HEALTH SCIENCES LIBRARY 
 OF THE 
 
 UNIVERSITY OF NORTH CAROLINA 
 AT CHAPEL HILL 
 

 
 
 
 
 
 
 
 
 
 
 
 
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 M H 
 
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 REPORT 
 
 ON THE 
 
 MEDICAL TOPOGRAPHY AND EPIDEMICS 
 
 OP 
 
 NORTH CAROLINA. 
 
 BY 
 
 JAMES H. DICKSON, M. D. 
 
 EXTRACTED FROM THE 
 
 TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
 
 PHILADELPHIA: 
 
 COLLINS, PRINTED, 705 JAYNE STREET. 
 
 1860. 
 


 7 
 
 REPORT ON THE MEDICAL TOPOGRAPHY AND 
 EPIDEMICS OF NORTH CAROLINA. 
 
 MEDICAL TOPOGRAPHY. 
 
 The State of North Carolina, embracing an area of more than 
 fifty thousand square miles, extending from 34° to 36° 30' of north 
 latitude and from longitude 1J° east to 7° west of Washington, 
 and from the Atlantic Ocean on the east to the Alleghany Moun¬ 
 tains on the west, would seem to present a sufficiently wide range 
 of geological, meteorological, and climatic conditions to give origin 
 to no inconsiderable variety of diseases. 
 
 If, however, any reliable results can be deduced from the con¬ 
 fessedly meagre and imperfect reports which I have been able to 
 procure from different parts of the State, there will be found very 
 great uniformity in the diseases of all parts of its extended area. 
 
 On the eastern or Atlantic border of the State, there is an ex¬ 
 tensive region of low, swampy, alluvial formation, but little elevated 
 above the level of the ocean, which, as the country recedes from the 
 coast, merges into a wide, flat, sandy region of a somewhat higher 
 level, covered with extensive forests of pine, and gradually in¬ 
 creasing in elevation until the head of navigation of its principal 
 rivers is reached, when the face of the country becomes rolling 
 and hilly, and the pine forests abruptly disappear; being replaced 
 by a growth of oaks of great variety, and of hickory, poplar, syca¬ 
 more, black walnut, beech, maple, &c. 
 
 The entire eastern section of the State, from the seacoast to 
 the first rapids in the principal rivers, at an average distance of 
 about an hundred miles from the ocean, is without doubt a marine 
 formation, or sedimentary deposits from water, and therefore wholly 
 unlike those of the middle and western parts, which are the pro¬ 
 duct of the slow decomposition of the primitive rocks; and occupy 
 
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 REPORT ON 
 
 the place upon the original formation, from which they were de¬ 
 rived. 
 
 The soil of the eastern section has evidently been transported 
 from a distance. Its prevailing character is silicious, derived ap¬ 
 parently from the granite which borders the tertiary formation on 
 the west. From the same source is probably also derived the 
 aluminous and feldspathic portions of the soil, which enter into 
 the composition of the inexhaustibly rich- swamp lands of the 
 eastern counties. 
 
 The hilly middle region of the State has generally an argillaceous 
 soil variously intermixed with silex, micft, and different mineral 
 ingredients. It has had, and still retains, a high character for the 
 salubrity of its climate and the fertility of its soil. We may regard 
 this section of the State as extending to the base of the Blue 
 Ridge Mountains by a gradually increasing elevation. 
 
 The mountainous portion of the State, as indicated by recent 
 surveys, embraces the highest elevation of any portion of North 
 America east of the Rocky Mountains. 
 
 The littoral margin of the State of North Carolina is unique 
 and almost peculiar in one of its geological features. At a distance 
 varying from two to five miles from the main land a narrow strip 
 of sandbank runs parallel with the coast and nearly continuous with 
 it, like a giant breakwater, thrown up apparently by the action of 
 the waves of the sea; these sandbanks are for the most part bare 
 of vegetation; some portions, however, are covered with a thick 
 growth of live-oak, cedar, and yopon, which latter shrub is regarded 
 by competent authority as v identical with the much valued matte of 
 Paraguay. The continuity of this strip of sandbanks, is occasion¬ 
 ally broken by narrow inlets; and between the banks and the main 
 land, there intervenes a shallow sound, which is for the most part 
 occupied with a rank growth of marsh grass, which is alternately 
 covered and left bare by the rising and falling tides. 
 
 It thus presents precisely those conditions of insalubrity which 
 Armstrong, in his “Art of Health,” so graphically groups in the 
 couplet which follows:— 
 
 “ Not'for the wealth of all the Indies roll’d 
 Fix near the marshy margin of the main.” 
 
 There is doubtless something of truth as well as poetry in the 
 lines, although we are apt to suspect the writer to have been 
 influenced in some degree by the beauty of the alliteration, when 
 
THE EPIDEMICS OF NORTH CAROLINA 1 7 
 
 A 
 
 penning them; however true they may be in their application to 
 many localities, our coast can hardly be ranked among them; for 
 it is favored with delightful breezes during the summer which 
 sweep away such impurities as are supposed to be engendered by 
 the action of the hot sun on marshy soils; at any rate, so far from 
 being more subject to the visitation of intermittent and remittent 
 fevers, than the adjacent counties, the seashore has acquired quite 
 a reputation for salubrity, and is a common summer resort for many 
 of the inhabitants of the interior. 
 
 In the most easterly portion of the State, the strip of sandbanks 
 just noticed recedes considerably farther from the main land, leaving 
 an intervening space of many miles in extent, which is occupied, 
 mainly, by Pamlico and Albemarle Sounds, extensive sheets of 
 water, into which most of the rivers which drain the middle and 
 eastern portions of the State, among which may be mentioned the 
 Roanoke, the Tar, the Neuse, disembogue by wide estuaries. 
 
 The country along the margin of the sounds and the estuaries of 
 the rivers, may be generally characterized as swampy; elevated 
 but a little above the level of the ocean, being of the most re¬ 
 cent geological formation, and consisting largely of decomposed 
 vegetable matter, which confers upon it great fertility, and at the 
 same time stamps it with the character of insalubrity. 
 
 A very considerable portion of all the littoral counties of the 
 State, especially along the margins of the rivers and creeks, is of 
 the same swampy character, for the most part fertile, but unhealthy. 
 'Throughout the middle and western divisions of the State, valua¬ 
 ble minerals are found in abundance; among them, ores of iron, 
 copper, and gold, and in the middle region of the State, on the belt 
 of sandstone, which crosses it, are found bituminous, semi-bitumi¬ 
 nous, and anthracite coals. 
 
 The mountainous portion of the State, embracing about one tenth 
 of its superficial area, is remarkable for its salubrity and its altitude, 
 and for a considerable extent, forms the dividing ridge, from which, 
 on the one side, the rivers flow into the Atlantic Ocean, and on the 
 other, into the Mississippi River and the Gulf of Mexico. From 
 one point, indeed, the waters flow north, south, east, and west, into 
 Virginia, South Carolina, Tennessee, and the Atlantic; a geographi¬ 
 cal feature which is believed to be peculiar to this State. 
 
 Another remarkable peculiarity of this mountain region of the 
 State of North Carolina, is the existence of a belt or zone, which is 
 characterized by an entire exemption from frost. Frost occurs 
 
8 
 
 REPORT ON 
 
 both above and below this remarkable zone, and the strange spec* 
 tacle is sometimes presented of vegetation blighted by frost both at 
 the base and apes of the mountain, while the intermediate region 
 presents to the eye the blooming verdure of spring. Here, fruit 
 falling from the trees, needs no protection during the winter; here, 
 the vine flourishes in great perfection, and our sanguine agricul¬ 
 turists are anticipating, for this part of the State, great success as a 
 wine making region. 
 
 DISEASES, 
 
 The great endemic of southern climates, Bilious Remittent Fever, 
 claims the first place in the nosography of this State. 
 
 BILIOUS REMITTENT FEVER. 
 
 For many years, it may be said to have been the reigning epi¬ 
 demic of the entire eastern section of the State, of such uniform 
 occurence in the summer and fall, and so formidable in its character, 
 that few who had the ability to remove to more salubrious localities, 
 were accustomed to remain during the season of its prevalence, in 
 the low country. 
 
 This form of fever, so unfailing in its periodical visitations, often 
 beginning as early as June and remaining until the occurrence of 
 frost, which generally takes place in the latter part of October, has 
 of late years, lost much of its malignity in the low country, but 
 seems to have acquired an increased power of diffusion, having 
 gradually encroached upon the middle region of the State, and ex¬ 
 tended itself almost to the base of the Blue Ridge Mountains. 
 
 A few years ago the remittent and intermittent forms of fever 
 were as prevalent in Salisbury, Concord, and Charlotte, in the 
 middle region of the State, as in any of the counties on the sea¬ 
 board. 
 
 I am informed by physicians resident in the mountains, that 
 these forms of fever are never known to originate there, but are 
 not unfrequently imported by travellers, and that the mountaineers 
 look upon a journey to Charlotte or Salisbury in autumn, with 
 much the same feeling of apprehension with which an inhabitant 
 of either of these towns would regard a visit to Wilmington, or 
 Washington, on the seaboard. 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 9 
 
 For some years past, remittent fever, as it has prevailed in the 
 eastern or sea-board counties of the State, has been almost uni¬ 
 formly of a mild type; very rarely presenting the severe gastric 
 and hepatic derangements which constituted such troublesome and 
 dangerous complications in former years. 
 
 Thirty years ago, this form of fever was frequently attended 
 with a duodenitis which extending along the hepatic ducts and 
 their ramifications, caused such a suspension of the functions of 
 the liver as to lead to the retention of the elements of the biliary 
 secretion in the blood and gave to the skin that icteric hue which 
 allied it closely, both in the popular and professional mind, with 
 the yellow fever of the tropics. 
 
 As experience has taught us that quinine is entitled to the rank 
 of the febrifuge par excellence in this form of fever, we have been 
 able, of late years, to dispense with much of what formerly con¬ 
 stituted the regular armamentarium medicorum in its treatment. 
 
 We have now but little use for sudorifics, effervescing draughts, 
 cold affusion, or the lancet, and the disease is rarely suffered to run 
 on long enough to give rise to organic complications. 
 
 In cases of much severity, or in which alarming indications pre¬ 
 sent themselves, the abortive method of treatment by the rapid 
 induction of a state of cinchonism has become a favorite plan of 
 proceeding. 
 
 It has rarely been found necessary in this locality (Wilmington)? 
 however, in order to produce.this effect, to resort to the very large 
 closes of the drug, which have been recently recommended in our 
 medical periodicals and practised in other parts of the State. In 
 the vast majority of cases, which occur here, the system may be 
 brought sufficiently under its influence, by doses of from two to 
 five grains every hour or two, until the muffled ear gives token of 
 its peculiar influence upon the nervous system and the reduction 
 of the excited pulse exhibits its influence on the vascular system. 
 
 One class of cases in which it is very desirable if not indispen¬ 
 sable to bring the system very speedily under the influence of 
 quinine is that which occurs among children attended with convul¬ 
 sions (Febris Remittens Convulsiva). In this class of cases the first 
 and sometimes the second paroxysm of fever may be unattended 
 with the appearance of any alarming symptoms, but the third 
 paroxysm is apt to be ushered in with a convulsion which seems 
 to replace the cold stage of the same disease in adults, and which 
 is always so alarming and dangerous an occurrence, as to make it 
 
10 
 
 REPORT ON 
 
 prudent to cut short the disease at once by bringing the system 
 very rapidly under the potent influence of the febrifuge. 
 
 For the very valuable suggestion upon which this practice is 
 founded we are indebted to Dr. Henry F. Campbell, of Georgia. 
 Detecting the fact that the convulsion was but a chill in disguise, 
 and therefore liable like the chill to a periodical recurrence, he has 
 put us on our guard and enabled us to ward off an imminent 
 danger. I feel assured that by acting in accordance with this 
 precept I have been enabled in a very large number of instances) 
 to divest this form of fever of its danger. 
 
 Although quinine has the. power of arresting the progress of 
 every variety of remittent fever, even after local inflammations and 
 congestions have been superinduced, still its salutary operation is 
 greatly obstructed by such occurrence. In cases which will admit 
 of delay, these local derangements should be relieved by the use of 
 such local and general remedies, as may be indicated by the special 
 complication; but in formidable cases, we should not hesitate to give 
 it concurrently with those remedies. 
 
 The ordinary cerebral and lumbar pains, which invariably accom¬ 
 pany remittent fever, do not contraindicate its use. On the con¬ 
 trary they are speedily relieved by it, and in many cases without 
 the use of those adjuvantia which are commonly prescribed for 
 their relief. When, however, these symptoms are more than usu¬ 
 ally violent, or unusually persistent, no prudent practitioner would 
 neglect the use of ancillary measures. 
 
 Where there are evident symptoms of gastritis, as indicated by 
 extreme irritability of stomach, especially when accompanied with 
 vomiting of a glairy white-of-egg-like fluid, local depletion, a blister 
 to the epigastrium and ice ad libitum will be found useful prepara¬ 
 tory or co-operative measures. 
 
 The symptomatology and pathology of this form of fever so 
 plainly point to the liver as an organ which bears in a large de¬ 
 gree the onus of the malady, as to make it important that we should 
 not overlook or neglect the remedies which experience has furnished 
 us with for the purpose of rectifying its disordered functions. , 
 
 The essential anatomical condition of this form of fever would 
 seem to be, according to the views of Drs. Swett, Stewardson, and 
 Howard, confirmed by the industrious and careful microscopic 
 examinations of Dr. Joseph Jones, of Georgia, to be that condition 
 of the liver which they have designated by the term bronzed liver. 
 
 Dr. Jones, in his very elaborate and learned paper on Malarial 
 
THE EPIDEMICS OF NORTH CAROLINA. 11 
 
 Fever, published in the twelfth vol. of the Trans, of the Amer. Med. 
 Association, attributes this peculiar color of the liver “to changes 
 in the coloring matter of the blood, as is indicated by the fact that 
 the blood from the capillaries of the liver will not change from the 
 dark reddish-brown and purplish color ; to the arterial hue on ex¬ 
 posure to the air. It is probable that the altered coloring matter 
 from the destroyed disintegrated blood-corpuscles, or from the blood- 
 corpuscles acted on by the malarial poison without actual disinte¬ 
 gration, escapes and permeates the surrounding tissues, and imparts 
 the peculiar color to the liver.” 
 
 In the same valuable paper it is stated that the glycogenic func¬ 
 tion of this organ is also frequently impaired. Whether this de¬ 
 rangement of function is to be regarded like the bronzed color, as 
 characteristic of this form of fever, can only be determined by more 
 extensive observations. 
 
 But whatever may be the precise deviation of this organ from 
 the healthy state, experience has demonstrated the advantage of 
 such remedies as are supposed to possess cholagogue properties, 
 among which mercurial cathartics rank highest with the profession 
 generally. 
 
 Though decidedly sceptical with regard to the possession of any 
 such property by any form of mercury, I still regard it (but solely 
 upon empirical grounds) as a very valuable medicine for rectifying 
 disordered hepatic functions. 
 
 I have, I think, occasionally witnessed the sad consequences of 
 neglecting the morbid condition of this viscus and relying too 
 exclusively on the remedial powers of quinine. 
 
 The highly inflammatory type of remittent fever is rare in this 
 locality (Wilmington), of late, and hence the use of the lancet is 
 seldom required in its treatment. Instead of its being the general 
 rule to bleed now, as it may be said to have been twenty years 
 ago, bloodletting is the rare exception to the rule. 
 
 That bleeding was an indispensable remedy in the highly phlo¬ 
 gistic diathesis, which prevailed twenty-five years ago, no man 
 whose experience reaches over that number of years, will be likely 
 to deny. 
 
 W T hetker the human constitution has been so influenced by the 
 external conditions to which it has of late years been subjected, as 
 to modify its morbid manifestations; or whether the nature of the 
 disease itself through some occult modification of its exciting causes, 
 has undergone some change, may not be very easy to determine. 
 
12 
 
 REPORT ON 
 
 But that a very decided change has come over the manifestation of 
 the disease and the indications of treatment within the last quarter 
 of a century, is a fact testified to us from all quarters. 
 
 While it is indisputably true, that great and notable advances 
 have been made in the diagnosis of diseases within the period under 
 review, and we might, therefore, not unreasonably doubt the accu¬ 
 racy of the diagnosis of our predecessors, who depended only on 
 the rational symptoms, and by logical inference deny the value of 
 their experience, as to the necessity or even utility of the reme¬ 
 dy, this would only avail so far as regards the thoracic complications 
 of the disease; for, as a general rule, although this disease presents 
 more or less diversity of aspect in different years, it rarely changes 
 its phasis to such an extent as to render its diagnosis a matter of 
 difficulty. 
 
 We are not, therefore, warranted in condemning the practice or in 
 ignoring the experience of the age which has just preceded us; nor 
 in pluming ourselves on any demonstrated superiority in practice- 
 Another cycle of twenty or thirty years may lead our successors 
 to wonder at what they may have good reason to regard as our 
 weak and inefficient methodus medendi. 
 
 That the type of disease varies, from year to year, or within a 
 series of years, is a proposition which has received the very general 
 assent of the profession since the days of Sydenham; and although 
 we may regard his ascription of it to some occult atmospheric con¬ 
 stitution, as but a hypothetical solution of the problem, it will not 
 be wise to disregard the great amount of observation and experi¬ 
 ence which has since been accumulated upon this point, and to con¬ 
 clude that because bloodletting does not now seem to be a sine qua 
 non in the treatment of inflammatory disorders, that it never has 
 been entitled to be so regarded. 
 
 Extreme opinions on medical, as on many other subjects, rarely 
 stand the test of time and experience, and though the aphoristic 
 words of Hippocrates, “experientia fallax judicium difficile” embo¬ 
 dies a desponding truth, experience must, I presume, still be re¬ 
 garded, as the great arbiter both of opinion and practice. 
 
 The congestive and adynamic types of remittent fever have been 
 of very rare occurrence of late years, in the maritime counties of 
 the State; but the interior and middle districts of the State have 
 not enjoyed a similar exemption from these grave forms of fever. 
 Dr. N. I. Pittman, of Edgecombe County, reports, “that during the 
 year 1857, we have had, in Edgecombe County, bilious remittent 
 
THE EPIDEMICS OF NORTH CAROLINA. 13 
 
 fever to prevail more generally than it had done for the preceding 
 eight years. Our summer and autumn were unprecedentedly hot 
 and dry, the spring months having been cool and wet. The type 
 of fever which has prevailed with us since the spring of 1855, has 
 been of a continued character, assuming often a typhoid or ady¬ 
 namic form; and occasionally we have had genuine idiopathic 
 typhoid fever, answering admirably to the descriptions of Louis, 
 Wood, Stokes, and others. 
 
 “In the treatment of the bilious remittent fever which visited our 
 section of the country, there was no special or novel practice insti¬ 
 tuted. We relied principally upon mercurial cathartics, quinine, 
 cinchona, diaphoretics, blisters to the epigastrium, nape of the neck, 
 and spine, as symptoms seemed to demand.” 
 
 Dr. H. Kelley reports the prevalence of remittent and intermit¬ 
 tent fevers, in the County of Iredell, in the western part of the 
 State. These diseases prevailed to a considerable extent, in the 
 neighborhood of large watercourses. Dr. Otis Frederick Manson, 
 of Granville County, gives us, in a paper read before the N. C. 
 Med. Society in 1856, a description of the adynamic and congestive 
 varieties of remittent fever as they prevailed in that section of the 
 State, from which I extract as follows:— 
 
 Adynamic Remittent .—Remittent fever of a low grade, and per¬ 
 sistent character, strongly simulating continued fever, may present 
 itself as a sequel to neglected or mismanaged cases of the ordinary 
 form of the disease, or may occur primarily. 
 
 Its approach is commonly, however, less abrupt than the usual 
 form, the invasion being often unattended by a decided chill. In 
 other respects the prodromise do not differ essentially from an ordi¬ 
 nary attack. The pulse is of ordinary frequency, not usually ex¬ 
 ceeding 100 per minute in adults. The exacerbations and remis¬ 
 sions are indistinctly marked, the pulse in many cases varying 
 only eight or ten beats in twenty-four hours. The heat of skin is 
 moderate, and very often attended with some moisture, during the 
 greater period of the attack. When the disease is fully formed, 
 the tongue becomes more or less pointed and red at its tip, and on 
 its edges, with a brown fur on its dorsum. The patient does not 
 usually experience much acute pain. A dull headache, but not 
 continuous, together with some abdominal uneasiness, is generally 
 present. Diarrhoea sometimes occurs, and although it may be absent, 
 a tendency towards it is manifested by a morbid susceptibility to 
 the action of cathartics; the mildest aperients producing severe 
 
 9 
 
14 
 
 REPORT ON 
 
 tormina, and frequent copious serous discharges. As the disease 
 advances, the tongue becomes dry, brown, and even black, or part¬ 
 ing with its coat, it presents a clean, red, shining surface. The ab¬ 
 domen becomes tympanitic, tense, and tender to the lightest touch, 
 or as, in some cases, although enlarged, yet it is soft, its walls 
 yielding to the weight of the viscera ; the skin being wrinkled, 
 dry, and desquamating, and the separate and relaxed muscular 
 fibres imparting a sensation to the hand as if the cavity was filled 
 with lumbrici. The mind is usually clear, in the first stages ; as the 
 disease advances, however, the intellect yields. Continuous mutter¬ 
 ing delirium, colliquative diarrhoea, and sometimes intestinal he¬ 
 morrhage supervene (the blood in the latter instance being fluid, 
 uncoagulable and horribly offensive), under which the patient soon 
 succumbs. 
 
 Grave Remittent Fever. —(Synonyms : Congestive Fever / Per¬ 
 nicious Fever; Algid Fever) Dr. Manson continues: We now pro¬ 
 ceed to describe a grade of remittent fever that may be justly 
 ranked with the most fearful and fatal scourges which afflict hu¬ 
 manity. In the phases of this affection, predescribed, nature seems 
 to have resisted the action of the morbific cause with energy and 
 promptness, but in this the vital power seems overwhelmed and 
 powerless and, unassisted, too often surrenders. 
 
 Grave remittent may occur as a primary form of disease, or, as 
 more generally the case in this region, it commences with the 
 symptoms of mild remittent or intermittent fever, when either from 
 its natural cause, or more frequently from exposure, or improper 
 treatment, such as ill-timed depletion or purgation, it suddenly 
 presents the graver and alarming symptoms which characterize it; 
 the most conspicuous of which are a prolonged cold stage and 
 failure or disappearance of the pulse. The symptoms, however, in 
 other respects, often widely vary, and in my opinion may be classed 
 under three heads, viz: Those referable to, and arising from, a 
 perverted action of different portions of the cerebro-spinal axis, as 
 follows: 1st. Symptoms arising from congestion of the cerebrum ; 
 2d. Those arising from congestion of the cerebellum, pons varolii 
 and medulla oblongata; and 3d. Those arising from congestion of the 
 spinal cord. We deem it proper to describe the symptoms pre¬ 
 sented in all these modifications. 
 
