A system of practical medicine. By American authors. Vol. 2 — Text and Context

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Authors: Pepper, William, 1843-1898 [Editor], Starr, Louis, 1849-1925 [Editor] Digital Source: Project Gutenberg Gutenberg Release Year: 2014 First Publication Year: Not confirmed

Key Word: Medicine -- Practice Target Reader: Readers of public-domain and historical texts

Book Edition: Project Gutenberg digital edition Book Language: en

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Words 695,242

Reading time 3023 min

Text sections 176

For A system of practical medicine. By American authors. Vol. 2 — Text and Context, the stored edition analysis reports 695,242 words, 50 hr 23 min estimated reading time, and 176 detected text sections.

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This editorial note examines the diagnostic reasoning and therapeutic logic in a late-19th-century American medical reference, focusing on how contributors like W.W. Johnston and J. Lewis Smith structure clinical observations and treatment protocols for digestive and general diseases.

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condition which Barwell proposes to call eccentric atrophy. "While these subjects are still youthful very little bone-earth is deposited, or at least remains in the very thin layer of osseous tissue that subsists. The relationship between infantile ostitis and extreme development of the intraosseous fat, though well known, is still occult; neither should we lose sight of the possibility that the softening process of ostitis may be due to a fatty acid. Now, fatty ostitis usually occurs in epiphyses. In these cases the shafts were affected."

[Footnote 18: _Trans._, xxxiv., 1883, pp. 203-208.]

PROGNOSIS.--The course and the prognosis of rachitis are, as a rule, favorable, but they change according to the degree and locality of the affection and the age of the patient. Generally there is neither fever nor rapid exhaustion. But the process lasts for months and even years. In favorable cases, when recovery takes place the teeth will grow faster, the bones become firmer, the epiphyses will diminish in relative size, the bowels become regular. But the length of the bones is, and remains, reduced, and the head remains large as compared with the length of the body. Not only are the bones of normal firmness, but the compact substance undergoes a process of hardening called eburnation by Guérin. The internal organs also become very active, perhaps because the total amount of blood has to supply only a body less extended in length. Nor does the brain suffer after complete recovery has taken place. On the contrary, it appears that the somewhat more than normal vascular dilatation, which under unfavorable circumstances leads to effusion, is {158} frequently apt to nourish the organ of intellect up to a higher standard. In all cases of rachitis, however, the curvatures of the extremities will not disappear altogether, while mild ones, it is true, are hardly recognizable in advanced age. Curvature of the ribs and of the vertebral column, however, will remain, and interfere with the expansion and the normal functions of the lungs and heart. In regard to the lungs, it appears that in many cases they do not find sufficient space to expand. As far as the heart is concerned, it touches the flattened, no longer elliptic, chest-wall over a larger surface, and is very apt to give rise to the suspicion of enlargement in consequence of extended dulness on percussion. The rachitic pelvis is well known to the obstetrician for the difficulties it gives rise to during parturition.

Thus, the prognosis would, as a general thing, be sufficiently favorable if it were not for the number of complications or severe symptoms. The chronic catarrh of the lungs accompanying rachitis, the enlargement of the tracheal and bronchial glands and the lymphatic glands in general, are apt to lead to inflammatory disease of the lungs, which, after having returned several times, leads to infiltration of the lungs with caseous deposits, and not infrequently results in phthisis. The nervous symptoms accompanying craniotabes may prove very dangerous. Spasm of the larynx and laryngismus stridulus may prove fatal in a single attack by suffocation, or general convulsion may set in during an attack of laryngismus or without it, in which the child may perish. Therefore the prognosis in every case of laryngismus and in every case of craniotabes has to be very guarded. It is my rule to wait from six to eight weeks before giving expression to a decided prognosis, because during that time medicinal and dietetic treatment will probably have resulted in such an improvement of the symptoms and condition as to render the prognosis more favorable. Under no circumstances, however, ought we to lose sight of the fact that, though rachitis may disappear, the causes leading to it may still linger on. Defective nutrition, diseases of the lungs, and intestinal affections which gave rise to or accompanied rachitis will complicate the prognosis, though rachitis itself, as far as the bones were concerned, be no longer in existence.

