. A bleeding from this 
 cause in an advanced stage of the disease is, as before 
 intimated, sometimes immediately fatal. 
 
 Another case of immediate death, where haemoptysis 
 exists, is that arising from the rupture of an aneurism 
 within the thorax. One man with this disease, on 
 waking in the morning, said to his companion that he 
 felt remarkably well. In the next minute the blood 
 began to issue from his mouth, and so much poured 
 out as to run across his chamber. The death was 
 immediate. There was not any post mortem exam- 
 ination in this case; but the disease had been distinctly 
 shown during life. Another died after having had 
 repeated bleedings for several successive days. In 
 this instance there was found an aneurism of the aorta, 
 in which an opening had occurred through its thick- 
 ened parietes, consisting mostly of coagula. This 
 opening was at first very small, but at length enlarg- 
 ing, the whole chest was inundated. 
 
 I have known, in my own practice, only two in- 
 stances in which death has immediately followed 
 haemoptysis, except such as would come under the 
 
ON PHTHISIS AND HEMOPTYSIS. 181 
 
 descriptions above given. One of these was in a young 
 man, in whom the spitting had been somewhat profuse 
 and had recurred several times. He was treated under 
 the direction of a very distinguished physician of the 
 day, — fifty years ago, — who prescribed Huxham's 
 tincture of bark, and stimulants generally. The phy- 
 sician took it for granted, as did most medical men at 
 the time, that the bleeding was due to the rupture of 
 an artery ; and he explained his practice in this way. 
 He said that two pieces of iron could not be welded 
 together unless they were red-hot ; and that two raw 
 surfaces must be strongly excited to make them heal 
 together. Twenty years afterwards I saw another 
 patient who died under haemoptysis. She was a ten- 
 der and delicate "woman ; not pampered ; the wife of a 
 mechanic. . During a year or more she had attacks of 
 haemoptysis several times. In the last attack I was 
 summoned to her hastily, and on entering the room 
 found her sitting up in bed, with a bowl before her. 
 into which she was spitting blood. Her whole aspect 
 showed that she was much exhausted. I passed round 
 her bed so as to stand between her and the window, 
 where I could see and examine her best. When 1 
 reached this point, in a moment she fell back and 
 expired. She died from the loss of blood, not from 
 16 
 
182 ON PHTHISIS AND HiEMOPTYSIS. 
 
 suffocation. In the preceding case I could not get 
 leave to make an examination of the bodj; but in this 
 last case I was more fortunate. I was assisted in the 
 examination by the late Dr. John G. Gorham. Before 
 opening the body, I stated that there were two ques- 
 tions to be kept in mind. One was, whether there were 
 tubercles. The patient had never had cough to any 
 amount, nor had she had hectic fever. The other 
 question was, how we should ascertain whether there 
 had been rupture of a blood-vessel. On this point I 
 said, if a vessel has been ruptured, we shall find an 
 ecchymosis containing a sufficient quantity of coagu- 
 lated blood to form a little knot, or hard mass. I 
 grounded this remark, first upon experience, having 
 once opened a body where hemorrhage had taken place 
 into the cavity of the peritoneum, such as to cause 
 death in a few hours. In this case, having removed 
 the blood, after a careful search, I discovered that in 
 one of the ovaries there was an appearance of an 
 ecchymosis ; and, at this point, there was a rupture 
 of the ovary, and around it an induration. I believe 
 that the nature of this accident in the ovary is now 
 well understood, and I will not stop to remark upon 
 it. But the appearance, which I had observed, led me 
 to this view of the subject. Whenever a blood-vessel 
 is ruptured, so that the blood shall escape from it, a 
 
ON PHTHISIS AND HEMOPTYSIS. 18o 
 
 portion of this blood must be retained and coagulate 
 in the cellular membrane around the rupture. If you 
 reflect on the matter, you will see that this must hap- 
 pen, wherever the blood-vessel is situated; whether 
 immediately under a serous membrane, so that that 
 membrane is also ruptured, and thus the blood is 
 poured into the serous cavity ; or whether in the im- 
 mediate vicinity of a bronchus, where the rent is con- 
 tinued into the bronchus, so that the blood may issue 
 through the mouth. Or, again, if the vessel is situ- 
 ated in the middle of any organ, surrounded by a 
 large mass of solid matter, the same ecchymosis must 
 be formed ; for, in every case, the vessel is immediately 
 connected with the surrounding parts by the cellular 
 membrane. Therefore, in the case before us, I deter- 
 mined to feel carefully in every part of the lung, and 
 wherever I should discover an indurated portion, 
 however small, to cut into that. 
 
 Proceeding with these views, I opened the body. 
 On inspection nothing was to be seen of an abnormal 
 kind on the face of the lungs. Then I divided the 
 trachea, when I found its branch on the right side 
 stained with blood, while that on the left was not so. 
 I divided this right bronchus, and pursued the dissec- 
 tion, taking the stain of blood for my guide, and in 
 this way was led to open some three or four branches 
 
184 ON PHTHISIS AND HiEMOPTYSIS. 
 
 of some size, with their subdivisions. While doing 
 this I watched carefully for any appearance of an 
 ecchymosiSj but did not find any. Thus far, I had 
 handled the lung as little as was consistent with the 
 examination made. Now I felt over every part of it, 
 going over it slowly and carefully ; and wherever I 
 could feel between my thumb and finger the small- 
 est knob, I laid the part open. But the parts, to 
 which I was thus led, were none of them abnormal ; 
 nor could I anywhere discover the appearance of an 
 ecchymosis. It is equally true that I could not dis- 
 cover any tubercles. In short, except the blood in the 
 bronchi, nothing abnormal was discovered. The left 
 lung was examined more cursorily, but there was no 
 stain of blood in its principal bronchus. 
 
 I may seem to have been more" minute than neces- 
 sary in describing the examination in this case. My 
 reason for being so is, that I assert a negative, namely, 
 that there was not any appearance of a ruptured blood- 
 vessel in the lung. It was, therefore, necessary to 
 show that I guarded against all chances of error. 
 Besides, though the opinion I maintain, that in com- 
 mon cases of haemoptysis the blood is discharged 
 through the exhalants and not through a wound in an 
 artery or vein, is now generally received, I do not 
 recollect ever to have seen such evidence advanced in 
 
ON PHTHISIS AND HAEMOPTYSIS. 185 
 
 its support, as this case affords. I am, therefore, 
 desirous to show that the statement may be relied on. 
 If we take this case alone, supposing that I was not 
 guilty of any oversight, it wo aid seem certain that the 
 blood escaped from its vessels through the extreme 
 arteries, the exhalants. As there were no tubercles 
 in this case, I may not be justified in saying that 
 haemoptysis in tuberculous subjects, occurring in the 
 early stages of the disease, takes place in the same 
 manner ; but this case shows that bleeding, sufficient 
 to destroy life, may take place by exudation. I feel 
 no doubt that it does happen in this way in the 
 tuberculous cases. Although such an opinion was not 
 very commonly received in my earlier days, I believe 
 that, at this day, there are few pathologists who enter- 
 tain any doubt on the subject. 
 
 It should be noted that, when blood is spit from the 
 mouth, it does not necessarily come from the lungs ; 
 and the interesting question, always urged by the 
 patient or his friends, is, whether it has been derived 
 from those organs. The blood discharged from the 
 mouth may be poured out from the exhalants, or larger 
 vessels, directly into that part. I once saw a lady 
 frequently spitting blood, in small quantities, which 
 oozed out from one of her gums. When the blood was 
 wiped off, the gum showed itself beautifully firm and 
 16* 
 
186 ON PHTHISIS AND HEMOPTYSIS. 
 
 not at all red. All her teeth and gums were perfectljP 
 sound. Ordinarily, the blood is derived from the back 
 part of the nose, or from the fauces, from the gullet 
 or stomach, or from the lungs. It is not difficult, 
 generally, even to common observers, to discover by 
 the manner whether the blood is derived from the 
 patient's mouth. If the amount is at all large, by 
 compressing the mouth and the parts around it, the 
 patient will promote the flow, and spit the blood with- 
 out any such effort as would be requisite to bring it 
 forward, even from the fauces. If the bleeding is in 
 the fauces, it may be discovered on inspection, in 
 some instances ; and, if in any quantity, it will be 
 brought forward, just as is frequently done with 
 mucus. If from the nose, some of the blood will 
 probably pass through the nostrils ; but, if not, the 
 patient may draw it down and bring it into the mouth, 
 just as he does with regard to mucus when lodged in 
 the posterior nares. If the bleeding is in the gullet or 
 stomach, it will be brought up by vomiting ; if from 
 the lungs, by coughing or hawking. It must be plain 
 that blood will not run up from the stomach, or lungs, 
 against gravity. I say this, because when it is from 
 the lungs, the patient often believes that it flows 
 up without either coughing or hawking. I pre- 
 sume it must always be brought up by one of those 
 
ON PHTHISIS AND HEMOPTYSIS. 187 
 
 eiFortSj though the patient and even the bystanders 
 sometimes think otherwise. If it ever does happen 
 otherwise, I think it must be where an aneurism has 
 been ruptured, and the blood is driven forward by the 
 power of the heart. In this case, if the patient be 
 lying in a position nearly horizontal, I presume that 
 the blood may flow through the windpipe into the 
 fauces and mouth. Generally, then, if a patient be 
 spitting blood from the lungs, he raises it by coughing 
 or hawking. If this be not apparent at first, when 
 the blood is flowing copiously, it becomes so, when the 
 bleeding slackens, and the coughing or hawking takes 
 place deliberately. In all this, I have reference to a 
 patient previously well, or, at least, not much advanced 
 in phthisis. We must distinguish, in such cases, the 
 discharge of a few drops of blood, whether pure, or 
 mixed with mucus, from such a flow as that the 
 patient spits out a mouthful at a time. When it 
 comes in the smaller quantity, it may be, if not from 
 the fauces, from the larynx, or trachea. Some persons 
 will very frequently spit some drops of blood in this 
 way, evidently derived from the trachea, there being 
 at the time other symptoms showing disease in that 
 part, while there are no physical signs of disease in 
 the lungs. As such cases excite unnecessary alarm, I 
 wish to make some remarks on them. We are told 
 
188 ON PHTHISIS AND HAEMOPTYSIS. 
 
 that they are attended with danger, for that the 
 disease may travel down from the trachea. I will not 
 say that this is not true, for that would be asserting 
 a universal negative — a very hard thing to prove ; but 
 I will say that I have watched this matter for a long 
 while, and have not seen any instance, in which 
 tuberculous disease travelled in this course. I have 
 often seen patients have this trouble in the windpipe, 
 and afterwards die of phthisis ; but these persons have 
 had the signs of disease in the lungs as early, or 
 earlier, than the signs of disease in the windpipe. 
 
 When pulmonary haemoptysis does take, place, it 
 varies much in the circumstances attending it, and in 
 the quantity of blood which is raised. It is most 
 commonly preceded by cough, or by some pain, or 
 other uncomfortable feeling, in the chest. This feeling 
 may be a sense of fulness, or a stricture in the chest, 
 so that some difficulty of breathing is felt, though not 
 manifested to bystanders. These local symptoms may 
 occur with the haemoptysis, if they do not precede it. 
 Febrile symptoms attend the spitting, in some in- 
 stances, especially an acceleration of the pulse. But 
 in other cases the hemorrhage comes on- quite alone. 
 It is not rare for the patient to tell you that he had 
 had some cough, or some uneasiness in the breast, but 
 that he awoke in the morning feeling uncommonly 
 
0^ PHTHISIS AND HEMOPTYSIS. 189 
 
 well, and soon after the blood began to come up. As 
 I write, I recall three instances among mj friends, 
 each of whom had been riding the day before, and who 
 awoke in a morning with this comfortable feeling, and in 
 each case within an hour a free hemorrhage took place. 
 But if there have not been any morbid feelings or 
 other signs of disease before, nor at the beginning of 
 the haemoptysis, this is often followed by cough and 
 constitutional symptoms. Yet cases do occur in which 
 there are scarcely any symptoms of disease, other than 
 the bleeding, before, or for a long time after, its occur- 
 rence, though at a later period phthisis becomes manifest. 
 In most cases the haemoptysis returns once, or several 
 times, before any other strong manifestation of disease 
 takes place. In such instances the termination of the 
 whole may be from two to ten years after the first 
 bleeding. 
 
 In the great majority of cases the hemorrhage 
 subsides spontaneously without any medicine ; but in 
 some it is too copious to be trusted. From what has 
 been before said, we may ordinarily assure the patient 
 that there is not any present danger. This is often 
 important to calm the agitation of mind. With the 
 same view, it is proper to administer some medicine 
 known to have a good tendency, but not of a kind to 
 produce any inconvenience. A popular remedy, often 
 
190 ON PHTHISIS AND HEMOPTYSIS. 
 
 employed by physicians, is common salt. This is 
 taken in a dry state, or more comfortably in a strong 
 solution. A more agreeable remedy is the diluted 
 sulphuric acid. Of this twenty drops may be taken 
 m sweetened water, and the same repeated once in 
 three or four hours, till the bleeding ceases. Rest 
 of body and mind, and '' holding the tongue," are 
 quite as important, at the moment of the bleeding, as 
 the medicinal articles. When the blood comes up 
 very copiously for some time, I employ more potent 
 remedies, particularly the sulphate of copper with 
 opium. The opium is useful in diminishing the cough, 
 by which the bleeding is promoted. The sulphate 
 acts as an astringent, as I suppose. More of this can be 
 used in a pill than in a liquid state. From a quarter 
 of a grain to a grain may be given at once, and this 
 may be repeated in six, or twelve hours, if the hemor- 
 rhage does not cease, unless too much nausea is 
 produced. If, however, it occasions vomiting, the 
 bleeding is not increased, but rather checked by it. 
 In an urgent case, which had continued four days, and 
 which I then saw in consultation, I gave a grain of 
 the sulphate with an equal quantity of opium. The 
 bleeding lessened very much soon after ; a second 
 dose was given at the end of twelve hours, from which 
 time the bleeding ceased. No inconvenience was 
 
ON PHTHISIS AND HEMOPTYSIS. 191 
 
 experienced from the copper. A single case like this 
 is not oflfered as a proof ; but this came to me in corrob- 
 oration of the benefit in many other cases, where there 
 was hemorrhage from other parts of the body, besides 
 the lungs. I have formerly made great use of blisters 
 and the like remedies in cases of haemoptysis, but I 
 gradually discontinued them from a conviction that 
 they were not necessary, and that they were sometimes 
 injurious. Yet I incline to the belief that, when the 
 bleeding continues for several days, the tendency may 
 be checked by a very small blister, or by the use of 
 croton oil, over a surface not more than an inch in 
 diameter ; and by the repetition of this, when the 
 bleeding does not cease. 
 
 Bloodletting has been often employed in this affec- 
 tion, with a view to guard against subsequent disease 
 of the lungs, as well as to arrest the bleeding. I 
 have very rarely seen an instance, where it seemed to 
 me to be called for ; yet it may sometimes be useful. 
 I think it was so in the case of one of my younger 
 medical friends in a neighboring town. His case 
 presents some points of interest, so that I think it 
 worth stating to you. It occurred more than twenty 
 years ago, and I am happy to say that the patient is 
 now alive and in good health. 
 
 In August, 1831, I was called to see my friend, 
 
192 ON PHTHISIS AND HiEMOPTYSIS. 
 
 Dr. Hosmer, of Watertown. and found him raising 
 blood from the lungs in a very unusual quantity. He 
 hadj as I knew, been frequently spitting blood for a 
 year preceding, in very small quantities, but had main- 
 tained good health, and was engaged in a very exten- 
 sive business in a circle of five miles' radius. I now 
 found him very hot, with a frequent and hard pulse. 
 The case was so urgent that both he and I thought it 
 most prudent that he should be bled. I bled him 
 twice within twenty-four hours, a pint each time ; and 
 we calculated that he could not have raised less than 
 two'pints of blood. We came to this conclusion with 
 the utmost caution, fully aware of the common exag- 
 geration on this point. We thought that he was ben- 
 efited by the venesection. He was, of course, much 
 weakened, and for some hours quite insensible; but 
 the haemoptysis ceased, and he soon began to recover 
 his strength. At the end of six weeks he was so well 
 that he could not easily keep out of business if he re- 
 mained at home ; he therefore went to the place of his 
 nativity, where he could take exercise freely in the open 
 air without being obliged to attend to patients. There 
 he spent three or four months. The winter was very 
 cold, and he was abroad every day. He then returned 
 well enough to resume his practice. The plan I laid 
 down for him was to live on milk and vegetable food, 
 
ON PHTHISIS AND HEMOPTYSIS. 193 
 
 and to keep abroad in all weathers, as much as pos- 
 sible on horseback, but to avoid exposure in the night. 
 In the ensuing spring and summer he gained flesh and 
 strength ; but, in September following, he told me 
 that he continued to spit a little blood occasionally, 
 and that his pulse would be accelerated at the time, so 
 that he had taken a little blood from his arm, on an 
 average, once a month. On an investigation of the 
 case, I learned that he had found it so inconvenient to 
 ride on horseback, that he travelled mostly on wheels 
 in attending to his business. I urged him to submit 
 to the inconvenience, and to stick to his horse. He did 
 so, and his first ride was too far and too hard. This 
 was followed by a new haemoptysis. After that he 
 began by riding moderately, but did stick to his horse, 
 and he ceased to spit blood from that time. He has 
 now for many years been in full flesh, with a fine 
 color, and appears very strong. He has been con- 
 stantly engaged in active business. After one year 
 he returned to common diet, and after a year more he 
 gave up the riding on horseback. 
 
 During the hemorrhage I could not make a good 
 exploration of the chest without incommoding him too 
 much. After his recovery I examined him carefully, 
 more than once, without discovering any physical sign/? 
 of disease in the lungs. 
 IT 
 
194 ON PHTHISIS AND HiEMOPTYSIS. 
 
 Dr. Hosmer's case was an uncommon one. I have 
 seen instances where the bleeding has been very 
 copious, but none where it has been so large as in 
 his ; nor have other circumstances been similar. But 
 I have seen others, for whom I have ordered the same 
 diet as I did for him, and I have believed that advan- 
 tage was derived from it. They have been instances 
 in which the constitution has shown vigor, and in 
 which the patient has kept up strength and flesh upon 
 the diet. In cases where the cachexy, so common to 
 tuberculous subjects, has shown itself, I have never 
 ventured to forbid the use of animal food. On the 
 contrary, I have advised this food, as far as the appe- 
 tite would permit, at least once a day. 
 
 You will observe, in Dr. Hosmer's case, that as soon 
 as the copious hasmoptysis had ceased, and the patient 
 had regained sufficient strength, I advised him to take 
 active exercise in the open air. A fear is sometimes 
 entertained that the bleeding may be brought on in 
 this way. By long-continued and exhausting fatigue, 
 this may be ; and the same after an unusual and vio- 
 lent exertion, as above stated in his case ; but such a 
 patient may be brought to very free, active exercise, 
 regardless of weather, without any injury, but with 
 
 benefit. Captain L belonged to a consumptive 
 
 family, and he was, I may say, in the habit of spitting 
 
ON PHTHISIS AND HEMOPTYSIS. 195 
 
 blood frequently for several years. He had some 
 other unpleasant symptoms. He was very fond of 
 sport, and, after some experience in the case, he 
 adopted the practice of taking his gun and dog, and 
 following the birds for several days, when the bleed- 
 ing took place, if the season permitted it. He found 
 that he got through the trouble in this way better 
 than in any other. His bleedings were not very 
 copious, though not trivial, and were not attended by 
 fever. He lived many years after the period when I 
 knew him, enjoying tolerably good health, and died 
 suddenly of an acute disease. In this case the prac- 
 tice was not prescribed by myself, though I encouraged 
 a continuance in it. 
 
 I am induced to go somewhat largely into this sub- 
 ject, because, while haemoptysis is justly regarded as a 
 precursor of phthisis, there is a chance for avoiding 
 this termination for a time, and even for a long life. 
 And, where the health does not break down imme- 
 diately after the bleeding, there is a period when much 
 is to be done for the security of the patient. I say, 
 then, that a patient, spitting blood, may be assured 
 that there is a good chance for his having some years 
 of good health, and some chance for a long life, even 
 though he be young when the bleeding occurs. I 
 
196 ON PHTHISIS AND HEMOPTYSIS. 
 
 could bring many instances to support this statement. 
 I will mention some of them. 
 
 In this city there are three gentlemen, whose busi- 
 ness brings them daily within a few doors of each 
 other, now in good health, but who have raised blood 
 freely from the lungs. One of them belongs to a con- 
 sumptive family. His mother died of phthisis, and 
 one brother and three sisters of his, all adults, died 
 within a few years after he first raised blood. He, 
 
 Mr. L , was about twenty years of age when he 
 
 was taken with a copious haemoptysis. He was on 
 a voyage to Calcutta. This was in the year 1802. 
 For some years after this he was much troubled with 
 cough, often accompanied by pain in the chest, and at 
 times with sputa to a large amount. In these sputa 
 there was, not rarely, a little blood. After the first 
 years he occasionally expectorated cretaceous matter, 
 in tlie whole to a large amount. This was evidence 
 that he had tubercles. He has been free from such 
 troubles for many years, though he has frequently 
 had bronchitis, and sometimes this has been protract- 
 ed. He now enjoys a green old age. His habits 
 have always been active ; and while his lungs were 
 much threatened he travelled a good deal. He has 
 had six children and many grandchildren. Of his 
 children one only has had phthisiSj and the youngest 
 
ON PHTHISIS AND HEMOPTYSIS. 197 
 
 is now nearly thirty years of age. This case alone 
 should give encouragement to persons affected with 
 this disease. 
 
 Of the other two, one spit blood largely for several 
 days, and was necessarily confined to his bed, in 1818. 
 He is noAV alive and well. The other spit blood freely 
 in April, 1838, and this was very often repeated for 
 six months. He was much reduced in flesh and 
 strength, though he kept on his feet. In October, he 
 was very short-breathed, and had a cough. He went 
 abroad at this time, and returned the next summer in 
 much better condition. Gradually he recovered his 
 health, and has been constantly engaged in an active 
 life to this day. I should say that, on his return from 
 his travels, I examined him carefully, and could not 
 find any physical sign of disease in his chest. Others, 
 most worthy of reliance, had thought at early periods 
 that they had discovered some slight, yet unequivocal 
 signs of tubercles. I trust, from feelings very differ- 
 ent from personal vanity, that my conclusion will be 
 justified by a long life. 
 
 I could give other examples of the same kind. But 
 I wish now to state two cases, where life was con- 
 tinued for more than twenty years after haemoptysis, 
 and where the disease was proved to be tuberculous. 
 One of these was a valued friend of mine, my clags- 
 17^ 
 
198 ON PHTHISIS AND HEMOPTYSIS. 
 
 mate in college, and a physician in this citj. He 
 consulted me after having spit blood copiously two or 
 three times. The particular object of the consulta- 
 tion was to decide whether it was expedient for him to 
 take up his residence in a southern climate. This 
 would have been very inconvenient to him, as he must 
 have left a lucrative business here. He had a very 
 good frame, and had always before enjoyed good 
 health. I advised him not to make the change. I 
 stated the opinion, which I had then entertained for 
 some years, and which has been confirmed by all my 
 subsequent experience, namely, that the most impor- 
 tant thing for all, threatened with phthisis, is to 
 lead an active life in the open air ; and that, if they 
 cannot do that without too much suffering in our cold 
 climate, they should go to a warmer one, where they 
 can do it ; but that this step is seldom necessary, ex- 
 cept for those, who have been in the habit of keeping 
 much in-doors. As he had passed his life in profes- 
 sional business, he had not become tender. He was, 
 however, accustomed to drive about in a gig, and I 
 advised that he should ride as much as possible on 
 horseback. I advised also milk and vegetable food for 
 his diet, for a year or two. He pursued this course, 
 and he lived about twenty-two years after the haemop- 
 tysis occurred. During this period he had a cough 
 
ON PHTHISIS AND HiEMOPTYSIS. 199 
 
 occasionally, and, perhaps, a little at all times; but 
 he pursued his business, and was often out in the night. 
 A few years before his death he was confined several 
 weeks, and was somewhat reduced by an attack on his 
 lungs, the precise character of which I do not now 
 remember. But, in general, he kept in good flesh and 
 strength, and, having a florid countenance, he had the 
 appearance of perfect health. His death took place 
 from an acute pneumonitis, on the right side, of only 
 five days' continuance. I saw him the day before his 
 death, when respiration was very difiicult ; but till 
 that day he did not believe his disease to be very seri- 
 ous. On examination, the lower two-thirds of the 
 right lung were found in a state of acute inflammation. 
 At the apex of each lung was found a cavity, that of 
 the right being the largest. Each contained a small 
 mass of putty-like matter, of a brown color. Every 
 appearance showed that these cavities were very old. 
 
 The other case was that of a clergyman, who was 
 about twenty-five years old when first attacked by 
 haemoptysis. He was a more feeble man than the 
 other, but he lived about twenty years after his attack. 
 During sixteen or more of these years he performed 
 the duties of his oflBce, and had tolerably good health, 
 though he was never very strong. For several months 
 before his decease he was obliged to give up the duties 
 
200 ON PHTHISIS AND HEMOPTYSIS. 
 
 of the church, and at last died suddenly under a pro- 
 fuse hsemoptysiSj such as I have described as some- 
 times occurring in the last stage of phthisis. There 
 was not any examination of his body, but the physical 
 and rational signs had given unequivocal evidence of 
 tuberculous cavities long before death. He had always 
 kept up the habit of exercise abroad, and at times, 
 especially in the first years, had taken much active 
 exercise. He had not done this so much as I wished, 
 yet, undoubtedly, he was supported very much by 
 what he did do. 
 