 The phenomena which forcibly arrest the attention of the observer 
 are those presented by the state of the skin, and the pulse. The 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 15 
 
 patient is cold, the features are sharp and shrunken, and the 
 surface is shrivelled. In some cases it is merely pale, but in the 
 worst cases, the skin is of a dusky purplish hue. It may be dry, 
 but usually it is damp, or even wet, with exhalation, which is some¬ 
 times glutinous in its character; it may be deficient in sensibility, 
 to such an extent that the common external irritants, such as rube¬ 
 facients, sinapisms and blisters, produce no impression. This con¬ 
 dition of skin may exist over the whole body, but usually within my 
 observation, it does not pervade the trunk, being confined to the 
 upper and lower extremities, the nose, cheeks and ears, the rest of 
 the head and body being of febrile heat. The pulse is very fre¬ 
 quent and small, and in some rare instances disappears entirely 
 from the wrist. The respiration is more or less disturbed. The 
 patient complains of a sense of oppression about his chest; he sighs 
 often, suffers from sensations of internal heat, demands cold drink, 
 desires to be fanned, and strenuously objects to any covering being 
 placed on his clay-cold limbs. The cardiac sounds and impulse are 
 normal, and in some cases more distinct than in health when the 
 coldness of the surface is confined to the extreme parts, but when it 
 pervades the whole periphery the sounds and impulse are indistinct 
 and feeble. The strength of the patient is often remarkable, so that 
 he is able to assist himself, and even to walk about his room for 
 some time. 
 
 Diarrhoea is sometimes present, but is not a constant symptom. 
 The duration of the cold stage varies very much, but it rarely con¬ 
 tinues beyond eight or ten hours; it however may endure much 
 longer. 
 
 Exacerbation .—The reaction may be perfect or partial. The heat 
 gradually returns to the surface, and extends to the extremities; the 
 pulse becomes less frequent and more expanded; the breathing 
 becomes disembarrassed; the symptoms common to the milder 
 grade being present in ratio with the development of the febrile 
 action. This stage endures from ten to twenty-four hours, and is 
 succeeded by a stage of congestion, which in turn yields to a re¬ 
 action more or less distinct, or is fatal, the disease having a tendency 
 to terminate on the third, fifth, and seventh days mortally, or sub¬ 
 siding into the mild form, or into intermittent fever. 
 
 Congestion of the Cerebrum. The cold stage .—The patient may be 
 suddenly seized with the symptoms of inordinate sanguineous de¬ 
 termination to the superior portion of the encephalon, but usually 
 there are some premonitions. He complains of pain in the frontal 
 
16 
 
 REPORT ON 
 
 region of an acute throbbing character; the intellect is confused 
 and wandering, and he is disposed to sleep, the drowsiness gradu¬ 
 ally increasing to coma. He seems to be in a profound sleep, but 
 sometimes can be aroused by shaking forcibly, and calling aloud, 
 when he may reply in monosyllables and intelligibly, but instantly 
 sinks into stupor again. He breathes softly, regularly, and but 
 little more frequently than in health. His extremities are cold and 
 of a bluish tint, the coldness extending to the pelvis and axillae, 
 the trunk and head being of febrile warmth. In some instances the 
 whole surface is cold, but this is rare. The skin is usually dry or 
 but slightly moist, this variety not being usually attended with 
 colliquative sweat. The pulse is frequent and small. 
 
 The exacerbation .—The pulse still indicates evidences of an im¬ 
 peded circulation and rarely regains its normal volume or force, 
 the breathing becomes more accelerated, the patient grows restless, 
 and gradually regains his faculties. He now complains of cephalic 
 pain, of nausea, and occasionally vomits, and the whole surface be¬ 
 comes warm and even hot. As the exacerbation declines, the 
 patient becomes more comfortable, and himself and friends look 
 forward to a speedy convalescence; but this is a deceitful calm. 
 The cold stage recurs with aggravation of the cerebral symptoms 
 and increased prostration of the general powers. In some cases, 
 however, without assistance, the second cold stage assumes a miti¬ 
 gated character, gradually subsiding into a mild remittent, or inter¬ 
 mittent form. When the disease, however, continues unabated, the 
 third paroxysm is prone to prove fatal, but the termination may be 
 postponed to a more advanced period. 
 
 Congestion of the Cerebellum , &c. The cold stage .— Unlike the 
 variety just described, the intellectual functions in this are undis¬ 
 turbed. The patient complains of fixed pain in the occipital region, 
 is very restless, constantly shifts his position, complains of great 
 difficulty of breathing, and often declares “ he will die for want of 
 air.” He experiences a distressing sense of internal heat and op¬ 
 pression. The respiration is irregular and laborious, the expira¬ 
 tions being forcible and prolonged. (By some, these symptoms 
 have been attributed to pulmonary engorgement, but it is now 
 known, that the lungs after death very rarely present the slightest 
 indication of such a condition having existed; the dyspnoea is 
 therefore evidently owing to impeded innervation, and this pro¬ 
 ceeding from a congested condition of the vessels of the cerebellum.) 
 The skin is cold, of a purple and mottled appearance, bedewed with 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 17 
 
 moisture. This state of the surface is usually confined to the ex¬ 
 tremities, the remaining surfaces being above the natural tempera¬ 
 ture. The tongue is dusky and expanded, and in extreme cases, 
 it is cold, as well as the breath. The bowels are generally sluggish, 
 but the urine is copious and limpid. The patient often arises from 
 his bed, but his gait is tottering and unsteady , and he sometimes falls 
 to the floor suddenly, as if stricken lifeless, but instantly arises 
 again ; thereby proving that it is not simply from debility that he 
 is unable to retain the erect position, but from a loss of control over 
 his muscular movements. The pulse is very frequent and small; 
 nausea is not usually present, but the patient makes frequent efforts 
 to vomit, thinking thereby to remove the thoracic oppression. 
 Insensibility of the stomach to the action of medicine, is a promi¬ 
 nent condition in this stage, which rarely endures for more than 
 ten hours. 
 
 The exacerbation. —The reaction gradually ensues, and in propor¬ 
 tion to its development, the symptoms belonging to the cold stage 
 disappear. The respiration becomes more regular and free, the 
 pulse slower and expanded, the skin becomes warm and even hot, 
 and the pain in the occipital region mitigated; nausea and vomit¬ 
 ing are apt to ensue, and the stomach responds to the action of 
 medicine readily. Without interference the cold stage again occurs, 
 the second paroxysm often proving fatal. 
 
 Spinal Congestion. The cold stage. —This is attended with symp¬ 
 toms of a milder character, and is of shorter duration than the 
 preceding varieties of the grave form. The spinal pain is confined 
 to the dorsal and lumbar regions, and is not of an acute character, 
 save when pressure is made on the affected region. Unlike the 
 former varieties, in this the intellect is unaffected and the respira¬ 
 tion free. 
 
 The diminished temperature is usually confined to the extremi¬ 
 ties, and rarely extends beyond the knee and elbow, nor is there 
 usually present any superabundance of moisture, the cold surface 
 being dry or merely damp, the remaining surface (always excepting 
 the facial extremes) being above the natural heat. The patient 
 (in this as in the former varieties) is ignorant of the coldness of 
 the extremities, and complains of heat, is restless and suffers 
 violently from spasmodic pain in hisboivels, which are usually costive. 
 To such an extent are the abdominal pains present, that the dis¬ 
 ease has been mistaken for an attack of colic. The pulse is not 
 usually much accelerated, but is irregular during the paroxysm of 
 
18 
 
 REPORT ON 
 
 abdominal pain. This stage rarely exceeds one or two hours in 
 duration. 
 
 The exacerbation .—Although the reaction is usually decided, the 
 fever is rarely intense. The skin becomes warm and expanded, 
 and often moist. The pulse, unlike as occurs in the former varie¬ 
 ties, now usually becomes morbidly sloiv and is characteristic of this 
 phase of remittent. This condition of the pulse, unless observed 
 and counted, is apt to throw the inexperienced off their guard. I 
 have known physicians of no mean skill, declare that the patient 
 was but slightly ill, who nevertheless expired in the next paroxysm. 
 More or less tenderness will be found on pressure of the abdomen, 
 chiefly in the umbilical region, but the spasmodic pains are always 
 mitigated, and sometimes entirely disappear in this stage, which is 
 more prolonged than in the other varieties. A complete remission, 
 late in the night, or during the morning hours, often ensues, in 
 which the patient sleeps quietly, and presents so few marked indi¬ 
 cations of disease, as to attract but little attention. The cold stage 
 however reappears, attended with more aggravated symptoms. The 
 abdomen becomes enlarged and exquisitely tender, and the ago¬ 
 nizing abdominal pains return. 
 
 As the disease advances, the abdomen becomes tympanitic; serous, 
 or as is more often the case, hemorrhagic discharges ensue, the 
 blood being black, liquid, and offensive; the coldness extends over 
 the whole surface, a clammy sweat breaks out, the features become 
 cadaveric, and the patient sinks into coma and expires. The fatal 
 termination is, however, usually postponed beyond the seventh day. 
 
 Diagnosis .—A well marked case of either disease would rarely 
 be mistaken by an observer of ordinary perception; but under 
 the head of adynamic remittent, we have endeavored to depict 
 a form which bears enough resemblance to typhoid fever to be 
 often confounded with it. Like typhoid fever, adynamic remittent 
 may appear at any season of the year. It is rarely attended with 
 much acute suffering, and is protracted in its duration. The resem¬ 
 blance is rendered more striking by the evidences of abdominal 
 lesion in both, the tongue being inclined in either to be red and 
 dry, and diarrhoea aud meteorism being symptoms common to both. 
 Here, however, we think the analogy ends. In remittent there is 
 an absence of that peculiar, stupid, vacant expression, deafness, and 
 the irregular exacerbations of continued fever. 
 
 Epistaxis and sudamina, so continually present in typhoid, are 
 rare in remittent fever. The chill of remittent differs from that 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 19 
 
 of any other disease whatever. In typhoid fever, there is a pecu¬ 
 liar condition of the patient, which, as we have never seen dis- 
 cribed, we think it proper to notice. The patient complains of a 
 sensation of intense cold, and in some instances will shiver as with 
 an ague. These nervous shudderings, or instances of extreme 
 nervous irritation as we deem them, may occur frequently during 
 the day or night with great irregularity, disappearing for several 
 days together, and then returning again. So far as our observation 
 extends, these rigors are unattended with the slightest diminution 
 of the temperature of any part, the whole surface being rather 
 above the normal standard, even to the most extreme parts; indeed 
 we have noticed these paroxysms to occur in many instances, 
 when the patients were in a warm perspiration. It is worthy of 
 notice that these chills (as writers term them) are not followed by 
 any perceptible increase of febrile excitement, which is an invaria- 
 able sequent of the chill of remittent. The pulse, although fre¬ 
 quent in both diseases yet is attended with fluctuations, so differ¬ 
 ent from each other, in the respective fevers, as to present a most 
 invaluable aid in diagnosis. Cullen, Parr, Good, and others, have 
 declared that in continued fever, there are two diurnal exacerba¬ 
 tions, whilst in remittent there is only one. We have often veri¬ 
 fied the truth of their distinction, and we feel assured that in 
 doubtful cases, the peculiar character of the fever may be detected 
 by this test. The pulse should be counted at short and regular 
 intervals throughout the day and night. If the case is continued 
 fever it will rise and decline twice, the first exacerbation occur- 
 ring in the morning, and the second in the afternoon, or night. 
 In remittent, only one exacerbation will thus be discovered. 
 
 The perspiration and urine have a peculiar odor in typhoid, 
 which I have never observed in remittent fever. The intestinal 
 evacuations are infinite in their varieties, in both diseases, but 
 there is a discharge of a peculiar character in typhoid, which I 
 have never seen in remittent. It is of a shining, reddish-brown 
 appearance, about the consistence of molasses, and seems glutinous 
 in its nature, adhering to the side of the vessel, and is very offen¬ 
 sive. The viscid, green-black, inodorous, bilious evacuations, which 
 almost certainly indicate a favorable termination in remittent, I 
 have never seen in typhoid fever. In the latter disease, healthful 
 and perfect digestion often returns, and natural and consistent 
 feces are evacuated, sometimes before the disappearance of febrile 
 excitement. These we have never witnessed in remittent, until 
 
20 
 
 REPORT ON 
 
 convalescence was established. Intestinal hemorrhage is often pre¬ 
 sent during the course of typhoid fever, but as a rule, attends only 
 the termination of remittent. In the former, it is often salutary, 
 the blood being of a bright-red color, coagulable and healthy in 
 appearance. In the latter, it is fluid, black, and offensive, and is 
 usually indicative of a fatal termination. I have not thought 
 proper to recapitulate all the diagnostic signs known, which would 
 be proper in a treatise, but supererogatory in a contribution. It 
 is believed that the foregoing will almost invariably enable the 
 practitioner to detect the proper character of the case. 
 
 Treatment of Mild Remittent. In the exacerbation .—If the pulse is 
 hard or full, and resisting, especially if attended with intense cere¬ 
 bral or spinal pain, a moderate bleeding from the arm will produce 
 great relief, but this will be very rarely necessary. Local bleeding 
 will be generally found sufficient, and is an invaluable adjunct. 
 Leeches to the temple, or cups to the occipital or spinal regions, 
 may be freely applied, as the determination may indicate. If nausea 
 or vomiting, or other symptoms of gastric irritation be present, 
 leeches or cups to the epigastrium will be followed by great relief; 
 and if these should be succeeded by a simple enema, under their 
 conjoined action, the bowels will gently respond, and add greatly 
 to the comfort of the patient. 
 
 Cold drinks, ice, the effervescing draught and lemonade, may be 
 freely allowed. At bedtime—say at nine or ten o’clock—it is al¬ 
 most our invariable rule to administer a cathartic dose of calomel 
 and rhubarb, of ten or twelve grains each. At some period, before 
 or after midnight, the fever will generally be found more or less 
 to decline. We prefer this period for the commencement of the 
 abortive means, because our experience convinces us that quinine, 
 the principal remedy, is then better borne, and produces its salu¬ 
 tary effects in a more decided and complete manner, than at any 
 other time. 
 
 We now, therefore, usually administer from ten to twenty grains 
 of quinine at a single dose, in pills or diffused in a wineglassful of 
 water. We regulate the dose by the degree of fever present. 
 If it is intense, we administer the larger quantity; if very mode¬ 
 rate, the lesser will answer. Under the combined action of the 
 mercurial and quinine, free evacuation of the bowels will usually 
 occur, but rarely excessive. Three or four hours are now suffered 
 to elapse, during which the topical bleeding is repeated, if the local 
 symptoms do not yield. The condition of the patient will now be 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 21 
 
 found generally much improved. The cerebro-spinal pain is either 
 removed or mitigated, the pulse less frequent, and more soft, the 
 skin relaxed and moist, and the gastric irritation subdued. We, 
 therefore, repeat the quinine, in diminished doses of five or six 
 grains every three or four hours, until the period of chill has 
 passed, generally exhibiting from twenty-five to forty grains be¬ 
 fore that time. In cases attended with much gastric irritation, or 
 diarrhoea, the addition of a full dose of opium—say one and a half 
 to two grains, to ten or twelve grains of the submuriate, at bed¬ 
 time, instead of the rhubarb—forms an excellent combination, 
 which will enable the stomach to retain the quinine afterwards ad¬ 
 ministered, with more certainty. Under this plan, remittent fever, 
 as it appears usually in this section, is certainly and safely cured. 
 We have, in this manner, arrested the disease in many hundred 
 cases, in one night. Owing, however, to the peculiar liability of 
 the affection to relapse, or terminate in protracted intermittent, we 
 usually continue the treatment. We think it advisable to prescribe 
 a mercurial alterative of calomel or mass hydrarg. for two or three 
 successive nights, followed by eight or ten grains of quinine, or 
 twenty-five drops of oil of turpentine, in divided doses, on the suc¬ 
 ceeding mornings. In cases attended with coma, delirium, or con¬ 
 vulsions, during the exacerbation, topical bleeding will be freely 
 required, and the application of cold. We have, however, been 
 more gratified with the effects of the cold douche , in these compli¬ 
 cations, than with any other remedy. A full dose of calomel 
 should be given, followed by stimulating enemata. 
 
 In the form described under the title of adynamic remittent, 
 occurring as a primary form, this mode of treatment will usually 
 suffice; but in protracted cases, a different practice will be found 
 necessary, as quinine is not borne well, and the antiphlogistic re¬ 
 medies detailed are contra-indicated. Minute doses of calomel 
 combined with opium, will usually be found of great service along 
 with the employment of the oil of turpentine, which may almost 
 be regarded as a specific in this variety. It is more suitable in 
 this condition than quinine, as it is better tolerated; and while 
 it possesses febrifuge properties very similar to the alkaloid, 
 it also exerts a happy influence over the gastric and intestinal 
 irritation so commonly present. It may be given in doses of ten 
 to twenty drops in emulsion, repeated every three or four hours 
 until the symptoms yield. It should be persisted in until the pa¬ 
 tient is fairly under its influence, unless the effects it occasionally 
 
22 
 
 REPORT ON 
 
 produces, viz: hsematuria, strangury, or its peculiar intoxication 
 supervene, when of course it should be discontinued. It would 
 require too much space to speak of this remedy in this place as it 
 deserves. 
 
 Treatment of Grave Remittent. The cold stage .—In this grade, ex¬ 
 ternal means are all-important. W arm applications are to be 
 assiduously made to the parts reduced in temperature, together 
 with stimulating frictions. These should be freely applied to the 
 whole length of the spinal column and to the extremities. A large 
 blister should be placed over the epigastrium, and if the head is 
 affected, another to the nape of the neck. 
 
 Medicine .—To produce reaction along with these applications I 
 prefer enemata of quinine. The plan preferred is to dissolve ten 
 grains in a wineglassful of weak infusion of capsicum, with the 
 addition of a few drops of elixir vitriol. This is thrown up the 
 rectum every half hour until reaction ensues. If diarrhoea has been 
 or is present, I prefer enemata of quinine and laudanum. By these 
 means alone, cases apparently hopeless have been rescued. In a 
 case of very protracted cold stage, a combination of one grain of 
 calomel, one of quinine, and one-fourth of a grain of opium, together 
 with frequent doses of camphor water, induced a speedy reaction. 
 The oil of turpentine, in spinal congestion, is also an excellent re¬ 
 medy. Ten or fifteen drops, alone or combined with laudanum, 
 may be given every hour or two, or more frequently. 
 
 The exacerbation .—The reaction is sometimes intense. When 
 this occurs, I have ventured on the abstraction of blood from the 
 arm in moderate quantity with decided benefit; but this is seldom 
 necessary. The case only requires to be treated as the milder 
 grade, save perhaps with a more liberal use of quinine. A mode¬ 
 rate dose of calomel (ten or fifteen grains), alone or combined with 
 one or two grains of opium, if there be much gastric irritation or 
 diarrhoea, is followed in two or three hours by a full dose of qui¬ 
 nine (twenty grains), and repeated in doses of five or ten grains 
 every three or four hours, until thirty-five or forty grains are taken. 
 The medicine should be so regulated, that the last dose may be 
 taken two or three hours before the expected paroxysm. I have 
 never seen a chill or cold stage recur after forty grains of Farr’s 
 quinine has been retained. Although the patient may generally be 
 considered out of danger when the paroxysms have been arrested, 
 yet I esteem it good practice to prevent a relapse, by placing the 
 
THE EPIDEMICS OF NOETH CAROLINA. 
 
 23 
 
 patient on a gentle alterative course, and to repeat the quinine in 
 diminished quantity for several days thereafter. 
 
 The foregoing graphic and discriminating description of the 
 
 several forms of remittent fever as they appear in Granville and 
 
 the adjacent counties, may perhaps be fairly regarded as applicable 
 
 to the entire middle district of the State. Dr. Manson’s report is 
 
 silent upon the point of the comparative frequency of the graver 
 
 types of the disease. If they constitute any considerable portion 
 
 of the cases which occur, if they are not very rare exceptions to 
 
 * 
 
 the great mass of cases, it would be fair to infer that the cause or 
 causes which give rise to this form of fever, exist in greater po¬ 
 tency in the elevated region of the interior of the State, than in the 
 low paludal districts of the seaboard. It is true, that we occasion¬ 
 ally meet in the tide-water counties, but little elevated above the 
 level of the ocean, with cases corresponding exactly with his ad¬ 
 mirable delineation of the features of the graver forms of the ma¬ 
 lady ; but these cases are exceedingly few compared with the very 
 large number of the milder forms. 
 
 The congestive type of the disease, though occurring more fre¬ 
 quently in some years than in others, can hardly be said to have 
 constituted the prevailing type for many years past, if ever. 
 
 TYPHOID FEVER. 
 
 This disease first began to prevail in the interior of the State, 
 and, as well asl have been able to discover, in the counties border¬ 
 ing on the State of Virginia, and was for a long time regarded by 
 the dwellers in the low country as an up-country disease. For a 
 series of years it seemed to be limited in its range, but has gradu¬ 
 ally spread in all directions, until it has come to occupy the entire 
 area of the State, from the mountains to the seaboard; the eastern 
 or seaboard counties, being the last to be brought within the sphere 
 of its influence. It would thus appear to be but little influenced 
 by the climatic or local conditions which obtain within the boun¬ 
 daries of the State. It has made a local habitation on the very 
 summit of the Blue Kidge, and a dwelling-place in the swamps of 
 the seacoast. Neither high nor low temperature exert much influ¬ 
 ence over it, for, though the worst forms of it occur in mid-winter, 
 it also prevails during the greatest heat of the summer months. 
 
 Without entering into the vexed question of its etiology or oc¬ 
 cupying space with an attempt at the portraiture of the disease, 
 
24 
 
 REPORT ON 
 
 which has been so often and so ably depicted in its varying aspects 
 and minutest features, I proceed to report such practical matter as 
 I have been able to procure upon the subject. 
 
 Dr. M. Whitehead, of Salisbury, reports, that during the last 
 twelve months, we have been remarkably exempt from remittent 
 and intermittent fevers, but have had an epidemic of typhoid fever. 
 
 Within the last few years, the character of our fevers has under¬ 
 gone a marked change. The periodic fevers, which once main¬ 
 tained such an overwhelming preponderance in our cases, and were 
 the endemic fevers of the country, have given place, in a very great 
 degree, to this form of continued fever. > 
 
 'T have no doubt that many cases of neglected and adynamic 
 remittent, have been classed and treated as typhoid fever; yet it 
 must still be apparent to every observer, that the circle of our 
 periodical fevers is diminishing, while that of typhoid and continued 
 fever is enlarging. This may be due to an improved system of 
 agriculture, to the draining and cultivation of the. low creek and 
 swamp lands. To whatever cause it may be due, the fact at any rate 
 is obvious, that as our periodic fevers have diminished in number 
 and importance, the continued forms of fever have increased, and 
 in a great measure replaced them. 
 