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In the second volume of A System of Practical Medicine, edited by William Pepper and Louis Starr, the clinical voice is notably systematic and differential. The excerpt on enteralgia (intestinal colic) exemplifies the editors' insistence on precise diagnostic parsing: the author, W.W. Johnston, methodically distinguishes enteralgia from dermalgia, gastralgia, myalgia, ileus, renal calculus, hepatic colic, lead-poisoning colic, syphilitic pain, and catarrhal inflammation. Each distinction rests on specific sensory and physical signs—such as whether light or deep pressure exacerbates pain, or whether pain radiates to the shoulder. This granular approach reflects the volume's broader commitment to equipping the physician with a checklist of observable features rather than relying on broad categories.

Differential Diagnosis as a Literary Structure

Johnston's prose on enteralgia reads less like a treatise and more like a clinical algorithm. He lists conditions in a logical sequence, each introduced by a short, declarative sentence: “In dermalgia the soreness is superficial,” “Gastralgia is more frequent than enteralgia,” “In ileus the pain is more continuous.” The pattern is consistent—condition, then its distinguishing trait. This structure mirrors the diagnostic process itself: a series of eliminations. The author also uses contrastive phrasing (“light pressure gives more pain than deep compression”) to sharpen boundaries. Such a method implies that the reader is expected to memorize or apply these distinctions at the bedside, not merely read them passively.

Therapeutic Specificity and Cautionary Notes

Treatment recommendations in the enteralgia section are notably conditional. Johnston advises antispasmodic sedatives for hysterical cases, but warns that in “pure enteralgia with frequently recurring paroxysms care must be taken not to create the demand for the remedy by giving it often.” This reflects a cautious, almost modern, awareness of opioid dependence. He also lists constitutional remedies keyed to specific etiologies: iodide of potassium and mercury for syphilitic or rheumatic origins, colchicum for gouty, quinia for malarial, and iron for anemic states. The specificity of these pairings—each poison or diathesis matched to a drug—demonstrates the era's faith in targeted pharmacotherapy, even as the underlying pathologies were poorly understood.

Voice and Authority Across Contributors

The volume assembles twenty-three American authors, each writing on a single disease or organ system. The excerpts show variation in rhetorical style: Johnston’s enteralgia entry is terse and algorithmic, while other sections (not excerpted here) may adopt a more narrative or historical tone. The editors, Pepper and Starr, impose consistency through the use of standardized subheadings—Etiology, Symptoms, Diagnosis, Prognosis, Treatment—but within that framework, individual voices emerge. For instance, Johnston’s prognosis for enteralgia is blunt: “Attacks are very apt to recur, and each one will, in all probability, prove more severe than the preceding.” Such directness contrasts with the more hedged language one might find in modern clinical guidelines.

The Role of Physical Examination in Text

Despite being a text-based medium, the volume repeatedly emphasizes hands-on examination. Johnston instructs the reader to locate a “lump of feculent matter” by palpation and percussion, and to note whether deep pressure increases pain—a sign of inflammation rather than neuralgia. The description of hepatic colic includes pain “reflected into the shoulder of the same side,” a classic referred pain pattern. These details ground the abstract diagnostic categories in tangible, tactile experience. The text thus functions as a bridge between the written word and the physical encounter, training the physician’s senses as much as their memory.

Readers approaching this volume should attend to the interplay between standardized structure and individual authorial choice. The diagnostic tables and therapeutic lists are not mere data dumps; they encode a method of reasoning that prioritizes observable signs over theoretical speculation. For historians of medicine, the work offers a snapshot of American clinical practice in the 1880s—confident in its taxonomies, cautious in its remedies, and deeply attentive to the patient’s body as a text to be read.

Reading the old clinicians’ careful weighing of symptoms in that volume, their unhurried confidence in observation, I found myself reaching for the quieter pages of Merck's 1899 Manual of the Materia Medica — A Closer Reading. There was something familiar—the same patient trust in what a body tells you, and what a plant might offer in reply. A different century, yet the same hush.