Essays on the secretory and the excito-secretory system of nerves in their relations to physiology and pathology. Comprising I. A new classification of febrile diseases. II. An exposition of the "ganglionic pathology" of all continued fevers, as illustrated in typhus and typhoid fever. III. The prize essay on the excito-secretory system of nerves in its relations to physiology and pathology.--IV. A letter to Dr. Marshall Hall, of London, claiming priority in the discovery and naming of the excito-secretory system of nerves

Front matter

Book J2 2, 4—

Gopigta'N?._

CDMRIGHT nEPOSJT.

Preface

The several papers composing the following little volume were on different occasions presented as reports to the American Medical Association, and, with the exception of the Letter to Dr. Marshall Hall, will be found published in the Transactions of that body. They have, at least most of them, been distributed privately to various distinguished members of the profession in pamphlet form. Their scattered condition, as they exist in the volumes of the Transactions, and the proverbially perishable nature of pamphlet literature, have induced us to bring in the close relation of a single volume, our several papers on the Nervous System, which appear to us to have a special relation to one another, in order that we may gain for our views before the reader that advantage which will accrue from a simple juxtaposition and an uninterrupted reading.

One of the most distinguished essayists 1 of modern times has remarked, that "the rarest works are frequently the most original; for precisely in proportion as an author is in advance of his age, is it likely that his works will be neglected ; and the neglect of contemporaries, in general, consigns a book, especially a small book, if not protected by accidental concomitants, at once to the tobacconist or tallow-chandler. This is more particularly the case with pamphlets." The same writer here instances the neglect sustained by the philosophical pamphlet of Arthur Collier, which, though long antecedent and far more original than the large volume of Bishop Berkeley, yet sank into oblivion, because it was a pamphlet and

1 Sir William Hamilton.

Vlll PREFACE.

not a volume. It is to save our pamphlet on "Typhoidal Fevers," •which we humbly hope contains at least the germ of the truth in regard to the pathology of this class of fevers, from the fate of passing into the department of " Forgotten Literature," that we now make it a part of a system, which admits of a board-bound volume for its elaboration.

The Letter to Dr. Marshall Hall, contains all of our earlier publications on the excito-secretory system, and we have therefore withheld the separate introduction of those papers in the present volume. This letter will be found also to contain the previous claim of priority made before the American Medical Association, on the announcement of Mons. C. Bernard in 1853. At the time of its publication, one or two of our friends said, that we but expressed views which they themselves had entertained in an indefinite form for years. Mr. Carlyle gives utterance to an idea which fully explains this general recognition of original views as things not altogether unfamiliar. It is something like this : that at a time immediately preceding every discovery in science or art, there are vague, detached, elementary portions of it floating through the brains of many, who, having only parts of the truth, but partly express it, or do not express it at all, or are not sufficiently convinced of the truth to proclaim it boldly, 1 but still it has become somewhat

1 " That man is not the discoverer of any art who first says the thing ; but he who says it so long, and so loud, and so clearly, that he compels mankind to hear him — the man who is so deeply impressed with the importance of the discovery that he will take no denial, but, at the risk of fortune and fame, pushes through all opposition, and is determined that what he thinks he has discovered shall not perish for want of a fair trial." — See Tyler Smith on Parturition.

The following, which comes to us while these pages are undergoing correction, is found in an obituary notice of Dr. Marshall Hall, and the very diction indicates who the author is. Here is the penetrating insight of the Philosopher yoked with the sprightly gleaming of the Poet. It is from the glowing pen of Dr. Oliver Wendell Holmes. In referring to Dr. Hall's discovery of Reflex action — Excito-motory action, and the disputations following its announcement by him, this writer uses the following striking language : —

" Others may have more or less perfectly observed and announced some of the facts in the series of demonstrations. But they spoke in a whisper or in a corner,