 The first cases of this epidemic, occurred in the family of a gen¬ 
 tleman residing eight miles west of Salisbury, in the month of 
 February, 1858, and continued spreading over the adjacent country 
 until the month of December. During that period nearly two hun¬ 
 dred cases have been treated, in this .county and in that portion of 
 Davidson immediately adjoining. 
 
 The premonitory symptoms were well marked. General malaise , 
 Loss of appetite, disagreeable taste, white and slightly coated tongue, 
 disturbed digestion, irregularity of the bowels, sense of muscular 
 soreness and feebleness, variable pulse, dulness of intellect, head¬ 
 ache, and vertigo, invariably preceded or accompanied its com¬ 
 mencement. In a few days, the patient would complain of great 
 chilliness, or have a decided rigor, and take to his bed, not to leave 
 it again during his illness. After several hours, reaction would 
 come on, the pulse would be quick and feeble and continue so 
 throughout the attack, ranging from ninety to one hundred and 
 thirty beats in the minute. I saw some cases, in which the pulse 
 was but little above the normal standard, for weeks never exceed¬ 
 ing eighty-eight at any period of the twenty-four hours. There 
 would be two slight remissions, and two exacerbations in the 
 
THE EPIDEMICS OF NORTH CAROLINA. 25 
 
 * 
 
 twenty-four hours. This I think is always the case in continued 
 fever. 
 
 Tenderness and gurgling in the right iliac region could always 
 be found early in the attack. Day after day presented the same 
 role of symptoms, until about the eighth or ninth day, when the 
 patient would complain of slight soreness of throat, and an eruption 
 on the chest and abdomen would generally make its appearance, 
 sparsely scattered over the surface. The time at which the enteric 
 complications and cutaneous eruptions made their appearance was 
 liable to very great variations, and in some of the cases, although 
 the other symptoms were well marked, the eruption could not be 
 found, although carefully sought for. About the same time, the 
 tongue would be coated in the centre with the same creamy coat as 
 at first, slightly thickened, but the edges and tip would be fiery 
 red, and the organ itself contracted, sharp, and pointed. The abdo¬ 
 men would now become tympanitic and diarrhoea ensue, or if this 
 latter symptom were absent, the bowels evinced unusual suscepti¬ 
 bility to the influence of laxative medicines. I remember produc¬ 
 ing hypercatharsis in one case, with six grains of hydrarg. c. creta, 
 administered in two-grain doses, at intervals of three hours. 
 
 As the disease progressed, in a large majority of.the cases the 
 tongue would clean off suddenly and become red, slick, dry and 
 shining, the abdomen become more tympanitic, and its tenderness 
 increased, and the gurgling more distinct. Delirium would now 
 set in, especially at night. The patient muttered when asleep, had 
 a besotted appearance, and exhibited indifference to surrounding 
 objects; subsultus also occurred. 
 
 Some of the cases had purpura, bleeding from the gums, nostrils, 
 &c. One case literally sweat blood. In nearly all of the cases 
 there was more or less abdominal hemorrhage. One case lost, in a 
 few hours, more than two gallons of pure blood from the bowels. 
 It flowed from the rectum, as I have felt and seen it flow from the 
 vagina, in uterine hemorrhage. He bled to death in a short time. 
 
 The time occupied in the evolution of the different phases of the 
 disease and its duration, varied in different subjects, some of the 
 cases terminating in two weeks; the majority lasting six, eight, 
 ten, or twelve weeks. 
 
 This epidemic I could not but regard as contagious. Commenc¬ 
 ing on the plantation mentioned, embracing a large family of whites 
 and blacks, it spread in every direction. 
 
 Ho visitors to the house, who remained all night and assisted in 
 
26 
 
 REPORT ON 
 
 nursing the sick, escaped. The attending physician, Dr. Luckey, 
 ventured to remain one night, and in eight or ten days the premoni¬ 
 tory symptoms made their appearance; he took to his bed after a 
 decided chill, and was confined to his room eight weeks, with well- 
 marked typhoid fever. The family with which he boarded, eight 
 miles from the first patients, all took the disease from the doctor. 
 During 'the harvest, those neighbors who sent their servants to 
 assist the gentleman first alluded to in saving his grain crops, soon 
 found that they had unwittingly introduced the pestilence into 
 their own families. 
 
 In a few months, it had spread over an area of four or five square 
 miles, crept along the creeks, and crossed the river into Davidson 
 County. I have myself been long convinced of its contagious cha¬ 
 racter. This epidemic was typhoid fever, and it was unmistakably 
 contagious. Rarely indeed do our physicians see an isolated case 
 of typhoid fever in a family. 
 
 Treatment .—The treatment at first adopted was in the first stage, 
 minute doses of mercury, opium, and ipecac, with saline diaphore¬ 
 tics ; quinine during the remissions, and Dover’s powder at night 
 to procure sleep. In the second and last stages stimulants, spts. 
 of turpentine, blisters, dry cups, acet. plumbi, and opium, to restrain 
 the diarrhoea and hemorrhages, with suitable nourishment, &c. Of 
 the first eight cases so treated, four died. 
 
 In consultation with the attending physicians, we determined to 
 put the rest of the cases on the use of ten grains of chlorate of 
 potassa, every four hours; small doses of laudanum to restrain the 
 bowels, nourishing, but easily digested broth, milk toddy, and when¬ 
 ever hemorrhage or any signs of purpura appeared, as large doses 
 of muriated tinct. of iron and ol. terebinth, as the stomach would 
 tolerate. 
 
 During the prevalence of the epidemic, chlorate of potassa was 
 the main remedy in every case. Other treatment was used only 
 as auxiliary to this medicine. The drink was a cold infusion of 
 slippery-elm with ice in the first stage; towards the decline of the dis¬ 
 ease, a warm decoction of Virginia snakeroot was substituted for it. 
 
 The exact ratio of mortality I am unable to give, as I did not 
 keep notes of the cases; but I am sure it did not exceed one in 
 forty after we adopted this treatment. 
 
 I have now passed through the fourth epidemic of typhoid fever 
 since my residence in North Carolina. I have attended alone, and 
 in consultation with other physicians, a very large number of cases; 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 27 
 
 and of one thing I am perfectly convinced, and that is, that no coup 
 d'etat of professional skill or dexterity can ever suddenly arrest the 
 progress of this disease. And yet I doubt the propriety of consider¬ 
 ing typhoid fever a “self limiting” disease. Indeed, I regard it 
 as a dangerous doctrine. Too often, indeed, the physician is com¬ 
 pelled to rely upon a very limited combination of resources, yet 
 his art is of avail, in treating the complications that are so often 
 superinduced. 
 
 In the “ abortive plan I have no confidence, yet it does not fol¬ 
 low because the disease cannot be thugged by heroic doses of qui¬ 
 nine, that treatment can in nowise directly contribute to the arrest 
 or favorable modification of the malady.” 
 
 I interpret rationed medicine , not to mean a mere folding of the 
 arms—an idle watching of the disease, but the proper adaptation of 
 the proper remedy at the proper time. To control symptoms is to 
 control results and duration. 
 
 While on the one hand bad treatment may accelerate the progress 
 and fatal termination of typhoid fever, on the other hand, judicious 
 treatment may often shorten its duration, and even cure the patient. 
 
 Dr. H. Kelley, of Gold Hill, Rowan County, reports that during the 
 fall and winter (1858) “ we had a good deal of typhoid fever. There 
 were two symptoms worthy of note, as occurring in this epidemic, 
 viz: violent pain from the occiput to the cervical vertebras, con¬ 
 tinuing for several weeks in some cases, and cerebral symptoms of 
 a grave character, lasting from two or three days to six weeks, pro- 
 educing a complete blank in the memory of the patient for the time 
 of their continuance.” 
 
 “ The only deviation from the ordinary treatment of the disease, 
 consisted in the earlier administration of the ol. terebinth, than has 
 been usual with us, and in larger doses than we had been accus¬ 
 tomed to give it. I gave it in a number of cases early in the attack, 
 and continued it throughout the course of the disease, and in not 
 a single case so treated did hemorrhage occur. 
 
 “The cerebral, as well as all the other symptoms, were much miti¬ 
 gated by the use of this remedy. I do not think we should wait 
 for the supervention of that condition of the tongue described by 
 writers on the disease, as indicating its use before resorting to it; 
 but should commence its administration at an early stage of the 
 malady. 
 
 “In the majority of cases alarming hemorrhages occurred, which 
 called for large doses of astringents and opiates frequently admin- 
 
23 
 
 REPORT ON 
 
 istered. After the hemorrhage from the bowels was arrested, ob¬ 
 stinate constipation was apt to supervene, and required the repeated 
 administration of castor oil to keep them in a soluble condition. 
 Convalescence took place slowly. Notwithstanding the severit}^ 
 of this epidemic, there were comparatively few deaths.” 
 
 Dr. R. D. Dickson, of Richmond County, bordering on the State 
 of South Carolina, reports “ typhoid fever as now (1858) and for 
 several years past the prevailing form of fever in that part of the 
 State, replacing to a great extent the remittent form of fever, which 
 was previously the great endemic of the county. 
 
 tl My invariable rule, in the treatment of this form of fe ver, is to 
 avoid all active perturbating measures, especially the administration 
 of strong purgative medicines. Where such have not been pre¬ 
 viously given, I find the disease for the most part a manageable one. 
 
 “ After moving the bowels with a mild aperient, I rely, as a ge¬ 
 neral remedy, upon the steady and persevering use of the sulph. of 
 quinine in moderate doses until a mild diaphoresis is induced by 
 it. The occurrence of this symptom (diaphoresis) I regard as a very 
 favorable indication. 
 
 “ Another remedy, of great and indispensable importance in this 
 disease, is opium in some form. It is with me a leading indication 
 to procure quiet sleep for the patient every night. For this pur¬ 
 pose, I generally prefer the administration of pulv. opii et ipecac, 
 comp. The regular exhibition of suitable nourishment with good 
 nursing, may be said to constitute the remainder of the treatment 
 adopted.” 
 
 Dr. Bedford Brown, of Caswell County, reports, 11 that a very 
 general epidemic of fever prevailed in his section of the State in 
 the year 1857. It commenced about the first of July, and ended 
 late in the ensuing November. The season was characterized by 
 an unusual amount of moisture, and a temperature below the ave¬ 
 rage of summer weather generally.” 
 
 This epidemic comprised three different forms of fever, to wit, 
 genuine continued or typhoid fever; bilious remittent; and a mixed 
 form, partaking of the character of both to some extent. 
 
 The localities in which typhoid was most prevalent, were the 
 high, poor ridges, while the bottom lands, and their vicinities, gave 
 rise to remittents. The mixed form was not restricted to either 
 locality. In the selection of locality, there was manifestly an 
 existing antagonism between typhoid and remittent fever. 
 
 Neither the origin of typhoid fever, nor its extension here could 
 
THE EPIDEMICS OF NOETH CAROLINA. 
 
 29 
 
 be accounted for on the principle of contagion. Frequently a 
 number of cases would appear simultaneously in the same family, 
 without any previous communication with cases of a similar cha¬ 
 racter. We could not do otherwise than attribute it to miasmatic 
 causes, modified either by local or constitutional influences. 
 
 “The disease was unusually protracted in its duration and of a 
 low character. The progress of the epidemic was in a westerly 
 direction, and by far the largest number of cases occurred among 
 our negro population. It not unfrequently happened, that the 
 entire black portion or a family would be attacked, while the 
 white members would remain exempt from the disease, contrary to 
 our preconceived opinions. The constitution of the negro also 
 resisted the disease better than that of the whites, the mortality 
 being greater among whites than blacks in proportion to the num¬ 
 ber attacked. 
 
 “ The cases which came under my observation were seldom or 
 never on the extremes of age, and by far the largest portion were 
 males. 
 
 “During the progress of the disease, there occurred but few local 
 complications. Parotitis occurred in several instances without 
 materially influencing the progress of the case. Hemorrhage to a 
 fatal extent occurred only occasionally. Sloughing of exposed 
 parts occurred very frequently, and what is remarkable, took place 
 about the period when recovery began. 
 
 “ In regard to treatment , my chief reliance was placed on the free 
 administration of diffusible stimulants, such as the different forms 
 of alcoholic liquors, carb. ammonias, &c., and the plentiful supply 
 of nourishment, judiciously selected with a view to its digestibility 
 and the amount of concentrated nutriment it contained, and the 
 exhibition of such remedies, as were calculated to prevent the ex¬ 
 cessive drain of material from the system, through the intestinal 
 canal. 
 
 “So fully satisfied am I of the superiority of this plan of treat¬ 
 ment, that I have repeatedly asserted, among medical men and 
 others, that any given number of cases of continued fever, without 
 regard to existing variations or complications, treated by a plenti¬ 
 ful exhibition of stimulants and nourishment, with proper atten¬ 
 tion to the usual diarrhoea, would afford more successful results, 
 than all other modes of treatment combined. 
 
 “ Intercurrent inflammations are rarely to be apprehended in 
 typhoid fever. There is in this disease an over-excitement, with co- 
 3 
 
30 
 
 REPORT ON 
 
 existing loss of vital power which produces a strong predisposition 
 to local congestions with a degree of sub-inflammatory action. To 
 obviate this condition of things, stimulants have a peculiar power, 
 by invigorating the vital forces. 
 
 “I have frequently pushed this treatment to an almost incredible 
 extent, and continued it for days and weeks, when fever and de¬ 
 lirium were constantly present, with ultimate good results. 
 
 “ In those cases in which the circulation was too much excited, 
 I have frequently used the veratrum viride ) and can testify to its 
 value. 
 
 “When the pulse, as it did in some cases, became so rapid and 
 feeble as to assume the character of a ‘ fluttering pulse,’ this drug 
 would reduce it to a normal state. The oil of turpentine , so highly 
 recommended by Prof. Wood, was frequently used, but never with 
 satisfactory results in typhoid fever. The nitrate of silver and 
 chlorate of potash, have in my experience answered a better pur¬ 
 pose. 
 
 “ That form of fever which I have termed mixed , presented many 
 of the leading characteristics of typhoid, yet differed essentially 
 in some particulars. This difference consisted chiefly in the more 
 rapid march of the disease, and in a regular diurnal remission, 
 febrile exacerbations and perspiration. This form of fever yielded 
 very readily to the sulphate of quinia, whereas this medicine ex¬ 
 erted no control whatever over the progress of genuine typhoid 
 cases. 
 
 “ About the middle of November, the epidemic of typhoid fever 
 ceased, and pneumonia of a decidedly typhoid type made its ap¬ 
 pearance. 
 
 “The spring months of 1858 were comparatively healthy, but 
 about the beginning of summer whooping-cough set in, and rapidly 
 spread over the country. It proved unusually fatal to young 
 infants; the fatal complications being congestion of the brain, 
 pneumonia, and infantile remittent fever. To this last complication 
 I will make more special allusion than to the others. 
 
 “Not unfrequently, all of the children from a few months to 
 twelve years old, in a family suffering from whooping-cough, would 
 be attacked also with this form of fever. The approach of the dis¬ 
 ease was generally gradual. At first there was constipation; as 
 the disease advanced diarrhoea supervened. Tympanitis was never 
 absent, indigestion and lientery were generally present, and pro¬ 
 duced marked prostration and emaciation. The pulse was invaria- 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 31 
 
 bly rapid. There were regular daily remissions in the morning, 
 with febrile exacerbations at evening, and copious perspirations at 
 night. This free perspiration afforded no protection against a re¬ 
 currence of the same symptoms. The secretions were always vi¬ 
 tiated and depraved. In all seven cases nervous symptoms were 
 developed; the urine was scanty, and loaded with solid material. 
 
 u In regard to the treatment of this disease, I wish to speak par¬ 
 ticularly of the inestimable value of the oil of turpentine, and 
 sulphate of quinia. The first would, by acting on the universal 
 mucous surface, relieve the cough, the lienteric form of diarrhoea, 
 and the tympanitis, and finally produce a copious flow of limpid 
 urine. In some instances the quantity of urine discharged was so 
 great, that I could compare it, with truth, to the amount discharged 
 in diabetes mellitus. This was usually an index of a change in 
 the patient’s condition, and of a subsidence of the attack. The 
 quinia produced most happy effects, by relieving the paroxysms of 
 fever.” 
 
 Typhoid fever is reported as prevailing to some extent in Hyde 
 County, in 1859, by Dr. Cramer, and in Perquimans County, by 
 Dr. Coxe, and in Franklin County, by Dr. Lankford. 
 
 The two first mentioned are extreme eastern counties bordering 
 on the sea, and in an alluvial region but little elevated above the 
 level of the ocean ; the last in the middle region of the State. 
 
 On the authority of Dr. Hackett, of Wilkesboro’, I am enabled 
 to report the prevalence of typhoid fever in the county of Wilkes, 
 in the most elevated mountain region of the State. He informs 
 me that he has seen it prevailing on the very* summit of the Blue 
 Kidge, and under circumstances almost conclusively establishing 
 its contagious character and marked by decided indications of pu- 
 trescency of the fluids. 
 
 It would thus seem to be entirely independent of ordinary at¬ 
 mospheric conditions; prevailing equally and with equal intensity 
 in the rare atmosphere of the mountains, and the denser air of the 
 sea coast. \ 
 
 The foregoing facts and observations would seem to have esta¬ 
 blished the point, that by a gradual and steady progress, typhoid 
 fever has come to occupy the entire State, and that like the strictly 
 zymotic diseases, it is irrespective of climate, of season, or of any 
 known local conditions. 
 
 Like them, too, there would seem to be good grounds for con¬ 
 cluding that it is, under certain conditions, a contagious malady. 
 
32 
 
 REPORT ON 
 
 There can be no doubt but that it is the same disease which has 
 been so carefully studied and investigated in this country, by Drs. 
 Gerhard, Bartlett, Flint, and others, and by Bouis, Jenner, Budd, 
 Stokes, and Tweedie in Europe. 
 
 Into the obscure question of its etiology and pathology, it would 
 be out of place to enter in such a paper as this. The careful obser¬ 
 vations and well sifted facts of that industrious and systematic 
 observer, Dr. Jenner, have only resulted in establishing its non¬ 
 identity with typhus fever, to which in many of its features it bears 
 so strong a resemblance. 
 
 The investigations of Dr. Budd have led him to infer that the 
 intestinal lesion, which constitutes so uniform a feature in this dis¬ 
 ease, is a sort of introverted exanthem, the specific eruption of a 
 contagious disease, and the intestinal discharges, the materies morbi 
 by which it is propagated. Some of our American physicians have, 
 I think, claimed to be able to detect what they have denominated 
 the typhoid element in the intestinal discharges and to base their 
 differential diagnosis of the disease on this symptom. Such views 
 have, I think, been announced by Dr. McCaw, of Kichmond, in the 
 Virginia Medical Journal . 
 
 If, as Dr. Budd thinks, the intestinal discharges are the media by 
 which typhoid fever is propagated, the conclusion of Dr. Jenner 
 that it is not the product of idio-miasma, is subverted by the obser¬ 
 vations of Dr. Budd, who, in tracing its contagiousness to a special 
 excretion, has settled this point with regard to typhoid, quite as 
 conclusively as has yet been done with regard to typhus , the con¬ 
 tagiousness of which has not been proved to depend upon any 
 particular excretion of the diseased organism. 
 
 When typhoid fever first began to prevail in the eastern section 
 of this State, cases exhibiting the blending or commingling of this 
 type of fever with remittent fever, were by no means uncommon, 
 and in these cases it was necessary to keep in view its hybrid cha¬ 
 racter, in the treatment; for such cases could not be well managed 
 without the use of quipine. .. 
 
 Treatment. —As typhoid fever, like other diseases which run a 
 definite course, has for the most part a tendency to terminate in a 
 restoration to health, it is somewhat difficult to determine the value 
 of remedies in its treatment. 
 
 Though, as a general rule, the nimia diligentia medici is to be 
 avoided, we can still prescribe with advantage for such symptoms 
 as appear to require attention, and if many cases are injured by 
 
THE EPIDEMICS OF NORTH CAROLINA. 33 
 
 injudicious hypermedication, it is equally certain that many cases 
 would prove fatal from the neglect of a proper use of remedies at 
 the proper juncture. 
 
 Without attempting to enter in extenso into the treatment, I will 
 content myself with referring to such remedies and modes of treat¬ 
 ment as have recently been found useful, or which may possess the 
 interest of novelty. 
 
 The chlorate of potash, it will be observed, is highly recommended 
 by Dr. Whitehead, as having been of notable utility in the treat¬ 
 ment of an epidemic of this disease, which prevailed in his neigh¬ 
 borhood, and which had been marked by great fatality before this 
 medicine had been resorted to. It has since then become a popular 
 prescription throughout the State, and I believe it maintains its 
 character with the profession generally. 
 
 The oil of turpentine, too, would seem to maintain the reputation 
 which it has acquired in the treatment of the advanced stages of 
 the disease. Dr. Kelly, of Rowan, tells us that, in treating the 
 disease as it prevailed in his neighborhood, it was found useful to 
 resort to it at an early stage of the disease and to administer it in 
 larger doses than had been usual. He is of opinion that so adminis¬ 
 tered, it exerted a prophylactic power against intestinal hemor¬ 
 rhage. 
 
 Bloodletting .—That bloodletting should be mentioned at all in 
 connection with typhoid fever as a remedy, will strike many with 
 unmingled surprise. 
 
 , We must not, however, suffer our preconceived notions or our 
 hypothetical views of the disease and its proper treatment, to blind 
 us as to the existence of facts which do not accord with these views. 
 Dr. Owen Hadley, of Richmond County, writes me, that for the last 
 thirteen years, he has been in the habit of using the lancet in the 
 treatment of the typhoid fever of his section of the State. 
 
 Finding the treatment ordinarily recommended by systematic 
 and practical writers on the disease, utterly unavailing and seem¬ 
 ingly worse than useless, he was led to adopt bloodletting as 
 apparently indicated in all cases in which there were evidences of 
 cerebral excitement, and finding that he was much more successful 
 in the management of such cases than he had been before resorting 
 to bleeding, he was induced to extend its use to other cases, and 
 particularly to the hemorrhagic forms of the disease. His experi¬ 
 ence (he says) has satisfied him that hemorrhage from the bowels 
 
EEPOET ON 
 
 34 
 
 particularly, is a very rare occurrence when bleeding has been 
 practised early in the case. 
 
 However opposed to the commonly received views of the profes¬ 
 sion and the practice founded on these views, the use of the lancet 
 in typhoid fever may seem, the experience of a calm discriminating 
 observer and conscientious practitioner cannot properly be ignored. 
 