 I have selected these cases from others, because the 
 patients were my friends, and I kept their histories in 
 remembrance. Such cases may be held up to patients 
 as an encouragement to make exertions. You will not 
 suppose that I should expect every one to prolong life 
 as much as these persons did, under the like difficulties. 
 But where the constitution shows good vigor, if the 
 patient can take and bear food, and if not deficient in 
 muscular power, you may hold up to him bright hopes, 
 provided he will steadfastly pursue the right course. 
 I had another clergyman under my care, who adhered 
 carefully to my rules after his first haemoptysis, which 
 was in 1812, for four years, and appeared quite rees- 
 tablished in his health, though he had been a good 
 deal reduced before I saw him. Late in 1816 he seut 
 
ON PHTHISIS AND HEMOPTYSIS. 201 
 
 for me on account of a second haemoptysis. Being 
 very conscientious, he stated to me, as soon as I came 
 near him, that for four months preceding he had not 
 adhered to my rules. These were not rules as to 
 medicine, for I had not given him any ; but rules as 
 to exercise in the open air. From this time he grew 
 more sick, and died about eighteen months afterwards. 
 It is an opinion often advanced that clergymen are 
 more liable than others to haemoptysis, and to other 
 diseases of the lungs. It is thought that they suffer 
 from public speaking. I feel assured that this is not 
 true. Besides what I have mentioned, I could refer 
 to one in a neighboring city who raised blood copiously 
 thirty years ago, soon after he began to preach. He 
 was troubled for some time with weakness of voice, 
 and difficulty of breathing, attended by a very quick 
 pulse. He followed my advice with a good and deter- 
 mined spirit. He has been a preacher the whole time, 
 with the exception of one or two years in the begin- 
 ning, and has had very good health. I have not the 
 least doubt that he has tubercles in his lungs. It is 
 supposed that clergymen must suffer from the amount 
 of their public speaking. The truth is that there are 
 men in other professions who try their voices much 
 more than clergymen do. Such are professors in 
 medical schools, many of whom lecture six days in the 
 
202 ON PHTHISIS AND HEMOPTYSIS. 
 
 week for three or four months. It is true that they 
 speak in rooms comparatively small, but it is usually 
 for an hour without resting. Lawyers and members 
 of legislative bodies often speak from two to four hours 
 at a time. In respect to the strenuous exertion of the 
 voice, there are many auctioneers who go far before 
 -clergymen. Now, I have been in the way of many 
 persons of these descriptions, and have not found them 
 subject to spitting of blood. 
 
 I am tempted to relate more cases of haemoptysis, 
 in which the results have been favorable, for they rise 
 in my mind as I write ; but I should cover too many 
 pages. I do not pretend to offer you such a statement, 
 in respect to numbers, as I might have done if I had 
 kept notes ; and, therefore, you will consider what I 
 do give you, as illustrating the effect of the principles 
 I advance, not as proving them to be true. 
 
LETTER XII. 
 
 ON DYSPEPST. 
 
 I WILL now call your attention to diseases in the 
 abdominal organs ; and, first, to dyspepsy. The 
 proper office of the stomach is to digest the food. The 
 digestion consists in dissolving or softening the food so 
 as to bring it into a pultaceous mass, and in bringing 
 about in this mass certain changes as to the chemical 
 composition of some of its proximate elements. In 
 health, this function is performed with ease, not calling 
 attention to the organ in which it is taking place, but 
 rather inducing a comfortable and grateful feeling 
 over the whole system, body and mind. But some- 
 times there is a difficulty in the process, causing unea- 
 siness in the stomach, and more or less elsewhere. To 
 this difficulty we give the name of dyspepsy. We do 
 not, however, apply this name to a temporary or 
 casual indigestion, but to a labor in the function which 
 recurs daily, or very frequently. It is not implied in 
 this description that the digestion does not take place. 
 
204 ON DTSPEPSY. 
 
 It maj be effected perfectly, but it is done with diffi- 
 culty ; this is all that is essential to the disease. It 
 is nevertheless true that there is, probably, in the 
 great majority of instances, some imperfection in the 
 results of the action of the stomach. There is, of 
 course, every variety in the degree of difficulty, or 
 amount of extra labor, in the cases of dyspepsy. Hence 
 must arise some difference in the manifestations of the 
 disease. 
 
 But there are symptoms accompanying dyspepsy, 
 arising from other sources, -which we must keep in 
 view if we would understand the disease. They are 
 those which are derived, not from the stomach, but from 
 the other organs of the abdomen connected with it. 
 Those other organs are the intestines, large and small, 
 the liver, pancreas and spleen. These three last I 
 call the subsidiary organs, and of these the liver 
 is most noted. This is the largest of the three 
 organs; its functions are probably the most important, 
 and, at any rate, its secretion, from its taste and 
 color, is most easily noted. To one acquainted with 
 the physiology of these organs the symptoms from 
 these various sources are not, in general, difficult to 
 anderstand. 
 
 This is not all. The stomach maintains a connec- 
 tion, by sympathy and otherwise, with all other parts 
 
ON DYSPEPSY. 205 
 
 of the body. Hence, diseases of other parts may 
 bring on dyspepsy j or this trouble in the stomach 
 may cause disturbances and derangements in various 
 parts of the body and in the mind. Thus the symp- 
 toms occurring in this disease are increased in number 
 and variety. 
 
 Dyspepsy consists, then, in a difficulty or labor in 
 the digestion of the food ; and this difficulty may be 
 various in degree. Its leading symptoms are oppres- 
 sion or uneasiness at the stomach, heartburn, flatu- 
 lence, eructation of wind, or efforts for this purpose, 
 regurgitation of the food, and sometimes vomiting. I 
 regard the oppression as evidence that the digestion is 
 going on, though with hard labor. It is not uncom- 
 mon to see food thrown from the stomach, perfectly 
 undigested, several hours after it was swallowed, where 
 there had not been any oppression meanwhile. Here 
 there would seem not to have been any effort to digest 
 the food. The oppression is various in degree. It is 
 somewhat indefinite as to its seat, as all internal feel- 
 ings are apt to be. It is generally referred to the 
 epigastrium, but it often extends upward under the 
 sternum ; when connected with a sense of flatulence it 
 even reaches up to the throat, with a feeling as if it 
 30uld be relieved only by bringing up the food, or some 
 wind. I will say here that, in these cases, the existence 
 18 
 
206 ON DYSPEPSY. 
 
 of air in the stomach is not so certain, as it seems to 
 be. The patient feels distressed, and finds relief when 
 an J wind is brought up ; and thence he believes that 
 there is a great body of air pent up, which is the cause 
 of his trouble. Mj suspicion is that the air does not 
 exist there in any extraordinary quantity, and that it 
 is food which prompts the efforts he makes. If air be 
 thrown up the relief is very partial, but it is greater 
 and more permanent if food be regurgitated. It is, 
 therefore, better for the patient not to make violent 
 efibrts to produce eructation. Persons, who vomit with 
 ease, will sometimes get relieved by thrusting a finger 
 into the fauces. This should not be encouraged. The 
 temptation to resort to this expedient is very great, 
 and the frequent repetition of it is injurious. Some 
 men will indulge their appetites improperly, relying 
 on relief in this way. 
 
 The oppression, or uneasiness at the stomach, usu- 
 ally follows a meal within an hour, but occasionally it 
 is deferred to a later period. It continues from one 
 to three or four hours. There is an uneasiness or. 
 pain, which I hardly know how to distinguish from the 
 above, which dyspeptics sometimes experience, from 
 two to four o'clock in the morning. This is the period 
 when gouty persons are apt to sufier. As this comes 
 after ?. long fast, for it will occur in persons who do 
 
ON DYSPEPSY. 207 
 
 not eat supper, it cannot be regarded as a trouble 
 attending the act of digestion. It is more probable 
 that it results from some acrid matter left in the 
 stomach after the entire conclusion of the digestion. 
 
 Heartburn is regarded as the effect of some acid 
 in the stomach. It is most noted when some acescent 
 food has been taken, and may commonly be avoided 
 by abstaining from such food. But it does not always 
 occur when there is an acid in the stomach ; for a dys- 
 peptic will sometimes throw up a very sharp acid, when 
 he has not had any heartburn. On the other hand, 
 I think that you will hear of this symptom from per- 
 sons, who abstain almost entirely from acescent food. 
 May not these facts be explained by the hypothesis, 
 that there is sometimes a very tender spot in the 
 mucous membrane of the stomach, and that the 
 smallest portion of acid may be enough to irritate 
 such a spot ? 
 
 Flatulence in the stomach, that is, air of some kind 
 developed in that organ, is probably the result of some 
 chemical change in undigested food. That explanation 
 does at least satisfy the most common cases of flatu- 
 lence in that organ. But, as has been intimated 
 before, the sensations of the patient are probably 
 sometimes deceptive as to the existence of much air in 
 the stomach. 
 
208 ON DYSPEPSY. 
 
 Regurgitation and vomiting of food occur much 
 more readily in some subjects than in others. It is 
 apparently in those, who have a facility in performing 
 an act, which others cannot bring about without great 
 effort, and that only under the influence of some pecu- 
 liar or very powerful stimulus. This peculiar facility, 
 and its opposite, the great difficulty in bringing up 
 the contents of the stomach, are original differences 
 not to be explained. Other things being equal, the 
 operations above mentioned are not produced so much 
 by the greater difficulty of digestion in one case than 
 in another, as by a greater tenderness in some part of 
 the stomach in some instances. Thus, an ulceration, 
 and, perhaps, even a slight one, in the mucous coat 
 of the stomach may cause the regurgitation, etc. Where 
 vomiting is very frequent, resisting all remedies, 
 there is good cause for suspecting organic disease of 
 the stomach. Yet it must not be admitted as proof 
 of such a disease. The following remarkable history, 
 which I will endeavor to state briefly, wall support what; 
 I say. This was a case where a severe and obsti- 
 nate dyspepsy continued for several years, not being 
 relieved by medicine, nor by travelling in this coun- 
 try and in Europe ; which at last, while the patient 
 was abroad, terminated in daily vomiting. The patient, 
 a lady, at length restricted herself to one meal a day, 
 
ON DYSPEPSY. 209 
 
 which she took ordinarily at three o'clock. She 
 seemed to throw up the whole of this within three 
 hours, invariably. I was an eje-witness to the act 
 verj often. Of course something was retained, as 
 she lived in this state between two and three years. 
 At length she died exhausted. The first symptoms 
 attending her failure seemed to belong to the brain. 
 I called on her in the morning, and she had her usual 
 smile, and asked common questions ; but she could not 
 remember what she had said, or what was said to her, 
 for three minutes. Within twenty-four hours she 
 became stupid, and she remained in this state two or 
 three days, when she expired. I mention these cir- 
 cumstances of her death as having some interest. It 
 was a death simply from the want of nutrition. The 
 disease began under circumstances of an aflBiicting and 
 depressing character. Time removed the feeling of 
 depression, and she grew cheerful. Her mind was 
 bright and active. She went abroad in a carriage as 
 long as she could, and never kept her bed till the last 
 days of her life. I cannot go into all the symptoms, 
 positive and negative. Suffice it to say that there 
 were not any physical signs of organic disease ; and, 
 after frequent and thorough investigation of all that 
 belonged to the case, I was perfectly satisfied that 
 there was not any such disease. The autopsy was 
 18* 
 
210 ON DYSPEPSY. 
 
 made by Dr. J. B. S. Jackson, in the presence of 
 Dr. John Ware, and made with all the precautions 
 necessary to prove a negative. There was not dis- 
 covered any change in the structure, or organization 
 of any one part. It may be proper to add that the 
 patient belonged to a family, in which some other 
 members had remarkable nervous diseases, though 
 each differing from the others. I relate this case to 
 show that we must be cautious in deciding that there 
 is organic disease of the stomach, even under the most 
 obstinate vomiting. All I would add, besides the 
 absence of physical signs in this case, is, that there 
 was not the physiognomy of organic disease. There 
 was not the sharp emaciation, nor the degeneration of 
 the skin, the roughness and loss of its natural color, 
 which organic disease ordinarily produces. 
 
 Dyspepsy is most commonly attended by costive- 
 ness, or at least by slowness in the bowels ; indeed, 
 the difficulty in the bowels often precedes, if it does 
 not cause, that in the stomach. It is not so easy to 
 manage the case w^hen the costiveness is added to it. 
 Instead of costiveness, diarrhoea occurs in some in- 
 stances, or the two alternate. The diarrhoea is not 
 constant, but follows the use of indigestible articles, 
 especially of those which are acid, or acescent. To the 
 symptoms belonging to the alimentary canal and its 
 
ON DYSPEPSY. 211 
 
 appendages, are added occasionally some in other 
 organs. Such are headache, vertigo, palpitation of 
 the heart, or uneasy sensations about that vital organ, 
 and pain in the breast, at various points. Likewise 
 the spirits are depressed in many instances ; and 
 sometimes you see a dyspeptic who becomes quite 
 incapable of intellectual labor. Some, who study 
 their symptoms, and constantly watch the effects of 
 food and remedies, become notional, and often very 
 unhappy. On this account the physician may be 
 obliged to give up a close inquiry into the course of 
 the disease. 
 
 After investigating the history of a dyspeptic, you 
 may find that the principal remote cause of this 
 disease was something which has passed away, but 
 has left a permanent effect. You may strive to 
 remove the effect, but the cause is beyond your reach. 
 Much more frequently you find that the remote cause 
 or causes continue to exist. In such cases you should 
 of course try to remove the effects ; but it is of the first 
 importance to remove, or to counteract the causes. 
 Sometimes this is beyond the power of man, though 
 nature may do it in due time ; but in the largest 
 number of instances it may be done, if the patient is 
 obedient. Then it becomes necessary to ascertain in 
 each case what pauses have produced the disease, and 
 
212 ON DYSPEPSY. 
 
 for this purpose it is often requisite to get a history 
 of the patient's life. 
 
 Prominent among the remote causes in question are 
 eiTors of diet. These errors ha^re regard to the 
 quantity, the quality, or the frequency of meals. As 
 to quantity, — one cannot say how much food any 
 individual may require, or can bear. There are 
 instances, in which it is quite' clear that the patient 
 does not take enough for his support. There are 
 vastly more, in which he takes too much. If one 
 takes more food than others at the same table, and 
 no other obvious cause for his dyspepsy can be dis- 
 covered, we may fairly conclude that he takes too 
 much. 
 
 In respect to the quality, it would occupy too much 
 space to point out all possible errors. Yet in practice 
 it is not very difficult to decide this point. Has your 
 patient lived on the coarsest vegetable food, and that 
 badly prepared, you will not doubt that there has been 
 a fault in his diet as to quality. You will as little 
 doubt it as to one, who has lived entirely on the most 
 savory articles, with the addition of the strongest 
 condiments. Nor is there much difficulty in the 
 decision, when the errors have been less glaring. 
 
 As to the frequency of meals, few adults can take 
 more than three in a day without injury. Children 
 
ON DYSPEPST. 213 
 
 can eat more frequently ; but between eighteen and 
 twentj-five you will find many dyspeptics, who get 
 relief on giving up their childish habits. These and 
 other remarks on diet are not shown to be groundless, 
 because many persons disregard them with impunity. 
 The question is not whether certain practices are 
 always injurious, but whether they are not often, or 
 sometimes so. 
 
 Next among the causes of dyspepsy may be men- 
 tioned a sedentary life, or a neglect of bodily exercise. 
 Prom these causes the student and the shoemaker are 
 equally liable to suffer. The evil may be greater, 
 perhaps, to one who undergoes much intellectual 
 labor; but that is not very certain, unless that labor is 
 attended by great responsibility, or by anxiety as to 
 its results. Anxiety alone very often induces dys- 
 pepsy. You see this in young men entering, on the 
 business of life. I have witnessed it equally in young 
 physicians and young mechanics. Whenever the 
 mind and the heart are too much devoted to one 
 object, the digestion is apt to fail. The same conse- 
 quence follows from a mere routine in business, 
 where the attention must be constantly maintained, 
 without any real interest in its object. 
 
 You find, then, your dyspeptics among those who 
 work in the houses, and not in the fields, who endure 
 
214 ON DYSPEPST. 
 
 great responsibility, or great anxiety, or who work in 
 a treadmill for a mere maintenance ; among those who 
 are half-starved, and among those who gormandize 
 and drink and smoke ; and among the dissolute and 
 licentious ; so that the disease comes to the wise and 
 to the foolish, to the best and to the worst of men. 
 
 A young clergyman, or a young schoolmaster, may 
 call on you, and tell a story, of which, when you have 
 heard the introduction, you might tell him all that 
 follows. It is this : He worked on his father's farm 
 till his eighteenth or twentieth year, and then deter- 
 mined to get an education. He crammed himself 
 with Latin and Greek, so as to get into college in two 
 years. While doing this his head began to suffer, and 
 he became costive ; but he thought these temporary 
 evils, and sought relief by salts, or other laxatives. 
 He entered college, studied hard, and his stomach 
 began to complain. If not at college, this increase of 
 trouble came on soon after he engaged in his profes- 
 sional studies ; and, perhaps, headache also. If your 
 patient be a clergyman, you probably find that he held 
 out till he was ordained, but soon afterwards he found 
 that the duties he had undertaken were too heavy for 
 him. Then his parish were alarmed, and he became 
 the object of sympathy. All began to discuss the 
 nature of his disease, its causes, and the remedies 
 
ON DYSPEPST. 215 
 
 appropriate to it. Each kind matron pressed her 
 favorite medicine- upon him, and all besought him to 
 avoid getting cold. I could add to the story, but that 
 is enough. 
 
 In the treatment of a dyspeptic, then, more than 
 of most other invalids, it is the first object to ascer- 
 tain the remote causes of the disease in his case. To 
 this end you must get a brief history of his life. This 
 requires some cross-questioning ; for the patient will 
 often hold back important facts, either because he re- 
 gards them as unimportant, or because they are such 
 as he does not wish to disclose. If you suspect the 
 last-named difiiculty, it is well to say to him that you 
 wish to know whether he has had any secret causes 
 of anxiety or trouble ; that, if so, it is enough for him 
 to make a general answer, that you would rather not 
 have the charge of his secrets. You will have the 
 best chance of aiding your patient, if you can keep 
 him under your eye and under your care for a while, 
 so as to ascertain his character and habits, and so as 
 to educate him as to his mode of life. In going over 
 the history of his life from day to day, you may sat- 
 isfy yourself and make him realize what are the 
 errors of his ways ; that he may be convinced that a 
 good life will lead to health ; that he must not sin for 
 a week, and seek absolution at the end of it by the aid 
 
216 ON DYSPEPSY. 
 
 of the apothecary. In this last course such a man 
 loses ground constantly. 
 
 In many instances, instead of prescribing a medi- 
 cine, I have found it necessary to give my dyspeptic 
 patient a moral lecture ; and that, even though he 
 wore a black coat. My lecture has indeed most often 
 had reference to sensual indulgences : but sometimes 
 it has turned upon points of a very different charac- 
 ter. Not unfrequently I have had to descant upon 
 the evils and the impropriety, if not the sin, of over- 
 conscientiousness ; of too great an anxiety to do right, 
 and of distressing regrets from the fear of having 
 erred, unintentionally, in some minute particular. In 
 this morbid state a man may waste his present hours 
 m lamenting the waste of minutes in time past. 
 
 But while it is necessary to have reference to the 
 moral state of the dyspeptic, and to advise him how 
 to gain a control over his feelings, this is not all. 
 You must direct him as to diet, exercise, etc., and 
 must prescribe drugs, so far as they are likely to be 
 beneficial to him. I refer mostly to the proper phys- 
 ical benefit to be derived from drugs ; but there is a 
 class of patients, over whom you cannot maintain any 
 control, unless you indulge them in some medicine. 
 For their own good, then, they should have some safe 
 article, such as may be useful ; but take care, in doing 
 
ON DYSPEPSY. 217 
 
 this, to have regard to the patient onlj, arid not your 
 own glory. 
 
 In deciding on the diet, I would first ascertain 
 whether the patient has an appetite for food. The 
 seaman finds his rudder of no avail, unless there is 
 wind enough to give his ship headway. It is of little 
 use to direct what should be eaten, when the patient 
 does not want to eat anything. One must, then, make 
 a choice among difficulties, and let • the patient have 
 that, which is least noxious, among those things which 
 he consents to swallow. Indeed, in such a case, we 
 have to consider whether, by some evacuant, or by 
 some tonic, we cannot bring back the appetite. If 
 there be an appetite, the diet for most dyspeptics 
 should consist of animal food, farinaceous articles in 
 their purest state, and butter. I know that this last 
 article is not thought so well of by all mankind, as it 
 is by me. Every little boy knows it has a bad name ; 
 and, if bad in quality, or excessive in quantity, it will 
 do harm. But of this I feel assured, that, where fari- 
 naceous substances will become acid in the stomach 
 if taken alone, they are less likely to become so if 
 taken with good butter. Also, it adds to the satisfac- 
 tion of the appetite, and to the nutrition, very much 
 more than in proportion to its quantity. In other 
 words, less bread will answer the purpose, if butter be 
 19 
 
218 ON DYSPEPSY. 
 
 added to it. The animal food is valuable because it is 
 easier of digestion than vegetable food, while it is 
 usually most agreeable to the taste. Add, also, that 
 it does not produce acidity, nor flatulence ; and it is 
 where these . symptoms exist, that we must hold to 
 the most rigid diet. You will remark that the arti- 
 cles I have mentioned may be called dry, in opposi- 
 tion to those which are succulent, and which com- 
 monly contain much water and saccharine matter. 
 Those, who suffer from acidity, must avoid vegetable 
 acids, and acescent substances, of which sugar is one 
 of the worst. Such patients should also be very abste- 
 mious in the use of liquids, as these promote acidity. 
 
 Some condiments must be allowed; at least com- 
 mon salt. If other condiments be required by the 
 habits of the patient, or because the sufferings from 
 flatulence are great, I think you will find the safest 
 to' be those in most common use, mustard and pepper, 
 especially the black pepper. The more aromatic 
 spices, such as cloves, are positively injurious to many 
 persons. They paralyze the stomach ; not in the 
 strict sense of the word, but they stop its action 
 upon the food. 
 
 If costiveness be combined with the dyspepsy, it is 
 very desirable to allow the use of some laxative food. 
 But this food is just such as I have pointed out as 
 
 /*k« 
 
ON DYSPEPSY. 219 
 
 hurtful to many patients suffering from this disease. It 
 is acescent and flatulent. Indeed, it would seem that 
 those parts of the food, which are not digested, are those 
 which exercise the most influence upon the bowels. 
 
 What shall we do, then, with the dyspeptic who is 
 costive ? To which shall we pay most regard in ar- 
 rano^ing the diet. — to the stomach, or to the bowels ? 
 I reply, to the stomach. You may subject that to 
 some slight inconveniences occasionally ; but it must 
 not be annoyed habitually for the sake of the bowels. 
 Keep that in good order, and, as the smaller evil, 
 employ artificial means for the regulation of the 
 bowels. Those means must be the mildest which will 
 effect the object ; and we must find out by trial what 
 these are in each particular case. 
 
 It is best to use injections into the bowels, if these 
 will answer the purpose. They will do so, if the 
 peristaltic motion is sufficiently active, and if the fail- 
 ure occurs in the rectum only. Then, we should 
 administer from one to two gills of cold, or cool water. 
 If this be insufficient, we may add soap and oil to the 
 water ; but very stimulating articles should not be 
 employed for this purpose habitually. The rectum 
 must be treated with caution. The comfort of life is 
 greatly impaired by any injury of this part ; a truth, 
 which it would be well if all men were aware of early 
 
220 ON DYSPEPSY. 
 
 in life. If the injections be insufficient, we must try 
 medicines by the stomach. In cases where the dys- 
 pepsy is not severe, we may often do well with Seidlitz 
 powders, or Congress water. One of these may be 
 taken every morning before food, in such quantity as 
 is found necessary to give one dejection. But for 
 some persons, especially those who take very little 
 food, it is found more advantageous to employ the lax- 
 ative medicine every other day. The quantity of 
 liquid in the saline articles above mentioned is an 
 objection to them in some instances of severe dys- 
 pepsy. In others, these articles are ineffectual. We 
 should, then, seek such as are more efHcient, and less 
 bulky. If we must use them, it is better to give 
 them in such small doses, as that they may operate 
 very slowly ; such as will rather crawl through the 
 bowels, than push through them. For the most part it 
 is better to combine two, or more articles, than to give 
 one alone. An article of this character may be used 
 under the name of a dinner-pill ; and the name helps 
 take off the odium of a cathartic medicine. A com- 
 bination may be made up, after trial, to suit each 
 case. You may introduce a very powerful article into 
 such a pill, in a very minute dose. Strychnia ia 
 employed in this way at the present day, and my triak 
 of it have led me to think well of it. But it should 
 
ON DYSPEPSY. 221 
 
 be given in a very small dose, from a twelfth to a 
 twenty-fourth part of a grain. It is very essential 
 that it should be equally distributed through the mass, 
 in the compound into which it enters. To effect this, 
 a grain of the strychnia may first be mixed very inti- 
 mately with a quarter part of the mass, and then this 
 portion may be mixed very thoroughly with the whole 
 of it. A dinner-pill may be taken every day soon 
 after, or just before dinner, as the patient may prefer. 
 He should be apprized that you want only a natural 
 dejection, and that the medicine operates best, when a 
 nurse would say that it had not operated at all. In 
 the use of such an article, one should not be troubled 
 if on some days it fails to have an effect. There are 
 persons for whom one such pill a day is insufficient, 
 and another must be allowed either in the morning or 
 the evening. The patient should be informed when his 
 dinner-pill contains a powerful article, though in a 
 small dose ; and he should be warned never to take two 
 at a time, nor even one, oftener than he is directed. If, 
 happily, the case will admit the use of laxative food, 
 we may dispense with all these medicines. In respect 
 to this point, and others for obviating costiveness, I 
 refer you to the letter on constipation. 
 