PREFACE. IX

familiar to many, so that when he who is justly entitled to be called the originator of the system announces it, " What he says," to use the author's own language, " all men were not far from saying — indeed, were longing to say. The thoughts of all start up, as from painful, enchanted sleep, round his thought, answering to it, 'Yes, even so!' We all feel as if we could, and some feel as if we did, fashion such a result. The built house seems all so fit, every way as it should be — as if it came there by its own law and the nature of things — that we forget the rude, disorderly quarry it was shaped from. The very perfection of the house, as if nature herself had made it, hides the builder's merit." We claim no great perfection for our work, nor merit for ourself, except the merit of originality already fully accorded us. We know that " the excitosecretory system will," as Dr. Marshall Hall says, " require many laborers and many years for its perfection." We claim no other merit, because it was to an incident of our early youth 1 that we owe the direction given to our mind which led to the result, however important it may have since proved and may yet prove. It is far from being, as yet, a " built house," but we claim to have, at least, been the first who fitted the materials and showed how they were to be put together.

The classification of febrile diseases found in the introduction to this volume, we sincerely believe to be the true one, and with truth for its basis, we do not hesitate to predict that, in time, it must become the accepted one.

We will make one remark about the prize essay near the end of this collection, and then close our rather lengthy preface. It will

and when they had once spoken, were quiet. He cried his doctrine and its proofs aloud in the street and in the academy ; he shouted it over and over again, until he was hoarse with calling ; he printed it in little pamphlets and big books ; he dressed it in Italics and capitals, as if it were an incendiary proclamation ; he wearied the very echoes with it, until at last the deaf and surly world took up its ear-trumpet and listened — and lo ! one of the startling truths that make a century luminous in the procession of time/and lift a withered student into planetary reputation!" — Boston Med. and Surg. Journal. 1 See note, p. 130.

X PREFACE.

doubtless appear to some readers, that we have given the motto of the essay too much prominence in the discussion ; where such is the opinion, we can only express our regret that we feel obliged to differ. The motto of this essay was intended by us, rather as a principal theme for discussion, equal in importance with the professed subject itself, than as, simply a motto; hence it will be found that a large portion of the paper, while it does not overlook the development of the excito-secretory system, is yet earnestly devoted to illustrating the fallacy of experiment when not properly governed by correct observation and reasoning ; while, on the other hand, we have endeavored to illustrate the great value of many observations where no experiment, in the technical sense, has been made, claiming for the observation at least equal value with the experiment when applied to the purposes of induction. " Observation is a lens which collects the distant rays of the past into a focus upon the present, that it may consume the false or kindle into higher life the true" 1

These remarks have been thus far prolonged, from the desire, on our part, to give to these essays, written on different subjects and at long intervals, that "oneness" which, in our opinion, a volume should ever present. And notwithstanding all our care, we feel constrained, in conclusion, to use the apt language of another, 2 " we are sensible that we have not disposed our materials to abide the test of captious controversy, but of a sober and even forgiving examination ; that they are not armed at all points for battle, but dressed to visit those who are willing to give a peaceful entrance to truth."

Augusta, Ga., July, 1857.

1 Bidwell's Eclectic Magazine.

2 Edmund Burke. On the Sublime and Beautiful.

Contents

PA.GE

I. The Classification of Febrile Diseases by their relation to the

Nervous System xiii

Introduction To Essay On Typhoidal Fevers

THE CLASSIFICATION OF FEBRILE DISEASES BY THEIR RELATION TO THE NERVOUS SYSTEM. 1

During the examination of our subject since the time of our appointment as a special committee, by this Association, we have been, at each step, more and more impressed with its importance, and at the same time with the extreme difficulty attending its full, clear, and thorough elaboration. "A man," says Lord Bacon, " must collect facts, in order to know the law of facts;" diligently and earnestly engaged for the year past, in collecting and interrogating the facts which have a bearing on the important subject of Febrile Diseases, in the relation assigned us for examination, we have scarcely had time to do more than note, here and there, the gleam of truth which has been evolved during a bare hasty collocation of data; much less to determine satisfactorily any fixed law in relation to the vast subjects involved in the investigation. That such laws will be recognized, and that the careful generalization of the facts will be productive of important, fruitful results, we have already seen enough fully to persuade us. Pleading then the magnitude, as well as the embarrassments of the subject, we ask of this Association the privilege of having our special committee continued for another year, allowing us at present to lay before this body a few conclusions arrived at, as the result of the investigation in its presest state of progress.