 It may be that the type of the disease which prevails in Dr. 
 Hadley’s section of the State is essentially different from the com¬ 
 monly prevailing form of the disease; or it may be that we have 
 allowed our hypothetical views of the nature and pathology of 
 the disease to influence us too strongly to the prejudice of blood¬ 
 letting. Dr. Hadley does not contend that the duration of the 
 disease is at all shortened by bleeding, but he insists upon it that 
 the severer symptoms are mitigated and the cases conducted to a 
 satisfactory termination in much larger proportion than when this 
 remedy has been omitted. So essential does he consider bloodlet¬ 
 ting in the earlier stages of the disease, that he does not hesitate to 
 pronounce it the remedy for which, in his experience, there is no 
 substitute. Where it has not been practised, he states that, in a 
 large number of cases, intestinal hemorrhage will come on in two 
 or three weeks, and three-fourths of the cases terminate fatallj 7 . 
 
 Veratrum viride .—This agent does not appear to have been ex¬ 
 tensively used in the treatment of typhoid fever in this State; at 
 least all the reports which I have received are silent upon this 
 point. Most of the cases of typhoid fever, which have fallen under 
 
 mv notice since the introduction of the verat. virid. into use as a 
 
 •/ 
 
 remedy for it, have not been characterized by any very remarkable 
 frequency of pulse, and hence the use of this drug has not apparently 
 been indicated. 
 
 Quinine .—In a disease of such protracted duration as typhoid 
 fever, the blood and tissues become impoverished in consequence 
 of the loss of the proper equilibrium, which should exist in the 
 process of repair and waste, and hence the secretions must become 
 abnormal and vitiated. 
 
 Whether it be true, as Dr. Casselberry maintains, 1 that quinine 
 supplies food for the automatic nervous system, which presides over 
 the function of nutrition, or not, its utility in the treatment of typhoid 
 fever can hardly be called in question. This invaluable medicine 
 seems to have the power of at the same time sustaining the tone of 
 
 1 Amer. Jour. Med. Sciences, April, 1858. 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 35 
 
 the nervous system, while it calms vascular excitement, and though 
 it is not entitled to the character of a specific, it can rarely be dis¬ 
 pensed with in the treatment of typhoid fever at some stage of its 
 progress. 
 
 Cold water .—Cold water must be regarded as a remedy of great 
 value in the treatment of typhoid fever. It not only adds greatly 
 to the comfort of the patient, but exerts a positive remedial agency 
 in abating the febrile excitement. As an irregular distribution of 
 heat is a notable feature in this disease, a very obvious indication 
 seems to be to endeavor to equalize it as much as possible, and I 
 know of no remedy equal to the steady use of cold water, in re¬ 
 ducing morbidly increased temperature. When the head is too 
 hot, a napkin wet with cold water should be wrapped around the 
 head. When there is inordinate heat of the abdomen or thorax, 
 similar applications should be made to them respectively. In the 
 latter stages of the disease, when there is evident bronchial compli¬ 
 cation, the application of cold water to the chest would not pro¬ 
 bably be so safe, and under such circumstances sinapisms and 
 epispastics are to be preferred. 
 
 As water is the universal solvent and depurative, it cannot be 
 dispensed with, in the early stages of the disease especially. Indeed, 
 it is indispensable in all its stages. Being the necessary vehicle 
 for the introduction of the new material to supply the waste of the 
 tissues, and for the removal of the effete material also, we are 
 constrained to regard it as the great febrifuge which nature prompts 
 us to adopt, and without which all other remedies would be of 
 little avail. 
 
 SCARLET FEVER. 
 
 Scarlatina may now be said to be one of our regular epidemics. 
 Yery few years pass, without the occurrence of sporadic cases of 
 this disease, and every three or four years we have it prevailing as 
 an epidemic. 
 
 No section.of the State can now be said to enjoy an exemption 
 from this terrible pestilence. Like typhoid fever, it was for many 
 years regarded by us of the eastern section of the State, as an up- 
 country disease, and there are now living medical men who prac¬ 
 tised their profession in the town of Wilmington for twenty-five 
 years without ever having encountered a case of scarlet fever during 
 the whole of that period. Nor are there any historical or tradition¬ 
 ary accounts of its ever having previously prevailed here. 
 
36 
 
 REPORT ON 
 
 About the year 1835, it effected a lodgement in this place and 
 lias never since entirely relinquished its hold. 
 
 Within the last five years, we have had two epidemics of 
 fever in Wilmington, of considerable severity. In both epidemics 
 the great majority of cases were of the milder type, but cases pre¬ 
 senting the disease in its most malignant form were by no means 
 rare. 
 
 Though more apt to prevail in winter and spring, I have known 
 one epidemic to extend into the summer months and reach its 
 culmination in June. It would thus seem to be quite as irrespec¬ 
 tive of season, as its congeners of the exanthematous class, rubeola 
 and variola. 
 
 While it is one of the special diseases of childhood, adults are 
 not exempt from it, and very young children, as far as my observa¬ 
 tion extends, are equally liable to it as those of a more advanced 
 age. 
 
 The number of cases which occurred in the last outbreak of scar¬ 
 latina as an epidemic in December and January, 1858, in Wilming¬ 
 ton, was not very great; but the epidemic exhibited the usual 
 variety of types, from the mildest form of scarlatina simplex to the 
 most malignant anginose variet} 7 . 
 
 The anginose affection very rarely presented the gangrenous form. 
 There was ordinarily swelling and erythematous redness of the soft 
 palate, tonsils and uvula, with patches of exudation. Difficulty of 
 deglutition, swelling of the submaxillary and cervical glands, were 
 commonly present. A yellowish pasty coating covered the tongue, 
 its edges and papillae being fiery red. A profuse secretion of 
 viscid mucus from the fauces, and a copious and acrid defluxion 
 from the nostrils occurred in most forms of the disease. The exu¬ 
 dative inflammation sometimes extended into the larynx, the patient 
 dying with all the indications of pseudo-membranous croup. In 
 a few cases the parotid gland on one side was swollen, and this soon 
 came to be regarded as a very unfavorable symptom, for recovery 
 was very rare after suppuration of this gland had taken place. 
 
 In a few cases, the disease was fatal in its incipient stages, the 
 highly poisoned blood seeming to give rise to a rapid form of ce¬ 
 rebral or cerebro-spinal meningitis with convulsions; or delirium 
 soon succeeded by coma would come oh, and the patient succumb 
 without any obvious effort on the part of the system at reaction. 
 
 Although the general features of the disease were for the most 
 part strikingly alike in all the cases, a case would occasionally 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 37 
 
 occur with some peculiar features superadded to the common role 
 of symptoms, characteristic of the malady. 
 
 Thus, in one case a tendency to sloughing exhibited itself, in a 
 well defined spot about the size of a dollar on the inside of one 
 thigh, and after the slough had separated and some expectations 
 were being entertained of the recovery of the patient, a gangre¬ 
 nous spot made its appearance on the instep of the same side, and 
 the case terminated fatally, with the supervention of anginose 
 symptoms on the twelfth day of the disease. 
 
 Dr. McKee, of Raleigh, reports in 1855, a form of scarlatina and 
 measles combined, as prevailing in that city and neighborhood. 
 His report states that so hybrid were these cases in their appear¬ 
 ance, that in some instances it was difficult to discriminate between 
 the two, or to determine which morbid element had the prepon¬ 
 derance. 
 
 In the spring and early part of the summer of 1854, a similar 
 form of the hybrid disease was of occasional occurrence in Wil¬ 
 mington. Measles was the predominant epidemic of the season, and 
 some of the cases were of an unusually severe character. 
 
 In a small number of instances, the disease assumed the con¬ 
 gestive type. The virulence or the amount of the poison seemed 
 so to prostrate the vital forces, as to preclude any effort at reaction. 
 Death seemed in such cases to be the result of an apparent paralysis 
 of the peripheral branches of the ganglionic system of nerves, and 
 of the capillary vascular system dependent upon them, and a gen¬ 
 eral coldness and lividity of the extremities, and of the entire super¬ 
 ficies of the body rapidly ushered in the fatal termination; the 
 nutritive calorific and blood-depurative functions being apparently 
 simultaneously arrested. 
 
 A large number of the cases in all of our epidemics were followed 
 by the ordinary sequelae of the disease. Anasarca and ascites were 
 not uncommon, attended with albuminuria and in some cases with 
 haematuria, indicative of great vascular congestion of the kidneys, 
 and requiring local depletion and the use of the milder diuretics 
 in its treatment. Deafness, and occasionally otorrhoea occurred as 
 sequelae; suppuration of the parotid and submaxillary glands now 
 and then occurred, with profuse suppurative discharge. 
 
 Uremic Eclampsia .—This is a very rare sequel of the disease, and 
 a very formidable one. It is more apt to follow mild than severe 
 cases of the disease. In cases in which the cutaneous efflorescence 
 is slight, the blood would seem to be less thoroughly depurated of 
 
38 
 
 REPORT. OX 
 
 its poisonous element, and severe sequelae are more apt to result. 
 These cases are marked by puffiness, or cedematous intumescence 
 of the face, and by remarkable drowsiness, almost amounting to 
 stupor. The urine is scanty in quantity, highly albuminous, turbid, 
 depositing in some cases a sooty material, having the appearance of 
 broken-down blood-globules, or there may be hsematuria, clear florid 
 blood passing off with the urine. 
 
 If this condition of the kidneys is not soon relieved by appro¬ 
 priate treatment severe convulsions follow, resembling in every 
 particular the convulsions of puerperal eclampsia. 
 
 Dr. Cox, of Perquimans County, reports the prevalence of 
 scarlet fever in his neighborhood, in the months of January and 
 February, 1858, in a mild form at first, but about the first of March 
 assuming a graver type, and diffusing itself more extensively. 
 
 In some families it assumed the malignant form, and carried off 
 its victims in a few hours from the overwhelming influence of the 
 poison on the nervous system, which completely prostrated them 
 in the first stages of the disease. In other families, the disease 
 assumed a mild form, and the patients required but little treatment. 
 ^Whichever type of the disease made its appearance in a family, 
 that type was apt to run though the family, whether it was the 
 simple, the anginose, or the malignant type. 
 
 Treatment .—As regards the treatment of scarlet fever, I have but 
 little to say. The milder forms of the disease got well with little 
 or no treatment, the severer type was not amenable to any treatment 
 I could devise. Almost all the remedies which have been recom¬ 
 mended in systematic treatises and in the periodicals have in turn 
 been tried, and with negative results in all cases. In the anginose 
 variety, bleeding, either general or local, has not been practised of 
 late years, as they have been found not only useless, but hurtful. 
 
 This was not the case when the disease first invaded this locality 
 (Wilmington) in 1835. Bleeding was then found to be decidedly 
 useful if practised early, and evidently mitigated the severity of the 
 subsequent fever. 
 
 Of late years, a tonic and supporting treatment has generally 
 been practised, and diffusible stimuli resorted to at all stages of 
 the disease. 
 
 Emetics were useful in dislodging the viscid mucus from the 
 fauces, and were generally resorted to in all cases complicated with 
 bronchitis. 
 
THE EPIDEMICS OF NORTH CAROLINA. 39 
 
 Sulph. quinine with infusion of serpentaria and capsicum was 
 occasionally used with seeming benefit. 
 
 Nitro-muriatic and acetic acid and the chlorate of potass were 
 also freely used. 
 
 But, upon the whole, the results of treatment were by no means 
 satisfactory. If the dose of the poison received into the system 
 happened to be greater than could be thrown off by the skin and 
 mucous surfaces, it was almost as certainly fatal as is the virus of 
 the crotalus or that of the cobra di capello. 
 
 CEREBRO-SPINAL MENINGITIS. 
 
 Dr. W. B. Sharpe, of Davie County, reports that this epidemic 
 appeared in his neighborhood in March, 1856, the spring succeeding 
 the first of the two cold winters, the severity of which has distin¬ 
 guished them from any others for the last fifteen years. 
 
 This epidemic to me (Dr. Sharpe) is striking. First, from its 
 novelty; secondly, from its fatal tendency; and thirdly, from the 
 rapidity with which it runs its course. The same disease prevailed 
 in 1857, but was much milder and more manageable than it was on 
 its first appearance. According to my observation, the age most 
 liable to be attacked was from fifteen to twenty-two years old ; 
 there were many younger, but not many older persons attacked. 
 Children from two years old and upwards were not exempt. 
 
 In some instances the attack was sudden, the patient at once 
 complaining of violent pain in the head, and in a short time would 
 in most cases be insensible, and in a few hours fall into convulsions, 
 death following in many cases in from six to twelve hours. In 
 other cases, especially among those from fifteen to twenty years 
 old, the patients would complain of slight pain in the head, with 
 some indisposition, for three or four days; and then would sud¬ 
 denly complain of severe pain, and fall in attempting to walk, and 
 in a short time become insensible, either talking incoherently, or 
 lying in stupor. In this condition he might remain twelve or 
 eighteen hours; but in many cases convulsions ensued earlier than 
 this, and even death. If called early, on approaching the patient 
 he would probably be found with flushed cheeks, full and bounding 
 pulse, with one eye looking a little watery and its conjunctiva 
 slightly injected and inflamed. In most cases the patient would 
 describe the pain as being confined to one side of the head, in one 
 temple, or over one eye. 
 
40 
 
 REPORT ON 
 
 If the case is about to prove successful, the patient may com¬ 
 plain of violent pain in one ear, or the eye and side of the face will 
 become swollen. Either of these occurrences (and especially the 
 latter), I hail as a favorable omen, as it is evident that the brain 
 and its membranes are being relieved, and that the disease is be¬ 
 coming external. The swelling of the face or the pain in the ear 
 soon subsides, and the patient is convalescent. 
 
 The swelling of the face (which is erysipelatous in its character), 
 is one of the best evidences that the disease of the brain is of a 
 like nature. After convulsions come on, there is no flush of the 
 cheek, and the temperature of the surface is but little if at all ele¬ 
 vated ; on the contrary it is often cool and pale, while the pulse is 
 but little affected, except as to frequency. As evidence of the 
 rapidly fatal nature of the disease, I may state that I have known 
 a young and apparently healthy lady, take a ride in the morning, 
 return, and before twelve o’clock complain of some pain in the head, 
 in a few hours become insensible, and before midnight a corpse. I 
 have also been called to a young man, who had complained of some 
 pain in the head for three or four days, and seemed indisposed to 
 move about or take exercise, or to pay attention to what was pass¬ 
 ing about him, yet give no uneasiness to his friends or family, until, 
 on the third or fourth day, he suddenly complained of violent pain 
 in the head, fell helpless and insensible to the floor, and whom I 
 found on my arrival, with one convulsion after another, continuing 
 until death. 
 
 This disease struck terror to the neighborhood when it first ap¬ 
 peared. I was myself shocked and confused with the first few 
 cases, which appeared as sudden and overwhelming as an avalanche. 
 I have seen this disease commence with the father of a family, and 
 in four days attack six children, one after another (leaving only 
 the mother and a sucking child untouched), each appearing to be 
 in perfect health an hour before the attack. 
 
 I have not been able to learn that this epidemic appeared in any 
 part of the country prior to its breaking out in this county. The 
 northern part of this county, which did not suffer from this epide¬ 
 mic in the spring of its first appearance here, was attacked in the 
 early part of the winter following. In the county north of this 
 and immediately adjoining the latter neighborhood, in the following 
 spring, it proved quite fatal. We had a recurrence of the epidemic 
 in the spring of 1857; but for the most part only in those neigh¬ 
 borhoods which were in a measure exempt during the spring of 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 41 
 
 its first appearance. It was of much milder type, showing itself 
 in many cases of swelling on one side of the face at the onset of 
 the disease. 
 
 This disease differs from ordinary inflammation of the brain and 
 its membranes'—first, in that it prevailed as an epidemic ; secondly, 
 that only one side of the head was in most of the cases complained 
 of; thirdly, that there was swelling on one side of the face, in very 
 many cases as the disease was giving way, and in some cases from 
 the onset, and especially so as the epidemic was subsiding; and 
 fourthly, that the very hot and dry skin, which is rarely wanting 
 in the first stage of ordinary inflammation of the brain, was rarely, 
 if ever, found in this disease. 
 
 I have not been able to learn much of the treatment of this epi¬ 
 demic, by the various practitioners who have had it to manage; 
 but so far as* I have learned, the treatment has been various, and 
 the success equally so. I must therefore be permitted to give my 
 own treatment of it as it appeared during the first spring of its 
 prevalence, viz., in 1856. 
 
 When called to children, if I found them rational, I usually com¬ 
 menced the treatment with an emetic of ipecac and followed this 
 with a large dose of rhubarb and calomel, directing the dose to be 
 repeated, or followed by castor oil in a few hours, if the first did 
 not act promptly and actively. After which I kept up pretty act¬ 
 ive purgation with calomel and rhubarb, and gave sudorifics in 
 the interval until the disease gave way. If I found the little pa¬ 
 tient, as I frequently did, insensible, I at once gave it a large dose 
 of calomel, and followed this in two hours with as much croton oil 
 as I thought it would bear. This, if the child had not fallen into 
 convulsions, would rarely fail to restore it to consciousness ; after 
 which a milder course of purgation was continued, until the little 
 patient was convalescent. Adults, and those over ten or twelve 
 years old, if the cheeks were flushed, the pulse full and strong, and 
 a good deal of heat of surface, I frequently bled; but I found it 
 important to be very careful in the selection of cases for the lancet. 
 To bleed while the surface was cool, although the patient was in¬ 
 sensible, was apt to prove injurious, if not fatal. 
 
 When the attack seemed violent, and especially if I found 
 the patient talking incoherently, or lying in a stupor, whether I 
 bled or not, I gave the patient at once a full dose of calomel, and 
 followed it in from two to four hours with as much croton oil as I 
 thought he would bear. This I repeated sooner or later, according 
 
42 
 
 REPOET ON 
 
 to the symptoms, but always by the next day. I think I never 
 found it necessary to give the croton oil after the second day ; then 
 a milder course of purgation, with calomel and some vegetable or 
 saline purgative was continued, with tartar emetic and sudorifics. 
 
 I could not discover that the cases which I bled did any better 
 than those which I did not bleed; but when I did not bleed, the 
 more active purgatives were used. I soon learned therefore to bleed 
 but little in this disease. Active purgatives were my chief reli¬ 
 ance. 
 
 After I had fully adopted this course and diligently and perse- 
 veringly carried it out, I had no reason to change the treatment, as 
 it was entirely successful. So far as I have been able to learn, those 
 who adopt a milder and less active course were less successful. 
 
 When convulsions have just supervened before I saw the patient 
 I at first bled, cupped, and scarified, gave croton oil and blistered 
 the occiput, but never with success, as I now remember. I finally 
 made it a rule to do but little, after convulsions had fully set in. 
 No case in my practice lasted more than twelve hours after convul¬ 
 sions came on. 
 
 The second epidemic, that of 1859, was much milder, and conse¬ 
 quently required a much less active treatment; but even here I found 
 purgative doses of calomel a very important part of the treatment. 
 In no disease which I have ever treated, have I found calomel and 
 active purgatives so imperatively demanded and so well borne. 
 
 As tinct. of chlorid. of iron is acknowledged to be a very im¬ 
 portant remedy in the treatment of ordinary erysipelas, it may be 
 asked why I did not adopt this as one of the chief medicines in the 
 treatment of this disease, which I considered to be erysipelatous in 
 its character. My answer to this would be, that owing to the deli¬ 
 cate structure of the parts attacked, their vital importance to the 
 economy, the violence of the disease, and the rapidity with which 
 it moved to a fatal result, I feared to trust a medicine so slow in 
 its effects. 
 
 I believe I might have used it to advantage in the epidemic of 
 1857, when the disease was milder and less rapid in its course. 
 The treatment, however, which I adopted after the first two or 
 three cases, in the previous epidemic, was so satisfactory in its re¬ 
 sults, that I had no reason to change it, but simply to modify ac¬ 
 cording to the diminished severity of the case or the strength of the 
 patient. 
 
 Dr. H. Kelly, in his report of the diseases most prevalent in 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 43 
 
 Iredell County in the years 1856 and ’57, makes mention of a cere- 
 bro-spinal meningitis which prevailed epidemically in that county 
 during the winter and spring of 1856. In some neighborhoods it 
 was very fatal, patients frequently dying within thirty-six hours 
 after the attack. The majority of those who died only withstood 
 it for from forty-eight to seventy-two hours. If they passed the 
 latter period convalescence took place slowly. 
 
 The treatment adopted in the early stage of the disease, was 
 bleeding, cupping, and blistering to the back of the neck and along 
 the spine. Internally, small doses of calomel and ipecac were ad¬ 
 ministered every third hour for fifteen or eighteen hours, particu¬ 
 larly if there was constipation or a want of healthy action of the 
 liver, which I always found to be the case. f 
 
 It is of the utmost importance to push the mercury to the extent 
 of producing its constitutional effects, if the disease is not speedily 
 subdued. After the inflammatory symptoms have subsided, the 
 exhibition of quinine, combined with small doses of ipecac, and 
 occasionally with opium or morphia, will do much good. Hot 
 mustard pediluvia were very serviceable in restoring warmth to 
 the cold extremities and aiding reaction. 
 
 Dr. J. J. Summered, of Salisbury, reports: “An occasional case 
 of cerebro-spinal meningitis I have now and then seen, during my 
 whole professional career (of nearly fifteen years); but only during 
 the spring of 1856 have I observed this disease to assume any¬ 
 thing of an epidemic character. 
 
 , “At that time, however, during the months of March and April 
 more especially, there was a great prevalence of what we had been 
 accustomed to call catarrhal fever ; a disease very closely resembling 
 that usually described as such in the books. Many of the children 
 and youth of the community were the subjects of its attack. 
 
 “The leading symptoms were drowsiness, heat of skin, rapid, 
 but rather feeble pulse, dry and slightly furred tongue, sordes on 
 the teeth, much prostration of the muscular strength, great oppres¬ 
 sion of the nasal passages, which were dry, and in most cases with¬ 
 out any secretion whatever, and such a turgid condition of the 
 Schneiderian mucous membrane as to render respiration through 
 the nostrils painful and difficult. 
 
 “ When aroused, the patient complained of most intense pain in 
 the region of the frontal sinuses. There were always marked 
 symptoms of catarrh, though by no means sufficient to account for 
 
44 
 
 REPORT ON 
 
 the great amount of constitutional disturbance present. The bowels 
 were generally confined, though sometimes unnaturally loose. 
 
 “ This condition of the patient would last for one, two, or three 
 days, with little or no alteration, when very generally there was 
 observed a small red spot on some part of the face, most frequently 
 on the eyelids and temporal spaces, slightly tumefied at first, but 
 increasing rapidly, and in some instances becoming so great as to 
 close the eyes in a few hours. In every case in which this swelling 
 or eruption was well marked, there was a speedy amelioration of 
 all the graver symptoms, and convalescence dated from that oc¬ 
 currence. 
 
 “This mani£estion of disease on the skin was unmistakably 
 erysipelatous in its character, and gives a satisfactory clue to the 
 nature of the epidemic. A large proportion of the cases terminated 
 with a slight erysipelatous eruption on the face; and as they every 
 one without exception recovered, this event was hailed by the 
 medical attendant as the sure ground upon which to base a favorable 
 prognosis. 
 