 It was said above that animal food was best adapted 
 to the dyspeptic ; but we must beware of universal 
 19* 
 
222 ON DYSPEPSY. 
 
 propositions and assertions. You will find some in- 
 stances, in which animal food cannot be digested, or 
 not without much difficulty ; but in which bread, rice, 
 and other vegetable food, not acid, are both grateful 
 and borne with ease. I cannot tell you how you are 
 to know, before trial, in what cases this peculiarity 
 occurs. It is not, I think, so common in men as in 
 women ; and I believe that it is not found in persons 
 of sedentary habits, whether scholars or artisans. 
 
 What shall I drink, is a question from a dyspeptic 
 not easily answered. I believe I have said that much 
 liquid is bad for such a one. In cases at all severe I 
 usually restrict the patient to three gills a day ; an 
 amount much less than he probably craves. But 
 what shall this be ? Water answers very well in some 
 instances, and it is free from the objections, to which 
 other beverages are liable. But it is too flat for most 
 persons. Let it, then, be tea, or coffee, or cocoa. 
 Chocolate, and other preparations of cocoa, give trouble 
 to some persons, and especially when they are dys- 
 peptic. They cause oppression, or acidity in the 
 stomach, or headache. If the use of them for a few 
 days do not reconcile the stomach to them, they should 
 be omitted. Again, tea and coffee do not suit some 
 individuals of the nervous class, and it is rather fash- 
 ionable to decry them. There is a notion that what 
 
ON DYSPEPSY. 223 
 
 13 agreeable must be bad ; but I hold just the contrary 
 doctrine, unless when the patient is induced to take 
 too much J because it is agreeable. It is clearly one 
 recommendation of any article that it is agreeable ; 
 and, if an objection is made to such an article, the 
 burden of proof should be thrown upon him who ob- 
 jects to it. Tea and coflfee do sometimes produce 
 inconvenience. They occasion watchfulness, or uneasy 
 sleep in the night; also, tremors of the hands and 
 palpitation of the heart, especially when taken without 
 any solid food. Let persons who suffer in these ways 
 use the tea or coffee w^eak ; and, if they still suffer, 
 let them give up the favorite articles. But do not 
 oblige others to give them up on this account. I have 
 watched very carefully, and have never had reason to 
 believe that these articles produced evils at a distant 
 period ; it is at the time, within the day when they 
 are used, that the evils come, if they come at all. 
 
 Persons who have been accustomed to wine, or 
 malt liquor, often find these salutary once or twice a 
 day. In a large proportion of dyspeptics they become 
 acid in the stomach ; and on this account, not because 
 they are stimulant, we are obliged to forbid them. In 
 such cases, where we want the stimulant, and wish to 
 avoid the acidity, brandy, or some other alcoholic 
 liquor, may be used. Whichever is allowed, wine or 
 
224 ON DYSPEPSY. 
 
 spirit, it is proper to prescribe the quantity. In gen- 
 eral, for an adult, a gill of good sherry in a day, or a 
 quarter, or a third of that quantity, of good brandy, 
 will suffice ; though we must sometimes increase the 
 doses. 
 
 I am fully aware of the terrible evils, which may 
 arise from the excessive indulgence in the articles 
 above mentioned ; and I have heard it said that phy- 
 sicians have made drunkards by allowing the use of 
 them. This is a matter to be considered gravely. So 
 I thought before the days of temperance reform. I 
 advise you to consider it in every case, where you 
 think of prescribing articles capable of producing in- 
 toxication. This should be done especially as to the 
 alcoholic articles, as the temptation is to use them, 
 mixed with water, stronger and stronger. Accord- 
 ingly, I would never order them to one, whom I sus- 
 pected to be deficient in prudence and self-control. 
 But, keeping these things in mind, I have often directed 
 the use even of brandy. In doing this, I have been 
 in the habit of saying to the patient, '' If I ever hear 
 of your indulging to excess in the use of this, or any 
 similar article, I will call on you and exhort you to 
 stop." In one instance, and only one, in the course 
 of a long life, have I been called upon to redeem my 
 pledge. This was in the case of a worthy lady, some 
 
ON DYSPEPSY. 225 
 
 twenty years after I had directed the measured use of 
 brandy. At my request she immediately gave up the 
 use of all spirituous and fermented liquors, and I have 
 reason to believe that she never resumed them. I do 
 not, then, call the risk very great of such prescrip- 
 tions, when made with proper caution. In regard to 
 the benefit in some cases of dyspepsy, and in various 
 other cases, I have not any doubt. And, that I may 
 tell the whole, let me say, that I have repeatedly seen 
 very great benefit from giving wine to young children. 
 The benefit has been particularly marked in some 
 children struggling feebly through the period of den- 
 tition ; and I can name some to whom I had made 
 this prescription more than forty years ago, among 
 whom not one has shown any peculiar fondness for 
 wine in subsequent years. I exhort all young people 
 in health not to adopt the practice of drinking wine. 
 I deprecate everything which shall tend to intemper- 
 ance, and I believe that many men sufier from the 
 use of wine and spirits even in a moderate way. But 
 I love to tell the truth, even when it is unfashionable. 
 I believe that very many persons are benefited by the 
 juice of the grape, and I choose to say so. Moreover, 
 I believe that persons disposed to intemperance are 
 not to be restrained from indulging their vicious pro- 
 pensity, by the abstinence of their more prudent 
 
226. ON DYSPEPSY. 
 
 neighbors. These are opinions at which I have arrived 
 after much attention to the subject. Others, men of 
 the first respectability, disagree with me entirely. Let 
 it be so ; but I trust that the majority will agree that 
 it is possible for them to be in the wrong, and not 
 insist upon controlling the minority on this subject, 
 any more than as to the question whether animal or 
 vegetable food is the most wholesome. It is not a 
 settled point whether woollen clothing should be worn 
 next the skin. Shall a minority be obliged to submit 
 to the majority in this matter ? 
 
 I have made some remarks in favor of moderation 
 in eating, but something definite may be expected on 
 this head. I believe that Mr. Abernethy limited his 
 patients to four ounces of meat at a meal. I would 
 as soon prescribe to every dyspeptic to wear a coat of 
 a certain size and shape, as to direct the food in this 
 way. This matter of more or less is difiicult to settle, 
 and yet every man of common sense knows what is 
 much and what is little for himself at a meal. Every 
 man can tell you whether it is raining hard or not ; 
 and yet any one would stare at you if you should ask, 
 in such a case, how much • it must rain in an hour for 
 you to say that it is raining hard. As to eating, a 
 man may compare himself with those about him, and 
 with himself, when in health, to decide whether he is 
 
ON DYSPEPSY. 22T 
 
 moderate or not. But if you must prescribe the 
 quantity, direct the patient with precision, for two or 
 three days, how much to take, and then judge by the 
 effects whether your allowance is too much or too 
 little. You need not have the food weighed ; it will 
 suffice if you look at the patient's thumb or finger, 
 and let him judge by that ; allowing him, for instance, 
 as much meat as two or four fingers, and twice as 
 much bread at his dinner. One rule you may always 
 give, to be regarded over all others, namely, not to eat 
 quite so much as the appetite demands. This, indeed, 
 must not be applied to a man without appetite. 
 
 1 must now add something respecting bodily exer- 
 cise. The importance of this is so familiar to my own 
 mind, that I feel as if I should be giving you truisms 
 in stating my views on the subject. I have said 
 already that the dyspeptics are foutid mostly among 
 those who live in the house. There are men, of the 
 true Dutch breed, who can live in the house fifty years 
 without finding out what dyspepsy is. But such per- 
 sons could hold out twenty years longer, if they would 
 take exercise abroad. I do not say this at a guess ; 
 for I have seen it tried, and, if it would not take up 
 too much time, I would state the cases. At any rate, 
 the dyspeptic must take exercise abroad; and, if he 
 says he is too weak, this only proves more strongly 
 
228 ON DYSPEPSY. 
 
 the necessity of obeying the law. If he can only 
 walk to the end of his street, or if he can walk only 
 five rods, let him do that as often as he can, and his 
 strength will increase. If he can take a good walk^ 
 let him go out at least twice in the day. If possible, 
 let him have some object, but not such as to burden 
 him. Or, as far as his strength will permit, let him 
 combine amusement with his exercise. At the com- 
 mencement of the treatment it is often expedient to 
 send the patient on a journey. In doing this he 
 should be cautioned to adhere to rules as to diet, so 
 far as possible. Likewise, he should take some exer- 
 cise on foot daily. He should not be on the road 
 more than four, or six hours iii the day. He should 
 get all the amusement which his strength will permit. 
 He should give proper time for sleep, and should not 
 be hurried off in the morning. Our railroads give us 
 great conveniences, but do not always allow the invalid 
 as much accommodation, as could be had before they 
 w^ere built. I have referred to walking as one mode of 
 exercise, and, if the patient can endure it, this should 
 never be omitted ; but those to whom it is convenient 
 should also ride on horseback. This is an excellent 
 mode of exercise anywhere, but it is particularly 
 valuable to men of business in a city, to whom it ia 
 important to make the most of a single hour. 
 
ON DYSPEPSY. 229 
 
 Next, as to the medicinal treatment. I have 
 already spoken of the remedies for constipation, or 
 slow bowels. One of the most obvious requisites for 
 the dyspeptic, at first view, is a tonic. Exercise is 
 a tonic above all medicinal articles; but these also 
 may be employed with advantage in many instances. 
 A faintness, or sinking at the stomach, .sometimes 
 even a painful faintness is among the annoying symp- 
 toms of dyspepsy. For this, the sub-nitrate of bis- 
 muth is a very valuable remedy. It is not always 
 successful, but often operates like a charm. But it 
 will be found best to intermit the use of it after two 
 or three weeks. It may be given in doses of five 
 grains three times a day. This dose is enough for 
 any one, and it is very rarely too much. The mode 
 of giving it is not unimportant. As it is a metallic 
 substance, it is most convenient to give it in some 
 viscid liquid, though it can be taken, out of a teaspoon, 
 with a little water. We commonly use a syrup, when 
 we want a viscid liquid for medicine ; but the stomach 
 of the dyspeptic does not bear this article very well. 
 It is better to use gum acacia ; and it is most conve- 
 nient to mix the bismuth with an equal quantity of 
 this gum in powder, and then to direct the patient to 
 take it, mixed with a few drops of water. This is 
 better than to put the medicine into the form of pills. 
 20 
 
230 ON DYSPEPSY. 
 
 When the appetite is deficient, a vegetable sub-tonic 
 may be given. There are abundance of these. I am 
 in the habit of using one, which may not. however, be 
 better than many others. I direct an ounce of casca- 
 rilla bark bruised, and from two to four drachms of 
 quassia rasped, to be mixed with a pint of boiling 
 water. This mixture should stand- for three or four 
 hours ; the liquid should be strained off, and to this 
 should be added one or two ounces of the tincture of 
 cardamoms; or, if there be any diarrhoea, tincture 
 of cinnamon. Of the liquid thus prepared, the patient 
 should take one to two tablespoonfuls three times a 
 day. When the object is to operate on the whole 
 system, especially for anaemic patients, some prepara- 
 tion of iron is preferable. The preparations of iron 
 are very numerous, and you may select the one best 
 adapted to the circumstances. The compound mixture 
 of iron is a very valuable one, in doses of from one to 
 two tablespoonfuls three times a day. One more 
 agreeable to the taste is the citrate of iron, in doses of 
 five grains or more. 
 
 Many dyspeptics gain very much by visiting min- 
 eral springs, particularly those at Saratoga. After 
 using the Congi^ess water at that place, for a short 
 time, the patient is apt to believe himself well. In 
 his third week he eats what he pleases, and as much 
 
ON DTSPEPSY. 231 
 
 as he pleases, and no evil ensues. But all this 
 depends on the daily use of the water. He leaves the 
 springs, and when he reaches home, perhaps the first 
 evening, he indulges in a supper. The next morning 
 he awakes with a crowded head, or a bad taste in his 
 mouth, and finds that he is no longer at Saratoga. 
 He complains of the bad air of the citj; but the 
 truth is, he did not get his water the morning before, 
 and the gutter has not been washed out. Neverthe- 
 less, with proper prudence, much may be gained at 
 the watering-place. The patient should be moderate 
 in his diet when he is there, and be especially careful 
 to avoid the errors above mentioned on his return 
 home. 
 
 Finally, many dyspeptics never get perfectly well ; 
 yet they recover enough to enjoy life, if they will 
 adhere to the restraints and to the efforts which 
 experience shows to be necessary. There is one 
 comfort, however. Not unfrequently, between sixty 
 and seventy years of age, men get over this complaint, 
 and can indulge in the use of food, which they had 
 not been able to bear for twenty or thirty years. 
 This is not, I think, so often true among women, as 
 in our sex. 
 
LETTER XIII. 
 
 LARLY OF THE CCECUM AND COLON. 
 
 This letter will be on diseases of the intestines. 
 You will not suppose that I shall embrace in so small 
 a compass even a brief account of all those diseases. 
 I shall present to jou some physiological and patho- 
 logical views in respect to the intestinal canal, which 
 I have long entertained, and which I think have aided 
 me in practice. I make no claim to originality as to 
 these views, or doctrines; for, in truth, I cannot 
 remember whether I have derived them from any one 
 else, or not. If you get to have just notions of the 
 simpler diseases of this important part of the organic 
 system, you will be prepared to study with greater 
 ease its more complicated affections. I shall after- 
 wards treat more particularly of two diseases of the 
 coecum and colon. 
 
 Our knowledge in regard to the functions of the 
 stomach is not so full, nor so precise, as we could 
 
ON DISEASES OF THE INTESTINES. 233 
 
 wish ; but our knowledge of the functions of the in* 
 testines is still more deficient. We know, indeed, 
 that the chyme, or mass poured out from the stomach 
 into the duodenum, is there mixed with the bile and 
 pancreatic juice ; that it is then carried slowly through 
 the small intestine ; and that, in its passage, the 
 chyle is taken up by the lacteals. It would seem, 
 at first view, that nothing remained but to carry off 
 the refuse, or faecal part of this mass. But there is 
 something more to be done ; and it is that which we 
 do not sufficiently understand. When you notice the 
 difference in the form and structure of the various 
 parts of the canal, you are led to inquire into their 
 different offices. To say nothing of the small glands 
 scattered through these organs, observe only the dis- 
 tinct characters of the small and large intestines. 
 The contents of the smaller, after the removal of the 
 chyle, are discharged into the larger, and they are 
 not permitted to return ; for a valve, placed in the 
 colon, prevents it. Having passed this barrier, the 
 mass falls into a blind sac, the coecum, evidently 
 designed to retain it for a certain time. Unquestion- 
 ably some change is wrought in the mass while in 
 this receptacle, and something, not chyle, must be 
 absorbed from it, while it is transported through the 
 long tract of the colon. What the change is, and 
 20* 
 
234 ON DISEASES OF THE INTESTINES. 
 
 what the material absorbed, has never been explained, 
 so far as I know. I do not speak of what has been 
 guessed, but of what has been ascertained. I have 
 never heard of anj shrewd guesses even. Suppose 
 it proved that some muriatic or other acid is found in 
 the coecum ; that will suggest that this acid has some 
 purpose ; but the question is, what ptirpose. We 
 must attach more importance to the operations of the 
 large intestine, when we notice that they are not 
 designed to carry forward their contents rapidly, but 
 the contrary. After its resting-spell in the coecum, 
 the faecal mass, a dead weight, must be started up 
 from that pouch, be carried through the ascending, 
 transverse, and descending colon, and in its course 
 must meet an obstacle, evidently designed, at the 
 angle formed between these two last portions of that 
 intestine. I may mention also some delay in the 
 passage through the sigmoid flexure of the same 
 intestine. Where there are provisions so evidently 
 fitted to hold back the mass in its course, we can see 
 how easily obstructions may take place to the easy 
 and perfect accomplishment of the functions of this 
 machinery. In addition to the mechanical obstacles 
 to the rapid passage of the faeces, we know that the 
 change of the semi-fluid mass to a state of comparative 
 solidity may be carried beyond its due point, and 
 
ON DISEASES QF THE INTESTINES. 235 
 
 thus a new difficulty arises in the process of defeca- 
 tion. 
 
 Some explanation is thus suggested of the habitual 
 constipation, so common among persons not leading 
 natural lives; and some explanation, also, in regard 
 to other diseases of the bowels. But there is a great 
 variety in these diseases, which we should, no doubt, 
 better understand, if their normal functions were more 
 fullj known to us. 
 
 A disorder in any one part of the alimentary canal 
 may, directly or indirectly, affect all other parts of it. 
 It is chyme, and not crude food, which can be acted 
 upon properly in the duodenum and other intestines. 
 If, then, the food, while in the stomach, be not changed 
 into chyme, more or less disorder may be produced 
 both in the small and large intestines. In like man- 
 ner, if a failure should occur in any part of the intes- 
 tines, the portion of the canal below that part must 
 receive the materials in a comparatively crude state, 
 so that here also the disorder would be propagated 
 from the superior to the inferior part. This, which 
 seems so obvious in theory, is found true in fact. But 
 I must add that this is not found to be true invariably. 
 We must always be cautious in adopting unqualified 
 and universal principles, especially in regard to living 
 bodies. In a vigorous state of the digestive organs, a 
 
236 ON DISEASES OF THE INTESTINES. ^ 
 
 proportion of the food may pass through the canal^ 
 quite unchanged, without occasioning any manifest 
 inconvenience. It is well known that seeds pass in 
 this way without losing their vitality, for they ger- 
 minate afterwards. 
 
 Again, it is often found that a disease in any part 
 of the intestines, the colon for -instance, disorders the 
 stomach and small intestine, as well as the parts 
 below it. Here a different explanation is required; 
 and the best is that the parts above the original dis- 
 ease are affected by sympathy. I shall not dispute 
 with any one who carps at this word, sympathy, so 
 long as he will allow that the influence of the lower 
 part upon the upper is to be attributed to a vital power ; 
 not like that considered above, which consists in the 
 transmission of a crude material. It should be noted 
 that the lower part may be influenced through the 
 same vital power, where the higher part is diseased. 
 Thus, a disease of the stomach may disorder .the parts 
 below it in two different modes. 
 
 I do not adduce evidence in support of the proposi- 
 tions I have laid down. A careful observer cannot, I 
 think, fail to discover instances which prove them. 
 But now, do you ask, whether we can always, in dis- 
 eases of the alimentary canal, satisfy ourselves as to 
 the part first affected, and as to the mode of the prop- 
 
ON DISEASES OF THE INTESTINES. 237 
 
 ftgation in each individual case ? To this question I 
 must answer, no. I have pointed out the modes in 
 which I believe that disease in one part affects another, 
 as preparatory to another statement ; this is, that in a 
 violent attack on any one part, others are affected 
 almost simultaneously, so as to throw much confusion 
 upon the subject. This is the great embarrassment in 
 the early stages of maladies in the digestive apparatus. 
 There are two other causes of embarrassment in the 
 same tribe of diseases. One is, that an inflammation 
 of the mucous membrane of the canal may extend from 
 day to day, so as to be subsiding on one part while it 
 is increasing upon another, as erysipelas does on the 
 skin, and as a fire does upon grass. The other is, 
 that the stomach is often, as the intestines are occasion- 
 ally, affected by sympathy with some distant organ ; 
 and the disorder, thus introduced into one part of the 
 canal, may in some way derange other parts of it. 
 
 Here are the difficulties. I believe that, when we 
 can get an exact history of the disease, and an account 
 of its precursors, a due consideration of the whole will 
 enable us to overcome these difficulties in a good 
 measure. Not, however, always, nor entirely. Such 
 embarrassments may bring to your mind what I have 
 eaid of our imperfect knowledge of the normal func- 
 tions of the organs concerned. 
 
238 ON DISEASES OF THE INTESTINES. 
 
 The difficulties, thus brought before jou, relate to 
 the question as to the primary seat of trouble, or of 
 disease, in disorders of the alimentary canal. When 
 this question is answered, we have to inquire what 
 this original affection consists in. To meet this in- 
 quiry, let me say that there are two very obvious 
 modes, in which a disorder in this canal may com- 
 mence. The^r^^ is by an article introduced into it, 
 which is offensive to it, or to some part of it. Thus, 
 ipecacuanha will occasion vomiting, and sulphate of 
 magnesia will occasion a diarrhoea. The second is a 
 disease on some one, or more spots in any one of the 
 coats, or tissues of the canal. Thus, an inflammation 
 in either of these coats, or a paralysis in the muscular 
 coat, may be supposed to be the primary affection. 
 An inflammation of the mucous coat of the stomach 
 may cause vomiting, as well as the introduction of 
 ipecacuanha into that organ. Vomiting occasioned 
 by ipecac, will usually cease soon after the offending 
 cause is removed; and, after a period of rest, the patient 
 is soon well, provided he "was well before. When the 
 mucous coat of the stomach is inflamed, the disease 
 must go through a certain course, during which the 
 functions of the stomach must be impaired or arrested ; 
 and other symptoms will ensue, more or less, accord- 
 ing to the extent, character, and violence of the in- 
 
ON DISEASES OF THE INTESTINES. 239 
 
 fiammation. Analogous remarks will hold true as to 
 cases, in which the intestines, in any of their parts, are 
 the seat of the inflammation. 
 
 It was stated that, when ipecac, is taken into the 
 stomach, it excites efforts by which it is removed ; and 
 other substances, so received, may be expelled by the 
 intestines, supposing in such cases that a sufficient 
 quantity is taken to provoke the necessary efforts. 
 Such, however, are not the effects of all offensive 
 substances ; and, when they are not, it may be proper 
 to adopt measures either to provoke the salutary evac- 
 uations, or to neutralize the offending article. 
 
 When it is ascertained that the disease is an inflam- 
 mation, we take measures, negative or positive, to 
 counteract this morbid affection. By negative meas- 
 ures, in this case, would be understood rest and absti- 
 nence, more or less complete ; allowing only bland 
 articles to be introduced into the stomach, and in 
 limited quantities, so as to allow the disease to go 
 through its ordinary processes with the least possible 
 interruption. Treated in this way, a diarrhoea, the 
 consequence of an inflammation in the mucous coat of 
 the intestines, may pass away with very little incon- 
 venience. 
 
 But now, suppose the inflammation to be severe, 
 and, perhaps, to extend to the muscular coat; then 
 
240 ON DISEASES OF THE INTESTINES. 
 
 motion of the diseased part may cause severe pain, 
 and the lameness may be so great as to impede the 
 passage of any material through it. To get a distinct 
 view of the subject, let us imagine the inflammation 
 to occupy a ring of the intestine, say four to twelve 
 inches in width. It is easy to understand that this 
 part may be lamed, as the fingers sometimes are, by 
 rheumatism, so that they cannot be opened or shut. 
 Suppose such a diseased patch in the colon, very much 
 less than we often find after a fatal dysentery, what 
 effects may we anticipate ? The patient may be pre- 
 sumed to have the usual materials in the canal, above 
 and below the diseased part. Those below it may be 
 discharged without material difficulty. Those above 
 it would occasion a great deal of difficulty ; more or 
 less, according to the extent, character and violence, 
 of the inflammation. The sound portions above would 
 continue to carry down their contents to the inflamed 
 part ; but here an embarrassment must ensue. This 
 lame part could not expand with freedom, nor yield 
 to the pressure so as to give an entrance to the mate- 
 rials brought to it. Or it might allow only a small 
 portion to enter it occasionally, carrying that through 
 it slowly and with pain. But this small portion would 
 not pass alone into the sound intestine below it. It 
 would be accompanied by some product from the 
 
ON DISEASES OF THE INTESTINES. 24^ 
 
 morbid surface. This surface would pour out an 
 extra portion of mucous or serous fluid, or, perhaps, 
 some blood, and, ultimately, some pus. Meanwhile, 
 the pressure of faeces from above would be constantly 
 provoking an attempt in the morbid part to receive 
 and transmit them. In such a case the actual dis- 
 charges from the bowels would consist mainly of the 
 fluids from the inflamed surface, as above described, 
 with very little, if any, faecal matter. This matter 
 would be wrapt up in the mucous and morbid products, 
 and would rarely pass in any great quantity until the 
 violence of the inflammation should subside. If such 
 a disease should be of large extent it would be attended 
 by constitutional affections, of which one symptom 
 would be great prostration of strength. You see here 
 we have a case of dysentery, vie^ved as if the parts 
 affected were opened to our inspection. My design 
 has been to give you what I consider the • true 
 explanation of this disease, including such general 
 remarks as would apply to milder affections of the 
 inflammatory kind in the intestinal canal. I shall 
 say nothing of treatment. My purpose is answered 
 if I have suggested the proper way of regarding dis- 
 eases of the alimentary canal. I have treated, in the 
 most elementary way, of inflammation as disqualifying 
 the canal for performing its common functions, and aa 
 21 
 
242 ON DISEASES OF THE INTESTINES. 
 
 occasioning the production of morbid matters, which 
 are discharged from the body. There are other 
 organic affections of the same parts, which may inter- 
 fere with the proper motions of the intestinal canal, 
 or obstruct the passage of its contents ; such as 
 tumors, whether benign or malignant. It is not in 
 my plan to treat of these. 
 
 To understand well a disease of the intestines we 
 should know from day to day all the ingesta ; every- 
 thing taken into the stomach, solid or liquid ; in- 
 cluding the time when each portion is taken and the 
 quantity. We should next see each dejection from 
 the bowels by itself, just as it took place, withoijt 
 any mechanical disturbance of it, noting the period 
 of its occurrence. Last, we should ascertain how the 
 patient has passed his time, whether in exercise, or at 
 rest ; whether at ease, or in pain ; whether under 
 febrile disturbance, or calm and cool. It is not so 
 easy to learn all these details respecting adults, as it 
 is in respect to young children. You will therefore 
 find a great advantage in studying diseases of the 
 stomach and bowels in children. If you get faithful 
 reports from their attendants, you may often under- 
 stand, almost exactly, what has been going on in their 
 digestive organs. It is true, indeed, that you see in 
 them the most simple diseases ; but a familiar 
 
ON DISEASES OF THE INTESTINES. 243 
 
 Acquaintance with these prepares you for the study 
 of other affections of the same parts. 
 