I. As all the normal phenomena of the living organism are known to occur under the superintending influence of the nervous system, and are dominated by it, so it is but rational to regard all morbid actions as being more or less influenced in their manifesta-

1 See " Partial Report on the Nervous System in Febrile Diseases." Trans. Amer. Med. Association, Vol. X.

XVI PAETIAL REPORT ON

tions by aberrated nervous action. In that class of diseases ordinarily designated fevers, our researches and observations have led us to the confident belief that the above law applies with sufficient prominence to constitute the basis of their classification, and we would here respectfully claim for it, that it is the only reliable basis of their classification, and further, that in its more extended application, it will hereafter be found to constitute what may be called par excellence, the Law of Febrile Diseases. Simply to assert the recognition of this law, and to suggest a new and more comprehensive classification of Fevers based upon it, is the sole object of the present brief exposition.

II. As in the Nervous System, we recognize two grand departments, viz: 1st. The Cerebro-spinal System, all the normal actions of which are subject to cessations and interruptions; and, 2dly. The Ganglionic System, all the normal actions of which are of a continuous and uninterrupted character, so in the manifestations of febrile diseases, do we distinctly recognize two grand distinguishing characteristics respectively typifying the normal actions of these two systems of nerves : thus, a character of paroxysm obtains in certain cases, while a character of continuousness as plainly marks the others.

III. Again : as in the Cerebro-spinal System, we find that its normal action pertains almost exclusively to sensation and to motion, with only a secondary and comparatively somewhat remote influence (which we have termed Excito-Secretory) upon nutrition and secretion, while in the normal action of the Ganglionic System the entire function is known to be, to preside over nutrition and the secretions ; so in paroxysmal fevers do we find intense pain, modified sensation, and symptoms allying them to neuralgic and convulsive diseases very prominent, while in continued fevers, modified nutrition and altered secretion, are the marked and most prominent characteristics. We would, therefore, announce as our classification of febrile diseases, two grand divisions of fevers corresponding with the two grand divisions of the nervous system, thus: —

I. Cerebro-spinal Fevers.

All Paroxysmal. The secretions and nutrition only secondarily affected.

II, Ganglionic Fevers.

All Continued. The secretions and nutrition primarily affected.

THE NERVOUS SYSTEM IN FEBRILE DISEASES. XV11

I. Under the head of Cerebro-spinal Fevers, we would place the whole family of Paroxysmal Fevers, whatever type they may assume, 1 and, also, the various forms of neuralgia, which are nearly always intermittent, as well as the sthenic forms of Traumatic Fever, together with the Fever accompanying simple Pharyngitis, Pneumonitis, Dysentery, 2 and many other diseases of malarial districts.

II. Under the head of Ganglionic Fevers, or Fevers of the Secretory System of Nerves, we think that we rind ample ground for bringing together many diseases heretofore widely estranged from each other. Thus, as the archetypal form of ganglionic fevers, we place at the head of the list, typhus and typhoid fever, 3 then, allied to these in various degrees of affinity, but all equally, in the one essential element, that they present themselves as manifestations of disease through the Ganglionic System, are variola, scarlatina, 4 rubeola, varicella, and many other forms of eruptive fevers, heretofore not classified by nosologists. All of these last diseases are marked by fever of a continued or non-paroxysmal character, all present marked aberrations of nutrition and secretion, and each has its own peculiar eruptive character; and, further, each one is definitely self-limited in its duration, as yet, no remedial interference having been found competent to arrest or shorten their progress.

We will here make the remark, that we do not wish to be mistaken as classifying these diseases in relation to their eruptive fea-

1 The primitive location of these fevers, in the cerebrospinal system, was developed by Prof. L. D. Ford, of the Medical College of Georgia, in the Southern Medical and Surgical Journal, in 1836, and called by Maillot, " Cerebro-spinal Intermittent Irritations."

2 See Clinical Lectures at Jackson Street Hospital " On the Pathology and Treatment of Dysentery, by Robert Campbell, M. D., Demonstrator of Anatomy in the Medical College of Georgia." In these Lectures the relation of Dysentery to Paroxysmal Fever is fully considered by my brother.