 “But it was not always our good fortune to behold this joyful 
 harbinger; for, occasionally, cases would occur in which there were 
 no external evidences of erysipelas, but bronchitis or pneumonia 
 would take the place of the eruption, and these cases, under judicious 
 treatment, as a general thing did well. 
 
 “ The treatment, however, most usually successful in common 
 asthenic thoracic inflammation was for the most part inadmissible 
 here, and our chief reliance in their management was on the stimu¬ 
 lating and supporting plan, modified according to circumstances, 
 and combined with such mild mercurial impressions as the asthenic 
 character of the disease would permit with safety. 
 
 “ But there was another class of cases (and it is to these that the 
 attention of the profession is particularly directed) which super¬ 
 vened upon the early symptoms described; and which, from their 
 fatal termination and the peculiar features they developed, gave 
 this epidemic its importance, and made it a subject of such deep 
 interest to the physician when it prevailed. 
 
 “ In these were developed all the leading symptoms of cerebro¬ 
 spinal meningitis. The sleep gradually advanced to coma, or the 
 pain over the brow, increasing to a most excruciating agony, soon 
 gave place to the wildest delirium. The pupils of the eyes became 
 in some cases so permanently dilated as either to destroy or greatly 
 impair the vision. In other cases they were closely contracted. 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 45 
 
 There was more or less stiffness of the muscles of the neck, and 
 a disposition to opisthotonos was observed in one case. The poor 
 victim soon lost all consciousness, and gradually sank as the func¬ 
 tions of the brain and spinal marrow were more and more deranged, 
 or, as I saw once, general convulsions ended the scene. 
 
 “Such was the termination of some of the cases of this epidemic, 
 a disease at its commencement, precisely similar to the one we are 
 accustomed to call catarrhal fever ; but widely differing in its sequo¬ 
 ias and results. It is needless to say that these brain-cases almost 
 always proved fatal. Cerebro-spinal meningitis, occurring under 
 the most favorable circumstances, is a very fatal disease ; but as it 
 presented itself in this epidemic, not one well marked and well 
 authenticated case recovered out of some twenty cases occurring 
 in the practice of the physicians of Salisbury. If there were any 
 recoveries I did not hear of them. In my own practice, there were 
 none out of six cases.” 
 
 Since the year 1856 erysipelas has prevailed more extensively 
 in Rowan and Cabarrus counties than was ever known before, but 
 cases of cerebro-spinal meningitis in any way connected with it 
 have seldom occurred. But whenever it has supervened on erysi¬ 
 pelas, if has been alike fatal, proving an opprobrium to the healing 
 art. 
 
 At first, of course, this disease gave rise to a good deal of dis¬ 
 cussion among the members of the profession and some diversity 
 of opinion as to its nature. But as opportunities for observation 
 were multiplied and the epidemic more diligently studied and care¬ 
 fully analyzed, professional belief seemed to become unanimous, that 
 these brain cases, as well as those of bronchitis and pneumonia 
 following these early symptoms of catarrh as described, were no 
 less of an erysipelatous character than were those where the erup¬ 
 tion manifested itself on the face. 
 
 The question as to why this form of inflammation of the brain 
 should be so much more fatal than the ordinary epidemics of 
 cerebro-spinal meningitis, as they have prevailed in this country 
 and in Europe, which are described in the books, finds in my mind 
 a satisfactory answer in the nature of erysipelatous inflammation. 
 
 It is not only a contagious and specific, but also an asthenic in¬ 
 flammation or disease, and is always associated with depression of 
 the vital functions and great vitiation of the blood. Every practi¬ 
 tioner will attest that erysipelas is more fatal than ordinary sthenic 
 inflammation even when it attacks the external surface, although 
 4 
 
46 
 
 REPORT ON 
 
 the pressure of the products of inflammation on important organs, 
 or their confined situation does not here necessarily offer an insur¬ 
 mountable obstacle to the curative powers of nature. But when 
 occurring in structures surrounded by unyielding bony walls in¬ 
 closing the brain, the very^ centre of life giving power, it seems to 
 me not at all surprising that this disease should prove so fatal. 
 
 I have had no opportunity of making autopsies, and therefore 
 cannot speak of the 'post-mortem appearances. But remembering 
 that the disease is erysipelas occurring within the cranium, I think 
 we may infer, that were such examination made, we should find 
 more diffuse inflammation of the membranes, greater tumefaction 
 of the tissues, and a larger amount of serum effused than in sthenic 
 inflammation, besides other products of an unorganizable nature, 
 wholly unaccompanied by any curative adhesive process. Hence, 
 we argue the almost necessarily fatal character of the disease, in 
 spite of the best directed efforts in the way of treatment. 
 
 Before closing this notice, it may not be improper to say some¬ 
 thing of the treatment pursued; and a few general remarks must 
 suffice. 
 
 When called to cases of catarrhal fever as described, at an early 
 period of the attack, an active purgative of calomel and jalap was 
 usually followed by some relief to the distinctive symptoms. The 
 impression thus made we endeavored to keep up by an occasional 
 small dose of the sub-muriate, and to moderate the force of the 
 heart’s action, by small doses of emetic tartar; or, in cases in which 
 there was irritability of the gastro-intestinal mucous membrane, 
 ipecac. 
 
 It was observed that as soon as the nasal secretion became free 
 the severe head symptoms abated in a marked degree. To assist 
 in bringing this about and to maintain it afterwards, a small flannel 
 bag, filled with fresh hops, and steeped in hot water, was laid over 
 the brow, and secured in its place by a napkin or cloth thickly folded 
 to prevent a too rapid escape of warmth and moisture. 
 
 Under such a course of treatment in the beginning, and quinine 
 in the latter stages, when the fever was remittent, as it was apt to 
 be, the patients soon recovered. When graver symptoms made 
 their appearance, constituting pneumonia or bronchitis, the treat¬ 
 ment, as before intimated, had to be conducted on the supporting 
 and stimulant plan, rather than by depletion and depressing agents. 
 
 When the membranes of the brain and spinal marrow became 
 the seat of the disease, local or general depletion, in some cases 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 47 
 
 which seemed to require it, calomel, mercurial alteratives, blisters 
 to different parts of the scalp and spine, and the hyd. potass, were 
 the remedies usually tried, but were all alike found to be unavail¬ 
 ing. The patients died in almost every such case, while the treat¬ 
 ment seemed to exercise no influence whatever in postponing the 
 fatal issue. 
 
 The muriated tincture of iron, which seems to exert an almost 
 specific influence over erysipelas occurring in other parts of the 
 body, I was deterred from using by a remark made by Professor 
 Barlow in relation to it in such cases. He says (speaking of the 
 treatment of erysipelas), u in severe cases, where there is no head 
 affection, the sesquichloride of iron, in doses of. ten minims of the 
 tincture, three or four times a day, appears to be almost a specific.” 
 
 But after some reflection on the subject, I am persuaded that 
 there is no sufficient reason for withholding the remedy, notwith¬ 
 standing the warning of the Professor; because all other modes of 
 treatment have effected next to nothing in staying its destructive 
 power. 
 
 DYSENTERY. 
 
 Dysentery, like the preceding epidemics of this State, prevails 
 throughout its entire extent, from the mountains to the sea shore. 
 Dr. Hackett, of Wilkesboro, on the summit of the Blue Ridge, de¬ 
 scribes it as a prevalent disease in that region; Dr. McKee, of Raleigh, 
 reports it occurring in the middle region of the State, while Dr. Cox, 
 of Perquimans County, in the extreme east and on the sea shore, 
 describes it as one of the ordinary epidemics of that portion of 
 the State. 
 
 The type of this disease has been a mild one for some years 
 past, at least so far as it has prevailed in this city (Wilmington) 
 and as reported to me from other localities. It is a rare thing of 
 late to meet with those formidable cases, which were of frequent 
 occurrence twenty years ago, and which approximated in severity 
 to the tropical forms of the disease, as described by Johnson and 
 Annesley. 
 
 In this locality, it prevails most generally in the months of June, 
 July, and August, and seems to be ordinarily concurrent with inter¬ 
 mittent and remittent fevers. Some of our physicians, indeed, are 
 inclined to regard it as a malarial disease, and to attribute it to 
 the same cause which they regard as productive of remittent and 
 
48 
 
 REPORT ON 
 
 intermittent fevers, with the superaddition of some modifying cir¬ 
 cumstance, which determines the expenditure of its force on the 
 mucous surface of the large intestines. 
 
 This view of its etiology can hardly be regarded as tenable at 
 present, when we consider that it prevails in the mountain district, 
 where as yet intermittents and remittents never originate spontane¬ 
 ously. 
 
 For the present, we must regard it as the result of a widely 
 spread atmospheric distemperature, or of causes which are not 
 limited to any particular locality in the State. 
 
 This disease is for the most part amenable to treatment, and 
 yields readily to a combination of laxative and anodyne medicines; 
 and as the liver is generally supposed to be implicated in the 
 morbid action which is going on in the system, mercurials are 
 usually selected as the laxative ingredients in the prescription. 
 If not used indiscriminately or pushed too far it must be admitted 
 that they are useful and perhaps at times indispensable remedies in 
 the treatment of this disease, but they are not now used as freely 
 as they formerly were in the treatment. 
 
 In some decidedly severe cases I have recently seen good results 
 from the use of large doses of ipecac, as recommended by a writer 
 in a late number of the London Lancet. By premising an opiate 
 the stomach can be made to tolerate it in large doses, by which 
 means it is rendered decidedly more efficient than when used in the 
 small nauseating doses in which it is more commonly adminis¬ 
 tered. 
 
 In the more advanced stages of the disease, bals. copaiba, in com¬ 
 bination with mucilage of gum Arabic, andtinct. opii, is found to be 
 serviceable. With some of our physicians, acet. plumb, with opium 
 is a favorite prescription under such circumstances. 
 
 CHOLERA INFANTUM. 
 
 This is one of our confirmed endemics, and is apt to ^prevail epi¬ 
 demically both in spring and autumn. Like dysentery, this is 
 regarded by many as belonging to the same generic class of maladies 
 of which intermittent and remittent fevers constitute the type. 
 There would seem, however, to be very little foundation for such 
 an opinion. The mere circumstance of their prevailing concur¬ 
 rently, can hardly be esteemed a satisfactory reason for assigning 
 to them the same origin. 
 
THE EPIDEMICS.OF NORTH CAROLINA. 
 
 49 
 
 To some extent, indeed, the same causes may be regarded as co¬ 
 operating in the production of both classes of disease. This is 
 probably true as regards high atmospheric temperature, which may 
 be regarded as essential and common to both fevers and cholera in¬ 
 fantum. Sudden changes of temperature may also be regarded as 
 equally operative in the production of both forms of disease. 
 
 Beyond these, however, there are probably no causes which can 
 be regarded as common to both classes of maladies,, and what may 
 be the occult causes which determine the one or the other form of 
 disease will probably continue to be a matter of speculation. 
 
 Of course, the time of life is one of the conditions which is pe¬ 
 culiar to cholera infantum. Errors in diet also are more directly 
 efficient exciting causes in cholera infantum than in fever, though 
 not without influence in the latter form of disease also. 
 
 In almost'all the cases of this disease, the stomach is relieved of 
 its irritating contents by spontaneous vomiting, so that the first 
 indication which generally presents itself, is to quiet the irritation 
 of that organ and of the bowels, and at the same time gently relieve 
 the latter of any offending matter which they may contain. 
 
 This may generally be accomplished, not by opiates, but by the 
 milder mercurials, such as hydrarg. c. creta, or the sub-muriate of 
 mercury. The calomel I have generally found to be most certain 
 and efficient. 
 
 After the operation of the mercurial, the treatment must consist 
 in the proper regulation of the diet, with the use of antacids, ab¬ 
 sorbents, opiates, and astringents, as may be indicated by the symp¬ 
 toms. In very severe cases, opiates are essential very early in the 
 treatment of the case; but as a general rule opiates are not pro¬ 
 ductive of benefit in the early stages. In protracted cases they 
 constitute, together with diffusible stimuli, our chief dependence. 
 
 STOMATITIS. 
 
 This disease prevailed so extensively in the early part of the 
 summer of 1858, as to be fairly entitled to the character of an epi¬ 
 demic. 
 
 The most common form which the disease assumed, was the 
 aphthous or follicular; some of the cases took the form of simple 
 erythematous inflammation of the buccal mucous membrane. 
 
 One case of the pustular variety of the disease occurred, in which 
 
50 
 
 REPORT ON 
 
 the tongue and mucous surface of the mouth were covered with 
 pustules resembling very much the pustules of variola discreta. 
 
 I saw no cases of the diphtheritic or pseudo-membranous form of 
 the disease, nor have I been able to hear of its prevalence in this 
 form in any other part of the State. 
 
 A few of the cases were attended with slight febrile disturbance 
 and headache, with gastric disorder. As there was usually some 
 constipation, a mild purgative was ordinarily prescribed, and as 
 the complaint was generally attended with symptoms indicative of 
 acidity of the stomach, the common eccoprotic rhubarb and mag¬ 
 nesia was the formula generally selected. 
 
 If the case was at all obstinate, an emetic of ipecacuanha would 
 often exert a salutary influence. 
 
 Astringent washes and the occasional use of a solution of the 
 nitrate of silver, constituted the local treatment. 
 
 It may not be amiss to notice, as evincing a very peculiar and 
 unusual epidemic constitution of the atmosphere , that about the period 
 of the prevalence of this epidemic stomatitis, a disease bearing some 
 resemblance to it, originated and prevailed very extensively among 
 domestic cattle, and among some of the ferae naturae , a form of 
 fever very fatal in its effects, and whose most striking characteristic 
 was an inflamed, ulcerated, and sometimes gangrenous condition of 
 the tongue. 
 
 Duringthe prevalence of this epidemic, the hunter very frequently 
 came across the carcasses of deer in every stage of decomposition 
 and with the characteristic black mouth. 
 
 JAUNDICE. 
 
 This disease has frequently, of late years, assumed the epidemic 
 form and prevailed extensively. The year 1847 was characterized 
 by the extensive prevalence of jaundice, in this city (Wilmington), 
 in the summer and autumnal months. There was at the same time 
 a remarkable exemption from the ordinary climatic fevers of the 
 season. 
 
 Whether the morbific cause, or causes which ordinarily produce 
 intermittent and remittent fevers, had any agency in the produc¬ 
 tion of the epidemic icterus, I will not undertake to determine. It 
 may well be regarded as highly probable that it had, inasmuch as 
 the jaundice seemed to replace the ordinary endemic diseases. 
 
 If we are correct in ascribing it to such agency, it furnishes a 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 51 
 
 rare example of the action of the morbific cause of fever, on a single 
 organ of the body. 
 
 The summer and fall of 1847 were not remarkable for any 
 striking meteorological peculiarities which ‘could account for the 
 appearance or production of the disease. Its type was for the most 
 part very mild, but few persons being confined to bed with it, and 
 in many cases it was treated by domestic remedies alone. A mild 
 mercurial cathartic or an emetic seemed to be all that was required 
 in the great majority of cases. The more obstinate cases yielded 
 to the iodide of potass. In some cases quinine was found to be a 
 useful remedy. 
 
 Dr. Whitehead, of Salisbury, reports that in September (1858), 
 an unusual number of cases of jaundice occurred in the practice of 
 the physicians of Salisbury and in the county of Rowan. The 
 first cases were amongst some negroes employed on a brickyard 
 in the suburbs, and the hands employed on the North Carolina and 
 Western Railroad. 
 
 “We soon found, from the numerous cases occurring in town and 
 county, that we had an epidemic to deal with. The first symp¬ 
 toms were great pain in the right and left hypochondriac regions, 
 extending round the body, and in some cases over the whole abdo¬ 
 men ; nausea and vomiting, bowels constipated, urine loaded with « 
 bile. Cups, mustard plasters, and warm fomentations to the abdo¬ 
 men, a large dose of calomel and opium, followed in a short time 
 with either a dose of castor oil and turpentine, or cream of tartar 
 and jalap, soon relieved the pain. 
 
 “In a few hours after the bowels were opened, the patient would 
 be jaundiced. No biliary calculi were passed that we could dis¬ 
 cover. The disease seemed to depend upon gastro-duodenal irrita¬ 
 tion, or a clogging up of the biliary ducts with inspissated bile. 
 So soon as the patient was well purged, the free use of taraxacum, 
 soda and nitre, with an occasional purgative of cream of tartar and 
 jalap, completed the cure. 
 
 “There were two fatal cases; both women in childbed. One died 
 in twenty, the other in twenty-six hours after the birth of the child. 
 Not a drop of urine was secreted in either case .after the birth of 
 the child.” 
 
 Dr. Bedford Brown, of Caswell County, reports “that jaundice 
 prevailed epidemically in that region of the State, in the year 1857, 
 accompanied in some instances with remittent fever. Active mer- 
 
52 
 
 REPORT ON 
 
 curia! cathartics, and sulph. quinine, when fever was present, usually 
 afforded relief. 
 
 U I consider this epidemic of jaundice as a line of demarcation 
 between the typhoid and active inflammatory types of morbid in¬ 
 fluences in our region. Since its disappearance, we no longer fear 
 the adoption, or doubt the propriety of using antiphlogistic reme¬ 
 dies.” 
 
 Dr. Wm. Cramer, of Beaufort, in Hyde County, reports the ex¬ 
 tensive prevalence of jaundice in that place, in autumn of the year 
 1857. He says, in the early part of November, a disease of an epi¬ 
 demic character was developed to an unusual extent. “ I think I 
 may safely say that one-half, if not two-thirds of the adult popula¬ 
 tion of this town and vicinity, are or have been affected by it. 
 This disease is jaundice. Yery few under twenty years of age have 
 been attacked ; but between twenty and thirty many, between thirty 
 and forty more, and between forty and fifty still more. 
 
 “ This disease generally came on gradually, with depression of 
 spirits, languor, and watchfulness, bowels constipated, tongue thickly 
 coated with a yellow covering, sometimes dry and whitish yellow. 
 Alvine evacuations light or clay colored. In very few cases there 
 was vomiting, in many there was nausea. Yery little pain in most 
 cases, but a sense of constriction about the epigastrium and abdo¬ 
 men (to use the expression of persons affected), as though a wide 
 band or belt was pressing against them. The urine was generally 
 very thick and muddy, and sometimes of a deep mahogany color, 
 the conjunctiva yellow, and a dusky yellowness of the whole body. 
 In some cases, there was great itching of the surface. 
 
 “ All of the cases yielded readily to treatment, and I have heard 
 of none proving fatal. 
 
 “ The usual treatment is to give a dose of comp, cathart. pills, 
 followed by rhubarb and magnesia if they fail to operate well; 
 then comp, tinct. of rhub. and aloes, twice a day, to keep the bowels 
 free. If necessary, in a day or two to repeat the pills. The first 
 operations from the pills are dark and tarry. When the evacuations 
 show bile, continue the tincture, and give acid, nitric, ten drops three 
 times a day ; sometimes a large dose of pulv. Dover! at night. In a 
 few cases I have given a full dose of calomel and Dover’s powder 
 at night, and followed it by rhubarb and magnesia in the morning. 
 
 a This disease between the early part of December and the mid¬ 
 dle of January, had nearly or quite subsided; but about the middle 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 58 
 
 of February, it commenced again, and is still prevailing at this 
 time (March) as extensively as before. 
 
 “There has been nothing in the weather which I can assign as 
 a cause for the prevalence of this form of disease. The winter has 
 been mild, with no more than the usual quantity of rain. 
 
 “ It may be proper to state, that pneumonia has been more pre¬ 
 valent than usual during the months of December, January, and 
 February, and attacked persons in preference who had been jaun¬ 
 diced. 
 
 “ In submitting the above remarks, it is natural to inquire what 
 peculiar state of things has produced this almost universal jaundice, 
 as it is certainly of very rare occurrence. 
 
 “ During the fall and early part of the winter, as stated before, 
 a universal predisposition to typhoid fever existed, producing 
 such depression of the nervous system and such torpor of all the 
 secretory organs, that the ordinary changes of temperature, aided 
 by the indolent habits of the inhabitants of this town and vicinity, 
 were sufficient to favor its development of the disease. From the 
 foregoing considerations, it is evident to my mind that jaundice, 
 when it prevails epidemically, has its origin in the brain and nerv¬ 
 ous system. The nervous energy being withheld from the mov¬ 
 ing forces of the system, the bile is either deteriorated or lessened 
 in quantity, or obstructed in its passage into the duodenum. 
 
 “In dyspepsia we find the same principle holds good. After 
 strong emotions of the mind, or after intense effort at study, or 
 dwelling intensely on one subject, the nervous energy necessary 
 to carry on the healthy operations of the stomach and digestive 
 organs is suspended, or withheld from these organs, and they are 
 all disordered and the disease readily developed. 
 
 “ Taking this view of the subject, I am led to believe that the 
 peculiar condition of the nervous systems of our citizens, from the 
 predisposition to typhoid fever, has subjected them to the disease 
 in question, from the slightest exciting causes.” 
 
 Dr. A. B. Pierce, of Halifax County, reports that there was one 
 disease which, from its rare occurrence as an epidemic, deserves 
 some notice. This disease is jaundice, which prevailed in Septem¬ 
 ber and October of 1858 in the town of Halifax. It was confined 
 almost exclusivelv to the town, and there were some twenty-five or 
 
 4/ • 
 
 thirty cases in a population of two or three hundred. From what 
 we could understand, it presented the usual characteristics of the 
 
54 
 
 KEPOKT ON 
 
 disease, only it seemed to be the essential disease, the primary affec¬ 
 tion, instead of the sequel of some other disease. 
 
 In some cases it set in with chill and fever, which lasted for 
 several days, and in others there seemed to be little or no fever 
 during the whole time of its continuance. There was scarcely any 
 form of malarial disease prevailing during the same season, with 
 the exception of a few cases of continued or typhoid fever. It is 
 worthy of remark that the first case occurred in the person of a 
 stranger who came to the place with it. 
 
 The treatment was the same usually pursued in jaundice. 
 
 PNEUMONIA. 
 
 This disease must be regarded as the great endemic of the winter 
 and spring seasons of the year, in this State, prevailing in all parts 
 of the same, whether on the seaboard, on the plains, or in the 
 mountains, and prevailing so extensively in almost every year as 
 frequently to be fairly entitled to the character of an epidemic. 
 
 It assumes, too, all the varieties of the malady known and 
 described by systematic writers, from the most exalted form of 
 sthenic inflammation to the gravest type of the adynamic and con¬ 
 gestive varieties. For the most part, of late , the type of the disease 
 has been subacute in its character, rarely acquiring the very active 
 depletory and antiphlogistic treatment which was deemed necessary 
 in years past. 
 
 The great majority of the cases now occurring may be treated 
 without resorting to the use of the lancet. Local bleeding, anti- 
 monials. and recently the verat. viride, seem to be capable of con¬ 
 trolling its progress, and yet cases are continually occurring which 
 cannot be safely or prudently managed without the use of general 
 bloodletting. 
 