 In the beginning of this letter I referred to two 
 affections of the coecum and colon, on which I have 
 something to offer you. The first I shall mention is 
 an undue enlargement of the ascending colon, some- 
 times, perhaps, extended to the whole colon. The 
 ascending colon has to carry up the faeces in opposition 
 to gravity, when the body is in an erect position. It 
 is fitted for its office, and performs* it without attract- 
 ing attention in persons leading a natural life. But 
 in some individuals a failure frequently takes place, 
 and an undue quantity of air accumulates in, and dis- 
 tends this part of, the intestine. A certain portion of 
 air excites the organ to contract, and thus is salutary. 
 But, if it fails, the muscular power of the organ is 
 impaired by the distention, and from year to year 
 that organ becomes less and less able to do its proper 
 work. It is in sedentary people, especially in those 
 of them who are fat and sluggish, moving slowly 
 when they do move, that this trouble is the worst ; 
 but I believe that it exists in a slight degree in many 
 individuals not like those above described. Tliose. 
 who are affected in this way, are habitually costive and 
 Buffer much from flatus in the bowels. They have 
 periods when they are generally uncomfortable and 
 
244 ON DISEASES OF THE INTESTINES. 
 
 complain particularly of some uneasiness about the 
 right side of the abdomen, where, if thej are not too 
 fiit, some fulness may be discovered. As happens 
 most frequently in regard to sensations within the 
 great cavities, the seat of the uneasiness is not very 
 clearly ascertained. Some doctor, who is so learned 
 as to know that the liver is on the right side, is apt 
 to think of that organ. The patient is then adjudged 
 to be bilious J and is under suspicion of a diseased 
 liver. He takes a blue pill for a few nights, and 
 Seidlitz powder in the mornings. The intestines are 
 unloaded and the patient is relieved. Then it is con- 
 sidered as proved that the dijGficulty was in the liver, 
 and that the blue pill, being the police officer, who has 
 the special charge of that organ, has put all things to 
 rights. I feel well assured that something like this 
 is the case in a large proportion of the " liver cases," 
 so called. Here is an error in diagnosis, it may bo 
 said, yet the patient finds relief from the treatment, 
 and that is enough. Is it so ? Does error often lead 
 to truth, or to a wise course ? The patient is led to 
 believe that he is the subject of a disease, or difficulty, 
 which cannot be helped without an active medicine, 
 frequently repeated. When he is better, he is not told 
 how to keep so. It is not suggested to him that a 
 cshange in his habits is requisite. The disease may 
 
ON DISEASES OF THE INTESTINES. 245 
 
 be too great and of too long standing to admit of 
 entire relief, but it may still be lessened b/ diet and 
 regimen. When not so confirmed, much may be done. 
 Exercise, and especially walking, must be enjoined as 
 absolutely necessary. To this should be added friction 
 over the abdomen, and espa^ially over the colon. In 
 this way the difficulty may be relieved, in part at 
 least. It may be useful to add laxative food ; but 
 how far this can be done with advantage must be 
 studied out in each case. The difficulty on this point 
 arises from the flatulence, which is increased by such 
 food, when it does not succeed in making the bowels 
 sufficiently active. Sometimes a portion of gently 
 stimulating articles, such as are called carminative, 
 will help the laxative articles. It is a case where 
 mustard-seed may be tried. But in obstinate cases, 
 such as come mostly under the charge of the physi- 
 cian, some laxative medicine must be used frequently, 
 perhaps daily. This medicine should be the mildest 
 which, on trial, is found to answer the purpose ; and 
 the patient must be made to understand that the 
 object is gimply to bring away the fseces ; and that 
 the medicine operates best, w^hen the dejection is the 
 most natural in its aspect. By pursuing such a 
 course st-eadily there is some chance for recovery in 
 persons nnder fifty ; but in those who are beginning 
 21* 
 
246 ON DISEASES OF THE INTESTINES. 
 
 to get old, we may be satisfied if we can prevent an 
 increase of the disease. In persons who suffer from 
 this disease of the colon an enema will not suffice, for 
 the faeces are not brought within its reach. In bad 
 cases Seidlitz powders. Congress water, and similar 
 articles may not be sufficient to bring the loaded and 
 debilitated organ into action. A dinner-pill, or a pill 
 at bed-time, or, perhaps, more than one, will be 
 needed to effect the object ; or rhubarb may be used 
 for those on whom it acts kindly. When the medi- 
 cine is not quite enough, the load may be helped 
 through by an injection of cold water. In this 
 troublesome disease the physician must watch the 
 patient for a while, and teach him how to judge of the 
 effects of remedies ; for there are few who can learn 
 their lesson without a tutor. 
 
 I may, perhaps, have exaggerated the picture of this 
 disease ; but something like it is frequent among 
 sedentary persons, especially among those who are 
 full feeders. Of course, there is every difference of 
 deo-ree. The disease mio;ht be included under that of 
 habitual constipation. But the constipation does not 
 necessarily include the general uneasy state of the 
 abdomen, nor the particular suffering, or discomfoi't on 
 the right side. In many cases of constipation the 
 whole trouble ia in, or near to the rectum. 
 
ON DISEASES OF THE INTESTINES. 247 
 
 There is another disease, in which the coecum may 
 be suspected to take a part, which is not extremely 
 rare ; and yet, so far as I know, it has not been dis- 
 tinctly described. I will attempt the description, but 
 may not be successful ; for there is great variety in 
 the severity and in all the circumstances of the cases, 
 which I include under this head. It came to my 
 knowledge gradually, in a group with other diseases 
 in the same vicinity. After I had been led to distin- 
 guish it from the others, I could look back and find 
 that I had seen it before. 
 
 In my early years I noticed, as others have done, 
 that in peritonitis the inflammation was greatest' on 
 the right side of the abdomen, and in the lowest half 
 of it. Let me call this lower half the iliac quarter , 
 for it extends somewhat beyond what is called the 
 iliac region. Subsequently I found that this quarter 
 was also the seat of other diseases, oftener than the 
 corresponding part on the left side. I may mention 
 painful affections and tumors of different sorts, which 
 I met with on the right side more than on the left. 
 At length, within the last fifteen years, perhaps, I got 
 to distinguish the particular disease, which I wish 
 now to make known to you. I must give a name to 
 this affection, as it is inconvenient to get on without 
 one ; therefore, in the present state of our knowledge, 
 
248 ON DISEASES OF THE INTESTINES. 
 
 I will denominate it a 'painful tumor near the 
 coecum. I will state some cases of it before giving a 
 general description. There is something in common 
 to these cases, while they differ in their extent, vio- 
 lence and duration. 
 
 A young lady, when absent from home in the 
 spring of the year, took cold, as she said. She 
 became quite sick, and had much trouble in the stom- 
 ach and bowels for two or three weeks. She did not 
 get quite well, and the same symptoms returned more 
 than once after she came home. It became a question 
 whether she had a partial peritonitis, and at any rate 
 there was suffering in the right iliac quarter. An 
 attack took place again in the summer, when she was 
 at some distance from home. This was more obstinate 
 than the earlier ones, and confined her to her bed. At 
 this period the case was described to me, and I asked 
 if there was not a little tumor in the right iliac 
 quarter. Her physician was very careful and 
 thoughtful ; he said he had examined the parts com- 
 plained of, and he believed there was not any such 
 tumor. He was not, however, then acquainted with 
 the disease. Soon after this I visited the lady and 
 detected the tumor. It did not lie superficially, so that 
 't was not felt in passing the hand over the abdomen ; 
 out it was perceived at once on pressing the fingers 
 
ON DISEASES OF THE INTESTINES. 249 
 
 down to some little depth. It was at the point where 
 a horizontal line, drawn from the anterior superior 
 spinous process of one ilium to that of the other, 
 crosses the outer edge of the right rectus muscle. It 
 was in shape rather oval than round, and flattened j 
 and was larger than an almond, somewhat movable, 
 and so tender to the touch that the patient wanced, or 
 cried out, every time that I pressed on it. The pres- 
 sure did not, however, cause extreme pain. I found 
 it at once, because I had before learned where and 
 how to feel for it ; otherwise I might have missed it. 
 The patient had now been sick for two or three weeks^ 
 her symptoms varying much in severity. The prin- 
 cipal complaint was a pain in the right side of the 
 abdomen, and more in the lower than the upper part 
 of that side. With this her appetite was quite lost at 
 times, but not constantly. She had frequent attacks 
 of the pain, with some febrile symptoms. They were 
 attributed to the food she took, to the exertions she 
 made when feeling better, and to a deficiency in the 
 alvine discharges. Laxatives afforded her great relief 
 for a time, but a frequent repetition of them was 
 necessary. She remained in a tender state for several 
 weeks, so as to delay her return home, and it was 
 necessary to remove her with peculiar care. At home 
 sdie soon recovered strength enough to move about, 
 
250 ON DISEASES OF THE INTESTINES. 
 
 but for many months she had an occasional attack of 
 the disease. As this -was now understood, it was 
 arrested very soon by evacuations of the bowels, a few 
 leeches, and, perhaps, a small blister, with bodilj rest 
 and abstinence. Within a year from her first attack 
 she became quite well, and eight or ten years have 
 how passed without any return of the malady. 
 
 I have seen cases more severe than this, and some 
 much more mild and shorter. Of the last description 
 is the following. 
 
 In 1849, H. M., a woman between thirty and forty, 
 of very good habits, and leading an easy life, though 
 a domestic, complained to me of pain on the right side 
 of the abdomen. She had had it for two or three 
 weeks, and felt less able to attend to her business than 
 usual, yet had not relinquished it entirely ; she could 
 not assign any cause for the pain. On examination I 
 found a tumor much like that in the preceding case, and 
 in the same situation. It was not discovered on light 
 pressure, but on pressing the fingers somewhat into the 
 abdomen while the patient was on her back. She was 
 not aware that there was any tumor, or that any was 
 suspected, but she complained at the moment Avhen I 
 touched it, and did not acknowledge any like tender- 
 ness upon pressure in any other part of the abdomen. 
 The pain, however, exten'ded beyond its seat, particu- 
 
ON DISEASES OF THE INTESTINES. 251 
 
 larly above it. She had one symptom, which I have 
 never known in any other case. This was pain in the 
 iliac quarter on sitting down and on rising from her 
 chair. It was not a severe pain. There was not any 
 strongly-marked constitutional affection, though she 
 felt less well than usual. 
 
 The remedies employed were cathartics, leeches 
 twice and blisters twice, over the seat of the tumor. 
 Under the use of these she grew better, but at the end 
 of a fortnight the tumor could still be felt. I then 
 ordered an ointment of iodine and hydriodate of potass 
 to be applied over it, and under the use of this she 
 got quite well within two or three weeks. Whether 
 the ointment helped it is uncertain; but, in respect 
 to the benefit of the other remedies, I felt no doubt, as 
 manifest relief followed each one of them. In this case 
 the tumor could be covered entirely by a half-dollar. 
 She has not had any return of the disease. 
 
 It was I believe at an earlier date that I saw Mr. 
 
 B , a young gentleman, in consultation, who had 
 
 acute pain in the abdomen, somewhat of the character 
 of colic pain. It was severe, and he was on his bed. 
 I saw him, I think, on the second day of the attack, 
 and was told that he had had a similar affection not 
 many weeks previous. On examination I found dis- 
 tinct tenderness at the spot before described, but there 
 
252 ON DISEASES OF THE INTESTINES. 
 
 was very little, if any, tumor. By remedies like 
 those used in the last case he was soon relieved entire- 
 ly. I inquired from time to time afterwards, and 
 found that he had not had a third attack. Though 
 the evidence of a tumor was very equivocal, and at 
 the most it was very small, I have always suspected 
 that the disease was the same as in the preceding cases, 
 and that its recurrence was probably prevented by the 
 remedies. If so, he gained by the severity of the 
 case, which obliged him to seek medical aid at once. 
 
 The following is a case of much greater severity 
 and duration, which, however, I consider as similar to 
 the others in its essential character. The patient, 
 
 Mr. E, , was past middle life, a business man, of 
 
 active habits, and of a distinctly nervous temperament. 
 He had been sick, much of the time in bed, for two or 
 three months before I was called to him in consulta- 
 tion. He had a good physician, who was not, however, 
 acquainted with the disease. This man had a large 
 tumor, two inches in diameter, which came under the 
 spot before described on the borders of the iliac 
 quarter. I do not mean that the angle of the lines 
 described was over the centre of the swelling. The 
 tumor laid nearer the surface than either of the others, 
 and felt as if extending deeper. In other words, it 
 was thicker than the others. It was painful and 
 
ON DISEASES OF THE INTESTINES. , 258 
 
 tender to the touch. There were febrile symptoms, 
 which had been varying from time to time. The 
 digestive apparatus was all wrong. He was so sick 
 that his life was considered in danger. Leeches and 
 vesication had decidedly good effects as regarded pain 
 and soreness, and the size of the tumor was lessened 
 somewhat under the use of them. Strong cathartics, 
 acting freely, afforded him great relief, so that he 
 never felt as if he had enough. The quantity of faeces 
 was very large, more than his food seemed to account 
 for. The evacuations never caused any marked change 
 in the swelling, as if an accumulation in the intestine 
 had taken place. For a while he gained in strength 
 and spirits, took food well, and the tumor became 
 smaller. But when he had been sick five or six 
 months a new trouble came on. This was insanity. 
 This occasioned his removal from town, and I saw no 
 more of him. This occurred ten or more years ago, 
 and I believe he is still living with his mind deranged. 
 So far as I have been able to learn, the first disease 
 has never been troublesome since he left town, and 
 probably it has subsided. The termination of this 
 case was the worst I have ever known. There was 
 not, however, anything to show that the two diseases 
 were connected, except that one followed the other. 
 I will give you one more case, and a very interest- 
 22 
 
254 . ON DISEASES OF THE INTESTINES. 
 
 ing one. It is that of a young physician, Dr. H ^ 
 
 who had been engaged in unwonted labor three or 
 four months before his sickness. It occurred in the 
 summer of 1846. When I first saw him he was on 
 his bed, prostrated, with a very bad and anxious 
 countenance, modified in expression by opium, which 
 he had been taking freely ; skin hot, pulse hard and 
 frequent. His abdomen was very hard, painful and 
 tender. His worst pain was in the right iliac quar- 
 ter^ and I found there a tumor in the usual place, of 
 which he was not aware. This was very tender to 
 the touch ; a silver dollar would about cover it. His 
 own recollection, of the preceding part of the disease 
 particularly, has been recently given to me in the fol- 
 lowing words : 
 
 " The disease commenced, I think, about twelve 
 days before you saw me. At that time, while driving 
 out of town in the evening, and through some low 
 ground, after leaving a very hot room, I became much 
 chilled. It was not merely a sensation of coldness, 
 but a distinct rigor, the effect lasting several hours. 
 This was followed in a day or two by tenderness of 
 the abdomen, and a general sensation of being ill. 
 The tenderness increased continually, so that, for sev- 
 eral days before I saw you, the motion of the vehicle 
 over the pavement caused me great pain. On Satur- 
 
ON DISEASES OF THE INTESTINES. 255 
 
 day the pain and tenderness were constant, and it 
 seemed as if I could count every stone I rode over. 
 At night I went to mj bed and took laudanum very 
 freely. The agony was such I could not remain in 
 bed, and much of the night I was walking about the 
 room. I continued the laudanum through the night, 
 but do not think much of it was retained ; at all events 
 it did not produce sleep, nor at all mitigate the pain. 
 On Sunday morning I went out as usual, but the 
 motion was so painful I could not allow the horse to 
 go beyond a walk. After seeing a few patients I felt 
 that I could do no more. I then got some leeches and 
 went home to apply them, but finding that I was 
 growing worse, sent for you soon afterwards. At 
 this time my abdomen was very hard all over, my 
 face, as I saw in the glass, of a dark purplish color, 
 my breathing very short, labored and painful ; in fact, 
 I thought I was dying. You immediately opened a 
 vein. The blood at first was very thick ; it looked to 
 me like 'tar, but it soon came to move freely and ran 
 a good stream ; this you allowed it to do till I was 
 faint. The relief, as to the pain and dyspnoea, was 
 decided and immediate. You then directed twenty 
 leeches to be applied to the abdomen (I had previously 
 applied a few), and in the evening you and Dr. Bige- 
 low advised a repetition of the bleeding, and I believe 
 
256 ON DISEASES OF THE INTESTINES. 
 
 about as much blood was taken as in the morning. 
 No blister was applied over the abdomen then ; but, 
 some time after, you directed a succession of them to 
 be applied over the hard bunch, which appeared in 
 the right iliac region, to promote absorption. This 
 bunch disappeared quite slowly, and it was a number 
 of weeks before the tenderness, which followed it, was 
 gone. During my convalescence I had repeated 
 attacks of pain, resembling colic, but have never had 
 any since, nor has there ever seemed to be any obstruc- 
 tion or dijfficulty in the bowels since that time, although 
 it took me more than a year to recover my strength. 
 Previous to your seeing me the action of the bowels 
 was regular." 
 
 This case differs from all others I have seen in its 
 violent acute symptoms ; it caused me to fear general 
 peritonitis and a fatal result. The relief following the 
 bleeding and subsequent purging, removed my fears. 
 But. though its violence was overcome, the disease 
 continued for a long time. Colics -occurred, as Dr. 
 
 H has stated ; and the tumor remained always 
 
 somewhat tender, and at times painful. The suiFering 
 was increased by food, if taken in more than the most 
 moderate quantity, even when the appetite was suffi- 
 cient and the whole disease nmch abated. Fruit and 
 acescent articles were especially hurtful to him. His 
 
ON DISEASES OF THE INTESTINES. 257 
 
 feelings led him to a constant desire for full purga- 
 tives. As in other cases of the kind, the relief from 
 them was decided, though not of long duration ; and 
 the discharges were always more copious than could 
 have been expected, from the quantity of food taken. 
 I do not remember any disease in which I have noticed 
 this peculiarity so strongly marked, except organic 
 affections of the liver. 
 
 Since this letter was written a friend has very kind- 
 ly handed me two cases, which he observed during the 
 last year, and which appear to be of the same descrip- 
 tion as the foregoing. The language in which he 
 describes the cases differs from mine, as any two men 
 may differ in relating the same thing. I had had a 
 conversation with him on the subject, and that led him 
 to take special note of these cases. 
 
 Two cases observed by Francis Minot, M. D. 
 
 ''Pain in the abdomen, with active febrile disturbance. 
 Relief after leeches and purgatives. Tumor in the 
 ilio-coecal region, remaining after convalescence. 
 
 " A little girl, aged eleven years, who had generally 
 enjoyed good health, became ill on Sunday, October the 
 eighth, 1854, without known cause. She felt chilly, 
 lost her appetite, and was inclined to lie on the sofa 
 all day. She went to school the two following days, 
 22* 
 
258 ON DISEASES OE THE INTESTINES. 
 
 though not feeling well. On the tenth she had great 
 pain in the abdomen, accompanied bj vomiting, and 
 followed by an evacuation of the bowels, the first since 
 the seventh, though they had previously been perfect- 
 ly regular. 
 
 " I found her on the tenth in bed. The face was 
 flushed, pulse one hundred and ten, tongue slightly 
 coated. She complained of severe pain in the abdo- 
 men, referred to the right side, and occurring in par- 
 oxysms about once an hour, leaving her comparatively 
 free in the intervals. She could lie only on her 
 back; the least motion, and even drawing a long 
 breath, also causing pain. The abdomen was moder- 
 ately full and resonant. On the right side it was 
 very sensitive to pressure, the tenderness being exces- 
 sive in the iliac region. A cathartic of calomel and 
 jalap was ordered. Before it operated the patient had 
 a sharp rigor, followed by heat and perspiration. 
 After the enema she had a large solid dejection. She 
 derived great comfort from a fomentation of spongio- 
 piline, and got some sleep after taking opiates. 
 
 " On the twelfth her general condition was about 
 the same. She lay with her legs drawn up, and sup- 
 ported by pillows, the slightest motion causing pain. 
 The face was pale and expressive of much suffering, 
 but not anxious. Skin of natural temperature ; tongue 
 
ON DISEASES OF THE INTESTINES. 259 
 
 covered with a thin, brownish, pasty coat ; breath 
 foul ; pulse one hundred and twelve, rather hard ; 
 respiration twenty, easy ; thirst, headache. The ab- 
 domen was extremely tender throughout the right 
 side, but mostly so in front of the anterior superior 
 spine of the ilium. Considerable fulness above and 
 in front of the same point was evident to the eye. 
 Four leeches were applied to the seat of pain, imme- 
 diately after which there was great relief to the pain. 
 In the evening she was able to move her limbs a 
 little. 
 
 '' On the thirteenth I found a smooth round tumor, 
 feeling like an egg, just in front of the spine of the 
 ilium. On account of its tenderness, it could not be 
 freely examined. In the course of the day she had a 
 very copious spontaneous dejection, the first part of 
 which consisted of hard, dry lumps, the remainder 
 being soft. She also passed much wind. After this, 
 the general condition was much improved. The pulse 
 fell from one hundred and six to ninety. The tender- 
 ness, except over the tumor, was greatly diminished. 
 
 " The next day I was able to examine the tumor with 
 more ^ exactness, and made the following record : 
 ' Its centre appears to be two inches from the ilium, 
 on the right side, on a line drawn through the two 
 superior spinous processes. It is globular, and smooth. 
 
260 ON DISEASES OF THE INTESTINES. 
 
 Its limits cannot be exactly felt, as the examination 
 gives considerable pain.' The patient had two abun- 
 dant dejections, after medicine, in the course of the 
 daj, and was altogether better in the evening. 
 
 ''Her improvement was uninterrupted, though slow. 
 She could not dispense with the pillow under the 
 right thigh before the sixteenth, nor could she lie on 
 the right side, though she was able to sit up in bed. 
 On the fifteenth the tumor is noted as being ' about 
 two inches long by one broad.' 
 
 " On the twentieth I recorded as follows : — ' She 
 has been well since the last visit (seventeenth), and 
 has not been confined to the house. The tumor is felt 
 deep beneath the surface, in the right iliac region. It 
 is hard and round, feeling like a horse-chestnut, and 
 of about the same size, almost entirely free from ten- 
 derness.' She recovered perfectly, but I cannot say 
 whether the tumor ultimately disappeared." 
 
 " Pain and tenderness, with a deep-seated tumor in 
 the ilio-coecal region, with slight febrile symptoms. 
 Convalescence in four days. 
 
 '' A married woman, aged about forty, was confined 
 for the eighth time on the 21st July, 1854. Nothing 
 unusual occurred during the labor or convalescence. 
 During the night of the third and fourth September she 
 
ON DISEASES OF THE INTESTINES. 261 
 
 was attacked with severe pain in the abdomen, which 
 was increased when she lay on the left side. No 
 cause could be ascribed for this attack, unless too 
 much exertion in lifting her children. 
 
 " On the morning of the fourth she was in bed, pulse 
 ninety-six ; tongue nearly clean ; skin of natural 
 temperature ; no headache, nor pain in the back or 
 limbs ; no chill ; had had no dejection for three days, 
 except a slight one yesterday. Decubitus dorsal. 
 Every movement of the body was painful, and she 
 could not lie on the right side. Abdomen moderately 
 tympanitic, everywhere soft, not tender, except in 
 the neighborhood of the spine of the ilium, on the 
 right side, where it was extremely tender for a space 
 four inches square. A smooth globular tumor was 
 felt in the same place. It was a few inches in diame- 
 ter, lay very deep beneath the surface, and was very 
 sensitive to the touch. In the course of the day the 
 pulse rose to one hundred and twenty. (Six leeches 
 to seat of pain. Castor oil, followed by enema.) 
 
 "September 5th. — The patient experienced great 
 relief after the application of the leeches. She had 
 four dejections. Is now free from pain, and feels 
 much better. Pulse eighty-eight, tongue moist, some 
 appetite, no thirst. The tenderness of the abdomen 
 
262 ON DISEASES OF THE INTESTINES. 
 
 has much diminished, but the tumor is with difficulty 
 felt, on account of its depth. 
 
 " September 7th. — Feels quite well, and free from 
 pain. Is still in bed. Bowels free. Tumor cannot 
 be distinctly felt. 
 
 " September 8th. — Sitting up. Free from pain 
 and tenderness." 
 
 The cases, which I have related, differ from each 
 other in their severity and duration, and in many 
 important details. If I could recall all I have seen 
 this would be more fully exemplified. I have not 
 seen one case of the disease which has proved fatal ; 
 so that no examination post mortem has enlightened 
 me upon its seat and particular chai-acteristics. 
 
 What, now, are the symptoms common to these 
 cases and which may be regarded as essential to 
 this disease ? They are pain in the right iliac 
 quarter, but not confined to this, for it often passes 
 beyond the limits of this quarter, particularly upward ; 
 and a tumor, varying in size, so deep-seated in the 
 abdomen as not to be felt without some direct pressure 
 on the part, more or less tender, sometimes very 
 tender. This tumor is to be felt near the outer edge 
 of the right rectus muscle of the abdomen, where this 
 IS crossed by a line drawn horizontally from the 
 
ON DISEASES OF THE INTESTINES. 263 
 
 anterior superior spinous process of the right ilium. 
 It- must not be understood that the centre of the 
 tumor is to be found exactly under the angle formed 
 by the lines above mentioned, only that some part of 
 the tumor lies under it. This may not be mathemat- 
 ically correct : but I believe that the indurated body 
 will always be found, when the fingers are pressed 
 down as near to this angle, as one Would come in an 
 examination of this sort. Constitutional affections 
 attend this disease in some stage of it, but they vary 
 much in severity ; and so also does its duration vary. 
 I may add, as a characteristic of this painful tumor near 
 the coecum, that purgatives give so much relief that 
 the patient is always anxious to have them. Perhaps 
 it may be true of all diseases, in which the coecum 
 and colon are concerned, that the patient has a strong 
 desire for something to relieve those intestines from 
 the faecal matter detained in them. 
 