3 As first developed in an essay entitled : "An Inquiry into the Nature of Typhoidal Fevers, based upon a Consideration of their History and Pathology, " presented to the American Medical Association, at its Session of May, 1853, by Henry F. Campbell, Chairman of Committee on Typhoid Fever. The implication of the ganglionic system of nerves, in typhus and typhoid fever, has been, in the above essay, argued at length. We would now assert — that Asiatic Cholera and its kindred diseases present a class of symptoms which pre-eminently manifest that the ultimate location of these affections is in the Ganglionic or Secretory system of nerves.

4 M. Trousseau, in his recent Lectures on Scarlatina, seems to take a similar view. He says : " The ganglionary system is implicated."

B

XV111 PARTIAL REPORT ON

ture, but only as signifying a recognition of the common influence of the secretory system of nerves in all of them by the eruption. In typhoid fever itself, it must be recollected that the eruption is not a prominent feature, and yet, we consider the secretory system of nerves primarily deeply affected, and place this at the head of the list, notwithstanding the fact, that the ganglionic implication manifests itself hut little upon the skin and mainly in the intestinal canal. 1

It may be asked, if all of these fevers are due to aberration in the innervation of the ganglionic or secretory system of nerves, why should they present such marked specific differences? A satisfactory answer may be given thus : that specificity of morbific cause must rationally be expected to secure a specificity of morbid manifestation ; thus, the virus of variola, when taken into the system, gives rise to the morbid manifestations peculiar to smallpox, while the morbific influence (of whatever nature it may be) of typhoid fever, produces a specific form of disease entirely different, but not the less for that reason, locatable in parts of the organism entirely controlled by the secretory nervous system.

Blending of Types of Fever. — Much interest has been taken by this Association, for the last five years, in the subject of the Blending of the Types of Fever. We would claim, for the present Pathology and Classification of Fevers, that it is the only one which admits of any plausible explanation of the mysterious phenomena comprehended under the term, "Blending of Types;" thus, a cerebrospinal or paroxysmal fever may assume, under certain circumstances, some of the characteristics of some one or other of the forms of continued fever. This, we hold, can be explained by attributing it to a propagation of the irritation, originally located in the spinal marrow, to the ganglia of the secretory system. Then, again, the reverse may obtain; we may find, and do often find, in continued fevers, especially in malarious districts (whether the case be typhoid fever, rubeola, or scarlatina), intermittent paroxysms, interrupting the even course of the continued form, sometimes obscuring the diagnosis, and making it necessary to modify the treatment. The use of quinine, it is well known, will generally break up these paroxysms, but not in the least modify the course of the continued fever. In the first of these cases, the morbific influence has been "centripetal" and in the second "centrifugal," and

1 See Inquiry, &c, pp. 53 and 54.

THE NERVOUS SYSTEM IN" FEBRILE DISEASES. xix

thus the "blending of types" may be rationally and philosophically explained.

We are aware that, in presenting thus a condensed exposition on the obscure subject of " The Nervous System in Febrile Diseases," without more argument and fuller elaboration, we are running the risk of being charged with "bare assertion," but we will honestly avow, that each proposition has been earnestly and carefully considered, keeping constantly in view all the phenomena of febrile diseases — comparing them faithfully with the normal actions of the two grand departments of the nervous system.

It will be remarked, that we have not attempted to define what is the exact morbid condition of the nervous centres, or of the nerves, which gives rise to the phenomena in the two classes of fever. Such a process of reasoning we have carefully abstained from, because such a discussion would be conversant about subjects which cannot as yet be said to have been brought within the legitimate domain of science. "We can only as yet trace the effects to their causes; it is a different thing to discuss the nature of the causes themselves ; and as Professor Whewell has made a distinction between the Laics of Phenomena and the Causes of Phenomena, so we only here claim to have recognized a Law, leaving the more recondite inquisition into the Causes, for a more advanced and enlightened age of science. In conclusion, we will say, we may have been, in the above exposition, unfortunately obscure in presenting to others what has become a clear and well defined conviction to us; but in the pertinent language of another, 1 whose deep philosophy has charmed us, while it has been of unspeakable service to us in many of our investigations, we will say, that " to our mind this doctrine stands firm and impregnable — assailable by no known fact consistent with every established truth."