 To attempt to ignore the experience of the profession in all ages 
 and in all countries, as to the efficacy of bloodletting (and its indis¬ 
 pensable necessity in some cases) in the treatment of acute inflam¬ 
 matory disorders, is altogether idle. 
 
 The deservedly high reputation of Dr. Bennett, of Edinburgh, 
 and Dr. Todd, of London, who seem to consider the use of this 
 remedy as opposed to all sound pathology, should not weigh a 
 feather in the determination of the general question, whatever 
 weight we may be disposed to give it in reference to the particular 
 
THE EPIDEMICS OF NOBTH CAKOLINA. 
 
 55 
 
 type of inflammatory diseases which have prevailed in their re¬ 
 spective localities. 
 
 It would surely be very unsafe for ns in this country to treat 
 pneumonia or pericarditis with brandy and ammonia instead of 
 bleeding and antimonials, on the authority and recommendation of 
 London and Edinburgh physicians, except in those rare cases, or 
 epidemics which now and then occur, and which are characterized 
 by prostration of the vital forces amounting almost to collapse. 
 
 We have in the veratrum viride (a medicine recently introduced 
 into practice) a remedy of great efficacy in the treatment of pneu¬ 
 monia, and one which may in many cases safely supersede the use 
 of the lancet; but certainly not in all cases. 
 
 When the inflammatory action is of a high grade, as indicated 
 by a sharp quick pulse, and great heat of skin, bloodletting both 
 general and local will, I apprehend, still be found indispensable. 
 
 I have certainly found it to be so in many cases, and I have 
 repeatedly found the veratrum to fail in the exercise of any salu¬ 
 tary influence. In one instance, even as an auxiliary measure, 
 after general and local bleeding it failed to subdue the vascular 
 excitement, although it was perseveringly used for forty-eight 
 hours. 
 
 In reference to the use of bloodletting in pneumonia, it will be 
 well for us to be governed by the wise injunction of Chomel, not 
 to treat diseases, but to treat patients affected with disease, and to 
 endeavor to adapt our remedies to the special requirements of the 
 'case before us. By so doing we will be very apt to avoid extremes 
 of opinion and practice, and fall into that “ middle way,” in which 
 safety is generally to be found. 
 
 In some cases of puerperal pneumonia occurring in my practice, 
 I have found the tinct. verat. virid. a very valuable remedy. This 
 complication is a very formidable one, the cases often proving fatal 
 under any form of treatment. 
 
 In one instance in which the lancet did not appear to be indi¬ 
 cated, the case was treated by the veratrum alone, with the excep¬ 
 tion of an occasional dose of pulv. ipecac, cp., and thus conducted to 
 a favorable issue. In another instance of the same form of pneu¬ 
 monia, it was deemed necessary to bleed freely and to repeat the 
 bleeding, after which the veratrum apparently aided materially in 
 the successful treatment of the case. Dr. Bedford Brown, of Yan¬ 
 cey ville, Caswell County, reports an epidemic of typhoid pneumonia, 
 which prevailed in the winter of 1857-8, and spring of 1858, in 
 
56 
 
 REPORT ON 
 
 that county. The paper describing this epidemic was published 
 in the Am. Journ. of Med. Sciences for October, 1858, from which I 
 extract it as presenting a rare form of the disease. 
 
 “ The winter and spring months of 1857 and 8 were characterized 
 by much wet and changeable weather, which gave rise to a very 
 extensive epidemic of malignant typhoid pneumonia. About forty 
 cases came under the observation of my partner Dr. Eoan and 
 myself. The access of the attack was generally sudden, and with 
 but little premonition; the victim having been in the apparent 
 enjoyment of health but a few hours previous. • The earliest 
 symptom was an acute pain in some part of the body, some¬ 
 times in the head or chest, shoulder, hip-joint, and occasionally in 
 the foot. This was followed in rapid succession by a distinct chill, 
 which frequently lasted for hours, and was always attended with 
 excessive vital prostration. It was not uncommon to find a patient 
 twelve hours after the first accession of the chill, with his system 
 sinking down without the first effort at reaction. The pectoral 
 symptoms were not usually troublesome. The patients complained 
 more of simple uneasiness than actual suffering or pain. In fact, 
 the nervous sensibilities were too much blunted by morbid influ¬ 
 ences to feel conscious of diseased sensations or impressions. This 
 destruction of the nervous energies and sensibilities, and want of 
 consciousness, was a remarkable feature in the disease. 
 
 “ Another alarming and constant concomitant symptom was 
 vital prostration. In many, the constitutional power seemed to be 
 too low to generate a reactive fever. Patients remained cold, 
 almost pulseless, and unconscious for days, and were only sus¬ 
 tained, even at this low point, by powerful stimulants, before any 
 improvement in the symptoms occurred. 
 
 “In all cases, without an exception, the pulse was remarkable for 
 two characteristics, extreme feebleness and diminution of volume, 
 while it varied much in frequency, often at one hundred and fifty, 
 and not unfrequently at seventy. In one patient, I observed it at 
 several of my morning visits at forty, while in the evening it 
 numbered about seventy. Frequently patients would be found 
 early in the morning without any perceptible pulse, and uncon¬ 
 scious. This I witnessed in several instances, and all reacted under 
 the influence of active and plentiful stimulation. I have never 
 observed any disease, in my own experience, in which the powers 
 of life can ebb so low and be made to flow back to a state of health. 
 
THE EPIDEMICS OF NORTH CAROLINA. 57 
 
 by the judicious and prompt administration of remedies, as typhoid 
 pneumonia. 
 
 . “Most of the cases were attended with a peculiar low remitting 
 form of fever, that had usually an exacerbation at evening, which 
 seemed to act as a stimulus to the patient and bolster him up for 
 a time; but during the night and morning a corresponding remis¬ 
 sion would come on, that invariably reduced the patient’s powers 
 proportionately low. In the appearance of the tongue there was 
 nothing constant. In some cases it was red and dry, while in 
 others it was soft, moist, and white; occasionally it was livid. 
 Diarrhoea was occasionally present. Symptoms of a nervous cha¬ 
 racter were prominently developed in nearly all cases. Low mut¬ 
 tering delirium and subsultus were very common. Stupor and 
 somnolence were almost invariably present. In one singular case 
 a paralysis confined to the muscles of deglutition, existed for 
 several days before improvement commenced. 
 
 “Among the pectoral symptoms cough was usually not trouble¬ 
 some, neither was pain in the chest complained of any great deal. 
 In many of our worst cases, both these symptoms were entirely 
 absent, or were not complained of. Dyspnoea was very distressing- 
 in only a few cases. The presence of these indications in a well 
 developed form was good evidence of a more sthenic type of pneu¬ 
 monia. 
 
 “ The expectoration in the early stages was usually composed of 
 thin bloody mucus, whilst in many others it was almost purely 
 ^sanguineous, partaking of the hemorrhagic character. The ap¬ 
 pearance of muco-purulent expectoration always denoted improve¬ 
 ment. Out of nearly fifty cases, I have witnessed but three with 
 genuine rust-colored expectoration. The presence of this matter 
 invariably indicated pneumonia of the sthenic form, and was a good 
 criterion for depletive treatment. 
 
 “ Of the physical signs, percussion elicited dulness over the whole 
 extent of the pulmonic disease. The fine crepitant rale of active 
 pneumonia I never was able to discover in the typhoid; as a 
 substitute, a coarse sub-crepitant rale generally existed; sometimes 
 in a few hours after the attack there was an absence of all sounds. 
 When improvement commenced, in place of the redux crepitation, 
 the ordinary submucous rales appeared. 
 
 “ It was a little remarkable that, in all the female patients except 
 one, there was a return of the menstrual period in a day or two 
 
58 
 
 REPORT ON - 
 
 after the attack of pneumonia. The exception spoken of did not 
 menstruate during the pneumonic attack, and died. 
 
 “ During the course of the disease, emaciation progressed with 
 great rapidity. In many, a few days sufficed to reduce the tissues 
 like an attack of Asiatic cholera. Another peculiar symptom 
 always present in the colored patients, was a dark jaundiced ap¬ 
 pearance of the sclerotic coat of the eye. 
 
 “ The evidences are strong in favor of the conclusion that much 
 of the fatality, in cases of typhoid pneumonia, is due to the poison 
 of carbonaceous matter being retained in the circulation. It is per¬ 
 fectly obvious that when, as is often the case, one-half and even 
 more than that extent, of the pulmonary circulation, is in a com¬ 
 plete state of obstruction, at least half the entire amount of blood 
 must be thrown out of the general circulation, and remain stagnant 
 in the system. 
 
 “ Another difficulty here presents itself, in the inability of the 
 heart and arteries to push the column of blood through the ob¬ 
 structed lungs. It is also probable that the vitality of both the blood 
 and capillaries, is so far annihilated in these cases, that the mutual 
 affinities between the fluids and the solids are lost, affording 
 another cause for the arrest of circulation. 
 
 “ As some proof of this theory, while the nervous and vital ener¬ 
 gies were crushed with the rapidity and force of a narcotic poison, 
 the complexion, in white patients, presented the lividity of a person 
 breathing carbonic acid gas. 
 
 “ Treatment .—The indications of treatment in these cases, were of 
 a threefold character: first, to arouse the vital energies ; secondly, 
 to push the stagnant blood through the obstructed pulmonary 
 capillaries and equalize the general circulation; and thirdly, by 
 means having a more permanent influence, to subdue the latent 
 inflammation peculiar to typhoid pneumonia. We discarded most 
 of the standard rules for treating sthenic pneumonia, and marked 
 out a course to suit the peculiar characteristics of the prevailing 
 epidemic. 
 
 “To arrest the sudden, rapid, and dangerous prostration that was 
 such an alarming feature of the disease, diffusible stimulants and 
 nourishment in the form of brandy, milk punch and ammonia were 
 administered freely and without reserve, from the beginning of the 
 treatment. Without them, some cases would have died in six 
 hours. The amount of stimulants given depended entirely on the 
 exigencies of the case. Some patients consumed a quart of brandy 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 59 
 
 per day—not for one day only, bat for many in succession, and 
 recovered without injurious consequences. 
 
 “At a morning visit, on one occasion, to a patient, I found her 
 cold, unconscious, and pulseless; brandy in ounce doses was for¬ 
 cibly poured down her throat every fifteen minutes, and under its 
 influence I could perceive the slow and gradual development of the 
 pulse, and a return of warmth to the surface. At first the pulsa¬ 
 tions numbered about twenty, and were scarcely perceptible to the 
 touch; but increasing in a few hours while I remained, they re¬ 
 covered sufficient volume and strength to sustain the patient. At 
 my next daily visit, the nurse informed me that she had given the 
 patient more than a quart of brandy by measurement, during the 
 twenty four hours, with decided benefit. This patient ultimately 
 recovered. 
 
 “It was our usual custom to administer brandy in ounce doses, 
 every hour or two according to the demands of the case. In com¬ 
 bination with stimulants, diet of the most nourishing and digestible 
 kind was as regularly enjoined as the remedies. I thought the 
 rich milk punch combined these qualities to a greater degree, and 
 suited the cases better than any other article. 
 
 “As an adjuvant to other remedies, I cannot speak too highly of 
 the carbonate of ammonia, given in large and frequent doses. It 
 appears to me to fulfil various indications, in these cases, while it 
 is a valuable diffusible stimulant, and affords a concentrated ma¬ 
 terial for assimilation and nutrition. I must place confidence in 
 , opinions lately published in regard to its influence as a solvent of 
 the plastic materials of the blood. When the vitality of both the 
 solids and fluids is reduced to as low a degree as they usually are 
 in typhoid pneumonia, the blood, after remaining for days in an 
 engorged lung, must tend to coagulation. The fact is, in many of 
 these malignant cases there is scarcely sufficient vitality to prevent 
 it. It is under these circumstances that the carb. ammonia is of 
 incalculable value. I am fully satisfied that it aids the circulation 
 through the congested pulmonic capillaries by its solvent powers. 
 
 “In most cases where the system possessed sufficient vital power 
 to react after the first chill, a very low form of remittent fever 
 was associated with the pneumonia. The pulse and animal heat 
 declined very much during the morning, but towards evening a 
 febrile exacerbation generallv occurred. This indication led to a 
 free use of quinine in combination with the other remedies, and I 
 thought with much advantage. 
 
60 
 
 REPORT ON 
 
 “In none of our typhoid cases was depletion, either local or gene¬ 
 ral, resorted to. Blisters were used in the latter stages of the dis¬ 
 ease, but with little perceptible effect. Mercury, generally in the 
 form of blue pill, was administered from the first, in all cases with¬ 
 out an exception, for the purpose of removing the latent pulmonic 
 inflammation; but as its effects were slow, the system of the pa¬ 
 tient had to be sustained by the powerful stimulation above men¬ 
 tioned, until the recurrence of the specific effects of the mercury. 
 
 “Our usual formula was pil. hydrarg. gr. iij ; sulph. quiniae gr. 
 iij; pulv. Doveri gr. ij, every three hours until the mercurial im¬ 
 pression occurred, at the same time continuing the use of stimu¬ 
 lants and nourishment. In many cases in which for days prostration 
 was so excessive as to prevent febrile reaction, as soon as the 
 specific impression of mercury was made, febrile reaction with a 
 good full pulse came on. Purgation was restrained with opiates, 
 generally in the form of Dover’s powder, or tinct. opii. 
 
 “Dr. Norwood’s tinct. of verat. virid. was resorted to in some of 
 our cases of active acute pneumonia. In such cases it is quite equal 
 to its reputation, and Dr. Norwood deserves, I think, great credit 
 for bringing it before the profession. 
 
 “One case I will mention of double pneumonia in which the pulse 
 was a hundred and fifty, but small; skin very hot, acute pain in 
 the chest on both sides, and great difficulty of breathing. The 
 tinct. of veratrum wa‘s given in four drop closes every three hours. 
 In twenty-four hours the general symptoms had so far subsided 
 that the patient considered herself well. 
 
 “On withdrawing the remedy, the same symptoms, but in a modi¬ 
 fied form, recurred again, and were a second and last time subdued 
 by the remedy. For the pneumonia of very young infants, the 
 veratrum in very minute doses was resorted to with the happiest 
 effects. For such cases, I believe it one of the safest and best 
 remedies in our possession. 
 
 “This constituted our entire treatment of nearly fifty cases of 
 typhoid pneumonia, with the loss of only one, in which the treat¬ 
 ment was too late. After apparent recovery in some cases, the 
 lung remained indurated and impervious to air for several months. 
 Iodide of potassium in large doses invariably removed the condition. 
 
 “A not inconsiderable observation of, and experience in, the 
 management of typhoid pneumonia, induces me to believe that,, 
 when treated as energetically by stimulants as we ordinarily 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 61 
 
 treat the acute form by depletion, the mortality would be about 
 equal in both forms of disease.” 
 
 Malarial Pneumonia .—A report descriptive of a form of pneu- ' 
 monia thus designated, was presented to the North Carolina Medi¬ 
 cal Society in 1857, by Dr. Otis Frederick' Manson, in which he 
 claims to have been the first to have directed the attention of the 
 profession to this particular type of the disease. 
 
 Dr. Manson remarks that “ the existence of a form of pneumonia 
 having some undefined connection with periodical fever, has long 
 been known and noticed; but unfortunately for the student of the 
 present day, the affection has not attracted the attention of recent 
 investigators, and is only cursorily and imperfectly noticed by any 
 of the modern standard authorities. The progress of pathology, 
 the advance of therapeutics, and, still more, the change of that 
 which Sydenham termed the Medical Constitution of the period, 
 render it imperatively necessary, not only for the attainment of 
 correct views of the nature of disease ; but even for the recognition 
 of its physiognomy, that its descriptions should be often revised if 
 not altogether rewritten. 
 
 “This work, to a great extent, has been accomplished in refer¬ 
 ence to diseases generally; but as this affection is chiefly seen in 
 regions, if not inimical, at least not fertile in authorship, the task 
 remains (so far as we are aware) for it unperformed. 
 
 “To supply this deficiency is 1161 the expectation of the writer- 
 but he trusts that he is enabled to afford some materials from his 
 observation which may r be of some aid to those who have not pos¬ 
 sessed his clinical advantages, and to others more competent who 
 may hereafter direct their special attention to the subject. 
 
 “In my opinion the phase of disease whose delineation is now 
 attempted, is the form of pneumonia generally seen by southern 
 observers; that its peculiarities are often unrecognized, being often 
 confounded with simple typhoid and other varieties of pulmonic 
 lesion. Not only this, but the assertion is here made, that, under 
 proper management, this disease, although of decidedly fatal tend 
 encies, is more under the control of remedial agents than any of 
 the so called phlegmasiae. 
 
 “If these declarations are true, how important is it that its fea¬ 
 tures should be familiarly known, in order that it may not be con¬ 
 founded with diseases chiefly affecting the same organ, but so unlike 
 in character and nature.” It may not be out of place here to state, 
 that the views and opinions of Dr. Manson have not been received 
 5 
 
62 
 
 REPORT ON- 
 
 without opposition. They have been especially subjected to a 
 minute analysis by Dr. W. T. Howard, of Warren ton, N. C., who 
 contends that the disease described by Dr. Manson as malarial 
 pneumonia, does not differ from the ordinary types of that disease 
 with a malarial impression superadded, and that in this form it has 
 been observed and described by numerous writers. Dr. Manson 
 continues:— 
 
 “ General course and progress .—Malarial pneumonia attacks sud¬ 
 denly, being almost invariably ushered in by a chill, which is fre¬ 
 quently of a severe intensity, and attended with rigors of variable 
 duration. In very grave cases, however, the system is prostrated 
 almost beyond the capability to react, and a prolonged cold stage is 
 the result. Death, however, rarely is produced from this cause in 
 the early stage, but fever more or less developed soon ensues. In 
 most cases the patient seems to hover for hours, and even days, be¬ 
 tween the state of chill and febrile excitement. Pain in the side of a 
 pleuritic character is generally next experienced, it being absent 
 in very few instances. To the reactive fever dyspnoea and cough 
 soon succeed. In some cases, however, the cough is tardy in its 
 appearance, or is so slight at the commencement, as to elude the 
 notice of the patient and physician. Headache, nausea, and vomit¬ 
 ing, are very frequent and prominent symptoms, and frequently 
 precede the cough and pain ; the fluids ejected from the stomach 
 being usually of a bilious character. The cough is commonly dry 
 at the commencement, or attended with an excretion of glairy mucus; 
 sooner or later, however, the sputa become more or less tinged with 
 blood, forming the pathognomonic ferruginous expectoration, the 
 hues of which are as numerous as the proportions in which blood 
 and mucus may be mingled. Thus we shall see, in some cases, the 
 latter merely tinged with blood; or, as more frequently happens, a 
 uniform thin, bloody, frothy fluid is only seen, possessing but little 
 viscidity or tenacity, whilst in some instances a pure and copious 
 haemoptysis is observed. Later, however, the expectoration is lia¬ 
 ble to great variations in color and hue ; thus it may be of the 
 various shades of brown, red, and yellow commingled, and in the 
 advanced stages may become green, or almost black. The febrile 
 action presents decided peculiarities, being usually distinctly par¬ 
 oxysmal and remittent. The remissions are, however, sometimes 
 obscure, and an active fever exists during day and night. On 
 watching the patient closely, however, a coolness of the extreme 
 parts will be almost invariably observed, generally occurring daily, 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 63 
 
 and during the morning hours. This reduction of temperature 
 may be confined to the ends of the nose, toes, and fingers, either 
 separately or combined, and in grave and rare cases may extend 
 over the entire extremities, or even the whole surface, amounting 
 to a state of collapse. This coolness of the skin is not generally 
 felt by the patient, but on the contrary, when it is present, he often 
 complains most intensely of sensations of excessive internal heat, 
 soliciting the introduction of cold air into his chamber; and as we 
 have witnessed, wishing the doors and windows to be opened, and 
 the fires extinguished w r hen the thermometer stood below the freez¬ 
 ing point near the bed of the sufferer. A marked increase of fever 
 follows this insensible chill, which continues to increase in intensity, 
 until an exacerbation more or less perfect is developed. The pulse, 
 which had been very frequent and contracted in the chill, becomes 
 expanded, acquires force, and sometimes, though rarely, becomes 
 full or tense. The term compressible applies to the usual condition 
 of the pulse, and the idea entertained on its careful examination is, 
 that the heart is acting with only a seeming force, and not with 
 real vigor. In some few cases, the pulse has been observed to be 
 nearly normal or morbidly slow. 
 
 “ The respiration in the chill is more frequent and the dyspnoea 
 more urgent than in the exacerbation. The breathing is usually 
 irregular on account of the pleuritic pain, but when this is absent, 
 or has been relieved, the respiration is often but slightly embarrassed 
 in severe cases in the early stage. 
 
 “ The disease continuing unchecked, the paroxysms usually be¬ 
 come less marked, the respiration becomes more continuously 
 frequent and difficult, the acts often exceeding sixty per minute; 
 yet, in some cases of a grave character, the breathing is scarcely 
 accelerated during the whole course of the disease. A new symp¬ 
 tom now sets in. The patient, who before may have been entirely 
 rational, or slightly incoherent in sleep, or at the heights of the 
 exacerbation, suddenly becomes wildly and persistently delirious. 
 
 u The cough now often ceases, the patient often breathing appa¬ 
 rently better than when in a more hopeful condition. The tongue 
 becomes brown or black and dry, sordes collect on the teeth, and 
 the skin and sclerotica assume a jaundiced hue. The delirium 
 increases in intensity, the patient growing almost uncontrollable, 
 and requiring force to keep him in bed; and, when not watched, 
 rushing out of the house when nearly pulseless and cold. Quiet 
 
64 
 
 REPORT ON 
 
 only succeeds to this raving to be quickly succeeded by the curtain 
 falling on the last scene in the agonizing drama. 
 
 “ Such are the usual phenomena presented by this affection, 
 when left to the unassisted efforts of nature. Death, however, 
 sometimes occurs evidently from the embarrassed functions of the 
 lungs, as in cases of the idiopathic disease, produced by an im¬ 
 permeable condition of its parenchyma. 
 
 “ The termination in health is marked by the gradual diminution 
 of the symptoms, by the occurrence of diaphoresis, by a copious 
 secretion of urine, and yet more often, by the discharge of greenish- 
 black, viscid, inodorous stools, closely resembling tar in appearance. 
 The passages by degrees become of a lighter color, passing through 
 shades of green and yellow, until they assume the natural hue. 
 The expectoration becomes less colored, the sputa becoming more 
 homogeneous, and gradually assuming the smooth straw colored 
 appearance characteristic of the resolution of pulmonic inflam¬ 
 mations. 
 
 “The disease, however, sometimes becomes chronic, with copious 
 purulent expectoration mingled with blood, the patient passing 
 into hectic, with the rational symptoms of phthisis, terminating in 
 death. In more fortunate cases, the disease, after many weeks, and 
 even months’ duration, may give place to entire restoration to 
 health. 
 