 I have mentioned the coecum as an organ affected 
 in this disease, but I have not shown that this is true. 
 We must now consider what is the organ affected ; 
 in which of its coats, or tissues, the affection is seated ; 
 and what is the nature of the affection. I cannot 
 answer these questions with an assurance of being 
 right. I have supposed that the coecum was the 
 organ affected, that the disease was seated on or in its 
 
264 ON DISEASES OF THE INTESTINES. 
 
 serous coat, and that this disease was an inflammation. 
 There are, however, great objections to this supposi- 
 tion ; it is upheld mostly on the ground that there are 
 greater objections to any other. In talking with my 
 medical friends, none more satisfactory has been 
 suggested to me. If there were absorbent glands, 
 lacteal or lymphatic, in the situation of the disease, 
 the explanation would be easy. 
 
 I think it will be readily admitted that, in the cases 
 I have related, the tumor is formed by the process of 
 inflammation. The part is painful and tender ; often 
 very tender. Unless in the case of Mr. B., I have 
 never seen the disease at its very beginning ; and if 
 that was the same as the others, it subsided so soon 
 as not to enlighten us upon its nature. In all the 
 others the tumor has enlarged and diminished gradu- 
 ally, as might happen to a phlegmon not passing on to 
 suppuration. It does not, however, come within our 
 notions of a phlegmon, if, as I believe, it never termi- 
 nates in suppuration. The tumor has never subsided 
 suddenly, so as to justify a suspicion that it has dis- 
 charged pus into the intestines, or elsewhere. Nor 
 have I ever found it to subside, or to be diminished 
 suddenly, after a purgative, as might happen if a 
 faecal mass had been confined in the coecum. - Indeed, 
 the feeling of the tumor does not resemble that of an 
 
ON DISEASES OF THE INTESTINES. 265 
 
 accumulation of faeces , such as I have sometimes met 
 with. It accords better, though not exactly, with an 
 enlarged lymphatic gland. It might be supposed that it 
 occupies, or extends through, all the coats of the 
 coecum. But then it would be such an obstacle to 
 any contraction of that organ, as to cause great pain 
 at the time ; so that the patient would get to have a 
 dread of cathartics, even though they might be fol- 
 lowed by relief But, as I have said, the patient is 
 always, or very often, anxious for cathartics. 
 
 Can there be a suppurative process on the mucous 
 membrane of the coecum, and is the tumor, in any 
 way, a secondary affection ? I have seen such a dis- 
 ease of the coecum, and had no hesitation in deciding 
 what it was. The case proved fatal, and fully con- 
 firmed my diagnosis. The symptoms were very 
 different from those I have stated as belonging to 
 this jjaififul tumor. 
 
 MM. Dupuytren and Grisolles, of Paris, and, I 
 believe, some other French writers, have given an 
 account of phlegmon and abscess in the iliac fossoe. 
 A slight knowledge of these diseases, especially the 
 name employed by Grisolles (Tumours phlegmoneuses 
 des fosses iliaques), might lead ono to suppose the 
 affections to be the same; but it is not so. I am 
 acquainted with those phlegmons, most common in 
 23 
 
266 ON DISEASES OF THE INTESTINES. 
 
 the puerperal state, but seen in other states. I have 
 been consulted about one, in a man, since I have been 
 engaged in writing these letters. These phlegmons 
 almost always suppurate, as is particularly shown by 
 M. Grisolles, and as my limited experience confirms. 
 I first became acquainted with this disease in examin- 
 ing a woman post mortem at our almshouse, more 
 than fifty years ago. That case was so remarkable in 
 one point, that I will diverge from my path to put it 
 on record. The abscess contained more than a gill 
 of pus. There was involved in it, lying in this bed 
 of pus, a portion of the external iliac vein. Where 
 this vein passed through the parietes of the abscess, 
 at both its upper and lower part, the vessel was clogged 
 up by coagulated lymph, showing that the adhe- 
 sive inflammation (in Mr. Hunter's language) had 
 taken place within the vein, as it had in the surrounding 
 cellular membrane. But, further, between these two 
 portions of lymph suppuration had taken place within 
 the vein. The pus in the vein was somewhat colored 
 by blood, but not so much as to leave any doubt as to 
 its character. The case had been a slow one probably. 
 The subject of it was an abandoned woman, who had 
 been brought to the house in an exhausted state. 
 You observe that the peculiarity of the case was that 
 the vein was insulated in the cavity of the abscess, 
 
ON DISEASES OF THE INTESTINES. 267 
 
 and had gone through the same processes as the 
 surrounding parts, without having had any opening, 
 by which it had communicated with them. On a 
 young admirer of John Hunter, as I was, this case, 
 illustrating his description of the different processes 
 of inflammation so distinctly, made an impression, 
 which has not been efikced by time. I am sure that 
 the essential circumstances are correctly stated, though 
 I have done it from memory. I believe I have a 
 a record of them, but cannot now put my hands on 
 it. 
 
 I have stated more than once that suppuration has 
 not occurred in any case of this painful tumor near 
 the coecum. On saying this lately to an ingenious 
 and learned friend, to whom I had been speaking of 
 this disease, he asked the following question : '' May 
 not your disease have been tuphlo-enteritis ; and may 
 it not be that in the cases, which did not terminate 
 fatally, the nature of the affection was not discovered ? " 
 This is a fair question, and I leave it to others • to 
 answer it from observation, if an opportunity occurs. 
 I replied to him that since the first case I saw of 
 tuphlo-enteritis, I have not seen one, which has been 
 proved to be so, that I did not recognize at once; 
 that this disease occurs mostly in children, though not 
 in them solely ; that its symptoms are usually, within 
 
268 ON DISEASES OE THE INTESTINES. 
 
 the first few days, much more violent than those in 
 my cases at so early a period ; that vomiting is, I 
 believe, among the early and obstinate symptoms in 
 tnphlo-enteritis, while in my cases it is much less 
 remarkable, though it occurred in some of them. To 
 this I should add that the little tumor felt in tuphlo- 
 enteritis is, I think, to be found somewhat lower, and 
 not so near to the median line as the tumor I have 
 described. I submit all this for consideration ; with 
 the hope that others will be able to explain the disease, 
 I have thus brought to notice, more perfectly than I 
 can do. 
 
 In describing cases of the disease under considera- 
 tion I have stated the remedies employed more or less 
 fully. I will bring them into one view, premising 
 that they must be used with greater or less freedom, 
 according to the violence of the disease. The indica- 
 tion is to bring about resolution in the inflamed 
 part. It is very probable that the final result would 
 be the same without medical aid, but there are two 
 reasons for adopting active treatment. First, there 
 is usually so much pain and distress when the physi- 
 cian is called, that present relief is a great object. 
 This relief treatment will afford. Second, in the 
 instances which I have seen, the disease has proved 
 more severe and more lasting, the longer it has con- 
 
ON DISEASES OF THE INTESTINES. 269 
 
 tinued before the appropriate treatment has been 
 adopted. This is an approximation to the truth, if not 
 a perfectly correct statement. 
 
 When colic, or great pain in the bowels, exists at 
 the commencement of the treatment, opium should be 
 given, in some form, until it gives ease. If, indeed, 
 there be a hot skin, a. frequent and hard pulse, and 
 the patient be sufficiently vigorous, venesection should 
 be the first remedy. In the case of Dr. H. the benefit 
 of free bleeding was unquestionable. The depletion 
 will probably, in all cases, diminish the pain and dis- 
 tress ; and, after it, opium will act more kindly than 
 before. Leeches should be applied where venesection 
 is not admissible, or not required ; in number from 
 six to twenty, according to circumstances. If there 
 be much pain the opiate should be used first. After 
 the bleeding a purgative should be given. After 
 bleeding the purgative will probably act more readily 
 and more easily, as the loss of blood will, if I may so 
 express it, liberate the intestine. On the following 
 day a blister should be drawn over the seat of the 
 tumor. This and the other remedies must, of course, 
 be repeated, or not, according to circumstances. 
 
 Through the whole treatment rest should be en- 
 joined, and the diet should be very moderate and 
 %imple, until the disease is evidently much lessened. 
 23* 
 
270 ON DISEASES OF THE INTESTINES. 
 
 If the treatment is not begun early, exacerbations are 
 verj apt to occur. They must be guarded against as 
 far as possible ; and, if they take place, active measures 
 should be adopted at once. In an old or severe case 
 the tumor will remain for a time with some tenderness, 
 after recovery has taken place in all other respects. 
 In this state I think the external use of iodine may 
 be useful. At least the tumor has gone off under this 
 remedy sooner than I had anticipated, and the patient's 
 mind has been kept easy, and no injury has ensued 
 
LETTER XIV. 
 
 ON CONSTIPATION OP THE BOWELS. 
 
 Constipation of the bowels is among the most 
 common evils, as respects health, among the inhabit- 
 ants of cities. It is occasioned in part by their diet, 
 but probably much more by their sedentary habits. 
 The same habits induce the same evil among persons 
 living in the open country. The great extent of this 
 evil is shown by the multitude of remedies for it ; of 
 quack remedies, the sale of which has enriched their 
 proprietors. It is not strange that persons, unin- 
 formed on this subject, and experiencing daily the 
 evils of constipation, should employ the pills and 
 draughts advertised and puffed by their mercenary 
 proprietors. Why should we speak with reproach of 
 these persons? The efficient elements in most of 
 their patent medicines are, I suppose, the same which 
 are employed by regular physicians. Most of them 
 are valuable articles, and some are exceedingly well 
 adapted to the purpose in view. The objections to 
 
272 ON CONSTIPATION OF THE BOWELS. 
 
 them are that they are used without discrimination as 
 to the cases, for which thej are respectively best 
 fitted; and, what is much worse, the sufferers are 
 induced to take medicine instead of relying on diet 
 and regimen, the more natural modes of relief 
 
 The tendency to constipation is constitutional in 
 some persons. Whether it is derived from some pecu- 
 liarity of structure, or whether connected with some 
 modification of the vital powers, I am not prepared to 
 say. There are men whose external appearance is 
 modified by this deep trouble, or at least I fancy so. 
 You may meet such a one daily in the street, moving 
 with a regular but rather slow gait, thin, bony, look- 
 ing down, his body slightly bent forward, having an 
 anxious countenance, with an expression as if worn by 
 a hidden grief; with a skin dry and somewhat coarse 
 or rough, and a dull complexion, rarely showing any 
 •red color. This melancholy-looking man attends to 
 business, and very probably is growing rich. In 
 conversation you find him more cheerful than you had 
 anticipated, and quite bright at times. But you dis- 
 cover that he is limited in all his conduct, not willing 
 to eat, drink, or sleep, out of his own house ; and 
 reminding you, perhaps, of a horse tethered out. You 
 may help such a man, but you cannot make him 
 anew. 
 
ON CONSTIPATION OF THE BOWELS. 27B 
 
 What, then, shall we saj to one habitually consti- 
 pated in the bowels ? We must make him acquainted 
 with the causes which have produced the evil, and 
 with the hygienic rules adapted to overcome it. First, 
 a laxative diet should be directed. Among the articles 
 adapted to this purpose, coarse bread, bread made from 
 meal, and not from the fine flour of the grain, may, 
 perhaps, be called the principal. In the fine flour we 
 have the nutritious portion of the seeds, which has 
 been procured by sifting it from the meal. In this 
 case the hull is left on the sieve. For nourishment 
 alone this hull is of very little value ; but far other- 
 wise when we take into view its effect on the bowels. 
 The more coarse the meal the better for the purpose 
 now in view. Indeed, it is found better to employ 
 the wheat simply cracked. This cannot be made into 
 bread, but if soaked from two to four hours in warm 
 water, so as to make a species of mush, the effect of 
 this preparation on the bowels is very great. It is, 
 however, an article which some stomachs do not well 
 bear. . 
 
 I cannot pass by my notice of this article without 
 stating the obligations our community is under to my 
 friend. Dr. John C. Warren. We had been in the 
 habit of employing rye meal, and sometimes Indian 
 meal, as laxative articles, and had thought that rye 
 
274 ON CONSTIPATION OF THE BOWELS. 
 
 had some peculiar property of this kind. It was 
 known that wheat was a better grain for nutriment 
 than the rye or maize ; but wheat being used, by us 
 in New England, only in the state of fine flour, it was 
 regarded as a constipating article. Many years ago 
 Dr. Warren recommended the bread made from the 
 wheat meal, sweetened with molasses. This bread 
 got the name of dyspepsy bread ; a name given to it, 
 I believe, by the bakers. It was introduced not be- 
 cause it was adapted to pure dyspepsy, but as a remedy 
 for habitual constipation. It is true that, when this 
 bread overcame the latter complaint, dyspepsy in cer- 
 tain cases was removed, or alleviated, showing that it 
 was caused by the constipation. Some years after this, 
 the same distinguished gentleman introduced the use 
 of groats, or cracked wheat, of which I have spoken 
 above. 
 
 The advantage of having bread of a laxative charac- 
 ter is, that this article is in such constant use. It 
 enters with most persons into every meal, and often 
 in a large proportion to other articles. 
 
 There is another form in which the meal, or coarse 
 flour, may be emploj^ed with advantage, especially by 
 those who cannot afford to use expensive fruits. This 
 is mush^ or hasty-pudding, made from any of the 
 grains, the rye perhaps being the best. Butter may 
 
ON CONSTIPATION OF THE BOWELS. 275 
 
 be used with this pudding, and molasses should be 
 added as increasing its value. 
 
 White mustard-seed was greatly in vogue here, some 
 thirty years ago, to regulate the bowels, and thereby 
 to do many other good things. It was recommended 
 by Cullen, I think, but was revived by some accident 
 at the time I refer to. It was taken in doses of from 
 one to eight teaspoonfuls a day. In many instances 
 it acted very kindly, but it too often failed, or pro- 
 duced some inconveniences, and it fell into disrepute. 
 It should not, however, be quite forgotten. 
 
 The articles we call fruits are most of them very 
 useful and very agreeable remedies for the difficulty 
 we have in view. Generally speaking, those which 
 are succulent and tender are to be preferred; and 
 those which are sweet are, perhaps, rather better than 
 such as are acid. To this last remark there are some 
 exceptions. Beginning with the berries, which we 
 find in the summer, in our climate, we go on to the 
 pears and apples in the autumn. As these, the apples 
 especially, last through the winter and spring, we get 
 a supply of fruit for most of the year. Of the pears, 
 those which are hard are not very valuable, if they 
 are at all so. The apple may be used without cook- 
 ing, by many persons; but they are better for all, 
 especially for those with tender stomachs, after being 
 
276 ON CONSTIPATION OF THE BOWELS. 
 
 cooked. Thej should be cooked in their skins, that 
 there may be the least possible loss of their juices. 
 The good pears are too tender to make this necessary, 
 but they are not injured by cookery. One advantage 
 of cooking these fruits is, that the stomach will bear 
 more of them, than when in the crude state. For the 
 purpose we have in view, the sweet apples are rather 
 better than others. It is remarkable, however, that 
 some dyspeptics can bear a sharp acid apple better 
 than a sweet one. The same persons will bear ripe 
 currants better than the sweet berries. This will not 
 seem so strange, if you bring to mind that the acidity 
 of the stomach, which troubles dyspeptics, is that 
 which arises from fermentation of the food. It may 
 be produced by acids taken into the stomach, especially 
 those of unripe fruits ; but not so readily by the acid 
 of a mature fruit, such as currants are in tb*i last week 
 of July and in August. Looking for fruits at the 
 different seasons of the year, I have provided for all 
 except the last half of the spring, and the first month 
 of the summer. But all persons cannot command the 
 delicate fruits. In the absence of these, oranges may 
 be resorted to. These are found among us at all 
 seasons; but the best, the most mature, are to be 
 found in the spring. We have also the resource of 
 the dried foreign fruits, at all seasons. The most 
 
ON CONSTIPATION OF THE BOWELS. 27T 
 
 valuable of these are figs and prunes. The latter are 
 made better by steaming. 
 
 I think the best time for the use of fruit is at 
 breakfast, though it may be taken at dinner if proper 
 room is allowed for it. The most agreeable time for 
 oranges is before sitting down at the breakfast-table. 
 Two of them taken at this time are all-sufficient in 
 many instances. I must not omit the rhubarb plant, 
 which resembles the acid fruits. This may be used in 
 May, and continued tilt midsummer. It should be 
 stewed with sugar, and taken at breakfast or dinner. 
 Though this article is called the pie-plant, let it be 
 noted that the pie-crust is not essential to it ; and to 
 those of tender stomachs it is injurious. 
 
 Thirdly. Vegetable food generally is more laxative 
 than animal food. This is particularly true of the 
 tender and succulent vegetables. There are two arti- 
 cles, which come under the name of vegetables at our 
 tables, which are especially useful, and which in 
 reality are fruits. These are the squash, the winter 
 squash especially, and the tomato. 
 
 Fourthly. To the foregoing I must add that ole- 
 aginous and fatty articles have a laxative effect. The 
 only vegetable oil we are accustomed to is that from 
 the olive, much more used in other lands than in ours, 
 •and certainly of great value. "We get a vegetable oil 
 24 
 
278 ON CONSTIPATION OF THE BOWELS. 
 
 in the nuts, especially in that called the oil or butter 
 nut. To those, who have not access to other laxative 
 food, this nut may be found very useful. Animal fat 
 is serviceable in the same way, and pork is the best 
 article of this kind, on account of its fat. I know that 
 this is contemned, and even thought injurious, by 
 many persons who are not Jews. To some stomachs 
 it certainly is offensive, even though it be of the best 
 quality. But to many persons our New England 
 corn-fed pork is easy of digestion, highly agreeable, 
 and, as the phrase is, very wholesome. That is the 
 term which, in my early days, many delicate persons 
 employed, when they meant that the article was good 
 for the bowels. Let me here mention another article, 
 on which the polite are apt to frown, and which we 
 can hardly recommend to young ladies ; this is the 
 onion, of which I am reminded by mentioning pork 
 It is quite valuable to those who cannot bear the 
 acescent vegetables. There is still another useful 
 vegetable, scarcely admitted on genteel tables, or not 
 without some apology. I refer to beans. The objec- 
 tion to them is that they often cause flatulence. For 
 some persons this is a sufficient objection, in whatever 
 way the article is prepared. But most persons can 
 tear beans very well if they be well cooked. They 
 should be boiled so as to be thoroughly tender, and 
 
ON CONSTIPATION OF THE BOWELS. 2T9 
 
 then baked slowlj, but not so as to be quite dry. 
 Some black pepper may be added to them. Pea-soup 
 is still another dish to be had in respectful remem- 
 brance. Both the peas and the beans are wholesome 
 to some, though not to all persons. 
 
 I have mentioned a variety of articles for the pur- 
 pose in view, and it is desirable to have a variety to 
 choose from. I have, however, omitted some which 
 miglit be mentioned. Some are very useful to one 
 person, and are not at -all so to another. People get 
 tired if confined too much to the same article, and 
 want a variety to suit the palate. Lastly, one may 
 be procured when others cannot. 
 
 It is not to be understood that persons of constipated 
 habits should be confined to the articles pointed out 
 above. On the contrary, these should be taken with 
 others, more or less, as the case may require at dif- 
 ferent periods. But none of them are to be relied on 
 as medicines for a temporary purpose. Generally, 
 their good effects do not show" themselves until they 
 have been taken for three or four days in succession. 
 
 I have treated of the diet fitted to obviate habitual 
 eostiveness. Next to this should be placed bodily 
 exercise. In many instances this is all that is wanted. 
 Care in diet is seldom sufficient without it. I say to 
 the sufferer under constipation, " Get exercise any 
 
280 ON CONSTIPATION OF THE BOWELS. 
 
 how, in any mode ; but, if you can, let it be on your 
 feet. Walk two hours every day, and as many hours 
 as you can on a holiday. It is best to walk with an 
 object, if possible. It is best, also, to get one good 
 walk soon after breakfast ; but walk in the eveninoj if 
 you cannot get leisure at other parts of the day." 
 Walking is better than riding or driving for the pur- 
 pose now in view ; but circumstances sometimes forbid 
 this, such as lameness of one kind or another. Then, 
 if possible, let the patient ge^ on horseback. In all 
 this I have reference to citizens^ the inhabitants of 
 cities, or of large and busy towns. A resident in the 
 country, who does not get his living by labor iii the 
 open air, more than half the year may resort to gar- 
 dening. This is the most luxurious exercise one can 
 have, if he has any taste for the pursuit. There is 
 one other mode of exercise, which may be enjoyed 
 wherever there is water at hand. This is rowing in a 
 boat. Though the oarsman is not on his feet, he 
 brings all parts of the body into use. This exercise 
 seems to belong to our sex, but it may be allowed to 
 the other, when they are in secluded places ; and some 
 of them know how to excel in this as they do in most 
 handiworks which they undertake. 
 
 Many persons learn for themselves the influence of 
 habit in keeping up the regular action of the bowels ; 
 
ON CONSTIPATION OF THE BOWELS. 281 
 
 but they do not always learn this before tlie middle 
 of life. The morning, soon after breakfast, in the 
 majority of cases, is found the most convenient time 
 for this purpose ; and almost any one, by a little care, 
 may avail himself of the readiness of the human body 
 to be influenced by habit, so as to fix on such a part 
 of the day as he pleases. Persons who are much 
 troubled by hemorrhoids, or by prolapsus ani, will 
 find it best to get their evacuations just before bed- 
 time. The advantage is that such persons derive 
 benefit from assuming the horizontal position for a 
 time after an alvine dejection. I must give a cau- 
 tion connected with this subject. One should not 
 allow himself to strain, nor to hurry himself from a 
 regard to habit, nor for any other reason. In this 
 way he may induce hemorrhoids, or prolapsus. These 
 are great evils, of which few persons are aware except 
 those who have suffered them. 
 
 It is best to get a dejection from the bowels once a 
 day. There are some who get two a day, and feel the 
 better for it; but they are rare exceptions. One 
 should strive to get one by all reasonable means ; but 
 persons of infirm health are sometimes unduly anxious 
 on the subject. They are made fidgety and really 
 unhappy if they miss a day. I believe it conduces to 
 good-humor to be regular on this point ; but I could 
 24* 
 
282 ON CONSTIPATION OF THE BOWELS. 
 
 bring good evidence to show that a man may have a 
 verj good share of health, and a great abundance of 
 generous good-humor, though he should relieve the 
 bowels only once in four days. Such a case is singu- 
 lar, no doubt, but there are many instances of persons 
 who have very comfortable health, while they get 
 relief only once in forty-eight hours. Nature does 
 not lay down universal rules on all points. 
 
 The great object of maintaining sufficient evacua- 
 tions is not attained by all men, though they follow 
 the directions above given with exactness. This some- 
 times arises from a constitutional peculiarity, but for 
 the most part it is produced by a long neglect of the 
 hygienic laws. When this neglect has arisen from 
 wilfulness, and not from ignorance, you may say a 
 man deserves the punishment which nature inflicts 
 upon him. If this be true, it is not the business of 
 the physician to leave him to his fate. He must try 
 to alleviate the evils, however induced, and gently, but 
 firmly, to persuade his patient to return, as far as he 
 can, to the right path. 
 
 What now shall we do to the patient who cannot 
 overcome the habit of constipation by such means as 
 have been pointed out ; by diet and regimen ? The 
 reply is, in general terms, that, when we are obliged 
 to resort to art, we must imitate nature as nearly as 
 
ON CONSTIPATION OF THE BOWELS. 283 
 
 we can. Bj imitating nature in this case, I mean that 
 we should strive to bring about the end in the quiet 
 and easy manner in which nature does it. Further, 
 as men in health do not effect the object in view per- 
 fectly, and equally, every day, we must be satisfied 
 if, by art, we can succeed pretty well on the whole, 
 though not every day. By trying to keep up to the 
 mark, without failure, we shall be liable often to over- 
 step it. 
 
 The simplest and safest of remedies for habitual 
 costiveness, in a large proportion of instances, is the 
 injection into the rectum of cold water, to the amount 
 of one or two gills. This remedy may be used every 
 day, with ordinary care, for many years, without any 
 injury. It is successful in' the cases where the faecal 
 mass is brought to the rectum and delayed there. If 
 the failure takes place above, so that the faeces are not 
 brought down, this remedy will not answer the pur- 
 pose. It is true that, in certain extraordinary cases 
 of constipation, benefit has been derived from injecting 
 three or four pints of water. In this way the fluid 
 may be made to pass up the colon, and, probably, even 
 to the coecum. But that is not a method to be 
 adopted for ordinary cases, and it is of these I am 
 treating. 
 