1 Dr. M'Cosh, on the Method of the Divine Government.

II. AN INClUIRY

AN INQUIKY

NATURE OF TYPHOIDAL FEVERS.

BASED UPON A CONSIDERATION OF

THEIR HISTORY AND PATHOLOGY,

AND ILLUSTRATING

THE GANGLIONIC PATHOLOGY OF ALL CONTINUED FEVERS.

To this confidence I have come, not merely through the convictions of my own consciousness, but from finding in this system, a centre and conciliation for the most opposite of philosophical opinions. — Hamilton.

ERRATA IN ESSAY ON TYPHOIDAL FEVERS.

Page 37, line 16, for " and that," read " or that."

Page 50, line 32, for " opposite," read " apposite."

Page 55, line 19, for "internal," read "intimate."

Page 56, line 14, for "Pathology ," read "pathological Anatomy."

Page 58, line 26, for " action," read " section."

Page 58, line 29, for " a normal action," read "abnormal action."

AN INQUIRY

Ax analysis of the symptoms of typhoid fever, with a view to its correct pathology, is embarrassed by the difficulty which presents itself in the selection of those phenomena and events which are really characteristic of the disease; for in the immense body of recorded observations with which the investigator is presented, there are comparatively but few which belong essentially to typhoid fever. In the following paper, it has been our object to give a brief but careful summary of its most prominent features, illustrating them when necessary by cases from the latest and most approved authorities, from a consideration of which our deductions have been made.

We have in no instance referred to our own observations of cases, for it is obvious to our mind that any views of disease founded mainly \upon rational induction, would be less liable to fallacy, when based on the recorded, careful observations of others, than when they are merely the interpretation of our own cases, always liable to preconceived opinions and foregone conclusions, which have ever proved most effectual and deplorable barriers to correct observation. It is true that, in the plan here adopted, the same objection to a great extent will be found to exist ; but by this method we are freed from the fallacies which would be apt to arise from a personal record, with a view to establish a doctrine, and will have to contend only witH those which must necessarily attach to the interpretation of data, the record of which has in many instances been intended to corroborate views entirely dissimilar and often opposed to our own.

b AN INQUIRY INTO THE

Typhoid fever has prevailed so widely and oftentimes with such great fatality that there are few diseases which have excited such general interest with the etiologist and pathologist. Its symptoms and phenomena have been repeatedly noted with the utmost accuracy, and the recorder of the present day must bound his aspirations, and be content, by simply verifying the observations of those who have preceded him. But with the analyst the case is far different; being in search of no new phenomenon, not professing to add anything to what are already cognate facts, in relation to the disease, his object being merely to interpret these facts from data founded upon them, repeated observation and record by others but strengthen and confirm his positions, and afford him a wider field and more abundant material from which to draw his conclusions.

History. — There are certain traits upon which nearly all writers have agreed as being usually characteristic of typhoid fever. In the first place there is always more or less prostration, with an impairment of the functions of the nervous system. Secondly, there is fever, which is continuous, but sometimes variable in its degree. Thirdly, in the vast majority of cases there is more or less diarrhoea, generally of an obstinate but passive character ; and fourthly, its most constant pathological appearances have been found to be those which refer to the abdominal viscera, there being very uniformly some special alteration in the follicles studding principally the mucous membrane of the mesenteric portion of the intestinal canal known as the glands of Peyer and Brunner.

In addition to the above, which may be considered as almost essential characteristics of the disease, there are a great variety of symptoms described by almost every author as very constantly attendant upon it, and by many considered among its essential attributes. These, although very numerous, will be found generally more or less referable to one or other of three classes of symptoms, the combination of which appears to constitute the disease, viz. disturbances of the nervous system, of the circulation, and of the digestive organs — and so far as practicable, we will thus classify them in our summary. The symptoms pertaining to the cerebro spinal system, commonly denominated the nervous symptoms of typhoid fever, consist in wandering pains in various parts of the body ; cephalalgia, pain in the back, loins, and extremities, more or less delirium, vigilance, somnolence, dulness of hearing, impaired vision, soreness of the muscles, and occasionally subsultus tendinum, together with prostration of muscular power.