 “ Physical signs and physical changes. First stage. Engorgement or 
 active congestion. —Advancing no claims to expertness in physical 
 diagnosis, I feel a great hesitation in expressing my opinion in re¬ 
 gard to the import and value of morbid sounds in this affection. 
 I feel it my duty, however, to say that the crepitous rlionchus 
 regarded by Laennec and his imitators, as the earliest pathogno¬ 
 monic sign of pneumonic inflammation in general, is not usually 
 present at the commencement, nor, indeed, at any of the stages of this 
 disease. 
 
 “ That it is sometimes heard, we know, but that it is so commonly 
 observed as to possess alone any very important signification in 
 estimating the extent, precise seat, or gravity of the disease, I do 
 not with my present experience believe. 
 
 “ Its pathognomonic value, called into question, at the time of its* 
 promulgation, by Andral, Chomel, Cruveilhier, and others, has been 
 more recently and strenuously contested by Stokes and the celebrated 
 professor Skoda, of the school of Vienna. I therefore feel more 
 confidence in candidly expressing my views. 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 65 
 
 “It is difficult, after perusing the works of Laennec, Williams, 
 Walsh, Barth, and Roger, and others, and observing the positive 
 declarations made by them, in regard to the existence and value of 
 this sound, to withhold a belief in their statements. On the other 
 hand, it is equalty impossible to consult the distinguished authori¬ 
 ties, above cited, without being convinced that they are penned by 
 skilful and truthful observers. I do not know how these conflict¬ 
 ing views can be reconciled, save by the supposition that their 
 authors were observing different forms of pneumonic lesion. 
 
 “If the peculiar variety of pneumonia now under consideration, 
 or, if this phrase is objectionable, if the condition of the organism 
 with which inflammation of the substance of the lungs in the 
 present disease is found associated, is widely different from that 
 described by the majority of authors, then it is reasonable to 
 suppose that some diversity in the physical signs should be ob¬ 
 served. 
 
 “ If in this disease, as we shall contend, the pathological condition 
 of the lung usually partakes more of the character of congestion 
 than open inflammatory action, then the absence of crepitation may 
 be explained without impeaching the testimony of those who have 
 sought to affix it to the first stage of pneumonia as the diagnostic 
 sound. The presence of crepitating rale is justly and reasonably 
 ascribed to the passage of air through the viscid pathognomonic 
 secretion in the air cells and minute bronchi; that secretion being 
 considered the result of inflammation. 
 
 * “Now, although this fluid, as proven by its expectoration, is 
 present in all varieties of pneumonia, yet it is usually more fluid 
 and more sanguineous in this than in simple pneumonia, and we 
 should, therefore, rationally conclude that the passage of air through 
 fluids of varying tenacity, density, and composition, would produce 
 sounds of varying character. 1 Again, it often occurs in the early 
 stages of this affection, that the cough is unattended with expecto¬ 
 ration for several days; indeed, we have seen cases of the most 
 violent character terminating in death by apnoea, with expectoration 
 scarcely sufficient in quantity to betray the character of the affec¬ 
 tion ; the cough being dry throughout and the dyspnoea extreme. 
 
 “ How in these cases we should be prepared to learn that no 
 crepitation would be heard, or if observed, not in proportion to the 
 extent or gravity of the pulmonary lesion. Again, in describing 
 
 1 Laennec himself only cites two cases of this form of pneumonia, in which the 
 glutinous sputa and crepitous rhonchus were observed. [Forbes’ Translation, 219.] 
 
66 
 
 REPORT ON 
 
 the anatomical characters of pneumonia, Laennec 1 admits, that 
 inflammation of the bronchi is a frequent attendant on the simple 
 form, its lining membrane being commonly very red, occasionally 
 swollen, the redness sometimes extending over the whole bronchi. 
 
 “Now if this be true, and who will gainsay it, how is it possible 
 that sonorous, sibilous and mucous rhoncbi, should not be often 
 heard, as maintained by Skoda, 2 and if present, drowning, accord¬ 
 ing to Andral, 3 the less audible sound of crepitation ? But, as has 
 been premised, as the anatomical character of this affection is doubt¬ 
 less an intense congestion of the parenchyma, associated, perhaps, 
 in some degree with inflammation, it is probable that the absence 
 of crepitation, in the large majority of cases, may be thus explained. 
 In the first stage of this disease, we may have, therefore, the 
 crepitating rale or mucous rales, in varying degrees, accordingly 
 as the character of the case may partake of inflammation or active 
 engorgement. 
 
 “ In many cases, however, the practitioner will fail to observe 
 any morbid sound, although the concurrent symptoms may render 
 the diagnosis positive. In these instances the crepitating rale may 
 sometimes be elicited by engaging the patient to cough forcibly, as 
 advised by Barth and Boger. Although as I believe crepitation 
 is neither pathognomonic, at least of this variety of pneumonia, or 
 confined to inflammatory affections of the parenchyma, being sim¬ 
 ply the sound produced by the passage of'air through a'viscid 
 fluid in minute tubes ; yet, when present, its importance should not 
 be undervalued, as when taken in connection with other signs and 
 symptoms it affords a valuable aid to diagnosis. 
 
 “ There are, however, as has been already indicated, other sounds 
 observed in the first stage of this disease. Early in the invasion, 
 in some cases on the first day of its existence, there is a copious 
 sero-sanguineous secretionor exhalation present, obstructing the cur¬ 
 rent of air in the bronchi, trachea, and larynx. In these instances, 
 therefore, we have abundant bronchial, tracheal, and laryngeal 
 rales, which may often be heard at some distance from the patient. 
 On the other hand, as we have observed, all sounds indicative of 
 disease are absent. Dyspnoea, pain, cough, peculiar sputa, and every 
 other symptom may be present, yet no sound save the vesicular 
 murmur, perhaps louder than in health, is heard, the chest being at 
 the same time clearly resonant on percussion. 
 
 1 Forbes’ Translation, 220. 2 Ibid., 306. 3 Note to Laennec, 246. 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 67 
 
 “In these cases the pneumonia is either central, or the secretion 
 in the air-cells and finer branches of the bronchi may not be pre¬ 
 sent in quantity sufficient to offer any obstacle to the passage of 
 air. Whatever explanation, however, may be offered, I am fully 
 persuaded, after careful exploration of the chests in many cases 
 daily and hourly made, that at least in the early stage of this form 
 of pneumonia no abnormal sounds can be observed. 
 
 “ Second stage. Solidification , Hepatization .—These terms are 
 synonymously used to denote that condition of the lung in pneu¬ 
 monia, in which it is no longer permeable to the air, but doubtless 
 too often indiscriminately used. In this affection, as we have 
 repeated and shall endeavor to maintain, the state of the lung pa¬ 
 renchyma partakes more of the character of congestion than active 
 inflammation. There can be but little doubt but that, in a great 
 proportion of cases, some degree of inflammation exists, as proven 
 by the presence of fixed pain, the peculiar sputa and other symp¬ 
 toms; but as we have premised, the expectoration is of a different 
 character, partaking more of the appearance of diluted blood or of 
 a sero-sanguineous nature. 
 
 “When therefore perfect dulness on percussion, and absence of 
 the respiratory sounds, betoken condensation of the lung in this 
 disease, it is not in my opinion due to an inflammatory process 
 with lymph effusion, as in the frank form of pneumonia, and to 
 which the term hepatization has been properly applied. We shall 
 endeavor to substantiate these views, when the nature of this affec¬ 
 tion is considered. 
 
 ‘‘ Lungs, says Walshe, which the naked eye would judge to be in 
 the same condition, in regard to their shares of air, fluid, and semi¬ 
 plastic substance, it is evident acoustically are in different physical 
 states; specimens of parenchyma apparently identical are, in re¬ 
 ality, widely different. In estimating the conducting power of 
 lungs, there can be but little doubt that varying homogeneousness 
 is a more important element than any so called ‘solidification in 
 pneumonia.’ 
 
 “ ‘ Dulness,’says Blakiston, 1 ‘will result from sanguineous con¬ 
 gestion of the cellular portion of the lungs in contact with the 
 walls of the thorax, whether of a passive character, being the re¬ 
 sult of obstruction to the circulation, or of an active character, as 
 in the early stages of pneumonia.’ 2 Andral considered hepatiza- 
 
 1 Pract. Observat. Dis. Chest, 37. 
 
 2 Patliol. Anat., vol. i. 511. 
 
68 
 
 REPORT ON 
 
 tion to arise from congestion of blood, and not from lymph effusion, 
 and in this opinion Stokes also concurs. 1 Blakiston we think rea 
 sonably concludes, and cites experiments in proof, that in pneu¬ 
 monia there are two forms of solidification, one of which is 
 produced by congestion, and the second by deposition of lymph.’ 
 
 “ Percussion signs of solidification .—‘ The thoracic walls,’ says 
 Skoda, ‘beneath which the hepatized lung lies, yield a dull percus¬ 
 sion sound, and their resistance is increased, provided the hepatized 
 portion of the lung has the thickness of about an inch, and an 
 extent greater than that of a pleximeter. The more extensive - the 
 hepatization, the duller is the sound, and the greater the resistance. 
 If the sound is completely flat, as elicited in striking the thigh, then 
 the lung is solidified throughout its whole thickness.’ 
 
 “ Auscultatory signs .—According to Laennec, in hepatization, the 
 crepitous rhonchus and vesicular murmur are absent in the affected 
 part, and this is frequently the only proof afforded of solidification 
 having occurred, bronchophony existing in certain cases, if the 
 inflammation is seated near the roots of the lungs, or in the su¬ 
 perior lobes, where the bronchial tubes are largest. When the pneu¬ 
 monia is central, bronchophony is absent or obscure, becoming 
 more manifest if the inflammation approaches the surface of the 
 lungs; this being easily accounted for, he observes, as a hepatized 
 lung is a better conductor of sound than a healthy one, broncho¬ 
 phony being nothing more than the resonance of the voice within 
 the bronchi of the inflamed part. 
 
 “Bronchial respiration and bronchial cough, according to the 
 same author, always accompany bronchophony, and when the he¬ 
 patization is near the surface and involves within it bronchial tubes 
 of considerable size, then it is frequently accompanied by a sensa¬ 
 tion of blowing into the ear (,souffle dans Voreille) and if a thin por¬ 
 tion of pulmonary substance not yet hepatized intervenes between 
 the ear and the affected bronchi, the sensation denominated the 
 veiled puff (souffle voile) is produced. 
 
 “ The auscultatory sounds as described by Skoda more nearly 
 accord with my limited experience. I however do not feel com¬ 
 petent to pronounce on the correctness of his theory of conso¬ 
 nance. He says, ‘ When the hepatized portion is extensive enough 
 to contain within it at least one of the larger bronchial tubes, and 
 if the tube contains air, is not obstructed and communicates with 
 
 1 Dis. Chest, 286. 
 
THE EPIDEMICS OF N0RTH CAROLINA. 
 
 69 
 
 the trachea, then the voice of the patient will consonate in the 
 bronchial tube and be heard either as loud or weak bronchophony 
 over those parts nearest the tube.’ 
 
 “ The respiratory sounds vary according to the nature of the 
 rales, in the larynx, trachea, or bronchi, through which the air must 
 pass before it enters the bronchial tube surrounded by the hepa- 
 tized tissue. The respiratory murmur may alone be heard, or, in 
 addition to this, hissing, whistling, and sonorous sounds, either 
 * separately or combined. If the hepatized portion of the lung be 
 not large enough to contain one of the larger bronchial tubes, or 
 if it be large enough, but the tube be filled with fluid or solid 
 matters, or if the communication between the tube and the trachea 
 be obstructed by mucus, blood, &c., then neither bronchophony nor 
 bronchial breathing, nor high, clear rales nor hissing, whistling, or 
 sonorous sounds, will be heard over the hepatized lung; the patient’s 
 voice will be inaudible , or recognizable onlv as a dull muttering, 
 and the respiratory murmur indistinct or absent. 
 
 “ Whether the explanation of Skoda is correct or not, I cannot 
 say, but certainly, in a large majority of my cases, neither broncho¬ 
 phony, bronchial breathing, or bronchial cough have been observed. 
 I am inclined, however, to attribute their absence to the fact, that 
 in this variety of pneumonia, the impermeability of the lung being 
 due to excessive engorgement, and not to lymph exudation, it, 
 therefore, does not possess the requisite density to make it a good 
 conductor of sound. 
 
 “ Third stage. Purulent infiltration. —This is a very rare termi¬ 
 nation in this form of pneumonia. When present, the physical 
 signs do hot differ from those of solidification. A well marked 
 case of this condition came under my care, which was attended with 
 copious purulent expectoration tinged with blood, being of a yel¬ 
 lowish-pink hue, the quantity evacuated being at least two pounds 
 per day for several consecutive days. Laryngeal, tracheal, and 
 bronchial rales were distinctly heard at a distance of several feet 
 from the patient. Percussion yielded a dull flat sound over the 
 whole thorax, below the fourth rib, on each side beneath which no 
 sound of the voice, cough, or respiration could be heard. Above 
 this line percussion yielded a clear sound, and the ear discovered a 
 coarse humid rhonchus with large bubbles, evidently due, like the 
 sound in the windpipe above, to the passage of air through the 
 abundant purulent secretion. 
 
 “ Signs of resolution. —When this occurs, according to Laennec, 
 
70 
 
 REPORT ON 
 
 in the first stage, the crepitous rhonchus becomes daily less per¬ 
 ceptible, and gradually yields to the normal respiratory murmur. 
 When hepatization has taken place, its resolution is announced by 
 the return of the crepitous rhonchus ( rale crepitant de retour rhon¬ 
 chus, rhonchus crepitans redux). Skoda, on the other hand, maintains, 
 and his views accord with my own observation, that the period of 
 resolution is not invariably attended with the appearance of the 
 crepitating rale, but in most cases is accompanied with a great 
 variety of rales, or by whistling, hissing, and sonorous sounds. 
 
 “In some rare cases, he adds, no rales whatever appear during 
 resolution, the bronchial breathing being at first indeterminate and 
 at last vesicular. £ The crepitating rale, or a rale resembling it,’ he 
 adds, is heard during the resolution of moderately severe cases of 
 pneumonia; it is also occasionally observed in severe cases at a 
 more advanced period of the resolution, when the secretion has 
 become scanty. 
 
 “ In the greater number of cases, the vesicular breathing does 
 not return immediately upon the resolution of the disease; but we 
 generally find, after all the functions are restored to their healthy 
 condition, and percussion no longer yields any abnormal sound, 
 that the respiration still remains indeterminate, or that the rales, 
 or hissing, whistling, and sonorous sounds continue. 
 
 “ Auscultation yields the same sound when the resolution is in¬ 
 complete.” In conclusion, the distinguished author sums up: “ It 
 follows, from the above, that the presence of pneumonia cannot be 
 determined by the auscultatory signs alone; that these are often 
 very indefinite, and that bronchophony, bronchial breathing, and 
 other sounds, as well as vesicular breathing, and fine equal bub- 
 ling rales, are signs which of themselves do not enable us to draw 
 accurate conclusions as to the condition of the lung parenchyma. 
 In forming our diagnosis, we must also take into consideration 
 every other symptom attainable by percussion, and by other means 
 at our command. 
 
 “ Diagnosis between Malarial and other Forms of Pneumonia. —The 
 varieties of pneumonia with which this affection is most liable to 
 be confounded, are simple or idiopathic pneumonia and typhoid 
 pneumonia. I shall, therefore, be necessarily compelled, in order 
 to institute a comparison between these disorders, to glance at their 
 predominant characteristics. I shall do this with all the brevity 
 which the importance of the subject and my faculty of condensation 
 will allow me to use. 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 71 
 
 n Simple Pneumonia .—The celebrated Cullen, whose descriptions 
 of the rational symptoms of diseases were masterpieces of faithful 
 delineation, and who doubtless drew his pictures from this form of 
 pneumonia, says: ‘Pneumonic inflammation, however various in its 
 seat, seems to me to be always known, and distinguished by the 
 following symptoms : pyrexia, difficult breathing, cough and pain in 
 some part of the thorax; and that, for the most part, the pulse is 
 frequent, full, strong, hard, and quick.’ 
 
 “ This portrait of the affection continued to be the principal 
 guide, from the time in which he wrote until the occurrence of the 
 modern discoveries in pathological anatomy and physical diagnosis. 
 To the symptoms laid down by Cullen, we have, therefore, the im¬ 
 portant aids furnished by those valuable additions to our science. 
 In drawing a comparison thus far between the general symptoms 
 of these affections, we perceive at once a close resemblance, which 
 would amount to identity, were it not for the dissimilarity in the 
 character and variations of the pulse, that in malarial pneumonia 
 being frequent, soft, of moderate fulness, compressible, and never 
 or rarely very full, tense, or hard. Nor is the circulation in simple 
 pneumonia subject to the same diurnal variations. It is true, that 
 writers aver that in some cases of the latter form, the fever is some¬ 
 times evidently remittent; but granting that those cases did not 
 belong to the malarial disease (though we strongly suspect the con¬ 
 trary), still I think that a marked paroxysmal character is seldom 
 or never observed in the simple form. 
 
 “The regularly recurring cold stage is another guide to discrimi¬ 
 nation, seldom absent in the malarial affection, whilst in the frank 
 form, the skin is uniformly of an elevated temperature in the great 
 proportion of cases, generally being hot and dry, at all periods of 
 the day and night, whilst in the exacerbation of the former disease, 
 the heat is more moderate, and is subject to a daily decline in the 
 remission, which occurs immediately before the reappearance of 
 the chill. The evidence of hepatic and gastric disorders has 
 gained for the malarial form the epithet of ‘ bilious,’ and although 
 we utterly reject that view of its pathology, which associates either 
 this disease or any form of malarial disease necessarily with hepatic 
 lesion, save as regards the occurrence of the latter, as a secondary 
 affection of minor importance, yet the frequent presence of nausea 
 and bilious vomiting, in several cases, will doubtless afford some 
 aid to diagnosis ; those hepatic symptoms dependent on sympathy 
 
72 
 
 REPORT ON 
 
 of contiguity, when the inferior lobe of the right lung is impli¬ 
 cated, in pure pneumonia, being of exceptional occurrence. 
 
 “The condition of the bowels in this disease and the latter is also 
 different. In the malarial form the intestinal canal seems generally 
 to be in a state of phlogosis or exalted sensibility. This is mani¬ 
 fested by the frequent presence of diarrhoea; and when this is not 
 evident, by the hypercatharsis often induced by the mildest aperi¬ 
 ents. Later, when the disease succumbs, convalescence is usually 
 announced, by those characteristic, and we may say critical, alvine 
 evacuations before described. 
 
 “The expectoration is often very different in the two diseases. 
 In this it is usually less viscid, less copious, and more fluid, par¬ 
 taking more of the character of blood mingled with serum; in fine,* 
 presenting more of the character of a defibrinized blood than the 
 usual product of inflammatory action. 
 
 “The presence of delirium is more common in the malarial than 
 in the simple form. In the former it is usually distinctly intermit¬ 
 tent or remittent in the early stages. At that period it also is 
 usually mild in its character, the patient seeming to be in a state be¬ 
 tween sleep and awake, muttering incoherent and rapidly changing 
 fancies, but when fully aroused and his attention directed, replying 
 in a rational manner. 
 
 “ The delirium is evidently of a neuralgic character, being often 
 attended with a cool skin and feeble pulse, with no other symptom 
 belonging to organic cerebral lesion, and like the hallucinations 
 of delirium tremens, to which it bears many and striking resem¬ 
 blances, is relieved by sleep to recur again, however, in the febrile 
 paroxysm. Delirium, however, supervenes under other circum¬ 
 stances, which although we have already noticed, constitute such 
 an important feature as will excuse a repetition. 
 
 “ Often, without any previous cerebral symptom whatsoever, 
 after the pneumonic symptoms have been mitigated, or have en¬ 
 tirely disappeared, and confident hopes are entertained of the 
 patient’s recovery, a furious delirium suddenly occurs. I cannot 
 refrain from adding this striking characteristic, as drawn by Cleg- 
 horn: ‘Besides some abatement of the fever, which happened every 
 morning, it was remarked that upon the third day or beginning of 
 the fourth, there was frequently a great remission, sometimes a 
 total cessation of every violent symptom, so that the sick were 
 thought to be out of danger, but on the fourth or fifth, a delirium 
 suddenly came on, or the breathing became more difficult than 
 
THE EPIDEMICS OF NORTH CAROLINA. 73 
 
 ever, and one or both of these symptoms increasing hourly, the 
 patient expired either suffocated or raving mad, unless nature or 
 art assisting, he had the good fortune to escape by some critical 
 evacuation.’ ” x 
 
 It has happened to the writer to have seen cases, in which every 
 rational and physical sign of convalescence had made its appear¬ 
 ance, but which on the next visit were found to be in the same 
 condition as when first attacked, without any known cause which 
 could probably be assigned for the change. In these cases it will 
 be perceived that the malady was strictly intermittent, and the 
 recurrence of the symptoms was evidently connected with the 
 periodical character of the affection and the liability of that class 
 of diseases to relapse. 
 
 "We have thus briefly pointed out the variations presented by 
 the several organs, functions, and secretions, to aid the beginner in 
 discriminating between this and the simple form; but there is 
 another phase of pneumonia, with which it is also too often con¬ 
 founded, and which of late years is seen frequently in malarial 
 regions, and from which it is equally important that it should be 
 distinguished, viz., typhoid pneumonia. 
 
 “By the term typhoid pneumonia, I designate that species of 
 pulmonic lesion which presents itself as a complication of the form 
 of continued fever, for many years widely prevalent in the old and 
 new world, and by general acceptation known as typhoid fever. 
 It is true that this term and its synonymes have often been applied 
 -to simple and malarial pneumonia, but I believe on erroneous 
 grounds. The designation typhoid, asthenic or sthenic, cannot be 
 applied to the latter disease, as the exhibitions of vital force or 
 reaction are too variable in their nature, intensity, and duration, 
 to render them appropriate. 
 
 “ Thus we have seen, in some cases of the malarial disease, the 
 vital powers were almost overwhelmed at its onset, continuing 
 thus for days together, and at last perhaps followed by violent 
 reaction; whilst in the cases generally, there were such diurnal 
 changes that the same patient might have been regarded in an 
 asthenic or sthenic state on the same day, accordingly as he may 
 have been seen in the remission, chill, or exacerbation. It is true 
 that the malarial affection, when continuing, finally places the 
 patient in an adynamic state, but this is true of acute diseases 
 
 1 Diseases of Minorca. 
 
KEPOKT ON 
 
 74 * 
 
 generally, and must be regarded as a sequent and not as an origi¬ 
 nal condition. 
 
 “ The term typhoid cannot be properly applied to any form of 
 simple inflammation. In my opinion pure inflammation of the 
 lungs, occurring in a previously healthy subject, cannot present 
 typhoid symptoms, unless it is associated with some morbid ele¬ 
 ment, which impairs the resistant powers of the organism. When, 
 therefore, such a patient prominently presents the symptoms of 
 pneumonia, attended with deficient vital reaction, the inflammation 
 of the lungs is a secondary or collateral affection, and not the pri¬ 
 mary or essential malady under which he is laboring. 
 