 In the cases, for which the daily or frequent use of 
 
284 ON CONSTIPATION OF THE BOWELS. 
 
 injections can be adopted with success, it is proper to 
 give instructions for the convenient management of 
 the process. Few men will adhere to this remedy, if 
 they must be put to great trouble every time they use 
 it. The first question is, what instrument shall be 
 used ? I think it very certain that the best instru- 
 ment, to be used on one's self, is a metallic syringe 
 with a curved pipe. This should be kept with pipe 
 screwed on to the cylinder, so as to be ready for use 
 without delay. After it has been used, it requires only 
 to be made clean externally. Plain water only being 
 used, it does not require any care for the internal 
 part, except to throw out any remnant of the water 
 which may be in it. Such instruments are to be 
 found among us, holding nominally six ounces, but 
 really holding about four ounces. They are better 
 than larger ones, though they must sometimes be used 
 twice, because they are as large as it is convenient to 
 handle. If you would have the best, get a philosophi- 
 cal instrument-maker to supply you a brass syringe 
 furnished with a metallic piston. The pipe should 
 be silvered over. There are other instruments, which 
 may appear to you better at first sight, but they do 
 not wear so well. This is true of all which have 
 flexible tubes, or India rubber in any part of them. 
 They get out of order very often ; they require more 
 
ON CONSTIPATION OF THE BOWELS. 285 
 
 care each time they are used, and the use of them is 
 not attended with the same facility. For a sick per- 
 son, lying in bed, Mawe's instrument, or one on the 
 same principle, is better than the syringe above de- 
 scribed. The French instrument, which goes ojBf upon 
 pressing a spring, is very convenient in some respects. 
 It is of comparatively little moment what instrument is 
 employed, if there be a valet de chambre, or a waiting 
 maid to take care of it. Not so when one takes the 
 whole matter into his own hands. I will not omit one 
 hint more, although one does not want to dwell too long 
 on the affairs now under consideration. This is, that 
 it is best to pass the instrument sideways under the 
 body, sitting in a water-closet, or on the appropriate 
 cabinet, and then rising up to bring the handle of the 
 syringe against the wall of the apartment ; then, by 
 carrying the body gently toward the w^all, the piston 
 may be pressed firmly and yet gently into the cylin- 
 der. 
 
 The treatment just stated is insufficient for those 
 cases, m which the faeces are not brought down to the 
 rectum. Besides, there are many persons who cannot 
 succeed in using injections, and more who will not 
 submit to the trouble of this simple and safe remedy. 
 We must then administer medicine, and in doing 
 this our object should be to employ the mildest and 
 
286 ON CONSTIPATION OF THE BOWELS. 
 
 safest article which will suffice. If there were one 
 such article, which would prove the best for every 
 case, the matter could be easily settled. This is 
 what is pretended by every quack, who advertises his 
 own wonderful discovery of a pill, or powder, for this 
 purpose. And the patient, who has found an article, 
 which suits himself, after having tried a dozen, is 
 very apt to recommend it to his friends as fitted for 
 all men. We doctors, like the tailors, find that coats 
 of the same size, and proportions, and fashion, will 
 not suit every individual. My own course is to study 
 the circumstances of each case, and endeavor to an- 
 ticipate which among the milder cathartics is most 
 likely to be suitable and efficient. I say suitable, for 
 the article must be one, which wiU give the least 
 inconvenience as to the taking it, and in its efiects on 
 the stomach and bowels. I say efficient, for we want 
 an article which shall be tolerably sure to act with 
 regularity as to time, without over-acting. Persons 
 who might be relieved by injections, but who will not 
 use them, will probably find the saline medicines, in 
 small doses, but largely diluted, the most suitable for 
 them. Such are many of the natural mineral waters, 
 among which the Congress water from our Saratoga is 
 as extensively famed, and as justly, as any. In most 
 instances a pint of this water, taken before breakfast, 
 
ON CONSTIPATION OF THE BOWELS. 287 
 
 is sufficient. This maj be divided into two, or more 
 portions. For some persons a quart is required ; but 
 here we must watch lest there be some harm from so 
 large a potation. It is true that there is scarcely any 
 liquid of which so much can be taken with impunity 
 as these natural waters, when containing a due quan- 
 tity of carbonic acid. Very similar in their effects to 
 these waters are the articles known as Seidlitz and 
 Rochelle powders. The most convenient of these arti- 
 cles is sold under the name of Butler's tasteless Seidlitz 
 powders. A common soda powder is enough for many 
 persons. I ought to add that some succeed very well 
 with a cheaper, though less agreeable article. This 
 is the sulphate of magnesia, or any similar neutral salt 
 having a laxative power, taken in the dose of a 
 teaspoonful, but dissolved in half a pint of water. 
 This may be made less disagreeable by adding sugar 
 and peppermint- water, ginger, or some other aromatic. 
 The morning, before breakfast, is the best time for 
 using any of the articles above named. The break- 
 fast may be taken shortly afterwards without any 
 harm. 
 
 From various causes, perhaps, none of these saline 
 articles suit some individuals. For such we must 
 furnish a medicine of greater efficiency, and given in a 
 smaller compass. These are required especially for 
 
288 ON CONSTIPATION OF THE BOWELS. 
 
 those whose bowels are sluggish ; in whom, probably, 
 there is a great delay of the faeces in the colon. You 
 will find some delicate and feeble women in this class. 
 In them it would seem as if there were a real want of 
 muscular power in the coecum and colon ; the more 
 when there is not any aid from bodily exercise. But 
 very many, who require similar aid, are men of strong 
 constitutions, who eat and drink freely, and who are 
 fitted for hard work, but do not indulge themselves 
 in it. In these cases I sometimes suspect that one 
 great process of the large intestines is carried too far. 
 The absorbents take up too much of the liquid con- 
 tained in the mass brought down through the ileum. 
 
 Among the very convenient and efficient medicines 
 for persons of this class is aloes. It is the substantial 
 part of Anderson's pills, which have had the most 
 extensive celebrity among the English and their 
 descendants for three or four generations, and, I 
 believe, i* enters largely into many other patent 
 articles of the same character. It is ordered as a shop 
 medicine in the regular pharmacopoeias, alone, or in 
 combination, in the form of pills ; and it is the es- 
 sential part of that grand old domestic tincture known 
 under the name of Elixir Proprietatts. So far 
 it would seem that aloes would meet all one's wishes ; 
 but like most of the good things on earth, it has its 
 
ON CONSTIPATION OF THE BOWELS. 289 
 
 defects. I do not refer to the pain it sometimes 
 causes in passing the bowels ; for, though it has this 
 fault, the same is true in a greater degree of many 
 other articles of its kind. "What I do refer to is its 
 tendency to produce haemorrhoids. This is true of 
 some other similar articles, but not to the same 
 extent. It is a reason for using this medicine watch- 
 fully, and for forbidding it to persons who have 
 haemorrhoids, or any other disease about the rectum. 
 Rhubarb is another article employed with great satis- 
 faction by many persons. Some men chew it daily, 
 and some when specially needed ; and for those, who 
 do not object to the taste, this is a good mode of using 
 the article. The nicest pieces are of course selected, 
 and usually the Turkey rhubarb is preferred for this 
 purj)Ose. The medicine may, however, be made into 
 pills, or into an infusion, and be combined with some 
 aromatic article. The tincture is valued highly by 
 some individuals, but it is objectionable because most 
 persons require of it a larger quantity than it is wise 
 to administer daily, or frequently, of a spirituous 
 article. Rhubarb more often causes griping than 
 aloes. I ruight go on to mention many other well- 
 known articles for the purpose in view, such as scam- 
 mony, colocynth, sulphur, magnesia, etc., etc. Sul- 
 phur and magnesia are comparatively bulky articles. 
 25 
 
290 ON CONSTIPATION OF THE BOWELS. 
 
 The sulphur, however, is now and then found to an- 
 swer very well, especially for persons liable to hemor- 
 rhoids. The magnesia is a favorite with many per- 
 sons subject to acidity of stomach. It is not, however, 
 an article to be commended for frequent use. It is 
 sometimes found to accumulate in the intestines. But 
 an evil much more common is that it is slow in opera 
 tion, often keeping up an uneasiness for many hours, 
 and causing many small dejections, instead of one 
 sufficient one. 
 
 It has been found that a combination of moderate 
 cathartics will act more kindly than any one alone ; 
 and sometimes a powerful article may enter into the 
 mixture, in an extremely small dose, without injury, 
 and, perhaps, with advantage. It is a convenience 
 of such an addition that we can get a sufficient dose 
 in a small compass. Gamboge has been employed in 
 this way. I am not, however, disposed to favor this 
 article, as it sometimes proves treacherous ; that is, 
 it will act with undue violence. Strychnia is employed 
 in the same way at the present day, and with care it 
 may be employed with advantage in cases hard to 
 manage. But it should be given in a very small dose, 
 not more than one twelfth part of a gi-ain in a dose 
 containing other articles. After trial the dose of 
 strychnia may be increased. When it is used two 
 
ON CONSTIPATION OF THE BOWELS. 291 
 
 precautions are necessary; one, that the medicine 
 should be prepared very faithfully, by a responsible 
 person, to insure the equal distribution of the strych- 
 nia through the mass into which it enters ; the other, 
 that the patient should be apprised of the properties 
 of the article, that he may not at any time take more 
 than the dose prescribed. 
 
 We should rarely employ such heroic medicines. 
 There are many safer combinations than those into 
 which these articles enter. There is one in our phar- 
 macopoeia, which is quite equal to our common needs, 
 when faithfully prepared. This is the compound ex- 
 tract of colocynth. Though there is some aloes in 
 this article, it is very rarely hurtful. Indeed, I have 
 never been satisfied that this preparation has brought 
 on hemorrhoids in any case. This may receive, in 
 combination, any other medicine of small bulk which 
 the occasion calls for. There is one, often prescribed 
 for rheumatism, which acts so pleasantly on the bowels 
 that I think it would be frequently employed, if it 
 could be brought into a small bulk. This is the resin 
 of guaiacum, of which the dose is one drachm. It 
 may now and then be convenient to remember this. 
 It should not be taken in the form of tincture, as the 
 requisite dose would contain too much alcohol. 
 
 I have been treating of habitual constipation. We 
 
292 ON CONSTIPATION OF THE BOWELS. 
 
 ineetj occasionally, instances of very great and obsti- 
 nate constipation, wliicli are to be regarded very differ- 
 ently. In some of these we see good reason to suppose 
 that the constipation depends on some organic or some 
 mechanical difficulty ; or on inflammation in some 
 part of the intestines. In all cases of peculiar consti- 
 pation, we must bear in mind that such obstacles may 
 exist; and, if so, that our cathartics would not only 
 fail to do good, but might do harm. We must, there- 
 fore, proceed with great caution and circumspection, 
 as the seaman does when he fears sunken rocks. We 
 should examine carefully in the usual seats of hernia. 
 If there be nothing found in them, we should ascertain 
 whether there is any tender spot in the abdomen upon 
 slight or deep pressure ; whether there is any tumor 
 or indurated organ in that cavity ; and whether there 
 are such constitutional symptoms as attend inflamma- 
 tion. If there be obstinate vomiting, our fears should 
 be more awakened. 
 
 If we find no evidence of such local difiiculties as 
 have been referred to, we should follow the plain indi- 
 cation to purge the bowels. We should try the safe 
 remedies ; that is, such as will not do harm if they 
 are retained. I would not, therefore, begin with 
 calomel, unless when the stomach is so irritable that 
 H is not likely to retain other medicines. In such a 
 
ON CONSTIPATION OF THE BOWELS. 293 
 
 case one or two doses of calomel may determine the 
 current downward, and leave the way open for more 
 active medicines. You may be surprised that I say 
 more active medicines ; but, in truth, calomel is slow 
 in its operation ; it starts the mass, but does not carry 
 it through ; so that I often compare it to the scraper 
 used by the chimney-sweep, which requires a brush 
 after it to bring away the soot. Besides calomel, other 
 medicines in small bulk are best, when the stomach is 
 irritable. The compound extract of colocynlh is a 
 very good article. But after these, or at first, if 
 the stomach is quiet, castor oil is the most appro- 
 priate. This medicine excites secretions sufficient to 
 soften the faeces, while it promotes the peristaltic 
 motion, so as to carry forward any mass which may 
 have accumulated. The neutral salts may answer the 
 purpose ; but it appears to me that, while they cause 
 copious watery secretions, they do not so act on the 
 muscular coat as to insure the removal of the solid 
 matter. Oftentimes in such cases there is a difficulty 
 in keeping the medicines upon the stomach. Then 
 we may resort to preparations of senna or jalap, or 
 both together, which should be given in liquid form, 
 and in small doses, frequently repeated. There is an 
 article, which I introduced into v^se at our hospital, 
 well known among us, under the name of the com- 
 25* 
 
2M ON CONSTIPATION OF THE BOWELS. 
 
 found infusion of senna. Besides the senna, it has 
 jalap, supertartrate of potass, and manna, in its com- 
 position; and with these the compound tincture of 
 senna. Where it is desirable to have the stimulus of 
 the tincture, this preparation may be used with 
 advantage ; but, otherwise, there is a more modern 
 preparation, which is better. This is the fluid extract 
 of senna. One advantage of this extract is, that in 
 the same dose it is about twice as powerful as the com- 
 pound infusion above mentioned ; a great advantage 
 when you have to do with an irritable stomach. Other 
 articles will always suggest themselves, when there are 
 objections to the above named. In these cases we 
 should also avail ourselves of injections into the rec- 
 tum, which should be large in quantity, and more or 
 less stimulant, as circumstances may indicate. I shall 
 mention one which I hold in high estimation in all 
 obstinate cases ; this is a mixture of oil and water, 
 with soap to make the oil miscible with the water, 
 and to break it up into small globules, without so 
 much soap as to make the oil entirely disappear. In 
 one of these obstinate cases I should use the follow- 
 ing : — take a heaping tablespoonful of soft soap, half a 
 pint of olive oil, and a pint and a half of warm water, 
 and mix them thoroughly ; the whole of this should 
 be used at once. It may be necessary to repeat both 
 
ON CONSTIPATION OF THE BOWELS. 295 
 
 the purgative medicines and the enemata. There are 
 cases, mostly in persons who have been much neg- 
 lected, where you find a great mass of faeces impacted 
 in -the rectum. In these it is best to resort to me- 
 chanical means, using something like a scoop to break 
 up and dig out the mass. 
 
 Where there is reason to suppose that there is a 
 mechanical obstacle, analogous to hernia, or where an 
 inflamed organ constitutes the obstacle, the treatment 
 must be varied to meet the circumstances. To go into 
 all the possible circumstances would lead me too far. 
 I will say, however, that where there is reason even 
 to suspect an inflammation in the intestines, blood- 
 letting at an early stage is the most important remedy. 
 It serves to relieve the distress and to liberate the 
 bowel ; for then it can yield to the effect of a cathartic. 
 Let me add further, that in blind cases, a masterly 
 inactivity should be adopted. This requires more 
 true courage than the exhibition of the most heroic 
 remedies. 
 
 I must make a small addition to this long letter, 
 in respect to diseases of the rectum. I have ref- 
 erence to hemorrhoids, prolapsus ani, and the fissure, 
 or crevasse of the rectum. "What I wish to say in 
 regard to these is, that the greatest and most perma- 
 nent relief may often be obtained by an operation. 
 
296 ON CONSTIPATION OF THE BOWELS. 
 
 As I have not practised surgery for nearlj half a 
 century, I shall not be suspected of wishing to exalt 
 my own art. I have, however, called in the aid of a 
 skilful surgeon in many such cases ; a number of 
 these have been ladies, who have subsequently ex- 
 pressed great gratitude to me in consequence of the 
 relief they have obtained. It is in bad cases of piles, 
 external or internal, most especially when bleeding, that 
 I have found surgery thus useful. In milder cases other 
 well-known remedies succeed, into the consideration of 
 which I shall not enter. In all cases of prolapsus and 
 of fissure I believe the sooner an operation is performed 
 the better. If the prolapse is slight, the slighter will 
 be the operation, and with proper subsequent care 
 there will be an end of the trouble. The subsequent 
 care has reference to the habitual costiveness, to which 
 the tendency is increased by the operation. Diet will 
 often overcome this after a few weeks or months ; for, 
 at first, some gentle laxative medicine is required. 
 But, at the worst, a daily injection of cold water may 
 become necessary. After a little habit this is found 
 not a very troublesome affair, and the relief from the 
 daily annoyance of the disease is beyond all price. 
 
LETTER XV. 
 
 ON BILIOUS DISEASES, BILIARY AND URINARY CAL- 
 CULI, AND IRRITABLE BLADDER. 
 
 In this letter I have a little to offer on several dif- 
 ferent topics, but only a little. You hear eveiy day 
 of bilious diseases, and diseases of the liver. Mes- 
 merizers, and people of that sort,, accuse the liver very 
 frequently. I have often said that the liver is like 
 the greatest rogue in the village, who is accused, upon 
 suspicion, wherever any mischief has been done. Such 
 an one has so bad a reputation, that it is not thought a 
 libel if you speak ill of him. I may almost say that 
 there are some among the brethren, who hardly think 
 of the liver but as an organ for the production of dis- 
 ease. When I began practice, some of my elder 
 brethren, excellent men too, almost always referred 
 an obscure chronic disease to the liver. They talked 
 familiarly of old liver cases, without a definite notion 
 of any particular disease. I believe that some of the 
 mesmerizers talk of the liver as being rotten, or all 
 
298 ON BILIOUS DISEASES, ETC. 
 
 decayed : states of the organ which the morbid anato- 
 mists, who cannot see through the parietes of the 
 abdomen, are not well acquainted with. 
 
 The term bilious is applied indiscriminately to dis- 
 eases, in which much bile is discharged from the 
 stomach or bowels, and to those, in which the bile is 
 entirely wanting in the alvine discharges. In both 
 cases, calomel and blue pill are regarded as the appro- 
 priate remedies. Now, the liver is an organ subsidiary 
 to the stomach and intestines, just as the salivary 
 glands are to the mouth. In the greatest proportion 
 of cases, which are called bilious, the real disease is 
 in the stomach or intestines ; and by this the liver is 
 provoked to pour out its secretion, just as the salivary 
 glands are when any acrid matter is taken into the 
 mouth, or when its mucous membrane is inflamed. 
 In these cases calomel is often very useful : but it 
 should not be given merely because there is too much 
 bile, or too little. It is undoubtedly true that a disease 
 in the liver itself may be attended by an increased 
 secretion of bile, or more frequently by a deficiency 
 of this secretion. Chronic diseases in the liver are 
 not rare among us, though not very frequent; but 
 acute diseases of the liver have very seldom occurred 
 under my observation. I have known acute hepatitis 
 sufficiently well marked. I have, also, sometimes 
 
299 
 
 met with abscesses in the liver, the existence of 
 which was not suspected during life. There is no 
 doubt that hepatitis is much more common in warm 
 climates, than with us ; and this is so especially in 
 Bengal. But even there the doctors are too ready to 
 believe that "it is the liver," if there is any pain in 
 the right side. A few years ago a young friend of 
 mine was there with a pleurisy attended by effusion 
 in the right thorax, and was treated unhesitatingly as 
 having hepatitis. Not mending under the treatment, 
 he went over land to England, and hurried home by a 
 steamer. Here the true disease was discovered at 
 once. This was not done by guessing, but by the use 
 of the senses. 
 
 I have thought it useful to make these general 
 remarks, although I do not design to go into the 
 diseases of the liver generally. But I wish to make 
 some observations on jaundice^ as one of its most 
 common diseases. 
 
 The name jaundice is sometimes loosely applied to 
 cases where there is only a yellowness of the skin. 
 In jaundice proper there is not only the golden color 
 of the skin, but also high colored urine, staining the 
 linen yellow, and an absence of bile in the faeces. 
 This last is essential. These symptoms seem to show 
 that there is an obstruction in the common bile duct. 
 
300 
 
 I know that this is denied ; and there may be cases 
 in which the obstruction is not discovered after death. 
 It isj however, clear, when these symptoms exist, that 
 the bile does not flow into the intestines. The causes 
 of the obstruction are very various, and we have not 
 any certain means of distinguishing them during life. 
 They are sometimes such as cannot be overcome. An 
 organic* disease at the right end of the pancreas may 
 involve the common bile duct, and close it perfectly. 
 Large calculi and other causes may do the same. 
 But there are some causes of obstruction, which are 
 removed by the spontaneous action of the parts. One 
 of these is a gall-stone stopping the passage and at 
 length finding its way into the duodenum. I have 
 long suspected that another is a disease of the mucous 
 membrane of the common duct in some part of its 
 course, or at its mouth. It is very probable that this 
 difficulty is combined with the calculus in some in- 
 stances, and that when the vascular fulness of the 
 mucous membrane has subsided, the calculus is allowed 
 to pass. Though I entertained this opinion, it had 
 never occurred to me to employ bleeding for relief, 
 until led to it by accident. About twenty years ago 
 I had a patient at the hospital, convalescent from 
 typhoid fever, who was taken with pain in the region 
 of the liver, and with other symptoms of inflammation, 
 
ON BILIOUS DISEASES, ETC. 301 
 
 not very severe ; but with these there were the signs 
 of icterus. On account of the inflammatory symp- 
 toms I applied leeches on the right hypochondrium. 
 Within forty-eight hours the bile flowed through the 
 intestines, and the symptoms of inflammation subsided. 
 This did not prove that my opinion was correct, but 
 it gave me a hint. Not long after, I employed the 
 same remedy in a case of icterus, also at the hospital, 
 and here, also, there was entire relief within forty- 
 eight hours. From that time I have continued to use 
 this remedy. I have tried it in cases at all periods 
 of the disease, from the second day to the fifth week. 
 Many of these cases have been seen in consultation. 
 In three instances, and, I believe, only three, the 
 relief has not followed this treatment, and yet the 
 patient has subsequently recovered. In all the other 
 cases, where it has failed, the disease has proved fatal. 
 In most of them, examinations after death have shown 
 some obstructions, which could not be overcome. 
 Indeed, this has been true of all, in which examinations 
 were allowed. I have not a record of my cases, but 
 the instances in which leeches have been followed by 
 relief cannot be less than twenty. I have failed to 
 give immediate relief, to an adult, where I have 
 used less than eight good leeches. But this has 
 happened, I believe, only twice, and in those instances 
 26 
 
802 ON BILIOUS DISEASES, ETC. 
 
 a second leeching has been followed by relief. The 
 relief has been shown by the appearance of bile in the 
 faeces within forty-eight hours after the leeches. 
 Now, I think it cannot be considered accidental that 
 relj^f should follow within this space of time, when the 
 remedy has been employed at such various periods of 
 the disease. I do not ask any one to admit, and I am 
 not sure myself, that this proves that the disease con- 
 sists in an inflammation of the bile-duct ; but certainly 
 it is a good ground on which to employ the remedy, 
 until something better is pointed out. I am aware 
 that icterus goes off spontaneously in some cases, and 
 probably it would have done so in many of mine ; 
 but not just at the periods when it did. It has some- 
 times been objected to this treatment that it is debili- 
 tating. I will take this occasion to say that I think 
 debility, and that of a bad kind, is much oftener pro- 
 duced by powerful drugs, than by blood-letting of any 
 kind. 
 
 Though I now feel almost hopeless when jaundice 
 does not yield to the leeches, yet I do not say that 
 nothing more should be tried. I should not be willing, 
 if it were my own case, to omit the trial of some 
 remedies which have been followed by recovery ; but 
 I should employ them merely as desperate remedies. 
 
 The passage of gall-stones through the ducts is 
 
ON BILIOUS DISEASES, ETC. 803 
 
 often attended with severe pain. In some persons, 
 pain from this cause occurs frequently, not obstruct- 
 ing the passage of bile every time, but once in four 
 or five times, as it may happen. It is a great object 
 to give relief to patients suffering in this way. I 
 have seen several such cases, for which I have directed 
 Slie bicarbonate of soda in liberal doses, such as a 
 drachm twice a day. So far as I have known, the 
 disease has disappeared in every instance, after con- 
 tinuing the use of this medicine for several months ; 
 but some of the patients have lived at a distance from 
 me, and I may not have been rightly informed 
 respecting them. 
 
 In connection with the above, I have a remark to 
 make with respect to urinary calculi. Cases of this 
 sort usually go into the hands of surgeons, and my 
 acquaintance w^ith them has not been extensive. I 
 had understood that the mulberry calculus (the 
 oxalate of lime) was of rare occurrence. Now, it has 
 happened to me to have had five cases of this calculus 
 within three years ; three of these within the last 
 year. In each case, the calculus has been examined 
 by Dr. John Bacon, on whose report I place entire 
 reliance. I mention this as showing that the mul- 
 berry calculus is not a rare occurrence in this vicin- 
 ity. 
 
304 
 
 An irritable bladder is among the common troubles 
 of old men. The first symptom, which attracts atten- 
 tion, in most instances, is a frequent micturition in the 
 night-time. Sometimes this does not occur in the 
 day ; and, when it does, it is not so inconvenient as in 
 the night. This is attributed in many instances to an 
 enlargement or an induration of the prostrate gland ; 
 sometimes in the middle lobe only. When it is so, 
 the disease may become very grave, and may prove 
 fatal. But in a very large proportion of the cases I 
 have seen, the results have not been of a serious 
 character. I have introduced the subject principally 
 to say this. I feel assured that many persons have 
 suiFered a good deal from their apprehensions under 
 this malady, and accordingly have not been satisfied 
 without the trial of troublesome, if not very powerful 
 remedies. To one affected with this malady, I would 
 say, " take care of your general health, keep every- 
 thing well balanced, do not make yourself weak by 
 confinement within doors, and do not fear a diet 
 sufl&ciently nutritious, nor too readily omit the use of 
 wine, if you have been accustomed to it. But then 
 I would add, watch the effect of your diet, and omit 
 acids, or wine, or anything else, which, on careful 
 observation, appears to aggravate your disease. Above 
 all, keep your bowels regular. Have you haemor- 
 
ON BILIOUS DISEASES, ETC. 805 
 
 rhoids or prolapsus ani, seek relief from the surgeon. 
 If diet and exercise will not keep the bowels regular, 
 use cold Avater injections ; but avoid purgatives, and 
 certainly harsh ones." These remarks in regard to 
 the state of the bowels are founded on the connection, 
 which I have found to exist, between the rectum and 
 the bladder in these cases ; and on the suspicion that 
 sometimes the trouble in the bladder has originated 
 in disease in the rectum. 
 
 Here is a short letter, but you may think it long 
 enough, as it does not furnish you with many weapons 
 for the relief of disease. I am sensible of the defi- 
 ciency, yet I hope the letter may be of some use to 
 you. It guards you against following popular no- 
 tions ; and may induce you not to employ violent 
 remedies till you are assured that they are needed. 
 20* 
 
LETTER XVI, 
 
 ON BOILS. 
 