In relation to this class of symptoms our reference to statistics has been attended with various results ; we find that they have generally been noted with a view to institute comparisons between the two types, typhoid and typhus, and the general result in regard to them, so far as we have been able to notice, has been ; that nervous symptoms of one or other character are present in a large proportion of typhoid cases, but they do not generally form such prominent features in this as in the typhus type, where their existence is almost invariable, and of a character much more alarming ; so that, of the two diseases, the common term "nervous fever" would be more applicable to typhus.

Disturbances of the Circulation are perhaps the most invariably present of the three classes of symptoms. Of these, we will notice the abnormal states of the pulse, abnormal temperature of the skin, and the capillary congestions frequently observed on the surface of the body.

The pulse is almost invariably more or less accelerated in both typhoid and typhus fever. In character, it is irritable, weak, and nervous, showing a remarkable contrast to the full, open, sthenic pulse, characterizing the paroxysms of periodic fever. Its frequency is far less than in the latter case, but it is nearly uniform ; and although occasionally subject to variations, this general feature of unintermitting continuousness is so constant, that it is from this probably more than from any other feature that these types have acquired the general name of continued fever. The average mean of the pulse, according to the accurate observations of Dr. Flint, is 95. T J in typhoid cases, while it was found by him to be 105. f in the typhus type, which I think will be found not to vary materially from the observations of others. His tables also show that irregularity and feebleness are much more common in typhus than in typhoid fever.

In relation to frequency he remarks : " There can be no doubt, if the pulse exceeds 120, except for a transient period, that the case is of dangerous severity ; and the danger increases in more than geometrical ratio, if it rises above this point."

Temperature of Surface. — There is, as in other forms of fever, more or less heat of surface, in continued fever, which varies from a little above tlie natural warmth to what is known technically as biting heat, color mordax ; but these aberrations are so common in every form of fever, that we cannot attach much importance to them in a pathological inquiry like the present.

Sweating and Moisture, we find more common in typhoid than in typhus fever. In the former, cases vary much in regard to these symptoms ; sometimes the skin will remain usually dry, having at intervals sudden profuse exudations of sweat, soon becoming dry again. In other cases, the surface will be kept in a soft and gentle moisture during the whole disease ; while, again, the most profuse colliquative sweats will shrivel the surface and rapidly exhaust the strength of the patient. Upon the whole, there is a greater tendency to moisture than to dryness of surface in typhoid fever; while in the typhus type, decidedly the reverse is found to obtain.

" It would be interesting," says Dr. Flint, " to acertain upon what ulterior conditions sweating is dependent. With reference to this point of inquiry, it would be important to establish any relations subsisting between this event and other phenomena belonging to the natural history of the disease. I have examined the histories of several of the cases characterized by sweating, in order to discover a clue to some connection of this kind, but without success. It occurs not only at different periods of the disease, but apparently irrespective of the circulation, the temperature of the skin, and other symptoms. The antecedent morbid condition or conditions upon which it depends, and the circumstances involved in its production are unknown. All that can be said of its causation is, that it is an event incident to the progress of continued fever, belonging in the category with other incidental events, such as acceleration of the pulse, coating of the tongue, somnolency, &c, all of which are not more rationally explicable than it."

Capillary Congestions. — Among the ordinary appearances of continued fever, there is no one which will strike the attention of the clinical observer more forcibly than the peculiar, diffused congestions on various parts of the cutaneous surface; and though the symptom is easily recalled to our minds by a bare mention of it, yet strange to say, it has been almost uniformly omitted by reporters until quite recently. Even Louis, with all his vigilance, seems to have allowed this symptom to escape his attention. Dr. Gerhard, of Philadelphia, appears to have made the earliest and most distinct reference to it, in his account of the epidemic typhus fever, in Philadelphia, in 1836. Published in the American Journal of Medical Sciences, and also in Graves s and Gerhard's Glinical Medicine.