 “ Typhoid pneumonia may be presented as an intercurrent 
 affection, but often the inflammation of the lungs is the first and 
 most conspicuous symptom. To such an extent and so marked is 
 the expression of this lesion, that the practitioner is liable to re¬ 
 gard the pulmonary affection as the sole cause of the illness of the 
 patient, and not perceiving the system condition with which it is 
 connected, may be led into the error of treating it as such. On 
 minutely inspecting the case, however, he will be enabled generally 
 to discern its true character, and recognize, under the veil of pneu¬ 
 monia, the peculiar form of fever on which it is engrafted. 
 
 “To the novice we offer a few observations as guides to a correct 
 diagnosis. Typhoid pneumonia usually differs from the forms 
 before mentioned: 1st. In its mode of access. It is usually more 
 gradual in its approach; and in cases in which the pneumonic 
 symptoms announce themselves suddenly, it will commonly be 
 found, on inquiry, that the patient has been indisposed for some 
 time before their appearance. 
 
 “ 2dly. In the character of the attendant fever. The regularly 
 recurring paroxysms of malarial pneumonia are absent, the firm 
 full pulse of the simple form is never observed, but, on the other 
 hand, symptoms of great depression of the vital powers are gene¬ 
 rally present. 
 
 “In short, we are usually enabled to discover the peculiarity of 
 the case, by bearing in mind that the patient before him is the 
 subject of typhoid fever with pneumonia superadded. 
 
 “Lastly. In diagnosing the various forms of pneumonia, we should 
 look around our patient and endeavor to ascertain the sources of dis¬ 
 ease to which he has been exposed, whether of transitions of tempera¬ 
 ture, moisture, contagion, endemic, or epidemic influence. 
 
 “Although the rules laid down are generally applicable, we 
 
THE EPIDEMICS OF NORTH CAROLINA. ‘75 
 
 should ever be on the alert for fear of a mistake. It is desirable 
 that it should be impressed on the mind of the beginner, that he 
 will often be compelled to diagnose and treat many cases of which 
 his knowledge must be chiefly drawn from the character of the 
 epidemic present. 
 
 “ Physical signs often interpret disease imperfectly; symptoms 
 are merely outward expressions of an internal departure from 
 normal vital action; they often vary, they are frequently obscure, 
 and the same morbific agent has so many different modes of dis¬ 
 playing its effects on the organism, that many instances must 
 present themselves to the observer in which no pathognomonic 
 guides will be perceived, or if present, undecidedly and imperfectly 
 pronounced. 
 
 “ Cause and Nature of Malarial Pneumonia .—The efficient cause 
 of this disease, as its name implies, I believe to be malaria. By 
 this term I desire to imply the identical cause of that class of 
 pyrexias now generally known as periodical fever. 
 
 “ In employing this description, I do not commit myself to, or 
 demand a belief in any of the theories concerning its origin, but as 
 naught, save the Great First Cause, can exist without a creator, so 
 periodical fever cannot, without being called into existence by 
 some morbid agency. * * * * 
 
 “Nevertheless there are some axioms which may be regarded as 
 established in reference to this source of disease, which, for the 
 elucidation of my views, it is necessary to bear in mind. 
 
 “First. The primary impression of malaria is depressing in its 
 character. 
 
 “Secondly. Periodical fever may owe its existence to an ex¬ 
 posure to its cause at a period considerably antecedent to its deve¬ 
 lopment. 
 
 “Thirdly. This class of fevers, though chiefly rife in the 
 warmer, may occur primarily at any season of the year. 
 
 “Fourthly. A person exposed to malaria may present indubitable 
 evidences of its pernicious influence, without any regular attack 
 of fever having occurred, such as anorexia, nausea, malaise, diar¬ 
 rhoea, neuralgia, debility, palpitation, emaciation, and anasmia. 
 
 “Fifthly. Persons constantly exposed to malarial influence may 
 retain perfect health. 
 
 “ Sixthly. In persons of this latter class, periodical fever is often 
 suddenly developed by any depressing cause, such as a blow, a fall, 
 a shock, and by the incidental occurrence of other diseases. 
 
70 
 
 REPORT ON 
 
 “ The doctrine that this form of pneumonia owes its existence to 
 malarial influence has long been entertained and acted upon, but ? 
 on the other hand, has been as strenuously contested, both in regard 
 to its correctness and legitimate consequences. The subject is one 
 of great interest and of the highest importance, involving unques¬ 
 tionably the lives of the inhabitants of many sections of our own 
 and other countries. 
 
 “The reader who has had frequent opportunities of observing 
 remittent fever at the bedside, or those who have not, who have 
 known the writer, by their perusal of his imperfect descriptions of 
 that disease, cannot fail to perceive the close resemblance between 
 the phenomena presented by that affection and the disease under 
 consideration. Indeed, the similitude is almost perfect, with the 
 addition of the signs and symptoms of the thoracic lesion. 
 
 “It will be observed, therefore, that the evidences of organic im¬ 
 plication are by no means confined to the organs of respiration; 
 and symptoms of gastro-intestinal disorder very frequently pre¬ 
 ceded the lung symptoms, and that both were very often preceded 
 by febrile excitement for hours and even days. AVe have seen that 
 the patient evidently does not always perish from the pathological 
 changes wrought in the lungs, death more often occurring from the 
 supervention of fierce delirium, not only independent of the lung 
 affection, but subsequent to its abatement or total disappearance. 
 These facts then clearly denote the connection between this dis¬ 
 ease and periodical fever, as they sufficiently prove that its 
 phenomena are not merely symptomatic of lesion of the lungs. 
 
 “By some, an explanation of the existence of this disease has 
 been given by attributing it to the combined influence of malaria 
 and atmospheric vicissitudes. This is doubtless often true, but it 
 does not offer a satisfactory solution of the fact, that many are 
 often attacked with it, who have not been exposed in any appre¬ 
 ciable degree to those changes. Indeed, this affection often attacks 
 a number of persons consecutively in the same household, with 
 sufficient intervals of time elapsing between the occurrence of the 
 cases to permit all conditions of temperature and humidity to ap¬ 
 pear, properly belonging to the season. 
 
 “‘It is probable,’ says Laennec, ‘that the epidemic peripneumony 
 is often owing to deleterious miasms, which have entered the 
 system by means of the cutaneous or pulmonary absorbents, since 
 nothing is more common than to meet with cases o! this disease, 
 to which we can assign no occasional cause. How many persons 
 
THE EPIDEMICS OF NORTH CAROLINA. 77 
 
 are seized with it in their very chambers and in spite of the utmost 
 care taken of their health. It is impossible that any observer of 
 ordinary perception, can have failed to have been often impressed 
 with this affection. Exposure to atmospheric alternations does 
 not, therefore, offer a complete and satisfactory explanation of the 
 general occurrence of this affection. 7 
 
 “ I propose with some diffidence to offer a few thoughts on the 
 subject. It is a fact which will scarcely be questioned, that during 
 the prevalence of any fever in seasons of low temperature, pulmo¬ 
 nary inflammation is prone to occur as a complication. In scarla¬ 
 tina, rubeola, typhoid fever and other febrile affections, it is very 
 common. There are some causes, therefore, existing and belonging 
 to the season, which either excite or predispose to lesion of the 
 lung parenchyma. 
 
 “ In instituting an inquiry into the operation of those causes, it 
 will be necessary to bear in mind, that the system has passed 
 through the fervid heat of summer, the balmy temperature of 
 autumn, by transitions more or less variable to the colder season 
 of the year. Usually the outward man has been prepared for this 
 change, the whole surface of the skin having been protected from 
 the effects of reduced temperature by clothing of proper quantity 
 and quality. But how is it with the lungs, the only remaining 
 surface besides its outlet, which is exposed to the direct contact 
 of air ? What has been done to protect that extensive, delicate 
 lining of the air tubes and air cells; that admirably contrived 
 membrane, abundantly supplied with bloodvessels of such re¬ 
 markable construction and tenuity, as to allow the permeation of 
 air through their delicate parietes, and yet allow, under ordinary 
 circumstances, no escape of their contents? 
 
 “ It is evident that this great annual change of temperature 
 cannot take place without some important physiological revolution 
 in the pulmonary circulation; to understand the nature of which, 
 it is only necessary to remember the usual effects of reduced tem¬ 
 perature upon vascular tissues in general. The first impression of 
 cold upon the lungs must necessarily be succeeded by contraction 
 of their capillary vessels. Happily, however, our organs are en¬ 
 dowed with a certain degree of resistance to depressing causes, 
 under the operation of which the vessels again expand and allow 
 the free transmission of their contents. In short, the equilibrium 
 of health is established. The resisting force which thus averts dis¬ 
 ease, or, in other words, the nervous force, the only power existing 
 6 
 
78 
 
 REPORT ON 
 
 in the system of which we are cognizant, must, however, be con¬ 
 tinued and maintained in order that no embarrassment to the cir¬ 
 culation may ensue; consequently throughout the colder seasons, 
 a greater amount of nerve power must be expended in the lungs to 
 preserve their physiological condition. 
 
 “ Again, the effects of reduced temperature will be in proportion, 
 first, to its intensity and duration, and secondly, to the capability 
 of resistance residing in the system. 
 
 “ If we suppose that the system is contaminated by the depress¬ 
 ing influence of malaria, whether enervated by open attacks of 
 malarial fever, or debilitated by its latent influence, it necessarily 
 follows that such a person must be in a favorable condition for the 
 development of pulmonary engorgement, from the fact that he is 
 subjected to a temperature requiring a healthy nervous force to 
 resist, which he does not possess. 
 
 “ There is plainly, then, a degree on the thermometric scale, 
 equivalent to disease with him, yet compatible with health in 
 others. 
 
 “ Let us advance one step further. The degree of cold being 
 present, beyond the nervous power to resist, or having endured so 
 long as to have for a time exhausted its resources, let us look again 
 to the capillaries of the lung. If the vessels contracted by the 
 application of cold do not possess the normal resistant vigor, as we 
 have assumed as an axiom in the malarial diathesis, the same or 
 greater effect is produced than by a more intense degree of cold 
 acting on a healthy subject. 
 
 “ Under ordinary circumstances, however, the nervous centres 
 will be stimulated to react (those cases attended with collapse in the 
 commencement being the exceptions), the reaction, according to a 
 law of the organism, being in proportion to the previous depression. 
 ‘An increased afflux of blood to the part consequently ensues, and 
 as the action of cold has indirectly produced the same effect as that 
 produced by a direct irritating cause, it will only be necessary to 
 follow the subsequent steps in the process to the state of active 
 congestion, as detailed in Kaltenbrunner’s experiments. 71 
 
 “ But there is yet another function, which has also to undergo 
 an important modification. The skin, which had been exalted in 
 the warm season to excessive activity, gradually falls into a state 
 of comparative repose as the bleaker season arrives. This evidently 
 
 1 Watson’s Practice, art. Active Congestion, p. 46. 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 79 
 
 occurs, however perfectly it may have been protected. This sub¬ 
 sidence of function must necessarily be followed by a determina¬ 
 tion of blood to the internal organs, the retrocession being greater 
 and more easily induced in malarial subjects for reasons before 
 adduced. 
 
 “ We have now an explanation of the modes by which cold and 
 malarial influence may act as exciting and predisposing causes of 
 this affection; but this solution does not wholly apply to those 
 cases occurring in previously healthy subjects, while sedulously 
 guarded from atmospheric vicissitudes. These cases are evidently 
 due to the evolution of malaria, the affection of the lungs being 
 produced by the predisposing tendencies of the season. 
 
 u Objection has been urged on many grounds to this view of its 
 causation; the principal one of which is, that pneumonia prevails 
 in seasons inimical to the existence of this mysterious agent. This 
 is plainly an error. Primary attacks of periodical fever not un- 
 frequently occur during the winter and spring months, especially 
 in the latter, which is also the season in which this form of pneu¬ 
 monia is usually prevalent. The opponents of the views I have 
 embraced seem to ignore this established fact, as old as the ancient 
 couplet:— 
 
 1 An ague in spring 
 Is fit for a king.” 
 
 “ They have, however, been compelled to yield the admission 
 that a form of disease similar to that we have described often pre- 
 wails as an epidemic. Now, whether it be regarded merely as a 
 complication, a compound, or as a hybrid affection, it cannot be 
 disputed, that it rages in these seasons of the year, the temperature 
 of which they assume to be distinctive of malarial influence. The 
 inconsistency is obvious. 
 
 “The occurrence of periodical fever not only in the spring, but 
 occasionally in the winter months, being easily established, 1 2 there 
 are conditions necessary to notice, closely associated with its nature 
 and phenomena, which, besides the tendencies of the season, assist 
 in producing a sanguineous determination to the lungs. 
 
 “ When discussing the subject of remittent fever, I briefly en¬ 
 deavored to prove its nature, from the character of the symptoms 
 
 1 Elliotson’s Practice, 242. 
 
 2 Under tlie name of adynamic remittent, I have described a form of remittent 
 fever often seen in the winter season in my region. See article before referred to. 
 
80 
 
 REPORT ON 
 
 existing daring life, and to show that there was constant tendency 
 in the vital current to retrocede from the extremities to the trunk, 
 and in grave cases from the whole surface to the internal organs. 
 Of the cause of that morbid afflux, I then avoided discussion. 
 I do so now; but in my opinion it is produced by an irritation of 
 the nervous centres of a peculiar character. As a consequence of 
 this irritation and congestion, delirium, difficult locomotion, dysp¬ 
 noea independent of pulmonary engorgement, with varying con¬ 
 ditions of pulse, and abdominal symptoms were observed accord¬ 
 ingly as different portions of the cerebro-spinal axis may have been 
 involved. 
 
 “To sum up our reflections on the pathology and etiology of 
 this form of pneumonia, we have therefore to explain its production 
 and phenomena. 
 
 “First. The predisposing tendencies of low temperatures to pro¬ 
 duce an afflux to the lungs, by direct contact with their interior 
 surface. 
 
 “Secondly. The same cause by repression of the cutaneous 
 evacuation, determining to the whole internal organs. 
 
 “Thirdly. The operation of malarial influence, which not only 
 diminishes the vital resistance to cold, but possesses an evident 
 inherent tendency to produce internal engorgement. 1 
 
 “A glance at the pathological condition of the lung will close our 
 observations on this division of the subject. 
 
 “ I have repeatedly stated in the foregoing pages, my impressions 
 in regard to the condition of the lung parenchyma in this affection, 
 as partaking rather of the nature of active congestion than of well 
 developed inflammation. This is proven in my opinion by the 
 following circumstances. First. The sudden occurrence of solidi¬ 
 fication, as evinced by perfect flatness on percussion and absence of 
 the respiratory murmur. This sometimes takes place in grave 
 cases in a few hours after its onset, involving more than half of 
 
 1 Broussais, wlio doubtless saw a vast number of cases of this disease whilst 
 serving in the French armies, and who lias noticed at great length the connection 
 between malarial fever and pneumonia, was fully impressed with similar views. 
 Cette concentration des forces a l’interieur ou si’l on condamne ces expressions, 
 cette accumulation violente du sang, dans les capillaires des visceres, qui existe 
 durant la x>eriod de froid, des intermittentes, devient surtout funeste au pournon 
 pendant la saison froide. Ilistoire des Plilegmasies ou Inflam. Clironiques, tome 
 ii. 588. See also works of Laennec (op. cit ), M. Bailly, Traite des Fievres Int. 
 Paris, 1825. Cleghorn (op. cit.). 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 81 
 
 the entire lungs, accompanied by a cold skin, flagging pulse, col¬ 
 liquative diarrhoea ; a condition of system totally incompatible with 
 the existence of the inflammatory process. Secondly. The disap¬ 
 pearance of the physical signs is too rapid, in many cases, to 
 suppose that inflammation terminating in plastic exudation had 
 produced this impermeable condition of the lungs. 
 
 u It is true, as we have stated, that there are some evidences of 
 inflammation 1 mingled with the symptoms, and, as active congestion 
 is a state closely allied to inflammation, the latter may, and doubt¬ 
 less does occur, but it is evident that inflammation cannot be the 
 general condition, as it is too expeditiously removed, in many cases 
 of several days’ duration, and by inadequate means, to render that 
 view admissible. 
 
 “ Treatment. In the chill .—In this stage, it is evident that the state 
 of internal congestion is most intense ; the indications are therefore 
 to remove or lessen this condition. As in ordinary cases the vital 
 powers are competent to produce reaction, the employment of active 
 measures will be unnecessary; but when the cold stage is serious 
 and protracted, the usual means adopted in remittent fever should 
 be called into requisition. Warm applications are to be assidu¬ 
 ously made over the whole length of the spinal column, and to the 
 extremities, together with stimulating frictions, and to these may 
 be added warm cataplasms of mustard, or of capsicum to the anterior 
 and lateral surfaces of the thorax. If these means should be un¬ 
 successful in restoring the circulation to the surface, enemata of the 
 - sulphate of quinine may be used. Eight or ten grains of the salt 
 dissolved in two ounces of mucilaginous fluid may be thrown into 
 the rectum every half hour or more often, until symptoms of reaction 
 ensue. If diarrhoea has been or is present, the following enema 
 will be more efficacious:— 
 
 Quinise sulpli. gr. x ; 
 
 Morphia sulpli. gr. ^ ; 
 
 Acid, sulpli. dilut. gtt. x ; 
 
 Aquae 3 ij.—Misce. 
 
 “ To be used as the former, but at longer intervals. 
 
 “ The action of the enemata may be assisted by the administra¬ 
 tion of the carbonate of ammonia by the mouth, or infusions of 
 ginger or capsicum whilst warm may be given. In extreme cases 
 
 1 In Laennec’s cases, he only mentions that “ traces of inflammation were found 
 after death” (op. cit., 249). 
 
82 
 
 REPORT ON 
 
 it will be necessary to resort to alcoholic stimuli. These, however, 
 should be used with caution, and their effects closely observed. 
 
 “Fortunately, however, it is rarely that much difficulty is en¬ 
 countered, in conducting the patient through the cold stage, and 
 medication may generally be postponed, until the febrile reaction 
 is developed. 
 
 “ The exacerbation .—The indications in this stage are to calm the 
 action of the heart, to remove congestion and to prevent the occur¬ 
 rence of the next paroxysm. If the pulse is hard, full, or tense, as 
 it is in rare and exceptional cases, or if the patient is robust, or pre¬ 
 viously healthy and possessing ordinary vigor, and the pain or 
 dyspnoea is very intense, and the character of the pulse or other 
 symptoms does not decidedly contraindicate its employment, then a 
 moderate quantity of blood may be taken from the arm. 
 
 “ In this disease, general bloodletting should be employed with 
 a view only to moderate and not with an expectation to cut short the 
 disease; nor should it be employed except in the instances referred 
 to. In cases where this is not followed by marked relief and in 
 those in which venesection is inadmissible, the local abstraction of 
 blood by cups or leeches should be resorted to, and may be used 
 as freely as considerations of safety will permit. The time at which 
 bleeding 1 by any mode should be practised is that period when the 
 exacerbation has reached its acme, which is almost invariably in 
 the afternoon or evening. 
 
 “The administration of medicine is generally postponed until 
 nine or ten o’clock P. M., at which time a full dose of calomel 
 (fifteen or twenty grains) is administered. If diarrhoea or a tend¬ 
 ency thereto is present, eight or ten grains of Dover’s powder are 
 generally combined with the mercurial. Two or three hours there¬ 
 after, this is followed by a full dose of quinine (fifteen or twenty 
 grains), in pills or diffused in a wineglassful of cold water. Three 
 or four hours are now allowed to elapse; we now usually repeat the 
 quinine in doses of five to ten grains, in proportion as the pulse 
 
 1 In the remittent fevers denominated pernicious peripneumonic, says Laennec, 
 it may no doubt sometimes be necessary to bleed during a paroxysm, in order to 
 prevent suffocation, but the utmost caution is necessary not to destroy unneces¬ 
 sarily the strength of the patien. We must ever keep in mind that bloodletting 
 cannot cure a disease which will certainly return after a few hours with fresh vio¬ 
 lence, and of which experience has long since demonstrated bark to be the only 
 remedy. Op. cit., 293. 
 
THE EPIDEMICS OF NORTH CAROLINA. 
 
 83 
 
 may have been reduced, until thirty-five to forty grains have been 
 administered and the patient is then left at rest. 
 
 “ According to my experience, the chill cannot recur whilst the 
 patient is under the influence of the above quantity of the alkaloid; 
 the fever may however continue, but usually in a very moderate 
 degree. Should this be the case, the local bleeding is repeated in 
 the evening exacerbation, and calomel in small doses of one or two 
 grains, with a half to one grain of ipecac, or two grains of Dover’s 
 powder, is given every one or two hours. 
 
 “ After midnight, the quinine is repeated in the same manner, 
 or in lesser quantity (in direct proportion to the degree of fever 
 present), until the period of chill has passed, when all medicine is 
 again suspended. It is rare, indeed, that cases thus treated in the 
 early stages do not exhibit the most flattering amendments, on the 
 day succeeding the first night on which the plan is adopted ; and 
 still more rare that every dangerous symptom has not disappeared 
 on the succeeding day. 
 
 “ Should the pneumonic symptoms, however, persist, the mercu¬ 
 rial should be continued until its constitutional effects are produced. 
 In some cases in which the arterial action is not disposed to yield, 
 and the dyspnoea continues, I have ventured on the use of tartar 
 emetic in small doses, in union with quinine. I am indebted to 
 Dr. Blakiston for a knowledge of the value of this combination. 
 The antimonial should however be carefully used; and it is better 
 to commence with a minimum dose of one-tenth or one-twelfth of 
 * a grain, to be gradually increased as it may be borne. I think it 
 proper to say too that the gastric irritation and tendency to diarrhoea, 
 so often present in this disease, contraindicate the employment of 
 tartar emetic generally. 
 
 “ Whether alone or in combination the quinine should, however, 
 be continued for several days after the active symptoms have dis¬ 
 appeared. Blisters may be employed at almost any stage of the 
 affection, but under this mode of treatment, may often be altogether 
 dispensed with. Of course their use is preferable after the arterial 
 action is moderated.” 
 
 I have thus endeavored to present a sketch of the principal epi¬ 
 demic diseases which have recently prevailed in the State of North 
 Carolina. I am profoundly sensible of its incompleteness and its 
 imperfections; for notwithstanding every effort on my part, I have 
 
84 REPORT ON THE EPIDEMICS OF NORTH CAROLINA. 
 
 been unable to secure that extent of co-operation among the phy¬ 
 sicians of the State, without which anything approaching a complete 
 picture of its prevalent diseases, is altogether impracticable ; and it 
 is now submitted only in obedience to the sense of obligation im¬ 
 posed upon me by the appointment of the Association, requiring 
 me at least to make an effort to respond to their wishes.