 Boils are among the troubles for which your friends 
 will laugh at you, rather than sympathize with you ; 
 and it is best to laugh, too, if you caT). But a boil is 
 a sore trouble ; proverbially so. It C.ts fallen to my 
 lot to study the natural history of boils somewhat, and 
 to study, also, the treatment of them. The common 
 accounts of them are too superficial. Dr. Watson, in 
 his lectures, gives the most correct description of them 
 which I remember to have seen ; but it is brief, and I 
 think something may be added to it with advantage. 
 
 A furuncle^ or boil^ commences in the form of a 
 pimple. It is a hard pimple, though very small at 
 first ; and sometimes, but not always, it is the seat of 
 a stinging pain which calls attention to it. When 
 pressed upon, the part is found to be somewhat sensi- 
 tive. Within two or three days this becomes a pus- 
 tule ; or, in other words, a little pus is formed on its 
 head, the pimple enlarging. A soreness comes on, and 
 
ON BOILS. 807 
 
 the tenderness increases ; and those, who watch their 
 sensations, feel as if something was piercing slowly 
 through the true skin. This sensation sometimes 
 conveys the idea of a caustic eating slowly through 
 the cutis. At the end of about a week this process, in 
 which the disease is, in fact, extending through the 
 skin, is finished ; and then the swelling begins to in- 
 crease, as if from something placed under the skin. 
 We may, perhaps, regard the primary disease as 
 terminating at this period. There is, then, something 
 formed under the skin which acts like a foreign sub- 
 stance. I take it that this something is fibrin, or 
 coagulable lymph, deposited in the subjacent cellular 
 membrane. I am not sure whether this is all, or 
 whether a minute portion of the cellular membrane is 
 involved, and, undergoing a species of gangrene, con- 
 stitutes, with the lymph, the foreign substance. It 
 would seem that what follows consists in the effort to 
 separate and throw out this slough, or foreign matter. 
 From this period, early in the second week of the 
 disease, the swelling and the pain increase. The ex- 
 tent of the tumefaction varies in its diameter from 
 three quarters of an inch to two inches. In some 
 cases an erysipelatous inflammation is added, and this 
 spreads over a space equal to the back of the hand, or 
 f^ven more. The part thus affected puffs up more or 
 
308 ON BOILS. 
 
 less, but this swelling usually subsides in three or four 
 days. It is not concerned in the regular process of 
 the boil. 
 
 In the first week, while the disease is extending 
 through the cutis, the pustule enlarges, and more or 
 less matter is formed. This is accompanied by a 
 burning pain, which the inexperienced attribute to the 
 purulent matter. If it be a bad boil, the patient 
 thinks he has already suffered enough, and punctures 
 the pustule, with a sanguine hope of relief For a 
 short time, perhaps, there is some relief, but within 
 two days, if not in one, he finds the swelling and the 
 pain decidedly augmented. Then, probably, he is 
 charged by those about him with carelessness, and 
 with having taken cold in the boil ; or, perhaps, it is 
 thought that he has used the wrong salve, or the 
 wrong poultice. It is thus that philosophical nurses 
 and goodies are always ready to explain the changes 
 in a disease, which meantime is pursuing its own 
 proper routine. The suppuration goes on beneath the 
 derma, and at length an opening takes place, so that 
 some matter is discharged from the depth of the boil, 
 and this matter is often colored, more or less, by blood ; 
 but the end is not yet. On the other hand, it is then, 
 ut the end perhaps of the second week, that the great 
 soreness is first noticed; the soreness which is proverbial. 
 
ON BOILS. 809 
 
 There is not any other disease, known to so large a pro- 
 portion of mankind, in which the soreness is so great as 
 in this ; and thence the common phrase, " as sore as a 
 boil." This soreness has its seat in the inner surface, 
 by which the core or slough is enclosed, and to which 
 it is attached. Accordingly, in cases where the parts 
 open so as to expose this core to view, if you touch it, 
 and, still more, if you attempt to draw it out, the 
 patient screams with the pain. It is like tooth-draw- 
 ing. When the opening has taken place, you do not 
 find a cup, but rather a boggy mass, from which the 
 pus oozes out. In the course of the third week there 
 comes a period, when the patient feels that the pain 
 and soreness have abated ; matter is discharged more 
 freely, and the swelling is evidently diminishing. In 
 twenty-four or forty-eight hours from this period, a 
 little ragged wad makes its exit from the cavity ; then 
 the parietes come together, and, in another day or two, 
 the trouble seems all over. When the core has been 
 looked for, and is at length brought out to sight, some 
 disappointment is often experienced. It is smaller 
 than was expected, even when it is in its most perfect 
 state. The truth is, that, from the moment it is de- 
 tached from the living parts about it, the core shrinks ; 
 and that is the time when the tenderness subsides. 
 Besides, it happens in most instances, that the core or 
 
810 ON BOILS. 
 
 elough is not discharged in an entire state. It has 
 been decaying, and I may say rotting, before its sepa- 
 ration ; and, when detained awhile before its expulsion, 
 it separates into parts, which are washed out with the 
 pus. After the discharge of this substance is quite 
 completed, there is not much more suffering, provided 
 the part is defended from injury ; but another week 
 passes even then before the skin is quite sound and 
 well, so as to bear pressure without inconvenience. 
 From the first pimple to this termination, four, and 
 often five, weeks are occupied ; but the really painful 
 period is one or two weeks, according to the severity 
 and extent of the boil. For, as neither all men nor 
 all oak-trees are of the same size, so the furuncle, also, 
 varies in its magnitude. 
 
 The description I have given is that of the disease 
 in its most regular and most usual course. But, like 
 its betters, the boil has it^ varieties. If you watch an 
 apple-tree from the time when its blossoms have fallen 
 and the fruit is set, you find this fruit falling off almost 
 daily, at every period of its. growth, varying accord- 
 ingly in size, and often imperfect in shape; and, at 
 last, when you come to the gathering, the apples differ 
 in shape, as well as in size ; for, in a large proportion 
 of them one half is more perfectly developed than the 
 other. So it is with boils at the present day ; and, I 
 
ON BOILS. 811 
 
 doubt not, if there had been some close observers 
 attending Job, the remarks I have made would have 
 been written down in his book. The variety, so com- 
 mon as to have acquired an appropriate epithet, is the 
 blind boil. This is only a dwarf, sometimes ill-shaped, 
 and like some human 'dwarfs it may have a sharp 
 temper. It seems to me that, in the case of the blind 
 boil, the boring through the cutis, or derma, and 
 forming the core, which I have described as the first 
 stage of the disease, is not perfected. This process 
 stops in some part of the swollen cutis, and the core 
 is not formed, or not fully. The swelling is not so 
 large as in the perfect boil ; and the duration of the 
 whole disease is shortened. As this stoppage may 
 take place at any point in the cutis, so the tumor will 
 vary in magnitude. Moreover, the suppuration is 
 very imperfect, and the bleeding is large in proportion. 
 The other varieties are marked only by imperfections 
 in different degrees, as happens to the apples. I must 
 except, however, one variety, in which, soon after the 
 boil opens, a fungus rises, circular in form, with a 
 flat head, a quarter of an inch or more above the sur- 
 face of the skin. No core is seen. The fungus is 
 exquisitely tender. After four or five days it sinks 
 down, and there is formed a much larger cicatrix than 
 in other cases. It seems that a considerable portion 
 
312 ON BOILS. 
 
 of the cutis is destroyed. We must infer that there 
 is not any core in such a case, but that some injury is 
 done to the parts which prevents the healing for a 
 time, just as happens when a wound in the flesh will 
 not heal because there is a piece of dead bone in the 
 bottom of it. But I cannot trace over the whole pro- 
 cess in accordance with this view of the case. It is a 
 hint which may lead some one to a discovery of the 
 true pathology in this little afiair. 
 
 It seldom happens that one boil comes alone. More 
 commonly there are several in succession, and not 
 rarely a dozen or twenty. Some persons count these 
 successive boils by hundreds. These will be recurring 
 during one, two, and even three years. It is not un- 
 common to see two, and sometimes there will be found 
 four or five, on the same person at one time ; but not 
 all of the same age. When large numbers occur in 
 succession, I believe it will be found that many of 
 them are small. 
 
 At some periods boils are epidemic. In 1852 and 
 1853 they were very common in this country, and in 
 Europe also. During these years there were many 
 persons, who could boast of the large numbers they had 
 endured. 
 
 Happy the man who can point out the causes of the 
 diseases he sees ! If one could show any peculiar state 
 
ON BOILS. 313 
 
 of the system giving rise to boils, he might, perhaps, 
 learn how to prevent them. I am not the happy man 
 in this instance, though I have been watching persons 
 affected with the disease for very many years. In 
 each individual instance you will find ingenious people 
 around the patient, who can explain the matter quite 
 to their own satisfaction. In one case butter and 
 gravy, and other articles called rich^ are accused as 
 the source of the evil. In another it is low living 
 which is suspected. I first learned that many boils 
 occurred in succession many years ago. I then had 
 two patients, one of whom had them for a year, the 
 other for eighteen months. One of these was a gen- 
 tleman, then young, of a very thin, spare habit, with 
 sharp and distinct features, a dry skin, abstemious in 
 his diet, and regular in his whole course of life. The 
 other was a lady, also young, above common size, 
 plump, rather fat, rotund, with a soft skin, looking as 
 if she lived on fat things. Comparing these two cases 
 carefully, I could not find anything common to them ; 
 but the contrary. The young lady was living at her 
 ease, though she could not be called indolent. The 
 gentleman was one of our active merchants, never idle. 
 I have been equally unfortunate since the time when 
 I saw these two patients. Others have differed from 
 each other as much, and in every way. They have 
 27 
 
S14 ON BOILS. 
 
 been of almost all ages, all temperaments, all habita 
 as to diet, etc. ; some perfectly healthy in their con- 
 stitutions, others far otherwise. Among them some 
 have been tuberculous. 
 
 The subjects of boils are comforted with the assur- 
 ance that they are, or will be, the better for them ; or, 
 at least, that they are saved by them from internal 
 diseases. One cannot prove that assertions like these 
 are ill founded. I Oan only say that I have looked 
 carefully and honestly for evidence, in support of 
 them, without success. A valued friend of mine, a 
 lady between forty and fifty years of age, has raised 
 blood, more or less freely, from her fourteenth year ; 
 and has at times been much impaired in health other- 
 wise, though always exhibiting a great power of 
 endurance, with the aid of a very strong mind. Since 
 she was forty she has had boils for two or three 
 years. During those years, and since, she has suf- 
 fered severely from the same complaints as before. 
 This has not happened under my observation, for she 
 was living at a distance from me, but I have the facts 
 on good authority. 
 
 Though I cannot point out the peculiar fault in the 
 constitution, or habits of patients who have boils, I can 
 show how they are brought on in some cases. Blis- 
 ters produced by cantharides will commonly heal in a 
 
ON BOILS. .815 
 
 few days, if the cuticle is not turned off from them. 
 But, when it is, they often take on a new inflamma- 
 tion, for a time will not heal, and become sore blisters. 
 As these sore blisters are healing you will, not unfre- 
 quently, find them surrounded by a thick crop of 
 pustules of various sizes. Watching the patient, you 
 may find these pustules followed by others of a larger 
 size, much fewer in number, and at a greater distance 
 from the blister. Next, at a still greater distance, you 
 will find a boil, and then another, and another. In 
 such a case you may find the same trouble continuing 
 for many months. Where poultices have been applied 
 to boils you will often find similar pustules on the 
 margin of the circle covered by the poultice, and a 
 new crop of boils extending from them. Nearly forty 
 years ago I made an issue on the breast of a consump- 
 tive patient. He shortly afterwards went to Cuba. 
 On his return he told me that he had a constant suc- 
 cession of boils during his absence. They began near 
 the issue, and they continued to show themselves for 
 nine months. The tuberculous disease went on, ap- 
 parently undisturbed by the disease on the skin. 
 
 It is well known that patients, whose skins become 
 sodden under hydropathic treatment, are very often 
 affected by boils; at first numerous and small, after- 
 wards fewer and larger. At least I believe that they 
 
316 ON BOILS. 
 
 pursue this course, juSt as happens when they arise 
 from blisters; only, after the water treatment, as I 
 take it, the boils come at once on various parts of the 
 body, instead of starting from a central point. The 
 cause in these cases is much the same as exists in the 
 the poultices. 
 
 Let it be understood that many persons are afflicted 
 with this same disease, without having been subjected 
 to any of the causes above described. 
 
 Having been thus full in the description of boils 
 and in the discussion of their causes, I come now to 
 the treatment. Is anything useful to be done to the 
 part affected ? Can anything be done to prevent the 
 recurrence of the disease ? 
 
 As to the first question I reply, unequivocally, in 
 the affirmative. The boil cannot be jugulated, as it 
 has no neck ; but its head may be split open in ita 
 embryo state, and there will be an end of it. I 
 endeavored to describe the disease from its very com- 
 mencement on this account. One could not say with 
 entire confidence, on examining a pimple, that it 
 would, or would not, become a boil. It has not 
 certain and specific characters. But if a man has 
 had one boil, and soon after has a pimple, such as I 
 have described, the probability is that this will grow 
 into another boil. If he has had two or three boils 
 
ON BOILS. 817 
 
 about his hand and arm, and a pimple comes in the 
 same region, it is almost certain that that will grow 
 into a boil. Now, what I have to say is, that if you 
 carry the point of a lancet through the middle of that 
 pimple it will dwindle away. The sooner this is done, 
 after the pimple is formed, the better. The treatment 
 succeeds if adopted on the second or third day ; and 
 even later it does some good. If done late the disease 
 is not entirely overcome ; it is blighted and is short- 
 lived. This treatment is not worth trying after the 
 fifth or sixth day ; not after the affection has extended 
 deep into the true skin. You will sometimes see, 
 when the pustule has just formed, if the cut does not 
 cross exactly in the centre, that a half, one-sided 
 pustule will be formed, yet the disease will not come 
 to much. Be it noted, however, that this operation 
 will not succeed, if it be not performed thoroughly 
 and exactly. The lancet should be plunged through 
 the cutis, beginning just outside of the pimple, and 
 be carried through this pimple, at the same depth, 
 dividing it as near as may be into two equal parts. 
 
 The difficulty in the treatment is to discover the 
 pimple on its first formation. Occasionally it will 
 come in a quarter, which the patient has not thought 
 of, and often where he cannot see it. But usually 
 the pimples come in the vicinity of the previous boils, 
 27=* 
 
318 ON BOILS. 
 
 as on the head, on one of the limbs, or on the parta 
 around the pelvis. If the patient is apprised where 
 the pimple will probably come, he may, by feeling 
 round the suspected region, be sure to discover it at 
 its first coming. For this purpose let him examine 
 himself twice a day. He may fancy that there are 
 pimples where there are not, but the physician will 
 decide that matter ; or, if both should be in error, it 
 is not a great evil to feel the lancet three times, if one 
 boil can be saved by it. 
 
 Let me give one example. A gentleman, about 
 seventy-five years of age, called me to see a boil formed 
 on the hairy scalp, near his ear. It was not of the 
 largest size, but it proved a sore trouble to him. 
 Nothing had occurred to explain the occurrence of it 
 Before this was well, he sent for me to see another, 
 much smaller, in the same vicinity, which had been 
 coming four or five days. I divided this freely, and 
 with as much success as I had promised him. The 
 disease went on, but the boil was much smaller than 
 the first. He now realized the importance of watch- 
 ing for the pimples, and he had six in rapid succession, 
 all under the hair. I divided each one, and arrested 
 the disease in each case. I began the use of the 
 sulphate of quinia as soon as the third boil commenced, 
 which was the first I saw in the state of a pimple. It 
 
UN BOILS. 319 
 
 required some days before I arrived at a sufficient dose 
 of this medicine to affect the system ; the patient being 
 an old man, I had been very cautious in the use of 
 it. From the time the constitutional effect of it 
 appeared the pimples ceased to show themselves. 
 
 In this case we have an instance of the tendency to 
 a recurrence of boils ; of their tendency to keep in one 
 neighborhood, which is not always but often shown ; 
 of the effects of an early division of the pimples ; and 
 of the effects of the quinia, which I shall treat of 
 presently. 
 
 Now, as to the second question ; when a patient has 
 had several boils can anything prevent their further 
 recurrence ? To this I cannot give so confident an 
 answer as to the first question ; but I think it may be 
 done in a large proportion of instances. If a man 
 has had ten boils in succession, you cannot be sure 
 that he will have one more. If, then, you administer 
 your medicine, and he has no more for a year, you 
 cannot be sure that the medicine has produced the 
 exemption. But if you use the same medicine for a 
 number of persons, of whom some have had three 
 boils, some ten, and so on to a hundred, and if in the 
 largest number of these persons the disease does not 
 recur, you then have a right to believe that the disease 
 was arrested by the medicine. Now, this is what has 
 
320 ON BOILS. 
 
 happened in my practice. For twenty or more years 
 I have given the sulphate of quinia with the result 
 above described. 
 
 In observing the effects of this medicine in intermit- 
 tent fever and intermittent headache, it appeared to 
 me certain that it did not produce its beneficial effects 
 by acting as a tonic. In those diseases the paroxysms 
 cease without any evidence of increase in strength, as 
 measured by observation of any of the functions, 
 organic, or animal. In what way, then, does the 
 cinchona, or do the other remedies, operate ? It has 
 seemed to me that they operate by taking away, or 
 overcoming, the susceptibility to the disease. This at 
 first was only an hypothesis. It was, however, suffi- 
 ciently plausible to lead me to bring it to the test of 
 experiment. Not to make a long story, I will say at 
 once that I have given the sulphate of quinia, the 
 most convenient preparation of cinchona, for many 
 years, on this principle, in various diseases ; that is, in 
 cases of boils, of styes upon the eyelids, and of some 
 eruptions which have kept recurring in different parts 
 of the body, though not severe in their character, and 
 in various painful affections. Of the effect in these last 
 I treated in another letter. The result has been very 
 satisfactory. I do not say that success has always 
 followed this treatment. It certainly has not; but 
 
ON BOILS. 82t 
 
 the results have been satisfactory in so largo a propor- 
 tion of instances, as not only to justify the practice, 
 but to make me regard it as my duty to pursue it and 
 to point it out to others. I have the less hesitation in 
 saying this, inasmuch as the treatment is not of a kind 
 likely to be injurious. 
 
 In stating my opinions on this subject I am not 
 anxious to make any claims to originality. The hon- 
 est truth is, that I cannot tell whether I got the first 
 hints from any one else, or not. It is the truth I 
 have cared for, in this and other cases, and this I wish 
 to present to others ; and not a statement of the rela- 
 tive claims of those, who may have been thought the 
 original discoverers. A day or two before I began to 
 write this letter, after looking into various works in 
 respect to boils, I took up the excellent, and well- 
 known lectures, by Dr. Watson, of London. I had 
 not any recollection of a mention of this disease by 
 him, but I found a brief, and, as far as it went, a cor- 
 rect statement on the subject. I was surprised to find 
 that he noticed, what I had not found done by any 
 one else, the commencement of a boil in " a tender 
 knot, just beneath the surface," which I regard rather 
 as a pimple; also, that he mentioned, as practised 
 by some persons, cutting " the hard tumor through 
 while it is yet crude," and the use of the sulphate of 
 
322 ON BOILS. 
 
 quinia in certain cases ; but this as a tonic, and not 
 probably in the full doses which I deem necessary. 
 My practice, however, was not derived from Dr. Wat- 
 son. I could mention various things, for which I am 
 indebted to this learned and sagacious professor, but 
 the treatment of the disease under consideration is not 
 one of them. His work was published in 1845, and 
 did not reach me till a year later, while the treatment, 
 which I have described, was adopted ten or twelve 
 years before that date. 
 
 It is well, perhaps, for me to state, distinctly, the 
 extent to which I use the sulphate of quinia. In the 
 case of an adult, I give from twelve to sixteen grains 
 of that article, divided into three or four doses, on the 
 first day ; and if the peculiar effects of the medicine 
 on the head or ears do not take place, I increase the 
 quantity, the next day, by four grains ; and continue 
 to increase the quantity daily by four grains, until 
 there is some evidence that the patient has got as 
 much as he can comfortably bear. On the day after 
 some inconvenience is occasioned by the medicine, I 
 lessen the daily allowance by four grains. If this is 
 borne well, or whatever daily allowance is borne with 
 ease, I continue the same for four or five days, and 
 then gradually bring the quantity down to two grains 
 in a day. I prefer not to omit the medicine entirely 
 
ON BOILS. 328 
 
 for three or four weeks. 1 state here the course which 
 I deem necessary to secure all the good effects, which 
 the medicine can afford ; but I will add that I have 
 reason to believe a shorter course of the medicine will 
 often suffice. Some persons have been too impatient 
 to do all I now advise, and have done well. Others, 
 however, have been obliged to go back and begin the 
 treatment over again. What I deem essential is to 
 begin with large doseS; so as to make a distinct im- 
 pression on the system as early as possible. This 
 having been done, smaller doses afterwards will main- 
 tain this good impression. Though we have no inter- 
 mittent fevers in our region, except casually, I believe 
 that the same principles should govern the use of the 
 quinia in that disease. It is very probable that 
 arsenic might produce all the good effects which 
 the quinia does, in cases of boils, but I have never 
 tried it. 
 
 I must say a few words on the local treatment of 
 boils. And, first of all, do not apply poultices to 
 them. It is enough that they may occasion an in- 
 crease of the disease. At particular times they are 
 thought to be comfortable ; but, on the whole, I regard 
 them as dirty and troublesome applications, and as 
 often causing much discomfort to the patient. They 
 are endured under the popular notion that they are 
 
324 ON BOILS. 
 
 necessary to bring the boil to its proper end ; that 
 they draw to the surface the noxious humors. I 
 always pay so much respect to popular notions as to 
 bring them to the test of experience, if I do not see 
 any certain objection to so doing. I did this long ago 
 as to poultices for boils, and I became satisfied that 
 there was an error on this subject. Occasionally, for 
 a few hours, a warm and moist application is soothing. 
 For that purpose a fomentation with warm water may 
 be directed. A better thing, however, where it can 
 be had, is a piece of spongio-piline^ wet in warm 
 water. This may be wet with ease at any moment, 
 and is free from some of the evils of a common poul- 
 tice. But much soaking of any kind is bad. For the 
 rest, the simplest applications are the best. The 
 spermaceti cerate, or something like it, is sufficient to 
 protect the diseased part from irritation, and that is 
 all which is needed. A piece of linen, or lint, spread 
 "with the cerate may be kept in its place by very nar- 
 row strips of adhesive plaster. Until some discharge 
 has taken place one dressing will last for two or three 
 days ; afterwards, the dressing should be renewed as 
 often as cleanliness requires. Let me add one more 
 direction to be observed, at least as long as the 
 soreness of the part continues, and this I shall add 
 
ON BOILS. 825 
 
 in words which I read more than fiftj years ago, and 
 
 have never forgotten, written I believe by Mr. Sharpe, 
 
 of Guy's Hospital, namely, " Do not cleanse the sore 
 
 too curiously." 
 
 ^ 28 
 
LETTER XVII. 
 
 ON THE TREATMENT OF TYPHOID FEVER. 
 
 This letter shall be devoted to the treatment of 
 typhoid fever. I need not describe the disease. You 
 already know it as the continued fever seen every- 
 where in New England, and to be found, probably, in 
 every part of the world. In our seaports we have had 
 the yellow fever, occasionally, within the last sixty 
 years, if not before. In my day, the spotted fever, 
 so called, prevailed for several years in different parts 
 of New England. The typhus fever, as understood 
 at the present day, has occasionally been seen among 
 us; but, probably, always imported from abroad. 
 But the continued fever, called typhoid, is the disease 
 which is never absent from us, and which, in some 
 seasons, prevails extensively, now in one place and 
 now in another. 
 
 It is the treatment of this disease I wish to discuss. 
 Can this disease be shortened in its duration, or dimin- 
 ished in its violence, or its danger to life lessened, by 
 
ON THE TREATMENT OF TYPHOID FEVER. 32T 
 
 treatment ? These are interesting questions, and it is 
 worth some trouble to ascertain the true answers to 
 them. Every year many persons suffer from this 
 disease, and some very severely ; many die, and that 
 at an early period of life, when just entering on its 
 active duties ; and, of those who survive, many have 
 their vigor lessened and their comfort and usefulness 
 abridged for months, and even for years, after the 
 disease has left them. Can these evils be dimin- 
 ished ? 
 
 I believe that the opinion has been gaining ground 
 among us, for twenty or thirty years past, that the 
 above questions must be answered in the negative. 
 Or, if it is thought that any benefit can be derived 
 from treatment, it is maintained that this is of very 
 small amount. This view of the subject is favored by 
 my friend Dr. Bigelow, in his admirable " Discourse 
 on Self-limited Diseases." 
 
 There is a great presumption in my mind that any 
 opinion advanced by Dr. Bigelow is well founded. In 
 this community his decisions have a most deserved 
 weight and influence; and most especially among 
 those who are the most competent judges. It gives 
 me great pleasure to bear testimony in public, as I 
 have often done in private, to his high claims to 
 respect as a scholar and philosopher. The discourse 
 
828 ON THE TREATMENT OF TYPHOID FEVER. 
 
 to which I have referred is full of wisdom. I could 
 say more, but I will restrain myself from a fear 
 that we may be thought to be bandying compli- 
 ments. 
 
 In the discourse on self-limited diseases Dr. Bige- 
 low says, as follows : 
 
 '' Before quitting the subject, I beg leave to intro- 
 duce the opinion of one or two medical writers, in 
 regard to the possibility of interrupting or breaking 
 up this disease by means of art. M. Louis, of whose 
 researches in regard to typhoid fever, it is but small 
 praise to say that they are more exact and comprehen- 
 sive than those of any living writer, is of opinion that 
 the disease cannot be thus intercepted. ' Experience,' 
 says he, ' has shown that a well-marked typhoid affec- 
 tion is not capable of being broken up.' To this tes- 
 timony of one of the most eminent teachers in the 
 French metropolis, it may net be amiss to add that of 
 an American physician, whose opportunities for observ- 
 ing the disease in different parts of New England were 
 extensive, and whose Essay on Typhus Eever well 
 merits an attentive perusal. The late Dr. Nathan 
 Smith, in the course of some remarks on the possibility 
 of interrupting this disease at its commencement, ob- 
 serves: ' During the whole of my practice I have never 
 
ON THE TREATMENT OF TYPHOID FEVER. 329 
 
 been satisfied that I have cut short a single case of 
 typhus, that I knew to be such.' * 
 
 " Having said thus much, I leave the subject of the 
 tractabilitj of typhus and typhoid fever to the light 
 of future investigation. It is but justice to state, that 
 numerous and highly respectable authorities are 
 declared in favor of the efiicacy of art in shortening 
 and mitigating these diseases ; and it will be a source 
 of gratification to the friends of humanity and science, 
 should it ultimately be settled that the active treat- 
 ment now usually pursued at the commencement of 
 cases, is instrumental in lessening their duration, 
 severity, or danger." 
 
 It will be seen that my friend is an unwillmg 
 doubter ; and no one would be more pleased than he, 
 if it can be shown that any check can be given to this 
 direful disease, and that the questions I have pro- 
 pounded can be answered in the afiirmative. I am 
 not prepared to assert, positively, that they can.be so 
 answered. But I believe that I can bring so much 
 evidence on that side of the question, as to justify the 
 
 * At the time of the publication alluded to, the distinction 
 between typhus and typhoid fevers had not been well made out. 
 The distinction is good, though writers of authority differ on th« 
 subject. 
 
 28* 
 
330 ON THE TREATMENT OF TYPHOID FE7EK 
 
 trial of active remedies under proper circumstances ; 
 naj, so much, as to make it our duty to trj them 
 until further evidence shall show that there is some 
 fallacy as to that which I shall adduce. 
 
 It is from my report on typhoid fever in the Massa- 
 chusetts General Hospital, made in 1838, that I shall 
 derive the evidence referred to. 
 
 Without going into all the particulars, I will take 
 what relates to the effects of emetics. This report 
 was grounded on the cases of that disease in the 
 hospital from 1822 to 1835, inclusive. From this it 
 appears (pp. 7 and 8) that on a fair estimate there 
 was one death in about eight cases. 
 
 Among those admitted to the hospital 
 in the first two weeks of the disease, one 
 hundred and fifty took emetics before or 
 after admission ; of these one hundred and 
 fifty, thirteen died, being 1 in 11.53 
 
 In the same period eighty were admit- 
 ted who did not take emetics ; of these ten 
 died, being 1 in 8.00 
 
 The difference is very striking. But of the one 
 hundred and fifty )vho took emetics, some took them 
 earlier and some later in the disease. It has been 
 thought that the earlier this and other active and 
 depletory remedies are administered, the greater the 
 
ON THE TREATMENT OF TYPHOID FEVER. 331 
 
 benefit. See how far this is confirmed by the same 
 report. 
 
 Fifty-nine entered the first week of the 
 disease, and took emetics in that week \ 
 four of these died, being 1 in 14.75 
 
 Thirty -one entered the same week, and 
 did not take emetics ; of these three died, 
 being 1 in 10.33 
 
 Ninety-one entered the second week, 
 and took emetics either before or after 
 admission ; of these nine died, being 1 in 10.11 
 
 Forty-eight entered the same week, 
 and did not take emetics ; of these seven 
 died, being 1 in 6.85 
 
 The advantage was on the side of those, who took 
 emetics ; but more decided as to those who entered the 
 first week, than as to those who entered the second. The 
 last had not probably been so well nursed in the first 
 week as the others. But also they had not on an 
 average taken the emetic so early ; and that, no doubt, 
 made a difference in favor of those entering the first 
 week. My own experience taught me long ago that 
 emetics were most useful when taken within the first 
 three days of the disease. This is confirmed by the 
 hospital cases. It appears from the report that thirty- 
 two patients took emetics within the first three 
 
332 ON THE TREATMENT OF TYPHOID FEVER. 
 
 days of the disease ; of these one died, 1 in 32 
 Twentj-seven took emetics within the last four 
 days of the first week ; of these three died, 
 being 1 in 9 
 
 Undoubtedly these last numbers, relative to those 
 who took emetics in the last four days of the first week, 
 are less favorable than would be found if the number 
 was larger ; for the proportion of deaths is greater than 
 in those who entered the second week, and took emetics, 
 and of whom the larger part, no doubt, took their 
 emetics at a later period of the disease than the above 
 twenty-seven. 
 
 If, now, we inquire what was the efiect on the 
 duration of the disease in those, who took emetics and 
 recovered, it does not seem to have been much if any- 
 thing to the advantage of those taking emetics later 
 than the third day. But as to those who took emetics 
 on either of the first three days the benefit is unequiv- 
 ocal. 
 
 Of those who took emetics on the first day of 
 the disease, the average day of convalescence 
 was the 14.66 
 
 Of those who took emetics on the second day, 
 the average day of convalescence was the 15.32 
 
 Of those who took emetics on the third day, 
 the average day of convalescence was the 16.46 
 
ON THE TREATMENT OF TYPHOID FEVER. 333 
 
 "While of those who took emetics on the fourth, 
 fifth and sixth days of the disease, and recov- 
 ered, the average day of convalescence was 
 the 19.45 
 
 It cannot surely be attributed to accident that these 
 results were so favorable to those, who took emetics, 
 among cases not selected but taken as they came, 
 through many successive years. But I feel assured 
 that the result would have been found much more 
 favorable had all those, who took emetics at an early 
 period, been properly managed afterwards. To the 
 best success of this mode of treatment it is necessary 
 that great care should be taken after the first relief 
 from the emetic. However well the patient may seem, 
 he should be treated as a sick man. The emetic 
 should be followed by an active cathartic on the fol- 
 lowing day, unless it should itself have had a powerful 
 operation on the bowels. Probably this was done in 
 most of the cases. And then, for a week at least, 
 however well the patient may appear, he should be 
 restrained from all efibrts of body or mind, and should 
 be kept on a very moderate, bland vegetable diet. 
 Though the headache and pain in the back and limbs 
 be removed, the pulse restored to a natural frequency, 
 the chills and heat subsided, still the liability to the 
 disease remains. Therefore the disease is easily 
 
334 ON THE TREATMENT OF TYPHOID FEVER. 
 
 lighted up anew ; and, if great errors are committed, 
 it maj return in its full force, and run through its 
 entire period. All this I have learnt, long ago, in 
 private practice. Now, when we consider the situa- 
 tion of patients who resort to a hospital, and that they 
 would not go there if they had the comforts of good 
 homes and careful attendance, it will be seen that few 
 of them will get the full advantage, which an active 
 treatment at the onset of the disease might have 
 afforded them. I am in truth surprised that so large 
 a proportion of those, to whom my report refers, did 
 derive such marked benefit from this treatment. Such 
 would not commonly be the result in hospital practice 
 of large cities. I think it may be explained in part 
 by the recollection that, in our hospital in its early 
 years, the great majority of the patients were of our 
 native stock, and bred up with some regard to the 
 rules of prudence. 
 
 In reading accounts of successful practice from a 
 medical man, however honest we may think him, it is 
 necessary to guard against the disposition on the part 
 of the reporter to see the results in a favorable light. 
 If the result is not in every case all he could wish, he 
 is prone to charge the patient with some commission, or 
 omission, which may explain the failure. The sugges- 
 tions in the last paragraph are not however to be looked 
 
ON THE TREATMENT OF TYPHOID FEVER. 335 
 
 at in this light. I do not say that the patients re- 
 ferred to were very imprudent. I say that I wonder 
 that there was so much prudence among them, as the 
 good results give evidence of. I must beg. also, to call 
 to mind some circumstances respecting these cases. 
 The patients were not treated by me from the begin- 
 ning. The number was small for whom I prescribed 
 the emetics. I did not plant the trees, and feel a 
 paternal solicitude in watering them. A very large 
 proportion of these patients had their emetics before 
 they entered the hospital ; probably some days before. 
 Nor, when they got there, did they all come under 
 my care ; a good part of them were under the care of 
 my colleagues. Those acquainted with our hospital 
 know that the case of ev6ry medical patient is taken 
 down on the day of his entrance by the house physi- 
 cian. He then notes the remedies employed before 
 the admission of the patient. The attending physician 
 dictates daily, if the case be an acute one, the state 
 of the patient and the treatment to be pursued. This 
 is all placed in the case-book within twenty-four 
 hours. There is no chance for interpolation at a 
 subsequent period. The attending physician, in going 
 his rounds, cannot be supposed to bear in mind every 
 typhoid patient, whose treatment began with an 
 emetic, and to make his reports more favorable accord- 
 
ON THE TREATMENT OF TYPHOID FEVER 
 
 ingly. Still less can it be suspected that the case- 
 book : would be falsified in any instance, in order to 
 make a favorite remedy appear to more advantage. 
 
 See, now, how the statements in my report on ty- 
 phoid fever were obtained frpm the hospital books. I 
 made out large blank tables, having columns for every 
 important symptom and for the remedies employed ; 
 distinguishing those administered before and those 
 after the entrance into the hospital. Then taking the 
 hospital books in their order, from the beginning, I 
 entered the name of each patient in my tables, and 
 the entries relative to him in the corresponding 
 columns. The particular^ had to be sought out 
 patiently, for the records had not been made with 
 reference to such a use of them. To go through three 
 hundred cases in this way was the labor of my spare 
 hours for several months. It was not until the work 
 was finished that I went over the cases to obtain the 
 results as to the symptoms of the disease, its treat- 
 ment, and its favorable or unfavorable termination. 
 These results, then, were as faithfully represented as 
 could by any means be done. More especially 
 whether death occurred more or less frequently under 
 one mode of treatment than under another, was 
 ascertained so certainly, as to preclude all chance of 
 error. 
 
ON THE TREATMENT OF TYPHOID FEVER. 337 
 
 Is it asked if those patients who took emetics did 
 not before, or afterwards, employ other remedies ? I 
 reply, that they did, probably in every instance. Then, 
 I may be told, that I might be misled in attributing 
 the favorable results to the emetics. I answer thai 
 the other remedies employed were, no doubt, the samo 
 as for those who did not take emetics. I say, no doubt ^ 
 because all were treated by the same physicians ; and 
 that in their treatment the physicians were guided by 
 the same general principles in one set of cases as in 
 the other. I should hope that a benefit was obtained 
 from this after treatment ; but this would not show 
 that the difference between the two classes of cases 
 was not to be attributed to the only difference in their 
 treatment, namely, that emetics were given to one 
 class, and not to the other. If, lastly, it be asked, 
 why emetics were not administered to all the typhoid 
 patients, I reply, that many of them were admitted at 
 too late a period to do this with advantage at the hos- 
 pital: why they were not administered before the 
 admission of the patients, must be answered by those 
 who had the care of them. I presume, however, that 
 most of these did not get medical advice early ; and 
 that, in some cases, the physicians aid not think well 
 ^f the practice, or found some objections in the cir- 
 cumstances of the particular patients under their care. 
 29 
 
ON THE TEEATMENT OF TYPHOID FEVER. 
 
 There are other remedieSj besides emetics, for the 
 utility of ■vvhich mj report affords some evidence ; of 
 which, cathartics at the commencement of the disease, 
 and antimonials in doses not sufficient to induce nau- 
 sea, or vomiting, are the principal. On these points 
 I must refer to the report in the Transactions of the 
 Massachusetts Medical Society. 
 
 I am aware that one doubt may lurk in the minds 
 of some of my brethren. That is, whether there was 
 not some error as to the disease in those patients^ 
 who were vomited early, and in whom the results 
 were favorable. I say there is not any reasonable 
 ground for such distrust. In examining the cases in 
 the hospital books, which had been called typhoid 
 fever, I threw out all which were doubtful, as is stated 
 in the report. But did we know how to diagnosticate 
 the disease? One answer to this is, that in every 
 fatal case, which we had denominated typhoid fever, 
 and in which the small intestines were examined 
 properly, the disease in Peyer's glands was discovered. 
 Another answer is, that a very large j^i'oportion of the 
 patients who were vomited early, were brought to the 
 hospital, and there underwent the disease for a longer 
 or shorter time ; and the records made there satisfied 
 my mind as to the disease. At last, then, comes tho 
 plain question, whether I was able to distinguish the 
 
ON THE TREATMENT OF TYPHOID FEVER. 839 
 
 disease. To this I shall reply plainly. I watched 
 and studied this fever through three or four seasons 
 when it Avas epidemic, and the sporadic cases of it for • 
 more than twenty years before our hospital was 
 erected ; and I made it most especially my study to 
 recognize it on its earliest days. I believe that I 
 studied it successfully ; but I must leave it to those 
 who know me, to decide that point. 
 
 And, now, a few words at parting. I shall take 
 the risk of repeating what I have said before, in my 
 desire to impress on you what I think essential to 
 your well doing. 
 
 The sick-room is to be the field of your labors. To 
 everything which occurs there you are to give your 
 attention, and every step there should be under your 
 direction. Questions of the deepest importance are 
 constantly arising there for your solution ; questions 
 on the constitution of man, on the powers and the 
 machinery by which his functions are performed, on 
 the manifestation of disorder in those functions, and 
 the causes which may induce disorder, on the mode of 
 restoring health, or of guarding against all aggrava- 
 tions of disejtse, so as to allow the best chance for a 
 favorable result by the spontaneous efforts of nature. 
 These, and the like questions, will be arising constant- 
 ly, and you must be prepared, as far as possible, to 
 
840 ON THE TREATMENT OF TYPHOID FEVER. 
 
 meet them. Look at the gardener going forth to his 
 labors furnished with all the tools and appliances 
 which can aid him in his cunning work, — thinking 
 no preparation too great, no precaution too small, if 
 he can thereby make success more certain. See him 
 seeking for each plant the site mo&t favorable to it, 
 and furnishing it with the soil best adapted to its 
 wants. Notice how minute are his directions to his 
 laborers, trusting as little as possible to their discre- 
 tion. Do not cares of the ■ like sort, looking to great 
 and small things, belong to the physician, who has to 
 do with what is so immeasurably more important than 
 the fruits and flowers of the garden ? He must be 
 clear, and exact, and minute, in his orders to the nurse, 
 as the gardener is to his laborers ; remembering that 
 everything may depend on the more or less, on the 
 how and the w^ien. For these duties the physician 
 cannot be prepared without the utmost familiarity with 
 the sick-chamber. This is to the physician what the 
 garden is to the cultivator ; the place for which all 
 his studies and labors should prepare him, and where 
 he should forever be advancing more and more toward 
 a. perfection which he can never reach. 
 
INDEX 
 
 Abscess in tonsils, 154. 
 
 « " " treatment, 155. 
 Abscess io liver, 299. 
 Agriculture, compared to medicine, 12. 
 Air, in intestines, salutary, 243. 
 " " " injurious, 243. 
 
 Alimentary canal, the mutual influence 
 
 of its parts, 236. 
 Animal system, its organic diseases, 46. 
 Animal Magnetism, 98. 
 
 •' " common doctrine in 
 
 respect to it, 99. 
 " " another doctrine, 99. 
 
 Anxiety, cause of dyspepsy, 213. 
 Apoplexy, 74. 
 
 Appetite, a pre-reqnisite to the regula- 
 tion of diet, 217. • 
 Bile, as a cause of disease, 132. 
 
 " false notions respecting, 132. 
 Bilious diseases, 297. 
 Bladder, irritable, 304. 
 Bleeding, in pneumonitis, 165. 
 " " hajmoptysis, 191. 
 Boils, 306. 
 " their varieties, 310. 
 " blind, 311. 
 " come in succession, 312. 
 " sometimes epidemic, 312. 
 " their causes, 313. 
 " treatment of, 316. 
 " local treatment, 323. 
 Brain, an out-growth of the organic sys- 
 tem, 44. 
 Brandy, 223. 
 
 29* 
 
 Brandy, caution as to its use, 224. 
 Bronchitis, 158. 
 
 « treatment of, 16^ 
 
 Calculi, biliary, 302. 
 " urinary, 303. 
 " mulberry, 303. 
 Catarrh, 158, 160. 
 
 " treatment of, 162. 
 Cause of disease, 36. 
 Cells, division, multiplication and ussa, 
 
 45. 
 Cholera Infantum, 132. 
 
 " " diagnosis, 134. 
 
 " " treatment of, 141. 
 
 Chorea, 85. 
 
 " its treatment, 85. 
 " fatal, 86. 
 
 " attending second dentition, 147. 
 Clairvoyance, 102. 
 
 " tested, 103. 
 
 Clergymen, how far liable to hsemop- 
 
 tysis, 201. 
 Coffee, 222, 223. 
 Cold, a, 158. 
 Colon, enlargement of, 243. 
 
 " " " treatment, 244. 
 
 Combination of cathartics, 290. 
 Condiments, 218. 
 Constipation of bowels, 271. 
 
 " " " common in cities, 
 
 271. 
 " " " causes of, 271, 
 
 " " " treatment of^ 
 
 273. 
 
842 
 
 INDEX. 
 
 Constipation, great and obstinate occa- 
 sionally, 292. 
 ** treatment, 292. 
 
 Convulsion fits of children, 69, 110. 
 
 " " " " treatment, 
 
 70. 
 Costiveness attending dyspepsy, 210, 
 218. 
 " treatment of, 219. 
 
 Cure of the sick, 16. 
 " " " priest, 16. 
 " " " physician, 16. 
 Dejections in Cholera Infantum, to be 
 analyzed, how, 136. 
 " as to their frequency, 281. 
 
 Dentition, 107. 
 
 " cause of disease, 107. 
 " second, 145. 
 " " treatment of, 147. 
 
 Diarrhoea, in dentition, 110. 
 
 " in teething children, 129. 
 " before the period of dentition, 
 
 130. 
 " attending dyspepsy, 210. 
 " treatment of, 239. 
 Diet and regimen, 17 
 " in infancy, 112. 
 " errors of, 212. 
 " " " in quantity, 212, 226. 
 « " " in quahty, 212. 
 " " " in frequency of meals, 
 
 212. 
 " for a dyspeptic, 217, 221. 
 " for constipation, 273. 
 Directions as to medicines, &c., 38. 
 Double consciousness, case of, 94. 
 Dreaming, 92. 
 Drink, for a dyspeptic, 222. 
 Drugs, powerful, caution in their use, 
 13. 
 " powerful, abuse of them, 13. 
 " the temper with which they are 
 used, 14. 
 Dysentery, 240. 
 Dpspepsy, 203. 
 
 Dyspepsy, its local symptoms, 205. 
 " treatment of, 211, 
 
 " medicinal treatment of, 229 
 " its subsidence in old age^ 
 231. 
 Education, 7. 
 
 Enteritis, in teething children, 112, 133. 
 Epilepsy, 61, 
 
 ■* paroxysm of, 61. 
 " apoplectic, 63. 
 
 " its termination, 64 
 
 " its proximate cause, 65. 
 " its exciting causes, 68. 
 " its treatment, 67. 
 Evidence, examination of, 27. 
 Examination of cases, method of, 28. 
 Exercise, want of, cause of dyspepsy 
 213. 
 " 227. 
 
 " for constipation, 279. 
 Faint turns, in epilepsy, 63- 
 Feeding, of infants, 113. 
 Fissure, or crevasse in rectum, 295. 
 Flatulence in stomach, 207. 
 
 " " " how far decep 
 
 tive, 207. 
 Food, liquid, tepid for infants, 118. 
 " solid, for infants, when, 118 
 " how often, 118. 
 " animal, 119. 
 " withheld in night, 120. 
 " under disease, 121. 
 " vomiting and regurgitation of 
 
 208. 
 (( a a u (( 
 
 caused by some tenderness of the 
 stomach, 208, 
 " vomiting of, long-continued, a 
 case, 208. 
 Furunculus, 306. 
 Gall stones, 302. 
 
 Gastritis, in teething children, 112, 133. 
 Gout, 171. 
 
 " treatment of, 171. 
 Gruel, mode of preparation, 115. 
 IIseDFoptysis, 179. 
 
INDEX. 
 
 343 
 
 Haemoptysis, from a tuberculous cav- 
 ity, 179. 
 " from aneurism in the 
 
 thorax, 180. 
 " case of, from exhalation 
 
 in lungs, 181. 
 " diagnosis, 185. 
 
 " frequent recurrence of, 
 
 189. 
 " treatment of, 189. 
 
 " prognosis in, 195. 
 
 " tiiree cases of, 196. 
 
 Headaclie, 49. 
 
 " sick, 49. 
 
 " " treatment of, 51. 
 
 " intermittent hemicrania, 54. 
 
 treatment of, 56. 
 
 " chronic, 57. 
 
 " " treatment of, 59. 
 
 " in pregnancy, 59. 
 
 " attending dyspepsy, 211. 
 
 Heartburn, its causes, 207. 
 Hemorrhoids, 295. 
 Hippocrates, 18. 
 Holyolie. Dr., his character, 19. 
 Hosmer, Dr., case of, 192. 
 Hydrocephalus, 72. 
 Icterus, 299. 
 Iliac quarter, 247. 
 Influenza, 161. 
 Insanity, 104. 
 
 " treatment, 104. 
 Intestines, diseases of, 232. 
 
 " physiology, 233. 
 
 " pathology of, 235. 
 
 " causes of disease in, 238. 
 
 " mode of studying their dis- 
 
 eases, 242. 
 Irritable bladder, 304. 
 Jaundice, 299. 
 Liberal profession, 9. 
 Liver diseases, suspected, 244, 297. 
 " " acute, rare, 298. 
 
 " " chronic, not very rare, 
 
 298. • 
 
 Living beings, the simplest, 42. 
 
 L 's, Captain, case. 194. 
 
 Magnetism, animal, 98. 
 Medicine, imperfect as an art, 12, 23. 
 " " " " " not so. 
 
 comparatively, 12. 
 " practice of, not limited to th« 
 use of drugs, 15. 
 Minot's, Dr., cases, 257, 260. 
 Mucous membrane, inflammation of, 
 111. 
 " " eruptions on. 111. 
 
 Navigation, compared to medicine, 11. 
 Nervous system, 42. 
 
 " " an outgrowth of the 
 
 organic system, 44. 
 
 " " its organic diseases, 
 
 46. 
 " " its normal functions, 
 
 47. 
 " " its simple diseases, 
 
 not explicable, 48, 49 
 Neuralgia, 87. 
 Non-naturals, 112. 
 Pain, 87. 
 " its treatment, 89. 
 " or uneasiness in breast, attending 
 dyspepsy, 211. 
 Pamful tumor near the coecum, 248. 
 Case I. of the above, 248. 
 " II. of the above, 250. 
 " III. of the above, 251. 
 " IV. of the above, 252. 
 " V. of the above, 254. 
 " VI. of the above, 257. 
 " VII. of the above, 260. 
 Painful tumor, near coecum, symptoma 
 of, 262. 
 " " its situation, 262. 
 « « not fiital, 262. 
 " " its pathology, 263. 
 " " diagnosis, 264. 
 
 " •" treatment of, 268. 
 Palpitation of the heart attending dyg 
 
 pepsy, 211. 
 Palsy, 74. 
 
844 
 
 INDEX. 
 
 Palsy, its treatment in certain cases, 76. 
 " cases of, 77, 78. 
 " facial, 79. 
 
 " " its treatment, 79. 
 
 " " cases of, 80, 81. 
 
 " from lead, treatment, 82. 
 " mimotic, 82. 
 " " its treatment, 84. 
 
 Peritonitis, in right iliac quarter, 247. 
 Phlebitis, with suppuration, 266. 
 Phthisis, 173. 
 
 " varying with age, 173. 
 " treatment of, 174. 
 " long-continued, after haemop- 
 tysis, two cases, 197. 
 Physician, the true, his pretensions, 15, 
 
 16. 
 Pneumonitis, 164. 
 
 " how far dangerous, 165. 
 
 " treatment of, 165. 
 
 Principles, application of to practice, 
 
 10. 
 Profession, liberal, 9. 
 Prolapsus ani, 295. 
 Quack, 16. 
 
 " remedies, 271. 
 '* " objections to them, 
 
 272. 
 tjuinia, its mode of operation in certain 
 
 cases, 320. 
 Regurgitation of food, 208. 
 Rheumatism, 167. 
 
 « acute, 167. 
 
 Rheumatism, treatment of, 168. 
 " local, 169. 
 
 " in small joints, 169. 
 
 Sick-room, conduct in, 25. 
 Sleep, perfect or imperfect, 92. 
 Somnambulism, 93, 100. 
 Spirit-rappers, 104. 
 Symptoms, objective, 30. 
 
 " subjective, 30. 
 
 Tea, 222, 223. 
 Teething, 107. 
 
 Tumeurs phlegmoneuses des fosses ili- 
 aqaes, 265. 
 " case of in a man, 266. 
 " case of in a woman, 266. 
 Typhoid fever, treatment of, 326. 
 
 " " effect of emetics on, 330, 
 
 Ulcuscula oris. 111, 150. 
 
 " " hereditary, 150. 
 
 " " acute, 152. 
 
 " " treatment of, 152. 
 
 Uvula, elongation of, 156. 
 " amputation of, 157. 
 Vein, suppuration within, 266. 
 Vertigo attending dyspepsy, 211. 
 Vesication in haemoptysis, 191. 
 Vomiting, in dentition, 109. 
 Vomiting of food, 208. 
 Weaning, 121. 
 
 « age for, 123, 124. 
 " season for, 124. 
 Wine, 223, 
 Worms in the intestines, 148. 
 
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